A qualitative evaluation of the effectiveness of behaviour change techniques used in the Healthy Eating and Active Lifestyles for Diabetes (HEAL-D) intervention

A qualitative evaluation of the effectiveness of behaviour change techniques used in the Healthy Eating and Active Lifestyles for Diabetes (HEAL-D) intervention | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A qualitative evaluation of the effectiveness of behaviour change techniques used in the Healthy Eating and Active Lifestyles for Diabetes (HEAL-D) intervention Amanda P Moore, Carol Rivas, Seeromanie Harding, Louise M Goff This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4436026/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 11 Feb, 2025 Read the published version in BMC Public Health → Version 1 posted 10 You are reading this latest preprint version Abstract Background Type 2 diabetes (T2D) is up to three times more common in people of Black African and Black Caribbean heritage living in the UK, compared to their White British counterparts. Structured education is the cornerstone of care but is less successful for people from minority ethnic groups. Healthy Eating and Active Lifestyles for Diabetes (HEAL-D) was developed to support diabetes self-management in people of Black African and Caribbean heritage living with T2D in the UK. The intervention was designed using COM-B/behaviour change wheel methodology to specify the theory of change. In a process evaluation study, we explored how the selected behaviour change techniques (BCTs) and components supported behaviour change in the intervention. Methods Focus groups and interviews were conducted with participants who were randomised to receive the HEAL-D intervention in a feasibility trial. A topic guide directed discussions to explore experiences of HEAL-D, key learnings and impact, and behaviour change; the interviews gave the opportunity to probe further the focus group themes and areas requiring clarification. Sessions were audio-recorded and transcribed. Framework analysis was used to explore how the selected BCTs supported behaviour change in those attending HEAL-D. Results Thirty-six participants took part in one or both activities (44% Black African, 50% Black Caribbean, 6% Mixed race; 61% female, 83% first-generation; mean age 59.5, SD 10.02). Participants reported increased physical activity, reduced carbohydrate portion size and engagement in weight monitoring behaviour. BCTs to increase social opportunity ( social comparison, social support ) and shift motivational barriers ( credible sources and modelling ) were effective in addressing cultural barriers around diet, stigma and health beliefs. BCTs to develop capability ( demonstration, instruction, information on health consequences ) were effective because of the cultural salience of the developed components. Less impactful BCTs were problem solving , graded tasks , goal setting , and feedback on outcomes . Conclusions BCTs identified in the development of the HEAL-D intervention were acceptable and effective, particularly useful were those promoting social opportunity as normative cultural habits and beliefs can conflict with diabetes self-management guidance. In addition, lifestyle interventions should include opportunity for experiential learning alongside culturally salient information provision. Trial registration number: NCT03531177; May 18th 2018 Type 2 diabetes ethnicity behaviour change process evaluation self-management behaviour change COM-B Figures Figure 1 Background Type 2 diabetes (T2D) is up to three times more common in people of Black African and Black Caribbean heritage living in the UK, compared to their White British counterparts [ 1 ]. It is predicted that by the age of 80, 40–50% of UK adults from Black ethnicities will have T2D [ 2 ], compared to 14% in the White British population [ 3 ]. Moreover, diagnosis occurs up to 10 years earlier than in White British, with poorer glycaemic control at diagnosis [ 4 ]. A range of factors contribute to this increased prevalence including socioeconomic, cultural, lifestyle and genetic factors [ 5 ]. People from Black minority ethnic groups are also less likely to complete annual T2D monitoring and are subject to prescribing disparities [ 6 ] and other structural barriers to equitable access [ 7 ]. Structured education programmes, are the cornerstone of T2D care, supporting people in diabetes self-management. Attendance at structured education is associated with improved glycaemic control [ 8 ], but people from minority ethnicities are less likely to attend [ 9 ], and, for Black participants, attendance is less likely to be associated with improved outcomes [ 10 ]. Multiple sociocultural factors shape diabetes self-management, including relationships with healthcare providers, community and cultural influences, socioeconomic drivers and other environmental factors [ 11 ]. As day-to-day self-management happens in primarily the social rather than clinical environment, sociocultural factors, such as normative dietary patterns, explanatory models of health, spiritual beliefs, taboo and stigma all influence engagement and outcomes [ 12 ]. Clinical guidelines in the UK identify a need for diabetes care to be culturally appropriate for people from different ethnicities [ 13 ] and a robust body of evidence suggests culturally tailored diabetes education can improve outcomes in both glycaemic control and knowledge [ 5 , 14 ]. However, there have been limited interventions designed to support people from Black African or Caribbean heritage in the UK setting [ 5 ]; the Healthy Eating and Active Lifestyles for Diabetes (HEAL-D) intervention was designed to address this need. HEAL-D is a culturally-tailored diabetes self-management education and support programme, which was co-designed with Black African and Caribbean adults with the objective of improving engagement with self-management guidance and supporting positive diabetes-related health behaviour [ 15 , 16 ]. During the development of the HEAL-D programme, people reported several barriers to optimal self-management including social pressures and personal desire to continue to enjoy traditional cultural foods, lack of empathy from or distrust of healthcare, traditional beliefs around body shape and a rejection of the relevance of BMI ranges for the Black body shape. A lack of detailed understanding of diabetes-related physiology, cultural attitudes towards food preparation, as well as sociocultural challenges around the pressures of caring roles, inflexibility of shift work and 'zero hours’ contracts, and socioeconomic pressures were also evident from the preliminary development work [ 17 ]. The development of the theory of change underpinning the design of the HEAL-D intervention and the choice of specific behaviour change techniques (BCTs) was specified using the behaviour change wheel (BCW) developed by Michie et al. [ 17 , 18 ]. Intervention components, designed to deliver the selected BCTs, included games, videos, exercise classes and education sessions. The intervention was delivered face-to-face over 7 sessions, in community settings, as part of a feasibility trial from March 2018 to April 2019 [ 19 , 20 ]. The full HEAL-D intervention [ 21 ] and the COM-B analysis and identification and operationalisation of BCTs have been previously described [ 17 ]. Exploring the mechanisms through which interventions bring about change is crucial to understanding both how the effects of a specific intervention occur and how these effects might be replicated or improved upon in similar future interventions [ 19 , 20 ]. As part of the process evaluation of the HEAL-D feasibility trial, we wanted to understand how participants interacted with the intervention and how the operationalised BCTs worked to support behaviour change within the context in which the intervention was delivered. This is the focus and aim of the current paper. Methods Design We used a qualitative study design based on focus groups and semi-structured interviews. Below we describe this in detail. Ethical approval was granted as part of the trial approvals by the NHS Health Research Agency (HRA) registration number 233419; participants provided written informed consent prior to participation. Participants Participants were taking part in the HEAL-D feasibility trial, a two-arm parallel group randomised controlled trial; all participants allocated to the HEAL-D intervention arm were eligible to take part in the process evaluation focus groups and were invited. They were given the option of an interview if they refused the focus group. Trial participants were adult (age ≥ 18 years) men and women of self-declared Black-African, Black-Caribbean or Black-British ethnicity living with T2D; purposive sampling was used to determine who to invite from the focus groups to attend the one-to-one interviews to a give a balance of gender and ethnic background. Participants were recruited to the trial through a combination of community-situated initiatives, such as awareness building in faith institutions and with charity partners and via general practitioners and secondary care diabetes self-management education referrals. These communities are often under-represented in medical research and some distrust of healthcare services has been reported particularly amongst those with lower health literacy [ 22 ], therefore community recruitment was particularly important to ensure inclusivity of the sample. Procedures Full details of the HEAL-D intervention have been previously published [ 21 ] but, in brief, HEAL-D is a group-based programme delivering a curriculum of diet and lifestyle behaviour change support in seven 2-hour sessions, facilitated by a specialist dietitian, a lay educator and exercise trainers. The details of the BCTs identified during the HEAL-D intervention co-design process and how these were operationalised across the intervention components are further illustrated in Table 2 . One focus group was planned at the end of each seven-session delivery of the HEAL-D programme, thus participants had attended the same group. Usually the focus group was conducted within two weeks of the intervention finishing. The semi-structured interviews were conducted to gain further insight into the focus group discussions, as well as explore personal perspectives. All data collection was undertaken by an experienced white British doctoral qualitative researcher (AM), who was known to the participants through their involvement in the feasibility trial. Each focus group lasted approximately 2 hours and participants were given a £10 gift voucher for their participation. Table 2 Description of the HEAL-D intervention components to support each BCT identified (Modified from Moore et al.,2019)[ 17 ] BCT Intervention component Information about health consequences (To educate developing knowledge and skills) The educational curriculum covered health consequences and benefits of various key lifestyle behaviours. A detailed file provided contained written information and activities to support each educational session. An animation video “Diabetes explained” explained the mechanisms of type 2 diabetes. Instruction on how to perform the behaviour (To educate developing knowledge and skills) The curriculum communicated health guidance clearly using culturally relevant examples. Demonstration (To educate developing knowledge and skills) Practical games, the weekly discussion tasks, a cooking session (with cooks in the family invited) and structured exercise sessions (including African dance music and dancing) provided guided demonstration. An exercise DVD using credible sources was provided for participants to follow at home. Graded tasks (To educate developing knowledge and skills) Physical activity sessions and targets were graded for ability to boost chances of success hence confidence and self-efficacy. Social support (unspecified) (Socially focused to Persuade and Enable) Social connectedness was fostered within the group by the discursive nature of the sessions and through shared engagement in activities and structured exercise sessions Social comparison (Socially focused to Persuade and Enable) The ‘task card’ homework activities gave participants opportunity to try the lifestyle targets and come back to discuss with the group and with educators. Participants were encouraged to share their successes to encourage comparison within the group. In addition, role models were featured in the case study video Credible sources (Socially focused to Persuade and Enable) Videos were used as part of the intervention including advice and tips from community leaders, healthcare practitioners and patients from the community that have successfully changed their habits Feedback on outcomes, self-monitoring of behaviour The programme started with personal measurements and blood results, and updated outcome measures were given at the end of the programme. Participants were encouraged to monitor weight loss progress by taking waist measurements through the course and completing their programme booklets. Self-monitoring of behaviour, action planning Participants were given pedometers to measure their steps and were taught to develop action plans and measure their progress against them. Goal setting (behaviour) Participants were guided through setting their own goals for the lifestyle targets that are important for them Problem solving The ‘task card’ homework activities were discussed at the beginning of each session, challenges were identified, and the group problem solve collectively. Problem solving also forms part of the education sessions about lifestyle habits. Action planning Participants were guided through how to develop and adjust action plans for each of the target behaviours and for their personal objectives, to help keep them motivated. The interviews were conducted in person in university rooms, the participant’s home or within a medical setting, depending on participant preference, and lasted approximately 60 minutes. They took place within 4 weeks of the intervention delivery being completed, with participants being given a £10 voucher for their time [ 22 ]. For both the focus groups and interviews, participants were briefed that the sessions were being conducted to help the research team understand what worked well and what needed to be improved in the HEAL-D intervention. The focus groups were structured using a topic guide which explored experiences of the intervention, key points of learning and impact, and behaviour change. Sessions began with participants describing their response to the intervention and any changes to their health behaviour as a result of their experience. Participants were given the opportunity for non-judgmental recall to understand the key drivers of change for each individual, followed by further probing around specific components. The interviews followed a similar topic guide but gave the opportunity to probe topics from the focus groups in more detail and areas requiring clarification. It was also useful to get a personal perspective on the topics which may be more sensitive to discuss within the group, such as the interaction between people from different ethnic backgrounds and between genders. Sessions were audio recorded and transcribed. Where needed, ethnically concordant transcribers were used to ensure accents were faithfully transcribed and the audio recordings were checked against the transcripts by the research team to ensure accuracy. Analysis The data were analysed using a framework approach with the intervention theory of change as a template [ 17 ]; data were coded by BCT, and general comments on the intervention as well as descriptions of behaviour change were also recorded. The framework facilitated an intersectional approach to the analysis to explore the influence of key contextual factors on the effectiveness of the BCTs. To give a general indication of the BCTs considered most beneficial by the participants, the interview transcripts were coded for recall of positive impact of each BCT by participant and results recorded in a coding density chart. The focus group data was not coded in this way due to the challenge of accurately matching the verbatim quotes to individuals. The data analysis was developed with input from the research team and participant advisors. In addition, interviews were held with two educators delivering the intervention to help frame and validate participant responses. The data are reported according to the COREQ guidelines (supplementary data 1). Results Thirty-six participants took part in this evaluation study; 15 participated in interview only, 16 in focus group only, and 5 took part in both an interview and focus group, Table 1 . Four focus groups were conducted. The sample was 83% first generation, predominantly female and both Black African and Caribbean ethnicities were approximately equally represented. Table 1 Participant characteristics % (n) Mean (SD) Ethnicity Black African 44.4 (16) Black Caribbean 50.0 (18) Mixed race (BA/WB) 5.6 (2) Gender Female 61.1 (22) Age 59.5 (10.02) Migration history First generation 83.3 (30) Second generation 16.7 (6) Overall, participants reported significant behaviour change as a result of participating in the HEAL-D intervention, suggesting the selected BCTs have practical utility in a real-world setting. Figure 1 illustrates the components that were most commonly reported to have supported behaviour change, principally these were BCTs to demonstrate the behaviour , which align to the educate function, those based on providing social support and social comparison , which align to the persuade and enable functions, and those promoting advice and support from credible sources , which align to the persuade function. Reported behaviour change Table 3 provides illustrative quotes for the most commonly reported behaviour changes: increased moderate to vigorous physical activity, reduced carbohydrate portions, and engagement in weight-monitoring behaviour. The majority of participants reported improvements in measurable outcomes including improved metabolic parameters, weight-loss, improved stamina or medication reduction. With regards to carbohydrate portions, knowing how portion guidance related to traditional starchy foods was empowering, so traditional foods could be enjoyed with confidence: “You're armed, you're tooled with the information now.” Equally some made their own decision to avoid some traditional starches, changing eating patterns developed over many years [ 16 ]. A general increased self-efficacy and confidence was reported following the intervention. Table 3 Participant reports of behaviour and self-efficacy changes Reduction in starchy carbohydrate intake “Do you know, since the programme, as of the middle of the programme and since the programme ended I have not taken the garri, the cassava one, I've not taken it. Interviewer: Why is that? Because I've come to realise after eating that garri, that cassava one, swallow, especially in the evening, I get so heavy in me. I can't do anything. I was tempted all throughout in Nigeria, but I avoided it. I realised one of the things I avoided was the garri, and I could eat a big bowl of rice… I cut my rice into half now.” (Participant 44, BA Male, Age 64, Nigeria) Reduction in necessary medication “They have taken me off glazi, what do you call it? [Glicazide], they've taken me off that they said because my blood sugar has gone down, I'm okay. I really love it. I'm just left with metformin now.” (Participant 24, BA Female, Age 58, UK) Reduction in waist size “I've lost weight, I think I have. Well, it's funny, I still weigh the same, but my trouser size is - I was taking size 36 trousers, yes? Now, all of a sudden, they're too big for me and I've started taking size 34 now… Yes, it's inches, isn't it.” (Participant 58, BC Male, Age 60, Dominica) Increased exercise and improved stamina “… because of the exercise, I mean I'm normally doing bits, but I can say that my stamina has increased. For instance, I went to Brixton today, and months back - I have a bad knee and a hernia - and I found myself walking around Brixton, so I maybe did about 45 minutes walk, so my stamina is definitely [improved]. I'm thinking it is nothing to climb up a hill and whatever, without puffing and things […] I can feel definitely that my stamina has increased.” (Participant 66, BC Female, Age 68, Jamaica) “The blood sugar has really gone down […] This thing dropped from seven and it's six. […] I think if you really look at my progress now, I think, I don't know how, I'm so confident. At the moment, I just feel that there's nothing wrong with me … even though there's still much to do, but I think I've really improved a lot in so many ways, and so… Just them telling me… I'm just happy… Just I have a good feeling for myself, you know, very confident, very confident. It's just like there's nothing disturbing me. It's just like part and parcel of me now. […] Before all the food, my living, the way I live now is, I don't know how I can describe it to you, the gap is so big.” (Participant 18, BA Male, Age 42, Cameroon) BCTs to educate and improve knowledge and skills Intervention components based on BCTs to improve knowledge and skills were seen to be pivotal to the success of the intervention for the majority. Illustrative quotes are presented in Table 4 . Participants valued the balance between the theoretical and practical components designed to demonstrate the behaviour . In HEAL-D, components based on these BCTs included food related games, participatory physical activity sessions, participatory cook and taste session, along-side verbal and visual information. Moreover, with regards to reducing carbohydrate intake, changing cooking habits and engaging in moderate to vigorous physical activity, the practical demonstration, anchored in cultural traditions, appeared vital. Components based on other BCTs to increase knowledge worked synergistically with the practical participatory demonstration. For example, the BCT Information on health consequences was the basis of a culturally aligned animation video called Diabetes Explained , and written, visual and verbal information about the links between behaviour and diabetes outcomes; and Instruction on how to perform behaviour was the basis of photographic representations of portion sizes, written details about understanding exercise intensity, and verbal instructions about which foods contain healthy fats. Participants valued the written resources providing Instruction and Information on health consequences , viewing them as a reference guide which could be reviewed outside the sessions: “That file, it can be under your pillow… a solution it reminds you back.” It was the cultural salience of the information and demonstration techniques that made the difference, compared to information they had received previously. The provision of written and visual materials was supported with the physical presence of the educator who successfully helped reinforce the information. Having an educator there in person was particularly important for older individuals who may struggle with biomedical understanding. Table 4 Participant reflections on BCTs chosen to increase knowledge and skills BCT: demonstration; instruction Component: Food knowledge game “That was the day I realised probably I had been a big fool. […] It was all fun and I took home a lot. It looks like a little game, but it brought the reality, the essence of the food we eat. It brought it into real-life play, and it was quite a very useful method of passing the message, other than just saying it with your mouth. … the shock is not the same thing.” (Participant 44, BA Male, Age 64, Nigeria) BCT : demonstration; instruction Component : Participatory exercise classes “There are lots of people, you tell them to exercise, and they say, 'Oh yes, I'll do it', yes, but to actually participate - because I'm sure there were lots of people in that group who never did what we did during that course. They say, 'Oh yes, I did, I do walking', but it opened your awareness to certain forms of exercise that you need to do.” (Participant 51, BC Male, Age 77, Guyana) BCT : demonstration; instruction Component : Cook and taste session “The food they prepared for us has given me a lot of ideas. I know I have to eat veg, but there are different ways you cook veg which they showed us the other day, which is very, very educative. They teach you how to put little bit of oil, not like the way we put. You think about eating veg, you put plenty of oil, you've spoilt it. They taught us a lot, that cooking.” (Participant 34, BA Female, Age 61, Nigeria) BCT : information about health consequences Component : Video “The videos are very good. When you are first diagnosed there are a lot of conspiracy theories about what diabetes is, or what it's not. That video tried to explain, when you say somebody's diabetic, what is really happening in the inside. It talks about the key, which is insulin, that will boost the vein, and it talks about what happen when the veins is clogged […] So that video is very concise, and it explained in the plain language that I think everybody was able to understand.” (Participant 54, BC Female, Age 55, UK) BCT : information about health consequences; Instruction Component : Written information “The book is good because basically, what I’ve been doing is going back to my book all the time, and that’s another thing its inspiring – you look back at what you’ve learnt. I actually find what works for me is sitting down, reading my book – I wrote little things in like if I’d done exercise – you can sit down and write your own experience.” (Participant 54, BC Female, Age 55, UK) BCT : information about health consequences; Instruction Component : Written information “Where we come from, your husband can go for another woman, just because of food. Like, my husband, when he's cooking, it's salt, salt, salt. He likes salt. So, I said to him, 'If you want to cook salt and kill yourself, I'll come to your burial, but please don't add it too much on my one. For me if I had not seen the information I wouldn't know. I would keep continue doing what we are doing.” (Participant 64, BA Female, Age 52, Nigeria) “Any problem, they are willing to answer our questions if we have anything. She demonstrate things, she gets to the board. She tells you what you didn't know or didn't understand…The clog. When the blood vessels, when they clog. That was like, woo! Yes, she was explaining over and over how it works. Explained everything. If you had a problem, if there's something that you didn't understand, nothing was too much for them to say, 'Right, I can go over it,' or you could stay back and talk to them” (Participant 62, BC Female, Age 84, Jamaica) Socially-focused BCTs to Persuade and Enable Intervention components based on social support (group sessions facilitating interaction and support) and social comparison (for example, sharing experiences and learning within the group) provided individuals with much needed social support to manage their diabetes. “It made you feel like, actually, I'm not too - you know, you are human because people make errors in assuming that you're in the same boat as well. So, it didn't make you feel, oh, you know what, you're so bad at doing this. It just shows you, seeing others actually, especially if you're new, like me, I'm new to it, so you're still finding your feet, and it's okay to fall, but just remember, you need to pick yourself back up. You can fall, but don't stay down. Pick yourself back up and go straight ahead.” (Participant 63, BC Female, Age 67, Guyana) The importance of the group interaction was evident, as individuals learnt a lot from each other and motivated each other (see Table 5 ). Because individuals were learning from each other, it gave the educational recommendations credibility and salience as participants discussed positive personal experience and insights. Table 5 Participant reflections on socially focused BCTs to persuade and enable BCT: social comparison Component: Group sessions “That was very good because people don't really realise that there are people, other people in the same boat as you are, suffering the same thing. Exchanging ideas and views, in some small way, although it might look insignificant, could be helpful to you. By listening to this person or seeing what this person does or hear what this person does, you can benefit from it” (Participant 51, BC Male, Age 77, Guyana) BCT : social support Component : Group sessions “If we can share, perhaps, they were going through a bad time and they've relapsed and they're not sticking to the programme, and their diabetes is going out of control. Be able to talk about it and properly try and get them back on track and that kind of thing…” (Participant 47, BC Female, Age 58, Guyana) BCT : social support Component : Exercise classes “Last week I was, two weeks ago I was ill. Pains all over my body. So, this young lady, I told her that, 'I can't do any exercise today because I'm…' She came to me, face to face and said, 'You can do it'. Said, 'But if you can't, sit down'. So, I sat down there. I felt guilty. People are doing, I'm not doing. So, I start on the chair. When she says, 'Do this', she said, 'Yes. That's what you should do. You don't have to stand up, you know'. I was feeling the pain but I enjoyed doing the thing. By the time we were finished, I stood up. [Laughs] the group …they encourage [me]” (Participant 65, BA Female, Age 58, Nigeria) BCT : credible sources Component : case study videos “The videos about the people that are living with diabetes, you see stories about people that encourage you. That some people have been doing this, have been diagnosed for years, and they are still living happily. That you can still live a happy life, even if you are diabetic […] Talking about the food and what we can eat, and our food, the type of food we have and how much carb there… It was amazing that we didn't… I still think up to this day a lot of Caribbean, African backgrounds, we're still not aware of that, and we still eat so much of it. So again, it was awareness and I find it was really good.” (Participant 22, BA Male, Age 41, Nigeria) “I find myself… that I was the least-informed in the group. So, I was learning from these elderly ladies and gentlemen. Seriously, I was listening to their experience, their practical experience and what they thought […] he, my fellow countryman… he taught me a lot of things that could really increase diabetes, if I was to eat or drink certain things. What I'm saying is that I wasn't aware before… and it's like… it was really verifiable information. So, it comes back right into say, well, awareness and discussing and sharing.” (Participant 22, BA Male, Age 41, Nigeria) These components supported the learning by improving confidence, making it acceptable to challenge traditions, and normalising diabetes, encouraging individuals to be open about their condition, where they would traditionally have been more hesitant about disclosure. “Where I come from, from the Northern part of Nigeria, it is a shame thing. That shame, that, 'Oh, how can you tell your family you have this?' So, you keep it to yourself, and it's like AIDS/HIV. So, you don't want to tell no one, and just so that you just can continue with it yourself. So, it has really helped me broaden out the kind of person I am. Going to these open courses, it give you a full mind like to expand your talk and get more confidence. then I thought, 'Oh, I can talk now, too” (Participant 64, BA Female, Age 52, Nigeria) Furthermore, it created strength to resist social pressures. The use of credible sources and modelling , for example having ethnically concordant lay educators and videos with tips from faith leaders and other trusted members of local Black communities, reinforced the social acceptability of the new behaviours. “The videos about the people that are living with diabetes, you see stories about people that encourage you. That some people have been doing this, have been diagnosed for years, and they are still living happily. That you can still live a happy life, even if you are diabetic […] Talking about the food and what we can eat, and our food, the type of food we have and how much carb there… It was amazing that we didn't… I still think up to this day a lot of Caribbean, African backgrounds, we're still not aware of that, and we still eat so much of it. So again, it was awareness and I find it was really good.” (Participant 22, BA Male, Age 41, Nigeria) BCTs to improve self-efficacy and behaviour regulation Components associated with BCTs to improve self-efficacy and behaviour regulation included: self-monitoring through measuring waist, weekly weighing, and using a pedometer goal setting and action planning through a SMART goal session and exercises, and weekly group goals; Feedback on outcomes through anthropometry and biochemical markers at the end of the intervention; and Problem solving . In general, these BCTs were less frequently mentioned in the data than the components associated with improving knowledge and developing social support. Yet they still seemed powerful for several individuals (see Table 6 ). Many of the participants had set themselves goals for the programme – from fitting into a dress that had become too tight to achieving 10,000 steps every day. Table 6 Participant reflections on BCTS to improve self-efficacy and behaviour regulation BCT: Goal setting Component: SMART goals “I was shopping yesterday and I was walking around Sainsbury's, and because you know we've got that goal target, of getting your waistline down? So, I'm about one inch away from my goal target... All I kept hearing, every time I walked past something naughty was, “one inch away from 33, don't do it”! We were actively encouraged. Like... 'This is a challenge, set yourself a goal every week. Set yourself a new different goal,' which is good because even now, like I said, I'm one step away from my waist goal, and I'm already thinking, all right, when I hit that, I've got to do the next goal. So, I'm always planning that in my head already.” (Participant 61, BC Female, Age 37, UK) BCT : Feedback on outcomes Component : HbA1C measurement “My blood HbAc [sic] when I went to my GP a few weeks ago, it was 53. I feel really good. I feel, 'Wow, all this hard work is working,' but it's not just something you do for three months and then think, oh, I'll go back to it. It's an ongoing thing. This is what people have to understand, it's not something you can just switch off for a few months and then think, oh, I'll come back to that. It's literally ongoing all the time.” (Participant 41, BC Female, Age 58, Barbados) BCT : Self-monitoring Component : weighing and measuring waist “Yes, I've been weighing, and I've been taking my measurement round, you know, bust, stomach, or especially my long waist, and I'm wearing dresses that I wasn't going into. I hate to give away my dresses because they are expensive. Yes. So, I appreciate coming to this course, and I can see. I used to have segmented neck here, but now when I look on the mirror, I see that's reduced. I am feeling better… I can even fight my husband now!” (Participant 63, BC Female, Age 67, Guyana) “We were actively encouraged. Like, 'This is a challenge, set yourself a goal every week. Set yourself a new different goal,' which is good because even now, like I said, I'm one step away from my waist goal, and I'm already thinking, all right, when I hit that, I've got to do the next goal. So, I'm always planning that in my head already.” (Participant 60, BA Female, Age 49, Sierra Leone) Those participants who set themselves a personal goal found it motivating and were assisted by the Self-monitoring element facilitated by the pedometer and waist tape measure: “When I saw the size 34 waist, it just gave me a bounce in my step. I was good for the day.” When individuals saw their Hba1C, weight and other parameters had reduced it had the effect of cementing and reinforcing the changes they had made. Discussion Participants reported that the HEAL-D intervention helped them actively change their diabetes-related health behaviours, particularly in relation to increasing moderate to vigorous physical activity, reducing carbohydrate portion size and engaging in behaviours to manage weight. The operationalised BCTs which underpinned the design of the HEAL-D intervention components were acceptable and effective. Those which had most impact were demonstration of the behaviour, social support, social comparison and credible sources. Of the other BCTs adopted in the HEAL-D intervention, those felt to be necessary but of secondary importance were BCTs to educate ( Information about health consequences, instruction how to perform the behaviour ) and BCTs to improve self-efficacy and behaviour-regulation ( Self-monitoring ). The less impactful BCTs were problem solving, graded tasks, goal setting and feedback on outcomes. One of the reported critical challenging factors for people from minority ethnic backgrounds living with T2D in high income countries, is the conflict between diabetes-related lifestyle guidance and social norms, particularly normative dietary traditions, body image ideals and beliefs around purposeful physical activity [ 23 , 24 ]. The strong reliance on starchy staples and oil and salt in cooking means that some dietary change is warranted to support diabetes management, although it does not require cultural foods to be eliminated from the diet. Dietary change is hard for all individuals as diet is one of the early learnt habits [ 25 ]. For migrant communities, however, cultural foods play a symbolic role in maintaining cultural identity [ 26 ]. The role of food culture is considered crucial in the diasporic experience [ 27 ]. It can help delineate ethnicity creating a sense of “us” [ 28 ], maintains a link with homeland [ 29 ], and reinforces social bonds [ 27 , 30 ]. Individual dietary-related behaviour change can be further hampered in African collectivist cultures, where family and group preferences are given precedence over those of the individual [ 24 ]. Our analysis highlights the particular value of BCTs increasing social opportunity ( social comparison, credible sources, social support, modelling ) to shift beliefs about the incompatibility of self-management behaviour change with cultural identity and, interestingly, to challenge the perceptions of others within their communities. The additional provision of culturally pertinent guidance on portion size ( instruction on the behaviour, demonstration ) empowered individuals to make dietary changes while still following cultural preferences. These findings support the development of specific interventions or adaptations for particular cultural groups and suggest the importance of community delivery or involvement in intervention delivery. This evaluation also highlights the perceived value of experiential learning amongst the participants. They found particular value in components designed to deliver the demonstration BCT, such as learning games and cooking sessions. This finding supports much of the existing literature. The importance of kinship, social interaction and collectivism is well-reported for those of Black African ancestry [ 31 – 33 ]. In communities of African ancestry living in high income countries, lack of social support has been identified as a particular barrier to lifestyle-related health behaviour change [ 34 – 36 ], particularly when healthcare advice may conflict with culturally influenced social norms [ 37 ]. Lifestyle interventions for African American individuals that focus on engaging in social networks have been shown to be particularly effective [ 36 , 38 ], and a review of weight management interventions to support African American women suggests that mobilising social support may be both “therapeutic and cost-effective” , acting to improve self-efficacy and individual perception of control [ 36 ]. Moreover, the presence of social support has been shown to be associated with positive diabetes self-management behaviour in African American communities, for example African Americans were more likely to successfully manage their diabetes when they could learn from family members with diabetes [ 39 ]. It is interesting that some of the BCTs that have their origins in control theory, such as action planning , goal setting, self-monitoring, feedback on outcomes , which have been identified in the development of other interventions to support lifestyle change, were less often mentioned across the group in this analysis, although were salient for some. These BCTs have been shown to be important in self-regulation for individuals living with diabetes [ 40 ]. In addition, several reviews highlight the value of these techniques in supporting change in physical activity and dietary behaviours [ 40 – 42 ]. We suggest that these BCTs were important to include, though perhaps were not central to the way the intervention worked to support behaviour change in this case. This analysis has strengths in the use of rigorous qualitative methods with analysis triangulated with patient and community advisors, an independent qualitative advisor, and community-driven recruitment to improve inclusivity. COM-B has now been used in formative research to identify BCTs and help specify the theory of change in the design of several interventions for diabetes [ 43 – 46 ] and gestational diabetes [ 47 – 49 ], though more rarely specifically for study populations from minority ethnicities [ 46 , 47 , 49 ]. To our knowledge none of these studies have reported process evaluations specifically related to the effectiveness and acceptability of identified BCTs in practice. Whilst a substantive multi-centre trial is now underway to evaluate the effectiveness of the HEAL-D intervention, this particular study is conducted in London, where there is a high population density of people from minority ethnicities. This may influence transferability to other geographies with a different ethnic density, where community dynamics and healthcare support may differ. The researcher conducting the data-collection for this evaluation was also involved in the intervention co-design and development. This had the benefit of increasing rapport and familiarity with participants, supporting frank and open discussion, however, using an independent researcher may have been preferable to prevent any introduction of bias. Triangulation of the analysis within the research team, participant representatives and data from educators delivering the intervention helped minimise bias resulting from this. Conclusions Our evaluation suggests that the COM-B/Behaviour change wheel methodology supported the identification of BCTs which were acceptable and effective in driving individual behaviour change in the HEAL-D intervention. BCTs promoting social opportunity are useful to support lifestyle behaviour change in Black African and Caribbean adults with T2D, where social norms can conflict with diabetes self-management guidance. In addition, lifestyle interventions should include opportunity for experiential learning alongside the information provision. These findings may be of particular value to researchers and clinicians developing healthcare interventions to engage people of Black African and Caribbean ethnicity, and researchers using COM-B and the Behaviour Change Wheel, as there is little published evaluation of the acceptability and effectiveness of BCTs selected and developed using this methodology for people from minority ethnicities. Abbreviations BA Black African BC Black Caribbean BCT Behaviour change technique BMI Body Mass Index HEAL-D Healthy Living and Active Lifestyles for Diabetes MR Mixed race NHS National Health Service NICE National Institute for Clinical Excellence RCT randomised controlled trial SMART goals Specific, Measurable, Achievable, Relevant, Time-bound goals T2D type 2 diabetes WB White British Declarations Ethics and approval and consent to participate Ethics approval was granted for the study by the Health Research Authority (London Fulham Research Ethics Committee; 17/LO/1954 under IRAS reference 194991. Informed consent was taken from all participants according to this ethical approval. Consent for publication Consent for publication of anonymised data was obtained from all participants. Availability of data and materials The data set from this study is not publicly available due to the restrictions associated with ethical approval but are available upon reasonable request to the corresponding author [LMG]. Competing interests The authors declare that they have no competing interests. Funding This report is independent research arising from a Career Development Fellowship ( LMG , CDF-2015-08-006) supported by the National Institute for Health Research. AM was supported by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care South London at King’s College Hospital NHS Foundation Trust, as part of her PhD funding. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health. Author’s contributions Study conception LMG, CR, SH; Data analysis as part of PhD thesis AM; Drafting the manuscript AM; All authors discussed the analysis, results and contributed to the final manuscript. Acknowledgements With thanks to Diabetes UK, Muslim Association of Nigeria, Baitul Rahman Masjid Mosque, The Latter Rain Outpouring Revival Church, Peckham, St John’s Church, Peckham. References Harrison G. Health beliefs of black and minority ethnic groups and the implications for diabetes care. J Diabet Nurs. 2014;18:362–8. Tillin T, Hughes AD, Godsland IF, Whincup P, Forouhi NG, Welsh P, et al. Insulin resistance and truncal obesity as important determinants of the greater incidence of diabetes in Indian Asians and African Caribbeans compared with Europeans: the Southall And Brent REvisited (SABRE) cohort. Diabetes Care. 2013;36(2):383–93. British Geriatric Society. Diabetes: Good practice guide. 2018. Paul SK, Owusu Adjah ES, Samanta M, Patel K, Bellary S, Hanif W, et al. 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London, UK: Hodder Arnold; 2007. Wright KE, Lucero JE, Ferguson JK, Granner ML, Devereux PG, Pearson JL et al. The influence of cultural food security on cultural identity and well-being: a qualitative comparison between second-generation American and international students in the United States. Ecol Food Nutr. 2021:1–27. Tat Shum TC. Culinary diaspora space: Food culture and the West African diaspora in Hong Kong. Asian Pac Migration J. 2020;29(2):283–311. Kershen AJ. Introduction: Food in the migrant experience. In: Kershen AJ, editor. Food in the migrant experience. London: Routledge; 2017. pp. 17–30. Gunew S, Introduction. Multicultural translations of food, bodies, language. J Intercultural Stud. 2000;21(3):227–37. Lin HM, Pang CL, Liao DC. Home food making, belonging, and identity negotiation in Belgian Taiwanese immigrant women's everyday food practices. J Ethnic Foods. 2020;7(1):1–8. Di Noia J, Furst G, Park K, Byrd-Bredbenner C. Designing culturally sensitive dietary interventions for African Americans: review and recommendations. Nutr Rev. 2013;71(4):224–38. Nishikawa E, Oakley L, Seed PT, Doyle P, Oteng-Ntim E. Maternal BMI and diabetes in pregnancy: Investigating variations between ethnic groups using routine maternity data from London, UK. PLoS ONE. 2017;12(6):e0179332. Resnicow K, Baranowski T, Ahluwalia JS, Braithwaite RL. Cultural sensitivity in public health: defined and demystified. Ethn Dis. 1999;9(1):10–21. Tyler DO, Allan JD, Alcozer FR. Weight loss methods used by African American and Euro-American women. Res Nurs Health. 1997;20(5):413–23. Wilbur J, Chandler P, Dancy B, Choi J, Plonczynski D. Environmental, policy, and cultural factors related to physical activity in urban, African American women. Women Health. 2002;36(2):17–28. Wolfe WA. A review: maximizing social support-a neglected strategy for improving weight management with African-American women. Ethn Dis. 2004;14:212–8. Moore A, Flynn AC, Adegboye ARA, Goff L, Rivas C. Factors influencing pregnancy and postpartum weight management in women of African and Caribbean ancestry living in high income countries: systematic review and evidence synthesis using a behavioural change theoretical model. Front Public Health. 2021;9. Kumanyika SK, Wadden TA, Shults J, et al. Trial of family and friend support for weight loss in african american adults. Arch Intern Med. 2009;169(19):1795–804. Madden MH, Tomsik P, Terchek J, Navracruz L, Reichsman A, demons Clark T, et al. Keys to successful diabetes self-management for uninsured patients: social support, observational learning, and turning points: a safety net providers' strategic alliance study. J Natl Med Assoc. 2011;103(3):257–64. Hankonen N, Sutton S, Prevost AT, Simmons RK, Griffin SJ, Kinmonth AL, et al. Which Behavior Change Techniques are Associated with Changes in Physical Activity, Diet and Body Mass Index in People with Recently Diagnosed Diabetes? Ann Behav Med. 2015;49(1):7–17. Olander EK, Fletcher H, Williams S, Atkinson L, Turner A, French DP. What are the most effective techniques in changing obese individuals’ physical activity self-efficacy and behaviour: a systematic review and meta-analysis. Int J Behav Nutr Phys Act. 2013;10:29. Michie S, Abraham C, Whittington C, McAteer J, Gupta S. Effective techniques in healthy eating and physical activity interventions: a meta-regression. Health Psychol. 2009;6:690–701. Stanton-Fay SH, Hamilton K, Chadwick PM, Lorencatto F, Gianfrancesco C, de Zoysa N, et al. The DAFNEplus programme for sustained type 1 diabetes self management: Intervention development using the Behaviour Change Wheel. Diabet Med. 2021;38(5):e14548. Félix IB, Guerreiro MP, Cavaco A, Cláudio AP, Mendes A, Balsa J et al. Development of a complex intervention to improve adherence to antidiabetic medication in older people using an anthropomorphic virtual assistant software. Frontiers in Pharmacology. 2019;10(JUN). Jennings HM, Morrison J, Akter K, Kuddus A, Ahmed N, Kumer Shaha S et al. Developing a theory-driven contextually relevant mHealth intervention. Global Health Action. 2019;12(1). Leon N, Namadingo H, Bobrow K, Cooper S, Crampin A, Pauly B et al. Intervention development of a brief messaging intervention for a randomised controlled trial to improve diabetes treatment adherence in sub-Saharan Africa. BMC Public Health. 2021;21(1). Murphy K, Berk J, Muhwava-Mbabala L, Booley S, Harbron J, Ware L et al. Using the COM-B model and Behaviour Change Wheel to develop a theory and evidence-based intervention for women with gestational diabetes (IINDIAGO). BMC Public Health. 2023;23(1). Smith R, Michalopoulou M, Reid H, Riches SP, Wango YN, Kenworthy Y et al. Applying the behaviour change wheel to develop a smartphone application ‘stay-active’ to increase physical activity in women with gestational diabetes. BMC Pregnancy Childbirth. 2022;22(1). Handley MA, Harleman E, Gonzalez-Mendez E, Stotland NE, Althavale P, Fisher L et al. Applying the COM-B model to creation of an IT-enabled health coaching and resource linkage program for low-income Latina moms with recent gestational diabetes: The STAR MAMA program. Implementation Science. 2016;11(1). Footnotes Participant 60, BA Female, Age, 37, Sierra Leone Participant 17, BA Male, Age 57, Sierra Leone It was difficult to distinguish between Action planning and Goal setting in the data so the two BCTs are treated collectively. Participant 61, BC Female, Age 37, UK Additional Declarations No competing interests reported. Supplementary Files Supplementaryfile1COREQChecklistHEALDPEmanuscript.pdf Cite Share Download PDF Status: Published Journal Publication published 11 Feb, 2025 Read the published version in BMC Public Health → Version 1 posted Editorial decision: Revision requested 02 Aug, 2024 Reviews received at journal 12 Jul, 2024 Reviews received at journal 11 Jul, 2024 Reviewers agreed at journal 22 Jun, 2024 Reviewers agreed at journal 19 Jun, 2024 Reviewers invited by journal 16 Jun, 2024 Editor invited by journal 22 May, 2024 Submission checks completed at journal 21 May, 2024 Editor assigned by journal 21 May, 2024 First submitted to journal 17 May, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4436026","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":306623272,"identity":"d01c66b8-a7fc-422c-b5a6-85b7bff5f1a0","order_by":0,"name":"Amanda P Moore","email":"","orcid":"","institution":"University College London","correspondingAuthor":false,"prefix":"","firstName":"Amanda","middleName":"P","lastName":"Moore","suffix":""},{"id":306623273,"identity":"97f4c42e-0fa3-4a3f-9f7a-c3e0c9ff622d","order_by":1,"name":"Carol Rivas","email":"","orcid":"","institution":"University College London","correspondingAuthor":false,"prefix":"","firstName":"Carol","middleName":"","lastName":"Rivas","suffix":""},{"id":306623274,"identity":"00ab7652-5509-4c1d-9326-e4f5f9ed2cfa","order_by":2,"name":"Seeromanie Harding","email":"","orcid":"","institution":"King's College London","correspondingAuthor":false,"prefix":"","firstName":"Seeromanie","middleName":"","lastName":"Harding","suffix":""},{"id":306623275,"identity":"c7b87da6-022a-4932-af01-f4f809ff8b2a","order_by":3,"name":"Louise M Goff","email":"data:image/png;base64,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","orcid":"","institution":"University of Leicester","correspondingAuthor":true,"prefix":"","firstName":"Louise","middleName":"M","lastName":"Goff","suffix":""}],"badges":[],"createdAt":"2024-05-17 10:21:06","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4436026/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4436026/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12889-025-21767-8","type":"published","date":"2025-02-11T15:56:52+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":57941013,"identity":"9d53f785-98f7-4b37-b85e-4a439c8124d8","added_by":"auto","created_at":"2024-06-07 18:54:41","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":140444,"visible":true,"origin":"","legend":"\u003cp\u003eCoding density by BCT by interview participant (the darker blue indicates greater coding density)\u003c/p\u003e","description":"","filename":"Figure1HEALDPEmanuscript.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4436026/v1/5a8b93c3e850b114e0a582b0.jpg"},{"id":76487496,"identity":"ebdfc467-c818-4943-b686-455a0d849784","added_by":"auto","created_at":"2025-02-17 16:08:15","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2248266,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4436026/v1/eed53bbf-7988-4a4f-9c35-457a3cee3de1.pdf"},{"id":57941014,"identity":"57cf072f-5af2-436f-9bac-f316fd180068","added_by":"auto","created_at":"2024-06-07 18:54:41","extension":"pdf","order_by":9,"title":"","display":"","copyAsset":false,"role":"supplement","size":364390,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryfile1COREQChecklistHEALDPEmanuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4436026/v1/7421e989d60469c6489cf099.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"A qualitative evaluation of the effectiveness of behaviour change techniques used in the Healthy Eating and Active Lifestyles for Diabetes (HEAL-D) intervention","fulltext":[{"header":"Background","content":"\u003cp\u003eType 2 diabetes (T2D) is up to three times more common in people of Black African and Black Caribbean heritage living in the UK, compared to their White British counterparts [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. It is predicted that by the age of 80, 40\u0026ndash;50% of UK adults from Black ethnicities will have T2D [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], compared to 14% in the White British population [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Moreover, diagnosis occurs up to 10 years earlier than in White British, with poorer glycaemic control at diagnosis [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. A range of factors contribute to this increased prevalence including socioeconomic, cultural, lifestyle and genetic factors [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. People from Black minority ethnic groups are also less likely to complete annual T2D monitoring and are subject to prescribing disparities [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] and other structural barriers to equitable access [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Structured education programmes, are the cornerstone of T2D care, supporting people in diabetes self-management. Attendance at structured education is associated with improved glycaemic control [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], but people from minority ethnicities are less likely to attend [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], and, for Black participants, attendance is less likely to be associated with improved outcomes [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMultiple sociocultural factors shape diabetes self-management, including relationships with healthcare providers, community and cultural influences, socioeconomic drivers and other environmental factors [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. As day-to-day self-management happens in primarily the social rather than clinical environment, sociocultural factors, such as normative dietary patterns, explanatory models of health, spiritual beliefs, taboo and stigma all influence engagement and outcomes [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Clinical guidelines in the UK identify a need for diabetes care to be culturally appropriate for people from different ethnicities [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] and a robust body of evidence suggests culturally tailored diabetes education can improve outcomes in both glycaemic control and knowledge [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. However, there have been limited interventions designed to support people from Black African or Caribbean heritage in the UK setting [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]; the Healthy Eating and Active Lifestyles for Diabetes (HEAL-D) intervention was designed to address this need.\u003c/p\u003e \u003cp\u003eHEAL-D is a culturally-tailored diabetes self-management education and support programme, which was co-designed with Black African and Caribbean adults with the objective of improving engagement with self-management guidance and supporting positive diabetes-related health behaviour [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. During the development of the HEAL-D programme, people reported several barriers to optimal self-management including social pressures and personal desire to continue to enjoy traditional cultural foods, lack of empathy from or distrust of healthcare, traditional beliefs around body shape and a rejection of the relevance of BMI ranges for the Black body shape. A lack of detailed understanding of diabetes-related physiology, cultural attitudes towards food preparation, as well as sociocultural challenges around the pressures of caring roles, inflexibility of shift work and 'zero hours\u0026rsquo; contracts, and socioeconomic pressures were also evident from the preliminary development work [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe development of the theory of change underpinning the design of the HEAL-D intervention and the choice of specific behaviour change techniques (BCTs) was specified using the behaviour change wheel (BCW) developed by Michie et al. [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Intervention components, designed to deliver the selected BCTs, included games, videos, exercise classes and education sessions. The intervention was delivered face-to-face over 7 sessions, in community settings, as part of a feasibility trial from March 2018 to April 2019 [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. The full HEAL-D intervention [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] and the COM-B analysis and identification and operationalisation of BCTs have been previously described [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Exploring the mechanisms through which interventions bring about change is crucial to understanding both how the effects of a specific intervention occur and how these effects might be replicated or improved upon in similar future interventions [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. As part of the process evaluation of the HEAL-D feasibility trial, we wanted to understand how participants interacted with the intervention and how the operationalised BCTs worked to support behaviour change within the context in which the intervention was delivered. This is the focus and aim of the current paper.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eDesign\u003c/h2\u003e \u003cp\u003eWe used a qualitative study design based on focus groups and semi-structured interviews. Below we describe this in detail. Ethical approval was granted as part of the trial approvals by the NHS Health Research Agency (HRA) registration number 233419; participants provided written informed consent prior to participation.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eParticipants were taking part in the HEAL-D feasibility trial, a two-arm parallel group randomised controlled trial; all participants allocated to the HEAL-D intervention arm were eligible to take part in the process evaluation focus groups and were invited. They were given the option of an interview if they refused the focus group. Trial participants were adult (age\u0026thinsp;\u0026ge;\u0026thinsp;18 years) men and women of self-declared Black-African, Black-Caribbean or Black-British ethnicity living with T2D; purposive sampling was used to determine who to invite from the focus groups to attend the one-to-one interviews to a give a balance of gender and ethnic background. Participants were recruited to the trial through a combination of community-situated initiatives, such as awareness building in faith institutions and with charity partners and via general practitioners and secondary care diabetes self-management education referrals. These communities are often under-represented in medical research and some distrust of healthcare services has been reported particularly amongst those with lower health literacy [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], therefore community recruitment was particularly important to ensure inclusivity of the sample.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eProcedures\u003c/h2\u003e \u003cp\u003eFull details of the HEAL-D intervention have been previously published [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] but, in brief, HEAL-D is a group-based programme delivering a curriculum of diet and lifestyle behaviour change support in seven 2-hour sessions, facilitated by a specialist dietitian, a lay educator and exercise trainers. The details of the BCTs identified during the HEAL-D intervention co-design process and how these were operationalised across the intervention components are further illustrated in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e2\u003c/span\u003e. One focus group was planned at the end of each seven-session delivery of the HEAL-D programme, thus participants had attended the same group. Usually the focus group was conducted within two weeks of the intervention finishing. The semi-structured interviews were conducted to gain further insight into the focus group discussions, as well as explore personal perspectives. All data collection was undertaken by an experienced white British doctoral qualitative researcher (AM), who was known to the participants through their involvement in the feasibility trial. Each focus group lasted approximately 2 hours and participants were given a \u0026pound;10 gift voucher for their participation.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDescription of the HEAL-D intervention components to support each BCT identified\u003c/p\u003e \u003cdiv class=\"Credit\"\u003e\u003cp\u003e(Modified from Moore et al.,2019)[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBCT\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention component\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInformation about health consequences\u003c/b\u003e \u003cem\u003e(To educate developing knowledge and skills)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe educational curriculum covered health consequences and benefits of various key lifestyle behaviours. A detailed file provided contained written information and activities to support each educational session.\u003c/p\u003e \u003cp\u003eAn animation video \u003cem\u003e\u0026ldquo;Diabetes explained\u0026rdquo;\u003c/em\u003e explained the mechanisms of type 2 diabetes.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInstruction on how to perform the behaviour\u003c/b\u003e \u003cem\u003e(To educate developing knowledge and skills)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe curriculum communicated health guidance clearly using culturally relevant examples.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDemonstration\u003c/b\u003e \u003cem\u003e(To educate developing knowledge and skills)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePractical games, the weekly discussion tasks, a cooking session (with cooks in the family invited) and structured exercise sessions (including African dance music and dancing) provided guided demonstration. An exercise DVD using credible sources was provided for participants to follow at home.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGraded tasks\u003c/b\u003e \u003cem\u003e(To educate developing knowledge and skills)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePhysical activity sessions and targets were graded for ability to boost chances of success hence confidence and self-efficacy.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSocial support (unspecified)\u003c/b\u003e \u003cem\u003e(Socially focused to Persuade and Enable)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSocial connectedness was fostered within the group by the discursive nature of the sessions and through shared engagement in activities and structured exercise sessions\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSocial comparison\u003c/b\u003e \u003cem\u003e(Socially focused to Persuade and Enable)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe \u003cem\u003e\u0026lsquo;task card\u0026rsquo;\u003c/em\u003e homework activities gave participants opportunity to try the lifestyle targets and come back to discuss with the group and with educators. Participants were encouraged to share their successes to encourage comparison within the group. In addition, role models were featured in the case study video\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCredible sources\u003c/b\u003e \u003cem\u003e(Socially focused to Persuade and Enable)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVideos were used as part of the intervention including advice and tips from community leaders, healthcare practitioners and patients from the community that have successfully changed their habits\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFeedback on outcomes, self-monitoring of behaviour\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe programme started with personal measurements and blood results, and updated outcome measures were given at the end of the programme. Participants were encouraged to monitor weight loss progress by taking waist measurements through the course and completing their programme booklets.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSelf-monitoring of behaviour, action planning\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eParticipants were given pedometers to measure their steps and were taught to develop action plans and measure their progress against them.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGoal setting\u003c/b\u003e (behaviour)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eParticipants were guided through setting their own goals for the lifestyle targets that are important for them\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eProblem solving\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe \u003cem\u003e\u0026lsquo;task card\u0026rsquo;\u003c/em\u003e homework activities were discussed at the beginning of each session, challenges were identified, and the group problem solve collectively. Problem solving also forms part of the education sessions about lifestyle habits.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAction planning\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eParticipants were guided through how to develop and adjust action plans for each of the target behaviours and for their personal objectives, to help keep them motivated.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe interviews were conducted in person in university rooms, the participant\u0026rsquo;s home or within a medical setting, depending on participant preference, and lasted approximately 60 minutes. They took place within 4 weeks of the intervention delivery being completed, with participants being given a \u0026pound;10 voucher for their time [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. For both the focus groups and interviews, participants were briefed that the sessions were being conducted to help the research team understand what worked well and what needed to be improved in the HEAL-D intervention. The focus groups were structured using a topic guide which explored experiences of the intervention, key points of learning and impact, and behaviour change. Sessions began with participants describing their response to the intervention and any changes to their health behaviour as a result of their experience. Participants were given the opportunity for non-judgmental recall to understand the key drivers of change for each individual, followed by further probing around specific components. The interviews followed a similar topic guide but gave the opportunity to probe topics from the focus groups in more detail and areas requiring clarification. It was also useful to get a personal perspective on the topics which may be more sensitive to discuss within the group, such as the interaction between people from different ethnic backgrounds and between genders. Sessions were audio recorded and transcribed. Where needed, ethnically concordant transcribers were used to ensure accents were faithfully transcribed and the audio recordings were checked against the transcripts by the research team to ensure accuracy.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eAnalysis\u003c/h2\u003e \u003cp\u003eThe data were analysed using a framework approach with the intervention theory of change as a template [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]; data were coded by BCT, and general comments on the intervention as well as descriptions of behaviour change were also recorded. The framework facilitated an intersectional approach to the analysis to explore the influence of key contextual factors on the effectiveness of the BCTs. To give a general indication of the BCTs considered most beneficial by the participants, the interview transcripts were coded for recall of positive impact of each BCT by participant and results recorded in a coding density chart. The focus group data was not coded in this way due to the challenge of accurately matching the verbatim quotes to individuals. The data analysis was developed with input from the research team and participant advisors. In addition, interviews were held with two educators delivering the intervention to help frame and validate participant responses.\u003c/p\u003e \u003cp\u003e The data are reported according to the COREQ guidelines (supplementary data 1).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThirty-six participants took part in this evaluation study; 15 participated in interview only, 16 in focus group only, and 5 took part in both an interview and focus group, Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Four focus groups were conducted. The sample was 83% first generation, predominantly female and both Black African and Caribbean ethnicities were approximately equally represented.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eParticipant characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e% (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEthnicity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlack African\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e44.4 (16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlack Caribbean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e50.0 (18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMixed race (BA/WB)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5.6 (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e61.1 (22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e59.5 (10.02)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMigration history\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFirst generation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e83.3 (30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecond generation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16.7 (6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eOverall, participants reported significant behaviour change as a result of participating in the HEAL-D intervention, suggesting the selected BCTs have practical utility in a real-world setting. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e illustrates the components that were most commonly reported to have supported behaviour change, principally these were BCTs to \u003cem\u003edemonstrate the behaviour\u003c/em\u003e, which align to the educate function, those based on providing \u003cem\u003esocial support\u003c/em\u003e and \u003cem\u003esocial comparison\u003c/em\u003e, which align to the persuade and enable functions, and those promoting advice and support from \u003cem\u003ecredible sources\u003c/em\u003e, which align to the persuade function.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eReported behaviour change\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e provides illustrative quotes for the most commonly reported behaviour changes: increased moderate to vigorous physical activity, reduced carbohydrate portions, and engagement in weight-monitoring behaviour. The majority of participants reported improvements in measurable outcomes including improved metabolic parameters, weight-loss, improved stamina or medication reduction. With regards to carbohydrate portions, knowing how portion guidance related to traditional starchy foods was empowering, so traditional foods could be enjoyed with confidence: \u003cem\u003e\u0026ldquo;You're armed, you're tooled with the information now.\u0026rdquo;\u003c/em\u003e\u003ca class=\"FNLink\" href=\"#Fn1\" id=\"#FNLinkFn1\"\u003e\u003c/a\u003e Equally some made their own decision to avoid some traditional starches, changing eating patterns developed over many years [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. A general increased self-efficacy and confidence was reported following the intervention.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eParticipant reports of behaviour and self-efficacy changes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReduction in starchy carbohydrate intake\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;Do you know, since the programme, as of the middle of the programme and since the programme ended I have not taken the garri, the cassava one, I've not taken it.\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eInterviewer: Why is that?\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eBecause I've come to realise after eating that garri, that cassava one, swallow, especially in the evening, I get so heavy in me. I can't do anything. I was tempted all throughout in Nigeria, but I avoided it. I realised one of the things I avoided was the garri, and I could eat a big bowl of rice\u0026hellip; I cut my rice into half now.\u0026rdquo; (Participant 44, BA Male, Age 64, Nigeria)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReduction in necessary medication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;They have taken me off glazi, what do you call it? [Glicazide], they've taken me off that they said because my blood sugar has gone down, I'm okay. I really love it. I'm just left with metformin now.\u0026rdquo;\u003c/em\u003e \u003cb\u003e(Participant 24, BA Female, Age 58, UK)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReduction in waist size\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;I've lost weight, I think I have. Well, it's funny, I still weigh the same, but my trouser size is - I was taking size 36 trousers, yes? Now, all of a sudden, they're too big for me and I've started taking size 34 now\u0026hellip; Yes, it's inches, isn't it.\u0026rdquo;\u003c/em\u003e \u003cb\u003e(Participant 58, BC Male, Age 60, Dominica)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIncreased exercise and improved stamina\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip; because of the exercise, I mean I'm normally doing bits, but I can say that my stamina has increased. For instance, I went to Brixton today, and months back - I have a bad knee and a hernia - and I found myself walking around Brixton, so I maybe did about 45 minutes walk, so my stamina is definitely [improved]. I'm thinking it is nothing to climb up a hill and whatever, without puffing and things [\u0026hellip;] I can feel definitely that my stamina has increased.\u0026rdquo;\u003c/em\u003e \u003cb\u003e(Participant 66, BC Female, Age 68, Jamaica)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;The blood sugar has really gone down [\u0026hellip;] This thing dropped from seven and it's six. [\u0026hellip;] I think if you really look at my progress now, I think, I don't know how, I'm so confident. At the moment, I just feel that there's nothing wrong with me \u0026hellip; even though there's still much to do, but I think I've really improved a lot in so many ways, and so\u0026hellip; Just them telling me\u0026hellip; I'm just happy\u0026hellip; Just I have a good feeling for myself, you know, very confident, very confident. It's just like there's nothing disturbing me. It's just like part and parcel of me now. [\u0026hellip;] Before all the food, my living, the way I live now is, I don't know how I can describe it to you, the gap is so big.\u0026rdquo;\u003c/em\u003e (Participant 18, BA Male, Age 42, Cameroon)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eBCTs to educate and improve knowledge and skills\u003c/h2\u003e \u003cp\u003eIntervention components based on BCTs to improve knowledge and skills were seen to be pivotal to the success of the intervention for the majority. Illustrative quotes are presented in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. Participants valued the balance between the theoretical and practical components designed to \u003cem\u003edemonstrate the behaviour\u003c/em\u003e. In HEAL-D, components based on these BCTs included food related games, participatory physical activity sessions, participatory cook and taste session, along-side verbal and visual information. Moreover, with regards to reducing carbohydrate intake, changing cooking habits and engaging in moderate to vigorous physical activity, the practical demonstration, anchored in cultural traditions, appeared vital. Components based on other BCTs to increase knowledge worked synergistically with the practical participatory demonstration. For example, the BCT \u003cem\u003eInformation on health consequences\u003c/em\u003e was the basis of a culturally aligned animation video called \u003cem\u003eDiabetes Explained\u003c/em\u003e, and written, visual and verbal information about the links between behaviour and diabetes outcomes; and \u003cem\u003eInstruction on how to perform behaviour\u003c/em\u003e was the basis of photographic representations of portion sizes, written details about understanding exercise intensity, and verbal instructions about which foods contain healthy fats. Participants valued the written resources providing \u003cem\u003eInstruction\u003c/em\u003e and \u003cem\u003eInformation on health consequences\u003c/em\u003e, viewing them as a reference guide which could be reviewed outside the sessions: \u003cem\u003e\u0026ldquo;That file, it can be under your pillow\u0026hellip; a solution it reminds you back.\u0026rdquo;\u003c/em\u003e\u003ca class=\"FNLink\" href=\"#Fn2\" id=\"#FNLinkFn2\"\u003e\u003c/a\u003e It was the cultural salience of the information and demonstration techniques that made the difference, compared to information they had received previously. The provision of written and visual materials was supported with the physical presence of the educator who successfully helped reinforce the information. Having an educator there in person was particularly important for older individuals who may struggle with biomedical understanding.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eParticipant reflections on BCTs chosen to increase knowledge and skills\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBCT: demonstration; instruction\u003c/p\u003e \u003cp\u003eComponent: Food knowledge game\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;That was the day I realised probably I had been a big fool. [\u0026hellip;] It was all fun and I took home a lot. It looks like a little game, but it brought the reality, the essence of the food we eat. It brought it into real-life play, and it was quite a very useful method of passing the message, other than just saying it with your mouth. \u0026hellip; the shock is not the same thing.\u0026rdquo; (Participant 44, BA Male, Age 64, Nigeria)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBCT\u003c/b\u003e: demonstration; instruction\u003c/p\u003e \u003cp\u003e\u003cb\u003eComponent\u003c/b\u003e: Participatory exercise classes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;There are lots of people, you tell them to exercise, and they say, 'Oh yes, I'll do it', yes, but to actually participate - because I'm sure there were lots of people in that group who never did what we did during that course. They say, 'Oh yes, I did, I do walking', but it opened your awareness to certain forms of exercise that you need to do.\u0026rdquo;\u003c/em\u003e \u003cb\u003e(Participant 51, BC Male, Age 77, Guyana)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBCT\u003c/b\u003e: demonstration; instruction\u003c/p\u003e \u003cp\u003e\u003cb\u003eComponent\u003c/b\u003e: Cook and taste session\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;The food they prepared for us has given me a lot of ideas. I know I have to eat veg, but there are different ways you cook veg which they showed us the other day, which is very, very educative. They teach you how to put little bit of oil, not like the way we put. You think about eating veg, you put plenty of oil, you've spoilt it. They taught us a lot, that cooking.\u0026rdquo;\u003c/em\u003e \u003cb\u003e(Participant 34, BA Female, Age 61, Nigeria)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBCT\u003c/b\u003e: information about health consequences\u003c/p\u003e \u003cp\u003e\u003cb\u003eComponent\u003c/b\u003e: Video\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;The videos are very good. When you are first diagnosed there are a lot of conspiracy theories about what diabetes is, or what it's not. That video tried to explain, when you say somebody's diabetic, what is really happening in the inside. It talks about the key, which is insulin, that will boost the vein, and it talks about what happen when the veins is clogged [\u0026hellip;] So that video is very concise, and it explained in the plain language that I think everybody was able to understand.\u0026rdquo;\u003c/em\u003e \u003cb\u003e(Participant 54, BC Female, Age 55, UK)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBCT\u003c/b\u003e: information about health consequences; Instruction\u003c/p\u003e \u003cp\u003e\u003cb\u003eComponent\u003c/b\u003e: Written information\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;The book is good because basically, what I\u0026rsquo;ve been doing is going back to my book all the time, and that\u0026rsquo;s another thing its inspiring \u0026ndash; you look back at what you\u0026rsquo;ve learnt. I actually find what works for me is sitting down, reading my book \u0026ndash; I wrote little things in like if I\u0026rsquo;d done exercise \u0026ndash; you can sit down and write your own experience.\u0026rdquo;\u003c/em\u003e \u003cb\u003e(Participant 54, BC Female, Age 55, UK)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBCT\u003c/b\u003e: information about health consequences; Instruction\u003c/p\u003e \u003cp\u003e\u003cb\u003eComponent\u003c/b\u003e: Written information\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;Where we come from, your husband can go for another woman, just because of food. Like, my husband, when he's cooking, it's salt, salt, salt. He likes salt. So, I said to him, 'If you want to cook salt and kill yourself, I'll come to your burial, but please don't add it too much on my one. For me if I had not seen the information I wouldn't know. I would keep continue doing what we are doing.\u0026rdquo;\u003c/em\u003e \u003cb\u003e(Participant 64, BA Female, Age 52, Nigeria)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Any problem, they are willing to answer our questions if we have anything. She demonstrate things, she gets to the board. She tells you what you didn't know or didn't understand\u0026hellip;The clog. When the blood vessels, when they clog. That was like, woo! Yes, she was explaining over and over how it works. Explained everything. If you had a problem, if there's something that you didn't understand, nothing was too much for them to say, 'Right, I can go over it,' or you could stay back and talk to them\u0026rdquo;\u003c/em\u003e (Participant 62, BC Female, Age 84, Jamaica)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eSocially-focused BCTs to Persuade and Enable\u003c/h2\u003e \u003cp\u003eIntervention components based on \u003cem\u003esocial support\u003c/em\u003e (group sessions facilitating interaction and support) and \u003cem\u003esocial comparison\u003c/em\u003e (for example, sharing experiences and learning within the group) provided individuals with much needed social support to manage their diabetes.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;It made you feel like, actually, I'm not too - you know, you are human because people make errors in assuming that you're in the same boat as well. So, it didn't make you feel, oh, you know what, you're so bad at doing this. It just shows you, seeing others actually, especially if you're new, like me, I'm new to it, so you're still finding your feet, and it's okay to fall, but just remember, you need to pick yourself back up. You can fall, but don't stay down. Pick yourself back up and go straight ahead.\u0026rdquo;\u003c/em\u003e (Participant 63, BC Female, Age 67, Guyana)\u003c/p\u003e \u003cp\u003eThe importance of the group interaction was evident, as individuals learnt a lot from each other and motivated each other (see Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). Because individuals were learning from each other, it gave the educational recommendations credibility and salience as participants discussed positive personal experience and insights.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eParticipant reflections on socially focused BCTs to persuade and enable\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBCT: social comparison\u003c/p\u003e \u003cp\u003eComponent: Group sessions\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;That was very good because people don't really realise that there are people, other people in the same boat as you are, suffering the same thing. Exchanging ideas and views, in some small way, although it might look insignificant, could be helpful to you. By listening to this person or seeing what this person does or hear what this person does, you can benefit from it\u0026rdquo; (Participant 51, BC Male, Age 77, Guyana)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBCT\u003c/b\u003e: social support\u003c/p\u003e \u003cp\u003e\u003cb\u003eComponent\u003c/b\u003e: Group sessions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;If we can share, perhaps, they were going through a bad time and they've relapsed and they're not sticking to the programme, and their diabetes is going out of control. Be able to talk about it and properly try and get them back on track and that kind of thing\u0026hellip;\u0026rdquo;\u003c/em\u003e \u003cb\u003e(Participant 47, BC Female, Age 58, Guyana)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBCT\u003c/b\u003e: social support\u003c/p\u003e \u003cp\u003e\u003cb\u003eComponent\u003c/b\u003e: Exercise classes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;Last week I was, two weeks ago I was ill. Pains all over my body. So, this young lady, I told her that, 'I can't do any exercise today because I'm\u0026hellip;' She came to me, face to face and said, 'You can do it'. Said, 'But if you can't, sit down'. So, I sat down there. I felt guilty. People are doing, I'm not doing. So, I start on the chair. When she says, 'Do this', she said, 'Yes. That's what you should do. You don't have to stand up, you know'. I was feeling the pain but I enjoyed doing the thing. By the time we were finished, I stood up. [Laughs] the group \u0026hellip;they encourage [me]\u0026rdquo;\u003c/em\u003e \u003cb\u003e(Participant 65, BA Female, Age 58, Nigeria)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBCT\u003c/b\u003e: credible sources\u003c/p\u003e \u003cp\u003e\u003cb\u003eComponent\u003c/b\u003e: case study videos\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;The videos about the people that are living with diabetes, you see stories about people that encourage you. That some people have been doing this, have been diagnosed for years, and they are still living happily. That you can still live a happy life, even if you are diabetic [\u0026hellip;] Talking about the food and what we can eat, and our food, the type of food we have and how much carb there\u0026hellip; It was amazing that we didn't\u0026hellip; I still think up to this day a lot of Caribbean, African backgrounds, we're still not aware of that, and we still eat so much of it. So again, it was awareness and I find it was really good.\u0026rdquo;\u003c/em\u003e \u003cb\u003e(Participant 22, BA Male, Age 41, Nigeria)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I find myself\u0026hellip; that I was the least-informed in the group. So, I was learning from these elderly ladies and gentlemen. Seriously, I was listening to their experience, their practical experience and what they thought [\u0026hellip;] he, my fellow countryman\u0026hellip; he taught me a lot of things that could really increase diabetes, if I was to eat or drink certain things. What I'm saying is that I wasn't aware before\u0026hellip; and it's like\u0026hellip; it was really verifiable information. So, it comes back right into say, well, awareness and discussing and sharing.\u0026rdquo;\u003c/em\u003e (Participant 22, BA Male, Age 41, Nigeria)\u003c/p\u003e \u003cp\u003eThese components supported the learning by improving confidence, making it acceptable to challenge traditions, and normalising diabetes, encouraging individuals to be open about their condition, where they would traditionally have been more hesitant about disclosure.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Where I come from, from the Northern part of Nigeria, it is a shame thing. That shame, that, 'Oh, how can you tell your family you have this?' So, you keep it to yourself, and it's like AIDS/HIV. So, you don't want to tell no one, and just so that you just can continue with it yourself. So, it has really helped me broaden out the kind of person I am. Going to these open courses, it give you a full mind like to expand your talk and get more confidence. then I thought, 'Oh, I can talk now, too\u0026rdquo;\u003c/em\u003e (Participant 64, BA Female, Age 52, Nigeria)\u003c/p\u003e \u003cp\u003eFurthermore, it created strength to resist social pressures. The use of \u003cem\u003ecredible sources\u003c/em\u003e and \u003cem\u003emodelling\u003c/em\u003e, for example having ethnically concordant lay educators and videos with tips from faith leaders and other trusted members of local Black communities, reinforced the social acceptability of the new behaviours.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;The videos about the people that are living with diabetes, you see stories about people that encourage you. That some people have been doing this, have been diagnosed for years, and they are still living happily. That you can still live a happy life, even if you are diabetic [\u0026hellip;] Talking about the food and what we can eat, and our food, the type of food we have and how much carb there\u0026hellip; It was amazing that we didn't\u0026hellip; I still think up to this day a lot of Caribbean, African backgrounds, we're still not aware of that, and we still eat so much of it. So again, it was awareness and I find it was really good.\u0026rdquo;\u003c/em\u003e (Participant 22, BA Male, Age 41, Nigeria)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eBCTs to improve self-efficacy and behaviour regulation\u003c/h2\u003e \u003cp\u003eComponents associated with BCTs to improve self-efficacy and behaviour regulation included: \u003cem\u003eself-monitoring\u003c/em\u003e through measuring waist, weekly weighing, and using a pedometer \u003cem\u003egoal setting\u003c/em\u003e and \u003cem\u003eaction planning\u003c/em\u003e\u003ca class=\"FNLink\" href=\"#Fn3\" id=\"#FNLinkFn3\"\u003e\u003c/a\u003e through a SMART goal session and exercises, and weekly group goals; \u003cem\u003eFeedback on outcomes\u003c/em\u003e through anthropometry and biochemical markers at the end of the intervention; and \u003cem\u003eProblem solving\u003c/em\u003e. In general, these BCTs were less frequently mentioned in the data than the components associated with improving knowledge and developing social support. Yet they still seemed powerful for several individuals (see Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e). Many of the participants had set themselves goals for the programme \u0026ndash; from fitting into a dress that had become too tight to achieving 10,000 steps every day.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eParticipant reflections on BCTS to improve self-efficacy and behaviour regulation\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBCT: Goal setting\u003c/p\u003e \u003cp\u003eComponent: SMART goals\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;I was shopping yesterday and I was walking around Sainsbury's, and because you know we've got that goal target, of getting your waistline down? So, I'm about one inch away from my goal target... All I kept hearing, every time I walked past something naughty was, \u0026ldquo;one inch away from 33, don't do it\u0026rdquo;! We were actively encouraged. Like... 'This is a challenge, set yourself a goal every week. Set yourself a new different goal,' which is good because even now, like I said, I'm one step away from my waist goal, and I'm already thinking, all right, when I hit that, I've got to do the next goal. So, I'm always planning that in my head already.\u0026rdquo; (Participant 61, BC Female, Age 37, UK)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBCT\u003c/b\u003e: Feedback on outcomes\u003c/p\u003e \u003cp\u003e\u003cb\u003eComponent\u003c/b\u003e: HbA1C measurement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;My blood HbAc [sic] when I went to my GP a few weeks ago, it was 53. I feel really good. I feel, 'Wow, all this hard work is working,' but it's not just something you do for three months and then think, oh, I'll go back to it. It's an ongoing thing. This is what people have to understand, it's not something you can just switch off for a few months and then think, oh, I'll come back to that. It's literally ongoing all the time.\u0026rdquo;\u003c/em\u003e \u003cb\u003e(Participant 41, BC Female, Age 58, Barbados)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBCT\u003c/b\u003e: Self-monitoring\u003c/p\u003e \u003cp\u003e\u003cb\u003eComponent\u003c/b\u003e: weighing and measuring waist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;Yes, I've been weighing, and I've been taking my measurement round, you know, bust, stomach, or especially my long waist, and I'm wearing dresses that I wasn't going into. I hate to give away my dresses because they are expensive. Yes. So, I appreciate coming to this course, and I can see. I used to have segmented neck here, but now when I look on the mirror, I see that's reduced. I am feeling better\u0026hellip; I can even fight my husband now!\u0026rdquo;\u003c/em\u003e \u003cb\u003e(Participant 63, BC Female, Age 67, Guyana)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;We were actively encouraged. Like, 'This is a challenge, set yourself a goal every week. Set yourself a new different goal,' which is good because even now, like I said, I'm one step away from my waist goal, and I'm already thinking, all right, when I hit that, I've got to do the next goal. So, I'm always planning that in my head already.\u0026rdquo;\u003c/em\u003e (Participant 60, BA Female, Age 49, Sierra Leone)\u003c/p\u003e \u003cp\u003eThose participants who set themselves a personal goal found it motivating and were assisted by the \u003cem\u003eSelf-monitoring\u003c/em\u003e element facilitated by the pedometer and waist tape measure: \u003cem\u003e\u0026ldquo;When I saw the size 34 waist, it just gave me a bounce in my step. I was good for the day.\u0026rdquo;\u003c/em\u003e\u003ca class=\"FNLink\" href=\"#Fn4\" id=\"#FNLinkFn4\"\u003e\u003c/a\u003e When individuals saw their Hba1C, weight and other parameters had reduced it had the effect of cementing and reinforcing the changes they had made.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eParticipants reported that the HEAL-D intervention helped them actively change their diabetes-related health behaviours, particularly in relation to increasing moderate to vigorous physical activity, reducing carbohydrate portion size and engaging in behaviours to manage weight. The operationalised BCTs which underpinned the design of the HEAL-D intervention components were acceptable and effective. Those which had most impact were \u003cem\u003edemonstration of the behaviour, social support, social comparison and credible sources.\u003c/em\u003e Of the other BCTs adopted in the HEAL-D intervention, those felt to be necessary but of secondary importance were BCTs to educate (\u003cem\u003eInformation about health consequences, instruction how to perform the behaviour\u003c/em\u003e) and BCTs to improve self-efficacy and behaviour-regulation (\u003cem\u003eSelf-monitoring\u003c/em\u003e). The less impactful BCTs were \u003cem\u003eproblem solving, graded tasks, goal setting and feedback on outcomes.\u003c/em\u003e\u003c/p\u003e \u003cp\u003eOne of the reported critical challenging factors for people from minority ethnic backgrounds living with T2D in high income countries, is the conflict between diabetes-related lifestyle guidance and social norms, particularly normative dietary traditions, body image ideals and beliefs around purposeful physical activity [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. The strong reliance on starchy staples and oil and salt in cooking means that some dietary change is warranted to support diabetes management, although it does not require cultural foods to be eliminated from the diet. Dietary change is hard for all individuals as diet is one of the early learnt habits [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. For migrant communities, however, cultural foods play a symbolic role in maintaining cultural identity [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. The role of food culture is considered crucial in the diasporic experience [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. It can help delineate ethnicity creating a sense of \u0026ldquo;us\u0026rdquo; [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e], maintains a link with homeland [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e], and reinforces social bonds [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Individual dietary-related behaviour change can be further hampered in African collectivist cultures, where family and group preferences are given precedence over those of the individual [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Our analysis highlights the particular value of BCTs increasing social opportunity (\u003cem\u003esocial comparison, credible sources, social support, modelling\u003c/em\u003e) to shift beliefs about the incompatibility of self-management behaviour change with cultural identity and, interestingly, to challenge the perceptions of others within their communities. The additional provision of culturally pertinent guidance on portion size (\u003cem\u003einstruction on the behaviour, demonstration\u003c/em\u003e) empowered individuals to make dietary changes while still following cultural preferences. These findings support the development of specific interventions or adaptations for particular cultural groups and suggest the importance of community delivery or involvement in intervention delivery.\u003c/p\u003e \u003cp\u003eThis evaluation also highlights the perceived value of experiential learning amongst the participants. They found particular value in components designed to deliver the \u003cem\u003edemonstration\u003c/em\u003e BCT, such as learning games and cooking sessions. This finding supports much of the existing literature. The importance of kinship, social interaction and collectivism is well-reported for those of Black African ancestry [\u003cspan additionalcitationids=\"CR32\" citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. In communities of African ancestry living in high income countries, lack of social support has been identified as a particular barrier to lifestyle-related health behaviour change [\u003cspan additionalcitationids=\"CR35\" citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e], particularly when healthcare advice may conflict with culturally influenced social norms [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Lifestyle interventions for African American individuals that focus on engaging in social networks have been shown to be particularly effective [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e], and a review of weight management interventions to support African American women suggests that mobilising social support may be both \u003cem\u003e\u0026ldquo;therapeutic and cost-effective\u0026rdquo;\u003c/em\u003e, acting to improve self-efficacy and individual perception of control [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Moreover, the presence of social support has been shown to be associated with positive diabetes self-management behaviour in African American communities, for example African Americans were more likely to successfully manage their diabetes when they could learn from family members with diabetes [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIt is interesting that some of the BCTs that have their origins in control theory, such as \u003cem\u003eaction planning\u003c/em\u003e, \u003cem\u003egoal setting, self-monitoring, feedback on outcomes\u003c/em\u003e, which have been identified in the development of other interventions to support lifestyle change, were less often mentioned across the group in this analysis, although were salient for some. These BCTs have been shown to be important in self-regulation for individuals living with diabetes [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. In addition, several reviews highlight the value of these techniques in supporting change in physical activity and dietary behaviours [\u003cspan additionalcitationids=\"CR41\" citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. We suggest that these BCTs were important to include, though perhaps were not central to the way the intervention worked to support behaviour change in this case.\u003c/p\u003e \u003cp\u003eThis analysis has strengths in the use of rigorous qualitative methods with analysis triangulated with patient and community advisors, an independent qualitative advisor, and community-driven recruitment to improve inclusivity. COM-B has now been used in formative research to identify BCTs and help specify the theory of change in the design of several interventions for diabetes [\u003cspan additionalcitationids=\"CR44 CR45\" citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e] and gestational diabetes [\u003cspan additionalcitationids=\"CR48\" citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e], though more rarely specifically for study populations from minority ethnicities [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. To our knowledge none of these studies have reported process evaluations specifically related to the effectiveness and acceptability of identified BCTs in practice. Whilst a substantive multi-centre trial is now underway to evaluate the effectiveness of the HEAL-D intervention, this particular study is conducted in London, where there is a high population density of people from minority ethnicities. This may influence transferability to other geographies with a different ethnic density, where community dynamics and healthcare support may differ. The researcher conducting the data-collection for this evaluation was also involved in the intervention co-design and development. This had the benefit of increasing rapport and familiarity with participants, supporting frank and open discussion, however, using an independent researcher may have been preferable to prevent any introduction of bias. Triangulation of the analysis within the research team, participant representatives and data from educators delivering the intervention helped minimise bias resulting from this.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eOur evaluation suggests that the COM-B/Behaviour change wheel methodology supported the identification of BCTs which were acceptable and effective in driving individual behaviour change in the HEAL-D intervention. BCTs promoting social opportunity are useful to support lifestyle behaviour change in Black African and Caribbean adults with T2D, where social norms can conflict with diabetes self-management guidance. In addition, lifestyle interventions should include opportunity for experiential learning alongside the information provision. These findings may be of particular value to researchers and clinicians developing healthcare interventions to engage people of Black African and Caribbean ethnicity, and researchers using COM-B and the Behaviour Change Wheel, as there is little published evaluation of the acceptability and effectiveness of BCTs selected and developed using this methodology for people from minority ethnicities.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eBA\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBlack African\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eBC\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBlack Caribbean\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eBCT\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBehaviour change technique\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eBMI\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBody Mass Index\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eHEAL-D\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHealthy Living and Active Lifestyles for Diabetes\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eMR\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMixed race\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eNHS\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNational Health Service\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eNICE\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNational Institute for Clinical Excellence\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eRCT\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003erandomised controlled trial\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eSMART\u003c/b\u003e goals\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSpecific, Measurable, Achievable, Relevant, Time-bound goals\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eT2D\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003etype 2 diabetes\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eWB\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWhite British\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics and approval and consent to participate\u003c/h2\u003e\n\u003cp\u003eEthics approval was granted for the study by the Health Research Authority \u003cstrong\u003e(London Fulham Research Ethics Committee; 17/LO/1954\u0026nbsp;\u003c/strong\u003eunder IRAS reference 194991. Informed consent was taken from all participants according to this ethical approval.\u003c/p\u003e\n\u003ch2\u003eConsent for publication\u003c/h2\u003e\n\u003cp\u003eConsent for publication of anonymised data was obtained from all participants.\u003c/p\u003e\n\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e\n\u003cp\u003eThe data set from this study is not publicly available due to the restrictions associated with ethical approval but are available upon reasonable request to the corresponding author \u003cstrong\u003e[LMG].\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThis report is independent research arising from a Career Development Fellowship (\u003cstrong\u003eLMG\u003c/strong\u003e, CDF-2015-08-006) supported by the National Institute for Health Research. \u0026nbsp; AM was supported by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care South London at King\u0026rsquo;s College Hospital NHS Foundation Trust, as part of her PhD funding. \u003cem\u003eThe views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health.\u003c/em\u003e\u003c/p\u003e\n\u003ch2\u003eAuthor\u0026rsquo;s contributions\u003c/h2\u003e\n\u003cp\u003eStudy conception\u0026nbsp;LMG, CR, SH;\u0026nbsp;Data analysis as part of PhD thesis\u0026nbsp;AM; Drafting the manuscript\u0026nbsp;AM; All authors discussed the analysis, results and contributed to the final manuscript. \u0026nbsp;\u003c/h2\u003e\n\u003ch2\u003eAcknowledgements\u003c/h2\u003e\n\u003cp\u003eWith thanks to Diabetes UK, Muslim Association of Nigeria, Baitul Rahman Masjid Mosque, The Latter Rain Outpouring Revival Church, Peckham, St John\u0026rsquo;s Church, Peckham.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eHarrison G. 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Addiction. 2010;105(11):1897\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGoff LM, Moore AP, Harding S, Rivas C. Development of Healthy Eating and Active Lifestyles for Diabetes (HEAL-D), a culturally‐tailored diabetes self‐management education and support programme for black‐British adults: a participatory research approach. Diabet Med. 2021;38(11):e14594.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePaul E, Fancourt D, Razai M. Racial discrimination, low trust in the health system and COVID-19 vaccine uptake: a longitudinal observational study of 633 UK adults from ethnic minority groups. J R Soc Med. 2022;115(11):439\u0026ndash;47.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePatel N, Ferrer HB, Tyrer F, Wray P, Farooqi A, Davies MJ, et al. Barriers and Facilitators to Healthy Lifestyle Changes in Minority Ethnic Populations in the UK: a Narrative Review. J Racial Ethn Health Disparities. 2017;4(6):1107\u0026ndash;19.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOsokpo O, James R, Riegel B. Maintaining cultural identity: A systematic mixed studies review of cultural influences on the self-care of African immigrants living with non‐communicable disease. J Adv Nurs. 2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHellman C. Culture, health \u0026amp; illness. 5th Edition ed. London, UK: Hodder Arnold; 2007.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWright KE, Lucero JE, Ferguson JK, Granner ML, Devereux PG, Pearson JL et al. The influence of cultural food security on cultural identity and well-being: a qualitative comparison between second-generation American and international students in the United States. Ecol Food Nutr. 2021:1\u0026ndash;27.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTat Shum TC. 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Designing culturally sensitive dietary interventions for African Americans: review and recommendations. Nutr Rev. 2013;71(4):224\u0026ndash;38.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNishikawa E, Oakley L, Seed PT, Doyle P, Oteng-Ntim E. Maternal BMI and diabetes in pregnancy: Investigating variations between ethnic groups using routine maternity data from London, UK. PLoS ONE. 2017;12(6):e0179332.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eResnicow K, Baranowski T, Ahluwalia JS, Braithwaite RL. Cultural sensitivity in public health: defined and demystified. Ethn Dis. 1999;9(1):10\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTyler DO, Allan JD, Alcozer FR. Weight loss methods used by African American and Euro-American women. Res Nurs Health. 1997;20(5):413\u0026ndash;23.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWilbur J, Chandler P, Dancy B, Choi J, Plonczynski D. Environmental, policy, and cultural factors related to physical activity in urban, African American women. Women Health. 2002;36(2):17\u0026ndash;28.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWolfe WA. A review: maximizing social support-a neglected strategy for improving weight management with African-American women. Ethn Dis. 2004;14:212\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoore A, Flynn AC, Adegboye ARA, Goff L, Rivas C. Factors influencing pregnancy and postpartum weight management in women of African and Caribbean ancestry living in high income countries: systematic review and evidence synthesis using a behavioural change theoretical model. Front Public Health. 2021;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKumanyika SK, Wadden TA, Shults J, et al. Trial of family and friend support for weight loss in african american adults. Arch Intern Med. 2009;169(19):1795\u0026ndash;804.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMadden MH, Tomsik P, Terchek J, Navracruz L, Reichsman A, demons Clark T, et al. Keys to successful diabetes self-management for uninsured patients: social support, observational learning, and turning points: a safety net providers' strategic alliance study. J Natl Med Assoc. 2011;103(3):257\u0026ndash;64.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHankonen N, Sutton S, Prevost AT, Simmons RK, Griffin SJ, Kinmonth AL, et al. Which Behavior Change Techniques are Associated with Changes in Physical Activity, Diet and Body Mass Index in People with Recently Diagnosed Diabetes? Ann Behav Med. 2015;49(1):7\u0026ndash;17.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOlander EK, Fletcher H, Williams S, Atkinson L, Turner A, French DP. What are the most effective techniques in changing obese individuals\u0026rsquo; physical activity self-efficacy and behaviour: a systematic review and meta-analysis. Int J Behav Nutr Phys Act. 2013;10:29.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMichie S, Abraham C, Whittington C, McAteer J, Gupta S. Effective techniques in healthy eating and physical activity interventions: a meta-regression. Health Psychol. 2009;6:690\u0026ndash;701.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStanton-Fay SH, Hamilton K, Chadwick PM, Lorencatto F, Gianfrancesco C, de Zoysa N, et al. The DAFNEplus programme for sustained type 1 diabetes self management: Intervention development using the Behaviour Change Wheel. Diabet Med. 2021;38(5):e14548.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eF\u0026eacute;lix IB, Guerreiro MP, Cavaco A, Cl\u0026aacute;udio AP, Mendes A, Balsa J et al. Development of a complex intervention to improve adherence to antidiabetic medication in older people using an anthropomorphic virtual assistant software. Frontiers in Pharmacology. 2019;10(JUN).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJennings HM, Morrison J, Akter K, Kuddus A, Ahmed N, Kumer Shaha S et al. Developing a theory-driven contextually relevant mHealth intervention. Global Health Action. 2019;12(1).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLeon N, Namadingo H, Bobrow K, Cooper S, Crampin A, Pauly B et al. Intervention development of a brief messaging intervention for a randomised controlled trial to improve diabetes treatment adherence in sub-Saharan Africa. BMC Public Health. 2021;21(1).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMurphy K, Berk J, Muhwava-Mbabala L, Booley S, Harbron J, Ware L et al. Using the COM-B model and Behaviour Change Wheel to develop a theory and evidence-based intervention for women with gestational diabetes (IINDIAGO). BMC Public Health. 2023;23(1).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSmith R, Michalopoulou M, Reid H, Riches SP, Wango YN, Kenworthy Y et al. Applying the behaviour change wheel to develop a smartphone application \u0026lsquo;stay-active\u0026rsquo; to increase physical activity in women with gestational diabetes. BMC Pregnancy Childbirth. 2022;22(1).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHandley MA, Harleman E, Gonzalez-Mendez E, Stotland NE, Althavale P, Fisher L et al. Applying the COM-B model to creation of an IT-enabled health coaching and resource linkage program for low-income Latina moms with recent gestational diabetes: The STAR MAMA program. Implementation Science. 2016;11(1).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Footnotes","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003e Participant 60, BA Female, Age, 37, Sierra Leone\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e Participant 17, BA Male, Age 57, Sierra Leone\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e It was difficult to distinguish between Action planning and Goal setting in the data so the two BCTs are treated collectively.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e Participant 61, BC Female, Age 37, UK\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Type 2 diabetes, ethnicity, behaviour change, process evaluation, self-management, behaviour change, COM-B","lastPublishedDoi":"10.21203/rs.3.rs-4436026/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4436026/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eType 2 diabetes (T2D) is up to three times more common in people of Black African and Black Caribbean heritage living in the UK, compared to their White British counterparts. Structured education is the cornerstone of care but is less successful for people from minority ethnic groups. Healthy Eating and Active Lifestyles for Diabetes (HEAL-D) was developed to support diabetes self-management in people of Black African and Caribbean heritage living with T2D in the UK. The intervention was designed using COM-B/behaviour change wheel methodology to specify the theory of change. In a process evaluation study, we explored how the selected behaviour change techniques (BCTs) and components supported behaviour change in the intervention.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eFocus groups and interviews were conducted with participants who were randomised to receive the HEAL-D intervention in a feasibility trial. A topic guide directed discussions to explore experiences of HEAL-D, key learnings and impact, and behaviour change; the interviews gave the opportunity to probe further the focus group themes and areas requiring clarification. Sessions were audio-recorded and transcribed. Framework analysis was used to explore how the selected BCTs supported behaviour change in those attending HEAL-D.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThirty-six participants took part in one or both activities (44% Black African, 50% Black Caribbean, 6% Mixed race; 61% female, 83% first-generation; mean age 59.5, SD 10.02). Participants reported increased physical activity, reduced carbohydrate portion size and engagement in weight monitoring behaviour. BCTs to increase social opportunity (\u003cem\u003esocial comparison, social support\u003c/em\u003e) and shift motivational barriers (\u003cem\u003ecredible sources\u003c/em\u003e and \u003cem\u003emodelling\u003c/em\u003e) were effective in addressing cultural barriers around diet, stigma and health beliefs. BCTs to develop capability (\u003cem\u003edemonstration, instruction, information on health consequences\u003c/em\u003e) were effective because of the cultural salience of the developed components. Less impactful BCTs were \u003cem\u003eproblem solving\u003c/em\u003e, \u003cem\u003egraded tasks\u003c/em\u003e, \u003cem\u003egoal setting\u003c/em\u003e, and \u003cem\u003efeedback on outcomes\u003c/em\u003e.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eBCTs identified in the development of the HEAL-D intervention were acceptable and effective, particularly useful were those promoting social opportunity as normative cultural habits and beliefs can conflict with diabetes self-management guidance. In addition, lifestyle interventions should include opportunity for experiential learning alongside culturally salient information provision.\u003c/p\u003e\u003ch2\u003eTrial registration\u003c/h2\u003e \u003cp\u003enumber: NCT03531177; May 18th 2018\u003c/p\u003e","manuscriptTitle":"A qualitative evaluation of the effectiveness of behaviour change techniques used in the Healthy Eating and Active Lifestyles for Diabetes (HEAL-D) intervention","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-07 18:54:36","doi":"10.21203/rs.3.rs-4436026/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-08-02T13:17:23+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-07-12T17:38:39+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-07-11T18:48:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"96631819880899751378503478037571104249","date":"2024-06-22T14:40:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"338106401500026327379322251725451120576","date":"2024-06-19T13:41:42+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-06-16T22:55:40+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-05-22T08:25:10+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-05-21T12:17:35+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-05-21T12:17:35+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2024-05-17T10:18:40+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"52adac3f-5ca0-4823-8af3-4dfc8eb23b82","owner":[],"postedDate":"June 7th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-02-17T16:01:08+00:00","versionOfRecord":{"articleIdentity":"rs-4436026","link":"https://doi.org/10.1186/s12889-025-21767-8","journal":{"identity":"bmc-public-health","isVorOnly":false,"title":"BMC Public Health"},"publishedOn":"2025-02-11 15:56:52","publishedOnDateReadable":"February 11th, 2025"},"versionCreatedAt":"2024-06-07 18:54:36","video":"","vorDoi":"10.1186/s12889-025-21767-8","vorDoiUrl":"https://doi.org/10.1186/s12889-025-21767-8","workflowStages":[]},"version":"v1","identity":"rs-4436026","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4436026","identity":"rs-4436026","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}