Abstract
Background Physical therapist interventions, such as those designed to change physical activity behavior, are often complex and multifaceted. In order to facilitate rigorous evaluation and implementation of these complex interventions into clinical practice, the development process must be comprehensive, systematic, and transparent, with a sound theoretical basis. Intervention Mapping is designed to guide an iterative and problem-focused approach to the development of complex interventions.
Purpose The purpose of this case report is to demonstrate the application of an Intervention Mapping approach to the development of a complex physical therapist intervention, a remote self-management program aimed at increasing physical activity after acquired brain injury.
Case Description Intervention Mapping consists of 6 steps to guide the development of complex interventions: (1) needs assessment; (2) identification of outcomes, performance objectives, and change objectives; (3) selection of theory-based intervention methods and practical applications; (4) organization of methods and applications into an intervention program; (5) creation of an implementation plan; and (6) generation of an evaluation plan. The rationale and detailed description of this process are presented using an example of the development of a novel and complex physical therapist intervention, myMoves—a program designed to help individuals with an acquired brain injury to change their physical activity behavior.
Conclusion The Intervention Mapping framework may be useful in the development of complex physical therapist interventions, ensuring the development is comprehensive, systematic, and thorough, with a sound theoretical basis. This process facilitates translation into clinical practice and allows for greater confidence and transparency when the program efficacy is investigated.
Physical therapist interventions are frequently complex and multifaceted in nature; therefore, the translation of evidence into practice is a significant challenge. The UK Medical Research Council (MRC) has reported that too often there is inadequate development and piloting of interventions and that the primary effort to conduct treatment efficacy trials misses the opportunity to fully develop and evaluate the theoretical and practical aspects of intervention.1 A lack of rigorous development can result in less useful interventions that are harder to evaluate and less likely to be implemented.1 The UK MRC recommends that complex interventions should include a coherent theoretical basis that clearly underpins the development process and that this process should be described fully to allow for implementation, replication, and robust evaluation.1
Physical therapy researchers seldom report on the process of intervention development. For example, in the area of physical activity interventions—a core element of many physical therapist interventions—the causal chain from determinants of behavior through to intervention objectives, methods, and practical applications is mostly absent from the literature.2 The result is a lack of information about how interventions are developed and their theoretical basis, how specific content is covered within the intervention, and how the method of implementation is designed.3 When information about the development of interventions is lacking, interpretation of treatment efficacy is problematic.4 For example, a complex intervention that has been found to be ineffective may have inadequately developed processes involved in the implementation of the intervention, rather than demonstrating deficiencies in the intervention content itself. However, without adequate analysis of the developmental process, these details cannot be derived, and the entire intervention may be labeled as ineffective and discarded when there is perhaps a simple solution to the implementation process.4 There is also little published about what has, and has not, worked in the development, implementation, and evaluation of existing interventions. This information is crucial, both in guiding clinical researchers in the development of new interventions or the adaptation of existing interventions to a different population group1,2,4 and in the translation of research into clinical practice.5
Intervention Mapping is an established approach used to develop complex theory- and evidence-based health promotion interventions.2,5 Developed by a group of US and Dutch health promotion researchers,6 the purpose of Intervention Mapping is to provide a framework for effective decision making at each step of intervention development, including planning, design, implementation, and evaluation.2 It is designed to reflect the complexity of the decision-making process, which needs to be collaborative, iterative, and cumulative.5 It also allows for practical and political considerations that relate to efficiency, feasibility, and ethics.5 The Intervention Mapping framework has been forged from the authors' experience in developing complex self-management programs for individuals with cystic fibrosis and asthma.2,7,8 Intervention Mapping also has been used to develop complex health promotion interventions in areas such as AIDS prevention and management, obesity prevention, workplace health, cancer screening, and sexual health.2 Intervention Mapping consists of 6 steps that serve as a blueprint for the design, implementation, and evaluation of an intervention based on a foundation of theoretical, empirical, and practical information.2 These steps are: (1) needs assessment; (2) identification of outcomes, performance objectives, and change objectives; (3) selection of theory-based intervention methods and practical applications; (4) organization of methods and applications into an intervention program; (5) creation of an implementation plan; and (6) generation of an evaluation plan. These steps are presented in a linear manner; however, it is known that intervention developers often move back and forth between the steps as information is gained.2
Intervention Mapping offers a systematic method of developing, implementing, and evaluating complex physical therapist interventions. The purposes of this case report are to describe the Intervention Mapping approach in more detail and to illustrate the application of Intervention Mapping to the development of a remotely delivered self-management program, myMoves, aimed at increasing physical activity after acquired brain injury (ABI). Increasing physical activity and reducing sedentary behavior are core aspects of many physical therapist interventions. With the growing burden of chronic diseases globally, many of which are caused by modifiable risk factors such as physical inactivity, there is an urgent need for more effective interventions to mediate this public health crisis. Physical therapists are “at the coalface” of this crisis, with the responsibility of helping individuals and communities change their health behaviors to optimize health and well-being. However, changing long-term physical activity behavior is difficult,9 and empowering individuals to change behaviors and self-manage their physical activity often requires complex interventions based on a sound theoretical foundation. Thus, this case report aims to serve as an example of how to apply Intervention Mapping in the context of complex physical therapist interventions and to highlight the potential benefits of this application.
Case Description
The Intervention Mapping approach is summarized here as it was applied to the development of the myMoves program. As is typical of the Intervention Mapping approach, we have presented the steps in a linear fashion. However, as is often the case, there was frequent movement between the steps where iterative changes were needed. There is no specified time line for the development of a complex intervention; rather, the developmental process should evolve as movement back and forth through these steps works to iteratively develop a sound intervention. It is likely, however, that complex intervention development will take time. In the development of the myMoves program, the Intervention Mapping process began with step 1 in December 2013, and step 4, which involved the production of the program materials, commenced in May 2014. Initial testing of the program commenced in February 2015. However, it should be noted this time line is specific to the development of our intervention, and with different interventions, time lines for development are likely to vary immensely. Where community participation was required, ethical approval was obtained from the Macquarie University Human Research Ethics Committee (Medical Sciences).
Step 1: Needs Assessment
The purpose of step 1 is to assess the health problem that has been identified in more detail, including the related behavioral and environmental conditions and the associated determinants. This process includes examining the scientific, epidemiological, behavioral, and social characteristics of the population of interest, as well as an effort to begin to understand the population. The ultimate products of this needs assessment are an empirically informed description of the health problem facing the target population and the development of a working model of the health problem.2 This working model is informed by the PRECEDE-PROCEED model, which guides the planning of a health intervention by focusing first on the health problem and then working backward to identify the determinants of behaviors related to that health problem.2,10
Different health problems and target populations necessitate different modes of needs assessment, often combining both quantitative and qualitative research methods.2 Our interest in developing the myMoves program was initially informed by similar work successful in other areas11 and the idea that a remotely delivered self-management program focused on physical activity may be of use to individuals living in the community with ABI. However, prior to development, we needed to know whether such a program was of interest to this population and, if so, what the needs of this population were in sufficient detail to inform the development of the program. Our needs assessment initially commenced with a literature review of research about physical activity after ABI, theories of behavior change used to change physical activity behavior, and the self-management of physical activity after ABI, including a systematic review of the efficacy of current self-management programs.3 These reviews served to clarify: (1) the difficulties in obtaining sustained improvement in physical activity levels of individuals with ABI12–14; (2) the shortage of available programs targeting long-term promotion and management of physical activity in people with ABI3,15,16; and (3) the importance of building self-management interventions, based on sound theories and principles of behavior change,17 to improve long-term health outcomes for individuals with ABI.3,17–19 This needs assessment also identified promising results of existing self-management interventions that have been delivered remotely to individuals with ABI.3
The next stage of the needs assessment focused on the determinants of reduced physical activity in this population. Existing literature on the barriers to physical activity was reviewed, and an online survey of a sample of Australian adults living in the community with an ABI was conducted.20 This approach established that individuals living in the community with ABI faced many barriers to physical activity, including mobility impairments, transport difficulties, limited local specialist services, financial costs, safety concerns, and a lack of knowledge about how to be active after an ABI.21–23 Of particular concern to those individuals surveyed was the need to be able to manage their pain or discomfort, their levels of fatigue, and the fear they experienced in regard to being more physically active.20 There was also a desire by individuals with ABI to have access to a program that specifically focused on physical activity and that could be accessed easily, such as those delivered remotely without the need to attend a clinic or health center.20
This complex needs assessment was summarized into a problem-focused model, displayed in the Figure. This model outlined the behavioral and environmental causes of the health problem identified by our needs assessment and the key determinants upon which our intervention needed to focus.2
Determinants of behavior based on needs assessment. ABI=acquired brain injury.
Step 2: Identification of Outcomes, Performance Objectives, and Change Objectives
The purpose of step 2 of the Intervention Mapping approach is to provide a focus for the development of the planned intervention by identifying what should change as a result of the intervention.2 This step is achieved by working down from the overall program goals, which, in the case of the myMoves program, were to increase physical activity and reduce sedentary behavior. Performance objectives are then identified from the overall goals. These performance objectives are what would need to be accomplished by the individuals in the intervention to achieve the program goals. These performance objectives are then mapped against important and changeable determinants of behavior, identified in step 1, in a table, resulting in a detailed matrix of change objectives. Change objectives are the specific actions that would need to occur in order to achieve the performance objectives and program goals.2 Broad conceptualizations, such as increasing physical activity, do not provide sufficient detail on which to base an intervention. However, by detailing specific objectives and actions, there is greater clarification on which to build a complex intervention. The change matrix for step 2 of the myMoves program development is displayed in Table 1.
Change Matrix for Increasing Physical Activity and Reducing Sedentary Behaviora
Step 3: Selection of Theory-Based Intervention Methods and Practical Applications
Step 3 of the Intervention Mapping approach involves identification of relevant theoretical methods that can contribute to achieving behavior change objectives and the practical applications that can operationalize these methods.2 Theoretical methods are defined by the authors of Intervention Mapping to be general techniques or processes for influencing changes in the determinants of behaviors, and practical applications are specific techniques for administering these methods.2 Therefore, step 3 provides clear information on how the intervention developers actually expect to cause changes in behavior via the potential components of their intervention.2
Importantly, Intervention Mapping encourages intervention developers to break away from the traditional approach of using a single theory and instead to use a variety of theories that consider the complexity of behavior change.2 There are numerous theories of behavior change that have been applied to building self-management skills and to improving physical activity behavior, including Bandura's Social Cognitive Theory,24 the Transtheoretical Model,25 the Health Beliefs Model,26–28 and the Theory of Planned Behavior.29,30 In developing the myMoves program, we were able to draw upon multiple theories of behavior change, such as these, allowing for different methods to be applied to different aspects of the program, such as increasing knowledge and awareness, building self-efficacy, and establishing new physical activity habits.
In order to ensure all change objectives are covered, a new matrix table is generated. This table focuses on key determinants of behavior as the primary organizing factors. These factors are selected from the information obtained in earlier steps. For each of these determinants and change objectives, appropriate theoretical methods are selected. Practical applications are then identified through brainstorming, discussion, and creative thinking among the intervention development team, developing a range of applications that fit the context and characteristics of program participants.2 An example of a portion of the matrix table for step 3 in the myMoves program development is shown in Table 2, with the full version available in the eAppendix.
Example of Methods and Applications for Change Objectivesa
Step 4: Organization of Methods and Applications Into an Intervention Program
Step 4 of the Intervention Mapping approach involves the development of the actual intervention program components and materials that are to be delivered to participants. The focus of this step is on the successful translation of the methods and applications outlined in step 3 to achieve the objectives identified in step 2.2 A more detailed framework for the intervention is mapped out, with the scope, sequence, and delivery methods for the intervention identified, ensuring that the intervention not only meets the needs of the population but also is suited to the budget and resources available.2 This framework ensures that the intervention meets the objectives outlined in step 2 and fits the requirements of practical applications identified in step 3.2
For the myMoves program, although the mode of delivery was decided early in the planning process, step 4 involved generating greater detail about the delivery model. The scope of the program was refined to providing 6 core lessons, released over 8 weeks, with a defined sequence that was established through brainstorming and team planning sessions. The lessons were sequenced to provide the core content of the myMoves program, and were each accompanied by detailed case stories, providing the opportunity for modeling, and a worksheet to enhance skill acquisition. The scope and sequence of the myMoves program are summarized in Table 3.
myMoves Program Outlinea
Once these details are established, the design and development of program content and materials are undertaken, ensuring that all change objectives are addressed through effective media.2 All additions to the program text, such as graphs and charts, should be carefully designed to ensure credibility, comprehensibility, and engagement, as well as consistency across all materials. All images should be carefully selected to portray the relevant emotion for each message to maximize engagement at all times.31 Revision of the draft materials should occur iteratively and include feedback from potential users in order to inform the final product. For the myMoves program, an evaluation of program materials and delivery was undertaken as part of the feasibility and acceptability testing (Jones et al, unpublished work).32
Step 5: Creation of an Implementation Plan
The purpose of step 5 is to ensure that, during the development of the program, there is consideration of how the program could be adopted, implemented, and sustained over time.2 Consideration of the pragmatics of the intervention are paramount to ensuring it will be translated into practice, if effective.33 It is important to recognize that adopters and implementers may include no only intended participants and program presenters but also any “gatekeepers” to delivery. These are individuals or organizations (eg, a classroom teacher, a caregiver, a consumer advocacy organization) that are involved in getting the intervention to potential participants.2 For the myMoves program, the adopters included not only potential participants but also organizations that have access to potential participants,2 such as the National Stroke Foundation and Brain Injury Australia.
The implementation plan also needs to consider how potential program adopters will gain awareness of and information about the program and how they will access the intervention itself. For the myMoves program, a website was designed and developed to provide both a source of information about the myMoves program and a point of contact with myMoves team members. This website provided an easy link between organizational adopters mentioned above, potential participants, and the program implementers at Macquarie University.
In developing a new intervention, such as the myMoves program, intervention developers may not yet have all of the details required for a comprehensive implementation plan. However, initial testing of the program can provide further information to inform a more detailed implementation plan for dissemination in the future.2 Therefore, for the myMoves program, the focus of this step was to plan for the initial feasibility and acceptability testing of the program.
Step 6: Generation of an Evaluation Plan
The purpose of step 6 of the Intervention Mapping approach is to ensure that the evaluation plan answers the question of whether the intervention is successful in achieving its goals and objectives.2 It also is important to ensure that the evaluation plan incorporates measures that are pragmatic and feasible to collect in busy, real-world settings.33 For example, in the initial testing phase of the myMoves program, the evaluation plan was focused on assessing the program's feasibility and acceptability. This plan included collecting valuable information about both the participant's experience during the intervention and ensuring the evaluation methods themselves are both feasible and acceptable to participants who were remote from the researchers. Both quantitative and qualitative methods were utilized and, again in demonstrating the iterative process, will be used to inform further improvements to the myMoves program itself and the evaluation plan. The evaluation of the feasibility and acceptability trial of the myMoves program (Jones et al, unpublished work) will be presented in a future publication.
Discussion
Greater detail and transparency regarding the development of complex physical therapist interventions are needed to better guide effective intervention development and adaptation, add clarification to the evaluation of interventions, and enhance the translation of research into clinical practice.1,2,4,5 Intervention Mapping provides a useful framework for the development of complex physical therapist interventions, such as those aimed at changing physical activity behavior. This framework guides developers through a systematic process that considers both the theoretical foundations upon which to build an intervention and the practical aspects of the intervention. Intervention Mapping encourages intervention developers to engage stakeholders in the developmental process and to pilot test interventions as part of the iterative process of development.2 Examination of the results of each step of the Intervention Mapping process could aid in more thorough reflection on the efficacy of an intervention. For example, if an intervention is found to be ineffective or only provides a mild-moderate level of efficacy, a thorough review of the outcomes of each step of the developmental process could assist in highlighting areas where improvement or alteration may alter the outcomes.2 Intervention Mapping also considers the pragmatics associated with both the implementation and the evaluation of complex interventions.2 These factors can increase the likelihood that resultant interventions are translated from a developmental and research space to a real-world setting.1,2,33
The purposes of this case report are to describe the Intervention Mapping approach in detail and to illustrate its application to the recent development of a remotely delivered self-management program, myMoves, that aims to increase physical activity after ABI. The myMoves program described in this report is yet to be tested for efficacy but is used here as an example of how the Intervention Mapping process can be applied to guide more rigorous development of a new physical therapist intervention than is typically undertaken. For example, at the commencement of the myMoves development process, we set out to build a program that supported individuals with ABI to become more physically active and less sedentary. However, the Intervention Mapping approach ensured that we delved deeper than these more abstract program goals to more specifically identify what it was that we were needing to change and which methods and practical applications could best be used to create an optimal environment for change. This attention to detail is a strength of the Intervention Mapping approach and ensured that all elements included in the myMoves program and all decisions made about the process of implementation and evaluation were based on a strong theoretical and evidence-based foundation. However, it also is important to emphasize the iterative nature of the Intervention Mapping process. Early testing of the feasibility and acceptability of programs, such as with the myMoves program, provides further information that can be fed back into earlier steps of the Intervention Mapping process. This testing allows for further refinement and enhancement of the intervention over time.
Intervention Mapping also offers potential benefits to those beyond the development team. It can provide a comprehensive framework that clearly articulates the developmental process to others, thus allowing for more transparency in the design and evaluation of these interventions.2 This framework may aid clinicians in assessing the suitability of an intervention to their specific setting or population or in assessing what changes may need to occur to the intervention in order to enhance its suitability. When adapting evidence-based programs to new settings or populations, there may be a requirement to make changes to the practical application, delivery strategies, or cultural elements of the program, while identifying and retaining the essential elements of the original program that are important for efficacy.2 Dissemination of greater detail regarding the development of complex interventions offers clinicians more information on which to base their decisions regarding the implementation of these interventions.
The Intervention Mapping approach is not meant to be a recipe that is simply repeated in the same manner for each new intervention. Rather, it is a framework, within which each step allows for adaptation to the differing requirements of the specific population, setting, and nature of the intervention.2,7 When conducted in full, developing an intervention using Intervention Mapping can be a lengthy and detailed process. For example, the development of the myMoves program commenced in December 2013 with the start of the needs assessment, production of the materials for the myMoves program commenced in May 2014, and initial testing of the program commenced in February 2015. However, physical therapist interventions often necessitate complexity due to the nature of the populations and settings within which we operate and the behaviors we are aiming to influence. We also operate in a diverse range of settings, which may require flexibility in our intervention application.1 For example, our team included members who are psychologists with a substantial background in the development and delivery of remote interventions. In designing interventions that are effective for the individuals with whom we work and in the different settings within which we work, it is important that we give significant consideration to the developmental process, including the team involved in this process, or we may risk producing interventions that are ineffective or not translatable to real-world settings.1,2,7 Intervention Mapping is a framework with which physical therapists can utilize a problem-driven approach to the development of real-world solutions that are backed by theory and empirical evidence.2 This framework, in turn, increases the likelihood that resultant solutions and interventions are efficacious, acceptable, and implementable.1,2,33
It is important to note that Intervention Mapping is not the only framework available to aid in the development or evaluation of complex health interventions. There are other valuable models, such as the Behaviour Change Wheel,34 MOST,35 and RE-AIM.36 We chose Intervention Mapping because it was developed through experience in designing self-management interventions, which were similar to the intervention we were aiming to develop, and it offered a framework with which we were able to engage stakeholders, consider both the theoretical and pragmatic aspects of the intervention, and continue to develop the intervention in an iterative manner.2 Our experience is that it offers a useful framework to physical therapists considering the development of a complex physical therapist intervention. However, it is important that developers consider a framework that best suits their needs.1
Intervention Mapping is a framework that may be useful in the development of complex physical therapist interventions to ensure that the development process is systematic and rigorous and is founded on a sound theoretical basis and with consideration of the pragmatics of application. The myMoves program has been enhanced by this approach to intervention development, which advocated for attention to detail in all aspects of the developmental process, including content inclusion, program implementation, and the process of evaluation. This process can allow for iterative improvements to the intervention over time and transparency when evaluating intervention efficacy testing and can facilitate the translation to real-world settings.
Footnotes
All authors provided concept/idea/project design and writing. Dr Jones provided data collection and participants. Dr Jones and Professor Dean provided data analysis. Dr Jones, Professor Dean, and Dr Hush provided project management. Professor Dean provided institutional liaisons. Dr Dear, Dr Hush, and Professor Dean provided consultation (including review of manuscript before submission).
Dr Jones was supported by a Macquarie University Research Excellence Scholarship. Dr Dear is supported by a National Health and Medical Research Council (NHMRC) Australian Public Health Fellowship.
- Received July 8, 2015.
- Accepted May 22, 2016.
- © 2016 American Physical Therapy Association
References
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