Planning Behaviour Change Programs

Introductive lecture – online + notes integrated with Chapter 1

Intervention mapping is a systematic approach* to program development, implementation, and evaluation
of behaviours à Intervention Mapping (IM) is a planning framework designed to guide health promotion
program planners toward e;ective decision-making throughout the process of planning, implementation, and
evaluation. IM systematically applies theory, empirical findings from literature, additional research data, and
uses an ecological approach in every step of program development.

• An individual’s behaviour related to health (what they do and what they don’t) may not always be under
their control => it is often influenced by factors in their environment
o Supranational
o Society
o Community
o Organization
o Interpersonal
o Individual
• This mean that, when we are planning a specific intervention to target a certain behaviour it is not
enough to focus just on the individual

*Intervention Mapping is founded on four key perspectives that shape the intervention planning process:

1. Theory and Evidence = the use of theory is essential in evidence-informed health promotion to describe the
factors causing health problems and the methods e;ective for achieving change

• IM adopts a problem-driven perspective: the main focus is solving a public health problem,
potentially using one or multiple theories, empirical evidence, and new research
• Interventions should be based on thorough evidence to increase their likelihood of e;ectiveness

2. Ecological and Systems Approaches = IM encourages understanding interventions within a complex

multilevel system (activities, actors, and settings)

• A systems perspective helps assess population needs, understand causal factors, and select the most
e;ective intervention points (leverage points)
• An intervention aimed at one environmental level can still influence causal factors across multiple
levels

3. Community Participation = program goals must always be related to the health of the public, and health
educators should proactively address issues that adversely a;ect health

• Partnering with the community and focusing on local competencies and resources helps enhance
community capacity for program development, implementation, and maintenance

4. Causal Logic of Public Health Problems and Solutions = IM uses logic models to outline the presumed
cause-e;ect pathways related to health problems and their solutions, articulated from theory and empirical
research. These models are indispensable guides for planning and evaluation

INTERVENTION MAPPING STEPS à Intervention Mapping is presented as a 6-step protocol that is generally
iterative but cumulative, meaning each step builds upon the products of the previous steps. The completion of
all steps creates a comprehensive blueprint for the intervention.

1. Developing a logical model of the behaviour => deeply understanding the mechanism that underlies
a behaviour/problem, its behavioural and environmental causes, and their determinants
2. State program outcomes and objectives => creating a logic model for change that specifies who and
what will change as a result of the intervention, linking change methods, determinants, and outcomes
3. Developing a program design => generating themes, components, scope, sequence, choosing theory-
and evidence-based change methods, and designing practical applications to deliver them
4. Program production => refining structure, preparing plans for materials, drafting messages and
protocols, and conducting pretesting and final production

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5. Program implementation plan => developing a plan for program adoption, implementation fidelity,
and maintenance
6. Program evaluation plan => planning for both e;ect (outcome) and process evaluation based on the
objectives and components defined in the previous steps.
Ä Even if this might seem a linear process, it is rather iterative and recursive, as experts often need to go
back and forth through these steps as new knowledge arises accumulates
Ä All health promotion program development, implementation, and evaluation should be based on
broad participation of community members. Participation
o Ensures that the program focus reflects community concerns
o Brings greater breadth of skills, knowledge, and expertise
o Improves external validity

STEP 1: NEEDS ASSESSMENT – LOGIC MODEL OF BEHAVIOUR/PROBLEM

• Establish and work with a planning group

• Conduct a needs assessment to create a logic model of the problem
• Describe the intervention context, including the population, setting, and community
• State program goals => which are the expected changes

The end product of step 1 is a logic model of the problem which outlines the health problem targeted, the
associated impacts, the ecological factors that influence it, the individual determinants involved, and the risk
behaviours connected to it

STEP 2: PROGRAM OUTCOMES AND OBJECTIVES – LOGIC MODEL OF CHANGE

• State the expected outcomes for individuals and environment

• Specify performance objectives for behavioural and environmental outcomes
• Select determinants for behavioural end environmental outcomes
• Construct matrices of change objectives
• Create a logic model of change

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STEP 3: PROGRAM DESIGN

• Generate program themes, components, scope, and sequence

• Choose theory-and-evidence-based change methods
• Select or design practical applications to deliver change methods

STEP 4: PROGRAM PRODUCTION

• Refine program structure and organization

• Prepare plans for program material
• Draft messages material and protocols
• Pretest program materials and protocol to make sure that they are country relevant, engaging, and
really applicable in real-world situations

STEP 5: PROGRAM IMPLEMENTATION PLAN

• Identify potential users (adopters, implementers, and maintainers) for the program
• State outcomes and performance objectives for program use
• Construct matrices of change objective for program use
• Design implementation interventions

STEP 6: EVALUATION PLAN

• Write e;ective and process evaluation questions

• Develop indicators and measures for assessment
• Specify the evaluation design
• Complete the evaluation plan

è The end product is an LOGIC MODEL OF INTERVENTION

§ Step 1 informs health and quality of life outcomes

§ Step 2 informs environmental outcomes
§ Step 3 informs the practical applications
§ Steps 4 and 5 inform implementation and program activities
§ All these steps inform the overall program evaluation

è CORE PROCESSES FOR USING THEORY AND EVIDENCE à Core Processes are presented as a helpful,
systematic way to answer questions that arise during various phases of intervention planning, from problem
analysis to evaluation. Unlike IM steps, which are iterative, the Core Processes follow a fixed order of six steps
[I core processes non devono essere considerati come una metodologia alternativa all’IM, ma piuttosto come una strategia utile per
guidare tutta la fase di intervention planning]

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• The Core Processes leverage expert knowledge, empirical evidence, and theory to ensure that planning
decisions are sound
• This systematic approach minimizes the likelihood of developing interventions based on incomplete
understanding or haphazard decisions

The steps of the Core Processes are:

1. Pose questions: define the specific question that needs answering at that moment (e.g., what are the
determinants?)
2. Brainstorm possible answers: a creative process involving free association and consulting experts to
generate provisional explanations. Explanations should describe a causal process and be plausible
a. The aim here is to generate as many answers as possible to guide following steps
3. Review empirical findings from published research: systematically search for evidence (starting with
reviews) to support or refute the provisional answers, disregarding those that are poorly supported
a. Topic approach / concept approach / general approach
4. Find theoretical support: look for theories that support the possible answers identified, using a topic-
related approach, a concept-related approach, or a general theories approach
5. Conduct new research (collect additional data): only necessary if steps 1-4 do not provide su;icient
evidence
6. Complete and assess the list of possible answers: finalize the working list of answers by evaluating
them for relevance (= strength of the association between the determinant and behaviour) and
changeability (= feasibility of realizing the proposed change through an intervention)

Let’s see an example à In this example, a group of students in a health education class designed a project to
prevent the transmission of HIV and other sexually transmitted infections (STIs) and pregnancy among urban
adolescents

1. Over the course of the project, they asked a number of questions, including: (1) Health problem. What
are the health problems associated with HIV, STIs, and pregnancy in adolescents (ages 13–18) in the
USA? (2) Behaviours. What are important risk behaviours for the transmission of HIV and STIs, and for
pregnancy among adolescents? How do these risk behaviours vary, for example, between boys and
girls? (3) Determinants. About the risk behaviour: Why don’t adolescent males use condoms when
having sex with steady girlfriends? Why do girls have sex with boys who do not use condoms? About the
health-promoting behaviour: Why would girls carry condoms? Why would adolescents discuss condom

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Planning Behaviour Change Programs
use with their partners? (4) Change methods. What change methods relate to what determinants? How
can change methods be translated into appropriate practical applications? (5) Implementation. How
could such an intervention be implemented?
2. Using “free association,” planning group members generate as many explanations as possible that can
later be dropped when poorly supported
3. The intervention planners identified empirical evidence for some issues related to unprotected sex that
were not already brainstormed, for example not perceiving condoms as a means of pregnancy
prevention or perceiving condoms as embarrassing
4. The literature review identified a meta-analysis study on the psycho-social determinants of condom
use in heterosexual populations. In the introduction and discussion sections, these authors refer to
di;erent psychosocial theories of (health) behaviour such as the Health Belief Model, the Theory of
Planned Behaviour, and the Aids Risk Reduction Model. By studying these theories in detail, additional
answers can be added to the list of potential explanations
5. In the next step, the planning group needed more information from their priority population about the
items on the provisional list in order to determine whether these proposed factors were relevant to their
particular population. To this end, the group conducted focus groups with seventh- and eighth-grade
students from the priority population. The new data called into question the notion of a lack of
knowledge about HIV or STIs in the adolescent population
6. In the final step, the planning group completes the provisional list of answers and summarizes it into a
working list for which the evidence is su;icient. The provisional list of answers from the brainstorm is
thus followed up by a list of answers for which theoretical and empirical support has been sought

THE ROLE OF CULTURE IN INTERVENTION PLANNING

A repeating theme in every IM step is the necessity of creating culturally relevant programs for diverse groups

• Planners must adopt an attitude of cultural humility, recognizing that achieving full "cultural
competency" is impossible, and instead prioritizing lifelong self-evaluation and self-critique

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Planning Behaviour Change Programs
• Cultural factors must be integrated throughout the planning process, influencing:
o The definition of performance objectives
o The selection and understanding of determinants
o The development of appropriate materials and applications (Steps 3 and 4)

Important Repeating Concepts à Several concepts are reiterated across the Intervention Mapping process:

• Matrices as a foundation: Matrices combine performance objectives (what needs to be done) with
determinants (why it is done) and form the basis for program development (Steps 2 and 5)
• Planning as an iterative process: Although presented sequentially, IM encourages planners to revisit
previous steps and refine their plans as new information is acquired
• Logic models: The development of the Logic Model of the Problem (Step 1) and the Logic Model of
Change (Step 2/3) are critical components that map causal relations
• Program evaluation: Evaluation planning starts during the needs assessment phase (Step 1) and
continues through every subsequent step

The Intervention Mapping process, supported by the rigorous application of Core Processes, functions like a
GPS system for intervention design: instead of blindly following intuition (driving without a map), it provides a
fixed sequence of inquiries (Core Processes) to accurately pinpoint the destination (the ultimate goal, Step 1),
carefully plot the route (the logic model of change, Step 2), select the right vehicle and tools (methods and
applications, Step 3), and ensure the final product is ready for the road (production and testing, Step 4),
guaranteeing e;icient travel (implementation, Step 5) while monitoring progress throughout the journey
(evaluation, Step 6)

è TAXONOMY OF HEALTH INTERVENTION DEVELOPMENT APPROACHES

The study, a systematic methods overview, aimed to identify a variety of published approaches for the
development or adaptation of interventions, programmes, or innovations to improve health. Eight categories of
approaches were identified based on the rationales stated by the authors of the approaches

CATEGORY DEFINITION (AS SYNTHESIZED BY THE INDEX TEAM)

The people for whom the intervention aims to help are involved in decision-making
1. Partnership about the intervention throughout the development process, having at least equal
decision-making powers with members of the research team

2. Target population- Interventions are based on the views and actions of the people who will use the
centred intervention

Interventions are based on combining published research evidence and formal

3. Evidence and
theories (e.g., psychological or organizational theories) or theories specific to the
theory-based
intervention.

4. Implementation- Interventions are developed with attention to ensuring the intervention will be used in
based the real world if e;ective

Components of an intervention are tested using experimental designs to determine

5. Ebiciency-based
active components and make interventions more e;icient (optimization)

Interventions are developed through emphasis on following a systematic set of

6. Stepped or phased
processes

7. Intervention- An approach is constructed for a specific type of intervention (e.g., digital, patient
specific decision support, group interventions)

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Existing approaches to intervention development are formally combined (e.g., the
8. Combination combination of Participatory Action Research, theories of Behaviour Change, and
Persuasive Technology)

THE 18 KEY ACTIONS

The actions derived from approaches across all eight categories were synthesized to identify a total of 18
actions to consider during intervention development. While intervention development is often a cyclical or
iterative process rather than strictly linear, these actions are presented within seven domains following a broad
sequence for easier understanding

Domain 1: CONCEPTION
1. Identify that there is a problem in need of a new intervention

Domain 2: PLANNING
2. Establish a group or set of groups to guide the development process, considering the engagement of
relevant stakeholders such as the public, patients, practitioners, and policymakers
3. Understand the problems or issues to be addressed, which includes understanding the experiences and
psycho-social context of the target population, assessing the causes of the problems, describing the wider
context, identifying evidence of e;ectiveness, and understanding wider stakeholders’ perspectives
4. Make a decision about the specific problem or problems that an intervention will address, and define the
aims or goals for the intervention (e.g., defining target behaviours)
5. Identify possible ways of making changes to address the problems, including the mechanisms of change
needed at individual, interpersonal, organizational, community, or societal levels
6. Specify who will change, how and when. Selections may be based on consideration of the likely impact of
the change and how easy it is to change
7. Consider real-world issues about cost and delivery of any intervention at this early stage to reduce the risk
of implementation failure at a later stage
8. Consider whether it is worthwhile continuing with the process of developing an intervention.

Domain 3: DESIGNING
9. Generate ideas about solutions, and components and features of an intervention, often creatively, by
working with stakeholders or using theory
10. Re-visit decisions about where to intervene, including the scope, target population, and key features of
the intervention
11. Make decisions about the content, format and delivery of the intervention
12. Design an implementation plan, thinking about who will adopt the intervention and maintain it.

Domain 4: CREATING
13. Make prototypes or mock-ups of the intervention, where relevant, often rapidly and cheaply to obtain
feedback

Domain 5: REFINING
14. Test on small samples for feasibility and acceptability and make changes to the intervention if possible
15. Test on a more diverse population, moving away from the single initial setting to improve external validity
and check if the intervention is working as intended
16. Optimise the intervention for eNiciency prior to a full Randomized Controlled Trial (RCT), possibly using
methods like fractional factorial designs to identify active components

Domain 6: DOCUMENTING
17. Document the intervention, describing the intervention so others can use it, and o;er instructions on how
to train practitioners delivering the intervention and how to implement it (often resulting in a "manual")

Domain 7: PLANNING FOR FUTURE EVALUATION

18. Develop the objectives of the outcome and process evaluations. This includes determining how
outcomes and mediators of change can be measured, and considering the feasibility of a full RCT

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Lecture & Tutorial 1 – 03/11/2025 + notes integrated with Chapter 4
STEP 1: NEED ASSESSMENT = The primary focus of Step 1 is to conduct a Needs Assessment to create a
Logic Model of the Problem. This step is built on the perspective of Participation as it requires establishing
and working with a planning group

• It consists in a systematic study of discrepancy between what it is and what should be

• A statement of need is a statement of a problem and does not suggest a solution
• It requires fully analysing the problem and its multiple causes to create a logic model of the problem
• A full analysis requires an adequate planning group of representatives and stakeholders
• A full analysis is needed before selection can be made based on relevance and changeability
o Relevance = evidence of strength of association (e.g. between behaviour & health outcome,
environmental factor & behaviour, determinant & behaviour, determinant & method, etc.)
o Changeability = strength of the evidence that the behaviour (environmental factor or
determinant) can be changed by an intervention
o Behaviours and environmental factors that are both more relevant and more changeable will be
a high priority for program focus

Step 1 divides into 4 tasks

 ESTABLISH AND WORK WITH A PLANNING GROUP à This involves assembling a diverse team, which is
the central engine for the needs assessment. Since intervention mapping embraces a participatory approach,
the group must represent a broad range of perspectives and expertise, including:

• Target population representatives: crucial for ensuring the program is acceptable and feasible.
• Implementers: Those who will deliver the program.
• Decision-makers and community leaders: For political support and resource allocation.
• Subject-matter experts: Professionals who understand the health problem and related determinants.

This participatory approach:

- Ensures that the intervention reflects actual concerns within a population or community
- Brings greater breadth of skills, knowledge and expertise
- Improves external validity
- Results in greater acceptance of the intervention that is going to be developed

Principles of collaboration:

• Recognize community identity and knowledge

• Balance science with local relevance
• Share power and decision-making equitably
• Build local capacity and sustainability
• Communicate openly and compensate community members

This first task of step 1 comprises describing the priority population

• The priority population is a group with definable boundaries and shared characteristics that is at
risk for certain health and quality-of-life problems, or that has health problems and are at risk for
the sequelae
o The boundaries of the pp will help define the scope of the need assessment

- What is the problem? – Who has it? - What are the incidence, prevalence and distribution of the problem? - Is
there a community? What are its characteristics, including its resources and strengths? - What segments of the
population have an excess burden from the health problem? – Where can the group at risk be reached by
program?

• The population at risk is often “epidemiologically” and “demographically” defined

• Note that the at-risk group is not necessarily the target group of intervention

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Planning Behaviour Change Programs
• When defining the priority population is fundamental to adopt a social-ecological perspective

To be e;ective, the planning group members should have some type of expertise in the health problem or its
causes, adopt diverse perspectives and community participation, and commit to the issue

• Who should be in the pg? Stakeholders who have an interest in the health problem, the program
development, and the expected outcomes of the program
• It is important to create a linkage system between a resource system (program developers), and
intermediate-user system (implementers), and ad end-user system (participants)
• Example = resource group (program developers, funders) + program adopters and implementers
(principals, teachers) + priority population (end-users)

‚ CONDUCT A NEEDS ASSESSMENT TO CREATE A LOGIC MODEL OF THE PROBLEM

The logic model of the problem contains all the factors that cause or influence the health problem and that will
be the focus of the intervention à it relies a lot on the PRECEDE model to obtain a social, epidemiological and
behavioural perspective on a community or population at risk for health-related problems

• The PRECEDE model focuses on educational and ecological diagnosis by assessing health and
quality of life needs, then identifying the predisposing, reinforcing, and enabling factors that
influence health behaviours and environmental conditions. This initial phase ensures that interventions
are based on a thorough understanding of the community's needs and the factors that contribute to its
health problems
• Moreover, the logic model informs Step 2, where planners define program outcomes and objectives

This is a PRECEDE model

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Planning Behaviour Change Programs
The creation of the logic model is a diagnostic process, moving from right to left – from the ultimate
outcomes (quality of life and health problems) to their proximal causes (behavioural and environmental
factors). The PRECEDE model (Predisposing, Reinforcing, and Enabling Constructs in Educational Diagnosis
and Evaluation) is an established framework often used to structure this diagnostic portion of the needs
assessment

è Using core processes can be very useful in this phase (+ see example on condom use among adolescents
above)

Depending on the problem/behaviour that we want to target, intervention mapping process should start
at diberent “points” of the logic model. For example:

• Researchers interested in reducing a specific health problem (e.g. cardiovascular disease) should start
at point 2
• Researchers interested in reducing a specific risk behaviour (e.g. reducing lack of physical activity
among kids) should start at point 3

The Needs Assessment requires collecting evidence to define the causal relationships and set priorities. Data
comes from two main sources:

• Secondary Data: Information already collected by others, such as:

o Scientific Literature and Systematic Reviews (for relevance and changeability evidence)
o Health Statistics (incidence, prevalence, mortality rates)
o Existing Program Data and reports
• Primary Data: New data collected specifically for the planning process, such as:
o Surveys and Questionnaires administered to the target population
o Focus Groups and Interviews with stakeholders and community members
o Observations of the priority environment or behaviour

In the need assessment researchers assess the extent and distribution of a problem in a population

• Vital indicators: disability, discomfort, fertility, fitness, morbidity, mortality, physiological risk factors
• Dimensions: distribution, duration, functional level, incidence and prevalence, intensity, longevity
• Identify health-related behavioural factors, as well as environmental factors, that could be causally
linked to the problem à always keep an ecological perspective!!!
o Environmental conditions are social or physical conditions that influence risk behaviours –
directly or indirectly causing the problem
o Environmental factors can be prioritized in terms of their importance and changeability

ƒ DESCRIBE THE INTERVENTION CONTEXT, INCLUDING SETTING, AND COMMUNITY à this task refines
the focus of the intervention by examining the environment and the target population

• It is important to balance the needs assessment with an assessment of the community’s assets,
capacities, and abilities
• Explore assets with the various environment within a geographic community, setting or ecological level
o Policy environment
o Community, state or national level
o Information environment
o Social/organizational environment
o Physical/built environment
• An asset-based approach should be used to identify existing resources and capacities within the
community (e.g., familial ties, available health workers) which can aid in enhancing program
implementation and sustainability
• Identify an appropriate setting for the intervention with widespread access to the priority population
and the capacity to implement the intervention with fidelity

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Planning Behaviour Change Programs
• To do so, it is crucial to conduct a first community asset assessment considering the social,
communicative, policy and physical environment around the chosen problem

„ STATE PROGRAM GOALS à what do we want to achieve? Which specific target group do we choose? How
much behaviour change can we expect from our target group? How quickly (or in what timeframe) would it be
possible to reach that goal? How likely it is to reach it? Are ePects on relevant health outcomes quantifiable
within the chosen relevant and realistic time frame or should we choose a certain behaviour or environment?

Program goals link the needs assessment directly to program and evaluation planning à Goals reflect the
desired impact on health, QOL, behaviours, and environmental outcomes

Before setting goals, it is crucial to consider:

• Trade-obs: Weighing the consequences of ignoring the needs versus the possible costs of
implementing a solution
• Political and Social Factors: Including community values, local/regional/national priorities,
public/leader expectations, momentum, and resource availability (funding and human resources).

Criteria for setting priorities:

• Magnitude between what is and what could be

• Di;erence in burden from a problem among groups
• Practical issues (e.g., consequences of ignoring the needs) vs. possible costs of implementing a
solution
• Political and social factors (e.g., community values, context of priorities / local, regional, national and
international), public and leader expectations, available interest and expertise, momentum, and
availability of funding and human resources
• While setting the desired goals it is crucial to take into account relevance (= evidence of strength
association – e.g. between beh. and health outcome, environmental factors and beh., determinants
and beh.), and changeability (= strength of the evidence that the behaviour can be changed by and
intervention) à behaviours and environmental factors that are both more relevant and more
changeable will be a high priority for program focus

Program goals: core questions to ask when setting goals

• Health outcomes = what will change in terms of the health problem? Among whom? By how much?
By when?
• Health-related behaviour outcomes = what health related behaviour will change? Among whom?
By how much? By when?
• Health-related environmental outcomes = what environmental conditions will change? By how
much? By when? By whom?

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To sum up à to get started:

• Brainstorm to identify what is the health problem, risk behaviour, or environmental condition we want to
target
• Define the priority population, identifying which subjects have excess burden
• Draft the PRECEDE model and decide where we want to enter the model (which phase)

PRACTICAL EXAMPLE: IT’S YOUR GAME ... KEEP IT REAL

"It’s Your Game ... Keep It Real" is a sexual-health education program for middle school students, developed
using the Intervention Mapping (IM) framework. This summary details how the program applied IM Step 1: Logic
Model of the Problem, which focuses on conducting a comprehensive Needs Assessment

Task 1: Establish and Work with a Planning Group

The planning team was highly diverse and included:

• Program Developers: Health educators, behavioural scientists, epidemiologists, a paediatrician, and a

human sexuality expert
• Implementers/Partners: Representatives from the school district (health, P.E., medical services),
school principals, a school nurse, and representatives from local medical, religious, and community
organizations
• End Users/Community: Parents
• Advisory Group: A teen advisory group (youth ages 12–15) was created to meet quarterly, ensuring
program materials were relevant and engaging for the priority population

Task 2: Conduct a Needs Assessment to Create a Logic Model of the Problem

The team used the PRECEDE model as the organizing framework for the needs assessment, starting with the
health problem and working backward to identify its causes.

Needs Assessment Methods

The team employed both secondary and primary data collection methods:

• Secondary Data: Literature reviews and surveillance data

• Primary Data: 10 focus groups with 7th and 8th-grade students, 7 focus groups with parents, interviews
with school district personnel, and planning group discussions

Describing Health Problems, Quality of Life (QOL), and the Population at Risk

• Priority Population: Predominantly African American and Hispanic middle school students in a
large, urban school district in the south-central U.S. (38 middle schools, 13,699 7th graders). 79%
participated in the free or reduced-cost lunch program (indicating low socioeconomic status)
• Health Problem: Excess burden of teen pregnancy, sexually transmitted infections (STIs), and HIV
infection among racial/ethnic minority youth
• Magnitude: Minority youth are disproportionately a;ected.
o Locally, many communities had teen birth rates higher than 100 per 1,000 girls (ages 15–19),
exceeding the state (63/1,000) and national (43/1,000) rates
o 75% of new HIV cases among youth (13–19 years old) in the target area were among African
American youth, and 15% were among Hispanics.
• QOL Impact: Teen pregnancy is a major factor in high school dropout and welfare dependency. STIs
increase the risk of other reproductive health problems (e.g., infertility, cancer) and psychological
issues related to stigma.

Describing Behavioural Factors

The risk behaviours contributing to the health problems include:

• Initiating sex at a younger age (African American and Hispanic youth are more likely to initiate earlier
than white youth)

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Planning Behaviour Change Programs
• Having multiple lifetime sexual partners, engaging in greater frequency of sex, and using alcohol or
drugs before sex
• Engaging in sex without a condom
• Dating older partners and experiencing dating violence
• Failing to get tested for STIs and HIV, which delays treatment and increases transmission risk.

Describing Determinants of Sexual Risk Behaviours

Psychosocial determinants (reasons why adolescents engage in risk behaviours) included:

• Lack of basic knowledge regarding STIs, contraceptive methods, and what constitutes “sex”
• Low self-e;icacy, negative beliefs, and low perceived susceptibility
• Students confirmed they needed information on contraceptive types and use

Describing Environmental Factors

Environmental factors at the interpersonal, community, and policy levels that influence behaviour:

• Interpersonal: Low parent-child communication about sexual health and low parental monitoring
• Health Care: Providers rarely discuss sexual-health issues during adolescent clinic visits
• Policy: Local and state policies on sexual-health education in schools and minors' access to services

Task 3: Describe the Context for the Intervention

• Setting: School—it was deemed a logical setting as adolescents spend most of their day there
• Support: Parent focus groups showed a majority supported sex education that discussed abstinence
and provided information on condoms/contraceptives. The school district was also a strong supporter,
willing to provide class time

Task 4: State Program Goals (Proxy Goals)

Since the evaluation timeframe was too short to assess the e;ect on long-term health outcomes (like STI
incidence), the team set measurable proxy goals focused on key sexual behaviours:

• After two years of the intervention, the percentage of students in the intervention group who have not
initiated sexual intercourse by ninth grade will be 10 percent higher compared to students in the non-
intervention group
• After two years of the intervention, the percentage of sexually active students in the intervention group
who used a condom at last sexual intercourse will be 10 percent higher compared to students in the
non-intervention group

è A PRACTICAL GUIDE TO EFFECTIVE BEHAVIOUR CHANGE: HOW TO IDENTIFY WHAT TO CHANGE IN THE
FIRST PLACE
Il testo fornisce una guida pratica e teorica per l'identificazione di cosa cambiare negli interventi di modifica del
comportamento, specialmente nel contesto della psicologia della salute. Poiché i metodi di cambiamento non agiscono
direttamente sul comportamento, è cruciale individuare i determinanti e le convinzioni pertinenti da influenzare. Vengono
spiegate le basi del comportamento umano, utilizzando la metafora dell'attivazione neuronale e dei concetti interconnessi per
descrivere come le credenze (entità psicologiche specifiche) formino i determinanti (variabili di livello superiore come
l'atteggiamento o l'autoefficacia). Il documento descrive un processo in tre fasi per identificare gli obiettivi di cambiamento: l'uso
di revisioni sistematiche della letteratura, la conduzione di interviste qualitative con la popolazione target, e infine,
una verifica quantitativa tramite sondaggi per stabilire l'importanza relativa dei determinanti e delle credenze. Infine, viene
introdotta la matrice degli obiettivi di cambiamento come strumento per organizzare sistematicamente le informazioni raccolte,
collegando i determinanti e le credenze ai sotto-comportamenti specifici (obiettivi di performance) e agli attori ambientali.

Foundational Concepts and Internal Influences

The guidelines outlined rely on several basic assumptions regarding the nature of psychological influences:

• Influences on human behaviour exist either inside a person or outside a person (environmental
conditions)

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Planning Behaviour Change Programs
• Internal influences are not directly observable and are studied using indirect methods (e.g., measuring
electrical signals, oxygen transport, or using questionnaires/reaction tasks)

• The human psyche fundamentally consists of, or functions through, activation patterns of neurons
that excite and inhibit each other. This concept of spreading activation serves as a useful metaphor for
explaining and changing human behaviour

Determinants and beliefs are crucial variables in this internal network:

• Beliefs are specific, low-level psychological entities corresponding to single thoughts, emotions,
perceptions, cognitions, or associations. This definition is intentionally broad and includes implicit
associations. Because of their narrow scope, mapping all beliefs theoretically allows for the prediction
of behaviour
• Determinants are higher-level, compound constructs that aggregate functionally similar or related
beliefs. Psychological theories (like the Reasoned Action Approach or Social Cognitive Theory)
postulate these variables (e.g., perceived behavioural control, attitude, self-e;icacy)
• It is crucial to determine which beliefs "belong" to which determinant because behaviour change
methods are usually matched to determinants, not to beliefs. Applying a method designed for self-
e;icacy (e.g., Guided Practice) to a belief that underlies subjective norm is likely to fail

THE SCOPE OF CHANGE: PERFORMANCE OBJECTIVES AND ENVIRONMENT

Broadly defined behaviours (like "safe sex" or "diet") typically consist of preparatory and/or sub-behaviours.
These specific steps must be clarified because determinants can di;er for each one:

• Performance Objectives are the preparatory and/or sub-behaviours that an intervention aims to
influence. If all performance objectives are achieved, the overarching behaviour is, by definition,
performed
• Environmental Conditions are external influences (e.g., free condoms, gym availability) that also
impact behaviour. These conditions can be changed by environmental agents or actors (e.g., parents,
nurses, politicians) who hold key positions
• Environmental agents are categorized by their proximity or role, often visualized in concentric circles:
interpersonal, organisational, communal, and societal (and sometimes global)

IDENTIFYING OBJECTIVES: THE THREE METHODOLOGICAL STEPS

Identifying the necessary performance objectives, environmental conditions, determinants, and beliefs
requires methodological flexibility, combining literature review, qualitative exploration, and quantitative
verification.

1. Systematic Reviews:

• Involves compiling available empirical evidence thoroughly, ideally for publication

• Can include meta-analysis to integrate quantitative evidence regarding correlations between
determinants and behaviour
• Should also include a qualitative review to gather evidence on specific beliefs, which are often
excluded from meta-analysis

2. Interviews (Qualitative Study):

• Involves talking directly to target population members and stakeholders

• Crucial for uncovering the specific beliefs important to the target population, as these beliefs inform
the specific messages an intervention must use
• The process involves developing a topic list, recruiting participants, conducting and transcribing
interviews, and coding the data to identify which observed beliefs belong to known determinants.

3. Survey (Quantitative Verification):

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Planning Behaviour Change Programs
• Necessary because people may not be aware of the true reasons for their behaviour, and beliefs they
subjectively consider important may not be significant predictors of behaviour
• Used to determine the relative importance of both determinants and the beliefs underlying them.
• Key steps include compiling all identified beliefs and determinants, developing concrete
operationalizations (avoiding categorical or dichotomous options), and running analyses
• Quantitative analyses include computing confidence intervals for correlation coe;icients to estimate
how strongly each determinant predicts the behaviour, and how strongly each belief predicts its
respective determinant

SYNTHESIS: THE MATRIX OF CHANGE OBJECTIVES

The final structured step involves organizing the wealth of information gathered into the matrix of change
objectives

• The matrix rows represent the performance objectives

• The columns represent the determinants
• In each cell, the relevant beliefs are listed, often phrased as change objectives (describing the
desirable situation to be achieved, e.g., "The target population individual expresses confidence
regarding going to the gym despite rainy weather")
• For environmental conditions, a separate matrix can be created for the environmental agents, where
their behaviours (performance objectives) are predicted by their own determinants and environmental
conditions

This structured matrix allows researchers to consult overviews of behaviour change methods and match them
directly to the relevant determinants and beliefs, providing clear empirical and theoretical evidence for the
intervention choices

Analogy: Identifying what to change is like an electrician diagnosing a house before installing a new system. You
don't just know the lights are out (the behaviour); you must trace the wires (the performance objectives), check
the fuse box (the determinants), and confirm which specific connections are broken (the beliefs) before you
choose the right tool (the behaviour change method) to fix the precise problem.

Lecture & Tutorial 2 – 10/11/2025 + notes integrated with Chapter 5

STEP 2: CREATE PROGRAM OUTCOMES AND OBJECTIVES à Step 2 of Intervention Mapping (IM), which
involves detailing who and what will change as a result of the planned intervention. This step uses the Logic
Model of the Problem (developed in Step 1) as a reference point to establish program outcomes and objectives,
culminating in the development of the Logic Model of Change. The Logic Model of Change illustrates the
proposed causal relationships among change methods, determinants, and the expected behavioural and
environmental outcomes. The key products of Step 2 are the matrices containing change objectives, which
serve as the direct targets for the subsequent program design steps

Step 2 consists of 5 sub-tasks:

1. State expected outcomes for behaviour and environment

2. Specify performance objectives for behavioural and environmental outcomes
3. Select determinants for behavioural and environmental outcomes

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Planning Behaviour Change Programs
4. Construct matrices of change objectives
5. Create a logic model of change

 STATE EXPECTED OUTCOMES FOR BEHAVIOUR AND ENVIRONMENT à The first task requires planners to
clearly articulate the desired Program Outcomes, specifying the expected results in the behaviour of the
priority population (Behavioural Outcomes - BOs) or the environment (Environmental Outcomes - EOs). The
statements must clearly express what participants are expected to do following the intervention. First of all, we
start considering again the logic model of the problem (risk problem) that was developed in Step 1

First question to be asked: What needs to change in the behavioural and environmental factors to have
improved health outcomes?

• In order to pass from the logic model of problem to the logic model of change we need to flip the first
model that we developed
• We then proceed to work from right to left in the logic model of change identifying the behavioural and
environmental changes needed to achieve health and quality of life outcomes

The expected outcomes should be formulated

according to the SMART paradigm:
• Specific – Objectives should specify what they
want to achieve
• Measurable – You should be able to measure
whether you are meeting the objectives or not
• Achievable – Are the objectives you set, achievable
and attainable?
• Realistic – Can you realistically achieve the
objectives with the resources you have?
• Time – When do you want to achieve the set
objectives?

BEHAVIOURAL OUTCOMES (BOs)= These are the major health-promoting behaviours desired from the at-risk
populationà we want to state behavioural outcomes in terms of the behaviours to be accomplished as a
result of the health promotion program

Ä For ex. For the It’s Your Game . . . Keep It Real (IYG) project, the primary BO for middle school students
was "Choose not to have sex". However, recognizing that some students might already be sexually
active, additional BOs included having healthy dating relationships, using condoms correctly and
consistently, and obtaining regular testing for pregnancy, HIV, and STIs

There are 3 types of behaviours that can either promote health or reduce risk:

1. Risk reduction behaviours => action designed to reduce illness or diseases (e.g. using condoms
correctly and consistently when having sexual intercourses)
2. Health-promoting behaviours => action designed to protect or enhance health (e.g. promoting
mammography screening)
3. Adherence and self-management behaviours => particularly important for individuals with chronic
disease to help them to better adhere to their prescribed treatment

è For same behaviours there are specific guidelines that can be consulted to identify behavioural outcomes
=> these should be incorporated when designing the intervention

ENVIRONMENTAL OUTCOMES (EOs) = These describe how the environment needs to change at interpersonal,
organizational, community, or societal levels. When stating the environmental desired outcomes, we always
need to keep an ecological perspective, accounting for all levels of the environment.

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Planning Behaviour Change Programs
Environmental conditions are social or physical conditions that influence risk behaviours – directly or
indirectly causing health problems

- Social environment: behaviours of parents, peers, employers, health care providers; access to
services, rules, policies, laws, availability of resources
o Examples of interpersonal environment are families (= primary influence for socialization for
children), peer groups, and influential roles
- Physical environment: water, air, housing

Environmental factors can present at an INTERPERSONAL, ORGANIZATIONAL, COMMUNITY AND SOCIETAL

level

- Interpersonal environment:
o Families – primary influence for socialization of children and continue to a;ect behaviour
throughout life
o Peer groups – beginning with playmates and continuing with friends, neighbours, member of
organizations etc.
o Influential roles – special influence through a role (e.g. teachers, coaches etc.)
o Support from social networks – emotional support, information or advice, material support,
social identity etc.
- Organizational environment:
o Norms
o Policies (e.g. policies that exert strong control over behaviour – ex. Worksite bans on smoking)
o Practices
o Facilities (e.g. health care facility characteristics – ex. Service hours might determine whether
workers obtain care)
- Community level environment:
o Access to health care
o Availability of recreational resources
o Smoking and other health ordinances
o Treatment resources for social problems such as child abuse, violence, and drug addiction
o Social capital (= capacity of the community to form and maintain health-promoting coalitions)
- Societal level environment:
o Legislation
o Enforcement
o Regulation
o Resource allocation
o Policies, programs, and facilities of large political and geographic groups
- Environmental factors can be prioritized in terms of their importance and changeability => factors that
are found to be non changeable should not be include is the intervention plan

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Planning Behaviour Change Programs
• For ex. The ToyBox-Study focused EOs on increasing preschoolers’ physical activity and decreasing their
sedentary behaviour targeting parents and teachers as agents of change

• Examples stated in terms of the environmental outcomes to be accomplished as a result of the health
promotion program:
o Parents support preschoolers to be more physically active (interpersonal level)
o Partners support women to breastfeed exclusively for 6 months (interpersonal level)
o Food service directors modify purchase orders to reduce the fat content of vendor-machines
foods (organizational level)
o State legislators prohibit smoking in all enclosed public places in the state (societal level)
o Etc.

‚ SPECIFY PERFORMANCE OBJECTIVES FOR BEHAVIOURAL AND ENVIRONMENTAL OUTCOMES à The

second task involves taking the broad BOs and EOs and breaking them down into precise, detailed
Performance Objectives (POs). POs define the exact sub-behaviours or steps necessary to achieve the
desired behavioural outcome (= they are observable subsets of the behaviour = actions that people
actually need to take to achieve the desired outcome – they are a small breakdown of the overall program goal)

For example: BO = use condoms consistently and correctly (this can seem like a very straightforward
behaviour, but it can actually be divided in many subsets)
PO = buy condoms / carry condoms / negotiate the use of condoms with the partner / correctly apply condoms
during use / maintain use overtime / etc.

• Formulation = POs are defined by asking what do the participants have to do to perform the health-
related behaviour? For environmental conditions, the question is: "What does someone in the
environment need to do to accomplish the environmental outcome?"
o What does the environmental agent need to do to accomplish the changes in environmental
factors?
o Note that Performance objectives are kind of sub-steps of behavioural outcomes
• Specificity and Clarity = POs use action words and make the expected performance specific. For
instance, "eliminating trans-fats from the diet" includes sub-behaviours like "read food labels" and
"select foods without trans fats"
• Complexity (Self-Management) = For complex chronic conditions (e.g., epilepsy management or ART
adherence), POs are often based on self-management processes, such as goal setting, self-monitoring,
and making plans (self-regulatory strategies)
o Ex. POs for condom use among HIV+ men who have sex with men (MSM) include "Purchase
condoms," "Carry condoms or have condoms easily available," and "Negotiate condoms for
anal sex"
• Performance objective are also for the environmental agents à Environmental POs = These explicitly
name the environmental agent performing the action

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Planning Behaviour Change Programs
• PO for the environmental outcomes must include who will perform the action à what does someone in
the environment need to do to accomplish the environmental outcome?
o For the T.L.L. Temple Foundation Stroke Project, an organizational PO for primary care providers
was to "educate o;ice sta; regarding how to recognize stroke and what to tell patients (such as
calling 911 immediately)"
• Validation = The initial list of POs should be validated with the priority population through
methods like surveys or focus groups to ensure they are realistic and congruent with actual
behaviours
o Self-report by individuals performing behaviour or changing environment
o Observation of behaviour or environment change
o Expert consensus
o Performance objectives predict or correlate with behaviour
• The correct formulation of a performance objective is X does Y à we are not thinking about what
people are capable of doing, but what they are required to do to accomplish a certain desired outcome
• For example: Use condoms correctly and consistently à firstly we think about sub-behaviours that
people have to do to maximise the desired ultimate behaviour (= using condom)
o Buy or obtain condoms
o Carry condoms or have condoms easily available (most frequent reason for not using condoms)
o Negotiate the use of a condom with a partner
o Correctly apply condoms during use
o Maintain use over time

è CORE PROCESSES are extremely useful when stating the performance objectives:

• Brainstorm performance objectives (write list) à what do people have to do to reach the health
promoting behavioural or environmental outcomes?
• Review the literature (adapt list)
• Look for theories that provide a rationale for performance objectives (refine list)
• Validate performance objectives, if necessary, with additional research (refine the list again)
• For example: regulate oneself food intake calories
o Monitor own food intake
o Compare intake to goals based on guidelines for a healthy diet
o Decide if discrepancies exist
o Make a detailed plan of implementation intentions and take action to improve dietary behaviour
o Evaluate the action’s e;ects
o Recycle to monitor one’s own food intake

ƒ SELECT DETERMINANTS FOR BEHAVIOURAL AND ENVIRONMENTAL OUTCOMES à The third task
focuses on selecting important and changeable determinants of the behavioural and environmental
outcomes. These are the personal factors (like knowledge, skills, attitudes, self-ebicacy, perceived
norms, normative beliefs, and perceived norms) that influence whether the POs will be performed

- Personal determinants = cognitive factors associated with the performance of the health behaviour
of the priority population

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Planning Behaviour Change Programs
- (personal) Determinants for the environmental agents = factors associated with the behaviour of the
environmental agents that have control or influence over environmental outcomes

Determinants: generic
psychological
constructs that cause
behaviour

Sub-determinants:
specific psychological
constructs that cause
behaviour
= self-ebicacy

Genetics and environment (which consists also of other people – environmental agents) all contribute to
determine and influence our behaviour

• Influences on human behaviour exist either inside

or outside a person (= environmental conditions)
• Influences within a person are not directly
observable
o Indirect research methods are used to draw
conclusions about a person’s psyche

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Planning Behaviour Change Programs
Use CORE PROCESSES to select the determinants:

- Pose a question (= why would a person perform a certain health-promoting behaviour? Why would a
certain environmental agent make an environmental modification?)
- Brainstorm
- Review findings
- Review theories
- Assess and address need for new data
- Formulate a working list of answers
• Criteria = Determinants are assessed based on two criteria:
1) Importance (strength of evidence for the causal relationship)
2) Changeability (strength of evidence that the proposed change can be realized by a program)
• Evidence Base = Selection relies on the initial needs assessment (Step 1) and empirical/theoretical
literature review
o For example, studies might show that Self-e;icacy (r=.71) and Personal norm (r=.78) have very
strong relationships with the intention to always use condoms
• Refinement = Qualitative and quantitative data collection (like focus groups or questionnaires) are
necessary to verify the salience and prevalence of determinants in the target group. If a population
already has high knowledge about a risk (e.g., AIDS), an intervention targeting knowledge is unlikely to
be e;ective

èThese determinants are crucial because they are the link for what will be done in step 3!!! + when going thru
step 3 it is crucial to dibentiate the intervention population (based on age, gender, culture, education,
socioeconomic status, geographic location, etc.)

First question to be asked in task 3:

• How do people ‘score’ on

certain determinants?
(Univariate distributions)
• And to what extent are
these determinants
associated with
behaviour? (E;ect sizes)

But which questions do actually

precede these? => What are the
determinants of X? (= a planning
question)

How to answer a planning question:

• Use CORE PROCESSES

o A helpful and systematic way to address questions relevant to problem definition and solution
using theory and evidence
o Essential within problem-driven applied psychology
• What is the di;erence between theory-driven and problem-driven applied psychology?
o Theory-driven applied psychology involves testing a theory in an applied setting, primarily in
order to gain insight into the external validity of the theory.
o Problem-driven applied psychology refers to scientific activities that focus on changing or
reducing a practical problem. In problem-driven applied psychology, theories are used, but
problem solving is the primary focus of this approach, and the criteria for success are
formulated in terms of problem reduction, with contributions to theory seen as a useful by-
product

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Planning Behaviour Change Programs
CORE PROCESSES:

• Posing planning problems as questions => problem-based learning

• Brainstorming or free-associating answers to planning questions and using current planning group
knowledge
• Searching the literature for empirical evidence and evaluating the strength of the evidence => existing
data
• Accessing and using theory
• Conducting new research for unanswered questions in the planning process => new data
• Developing the final summary of answers to the posed questions => integration

Research methods:

• Systematic reviews
o Quantitative & qualitative
o These are structured, systematic process involving several steps
§ Formulate the question
§ Plan the review
§ Comprehensive search
§ Unbiased selection and abstraction process
§ Critical appraisal of data
§ Synthesis of data (may include meta-analysis pooling e;ect sizes)
§ Interpretation of results
• Interviews
o Qualitative
o They can either involve belief elicitation or in-depth exploration
o Example of belief elicitation: with regard to attitude
o What do you see as the advantages of your exercising for at least 20 minutes, three times a
week, for the next 3 months?
o What do you see as the disadvantages of your exercising for at least 20 minutes, three times a
week, for the next 3 months?
o What else comes to mind when you think about exercising for at least 20 minutes, three times a
week, for the next 3 months?
o TACT: Target, Action, Context, Time
• Survey
o Quantitative
• In this field, the best strategy often consists in combining these di;erent methods

While discussing task 3 it is important to keep in mind:

1. Relevance, univariate distributions, and ebects sizes with confidence intervals

2. Changeability (score data – rely on theoretical or conceptual basis)
3. Costs and participant’s burden

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Planning Behaviour Change Programs
„ CONSTRUCT MATRICES OF CHANGE OBJECTIVES à The synthesizing task of Step 2 is the creation of
matrices of change objectives. This involves crossing the detailed Performance Objectives (POs) with the
selected Determinants. The intersection of a PO and a necessary determinant creates a specific, measurable
Change Objective (COs)

Keep in mind that a matrix of change objectives is created for each ecological level to be included in the
intervention (individual, interpersonal, organizational, community, and societal)

Change objectives are constructed by crossing performance objectives with determinants + the complete
matrix includes change objective for all performance objectives!!!

• Definition: The CO clearly articulates the precise expected change in the determinant needed for
the specific PO to be achieved
• Action Verbs: COs are phrased using action verbs that define the complexity of the learning task (e.g.,
define, list, describe, demonstrate, express confidence, apply, analyse). These verbs are categorized by
levels of complexity, such as Knowledge, Comprehension, Application, Analysis, Synthesis, and
Evaluation
• Utility: The explicit COs derived in Step 2 provide a clear roadmap for selecting intervention methods
and practical applications in Step 3, and are essential for formulating evaluation questions and
designing measurement tools in Step 6

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Planning Behaviour Change Programs
The development of these matrices ensures that every proposed intervention activity (defined later in Step 3)
is intentionally linked back to a measurable change in a specific determinant required to perform a
specific behaviour or change a specific environmental condition. This process is foundational, like
establishing the core programming code of an operating system before writing the applications that run on it.

For example: Providing support for children

with asthma

• Objectives are formulated as outcomes of

the program
o BO: Parents manage their child’s asthma
o PO: Parents observe child for symptoms
o CO: Parents express confidence in being
able to recognize symptoms
o Parents need to learn the skills to identify
symptoms
o Parents demonstrate the skills for being
able to recognize symptoms

CREATE A LOGIC MODEL OF CHANGE à This is the last task of Step 2, which basically integrates and
synthetises the 4 previous tasks. Planners create a
Logic Model of Change based on the matrices of
change objectives (Task 4) and the health and quality
of life outcomes identified in Step 1

• In Step 1 planner create a RISK MODEL, while in

Step 2 they create a HEALTH PROMOTING
MODEL
• The logic model of change clearly states what
needs to change in the behaviour and in the
environment to improve the health problem
and quality of life outcomes
• This model will guide planners in the evaluation of design later on
• In summary, Task 5 integrates the first four activities (program outcomes, performance objectives,
determinants, and change objectives) into a unified causal model

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Planning Behaviour Change Programs

In intervention mapping, an ABCD is an Acyclic Behavior Change Diagram, which is a visual tool that shows
the causal assumptions of an intervention. It is created using an ABCD matrix, a table that details the links
between the intervention's components, the determinants of behaviour it targets, and the desired outcomes.
The diagram and matrix work together to make the intervention's logic transparent and help with planning,
evaluation, and reporting.

Key components of an ABCD:

• The Diagram: A visual, "acyclic" (all arrows point in the same direction, typically forward)
representation of the intervention's logic

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Planning Behaviour Change Programs
• The Matrix: A table that breaks down the intervention into its core causal-structural chains. Each row
represents one chain, linking a specific method, application, and parameters to a targeted change
objective (determinant) and the ultimate behaviour
o Column A (Method): The specific intervention method being used
o Column B (Application): How the method is applied
o Column C (Parameters): The parameters that make the application e;ective
o Column D (Change Objective): The specific psychological determinant being targeted
o Column E (Determinant): The broader category of the change objective
o Column F (Performance Objective): The sub-behaviour or outcome of the change objective
o Column G (Target Behaviour): The overall behaviour being changed.

How it is used:

• Transparency: Makes implicit assumptions explicit, ensuring the team and stakeholders understand
how the intervention is supposed to work
• Planning: Helps design interventions by systematically linking methods to specific change objectives
• Evaluation: Provides a clear roadmap for evaluation by showing what is supposed to cause what
• Reporting: Allows for clear, concise, and consistent reporting of interventions, making them easier to
replicate or analyse
• Reproducibility: The machine-readable nature of the matrix can facilitate easy data import into other
databases for systematic reviews.

è ON WORMS, MIRROR NEURONS AND EXPLAINING HUMAN BEHAVIOUR

The Context-Dependency of the Neural System and Its Complexity

The primary challenge for psychological theorizing is determining the levels at which the best explanations
and predictions of human behaviour can be found. While the dominant view often favours lower levels like
neuroscience and biology (explanatory reductionism), this approach can be widely discussed, particularly due
to the immense complexity and context-dependency of biological systems

We can use the model organism C. elegans (a nematode with only 302 neurons, whose connectome is fully
mapped) as a case study to demonstrate this di;iculty à Despite its relative simplicity and the vast
neurobiological knowledge available, understanding the biological basis of its behaviour remains limited.

• The anatomical wiring diagram does not provide an adequate picture of how the system functions, as
the same anatomical connections can play di;erent functional roles depending on the context
• The system is not stable or invariant, but highly dynamic, exhibiting di;erent functions in various
sensory and motor contexts
• A key factor driving this context-dependence is neuromodulation, where molecules released by other
neurons modify the activity and dynamics of a circuit
• For instance, depending on whether food odors are present, the activity of a specific neuron (AIA) can
correlate with two basically opposite behaviours: forward moving or dwelling => the AIA neuron heavily
depend on the context and behaviour + this neuron can lead to both moving and not moving
• This necessity to consider context is not unique to C. elegans; neuromodulation is a widespread
mechanism, including in mammals
• Consequently, we cannot even decipher the function of a single neuron without considering the overall
dynamics and context of the system

The same context-dependency applies to research on mirror neurons in macaques and humans. It is highly
unlikely that the role of a neuron can be derived solely from its firing activity in a specific context. Given that
neurons in the human cortex are connected to thousands of others, their activity is likely far more context-
dependent than that of C. elegans neurons.

FOCUSING ON ROBUST PHENOMENA: LESSONS FROM PHYSICS

Given the intractable complexity arising from context-dependency at the neuronal level, developing

27
Planning Behaviour Change Programs
predictive or explanatory neuroscientific theories of human behaviour is highly unlikely. Instead, e;orts
should focus on conceptual work and discovering robust phenomena. This complexity enigma is compared to
physics using the example of gas molecules:

• The behaviour of gasses involves an enormous number of individual molecules, making individual
modelling computationally intractable
• Fortunately, physics found a way around this by utilizing macro variables such as pressure, volume, and
temperature
• These higher-level variables work because of "conditional irrelevance": if the values of the higher-level
variables (e.g., pressure and volume) are known, further variations in the lower-level variables (e.g.,
the positions of individual gas molecules) are not relevant for the phenomenon being explained

The challenge in neuroscience is that it might su;er from "ill-behaved complexity" à While individual
neuronal behaviour is too complex to track, biology is "messy" (unlike gas molecules, each neuron is a distinct
individual with its own history and context-dependent function). Therefore, nature might not o;er su;iciently
useful, causally explanatory higher-level neuroscientific variables where conditional irrelevance holds, leaving
both lower and higher neuroscientific levels hopeless for strong predictions.

CONTEXT AND BEHAVIOUR AS THE BEST SOURCES FOR PREDICTION

In the face of this potential neuroscientific intractability, the focus should shift to the psychological and
behavioural levels, where context and behaviour remain the best sources for powerful predictions and
explanations.

• Even in the case of C. elegans, the most reliable and e;icient predictions are currently made using
models based on behavioural data (e.g., video recordings of movement patterns) rather than
neurobiology
• In human interaction, we manage to anticipate behaviour by tracking real patterns of behaviour

MINDREADING AND MIND SHAPING – how humans tackle behavioural complexity successfully,
fundamentally relying on context and behaviour

• Mindreading: This is the practice of attributing mental states (like beliefs, desires, and emotions) to
agents to explain and predict their behaviour, and it is crucial for social coordination. For instance,
attributing the desire for a banana and the belief that bananas are at the grocery store explains why
someone left home and predicts where they are heading
• The Paradox: Successfully inferring mental states and predicting subsequent actions should be a
computationally intractable problem given the sheer number of possible mental states in any situation
• Mind shaping as the Solution: The success is reconciled by the hypothesis that humans are "mind
shaping" themselves and others to make life more tractable => The framework of folk psychology
and mindreading developed through cultural evolution to make behaviour predictable and facilitate
e;icient cooperation
• Norms and Conventions: Through shared vocabulary, rules, norms, and agreements, humans actively
make their behaviour predictable and understandable. People learn to follow these normative patterns,
allowing others to predict their actions
• Contextual Necessity: Context is vital for successful prediction (e.g. a scream of "Help!" means
something di;erent in a theatre play than next to a burning building)
• The human nervous system is nearly intractably complex, but human behaviour is not, as it follows
these patterns resulting from mind shaping à Crucially, the normative dimension (the fact that people
follow these rules because they ought to) provides predictive power, but this dimension is completely
lost if explanations are sought only in brain states, as norms are not visible in brain states.
• Therefore, to construct a theory to predict and explain human behaviour, any realistic attempt
must rely on behavioural patterns and (folk) psychology

To clarify the di;erence between the intractable complexity of the brain and the tractability of behaviour => If
understanding the brain is like trying to predict the exact path of every drop of water in river (intractable lower-

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Planning Behaviour Change Programs
level complexity), then understanding behaviour through mind shaping is like knowing that, due to the
established irrigation canals and cultural traditions, the water will reliably flow toward the communal rice fields
(predictable higher-level patterns imposed by context and norms).

è FACILITATING DECENTRALIZED, UNEQUIVOCAL PUBLICATION OF AND REFERENCE TO

PSYCHOLOGICAL CONSTRUCT DEFINITIONS AND INSTRUCTIONS

A fundamental shift towards clear, comprehensive, and explicit definitions of core theoretical constructs
is necessary to resolve underlying crises in psychological science and facilitate cumulative knowledge
accumulation. The paper introduces Decentralized Construct Taxonomy specifications (DCTs) as a practical
tool to achieve this essential conceptual clarity.

THE NEED FOR CONCEPTUAL CLARITY: UNDERSTANDING THE CRISES

The recent self-reflection period in psychological science, often termed the "replication crisis" or "credibility
revolution," was triggered by disappointing replication results. Although Open Science principles (like Open
Data and pre-registrations) o;er partial solutions, more fundamental issues underlie this crisis: the
measurement crisis and the theory crisis. The inadequacy of construct definitions plays a central role in both
issues:

• The Measurement Crisis: This concerns the validity of instruments used to measure psychological
constructs. It is characterized by the failure of measurement instruments to consistently capture the
intended attribute
• The Jingle Fallacy: Measurement instruments supposedly measuring the same construct often turn
out to measure di;erent things
• The Jangle Fallacy: Measurement instruments for di;erent constructs often turn out to measure the
same thing
• These fallacies highlight that constructs are frequently treated as if they represent discrete, modular
"natural kinds" (implicit realism), even though few researchers explicitly subscribe to this ontological
view. This leads to brief and incomplete construct definitions

THE PROBLEM OF HIDDEN HETEROGENEITY = di;erent groups/people/researchers use di;erent definition of

the same construct
Current theoretical practice often results in construct definitions that are relatively short. This brevity is
problematic because these definitions require further elaboration to be usable in empirical research. Given the
diversity in researchers' training and theoretical backgrounds, di;erent groups inevitably arrive at di;erent
implicitly elaborated construct definitions. This hidden heterogeneity is highly detrimental to scientific
progress and replication e;orts

• Variability in Measurement: Di;erent measurement instruments used for the same construct (e.g.,
depression severity or mindfulness) often measure di;erent subsets of aspects, threatening
generalizability and replicability
• Untransparent Research: Researchers frequently report on studies without transparently
communicating how the central psychological constructs are defined
• Prohibition of Synthesis: The lack of clarity about what is being studied in a given project prevents
reliable evidence syntheses and knowledge accumulation

DCTs AS THE SOLUTION FOR EXPLICIT DEFINITIONS

To address hidden heterogeneity, the solution is to make diberences explicit by publishing comprehensive
construct definitions. These definitions should be so thorough that they eliminate the need for implicit
elaboration by researchers intending to use the construct. This transparency enables critical reflection,
discussion, and empirical testing of the implications of subtle di;erences in definitions, accelerating scientific
progress through epistemic iteration. The paper introduces DECENTRALIZED CONSTRUCT TAXONOMY
SPECIFICATIONS (DCTs) as the tool for this purpose à DCTs are designed to facilitate decentralized,
unequivocal communication and knowledge accumulation.

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Planning Behaviour Change Programs
A DCT specification consists of several integrated components:

• A single construct definition: This must be as comprehensive as possible, forming the bedrock of
empirical research and preventing vague or excessively brief descriptions
• Instructions to develop measurement instruments: This outlines theoretical prerequisites,
constraints, and auxiliary assumptions for quantitative research, minimizing researcher degrees of
freedom
• Instructions to code measurement instruments: This guides systematic reviews by describing when
an existing instrument measures the construct as defined, helping to prevent bias in synthesized
estimates (due to the jingle-jangle jungle)
• Instructions to elicit qualitative data: This describes how informative qualitative data can be obtained
(e.g., specific interview questions or observation procedures)
• Instructions to code qualitative data: This describes when qualitative data can be considered
informative about the construct's content
• Unique identifiers (UCIDs) and metadata: These enable unequivocal reference to the specific
definition and instructions.

By creating and sharing DCT specifications, researchers make their foundational conceptual choices explicit.
This process fosters transparency, debate, and comparison, regardless of whether researchers agree with the
definition, ultimately leading to a psychological science that progresses in a cumulative fashion.

Lecture & Tutorial 3 – 17/11/2025 + notes integrated with Chapter 6

STEP 3: DEVELOPING A PROGRAM DESIGN à The objective is to move from the matrices and the logic model
of change developed in Step 2 to designing a coherent, deliverable intervention. This process involves
matching change methods (theory and evidence-based) to the change objectives they are intended to
influence and then selecting practical applications to deliver these methods to the priority populations.
The process is iterative, meaning planners may move back and forth between objectives, methods, and
applications, or even brainstorm methods and applications simultaneously.

• A change method is a defined process derived from theory or empirical research that explains how
change occurs
• A practical application is the manner in which the method is organized, operationalized, and delivered

The third step comprises 3 main tasks:

• Generating programme themes, components, scope and sequence

• Choosing theory-and-evidence-based change methods
• Selecting or designing practical applications to deliver change methods

Key perspectives discussed include:

• Methods vs. Applications: Intervention descriptions frequently lack explicit detail regarding the
change methods used, often presenting only the application (e.g., a tailored letter) without mentioning
the underlying theoretical method (e.g., persuasion, commitment).
• Theoretical Parameters: To ensure effectiveness, methods must be applied correctly using their
established theoretical parameters – the conditions under which the method has been shown to be
effective
• Ecological Levels: Change methods applied at the individual level can also be directed toward agents
at higher ecological levels (interpersonal, organizational, community, societal), although the
application may be different depending on the target (e.g., persuading a legislator vs. persuading an
individual jogger)

 GENERATING PROGRAM THEMES, COMPONENTS, SCOPE AND SEQUENCE à the first part of step 3
consists in developing an initial plan that will describe the entire program or health intervention

• Approach: some planning groups will begin with less abstract ideas about their intervention (= how it
will be delivered, themes, components, scope and sequence), while others will move from change

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Planning Behaviour Change Programs
objectives to change methods and then to applications. Moreover, others could also move from
objectives to applications, and then back to underlying methods
o For ex., a health promoter may think of commitment as a theoretical method for increasing self-
e;icacy of adolescents to remain nonsmokers and then brainstorm about practical applications
to apply that method. Another health promoter may think of a nonsmoking contract as an
application for improving self-e;icacy, later finding out from the literature that the underlying
theoretical method is commitment
• Regardless of the approach, it is important to:
o Dismiss all preconceived notions and program constrains => create a creative flow of ideas
in order to design an impactful intervention
o Ensure that the program design incorporates the “active ingredients” – including theoretical
methods and practical applications based on an understanding of the population, setting, and
communication channels

An important step in design a health intervention is generating di;erent program ideas to actually implement
the intervention [avoiding to just go for the first one that comes to mind] à CORE PROCESSES can be very
helpful in this situation:

• Brainstorming = asking the group what the most powerful thing would be to do; exploring specific
methods and applications
• Reviewing the literature = review existing applications and programs
• Using theory = generate or identify methods
• Exploring context (including settings)

PROGRAM THEMES: a theme is a general organizing construct for a program, and are typically incorporated
in the title or logo of the program. Themes can be related to:

• The quality of life of health issue

• The behavioural or environmental outcomes
• The priority population
• The program content
• Other creative narrative or engaging motif
- Note that some programs have several subthemes or ideas that "brand" the program while conveying a
key message related to change objectives

PROGRAM COMPONENTS, SCOPE, AND SEQUENCE:

- Program components = units or modules of the program that combine change methods, practical
applications, and delivery mechanisms aimed at various objectives
- Scope = the breadth and amount of a program, reflecting the chosen change objectives, and the
duration
- Sequence = the order in which program components and activities are delivered [across time]
- Note that it is common to have:
o A global scope and sequence for all components (e.g. what is the sequence for rolling out
di;erent components, such as public awareness campaign, community-based vaccinations,
policy for school vaccinations and enforcement components?)
o A component specific scope and sequence (e.g. classroom curriculum component: session 1,
session 2, etc.)
è A scope & sequence is NOT a timeline in the traditional sense of a project timeline!!! The scope and
sequence specifically focus on the amount of the intervention and the sequence of intervention
components and activities

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Planning Behaviour Change Programs
In defining and designing components, consider:

• Settings to reach the population (e.g. components based in settings such as classrooms, cafeterias,
workplace etc.)
• Population/subgroups (e.g. child components vs. parents’ components)
• Communication channels and delivery vehicles (e.g. web-based components, home visit
components etc.)
• Multi-level / Socio-ecological framework in which levels / environments reinforce each other (e.g.
policy level / components [‘no sitting for more than 10 minutes’] and social or organizational level /
components [‘teacher-led activity breaks’])

Communication channels & delivery vehicles = planners identify how the program components will be
delivered, considering logistical limitations, budget constraints, and the needs of the priority audience

- even if there is clear overlap between these two concepts, we can think about DV as the way a specific
message or communication plan reaches the intended audience
• Interpersonal communication channels à volunteers, peer leaders, teachers, health care providers,
community health workers etc.
• Mediated communication channels
o Circulation print: local and online newspapers, magazines, newsletters, email blasts, flyers etc.
o Display print: billboards, posters, brochures, flip charts etc.
o Radio: new items, interviews etc.
o Television: new stories, talk shows, interviews, edutainment, infomercials, novellas etc.
o Videotape: training, documentary, role model stories etc.
o Computer and internet-based: decision support, curricula, serious games, simulations,
websites
o Phones and smartphones: text messages, apps etc.
o Social media
• In selecting communication channels and delivery vehicles it is important to seek for the
preferred and most accepted media used by the intended audience
• Choosing delivery vehicles is a matter of balancing the needs and preferences of the intended program
participants with logistics, budget constraints, team skills, and sustainability

‚ CHOOSE THEORY-AND-EVIDENCE-BASED CHANGE METHODS à Planners use the matrices from Step 2
to reorganize change objectives by determinant (e.g., attitude, self-e;icacy, knowledge) and then match
specific change methods to influence those determinants. They rely on two core processes: reviewing existing
empirical evidence and reviewing theories of change

A theory- and evidence-based change method is a general technique for influencing the determinants of
behaviours and environmental conditions. Practical applications refer to delivery of the methods in ways
that fit the intervention population and the context in which the intervention will be conducted

Planners choose methods and applications to influence change objectives. Change objectives describe the
desired changes in the determinants of performance objectives for health behaviour, and environmental
conditions, at both individual and higher environmental levels. Modelling may change individual health
behaviour, but it could also be applied to influence the behaviour of decision makers in organizations that are
required to make changes in the environment

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Planning Behaviour Change Programs

• A METHOD is a general process for influencing changes in the determinants of behaviour and
environmental conditions
o It is often rooted in theory but can also be informed by empirical evidence
o Examples: modelling, guided practice, positive reinforcement, structural redesign, fear arousal
o Two of the core processes presented in Chapter 1 are essential for identifying and selecting
change methods: reviewing existing empirical evidence in the literature and reviewing theories
of change
• Individual Level (Basic Methods): Techniques applicable across various determinants and levels,
such as participation, persuasive communication, modelling, feedback, and reinforcement
o Change methods at the individual level can be directed toward agents at higher ecological
levels
o Planners frequently bundle together methods at the individual level to create a change method
at a higher ecological level
• Methods to Increase Knowledge: Includes techniques like chunking (using labels or acronyms to aid
memory), advance organizers (presenting an overview of material), and elaboration (stimulating the
learner to add meaning to information)
• Methods for Changing Environmental Conditions: These methods are applied to environmental
agents (parents, leaders, managers, etc.). They often bundle individual-level methods to accomplish
change specific to the context (e.g., community organization, sense-making in organizations, media
advocacy for policy change)

ð Theories that focus on individual behaviour change are more likely to focus on processes (that is, closer to
what we call methods), whereas theories regarding environmental change are more likely to focus on practice
(that is, closer to what we call applications)

One source of confusion about change methods may be that the same concept, such as modelling or
reinforcement, can be used to describe both determinants and methods. The double use of these concepts
suggests that the theory explains both behaviour and behaviour change. The difference for health
promoters is that modelling as a determinant refers to what happens in the actual situation, whereas
modelling as a method will be part of a well-designed program
• For instance, with respect to condom use, modelling that occurs in the television shows and movies
that adolescents see may be negative, whereas health promoters may use positive role models in their
interventions to compensate for those negative counterparts in the media
• Translating methods into applications demands a sufficient understanding of the theory behind the
method, especially the theoretical parameters that are necessary for the effectiveness of the
theoretical process
• An APPLICATIONS is a practical technique for the operationalizing methods in ways that fit with the
intervention group and the context in which the intervention will be conducted
o Examples: policy in employee handbook to restrict smoking, newsletter role models stories,
social support groups, certificate of achievements, no smoking signs etc.

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Planning Behaviour Change Programs
In selecting methods, behavioural planners need to review the behavioural and environmental outcomes,
the performance objectives and the change objectives that they aim to implement

• Select methods for all change objectives in both behavioural and environmental matrices
• Note that di;erent methods are e;ective for influencing di;erent determinants
• Pay attention to parameters for use
o Ex. Parameters for role modelling include identification of target audience

Examples: taxonomy of behaviour change methods

- Basic methods for individual level à persuasive communication or active learning

- Basic methods for environmental level à individual level methods (we assume that the environment
also consists in human agents), participatory problem solving, technical assistance

CORE PROCESSES FOR SELECTIN METHODS => there are di;erent approaches

• Organize complete list of change objectives by determinants (the matrix columns)

• Formulate questions about methods
• Brainstorm provisional list of methods that may influence each determinant
• Topic approach: go to the literature related to the specific problem to identify evidence to support,
refute, or add to list pf methods
• Construct approach: review the list of methods, determinants, and objectives, and follow these
constructs to theories
• General theory approach: review the list of methods for general theoretical patterns
Ä Consider the need to collect additional data on methods through qualitative or quantitative research
and environmental agents

ƒ SELECTING AND DESIGNING PRACTICAL APPLICATIONS TO DELIVER CHANGE METHODS à This final
task involves translating the chosen methods into creative applications. The crucial part of this translation is
ensuring that the practical application adheres to the theoretical parameters of the method

• Select or design practical applications to operationalize change methods

• One change method may be accomplished by many applications, and one application may deliver
various change methods (e.g. the simple method of information transfer to teach about covid
protective behaviour may be delivered via application of small group discussion, flyers, public service
announcements etc.)
• Consider the applications that best fit the intervention’s context
- Adherence to Parameters: For example, when using modelling as a method, the practical application
(like a role-model video) must ensure that the model exhibits certain characteristics (such as being
reinforced for the behaviour) that align with Social Cognitive Theory parameters.
- Application Examples: Applications can range from videotaped testimonials for modelling, to group
discussion used for active learning, or scenario-based risk information presented via mock TV game
shows to improve skills and self-efficacy
- Final Check: Before moving to Step 4 (Program Production), planners must ensure that all objectives
originally identified for the program are still addressed and covered by the applications developed in
Step 3
è The final product of task 2 and 3 is the creation of a METHODS AND APPLICATION TABLE à in it, planners
connect the determinants and change objectives with the proposed theoretical change methods and their
practical applications

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Planning Behaviour Change Programs
• In developing this table planners may choose to organize
all the change objectives related to a given determinant, and
then explore theoretical methods specific to addressing that
determinant
• Alternatively, planners may consider to first choose a
specific application for a given determinant and then explore
methods that can support that application
• The strength of this process is its flexibility in allowing
planners to organize their table in a way that works best for
the planning group, settings, and the selected topic

Example

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Planning Behaviour Change Programs
This section describes theoretical methods for change, summarized in tables. The first part presents basic
methods and methods geared to changing certain determinants (e.g., attitude and skills) of the at-risk
individuals. The second part presents basic method and methods for change in determinants of agents within
the various environmental levels. In each table, for each method there is a definition, description, example of
use, and parameter for ePectiveness.

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Planning Behaviour Change Programs

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Planning Behaviour Change Programs

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Planning Behaviour Change Programs

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Planning Behaviour Change Programs

We gain knowledge of the methods that we should

implement to change determinants (and eventually
behaviour) from theories (theories => methods =>
applications)

- So, the key to behavioural change is finding out

why people do what they do (by talking to them, for
ex.), understanding which constructs and
determinants prompt certain behaviours, looking for
theories and methods that can change those
determinants

è A PRACTICAL GUIDE TO EFFECTIVE BEHAVIOUR CHANGE. HOW TO APPLY THEORY- AND EVIDENCE-
BASED BEHAVIOUR CHANGE METHODS IN AN INTERVENTION

Ebective Behaviour Change: Challenges and Protocol

Planning for behaviour change involves three major challenges: correctly identifying the change objectives
and evaluation outcomes; selecting and applying appropriate behaviour change methods within an
intervention; and ensuring adequate implementation of the intervention. Intervention failures frequently
result from deficiencies in these three areas.

This guide focuses specifically on the second challenge: selecting behaviour change methods, translating
them into practical strategies, and combining these strategies to develop an e;ective intervention. The
overarching approach used for intervention development is based on Intervention Mapping (IM). IM is
described as a protocol for systematic planning that is both theory- and evidence-based.

THE SIX STEPS OF INTERVENTION MAPPING (IM)

IM describes an iterative pathway from problem identification to problem solving or reduction. Completing

40
Planning Behaviour Change Programs
the tasks within each step creates a product that guides the subsequent step, ultimately forming a blueprint for
intervention design, implementation, and evaluation

1) Conducting a Needs Assessment or Problem Analysis: This involves establishing a participatory

planning group, assessing community capacity, and specifying program goals
2) Creating Matrices of Change Objectives: This is done by combining (sub)behaviours with behavioural
determinants. This step, along with Step 1 and part of Step 6, comprises the challenge of identifying
change objectives
3) Selecting Theory-based Intervention Methods and Translating them into Practical Applications:
This step involves identifying theoretical methods and choosing program methods
4) Integrating Methods and Applications into an Organized Program (Intervention Program): This
involves creating themes, scope, and sequence, preparing design documents, and pretesting materials
5) Planning for Adoption, Implementation, and Sustainability: This plan should be developed from the
start of the IM process. This step addresses the challenge of adequate implementation
6) Generating an Evaluation Plan: This plan is also developed from the start of the IM process

IM emphasizes planning, research, and theory, providing vocabulary and procedures for program planning, and
technical assistance for matching theory-based determinants with appropriate change methods.

PERSPECTIVES GUIDING INTERVENTION MAPPING

The IM protocol is informed by three primary perspectives:

 The MULTI-THEORY APPROACH dictates that multiple theories should be used, as one theory alone will
seldom explain all aspects of a real-life problem or inform all aspects of the process

• Theories are useful for identifying behavioural determinants (e.g., Reasoned Action Approach, Social
Cognitive Theory) and for choosing and applying behaviour change methods
• However, attempting to integrate various theories into a single overarching framework is generally
unhelpful

‚ The ECOLOGICAL APPROACH recognizes that human behaviour is part of a complex system, where
individuals exist within multi-level environments (interpersonal, organizational, community, and societal).

• Changing people's health behaviours often requires changing the relevant environmental conditions
(e.g., the workplace)
• Since environments are often controlled by agents or decision makers (e.g., a manager), changing
an environmental condition means changing the behaviour of that environmental agent
• Environmental agents can be targeted using both individual-level behaviour change methods and
environmental-level methods (e.g., organizational change or community development methods).

The PARTICIPATION PERSPECTIVE views intervention planning as teamwork, requiring the involvement of all
stakeholders (e.g., target population, intended implementers, decision makers)

• Insu;icient participation from these stakeholders is often the cause of major planning failures, such as
incorrectly identifying determinants or poorly translating methods

METHODS, PARAMETERS, AND PRACTICAL APPLICATIONS

A theory-based behaviour change method is a general technique designed to influence the determinants of
behaviour (such as attitude or self-e;icacy). These methods are based on literature regarding e;ective
behaviour change. Since they are general techniques rooted in psychology, they must be translated into
practical applications for use in interventions

• Linking Objectives to Methods: Methods are linked to change objectives through determinants;
theory-based methods target determinants (e.g., attitude), which are then thought to influence the
behaviour
• Translation Process: Practical applications are specific translations that must be tailored to the
intervention population and context. The same method can result in a "myriad of possible applications"

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Planning Behaviour Change Programs
depending on the population (e.g., using a videotaped demonstration for adolescents vs. a booklet of
authentic stories for intravenous drug-users for the method of modelling)
• The Risk of Loss in Translation: Theory-based methods often "disappear in translation" when
developed into actual materials and messages, sometimes due to overwhelming logistical issues or a
lack of understanding regarding the theoretical mechanisms

THE CRITICAL ROLE OF PARAMETERS

All methods have specific parameters for ebectiveness which determine whether the theoretical process will
be e;ective => No method is always ebective. Behavioural scientists are responsible for ensuring these
parameters remain intact during the translation process

• Modelling: This method is only e;ective when certain parameters are met, such as the model being
reinforced for the demonstrated behaviour. People imitate models only when they expect to be similarly
reinforced
• Goal Setting: This is only e;ective when the goal is both challenging and acceptable for the actor
• Fear Appeals: These are only e;ective when the at-risk population has high self-e;icacy; they can be
counter-e;ective when e;icacy is low
• Implementation Intentions: These are only e;ective when people already possess a positive intention

The conclusion emphasizes that the highest chance for success is expected from a theory- and evidence-
based process like IM. The most important message is that METHODS ARE ONLY EFFECTIVE WHEN
APPLIED WITHIN THEIR SPECIFIC THEORY- AND EVIDENCE-BASED PARAMETERS. Consequently, well-
trained behavioural scientists are essential in the planning process

è A TAXONOMY OF BEHAVIOUR CHANGE METHODS: AN INTERVENTION MAPPING APPROACH (IM

Taxonomy)
The paper introduces the Intervention Mapping (IM) taxonomy of behaviour change methods, highlighting its
potential development into a coding taxonomy. Originally, IM was created as a tool for intervention
development, meaning it is designed to guide planners in creating e;ective programs, rather than just
categorizing existing content (which is the primary goal of coding taxonomies)

• The IM approach emphasizes the crucial distinction between theory-based methods and their
practical applications, arguing that poor translation of methods often leads to erroneous
conclusions about their ebectiveness

CORE CONCEPTS OF INTERVENTION MAPPING (IM)

The IM framework addresses the fundamental dynamics required for behaviour change methods to be
e;ective:

• Determinant Targeting: The method selected must target a determinant that empirically predicts the
specific behaviour being addressed
• Capacity for Change: The method must possess the inherent ability to change that targeted
determinant (e.g., guided practice is e;ective for self-e;icacy, but not subjective norms)
• Preservation of Parameters: The method must be translated into a practical application in a manner
that preserves its parameters for ebectiveness and ensures fitness with the target population, culture,
and context

The IM protocol itself is an iterative, six-step process for designing, implementing, and evaluating interventions,
grounded in planning, research, and theory

Key Definitions within IM:

• Determinants: Generic modifiable psychological variables or regulatory processes that are

assumed to be causal antecedents of behaviour. They are aggregates of specific lower-level
elements. For example, "attitude" is a determinant aggregating specific beliefs (e.g., beliefs about
decreased likelihood of infection or decreased sensation during intercourse)

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Planning Behaviour Change Programs
• Theory-based methods: General techniques or processes originating in behavioural and social
science theories that have been shown to be able to change one or more generic determinants of
behaviour (such as attitude or self-e;icacy)
• Practical applications: Specific translations of theory-based methods for practical use that fit the
intervention population and context. A single method (e.g., modelling) can be translated into countless
applications (e.g., a videotaped demonstration for adolescents vs. a role-playing session with an actor
for middle-aged migrants)
• Parameters for ebectiveness: The necessary conditions that must be satisfied in practical
applications for the theoretical method to be e;ective. If a practical application violates these
parameters, it will be less e;ective or even counter-e;ective (e.g., goal setting requires the goal to be
challenging and acceptable; fear appeals are only e;ective when the population has high self-e;icacy).

è THE BEHAVIOUR CHANGE TECHNIQUE TAXONOMY (V1) OF 93 HIERARCHICALLY CLUSTERED

TECHNIQUES (BCT Taxonomy v1)
This article describes the development of the Behaviour Change Technique Taxonomy (v1), an extensive,
hierarchically structured taxonomy of 93 distinct behaviour change techniques (BCTs). The primary
motivation was the urgent need for standardized labels and reliable methods for specifying intervention
content, especially given the call from guidelines like CONSORT for precise reporting of complex interventions.
The goal is to establish a shared, international vocabulary for scientific communication.

DEFINITION AND STRUCTURE OF BCT TAXONOMY v1

A BCT is defined as an observable, replicable, and irreducible component of an intervention designed to
alter or redirect causal processes that regulate behaviour à it is considered an "active ingredient". The
taxonomy was built collaboratively through a consensus process involving 54 international experts from various
disciplines and countries, including Delphi-type exercises and open-sort grouping tasks.

• Comprehensive Inventory: The final taxonomy includes 93 distinct BCTs

• Hierarchical Clustering: An open-sort grouping task and subsequent hierarchical cluster analysis
identified an optimal solution of 16 clusters (groups) based on similarity of active ingredients, aimed at
improving usability and recall
• Examples of Clusters: The 16 clusters include groupings such as Scheduled consequences, Reward
and threat, Repetition and substitution, Antecedents, Associations, Goals and planning, Social support,
and Feedback and monitoring
• Reliability Assessment: Inter-rater reliability was assessed by coding intervention descriptions. Out of
the 26 BCTs that occurred frequently (five or more times), 23 achieved adjusted kappa scores of 0.60
or above, confirming they met the criteria for a reliable BCT

IMPLICATIONS AND FUTURE WORK

The BCT Taxonomy v1 serves as a foundational methodological tool for specifying intervention content, paving
the way for identifying active ingredients and improving replication

• Accumulating Evidence: Using this taxonomy facilitates systematic reviews and meta-analyses,
allowing reviewers to synthesize evidence and identify e;ective component BCTs across
heterogeneous interventions
• Distinction from Theory: The BCT Taxonomy v1 is a methodological tool focused purely on content
specification and does not inherently link BCTs to specific theories or mechanisms of action, though
ongoing research aims to establish these links
• Scope and Development: Currently, the taxonomy predominantly focuses on interventions delivered
to individuals, and future work is planned to extend the taxonomy to cover BCTs relevant to community
and population-level interventions
• Beyond Content: The authors note that specification and taxonomies for other intervention
dimensions, such as mode and context of delivery, and the competence of those delivering the
intervention, would also be beneficial

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Planning Behaviour Change Programs
The development of BCT Taxonomy v1 is viewed as an ongoing, iterative process guided by an international
network to ensure continuous refinement, usability, and stability across various behavioural domains and
cultural contexts.

Analogy for the Diberence in Focus:

The relationship between the Intervention Mapping (IM) taxonomy and the Behaviour Change Technique (BCT)
Taxonomy v1 is like the relationship between an architect's blueprint and a materials catalog

• The IM taxonomy (blueprint) provides a systematic, theory-driven procedure for designing a structure
(intervention), dictating what components (determinants and methods) must be chosen and how they
must be combined (parameters for e;ectiveness) to ensure the building stands strong
• The BCT Taxonomy v1 (materials catalog) provides a reliable, universally agreed-upon list of the
materials (BCTs) used in construction, ensuring that when builders or inspectors describe the finished
structure, they all use the exact same labels for the parts they find

Lecture & Tutorial 4 – 24/11/2025

STEP 4: PROGRAM PRODUCTION à The overarching purpose of Step 4 in Intervention Mapping (IM) is to
produce creative program messages, materials, and protocols that support the planned health promotion
interventions. The foundation for the materials created in this step lies in the detailed planning completed in
Steps 1 through 3. The aim of this step is to “bring the program to life” and focus on actual program production.

- The main challenge in Program Production is the translation of theoretical methods and practical
applications into ebective support materials, ensuring the resulting materials are culturally
relevant, feasible to implement, and fit within the intervention context and population
- This step focuses on materials directed at both the priority population and the environmental
agents. The final product of this step consists of all the support materials needed for the intervention,
refined and ready for use

Step 4 consists of 4 sub-tasks:

 REFINE PROGRAM STRUCTURE AND ORGANIZATION à This task involves reviewing and refining the
themes, components, scope, and sequence that were initially outlined in Step 3.

• This stage acts as a crucial "reality check" before the intensive material preparation begins à Planners
revisit the preliminary program plans to confirm the feasibility of producing and delivering the
intervention within the practical constraints of the budget, time frame, and implementation context
• While major revisions are typically avoided if feasibility was assessed earlier in Step 3, this task is
essential to prevent significant issues from arising during the actual production process
o Will intended program participants be able to interact with the program?
o Will intended implementers have time and resources to implement program?
o Check budget and time constrains

In this phase it is also very important to make sure that we are delivering a program that is actually relevant to
the targeted culture (the program must be culturally relevant and responsive)

• Community involvement from the beginning à E;ective program design requires the early and
continued involvement of potential program adopters and implementers
o Their input on factors such as program complexity, fit with existing organizational routines, and
resource requirements is critical. Engaging these stakeholders provides invaluable insights into
what materials can be delivered feasibly and what characteristics – such as being resource-
conserving and easy to try – make a program attractive to them
o Considering the program from the perspective of these gatekeepers is essential for facilitating
both initial implementation and successful long-term dissemination

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Planning Behaviour Change Programs
• Ensuring cultural relevance à Cultural concerns a;ect every part of program planning – deciding on
behavioural and environmental change outcomes, determinants and change objectives, methods,
applications and program materials, and delivery
• Cultural relevance is a cornerstone of ebective program design, ensuring that materials are
accepted and understood by the priority population. Program development must address two
primary dimensions of culture:
o Surface Structure = This refers to the observable and superficial characteristics of a
population, such as preferred language, colours, music, food, and communication channels.
Matching materials to these characteristics enhances their receptivity
o Deep Structure = This involves the more influential cultural, social, and historical factors that
shape health behaviours. These include family relationships, spirituality, individualism or
collectivism, and perceptions of medical mistrust. While these deep-structure factors should
have been thoroughly analysed in the needs assessment of Steps 1-3, their application in Step 4
ensures that the program's core messages and methods have true salience with the intended
group
• After refining the program's high-level structure and cultural grounding, the focus shifts to the more
granular work of planning the specific materials that will bring the intervention to life

Mechanisms for incorporating aspects of culture in intervention design:

When developing program materials, it is always a good idea to see which materials are already available and
how e;ective they are. When reviewing existing material, it is important to consider:

• Does the proposed existing material enable the relevant change objectives to be met?
• Does it deliver the intended change methods and practical applications?
• Does the material represent the correct surface aspects of the culture of the intended audience?
• Does the material fit into the planned scope and sequence of the program?
• Is the material suitable and available?
- It is often di;icult to make all these matches, but sometimes partes of existing programs work well and
can provide a base for development of any materials to address gaps

‚ PREPARE PLANS FOR PROGRAM MATERIALS àThis task involves creating the detailed architectural
plans for each of the program's components. These plans, known as design documents, serve as the
essential communication tool between program planners and creative consultants such as writers, designers,
or videographers. Their purpose is to ensure that every final product aligns perfectly with the program's
theoretical foundations and strategic goals For this task, the first design documents are the matrices,
because they already include all of the content matters

45
Planning Behaviour Change Programs
• Design documents bridge the gap between the planning team's intentions and the creative team's
execution. An initial high-level design document, often called a "project prospectus," outlines the core
specifications for a particular material
• Include creative personnel in team meetings
• Prepare design documents specific to each product of the intervention, containing the exacts
specification of that product. Those specifications might include:
o Overview
o Detailed description of the content – might include storyboards (to show what the learners will
see and experience) and flowcharts
o Audience
o User interaction
o Purpose
o Budget
o Message, themes, content, sequence
o Interactive points and tailoring variables (if appropriate)
o Timeline, production qualities

Tailoring is another important consideration in program production = the use of computer-based applications
to create (and sometimes deliver) messages based on measured characteristics of an individual program
participant

• Characteristics used for tailoring: aspects of culture; behavioural history; stage of change for the
behaviour; physiological characteristics
• The more we can tailor and individual’s activities, the more impactful it will be

The specific planning documents required will vary depending on the medium being used.
Media Type Required Planning Documents
Documents detailing the initial rough design, layout, copywriting requirements,
Print Materials
graphics, and suggestions for paper stock.
A more complex set of documents is required, including:
Flowcharts: These depict the sequence of content and the branching logic based on
user input. For example, the flowchart for the MINDSET epilepsy tool showed how
Interactive patient data on adherence, importance, and self-e;icacy would be used to generate a
Technology (e.g., tailored action plan
Computer Programs) Screen Maps: These are mock-ups that depict the layout of each screen and define the
function of its components (what the user will see and do)
Scripts/Storyboards: These provide a written list of all audio and visual elements for any
embedded animations, videos, or other interactive activities
With detailed plans in place, the project can confidently move from the architectural phase to the creative
drafting of program messages and materials

ƒ DRAFT MESSAGES, MATERIALS, AND PROTOCOLS à In this task program planners start to flash out what
a specific material or activity will look like. This task represents the core creative process where the abstract
objectives and methods from the program matrices are given voice, form, and substance. All drafting must be
meticulously guided by the design documents to maintain fidelity to the program's theoretical underpinnings
and strategic goals. In doing so, it is important to:

• Consider the change methods and practical applications for a particular set of change objectives
• Identify which will “fit” together for presentation in a particular vehicle (e.g. a newspaper story)
• Draft messages matched to each change objective or combination of change objectives
• Draft contextual messages that will be incorporated into the vehicle

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Planning Behaviour Change Programs
Production process: Regardless of what type of material we are developing, there’s a very well-structured
typical production process that guides its development, which requires a lot of interaction between the
program planners, the creative experts and the target audience

• Initial script, storyboard, or layout

• Pre-production (identify role-models, actors, locations)
• First rough cut, or proofs
• Review and pre-test (target audience + experts – to make sure to be on track)
• Second rough cut / post-production / proofs
• Review, pre-test, revise, final approval

Health promotion materials typically contain two distinct types of messages:

1) Focused Messages: These are written specifically to address a change objective from the matrices.
For instance, a message designed to increase a participant's knowledge about risk factors or to bolster
their self-efficacy for a specific behaviour is a focused message
2) Contextual Messages: These messages provide an engaging narrative, set up a scenario for an
activity, or give information about the program itself. While they do not directly target a change
objective, they are crucial for creating a compelling and understandable user experience

To ensure messages are effective, planners should adhere to several key principles of communication:
• Use Clear and Active Voice
• Provide Context First
• Use a Careful Hierarchy
• Write for Interaction

„ PRETEST, REFINE, AND PRODUCE MATERIALS à Pre-test (= trying out specific messages,
characteristics and other program materials with the intended program participants – it is important to
assess whether the audience comprehends the information that is being provided) and Pilot test (= trying out
the program as it will be implemented, with both the implementers and the participants) are crucial task
prior to final production

• Its purpose is to ensure materials are acceptable, understandable, and motivating before committing to
the high cost of large-scale production
• This is often a staged process that may involve multiple methods, such as individual interviews to
assess initial comprehension, followed by focus groups to gauge group dynamics and acceptability,
before a final pilot test in a real-world setting

Pre-test for:

• Concept
• Readability, comprehension, usability
• Message
• Impact
• Cultural sensitivity
• Acceptability

Pilot-test for:

• Adoption and implementation issues in real world settings

• Logistics and time needed
• Acceptability

Pre-testing and Pilot-testing will generate a lot of data, often with conflictive opinions, therefore, it is important
to:

• Tabulate all the data and track recommended changes

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Planning Behaviour Change Programs
• Develop a plan for dealing with conflicting results
• If something is changed, make sure the change does not disrupt or eliminate an important element or
change method
• If activities or change methods are deleted, attempt to replace them with equally powerful methods
and messages

To ensure e;ectiveness and resonance, pretesting should assess materials across four key areas with feedback
gathered from key stakeholder groups, including program participants, implementers, and subject matter
experts:

• Comprehensibility: Is the central message clear and easily understood by the audience?
• Acceptability: Is the material, along with its tone and style, appropriate and well-received?
• Attraction: Does the material successfully capture and hold the audience's attention?
• Relevance: Do participants perceive the material as being "for them" and pertaining directly to their
lives and experiences?

For example: in the “It’s Your Game” program for safe sex and consistent condom use

- Community advisory board members reviewed program, materials

- Teen advisory board members pre-tested video scripts, role-plays, and other interactive activities
- Project sta; pilot-tested classroom lessons in middle school
- 7th and 8th graders beta-tested computer lessons, and afterwards completed usability surveys, gave
ratings on the understanding of content domains and perceived self-e;icacy to perform targeted
behaviours

è CHAPTER 10: ADAPTING EVIDENCE-BASED INTERVENTIONS

INTRODUCTION: THE RATIONALE FOR ADAPTING INTERVENTIONS

This chapter introduces the application of Intervention Mapping (IM) specifically for adapting evidence-
based interventions (EBIs) for use in new populations and settings à An EBI is an intervention (including
programs, policies, or practices) that has demonstrated e;ectiveness in reducing a health problem or its
causes through systematic scientific testing. This approach allows planners to leverage programs that have
already demonstrated e;ectiveness, saving considerable time and resources compared to building an
intervention from the ground up

• The central challenge this chapter addresses is navigating the inherent tension between maintaining
fidelity to an EBI's core, theory-based components and the practical necessity of adaptation to
ensure its relevance and feasibility in a new context
• As the text observes, practically speaking, "adaptation happens." The problem is that it sometimes
happens poorly and leads to incomplete interventions that have little chance of maintaining
e;ectiveness
• To navigate this challenge, a structured methodology is required to ensure that adaptations are
purposeful, evidence-based, and enhance (rather than dilute) an intervention's potential impact
• IM Adapt provides the methodological discipline required to protect the validity of an EBI when
transferring it to a new setting

The primary competency developed in this chapter is the ability to make sound, evidence-informed decisions
about whether and how to adapt an EBI. This involves mastering several key objectives:

1. Needs Assessment: Conduct a comprehensive needs assessment to describe the health and
behavioural problems in the new context and develop corresponding logic models of the problem and
of change
2. Search: Systematically search for and identify relevant evidence-based interventions that align with the
identified needs

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Planning Behaviour Change Programs
3. Fit & Planning: Meticulously assess the fit of a candidate EBI against the new context and develop a
detailed plan for necessary adaptations
4. Adaptation: Execute the planned adaptations by modifying program materials and activities, ensuring
core e;ective components are preserved
5. Implementation: Develop a robust plan for the implementation of the newly adapted EBI in the target
setting
6. Evaluation: Create an evaluation plan specifically designed to assess not only the overall e;ectiveness
of the adapted EBI but also the impact of the adaptations themselves

To address this complex challenge, the chapter introduces a structured framework, "IM Adapt", which
repurposes the core logic of Intervention Mapping to guide practitioners through this critical process

THE IM ADAPT FRAMEWORK: A SYSTEMATIC PROCESS FOR ADAPTATION

The chapter proposes a modified application of the Intervention Mapping protocol, termed "IM Adapt,"
specifically designed for adapting existing programs. This framework is not an entirely new process but a
repurposing of the core IM logic and its iterative, step-by-step approach

- It applies the systematic, theory-driven logic of Intervention Mapping to ensure adaptation decisions
are evidence-based rather than ad hoc
- It provides practitioners with a rigorous methodology to ground decisions about what to keep, change,
add, or delete from an EBI in a thorough analysis of the new context and the original program's
theoretical foundations

Ü The IM Adapt process consists of six steps that guide the planner from initial needs assessment to final
evaluation planning:

1. Conduct a Needs Assessment & Create Logic Models: Understand the new population's specific
health problem and its determinants, and define the behavioural and environmental changes required
to address it
2. Search for Evidence-Based Interventions (EBIs): Find and select potential evidence-based programs
that match the needs and desired changes identified in the logic models
3. Assess Fit and Plan Adaptations: Perform a detailed comparative analysis of a candidate EBI to
determine which components must be kept for fidelity and which require adaptation, addition, or
deletion to fit the new context
4. Make Adaptations: Modify the program materials, activities, and delivery protocols based on the
detailed adaptation plan developed in the previous step
5. Plan for Implementation: Develop a comprehensive protocol for delivering the adapted program,
including training implementers and specifying their roles and tasks in the new setting
6. Plan for Evaluation: Design an evaluation that assesses both the overall e;ectiveness of the adapted
program and the specific impact of the adaptations made

The following sections provide a detailed analysis of each of these six steps, o;ering a clear roadmap for
practitioners seeking to e;ectively leverage existing evidence in new contexts.

Step 1: Foundational Analysis for the New Context

The strategic importance of Step 1 in the IM Adapt process cannot be overstated. Before an existing EBI can be
selected, let alone adapted, planners must first conduct a rigorous needs assessment of the new
population and setting à Skipping this step and proceeding directly to selecting an EBI invalidates the entire
adaptation process, as decisions would be based on assumptions about the new context rather than evidence

• This foundational analysis is identical in principle to the first step of creating an intervention from
scratch, ensuring that all subsequent decisions are grounded in a deep understanding of the local
context
• The core of this step involves a logical progression from problem analysis to solution design à
Planners first develop a Logic Model of the Problem for the new population = This model visually

49
Planning Behaviour Change Programs
identifies the health problem, quality of life issues, and the specific behavioural and environmental
factors contributing to them
• It necessitates an analysis of the personal and external determinants influencing those factors within
the new context
• From this problem analysis, planners then create a Logic Model of Change à This model outlines the
specific behavioural and environmental outcomes an intervention must achieve to solve the health
problem, establishing the primary benchmark against which candidate EBIs will be measured

In addition to developing these logic models, this step includes other critical planning activities that provide
necessary inputs for subsequent steps:

• Assess Organizational Capacity: Planners must evaluate the implementing organization's capacity to
deliver an EBI, including its resources, leadership support, workforce skills, and organizational culture
• Write Program Goals: Based on the needs assessment, the team defines clear, measurable program
goals related to the ultimate health and quality-of-life outcomes the adapted intervention is expected
to achieve

Once this comprehensive understanding of the new context, its needs, and its capacities is established, the
planner is equipped to begin the systematic search for a suitable Evidence-Based Intervention.

Steps 2 & 3: Searching for, Selecting, and Assessing Candidate Interventions

This phase of the IM Adapt framework encompasses a two-step process: a systematic search for potential EBIs
(Step 2), followed by a rigorous assessment to select the best-fitting candidate and meticulously plan the
required adaptations (Step 3)

Searching for EBIs (Step 2) à A significant challenge for practitioners is finding "full EBIs," which include not
only evidence of e;ectiveness but also the complete set of program materials and protocols necessary for
implementation. The text recommends focusing on sources that provide access to these complete program
packages

Recommended Sources for

Description
EBIs

RTIPs (Research-Tested A service of the National Cancer Institute that describes programs and often
Intervention Programs) makes materials available for download or by contacting developers.

Provides full-text reviews of public health strategies by topic, with evidence

The Community Guide tables and logic models. It includes quality ratings and links to other sites like
RTIPs for available EBIs.

O;ers thousands of quality-rated systematic reviews and meta-analyses of

Health Evidence (Canada) public health strategies, with tools and search filters to help users find relevant
evidence.

Assessing Fit and Planning Adaptations (Step 3) à Once a candidate EBI is identified, Step 3 involves a
systematic, model-to-intervention gap analysis. This is not a simple comparison but a rigorous process where
the candidate EBI is measured against the Logic Model of Change developed for the new population in Step
1 => This analysis determines whether the EBI is a good fit and identifies precisely what needs to be adapted.
The critical areas of fit include:

• Behavioural and Environmental Fit: Does the EBI target the same health-promoting behaviours and
environmental conditions that the planning team identified as critical in the new population's logic
models? A mismatch here suggests the EBI may be addressing the wrong causal factors

50
Planning Behaviour Change Programs
• Determinants and Change Methods Fit: Does the EBI employ theory-based change methods likely to
influence the key determinants of behaviour in the new population? To assess this, planners must
"reverse engineer" the EBI. This involves deconstructing the candidate intervention to identify its
implicit Logic Model of Change – specifically, its targeted determinants (e.g., self-e;icacy, outcome
expectations) and the theory-based change methods used (e.g., modelling, persuasion). This provides
an "apples-to-apples" comparison with the new population's Logic Model of Change
• Delivery and Cultural Fit: Is the EBI's mode of delivery (e.g., in-person, web-based) feasible and
acceptable for the new audience and setting? Are its cultural elements, such as language, imagery, and
examples, appropriate and resonant?
• Implementation Fit: Do the resources and requirements for implementing the EBI – such as staP skills,
time, and costs – align with the capacity of the adopting organization as assessed in Step 1?

To systematically document the outcome of this assessment, planners create an adaptation "to-do list". For
each component of the EBI, a decision is made on one of four actions:

- Keep as is
- Adapt to better fit the context
- Add a new component to address a gap
- Delete an irrelevant component
Ä This detailed assessment yields a clear blueprint for modifying the intervention

Steps 4, 5, & 6: The Adaptation, Implementation, and Evaluation Cycle

The final three steps of the IM Adapt framework represent the action-oriented phase where the planned
changes are executed, the program is prepared for delivery, and a robust evaluation is designed to
measure the results

• Make Adaptations (Step 4): This step involves the tangible work of modifying program materials and
activities according to the blueprint created in Step 3. Functionally, this step is about ensuring the
message and materials are understood and accepted by the target population. A critical task is to
pretest all adapted components with members of the new population to ensure new messages,
images, and activities are culturally relevant, clear, and acceptable. Throughout this process,
planners must remain vigilant to avoid deleting the EBI's core elements => the theory-based change
methods essential to its e;ectiveness
• Plan for Implementation (Step 5): This step focuses on creating a practical plan for delivering the
adapted program. Its function is to ensure the program can be delivered ePectively by the
implementers. This requires identifying who will implement the program (e.g., community health
workers, teachers), specifying their required tasks and performance objectives, and developing new
training materials and protocols. A clear scope and sequence for program delivery must be established
to provide a practical guide for implementers in the new context
• Plan for Evaluation (Step 6): The final step is to create a comprehensive evaluation plan. An
evaluation of an adapted EBI must be designed to assess not only the overall e;ectiveness of the
program in achieving its health goals but also the specific impact of the adaptations themselves.
This assessment of the adaptations is what transforms a local adaptation project into a contribution to
the broader field of implementation science

By generating data on how and why adaptations work, this evaluation helps fill a critical knowledge gap,
provides valuable insights for the implementing organization, and completes the rigorous scientific process
initiated in Step 1

Ultimately, Chapter 10 provides an invaluable guide for public health practitioners à The IM Adapt framework
obers a robust, systematic, and theory-driven process that empowers them to leverage existing evidence
ebectively. By balancing the scientific demands of fidelity with the practical need for adaptation, practitioners
can save critical resources while maximizing the potential for positive health outcomes in diverse
communities.

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Planning Behaviour Change Programs
Intervention Mapping Step 5: Program Implementation Plan

What is Step 5? Intervention Mapping (IM) Step 5 focuses on developing the program implementation plan.
This step is essential because the ultimate impact of a health program depends not only on the e;ectiveness of
the intervention but also on its reach in the population. The central goal of Step 5 is to structure the plan for
initial implementation, ensuring the program is used as intended, and/or to develop an implementation
intervention to enhance dissemination, adoption, and wide-spread use.

Own objectives, and determinants but for program implementors and stakeholders!
Doing step 2 but for the implementors!

How does Step 5 work? The tasks in Step 5 are similar to Steps 2, 3, and 4, but the focus shifts from the at-risk
population to the program implementers. Step 5 involves creating a separate, deliberate, and strategic
Implementation Intervention designed specifically to promote the adoption, implementation, and maintenance
of the Evidence-Based Intervention (EBI).

The systematic tasks within Step 5 include:

1. Identifying program adopters(allow for the program to be used), implementers(people delivering the
program),stakeholders (people benefiting from the program), and maintainers(people that
institutionalized the program- implementers can be the maintainers): This involves identifying all agents
responsible, such as decision-makers and the professionals who will deliver the program.

2. Stating outcomes and performance objectives for the three stages of program use: adoption,
implementation, and maintenance. Performance objectives describe what implementers must do
successfully.

3. Identifying determinants for these outcomes (e.g., awareness, self-e;icacy, perceived benefits).

4. Constructing matrices of change objectives for the implementation intervention (crossing performance
objectives with determinants).

5. Designing the implementation intervention by selecting change methods and practical applications to
influence program use.

Intervention Mapping Step 6: Develop an Evaluation Plan

What is Step 6? IM Step 6 involves developing a comprehensive evaluation plan. This evaluation aims to
assess the program’s success, improve program management, and generate new knowledge. Evaluation
stakeholders (who are often selected in Step 1) have varied reasons for involvement and seek di;erent types of
information.

How does Step 6 work? The process of developing the evaluation plan involves four main tasks:

1. Writing ebect(was it ebective?what changed?) and process (how was the

implementation,activities,dose,scope?) evaluation questions: These questions must be relevant to
stakeholders, measurable, specific, and time-bound. They are often derived from the program's logical models
developed in earlier IM steps.

2. Developing indicators and measures for assessment: Indicators are the constructs being measured, and
measures are the devices used to quantify or categorize the indicator, requiring consideration of reliability and
validity.

3. Specifying the evaluation design: This involves selecting appropriate research designs (e.g., qualitative
methods for process evaluation, or designs considering threats to validity like maturation or testing, focus
groups, observation studies).

4. Completing the evaluation plan.

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Planning Behaviour Change Programs

Dibusion of Innovation Model and Roles The sources mention the Dibusion of Innovations Theory as a
model explaining how new ideas and practices spread in a population.
(the success of the spread of the new intervention depends on: the program itself, the duration, the salience,
the social organization, the barriers, budget)

• Dibusion is defined as the passive, untargeted, unplanned, and uncontrolled spread of new interventions.

• Dissemination is distinct from di;usion; it refers to planned, systematic e;orts to increase program use in a
target population or system.

The sources identify various systems and agents involved in the implementation process, such as program
developers (resource system), implementers (intermediate-user system), and participants (end-user system).
Program champions or change agents are also noted as key parts of the linkage system that bridges the gap
between developers and users.

The sources define the theory and concept of di;usion but do not explain the specific roles (like "innovators,"
"early adopters," etc.) often associated with the Di;usion of Innovation model.

--------------------------------------------------------------------------------

Measuring Program Achievement and Ebect Evaluation

How do we measure program achievement? Program achievement is measured through evaluation, which
typically includes three levels in the Evaluation Pyramid:

1. Economic Evaluation: Assesses whether the program has a positive e;ect relative to the costs (Cost Benefit
Analysis).

2. Ebect Evaluation (Outcome/Impact Evaluation): Assesses the program’s ebect on the intended
outcomes.

3. Process Evaluation: Aims to understand how the program is implemented, focusing on dimensions like
Fidelity, Dose, Completeness, and Reach.

What is ebect evaluation? E;ect evaluation describes the di;erences in outcomes that occur with and
without the program (also called outcome or impact evaluation). It addresses the question of whether the
program was successful or had an e;ect on the intended outcomes.

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Planning Behaviour Change Programs
• Ebicacy refers to e;ect evaluation under optimal conditions (e.g., with cash rewards for participation).

• Ebectiveness refers to e;ect evaluation under real-world conditions.

If health outcomes cannot be measured within the evaluation timeframe, evaluators may use changes in
behavior, the environment, and determinants as intermediate measures, provided there is strong evidence that
changes in these intermediate indicators lead to changes in the health outcome.

--------------------------------------------------------------------------------

Definition and Explanation of Key Concepts

Concept Definition and Explanation

Dose Delivered The amount of intended units of each program component that is delivered.

Dose Received The extent to which participants engage with the program.

Program
The proportion of intended program activities and components delivered.
Completeness

Fidelity (how true The degree to which the program is implemented with its change methods and
implementers were to practical applications intact. It refers to the extent the intervention was delivered
the plan) as intended.

Modifying Evidence-Based Interventions (EBIs) to specific contexts and audiences

using the IM Adapt process. Adaptation is crucial to increase relevance and
Adaptation
ebectiveness, but planners must ensure changes do not abect the core
components of the EBI responsible for its ebectiveness.

Infusion This concept is not defined or explained in the provided sources.

--------------------------------------------------------------------------------

Frameworks in IM Step 5

Frameworks for dissemination and implementation are used in IM Step 5 to explain how programs are adopted
and implemented. They help planners systematically think about implementation outcomes, identify adapters
and implementers, and consider factors influencing their actions and required capacity.

• Interactive Systems Framework (ISF): This framework helps bridge the gap between research and reality by
describing three systems that work together to facilitate implementation.

1. Prevention Synthesis and Translation System: Summarizes scientific evidence and makes it accessible
for professionals.

2. Prevention Support System: Provides training, tools, and technical assistance to enhance the capacity of
professionals and organizations.

3. Prevention Delivery System: Includes the organizations and professionals who actually implement the
program. The ISF emphasizes that successful implementation requires collaboration between these three
systems.

• RE-AIM: Used to promote consistent reporting and evaluate the overall impact of health programs. Planners
can use it during Step 5 to set explicit targets for the impact and reach of the intervention, balancing internal
and external validity. RE-AIM components are Reach, E;ectiveness, Adoption, Implementation, and
Maintenance.

• Consolidated Framework for Implementation Research (CFIR): This overarching framework assesses
contextual and other factors influencing implementation. It categorizes factors into five domains:

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Planning Behaviour Change Programs
Characteristics of the intervention, External environment, Internal environment, Characteristics of individuals,
and Implementation process. Planners use these domains to identify contextual factors that may influence
implementation, aiding in identifying implementers and formulating objectives to influence the context.

• Theoretical Domains Framework (TDF): TDF helps identify determinants of behavior and select appropriate
interventions to change that behavior. It is based on a synthesis of psychological theories and includes 14
domains (such as Knowledge, Skills, Beliefs about consequences, and Social influences). It can be used to
analyze why people behave in a certain way and develop interventions aimed at addressing specific barriers
and facilitators to behavioral change among implementers.

55