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THE HEALTH BELIEF
MODEL
Factors Influencing Patient Compliance
Reading for the lecture:
Health Psychology by Jane Ogden
Chapter 2: HEALTH BELIEFS
Theories 3
Health Belief Model
Irwin Rosenstock. Historical Origins of the Health Belief Model. Health Education Monographs. Vol. 2 No. 4, 1974.
M.H. Becker. The Health Belief Model and Personal Health Behavior. Health Education Monographs. Vol. 2 No. 4, 1974.
Theory of Reasoned Action/Theory of Planned Behaviour
The Transtheoretical Model (stages of change model)
What we will be considering
Healthy Living = 3 Areas
Theories of health belief
Methods of health promotion
Features of adherence to medical regimes
First we focus on theories of health belief
Behavioural factors affecting
longevity (how long we live)
Belloc & Breslow (1972) found a correlational
relationship between mortality rates and
behaviour in a study of 7,000 people
The 7 health behaviours identified were also
found to show a correlation with mortality in a
prospective study carried out at 5.5 and 10
years follow-up
Behaviours related to health
Sleeping 7-8 hours a day
Having breakfast every day
Not smoking
Rarely eating between meals
Being near or at prescribed weight
Having moderate or no use of alcohol
Taking regular exercise
How can we predict health-related
behaviours?
Kristiansen (1985)- correlational study
Relationship between 7 health behaviours and
a person’s beliefs
Found 7 health behaviours correlated with:
A high value on health
A belief in world peace (!)
A low value on leading an exciting life
Health Behaviours
What we do to remain healthy
Our concern is with why individuals adopt
certain health behaviours.
Theories of health belief
Social – how others influence our behaviour
Main approach
Cognitive – assumes that we think through our
actions logically, before rationally choosing a
behaviour to adopt
Do we always think logically?
There are still times where we will choose to
adopt an illogical behaviour
What factors affect our decision making process
when we make choices about our health?
How many of you:
1. Binge drink
2. Smoke
3. Take or do not take prescription or non prescription drugs
4. Exercise less than once a week
5. Eat a lot of junk food
6. Go or do not go for health checks
7. Do not always use a condom
8. Floss your teeth
Why do some people…?
do things that
are bad for
their health
such as
smoking
cigarettes?
12
Why?
Choose one of things you said „yes” to on
slide 10 and think about why you do that
behaviour.
Start each of your explanations with the words:
I believe I am lucky because….. (and so my
risk of becoming ill is smaller)
I believe ….. I will give up ………
(smoking/drinking/whatever/ before I get ill)
Why is it important to investigate Health
Beliefs?
What kind of beliefs might be behind young
single teenage girls becoming mothers?
What are Health Beliefs?
What I believe about smoking
I believe smoking causes
lung cancer
I believe only some people are susceptible
to cancer
I believe I look cool when
I smoke
What are Health Beliefs?
I believe a belief in God can help me
overcome illness
I believe I have no genetic predisposition
to cancer in my family so I believe I am at less risk
than other people
I believe I have plenty of time later to
worry about my health – Ill health will not happen
to me – yet!
I do not believe doctors always know what
they are talking about I do not believe I can always
trust them
Psychology and Health Beliefs
Psychologists have been interested in finding out what beliefs are behind: 1. Reasons for going or not going to the doctor 2. Decision making behind unhealthy or healthy behaviours (It is ok to
eat cake all day because I deserve it) 3. How seriously we view different illnesses (I am scared of all cancer
because it kills you) 4. Beliefs based on religion or culture 5. A range of different health beliefs 6. https://www.youtube.com/watch?v=aVp4eNIEXv0 And today we might add: 1. Beliefs concerning coronavirus 2. https://www.youtube.com/watch?v=xqK4NfOOF9A
If we know what people
believe we have more of
a chance of
understanding and
predicting their
behaviours and then
possibly changing those
behaviours!
3 lifestyle theories To explain our adoption of health behaviours
Health belief model – predicts uptake of health behaviours based on several factors
Locus of control – where people believe their health is controlled by themselves or others
Self–efficacy – how effective people believe they will be in changing their behaviour directly influences their tendency to change
The Health Belief Model
With the beginning of
widespread media
advertising in the 1950s
psychologists started to
investigate why so
many people ignored
preventative health
campaigns such as free
tuberculosis screening!
Tuberculosis screening
At the beginning of the twentieth century
tuberculosis (TB) was a major cause of death.
Later when screening and treatment became
readily available, people did not go for screening
They did not go even when the screening came
to them in the form of mobile units which came to
where they lived and all they had to do was to
step out of their homes and walk a few metres to
be X-rayed for the disease
The Health Belief Model Hochbaum (1958) first
developed a model about health beliefs when he found that:
1. Those who believed TB was very dangerous
2. Those who believed they were susceptible to developing TB
3. Those who believed x-ray screening was useful in early detection
4.Those who perceived few barriers to attending the x-ray
Were most likely to attend for screening!
Health Belief Model (HBM) 23
Developed in 1950s by social psychologists (Godfrey Hochbaum, Irwin Rosenstock, Stephen Kegels) working in the U.S. Public Health Services in response to the failure of a free tuberculosis health screening programme.
Focus is on individual’s decision to avoid a negative health consequence and considers the following factors identified by Hochbaum (previous slide) as deciding whether a person would attend for screening:
• Severity
• Susceptibility
• Costs/Benefits
• Barriers
Health Belief Model Adopts the Cognitive approach
Why people did or did not go for tuberculosis screening
The four factors: severity, susceptibility, costs/benefits, barriers -
indicated that the main consideration was how serious they perceived TB to be to their health.
Serious threat to health = screened and treated
Beck and Rosenstock developed the HBM from this study on tuberculosis screening.
The Health Belief Model (HBM)
The HBM has been since adapted to explore
various long-term and short-term health
behaviours, including:
Cervical cancer screening
Behaviours associated with high risk for CHD
Managing diabetes
Sexual risk behaviours
Transmission of HIV/AIDS
and many others
Core assumptions of HBM
A person will take a health-related action (i.e.
take regular exercise) if the person:
Feels that a negative health condition can be avoided
(e.g CHD)
Has a positive expectation that by taking the
recommended action, s/he will avoid the negative
health condition (e.g. exercise will prevent CHD)
Believes that s/he can successfully take the
recommended health action (e.g. is able to exercise
regularly without unreasonable effort
Factors affecting adoption of health
behaviours
There are 2 aspects to any perceived threat to health Perceived seriousness (will it actually kill me)
Perceived susceptibility (am I likely to get it)
Cost benefit analysis The cost and benefits of adopting a behaviour are weighed up and the individual decides whether the costs outweigh the benefits;
Barriers How difficult is it for me to engage in these behaviours? This may include distance to health facility or feeling embarrassed about having a medical examination
The four constructs of the HBM
The 4 constructs of the HBM were defined as
the person’s „readiness to take action”.
Perceived severity
Perceived susceptibility
Perceived benefits and
Perceived barriers
Perceived Severity
The consequence is
perceived as being
severe as opposed
to mild.
29
Perceived Susceptibility
How likely a person
thinks there is a risk of a
bad outcome
(e.g., getting ill) if he/she
persists in a behaviour
(i.e. doesn’t change).
30
Perceived Costs and Benefits
The individual’s
estimation of the
benefits of treatment
weighed against
cost, risks and
inconvenience.
Perceived barriers to behaviour
There are not
significant
psychological,
financial or other
barriers to engaging
in the behaviour.
33
Jane is not likely to continue
smoking because… 34
She thinks that she might get lung cancer if she continues to smoke (susceptibility).
She believes that dying from lung cancer is terrible (severity).
Jane does not find smoking very pleasurable (cost/benefits).
Her friends are supportive of her giving up (absence of barrier)
John is likely to continue smoking
because 35
He agrees with the tobacco industry--smoking
doesn’t cause lung cancer (susceptibility).
He believes that dying from lung cancer is not
any worse than any other way of dying
(severity).
John feels that smoking relaxes him
(cost/benefits).
His friends offer him cigarettes (barrier to
quitting)
However…
There are other factors that influence our
health beliefs… These can be...
Cultural
Related to age
Related to gender
Or information from the media…
Health Motivation
The individual’s
general interest in
health matters,
which may correlate
with personality,
social class, ethnic
group, religion etc
etc.
Demographic variables
Can influence the final decisions e.g.
income, age, sex, occupation, education, family size
External and internal cues may remind us
about the behaviour
TV adverts Period of ill health
External Cues
Trigger factors such
as alarming
symptoms, advice
from family or
friends, messages
from the media,
disruption of work or
play.
The Health Belief Model
was then developed by Becker 1970.
Becker added other factors to the HBM:
Factors which affect our beliefs / decisions are:
1) Demographic variables like age, sex, education, occupation, family size, income etc.
Then our decision making is based on cost benefit analysis between:
2) Perceived seriousness of the decision (will it actually kill me?)
3) Perceived susceptibility (am I likely to get it?)
4) Cues from external factors like advertising
5) How motivated we are
Health belief model A person will adopt
a healthy behaviour
If they
perceive a
threat to their
health if they
don’t
If the
benefits
Outweigh
the costs
If they are
reminded by
internal
And/or
external ‘cues’
Demographic
variables
Perceived
Seriousness
Will increase
The threat
Perceived
Susceptibility
Will increase
The threat Beck and Rosenstock (1978)
The Health Belief Model
KEY STUDY Becker (78) compliance with a medical regimen for asthma
Research support for HBM
Becker (1978) found a positive correlation
between health beliefs reported in interviews
and compliance of administration of asthma
medication by mothers to their children. A blood
test was also used to confirm the mothers were
being accurate in their self reporting.
Champion (1990) found that motivation
correlated with whether women self examined
their breasts.
The main ideas:
HBM sees people as rational and suggests that the likelihood that they will engage in healthy behaviour depends on factors such as:
Evaluation of threat (perceived vunerability). The model suggests that people only act if they perceive their behaviour to be dangerous.
Cost-benefit analysis. Will the benefits be higher than perceived barriers (the costs)? Is it worth it? If so – action will take place according to the model.
Health Beliefs About Illness or
Symptoms
Difficult to elicit.
Patients frightened of looking foolish or
ignorant.
Patients may be reluctant to “waste a doctor’s
time” with personal views and attitudes.
But this does NOT mean that patients don’t
have health beliefs!
Why is eliciting health beliefs important?
Half of medical advice is not taken up.
£100 million of prescribed medication is
discarded every year, at least.
Compliance with screening or preventative
programmes is essential if they are to be
effective.
Health Beliefs About Illness or
Symptoms
Avoid direct questions e.g. “What do you think
will happen if you don’t get your blood
pressure checked?”
Indirect questions helpful:
“What is going through your mind?”
“What does your wife / husband think?”
Etc etc.
Checklist
Elicit patient’s health
beliefs.
Reinforce positive
attitudes to health.
i.e. praise for giving
up smoking for a
period in the past,
don’t dwell on the fact
they re-started.
Checklist
Counter myths and
negative attitudes.
Inform patient about
causes and
prognosis.
Checklist
Plan an appropriate
course of action to
suit his/her needs
and lifestyle.
Don’t ask them to
give up cigarettes,
alcohol and sexual
promiscuity all at
once !
We also need to consider…
Why we would adopt a health behaviour
2nd theory
Rotter’s (1966) locus of control theory
From the Latin meaning ‘place’
Rotter ‘Locus of Control’ 1966
This theory looked at the beliefs or perceptions of an
individual about the underlying causes of the main
events in their lives.
Think of something important to you – finding a new
boyfriend, finishing with a partner, taking an exam. What
things made it good and what things made it bad? How
much of your life is affected by fate or chance?
Rotter: Locus of Control
Some people have a powerful belief in fate and
the power of external forces to shape their lives.
Other people have a strong belief that what
happens in their lives is all down to themselves
and their own actions and choices.
Rotter’s Locus of Control Theory
Reductionist = reduces the explanation down
to a person’s locus of control
Deterministic theory which is quite pessimistic
Suggests that where a person thinks the
control of their health lies will influence
whether they adopt a certain health behaviour
KEY STUDY Rotter (1966) investigated internal versus external Locus of Control
Evidence to support Rotter
James et al (1965) found that male smokers who did not relapse had a higher level of internal locus of control than those who did not quit smoking.
Rotter’s studies
Rotter carried out numerous studies investigating how his concept of „locus of control” i.e. the perception of individuals that they have control over the outcomes of things that happen to them, including illness.
He found that people with an „internal locus of control” were more able to show behaviours that would enable them to cope with a threat than those who had an „external locus of control”.
Rotter concluded that „locus of control” affects many of our behaviours, not just health.
The concept continues to be widely used, especially in industry.
Bandura
Agreed that concepts such as Locus of Control
affect behaviour
Thought that determining behaviour went
beyond such a simple explanation
Bandura
He introduced another key concept
A person’s belief that they can successfully do
whatever is required to achieve the outcome
Efficacy expectation
Self Efficacy: Bandura 1986
Self efficacy: the belief in oneself to organize and execute a course of action. Your belief in your ability to succeed or fail in a particular situation.
Self-efficacy
A cognitive model based on thought processes
of the individual
How effective a person THINKS they will be at
successfully changing/adopting a health
behaviour directly influences their tendency to
change
Bandura (1977)
Previous experiences give a person a likely
outcome
Have you ever not done something because you
knew how it would turn out?
Felt learning from consequences was
a cognitive process and would result in an
outcome expectancy
Key concept
Also . . .
Cognitive appraisal of a situation might also
affect expectations of personal efficacy.
Could be …. Social, situational and temporal
circumstances
A person’s self-efficacy can alter depending on
the situation
Limited time
thinking
Self Efficacy
People with a strong self efficacy:
View challenging problems as tasks to be mastered.
People with a weak self efficacy:
Avoid challenging tasks
Bandura suggests that LOC and SE
are different
Locus of control
Concerned with the outcome
Self-efficacy
Linked to the cognitive idea of locus of control
Is a person’s conviction that their own behaviour will influence the outcome
Unchangeable
belief
Internal and external
3 key factors which affect efficacy
expectation
1. Vicarious experience– seeing other people
do something successfully
2. Verbal persuasion – someone telling you
that you can do something
3. Emotional arousal – too much anxiety can
reduce a person’s self-efficacy
Practical example
A typical scenario for each of the 3 factors can
be found in
Weight watchers and the 3 factors
Vicarious experience – seeing someone else losing weight (you can lose it)
Verbal persuasion – meeting is about achievable goals and building self confidence. (you can do it).
Emotional arousal – standing on the scales creates anxiety (I can’t do this)
How do we develop self efficacy?
Life experiences, being or successful or
unsuccessful at previous at tasks?
Seeing other people succeed (modelling and
vicarious reinforcement)?
Verbal support and encouragement from others?
Our psychological responses (mood stress and
emotional state can effect self efficacy) for
example if we are naturally nervous?
KEY STUDY Bandura and Adams (1977) analysis of self efficacy theory of behavioural change
Evidence to support Bandura
Bandura and Adams (1977) carried out a controlled quasi experiment with patients with snake phobias undergoing a course of desensitisation. Findings showed that the higher the levels of self efficacy before the desensitisation predicted the success of the technique.
Mittag (1993) low perceived self efficacy regarding re-employment in the unemployed was associated with heavy drinking when high self efficacy was not.
THEORY OF REASONED
ACTION FISHBEIN (1975)
The theory of reasoned action states that
intention is the best predictor of health
behaviour.
Theory of reasoned action
Theory of Reasoned Action 79
Attitudes
Beliefs (outcome expectancies)
Values
Subjective Norms
Beliefs (about what others think you should do)
Motivation to comply
Intentions
Attitudes 80
One’s positive or negative evaluation of
performing a behaviour
Beliefs: about the consequences of performing
the behaviuor (outcome expectancies)
Values: appraisal (importance) of the
consequences
Subjective Norms 81
One’s perception of the social pressures to
perform or not perform a behaviour.
Beliefs: about whether specific individuals or
groups think one should perform the behavior.
Motivation to comply with these people.
Intentions 82
“Barring unforeseen events, a person will
usually act in accordance with his or her
intentions” (Ajzen & Fishbein, 1980).
Someone likely to smoke 83
ATTITUDE: Bob feels positive about smoking because he expects it will relax him and being relaxed is important to him (beliefs about the consequences and values)
SUBJECTIVE NORM: Other students encourage Bob to smoke (belief) and he wants them to like him (motivation to comply)
INTENTION: Bob intends (expects) to smoke with friends after school (intentions).
THEORY OF PLANNED
BEHAVIOUR
Watch the video
The theory of planned behaviour:
https://www.youtube.com/watch?v=77QiDn8lsUA
Theory of Planned Behaviour 86
Behavioural Control/Locus of Control/Self-
Efficacy
Intention to behaviour link is problematic when
not fully under the individual’s control
Past Behaviour
Always the best predictor of future behaviour
HEALTH PROMOTION
1. KNOWLEDGE APPEALS
Q. Does explaining
healthy eating
actually increase
healthy eating?
Of course it
does!
FOOD AND HEALTH PARTNERSHIP
Using nursery children in the UK, they
designed a “Healthy Eating” programme ;
Used two classes in a multicultural school
within an area of high poverty.
Children’s eating habits before, during and
after intervention were studied.
Interviews and questionnaires with nursery
workers and from parental feedback.
Experimental Intervention
Series of three minute videos, shown at
snack time in nurseries.
Children given the foodstuff featured in
the video as a snack.
Those that ate the food were given a
wall-chart with stickers as a reward.
Child receives a prize when wall chart
complete (Operant conditioning).
RESULTS
Nursery leaders reported day to day
improvements in eating in the experimental
group (but not the control group).
Parents reported children in experimental
group more adventurous in their eating habits
at home.
CONCLUSION:
Q. Does giving people knowledge
actually change their behaviour?
Q. What else needs to be involved?
A fear appeal is......
a persuasive
message which
emphasises the
harmful
physical/social
consequences of
failing to comply with
the recommendations
of the message
2.
The HEALTH BELIEF MODEL and the
THEORY OF PLANNED BEHAVIOUR
both suggest that perceived threat is
necessary for a person to change their
behaviour.
Q. Why do we use fear appeals?
The most obvious way to introduce this
threat is through FEAR APPEAL adverts.
TASK: 1. Consider whether each advert is a mild, moderate or strong fear appeal.
2. Would it alter your behaviour? 3. What emotions does it create in you?
1
2
3
4
5
Q. Do these adverts work?
Janis and Feshbach (1953)
Researched the
use of fear for
promoting oral
hygiene.
METHOD: 4 groups of participants.
3 were given a 15 min lecture on tooth
decay and oral hygiene consisting of:
AIM:
To study the
motivational effects
of fear arousal in
health promotion
PARTICIPANTS
The entire freshman
year of a large
Connecticut high
school, average age
15 years.
GROUP 1
Strong fear appeal
They received pictures and descriptions of diseased mouths, including explanations about the pain of tooth decay and gum
disease and awful consequences like cancer and blindness.
GROUP 2
moderate fear appeal
They received similar pictures and descriptions but they were much less
disturbing and dramatic.
GROUP 3
MINIMAL FEAR APPEAL
A lecture about teeth and cavities but without referring to very serious
consequences and using diagrams and x-rays rather than emotive pictures.
LECTURE FORM STRONG MODERATE MINIMAL CONTROL
INCREASED ANXIETY
APPRAISAL OF INFO
CHANGE IN HEALTH CARE
42 % increase
24 % increase
0% increase
Highest appraisal
Lowest appraisal
27 % increase
8% increase
36% increase
0 % increase
CONCLUSION?
Q. Was fear generated by the campaign?
The strong fear appeal created the most worry in the students and was rated as more interesting
Q. Did fear change the behaviour?
The overall effectiveness of a health promotion campaign is likely to be REDUCED by the use of strong fear appeal. It produced the least change in behaviour.
Research: Quist Paulsen (2003)
Field experiment investigating participants with heart problems.
Aim: to see whether intervention including fear arousal (information, personal advice stressing the risks) would promote smoking cessation and prevent relapse. Normal 30-45 stop smoking by themselves.
Result: 57% of the intervention group (compared to 37% of the control gruop) had stopped smoking.
Davis-Kirsch & Pullen (2003)
500,000 children in the U.S. are injured in bicycle
crashes annually,
252 die - 97% of whom were not wearing a helmet.
School-based evaluation study to examine students'
knowledge retention and behavioural changes.
Purpose: to identify associations between student-
reported knowledge of safety-related behaviours, reports
of current safety-related practices and students'
participation in the Safety Central program while in the
4th grade.
Davis-Kirsch & Pullen (2003)
Aim:
To increase fear
arousal of not
wearing bike
helmets
To increase the self-
efficacy of children
attempts to wear
cycle helmets.
Method/procedure
Five schools took part in “Safety Central
initiative” (four schools were given program,
one was control group).
Questionnaires given to 284 students & 11
teachers on their cycling behaviour.
Students were aged 10-12 years old.
Procedure cont. Observers sent to the four schools to watch;
a. Whether helmets were worn.
b. If helmets worn properly
c. Time of day, weather conditions
d. Gender, age, size of group, ethnicity
RESULTS of the Questionnaire?
90% owned a helmet.
82% believed helmets were important for safety.
74% said they wore a helmet the last time they
cycled.
Those on the program reported more willingness
to wear helmets.
55% were able to identify correct fitting points.
Davis-Kirsch & Pullen (2003)
Findings showed a statistically significant association
between participation in the Safety Central program and
retention of knowledge and enactment of safety
messages after a 1- and 2-year period.
Motivators included accessibility to helmets and media
messages about helmets being „cool” (used in „extreme”
sports).
Barriers to helmet use found in older males who tended
to ride alone and used their bicycles 5 days a week.
Most at risk for injury.
Stanford three-city project
AIM:
To promote health behaviours to reduce heart disease.
PROCEDURE
SAMPLE:
Residents from three cities in the USA
PROGRAMME:
CITY 1: Promotion of behaviours to reduce heart disease including a mass media
campaign, school based health education and screening programmes in the work place to
provide early warning
CITY 2: All of the above + one to one counselling
for individuals identified as being at risk
CITY 3: No intervention (control)
Residents interviewed before, during and
after two year project.
Researchers assessed health knowledge and
risk of heart disease.
RESULTS: Farquhar et al, 1985
Initial evaluation showed factors linked with
heart disease INCREASED in control city and
DECREASED in other two.
Further evaluation showed residents in City 1
showed increases in health knowledge BUT
little change.
Residents in City 2 showed dramatic increase
in actual health behaviour.
Results: Three Community Study
Statistically significant reduction was achieved in the risk score for cardiovascular disease
declines in blood pressure, smoking and cholesterol levels.
Risk score decreased approximately 25% for the media-only community and
30% for the community in which media were supplemented by face-to face instruction.
In control community, there was a minimal decrease in risk score (less than 5% for both the total and high-risk participants)
Results: Five City Project
The success of the intial 3 community study led researchers to expand their work to five cities in U.S.
Smoking rates decreased by 14% in proportion of smokers compared to control communities.
The intervention cities also experienced a 15% decrease in risk score based on improvements in blood pressure, physical activity, and cholesterol.
Numerous sub-campaigns including a curriculum for 4th, 7th and 10th grade students were found effective in increasing awareness of nutrition, physical activity and smoking cessation as essential to heart health.
However no effect on exercise
Study strengths
Random sampling from an open population and ability
to assess effectiveness of a community intervention.
While the curriculum, counselling and media
campaigns were successful in the Stanford Community
Trials, the authors were sceptical about the ability to
implement such efforts on a national scale.
Concerns included lack of trained staff, overstretch of
county health departments and the decentralization of
public schools.
Problems with the study
Relatively high cost
Small demonstrable change in health
behaviour at the community level.
Difficulty in comparing the effect of such
campaigns among small numbers of relatively
healthy communities that are already
undergoing large changes in health behaviour.
ADHERENCE TO
MEDICAL ADVICE
What is adherence?
“the extent to which a person’s behaviour (in
terms of taking medications, following diets, or
executing life style changes) coincides with
medical or health advice”
(Haynes, 1979, pp 2-3)
“a person’s behaviour in relation to a prescribed
medical regimen” (La Greca & Bearman, 2003)
Evolution of terminology
COMPLIANCE
SELF-MANAGEMENT ADHERENCE
CONCORDANCE
Theories of Adherence
The Adherence/Compliance Approach
Applies to patients with an existing problem
Assumptions:
Pt. needs to be treated
Pt. wants to initiate/maintain treatment and has sought medical
care for that purpose
Pt. should be motivated to comply for symptom relief
Limitations: asymptomatic conditions, overlooks
barriers
Theories of Adherence
Health Belief Model
Can be applied to preventative treatments
Views patients as autonomous “decision makers”
Considers the patient’s perceptions of:
Threat of illness
Effectiveness of treatment
Barriers to treatment
Theories of Adherence
Transtheoretical Model (Stages of Change)
Five stages in the adoption of health-related
behaviors:
Precontemplation
Contemplation
Preparation
Action
Maintenance
Match intervention to stage
Stages of Behaviour Change
Precontemplation
Contemplation
Preparation
Action
Maintenance
Relapse
Precontemplation
Contemplation
Preparation Action
Maintenance
Prochaska, Norcros & DiClemente
Relapse
Evaluating Stages of Change
Precontemplation (Denial) “What problem? I’m not thinking about it.”
Contemplation (Ambivalence) “I wonder if I might have a problem? I’m thinking about it but not
ready to decide anything yet.”
Preparation / Determination (Admission) “I have a problem.”
Action (Taking steps / Making changes) “I have a problem and I’m ready to do something about it.”
Maintenance (Continuing what works) “I’m stabilized and doing well. How can I support my ongoing
recovery?”
Relapse / Recycle (Trying again) “I’m stabilized but have relapsed. How can I get back into active
recovery?”
Precontemplation: “Huh? What problem?”
A Precontemplation-
stage person is
described as, “It’s not
that they can’t see the
solution. It’s that they
can’t see the problem.”
This stage of change has
been given the label of
“Denial” in the past.
Precontemplation: “Huh? What problem?”
Treatment for someone in
the Precontemplation
stage would seek to
engage them in the
process of objectively
evaluating whether
they have a problem,
and supporting movement
along to the Contemplative
stage of change.
Precontemplation
Am I Precontemplative?
“What Problem?”
“Who, me?”
“I see no reason to change.”
“I wish people would just leave
me alone!”
Evaluating Stages of Change
Precontemplation (Denial) “What problem? I’m not thinking about it.”
Contemplation (Ambivalence) “I wonder if I might have a problem? I’m thinking about it but not
ready to decide anything yet.”
Preparation / Determination (Admission) “I have a problem.”
Action (Taking steps / Making changes) “I have a problem and I’m ready to do something about it.”
Maintenance (Continuing what works) “I’m stabilized and doing well. How can I support my ongoing
recovery?”
Relapse / Recycle (Trying again) “I’m stabilized but have relapsed. How can I get back into active
recovery?”
Contemplation: “Problem? Yeah . . . Action? Nah.”
Contemplation-stage people may know their destination, and even how to get there, but they are “not ready yet.”
Someone in this stage of change may be ambivalent about doing anything about a problem that they can clearly identify having.
Contemplation: “Problem? Yeah . . . Action? Nah.”
Treatment for someone in
the Contemplation stage
would seek to engage them
in the process of gaining
motivation to address their
problem, and supporting
movement along to the
Preparation stage of
change.
Conte
mpla
tion
Am I Contemplative?
“I might have a
problem.”
“I’m not ready to
make any decisions
yet.”
“Problem? Maybe.”
Considering change,
but ambivalent.
Evaluating Stages of Change
Precontemplation (Denial) “What problem? I’m not thinking about it.”
Contemplation (Ambivalence) “I wonder if I might have a problem? I’m thinking about it but not
ready to decide anything yet.”
Preparation / Determination (Admission) “I have a problem.”
Action (Taking steps / Making changes) “I have a problem and I’m ready to do something about it.”
Maintenance (Continuing what works) “I’m stabilized and doing well. How can I support my ongoing
recovery?”
Relapse / Recycle (Trying again) “I’m stabilized but have relapsed. How can I get back into active
recovery?”
Preparation: “Almost ready to take action . . .”
Preparation-stage individuals are planning to take future action, but are still making the final adjustments before committing.
Someone in this stage of change may be working through the final obstacles that are getting in the way of taking action.
Preparation: “Almost ready to take action . . .”
Treatment for someone in the Preparation stage would seek to engage them in the process of taking action to address their problem, i.e., supporting movement along to the Action stage of change.
Preparation
Am I in Preparation?
“I have a problem, but
don’t want to commit
to doing anything
about it yet”
“I’m developing plans
to change”
“Problem? Yes…
Change? Not yet…”
Evaluating Stages of Change
Precontemplation (Denial) “What problem? I’m not thinking about it.”
Contemplation (Ambivalence) “I wonder if I might have a problem? I’m thinking about it but not
ready to decide anything yet.”
Preparation / Determination (Admission) “I have a problem.”
Action (Taking steps / Making changes) “I have a problem and I’m ready to do something about it.”
Maintenance (Continuing what works) “I’m stabilized and doing well. How can I support my ongoing
recovery?”
Relapse / Recycle (Trying again) “I’m stabilized but have relapsed. How can I get back into active
recovery?”
Action: “Let’s get going”
The Action Stage is described as the one in which individuals most overtly modify their behaviour and surroundings to accomplish their goal.
Someone in this stage of change is taking visible steps and making visible changes in order to work on their recovery.
Action: “Let’s get going”
Treatment for someone
in the Action stage
would seek to assist
them in taking all
indicated steps to be
successful in their
recovery, and to support
movement along to the
Maintenance stage of
change.
Action
Am I at the Action stage?
“I have a problem and
I’m ready to do
something about it.”
“I’m making changes.”
“Problem? Yes…
Change? YES!”
Evaluating Stages of Change
Precontemplation (Denial) “What problem? I’m not thinking about it.”
Contemplation (Ambivalence) “I wonder if I might have a problem? I’m thinking about it but not
ready to decide anything yet.”
Preparation / Determination (Admission) “I have a problem.”
Action (Taking steps / Making changes) “I have a problem and I’m ready to do something about it.”
Maintenance (Continuing what works) “I’m stabilized and doing well. How can I support my ongoing
recovery?”
Relapse / Recycle (Trying again) “I’m stabilized but have relapsed. How can I get back into active
recovery?”
Maintenance: “I’m in a good place, let’s keep it up!”
In the Maintenance Stage, the focus is on consolidating gains and preventing relapse.
Someone is this stage has an
effective set of tools and “program
of recovery” that they commit to
continuing to practice.
Treatment for someone in the
Maintenance stage would seek to
strengthen and increase their “tool
kit” and to support ongoing recovery
success.
Maintenance
Am I at Maintenance?
“I’m stabilized and
doing well. How can I
support my ongoing
recovery?”
“I’ve made the
changes I want; now I
want to maintain my
gains.”
Evaluating Stages of Change
Precontemplation (Denial) “What problem? I’m not thinking about it.”
Contemplation (Ambivalence) “I wonder if I might have a problem? I’m thinking about it but not
ready to decide anything yet.”
Preparation / Determination (Admission) “I have a problem.”
Action (Taking steps / Making changes) “I have a problem and I’m ready to do something about it.”
Maintenance (Continuing what works) “I’m stabilized and doing well. How can I support my ongoing
recovery?”
Relapse / Recycle (Trying again) “I’m stabilized but have relapsed. How can I get back into active
recovery?”
Relapse / Recycle: “How can I get back on track?”
Relapse is often part of the chronic
disease process, and recovering
individuals need to be prepared to
deal with it, including damage-
control strategies.
“Progress not perfection,”
supports gentleness and freedom
from shame, and “Progress not
permission” emphasizes the
importance of personal responsibility to stay active in one’s own recovery, even when slips or relapses occur.
The Recycling aspect of relapse supports the view that recovery-strengthening lessons can be learned from relapse episodes – “The only bad relapse is a WASTED relapse”
Relapse / Recycle
Relapse / Recycle
“I’m stabilized but
have relapsed. How
can I get back into
active recovery?”
“How can I learn from
my relapse to
strengthen my
recovery plan?”
