Multiple outcome measures and mixed methods for evaluating the effectiveness of theory-based behaviour-change interventions: a case study targeting health professionals' adoption of a national suicide prevention guideline

Interest in behaviour-change interventions targeting health professionals' adoption of clinical guidelines is growing. Recommendations have been made for interventions to have a theoretical base, explore the local context and to use mixed and multiple methods of evaluation to establish intervention effectiveness. This article presents a case study of a behaviour-change intervention delivered to community mental health professionals in one Primary Care Trust, aimed at raising adherence to a national suicide prevention guideline. A discussion of how the theory-base was selected, the local context explored, and how the intervention was developed and delivered is provided. Time series analysis, mediational analysis and qualitative process evaluation were used to evaluate and explore intervention effectiveness. The time series analysis revealed that the intervention was not effective at increasing adherence to the guideline. The mediational analysis indicates that the intervention failed to successfully target the key barrier to adoption of the guidance, and the qualitative process evaluation identified certain intervention components that were well received by the health professionals, and also identified weaknesses in the delivery of the intervention. It is recommended that future research should seek to further develop the evidence-base for linking specific intervention strategies to specific behavioural barriers, explore the potential of theories that take into account broader social and organisational factors that influence health professionals' practice and focus on the process of data synthesis for identifying key factors to target with tailored interventions. Multiple and mixed evaluation techniques are recommended not only to explore whether an intervention is effective or not but also why it is effective or not.     

The justification of paternalistic actions in psychotherapy

This article defines the nature of paternalistic interventions in psychotherapy and discusses reasons why the client's right to consent to treatment is important. We describe a reasoning process developed by Culver and Gert (1982) that can be used to determine when paternalistic actions are and are not ethically justifiable in mental health practice. We demonstrate how this procedure may be applied to psychotherapy by using a number of case illustrations.     

The Justification of Paternalistic Actions in Psychotherapy

This article defines the nature of paternalistic interventions in psychotherapy and discusses reasons why the client's right to consent to treatment is important. We describe a reasoning process developed by Culver and Gert (1982) that can be used to determine when paternalistic actions are and are not ethically justifiable in mental health practice. We demonstrate how this procedure may be applied to psychotherapy by using a number of case illustrations.     

Towards a new framework of personalized psychological interventions to improve intergroup relations and promote peace

Recent increases in intergroup tensions and violence have global negative implications and underline the need for effective interventions to ameliorate conflictual relations. Despite the ongoing trend in social psychology toward an interventionist approach, there is still a theoretical and empirical gap in personalizing intergroup interventions to achieve optimal effectiveness. Integrating interventions aimed at prejudice reduction and promoting peace, we present a theoretical framework for personalizing these intergroup interventions. We propose a three‐layer model: personalization parameters, intergroup interventions, and mechanisms that link parameter and intervention. To illustrate the model, three sample parameters are described (ideology, dominant emotional sentiments, and Big Five personality types) and three corresponding mechanisms (level of intervention congruency; the degree to which an intervention addresses core appraisal theme; and a needs‐based mechanism). We demonstrate how the parameters and mechanisms map onto different established intergroup interventions, and suggest some empirical directions to test and later apply the theoretical framework. Finally, we discuss the potential of personalized interventions to substantially improve intergroup relations.     

Chicago Urban Resiliency Building (CURB): An Internet-Based Depression-Prevention Intervention for Urban African-American and Latino Adolescents

Early preventive interventions for depressive disorders in racial/ethnic minorities may help to reduce lifetime depression outcome disparities by improving developmental trajectories and social outcomes. We describe the development process, intervention and evaluation plan for a culturally adapted, low-cost, primary care/Internet-based depression-prevention intervention (CURB, Chicago Urban Resiliency Building). CURB is culturally adapted for socio-economically disadvantaged African-American and Latino adolescents according to the PEN-3 model of health promotion programs (Airhihenbuwa in Health and culture: beyond the Western paradigm, Sage Publishers, Thousand Oaks, 1995). Based on the idea that health behavior is rooted in culture, the PEN-3 model contains three interdependent dimensions that influence health beliefs and behaviors. Within each dimension are factors (using the acronym PEN) that must be considered about the target culture. Application of the PEN-3 model occurred in 3 phases. In each phase, a dimension of the model was explored and subsequent changes were made to the intervention so as to be more culturally suitable. In the CURB clinical trial, adolescents ages 13–17 will be recruited from wait-lists for mental health services at community health care provider organizations and screened for risk of future depressive disorder in the primary care sites. Adolescents screening positive for persistent depressed mood will be randomly assigned to either the CURB intervention group or the wait-list control group. The study aims are to determine if participants in the CURB intervention group will have lower levels of depressive symptoms and/or a lower cumulative incidence of depressive episodes.     

Consumer engagement and the development, evaluation, and dissemination of evidence-based parenting programs

A consumer perspective can contribute much to enhancing the "ecological fit" of population-level parenting interventions so they meet the needs of parents. This approach involves building relationships with consumer groups and soliciting consumer input into the relevance and acceptability of interventions, clarifying the enablers and barriers to engagement and involvement of parents, and clarifying variables that influence a parent's program completion. The adoption of a more collaborative approach to working with consumers is important if meaningful population-level change in the prevalence of serious social, emotional, and behavioral problems in children and young people is to be achieved. Parents seeking assistance for their children's behavior come from a diverse range of socioeconomic backgrounds, educational levels, cultures, and languages. This paper examines consumer engagement strategies that can be employed throughout the process of program development, evaluation, training, and dissemination, and in "scaling up" the intervention. We argue that a multilevel public health approach to parenting intervention requires a strong consumer perspective to enable interventions to be more responsive to the preferences and needs of families and to ensure improved population reach of interventions. Examples from large-scale dissemination trials are used to illustrate how consumer input can result in an increasingly differentiated suite of evidence-based parenting programs.     

Work engagement interventions can be effective: a systematic review

Work engagement is associated with important individual and organisational outcomes (e.g. employee health and well-being, performance). This narrative systematic review aims to synthesise the increasing number of work engagement interventions and inform future research by exploring: (1) the specific intervention foci, delivery methods and content of engagement interventions; (2) intervention effectiveness; and (3) underlying mediators and moderators. A systematic search for interventions employing a validated engagement measure revealed 40 studies. Five were personal resource building, twelve job resource building, three leadership training, eighteen health promotion, and two job and personal resource building. Twenty (50%) studies observed significant positive effects on work engagement, two (5%) had a negative effect, and eighteen (45%) had no effect. Job and personal resources, job demands and well-being were important mediators. Moderators included the specific intervention focus and delivery method, employee participation, manager support, and intervention level (top-down vs bottom-up). Bottom-up interventions, and job crafting and mindfulness interventions particularly, were most successful. Implementation difficulties were common, including poor response and attrition rates, and adverse factors (e.g. organisational restructuring, redundancy, economic downturn). We highlight implications for research and practice and stress the need to test underlying theories to build knowledge around how, why, and when interventions work.     

Lessons Learned: Providing Supportive Accountability in an Online Anxiety Intervention

Technology-delivered interventions have the potential to help address the treatment gap in mental health care but are plagued by high attrition. Adding coaching, or minimal contact with a nonspecialist provider, may encourage engagement and decrease dropout, while remaining scalable. Coaching has been studied in interventions for various mental health conditions but has not yet been tested with anxious samples. This study describes the development of and reactions to a low-intensity coaching protocol administered to N = 282 anxious adults identified as high risk to drop out of a web-based cognitive bias modification for interpretation intervention. Undergraduate research assistants were trained as coaches and communicated with participants via phone calls and synchronous text messaging. About half of the sample never responded to coaches’ attempts to schedule an initial phone call or did not answer the call, though about 30% completed the full intervention with their coach. Some anxious adults may choose technology-delivered interventions specifically for their lack of human contact and may fear talking to strangers on the phone; future recommendations include taking a more intensive user-centered design approach to creating and implementing a coaching protocol, allowing coaching support to be optional, and providing users with more information about how and why the intervention works.     

Process Evaluation for Stressor Reduction Interventions in Sport

Stressor reduction interventions may have the potential to improve the well-being of those involved in sport. Organizational psychologists have used these primary interventions in various performance domains. The authors describe the stressor reduction design and implementation processes, and the contexts in which they occur, that impact on these interventions. The authors then examine how process evaluation methods can be applied during stressor reduction in sport settings. Process evaluation requires the frequent collection of data about intervention experiences and events from multiple sources using a mixed-methods approach. The article contains practical recommendations for sport psychologists who implement stressor reduction interventions.     

Organisational interventions to improve employees' health and wellbeing: A realist synthesis

Although organisational interventions have shown promising results in improving employees' health and wellbeing, reviews of the effectiveness of such interventions conclude results are inconsistent. Realist synthesis is considered an appropriate method of literature review to improve the consistency of empirical evidence by developing generalisable statements of ‘what works for whom in which circumstances’. In this article, to identify and synthesise existing evidence from the empirical studies of organisational interventions, we conducted a realist synthesis according to the RAMESES publication standards. We reviewed 28 articles. Six realist programme theories were developed that explain how different mechanisms of organisational interventions may bring about different outcomes in different contexts. These realist programme theories are based on the process mechanisms of implementation adherence, communication, employees' participation, senior management support, middle management support and external consultants/researchers support. This realist synthesis enhances the understanding of how organisational interventions may improve employees' health and wellbeing, in which contexts, and for which group of employees. As such, it makes an important potential contribution to designing, implementing and evaluating future organisational interventions.     

A Community‐Responsive Adaptation to Reach and Engage Latino Families Affected by Maternal Depression

As family researchers and practitioners seek to improve the quality and accessibility of mental health services for immigrant families, they have turned to culturally adapted interventions. Although many advancements have been made in adapting interventions for such families, we have yet to understand how the adaptation can ensure that the intervention is reaching families identified to be in greatest need within a local system of care and community. We argue that reaching, engaging, and understanding the needs of families entails a collaborative approach with multiple community partners to ensure that adaptations to intervention content and delivery are responsive to the sociocultural trajectory of families within a community. We describe a cultural adaptation framework that is responsive to the unique opportunities and challenges of identifying and recruiting vulnerable families through community partnerships, and of addressing the needs of families by incorporating multiple community perspectives. Specifically, we apply these principles to the cultural adaptation of an intervention originally developed for low‐income African American and White families facing maternal depression. The new intervention, Fortalezas Familiares (Family Strengths), was targeted to Latino immigrant families whose mothers were in treatment for depression in mental health and primary care clinics. We conclude with key recommendations and directions for how family researchers and practitioners can design the cultural adaptation of interventions to be responsive to the practices, preferences, and needs of underserved communities, including families and service providers.     

Using Ecological Theory to Evaluate the Effectiveness of an Indigenous Community Intervention: A Study of Sexual Assault Nurse Examiner (SANE) Programs

In recent years, there has been renewed interest among community psychologists in indigenous interventions, which are programs created by local practitioners (rather than researchers) already rooted in their communities. Indigenous interventions have strong ecological validity, but their effectiveness is often unknown because so few are rigorously evaluated. The goal of this project was to use Kelly and Trickett’s ecological theory as a conceptual framework for evaluating an indigenous intervention and its mediating mechanisms of effectiveness. The focal intervention was a midwestern Sexual Assault Nurse Examiner (SANE) program, which provides post-assault medical care, crisis intervention, and medical forensic exams for sexual assault survivors. Prior studies of SANE programs have suggested that these interventions may help increase sexual assault prosecution rates. In this case example, we used a mixed methods design to determine if this program contributed to increased prosecution rates, and if so, why. Based on qualitative interviews with key stakeholders, we found substantial evidence for the Principle of Interdependence such that the SANE program strengthened the interconnections between the legal and medical systems, which contributed to increased prosecution. The intervention was effective in these outcomes because it promoted Cycling of Resources throughout the systems and fostered Adaptation of new roles for legal and medical personnel. Moving beyond this specific case example, this paper also examines cross-cutting advantages and struggles of using an ecological approach in the evaluation of indigenous community interventions.     

Deaths of Despair: Conceptual and Clinical Implications

Since the late 1990s, mortality rates for middle-aged (45-55), White non-Hispanic (WNH) Americans began to rise while rates declined for all other demographic and age groups. Coinciding with the rise in mortality, rates of death due to suicide, drug- and alcohol-related overdoses, and alcohol-related liver diseases increased as well for this demographic. Research suggests these causes of death (i.e., suicide, poisoning, alcohol-related liver disease) are driving the overall mortality rate for middle-aged WNHs and have been described as “deaths of despair” in the literature. In the current paper, we describe the social and clinical features of “deaths of despair,” explore theoretical models of psychopathology (e.g., depression, posttraumatic stress disorder) that may inform our understanding of mechanisms of risk for negative mental health outcomes, and propose an initial conceptual model of “deaths of despair” to identify intervention targets. We then review an applied case example demonstrating how this model could be used for clinical application. We conclude our paper by describing how current cognitive-behavioral interventions may address these mechanisms of “despair.”     

Introduction to Multi-Level Community Based Culturally Situated Interventions

This introduction to a special issue of the American Journal of Community Psychiatry is the result of a symposium at the Annual Meeting of the Society for Applied Anthropology, 2006, that brought together anthropologists and psychologists involved in community based collaborative intervention studies to examine critically the assumptions, processes and results of their multilevel interventions in local communities with local partners. The papers were an effort to examine context by offering a theoretical framework for the concept of “level” in intervention science, and advocating for “multi‐level” approaches to social/behavioral change. They presented examples of ways in which interventions targeted social “levels” either simultaneously or sequentially by working together with communities across levels, and drawing on and co‐constructing elements of local culture as components of the intervention. The papers raised a number of important issues, for example: (1) How are levels defined and how should collaborators be chosen; (2) does it matter at which level multilevel interventions begin; (3) do multilevel interventions have a greater effect on desired outcomes than level‐specific interventions; (4) are multilevel interventions more sustainable; (5) are multilevel interventions cost effective to run, and evaluate; (6) how can theories of intervention be generated and adapted to each level of a multilevel intervention; (7) how should intervention activities at each level coordinate to facilitate community resident or target population empowerment? Many of these questions were only partially addressed in the papers presented at that time, and are more fully addressed in the theoretical papers, case studies and approach to evaluation included in this collection.     

The Application of Intensive Longitudinal Methods to Investigate Change: Stimulating the Field of Applied Family Research

The use of intensive longitudinal methods (ILM)—rapid in situ assessment at micro timescales—can be overlaid on RCTs and other study designs in applied family research. Particularly, when done as part of a multiple timescale design—in bursts over macro timescales—ILM can advance the study of the mechanisms and effects of family interventions and processes of family change. ILM confers measurement benefits in accurately assessing momentary and variable experiences and captures fine-grained dynamic pictures of time-ordered processes. Thus, ILM allows opportunities to investigate new research questions about intervention effects on within-subject (i.e., within-person, within-family) variability (i.e., dynamic constructs) and about the time-ordered change process that interventions induce in families and family members beginning with the first intervention session. This paper discusses the need and rationale for applying ILM to family intervention evaluation, new research questions that can be addressed with ILM, example research using ILM in the related fields of basic family research and the evaluation of individual-based interventions. Finally, the paper touches on practical challenges and considerations associated with ILM and points readers to resources for the application of ILM.     

Understanding and Using Informants’ Reporting Discrepancies of Youth Victimization: A Conceptual Model and Recommendations for Research

Discrepancies often occur among informants’ reports of various domains of child and family functioning and are particularly common between parent and child reports of youth violence exposure. However, recent work suggests that discrepancies between parent and child reports predict subsequent poorer child outcomes. We propose a preliminary conceptual model (Discrepancies in Victimization Implicate Developmental Effects [DiVIDE]) that considers how and why discrepancies between parents’ and youths’ ratings of child victimization may be related to poor adjustment outcomes. The model addresses how dyadic processes, such as the parent–youth relationship and youths’ information management, might contribute to discrepancies. We also consider coping processes that explain why discrepancies may predict increases in youth maladjustment. Based on this preliminary conceptual framework, we offer suggestions and future directions for researchers who encounter conflicting reports of community violence exposure and discuss why the proposed model is relevant to interventions for victimized youths.     

Internet-based intervention for mental health and substance use problems in disaster-affected populations: a pilot feasibility study

Early interventions that reduce the societal burden of mental health problems in the aftermath of disasters and mass violence have the potential to be enormously valuable. Internet-based interventions can be delivered widely, efficiently, and at low cost and as such are of particular interest. We describe the development and feasibility analysis of an Internet-delivered intervention designed to address mental health and substance-related reactions in disaster-affected populations. Participants (n = 285) were recruited from a cohort of New York City-area residents that had been followed longitudinally in epidemiological research initiated 6 months after the terrorist attacks of September 11, 2001. The intervention consisted of 7 modules: posttraumatic stress/panic, depression, generalized anxiety, alcohol use, marijuana use, drug use, and cigarette use. Feasibility data were promising and suggest the need for further evaluation.