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 Table of Contents  
Year : 2022  |  Volume : 17  |  Issue : 1  |  Page : 97-98

Theory of Planned Behavior – The Need of the Hour?

1 MBBS student, Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
2 Department of Psychiatry, Community Mental Health team, Exeter, UK
3 Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

Date of Submission08-Sep-2020
Date of Acceptance01-Nov-2020
Date of Web Publication15-Mar-2022

Correspondence Address:
Dr. Latika Gupta
Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/injr.injr_252_20

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How to cite this article:
Raj R, Agarwal S, Gupta L. Theory of Planned Behavior – The Need of the Hour?. Indian J Rheumatol 2022;17:97-8

How to cite this URL:
Raj R, Agarwal S, Gupta L. Theory of Planned Behavior – The Need of the Hour?. Indian J Rheumatol [serial online] 2022 [cited 2022 Oct 1];17:97-8. Available from:

Dear Editor,

We read with great interest the article by Morowatisharifabad et al.[1] on the utility of the theory of planned behavior (TPB) in Osteoarthritis of the knee. The authors have raised the pertinent issue of TPB for successful interventions of any kind, including coping behaviors, compliance, and overall work and personal hygiene.

Intention to comply with treatment is vital to the successful management of any disease. TPB may be useful in the management of rheumatic diseases (RDs) such as spondyloarthritis (SpA) and chronic pain syndromes such as fibromyalgia, where regular exercise remains the cornerstone of management. Self-care behavior becomes even more relevant during the pandemic for the management of RDs when access to healthcare services has become limited. In addition, the TPB plays a vital role in the prevention and control of coronavirus disease 2019 (COVID-19) itself.

Taal et al. discuss the role of self-care in the management of rheumatoid arthritis (RA) in a systematic review. The constant need to adjust exercise regimes according to disease activity poses a challenge to adherence for patients. Thus, patient education assumes a larger role, not only to equip the patients with the correct exercise regimens, but also as a responsible member in problem-solving and shared-decision making initiative with the rheumatologist, general practitioner, and physiotherapist. Self-efficacy expectation comprises of a person's belief in themselves to successfully carry out a required behavior. It is likely to impact an individual's choice of behavior, the quantity of effort, and perseverance while self-managing. Patient education is the key to improving self-efficacy expectations and has demonstrated improved health outcomes in RA. It is associated with a decrease in pain, physical disability, depression, and stress; and improvement in coping behavior.[2]

Social interaction also plays an important role in the development of and adherence to self-care behavior. For patients with RA who depend on a partner or relative for activities of daily living, how the caretaker perceives their coping abilities has an impact on the adaption of positive or negative self-care behavior. Negative criticism from the partner inspires maladaptive coping behavior and increased depression, while positive support inspires productive outcomes and less depression.[2] Thus, the lifestyle and family structure of the Indo-Pak region, where living in joint families is the norm, may be beneficial to patients with RDs compared to other parts of the world where independent living is more common.[3]

SpA, another chronic and disabling RD, relies heavily on regular physical activity for management.[4] Barriers to compliance with regular exercise in patients with SpA include time constraints, fatigue, and disease symptoms like pain, while the pleiotropic benefits of exercise, disease-symptom management, and motivation facilitate compliance.[5] It is well established that supervised group exercise is associated with better health outcomes and satisfaction in patients with SpA.[6] In addition, patient education targeting the benefits of exercise and overcoming barriers to coping with it and personalized exercise routines according to patient's needs and abilities is associated with better exercise behavior.[6],[7]

Achieving this can be challenging in current times of the pandemic when work from home has encouraged a sedentary lifestyle, and supervised group exercises may not be possible to attend. In India, the popularity of yoga may provide an answer to these problems. Education, both at the end of physicians and patients, and a dearth of rheumatologists is a huge barrier in India.[8] It creates a gap in the patient's understanding of their disease, increases misinformation, and hence results in decreased adherence to self-management behaviors. There is a need to increase awareness of RDs at all levels of medical education and specialization in India, including physiotherapists and patients.[8]

TBP can be applied in the management of almost any medical condition by tailoring it to the specific needs of the patients according to their disease. Pastor-Mira et al.[9] suggested that the intention-adherence gap in women with fibromyalgia may be addressed by discussing specific plans that include advice on dealing with factors inhibiting adherence to intended behavior. This is in line with the findings of studies by Hilberdink et al.[6],[7] and McDonald et al.[10] in patients with SpA.

The TPB can also explain why compliance with preventive measures for COVID-19 disease has been challenging.[11],[12],[13] Individuals driven by controlled motivation (i.e., acting for external rewards or in response to fear of retribution) tend to adopt preventive self-care behaviors in response to imposed legislation but are unlikely to adhere to them in the long run compared to individuals driven by autonomous motivation (i.e., acting for internal rewards). Social factors such as obeyance of protocols by kin and ample access to information encourage adherence to preventative self-care behaviors. An inconsistency in instructions on preventive measures, lack of protective equipment, perceived behavioral control, and negative attitudes of people towards those following standard operating procedures (SOPs) is discouraging.[12] On similar lines, Ahmad et al.[11] found that government-issued instructions were the main drivers of intention to adopt preventive measures followed by the perception of the risk of contracting the infection and knowledge about the pandemic. In contrast, an individual's perception of the usefulness of adopting preventive behaviors was an important barrier to their intention to engage in them.

Thus, patient education remains an important factor in the adoption of and adherence to any intended behavior. A cross-sectional survey of adults with chronic comorbids living in Chicago, USA, found that the majority lacked important knowledge about the COVID-19 disease, and there was a disparity in the risk perception of the infection and therefore, in the adoption of preventive measures.[13]

In conclusion, we would like to congratulate the authors on having brought forward a very relevant and clinically applicable theory to the forefront of academic discussion and suggest that the adoption of this technique be considered for the management of all chronic and disabling RDs.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Morowatisharifabad MA, Gerayllo S, Karimiankakolaki Z, Dehghan A, Salehabadi HS, Fallahzadeh H. Determinants of self-care behaviors in patients with knee osteoarthritis based on the theory of planned behavior in Iran. Indian J Rheumatol 2020;15:201-6.  Back to cited text no. 1
  [Full text]  
Taal E, Rasker JJ, Wiegman O. Patient education and self-management in the rheumatic diseases: A self-efficacy approach. Arthritis Care Res 1996;9;229-38.  Back to cited text no. 2
Kool MB, Geenen R. Loneliness in patients with rheumatic diseases: The significance of invalidation and lack of social support. J Psychol Interdiscip Appl 2012;146:1-2, 229-241.  Back to cited text no. 3
Gupta L, Ahmed S, Choudhury GD, Misra DP, Agarwal V. Poor quality of life in Indian ankylosing spondylitis patients. Indian J Rheumatol 2018;13:101-6.  Back to cited text no. 4
  [Full text]  
Morais S, Liu S-H, Lapane K, Kay J. Sat0619 attitudes and perceptions of physical activity in patients with spondyloarthritis: a systematic review. Ann rheum dis. 2019;78 (Suppl 2):1405. doi:10.1136/annrheumdis-2019-eular.4410.  Back to cited text no. 5
Hilberdink B, van der Giesen F, Vliet Vlieland T, van Gaalen F, van Weely S. Supervised group exercise in axial spondyloarthritis: Patients' satisfaction and perspective on evidence-based enhancements. Arthritis Care Res 2020;72:829-37.  Back to cited text no. 6
Hilberdink B, van der Giesen F, Vliet Vlieland T, van Gaalen, F. and van Weely, S. (2020), Supervised Group Exercise in Axial Spondyloarthritis: Patients' Satisfaction and Perspective on Evidence-Based Enhancements. Arthritis Care Res, 72:829-37. doi:10.1002/acr.23892.  Back to cited text no. 7
Handa R. Rheumatology in India Quo vadis? Nat Rev Rheumatol 2015;11:183-8.  Back to cited text no. 8
Pastor-Mira MA, López-Roig S, Peñacoba C, Sanz-Baños Y, Lledó A, Velasco L. Predicting walking as exercise in women with fibromyalgia from the perspective of the theory of planned behavior. Women Health. 2020;60:412-25. doi:10.1080/03630242.2019.1662869.  Back to cited text no. 9
McDonald MT, Siebert S, Coulter EH, McDonald DA, Paul L. Level of adherence to prescribed exercise in spondyloarthritis and factors affecting this adherence: A systematic review. Rheumatol Int 2019;39:187-201.  Back to cited text no. 10
Ahmad M, Iram K, Jabeen G. Perception-based influence factors of intention to adopt COVID-19 epidemic prevention in China. Environ Res 2020;190:109995.  Back to cited text no. 11
Chan DKC, Zhang CQ, Weman-Josefsson K. Why people failed to adhere to COVID-19 preventive behaviors? Perspectives from an integrated behavior change model [published online ahead of print, 2020 May 15]. Infect Control Hosp Epidemiol. 2020;1-2. doi:10.1017/ice.2020.245.  Back to cited text no. 12
Wolf MS, Serper M, Opsasnick L, O'Conor RM, Curtis L, Benavente JY, et al. Awareness, attitudes, and actions related to COVID-19 among adults with chronic conditions at the onset of the US outbreak. A cross-sectional survey. Ann Intern Med 2020;173:100-9.  Back to cited text no. 13


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