Although using theory is essential to the development, testing, and implementation of an intervention, there are challenges. First, it may be difficult to find a theoretical base for a particular intervention approach. Some theories of interest may lack a strong empirical foundation. Applying theory to an identified problem area may not be straightforward. This is particularly the case for theories that are not well fleshed out or which do not have empirical support.

Second, a theory may suggest what needs to be changed, but not specifically how to induce change. As discussed earlier, the stress process model provides an understanding of what needs to be changed (e.g., cognition, external stressors) but not how to change it; augmenting it with the TTM can help inform the specific strategies to use when delivering an intervention to support desired changes.

A third challenge is that prevailing behavior change and health behavior theories tend to explain behavioral intentions or motivation, but they do not necessarily explain or predict actual behavior or behavior change. Other theories may need to be called upon to fill the gap between intention and actual behavior.

Yet another challenge is that many journals, particularly medical, do not encourage or support discussion of the theory base for an intervention. The theory base for an intervention is not even mentioned in the Consolidated Standards of Reporting Trials checklist that is used as a guide for reporting intervention work (see Chapter 24 for a discussion on publishing; see for checklist of items). Most publications reporting the outcomes of a behavioral intervention study do not describe a theoretical foundation for the intervention. If a theoretical basis for the intervention is mentioned, it is done so briefly, often making it difficult to decipher connections between treatment components, measures, and outcomes. Thus, it is often difficult to understand how theory informs a published intervention as there is not an expectation that this needs to be articulated. As such, the role of theory and its importance tends to be minimized, and the replication potential of an intervention is potentially and inadvertently diminished.

Finally, a theory may not work. This may be due to various reasons: the choice of theory may not be appropriate or may not adequately explain the phenomenon of interest; the theory may lack clearly defined and testable relationships; the intervention informed by the theory may have been poorly developed and/or implemented (see Chapter 12 on fidelity); or the lack of significance may reflect a measurement error (see Chapter 14; ICEBeRG, 2006). If a theory does not work, it is important to determine the reasons why this might be the case. This can in turn lead to a refinement of the original theory, refutation of the theory, or modification of the intervention and measures to align better with theory.

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