Health promotion, health maintenance, and health restoration all depend on individuals completing certain behaviors that are well known to contribute to those goals. Healthy lifestyle habits of exercise and good nutrition, smoking avoidance or cessation, and stress management are building blocks of good health. For many older adults, more specific health behaviors such as following a special diet or taking prescribed medications as directed are other important health behaviors that play a critical role in health restoration. It is often the nurse's role to educate clients and assist them in changing their behaviors to ones that are more health promoting. This can be difficult and frustrating for nurses. Even after the best education, clients often make no change or practice the healthy behavior for only a short time, then revert back to their previous unhealthy patterns. A new approach is needed. The purpose of this article is to present the Transtheoretical Model (TTM) of behavior change as an effective and readily applicable model for promoting healthy lifestyle changes in older adults.
It is a widely perpetuated myth that it is too late for older adults to benefit from changing their lifelong unhealthy habits. Healthy lifestyle habits of good nutrition, regular exercise, stress management, and smoking avoidance or cessation have been demonstrated to play a critical role in successful aging (Berg & Cassells, 1990; Rowe & Kahn, 1997). Poor health habits throughout life have been linked to increased chronic illnesses and decreased functional status in older age (Abrams, Beers, & Berkow, 1995; Black & Kapoot, 1990; Gilford, 1988). Research has documented dramatic positive effects related to increasing exercise among individuals who were sedentary (United States Department of Health and Human Services, 1996), weight loss and improvement in diet among individuals who were overweight (Gordon & Rifkind, 1989), stress management (Weinberger, 1991) and smoking cessation (Kaplan, Seeman, Cohen, Knudsen, & Guralnik, 1987; Wolf, D'Agostino, Kannel, Bonita, & Belanger, 1988; Castelli et al., 1981). With rapidly growing numbers of older people, it is especially important to educate the public that it is never too late to change to a healthier lifestyle. A key to success is the development of nursing interventions to assist older adults to make the necessary changes in behaviors. Empirical data support efforts to promote lifestyle changes among older adults.
Traditional methods used to change health behaviors primarily centered on education, had a low participation rate, and had a high recidivism rate (Prochaska, DiClemente, & Norcross, 1992). The TTM of behavior change has been presented as an integrative and comprehensive model of behavior change and an exciting alternative to traditional methods (Prochaska & DiClemente, 1983, 1985). Original work based on the TTM was with smoking cessation. Subsequently the TTM has been applied successfully to numerous health risk behaviors among all age groups (Prochaska & DiClemente, 1983, 1985). More recently, the TTM has been successfully used to understand and promote change in diet behavior (Bowen, Meischke, & Tomoyasu, 1994), weight loss (Laforge, Velicer, Richmond, & Owen, 1999; O'Connell & Velicer, 1988), low-fat diet (Laforge, Velicer, et al., 1999), decreased ultraviolet light exposure (Rossi, 1989), decreased alcohol use, (DiClemente & Hughes, 1990; Snow, Prochaska, & Rossi, 1994), stress reduction (Laforge, Rossi, et al., 1999), mammography screening (Crane et al., 1998; Rakowski et al., 1992), increased exercise (Ingledeiv, Markland, & Medley, 1998; Marcus et al., 1992; Nigg & Courneya, 1998), and genetic testing (Jacobsen, Valdimarsdottier, Brown, & Offit, 1997).
THE TRANSTHEORETICAL MODEL
The TTM initially was developed as a general explanatory model of intentional behavior change (Prochaska & DiClemente, 1983). The model is based on the premise that people move through a series of stages in their attempt to change a behavior. Five stages of change have been identified reliably across health behaviors:
* Precontemplation: no intention to change behavior in the foreseeable future or denial of the need to change.
* Contemplation: intention to change within the next 6 months.
* Preparation: serious intention to change within the next 30 days.
* Action: engaged in behavioral change at required level.
THE PROCESSES OF CHANGE
* Maintenance: sustaining behavioral change for 6 months or more. Movement through these stages may occur in a linear fashion. However, more often individuals move through the stages repeatedly in a cyclical manner before maintenance is reached.
As people progress through the stages of change they participate in overt and covert activities to alter their experiences and environments to change their behavior. These activities are called processes of change (Prochaska et al., 1992; Prochaska & Marcus, 1993). Ten processes of change have been identified as the strategies used most frequently and most successfully by people as they move through the stages. The 10 processes are divided into two higher-order factors representing experiential (where relevant information is generated by an individual's own actions or experiences) and behavioral (where the information is generated by environmental events and behaviors) processes of change (Prochaska & DiClemente, 1983; Prochaska et al., 1992; Prochaska & Marcus, 1993). The processes are defined in Table 1.
The TTM also proposes integration of the stages of change with decisional balance and self-efficacy. The stages represent a temporal dimension describing when cognitive and behavioral changes occur. Decisional balance focuses on the benefits (i.e., pros) and costs (i.e., cons) of a behavior (Janis & Mann, 1977) and is thought to be important in decision-making and, hence, in behavior change. The pros of making a healthy behavior change have been found to increase and the cons to decrease an individual's progress on the continuum from precontemplation to maintenance. Self-efficacy involves a judgment regarding one's abilities to engage in a behavior and is thought to be critical in behavior change (Bandura, 1982, 1986).
Assessing individuals' stages of change and then tailoring behavior change interventions to their stage of change has received support in several research studies. Marcus et al. (1992) found that a 6- week intervention program using written materials tailored to the stages of change increased the stage of exercise adoption for most participants. Matching interventions to all variables of the TTM, not only tailoring to stage, has been found to be effective in smoking cessation (Prochaska, DiClemente, Velicer, & Rossi, 1993). Prochaska et al. (1992) also have demonstrated that the amount of progress people make in a program is related directly to the stage they were in prior to the program. For example, one study assessed a worksite weight loss program that had an 80% dropout rate. The results suggested participants who were not in the preparation or action stage early in the program were highly likely to drop out or fail to progress. There was a mismatch between the type of program offered (i.e., action oriented) and the level of motivation of the population (i.e., precontemplation). Interventions that are mismatched to stage have been found to be less effective than stagematched interventions (Prochaska et al., 1993). Recent research by Laforge, Velicer, Richmond, and Owen (1999) found the pattern of distribution across the stages of change for five risk factors was stable. The authors concluded that interventions matched by stage may have broad application. The TTM recently has been applied to nursing. For example, Ulbrich (1999) developed a nursing practice theory of exercise as self-care using triangulation of Orem's self-care deficit theory (1995) and the TTM. This practice theory was proposed to target individuals at risk for cerebral vascular disease, and thus is relevant to the older adult population.
THE TRANSTHEORETICAL MODEL AND APPLICATION TO OLDER ADULTS
Despite a tremendous increase in use of the TTM overall, a literature review revealed that comparatively few of these studies specifically applied and tested the TTM with older adults. Clearly more research is needed in this area. Several studies specific to older adults are of interest. In one study, stage-tailored interventions combined with telephone counseling resulted in significantly higher smoking cessation rates at 3 months (Rimer et al., 1994). The tailored guide also was rated more highly, and participants in the targeted group were more likely to have quit smoking at 12 months (Rimer et al., 1994). Clark, Kviz, Prohaska, Crittenden, and Warnecke (1995) examined stages of readiness to quit smoking in a sample of older adults. This work validated that older adults are concerned about health and are able and willing to change their health behaviors. Different factors were found to be important at different stages of the smoking cessation process. A recent study investigated the stage distribution and interrelationships of 10 healthy behaviors (i.e., seatbelt use, regular exercise, avoidance of highfat foods, eating a high-fiber diet, attempting to lose weight, avoidance of sun exposure, sunscreen use, attempting to reduce stress, smoking cessation, conducting cancer selfexaminations). The majority of older adults (total N= 1,615) were found to be in either precontemplation or maintenance stages, demonstrating the need to target interventions to the precontemplation stage (Nigg et al, 1999).
The stages of change model has been applied successfully to exercise in older adults. Barke and Nicholas (1990) demonstrated that the stages of change model effectively differentiated between active and inactive older adults. Lee (1993) surveyed exercise patterns of older women and found that the stages of change related to attitudes, knowledge, and demographic variables including age. Courneya's (1995) research supported the stages of change model and found that perceived severity of the consequences of physical inactivity distinguished precontemplators from contemplators and those in the preparation stage from those in action and maintenance stages. Gorely and Gordon (1995), Courneya, Estabrooks, and Nigg (1997), and Lee (1993) provided evidence that supported the application of TTM constructs across age groups and cultures in the exercise domain. Five of the 10 processes of change, self-efficacy, and pros and cons made unique contributions to discrimination between stages for an older Australian sample (Gorely & Gordon, 1995). Potvin, Gauvin, and Nguyen (1997) documented differing prevalence rates for stages of change across rural, suburban, and urban communities, suggesting structural components are related to readiness to change. A recent review of nine studies examined older individuals using the stage of change model in the exercise domain. A major conclusion was that the same five stages of change exist for exercise in older individuals and that they can be distinguished readily (Nigg, 1999).
Figure. Questions for assessment of stages of change.
Because interventions are tailored to the client's stage of change, the stage for each client must be assessed prior to implementing any behavior change program. Questions to be used for assessment can be found in the Figure. Exercise behavior is used in this article as an example. This same format may be used to assess stage of change for any behavior by substituting the targeted behavior for exercise in these questions. It is important to define the target behavior as accurately and specifically as possible to maximize the client's understanding.
After each individual's stage of change is assessed, interventions can be tailored to the stage of change for each health behavior. The example of exercise is used in this article to demonstrate specific interventions designed for each stage. For individuals in the stage of precontemplation who do not intend to change their behavior, the goal is to increase awareness of the need to change. Processes of change that are important at this stage include consciousness raising, dramatic relief, and environmental revaluation. Nurses should provide education about the risks of not exercising along with the benefits of adopting increased activity levels. Nurses can distribute written materials providing information and research evidence about the increased risk of specific chronic illnesses for individuals who are not exercising, along with evidence about the positive benefits of exercise. This information can be specifically pertinent to illnesses common to the older population, and can include the benefits of exercise for individuals who already are experiencing some functional limitations. Fall prevention, increased mobility, and other more general health promoting benefits can be emphasized. These benefits may be included in a list of pros for exercising, with space allotted for the individual to write "What are the pros of exercising for me?". It is important for this material to be personalized by the nurse for each individual, if possible. Mutual planning for individuals in the precontemplation stage is not useful because behavior change is not yet a goal. Consciousness raising must occur first before the individual can begin to participate in the mutual planning process. Follow up after the individual has had an opportunity to review the materials is important to assess if the individual has considered changing their intention regarding exercise. If the individual is interested in change, they will have progressed to the contemplation stage, and strategies for that stage can begin.
PROCESSES AND RELATED STRATEGIES FOR EACH STAGE OF EXERCISE BEHAVIOR CHANGE
Individuals in the contemplation stage are intending to change unhealthy behavior within the next 6 months. The goal for people in this group is to increase their motivation and their self-confidence in their ability to change. The primary processes used are consciousness raising, self-reevaluation, social liberation, and self-liberation. Effective interventions for this group have several components. First, nurses may assist contemplators to identify their own pros and cons for exercising. Second, nurses may use imagery to increase emotional awareness of feelings of regret for not having changed, and to increase positive feelings about taking steps to control and change to a more healthy lifestyle. Third, individuals should identify questions about the benefits of exercising or how to begin exercising. Nurses should ask these individuals to identify circumstances that contribute to a lack of exercise and the consequences of not exercising. Fourth, nurses may help contemplators create a new self-image by trying to break old habits and by imagining themselves reaping the benefits of exercise. Fifth, nurses should identify small steps leading to the larger goal of beginning to exercise, and the individual should be encouraged to try at least one of the small steps during the upcoming month. Sixth, nurses should encourage individuals to review how others fit exercise into their lives without replacing social or other important activities. Lastly, information should be presented about the proper way to begin an exercise program. These components can be presented in small group discussions using a written workbook format. Individuals who attend can complete and return the workbook for further discussion in a follow-up group session.
Individuals in the preparation stage are ready to begin exercising within the next month. The goal is to work with clients to negotiate a plan for beginning exercise. Strategies used in this stage incorporate the processes of self-reevaluation, helping relationships, and self-liberation. These strategies include assisting the individual to continue to create a new self-image, encouraging a public commitment to begin to exercise, identifying a plan which includes several alternatives for exercise, making choices for beginning to take action, and gathering support from others. Participants in this stage should be given a list of community resources and alternatives for exercise programs. They should be asked to determine three alternative types of exercise programs which may be best for them, and to identify a plan for beginning one of them. They should be encouraged to find an exercise buddy. Again, these strategies also can be accomplished in a group format, for example by participants sharing their plans and alternatives.
People in the action stage recently have made significant changes in their behavior. The goal for this stage is to reaffirm commitment and follow up using processes such as reinforcement management, helping relati onships, counterconditioning, and stimulus control. Individual and group alternatives for exercise should be offered. A meeting to introduce participants to the variety of exercise modalities available for different functional abilities is important. Individualized in-home progressive exercise programs can be designed. Walking clubs can be initiated. More formal exercise programs also may meet the needs of others. To remind individuals to exercise, useful strategies include putting walking shoes by the front door or keeping a calendar with exercise days and activities highlighted. Posting a list of benefits of exercise on the refrigerator is also a helpful reminder. The nurse may assist clients to identify a reinforcement that is meaningful (and healthy) for them to be used as a personal reward for meeting small exercise goals.
Individuals in the maintenance stage have been participating in exercise for 6 or more months. The goal is to encourage active problem solving to prevent relapse. Processes for this stage include counterconditioning, helping relationships, and reinforcement management. Strategies include assisting individuals to continue reinforcing themselves through positive self-talk and rewards for completing programs. Nurses should work with clients to identify and remove cues that keep them inactive, such as a habit of getting something to eat during television commercials. For example, nurses may encourage individuals to change this habit by suggesting the commercials be used as cues to exercise for a minute or two. Social support (i.e., helping relationships) is important at this stage. Therefore, recommendations of support groups and exercise buddies are helpful in preventing relapse and maintaining the behavior. Clients need to be educated to plan ahead for potential problems and substitute different activities if necessary, to recycle back to exercise if relapse occurs, and to use relapses as learning experiences, should they occur. Written information about how to accomplish these strategies is useful and should be provided to all clients who have participated in an exercise program for more than 1 month. See Table 2 for a summary of stage-based strategies and processes.
Success in behavior change should be measured in smaller increments because stage progression is the goal, rather than merely a dichotomous distinction of whether or not a healthy behavior is practiced. This allows for a more realistic, practical evaluation of progress toward health.
The TTM is an integrative model of behavior change that is applicable to older adults and can be used easily by nurses in any health care setting. This model has strategies targeting a broad range of individuals, from people who are not intending to change to people who have been engaging in healthy behaviors for some time. It also provides for a range of alternatives for behavior change, which is necessary to meet the needs of a heterogeneous group such as the older adult population. This is an improvement over traditional action-based programs or blanket suggestions for everyone, regardless of cognitive or behavioral differences. Further, the recommendations from the TTM are well suited to nurses working with older people and can be used both in individual interactions or group sessions.
Further research is needed to determine types of stage-based interventions holding the most promise for success with older adults. Special attention needs to be given to testing strategies with individuals in the precontemplation and contemplation stages to determine which strategies are most successful in promoting stage progression. Studies are needed to determine whether older individuals use the same processes of change in the same ways as younger adults. For individuals in the action and maintenance stages, cost-effective strategies need to be evaluated to determine the most effective ways of preventing relapse into previous unhealthy patterns. The TTM holds great promise as a framework for nursing interventions to assist older adults to make and maintain behavior changes promoting healthier, more satisfying lives.
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THE PROCESSES OF CHANGE
PROCESSES AND RELATED STRATEGIES FOR EACH STAGE OF EXERCISE BEHAVIOR CHANGE