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Theory Domains Framework

Several behaviour change techniques have been described, however, it has been documented that implementation of interventions without theoretical evidence of effectiveness or identification of the barriers to change, are of little benefit (Hakkennes and Dodd, 2008). By using a theoretical approach, factors which may influence whether or not a behaviour is performed can be identified (Michie et al., 2007). There are many psychological models in the literature which investigate behaviour change, however, the TDF offers an accessible tool which can be used easily by a non-psychologist. The TDF is focused, efficient and structured and covers a very broad range of constructs, so minimising the risk that influencing factors are missed (McSherry et al., 2012). It has been used several times over recent years to investigate the behaviour of health care staff and the implementation of evidence based guidelines using both qualitative and quantitative approaches and therefore is a suitable tool to use to investigate midwives’ behaviour. The domain list enhances the understanding of the

behaviour change process (Michie et al., 2005) and the framework can be used systematically to select the most appropriate theories to develop interventions to change specific behaviours (Francis et al., 2012).

When using the TDF it should be remembered that it only provides a theoretical understanding rather than definitive answers (Michie et al., 2007). It generates hypotheses about factors which may influence a behaviour, it does not generate the evidence that these are influencing factors (Francis et al., 2012). In this study it would appear that lack of skill, memory/attention and decision

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processes are acting as barriers to performing the behaviour. The TDF also relies on the presence of evidence based guidelines regarding the behaviour under investigation (Francis et al., 2012). Even when guidelines are in place some clinicians, managers and policy makers do not adhere to guidance, believing they know best and are reluctant to implement new evidence (Eccles et al., 2005). Research may provide the hypothesized determinants of a

behaviour and the framework to design effective interventions however time, investment and experience is required to implement them (Eccles et al., 2005, Kolehmainen and Francis, 2012).

Achieving an acceptable internal consistency for each domain was essential but it meant that almost a quarter of potentially available data was lost. This is possibly due to difficulties with the phrasing and construction of questions to make them attributable to distinct concepts, or a superficial interpretation of domain definitions (Francis et al., 2012). It was also impossible to achieve internal consistency for the ‘environment, context, resources’ domain score and therefore, whilst constructs within this domain may be acting as barriers to performing the behaviour no reliable conclusions can be drawn.

Whilst the midwives comments provided some interesting information this method of data capture does have limitations. Not all midwives provided

comments, and not all comments were relevant to ‘nature of the behaviour’. The use of semi-structured interviews with a standard topic guide may have

provided a richer source of data relating to this domain and, as previously described, this methodology has been used many times to explore

implementation of guidelines by health care professionals. Future research may benefit from adopting a mixed methods approach, integrating both qualitative and quantitative methodologies and optimising the strengths of each to answer the research questions (Creswell et al., 2011).

It should be noted that since the design and implementation of this study the original TDF has been refined. The domain ‘Nature of the behaviour’ has been removed as it was not adequately represented in the revalidation and

identification of the domains. ‘Beliefs about capabilities’, ‘beliefs about

consequences’ and ‘motivation and Goals’ were retained but divided into new domains, ‘Optimism’, ‘Reinforcement’, ‘Intentions’ and ‘Goals’ (Cane et al.,

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2012). This indicates that the TDF remains a work in progress and there is still some debate about how distinct and definable the individual domain definitions are.

Response rate

The overall questionnaire response rate was 52.6%, this is comparable to other similar NHS staff surveys; Beenstock (Beenstock et al., 2012) had a 43%

response rate from midwives in the North East of England when carrying out a similar cross-sectional survey while Brotherton (Brotherton et al., 2010) had a 32% response rate from a postal questionnaire to general practitioners, McNally (McNally et al., 2006) had a 51% return rate from mental health service staff in acute and community settings, Dyson (Dyson et al., 2011) had a 37% return rate from nursing staff in the North of the UK, and Maclaod (Macleod et al., 2012) had a 32% response rate from an e-mailed survey to midwives in Scotland. The aim of a good questionnaire is to gather reliable and valid data from a representative sample of respondents (McColl et al., 2001). Poor survey response rates are known to contribute to error and bias. It is impossible to know if the results are representative of staff opinions or the views and opinions of a motivated sub-set as opposed to the general midwife population.

Alongside this a small number of participants did not answer some of the questions, potentially leading to non-response bias. It is possible that non- response to specific questions results because the respondent had difficulties with the specific domain that the question was linked to, the question may have been badly phrased and difficult to understand or it may have simply been missed (Michie et al., 2007). Mode of administration, the length, ordering, wording of questions and even the appearance of the questionnaire can affect response rate (McColl et al., 2001, Edwards et al., 2009).

Some midwives declined to participate and verbally stated that they felt, despite reassurances, their managers were somehow monitoring individual responses. Whilst the aim of the covering letter which was distributed with the questionnaire was to endorse the research and encourage participation, it may have re-

enforced the feelings of ‘spying’ as the maternity unit managers signed them. Similarly, whilst the questionnaire was anonymous and it was hoped that this would encourage the midwives to respond honestly and reduce the risk of social desirability or self-report bias (Donaldson and Grant-Vallone, 2002), a small

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number of midwives commented that they believed the coloured numbering system was some form of code which would result in their responses being known. Others were not concerned at all and did not even bother to remove the number from the front of the questionnaire before returning it. Previous survey research has found that respondents are more likely to disclose the truth and express their views and opinions candidly if the survey is anonymous,

especially with sensitive topics (Ong and Weis, 2000). In contrast Campbell, (Campbell and Waters, 1990), found that anonymity does not necessarily increase response rates, therefore it is impossible to say if anonymity improved or reduced our response rate.

A systematic review examining health service staff return rates found that postal and telephone surveys had the highest response rate, however the option of a mixed mode format was also favoured by busy physicians (VanGeest et al., 2007). With the increasing use of technology in today’s NHS many staff may have found an internet based survey more accessible. However as many of the community midwives did not have ready access to a computer, a paper based survey was deemed more appropriate. Length of questionnaire, perceived relevance and importance of the topic, endorsements and monetary incentives all affect response rates (VanGeest et al., 2007). A Cochrane Review

examining methods to increase response rate also encouraged the use of at least one reminder and to adopt a more personal approach to distribution (Edwards et al., 2009). Attempts were made to incorporate as much of this advice as possible.

Overall the response rate for the Newcastle upon Tyne Hospitals Trust was lower than the other two sites. This is possibly because of the size of the unit and the number and distribution of staff. Despite the second reminder

questionnaire, e-mail reminders and posters it was very difficult to personally encourage individual staff to participate, whilst the research midwives at North and South Tyneside had regular face to face contact with individual staff members and groups and were able to verbally encourage participation.

Design issues

Honesty and social desirability bias are problems encountered with all self- report questionnaires. Respondents have a tendency to answer the questions in a way that is viewed favourably; this may have been the case with the current

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question, ‘discuss/advise PA with obese pregnant women’. This type of bias can result in over reporting of positive, ‘good’ behaviour and under reporting of negative ‘bad’ behaviour. Subsequently this can affect the interpretation of results but in reality can only be avoided by observing the behaviour under investigation or interviewing the women afterwards to confirm the behaviour. This was found to be the case in a qualitative study carried out in the USA: researchers interviewed pregnant women and obstetricians from the same antenatal clinic and, whilst obstetricians stated that they discussed nutrition and PA with all pregnant women, the women said that the obstetricians either

discussed the issues in general terms or not at all (Duthie et al., 2013).

Respondents were also asked to rate their own activity levels on a scale of 1 to 10, (1 being very sedentary, 10 being very active). The aim of this question was to identify if respondents own perceived activity level influenced their attitude towards PA advice, or the likelihood of discussing and advising activity with obese pregnant women. Previous research has shown this to be the case with certain health behaviours, such as regular exercise, but not with diet (Howe et al., 2010). However, this was not found to be the case with this study. The activity scale had a low correlation with ‘beliefs about capabilities’, and the ‘behaviour’ under investigation. This may reflect the subjective nature of self- reporting, but more likely reflects the fact this was not a validated scale. Thus it cannot be concluded that there is no relationship with respondent PA. Asking participants to self-report their own BMI was also considered as a potential question, however, as well as possibly causing offence, a recent systematic review reported no difference between the assessment and referral of overweight and obese patients by health care staff who were themselves overweight, compared to their leaner counterparts (Zhu et al., 2011). An Australian qualitative study has, however, subsequently reported that some midwives felt uncomfortable about advising obese pregnant women regarding healthy lifestyle choices as they themselves were overweight or obese (Knight- Agarwal et al., 2013).