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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 
Background
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).
Methods
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.
Results
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.
Conclusion
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.
doi:10.1186/1479-5868-9-96
PMCID: PMC3489870  PMID: 22866956
Exercise; Motivation; Social cognitive models; Correlates
2.  Cardiovascular risk profile: Cross-sectional analysis of motivational determinants, physical fitness and physical activity 
BMC Public Health  2010;10:592.
Background
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.
Methods
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.
Results
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.
Conclusions
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.
doi:10.1186/1471-2458-10-592
PMCID: PMC3091554  PMID: 20929529
3.  The Theory of Planned Behavior as Applied to Preoperative Smoking Abstinence 
PLoS ONE  2014;9(7):e103064.
Abstinence from smoking on the morning of surgery may improve outcomes. This study examined the explicatory power of the Theory of Planned Behavior (TPB) to predict smoking behavior on the morning of surgery, testing the hypothesis that the constructs of attitude, subjective norm, and perceived behavioral control (PBC) will predict intent to abstain from smoking the morning of surgery, and that intent will predict behavior. TPB constructs were assessed in 169 pre-surgical patients. Smoking behavior on the morning of surgery was assessed by self-report and CO monitoring. Correlations and structural equation modeling (SEM) were used to determine associations between measures and behavior. All TPB measures, including intent as predicted by the TPB, were correlated with both a lower rate of self-reported smoking on the morning of surgery and lower CO levels. The SEM showed a good fit to the data. In the SEM, attitude and PBC, but not subjective norm, were significantly associated with intent to abstain, explaining 46% of variance. The effect of PBC on CO levels was partially mediated by intent. The amount of variance in behavior explained by these TPB constructs was modest (10% for CO levels). Thus, attitude and perceived behavioral control explain a substantial portion of the intent to maintain preoperative abstinence on the morning of elective surgery, and intent and perceived behavioral control explain a more modest but significant amount of the variance in actual smoking behavior.
Trial Registration: Clinical Trials.gov registration: NCT01014455
doi:10.1371/journal.pone.0103064
PMCID: PMC4109996  PMID: 25057969
4.  Determinants of Fast Food Consumption among Iranian High School Students Based on Planned Behavior Theory 
Journal of Obesity  2013;2013:147589.
Objective. This study was conducted to identify some factors (beliefs and norms) which are related to fast food consumption among high school students in Isfahan, Iran. We used the framework of the theory planned behavior (TPB) to predict this behavior. Subjects & Methods. Cross-sectional data were available from high school students (n = 521) who were recruited by cluster randomized sampling. All of the students completed a questionnaire assessing variables of standard TPB model including attitude, subjective norms, perceived behavior control (PBC), and the additional variables past behavior, actual behavior control (ABC). Results. The TPB variables explained 25.7% of the variance in intentions with positive attitude as the strongest (β = 0.31, P < 0.001) and subjective norms as the weakest (β = 0.29, P < 0.001) determinant. Concurrently, intentions accounted for 6% of the variance for fast food consumption. Past behavior and ABC accounted for an additional amount of 20.4% of the variance in fast food consumption. Conclusion. Overall, the present study suggests that the TPB model is useful in predicting related beliefs and norms to the fast food consumption among adolescents. Subjective norms in TPB model and past behavior in TPB model with additional variables (past behavior and actual behavior control) were the most powerful predictors of fast food consumption. Therefore, TPB model may be a useful framework for planning intervention programs to reduce fast food consumption by students.
doi:10.1155/2013/147589
PMCID: PMC3723084  PMID: 23936635
5.  Correlates of exercise motivation and behavior in a population-based sample of endometrial cancer survivors: an application of the Theory of Planned Behavior 
Background
Despite evidence of the benefits of exercise in cancer survivors, exercise participation rates tend to decline after treatments. Few studies have examined the determinants of exercise in less common cancer sites. In this study, we examined medical, demographic, and social cognitive correlates of exercise in endometrial cancer survivors using the Theory of Planned Behavior (TPB).
Methods
A mailed survey was completed by 354 endometrial cancer survivors (1 to 10 years postdiagnosis) residing in Alberta, Canada. The study was cross-sectional. Exercise behavior was assessed using the Godin Leisure Time Exercise Questionnaire and the TPB constructs were assessed with standard self-report scales. Multiple regression analyses were used to determine the independent associations of the TPB constructs with intention and behavior.
Results
Chi-square analyses indicated that marital status (p = .003), income level (p = .013), and body mass index (BMI) (p = .020) were associated with exercise. The TPB explained 34.1% of the variance in exercise behavior with intention (β = .38, p < .001) and self-efficacy (β = .18, p = .029) being independent correlates. For intention, 38.3% of the variance was explained by the TPB with self-efficacy (β = .34, p < .001) and affective attitude (β = .30, p < .001) being the independent correlates. The TPB mediated the associations of marital status and BMI with exercise but not income level. Age and BMI moderated the associations of the TPB with intention and behavior.
Conclusion
The TPB may be a useful framework for understanding exercise in endometrial cancer survivors. Exercise behavior change interventions based on the TPB should be tested in this growing population.
doi:10.1186/1479-5868-4-21
PMCID: PMC1894812  PMID: 17537255
6.  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.
Background
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.
Methods
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.
Results
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.
Conclusions
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.
doi:10.1186/1471-2458-13-140
PMCID: PMC3599811  PMID: 23414398
HIV/AIDS; VCT; HCT; Health professionals; Intention; TPB; Jimma zone; Ethiopia
7.  Understanding Athletic Trainers' Beliefs Toward a Multifacted Sport-Related Concussion Approach: Application of the Theory of Planned Behavior 
Journal of Athletic Training  2013;48(5):636-644.
Context:
Practice guidelines recommend a multifaceted approach for managing concussions, but a relatively small percentage of athletic trainers (ATs) follow these recommendations. Understanding ATs' beliefs toward the recommended concussion practice guidelines is the first step in identifying interventions that could increase compliance. The theory of planned behavior (TPB) allows us to measure ATs' beliefs toward the recommended concussion practice guidelines.
Objective:
To examine the influence of ATs' beliefs toward the current recommended concussion guidelines on concussion-management practice through an application of the TPB.
Design:
Cross-sectional study.
Setting:
A Web link with a survey was e-mailed to 1000 randomly selected members of the National Athletic Trainers' Association (NATA).
Patients or Other Participants:
A total of 221 certified ATs working in secondary school/clinic, high school, and college/university settings.
Main Outcome Measure(s):
A 66-item survey reflecting the current recommended concussion guidelines of the NATA and International Conference on Concussion in Sport was created to measure beliefs using the TPB constructs attitude toward the behavior (BA), subjective norms (SN), perceived behavioral control (PBC), and behavioral intention (BI) of ATs. We used a linear multiple regression to determine if the TPB constructs BA, SN, and PBC predicted BI and if PBC and BI predicted behavior according to the TPB model.
Results:
We found that BA, SN, and PBC predicted BI (R = 0.683, R2 = 0.466, F3,202 = 58.78, P < .001). The BA (t202 = 5.53, P < .001) and PBC (t202 = 9.64, P < .001) contributed to the model, whereas SN (t202 = −0.84, P = .402) did not. The PBC and BI predicted behavior (R = 0.661, R2 = 0.437, F2,203 = 78.902, P < .001).
Conclusions:
In this sample, the TPB constructs predicted BI and behavior of ATs' compliance with recommended concussion-management guidelines. The BA and PBC were the most influential constructs, indicating that those with positive attitudes toward concussion-management recommendations are more likely to implement them, and ATs are less likely to implement them when they do not believe they have the power to do so. We theorize that interventions targeting ATs' attitudes and control perceptions will lead to improved compliance.
doi:10.4085/1062-6050-48.3.10
PMCID: PMC3784365  PMID: 23848518
concussion management; traumatic brain injuries; practice guidelines
8.  Predicting active school travel: The role of planned behavior and habit strength 
Background
Despite strong support for predictive validity of the theory of planned behavior (TPB) substantial variance in both intention and behavior is unaccounted for by the model’s predictors. The present study tested the extent to which habit strength augments the predictive validity of the TPB in relation to a currently under-researched behavior that has important health implications, namely children’s active school travel.
Method
Participants (N = 126 children aged 8–9 years; 59 % males) were sampled from five elementary schools in the west of Scotland and completed questionnaire measures of all TPB constructs in relation to walking to school and both walking and car/bus use habit. Over the subsequent week, commuting steps on school journeys were measured objectively using an accelerometer. Hierarchical multiple regressions were used to test the predictive utility of the TPB and habit strength in relation to both intention and subsequent behavior.
Results
The TPB accounted for 41 % and 10 % of the variance in intention and objectively measured behavior, respectively. Together, walking habit and car/bus habit significantly increased the proportion of explained variance in both intention and behavior by 6 %. Perceived behavioral control and both walking and car/bus habit independently predicted intention. Intention and car/bus habit independently predicted behavior.
Conclusions
The TPB significantly predicts children’s active school travel. However, habit strength augments the predictive validity of the model. The results indicate that school travel is controlled by both intentional and habitual processes. In practice, interventions could usefully decrease the habitual use of motorized transport for travel to school and increase children’s intention to walk (via increases in perceived behavioral control and walking habit, and decreases in car/bus habit). Further research is needed to identify effective strategies for changing these antecedents of children’s active school travel.
doi:10.1186/1479-5868-9-65
PMCID: PMC3419676  PMID: 22647194
Theory of planned behavior; Habit; Active school travel; Walking; Children
9.  Predicting intention to treat HIV-infected patients among Tanzanian and Sudanese medical and dental students using the theory of planned behaviour - a cross sectional study 
Background
The HIV epidemic poses significant challenges to the low income countries in sub Saharan Africa (SSA), affecting the attrition rate among health care workers, their level of motivation, and absenteeism from work. Little is known about how to deal with deterioration of human resources in the health care systems. This study aimed to predict the intention to provide surgical treatment to HIV infected patients among medical- and dental students in Tanzania and Sudan using an extended version of the Theory of Planned Behaviour (TPB).
Methods
Four hundred and seventy five medical- and dental students at the University of Dar es Salaam (mean age, 25 yr) and 642 dental students attending 6 public and private dental faculties in Khartoum (mean age 21.7 yr) completed self-administered TPB questionnaires in 2005 and 2007, respectively.
Results
Both Tanzanian and Sudanese students demonstrated strong intentions to provide care for people with HIV and AIDS. Stepwise linear regression revealed that the TPB accounted for 51% (43% in Tanzania and Sudan) of the variance in intention across study sites. After having controlled for country and past behaviour, the TPB in terms of attitudes, subjective norms and perceived behavioural control accounted for 34% and moral norms for an additional 2,3% of the explainable variance in intention. Across both study sites, attitudes were the strongest predictor of intention followed in descending order by subjective norms, moral norms and perceived behavioural control.
Conclusion
The TPB is applicable to students' care delivery intentions in the context of HIV and AIDS across the two SSA countries investigated. It is suggested that attitudes, subjective norms, moral norms and perceived behavioural control are key factors in students' willingness to treat AIDS and HIV infected patients and should be targets of interventions aimed at improving the quality of health care delivery in this context.
doi:10.1186/1472-6963-9-213
PMCID: PMC2784770  PMID: 19930555
10.  Development and validation of a generic questionnaire for the implementation of complex medical interventions 
GMS German Medical Science  2014;12:Doc08.
Introduction: The implementation of complex medical interventions in daily practice is often fraught with difficulties. According to the iterative phase model proposed by the British Medical Research Council (MRC), the development, implementation and evaluation of complex interventions should be theory-driven. A conceptual model that seems to be a promising framework is the Theory of planned behaviour (TPB). In our study we aimed to develop and validate a generic and multifaceted questionnaire based on the TPB to detect physicians’ willingness to implement complex medical interventions and the factors influencing this willingness.
Methods: The questionnaire was developed according to the literature and was informed by previous qualitative research of our department. It was validated on the example of an electronic library of decision aids, arriba-lib. The sample consisted of 181 General Practitioners (GPs) who received a training regarding arriba-lib and subsequently filled in the questionnaire, assessing the TPB variables attitude, subjective norm, perceived behaviour control and intention. Follow-up assessments were conducted after two (assessing retest reliability) and eight weeks (assessing target behaviour). We performed a confirmatory factor analysis investigating the factorial structure of our questionnaire according to the TPB. Beside the calculation of the questionnaire’s psychometric properties we conducted a structural equation model and an ordinal regression to predict actual behaviour regarding the installation and application of arriba-lib.
Results: The postulated three factorial model (attitude, subjective norm, perceived behaviour control) of our questionnaire based on the TPB was rejected. A two factorial model with a combined factor subjective norm/perceived behaviour control was accepted. The explained variance in the ordinal regression was low (Nagelkerke’s R2=.12). Neither attitude nor intention were able to predict the use or non-use of arriba-lib (attitude: p=.68, intention: p=.44). For the combined factor subjective norm/perceived behaviour control a significant, but small effect (p=.03) was shown.
Conclusions: The TPB is not an adequate theoretical framework to guide the development of a generic questionnaire in the context of the implementation of complex interventions. To enable the successful implementation of complex medical interventions evaluators have to go through the whole development and evaluation process according to the MRC-model, without short cuts. Further, it has to be discussed if a generic instrument can be valid and useful. Regarding the TPB a publication bias regarding the theory’s applicability might have to be considered.
doi:10.3205/000193
PMCID: PMC3972438  PMID: 24696674
implementation; questionnaires; primary health care; theory of planned behaviour
11.  Understanding physical activity intentions among French Canadians with type 2 diabetes: an extension of Ajzen's theory of planned behaviour 
Background
Regular physical activity is considered a cornerstone for managing type 2 diabetes. However, in Canada, most individuals with type 2 diabetes do not meet national physical activity recommendations. When designing a theory-based intervention, one should first determine the key determinants of physical activity for this population. Unfortunately, there is a lack of information on this aspect among adults with type 2 diabetes. The purpose of this cross-sectional study is to fill this gap using an extended version of Ajzen's Theory of Planned Behavior (TPB) as reference.
Methods
A total of 501 individuals with type 2 diabetes residing in the Province of Quebec (Canada) completed the study. Questionnaires were sent and returned by mail.
Results
Multiple hierarchical regression analyses indicated that TPB variables explained 60% of the variance in intention. The addition of other psychosocial variables in the model added 7% of the explained variance. The final model included perceived behavioral control (β = .38, p < .0001), moral norm (β = .29, p < .0001), and attitude (β = .14, p < .01).
Conclusion
The findings suggest that interventions aimed at individuals with type 2 diabetes should ensure that people have the necessary resources to overcome potential obstacles to behavioral performance. Interventions should also favor the development of feelings of personal responsibility to exercise and promote the advantages of exercising for individuals with type 2 diabetes.
doi:10.1186/1479-5868-6-35
PMCID: PMC2708123  PMID: 19531261
12.  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 
Background
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.
Methods
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.
Results
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).
Conclusion
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.
doi:10.1186/1748-5908-3-50
PMCID: PMC2603022  PMID: 19019242
13.  Preparatory behaviours and condom use during receptive and insertive anal sex among male-to-female transgenders (Waria) in Jakarta, Indonesia 
Introduction
The male-to-female transgender (waria) is part of a key population at higher risk for HIV. This study aims to test whether psychosocial determinants as defined by the theory of planned behaviour (TPB) can explain behaviours related to condom use among waria. Three preparatory behaviours (getting, carrying, and offering a condom) and two condom use behaviours (during receptive and insertive anal sex) were assessed.
Methods
The study involved 209 waria, recruited from five districts in Jakarta and interviewed by using structured questionnaires. Specific measures were developed to study attitudes, subjective norms and perceived behavioural control (PBC) in order to predict intentions and behaviours.
Results
The explained variance between intentions with regard to three preparatory behaviours and two condom uses ranged between 30 and 57%, and the variance between the actual preparatory behaviours of three preparatory and two condom uses ranged between 21 and 42%. In our study, as with several previous studies of the TPB on HIV protection behaviours, the TPB variables differed in their predictive power. With regard to intention, attitude and PBC were consistently significant predictors; attitude was the strongest predictor of intention for all three preparatory behaviours, and PBC was the strongest predictor of intention for condom use, both during receptive and insertive anal sex. TPB variables were also significantly related to the second parameter of future behaviour: actual (past) behaviour. TPB variables were differentially related to the five behaviours. Attitude was predictive in three behaviours, PBC in three behaviours and subjective norms in two behaviours.
Conclusions
Our results have implications for the development of interventions to target preparatory behaviours and condom use behaviours. Five behaviours and three psychological factors as defined in the TPB are to be targeted.
doi:10.7448/IAS.17.1.19343
PMCID: PMC4273177  PMID: 25529498
transgender; theory of planned behaviour; preparatory behaviours; condom use; HIV/AIDS; Indonesia
14.  Predicting intention to use voluntary HIV counseling and testing services among health professionals in Jimma, Ethiopia, using the theory of planned behavior 
Background
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.
Objective
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.
Methods
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.
Results
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).
Conclusion
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.
doi:10.2147/JMDH.S49339
PMCID: PMC3798200  PMID: 24143111
HIV/AIDS; VCT; health professionals; intention; TPB
15.  The environment and physical activity: The influence of psychosocial, perceived and built environmental factors 
This study sought to integrate perceived and built environmental and individual factors into the Theory of Planned Behavior (TPB) model to better understand adolescents' physical activity.
Participants (n = 110) aged 12 to 17 years (M = 14.6 ± 1.55) were recruited from two large metropolitan high schools in Auckland, New Zealand, were included in the analysis. Participants completed measures of the revised TPB and the perceived environment. Individual factors such as ethnicity and level of deprivation were also collected. Geographical Information Systems (GIS) software was used to measure the physical environment (walkability, access to physical activity facilities). Physical activity was assessed using the ActiGraph accelerometer and the Physical Activity Questionnaire for Adolescents (PAQ-A). Data from the various sources were combined to develop an integrated model integrated for statistical analysis using structural equation modeling.
The TPB model variables (intention and perceived behavioral control) explained 43% of the variance of PAQ-A. Unique and individual contributions were made by intention and PBC and home ownership of home equipment. The model explained 13% of time spent in moderate and vigorous physical activity (Actigraph). Unique and individual contribution was made by intention.
Social cognitive variables were better predictors of both subjective and objective physical activity compared to perceived environmental and built environment factors. Implications of these findings are discussed.
doi:10.1186/1479-5868-6-19
PMCID: PMC2683167  PMID: 19331652
16.  Applying psychological theories to evidence-based clinical practice: Identifying factors predictive of managing upper respiratory tract infections without antibiotics 
Background
Psychological models can be used to understand and predict behaviour in a wide range of settings. However, they have not been consistently applied to health professional behaviours, and the contribution of differing theories is not clear. The aim of this study was to explore the usefulness of a range of psychological theories to predict health professional behaviour relating to management of upper respiratory tract infections (URTIs) without antibiotics.
Methods
Psychological measures were collected by postal questionnaire survey from a random sample of general practitioners (GPs) in Scotland. The outcome measures were clinical behaviour (using antibiotic prescription rates as a proxy indicator), behavioural simulation (scenario-based decisions to managing URTI with or without antibiotics) and behavioural intention (general intention to managing URTI without antibiotics). Explanatory variables were the constructs within the following theories: Theory of Planned Behaviour (TPB), Social Cognitive Theory (SCT), Common Sense Self-Regulation Model (CS-SRM), Operant Learning Theory (OLT), Implementation Intention (II), Stage Model (SM), and knowledge (a non-theoretical construct). For each outcome measure, multiple regression analysis was used to examine the predictive value of each theoretical model individually. Following this 'theory level' analysis, a 'cross theory' analysis was conducted to investigate the combined predictive value of all significant individual constructs across theories.
Results
All theories were tested, but only significant results are presented. When predicting behaviour, at the theory level, OLT explained 6% of the variance and, in a cross theory analysis, OLT 'evidence of habitual behaviour' also explained 6%. When predicting behavioural simulation, at the theory level, the proportion of variance explained was: TPB, 31%; SCT, 26%; II, 6%; OLT, 24%. GPs who reported having already decided to change their management to try to avoid the use of antibiotics made significantly fewer scenario-based decisions to prescribe. In the cross theory analysis, perceived behavioural control (TPB), evidence of habitual behaviour (OLT), CS-SRM cause (chance/bad luck), and intention entered the equation, together explaining 36% of the variance. When predicting intention, at the theory level, the proportion of variance explained was: TPB, 30%; SCT, 29%; CS-SRM 27%; OLT, 43%. GPs who reported that they had already decided to change their management to try to avoid the use of antibiotics had a significantly higher intention to manage URTIs without prescribing antibiotics. In the cross theory analysis, OLT evidence of habitual behaviour, TPB attitudes, risk perception, CS-SRM control by doctor, TPB perceived behavioural control and CS-SRM control by treatment entered the equation, together explaining 49% of the variance in intention.
Conclusion
The study provides evidence that psychological models can be useful in understanding and predicting clinical behaviour. Taking a theory-based approach enables the creation of a replicable methodology for identifying factors that predict clinical behaviour. However, a number of conceptual and methodological challenges remain.
doi:10.1186/1748-5908-2-26
PMCID: PMC2042498  PMID: 17683558
17.  Aerobic physical activity and resistance training: an application of the theory of planned behavior among adults with type 2 diabetes in a random, national sample of Canadians 
Background
Aerobic physical activity (PA) and resistance training are paramount in the treatment and management of type 2 diabetes (T2D), but few studies have examined the determinants of both types of exercise in the same sample.
Objective
The primary purpose was to investigate the utility of the Theory of Planned Behavior (TPB) in explaining aerobic PA and resistance training in a population sample of T2D adults.
Methods
A total of 244 individuals were recruited through a random national sample which was created by generating a random list of household phone numbers. The list was proportionate to the actual number of household telephone numbers for each Canadian province (with the exception of Quebec). These individuals completed self-report TPB constructs of attitude, subjective norm, perceived behavioral control and intention, and a 3-month follow-up that assessed aerobic PA and resistance training.
Results
TPB explained 10% and 8% of the variance respectively for aerobic PA and resistance training; and accounted for 39% and 45% of the variance respectively for aerobic PA and resistance training intentions.
Conclusion
These results may guide the development of appropriate PA interventions for aerobic PA and resistance training based on the TPB.
doi:10.1186/1479-5868-5-61
PMCID: PMC2633303  PMID: 19055725
18.  Applying the theory of planned behaviour to explain HIV testing in antenatal settings in Addis Ababa - a cohort study 
Background
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.
Methods
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.
Results
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.
Conclusion
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.
doi:10.1186/1472-6963-11-196
PMCID: PMC3169463  PMID: 21851613
19.  Applying theory of planned behavior to predict exercise maintenance in sarcopenic elderly 
This study aimed to determine the factors associated with exercise behavior based on the theory of planned behavior (TPB) among the sarcopenic elderly people in Cheras, Kuala Lumpur. A total of 65 subjects with mean ages of 67.5±5.2 (men) and 66.1±5.1 (women) years participated in this study. Subjects were divided into two groups: 1) exercise group (n=34; 25 men, nine women); and 2) the control group (n=31; 22 men, nine women). Structural equation modeling, based on TPB components, was applied to determine specific factors that most contribute to and predict actual behavior toward exercise. Based on the TPB’s model, attitude (β=0.60) and perceived behavioral control (β=0.24) were the major predictors of intention to exercise among men at the baseline. Among women, the subjective norm (β=0.82) was the major predictor of intention to perform the exercise at the baseline. After 12 weeks, attitude (men’s, β=0.68; women’s, β=0.24) and subjective norm (men’s, β=0.12; women’s, β=0.87) were the predictors of the intention to perform the exercise. “Feels healthier with exercise” was the specific factor to improve the intention to perform and to maintain exercise behavior in men (β=0.36) and women (β=0.49). “Not motivated to perform exercise” was the main barrier among men’s intention to exercise. The intention to perform the exercise was able to predict actual behavior regarding exercise at the baseline and at 12 weeks of an intervention program. As a conclusion, TPB is a useful model to determine and to predict maintenance of exercise in the sarcopenic elderly.
doi:10.2147/CIA.S60462
PMCID: PMC4172048  PMID: 25258524
theory planned behavior; aging; elderly; sarcopenic; exercise
20.  Oh baby! Motivation for healthy eating during parenthood transitions: a longitudinal examination with a theory of planned behavior perspective 
Background
Transitioning to parenthood is a major life event that may impact parents’ personal lifestyles, yet there is an absence of theory-based research examining the impact of parenthood on motives for dietary behaviour. As a result, we are unaware of the social cognitive variables that predict eating behaviour among those transitioning to parenthood. The purpose of the study was to examine eating behaviour motives across 12 months within the framework of the theory of planned behavior (TPB) and compare these across groups of new parents, non-parents, and established parents.
Methods
Non-parents (n = 92), new parents (n = 135), and established parents (n = 71) completed TPB questionnaires assessing attitudes, subjective norms, perceived behavioral control (PBC), and intentions and three day food records at baseline, and 6- and 12-months post-delivery (for parents) and 6- and 12-months post-baseline (for non-parents).
Results
Repeated measures ANOVAs revealed that among men, new- and established-parents had greater intentions to eat healthy compared to non-parents, F(2) = 3.59, p = .03. Among women, established parents had greater intentions than new- and non-parents, F(2) = 5.33, p = .01. Among both men and women during the first 6-months post-delivery, new-parents experienced decreased PBC, whereas established parents experienced increased PBC. Overall, affective attitudes were the strongest predictor of intentions for men (β = 0.55, p < .001) and women (β = 0.38, p < .01). PBC predicted changes in fruit and vegetable consumption for men (β = 0.45, p = .02), and changes in fat consumption for men (β = −0.25, p = .03) and women (β = −.24, p < .05), regardless of parent status.
Conclusion
The transition to parenthood for new and established parents may impact motivation for healthy eating, especially PBC within the framework of TPB. However, regardless of parental status, affective attitudes and PBC are critical antecedents of intentions and eating behaviour. Interventions should target affective attitudes and PBC to motivate healthy eating and may need to be intensified during parenthood.
doi:10.1186/1479-5868-10-88
PMCID: PMC3706269  PMID: 23829582
Theory of planned behaviour; Nutrition; Dietary behaviour; Parenthood
21.  How to Reduce the Latent Social Risk of Disease: The Determinants of Vaccination against Rabies in Taiwan 
To control the latent social risk of disease, the government usually spreads accurate information and attempts to improve the public’s attitude toward adopting prevention. However, these methods with the Knowledge, Attitudes, and Practices (KAP) model do not always work. Therefore, we used the theory of planned behavior (TPB) to understand dog owners’ behavior and distinguished the knowledge effect as objective knowledge (OK) and subjective knowledge (SK). A total of 310 dog owners completed a questionnaire based on our model. We employed structural equation modeling to verify the structural relationships and found three main results. First, our model was fit, and each path was significant. People with better attitudes, stronger subjective norms, and more perceptive behavioral control have stronger behavioral intention. Second, perceived behavioral control, not attitude, was the best predictive index in this model. Finally, on perceived behavioral control, subjective knowledge showed more influence than objective knowledge. We successfully extended TPB to explain the behavioral intention of dog owners and presented more workable recommendations. To reduce the latent social risk of disease, the government should not only address dog owners’ attitudes, but also their subjective norms and perceptive behavioral control. Indeed, perceptive behavioral control and SK showed the most influence in this model. It is implied that the self-efficacy of dog owners is the most important factor in such a behavior. Therefore, the government should focus on enhancing dog owners’ self-efficacy first while devoted to prevention activities.
doi:10.3390/ijerph110605934
PMCID: PMC4078556  PMID: 24901413
social risk; rabies; vaccination; the theory of planned behavior
22.  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.
doi:10.1016/j.psychres.2012.09.016
PMCID: PMC3538109  PMID: 23031803
Functioning; Motivation; Reasoned Action; Attitudes; Norms; Self-Efficacy
23.  Evidence base for an intervention to maximise uptake of glaucoma testing: a theory-based cross-sectional survey 
BMJ Open  2012;2(2):e000710.
Objective
To identify factors associated with intention to attend a hypothetical eye health test and provide an evidence base for developing an intervention to maximise attendance, for use in studies evaluating glaucoma screening programmes.
Design
Theory-based cross-sectional survey, based on an extended Theory of Planned Behaviour (TPB) and the Common Sense Self-Regulation Model, conducted in June 2010.
Participants
General population including oversampling from low socioeconomic areas.
Setting
Aberdeenshire and the London Boroughs of Lewisham and Southwark, UK.
Results
From 867 questionnaires posted, 327 completed questionnaires were returned (38%). In hierarchical regression analysis, the three theoretical predictors in the TPB (Attitude, Subjective norm and Perceived Behavioural Control) accounted for two-thirds of the variance in intention scores (adjusted R2=0.65). All three predictors contributed significantly to prediction. Adding ‘Anticipated regret’ as a factor in the TPB model resulted in a significant increase in prediction (adjusted R2=0.74). In the Common Sense Self-Regulation Model, only illness representations about the personal consequences of glaucoma (How much do you think glaucoma would affect your life?) and illness concern (How concerned are you about getting glaucoma?) significantly predicted. The final model explained 75% of the variance in intention scores, with ethnicity significantly contributing to prediction.
Conclusions
In this population-based sample (including over-representation of lower socioeconomic groupings), the main predictors of intention to attend a hypothetical eye health test were Attitude, Perceived control over attendance, Anticipated regret if did not attend and black ethnicity. This evidence informs the design of a behavioural intervention with intervention components targeting low intentions and predicted to influence health-related behaviours.
Article summary
Article focus
The current UK practice of opportunistic case finding during routine sight tests misses a majority of those with glaucoma. Early detection and treatment of glaucoma reduces the risk of blindness.
The feasibility and cost-effectiveness of screening programmes is largely determined by uptake by the target population.
This study identified empirical evidence, based on models of behaviour change, to inform the design of an intervention to maximise uptake.
Key messages
Intention to attend an eye health check to detect glaucoma is associated with positive Attitude, Perceived control over screening attendance, Anticipated regret if test is not attended, perceived consequences of glaucoma and black ethnicity. These factors can be targeted in an intervention to maximise uptake.
Strengths and limitations of this study
This study is the largest of its kind and uses a robust methodology based on plausible models of change to identify potential barriers to attendance for eye care.
The response rate was 38%, which is higher than generally achieved in similar population-based surveys.
There was evidence to suggest that this sample was representative of the target population (general population with over-representation of black ethnicity or of low socioeconomic status).
doi:10.1136/bmjopen-2011-000710
PMCID: PMC3293143  PMID: 22382121
24.  Factors influencing the surgery intentions and choices of women with early breast cancer: the predictive utility of an extended theory of planned behaviour 
Background
Women diagnosed with early breast cancer (stage I or II) can be offered the choice between mastectomy or breast conservation surgery with radiotherapy due to equivalence in survival rates. A wide variation in the surgical management of breast cancer and a lack of theoretically guided research on this issue highlight the need for further research into the factors influencing women’s choices. An extended Theory of Planned Behaviour (TPB) could provide a basis to understand and predict women’s surgery choices. The aims of this study were to understand and predict the surgery intentions and choices of women newly diagnosed with early breast cancer, examining the predictive utility of an extended TPB.
Methods
Sixty-two women recruited from three UK breast clinics participated in the study; 48 women, newly diagnosed with early breast cancer, completed online questionnaires both before their surgery and after accessing an online decision support intervention (BresDex). Questionnaires assessed views about breast cancer and the available treatment options using items designed to measure constructs of an extended TPB (i.e., attitudes, subjective norms, perceived behavioural control, and anticipated regret), and women’s intentions to choose mastectomy or BCS. Objective data were collected on women’s choice of surgery via the clinical breast teams. Multiple and logistic regression analyses examined predictors of surgery intentions and subsequent choice of surgery.
Results
The extended TPB accounted for 69.9% of the variance in intentions (p <.001); attitudes and subjective norms were significant predictors. Including additional variables revealed anticipated regret to be a more important predictor than subjective norms. Surgery intentions significantly predicted surgery choices (p <.01).
Conclusions
These findings demonstrate the utility of an extended TPB in predicting and understanding women’s surgery intentions and choices for early breast cancer. Understanding these factors should help to identify key components of interventions to support women while considering their surgery options.
doi:10.1186/1472-6947-13-92
PMCID: PMC3849725  PMID: 23962230
Breast cancer; Mastectomy; Breast conserving surgery; Decision making; Theory of planned behaviour
25.  Applying Theory of Planned Behavior in Predicting of Patient Safety Behaviors of Nurses 
Materia Socio-Medica  2013;25(1):52-55.
Background:
Patient safety has become a major concern throughout the world. It is the absence of preventable harm to a patient during the process of health care, ensuring safer care is an enormous challenge, psychosocial variables influences behaviors of human. The theory of planned behavior (TPB) is a well-validated behavioral decision-making model that has been used to predict social and health behaviors. This study is aimed to investigate predictors of nurse’s patient safety intentions and behavior, using a TPB framework.
Methods:
Stratified sampling technique was used to choose 124 nurses who worked at the selected hospitals of Isfahan in 2011. Study tool was a questionnaire, designed by researchers team including 3 nurses a physician and a psychologist based on guideline of TPB model. Questionnaire Validity was confirmed by experts and its reliability was assessed by Cronbach’s alpha as 0.87. Binary logistic regression analysis was performed to evaluate how well each TPB variables predicted the variance in patient safety behavior. Analyzing was done by SPSS18.
Results:
Finding revealed that “normative beliefs” had the greatest influence on nurses intention to implement patient safety behaviors. Analyzing data by hospital types and workplace wards showed that both in public and private hospitals normative beliefs has affected safety behaviors of nurses more than other variables. Also in surgical wards, nurses behaviors have been affected by “control beliefs” and in medical wards by normative beliefs.
Conclusion:
Normative beliefs, and subjective norms were the most influential factor of safety behavior of nurses in this study. Considering the role of cultural context in these issues, it seemseducation of managers and top individuals about patient safety and its importance is a priority also control believes were another important predicting factor of behavior in surgical wards and intensive care units. Regarding the complexity of work in these spaces, applying medical guidelines and effective supervision must be seriously followed.
doi:10.5455/msm.2013.25.52-55
PMCID: PMC3655788  PMID: 23687461
nurses; patient safety; psychology; theory of planned behavior (TPB).

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