Background
Methods
Explanatory measures and theories
Constructs (number of questions) | Example Question(s) |
---|---|
Theory of Planned Behavior[15] | |
Behavioral intention (3) | I intend to refer patients with back pain for an X-ray as part of their management |
Attitude: Direct (3); Indirecta (8 behavioral beliefs (bb) multiplied by 8 outcome evaluations (oe). The score was the mean of the summed multiplicatives.) | Direct: In general: The possible harm to the patient of a lumbar spine X-ray is outweighed by its benefits; Indirect: In general, referring patients with back pain for an X-ray would reassure them (bb) x reassuring patients with back pain is (oe: un/important) |
Subjective Norm: Indirect (4 normative beliefs (nb) multiplied by 4 motivation to comply (mtc) questions. The score was the mean of the summed multiplicatives). | I feel under pressure from the NHS not to refer patients for an X-ray (nb) x How motivated are you to do what the NHS thinks you should (mtc: very much/not at all) |
Perceived Behavioral Control: Direct (4); Indirect/power (14)c
| Direct: Whether I refer patients for a lumbar X-ray is entirely up to me. Indirect: Without an X-ray, how confident are you in your ability Not at all Extremely to treat patients with back pain who: Expect me to refer them for an X-ray |
Social Cognitive Theory[16] | |
Risk Perception (3) | It is highly likely that patients with back pain will be worse off if I do not refer them for an X-ray. |
Outcome Expectancies Self (2 × 2), Behavior (8x8). The score was the mean of the summed multiplicatives. | Self: If I refer a patient with back pain for an X-ray, then I will think of myself as a competent GP x Thinking of myself as a competent GP is (Un/Important) Behavior: See Attitude (Theory of Planned Behavior) |
Self Efficacy: General: Generalized Self-Efficacy Scale[17] (10: 4 point scale, not at all true/exactly true); Specific (7) | General: I can always manage to solve difficult problems if I try hard enough Specific: How confident are you in your ability to treat back problems without using an X-ray report |
Implementation Intention[21] | |
Action planning (3) | Currently, my standard method of managing patients with back pain does not include referring them for an X-ray |
Anticipated consequences (3) | If I start routinely referring patients with back pain then, on balance, my life as a GP will be easier in the long run |
Evidence of habit (2) | When I see a patient with back pain, I automatically consider referring them for an X-ray |
Experienced (rewarding and punishing) consequences (4: more likely to refer (score = 1); less likely (score = -1); unchanged/not sure/never occurred (score = 0)). Scores were summed. | Think about the last time you referred a patient for a lumbar spine X-ray and felt pleased that you had done so. Do you think the result of this episode has made you: Think about the last time you decided not to refer a patient for a lumbar spine X-ray and felt sorry that you had not done so. Do you think the result of this episode has made you: |
Perceived identity (3) | Back pain as seen in general practice is generally of an intense nature |
Perceived cause (8) | Back pain is caused by stress or worry |
Perceived controllability (7) | What the patient does can determine whether back pain gets better or worse, What I do can determine whether the patient’s back pain gets better or worse |
Perceived duration (5) | Back pain as seen in general practice is very unpredictable |
Perceived consequences (3) | Back pain does not have much effect on a patient’s life |
Coherence (2) | I have a clear picture or understanding of back pain |
Emotional response (4) | Seeing patients with back pain does not worry me |
Current stage of change. A single statement is ticked to indicate the behavioral stage | Unmotivated (3): I have not yet thought about changing the number of lumbar X-rays I currently request. It has been a while since I have thought about changing the number of lumbar X-rays I request. Motivated (2): I have thought about it and decided that I will not change the number of lumbar X-rays I request. I have decided that I will request more lumbar X-rays. I have decided that I will request less lumbar X-rays. Action (1): I have already done something about increasing the number of lumbar X-rays I request I have already done something about decreasing the number of lumbar X-rays I request |
Other Measures
| |
Knowledge (5) (True/False/Not Sure) | The presence of spondolytic changes on a lumbar spine X-ray correlates well with back pain |
Demographic | Post code, gender, time qualified, number of other doctors in practice, trainer status, hours per week, list size |
Behaviors, simulated behavior, and behavioral intention (dependent variables)
Study Behaviors | Objective measures of behavior | Mean (SD) rates of behavior | Simulated behavior Mean (SD) scenario scores (out of 5) | Intention Mean (SD) (out of 7) |
---|---|---|---|---|
General Dental
| ||||
Taking Dental Radiographs: Taking small or medium intra-oral radiographs (not for orthodontic reasons) | Number of intra oral radiographs taken per course of treatment Data obtained from a national fee claims database used for paying dental practitioners | 20.3 (9.0) radiographs per 100 courses of treatment | Would take 2.4 (1.2) radiographs | 4.8 (1.3) |
Performing Dental Restorations: The use of restorations in managing caries in permanent teeth in children (patients under 17 years of age) | Number of restorations per 100 courses of treatment Data obtained from a national fee claims database used for paying dental practitioners. | 10.4 (4.3) restorations per 100 courses of treatment | Would restore in 2.9 (1.1) cases | 4.9 (1.1) |
Placing Fissure Sealants: Placing a fissure sealant in a 6 to 16 year old patient | Unable to reliably measure behavior given the target age group | Would place fissure sealants for 2.03 (1.54) cases | 4.9 (1.2) | |
General Medical
| ||||
Managing URTIs Without Prescribing Antibiotics: Managing patients presenting with an upper respiratory tract infection (include sore throats, nasal discharge and coughs) in primary care without prescribing an antibiotic | Mean number of prescriptions for an antibiotic issued per 100 patients registered with each primary care practice per year Data derived from a national database of issued prescriptions | 57 (31) prescriptions per 100 patients registered per year | Would prescribe for 1.6 (1.2) cases | 5.8 (0.8) |
Managing Low Back Pain Without Ordering Lumbar Spine X-rays: Managing patients presenting with uncomplicated low back pain in primary care without referring them for a lumbo-sacral spine x-ray | Mean number of lumbar spine x-rays taken per 1000 patients registered with each primary care practice per year Data derived from the reporting systems of the hospitals where the x-rays were performed | 5.0 (8.9) x-rays per 1000 patients registered per year | Would refer for lumbar spine x-ray in 1.5 (1.2) cases | 5.9 (1.0) |
Procedure
Statistical analysis
Ethics approval
Results
Response rates
Summary of scores
Theory | Predictive constructs | Taking dental radiographs | Performing dental restorations | Placing fissure sealants | Managing URTIs | Managing low back pain | Min | Med | Max | |||||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
N | Alpha | Mean | SD | N | Alpha | Mean | SD | N | Alpha | Mean | SD | N | Alpha | Mean | SD | N | Alpha | Mean | SD | of Mean | ||||
Attitude direct | 2 | 0.40 | 5.85 | 1.00 | 2 | 0.37 | 4.70 | 1.10 | 2 | 0.57 | 5.64 | 0.99 | 3 | 0.54 | 5.10 | 0.93 | 2 | 0.25 | 3.40 | 1.20 | 3.40 | 5.10 | 5.85 | |
Theory of Planned Behavior
| Attitude indirect | 12 | 0.75 | 4.30 | 0.76 | 6 | 0.65 | 3.31 | 0.81 | 7 | 0.76 | 4.28 | 0.95 | 7 | 0.56 | 4.97 | 0.73 | 4 | 0.75 | 5.34 | 0.99 | 3.31 | 4.30 | 5.34 |
Subjective Norm | 5 | 0.83 | 1.53 | 0.91 | 4 | 0.77 | 2.19 | 0.95 | 3 | 0.70 | 2.13 | 1.03 | 3 | 0.68 | 5.61 | 0.90 | 4 | 0.68 | 5.86 | 0.69 | 1.53 | 2.19 | 5.86 | |
Intention | 3 | 0.73 | 4.77 | 1.27 | 3 | 0.79 | 4.90 | 1.13 | 3 | 0.79 | 4.90 | 1.24 | 3 | 0.68 | 5.83 | 0.83 | 3 | 0.69 | 5.90 | 1.00 | 4.77 | 4.90 | 5.90 | |
PBC direct | 4 | 0.76 | 2.48 | 1.00 | 4 | 0.71 | 3.58 | 1.08 | 5 | 0.61 | 4.53 | 0.96 | 4 | 0.70 | 4.25 | 1.13 | 4 | 0.63 | 4.50 | 1.10 | 2.48 | 4.25 | 4.53 | |
PBC indirect/power | 12 | 0.84 | 4.09 | 0.87 | 10 | 0.73 | 3.68 | 0.81 | 10 | 0.80 | 3.98 | 0.97 | 7 | 0.86 | 4.51 | 0.94 | 14 | 0.91 | 4.90 | 1.00 | 3.68 | 4.09 | 4.90 | |
Social
| Risk perception | 2 | 0.51 | 4.60 | 1.30 | 3 | 0.51 | 4.30 | 1.00 | 6 | 0.60 | 4.84 | 0.79 | 3 | 0.61 | 5.07 | 0.93 | 2 | 0.46 | 5.80 | 1.00 | 4.30 | 4.84 | 5.80 |
Cognitive Theory
| Outcome expectancies (behavior) | 12 | 0.75 | 4.30 | 0.76 | 8 | 0.70 | 3.82 | 0.89 | 9 | 0.80 | 3.56 | 0.67 | 7 | 0.56 | 4.96 | 0.73 | 6 | 0.76 | 6.01 | 1.19 | 3.56 | 4.30 | 6.01 |
Outcome expectancies (self) | 2 | 0.75 | 3.74 | 1.64 | 2 | 0.80 | 2.58 | 1.07 | 2.58 | 3.16 | 3.74 | |||||||||||||
Self efficacy | 12 | 0.83 | 3.77 | 0.77 | 10 | 0.69 | 4.13 | 0.63 | 10 | 0.82 | 4.55 | 0.89 | 6 | 0.88 | 2.02 | 1.85 | 14 | 0.93 | 4.80 | 0.80 | 2.02 | 4.13 | 4.80 | |
Generalized self efficacy | 10 | 0.87 | 3.00 | 0.37 | 10 | 0.83 | 2.99 | 0.37 | 10 | 0.87 | 3.05 | 0.38 | 10 | 0.85 | 2.86 | 0.36 | 10 | 0.87 | 2.80 | 0.40 | 2.80 | 2.99 | 3.05 | |
Implementation Intention
| Action Planning | 1 | - | 5.40 | 1.60 | 1 | 5.10 | 1.50 | 1 | - | 5.15 | 1.59 | 1 | 5.10 | 1.70 | 1 | - | 5.60 | 1.60 | 5.10 | 5.15 | 5.60 | ||
Learning Theory
| Anticipated consequences | 2 | 0.51 | 4.65 | 1.30 | 3 | 0.51 | 4.30 | 1.00 | 3 | 0.42 | 4.84 | 0.89 | 3 | 0.61 | 5.07 | 0.93 | 2 | 0.46 | 5.80 | 1.00 | 4.30 | 4.84 | 5.80 |
Evidence of habitual behavior | 2 | 0.62 | 3.80 | 1.35 | 3 | 0.86 | 4.40 | 1.40 | 3 | 0.86 | 4.37 | 1.61 | 2 | 0.70 | 5.65 | 1.05 | 2 | 0.60 | 4.70 | 1.70 | 3.80 | 4.40 | 5.65 | |
Other
| Knowledge | 5 | 0.20 | 4.40 | 0.80 | 7 | 0.01 | 2.70 | 1.30 | 7 | 0.00 | 3.30 | 1.10 | 5 | 0.00 | 2.90 | 0.90 | 5 | 0.21 | 3.1 | 1.00 |
Descriptive summary of variance explained
Dependent variable | Percentage of variance in DV explained by theory and constructs predicting behavior | ||||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
TPB | SCT | II | LT | CSSRM | K | ||||||||||
Taking Dental Radiographs (DRa)
| Intention | 28*** | 39*** | 28*** | 43*** | 3 | 4** | ||||||||
Behavioral simulation | 16*** | 9*** | 10*** | 9*** | 3 | 0 | |||||||||
Behavior | 13*** | 7** | 11*** | 8*** | 0 | 0 | |||||||||
I, PBC(i), PBC(d) | SE, RP | AP | AC | ||||||||||||
Performing Dental Restorations (DRe)
| Intention | 27.9*** | 21.4*** | 24.5*** | 24.5*** | 18.8 | 0 | ||||||||
Behavioral simulation | 5.3** | 13.1*** | 3.7 | 5.9* | 0 | 0 | |||||||||
Behavior | 1.1 | 0 | 0 | 0 | 0 | 5** K | |||||||||
Placing Fissure Sealants (FS)
| Intention | 30*** | 25*** | 58*** | 1 | 0 | |||||||||
Behavioral simulation | 25*** | 28*** | 7** | 30*** | 2 | 0 | |||||||||
Intention | 30.2*** | 28.9*** | 42.6*** | 27.2*** | 2.3** | ||||||||||
Managing URTI (URTI)
| Behavioral simulation | 26.7*** | 25.9*** | 6.2** | 24*** | 16 | 4.5*** | ||||||||
Behavior | 3.3* | 4.9** | 2.4 | 6.3*** H | 2.8 | 0 | |||||||||
I, PBC(i), PBC(d) | RP, OE | ||||||||||||||
Intention | 25*** | 21.5*** | 26.3*** | 11.3*** | 2.3** | ||||||||||
Managing Back Pain (LBP)
| Behavioral simulation | 11.6*** | 12.1*** | 1.5* | 8.1*** | 3.6 | 0.5 | ||||||||
Behavior | 0.4** | 0.2 | 0 | 0.4 | 0 | 0 | |||||||||
Min | Med | Max | Min | Med | Max | Min | Med | Max | Min | Med | Max | ||||
Intention$ | 25 | 28 | 30.2 | 21.4 | 25 | 39 | 24.5 | 42.6 | 58 | ||||||
LBP | DRa | URTI | DRe | FS | DRa | DRe | URTI | FS | |||||||
Behavioral simulation | 5.3 | 16 | 26.7 | 9 | 13.1 | 28 | 1.5 | 6.2 | 10 | 5.9 | 9 | 30 | |||
DRE | DRa | URTI | DRa | DRe | FS | LBP | URTI | DRa | DRe | DRa | FS | ||||
Behavior$$ | 1.1 | 3.3 | 13 | 0 | 4.9 | 7 | 0 | 2.4 | 11 | 0 | 6.3 | 8 | |||
DRe | URTI | DRa | DRe | URTI | DRa | DRe | URTI | DRa | DRe | URTI | DRa |