Richmond Austria 1998-08933 COMM 391 Unit II Assignment 3

Communicating Quality Improvement to Healthcare Professionals: Use of Theory of Planned

Behavior to Understand Compliance Behavior
By Richmond Austria
Overview of the Research Proposal
The purpose of this research is to develop an understanding of the factors that influence
behaviors of nurses, doctors and allied health staff using the theory of planned behavior (TPB)
towards their compliance with the implementation of quality indicators set by the health
regulator for a hospital in Abu Dhabi, UAE as communicated to them by the management. As
such, the theory of planned behavior is one of the most widely utilized and researched theoretical
frameworks for explaining human behavior (McEachan et al., 2011). This will allow the
management to identify which predictors can be used as behavioral motivators and improve the
compliance of healthcare professionals with this regulatory requirement. This will also present
to the management some evidence-based recommendations for the development of sub-
programs that can influence healthcare professionals’ engagement using the most effective
predictors for such behavioral compliance. While TPB has been successfully applied in many key
public health interventions, it remains greatly underutilized in healthcare quality improvement.
Understanding and applying such methodologies to quality improvement could potentially
provide better health outcomes especially for regulatory requirements that are being
communicated by the management for healthcare workers to comply with.
The Theory being tested in the Model
A person’s Intention is thought to be a factor that can influence human Behavior directly.
As such, the Theory of Planned behavior provides that such behavioral Intention is influenced by
three factors-the Attitude, the Subjective Norms and Perceived Behavioral Control.
The Attitudes towards quality compliance behavior which is determined by behavioral
beliefs (whether the individual believes that the behavior will improve quality performance) and
evaluation of behavioral outcomes (whether the individual has experienced the improved quality
performance resulting from the behavior) as explained by Wakefield et al. (2010).
The Subjective Norms which are determined by normative beliefs (a person’s belief about
how the people around them think they should behave in order to keep quality performance)
and motivation to comply (the degree to which the individual is motivated to comply with the
wishes of the people around them)as described by Wakefield et al. (2010).
The Perceived Behavioral Control which is determined by control beliefs (the degree to
which an individual believes that their own contribution can lead to the improvement of quality
compliance) and their perceived power (an individual’s perception of whether they have the
power to engage in the quality compliance behavior) as mentioned by Wakefield et al. (2010).

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Richmond Austria 1998-08933 COMM 391 Unit II Assignment 3

Based from this Theory of Planned Behavior, the schematic diagram can be illustrated in
Figure 1. This shows that Attitude, Subjective Norms, and Perceived Behavioral Control can be
associated with the Intention. The Intention can then be associated with the Behavior.

Figure 1. The Schematic Diagram (Model) of the variables of interest based on the Theory of
Planned Behavior

ATTITUDE
Work Satisfaction

Belief in the paradigm

of quality

Belief in the
paradigm of open
disclosure
Preventive action
beliefs

SUBJECTIVE
(Intention)
NORMS follow hospital clinical guidelines
Management that relate to DOH indicators Behavior
responsiveness coordinate with quality
Level of
department and the management
awareness
especially for issues related to
and
DOH indicators
Hospital and Quality performance
communicate difficulties to on DOH
Department support colleagues related to compliance indicators
to DOH indicators

Incident analysis support the management for

changes that are necessary for
compliance to DOH indicators

Professional peer
behavior

PERCEIVED
BEHAVIORAL
CONTROL
Behavioral norms

Attendance to
Quality
Improvement
Workshop

Personal causes of
errors

System causes of
errors

As specified in the variables listed in Assignment 1 of this Unit II, the Attitude can be
represented by four observable items in the questionnaire (Work Satisfaction, Belief in the
paradigm of quality, Belief in the paradigm of open disclosure, Preventive action beliefs). Similarly,
the Subjective norms can be described in four items (Management responsiveness, Hospital and
Quality Department Support, Incident analysis, and Professional Analysis). The Perceived

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Behavioral Control could be represented by four constructs (Behavioral norms, Attendance to

Quality Improvement Workshop, Personal causes of errors, System cause of errors). Whereas,
the Intention can be represented by items related to staff following hospital clinical guidelines
that relate to DOH indicators, coordinating with Quality Department and the management on
issues related to DOH indicators, communicating difficulties to colleagues relate to compliance
with DOH indicators and supporting the management for changes that are necessary for
compliance with DOH indicators. These items for the Intention can then be related to the
Behavior measured using the Level of awareness and performance of the staff on complying with
the DOH quality indicators. These items were based from the previous study conducted by
Wakefield et al. (2010) which also used the Theory of Planned Behavior. As such, the model
presented in Figure 1 can be tested using modeling techniques such as path analysis, structural
equation modeling and network analysis. This will provide various options for causal modeling
that examine and test the relationships between and among one or more dependent variables
and two or more predictors or independent variables.
Use of Path Analysis
In the path analysis shown in Figure 2, the composites of the Attitude, Subjective Norms
and Perceived behavioral control act as the exogenous variables toward the Intention which acts
as the mediating variable towards the Behavior as the endogenous variables. The composite
scores align with the variables specified in Figure 1.
Figure 2. The Path Analysis based on the Theory of Planned Behavior

Attitude

Subjective Norms Intention Bahavior

Perceived
Behavioral Control

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Richmond Austria 1998-08933 COMM 391 Unit II Assignment 3

From this relationship, we could also look at the correlation among the exogenous
variables in this path analysis which provides an inclusion of causal relationships among the
predictor variables-relationships among the three exogenous variables (Allen et al., 2009). As
such, the Attitude can be associated with both Subjective Norms and Perceived Behavioral
Control. Similarly, Subjective Norms can be associated with both Attitude and Perceived
Behavioral Control. Whereas, Perceived Behavioral Control can be associated with both
Subjective Norms and Attitude. The relationship also depicts that Attitude, Subjective Norms and
Perceived Behavioral Control are associated with the Intention which in turn can be associated
with the Behavior. Hence, the path analysis shows us how such variables can be associated with
one another and test the level of such relationship between variables using statistical testing.
Although path analysis and Structural Equation Modeling (SEM) are very similar, there is
an important difference. Whereas path analysis uses variables to test relationships, those
variables are most typically composite variables generated from adding together survey items
similar to the variables in Figure 1 that are used to make such composites in Figure 2 (Allen et al.,
2009). The next model shows the SEM to differentiate with that of the Path Analysis.

Use of Structural Equation Modeling

In the Structural Equation Modeling (SEM) shown in Figure 3, the individual survey items
were included as part of the structural model. Thus, any unreliability can be accounted for in the
model (Allen et al., 2009). Because SEM allows more information to be available in the analysis,
this technique can be very powerful in testing all theoretical assumptions underpinning the
Theory of Planned Behavior. As composites were developed, a measure of reliability such as
Cronbach’s alpha will be crucial in this model. This will test the reliability to be at least 0.7 to be
acceptable on its internal consistency (Wakefield et al., 2010).
The observed variables in the model are represented by the rectangular shapes that are
directly measured in the questionnaire. The latent variables are represented by the Attitude,
Subjective Norms, Perceived Behavioral Control and Intention which are unobserved variables
and are shown in this model using the composites that were previously introduced in the model
shown in Figure 1. In SEM, there are two models that are tested simultaneously via specialized
software such as AMOS, the structural model, which specifies the relationships among latent
variables; and the measurement model, which specifies the relationships among latent variables
and the observed variables (Grapentine, 2000).

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Figure 3. The Structural Equation Modeling based on the Theory of Planned Behavior

Work Satisfaction

Belief in the paradigm follow hospital clinical guidelines

of quality that relate to DOH indicators

Attitude coordinate with quality

department and the management
Belief in the especially for issues related to
paradigm of open DOH indicators

disclosure communicate difficulties to

colleagues related to compliance
to DOH indicators
Preventive action
beliefs support the management for
changes that are necessary for
Management compliance to DOH indicators
responsiveness

Bahavior
Hospital and Quality “Level of awareness and
Department support Subjective Norms Intention performance on DOH
indicators”

Incident analysis

Professional peer
behavior
Behavioral norms

Attendance to
Perceived Behavioral
Quality Control
Improvement
Workshop

Personal causes of
errors

System causes of
errors

Use of Network Analysis

The use of network analysis for understanding the Theory of Planned Behavior has been
explored in Figure 4. The development of this network analysis was based on the schematic
diagram shown in Figure 1 which depicts the variables that are associated in the proposed study
in using the concepts of the Theory of Planed Behavior represented by the Attitude, Subjective
Norms, Perceived Behavioral Control and Intention towards the Behavior. Hence, we could use
network analysis to understand the networks that define the interactions between the
constituent variables.
The network analysis shows the various interrelationships among the observable
variables known us nodes represented by the questionnaire items in the proposed study in Figure
1. It elaborates the different associations that can be explored from one variable to another as
shown in the change edges of the network analysis (Hevey, 2018). The relationships can be drawn
from the substantial theory that can be tested in this modeling technique such as the use of the
Theory of Planned Behavior in explaining behavioral compliance.

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Richmond Austria 1998-08933 COMM 391 Unit II Assignment 3

Figure 4. The Network Analysis based on the Theory of Planned Behavior

Work Satisfaction

Belief in the paradigm follow hospital clinical guidelines

of quality that relate to DOH indicators

Belief in the
paradigm of open
disclosure
Preventive action
beliefs
Management
coordinate with quality
responsiveness department and the management
especially for issues related to
DOH indicators
Hospital and Quality
Bahavior
Department support “Level of awareness and
performance on DOH
indicators”
Incident analysis

Professional peer
behavior communicate difficulties to
colleagues related to compliance
Behavioral norms to DOH indicators

Attendance to
Quality
Improvement
Workshop

Personal causes of
errors support the management for
changes that are necessary for
compliance to DOH indicators
System causes of
errors

The network analysis could test the association between the variables and whether this
is statistically significant. Upon using a software such as R to conduct this, only those paths
between nodes that are significant would be shown to depict the meaningful relationships. In
particular, the size and density of the edges between nodes could represent the strength of
connectedness. The software could also present centrality, stability of centrality indices, edge
weight as described by Hevey (2018).
Summary
The modeling techniques such as path analysis, structural equation modeling and
network analysis provide various options for causal modeling that examine and test the
relationships among variables. These tools can be used for exploring relationship of variables
based on an established theory such as the Theory of Planned Behavior which provides that a
behavioral Intention is influenced by three factors- the Attitude, the Subjective Norms and
Perceived Behavioral Control. Hence, modeling using these techniques can be applied to
understand the correlations among variables, their relationships and the strength of such
relationships as being studied in the framework proposed in the study.

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Richmond Austria 1998-08933 COMM 391 Unit II Assignment 3

References:
Allen, M., Titsworth, S., and Hunt, S. (2009). Quantitative Research in Communication. SAGE
Publishing.
Grapentine, T. (2000). Path Analysis vs. Structural Equation Modeling. Marketing Research.
12(3): 12-20. Available from: https://www.researchgate.net/publication/285089357_
Path_analysis_vs_structural_equation_modeling
Hevey, D. (2018). Network analysis: a brief overview and tutorial. Health Psychology and
Behavioral Medicine. Available from: https://www.tandfonline.com/doi/full/10.1080/
21642850.2018.1521283
McEachan RR, Conner M, Taylor NJ, Lawton RJ. (2011). Prospective prediction of
health-related behaviours with the theory of planned behaviour: a meta-analysis. Health
Psychol Rev.;5(2):97-144.
Wakefield, John G ; McLaws, Mary-Louise ; Whitby, Michael ; Patton, Leanne (2010).
Patient safety culture: factors that influence clinician involvement in patient safety
behaviours. Quality & Safety in Health Care; London Vol. 19, Iss. 6, (Dec 2010): 585.
DOI:10.1136/qshc.2008.030700

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