Introduction
Methods
Setting
Design
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stage 1: understanding the behaviour
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stage 2: identification of intervention options
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stage 3: identification of intervention content and implementation options.
Stage 1: understanding the behaviour
Stage 2: identification of intervention options
Stage 3: intervention content
Results
Stage 1: understanding the behaviour
What target behaviour? | Increasing and maintaining physical activity |
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Who needs to perform the behaviour? | Insufficiently active women with Gestational Diabetes Mellitus |
What does the person need to do to have the preferred outcome? | Participate at least 150 min per week, motivation to be more active |
Who is involved in performing the behaviour? | By themselves, or with others or groups or in group classes or family members. |
When will they perform the behaviour? | Time convenient to them/(opportunities) |
Where will they perform the behaviour? | Parks, walking routes, place of work, leisure centre, at home, gym |
COM-B component | Theme | Example of Enablers | Example of Barriers |
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Psychology capability – knowledge or psychological skills, strength or stamina to engage in the necessary mental process | Limited specific knowledge of PA benefits, types of PA in pregnancy and PA resources in GDM Safety concerns | Awareness of the types of activity to perform; reassurance activity can be started gradually Awareness of specific benefits to blood glucose control and reducing weight gain. Information from a source in which they had confidence . Instructions for the specific exercise, what type of activity ‘am I ok to do’. Understanding the importance of activity in the treatment of GDM | So much information on the internet, difficulty knowing what to trust. Lack of confidence to start a new exercise and fear of causing harm |
Physical capability – physical skill, strength, stamina | Pregnancy symptoms (pain, nausea, lack of energy, tiredness) | Exercise can improve symptoms ‘I would always feel better once had been for a walk’ | ‘Had nausea in the 1st Trimester, I completely stopped doing all activity’ |
Social opportunity – Opportunity afforded by interpersonal influences, social cues and cultural norms that influence the way we think | Partners & family support Work & childcare Support from Classes | Social support ‘Since the diagnosis my partner has been more supportive and is almost dragging me out for walks’ Zoom and Facebook instruction classes were really helpful’ | Difficulties with Work, Childcare and maintaining consistency |
Physical Opportunity – Opportunity afforded by the environment involving time, resources, location, cues physical affordance | Finding Time for activity Finding local activity Weather | Online classes and home exercises have been really helpful especially in lockdown – ‘I am more comfortable to exercise at home and can fit in with my schedule’ Activity groups close to home | ‘Finding the time when you have look after a two-year-old all day’ ‘Exercising in daylight hours, you just don’t feel like going out for a walk in the dark’ Having the time and adapting around children |
Reflective Motivation – Reflective process involving plans (self-conscious intentions) and evaluations (beliefs about what is good and bad) | For Health of the Baby and reducing the risk of complication Intention: GDM was a prompt to start to activity | Every pregnancy is different, depends on the person and the time in the pregnancy Baby Health and Responsibility ‘Concerns about the baby and doing everything I can’ & It isn’t about me it is about my baby’ Getting a diagnosis of GDM – has been ‘prompt for me to review my activity level’ ‘Activity is now even more important to my health since the diagnosis of GDM’ Desire to be in good shape for labour, want to be active for the future, ‘Doing some activity made me feel better.’ | Mind-set: ‘you get into a comfortable zone and that a change to the routine will stress you out’ Habit: ‘Had a sense that I did not need to be active’ |
Automatic Motivation – automatic processes involving emotional reactions, desires (wants and needs) impulses inhibitions drive states and reflex responses | Desire Worry and fear | Having high blood sugar levels can prompt me to do activity Worry: ‘about the health of the baby and that I am doing everything I can’ Worry of having to go onto medication |
COM-B component | Barriers and facilitators to PA in women with GDMa | Theoretical Domains Framework | What needs to happen for change to occur? |
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Psychological capability | Information is considered as important, awareness of specific benefits of PA with GDM (Both mother & Baby), (+) Information can positively influence individuals’ intentions towards maintaining PA (+) Family/partners understanding of the importance of PA affects the women’s attitudes to PA (+) Resilience to make change (+) Lack of knowledge & understanding of what counts towards PA, types of PA & location of specific resources (−) Fear over safety of activity (−) Lack of awareness of the implication of being inactive with GDM (−) | Knowledge & understanding decision making | Awareness of specific benefits from a credible source, given permission, support from partner/family Awareness what activity is safe for them |
Self- monitoring, Women expressed interest in goal setting (+) | Behaviour regulation | ||
Physical capability | Effects/Medical conditions of pregnancy & symptoms (nausea, fatigue) (−) Ability to perform activity due to pregnancy (high risk) concerns (−) PA can improve physical symptoms (+) | Skills | No change required - the individuals will have the exercise capacity to maintain PA |
Social opportunity | Exercise based programmes from Maternity HCP is regarded as safe/supportive as they are associated with the health care system (+) Support and understanding from HCPs is important e.g. HCPs provide a sense of security/comfort (+) Maintenance of support from family and friendly is important, e.g. partner provide a sense of solidarity/support (+) Acceptability & culture of PA in pregnancy, particularly within families (e.g. overprotective) (+/) Interaction with other pregnant women Home responsibilities; caring for child or partner limits PA opportunities (−) Negative pressure/culture from family leads to avoidance of PA (−) | Social influences (Process that can change thoughts feelings or behaviours – social pressure) | Individuals confident with PA programmes Support from HCP |
Physical opportunity | Lack of access to physical activity/leisure (facilitates) (−) Lack of outdoor space to be space (−) Lack of time (childcare/work commitments) (−) | Environmental context and resources (persons situation or environment) | Time, resources and location influence PA choice, affecting behaviour. |
Reflective motivation | Belief about capacity ‘time for change’ particularly for the benefit of the baby’) (+) PA is associated with feeling of guilt or frustration/concerns due to reduce capacity compared to pre-pregnancy, which leads to avoidance of PA (−) Feeling responsible (+) | Beliefs about capability (acceptance of the truth, reality or validity about an ability, perceived behavioural control, self-esteem, confidence) | Self-efficacy influences approach to PA. Belief about capability toward PA Increased self-monitoring and feedback |
Recognition of improvements through self-monitoring and feedback leads individuals to recognise their capabilities and increase motivation for PA (+) | Goals | ||
Belief that PA is enjoyable and leads to health benefits (+) Self-efficacy: activity may lead to harm & avoidance of PA (due to health beliefs) | Belief about consequences | ||
Automatic motivation | PA is associated with discomfort/pain, which leads to avoidance of PA (−) (due to negative emotions associated activity) Establishing a routine (+) and maintaining habits after (+) are important in the maintenance of PA Pre-pregnancy PA habits (+/−) Apprehensive of PA in public place (−) Fear/anxiety based on previous pregnancy/miscarriage _(−) | Emotion | Habits and routines influence behaviour |
Psychological capability
Physical capability
Physical opportunity
‘I am more comfortable to exercise at home and can fit in with my schedule’
Social opportunity
‘Since the diagnosis my partner has been more supportive and is almost dragging me out for walks’
Reflective motivation
‘Concerns about the baby and doing everything I can’ &’ it isn’t about me now; it is about my baby’
‘Activity is now even more important to my health since the diagnosis of GDM’
Automatic motivation
Stage 2: identification of intervention options
Behaviour source targeted in the intervention | Intervention functions | Policy Category | BCTs | App Feature/Mode of delivery |
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Psychological capability women (knowledge) report unaware of PA opportunities) | Education Information about health consequence Training: Instruction on how to perform the behaviour | Service provision Communication | Information about health consequences (5.1), Credible source (9.1), written persuasion about capabilities (15.1) | Resource centre within the application specific information about the PA & GDM (Hospital Trust leaflet) Exercise booklet on examples of home exercise; promotional posters with a short film of typical activities & health benefits within the resource centre Users are able on the application search for local specific antenatal PA |
Psychological capacity Behaviour Regulation & Goals | Training: Education Enablement: | Service provision Communication | Training: • Self-monitoring of behaviour (2.3) Education • prompts/cue (7.1) • feedback on behaviour (2.2) • self-monitoring of behaviour (2.3) •; Enablement: • Goal setting (behaviour)(1.1) • Action planning (1.4) • Review behaviour goals (1.5) | Women can set, monitor and review PA Goals with HCP via the application Ability to self-monitor goals via performance wheel Feedback given on performance by automated & personalised message from MI midwife. Reminders & promotional messages Telephone/online weekly review by midwife and plan/adjust weekly goals |
Social Opportunity Individuals feel self-conscious being active by themselves. | Enablement Environmental restructuring | Communication | Credible source (9.1) Prompts/cues (7.1) | Support from HCP via App/+/− family/partner. |
Physical Opportunity Environmental context and resources (persons situation or environment) | Enablement | Communication | Instruction to perform the behaviour (4.1.) | Resource centre: Home exercise booklet within the Stay-Active enabling an option for women to fit activity into their lifestyle (learn this skill) |
Reflective motivation | Education Persuasion | Service provision | Self-monitoring of behaviour (2.3) Credible source (7.1) Written persuasion about capabilities (15.1) Feedback on Behaviour (2.2) | Application Messages encourage/prompt users to reflect on their activity Reflection and feedback from HCP (represent a credible source) as users complete and successfully maintain PA Weekly goals educate/inform users about their PA capabilities When a goal is completed, a positive message is displayed |
Automatic motivation | Enablement | Communication Service provision | Prompts/cues (7.1) | Regular reminders & promotional messages to prompt a positive habit change/maintenance |
Stage 3: intervention content
Behaviour Change Technique | BCT description |
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Goal setting [1.1] | set or agree a goal defined in terms of behaviour to be achieved |
Action planning [1.4] | prompt detailed planning of performance of the behaviour must include at least one of the context, frequency, duration and intensity |
Review behaviour goals. [1.5] | review behaviour goals (s) jointly with the person and consider modifying goal(s) or behaviour change strategy in light of achievement |
Self- monitoring of behaviour [2.3] | Establish a method for a person to monitor and record their behaviour(s)as part of a behaviour change strategy |
Instruction to perform the behaviour [4.1] | advice or agree on how to perform behaviour |
Credible source [9.1] | present verbal or visual communication from a credible source in favour of or against the behaviour |
Written persuasion about capabilities [15.1] | inform the person that they can successfully perform the wanted behaviour |
Prompts and cues [7.1] | introduce or define environmental or social stimulus with the purpose of prompting or cueing the behaviour |
Feedback on behaviour [2.2] | monitor and provide informative or evaluative feedback on performance of the behaviour |
Information about health Consequence [5.1] | provide information (e.g. written,verbal, visual) about health consequence |
Stay-active
Themesa | Motivational Interviewing session | Stay-Active |
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Information on benefits of PA | Yes | Yes |
Information on Types of PA | Yes | Yes |
Addressing concerns | Yes | Yes |
Provide emotional support | Yes | Yes |
Encourage involvement with friend and family | Yes | No |
Using prompt or reminder to be physical activity | No | Yes |
Accessible resources | No | Yes |
Information on resource available in the community (classes for pregnant women) | Yes | Yes |
Monitor PA progress | No | Yes |
Change social norm (you can be active in pregnancy | Yes | Yes |
Time to be physically active | No | No |
Home based exercise | Yes | Yes |
Supervision/follow input | Yes | Yes |