Table 3

Development of seven IPTs to five final programme theories and CMOcs

Prioritised IPT No and TDF domain/mechanism	IPT	Refined/new IPT	Rationale for refinement	Final Context-Mechanism-Outcome configuration (CMOc)	Target behaviour
1 Knowledge	If healthcare professionals are given education about the signs, symptoms and risk factors of dysphagia, then they are more likely to proactively identify OD, because they have the appropriate knowledge.	If healthcare professionals are not provided with basic education about the signs, symptoms and risk factors of dysphagia, then they will be less likely to proactively identify and provide initial advice and support for older adults with suspected OD, because they do not have the appropriate knowledge.	Refined from IPTs 1 and 2. Evidence suggested HCPs require both knowledge and skills to proactively identify OD as well as provide initial advice and support. Negatively worded to reflect majority of evidence demonstrating healthcare professionals without required knowledge and skills did not undertake the target behaviour(s). Interventions which targeted knowledge and skills were pragmatic—brief and basic.	CMOc 1 Healthcare professionals without OD education and training (C) will not have the required knowledge and skills (M) to proactively identify and provide initial advice and support to older adults with suspected OD (O). 17 19–23 65 67–69 71 72 76–81 91	Proactively identify potential OD in older adults. Provide initial OD advice and support prior to formal assessment by a specialist.
2 Skills	If healthcare professionals are trained to provide initial advice and support to older adults with suspected OD, then they are more likely to provide this, because they have the necessary skills to do so.	If healthcare professionals are not provided with basic training about how to identify signs, symptoms and risk factors of dysphagia, then they will be less likely to proactively identify and provide initial advice and support for older adults with suspected OD, because they do not have the appropriate skills.		Merged with CMOc 1	N/A
3 Memory, attention and decision processes	If healthcare professionals have a screening tool to follow, then they will be more likely to proactively identify OD, because it facilitates decision-making.	If healthcare professionals do not have the required knowledge and skills, then they will be less likely to proactively identify and provide initial advice and support for older adults with suspected OD, because they will not be able to make correct decisions around what and how to screen for OD.	Refined from IPT 3. Evidence suggested that screening tools address a lack of knowledge and skills required to make correct decisions regarding OD identification. Screening tools are a standardised approach to facilitating HCPs’ (correct) decision-making.	CMOc 2 Healthcare professionals without the required knowledge and skills (C) will fail to make correct decisions (M) about proactively identifying and providing initial advice and support to older adults with suspected OD (O). 17 68 70 71 74 77 80–82 84 87 100 101	Proactively identify potential OD in older adults. Provide initial OD advice and support prior to formal assessment by a specialist.
4 Environmental context and resources	If there are websites, forums, information leaflets, etc to give to patients, then healthcare professionals are more likely to provide initial guidance and support for older adults with suspected OD, because they have the required resources.	N/A	Discarded—insufficient evidence to support mechanism.	Merged with CMOc 1	N/A
NEW Environmental context and resources	N/A	If OD identification is incorporated into existing health reviews/assessments/systems used by healthcare professionals for older adults, such as medication reviews, then they will be more likely to proactively identify suspected OD in older adults, because of a more conducive work environment.	Evidence supported IPT without refinement.	CMOc 3 Incorporating OD identification into existing workflow (C) will create a conducive environment (M) for healthcare professionals to carry out this behaviour (O). 19 67 71 86–88	Proactively identify potential OD in older adults.
5 Social, professional role and identity	If healthcare professionals perceive that their role includes proactively identifying OD and providing initial advice and support for older adults with suspected OD, then they will be more likely to carry this out, because they feel obligated to.	Discarded—insufficient evidence to support mechanism.	N/A	N/A	N/A
NEW Social influence	N/A	If healthcare professionals are aware that patients and carers expect them to address OD, then they will be more likely to proactively identify and provide initial advice and support for older adults with suspected OD, because they will be encouraged to address patient concerns/wishes.	Evidence supported IPT without refinement.	CMOc 4 Healthcare professionals who are aware that older adults and carers expect them to address OD (C) will be encouraged (M) to proactively identify OD and provide initial advice and support to older adults with suspected OD (O). 18 89 90	Proactively identify potential OD in older adults. Provide initial OD advice and support prior to formal assessment by a specialist.
6 Beliefs about consequences	If the negative outcomes that occur from unaddressed OD are highlighted to healthcare professionals, then they will be more likely to proactively identify OD and provide initial advice and support to older adults with suspected OD, because they are aware of the adverse consequences of not doing so.	N/A	Evidence supported IPT without refinement.	CMOc 5 Healthcare professionals who are aware of the adverse outcomes associated with OD (C) will recognise the importance (M) of proactively identifying OD and providing initial advice and support for older adults with suspected OD (O). 17 19 65 69 78 88 102	Proactively identify potential OD in older adults. Provide initial OD advice and support prior to formal assessment by a specialist.
7 Optimism	If healthcare professionals hear about examples of positive outcomes associated with proactively identifying OD and providing initial advice and support to older adults with suspected OD, then they will be more likely to carry this out, because they will be confident that them undertaking the behaviour will also lead to positive outcomes.	Discarded—insufficient evidence to support mechanism.	N/A	N/A	N/A

HCP, healthcare professional; IPT, initial programme theory; OD, oropharyngeal dysphagia; TDF, theoretical domains framework.