Dr. Casper is affiliated with the Department of Psychiatry, Drexel University College of Medicine, P.O. Box 45357, Philadelphia, PA 19124-2399 (e-mail: ecasper@nyc.rr.com).

The theory of planned behavior states that people's behavior is determined by their intention to perform a given behavior (1,2,3). Intentions are the most immediate antecedents to a behavior and represent the convergence of the cognitive, motivational, and affective internal processes associated with a given behavior. Intention is considered the best predictor of a deliberate behavior. The theory of planned behavior postulates that intentions are a function of three factors: attitudes toward the behavior, subjective norms, and perceived control over the behavior. Attitudes refer to beliefs about the outcomes associated with performing a particular behavior. Subjective norms refer to perceptions about how others would judge a person for performing the behavior. Perceived control is the self-assessment of both the capability or skill and the opportunity to perform the behavior. Positive attitudes, social approbation, self-efficacy, and decisional autonomy combine to strengthen the intention and therefore the likelihood of performing a behavior.

The theory of planned behavior also provides a model for behavior modification in addition to prediction. Assessing people's attitudes, norms, and perceived control, all of which underpin their intention to perform a given behavior, can reveal information that may be applied to create communication strategies to alter these elements and thereby intention and behavior. This assessment process is known as an elicitation study. Two meta-analyses (4,5) reported that communication strategies informed by the theory of planned behavior can effectively reduce health risk behaviors, such as smoking, binge drinking, unsafe sex, and speeding, as well as promote healthy behaviors, such as low-fat diets, physical exercise, various cancer self-examinations, sunscreen use, and condom use. It is estimated that the theory of planned behavior supplied the theoretical model for more than 600 empirical studies of behavior prediction and change in the past 20 years (6).

The theory of planned behavior has application in adult educational settings in which professionals are being taught the use of a new technique or intervention. It has become an axiom of adult continuing education theory that knowledge dissemination alone does not guarantee the practice of new technologies. The observed lag in the translation of research findings into practice in many fields has prompted the need for educational communication strategies that attend to adult learners' attitudes (7). The theory of planned behavior model can guide the design of communication strategies in a continuing education class by means of an elicitation study so that the practitioners' intentions to implement a new technique are strengthened.

The theory of planned behavior has predicted the application of new techniques and information by physicians and nurses in medical (8,9,10,11,12) and behavioral health (13,14,15,16,17) settings. However, there are few studies (18,19,20) that demonstrate the effectiveness of theory-guided educational programs in modifying health care practitioners' intentions to implement new techniques. There appear to be no such studies in the psychiatric treatment and rehabilitation field. Yet the education and training of the national mental health workforce have been criticized as representing a national crisis (21,22). In addition the President's New Freedom Commission (23) has cited the time lag between the discovery and routine practice of evidence-based services as a significant obstacle to achieving the promise of quality care for all Americans with mental illnesses. A trial of the theory in the design and delivery of a continuing education intervention for mental health practitioners appears to be warranted.

This study compared the effects of a continuing education class that was designed according to the principles of the theory of planned behavior and another class that used a standard format addressing the intentions and behavior of mental health practitioners to apply a new assessment tool. The class for the theory of planned behavior used communication strategies that were derived from theory principles to convey the class content. The participants were mental health practitioners whose attitudes, norms, perceived control, and intentions regarding the new assessment tool were assessed at the beginning and end of each class. Preclass and postclass intention differences for the two classes were compared by analysis of covariance. Three months after the completion of the classes, the practitioners' use of the assessment tool was measured via self-reports. Utilization differences between the theory of planned behavior and standard class participants were compared by chi square and t tests.

Setting and participants

This study was conducted by the Behavioral Healthcare Education division of the psychiatry department at Drexel University College of Medicine. The division has been contracted by the Pennsylvania Office of Mental Health and Substance Abuse Services to provide continuing education classes to mental health practitioners statewide. Classes are conducted at no cost to practitioners and at venues throughout the state. This study's classes were conducted during the fall of 2006 in Philadelphia and Pittsburgh, where the registrants worked. The Drexel University College of Medicine's institutional review board approved this study. All registrants were informed that class attendance would involve research participation.

Class topic

The class topic was the Need for Change Employment scale (NfC). This is a brief, self-report scale that assesses consumers' felt need for employment. This topic was chosen for several reasons. The Pennsylvania Office of Mental Health had initiated a statewide promotion of employment services for persons with mental illnesses. It was anticipated that this would provide some motivation for practitioners to attend a continuing education class on this topic.

In addition, several reviews of supported employment services (24,25,26) had claimed that this evidence-based practice was underused nationally. One putative reason given for this underutilization was discrepancies regarding the need for these services between consumers and their practitioners. Two recent studies (27,28) found that consumer-practitioner discrepancies accounted for a 28% underutilization of supported employment services. In those studies the NfC was shown to reduce most of the observed underutilization. These studies concluded that practitioners should consider a trial of the NfC when referring consumers to employment services.

Administering the NfC is a specific, deliberate behavior that also made it an ideal candidate for examining behavior change in association with the theory of planned behavior. Given the NfC studies' recency it was unlikely that many practitioners had already implemented the NfC.

Class formats: theory of planned behavior versus standard

This study's independent variable was the class format, that is, theory of planned behavior versus standard. Both formats used the same PowerPoint software presentation on the supported employment model, its underutilization, the NfC studies' findings, and the views of national and local professionals and administrators on this topic.

The theory-guided format differed from the standard format in that it used an elicitation study. The elicitation study followed the recommendations of Francis (6). When the class began, participants were asked to consider the following statement, which was oriented to the theory of planned behavior: "I shall in the next three months refer consumers to employment services based upon their expressed felt need for work." This statement expressed the class's goal. Participants were then asked to list the advantages and disadvantages of such a referral, those who would approve and disapprove of it, and the conditions that would make it easy and difficult if they acted according to the theory-driven statement. The participants next assembled into small groups where they each shared their individual responses and achieved a consensus among themselves. Each small group reported to the class their consensus responses in order to develop a total group consensus. These responses were recorded on a flip chart, confirmed with the participants, and posted about the classroom.

The goal of the elicitation exercise was to obtain information on the group's common attitudes, social norms, and perceived control regarding the statement based on the theory of planned behavior. This information guided the instructor's class communication strategy. The sequence, emphasis, and discussions of the class content were guided by the elicitation study findings. These included the presentation of research findings to correct mistaken beliefs, testimonials from significant people and organizations to maximize social approval, and resources and opportunities to promote perceived control. The objective was to present the material in such a manner as to mitigate the perceived disadvantages, social disapproval, and perceived control difficulties and to promote the perceived advantages, social approval, and perceived control enhancements of the participants. The communication strategy's goal was to strengthen the participants' intentions to act according to the theory-driven goal statement.

The standard format did not include an elicitation study but instead presented the same material in a prearranged, straightforward manner. However, participants in the standard classroom format were encouraged by the instructor to apply the NfC in their practice.

Instruments

Questionnaires to measure intentions, attitudes, norms, and perceived control were developed according to guidelines described by Francis (6). Each questionnaire uses the same theory-driven goal statement that was presented earlier as a referent. The intentions scale has nine items, and the remaining scales have four items each. These items were arranged in random order to construct a 21-item questionnaire. The intention scale includes four scenarios that describe consumers of varying sexes, ages, and work histories who express a felt need for work. Respondents were asked, on a 7-point agreement scale, if they would refer each consumer to employment services.

A knowledge test comprising 12 multiple-choice items assessed the participants' knowledge of the material contained in the cited studies (24,25,26,27,28). Participants were asked to provide background information on their years of experience in the mental health field, their academic degrees and discipline, professional role, and caseload size. Participants were also asked if their job responsibilities included referring consumers to employment services and whether they used a standardized assessment tool for that purpose.

Procedures and analyses

Class registrants from each location were randomly assigned to one of the two class format conditions. At the beginning of each class the participants anonymously provided their background information. They then anonymously completed the knowledge test and the 21-item theory of planned behavior questionnaire and repeated them at the conclusion of the class. Three months after the class's completion the participants were contacted via e-mail. They were asked whether they had implemented the NfC with their consumers. They were also asked to provide summary results data for the consumers whom they had assessed with the NfC. Preclass, postclass, and follow-up data were matched for each participant by a coding system that preserved the participant's anonymity.

The main analyses were conducted to compare the postclass intention scores for the two class format conditions with the use of analyses of covariance, with preclass intention scores and knowledge gain scores as covariates. This analysis assessed the formats' impact on the participants' intentions. Chi square analysis was used to compare the number of participants from each format who implemented the NfC scale during the three-month follow-up period. Student's t test was used to compare the formats on the percentage of each participant's caseload that was given the NfC scale. These two analyses determined the format's impact on practitioner behavior.

The 98 registrants were randomly assigned to the two format conditions. Of these 94 attended, 46 for the theory of planned behavior class and 48 for the standard classes. Their characteristics are reported in Table 1. There were no statistically significant differences among the participants in the two format conditions. These participants exhibited moderately positive intentions but minimal knowledge about supported employment. Preclass attitudes, norms, and perceived control accounted for 63% (R=.79) of the variance in preclass intentions of the entire 94 participants, which is consistent with expectations of the theory of planned behavior.

The elicitation study for the conditions guided by the theory of planned behavior revealed the following consensus. The major perceived advantage of acting according to the theory-driven statement was the promotion of consumers' self-determination and personal responsibility for their recovery. Participants judged that those approving the referral to employment services would be consumers themselves and the state office of mental health. Acting according to the theory-driven statement was considered to be easier for consumers who had some work experience. On the negative side the disadvantages were the unreliability of consumer-expressed needs and the potential of referring many consumers who were not ready for work. Disapproval was expected from clinical treatment teams and some consumers' families. The practitioners' own inexperience with assessing employment readiness and the possible loss of disability medical benefits by the consumers were the major difficulties that were associated with acting according to the theory-driven statement.

In the theory-guided conditions the instructor used these elicitation study results to orchestrate the presentation of the class content. Particular emphasis was given to the reported obstacles. For example, research findings that attested to the NfC scale's reliability and its predictive validity were presented to counter the perceived disadvantages that were expressed in the elicitation study. Pennsylvania's special low-cost medical insurance for people with disabilities was described to address a perceived difficulty. Testimonials by the national and state chapters of the National Alliance on Mental Illness, which emphasized the rehabilitative importance of employment, were discussed in order to mitigate the perceived disapproval of families toward the employment of their relatives with disabilities.

Overall there were significant knowledge gains (paired t=43.30, df=93, p<.001) for both classes, but no significant difference in knowledge gains between the two formats. Therefore, postclass intentions between the two formats were compared with preclass intentions as the only covariate. The theory-guided format resulted in significantly and substantially greater mean postclass intentions than the standard format (M±SD=58.5±2.7 versus 50.4±6.9, F=73.1, df=1 and 91, p<.001, Cohen's d [ANCOVA models]=1.09). A panel analysis of the postclass intentions for all participants accounted for 64% of postclass intention variance. In that panel analysis, changes in attitude, norms, and perceived control combined accounted for 30% of the variance, whereas knowledge gains accounted for just 1% of the postclass intention variance.

Three months after the classes 34 (74%) participants in the theory of planned behavior format and 33 (69%) participants in the standard format replied to the anonymous electronic survey. There were no significant differences between the two formats in reply rates. Table 2 reports the rates of implementation and the percentage of the caseload assessed for the two class formats. Participants in the theory of planned behavior class had significantly higher implementation rates. Among those who implemented the assessment tool the participants in the theory of planned behavior class also assessed significantly more of their caseload. The correlations between implementation and postclass intentions and postclass knowledge were η=.58 and η=.16, respectively.

This study found that a continuing education class that applied the theory of planned behavior principles resulted in stronger intentions by the participants to implement an assessment tool than did a class structured in the standard format. Implementation rates of the assessment tool were also higher among participants who attended the theory of planned behavior class. This superiority did not appear to be a result of enhanced knowledge gains among the participants in the theory of planned behavior class. Changes in attitudes, norms, and perceived control accounted for the postclass intentions and subsequent variance in implementation behavior as predicted by the theory.

The theory of planned behavior has application in continuing education settings as a method of modifying practice among mental health practitioners. It provides a theoretical framework and the practical means of going beyond information dissemination that is required to translate new discoveries into improved practice. The "knowledge gap" among the national mental health workforce as described by the Annapolis Coalition and the "translation lag" in evidence-based practices as described by the New Freedom Commission can be ameliorated in part by training formats that are informed by the theory. This possibility rests on the theory's postulated relationship between intentions and behavior. A recent meta-analysis (29) concluded that interventions that change intentions are consistently if moderately associated with behavior changes. An intervention that applies the theory of planned behavior consistently enhanced the intention-and-behavior relationship. It was also observed that a group format did not attenuate the intention-and-behavior relationship, and a health educator as provider of the intervention actually enhanced the relationship. These factors were all evident in this study's theory of planned behavior format, as they are in most continuing education settings. Continuing education that is structured with a theory of planned behavior format may be particularly well positioned to capitalize on the intention-and-behavior relationship.

In this study the elicitation study exercise was conducted in class. It may be preferable to conduct the elicitation study before the class. Today this can be accomplished by using electronically conducted surveys. The advantage would be to provide the instructor with critical information before the class. This information could be used to design the class presentation in advance rather than impromptu, as was done here. The effectiveness of this study's impromptu class presentation may have been intensified by the participants' already positive intentions and their lack of an available technology to exercise their intentions. However, when a new technique must compete with an existing one that has been repeatedly used and enjoys an established, stable supporting environment, then an elicitation study conducted in advance of the class may be essential. Reviews by Ouellette and Wood (30) and Wood and colleagues (31) suggest that altering habitual behaviors, which can include standard mental health practices, requires modifications in the behavior's supporting environment in order to sustain individual behavior change. An in-depth elicitation study conducted in advance of the class can elucidate the specific environmental features that prompt and maintain the habitual behavior. Such elicitation studies could also yield data to inform broader system transformation projects that transcend the staff training level.

This study's findings may be limited by the use of self-reports as measures of behavior. There is evidence that physicians' self-reports of their practice overestimate their adherence to guidelines (32). However, replying here was anonymous with no incrimination or benefits. Forty-two percent of those who replied in this study admitted to not implementing the assessment. All of those who reported implementation also supplied summary data. Although that is not a guarantee of accuracy, it would have required additional effort to be deceptive and for no gain. Ultimately, the effect of self-reports is an empirical question that may vary with conditions. Future applications of the theory to continuing education sessions should attempt to assess any effects of self-reports in these types of educational settings.

When applied in a continuing education setting, the theory of planned behavior can modify practitioners' practice behavior much like it does people's behavior in other settings. The theory can improve the outcomes of continuing education sessions and may be well suited for this task.

The author reports no competing interests.