Stages of Change model/chap-3

 Transtheoretical Model (Stages of Change)

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The Transtheoretical Model (also called the Stages of Change Model), developed by Prochaska and DiClemente in the late 1970s, evolved through studies examining the experiences of smokers who quit on their own with those requiring further treatment to understand why some people were capable of quitting on their own. It was determined that people quit smoking if they were ready to do so. Thus, the Transtheoretical Model (TTM) focuses on the decision-making of the individual and is a model of intentional change. The TTM operates on the assumption that people do not change behaviors quickly and decisively. Rather, change in behavior, especially habitual behavior, occurs continuously through a cyclical process. The TTM is not a theory but a model; different behavioral theories and constructs can be applied to various stages of the model where they may be most effective.

The TTM posits that individuals move through six stages of change: precontemplation, contemplation, preparation, action, maintenance, and termination. Termination was not part of the original model and is less often used in application of stages of change for health-related behaviors. For each stage of change, different intervention strategies are most effective at moving the person to the next stage of change and subsequently through the model to maintenance, the ideal stage of behavior.

1.    Precontemplation - In this stage, people do not intend to take action in the foreseeable future (defined as within the next 6 months). People are often unaware that their behavior is problematic or produces negative consequences. People in this stage often underestimate the pros of changing behavior and place too much emphasis on the cons of changing behavior.

2.    Contemplation - In this stage, people are intending to start the healthy behavior in the foreseeable future (defined as within the next 6 months). People recognize that their behavior may be problematic, and a more thoughtful and practical consideration of the pros and cons of changing the behavior takes place, with equal emphasis placed on both. Even with this recognition, people may still feel ambivalent toward changing their behavior.

3.    Preparation (Determination) - In this stage, people are ready to take action within the next 30 days. People start to take small steps toward the behavior change, and they believe changing their behavior can lead to a healthier life.

4.    Action - In this stage, people have recently changed their behavior (defined as within the last 6 months) and intend to keep moving forward with that behavior change. People may exhibit this by modifying their problem behavior or acquiring new healthy behaviors.

5.    Maintenance - In this stage, people have sustained their behavior change for a while (defined as more than 6 months) and intend to maintain the behavior change going forward. People in this stage work to prevent relapse to earlier stages.

6.    Termination - In this stage, people have no desire to return to their unhealthy behaviors and are sure they will not relapse. Since this is rarely reached, and people tend to stay in the maintenance stage, this stage is often not considered in health promotion programs.  

To progress through the stages of change, people apply cognitive, affective, and evaluative processes. Ten processes of change have been identified with some processes being more relevant to a specific stage of change than other processes. These processes result in strategies that help people make and maintain change.

1.    Consciousness Raising - Increasing awareness about the healthy behavior.

2.    Dramatic Relief - Emotional arousal about the health behavior, whether positive or negative arousal.

3.    Self-Reevaluation - Self reappraisal to realize the healthy behavior is part of who they want to be.

4.    Environmental Reevaluation - Social reappraisal to realize how their unhealthy behavior affects others.

5.    Social Liberation - Environmental opportunities that exist to show society is supportive of the healthy behavior.

6.    Self-Liberation - Commitment to change behavior based on the belief that achievement of the healthy behavior is possible.

7.    Helping Relationships - Finding supportive relationships that encourage the desired change.

8.    Counter-Conditioning - Substituting healthy behaviors and thoughts for unhealthy behaviors and thoughts.

9.    Reinforcement Management - Rewarding the positive behavior and reducing the rewards that come from negative behavior.

10.  Stimulus Control - Re-engineering the environment to have reminders and cues that support and encourage the healthy behavior and remove those that encourage the unhealthy behavior.

Limitations of the Transtheoretical Model

There are several limitations of TTM, which should be considered when using this theory in public health. Limitations of the model include the following:

·         The theory ignores the social context in which change occurs, such as SES and income.

·         The lines between the stages can be arbitrary with no set criteria of how to determine a person's stage of change. The questionnaires that have been developed to assign a person to a stage of change are not always standardized or validated.

·         There is no clear sense for how much time is needed for each stage, or how long a person can remain in a stage.  

·         The model assumes that individuals make coherent and logical plans in their decision-making process when this is not always true.

The Transtheoretical Model provides suggested strategies for public health interventions to address people at various stages of the decision-making process. This can result in interventions that are tailored (i.e., a message or program component has been specifically created for a target population's level of knowledge and motivation) and effective. The TTM encourages an assessment of an individual's current stage of change and accounts for relapse in people's decision-making process.

Importance of Physical Activity/chapter-3

Importance of Physical Activity

Physical activity provides long-term health benefits for everyone! By being active, you will burn calories that you store from eating throughout the day and—it can be as easy as walking the dog or as rigorous as running a marathon. Providing opportunities for children to be active early on puts them on a path to better physical and mental health. It's never too late to jumpstart a healthy lifestyle.

Physical Activity & Obesity

Physical activity, along with proper nutrition, is beneficial to people of all ages, backgrounds, and abilities. And it is important that everyone gets active: over the last 20 years, there's been a significant increase in obesity in the United States. About one-third of U.S. adults (33.8%) are obese and approximately 17% (or 12.5 million) of children and adolescents (aged 2-19 years) are obese.¹

The health implications of obesity in America are startling:

·         If things remain as they are today, one-third of all children born in the year 2000 or later may suffer from diabetes at some point in their lives, while many others are likely to face chronic health problems such as heart disease, high blood pressure, cancer, diabetes, and asthma.²

·         Studies indicate that overweight youth may never achieve a healthy weight, and up to 70% of obese teens may become obese adults.³

·         Even more worrisome, the cumulative effect could be that children born in the year 2000 or later may not outlive their parents. ⁴

The impact of obesity doesn't end there. Obesity has personal financial and national economic implications as well. Those who are obese have medical costs that are $1,429 more than those of normal weight on average (roughly 42% higher).⁵ And annual direct costs of childhood obesity are $14.3 billion.⁶

By incorporating physical activity into your daily life—30 minutes for adults and 60 minutes for children—as well as healthy eating, you will experience positive health benefits and be on the path for a better future.

The Impact of Physical Activity on Your Health

Regular physical activity can produce long-term health benefits. It can help:

·         Prevent chronic diseases such as heart disease, cancer, and stroke (the three leading health-related causes of death)

·         Control weight

·         Make your muscles stronger

·         Reduce fat

·         Promote strong bone, muscle, and joint development

·         Condition heart and lungs

·         Build overall strength and endurance

·         Improve sleep

·         Decrease potential of becoming depressed

·         Increase your energy and self-esteem

·         Relieve stress

·         Increase your chances of living longer

When you are not physically active, you are more at risk for:

·         High blood pressure

·         High blood cholesterol

·         Stroke

·         Type 2 diabetes

·         Heart disease

·         Cancer

physical activity

Physical activity or exercise can improve your health and reduce the risk of developing several diseases like type 2 diabetes, cancer and cardiovascular disease. Physical activity and exercise can have immediate and long-term health benefits. Most importantly, regular activity can improve your quality of life. A minimum of 30 minutes a day can allow you to enjoy these benefits.  

Benefits of regular physical activity

If you are regularly physically active, you may:

·         reduce your risk of a heart attack 

·         manage your weight better 

·         have a lower blood cholesterol level 

·         lower the risk of type 2 diabetes and some cancers 

·         have lower blood pressure 

·         have stronger bones, muscles and joints and lower risk of developing osteoporosis 

·         lower your risk of falls 

·         recover better from periods of hospitalisation or bed rest 

·         feel better – with more energy, a better mood, feel more relaxed and sleep better

A healthier state of mind 

A number of studies have found that exercise helps depression. There are many views as to how exercise helps people with depression:

·         Exercise may block negative thoughts or distract you from daily worries. 

·         Exercising with others provides an opportunity for increased social contact. 

·         Increased fitness may lift your mood and improve your sleep patterns. 

·         Exercise may also change levels of chemicals in your brain, such as serotonin, endorphins and stress hormones.  

Aim for at least 30 minutes a day 

To maintain health and reduce your risk of health problems, health professionals and researchers recommend a minimum of 30 minutes of moderate-intensity physical activity on most, preferably all, days. 

Physical activity guideline

It states that:

·         Doing any physical activity is better than doing none. If you currently do no physical activity, start by doing some, and gradually build up to the recommended amount.

·         Be active on most, preferably all, days every week. 

·         Accumulate 150 to 300 minutes (2 ½ to 5 hours) of moderate intensity physical activity or 75 to 150 minutes (1 ¼ to 2 ½ hours) of vigorous intensity physical activity, or an equivalent combination of both moderate and vigorous activities, each week. 

·         Do muscle strengthening activities on at least two days each week.

Ways to increase physical activity

Increases in daily activity can come from small changes made throughout your day, such as walking or cycling instead of using the car, getting off a tram, train or bus a stop earlier and walking the rest of the way, or walking the children to school.  

See your doctor first

It is a good idea to see your doctor before starting your physical activity program if:

·         you are aged over 45 years 

·         physical activity causes pain in your chest 

·         you often faint or have spells of severe dizziness 

·         moderate physical activity makes you very breathless 

·         you are at a higher risk of heart disease 

·         you think you might have heart disease or you have heart problems 

·         you are pregnant. 

Pre-exercise screening is used to identify people with medical conditions that may put them at a higher risk of experiencing a health problem during physical activity. It is a filter or ‘safety net’ to help decide if the potential benefits of exercise outweigh the risks for you. 

Depression

While we all feel sad, moody or low from time to time, some people experience these feelings intensely, for long periods of time (weeks, months or even years) and sometimes without any apparent reason. Depression is more than just a low mood – it's a serious condition that has an impact on both physical and mental health. 

Depression is common

In any one year, around one million people in Australia experience depression. One in six women and one in eight men will experience depression at some time in their life. The good news is, depression is treatable and effective treatments are available. The sooner a person with depression seeks support, the sooner they can recover.

Symptoms of depression

Depression affects how people think, feel and act. Depression makes it more difficult to manage from day to day and interferes with study, work and relationships. A person may be depressed if for more than two weeks they have felt sad, down or miserable most of the time or have lost interest or pleasure in most of their usual activities, and have also experienced several of the signs and symptoms across at least three of the categories in the list below. It’s important to note, everyone experiences some of these symptoms from time to time and it may not necessarily mean a person is depressed. Equally, not every person who is experiencing depression will have all of these symptoms.  

Feelings caused by depression

A person with depression may feel:

·         sad 

·         miserable

·         unhappy

·         irritable

·         overwhelmed

·         guilty

·         frustrated

·         lacking in confidence

·         indecisive

·         unable to concentrate

·         disappointed.

Thoughts caused by depression

A person with depression may have thoughts such as:

·         ‘I’m a failure.’

·         ‘It’s my fault.’

·         ‘Nothing good ever happens to me.’

·         ‘I’m worthless.’

·         ‘There is nothing good in my life.’

·         ‘Things will never change.’

·         ‘Life’s not worth living.’

·         ‘People would be better off without me.’

Behavioural symptoms of depression

A person with depression may:

·         withdraw from close family and friends

·         stop going out

·         stop their usual enjoyable activities

·         not get things done at work or school

·         rely on alcohol and sedatives.

Physical symptoms of depression

A person with depression may experience:

·         being tired all the time

·         feeling sick and ‘run down’

·         frequent headaches, stomach or muscle pains

·         a churning gut

·         sleep problems

·         loss or change of appetite

·         significant weight loss or gain.

Causes of depression

While the exact cause of depression isn’t known, a number of things can be associated with its development. Generally, depression does not result from a single event, but from a combination of biological, psychological, social and lifestyle factors.

Personal factors that can lead to depression

Personal factors that can lead to a risk of depression include:

·         family history – depression can run in families and some people will be at an increased genetic risk. However, this doesn’t mean that a person will automatically experience depression if a parent or close relative has had the condition.

·         personality – some people may be more at risk because of their personality, particularly if they tend to worry a lot, have low self-esteem, are perfectionists, are sensitive to personal criticism, or are self-critical and negative

·         serious medical conditions – these can trigger depression in two ways. Serious conditions can bring about depression directly or can contribute to depression through the associated stress and worry, especially if it involves long-term management of a condition or chronic pain

·         drug and alcohol use – can both lead to and result from depression. Many people with depression also have drug and alcohol problems. 

Life events and depression

Research suggests that continuing difficulties, such as long-term unemployment, living in an abusive or uncaring relationship, long-term isolation or loneliness or prolonged exposure to stress at work can increase the risk of depression. 

Significant adverse life events, such as losing a job, going through a separation or divorce, or being diagnosed with a serious illness, may also trigger depression, particularly among people who are already at risk because of genetic, developmental or other personal factors.

Changes in the brain

Although there has been a lot of research in this complex area, there is still much that we do not know. Depression is not simply the result of a chemical imbalance, for example because a person has too much or not enough of a particular brain chemical. However, disturbances in normal chemical messaging processes between nerve cells in the brain are believed to contribute to depression. 

Some factors that can lead to faulty mood regulation in the brain include:

·         genetic vulnerability

·         severe life stressors

·         taking some medications, drugs and alcohol

·         some medical conditions.

Most modern antidepressants have an effect on the brain’s chemical transmitters, in particular serotonin and noradrenaline, which relay messages between brain cells. This is thought to be how medications work for depression. 

Other medical treatments such as transcranial magnetic stimulation (TMS) and electroconvulsive therapy (ECT) may sometimes be recommended for people with severe depression who have not recovered with lifestyle change, social support, psychological therapy and medication. While these treatments also have an impact on the brain’s chemical messaging process between nerve cells, the precise ways in which these treatments work is still being researched.  

Seek support for symptoms of depression

Depression is often not recognised and can go on for months or even years if left untreated. It’s important to seek support as early as possible, as the sooner a person gets treatment, the sooner they can recover. 

Untreated depression can have many negative effects on a person’s life, including serious relationship and family problems, difficulty finding and holding down a job, and drug and alcohol problems. 

There is no one proven way that people recover from depression. However, there is a range of effective treatments and health professionals who can help people on the road to recovery. 

There are also many things that people with depression can do for themselves to help them recover and stay well. The important thing is to find the right treatment and the right health professional for a person’s needs.

Types of depression

There are different types of depression. The symptoms for each can range from relatively minor through to severe. 

Major depression

Major depression, or major depressive disorder is the technical term used by health professionals and researchers to describe the most common type of depression. Other terms sometimes used include unipolar depression or clinical depression. 

Depression can be described as mild, moderate or severe.

Melancholia

Melancholia is an older term for depression and is still sometimes used to describe a more severe form of depression with a strong biological basis, where many of the physical symptoms of depression are particularly evident. For example, one of the major changes is that the person can be observed to move more slowly, or to be experiencing significant changes to their sleep pattern and appetite. 

A person with melancholia is also more likely to have a depressed mood that is characterised by complete loss of pleasure in everything or almost everything.

Dysthymia

The symptoms of dysthymia (sometimes called Persistent Depressive Disorder) are similar to those of major depression, but are less severe and more persistent. A person has to have this milder depression for more than two years to be diagnosed with dysthymia.

Psychotic depression

Sometimes, people with a depressive condition can lose touch with reality. This can involve hallucinations (seeing or hearing things that are not there) or delusions (false beliefs that are not shared by others), such as believing they are bad or evil, or that they are being watched or followed or that everyone is against them. This is known as psychotic depression.

Antenatal and postnatal depression

Women are at an increased risk of depression during pregnancy (known as the antenatal or prenatal period) and in the year following childbirth (known as the postnatal period). This time frame (the period covered by pregnancy and the first year after the baby’s birth) may also be referred to as the perinatal period.

The causes of depression at this time can be complex and are often the result of a combination of factors. In the days immediately following birth, many women experience the ‘baby blues’, which is a common condition related to hormonal changes, affecting up to 80 per cent of women who have given birth. 

The ‘baby blues’, or the general stress of adjusting to pregnancy or a new baby, are common experiences, but are different from depression. 

Depression is longer lasting and can affect not only the mother, but her relationship with her baby, the child’s development, the mother’s relationship with her partner and with other members of the family.

Up to one in 10 women will experience depression during pregnancy. This increases to 16 per cent in the first three months after having a baby.

Bipolar disorder

Bipolar disorder used to be known as ‘manic depression’ because the person experiences periods of depression and periods of mania with periods of normal mood in between. The symptoms of mania are opposite to the symptoms of depression and can vary in intensity. They include:

·         feeling great

·         having plenty of energy

·         racing thoughts

·         little need for sleep

·         talking fast

·         having difficulty focusing on tasks

·         feeling frustrated and irritable. 

This is not just a fleeting experience. Sometimes, the person loses touch with reality and experiences hallucinations or delusions, particularly about their ideas, abilities or importance. A family history of bipolar disorder can increase a person’s risk of experiencing bipolar disorder. 

Because bipolar disorder includes periods of depression, it is not uncommon for a person with bipolar disorder to be misdiagnosed as having major depression until they have a manic or hypomanic episode. Bipolar disorder can also sometimes be confused with other mental health conditions such as schizophrenia. 

The treatment for bipolar disorder is often different to that for major depression. It is therefore important to check for this condition whenever a person is being assessed for depression. 

Cyclothymic disorder

Cyclothymic disorder is an uncommon condition which is often described as a milder form of bipolar disorder. The person experiences chronic fluctuating moods over at least two years, involving periods of hypomania (a mild to moderate level of mania) and periods of depressive symptoms, with very short periods (no more than two months) of normality between. 

The symptoms last for a shorter time, are less severe, and are not as regular, so they don’t fit the criteria of bipolar disorder or major depression.

Seasonal affective disorder (SAD)

SAD is a mood disorder that has a seasonal pattern. The cause is unclear, but may be related to the variation in light exposure in different seasons. SAD is characterised by mood disturbances (either periods of depression or mania) that begin and end in a particular season. Depression in winter only is the most common way in which people experience SAD. 

SAD is usually diagnosed after the person has had the same symptoms during winter for two or more years. People with SAD are more likely to experience lack of energy, sleep too much, overeat, gain weight and crave carbohydrates. 

SAD is rare in Australia, and more likely to be found in countries with short days and longer periods of darkness, such as the cold climate in the Northern Hemisphere.