Appendix E. Stages of Change and Your Patients

Patients' motivation to change their health risk behavior can range from resistance to ambivalence to commitment and can fluctuate over time. Researchers refer to this fluctuating motivation as stages of change (Prochaska and DiClemente, 1992). These stages have been labeled:

Precontemplation.
Contemplation.
Preparation.
Action.
Maintenance.

Patients who are not quite ready to change may vacillate over modifying their health risk behavior before making a commitment to change and acting on it. Your communication strategies should take your patients' stage of change and consequent motivation into account. You can determine which stage of change your patients are in by asking them simple questions about their behaviors. You can then proceed with the appropriate education/counseling and attempt to move patients from one stage to the next in a responsive, patient-centered manner.

A table with each of the stages of change and sample questions follows. You can adapt these questions to the particular behavior change you are encouraging. To facilitate understanding, smoking cessation is used as an example.

Stages of Change

Question: Do you intend to quit smoking in the next 6 months?

Stage: If the answer is "No," then the person is in the Precontemplation stage. Here, the only education that will have any effect is one that encourages the patient to consider quitting.

Remember, the patient has not given any serious thought to quitting in the future. Either because of ignorance of the effects of smoking on health or because he or she feels that quitting is impossible, this patient has never given serious thought to the possibility.

Do not minimize the difficulty of smoking cessation, but you can tell the patient, "We've learned a lot in the past few years about helping people quit smoking. We're having more success, and we are here to help you when you are ready."

If the answer is "Yes," then the person is in the Contemplation stage. Here, your task as an educator will be different. At this stage, the person has seriously considered quitting but may lack the motivation to start the process. This is the moment when you can provide motivation and share success stories of other patients. You may even use other patients to function as peer volunteers. An ex-smoker may be the best one to talk about the different approaches to smoking cessation and the options available to the patient.

If the answer is "Maybe," then the person is probably feeling ambivalent. Explore with the person his or her values and discuss how they may conflict (e.g., children's health versus the pleasures of smoking).

Question: Do you intend to quit smoking in within the next 30 days?

Stage: If the answer is "No," then your patient is still in the Precontemplation phase, and you should provide the education/counseling suggested above for that stage.

If the answer to this question is "Yes," your patient is in the Preparation stage. He or she has already made the decision to attempt the change and is ready to prepare to quit. Here, it is your task to give the patient the necessary tools to cause the behavior change. You should either refer the patient to a smoking cessation program that you know to be effective or you should facilitate the cessation process yourself. It is important to focus—at this stage—on increasing the patient's confidence (self-efficacy) so that he or she can attempt this change and succeed.

Small steps, close follow-up, reinforcement, and encouragement are also very important. The use of contracts between the patient and the educator may be useful tools for mastering each step of the process. (Here the educator writes down the goal to be accomplished in the next week[s] and the patient signs the contract, agreeing to perform the tasks specified in the document.)

Question: Are you in the process of giving up smoking?

Stage: If the answer is "Yes," then the needs of your patient are different from those in the previous stages. This patient is in the Action stage. Here, he or she most likely needs positive reinforcement for the changes already attained and support for moving on to the Maintenance stage. Attention to self-efficacy is also important.

Question: Have you quit smoking for more than 6 months?

Stage: If the answer is "Yes," then your patient is in the Maintenance stage. At this point, it is important to focus on learning coping mechanisms to prevent relapse and on recruiting this patient as a potential peer volunteer to motivate others and share his or her experience.

References

Prochaska JO, DiClemente CC. Stages of change in the modification of problem behaviors. Prog Behav Modif 28:183-218, 1992.