Gerjo Kok

Intervention Mapping: A Process for Developing Theory and Evidence-Based Health Education Programs

The practice of health education involves three major program-planning activities: needs assessment, program development, and evaluation. Over the past 20 years, significant enhancements have been made to the conceptual base and practice of health education. Models that outline explicit procedures and detailed conceptualization of community assessment and evaluation have been developed. Other advancements include the application of theory to health education and promotion program development and implementation. However, there remains a need for more explicit specification of the processes by which one uses theory and empirical findings to develop interventions. This article presents the origins, purpose, and description of Intervention Mapping, a framework for health education intervention development. Intervention Mapping is composed of five steps: (1) creating a matrix of proximal program objectives, (2) selecting theory-based intervention methods and practical strategies, (3) designing and organizing a program, (4) specifying adoption and implementation plans, and (5) generating program evaluation plans.

Scary warnings and rational precautions: A review of the psychology of fear appeals.

Abstract Research into the effects of fear-arousal on precautionary motivation and action is reviewed. Current models do not adequately distinguish between emotional (i.e., fear arousal) and cognitive (i.e., threat perception) responses to fear appeals and, in general, are not well supported. Evidence suggesting that (i) coping appraisals are more powerful predictors of precautionary action than threat perception and that (ii) fear control processes may interfere with precautionary motivation, recommends cautious and limited use of fear appeals in health promotion. It seems likely that fear arousal is less important in motivating precautionary action than perceptions of action effectiveness and self-efficacy. Moreover, perceived personal relevance may be critical to the emotional and cognitive impact of threat information. Available findings are summarised in the form of a process model that highlights the potential complexity of fear arousal effects. Sequential measurement of fear arousal, other than by self-report, is recommended in studies seeking to clarify these effects.

Intervention Mapping: Protocol for Applying Health Psychology Theory to Prevention Programmes

Evidence-based health promotion programmes are based on empirical data and theory. While a broad range of social and behavioural science theories are available, the actual application of these theories in programme design remains a real challenge for health promotion planners. Intervention Mapping describes a protocol for the development of theory- and evidence-based health promotion programmes. It provides guidelines and tools for the selection of theoretical foundations and underpinnings of health promotion programmes, for the application of theory, and for the translation of theory in actual programme materials and activities. This article presents the protocol and elaborates on the application of theory, using examples from successful intervention programmes.

The Impact of Computer-Tailored Feedback and Iterative Feedback on Fat, Fruit, and Vegetable Intake

A randomized trial was conducted to study the impact of individualized computer-generated nutrition information and additional effects of iterative feedback on changes in intake of fat, fruits, and vegetables. Respondents in the experimental group received computer-generated feedback letters tailored to their dietary intake, intentions, attitudes, self-efficacy expectations, and self-rated behavior. After the first feedback letter, half of the experimental group received additional iterative feedback tailored to changes in behavior and intentions. The control group received a single general nutrition information letter in a format similar to the tailored letters. Computer-tailored feedback had a significantly greater impact on fat reduction and fruit and vegetable intake than did general information. Iterative computer-tailored feedback had an additional impact on fat intake. The results confirm that computer-generated individualized feedback can be effective in inducing recommended dietary changes and that iterative feedback can increase the longer term impact of computertailored nutrition education on fat reduction.

Threatening communication: a critical re-analysis and a revised meta-analytic test of fear appeal theory

Abstract Despite decades of research, consensus regarding the dynamics of fear appeals remains elusive. A meta-analysis was conducted that was designed to resolve this controversy. Publications that were included in previous meta-analyses were re-analysed, and a number of additional publications were located. The inclusion criteria were full factorial orthogonal manipulations of threat and efficacy, and measurement of behaviour as an outcome. Fixed and random effects models were used to compute mean effect size estimates. Meta-analysis of the six studies that satisfied the inclusion criteria clearly showed a significant interaction between threat and efficacy, such that threat only had an effect under high efficacy (d=0.31), and efficacy only had an effect under high threat (d=0.71). Inconsistency in results regarding the effectiveness of threatening communication can likely be attributed to flawed methodology. Proper tests of fear appeal theory yielded the theoretically hypothesised interaction effect. Threatening communication should exclusively be used when pilot studies indicate that an intervention successfully enhances efficacy.

Self-rated dietary fat intake: Association with objective assessment of fat, psychosocial factors, and intention to change*

Abstract In order to study the role of awareness of dietary fat intake as a possible factor in the process of dietary behavior change, data on 1507 adult subjects gathered in The Netherlands were analyzed. Objective assessments of dietary fat intake were compared to self-rated, or subjective, dietary fat intake among a Dutch study population. A majority of the respondents had an unrealistic view of their own fat intake. Men were more often unrealistic than women. Underestimation of fat intake was especially prevalent. Self-rated dietary fat intake, and not objectively assessed fat intake, proved to be a significant correlate of intention to reduce fat consumption in the near future among women. Psychosocial determinants of fat intake were stronger correlates of self-rated fat intake than of objectively assessed fat intake. It was concluded that underestimation of ones own dietary fat intake could be a major barrier in healthy diet promotion aimed at reducing fat consumption in The Netherlands. Therefore, improving dietary fat intake awareness should be given priority as a first step in healthy diet promotion strategies. Personal feedback and advice could be a means to improving the realistic estimation of dietary fat intake.

Standard Care Impact on Effects of Highly Active Antiretroviral Therapy Adherence Interventions: A Meta-analysis of Randomized Controlled Trials

BACKGROUND Poor adherence to medication limits the effectiveness of treatment for human immunodeficiency virus. Systematic reviews can identify practical and effective interventions. Meta-analyses that control for variability in standard care provided to control groups may produce more accurate estimates of intervention effects. METHODS To examine whether viral load and adherence success rates could be accurately explained by the active content of highly active antiretroviral therapy (HAART) adherence interventions when controlling for variability in care delivered to controls, databases were searched for randomized controlled trials of HAART adherence interventions published from 1996 to January 2009. A total of 1342 records were retrieved, and 52 articles were examined in detail. Directly observed therapy and interventions targeting specific patient groups (ie, psychiatric or addicted patients, patients <18 years) were excluded, yielding a final sample of 31 trials. Two coders independently retrieved study details. Authors were contacted to complete missing data. RESULTS Twenty studies were included in the analyses. The content of adherence care provided to control and intervention groups predicted viral load and adherence success rates in both conditions (P < .001 for all comparisons), with an estimated impact of optimal adherence care of 55 percentage points. After controlling for variability in care provided to controls, the capacity of the interventions accurately predicted viral load and adherence effect sizes (R(2) = 0.78, P = .02; R(2) = 0.28, P < .01). Although interventions were generally beneficial, their effectiveness reduced noticeably with increasing levels of standard care. CONCLUSIONS Intervention and control patients were exposed to effective adherence care. Future meta-analyses of (behavior change) interventions should control for variability in care delivered to active controls. Clinical practice may be best served by implementing current best practice.

Sixty years of fear appeal research: current state of the evidence.

Fear arousal is widely used in persuasive campaigns and behavioral change interventions. Yet, experimental evidence argues against the use of threatening health information. The authors reviewed the current state of empirical evidence on the effectiveness of fear appeals. Following a brief overview of the use of fear arousal in health education practice and the structure of effective fear appeals according to two main theoretical frameworks-protection motivation theory and the extended parallel process model-the findings of six meta-analytic studies in the effectiveness of fear appeals are summarized. It is concluded that coping information aimed at increasing perceptions of response effectiveness and especially self-efficacy is more important in promoting protective action than presenting threatening health information aimed at increasing risk perceptions and fear arousal. Alternative behavior change methods than fear appeals should be considered.

A taxonomy of behaviour change methods: an Intervention Mapping approach

ABSTRACT In this paper, we introduce the Intervention Mapping (IM) taxonomy of behaviour change methods and its potential to be developed into a coding taxonomy. That is, although IM and its taxonomy of behaviour change methods are not in fact new, because IM was originally developed as a tool for intervention development, this potential was not immediately apparent. Second, in explaining the IM taxonomy and defining the relevant constructs, we call attention to the existence of parameters for effectiveness of methods, and explicate the related distinction between theory-based methods and practical applications and the probability that poor translation of methods may lead to erroneous conclusions as to method-effectiveness. Third, we recommend a minimal set of intervention characteristics that may be reported when intervention descriptions and evaluations are published. Specifying these characteristics can greatly enhance the quality of our meta-analyses and other literature syntheses. In conclusion, the dynamics of behaviour change are such that any taxonomy of methods of behaviour change needs to acknowledge the importance of, and provide instruments for dealing with, three conditions for effectiveness for behaviour change methods. For a behaviour change method to be effective: (1) it must target a determinant that predicts behaviour; (2) it must be able to change that determinant; (3) it must be translated into a practical application in a way that preserves the parameters for effectiveness and fits with the target population, culture, and context. Thus, taxonomies of methods of behaviour change must distinguish the specific determinants that are targeted, practical, specific applications, and the theory-based methods they embody. In addition, taxonomies should acknowledge that the lists of behaviour change methods will be used by, and should be used by, intervention developers. Ideally, the taxonomy should be readily usable for this goal; but alternatively, it should be clear how the information in the taxonomy can be used in practice. The IM taxonomy satisfies these requirements, and it would be beneficial if other taxonomies would be extended to also meet these needs.

The Relationship Between Self-efficacy, Attitudes, Intake Compared to Others, Consumption, and Stages of Change Related to Fruit and Vegetables

Purpose. This study examined whether eating practices and psychosocial factors differed across stages of change for fruit and vegetables. Design. Data were collected using a self-administered written survey among a convenience sample of 739 Dutch adults. Response rate was 92%. Setting. Data were collected as part of the baseline assessment for a nutrition intervention study. Measures. Fruit and vegetable intake was measured as self-reported consumption with a validated eight-item food frequency questionnaire. Psychosocial variables were measured with six items on bipolar seven-point scales and stage-of-change classifications were based on separate four-item algorithms for fruits and vegetables. Differences in psychosocial factors and consumption were analyzed using one-way analysis of variance with Scheffés multiple-comparison test. Results. Significant differences were found between stages of change in dietary intake, attitudes, self-efficacy, and judgment of ones own intake compared to others. Attitudes were most positive in preparation and action and least positive in precontemplation. Intake and self-efficacy were more positive in action/maintenance than in pre-action stages. Conclusions. The findings suggest that nutrition education aimed at encouraging higher intake of fruits and vegetables might be most effective if it is stage-tailored. Messages to influence attitudes about fruits and vegetables are likely to affect people in precontemplation, and self-efficacy information to increase confidence in overcoming barriers to consumption is likely to be effective with persons in contemplation and preparation stages.