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1.  Correlates of physical activity in a population-based sample of kidney cancer survivors: an application of the theory of planned behavior 
Over half of kidney cancer survivors (KCS) are completely inactive and only a quarter are meeting physical activity (PA) guidelines. This highlights the need to identify and understand the determinants of PA in this understudied population. The purpose of this study is to determine the social cognitive correlates of PA intention and behavior in KCS using the Theory of Planned Behavior (TPB).
All 1,985 KCS diagnosed between 1996 and 2010 in Alberta, Canada were mailed a self-report survey that consisted of the Godin Leisure Time Exercise Questionnaire and standard TPB items for intention, planning, perceived behavioral control (PBC), affective and instrumental attitudes, and descriptive and injunctive norms. Standard demographic and medical variables were also collected.
Completed surveys were received from 703 of 1,654 (43%) eligible KCS. The TPB was tested using structural equation modelling and demonstrated an adequate-to-good fit to the data [χ² = 256.88, p < .001; TLI = 0.97; CFI = 0.98; RMSEA = 0.06, 90% CI = 0.05-0.06].
There were significant pathways to PA from PBC (ß = 0.18, p = 0.02), planning (ß = 0.22, p < 0.01), and intention (ß = 0.31, p < 0.01); and to planning from intention (ß = 0.81, p < 0.01). In addition, there were significant model pathways to intention from instrumental attitude (ß = 0.28, p = 0.03), descriptive norm (ß = 0.09, p = 0.01), and PBC (ß = 0.52, p < 0.01). Overall, the TPB accounted for 69%, 63%, and 42% of the variance in intention, planning and PA, respectively.
The TPB appears to be a useful model for explaining PA in KCS. All TPB constructs except injunctive norm and affective attitude were useful for explaining intention with PBC emerging as the largest correlate. Developing PA interventions based on the TPB may be effective in promoting PA in KCS and may lead to important improvements in health.
PMCID: PMC3489870  PMID: 22866956
Exercise; Motivation; Social cognitive models; Correlates
2.  The Role of Issue Familiarity And Social Norms: Findings on New College Students’ Alcohol Use Intentions 
Scholars in a variety of disciplines are interested in understanding the conditions under which social norms affect human behavior. Following the distinction made between descriptive and injunctive norms by the focus theory of normative conduct, the theory of normative social behavior predicts that the influence of descriptive norms on behavior is moderated by injunctive norms, outcome expectations, and group identity. We extended the theory by testing the proposition that the influence of descriptive norms on behavior would be greater under conditions of greater issue familiarity, defined as the ease with which one can cognitively access the behavior or behavioral issue.
Design and Methods
The model was tested in the domain of alcohol consumption intentions by conducting a survey among incoming students (n=719) to a large university in the United States. Data indicated that students in the sample were well representative of the university population.
The influence of descriptive norms on behavioral intentions was moderated by issue familiarity, as predicted. Familiarity was a facilitator of behavior: the influence of descriptive norms on behavioral intentions was greater under conditions of high, rather than low, familiarity. The overall model explained 53% of the variance in alcohol consumption intentions.
Public health interventions promoting health behaviors need to take into account the extent to which the behaviors are familiar to the target audience. The influence of norms appears to be weaker when the behavior is unfamiliar or novel. Implications for theory and interventions for reducing alcohol consumption are discussed.
PMCID: PMC4140328  PMID: 25170478
descriptive norms; alcohol; theory of normative social behavior; familiarity
3.  Exploring motivations to seek and undergo prosthodontic care: an empirical approach using the Theory of Planned Behavior construct 
Motivations for seeking and undergoing prosthodontic care are poorly understood and are not often explored for clinical purposes when determining treatment need and understanding the factors related to the demand for health care and effective use. This article uses the Theory of Planned Behavior construct to identify factors related to the motivations of edentulous subjects to seek and undergo prosthodontic treatment. The conceptual framework of the Theory of Planned Behavior includes attitude toward behavior, an individual’s positive or negative evaluation of self-performance of the particular behavior; the subjective norm, an individual’s perception of social normative pressures or relevant others’ beliefs that he or she should or should not perform such behavior; and perceived behavioral control, or an individual’s perceived ease or difficulty in performing the particular behavior, determined by the total set of accessible control beliefs. These components mediate a subject’s intention and behavior toward an object and may also explain health-related behaviors, providing strong predictions across a range of health behaviors. This study suggests categories for each component of the Theory of Planned Behavior, based on clinical evidence and practical reasoning. Attitudes toward behavior include perceived consequences of no treatment, perceived potential benefits and risks of treatment, dental anxiety, previous experiences, and interpersonal abilities of the health care providers. The subjective norm includes the opinions of relevant others, advertisement, professionally defined normative need, perceived professional skills, and technical quality of care. Perceived behavioral control includes subject’s time, availability and opportunity, treatment costs, subject’s perceived need, and accessibility to dental care. This conceptual model represents a theoretical multidimensional model that may help clinicians better understand the patient’s treatment behaviors and provide additional information for clinical research on patient’s adherence to interventions in prosthodontics.
PMCID: PMC4168850  PMID: 25246777
edentulous patient; prosthodontics; health services needs and demand; behavior
4.  Development of a Health Information Technology Acceptance Model Using Consumers’ Health Behavior Intention 
For effective health promotion using health information technology (HIT), it is mandatory that health consumers have the behavioral intention to measure, store, and manage their own health data. Understanding health consumers’ intention and behavior is needed to develop and implement effective and efficient strategies.
To develop and verify the extended Technology Acceptance Model (TAM) in health care by describing health consumers’ behavioral intention of using HIT.
This study used a cross-sectional descriptive correlational design. We extended TAM by adding more antecedents and mediating variables to enhance the model’s explanatory power and to make it more applicable to health consumers’ behavioral intention. Additional antecedents and mediating variables were added to the hypothetical model, based on their theoretical relevance, from the Health Belief Model and theory of planned behavior, along with the TAM. We undertook structural equation analysis to examine the specific nature of the relationship involved in understanding consumers’ use of HIT. Study participants were 728 members recruited from three Internet health portals in Korea. Data were collected by a Web-based survey using a structured self-administered questionnaire.
The overall fitness indices for the model developed in this study indicated an acceptable fit of the model. All path coefficients were statistically significant. This study showed that perceived threat, perceived usefulness, and perceived ease of use significantly affected health consumers’ attitude and behavioral intention. Health consumers’ health status, health belief and concerns, subjective norm, HIT characteristics, and HIT self-efficacy had a strong indirect impact on attitude and behavioral intention through the mediators of perceived threat, perceived usefulness, and perceived ease of use.
An extended TAM in the HIT arena was found to be valid to describe health consumers’ behavioral intention. We categorized the concepts in the extended TAM into 3 domains: health zone, information zone, and technology zone.
PMCID: PMC3510715  PMID: 23026508
Technology Acceptance Model; health behavior; intention; consumer
5.  Looking inside the black box: results of a theory-based process evaluation exploring the results of a randomized controlled trial of printed educational messages to increase primary care physicians’ diabetic retinopathy referrals [Trial registration number ISRCTN72772651] 
Theory-based process evaluations conducted alongside randomized controlled trials provide the opportunity to investigate hypothesized mechanisms of action of interventions, helping to build a cumulative knowledge base and to inform the interpretation of individual trial outcomes. Our objective was to identify the underlying causal mechanisms in a cluster randomized trial of the effectiveness of printed educational materials (PEMs) to increase referral for diabetic retinopathy screening. We hypothesized that the PEMs would increase physicians’ intention to refer patients for retinal screening by strengthening their attitude and subjective norm, but not their perceived behavioral control.
Design: A theory based process evaluation alongside the Ontario Printed Educational Material (OPEM) cluster randomized trial. Postal surveys based on the Theory of Planned Behavior were sent to a random sample of trial participants two months before and six months after they received the intervention. Setting: Family physicians in Ontario, Canada. Participants: 1,512 family physicians (252 per intervention group) from the OPEM trial were invited to participate, and 31.3% (473/1512) responded at time one and time two. The final sample comprised 437 family physicians fully completing questionnaires at both time points. Main outcome measures: Primary: behavioral intention related to referring patient for retinopathy screening; secondary: attitude, subjective norm, perceived behavioral control.
At baseline, family physicians reported positive intention, attitude, subjective norm, and perceived behavioral control to advise patients about retinopathy screening suggesting limited opportunities for improvement in these constructs. There were no significant differences on intention, attitude, subjective norm, and perceived behavioral control following the intervention. Respondents also reported additional physician- and patient-related factors perceived to influence whether patients received retinopathy screening.
Lack of change in the primary and secondary theory-based outcomes provides an explanation for the lack of observed effect of the main OPEM trial. High baseline levels of intention to advise patients to attend retinopathy screening suggest that post-intentional and other factors may explain gaps in care. Process evaluations based on behavioral theory can provide replicable and generalizable insights to aid interpretation of randomized controlled trials of complex interventions to change health professional behavior.
Trial registration
Electronic supplementary material
The online version of this article (doi:10.1186/1748-5908-9-86) contains supplementary material, which is available to authorized users.
PMCID: PMC4261878  PMID: 25098442
Process evaluation; Theory of planned behavior; Printed educational material; Healthcare professional behavior; Behavior change
6.  Explaining the effects of an intervention designed to promote evidence-based diabetes care: a theory-based process evaluation of a pragmatic cluster randomised controlled trial 
The results of randomised controlled trials can be usefully illuminated by studies of the processes by which they achieve their effects. The Theory of Planned Behaviour (TPB) offers a framework for conducting such studies. This study used TPB to explore the observed effects in a pragmatic cluster randomised controlled trial of a structured recall and prompting intervention to increase evidence-based diabetes care that was conducted in three Primary Care Trusts in England.
All general practitioners and nurses in practices involved in the trial were sent a postal questionnaire at the end of the intervention period, based on the TPB (predictor variables: attitude; subjective norm; perceived behavioural control, or PBC). It focussed on three clinical behaviours recommended in diabetes care: measuring blood pressure; inspecting feet; and prescribing statins. Multivariate analyses of variance and multiple regression analyses were used to explore changes in cognitions and thereby better understand trial effects.
Fifty-nine general medical practitioners and 53 practice nurses (intervention: n = 55, 41.98% of trial participants; control: n = 57, 38.26% of trial participants) completed the questionnaire. There were no differences between groups in mean scores for attitudes, subjective norms, PBC or intentions. Control group clinicians had 'normatively-driven' intentions (i.e., related to subjective norm scores), whereas intervention group clinicians had 'attitudinally-driven' intentions (i.e., related to attitude scores) for foot inspection and statin prescription. After controlling for effects of the three predictor variables, this group difference was significant for foot inspection behaviour (trial group × attitude interaction, beta = 0.72, p < 0.05; trial group × subjective norm interaction, beta = -0.65, p < 0.05).
Attitudinally-driven intentions are proposed to be more consistently translated into action than normatively-driven intentions. This proposition was supported by the findings, thus offering an interpretation of the trial effects. This analytic approach demonstrates the potential of the TPB to explain trial effects in terms of different relationships between variables rather than differences in mean scores. This study illustrates the use of theory-based process evaluation to uncover processes underlying change in implementation trials.
PMCID: PMC2603022  PMID: 19019242
7.  Intention to voluntary HIV counseling and testing (VCT) among health professionals in Jimma zone, Ethiopia: the theory of planned behavior (TPB) perspective 
BMC Public Health  2013;13:140.
Voluntary HIV Counseling and Testing (VCT) forms one of the cornerstones of HIV prevention strategies. It is imperative to understand HIV testing correlates and their theoretical underpinnings in order to promote VCT uptake. The aim of this study was to predict the intention to VCT and associated factors among health professionals in Jimma zone, Ethiopia using the theory of planned behavior.
An institution based cross-sectional quantitative study among a sample of 336 health professionals in 12 selected districts of Jimma, Ethiopia was conducted in 2012. The constructs and principles of the theory of planned behavior (TPB) were measured. Data were collected using structured questionnaire on self administered basis. A multivariable linear regression model was used to predict the role of independent variables/TPB constructs on the intention to use VCT using SPSS version 16.0.
The components of TPB independently explained the variance in intention to VCT by 30.3%. Both components of TPB and socio-demographic characteristic in the final model explained 32.7% of variance in the intention to use VCT services. Significant proportions (33.0%) of the respondents have never been tested for HIV. The respective indirect components of the TPB predicted the direct components. The strongest predictors of intention to VCT were subjective norm (β=0.39, p<0.001) and attitude (β= 0.19, p<0.001) whereas, none of the socio-demographic variables were significantly predicted the intention to use VCT. Past VCT experience did not have significant statistical association with VCT use intention.
Behavioral intention to use VCT was a function of attitude and perceived social pressure. Demographic related social determinants were not barriers for VCT use intention. Most health workers test their blood by themselves. Strategies to empower health professionals on social pressure resistance and programs targeted at changing negative attitude on VCT use can enhance intention of health professionals to use VCT.
PMCID: PMC3599811  PMID: 23414398
HIV/AIDS; VCT; HCT; Health professionals; Intention; TPB; Jimma zone; Ethiopia
8.  Women’s Perceptions of Their Community’s Social Norms Towards Assisting Women Who Have Experienced Intimate Partner Violence 
The role of social norms has played an often unrecognized role in the perception of and action to assist low-income urban women who are in violent relationships. Two forms of social norms will be assessed, including descriptive norms—what people typically do to assist women in a violent relationship—and injunctive norms—defined as what people should do to assist women. This study will present our initial findings into the development of measures to assess women’s perception of their community’s social norms toward assisting women who have experienced intimate partner violence (IPV) and how these norms are related to women’s perception of the community, reasons for community assistance toward women experiencing IPV, and women’s own experience of IPV. Systematic measurement development processes were applied to reliably and validly develop the social norms measures. A three-phase approach was used to develop eight paired items measuring descriptive and injunctive norms. A total of 176 low-income urban women were interviewed and the scale responses were compared to length of time at the residence, perceptions of their neighborhood, perceived reasons for community involvement and non-involvement in assisting women experiencing IPV, and IPV experienced as an adult. The two developed social norms scales were found to have high internal consistency alpha coefficients of 0.84 for descriptive norms and 0.93 for injunctive norms. Paired t tests were statistically significant, denoting higher injunctive than descriptive social norms. Lowered descriptive norms were found among younger women, women who reported that they did not think their neighborhood was a good place to live, women who had ever experienced intimate partner violence as an adult, and perceived lower reasons for neighbor involvement and higher reasons for neighbor non-involvement toward assisting women experiencing IPV. Higher levels of injunctive social norms were statistically associated with living in a good place and increased perceived reasons for neighbor involvement toward assisting women experiencing IPV. Significant differences between descriptive and injunctive norms suggest that women, especially those who are currently experiencing IPV, would prefer greater support from community neighbors than they are currently providing. The descriptive and injunctive social norms scales demonstrated a high level of internal reliability and significantly associated with other influencing factors thought to be associated with social norms. Overall, the performance of the injunctive and descriptive norms scales support their use as a tool to investigate social norms toward neighbors taking action to assist women experiencing IPV.
PMCID: PMC3079036  PMID: 21336504
Social norms; Intimate partner violence; Urban; Women
9.  Predictors of Chemotherapy Patients' Intentions to Engage in Medical Error Prevention 
The Oncologist  2010;15(8):903-912.
Attitudes, norms, behavioral control, and chemotherapy patients' intentions to participate in medical error prevention were examined using the theory of planned behavior.
Patients can make contributions to the safety of chemotherapy administration but little is known about their motivations to participate in safety-enhancing strategies. The theory of planned behavior was applied to analyze attitudes, norms, behavioral control, and chemotherapy patients' intentions to participate in medical error prevention.
A quantitative, cross-sectional survey study among chemotherapy patients treated at the oncology/hematology department of a large regional hospital was conducted. Confirmatory factor analysis and structural equation modeling were used to investigate the relationship between patients' responses to measures of attitudes, norms, and behavioral control and their intentions.
Four hundred seventy-nine patients completed the survey (52% response rate). Attitudes, perceived behavioral control, and subjective norms explained 62% of the variance in intentions to engage in error monitoring and reporting. Perceived behavioral control (β = 0.476), norms relating to patients' relatives (β = 0.343), and instrumental attitudes (β = 0.281) were the strongest (direct) predictors of patients' intentions. Experiential attitudes had the smallest effect on intentions (β = 0.178). Subjective norms relating to expectations attributed to oncology staff had strong direct and indirect effects on patients' intentions (total effect, 0.382).
Patients acknowledge the benefit of error monitoring and reporting and anticipate positive outcomes of involvement, but their valuations of the process of engaging in error prevention are less positive. Behavioral control and perceptions of staff approval are central for patients. Involvement of cancer patients in safety requires oncologists to address their patients' normative and control beliefs through education and proactive approval of patient engagement.
PMCID: PMC3228023  PMID: 20682607
Chemotherapy; Patient safety; Medication errors; Theory of planned behavior; Patient-centered care
10.  Determinants of the intention of elementary school nurses to adopt a redefined role in health promotion at school 
The quest for greater efficiency in the provision of primary healthcare services and the implementation of a "health-promoting school" approach encourage the optimal redefinition of the role of school nurses. School nurses are viewed as professionals who might be significant actors in the promotion of youth health. The aim of this study was to identify the determinants of the intention of elementary school nurses to adopt a new health-promotion role as a strategic option for the health-promoting school.
This study was based on an extended version of the theory of planned behaviour (TPB). A total of 251 respondents (response rate of 70%) from 42 school health programs across the Province of Québec completed a mail survey regarding their intention to adopt the proposed health-promotion role. Multiple hierarchical linear regression analyses were performed to assess the relationship between key independent variables and intention. A discriminant analysis of the beliefs was performed to identify the main targets of action.
A total of 73% of respondents expressed a positive intention to accept to play the proposed role. The main predictors were perceived behavioural control (β = 0.36), moral norm (β = 0.27), attitude (β = 0.24), and subjective norm (β = 0.21) (ps < .0001), explaining 83% of the variance. The underlying beliefs distinguishing nurses who had a high intention from those who had a low intention referred to their feelings of being valued, their capacity to overcome the nursing shortage, the approval of the school nurses' community and parents of the students, their leadership skills, and their gaining of a better understanding of school needs.
Results suggest that leadership is a skill that should be addressed to increase the ability of school nurses to assume the proposed role. Findings also indicate that public health administrators need to ensure adequate nurse staffing in the schools in order to increase the proportion of nurses willing to play such a role and avoid burnout among these human resources.
PMCID: PMC3003233  PMID: 21110872
11.  The use of the Theory of Planned Behavior to Predict Engagement in Functional Behaviors in Schizophrenia 
Psychiatry research  2012;205(1-2):36-42.
In Schizophrenia, low motivation may play a role in the initiation and frequency of functional behaviors. Several reviews support the efficacy of the Theory of Planned Behavior (TPB) to predict engagement in various behaviors, but little research has utilized the TPB to explain functional behavior in schizophrenia. This study tested the TPB for predicting prospective engagement in functional behaviors in a sample of 64 individuals with schizophrenia. Participants completed questionnaires assessing their attitudes toward, social norms regarding, perceived behavioral control over, and intention to engage in various functional behaviors during the upcoming week. Follow-up questionnaires assessed engagement in functional behaviors. Zero-order correlations indicated that positive attitudes, social norms, and perceived behavioral control were positively correlated with intentions to engage in functional behaviors. In turn, intentions were positively correlated with engagement in functional behaviors. Using path analysis, social norms and control were significantly related to intentions, which in turn predicted greater engagement in functional behaviors. Results suggest that patients with schizophrenia make reasoned decisions for or against engaging in functional behaviors. Skills training interventions that also target components of the TPB may be effective for increasing motivation to engage in learned behaviors.
PMCID: PMC3538109  PMID: 23031803
Functioning; Motivation; Reasoned Action; Attitudes; Norms; Self-Efficacy
12.  Predicting intention to use voluntary HIV counseling and testing services among health professionals in Jimma, Ethiopia, using the theory of planned behavior 
To endorse involvement in voluntary HIV counseling and testing (VCT), it is essential to recognize factors that influence people in deciding whether to access VCT services and their underlying route factors. Theory of planned behavior (TPB) constitutes a proficient framework for predicting behaviors and intentions.
The aim of the study reported here was to assess the predicting ability of TPB in determining the intended use of VCT services among health professionals in Jimma, southwest Ethiopia.
This was an institution-based cross-sectional quantitative study of a sample of 336 health professionals in 12 selected districts of Jimma, southwest Ethiopia between February 5 to March 28, 2012. Data were collected using structured questionnaire self-administered by the study participants. A hierarchal multivariable linear regression model was used to predict the role of TPB constructs that can influence the intention to use VCT services.
The constructs of TPB explained the variability in intention to use VCT by 27% (R2 adjusted = 0.27). The standardized regression coefficients showed that the strongest predictor of intention to use VCT was subjective norms (β = 0.32, P < 0.0005) followed by attitude (β = 0.21, P < 0.002). Perceived behavioral control was not a significant predictor of intention to use VCT among the study group (P = 0.12).
The study revealed the possibility of describing the intention to use VCT among health professionals using TPB, with perceived social pressure being the leading predictor. In light of this, health intervention programs should be designed to develop health professionals’ ability to resist norms that oppose the use of VCT and to change community-held norms against VCT use, provided they help individuals develop a positive attitude toward the services.
PMCID: PMC3798200  PMID: 24143111
HIV/AIDS; VCT; health professionals; intention; TPB
13.  Health Belief Model and Reasoned Action Theory in Predicting Water Saving Behaviors in Yazd, Iran 
Health Promotion Perspectives  2012;2(2):136-144.
Background: People's behaviors and intentions about healthy behaviors depend on their beliefs, values, and knowledge about the issue. Various models of health education are used in deter¬mining predictors of different healthy behaviors but their efficacy in cultural behaviors, such as water saving behaviors, are not studied. The study was conducted to explain water saving beha¬viors in Yazd, Iran on the basis of Health Belief Model and Reasoned Action Theory.
Methods: The cross-sectional study used random cluster sampling to recruit 200 heads of households to collect the data. The survey questionnaire was tested for its content validity and reliability. Analysis of data included descriptive statistics, simple correlation, hierarchical multiple regression.
Results: Simple correlations between water saving behaviors and Reasoned Action Theory and Health Belief Model constructs were statistically significant. Health Belief Model and Reasoned Action Theory constructs explained 20.80% and 8.40% of the variances in water saving beha-viors, respectively. Perceived barriers were the strongest Predictor. Additionally, there was a sta¬tistically positive correlation between water saving behaviors and intention.
Conclusion: In designing interventions aimed at water waste prevention, barriers of water saving behaviors should be addressed first, followed by people's attitude towards water saving. Health Belief Model constructs, with the exception of perceived severity and benefits, is more powerful than is Reasoned Action Theory in predicting water saving behavior and may be used as a framework for educational interventions aimed at improving water saving behaviors.
PMCID: PMC3963631  PMID: 24688927
Predictor; water saving behaviors; Health Belief Model; Reasoned Action Theory
14.  Cardiovascular risk profile: Cross-sectional analysis of motivational determinants, physical fitness and physical activity 
BMC Public Health  2010;10:592.
Cardiovascular risk factors are associated with physical fitness and, to a lesser extent, physical activity. Lifestyle interventions directed at enhancing physical fitness in order to decrease the risk of cardiovascular diseases should be extended. To enable the development of effective lifestyle interventions for people with cardiovascular risk factors, we investigated motivational, social-cognitive determinants derived from the Theory of Planned Behavior (TPB) and other relevant social psychological theories, next to physical activity and physical fitness.
In the cross-sectional Utrecht Police Lifestyle Intervention Fitness and Training (UP-LIFT) study, 1298 employees (aged 18 to 62) were asked to complete online questionnaires regarding social-cognitive variables and physical activity. Cardiovascular risk factors and physical fitness (peak VO2) were measured.
For people with one or more cardiovascular risk factors (78.7% of the total population), social-cognitive variables accounted for 39% (p < .001) of the variance in the intention to engage in physical activity for 60 minutes every day. Important correlates of intention to engage in physical activity were attitude (beta = .225, p < .001), self-efficacy (beta = .271, p < .001), descriptive norm (beta = .172, p < .001) and barriers (beta = -.169, p < .01). Social-cognitive variables accounted for 52% (p < .001) of the variance in physical active behaviour (being physical active for 60 minutes every day). The intention to engage in physical activity (beta = .469, p < .001) and self-efficacy (beta = .243, p < .001) were, in turn, important correlates of physical active behavior.
In addition to the prediction of intention to engage in physical activity and physical active behavior, we explored the impact of the intensity of physical activity. The intentsity of physical activity was only significantly related to physical active behavior (beta = .253, p < .01, R2 = .06, p < .001). An important goal of our study was to investigate the relationship between physical fitness, the intensity of physical activity and social-cognitive variables. Physical fitness (R2 = .23, p < .001) was positively associated with physical active behavior (beta = .180, p < .01), self-efficacy (beta = .180, p < .01) and the intensity of physical activity (beta = .238, p < .01).
For people with one or more cardiovascular risk factors, 39.9% had positive intentions to engage in physical activity and were also physically active, and 10.5% had a low intentions but were physically active. 37.7% had low intentions and were physically inactive, and about 11.9% had high intentions but were physically inactive.
This study contributes to our ability to optimize cardiovascular risk profiles by demonstrating an important association between physical fitness and social-cognitive variables. Physical fitness can be predicted by physical active behavior as well as by self-efficacy and the intensity of physical activity, and the latter by physical active behavior.
Physical active behavior can be predicted by intention, self-efficacy, descriptive norms and barriers. Intention to engage in physical activity by attitude, self-efficacy, descriptive norms and barriers. An important input for lifestyle changes for people with one or more cardiovascular risk factors was that for ca. 40% of the population the intention to engage in physical activity was in line with their actual physical active behavior.
PMCID: PMC3091554  PMID: 20929529
15.  The Theory of Reasoned Action as Parallel Constraint Satisfaction: Towards a Dynamic Computational Model of Health Behavior 
PLoS ONE  2013;8(5):e62490.
The reasoned action approach, although ubiquitous in health behavior theory (e.g., Theory of Reasoned Action/Planned Behavior), does not adequately address two key dynamical aspects of health behavior: learning and the effect of immediate social context (i.e., social influence). To remedy this, we put forth a computational implementation of the Theory of Reasoned Action (TRA) using artificial-neural networks. Our model re-conceptualized behavioral intention as arising from a dynamic constraint satisfaction mechanism among a set of beliefs. In two simulations, we show that constraint satisfaction can simultaneously incorporate the effects of past experience (via learning) with the effects of immediate social context to yield behavioral intention, i.e., intention is dynamically constructed from both an individual’s pre-existing belief structure and the beliefs of others in the individual’s social context. In a third simulation, we illustrate the predictive ability of the model with respect to empirically derived behavioral intention. As the first known computational model of health behavior, it represents a significant advance in theory towards understanding the dynamics of health behavior. Furthermore, our approach may inform the development of population-level agent-based models of health behavior that aim to incorporate psychological theory into models of population dynamics.
PMCID: PMC3643950  PMID: 23671603
16.  Factors influencing voluntary premarital medical examination in Zhejiang province, China: a culturally-tailored health behavioral model analysis 
BMC Public Health  2014;14:659.
Premarital medical examination (PME) compliance rate has dropped drastically since it became voluntary in China in 2003. This study aimed to establish a prediction model to be a theoretic framework for analyzing factors affecting PME compliance in Zhejiang province, China.
A culturally-tailored health behavioral model combining the Health Behavioral Model (HBM) and the Theory of Reasoned Action (TRA) was established to analyze the data from a cross-sectional questionnaire survey (n = 2,572) using the intercept method at the county marriage registration office in 12 counties from Zhejiang in 2010. Participants were grouped by high (n = 1,795) and low (n = 777) social desirability responding tendency (SDRT) by Marlowe-Crowne Social Desirability Scale (MCSDS). A structural equation modeling (SEM) was conducted to evaluate behavioral determinants for their influences on PME compliance in both high and low SDRT groups.
69.8% of the participants had high SDRT and tended to overly report benefits and underreport barriers, which may affect prediction accuracy on PME participation. In the low SDRT group, the prediction model showed the most influencing factor on PME compliance was behavioral intention, with standardized structural coefficients (SSCs) being 0.75 (P < 0.01), and the intention was positively determined by individual’s attitude toward PME (SSCs = 0.48, P < 0.01) and subjective norms (SSCs = 0.22, P < 0.01) and negatively determined by perceived threat (SSCs = -0.08, P = 0.028). Attitudes and subjective norms were more crucial predictors for PME compliance than perceived threat (SSCs = 0.36, 0.269, and -0.06, respectively). County environmental factors played a role in PME compliance while less influential than behavioral determinates (16% vs. 84% in across factor variance partition coefficient).
PME compliance might be influenced by demographic, behavioral, and social environmental factors. The verified prediction model was tested to be an effective theoretic framework for the prediction of factors affecting voluntary PME compliance. It also should be noted that internationally available behavioral theories and models need to be culturally tailored to adapt to particular populations. This study has provided new insights for establishing a theoretical model to understand health behaviors in China.
PMCID: PMC4094453  PMID: 24972866
Premarital medical examination; Health belief model; Theory of reasoned action; Multilevel analysis model; Structural equation modeling; Marlowe-Crowne social desirability scale
17.  Intentions of Chiropractic Interns Regarding use of Health Promotion in Practice: Applying Theory of Reasoned Action to Identify Attitudes, Beliefs, and Influencing Factors 
The theory of reasoned action is a health behavioral theory that has been used to predict personal health behaviors and intentions as well as those of providers delivering health care. The purpose of this study was to determine interns' future practices regarding the use of health promotion using this model to develop survey questions and to determine attitudes and perceived influences on their prospective behaviors in general, toward the use of health promotion once in practice.
Across the course of one year, all graduating interns at a chiropractic college were queried with a 20 question survey designed using the theory of reasoned action. Frequencies and inferential statistics were performed including prediction modeling using logistic regression.
A majority (>85%) of interns indicated they would use health promotion in practice. Differences were noted based on perceived skill levels, perception of educational emphasis, various normative beliefs, and gender.
Most interns will use some form of health promotion in practice. Normative influences including those seen as key influencers are as powerful a predictor as perceived education or skill levels on future practice of health promotion.
PMCID: PMC2670231  PMID: 19390679
Chiropractic; Health Promotion; Public Health Practice; Health Behavior
18.  Intention to quit smoking among lesbian, gay, bisexual, and transgender smokers 
Nicotine & Tobacco Research  2009;11(11):1312-1320.
Smoking is highly prevalent among lesbian, gay men, bisexual, and transgender (LGBT) persons and contributes to health disparities. Guided by the theory of planned behavior (TPB), we identified beliefs related to attitudes, perceived behavioral control, and subjective norms, as well as LGBT-specific variables, to explain variance in intention to quit smoking in the next 6 months in LGBT smokers.
Individual interviews (n = 19) identified beliefs about quitting smoking and LGBT-salient variables and aided in survey development. Surveys were sent to a random sample from an LGBT community center's mailing list and center attendees, with a 25.4% response rate. Bivariate and multivariate analyses were conducted with the final sample of 101 smokers.
No sociodemographic or LGBT-specific variables beyond the TPB constructs were related to intention to quit smoking. A multivariate TPB model explained 33.9% of the variance in quitting intention. More positive attitudes and specific beliefs that cessation would make smokers feel more like their ideal selves and improve health and longevity were related to greater intention to quit (p values < .05). Subjective norm and perceived behavioral control were marginally significant, with perceived approval of partners and others and beliefs that life goal achievement would make it easier to quit positively related to intention. Depression and stress levels were high.
This is among the first studies to examine theoretically grounded variables related to intention to quit smoking in LGBT smokers. We identified specific behavioral, normative, and control beliefs that can serve as intervention targets to reduce smoking in the LGBT community.
PMCID: PMC2762930  PMID: 19778994
19.  Predicting Pediatricians’ Communication With Parents About the Human Papillomavirus (HPV) Vaccine: An Application of the Theory of Reasoned Action 
Health communication  2011;26(4):303-312.
This study examines the ability of the theory of reasoned action (TRA) and the theory of planned behavior (TPB) to predict whether or not pediatricians encourage parents to get their adolescent daughters vaccinated against the human papillomavirus (HPV). Four-hundred and six pediatricians completed a mail survey measuring attitudes, subjective norms, perceived behavioral control, intentions, and behavior. Results indicate that pediatricians have positive attitudes, subjective norms, and perceived behavioral control toward encouraging parents to get their daughters vaccinated, that they intend to regularly encourage parents to get their daughters vaccinated against HPV in the next 30 days, and that they had regularly encouraged parents to get their daughters vaccinated against HPV in the past 30 days (behavior). Though the data were consistent with both the TRA and TPB models, results indicate that perceived behavioral control adds only slightly to the overall predictive power of the TRA, suggesting that attitudes and norms may be more important targets for interventions dealing with this topic and audience. No gender differences were observed for any of the individual variables or the overall fit of either model. These findings have important theoretical and practical implications for the development of health communication messages targeting health care providers in general, and for those designed to influence pediatricians’ communication with parents regarding the HPV vaccine in particular.
PMCID: PMC4154063  PMID: 21424964
20.  Psychological Factors Explaining the Referral Behavior of Iranian Family Physicians 
The recently developed policy of the family practice program in rural regions of Iran faced some challenges such as inefficient referral system. The health insurance organizations (purchaser) and health policy makers are concerned about the high rate of patient referrals from family physicians to specialists due to imposing unnecessary services and costs.
This study examined utility of the theory of planned behavior to explain intention of Iranian family physicians to reduce referral rate of patients with respiratory diseases to medical specialist.
Patients and Methods:
An exploratory cross-sectional study, employing a correlational design directed by the theory of planned behavior was conducted. A questionnaire was developed based on an eliciting study and review of literature. One hundred and seventy-four family physicians working at primary care centers in two provinces of Iran completed the questionnaire (response rate of 86%).
The finding revealed that intention of family physicians to reduce referral rate of patients to specialists was significantly related to two theory-based variables of subjective norms (r = 0.38, P < 0.001) and perceived behavioral control (r = 0.43, P < 0.001), and not to attitudes. A stepwise regression entering direct measures of the theory variables explained 35% of the variance on the intention, with perceived behavioral control being the strongest predictor. Adding background variables to the model achieved further 5% by variables of practice size and past referral rate behavior.
The results indicated that psychological variables of the theory of planned behavior could explain a noticeable proportion of variance in family physician's intention to decrease the rate of referring patients with respiratory diseases to medical specialists. The intention is primarily influenced by normative and control considerations. These findings contribute to a better understanding of referral decisions by family physicians and are of great value in developing interventions to reduce the variation in referral rate of patients to medical specialists at primary care health centers.
PMCID: PMC4028771  PMID: 24910798
Physicians, Primary Care; Referral and Consultation; Iran
21.  Understanding African American Women’s Decisions to Buy and Eat Dark Green Leafy Vegetables: An Application of the Reasoned Action Approach 
Examine intentions to buy and eat dark green leafy vegetables (DGLV).
Cross-sectional survey assessing demographics, behavior, intention, and Reasoned Action Approach constructs (attitude, perceived norm, self-efficacy).
Marion County, Indiana.
African American women responsible for buying and preparing household food.
Main Outcome Measure(s)
Reasoned Action Approach constructs explaining intentions to buy and eat DGLV.
Summary statistics, Pearson correlations, and multiple regression analyses.
Among participants (n = 410, mean age = 43 y), 76% and 80%, respectively, reported buying and eating DGLV in the past week. Mean consumption was 1.5 cups in the past 3 days. Intentions to buy (r = 0.20, P < .001) and eat (r = 0.23, P < .001) DGLV were positively associated with consumption. Reasoned Action Approach constructs explained 71.2% of the variance in intention to buy, and 60.9% of the variance in intention to eat DGLV. Attitude (β = .63) and self-efficacy (β = .24) related to buying and attitude (β = .60) and self-efficacy (β = .23) related to eating DGLV explained significant amounts of variance in intentions to buy and eat more DGLV. Perceived norm was unrelated to either intention to buy or eat DGLV.
Conclusions and Implications
Interventions designed for this population of women should aim to improve DGLV-related attitudes and self-efficacy.
PMCID: PMC4041387  PMID: 24021457
health behavior; diet; vegetable consumption; African American; women; Reasoned Action Approach
22.  An Integrative Behavioral Model of Information Security Policy Compliance 
The Scientific World Journal  2014;2014:463870.
The authors found the behavioral factors that influence the organization members' compliance with the information security policy in organizations on the basis of neutralization theory, Theory of planned behavior, and protection motivation theory. Depending on the theory of planned behavior, members' attitudes towards compliance, as well as normative belief and self-efficacy, were believed to determine the intention to comply with the information security policy. Neutralization theory, a prominent theory in criminology, could be expected to provide the explanation for information system security policy violations. Based on the protection motivation theory, it was inferred that the expected efficacy could have an impact on intentions of compliance. By the above logical reasoning, the integrative behavioral model and eight hypotheses could be derived. Data were collected by conducting a survey; 194 out of 207 questionnaires were available. The test of the causal model was conducted by PLS. The reliability, validity, and model fit were found to be statistically significant. The results of the hypotheses tests showed that seven of the eight hypotheses were acceptable. The theoretical implications of this study are as follows: (1) the study is expected to play a role of the baseline for future research about organization members' compliance with the information security policy, (2) the study attempted an interdisciplinary approach by combining psychology and information system security research, and (3) the study suggested concrete operational definitions of influencing factors for information security policy compliance through a comprehensive theoretical review. Also, the study has some practical implications. First, it can provide the guideline to support the successful execution of the strategic establishment for the implement of information system security policies in organizations. Second, it proves that the need of education and training programs suppressing members' neutralization intention to violate information security policy should be emphasized.
PMCID: PMC4058133  PMID: 24971373
23.  Intention to Smoke Tobacco Using Waterpipe among Students in a Southeastern U.S. College 
Guided by the Theory of Reasoned Action this study examined the association of behavioral beliefs, attitudes, normative beliefs and subjective norms with waterpipe tobacco smoking intention in college students.
Design and Sample
A cross-sectional design was used. A web-based survey was sent to a random sample of 1,000 undergraduate students from a public institution in the Southeast to recruit participants.
The Theory of Reasoned Action Waterpipe Questionnaire, a modified version of the Fishbein-Ajzen-Hanson Questionnaire, was used to capture modal constructs of the Theory of Reasoned Action related to waterpipe use. Cronbach’s alpha coefficients for the scales of the Theory of Reasoned Action Waterpipe Questionnaire ranged from .76 to .95.
Of the sample (n=223), 13.5% currently smoked a waterpipe and 61% had ever done so. Using multiple regression, attitudes, behavioral beliefs, and subjective norms were associated with intention to smoke a waterpipe in the next three months and collectively explained 35% of the variance in intention. The full model, which included all the constructs of the Theory of Reasoned Action, demographic variables, and tobacco use variables, explained 83% of the variance in intention to smoke a waterpipe in the next three months.
This study provides valuable information that may be used to target students at risk for waterpipe smoking and serves as a starting point in developing theoretically-driven interventions to prevent waterpipe smoking.
PMCID: PMC3319667  PMID: 22092459
health promotion; health risk behaviors; tobacco; waterpipe
24.  Psychosocial Factors of Dietitians' Intentions to Adopt Shared Decision Making Behaviours: A Cross-Sectional Survey 
PLoS ONE  2013;8(5):e64523.
While shared decision making (SDM) promotes health-related decisions that are informed, value-based and adhered to, few studies report on theory-based approaches to SDM adoption by healthcare professionals. We aimed to identify the factors influencing dietitians' intentions to adopt two SDM behaviours: 1) present dietary treatment options to patients and 2) help patients clarify their values and preferences.
We conducted a cross-sectional postal survey based on the Theory of Planned Behaviour among 428 randomly selected dietitians working in clinical practice across the Province of Quebec, Canada. We performed descriptive analyses and multiple regression analyses to determine the variables that explained the variance in intention to perform the behaviours.
A total of 203 dietitians completed the questionnaire. Their ages were from 23 to 66 and they had been practising dietetics for 15.4±11.1 years (mean ± SD). On a scale from 1 to 7 (from strongly disagree to strongly agree), dietitians' intentions to present dietary treatment options and to clarify their patients' values and preferences were 5.00±1.14 and 5.68±0.74, respectively. Perceived behavioural control (β = 0.56, ρ<0.0001), subjective norm (β = 0.16, ρ<0.05), and moral norm (β = 0.22, ρ<0.0001), were the factors significantly predicting the intention to present dietary treatment options, while perceived behavioural control (β = 0.60, ρ<0.0001), attitude (β = 0.20, ρ<0.05), and professional norm (β = 0.22, ρ<0.001), significantly predicted the intention to help patients' clarify their values and preferences.
Our results showed that dietitians intend to adopt the two SDM behaviours studied. Factors influencing intention were different for each behaviour, except for perceived behavioural control which was common to both behaviours. Thus, perceived behavioural control could be a key factor in interventions aiming to encourage implementation of SDM by dietitians.
PMCID: PMC3659101  PMID: 23700484
25.  Applying the theory of planned behaviour to explain HIV testing in antenatal settings in Addis Ababa - a cohort study 
To facilitate access to the prevention of mother-to-child HIV transmission (PMTCT) services, HIV counselling and testing are offered routinely in antenatal care settings. Focusing a cohort of pregnant women attending public and private antenatal care facilities, this study applied an extended version of the Theory of Planned Behaviour (TPB) to explain intended- and actual HIV testing.
A sequential exploratory mixed methods study was conducted in Addis Ababa in 2009. The study involved first time antenatal attendees from public- and private health care facilities. Three Focus Group Discussions were conducted to inform the TPB questionnaire. A total of 3033 women completed the baseline TPB interviews, including attitudes, subjective norms, perceived behavioural control and intention with respect to HIV testing, whereas 2928 completed actual HIV testing at follow up. Data were analysed using descriptive statistics, Chi-square tests, Fisher's Exact tests, Internal consistency reliability, Pearson's correlation, Linear regression, Logistic regression and using Epidemiological indices. P-values < 0.05 was considered significant and 95% Confidence Interval (CI) was used for the odds ratio.
The TPB explained 9.2% and 16.4% of the variance in intention among public- and private health facility attendees. Intention and perceived barriers explained 2.4% and external variables explained 7% of the total variance in HIV testing. Positive and negative predictive values of intention were 96% and 6% respectively. Across both groups, subjective norm explained a substantial amount of variance in intention, followed by attitudes. Women intended to test for HIV if they perceived social support and anticipated positive consequences following test performance. Type of counselling did not modify the link between intended and actual HIV testing.
The TPB explained substantial amount of variance in intention to test but was less sufficient in explaining actual HIV testing. This low explanatory power of TPB was mainly due to the large proportion of low intenders that ended up being tested contrary to their intention before entering the antenatal clinic. PMTCT programs should strengthen women's intention through social approval and information that testing will provide positive consequences for them. However, women's rights to opt-out should be emphasized in any attempt to improve the PMTCT programs.
PMCID: PMC3169463  PMID: 21851613

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