Behavoural changes ie smoking censation
Behavoural Changes ie smoking censation
This essay will discuss the Behaviour Change Model of Health education or The Trans-theoretical Model, (TTM) in relation to smoking cessation.
As G. K. Chesterton
once said, “It isn’t that they can’t see the solution. It is that they can’t see the problem.” Families, friends, neighbours, or employees, however, are often well aware that the pre-contemplators have problems.
Stages of Change
Prochaska & DiClement`s transtheoretical model (1984,1986; Prochaska et al 1992) is important in describing the process of change. The model derived from their work on encouraging change in addiction behaviours, although it can be used to show that most people go through stages when trying to change or acquire behaviours.
American psychologists, Jim Prochaska and Carlo Di Clement,
Termination.
Process of change.
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4 ADDICTIONS NURSING NETWORKNOLUME 5, NUMBER 1,1993
In our studies using the discrete categorization
measurement of stages of change, we ask whether
the individual is seriously intending to change the
problem behavior in the near future, typically within
the next six months. If not, he or she is classified as a
precontemplator. Even precontemplators can wish to
change, but this seems to be quite different from
intending or seriously considering change in the next
six months. Items that are used to identify precontemplation
on the continuous stage of change measure
include “As far as I’m concerned, I don’t have
any problems that need changing” and “I guess I
have faults, but there’s nothing that I really need to
change.” Resistance to recognizing or modifying a
problem is the hallmark of precontemplation .
Splral Pattern of Change.
Many New Year’s resolvers
report five or more years of consecutive pledges
before maintaining the behavioral goal for at least six
months (Norcross & Vangarelli, 1989). Relapse and
recycling through the stages occur quite frequently
as individuals attempt to modify or cease addictive
behaviors. Variations of the stage model are being
used increasingly by behavior change specialists to
investigate the dynamics of relapse (e.g., Brownell
et al., 1986; Donovan & Marlatt, 1988).
Because relapse is the rule rather than the exception
with addictions, we found that we needed to
modify our original stage model. Initially we conceptualized
change as a linear progression through
the stages; people were supposed to progress simply
and discretely through each step. Linear progression
is a possible but relatively rare phenomenon with
addictive behaviors.
Figure 1 presents a spiral pattern that illustrates
how most people actually move through the stages of
change. In this spiral pattern, people can progress
from contemplation to preparation to action to maintenance,
but most individuals will relapse. During
relapse, individuals regress to an earlier stage. Some
TERYINATION a YAHTENANCE
PRECONTEYPLATIOW CONTEYPLATKJN PREPARATKJ
relapsers feel like failures-embanassed, ashamed,
and guilty. These individuals become demoralized
and resist thinking about behavior change. As a result,
they return to the precontemplation stage and
can remain there for various periods of time. Approximately
15% of smokers who relapsed in our
self-change research regressed back to the precontemplation
stage (Prochaska & DiClemente, 1986).
Fortunately, this research indicates that the vast
majority of relapsers–85% of smokers, for example-
recycle back to the contemplation or preparation
stages (Prochaska & DiClemente, 1984). They
begin to consider plans for their next action attempt
while trying to learn from their recent efforts. To
take another example, fully 60% of unsuccessful
New Year’s resolvers make the same pledge the next
year (Norcross, Ratzin, & Payne, 1989; Norcross &
Vangarelli, 1989). The spiral model suggests that
most relapsers do not resolve endlessly in circles and
that they do not regress all the way back to where
they began. Instead, each time relapsers recycle
through the stages, they potentially learn from their
mistakes and can try something different the next
time around (DiClemente et al., 1991).
On any one trial, successful behavior change is
limited in the absolute numbers of individuals who
are able to achieve maintenance (Cohen et al., 1989;
Schachter, 1982). Nevertheless, in a cohort of individuals,
the number of successes continues to increase
gradually over time. However, a large number
of individuals remain in contemplation and
precontemplation stages. Ordinarily, the more action
taken, the better the prognosis. Much more research
is needed to better distinguish those who benefit
from recycling from those who end up spinning their
wheels.
Arguments for and against
Conclusion
Influencing the people to change behaviours such as how they eat,excersice ,drink, smoke requires a long term commoitment but it is a process that they can sucseed. Nurses have a key role to play in influencing behaviour of their patients, and health promotion should be embed
MAINTENANCE:
practice required for the
new behaviour to be consistently maintained,
incorporated into the repertoire of behaviours
available to a person at any one time.
ACTION: people make changes, acting on
previous decisions, experience, information,
new skills, and motivations for making the
change.
PREPARATION:
person prepares to
undertake the desired change – requires
gathering information, finding out how to
achieve the change, ascertaining skills
necessary, deciding when change should
take place – may include talking with others to
see how they feel about the likely change,
considering impact change will have and who
will be affected.
CONTEMPLATION:
something happens to
prompt the person to start thinking about
change – perhaps hearing that someone has
made changes – or something else has
changed – resulting in the need for further
change.
PRECONTEMPLATION:
changing a
behaviour has not been considered; person
might not realise that change is possible or
that it might be of interest to them.
Source:
The Behavior Change spiral from “What do they want us to do now?” AFAO 1996
ded in daily practice. E
following review explores and considers some of the major theories of behaviour
and behaviour change that may be pertinent to the development of effective
interventions in travel behaviour, including theories and concepts from mainstream
psychology, and the associated sub-disciplines of health, leisure, recreation, physical
activity and exercise psychology.
For many years conceptual models of behaviour change, such as Bandura’s Social
Cognitive Learning Theory (1986), Becker’s Health Belief Model (1974), Azjen and
Fishbein’s Theory of Reasoned Action (1975); have been applied across a wide
variety of disciplines, including travel and road user behaviour.
Considerable attention has been given in the literature to models of individual
behaviour change per se – but much less attention has been given to models or
theories that attempt to understand behaviour change within groups, organisations and
whole communities. The design of programs to reach populations requires an
understanding of how those communities work, their barriers and enablers to change,
and what influences their behaviours in general.
Stage Theories of Behaviour Change
Mounting evidence suggests that behaviour change occurs in stages or steps and that
movement through these stages is neither unitary or linear, but rather, cyclical,
involving a pattern of adoption, maintenance, relapse, and readoption over time.
The work of Prochaska and DiClemente (1986) and their colleagues have formally
identified the dynamics and structure of staged behaviour change. In attempting to
explain these patterns of behaviour, Prochaska and DiClemente developed a
transtheoretical model of behavioural change, which proposes that behaviour change
occurs in five distinct stages through which people move in a cyclical or spiral
pattern.
The first of these stages is termed precontemplation. In this stage, there is no intent
on the part of the individual to change his or her behaviour in the foreseeable future.
The second stage is called contemplation, where people are aware that a problem
exists and are seriously considering taking some action to address the problem.
However, at this stage, they have not made a commitment to undertake action. The
third stage is described as preparation, and involves both intention to change and
some behaviour, usually minor, and often meeting with limited success.
Action is the fourth stage where individuals actually modify their behaviour,
experiences, or environment in order to overcome their problems or to meet their
goals. The fifth and final stage, maintenance, is where people work to prevent relapse
and consolidate the gains attained in the action stage. The stabilization of behaviour
change and the avoidance of relapse are characteristic of the maintenance stage.
Prochaska and DiClemente further suggest that behavioural change occurs in a
cyclical process that involves both progress and periodic relapse. That is, even with
successful behaviour change, people likely will move back and forth between the five
stages for some time, experiencing one or more periods of relapse to earlier stages,
before moving once again through the stages of contemplation, preparation, action
and eventually, maintenance. In successful behavioural change, while relapses to
earlier stages inevitably occur, individuals never remain within the earlier stage to
MAINTENANCE:
practice required for the
new behaviour to be consistently maintained,
incorporated into the repertoire of behaviours
available to a person at any one time.
ACTION:
people make changes, acting on
previous decisions, experience, information,
new skills, and motivations for making the
change.
PREPARATION:
person prepares to
undertake the desired change – requires
gathering information, finding out how to
achieve the change, ascertaining skills
necessary, deciding when change should
take place – may include talking with others to
see how they feel about the likely change,
considering impact change will have and who
will be affected.
CONTEMPLATION:
something happens to
prompt the person to start thinking about
change – perhaps hearing that someone has
made changes – or something else has
changed – resulting in the need for further
change.
PRECONTEMPLATION:
changing a
behaviour has not been considered; person
might not realise that change is possible or
that it might be of interest to them.
Source:
The Behavior Change spiral from “What do they want us to do now?” AFAO 1996
which they have regressed, but rather, spiral upwards, until eventually they reach a
state where most of their time is spent in the maintenance stage.
Further work undertaken and reported by Prochaska et el (1992) suggests that
behaviour change can only take place in the context of an enabling or supportive
environment.
Prochaska’s and DiClemente’s model has received considerable support in the
research literature. Their model has also been shown to have relevance for
understanding, among other things, patterns of physical activity participation and
adherence and would have relevance in bringing about change in travel behaviours.
Consistent with the above perspective, Sallis and Nader (1988) also have suggested a
stage approach to explaining movement behaviour, particularly in family groups, with
research aimed at understanding better the cyclical patterns of movement activity
SOCIAL FEATURES
– nature of personal elationships; expectations of class, position, age, gender;access to knowledge,
information.
CULTURAL FEATURES
– the behaviours and attitudes considered acceptable in given contexts – eg. relating to sex, gender, drugs, leisure, participation.
ETHICAL & SPIRITUAL FEATURES
– influence of personal and shared values and discussion about moral systems from which those are derived – can include rituals, religion nd rights of passage.
LEGAL FEATURES
– laws determining what people can do and activities to encourage observance of those laws .
POLITICAL FEATURES
– systems of governance in which change will have to take place – can, for example, limit access to information and involvement in social action.
RESOURCE FEATURES
– affect what is required to make things happen – covers human, financial and material resources;
community knowledge and skills; and items for exchange
Source:
The Behavior Change spiral from “What do they want us to do now?” AFAO 1996
involvement, including adoption, maintenance, and relapse, and interventions aimed
at minimizing the amount of time individuals spend in the relapse stage as well as
maximizing time spent in action or maintenance.
This stage approach is contrasted to the “all or none” approach to physical activity
participation that often characterized early research on exercise adherence.
Such a staged approach sits well with any school based program that is focussed on
travel behaviour change – given that the context in which the program is to be applied
would see fluctuations in the positive and negative influences according to such things
as work and time demands of family members, weather, events or incidents in the
local neighbourhood that may influence perceptions of safety.
Parallel with the work of Prochaska and DiClemente, Rogers, (1983) also developed a
stage-based theory to explain how new ideas or innovations are disseminated and
adopted at the community and population levels. Rogers identified five distinct stages
in the process of diffusion of any new initiative or innovation. These are knowledge,
persuasion, decision, implementation, and confirmation. Rogers argued that the
diffusion of an innovation is enhanced when the perceived superiority of an
innovation is high compared to existing practice (i.e. the relative advantage), and
when the compatibility of the innovation with the existing social system is perceived
to be high (i.e. compatibility).
Other important influences on the diffusion process are said to be complexity,
triability, and observability, with innovations which are of low complexity, easily
observed, and that are able to be adopted on a trial basis, being associated with greater
adoption and swifter diffusion. Building success and comfort during the early stages
of the implementation of the TravelSMART Schools program will be paramount to its
success.
Rogers classifies individuals as innovators, early adopters, early majority, late
majority, late adopters, and laggards, dependent upon when during the overall
diffusion process they adopt a new idea or behaviour. While this model has not been
tested empirically to date, it has been adapted and applied in health promotion settings
usually in conjunction with social learning theory and/or self-efficacy theory, with
some success. It certainly warrants attention in the development of the
TravelSMART Schools program.
In summarizing the various stage models of behaviour change that have been
proposed over the past two decades, Owen and Lee (1984) highlighted a number of
commonalties they share.
These authors propose an integrated stage-based model in which behaviour change is
viewed as a cyclical process that involves five stages of:
- awareness of the problem and a need to change
- motivation to make a change
- skill development to prepare for the change
- initial adoption of the new activity or behaviour, and
- maintenance of the new activity and integration into the lifestyle.
In terms of a TravelSMART program this may mean:
Five stages of behaviour change Examples of content and processes
- Awareness of the problem and a need
to change
Provision of, or ways to seek information
on the dependence on motorised travel;
evidence of the greenhouse effect; issues
relation to building relationships and
fitness
- Motivation to make a change Benefits of increased personal fitness;
benefits of leaving the car at home – eg.
environmental and social
- Skill development to prepare for the
change
Mapping of the local area to identify
alternative forms of travel, ways to
negotiate with reluctant family members
or peers to manage the need to carry;
strategies for trip chaining and travel
blending
- Initial adoption of the new activity or
behaviour
Self monitoring of newly adopted
behaviours to, opportunities for
reflections and comparisons
- Maintenance of the new activity and
integration into the lifestyle
Provision of feedback on how the change
is going, and an injection of new ideas or
strategy
An important aspect of both Prochaska’s and DiClemente’s approach and that
suggested by Owen and Lee is that each of the five stages of behaviour change is said
to involve different cognitive processes and require different treatments or
intervention strategies for the overall change process to be successful. Prochaska and
DiClemente (1992) outlined a number of cognitive change processes that have been
found to be associated with each stage.
Other researchers also propose that different stages in the change process require
different intervention strategies, and generally recommend a multifaceted,
community-based approach to intervention in which all stages are addressed so that
individuals at all stages of “readiness for change” can potentially be influenced. This
sits well with the overall TravelSMART programs – TravelSMART Communities,
TravelSMART Workplaces and TravelSMART Schools.
A major insight offered by stage theories of behaviour change, then, is the emphasis
they place on matching interventions to the stage of readiness of the individual. This
kind of approach provides an excellent framework for understanding and examining
individual differences in motivation for, and involvement in, change in travel
behaviours over time, including patterns of initiation, maintenance, relapse, and
resumption.
In summary, theories that conceptualise behaviour change in terms of a cyclical
process through which individuals move in stages, have received empirical support in
the research, and appear to offer much promise for understanding travel behaviours
and curricula to bring about changes in travel behaviour.
A major strength of the Stages of Change model is that it has also been used in
conjunction with a variety of other theories and models that are relevant to different
levels of influence at an intrapersonal, interpersonal, institutional, community or
public policy level. (Glanz and Rimer (1995) as reported by Oldenberg et al (1999))
Social Cognitive-Behavioural Theories and Similar Theories
Social Cognitive Theory explains human behaviour in terms of a triadic, dynamic and
reciprocal model in which behaviour, personal factors, and environmental influences
interact. It addresses both the psychological dynamics underlying behaviour and their
methods for promoting behaviour change. It is a very complex theory and includes
many key constructs. Self-efficacy is one of the key concepts.
Self-efficacy refers to one’s confidence in the ability to take action and persist in
action. It is seen by Bandura (1986) as perhaps the single most important factor in
promoting changes in behaviour. Measures of self-efficacy and some of the other key
concepts from Social Cognitive Theory have also been identified as key determinants
of movement through the stages of change, (Oldenburg, 1999).
Self-efficacy expectations have been found repeatedly to be important determinants
of:
- the choice of activities in which people engage
- how much energy they will expend on such activities and
- the degree of persistence they demonstrate in the face of failure and/or
adversity.
In general, higher levels of self-efficacy for a given activity are associated with higher
participation in that activity.
Similarly, and closely aligned to Social Cognitive Theory, Attribution Theory
proposes that individuals generally view their performance (and thus, their successes
and failures) as dependent upon ability, effort, task difficulty, and luck. In addition,
causal influences are seen as either internal to the individual (e.g. personal ability), or
external (e.g. barriers to community safety, lack of convenient and attractive travel
alternatives).
The distinction between internal and external attributions is an important one, in that
how we attribute our personal successes and failures has been shown to be related to
not only our behaviour, but our self-esteem, our perceptions of personal control, our
self-efficacy for different tasks and/or performance situations, and our ongoing
involvement in different activities.
For example, a person who attributes their failure to change their dependence on
motorised travel to their inherent lack of ability to identify and use alternatives will be
less likely to continue with the alternative modes of travel after the educational
program has ceased.
A person’s attributions for personal success and failure in a given situation, then,
determines how that person feels about the task, as well as the amount of effort he or
she is likely to invest in the task the next time around. When failure is attributed to
low personal ability and a difficult task, individuals are more likely to give up sooner,
select easier alternatives, such as using personal motorised travel, and lower their
goals. Conversely, when failure is attributed to external factors such as bad luck,
individuals are likely to have higher motivations to continue and to try again for
success.
Attitudes and their potential relationship to behaviour also have been studied
extensively. In general, attitudes have not generally been found to be consistently
related to behaviour. This failure to demonstrate a consistent relationship between
attitudes and behaviour may be because situational factors also exert a powerful
influence on behaviour. In addition, how attitudes have been defined and measured in
different studies varies considerably.
Research has demonstrated consistently that an attitude is likely to predict behaviour
when:
- the attitude includes a specific behavioural intention
- when both the attitude and the intention are very specific and
- when the attitude is based on first-hand experience .
These aspects of the behaviour-attitude relationship have been addressed in the
Theory of Reasoned Action, which focuses on the role of context-specific attitudes in
defining behaviour. In this model, behaviour is seen as a function of a person’s
intention, which in turn is comprised of the individual’s attitudes towards performing
the behaviour and the influence of perceived social norms concerning the
performance of the behaviour. Attitudes are affected by the person’s beliefs about the
perceived consequences of performing a given action, and his or her subjective
evaluation of each of the consequences.
Drawing this together, any published individually focused and community based
health behaviour change and health promotion programs have generally been based
on Social Cognitive theories utilising techniques that emphasise the cognitive and
social mediators of behaviour. Interventions based on cognitive learning theory
emphasize self-management principles and strategies.
Other Theories to Consider
Personality Theories
Personality theories explain behaviour largely in terms of stable traits or patterns of
behaviour which are viewed as resistant to change and inalterable. Rogers’, (1985),
classification of individuals into the five categories of innovators, early adopters,
early majority, late majority, late adopters, and laggards is an example of this kind of
approach to understanding behaviour.
A major limitation of personality theories is that they do not take account of important
aspects of the physical, social and economic environments, or the previous
experiences of the individual, which also are known to strongly influence behaviour.
For this reason, personality theories alone now are generally considered inadequate to
explain behaviour change.
Learning and Behaviour Theories
Learning theorists have demonstrated that behaviour can be changed by providing
appropriate rewards, incentives, and/or disincentives. In learning or behaviourist
approaches, these rewards and incentives are typically incorporated into structured
reinforcement schedules, and the process of behaviour changes is often termed
behaviour modification.
While effective in bringing about behaviour change, such approaches require a high
level of external control over both the physical and social environment, and the
incentives (or disincentives) used to reinforce certain behaviours and discourage
others. This kind of control is hard to maintain in real life settings, and thus, strict
behaviourist approaches are subject to a number of limitations.
Social Learning Theory
Social learning theory is similar to learning and behaviour theories in that it focuses
on specific, measurable aspects of behaviour. Learning theories, however, view
behaviour as being shaped primarily by events within the environment, whereas social
learning theory views the individual as an active participant in his or her behaviour,
interpreting events and selecting courses of action based on past experience.
Again, one important theory deriving from social learning theory which has had a
major impact on many current models of behaviour change is that of self-efficacy. As
stated earlier, self-efficacy expectations have to do with a person’s beliefs in his or her
abilities to successfully execute the actions necessary to meet specific situational
demands. Such expectations have been found to be consistently related to behaviour
across a wide range of situations and populations sub-groups.
Social Psychological Theories
Social psychological theories are concerned with understanding how events and
experiences external to a person (i.e. aspects of the social situation and physical
environment) influence his or her behaviour.
Emphasis is placed on aspects of the social context in which behaviour occurs,
including social norms and expectations, cultural mores, social stereotypes, group
dynamics, cohesion, attitudes and beliefs. A number of useful concepts have emerged
from social psychological theories, including attribution, locus of control, and
cognitive dissonance, to name a few.
Social Cognitive Approaches
Social cognitive approaches combine aspects of social psychological theories with
components of both social learning theory and cognitive behavioural approaches.
Social-cognitive approaches emphasize the person’s subjective perceptions and
interpretations of a given situation or set of events, and argue that these need to be
taken into account if we are to understand adequately both behaviour and the
processes of behaviour change.
A number of social psychological concepts have been found to be consistently related
to behaviour change across a wide range of situations. For example, the social reality
of a the group (e.g. peer group, school group, family group etc.) will affect an
individual’s behaviour. All groups are characterized by certain group norms, beliefs
and ways of behaving, and these can strongly affect the behaviour of the group
members.
Expectations of significant or respected others can also have a strong influence on a
person’s behaviour. This phenomenon has been most consistently demonstrated in the
early research on self-fulfilling prophecies, which showed that teachers’ expectations
of their students were consistently related to the students’ subsequent performance,
even when these expectations were based on falsified information. Thus, support and
encouragement, or conversely, low expectations from significant or respected others,
can affect and bring about, (or not), changes in individual behaviour.
Health Belief Model
The Health Belief Model attempts to explain health-behaviour in terms of individual
decision-making, and proposes that the likelihood of a person adopting a given healthrelated
behaviour is a function of that individual’s perception of a threat to their
personal health, and their belief that the recommended behaviour will reduce this
threat.
Thus, a person would be more likely to adopt a given behaviour (e.g. walk or cycle
regularly) if non-adoption of that behaviour (e.g. unclean air or confused traffic
situations) is perceived as a health threat and adoption is seen as reducing that threat.
To date, the Health Belief Model has not received consistent or strong support in
explaining behaviour change. When the concept of self-efficacy is added to the
model, however, prediction of behaviour increases.
Social Marketing
Another approach that has been used to bring about behaviour change is that of social
marketing. The concept of social marketing is based on marketing principles and
focuses on four key elements, including:
- development of a product
- the promotion of the product
- the place
- the price.
As such, this approach is not so much a theory of behaviour change but a proposed
framework, which situates people as “consumer” who will potentially “buy into” a
certain idea or argument, given the appropriate selling techniques are applied. It is
then assumed that the “buying in” to that idea by individuals will result in behaviour
change.
Theory of Interpersonal Behaviour
Habit strength is another concept that has been found to be important in predicting or
changing behaviour. Habit is an important element of the theory of interpersonal
behaviour, which proposes that the likelihood of engaging in a given behaviour is a
function of:
- the habit of performing the behaviour
- the intention to perform the behaviour
- conditions which act to facilitate or inhibit performance of the behaviour.
In turn, intentions are said to be shaped by a cognitive component, an affective
component, a social component, and a personal normative belief. The theory of
i
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