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Chapter 6

Health Sciences 4202A/B Chapter Notes - Chapter 6: Transtheoretical Model, Health Promotion, Decisional Balance Sheet

Health Sciences
Course Code
HS 4202A/B
Tamara Thompson

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Chapter 6 Stage Models for Health Promotion
Stage theories share the same underlying principles and assumptions as valueexpectancy theories, but
they are distinguished from these theories by suggesting that change occurs as a result of individuals
passing through a series of sequential stages that culminate either in the elimination of a health-risk
behavior (e.g., smoking) or the long-term adoption of a health-protective behavior
Characteristically, these theories suggest that an individual’s trajectory through a hierarchy of stages is
dependent on the successful completion of the tasks of the previous stage in order to achieve lasting or
durable behavior change
- The eloquence of stage models is that they allow intervention programs to be matched or targeted
to a particular stage, meaning that the objective is to intervene “where people are” in the behavior
change continuum and move them one step (one stage) closer to lasting behavior change
This type of approach to behavior change implies that a single intervention is not be the optimal
approach to promoting behavior change across any given population
- This is the case because people comprising a population are typically distributed across the
spectrum of stages (i.e., people are “located” at different points on the change continuum)
- To be most effective at facilitating behavior change, stage theories recommend that interventions,
be “matched” to an individual’s specific stage of change
This targeted approach maximizes the likelihood that the intervention can facilitate
moving individuals from their current stage to the next one
Stage theories also assert that asking individuals to move one stage forward will be more acceptable
and more efficacious in the long run than asking them to simply take action (change their behavior)
regardless of their level of readiness of change that specific behavior, which is characteristic of most
traditional action-oriented programs
Matching intervention constructs to an individual’s stage of change can optimize the potential for
progress to the next stage and, working systematically, to higher stages, until achieving lasting
behavior change
There are two stage theories that predominate in health-promotion research and practice: the
Transtheoretical Model of Change (TMC) and the Precaution Adoption Process Model (PAPM)
- Both theories have been used successfully to change a diverse array of health behaviors, either
facilitating the elimination of health-risk behaviors or the adoption of health-protective behaviors
- The TMC, however, was the original stage theory in the field of health promotion and it has been
used significantly more often than the PAPM to provide the theoretical foundation guiding a
range of health-promotion interventions
Key Concepts
Origins of the Transtheoretical Model of Change
The TMC is a model of intentional behavior change that describes the phases that people go through
(stages of change) and the mechanisms that people use (processes of change, decisional balance,
efficacy) when they adopt or modify new health-promoting behaviors or eliminate old health-risk
This model provides a description of how people change their behaviors.
The TMC integrates processes and principles of individual-level behavior change from across major
theories of psychotherapy, hence the name transtheoretical.
- James O. Prochaska and his colleagues have noted that the intellectual impetus for developing the
TMC was “the lack of an overall guiding theory, the search for the underlying principles, the
growing acknowledgement that no single therapy is more ‘correct’ than any other, and general
dissatisfaction with their often limited approaches”
- Thus, this model emerged from a comparative analysis of leading theories of psychotherapy and
behavior change.

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- The comparative analysis identified 10 processes of change among these theories, derived from
psychological approaches developed by prominent theoreticians such as Freud, Skinner, Rogers,
and others
The Stages of Change
The TMC, like all theories and models of health promotion, is predicated on a set of core assumptions
or principles of how people intentionally change their behavior
Understanding these assumptions can be valuable in selecting a theory to guide a particular behavior
change intervention
The TMC originally assumed six sequential stages through which individuals proceed to affect lasting
behavior change
However, further refinements of the model often omitted the last stage, termination, as this reflected
its origins in the field of psychotherapy and applied mainly to addictive behaviors. The five stages of
the TMC are: precontemplation (PC), contemplation (C), preparation (PR), action (A), and
maintenance (M)
- The sequence of stages is important, because it represents the progression that describes how
people change
- The explicit goal of health promotion becomes one of moving people successfully through the
stages until they ultimately achieve maintenance
- Each stage has its own set of unique challenges, thus any intervention program can more
appropriately be construed as being, in reality, four programs rather than one.
- This is the stage in which people have no intention to take action in the foreseeable future (usually
defined as within the next 6 months)
- People may be in this stage because they are uninformed or under-informed about the

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consequences of their behavior, they may have tried to change a particular behavior a number of
times and have become demoralized about their capability to change, or they may not even
recognize that they need to change a particular behavior
- Both uninformed and under-informed groups tend to avoid reading, talking, or thinking about
their high-risk behaviors
- They are often characterized in other theories as resistant or unmotivated individuals or as “not
ready” for health-promotion programs.
- Cognitive processes
- The challenge of this stage is to arrive at an affirmative resolution to adopt a health-protective
behavior or to eliminate a health-risk behavior
This resolution is the impetus for personal intent to change behavior in the near future
- One especially valuable construct for this stage is known as decisional balance, which represents
a mental weighing of the importance of the pros and cons associated with changing behavior
- Successfully passing through higher-level stages results in a reversal of this initial relation of pros
to cons, meaning that the pros will become relatively more important in
Reversal of this initial relation of pros to cons, meaning that the pros will become
relatively more important in comparison to the cons
- Clearly, implications for behavior change interventions are based on: (1) enhancing perceptions of
the advantages of changing behavior, and (2) minimizing perceptions of the barriers to adopting
these behavior changes
- People intend to adopt a new behavior in the immediate future, usually defined as within the next
month. They may have already taken some steps in preparation to change their behave
- A primary assumption of this stage is that lasting change will require some combination of skills
and resources, both of which take time to acquire
- People have made specific overt modifications in their lifestyles within the past 6 months
- Behavioral change has often been equated with action; however, not all behavioral changes
qualify as action
- People must achieve a level of behavior change that scientists and professionals agree is sufficient
to reduce the risk of disease.
- Regardless of the behavior, the action criterion should reflect the degree of behavior change that
is significant from a public health (epidemiological) standpoint to reduce the risk of adverse
health outcomes or, conversely, enhance the likelihood of improved health outcomes
- In this final stage, people still work to prevent relapse, but they do not need to apply change
processes as frequently as do people in the action stage
- They are less tempted to relapse and increasingly more confident that they can maintain their
behavior change
- Typically, maintenance of behavior is defined as sustaining that specified behavior for 6 months
or longer
Movement Across the Stages of Change
The spiral model reflects the principle that behavior change is neither a binary, all-or-nothing
phenomenon, nor a unidirectional, linear process
- A key underlying assumption of the TMC is that the amount of time that an individual is in a
particular stage varies greatly within and across populations and across various behaviors
- However, because behavior change may not be linear for any individual, individual paths across
the stages can be highly variable, including relapse to earlier stages and/or re-cycling through the
The TMC was originally developed to aid people in their efforts at smoking cessation and, as you
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