The Theoretical Domains Framework (TDF)

Assessing & Addressing Behavioural Factors in Implementation Science

By Masood Khan & Trish Roche

In a previous post, Leah summarized the Knowledge-to-Action Framework for the process of knowledge translation. In this post, we break down another framework, the Theoretical Domains Framework (TDF), which is used for implementation studies to assess and address factors that impact behaviour.

Addressing the challenge of changing the behaviours of healthcare practitioners in response to new evidence, the TDF is one of the most commonly used frameworks in implementation science [1].

Why Do We Need a Framework?

Determining the factors that influence a given behaviour is essential for any successful intervention that aims to change existing behaviour. Evidence demonstrates that behaviour change interventions based on theory are more effective than those without a theoretical base [2]. The effectiveness of a theory-based intervention may also increase with the number of theories incorporated [3].

But given the abundance of — and often overlapping concepts within — psychological theories of behaviour (a 2015 scoping review identified 82 behaviour change theories in the social sciences [4]), researchers face a dilemma when trying to select and apply the most appropriate theory(ies) in their work. Frameworks, on the other hand, incorporate a wide range of theories, and thus allow researchers to capture and evaluate more behaviour determinants than they would with a theory alone.

The Theoretical Domains Framework

In 2005, to simplify the use of theory in behaviour change studies, a group of health psychologists, health psychology theorists, and implementation researchers developed the Theoretical Domains Framework (TDF). Their goal: to make the use of behaviour change theories more accessible to implementation researchers.

The initial version of the TDF integrated 33 psychological theories relevant to behaviour change into 128 constructs (component parts of theories) that were sorted into 12 domains (a broad area or concept where a theory applies, e.g. motivation). In 2012, the TDF was revised and validated [5], and now consists of 84 constructs sorted into 14 domains, described in the table below.

The revised TDF is a comprehensive framework researchers can use to identify factors (i.e. barriers and facilitators) that may influence behaviours, as well as desired behaviour changes. Whereas many theories focus on individual factors (e.g. beliefs and motivations), the TDF goes a step further by also including social and environmental factors. It can serve as:

• a planning tool to help identify determinants (and appropriate techniques) to address previously identified barriers and facilitators to positively impact outcomes of an implementation strategy; and,
• an evaluation tool to assess how effective an intervention was at targeting specific behaviour determinants and/or to retrospectively identify factors that contributed to success and/or failure of an intervention [6].

For example, Lynch et al. [7] held focus groups with health professionals to investigate why patients were or were not assessed for rehabilitation after stroke. Responses were then mapped to the appropriate domains of the TDF, identifying key factors of behaviour that could be targeted in subsequent implementation studies, such as ‘beliefs about consequences’ of changing practice (i.e. whether assessment affects access to rehabilitation or not).

Another example is a study by Fleming et al. [8] that examined the views of healthcare professionals on antibiotic prescribing in long-term care facilities. In this study, the researchers conducted interviews to determine what factors influenced the prescribing patterns of healthcare professionals, and mapped those to the TDF. In doing so, Fleming et al. identified a need for ‘behavioural regulation’ in prescribing practices in long-term care facilities.

What the TDF is Not

As its name indicates, the TDF is a framework — helping to identify and describe the factors that influence a behaviour, but not to explain or offer causality about the determinants of a behaviour in a given context. The TDF doesn’t propose conclusive and testable hypotheses about determinants of a behaviour. Instead, it “provides a theoretical lens through which to view the cognitive, affective, social and environmental influences on behaviour” [9]. Rather than an explanation of how change takes place, the TDF provides a list of factors that could potentially influence a given behaviour [6].

Using the TDF

The TDF was initially aimed at changing the behaviours of health care professionals, but it has also been adapted successfully in studies of individual behaviour change [10]. Stay tuned for a future post that discusses how the TDF is used in practice, along with its strengths and weaknesses.

References

1. Birken S, et al. Criteria for selecting implementation science theories and frameworks: results from an international survey. Implement Sci, 2017;12:124.
2. Glanz K & Bishop DB. The Role of Behavioral Science Theory in Development and Implementation of Public Health Interventions. Annu Rev Public Health, 2010;31:399–418.
3. Bluethmann S, et al. Use of Theory in Behaviour Change Interventions: An Analysis of Programs to Increase Physical Activity in Posttreatment Breast Cancer Survivors. Health Educ Behav, 2017;44(2):245–253.
4. Davis R, et al. Theories of behaviour and behaviour change across the social and behavioural sciences: a scoping review. Health Pyschol Rev, 2015;9(3):323–344.
5. Cane J, et al. Validation of the theoretical domains framework for use in behaviour change and implementation research. Implement Sci, 2012;7:37.
6. Nilsen P. Making sense of implementation theories, models and frameworks. Implement Sci, 2015;10:53.
7. Lynch E, et al. A qualitative study using the Theoretical Domains Framework to investigate why patients were or were not assessed for rehabilitation after stroke. Clin Rehabil, 2017;3(7):966–977.
8. Fleming A, et al. Antibiotic prescribing in long-term care facilities: a qualitative, multidisciplinary investigation. BMJ Open, 2014;4(11).
9. Atkins L, et al. A guide to using the Theoretical Domains Framework of behaviour change to investigate implementation problems. Implement Sci, 2017;12:77.
10. Marshman Z, et al. Parents’ Experiences of Toothbrushing with Children: A Qualitative Study. JDR Clin Trans Res, 2016;1(2):122–130.

About the Authors

Trish Roche (she/her) is a knowledge broker with the George & Fay Yee Centre for Healthcare Innovation (CHI).

Masood Khan is a Research Coordinator with CHI and the Department of Community Health Sciences at the University of Manitoba.