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.
HOW DO PEOPLE SUCCESSFULLY CHANGE THEIR OWN
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.
THE TRANSTHEORETICAL MODEL OF BEHAVIOR CHANGE
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
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.
2--Contemplation. Individuals acknowledge having a problem and begin to
deliberately increase awareness and knowledge related to the problem.
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.
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.
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
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?
Having a realistic view of the work involved in behavior change may better
prepare individuals for the effort and vigilance needed to avoid setbacks.
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.
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.
HOW EDUCATORS CAN APPLY THE TRANSTHEORETICAL MODEL
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.
Some of the processes that are most helpful in the early stages of change
Consciousness raising--Providing information and giving feedback to increase
awareness of a particular problem and its triggers, consequences, and cures.
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.
Self-reevaluation--envisioning one's self with and without the unhealthy habit.
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:
Active problem solving--Educators can help students plan to establish cues and
rewards for healthy behaviors and remove or minimize contact with triggers for
Counterconditioning--substituting a healthy behavior for an unhealthy one.
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.
SKILLS FOR BEHAVIOR CHANGE
"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).
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Brownell, K. D., Marlatt, G. A., Lichtenstein, E., & Wilson, G. T.
(1986). Understanding and preventing relapse. AMERICAN PSYCHOLOGIST, 41,
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