Behavior Change Project
The Transtheoretical Model
The Transtheoretical Model (TTM) is an integrative model developed in the early 1980’s by Prochaska and DiClemente to conceptualize the process of intentional behavior change (Pro- Change Behavior Systems, 2015). The TTM emerged from a comparative analysis of the most powerful principles and processes of change from leading theories in psychotherapy and behavior change, including Conscious Raising by Sigmund Freud, Contingency Management by BF Skinner and Helping Relationships by Carl Rogers (Hayden, 2014; Hergenrather, 200*; Pro- Change Behavior Systems, 2015). Whereas other models of behavior change focus exclusively on certain dimensions of change such as social or biological, the TTM seeks to include and integrate key constructs from other theories into a comprehensive theory of change that can be applied to a variety of behaviors, populations, and settings including treatment settings, prevention and policy-making settings. Thus the name Transtheoretical (Pro- Change Behavior Systems, 2015).
Stages of change
It is not easy to for individuals to change from an unhealthy behavior to a healthy one. Therefore, the TTM focuses on the decision-making of the individual. It operates on the assumption that people do not change behavior quickly and decisively, rather, change in behavior, particularly long-term behavior, occurs continuously through a cyclical process (Boston University School of Public Health, 2016). The TTM postulates that individuals move through five stages of change: pre-contemplation, contemplation, preparation, action, and maintenance. For each stage of change, different intervention strategies are most effective at moving the person to the next stage of change and subsequently through to the maintenance stage, which is the ideal stage of behavior.
1. Precontemplation - In this stage, the individual does not intend to take action within the next 6 months. The individual may be unaware that their behavior is problematic or produces negative consequences. The individual may have tried to change and failed and feels demoralized. The pros of behavior change is often underestimated and too much emphasis is placed on the cons of behavior change.
2. Contemplation - In this stage, the individual intends to take action in the next six months. The individual recognizes that their behavior may be problematic and a more thoughtful and practical consideration of the pros and cons of changing the behavior takes place. Ambivalence regarding behavior change may still be felt in this stage.
3. Preparation - In this stage, the individual is ready to take action within the next 30 days. Small steps toward the behavior change is taken and they believe changing their behavior can lead to a healthier life.
4. Action - The individual in this stage has recently changed their behavior and intends to keep moving forward with that behavior change. The individual may exhibit this by modifying the problem behavior or acquiring new healthier behaviors.
5. Maintenance - This stage begins six months after the action stage and involves sustainment of the behavior change with the intent to maintain the behavior change going forward. People in this stage work to prevent relapse to earlier stages.

Processes of change
Whereas the stages of change are designed to help understand when people will change their behavior, the process of change helps to understand how this behavior change occurs (Hayden, 2014). To progress through the stages of change, an individual applies cognitive and behavioral processes. Ten processes of change have been identified with some processes being more relevant to a specific stage of change than others.
1. Consciousness Raising - Increasing awareness about why it is important to change behavior.
2. Dramatic Relief - Emotional arousal about the health behavior, whether positive or negative.
3. Self-Reevaluation – The individual looks at him/herself with or without the behavior and assesses whether the healthy behavior is part of who they want to be.
4. Environmental Reevaluation – Looks at the unhealthy behavior in light of its impact both socially and environmentally.
5. Social Liberation - Environmental opportunities that exist to show society is supportive of the behavior change.
6. Self-Liberation - Individual believes they can make the change and commits to it, freeing themselves from a behavior in which they choose to no longer engage.
7. Helping Relationships - Finding supportive relationships that encourage the desired change and acts as a support system for the individual.
8. Counter-Conditioning - Substituting healthy behaviors and thoughts for unhealthy behaviors and thoughts.
9. Reinforcement Management - Rewarding the positive behavior and reducing the rewards that come from the negative behavior.
10. Stimulus Control - Re-engineering the environment to have reminders and cues that support and encourage the healthy behavior and remove those that encourage the unhealthy behavior.
(Boston University School of Public Health, 2016; Hayden, 2014).

The processes of change includes five behavioral and five cognitive strategies that an individual uses as they move from pre-contemplation to maintenance. Examples of behavioral processes are the use of a support partner (helping relationships) or rewards (reinforcement management). Cognitive processes include dramatic relief and self- reevaluation. Decisional balance refers to the process of weighing the pros against the cons of adopting and/or increasing exercise (Spencer, et al., 2006). As the pros increase and the cons decrease, a person will move forward from contemplation into preparation and action (Spencer et al., 2006).
Past Research Using the TTM
When a search is performed regarding uses of the TTM, one can see that it can be used for a myriad of behavioral changes, including, alcohol and drug abuse, physical exercise, diet, tobacco cessation, and HIV and STD prevention, just to name a few. Since my client wanted to increase his weekly physical activity, a review of the literature was restricted to the use of the TTM in regards to physical activity. Because the theory is an older theory, current research only focusing on the use of the TTM and physical fitness within the past 10 years is difficult to find. Current research articles look at the use of the TTM in behavior change in various ethnicities, people with chronic diseases, and cancer related fatigue.
Spencer et al. (2006) reviewed 150 articles to determine the effectiveness of the TTM as applied to exercise. Several conclusions were drawn that related to practitioners use of the TTM as applied to exercise. First, it is important to apply the entire model and not just the stage of change measure (Spencer et al., 2006). Ensuring that participants use the appropriate processes of change as they move through the stages is essential for their success. The authors found that a multi-intervention format had better results. The use of print materials, computer and Web-based interaction, brief physician counseling, class meetings, telephone counseling, and mass media channels all appeared to be useful strategies in promoting forward movement through the stages in regards to exercise (Spencer et al., 2006).

The Client
Mark is a 53 year old male with no significant medical history. At 6’3” and 210 pounds he is very active and enjoys surfing, paddle boarding, bike riding, hiking, skiing, running/walking with his dog, and coaches a 17-19 year old club soccer team. He is a salesperson for a fire protection company and has been with the company for 20 years. The job has days of sitting at his desk writing proposals and days of driving to and from appointments or job sites.
His mother is alive and is 83 years old. At 79 years of age, she was diagnosed with colon cancer, which was taken care of by an uncomplicated colectomy. His father died at 62 years of age from respiratory complications secondary to Parkinson’s disease. His father was diagnosed with early onset Parkinson’s at 30 years of age. His sister is 55 years old and is very active like her younger brother. She went through breast cancer treatment, including a double mastectomy, when she was 49. She is cancer free at this time. Mark had not seen a doctor in several years, and due to the fact that his mother had colon cancer, his mother and I emphasized he was three years overdue for his initial screening and it was imperative that he get this done. Mark scheduled an appointment with his doctor, and after receiving a referral, scheduled an appointment for a colonoscopy of which after the procedure the RN said his was the only normal colonoscopy of the entire day.
While Mark is very active, most of his physical activity occurs on weekends. During the winter months this becomes challenging since the weather is not conducive for the activities he enjoys and he gets complacent with exercising in the winter. When spring rolls around and he wants to go surfing or paddle boarding he struggles to get into shape since surfing is very taxing and requires both cardiovascular and physical endurance. His neighborhood has a fitness facility, of which there is only one elliptical trainer and one treadmill. There have been times when Mark has gotten up at 0500 to exercise only to find that the elliptical trainer, which he prefers, is unavailable. When this happens, he takes his dog on a long morning walk instead. He enjoys running and in the past had used running as his primary source of exercise, running seven miles, three days a week. However, three years ago he was plagued with a very severe case of plantar fasciitis, and has been unable to retain a consistent running routine without experiencing pain. I suggested he invest in some compression socks and new shoes to combat this, and he did, but he continues to experiences pain a few miles into his run, so he then walks. On the days when wants to run, he alternates running and walking.
It was January timeframe when Mark agreed to work with me on his behavior change. I inquired as to what change he wanted to occur and how he wanted it to look. He replied that he wanted to have a consistent workout routine during the winter so he could be in shape for surfing in late April. When asked his barriers to reaching this goal he stated he had a sedentary job, sat at a desk most of the day, and lacked time, particularly in the winter with less daylight. Together we decided that his goal would be to work out two times during the week and two times on the weekends throughout the winter in order to be prepared for surfing season.
In order to keep track of his physical activity he purchased a FitBit. A FitBit is a fitness product that helps with motivation and improves health by tracking activity, exercise, food, weight and sleep. It is worn on the wrist, like a watch, and measures distance walked, calories burned, floors climbed and activity duration and intensity. It also measures how long it takes the user to fall asleep and how long they are actually asleep. When connected to a computer the tracker will upload data to the Fitbit website, where a number of features are available including an overview of physical activity, setting and tracking goals, keeping food and activity logs, water intake and sleep activity. Currently, FitBits are very popular, and as a fitness instructor myself, I have seen how the use of the FitBit has motivated people to increase their physical activity. As to whether this product incurs long-term changes, or is a fad, at the very least it is a motivational tool.
A healthy diet is a staple for Mark, which includes a Kashi bar, banana and carrot juice for breakfast and fresh fish two days a week as well as spinach, avocados, brussel sprouts, tomatoes, asparagus, and chicken in the evening. He may eat red meat once a month or once every other month, but his preference is chicken and fish. Twice daily Mark takes a Shaklee multi-vitamin, B-complex, vitamin C, flaxseed oil and glucosamine. Because his job requires him to be at a desk for most of the day, he prefers to take his lunch hour out of the office. Once a week he treats himself to his favorite lunch spot, The Broken Egg, where he orders a Mediterranean egg white omelet, and on other days he purchases something from a local eatery. If the weather is nice he will grab a sandwich or salad at a local grocery store and enjoy lunch at a park close to his office. Sometimes lunch is a bit heavier, especially if he is out to eat with a client.
When I first asked Mark if he would be my client, I discussed with him the various stages of the TTM. At that time, which as I previously mentioned was January timeframe, he vocalized that he was in the contemplation stage and not ready to take immediate action, but preparing to do so. It was February when he became serious and ready to start. He had purchased the FitBit and that appeared to be a motivational tool. Whether it was the cost of purchasing the FitBit or just ready to start the change process, he started keeping track of his food and water intake, as well as wearing the FitBit all the time. He started going to bed earlier and waking up earlier in order to exercise before going to work. We spoke daily and Mark would inform me of his activity, which included the elliptical trainer or taking his dog on a long morning walk on
Tuesday or Thursday and bike riding or taking his dog for a run/walk on Saturday and Sunday. Mark had moved into the action stage and was in the self-liberation stage of change. About three weeks into his workout routine, Mark was unable to exercise due to an upper respiratory virus. He felt terrible, was running a fever, had nasal congestion and a headache and spent the weekend in bed. Having to go back to work on Monday and still feeling run down, he did not exercise that week. However, when he felt better the following week, he eased back into his workout routine. I talked with him about easing back into his routine in order to let his body readapt to exercising. After that hurdle, Mark has been able to get back into his exercise routine and is preparing for surfing soon. After 14 weeks, he is still in the infancy stage of behavior change, but has made positive strides. He has remained in the Action stage of change and has cognitively evaluated that he feels better prepared for the surfing season and committed to change now that he sees positive outcomes. I serve as his support system and bike ride with him on the weekends we are able to spend together. It has been good for me as well as I had never spent much time biking or hiking and he has shown me how fun these activities are. While not enough time has elapsed to move into the Maintenance stage, Mark remains in the Action stage at the end of this project.

Table 1
Week 1
Preparation. Talking about what behavior change he wants to occur
Week 2
Preparation. Working together to develop a plan
Week 3
Preparation. Purchased a FitBit and set it up. Started logging food and water intake.
Week 4
30 minutes on elliptical trainer on Tuesday
18 mile bike ride on Saturday
7 mile walk/run with dog on Sunday
Continue to log food and water intake
Week 5
30 minutes on elliptical trainer on Tuesday
7 mile walk/run with dog on Saturday
18 mile bike ride on Sunday
Continue to log food and water intake
Week 6
20 minute morning walk with dog on Tuesday
30 minutes on elliptical trainer on Thursday
25 mile bike ride on Saturday
3 mile paddle boarding on Sunday
Continue to log food and water intake. Asking questions regarding proper caffeine intake. Concerned he drinks too much coffee at work.
Week 7
30 minute morning walk with dog on Tuesday
30 minutes on elliptical trainer on Thursday
Started running a fever Friday evening and was in bed sick all weekend.
Week 8
No exercise during the week
5 mile walk with dog on Saturday
10 mile bike ride on Sunday
Continue to log food and water intake
W eek 9
20 minute morning walk with dog on Tuesday
30 minutes on elliptical trainer on Thursday
25 mile bike ride on Saturday
25 mile bike ride on Sunday
Continue to log food and water intake.
Week 10
20 minute morning walk with dog on Tuesday
30 minutes on elliptical trainer on Thursday
12 mile hike in mountains on Saturday
10 mile hike in mountains on Sunday
Continue to log food and water intake.
Week 11
30 minutes on elliptical trainer on Tuesday
30 minutes on elliptical trainer on Thursday
7 mile walk/run with dog on Saturday
18 mile bike ride on Sunday
Continue to log food and water intake
Week 12
20 minute morning walk with dog on Tuesday
30 minutes on elliptical trainer on Thursday
25 mile bike ride on Saturday
25 mile bike ride on Sunday
Continue to log food and water intake.
Week 13
30 minutes on elliptical trainer on Tuesday
30 minutes on elliptical trainer on Thursday
7 mile walk/run with dog on Saturday
25 mile bike ride on Sunday
Continue to log food and water intake
Week 14
20 minute morning walk with dog on Tuesday
At current time, Mark remains in the Action stage.

References

Behavioral Change Models. (2016, January 6). In Boston University School of Public Health.
Retrieved April 10, 2016, from http://sphweb.bumc.bu.edu/otlt/MPH-Modules/SB/SB721-Models/index.html
Hayden, J. (2014). Introduction to Health Behavior Theory (Second ed., pp. 137-150).
Burlington, MA: Jones & Bartlett Learning.
Hergenrather, K. C. (n.d.). The Transtheoretical Model and Stages of Change . In Auburn
University. Retrieved April 10, 2016, from http://www.auburn.edu/academic/education/sences/classinfo/transtheortical.html
Spencer, L., TB, A., Malone, S., Roy, L., & Yost, E. (2006). Applying the transtheoretical model to exercise: a systematic and comprehensive review of the literature. Health Promotion Practice, 7(4), 428–443. Retrieved from http://ezproxy.simmons.edu:2048/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=106255357&site=eds-live&scope=site
The Transtheoretical Model. (2015). In Pro-Change Behavior Systems, Inc. Retrieved April 10, 2016, from http://www.prochange.com/transtheoretical-model-of-behavior-change