Fall Prevention through Behavior Change: Exercise Interventions with the Transtheoretical Model Patricia Burbank, DNSc, RN Professor URI College of Nursing RI Geriatric Education Center

Objectives Describe the Transtheoretical Model of Behavior Change as it applies to exercise and fall prevention. Describe the Transtheoretical Model of Behavior Change as it applies to exercise and fall prevention. Assess the stages of change for exercise behavior. Assess the stages of change for exercise behavior. Discuss processes and strategies for exercise behavior change among older adults. Discuss processes and strategies for exercise behavior change among older adults. Identify strategies for exercise behavior change to identified stages of change. Identify strategies for exercise behavior change to identified stages of change.

Transtheoretical Model of Behavior Change (TTM) Prochaska & DiClemente, 1984 Prochaska & DiClemente, 1984

Dimensions of TTM Dimensions of TTM Stages of change Stages of change Processes of change Processes of change Decisional balance Decisional balance Self efficacy Self efficacy

Stages of change (5) Precontemplation - no intention to change behavior in foreseeable future Precontemplation - no intention to change behavior in foreseeable future Contemplation - seriously considering changing behavior within 6 months Contemplation - seriously considering changing behavior within 6 months Preparation - Intending to take action within next month Preparation - Intending to take action within next month

Stages of change (cont’d) Action - successfully altered behavior for one day to 6 months Action - successfully altered behavior for one day to 6 months Maintenance - a continuation of changed behavior from 6 months to indefinite Maintenance - a continuation of changed behavior from 6 months to indefinite

Processes of change (10) Cognitive: Consciousness raising Consciousness raising Dramatic relief Dramatic relief Environmental reevaluation Environmental reevaluation Self-reevaluation Self-reevaluation Social liberation Social liberation

Processes of change (cont’d) Behavioral: Counter-conditioning Counter-conditioning Helping relationships Helping relationships Reinforcement management Reinforcement management Self-liberation Self-liberation Stimulus control Stimulus control

Description of Processes Consciousness raising - seek new information about the behavior Consciousness raising - seek new information about the behavior Dramatic relief - Express feelings about problem or behavior Dramatic relief - Express feelings about problem or behavior Environmental reevaluation - Assess how problem affects physical and social environment Environmental reevaluation - Assess how problem affects physical and social environment

Description of Processes (cont’d) Self re-evaluation - Re-appraise values regarding the behavior Self re-evaluation - Re-appraise values regarding the behavior Social liberation - Develop awareness and acceptance of changed lifestyle Social liberation - Develop awareness and acceptance of changed lifestyle Counter-conditioning - Substitute alternative for problem behavior Counter-conditioning - Substitute alternative for problem behavior

Description of Processes (cont’d) Helping relationships - Use support from others Helping relationships - Use support from others Reinforcement management - Reward changed behavior Reinforcement management - Reward changed behavior Self-liberation - Commit to action; belief that change is possible Self-liberation - Commit to action; belief that change is possible Stimulus control - Control situations and cues that support problem behavior Stimulus control - Control situations and cues that support problem behavior

Decisional Balance Precontemplation - cons of changing outweigh pros Precontemplation - cons of changing outweigh pros Contemplation - pros stronger but still may not outweigh cons, crossover may occur Contemplation - pros stronger but still may not outweigh cons, crossover may occur Preparation - crossover (pros stronger than cons) Preparation - crossover (pros stronger than cons) Action - Action - cons pros

Self efficacy Self efficacy increases across stages Self efficacy increases across stages Temptation scores decrease across stages Temptation scores decrease across stages Maximum self efficacy and minimal temptation occurs in maintenance Maximum self efficacy and minimal temptation occurs in maintenance

Moving through Stages of Change Precontemplation Contemplation Preparation ActionMaintenance Relapse Termination

Precontemplation: Goals and Strategies Increase awareness of need to change. Give personalized information and feedback Give personalized information and feedback Encourage thinking about change Encourage thinking about change

Contemplation: Goals and Strategies Motivate and increase confidence in ability to change. Emphasize benefits of change Emphasize benefits of change Express empathy and provide support Express empathy and provide support Explore concerns and fears Explore concerns and fears Clarify misconceptions Clarify misconceptions

Preparation: Goals and Strategies Negotiate a plan. Set realistic goals. Set realistic goals. Recommend a plan; provide options Recommend a plan; provide options Individualize plan Individualize plan Reinforce small change Reinforce small change

Action: Goals and Strategies Reaffirm commitment and follow- up. Reaffirm agreed-upon plan Reaffirm agreed-upon plan Teach behavioral skills Teach behavioral skills Provide educational materials Provide educational materials Enhance social support Enhance social support Arrange follow-up date Arrange follow-up date

Maintenance: Goals and Strategies Encourage active problem-solving. Encourage planning for potential difficulties Encourage planning for potential difficulties Enhance support network Enhance support network

Relapse: Goals and Strategies Assist in coping. Help overcome shame and guilt Help overcome shame and guilt Reframe as learning opportunity Reframe as learning opportunity Analyze stumbling blocks Analyze stumbling blocks

Assessing Stage of Change Identify behavior first, then: Yes, I have been for more than 6 months Yes, I have been for more than 6 months Yes, I have been, but for less than 6 months Yes, I have been, but for less than 6 months No, but I intend to in the next 30 days No, but I intend to in the next 30 days No, but I intend to in the next 6 months No, but I intend to in the next 6 months No, and I do not intend to in the next 6 months No, and I do not intend to in the next 6 months

Tailor interventions to stage of change

Summary Behavior change occurs in stages Behavior change occurs in stages TTM: 4 main components TTM: 4 main components Behavior change works better if interventions are tailored to stage of change Behavior change works better if interventions are tailored to stage of change Design stage-tailored strategies for population group and setting Design stage-tailored strategies for population group and setting