Tabla de Atributos

The fundamental concept of the TTM (Prochaska 1993; Prochaska and Velicer 1997) is that behaviour change is most successful when behavioural strategies called processes of change are applied at the correct time (Prochaska et al. 1992). The model was initially developed as an approach to psychotherapy, but was then applied to health and lifestyle behaviours such as tobacco cessation and cancer screening behaviour (Prochaska et al. 1992). The TTM proposes that a behaviour change occurs in five different stages from precontemplation (not planning to change within the next six months), contemplation (thinking about changing), preparation (taking steps to change), action (attempting the change) and maintenance (having changed for at least six months). Although the stages are presented in a linear fashion, in reality individuals may pass back and forth through different stages. It is proposed that individuals in the early stages of change use cognitive or experiential strategies, such as self-re-evaluation, to progress forward through the stages of change. Individuals in the later stages use behavioural

processes such as helping relationships or stimulus control more frequently. As the individual progresses further through the processes of change, the cons relating to a particular health behaviour should decrease whilst the pros should increase.

The TTM processes as applied to HPV self-sampling will be outlined below. The first stage (precontemplation) involves increasing awareness about HPV self-sampling

30 and improving accuracy of information about HPV self-sampling and the self

(consciousness raising), experiencing and releasing feelings about HPV self-sampling and engaging in HPV self-sampling (dramatic relief), and thinking that engaging in HPV self-sampling would impact on the social environment (environmental re-evaluation). The second stage (contemplation) refers to the cognitive and affective assessments of how engaging in HPV self-sampling may impact on the individual’s self-image. The third stage (preparation) refers to an individual’s belief that they are able to overcome previous barriers related to HPV self-sampling and their commitment to act on the belief (self-liberation). The fourth stage is the action stage and refers to the utility and availability of helping relationships, counter-conditioning, reinforcement management and stimulus control. The final stage is maintenance and involves social liberation, social, policy or environmental changes that support healthy behaviour.

Figure 2.1: The TTM applied to HPV self-sampling (SS), adapted from (Prochaska and DiClemente 1982)

A further two intervening variables are proposed to influence movement from stage to stage: decisional balance and self-efficacy. Decisional balance refers to the perceived benefits and barriers associated with engaging in health behaviour such

Contemplation

Preparation Action

Maintenance

No previous HPV SS or previous SS but no plan to

get one at this screening round.

Having a SS and planning to have one at next screening invitation.

31 as self-sampling. When more benefits are perceived, a change is more likely. Self-efficacy is defined as a person’s beliefs about their ability to carry out behaviour in any given situation (Michie et al. 2014). Self-efficacy refers to both behaviour change and to temptations to carry out the problem behaviour (or in the case of self-sampling to avoid the healthy behaviour). Self-efficacy influences the processes of change throughout the different stages. Self-efficacy level increases and

temptation levels decrease over time (Michie et al. 2014).

The TTM has been utilised as a theoretical framework in a number of studies investigating cervical screening and mammography attendance (Rimer et al. 1996;

Kelaher et al. 1999; Abdullah and Su 2013). Studies have identified that cervical smear test screening and mammography behaviour were largely influenced by women’s decisional balance of pros and cons. Cons included advanced age, lack of education and misconceptions about the screening method (Rimer et al. 1996).

Abdullah and Su (2013) identified that women who were in the pre-contemplation stage were most likely to be at an action stage following exposure to an

intervention designed to increase cervical screening, such as the introduction of a call/recall system.

Although the TTM has been used to investigate women’s intentions to engage in cervical smear test screening attendance, staging as proposed by the TTM may be problematic in the cervical screening context, in which the behaviour occurs once every three or five years. The TTM has been criticised for the concept of staging and the proposition that discreet and categorical stages exist for any given behaviour (Sutton 2000). It has been argued that individuals do not progress through discreet stages but that they progress along a continuum of change (Sutton 2000). Staging for cervical screening behaviour, such as HPV self-sampling, can be difficult because of variations in screening recommendations based on previous cervical screening history and policy variations between different countries. Cervical screening recommendations in terms of age of onset of cervical screening, frequency of screening and the introduction of HPV testing, have been modified as further advances in cervical screening have been made. Furthermore, cervical screening is

32 stratified based on women’s previous cervical screening history (e.g. women who have had a previous cervical abnormality are under increased surveillance and screened more frequently, whilst in some areas in the UK older women are screened at longer intervals). Therefore, if staging for cervical screening occurs every three years, depending on which cervical screening strata (e.g. standard screening vs increase surveillance) a woman is in, she could be classified as being in an action stage or a relapse stage (Spencer et al. 2005).

The TTM is better used to account for frequent behaviour, especially

operationalising the issue of resisting temptation (as in smoking cessation) as well as the stages from action to maintenance. A cancer detection behaviour that might be better suited to this model is breast self-examination (BSE) behaviour, which can be conducted and maintained at regular time points. Although it may be argued that cervical screening may be seen as a habitual behaviour (as women may have up to twelve routine cervical screens in their lifetime), it still requires

re-engagement with the programme, booking of an appointment and having the cervical smear conducted. This would also be applicable to the potential routine introduction of HPV self-sampling as a primary screening method at infrequent intervals, similarly to the UK cervical smear and the FOBT screening programmes.

Therefore, a theory that does not delineate specific staging of habitual behaviour would be better suited to understanding women’s attitudes towards HPV self-sampling.