Applying evidence-based intervention (EBI) mapping to identify the components and logic of colorectal cancer screening interventions

Abstract

Implementation of evidence-based interventions (EBIs) can help to increase colorectal cancer screening (CRCS). Potential users of CRCS EBIs are often unclear about the specific features, logic, and core elements of existing EBIs, making it challenging to use or adapt them. We used EBI Mapping, a systematic process developed from Intervention Mapping that identifies an EBI’s components and logic, to characterize existing CRCS EBIs from the National Cancer Institute’s Evidence-Based Cancer Control Programs website. The resulting information can facilitate intervention adoption, adaptation, and/or implementation. Two trained coders independently coded intervention materials to describe intervention components and logic (n = 20). We display CRCS EBI components (potential mechanism of change) using evidence tables and heat maps. All EBIs addressed completion of at least one CRCS behavior (stool-based test, n = 9; stool-based test or another CRCS test, n = 8; colonoscopy, n = 3; colonoscopy or sigmoidoscopy, n = 1). The psychosocial determinants most frequently addressed by these interventions were knowledge (n = 19), attitudes (n = 17), risk perception/perceived susceptibility (n = 16), skills (n = 15), and overcoming barriers (n = 15). Multi-level EBIs (n = 9) attempted to change an average of 2.1 ± 1.1 conditions in the patients’ environment (e.g., accessibility of CRCS); only four EBIs used environmental change agents (e.g., providers, nurses). From the heat maps of EBIs, we describe common theoretical change methods’ (e.g., facilitation) used for addressing determinants (e.g., overcoming barriers). EBI Mapping can help users identify important components of a CRCS EBI’s logic; these proposed mechanisms of action can inform adoption, adaptation, and implementation in new settings, and facilitate scale up of EBIs.

Implications.

Practice: Practitioners should consider addressing patients’ knowledge, attitudes, risk perception/perceived susceptibility, skills, and ability to overcome barriers when designing or adapting colorectal cancer screening (CRCS) interventions.

Policy: Health care organizations may need to focus on using multi-level interventions that include organizational changes to improve CRCS, as half of effective CRCS interventions attempted to change an environmental condition.

Research: Evidence-Based Intervention Mapping can help researchers identify important components of a CRCS intervention’s logic to inform selection, adoption, adaptation, and implementation.

INTRODUCTION

Colorectal cancer is the second leading cause of cancer-related deaths among men and women combined in the United States (U.S.), accounting for an estimated 53,000 deaths annually [1]. Screening plays an essential role in reducing colorectal cancer mortality, as colorectal cancer is treatable if diagnosed at a localized stage [2–4]. Despite gradual increases in screening over the past decade, colorectal cancer screening (CRCS) rates remain well below the national recommendation of 80% in every community [5, 6]. CRCS rates are around 60% for individuals 50–75 years old but are substantially lower (24.8%) among economically vulnerable individuals, such as the medically uninsured [1, 5]. Increasing national CRCS rates to 80% has the potential to prevent approximately 200,000 deaths by 2030 [7].

An effective approach to increasing CRCS rates is through the delivery of evidence-based interventions (EBIs) that have been shown to increase screening. EBIs are programs, policies, and practices with proven efficacy and effectiveness that are developed for a specific population and setting (e.g., Flu-FIT intervention) [8–10]. Yet, a recent systematic review reported that two of the top five barriers that prevent community organizations from delivering EBIs include challenges adapting the EBI (41.9% of studies) and challenges understanding how to best implement the EBI (28.1% of studies) [11]. These are important hurdles for using EBIs in practice. Consequently, identifying innovative solutions that can improve adaptation and implementation processes may help community organizations improve the delivery of EBIs in practice.

Basing EBIs (interventions with specific components, materials, and protocols) on general evidence-based approaches (EBAs), such as those recommended by the Guide to Community Preventive Services, (e.g., provider reminders), may be one approach to improving their delivery [8–10]. EBAs are categories of interventions, usually defined by delivery mode, that have been found to be effective through systematic reviews of specific EBIs (e.g., client reminders) [8–10]. For example, Prevention Care Management, a specific “packaged” EBI, is an example of the use of client reminders, an EBA from the Community Guide, to improve CRCS in women over the age of 50 at their healthcare clinics [12, 13]. Other EBAs recommended for increasing CRCS by the Community Guide include multicomponent interventions, one-on-one education, small media interventions, and reducing structural barriers [12, 14, 15].

Resources such as the National Cancer Institute’s Evidence-Based Cancer Control Programs’ (EBCCP; formerly RTIPs) website are also designed to improve the use of CRCS EBIs by making intervention information and materials accessible and summarizing information about intervention features, including characteristics of the at-risk population, level of effectiveness, setting, goals, time, cost, and staff required to deliver the intervention [16–18]. This information can clarify the intent of the EBI, its practical characteristics, and evidence base, but the EBCCP website does not provide information about the mechanisms through which the EBIs operate. Specifically, EBCCP does not provide information on the behavioral determinants that the EBI addresses, or the theoretical change methods used to address the determinants (i.e., intervention mechanisms or functions), both of which are important for understanding the logic of the intervention (Table 1) [8, 19]. Although identifying the determinants and theoretical change methods helps users to understand the form and function of the EBI, they are not yet part of standard reporting within scientific manuscripts, and they can be difficult to identify within intervention materials [8, 19]. Nevertheless, determinants and theoretical change methods may be the intervention components responsible for the EBI’s effectiveness (i.e., potential core components); thus, they are important to identify before adopting or using an EBI [20].

Table 1.

Comparison of intervention characteristics provided by EBCCP and EBI Mapping

EBCCP-provided intervention characteristic	Definition	What EBI Mapping adds	Definition
Intervention setting	The location of the delivered intervention	Environmental change agents	People who can bring about change in the at-risk population’s interpersonal, organizational, policy, or societal environment
At-risk population	Population that has a health problem or is at risk for acquiring a health problem due to a behavior or environmental exposure	Implementers	Individuals who are directly or indirectly responsible for implementing EBI components
Health behavior (i.e., CRCS test)	An action or set of actions performed by the at-risk population that is expected to decrease the health problem or decrease complications or increase quality of life	At-risk population’s determinants	Factors that reside within the at-risk population that influence their behaviors
Health problem (i.e., colorectal cancer)	A deficit of health, excess of disease or risk factor for disease in a defined population	Environmental change agents’ determinants	Factors that reside within the environmental change agents that influence their behaviors
Community Guide EBAs	Proven strategies for promoting colorectal cancer screening	Specific theoretical change methods	Techniques or processes for influencing positive change in specific determinants of behaviors
		Basic theoretical change methods	General technique or process for influencing positive change in multiple determinants or an environmental condition
		Practical applications	A specific technique for the practical use of a theoretical change method used by an EBI
		Environmental conditions	Factors in an individual’s social or physical environment (surroundings) that influence the health of the at-risk population or their behaviors

From EBCCP website (https://ebccp.cancercontrol.cancer.gov).

CRCS colorectal cancer screening; EBAs evidence-based approaches; EBCCP Evidence-Based Cancer Control Programs; EBI evidence-based intervention.

EBI Mapping was developed and refined over multiple editions of the Intervention Mapping textbooks and work to produce IM-Adapt Online, a tool for intervention planners that assists in EBI adaptation [20, 21]. It also helps intervention planners to better understand EBIs more generally [16, 20, 22–24]. EBI Mapping, part of the IM Adapt process, can be useful any time practitioners are planning the implementation of an EBI (whether or not they will be adapting it) because it helps identify the who (i.e., the at-risk population), what (i.e., health behavior and health problem), why (i.e., behavioral determinants), and how (i.e., theoretical change methods and practical applications) of an EBI (definitions in Table 1). EBI Mapping also arranges intervention components into a logic model that can help planners to visualize the potential mechanisms through which the EBI operates; a tool that also makes it easier to share information with community partners [16, 20, 22–24]. Further, researchers can apply EBI Mapping to gain a better understanding of programmatic features and trends across multiple EBIs, such as frequently used theoretical change methods and behavioral determinants or links between them. From an implementation science standpoint, EBI Mapping provides intervention planner a better understanding of the specific features, logic, and core elements of existing interventions, a level of detail that is currently lacking in many intervention reports but can help improve the use of EBIs in practice. Summaries such as the one presented here provide information across CRCS EBIs that can inform future work related to adapting, adopting, and implementing EBIs for a particular health problem, as well as provide data that can generate recommendations for intervention planners and/or community partners.

To provide guidance to EBI users, our team used EBI Mapping to describe components of CRCS EBIs on the EBCCP website. We also identify patterns of determinants addressed across this set of EBIs and the theoretical change methods used to influence determinants. Finally, we describe how intervention planners can use components produced from EBI Mapping to help make decisions when adopting, adapting, and planning the implementation of EBIs.

METHODS

In the spring of 2019, we identified all CRCS EBIs on the EBCCP website (N = 21) and collected their available materials and primary manuscripts [18]. Materials often included journal publications, implementation manuals, standard operating procedures, participant handbooks, websites, worksheets, videos, flyers, and so forth. From the EBCCP website, we recorded some previously defined EBI characteristics, including the intervention setting, at-risk population, health behavior, health problem, and Community Guide EBAs (Table 1). Next, coders with training in Intervention Mapping used IM-Adapt Online, an online tool for adapting interventions, to describe the important components of EBIs not already listed on the EBCCP website [16, 24]. IM-Adapt (available at https://www.imadapt.org/#/) is divided into a series of steps that are guided by drop-down menus, built-in skip logic, helpful tips, and resource materials. In Step 3 of IM-Adapt, the sub-steps include (3a) describing the important components of an EBI and (3b) making adaptation decisions by comparing the determinants of the new population with the EBI. For this project, coders specifically used Step 3a, a process we named EBI Mapping, to code CRCS EBIs.

EBI Mapping comprises five tasks, including (a) documenting the EBI’s materials and activities, and their audiences (at-risk population and environmental change agents), (b) identifying the key content, major components, targets, and features of the EBI, (c) identifying the theoretical change methods and practical applications, (d) describing the design features and delivery channels, and (e) describing implementers, their tasks, and needed resources (Fig. 1). Tasks two through five are repeated for each at-risk population and environmental change agent (e.g., providers who recommend a CRCS test) included in a multi-level EBI (detailed methods are currently under review in Walker et al., EBI Mapping: A Systematic Approach to Map EBI Components and Logic).

Fig 1.

EBI Mapping tasks.

Two coders independently used EBI Mapping on an initial set of five EBIs and took notes on challenges and discrepancies discovered in the coding process. Coders met after coding each of the five interventions to resolve discrepancies through discussion to consensus and made notes to help inform agreement for future coding. Coders also met weekly with the larger research team to discuss coding challenges, which resulted in refinements to the coding process and the development of a coding workbook that provides additional guidance (https://sph.uth.edu/research/centers/chppr/research/ebi-mapping/index#sph.uth.edu). After coding the initial five EBIs, the coders independently extracted information from the remaining 15 EBIs. They continued to meet with the research team weekly and with one another as needed.

Synthesis

We created an evidence table to summarize the information extracted from the EBCCP website and the EBI Mapping process, as well as provide a brief overview of each CRCS intervention (Table 2). The components added through the EBI Mapping process include environmental conditions, determinants for the at-risk population and environmental change agents, and theoretical change methods and practical applications used to change those determinants for the at-risk population and environmental change agent(s). For EBIs that addressed an environmental condition, we also described their ecologic level (i.e., interpersonal, organizational, community, societal) and the theoretical change methods used to create change at each level. Theoretical change methods take two forms: (a) basic change methods, which address an environmental condition or multiple determinants of the at-risk population, and (b) specific methods, which create change by influencing specific determinants of the at-risk population or environmental change agents. For a single EBI, we display components in a logic model (Fig. 2), which is a useful way for sharing information about an EBI with community partners. We also created two heat maps—one at the level of the at-risk population (Fig. 3) and one at the level of the environmental change agents (Appendix Fig. A1)—which sum the number of times determinants and theoretical change methods were used across EBIs and display the proportion of interventions that use a theoretical change method to address a determinant (numerator) divided by the number of interventions with that determinant (denominator). Heat maps such as this can also be useful for generating information about common practices within a specific category of EBIs (i.e., CRCS).

Table 2.

Setting, at-risk population, environmental change agents, environmental conditions, determinants, methods, health behaviors, and Community Guide EBAs for interventions

Intervention/setting	At-risk population, environmental change agents/conditions, and desired behaviors	Determinant	Methods	Community Guide EBAs
Interventions that address the at-risk population only
CRCS in Chinese Americans project Community primary care clinics with access to a bilingual health educator	Lower-income, less-acculturated Chinese immigrants, aged 50–78 years; no FOBT <1 year; no colonoscopy <10 years; will complete an FOBT/FIT	Attitudes	Anticipated regret, belief selection, cultural similarity, direct experience, persuasive communication, repeated exposure, self-reevaluation	Small media
		Knowledge	Active learning, advance organizers, discussion, individualization
		Outcome expectations	Arguments, dramatic relief, environmental reevaluation, improving physical and emotional states, self-reevaluation
		Overcoming barriers	Facilitation, modeling, nudging, persuasive communication, planning coping responses
		Perceived severity	Belief selection, consciousness raising, cultural similarity, elaboration
		Risk perception/perceived susceptibility	Belief selection, consciousness raising, fear arousal, framing, personalize risk, scenario-based risk information
		Skills	Instructional information step by step, modeling, nudging
		Social norms	Modeling, opportunities for social comparison
		Subjective norms	Information about others’ approval, modeling
Mailed reminder to increase completion of fecal occult blood testing Primary care setting and in the patient’s home	U.S. veterans aged >50 years who are not currently receiving inpatient care will complete an FOBT	Attitudes	Consciousness raising, cultural similarity	Client reminders
		Knowledge	Advance organizers, reinforcement, imagery
		Outcome expectations	Belief selection, framing, persuasive communication
		Perceived severity	Consciousness raising, fear arousal
		Risk perception/perceived susceptibility	Belief selection, consciousness raising, framing
		Social norms	Information about others’ approval, modeling
Effect of a mailed brochure on appointment keeping for screening colonoscopy Ambulatory primary care practices, clinic	Asymptomatic men and women aged ≥50 years who receive a provider referral will complete a colonoscopy	Knowledge	Advance organizers, individualization, tailoring	Multicomponent Small media Client reminder
		Outcome expectations	Consciousness raising, feedback, framing
		Perceived severity	Consciousness raising, fear arousal, feedback, framing
		Risk perception/perceived susceptibility	Belief selection, consciousness raising, fear arousal, framing, personalize risk, scenario-based risk information, tailoring
		Skills	Active learning
		Social norms	Persuasive communication
		Subjective norms	Arguments, persuasive communication
Family care (colorectal cancer awareness and risk education) project Community and clinical settings	Adults with a family history of CRC (i.e., first-degree relative diagnosed with CRC before age 60, or first-degree relative diagnosed at age ≥60 years and additional first- or second-degree relative diagnosed at any age, will complete a colonoscopy	Attitudes	Arguments, belief selection, cultural similarity, modeling	Multicomponent One-on-one education Client reminder
		Knowledge	Active learning, advance organizers, elaboration, individualization, motivational interviewing, tailoring, using imagery
		Outcome expectations	Contingent rewards, improving physical and emotional states, modeling
		Overcoming barriers	Contingent rewards, facilitation, nudging, planning coping responses, reinforcement
		Perceived severity	Anticipated regret, consciousness raising, environmental reevaluation
		Risk perception/perceived susceptibility	Active learning, belief selection, consciousness raising, framing, personalize risk, scenario-based risk information, tailoring
		Self-efficacy	Goal setting, individualization, reinforcement, set graded tasks, tailoring, verbal persuasion
The colorectal health project Community healthcare clinics	Hispanic adults aged 50–79 years who have not had a recent colorectal screening exam will complete an FOBT	Attitudes	Arguments, belief selection, cultural similarity, persuasive communication, reinforcement	Multicomponent Small media One-on-one education Client reminder
		Knowledge	Active learning, advance organizers, belief selection, elaboration, individualization, providing cues, tailoring
		Outcome expectations	Belief selection, reinforcement
		Overcoming barriers	Facilitation, improving physical and emotional states, nudging
		Perceived severity	Anticipated regret, consciousness raising
		Risk perception/perceived susceptibility	Active learning, belief selection, consciousness raising, environmental reevaluation, framing, individualization, motivational interviewing, personalize risk, self-reevaluation, tailoring
		Skills	Feedback, reinforcement
		Subjective norms	Belief selection, information about others’ approval
Culturally tailored navigator intervention program for CRCS Urban community health centers and gastroenterology departments	Adults aged 52–79 years with low income and low proficiency in English will complete a colonoscopy.	Attitudes	Arguments, belief selection, persuasive communication	Reducing structural barriers for clients
		Knowledge	Active learning, advance organizers, discussion, tailoring
		Outcome expectations	Active learning, reinforcement
		Overcoming barriers	Facilitation, improving physical and emotional states, individualization
		Perceived severity	Active learning, consciousness raising
		Skills	Active learning, instructional information
		Subjective norms	Belief selection, shifting focus
Colorectal cancer education, screening, and prevention program Healthcare providers with an electronic health records system	Adults aged 50–75 years will complete an FOBT/FIT, sigmoidoscopy, or colonoscopy	Attitudes	Arguments, belief selection, persuasive communication	Group educationa
		Knowledge	Active learning, advance organizers, discussion
		Outcome expectations	Active learning, improving physical and emotional states, reinforcement
		Overcoming barriers	Active learning, facilitation, feedback, individualization, nudging
		Perceived severity	Fear arousal
		Risk perception/perceived susceptibility	Belief selection, consciousness raising
		Skills	Active learning, goal setting
FIT and colonoscopy outreach Primary care setting within urban communities	Racially diverse and socioeconomically disadvantaged adults aged 50–64 years will complete an FOBT/FIT or colonoscopy.	Attitudes	Arguments, belief selection, persuasive communication	Small media Client reminder
		Knowledge	Advance organizers, individualization, tailoring, using imagery
		Overcoming barriers	Facilitation
		Risk perception/perceived susceptibility	Belief selection, consciousness raising, framing, personalize risk
		Self-efficacy	Reinforcement
		Skills	Active learning, instructional information
Automated telephone call improve completion of FOBT Clinical and group-model health maintenance organization setting	Adults (51–80 years old) at average risk for colorectal cancer and due for routine screening will complete an FOBT/FIT	Attitudes	Arguments, belief selection, environmental reevaluation, persuasive communication	Client reminder
		Knowledge	Chunking, providing cues, using imagery
		Overcoming barriers	Facilitation
		Perceived severity	Consciousness raising, fear arousal, framing
		Risk perception/perceived susceptibility	Belief selection, consciousness raising, dramatic relief, framing
		Skills	Active learning, instructional images
Colorectal cancer screening intervention program Participants in senior centers, churches, community centers, and public health clinics	African American adults aged ≥49 years will complete an FOBT, colonoscopy, sigmoidoscopy, double-contrast barium enema, or digital rectal exam. Program also includes reduction of risky drinking, smoking/tobacco cessation, and increasing physical activity	Attitudes	Belief selection, cultural similarity, modeling, motivational interviewing, persuasive communication	Group educationa
		Knowledge	Chunking, discussion, elaboration
		Outcome expectations	Advance organizers, feedback
		Risk perception/perceived susceptibility	Belief selection, elaboration, framing
		Self-efficacy	Goal setting, motivational interviewing, verbal persuasion
		Skills	Active learning, goal setting
		Subjective norms	Information about others’ approval, modeling, motivational interviewing, stimulate communication to mobilize social support
Healthy colon, healthy life Primary care clinics with a high proportion Latino and/or Vietnamese patients that can collaborate with a community-based organization	Vietnamese and Hispanic or Latino adults aged ≥40 years will complete an FOBT/FIT, colonoscopy, or sigmoidoscopy	Attitudes	Belief selection, cultural similarity, elaboration, persuasive communication	Multicomponent Small media One-on-one education
		Knowledge	Active learning, advance organizers, individualization, motivational interviewing
		Overcoming barriers	Facilitation, individualization, motivational interviewing
		Risk perceptions/perceived susceptibility	Consciousness raising
Interventions that address both an at-risk population and an environmental condition
Filipino-American health study Community-based orgs and churches that serve Filipino-Americans	Filipino-Americans aged 50–70 years with no CRCS within guidelines will complete an FOBT	Attitudes	Cultural similarity, direct experience, tailoring	Multicomponent Small media Client reminder Group education
		Knowledge	Advance organizers, discussion
		Outcome expectations	Advance organizers, cultural similarity, provide opportunities for social comparison
		Overcoming barriers	Active learning, modeling, persuasive communication
		Perceived severity	Consciousness raising, fear arousal, framing
		Risk perception/perceived susceptibility	Active learning, consciousness raising, fear arousal, framing, personalize risk
		Self-efficacy	Active learning, goal setting, public commitment, reinforcement
		Skills	Active learning, goal setting, instructional (step-by-step) information, modeling
		Subjective norms	Participation, stimulate communication to mobilize social support
	Environmental condition (level)		Basic change methods
	Increased patient accessibility to CRCS. (Organizational)		Systems change
Kukui Ahi (light the way) patient navigation Community healthcare clinics in rural settings	Asian and Pacific Islander adults enrolled in Medicare will complete an FOBT/FIT, sigmoidoscopy, or colonoscopy. Program also includes Pap testing, mammography, and prostate cancer: informed decision.	Knowledge	Active learning, tailoring	Multicomponent Group education Client reminder Reducing structural barriers for clients
		Overcoming barriers	Facilitation, individualization, providing cues
	Environmental conditions (level)		Basic change methods
	Improve continuity of care for patients by enhancing communication between patient navigators and providers. (Interpersonal)		Enhancing network linkages, systems change
	Develop volunteer patient recruiters within community organizations. (Community)		Developing a new social network linkage
New Hampshire CRCS program Home and clinical settings in rural, suburban, and urban communities	Men and women aged 50–64 years who are low-income (<250% of federal poverty level), uninsured, and/or underinsured patients in New Hampshire will complete a colonoscopy	Attitudes	Arguments, belief selection, elaboration, persuasive communication, repeated exposure	Multicomponent Small media One-on-one education Reduce structural barriers for clients
		Knowledge	Active learning, advance organizers, individualization
		Outcome expectations	Modeling
		Overcoming barriers	Facilitation, improving physical and emotional states, motivational interviewing
		Risk perception/perceived susceptibility	Belief selection, consciousness raising, personalize risk
		Self-efficacy	Active learning, guided practice, reinforcement
		Skills	Active learning, guided practice, modeling
	Environmental conditions (level)		Basic change methods
	Improve patient’s continuity of care by enhancing patient navigator-endoscopist communication. (Interpersonal)		Enhancing network linkages, systems change
	Increase provider referral for endoscopy. (Organizational)		Systems change
	Organizations partner to provide free colonoscopy screening for low-income, uninsured or underinsured individuals. (Organizational)		Forming coalitions
Smart options for screening Healthcare providers with an electronic health records system	Adults aged 51–80 years at average risk for colorectal cancer and due for routine screening will complete an FOBT, sigmoidoscopy, or colonoscopy	Attitudes	Arguments, belief selection, persuasive communication	Multicomponent Small media One-on-one education Client reminder Reduce structural barriers for clients
		Knowledge	Advance organizers, belief selection
		Outcome expectations	Contingent rewards, improving physical and emotional states
		Overcoming barriers	Active learning, facilitation, feedback, individualization, nudging, reinforcement
		Perceived severity	Fear arousal
		Risk perception/perceived susceptibility	Consciousness raising, environmental reevaluation, personalize risk, scenario-based risk information
		Skills	Active learning, guided practice
	Environmental conditions (level)		Basic change methods
	Improve patient’s continuity of care for by enhancing nurse-provider communication. (Interpersonal)		Enhancing network linkages, systems change
Prevention care management Clinical, urban/inner city	Women aged 50–69 years will complete an FOBT/FIT. Program also includes Pap testing and mammography	Attitudes	Persuasive communication	Client reminder
		Knowledge	Active learning, individualization, providing cues
		Overcoming barriers	Active learning, facilitation, feedback, improving physical and emotional states, planning coping responses
		Self-efficacy	Goal setting, verbal persuasion
		Skills	Active learning, goal setting
		Social norms	Information about others’ approval, stimulate communication to mobilize social support
	Providers will refer patients to prevention care management, recommend screening, and follow up on abnormal screening results.	Knowledge	Feedback, providing cues, reinforcement
		Overcoming barriers	Cue altering, facilitation
		Risk perception	Consciousness raising
	Environmental conditions (level)		Basic change methods
	Improve provider recall and reminder systems. (Organizational)		Systems change
Targeting cancer in African Americans Public health clinics, barber shops, hair salons, churches, and religious organizations within African American communities	African American adults aged 18 years and older will complete an FOB/FIT, colonoscopy, or prostate cancer and Pap testing. Program also includes mammography, smoking/tobacco cessation, healthy nutrition, and physical activity	Attitudes	Arguments, belief selection, persuasive communication	Multicomponent Small media Group education Mass media
		Knowledge	Active learning, advance organizers
		Outcome expectations	Arguments, facilitation
		Perceived severity	Consciousness raising, fear arousal
		Risk perceptions/perceived susceptibility	Consciousness raising, framing, personalize risk
		Self-efficacy	Active learning
		Skills	Active learning, feedback, instructional information
	Co-change agents (i.e., community members who have committed to helping deliver the program) host or deliver education programs, distribute educational materials, and make community referrals.	Attitudes	Persuasive communication
		Knowledge	Active learning, discussion
		Social norms	Belief selection, stimulate communication to mobilize social support
	Environmental conditions (level)		Basic change methods
	Increase awareness of cancer prevention resources and support for cancer screening in the community. (Community)		Developing new social network linkages, enhancing network linkages, forming coalitions, mass media role-modeling, mobilizing social networks, peer education, systems change
Flu-FIT and flu-FOBT program Community health centers, pharmacies, managed care organizations, and other healthcare settings that provide flu shots and offer fit/FOBT	Adults aged 50–75 years who are due for CRCS and receive annual flu shots during primary care visits or at drop-in flu shot clinics will complete an FOBT/FIT	Attitudes	Arguments, belief selection, cultural similarity, framing, modeling, persuasive communication	Multicomponent Small media One-on-one education
		Knowledge	Advance organizers, belief selection, verbal persuasion
		Outcome expectations	Anticipated regret
		Overcoming barriers	Cue altering, facilitation, individualization, persuasive communication
		Perceived severity	Consciousness raising
		Risk perception/perceived susceptibility	Consciousness raising, framing, personalized risk, scenario-based risk information
		Self-efficacy	Guided practice, modeling, verbal persuasion
		Skills	Active learning, guided practice
	Environmental conditions (level)		Basic change methods
	Increased awareness of FOBT availability. (Organizational)		Structural redesign, systems change
	Improve provider recall and reminder systems. (Organizational)		Systems change, technical assistance
	Reduction of logistical barriers for returning FOBT test. (organization)		Systems change
Against CRC in our neighborhoods Clinic (serving the uninsured) and community settings (e.g., churches, health fairs, food pantries, low-income housing complexes, community centers).	Uninsured Hispanic adults aged 50–75 years who are due for CRCS will complete an FOBT or colonoscopy.	Attitudes	Anticipated regret, belief selection, cultural similarity, persuasive communication	Multicomponent Client reminder Reduce structural barriers for clients Group education
		Knowledge	Active learning, advance organizers, chunking, discussion, elaboration, feedback, individualization, providing cues
		Outcome expectations	Anticipated regret
		Overcoming barriers	Facilitation, modeling, motivational interviewing
		Perceived severity	Anticipated regret, belief selection
		Risk perception/perceived susceptibility	Belief selection, consciousness raising, dramatic relief, fear arousal, framing, scenario-based risk information
		Self-efficacy	Guided practice, modeling, verbal persuasion
		Skills	Instructional images, step-by-step instructions
		Subjective norms	Belief selection, information about others’ approval
	Promotora/community health workers will develop an action plan, compile a community resource list, and identify community partners to disseminate CRC education program.	Habits	Public commitment
		Knowledge	Active learning, discussion
		Overcoming barriers	Active learning, participation
		Self-efficacy	Set graded tasks
	Environmental conditions (level)		Basic change methods
	Improve patient’s continuity of care for by enhancing navigator-provider communication. (Interpersonal)		Developing a new social network linkage, enhancing network linkages
	Increase the network of organizations promoting CRC education and providing resources for CRC. (Community)		Community assessment, use of lay health workers
	Decease logistical and remove cost barriers for CRCS. (Community)		Forming coalitions, systems change
	Increase the number of CRC positive patients with access to treatment. (Community)		Community assessment, forming coalitions
Interventions that address an environmental condition only
Physician-oriented intervention on follow-up in colorectal cancer screening Clinic or primary care office	Providers will perform complete diagnostic evaluation (CDE) for FOBT+ patients, attend academic visits, review CDE reminders, recommend eligible patients to get CDE, and spot abnormal FOBT results (past 60 days).	Knowledge	Active learning, discussion, elaboration, feedback	One-on-one education Client reminder
		Overcoming barriers	Discussion, facilitation, nudging, tailoring
	Environmental conditions (level)		Basic change methods
	Providers who do not perform CDE screenings for FOBT+ patients; physician provides thorough CDE among patients with FOBT+ result. (Organizational)		Problem-posing education, structural redesign, systems change, technical assistance

CRCS colorectal cancer screening; EBAs evidence-based approaches; EBCCP Evidence-Based Cancer Control Programs; EBI evidence-based intervention; FIT fecal immunochemical test; FOBT fecal occult blood test.

^aGroup education has insufficient evidence as a community guide strategy when used alone.

Fig 2.

Logical model of core components from the Prevention Care Management EBI [12, 24]. Letters and numbers link methods to determinants.

Fig 3.

Heat map of theoretical change methods used to address the determinants of at-risk populations.

RESULTS

Overview

The EBCCP website contained 21 CRCS EBIs, 20 of which had available materials and were published in peer-reviewed journals from 2004 to 2017 (Table 2). Most EBIs (n = 16) focused on CRCS alone, and the remainder included at least one other cancer screening or cancer risk behavior (e.g., physical activity). About half (n = 11) addressed the at-risk population’s behaviors alone, one addressed an environmental condition alone, and the remaining (n = 8) multi-level EBIs addressed both the at-risk population’s behaviors and environmental conditions. One third (n = 8) of the EBIs aimed to increase use of a stool-based test (i.e., fecal immunochemical test [FIT] and/or fecal occult blood test [FOBT]); three, a colonoscopy; one, a colonoscopy/sigmoidoscopy; and eight included both a stool-based test and another CRCS test.

General EBAs recommended by the Community Guide that corresponded with the specific EBIs we reviewed were client reminders (n = 12) and multi-component interventions (n = 11). Although group education was used as part of a multi-component intervention (n = 4), two interventions used this general EBA alone, an application that was not recommended in the 2009 Community Guide review.

At-risk population (N =19)

The at-risk populations were defined as individuals 50 years and over, with some specified as women (n = 1), low socioeconomic status (n = 6), having a specific race/ethnicity (Asian or Pacific Islander, n = 4; Hispanic, n = 3; African American, n = 2), or other population-specific criterion (e.g., U.S. Veteran). The determinants most frequently addressed included knowledge of colorectal cancer and CRCS (n = 19), followed by attitudes (n = 17), risk perception/perceived susceptibility (n = 16), skills (n = 15), and overcoming barriers (n = 15), with self-efficacy (n = 9), subjective norms (n = 7), and social norms (n = 7) addressed less often. Theoretical change methods often used to address these determinants included belief selection and persuasive communication for attitudes, advanced organizers for knowledge, consciousness raising and framing for risk perception/perceived susceptibility, active learning for skills, and facilitation for overcoming barriers (Fig. 3). Some theoretical change methods addressed multiple determinants (e.g., active learning, modeling, reinforcement, motivational interviewing, belief selection, and feedback), whereas other EBIs used other theoretical change methods (e.g., public commitment, repeated exposure, scenario-based risk information) to address a single determinant only. Definitions of specific determinants and theoretical change methods can be found at https://www.imadapt.org/#/.

Environmental conditions (N = 9)

The EBIs that included environmental conditions frequently addressed more than one condition (averaging 2.1 ± 1.1 [range: 1–4]). Four EBIs focused on increasing patient accessibility to CRCS by reducing cost and logistical barriers or by connecting people with organizations that could provide screening. Four EBIs focused on improving patients’ continuity of care using patient navigators. Four EBIs aimed to increase provider referral and/or reminder systems for CRCS. Three EBIs focused on increasing the number of individuals and organizations in the community that link people to CRCS or provide CRCS to patients. One EBI attempted to increase awareness of an EBI by linking it to another annual procedure (i.e., flu shot).

Just over half of the EBIs addressed the environmental conditions through theoretical change methods that aimed to influence the environmental condition directly (n = 5) as opposed to through environmental change agents (n = 4). Environmental change agents included in the EBIs were providers (n = 2), community health workers (n = 1), and community members (n = 1). More than one EBI focused on providing knowledge (n = 4), overcoming barriers (n = 3), and changing attitudes (n = 2) to influence environmental change agent’s determinants, which they addressed through a variety of theoretical change methods (Appendix Fig. A1). For EBIs that focused on directly changing environmental conditions (i.e., not through an environmental change agent), commonly used theoretical change methods included systems change (n = 9), enhancing network linkages (n = 5), developing a new social network linkage (n = 3), and forming coalitions (n = 3).

Example applications

We provide three examples of how an intervention planner can use theoretical change methods and determinants to adopt, adapt, and implement EBIs.

Adoption

When conducting a needs assessment, an intervention planner may, for example, identify skills and social norms as important determinants of their at-risk population’s CRCS behaviors. Finding that these determinants are included in only three EBIs on EBCCP, the intervention planner has provisionally narrowed 20 interventions to three. Next, he or she can make an adoption decision based on the resources, staff engagement, and other needs of their organization. For example, only one EBI—Prevention Care Management—includes components directed at environmental change agents (i.e., providers) [13, 25]. The two other EBIs use small media to change the at-risk population’s behavior, but only one of the two EBIs—Mailed Brochure on Appointment Keeping for Screening Colonoscopy—uses small media plus a client reminder [26, 27]. These differences in EBI characteristics, described on the EBCCP website and identified through EBI Mapping, provide information to help intervention planners make adoption decisions. If, however, no EBIs address important determinants (e.g., skills and social norms) the user can plan adaptations and add messages or strategies to address these; thus, adapting an otherwise suitable EBI such as in the example below.

Adaptation

The Kukui Ahi Patient Navigation intervention’s at-risk population is Asian and Pacific Islander adults enrolled in Medicare [28, 29]. We found that this EBI addresses knowledge and overcoming barriers as important behavioral determinants. Thus, if knowledge and overcoming barriers are determinants that are highly relevant to an intervention planner’s at-risk population, then they may choose to use Kukui Ahi and adapt it to their population’s culture. We note, however, that a more detailed examination of intervention logic is needed to ensure that Kukui Ahi is the right intervention to adapt for the new population and setting (i.e., the same type of knowledge and barriers).

Implementation

The heat map identifies several theoretical change methods that intervention planners can use to address determinants. For example, virtually all the EBIs that address overcoming barriers include facilitation (i.e., reducing a barrier to action) as a theoretical change method. Similarly, EBIs that address perceived susceptibility include consciousness raising (i.e., providing information about the causes, consequences, or alternative for a problem behavior) as a theoretical change method. Consequently, it may be useful for intervention planners to design implementation strategies that emphasize the importance of using specific theoretical change methods to address a determinant. Further, fidelity checklists that evaluate the use of theoretical change methods for addressing determinants may also be helpful in process evaluation to assess implementation outcomes.

DISCUSSION

This study used EBI Mapping to highlight intervention components of CRCS EBIs on EBCCP, including behavioral determinants, environmental conditions, environmental change agents, and theoretical change methods used to change determinants and environmental conditions [20]. Gaining a better understanding of the details of EBIs enables us to better articulate not only the various components and content of the interventions but also the mechanisms through which interventions operate. After we consider the strength of evidence and the setting of an EBI, the additional core components that we identified in this study, which include potential mechanisms of action, provide additional criteria that users may find helpful when adopting, adapting, and implementing their interventions.

It is important to note that the inclusion of specific component(s) within an intervention, however, does not necessarily suggest that those components are responsible for creating an intervention’s effect. Nevertheless, identifying these components and articulating how (the potential mechanism) they are hypothesized to work is a necessary step in designing research that can begin to evaluate how given components affect intervention outcomes. When developing and reporting on an intervention, researchers should use systematic approaches and intervention logic models, such those provided by Intervention Mapping, that identify components of interventions and specify (a priori) how the components influence (individually or synergistically) the overall intervention effect on outcomes. Further, some study designs, such as Multiphase Optimization Strategy, step-wedge, or factorial designs, that add and/or remove specific components at different periods within a trial, can test their contribution to an intervention’s effect [30].

Across the CRCS interventions we analyzed, the most common behavioral determinants addressed in the at-risk population were knowledge, attitudes, risk perceptions/perceived susceptibility, skills, and overcoming barriers. A previous review that examined the use of three behavioral theories for improving CRCS found that determinants from the health belief model, including benefits (i.e., outcome expectations), perceived barriers, and perceived susceptibility were most commonly used to change CRCS behaviors [31]. Our analyses indicate that existing EBIs also commonly address attitudes, knowledge, and skills, especially related to tests for fecal occult blood in the stool (FIT and FOBT). Future studies should measure and evaluate these determinants to identify for which CRCS behaviors, and under what conditions, these determinants are important. Further, testing which theoretical change methods and practical applications most effectively influence these determinants can help to improve the quality and effectiveness of CRCS interventions.

In our analyses, the following theoretical change methods (potential mechanisms) were identified: active learning, belief selection (i.e., using messages to strengthen, weaken, or change beliefs), feedback, modeling, motivational interviewing, and reinforcement, were associated with five or more determinants of at-risk populations across EBIs. Intervention Mapping classifies all these methods as basic theoretical change methods (i.e., methods that address multiple determinants of the at-risk population) [20]. Similarly, EBIs used some specific theoretical change methods to address a specific determinant (e.g., discussion for changing knowledge). It is encouraging to see that interventions with evidence for their effectiveness have findings consistent with behavioral theory and that EBI developers are using these two types of methods appropriately in their development process.

Of the nine interventions that included environmental conditions, all used theoretical change methods that address the environmental condition directly, whereas only four interventions addressed environmental conditions by attempting to influence the determinants of environmental change agents. These findings may be a result of EBIs’ underspecifying determinants and theoretical change methods for environmental change agents who also serve a dual role as an intervention implementer. For example, in the Smart Options for Screening intervention, registered nurses were responsible, as intervention implementers, for making patient navigation phone calls, providing patient education, and identifying resources for patients [32]. The same EBI also addressed the continuity of care between nurses and providers as an environmental condition, but did not provide enough detail to list nurses as environmental change agents and did not specify the determinants and theoretical change methods used to address nurses’ behaviors. Consequently, we describe theoretical change methods used to address the environmental conditions directly, but determinants and theoretical change methods for addressing the nurses’ behaviors are lacking. For intervention adaptation, translation, and sustainability, it is important to document environmental changes that include intervention implementers; identification of the determinants and theoretical change methods used to improve nurse-provider coordination can improve study transparency and may be important for future efforts to deliver this EBI in another setting.

LIMITATIONS AND STRENGTHS

This study did not systematically identify all CRCS EBIs in the literature and, instead, relied on EBCCP to identify them. By specifically using EBCCP, we could ensure that intervention materials would be available and interventions would be evidence-based, which are two requirements of EBI Mapping. Although this EBI selection process was ideal for using EBI Mapping, these EBIs may not be representative of the CRCS literature. EBI Mapping users should reach out to intervention developers to obtain materials before undertaking an EBI Mapping project.

Identifying EBI components can be challenging, even with detailed implementation guides, intervention materials, and publications. While the EBI Mapping process makes this easier, those unfamiliar with Intervention Mapping may find it difficult to translate each individual intervention developer’s nomenclature to the EBI Mapping taxonomy. Specifically, details such as behavioral determinants and the theoretical change methods used to change those determinants may be difficult to determine. To improve the coding process, we used an existing online resource, developed a supplemental workbook with additional resources, and provided coders with multiple tools that are now publicly available (https://sph.uth.edu/research/centers/chppr/research/ebi-mapping/index#sph.uth.edu). For example, the workbook and online tool provide partial logic models that can help users to summarize their results after each coding task and combines these partial logic models to form a full logic model of the EBI. To improve coding consistency, we also recommend coding constructs only when the language is explicit and linked to CRCS. By taking this approach, we increased confidence in the reliability of our findings. To obtain a more complete understanding of EBIs, however, the development and use of reporting guidelines for manuscripts and intervention materials, as they relate to specifying intervention mechanisms including articulating theoretical change methods and determinants, is recommended. This type of reporting will help EBI users to better identify the form and function of the interventions, as well as potential mechanisms of action [19].

When using the EBI Mapping process, it is important to engage the local community and intervention planners in the process. EBI Mapping provides extensive detail on the logic of an intervention; however, community organizations who are adopting, adapting, or implementing CRCS interventions have implicit knowledge and experience that is highly relevant to adaptation and implementation decision-making. The concepts that are made clearer through the EBI Mapping process can be described to community partners in a more straightforward way. In doing so, EBI Mapping can help intervention planners to benefit from the knowledge and experience of their community partners.

A strength of this research is that we used a publicly available website (https://sph.uth.edu/research/centers/chppr/research/ebi-mapping/index#sph.uth.edu) combined with a systematic approach to identify the potential core components of each EBI. We also had two trained researchers code each intervention independently, and we compared entries and reconciled differences through discussion. Through this process, we provide examples and critical decision points. By documenting this systematic process, we hope that other researchers and practitioners will be able to consistently apply this process and produce replicable results.

CONCLUSIONS

EBI Mapping can be useful for coding the components, content and potential core elements of an existing EBI, which intervention planners can use to inform adoption, adaptation, and implementation of CRCS interventions. EBI Mapping also can be applied to other topic areas and contexts beyond CRCS. Given that additional materials were developed to support coding throughout the EBI Mapping process, future studies should continue to evaluate the feasibility and replicability of EBI Mapping. Additionally, more work needs to be done to determine whether the identified components are related to critical intervention outcomes, such as adoption, reach, effectiveness, implementation, and maintenance. This study illustrates a systematic way to move toward a process for identifying key features of effective interventions that can help increase the use of EBIs in practice.

APPENDIX

Fig. A1.

Heat map of methods used to address an ECAs’ determinants

Compliance with Ethical Standards

Conflicts of Interest: All authors declare that they have no conflicts of interest.

Human Rights: This article does not contain any studies with human participants performed by any of the authors.

Informed Consent: This study does not involve human participants, and informed consent was therefore not required.

Welfare of Animals: This article does not contain any studies with animals performed by any of the authors.

Transparency Statement

This study and data analytic plan were not formally registered. Data, analytic code, and materials for this study are available from the authors upon request.