Fall Prevention through Fall Prevention through Behavior Change: Behavior Change: Exercise Interventions with the Exercise Interventions with the Transtheoretical ModelTranstheoretical Model

Patricia Burbank, DNSc, RNPatricia Burbank, DNSc, RNProfessorProfessorURI College of NursingURI College of NursingRI Geriatric Education CenterRI Geriatric Education Center

ObjectivesObjectives

Describe the Transtheoretical Model Describe the Transtheoretical Model of Behavior Change as it applies to of Behavior Change as it applies to exercise and fall prevention. exercise and fall prevention.

Assess the stages of change for Assess the stages of change for exercise behavior.exercise behavior.

Discuss processes and strategies for Discuss processes and strategies for exercise behavior change among exercise behavior change among older adults.older adults.

Identify strategies for exercise Identify strategies for exercise behavior change to identified stages behavior change to identified stages of change.  of change. 

Transtheoretical Model Transtheoretical Model of Behavior Change of Behavior Change (TTM)(TTM)

Prochaska & DiClemente, Prochaska & DiClemente, 19841984

Dimensions of Dimensions of TTMTTM

Stages of changeStages of change Processes of changeProcesses of change Decisional balanceDecisional balance Self efficacySelf efficacy

Stages of change (5)Stages of change (5)

PrecontemplationPrecontemplation - no intention to - no intention to change behavior in foreseeable change behavior in foreseeable futurefuture

ContemplationContemplation - seriously - seriously considering changing behavior considering changing behavior within 6 monthswithin 6 months

PreparationPreparation - Intending to take - Intending to take action within next monthaction within next month

Stages of change Stages of change (cont’d)(cont’d)

Action Action - successfully altered - successfully altered behavior for one day to 6 monthsbehavior for one day to 6 months

MaintenanceMaintenance - a continuation of - a continuation of changed behavior from 6 months changed behavior from 6 months to indefiniteto indefinite

Processes of change Processes of change (10)(10)

Cognitive:Cognitive: Consciousness raisingConsciousness raising Dramatic reliefDramatic relief Environmental reevaluationEnvironmental reevaluation Self-reevaluationSelf-reevaluation Social liberationSocial liberation

Processes of change Processes of change (cont’d)(cont’d)

Behavioral:Behavioral: Counter-conditioningCounter-conditioning Helping relationshipsHelping relationships Reinforcement managementReinforcement management Self-liberationSelf-liberation Stimulus controlStimulus control

Description of Description of ProcessesProcesses Consciousness raisingConsciousness raising - seek new - seek new

information about the information about the behaviorbehavior

Dramatic reliefDramatic relief - Express feelings - Express feelings about problem or behaviorabout problem or behavior

Environmental reevaluationEnvironmental reevaluation - - Assess how problem affects Assess how problem affects physical and social environmentphysical and social environment

Description of Description of ProcessesProcesses (cont’d)(cont’d)

Self re-evaluationSelf re-evaluation - Re-appraise - Re-appraise values regarding the behaviorvalues regarding the behavior

Social liberationSocial liberation - Develop - Develop awareness and acceptance of awareness and acceptance of changed lifestylechanged lifestyle

Counter-conditioningCounter-conditioning - Substitute - Substitute alternative for problem behavioralternative for problem behavior

Description of Description of ProcessesProcesses (cont’d)(cont’d) Helping relationshipsHelping relationships - Use support - Use support

from othersfrom others Reinforcement managementReinforcement management - -

Reward changed behaviorReward changed behavior Self-liberationSelf-liberation - Commit to action; - Commit to action;

belief that change is possiblebelief that change is possible Stimulus controlStimulus control - Control situations - Control situations

and cues that support problem and cues that support problem behaviorbehavior

Decisional BalanceDecisional Balance

Precontemplation - cons of changing Precontemplation - cons of changing outweigh prosoutweigh pros

Contemplation - pros stronger but still Contemplation - pros stronger but still may not outweigh cons, crossover may may not outweigh cons, crossover may occuroccur

Preparation - crossover (pros stronger Preparation - crossover (pros stronger than cons)than cons)

Action -Action -cons

pros

Self efficacySelf efficacy

Self efficacy increases across Self efficacy increases across stagesstages

Temptation scores decrease Temptation scores decrease across stagesacross stages

Maximum self efficacy and Maximum self efficacy and minimal temptation occurs in minimal temptation occurs in maintenancemaintenance

Moving throughMoving through Stages of Stages of ChangeChange

Precontemplation

Contemplation

Preparation

ActionMaintenance

Relapse

Termination

Precontemplation: Precontemplation: Goals and StrategiesGoals and Strategies

Increase awareness of need to Increase awareness of need to change.change.

Give personalized information and Give personalized information and feedbackfeedback

Encourage thinking about changeEncourage thinking about change

Contemplation:Contemplation:Goals and Strategies Goals and Strategies

Motivate and increase Motivate and increase confidence in ability to change.confidence in ability to change.

Emphasize benefits of changeEmphasize benefits of change Express empathy and provide Express empathy and provide

support support Explore concerns and fearsExplore concerns and fears Clarify misconceptionsClarify misconceptions

Preparation:Preparation:Goals and Strategies Goals and Strategies

Negotiate a plan.Negotiate a plan.

Set realistic goals.Set realistic goals. Recommend a plan; provide Recommend a plan; provide

optionsoptions Individualize planIndividualize plan Reinforce small changeReinforce small change

ActionAction ::Goals and Strategies Goals and Strategies

Reaffirm commitment and Reaffirm commitment and follow-upfollow-up..

Reaffirm agreed-upon planReaffirm agreed-upon plan Teach behavioral skillsTeach behavioral skills Provide educational materialsProvide educational materials Enhance social supportEnhance social support Arrange follow-up dateArrange follow-up date

Maintenance:Maintenance:Goals and Strategies Goals and Strategies

Encourage active problem-Encourage active problem-solvingsolving..

Encourage planning for potential Encourage planning for potential difficulties difficulties

Enhance support networkEnhance support network

Relapse:Relapse:Goals and Strategies Goals and Strategies

Assist in coping.Assist in coping.

Help overcome shame and guiltHelp overcome shame and guilt Reframe as learning opportunityReframe as learning opportunity Analyze stumbling blocksAnalyze stumbling blocks

Assessing Stage of Assessing Stage of ChangeChangeIdentify behavior first, then:Identify behavior first, then:

Yes, I have been for more than 6 monthsYes, I have been for more than 6 months Yes, I have been, but for less than 6 Yes, I have been, but for less than 6

monthsmonths No, but I intend to in the next 30 daysNo, but I intend to in the next 30 days No, but I intend to in the next 6 monthsNo, but I intend to in the next 6 months No, and I do not intend to in the next 6 No, and I do not intend to in the next 6

monthsmonths

Tailor interventions to stage of change

SummarySummary

Behavior change occurs in stagesBehavior change occurs in stages TTM: 4 main componentsTTM: 4 main components Behavior change works better if Behavior change works better if

interventions are tailored to stage interventions are tailored to stage of changeof change

Design stage-tailored strategies Design stage-tailored strategies for population group and settingfor population group and setting