The Transtheoretical Model and the “stages” of patient adherence
- The Transtheoretical Model proposes a stepwise approach to effectively change health behavior
- The model can help providers evaluate patients’ beliefs and behavior regarding their treatment, and indicates the support needed to motivate positive change.
- The TTM is one of the most widely used health behavior models and has been shown to have a positive impact on various issues including adherence.
The Transtheoretical Model: a tool for influencing positive behavioral change
Neurological disorders are a significant public health issue worldwide.1 Non-adherence to therapy for these conditions results in poor response to therapy, impacts on the quality of life of patients and causes associated costs to them and healthcare systems.2,3 Non-adherence rates have been shown to be high in neurological disorders including Parkinson’s disease (10–67%),3 epilepsy (30–50%)4 and bipolar disorder (~50%).5
Different behavioral theories and models have been applied to explain and improve adherence, resulting in six main theoretical “perspectives”: biomedical, behavioral, communication, cognitive, self-regulatory and stage.6 Cognitive and stage perspectives are the most recurrently used according to the literature. Cognitive theories such as the Theory of Planned Behavior (TPB), discussed previously in this series, examine how attitudes and beliefs drive individual behavior.7 Stage-based theories contend that people learn, develop, and change their behavior according to discrete steps.6 The two types of model can be used together: cognitive theories provide insights on why people change behavior, and stage perspectives generate insights on how, by describing the actual change process.8 The Transtheoretical Model (TTM), also known as the transtheoretical change model, is the most prominent and widely applied among stage models,6 and it is different from other prominent behavioral models in that it was specifically designed to facilitate change and to describe the change process.9 The TTM has been used to address a wide range of health behaviors, and can be used to assess therapy adherence for patients with neurological disorders (such as epilepsy) and provide targeted feedback for improvement.6,10
The TTM characterizes adherence according to an individual’s readiness to change
The first version of the TTM was proposed by James Prochaska and Carlo DiClemente in the 1980s with a focus on nicotine addiction and has since been applied to a number of different health behaviors.11,12
The TTM consists of two major components: Stages of Change and Processes of Change. The Stages of Change are the temporal “core” of the model and portray an individual’s actual readiness and willingness to change according to 5 distinct steps. The Stages can be considered from the perspective of a patients’ adherence behavior to their therapy:6
- Precontemplation. The patient is not following his treatment regimen as directed by his doctor and is not really considering changing his behavior because he is unaware of reasons to change11
- Contemplation. The patient is aware of reasons to change his behavior and is considering changing it but is not currently making an effort to do so. According to Prochaska, this phase includes individuals who plan to change their behavior at some point in the next six months, but not in the next 30 days. Any preparation at this point is purely mental / emotional.
- Preparation. The patient plans to change his treatment behavior within 30 days. He is actively preparing to change, for example by trying to take his medication as directed, but he is not doing so regularly.
- Action. The patient has changed his behavior and is following the treatment regimen as directed but has not yet reached the six-month mark. The new behavior still requires effort.
- Maintenance. The patient has been following his doctor’s recommendations and taking his medication as directed for at least six months.11 It has become a habit and no longer requires much conscious effort.
Progression through the Stages of Change is proposed to be linear but is not assumed to be positive, thereby accounting for the cyclical nature of behavioral change and the potential for individuals to regress as well as advance.6,11 For example, hypertensive patients in the “Action” phase who have been adherent for some months may become non-adherent and “fall back” to the Preparation or even Contemplation phases.11 Note that they typically do not fall back to pre-contemplation, because this would imply that they have forgotten why they were following recommendations in the first place.13 Thus, people who “regress” in their behavior may be easier to get back on track.
Ten Processes of Change were identified as facilitating the transition from one stage to the next and are classified as being either experiential or behavioral.6,11
- Experiential processes are useful primarily in early stages of change, such as Contemplation. Such processes include consciousness raising, for example the patient’s realization of the benefits of his treatment for controlling his symptoms, and environmental reevaluation, the patient’s belief that his environment will benefit from his treatment adherence. The others are dramatic relief, social liberation and self-re- evaluation6,11
- Behavioral processes are used primarily in later stages and include stimulus control, for example the removal of barriers to treatment adherence by the patient and the use of stimuli for positive reinforcement, and helping relationships, or access to people who are important to the patient and will help him be adherent. The other behavioral processes are counter conditioning, reinforcement management and self-liberation6,11
The TTM can help providers assess patient adherence and determine useful feedback11
The TTM can serve as a helpful tool for providers to assess patients’ adherence and respond with useful feedback as needed.11 Consider the example of a typical patient with epilepsy. At his appointment, his doctor asks him a few targeted questions regarding his therapy:
- How strictly the patient is adhering to his therapy regimen, and whether he is following lifestyle recommendations,
- If the patient has considered changing this behavior at any point,
- If the patient understands the benefits of the therapy and the risks of non-adherence.
The patient’s answers reveal that he does not strictly adhere to his treatment and is unaware that this is problematic. Given that his symptoms are sporadic, the benefits of adherence are not obvious for him. His doctor provides him with information on the risks of uncontrolled seizures caused by not taking his medication, and the benefits of following the therapy regimen, using the Health Belief Model to help guide the discussion. The patient is now aware of the benefits of adherence and may consider changing his behavior and pass into the Contemplation phase via the “consciousness raising” process.
The TTM is a useful and actionable tool to improve adherence
The TTM is a widely used tool and can supplement other health models such as the TPB and the Health Behavior Model with insights into facilitating behavior change and tracking its progress.6,8 It may be particularly useful in informing the way that adherence information is provided, as well as in the design of adherence interventions.14 The TTM has been applied to treatment use and adherence,14,15 with studies demonstrating that patients respond well to the individualized feedback.11 It is different from the HBM and TPB in that it was specifically designed to facilitate change.9 Newer tools, such as COM-B, build on these existing models and will be discussed further in subsequent articles.16
- World Health Organization. Neurological Disorders: Public Health Challenges. 2006 Available at: https://www.who.int/mental_health/publications/neurological_disorders_ph_ Challenges/en/ [Accessed March2021].
- Moura LMVR, et al. Patient-reported financial barriers to adherence to treatment in neurology. ClinicoEconomics and Outcomes Research 2016;8:685–94.
- Straka I, et al. Adherence to Pharmacotherapy in Patients With Parkinson’s Disease Taking Three and More Daily Doses of Medication. Frontiers in Neurology 2019;10:799.
- Ferrari CMM, et al. Factors associated with treatment non-adherence in patients with epilepsy in Brazil. Seizure 2013;22:384–9.
- Jawad I, et al. Medication nonadherence in bipolar disorder: a narrative review. Ther Adv Psychopharmacol 2018;8(12):349–63.
- Sardi L, et al. Applying trans-theoretical model for blood donation among Spanish adults: a cross-sectional study. BMC Public Health 2019;19:1724
- Ajzen I. “From intentions to actions: A theory of planned behavior.” In: J. Kuhl & J. Beckmann, Eds. Action Control. Berlin, Heidelberg: Springer Berlin Heidelberg, pp. 11–39.
- Boonroungrut C and Fei H. The Theory of Planned Behavior and Transtheoretical Model of Change: a systematic review on combining two behavioural change theories in research. Journal of Public Health and Development 2018;16(1):75–87.
- Taylor D, et al. A review of the use of the Health Belief Model (HBM), the Theory of Reasoned Action (TRA), the Theory of Planned Behaviour (TPB) and the Trans-Theoretical Model (TTM) to study and predict health related behaviour change. 2006.
- DiIorio C, et al. Evaluation of WebEase: an epilepsy self-management Web site. Health Educ Res 2009;24(2):185–97.
- Johnson SS, et al. Efficacy of a transtheoretical model-based expert system for antihypertensive adherence. Dis Manag 2006;9(5):291–301.
- Prochaska JO and DiClemente CC. Stages and Processes of Self-Change of Smoking: Toward An Integrative Model of Change. Journal of Consulting and Clinical Psychology 1983;51:390– 5.
- Velicer WF, et al. Smoking cessation and stress management: Applications of the transtheoretical model of behavior change. Homeostasis in Health and Disease 1998;38:216– 33.
- Johnson SS, et al. Transtheoretical model intervention for adherence to lipid-lowering drugs. Dis Manag 2006;9(2):102–14.
- Ficke DL and Farris KB. Use of the Transtheoretical Model in the Medication Use Process. Annals of Pharmacotherapy 2005;39:1325–30.
- Jackson C, et al. Applying COM-B to medication adherence: A suggested framework for research and interventions. Eur Health Psychol 2014;16(1):7–17.