Using theories of behaviour to understand transfusion prescribing in three clinical contexts in two countries: Development work for an implementation trial

Jillian Francis, A Tinmouth, S J Stanworth, J Grimshaw, Marie Johnston, C Hyde, C Stockton, J C Brehaut, D Fergusson, M P Eccles

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Background: Blood transfusion is an essential part of healthcare and can improve patient outcomes. However, like most therapies, it is also associated with significant clinical risks. In addition, there is some evidence of overuse. Understanding the potential barriers and enablers to reduced prescribing of blood products will facilitate the selection of intervention components likely to be effective, thereby reducing the number of costly trials evaluating different implementation strategies. Using a theoretical basis to understand behaviours targeted for change will contribute to a 'basic science' relating to determinants of professional behaviour and how these inform the selection of techniques for changing behaviour. However, it is not clear which theories of behaviour are relevant to clinicians' transfusing behaviour. The aim of this study is to use a theoretical domains framework to identify relevant theories, and to use these theories to identify factors that predict the decision to transfuse.

Methods: The study involves two steps: interview study and questionnaire study. Using a previously identified framework, we will conduct semi-structured interviews with clinicians to elicit their views about which factors are associated with waiting and further monitoring the patient rather than transfusing red blood cells. Interviews will cover the following theoretical domains: knowledge; skills; social/professional role and identity; beliefs about capabilities; beliefs about consequences; motivation and goals; memory, attention, and decision processes; environmental context and resources; social influences; emotion; behavioural regulation; nature of the behaviour. The interviews will take place independently in Canada and the UK and involve two groups of physicians in each country (UK: adult and neonatal intensive care physicians; Canada: intensive care physicians and orthopaedic surgeons). We will: analyse interview transcript content to select relevant theoretical domains; use consensus processes to map these domains on to theories of behaviour; develop questionnaires based on these theories; and mail them to each group of physicians in the two countries. From our previous work, it is likely that the theories will include: theory of planned behaviour, social cognitive theory and the evidence-based strategy, implementation intention. The questionnaire data will measure predictor variables (theoretical constructs) and outcome variables (intention and clinical decision), and will be analysed using multiple regression analysis. We aim to achieve 150 respondents in each of the four groups for each postal survey.
Original languageEnglish
Article number70
JournalImplementation Science
Early online date24 Oct 2009
Publication statusPublished - 2009

Bibliographical note

© 2009 Francis et al; licensee BioMed Central Ltd.

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

This study was funded by the Department of Health for England and the Canadian Blood Services. We thank the participants for generously sharing their views. Jill Francis is 50% funded by the Chief Scientist Office of the Scottish Government Health Directorates. Jeremy Grimshaw holds a Canada Research Chair. Alan Tinmouth is supported by a Canadian Blood Services/Canadian Institutes of Health New Investigator Award. Dean Fergusson is supported by a Canadian Institutes of Health New Investigator Award. The views expressed are not necessarily those of the funding bodies. We thank Dr Rafat Islam for her contribution in developing the interview topic guide for the Canadian study.


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