Nursing and Health Interventions. Souraya Sidani
The process for designing or developing health interventions is systematic and rigorous. It involves critical analysis and thorough application of relevant approaches and methods to gain a lucid understanding of the health problem requiring remediation, which is represented in the theory of the problem (Chapter 3). This understanding informs the specification of the intervention's elements, which is represented in the implementation theory, and the delineation of the mechanism underlying the intervention's effects on the outcomes, which is reflected in the theory of change (Chapter 4). The process culminates in the generation of the intervention theory (Chapter 5) that guides the delivery and evaluation of the intervention.
The development of a thorough and comprehensive understanding of the health problem requiring remediation is foundational for designing interventions (Bleijenberg et al., 2018; Wight et al., 2016). The understanding entails clarification of what the problem is, how it is experienced, by what population and in what context (Aráujo‐Soares et al., 2018). Different approaches and methods can be utilized to gain an understanding of the problem; using a combination of approaches and methods is recommended to iteratively delineate the theory of the problem that is well grounded in pertinent theory, supported by evidence, and reflective of the target client population's experience and context.
In this chapter, the importance of understanding the health problem, captured in the theory of the problem, is explained. The elements of the theory are identified and illustrated with examples. The theoretical, empirical, and experiential approaches, and their respective methods, for developing the theory of the problem are discussed.
3.1 IMPORTANCE OF UNDERSTANDING HEALTH PROBLEMS
The terms health problem, diagnosis, and need are often used (in different health‐related discipline or professions) interchangeably to reflect a situation requiring a solution. Clients (individuals, families, communities) experience a range of health problems and seek health professionals' assistance in selecting and applying appropriate interventions to address the problems. Health problems are the triggers for designing interventions since remedying the problem requires understanding it first (Kok et al., 2016). Poor conceptualization of the problem could result in the design of inappropriate and potentially ineffective intervention, that is, type III error (Renger, 2011). Accordingly, understanding the health problem requiring remediation provides directions for: specifying the goals of the intervention; identifying its active ingredients that are expected to successfully address the problem; and delineating contextual factors that should be considered in operationalizing and providing an intervention. Interventions designed in a way that is responsive to the target client populations' experience of the health problem and context are likely to be acceptable, efficient, and effective (Huntink et al., 2014; Yardley et al., 2015). For instance, Glanz and Bishop (2010) stated that the most successful public health interventions are based on an understanding of health behaviors and the contexts in which they occur. The understanding is best represented in the theory of the problem.
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 different 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' circumstances 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.
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 undesirable 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 adherence 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 inadequacy 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 behaviors 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 comprehensive care to the growing aging population and prevent admission to acute care hospitals.
The categorization of health problems determines the overall goal of the intervention 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. proscribed 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 intervention. 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. Interventions focusing only on education are not consistent with these conceptualizations of insomnia and, therefore, are likely to be ineffective in resolving this health problem.