Developing a theory-driven contextually relevant mHealth intervention

Figures & data

Table 1. Steps for developing a theory informed implementation intervention: summary of French et al (2012) and mHealth intervention content development.

Step	Tasks (summarised)	mHealth intervention
STEP 1: Who needs to do what, differently?	Identify the evidence-practice gap Specify the behaviour change needed	The specific outcomes and areas of behaviour change were identified
STEP 2: Using a theoretical framework, which barriers and enablers need to be addressed?	Select which theory(ies)/theoretical framework(s) are likely to inform the pathways of change Use the chosen theory/framework, to identify possible barriers and enablers to that pathway Use qualitative and/or quantitative methods to identify barriers and enablers to behaviour change	TDF and COM-B were selected. Barriers and enablers to behaviour change identified through qualitative formative research Barriers and enablers categorised in terms of TDF
STEP 3: Which intervention components could overcome the barriers and enhance the enablers?	Use the chosen theory/framework, to identify potential BCTs to overcome the barriers and enhance the enablers Identify evidence to inform the BCTs Identify what is likely to be feasible, locally relevant, and acceptable	BCTs identified according to specific enabler and barrier domains
STEP 4: How can behaviour change be measured and understood?	Identify mediators of change to investigate the proposed pathways of change Select appropriate outcome measures and determine their feasibility	Through the process evaluation and cluster randomised controlled trial design the mechanisms of change will be evaluated. This is not directly part of the message development.

Table 2. Steps to message content development.

Step	Summary of step
STEP 1: Context of the intervention	The formative research provides an in-depth analysis of the context of the intervention.
STEP 2: Break down intended outcomes	Related to the formative research and the overall outcomes of the project, specific outcomes for the five areas of focus, i.e. care-seeking, diet, physical activity, smoking and stress, were identified.
STEP 3: Identify and list the enablers and barriers to behaviour change	Enablers to promoting a healthy lifestyle and barriers to implementing a healthy lifestyle were identified from the formative research and listed.
STEP 4: Categorise the barriers and enablers according to COM-B and the TDF	The identified enablers and barriers were categorised according to TDF and COM-B.
STEP 5: Suggest behaviour change approaches for each enabler and barrier	In light of the appropriate transtheoretical domains, behaviour change approaches were identified for each enabler and barrier
STEP 6: Table of message content produced based on the intended outcomes, barriers and enablers and BCTs	A table of message was produced based on the intended outcomes and assigned BCTs addressing each enabler and barrier.

Table 3. Context from formative research.

Aspect	Description	Influence on the messages
Religion and belief	The importance of religion and a belief that everything is under the control of Allah was crucial in peoples’ understanding of their health. While many still valued medical advice, this belief could lead to people being fatalistic about their health and less motivated to change behaviour as explained by one respondent ‘Allah has given us this disease…It’s not about being rich or being poor. Who has bad luck will have diabetes no matter what they do’ (diabetic woman, FGD021). However, some people also spoke about how because Allah gave life it is one’s responsibility to look after it. Additionally during Ramadan ‘bad habits’ and ‘unhealthy’ behaviour (such as smoking) reduced.	Emphasis on responsibility to look after ones’ health. Additional messages were created to correspond with the month of Ramadan and how diet should be approached
Balance	Routines, balance and moderation were perceived as key to achieving health; eating regularly and reasonable portion sizes, getting enough rest and work are examples of balance. One respondent explained ‘Maintaining three proper meals every day is enough to keep us healthy. Regular eating, bathing, and proper lifestyle – that is enough’ (diabetic man, FGD023).	This was built on – the need for regular and reasonable sized meals was emphasised
Family and social pressure	Whether family members valued and supported each other affected an individual’s access to treatment and their welfare; for example women often rely on their husband to take them to the doctor, and the family diet depends on what the mother has prepared. Social norms are important factors in affecting one’s behaviour. For example, hospitality is very important with people expected to serve and consume different foods during visits and on special occasions, as explained by a respondent ‘In a social ritual…or in a gathering, if I refuse the dishes offered to me it would not be polite.’ (diabetic woman SSI008).	Messages targeted the whole family. Specific examples in social situations were drawn on/highlighted
Gender	Social norms are highly gendered as women are expected to behave in a certain way and are judged accordingly. Seclusion prevents some women from going outside of the home making it difficult for them to walk or be physically active. One health worker explains ‘walking is hardly possible for most of the women in the village for some reasons. Where should they walk?’(health worker SSI020). Additionally there are strict gender roles within society and families – for example men do most of the food shopping and women prepare and cook.	Messages were tailored to men and women, they also highlighted the importance of women being able to engage in ‘healthy’ behaviour.

Figure 1. List of intended outcomes for the intermediate and trial outcomes.

Table 4. Examples of barriers and enablers to a healthy lifestyle (from formative research)^a.

Enablers	Barriers
General
Allah gave you life it’s your responsibility to keep it healthy	Fate determines diabetes/health status
Care-seeking
Diabetics tend to go for check-ups/testing if they feel unwell	Lack of consistency in taking medicines: patients may decide themselves that they feel better and stop taking medication
Diet
Family support and encouragement to change eating habits i.e. all eating ruti in the evenings, mother cooking ‘healthy’ foods, daughter encourages grandmother to eat with less salt etc.	Family not changing or supporting different eating habits i.e. husband demanding food is cooked with more oil, wife not changing cooking practices
Physical activity
Can integrate walking into routine (walking children to school, going to the shops, walking to work etc.)	Social acceptability: Not always socially acceptable for women to be walking outside and judgements made
Smoking
Knowledge: greater public awareness of health and smoking i.e. warnings of cigarette packages and doctor’s advice	Knowledge: overall general unawareness about the harmfulness of smoking to health No awareness regarding smoking and the link to diabetes
Stress
Some coping mechanisms identified: talking to someone, music, religious rituals etc.	‘Unhealthy’ coping mechanisms: smoking, taking too many or unnecessary pills

^aThere are some empty cells in this tables. This is because where possible we match barriers to enablers. If there is not a matching enabler or barrier we leave the corresponding cell blank.

Table 5. Examples of barriers and enablers to a healthy lifestyle divided by COM-B and TDF domains, and associated Behaviour Change Techniques.

TDF Domain/ COM-B	Enabler	Barrier	Behaviour Change Technique
TDF: 1. Knowledge COM-B: Capability	Greater public awareness of the link between smoking and ill health	Overall lack of awareness regarding the link between smoking and ill health, particularly diabetes and smoking	Shaping knowledge Information about consequences
TDF: 2. Skills COM-B: Capability	Some coping mechanisms identified: talking to someone, music, religious rituals etc.	Lack of control and coping mechanisms	Shaping knowledge: identify stress, look for coping strategies Modelling behaviour
TDF: 6. Beliefs about consequences COM-B: Motivation	Religious beliefs and responsibility	Religious beliefs and fate	Information about consequences Shaping knowledge: personal responsibility and reinforcing the enabler
TDF: 11. Environmental context and resources COM-B: Opportunity	Walking with other people	Women feel unsafe walking alone	Modelling behaviour: examples of people walking together
TDF: 12. Social influences COM-B: Motivation	Family supporting different/healthy eating habits	Cooking: women cooking with high levels of oil etc., men asking for it	Modelling behaviour Shaping knowledge

Table 6. Complete list of barriers and enablers to a healthy lifestyle divided by COM-B and TDF domains, and associated Behaviour Change Techniques.

General
TDF domain/ COM-B	Enabler	Barriers	Behaviour change technique
TDF: 1. Knowledge COM-B: Capability	People have some knowledge about diabetes and its management	Lack of in-depth knowledge about the causes of diabetes	Shaping knowledge: build on enablers
	Some knowledge that sedentary lifestyle causes diabetes		Shaping knowledge
	Some knowledge about hereditary nature of high blood pressure and connection between high BP and diabetes	Belief that diabetes is contagious	Shaping knowledge: challenge incorrect beliefs
		Lack of knowledge about how to prevent diabetes	Shaping knowledge
TDF: 4. Beliefs about capabilities COM-B: Motivation		Beliefs: too many pills can make one unwell, older people put on weight, complications other than diabetes blamed for making one feel unwell	Shaping knowledge Information about health consequences
		Feelings of lack of control over body weight, health and diabetes	Modelling behaviour Goal setting Information about health consequences
		Difficulties to convince pre-diabetics to change	Modelling behaviour Goal setting
TDF: 6. Beliefs about consequences COM-B: Motivation	Religious beliefs and responsibility	Religious beliefs and fate	Information about health consequences Shaping knowledge
	Bad habits stopped during Ramadan		Modelling behaviour: encourage this to continue
	Routine, balance and moderation = healthy lifestyle		Modelling behaviour
		People not taking responsibility for their health	Information about health consequences
TDF: 10. Memory, attention and decision making COM-B: Capability		Difficulties to maintain a routine	Modelling behaviour Social support (encourage)
		People identified as being ‘careless’	Modelling behaviour, Social support (encourage)
		Perception that if you are addicted there is nothing that can be done (smoking, sugar etc.)	Modelling behaviour
TDF: 11. Environmental context and resources COM-B: Opportunity	Lifestyle changes are not too complicated and within peoples’ reach	Poverty makes it difficult to maintain a moderate, regular lifestyle	Modelling behaviour
		Poverty and time constraints make it difficult to manage/control diabetes	Modelling behaviour
		Increase in stress = increased BP and poor health	Social support (encourage)
TDF: 12. Social influences COM-B: Opportunity	‘Slim’ perceived as being healthy	Fat looking good	Shaping knowledge: challenge perception
	Diabetes thought to damage appearance		Shaping knowledge
	Advice and criticism from friends	Criticism from friends	Social support (encourage)
	Family support for management of diabetes		Social support (encourage) Modelling behaviour
TDF: 13. Emotion COM-B: Motivation	Good explanations of diabetes can reduce fear	Diabetes and complications cause fear	Shaping knowledge
Care Seeking
TDF Domain/ COM-B	Enabler	Barrier	Behaviour Change Technique
TDF: 1. Knowledge COM-B: Capability	Doctors offering advice on lifestyle improvement factors	Lack of awareness on how to prevent diabetes	Shaping knowledge
TDF: 3. Social/Professional Role and Identity COM-B: Motivation	Women and poor people go for regular check-ups	Better-off don’t think check-ups are so important	Shaping knowledge: everyone needs to go to the doctor Modelling behaviour
TDF: 4. Beliefs about capabilities COM-B: Motivation		Belief in fate and a lack of control to seek care	Shaping knowledge Information about health consequences Modelling behaviour
	Testing own blood sugar is empowering and motivates a person to control their diabetes		Pros and cons Shaping knowledge
	Taking medicinal plants makes someone feel in control of their diabetes	Medicinal plants unregulated and could be safety concerns	Pros and cons Shaping knowledge
TDF: 6. Beliefs about consequences COM-B: Motivation	Diabetics will go for check-ups if they feel unwell	Not taking medicines because they are not improving or because they improve feel they no longer need to take them	Modelling behaviour Shaping knowledge Information about health consequences
		Waiting until diabetes is ‘bad’ or suffering from complications before seeking care	Shaping knowledge Information about health consequences
		Belief that medication is enough to treat diabetes, without lifestyle changes	Shaping knowledge Modelling behaviour
TDF: 10. Memory, attention and decision process COM-B: Capability		Forgetting to take medication, particularly when not in a routine	Habit formation: suggest a reminder Imaginary reward
		Descriptions of being too ‘lazy’ and ‘careless’ to take medicine	Habit formation Shaping knowledge
		Diabetes book (provided by healthcare providers) difficult to understand	Shaping knowledge: providing straight forward information
TDF: 11. Environmental context and resources COM-B: Opportunity	Some people request local pharmacy to carry medicine	Strips, insulin etc. not always available locally	Modelling behaviour
	Examples of high quality of care	Low quality of care, chaotic treatment; having to wait/crowds	Modelling behaviour: Acknowledge difficulties and suggest ways of overcoming
	Dr’s consulting specialists by phone, specialists visiting villages once a month	Lack of training and resources to treat diabetes locally	Modelling behaviour: Pros and cons
	Free services will motivate people to seek care	Costs: travel, tests, check-ups, medicine	Shaping knowledge: importance of check-ups Pros and cons
	Doctors prescribing locally		Shaping knowledge
		Local services can’t confirm a diagnosis of diabetes – will refer to specialists/Faridpur	Modelling behaviour: Pros and cons
		Herbs taken due to costs of medicines	Shaping knowledge Pros and cons
		Business/lack of time to take medicine and visit facilities: particularly for women	Modelling behaviour: examples of balancing and prioritising Pros and cons
TDF: 12. Social influences COM-B: Opportunity	Family support: taking to health facilities, arranging appointments, encouraging to seek care	Lack of family support: women rely on husbands to get strips and to take them to the doctor	Modelling behaviour: examples of how can support family
		Women not feeling comfortable talking about health/sensitive issues	Modelling behaviour
TDF: 13. Emotion COM-B: Motivation	People reporting understanding a doctors’ advice	Fear of doctors	Shaping knowledge
	Trust, rapport with a doctor		Modelling behaviour Pros and cons
	Fear of dying can mean people take advice seriously		Shaping knowledge
		Fear after diagnosis prevents patients coming back for care/check-ups	Shaping knowledge: stress diabetes is manageable if controlled
		Feeling out of control	Shaping knowledge:
TDF: 14. Behavioural regulation COM-B: Capability	If treatment is planned in stages patients more likely to return and not feel overwhelmed		Modelling behaviour Goal setting: encourage people to have targets
Diet
TDF Domain/ COM-B	Enabler	Barrier	Behaviour Change Technique
TDF: 1. Knowledge COM-B: Capability	Basic knowledge about a diabetic diet	Lack of in-depth knowledge/knowledge on portions	Shaping knowledge
	Basic knowledge about ‘good’/’bad’ food	Lack of in-depth knowledge, confusion, incorrect knowledge	Shaping knowledge
	Desire for more knowledge		Shaping knowledge
	Dr’s advice valued and people report trying to follow it
		Lack of knowledge about diet and prevention of diabetes	Shaping knowledge
		General lack of understanding about the seriousness of diabetes	Shaping knowledge
TDF: 2. Skills COM-B: Capability	Growing vegetables/home gardens		Modelling behaviour
TDF: 4. Beliefs about capabilities COM-B: Motivation		Lack of control: belief will put on weight despite what one eats, concept of ‘body letting me down’	Shaping knowledge
TDF: 6. Beliefs about consequences COM-B: Motivation	Allah gave life and our responsibility to look after it	Religious beliefs and fate – changing eating habits will not help	Information about health consequences Shaping knowledge
	‘Home-cooked’ food believed to be healthy and ‘outside’ food unhealthy		Shaping knowledge: building on existing knowledge
	Balance in food considered to be good		Shaping knowledge
	Diagnosis of diabetes encouraging to change eating habits		Shaping knowledge Information about health consequences
	Border-line/people at risk of diabetes will try to follow doctor’s advice		Shaping knowledge Information about health consequences: building on existing motivation
		Feeling better after changing diet/medication means diabetics may revert to old habits as believe they are ‘better’	Shaping knowledge Modelling behaviour
		Belief that non-diabetics can eat whatever they like	Shaping knowledge
TDF: 8. Intentions COM-B: Motivation	Personal motivation to eat well and refuse certain foods		Modelling behaviour
	Good practices: making snacks with reduced sugar, replacement sugars in tea, ‘raw tea’ drinking		Modelling behaviour
TDF: 10. Memory, attention and decision process COM-B: Capability	Good practice: developing the habit of eating with less salt and sugar		Modelling behaviour
		Habit of snacking inside and outside the home	Shaping knowledge
TDF: 11. Environmental context and resources COM-B: Opportunity	Cost of food: daal and vegetables reasonable price	Cost of food: ruti, eggs, meat, fruit more expensive	Shaping knowledge Modelling behaviour
	Education: means people are more likely to follow ‘rules an regulations’	Lack of education	Shaping knowledge
	Booklet provided by some care providers explaining what food and portions diabetics should eat found useful	Lack of availability of this booklet and other resources	Shaping knowledge: increase awareness of available resources
		Underweight and malnourishment a problem	Shaping knowledge: giving practical advice that considers a range of people
		Lack of time to eat regularly	Modelling behaviour
		Lack of time to cater to everyone’s nutritional needs	Modelling behaviour Pros and cons
		Availability of ‘unhealthy’ food inside and outside the home	Modelling behaviour Pros and cons
		Convenience of eating outside the home	Modelling behaviour Pros and cons
		Fertilisers, chemicals etc. used to grow food	Shaping knowledge Pros and cons
TDF: 12. Social influences COM-B: Opportunity	Body image: Being ‘slim’ perceived as healthy (not too thin, not too fat)	Body image: being ‘heavier’ perceived as healthy and beautiful	Shaping knowledge: changing/reinforcing perceptions
	Body image: extra fat meaning there are more diseases, can cause difficulties		Shaping knowledge
	Cooking: women may cook with lower levels of oil etc.	Cooking: women cooking with high levels of oil etc. as men (husbands, fathers, in-laws etc.) are asking for it	Modelling behaviour Shaping knowledge: whole family affected by cooking
	Family supporting different/healthy eating habits	Family not supporting different/healthy eating habits	Modelling behaviour Pros and cons
	Shopping: men shop, women can intervene		Modelling behaviour
	Good practices: family and friends bringing/serving alternatives to sweets/snacks	Hospitality: expected to eat and serve foods during social occasions and visits	Modelling behaviour
		Social gatherings and meeting in tea shops	Modelling behaviour
		Status and food: eating meat, ghee etc. can be associated with being a higher social status	Shaping knowledge Pros and cons
TDF: 13. Emotion COM-B: Motivation	Feeling unwell when eating unhealthy food	Feeling unwell, hungry, having gas etc. when having smaller portions/healthy food	Shaping knowledge: stress long-term benefits
	Diabetics feeling better when eating healthy food		Shaping knowledge Modelling behaviour
	Eating less and better during Ramadan		Shaping knowledge Goals setting: suggest continuing some of the behaviour after Ramadan
		Taste and enjoyment of certain foods that are unhealthy	Information about health consequences Pros and cons Shaping knowledge: promoting moderation Modelling behaviour: cooking tasty, healthy food
		Lack of concern for health and living for ‘now’	Information about health consequences Pros and cons Shaping knowledge:
		Importance of rice: complete meal, nourishment etc.	Information about health consequences Pros and cons Shaping knowledge
Physical Activity
TDF Domain/ COM-B	Enablers	Barrier	Behaviour Change Technique
TDF: 1. Knowledge COM-B: Capability	Some knowledge exercise is good for diabetics	Not a detailed knowledge of the relationship between exercise and diabetes	Shaping knowledge
	Some awareness exercise is related to body weight		Shaping knowledge
	Doctors advice that walking helps the body to create its own insulin		Shaping knowledge: reinforce/build on this knowledge
	Diabetics understand/take doctors’ advice		Shaping knowledge Modelling behaviour
		Lack of knowledge that exercise can help prevent diabetes	Shaping knowledge Information about health consequences
TDF: 2. Skills COM-B: Capability	Men: Swim, do push-ups, walk, some sports Women: walk, stretch, occasionally swim		Shaping knowledge Modelling behaviour
TDF: 3. Professional role and identity COM-B: Motivation	People who exercise seen as educated		Modelling behaviour: exercise is for everyone
		Exercise is seen as a sign of having diabetes/done by ‘fat’ people	Shaping knowledge Modelling behaviour
TDF: 4. Beliefs about capabilities COM-B: Motivation		Having diabetes makes people feel unwell, therefore difficult to do exercise	Shaping knowledge: exercise makes people feel better in the long-term Goal setting
TDF: 6. Beliefs about consequences COM-B: Motivation		Unsure/unconvinced about the benefits of exercise:	Shaping knowledge
		Belief hard work is enough to keep healthy, there is no need to do other exercise	Shaping knowledge
TDF: 10. Memory, attention and decision making processes COM-B: Capability		No habit of walking (availability of cheap transport)	Goal setting Repetition and substitution: habit formation
TDF: 11. Environmental context and resources COM-B: Opportunity	Able to integrate walking into everyday routine	Lack of time to exercise/walk	Shaping knowledge: Modelling behaviour
	Walking with other people	Women feel unsafe walking alone	Modelling behaviour:
	Rural areas do have more open spaces than urban areas	Lack of space/places to exercise	Shaping knowledge: types of exercise that are possible
		Weather/muddy roads make it difficult to walk	Pros and cons
		Other people do household works (women, servants, younger people), therefore others are less active	Shaping knowledge
TDF: 12. Social influences COM-B: Opportunity	Friends recommending to walk to manage diabetes		Modelling behaviour
	Walking with friends feels good, encourages walking		Modelling behaviour
	Not walking viewed as ‘lazy’		Modelling behaviour (Need to be careful not to stigmatise people)
		Social acceptability: sports not seen as socially acceptable for older people or women	Shaping knowledge: importance of exercise and challenge perceptions Social support: encourage support
		Women feel judged/shamed if walking around outside (especially if they get muddy etc.)	Social support Pros and cons
		Exercise viewed as not a normal thing to do	Social support Pros and cons
		Exercise viewed as only for those in the city who have no manual labour	Social support Pros and cons
TDF: 13. Emotion COM-B: Motivation	Feeling better/good after manual work/exercise		Shaping knowledge Information about consequences
		Fear of getting injured when playing ha dudu; risk of getting cold after swimming	Pros and cons
Smoking
TDF Domain/COM-B	Enablers	Barrier	Behaviour Change Technique
TDF: 1. Knowledge COM-B: Capability	Greater public awareness of the link between smoking and ill health	Overall lack of awareness regarding the link between smoking and ill health. No awareness of the link between smoking and diabetes	Shaping knowledge Information about health consequences
	Dr’s advise to give up smoking		Shaping knowledge: reinforce doctor’s advice
TDF: 4. Beliefs about capabilities COM-B: Capability		Belief that can only give up by quitting completely	Shaping knowledge: about how to reduce gradually Goal setting
TDF: 6. Beliefs about consequences COM-B: Motivation	People quit due to physical health problems	People wait to quit until they have physical health problems	Shaping knowledge Information about health consequences
TDF: 8. Intentions COM-B: Motivation	Personal motivation to stop smoking	People still smoke despite doctor’s advise	Pros and cons Information about health consequences
TDF: 10. Memory, attention and decision process COM-B: Capability		Addiction to smoking	Goal setting Pros and cons
TDF: 11. Environmental context and resources COM-B: Opportunity TDF: 12. Social influences COM-B: Motivation	Economic costs discourages from smoking	People smoke to suppress hunger	Pros and cons
	Stigma: generally not accepted for women to smoke	Very normal for men to smoke	Shaping knowledge Social support
	Stigma: when smoking in front of elders, women etc.		Shaping knowledge: information on the effects of passive smoking
	Not acceptable to smoke in public spaces (bus, mosques etc)		Shaping knowledge Information about health consequences
	Family: less likely to smoke if it is not done in the family		Modelling behaviour
	Family: discouraging smoking/encouraging to give up		Modelling behaviour Social support (encouraging)
	Religion discouraging smoking, people giving up for religious reasons		Modelling behaviour: build on this motivation
	Quitting smoking because of work		Shaping knowledge: reasons to quit Pros and cons
	Less likely to smoke with age		Shaping knowledge:
		Smoking perceived to be common among certain groups: farmers, younger people, people in rural areas, people in university	Shaping knowledge: on the extent of problem Social support: encouraging people to quit Modelling behaviour
		Introduction at a young age to smoking by others	Modelling behaviour: example of someone introduced to smoking and later regretting it Information about health consequences
		Peer pressure to smoke	Modelling behaviour: examples of peer pressure
		Smoking is a social activity	Modelling behaviour Pros and cons
		Incentives to smoke: as part of a political campaign	Modelling behaviour Pros and cons
		Men and women also take other tobacco products	Shaping knowledge: information about other tobacco products
TDF: 13. Emotion COM-B: Motivation		Pleasure and comfort of smoking	Pros and cons: acknowledge comforts of smoking, but also the negatives
		Smoking relieves stress	Pros and cons Modelling behaviour: alternative ways to deal with stress
Stress
TDF Domain/ COM-B	Enablers	Barrier	Behaviour Change Technique
TDF: 1. Knowledge COM-B: Capability	Some knowledge that stress can make diabetes worse	Most people did not link stress and diabetes	Shaping knowledge: the link between diabetes and stress
	Some understanding that stress affects health		Shaping knowledge
TDF: 2. Skills COM-B: Capability	Some coping mechanisms identified: talking to someone, music, religious rituals etc. (See more below)		Modelling behaviour
TDF: 4. Beliefs about capabilities COM-B: Motivation		Lack of control and coping mechanisms	Shaping knowledge: identify stress, look for coping strategies, acknowledge some things are not within the individuals’ control Modelling behaviour
TDF: 10. Memory, attention and decision making process TDF: Capability	Coping mechanisms: music, watching TV, reading		Modelling behaviour Pros and cons: of different coping mechanisms, stress finding the right ones
	Coping mechanisms: distraction, focusing on other things		Modelling behaviour Pros and cons
		‘Unhealthy’ coping mechanisms: smoking, taking pills	Pros and cons
TDF: 11. Environmental context and resources COM-B: Opportunity	Identified sources of pleasure: money, security, health	Identified sources of stress: money, poverty, land	Shaping knowledge
	Health professionals able to treat the symptoms of stress: hypertension, headaches etc.	Not dealing with the root causes of stress	Shaping knowledge Pros and cons
TDF: 12. Social influences COM-B: Opportunity	Sources of pleasure: family, socialising	Sources of tension: family, responsibilities, early marriage, conflict in family	Shaping knowledge
	Coping mechanisms: talking to others	Others will know their problems if they talk about them	Social support (encourage) Modelling behaviour
	People of the village come together to help those in need e.g. if sick		Social support (encourage) Modelling behaviour
TDF: 13. Emotions COM-B: Motivation	Coping mechanisms: music, praying, rituals, being alone, resting		Modelling behaviour Pros and cons
		Symptoms of stress: poor health, headaches etc.	Shaping knowledge

Additional notes

In the working table of content for script writers there was an additional column entitled ‘message number’ – this way we were able to add the message numbers that addressed the individual barriers and enablers – allowing us to track the messages and ensure all the barriers and enablers were addressed.

In the final column of this table ‘behaviour change technique’ some additional information explaining how the BCT can be approached is occasionally added – again there was more information in the original table.

The BCT ‘modelling behaviour’ refers to ‘demonstration of the behaviour’ in the BCT taxonomy.

Table 7. Example of a message (relating to diet) from the table of content.

Area	TDF	BCT	Barriers	Enablers	Content	Audience	Format
Diet	Social influences	Modelling behaviour	Hospitality: being expected to eat sweets/rich food at social occasions such as weddings		Scenario: A person newly diagnosed with diabetes goes to a wedding and tries to resist large amounts of biryani and sweets. Friends pressure him to eat them.	Men and women Diabetic	Drama
					Strategies used by the person with diabetes: - Requests a smaller portion and does not have any sweets - Explains to his friends why he needs to be careful and control his diabetes
					Other messages: - Everyone needs to be careful about what they eat - It is important to be supportive of people and allow them to have smaller portions/have alternatives to rich and sweet food

Table 8. Further examples of messages from the table of content for script writers.

Message no	Focus area	Aspect	Communication objective (BCT)	Barrier	Enabler/motivator	Content/key message		Audience	Format	Comments
48	General	Memory, attention and decision making Environment	Modelling behaviour	Difficulties in maintaining a routine Poverty makes it difficult to maintain a moderate, regular lifestyle	Routine, balance and moderation = healthy lifestyle Lifestyle changes are not too complicated and within peoples’ reach	Scenario: conversation between someone who is drinking lal cha with no sugar and a friend/relative about healthy lifestyles.		Men and women Non-diabetic	Drama/conversation	Could have a woman and/or an older person
						Friend	Response
						Why are you drinking lal cha and no sugar?	I try not to have too much sugar. I also try to eat regularly and not too much. If I do have sweets just have a little bit. I don’t have oily food at home, but on certain occasions when I have pilou I will just have a little bit.
						So you try to keep to a routine?	When I can. I walk in the morning, eat regularly and have a balance of different types of food. I don’t smoke or eat many snacks.
						Is it hard to have this lifestyle?	No, you just have to be careful. When you start it is possible to continue. It is good for all the family, we all eat a moderate, balanced diet and I walk with my sister.
						When you are working can you do this?	Yes. I just plan things around my work. Everyone rich and poor needs to think about how they can have a healthy lifestyle and plan accordingly.
						And do you keep healthy?	Yes the doctor said I am very well, and I feel healthy. My blood pressure is good and I don’t have diabetes.
						Oh I have high sugar, or pre-diabetes, can I still do this?	Yes of course! See your doctor, but eating well and exercising regularly is important way of managing your health
						Key messages: - Strive for a moderate lifestyle; regular exercise and eating reasonable amounts, having small amounts of ‘unhealthy’ food - lifestyle changes are within people’s reach: rich and poor, male and female. - They help keep you healthy and manage illness
68	General (Diet, smoking)	Beliefs about consequences Environment, context and resources Social influences	Shaping knowledge	Religious beliefs and fate Poverty makes it difficult to maintain a moderate, regular lifestyle	Religious beliefs and responsibility Routine, balance and moderation = healthy lifestyle Lifestyle changes are not too complicated and within peoples’ reach Balance in food considered to be good Religion discouraging smoking	Doctor and an imam: - A balanced, regular lifestyle is healthy for diabetics and non-diabetics - Try to eat a balanced diet in moderation - Exercise everyday - Try to avoid bad habits like smoking and smokeless tobacco products - Draw on support from your families and communities - These changes are possible for everyone, rich or poor - Islam teaches we need to look after our bodies and health - We can change ourselves, our families and communities		Men and women Diabetic and non-diabetic	Straight information	Motivational message to encourage a moderate, healthy lifestyle
49	Care seeking	Beliefs about consequences	Health consequences Shaping knowledge: complications of diabetes	Wait until diabetes is bad before seeking care		The story of a diabetic: I suffered from some of the complications of diabetes. I went to the doctor due to having problems with my feet being red, warm, swollen and with cracks. The doctor helped treat my feet but also sent me for a blood test. I found I had diabetes. The doctor helped me to understand I can control my diabetes with medicine, diet and later exercise. If diabetes is left untreated like mine you can get many complications. Such as: foot problems, problems with eyesight, nerve damage and kidney damage. These are all very serious. The good news is that diabetes can be managed and prevented. It is better to seek help and make lifestyle changes before you get very sick Key points: If you delay seeking care and have diabetes you can get complications The complications of diabetes Diabetes can be prevented and managed		Men and women Diabetic	Personal story/account	A personal story or account about diabetes might motivate people to seek care and try to prevent diabetes It would be good if at least one of message 49 and 50 could be a female
72	Care seeking	Behavioural regulation	Goal setting		If treatment is planned in stages patients more likely to return and not feel overwhelmed	If you have diabetes it is sometimes easier to plan your treatment/behaviour change in stages. Talk to your doctor about this. - Example of planned behaviour could be: - Planned behaviour: - At the beginning: - Take medicine as advised - Exercise when can - Slowly reduce portions, fat and sugar - After a couple of weeks: - Walk everyday - Weigh self regularly - Talk to family about diet and cooking - Take medication - After one month: - Walking half an hour everyday - Family changing eating habits - Reduced fat, sugar and portion sizes - Taking medication regularly - Continue going for testing		Diabetic Men and women	Pros and cons	Check with medics if this is feasible We could also say that anyone can plan to change their behaviour
51	Exercise	Professional role and identity Emotion, Skills	Shaping knowledge Health consequences	Lack of knowledge that exercise can help prevent diabetes Able to integrate walking into everyday routine People who exercise seen as educated Not walking seen as ‘lazy’ Too cold to swim	Lack of time to exercise/walk People who exercise seen as educated Not walking seen as ‘lazy’ Men: Swim, do push-ups, walk, some sports in the past Women: walk, stretch, swim	Exercise is very important. Exercise will make your heart beat faster and increase blood flow and oxygen to your muscles and organs. It can help to prevent diabetes, control your weight, as well as decrease the risk of heart problems and blood pressure and is good for your general well being. It also helps to control diabetes. Exercise stimulates brain chemicals and can make you feel happier. Exercise is for not just for the educated and affluent. It should be done whether you have diabetes or not, are rich or poor, old or young, man or woman. Everyone should aim to do half an hour exercise a day. It is important to make exercise a priority and try to do some everyday. Everyone can find a type of exercise they like or can do. There are many types of exercise. Exercises include: walking, running, sports, swimming, riding bicycle etc. If it is too cold to swim, walk. You can try different types of exercises too. Make time to exercise – try to walk places instead of getting transport, instead of watching TV do some exercise!		Men and women Diabetic and non-diabetic	Dr: Straight information
52	Exercise	Environment, Social influences, Memory/attention, Emotions	Modelling behaviour Social support	Women feel judged/shamed walking outside Women feel unsafe walking alone Lack of time to exercise/walk Exercise viewed as not a normal thing to do	Walking with other people Walking with friends feels good Able to integrate walking into everyday routine	Scenario Two females walking together – they talk to another female neighbour and try to encourage her to join them.		Women Non-diabetic	Drama	Keep as females: it would be good if we can try and encourage females to encourage each other
						Question	Response
						Where are you walking?	We are walking for health reasons. We also enjoy walking together.
						Do you have diabetes?	No. It is always good to walk. Walking can prevent diabetes.
						As a woman doesn’t it look bad? Do you feel safe?	Women need to walk too. By walking together we feel safer. If women all walk then we will change how people think about women walking. We see exercise as a normal thing to do.
						Do you have time to walk?	We walk every morning as part of our routine. We also think of when we can walk – sometimes we walk instead of getting transport.
						Is it not tiring?	At first it was hard, but now we enjoy it and you feel better in the long-term. It is also fun to walk together
						Final message – try to encourage other women to walk, that way everyone will benefit and we can change public responses. Exercise will then be seen as normal.
57	Stress	Environment, context Memory, attention and decision making	Pros and cons	Not dealing with the root causes of stress Coping mechanisms: smoking, taking pills		In the last message we spoke about ways people deal with stress. Now we are going to talk about the pros and cons (good and bad points) about each. Some people when they are stressed will take sleeping pills, smoke and take pain killers. Pros/why you do it: The reasons people do this are: - will help them sleep sometimes and take away pain - gives some relief in the short term Cons/why you maybe shouldn’t rely on this: - These might help in the short term but won’t help in the long-term - Smoking is very bad for your health - Taking too many pills can be harmful (Pros outweigh pros) The other coping mechanisms: talking to others, exercising, looking at the bigger picture, exercise and some religious rituals. Cons/reasons people don’t it: - Might be harder to do in the short term - May not think of it/may not be obvious Pros/reasons to do them: - Better long-term solutions that you can do - Exercising is good for your physical health - Talking to people you trust can help relations and give long-term support (Pros outweigh cons)		Men and women Diabetic and non-diabetic	Straight information	Could be a doctor
58	Stress	Social influences	Modelling behaviour Social support	Others will know their problems if they talk about them	Coping mechanisms: talking to others People of the village come together to help those in need e.g. if sick	Scenario: female very distressed because her son is sick and she has money problems. She has a discussion with her neighbours who are very supportive and offer support, encouraging her to talk to them and they offer practical support. - Key messages: - support one another - sometimes just listening helps - talk to people you trust		Men and women Diabetic and non-diabetic	Drama
60	Diet	Environmental context and resources Memory, attention and decision Social influences Beliefs about consequences	Modelling behaviour Pros and cons	Availability of ‘unhealthy’ food inside and outside the home Convenience of eating outside the home Habit of snacking inside and outside the home Social gatherings and meeting in tea shops	‘Home-cooked’ food believed to be healthy and ‘outside’ food unhealthy	Scenario: two men outside of the home and one wants to go for snacks and sweet tea, the other wants to go home and have food at home. They discuss the pros and cons of eating outside the home and		Men Non-diabetic	Drama
						1^st man: pros of eating outside	2^nd man: response, cons
						There is so much food outside, it is very convenient	Yes that is true, but a lot of it is also fried and unhealthy. At home we can decide better what to eat.
						The fried food such as shingaras, puris etc. are so tasty	Yes that is true. But too many are unhealthy. We can try to only go there occasionally.
						But I am in the habit of going to the tea shop and it is very sociable, we see are friends there.	Ok, lets go and just get some lal cha without sugar. We can still see our friends. Later we can eat at home.
						But at home there is also unhealthy food!	This is true! But we can decide better what we eat. Let’s go to my house and we can have some fruit and lal cha and then later we can have some dinner.
						Key messages: - moderate the amount of time you eat outside the home - you can go out and eat less fried food - at home you have more control over what you eat
61	Diet	Social influences	Shaping knowledge Social support	Cooking: women may cook with lower levels of oil etc. Family not supporting different/healthy eating habits	Cooking: women cooking with high levels of oil etc., men asking for it Family supporting different/healthy eating habits Shopping: men shop, women can intervene	Straight information: Families usually eat together. Everyone in the family has a role in eating well and changing eating habits. They include:		Men and women Non-diabetic and diabetic	Straight information	Could be a song, poem, or different voices from a family or a doctor
						Men	Men/husbands usually shop. Talk to your wife about what you will buy. Try to buy lots of vegetables and fruit. Get vegetable oil instead of ghee. Get cheaper more healthy sources of protein such as fish, eggs and chicken instead of meat. If possible get brown rice and flour.
						Women	Women/wives/daughter in-laws do most of the cooking. Talk to your husband about what they should buy. Try to cook with lots of vegetables and make salads. Only cook with as much oil as you need. Avoid deep frying food. Explain to your family why you are cooking like this. Food can still be tasty with lots of flavour.
						Older: in-laws	You have lots of influence. Encourage members of the family to shop and cook well. Praise healthy food and cooking.
						Younger: children	You can encourage your parents to shop and cook well. Explain to them why it is important.
						Key messages:All the family need to be involved in changing eating practices - Good cooking and eating practices benefits the whole family
74	Smoking	Knowledge Social influences	Shaping knowledge Health consequences	Overall lack of awareness regarding the link between smoking and ill health. No awareness of the link between smoking and diabetes Smoking perceived to be common among certain groups: farmers, younger people etc.	Stigma: smoking in front of elders, women etc. Not acceptable to smoke in public spaces (bus, mosques etc) Family: less likely to smoke if it is not done in the family Family: discouraging smoking/encouraging to give up Peer pressure to smoke Religion discouraging smoking Quitting because of work Less likely to smoke with age	Straight information about smoking and perceptions of smokers: - Perceptions of people who smoke: mostly men, young, farmers, students, rural areas. - It is more men than women who smoke, but all different types of people smoke. They also may take other tobacco products. - There is some stigma regarding smoking, for example people will not smoke in front of their elders, women and in spaces such as the mosque. - It is important not to smoke in front of people as passive smoking can also cause harm to those around them. - Family and peer groups have an important role in not smoking – people are less likely to start smoking if their friends and family don’t smoke. We can also encourage each other to stop smoking. - People may also give up smoking because of their age, health, religious reasons and because of their work. - It is good to be motivated to give up smoking. There are also health consequences of smoking. - Reminder of the consequences of smoking: - People who smoke are at increased risk of diabetes, cancer, lung diseases, heart diseases, brain stroke and poor circulation, erectile dysfunction in males and infertility in women, tooth and gum disease. - Diabetics who smoke are less able to control their diabetes. Smokers with diabetes have a higher risk for complications of diabetes such as: heart and kidney disease, poor blood flow in the legs and feet that can lead to ulcers and infections, eye problems and damaged nerves		Men and women Diabetic and non-diabetic	Doctors voice	Perceptions of smoking and stigma is taken from the formative research
77	Smoking	Beliefs about capabilities Memory, attention and decision process Social influences	Modelling behaviour Shaping knowledge Social support	Belief that can only give up smoking by quitting completely Addiction to smoking	Family: less likely to smoke if it is not done in the family Family: discouraging smoking/encouraging to give up	Scenario: an uncle discovers his nephew smokes. His nephew admits he does but does not know how to stop as he is addicted. The uncle offers family support and also gives tips for giving up smoking. - Tips for giving up smoking: - You need to be personally motivated, think of the reasons you don’t want to smoke - Distract yourself with other things: talk to other, sport, work - You can cut down slowly the number of cigarettes you smoke every day until or stop completely - Keep trying eventually you will be able to give up - You can try and stop smoking with someone else - Change routines associated with smoking/do other things: exercise, namaj, talk to people - Spend time with friends/family who do not smoke - Key messages: - ways to give up smoking - family support to give up smoking		Men Non-diabetic	Drama