Planning Health Promotion Programs

An Intervention Mapping Approach

L. Kay Bartholomew Eldredge, Guy S. Parcel, Gerjo Kok, Nell H. Gottlieb

• Publisher: Jossey-Bass
• Year: 2011
• ISBN:
  9781118046845
• Edition: 2
• Topic: Medicine
• Subtopic: Public Health, Administration & Care

This guide to the planning of health promotion programs uses the increasingly popular Intervention Mapping approach, a theory- and evidence-based interactive process that links needs assessment with program planning in a way that adds efficiency and improves outcomes. Students, researchers, faculty, and professionals will appreciate the authors' approach to applying theories of behavior and social change to the design of coherent, practical health education interventions. Written by internationally recognized authorities in Intervention Mapping, the book explains foundations in Intervention Mapping, provides an overview of the role of behavioral science theory in program planning¾including a review of theories and how to assess theories and evidence¾and a step-by-step guide to Intervention Mapping, along with detailed case examples of its application to public health programs. Planning Health Promotion Programs is the second and substantially revised edition of the bestselling resource Intervention Mapping.

PART ONE

FOUNDATIONS

CHAPTER ONE

OVERVIEW OF INTERVENTION MAPPING

Reader Objectives

• Explain the rationale for a systematic approach to intervention development

• Describe an ecological approach to intervention development

• Explain the types of logic models that can be used to conceptualize various phases of program development

• List the steps, processes, and products of Intervention Mapping

In this chapter we present the perspective from which Intervention Mapping was conceived as well as its purpose. We also present a preview of the program-planning framework, which is detailed in the remaining chapters.

The purpose of Intervention Mapping is to provide health promotion program planners with a framework for effective decision making at each step in intervention planning, implementation, and evaluation. Health promotion has been defined as “Any combination of education, political, regulatory and organizational supports for actions and conditions of living conducive to the health of individuals, groups or communities” (Green & Kreuter, 2005, p. G-4), and health education is a subset of health promotion strategies that are primarily based on education. We recognize this distinction but also the fact that many people in the health field practice health promotion; some of them specialize in health education. Often the boundaries are quite blurred. This book uses the terms health educator, health promoter, and program planner interchangeably when a subject is needed to mean someone who is planning an intervention meant to produce health outcomes. An intervention can be designed to change environmental or behavioral factors related to health, but the most immediate impact of an intervention is usually on a set of well-defined determinants of behavior and environmental conditions.

A difficulty that planners may encounter is that of delineating tasks for the development of health promotion or education programs that are based on theory, empirical findings from the literature, and data collected from the at-risk population. Existing literature, appropriate theories, and additional research data are basic tools for any health educator; but often it is unclear how and where these tools should be used in program planning. In Intervention Mapping, these tools are systematically applied in the steps of program development.

Box 1.1. Mayor’s Project

Imagine a health educator in a city health department. The city’s mayor, who has recently received strong criticism for inattention to a number of critical health issues, has now announced that a local foundation has agreed to work with the city to provide funding to address health issues. Youth violence, adolescent smoking, and other substance abuse as well as the high incidence of HIV/AIDS are among the issues competing for the mayor’s attention. Not only does the allocated sum of money represent a gross underestimation of what is needed to address these issues, but also the city council is strongly divided on which health issue should receive priority. Council members do agree, however, that to dilute effort among the different issues would be a questionable decision, likely resulting in little or no impact on any single issue. As a response to increasing pressures, the mayor makes a bold political move and presents a challenge to the interest groups lobbying for public assistance. The mayor agrees to help secure funds on a yearly basis, contingent on the designated planning group’s demonstrating significant, measurable improvements in the issues at hand by the end of each fiscal year.

The head of the health promotion division of the city health department is a social psychologist. She intends to use the mayor’s challenge as a testing ground for her favorite behavioral science theory, but she has appointed the health educator to lead the project. Although apprehensive about the professional challenge as well as the complications inherent in facilitating a highly visible political project, the health educator is encouraged by the prospect of working with community and public health leaders.

The first step the health educator takes is to put together the planning group for the project. She considers the stakeholders concerned with youth health in the city. These are individuals, groups, or other entities that can affect or be affected by a proposed project. She develops a list of community and public health leaders and invites these individuals to an initial meeting whose purpose is to expand this core group. She uses a “snowball” approach whereby each attendee suggests other community members who may be interested in this project. The superintendent of schools begins the process by suggesting interested parents, teachers, and administrators. Later these individuals may have additional suggestions. After the first meeting, the health educator has a list of 25 people to invite to join the planning group.

Twenty-five people is a lot of people for one group, and the health educator knows that this multifaceted group will have to develop a common vocabulary and understanding, work toward consensus to make decisions, maintain respect during conflicts, and involve additional people throughout the community in the process. Members must be engaged, create working groups, believe that the effort is a partnership and not an involuntary mandate, and work toward sustainability of the project (Cavanaugh & Cheney, 2002). The health educator knows that she has taken on a complex task, but she is energized by the possibilities.

The composition of the city’s planning group is diverse, and group members are spurred by the mayor’s challenge and enthusiastic to contribute their expertise. With this early momentum, the group devotes several weeks to a needs assessment, guided by the PRECEDE model (Green & Kreuter, 1999, 2005). The members consider the various quality-of-life issues relevant to each of the health problems, the segments of the population affected by each issue, associated environmental and behavioral risk factors for each health problem, and determinants of the risk factors.

Members recognize the relative importance of all three issues, but they select youth violence because violence is a particular problem in their community, which disproportionately affects underserved minorities. Also, they are challenged by the lack of effective or evaluated violence prevention programs in the field (Tolan & Guerra, 1994, 1996; World Health Organization, 2002; Centers for Disease Control & Oak Ridge Institute for Science and Education, 2003), and the interests and expertise of the individual group members are well suited to working on this problem. The results of the needs assessment indicate that violence is the leading cause of death among young people aged fifteen to twentyfour in the United States and the primary cause of death among Hispanics and African Americans in this age group (Singh & Yu, 1996). Moreover, for every violent death, conservative estimates suggest that 100 nonfatal injuries result from violence (Rennison, Rand, & U.S. Department of Justice, 2003). The group reviews the literature to identify the behavioral and environmental causes of violence and finds that the factors related to violence are diverse.

For example, socioeconomic status, education, and job mobility are all factors that may be related to personal involvement in violence. The lack of conflict resolution and communication skills are enabling factors related to personal violence. At the same time, the sudden occurrence of situational antagonism, such as verbal or physical assault, is a contextual factor that is also likely to incite violent behavior (Reiss, Miczek, & Roth, 1993). The planning group reviews a long list of factors related to violence. They recognize that their one-year program can address certain of these. However, they also realize that broad social problems such as poverty and lack of opportunities for success in school and employment must be taken into account even though they are not easy to address. Further investigation reveals that little empirical evidence is available on the effectiveness of existing programs that address a broad array of determinants of violent behavior (Tolan & Guerra, 1994).

Even though the planning group comprises many segments of the city’s leadership, health sector, and neighborhoods, the members realize that they do not have a deep enough perspective on youth violence in their community. A subgroup takes on the role of community liaison to meet with members of various communities within the city that have been disproportionately affected by violence. The community liaison group wants to understand community members’ perceptions of their needs, but it is equally concerned with understanding the strengths of the communities and their unique potential contributions to a partnership to prevent violence. The subgroup invites members of each interested neighborhood to join the planning group. Jointly, the planning group, the communities, and the funders agree to select this problem as the focus of a health education and promotion intervention.

The group’s work on the needs assessment facilitated group cohesion and cultivated even greater enthusiasm about generating a solution for the health problem. Several members of the group even began to imagine the victory that would be had if the group were to produce a change in half the allotted time because so much of the needed background information had already been gathered. The health educator remains apprehensive about the time frame yet comfortable with the group’s pace and productivity. Now that the group has decided which issue to address, it faces the challenge of moving to the program-planning phase. In her previous work the health educator had implemented and evaluated programs designed by others, but she had not created new programs. However, bolstered by its good work, the group schedules the first program-planning meeting.

What the health educator hadn’t anticipated was that in the course of conducting the needs assessment, each group member had independently begun to conceive of the next step in the planning process as well as to visualize the kind of intervention that would be most suitable to address the problem. The day of the meeting arrived, and on the agenda was a discussion of how the group should begin program planning. What follows is a snapshot of dialogue from the planning group that illustrates several differing perspectives.

Participant A:	As we see from the needs assessment, violence is a community problem. According to community development techniques, we have to start where the people are. I think we should begin by conducting a series of focus groups and have the kids tell us what to do.
Participant B:	But why do you use the kids to develop a program for the com munity? I say we address violence at the family level, using a se ries of conflict resolution training workshops for kids and their parents.
Participant C:	Community and family are only two dimensions of the problem. The literature says you have to address multiple levels in a comprehensive approach. Plus, onetime workshops have no long -term impact. I say we find a nonprofit group to serve as a community coordinating center from which various interventions and services can be implemented. That way, programs are sus tainable, and a variety of activities can be offered.
Participant D:	One of the national violence prevention centers has great brochures and videos—in three languages. We have numerous testimonials from kids, teachers, and parents about how moti vated they were by these interventions. This approach is quick and easy; it’s low cost; and I’ve already made sure we can get the materials. Plus, if the materials come from a national center, they must be effective.
Participant B:	But are those materials really powerful enough? How would you address the different levels of the community? Moreover, violence is a human problem. The root of the problem is that kids don’t have anyone or anything they can relate to. In school we always started with learning objectives that reflect the needs of the specific patient population.
Participant E:	Yes, but we know it takes more than learning information to change behavior. We have to address factors such as attitudes and self-efficacy. But how do we measure a change in attitudes? I think we should measure behavior directly.
Participant F:	Well, clearly we have to begin by designing a curriculum. What are our learning objectives?

The health educator in our example must first consider what steps to follow to construct the intervention and then must consider how to design each step to incorporate the needs, ideas, training, and experience of the various members of the planning group. The planning group began well by completing a comprehensive needs assessment using an effective model that has been applied to many health issues (Green & Kreuter, 2005). The members began the program-planning phase armed with an ecological perspective, that is, the belief that one must intervene at individual, organizational, community, and societal levels to resolve a problem (McLeroy, Bibeau, Steckler, & Glanz, 1988; Simons-Morton, Greene, & Gottlieb, 1995; Kreuter, De Rosa, Howze, & Baldwin, 2004). But, as the group dialogue indicates, each group member brought a different set of experiences and training to the meeting. This is a common experience in group activities. Although group members may become critical of other perspectives, each member makes an important and relevant contribution worthy of consideration in the creation of the intervention.

Perspectives

Intervention Mapping is based on the importance of planning programs that...

Table of contents

• Title Page
• Copyright Page
• Table of Figures
• List of Tables
• PREFACE
• Acknowledgments
• THE AUTHORS
• PART ONE - FOUNDATIONS
• PART TWO - INTERVENTION MAPPING STEPS
• PART THREE - CASE STUDIES
• REFERENCES
• NAME INDEX
• SUBJECT INDEX