Behaviour settings theory as a pragmatic framework for intervention transferability and adaptation
File(s)
Submitted version
Author(s)
Mariani, Anna
Baxter, Weston
Amengu, Angelina
Porat, Talya
Type
Journal Article
Abstract
Background: Implementation outcomes vary widely across contexts, yet existing theories, models and frameworks (TMFs) flag context as important without specifying its causal structure. We argue that ecological psychology's Behaviour Settings Theory (BST) can serve as a pragmatic framework for surfacing the setting-level mechanisms by which a setting produces regularised patterns of behaviour across contexts. Methods: We explore BST's explanatory and practical value by examining the transfer of a self-measured blood pressure (SMBP) monitoring intervention from the United Kingdom (UK) to rural Ghana, where SMBP monitors are less commonly available. We used a multistep approach to assess transfer potential. First, we mapped the UK at-home SMBP monitoring setting using the Behaviour Setting Canvas (BSC), a tool designed to capture BST insights. We then compared this with the at-home SMBP setting in Ghana, where a field experiment was conducted. We analysed differences in routines, role enactment, and setting-specific mechanisms affecting intervention functioning. We frame this study as an exploratory, qualitative comparative case study serving as a proof-of-concept demonstration of BST as an analytic and prescriptive lens, not as an empirical test or validation of BST's causal claims, nor as a measure of implementation or proof of the transferability of outcomes. Results: Applying BST, we interpret synomorphy—alignment between a setting's elements and its overarching objective—as shaping SMBP monitoring within and across contexts, yielding both localised and generalisable learning. In the UK, SMBP monitoring is oriented toward real-time sharing with clinicians, supported by infrastructure and props, user knowledge and skills, and maintenance mechanisms enforcing adherence. In Ghana, weaker synomorphy stemmed from resource gaps, limited capabilities, and distributed roles. Routines were less established, and maintenance mechanisms were nascent and inconsistent. We identified macro-and micro-level drivers of variation and insights for adaptation. Conclusions: BST provides a new lens for understanding how interventions interact with setting mechanisms. It supports profiling settings as structured systems, informing context-sensitive adaptation, and advancing implementation science. While promising, the approach is still being codified—it needs clearer guidance for identifying mechanisms and more support for informing design decisions. These are exciting frontiers for future work to strengthen BST's utility and impact.
Date Acceptance
2026-08-26
Citation
Frontiers in Health Services
ISSN
2813-0146
Publisher
Frontiers Media S.A.
Journal / Book Title
Frontiers in Health Services
Copyright Statement
Copyright This paper is embargoed until publication. Once published the Version of Record (VoR) will be available on immediate open access.
License URL
Publication Status
Accepted