The transtheoretical model of behavior change (TTM), an evidence-based approach commonly used in weight management counseling, involves assessing an individual’s readiness to engage in healthy behaviors. By identifying the individual’s stage of change, a practitioner can better tailor an intervention whether the individual is in a stage of Precontemplation (not ready), Contemplation (getting ready), Preparation (ready), Action (doing the healthy behavior), or Maintenance (doing the healthy behavior for six (6) or more months).
With the evolution of technology, web-based programs are being developed that can individualize behavior change guidance, offering a format that saves both individuals and practitioners time and money, while offering consistency in results. Pro-Change Behaviors Systems, Inc., a company that offers engaging and evidence-based behavior change solutions through a variety of technologies, uses the TTM as a basis for their URAC award-winning program in weight management.
How is Readiness to Change Assessed?
First, participants are staged on their readiness to:
- Eat 500 fewer calories a day to reach and maintain a healthy weight;
- Eat a diet low in unhealthy saturated and trans fat;
- Exercise at least 150 minutes/week; and
- Manage emotions using healthy strategies like relaxation instead of eating.
How is the Weight Management Intervention Delivered?
After participants, are staged in a computerized tailored intervention (CTI) session and assessed on their pros and cons, confidence, and processes of change. They receive feedback through the following four categories:
- Pros and Cons: Lists the pros of adopting or engaging in the new healthy behavior (e.g., regular exercise and eating healthy) and how the participant’s scores compare to those of others who have changed successfully, including strategies for increasing the pros, and decreasing the cons.
- Confidence: Identifies situations in which the participant is most tempted to engage in the unhealthy behavior (e.g., skip exercising or indulge in overeating) and ideas for coping with those situations.
- Processes of change: Identifies how frequently the participant is using specific stage-matched processes of change and how he or she compares with others who were most successful in progressing to the next stage of change.
- Strategies: Determines small steps for progressing to the next stage of change (e.g., starting to walk for one-quarter mile each day or reducing calorie intake by 100 calories a day).
Participants are then able to access a printed report as well as an online Personal Activity Center (PAC) where they can find information and activities designed to elaborate on and reinforce ideas presented during the CTI session.
Specific activities are suggested based on the participant’s stage of change, and include:
- Listing the benefits of the new healthy behavior;
- Examining their self-image as it relates to the healthy behavior;
- Developing a plan for action;
- Getting support;
- Substituting unhealthy behaviors with healthy behaviors;
- Avoiding people, places, and things that increase temptation to engage in the unhealthy behaviors; and
- Identifying intrinsic and extrinsic rewards for healthy behaviors.
How are Participants Monitored and Evaluated?
In addition to the CTI feedback reports and the PAC, participants can receive tailored text messages every one to three days, depending on their current stage of change. All text message feedback is individually tailored to the participant’s most recent stage of change and scores on measures to include pros and cons, confidence, and processes of change. For example,
- Individuals in Precontemplation and Maintenance receive a text message every three days, with a maximum of 30 messages between CTI sessions. A participant in the Precontemplation stage for reducing calories might receive the following message to facilitate Consciousness Raising: “Start learning about all the pros of having a healthy weight. It could inspire you to start thinking about healthy eating.”
- Individuals in Contemplation receive a message every two days, with a maximum of 45 messages between CTI sessions.
- Individuals in Preparation and Action receive a message every day, with a maximum of 90 messages between CTI sessions. A participant in Preparation might receive the following message to increase confidence: “Read about relaxation techniques you can use to relax. It will make you more confident not to overeat when you are stressed. Login at [link to activity in the PAC].” A participant in the Action stage might receive the following message to facilitate Counter Conditioning: “When you feel the urge to stay on the couch and not exercise, resist it by substituting healthier thoughts on how good you will feel if you exercise.”
The Benefits of Using a Web-based Approach to Deliver Interventions
Given their capacity to reach individuals at all levels of readiness to change, digitally-assisted TTM programs are population-based but provide a completely customized experience for each end user with feedback that is dynamically updated when users return to the program. The customized behavior change guidance is based on the comparison of the user’s responses to reliable and valid assessment questions to pre-programmed, statistically-derived decision rules.
In a randomized controlled trial of the Pro-Change weight management program, significant treatment effects were found for healthy eating (47.50% versus 34.30%), exercise (44.90% versus 38.10%), managing emotional eating (49.70% versus 30.30%), and untreated fruit and vegetable intake (48.50% versus 39.0%) progressing to Action/Maintenance at 24 months. The groups differed on weight loss at 24 months with 30% of the treatment group losing 5% of their weight (Johnson et al. 2008). The digital weight management program also has a coach facing option where coaches can give the assessment questions and then be given evidence-based bulleted tailored guidance to deliver to their clients.
Pro-Change’s weight management program demonstrates the ability of TTM-based tailored feedback to improve health eating, exercise, managing emotional eating, and weight on a population basis.
Demos of the Weight Management and other programs, including a healthy eating and exercise program for teens, are available at http://www.prochange.com/online-behavior-change-programs.
Janice M. Prochaska is the President and CEO of Pro-Change Behavior Systems, Inc. She earned a Master’s degree in Social Work from Wayne State University and a Ph.D. in Social Work Administration and Policy from Boston College.
Johnson, S.S., Pavia, A.L., Cummins, C.O., Johnson, J.L., Dyment, S.J., Wright, J.A., Prochaska, J.O., Prochaska, J.M., Sherman, K. (2008). Transtheoretical model-based multiple behavior interventions for weight management: Effectiveness on a population basis. Preventive Medicine, 46, 238-246.