Transtheoretical Model

1. Article Citation:
Fahrenwald, N., & Walker, S. (2003). Application of the transtheoretical model of behavior change to the physical activity behavior of WIC mothers. Public Health Nursing, 20(4), 307-317.

2. Article summary (purpose, methodology, results, analysis -incl. potential sources of bias),

The purpose of the article was to examine the Transtheoretical Model (TTM) of behavior change in relationship to the physical activity behavior of mothers receiving assistance from the Women, Infants, and Children program (WIC). The WIC program provides food, nutrition counseling, and access to health resources and services for low-income women, infants, and children. The specific aims of the study were to examine the relationship

between stage of physical activity behavior change and self-reported physical activity behavior, to examine the relationships between stage of physical activity behavior change and other TTM constructs (i.e., self-efficacy, decisional balance, and the process of behavior change), and to identify the perceived pros and cons of physical activity among WIC mothers.
A stratified sample of WIC mothers was drawn from a WIC program in a small Midwest city.

Inclusion criteria were nonpregnant women with children, aged 19 and older, with access to a telephone and able to respond to questions over the telephone. The Stage of Exercise Adoption (SEA) tool was administered to identify the woman’s stage of physical activity behavior change, and an appointment for telephone data collection was made. Data collection took place over the telephone at a pre-established time and took approximately 30 minutes. Recruitment continued until a sample of six women at each of the five stages of physical activity behavior change was obtained (N =

30).
Physical activity behavior was measured using the Seven-day Physical Activity Recall (7-day PAR) [1]. The 7-day PAR measures self-report in a 15-minute phone interview of the past week’s physical activity by estimating energy expenditure using the MET. The perceived pros and cons to physical activity were measured using benefits and barriers scales of the Exercise Benefits/Barriers Scale (EBBS). The EBBS has 43 items and uses a 4-point forced Likert response format (1 = strongly disagree, 4 = strongly agree). The instrument includes 29 benefit items and 14 barrier items. Two open-ended questions were used in the current study to identify additional pros and cons about physical activity for WIC mothers. The questions were, ‘‘Are there other barriers that prevent you from being physically active?’’ and ‘‘Are there other benefits of physical activity for you?’’ Self-efficacy for physical activity was measured using the Self-Efficacy for Exercise (SEE) scale [2]. The SEE has five items that measure confidence in resisting relapse, making time for activity, and overcoming negative affect. Nine of the 10 processes of behavior change were measured using the corresponding subscales of the Processes of Exercise Adoption (PEA) instrument [2]. The helping relationships process of change was measured by the Social Support for Exercise scale (SSE) [4]. An appointment for a 2-week follow-up interview was made to assess test-retest reliability for the TTM-derived instruments, but it did not include the 7-day PAR. Mean scores were calculated to identify the most frequently identified pros and cons of physical activity. Frequency counts were used to identify top pros and cons cited in response to the open-ended questions.
The examination of the relationships between physical activity behavior and stage of behavior change was calculated by the past week’s total activity METs summed and divided by 7 to provide an index of total daily energy expenditure (EE).

For all three behavioral indices, participants in the precontemplation stage reported the least physical activity behavior, whereas participants in the action and maintenance stages of behavior change reported the most physical activity behavior. In addition, physical activity behavior progressively increased from the precontemplation to the action stage of behavior change for all three indices. The results for the relationships between the stages of behavior change and other TTM constructs were that each of the TTM behavior change constructs had a statistically significant relationship with stage of physical activity behavior change. These relationships were positive for self-efficacy, pros, and decisional balance and negative for cons. The results for the perceived pros and cons of physical activity were divided into the top four pro (benefit) statements and the top three con (barriers) statements. The four top pro statements were: 1) sense of personal accomplishment, 2) increased muscle strength, 3) improved muscle tone, and 4) improved mental health. The three top cons (barriers) were: 1) physical activity tires me, 2) I am fatigued by physical activity, and 4) physical activity is hard work for me. Frequency counts were used to

report responses to the open-ended questions.
3. Application to practice/nutrition education and/or counseling-
One of the potential sources of bias or limitation is not only the small sample size of WIC mothers (N=30), but also that they were ethnically homogenous, therefore limiting the generalizability of the findings. Another potential source of bias is that physical activity behavior was measured only through self-report and not by any objective measures.
The TTM’s approach to health behavior change acknowledges that there is no single determinant that explains health behavior [3]. Additionally, the Study findings did show that self-efficacy increased across the stages of physical activity behavior change for WIC mothers. In applying this knowledge, a TTM-derived approach to counseling WIC mothers for physical activity behavior should include an assessment of the stage of behavior change and apply strategies that increase self-efficacy, while decreasing the perceived cons of changing and increasing the pros of changing.