2 Step 2
In step 1, the focus was on the problem and the corresponding problematic behaviors. However, when you want people to do something differently, you have to be able to recommend a course of action to replace the undesirable behavior or to increase healthy behaviors: you want to change behavior. IM experts call this “the Flip”. Step 2 starts with “The Flip”.
In the 4th edition of the Intervention Mapping textbook, step 2 is discussed in Chapter 5, where the following learning objectives and tasks are discussed:
- State expected outcomes for behavior and environment
- Specify performance objectives for behavioral and environmental outcomes
- Select determinants for behavioral and environmental outcomes
- Construct matrices of change objectes
- Create a logic model of change
In this workbook, we still do the same work. However, the following exercises deviate from the structure in the textbook, as it is easier to split up each task into subtasks.
2.1 The Flip
2.1.1 List target group
First, you decide on the target group (the population whose behavior your program should change). This can be the at-risk group, but it is also possible that your intervention will have to target another group. For instance, when your at-risk group is “new-born baby’s” your target group will likely be the parents, or GP’s.
2.1.2 Define the target behavior
Second, you define the target behavior. This is the desirable behavior of the target group: what should they do exactly?
2.1.3 List environmental conditions
Third, list the environmental conditions you want to realise. Similar to the target behavior, this should be the desirable state.
Note that in step 1 environmental program goals are not always specified. In that case, you also do not specify environmental conditions here yet (but you may still end up specifying environmental conditions below).
Environmental conditions typically resolve or mitigate barriers your target population may encounter. Make sure you do not fall into the trap of including “potential interventions” here.
In many situations (but not all), examples of “wrong” environmental conditions are:
- The school does not provide enough education
- Or, formulated flipped into the desirable state: the school provides adequate education
- Parents (or peers, colleagues) do not discuss subject X enough
These are problematic because you’re sneakily thinking about interventions you might want to implement. However, if you start thinking about interventions/solutions already in this phase, you will narrow your perspective and become biased, prohibiting you from attaining a full understanding of the situation.
In addition, realize that environmental conditions are typically things that could come out of an interview with a target population member. Because of this, they are often not the absence of something (people rarely experience the absence of something as a barrier).
2.2 Identify sub-behaviors/performance objectives
Target behaviors are often very broadly defined (see the examples below). It is therefore important to identify the sub-behaviors that make up the target behaviors. These ultimately being objectives you want to achieve with your intervention, In Intervention Mapping, these sub-behaviors are called Performance Objectives.
To identify the performance objectives for your target behavior, ask yourself the following question: “What do the people have to do to perform this target behavior?”
Formulate performance objectives in a way that includes the target group and that makes them measurable and that describes action, for example in the form of a statement like “[target population] [sub-behavior]”, such as “Women recovering from breast cancer register at their local gym”.
A major mistake is to formulate performance objectives as determinants, for example, by expressing skills or knowledge. For example, “X should be able to do Y”. That statement does not describe the performance of an action; it describes a prerequisite for performance of an action. A performance objective should be: “X does Y”.
A useful guideline is that if all performance objectives, as you formulated them, are true, the target behavior should by definition be performed. For example, if the statements “University students consistently carry condoms” and “University students consistently use condoms when engaging in sex” are true, you know that the target behavior “condom use” is achieved. That is, assuming these two performance objectives exhaustively cover the target behavior!
For example, when the target behavior is “washing hands”, valid sub-behaviors/performance objectives are:
- Use soap
- Wash hands at least 20 secs
- Clean thoroughly (also the wrists, and under the nails)
- Use paper towel to dry hands
- Use paper towel to close the watertap
For example, when you like to promote condom use (health promoting behavior), you want people to plan condom use.
- Plan to purchase condoms
- Go to the store and buy condoms
- Use condoms
- List the performance objectives that comprise the target behavior.
“In real life”, if you did not select a target group and target behavior in The Flip, you do not select performance objectives here yet. Also note that even if in another situation, you do not select a target population and a target behavior, you will still select performance objectives for your environmental agent(s). The concept is quite central to Intervention Mapping.
2.3 Identify environmental conditions and environmental agents
In this section, you merge two lists:
- All environmental conditions that you listed in The Flip; and
- All environmental conditions for the performance objectives.
For each performance objective, specific environmental conditions may be relevant. To identify these think about what could be barriers hindering each performance objectives, and what could facilitate them?
- Target behavior: handwashing at work
- Environmental condition = Soap is available in every bathroom at work
- Environmental agent = the boss (the boss is at the organisational level)
- Environmental agents’ target behavior = the boss provides soap
- Performance objective 1: the boss buys soap
- Performance objective 2: the boss tasks employee to regularly refill soap containers
- Target behavior: condom use in gay sauna
- Environmental condition: Sauna visitor is welcomed in a non-judgmental fashion towards using condoms in the sauna
- Performance objective 1: Sauna employees receive customers in a non-judgmental fashion and have an empathic attitude (interpersonal level)
- Performance objective 2: Sauna owner buys condoms (organisational level)
- List all potentially relevant environmental conditions.
- For each environmental condition, list the corresponding environmental agent(s).
- For each agent, list their environmental level (i.e. the interpersonal level, the organizational level, and the community / societal level).
2.4 Identify environmental agent (sub-)behaviors
Environmental agents (the people, groups, or organisations that have the agency to control one or more environmental conditions) control their corresponding environmental conditions through their behavior.
To achieve the environmental conditions you aim for, you need to identify what those environmental agents need to do. Similar as for target groups, this means identifying the constituent performance objectives (sub-behaviors).
2.4.1 Target behaviors
In many cases, environmental agents will be involved in work you yourself are unfamiliar with, so a good specification of the target behaviors is sometimes not straightforward. Fortunately, broad definitions are acceptable at the target behavior level.
2.4.2 Sub-behaviors / performance objectives
Because target behaviors for environmental agents are broadly defined, intervening on them requires specification. You specify them by formulating sub-behaviors or performance objectives. So, repeat what you did for the target group, but do it now for the environmental agents’ target behaviors.
To find out the performance objectives for the environmental conditions, ask yourself the following question: “What does the environmental agent need to do to accomplish the changes in environmental condition?”
- Environmental condition = hand hygiene resources are available for employees
- Environmental agent = employer
- Target behavior of environmental agent = “make hand hygiene resources available”.
- This target behavior is accomplished through the following performance objectives:
- employer adjusts budgets for purchasing soap, towels, etc
- employer task somebody with ensuring full soap dispensers
- Environmental condition = people keep 1.5 meter distance in a small street
- Environmental agent = municipality
- Target behavior of environmental agent = “clearly indicate with signs that people should keep distance”
- Performance objective = municipality orders the placing of signs (organisational level)
- List the target behavior for each environmental agent
- List the performance object for each target behavior
2.5 Identify determinants and sub-determinants
If you get to this point, you mapped out the more concrete parts of the intervention. You should next get a clear idea of what the world should look like: what do you think the environment of the important groups in your situation should look like, and how should everybody in those groups behave (at-risk group, the target group, and/or one or more environmental agents)?
To achieve these even more tangible goals, people shall actually have to change their behavior. The behavior of the at-risk group and the target group is directly relevant to your intervention, and the behavior of the environmental agents is instrumental to achieving the environmental conditions.
Roughly speaking, people’s behavior is a consequence of their environments and their psychology. You have identified the relevant environmental influences and processed them above as environmental conditions, which yielded environmental agents and their behaviors (and potentially, more environmental conditions). That means that at this point, only psychology remains.
There are many theories that explain why people behave like they do. Each theory is designed for a specific purpose: some deal with habitual behavior, some with health behavior, some with reasoned behavior, and some with impulsive behavior. These theories postulate constructs to describe aspects of the human psychology that, according to the relevant theory, contribute to determining behavior. In the context of behavior change, constructs that are theoretically assumed to predict behavior are called determinants.
Determinants are generally defined at a general level. For instance, attitude, knowledge, habits, perceived norms, self-efficacy, willingness, self-identity, and risk perception are all determinants. Such general definitions are useful when studying human behavior over a variety of populations and behaviors, but the generic level of definition provides no guidance for intervention development.
In an intervention, you don’t target “attitude” or “knowledge”: you communicate about specific facts or list specific advantages or disadvantages. Therefore, when developing a behavior change intervention, the most important thing is identifying the more specifically defined sub-determinants.1 You identify the relevant sub-determinants and determinants for each performance objective in two steps: listing, en selecting.
2.5.1 Long-list sub-determinants and determinants
First, you establish a long list by simply including everything that might be important. Normally, you do this for every performance objective - for the target behavior of your target population, but also for the target behavior of each environmental agent. In real IM life you use all core processes and thus should look at theories, literature (e.g. meta-analyses), do your own experimental studies, or qualitative research, or do all of them. However, in this workbook, just select one environmental agent.
- Brainstorm and use literature and behavioral theories (see chapter 2 of the book) to compile a long list of determinants for the individuals’ target behavior and for the environmental agent(s).
Target behavior individual = hand washing
- Determinants of the individuals’ target behavior:
- expectations regarding effectivenes of hand washing;
- degree to which hand washing is automated; etc
Environmental agent = employer
- Determinants regarding hand washing:
- belief that handwashing will reduce work production;
- belief that illness will reduce work production;
- perceived norm regarding good employership, etc.
Environmental agent = Gay sauna owner
Target behavior = promoting safe sex in his sauna
- Determinants regarding safe sex:
- expectation that more customers will come when free lube is provided;
- potential false belief: with free lube, people will slip and die.
Target behavior individuals = keeping distance from eachother in the busy street
- Determinants regarding social distancing:
- belief that becoming ill sooner than later is a positive thing because ICU’s might be full in two months;
- expectation that one’s immune system is strong enough;
- negative attitude towards elderly people in the streets; etc.
- Create a long list of potential (sub-)determinants in the spreadsheet linked to from the Google doc (complete columns A-E).
2.5.2 Select, defer, or forgo sub-determinants and determinants
Second, you go through the list and you select those (sub-)determinants and determinants you wish to keep for your intervention. There are three potential actions at this point:
- Select a (sub-)determinant: you will retain this (sub-)determinant for step 3, to target it with your intervention.
- Defer a (sub-)determinant: you lack the resources to (also) target this (sub-)determinant in this intervention. You think that this (sub-)determinant is important (and changeable), but you keep it for potential future iterations of your intervention.
- Forgo a (sub-)determinant: you decide that the (sub-)determinant is probably not so important for the target behavior; or that it is important, but not changeable with the means you have available or can conceivably secure in the future.
Select from your list the most relevant determinants for your intervention that are important - they contribute significantly to the behavior (0, +, or ++), and that are changeable - they can be changed with the available methods (0, +, or ++). Consult the literature and your common sense to make these decisions.
- Read ‘Rating importance of determinants’, IM Book, pp. 306-308.
- Decide for each determinant whether to select, defer, or forgo it, based on information about the determinants’ associations to (proxies of) behavior in the case of the population (e.g., your target group or an environmental agent), and information about the changeability of the determinants, for example based on psychological theory.
Here are links with examples of determinant selection based on importance and changeability:
Cannabis use: https://www.healthpsychologybulletin.com/articles/10.5334/hpb.18/
Eating behavior: https://www.sciencedirect.com/science/article/abs/pii/S0195666320300672
Using a high dose of MDMA: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5508122/
- Process each sub-determinant listed in the spreadsheet doc and select, defer, or forgo each (sub-)determinant (complete columns F and G)
2.6 Select environmental conditions (and so, agents), and sub-behaviors and sub-determinants
Out of the long list of potentially important stuff, decide which you select. If you do not select something, you can either defer (retain for potential later intervention) or forgo (eliminate, e.g. because it’s irrelevant).
Selection based on how important stuff is for the behavior (relevance; usually correlational evidence) and how easy it is to change something (sadly, this is too often just anecdotal evidence; sometimes for determinants meta-analyses or systematic reviews)
- List your decisions regarding environmental conditions and agents
2.7 Produce Matrices of Change Objectives
Matrices of change objectives are generally made for each level of intervention planning:
- Individual
- Interpersonal
- Organizational
- Community
- Societal
Change objectives are the specific goals of your intervention. Change objectives literally state what should change at the individual levels, or what should change among environmental agents. A change objective is a sub-determinant that you selected from the long list, but reformulated. You formulate change objectives according to similar principles as you applied for performance objectives. Change Objectives are statements that, when true, mean that the corresponding sub-determinant has been achieved. The idea is that while sub-determinants express a psychological state or process, change objectives are formulated to be measurable (‘SMART’).
SMART refers to:
- Specific: Define your change objectives as specific as possible: e.g., what should change in the target group and/or the environment in order to deal with or reduce the health-related problem. What should change, among whom?
- Measurable: Can you measure the change (objectives)?
- Achievable: Are the change objectives you set achievable and attainable?
- Realistic: Can you realistically achieve the objectives with the resources you have?
- Time: Within what period will you achieve your change goals?
For change objective at the individual level ask: “What do people need to learn with regard to the determinant to do the performance objective?”
- For example, for a change objective regarding self-efficacy, you might ask: “What do people need to learn with regard to self-efficacy to carry a condom?”
For environmental level change objectives you might ask: “What do agents need to learn with regard to the determinant in order to do the performance objective?”
- For a change objective regarding social norms in the community you might thus ask: “What do people in the community need to learn in order for the person to keep a social distance in a busy street?”
Formulate change objectives in a way that makes them measurable by using active verbs such as “shows”, “indicates”, “demonstrates” etc; see page 317 of the IM book for examples of active verbs (4th ed.: Table 5.10, p. 317).
Note that (sub-)determinants that you deferred or forwent are not included in your Matrix of Change Objectives.
Background Step 2: IM change objectives have to be specified explaining who and what will change as a result of the intervention.
Who or what will change can be at
- the individual level of change, e.g.,“adolescents will express confidence regarding negotiating condom use with a sexual partner”
- the organizational level change, e.g., “sauna owners will acknowledge the advantages of condom distribution in the sauna’
- or the community level change, e.g., “community leaders will approve of extracurricular physical workouts in school buildings”.
The Matrix of Change Objectives is structured as follows:
- Each row corresponds to a performance objective;
- Each column corresponds to a determinant;
- Each cell contains all change objectives for that performance objectives and determinant.
Note that some cells will contain multiple change objectives, and some cells will be empty, because not all determinants are important for all performance objectives.
- Produce a Matrix of Change Objectives for each target behavior (for the target group and for each environmental agent).
2.8 Start on the logic model of change
The logic model of change is a model showing how you expect your intervention to work. These logic models can be easily produced using Acyclic Behavior Change Diagrams (ABCD).
To produce the ABCDs, you first fill in the ABCD matrix. The ABCD matrix is a table into which you copypaste (in columns 4, 5, 6 and 7) the information in your Matrix of Change Objectives. This ABCD matrix is then used to produce the ABCD itself.
Open the Matrix of Change Objectives that you just produced, and open the empty ABCD matrix provided in the Google document. Then, copy the following cells from the Matrix of Change Objectives spreadsheet to the ABCD matrix spreadsheet:
- Cell A1 lists the target behavior: copy it to cell G2, and then duplicate it to the cells in column G for every row you end up filling in the ABCD matrix.
- The row headers (column A) contain the performance objectives (the sub-behaviors). Copy these to column F of the ABCD matrix.
- The column headers (row 1) contain the determinants. You will eventually copy these to column E of the ABCD matrix (but see the next bullet).
- In the cells, the Matrix of Change Objectives contains the Change Objectives themselves. These are sub-determinants that have been rephrased conform the specific guidelines for Change Objective phrasing. Each of these sub-determinants/Change Objectives has its own line in the ABCD matrix. The sub-determinant/Change Objective itself is in column D of that row. Note that the Matrix of Change Objectives can have multiple Change Objectives in one cell. Some cells in your Matrix of Change Objectives may thus end up corresponding to multiple rows in your ABCD matrix, because in your ABCD matrix, it is crucial that each sub-determinant/Change Objective has its own line.
- After you copy-pasted all sub-determinants/Change Objectives into column D of the ABCD matrix, verify that every row also has the corresponding determinant in column E, the corresponding sub-behavior/performance objective in column F, and the corresponding target behavior in column G.
You will fill in columns A, B, and C in step 3.
Note that it is also crucial to know the corresponding overarching determinants - you will need that information in step 3.↩︎