Health consumers’ behaviours are a major determinant of their health (Fisher 2011; Swann 2010) and are the largest source of variance in their health outcomes (Ryan 2008; Schroeder 2007), meaning an individual's behaviour largely determines his or her health. Similarly, healthcare professionals’ behaviours are major determinants of whether they deliver evidence-based care and advice to health consumers (Eccles 2005). Yet, behaviours that reflect the use of best evidence by health consumers and healthcare professionals are sub-optimal. For example, only one-third of consumers experiencing a cardiac event take up cardiac rehabilitation (British Heart Foundation 2009) and up to one quarter of individuals in commercial weight management programmes drop out (Tsai 2005). This can lead to serious health consequences for consumers. For example, cardiac rehabilitation participation is consistently associated with reduced all-cause and cardiovascular mortality in people who have experienced myocardial infarction, percutaneous coronary intervention, or coronary artery bypass graft surgery (Hammill 2009; Heran 2011; Suaya 2009; Witt 2004).
Comparable findings are seen with healthcare professionals, which in turn also impact on health outcomes for consumers. Results of studies in the USA and the Netherlands (Grol 2001; Schuster 1998) suggest that about 30% to 40% of consumers do not receive care according to present scientific evidence, and that about 20% to 25% of care provided is not needed or is potentially harmful. McGlynn and colleagues (McGlynn 2003) observed that patients in the USA received only 55% of recommended care, and that quality varied by medical condition, ranging from 79% of recommended care for senile cataract to 11% of recommended care for alcohol dependence. Similar findings are reported globally (Grol 2001). Our understanding of how to improve health consumers’ and healthcare professionals’ use of best evidence is also incomplete. This has resulted in considerable interest in knowledge translation (KT). KT is concerned with the assessment, review, and utilisation of scientific research. As a result, strategies to improve KT often require an increase in knowledge by health consumers and healthcare professionals, and that they change some aspect of their behaviour.
Description of the intervention
'Conditional plans' comprise statements that specify specific cues and behaviour(s) that one will undertake to realise a (health) intention or goal. The behaviour will occur in response to these cues; meaning it is the cues rather than the process of deliberation that results in the behaviour. With conditional plans, individuals form a mental image of some combination of when (time), where (cues), and how (response) they will execute the intended behaviour (Gollwitzer 1993). Conditional plans can be either provided to the person (e.g., in the form of a guideline, e.g., ‘if (when) X occurs, I will do Y (behaviour)’/ If you develop hypoglycaemia (the sugar in your blood drops to less than 4 mmol/L), take a fast-acting carbohydrate such as 15g of glucose or sucrose in the form of tablet or solution) or can be self-formulated (i.e., the individual participates in developing the plan). Self-formulated plans can be formed entirely by the individual completing the health behavior or in conjunction with another person. In the case of conditional plans focused on patients, the other person may be a healthcare professional (e.g., physician, nurse, pharmacist, allied health professional, etc) or a researcher. In the case of conditional plans focused on healthcare professionals, i.e., plans aimed at changing the professional's own behaviour rather than the behaviour of consumers, the other person will often be a researcher.
We will illustrate this with two real examples. With respect to self-formulated conditional plans focused on consumers, Jackson and colleagues (Jackson 2006) asked consumers to follow a set of instructions to form a conditional plan (in the form of an if...then…statement) for each daily dose of antibiotic they were prescribed, to determine whether self-formulated conditional plans increased adherence to short-term antibiotics. With respect to self-formulated conditional plans focused on healthcare professionals, Casper (Casper 2008) conducted a study with mental health practitioners, who were instructed (by a researcher) to create a conditional plan that identified the best time and place ('when' and 'where') to use a psychiatric care directive ('how').
In this review, we will focus on self-formulated conditional plans because there is evidence to suggest that involving consumers in their own health care leads to the development and provision of interventions that are both more responsive to their needs and offer better outcomes of care (Liddell 2008). There is also less risk of interventions being designed inappropriately if health consumers are involved in the development and planning phase (Elwell 2013), and interventions are more likely to be provided in a way that they want (Elwell 2013). Furthermore, organisations that support healthcare professionals and others in providing high quality care to health consumers (such as The National Institute for Health and Clinical Excellence (NICE) in the UK) recommend both consumer and healthcare professional input for best outcomes when planning behaviour change interventions (Elwell 2013; NICE 2007). Finally, consumers have a legal right to, and should participate in, the development of plans related to their health.
There are a variety of forms that conditional plans can take. The most commonly reported form is implementation intentions that formulate conditional plans as specific 'if/then' statements; for example, if X (I have breakfast), then I will do Y (take my insulin). Intervention strategies using implementation intentions have been successful in changing a variety of health consumer behaviours (e.g., improved dietary practices (Adriaanse 2011), increased physical activity (Belanger-Gravel 2011), increased attendance at cervical cancer screening (Sheeran 2000), and performing breast self-examination (Sheeran 1999)). They have also been used successfully, albeit less often, with healthcare professionals (e.g., the use of a psychiatric care directive by mental health practitioners (Casper 2008), and improving hand hygiene compliance by professional nurses (Erasmus 2010)).
Other complementary conditional plan approaches to implementation intentions include action plans and coping plans. Action plans link goal-directed responses to situational cues by specifying when, where, and how to act in accordance with one’s goal intention; they are not however presented as if/then statements like implementation intentions (Kwasnicka 2013; Sniehotta 2006). Coping plans are designed specifically to overcome the barriers that are perceived to prevent intentions and action plans from working (Kwasnicka 2013; Sniehotta 2006).
How the intervention might work
Most people intend to change an aspect of their health-related behaviour at some point in time, whether it is to quit smoking, or obtain screening for a disease by health consumers, or to follow established best practice guidelines by healthcare professionals. Systematic reviews illustrate that such intentions reliably predict behaviour. For example, in an overview of meta-analyses of the intention-behaviour relationship across 422 studies involving 82,107 individuals, Sheeran (Sheeran 2002) showed that intentions accounted for 28% of the variance in health consumers’ behaviours, on average. Similarly, in a recent review of healthcare professionals, Godin and colleagues (Godin 2008) demonstrated that across 12 studies involving 1754 professionals, intentions accounted for 22% of the variance in professional behaviour. Further support for the importance of intentions to enacting behavior can be seen in a recent review showing that an actual change in intention can lead to a change in health behaviour. In a meta-analysis of 47 studies of consumer health intention-behavior relations, a medium-to-large change in intention (d = 0.66) led to a small-to-medium change in behavior (d = 0.36) (Webb 2006). Thus, for some people health intentions can be and are translated into successful behaviour change. However, for many others, intentions never result in the targeted behaviour (Ogden 2007). A meta-analysis of 51 studies (involving 8166 health consumers) showed almost half (47%) of individuals with positive intentions to engage in health-related behaviours did not realise these intentions (i.e., they did not change their behaviour to meet the intention) (Sheeran 2002). This is known as the ‘intention-behaviour gap’ (Orbell 1998; Sheeran 2005).
Why is it so difficult for people to enact their intentions?
Several methodological and measurement reasons (e.g., Sutton 1998) as well as substantive explanations (e.g., Sheeran 2005) for the intention-behaviour gap are suggested in the health psychology literature. Common measurement problems include, for example: violation of the Principle of Compatibility (i.e., not measuring intention and behaviour at the same level of specificity or generality); lack of scale correspondence (i.e., use of different magnitudes, frequencies, or response formats for the assessment of intention and behavior); and unequal number of response categories when measuring intention and behavior ( Sutton 1998). While these and other methodological issues are important, in this review, we focus on substantive reasons for the intention-behaviour gap.
In performing behaviours, individuals are theorised to pass through two phases: a motivational (pre-decisional) phase which includes obtaining the required knowledge to change, followed by a volitional (post-decisional) phase (Gollwitzer 1993; Heckhausen 1991). The motivational phase encompasses an individual’s orientation toward engaging in the behaviour and culminates in the formation of a behavioural or goal intention. Intentions are the instructions that people give themselves to perform particular behaviours or to achieve certain goals (Triandis 1980) and are characteristically measured by items of the form ‘I intend to do X’ (Sheeran 2005). Intentions represent the culmination of the decision-making process; that is, they signal the end of deliberation about behaviour and capture the standard of performance that a person has set for him or herself, their commitment to the performance, and the amount of time and effort that will be expected during action (Ajzen 1991; Gollwitzer 1990; Sheeran 2005; Webb 2005). The second phase of behaviour (the volitional phase) refers to the actual performance of the targeted behaviour (i.e., realisation of one’s intention).
Two central processes are suggested to underlie why people sometimes do not progress past the motivational (intention) phase into the volitional (behaviour) phase: (1) intention elaboration and (2) intention activation (Sheeran 2005). Intention elaboration refers to specifying, in sufficient detail, the particular actions and contextual opportunities that will permit realisation of an intention (Sheeran 2005). This requires identifying both the means (actions) and the context (internal or external cues) that will permit intention realisation. In the absence of such intention elaboration, people are likely to miss the opportunity to act or even know how to act if the opportunity arises (Sheeran 2005). Intention activation refers to the extent to which contextual demands alter the salience, direction or intensity of a focal intention relative to other intentions (Sheeran 2005). For example, for most health behavior intentions, an individual is likely to have multiple (and often conflicting) goals pertaining to that exact time. This can result in prospective memory failure (where one forgets to do the behaviour) and/or goal reprioritisation (where the intention fails to attract sufficient activation to permit its realisation, and is postponed/abandoned) (Sheeran 2005). In addition, several other factors or barriers to change can come into play, including contextual factors such as structural or environmental factors and the availability of specific resources required to carry out the behaviour, e.g., lack of access to affordable opportunities for physical activity, domestic responsibilities, or lack of information or resources.
Recently, Flottorp and colleagues (Flottorp 2013) conducted a systematic review of frameworks of determinants of professional practice behaviour followed by a consensus process, resulting in the development of a checklist with 57 potential behavioural determinants grouped in 7 domains: guideline factors, individual health professional factors, patient factors, professional interactions, incentives and resources, capacity for organisational change, and social, political, and legal factors. These studies have led to an interest in KT interventions that can bridge the intention-behaviour gap in both consumer and health professional behaviours. Conditional plans are one strategy for this gap and thus increase the likelihood of individuals enacting targeted health behaviours (Gollwitzer 1993; Gollwitzer 1996; Gollwitzer 1998; Gollwitzer 2005).
Why it is important to do this review
Despite the widespread use of conditional plans to change health-related behaviours, there remains a paucity of synthesised evidence summarising their effects with health consumers and healthcare professionals broadly (i.e., across a range of behaviours). A few syntheses exist of the effects of a single form of conditional plans, including self-formulated plans, that target a specific condition or narrowly-defined set of behaviours; for example, action plans for chronic obstructive pulmonary disease (Walters 2010), implementation intentions for physical activity (Belanger-Gravel 2011), and implementation intentions for healthy eating (Adriaanse 2011)). In these reviews, the form of conditional plan was reported as effective overall, providing support for the intervention in a specific context.
Two additional reviews have examined a single form of conditional plan across multiple behaviours. Gollwitzer and Sheeran (Gollwitzer 2006) reviewed the evidence for implementation intentions across different behaviours, and reported a positive effect overall (effect size = 0.59, 95% CI 0.52 to 0.67). This review however has several limitations and requires updating. First, a narrow search strategy was used: (i) a single health database (MEDLINE) was searched; (ii) the search was restricted to the period 1993 and 2003, so is now 10 years old; and, (iii) search terms were limited to ‘implementation intentions’ and ‘plans’. Second, few of the included studies focused on health consumers or healthcare professionals (n = 23). Third, no assessment of methodological quality (risk of bias) was reported. Fourth, forms of conditional plans other than implementation intentions were excluded. Fifth, assessment of ‘self-formulated’ plans was not a focus.
Recently, Kwasnicka and colleagues (Kwasnicka 2013) conducted a review of the effects of "promoting individuals to form coping plans" to encourage health-related behaviour change. This review also has limitations: the search was limited to three databases (MEDLINE, EMBASE, PsycINFO), one form of conditional plans (coping plans) was included, and it only targeted health consumers. Eleven studies were included; the authors concluded that coping plans "appear" to be effective when individuals are "supported" in the process of their development (Kwasnicka 2013), offering additional support for using self-formulated conditional plans. Based on our preliminary scoping of the literature (Appendix 1), a large unsynthesised body of randomised controlled trial (RCTs) evidence currently exists that examines the effects of different forms of conditional plans across a variety of behaviours with both health consumers and healthcare professionals. We will conduct a synthesis of this literature.