Table 2 IINDIAGO MATRIX: Expanded COM-B: TDF domains, theoretical constructs and relevance to GDM women (identified barriers & enablers): DIET
CAPABILITY Psychological | Formative Assessment | For behaviour change to occur, women with GDM would need to: | Intervention Function: What needs to be done to change behaviour | Behaviour change techniques (BCTS) | Resources, tools and activities |
KNOWLEDGE (Awareness) Do you know about X? | • Not well informed about the relationship between GDM andT2D; what constitutes a healthy diet for (self, kids, T2D diabetics); role of diet in T2D • Have general misconceptions about healthy eating and body size • Health care providers (HCP) give inconsistent or confusing messages/info | Increase knowledge of • GDM/T2D; foetal programming; role of diet in developing T2D, potential for prevention through lifestyle changes • what constitutes a healthy diet for self, kids, GDM • role of portion control especially during pregnancy (eating for 2 myth) • role of glucose and insulin • how to sustain a healthy diet through life course | EDUCATION • About ways of enacting desired behaviour and avoiding undesirable one • Need to provide credible, appealing info to take home • Clear, consistent, standardised messages • Info needs to address prevalent misconceptions about healthy eating and dispel myths | 5.1 Information about health consequences | • Brochure on Diet Leaflet on diabetes • Individual counselling, peer group discussion • Visual aids for raising awareness of sugar and fat content (coke, fruit juice etc.- produce kit for the counsellors) • Visual aid for appropriate weight gain for baby/child |
Cognitive and Interpersonal Skills (Ability acquired with practice) Do you know how to do X? | • Lack skills in purchasing of healthy foods • Don’t know how to control portions • Lack skills to negotiate or challenge social and family norms | Acquire skills • to purchase healthy food; to read food labels and to exercise portion control • to change family diet and/or persuade family to change their diet • to plan healthy meals | TRAINING • Provide tools to understand food labels to use when shopping • Demonstrate portion control • Provide skill training and practice to improve communication skills • Provide tips for planning healthy meals | 4.1 Instruction how to perform behaviour 15.2 Mental rehearsal of successful performance | Diet brochure (food labels graphic and portioned plate graphic) • Recipe book • Peer group workshop ‘agent for change’ • Activity: problem solving strategies for negotiating change • Home visit to engage family • Meal planning tips pg 6 of Recipe book |
Memory, Attention, decision, processes (Retain, focus on info, make decisions) Is X something you usually do? Do you actually do X in your context/situation? | • Lose focus on healthy diet once pregnancy is over • Need reminders to apply knowledge about diet in real life settings to make better choices | • focus on diet and make healthier decisions and choices • pay more attention to diet on a long-term basis • translate knowledge about diet to actually making healthy food choices/decisions | TRAINING • Identify opportunities to practice making healthier decisions in different settings (eating out; supermarket; work; home) • Assist woman to make realistic appropriate decisions for long term in their context • Provide social support (peers, PC) and feedback | 6.1 Demonstration of the behaviour 2.2 Feedback on behaviour 3.2 Social support 8.2 Behaviour substitution | Diet brochure: (pg10 Label tool for the purse as reminder, pg3 plate model for fridge) • Place mat colouring activity for kids • Peer group workshop ‘making healthy choices’ • Supermarket corner activity • Analysing sample menus |
Behavioural regulation (Anything aimed at managing or changing objectively observed action) Do you have systems or tools for monitoring whether or not you have carried out X? | • Women do not have tools to monitor dietary change and weight • Dietary monitoring ends after pregnancy (self and HCP) • Misconceptions about food cravings in pregnancy result in lapses in dietary regulation | • improve capacity to monitor dietary behaviour • set goals and review progress about diet during and after pregnancy • use healthy foods to manage pregnancy cravings • recognise signs and symptoms of hypo/hyperglycaemia and use healthy foods to self-manage | ENABLEMENT • Provide opportunity, support and tools to self-monitor dietary behaviour or habits • Offer strategies for glucose regulation and managing pregnancy cravings using healthy foods • Provide continuation of care—ongoing follow up through counselling | 2.3 Self-monitoring of behaviour 2.4 Self-monitoring of outcomes (Method to record outcome) 2.6 Biofeedback (not just weight) 1.5 Review of behaviour goals (jointly with HCP) | • Reviewing food shopping receipts, competition as part of ‘making healthier choices workshop’ • Supportive counselling: Negotiated joint review of progress about dietary change Diary (to record details about food, energy, sleep, physical symptoms, attitude, motivation) • Scale available at peer meetings |
CAPABILITY Physical | Formative Assessment | For behaviour change to occur, women with GDM would need to: | Intervention Function: What needs to be done to change behaviour | BCTS | Resources/Tool and activities |
Physical Skills Do you have the physical skills necessary to do X? | • Lack adequate cooking skills for healthy foods | • acquire the physical skills to prepare foods using healthier ingredients and methods | TRAINING • provide guidelines and recipes MODELLING provide cooking demonstrations | 4.1 Instruction on how to perform behaviour 6.1 Demo of behaviour | • Cooking demonstrations, chopping methods • Recipe books with instructions on how to improve family meals using healthier methods |
MOTIVATION Reflective a | Formative Assessment | For behaviour change to occur, women with GDM would need to: | Intervention Function: What needs to be done to change behaviour | BCTS | Resources, tools and activities |
Social role and identity Is doing X compatible or in conflict with your identity? | • Women prioritise their role /identity as mothers and as carers for family • Do not fully recognise the compatibility of their identity as mothers and their potential influence on the diet of family | • Personally identify with a healthy lifestyle to be a confident example to their family • Feel that managing dietary behaviours of the family is an important part of their maternal role | PERSUASION • Highlight compatibility with current identity, but expand it to include NCD prevention Emphasise role of mother as change agent and importance of role modelling for kids | 5.2 Salience of health consequences 13.2 Reframing 13.1 Identification of self as role model 13.5 Identity associated with changed behaviour | • Facilitated peer group discussion (being a change agent in family) • Value exercise – explore value related to self-identity • Affirm personal strengths and identity as part of change strategy in counselling |
Beliefs about capabilities (acceptance of the truth, reality or validity about ability How difficult or easy is it to do X? | • Women feel insufficient sense of agency about food choices • Not confident to maintain dietary change after delivery in the long term | • Believe they are capable of change despite constraints • Feel able to make healthier choices for themselves and family. (greater agency and locus of control) • Believe that healthier eating can be a sustainable lifestyle | PERSUASION • To enhance self-efficacy and self-monitoring ENABLEMENT • Assist problem solving to address overcoming context specific barriers • Facilitate activities that promote self-efficacy | 3.1 Social support 6.1 Modelling 1.2 Problem solving 15.3 Focus on past success | • Non-directive individualized counselling to enhance self-esteem, confidence and self-autonomy • Confidence scale tool in one-to-one counselling to promote change talk • Peer group theme “overcoming barriers” to address problems/barriers in group setting |
Optimism (confidence that goals will be achieved) How confident are you that you can overcome/manage X? | • Believe T2D/ GDM is mainly related to family history i.e., their fate • Lack sense of agency/ fatalistic • Felt very anxious and scared at diagnosis | • Need to feel optimistic that they can prevent progression to T2D with dietary adjustment • Establish a new perspective and aspire to emulate others who have achieved dietary change • Feel optimistic that dietary change for themselves and family is possible | ENABLEMENT • Build optimism in capability to change diet EDUCATION • Need to dispel belief that T2D is inevitable and related to family history and it is irreversible PERSUASION • Convince women that dietary change can prevent/reverse negative health outcomes | 3.3 Social support emotional 15.1 Verbal persuasion about capability 13.2 Reframing 6.2 Social comparison | • Non-directive counselling approach will build optimism and self-efficacy • Affirmation and acknowledgement of small changes in counselling • Testimonials in IC4H • Peer modelling success stories as part of peer group discussion “Overcoming barriers” |
Beliefs about Consequences (acceptance of reality validity of outcomes about behaviours) What do you think will happen if you do X? | • Underestimate personal dietary risk and association between GDM/T2D and diet • Believe consequences related to pregnancy only • Do not extend beliefs about consequence to the family • Negative beliefs about healthy foods (that food is tasteless or boring; or the health eating will leave them socially isolated, hungry, and will affect family relationships) • Negative beliefs based on experience of hospital food | • Assess risk more accurately • Make clear link between behaviour and health outcomes • Believe GDM = both a warning sign that diet is unhealthy and a red flag for future risk • Believe in benefits of healthy diet for self and family • Believe healthy eating can be sustainable, palatable and affordable | EDUCATION • Provide tools to assess risk that can be shared with family to change PERSUASION • Reframe what GDM signifies for self and family MODELLING • Provide strategies to deal with potentially negative consequences of eating healthily | 5.1 Information about health consequences 13.2 Reframing 6.1 Demonstration of the behaviour 8.1 Behaviour practice/rehearsal | • Food quiz in IC4H brochure to assess diet of self and family • Dispelling of myths related to risk and address beliefs/attitudes about healthy eating (Peer group “Overcoming Barriers” • Cooking demo with emphasis on attractive presentation |
Intentions (A conscious decision or resolve to act) Have you made a decision to do X (long term)? | • Intentions during pregnancy differ to those pre-pregnancy or post- partum • Commitment is short term i.e., during pregnancy only • Intentions to change dietary behaviour seen as only necessary for self/mother not the larger family | • form long term intentions after pregnancy (Stability of intentions) to change diet for self and family • expand intentions to include diet of partner and children | ENABLEMENT • Encourage and support in formulating intentions to change diet for self and family in long term | 9.2 Pros and Cons 9.3 Comparative imagining of future outcomes | • Assessing readiness to change. (use 1–10 Motivational Interviewing scale in individual counselling) • Decisional balance sheet used as an interactive peer activity in workshop “overcoming barriers” and individual counselling |
Goals (Outcomes that individual wants to achieve) How much do you want to do X? [What exactly are you going to do?] | • Don’t set goals beyond pregnancy • Lack support and guidance in realistic goal setting | • Set goals for dietary change for self and family (SMART and personalised) • Set small achievable, and interim goals | ENABLEMENT • Provide support and guidance for realistic goal setting • Affirm small interim goal setting • Prompt planning during and after pregnancy | 1.3 Goal setting (outcome) 1.1 Goal setting (Behaviour) 1.9 Commitment 8.7 Graded tasks 1.4 Action planning | • Non-directive counselling approach to define personalized goals • R2H Card/ health care case record • Group game for promoting commitment: Group chooses a recipe a week to try out or adapt own recipe and give feedback in peer groups |
MOTIVATION Automatic b | Formative Assessment | For behaviour change to occur, women with GDM would need to: | Intervention Function: What needs to be done to change behaviour | BCTS | Resources/Tool and activities |
Reinforcement (Rewards, incentives, sanctions, punishments, consequences, contingencies) Are there any incentives to do X? | • Currently have healthier eating habits during pregnancy followed by a relapse post-partum (baby = incentive) • Entrenched unhealthy eating habits or patterns | • Substitute unhealthy eating habits with healthy ones • Develop strategies which will help in establishing new habits and patterns | TRAINING give tips on environmental restructuring to aid habit formation and habit reversal | 8.3 Habit formation 8.4 Habit reversal | • Explore incentives/rewards for change pp (agent of change workshop) • Offer prompts and tips on how to develop habits (e.g. association, repetition) for replacing unhealthy behaviour with alternate behaviour • Prompt thinking about how to restructure home environment to enforce new healthy habits (e.g. Cold water in the fridge, no salt on table, available healthy snacks and visual cues) • Repeated stimulus in affirming health foods to kids |
Emotion (A complex reaction pattern for dealing with event or issue) Does doing X evoke and emotional response? | • Experience negative emotions when diagnosed (anxiety, feeling overwhelmed) • Experience negative emotions related to the challenge of having to change their diet (feelings of isolation, failure, guilt, shame) • Feelings of stress can result in unhealthy eating patterns • Identity, culture and tradition play a role in dietary choices and perceptions of body shape | • Associate positive emotions with healthy eating and healthy foods • Understand relationship between stress and unhealthy eating patterns • Develop more positive emotional responses to challenges of dietary change | PERSUASION • Help woman deconstruct emotional associations with food ENABLEMENT • Provide a supportive environment for women to explore emotional responses to the prospect of dietary change create a safe space for a conversation about dietary change without invoking the success/failure paradigm or stigma | 5.6 Information about emotional consequences 3.3 Social support (emotional) 5.4 Monitoring of emotional consequences 13.2 Persuasion reframing | • Activity around deconstructing emotional eating and cravings in peer group “making healthier choices” • sensitization of counsellors regarding emotionally loaded words or terms around diet and weight |
OPPORTUNITY Environmental/social | Formative Assessment | For behaviour change to occur, women with GDM would need to: | Intervention Function: What needs to be done to change behaviour | BCTS | Resources, tools and activities |
Physical Environmental Context and resources To what extent do physical or resource factors facilitate or hinder X? | • Time is perceived as a barrier • Perception that healthy foods are too expensive, yet spending on take away and processed food (e.g., KFC) • Have the means to prepare healthy food at home (i.e., kitchen equipment) • Experience high exposure to promotion of unhealthy choices and relatively little exposure to healthy eating messages | • Learn and practice how to prepare healthy recipes quickly and efficiently • Learn how to eat healthily on a budget by reallocating money spent on take-away • Have critical understanding of the obesogenic environment • Have access to information and resources that promote healthy eating | TRAINING • Strategies to eat healthily on a budget ENABLEMENT • Increase critical awareness of ads marketing unhealthy foods • Provide resources and information that can serve as cues/reminders for healthy choices | 6.1 Demonstration of the behaviour 4.1 Instruction on how to perform the behaviour 13.2 Reframing 12.5 Adding objects to environment | • Cooking prep and demos which do not cost more than usual • Provide recipe book as a take home resource • Facilitated discussion with peer group in workshops “Overcoming barriers and Making healthy choices” • Activity – deconstruct ads • Recipe books and brochure • Posters/visuals in peer group venue to reinforce healthy messages |
Social Influence (social pressure, norms, support, power relations, group identity, modelling) To what extent do social influences hinder or facilitate X? | • Women receive good support during pregnancy, less pp from partners, family. HCPS and other GDM women • Believe GDM is the mother’s issue only • Post-partum—no longer have support from HCPS and other GDM women and family • Experience social pressure to conform group identity eating habits • Enjoyed peer interaction of focus group, wished they had such support during pregnancy | • Continued social support in pp period from HCPS, GDM women, partners and family • Perceive social norms supportive of change believe others are doing it to feel less isolated • Relatedness- feel more support from HCPS, believe that they care about preventing progression to T2D and value their health • Understand GDM as a family issue | ENABLEMENT • Require health care system follow up post-partum • Family and friend invited to peer group and counselling sessions • Reframe GDM as whole family issue MODELLING • Provide testimonials in materials (success stories) to promote relatedness | 3.3 Social support 3.1 Unspecified 13.2 Reframing 6.2 Social comparison | • Peer group and home visits establish continuity of care • Lay counsellors to use non-directive counselling style to address power imbalance and promote relatedness • Group sharing of recipes, cooking methods can promote feelings of social support • Choose recipes for a week. Everyone gives feedback on experience |