Today
• Health interventions
• Technology-mediated interventions
• JITAIs
• The process of illness and illness cognitions
• Illiness cognitions
• Stress, Pain (May 10)
Assignments
• Assignment 3 – mismatch between theory and methods and
strategies
• APA formatting
• Adhere to page limit
• Academic writing tips
• Formal vs. informal
• Not necessarily passive voice
• Watch out for word choices (pretty, well, …)
• Do not abbreviate – it’s ….it is
• Effective transition sentences versus “filler” sentences
• Consider the difference
• In the next section, I will write about a theory that I can apply towards achieving my
goals.
Vs.
• Health behavior theories can be useful in guiding interventions towards achieving
goals.
Focus on Theory-Based Interventions
Implementation
and evaluation
Design and
planning
Theoretical
foundation
General Steps in Planning Models
• Step 1
• Identify behavior and target population
• Step 2
• Identify relevant influences on behavior
• Step 3
• Select intervention methods
• Step 4
• Develop intervention strategies
Steps 1 & 2
• Should involve needs assessment
• Should result in the identification of appropriate
intervention goals and objectives
Need Assessment
• Key is to identify needs based on evaluation of
current conditions and desired conditions
• Involves gathering of new data as well as use of
existing secondary data sources
• Ultimately should inform why intervention needs to
take place and what may be the key intervention
components.
• Various methods utilized to complete need
assessment (surveys, focus groups, observation
groups, interviews, community or expert forum,
public health data and databases, etc.)
Steps 3 & 4
• Are informed by research in Step 1 & 2
• Involve selection of intervention methods and strategies
• What will be done in order to change behavior?
• These steps represent the creative part of intervention
planning – this is where planning becomes reality
Steps 3 & 4
• Brainstorming methods
• How can we use the performance objective to alter the determinant?
• Delineating methods
• Which methods have been successfully used in the past?
• How were previous programs similar/different from this program?
• Translating methods into strategies
• How can we deliver our program to our target population?
• Is there a necessary sequence in the methods we will use?
• Operationalize strategies
• Organize strategies into a deliverable program
• Specify channels of delivery/communication
• Design program materials
• Planning documents, schedules
• How do you hold yourself accountable?
• Pretest instruction materials
• Produce program materials
Helps answer your questions:
1. How do I set appropriate intervention goals?
2. When in the planning process do I use theory to guide
decisions?
3. How do I know what theory, methods to use?
4. How do I develop concrete strategies?
5. How do I implement them?
6.…
Intervention Mapping
Let’s Create an Intervention Map
Outcomes
Proximal Program
Objective Matrices
Theoretical Methods
and Practical Strategies
Program Design
Adoption &
Implementation Plan
Monitoring & Evaluation
Plan
INTERVENTION MAP
Tasks
•Specify the performance objectives
•Specify important, changeable determinants
•Differentiate the target population
•Create matrices of proximal program objectives
•Brainstorm methods to achieve proximal program objectives
•Use the theoretical and empirical literature to further delineate methods
•Translate methods into strategies
•Operationalize the strategies into plans considering implementors and sites
•Design instruction materials
•Pretest instruction materials with the target group
•Produce the materials
•Develop a linkage system
•Specify adoption and implementation performance objectives
•Specify determinants of adoption and implementation
•Write the implementation plan
•Develop an evaluation model using information from previous steps of intervention
mapping and information from the needs assessment
•Develop effect evaluation questions, referring to the matrices of proximal program
objective as blueprints for instrument development
•Develop process evaluation questions from the needs assessment and intervention
map
NEEDS ASSESSMENT
Identify the at-risk population,
quality of life and health problemDistinguish environmental and
behavioral causes
Review key determinants
EVALUATION
IMPLEMENTATION
Intervention Mapping
Intervention Goal Determinant Determinant
Lack of Knowledge Lack of Resources
Accumulate 30 minutes of
VIGOROUS PA outside of
school
???
Limit time TV/computer
screen time to 1 hour per
day
Population: African American Urban Youth
•Proximal program objective: Action statement indicating
what individuals must learn or what must change in the social
context as a result of the program.
Question
A. Lack knowledge about the benefits of vigorous PA and
amount needed.
B. Understands the health benefits of vigorous PA and
amount recommended.
C. Has barriers to performing 30 minutes of vigorous PA
outside of school.
Intervention Goal Determinant Determinant
Lack of Knowledge Lack of Resources
Accumulate 30 minutes of
VIGOROUS PA outside of
school
???
What is an appropriate proximal program objective for ???
Question
• What is an intervention method?
A. Use of exercise logs
B. Self-monitoring
C. Face-to-face instruction
D. Pedometers
Question
• What is an intervention strategy?
A. Self-talk
B. Goal-setting
C. Weekly feedback forms
D. Reinforcement
Methods versus Strategies
• Theoretical methods: A generalized technique used to
influence a determinant
• Practical strategies: A plan for organizing and delivering
methods
Methods versus Strategies
Methods versus Strategies
METHODS STRATEGIES
Applying Intervention Mapping
• Treatment Resistant Depression Exercise Trial – Planning
Phase
Intervention objectives Determinant 1
Lack of
energy/fatigue
Determinant 2
Lack of
enjoyment
Determinant 3
Time
constraints
Reach level of PA
guidelines
Understands
importance of
gradual
progression and
allowing time for
adaptation
Understands
importance of
moderate
intensity and
explores
enjoyable types
of exercise
Learns how to
schedule 150
min of physical
activity into a
week in a
flexible manner
Improve symptoms of
depression
Steps 3 & 4
• Brainstorming methods
• How can we use the performance objective to alter the determinant?
• Delineating methods
• Which methods have been successfully used in the past?
• How were previous programs similar/different from this program?
• Translating methods into strategies
• How can we deliver our program to our target population?
• Is there a necessary sequence in the methods we will use?
• Operationalize strategies
• Organize strategies into a deliverable program
• Specify channels of delivery/communication
• Design program materials
• Planning documents, schedules
• Pretest instruction materials
• Produce program materials
TRD Example
Methods Strategies
Information provision Provide information in a booklet (importance of PA,
recommended levels, relevance for depression and other
health risks/benefits)
Teaching behavioral
skills
In-person instruction and provide information in booklet,
handouts, newsletters (self-monitoring, selecting
appropriate activities across different settings)
Increasing motivation Provision of feedback and encouragement through
feedback reports and instructor consultation
Teaching self-regulation
skills
In-person instruction and provide information in booklet
(time management strategies, use of implementation
plans, how to overcome common barriers and recover
from setbacks)
Self-efficacy Self-monitoring through exercise logs, feedback reports, inperson
consultation about progress and success, vicarious
learning through interaction with other participants
TRD Example
Program Description
Mode Face-to-face
Location University fitness center
Schedule Flexible hours (morning, mid-day, evening classes) plus
general membership
Treatment Duration 12 weeks
Treatment Progression Weeks 1-4 – 3 supervised + 2 home-based per week
Weeks 5-8 – 2 supervised + 3 home-based per week
Weeks 9-12 – 1 supervised + 4 home-based per week
Weeks 1-6 – gradually increase duration per session (start at 15
min up to 45 min) at low-to-moderate intensity (RPE = 10-12; HR
= 50-60% MaxHR)
Weeks 7-12 – maintain duration and increase intensity to
moderate range (RPE = 12-15; HR = 60-70% Max HR)
Group Activity
• Create intervention objectives
• Brainstorm methods using CALO-RE taxonomy
• Which methods can we use to achieve proximal objectives and
change intervention determinants?
• Translate methods into practical strategies
• How can we deliver the methods to participants?
• Determine the overall parameters of your intervention
• Design, channel/platform, duration, frequency of contact, etc.
Intervention Goal Determinant Determinant
Logic Models
• Logic models help identify the factors that will impact your
program and enable you to anticipate the data and
resources you will need to achieve success.
• Cataloguing of the resources and actions you believe you will need
to reach intended results.
• Documentation of connections among your available resources,
planned activities and the results you expect to achieve.
• Description of the results you are aiming for in terms of specific,
measurable, action-oriented, realistic and timed outcomes.
Logic Models
Logic Models
illustrate first the outcomes and impacts sought and then the outputs. You can then
look at the completed template on page 26 to see compare your interpretation with that
produced by the Mytown folks.
Exercise1usestheBasicLogicModel Development Template
RESOURCES ACTIVITIES OUTPUTS SHORT & LONGTERM
OUTCOMES
IMPACT
In order to accomplish
our set of activities we
will need the
following:
In order to address
our problem or asset
we will conduct the
following activities:
We expect that once
completed or
underway these
activities will produce
the following evidence
of service delivery:
We expect that if
completed or ongoing
these activities
will lead to the
following changes in
1-3 then 4-6 years:
We expect that if
completed these
activities will lead to
the following changes
in 7-10 years:
Outcomes and Impacts should be SMART:
· Specific
· Measurable
Logic Models
Resources Activities Outputs Short & longterm
outcomes
Impact
In order to accomplish our
set of activities we will
need the following:
In order to address our
problem or asset we will
conduct the following
activities
We expect that once
completed, these
activities will produce the
following evidence of
service delivery:
We expect that the
activities will lead to the
following changes in the
next 6 months – 1 year…
We expect that the
activities will lead to the
following changes in the
next 5 years…
• Qualified &
dedicated
staff
• Endorsement
from Psychiatric
clinic
• Donated hospital
fitness center time
• Job descriptions
for staff
• First year’s
funding
($50,000)
• Equipment
•
.
.
.
• Launch staff
search
• Secure clinic
endorsement and
fitness center time
• Create job
descriptions and
staff manual
• Design and
implement funding
strategy
• Secure
equipment
.
• # of patients
recruited/referred
• # of staff
members trained
• Level of funding
secured
.
Or:
Proximal
Outcomes
Or:
Distal
Outcomes
Mediated Interventions
• Use of non-face-to-face approaches (especially
technology)
• Goals
• Providing interventions to large numbers of people at low cost
(SCALABILITY)
• Provide health messages to the population
• What are the platforms?
• mass-reach broadcast media
• print-based materials (by mail)
• audiovisual materials (videos, tapes)
• newer multimedia (internet, cell phones, smartphones, ipads/tablets,
exergaming, etc.)
Communication Theory
S-M-C-R model
• Computer-mediated communication
S-M-C-R-F model
• Human computer interaction
Source (interventionist/intervention system)
Message (content of intervention)
Channel (platform)
Receiver (users/participants)
Feedback (sensor device)
Mass Media Campaigns
• Participaction
• Since 1971
• Social marketing approach to physical activity promotion
• a national not-for-profit organization solely dedicated to
inspiring and supporting active living and sport
participation for Canadians
• sectors represented include business, education,
entertainment, media, social service, government,
healthcare, physical activity, sport and recreation and
research
• http://www.youtube.com/watch?v=a6j9VdMcN9k
Other Media
• Interactive Voice Recordings (IVR)
• Avatars
• Social Media
• Populations?
• Your experiences?
• Text messaging
• Content, frequency versus message exposure
• Smartphones
• Integration of technology – built-in accelerometers
• Other?
Apps
• Apps generally observed to be lacking in theoretical
content
• The health belief model was the most prevalent theory
• Higher priced apps and apps that addressed a broader
activity spectrum associated with higher theoretical fidelity
and credibility
• More likely to be used personally or recommended to a
health care client
• Many cater to already active populations
• What is their longevity????
• What was your experience?
Apps – cont.
Cowan et al. (2012):
• Content analysis of 127 apps from Apple's (App Store)
Health & Fitness category
• Inclusion of theoretical constructs from prominent
behavior change theories (20 theoretical constructs)
• Apps were generally observed to be lacking in theoretical
content (89%)
• Theory scores ranged from 1 to 28 on a 100-point scale.
• The health belief model was the most prevalent theory,
accounting for 32% of all constructs
• Higher priced apps and apps that addressed a broader
activity spectrum were associated with higher total theory
scores.
Apps – cont.
West et al. (2012)
• Content analysis of health and fitness app descriptions
available on iTunes during February 2011 (3336 paid
apps)
• Only 1.86% (62/3336) included predisposing, enabling,
and reinforcing factors
• Compared to apps with a cost less than US $0.99, apps
exceeding US $0.99 were more likely to be scored as
intending to promote health or prevent disease to be
credible or trustworthy
• More likely to be used personally or recommended to a
health care client
SMART
• Sequential, Multiple Assignment, Randomized Trial
• Adaptive interventions, individually tailored treatments
Lei H, Nahum-Shani I, Lynch K, Oslin D, Murphy SA. Annu Rev Clin Psychol.
2012;8:21-48
SMART
• Just-in-Time Adaptive Interventions (JITAIs)
• Adaptation guided by
• Distal and proximal reponse
• Adaptation made up of
• Tailoring variables
• Decision rules
• Treatments
• Adaptation triggered at
• Decision points
Nahum-Shani I, Smith SN, Spring BJ, Collins LM, Witkiewitz K, Tewari A, Murphy
SA (2016) Ann Behav Med.
JITAI
• Hypothetical example
• Treatment
• Self-monitoring (daily
step count)
• Feedback provision
(automated)
• Goal setting (medium)
• Daily prompts
(tailored)
• Distal response – overal physical activity
• Proximal response – step count over next hour
• Tailoring variable (e.g., what could moderate
response?)
• Availability
• Location
• Step count
• Decision rule
• IF available, THEN
If at home = Yes,
THEN Text=prompt tip for
home exercise
Else if at home = No
THEN Text=prompt tip for
…..
• Else if not available, THEN Text= do nothing
• Decision point (guided by dynamics of tailoring variable
and effects of treatment)
• Every 2 hours
JITAI
• In what context are pushed messages most effective?
(home versus work or morning versus afternoon)
• What is the appropriate frequency of pushed
messages?
• Micro-randomized trial
• Randomize each participant between treatments at each
decision point
(100-1000 or more randomizations)
• Sequential, factorial designs
• Time-varying main effects, interactions/moderation (are then used to
inform decision rules…)
• This approach becoming a standard in developing mobile
health interventions
Nahum-Shani I, Hekler EB, Spruijt-Metz D. (2015) Health Psychology.
www.methodology.psu.edu
The Process of Illness
• Think of the last time you were ill (e.g., headache, flu,
broken limb, etc.).
• Consider the ways in which you made sense of your
illness, how they related to your coping strategies and
how you recovered.
What does it mean to be ill?
• Not feeling normal
• Specific symptoms
• Specific illnesses
• Consequences of illness
• Time line
• Absence of health
Illness Cognitions
• Leventhal et al. (1980)
Identity
Cure /
Control
Perceived
cause
Illness
cognitions
Consequences
Time line
• A patient’s own implicit
common sense beliefs about
their illness
• Provide schema for coping
with illness, understanding
their illness, warning signs
Self-Regulatory Model of Illness Behavior
Stage 1:
Interpretation
• Symptom
perception
• Social messages
Representation of
health threat
• Identity
• Cause
• Consequences
• Time line
• Cure/Control
Stage 2: Coping
• Approach coping
• Avoidance coping
Emotional response
to health threat
• Fear
• Anxiety
• Depression
Stage 3: Appraisal
• Was my coping
strategy
effective?
Symptom Perception
• Discuss
• Symptoms are more than just a sensation.
• What influences symptom perception?
• Draw a model
Symptom Perception
Symptom
perception
Demographics
Internal/external
focus
Social context
Attachment style
Cognition
Mood
Coping
• Illness as a crisis (Moos & Schaefer, 1984)
• Changes in identity
• Changes in location
• Changes in role
• Changes in social support
• Unpredicted event
• Insufficient or unclear information about illness
• Decision needed quickly
• Ambiguous meaning
• Limited prior experience
• Coping as a process (Moos & Schaefer, 1984)
• (1) Cognitive appraisal (2) Adaptive tasks (3) Coping skills
Coping with the crisis of illness
The crisis
of illness
Background
factors
• Demographic
and social
factors
• Physical/social
environmental
factors
• Illness-related
factors
Adaptive tasks
• Illness-specific
• General
Cognitive appraisal
Is my illness
serious?
Coping skills
• Appraisal-focused
• Problem-focused
• Emotion-focused
OUTCOME
Videos
• https://www.youtube.com/watch?v=YY3d4dyFRog
• Harvard Innovation Lab talk
• https://www.youtube.com/watch?v=oPrlBJZah5Y
• https://www.youtube.com/watch?v=kVZLR_rxjfE