Using Intervention Mapping methodology to design an HIV linkage intervention in a refugee settlement in rural Uganda

Figures & data

Figure 1. Logic model of the problem of untreated HIV (Step 1). The logic model of the problem of untreated HIV, as described by the Intervention Mapping working group in Nakivale Refugee Settlement. From right to left, the ways in which untreated HIV affects quality of life and health (Phases 1 and 2); the behavioral and environmental factors which contribute (Phase 3); and the behavioral and environmental determinants of those factors (Phase 4).

Table 1. Six steps of Intervention Mapping (adapted from Bartholomew et al., 2016).

Step 1: Logic Model of the Problem	What is the problem? Establish and work with a planning group Conduct a needs assessment to create a logic model of the problem Describe the context (population, setting, community) State program goals
Step 2: Program Outcomes and Objectives – Logic Model of Change	Why is the problem happening? How could it change? State expected outcomes for behavior and environment Specify performance objectives for behavioral and environmental outcomes Select determinants for behavioral and environmental outcomes Construct matrices of change objectives Create a logic model of change
Step 3: Program Design	How will the intervention achieve the desired change? Generate program themes, components, scope, and sequence Choose theory- and evidence-based change methods Select or design practical applications to deliver change methods
Step 4: Program Production	What are the materials and messages for the intervention? Refine program structure and organization Prepare plans for program materials Draft messages, materials, and protocols Pretest, refine, and produce materials
Step 5: Program Implementation Plan	How will the intervention be disseminated, adopted, implemented, and maintained? Identify potential program users (implementers, adopters, maintainers) State outcomes and performance objectives for program use Design implementation interventions
Step 6: Evaluation Plan	How will we know if the intervention is effective? Write effect and process evaluation questions Develop indicators and measures for assessment Specify the evaluation design Complete the evaluation plan

Table 2. Matrices of Change Objectives (Step 2).

A. Behavioral Outcome #1: Newly diagnosed individuals attend HIV clinic.
Personal Determinants: Why would a person take these actions?
	Performance Objectives: What actions need to happen?
	Attitudes & Values	Skills & Self-Efficacy	Knowledge	Social Influence
A.1. Accept HIV+ diagnosis.	a. Maintain hope about the future. b. Recognize that accepting HIV diagnosis will allow them to continue to care for loved ones.	a. Work with HIV counselor to brainstorm strategies for attending clinic, disclosing status, coping with stigma. b. Practice sharing emotions with HIV counselor.	a. Recognize that they can live a healthy life if HIV is properly treated. b. Recognize that they have HIV even if they feel healthy.	Trust accuracy of diagnostic tests (despite rumors of false results).
A.2. Prioritize HIV clinic days.	Decide that the benefits of attending HIV clinic outweigh the barriers to seeking care.	a. Demonstrate how to arrange clinic transport. b. Arrange plan to overcome competing demands (childcare, food distribution). c. Demonstrate ability to track clinic dates.	a. State the benefits of attending HIV clinic, and the consequences of not attending HIV clinic. b. List community resources available to assist with transport, competing needs, etc.	a. Strategize how to cope with negative reactions toward HIV care from partner, family, neighbors, etc. b. Request assistance from individuals for transport and competing demands.
A.3. Take ownership of HIV diagnosis.	a. Describe their role in maintaining their own health. b. Express reasons for health maintenance (family, religion, etc.).	Express confidence in ability to cope with HIV care.	Actively seek information about HIV care from HIV counselors and others.	Consider disclosing status to trusted individuals.
B. Environmental Outcome #1: HIV clinics are accessible to clients in their communities.
Personal Determinants: Why would a person take these actions?
	Performance Objectives: What actions need to happen?
	Attitudes & Values	Skills & Self-Efficacy	Outcome Expectations	Knowledge
B.1. Program implementers identify and involve community leaders.	Program implementers recognize the importance of involving community leaders.	Program implementers are able to persuade community leaders to participate in the program.	Program implementers expect that HIV outcomes will improve if community leaders participate.	Program implementers have the expertise to identify community leaders.
B.2. Community leaders encourage clients to engage with HIV care.	Community leaders believe that PLHIV deserve accessible HIV care.	a. Community leaders recognize their role in ensuring accessible HIV care for their communities. b. Community leaders are able to influence clients to engage in HIV care.	Community leaders expect that HIV outcomes will improve if people can access care in their community.	Community leaders demonstrate accurate, appropriate knowledge of HIV diagnosis, transmission, and management.
B.3. Program implementers and community leaders work together to identify HIV care venues that are safe and convenient.	Program implementers and community leaders recognize the importance of an accessible, safe, confidential HIV treatment space.	Program implementers and community leaders are able to negotiate for use of community spaces.	Program implementers and community leaders expect clients will engage in care if treatment is offered in an accessible, safe, confidential location.	Program implementers and community leaders know which locations are accessible, safe, and confidential for community members.
C. Environmental Outcome #2: Clinic staff provide high-quality, empathic care to clients with HIV.
Personal Determinants: Why would a person take these actions?
	Performance Objectives: What actions need to happen?
	Attitudes & Values	Knowledge	Outcome Expectations	Behavioral Capability
C.1. Clinic staff provide clients with accurate, accessible information about HIV care, in the clients’ own languages.	Clinic staff express personal responsibility for improving their HIV expertise and counseling skills.	a. Clinic staff are knowledgeable about HIV. b. Clinic staff know how to access and use interpreter services.	Clinic staff expect that clients will have better health outcomes and quality of life if information is accurate and accessible.	Clinic staff are well trained in providing clients with accurate, accessible information.
C.2. Clinic staff protect the confidentiality of clients.	Clinic staff express personal responsibility for maintaining patient confidentiality.	a. Clinic staff can explain why it is important to protect confidentiality. b. Clinic staff can list ways confidentiality might be compromised.	Clinic staff expect that clients will be more likely to engage with care if confidentiality is preserved.	Clinic staff are well trained in protecting patient confidentiality.
C.3. Clinic has adequate supplies of HIV test kits and ART.	Clinic leaders take responsibility for obtaining adequate supplies.	Clinic leaders know what HIV supplies are needed and how to obtain them.	Clinic leaders expect that HIV outcomes will improve if clinics have adequate supplies.	Clinic leaders demonstrate a system for tracking and restocking HIV supplies.
C.4. Clinic has organized records and reliable hours.	Clinic staff are willing to make a personal effort to maintain a consistent clinic schedule and keep records organized.	Clinic staff recognize that a disorganized, unreliable HIV clinic is a barrier to care.	Clinic staff expect that clients will receive better care if records are organized and the schedule is reliable.	Clinic staff demonstrate a system for maintaining organized records and reliable hours.
D. Environmental Outcome #3: Clients can access supportive social networks.
Personal Determinants: Why would a person take these actions?
	Performance Objectives: What actions need to happen?
	Attitudes & Values	Knowledge	Perceived Norms	Social influence
D.1. Partners and family members accept HIV positive diagnosis compassionately and assist with HIV care.	Partners and family members express compassion to the client.	a. Partners and family members know that risk for transmission is low if on ART. b. Partners and family know that social support is important.	Partners and family members perceive that families should be compassion-ate and supportive.	Partners and family members are prepared to cope with the stigma of having a partner or family member living with HIV.
D.2. Neighbors and community members provide social support.	Community members express compassion for neighbors living with HIV and wish to support them in their illness.	Community members know that HIV is not transmitted through casual contact.	Community members perceive they should treat neighbors living with HIV with compassion rather than stigma.	Community members treat neighbors living with HIV with compassion even if they see others discriminating against them.
D.3. Health providers replace blame and stereotyping with empathy.	Health providers express compassion for the client.	Health providers know that social support is a key factor in linkage and maintenance of HIV care.	Health providers feel responsible for providing social support to clients with HIV.	Health providers deliver compassionate care to PLHIV even if others do not.
D.4. Community leaders influence people in the community to reduce stigma against PLHIV.	Community leaders believe that PLHIV deserve compassion and support.	Community leaders are knowledgeable about their community members’ beliefs about HIV.	Community leaders perceive they should influence people toward compassionate treatment of PLHIV.	Community leaders are willing to publicly support PLHIV even if other community leaders disagree.
D.5. Clients receive social support from other PLHIV.	Clients are open to sharing experiences with other PLHIV.	Clients know social support is a critical component of HIV care.	Clients perceive that PLHIV often support each other.	Clients are comfortable publicly associating with other PLHIV.

Table 3. Change Methods and Practical Applications (Step 3).

Determinant: Attitudes & Values
Change Objectives	Change Method(s)	Practical Applications
A.1 Maintain hope about the future. Recognize that accepting HIV diagnosis will allow them to continue to care for loved ones.	Individualization Modeling Provide opportunities for social comparison Stereotype-inconsistent information	Posttest counseling Expert client support
A.2 Decide that the benefits of attending HIV clinic outweigh the barriers to seeking care.	Persuasive communication Motivational interviewing Personalize risk Self-reevaluation Environmental reevaluation Anticipated regret	Posttest counseling Combine HIV clinic with other services to increase the benefits
A.3 Describe their role in maintaining their own health. Express reasons for health maintenance (family, religion, etc.).	Belief selection Individualization Framing Anticipated regret Shifting focus Tailoring Modeling Motivational interviewing	Posttest counseling
C.1 Clinic staff express personal responsibility for improving their HIV expertise and counseling skills. C.2 Clinic staff express personal responsibility for maintaining patient confidentiality. C.3 Clinic leaders take responsibility for obtaining adequate supplies. C.4 Clinic staff are willing to make a personal effort to maintain a consistent clinic schedule and keep records organized.	Participation Persuasive communication Tailoring Modeling Consciousness raising Self-reevaluation Environmental reevaluation Enhancing network linkages Empathy training	Support for clinic staff – to express appreciation and prevent burnout (e.g., social events) Staff workshop to build empathy and foster sense of personal responsibility for work
D.2 Community members express compassion for neighbors living with HIV and wish to support them in their illness.	Belief selection Tailoring Consciousness raising Self-reevaluation Environmental reevaluation Stereotype-inconsistent information Interpersonal contact Empathy training Entertainment education	Use community leaders to influence community
D.3 Health providers express compassion for the client.	Same as C.1 to C.4 above	Same as C.1 to C.4 above
D.4 Community leaders believe that PLHIV deserve compassion and support.	Belief selection Persuasive communication Tailoring Consciousness raising Self-reevaluation Environmental reevaluation Stereotype-inconsistent information Interpersonal contact Empathy training	Community leader workshops
D.5 Clients are open to sharing experiences with other PLHIV.	Modeling Facilitation Interpersonal contact Empathy training Developing new social network linkages	Confidential space Facilitated patient group
Determinant: Skills & Self-Efficacy
Change Objective	Change Method(s)	Practical Applications
A.1 Work with HIV counselor to brainstorm strategies for attending clinic, disclosing status, coping with stigma. Practice sharing emotions with HIV counselor.	Individualization Scenario-based risk information Resistance to social pressure Guided practice Planning coping responses Enhancing network linkages	Posttest counseling Confidential space
A.2 Demonstrate how to arrange clinic transport. Arrange plan to overcome competing demands (childcare, food distribution). Demonstrate ability to track clinic dates.	Individualization Feedback Guided practice Goal setting Self-monitoring of behaviors	Posttest counseling Group education sessions with clients
A.3 Express confidence in ability to cope with HIV care.	Tailoring Modeling Verbal persuasion Goal setting	Posttest counseling Facilitated patient group
B.2 Community leaders recognize their own role in ensuring accessible HIV care for their communities. Community leaders are able to influence clients to engage in HIV care.	Modeling Self-reevaluation Environmental reevaluation Verbal persuasion Participation Cultural similarity Guided practice	Community leader workshops Evaluation and feedback
Determinant: Knowledge
Change Objective	Change Method(s)	Practical Applications
A.1 Recognize that they can live a healthy life if HIV is properly treated. Recognize that they have HIV even if they feel healthy.	Belief selection Modeling Elaboration Personalize risk	Posttest counseling Group education sessions with clients
A.2 State the benefits of attending HIV clinic, and the consequences of not attending HIV clinic. List community resources available to assist with transport, competing needs, etc.	Belief selection Discussion Personalize risk Guided practice	Posttest counseling Group education sessions with clients
B.1 Program implementers have the expertise to identify community leaders.	Participatory problem solving Cultural similarity Use of lay health workers	Community leader workshops Feedback from community members and lay health workers
B.2 Community leaders demonstrate accurate, appropriate knowledge of HIV diagnosis, transmission, and management.	Belief selection Feedback Guided practice	Community leader workshops Evaluation and feedback
B.3 Program implementers and community leaders know which locations are accessible, safe, and confidential for community members.	Same as B.1 above	Same as B.1 above
C.1 Clinic staff are knowledgeable about HIV. Clinic staff know how to access and use interpreter services. C.2 Clinic staff can explain why it is important to protect confidentiality. Clinic staff can list ways in which confidentiality might be compromised. C.4 Clinic staff recognize that a disorganized, unreliable HIV clinic is a barrier to care.	Providing cues Guided practice Goal setting Feedback Consciousness raising	Staff training (with staff members helping to plan the training) Training involves guided practice, roleplaying, motivational interviewing
D.1 Partners and family members know that risk for transmission is low if on ART. Partners and family know that social support is important.	Elaboration Verbal persuasion Mobilizing social networks Use of lay health workers	Use community leaders to influence community Reinforcement from lay health workers
D.2 Community members know that HIV is not transmitted through casual contact.	Discussion Mass media role modeling Entertainment education Verbal persuasion	Disseminate educational materials in places where community members socialize Drama performance by clients who choose to disclose status Use community leaders to influence community
D.3 Health providers know that social support is a key factor in linkage and maintenance of HIV care.	Discussion Verbal persuasion	Staff training
D.5 Clients know that social support is a critical component of HIV care.	Modeling Discussion Mobilizing social networks Enhancing network linkages Developing new social network linkages	Posttest counseling Facilitated patient group Expert client support
Determinant: Social Influence
Change Objective	Change Method(s)	Practical Applications
A.2 Strategize how to cope with negative reactions toward HIV care from partner, family, neighbors, etc. Request assistance from trusted individuals for transport and competing demands. A.3 Consider disclosing status to trusted individuals.	Individualization Providing cues Resistance to social pressure Shifting focus Mobilizing social support Opportunities for social comparison Planning coping responses	Posttest counseling Group education sessions and workshops with clients Expert client support Assisted Partner Notification
D.2 Community members treat neighbors living with HIV with compassion even if they see others discriminating against them.	Tailoring Self reevaluation Environmental reevaluation Resistance to social pressure Shifting focus Mobilizing social support Planning coping responses	Disseminate educational materials in places where community members socialize Drama performance by clients who choose to disclose status Use community leaders to influence community
D.4 Community leaders are willing to publicly support PLHIV even if other community leaders disagree.	Participation Tailoring Modeling Environmental reevaluation Resistance to social pressure Shifting focus Planning coping responses	Community leader workshops
Determinant: Outcome Expectations
Change Objective	Change Method(s)	Practical Applications
C.2 Clinic staff expect that clients will be more likely to engage with care if confidentiality is preserved.	Persuasive communication Environmental reevaluation	Staff training
Determinant: Behavioral Capability
Change Objective	Change Method(s)	Practical Applications
C.1 Clinic staff are well trained in providing clients with accurate, accessible information.	Feedback Guided practice	Staff training
C.2 Clinic staff are well trained in protecting patient confidentiality.	Feedback Guided practice	Staff training
C.3 Clinic leaders demonstrate a system for tracking and restocking HIV supplies.	Participatory problem solving Facilitation Nudging Organizational diagnosis and feedback Structural redesign	Feedback to leadership Participation from clinic staff
C.4 Clinic staff demonstrate a system for maintaining organized records and reliable hours.	Feedback Facilitation Participatory problem solving Organizational diagnosis and feedback Structural redesign	Feedback to leadership Staff training
Determinant: Perceived Norms
Change Objective	Change Method(s)	Practical Applications
D.2 Community members perceive they should treat neighbors living with HIV with compassion rather than stigma.	Belief selection Tailoring Modeling Environmental reevaluation Entertainment education	Use community leaders to influence community Disseminate educational materials in places where community members socialize Drama performance by clients who choose to disclose status
D.3 Health providers feel responsible for providing social support to clients with HIV.	Persuasive communication Environmental reevaluation	Staff training
D.4 Community leaders perceive they should influence people toward compassionate treatment of PLHIV.	Modeling Environmental reevaluation	Community leader workshops

Bartholomew Eldredge, L. K., Markham, C. M., Ruiter, R. A., Fernandez, M. E., Kok, G., & Parcel, G. S. (2016). Planning health promotion programs: An Intervention Mapping approach (4th ed.). Jossey-Bass & Pfeiffer Imprints, Wiley.

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