The Transtheoretical Model and the stages of patient adherence

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The Transtheoretical Model and the stages of patient adherence



The Transtheoretical Model: A tool for positive change

Non-adherence patterns for cardiovascular disease (CVD) treatment are associated with increased healthcare costs and worse outcomes.1,2 While most data on the impact of non-adherence comes from industrialized countries, most people with CVD live in low- and middle-income countries where adherence problems and their consequences are exacerbated by economic conditions.3 In previous articles, we have examined several behavioral theories to understand the mechanisms of patient treatment adherence behavior. The different theories encompass six theoretical perspectives: biomedical, behavioral, communication, cognitive, self-regulation, and stages.4 Cognitive and stage perspectives are the most frequently discussed theories in the academic literature. Cognitive theories such as the Theory of Planned Behavior (TPB), previously discussed in this series, examine how attitudes and beliefs drive behavior. Stage-based theories contend that people learn, develop, and change their behavior according to discrete steps. Cognitive and stage-based models can be effectively used together; cognitive theories provide insight on why people change their behavior, and stage-based perspectives generate insights on how the change is implemented. The Transtheoretical Model (TTM), also known as the Transtheoretical Stages of Change model, is the most prominent and widely applied stage model.4 It is different from many other prominent behavioral models; it was specifically designed not only to describe the change process but also to facilitate change toward healthier actions.5 The TTM has been applied to a wide range of health behaviors, and it can easily be tailored to assess therapy adherence for patients with CVD and provide them with personalized feedback to improve their adherence to treatment and overall outcomes.


The TTM characterizes adherence based on an individual’s readiness to change

The first version of the TTM was proposed in the 1980s by James Prochaska and Carlo DiClemente, who focused on nicotine addiction; since then, it has been applied to a number of different health behaviors.4,6,8

The TTM consists of two major components: stages of change and processes of change. The stages of change are at the core of the model and portray an individual’s actual readiness and willingness to change according to five distinct steps. Applying these stages to a hypertension patient might look like this:

  • Stage 1: Precontemplation. The patient is not following his treatment regimen as directed by his doctor and is not really considering changing his behavior because he is unaware of reasons to change.4
  • Stage 2: Contemplation. The patient becomes aware of reasons to change his behavior and is contemplating but not currently making an effort to change. Any preparation for change at this point is purely mental/emotional rather than practical. According to Prochaska, this phase describes individuals who plan to change their behavior at some point in the next six months but not in the next 30 days.
  • Stage 3: Preparation. The patient plans to change his treatment adherence behavior within 30 days, and he is actively preparing to change; for example, he may be making an effort to try to take his medication as directed, but is still not doing so regularly.
  • Stage 4: Action. The patient has changed his behavior and is following the treatment regimen as directed but has not yet reached the six-month mark following the change. The new behavior still requires effort.
  • Stage 5: Maintenance. The patient has taken his medication as directed and followed his doctor’s recommendations for at least six months.6  It has become a habit and no longer requires much conscious effort.

Progression through the stages is represented here as linear, but in application, it may be cyclical. Due to the nature of behavioral change, there is a potential for individuals to regress as well as advance. For example, hypertensive patients in the Action stage  who have been adherent for some months may become non-adherent and fall back to the Preparation or even Contemplation stages.6 They do not, however, typically fall back to Precontemplation because this would imply that they have forgotten why they were following recommendations in the first place. Patients who regress in their behavior are often easy to get back on track.


The processes of change facilitate the transition from one stage to the next and are classified as being either experiential or behavioral.

  • Experiential processes are useful primarily in early stages of change, such as Contemplation. These processes may include, for example, raising consciousness, i.e. the patient’s growing recognition that he benefits from his treatment, as it controls his hypertension symptoms. 
  • Behavioral processes are used primarily in later stages. These include stimulus control, e.g. resolving stimuli that provoke undesirable behavior, and helping relationships, i.e. seeking out people who are important to the patient and will help him with adherence.4


The TTM helps providers assess adherence and determine useful feedback

The TTM can serve as a helpful tool for providers to assess patient adherence and provide useful feedback or suggestions as needed. For example, consider a typical patient with hypertension. At his appointment, the doctor asks a few targeted questions regarding his therapy, including:

  • How strictly the patient is adhering to the therapy regimen and lifestyle recommendations?
  • Has the patient considered changing his behavior? 
  • Does the patient understand the benefits of the therapy and the risks of non-adherence?

The patient’s answers reveal that he does not strictly adhere to his treatment recommendations and is unaware that this is problematic. Because hypertension symptoms are not manifest, the benefits of adherence are not obvious. The doctor can then use the Health Belief Model to guide the discussion and provide information on the risks of uncontrolled hypertension and the benefits of following the therapy regimen. The patient, now aware of the benefits of adherence, may consider changing his behavior and progress into the Contemplation phase via this consciousness raising process.


The TTM is a useful and actionable approach to improve adherence

The TTM is a widely used tool and can supplement other health models such as the TPB and the Health Behavior Model by facilitating behavior changes and tracking progress through the stages. It may be particularly useful in informing the way that adherence information is provided to the patient and influence the design of adherence interventions. The TTM has been successfully used to address non-adherence to antihypertensive and lipid-lowering treatments7; studies demonstrate that patients respond well to the individualized feedback informed by the TTM.6 However, TTM-based interventions are not always more effective than other reasonably designed approaches,5 and health behavior research increasingly prioritizes more recent behavioral models, such as COM-B, and other developments in behavioral theory that will be discussed in other articles. These models are complimentary and provide important insights into the patient journey.


1. Shalini Lynch (2019). “Adherence to drug treatment,” MSD Manual Consumer Version, August 2019.

2. Ian M. Kronish & Ye Siqin (2013). “Adherence to cardiovascular medications: Lessons learned and future directions,” Progress in Cardiovascular Diseases, (55):6, pp. 590–600. https://doi:10.1016/j.pcad.2013.02.001

3. Tracey-Lea Laba et al. (2013). “Strategies to improve adherence to medications for cardiovascular diseases in socioeconomically disadvantaged populations: A systematic review,” International Journal of Cardiology, (167):6, pp. 2430–2440. https://doi:10.1016/j.ijcard.2013.01.049

4. Lamyae Sardi et al. (2019). “Applying trans-theoretical model for blood donation among Spanish adults: A cross-sectional study.” BMC Public Health, (19):1, p. 1724. https://doi:10.1186/s12889-019-8046-9

5. David Taylor et al. (2006). “A review of the use of the Health Belief Model (HBM), the Theory of Reasoned Action (TRA), the Theory of Planned Behaviour (TPB) and the Trans-Theoretical Model (TTM) to study and predict health related behaviour change” London, UK: National Institute for Health and Clinical Excellence, pp. 1–215.

6. Sara Johnson et al. (2006). “Efficacy of a transtheoretical model-based expert system for antihypertensive adherence,” Disease Management, (9):5, pp. 291–301. https://doi: 10.1089/dis.2006.9.291

7. Sara Johnson et al. (2006). “Transtheoretical Model intervention for adherence to lipid-lowering drugs,” Disease Management, (9):2, pp. 102 –114.

8. James Prochaska & Carlo C. DiClemente, (1983). “Stages and processes of self-change of smoking: Toward an integrative model of change,” Journal of Consulting and Clinical Psychology, (51):3, p. 390. https://doi: 10.1037//0022-006x.51.3.390