INTERVENTIONS
3.2 THEORY OF THE PROBLEM
The theory of the problem is also called logic model of the problem (Dalager et al., 2019). It presents a systematic articulation of the health problem requiring remediation. Health problems are experienced in different domains of health, in dif- ferent ways, by different clients presenting with different personal and health profiles.
The problems are brought about, caused, or influenced by a range of factors operating at different levels, in different contexts. This heterogeneity or variation in experience demands a clarification of the health problem as encountered in the clients’ circum- stances or contexts (Butner et al., 2015; Leask et al., 2019). The theory of the problem is a middle range theory that provides a comprehensive conceptualization of the health problem requiring remediation. The theory defines the problem, identifies influential factors, and explains the relationships among them, that is, how the factors contribute to the problem. The theory can also specify possible consequences if the problem is not addressed.
3.2.1 Definition of the Health Problem
The theory identifies the health problem (i.e. what it is called such as insomnia), defines it at the conceptual and operational levels. The conceptual definition describes the nature of the problem, whereas the operational definition delimits its attributes.
3.2.1.1 Conceptual Definition
The nature of the health problem characterizes what it is about. It is described in terms of its categorization as actual or potential, and by the domain of health in which it is experienced.
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Categorization of Health Problems
An actual problem is an existing situation with which clients present that requires intervention. It reflects an alteration in health, or a dysfunction, and/or an undesir- able behavior that clients actually experience or exhibit, respectively at a particular point in time. Examples of actual health problems include symptoms such as pain and fatigue; difficulty performing activities of daily living; less-than-optimal adher- ence to treatment recommendations; an epidemic or spread of infectious disease in the community; and caregiving burden.
A potential problem refers to a discrepancy between a current situation (i.e. the way things are) and an ideal situation (i.e. the way things ought to be). It reflects an inade- quacy in the type or level of current functioning, and/or an inadequacy in the type or level of healthcare services, that increases the probability of resulting in an actual problem. Potential problems are illustrated by: engagement in undesirable health behav- iors such as smoking that increases the risk of lung cancer; the need for information, support, or additional services to promote engagement in physical activity; or shortage in the number of nurse practitioners with expertise in geriatrics care to provide comprehen- sive care to the growing aging population and prevent admission to acute care hospitals.
The categorization of health problems determines the overall goal of the inter- vention and the timing within the trajectory of the health problem experience for its delivery. For actual health problems, interventions are designed to manage them, that is, to improve the problems’ experience, treat or resolve them, or assist clients to manage them successfully. The interventions are provided after the occurrence of the actual problem. For potential health problems, interventions are geared to prevent them, that is, reduce the chances of their occurrence. The interventions are offered before the occurrence of the problems.
Domains of Health Problems
The nature of the health problem also reflects the domain of health in which it is experienced. Actual or potential problems exhibit as alterations in any or combination of health domains: biological (e.g. bone fracture, muscle injury); physiological (e.g.
high blood pressure or glucose levels); physical (e.g. difficulty walking); cognitive (e.g. difficulty remembering things); psychological/emotional (e.g. stress); behavioral (e.g. substance abuse); social (e.g. lack of social support network); cultural (e.g. pro- scribed practices); and spiritual (e.g. lost meaning in life).
The conceptualization of the problem as experienced in a particular or combination of health domains informs the general strategy underlying the interven- tion. The strategy should be consistent with the nature of the problem. For instance, conceptualizing insomnia as a cognitive problem (e.g. Harvey et al., 2017), or a behavioral problem (e.g. Bootzin & Epstein, 2011), or a combined cognitive and behavioral problem (e.g. Schwartz & Carney, 2012) suggests the need for a cognitive, behavioral, or cognitive-behavioral approach, respectively, for its management. Inter- ventions focusing only on education are not consistent with these conceptualizations of insomnia and, therefore, are likely to be ineffective in resolving this health problem.
3.2.1.2 Operational Definition
The attributes of the health problem are the indicators of its presence and distinguish it from other problems. The attributes are described in terms of the type and level of indicators that define the problem, as well as the severity and duration with which the problem is experienced.
Type and Level of Indicators
Indicators reflect how the problem is manifested. They are the particular alterations or changes in structure or function that point to the presence of the problem. The indicators may be objectively observed (i.e. signs) or subjectively reported (i.e. symp- toms). For example, difficulty initiating sleep (i.e. falling asleep) and maintaining sleep (i.e. staying asleep) are two indicators of insomnia. It is important to note that the experience of the indicators may vary within and across client populations. The variation may be associated with different client characteristics such as age, gender, and culture. For example, the indicators of insomnia vary with age: Middle-aged per- sons frequently report experiencing difficulty falling asleep, whereas older persons frequently report difficulty staying asleep (Sidani et al., 2018a).
The identification of the indicators can be supplemented by the specification of the level at which they are experienced in order to operationally define the health problem.
Level of experiencing the indicators is reflected in a range of values or cutoff scores that should be observed or reported to indicate the presence of the problem. For example, difficulty falling asleep and/or staying asleep may be experienced by anyone, under a wide range of circumstances (e.g. clients may not sleep well a few days before surgery).
To indicate the presence of insomnia, these sleep difficulties or disturbances should occur for 30 minutes or more per night, over at least three nights per week.
Severity and Duration of the Health Problem
Severity refers to the intensity with which the health problem is experienced. It has to do with “how badly,” serious and/or distressing the problem is. The level of severity can be objectively assessed (e.g. level of dependence in performance of activities of daily living, or number of cigarettes smoked) or subjectively rated for its distress or burden by clients, using relevant measures and rating scales. For example, the Insomnia Severity Index assesses clients’ perception of how distressing their sleep problem is, and how much it interferes with daytime functioning; the total score quantifies the level of insomnia severity (Morin et al., 2011).
Duration refers to the time period over which the health problem is experienced.
It determines the acuity or chronicity of the problem, which may be associated with different sets of contributing factors. For example, the experience of the sleep diffi- culties as described previously, over at least three months, indicates the presence of chronic insomnia, which is primarily associated with sleep-related behaviors; acute insomnia is experienced as a result of life events.
Generating a list of indicators, describing each indicator accurately, and speci- fying the severity and duration of the health problem’s experience are important. A critical analysis of the indicators points to those that are amenable to change and for which interventions or components of an intervention can be designed to directly address them and, hence, contribute to the management or resolution of the problem.
For example, dyspnea is manifested by rapid short breathing, suggesting that clients can be instructed to perform deep breathing exercises to control this specific indicator of dyspnea. The severity and duration of the health problem’s experience inform the identification of factors that contribute to the problem.
3.2.1.3 Factors Contributing to the Problem
Generating a comprehensive understanding of the health problem requires the identification of influential factors and the delineation of their inter-relationships with the problem.
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Identification of Factors
Causative factors, risk factors, or determinants of the health problem are circum- stances, events, conditions, or capabilities that contribute to its experience. It is now well recognized that multiple factors, taking place at different levels, conduce to the occurrence (e.g. Aráujo-Soares et al., 2018; Golfam et al., 2015) or maintenance (e.g.
Glanz & Bishop, 2010) of a particular problem. The factors exhibit in any domain of health and life, at the intrapersonal, interpersonal, social, and environmental levels (Bartholomew et al., 2016). Intrapersonal factors include biological characteristics (e.g. sex and age) and physiological, physical, behavioral, psychological, and cognitive conditions. Interpersonal factors entail challenges in the relationships between individual clients and others in their immediate environment (e.g. home, work) and the availability or accessibility of resources and support. Social factors relate to beliefs, values, and norms commonly held by a group or community. Environmental factors represent features of the physical, socioeconomic, and political setting or con- text in which clients reside (Craig et al., 2018).
In addition to identifying the types and levels at which the factors occur, it may be useful to (1) categorize them into factors that contribute to the development or to the maintenance of the health problem (Butner et al., 2015; Glanz & Bishop, 2010);
(2) determine if and how they are inter-related and (3) if they vary across populations and time. Overall, the factors can be categorized into predisposing, precipitating, and perpetuating factors as was done for factors contributing to insomnia.
1. Predisposing factors are usually innate characteristics that increase clients’
susceptibility or tendency to experience the problem. This category of factors is illustrated with sex and age, which have been found to increase clients’ vul- nerability to experience insomnia.
2. Precipitating (also called enabling) factors are conditions or events that bring about or trigger the problem. This category of factors is illustrated with the onset of illness or stress-related events that disrupt sleep.
3. Perpetuating (also called reinforcing) factors serve to maintain the problem.
In the case of insomnia, perpetuating factors represent sleep habits or behaviors that clients engage in an attempt to deal with poor sleep but are ineffective.
Delineation of Inter-relationships
In the real world, the determinants are interconnected, forming a web of factors con- tributing to the experience of the health problem. The determinants can co-occur simultaneously or sequentially, and interact with each other to produce the health problem. For instance, older persons are prone to arousability (i.e. light sleep), which may be exacerbated if they reside in a noisy neighborhood (simultaneous); they start drinking alcohol (sequential) thinking that it would help them sleep better; alcohol causes light sleep thereby further contributing to awakenings at night, and intensifies the effects of medications such as sleeping pills and other antidepressants (interac- tion). The specific determinants or combination of factors contributing to the health problem could vary across client populations or within the same population over time. For example, young and middle-aged adults (compared to older adults) report difficulty falling asleep, which they attribute to stress related to daily life and work;
the level at which they experience this sleep difficulty fluctuates over time as a result
of changes in life and work events and clients’ use of effective strategies to promote sleep (e.g. engagement in relaxation).
The identification and the specification of the inter-relationships among deter- minants are essential for understanding why and how the health problem is gener- ated and maintained. A critical analysis of the inter-relationships (described in Chapter 4) assists in determining the factors that are and are not amenable to change (Aráujo-Soares et al., 2018; Bartholomew et al., 2016; Fernandez et al., 2019; Lippe &
Ziegelman, 2008). Factors that are malleable and have the greatest scope for change are targeted by the intervention (Wight et al., 2016); they inform the specification of its active ingredients. Factors that cannot be modified (e.g. personal and contextual characteristics) are considered as potential moderators, indicating the need for tai- loring of the intervention (Fleury & Sidani, 2018).
3.2.2 Consequences of the Problem
Consequences of the health problem represent complications that may arise if the problem is not effectively addressed. Complications are changes in condition result- ing from the problem and interfering with clients’ general functioning, health and well-being. Examples of consequences associated with insomnia include: physical and mental fatigue that limit physical and psychosocial functioning, which in turn, contributes to accidents. The experience of consequences may be the reason for which clients seek healthcare. As such, interventions are designed to address the