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Registered Massage Therapists’ Intention to Use Standardized Outcome Measures Hemsworth, Robert B. 2017-04

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Registered Massage Therapists’   1  Running head: STANDARDIZED OUTCOME MEASURES               Registered Massage Therapists’ Intention to Use Standardized Outcome Measures Robert B. Hemsworth Dr. Lesley Bainbridge University of British Columbia                Registered Massage Therapists’   2 Table of Contents Abstract                             4. Introduction                            6. Methods                             8. Participants                           8. Measures: RMT survey                       8. Procedure                           10. Analysis                            10. Results                              10 Response Rate                          10. Practice characteristics of participants                   11. TPB measures                          13. SOM practice benefits and barriers                    15. Discussion                            16. Limitations of the research                      18. Direction for future research                      18. Conclusions                            19. Conflict of interest notification                      19. Copyright                            19. Appendices                            20.               Registered Massage Therapists’   3 List of Tables Table 1. Survey distribution of TPB Items                   9. Table 2. Practice Characteristics                     12. Table 3. Descriptive statistics (counts; sums; means; standard deviations)        13. Table 4. ANOVA                          13. Table 5. Model Summary                        14. Table 6. Coefficients                         14. Table 7. SOM Practice Benefits & barriers (rankings; counts/percentages; themes; TPB factors)  16.  List of Figures Figure 1. A framework of the theory of planned behavior              8. Figure 2. Normal probability plot of regression standardized residual          15.                       Registered Massage Therapists’   4 Abstract Background: With the emergence of evidence-based practice (EBP) in healthcare, the use of standardized outcome measures (SOMs) has become important for providing credible and reliable treatment justification (Jette, 2009; Fawcett, 2007). However there are concerns that clinical decision-making by registered massage therapists (RMTs) may be based on education, prior experience, and peer opinion, rather than research and scientific evidence (Schroff, 2012; Fawcett, 2007). The theory of planned behavior (TPB) offered a theoretical basis to explain SOM behavior by RMTs and provide behavior change recommendations (Ajzen, 1988; 1991; 2005; 2006). Purpose: This study was framed by the TPB to measure and explain SOM behavior by RMTs. The primary research question was: What are RMTs’ intention to use SOMs? Sub questions were: Which theory-based factors most influence RMTs’ intention to use SOMs? And Which RMT beliefs contribute most to the factors of the TPB? Settings: The massage therapy (MT) profession of British Columbia, Canada. Participants: Members of the Registered Massage Therapists’ Association of British Columbia (RMTBC). Research Design: An anonymous cross-sectional online survey consisting of multiple-choice questions, Likert-type scale and short answers was used. Main Outcome Measures: Multiple regression analysis of nine TPB items reported construct measures of behavior-related attitudes (BA), normative expectations (SN), control perceptions (PBC), and intention (BI). Thematic analysis of text from two open-ended items enabled the reporting of themes within the data.  Results: The combination of BA, SN, and PBC significantly explained 78% of the variance in RMTs’ intention to use SOMs [F(3,203)=239.08, p<.001, R2=0.78, R2Adjusted=0.78]. The combination of PBC and BI significantly explained 15% of the variance in SOM behavior [F(2,204)=18.89, P<.001, R2=0.16, R2Adjusted=0.15]. The BA (ß= 1.13, t=17.20, P<.001) and PBC (ß=0.20, t=2.57, P=.01) significantly influenced BI, whereas SN did not (ß=0.04, t=0.55; P=.58). Beliefs about SOM practice benefits and barriers were represented in three themes: behavioral, normative, and control beliefs. RMTs perceive numerous resource and ability-related practice barriers (time; knowledge; access; skills) that weaken control over SOM behavior.  Conclusions: Few RMTs acknowledged using SOMs, even though most held positive intention towards doing so. RMTs’ intention to perform SOMs was significantly explained by behavior-related attitudes, norms, and perceptions of control. Attitudes and perceptions of control most influenced behavioral intention, indicating that RMTs with favorable attitudes are more likely to perform SOMs, and less likely to do so when a perceived lack of control exists. Despite holding favorable attitudes and positive Registered Massage Therapists’   5 intention, RMTs perceive numerous resource and ability-related practice barriers that weaken control over SOM behavior. Future interventions should address time, knowledge, access, and skills required to perform SOMs in MT. More research is needed to better understand SOM behavior by RMTs and further promote SOM uptake and sustained use in MT.                           KEYWORDS: Massage therapy; registered massage therapist; CAM; standardized outcome measure; beliefs; attitudes; intention, behavior; theory of planned behavior   Registered Massage Therapists’  INTRODUCTION The drive towards evidence-based practice (EBP) in healthcare has challenged health professionals to demonstrate fiscal responsibility through the delivery of clinically effective and cost effective treatment interventions (Fawcett, 2007). Accordingly, standardized outcome measures (SOMs) are considered important for establishing intervention efficacy and efficiency, and providing credible and reliable treatment justification (Jette, 2009; Fawcett, 2007). ‘Outcome measures’ refer to instruments that objectively measure patient progress before and after an intervention (Jette, 2009; Fawcett, 2007). ‘Standardized’ refers to outcome instruments that use closed-ended questionnaire formats or specific implementation protocols, provide scores that allow quantitative assessment of change in ability, and have been evaluated for their psychometric properties (Jette, 2009). Besides demonstrating therapeutic value, SOMs promote mutual goal setting and patient-centered care (Fawcett, 2007). In British Columbia (BC), Canada, political and financial drivers increasingly influence registered massage therapists’ (RMTs’) use of shared and informed decision-making practices, based upon the understanding of patient needs, values and preferences (British Columbia Ministry of Health, 2016; Registered Massage Therapists’ Association of BC, 2016). Massage therapy (MT) is one of the most commonly used complementary and alternative medicine (CAM) modalities in North America, and is legislated under the BC Health Professions Act (Grant, 2008; Esmail, 2007; Kania, 2009; Barnes, 2009; Shroff, 2012). RMTs hold high training standards and work with illness, injury and disability in diverse and broad populations by focusing on disorders of the musculoskeletal and related systems (RMTBC, 2016). Increased demand for MT services has reinforced the need for outcomes research development to support MT effectiveness as a respected healthcare intervention (Munk, 2010; Grant, 2008). Accordingly, the routine use of valid, reliable, and relevant measurement instruments by RMTs has become important to building a sound evidence-base for MT (Kania, 2009). This understanding was reaffirmed in a recent MT study that advocated for RMTs to adopt instruments considered appropriate for measuring pain, stress, function, and well-being (Kennedy, 2016). Doing so was considered essential for supporting EBP in MT and aligning clinical assessment practices with those of allied professions. Furthermore, the quantity of outcome measures considered relevant to massage therapy practice has been steadily growing due to such demand (Kania 2009; Grant, 2008; Brosseau, 2011; 2012; Kennedy, 2015; Moyer, 2009).  Numerous research reports have identified practice barriers to the use of SOMs among rehabilitation professionals (Kennedy, 2015, 2016; Jette, 2009; Bland, 2013; Salbach, 2011; Swinkles, 2011; Jenson-Doss, 2010, Hutchinson, 2006, Russek, 1997). In MT research, common practice barriers have been identified as limitations to knowledge, access, and time (Kania, 2009). Verhoef (2006) investigated how CAM practitioners searched for outcome measures and found that most referred to colleagues as a Registered Massage Therapists’   7 resource (34%), followed by libraries (27.4%), and the internet (22.3%). Another BC study highlighted how a paucity of outcomes-based literature in MT could facilitate decision-making by RMTs that is based more upon education, prior experience and peer opinion, than on research and scientific evidence (Schroff, 2012). If true, clinical judgment that is based on intuitive guesswork is less likely to be rational and consequently defensible (Fawcett, 2007). No research has explored how to support the uptake and sustained use of SOMs in MT.  In order to examine SOM behavior by RMTs, a behavioral model was used in this study to frame a methodology. The theory of planned behavior (TPB; Ajzen, 1988, 1991; Figure 1) proposes a predictive model relating to how social human behavior is guided (Figure 1). Behavioral intention (BI) is considered to be the immediate antecedent of actual behavior. BI, in turn, is determined by behavioral attitude (BA), subjective norm (SN), and perceived behavioral control (PBC). The BA construct is defined as one’s personal evaluation of a behavior, and is based on the positive and negative outcomes expected to be associated with it (behavioral beliefs). The SN construct represents perceived social pressures to engage in or avoid a given behavior, and is based on the perceived normative expectations of important referents (normative beliefs).  The PBC construct represents one’s perceived ability to perform a given behavior, and is based on beliefs about factors that may facilitate or impede performance of that behavior (control beliefs). Importantly, the PBC influences behavior both directly and indirectly (through BI).  The TPB has been found to be appropriate as a predictive model for explaining health-related behavior in a variety of healthcare fields (Karmali, 2014; Lopez, 2013; Ferri 2013; Johnston, 2012; Underhill, 2009) and professions (Godin, 1996; 2008; Armitage, 2001). A few studies (Rigby et al, 2013; Kortteisto et al, 2010) have modelled clinical assessment behaviors of health professionals from the TPB to explain intentions, understand influences, and/or design interventions. For example, Rigby (2013) examined Athletic Trainers’ (ATs) intention to use a recommended concussion guideline. Results showed that behavior-related factors (BA; SN; PBC; BI) significantly explained ATs’ intention (R=0.683; R2=0.466; F=58.78; P<.001) and behavior (R=0.661; R2=0.437; F=78.902; P<.001). Additionally, BA and PBC demonstrated the strongest influence on BI. Accordingly, the authors recommended that interventions should target behavior-related attitudes and perceptions of control to increase guideline uptake by ATs. Also, Kortteisto (2010) investigated health professionals’ intention to use clinical practice guidelines within a multidisciplinary hospital setting. TPB factors (BA; SN; PBC) significantly explained BI (F=37.41, P<.001). However, the influence of behavior-related attitudes, normative expectations, and control perceptions on BI varied for each profession type. Consequently, the authors recommended that interventions should target the most influential factors for each profession type to increase guideline uptake. To date, no MT research has applied a health behavior theory to investigate SOM behavior by RMTs and/or guide intervention design to support SOM uptake and sustained use in MT.   Registered Massage Therapists’   8  Figure 1. A framework of the theory of planned behavior [Ajzen, 1988; 1991]  Because of a paucity of research relating to the use of SOMs in MT, the TPB was chosen to frame the research design and to explain the findings of the research. The primary research question was: What are RMTs’ intention to use SOMs? A sub question was: Which theory-based factors most influence RMTs’ intention to use SOMs? A final sub question was: Which RMT beliefs contribute most to the factors of the TPB? METHODS Participants This study included a cross-sectional sample of registered massage therapists (RMTs) in British Columbia (BC), Canada. Cross-sectional data was collected pertaining to current SOM practices by RMTs. Regression analysis of data explained how RMTs’ motivation impacted SOM behavior. Contact information for these therapists was obtained through their professional organization, the Registered Massage Therapists’ Association of BC (RMTBC). The RMTBC provides support, assistance, and services to a large majority of RMTs in BC (RMTBC, 2016). The target population was chosen for two primary reasons. First, previous studies have not explored SOM behavior by RMTs. Second, provincial legislation and College of Massage Therapists of BC (CMTBC) bylaws provide the framework for regulating the massage therapy profession in BC, suggesting that RMTs share some degree of equivalency in training, knowledge, skills, and continuing education. In October 2016, over 3000 RMTBC members were available for sampling. Measures: RMT Survey A survey method was chosen to assess thoughts, opinions, and feelings of RMTs regarding SOM behavior. This necessitated the development of a 17-item questionnaire, with closed and open ended BehavioralLikelihoodBehavioral Intention (BI)weak - strongBehavioral Attitude (BA)negative - positiveSubjective Norm (SN)disapproval - approvalPerceived Behavioral Control (PBC)hard - easyRegistered Massage Therapists’   9 questions, to provide a descriptive and exploratory understanding about SOM practices in MT. The survey consisted of three sections: participant characteristic questions (n=6); TPB questions (n=9); open ended questions (n=2). An early version of the survey was piloted by three individuals (two RMTs) who’s data were not included in final study results.  Participant Characteristics The four-page survey began with questions regarding the following practice characteristics: years of experience; work hour classification; primary practice setting; insurance service provider status. In addition, respondents were asked to report their use of SOMs, with three response options (always, occasionally, or never). TPB measures TPB measures are most commonly inferred from survey research methods (Oluka, 2014). Since a literature search failed to identify a suitable instrument for this project, nine TPB-related items were created from recommended guidelines (Ajzen, 2002; Eccles, 2004) to measure and explain SOM behavior by RMTs. All TPB items were rated on a 7-point Likert scale, ranging from strongly agree to strongly disagree. The BI items (n=3) measured RMTs’ perceived likelihood of engaging in SOM behavior. The BA items (n=2) measured RMTs’ personal evaluation of SOM behavior. The SN items (n=2) measured RMTs’ perceived social pressure to engage in or avoid SOM behavior. The PBC items (n=2) measured RMTs’ perceived ability to carryout SOM behavior. The distribution of TPB items is outlined in Table 1.  Table 1. Survey Distribution of TPB Items TPB Constructs and Items Scale Behavioral Intention (BI) 1. I want to conduct SOMs 2. I expect to conduct SOMs 3. I intend to conduct SOMs 7-point Likert scale (strongly agree to strongly disagree)  Behavioral Attitude (BA) 1. It is useful to conduct SOMs 2. It is important to conduct SOMs 7-point Likert scale (strongly agree to strongly disagree)  Subjective Norm (SN) 1. Respected colleagues conduct SOMs 2. Respected people/groups approve my conducting of SOMs 7-point Likert scale (strongly agree to strongly disagree)  Perceived Behavioral Control (PBC) 1. I could easily conduct SOMs 2. I have autonomy to conduct SOMs 7-point Likert scale (strongly agree to strongly disagree)       Registered Massage Therapists’   10 Beliefs about SOM Benefits and Barriers  Two open-ended questions were designed to identify important RMT beliefs about benefits and barriers to SOM practices. Participants were asked to type responses (maximum six per question) in point form.  Procedure Due to project scope (objectives; timelines; tasks; costs), a web-based survey was carried out from October to November 2016 to provide a ‘snapshot’ of SOM behavior by RMTs. Data was collected using UBC Survey Tool (FluidSurveys/SurveyMonkey, 2016). As agency sponsor for this study, the RMTBC was asked to e-mail a cover letter and survey link to its membership. The e-mail was sent by the RMTBC to preserve member confidentiality and participants were instructed via the cover letter that gaining access to the 5-minute survey implied informed consent. A one-month window was provided to access and complete the survey. Two follow-up reminders were e-mailed before the data set was closed on November 16, 2016, one-month after the initial invitation. Participants were allowed to withdraw from the study at any time and to skip questions without any penalty. The study was reviewed and approved in August 2016 by the principal investigator’s university institutional review board. All survey responses were coded and potential identifying information about respondents was permanently hidden (email addresses; IPs; invite codes; referring URLs). All survey data has been stored in Canada and is compliant with British Columbia privacy legislation (FOIPPA). Analysis Multiple regression analysis of nine TPB items was supported electronically (Analysis ToolPak in Excel 2016) to report the following results tables: Descriptive Statistics; ANalysis Of VAriance (ANOVA); Model Summary; Coefficients. Assumptions that underpin multiple regression (outliers; collinearity; independent errors; random normally distributed errors; homoscedasticity and linearity; non-zero variances) were examined to strengthen the validity of results (Loosveldt, 2015). Thematic analysis of text from two open-ended items (Braun, 2006) was supported electronically (FluidSurveys/SurveyMonkey, 2016) to identify, analyze, and report themes within data.  RESULTS Response Rate A total of 320 RMTs (11%) responded to the survey invitation. Of those, 153 respondents completed all survey items (48% completion rate), 258 respondents completed all practice characteristic items, 207 respondents completed all TPB items, 153 respondents completed the first open question about SOM benefits, and 165 respondents completed the second open question about SOM barriers.   Registered Massage Therapists’   11 Practice Characteristics of Participants The results of practice characteristics are outlined in Table 2. The majority of respondents (144 of 258 [56%]) worked full-time for more than 30 hours per week as an RMT. Nearly half of respondents (125 of 259 [48%]) had 10+ years of work experience and the vast majority (228 of 259 [88%] practiced within a massage/multidisciplinary clinic setting. Over three-quarters of respondents (198 of 259 [76%]) were registered as insurance service providers with ICBC, whilst only one third (175 of 259 [68%]) were registered as insurance service providers with WorkSafeBC. Lastly, respondents reported to always (12 of 258 [5%]), occasionally (62 of 258 [24%]), or never (184 of 258 [71%]) use SOMs. Notably, background factors (clinical experience; insurance service provision) did not significantly influence daily (3-6%) or occasional (22-29%) use of SOMs when compared to general population results (always [5%]; occasional [24%]).                                      Registered Massage Therapists’   12 Table 2. Practice Characteristics  Characteristics Number (N) Percentage (%) Years Experience a. Under 5 years b. 5-to-10 years c. Over 10 years  N=76  N=58   N=125  29.3% 22.4% 48.3% Work Hour Classification a. Full time (30 hours or more/week) b. Part time (<30 hours/week)  N=144 N=114  55.8% 44.2% Primary Employment Setting a. Massage/multidisciplinary clinic b. Home care/visit c. Educational institution d. Professional association or college  e. Spa/wellness f. Other  N=228 N=4 N=4 N=1 N=9 N=13  88.0% 1.50% 1.50% 0.40% 3.50% 5.00% Motor-vehicle accident insurance service provision (ICBC) a. Yes b. No  N=198 N=61  76.4% 23.6% Workplace accident insurance service provision (WorkSafeBC) a. Yes b. No  N=84 N=175  32.4% 67.6% General use of SOMs a. Never b. Occasionally (weekly/monthly) c. Daily  N=184 N=62 N=12  71.3% 24.0% 4.70% Work experience and use of SOMs i. Under 5 years a. Never b. Occasionally (weekly/monthly) c. Daily ii. 5-10 years a. Never b. Occasionally (weekly/monthly) c. Daily iii. Over 10 years a. Never b. Occasionally (weekly/monthly) c. Daily   N=56 N=17 N=2  N=35 N=17 N=6  N=91 N=27 N=5   74.7% 22.7% 2.70%  60.3% 29.3% 10.3%  74.0% 22.0% 4.10% Insurance Service Provision and Use of SOMs i. Insurance Corporation of BC (ICBC) a. Never b. Occasionally (weekly/monthly) c. Daily ii. Workers’ Compensation Board of BC (WorkSafeBC) a. Never b. Occasionally (weekly/monthly) c. Daily   N=142 N=46 N=10  N=57 N=19 N=5   71.7% 22.0% 4.10%  70.4% 23.5% 6.2% Note. A minority (29%) of respondents reported using SOMs on a daily (5%) or occasional (24%) basis. Background factors (clinical experience; insurance service provision) did not significantly influence SOM use on a daily (3-6%) or occasional (22-29%) basis.   Registered Massage Therapists’   13 TPB Measures A multiple regression was conducted to see if behavior-related attitudes (BA), norms (SN), and perceptions of control (PBC) predicted RMTs’ intention (BI) to use SOMs. Descriptive statistics were first reported to provide data for regression analysis. Various TPB item measures (counts; means; standard deviations) are summarized in Table 3.  Table 3. Descriptive Statistics (Counts, Means, Standard Deviations) Construct/Item Count (N) Item (Mean, SD) Total  (Mean, SD) Behavior 1. Frequency of SOM use  207   1.3, 0.6  1.3, 0.6 Behavioral Intention (BI) 1. I want to conduct SOMs 2. I expect to conduct SOMs 3. I intend to conduct SOMs  207 207 207   5.0, 1.5 4.4, 1.5 4.6, 1.6  14.1, 4.3 Behavioral Attitude (BA) 1. It is useful to conduct SOMs 2. It is important to conduct SOMs  207 207   5.0, 1.5 4.8, 1.6  9.8, 3.0 Subjective Norm (SN) 1. Respected peers conduct SOMs 2. Respected people/groups approve conducting SOMs  207 207   4.3, 1.5 5.5, 1.3  9.8, 2.5 Perceived Behavioral Control (PBC) 1. I could easily conduct SOMs 2. I have autonomy to conduct SOMs  207 207   4.8, 1.5 5.7, 1.3   10.6, 2.3 Note. A majority of RMTs held positive intention toward using SOMs.   Analysis of variance (ANOVA) was conducted to determine if overall analysis of results was statistically significant (p<.05). Table 4 presents a significance value that is less than .05 (Sig. F=2.39-66), confirming that findings were statistically significant.  Table 4. ANOVA b Model Sum of Squares df Mean Square F Sig. F 1. Intention model            Regression          Residual          Total  2917.516 825.740 3743.256  3 203 206  972.505 4.067   239.080  2.3908E-66a a Intention predictors: (Constant), behavior attitude, subjective norm, perceived behavioral control. b Dependent variable: Behavioral intention.  A model summary determined how much of the variance in behavioral intention was explained by behavior-related attitudes (BA), norms (SN), and perceptions of control (PBC). The results outlined in Table 5 show that behavior-related attitudes (BA), norms (SN) and control perceptions (PBC) explained Registered Massage Therapists’   14 78% of RMTs’ intention (BI) to perform SOMs (F(3,203)=239.08, p<.001, R2=0.78, R2Adjusted=0.78). Notably, a low intention-behavior relationship was confirmed, as PBC and BI factors explained only 15% of the variance in actual behavior (F(2,204)=18.89, P<.001, R2=0.16, R2Adjusted=0.15).  Table 5. Model Summary b Model R R Square Adjusted R Square Std. Error of the Estimate Durbin-Watson Intention Model 0.88 0.78a 0.78 2.02 2.130  Note. The R Square value (0.78) confirms 78% of RMTs’ BI was explained by BA, SN, and PBC. a Predictors: (Constant), Behavioral Attitude, Subjective Norm, Perceived Behavioral Control. b Dependent Variable: Behavioral Intention.   Measures of coefficients were conducted to report how behavior-related attitudes (BA), norms (SN), and control perceptions (PBC) influenced RMTs’ intention to perform SOMs. The results outlined in Table 6 show that SN (ß=0.04, t=0.55; P=.58) did not significantly influence BI. However, BA (ß= 1.13, t=17.20, P<.001) and PBC (ß=0.20, t=2.57, P=.01) did significantly influence BI. The regression equation was: predicted BI = constant variable coefficient + predictor variable coefficient x (predictor variable score). Also, analysis found that PBC (ß= 0.09, t=0.49, p=.06) did not significantly influence behavior, whereas BI (ß= 0.05, t=4.85, p<.05) did significantly influence behavior.  Table 6. Coefficients a Model Std. Error ß t-stat p-value VIF Intention Model a (Constant) BA SN PBC  0.721 0.066 0.075 0.080  0.432 1.129 0.041 0.204  0.599 17.195 0.554 2.567  0.550 1.752-41 0.580 0.011   0.400 0.775 1.031 a Dependent variable: Behavioral Intention.            Registered Massage Therapists’   15 A normal probability plot (Figure 2) was performed to illustrate whether or not data followed a normal distribution. The illustration shows that data points formed a linear pattern and ran close to the normal distribution line. This confirmed a normal distribution of data, suggesting that results were valid and should match reality.   Figure 2. Normal probability plot of regression standardized residual  SOM Practice Benefits and Barriers  RMT beliefs about important benefits and barriers to SOM practices are reported in Table 7. Practice benefits (153 count) were categorized and ranked to include: professional communications (39%); clinical assessment (38%); treatment planning (33%); evidence-based practices (29%); treatment outcomes (25%); treatment evaluation (24%); decision-making (21%); progress monitoring (16%); treatment justification (15%). Practice barriers (165 count) were categorized and ranked to include: time (55%); knowledge (30%); confidence (17%); access (12%); skills (12%); desire (10%); patient expectation (9%); workplace culture (6%). Thematic analysis of text enabled the reporting of three distinct themes: behavioral beliefs; normative beliefs; control beliefs. Themes were found to influence SOM-related attitudes, normative expectations, and control perceptions of RMTs.        05101520250 20 40 60 80 100 120Expected ProbabilityObserved ProbabilityNormal Probability PlotRegistered Massage Therapists’   16 Table 7. SOM Practice Benefits and Barriers (counts/percentages; belief rankings; belief themes; TPB factors)  Topics Counts / % Belief Rankings Belief Themes TPB Factors Benefits (153 count) n = 60 (39%) n = 58 (38%) n = 51 (33%) n = 44 (29%) n = 38 (25%) n = 36 (24%) n = 32 (21%) n = 24 (16%) n = 23 (15%) 1. Professional communications b 2. Clinical assessment b 3. Treatment planning b 4. Evidence-based practices b 5. Treatment outcomes b 6. Treatment evaluation b 7. Decision-making b 8. Progress Monitoring b 9. Treatment justification b Control beliefs d Behavior beliefs e Norm beliefs f Control perceptions (PBC) Attitudes (BA) Norms (SN)  Barriers (165 count) n = 90 (55%) n = 49 (30%) n = 28 (17%) n = 20 (12%) n = 19 (12%) n = 17 (10%) n = 15 (9%) n = 11 (6%) 1. Time a 2. Knowledge a 3. Confidence a 4. Access a 5. Skills a 6. RMT disapproval b 7. Patient disapproval c 8. Workplace support a   Note. RMTs hold favorable behavioral beliefs that strengthen BA and increase likelihood of SOM use. RMTs hold ability and resource-related control beliefs that weaken PBC and decrease likelihood of SOM use. a  Represents a control belief. b Represents a behavioral belief. c Represents a normative belief. d Contributes to PBC. e Contributes to BA. f  Contributes to SN.  DISCUSSION Standardized outcome measures (SOMs) have become important for establishing intervention efficacy and efficiency, and providing credible and reliable treatment justification (Jette, 2009; Fawcett, 2007). However, only 29% of respondents acknowledged practicing SOMs on a daily (5%) or occasional (24%) basis. Furthermore, RMT use of SOMs was not significantly influenced by practice experience or insurance service provision. Poor uptake of outcome measures by professionals has been reported in numerous research reports (Kennedy, 2015, 2016; Jette, 2009; Bland, 2013; Salbach, 2011; Swinkles, 2011; Jenson-Doss, 2010, Hutchinson, 2006, Russek, 1997). For example, Salbach (2011) investigated physical therapists’ use of standardized assessments of walking ability post-stroke and found that only a moderate number of therapists consistently used tools to evaluate (44.6%) or monitor (42.9%) health status change. From a MT perspective, poor compliance toward SOM behavior implies that decision making by RMTs is less likely to be rational and consequently defensible (Shcroff, 2012; Fawcett, 2007).  The TPB presented a framework of constructs to measure and explain SOM behavior by RMTs. Results showed that RMTs’ behavioral intention (BI) was significantly explained (79%) by behavior-related attitudes (BA), norms (SN), and perceptions of control (PBC). Conversely, SOM behavior was not significantly explained (15%) by BI and PBC factors. This indicated a low intention-behavior relationship, as only 29% of respondents acknowledged performing SOMs, despite carrying positive Registered Massage Therapists’   17 intention toward doing so. It has been suggested that strong correlation cannot be expected if: (1) there is little, or no variance in either BI or behavior, and/or (2) PBC is considered weak, as it has a direct effect on both BI and behavior (Ajzen, 2005). BA and PBC factors significantly influenced BI toward SOM behavior, whereas SN did not. This implied that RMTs with positive attitudes are more likely to perform SOMs, and less likely do so if control perceptions are weak (Ajzen, 2006). Research has suggested positive professional attitude to be a strong predictor, although insufficient on its own, of positive evidence-based behavior (Hutchinson, 2006; Gowan-Moody, 2013; Jenson-Doss, 2011; Jette, 2009; Leach, 2008; 2011). For example, Jette (2009) investigated the use of SOMs in physical therapy and found that only 48% of PTs performed such practices, even though a majority (>90%) believed outcome measures enhanced patient communication and helped direct plan of care. Thus, results suggested that poor SOM compliance by RMTs could be explained by the presence of unfavorable attitudes (BA) and/or weak control perceptions (PBC). In order to recommend appropriate interventions, it was important to first understand the beliefs that underlie SOM behavior. Beliefs about SOM practice benefits and barriers were represented in three themes (behavioral beliefs; normative beliefs; control beliefs) that linked back to motivational factors (BA; SN; PBC) of the TPB. For example, all practice benefits exemplified behavioral beliefs that were considered favourable to BA and subsequent SOM behavior. Conversely, most practice barriers represented resource or ability-related control beliefs (time; knowledge; confidence; access; skills) that weakened control (PBC) over SOM behavior. Also, patient disapproval characterized a normative belief that placed negative expectation on SN and subsequent SOM behavior. However, overall results showed that normative influences (patients; colleagues; insurers; professional bodies) did not have significant roles in understanding RMTs BI and subsequent SOM behavior. Despite holding favorable attitudes and positive intention, RMTs were found to experience numerous ability and resource-related barriers that weaken control over SOM behavior.  This study represented the first step toward explaining SOM practices in MT and recommending strategies to improve behavioral compliance by RMTs. The literature suggested that interventions can be designed to influence intention-behavior change by targeting factors (BA; SN; PBC) of the TPB (Ajzen, 2006). A meta-analysis (Webb, 2006) of behavior change intervention research (n=47) reported that a medium-to-large change in intention (d=0.66) lead to a small-to-medium change in behavior (d=0.36). Interventions should be designed to target behavior-related attitudes and perceptions of control in order to make SOM practices more favorable to and within control of RMTs. For example, educational interventions (mail-outs; conferences; symposiums; courses) could strengthen BA by informing RMTs about SOM benefits and convincing them that such practices are worthwhile. Also, because RMTs perceptions of control (PBC) were found to be weak, interventions (resource development; courses; Registered Massage Therapists’   18 workshops) should address ability and resource-related practice barriers (time; knowledge; access; skills) to increase control over SOM behavior. The IN-CAM Outcomes Database (Kania, 2012) is one example of a centralized location where RMTs could develop skills and confidence required to access information on outcome measures considered relevant to the MT profession.  In summary, only 29% of RMTs acknowledged using SOMs on a daily (5%) or occasional (24%) basis. This behavior was not influenced by clinical experience or insurance service provider status. Regression analysis reported that RMTs’ intention (BI) toward SOM behavior was significantly (79%) explained by behavior-related attitudes (BA), norms (SN), and control perceptions (PBC). However, only 15% of SOM behavior was explained by BI and PBC, indicating a low intention-behavior relationship. The BA and PBC were found to exert the greatest impact on BI, suggesting that RMTs with positive attitudes are more likely to perform SOMs, and less likely when a perceived lack of control exists. Thematic analysis of practice benefits and barriers to SOM practices enabled the reporting of three distinct themes (behavioral beliefs; normative beliefs; control beliefs) that linked to motivational factors (BA; SN; PBC) of the TPB and explicated quantitative findings. Despite holding favorable attitudes and positive intention, RMTs perceived numerous resource and ability-related practice barriers that weaken control over SOM behavior. Future interventions should address time, knowledge, access, and skills required to perform SOMs in MT.  Limitations of the study This study was the first step in understanding determinants to the performance of SOMs by RMTs. Inherent limitations of survey research are associated with this study. First, a low response rate and missing values may lead to non-response bias, restricting ability to interpret results and generalize findings. Second, measurement error could result, as survey items were created from recommended guidelines, but not psychometrically tested. Third, difficulty reading or interpreting questions by respondents may bring about greater response variability and bias. Finally, observation bias may ensue from the inability to verify item responses through actual behavioral observation. Direction for future research Future research will be vital to reinforcing and extending this study’s findings. First, repeated TPB measures based on population characteristics will be required to strengthen understanding of SOM behavior by RMTs. Second, future survey design should include indirect belief-based measures to further explicate how beliefs influence RMTs’ intention towards SOM behavior. Third, longitudinal research should be conducted to determine how effective behavior change strategies are at increasing the uptake and sustained use of SOMs by RMTs. Finally, a process for SOM data collection will be vital to developing a sound evidence-base for the MT profession and providing credible treatment justification to RMTs. Registered Massage Therapists’   19 CONCLUSIONS A low intention-behavior relationship exists, as very few RMTs perform SOMs, despite holding positive intention (BI) towards doing so. RMTs’ intention towards SOM behavior was significantly explained by behavior-related attitudes (BA), norms (SN), and control perceptions (PBC). RMTs’ intention to perform SOMs were most influenced by their attitudes (BA) and perceptions of control (PBC), indicating that therapists with positive attitudes are more likely to perform SOMs, and less likely when weak control perceptions exist. Despite holding favorable attitudes and positive intention, RMTs perceive numerous resource and ability-related practice barriers that weaken control over SOM behavior. Future interventions should address time, knowledge, access, and skills required to perform SOMs in MT. More research is needed to better understand determinants to SOM behavior by RMTs and further promote SOM uptake and sustained use in MT. CONFLICT OF INTEREST NOTIFICATION RH and LB declare that they have no competing or conflicting interests that may bias or influence this work. RH is a registered massage therapist (RMT) and acted as an independent researcher for the purposes of this manuscript. 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