Table 4 Practical guidelines for designing behavioral interventions using the IIT-ICM

General principles

•Involve members of the population under study in all steps of this analysis and design process (e.g., participatory action research models)

•Involve content experts in both upstream (systemic/distal) and downstream (proximal) factors in all steps of this analysis and design process, including those with lived experience

•Use these steps in an iterative manner and return to previous steps to revise the analyses, model, and intervention content as needed

Step 1

Identify the public health problem to address

Step 2

Define the specific behavior to change (the behavior of interest)

Step 3

Identify the upstream historical, structural, and systemic factors that create or contribute to this public health problem and analyze how they influence the behavior of interest

•“Center the margins” to prioritize the perspectives of the population under study, rather than the dominant group

•Consider racism and inequality from a systemic lens

Elicit and understand counter-narratives that may influence behavior change

•Consider how systems and structures intersect to create risk (called “structural intersectionality”)

•Identify sources of population- and individual-level resistance, strengths, and resilience

Step 4

Identify the more proximal downstream factors that promote or impede the behavior of interest (e.g., attitudes, beliefs, social factors, social network factors, access factors)

Step 5

The range of factors that influence the behavior of interest, both upstream and downstream and modifiable and non-modifiable, have now been identified. These modifiable factors can now be organized into a conceptual model using the theory of triadic influence (or a similar flexible multi-level theory) that articulates multiple levels of influence on behavior; e.g., structural-, social-, and individual/attitudinal levels of influence

•Not all upstream and downstream factors will need to be placed in the resultant conceptual model, but the model should reflect the primary potentially modifiable factors that promote/impede the behavior of interest

•Ideally, the factors in the model will be addressed in the intervention/intervention components and be conceptualized as mediators of the intervention

Step 6

To develop the specific intervention or intervention components and the optimal behavior change techniques, at this step bring in an existing intervention development framework such as intervention mapping (Bartholomew) or the behavior change wheel (Michie)

•The intervention or intervention components will entail specific behavior change techniques. A behavior change technique is an observable and replicable component designed to change behavior (e.g., habit formation, problem solving, social support, self-talk, review of behavioral goals)

•Consider how the behavior change techniques relate to the IIT-ICM

•Some behavior change techniques will align better with the IIT-ICM than others

•Interventions/intervention components generally also have a counseling or delivery method or approach, which are guided by theory and may entail of multiple behavior change techniques. Examples include cognitive-behavioral therapy, mindfulness-based therapy, behavioral therapy, group counseling, and motivational interviewing

•Motivational interviewing aligns with the IIT-ICM. Consider whether the motivational interviewing approach would enhance the intervention/intervention components

Step 7

Evaluate how the intervention structure, modalities, delivery, and content will be implicitly and explicitly structurally salient

•Ask whether the intervention implicitly and explicitly locates the primary causes of the public health problem at an upstream level and evaluate whether this is communicated in the intervention content

•E.g., interventions can guide participants through an analysis of barriers to a health problem that starts with structural/systemic causes

Step 8

Evaluate how the intervention structure, modalities, delivery, and content will be implicitly and explicitly culturally salient

•Examples include introducing and/or listening for culturally salient factors such as medical distrust, fear of medications, counter-narratives about health problems, and attending to sources of resistance and resilience grounded in culture

Step 9

Evaluate the intervention or intervention components for the following characteristics and revise as needed. How are they implicitly and explicitly supportive of personal autonomy, trust building, de-stigmatizing, non-judgmental, and dignity enhancing? Are there no pre-conditions for treatment? Do intervention components guide toward any positive change?