User:CTFSamot/sandbox

Extension.... decisional balance...
The evaluation of pros and cons is part of the formation of attitudes. Attitude is defined as a "psychological tendency that is expressed by evaluating a particular entity with some degree of favour or disfavour". This means that by evaluating pros and cons we form a positive or negative attitude about something or someone. During the change process individuals gradually shift from cons to pros, forming a more positive attitude towards the target behaviour. Attitudes are one of the core constructs explaining behaviour and behaviour change in various research domains. Other behaviour models, such as the Theory of Planned Behavior (TPB) and the stage model of self-regulated change, also emphasise attitude as an important determinant of behaviour. The progression through the different stages of change is reflected in a gradual change in attitude before the individual acts. Most of the processes of change aim at evaluating and reevaluating as well as reinforcing specific elements of the current and target behaviour. The processes of change contribute to a great degree on attitude formation. Due to the synonymous use of decisional balance and attitude, travel behaviour researchers have begun to combine the TTM with the TPB. Forward uses the TPB variables to better differentiate the different stages. Especially all TPB variables (attitude, perceived behaviour control, descriptive and subjective norm) are positively show a gradually increasing relationship to stage of change for bike commuting. As expected, intention or willingness to perform the behaviour increases by stage. Similarly, Bamberg uses various behavior models, including the transtheoretical model, theory of planned behavior and norm-activation model, to build the stage model of self-regulated behavior change (SSBC). Bamberg claims that his model is a solution to criticism raised towards TTM. Some researchers in travel, dietary and environmental research have conducted empirical studies, showing that the SSBC might be a future path for TTM-based research.

Extension... Self-efficacy
ADAPTATION OF EXISTING SECTION: This core construct is "the situation-specific confidence people have that they can cope with high-risk situations without relapsing to their unhealthy or high risk-habit". The construct is based on Bandura's self-efficacy theory and conceptualizes a person's perceived ability to perform on a task as a mediator of performance on future tasks. In his research Bandura already established that greater levels of perceived self-efficacy leads to greater changes in behavior. Similarly, Ajzen mentions the similarity between the concepts of self-efficacy and perceived behavioral control. This underlines the integrative nature of the transtheoretical model which combines various behavior theories. A change in the level of self-efficacy can predict a lasting change in behavior if there are adequate incentives and skills. The transtheoretical model employs an overall confidence score to assess an individual's self-efficacy. Situational temptations assess how tempted people are to engage in a problem behavior in a certain situation

Extension....processes of change
In health research extended Prochaska's and DiClemente's 10 original processes of change by an additional 21 processes. Bartholomew et al. (2010) summarise the processes that have been identified in a number of studies to build a generic intervention design tool. The additional processes are: While most of these processes are associated with health interventions such as smoking cessation and other addictive behaviour, some of them are also used in travel interventions. Depending on the target behaviour the effectiveness of the process should differ. Also some processes are recommended in a specific stage, while others can be used in one or more stages. Recently, these processes have been identified in travel interventions, broadening the scope of TTM in other research domains.
 * 1) Risk comparison (understand the risks) - comparing risks with similar dimensional profiles: dread, control, catastrophic potential and novelty
 * 2) Cumulative risk (get the overall picture)- processing cumulative probabilities instead of singe incident probabilities
 * 3) Qualitative and quantitative risks (consider different factors) - processing different expressions of risk
 * 4) Positive framing (think positively) - focusing on success instead of failure framing
 * 5) Self-examination relate to risk (be aware of your risks) - conducting an assessment of risk perception e.g. personalisation, impact on others
 * 6) Reevaluation of outcomes (know the outcomes) - emphasising positive outcomes of alternative behaviours and reevaluating outcome expectancies
 * 7) Perception of benefits (focus on benefits) - perceiving advantages of the healthy behaviour and disadvantages of the risk behaviour
 * 8) Self-efficacy and social support (get help) - mobilising social support; skills training on coping with emotional disadvantages of change
 * 9) Decision making perspective (decide) - focusing on making the decision
 * 10) Tailoring on time horizons (set the time frame) - incorporating personal time horizons
 * 11) Focus on important factors (prioritise) - incorporating personal  factors of highest importance
 * 12) Trying out new behaviour (try it) - changing something about oneself and gaining experience with that behaviour
 * 13) Persuasion of positive outcomes (persuade yourself) - promoting new positive outcome expectations and reinforcing existing ones
 * 14) Modelling (build scenarios) - showing models to overcome barriers effectively
 * 15) Skill improvement (build a supportive environment) - restructuring environments to contain important, obvious and socially supported cues for the new behaviour
 * 16) Coping with barriers (plan to tackle barriers) - identifying barriers and planning solutions when facing these obstacles
 * 17) Goal setting (set goals) - setting specific and incremental goals
 * 18) Skills enhancement (adapt your strategies) - restructuring cues and social support; anticipating and circumventing obstacles; modifying goals
 * 19) Dealing with barriers (accept setbacks) - understanding that setbacks are normal and can be overcome
 * 20) Self-rewards for success (reward yourself)  - feeling good about progress; reiterating positive consequences
 * 21) Coping skills  (identify difficult situations) - identifying high risk situations; selecting solutions; practicing solutions; coping with relapse

Part of outcomes of TTM programs... Travel research
The use of TTM in travel behaviour interventions is rather novel. A number of cross-sectional studies investigated the individual constructs of TTM, e.g.stage of change, decisional balance and self-efficacy, with regards to transport mode choice. The cross-sectional studies, identified both motivators and barriers at the different stages regarding biking, walking and public transport. The motivators identified were e.g. liking to bike/walk, avoiding congestion and improved fitness. Perceived barriers were e.g. personal fitness, time and the weather. This knowledge was used to design interventions that would address attitudes and misconceptions to encourage an increased use of bikes and walking. These interventions aim at changing people's travel behaviour towards more sustainable and more active transport modes. In health-related studies, TTM is used to make people walk or bike more instead of using the car. Most intervention studies aim to reduce car trips for commute to achieve the minimum recommended physical activity levels of 30 minutes per day. Other intervention studies using TTM aim to encourage sustainable behaviour. By reducing single occupied motor vehicle and replacing them with so called sustainable transport (public transport, car pooling, biking or walking), green house gas emissions can be reduced considerably. A reduction in the number of cars on our roads solves other problems such as congestion, traffic noise and traffic accidents. By combining health and environment related purposes, the message becomes stronger. Additionally, by emphasising personal health, physical activity or even direct economic impact, people see a direct result from their changed behaviour, while saving the environment is a more general and effects are not directly noticeable.

Different outcome measures were used to assess the effectiveness of the intervention. Health-centred intervention studies measured BMI, weight, waist circumference as well as general health. However only one of three found a significant change in general health, while BMI and other measures had no effect. Measures that are associated with both health and sustainability were more common. Effects were reported as number of car trips, distance travelled, main mode share etc. Results varied due to greatly differing approaches. In general, car use could be reduced between 6 and 55 per cent, while use of the alternative mode (walking, biking and/or public transport) increased between 11% and 150%. These results indicate a shift to action or maintenance stage, some researchers investigated attitude shifts such as the willingness to change. Attitudes towards using alternative modes improved with approximately 20 to 70 per cent. Many of the intervention studies did not clearly differentiate between the five stages, but categorised participants in pre-action and action stage. This approach makes it difficult to assess the effects per stage. Also, interventions included different processes of change, in many cases these processes are not matched to the recommended stage. It highlights the need to develop a standardised approach for travel intervention design. Identifying and assessing which processes are most effective in the context of travel behaviour change should be a priority in the future in order to secure the role of TTM in travel behaviour research.

Criticisms
[Copied from Wikipedia Transtheoretical model for rewriting and addition (ATTENTION REFERENCES WERE HAVE TO BE INCLUDED WITHIN THE PUBLISHED ARTICLE):

It is "arguably the dominant model of health behaviour change, having received unprecedented research attention, yet it has simultaneously attracted criticism".(ARMITAGE NR.14 in main article). Depending on the field of application, e.g. smoking cessation, substance abuse, condom use, diabetes treatment, obesity and travel somewhat different criticism has been raised.

In a systematic review, published in 2003, of 23 randomized controlled trials, the authors found that "stage based interventions are no more effective than non-stage based interventions or no intervention in changing smoking behaviour.[REF44]. However, it was also mentioned that stage based interventions are often used and implemented inadequately in practice. Thus, criticism is directed towards the use rather the effectiveness of the model itself. Looking at interventions targeting smoking cessation in pregnancy found that stage-matched interventions were more effective than non-matched interventions. One reason for this was the greater intensity of stage-matched interventions. [Ref 48]. Also, the use of stage-based interventions for smoking cessation in mental illness proved to be effective . Further studies, e.g. randomized controlled trail published in 2009 found no evidence that a TTM based smoking cessation intervention was more effective than a control intervention not tailored to stage of change. The study claims that those not wanting to change (i.e. precontemplators) tend not to be responsive to neither stage nor non-stage based interventions. Since stage-based interventions tend to be more intensive they appear to be most effective at targeting contemplators and above rather than pre-contemplators [Ref 49]. A 2010 systematic review of smoking cessation studies under the auspices of the Cochrane Collaboration found that "stage-based self-help interventions (expert systems and/or tailored materials) and individual counselling were neither more nor less effective than their non-stage-based equivalents.[REF 51].

Main criticism is raised regarding the "arbitrary dividing lines" are drawn between the stages. West claims that a more coherent and distinguishable definition for the stages is needed. Especially the fact that the stages are bound to a specific time interval is perceived to be misleading. Additionally, the effectiveness of stage-based interventions differs depending on the behavior. A continuous version of the model (Noel, 1999 REF 55) has been proposed, where each process is first increasingly used, and then decreases in importance, as smokers make progress along some latent dimension. This proposal suggests the use of processes in the absence of the stage concept. The model "assumes that individuals typically make coherent and stable plans," when in fact they do not. [REF 54] Within research on prevention of pregnancy and sexually transmitted diseases a systematic review from 2003 comes to the conclusion that "no strong conclusions" can be drawn about the effectiveness of interventions based on the transtheoretical model. [REF 45]. Again this conclusion is reached due to the inconsistency of use and implementation of the model [REF 45]. This study also confirms that the better stage-matched the intervention the more effect it has to encourage condom use [REF 45].

Within the health research domain, a 2005 systematic review of 37 randomized controlled trials claims that "there was limited evidence for the effectiveness of stage-based interventions as a basis for behavior change.[REF 46]. Studies with which focused on increasing physical activity levels through active commute however showed that stage-matched interventions tended to have slightly more effect than non-stage matched interventions . Since many studies do not use all constructs of TTM, additional research suggested that the effectiveness of interventions increases the better it is tailored on all all core constructs of the TTM in addition to stage of change.[REF 47]. In diabetes research the "existing data are insufficient for drawing conclusions on the benefits of the transtheoretical model" as related to dietary interventions. Again, studies with slightly different design, e.g. using different processes, proved to be effective in predicting the stage transition of intention to exercise in relation to treating patients with diabetes.

TTM has generally found a greater popularity regarding research on physical activity, due to the increasing problems associated with unhealthy diets and sedentary living, e.g. obesity, cardiovascular problems. A 2011 Cochrane Systematic Review found that there is little evidence to suggest that using the Transtheoretical Model Stages of Change (TTM SOC) method is effective in helping obese and overweight people lose weight. (See weight management abstract above). Earlier in a 2009 paper, the TTM model was considered to be useful in promoting physical activity. In this study, the algorithms and questionnaires that researchers used to assign people to stages of change lacked standardisation to be compared empirically, or validated. [REF 56, 57].

Similar criticism regarding the standardisation as well as consistency in the use of TTM is also raised in a recent review on travel interventions. With regard to travel interventions only stages of change and sometimes decisional balance constructs are included. The processes used to build the intervention are rarely stage-matched and short cuts are taken by classifying participants in a pre-action stage, which summarises the precontemplation, contemplation and preparation stage, and an action/maintenance stage. More generally, TTM has been criticised within various domains due to the limitations in the research designs. For example, many studies supporting the model have been cross-sectional, but longitudinal study data would allow for stronger causal inferences. Another point of criticism is raised in a 2002 review, where the model's stages were characterized as "not mutually exclusive". Furthermore, there was "scant evidence of sequential movement through discrete stages." While research suggests that movement through the stages of change is not always linear, a study conducted in 1996 demonstrated that the probability of forward stage movement is greater than the probability of backward stage movement.

Due to the variations in use, implementation and type of research designs, data confirming TTM are ambiguous. More care has to be taken in using a sufficient amount of constructs, conducting longitudinal data and trustworthy measures are used.