Integrating COM-B and the person-based approach to develop an ACT based therapy programme to raise self-determination in adolescents with obesity

Understanding the population for whom the intervention is being designed is a fundamental first step [25]. A service review was first conducted over ten-years ago [19], and so the review was repeated in 2019 [26]. A high reliance on the support of the clinical team was found, with desire for more intensive medical involvement in the weight-loss process, with low levels of patient belief that they had the capability to sustain change themselves. Parallels with the three components of self-determination theory were drawn, as the patients did not demonstrate fulfilment of relatedness (feeling supported), autonomy (empowered to make their own choices), or a sense of competency (feel able to make changes) [27‐29]. Without self-determination, which includes being attuned with our intrinsic motivations (in this case, internal reasons for weight change), weight-loss relies on external factors. Indeed, patients appeared not to utilise intrinsic motivations, meaning there is a potential for improving weight-loss outcomes if these components are increased. Evidence suggests that lifestyle changes that are intrinsically rewarding to the individual in and of themselves, are more likely to be sustained [30, 31]. The findings from the service review suggested that if self-determination can be increased in this population, it not only offers opportunity for improved weight-management outcomes but also facilitates improved self-management skills that can be transferable throughout the young person's life. The rich qualitative data in the study [26] provided the opportunity for re-analysis from an intervention planning perspective that is presented here.

Semi-structured interviews were conducted with twelve families who attended the Care of Childhood Obesity clinic [26]. The interviews were open to all service users, however all but one of those who took part were not currently seeing changes to their weight or co-morbidities following the current service approach. The views of the service user achieving weight-loss were removed from this analysis as data saturation in this area was not met. Interviews were conducted via telephone and audio recorded between January and August 2019, except one which was conducted in person. The interview data were thematically analysed following the six-step procedure of Braun & Clarke [32] by two independent and experienced qualitative researchers (JC and AS). For this intervention planning process, the transcripts were re-visited to extrapolate useful insights on the pragmatic and logistical aspects of the clinic experience, which were not focused on in the previous publication [26].

Our additional qualitative extrapolation of the interviews focussed on two themes that were framed with regard to (1) access to the clinics and the perceived support provided by clinic staff and (2) thoughts on group-based interventions provided by the clinic.

Pragmatically, the service user group were clear in reporting the difficulties of in-person attendance at this clinic, with travel, missing school and the cost being significant barriers (Table 1; Part 1). The interviews were conducted prior to the Covid-19 pandemic and the concept of online services was considered tentatively. The service users’ perspective on group work was more nuanced, with some in favour of the peer-support offered by group work and others preferring the confidentiality of one-to-one sessions due to the sensitivity that young people and peers may experience during adolescence (Table 1; Part 2).

Whilst knowledge about the behaviours we should be increasing (e.g. activity), and those we should be decreasing (e.g. fast food consumption) is important, on its own this knowledge is rarely sufficient to create sustained change in behaviour [33]. Research into the psychology of behaviour change suggests that to be able to sustain changes, the individual needs to have the Capability, Opportunity and Motivation to perform the new Behaviour [24]. This COM-B offers a framework on which to design interventions with these key facets of behaviour change in mind [23, 34].

Using the rigorous COM-B framework for intervention design [23], an in-depth behavioural analysis was conducted to understand what needs to change before the target group (in this instance a clinical paediatric population with obesity) can change the target behaviour (in this instance, self-determination). The analysis is structured through the completion of a series of COM-B worksheets, each focussing on a different aspect to help determine how the behaviour change could be brought about. The final stages of the COM-B model guide the content and intervention implementation options and involve understanding which of 93 behaviour change techniques (BCTs), would be effective in bringing about change and via what delivery mode. Throughout, the model utilises the APEASE (Practicability, Effectiveness, Affordability, Side-effects, Equity) framework to ensure feasibility of the selected intervention. Three authors (JC, EH & AS) independently completed the COM-B process worksheets then met with clinical expert (JHS) to finalise decisions and create an overarching document (Supplementary materials).

Consideration was then given to evidence regarding the extent to which existing psychological therapies can achieve the behavioural change techniques identified from the COM-B process. Three authors (EH, AS and JC) reviewed the evidence to determine what interventions were currently being used to elicit self-determination and intrinsic motivation, in the context of weight management.

It was apparent that an intervention to raise service users’ sense of self-determination could be successfully achieved by targeting psychological capability, social opportunity and reflective motivation or automatic motivation (Supplementary materials, Worksheet 4).

The intervention could be effectively delivered via education, modelling, training, or enablement pathways (Supplementary materials, Worksheet 5). If the intervention were to look at changing policy, the policy categories that could be applicable were to look to influence guidelines and service provision (Supplementary materials, Worksheet 6). Based on these results, and the perspective of a clinical expert (JHS) and PPI, it was agreed that a training approach was more in-keeping with ACT’s standpoint of working alongside service users to develop collaborative solutions, rather than taking a teaching approach. It was also agreed that the clinical team modelling desired behaviours, to demonstrate how a service user could embody the behaviour change, would be an appropriate technique.

To establish which behaviour change techniques (BCTs) were helpful to include, the BCTs were considered through the lens of increasing self-determination and were chosen based on their ability to support self-determination and intrinsic motivation. Worksheet 7a (Supplementary materials) documents all the beneficial BCTs, which include behavioural practice/rehearsal (for example practising mindfulness when feeling calm, for the skill to be more readily available in times of stress), and valued self-identity (affirming the person’s self-identity in line with the behaviour change). Furthermore, a tailored list of specific motivational BCTs (MBCTs) has been developed by expert consensus, including the authors of the COM-B model and self-determination theory. It therefore seemed pertinent to also include these MBCTs in the intervention, with items such as using empathic listening, clarifying expectations, and dealing with pressure being highly relevant (Supplementary materials, Worksheet 7b).

For clarifying modes of delivery, COM-B identified face-to-face or phone to be potential delivery options, particularly by video-call (Supplementary materials, Worksheet 8). The qualitative interviews demonstrated the difficulty patients have in accessing the clinic due to its city-centre location and the costs this incurs (Table 1), therefore we opted to run the programme via video-call.

The development of guiding principles helps to clarify an intervention’s objectives and ensure the design meets the needs of the end user. Throughout intervention iterations, the guiding principles should be consulted to ensure the intervention retains its focus.

To develop the guiding principles, a person-based approach was utilised [24]. Together, the knowledge gained from the COM-B behavioural analysis, qualitative research study, review of the evidence and the PPI groups was considered, and overarching objectives of the intervention were agreed on by the research team. Key features of the intervention that will ensure each principle is achieved are detailed in Table 2. The development of guiding principles and key features is iterative (Fig. 1), as the intervention continues to evolve in response to PPI feedback and feasibility work with the clinical population, so it is likely that these principles will evolve too.

The guiding principles (at point of publication), and the key features of the intervention that will help the principles be achieved, are detailed in Table 2.

To ensure the programme works for the end-user, PPI is vital throughout the intervention process.

Based on the planning and development work described above, a protocol ACT therapy manual was developed by a health psychologist trained in ACT (JC). The concepts were discussed with four PPI groups: one with young people of healthy weight and two with adults with obesity who had experienced obesity during their childhood and adolescence (some of these participants’ children were also currently experiencing obesity). The fourth group were young people with obesity who were currently engaged with a tier-3 weight management programme (Table 3).

The feedback of the PPI group members has actively influenced both the content and the delivery of the intervention. This rich and significant feedback, and how it has been incorporated into the development process, is documented in a Table of Changes (Supplementary materials).

The PPI groups were in favour of the focus on intrinsic motivation and taking an approach of working collaboratively, with many reflecting on their own experiences of failed diet attempts when driven by external reasons, and the negative impact this pressure has had on them. Participants perceived this potential intervention as giving them a new perspective on weight management (“a new way to consider this”), whilst resonating with their own experiences (“I feel like you described my teenage years”). Changes were made to the structure of sessions (see Table of Changes, Supplementary materials), with young people now being given the option as to whether their parent, or another support figure, attends sessions with them or not. The use of the term ‘mindfulness’ was also challenged due to the term “constantly being thrown at us at school”. Overall, the group considered the approach holistic, where the therapist would seek to “build a relationship with them beyond their weight”. The transferability of the skills involved offered them “help for life”, rather than a programme that was purely about weight loss.