Understanding different stages of a person/patient unwilling to do a task beneficial to him/her to Keep him/her on that path for the rest of his/her life for his/her own benefit

1. Stage Based Model
&
Intervention Program
Presenter: Shahan Ullah (PhD)
Discipline: Pharmacy Practice
Subject: Public Health Pharmacy

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Stage Based Model/Transtheoretical Model/Stages of
Change Model
Issues/Concerns
Understanding a Change
Stages of Change
Interventions for helping a “Stuck”
Patient
“Readiness to Change” Ruler
Agenda-Setting Chart
Tools to elicit a Change
Limitations

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Health-Care Professionals assist patients in changing behaviour for health improvement
Diet control, stress management techniques, exercise programs & dietary restrictions are
interventions that need patient’s motivation
Change in lifestyle is necessary for successful management of long term illness
The “JUST DO IT” approach has been changed to follow up calls, record keeping, extended
office visits etc
Repeatedly educating patient technique eventually becomes frustrating for both the
Patient & Physician
Promising patient an improved outcome does not guarantee their motivation for long-term
change
The Confrontational Approach by the physician is seen as CRITICAL rather than supportive
BUT
The Relapse is seen as failure; results in Physician avoidance & Giving up Treatment
After the Failure; investment of time & energy; The Patient is termed as
NON-COMPLIANT & UNMOTIVATED

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Behaviour Change is rarely a discrete, single event
Change implies a phenomena occurring over time
Change is a process that unfolds over time, involving progress through a series of stages
Patients after experiencing a medical crisis readily comply when advised for behavior
changing by the Physician
More often Physicians encounter patients, unable or unwilling to change
Currently Change has been understood as a process of identifiable stages through which
patients have to pass

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Stage Based Model/Transtheoretical Model/Stages of
Change Model
This model integrates key constructs from other theories into a
comprehensive theory of change
The concept is then applied to a variety of behaviours, populations
and settings (Therapy, Prevention, Policy making etc)

7. Prevent Relapse
Facilitate Progress
7
Processes
of Change
Self-
Efficacy
Decisional
Balance Reduce Resistance

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Do not intend to take action for the foreseeable future (6 months)
Being uninformed or under informed about the consequences for/of one’s behaviour
Smokers “in Denial” may not see the advice applies to them personally
Patients with high cholesterol level may seem “immune ” to problems that strike others
Obese may try to lose weight unsuccessfully and may have simply given up
Multiple unsuccessful attempts about the ability to change lead to demoralization
Both uninformed and under informed tend to avoid reading, talking or thinking about their
high risk behaviours
Such patients are often characterized as RESISTANT, UNMOTIVATED or UNREADY for help

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Patients are ambivalent about changing (Tend to change in next 6 months)
Giving up enjoyed behaviour causes them to feel a sense of loss, despite the perceived gain
During this stage Patient assess barriers as well as benefits of change
Time, Expense, Hassle,
Fear…
I Know I need to, Doc,
but…
Patients are more aware of PROS, but Acutely aware of CONS
This Weighing b/w Costs & Benefits of changing produce profound ambivalence and patients remain in this stage
for very long period of time
Chronic Contemplation
Or
Behavioral
Procrastination
Individuals in this stage are not ready for Traditional Action-Oriented Programs

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Patients prepare to take specific action in immediate future(usually in next month)
Some patients have already taken significant action
Experiment with small changes, as their determination to change increases
Sampling low fat foods may be an experimentation with a move toward greater dietary modification
Switching to different brand of cigarette or decreasing their drinking indicates change
Joining Health education class Consulting a counselor Talking to a Physician
Buying a self help book Relying on a self-change approach
These People should be recruited for action-oriented programs

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Physicians are eager for their patients to reach at this stage
But, If the previous stages has been glossed over, action itself is often not enough
Any action by the patients should be praised, because it demonstrates the desire for lifestyle change
In this people have made overt modifications in their life style within past 6 months
Because action is observable, overall process of behaviour change has been equated with action
But in TTM, Action is just one of the Six stages
Typically Not all modifications of behaviour count as action in this model
Decreasing no of cigarettes or switching to low tar /nicotine cigarettes is not enough
People have to attain a certain criteria for complete disease prevention

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Changes have been made Overt modifications in lifestyle have been made
Work is focused on to prevent relapse People are less tempted to relapse
People/Patients are growing more confident that they can continue their changes
Based on Self-Efficacy data researchers have estimated that maintenance lasts from
6 months-5 years
Involves incorporating the new behaviour “over the long haul”
Discouragement over occasional “slips” may halt the change process and result in patient giving up
In a study by Surgeon in 1990 stated; 12 months abstinence, 43% returned to smoking
5 years of continuous abstinence; risk of
relapse dropped to 7%
However, Patients
recycle through the
stages of change
several times before
the change becomes
truly established.
Termination
Individuals
are not
tempted
They have
100% self-
efficacy
No Matter
What, They
wouldn’t
Do It Again

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SBM is useful for selecting appropriate interventions Rather than to educate & admonish, intervention should
be tailored to enhance patient success
Identifying a patient’s position in change process,
physician can tailor the interventions
Focus of office visit is to help patient move along the
stages; not to convince him to change behaviour
The goal for a single encounter is a shift from
“Grandoise” to the “Realistic”
Get Patient
to Change
Unhelathy
Behaviour
Identify the stage
of Change and
engage patient in
a process to
move to the next
stage
Starting with Brief and Simple Advice makes sense b/c
patients change behaviour at the directive of physician
This step should be viewed as OPENING ASSESSMENT
rather than INTERVENTION
This Step Prevents
contemplators from
rationalizing
that,”My Doctor
never told me to
Quit”
Patient response to this provides helpful information on
which next patient-physician dialogue can be based
Physician concrete advice and Patients rhetorical
response
A few minutes listening to the patient and tailoring the
intervention can produce successful improvement
Patients at Pre/Contemplation are challenging for the
physicians
Empathetic therapist style was more fruitful than
Confrontational style (increased drinking)
Motivational interviewing is a tool which incorporates:
EMPATHY
REFLECTIVE
LISTENING
KEY QUESTIONS
Physicians are simultaneously patient-centered &
directive

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Patient is stuck in precontemplation and contemplation stage
Argumentative Hopeless In Denial
Physicians have to convince them which engenders RESISTANCE
Physicians have to use EMPATHY & THOUGHT PROVOKING questions
WORDINGS of the questions and patient’s, “Not thinking about the change” is also important
Upon the response of Precontemplators; don’t jump to advice or be judgmental
Reflecting with empathy, Instilling Hope, pointing out discrepancies b/w goals & statements
Do you want to Die from this? How will you know that it’s time to Quit?

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Score Readiness Stage of Change
0-3 Not ready Pre-Contemplation;
Early contemplation
4-7 Unsure Contemplation
8-10 Ready Preparation; Action

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Score 0-3
Elicit patient’s perceived
negative consequences
Express Concern Offer Information Support and Follow-Up
What kinds of things
have happened while
drinking that you later
regretted?
I am concerned about
how smoking is
contributing to your
asthma?
Would you like more
information about the
effects of cocaine on
your health?
I understand you aren’t
ready to talk about
you’re your drinking &
that’s OK.
I would like to ask about
it again at our next appt.
Is that okay?
Please call if you have
any questions.

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Score 4-7
Negotiate a Plan to cut back or Quit Offer support & Follow up
What are some steps you think
you could take to start cutting
back?
Support patient’s autonomy and
ask about following up

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Score 8-10
Help patient develop action plan Identify resources
What would change look like
for you?
Lets identify the steps
necessary to help you stop
smoking.
What would be your first
step?
Who’s been supportive of you
before?
How can He or She help you
stop drinking?
Instill Hope
You’ve been successful in
getting your diabetes under
control, so you have the
ability to stop using cocaine.

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Limited
Intervention
0-3 4-7
Elicit patient’s motivation to change
8-10
Elicit perceived
negative
consequences,
Expresss concern,
Offer information,
Support & Follow up
Negotiate a Plan to Cut
back or Quit,
Offer Support & Follow
Up?
Help Patient develop
action plan,
Identify resources,
Instill Hope

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Smoking
Less No of
Cigarettes
No Smoking
Drinking DRY
Diabetic
Diet
Control
No
Temptation

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