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Table 1 Summary of the explanatory measures

From: Applying psychological theories to evidence-based clinical practice: identifying factors predictive of lumbar spine x-ray for low back pain in UK primary care practice

Theory of Planned Behaviour (Ajzen, 1991)
   Constructs (number of questions) Example Question(s)
Behavioural intention (3) I intend to refer patients with back pain for an X-ray as part of their management
Attitude: Direct (3); Indirecta (8 behavioural 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 Behavioural 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 to treat patients with back pain who expect me to refer them for an X-ray
Social Cognitive Theory (Bandura,1998)
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 (2x2), Behaviour (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) Behaviour: See Attitude (Theory of Planned Behaviour)
Self Efficacy: General: Generalized Self-Efficacy Scale (Schwarzer, 1992) (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 (Gollwitzer, 1993)
Action planning (3) Currently, my standard method of managing patients with back pain does not include referring them for an X-ray
Operant Learning Theory (Skinner, Blackman, 1974)
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:
Common Sense Self-regulation Model d (Leventhal et al., 1984)
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
Precaution Adoption Process (Stage model)(Weinstein, 1988; Weinstein, Rothman & Sutton, 1998)
Current stage of change. A single statement is ticked to indicate the behavioural 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
  1. a All indirect measures consist of specific belief questions identified in the preliminary study as salient to the management of low back pain.
  2. b These individuals and groups were identified in the preliminary study as influential in the management of low back pain
  3. c An indirect measure of perceived behavioural control usually would be the sum of a set of multiplicatives (control beliefs x power of each belief to inhibit/enhance behaviour). However, the preliminary study demonstrated that it proved problematic to ask clinicians meaningful questions which used the word 'control' as clinicians tended to describe themselves as having complete control over the final decision to perform the behaviour. Support for measuring perceived behavioural control using only questions as to the ease or difficulty of performing the outcome behaviour was derived from a metanalysis which suggested that perceived ease/difficulty questions were sensitive predictors of behavioural intention and behaviour (Trafimow et al., 2002).
  4. d Illness representation measures were derived from the Revised Illness Perception Questionnaire (Moss-Morris, R., Weinman, J., Petrie, K. J., Horne, R., Cameron, L.D., & Buick, D. 2002)