The Transtheoretical Model (TTM) of Behavioral Change is a model proposed by Prochaska and DiClemente to identify different stages through which clients experience change and the antecedents that maintain a behavior. The model comprises of five main steps for change. The model brings three key fields that are involved in intended behavior change. Determining the respective patient's stage allows for a better understanding of a patient's perspectives on adopting healthy changes in his/her life and help him or her go through the stages. This paper discusses The Transtheoretical Model and relates it to a patient (Jane) in its applicability to change in her physical activity. The patient lacks exercise, which is essential for her health. The volunteer patient requires physical activity to prevent a recurrence of cancer, diminish treatment effects, and improve the quality of life. The patient will exercise for 45 minutes every day by the end of the three months.
Health History
Two years ago, the patient received a colon cancer with metastasis to the liver diagnosis. As a result, she underwent a laparoscopic colon open surgery with anastomosis and liver resection. After eight months of chemotherapy, she was declared cancer-free and is seen by an oncologist every three to six months. Before the cancer diagnosis, the patient was overweight, a smoker using 4-5 cigarettes every day, and the same number of drinks every week. After diagnosis, she decided to quit smoking, alcohol and made changes in her diet by doing away with unhealthy foods and incorporating healthy food choices. However, she did not exercise and did not include it in her health promotion activities after diagnosis. The patient is also not only disabled but also depressed and leads a life of isolation. With her family's assistance, she enrolled for a Cornerstone program in which she exercises twice a week.
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Rationale
Globally, lack of physical activity ranks fourth among the leading causes of mortality. The risk of developing some cancers such as colon cancer is increased by obesity and overweight (Lui et al., 2018, p. 218). According to Lui et al. (2018), there exist various possible ways through which physical inactivity increases the likelihood of developing cancer. The mechanisms include reducing weight, changes in the amounts of metabolic and sexual hormones, and less oxidative stress (Lui et al., 2018, p. 218). Existing evidence shows that physical activity can minimize the likelihood of developing certain kinds of cancer by reducing systemic inflammation as well as improving an individual's defense mechanism. The findings of Lui et al. (2018, p. 229) show a significant decrease in colon cancer among women who had a physical activity for more than four hours every week.
Physical activity is effective in eliminating the negative effects associated with cancer treatment, development of the disease, and its recurrence (Malek, 2018, p. 306). It helps enhance overall health, the quality of life, and many other positive patient outcomes. According to Nadler et al. (2017, p. 2298), resistance and aerobic activities enhance the quality of life for patients who have cancer during the treatment process and after treatment. Besides, the physical activities not only improve their muscular fitness but aerobic well-being also. Evidence suggests that both resistance and aerobic physical activities are safe for cancer patients and survivors (Nadler et al., 2017, p. 2298). However, although not common, the negative experiences related to exercise that have been observed include sore muscles and musculoskeletal bruises.
Overview of the Transtheoretical Model (TTM)
Stages of TTM
The TTM is a framework of change used in creating effective interventions for positive behavior change to improve health. It explains how an individual's behavior can be modified or develops positive behavior. The model pays attention to a person's decision making and the change created is intentional. Change occurs through a pattern of five main stages. These TTM stages include:
Pre-contemplation
Contemplation,
Preparation,
Action
Maintenance
In pre-contemplation, a person does not intend to do anything about the near future, which is, in most cases, explained in terms of the following six months (Velicer et al., 1998, p. 218). An individual can be in this stage as a result of not being informed or less informed about the results of his/her conduct. Individuals in the contemplation stage are those who intend to make changes in their lifestyles within the next six months (Velicer et al., 1998, p. 218). People at this stage are adequately informed on the advantages of implementing change and the disadvantages. Challenges in balancing costs and gains of implementing change can make people stay in this stage for a long time. Preparation involves an intention to take action on lifestyle changes soon, which is defined as within the next month. Such people have plans for activities such as joining an exercise program or see a counselor, among other actions. In the action stage, an individual has made some significant changes within the previous six months or so (Velicer et al., 1998, p. 218). Being vigilant in this stage is essential in the prevention of a relapse. Maintenance is the last stage of the change process and involves efforts to avoid a relapse. Also, people in this stage do not implement change activities as often as those in the action stage.
How TTM works
Readiness to change is one of the essential factors in enhancing behavior change in people who need to change their living styles for health reasons. On its part, motivation influences choice, adherence, and effectiveness of treatment. TTM suggests three measures that are sensitive throughout all the five stages of change. The measures include decisional balance and situational temptation measures. Besides, self-efficacy is one of the measures for readiness to change and motivation. The decision balance measure shows a person's balance of advantages and disadvantages of change. It involves measuring the importance of advantages and disadvantages. A predictable series is always seen of how both advantages and disadvantages relate to each stage of the change process. The self-efficacy measure indicates a person's confidence specific to a certain situation to cope without falling back to practices that are not healthy. Situational temptation shows the degree of compulsion to engage in a particular activity when experiencing a difficult circumstance (Prochaska, 2008). The situational temptation is the opposite of self-efficacy. Both use similar measurement aspects but different response methods.
The self-efficacy measure and temptation measures are sensitive to variations in the last two stages of the change process and therefore, can be used to predict a setback (Velicer et al., 1998, p. 221). Self-efficacy usually increases in function throughout the change process stages, while temptation decreases throughout the stages. Prochaska and Declemente identified several strategies that can enable people to execute and maintain changes in their behaviors. The strategies are referred to as processes of change, and they include increasing awareness, dramatic reassurance, environmental re-assessment, personal re-examination, social liberation, social freedom, counter-conditioning, stimulus management, assisting relationships, rewarding, and personal deliverance (Velicer et al., 1998, p. 222).
Application of TTM
The patient being analyzed is in the action stage of her change process. She has made some changes in her lifestyle in the past six months. She quit smoking, stopped drinking alcohol, and made several changes in her diet, such as reducing the amount of red meat consumed elimination of refined foods, and inclusion of wholesome foods in her diet. Also, she has enrolled in an exercise program (Corner Stone Program), where she does exercise twice a week. The patient has increased awareness of the causes, outcomes, and interventions for her behavior. She also has a helping relationship, whereby her family members have supported her in the cornerstone program. To assist the patient to enter the next stage, which is maintenance; motivational counseling once in two weeks for three months would be used.
Different people are motivated by different reasons to engage in exercise. Some are motivated by reasons such as personal goals. Motivation towards exercise changes with increasing age. Younger people tend to enjoy exercise more than elderly ones. The patient being analyzed in this paper is an older woman aged 61 years. There is a need to motivate the patient to progress to the next stage because the motivation to exercise reduces with age. From a psychological perspective, motivation is in most cases tied to emotion; meaning that a positive response to a message that explains the benefits of physical activity can cause a positive variation in attitude and the end lead to improved behavior changes (Steltenpohl et al., 2019, p. 710). Positive encounters and emotions are effective in the elderly, and that is why motivation counseling would be effective for the patient. The fact that she is disabled may hinder her progression to the next stage. However, with effective motivation counseling, the barrier can be overcome.
Excess weight is closely associated with physical inactivity. The physical activity presents several significant benefits to survivors of colon cancer. Exercise involvement in cancer patients and survivors is effective and safe when undergoing treatment and after therapy. Also, activities such as walking faster decrease the risk of some cancers, among them colon cancer. The change process involves five steps in which readiness to change, and motivation plays a vital role. With counseling, the patient can be motivated to progress to the next stage.
There are different types of nursing interventions which aim at improving the behavior of a patient in certain situations. One such intervention is known as reinforcement. Reinforcement is a nursing intervention principle that helps to increase the probability that a particular behavior will recur in future due to a certain stimulus after a behavior is exhibited. There is positive reinforcement which motivates an individual to repeat a particular action. It is a reinforcing stimulus that makes the behavior to more likely happen in future. A nurse can intervene in a situation where a patient has an addiction problem by a certain stimulus such as helping with the withdrawal process by providing the necessary plan of withdrawal. It can be done through gradual withdrawal of the said drug which will encourage less use of the drug. On the other hand, there is negative reinforcement when a particular stimulus is eliminated after a particular behavior is observed. The removal of the negative consequence encourages the possibility of the behavior from increasing in future. Negative reinforce is a form of punishing intervention which aims at encouraging a certain type of behavior.
In nursing practice the principle of self-liberation is the belief that the patient can develop awareness of the interventions being put in place to support his social changes and his acceptance of the societal influences which will encourage a change in behavior to that which is desirable. The nurse will assess how the patient feels about the self and makes corrective measures to channel his behaviors into a desirable outcome. The nurse will engage the patient into a helpful relationship that will help him to transit to the next stage. For example a patient with a weight problem will be encouraged to embrace healthy eating habits and performance of exercises to help him solve his overweight problem. All these nursing interventions helps the patient to change his behaviors to a desired outcome.
References
Malek, L., Wan, B. A., Gao, M., Diaz, P., Lam, H., Fiona Lim, DeAngelis, C., Silva, M. F., & Chow, E. (2018). Perspectives of patients and heath care providers on cancer and exercise. Journal of Pain Management , 11 (3), 305–309.
Lui, L., Lim, F., Yuen, M., Wan, B. A., Lam, H., Diaz, P., DeAngelis, C., Silva, M. F., & Malek, L. (2018). Cancer prevention with exercise. Journal of Pain Management, 11 (3), 217–233.
Nadler, M., Bainbridge, D., Tomasone, J., Cheifetz, O., Juergens, R., Sussman, J., & Juergens, R.A. (2017). Oncology care provider perspectives on exercise promotion in people with cancer: an examination of knowledge, practices, barriers, and facilitators. Supportive Care in Cancer , 25 (7), 2297–2304.
Prochaska, J. O. (2008). Decision making in the transtheoretical model of behavior change. Medical decision making , 28 (6), 845-849.
Steltenpohl, C. N., Shuster, M., Peist, E., Pham, A., & Mikels, J. A. (2019). Me Time, or We Time? Age Differences in Motivation for Exercise. Gerontologist , 59 (4), 709–717.
Velicer, W. F., Prochaska, J. O., Fava, J. L., Norman, G. J., & Redding, C. A. (1998). Smoking Cessation and Stress Management: Applications of the Transtheoretical Model of Behavior Change. Homeostasis Praha-, 38, 216-233.
