Using a multi-theoretical model to design supplementation interventions

Willardson SL1, McNerny BE1, Dickerson TT1, Benson LS1, Manortey SO1, Ansong D2, Boakye I3, Marfo J3, Arhin B3, Alder SC1

University of Utah1, Kwame Nkrumah University of Science and Technology2, Komfo Anokye Teaching Hospital3

Background: Experience has taught that simply providing information to increase awareness does not equate with appropriate behavior change1.  Such interventions assume that change is overcome by dispensing information to recipients who will independently adapt their situation and change behavior as necessary2.  Behavior change theories address this challenge by describing the complex process of behavior change and identifying variables that encourage change3.  While initiating a supplementation intervention in rural Ghanaian communities, we used this approach to determine more effective methods for maximizing compliance to a daily supplement regimen.  

Methods: Using the IMPART model as a guide4,5, a multi-theoretical framework based on constructs from the Health Belief Model and Theory of Planned Behavior was developed (see Figure 1).  These components were investigated in focus groups consisting of our target population in six communities.  Results from this formative research were used to develop a behavioral intervention to encourage compliance among this population.  

Results: The discussions indicated a lack of awareness regarding a supplement’s purpose.  Perceived benefits of supplementation included better health and stimulated appetite to increase daily intake of nutrients.  To some, this meant increased food purchases which intensified existing financial constraints.  Additional perceived barriers included cost, forgetfulness, and unsustainability.  Facilitators for compliance incorporated visual reminders, daily announcements, and peer support for reinforcement.       

An intervention was then developed such that participating women receive instruction on the benefits of supplementation as a means of promoting health, endorsement of the importance of supplementation, and specific direction on how to use supplements (see Table 1).  To establish a pattern of use, initial daily community announcements will be made each afternoon, reminding mothers to take their supplement.  Mothers will also use a ‘keeper’ system—checking in with a peer daily to ensure compliance.  Additionally, participants will receive a calendar with a series of photographs to reinforce these messages.  This intervention is currently being implemented among our target population.  

Conclusions: Using a multi-theoretical framework provides a sound, established method for promoting appropriate behaviors by focusing on behavior, rather than information.  This practical resource can be employed in several settings and may be particularly useful in a global-health approach.   

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