The Transtheoretical Model of Healthcare - Essay Example

Running Head: PSYCHOLOGY OF EXERCISE & HEALTH Psychology of Exercise & Health [The of the appears here] [The of the institution appears here] Introduction Future-oriented self-perceptions represent how individuals think about their potential and their future. The question of what motivates individuals to exercise is an intriguing one. Although exercise and other forms of physical activity have been linked to psychological, physiological, and social benefits (Alfermann & Stoll, 2000), few adults choose to participate in physical activity on a regular basis. Physical inactivity leads to a host of chronic degenerative conditions and premature death, the promotion of a physically active lifestyle is an important public health objective. "Sedentary lifestyle is a major underlying cause of death, disease, and disability. Approximately 2 million deaths every year are attributable to physical inactivity; and preliminary findings from a WHO study on risk factors suggest that sedentary lifestyle is one of the ten leading causes of death and disability in the world. Physical inactivity increases all causes mortality, doubles the risk of cardiovascular disease, type II diabetes, and obesity. It also increases the risks of colon and breast cancer, high blood pressure, lipid disorders, osteoporosis, depression and anxiety." (World Health Organization 2002) Data Analysis The Transtheoretical Model: A Guide to Exercise Behaviour Change The transtheoretical model (TTM) of behaviour change, developed in the late 1970s and early 1980s, is a model of intentional behaviour change which focuses on the decision making of the individual. Originally designed to describe changes in addictive behaviour, the TTM has expanded to include the adoption of preventive health behaviours and the use of medical services (Burkholder & Evers, 2002). In the early 1990s, Marcus and others applied the TTM to exercise behaviour (Marcus, Selby et al., 1992). Since then, several researchers have used the TTM to develop exercise interventions. The TTM suggests that people do not change all at once, rather they move through a series of five stages toward behaviour change. There are three pre-action stages and two action stages, each defined by a temporal component related to the behaviour change. People in the first stage of pre-contemplation are not exercising and have no intention to exercise. In contemplation, people intend to exercise in the distant future, beginning sometime in the next 6 months. Preparation is the third stage where people intend to begin to exercise sometime in the next 30 days. The next stage, action, occurs when the person begins to exercise for at least 1 day to 6 months. In the stage of maintenance, the person has been exercising consistently for at least 6 months. The transtheoretical model proposes a set of constructs that are thought to influence movement through stages of change. These constructs include self-efficacy, decisional balance, and the processes of change. Self-efficacy is the belief in one's capability to engage successfully in a specific behaviour. Decisional balance is the evaluation of the pros and cons of engaging in the target behaviour. The processes of change are the cognitive and behavioural strategies used for changing behaviour and moving through the five identified stages: consciousness raising; dramatic relief; environmental re-evaluation; self re-evaluation and social liberation. Decisional balance, an analysis of the pros and cons of the behaviour change, is believed to influence exercise behaviour. Based on the work of Janis and Mann (1977), perceived costs and benefits to oneself and significant others influence behaviour change. Pros tend to increase to action and level off, while cons decrease with movement to each subsequent stage. Most of the evidence for exercise indicates that the crossover occurs during the preparation stage, which is consistent with several other behaviours. Prochaska and DiClemente identified 10 basic processes or strategies people use to change behaviour based on an analysis of the leading systems of psychotherapy (Prochaska & DiClemente, 1982). Five processes are cognitive in nature while five have a behavioural focus. These studies indicate that the processes of change used are different based on the person's stage of change. Differences in reported processes of change as a function of exercise stage have been used to develop stage-matched interventions focusing on different processes as a function of stage in community (Dunn et al., 1999), medical settings (Calfas et al., 1996) and clinical settings (Nigg et al., 1997). To promote behavioural change, teaching and counselling strategies should be tailored to each individual stage of change. According to the TTM, behaviour change interventions fail, in part, because the strategies applied do not match the stage of the participants. The nurse can directly tailor intervention strategies to meet individual client needs based on their assessed stage of change. A basic understanding of the model is needed, including the stages of change, decisional balance, self-efficacy, processes of change, and focusing on how to use these components to tailor interventions to particular stage-based needs. Numerous approaches have been used to train providers, especially physicians, to use the TFM, though it has been suggested that training nurses, who spend more of their time in direct contact with clients, may be more effective (Padula & Burbank, 2002). Application: A 20 year old female The first step is to assess the client's stage of change. Before using the staging questions, it is important to precisely identify and define the target behaviour, in this case exercise. The individual completing the questions must clearly understand not only how exercise is defined, but also the required frequency and duration. Questions to assess stage of change related to exercise are illustrated in Appendix Figure 1. It should be noted that these questions could be used for any target behaviour by simply replacing the term exercise in the questions with the desired target behaviour. Shortly after admission, using the staging questions, it can be identified that the young female was in the stage of pre-contemplation since she is not exercising according to the criteria and has no intention of increasing the rate of exercise. The goal in the pre-contemplation stage is to increase awareness of the need for change. Emphasis should be placed on increasing the young female's awareness of the benefits or pros of exercise. The processes of change most relevant to the pre-contemplation stage include consciousness raising, dramatic relief, and environmental re-evaluation. Using consciousness raising, the nurse could help the young female focus on the benefits of regular exercise by providing information and written materials emphasizing how regularity in her exercise routine can benefit her. Asking the young female to actually list her own personal pros of exercising would be a beneficial way to individualize the intervention plan. While emphasizing the pros, some discussion of the risks of not exercising should also be included. Using what the young female has already learned, and combining it with the process of dramatic relief, the nurse could encourage her to talk about how she feels about her physical abilities, and what those mean to her. The process of environmental re-evaluation could be used to help the young female examine how her inactivity has impacted on her social relationships in the housing site. Contemplators are considering the possibility of adopting a behaviour change in the next 6 months. They are aware that a problem exists, but they remain indecisive and lack commitment. However, they are more open to new information (Grimley et al., 1995). Processes of change most useful in the contemplation stage include consciousness raising, self-re-evaluation, social liberation, and self-liberation. Employing consciousness raising, the nurse would continue to provide the young female with information about the benefits of regular exercise, focusing more now on the risks associated with not exercising. Identifying small steps that could be used toward increasing exercise would be beneficial (e.g., completing range-of-motion exercises as instructed). Self re-evaluation could be used to help the young female become aware of the inconsistencies of her values. On the one hand, she fiercely wants to maintain independent functioning in her home and work. On the other hand she has been extremely resistant to a regular exercise routine. Using social liberation, the nurse could use the media, literature, television, or local role models to show the young female people who remain successful in exercising on a regular basis. Self-liberation is the belief in the ability to change and making the commitment to act on that belief (Cassidy, 1997). An appropriate intervention would be to encourage the young female to set a realistic benchmark for herself related to exercise, something that she could comfortably work toward. For example, she might commit to working out an additional 10 minutes per day. Praising her for movement toward achieving that goal, no matter how small, would be extremely important. If the young female were to move to the preparation stage, she would be ready to begin exercising within the next month. The goal of this stage is to negotiate a plan for beginning exercise. The young female should be encouraged and assisted to identify a specific achievable goal, to experiment with new skills, and to identify several alternative types of exercise that she would be willing to try. Using self-liberation and helping relationships, the nurse could encourage the young female to verbalize her commitment to exercise and to encourage her to find someone who might be willing to exercise with her. Alternatively, the young female could ask someone who she has identified as active if she could join along with that person in some of his/her activities. Application: A 45 year old Male Using the staging criteria, it is evident that older male is currently in the action stage, despite his commitments. The primary objective of the action stage is to support change efforts, so it would be imperative for the nurse to support and realistically encourage his desire to be as physically active as possible in his current situation. Processes of change appropriate to this stage include reinforcement management, helping relationships, counter-conditioning, and stimulus control. Using the process of reinforcement management, it would be important to recognize older male's dedicated attention to his exercise program through praise and recognition of his sound decisions as well as his progress. Counter-conditioning could be applied by offering older male the chance to participate in an available group exercise program, as well as providing him with specific examples of other exercise modalities appropriate to his present condition that he could try. Substituting acceptable alternative exercises for some of the more sedentary activities he had been required to follow would be appropriate. Older male expressed some concern that his wife had been overcautious regarding his exercise, and tried to discourage him from some activities. To help foster a more helping relationship, clarify any of her misconceptions, assure her of his progress and history of good judgments, and realistically deemphasize restrictions and focus on abilities. His wife admitted encouraging more passive activities like watching TV. Helping her to balance those suggestions with more active approaches, like walking, would be an example of stimulus control. Individuals in the maintenance stage have been participating in exercise for 6 months or more. It can be reasonably anticipated that older male will likely progress quite easily to the maintenance stage, given his overall physical condition and his motivation to exercise. The goal of the maintenance stage is to continue the behaviour change and avoid relapse. Processes that are important in the maintenance stage include counter-conditioning, helping relationships, and reinforcement management. Counter-conditioning is in essence the process of substituting alternatives. Encouraging older male to start, e.g., a golf game gradually instead of simply working around the yard would represent counter-conditioning. Discussing with his wife the importance of she, herself, resuming her interest in golf so she can support him to develop interest would facilitate a helping relationship. An example of reinforcement management for both the older male and his wife might be to encourage them to take a vacation where they can establish their love of exercise e.g. via sports like golf and tennis as a reward for their accomplishments and successes. Conclusion Since its inception in the early 1980s, the TTM has received much empirical support as a useful tool for promoting behaviour change in many areas. The examples in the previous section have illustrated how to assess stage of change in clients. Once stage is known, stage-appropriate goals can be set and behaviour change interventions can be tailored to the appropriate stage of change. References Alfermann, D., & Stoll, O. (2000). Effects of physical exercise on self-concept and well-being. International journal of Sport Psychology, 30, 47-65. Source: http://home.eplus-online.de/oliverstoll/download/Psychology.PDF Burkholder, G.J., & Evers, K.A. (2002). Application of the Transtheoretical Model to several problem behaviours. In P.M. Burbank & D. Riebe (Eds.), Promoting exercise and behaviour change in older adults (pp. 85-145). NY: Springer. Calfas, K.J., Long, B.J., Sallis, J.F., Wooten, W., Pratt, M., & Patrick, K. (1996). A controlled trial of physician counselling to promote the adoption of physical activity. Preventive Medicine, 25, 225-233. Cardinal, B.J. (1997). Construct validity of stages of change for exercise behaviour. American Journal of Health Promotion, 12(1), 68-74. Dunn, A.L, Marcus, B.H., Kampert, J.B., Garcia, M.E., Kohl, H.W. III, & Blair, S.N. (1999). Comparison of lifestyle and structured interventions to increase physical activity and cardio respiratory fitness: A randomized trial. Journal of the American Medical Association, 281(4), 327-34. Grimley, D., DiClemente, C., Prochaska, J., & Prochaska, G. (1995, Spring) Preventing Adolescent pregnancy, STD, and HIV: A promising new approach. Florida Educator, 7-15. Janis, I.L., & Mann, L. (1977). Decision making: A psychological analysis of conflict, choice, and commitment. New York: Free Press. Marcus, B.H., Selby, V.C., Niaura, R.S., & Rossi, J.S. (1992). Self-efficacy and the stages of exercise behaviour change. Research Quarterly for Exercise and Sport, 63, 60-66. Nigg, C.R., Norman, G,J., Prochaska, J.O., Riebe, D., & Stillwell, K.M. (1997). Adapting and maintaining physical activity in a clinic based weight management program. Paper presented at Physical Activity Intervention, The Cooper Institute Conference Series, American College of Sports Medicine Specialty Conference, Dallas, TX. Padula, C.A., & Burbank, P.M. (2002). Applying the Transtheoretical Model: Behaviour change among family caregivers and nursing care staff. In P.M. Burbank & D. Riebe (Eds.), Promoting exercise and behavior change in older adults (pp. 269-298). New York: Springer. Prochaska, J.O., & DiClemente, C.C. (1982). Transtheoretical therapy: Toward a more integrative model of change. Psychotherapy: Theory, research and practice, 19(3), 276-288. World Health Organization. (2002) Sedentary Lifestyle: A Global Public Health Problem. Source: http://dodge-ball.com/site/who.pdf Appendix Figure 1 Questions for Assessment of Stages of Change for Exercise The following five statements will assess how much you currently exercise in your leisure time (exercise done outside of a job). Regular exercise is any planned physical activity (e.g., brisk walking, jogging, bicycling, tennis, swimming, rowing) performed to increase physical fitness. This activity should be performed 3 or more times per week for 20 or more minutes per session to be considered at a level that increases your breathing rate and causes you to break a sweat. Do you exercise regularly according to the definition above Please mark only ONE of the five statements: 1. -----No, and I do not intend to begin exercising regularly in the next 6 months. 2. -----No, but I intend to begin exercising regularly in the next 6 months. 3.---No, but I intend to begin exercising regularly in the next 30 days. 3. -----Yes, I have been, but for less than 6 months. 4. -----Yes, I have been for more than 6 months. Scoring: Item 1 = Pre-contemplation; Item 2 = contemplation; Item 3 = Preparation: Item 4 = Action; Item 5 = Maintenance Read More