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.