Prospective prediction of health-related behaviours with the Theory of Planned Behaviour: a meta-analysis

The Theory of Planned Behaviour and dietary patterns: A systematic review and meta-analysis

OBJECTIVE

Promoting adherence to healthy dietary patterns is a critical public health issue. Models of behaviour, such as the Theory of Planned Behaviour (TPB) allow programme designers to identify antecedents of dietary patterns and design effective interventions. The primary aim of this study was to examine the association between TPB variables and dietary patterns.

METHODS

A systematic literature search was conducted to identify relevant studies. Random-effects meta-analysis was used to calculate average correlations. Meta-regression was used to test the impact of moderator variables.

RESULTS

In total, 22 reports met the inclusion criteria. Attitudes had the strongest association with intention (r+=0.61) followed by perceived behavioural control (PBC, r+=0.46) and subjective norm (r+=0.35). The association between intention and behaviour was r+=0.47, and between PBC and behaviour r+=0.32. Moderator analyses revealed that younger participants had stronger PBC-behaviour associations than older participants had, and studies recording participants' perceptions of behaviour reported significantly higher intention-behaviour associations than did those using less subjective measures.

CONCLUSIONS

TPB variables were found to have medium to large associations with both intention and behaviour that were robust to the influence of key moderators. Recommendations for future research include further examination of the moderation of TPB variables by age and gender and the use of more valid measures of eating behaviour.

Development of the REFOCUS intervention to increase mental health team support for personal recovery

BACKGROUND

There is an emerging evidence base about best practice in supporting recovery. This is usually framed in relation to general principles, and specific pro-recovery interventions are lacking.

AIMS

To develop a theoretically based and empirically defensible new pro-recovery manualised intervention--called the REFOCUS intervention.

METHOD

Seven systematic and two narrative reviews were undertaken. Identified evidence gaps were addressed in three qualitative studies. The findings were synthesised to produce the REFOCUS intervention, manual and model.

RESULTS

The REFOCUS intervention comprises two components: recovery-promoting relationships and working practices. Approaches to supporting relationships comprise coaching skills training for staff, developing a shared team understanding of recovery, exploring staff values, a Partnership Project with people who use the service and raising patient expectations. Working practices comprise the following: understanding values and treatment preferences; assessing strengths; and supporting goal-striving. The REFOCUS model describes the causal pathway from the REFOCUS intervention to improved recovery.

CONCLUSIONS

The REFOCUS intervention is an empirically supported pro-recovery intervention for use in mental health services. It will be evaluated in a multisite cluster randomised controlled trial (ISRCTN02507940).

Developing Items to Measure Theory of Planned Behavior Constructs for Opioid Administration for Children: Pilot Testing

The Theory of Planned Behavior (TpB) is useful to direct nursing research aimed at behavior change. As proposed in the TpB, individuals' attitudes, perceived norms, and perceived behavior control predict their intentions to perform a behavior and subsequently predict their actual performance of the behavior. Our purpose was to apply Fishbein and Ajzen's guidelines to begin development of a valid and reliable instrument for pediatric nurses' attitudes, perceived norms, perceived behavior control, and intentions to administer PRN opioid analgesics when hospitalized children self-report moderate to severe pain. Following Fishbein and Ajzen's directions, we were able to define the behavior of interest and specify the research population, formulate items for direct measures, elicit salient beliefs shared by our target population and formulate items for indirect measures, and prepare and test our questionnaire. For the pilot testing of internal consistency of measurement items, Cronbach alphas were between 0.60 and 0.90 for all constructs. Test-retest reliability correlations ranged from 0.63 to 0.90. Following Fishbein and Ajzen's guidelines was a feasible and organized approach for instrument development. In these early stages, we demonstrated good reliability for most subscales, showing promise for the instrument and its use in pain management research. Better understanding of the TpB constructs will facilitate the development of interventions targeted toward nurses' attitudes, perceived norms, and/or perceived behavior control to ultimately improve their pain behaviors toward reducing pain for vulnerable children.

Understanding Walking Behavior among University Students Using Theory of Planned Behavior

Walking has been shown to improve physical and mental well-being, yet insufficient walking among university students has been increasingly reported. This study aimed to understand walking behavior of university students using theory of planned behavior (TPB). We recruited 169 undergraduate students by university mass email of the Chinese University of Hong Kong, and first administered a salient belief elicitation survey, which was used to design the TPB questionnaire, to a subset of the study sample. Secondly, all participants completed the TPB questionnaire and walking-oriented diary in a two-day period in December 2012. We mapped the walking behavior data obtained from the diary using geographic information system, and examined the extent to which TPB constructs explained walking intentions and walking behavior using Structural equation model (SEM). We found perceived behavioral control to be the key determinant of walking intention. Shaped by participants’ perceived behavioral control, attitude toward walking and subjective norms, and behavioral intention, in turn had a moderate explanatory effect on their walking behavior. In summary, our findings suggest that walking behavior among university students can be understood within the TPB framework, and could inform walking promotion interventions on the university campuses.

Building intentions with the theory of planned behaviour: a qualitative assessment of salient beliefs about pharmacy value added services in Malaysia

Objective

To improve pharmaceutical care delivery in Malaysia, the Ministry of Health (MOH) had introduced the concept of value added services (VAS). Despite its reported convenience and advantages, VAS utilization rate is low in the country. The study aims to explore patients’ understanding, beliefs and expectations towards VAS in Malaysia using the theory of planned behaviour (TPB) as the theoretical model.

Methods

A qualitative methodology was used whereby face‐to‐face interviews were conducted with 12 patients who collected partial medicine supplies from government pharmacies. Participants were recruited using purposive and snowball sampling method in the state of Negeri Sembilan, Malaysia. Interviews were audio‐recorded. Verbatim transcription and thematic content analysis were performed on the data.

Results

Thematic content analysis yielded five major themes: (i) attitudes towards using VAS, (ii) subjective norms, (iii) perceived behavioural control, (iv) lack of knowledge and understanding of VAS and (v) expectations towards VAS.

Conclusion

The interviews explored and informed new information about salient beliefs towards pharmacy VAS. The findings suggest that VAS is still in its infancy and a more robust and effective advertising and marketing campaign is needed to boost the adoption rate. Behavioural attitudes, subjective norms and perceived control elements were discussed and serve as important variables of interest in future study. Expectations towards VAS serve as an important guideline to further improve patient‐oriented services.

Apple or Chocolate – Intentional and Social-Reactive Processes in Eating Behavior Among Adolescents

Abstract. Two studies examined the main assumption of the Prototype/Willingness Model for eating behavior. Accordingly, health-behavior in adolescents results from intentional and social-reactive processes, namely behavioral intentions and behavioral willingness. The hypothesis was that willingness explains eating behavior over and above intentions with respect to eating behavior in general and in the peer context. This was tested in a cross-sectional (N = 286) and a longitudinal (N = 335) study. Intentions and willingness were assessed for healthy and unhealthy eating, eating behavior using an eating pattern index, and observed food consumption in the peer context. Willingness explained variance in eating behavior over and above intentions. Intentional as well as social-reactive processes contribute to adolescents’ eating behavior. Implications for practice are discussed.

Explaining Vegetable Consumption among Young Adults: An Application of the Theory of Planned Behaviour

Although fruit and vegetable consumption is highly recommended for a healthy and balanced daily diet, several European countries do not meet these recommendations. In Italy, only 45% of young people are consuming at least one portion of vegetables per day. Therefore, this paper aims to understand the main determinants of vegetables consumption among young adults to suggest possible intervention strategies. A cross-sectional study was conducted on a samples of Italian students (n = 751), using the theory of planned behaviour (TPB) as a conceptual framework. A structural equation model (SEM) was developed to test the TPB predictors for vegetable consumption, and the role of background factors (socio-demographic and personal characteristics) in improving the TPB model’s explaining power. Overall, 81% and 68%, respectively, of intentions and behaviour variance is explained by the TPB model. Socio-demographic and personal characteristics were found to influence intentions and behaviour indirectly by their effects on the theory’s more proximal determinants. Interventions should be targeted to improve perceived behavioural control (PBC), attitudes and subjective norms that significantly affect intentions. Tailored interventions for male students, enrolled in courses other than food science, and doing less physical activity may have a larger effect on behavioural change.

Children's and adolescents' snacking: interplay between the individual and the school class

Objective: In schools, perceived norms of classmates facilitate but can also inhibit unhealthy food intake in children and adolescents. However, the role of actual class behaviors and attitudes is less established. Thus, the present study examined classmates' actual eating behavior and food preferences in relation to actual food intake. In addition, it tested whether these normative effects are facilitated by corresponding individual and class food preferences or a positive social self-concept.

Methods: The food preferences, social self-concept, and unhealthy snacking frequency of 734 Finnish, 829 German, and 555 Romanian children and adolescents (aged 8–19) from 127 school-classes were assessed.

Results: Multilevel analysis at individual and class level showed that classmates shared similar snacking habits (14.7% variance). Moreover, the unhealthy food preference of a school-class was associated with its collective snacking [χ(1)2=54.67, p < 0.001, PRV = 0.32). This effect was facilitated by individual, unhealthy food preferences [χ(1)2=16.72, p < 0.001, PRV = 0.57] and a positive social self-concept [χ(1)2=5.91, p = 0.015, PRV = 0.12].

Conclusions: Actual class norms are related to children's and adolescents' eating, but their impact depends on individual differences in preferences and social self-concept.

Belief incongruence and the intention-behavior gap in persons with at-risk alcohol use

INTRODUCTION

When intentions are expressed, e.g., when filling in a health questionnaire, people may have unrealistic beliefs towards behavior change resulting in strong intentions to change. These may fail to correspond to reality when the behavior actually should be performed. Belief incongruence was tested as a possible source of the intention-behavior gap.

METHODS

The study sample consisted of 433 job agency clients with at-risk alcohol use (64% men, mean age=30.6 (SD=11.6) years). Behavioral, normative, and control beliefs, intention, and alcohol use were assessed at baseline and three months later. The influence of belief incongruence on the intention-behavior gap was examined using latent interaction models.

RESULTS

The gap between stated intentions and at-risk alcohol use three months later was larger when the according normative beliefs were incongruent (total effect: b=-0.44, p<0.05 for persons with congruent beliefs vs. b=-0.06, p>0.10 for persons with incongruent beliefs). When controlling for the mediating effect of changes in intentions, the association between belief incongruence and intention-behavior gap was attenuated (direct effect: b=-0.56, p<0.01 for persons with congruent beliefs vs. b=-0.28, p<0.05 for persons with incongruent beliefs). Neither behavioral belief incongruence nor control belief incongruence was significantly associated with the intention-behavior gap.

CONCLUSIONS

Normative belief incongruence may contribute to the gap between intentions to adhere to recommended drinking limits and subsequent at-risk alcohol use. Focusing on the reduction of misperceptions about drinking norms could help to increase the proportion of persons who succeed in translating their intentions into behavior.

The moderating impact of temporal separation on the association between intention and physical activity: a meta-analysis

Previous meta-analyses have estimated that the intention-behaviour association in physical activity (PA) is large in magnitude. However, these prior meta-analyses have also revealed a large degree of heterogeneity, suggesting the presence of moderating variables. This study examines the impact of one such moderator, testing the hypothesis that the magnitude of the association between intention and behaviour decreases as the temporal separation between the two increases. A systematic literature search was used to identify published and unpublished studies that met the inclusion criteria. A random-effects meta-regression was conducted to test the study hypothesis. A total of 78 journal articles and 11 unpublished dissertations were identified, yielding 109 effect sizes. The mean number of weeks between the measurement of intention and behaviour was 5.4 (SD = 6.6, range = .43, 26). The average correlation between intention and behaviour was r = 0.51. In line with theoretical predictions, temporal separation was a significant moderator of the intention-behaviour correlation (B = -.014, p < .001) and explained 24% of the between-study variance. This result remained unchanged when entered simultaneously with several control variables. The results of this analysis have important implications both for researchers and for intervention designers aiming to increase rates of PA.

Understanding physical activity participation in spinal cord injured populations: Three narrative types for consideration

The aim of this study was to identity the types of physical activity narratives drawn upon by active spinal injured people. More than 50 h of semi-structured life-story interview data, collected as part of larger interdisciplinary program of disability lifestyle research, was analysed for 30 physically active male and female spinal cord injury (SCI) participants. A structural narrative analysis of data identified three narrative types which people with SCI draw on: (1) exercise is restitution, (2) exercise is medicine, and (3) exercise is progressive redemption. These insights contribute new knowledge by adding a unique narrative perspective to existing cognitive understanding of physical activity behaviour in the spinal cord injured population. The implications of this narrative typology for developing effective positive behavioural change interventions are critically discussed. It is concluded that the identified narratives types may be constitutive, as well as reflective, of physical activity experiences and therefore may be a useful tool on which to base physical activity promotion initiatives.

E-cigarette use and willingness to smoke: a sample of adolescent non-smokers

OBJECTIVE

There is little evidence on the consequences of using electronic cigarettes (e-cigarette) in adolescence. With a multiethnic sample of non-smokers, we assessed the relation between e-cigarette use and social-cognitive factors that predict smoking of combustible cigarettes.

METHODS

School-based cross-sectional survey of 2309 high school students (mean age 14.7 years). Participants reported on e-cigarette use and cigarette use; on smoking-related cognitions (smoking expectancies, prototypes of smokers) and peer smoker affiliations; and on willingness to smoke cigarettes. Regression analyses conducted for non-cigarette smokers tested the association between e-cigarette use and willingness to smoke cigarettes, controlling for demographics, parenting, academic and social competence, and personality variables. Structural equation modelling (SEM) analysis tested whether the relation between e-cigarette use and willingness to smoke was mediated through any of the three smoking-related variables.

RESULTS

Non-smokers who had used e-cigarettes (18% of the total sample) showed more willingness to smoke cigarettes compared with those who had never used any tobacco product; the adjusted OR was 2.35 (95% CI 1.73 to 3.19). SEM showed that the relation between e-cigarette use and willingness to smoke was partly mediated through more positive expectancies about smoking, but there was also a direct path from e-cigarette use to willingness.

CONCLUSIONS

Among adolescent non-smokers, e-cigarette use is associated with willingness to smoke, a predictor of future cigarette smoking. The results suggest that use of e-cigarettes by adolescents is not without attitudinal risk for cigarette smoking. These findings have implications for formulation of policy about access to e-cigarettes by adolescents.

A systematic literature review and meta-analysis: The Theory of Planned Behavior's application to understand and predict nutrition-related behaviors in youth

BACKGROUND

Efforts to reduce unhealthy dietary intake behaviors in youth are urgently needed. Theory-based interventions can be effective in promoting behavior change; one promising model is the Theory of Planned Behavior (TPB).

PURPOSE

The aim of this study was to determine, using a systematic literature review, how the TPB has been applied to investigate dietary behaviors, and to evaluate which constructs are associated with dietary behavioral intentions and behaviors in youth.

METHODS

Publications were identified by searching electronic databases, contacting experts in the field, and examining an evolving Internet-based TPB-specific bibliography. Studies including participants aged 2-18years, all TPB constructs discernible and measured with a description of how the variables were assessed and analyzed, were published in English and peer-reviewed journals, and focused on nutrition-related behaviors in youth were identified. Accompanying a descriptive statistical analysis was the calculation of effect sizes where possible, a two-stage meta-analysis, and a quality assessment using tenants from the Consolidated Standards of Reporting Trials (CONSORT) and Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statements.

RESULTS

Thirty-four articles, including three intervention studies, were reviewed. The TPB was most often used to evaluate healthy eating and sugary snack and beverage consumption. Attitude had the strongest relationship with dietary behavioral intention (mean r=0.52), while intention was the most common predictor of behavior performance (mean r=0.38; both p<0.001). All three interventions revealed beneficial outcomes when using the TPB (e.g. η(2)=0.51 and ds=0.91, 0.89, and 0.79); extending the Theory with implementation intentions may enhance its effectiveness (e.g. η(2)=0.76).

CONCLUSIONS

Overall, the TPB may be an effective framework to identify and understand child and adolescent nutrition-related behaviors, allowing for the development of tailored initiatives targeting poor dietary practices in youth. However, support from the literature is primarily from observational studies and a greater effort towards examining these relationships within intervention studies is needed.

Using the Theory of Planned Behaviour to examine health professional students' behavioural intentions in relation to medication safety and collaborative practice

BACKGROUND

Safe medication practices depend upon, not only on individual responsibilities, but also effective communication and collaboration between members of the medication team. However, measurement of these skills is fraught with conceptual and practical difficulties.

AIMS

The aims of this study were to explore the utility of a Theory of Planned Behaviour-based questionnaire to predict health professional students' behavioural intentions in relation to medication safety and collaborative practice; and to determine the contribution of attitudes, subjective norms, and perceived control to behavioural intentions.

DESIGN

A descriptive cross-sectional survey based upon the Theory of Planned Behaviour was designed and tested.

PARTICIPANTS

A convenience sample of 65 undergraduate pharmacy, nursing and medicine students from one semi-metropolitan Australian university were recruited for the study.

METHODS

Participants' behavioural intentions, attitudes, subjective norms, and perceived control to behavioural intentions in relation to medication safety were measured using an online version of the Theory of Planned Behaviour Medication Safety Questionnaire.

RESULTS

The Questionnaire had good internal consistency with a Cronbach's alpha of 0.844. The three predictor variables of attitudes, subjective norms, and perceived control accounted for between 30 and 46% of the variance in behavioural intention; this is a strong prediction in comparison to previous studies using the Theory of Planned Behaviour. Data analysis also indicated that attitude was the most significant predictor of participants' intention to collaborate with other team members to improve medication safety.

CONCLUSION

The results from this study provide preliminary support for the Theory of Planned Behaviour-Medication Safety Questionnaire as a valid instrument for examining health professional students' behavioural intentions in relation to medication safety and collaborative practice.

Using impairment and cognitions to predict walking in osteoarthritis: A series of n-of-1 studies with an individually tailored, data-driven intervention

OBJECTIVES

First, this study compares the ability of an integrated model of activity and activity limitations, the International Classification of Functioning, Disability and Health (ICF), and the Theory of Planned Behaviour (TPB) to predict walking within individuals with osteoarthritis. Second, the effectiveness of a walking intervention in these individuals is determined.

DESIGN

A series of n-of-1 studies with an AB intervention design was used.

METHODS

Diary methods were used to study four community-dwelling individuals with lower-limb osteoarthritis. Data on impairment symptoms (pain, pain on movement, and joint stiffness), cognitions (intention, self-efficacy, and perceived controllability), and walking (step count) were collected twice daily for 12 weeks. At 6 weeks, an individually tailored, data-driven walking intervention using action planning or a control cognition manipulation was delivered. Simulation modelling analysis examined cross-correlations and differences in baseline and intervention phase means. Post-hoc mediation analyses examined theoretical relationships and multiple regression analyses compared theoretical models.

RESULTS

Cognitions, intention in particular, were better and more consistent within individual predictors of walking than impairment. The walking intervention did not increase walking in any of the three participants receiving it. The integrated model and the TPB, which recognize a predictive role for cognitions, were significant predictors of walking variance in all participants, whilst the biomedical ICF model was only predictive for one participant.

CONCLUSION

Despite the lack of evidence for an individually tailored walking intervention, predictive data suggest that interventions for people with osteoarthritis that address cognitions are likely to be more effective than those that address impairment only. Further within-individual investigation, including testing mediational relationships, is warranted.

STATEMENT OF CONTRIBUTION

What is already known on this subject? N-of-1 methods have been used to study within-individual predictors of walking in healthy and chronic pain populations An integrated biomedical and behavioural model of activity and activity limitations recognizes the roles of impairment and psychology (cognitions) Interventions modifying cognitions can increase physical activity in people with mobility limitations What does this study add? N-of-1 methods are suitable to study within-individual predictors of walking and interventions in osteoarthritis An integrated and a psychological model are better predictors of walking in osteoarthritis than a biomedical model There was no support for an individually tailored, data-driven walking intervention.

Reflective and automatic processes in health care professional behaviour: a dual process model tested across multiple behaviours

BACKGROUND

Clinicians' behaviours require deliberate decision-making in complex contexts and may involve both impulsive (automatic) and reflective (motivational and volitional) processes.

PURPOSE

The purpose of this study was to test a dual process model applied to clinician behaviours in their management of type 2 diabetes.

METHODS

The design used six nested prospective correlational studies. Questionnaires were sent to general practitioners and nurses in 99 UK primary care practices, measuring reflective (intention, action planning and coping planning) and impulsive (automaticity) predictors for six guideline-recommended behaviours: blood pressure prescribing (N = 335), prescribing for glycemic control (N = 288), providing diabetes-related education (N = 346), providing weight advice (N = 417), providing self-management advice (N = 332) and examining the feet (N = 218).

RESULTS

Respondent retention was high. A dual process model was supported for prescribing behaviours, weight advice, and examining the feet. A sequential reflective process was supported for blood pressure prescribing, self-management and weight advice, and diabetes-related education.

CONCLUSIONS

Reflective and impulsive processes predict behaviour. Quality improvement interventions should consider both reflective and impulsive approaches to behaviour change.

The Impact of Asking Intention or Self-Prediction Questions on Subsequent Behavior: A Meta-Analysis

The current meta-analysis estimated the magnitude of the impact of asking intention and self-prediction questions on rates of subsequent behavior, and examined mediators and moderators of this question-behavior effect (QBE). Random-effects meta-analysis on 116 published tests of the effect indicated that intention/prediction questions have a small positive effect on behavior (d+ = 0.24). Little support was observed for attitude accessibility, cognitive dissonance, behavioral simulation, or processing fluency explanations of the QBE. Multivariate analyses indicated significant effects of social desirability of behavior/behavior domain (larger effects for more desirable and less risky behaviors), difficulty of behavior (larger effects for easy-to-perform behaviors), and sample type (larger effects among student samples). Although this review controls for co-occurrence of moderators in multivariate analyses, future primary research should systematically vary moderators in fully factorial designs. Further primary research is also needed to unravel the mechanisms underlying different variants of the QBE.

Mental toughness as a moderator of the intention-behaviour gap in the rehabilitation of knee pain

OBJECTIVES

The purpose of this study was to investigate the role of mental toughness in maximising the effect of intentions to perform rehabilitative exercises on behaviour among a sample of people with knee pain.

DESIGN

Cross-sectional survey, with a 2-week time-lagged assessment of exercise behaviour.

METHODS

In total, 193 individuals (nfemale=107, nmale=84) aged between 18 and 69 years (M=30.79, SD=9.39) participated, with 136 (70.5%) retained at both assessment points. At time 1, participants completed an online, multisection survey that encompassed measures of demographic details, severity of problems associated with the knee (e.g., pain, symptoms), past behaviour, mental toughness, and the theory of planned behaviour constructs (TPB; attitudes, subjective norms, perceived behavioural, intentions). Two weeks later, participants retrospectively reported their exercise behaviour for the past 14 days using an online survey.

RESULTS

Moderated regression analyses indicated that mental toughness and its interaction with intention accounted for an additional 3% and 4% of the variance in exercise behaviour, respectively. Past behaviour, attitudes, and mental toughness all had direct effects on behaviour, alongside a meaningful interaction between intentions and mental toughness. Specifically, intentions had a stronger effect on exercise behaviour among those individuals high in mental toughness compared to those low in this personal resource.

CONCLUSIONS

The results of this study shed new light on the intention-behaviour gap by indicating that mental toughness increases the likelihood that intention is translated into action.

Anterior Cruciate Ligament Reconstruction-Not Exactly a One-Way Ticket Back to the Preinjury Level: A Review of Contextual Factors Affecting Return to Sport After Surgery

CONTEXT

A recently updated meta-analysis of return-to-sport rates after anterior cruciate ligament (ACL) reconstruction demonstrated that 65% of athletes returned to their preinjury level of sport after surgery. The aim of this clinical review was to explore contextual factors associated with returning or not returning to the preinjury level after ACL reconstruction.

EVIDENCE ACQUISITION

Data were obtained from peer-reviewed literature via a search of the electronic databases Medline, Embase, CINAHL, and SPORTDiscus from database inception to January 2015. The keywords anterior cruciate ligament and return to sport were used. Additional literature was identified via hand-searching of the reference lists of relevant articles and the ePublication lists of key scientific journals. Random effects meta-analyses were used to pool the results of modifiable contextual factors and to examine their association with returning or not returning to the preinjury level of sport after surgery.

STUDY DESIGN

Clinical review.

LEVEL OF EVIDENCE

Level 2.

RESULTS

Lower fear of reinjury (standardized mean difference, 0.7), greater psychological readiness to return to sport (standardized mean difference, 1.0), and a more positive subjective assessment of knee function (standardized mean difference, 0.9) favored return to the preinjury level after surgery.

CONCLUSION

Returning or not returning to the preinjury level after ACL reconstruction is complex and multifactorial. Screening for potentially modifiable contextual factors, particularly psychological factors, early after ACL injury may help clinicians identify athletes who could be at risk of not returning to the preinjury level of sport and institute interventions that could improve returning to sport.

Personal and psychosocial predictors of doping use in physical activity settings: a meta-analysis

BACKGROUND

There is a growing body of empirical evidence on demographic and psychosocial predictors of doping intentions and behaviors utilizing a variety of variables and conceptual models. However, to date there has been no attempt to quantitatively synthesize the available evidence and identify the strongest predictors of doping.

OBJECTIVES

Using meta-analysis, we aimed to (i) determine effect sizes of psychological (e.g. attitudes) and social-contextual factors (e.g. social norms), and demographic (e.g. sex and age) variables on doping intentions and use; (ii) examine variables that moderate such effect sizes; and (iii) test a path analysis model, using the meta-analyzed effect sizes, based on variables from the theory of planned behavior (TPB).

DATA SOURCES

Articles were identified from online databases, by contacting experts in the field, and searching the World Anti-Doping Agency website.

STUDY ELIGIBILITY CRITERIA AND PARTICIPANTS

Studies that measured doping behaviors and/or doping intentions, and at least one other demographic, psychological, or social-contextual variable were included. We identified 63 independent datasets.

STUDY APPRAISAL AND SYNTHESIS METHOD

Study information was extracted by using predefined data fields and taking into account study quality indicators. A random effects meta-analysis was carried out, correcting for sampling and measurement error, and identifying moderator variables. Path analysis was conducted on a subset of studies that utilized the TPB.

RESULTS

Use of legal supplements, perceived social norms, and positive attitudes towards doping were the strongest positive correlates of doping intentions and behaviors. In contrast, morality and self-efficacy to refrain from doping had the strongest negative association with doping intentions and behaviors. Furthermore, path analysis suggested that attitudes, perceived norms, and self-efficacy to refrain from doping predicted intentions to dope and, indirectly, doping behaviors.

LIMITATIONS

Various meta-analyzed effect sizes were based on a small number of studies, which were correlational in nature. This is a limitation of the extant literature.

CONCLUSIONS

This review identifies a number of important correlates of doping intention and behavior, many of which were measured via self-reports and were drawn from an extended TPB framework. Future research might benefit from embracing other conceptual models of doping behavior and adopting experimental methodologies that will test some of the identified correlates in an effort to develop targeted anti-doping policies and programs.

A cluster randomised trial testing an intervention to improve parents' recognition of their child's weight status: study protocol

Background

Parents typically do not recognise their child’s weight status accurately according to clinical criteria, and thus may not take appropriate action if their child is overweight. We developed a novel visual intervention designed to improve parental perceptions of child weight status according to clinical criteria for children aged 4–5 and 10–11 years. The Map Me intervention comprises age- and sex-specific body image scales of known body mass index and supporting information about the health risks of childhood overweight.

Design

This cluster randomised trial will test the effectiveness of the Map Me intervention. Primary schools will be randomised to: paper-based Map Me; web-based Map Me; no information (control). Parents of reception (4–5 years) and year 6 (10–11 years) children attending the schools will be recruited. The study will work with the National Child Measurement Programme which measures the height and weight of these year groups and provides feedback to parents about their child’s weight status. Before receiving the feedback, parents will complete a questionnaire which includes assessment of their perception of their child’s weight status and knowledge of the health consequences of childhood overweight. The control group will provide pre-intervention data with assessment soon after recruitment; the intervention groups will provide post-intervention data after access to Map Me for one month. The study will subsequently obtain the child height and weight measurements from the National Child Measurement Programme. Families will be followed-up by the study team at 12 months. The primary outcome is any difference in accuracy in parental perception of child weight status between pre-intervention and post-intervention at one month. The secondary outcomes include differences in parent knowledge, intention to change lifestyle behaviours and/or seek advice or support, perceived control, action planning, coping planning, and child weight status at 12 month follow-up.

Discussion

The Map Me tool has potential to make a positive impact on children’s health at a population level by introducing it into current intervention programmes to improve accuracy of parental perception of child’s weight status. This trial will inform the action of researchers, educators, health professionals and policy makers.

Trial registration

Current Controlled Trials ISRCTN91136472. Registered 3 May 2013

Psychosocial determinants of Chinese parental HPV vaccination intention for adolescent girls: preventing cervical cancer

BACKGROUND

Intention is an important precursor of decisions to undergo vaccination. Using an extensively modified theory of planned behaviour, we explored psychosocial determinants of vaccination intention against human papillomavirus (HPV) among Hong Kong Chinese parents.

METHODS

A random sample of 368 (response rate 54.6%) Chinese parents who had at least one daughter aged 12-17 years, had heard of HPV vaccine before but had not vaccinated daughters against HPV and had completed telephone interviews between February and April 2014. Hierarchical multiple regression analysis examined the additive effect of theoretical constructs. Stepwise multiple regression analysis determined which variables contributed the most to the prediction of vaccination intention.

RESULTS

Principal determinants of parental HPV vaccination intention were anticipated worry if not vaccinated (β = 0.23, p = 0.001), anticipated anxiety reduction after HPV vaccination (β = 0.19, p = 0.005), proneness to peer influence (β = 0.17, p = 0.002), private health insurance for children (β = 0.14, p = 0.009), perceiving daughter's susceptibility to cervical cancer (β = 0.17, p = 0.003), number of daughters (β = -0.13, p = 0.011), descriptive norms of HPV vaccination (β = 0.13, p = 0.021), perceiving cervical cancer as behaviour-preventable disease (β = -0.11, p = 0.031) and anticipated regret if not vaccinated (β = 0.14, p = 0.046). Cervical cancer-related worry/anxiety explained 32.8% of the variance in parental HPV vaccination intention.

CONCLUSIONS

Results suggest that cervical cancer-related worry/anxiety is the most important predictor of parental HPV vaccination intention in Hong Kong Chinese and possibly other populations. Social influences also play an important role affecting parental vaccination intention, particularly peer influence and descriptive norm beliefs. Implications of these results are discussed in terms of future HPV vaccination promotion and cervical cancer prevention programme. Copyright © 2015 John Wiley & Sons, Ltd.

Social cognitions measured in 4 to 6 year olds are predictive of objectively measured physical activity

OBJECTIVE

This study tested whether social cognitions from the reasoned action approach (RAA) can be reliably measured in a sample of primary school children (aged 4-6 years) and whether these RAA measures are predictive of physical activity.

DESIGN

Longitudinal observational study with repeated measures over six months.

MEASURES

RAA variables were measured using a novel choice paradigm between physically active and sedentary pastimes. Relative reinforcing value, covariates (sex, age, deprivation and BMI) and physical activity by accelerometry (primary outcome) were also measured.

RESULTS

RAA cognitions could be measured with acceptable retest reliability and discriminant validity and social norms regarding parents and teachers (but not friends) were correlated with physical activity and change in physical activity when relative reinforcing value and other covariates were controlled for.

CONCLUSIONS

RAA cognitions can be reliably measured in primary school children aged 4-6 and RRA measures appear useful in understanding children's activity choices and may potentially inform future interventions.

Supporting recovery in patients with psychosis through care by community-based adult mental health teams (REFOCUS): a multisite, cluster, randomised, controlled trial

BACKGROUND

Mental health policy in many countries is oriented around recovery, but the evidence base for service-level recovery-promotion interventions is lacking.

METHODS

We did a cluster, randomised, controlled trial in two National Health Service Trusts in England. REFOCUS is a 1-year team-level intervention targeting staff behaviour to increase focus on values, preferences, strengths, and goals of patients with psychosis, and staff-patient relationships, through coaching and partnership. Between April, 2011, and May, 2012, community-based adult mental health teams were randomly allocated to provide usual treatment plus REFOCUS or usual treatment alone (control). Baseline and 1-year follow-up outcomes were assessed in randomly selected patients. The primary outcome was recovery and was assessed with the Questionnaire about Processes of Recovery (QPR). We also calculated overall service costs. We used multiple imputation to estimate missing data, and the imputation model captured clustering at the team level. Analysis was by intention to treat. This trial is registered, number ISRCTN02507940.

FINDINGS

14 teams were included in the REFOCUS group and 13 in the control group. Outcomes were assessed in 403 patients (88% of the target sample) at baseline and in 297 at 1 year. Mean QPR total scores did not differ between the two groups (REFOCUS group 40·6 [SD 10·1] vs control 40·0 [10·2], adjusted difference 0·68, 95% CI -1·7 to 3·1, p=0·58). High team participation was associated with higher staff-rated scores for recovery-promotion behaviour change (adjusted difference -0·4, 95% CI -0·7 to -0·2, p=0·001) and patient-rated QPR interpersonal scores (-1·6, -2·7 to -0·5, p=0·005) at follow-up than low participation. Patients treated in the REFOCUS group incurred £1062 (95% CI -1103 to 3017) lower adjusted costs than those in the control group.

INTERPRETATION

Although the primary endpoint was negative, supporting recovery might, from the staff perspective, improve functioning and reduce needs. Implementation of REFOCUS could increase staff recovery-promotion behaviours and improve patient-rated recovery.

FUNDING

National Institute for Health Research.

A systematic review of adherence to restricted diets in people with functional bowel disorders

Functional bowel disorders such as irritable bowel syndrome are commonly experienced within the population, and have an adverse impact on emotions, physical well-being, social activity, and occupational output. Adherence to a restricted diet can reduce symptoms, which in turn leads to increased quality of life and well-being. The aim of this review was to assess the extent to which predictors of dietary adherence have been considered in studies relating to functional bowel disorders and following a restricted diet. This was done firstly by examining such studies which contained a measure or indicator of adherence, and then by examining predictors of adherence within and between studies. A search of PsycINFO, Medline, CINAHL, Web of Science, and Cochrane databases was performed during July 2014, with the search criteria including relevant terms such as gastrointestinal disorder, irritable bowel syndrome, diet, and adherence. Of an initial 7927 papers, 39 were suitable for inclusion. Fourteen of the 39 studies included had a structured measure or indicator of dietary adherence, and the remaining 25 mentioned adherence without any structured levels of adherence. There was little investigation into the predictors of adherence, with symptom relief or induction being the primary goal of most of the studies. This review indicates that predictors of dietary adherence are rarely considered in research regarding functional bowel disorders. Further investigation is needed into the variables which contribute to rates of adherence to restricted diets, and more rigorous research is needed to characterise those individuals most likely to be non-adherent. Such research is necessary to ensure that people with these conditions can be provided with appropriate support and interventions.

A Psychophysiological Mechanism Underlying Women’s Weight-Management Goals

Three studies demonstrated that conception risk was associated with increased motivations to manage weight. Consistent with the rationale that this association is due to ovulatory processes, Studies 2 and 3 demonstrated that it was moderated by hormonal contraceptive (HC) use. Consistent with the rationale that this interactive effect should emerge when modern appearance-related concerns regarding weight are salient, Study 3 used a 14-day diary to demonstrate that the interactive effects of conception risk and HC use on daily motivations to restrict eating were further moderated by daily motivations to manage body attractiveness. Finally, providing evidence that this interactive effect has implications for real behavior, daily fluctuations in the desire to restrict eating predicted daily changes in women’s self-reported eating behavior. These findings may help reconcile prior inconsistencies regarding the implications of ovulatory processes by illustrating that such implications can depend on the salience of broader social norms.

A comparison of Theory of Planned Behavior beliefs and healthy eating between couples without children and first-time parents

OBJECTIVE

To examine the relationship between Theory of Planned Behavior (TPB) beliefs and eating behavior, explore which beliefs have the greatest association with eating behavior, and explore differences between adults without children and first-time parents.

DESIGN

Longitudinal evaluation via questionnaires and food records at baseline and 6 and 12 months.

PARTICIPANTS

Couples without children (n = 72) and first-time parents (n = 100).

DEPENDENT VARIABLES

fruit and vegetable consumption and fat consumption.

INDEPENDENT VARIABLES

TPB beliefs.

ANALYSIS

Pearson correlations between TPB beliefs and eating behavior; exploratory data reduction via linear regression.

RESULTS

Control beliefs were associated with eating behavior (r = .26-.46; P < .05). After controlling for past behavior, control beliefs were associated with eating behavior for first-time parents only. Control beliefs regarding preparation and time had the strongest associations with fruit and vegetable consumption for mothers (β = .26; P < .05) and fathers (β = .38; P < .01). The absence of a ceiling effect for control beliefs suggests room for improvement via intervention.

CONCLUSIONS AND IMPLICATIONS

Interventions guided by TPB should target control beliefs to enhance healthy eating among new parents. Strategies (eg, individual, environmental, policy) to enhance control beliefs regarding healthy eating despite limited time and opportunity for preparation may be particularly valuable.

Concussion reporting intention: a valuable metric for predicting reporting behavior and evaluating concussion education

OBJECTIVE

This study aimed to evaluate whether preseason concussion knowledge and reporting intention predicted in-season concussion reporting behavior.

DESIGN

Prospective cohort study.

SETTING

Collegiate athletic facility of each participating team.

PARTICIPANTS

National Collegiate Athletic Association Division I men's ice hockey players in 1 conference of competition (n = 116).

INDEPENDENT VARIABLES

Intention to report symptoms of a "minor" concussion and concussion knowledge were assessed at preseason.

MAIN OUTCOME MEASURES

Postseason recall of non-report of postimpact symptoms.

RESULTS

Preseason concussion knowledge was not significantly associated with in-season reporting behavior. Intention to report concussion symptoms was significantly related to in-season reporting behavior. There was a significant interaction between the number of different symptoms experienced and both preseason reporting intention and in-season reporting behavior.

CONCLUSIONS

Evaluations of concussion education programs tend to measure concussion knowledge. The present findings suggest that reporting intention may be more strongly predictive of reporting behavior than concussion knowledge and should be included in evaluations of concussion effectiveness. New concussion education initiatives should consider targeting psychosocial constructs that increase reporting intention.

CLINICAL RELEVANCE

Sports medicine clinicians who are involved in evaluating concussion education programs should measure constructs other than just concussion knowledge. Intention, to report symptoms or to continue play while experiencing symptoms of a concussion, seems to be an important and feasible construct to include as part of proximal evaluations of education effectiveness.

The effects of a brief intervention to promote walking on Theory of Planned Behavior constructs: a cluster randomized controlled trial in general practice

OBJECTIVE

Perceived behavioral control (PBC) is a consistent predictor of intentions to walk more. A previously successful intervention to promote walking by altering PBC has been adapted for delivery in general practice. This study aimed to evaluate the effect of this intervention on Theory of Planned Behavior (TPB) constructs in this context.

METHODS

Cluster randomized controlled trial, with n = 315 general practice patients. Practice nurses and Healthcare Assistants delivered a self-regulation intervention or information provision (control). Questionnaires assessed TPB variables at baseline, post-intervention, 6 weeks and 6 months. Walking was measured by pedometer.

RESULTS

The control group reported significantly higher subjective norm at all follow-up time points. There were no significant differences between the two groups in PBC, intention, attitude or walking behavior. TPB variables significantly predicted intentions to walk more, but not objective walking behavior, after accounting for clustering.

CONCLUSION

The lack of effect of the intervention was probably due to a failure to maintain intervention fidelity, and the unsuitability of the behavior change techniques included in the intervention for the population investigated.

PRACTICE IMPLICATIONS

This previously successful intervention was not successful when delivered in this context, calling into question whether practice nurses are best placed to deliver such interventions.

Predicting intentions and behaviours in populations with or at-risk of diabetes: A systematic review

Purpose

To systematically review the Theory of Planned Behaviour studies predicting self-care intentions and behaviours in populations with and at-risk of diabetes.

Methods

A systematic review using six electronic databases was conducted in 2013. A standardised protocol was used for appraisal. Studies eligibility included a measure of behaviour for healthy eating, physical activity, glucose monitoring, medication use (ii) the TPB variables (iii) the TPB tested in populations with diabetes or at-risk.

Results

Sixteen studies were appraised for testing the utility of the TPB. Studies included cross-sectional (n = 7); prospective (n = 5) and randomised control trials (n = 4). Intention (18%–76%) was the most predictive construct for all behaviours. Explained variance for intentions was similar across cross-sectional (28–76%); prospective (28–73%); and RCT studies (18–63%). RCTs (18–43%) provided slightly stronger evidence for predicting behaviour.

Conclusions

Few studies tested predictability of the TPB in populations with or at-risk of diabetes. This review highlighted differences in the predictive utility of the TPB suggesting that the model is behaviour and population specific. Findings on key determinants of specific behaviours contribute to a better understanding of mechanisms of behaviour change and are useful in designing targeted behavioural interventions for different diabetes populations.

•

Intention was the most predictive construct for diabetes self-care behaviours (18% – 76% of explained variance).

•

Studies included cross-sectional (n = 7); prospective (n = 5) and randomised control trials (n = 4).

•

Explained variance for intentions were similar across the study designs and RCTs provided slightly stronger evidence for predicting diabetes-related behaviour.

•

The predictive utility of the TPB is behaviour specific and depends largely on the target population.

Beliefs about using an outdoor pool: Understanding perceptions of place in the context of a recreational environment to improve health

Following the Reasoned Action Approach, an online survey of 74 outdoor pool users illustrates how a theory-based behavioral analysis can be used to identify people's perceptions of a place in their environment. Regression analysis of close-ended data demonstrated that intention "to use the outdoor pool next summer season" was predicted (R(2)=.636, p<.0001) from the weighted combination of attitude (β=.663, p<.0001) and perceived control (β=.197, p<.05). The importance of attitude suggests that use can be encouraged by addressing advantages. The content analysis of open-ended elicitation data revealed that users believed that pool use provides physical, social, and emotional advantages and could be made easier by modifying facility parameters. Implications for promoting and designing public health spaces to attract users to aquatic environments and to improve health are discussed.

Motivational mechanisms influencing error reporting among nurses

Purpose

– The purpose of this paper is to explore antecedents, namely reasons for/against error reporting, attitudes, subjective norms, and perceived control, of nurses’ intentions to report their errors at work.

Design/methodology/approach

– A structured equation model with cross-sectional data were estimated to test the hypotheses on a sample of 188 Italian nurses.

Findings

– Reasons for/against error reporting were associated with attitudes, subjective norms and perceived control. Further, reasons against were related to nurses’ intentions to report errors whereas reasons for error reporting were not. Lastly, perceived control was found to partially mediate the effects of reasons against error reporting on nurses’ intentions to act.

Research limitations/implications

– Self-report data were collected at one point in time.

Practical implications

– This study offers recommendations to healthcare managers on what factors may encourage nurses to report their errors.

Social implications

– Lack of error reporting prevents timely interventions. The study contributes to documenting motivations that can persuade or dissuade nurses in this important decision.

Originality/value

– This study extends prior research on error reporting that lacks a strong theoretical foundation by drawing on behavioral reasoning theory.

Acceptability of home-based chlamydia and gonorrhea testing among a national sample of sexual minority young adults

CONTEXT

STDs are common among older adolescents and young adults; hence, STD screening is a public health priority. Home-based STD testing could be a strategy to improve screening rates, particularly among at-risk populations, including sexual minority (i.e., nonheterosexual) young adults.

METHODS

Data were collected from a national sample of 971 sexual minority young adults aged 18-26 through an online survey in the fall of 2013. Logistic regression analyses identified associations between respondents' characteristics and their willingness to use a home-based test for chlamydia and gonorrhea.

RESULTS

A greater proportion of men than of women were willing to use a home-based STD test (81% vs. 68%). Willingness was more likely among gay than among bisexual men, among men insured through their parents than among the uninsured and among those who had had two or more sexual partners in the past year than among those who had had fewer (adjusted odds ratios, 2.0-2.2). Among men, students were less likely than the employed to report willingness for home-based testing (0.4). Among women, willingness was more likely among those who reported at least two partners in the past year than among those who reported fewer (1.6). Overall, respondents' most common concerns about home-based STD testing regarded test accuracy, their ability to do the test correctly and their preference to see a doctor for testing.

CONCLUSIONS

Home-based STD testing may be a promising strategy for screening sexual minority young adults; understanding correlates of willingness and young adults' concerns may help inform self-testing programs.

Mediation of effects of a theory-based behavioral intervention on self-reported physical activity in South African men

OBJECTIVE

Increasing physical activity is an important public-health goal worldwide, but there are few published mediation analyses of physical-activity interventions in low-to-middle-income countries like South Africa undergoing a health transition involving markedly increased mortality from non-communicable diseases. This article reports secondary analyses on the mediation of a theory-of-planned-behavior-based behavioral intervention that increased self-reported physical activity in a trial with 1181 men in Eastern Cape Province, South Africa.

METHOD

Twenty-two matched-pairs of neighborhoods were randomly selected. Within pairs, neighborhoods were randomized to a health-promotion intervention or an attention-matched control intervention with baseline, immediate-post, and 6- and 12-month post-intervention assessments. Theory-of-planned-behavior constructs measured immediately post-intervention were tested as potential mediators of the primary outcome, self-reported physical activity averaged over the 6- and 12-month post-intervention assessments, using a product-of-coefficients approach in a generalized-estimating-equations framework. Data were collected in 2007-2010.

RESULTS

Attitude, subjective norm, self-efficacy, and intention were significant mediators of intervention-induced increases in self-reported physical activity. The descriptive norm, not affected by the intervention, was not a mediator, but predicted increased self-reported physical activity.

CONCLUSION

The results suggest that interventions targeting theory-of-planned-behavior constructs may contribute to efforts to increase physical activity to reduce the burden of non-communicable diseases among South African men.

Action control bridges the planning-behaviour gap: a longitudinal study on physical exercise in young adults

OBJECTIVES

Maintaining physical exercise levels may not only require motivation and planning but also action control which is supposed to mediate between planning and exercise.

DESIGN

Behavioural intention, action planning, coping planning and past behaviour were assessed at baseline, and action control and concurrent exercise were measured one month later in 497 young adults.

METHOD

Three nested structural models were specified to examine different mediation mechanisms. One model reflected the intention-planning-behaviour chain, the other one focused on the intention-action control-behaviour chain and the third model comprised the full sequence.

RESULTS

Indirect effects from intentions on exercise involved either planning or action control as mediating variables. In Model 3, all three constructs (action planning, coping planning and action control) were sequential mediators between intentions and later physical exercise levels. Action and coping planning were not directly but indirectly related to exercise via action control.

CONCLUSIONS

Findings support the sequential mediation for planning and action control as antecedents of physical exercise. Action control is needed for exercise, because planning in itself is not always sufficient. Maintaining exercise levels may be attributed to effective self-regulatory strategies such as action control in combination with planning.

Models accounting for intention-behavior discordance in the physical activity domain: a user's guide, content overview, and review of current evidence

There is a growing concern among researchers with the limited effectiveness and yet subsequent stagnation of theories applied to physical activity (PA). One of the most highlighted areas of concern is the established gap between intention and PA, yet the considerable use of models that assume intention is the proximal antecedent of PA. The objective of this review was to: 1) provide a guide and thematic analysis of the available models that include constructs that address intention-behavior discordance and 2) highlight the evidence for these structures in the PA domain. A literature search was conducted among 13 major databases to locate relevant models and PA studies published before August 2014. Sixteen models were identified and nine overall themes for post-intentional constructs were created. Of the 16 models, eight were applied to 36 PA studies. Early evidence supported maintenance self-efficacy, behavioral regulation strategies, affective judgments, perceived control/opportunity, habit, and extraversion as reliable predictors of post-intention PA. Several intention-behavior discordance models exist within the literature, but are not used frequently. Further efforts are needed to test these models, preferably with experimental designs.