INTERVENTIONS
3.3 APPROACHES FOR GENERATING THEORY OF THE HEALTH PROBLEM
3.3.1 Theoretical Approach .1 Overview
The theoretical approach relies on relevant theories to develop an understanding of the health problem requiring intervention. Middle range theories are most useful because they describe the health problem and explain its associations with determi- nants, within a particular context (Moore & Evans, 2017).
Elements of Theory
Theories consist of a group of statements, based on careful reasoning and/or evi- dence that present a systematic and logical view of the health problem. The state- ments are logically organized to identify, define, and describe the problem and its determinants, and to explain the direct and indirect relationships among the deter- minants and the problem. The explanations clarify conceptually why and how the relationships come about, that is, what goes on that connects each determinant to the problem. For example, the following pathway explains the association between age and insomnia: As individuals age, they spend more time in light, than deep, stages of sleep; they are prone to arousability resulting in frequent awakenings during the night, manifested in difficulty maintaining sleep.
Types of Relationships
A direct relationship reflects an immediate linkage between a determinant and the problem, where the problem flows straightforwardly from or is a function of the determinant. For example, there is a direct association between caffeine and nicotine intake close to bedtime and insomnia; caffeine and nicotine are stimulants that inter- fere with sleep.
An indirect relationship can take either of two forms: mediated or moderated.
The relationship between a determinant and the health problem is considered mediated when another factor intervenes between the two, whereby the determi- nant influences the mediator (also called intervening factor), which in turn affects the health problem (MacKinnon & Fairchild, 2009). For example, cognitions are erroneous beliefs, resulting from worry or rumination about sleep-related issues
Contributing factors Problem Consequences
Insomnia
(difficulty initiating and/or maintaining sleep)
fatigue function (limited) Determinants:
Precipitating factors (illness, stress) Perpetuating factors (sleep habits or behaviors, cognitions)
Moderators:
Predisposing factors (age, gender)
Environmental features (noise, light, temperature)
FIGURE 3.1 Representation of theory of insomnia.
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such as inability to get eight hours of sleep and the negative impact of insomnia on daytime functions. These cognitions increase arousal and drive engagement in sleep behaviors in an attempt to alleviate arousal; however, these behaviors may be ineffec- tive and the repeated experience of arousal in bed results in conditional arousal (i.e.
associating the bed with wakefulness), which contributes to insomnia (Schwartz &
Carney, 2012). The relationship between a determinant and the health problem is characterized as moderated when it is affected by another factor (also called moder- ator). The moderator is the condition (e.g. personal or environmental feature) under which the relationship exists, that is, the presence, strength or magnitude, and/or direction of the relationship between the determinant and the health problem vary according to the value of the moderator (Fleury & Sidani, 2018). For instance, gender could moderate the association between arousal and insomnia; women may experi- ence life stress (because of multiple roles’ demands) and worry, which is likely to strengthen the relationship between arousal and insomnia if not well managed.
Examples of Theory
A wide range of middle range theories are available and have been used to generate an understanding of health problems. Theories that have commonly informed the understanding of the occurrence of health behaviors (e.g. physical inactivity, diet, medication adherence) include the health beliefs model, the transtheoretical model, social cognitive theory, social ecological model, and theory of planned behavior (Beall et al., 2014; Durks et al.m 2017; Fassier et al., 2019; Glanz & Bishop, 2010; Lamort- Bouché et al., 2018). Other theories include self-determination theory and self- regulation theory (e.g. Muellmann et al., 2019). Cognitive theories have been used to understand some psychological health problems such as depression (Vittengl et al., 2014) and insomnia (Harvey et al., 2007). Kwasnicka et al. (2016) reviewed theories that explain how behaviors are maintained.
Selection of Theory
Different middle range theories propose different conceptualizations of the same health problem. The theories identify different sets of determinants, operating at dif- ferent levels and/or related to the health problem through different pathways or mechanisms. Selection of a theory or theories should take into consideration the complexity of the real world (i.e. multiple factors, at different levels, contribute to the health problem). Attending to complexity demands the careful review, appraisal, and, if necessary, integration of different theories (or elements of theories) to explain the health problem as experienced by the target client population within the respec- tive context (Bleijenberg et al., 2018; Moore & Evans, 2017). For example, conceptu- alizing insomnia from a behavioral perspective alone may not be adequate, as it is recognized that behaviors are shaped by cognitions (i.e. beliefs), attitudes, personal sense of control, sociocultural norms, and physical environment (Dohnke et al., 2018).
Therefore, the selection of middle range theories to generate the theory of the health problem should be carefully done.
3.3.1.2 Methods
To be useful in understanding the health problem, middle range theories need to be relevant to the problem of interest. This necessitates a clarification of the problem, identification of available theories, and critical analysis of the theories’ description of the problem and propositions regarding its determinants.
Step 1 – Clarification of the Problem
Clarification of the health problem entails an initial delineation of its nature. This is done by addressing the questions: What is the problem exactly about? Is it an actual or potential problem? How is the problem manifested? In what domain of health is it experienced, in what way, by whom, in what context, at what time? Is the concern about the occurrence or the maintenance of the problem? Answers to these questions generate a clear definition of the problem and specification of its attributes, experi- enced by a particular client population, in a particular context. For example health behaviors are described relative to target, action, context, time, and actors (Aráujo- Soares et al., 2018). The clarification of the problem guides the search for relevant theories; it provides key terms and sets limits (e.g. client population, context) for conducting the search.
Step 2 – Identification of Theories
Two general methods can be used to identify relevant theories that explain the health problem as defined in Step 1. The first method relies on consultation with scholars and/or health professionals who have expert theoretical and/or clinical knowledge of the health problem. They may have developed, adapted, or been aware of relevant theories. The second method consists of a literature search. The search covers a wide range of sources including: theoretical or conceptual papers that focus on the presen- tation of the theory or its adaptation to a particular client population or context; text- books or chapters that describe the health problem from a theoretical or clinical perspective; and grey literature such as professional organizations’ websites providing access to white papers or conference presentations about the problem and relevant theories. The search may be extended to empirical papers reporting on studies that tested the theories in different client populations and contexts. Literature sources are selected if they offer a clear description of the theory, which contains a definition of the health problem, identification of its determinants, and propositions explaining the relationships (direct and indirect) between the determinants and the problem.
Step 3 – Analysis of Theories
The analysis of theories consists of the following:
1. The analysis begins by extracting from the selected sources, information on the following elements of each theory identified as relevant to the health problem: name of the theory; conceptual definition of the problem; opera- tional definition of the problem; and possible variations in its indicators across client populations, subgroups comprising a population, and contexts; specifi- cation of determinants at different levels; definition of each determinant;
delineation of the relationships (direct, indirect) among determinants and the health problem; conceptual explanation of the proposed relationships; and if available, empirical evidence supporting the proposed relationships.
2. The information pertaining to each theory is synthesized across all sources in order to generate a full and accurate description of the theory and its elements.
The description is entered into a matrix illustrated in Table 3.2, in preparation for the analysis.
3. The analysis is done for each theory to determine its logical coherence (i.e.
consistency between conceptual and operational definitions, logical explana- tion of the proposed relationships), usefulness in generating a comprehensive and in-depth understanding of the health problem (e.g. comprehensive list of determinants at different levels), and applicability to the context of the target client population (Mayne, 2017; The Improved Clinical Effectiveness through Behavioral Research Group, 2006).
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4. The analysis is also done across theories. This analysis consists of com- paring and contrasting, qualitatively, the different elements of the theories, as well as their logical coherence, usefulness, and applicability. The results indicate whether (1) a particular theory is most appropriate, logical and consistent with the initial clarification of the problem experienced by the client population within the context of interest; this theory is selected as the theory of the health problem; (2) elements of different theories are com- plementary or provide supplementary information about the problem and its determinants; these elements are integrated into the theory of the health problem to present a complete and clear understanding of the problem and its determinants; or (3) a theory or integrated elements is(are) useful in understanding the problem but its(their) applicability to the target client population and context cannot be confirmed; in this case, other approaches (e.g. empirical, experiential) could be used to generate the theory of the problem.
The information gained from this analysis assists in formulating the theory or logic model of the health problem. Specifically, the initial definition of the problem is refined as needed. A comprehensive list of determinants is generated and their direct and indirect relationships with the problem are delineated and explained, and where available, supported by empirical evidence.
3.3.1.3 Strengths
The theoretical approach to generate an understanding of the health problem is advantageous. Theories provide a generalizable conceptualization of the problem and its determinants (Foy et al., 2007). By transcending individual cases, middle range theories describe clearly the nature of the problem and identify its determi- nants or “root causes” (Davidoff et al., 2015). They provide explicit, logical explana- tions of why and how the determinants affect the problem directly or indirectly.
TABLE 3.2 Matrix for analysis of theories.
Element of theory Theory 1 Theory 2
Name
Conceptual definition of health problem Operational definition of health problem a. Defining indicators
b. Variations in indicators Determinants
a. List of determinants at each level b. Definition of determinants c. Direct determinants d. Indirect determinants:
• Mediators
• Moderators
Conceptual explanation of a. Direct relationships b. Mediated relationships c. Moderated relationships Empirically supported relationships
Thus, theories prevent the danger of (1) mislabeling and vaguely defining health problems, (2) missing or omitting important determinants; and (3) misinterpreting associations (specifically bivariate ones that link the problem to one determinant) between the determinants and the problem, all of which have the potential to mis- lead the design of interventions. Middle range theories do not only explain the path- ways linking the determinants to the problem, but also point to the context under which the problem is experienced and maintained, and the pathway is induced. Var- iations in the pathway across clients and contexts highlight the need to adapt or tailor the design of interventions. Briefly, theories are powerful tools to understand the health problem and to make informed decisions when designing interventions (e.g.
Aráujo-Soares et al., 2018; Bleijenberg et al., 2018; Medical Research Council, 2019).
3.3.1.4 Limitations
The theoretical approach has some limitations in gaining a comprehensive under- standing of the health problem. The reliance on one single middle range theory con- strains the perspective on the nature and determinants of the problem to those identified in the theory. Therefore, additional factors (in particular contextual or environmental) that may contribute to the problem could be missed; this limits the capacity to account for all possible determinants pertinent to complex problems experienced by particular client populations in particular contexts. For many health- related problems there is a limited, if any, number of relevant middle range theories that provide an adequate understanding of the problem and all its determinants.
Further, of the available middle range theories, a few have been subjected to exten- sive empirical test across the range of client populations and contexts, and for those tested (e.g. transtheoretical model), the results are often mixed.
Middle range theories may have limited utility if they are not supported empiri- cally. The theoretical approach can be complemented with the empirical approach to gain a comprehensive and accurate understanding of the health problem as actually experienced in the target client population and context.