1. INTEGRATION OF BEHAVIORAL ECONOMICS WITH THE TRANSTHEORETICAL MODEL 1
Integration of Behavioral Economics with the Transtheoretical Model and Stages of Change
Deborah S Storlie
Creighton University
HWC 650 WB: Health Behavior Modification
Dr. Donna Allen
March 27, 2015

2. INTEGRATION OF BEHAVIORAL ECONOMICS WITH THE TRANSTHEORETICAL MODEL 2
Abstract
Human health behavior change is not an event but a process. The Transtheoretical
Model (TTM) is a framework that explains human health behavior change as a sequential
six-stage model where change is promoted by ten supporting processes. This model
developed out of research of self-changers. It compared smokers and incorporated over
300 theories of psychotherapy in the mid 1980’s. (Glanz et al, 2008) The TTM has been
widely applied to understand and influence human health behavior to promote change or
adoption of desired evidence-based behavior by individuals and populations. Decisional
balance (weighing pros and cons) as well as perceived self-efficacy (confidence) are
additional influencing factors that correlate to stage advancement and preventing relapse
to earlier stages and behavior deterioration. Although the TTM is a comprehensive model
to understand human behavior change, it is prudent to also understand human decision-
making principles because most behaviors are a grouping of complex interdependent
choices. As such, it is beneficial to understand the natural psychosocial forces acting on
individuals during decision–making at each stage of change and through the processes
that support change. For this we turn to the discipline of behavioral economics (BE). BE
studies behavioral decision making and evolved from the concept of bounded rationality.
This idea explains why people do not always act rationally. Decision-making is limited by
the information available, cognitive resources and time. Heuristics (rules of thumb) are
often leveraged to overcome such limitations. (Jones, B. 1999)
Keywords: Transtheoretical model, stages of change, decision-making, behavioral
economics

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Integration of Behavioral Economics with the Transtheoretical Model and Stages of
Change
The Transtheoretical model (TTM) is not a complete toolbox for health behavior
change. It is, however, easily understood, highly adaptable and offers utility in most
research and intervention design efforts for health educators, care providers and health
coaches to move individuals and populations closer to adopting better health activities.
This model has been used extensively for efforts to improve smoking cessation, physical
activity levels and adherence to preventative screening interventions. This empirical model
has substantiated efficacy in predicting and influencing an individual’s likelihood of moving
through six stages of behavior change: precontemplation, contemplation, preparation,
action, maintenance and termination. The compilation of research used to develop this
framework isolated ten processes of change that support movement through the stages
from behavioral intention to behavior. These processes are a combination of experiential
and behavioral processes and describe how individuals evolve from intention to action.
Additionally, human health behavior change is also heavily dependent on decisional
balance (weighing pros and cons of a behavior change) and perceptions of self-efficacy
(confidence to overcome competing priorities and temptations).
The TTM applies scientific principles to the art of behavior change. The model
emphasizes the importance of matching the interventions (processes) to the individual’s
current stage of change. Program developers using interventions that are stage-matched
to individuals within the target population increase their potential for population impact
through higher participant retention and rate of efficacy of stage progression. In early
stages of change, interventions relying on cognitive, affective and evaluative processes
are leveraged whereas in later stages change behavior is influenced by commitments,
conditioning, contingencies, environmental controls and social support. It is critical for
change agents to understand the stage distribution of the target population. This refers to
identifying the percent of individuals within the population in each stage of change for the
desired behavior and designing intervention programs accordingly.
Critics of the model focus on the fact that most participants will not reach the
termination stage and question the value of the model for not explicitly focusing on
achieving behavior change. They do not celebrate the intermediate success of progression
toward change from resistance to action to sustained change.

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Individual health behaviors are an expression of judgment and manifest from
multiple choices and decisions. Behaviors reflect a balance of cognitive, emotional and
physical trade-offs and decision-making. As such, once can best attempt to understand
human behavior change management by not only studying the most prevalent health
behavior change model, the TTM, but also learning about decision-making constructs and
strategies (rational and intuitive) as described in behavioral economics.
The Transtheoretical Model Stages of Change Explained
The TTM is a framework for understanding the process by which human health
behavior evolves from resistance through incontestable commitment. The model has been
heavily leveraged to assess and plan the advancement of human health behavior from
less desirable to more desirable choices. Examples include but are not limited to smoking
cessation, weight loss, increased physical activity and improved nutritional intake. The
framework pulls from a rich body of research including over 300 disparate frameworks
from social cognitive behavioral research. The context of the work purports that humans
advance through the six stages described in detail below with the support of ten processes
of change and also emphasizes that change is heavily dependent on decisional balance
and perceptions of self-efficacy. Change agents, individuals or groups who desire to
change human health behavior toward a specified action, should approach individuals in
each stage using specific techniques that align with the ten processes of change and
employ knowledge of human decision-making paradigms.
Precontemplation is the beginning stage of change when people are uninformed
or under-informed about the potential benefits of the desired change (any behavior
they desire to start or stop). The resources required for change are perceived to be
too high and the cons of change outweigh the pros. Change agents should address
individuals in this stage with interventions to create awareness and interest to get
them thinking about making the change. This stage is representative of the “status
quo bias”, the preference for things to remain the same. Moving to the next stage
requires overcoming the inertia of the status quo.
Contemplation represents a shift from resistance to willingness to consider making
the change. The pros and cons of changing behavior are perceived to be about
equal. Individuals in this stage are often referred to as contemplators. To capitalize
on this readiness, and prevent “chronic contemplation”, change agents should focus
on persuading and motivating the individual. The mind is the gateway to action. At

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this stage the mind is open to gathering new information and forming new habits.
These individuals are motivated but not committed. During this stage of information
gathering, due to the large volume of information and sensory stimulation,
individuals may lean heavily on heuristics (cognitive shortcuts) which pull from an
individual’s intuitions, impressions and automatic thought processes. (Samson, A,
2014)
Preparation is the stage when the paradigm shift occurs from thought to tangible
action. These individuals are aligning resources to support the desired action. This
is when a plan starts to come together and capitalizing on this readiness is critical
to prevent a boomerang effect back to a previous stage. Underestimation of time or
resources needed or overestimation of readiness (lack of planning) can cause this
person to advance to action too quickly and become discouraged because not
enough time was spent building confidence (self-efficacy) and a plan. The optimism
bias is a natural tendency of people to overestimate the likelihood of positive
outcomes and underestimate the likelihood of negative events. These individuals
are motivated to become committed to the new or replacement behavior. (Samson,
A, 2014)
Action represents the culmination of multiple choices and actions to support the
new behavior or the behavior change. Momentum is building to turn the behavior
into a new habit. Remaining in this stage depends on staying focused and
committed. Building a habit is an important concept of behavioral economics. Habits
grow from habit loops which “involve a cue that triggers an action, the actual
behavior, and a reward using resources and commitment to create action. For
example, habitual drinkers may come home after work (the cue), drink a beer (the
behavior), and feel relaxed (the reward).” (Samson, A, 2014, p.17)
Maintenance is the stage of change following six months in the action stage. The
individual or change agent working with a population is focused on interventions to
maintain the change by overcoming temptations to revert to less desirable
behaviors or major life events. Some TTM literature refers to a regression in
commitment as a relapse stage. Many behaviors have an average number of action
attempts before individuals become long-term maintainers. Smokers, on average,

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make three to four attempts before reaching this stage. (Prochaska, J, DiClemente,
C, Nocross, J. 1992)
Termination refers to a transition from “doing” to “being”. The behavior is no longer
an action, it is a lifestyle. This stage has also been referred to as the adoption
stage. (Sholl, 2011)
Progression through these stages is sequential but not always unidirectional. It is
well established that this is the order in which human health behavior develops. However,
it is not uncommon to see an individual’s health behavior regress to an earlier stage or
move bidirectional between stages. In 1992 Prochaska et al proposed a modified version
of the TTM termed “The Spiral Model of Stages of Change” to represent the stages in the
context of common, perhaps even inevitable, relapse occurrences. The spiral model
shows relapse and recycling through the stages not once but multiple times.
Advancing Through the Stages of Change: Processes That Turn Intention into
Action
The TTM stages are thresholds of change but they do not affect behavior. They
represent milestones along the health behavior change journey. The ten processes of
change are constructs that give context and explanation to influencing factors. They
leverage various facets of human decision-making that advance people along the change
continuum and can be leveraged to prevent relapse. These factors act as a catalyst for
change by leveraging behavioral economics constructs including but not limited to social
norms, incentives, perceptions of self and choice architecture.
Consciousness raising – In this primary process, the individual is becoming increasingly
aware of the causes or consequences of, or cure related to, an undesirable behavior. Self-
awareness is also increasing. This is a stage where feedback is provided regarding the
individual’s current state behavior. Change agents can use education, feedback or social
media to increase the target population knowledge. This process is most effective to move
individuals in the pre-contemplation or contemplation stages. This allows for better-
informed decision making. Individuals must overcome the cognitive bias created by the
anchoring effect which is the over-reliance on early information obtained about a subject
and not succumb to confirmation bias, the practice of seeking out information that affirms
existing beliefs or preconceptions. Both of these subconscious processes pose a

7. INTEGRATION OF BEHAVIORAL ECONOMICS WITH THE TRANSTHEORETICAL MODEL 7
significant risk to informed decision-making. (Samson, A, 2014) It is also important to
leverage the fluency heuristic. Individuals tend to trust and value information more if it is
clear and easy to understand. (Samson, A, 2014)
Dramatic relief – This experiential process evokes emotional responses about the desired
behavior change. Emotional arousal, especially negative emotions such as fear, anxiety or
worry, may serve as motivation for change. Techniques used to induce an emotional
reaction include psychodrama, personal health feedback or a health incident suffered by
someone close, role playing and social media campaigns. Based on the 2008 work by
Pfister and Bohm, it is recognized that emotions play a significant role in meeting the four
central needs of decision-making. Emotional mechanisms provide information about
pleasure and pain for preference construction, enable rapid choices under time pressure,
focus attention on relevant aspects of a decision problem and generate commitment
concerning morally and socially significant decisions. “People without the capacity for
emotion are generally without the capacity for making decisions.” Therefore, the
importance of this process should not be discounted. (Redlawsk, D and Lau, R, 2012)
Self reevaluation – This is a process whereby the individual compares self-image
between desired and actual behavior and identifies discrepancies. It combines both
cognitive and affective evaluation of one’s opinion of self. Change agents can use
conversations to clarify the individual’s values, discuss healthy role models, and leverage
images of the desired behavior. Cognitive dissonance is the mental stress experienced
when one’s self-image related to a behavior conflicts with one’s desired self-image.
(Samson, A, 2014) This awareness and the related emotions can be leveraged to promote
action. “Behavior that is incongruent with a person’s perception of self is not maintained
when made conscious. Therefore, an opportunity for self-reflection can be a powerful
motivator for generating change.” (Longmire-Avital, B., Golub, S., Parsons, J, 2010)
Environmental reevaluation – A combination of cognitive and affective assessments of
one’s social environment leads to the realization of the negative impact on others of a
current behavior or the potential positive impact of the desired behavior. It can also include
the awareness that one serves as a positive or negative role model for others. This
awareness can be evoked through empathy training, interventions or documentaries.
Social norms can have a profound influence on behavior. Social norms are behavioral
expectations within a society. Health behavior change programs leverage descriptive
normative feedback (e.g. how one’s behavior compares to the national average). “Human

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susceptibility to feedback about social norms is related to our desire to maintain a positive
view of who we are as a person. When the outcome of an action threatens this desire, we
may change our behavior, though we often simply change our attitudes or beliefs.”
(Samson, 2014; p.9) This emphasizes the importance for change agents to focus on the
individual’s perspective about the impact of his or her behavior on society so that
rationalization does not impede progress.
Self liberation – This two-fold process is very familiar to many. It reflects the belief that
one can change (self-efficacy) and a commitment or recommitment to take action on that
belief. The effectiveness of this process is derived from people’s motivation to maintain a
positive self-image and to avoid reputational damage or cognitive dissonance.
Commitments may be made publicly or privately including New Year's resolutions, public
testimonies, a signed contract with a counselor or a simple note on the mirror. “Motivation
research indicates that people with two choices have greater commitment than people with
one choice; those with three choices have even greater commitment; four choices do not
further enhance will power. So with smokers, for example, three excellent action choices
they can be given are cold turkey, nicotine fading and nicotine replacement. (Velicer, W.,
Prochaska, J., Fava, J., Rossi, J., Redding, C., Laforge, R., Robbins, M., pp. 10-11)
Social liberation – Efforts are made by change agents to improve physical environments
and policies during this process. Adjusting environmental designs to support the desired
behavior provides alternatives and opportunities to individuals in a social setting to align
their behavior with their intentions for improved health. Examples include smoke-free
restaurants, salad bars in school lunch rooms, and free bottles of water at a bar to
promote responsible drinking. Additionally, policy advocacy and empowerment
procedures can increase opportunities for underserved or ostracized populations to
access healthcare and health promoting resources. Individuals and change agents can
use the design technique of default options (opt-out rather than opt-in) to capitalize on
people’s propensity not to take action to change from the default (e.g. serving sizes,
default side item selection, food subsidies). (Stulberg, B, 2014) This strategy has been
adopted in many ways including promoting organ-donation and portion control.
Counter conditioning – This is the proactive replacement of desired health behaviors in
lieu of undesirable behaviors. This requires overcoming the “status quo bias” described in
the previous section. An individual engaged in this process may require support to identify

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and implement substitutions for existing behavior or situational stressors. Advocates for
change can use choice architecture, the practice of influencing healthy choices by using
defaults and framing to describe options. (Samson, A, 2014) Providing choices is
important because people respond better when they maintain the freedom of choice and
they do not feel a choice was forced on them. Also, individuals will respond to choices
based on how the information is presented (framed). For example, if asked to choose,
people will select a surgery with a 9 out of 10 chance of survival rather than a 1 in 10
chance of dying. (Samson, A, 2014) This knowledge can be used when offering food
substitution choices, exercise alternatives and medical interventions.
Stimulus control – Each health behavior is a reflection of compound decision making
which means the individual has made many evaluations and choices. In this process, a
particular focus is put on identifying and removing stimuli that are associated with the
undesirable behavior and adding triggers to support the preferred behavior. Google
redesigned their cafeteria to promote employee nutrition. The company implemented a
traffic-light rating system that marks unhealthy foods with a red “warning” sticker and
healthy options with a green sticker. The standard plates are smaller and have a message
on them which reads “bigger dishes prompt people to eat more”. (Stulberg, B, 2014) This
is an example of environmental re-engineering. Additionally self-help groups and posters
can be beneficial to support change and reduce the risk for relapse. Given the complexity
of behavior change, it can be helpful to use the decision-making skill of decomposition
which means breaking a decision or problem down into component parts, each of which is
presumably easier to evaluate than the entire decision. Problem decomposition allows
targeted interventions to be put in place for each individual stimulus. (Redlawsk, D, Lau,
R., 2012) In a 2012 review of the literature on behavior economics it was identified that
“people tend to pay little attention to the small but cumulative consequences of repeated
decisions, such as the effect on weight of repeated consumption of sugared beverages or
the cumulative health effect of smoking, a decision error dubbed the “peanuts effect.”
(Lowenstein, G., Asch, D., Friedman, J., Melichar, L. , Volpp, K., 2012)
Contingency (reinforcement) management – “For every action there is a reaction.” This
is Newton’s third law of motion. It acknowledges that for every action we make there are
consequences. In the change supporting process of reinforcement management,
individuals receive feedback for taking steps in a particular direction, either rewards or

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penalties. “While reinforcement management can include the use of punishments, we
found that self-changers rely on rewards much more than punishments.” (Velicer et al
2000) It is also important to be cognizant of the frequency of feedback. “…research shows
that small rewards and punishments have greater impact if they occur immediately.”
(http://knowledge.wharton.upenn.edu/article/one-way-to-lower-health-costs-pay-people-to-
be-healthy/ Retrieved 3/25/15)
Helping relationships – Social support is often one of the earliest processes targeted by
individuals to support health behavior change and includes alliances with like-minded
individuals, finding a partner or calling a counselor if needed. Building one’s community of
support is a process that not only helps motivate in earlier stages of change but is also
critical for maintained commitment to reach the latest stages. Social support is a very
strong incentive for change. It was identified that people have the “tendency not to change
behavior unless the incentive to do so is strong” (Samson, A, 2014; pp.5-6).
Stages of Change: Effects of Decisional Balance and Self-Efficacy
Throughout the processes that support stages of change, individuals are weighing
the pros and cons of alternatives. This is often referred to as the benefit to cost ratio.
Within the discipline of behavioral economics a field of research termed intermporal
choice has emerged which looks at the relative value people allocate to payoffs at
different times. Findings in this research indicate that people have a present bias (giving
more weight to rewards closer to the present) and they tend to discount the value of
rewards at a later date. This is often referred to as a preference for immediate gratification.
(Samson, A., 2014)
Behavioral economics research has also identified that “avoiding loss is more
motivating than pursuing equivalent gains”. (Samson, A, 2014, p.101) This loss aversion is
estimated to be twice as powerful as the potential for gain. This explains why tying a
penalty to failing to meet a commitment can be a strong motivator.
Self-efficacy refers to the individual’s confidence in one’s own ability to be
successful with a specific behavior. Self-efficacy is built or depleted through personal
experience, vicarious experience (watching or hearing about other’s experience with the
same behavior), social persuasion and physiological factors (physical and emotional
responses). Self-efficacy is an important construct of other individual-focused health
behavior change models due to its identified influence in determining a person’s behavior
change. (Bandura, A 1986) Self-efficacy influences human behavior though it’s direct

11. INTEGRATION OF BEHAVIORAL ECONOMICS WITH THE TRANSTHEORETICAL MODEL 11
impact on decision-making. Specifically it influences cognitive processes (visioning),
motivation (goal-setting and commitment level), affective processes (reactions to stimuli)
and selection process (type of activities). (Koring, M, Lippke, S., Parschau, L., Reuter, T.,
Schwarzer, R 2012) (Lippke, S, Wiedemann, A., Ziegelmann, J.P., Reuter, T., Schwarzer,
R. 2009)
Summary
Influencing change in human health behavior requires an understanding of the
natural progression of change through six well defined stages of change, the ten
processes that support the behavior change and the body of literature on human decision-
making termed behavioral economics. Individuals progress bidirectionally through the
stages of change, often relapsing and repeating stages. The TTM explains how and why
successful adoption of desired behavior correlates to individuals who progress linearly
through each stage and who leverage all ten processes to support adoption of the new
behavior. Individuals who move too quickly through or skip a stage will likely not build the
necessary self-efficacy to maintain the change and may not spend enough time
understanding the balance of the pros and cons (decisional balance).
Behavioral economics constructs lend a large body of information to understand
how individuals make decisions. It also provides techniques that can be leveraged during
each process of change to incentivize people to change their behavior. The discipline
explains why people make choices that sometimes seem irrational and explains the
fundamental cognitive and affective tools people use to make choices with a strong focus
on heuristics, biases, framing and social norms.

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