ACTIVE INGREDIENTS
4.3 THEORY OF IMPLEMENTATION .1 Overview
The process for designing health interventions, using any or a combination of approaches, yields information on aspects of the health problem amenable to change, the active ingredients to address the aspects of the problem, and the desired changes TABLE 4.3 Combined approach: steps for conducting group meetings.
Step Activities
Step 1 Clarify the task at hand, which is to learn about participants’ views of the strategies proposed to address the health problem
Step 2 Describe the health problem in detail, informed by the theory or logic model of the problem, using simple easy to understand terms. The description clarifies the definition of the problem (what it is), depicts its indicators (how it is experienced), identifies its determinants (what contributes to the problem) and their relationships with the problem (how the factors leads to the problem), and highlights the consequences of the problem (how it impacts health/life)
Step 3 Identify aspects of the problems that are amenable to change and, therefore, can be modified in order to address the health problem and mitigate its consequences
Step 4 Introduce the map as a blueprint for ways to address the problem
Step 5 Review the information in the map pertinent to each potentially modifiable aspect of the problem
Clarify the aspect, describe the proposed techniques, and explain the desired changes expected of the use of these techniques
Step 6 Engage participants in a group discussion to elicit their views on the appropriateness, utility, and feasibility of the techniques proposed for each aspect of the problem
Participants may be asked to rate each proposed technique for its appropriateness in addressing the respective aspect of the problem, its potential utility or effectiveness in producing the desired changes, and its ease of use in the context of daily life (for clients) and practice (for health professionals), using validated items.
Participants are encouraged to express their opinion on the proposed techniques by answering open-ended questions such as:
• What makes this technique appropriate/inappropriate? Potentially useful/not useful? Feasible/not feasible?
• How can the technique be modified to improve its delivery?
Step 7 Generate a list of techniques rated highly or viewed favorably for each modifiable aspect of the problem
Step 8 Have participants review the list and agree on the techniques to be selected for inclusion in the intervention
expected of the active ingredients and that contribute to the prevention, management, or resolution of the problem. It is possible to have the same techniques for addressing different aspects of the problem. For example, education can be used to convey information about determinants of insomnia and about techniques recommended to address each determinant. The techniques can be integrated into a component.
A component is a set of inter-related techniques or activities that have a common goal (e.g. relay information) and/or address a particular aspect of the problem (e.g. behavioral techniques to change sleep habits).
The theory of implementation identifies the active ingredients of an interven- tion, specifies the components that operationalize the ingredients, and describes each component. As such, the theory of implementation is the blueprint that informs what the intervention is about and how it is delivered. Each component is described in detail to show its correspondence with the respective active ingredients and to point to its most appropriate delivery. In the theory of implementation, the descrip- tion of a component specifies: the desired changes (objective/goal) it is set to achieve;
the information (content/topics) to be relayed including the techniques, behaviors or treatment recommendations that clients are recommended to perform in everyday life in order to achieve the desired changes; the activities in which clients are engaged during the delivery of the intervention; and the mode(s) for providing the compo- nent. The components are organized in a meaningful way, indicating the sequence for their delivery through the respective mode.
4.3.2 Illustrative Example
In the example of insomnia, education is an active ingredient designed to inform clients about: (1) sleep: what is sleep, why we sleep, and what produces sleep (e.g.
circadian rhythm); (2) insomnia: what is insomnia and how it can be experienced;
and (3) personal factors and behaviors (e.g. pattern of food and fluid intake, worry- ing in bed) and environmental factors (e.g. exposure to daylight, sleep environment such as bed room temperature, light and noise) that interfere with sleep and keep insomnia going. This information can be integrated into a component, sleep educa- tion, and presented in the specified sequence (i.e. sleep, insomnia, factors), within the first intervention session. This timing is essential as this information helps clients understand their sleep problem, appreciate the contribution of their (non) actions or behaviors to the problem, and the rationale for treatment recommenda- tions. Clients who understand the “why” of the treatment are likely to “buy-in” the treatment, judge it as credible, and therefore engage and adhere to it (Davidoff et al., 2015), which has been shown to improve outcomes (e.g. Constantino et al., 2018). Multiple modes are useful to provide the sleep education component in a way that is attractive and effective for clients with different literacy levels and learning styles. The modes of delivery include: (1) oral presentation by the interven- tionist to relay and clarify the information in simple terms; (2) written booklet that clients can use to follow through the presentation and take notes for future reference;
(3) self-reflection exercise inviting clients to reflect on the personal and environ- mental factors that are salient in their individual context. This exercise assists clients in recognizing and prioritizing the factors that they should address to promote a good night’s sleep. The sleep education component is useful to enhance clients’ awareness of factors that interfere with sleep and knowledge of how they perpetuate insomnia. However, as described, this component does not help them learn and apply techniques to change these factors.
4.3 Theory of Implementation
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Support is another active ingredient of the intervention to manage insomnia.
Support is operationalized in the component sleep hygiene that consists of: (1) relaying information on the techniques recommended to modify the factors contributing to insomnia; the information is presented for each factor, describing what is to be done by the clients, how and why; (2) having clients develop an individual plan of action for engaging in the techniques recommended for the factors they identify as salient in their life context. Clients’ participation in the development of the action plan generates a sense of ownership. In addition, tailoring the plan to the individual’s life circumstances or context promotes its acceptability and feasibility, which enhance clients’ engage- ment, motivation, and proper execution of the plan; (3) encouraging clients to apply the action plan in everyday life (also called “homework assignment”); and (4) discuss- ing clients’ experience in applying the action plan to identify barriers, enablers, and impact of the applied techniques on sleep. The discussion can also be geared toward generating or exchanging ideas to overcome the barriers and reinforce the enablers.
The first three activities of the sleep hygiene component are performed in the specified sequence within the first session of the intervention (e.g. following the sleep education component). The mode of providing these activities includes using oral presentation and written booklet to relay the information to all clients attending the session, and individual or small group activity to develop the action plan. The last activity (i.e.
discussion) is done in a subsequent session to give clients the opportunity to execute the action plan and report on their experience, in a group format to support each other in finding ways to overcome the barriers (Paul-Ebhahimhen & Arenell, 2009), persuade each other of their ability to apply the recommended techniques, and exchange ideas or tips on how best to apply them. Further, in a group format, clients who are successful in carrying out the plan and experienced improvement in sleep, serve as role models for others. The content and activities comprising the sleep hygiene component are expected to increase clients’ knowledge, self-efficacy, skills, and consistent application of the recommended techniques.
4.3.3 Elements of the Theory of Implementation
The information presented in the previous sections illustrates the theory of implemen- tation. The theory of implementation helps in understanding health interventions, as designed, and provides directions for their delivery to the client population in the con- text of interest (Blamey et al., 2012; Renger et al., 2013). To be useful, the theory of implementation explains the what, how, and why of the intervention. It offers prac- tical guidance on what to do and how to do it when delivering the intervention, which is important for the accurate delivery of the intervention. The theory also provides corresponding conceptual explanations of the techniques to be performed, which are important for appreciating the rationale of the selected intervention components, content, activities, and mode of delivery. In general, understanding the what, how, and why promotes the quality or adequacy of the intervention delivery. Accordingly, the theory of implementation:
1. Delineates the active ingredients of the intervention in relation to the poten- tially modifiable aspects of the problem and the desired changes.
2. Defines the active ingredients at the conceptual level and explains how they are operationalized into components.
3. Describes the components in detail. The description depicts: (1) the goal or desired change the component is set to achieve; (2) the content to be covered;
(3) the treatment recommendations that clients should carry out in daily life;
(4) the activities to be performed by the interventionist and the clients when delivering the component; and (5) the modes for delivering the components.
The sequence for providing the content and/or performing the activities is specified for each component. The sequence for giving the components and the dose for the intervention (comprised of all components) are clarified.
4. Explains the rationale for the selected components, activities, and modes of delivery, as well as their linkages to the desired changes.
5. Identifies the dose at which the intervention (including all components) is provided.
The theory of implementation provides the blueprint for detailing the “nuts and bolts” of the intervention (Blamey et al., 2012) in the intervention manual (see Chapter 7).