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Table 2 COM-B and TDF analysis of the identified target behaviours influencing adherence to dietary and physical activity guidelinesa

From: The development of a theory informed behaviour change intervention to improve adherence to dietary and physical activity treatment guidelines in individuals with familial hypercholesterolaemia (FH)

COM-BTDF DomainRelevance of domainAppropriate intervention function(s)Behaviour change technique(s)Description of how behaviour change technique will be incorporated into intervention
Physical capabilityPhysical skillsIndividuals lack the skills to be able to prepare suitable meals especially for those who are gaining independence during critical periods of transitioning i.e. to live away from home for universityTrainingInstruction on how to perform behaviourAdvise individual how to modify current cooking techniques to fit with dietary guidelines i.e. baking instead of frying.
Demonstration of the behaviourIndividual to be signposted to resources which can aid with demonstration of the behaviour i.e. step by step recipe videos or pictorial guides and parents encouraged to demonstrate cooking skills to CA
Behavioural practice/rehearsalPrompt individual to practice cooking during intervention and adults to encourage CA to help them
Graded tasksCA to be prompted to help with food preparation -starting with simple task such as preparing vegetables, progressing to more complex tasks until able to prepare entire meal themselves
Parents impart skills of preparing meals
Adults to be prompted to start cooking meals- starting with simple recipes and progressing to more complex ones
Self-monitoring of behaviourIndividuals asked to record their cooking skills development progress in weekly reflection diaries
Physiological capabilityKnowledgeIndividuals lack, or have incorrect, knowledge of the guidelinesEducationInstruction on how to perform behaviourIndividual to receive detailed verbal and written information about the lifestyle guidelines and the chance to ask any questions they have- to prevent misinformation being passed to CA. Carried out during initial intervention session and during follow-up sessions.
Intergenerational transmission of inadequate and/or incorrect knowledge from parent to childIndividuals will receive detailed instructions about food swaps and cooking methods.
The dietary intake data will be analysed ahead of intervention to establish any existing eating habits that are indicative of misinformation i.e. cooking with coconut oil or eating lots of eggs. This will be proactively brought up for discussion with participant.
Behavioural regulationPeople find it hard to regulate their behaviour because they perceive the lifestyle guidelines to be restrictive and not allow for consumption of foods they enjoy (dietary) and hard to achieve/fit into their lifestyles (physical activity)EnablementSelf-monitoring of behaviourIndividuals asked to complete weekly reflection diaries in which they record whether they have been able to meet the goals set for lifestyle behaviours which will be discussed during follow-ups
Goal setting (behavioural)Individual prompted to set their own goals which they feel are achievable-which take into consideration their food preferences, fitness levels, readiness to change and lifestyles. The goals will be SMART.
Review behavioural goal(s)All goals will be reviewed at each follow-up session and, depending on level of achievement, will be increased or stay the same or a new additional goal will be created.
Action planningIndividual will be prompted to develop specific planning of how they will achieve each goal set i.e. if increasing fibre intake then the food swap or additional food to be included in diet will be specified, along with what meal or snack they will include it in and how many times per day or week.
Behaviour substitutionIndividual and dietitian to brainstorm other foods that they enjoy which are more in line with dietary guidelines which they could choose instead
Prompts and cuesIndividual advised to leave intervention booklet in a place where they regularly eat to prompt them to engage in the agreed dietary goals and set reminders on phones/fitness monitors to move regularly
Restructuring the physical environmentAdvise individual to keep food choices they enjoy eating, that are in line with the guidelines, in the house/at work/in car to encourage consumption of these when they want to eat foods which aren’t necessarily in line with desired behaviours
EducationInformation about antecedentsIndividual prompted to consider specific contexts in which they find it hard to adhere to dietary guidelines and identify triggers for this behaviour. The findings will be addressed in action planning and problem-solving session of the intervention.
Information about emotional consequencesDietitian to discuss with individual the potential improvement in their mood that they could experience if they choose to engage in dietary behaviours.
Dietitian to emphasis to individual that if they find foods that they enjoy that fit the guidelines, they will also experience the same enjoyment of these foods as with previous foods
Cognitive & interpersonal skillsNot found to be relevant
Memory, attention and decision processesIndividuals who have developed habits in accordance with the physical activity and dietary guidelines find their behaviours easier to regulate since their actions are less focused around conscious decisions and more about habituationEnablementIdentification of self as a role modelParents encouraged to view themselves as role models for their children and make their behaviours part of everyday life for their children to help them foster adoption of healthy habits from a young age.
Behavioural substitutionIndividuals encouraged to set goals that involve swapping something they currently do everyday with something that will help them achieve the guidelines to help establish new healthy habits i.e. walking to and from work instead of driving or always having a piece of fruit when they make their morning cup of tea instead of a biscuit.
Social opportunitySocial influencesEasier to follow guidelines if surrounded by family members also doing soEnablementSocial support (emotional)Dietitian to provide support during follow-up sessions- individuals advised to keep reflection diaries to record any emotional difficulties they have had which can then be discussed at follow-up.
Individual also encouraged to seek support from the family member(s) they are taking part in the intervention with- to view it as a ‘team effort’ and provide support and encouragement to each other
Individuals do not want to draw attention to themselves by eating differently in social situations
Social support (practical)Individuals encouraged to seek support from family members (including those not taking part in intervention) and friends if they are struggling to engage in the behaviours i.e. arranging to go to the gym with a friend or having partner/sibling help with food shopping or meal preparation.
Children and young adults model what parents do
Dietitian will also provide practical support during follow-up sessions- helping individual to identify methods to help encourage the behaviour i.e. links to online resources or suggestions on how they could obtain practical support from friends or family i.e. having their parent prepare help make their lunch
Individuals find it hard to follow dietary guidelines when with others due to social norms around eating.
Identification of self as role modelIndividual to communicate to parents how influential their behaviours are to their children and encourage them to engage in the behaviours they want their children to.
Young adults feel there is stigma around disclosure of their condition and it’s dietary guidelinesChildren also encouraged to view themselves as role models for their parents, other siblings and friends. Dietitian to communicate the benefits engaging in the behaviours could bring to these significant others.
Problem solvingDuring intervention ‘barriers and solutions’ section, dietitian will encourage individual to think of situations in which they feel they will struggle to engage in the desired behaviours (i.e. social situations) and think of solutions to overcome these. These will be reviewed at follow-up sessions.
Young adults want to eat with their friends at fast food outlets
Restructuring of physical environmentIndividuals encouraged to socialise with friends and family in places that facilitate engagement of desired behaviours i.e. meet in the park or choose restaurants in which there are suitable options for them so that they don’t have to draw attention to their food choices.
Physical opportunityEnvironmental context and resourcesLack of available healthy food easily accessible within their environment e.g. due to expense or where people typically source foodTrainingInstruction on how to perform the behaviourThe instructions provided from dietitian to individual will be individualised in terms of their lifestyles and other conflicting events in life that demand their focus. The advice given will provide instructions to individual about how they can achieve the desired behaviours in their current context i.e. cheaper options for suggested food swaps, suggested food swaps one they can obtain in the current place they shop, easy and quick options for meals if individual has limited time to cook and suggestions of PA they can fit into their current routines such as walking instead of bus/car.
Conflicting events in life (such as illness or new job) can reduce their available capacity/resources/time to follow the guidelines
EnablementSocial support (emotional)Dietitian to provide emotional support during intervention and follow-up sessions- discussing with them what else is going on in their life and how this is influencing their ability to adhere to guidelines.
Individuals also encouraged to seek the emotional support of friends and family
Social support (practical)The dietitian will encourage the whole family (both with and without FH) to engage in the dietary and PA guidelines to provide support to the individuals taking part in intervention.
People how have grown up with other family members who have FH have the skills and ability to follow the guidelines themselves
Individuals who may struggle to be able to make the changes required to meet the guidelines encouraged to enlist help of family or friends to help them with cooking or food shopping or taking children to sport classes
Restructuring the social environmentThe intervention is delivered at a family-based level with parent and child making dietary and PA choices together. Any other family members will also be encouraged to make the changes aswell to facilitate a home environment that encourages adherence to the dietary and PA guidelines.
Reflective motivationProfessional/social role and identityWhen they had a genetic diagnosis, as opposed to a clinical diagnosis of ‘possible’ FH, individuals feel that following guidelines are a natural part of their identity as someone with FHPersuasionFraming/reframingGuidelines communicated to individual as being specifically for individuals with FH as opposed to general healthy lifestyle guidelines provided to all individuals. The inclusion of two specific dietary guidelines for individuals with FH such as eating foods fortified with plant stanols/sterols and reducing dietary cholesterol intakes will help individuals to buy into the idea that following the guidelines is part of their identity of having FH. The benefits of following the guidelines in the management of their FH will be emphasised, in addition to general overall health benefits.
Beliefs about capabilitiesLack of confidence in ability to adhere to guidelines as they are perceived as being restrictive (dietary) and difficult to follow (dietary and PA)PersuasionFraming/reframingDietary guidelines to be communicated as a healthy lifestyle rather than a restrictive diet, with all foods permitted. Emphasis will be put on foods to add into the diet (fruits, vegetables, fibre rich foods, plant sterols/stanols) to help individual view dietary choices are positive and enjoyable.
Physical activity to be communicated positively, with emphasis placed upon finding activities that the individual enjoys doing, either alone or with friends or family, rather than it being a chore they have to try and fit into their day without enjoying it.
Verbal persuasion about capabilitiesDietitian to encourage individual and tell them that they are capable of changing their behaviours- to be included during initial session and follow-ups.
Focus on past successIndividuals asked to keep weekly reflection diaries to record progress in between follow-ups. Dietitian to ask during follow-up what the individual has recorded and to focus on any successful changes they have made and refer back to these to provide encouragement and motivation to individual to carry on and make more changes.
Feedback on outcomes of behaviourIndividual to receive feedback about how their dietary intakes and PA levels compare to the guidelines at the start and end of the intervention as evidence of their capability of adhering to the guidelines to promote maintenance of behaviours after intervention ended.
Beliefs about consequencesNot believing that FH poses a health risk so they do not feel the need to follow guidelines.EducationInformation about health consequencesThe intervention starts with explanation from dietitian about the importance of lifestyle guidelines in the management of FH. It will be explained that despite use of medication, many individuals with FH may still be at higher risk of cardiovascular disease and adherence to lifestyle guidelines can help reduce this risk. The benefits to their overall health will also be communicated.
Individuals to be informed about the ‘silent’ nature of cholesterol and the importance of keeping cholesterol as low as possible for your whole life, before any symptoms occur.
Especially salient in people who are asymptomatic and people who do not have a family history of FH
PersuasionCredible sourcesIntervention delivered by a dietitian who will explain the training they have undertaken to gain that title- to help individual recognise that their advice is credible. All individuals will also be informed that their doctor is aware and supportive of them receiving the intervention as they view it as being part of their clinical care.
As they are taking medication, they feel absolved from the need for following the guidelines.
Individual to be receive verbal and written advice about the guidelines which will include information about where the guidelines have come from- national committees across several countries who have reviewed all the available scientific evidence and come to same conclusion about the guidelines that individuals with FH should be following.
Individuals do not believe that following the guidelines will impact on their health outcomes.
BiofeedbackIndividual to be provided with weight, body fat % and blood pressure before starting the intervention to prompt adoption of guidelines- either to improve these figures or maintain them. Also will be provided with this information at the end of the intervention to compare with their results at the start of the intervention which will be discussed in relation to the behaviour changes made over the intervention.
IntentionsWhen people become parents, their intentions to look after their own health increases as they feel responsible to live longer for their childrenPersuasionComparative imaging of future outcomesDietitian to prompt individual to think about what the possible health outcomes would be if they choose to follow guidelines vs if they chose not to- with emphasis on what this would mean for their children or parents.
Identification of self as role modelDietitian to emphasis to parent that CA are heavily influenced by their behaviours, to encourage them to engage in guidelines for the sake of their childs health.
Information about health consequencesIndividuals to be informed about the ‘silent’ nature of cholesterol and the importance of keeping cholesterol as low as possible for your whole life, before any symptoms occur. The importance of the role of lifestyle guidelines to be discussed in context of benefits they provide over and above medication alone.
Children and young adults do not have the intention to deal with their condition yet
GoalsIndividuals desire to be actively involved in treatment decisions for themselves and their childrenEnablementGoal setting (behavioural)Individuals will decide (with help from dietitian and family members) upon goals for each of the guidelines and will be recorded in their intervention booklets. These goals will be SMART in nature and will be tailored toward the individuals individual circumstances, lifestyles and food preferences and readiness to change. Goals will not be prescribed- individual encouraged to think of them themselves.
Parents will be encouraged to help CA with setting their goals.
Review goal (behavioural)At each follow-up session, dietitian and individual will review the goals set at previous session or follow-up. Together they will agree to either: keep goal the same, modify the goal or create new goal. These decisions will be based upon individuals levels of achievement and willingness to change.
Self-monitoring of behaviourIndividual asked to record their achievement with the goals they set in weekly reflection diaries to be discussed at each follow-up sessions.
OptimismNot found to be relevant
Automatic motivationReinforcementParents are incentivised to enable child to follow guidelines to ensure that the child will achieve the best possible health outcomesPersuasionIdentification of self as role modelDietitian to emphasis to parent that CA are heavily influenced by their behaviours, to encourage them to engage in lifestyle guidelines for the sake of their childs health.
Comparative imaging of future outcomesDietitian to prompt individual to think about what the possible health outcomes would be if they choose to follow lifestyle guidelines vs if they chose not to- with emphasis on what this would mean for their children or parents.
Parents are also incentivised to take care of themselves so that they are healthy and able to take care of their child.Framing/ reframingIndividual prompted to view engaging in the behaviours as something that will benefit their children, rather than just themselves.
EnablementSocial support (emotional)Dietitian to encourage parent and CA to provide support to each other throughout the intervention and encourage each other to engage in the behaviours
EmotionIndividuals who themselves, or their family members, have experienced CVD symptoms experience stress and anxiety about the long-term health outcomes related to FHPersuasionFraming/ reframingIndividual prompted to view the guidelines as behaviours that can help reduce their risk of developing symptoms as their family members have, or reduce the likelihood of experiencing further symptoms. They are something the individual can do to help take control of their health.
Comparative imaging of future outcomesDietitian to prompt individual to think about what the possible health outcomes would be if they choose to follow guidelines vs if they chose not to.
Social support (emotional)Dietitian to encourage parent and CA to provide support to each other throughout the intervention and encourage each other to engage in the guidelines
  1. a ‘guidelines’ refers to both dietary and physical activity guidelines. In instances where only dietary or only physical activity guidelines are being referred to, this is specifically stated. CA: children and adolescents; SMART: specific, measurable, acceptable, realistic, time based