BCTs
Twenty-one unique BCTs were operationalised across the identified strategies/resources used by the three PHUs. Table 2 below shows the operationalised BCTs for identified PHU strategies and resources (behaviour-specific and population-specific), and their frequencies.
Table 2. Behaviour Change Techniques (BCTs) and frequencies identified in Public Health Unit (PHU) strategies and resources in support of COVID-19 vaccination.
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BCTs
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PHU Strategies and resources
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Frequency across PHUs
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3.1. Social support (unspecified)
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Videos of community ambassadors, HCPs, and general public sharing personal experiences and reasons why they got vaccinated, clinics and information sharing at community hubs and events (e.g., faith centres, hair salons), encouraging discussions with peers and community members about getting vaccinated, engagement sessions with health experts of different cultural backgrounds, neighbourhood vaccine engagement and outreach teams
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40
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3.2. Social support (practical)
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Clinic transportation services and vouchers, low-barrier clinics with extended hours/childcare/accessibility supports (e.g., ramps, no insurance needed), clinics that can be requested and led by community members, neighbourhood vaccine engagement and outreach teams, town halls and webinars with HCPs, multilingual community ambassadors
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45
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3.3. Social support (emotional)
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Clinic companions for mitigating needle fear
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1
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4.1. Instruction on how to perform behaviour
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Appointment booking links, clinic locations and access information (e.g., walk-in, parking, transit routes), how/where to get vaccinated webpages (e.g., search tool to find nearby clinic), eligibility information
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62
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5.1. Information about health consequences
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Information about benefits of vaccination and risks of COVID-19 infection
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76
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5.2. Salience of consequences
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Videos of community members describing impact of COVID-19 infection on themselves/loved ones (as reasons for getting vaccinated)
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3
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5.3. Information about social and environment consequences
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"Protect others/loved ones” messaging, describing impact on community and disproportionate impact on Black communities
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8
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6.1. Demonstration of the behaviour
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"I received my first dose" graphic for sharing on social media; video testimonials of people at clinics during/after vaccination
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7
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6.2. Social comparison
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Announcing vaccination rates, HCPs sharing why they got vaccinated, videos of community members talking about why they got or changed their mind about getting the vaccine, "I received my first dose" graphic for sharing on social media
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16
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6.3. Information about others’ approval
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Videos, town halls, and engagement sessions with HCPs providing information and answering questions, community ambassadors, members, and HCPs sharing why they got vaccinated and encouraging others to get vaccinated, "I received my first dose" graphic for sharing on social media
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27
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7.1. Prompts/cues
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Social media reminder posts, banners at the top of webpages with reminders about vaccination, physical and digital ad campaigns, auto-calls and mass text campaigns, flyers, community ambassador door-knocking programs
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29
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8.6. Generalisation of target behaviour
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Combining with influenza vaccine reminders, messaging, and clinics
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1
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9.1. Credible source
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Videos, town halls, and engagement sessions with HCPs answering questions and discussing safety and benefits of vaccination, community leaders and HCPs talking about why they got vaccinated
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27
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10.1. Material incentive (behaviour)
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Incentive programs (financial voucher) in shelter settings and for precariously housed populations
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1
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10.2. Material reward (behaviour)
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Financial voucher provided to those who get the vaccine in shelter settings and for precariously housed populations
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3
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10.6. Nonspecific incentive
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"Getting back to the things we love/normal" messaging
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3
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11.2. Reduce negative emotions
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Conversations, panels, and information sessions with community ambassadors and HCPs to address concerns about vaccination
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12
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11.3. Conserve mental resources
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Multilingual promotional materials (e.g,. shared in person or via WhatsApp) and community ambassadors
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6
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12.1. Restructuring the physical environment
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Pop-up and community clinics (e.g., clinics at shopping centres, transit stations), mobile clinics (e.g., busses, vans), clinics with extended hours, childcare, walk-ins, or other access supports
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41
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12.2. Restructuring the social environment
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Community clinics, mobile clinics, pop-up clinics that can be requested and led by community members, social media ad campaigns and engagement sessions (e.g., WhatsApp), clinics and information sharing at community hubs and events (e.g., faith centres, hair salons)
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20
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12.5. Adding objects to environment
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Pop-up and community clinics (e.g., shopping centres, transit stations), mobile clinics (e.g., busses, vans)
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38
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Note. HCPs= health care professionals
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Overall, the most frequently operationalised BCTs across all PHU strategies/resources were: information about health consequences, instruction on how to perform behaviour, social support (unspecified), social support (practical), restructuring the physical environment, and adding objects to the environment.
Use of information about health consequences refers to both negative and positive consequences (i.e., effects or results) of engaging in a behaviour and is a highly relevant BCT for individuals who are at the decision-making stage about whether they should receive a dose of the COVID-19 vaccine or not. It was the most frequently identified BCT across PHU strategies/resources. All PHUs integrated information sharing throughout their online and in-person strategies/resources, through various communication channels including links and text on websites, posts and videos on social media, and information sessions and outreach both in-person (e.g., door knocking, mailing flyers) and on social media (e.g., WhatsApp).
Instruction on how to perform behaviour was operationalised by all PHUs through resources that provided instructions or information on how to receive a dose of a COVID-19 vaccine. This included links, tools, and information for determining dose eligibility, locating, booking, and accessing COVID-19 vaccines, such as instructions on which public transit routes to take and when to access specific clinics in a local area. Many of these strategies/resources were found online and several instances were second-order links to provincial webpages with appointment booking tools.
Two BCTs for types of social support, unspecified and practical, were also frequently used across PHU strategies. Social support (practical) describes any form of practical help (e.g., from friends, relative, colleagues, or staff) in performing a behaviour. This was operationalised by PHUs through strategies that addressed barriers to accessing vaccination or getting information about vaccination, such as free transportation to/from clinics, in-home vaccination programs, neighbourhood and community outreach/engagement with multilingual staff/volunteers, and access supports at clinics (e.g., extended hours, free childcare, walk-ins allowed). Social support (unspecified) more broadly encompasses any form of social support to support performance of a behaviour, such as counselling and encouragement. This was operationalised by PHUs largely through their respective community outreach/engagement campaigns, involving community members and healthcare professionals sharing their experiences with COVID-19 vaccination, answering questions, providing information, and encouraging others to get vaccinated. For all PHUs, community-based outreach was (and continues to be) conducted both online (e.g., videos on YouTube and PHU websites, WhatsApp), and in-person (e.g., events at community hubs such as churches and libraries, door knocking).
Another two frequently identified BCTs were related to changes in or additions to the physical environment implemented by PHUs to increase or facilitate access to COVID-19 vaccines. Restructuring the physical environment and adding objects to the environment describe exactly that and were both operationalised by all PHUs through pop-up vaccine clinics in local hubs, such as malls, schools, workplaces, transit stations, parking lots, or community centres. The former included accessibility supports at clinics such as those mentioned previously and was therefore operationalised slightly more frequently than the latter. A related but less frequently operationalised BCT is restructuring the social environment, used by PHUs in resources/strategies which involved offering information and engagement sessions with healthcare professionals at social and community hubs both in-person (e.g., community centres) and online (e.g., Facebook, WhatsApp).
Some PHU strategies/resources operationalised several BCTs. For example, all PHUs used a combination of YouTube video campaigns, town halls, and webinars with healthcare professionals of various cultural backgrounds discussing vaccines and address concerns about safety and development in different languages. The delivery of strategies/resources multilingually operationalises the BCT conserve mental resources by communicating in a language that may be more accessible and/or easily understood. The presence of an expert or authority figure expressing approval of a behaviour (in this case, urging individuals to get vaccinated against COVID-19) operationalises the BCT codes information about others’ approval and credible source. The social aspect of these engagement strategies/resources operationalise the BCT codes social support (unspecified) and social support (practical), and the informational aspect operationalises the BCT information about health consequences, as well as information about social and environment consequences when the impact of COVID-19 on specific communities is discussed. When these health professionals and ambassadors address concerns about vaccines, such as side-effects or development, they operationalise the BCT reduce negative emotions. Some of these campaigns also included community members and ambassadors sharing their experiences with and reasons for getting the COVID-19 vaccine, often including real stories of how COVID-19 infections impacted themselves and/or loved ones which operationalises the BCTs salience of consequences and social comparison. Sometimes, these videos were filmed while individuals received a dose of the COVID-19 vaccine on camera, which operationalises the BCT demonstration of behaviour. The BCT social comparison was also operationalised a few times through social media posts and webpages sharing vaccine coverage/uptake data (e.g., “50% of our city has received their first dose”), which draws attention to others’ vaccination behaviour to allow comparison with one’s own vaccination behaviour.
The BCT prompts/cues describes anything that reminds the individual about performing the intended behaviour and was operationalised somewhat frequently across many different types of strategies/resources. Examples include an eye-catching yellow banner at the top of all Toronto PHU webpages, reminding residents to get vaccinated against COVID-19 with links for more information, social media posts from all PHUs reminding the public about COVID-19 vaccines, digital and physical advertising campaigns (e.g., on social media, busses, flyers in the mail), and vaccine engagement/outreach through community partners (e.g., door-knocking, community events).
BCTs which were least frequently operationalised by PHUs were social support (emotional), salience of consequences, generalisation of target behaviour, and material incentive (behaviour), material reward (behaviour), and nonspecific incentive.
Social support (emotional) was operationalised once by a Toronto vaccine clinic that promoted the availability of nurses and support persons trained to mitigate needle fear. Generalisation of target behaviour was also operationalised once in Toronto by including the promotion of COVID-19 vaccines alongside the regular promotion of influenza vaccines. Two related BCTs, material incentive and material reward, were operationalised by financial incentive programs implemented in housing shelters and street outreach campaigns, where individuals were offered money or vouchers after receiving a dose of the COVID-19 vaccine. The incentive in this case is the money/vouchers that are offered to individuals if they compete the behaviour (receiving a dose of the COVID-19 vaccine), and the reward is the delivery of the money/voucher after completion of the behaviour. Lastly, a third BCT, nonspecific incentive, was operationalised through PHU strategies/resources that encouraged individuals to get vaccinated in order to “return to normal”, “get back to the things we love”, and other similar messaging that incentivizes COVID-19 vaccination without specifying a clear reward.
A few strategies/resources which were included in analysis did not operationalise any BCTs that directly supported vaccination behaviours, such as translation options on PHU webpages and funding and member information for vaccine engagement teams.
Behaviour-specific
A total of 15-20 BCTs were operationalised within 39-79 behaviour-specific strategies/resources per PHU (Table 3). All strategies/resources included in analysis were behaviour-specific.
Table 3. Behaviour Change Techniques (BCTs) and linked Theoretical Domains Framework (TDF) domains for Public Health Unit (PHU) strategies in support of COVID-19 vaccination.
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Behaviour-specific strategies/resources
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Total strategies and resources
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Total BCTs used
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BCT Taxonomy codes (see Table 2)
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Ottawa (3rd dose)
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39
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15
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3.1, 3.2, 4.1, 5.1, 5.2, 5.3, 6.1, 6.2, 6.3, 7.1, 9.1, 11.3, 12.1, 12.2, 12.5
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Peel (1st dose)
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49
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17
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3.1, 3.2, 4.1, 5.1, 5.3, 6.1, 6.2, 6.3, 7.1, 9.1, 10.2, 10.6, 11.2, 11.3, 12.1, 12.2, 12.5
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Toronto (1st dose)
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79
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20
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3.1, 3.2, 3.3, 4.1, 5.1, 5.2, 5.3, 6.1, 6.2, 6.3, 7.1, 8.6, 9.1, 10.1, 10.2, 10.6, 11.2, 12.1, 12.2, 12.5
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Population-specific strategies/resources
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|
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Ottawa (low SES neighbourhoods)
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13
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10
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3.1, 3.2, 4.1, 5.1, 6.2, 7.1, 11.3, 12.1, 12.2, 12.5
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Peel (Eastern European communities)
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21
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12
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3.1, 3.2, 4.1, 5.1, 5.3, 6.2, 7.1, 11.2, 11.3, 12.1, 12.2, 12.5
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Toronto (Black communities in low uptake neighbourhoods)
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31
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17
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3.1, 3.2, 4.1, 5.1, 5.2, 5.3, 6.1, 6.2, 6.3, 7.1, 9.1, 10.1, 10.2, 11.2, 12.1, 12.2, 12.5
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Note. SES= socioeconomic status.
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Across PHUs, strategies/resources usually focused on promoting COVID-19 vaccination in general rather than by specific dose (i.e., “get vaccinated against COVID-19” instead of “get your first/third dose of the COVID-19 vaccine”). We found a few social media posts from the Ottawa PHU promoting the availability of booster doses at specific clinics. The Ottawa PHU also had several in-person strategies/resources promoting booster doses specifically, such as mobile clinics offering booster doses at community locations (e.g., aging in place builds, malls, schools, long-term care homes) and community partnerships (e.g., with religious leaders, residents) for peer-to-peer information sharing about the third dose.
Population-specific
A total of 10-17 BCTs were operationalised within 13-31 population-specific strategies/resources per PHU. Overall, we found fewer strategies/resources from all PHUs that were tailored to the priority populations, and fewer BCTs. Compared to behaviour-specific BCTs, population-specific BCTs tended to be less frequently operationalised, but the BCTs and how they were operationalised tended to be similar.
In Ottawa, a few mentions of clinic locations/hours and vaccine availability within the prioritised population (neighbourhoods) were found in online strategies/resources, operationalising the BCT instruction on how to perform behaviour. We found more population-specific strategies/resources and BCTs which were delivered in-person than online, such as pop-up clinics and information sharing and outreach in the priority neighbourhoods. Of note, because the Ottawa PHU prioritised neighbourhood populations, we explored their tailoring at a geographic level only, whereas Peel and Toronto prioritised cultural/ethnic/age groups and/or neighbourhoods, thus potentially providing more opportunities for identifying tailored strategies/resources.
In Peel, a few population-specific strategies/resources were found on the PHU website. There was a sidebar option for translation, including into Russian, Polish, and Ukrainian (implicit tailoring), and a few documents in Russian and Polish languages with information about COVID-19 vaccines (e.g., questions and answers). No strategies/resources tailored to the Peel prioritised age group (30-49 years) were found. A few in-person strategies were tailored to Eastern European populations including outreach via community ambassadors to faith-based institutions (e.g., churches, cultural centres), businesses, and community events (e.g., cultural celebrations). However, the Peel PHU noted that these outreach attempts were sometimes turned down by Eastern European organisations and groups, who explained that they would prefer to remain neutral on the topic of COVID-19 vaccination.
In Toronto, the PHU’s tailored strategies/resources were primarily YouTube videos featuring healthcare professionals and scientific experts from Black communities (credible source) discussing information about COVID-19 vaccines (information about health consequences) and the impact of COVID-19 on Black communities (information about social and environment consequences), addressing concerns about vaccine development, side-effects, and adverse reactions (reduce negative emotions), and encouraging all individuals including members of Black communities to get vaccinated against COVID-19 (unspecified social support). These videos often featured speakers from diverse cultural backgrounds, in different languages (practical social support and conserve mental resources). The Toronto PHU developed focused, in-person initiatives to support vaccination among Black communities during COVID-19, such as the Black Scientists’ COVID-19 Task Force and the Black Vaccine Engagement Team which operationalise the same BCTs. Some strategies/resources tailored to the prioritised neighbourhoods were found, but we found fewer BCTs or strategies/resources tailored to members of Black communities who live in the prioritised neighbourhoods.
TDF Domains
Together, the PHUs addressed 11 of the 14 TDF domains through empirically linked BCTs operationalised within their strategies/resources (Figure 1).
Based on the BCTs used and how they there were operationalized, the TDF-based domains that were most frequently addressed overall included Environmental context and resources and Knowledge, followed by Beliefs about consequences. Social influences and Memory, attention, and decision processes were also somewhat frequently addressed. These domains were also addressed by more types of BCTs (i.e., 3 to 6 different linked BCTs) than the domains which were less frequently addressed (I.e., 2 or fewer different linked BCTs). For example, Environmental context and resources has 5 linked BCTs and Beliefs about consequences has 6, while the Beliefs about Capabilities and Skills domains both share the same 1 linked BCT (instruction on how to perform behaviour).
The Goals, Optimism, and Social/professional role and identity domains were not conclusively linked to any BCTs found to be used by PHUs; however, the Goals and Social/professional role and identity domains have been inconclusively linked to 4 identified BCTs (material reward, and social support (unspecified), social comparison, and credible source, respectively). The Optimism domain has not been conclusively linked to any BCTs (13). BCTs linked inconclusively only to domains and therefore not included in analysis were generalisation of behaviour and credible source.