Developing an integrated theoretical framework
Your search for evidence probably turned up an abundance of measures you could try. But you can`t just choose from a shopping list. To be effective, you need to combine interventions that will work together to create synergy. To choose the best set of interventions for your program, you have to develop an integrated theoretical framework. Here is an example of a framework, developed for our fall-prevention program.
Fall prevention and the elderly - Developing an integrated conceptual framework
Edwards, N., Lockett, D., Sveistrup, H., Toal-Sullivan, D. von Zweck C. (2004). Does a community action process increase awareness and accessibility of assistive devices for community-living seniors and veterans?
The integrated conceptual framework to guide a program is provided in Diagram 1, Integrated Theoretical Components of Falls among Frail Seniors.
We developed this framework for a community initiative funded by Health Canada and Veterans Affairs Canada. Its goals were to increase awareness of the need for assistive devices for all seniors; get seniors, veterans and community stakeholders to promote use of assistive devices; and increase acceptance of assistive devices by seniors and veterans, their caregivers and community stakeholders. Our targets were businesses, such as pharmacies, hardware stores, hotels and home builders, which could support the use of assistive devices to prevent falls.
The framework was developed by a multidisciplinary team using a wide range of theories for changing individual behaviour and policy and driving collective action and knowledge translation. As the framework shows, a combination of social marketing theory, Kingdon’s model of policy change, community organization theory and Roger’s diffusion of innovation theory dictated our intervention strategies.
Social marketing theory considers the 4 Ps — product, price, place and promotion. We used the media and champions from the senior community to communicate the benefits of assistive devices and their affordability. We gave information on government programs that provide financial assistance for home modifications and worked with another team to develop public-service announcements. We made assistive devices easier to find in places seniors shop, such as pharmacies, and encouraged retailers to make assistive devices more prominent in their stores by suggesting that displays of bathroom hardware could include grab bars. We lobbied retailers to advertise the devices in their catalogues. All of this was focused on encouraging seniors to buy and install grab bars.
Community organization theory led us to establish community advisory groups with representatives from organizations and individual seniors. These were our “champions,” volunteers who visited local businesses to promote assistive devices. We also paid community co-ordinators to work with local home builders, retailers and hotels to encourage them to make assistive devices more accessible and visible.
Roger’s diffusion of innovation theory led us to identify high-profile innovators such as retailers, who have frequent encounters with seniors. Innovators can increase community and market demand for products. Roger’s theory also informed our thinking about characteristics of innovation that increase uptake, which reinforced our efforts to increase the visibility of assistive devices in retail outlets, in catalogues, in model homes and in hotels.
Kingdon’s theory says community demand and public opinion shape the policy environment. We believed that as seniors got better access to assistive devices and gained experience with them, they would get more positive about using them. That, in turn, would sway public opinion to increase demand for them and would influence decisions about adding them to national building code recommendations.
Identify the range of theories guiding the interventions
Because multiple intervention programs use a variety of approaches at different levels, they can be affected by many theories. There are various theories of action, or change theories, to explain how interventions address health issues. These questions will help you determine the type of theory you need:
- How do people make decisions and change behaviour?
- How are messages communicated?
- How do organizations change their focus and ways of working?
You may find answers to those questions in theories on:
- Community mobilization
- Organizational change
Specific theories that may have particular relevance to community health include:
- Diffusion of innovation
- Social learning theory
- Community organization theory
- Environmental-fit theory
- Kingdon’s model of policy change
Mapping the theoretical components of intervention pathways
Program logic models identify interventions that will help you meet your objectives. An integrated theoretical framework maps the theoretical components of the ways you expect interventions to work at various socio-ecological system levels. You can see how we mapped the theoretical frameworks for the fall prevention program in diagrams 1-6. When we map theoretical frameworks like this, it helps us understand the relationships among the intervention theories and can highlight ‘catalyst’ or alternative interventions. For more information please refer to Example 13 – Project ALERT drug prevention program.
Diagrams 1-6 Integrated Theoretical Components of MIP for Prevention of Falls among Frail Seniors
To show you framework mapping, we’ll use the fall-prevention example again. One way to increase the use of assistive devices among frail seniors is to reduce their association with the stigma and negativism of frailty and loss of independence. Once the pathways to changing those social norms are identified, it’s easier to see how social marketing, Kingdon’s model of policy change, community organization and the diffusion of innovation theories integrate. The first diagram shows the integrated conceptual framework and the second shows the integrated theoretical framework for assistive device use. The next four highlight the impact of a different theory on the framework.
Diagram 2: Integrated Theoretical Framework
Illustrates the ways assistive devices lead to enhanced
independent living and a decrease in risk and severity of falls
(Edwards, May 2005)
Diagram 3: Social Marketing
Diagram 4: Kingdon's model of policy change