Motivation and emotion/Book/2024/Theoretical domains framework

Theoretical domains framework:
What is the TDF and how can it be used to guide behaviour change?

Overview

Consider this scenario

A 46 year old man is committed to quitting smoking but struggles to reduce the number of cigarettes he has a day. He understands the importance of quitting smoking and how it will improve his health and wellbeing but does not know what is stopping him from quitting completely. How does the theoretical domains framework explain this behaviour? Often people are unaware of the barriers and facilitators that affect one's ability to change their behaviour.

Have you ever tried to change a behaviour and found it difficult to do so and don't know why (see Figure 1)? You might be experiencing unknown barriers or facilitators influencing your behaviour change journey. The theoretical domains framework (TDF) is a psychological framework that aims to identify barriers and facilitators of a specific behaviour one is trying to change and to help guide that behaviour change through providing theoretically evidence-based interventions (Atkins et al., 2017). There are a large number of behaviour change theories and models that can help one guide their behaviour change journey (Atkins et al., 2017). The TDF aims to use most of these theories to create an implementation framework that helps the effectiveness of implementation interventions when individuals use them (Atkins et al., 2017). The TDF can help in many aspects of behaviour change; independent specific behaviour change, health interventions and behaviour change in organisations (Atkins et al., 2017). This chapter explains what the TDF is, how it works and how it can be used to guide behaviour change.

Focus questions:

What is the TDF?
How can the TDF be used to guide behaviour change?
What are the limitations of the TDF?

What is the TDF?

The TDF is an in-depth psychological theory and implementation science based framework which identifies barriers and facilitators that influence specific unwanted or desired behaviours; guiding which behavioural intervention techniques should be implemented to reduce the influence that the barrier has on the behaviour and change the behaviour (Atkins et al., 2017). It was originally developed by a group consisting of health psychology theorists (who were interested in theories related to behaviour change and implementation), health service researchers, and health psychologists (Michie et al., 2005). This collaborative group aimed to provide a solution to the ineffective evidence-based implementations that were resulting in poor health outcomes through simplifying the large number of behaviour change theories by making the theories more accessible and useable for other fields of study (Michie et al., 2005). This first version of the TDF used 33 psychological behaviour change theories and 128 constructs (aspects within the theories) that were grouped into 12 domains (categories); (Michie et al., 2005).

7 years later Cane et al. (2012) evaluated the TDF, testing its validity and resulting in an updated TDF version 2 which has a stronger research foundation and revises the original 12 domains into 14 and 128 constructs to 84. This TDF establishes that the barriers and facilitators influencing specific behaviours can be identified easily through one of the 14 theoretical domains (through asking participants previously developed interview questions) and can then help guide behaviour change through helping develop or recommend implementation strategies (Atkins et al., 2017). Current research of which most use the second version of the TDF shows that the TDF can be used throughout implementation and behaviour change areas including but not limited to:

Determinants of clinical trial participant dropout (Newlands et al., 2021).
Identifying determinants of medication adherence (Minian et al., 2024).
Barriers to health practitioners’ participation in vaccination administration (el Hajj et al., 2022).
Determinants affecting health behaviour change, for example physical activity (Brown et al., 2024).

The theories behind the motivation and ability of individuals to change their behaviour either from stopping an unwanted behaviour or adapting a desired new behaviour has been in debate and researched for centuries (Atkins et al., 2017). A huge number of behaviour change theories have been developed from this research (Atkins et al., 2017). The TDF uses a combination of 33 psychological and organisational behaviour change theories to create a theoretical viewpoint which identifies a broad range of barriers and facilitators affecting behaviour change, which further informs implementation of behaviour change interventions and how to make them more effective (Cane et al., 2012).

Each domain is separated into constructs, through which behaviour change implementation programs can be applied to specific behaviours (Cane et al., 2012). When exploring behaviour and change in behaviour, these domains ensure that no theoretical construct of behaviour change has been missed (Atkins et al., 2017). The domains cover a wide coverage of potential implementation problems related to behaviour change implementation programs (Atkins et al., 2017). Notably some theories and constructs overlap (Atkins et al., 2017) see Table 1.

Table 1

The Refined Theoretical Domains Framework (2nd version)


TDF Domain (definition)	Construct
1. Knowledge (An awareness of the existence of something)	Knowledge (including knowledge of condition/scientific rationale) Procedural knowledge Knowledge of task environment
2. Skills (An ability or proficiency acquired through practice)	Skills Skills development Competence Ability Interpersonal skill Practice Skill assessment
3. Social/professional role and identity (A coherent set of behaviours and displayed personal qualities of an individual in a social or work setting)	Professional identity Professional role Social identity Identity Professional boundaries Professional confidence Group identity Leadership Organisational commitment
4. Beliefs about capabilities (Acceptance of the truth, reality or validity about an ability, talent or facility that a person can put to constructive use)	Self-confidence Perceived competence Self-efficacy Perceived behavioural control Beliefs Self-esteem Empowerment Professional confidence
5. Optimism (The confidence that things will happen for the best or that desired goals will be attained)	Optimism Pessimism Unrealistic optimism Identity
6. Beliefs about Consequences (Acceptance of the truth, reality, or validity about outcomes of a behaviour in a given situation)	Beliefs Outcome expectancies Characteristics of outcome expectancies Anticipated regret Consequents
7. Reinforcement (Increasing the probability of a response by arranging a dependent relationship, or contingency, between the response and a given stimulus)	Rewards (proximal / distal, valued / not valued, probable / improbable) Incentives Punishment Consequences Reinforcement Contingencies Sanctions
8. Intentions (A conscious decision to perform a behaviour or a resolve to act in a certain way)	Stability of intentions Stages of change model Transtheoretical model and stages of change
9. Goals (Mental representations of outcomes or end states that an individual wants to achieve)	Goals (distal / proximal) Goal priority Goal / target setting Goals (autonomous / controlled) Action planning Implementation intention
10. Memory, attention and decision processes (The ability to retain information, focus selectively on aspects of the environment and choose between two or more alternatives)	Memory Attention Attention control Decision making Cognitive overload / tiredness
11. Environment context and resources (Any circumstance of a person’s situation or environment that discourages or encourages the development of skills and abilities, independence, social competence and adaptive behaviour)	Environmental Stress Resources / material resources Organisational culture / climate Salient events / critical incidents Person x environment interaction Barriers and facilitators
12. Social influences (Those interpersonal processes that can cause individuals to change their thoughts, feelings, or behaviours)	Social pressure Social norms Group conformity Social comparisons Group norms Social support Power Intergroup conflict Alienation Group identity Modelling
13. Emotion (A complex reaction pattern, involving experiential, behavioural, and physiological elements, by which the individual attempts to deal with a personally significant matter or event)	Fear Anxiety Affect Stress Depression Positive / negative affect Burn-out
14. Behavioural regulation (Anything aimed at managing or changing objectively observed or measured actions)	Self-monitoring Breaking habit Action planning

Note. From "Validation of the theoretical domains framework for use in behaviour change and implementation research" by J. Cane, D. O'Connor and S. Michie, 2012, Implementation Science, 7(1), p. 13-14 (https://doi.org/10.1186/1748-5908-7-37). Copyright 2012 by BioMed Central Ltd.

These domains are used to develop interview questions for the constructs (Michie et al., 2005). These construct interviews provide clear direct insights into which domains are most relevant for implementation of the specific unwanted or desired behaviours and guide towards potential intervention strategies (Michie et al., 2005). It is important to note that not all research using the TDF will be related to every single domain and only some questions will need to be developed and used (Atkins et al., 2017). Michie et al. (2005) developed example questions associated with some constructs that apply to the TDF version 2.

Quiz

Case study

A new and more effective medication has been suggested to a doctor to prescribe for patients diagnosed with the flu. Although the doctor has since seen patients with the flu, the doctor has provided previous treatment options and has not prescribed the new medication. Upon interviewing the doctor two explanations arose as to why the new medication had not been prescribed.

The first was in relation to domain 6 (beliefs about consequences). It was identified that the doctor was unsure about prescribing the new medication due to their belief of the potential unknown side effects. The second possible explanation was identified in relation to domain 13 (emotion). Due to the product being new and the uncertainty of its effectiveness the doctor found it stressful prescribing the medication.

Suggestions for the doctor to help change their behaviour and prescribe the new medication would be to actively seek out the research surrounding the medication and also to ask other health practitioners in the area their viewpoints on the effectiveness and known side effects of the new medication.

How does the TDF guide behaviour change?

Due to its simplicity and usability, the TDF has been used across a broad range of fields including psychology, health, organisational theory, and implementation theory (Atkins et al., 2017). The TDF can guide behaviour change through identification of barriers and facilitators and suggesting evidence-based behaviour change interventions (Atkins et al., 2017). The TDF can also guide behaviour change through fixing implementation problems, and helping develop new effective behaviour implementation frameworks (Atkins et al., 2017).

*Figure 2.* Interview example identifying which domain the barriers and facilitators are apart of.

Identification of barriers and facilitators

As previously discussed one of the main strengths of the TDF is the broad psychological and organisation behaviour change theoretical coverage which allows for easy identification of barriers of desired behaviours and facilitators of unwanted behaviours (McGowan et al., 2020). Researchers identify these barriers and facilitators by conducting interviews using questions associated with the domains (see Figure 2); (Michie et al., 2005). By identifying these influences on behaviour, the TDF then allows for mapping to evidence-based interventions which guide one's behaviour change journey (Atkins et al., 2017). These implementations are more likely to be effective in guiding behaviour change as they use theories that focus on the specific behaviours being targeted and determinants influencing the behaviour (Atkins et al., 2017).

Research examples

A study by Newlands et al. (2021) used the TDF to identify the barriers and facilitators related to keeping participants in clinical trials (specifically follow up clinical appointments and final questionnaires). These barriers were categorised into the following domains; knowledge, beliefs about their capabilities and beliefs about consequences in relation to performing the behaviour or not. Now a guide for behavioural implementation in new research, it also helps steer which evidence-based science implementation will help increase clinical participant retention (Newlands et al., 2021).
A study by Debono et al. (2024) used the TDF to identify the barriers to the nurse use or non use of electronic medication management systems. The two main barrier domains were environmental context and resources and social/professional role and identity. The identification of these two domains enabled the researchers to suggest the following. The implementation of hand-held electronic medication systems with greater portability and easier cleaning addressed the environmental domain (Debono et al., 2024). The implementation of social process of encouragement (team and managerial support) was aimed at the domain of social/professional role and identity (Debono et al., 2024).
A study by el Hajj et al. (2022) used the TDF to identify the barriers related to community pharmacists' participation in vaccine administration. The five domains identified were knowledge, skills, belief about capabilities, environmental resources and behaviour regulation (el Hajj et al., 2022). The implementation of more thorough training, improving organisational structures, equipping pharmacies with more appropriate resources will address these four domains (el Hajj et al., 2022).

Case study

You have been trying to improve your physical activity by going to the gym. However, when you decide to go you sit in the carpark and cannot enter the gym. You are unaware of why this is the case and would like to change your behaviour and attend the gym.

You have heard about the TDF and have decided to try and use it to guide changing your behaviour. Although you do not have any questions ready you know that you can use Michie et al. (2005). You go down the list of domains and find that you relate to domain 4 (beliefs about capabilities). You ask yourself the questions from the list and realise that the barrier you face is that you do not feel comfortable or confident attending the gym.

After identifying those barriers you decide to look up potential solutions. You decide on getting a personal trainer. The next day you park outside the gym and instead of staying in your car you get out, go into the gym, meet the trainer and start exercising. You have been going to the gym consistently for three months now. You have used the TDF to identify your barriers and change your behaviour to attend the gym.

Develop and fix implementations

As the TDF identifies the determinants influencing a specific behaviour, researchers are able to understand in more depth the mechanisms related to behaviour change and how it is influenced (Atkins et al., 2017). This allows researchers to understand the gaps and problems within the evidence-based behaviour change interventions (French et al., 2012). Through identifying the problems related to current evidence-based practice behaviour change interventions, the TDF can help identify which related techniques will help an individual to change their behaviour (French et al., 2012). These techniques can then help researchers develop new implementation programs and improve current behaviour change implementation programs by adding new developed techniques for behaviour change (French et al., 2012).

Research examples

In a study by French et al. (2012) the TDF identified theoretical behaviour change components to help create a four step method framework designed to be adaptable to specific behaviours presented by healthcare clinicians. The TDF helped in developing this implementation program as it was the theory informed behaviour change framework that in step two identified the barriers and facilitators (French et al., 2012). In step three the TDF helped inform behaviour change techniques related to step two (French et al., 2012).
In a study by Haskell et al. (2021), the TDF was used as a guide to identify barriers associated with poor management of infant bronchitis and design an implementation program. The TDF helped develop the implementation through step two (identifying barriers and facilitators) and step three (selecting which behaviour change techniques to implement); (Haskell et al., 2021). A six step behaviour change framework was then developed to guide an increase in the effectiveness of improved management along with de-implementing past techniques that do not guide behaviour change well (Haskell et al., 2021).
In a study by Craig et al. (2017), the TDF was used as a guide to identify barriers related to healthcare worker behaviours in emergency department triage. The TDF helped develop the implementation through step two (identifying barriers and facilitators) and step three (selecting which behaviour change techniques to implement); (Craig et al., 2017). Once the TDF identified the barriers the researchers developed a successful implementation intervention to help guide the clinicians[grammar?] behaviours to improve triage, treatment and transfer of patients (Craig et al., 2017).

What are the limitations of the TDF?

*Figure 3.* Remember the TDF has limitations.

Whilst the TDF has been shown to be effective in guiding behaviour change it is important to highlight that the TDF has limitations (see Figure 3). The limitations include:

The TDF identifies the barriers and facilitators associated with one’s ability and motivation to change a behaviour however, the TDF does not establish the cause of why these barriers and facilitators (Atkins et al., 2017). If these causes are not addressed the TDF will be ineffective (Atkins et al., 2017).
Whilst the framework is effective independently, the research shows that TDF is even more effective for behaviour change when implemented with another behaviour change theory model such as the COM-B or behaviour change wheel (Atkins et al., 2017).
The interviewing process for the TDF can be time consuming for candidates who may experience participant fatigue when answering the questions (Atkins et al., 2017). This could mean that the information gathered is not completely accurate potentially reducing the effectiveness of the TDF (Atkins et al., 2017).
There have been issues with researchers coding the interview questions into the allocated 14 domains as domains often overlap (Little et al., 2015). This can cause problems when identifying the barriers and facilitators associated with the behaviour change (Little et al., 2015).

Conclusion

The TDF is an in-depth psychological behaviour change theory and implementation science-based framework which identifies barriers and facilitators that influence specific unwanted or desired behaviours; guiding which behavioural intervention techniques should be implemented to overcome the barrier or facilitator and change the behaviour (Atkins et al., 2017). The TDF can guide behaviour change by identifying barriers and facilitators of a specific behaviour that one is trying to change and provide evidenced-based interventions specific to the behaviour (Atkins et al., 2017). The TDF can also guide behaviour change by finding problems in behaviour change implementations and providing solutions to help develop new implementations strategies (Atkins et al., 2017). There are some limitations of the TDF including not being able to determine the cause of barriers and facilitators, being time consuming, coding difficulties, overlapping of theoretical constructs and domains (Little et al., 2015). The research suggests that the TDF is more effective in collaboration with other behaviour change models (Atkins et al., 2017). People throughout their lifetime will most likely want to change a behaviour at some point. Using the TDF can be useful in identifying potential personal barriers and facilitators for a specific behaviour and then choosing suitable behaviour change interventions before commencing one's behaviour change journey (Atkins et al., 2017).

Many people encounter reasons as to why they cannot change a behaviour. If you are having trouble making a behaviour change, consider using the TDF to help you.

References

Atkins, L., Francis, J., Islam, R., O’Connor, D., Patey, A., Ivers, N., Foy, R., Duncan, E. M., Colquhoun, H., Grimshaw, J. M., Lawton, R., & Michie, S. (2017). A guide to using the theoretical domains framework of behaviour change to investigate implementation problems. Implementation Science, 12(1), Article 77. https://doi.org/10.1186/s13012-017-0605-9

Brown, C., Richardson, K., Halil-Pizzirani, B., Atkins, L., Yücel, M., & Segrave, R. A. (2024). Key influences on university students’ physical activity: A systematic review using the theoretical domains framework and the COM-B model of human behaviour. BMC Public Health, 24(1), 418–423. https://doi.org/10.1186/s12889-023-17621-4

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(1), Article 37. https://doi.org/10.1186/1748-5908-7-37

Craig, L. E., Taylor, N., Grimley, R., Cadilhac, D. A., McInnes, E., Phillips, R., Dale, S., O’Connor, D., Levi, C., Fitzgerald, M., Considine, J., Grimshaw, J. M., Gerraty, R., Cheung, N. W., Ward, J., & Middleton, S. (2017). Development of a theory-informed implementation intervention to improve the triage, treatment and transfer of stroke patients in emergency departments using the theoretical domains framework (TDF): The T3 trial. Implementation Science, 12(1), Article 88. https://doi.org/10.1186/s13012-017-0616-6

Debono, D., Taylor, N., Lipworth, W., Greenfield, D., Travaglia, J., Black, D., & Braithwaite, J. (2024). Applying the theoretical domains framework to identify barriers and targeted interventions to enhance nurses’ use of electronic medication management systems in two Australian hospitals. Implementation Science, 12(1), Article 42. https://doi.org/10.1186/s13012-017-0572-1

el Hajj, M. S., Al‐Ziftawi, N., Stewart, D., & Al‐Khater, D. M. A. Y. (2022). Community pharmacists’ participation in adult vaccination: A cross‐sectional survey based on the theoretical domains framework. British Journal of Clinical Pharmacology, 89(2), 773–786. https://doi.org/10.1111/bcp.15529

French, S. D., Green, S. E., O’Connor, D. A., McKenzie, J. E., Francis, J. J., Michie, S., Buchbinder, R., Schattner, P., Spike, N., & Grimshaw, J. M. (2012). Developing theory-informed behaviour change interventions to implement evidence into practice: A systematic approach using the theoretical domains framework. Implementation Science, 7(1), Article 38. https://doi.org/10.1186/1748-5908-7-38

Haskell, L., Tavender, E. J., Wilson, C. L., O’Brien, S., Babl, F. E., Borland, M. L., Cotterell, E., Sheridan, N., Oakley, E., & Dalziel, S. R. (2021). Development of targeted, theory-informed interventions to improve bronchiolitis management. BMC Health Services Research, 21(1), 1-13. https://doi.org/10.1186/s12913-021-06724-6

Little, E. A., Presseau, J., & Eccles, M. P. (2015). Understanding effects in reviews of implementation interventions using the theoretical domains framework. Implementation Science, 10(1), Article 90. https://doi.org/10.1186/s13012-015-0280-7

McGowan, L. J., Powell, R., & French, D. P. (2020). How can use of the theoretical domains framework be optimized in qualitative research? A rapid systematic review. British Journal of Health Psychology, 25(3), 677–694. https://bpspsychub.onlinelibrary.wiley.com/doi/abs/10.1111/bjhp.12437

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 and Safety in Health Care, 14(1), 26–33. https://doi.org/10.1136/qshc.2004.011155

Minian, N., Wong, M., Hafuth, S., Rodak, T., Rahimi, A., Gjomema, D., Rose, J., Zawertailo, L., Ratto, M., & Selby, P. (2024). Identifying determinants of varenicline adherence using the theoretical domains framework: A rapid review. BMC Public Health, 24(1), Article 679. https://doi.org/10.1186/s12889-024-18139-z

Newlands, R., Duncan, E., Presseau, J., Treweek, S., Lawrie, L., Bower, P., Elliott, J., Francis, J., MacLennan, G., Ogden, M., Wells, M., Witham, M. D., Young, B., & Gillies, K. (2021). Why trials lose participants: A multitrial investigation of participants’ perspectives using the theoretical domains framework. Journal of Clinical Epidemiology, 137, 1–13. https://doi.org/10.1016/j.jclinepi.2021.03.007

External links

Approaches to behaviour change (NHS England workforce, training and Education x youtube)
How to change your behavior for the better (TED.com)
How to motivate yourself to change your behavior (TEDx Talks x Youtube)
Theoretical domains framework and behaviour change wheel (Vimeo x Mater research institute UQ)
Using the theoretical domains framework in implementation research (Australian Institute of Health Innovation x YouTube)