A Critical evaluation of the Transtheoretical model of health behaviour change in light of my own experience of exercise behaviour change.
“Morbidity and mortality in industrialized societies is due, in part, to individual patterns of behaviour” (Bridle 2004). Individuals contribute to their own health by avoiding health damaging behaviours such as smoking, and by adopting health enhancing behaviours such as exercise or healthy eating. There are many heath interventions in place to help people make positive lifestyle changes, and these interventions are commonly based on stage theories/models of behaviour change, providing a diagrammatic approach and a framework for research, in order to understand, predict and ultimately change behaviour (Bridle 2004 pg284). Behaviour change is seen as a dynamic process involving movement through a sequence of discrete qualitatively distinct stages, and commonly stage based interventions are more effective then non-stage based interventions (Adams and White 2005). However, recent research into the effectiveness of stage based models suggests that despite the widespread popularity in both practice and research, more caution is necessary (see Bridle et al 2004 for a review).
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For the purpose of this project I chose to adopt a healthier lifestyle by increasing the amount of exercise that I did each week. The benefits of exercise are well documented (Department of health 2004) and for the purpose of this study I set a target of exercising three times a week (this is around three times as much as I previously exercised) and I did this for a six week period. I began by jogging for as long as I could manage three times a week, but after the first two weeks I realised that I was lacking motivation, so instead I joined the gym, and continued my regime with the better facilities provided at the gym and monitored my progress in the form of a diary. In the forthcoming essay I will evaluate my experience in light of models of health behaviour change, but more specifically the Transactional model of health behaviour.
There is no overall consensus regarding which is the best model of behaviour change but The Transtheoretical model (TTM) (Prochaska & DiClemente, 1983; (also known as stages of change model) Prochaska, DiClemente & Norcross, 1992)) is commonly considered the dominant model of behaviour change in health Psychology (Norman et al 2000). The TTM of health behaviour suggests that behaviour change is not a continuous process but something that occurs through a series of qualitatively different stages (Bridle et al pg284). It suggests a total of five stages that people go through when experiencing a behaviour change and in addition to these five stages, ten social and psychological aspects of health behaviour and different self-change strategies, the so-called ‘processes of change', that are involved in the movement between different stages (Prochaska et al 1997). Different stages are associated with different beliefs such as the assessment of the ‘pros' and ‘cons' of the behaviour and self-confidence in ability to change the behaviour. Prochaska et al (1997) argue that interventions to promote change should be designed so that they are appropriate to an individual's current stage and moving an individual from one stage to another using the TTM will eventually lead the person to achieve the ‘maintenance' whereby long term change is achieved.
The Transtheoretical model provided me with a great insight into my motivational behaviour and the factors that affected my motivation within each stage. For example, the transition between ‘contemplation' and ‘action' only occurred when I re-located my exercise behaviour to the gym, as described in the TTM, I required environmental re-evaluation and consciousness raising (provided by staff at the gym) before I could move to the ‘action stage'. However, motivation was a serious problem, even when I was regularly exercising (weeks 5 and 6) my motivation would fluctuate or increase on a whim, my mood was a strong motivating and de-motivating factor and often other factors such as work, money and other commitments would take priority. These factors can be placed within the ‘decisional balance' when weighing up the pros and cons, for example in the third week when I had a lot of university work to do, my exercise was less important which is why I moved from ‘action' to ‘preparation' then back to ‘action', and according to the TTM other factors such as self-efficacy and situational temptations may have also had an influence on my mood and exercise behaviour. However, this was not always the case and my behaviour was not always as structured or as cognitively coherent as the TTM describes. Even with support from peers to do more exercise and no reason not to do exercise, I was still not motivated to actually do it, suggesting that my behaviour did not always follow decision making rules such as the pros and cons of exercise behaviour that TTM proposes. West et al (2005) provides commentary on this by suggesting that by focussing on conscious decision making and planning processes draws attention away from what are known to be important underpinnings of human behaviour (West et al 2005). Even if my behaviour was accountable under the ‘processes of change' it still remains that on some occasions these processes were not apparent to me, I simply did not want to do exercise and I easily fell into my old routine of no exercise. This however did lead to ‘regret' which in turn motivated me. Sometimes I would chose not to do exercise and regret not doing it, then feel motivated by regret at a later date, it may be worth incorporating the Regret Theory (Bell 1982) into TTM as part if the ‘decisional balance'.
Another problem that I found with the TTM was that I felt that my behaviour was not always ‘stage specific' and I at times I felt as though I was in both ‘pre-contemplation' and ‘action' stages at the same time. However as Sutton et al (1991) observed if one can be in more than one stage at once, “the concept of stages loses its meaning” (p.195). It is a bold suggestion to make when analysing a widely used model, and research into the evidence for qualitatively different stages has provided mixed outcomes. Prochaska & DiClemente claim strong empirical support for the stages of change across a wide range of populations and problems (Prochaska, DiClemente, Velicer, & Rossi, 1992; Prochaska & Velicer, 1997; Prochaska, Velicer, et al., 1994; Velicer, Hughes, Fava, Prochaska, & DiClemente, 1995; Velicer, Rossi, Prochaska, & DiClemente, 1996). However a review of stages of change literature (Littell & Girvin, 2002) has provided mixed results regarding the validity of the qualitatively distinct stages. Identifying a person stage is a fundamental step in applying stage-based interventions, but few staging methods have been validated to confirm that they accurately place the individuals in the correct stage of activity change (Adams, 2005). Not only this, researchers often adapt and change existing algorithms when they are not comfortable with the existing one (Brug, 2003). Littell's review provides evidence for and against SOC, from a variety of studies using factor analysis and/or cluster charts to reveal patterns of behavioural intention. The studies provided mixed results; Carey et al (1999) found that “the number of identifiable clusters is sample dependent and highly variable” and that some clusters “do not have clear correlates in the Transtheoretical Model” (p. 251), however a separate review (Davidson 1998) found “clear profiles corresponding to the predicted stages emerged with considerable consistency” (p. 27). This mix match of results lead Littell at al to conclude; with the exception of pre-contemplation “stages do not emerge with any consistent manner, in principle components within problem behaviours, and rather then being in one stage or another clients show patterns of differential involvement in each of the stages” (Littell, 2002). This lends support to my personal experience of SOC with regards to exercise behaviour, suggesting that the distinct stages of behaviour change identified by Prochaska et al may not be as accurate as they had originally proposed and without an accurate measurement tool, stage based interventions are of limited utility.
The application of stage based interventions to exercise has provided some positive results for short term behaviour change, however little research has found support for the long term benefits of stage based interventions in behaviour change. This has been a topic of much debate over recent years, and a review by Adams and White lead to three main reasons why this may be. The aforementioned problems with validated staging algorithms are noted in Adams et al's research, but also the complexity of physical activity, and the possibility that the real determinants of activity change are not included in the Transtheoretical model. Adams et al suggest that the exercise behaviour is not a single behaviour but actually a complex set of behaviour patterns. By reducing exercise behaviour down to one single entity interventions are failing to measure a whole behaviour, rather a part of a behaviour. Marttila et al, for example, identified five different categories of physical activity (occupational activities, fitness activities, life style activities, commuting activities, and sports activities), and peoples pro's cons and self efficacy beliefs were different for each behaviour. In my case, I had pro's associated with going to the gym during my behaviour change but I did not have pro's associated with walking to work every day (occupational activities), or going dancing through the night (life style activities), these behaviours do however constitute as physical activity, I was trying to increase my fitness activities and not taking into account any occupational or life style activities. Unlike smoking or substance use, exercise behaviour is multi-faceted and by failing to recognise this, investigators may be failing to recognise the true complexity and specificity of interventions required to promote activity (Adams et al), not only this, it may explain, in part the problem of validating the stages because people are falling into two groups of behaviour change for different behaviours. Adams et al also suggest that motivational factors for exercise behaviour are more complex then TTM can account for, factors such as age, gender and socioeconomic position, these factors all have an effect of our behaviour but why not behaviour change? A study by Kearney et al (1999) looked at stages of change over a nationally representative sample and found that TTM was effective in identifying stage and attitudes towards exercise behaviour but there was considerable ‘intercountry' and ‘sociodemographic' variation in the distribution of stages of change. They concluded by suggesting that targeted programmes aimed at specific subgroups might be more effective in promoting physical activity.
From this brief introduction to TTM research, and in light of my own behaviour change it would appear that TTM and other stage based interventions targeting exercise behaviour have a long way to go before they can significantly aid long-term behaviour change. I believe that the TTM provided me with a good insight into motivational elements my own behaviour change, however, in my opinion the spontaneous nature of my desire to/not to take part in physical activity did not always fall into the features described in the ‘processes of change' or ‘decisional balance'. My experience showed that consciousness raising and environmental evaluation had a part to play in stage movement, which allowed for a successful short term behaviour change, but I am not convinced that my behaviour was always stage specific. As mentioned by Bandura ‘human functioning is simply too multifaceted and multi-determined to be categorized into a few discrete stages' (Bandura, 1997 pg8) and research has provided evidence to suggest that the staging process may not be validated, confirming my experience of stages of change (TTM). Possible suggestions for the future of TTM are as follows: West et al argues that interventions should revert back to the simplistic supportive role that GPs took before stage based interventions were devised, focussing on desire to change as opposed to stages (West 2005) and Littell et al (2004) argues for a feedback system whereby stage based groups are coupled with discussions about motivation to change. In my opinion, further research is needed in to tailored behaviour interventions, and/or like Littell et al suggests coupling TTM with a personalized interview suitable for long term behaviour change.
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