Transtheoretical Model

The Transtheoretical Model (TTM) was originally developed to understand behaviour change related to smoking cessation (Prochaska and DiClemente, 1983), but has since been applied to exercise behaviour (Prochaska and Marcus, 1994). Interventions based on the TTM have been effective in promoting and maintaining physical activity (Marcus, et al., 1992a; Marcus, et al., 1998a, 1998b; Bock, et al., 2001). The model proposes that individuals attempting to change their physical activity behaviour progress through five stages (Marcus and Simkin, 1994). The stages differ according to an individual's intention and behaviour and have been labelled as follows:

• Precontemplation (inactive and no intention to change);

• Contemplation (inactive, but intending to change in the next six months);

• Preparation (engaging in some activity, but not regularly);

• Action (regularly physically active, but only began in the past six months);

• Maintenance (regularly active for more than six months).

Movement through these stages often occurs in a cyclic pattern because many individuals relapse to an earlier stage when attempting behaviour change.

Three components of the TTM are hypothesised to mediate the behaviour change process: the decisional balance, self-efficacy and the processes of change. Decisional balance involves a comparison of the perceived pros and cons of engaging in behaviour. Studies have demonstrated a significant relationship between exercise adherence and perceived pros and cons of exercise in patients with CHD (Tirrell and Hart, 1980; Robertson and Keller, 1992; Hellman, 1997).A recent meta-analysis (Marshall and Biddle, 2001) found that the decisional balance is related to the stage of exercise behaviour change as depicted in Figure 8.1.

The pros of exercise increase with advancing stage of change, with the largest increase evident from the precontemplation to the contemplation stage. The perceived cons of change decrease across the stages, with the most pronounced decline occurring from precontemplation to contemplation. Therefore, it seems that increasing perception of the pros and decreasing perception of the cons of exercise are important to increase physical activity. Similarly, Hellman (1997) reported a decline in the perceived costs of exercise and an increase in the perceived benefits of exercise, with advancing stage of change in a group of patients who had previously attended in-patient CR.

Self-efficacy was integrated into the TTM from Bandura's Self-Efficacy Theory (Bandura, 1977), and is defined as an individual's confidence in his or her ability to perform a specific behaviour. Self-efficacy is an important determinant of exercise compliance in cardiac rehabilitation settings (Robertson and Keller, 1992; Vidmar and Rubinson, 1994). Findings from the meta-analysis (Marshall and Biddle, 2001) demonstrated a significant relationship between exercise self-efficacy and stage of change, as illustrated in Figure 8.1. The graph shows that confidence to be active increases with each forward movement in stage of change. Individuals in the precontemplation stage demonstrate the lowest self-efficacy, whereas those in maintenance have the highest self-efficacy. Furthermore, the relationship between exercise self-efficacy and stage of change is non-linear, and self-efficacy seems to be

Figure 8.1. Relationship between the stages of change and decisional balance, self-efficacy and processes of change.

(Adapted from Marshall and Biddle, 2001.)

Figure 8.1. Relationship between the stages of change and decisional balance, self-efficacy and processes of change.

(Adapted from Marshall and Biddle, 2001.)

Table 8.1. Processes of Exercise Behaviour Change

Process of Change

Definition (adapted from Marcus, et al., 1992b)


Consciousness raising

Dramatic relief Environmental reevaluation


Social liberation



Helping relationships

Reinforcement management


Stimulus control

Providing information about the benefits of physical activity and discuss the current physical activity recommendations Discussing the risks of inactivity Emphasise the social and environmental benefits of physical activity Review current physical activity status and assess values related to physical activity Raise awareness of potential opportunities to be active and discuss how acceptable and available they are to the individual

Discussion of how to substitute inactivity for more active options (e.g. taking the stairs instead of the lift)

Seeking out friends, family and work colleagues who can provide support Rewarding successful attempts at being active Making commitments for activity (e.g. goal setting) Control of situations that may have a negative impact on physical activity and developing ways to prevent relapse during these situations especially important when moving from action to maintenance. Similarly, Hellman (1997) reported that exercise self-efficacy is significantly related to stage of exercise behaviour change in CR participants.

The processes of change are strategies and techniques that individuals use when changing their exercise behaviour (Marcus, et al., 1992b). There are ten processes: five experiential and five behavioural. A description of each is provided in Table 8.1.

The meta-analysis (Marshall and Biddle, 2001) found that the frequency of using the processes of change varies across the five stages of change (see Figure 8.1). The use of experiential and behavioural processes increases with advancement through stages, with the largest increase occurring from pre-contemplation to contemplation and preparation to action. Furthermore, the frequency of using the behavioural processes is more important than that of experiential processes, from the contemplation stage onwards. There is little change in process use from the action to maintenance stages, implying either that maintenance of physical activity does not require further change in experiential and behavioural strategies, or that individuals use additional strategies to those proposed by the processes of change. Similarly, an observational study of patients who had previously attended a cardiac rehabilitation programme found that the experiential and behavioural processes were used more frequently with advancing through the stages of exercise behaviour change (Hellman, 1997).

Changes in the stages and processes of change for exercise behaviour from baseline to six months were measured in a longitudinal study of a group of healthy individuals (Marcus, et al., 1996). At six months, individuals were categorised into four groups: stable sedentary (remained in either precon-templation or contemplation at both assessments), stable active (remained in preparation, action or maintenance at both assessments), adopters (progression from precontemplation, or contemplation to preparation, action or maintenance) and relapsers (regression from preparation, action or maintenance to either contemplation or precontemplation). This study found that behavioural change process use did not change for individuals in the stable active or stable sedentary categories. However, behavioural change process use was significantly greater for individuals who remained active, compared to those who stayed inactive over the study period. Adopters reported a significant increase in the use of experiential and behavioural processes, whereas relapses reported a significant decline in the use of all behavioural processes and one experiential process (dramatic relief). These findings suggest that continued use of behavioural strategies may be important to prevent relapse. Furthermore, a significant decline in dramatic relief among relapses suggests that either belief in the health benefits of physical activity decreases considerably when individuals are no longer physically active, or that inactivity is no longer viewed as an emotional issue.

Application of the TTM in CR setting

Bock, et al. (1997) measured the components of the TTM and physical activity in 62 cardiac patients at the beginning and end of a 12-week phase II supervised exercise programme and at three months follow-up. At the beginning of phase II, 43% of participants were in the action and maintenance stages (i.e. accumulating a minimum of 30 minutes of moderate activity on most days per week). At the end of the programme, 96% of participants were in the action and maintenance stages, and self-reported physical activity had significantly increased. Moreover, there were significant increases in exercise self-efficacy and the use of behavioural processes, and a significant reduction in the perceived cons of exercise, with no change in the use of experiential processes or perceived pros of exercise. Three months after programme completion, the proportion of patients in the action and maintenance stages had decreased to 80%, and nearly 50% of participants had reduced their physical activity compared to the end of the phase II programme. Individuals who had regressed at the three-month follow-up had significantly lower scores for self-efficacy and use of behavioural processes, and they had more negative decisional balance scores at the end of the phase II programme, compared to participants who remained physically active at three months. Thus, maintenance of physical activity after completion of a CR exercise programme appears to be associated with changes in self-efficacy, decisional balance and behavioural processes. These findings suggest that interventions based on components of the TTM may promote maintenance of physical activity after CR programme completion.

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