Chapter 6 Processes of Change Kristty Polanco Castillo MPH-IH

Transtheoretical Model of Change Five Stages: Pre-contemplation (PC) Contemplation (C) Preparation (PR) Action (A) Maintenance (M) Recap of what Monica has talked about: TMC- predicated on a set of core assumptions or principles of how people intentionally change their behavior. Five stages that individuals proceed to affect lasting behavior change

Processes of Change Essential principles that promote change Promotion of elimination of unhealthy behaviors or adoption of a healthy behavior. Important in program planning Implementation of strategies that will promote progression to achieve desired behavior change. Intervention strategies that help modify a person’s thinking, feeling and behavior These processes help individuals move from one stage of change to another until the desired behavior change is achieved.

Processes of Change Consciousness raising: Increase awareness of health risks and protective behaviors. Dramatic relief: Increase emotional reaction to health- risk behavior, followed by a solution. Self-reevaluation: Visualization of oneself and life without the health-risk behavior. Environment reevaluation: Helps understands how the the health behavior may affect other’s social environment. Techniques used to enhance processes of change: #1- Consciousness raising- Example: Informing a person of the risk of developing risk cancer by too much exposure to sun; reduced by wearing sunscreen. Risk of developing lung cancer by smoking; reduced by quitting smoking. #2- Dramatic relief- Example: seeing pictures of skin cancer or sun-damaged skin which can be avoided by wearing sun-screen #3- Self-reevaluation- Example: An obese person picturing one-self as an energetic, fit person. #4- Environment reevaluation- Example: obese or diabetic parent focusing on the example they’re setting for their children, motivating them to change. Application to my previous experience in HE: Family is big motivator for the Latino population that I have worked in when managing disease. Has also been main motivator for change for my own parent’s eating behavior in managing diabetes.

Processes of Change 5. Self-liberation: The belief that one can change and reinforcement on the commitment to change. 6. Helping relationships: Utilization of support from others to promote behavior change. 7. Counterconditioning: Substituting healthy behaviors for unhealthy ones. 8. Contingency Management: (reinforcement management) rewarding positive behavior or punishment for health threatening behaviors. #5 Self-liberation- Example: I decide to change my diet and start eating healthier; I announce it to my family, classmate, friends, and acquaintances (Reinforcement). This in turn make me feel empowered to initiate and maintain the healthy diet. #6 Helping relationships- Example: Buddy system.Rose decides she needs to exercise but has hard time keeping an exercise routine. Partnering up with a friend will help Rose reinforce that routine and provide motivation to maintain exercise routine. #7 Counterconditioning- Example: John has been thinking of quitting smoking but has been reluctant since he believes smoking has helped him cope with stress. Thus, Jim can learn more effective coping strategies for dealing with stress. #8 Contingency Management: Usually rewards are more likely to be effective. Philosophy of this model is to work with people’s natural ways of changing. Positive Example: Rose decides to quit smoking and use the money that she would have spent on cigarettes and use it to go on a vacation or buy something special for herself. Negative example: Gaining weight after eating unhealthy causing an individual to eat healthy to lose weight.

Processes of Change 9. Stimulus control: Removes cues for unhealthy behaviors and adds cues that support the adoption and maintenance of healthy behaviors. 10. Social Liberation: focuses on utilizing/increasing social opportunities that support health promoting behavior change. #9 Stimulus control- Example: Ann is eating healthier; she removes all unhealthy foods from her home to avoid temptation of eating them. #10 Social Liberation- Example: Elimination of trans fats (policy) instrumental in supporting health-promoting behavior change.

PERSONALITY SITUATION ENVIRONMENT THE THEORY OF TRIADIC INFLUENCE Distal Influences Proximal Predictors Levels of Causation Ultimate Causes Social/ Personal Nexus Expectancies & Evaluations Affect and Cognitions Decisions Experiences Intrapersonal Stream Social/Normative Stream Cultural/Attitudinal Stream Biological/Nature Nurture/Cultural BIOLOGY/ PERSONALITY SOCIAL SITUATION CULTURAL ENVIRONMENT 1 2 3 4 5 6 Sense of Social Interpersonal Others’ Interactions w/ Social Instit’s Information/ Self/Control Competence Bonding Beh & Atts Opportunities Question for class: Can someone state which path path or paths exemplify some of the processes? Examples: Social situation path exemplified by “Helping relationships” and “Contingency Management” processes of change. Biological/Personality path exemplified by “self-determination” process of change Cultural/Environment path exemplified by “consciousness raising” 7 8 9 10 11 12 Self Skills: Motivation Perceived Values/ Knowledge/ Determination Social+General to Comply Norms Evaluations Expectancies 13 14 15 16 17 18 SELF-EFFICACY BEHAVIORAL CONTROL SOCIAL NORMATIVE BELIEFS ATTITUDES TOWARD THE BEHAVIOR 19 20 21 22 23 DECISIONS/INTENTIONS Trial Behavior EXPERIENCES: Expectancies -- Social Reinforcements -- Psychological/Physiological

Stage-Matched Interventions Matching POC strategies to TMC stages: Pre-Contemplation to Contemplation: consciousness raising, dramatic relief, environmental reevaluation Contemplation to Preparation: self-reevaluation, environmental reevaluation, self-liberation, self-efficacy, stimulus control Preparation to Action: self-liberation, self-efficacy, stimulus control, counterconditioning, helping relationships. Action to Maintenance: stimulus control, counterconditioning, helping relationships, reinforcement management. Important: Critical aspects of stage theories that allows for more precise targeting of the intervention, thus enhancing the likelihood that the intervention will be effective in promoting the desired behavior change. Change processes are not universally applicable across stages Early stages people apply cognitive, affective, and evaluative processes to progress through the stages Later stages people rely more on commitments, conditioning, contingencies, environmental controls, and support for progressing toward maintained behavior change. Example: Efficiency of a Health Educator implementing for a person in the pre-contemplation stage to implement an intervention based on self-liberation when that person only thinking about changing the behavior and does not have locus of control to practice self-liberation

Key constructs in TMC Decisional Balance: (Janis and Mann 1977)- reflect’s an individual’s relative weighing pros and cons of changing his or her behavior Decisional Balance: DB and its relationship to the stages of change have been validated meta-analytically for at least 48 different health behaviors across different languages and countries Meta-analytic evidence supported the strong principles of progress meaning that the pros of the heath behavior change must increase by about one standard deviation (SD) from “PC” to “A” Also supported the weak principle, meaning that the cons of the health behavior change must decrease by one-half SD from “PC” to “A” Supports the idea that there’s a tipping point when an individual’s internal scales weighing the pros and cons tip in fair of the pros, leading to progress to the next sate of change. Similar to Net gain in chapter 5.

Key constructs in TMC 2. Self-efficacy (Alber Bandura 1986) Confidence- primary construct referring to individual’s perceived ability to cope with high-risks situations without relapsing to unhealthy behaviors Temptation- intensity of urges to engage in a specific behavior when confronted with challenging situations. Resilient self-efficacy Resilient self-efficacy: people with sufficient high levels of self-efficacy that the behavior can be performed despite extremely challenging circumstances.

Application across health behaviors TMC interventions developed: stage-matched peer-advisors, motivational interviewing or enhancement, staged targeted material, expert system (computer-based). Problematic assumption: applying common set of change processes to broad range of behaviors Support for 10 processes of change for problem behaviors such as: smoking, unhealthy diet, being sedentary, etc. First bullet point: Highly tailored systems have been found effective in changing health risk behaviors: smoking cessation, dietary fat- reduction, stress management. Second bullet point: More work is needed to determine and further understand the relationships between the processes of change and the stage of change within the TMC. When designing a program intervention it is important to collect data to examine the relationships between the stages and processes of change within a problem behavior area; in order to assure efficiency of the intervention.

Thank you.