Poorly designed interventions can waste resources (Moore et al., 2019): Despite the effort expanded by health professionals and clients in carrying them out, the interventions are not useful in preventing, managing, or resolving the health problem. Therefore, it is essential to carefully design health interventions in order to improve their success in addressing the health problem. 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. 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. 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. 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. 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. 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. 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. The attributes of the health problem are the indicators of its presence and distinguish it from other problems. The attributes are described in terms of the type and level of indicators that define the problem, as well as the severity and duration with which the problem is experienced. Indicators reflect how the problem is manifested. They are the particular alterations or changes in structure or function that point to the presence of the problem. The indicators may be objectively observed (i.e. signs) or subjectively reported (i.e. symptoms). For example, difficulty initiating sleep (i.e. falling asleep) and maintaining sleep (i.e. staying asleep) are two indicators of insomnia. It is important to note that the experience of the indicators may vary within and across client populations. The variation may be associated with different client characteristics such as age, gender, and culture. For example, the indicators of insomnia vary with age: Middle‐aged persons frequently report experiencing difficulty falling asleep, whereas older persons frequently report difficulty staying asleep (Sidani et al., 2018a). The identification of the indicators can be supplemented by the specification of the level at which they are experienced in order to operationally define the health problem. Level of experiencing the indicators is reflected in a range of values or cutoff scores that should be observed or reported to indicate the presence of the problem. For example, difficulty falling asleep and/or staying asleep may be experienced by anyone, under a wide range of circumstances (e.g. clients may not sleep well a few days before surgery). To indicate the presence of insomnia, these sleep difficulties or disturbances should occur for 30 minutes or more per night, over at least three nights per week. Severity refers to the intensity with which the health problem is experienced. It has to do with “how badly,” serious and/or distressing the problem is. The level of severity can be objectively assessed (e.g. level of dependence in performance of activities of daily living, or number of cigarettes smoked) or subjectively rated for its distress or burden by clients, using relevant measures and rating scales. For example, the Insomnia Severity Index assesses clients’ perception of how distressing their sleep problem is, and how much it interferes with daytime functioning; the total score quantifies the level of insomnia severity (Morin et al., 2011). Duration refers to the time period over which the health problem is experienced. It determines the acuity or chronicity of the problem, which may be associated with different sets of contributing factors. For example, the experience of the sleep difficulties as described previously, over at least three months, indicates the presence of chronic insomnia, which is primarily associated with sleep‐related behaviors; acute insomnia is experienced as a result of life events. Generating a list of indicators, describing each indicator accurately, and specifying the severity and duration of the health problem’s experience are important. A critical analysis of the indicators points to those that are amenable to change and for which interventions or components of an intervention can be designed to directly address them and, hence, contribute to the management or resolution of the problem. For example, dyspnea is manifested by rapid short breathing, suggesting that clients can be instructed to perform deep breathing exercises to control this specific indicator of dyspnea. The severity and duration of the health problem’s experience inform the identification of factors that contribute to the problem. Generating a comprehensive understanding of the health problem requires the identification of influential factors and the delineation of their inter‐relationships with the problem. Causative factors, risk factors, or determinants of the health problem are circumstances, events, conditions, or capabilities that contribute to its experience. It is now well recognized that multiple factors, taking place at different levels, conduce to the occurrence (e.g. Aráujo‐Soares et al., 2018; Golfam et al., 2015) or maintenance (e.g. Glanz & Bishop, 2010) of a particular problem. The factors exhibit in any domain of health and life, at the intrapersonal, interpersonal, social, and environmental levels (Bartholomew et al., 2016). Intrapersonal factors include biological characteristics (e.g. sex and age) and physiological, physical, behavioral, psychological, and cognitive conditions. Interpersonal factors entail challenges in the relationships between individual clients and others in their immediate environment (e.g. home, work) and the availability or accessibility of resources and support. Social factors relate to beliefs, values, and norms commonly held by a group or community. Environmental factors represent features of the physical, socioeconomic, and political setting or context in which clients reside (Craig et al., 2018). In addition to identifying the types and levels at which the factors occur, it may be useful to (1) categorize them into factors that contribute to the development or to the maintenance of the health problem (Butner et al., 2015; Glanz & Bishop, 2010); (2) determine if and how they are inter‐related and (3) if they vary across populations and time. Overall, the factors can be categorized into predisposing, precipitating, and perpetuating factors as was done for factors contributing to insomnia. In the real world, the determinants are interconnected, forming a web of factors contributing to the experience of the health problem. The determinants can co‐occur simultaneously or sequentially, and interact with each other to produce the health problem. For instance, older persons are prone to arousability (i.e. light sleep), which may be exacerbated if they reside in a noisy neighborhood (simultaneous); they start drinking alcohol (sequential) thinking that it would help them sleep better; alcohol causes light sleep thereby further contributing to awakenings at night, and intensifies the effects of medications such as sleeping pills and other antidepressants (interaction). The specific determinants or combination of factors contributing to the health problem could vary across client populations or within the same population over time. For example, young and middle‐aged adults (compared to older adults) report difficulty falling asleep, which they attribute to stress related to daily life and work; the level at which they experience this sleep difficulty fluctuates over time as a result of changes in life and work events and clients’ use of effective strategies to promote sleep (e.g. engagement in relaxation). The identification and the specification of the inter‐relationships among determinants are essential for understanding why and how the health problem is generated and maintained. A critical analysis of the inter‐relationships (described in Chapter 4) assists in determining the factors that are and are not amenable to change (Aráujo‐Soares et al., 2018; Bartholomew et al., 2016; Fernandez et al., 2019; Lippe & Ziegelman, 2008). Factors that are malleable and have the greatest scope for change are targeted by the intervention (Wight et al., 2016); they inform the specification of its active ingredients. Factors that cannot be modified (e.g. personal and contextual characteristics) are considered as potential moderators, indicating the need for tailoring of the intervention (Fleury & Sidani, 2018). Consequences of the health problem represent complications that may arise if the problem is not effectively addressed. Complications are changes in condition resulting from the problem and interfering with clients’ general functioning, health and well‐being. Examples of consequences associated with insomnia include: physical and mental fatigue that limit physical and psychosocial functioning, which in turn, contributes to accidents. The experience of consequences may be the reason for which clients seek healthcare. As such, interventions are designed to address the health problem with the ultimate goal of preventing or minimizing the severity of its consequences. Once developed, the theory or logic model of the health problem is presented textually to detail the conceptual and operational definitions of the problem; identify and describe its determinants and consequences; and explain the proposed direct and indirect (mediated and/or moderated) relationships among them. The theory is also summarized in a table and its main propositions illustrated in a figure. Table 3.1 and Figure 3.1 illustrate the theory of insomnia. Different approaches can be utilized, independently or in combination, to gain an understanding of the health problem and generate a theory of the problem. The approaches include theoretical, empirical, and experiential. They reflect different logic and methods of reasoning: deductive (top‐down), inductive (bottom‐up), retroductive (backtracking process of logical inference going beyond an existing theory and empirical observations), and abductive (alternative explanation process). The approaches can be used independently. With the emphasis on evidence‐based practice, the empirical approach was considered the most robust. With the recent emphasis on client engagement in the design of health services and in research, and the widening recognition of the role of context in health and healthcare, the experiential approach has been increasingly advocated. Since each approach has its strengths and limitations, the use of a combination of approaches is recommended (e.g. Aráujo‐Soares et al., 2018; Bartholomew et al., 2016; Bleijenberg et al., 2018) to develop a comprehensive understanding of the health problem as experienced by the target client population in the respective context. The approaches and methods for applying them are discussed next. TABLE 3.1 Summary of the theory of insomnia. FIGURE 3.1 Representation of theory of insomnia. The theoretical approach relies on relevant theories to develop an understanding of the health problem requiring intervention. Middle range theories are most useful because they describe the health problem and explain its associations with determinants, within a particular context (Moore & Evans, 2017). Theories consist of a group of statements, based on careful reasoning and/or evidence that present a systematic and logical view of the health problem. The statements are logically organized to identify, define, and describe the problem and its determinants, and to explain the direct and indirect relationships among the determinants and the problem. The explanations clarify conceptually why and how the relationships come about, that is, what goes on that connects each determinant to the problem. For example, the following pathway explains the association between age and insomnia: As individuals age, they spend more time in light, than deep, stages of sleep; they are prone to arousability resulting in frequent awakenings during the night, manifested in difficulty maintaining sleep. A direct relationship reflects an immediate linkage between a determinant and the problem, where the problem flows straightforwardly from or is a function of the determinant. For example, there is a direct association between caffeine and nicotine intake close to bedtime and insomnia; caffeine and nicotine are stimulants that interfere with sleep. An indirect relationship can take either of two forms: mediated or moderated. The relationship between a determinant and the health problem is considered mediated when another factor intervenes between the two, whereby the determinant influences the mediator (also called intervening factor), which in turn affects the health problem (MacKinnon & Fairchild, 2009). For example, cognitions are erroneous beliefs, resulting from worry or rumination about sleep‐related issues such as inability to get eight hours of sleep and the negative impact of insomnia on daytime functions. These cognitions increase arousal and drive engagement in sleep behaviors in an attempt to alleviate arousal; however, these behaviors may be ineffective and the repeated experience of arousal in bed results in conditional arousal (i.e. associating the bed with wakefulness), which contributes to insomnia (Schwartz & Carney, 2012). The relationship between a determinant and the health problem is characterized as moderated when it is affected by another factor (also called moderator). The moderator is the condition (e.g. personal or environmental feature) under which the relationship exists, that is, the presence, strength or magnitude, and/or direction of the relationship between the determinant and the health problem vary according to the value of the moderator (Fleury & Sidani, 2018). For instance, gender could moderate the association between arousal and insomnia; women may experience life stress (because of multiple roles’ demands) and worry, which is likely to strengthen the relationship between arousal and insomnia if not well managed. A wide range of middle range theories are available and have been used to generate an understanding of health problems. Theories that have commonly informed the understanding of the occurrence of health behaviors (e.g. physical inactivity, diet, medication adherence) include the health beliefs model, the transtheoretical model, social cognitive theory, social ecological model, and theory of planned behavior (Beall et al., 2014; Durks et al.m 2017; Fassier et al., 2019; Glanz & Bishop, 2010; Lamort‐Bouché et al., 2018). Other theories include self‐determination theory and self‐regulation theory (e.g. Muellmann et al., 2019). Cognitive theories have been used to understand some psychological health problems such as depression (Vittengl et al., 2014) and insomnia (Harvey et al., 2007). Kwasnicka et al. (2016) reviewed theories that explain how behaviors are maintained. Different middle range theories propose different conceptualizations of the same health problem. The theories identify different sets of determinants, operating at different levels and/or related to the health problem through different pathways or mechanisms. Selection of a theory or theories should take into consideration the complexity of the real world (i.e. multiple factors, at different levels, contribute to the health problem). Attending to complexity demands the careful review, appraisal, and, if necessary, integration of different theories (or elements of theories) to explain the health problem as experienced by the target client population within the respective context (Bleijenberg et al., 2018; Moore & Evans, 2017). For example, conceptualizing insomnia from a behavioral perspective alone may not be adequate, as it is recognized that behaviors are shaped by cognitions (i.e. beliefs), attitudes, personal sense of control, sociocultural norms, and physical environment (Dohnke et al., 2018). Therefore, the selection of middle range theories to generate the theory of the health problem should be carefully done. To be useful in understanding the health problem, middle range theories need to be relevant to the problem of interest. This necessitates a clarification of the problem, identification of available theories, and critical analysis of the theories’ description of the problem and propositions regarding its determinants. Step 1 – Clarification of the Problem Clarification of the health problem entails an initial delineation of its nature. This is done by addressing the questions: What is the problem exactly about? Is it an actual or potential problem? How is the problem manifested? In what domain of health is it experienced, in what way, by whom, in what context, at what time? Is the concern about the occurrence or the maintenance of the problem? Answers to these questions generate a clear definition of the problem and specification of its attributes, experienced by a particular client population, in a particular context. For example health behaviors are described relative to target, action, context, time, and actors (Aráujo‐Soares et al., 2018). The clarification of the problem guides the search for relevant theories; it provides key terms and sets limits (e.g. client population, context) for conducting the search. Step 2 – Identification of Theories Two general methods can be used to identify relevant theories that explain the health problem as defined in Step 1. The first method relies on consultation with scholars and/or health professionals who have expert theoretical and/or clinical knowledge of the health problem. They may have developed, adapted, or been aware of relevant theories. The second method consists of a literature search. The search covers a wide range of sources including: theoretical or conceptual papers that focus on the presentation of the theory or its adaptation to a particular client population or context; textbooks or chapters that describe the health problem from a theoretical or clinical perspective; and grey literature such as professional organizations’ websites providing access to white papers or conference presentations about the problem and relevant theories. The search may be extended to empirical papers reporting on studies that tested the theories in different client populations and contexts. Literature sources are selected if they offer a clear description of the theory, which contains a definition of the health problem, identification of its determinants, and propositions explaining the relationships (direct and indirect) between the determinants and the problem. Step 3 – Analysis of Theories The analysis of theories consists of the following: TABLE 3.2 Matrix for analysis of theories. The information gained from this analysis assists in formulating the theory or logic model of the health problem. Specifically, the initial definition of the problem is refined as needed. A comprehensive list of determinants is generated and their direct and indirect relationships with the problem are delineated and explained, and where available, supported by empirical evidence. The theoretical approach to generate an understanding of the health problem is advantageous. Theories provide a generalizable conceptualization of the problem and its determinants (Foy et al., 2007). By transcending individual cases, middle range theories describe clearly the nature of the problem and identify its determinants or “root causes” (Davidoff et al., 2015). They provide explicit, logical explanations of why and how the determinants affect the problem directly or indirectly. Thus, theories prevent the danger of (1) mislabeling and vaguely defining health problems, (2) missing or omitting important determinants; and (3) misinterpreting associations (specifically bivariate ones that link the problem to one determinant) between the determinants and the problem, all of which have the potential to mislead the design of interventions. Middle range theories do not only explain the pathways linking the determinants to the problem, but also point to the context under which the problem is experienced and maintained, and the pathway is induced. Variations in the pathway across clients and contexts highlight the need to adapt or tailor the design of interventions. Briefly, theories are powerful tools to understand the health problem and to make informed decisions when designing interventions (e.g. Aráujo‐Soares et al., 2018; Bleijenberg et al., 2018; Medical Research Council, 2019). The theoretical approach has some limitations in gaining a comprehensive understanding of the health problem. The reliance on one single middle range theory constrains the perspective on the nature and determinants of the problem to those identified in the theory. Therefore, additional factors (in particular contextual or environmental) that may contribute to the problem could be missed; this limits the capacity to account for all possible determinants pertinent to complex problems experienced by particular client populations in particular contexts. For many health‐related problems there is a limited, if any, number of relevant middle range theories that provide an adequate understanding of the problem and all its determinants. Further, of the available middle range theories, a few have been subjected to extensive empirical test across the range of client populations and contexts, and for those tested (e.g. transtheoretical model), the results are often mixed. Middle range theories may have limited utility if they are not supported empirically. The theoretical approach can be complemented with the empirical approach to gain a comprehensive and accurate understanding of the health problem as actually experienced in the target client population and context. The empirical approach relies on systematically generated evidence to gain an understanding of the health problem. The evidence is obtained through these methods: a review of pertinent literature, conduct of primary studies, and/or analysis of available data. Literature reviews are essential to analyze and synthesize available empirical evidence on the health problem. The literature encompasses primary quantitative and qualitative studies that investigated the problem, as well as reviews that synthesized the evidence on the experience of the problem (i.e. its indicators) and its association with determinants. Quantitative studies to include in the review are the ones that aimed to describe the health problem and/or to examine its relationships, direct or indirect, with its determinants and consequences within particular client populations and settings. The studies may use different research designs. Results of descriptive cross‐sectional
CHAPTER 3
Understanding Health Problems
3.1 IMPORTANCE OF UNDERSTANDING HEALTH PROBLEMS
3.2 THEORY OF THE PROBLEM
3.2.1 Definition of the Health Problem
3.2.1.1 Conceptual Definition
Categorization of Health Problems
Domains of Health Problems
3.2.1.2 Operational Definition
Type and Level of Indicators
Severity and Duration of the Health Problem
3.2.1.3 Factors Contributing to the Problem
Identification of Factors
Delineation of Inter‐relationships
3.2.2 Consequences of the Problem
3.2.3 Illustrative Example
3.3 APPROACHES FOR GENERATING THEORY OF THE HEALTH PROBLEM
Conceptual definition
Nature
Insomnia is conceptualized as a learned behavior
Insomnia refers to self‐reported disturbed sleep in the presence of adequate opportunity and circumstances for sleep
Insomnia is actually experienced by clients across the life span
Operational definition
Defining indicators
Types:
Insomnia is manifested in any or a combination of difficulty initiating or maintain sleep
Levels:
Sleep difficulties reported at ≥30 minutes per night, reported on ≥3 nights per week
Severity
Insomnia Severity Index total score:
≤7 = no clinically significant insomnia
8–14 = subthreshold insomnia
15–21 = clinical insomnia of moderate severity
22–28 = clinically severe insomnia
Duration
Acute insomnia: indicators experienced at the specified level, periodically for <3 months
Chronic insomnia: indicators experienced at the specified level for ≥3 months
Contributing factors
Determinants
Precipitating factors: onset of illness, stress, life or work‐related events that disrupt sleep
Perpetuating factors: cognitions (unrealistic beliefs about sleep, insomnia and its consequences); general behaviors (physical inactivity, smoking); sleep habits or behaviors (irregular sleep schedules, engaging in activities in bed); and engagement in behaviors (extended time in bed) that fuel or maintain insomnia
Moderators
Predisposing factors: innate characteristics (age, sex, familial or genetic tendency) that increase vulnerability to poor sleep
Environment
Features (light, noise, temperature) in the sleep environment that interfere with good sleep
Consequences
Physical and mental daytime fatigue; reduced engagement in physical and psychosocial functions; home, work, or traffic accidents; development of physical (e.g. hypertension) and psychological (e.g. depression) health conditions 
3.3.1 Theoretical Approach
3.3.1.1 Overview
Elements of Theory
Types of Relationships
Examples of Theory
Selection of Theory
3.3.1.2 Methods
Element of theory
Theory 1
Theory 2
Name
Conceptual definition of health problem
Operational definition of health problem
Determinants
Conceptual explanation of
Empirically supported relationships
3.3.1.3 Strengths
3.3.1.4 Limitations
3.3.2 Empirical Approach
3.3.2.1 Literature Review
Overview
Review of Quantitative Studies
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