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Determine the Pathways by Which the Identified Problem Occurs

A fourth consideration is to determine the primary pathway(s) by which a problem occurs. This necessitates identifying relevant and available theoretical or conceptual frameworks and examining if there is empirical evidence as to what contributes to the identified problem area. This in turn will help to explain how and why an intervention may have an impact on the outcomes being targeted, in subsequent evaluative phases.

Typically, multiple factors contribute to complex behavioral and health problems such as chronic disease, delirium, school-related problem behaviors, or social isolation. For example, falls are due to multiple causes including poor balance, environmental factors, sensory changes, certain medications and/or their combination, and a fear of falling. Hence, preventing or reducing falls requires a multifactorial approach to impact the different implicated pathways (Eldridge et al., 2005; Gillespie et al., 2012).

Similarly, complex health and social problems may require what is referred to as a “multimodal” approach. This would entail an intervention that combines different strategies that work through different modalities or pathways to achieve a desired outcome. For example, let’s say of interest is improving lifestyle behaviors in middle-aged adults to reduce the risk of heart disease. A combination of approaches that impact different pathways contributing to risk of heart disease would be necessary; this might include physical exercise to improve physical strength and aerobic capacity; health eating habits to reduce fat and cholesterol levels; cognitive techniques to improve reframing daily habits and associated stressors; and stress reduction techniques to reduce situation stress.

Accordingly, it may be necessary to draw upon more than one theory base to understand complex problem areas that are being targeted for intervention (see Chapter 4 on theory). Furthermore, as problems occur within contexts, structures, and/or organizations, drawing upon organizational or systems theories or theories of implementation (see Chapter 19) may help to identify the contextual forces or factors that serve to perpetuate the problem area.

For the ABLE Program, several frameworks, the Disablement Model (Nagi, 1964; Verbrugge & Jette, 1994) and Motivational Theory of Life-Span Development (Heckhausen & Schulz, 1995; Heckhausen, Wrosch, & Schulz, 2010), were used to understand the primary pathways by which functional limitations have negative sequelae for older adults and impact daily quality of life. The Disablement Model suggests that intrinsic (e.g., cognitive and behavioral) and extrinsic (home environment) factors contribute to poor functional outcomes. Briefly, the Motivational Theory suggests the use of control-oriented strategies (e.g., compensatory techniques, seeking help, and using environmental adjustments) to accomplish meaningful activities and to exert control over behavior-event contingencies. Thus,

ABLE targeted both: extrinsic housing features that served as a barrier to daily performance through the provision of home modifications and assistive devices; and intrinsic coping strategies through the instruction in positive problem solving and cognitive reframing techniques as well as in the use of compensatory behavioral strategies (e.g., sit to perform meal preparation). A single bullet approach such as only improving home safety would not have resulted in the same desirable and expected outcomes.

Identifying the primary pathway(s) of the problem at the discovery phase will subsequently shape the level of complexity, content, and delivery characteristics of an intervention (see Chapter 5 on delivery characteristics).

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