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close this bookFacilitating Sustainable Behaviour Change - A Guidebook for Designing HIV Programs (UNDP; 1999; 59 pages)
View the documentAcknowledgments
View the document1. Introduction
View the document2. Problems with some common ways of thinking about behaviour change
View the document3. The behaviour change spiral
View the document4. The enabling environment
View the document5. Capacity development
View the document6. The role of programs
View the document7. Summary of the framework and steps to take in program design
View the documentWorkshop Outline
 

3. The behaviour change spiral

Behaviour change is a process that takes place over time. It is never straight forward, nor is it a single event. People go through stages before final changes are made, and many things happen after they start to make changes. This section summarises the recently developed “stages of change” model, suggesting stages of behaviour change and processes that influence people's progression through those stages9,10.

 

9 JO Prochaska, CC DiClemente, JC Norcross, (1992) In search of how people change: applications to addictive behaviours. American Psychologist 47(9): 1102-1114

10 JO Prochaska, et al. (1994) Stages of change and decisional balance for twelve problem behaviours. Health Psychology 13: 39-51

Pre-contemplation stage

In the beginning, a person might not realise that change is possible, desirable, or relevant to them. This stage has been called pre-contemplation. The person has not begun to contemplate change or the need for change.

Contemplation stage

Later, something happens to prompt the person to start thinking about change. Perhaps hearing that someone else has made changes? Maybe something else has changed, resulting in the need for further change? This stage is called contemplation. The person has started the process of contemplating change.

Preparation stage

The next stage is called preparation for change. The person prepares to undertake the change. This will require gathering information about the change, finding out how to achieve the change, learning what skills are necessary and deciding when the change will take place. It may include talking with others to assess how they feel about the likely change. There might be intense feelings associated with the change, and the person might need time to reflect on those feelings. The person may consider what impact the change might have and who will be affected. The preparation stage may occur quickly and easily or it may take some time.

Action stage

Eventually, the person will change their behaviour. This is called the action stage. The person is acting on previous decisions, experience, information, new skills and motivations for making the change. A new behaviour has been adopted!

Maintenance stage

Once a new behaviour has been adopted, practice is required for the behaviour to be consistently maintained. Maintenance occurs when the behaviour has been incorporated into the rest of the person's life. It becomes just one of a whole range of behaviours the person undertakes. Once behaviour is familiar, and occurs without requiring active thinking, it can be said that the behaviour has been maintained.

Presenting the stages

These stages can be illustrated using a curved line, to show how a person moves through one stage to another. Change is rarely straight forward, so a curved line is used to emphasise complexity within this staged process.


The first stages of behaviour change

Now what happens?

The process is not yet complete. It may never be complete. Many things can affect behaviour change. At the start a person may just be trying out a new behaviour, to see if it works and to find out what happens. They may try it twice to see if it can be repeated, or to see how other people react. They might return to previous behaviours - maybe for a time, perhaps forever.

Although a person may want to maintain a new behaviour, other things might make this difficult. At first the change might have been easy, but it may later become hard to sustain. The available resources might disappear. Other people who initially supported the change might move away, or withdraw support. A new situation might make old behaviours seem more appealing.

For all sorts of reasons, people might move back to the earlier stages of behaviour change and work through the stages again. Importantly, though, they do not return to exactly where they started. Things are different now. Other people have changed too.

People never return to the pre-contemplation stage. They might return to the contemplation stage for more reflection and thinking, or to the preparation stage to gather new skills or more support, before continuing on again through the other stages.

To illustrate how this movement occurs, the earlier curve can be continued and circle back to a new starting place. Because the starting place is not the same - the person has changed, the world has changed - the illustration is a spiral rather than a circle.


The ongoing spiral of behaviour change

Maintaining behaviour means a person might have to go through some of the same stages more than once. This movement will not be exactly the same each time. The person might think about the change again, but in different ways. They might decide to make a change, but not exactly the same one first tried.

Once a person reaches the action stage again, there might still be a return to the processes of the earlier stages. To illustrate this long-term movement, a longer spiral can be drawn. The person continues the new behaviour, or at least continues to move through their own spiral-like process.

Eventually people will continue to act in ways that make sense to them. They will respond to other influences, but long-term behaviour change will have occurred.


The full spiral of stages of behaviour change

Everyone changes

In the long term, people make changes that work for them. These changes, however, will not be straightforward. Different people will think about options, challenge one another, try new things, and move about. They might go through the five stages one after the other or sometimes they might miss a stage. When people make changes they spiral about. They might return to older behaviours, they might circle about working through different stages, or they might make permanent changes. For ongoing behaviour change, they will eventually need to move through all the stages.

How people move through the behaviour change spiral

Something has to happen for a person to embark upon behaviour change. Such an event may be initiated by the person or may be a response to something else that happens. Behaviours do not happen in isolation. They are also affected by influences such as a person's beliefs, expected benefits and other people's expectations.

When moving through the behaviour change spiral, people draw on a range of processes to assist movement through each stage. These processes will vary according to the types of changes people are undertaking. They will not be the same for all people, and can differ according to cultural situations and opportunities.

Some processes that may be important at each stage are outlined in this box.


Processes influencing movement through the stages of change [after Prochaska and DiClemente (1992)]

Each process is listed under the stage of behaviour change to which it is most relevant. Because each stage of behaviour change is closely related to the stage before and after it, the listed processes do not always appear directly under the headings for each stage. Some processes are included more than once, because the same process may be used again as people move through different stages of behaviour change.

Each process is further explained here:

Becoming aware

Becoming aware of the issues; the impact of the issues on themselves; the relevance of the issues to them; the way the issues fit within the current setting.

Emotional response

Experiencing and expressing feelings about the issues, the situation and possible solutions.

Environment analysis

Assessing how the issues relate to the physical environment.

Thinking through the issue

Making an assessment of feelings and thoughts about the issue and the situation.

Seeing other options

Learning new behaviours and skills as alternative options.

Self-efficacy

A sense of being able to do something: choosing to act, making a commitment to change, having a belief in their ability to change.

Social support

Alternative behaviours and solutions are occurring in the rest of the community, and support for change is available.

Helping relationships

Being open and trusting with others about the difficulties and the new behaviour.

Reinforcement

Rewarding themselves, or being rewarded by others, for making changes to behaviour.

Although these processes are useful for understanding the way people change behaviours, not all people need to go through all the same processes for every change they make. Depending upon the situation, the motivation, the need to change and the change itself, some processes are used more often than others. Therefore, programs to bring about behaviour change need to facilitate a wide range of processes. They must allow people to become aware of the issues, and to learn to adopt new behaviours and skills as and when it is right for them: not when it seems right to program designers.

The “stages of change” model is useful in explaining how behaviour change can be achieved and maintained. However, no behaviour occurs in isolation. Many influences around a person can assist or hinder change. Some of these are outlined in the next section.

 

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