Using the Theory of Planned Behaviour when designing motivational letters: Exploring through patient interviews how determinants of behaviour are operationalised in letters of invitation to cardiac rehabilitation

Keywords: health behaviour, qualitative research, theory of planned behaviour, illness behaviour, cardiac rehabilitation


 Background & Aim: While health behaviour theories are often used to develop written material for health care interventions, descriptions of how to operationalise such theories are lacking in the literature. Paradoxically, it is precisely this information that is supposed to influence patient behaviour. Letters inviting patients to participate in cardiac rehabilitation are further examined here.

Materials & Methods: Semi-structured interviews were conducted to explore how concepts from the Theory of Planned Behaviour had been operationalised in invitation letters, focusing on the motivational potential of different passages.

Results: Thirteen participants were interviewed and asked to comment on the invitation letters. Without having been informed about the Theory of Planned Behaviour, most commented on passages that were based on the theory. It seemed important to many participants that the content is more relatable and personal. Message framing and the use of the future tense in sentences meant to motivate patients to attend cardiac rehabilitation appeared to be important. Using simple language might be more effective than technical terms.

Conclusion: When using health behaviour theories such as the Theory of Planned Behaviour to compose materials motivating patients to behave in certain ways, message framing and relatable content are approaches to operationalizing theoretical concepts.


Alter DA, Oh PI, Chong A. Relationship between cardiac rehabilitation and survival after acute cardiac hospitalization within a universal health care system. Eur J Cardiovasc Prev Rehabil 2009;16:102-13.

Heran Balraj S, Chen Jenny MH, Ebrahim S, Moxham T, Oldridge N, Rees K, et al. Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database Syst Rev 2011:10.1002/14651858.CD001800.pub2.

Jolliffe J, Rees K, Taylor RS, Thompson DR, Oldridge N, Ebrahim S. Exercise-based rehabilitation for coronary heart disease.

Cochrane Database Syst Rev 2001:10.1002/14651858.CD001800.

Piepoli MF, Corr U, Benzer W, Bjarnason-Wehrens B, Dendale P, Gaita D, et al. Secondary prevention through cardiac rehabilitation: from knowledge to implementation. A position paper from the Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation. Eur J Cardiovasc Prev Rehabil 2010;17:1-17 0.1097/HJR.0b013e3283313592.

Taylor RS, Brown A, Ebrahim S, Jolliffe J, Noorani H, Rees K, et al. Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials. The American Journal of Medicine 2004;116:682-92.

Hutchinson P, Meyer A, Marshall B. Factors Influencing Outpatient Cardiac Rehabilitation Attendance. Rehabil Nurs 2015;40:360-7.

Evenson KR, Rosamond WD, Luepker RV. Predictors of Outpatient Cardiac Rehabilitation Utilization: The Minnesota Heart Survey Registry. J Cardiopulm Rehabil Prev 1998;18:192-8.

Menezes AR, Lavie CJ, Milani RV, Forman DE, King M, Williams MA. Cardiac Rehabilitation in the United States. Prog Cardiovasc Dis 2014;56:522-9.

Dressler C, Lewin RJ. UK survey of patient cardiac rehabilitation attendance. British Journal of Cardiac Nursing 2013;8:603-9.

Mosleh SM, Kiger A, Campbell N. Improving uptake of cardiac rehabilitation: Using theoretical modelling to design an intervention. Eur J Cardiovasc Nurs 2009;8:161-8.

Wyer SJ, Earll L, Joseph S, Harrison J, Giles M, Johnston M. Increasing attendance at a cardiac rehabilitation programme: an intervention study using the Theory of Planned Behaviour. Coronary Health Care 2001;5:154-9.

Clark AM, King-Shier KM, Spaling MA, Duncan AS, Stone JA, Jaglal SB, et al. Factors influencing participation in cardiac rehabilitation programmes after referral and initial attendance: qualitative systematic review and meta-synthesis. Clin Rehabil 2013;27:948-59.

Michie S, Johnston M, Francis J, Hardeman W, M. E. From Theory to Intervention: Mapping Theoretically Derived Behavioural Determinants to Behaviour Change Techniques. Applied Psychology An International Review 2008;57,:660-80.

Michie S, Atkins L, West R. The Behaviour Change Wheel : A Guide to Designing Interventions. Great Britain: Silverback Publishing; 2014.

Ajzen I. The theory of planned behavior. Organ Behav Hum Decis Process 1991;50:179-211.

Ajzen I. Constructing a TPB questionnaire: Conceptual and methodological considerations.,,; 2006 [accessed 25.06.2018].

Ajzen I. Behavioural intervention based on the theory of planned behaviour,; 2006 [accessed 25.06.2018].

Neil S, Ferguson MA, Henshaw H, Heffernan E. Applying theories of health behaviour and change to hearing health research: Time for a new approach. Int J Audiol 2016;55:S99-S104.

Dressler C. Improving the uptake of cardiac rehabilitation in invited patients: a multi-method evaluation. . Department of Health Sciences. PhD. University of York; 2013.

Mosleh SM, Bond CM, Lee AJ, Kiger A, Campbell NC. Effectiveness of theory-based invitations to improve attendance at cardiac rehabilitation: A randomized controlled trial. Eur J Cardiovasc Nurs 2013.

Wyer SJ, Earll L, Joseph S, Harrison J. Deciding whether to attend a cardiac rehabilitation programme: an interpretative phenomenological analysis. Coronary Health Care 2001;5:178-88.

Silverman D. Doing Qualitative Research. London: Sage Publications; 2009.

Morse JM. Confusing categories and themes. Qual Health Res 2008;18:727-8.

Pope C, Ziebland S, Mays N. Analysing qualitative data. BMJ 2000;320:114-6.

Sutton S. Using Social Cognition Models to Develop Health Behaviour Interventions: The Theory of Planned Behaviour as an Example. In: French DP, Vedhara K, Kaptein AA, Weinman J, editors. Health Psychology. Pondicherry, India: BPS Blackwell; 2010.

Updegraff JA, Rothman AJ. Health Message Framing: Moderators, Mediators, and Mysteries. Soc Personal Psychol Compass 2013;7:668-79.

Myers RE. Promoting healthy behaviors: How do we get the message across? Int J Nurs Stud 2010;47:500-12.

O'Keefe DJ, Jensen JD. Do Loss-Framed Persuasive Messages Engender Greater Message Processing Than Do Gain-Framed Messages? A Meta-Analytic Review. Communication Studies 2008;59:51-67.

Levin IP, Schneider SL, Gaeth GJ. All Frames Are Not Created Equal: A Typology and Critical Analysis of Framing Effects. Organ Behav Hum Decis Process 1998;76:149-88.

Carver CS, Sutton SK, Scheier MF. Action, emotion, and personality: Emerging conceptual integration. Pers Soc Psychol Bull 2000;26:741-51.

Gallagher KM, Updegraff JA. Health message framing effects on attitudes, intentions, and behavior: a meta-analytic review. Ann Behav Med 2012;43:101-16.

McCall LA, Ginis KAM. The Effects of Message Framing on Exercise Adherence and Health Beliefs Among Patients in a Cardiac Rehabilitation Program. Journal of Applied Biobehavioral Research 2004;9:122-35.

Bartholomew LK, Parcel GS, Kok G, Gottlieb NH. Planning health promotion programs : an intervention mapping approach. San Francisco: Jossey-Bass; 2006.

Manning M. The effects of subjective norms on behaviour in the theory of planned behaviour: A meta-analysis. Br J Soc Psychol 2009;48:649-705.

Diefenbach MA, Leventhal H. The common-sense model of illness representation: Theoretical and practical considerations. Journal of Social Distress and the Homeless 1996;5:11-38.

Keib CN, Reynolds NR, Ahijevych KL. Poor use of cardiac rehabilitation among older adults: A self-regulatory model for tailored interventions. Heart Lung 2010;39:504-11.

Cooper A, Lloyd G, Weinman J, Jackson G. Why patients do not attend cardiac rehabilitation: role of intentions and illness beliefs. Heart 1999;82:234-6.

How to Cite
Dressler C. Using the Theory of Planned Behaviour when designing motivational letters: Exploring through patient interviews how determinants of behaviour are operationalised in letters of invitation to cardiac rehabilitation. NPT. 5(4):403-412.
Original Article(s)