Health Education &

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

Health Education Programs
L. Kay Bartholomew, Guy S. Parcel and Gerjo Kok
Health Educ Behav 1998 25: 545
DOI: 10.1177/109019819802500502

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Perspective

Intervention Mapping: A Process for

Developing Theory- and Evidence-Based
Health Education Programs
L. Kay Bartholomew, EdD, MPH
Guy S. Parcel, PhD
Gerjo Kok, PhD

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.

INTRODUCTION

Background
The purpose of Intervention Mapping is to provide health education program planners
with a framework for effective decision making at each step in the intervention develop-

L. Kay Bartholomew is assistant professor of behavioral sciences at the Center for Health Promotion
Research and Development, University of Texas Health Science Center, Houston. Guy S. Parcel is director of
the Center for Health Promotion Research and Development and the John P. McGovern professor of health
promotion at the University of Texas Health Science Center, Houston. Gerjo Kok is the dean of the Faculty of
Psychology, University of Maastricht, the Netherlands.
Address reprint requests to L. Kay Bartholomew, EdD, MPH, Center for Health Promotion Research and
Development, The University of Texas Health Science Center at Houston, P.O. Box 20186 (W-902), Houston,
TX 77225; phone: 713-500-9630; fax: 713-500-9602; e-mail: lkb@utsph.sph.uth.tmc.edu
We wish to thank Jennifer Conroy for editorial assistance with this article, and Drs. Patricia Mullen, Janet
Groff, Herman Schaalma, and Nell Gottlieb for assistance in review and teaching of the intervention mapping
process.
Health Education & Behavior, Vol. 25 (5): 545-563 (October 1998)
© 1998 by SOPHE
545

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546 Health Education & Behavior (October 1998)

ment process. The steps and procedures included in Intervention Mapping provide a
system for the integration of theory, empirical findings from the literature, and informa-
tion collected from the target population. These information resources are not new to the
experienced health educator. However, a framework for using them in a systematic
sequence of steps and tasks that guide intervention development represents an innovation
for the practice of health education. The origins, purpose, and description of Intervention
Mapping are presented as an introduction to the framework.
The practice of health education involves three major program planning activities:
conducting a needs and capacity assessment, developing and implementing a program,
and evaluating the program's effectiveness. Over the past 20 years, significant enhance-
ments have been made to the conceptual base and practice of health education, especially
in needs assessment and program evaluation.`3 The health education community has been
slower to specify the processes involved in program design and development. Advances
have been made in the application of behavioral and social science theories to intervention
design,4'5 but even in this regard, the application processes involved are not typically made
explicit in the research or practice literature.
In addition to models for conducting a needs assessment and program evaluation, the
literature provides ecological models for conceptualizing the multiple levels of health
education intervention,67 but it lacks specific models for program development. In our
experience, students have been able to understand theories of behavior and social change,
but often have not been able to use them to design a coherent, practical health education
intervention. Students frequently ask: When in the planning process do I use theory to
guide my decisions? How do I know what theory to use? How do I make use of the
experience of others and the results of other program evaluations? How do I decide what
intervention methods to use? How can I get from program goals and objectives to the
specific intervention strategies for the program participants? How do I link program
design with planning for program implementation? How do I address changing the
environment especially when behavior change interventions directed toward the at-risk
population would not be ethical or effective?
Motivated by these questions, we began to examine programs developed in our work
as researchers and practitioners and to identify the general principles and procedures we
had used in their development. One of our early case examples was the Cystic Fibrosis
Family Education Program, 8-13 an intervention to improve the self-management behavior,
health, and quality of life of cystic fibrosis (CF) patients and their families. This example
served as an important vehicle in the delineation of Intervention Mapping steps, and we
refer to it to demonstrate the framework.
To substantiate the steps of Intervention Mapping and to further delineate the tasks
required for each, we then conducted a retrospective review of several large demonstra-
tion projects in the United States and elsewhere.""24 This review led to a working
framework for health education program development. To further evolve the steps of the
framework, we used Intervention Mapping prospectively to plan health education pro-
grams. Long Live Love (an HIV-prevention program for Dutch adolescents), the Asthma
Partnership System (a computerized self-management program for children with asthma),
and Five a Day (a nutrition education program for 9- to 12-year-old girls) are among the
projects used to test, revise, and refine Intervention Mapping steps and tasks.2530 Addi-
tional experience with and refinement of the Intervention Mapping framework has
occurred throughout the course of 5 years of graduate instruction in health promotion
planning and implementation at the University of Texas School of Public Health, at the
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 Bartholomew et al. / Intervention Mapping 547

School of Health Sciences, University of Maastricht, The Netherlands, and through

outreach courses conducted in the United States and other countries.

Intervention Mapping Overview

Analogous to geographic mapping, Intervention Mapping enables the planner to
discover relations, locate desired destinations, plan a route for getting from one place to
another, and execute the plan. It also has a visual component including numerous
diagrams and matrices used as landmarks for logical program development. Unlike a road
map, however, the framework is iterative; the planner is expected to return to early
planning steps as insights are gained and as the effects of early decisions on subsequent
steps are experienced.
Intervention Mapping is intended to make the steps in planning interventions explicit
enough to demystify the process to facilitate collaborative planning by individuals of
varying backgrounds. The philosophy of health education and promotion is built on the
principle of self-determination of individuals and communities.' The field has a history
of community participation in program development, and currently, there is considerable
work taking place on the empowering or capacity-building effects of participation on
health.3'134 We describe program development as requiring a linkage between a resource
system (developers), an intermediate user system (implementers), and an end user system
(program participants).35'3" The linkages can span the range from inclusion of prospective
program participants and intermediate users as planning team members, through a
community empowerment model in which the community members are the planners.
Intervention Mapping is one part of dynamic health promotion intervention planning.
The planning process always begins with a needs assessment in which the health educator
collaborates with the community or population group that is experiencing (or at risk for)
a health problem and related quality of life consequences, to develop a description of
both. The assessment (which should use theory and both qualitative and quantitative data)
also includes an analysis of behavioral and environmental causes of the problem(s); a
preliminary description of what is known about determinants (or predictors) of the
behavioral and environmental causes; and the resources of the community.1,37-42 The
purpose of the needs assessment is to provide a comprehensive assessment of the health
problem and its causes. Based on this description, program goals specify desired change
in health status, quality of life, behavior, and environmental conditions. Completion
of the needs assessment provides the foundation from which to begin intervention
development.
The steps of the Intervention Mapping framework are illustrated in Figure 1. Each step
requires performance of several specific tasks leading to a product that provides the basis
for the subsequent steps. The result is the intervention "map," consisting of matrices and
plans that guide the design, implementation, and evaluation of an intervention. The five
fundamental steps of the Intervention Mapping process are (1) creating matrices of
proximal program objectives from performance objectives and determinants of behavior
and environmental conditions, (2) selecting theory-based intervention methods and
practical strategies, (3) designing and organizing programs, (4) specifying adoption and
implementation plans, and (5) generating an evaluation plan. Before we explain the steps,
we will describe the core processes for Intervention Mapping: searching empirical
findings from the literature, accessing and using theory, and collecting and using new
information from the target population.

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 548 Health Education & Behavior (October 1998)

M-

Identify the at-risk

population, quality of life
Distinguish environmental and health problems
Review key and behavioral causes
determinants

INTERVENTION MAP
Outcomes Tasks
Proximal Program * specify the performance objectives
Objectives Matrices * specify important, changeable determinants
* differentiate the target population
* create matrices of proximal program objective
T heoretical * brainstorm methods to achieve proximal
Methods and program objectives
Practical Strategies * use the theoretical and empirical literature to
further delineate the methods
* translate methods into strategies
Program Design * operationalize the strategies into plans
I_ considering implementors and sites
__
* design instruction materials
* pretest instruction materials with the target
group
* produce the materials

Adoption & * develop a linkage system

Im plem entation * specify adoption and implementation
Plan performance objectives
* specify determinants of adoption and
implementation
* writean implementation plan

Monitoring & * develop an evaluation model using

Evaluation Plan information from the previous steps of
Intervention Mapping and information
from the needs assessment.
* develop effect evaluation questions, referring
to the matrices of proximal program objective
as blueprints for instrument development.
* develop process evaluation questions from
the needs assessment and intervention map.

I
p

I-

Figure 1. Steps of the Intervention Mapping framework.

CORE PROCESSES FOR INTERVENTION MAPPING

Intervention development requires a thorough understanding of the problem using
theory and empirical evidence to specify determinants of behavior and environmental
conditions and to propose a change process. However, the literature and practitioners
report difficulty in applying theory.43,' In most health education training, students learn
selected theories and their application to a few problems, in that order: theory to
application.45 This approach does not meet the needs of practice where the starting point

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 Bartholomew et al. / Intervention Mapping 549

for the development of behavior and environmental change interventions is the practical
problem. The health educator must define questions related to the problem and select
theories and data to answer these questions.
Intervention Mapping steps provide a framework for asking "why" or "how" questions
about determinants of behavior and environmental conditions, subgroups of the target
population, behavior and environmental change methods and strategies, and program
adoption and implementation. For example, a question regarding determinants is "Why
do adolescents fail to use condoms during sexual intercourse?" A question regarding
methods is "How can self-efficacy for using condoms be increased?" Brainstorming
techniques help the planner uncover provisional answers to the planning questions, which
are listed and then refined using multiple approaches to literature review and information
gathering from the target population.46'47

Searching the Literature for Empirical Findings

Once a question is posed and a provisional list of answers is made, a planner focuses
on the topic at hand and searches the literature for empirical findings. What have others
found about the causes or solutions to a specific problem, for example, failure to use child
safety restraints? In this topical approach to the literature, broadening the topic to include
related issues and target populations is important, for example, reviewing what is known
about seat belt use. From this topical review, the provisional list of answers to the posed
question is refined. Often, however, in this initial review, there is inadequate theoretical
perspective and the planner must go further to search for theory useful in addressing the
question.

Accessing and Using Theory

The planner can use three approaches, issue, concept, and general theories, to search
the literature for applicable theories.4647 The issue approach is much like the topical
review. It focuses on the problem at hand and guides the search for theory dealing with
the issue. For example, in self-management of CF, the issue approach leads to a search
for theories that address the self-management of chronic illness, such as asthma or
diabetes. Using this approach, the planner may encounter the use of a specific theory such
as self-regulation applied to chronic disease.48
The concept approach begins with the concepts in the provisional answers from
brainstorming, which lead to theoretical constructs and to evidence ofthe relation of those
constructs to the behavior of interest. If, for example, behavioral capability (i.e., knowl-
edge of what to do and how to do it) for providing treatments were on the provisional list
of answers to a question about determinants of self-management of CF, a literature search
for this construct would yield social cognitive theory49and related constructs of skills,
self-efficacy, and outcome expectations-constructs that might also be helpful in under-
standing self-management of CF.
Using the general theory approach begins with a question regarding determinants,
intervention, or implementation and considers general theories that might be applicable.4
For example, for a question concerning adolescents and condoms, a planner might
consider the theory of planned behavior5s in the unlikely event that this theory had not

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550 Health Education & Behavior (October 1998)

already been encountered through the issue or concept approaches. Or, if the question
concerned program adoption and implementation, diffusion theory would be a logical
place to search.5' Once one or more general theories are selected, the planner considers
the applicability of each of the specific theoretical constructs or processes to the specific
question.

Collecting and Using New Data

At this point, it is also important to identify gaps in the information obtained. For
example, after planners have discovered determinants of a certain behavior from the
literature, both quantitative and qualitative methods are used to verify the determinants
in the target population and to explore their idiosyncratic expression. Aqualitative method
such as interviews or focus groups can be used to find out the target population members'
views about determinants of their behavior, and then a quantitative method such as a
structured questionnaire can assess the prevalence and strength of the determinants. Data
collection with the target population and implementers also is necessary for questions
other than those regarding determinants, such as questions about methods and program
implementation.
In searching the literature and collecting new data, evidence is used to confirm whether
certain theoretical and atheoretical concepts from the provisional list are supportive of
hypothesized determinants or intervention methods. Through this process, the planner
adds to and deletes from the list of determinants or methods. The ultimate objective of
integrating existing theory and empirical evidence is to tighten the provisional list of
determinants into a final, plausible, and empirically supported causal model for explain-
ing and changing factors that influence behavior and environmental conditions that cause
health and quality of life problems.

THE STEPS OF INTERVENTION MAPPING

Intervention Mapping, Step 1: Proximal Program Objectives

Step 1 provides the foundation for the steps that follow by specifying proximal
program objectives. These objectives explicate who and what will change as a result of
the intervention. We use the term proximal program objective to distinguish the product
of step 1 from the many other uses in the literature of the term "objective." The products
of step 1 are matrices containing cells created by the intersection of behavioral or
environmental performance objectives with the theoretically and empirically based,
important and changeable determinants of a behavior or environmental conditions. Each
cell contains a statement, called a change objective, which specifies what individuals need
to learn or what must be changed in the organizational or community environment as a
result of the program. As the most immediate objectives to be addressed by the interven-
tion, these proximal program objectives represent the starting point for change, leading
to accomplishment of the performance objectives and eventually changes in behavioral
and environmental outcomes.

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 Bartholomew et al. / Intervention Mapping 551

Task 1.1, Writing Performance Objectives

This task begins with refraining problem behaviors and environmental causes of health
problems from the needs assessment as desirable behaviors and environmental outcomes.
Performance objectives answer two categories of questions in specifying health-promoting
behavior and environment. First, behavior: What do the participants in this program need
to do to perform the health-related behavior? Second, environment: What will change in
the environment as a result of the program, and who will effect the change? In response
to these questions, effective performance objectives break down the health-promoting
behavior and the desired environmental conditions into clear, concise statements that
describe the criteria for achieving the desired change. For a program designed to increase
the consumption of fruits and vegetables, "eat more fruits and vegetables" is not specific
enough to be an effective performance objective. Useful performance objectives specify
a list of more detailed subbehaviors such as "substitute fruits or vegetables for junk food
snacks after school." Other performance objectives would pertain to changes in the
environment, such as "the school cafeteria manager will increase the fruit and vegetable
choices in the school lunch menu of each school day." Writing performance objectives
often alerts the planner to the need for target population differentiation-the third task in
step 1.

Task 1.2, Specifying Determinants

This task continues from the needs assessment specification of determinants of the
behavioral and environmental causes of health problems. The core processes (discussed in
the preceding section) are used to specify determinants of the stated performance objectives
for the health-promoting or risk-reducing behaviors and environmental conditions.
Determinants can be personal determinants, influencing factors that rest within the
individual (i.e., cognitive factors), or external determinants, influencing factors outside
the individual (i.e., social and structural factors). Several questions are instrumental in
refining the list of determinants: "What factors have been found to be related to the health
behavior(s) or environmental condition(s) that cause the health problem in the population
at risk?" "How strong is the empirical evidence or theoretical reasoning linking the factors
to the behavior or condition?" "What is the evidence that the determinant can be changed
and that the determinant change will lead to a change in the behavior or environmental
conditions?" "Which may be most successfully changed via health education and promo-
tion methods?" The final stage of refinement of the determinants is to narrow them to the
most important (i.e., most closely related to the behavior or condition) and the most
changeable. For the Cystic Fibrosis Family Education Program, we found evidence of
the usefulness of a social cognitive theory framework for chronic disease managemene5-57
and hypothesized behavioral capability, self-efficacy, reinforcement, and outcome expec-
tations" as determinants of the performance objectives.

Task 1.3, Differentiating the Target Population

This task is necessary if performance objectives or determinants of the performance

objectives differ by subgroup. The following variables, among others, can influence

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552 Health Education & Behavior (October 1998)

decisions about appropriate performance objectives and determinants: age and psycho-
logical development, socioeconomic status, race/ethnicity, previous exposure to a behav-
ior, and theoretical variables such as stage of change.52 Differentiation is done only if
separate matrices of proximal program objectives are needed to assure that the program
is based on the correct performance objectives and determinants for a target group. For
example, in the CF program, we differentiated based on developmental stage of the child,
since the performance of CF self-management varies vastly with the child's age, and
separate matrices are needed (see Table 1). Separate matrices are also needed for parents
and health care providers because performance objectives will be different than the
performance for the patients.
Other ways of distinguishing the target population may be necessary in later stages of
Intervention Mapping but should not be confused with differentiation. Target population
segmentation (grouping the target population by variables such as preferred communica-
tion network that will influence the effectiveness of a message)53 and message tailoring
(the use of computer technology to individualize intervention messages based on mea-
sured characteristics)54 can both be used in later Intervention Mapping steps for selecting
methods and strategies.

Task 1.4, Developing a Matrix of Proximal Program Objectives

The last task in Intervention Mapping, Step 1, combines performance objectives with
determinants to create the proximal program objectives that are the foundation for
designing the intervention. Programs may require multiple matrices: (1) an individual-
level matrix that links the target group health-promoting behavior performance objectives
with determinants, (2) an organizational-level matrix that links environmental perfor-
mance objectives for organizational changes with determinants, and (3) a community-
level matrix that links environmental performance objectives for community changes
with determinants. The number of matrices may be expanded if the target population was
differentiated in the previous task (1.3). Two types of objectives are possible in the cells
of each matrix: (1) learning objectives, which are the union of a performance objective
and a personal determinant in response to the question "What do the participants in the
program or in the environment need to learn to achieve the performance objective?" and
(2) change objectives, which are the union of a performance objective and an external
determinant in response to the question "What needs to be changed related to an external
determinant to accomplish the performance objective?" The answers to the questions
posed above appear in the cell at the intersection of a performance objective and a
determinant. Objectives are only stated for cells whose determinant is important to the
accomplishment of the performance objective. An example of part ofa behavioral matrix
is included in Table 2.
The organizational- and community-level matrices are used to address the perfor-
mance objectives for the environmental conditions. The environmental matrix is different
from the behavioral matrix because all the environmental conditions related to a health
problem are not usually mediated by a single person or by the at-risk target group.
Depending on the nature of the objective, different individuals or groups will be expected
to carry out the environmental performance objectives, and each environmental perfor-
mance objective should specify the person or group that is expected to perform the
environmental change. For example, in planning for a reduction of fat intake among

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 Bartholomew et al. / Intervention Mapping 555

school children, performance might be specified for both parents and school cafeteria
managers to influence a change in availability of high-fat foods at home and at school.'6

Intervention Mapping, Step 2:

Theoretical Methods and Practical Strategies
Intervention methods have their origins in behavioral and social science theories, and
they directly effect changes in behavior of individuals and groups, as well as indirectly
effect behavioral change through determinants. Examples of intervention methods com-
monly used in health education and promotion include community empowerment,
modeling, skill development, contracting, incentives, social reinforcement, persuasive
communication, reattribution training, social support, community planning, and organi-
zational change.
Whereas a method is a theoretically or empirically derived generalized technique used
to directly influence determinants of behavior or environmental conditions, a strategy is
a practical way of organizing and delivering the intervention method. Examples of
strategies designed to accomplish methods include the strategy of community meetings
for the method of persuasive communication, group meetings for problem solving, diaries
for self-monitoring, self-talk for cognitive behavioral restructuring, support groups for
social support, role-model stories for symbolic modeling, and role playing for skill
practice.
The goal of Intervention Mapping, Step 2, is to generate a list of intervention methods
that are matched to the proximal program objectives stated in the matrices from step 1
and to think of practical and appropriate ways of delivering those methods to the target
groups. Often during planning, health educators have creative ideas about strategies, but
they neglect the consideration of the methods that produce change. This step guides
planners to be specific about what methods are "housed" in the program strategies.

Task 2.1, Brainstorming Methods

This task begins the application of the core processes to generate a provisional list of
theoretical methods that seem likely to influence the learning and/or change objectives
related to each determinant. The question to ask is "How can change in the determinant
be influenced to accomplish the proximal program objectives?" From the cystic fibrosis
program matrix, for example, we asked "How can parents' self-efficacy for observing
sputum to monitor for lower respiratory infection be increased?"

Task 2.2, Delineating Methods

This task extends the application of the core processes to search the empirical literature
and to use the issue, concept, and general theories approaches to make a working list of
methods. The planner also judges the evidence to support the potential of the methods on
the provisional list to produce change as well as to assure that the parameters within which
particular methods can be expected to work are considered. For example, if modeling is
identified as a method, one would need to know (1) whether modeling has been found

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556 Health Education & Behavior (October 1998)

effective in producing the desired change and (2) what type of role model could be
expected to work to model certain behaviors in certain target groups.
In the CF program, methods included symbolic modeling, goal setting, self-monitoring,
reinforcement, skill training, problem solving, persuasive communication, cognitive
rehearsal, and knowledge acquisition. These methods were intended to influence the
proximal program objectives depicted in Table 2.

Task 2.3, Translating Methods Into Strategies

This task encompasses the determination of ways each method can be used with the
specific target group. In making a choice among strategies, the health educator thinks
about delivery and whether the target population would be willing to participate in the
strategy and would find it acceptable. For example, adolescents with CF were unwilling
to participate in group meetings; therefore, the method of modeling was delivered via
news magazine print format using role model stories from adolescents with CF.

Intervention Mapping, Step 3:

Design Program
The product of step 3 is a plan for the production and delivery of an organized program.
The linkage system developed with the program adopters and implementers as well as
the target population as described in the section Intervention Mapping Overview is an
important source for identifying and testing program components. In step 3, the planner
uses qualitative methods such as focus groups to assure that the proposed strategies and
program components are salient and acceptable to both implementers and participants.
Movement back and forth between this task and step 4 (Adoption and Implementation)
is required.

Task 3.1, Operationalizing the Strategies

This task constitutes the organization of strategies into a deliverable program with
discrete components and mechanisms for their delivery. In this task, planners specify
scope and sequence for the components. The plan specifies intervention strategies as well
as channels of delivery (interpersonal, mediated, or a combination), and a delivery system
(how each part of the program will reach the target group, e.g., radio public service
announcements, newsletters, videotape, a lesson delivered by a classroom teacher).

Task 3.2, Designing Program Materials

This task creates planning documents such as script treatments and story boards to
describe fully to producers the characteristics of each product for each program compo-
nent. Working documents express the messages, themes, and motifs of each product in a
way that can guide whoever is going to produce the materials (e.g., health educators,
designers, videographers, artists, printers).

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 Bartholomew et al. / Intervention Mapping 557

Task 3.5, Producing or Choosing and Pretesting Materials

This task requires working from the planning documents produced in the previous step
to produce draft or pilot versions ofeverything to be used in an intervention. In these days
of videocams and desktop publishing, health education planners often have considerable
production capability. This can be particularly helpful when producing pilot materials,
because pilot testing can occur in several stages, for example, first testing individual
messages and images before testing an entire product. Final pretesting of a final product
in the context of its proposed use should be done when materials are as close as possible
to the finished product. The pretest requires new representatives of the target group, and
not persons on the development team whose representativeness of the target population
may have been changed. Testing can be accomplished with focus groups, interviews, and
consultant teams of target group members, and in a trial implementation.59

Intervention Mapping, Step 4:

Adoption and Implementation

A solid diffusion process is vital to ensure program success. Several stages are integral
to the diffusion process: dissemination, adoption, implementation, and mainte-
nance.3649516061 For each stage, the planner must identify a target group for which
adoption, implementation, and maintenance outcomes can be stated and determinants
selected. The product of this step is a detailed plan of what needs to be done to ensure
delivery of the program at acceptable levels of completeness and fidelity.

Task 4.1, Developing a Linkage System

Developing a linkage system, mechanisms to involve program adopters and imple-

menters, actually is best done when the health educator first begins a project. But, because
adoption and implementation fits logically in the planning process, it is described here.
A linkage system comprises opportunities for program users to adapt the intervention to
their own organizational objectives, and it engenders feelings of program ownership
among the people who will be making the decision to use the program and the people
who will run the program day to day.36 For example, the linkage system for the CF
program included involving care givers in the planning team and in a network of regional
coordinators for the diffusion to CF Centers throughout the United States and Canada.6'
The coordinators trained program champions62 to conduct team review and adaptation of
the program in each care center to create feelings of program ownership. The center teams
then created an individualized implementation plan to accommodate its goals and patient
care routine.

Task 4.2, Specifying Adoption and

Implementation Performance Objectives
This task requires the planner to delineate what decision makers need to do to assure
program adoption and what individuals who are implementing the program need to do to
assure reliable and appropriate implementation. Two examples of performance objectives

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558 Health Education & Behavior (October 1998)

for implementation of the CF program were that the health care providers will (1) work
together to design an implementation plan for the program, including forming an
implementation team, scheduling team meetings, and creating workflow and documen-
tation plans, and (2) integrate discussions of families' use of the programs as a routine
part of rounds and case meetings.

Task 4.3, Specifying Determinants

of Adoption and Implementation
This is similar to the earlier specification of determinants of behavior and environ-
mental conditions (step 1, task 1.3). For example, hypothesized determinants of adoption
of the CF program by caregivers included existence of a program champion, awareness
of the program, outcome expectations that the program positively influence patient care,
and self-efficacy for encouraging adoption.62

Task 4.4, Writing an Implementation Plan

This task requires the planner to describe in detail the methods and strategies to be
used to promote dissemination, adoption, implementation, and maintenance of the
program. The methods and strategies are matched to the performance objectives and
determinants specified in previous tasks.

Intervention Mapping, Step 5:

Monitoring and Evaluation
The products of the steps of Intervention Mapping are not only the basis for interven-
tion development; they are tools for evaluation of the process and effects of the interven-
tion. The product of this step is a plan for evaluating the impact of the intervention on
determinants, behavior, and environmental conditions, and on health and quality of life
outcomes. In this step, the health educator or evaluation researcher also creates measure-
ment instruments from the matrices of proximal program objectives. The performance
objectives provide a basis for measuring behavior and environmental outcomes. The
determinants identify the constructs to be measured, and the change objectives provide
content items to form measurement scales. Intervention Mapping enables thoughtful
formative evaluation to ascertain to what degree the decisions, assumptions, and expec-
tations of the intervention map have been realized and whether program changes are
needed.

Task 5.1, Developing an Evaluation Model

This task uses objectives from both the needs assessment and Intervention Mapping.
Intervention Mapping is a stepwise process that results in a logic model from design and
correct execution of an intervention, to change in proximal program objectives, determi-
nants, behavior, and environmental conditions, to change in health and quality of life.
The evaluator includes indicators of these variables and their intended relations in an

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 Bartholomew et al. / Intervention Mapping 559

evaluation model. The time frame for expected change is an important part of the model.
For example, CF is a disease that causes a usually slow decline in lung function mediated
by many physiological and external factors. Therefore, health changes resulting from the
self-management program could be expected to occur and be measurable over a 5- to
10-year time frame rather than the 2 years allotted for the program evaluation.

Task 5.2, Measuring Process and Effect

This task, like the evaluation model, is based on the measurable goals and objectives
from the needs assessment (health, quality of life, behavior, and environmental condition
indicators) and Intervention Mapping (performance objectives for behaviors and envi-
ronmental conditions and proximal program objectives). In this task, the matrices of
proximal program objectives form the blueprints, column by column, for the measures
of determinants. For example, in the CF program, we developed measures of behavioral
capability, self-efficacy, and outcome expectations by working from the determinant
columns of the matrix of proximal program objectives to select content of items for
measures of the constructs defined by the determinants. Assumptions related to theoretical
methods, practical strategies, and the implementation plan also can be assessed in
formative and process evaluation through both qualitative and quantitative methods to
study the rate of program dissemination, adoption and implementation, participant
exposure, and both program user's and participant's reaction to the program.

DISCUSSION

In the past two decades, health education and related fields have adopted more
sophisticated planning processes, including the needs assessment process, multilevel
interventions, the application of theory in understanding the determinants of behavior and
behavior change, and assuring adequate program implementation. There remain, how-
ever, gaps in explanation of how to integrate the wealth of information, theories, ideas,
and models to develop interventions. Intervention Mapping is a comprehensive approach
to health education planning that links intervention development and design with needs
assessment, program implementation, and evaluation.
Practitioners of health education and promotion approach intervention and the use of
theory in a way that is fundamentally different from either the theory generation or single
theory testing often done by scientists. A health educator needs to be able to confront a
problem and bring to it multiple theoretical and experiential perspectives, rather than
define a practice or research agenda around a theoretical approach. Understanding the
problem should begin with a specific health or social issue; the health educator then
accesses social and behavioral science theories of causation at multiple levels, which in
turn suggest intervention methods. Intervention Mapping provides a detailed framework
for this problem-oriented use of theory with the matrix of proximal program objectives
as the focal point for the integration of theory with desired behavior and environmental
changes.
One of the potential drawbacks to any planning model is that it will be used as a
cookbook. Intervention Mapping is intended as a framework that will enable a thoughtful,
iterative, and interactive approach to intervention. In our experience, the products of each
step communicate the foundation of the intervention clearly enough to engender partici-
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560 Health Education & Behavior (October 1998)

pation by team members with widely divergent backgrounds. The iterative nature of the
process enables thoughtful planners to incorporate a wide range of contributions and to
allow decisions to stimulate return to and reconsideration of earlier steps. Planners,
production staff, and program users can have a clear picture of what the program is
expected to accomplish and how the program will work to obtain the expected outcomes.
This planning process recognizes the equal importance of behavioral and environ-
mental factors to health. The planner should use the framework to place as much emphasis
on changing the environment as judged to be warranted by the nature of the problem. In
fact, some problems may require an intervention that is entirely focused on changing
environmental conditions. The only prerequisite is that there is a careful analysis of who
is responsible for environmental change, what will determine that change, and how
methods and strategies are expected to influence those determinants.
As researchers and developers of demonstration projects, we use the Intervention
Mapping framework to design evaluation studies and measurement instruments. It can
be especially useful in guiding the formulation of health education research and clarifying
the conceptual basis for experimental interventions in multidisciplinary teams where not
all members are fluent in behavioral and social science methods. Furthermore, the
intervention map can also serve as a basis for analyzing possible causation of program
failure. As with a road map, the planner can at any point in the process determine where
he or she took a wrong direction and correct the route.

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