By Gerjo Kok, Maastricht University, the Netherlands; University of Texas at Houston, USA

A wide range of campaigns and interventions to improve public health and change health behaviors currently exists, but many of these are not “theory- and evidence-based”. This post will briefly describe the processes health psychologists undertake when developing interventions, and highlight how these differ from (and improve upon) similar processes commonly undertaken elsewhere.

Steps

Planning behavior change interventions is a step-by-step process, which often involves taking two steps forward and one step back. This is especially important, as each step builds on previous steps, and inattention to one step may lead to mistakes and inadequate decisions in another. The so-called Intervention Mapping (IM) protocol identifies six steps in intervention development which help the planner to create on intervention based on theory and evidence:

Step 1: Needs assessment

In this step, a planning group, consisting of all parties involved – including target population, stakeholders, experts, researchers and future implementers – assesses the problem. This includes identifying the behavioral and environmental causes of the problem, as well as the determinants of these behavioral and environmental causes. These pieces can then be depicted in a “logic model” of the problem – like the (simplified) one below on adolescents’ STI/HIV prevention – which offers a clear picture of how the various pieces fit together.

Step 2: Identifying objectives

Once the problem and its causes are clearly defined, specific program outcomes and objectives can be defined as well. This includes specifying how determinants of individuals’ behaviors and environments’ agents (decision makers) will need to be changed in order to alleviate the problem. For example, from the logic model above, to promote adolescents’ condom use, the intervention should increase risk perception as well as the perceived effectiveness of condoms to reduce risk perception. The intervention should also influence the partner directly, if possible, in combination with improving adolescents’ negotiating self-efficacy. Finally, depending on existing societal norms, access to family planning services can be facilitated.

Step 3: Intervention design

A coherent, deliverable intervention is designed. Theory-based intervention methods and practical applications to change (determinants of) behavior are selected, and program themes, components, scope and sequence are generated. IM distinguishes so-called behavior change methods (or techniques) that have been shown effective in changing determinants of behavior and/or environmental causes. For example, risk perception can be increased by scenario-based risk information. Self-efficacy may be improved by modeling and feedback. Advocacy and lobbying may influence decision-making at the policy level. All these change methods require translation into practical applications, taking into account the theory and evidence-based parameters. For example for modeling: the learner will identify with the model, the learner observes that the model is reinforced, the learner has sufficient self-efficacy and skills for the action, and the model serves as a coping model instead of a mastery model.

Step 4: Intervention production

This is the actual production of the intervention. Program structure is refined, and messages and materials are drafted, pretested, and produced. For the example above, the Dutch ‘Long Live Love’ program was developed, implemented and has been repeatedly shown to promote safer sex in adolescents in schools.

Step 5: Implementation plan

A program implementation plan is generated. Potential program users are identified, performance objectives and change objectives for program use are specified, and implementation interventions are designed, again using the steps of IM. For the example above, the intervention targeted 14-15 years old adolescents at schools. The implementation intervention targeted dissemination to the schools, adoption by the school directors and teachers, correct implementation by the teachers, and finally institutionalization of the intervention by the school directors and boards.

Step 6: Evaluating effectiveness plan

Developing an intervention is not the end of the road. It is also important to evaluate whether an intervention achieved its objectives (i.e., effectiveness evaluation), and whether or not the intervention was implemented as intended (i.e., process evaluation). Activities for steps 5 and 6 should start as early as possible in the planning process. Information from these evaluations can be used to refine and improve interventions, moving back and forth between steps.

Broad perspectives

The planning of behavior change interventions should always:

(1) Use behavioral theories and evidence as foundations;

(2) Take an ecological approach to assessing and intervening in (health) problems; and

(3) Make sure that agents in the target communities and other relevant stakeholders participate.

An individual with a health problem is part of a system, as is the potential solution for the health problem. Therefore, broad participation across different levels of a system can bring a greater breadth of skills, knowledge, and expertise to a project and can improve how applicable the intervention is in real world settings and how best to evaluate the intervention.

Core processes

IM also suggests “core processes”, key actions for applying theory and evidence: posing questions, brainstorming answers, reviewing empirical findings, accessing and using theory, identifying and addressing the need for new research, and finally formulating the working list of answers.

Especially the process of accessing and applying theory is the challenge that health psychologists are especially trained for. Searching the literature for evidence on the topic, the program planner will encounter theoretical ideas, as well as concepts that may be linked to theories. Finally, planners may use theories that they are familiar with, for example the theory of planned behavior for determinants of behavior, or self-regulatory theories for changing behavior.

Practical recommendations

• Every planning group for a behavior change intervention should have a behavioral science expert as one of its members, e.g., a well-trained health psychologist.
• When developing behavior change interventions, use theory and evidence, take a systems approach, and improve participation in the intervention.
• Planning behavior change interventions is a step-by-step process, wherein each step builds on those preceding it. The IM protocol can help guide people through these steps.
• The ‘core processes’ may assist the health psychologist in finding theoretical answers for planning questions.
• Particularly relevant for intervention planning are: identifying changeable and important determinants of behavior, taking into account the theoretical parameters that make behavior change methods effective, and making sure that the intervention is implemented as planned.