THE S CIENCE OF

Behavior Change The Transtheoretical Model of Health Change

James O. Prochaska, Wayne F. Velicer

Abstract The transtheoretical model uses a temporal dimension, the stages of The transtheoretical model posits that health behavior change involves progress through change, to integr~.te processes and six stages of change: precontemplation, contemplation, preparation, action, maintenance, principles of change from different and termination. Ten processes of change have been identified for producing progress along theories of intervention, hence the with decisional balance, self-efficacy, and temptations. Basic research has generated a rule name transtheoretical. This model of thumb for at-risk populations: 40 % in precontemplation, 40 % in contemplation, and emerged from a comparative analysis 20%in preparation. Across 12 health , consistent patterns have been found be- of leading theories of tween the pros and cons of changing and the stages of change. Applied research has dem- and behavior change. The goal was a onstrated dramatic improvementsin recruitment, retention, and progress using stage- systematic integration of a field that matched interventions and proactive recruitment procedures. The most promising outcomes had fragmented i:ato more than 300 to date have been found with computer-based individualized and interactive interventions. theories of psychotherapy. 1 The com- The most promising enhancement to the computer-based programs are personalized counsel- parative analysis i,zlentified 10 distinct ors. Oneof the most striking results to date for stage-matchedprograms is the similarity processes of change, such as con- between participants reactively recruited whoreached us for help and those proactively re- sciousness raising from the Freudian cruited who we reached out to help. If results with stage-matched interventions continue to tradition, be replicated, health promotion programswill be able to produce unprecedented impacts on from the Skinnerian tradition, and entire at-risk populations. (Am J Health Promot 1997;1211]:38-48.) helping relationships from the Ro- Key Words: Transtheoretical Model, Stages of Change, Proactive Recruitment, gerian tradition. Computerized Interventions, Decisional Balance, Processes of Change In an empiric~.l analysis of self- changers compared to smokers in professional treatments, we assessed how frequently each group used each of the 10 processes. 2 Our research participants kept saying that they used different processes at different times in their straggles with . These naive subjects were teaching us about a phenomenon that was not included in any of the multitude of therapy theories. They were revealing to us that behavior change unfolds through3 a series of stages. From the initial studies of smok- ing, the stage model rapidly expand- ed in scope to ir.clude investigations and applications with a broad range James o. Prochaska, PhD, and WayneF. Velic~ PhD, are at the Cancer Prevention Research of health and behav- Cent~ University of Rhode Island, Kingston, Rhode Island. iors. These include alcohol and sub- stance abuse, anxiety and panic dis- Send reprint requests to James o. Prochaska, Cancer Prevention Research Center, 2 ChafeeRoad, University of RhodeIsland, Kingston, RI 02881-0808; [email protected]. orders, delinquency, eating disorders and obesity, high-fat diets, AIDS pre- Thismanuscript was submitted April 1, 1997;revisions roere requested April 7, 1997;the manuscriptwas accepted for publicationMay 5, 199Z vention, mammography screening, medication compliance, unplanned AmJ HealthPromot 1997;12(1):38-48. Copyright© 1997 by AmericanJournal of HealthPromotion, Inc. pregnancy prevention, pregnancy 0890-1171/97/$5.00+ 0 and smoking, ration testing, seden-

38 AmericanJournal of HealthPromotion tary lifestyles, sun exposure, and phy- people are intending to take action we viewed relapse as a separate stage. sicians practicing preventive medi- in the immediate future, usually mea- Relapse is one form of regression, cine. Over time, these studies have sured as the next month. They have which is a return to an earlier stage. applied, expanded, validated, and typically taken some significant ac- Relapse is the return from action or challenged the core constructs of the tion in the past year. These individu- maintenance to an earlier stage. The transtheoretical model. als have a plan of action, such as bad news is that relapse tends to be joining a class, con- the rule when action is taken for CORE CONSTRUCTS sulting a counselor, talking to their most health behavior problems. The physician, buying a self-help book, or good news is that for smoking and Stages of Change relying on a self-change approach. exercise only about 15% of people The stage construct is important These are the people we should re- regress all the way to the precontem- in part because it represents a tem- cruit for such action-oriented pro- plation stage. The vast majority re- poral dimension. Change implies grams as , weight turn to contemplating or preparing phenomena occurring over time, but loss, or exercise. for another serious attempt at action. surprisingly, none of the leading the- Action is the stage in which peo- Termination is the stage in which ories of therapy contained a core ple have made specific overt modifi- individuals have zero temptation and construct representing time. Behav- cations in their life styles within the 100% self-efficacy. No matter whether ior change was often construed as an past 6 months. Since action is observ- they are depressed, anxious, bored, event, such as quitting smoking, able, behavior change often has been lonely, angry, or stressed, they are drinking, or overeating. The trans- equated with action. But in the trans- sure they will not return to their old theoretical model construes change theoretical model, action is only one unhealthy habit as a way of coping. It as a process involving progress of six stages. Not all modifications of is as if they never acquired the habit through a series of six stages. behavior count as action in this mod- in the first place. In a study of for- Precontemplation is the stage in el. People must attain a criterion that mer smokers and alcoholics, we which people are not intending to scientists and professionals agree is found that less than 20% of each take action in the foreseeable future, sufficient to reduce risks for disease. group had reached the criteria of usually measured as the next 6 In smoking, for example, the field zero temptation and total self-effica- months. People may be in this stage used to count reduction in the num- cy. -~ The criteria may be too strict, or because they are uninformed or un- ber of cigarettes as action, or switch- it may be that this stage is an ideal derinformed about the consequences ing to low tar and nicotine cigarettes. goal for the majority of people. In of their behavior. Or they may have Now, the consensus is clear--only to- other areas, like exercise, consistent tried to change a number of times tal abstinence counts. In the diet condom use, and weight control, the and become demoralized about their area, there is a consensus that less realistic goal may be a lifetime of abilities to change. Both groups tend than 30% of calories should be con- maintenance. Since termination may to avoid reading, talking, or thinking sumed from fat. But there are those not be a practical reality for a majori- about their high risk behaviors. They who believe that this guideline needs ty of people, it has not been given as are often characterized in other the- to be lowered to 25% or even 20%. much emphasis in our research. ories as resistant or unmotivated cli- Maintenance is the stage in which ents or as not ready for therapy or people are working to prevent re- Processes of Change health promotion programs. The fact lapse but they do not apply change Processes of change are the covert is, traditional health promotion pro- processes as frequently as do people and overt activities that people use to grams were not ready for such indi- in action. They are less tempted to progress through the stages. Process- viduals and were not motivated to relapse and increasingly more confi- es of change provide important match their needs. dent that they can continue their guides for intervention programs, Contemplation is the stage in changes. Based on temptation and since the processes are like the inde- which people are intending to self-efficacy data, we estimated that pendent variables that people need change in the next 6 months. They maintenance lasts from 6 months to to apply to move from stage to stage. are more aware of the pros of chang- about 5 years. While this estimate Ten processes have received the most ing but are also acutely aware of the may seem somewhat pessimistic, lon- empirical support in our research to cons. This balance between the costs gitudinal data in the 1990 Surgeon date.6 and benefits of changing can pro- General’s report gave some support Consciousness Raising involves in- duce profound ambivalence that can to this temporal estimate. 4 After 12 creased awareness about the causes, keep people stuck in this stage for months of continuous abstinence, consequences, and cures for a partic- long periods of time. We often char- the percentage of individuals who re- ular problem behavior. Interventions acterize this phenomenon as chronic turned to regular smoking was 43%. that can increase awareness include contemplation or behavioral procras- It was not until 5 years of continuous feedback, education, confrontation, tination. These folks are also not abstinence that the risk for relapse interpretation, bibliotherapy, and me- ready for traditional action-oriented dropped to 7%. dia campaigns. programs. In one of our early articles, we Dramatic Relief initially produces in- Preparation is the stage in which gave the misleading impression that creased emotional experiences foi-

September/October1997, Vol. 12, No. 1 39 lowed by reduced affect if appropri- willpower. Motivation research indi- probability that healthier responses ate action can be taken. Psychodra- cates that people with two choices will be repeated. ma, role playing, grieving, personal have greater commitment than peo- Helping Relation,chips combine car- testimonies, and media campaigns ple with one choice; those with three ing, trust, openness, and acceptance are examples of techniques that can choices have even greater commit- as well as support :!or the healthy be- move people emotionally. ment; having four choices does not havior change. Rapport building, a Self-reevaluation combines both cog- further enhance willpower. 4 So with therapeutic alliance, counselor calls, nitive and affective assessments of smokers, for example, three excellent and buddy systems can be sources of one’s self-image with and without a action choices they can be given are social support. particular unhealthy habit, such as cold turkey, nicotine fading, and nic- one’s image as a couch potato and otine replacement. Decisional Balance, an active person. Value clarification, Social Liberation requires an in- Decisional balance reflects the in- healthy role models, and imagery are crease in social opportunities or al- dividual’s relative weighing of the techniques that can move people eval- ternatives especially for people who pros and cons of changing. Original- uatively. are relatively deprived or oppressed. ly, we relied on Janis and Mann’s Environmental Reevaluation com- Advocacy, empowerment procedures, model of decision making that in- bines both affective and cognitive as- and appropriate policies can produce cluded four categories of pros (in- sessments of how the presence or ab- increased opportunities for minority strumental gains for self and others sence of a personal habit affects health promotion, gay health promo- and approval for self and others).7 one’s social environment such as the tion, and health promotion for im- The four categoric s of cons were in- effect of smoking on others. It can poverished people. These same pro- strumental costs tc, self and others also include the awareness that one cedures can also be used to help all can serve as a positive or negative people change such as smoke-free and disapproval from self and others. role model for others. Empathy train- zones, salad bars in school lunches, In a long series of studies attempting ing, documentaries, and family inter- and easy access to condoms and oth- to produce this structure of eight fac- ventions can lead to such reassess- er contraceptives. tors, we always found a much simpler ments. Counterconditioning requires the structure--just the pros and cons of 8 A brief television spot from Cali- learning of healthier behaviors that changing. fornia’s antitobacco campaign was can substitute for problem behaviors. designed to help smokers in precon- Relaxation can counter stress; asser- Self-efficacy templation to progress. In this spot, a tion can counter peer pressure; nico- Self-efficacy is the situation-specific middle-aged man clearly in grief says, tine replacement can substitute for confidence people have that they can "I always worried that my smoking cigarettes; and fat-free foods can be cope with high risk situations without would cause lung cancer. I was always safer substitutes. relapsing to their unhealthy or high afraid that my smoking would lead to removes cues for risk habit. This construct was inte- an early death. But I never imagined unhealthy habits and adds prompts grated from Bandura’s self-efficacy that it would happen to my wife." for healthier alternatives. Avoidance, theory.9,l0 Then on the screen is flashed the environmental reengineering, and message, "50,000 deaths per year due self-help groups can provide stimuli Temptation to passive smoking"--California De- that support change and reduce risks Temptation reflects the intensity partment of Health. for relapse. Planning parking lots There are no action directives in . with a 2-minute walk to the office of urges to engage, in a specific habit when in the midst of difficult situa- this intervention but there is: (1) and putting art displays in stairwells consciousness raising--50,000 deaths are examples of reengineering that tions. In our research, we typically per year; (2) dramatic relief---around can encourage more exercise. find three factors reflecting the most grief, guilt, and fear that can be re- Contingency Management provides commontypes of ::empting situations: duced if appropriate action is taken; consequences for taking steps in a negative affect or .emotional distress, (3) self-reevaluation--how do I think particular direction. While contin- positive social situations, and crav- and feel about myself as a smoker; gency management can include the ing.~ ~ and (4) environmental reevalua- use of punishments, we found that The transtheoretical model has tion-how do I feel and think about self-changers rely on rewards much concentrated on five stages of the effects of my smoking on my en- more than punishments. So rein- change, 10 proces.ses of change, the vironment. forcements are emphasized, since a pros and cons of c hanging, self-effi- Self-liberation is both the belief that philosophy of the stage model is to cacy, and temptati3n. In addition, one can change and the commit- work in harmony with how people the model includes a measure of the ment and recommitment to act on change naturally. Contingency con- target behavior. The transtheoretical that belief. NewYear’s resolutions, tracts, overt and covert reinforce- model is also base :1 on critical as- public testimonies, and multiple rath- ments, positive self-statements, and sumptions about tlae nature of behav- er than single choices can enhance group recognition are procedures for ior change and in:erventions that self-liberation or what the public calls increasing reinforcement and the can best facilitate ~uch change.

40 AmericanJournal of HealthPromotion Critical Assumptions The following are a set of assump- Table 1 tions that drive transtheoretical theo- ry, research, and practice. Distribution of Smokersby Stage Across Four Different Samples*

(1) No single theory can account for Precon- all of the complexities of behav- Sample templation Contemplation Preparation SampleSize ior change. Therefore, a more Randomdigit dial 42.1% 40.3% 17.6% 4144 comprehensive model will most FourU.S. worksites 41.1% 38.7% 20.1% 4785 likely emerge from an integra- California 37.3% 46.7% 16.0% 9534 tion across major theories. RI high schools 43.8% 38.0% 18.3% 208 (2) Behavior change is a process that * Thesestudies assess current smokers; therefore, no respondentsare in actionor mainte- unfolds over time through a se- nance. quence of stages. (3) Stages are both stable and open to change, just as chronic behav- the stage distributions of specific much simpler structure than Janis ioral risk factors are both stable high risk behaviors. Table 1 presents and Mann’s theory suggests. Across results from a series of studies on studies of 12 different behaviors and open to change. smoking that have clearly demon- (4) Without planned interventions, (smoking cessation, quitting cocaine, strated that less than 20% of smokers populations will remain stuck in weight control, dietary fat reduction, are in the preparation stage in most safer sex, condom use, exercise ac- the early stages. There is no in- populations, l’~ Approximately 40% of quisition, sunscreen use, radon test- herent motivation to progress smokers are in the contemplation through the stages of intentional ing, delinquency reduction, mam- stage, and another 40% are in pre- change as there seems to be in mography screening, and physicians contemplation. These results show practicing preventive medicine), the stages of physical and psychologi- that action-oriented cessation pro- cal development. two-factor structure was remarkably grams will not match the needs of stable. 14 (5) The majority of at-risk popula- the vast majority of smokers. tions are not prepared for action With a sample of 20,000 members and will not be served by tradi- Integration of Pros and Cons and of an HMO,the stage distribution tional action-oriented prevention Stages of Change Across 12 Health was assessed for 15 health behav- programs. Health promotion can Behaviors iors. 1-~ While there are variations in have much greater impacts if it Stage is not a theory; it is a vari- the distributions, for these high risk shifts from an action paradigm able. A theory requires systematic re- behaviors, the results support a gen- to a stage paradigm. lationships between a set of variables, eral rule of thumb: 40% in precon- (6) Specific processes and principles ideally culminating in mathematical templation, 40% in contemplation, of change need to be applied at relationships. Figure 1 shows that in and 20% in preparation. specific stages if progress all 12 studies, the pros of changing Our research has focused on the through the stages is to occur. In are higher than the cons for people stage distribution of people currently the stage paradigm, intervention in precontemplation. 14 In all 12 stud- at risk because these are the groups ies, the pros increase between pre- programs are matched to each typically targeted for health promo- contemplation and contemplation. individual’s stage of change. tion programs. There is research in There arc no systematic differences (7) Chronic behavior patterns are the literature on the percentages of usually under some combination on the cons between prccontcmpla- populations who were formerly at tion and contemplation. But from of biological, social, and self-con- risk but not currently at risk. For ex- contemplation to action for all 12 be- trol. Stage-matched interventions ample, of ever smokers, about 45% haviors, the cons of changing arc have been primarily designed to are former smokers. The Surgeon lower in action than in contempla- enhance self-controls. General’s Report of 1990 reports the tion. In 11 of the 12 studies, the pros percent of ever smokers who quit in of changing are higher than the cons BASIC RESEARCH SUPPORT the last year (57%), 1 to 5 years (10%), and more than 5 years for people in action. These basic findings suggest prin- Each of the core constructs has (30%).4 While such data have epide- been subjected to a wide variety of miological significance, they are not ciples for progressing through the studies across a broad range of be- nearly as helpful in program plan- stages. To progress from precontem- haviors and populations. Only a sam- ning as is the stage distribution of plation to contemplation, the pros of pling of these studies can be re- populations currently at risk. changing must increase. To progress viewed here. from contemplation to action, the Pros and Cons Structure Across 12 cons of changing must decrease. So Stage Distribution Behaviors with people in precontcmplation, we If we are to match the needs of As indicated earlier, the pros and would target the pros for interven- entire populations, we need to know cons of decisional balance have a tion and save the cons for after they

September/October1997, Vol. 12, No. 1 41 progress to contemplation. Before Figure 1 progressing to action, we would want to see the pros and cons crossing The Pros and Cons of Changing Across the Stages of Changefor 12 Problem over, with the pro., higher than the Behaviors cons as a sign of being well prepared for action.

55 Strong and Weak Principles of Progress Across these saine 12 studies, mathematical relationships were 45 45 found between th,. ~ pros and cons of changing and progress across the 40 P C A M PC C A M stages. 1,~ Stage of Smoking Stage of Condom Use 60 60 The Stron[: Principle is.’ PC-~ A - i[ SD T PROS 55 Progress from precontemplation to

50 50 action involves approximately one standard deviation (SD) increase the pros of changing. On intelli- gence tests, a one-SD increase would 40 40 C C A M PC C A M be 15 points, which is a substantial Stage of Quitting Cocaine Stage of Using Sunscreens increase. 60 6o The Weak Principle is:

55 PC-~ A = .5 SD $ CONS

Progress from precontemplation to action involves approximately a 45 .5-SD decrease in the cons of chang- ing. Because the first principle in- Pc c A M PC c A volves twice as gr._~at a change as the Stage of Weight Control Stage of Radon Testing second, we titled the first strong and the second weak. Practical implications of these principles are that the pros of chang- ing must increase twice as much as the cons decrease. Perhaps twice as Stage of Reducing Fat 60 much emphasis should be placed on raising the benelits as on reducing Pc c P A M the costs or barr!.ers. For example, if Stage of Exercising couch potatoes in precontemplation so can list only five pros of exercise, then being too lzusy will be a big bar- rier to change. ]~.ut if program partic- ipants come to appreciate that there can be more than 50 benefits for 60 Stages of Changing Delinquency minutes of exercise a week, being too busy becomes a relatively smaller barrier. 55 Pc Stage of Mammography Screening 60 Processes of Change Across Behaviors One of the a.,sumptions of the transtheoretical model is that there is a common set o~ change processes Stage of Safer Sex people can applv across a broad range of behaviors. While we have fo- ¯ PROS cused most on 10 separate processes, CONS Stage of Arranging Followup Appointments

42 AmericanJournal of HealthPromotion we have also examined how these 10 factor together. This is called the Table 2 higher order structure of the pro- cesses. With the higher order, we Stages of Changein Which ChangeProcesses Are Most Emphasized consistently find two factors: (1) expe- riential processes that include more in- Stagesof Change ternal experiences like consciousness Precontem- raising, dramatic relief, and self-re- plation Contemplation Preparation Action Maintenance evaluation; and (2) behavioral processes Processes Consciousnessraising that include more overt activities like Dramaticrelief helping relationships, contingency Environmentalreevaluation management, and stimulus control. Self-reevaluation The experiential and behavioral pro- Self-liberation cesses have replicated across problem Contingencymanagement behaviors better than have the 10 Helpingrelationship specific16 processes. Counterconditioning Typically, we have found support Stimuluscontrol for our standard set of 10 processes across such behaviors as smoking, diet, cocaine use, exercise, condom nitive, affective, and evaluative pro- Americans continue to smoke. Over use, and sun exposure. But the struc- cesses to progress through the stages. 400,000 preventable deaths per year ture of the processes across studies In later stages, people rely more on are attributable to smoking.4 Global- has not been as consistent as the commitments, conditioning, contin- ly, the problem promises to be cata- structure of the stages and the pros gencies, environmental controls, and strophic. Of the people alive in the and cons of changing. In some stud- social support for progressing toward world today, 500 million are expect- ies, we find fewer processes and occa- termination. ed to die from this single behavior, sionally, we find evidence for one or Table 2 has important practical losing approximately 5 billion years two more. It is also very possible that implications. To help people progress of life to tobacco use. v~ If we could with some behaviors fewer change from precontemplation to cohtem- make even modest gains in our sci- processes may be used. With an in- plation, we need to apply such pro- ence and practice of smoking cessa- frequent behavior like yearly mam- cesses as consciousness raising and tion, we could prevent millions of mograms, for example, fewer process- dramatic relief. Applying processes premature deaths and help preserve es may be required to progress to like contingency management, coun- billions of years of life. long-term7 maintenance) terconditioning, and stimulus control Currently, smoking cessation clin- to people in precontemplation would ics have little impact. Whenoffered Integration of Relationships Between represent a theoretical, empirical, for free by HMOsin the United Stages and Processes of Change and practical mistake. But for people States, such clinics recruit only 1% of One of our earliest empirical inte- in action, such strategies would rep- subscribers who smoke. Such behav- grations was the discovery of system- resent an optimal matching. ior health services simply cannot atic relationships between the stage As with the structure of the pro- make much difference if they treat people were in and the processes cesses, the integration of the process- such a small percentage of the prob- they were applying. This discovery al- es and stages has not been as consis- lem.20 lowed us to integrate processes from tent as the integration of the stages Startled by such statistics, behav- theories that were typically seen as and pros and cons of changing. ioral scientists took health promotion incompatible and in conflict. For ex- While part of the problem may be programs into communities. The re- ample, Freudian theory that relied due to the greater complexity of inte- sults are now being reported, and in almost entirely on consciousness rais- grating 10 processes across five the largest trials ever attempted, the ing for producing change was viewed stages, the processes of change need outcomes are discouraging. In the as incompatible with Skinnerian the- more basic research. Minnesota Heart Health Program, ory that relied entirely on contingen- for example, $40 million was spent cy management for modifying behav- APPLICATIONS OF THE with 5 years of intervention in four ior. But self-changers did not know TRANSTHEORETICAL MODEL: communities totalling 400,000 peo- that these processes were theoretical- SMOKING CESSATION ple. There were no significant differ- ly incompatible, and they taught us INTERVENTIONS AS ences between treatment and control that processes from very different PROTOTYPES FOR STAGE- communities on smoking, diet, cho- theories needed to be emphasized at MATCHED PROGRAMS lesterol, weight, blood pressure, and different stages of change. Table 2 overall risks for cardiovascular dis- 21 presents our current empirical inte- Smoking is costly to individual CaSe. gration. Is This integration suggests smokers and to society. In the United What went wrong? The investiga- that in early stages, people apply cog- States, approximately 47 million tors speculate that maybe they dilut-

September/October1997, Vol. 12, No. 1 43 ed their programs by targeting multi- smokers to stage-matched interven- ple behaviors. But the COMMITtrial tions. For each of five stages, these Figure 2 had no effects with its primary target interventions included self-help man- Pre-therapy Stage Profiles for of heavy smokers and only a small ef- uals; individualized computer feed- z’~ Premature Terminators, Appropriate fect with light smokers, back reports based on assessments of Terminators, ~nd Continuers A closer look at participation rates the pros and cons, processes, self-effi- may explain some of the disappoint- cacy, and temptations; and, for some 55 ing results. In the Minnesota study, participants, counselor protocols 53 nearly 90% of smokers in both the based on the computer reports. Us- treatment and control communities ing these proactive recruitment ~ 51 had processed media information methods and stage-matched interven- ~ 49 about smoking in the past year. But tions, we were able to generate par- only about 10% had been advised to ticipation rates of 82 to 85%, respec- PrematureTerml ~ation z:~ 45 -- o.. AppropriateTern ~lnation quit by their physicians, And only tively (Prochaska, et al., unpublished -~- Continuers about 3% had participated in the manuscript; Velicer, et al., unpub- 43 most powerful behavioral programs, lished manuscript). Such quantum Pre-Contemplati0n Action Conten tplation Maintenance such as individualized and interactive increases in participation rates pro- clinics, classes, and contests. In one vide the potential to generate un- of the Minnesota Heart Health stud- precedented impacts with entire pop- ies, smokers were randomly assigned ulations of smokers. 35% of smokers ir~ precontemplation to one of three recruitment methods Population impact equals partici- signing up. But ortly 3% showed up for’~4 home-based cessation programs. pation rate times the rate of efficacy and 2% finished. With a combination These announcements generated 1 or action. "~5 If a program produced of smokers in con :emplation and to 5% participation rates, with a per- 30% efficacy (such as long-term absti- preparation, 65% signed up, 15% sonalized letter doing the best. We nence), historically it was judged to showed up, and 111% finished. cannot have much impact on the be better than a program that pro- To optimize our impacts, we need health of our communities if we only duced 25% abstinence. But a pro- to use proactive p::otocols to recruit interact with a small percentage of gram that generates 30% efficacy but participants to programs that match populations at high risk for disease only 5% participation has an impact the stage they are in. Once we gener- and early death. of only 1.5% (30% × 5%). A pro- ate high recruitm~:nt rates, we then One alternative is to shift from an gram that produces only 25% effica- have to be concerned about high re- action paradigm to a stage paradigm, cy but 60% participation has an im- tention rates, lest we lose many of in order to increase our reach and pact of 15%. With health promotion the initial participants in our health interact with a much higher percent- programs, this would be 1000% promotion programs. age of populations at risk. Let us ex- greater impact on a high risk popula- amine how the stage paradigm has tion. Retention been applied to five of the most im- The stage paradigm would shift One of the ske~etons in the closet portant phases of health promotion our outcomes from efficacy alone to of psychotherapy and behavior programs. impact. To achieve such high impact, change interventions is their relative- we need to shift from reactive re- ly poor retention cares. Across 125 Recruitment cruitment, where we advertise or an- studies, the average retention rate Recall that action-oriented cessa- nounce our programs and react was only about 50%.27 Furthermore, tion programs falter in this first when people reach us, to proactive this meta-analysis found few consis- phase of intervention and produce recruitments, where we reach out to tent predictors of which participants low participation rates. Table 1 re- interact with all potential partici- would drop out p::ematurely and ported results that can help explain pants. which would conttnue in therapy. In such low rates. Across four different But proactive recruitment alone studies on smoking, weight control, samples, 20% or less of smokers were won’t work. In the most intensive re- substance abuse, and a mixture of in the preparation stage, v’ When we cruitment protocol to date, Lichten- Diagnostic and S~:ttistical Manual IV advertise or announce action-orient- stein and Hollis had physicians spend (DSM-IV) disordecs, stage-of-change ed programs, we are explicitly or im- time with each smoker just to get measures proved ~:o be the best pre- plicitly targeting less than 20%of a them to sign up for an action-orient- dictors of premature termination. population. The other 80% plus are ed cessation clinicY 6 If that didn’t Figure 2 presents the stage profile of left on their own. work, a nurse spent 10 minutes per- three groups of therapy participants In two home-based recruitments suading each smoker to sign up, fol- in treatment for a variety of mental with approximately 5000 and 4600 lowed by 12 minutes with a videotape health problems: the pretreatment smokers in each study, we reached and health educator and even a stage profile of the entire 40% who out either by telephone alone or by proactive counselor call if necessary. dropped out prematurely as judged personal letters followed by tele- The base rate was 1% participation. by their therapist~ was that of pa- phone calls, if needed, and recruited This proactive protocol resulted in tients in precontemplation. The 20%

44 AmericanJournal of HealthPromotion who terminated quickly but appropri- tance with individuals in precontem- ately had a profile of patients in ac- Figure 3 plation. With these individuals, more tion. Using pretreatment stage-relat- experiential processes like conscious- Percentage Abstinent over 18 ed measures, we were able to correct- ness raising and dramatic relief can Months for Smokersin ly predict retention status for 93% of move people cognitively and affec- Precontemplation(PC), the three groups (Medeiros, et al., tively, and help them shift to contem- Contemplation(C), and PreparatiOn -~ unpublished manuscript). (C/A) Stages Before Treatment (n plation. We simply cannot treat people 570) After 15 years of research, we have with a precontempla.tion profile as if identified 14 variables on which to they were ready for action interven- POINT-PREVALENTABSTINENCE (%) intervene in order to accelerate BY STAGEOF CHANGE tions and expect them to stay in 30 progress across the first five stages of treatment. Relapse prevention strate- change. -~° At any particular stage, we gies would be indicated with smokers only need to intervene with a maxi- who are taking action. But those in mumof six variables. To help guide precontemplation are more likely to 20 individuals at each stage of change, need dropout prevention strategies. we have developed computer-based The best strategy we have found expert systems that can deliver indi- to promote retention is matching our vidualized and interactive interven- interventions to stage of change. In tions to entire populations. "~ These four smoking cessation studies using computer programs can be used such matching strategies, we found alone or in conjunction with counsel- we were able to retain smokers in the o ors. precontemplation stage at the same Pretest 1 6 12 18 high levels as those who started in ASSESSMENTPERIODS Outcomes the preparation stage (Prochaska, et In our first large-scale clinical tri- al., unpublished manuscript; Velicer, al, we compared four treatments: (1) et al., unpublished manuscript). tional . With stage- one of the best home-based action- matched counseling, the strategic oriented cessation programs (stan- Progress goal is to help each patient progress dardized); (2) stage-matched manu- The amount of progress partici- one stage following one brief inter- als (individualized); (3) expert pants make following health promo- vention. One of the first reports is a tem computer reports plus manuals tion programs is directly related to marked improvement in the morale (interactive); and (4) counselors the stage they were in at the start of of such health promoters intervening computers and manuals (personal- the interventions. This stage effect is il- with all patients who smoke, abuse ized). We randomly assigned by stage lustrated in Figure 3, where smokers substances, and have unhealthy diets 739 smokers to one of the four treat° initially in precontemplation show (E Mason, unpublished data, 1996). ments.28 the smallest amount of abstinence These professionals now have strate- In the computer condition, partic- over 18 months and those in prepa- gies that match the needs of all of ipants completed by mail or tele- ration progress the most. 2s Across 66 their patients, not just the minority phone 40 questions that were en- different predictions of progress, we prepared to take action. Further- tered in our central computers and found that smokers starting in con- more, these professionals can assess generated feedback reports. The re- templation were about two-thirds progress across stages in the majority ports informed participants about more successful than those in pre- of their patients, where previously their stage of change, their pros and contemplation at 6-, 12-, and they experienced mostly failure when cons of changing, and their use of 18-month follow-ups. Similarly, those taking action was their only measure change processes appropriate to their in preparation were about two-thirds of movement. stages. At baseline, participants were more successful than those in con- given positive feedback on what they templation’,9 at the same follow-ups. Process were doing correctly and guidance These results can be used clinical- To help populations progress on which principles and processes ly. A reasonable goal for each thera- through the stages, we need to un- they needed to apply more in order peutic intervention with smokers is derstand the processes and principles to progress. In two progress reports to help them progress one stage. If of change. One of the fundamental delivered over the following 6 over the course of brief therapy they principles for progress is that differ- months, participants also received progress two stages, they will be ent processes of change need to be positive feedback on any improve- about two-and-two-thirds times more applied at different stages of change. ment they made on any of the vari- successful29 at longer term follow-ups. Traditional conditioning processes ables relevant to progressing. So, de- This strategy has been taught to like counterconditioning, stimulus moralized and defensive smokers more than 4000 primary care physi- control, and contingency control can could begin progressing without hav- cians, nurses, health educators, and be highly successful for participants ing to quit and without having to physicians’ assistants in Britain’s Na- taking action but can produce resis- work too hard. Smokers in the con-

September/October1997, Vol. 12, No. 1 45 er plus counselor conditions paral- abstinence rate fo:: the expert system Figure 4 leled each other for 12 months. was 23.2% vs. 17.5% for assessment Then, the effects of the counselor alone. The difference between the Point PrevalenceAbstinence (%) for condition flattened out while the Four TreatmentGroups at Pretest expert system and assessment alone and at 6, 12, and18 Months computer condition effects contin- for the two studie~ was 5.9 and 5.7 ued to increase. Wecan only specu- percentage points, respectively. These late as to the delayed differences be- replicated differences were highly sig- tween these two conditions. Partici- nificant as well. ~]aile working on a pants in the personalized condition population basis, we were able to 2O may have become somewhat depen- produce the level of success normally dent on the social support and social found only in intense clinic-based control of the counselor calling, The programs with low participation rates last call was after the 6-monthassess- of much more selected samples of ment, and benefits were observed at smokers. The implication is that once 12 months. Termination of the coun- expert systems ar,. ~ developed and selors could result in no further showeffectivenes;~ with one popula- Pretest 6 12 18 progress because of the loss of social tion, they can be transferred at much ASSESSMENTPERIODS support and control. The classic pat- lower cost and produce replicable tern in smokingcessation clinics is changes in new Fopulations. rapid relapse beginning as soon as templation stage could begin taking the treatment is terminated. Someof EnhancingInteractive Interventions small steps, like delaying their first this rapid relapse could well be due In recent bem:hmarking research, cigarette in the morning for an extra to the sudden loss of social support we have been trying to create en- 30 minutes. They could choose small or social control provided by the hancements to o~r expert system to steps that wouldincrease their self-ef- counselors and other participants in produce even greater outcomes. ficacy and help them become better the clinic. In the first enhancement in our prepared for quitting. The next test was to demonstrate HMOpopulatior~, we added a per- In the personalized condition, the efficacy of the expert system sonal hand-held ~omputer designed smokers received four proactive when applied to an entire population to bring the behavior under stimulus counselor calls over the 6-month in- recruited proactively. With over 80% control (Prochaska, et al., unpub- tervention period. Three of the calls of 5170 smokers participating and lished manuscript). This commercial- were based on the computer reports. fewer than 20%in the preparation ly successful innovation was an ac- On the other call, counselors report- stage, we demonstrated significant tion-oriented intervention that did ed muchmore difficulty in interact- benefits of the expert system at each not enhance om expert system pro- ing with participants without any 6-month follow-up (Prochaska, et al., gram on a poputation basis. In fact, progress data. Without scientific as- unpublished manuscript). Further- our expert system alone was twice as sessments, it was muchharder for more, the advantages over proactive effective as the system plus the en- both clients and counselors to tell assessment alone increased at each hancement. There are two major im- whether any significant progress had followupfor the full 2 years assessed. plications here: (1) more is not nec- occurred since their last interaction. The point prevalence abstinence essarily better, and (2) providing in- Figure 4 presents point prevalence rates for the expert system at 6, 12, terventions that are mismatched to abstinence rates for each of the four 18, and 24 months were 9.78, 18.0, stage can make 3utcomes markedly treatment groups over 18 months 21.7, and 25.6%, respectively, com- worse. with28 treatment ending at 6 months. pared to 7.4, 14.5, 16.6, and 19.7% The two self-help manual conditions for the assessment alone. The impli- Counselor Enh~ ncements paralleled each other for 12 months. cations here are that expert system In our HMOpopulation, counsel- At 18 months, the stage-matched interventions in a population can ors plus expert :;ystem computers manuals movedahead. This is an ex- continue to demonstrate benefits were outperforraing expert systems ampleof a delayed action effect, which long after the intervention has end- alone at 12 months (Prochaska, et we often observe with stage-matched ed. al., unpublished manuscript). But at programs. It takes time for partici- We then showed excellent replica- 18 months, the counselor enhance- pants in early stages to progress all tion of the expert system’s efficacy in ment had declined while the com- the way to action. Therefore, some an HMOpopulation of 4653 smokers puters alone had increased. Both in- treatment effects as measured by ac- with 85%recruited (Prochaska, et terventions wer,_~ producing identical tion will be observed only after con- al., unpublished manuscript; Velicer, outcomes of 23 2% abstinence, which siderable delay. But it is encouraging et al., unpublished manuscript). At are excellent for an entire popula- to find treatments producing thera- 18-monthfollow-up in the first study, tion. Whydid the effect of the coun- peutic effects months and even years the abstinence rate for the expert selor condition drop after the inter- after treatment ended. system was 21.7% vs. 16.6% for assess- vention? Our leading hypothesis is The computer alone and comput- ment alone. In the HMOstudy, the that people can become dependent

46 AmericanJournal of HealthPromotion on counselors for the social support lations will be interactive. In the re- our proactive counseling protocol and social monitoring that they pro- active clinical literature, it is clear had been revised and hopefully im- vide. Oncethese social influences are that interactive interventions such as proved based on previous data and withdrawn, people may do worse. behavioral counseling produce great- experience. But, the point is, if we The expert system computers, by er long-term abstinence rates (20 to reach out and offer people improved contrast, maymaximize self-reliance. 30%) than do noninteractive inter- health behavior programs that are In a current clinical trial, we are fad- ventions such as self-help manuals appropriate for their stage, we proba- ing out counselors over time as a (10 to 20)?"-’~4 It should be kept in bly can produce efficacy or absti- method for dealing with dependency mindthat these traditional action-ori- nence rates at least equal to those we on the counselor. If fading is effec- ented programs were implicitly or ex- produce with people who reach out tive, it will have implications for how plicitly recruiting for populations in to us for help. Unfortunately, there is counseling should be terminated: the preparation stage. Our results in- no experimental design that could gradually over time rather than sud- dicate that even with proactively re- permit us to randomly assign people denly. cruited smokers with less than 20% to proactive vs. reactive recruitment Webelieve that the most powerful in the preparation stage, the long- programs. Weare left with informal change programs will combine the term abstinence rates are in the 20 but provocative comparisons. personalized benefits of counselors to 30%range for the interactive in- If these results continue to be rep- and consultants with the individual- terventions and in the 10 to 20% licated, health promotion programs ized, interactive, and dam-basedben- range for the noninteractive inter- will be able to produce unprecedent- e fits of expert system computers. But ventions. The implications are clear. ed impacts on entire populations. We to date we have not been able to Providing interactive interventions believe that such unprecedented im- demonstrate that more costly coun- via computers are likely to produce pacts require scientific and profes- selors, who had been our most pow- greater outcomes than relying on sional shifts: erful change agents, can actually add noninteractive communications, such value over computers alone. These as newsletters, media, or self-help (1) from an action paradigm to findings have clear implications for manuals. stage paradigm; cost-effectiveness of expert systems (2) from reactive to proactive re- for entire populations needing Proactive vs. Reactive Results cruitment; health promotion programs. Webelieve that the future of (3) from expecting participants health promotion programs lies with match the needs of our pro- Interactive vs. Noninteractive stage-matched, proactive, and interac- grams to having our programs Interventions tive interventions. Muchgreater im- match their needs; and Another important aim of the pacts can be generated by proactive (4) from clinic-based to population- HMOproject was to assess whether programs because of much higher based behavioral health pro- interactive interventions (computer- participation rates, even if efficacy gramsthat still apply the field’s generated expert systems) are more rates are lower. But we also believe most powerful individualized and effective than noninteractive commu- that proactive programs can produce interactive intervention strate- nications (self-help manuals) when comparable outcomes to traditional gies. controlling for number of interven- reactive programs. It is counterintu- tion contacts (Velicer, et al., unpub- itive to believe that comparableout- Acknowledgments lished manuscript). At 6, 12, and 18 comes can be produced with people This research zoas partially supported by Grants CA months for groups of smokers receiv- whowe reach out to help as with 50087 and CA 27821 fiom the Natio~ml Cancer Insti- tute and Grant HC48190 fiom the National Heart, ing a series of one, two, three, or six people whocall us for help. But that Lung, and Blood b*stitute. interactive vs. noninteractive con- is what informal comparisons strong- tacts, the interactive interventions ly suggest. We compared 18-month References (expert system) outperformed the follow-ups for all subjects whore- 1. ProchaskaJO. Systems of Psychotherapy: A noninteractive manuals in all four ceived our three expert system re- Transtheoretical Analysis. 2ud ed. Pacific comparisons. In three of the compar- 2s Grove, California: Brooks-Cole, 1984. ports in our previous reactive study 2. DiClemente CC, ProchaskaJO. 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The Health Benefits of Smoking Cessa- ed smokers working with counselors tion: A Report of the Surgeon General. active interventions. and computers had higher absti- DHHSPublication No. CDC90-8416. Wash- These results support our hypoth- nence rates at each follow-up than ington, DC: US Governmeut Priuting Office, 1990. esis that the most powerful health did the smokers who had called for 5. Snow MG,Prochaska JO, Rossi JS. Processes promotion programs for entire popu- help. One of the differences is that of change in AA: maintenance factors in

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48 American Journal of Health Promotion