ERIC Identifier: ED429053
Publication Date: 1998-12-00
Author: Sullivan, Karen T.
Source: ERIC Clearinghouse on Teaching and Teacher Education Washington DC.

Promoting Health Behavior Change. ERIC Digest.

Health-related habits develop early in life. The period during junior high school is especially important for developing these habits and also presents a window of vulnerability for initiating behaviors related to smoking, drug use, and sexual risk taking (Cohen, Brownell, & Felix, 1990; Taylor, 1999). Because adolescent behaviors may be better predictors of disease after age 45 than adult health behaviors, interventions with children and adolescents are important (Taylor, 1999). Few of us emerge from adolescence with ideal health habits. Thus, mastering behavior change is critical to our quality of life.

Several theories and models have been developed to explain how people change their behavior, such as social cognitive theory, the theory of reasoned action/planned behavior, and the health belief model. This Digest explores the more recently developed Transtheoretical Model and discusses how educators can apply it in working with students.


Countless individuals have initiated behavior changes only to relapse after a few weeks, months, or years. To be successful, behavior change must be maintained, and this requires considerable time, effort, and energy. Behavior change is typically regarded primarily in terms of getting started. The struggle to overcome inertia often seems so great that people assume it must get easier from that point on. This is seldom true. To accomplish permanent changes in habits, many tools are needed.


Prochaska and colleagues studied the business of behavior change for over 2 decades and developed the Transtheoretical Model (Prochaska, DiClemente, & Norcross, 1992; Prochaska, Norcross, & DiClemente, 1994; Prochaska, Redding, & Evers, 1997). Their work revealed that behavior change evolves through different stages:

Stage 1--Precontemplation. Individuals in this stage do not believe they have a problem and have often constructed defenses that aid in denial of the problem.

Stage 2--Contemplation. Individuals acknowledge having a problem and begin to deliberately increase awareness and knowledge related to the problem.

Stage 3--Preparation. Before initiating behavior change, individuals should reevaluate themselves with respect to the problem, develop commitment to change, and construct a detailed plan for change. By the time they reach this stage, individuals begin to perceive greater benefits than barriers to change.

Stage 4--Action. Behavior change is initiated. Others are likely to recognize a person's progress toward change. After at least 6 months in the action stage, the person may move into the fifth stage.

Stage 5--Maintenance. Though change is maintained more easily now, some vigilance is still required to avoid slips or setbacks. If and when the change becomes so automatic that there is no possibility of reverting to a former behavior, the goal--"Termination"--is reached.

The typical path of behavior change is not one of linear progression, but usually involves slips backward and has been described as a spiral pathway (Prochaska, Norcross, & DiClemente, 1994). However, if one slips to an earlier stage, all is not lost, because progression may occur more quickly due to insights and experience already gained when previously in earlier stages.

Why is understanding of the stages of change important for those who will be attempting behavior change?

1. Having a realistic view of the work involved in behavior change may better prepare individuals for the effort and vigilance needed to avoid setbacks.

2. Individuals may better understand how progress toward change occurs even in the absence of action. Gaining awareness about one's self, experiencing the emotions that awareness of the problem may trigger, and changing beliefs, attitudes, and thoughts constitute progress.

3. It helps to distinguish between a lapse, that is, an isolated mistake or temporary slip, versus a relapse, that is, a complete setback (Brownell, Marlatt, Lichtenstein, & Wilson, 1986; Watson & Tharp, 1997). Knowing the factors that often precipitate a lapse or relapse, such as emotional distress, may help people recognize where work is needed in their lives.


Only a small percentage of any group is ready for change at a given time. For educators to reach their audiences, they must be prepared to use a variety of "processes of change," that is, "any activity that you initiate to help modify your thinking, feeling or behavior" (Prochaska, Norcross, & DiClemente, 1994, p. 25).

Some of the processes that are most helpful in the early stages of change are:

1. Consciousness raising--Providing information and giving feedback to increase awareness of a particular problem and its triggers, consequences, and cures.

2. Emotional arousal--This may occur as a result of observing a vivid case history or personal testimony of someone who has solved a problem shared by others; role-playing can also help.

3. Self-reevaluation--envisioning one's self with and without the unhealthy habit.

4. Commitment--accepting one's personal responsibility for change and truly believing that one can make the change. Self-efficacy, "the conviction that one can successfully execute the behavior required to produce the outcomes" (Bandura, 1977, 1982) relates to commitment and can be improved in a number of ways. For example, mastery experiences can be used to improve perceived self-efficacy (Bandura, 1986). Watson and Tharp (1997) suggest rank-ordering situations from easiest to most difficult and working to master behavior change in situations of increasing difficulty.

Some of the processes that are most helpful in the action stage are:

1. Active problem solving--Educators can help students plan to establish cues and rewards for healthy behaviors and remove or minimize contact with triggers for unhealthy behaviors.

2. Counterconditioning--substituting a healthy behavior for an unhealthy one.

3. Helping relationships--Giving and receiving help is a process that is important in every stage of change (Prochaska, Norcross, & DiClemente, 1994).

An appreciation of the Transtheoretical Model can help students avoid two common problems of behavior change: rushing to premature action or indefinitely substituting thinking, talking, and learning about a problem for acting to change a problem. Understanding the necessary tasks that need to be completed in the stages prior to action may help in avoiding the rush to action. Knowing what should follow increased knowledge and awareness of a problem behavior can help educators guide students forward through the stages of change. Just as coaches use planning and pacing in devising workouts for their athletes, educators can help students plan and pace the change process.


"Self-monitoring" is an essential skill for increasing self-awareness. Students can practice keeping records of their behaviors and the antecedents and consequences of those behaviors. Antecedents and consequences may be internal, such as self-talk or certain feelings, and/or external, such as tempting cues or the presence or approval of certain individuals. Behavioral analysis involves studying behavior records to discern patterns that relate to the target behavior.

"Effective goal" setting also can help students plan for change. Students need practice in setting realistic and specific goals that, when possible, are measurable. Long-term goals should be divided into short-term goals. Students should focus on behaviors they can change rather than outcomes that may be outside their control.

"Relapse prevention skills" are critical. Because emotional distress is a primary factor in lapses and relapses (Brownell, Marlatt, Lichtenstein, & Wilson, 1986), learning to cope effectively with stress is invaluable for the individual trying to effect a major change in behavior, which is a major stressor unto itself. Stress management skills may minimize counterproductive negative emotions. For example, cognitive restructuring or modifying self-talk to decrease negative thinking can be learned with practice (Seaward, 1997). Other relevant skills worth developing relate to time management, conflict resolution, assertiveness, and decision making. An individual planning to change behavior should practice recognizing high-risk situations for a lapse or relapse and specific coping skills for those situations. Plans for effectively responding to a lapse or relapse are advisable. Mental imagery to help picture one's self in the future with healthier habits may help maintain the hope needed to get back on track and continue to pursue change.

Developing "assertiveness skills" can be helpful in a number of ways. Assertiveness may help a teenager refuse peer demands. Skills in assertiveness may help us to ask others for feedback about our unhealthy habits and guidance in making changes. As we become more aware of our strengths, weaknesses, and needs, we can be assertive in recruiting others' support for our change efforts.

"Counterconditioning, stimulus control, and reward skills," three processes of change that are especially important in the action stage, can also be practiced. Finding a healthy behavior that works well as a substitute for an unhealthy behavior may require some trial and error. The same is true for stimulus control and reward; we may not immediately recognize the most powerful cues for our behaviors or the most rewarding consequences.


While behavior change seems simple and straightforward, rarely do people find it either. Before attempting behavior change, it is wise to develop a realistic perspective regarding the time, attention, and effort that will be involved. Knowing and having skills in the various processes of change is akin to having, and knowing when and how to use, a full set of tools for building a house. As we work toward behavior change, we are, in effect, building a new self.


References identified with an EJ or ED number have been abstracted and are in the ERIC database. Journal articles (EJ) should be available at most research libraries; most documents (ED) are available in microfiche collections at more than 900 locations. Documents can also be ordered through the ERIC Document Reproduction Service (800-443-ERIC).

Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavior change. PSYCHOLOGICAL REVIEW, 84, 191-215.

Bandura, A. (1982). Self-efficacy mechanism in human agency. AMERICAN PSYCHOLOGIST, 37, 122-147.

Bandura, A. (1986). The explanatory and predictive scope of self-efficacy theory. JOURNAL OF SOCIAL AND CLINICAL PSYCHOLOGY, 4, 359-373.

Brownell, K. D., Marlatt, G. A., Lichtenstein, E., & Wilson, G. T. (1986). Understanding and preventing relapse. AMERICAN PSYCHOLOGIST, 41, 765-782.

Cohen, R. Y., Brownell, K. D., & Felix, M. R. J. (1990). Age and sex differences in health habits and beliefs of schoolchildren. HEALTH PSYCHOLOGY, 9, 208-224.

Prochaska, J. O., DiClemente, C. C., & Norcross, J. C. (1992). In search of how people change: Applications to addictive behaviors. AMERICAN PSYCHOLOGIST, 47(9), 1102-1114.


Prochaska, J. O., Redding, C. A., & Evers, K. E. (1997). The transtheoretical model and stages of change. In K. Glanz, F. M. Lewis, & B. K. Rimer (Eds.), HEALTH BEHAVIOR AND HEALTH EDUCATION: THEORY, RESEARCH, AND PRACTICE (2nd ed.) (pp. 60-84). San Francisco: Jossey-Bass Publishers.

Seaward, B. L. (1997). MANAGING STRESS: PRINCIPLES AND STRATEGIES FOR HEALTH AND WELL BEING (2nd ed.). Sudbury, MA: Jones and Bartlett Publishers.

Taylor, S. (1999). HEALTH PSYCHOLOGY (4th ed.). Boston: McGraw-Hill.

Watson, D. L., & Tharp, R. G. (1997). SELF-DIRECTED BEHAVIOR: SELF-MODIFICATION FOR PERSONAL ADJUSTMENT (7th ed.). Pacific Grove, CA: Brooks/Cole Publishing Company.

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