This book is developed with these complexities and challenges in mind. It seeks to sort out and provide best practices and guide a thoughtful approach to designing, evaluating, and implementing behavioral interventions when the goal is to change current practices or address newly emerging problems or health care challenges with real-world solutions.
Our approach to understanding behavioral intervention research is guided by a socioecological systems framework. This framework, shown in Figure 1.2, conceptualizes interventions as being embedded within a complex system involving multiple and interacting components or levels of influence that also change over time. These interconnected levels include the personal or individual level (e.g., end user of an intervention), the physical environment or setting, the formal and informal social network, the community, neighborhood, organization, and the policy environment.
Consider a drug abuse prevention program whose overall objective is to reduce or prevent the use of illegal substances among high school students. The intervention includes video skill-building sessions that are delivered to both students and parents in the school and overseen by a trained facilitator. In this case, the personal and social levels include the students, teachers/school principal, and parents. The setting and community include the school and classroom where the sessions will be delivered and the surrounding neighborhood. The organizational and policy levels include the school district and school board as well as policies regarding training by outside sources, availability of classrooms for after-hours training, and so forth. Each level has varying and dynamic characteristics, and the interactions among the levels, in turn, can have a significant influence on the degree to which the goals and objectives of an intervention can be achieved and what its delivery characteristics ought to be to maximize benefits. For example, if most of the parents work, it would be difficult to schedule group sessions during the day; if the school policy is to forbid classroom use in the evening, then location could be an issue. Furthermore, the content of each session may need to be carefully reviewed and approved by the full school board prior to its implementation. Knowledge of the characteristics of these levels directly informs construction of an impactful intervention.
By means of our social ecological framework, several guiding principles for behavioral intervention research can be derived.
First, interventions must be understood as occurring within a context that includes multiple levels—the individual, the setting in which the intervention will be delivered (e.g., home, school, clinic, workplace), formal and informal networks and social support systems, the community, and the policy environment (Figure 1.2). Health and behavior, and hence intervention delivery characteristics, may be shaped by influences at each of these levels.
Second, as there are significant interactions among these levels, interventions are more likely to be successful and sustainable if they consider the characteristics of each level and the interactions among them. In other words, interventions cannot be designed in isolation or in a vacuum and focus solely on individual-level determinants of health and behaviors, as has typically been the practice. Rather, interventions must consider the independent and joint influences of determinants at all of the specified levels. Levels will be proximal and distal to the immediate outcomes sought (e.g., increasing physical activity among minority populations); however, at some point in the process of developing the intervention, each level will need to be actively considered.
Third, the levels and the interactions among them are dynamic, and determinants may change with time. Therefore, for interventions to be sustainable, their characteristics must be adaptable to potential changes and dynamic relationships over time.
Figure 1.2 Social Ecological Systems Framework for Understanding Interventions.
Source: Adapted from: Czaja, S.J., Sharit, J., Charness, N., and Fisk, A.D. (2001). The Center for Research and Education on Aging and Technology Enhancement (CREATE): A program to enhance technology for older adults. Gerontechnology, 1,50-59.
These principles are interwoven throughout this book and, taken as a whole, suggest that we need new ways of thinking about and acting upon the design, evaluation, and implementation of interventions.