ROLE OF THEORY ALONG THE PIPELINE
The specific role of theory in informing an intervention and its development depends upon the phase of the intervention along the pipeline. Figure 4.1 illustrates
Figure 4.1 Role of theory in development, evaluation, and implementation phases.
the changing role of theory and the specific questions that a theory addresses at each phase of advancing an intervention.
As discussed in Chapter 2, the development phases refer to the initial efforts to identify an intervention idea and advance its characteristics and components. This includes: the period of discovery; Phase I, feasibility; and Phase II, proof of concept. In this early phase, theory helps to answer why an intervention should work. It also helps to guide the selection of treatment components, treatment outcomes, and approach to delivering the intervention.
Why an Intervention May Work
As an example, let’s say one is designing an intervention to address family burdens associated with caring for persons with dementia. A common approach used in caregiving research is the classic stress process model (Pearlin, Mullan, Semple, & Skaff, 1990) to understand family caregiver burden. Briefly, this model suggests that burden is an outcome of a particular pathway that involves the caregivers’ initial appraisals of whether the external demands of caregiving pose a potential threat to themselves and if so, whether they have sufficient coping mechanisms to manage effectively. If caregivers perceive external demands as threatening and their coping resources as inadequate, the model suggests that caregivers will experience burden. Consequently, the appraisal of stress may contribute to negative emotional, physiological, and behavioral responses that place caregivers at increased risk for poor health and psychiatric symptoms.
Applied to the context of an intervention, the model suggests that changing caregivers’ cognitive appraisals of their situation and instructing in positive coping mechanisms may reduce burden. The target of such an intervention is therefore the caregivers’ cognitions. Intervention activities may include instruction in cognitive reframing and effective coping techniques. A reduction in burden would be explained via the pathway outlined by the stress process model; that is, the intervention is hypothesized to have its effect on caregiver burden by changing cognition or how caregivers appraise their situation and their emotional coping style.
Alternately, let’s say one uses a different iteration of the stress process model. The National Institutes of Health Resources for Enhancing Alzheimer’s Health (REACH II) initiatives, for example, developed a variant of this model, which recognized objective factors in the care environment such as the lack of social resources or behavioral symptoms of persons with dementia (Schulz, Gallagher-Thompson, Haley, & Czaja, 2000). As shown in Figure 4.2, the inclusion of objective indicators of burden in the conceptual model leads to a different intervention approach. The expanded REACH stress process model suggests that multiple factors contribute to burden along the explicated pathways. Figure 4.2 thus suggests that to boost intervention impact, each of these factors should be targeted. REACH II therefore tested a multicomponent intervention that addressed five areas of caregiver risks for burden. These components and their associated activities included caregiver depression through the provision of education and mood management techniques including pleasant event activities; caregiver burden through the provision of
Figure 4.2 Role of theory in guiding treatment components and specific activities of the REACH II intervention.
education, instruction in stress reduction techniques, and specific skills to manage problem behaviors; self-care and healthy behaviors through the provision of education, helping caregivers track self-care practices; social support by providing opportunities to participate in tele-education and support sessions; and addressing problem behaviors through a structured problem-solving and brainstorming approach to identify specific strategies. As illustrated, even a seemingly small change to a conceptual model alters the intervention focus, its treatment components, and delivery characteristics.
Yet another example of the role of theory in intervention development is the Get Busy Get Better (GBGB) program designed to address depressive symptoms in older African Americans (Gitlin et al., 2012). This multicomponent intervention draws upon several complementary theoretical approaches. First, it uses a broad social ecological model of depression. This model suggests that situational factors (e.g., financial, housing, or health concerns) may provide low levels of positive reinforcement and minimal control, thus negatively impinging upon mood.
Second, GBGB draws upon behavioral theories of depression, which suggest that depressed affect is the consequence of environmental contingencies that decrease healthy responses within one’s behavioral repertoire and increase avoidance of aversive stimuli (Hopko, Lejuez, Ruggiero, & Eifert, 2003). Behavioral theories further suggest that becoming activated can help individuals break the behavior-mood cycle by moving a person from avoidance to action (Hopko et al., 2003).
On the basis of these complementary frameworks, GBGB was designed to involve five conceptually linked components as shown in Figure 4.3: care management
Figure 4.3 Theoretical frameworks informing the Get Busy Get Better intervention.
involving a comprehensive assessment to identify unmet needs; referrals and linkages to minimize situational or environmental stressors; education about depression symptoms and specific actions for self-management to enhance cognitive and behavioral self-awareness; instruction in stress reduction techniques to provide immediate relief from stressful situations; and behavioral activation by identifying a valued activity goal and specific steps to achieve it. The working hypothesis based on these conceptual frameworks is that treatment components operate in tandem such that each is necessary to bring about reductions in depression. This is a testable hypothesis that can be examined through mediation analyses in an evaluation phase, as discussed later.
Here is yet another example of how theory informs hypothesis generation, choice of treatment components, delivery characteristics and outcomes, and in turn the link to anticipated underlying mechanisms of an intervention designed to reduce maternal gestational diabetes mellitus (GDM) and delivery of a large for gestational age (LGA) infant.
The protocol presented here describes a complex behavioral intervention comprising dietary and physical activity changes which we have developed with the aim of improving glycemic control in obese pregnant women. The intervention is based on established control theory with elements of social cognitive theory. The primary hypothesis being tested is that an antenatal intervention package of low glycemic dietary advice combined with advice on increased physical activity will reduce the incidence of maternal GDM and LGA infants. A secondary hypothesis is that the intervention will reduce the risk of obesity in the child. (Briley et al., 2014, p. 3)