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Explaining clinical behaviors using multiple theoretical models

Martin P Eccles1, Jeremy M Grimshaw2, Graeme MacLennan3, Debbie Bonetti4, Liz Glidewell5, Nigel B Pitts4, Nick Steen1, Ruth Thomas3, Anne Walker3 and Marie Johnston6*

Author Affiliations

1 Institute of Health and Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX, United Kingdom

2 Clinical Epidemiology Programme, Ottawa Health Research Institute and Department of Medicine, University of Ottawa, 1053 Carling Avenue, Administration Building Room 2-017, Ottawa, ON, K1Y 4E9, Canada

3 Health Services Research Unit, University of Aberdeen, Foresterhill, Aberdeen, AB25 2ZD, United Kingdom

4 Dental Health Services & Research Unit, University of Dundee, MacKenzie Building, Kirsty Semple Way, Dundee, DD2 4BF, United Kingdom

5 Leeds Institute of Health Sciences, Charles Thackeray Building, University of Leeds, 101 Clarendon Road, Leeds, LS2 9LJ, United Kingdom

6 College of Life Sciences and Medicine, University of Aberdeen, Health Sciences Building (2nd floor), Foresterhill, Aberdeen, AB25 2ZD, United Kingdom

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Implementation Science 2012, 7:99  doi:10.1186/1748-5908-7-99

Published: 17 October 2012



In the field of implementation research, there is an increased interest in use of theory when designing implementation research studies involving behavior change. In 2003, we initiated a series of five studies to establish a scientific rationale for interventions to translate research findings into clinical practice by exploring the performance of a number of different, commonly used, overlapping behavioral theories and models. We reflect on the strengths and weaknesses of the methods, the performance of the theories, and consider where these methods sit alongside the range of methods for studying healthcare professional behavior change.


These were five studies of the theory-based cognitions and clinical behaviors (taking dental radiographs, performing dental restorations, placing fissure sealants, managing upper respiratory tract infections without prescribing antibiotics, managing low back pain without ordering lumbar spine x-rays) of random samples of primary care dentists and physicians. Measures were derived for the explanatory theoretical constructs in the Theory of Planned Behavior (TPB), Social Cognitive Theory (SCT), and Illness Representations specified by the Common Sense Self Regulation Model (CSSRM). We constructed self-report measures of two constructs from Learning Theory (LT), a measure of Implementation Intentions (II), and the Precaution Adoption Process. We collected data on theory-based cognitions (explanatory measures) and two interim outcome measures (stated behavioral intention and simulated behavior) by postal questionnaire survey during the 12-month period to which objective measures of behavior (collected from routine administrative sources) were related. Planned analyses explored the predictive value of theories in explaining variance in intention, behavioral simulation and behavior.


Response rates across the five surveys ranged from 21% to 48%; we achieved the target sample size for three of the five surveys. For the predictor variables, the mean construct scores were above the mid-point on the scale with median values across the five behaviors generally being above four out of seven and the range being from 1.53 to 6.01. Across all of the theories, the highest proportion of the variance explained was always for intention and the lowest was for behavior. The Knowledge-Attitudes-Behavior Model performed poorly across all behaviors and dependent variables; CSSRM also performed poorly. For TPB, SCT, II, and LT across the five behaviors, we predicted median R2 of 25% to 42.6% for intention, 6.2% to 16% for behavioral simulation, and 2.4% to 6.3% for behavior.


We operationalized multiple theories measuring across five behaviors. Continuing challenges that emerge from our work are: better specification of behaviors, better operationalization of theories; how best to appropriately extend the range of theories; further assessment of the value of theories in different settings and groups; exploring the implications of these methods for the management of chronic diseases; and moving to experimental designs to allow an understanding of behavior change.