Keywords

Introduction

In response to the increasing percentages of Americans who have multiple poor health behaviors (Ford, Zhao, Tsai, & Li, 2011), are overweight or obese (“Obesity and Overweight,” 2015), and are diagnosed as prediabetic or diabetic (“Employers Are Working to Defeat Diabetes,”), our nation is finally dedicating attention, resources, and even legislation toward health and wellness programs. There are more accountability and requirements placed on health care providers to assist with disease prevention and management (Koh & Sebelius, 2010). Employers are responding to the sky rocketing cost of insuring an unhealthy workforce by offering wellness programs and onsite health clinics (Mattke et al., 2013). Health coaching is a burgeoning field and there are countless mobile apps for every health condition imagined. With a myriad of support options literally at their fingertips, at first glance it may appear bewildering as to why people, even those who need the help most, are not engaging in the many low or no cost options that abound.

To gain a clearer picture, let us take a closer look at typical engagement strategies :

  1. 1.

    When an employer sends an email promoting a Biggest Loser or Couch to 5 K program, which employees are likely to participate?

  2. 2.

    When a physician recommends quitting smoking to a patient and offers a prescription for a nicotine replacement product or drug, which patients are likely to fill the prescription?

  3. 3.

    When an insurer sends a postcard offering free telephonic or digital health coaching for diabetes, which members are likely to respond?

The answer to those three questions is the same— those who are READY to change.

Each of the typical engagement scenarios above make certain assumptions: that the majority of individuals are ready to change, that the same recruitment message and programming will be applicable and effective for everyone, and that good information is enough to help people change.

Over the last 35 years, research using the Transtheoretical Model of Behavior Change (TTM) has identified that for any particular behavior the majority of any at-risk population is not ready to change (Laforge, Velicer, Richmond, & Owen, 1999; Velicer et al., 1995). Yet, the majority of programs are geared to those who are ready to change. The ground-breaking insights of Dr. James O. Prochaska and colleagues who developed the TTM teach that people who are not ready are often uninformed, under-informed, and unwillingly or too discouraged to take action (DiClemente & Prochaska, 1982; Prochaska & Diclemente, 1983). Working with people across many different areas of health, we have also learned that wanting to change is not necessarily the same things as intending to change. You might ask, why would someone want to change but not intend to change? Take a moment to think about your own life. Certainly, you can think of an area in which you’d like to make a change, one which you’d know it would be good to change, but despite this interest and awareness, you just keep doing your old behavior. Why does this happen? Your attention and efforts might be focused elsewhere, you might not know how to get started, or maybe you’ve tried in the past, failed, and feel demoralized. In this chapter, we’ll describe how the Transtheoretical Model (TTM) can be applied to facilitate engagement in health behavior treatment . By recognizing that not everyone is ready to change, we can adapt our perspective, communications, strategies, and programs to engage individuals across different stages of readiness to change.

The overarching goals of this chapter are to:

  • Provide an overview of the Transtheoretical Model of Behavior Change and the efficacy of using the model to facilitate behavior change

  • Describe characteristics of individuals across the stages of change and how they relate to engagement

  • Identify key principles of using a stage approach to facilitate treatment engagement

The TTM can help multidisciplinary health care providers and clinicians (physicians, nurses, pharmacists, health coaches, etc.) to effectively communicate with patients around their health behaviors and match engagement strategies to their patient’s level of readiness to change. The TTM also can help researchers across various health disciplines, psychology, and behavioral sciences to successfully recruit and engage individuals who are not ready, getting ready, and ready to engage in their research.

Using a stage approach often requires a significant shift in perspective. With this Model, change is conceptualized as a process and journey. Success is measured incrementally by engagement in the journey rather than just upon reaching the destination. It requires recognizing progress not only when you help a patient make a change, but also when you help someone begin to consider making a change. It requires patience and follow-up, as you guide patients through the journey, knowing that with each step you help them take, they are that much closer to the destination. It may require changing your default messages and suggestions to patients around health behavior changes. You may need to practice identifying someone’s readiness to change and matching your engagement strategy accordingly. For some, this might entail small shifts in your work flow and for others it might mean significant overhaul. Any successful change requires readiness to change, a commitment to change, an understanding of how to change, perceived benefits of changing for you and others, support, and reinforcement. As you embark on your own journey, consider your level of readiness to integrate a stage approach in your work. Are you not ready, getting ready, ready, recently implementing it, or maintaining it? It’s ok if you’re not yet ready to embrace the stage approach . Try to keep an open mind as you read this chapter, and we’ll ask your intentions again at the end.

Overview of the Transtheoretical Model of Behavior Change

The Transtheoretical Model of Behavior Change (TTM), also known as the Stages of Change model, is a comprehensive model that integrates ideas of several different theories and approaches to change (hence the name “transtheoretical”) to explain and predict how and when individuals stop high-risk behaviors or adopt healthy ones (Prochaska, 1979). The TTM construes the change process into distinct stages of readiness (Precontemplation, Contemplation, Preparation, Action, and Maintenance) and provides approaches to help people move forward through the stages (Prochaska & Diclemente, 1983). Decades of research on a wide variety of health behaviors has found that certain principles and processes of change work best at each stage to reduce resistance, facilitate engagement and progress, and prevent relapse (Prochaska, 1994). These include decisional balance, self-efficacy, and processes of change.

Readiness to Change

Stages of Change is the TTM’s central organizing construct. Longitudinal studies of change have found that people move through a series of five stages when modifying behavior on their own or with the help of formal interventions (DiClemente & Prochaska, 1982; Prochaska & Diclemente, 1983). Understanding the stages of change allows us to appreciate change as a dynamic process and helps us learn the variability in patients’ responses to and uptake of health behavior interventions. As you read the following characterizations of the stages of change, consider examples from your own work (Fig. 3.1).

Fig. 3.1
figure 1

Stages of Change

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Precontemplation

Precontemplation is the stage of change in which individuals are not intending to change a target health behavior in the foreseeable future (typically defined as the next 6 months). It’s important to understand that there isn’t just one prototype of the typical patient in Precontemplation. Patients may be not ready to change for a myriad of reasons. Individuals may deny they have a problem (it’s normal to have a few beers every night), may be unaware of the negative consequences of their behavior (my weight is fine so it doesn’t matter what I eat), believe the consequences are insignificant (nothing is going to happen if I don’t take my cholesterol medicine every day as long as I take it sometimes), or feel helpless toward avoiding a negative consequence (everyone’s going to die from something, why not enjoy life while I can). Other precontemplators may want to change, but are not ready to do so because of perceived barriers (how can I quit when everyone around me smokes), have low self-efficacy (I’ve tried to exercise in the past but never kept it up for more than 2 weeks), or lack of information on how to get started (I’d like to add strength training but I have no idea how to get started). Depending on their perspective, precontemplators may express denial, defensiveness, discouragement, demoralization, resistance, rationalization, or minimization of the problem. Precontemplators often perceive more cons to changing than benefits, and may experience change as coerced. These are the most difficult patients to engage in the change process, therefore are often ignored and dismissed as unchangeable. The good news is that by using a change approach, you can effectively communicate with and engage precontemplators.

Contemplation

Individuals in Contemplation are intending to make a behavior change in the next 6 months. They are more likely to recognize the benefits of changing their behavior than those in Precontemplation, but they also are acutely aware of the cons or drawbacks of changing. This ambivalence can get them stuck in Contemplation (sometimes referred to as chronic contemplation ). These individuals often lack the confidence and commitment they need to make the behavior change. Patients in Contemplation likely will agree with you that change is important and would be helpful, but they’ll also list many barriers to changing. Health professionals sometimes misclassify contemplators in Preparation because of their interest in changing. Remember desire to change does not equal intention or readiness to change. Patients in Contemplation might say, “Yes, I need to get more physical activity. I’ll start taking walks once the weather breaks,” or “I want to quit smoking. I know how bad it is for my health and the health of my family.” Those patients might initially appear engaged and ready, but later in the chapter, we’ll describe how to appropriately stage and engage them.

Preparation

Individuals in Preparation are seriously intending to make a behavior change within the next 30 days and have already begun to take small steps toward the goal. They identify more pros to changing than cons, and they are confident about their plan to make a change. Patients in Preparation are ideal program participants for action-oriented programs like Weight Watchers or nicotine replacement therapies. These are the easiest patients to engage as they are ready to make a change. We’ll review later the important strategies to utilize toward engaging them in treatment so as to increase movement to Action.

Action

Individuals in Action have adopted a health behavior change within the last 6 months and are actively using strategies to maintain the change. At this point, the new behavior takes a good amount of effort and they may experience a strong urge to revert back to the old behavior. Unfortunately, relapse tends to be the rule rather than the exception. The good news is that after a slip, it’s typically easier to get back on track to Action than when making the initial change. Patients in Action need continued engagement to support and reinforce their change efforts and prevent relapse.

Maintenance

Individuals in Maintenance have been able to sustain Action for at least 6 months and are actively striving to prevent relapse. Those individuals are characterized by higher self-efficacy and improved coping skills. Traditional programs tend to exclude those in Maintenance; however, patients in Maintenance can benefit from reinforcement, boosts in self-efficacy , and continued support to prevent relapse.

Beyond Stage of Change: Other Important Change Variables

An individual’s stage of change has important implications for selecting engagement and treatment strategies and messaging. Other constructs of the TTM , including decisional balance, self-efficacy, and processes of change, can be leveraged to facilitate engagement and progress. Figure 3.2 depicts for each stage of change which of these constructs are most important to be addressed.

Fig. 3.2
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Processes of Change

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Decisional Balance

Decisional balance represents an individual’s relative weighing of the pros (benefits) and cons (drawbacks or barriers) of changing (Velicer, Diclemente, Prochaska, & Brandenburg, 1985). A meta-analysis across 48 behaviors demonstrated a replicable and robust pattern of how the weighing of the pros and cons shift as individuals progress through the stages of change (Hall & Rossi, 2008). Research also found that raising the pros is twice as important as reducing the cons, as successful changers tend to increase their pros by double the amount that the cons decrease. In Precontemplation the cons outweighed the pros, by the middle stages the pros surpassed the cons, and by the Action stage the pros outweighed the cons (Prochaska, 1994). Examples of the pros of changing a health risk behavior might be: feeling better, having more energy, or being a good role model. Examples of the cons of changing a health risk behavior might be: it’ll take too much effort, I don’t have the time, or I’ll feel out of place.

Self-Efficacy

Self-efficacy is the degree to which an individual believes he or she has the capacity to attain a desired goal (Bandura, 1982). Within the TTM it is operationalized as confidence to make and sustain changes or temptation to relapse in difficult situations. Self-efficacy differs systematically across the stages of change and can predict who is likely to take action and sustain positive outcomes. TTM research demonstrates that across behaviors and populations, individuals further along in the stages generally experience greater confidence, individuals further along in the stages generally experience less temptation (Diclemente et al., 1991). Identifying tempting situations is critical for relapse prevention. Given the importance of self-efficacy, it needs to be addressed early by assisting individuals in setting and achieving small goals that will build their confidence for taking on increasingly difficult challenges.

Processes of Change

The processes of change represent both the covert and overt behavior change strategies that individuals use to progress through the stages of change (Prochaska, Diclemente, & Norcross, 1992). Individuals in the early stages of change tend to reply on experiential processes of change (cognitive, affective, and evaluative techniques) and individuals in the later stages of change tend to rely upon behavioral strategies of change (social support, commitments, and behavior management techniques) (Prochaska, Velicer, Diclemente, & Fava, 1988). Research demonstrates that processes differ significantly across the stages of change. Table 3.1 lists and defines each of the processes of change.

Table 3.1 Processes of change
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The Data Don’t Lie: Using a Stage Approach Increases Impact

Before we explore how the TTM can facilitate engagement, let’s briefly summarize the supporting data. Toward comparing TTM-based approaches to non-TTM-based approaches, it’s important to appreciate that the impact of treatment is a combination of both the participation or engagement and the efficacy (Velicer & DiClemente, 1993). This is represented by the following equation: Participation × Efficacy = Impact.

In this section, we’ll review how the stage approach facilitates both participation and efficacy, thereby producing more meaningful impact on overall patient populations.

TTM -based approaches result in increased participation and engagement because they appeal to the whole population rather than just the minority ready to take action. TTM research across many behaviors and populations has demonstrated repeatedly that only a minority of any at-risk group are in Preparation (typically 20 %) with the majority in Precontemplation and Contemplation (typically 80 %) (Velicer et al., 1995; Wewers, Stillman, Hartman, & Shopland, 2003). Yet, most behavior change messaging and treatments are action-oriented and assume readiness to participate. Such methods engage just the 20 % or so of people who are ready to change and mis-serve the majority of at-risk people who are not prepared to take action. With this information at hand, it isn’t surprising that the average participation of health promotion programs is quite modest with one worksite health promotion review of 59 studies finding a median retention rate of 57 % (Soler et al., 2010), while TTM -based programs often achieve greater than 80 % participation (Prochaska, Velicer, Fava, Rossi, & Tsoh, 2001). TTM approaches engage whole populations because they are perceived as more respectful, relevant, engaging, and appealing, thereby reducing resistance and reactance among early stage individuals. By using a stage approach, more people are engaged, which is a critical factor toward population-based impact.

Consider this example: You have a patient who is middle aged, overweight, has elevated blood sugar levels, and a family history of diabetes . You’ve diagnosed the patient as prediabetic. You know the patient needs intensive lifestyle changes and support to reverse the path toward Type II Diabetes . It may seem logical to recommend the Diabetes Prevention Program at the local hospital, as that is an evidence-based national program for improving lifestyle, losing weight, and reversing elevated blood sugar. Diabetes Prevention Programs entail 6 months of personalized coaching, group sessions, and structured exercise, and another 6 months of monthly meetings (Knowler et al., 2002; “The Diabetes Prevention Program,” 1999). For which stage do you think this program is best suited?

The Diabetes Prevention Program would be ideal for someone in Preparation. But, what if your patient is in Precontemplation? Do you think someone not intending to change would be willing to make such an intensive time commitment? This example elucidates why it’s important to know the stage of readiness of your patients, and to engage them in a treatment matched to their readiness. Perhaps a better initial engagement strategy for someone in Precontemplation is to ask if they’d be willing to meet with a diabetes educator to learn more about prediabetes and their risk factors. Such an engagement strategy can work to increase their awareness of their health risks and potentially move them to Contemplation. If they agree to see the diabetes educator, that step might even prepare them to be ready for engagement in the Diabetes Prevention Program. A stepped-care approach is critical toward matching treatments based on stage of change.

It’s important to communicate upfront that the goals you set with your patient will correspond with where they are in the change process. By doing so you not only will engage more early stage individuals, you also will keep them engaged on an ongoing basis. In a current randomized clinical trial of a mobile health program for risky drinking adults, we’ve been able to retain 70 % of the proactively recruited at-risk sample 12 months later because we engaged them with messages matched to their readiness to change (Mauriello, 2014). During the initial engagement, we worked to reduce resistance and reactance among high-risk drinkers in Precontemplation with such messaging:

“This program is not about asking you to stop drinking alcohol. It’s about helping you make the best choices about alcohol use in your life. This program is designed to help whether you:

  • Drink alcohol every day, every week, or once a month

  • Are thinking about cutting back on alcohol or not

We're not pushing you to make any changes. Our goal is to respect where you’re at and develop a personal plan that works for you.”

Consider your own typical engagement messaging and treatment prescriptions. How matched are they to level of readiness to change?

TTM -based approaches can accelerate rates of behavior change. While, action-oriented programs may do well to help those ready to change, their impact is limited to the small percentage of people who are ready to change. By using a stage approach we not only increase participation, we also increase the likelihood that individuals will eventually take action. Research demonstrates that helping participants move forward at least one stage of change (such as moving from Precontemplation to Contemplation) can as much as double the likelihood that they will move to the Action stage in the next 6 months. Helping them move two stages can triple their chances of taking action (Prochaska et al., 2001). This information leads us to reconceptualize success as stage progress rather than taking action. This reconceptualization is often reported by health professionals working to integrate a stage approach as the biggest shift in their perspective. By conceptualizing success as progress, you and your patients have the opportunity to appreciate change and success incrementally, while at the same time increasing the likelihood that they will reach the long-term desired outcomes.

TTM -based approaches are more efficacious. A large body of literature supports the increased efficacy of stage-matched programs over action-oriented and one size fits all interventions. Meta-analyses conclude that tailoring on TTM constructs produces greater impacts than tailoring on most constructs of other behavior change theories (Krebs, Prochaska, & Rossi, 2010; Noar, Benac, & Harris, 2007). TTM-based treatments have been found effective across dozens of behaviors and populations (Evers et al., 2006; Johnson, Driskell, Johnson, Dyment, et al. 2006; Johnson, Driskell, Johnson, Prochaska, et al. 2006; Johnson et al., 2008; Levesque, Ciavatta, Castle, Prochaska, & Prochaska, 2012; Mauriello et al., 2010), and have been found to surpass the average outcomes of other behavior change programs identified as benchmarks by a national task force (Johnson et al., 2013). Recent research demonstrates the additional impact TTM-based treatment can have on overall and specific domains of well-being (Prochaska et al., 2012).

TTM -based approaches impact multiple risks. During the last decade, several randomized clinical trials of TTM-based interventions have demonstrated the ability to impact multiple risks, even risks that were not specifically treated (Johnson et al., 2014; Johnson & Evers, 2015). This research includes areas such as adherence to antihypertension and lipid-lowering medication, weight management, and obesity prevention (Johnson et al., 2008; Johnson, Driskell, Johnson, Dyment, et al. 2006; Johnson, Driskell, Johnson, Prochaska, et al. 2006; Mauriello et al., 2010; Velicer et al., 2013). Through this research, the phenomena of coaction have been described as the increased probability that individuals who adopt one health behavior will adopt another health behavior. For example, in a randomized clinical trial of a TTM tailored weight management intervention for overweight adults, the treatment group demonstrated a 2.5–5.2 increased likelihood of success on a second behavior. The control group demonstrated a 1.2–2.6 increased likelihood of success on a second behavior (Johnson et al., 2014). Given the vast differences in probability of additional behavior change between successful changers in the treatment group compared to control, it can be concluded that this is not a naturally occurring phenomenon. Similar findings from other multiple behavior trials cumulate evidence that coaction occurs more in groups receiving tailored behavior change treatments. It can be hypothesized that by teaching individuals strategies that support the change process, they then apply those strategies successfully to other areas.

Key Principles of Using a Stage Approach to Facilitate Treatment Engagement

Let’s apply the TTM principles to the topic at hand: treatment engagement. Whether you’re a diabetes educator, nurse practitioner at a worksite clinic, family practice physician, midwife at a community health center, a registered nurse on an in-patient unit for cardiac rehabilitation, or a research scientist recruiting participants in a clinical trial on medication adherence, you likely face daily challenges in engaging patients and participants in health behavior change treatment. Using the TTM and stages of change as a framework in your interactions with patients, can provide helpful assistance in that process.

Assess Stage of Change

In order to use the stage approach, a necessary first step is identifying which stage of readiness best classifies your patient. First, we’ll review what’s entailed in assessing stage of readiness and then we’ll describe how you can accomplish the assessment.

Operationalize the Target Behavior (Action Criteria )

A critical component of assessing stage of readiness is clearly operationalizing the target behavior and action criteria. This can be thought of as what one would be doing if they were in Action. Sometimes that’s an easy step. For example, the action criteria for smoking cessation are not smoking . Sometimes, the behavior might have multiple criteria. For example, the national guidelines for getting enough exercise includes a specific level of moderate-level and/or vigorous-level aerobic activity combined with strength training. Whenever possible, it’s best to use national guidelines for the definition of the target behavior’s action criteria.

Assess Stage of Readiness to Do a Behavior Not Meet an Outcome

Another important consideration when identifying stage of readiness is assessing readiness to engage in a behavior and not to meet an outcome. It’s not appropriate to stage on readiness to lose weight or lower their A1C. Those are outcomes that you’ll monitor. It’s important to stage on specific and concrete action criteria.

Assess Stage of Readiness for All Relevant Health Behaviors

In areas such as weight management or diabetes management, there certainly may be multiple behaviors that are important to assess and treat. While multiple behavior change is a challenging area, as described earlier the TTM has been used to successfully change multiple behaviors and reduce multiple risks. It’s important that you understand your patient’s readiness to do each of the relevant healthy behaviors. You’ll be able to use that information to set appropriate goals and treatment plans.

For example, consider you’re working with a patient with hypertension (let’s pretend this patient is of normal weight so weight management is not an issue). Upon diagnosis, you may want to know if they smoke, if they drink alcohol heavily, if they are sedentary, if they have a high consumption of sodium in their diet. The patient reports smoking, very little physical activity, but reasonable levels of sodium and alcohol consumption, There are two health risks that you’ll want to understand their readiness to change (smoking cessation and physical activity). But, you also plan to prescribe an antihypertension oral medication. You’ll also want to know their readiness to take the medication as prescribed.

To begin with, you’ll want to assess their readiness to quit smoking , to get at least 150 min of moderate exercise each week, and to take their newly prescribed medication according to your instructions. Upon understanding their readiness, you can use that information and your clinical judgment to set goals and identify treatment plans. In working with multiple risks, it’s often beneficial to prioritize the at-risk behavior that the patient is most ready to change. If someone is in the Preparation stage , you can set goals and offer treatment options that will likely help them fairly quickly reach action. Upon making that successful behavior change, they will have a success under their belt and likely will have increased confidence and skills to make additional behavior changes. However, at times your clinical judgment might require addressing a critical behavior for which they are in an earlier stage of change. For example, you may need to focus in a stage-appropriate way on insulin adherence with an uncontrolled diabetic or smoking cessation with a heart failure patient or a pregnant woman because of the timely and critical nature of the condition.

Assessment Options

There are several options by which stage of change can be assessed in clinical and research settings. For many health areas reliable and valid assessment tools have been developed and can be found in published articles or online and available in the public domain. Other times measures can be licensed through the companies that developed them. To gather a complete assessment of patient health risks, Health Risk Assessments and Interventions can be licensed and incorporated within your patient portal or electronic medical software. A list of companies with Health Risk Assessments certified by the National Committee for Quality Assurance (NCQA) can be found at http://www.ncqa.org/. Using certified assessment tools offers the most reliable and consistent way to monitor and report patient health behaviors and risks longitudinally. For those without the resources to implement standardized protocols, providers can administer staging questions during their patient interview. In doing so, it’s important to identify a specific and well-defined behavior and to ask their intention to do the behavior according to this sample:

  • Do you intend to {insert action criteria}?

  • No I don’t intend to do so in the next 6 months (Precontemplation).

  • Yes, I intend to do so in the next 6 months (Contemplation).

  • Yes, I intend to do so in the next 30 days (Preparation).

  • Yes, I have been doing so for less than 6 months (Action).

  • Yes, I have been doing so for more than 6 months (Maintenance).

Use Stage-Matched Communications

Once you’ve identified the action criteria and understand your patient’s intention to do the action criteria, the next step is to use that knowledge to target your engagement strategy. You can be empowered to be proactive and reach entire populations—not just those ready to change. To be successful, approach engagement as a process that is inclusive, empathetic, respectful, and optimistic. Below are guidelines for considering the patient perspective and approaching engagement by stage of change.

Precontemplation

Patient perspective

Approach to Engagement

• Not ready to change/not intending to change

• May experience change as coerced

• Might feel defensive, demoralized, or reluctant

• May respond with denial, reactance, or resistance

• Under or unaware of problem

• Identifies many cons to changing

• Under-recognizes benefits to changing

• Engage them in the change process

• Use motivational interviewing techniques (e.g., open-ended questions, reflection)

• Avoid lectures or confrontation

• Increase awareness of the problem

• Discuss benefits of changing

• Move them emotionally based on current and future consequences of the unhealthy behavior

• Encourage movement to Contemplation

• Suggest less intense treatment options

Contemplation

Patient perspective

Approach to engagement

 • Aware that problem exists

 • Expresses some interest in changing eventually

 • Recognizes benefits to changing

 • Marked by ambivalence

 • Acutely aware of the cons or barriers to changing

 • Lacks commitment to change

 • Lacks confidence to change

 • Might feel stuck—not sure how to make progress

 • Resolve ambivalence so pros outweigh the cons

 • Help problem solve around significant cons perceived by patient

 • Reinforce benefits to changing (the longer the list the better)

 • Encourage self-reflection of own current behavior and patterns

 • Encourage reflection of how self-image would improve if behavior changed

 • Don’t encourage action

 • Encourage small steps

 • Interventions can involve some level of demands (but still low intensity)

Preparation

Patient perspective

Approach to engagement

 • Intending to make a change in the next month

 • Preparing to act

 • Has taken some small steps

 • Recognizes more benefits than cons to changing

 • Expresses commitment to change

 • Has confidence in ability to change

 • Developing a plan toward meeting action criteria

 • Goal is to encourage, excite, and empower patient

 • Provide support

 • Create an action plan that includes start date and steps to action

 • Ensure patient has necessary support systems

 • Encourage reflection on how self-image will change

 • Problem-solve any barriers to change

 • Provide examples and inspiration of successful changers

 • Refer to more intense action-oriented treatment options

Action

Patient perspective

Approach to engagement

 • Recently made a behavior change

 • Still actively working (giving time and energy) to sustain the change

 • May experience strong urge to revert back to old behavior

 • Identifying difficult times to stay adherent

 • Slips and recycling to earlier stage common

 • Support action

 • Provide praise and recognition

 • Communicate that sustaining action takes effort and commitment

 • Encourage coping skills to handle urges to slip

 • Ensure patient recognizes rewards associated with the new behavior

 • Ensure their environment and routine support lasting action

 • Assist with strategies to prevent relapse

 • Intense treatment options still appropriate

Maintenance

Patient perspective

Approach to engagement

 • Maintaining a behavior change for at least 6 months

 • High confidence

 • High commitment

 • Slips still can happen

 • Experience fewer temptations to slip back

 • Risk for relapse highest during times of distress

 • Understand that change is dynamic and slips are the rule not exception

 • Consult on challenge of ongoing doing the healthy behavior

 • Focus on relapse prevention

 • Ensure good coping skills for times of distress and ongoing stress management

 • Assist with keeping confidence high

 • Create plan for dealing with distress

 • Encourage patients to learn from slips and plan accordingly

Call-Out Box:

Using a Stage Approach for Recruitment Messages

When introducing or advertising a health behavior treatment , it’s important that recruitment messages are representative of all stages or specific to a stage of readiness. Be cautious of action-oriented wording. Typical recruitment messages assume readiness and interest in changing. Here are some examples of promotional materials grounded in a stage approach:

If using one message to appeal to people across the stages:

Whether you’re ready, getting ready, or not ready….This program can help you. Wherever you are at, we can work with that. ™ This program provides guidance based on your readiness for making lifestyle changes.

If using stage-matched materials specific to a stage:

For Precontemplation:

Not ready to quit smoking? We hear you and we can help. This program is designed to help you at your pace, when YOU are ready.

For Preparation:

Ready to quit smoking? This program offers the help you need to succeed.

Assist in Stage Appropriate Way

Part of your engagement strategy should include assisting with a stage appropriate goal or treatment plan. Table 3.2 lists some examples of stage-matched patient goals applied to exercise behavior. Just as your engagement strategy and treatment goals should be sensitive to stage of readiness, so should the treatment options and next steps. Stage of readiness and TTM principles of change should drive the design of behavior change programs. Programs need to be appropriate for patients in all stages of change or prescribed to those for whom it is relevant. TTM-based computer-tailored interventions are one option of health behavior counseling that is appropriate for all patients because the programs are individualized based on their stage of readiness for specific target behaviors (for more information refer to http://www.prochange.com/myhealth-lifestyle-management). To see a demonstration of such a program, go to www.prochange.com/exercisedemo. Before referring patients to a treatment resource, consider how relevant and helpful the program will be given their intention to change. Remember that action-oriented programs such as weight loss programs or nicotine replacement products should be limited to those who are ready to change. In deciding if a program is suitable for someone in early stages of change, consider the intensity and demands, the goals, and the communication style of the program. Joining an online support group around a specific health behavior or condition is an example of a low intensity, low demand, and convenient means to engage someone in Precontemplation or Contemplation .

Table 3.2 Example stage-matched goals for exercise
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Follow-up is an important aspect to assisting and engaging patients in health behavior change. When resources allow, it’s ideal to follow up regularly to assess progress with goals. Follow-up touch points can be matched to readiness to change, with those in Preparation and Action requiring the most frequent follow-up. As patients progress through the stages of change, be sure to alter your recommendations based on their stage movement.

Conceptualize Success as Progress

As mentioned in the introduction, an important component to implementing a stage approach is re-conceptualizing success as progress rather than action. Actually doing the target behavior to criteria is a measurement of success for those in Preparation, Action, and Maintenance. That is not a reasonable goal for patients in Precontemplation and Contemplation. Instead, a patient progressing to the next stage of change is a measure of success. Helping patients move forward at least one stage of change (such as moving from Precontemplation to Contemplation ) can as much as double the likelihood that they will move to the Action stage in the next 6 months. Helping them move two stages can triple their chances of taking action (Prochaska et al., 2001). By re-conceptualizing success as stage progress rather than taking action, we are given opportunity to praise, appreciate, and endorse progress as metrics of change. At times incentives are used as a way to promote participation in health promotion activities. It’s also reasonable to offer incentives to those in early stages for meeting stage-matched goals and for making stage progress. By recognizing progress, you can help your patients engage and embrace the change process.

Conclusions

After reading this chapter, hopefully you feel more enlightened, empowered, and prepared to incorporate a stage approach in your work. Recognizing the unique needs of individuals in early stages and re-conceptualizing progress as movement to the next stage can assist in significantly increasing the impact of your engagement with patients. Those who seek additional guidance can participate in an e-Learning module developed on using the TTM for coaching (details at www.prochange.com/e-learning) or refer to Mastering Change: A Coach’s Guide to Using the Transtheoretical Model with Clients (“Mastering Change,” 2001). Decades of research on and implementation of the TTM in clinical, worksite, research, community, and digital settings provides replicated evidence of the utility of the Model to engage, effect, and impact health behavior change. Health professionals who have implemented the Model report great success and satisfaction both in their interactions with patients and their ability to effect change. Embracing a stage approach can be quite powerful and lead to systemic changes in how organizations approach patient interaction, behavior change programming, and metrics of success. There are many benefits integrating a stage approach to patient engagement including:

  • Prepares you to communicate and work with entire populations wherever they are in the stages of change.

  • Helps you to increase engagement and reduce resistance among your patients.

  • Allows you to see and appreciate how your patients are making progress in stages.

  • Enables you to set stage-matched goals with patients.

  • Empowers you to offer and prescribe behavior change programs that are stage appropriate or population-based.

  • Teaches you the principles and processes of change that are applicable across all health behaviors.

  • Shows you an approach that’s successful at increasing engagement, increasing health behaviors, reducing multiple risks, and enhancing multiple domains of well-being and productivity.

With the knowledge and tools needed to move forward, we end with a final question for your consideration.

How ready are you to integrate a stage approach in your work?

  1. 1.

    I don’t intend to integrate a stage approach in my work in the next 6 months.

  2. 2.

    I intent to integrate a stage approach in my work in the next 6 months.

  3. 3.

    I intend to integrate a stage approach in my work in the next month.

  4. 4.

    I have been integrating a stage approach in my work for less than 6 months.

  5. 5.

    I have been integrating a stage approach in my work for more than 6 months.

Use your readiness to guide your next steps.

  1. 1.

    If you’re in Precontemplation , look for more information on using a stage approach and consider how your work, your patient interactions, and your colleagues might benefit by adopting a stage approach.

  2. 2.

    If you’re in Contemplation , learn more about using a stage approach by talking with others who use it and seeking additional training in the approach, identify what barriers might be in the way and consider ways to overcome them, and feel inspired by how the stage approach has helped others to more successfully engage patients.

  3. 3.

    If you’re in Preparation , make a commitment to begin using a stage approach and share that commitment with others, build your confidence by role playing or practicing the approach with patients, and ask colleagues to support and assist your efforts, and notice the benefits.

  4. 4. or 5.

    If you’re in Action or Maintenance , keep this chapter and other training materials visible to make it easy to use a stage approach, appreciate the benefits it offers you and your patients, and boost confidence by using the approach even with resistant patients.