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Getting inside the black box of health promotion programmes using Intervention Mapping

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Gerjo Kok at Maastricht University
Gerjo Kok
Ilse Mesters at Maastricht University
Ilse Mesters
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Abstract

The practice of health education and promotion entails three key programme-planning activities: needs assessment, programme development and evaluation. Planners need to answer many questions on their way to their programme. If some of these questions are not adequately answered, the final programme may have no effect or even a counter-productive effect. There are many examples of inadequate planning unfortunately: trying to change behaviour that was not related to the problem, trying to change determinants for behaviours that were not relevant to the behaviour, trying to change individual behaviour while environmental factors were responsible, trying to apply change methods that were never shown to be effective, trying to implement programmes by health professionals that were inadequately trained to do so, and so forth. Over the past two decades, planning models in health promotion have helped improve the quality of the planning process, especially in optimizing target group assessment and programme evaluation. The most popular planning model used is Green and Kreuter's Precede-Proceed model 1 , but others are available and all have their distinct unique attributes. 2 One lesser developed aspect of most planning models is an explicit specification of the processes by which one uses theory and empirical findings to develop intervention, and thus, how to design the programme in the end.
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Editorial
Getting inside the black box
of health promotion
programmes using
Intervention Mapping
Gerjo Kok
1
and Ilse Mesters
2
The practice of health education and
promotion entails three key programme-
planning activities: needs assessment, pro-
gramme development and evaluation.
Planners need to answer many questions on
their way to their programme. If some
of these questions are not adequately
answered, the final programme may have
no effect or even a counter-productive effect.
There are many examples of inadequate
planning unfortunately: trying to change
behaviour that was not related to the
problem, trying to change determinants
for behaviours that were not relevant to the
behaviour, trying to change individual
behaviour while environmental factors were
responsible, trying to apply change methods
that were never shown to be effective, trying
to implement programmes by health profes-
sionals that were inadequately trained to do
so, and so forth.
Over the past two decades, planning
models in health promotion have helped
improve the quality of the planning process,
especially in optimizing target group assess-
ment and programme evaluation. The most
popular planning model used is Green
and Kreuter’s Precede-Proceed model
1
, but
others are available and all have their
distinct unique attributes.
2
One lesser devel-
oped aspect of most planning models is an
explicit specification of the processes by
which one uses theory and empirical findings
to develop intervention, and thus, how to
design the programme in the end. But, this
field has advanced as well, considering the
diverse initiatives available today to help
programme developers to create their pro-
gramme’s logic model. Table 1 provides a
glimpse of some tools available.
The above tools may be of interest to
the readers of Chronic Illness because too
often, health promotion intervention are
not systematically developed and/or not
well described. Especially, the latter impedes
programme replication or larger-scale dis-
semination beyond the intervention trial
because to those who search for existing
programmes to improve quality of health-
care, the programme theory and compo-
nents are unclear. Here, we will illustrate the
tool Intervention Mapping
3
in a patient
education application to give a description
of actual programme development activities
needed. Intervention Mapping was chosen
over other tools mentioned in Table 1
Chronic Illness
7(3) 176–180
!The Author(s) 2011
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DOI: 10.1177/1742395311403013
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1
Department of Work and Social Psychology, Maastricht
University, Maastricht, The Netherlands
2
Department of Epidemiology, Maastricht University,
Maastricht, The Netherlands
Corresponding author:
Ilse Mesters, Department of Epidemiology, Maastricht
University, Maastricht, The Netherlands
Email: ilse.mesters@maastrichtuniversity.nl
at MAASTRICHT UNIVERSITY on September 28, 2011chi.sagepub.comDownloaded from
because it provides the most detailed guide
on what to do and especially on how to
conduct required activities to achieve pro-
gramme transparency.
Intervention Mapping describes the iter-
ative path from problem identification to
problem solving or mitigation. Each of the
six steps of Intervention Mapping comprises
several tasks. The completion of the tasks in
a step creates a product that is the guide for
the subsequent step. The completion of all of
the steps serves as a blueprint for designing,
implementing and evaluating an interven-
tion based on a foundation of theoretical,
empirical and practical information. The six
steps and related tasks of the Intervention
Mapping process are the following; each
illustrated with an example from the ‘Lively
Legs’ programme (LL), supporting adher-
ence and healthy lifestyles in leg ulcer
patients:
4
(1) Conduct a needs assessment or problem
analysis: establish a participatory plan-
ning group, conduct the needs assess-
ment, assess community capacity and
specify programme goals for health and
quality-of-life. LL: serious quality of life
issues (e.g. pain, mobility impairment),
relevant behaviours identified (e.g. inad-
equate adherence, insufficient exercise),
and relevant determinants identified
(e.g. knowledge, experiences, skills and
social support).
(2) Create matrices of change objectives:
state outcomes for behaviour and envi-
ronmental change, state performance
objectives, select important and change-
able determinants and create a matrix of
change objectives. Examples from LL:
patients describe beneficial effects of
exercise, demonstrate skills in planning
for vegetable consumption, and are able
to find walking partners.
(3) Select theory-based intervention meth-
ods and practical applications: gener-
ate programme ideas with the planning
group, identify theoretical methods,
choose programme methods, select or
design practical applications and
assure that applications address
change objectives. Illustrations from
LL: main theories are social cognitive
theory, with elements of goal setting
theory and the precaution adoption
model. Chosen methods (e.g. tailoring)
are integrated in motivational
interviewing.
Table 1. Logic model development tools
#Online course on developing logic models and evaluation plans
University of Wisconsin (www1.uwex.edu/ces/lmcourse/)
#Logic Model Overview
University of Wisconsin, includes links to workbooks, PowerPoint presentations, etc.
(www.uwex.edu/ces/pdande/evaluation/evallogicmodel.html)
#W.K.Kellogg Foundation Logic Model Development Guide
(www.wkkf.org/Pubs/Tools/Evaluation/Pub3669.pdf)
(www.wkkf.org/knowledge-center/resources/2010/Logic-Model-Development-Guide.aspx)
#List with Logic Model Tools.
CDC. (www.cdc.gov/eval/resources.htm#logic%20model)
#Innovation Network’s Workstation.
Online workstation with evaluation and planning tools (www.innonet.org)
#Community Tool Box.
ctb.ku.edu/tools/en/sub_section_examples_1877.htm
#Intervention Mapping
www.interventionmapping.com
Editorial 177
at MAASTRICHT UNIVERSITY on September 28, 2011chi.sagepub.comDownloaded from
(4) Translate methods and applications
into an organized programme: consult
intended participants and implementers,
create programme themes, scope,
sequence and materials, prepare design
documents, review available pro-
gramme materials, draft programme
materials and protocols, pre-test pro-
gramme materials and protocols, and
produce materials and protocols. In LL:
key feature of the programme is health
counselling by nurses, comprising
assessment of health behaviours and
exploring motivations and obstacles
for change, setting feasible goals for
change, monitoring progress, providing
feedback, offering alternatives, extend-
ing goals and maintenance.
(5) Plan for adoption, implementation and
sustainability of the programme: iden-
tify potential adopters and implemen-
ters, re-evaluate the planning group,
state programme use outcomes and
performance objectives, specify determi-
nants for adoption and implementation,
create a matrix of change objectives,
select methods and practical applica-
tions and design interventions for
adoption and implementation. LL: the
programme is developed to stimulate
future implementation, e.g. training for
nurses, organizing requirements at
clinics, evaluating cost-effectiveness.
(6) Generate an evaluation plan: review the
programme logic model, write effect
evaluation questions, write evaluation
questions for changes in the determi-
nants, write process evaluation ques-
tions, develop indicators and measures
and specify evaluation design. LL: pos-
itive effects on quality of life, leg ulcer
recurrence, and duration of leg ulcer
healing and leg ulcer free months.
Even though Intervention Mapping is
presented as a series of steps, the process
is iterative rather than completely linear.
Programme developers move back and
forth between tasks and steps as they
gain information and perspective from var-
ious activities. However, the process is also
cumulative. Developers base each step on
the previous steps, and inattention to a step
can jeopardize the potential effectiveness of
the intervention by narrowing the scope and
compromising the validity with which later
steps are conducted.
Intervention Mapping has been found
to be a useful tool for tailoring, in a
systematic way, existing programmes as
well.
5
Frequently, providers are interested
in adapting existing evidence-based pro-
grammes for new populations and settings.
Working from a logic model perspective
enables them to ask relevant questions about
appealing programmes; so, adoption deci-
sions are based on adequate insights about
a programme. Debate continues about
whether adaption of evidence-informed pro-
grammes can be justified. When and if so, a
systematic approach to adoption of pro-
grammes and their possible adaptation
can help programme planners identify and
retain essential programme elements as
programmes are translated to communities
and settings other than those in which they
were first developed and evaluated.
6,7
The key words in Intervention
Mapping are planning, research and
theory. Intervention Mapping provides a
vocabulary for programme planning, proce-
dures for planning activities, and technical
assistance with identifying theory-based
determinants and methods for change.
Intervention Mapping has successfully
been applied in various settings, among
others in the patient education field,
5,8–15
and to a wide range of different behaviours.
More specifically, Intervention Mapping
ensures that theoretical models and empir-
ical evidence guide planners in two areas: (1)
the identification of behavioural and envi-
ronmental determinants related to a target
health problem, and (2) the selection of the
178 Chronic Illness 7(3)
at MAASTRICHT UNIVERSITY on September 28, 2011chi.sagepub.comDownloaded from
most appropriate theoretical methods and
practical applications to address the identi-
fied determinants.
Although Intervention Mapping is con-
sidered a helpful tool to design programmes,
it seems fair to make a few critical comments
as well. Intervention Mapping has been
described as tiresome,
4
complex,
11
elabo-
rate, expensive and time consuming.
13
Furthermore, faulty logic models occur
when the essential problem has not been
clearly stated and defined, factors influenc-
ing a problem are not well understood or an
inadequate theory was chosen.
16
Besides, no
matter how logical a programme model
seems, there is always a danger that it will
be wrong. When dealing with novel prob-
lems, for instance, contemporary knowledge
may be insufficient, which means researchers
may not comprehend the logic of change
until after the fact. In addition, one cannot
control or anticipate all influences on the
intended intervention effect once imple-
mented in the real world.
Nevertheless, all these authors who
assessed Intervention Mapping critically
also indicated that Intervention Mapping
helped bringing the development of inter-
ventions to a higher level. In the end,
advantages outweighed disadvantages.
To conclude, applying Intervention
Mapping to health promotion and in par-
ticular patient education may help the devel-
opment of more effective behaviour change
interventions and may help in making a
black box programme transparent to aid
effective adoption and implementation.
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  • May 2021
  • Waterlines
Use of human excreta as fertilizer is not a new concept. However, with the use of the modern water-flush toilet, human excreta becomes mixed with water and causes environmental pollution. To reemphasize the nutritional value of human urine in the field, a urine diversion toilet was constructed in a community school situated in Kavre, Nepal. The purpose of establishing the urine diversion toilet is to improve hygiene outcomes through promoting proper sanitation and transforming the school community’s regular practice and attitudes towards urine as a resource. To ensure effective implementation of the urine diversion toilets, intervention mapping was used as a guiding framework. The aim of this paper is to document how the urine diversion toilet was planned and implemented in the school and how the urine diversion toilet was connected with the curriculum to address concerns regarding water, sanitation, and hygiene with a focus on sustainability through intervention mapping. This study highlights the benefits of intervention mapping as a systematic and step-by-step process for the planning and implementation of the urine diversion toilet. This study also highlights the benefits of connecting urine diversion toilets with school gardening, and engaging with local government and other stakeholders about the value of the approach.
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... after checking the proper implementation of the intervention, change in knowledge and attitudes as well as behaviours will be evaluated; this will help us to understand the overall impact of the intervention. thus, an evaluation plan includes some evaluation questions, designs, indicators, measures, time, resources, the way the data will be collected, analysed, and reported (Bartholomew et al., 2006;Kok and Mesters, 2011). Some of the questions that the evaluation plan addresses are 'Did the students' perception change on urine as waste?' 'How many students' knowledge, attitudes and practices have changed due to implementation of UDt in the school?' ...
Intervention mapping as a framework for planning the implementation of urine diversion toilets and Ecosan education in a community school in Kavre, Nepal.
Article
  • May 2021
Use of human excreta as fertilizer is not a new concept. However, with the use of the modern water-flush toilet, human excreta becomes mixed with water and causes environmental pollution. To reemphasize the nutritional value of human urine in the field, a urine diversion toilet was constructed in a community school situated in Kavre, Nepal. The purpose of establishing the urine diversion toilet is to improve hygiene outcomes through promoting proper sanitation and transforming the school community's regular practice and attitudes towards urine as a resource. To ensure effective implementation of the urine diversion toilets, intervention mapping was used as a guiding framework. The aim of this paper is to document how the urine diversion toilet was planned and implemented in the school and how the urine diversion toilet was connected with the curriculum to address concerns regarding water, sanitation, and hygiene with a focus on sustainability through intervention mapping. This study highlights the benefits of intervention mapping as a systematic and step-by-step process for the planning and implementation of the urine diversion toilet. This study also highlights the benefits of connecting urine diversion toilets with school gardening, and engaging with local government and other stakeholders about the value of the approach.
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Using intervention mapping (IM) to develop a self-management programme for employees with a chronic disease in the Netherlands
Article
Full-text available
  • Jun 2010
  • BMC PUBLIC HEALTH
Employees with a chronic disease often encounter problems at work because of their chronic disease. The current paper describes the development of a self-management programme based on the Chronic Disease Self-Management programme (CDSMP) of Stanford University to help employees with a chronic somatic disease cope with these problems at work. The objective of this article is to present the systematic development and content of this programme. The method of intervention mapping (Bartholomew 2006) was used to tailor the original CDSMP for employees with a chronic somatic disease. This paper describes the process of adjusting the CDSMP for this target group. A needs assessment has been carried out by a literature review and qualitative focus groups with employees with a chronic disease and involved health professionals. On the basis of the needs assessment, the relevant determinants of self-management behaviour at work have been identified for the target population and the objectives of the training have been formulated. Furthermore, techniques have been chosen to influence self-management and the determinants of behaviour and a programme plan has been developed. The intervention was designed to address general personal factors such as lifestyle, disease-related factors (for example coping with the disease) and work-related personal factors (such as self-efficacy at work). The course consists of six sessions of each two and a half hour and intents to increase the self management and empowerment of employees with a chronic somatic disease. Intervention mapping has been found to be a useful tool for tailoring in a systematic way the original CDSMP for employees with a chronic somatic disease. It might be valuable to use IM for the development or adjusting of interventions in occupational health care.
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Development of a nursing intervention to facilitate optimal antiretroviral-treatment taking among people living with HIV
Article
Full-text available
  • Feb 2009
  • BMC HEALTH SERV RES
Failure by a large portion of PLHIV to take optimally ARV treatment can have serious repercussions on their health. The absence of a systematic treatment-taking promotion program in Quebec prompted stakeholders to develop jointly a theory- and evidence-based nursing intervention to this end. This article describes the results of a collective effort by researchers, clinicians and PLHIV to share their knowledge and create an appropriate intervention. Intervention mapping was used as the framework for developing the intervention. First, the target population and environmental conditions were analyzed and a literature review conducted to identify predictors of optimal treatment taking. The predictors to emerge were self-efficacy and attitudes. Performance objectives were subsequently defined and crossed-referenced with the predictors to develop a matrix of change objectives. Then, theories of self-efficacy and persuasion (the predictors to emerge from step 1), together with practical strategies derived from these theories, were used to design the intervention. Finally, the sequence and content of the intervention activities were defined and organized, and the documentary material designed. The intervention involves an intensive, personalized follow-up over four direct-contact sessions, each lasting 45-75 minutes. Individuals are engaged in a learning process that leads to the development of skills to motivate themselves to follow the therapeutic plan properly, to overcome situations that make taking the antiretroviral medication difficult, to cope with side-effects, to relate to people in their social circle, and to deal with health professionals. The intervention was validated by various health professionals and pre-tested with four PLHIV. Preliminary results support the suitability and viability of the intervention. A randomized trial is currently underway to verify the effectiveness of the intervention in promoting optimal antiretroviral treatment taking.
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Development of E-Info Gene(ca): A Website Providing Computer-Tailored Information and Question Prompt Prior to Breast Cancer Genetic Counseling
Article
Full-text available
  • Jun 2009
  • J Genet Counsel
This article describes the stepwise development of the website 'E-info gene(ca)'. The website provides counselees in breast cancer genetic counseling with computer-tailored information and a question prompt prior to their first consultation. Counselees generally do not know what to expect from genetic counseling and they tend to have a passive role, receiving large amounts of relatively standard information. Using the "intervention mapping approach," we developed E-info gene(ca) aiming to enhance counselees' realistic expectations and participation during genetic counseling. The information on this website is tailored to counselees' individual situation (e.g., the counselee's age and cancer history). The website covers the topics of the genetic counseling process, breast cancer risk, meaning of being a carrier of a cancer gene mutation, emotional consequences and hereditary breast cancer. Finally, a question prompt encourages counselees to prepare questions for their genetic counseling visit.
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Systematic Development of a Self-Help and Motivational Enhancement Intervention to Promote Sexual Health in HIV-Positive Men Who Have Sex with Men
Article
Full-text available
  • Jan 2007
The objective of this study was to describe the application of a systematic process-Intervention Mapping-to developing a theory- and evidence-based intervention to promote sexual health in HIV-positive men who have sex with men (MSM). Intervention Mapping provides a framework that gives program planners a systematic method for decision-making in each phase of intervention development. In Step 1, we focused on the improvement of two health-promoting behaviors: satisfactory sexual functioning and safer sexual behavior. These behaviors were then linked with selected personal and external determinants, such as attitudes and social support, to produce a set of proximal program objectives. In Step 2, theoretical methods were identified to influence the proximal program objectives and were translated into practical strategies. Although theoretical methods were derived from various theories, self-regulation theory and a cognitive model of behavior change provided the main framework for selecting the intervention methods. The main strategies chosen were bibliotherapy (i.e., the use of written material to help people solve problems or change behavior) and motivational interviewing. In Step 3, the theoretical methods and practical strategies were applied in a program that comprised a self-help guide, a motivational interviewing session and a motivational interviewing telephone call, both delivered by specialist nurses in HIV treatment centers. In Step 4, implementation was anticipated by developing a linkage group to ensure involvement of program users in the planning process and conducting additional research to understand how to implement our program better. In Step 5, program evaluation was anticipated based on the planning process from the previous Intervention Mapping steps.
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Health Program Planning: An Educational And Ecological Approach
Article
  • Jan 2005
This 4th edition of the text introducing the Precede-Proceed model provides extensive links (via www.lgreen.net) to the research and theory on which it has built since previous editions. A 5th edition is in progress, featuring new published applications of the model in community, school, and healthcare settings.
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Development of an Intervention Program for Alzheimer's Family Caregivers Following Diagnostic Disclosure
Article
  • Mar 2009
  • Clin Nurs Res
The purpose of this qualitative study was to develop a pro-active psycho-educational intervention program for Alzheimer's family caregivers following diagnostic disclosure. Based on a theoretical model of role transitions and a participatory approach, the study comprised four steps: (a) exploring caregiver needs; (b) developing and validating a program proposal based on caregiver-expressed needs; (c) formalizing program through intervention mapping; and (d) testing and qualitatively evaluating the program. The psycho-educational program consisted of seven individual sessions aimed at fostering knowledge and skills required to ensure successful transition to the caregiver role. The approach used in this study can serve as a guide for the development of nursing intervention programs. Intervention mapping allowed, in particular, integrating theoretical and empirical elements in a formal intervention model.
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Program Development for Enhancing Adherence to Antiretroviral Therapy among Persons Living with HIV
Article
  • Jan 2009
  • AIDS PATIENT CARE ST
In this paper the development of a self-management program to optimize long-term adherence to antiretroviral therapy for people living with HIV/AIDS is presented. The program is based on intervention mapping: that is, a framework that facilitates the use of theory and empirical evidence in intervention development. In the preparatory phase we conducted a needs-assessment. The results of this phase were then used in the operational phase in which the program was elaborated as follow: in Step 1 we established program objectives; in Step 2 we translated theoretical methods into practical strategies; and in Step 3 we integrated the strategies into a self-management program which were designed to help individuals mobilize their skills to cope with their antiretroviral therapies (ART). These particular abilities are: ability to integrate ART in daily routine, to cope with side effects, to handle situations in which ART is difficult to take, to interact with health professionals and to maintain relationships with social contacts. To address individuals' resources and skills in conjunction with the experience of taking the medication, we developed two different modalities to deliver the intervention: direct support and virtual support. Direct support consists of four 45-minute individualized, face-to-face sessions with a health professional. The Web application involved at least four interactive sessions with a computer. This application was developed with the intention to support individuals in managing their therapy, in a punctual, real-time mode. Treatment adherence behavior is an indicator or gauge that can reveal problems in being able to manage the therapy.
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Program development for promoting adherence during and after exercise therapy for urinary incontinence
Article
  • Oct 2002
  • PATIENT EDUC COUNS
This paper presents the development process of a health education program to promote adherence to a pelvic floor muscle exercise (PFME) therapy for women with urinary incontinence (UI). The development process started with a needs assessment phase in which the health problem, health-related quality of life, and behavioral and environmental determinants were assessed. Guided by the intervention mapping (IM) approach, program objectives were formulated and, on the basis of both empirical and theoretical data, intervention methods for influencing determinants of adherence to PFME therapy were chosen and translated into practical strategies. This information was assimilated to a transparent description of the program design. The theoretical rationale of the program was based on the transtheoretical model, the self-regulation theory and principles of targeted communication and sex-specific health care.
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Supporting adherence and healthy lifestyles in leg ulcer patients: Systematic development of the Lively Legs program for dermatology outpatient clinics
Article
  • Jun 2006
  • PATIENT EDUC COUNS
The objective of our project was to develop a lifestyle program for leg ulcer patients at outpatient clinics for dermatology. We used the intervention-mapping (IM) framework for systematically developing theory and evidence based health promotion programs. We started with a needs-assessment. A multidisciplinary project group of health care workers and patients was involved in all five IM steps; formulating proximal program objectives, selecting methods and strategies, producing program components, planning for adoption and implementation and planning for evaluation. Several systematic literature reviews and original studies were performed to support this process. Social Cognitive Theory was selected as the main theory behind the program 'Lively Legs' and was combined with elements of Goal-Setting Theory, the precaution adoption model and motivational interviewing. The program is conducted through health counseling by dermatology nurses and was successfully pre-tested. Also, an implementation and evaluation plan were made. Intervention mapping helped us to succeed in developing a lifestyle program with clear goals and methods, operational strategies and materials and clear procedures. Coaching leg ulcer patients towards adherence with compression therapy and healthy lifestyles should be taken on without delay. Systematic development of lifestyle programs for other patient groups should be encouraged.
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Using Intervention Mapping to Develop a Breast and Cervical Cancer Screening Program for Hispanic Farmworkers: Cultivando La Salud
Article
  • Nov 2005
  • Health Promot Pract
This article describes the development of the Cultivando La Salud program, an intervention to increase breast and cervical cancer screening for Hispanic farmworker women. Processes and findings of intervention mapping (IM), a planning process for development of theory and evidence-informed program are discussed. The six IM steps are presented: needs assessment, preparation of planning matrices, election of theoretic methods and practical strategies, program design, implementation planning, and evaluation. The article also describes how qualitative and quantitative findings informed intervention development. IM helped ensure that theory and evidence guided (a) the identification of behavioral and environmental factors related to a target health problem and (b) the selection of the most appropriate methods and strategies to address the identified determinants. IM also guided the development of program materials and implementation by lay health workers. Also reported are findings of the pilot study and effectiveness trial.
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