Theoretical Domains Framework:
is this a useful tool for interrogating
behaviour change in complex interventions?
Susan Jones
Dr. Sharon Hamilton
Prof. Janet Shucksmith
Dr. Vera Araujo-Soares
Aim of the presentation
Theoretical Domains Framework (TDF)
• What it is
• How it was developed
• How it has been used
What is the Theoretical Domains Framework?
A method to bring together the models and theories of
behavioural change
What is the Theoretical Domains Framework used for?
To identify ….
which model and theory to use when designing an
intervention
How to …
implement the intervention most effectively
Background to the TDF
• Developed by Susan Michie and team at UCL
• Originally had 12 domains
• Each domain derived from the constructs of
many behavioural change theories
• Designed to be used in changing professional
behaviour
Michie, S., Johnston, M., Abraham, C., Lawton, R., Parker, D., Walker, A. (2005) Making
psychological theory useful for implementing evidence based practice: a consensus
approach. Quality & Safety in Health Care, 14:26-33.
How was the TDF created?
• Experts – theorists, researchers/implementers
and health psychologists
• 33 theories and 128 constructs generated
• Grouped constructs into domains
• Interdisciplinary validation process by the
health psychologists
Further validation of the TDF
Used in a number of settings with a variety of
topics
Sorting exercise to validate the domains
explained in:
Cane J., O’Connor D., Michie S. (2012) Validation of the theoretical domains
framework for use in behaviour change and implementation research. Implementation
Science, 7, 37.
Number of domains increased to 14
TDF domains
TDF 2005
TDF 2012
Knowledge
Knowledge
Skills
Skills
Social influences
Social influences
Memory, Attention and Decision processes
Memory, Attention and Decision processes
Action plans
Behavioural regulation
Professional/Social Role & Identity
Professional/Social Role & Identity
Beliefs about Capabilities
Beliefs about Capabilities
Beliefs about Consequences
Beliefs about Consequences
Optimism
Motivation and goals
Intentions
Goals
Emotion
Emotion
Environmental Context and Resources
Environmental Context and Resources
Reinforcement
Nature of behaviour
Theoretical constructs
TDF 2012
Knowledge
Skills
Social influences
Memory, Attention and Decision processes
Behavioural regulation
Professional/Social Role & Identity
Beliefs about Capabilities
Beliefs about Consequences
Optimism
Intentions
Goals
Emotion
Environmental Context and Resources
Reinforcement
Self-confidence
Perceived competence
Self-efficacy
Perceived behavioural control
Beliefs
Self-esteem
Empowerment
Professional confidence
Using the TDF
• Public health guidance 26, How to stop smoking in
pregnancy and following childbirth.
National Institute for Health and Clinical Excellence
(2010)
• Team at Newcastle University wanted to look at:
• What helps and hinders midwives in engaging with
pregnant women about stopping smoking?
• The original 12 TDF domains were used by Jane
Beenstock and colleagues to develop a questionnaire
Findings from Beenstock et al’s questionnaire
Midwives were
• in favour of providing stop smoking advice
• had high levels of motivation
• saw it as an integral part of their role
BUT … Midwives were not sure about
• the consequences of their actions (relating to SS)
• the environmental context
• the availability of resources
babyClear© as an example
What is babyClear?
Enhanced stop smoking service to support pregnant women to quit
Project title:
Process evaluation of a complex intervention to promote increased
smoking cessation rates among pregnant women in maternity care
Evaluation has two parts: quantitative (Newcastle University);
qualitative (Teesside University).
TDF (and NPT) used to inform the qualitative evaluation of the
implementation of babyClear©.
Applying the TDF to babyClear©
• Two sets of participants: HCPs and pregnant
women who smoke
• Method: qualitative (semi-structured
interviews)
• HCPs’ interview schedules: combined NPT and
TDF
• Pregnant women’s interview schedules: TDFbased, elements of NPT
Data analysis
Data from staff
Data analysis method: Framework Analysis
Link into the key elements e.g.
• about (un)successful change management
• the thinking behind actions coded in NPT,
especially reflexive monitoring.
Example of a domain
TDF 2012
Knowledge
Skills
Social influences
Memory, Attention and Decision processes
Behavioural regulation
Professional/Social Role & Identity
Beliefs about Capabilities
Beliefs about Consequences
Optimism
Intentions
Goals
Emotion
Environmental Context and Resources
Reinforcement
Environmental stressors
resources / material resources
organisational culture / climate
salient events / critical incidents
person x environment interaction
barriers and facilitators
Coding to ‘resources’
Material resources:
• Capacity for increased activity
• Availability and maintenance of material resources
• Capability of resources to meet the requirements
• Funding/financing of resources; extra costs
Other related issues:
• Suitability of resources
• Use-ability of machinery
• Reliability of resources
• Prioritising of adequate resources
• Appropriate staff available and financed
Identifying mechanisms of change
• TDF – analysing influences on behaviour
• Behaviour Change Wheel – analysing the
nature of behaviour
Michie S, van Stralen M, West R (2011) The Behaviour Change Wheel: a new
method for characterising and designing behaviour change interventions.
Implementation Science, 6:42.
Strengths and Limitations
Strengths
• Provides a clear structure
• Multidisciplinary application
Limitations
• Still on trial
• Confusion around if it is a theory of itself or
only a framework of theories
• Large number of constructs
Key points
• Developed over the last decade
• Re-validated in 2012
• Applied widely to investigating the application of
guidance in healthcare
• Uncovered some of the issues within the
research-implementation gap
• Still under development, especially as regards
how it can be used in designing interventions,
with various staff and patient groups, in
combination with theories
References
Beenstock J, Sniehotta FF, White M, Bell R, Milne EM, Araujo-Soares V (2012) What helps and hinders
midwives in engaging with pregnant women about stopping smoking? A cross-sectional survey of
perceived implementation difficulties among midwives in the North East of England. Implementation
Science, 7:36.
Cane J, O’Connor D, Michie S (2012) Validation of the theoretical domains framework for use in
behaviour change and implementation research. Implementation Science, 7, 37.
Michie S, van Stralen M, West R (2011) The Behaviour Change Wheel: a new method for characterising
and designing behaviour change interventions. Implementation Science, 6:42.
Michie, S, Pilling, S, Garety, P, Whitty, P, Eccles, M P, Johnston, M, Simmons, J (2007) Difficulties
implementing a mental health guideline: an exploratory investigation using psychological theory.
Implementation Science, 2:8.
Michie, S, Johnston, M, Abraham, C, Lawton, R, Parker, D, Walker, A (2005) Making psychological theory
useful for implementing evidence based practice: a consensus approach. Quality & Safety in Health
Care, 14:26-33.
National Institute for Health and Clinical Excellence (2010) Public health guidance 26, How to stop
smoking in pregnancy and following childbirth. NICE: London.
Contact details
Susan Jones
Teesside University
[email protected]
MOTIVATION THEORIES
• Theory of planned behaviour (+ theory of
reasoned action,
• protection motivation theory, health belief
model)
• Social cognitive theory
• Locus of control theories
• Social learning theory
• Social comparison theory
• Cognitive adaptation theory
• Social identity theory
• Elaboration likelihood model
• Goal theories
• Intrinsic motivation theories
• Self‐determination theory
• Attribution theory
• Decision making theories (e.g. social judgment
theory, ‘‘fast and frugal’’ model, systematic
versus heuristic decision making)
• Fear arousal theory
ACTION THEORIES
• Learning theory
• Operant theory
• Modelling
• Self‐regulation theory
• Implementation theory/automotive model
• Goal theory
• Volitional control theory
• Social cognitive theory
• Cognitive behaviour therapy
• Transtheoretical model
• Social identity theory
ORGANISATION THEORIES
• Effort‐reward imbalance
• Demand‐control model
• Diffusion theory
• Group theory (e.g. group minority theory)
• Decision making theory
• Goal theory
• Social influence
• Person situation contingency models
KT interventions using this approach
Michie et al. >150 citations (Web of Knowledge)
Australia
• Improving implementation of
guidelines for acute low back pain in
primary care. – McKenzie et al.
• Diagnosis and post‐diagnosis
management of people with dementia
– Green et al.
• Implementing preconception care
guidelines in the general practice
Setting. – Mazza et al.
Canada
• Chiropractors compliance with
diagnostic imaging guideline
recommendations for spine disorders
– Bussieres et al.
Finland
• Guidelines on tobacco and nicotine
dependency treatment. – Kinnunan et al.
Ireland
• Primary care practitioners' HPV related
Behaviours. – McSherry et al.
Netherlands
• Blood transfusion management in
elective hip and knee arthroplasties. – Voorn et al.
UK
• Physicians’ transfusion practice. – Eccles et al.
• Hospital staff hand hygiene. – Sheldon et al.
• A suite of dental guidelines across
Scotland. – Clarkson et al.
MRC guidance 2008
• Developing and evaluating complex
interventions: new guidance (2008)
Craig P, Dieppe P, Macintyre S, Michie S, Nazareth I, Petticrew M,
Medical Research Council Guidance: Developing and evaluating
complex interventions: the new Medical Research Council
guidance. BMJ 2008, 337:a1655.
Examples by Michie of how the TDF has been used
• NICE recommendation for families of people with
schizophrenia
Michie, S., Pilling, S., Garety, P., Whitty, P., Eccles, M. P., Johnston, M., Simmons, J.
(2007) Difficulties implementing a mental health guideline: an exploratory
investigation using psychological theory. Implementation Science, 2:8.
• Finnish guideline for dental staff to offer a brief
stop smoking intervention
Amemori, M., Korhonen, T., Kinnunen, T., Michie, S., Murtomaa, H. (2011) Enhancing
implementation of tobacco use prevention and cessation counselling guideline among
dental providers: a cluster randomised controlled trial. Implementation Science 2011,
6:13.
Another example …
• Primary care practitioners’ HPV-related
behaviours
McSherry et al. (2012) ‘It’s a can of worms’: understanding
primary care practitioners’ behaviours in relation to HPV using
the theoretical domains framework. Implementation Science,
7:73.
Data analysis
• Data from pregnant women
• Snug fit with the themes that are emerging
from the data
• Gap between NICE recommendations and the
mechanism by which they are expected to
work
• Will the TDF provide some answers?