Stages of Change: A Key to Successful Wellness

Janice Stanger

Mar 8, 2013

Stages of Change: A Key to Successful Wellness

It is important to know if a wellness program is achieving all the goals set for it, or if the measurable results are uneven.  For an employer, until employees actually make meaningful and long-lasting changes in their behavior, there will not be improvements in health or productivity. Yet establishing and sustaining behavior change is tough for even the best-trained coaches and psychologists to bring about.

The good news for employers is that working with predictable stages of change lays the groundwork for achieving lifestyle changes that matter. The Stages of Change Model, which explains why people don't immediately change unhealthy choices, has been researched since the 1970s. Wellness programs seldom make focused use of this knowledge. When an organization understands and applies the basic ideas of stages of change, a wellness program's results can soar above the average.

How Stages of Change Impact Lifestyle Improvements

Here are the fundamental teachings of the Stages of Change Model.

  1. Change is a learning process, not unlike mastering reading. A child who has not learned the ABC's is not expected to read Shakespeare. Similarly, it does not make sense to expect an unhealthy employee who has not been through the initial stages of behavior change to suddenly quit smoking and eat cups of vegetables throughout the day.
  2. Change occurs gradually and in predictable steps, each leading to the other. While some people make major leaps in behavior seemingly overnight, most do not. And often the ones that change quickly revert to original unhealthy choices before long.
  3. Change cannot be forced on someone who is not ready for it. Long-lasting change has an internal component that must be honored. A well-planned wellness program can set fertile ground for change, though, and accelerate and guide the process.
  4. Helping others to change takes persistence, patience, and insight. Simply offering money, gift cards, or a day off will not form an organization in to a healthy workforce with low medical costs and genuine engagement.

The Five Stages of Change

Researchers have identified five discrete stages of change on the road to healthier choices.

  1. Precontemplation
  2. Contemplation
  3. Preparation/planning
  4. Action
  5. Maintenance

Here is an overview of each stage.

Precontemplation. At this stage, employees are not even aware of a problem or simply do not care. Workers will smoke, spend time sitting around and avoiding exercise, ignore disease risk factors, and scarf down fast food, soda, and other health-killers while in denial of the consequences. Common rationalizations and justifications include:

  • "No one lives forever."
  • "My Aunt Sadie smoked three packs a day and lived to 95."
  • "No one knows what is healthy so I might as well do what I want."
  • "I need to eat ice cream to control my stress."

Does this thinking sound familiar? In order to move to the next step, the employee needs to recognize and care about the problem.

Contemplation. Employees now acknowledge and care about health challenges and poor choices, and want change but are ambivalent. Internally, there is still argument about the desirability and possibility of any change. Breaking old habits seems difficult and perhaps not worth the effort. An employer may hear comments such as:

  • Bad health just runs in my family. I don't think I can get past it."
  • "I want to lose weight, but have never succeeded on a diet for more than a few months."
  • "I'd like to find a better way to handle stress, but have no idea what that would be. I'm definitely not into yoga."

To move forward, employees must master ambivalence. This is truly the most difficult stage.

Preparation/planning. Employees have pushed past ambivalence and are making plans for improvement. Preparation does not have to take a long time, but it does need to be thoughtful. This stage is fun, but also hard work. Some are tempted to skip it and jump right into action. This would be a mistake, like expecting a child to do algebra right after learning how to add. Employees will be excited and state things like:

  • I'm figuring out what kind of nicotine replacement will help me the most."
  • "I joined a biking club and am going for my first ride with them next week."
  • "I'm collecting recipes for how to cook vegetables and make them taste fantastic."

At this stage, people might actually have to be slowed down, to avoid initiating too rapid of behavior changes that can lead to experience failure. For long-term improvements, it is critical employees build confidence by being successful.

Action. Employees are making meaningful changes in choices that impact health. This is the most rewarding stage. Workers experience the thrill of success by moving ahead and confidence soars. The major task is to keep on track one day at a time. It is fine if change is slow and uneven, as long as progress is being made. Employees may share experiences:

  • "I lost five pounds in the last month."
  • "I've been going to the gym three times a week. I skipped last weekend because it was my daughter's birthday, but I'm beginning my schedule again tonight."
  • "I've started going to bed an hour earlier every night, and feel much more rested."

It is critical to remember, however, that momentary success does not ensure long-term results.

Maintenance. At this stage, what was once a distant goal for employees now has become habit. Their task now is to keep up the positive choices and not become complacent. Employers may hear employees wrestling with maintenance in a variety of remarks:

  • "I was tempted to have a cigarette when I saw my old high school buddies, but then I remembered what a hard time I had quitting, and decided not to."
  • "I've gained back 10 of the 50 pounds I lost. I've set my mind to get back on track."
  • "My friend left a two-liter bottle of soda in my refrigerator. I had a glass of it, then poured the rest down the drain."

Maintenance is an active process.  Long-term and permanent success is within sight as long as everyone understands that simply coasting on past results is not enough. If maintenance fails, the employee relapses, perhaps all the way to the precontemplation stage.

How To Use Stages of Change to Get Better Wellness Results

The components of a typical wellness program address different stage of change issues, as the following table shows

Program component

Pre-
contemplation

Contemplation

Preparation/
Planning

Action

Maintenance

Biometrics

May wake up some, but most will shrug off results

If results show high risk, may help push to the next stage

Not too useful although may indicate areas that need attention

Improvements in risk factors help with motivation and confidence

Improvements are motivating, but lack of results or backsliding can justify relapse for some

Health risk
appraisals

Completing the form may get some employees to think about change

May help move the employee to the next stage or justify continuing ambivalence

Not too useful although may indicate areas that need attention

May indicate where further action is needed

If taken periodically, the health profile indicates how maintenance has succeeded over time

Health coaching

Likely to be ignored unless there is a financial reason to complete it. Then the impact may be superficial

The availability of support may get the employee moving to the next stage

May shorten the process by providing a convenient resource with the employer's "stamp of approval"

Skilled coaching will excite the employee with measurable results. Mediocre coaching can have opposite effect

Coaching is not too useful if the employee has already achieved the goals

Health challenges

Likely to be ignored unless there is a financial reason to complete it. Then the impact may be superficial

If the employee participates and sees measurable results, motivation may  overcome ambivalence

Not very useful for information gathering

The employee is taking action, so this is a natural fit for this stage

The novelty of a new program can reinforce maintenance

Lunch and learns

A brief hour talk or demo may actually catch the employee by surprise and evoke thoughts about change

The employee may pick up information or a behavioral tip to help overcome ambivalence

May provide information to help with planning

The employee may rather go out for a walk than sit in a lunch and learn

Depends on the quality of the information; new ideas help maintain hard-fought results

Higher medical contributions for smoking or other risk factors

May get employees to think "am I really that much more likely to be sick?"

Money becomes another factor pushing the employee off the fence into the next step

Not very useful for information gathering

As employees feel better, inner satisfaction should outweigh external rewards in propelling action

May help sustain maintenance, but unlikely to accomplish this without other actions and motivation

Additional, creative pieces of a wellness program, less commonly used, can motivate employees and help them overcome challenges at various stages of change.

  • Goal setting. Encourage employees to set specific, realistic lifestyle change goals in writing and track progress toward those goals. A goal to lose two pounds a month is much more likely to move an employee successfully through the stages of change than is a vague goal to "lose weight" or an overly ambitious goal to lose ten pounds a month. 
  • Visualization. When an employee visualizes successfully carrying out a planned action, the experience is encouraging. It is as if the employee actually experienced this success, which builds confidence and motivation. Audio files that help employees use visualization to move through the stages of change are a low-cost investment that can have a big payoff.  
  • Peer example. Just as visualization does, seeing others chose and execute healthy choices and achieve results encourages other employees to imitate this behavior. Recognizing success stories and having employees share progress and methods can help at every stage of change.
  • Make healthy choices convenient. Apples and bananas in vending machines, water instead of soda at meetings, and a low-cost salad bar as a staple in the company cafeteria all encourage change by making it an easy option to select.

As an organization learns more about stages of change, it will be able to thoughtfully use this knowledge to move a wellness program to creative design and measurable results.

About the Author

Janice Stanger is an account executive for EPIC (www.edgewoodins.com) a retail property casualty and employee benefits insurance brokerage based in San Mateo, Calif. Stanger has 28 years of experience in healthcare, benefits consulting, compliance, and wellness. She holds a Bachelor’s degree from Princeton University in Anthropology as well an MBA from University of California, Berkeley and a PhD in Human Development and Aging from University of California, San Francisco.

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