ISSN 2379-6391 SPORTS AND EXERCISE MEDICINE Open Journal PUBLISHERS Systematic Review Adoption of Change: A Systematic Review of the Transtheoretical Model Caitlin Vela, PT, DPT, CSCS1; Catherine Ortega, PT, EdD, ATC, OCS2* 1Baptist Health Link, San Antonio, Texas, USA 2Department of Kinesiology, University of Texas at San Antonio, San Antonio, Texas, USA *Corresponding author Catherine Ortega, PT, EdD, ATC, OCS Associate Professor, Department of Kinesiology, University of Texas at San Antonio, San Antonio, Texas, USA; E-mail: [email protected] Article information Received: September 9th, 2020; Accepted: September 19th, 2020; Published: September 28th, 2020 Cite this article Vela C, Ortega C. Adoption of change: A systematic review of the transtheoretical model. Sport Exerc Med Open J. 2020; 6(1): 27-38. doi: 10.17140/SEMOJ-6-179 ABSTRACT Introduction Sedentary lifestyle is a risk factor for life-altering comorbidities. Though the World Health Organization (WHO) and the Centers for Disease Control (CDC) have provided guidelines, 80% of Americans do not get the recommended physical activity (PA) dose per day. Motivation continues to be an important and elusive factor to effect change. Purpose Assess the available evidence regarding the application of the transtheoretical model and stages of change theory (TTM-SOC) in the last 10-years to behavior changes for PA. Methods Databases including PSYCInfo, ERIC, CINAHL, EBM, DARE, and OVID, were searched with the following key search terms: “Lifestyle Changes” OR “Lifestyle” OR “Active Living” OR “Lifestyle Changes” OR “Physical Activity” OR “Actigraphy” OR “Exercise” OR “Activity Level” AND “Transtheoretical Model” OR “Stages of Change”. Seventy-nine studies fit the inclusion criteria and were assessed for quality and validity using the PEDrO scale for experimental studies and the specialist unit for review evidence (SURE) for cohort investigations. Results Of the five (5) interventional studies included, none used all four components of the TTM-SOC, namely, stages of change, deci- sional balance, processes of change and self-efficacy. Observational studies were assessed with eleven (11) classified as observa- tional analytical and nineteen (19) as observational descriptive. Conclusion None of the investigations assessed the full TTM-SOC. As such, there can be no definitive conclusions with regard to the effec- tiveness of stage-matched interventions to promote a change from sedentary lifestyle to adoption of PA. There is a need for more rigorous research to test the application of TTM-SOC with both physiologic and quantitative measures for PA. Keywords Systematic review; Transtheoretical model; Stage of change; Physical activity. BACKGROUND participate in 30-minutes of physical activity per day.2 Current evidence suggests that sedentary lifestyles are associated with co- t is recommended that adults perform at least 2.5-hours of morbidities such as obesity, diabetes mellitus and cardiovascular Imoderate-intensity aerobic exercise or 1.25-hours of vigorous- disease,3 as well as poor health outcomes such as hypertension, intensity activity or some combination of both types of exercise hyperlipidemia, stroke, metabolic syndrome, osteoporosis, and in a week.1 However, on average, less than five percent of adults certain types of cancers.4,5 Though the cause of these comorbidi- cc Copyright 2020 by Ortega C. This is an open-access article distributed under Creative Commons Attribution 4.0 International License (CC BY 4.0), which allows to copy, redistribute, remix, transform, and reproduce in any medium or format, even commercially, provided the original work is properly cited. Systematic Review | Volume 6 | Number 1| 27 Sport Exerc Med Open J. 2020; 6(1): 27-38. doi: 10.17140/SEMOJ-6-179 PUBLISHERS ties are multifactorial, a key component to development of these methods.7,8 The evidence available regarding TTM-based behavior chronic diseases is lack of physical activity. Conversely, increased change interventions applied to exercise as moderate physical ac- physical exercise is correlated with a decreased risk for developing tivity has been focused upon one component, namely, the stages these diseases.6 of change, versus all four of the components of the model.7 An ad- ditional recommendation is that the full model should be assessed Change is needed. Decades of research into human be- fully/holistically.8 havior has expanded our understanding of motivation which is key to any behavior change. Attempts to apply the transtheoretical There is a need to assess whether evidence during the model and stages of change theory (TTM-SOC) to physical activ- most recent decade has provided more rigorous evaluation and ity, have resulted in non-conclusive findings to support or negate application of the TTM-SOC with and its full components with this application of the model.7,8 regard to physical activity. Transtheoretical Model Defined PURPOSE The TTM-SOC, was created as a compilation of psychological The purpose of this review was to determine how the TTM- theories to explain behavior change as related to addiction (Pro- SOC has been applied for adoption of physical activity in the last chaska et al). The TTM-SOC initially included the components 10-years. of stages of change (SOC), decisional balance and processes of change (POC) with self-efficacy (SE) subsequently added. As a METHODS motivational theory used to guide interventions for change, the transtheoretical model (TTM) describes the SOC as progressions Search Strategy a person must advance through for the purpose of making an ef- fective behavior change. The SOC consist of precontemplation, The following databases were searched and accessed May 2017 contemplation, preparation, action, maintenance and for some be- with updates January 2018 and May 2019: PSYCInfo, ERIC, CI- haviors, termination.9 The TTM purports that each stage aligns NAHL, EBM, DARE, OVID. Key search terms for this literature with the constructs of decisional balance-the weighing of pros review included: “Lifestyle Changes” OR “Lifestyle” OR “Active and cons for behavior change; self-efficacy-confidence to make Living” OR “Lifestyle Changes” OR “Physical Activity” OR “Ac- and maintain the change; and processes of change-both cognitive tigraphy” OR “Exercise” OR “Activity Level” AND “Transtheo- and behavior.9 retical Model” OR “Stages of Change.” Inclusion criteria consisted of full text availability, English language, peer reviewed investiga- Previous Research tions published in the last 10-years, relating to Transtheoretical Model Stages of Change and its application to influence health The TTM has been applied with smoking cessation with physi- outcomes via physical activity were included in the study. Searching cians and other practitioners adopting stage assessment tools and the following additional databases, namely, American Periodicals, stage matched interventions.10 Use of the theory has expanded to ARTbibliographies Modern (ABM), British Periodicals, Digital explain behavior change with regard to exercise and sedentary life- National Security Archive, ebrary, e-books, GeoRef, PAIS Index, styles. In a systematic review, authors concluded that there was cau- Periodicals Archive Online, ProQuest Dissertations & Theses tious support for stage matched exercise interventions.11 Global, SciTech Premium Collection, nine (9) articles were found. Of these, all non-peer reviewed findings were omitted. In a systematic review by Bulley et al,7 (preferred report- ing items for systematic reviews and meta-analyses (PRISMA) Inclusion criteria: Investigations that were 1) related score=10/27), authors concluded that the accuracy of self-assign- to the use of the TTM with physical activity, 2) performed with ment for stages of action or maintenance for physical activity was adults, 3) peer-reviewed, 4) published after 2007, and 5) in the eng- frequently inconsistent with recommended physical activity guide- lish language (Figure 1). lines. Furthermore, measurements to assess stages of change for exercise were not found to be valid or standardized, suggesting Initial Review that more research was needed to investigate the validity of this measure.7,12 The search dating 2007-2019 yielded 126 articles. Investigations of reliability and/or validity of model constructs were sequestered Validity limitations of the evidence available for the TTM- from experimental design/randomized controlled trials, though all SOC prior to 2007 include that stage allocation for exercise was were organized for further review. Following removal of excluded linked with self-reported activity, and the physiological parameters articles and all subsequent duplicates from overlapping databases, (body composition, physical fitness) used are indirect measure- a total of seventy-nine (79) relevant articles were assessed for rigor ments for changes in stage.7 Additionally, though not direct mea- and inclusion (Figure 1). Articles were organized into two catego- sures of exercise or physical activity, body mass index, weight and ries: 1) observational (n=61), which included descriptive or analyti- girth measurements were used to assess stage progression. With cal studies,and 2) interventional (n=18), consisting of randomized regard to outcome measures used and construct validity, future in- controlled and quasi-experimental studies (Table 1). vestigations require validation of instruments with more rigorous 28 Ortega C et al Systematic Review | Volume 6 | Number 1| Sport Exerc Med Open J. 2020; 6(1):