The transtheoretical model is also known by the abbreviation "TTM" and sometimes by the term "stages of change", Pro-Change Behavior Systems. About us. Transtheoretical model. 2008 Mar. Accessed 2009 Mar 21. although this latter term is a synecdoche since the stages of change are only one part of the model along with processes of change, levels of change, etc. Several self-help books—Changing for Good (1994), Changeology (2012), and Changing to Thrive (2016)—and articles in the news mediaGoleman, Daniel. New addiction approach gets results. New York Times 1993 Sep 1. Accessed 2009 Mar 19.Miller, Kay. Revolving resolutions – Year after new year, we vow to lose weight, stop smoking, find love or a better job -- only to fail. A few simple strategies could set us straight. Star Tribune: Newspaper of the Twin Cities 2001 Dec 29.Stettner, Morey. A methodical way to change bad behavior. Investor's Business Daily 2005 Dec 19.Understanding change: expect a few bumps. Washington Post 2007 Jan 2. Accessed 2009 Mar 19.Carbine, Michael E. Health plans use a variety of strategies to identify and ensure compliance among diabetics. AIS's Health Business Daily 2009 Mar 6. Accessed 2009 Mar 19. have discussed the model. It has been called "arguably the dominant model of health behaviour change, having received unprecedented research attention, yet it has simultaneously attracted criticism". Relapse (recycling)DiClemente, CC; Prochaska, JO; Gibertini, M. Self-efficacy and the stages of self-change of smoking. Cognit Ther Res 1985;9(2):181–200. Accessed 2009 Mar 22. Prochaska, JO; DiClemente, CC; Velicer, WF; Rossi, JS. Standardized, individualized, interactive, and personalized self-help programs for smoking cessation. Health Psychol 1993 Sep;12(5):399–405. Accessed 2009 Mar 18. Multiple studies have found individualized interventions tailored on the 14 TTM variables for smoking cessation to effectively recruit and retain pre-Action participants and produce long-term abstinence rates within the range of 22\% – 26\%. These interventions have also consistently outperformed alternative interventions including best-in-class action-oriented self-help programs, non-interactive manual-based programs, and other common interventions. Furthermore, these interventions continued to move pre-Action participants to abstinence even after the program ended. Velicer, W.F., Fava, J.L., Prochaska, J.0., Abrams, D.B., Emmons, K.M., Pierce, J. (1995) Distribution of smokers by stage in three representative samples Preventive Medicine 24, 401-411. For a summary of smoking cessation clinical outcomes, see Velicer, Redding, Sun, & Prochaska, 2007 and Jordan, Evers, Spira, King & Lid, 2013. Travel research The use of TTM in travel behaviour interventions is rather novel. A number of cross-sectional studies investigated the individual constructs of TTM, e.g. stage of change, decisional balance and self-efficacy, with regards to transport mode choice. The cross-sectional studies identified both motivators and barriers at the different stages regarding biking, walking and public transport. Mundorf, N.; Redding, C.A.; Fu, T.; Paiva, A.; Brick, L.; Prochaska, J.O. Promoting sustainable transportation across campus communities using the transtheoretical model of change. Commun. commons 2013, 427–438. The motivators identified were e.g. liking to bike/walk, avoiding congestion and improved fitness. Perceived barriers were e.g. personal fitness, time and the weather. This knowledge was used to design interventions that would address attitudes and misconceptions to encourage an increased use of bikes and walking. These interventions aim at changing people's travel behaviour towards more sustainable and more active transport modes. In health-related studies, TTM is used to help people walk or bike more instead of using the car. Hemmingsson, E.; Udden, J.; Neovius, M.; Ekelund, U.; Rössner, S. Increased physical activity in abdominally obese women through support for changed commuting habits: A randomized clinical trial. Int. J. Obes. 2009, 33, 645–652. Most intervention studies aim to reduce car trips for commute to achieve the minimum recommended physical activity levels of 30 minutes per day. Other intervention studies using TTM aim to encourage sustainable behaviour. By reducing single occupied motor vehicle and replacing them with so called sustainable transport (public transport, car pooling, biking or walking), greenhouse gas emissions can be reduced considerably. A reduction in the number of cars on our roads solves other problems such as congestion, traffic noise and traffic accidents. By combining health and environment related purposes, the message becomes stronger. Additionally, by emphasising personal health, physical activity or even direct economic impact, people see a direct result from their changed behaviour, while saving the environment is a more general and effects are not directly noticeable. In a systematic review, published in 2003, of 23 randomized controlled trials, the authors found that "stage based interventions are no more effective than non-stage based interventions or no intervention in changing smoking behaviour. Riemsma, RP; Pattenden, J; Bridle, C; Sowden, AJ; Mather, L; Watt, IS; Walker, A. Systematic review of the effectiveness of stage based interventions to promote smoking cessation. BMJ 2003 May 31;326(7400):1175–7. Accessed 2009 Mar 18. However, it was also mentioned that stage based interventions are often used and implemented inadequately in practice. Thus, criticism is directed towards the use rather the effectiveness of the model itself. Looking at interventions targeting smoking cessation in pregnancy found that stage-matched interventions were more effective than non-matched interventions. One reason for this was the greater intensity of stage-matched interventions. Aveyard, P; Lawrence, T; Cheng, KK; Griffin, C; Croghan, E; Johnson, C. A randomized controlled trial of smoking cessation for pregnant women to test the effect of a transtheoretical model-based intervention on movement in stage and interaction with baseline stage. Br J Health Psychol 2006 May;11(2):263–78. Accessed 2009 Mar 18. Also, the use of stage-based interventions for smoking cessation in mental illness proved to be effective. Hall, S.M., Tsoh, J.Y., Prochaska, J.J., Eisendrath, S., Rossi, J.S., Redding, C.A., Rosen, A.B., Meisner, M., Humfleet, G.L., Gorecki, J.A., 2006. Treatment for Cigarette Smoking Among Depressed Mental Health Outpatients: A Randomized Clinical Trial American Journal of Public Health 1808; 96-1814. Further studies, e.g. a randomized controlled trial published in 2009, found no evidence that a TTM based smoking cessation intervention was more effective than a control intervention not tailored to stage of change. The study claims that those not wanting to change (i.e. precontemplators) tend to be responsive to neither stage nor non-stage based interventions. Since stage-based interventions tend to be more intensive they appear to be most effective at targeting contemplators and above rather than pre-contemplators. A 2010 systematic review of smoking cessation studies under the auspices of the Cochrane Collaboration found that "stage-based self-help interventions (expert systems and/or tailored materials) and individual counselling were neither more nor less effective than their non-stage-based equivalents. Within research on prevention of pregnancy and sexually transmitted diseases, a systematic review from 2003 comes to the conclusion that "no strong conclusions" can be drawn about the effectiveness of interventions based on the transtheoretical model. Horowitz, SM. Applying the transtheoretical model to pregnancy and STD prevention: a review of the literature. Am J Health Promot 2003 May–Jun;17(5):304–28. Accessed 2009 Mar 18. Again this conclusion is reached due to the inconsistency of use and implementation of the model. This study also confirms that the better stage-matched the intervention the more effect it has to encourage condom use. Within the health research domain, a 2005 systematic review of 37 randomized controlled trials claims that "there was limited evidence for the effectiveness of stage-based interventions as a basis for behavior change. Bridle, C; Riemsma, RP; Pattenden, J; Sowden, AJ; Mather, L; Watt, IS; Walker, A. Systematic review of the effectiveness of health behavior interventions based on the transtheoretical model. Psychol Health 2005;20:283–301. Accessed 2009 Mar 18. Studies with which focused on increasing physical activity levels through active commute however showed that stage-matched interventions tended to have slightly more effect than non-stage matched interventions. Since many studies do not use all constructs of the TTM, additional research suggested that the effectiveness of interventions increases the better it is tailored on all core constructs of the TTM in addition to stage of change. In diabetes research the "existing data are insufficient for drawing conclusions on the benefits of the transtheoretical model" as related to dietary interventions. Again, studies with slightly different design, e.g. using different processes, proved to be effective in predicting the stage transition of intention to exercise in relation to treating patients with diabetes. TTM has generally found a greater popularity regarding research on physical activity, due to the increasing problems associated with unhealthy diets and sedentary living, e.g. obesity, cardiovascular problems. A 2011 Cochrane Systematic Review found that there is little evidence to suggest that using the Transtheoretical Model Stages of Change (TTM SOC) method is effective in helping obese and overweight people lose weight. There were only five studies in the Review , two of which were later dropped due to not being relevant since they did not measure weight. Earlier in a 2009 paper, the TTM was considered to be useful in promoting physical activity. In this study, the algorithms and questionnaires that researchers used to assign people to stages of change lacked standardisation to be compared empirically, or validated. Similar criticism regarding the standardisation as well as consistency in the use of TTM is also raised in a recent review on travel interventions. With regard to travel interventions only stages of change and sometimes decisional balance constructs are included. The processes used to build the intervention are rarely stage-matched and short cuts are taken by classifying participants in a pre-action stage, which summarises the precontemplation, contemplation and preparation stage, and an action/maintenance stage. More generally, TTM has been criticised within various domains due to the limitations in the research designs. For example, many studies supporting the model have been cross-sectional, but longitudinal study data would allow for stronger causal inferences. Another point of criticism is raised in a 2002 review, where the model's stages were characterized as "not mutually exclusive". Littell, JH; Girvin, H. Stages of change. A critique. Behav Modif 2002 Apr;26(2):223–73. Accessed 2009 Mar 19. Furthermore, there was "scant evidence of sequential movement through discrete stages". While research suggests that movement through the stages of change is not always linear, a study  conducted in 1996 demonstrated that the probability of forward stage movement is greater than the probability of backward stage movement. Due to the variations in use, implementation and type of research designs, data confirming TTM are ambiguous. More care has to be taken in using a sufficient amount of constructs, trustworthy measures, and longitudinal data.
The transtheoretical model is also known by the abbreviation "TTM" and sometimes by the term "stages of change", For example: although this latter term is a synecdoche since the stages of change are only one part of the model along with processes of change, levels of change, etc. Several self-help books—Changing for Good (1994), Changeology (2012), and Changing to Thrive (2016)—and articles in the news mediaExamples of articles in the news media include: have discussed the model. It has been called "arguably the dominant model of health behaviour change, having received unprecedented research attention, yet it has simultaneously attracted criticism". Relapse (recycling)DiClemente, CC; Prochaska, JO; Gibertini, M. Self-efficacy and the stages of self-change of smoking. Cognit Ther Res 1985;9(2):181–200. Accessed 2009 Mar 22. Multiple studies have found individualized interventions tailored on the 14 TTM variables for smoking cessation to effectively recruit and retain pre-Action participants and produce long-term abstinence rates within the range of 22\% – 26\%. These interventions have also consistently outperformed alternative interventions including best-in-class action-oriented self-help programs, non-interactive manual-based programs, and other common interventions. Furthermore, these interventions continued to move pre-Action participants to abstinence even after the program ended. For a summary of smoking cessation clinical outcomes, see Velicer, Redding, Sun, & Prochaska, 2007 and Jordan, Evers, Spira, King & Lid, 2013. Travel research The use of TTM in travel behaviour interventions is rather novel. A number of cross-sectional studies investigated the individual constructs of TTM, e.g. stage of change, decisional balance and self-efficacy, with regards to transport mode choice. The cross-sectional studies identified both motivators and barriers at the different stages regarding biking, walking and public transport. The motivators identified were e.g. liking to bike/walk, avoiding congestion and improved fitness. Perceived barriers were e.g. personal fitness, time and the weather. This knowledge was used to design interventions that would address attitudes and misconceptions to encourage an increased use of bikes and walking. These interventions aim at changing people's travel behaviour towards more sustainable and more active transport modes. In health-related studies, TTM is used to help people walk or bike more instead of using the car. Most intervention studies aim to reduce car trips for commute to achieve the minimum recommended physical activity levels of 30 minutes per day. Other intervention studies using TTM aim to encourage sustainable behaviour. By reducing single occupied motor vehicle and replacing them with so called sustainable transport (public transport, car pooling, biking or walking), greenhouse gas emissions can be reduced considerably. A reduction in the number of cars on our roads solves other problems such as congestion, traffic noise and traffic accidents. By combining health and environment related purposes, the message becomes stronger. Additionally, by emphasising personal health, physical activity or even direct economic impact, people see a direct result from their changed behaviour, while saving the environment is a more general and effects are not directly noticeable. In a systematic review, published in 2003, of 23 randomized controlled trials, the authors found that "stage based interventions are no more effective than non-stage based interventions or no intervention in changing smoking behaviour. However, it was also mentioned that stage based interventions are often used and implemented inadequately in practice. Thus, criticism is directed towards the use rather the effectiveness of the model itself. Looking at interventions targeting smoking cessation in pregnancy found that stage-matched interventions were more effective than non-matched interventions. One reason for this was the greater intensity of stage-matched interventions. Also, the use of stage-based interventions for smoking cessation in mental illness proved to be effective. Further studies, e.g. a randomized controlled trial published in 2009, found no evidence that a TTM based smoking cessation intervention was more effective than a control intervention not tailored to stage of change. The study claims that those not wanting to change (i.e. precontemplators) tend to be responsive to neither stage nor non-stage based interventions. Since stage-based interventions tend to be more intensive they appear to be most effective at targeting contemplators and above rather than pre-contemplators. A 2010 systematic review of smoking cessation studies under the auspices of the Cochrane Collaboration found that "stage-based self-help interventions (expert systems and/or tailored materials) and individual counselling were neither more nor less effective than their non-stage-based equivalents. Within research on prevention of pregnancy and sexually transmitted diseases, a systematic review from 2003 comes to the conclusion that "no strong conclusions" can be drawn about the effectiveness of interventions based on the transtheoretical model. Again this conclusion is reached due to the inconsistency of use and implementation of the model. This study also confirms that the better stage-matched the intervention the more effect it has to encourage condom use. Within the health research domain, a 2005 systematic review of 37 randomized controlled trials claims that "there was limited evidence for the effectiveness of stage-based interventions as a basis for behavior change. Studies with which focused on increasing physical activity levels through active commute however showed that stage-matched interventions tended to have slightly more effect than non-stage matched interventions. Since many studies do not use all constructs of the TTM, additional research suggested that the effectiveness of interventions increases the better it is tailored on all core constructs of the TTM in addition to stage of change. In diabetes research the "existing data are insufficient for drawing conclusions on the benefits of the transtheoretical model" as related to dietary interventions. Again, studies with slightly different design, e.g. using different processes, proved to be effective in predicting the stage transition of intention to exercise in relation to treating patients with diabetes. TTM has generally found a greater popularity regarding research on physical activity, due to the increasing problems associated with unhealthy diets and sedentary living, e.g. obesity, cardiovascular problems. A 2011 Cochrane Systematic Review found that there is little evidence to suggest that using the transtheoretical model stages of change (TTM SOC) method is effective in helping obese and overweight people lose weight. There were only five studies in the review , two of which were later dropped due to not being relevant since they did not measure weight. Earlier in a 2009 paper, the TTM was considered to be useful in promoting physical activity. In this study, the algorithms and questionnaires that researchers used to assign people to stages of change lacked standardisation to be compared empirically, or validated. Similar criticism regarding the standardisation as well as consistency in the use of TTM is also raised in a recent review on travel interventions. With regard to travel interventions only stages of change and sometimes decisional balance constructs are included. The processes used to build the intervention are rarely stage-matched and short cuts are taken by classifying participants in a pre-action stage, which summarises the precontemplation, contemplation and preparation stage, and an action/maintenance stage. More generally, TTM has been criticised within various domains due to the limitations in the research designs. For example, many studies supporting the model have been cross-sectional, but longitudinal study data would allow for stronger causal inferences. Another point of criticism is raised in a 2002 review, where the model's stages were characterized as "not mutually exclusive". Furthermore, there was "scant evidence of sequential movement through discrete stages". While research suggests that movement through the stages of change is not always linear, a study of smoking cessation conducted in 1996 demonstrated that the probability of forward stage movement is greater than the probability of backward stage movement. Due to the variations in use, implementation and type of research designs, data confirming TTM are ambiguous. More care has to be taken in using a sufficient amount of constructs, trustworthy measures, and longitudinal data.
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Pro-Change Behavior Systems. About us. Transtheoretical model. 2008 Mar. Accessed 2009 Mar 21.
For example:
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mediaGoleman, Daniel. New addiction approach gets results. New York Times 1993 Sep 1. Accessed 2009 Mar 19.Miller, Kay. Revolving resolutions – Year after new year, we vow to lose weight, stop smoking, find love or a better job -- only to fail. A few simple strategies could set us straight. Star Tribune: Newspaper of the Twin Cities 2001 Dec 29.Stettner, Morey. A methodical way to change bad behavior. Investor's Business Daily 2005 Dec 19.Understanding change: expect a few bumps. Washington Post 2007 Jan 2. Accessed 2009 Mar 19.Carbine, Michael E. Health plans use a variety of strategies to identify and ensure compliance among diabetics. AIS's Health Business Daily 2009 Mar 6. Accessed 2009 Mar 19.
mediaExamples of articles in the news media include:
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Prochaska, JO; DiClemente, CC; Velicer, WF; Rossi, JS. Standardized, individualized, interactive, and personalized self-help programs for smoking cessation. Health Psychol 1993 Sep;12(5):399–405. Accessed 2009 Mar 18.
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Velicer, W.F., Fava, J.L., Prochaska, J.0., Abrams, D.B., Emmons, K.M.,
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Pierce, J. (1995) Distribution of smokers by stage in three representative samples Preventive Medicine 24, 401-411.
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Mundorf, N.; Redding, C.A.; Fu, T.; Paiva, A.; Brick, L.; Prochaska, J.O. Promoting sustainable transportation across campus communities using the transtheoretical model of change. Commun. commons 2013, 427–438.
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Hemmingsson, E.; Udden, J.; Neovius, M.; Ekelund, U.; Rössner, S. Increased physical activity in abdominally obese women through support for changed commuting habits: A randomized clinical trial. Int. J. Obes. 2009, 33, 645–652.
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Riemsma, RP; Pattenden, J; Bridle, C; Sowden, AJ; Mather, L; Watt, IS; Walker, A. Systematic review of the effectiveness of stage based interventions to promote smoking cessation. BMJ 2003 May 31;326(7400):1175–7. Accessed 2009 Mar 18.
D
Aveyard, P; Lawrence, T; Cheng, KK; Griffin, C; Croghan, E; Johnson, C. A randomized controlled trial of smoking cessation for pregnant women to test the effect of a transtheoretical model-based intervention on movement in stage and interaction with baseline stage. Br J Health Psychol 2006 May;11(2):263–78. Accessed 2009 Mar 18.
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Hall, S.M., Tsoh, J.Y., Prochaska, J.J., Eisendrath, S., Rossi, J.S., Redding, C.A., Rosen, A.B., Meisner, M., Humfleet, G.L., Gorecki, J.A., 2006. Treatment for Cigarette Smoking Among Depressed Mental Health Outpatients: A Randomized Clinical Trial American Journal of Public Health 1808; 96-1814.
D
Horowitz, SM. Applying the transtheoretical model to pregnancy and STD prevention: a review of the literature. Am J Health Promot 2003 May–Jun;17(5):304–28. Accessed 2009 Mar 18.
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Bridle, C; Riemsma, RP; Pattenden, J; Sowden, AJ; Mather, L; Watt, IS; Walker, A. Systematic review of the effectiveness of health behavior interventions based on the transtheoretical model. Psychol Health 2005;20:283–301. Accessed 2009 Mar 18.
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Transtheoretical Model Stages of Change
transtheoretical model stages of change
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Review
review
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Littell, JH; Girvin, H. Stages of change. A critique. Behav Modif 2002 Apr;26(2):223–73. Accessed 2009 Mar 19.
A
of smoking cessation