Developing an integrated intervention to co-manage diabetes and hypertension in China: an application of the Behaviour Change Wheel Framework

Developing an integrated intervention to co-manage diabetes and hypertension in China: an application of the Behaviour Change Wheel Framework | 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 Perspective Developing an integrated intervention to co-manage diabetes and hypertension in China: an application of the Behaviour Change Wheel Framework Mei Chen Yap, Haizhu Song, Wai Yan Min Htike, Yuxuan Zhou, Lu Yang, and 9 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6467750/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract The increasing prevalence of multimorbidity and aging society present a major challenge for China’s health system. The co-management of hypertension and type 2 diabetes—one of the most common and clinically significant multimorbidity cluster—have been placed in the forefront of China’s national health policies. Substantial evidence base exists for lifestyle practices and treatment plans for managing this multimorbidity. Yet, implementation challenges persist within the existing structure and resources of primary health care in China. Behavioural science frameworks hold great potential to address these implementation challenges via identifying the behavioural barriers and rendering tailored implementation strategies. However, existing multimorbidity interventions often do not explicitly link behavioural influences with intervention design. This paper presents a case report of applying Behaviour Change Wheel (BCW) framework to guide the rapid development of an intervention for hypertension and diabetes co-management. The resulting evidence-based, people-centred, integrated care (EPIC) intervention restructures the standard of care by delivering three core features: personalized lifestyle prescriptions, digital tool assistance, and caregiver engagement. The BCW enables seamless integration of multiple intervention components and informed context-specific design. Specifically, the EPIC intervention can be readily implemented during the routine follow-up of older adults with hypertension and diabetes at primary health care facilities in a county-level city. Our case highlights the potential of behavioural science frameworks to address the complex challenge of multimorbidity. To fully realize this potential, empirical evidence is urgently needed to link mechanisms of change and implementation outcomes in theory-informed interventions. multimorbidity primary health care hypertension type 2 diabetes behaviour change wheel Figures Figure 1 Figure 2 Co-management of hypertension and type 2 diabetes in China China is on a fast track to become a super-aged society ( 1 ). Accompanying population aging is a rising burden of multimorbidity, which is defined as the co-occurrence of two or more chronic health conditions ( 2 ). In China, about one in three adults aged 60 and above experience multimorbidity, and the co-occurrence of hypertension and type 2 diabetes is among the most common and clinically significant combinations ( 3 , 4 ). The combined presence of both diseases is associated with increased risks of adverse cardiovascular events and cardiovascular mortality compared to either hypertension or diabetes alone ( 5 , 6 ). Older adults with both hypertension and diabetes face complex treatment regimens, including multiple medications, intricate dosing schedules, and lifestyle modifications ( 7 ). These demands contribute to poor adherence, increased risk of side effects, and higher occurrence of catastrophic health expenditure ( 8 ). Recognizing the pivotal role of primary health care for managing chronic diseases, China’s central government has committed to strengthening the primary health care system since 2009 ( 9 ). As part of this effort, the National Essential Public Health Services Standards was introduced in 2009, and it stipulates the national essential public health service package (hereafter referred to as the NEPHSP) delivered at the primary health care level for all residents ( 10 ). The screening and routine management of hypertension and type 2 diabetes for all residents aged 35 and above is part of the NEPHSP ( 10 ). However, empirical evidence suggests that current care practices remain fragmented, with limited coordination along care cascade from diagnosis to control ( 4 ). Moreover, a structured co-management approach has not yet been established. Under NEPHSP, primary health care providers in China are tasked with routinely following up with and providing evidence-based care to individuals with hypertension and diabetes for tertiary prevention. The promotion of medication adherence and sustained lifestyle changes—particularly in diet and physical activity—if achieved, can significantly improve clinical outcomes in older population with both conditions ( 11 – 13 ). However, past surveys found lower than 65% adherence to NEPHSP among older adults with hypertension and type 2 diabetes ( 4 ). The low adherence indicates barriers in translating evidence-based practices within the primary health care policy framework. The key question is how to effectively address these implementation barriers for improving the adherence to pharmacological treatment and lifestyle recommendations among older adults with hypertension and diabetes. Closing this implementation gap will be essential to realize the full potential of primary health care and improve population health in China and developing countries facing similar challenges. Application of Behaviour Change Wheel (BCW) for multimorbidity management There is growing recognition of the need for integrated, patient-centred interventions that go beyond disease-specific management to address the broader behavioural and contextual challenges faced by older adults with multimorbidity. The Behaviour Change Wheel (BCW) framework, underpinned by the COM-B model (Capability, Opportunity, Motivation – Behaviour), offers a systematic and theory-driven method to design complex health interventions ( 14 ). This rigorous approach has been applied to address challenges in managing chronic conditions among older adults, ranging from promoting physical activity to improving cognitive health ( 15 – 18 ). BCW is appropriate for hypertension and diabetes co-management intervention development where practical feasibility and stakeholder alignment are essential. We applied the BCW framework to form an Evidence-based, People-centred, Integrated, Co-management (EPIC) intervention. The EPIC intervention targeted community-dwelling older adults aged 65 years or older who have been diagnosed with both hypertension and type 2 diabetes, with or without other concurrent chronic conditions. The intervention was designed to be pilot in Kunshan, a county-level city in southeastern China with an older population of 257,411 in 2021 ( 19 ). Kunshan had a primary health care system consisting of 18 community health centres and 100 community health service stations managed by family physicians and allied health workers in 2024 ( 20 ). In the next sections, we reported the use case of the BCW framework to identify behavioural determinants, link behavioural change solutions, and integrate implementation strategies. Our case report illustrated how BCW, a framework originally developed in high-income countries, can be applied to address the multimorbidity management challenges in China's primary care setting. Our application of the BCW framework focused on three lifestyle factors strongly associated with improved clinical outcomes in our target population: medication adherence, physical activity, and sodium intake literature ( 21 – 23 ). We presented below the stage-by-stage application of BCW for each lifestyle factor, beginning with medication adherence and ending with the overview of EPIC intervention integrating behavioural change strategies for all three lifestyle factors (see Fig. 1 ). Full details of the BCW steps and decision criteria are in supplementary file. Improving medication adherence In stage 1 of the BCW framework, we set the target behaviour—namely the behaviour expected following successful change ( 24 )—as taking antihypertensive and/or antidiabetic medication at the prescribed time, dose, and duration (see details in supplementary file Table S1 -S3). Following the COM-B model, we identified determinants causing many older adults to mistime their medication, miss doses, or stop treatment without consulting professional (see Table 1 ). Old age imposed both psychological and physical limitations on older adults’ capability to remember and clearly read prescriptions. Additionally, many older adults had low literacy and limited health literacy. Since most community-dwelling older adult remain functional, their caregivers or adult children often paid insufficient attention to their medication schedule. Furthermore, certain medications required older adults to purchase from commercial pharmacy as they were difficult to consistently obtain from primary health care facilities. Motivation was also a concern: some participants questioned the need for medication when symptoms were absent, while others held fatalistic beliefs or had not developed consistent medication-taking habits. Table 1 COM-B diagnosis on drivers for target behavioural changes COM-B Categories Medical Adherence Salt Reduction Physical Activity What needs to happen? Change needed? What needs to happen? Change Needed? What needs to happen? Change needed? Capability Psychological Knowledge of the importance of adherence and strategies to overcome forgetfulness. Yes Understand the health benefits of LSSS; Can accurately select LSSS when shopping. Yes Understand the health benefits of regular physical exercises. Yes Physical Ability to purchase medication and manage doses independently No Able to go to shopping and cook or have family support to do so. No Have the physical ability to perform moderate activities, such as walking or light exercises. No Opportunity Social Have family support to take medication as prescribed. Yes Have family support to purchase LSSS; Have caregiver cook with LSSS. Yes Support from family, friends, or community members to encourage exercises or exercise together. Yes Physical Consistent supply of medication at pharmacy or other health facilities Yes Availability of LSSS in the supermarket. No Access to safe, accessible areas or facilities (e.g., parks, community centres) for physical activity. Yes Motivation Reflective Recognize the importance of medication adherence and willing to commit to habitual compliance. Yes Willing to change current cooking/eating habits related to salt. Yes Willing to change current sedentary habits and incorporate physical activity into their daily routine. Yes Automatic Not applicable. No Not applicable. No Not applicable. No. Note: COM-B Capability, Opportunity, Motivation—Behaviour, LSSS Low sodium salt substitutes In stage 2, we applied the Affordability, Practicability, Effectiveness, Acceptability, Safety, Equity (APEASE) criteria to select intervention functions, and subsequently policy categories, to address the barriers identified through COM-B analysis (see details in supplementary file Table S4-S5). Education delivered through culturally tailored sessions and printed materials can likely boost health literacy and psychological capability, which in terms can improve motivation. Policy supports in terms of communication campaigns and clinical guidelines can support the delivery of education intervention efforts. Environmental restructuring, such as digital tools that can send reminder or help purchase medications, can likely fill the gap in physical opportunity and social opportunity. These efforts can be supported via policies that regulate or organize the physical environment around older adults’ medication management routines. Enablement such as one-on-one support from community peer leaders and family members can especially improve adherence among those with limited literacy or social support to understand their medical prescription. Policies initiating changes to health care service provision and to social environment that shape older adults medication use can enhance the delivery of enablement intervention. In stage 3, we finalized our intervention design by specifying the active intervention components, known as behaviour change techniques (BCTs) (see details in supplementary file Table S6-S7). The education intervention function was operationalized via three BCTs: information about health consequences, prompts/cues, and feedback on behaviour. The environmental restructuring intervention function was operationalized via BCT of prompts/cues. The enablement intervention function was operationalized via three BCTs: social support (practical), goal setting (outcome), and action planning. The delivery modes of these BCTs included both face-to-face and distance modalities focusing on individual-level interaction. Reducing sodium intake In stage 1, we set the target behaviour as purchasing and consistently using low-sodium salt substitute in home cooking (see details in supplementary file Table S8-S10). Applying the COM-B model, we found multiple barriers preventing the adoption of low-sodium salt substitute among older adults with hypertension and diabetes (see Table 1 ). Older adults often lack knowledge about the health risks of high sodium intake and the benefits of low-sodium salt substitute. For community-dwelling older adults, food choices and cooking practices are often influenced by family members or caregivers, who may not support the use of low-sodium salt substitutes. For those with low literacy, they are unable to distinguish low-sodium salt substitute from other type of salt when shopping or make such purchase online when they are not available in nearby stores. Moreover, many participants are unwilling to change lifelong cooking or eating habits. In stage 2, we selected intervention functions and policy categories to enhance knowledge, build supportive household environments, and reshape attitudes towards sodium and salt consumption (see details in supplementary file Table S11-12). Educational efforts focused on the benefits of low-sodium salt substitutes and the risks associated with sodium intake can fill knowledge gaps and encourage sodium reduction practices. These efforts can be supported via communication/marketing, regulation, and service provision related policies. Environmental restructuring that places the recommendation of low-sodium salt substitute at the centre of sodium reduction health education at primary health care level can further promote widespread adoption. Policy supports such as guidelines on health education components can enhance the delivery of such environmental restructuring intervention. Enablement such as tools supporting older adults and caregivers to identify low-sodium salt substitutes in local supermarkets likely address the opportunity and motivation gap and spark salt reduction discussion in families. Policies initiating changes to health care service provision and to physical environment related to purchase of cooking salt can enhance the delivery of enablement intervention. In stage 3, we operationalized these intervention functions by identifying specific BCTs (see details in supplementary file Table S13-14). The education intervention function was operationalized via three BCTs: information about health consequences, prompts/cues, and feedback on outcomes of the behaviour. The environmental restructuring intervention function was operationalized via the BCT of prompts/cues. The enablement intervention function was operationalized via the BCT of social support (practical). These BCTs were planned to be delivered through in both remote and in-person formats, aiming to normalize low-sodium salt substitute use and embed it into daily life. Increasing physical activity In stage 1, we set the target behaviour as increasing older adults’ engagement in moderate-intensity aerobic physical activity to meet World Health Organization’s recommendation of 150 minutes of such exercise per week ( 21 ) (see details in supplementary file Table S15-S17). Our COM-B analysis indicated multiple barriers in reaching the target behaviour (see Table 1 ). Older adults reported not knowing what types of exercises are appropriate or safe for them. They were further constrained by lack of access to community spaces appropriate for physical activity, particularly when weather is hot, cold or rainy. Meanwhile, exercising together with peers or family members was not an option easily available to all older adults. Motivation for increasing physical activity was also low among many older adults as they perceive physical activity as unnecessary or even risky at their age. In stage 2, we selected intervention functions and policy categories to increase and sustain engagement in physical activity to the recommended level (see details in supplementary file Table S18-S19). Education efforts that improve knowledge on health benefits and safety of various physical activities can likely address the gaps in psychological capability and motivation. These efforts can be supported via policies encouraging communication campaigns and expanding health care service provision. Environmental restructuring focused on changing the physical or social environment to make physical activity easier or more enjoyable can increase physical and social opportunity. While building new venues for exercises was outside the scope of primary health care, it was plausible to change the social context of physical activity. Regulatory policies can support the implementation of such intervention. Enablement focused on identification of exercise plans, venues and group activities can address the psychological capability and social opportunity gap. Policies expanding health care service provision and changing social or physical environment where older adults choose physical activities can enhance the delivery of enablement intervention. Modelling intervention that demonstrates standard and safe exercises through peers or health care workers may help older adults build confidence to engage in physical activity. The modelling intervention can be supported by social media campaigns with videos or expanding primary health care service provisions. In stage 3, we translated the selected intervention functions into specific strategies using BCTs (see details in supplementary file Table S20-S21). The education intervention function was operationalized via three BCTs: information about health consequences, prompts/cues, and feedback on outcomes of the behaviour. The environmental restructuring intervention function was operationalized via the BCT of prompts/cues. The enablement intervention function was operationalized via two BCTs: action planning and social support (practical). The modelling intervention function was operationalized via the BCT of demonstration of the behaviour. The delivery modes of these BCTs included both face-to-face and remote modalities with a primary focus on individual-level interaction. [Table 1 here] Overview of the EPIC intervention We integrated the selected intervention functions, BCTs, and delivery modes to form the EPIC intervention (see Fig. 2 ). The intervention cycle begins when each older adult with coexisting hypertension and diabetes presents to a community health service station for a routine follow-up visit. At the initial visit, the older adult receives a lifestyle prescription from their family physician in addition to the standard medication prescription. The family physician personalizes the lifestyle prescription with the aid of clinical decision support system. The clinical decision support system assists family physicians by converting patient data and clinical guidelines into actionable recommendations at the point of care. For example, they could assess a patient's suitability for replacing daily cooking salt with the low-sodium salt substitutes based on prior diagnosis stored in the system. Additional resources such as maps and schedules of community exercise programs are handed to the older adults to facilitate adherence to lifestyle prescriptions. Under NEPHSP, routine follow-up visits are scheduled between two weeks and three months apart, depending on the older adult’s blood pressure and blood sugar control levels. During the subsequent visit, the family physician and the older adult jointly review the lifestyle prescription to assess progress and determine whether any adjustments or additional support are required. This regular review of lifestyle prescriptions ensures sustained support to lifestyle changes and can meet dynamic needs of older adults with multimorbidity throughout their disease journey. Between routine follow-up visits, older adults receive voice messages containing reminders and health education information on all three lifestyle factors. For older adults requiring social support to complete their lifestyle prescription, the family physician would also send the lifestyle prescription and these voice messages to their caregivers. These voice messages will be sent via an automated calling system, known as voice bot. The use of voice messages to facilitate chronic disease management among older adults population with low literacy level has been positively evaluated in the rural context in China ( 25 ). Lastly, to specifically promote physical activity, community health service stations would periodically organize group exercise events to demonstrate safe and effective exercise routines. Strengths of BCW in designing multimorbidity intervention The systematic application of the BCW framework allowed the EPIC intervention to be complex, with multiple components accounting for different stakeholders’ perspectives, yet specific, tailored to primary health care settings and patient-level barriers in Kunshan. Despite the multifaceted barriers to achieving the three target behaviours, the structured process of selecting locally appropriate intervention functions established a unified and coherent strategy for addressing these complexities. Since intervention functions, in conjunction with the APEASE criteria, serve as the foundation for selecting policy categories, BCTs, and delivery modes, their consistency has enabled the seamless integration of three lifestyle interventions into a single, cohesive intervention. While previous multimorbidity intervention development studies have largely focused on conceptual frameworks without specifying implementation strategies ( 26 , 27 ), our study demonstrates how BCW and APEASE can bridge the gap between theory and practice. Another strength of the BCW framework is that it helped to establish clear links between behavioural influences, interventions, mechanisms, and the planned implementation outcomes for each component of this complex intervention. Specifically, influences on change, identified through a COM-B diagnosis, informed the selection of intervention functions. These, in turn, signposted BCTs likely to be effective. These clear links may help future intervention developer or practitioner identify which components of the existing intervention are applicable to their context based on local barriers. Limitations of BCW in designing multimorbidity intervention Despite the advantages of the BCW framework, there are limitations that should be addressed in its application. While the APEASE criteria guide the decision-making process in intervention development, it offers dimensions for decision-making rather than a quantifiable scale. This room for subjectivity is a common issue discussed by intervention studies using BCW ( 15 , 28 , 29 ). To minimize bias, we incorporated expert consultation during the design phase, a strategy also employed by other BCW-based studies in China ( 29 , 30 ). If helpful, the APEASE dimensions can be developed into quantifiable scales to allow comparison of options. The behavioural focus of BCW makes it difficult to integrate system- and organization-level factors in the initial stages of intervention design. To address this issue, we prioritized understanding patient-level barriers in steps 1 to 4. Systems-level factors and stakeholder perspectives were then integrated during later stages through focus group discussions with local health authorities. This approach requires an iterative process, where each revision is carefully aligned with the feedback from community members and stakeholders and mapped to the corresponding BCW steps. While this process ensures the intervention is contextually relevant, it is also time-consuming. Unanswered questions and future research in multimorbidity interventions The EPIC intervention proposed the use of digital health tools to enhance the delivery and effectiveness of lifestyle prescriptions. The implementation strategies for this intervention will depend on the particular healthcare context, which raises questions for future research. The EPIC intervention focuses on clinical decision support systems and voice bots as the main digital health solutions to address human resource shortage. There are many other digital technologies worth exploring for improving care for older adults with multimorbidity in primary care settings ( 31 ). For example, sharing audio recordings of clinic visits has been found to be feasible and effective in improving understanding, recall, and family engagement in treatment for a U.S. older adult population with hypertension and diabetes multimorbidity ( 32 ). In the implementation context of EPIC, most older adults had already been diagnosed with diabetes and hypertension for a long time. The time lapse between diagnosis and intervention significantly impacts medication adherence, as chronic conditions tend to feel less life-threatening over time ( 33 ). Devising personalized methods to boost motivation of patients is a potential pathway to engage with older adults with distinct levels of motivation for lifestyle changes. Personalization has been found to be key for the success of lifestyle interventions ( 34 ). Research suggests that approaches such as motivational interviewing ( 35 ) and just-in-time interventions ( 36 ) have potential for managing multimorbidity among older adults. However, the evidence base for these approaches is limited. Additionally, task-sharing or task-shifting intervention has also proven to be effective in managing individuals with multimorbidity ( 36 ). Furthermore, there remains a dearth of evidence that explicitly links mechanisms of change and implementation outcomes in multimorbidity interventions. Future research should consider applying frameworks such as BCW to clarify the mechanisms of changes for advancing the evidence to design, adapt, evaluate, and sustain effective multimorbidity interventions across diverse settings and populations. Conclusion There are enormous opportunities to improve population health and to relieve health system burden via strengthening multimorbidity management delivered at the primary health level. Our case report of BCW application illustrates that behavioural science frameworks can serve as powerful tools to systematically diagnose behavioural barriers, align intervention components, and develop integrated strategies for the co-management hypertension and diabetes multimorbidity. The EPIC intervention proposed restructuring of the standard of care, integration of digital tools and engagement of family caregiver for the effective co-management of hypertension and type 2 diabetes among older adults. To advance implementation science in developing countries, we call on future researchers and practitioners to document their experiences and contribute insights on applying behavioural science frameworks to address multimorbidity challenges across diverse cultural and socioeconomic conditions. Abbreviations APEASE Affordability, Practicability, Effectiveness, Acceptability, Safety, Equity BCW Behaviour Change Wheel BCT Behaviour Change Technique COM-B Capability, Opportunity, Motivation, and Behaviour EPIC Evidence-based, People-centred, Integrated Care NEPHSP National Essential Public Health Service Package Declarations Ethics approval and consent to participate The qualitative research led up to this intervention development study was approved by the Duke Kunshan University Institutional Review Board (registration number FWA00021580). All participants provided written consent to participate. Consent for publication Not applicable. Availability of data and materials The details on step-by-step application of BCW is provided in the supplementary file 3. The transcripts and other qualitative data are not publicly available to maintain privacy of the participants. They may be made available from the corresponding author on reasonable request. Competing interests The authors declare no competing interests. Funding This research was supported by the National Key R & D program of China (Grant No. 2023 YFC3605002) and the Duke Kunshan University Innovation and Entrepreneurship Initiative and the Innovation Incubator Program. The research results of this article are sponsored by the Kunshan Municipal Government research funding. Authors' contributions MCY, HS, WYMH, YX, MJ, and YM conducted the literature review and analysed the qualitative findings to inform the step-by-step application of BCW. MCY, HS, WYMH and YX wrote the main manuscript, prepared tables and figures and supplementary files. LY, XY, YS, BX, EG, BY provided critical feedback to the design of the intervention design. SM provide critical inputs in revising the manuscript. LLY conceptualized the study and oversaw the project administration. All authors reviewed and approved the final manuscript. Acknowledgements We express our sincere gratitude to the patients, family members and family physicians who participated in this study. Also, we would like to thank student research assistants Xiaoyu Zhou, Chunyuan Li, Li Di, Jingxuan Zhuge, Juntian Shen, Hanting Zhang, Weijing Song, Yitong Su, Fangyu Wu, Chen Zhang, Yunrong Gu, Yilin Wang, Gao Fan for supporting the semi-structured interviews, particularly the translating and transcribing the interviews. We also thank the officials from Kunshan Community Health Centres and Kunshan Health Commission who supported participants’ recruitment and provided venues for the semi-structured interviews and focus group discussions. References Luo Y, Su B, Zheng X. Trends and Challenges for Population and Health During Population Aging — China, 2015–2050. China CDC Wkly. 2021 Jul 9;3(28):593–8. Valderas JM, Starfield B, Sibbald B, Salisbury C, Roland M. Defining comorbidity: implications for understanding health and health services. Ann Fam Med. 2009;7(4):357–63. Xue X, Wang Z, Qi Y, Chen N, Zhao K, Zhao M, et al. Multimorbidity patterns and influencing factors in older Chinese adults: a national population-based cross-sectional survey. J Glob Health. 2025 Feb 21;15:04051. Zhang X, Liu T, Li Z, Yang J, Hou H, Hao T, et al. Using primary and routinely collected data to determine prevalence and patterns of multimorbidity in rural China: a representative cross-sectional study of 6474 Chinese adults. Lancet Reg Health – West Pac [Internet]. 2025 Jan 1 [cited 2025 Mar 2];54. Available from: https://www.thelancet.com/journals/lanwpc/article/PIIS2666-6065(24)00266-9/fulltext?uuid=uuid%3A6ab7c322-135e-4665-b292-513e45373ac7 Seidu S, Hambling CE, Kunutsor SK, Topsever P. Associations of blood pressure with cardiovascular and mortality outcomes in over 2 million older persons with or without diabetes mellitus: A systematic review and meta-analysis of 45 cohort studies. Prim Care Diabetes. 2023 Dec;17(6):554–67. Nirmal S, Chowdhury HA. Hypertension in diabetes and the risk of cardiovascular disease. Cardiovasc Endocrinol Metab. 2017 Mar;6(1):33. Kwakye AO, Kretchy IA, Peprah P, Mensah KB. Factors influencing medication adherence in co-morbid hypertension and diabetes patients: A scoping review. Explor Res Clin Soc Pharm. 2024 Feb 29;13:100426. Tran PB, Kazibwe J, Nikolaidis GF, Linnosmaa I, Rijken M, van Olmen J. Costs of multimorbidity: a systematic review and meta-analyses. BMC Med. 2022 Jul 19;20(1):234. Xiong S, Cai C, Jiang W, Ye P, Ma Y, Liu H, et al. Primary health care system responses to non-communicable disease prevention and control: a scoping review of national policies in Mainland China since the 2009 health reform. Lancet Reg Health – West Pac [Internet]. 2023 Feb 1 [cited 2025 Jul 16];31. Available from: https://www.thelancet.com/journals/lanwpc/article/PIIS2666-6065(22)00009-8/fulltext Notice from the national health and family planning commission on issuing the national basic public health services standards (third edition) [Internet]. 2017. Available from: http://www.nhc.gov.cn/ewebeditor/uploadfile/2017/04/20170417104506514.pdf Abbasnezhad A, Falahi E, Gonzalez MJ, Kavehi P, Fouladvand F, Choghakhori R. Effect of different dietary approaches compared with a regular diet on systolic and diastolic blood pressure in patients with type 2 diabetes: A systematic review and meta-analysis. Diabetes Res Clin Pract. 2020 May 1;163:108108. Park S, Kim J, Lee J. Effects of Exercise Intervention on Adults With Both Hypertension and Type 2 Diabetes Mellitus: A Systematic Review and Meta-analysis. J Cardiovasc Nurs. 2021;36(1):23–33. Anderson LJ, Nuckols TK, Coles C, Le MM, Schnipper JL, Shane R, et al. A systematic overview of systematic reviews evaluating medication adherence interventions. Am J Health Syst Pharm. 2020 Jan 8;77(2):138–47. Michie S, van Stralen MM, West R. The behaviour change wheel: A new method for characterising and designing behaviour change interventions. Implement Sci. 2011 Apr 23;6(1):42. 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. Front Pharmacol [Internet]. 2019 Jun 21 [cited 2024 Oct 18];10. Available from: https://www.frontiersin.org/journals/pharmacology/articles/10.3389/fphar.2019.00680/full Combes S, Forbes G, Gillett K, Norton C, Nicholson CJ. Development of a theory-based intervention to increase cognitively able frail elders’ engagement with advance care planning using the behaviour change wheel. BMC Health Serv Res. 2021 Jul 20;21(1):712. Nelligan RK, Hinman RS, Kasza J, Bennell KL. Effectiveness of internet-delivered education and home exercise supported by behaviour change SMS on pain and function for people with knee osteoarthritis: a randomised controlled trial protocol. BMC Musculoskelet Disord. 2019 Jul 27;20(1):342. Lin R, Yan Y, Chen Z, Huang C, Zhao J, Chen M, et al. A mobile-based multidomain lifestyle intervention using Cognitive Evergreenland for older adults with subjective cognitive decline: a feasibility study. BMC Geriatr. 2025 Jan 20;25(1):41. Kunshan Municipal People’s Government [Internet]. 2021 [cited 2025 Mar 2]. Results from Kunshan City’s Census. Available from: https://www.ks.gov.cn/kss/ttxw/202106/8ff6d2d3e1204b60a157f14815d7bfce.shtml Kunshan Municipal People’s Government [Internet]. 2024 [cited 2024 Dec 6]. Performance evaluation of Suzhou’s 2023 National Basic Public Health Service Program. Available from: https://www.ks.gov.cn/kss/bmdt/202404/60235c3bdb4440c3aadd6aea7c18bd0d.shtml World Health Organization. Guidelines on physical activity and sedentary behaviour [Internet]. World Health Organization; 2020. Available from: https://www.who.int/publications/i/item/9789240015128 World Health Organization. Adherence to long-term therapies : evidence for action. [Internet]. World Health Organization; 2003. Available from: https://iris.who.int/handle/10665/42682 World Health Organization. Guideline: Sodium intake for adults and children [Internet]. World Health Organization; 2012. Available from: https://iris.who.int/bitstream/handle/10665/77985/9789241504836_eng.pdf Michie S, Lou Atkins, Robert West. The behavioural change wheel: A Guide to designing interventions. Great Britain: Silverback Publishing; 2014. Yan LL, Gong E, Gu W, Turner EL, Gallis JA, Zhou Y, et al. Effectiveness of a primary care-based integrated mobile health intervention for stroke management in rural China (SINEMA): A cluster-randomized controlled trial. PLoS Med. 2021;18(4):1–20. Patton DE, Ryan C, Hughes CM. Development of a complex community pharmacy intervention package using theory-based behaviour change techniques to improve older adults’ medication adherence. BMC Health Serv Res. 2020 May 13;20(1):418. Jayanna K, Swaroop N, Kar A, Ramanaik S, Pati MK, Pujar A, et al. Designing a comprehensive Non-Communicable Diseases (NCD) programme for hypertension and diabetes at primary health care level: evidence and experience from urban Karnataka, South India. BMC Public Health. 2019 Apr 16;19(1):409. Mabweazara SZ, Leach LL, Ley C. Development of a context-sensitive physical activity intervention for persons living with HIV and AIDS of low socioeconomic status using the behaviour change wheel. BMC Public Health. 2019 Jun 17;19(1):774. Wang H, Blake H, Chattopadhyay K. Development of a School-Based Intervention to Increase Physical Activity Levels Among Chinese Children: A Systematic Iterative Process Based on Behavior Change Wheel and Theoretical Domains Framework. Front Public Health [Internet]. 2021 Apr 27 [cited 2024 Oct 18];9. Available from: https://www.frontiersin.org/journals/public-health/articles/10.3389/fpubh.2021.610245/full Chen D, Shao J, Zhang H, Wu J, Xue E, Guo P, et al. Development of an individualized WeChat mini program-based intervention to increase adherence to dietary recommendations applying the behaviour change wheel among individuals with metabolic syndrome. Ann Med. 2023 Dec 12;55(2):2267587. Zhang W, Cheng B, Zhu W, Huang X, Shen C. Effect of Telemedicine on Quality of Care in Patients with Coexisting Hypertension and Diabetes: A Systematic Review and Meta-Analysis. Telemed E-Health. 2021 Jun;27(6):603–14. Barr PJ, Masel M, Bratches RW, Carpenter-Song E, O’Malley AJ, Bruce ML, et al. The feasibility of sharing digital audio-recordings of clinic visits online with older adults in primary care settings: A multisite trial. Patient Educ Couns. 2025 Feb 1;131:108574. Raj JP, Mathews B. Effect of behavioral intervention on medication adherence among elderly with select non-communicable diseases (ENDORSE): Pilot randomized controlled trial. Geriatr Gerontol Int. 2020 Nov;20(11):1079–84. Tong HL, Quiroz JC, Kocaballi AB, Fat SCM, Dao KP, Gehringer H, et al. Personalized mobile technologies for lifestyle behavior change: A systematic review, meta-analysis, and meta-regression. Prev Med. 2021 Jul 1;148:106532. Papus M, Dima AL, Viprey M, Schott AM, Schneider MP, Novais T. Motivational interviewing to support medication adherence in adults with chronic conditions: Systematic review of randomized controlled trials. Patient Educ Couns. 2022 Nov 1;105(11):3186–203. Vandelanotte C, Trost S, Hodgetts D, Imam T, Rashid M, To QG, et al. Increasing physical activity using an just-in-time adaptive digital assistant supported by machine learning: A novel approach for hyper-personalised mHealth interventions. J Biomed Inform. 2023 Aug 1;144:104435. Additional Declarations No competing interests reported. Supplementary Files SupplementaryFileBCWTables.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 11 Oct, 2025 Reviews received at journal 02 Oct, 2025 Reviews received at journal 24 Sep, 2025 Reviewers agreed at journal 24 Sep, 2025 Reviewers agreed at journal 24 Sep, 2025 Reviews received at journal 20 Aug, 2025 Reviewers agreed at journal 10 Aug, 2025 Reviewers agreed at journal 03 Aug, 2025 Reviewers invited by journal 01 Aug, 2025 Submission checks completed at journal 30 Jul, 2025 First submitted to journal 30 Jul, 2025 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. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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-6467750","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Perspective","associatedPublications":[],"authors":[{"id":495524244,"identity":"36c8c85d-3672-48b2-95d5-90ac943191de","order_by":0,"name":"Mei Chen Yap","email":"","orcid":"","institution":"Global Health Research Center, Duke Kunshan University","correspondingAuthor":false,"prefix":"","firstName":"Mei","middleName":"Chen","lastName":"Yap","suffix":""},{"id":495524245,"identity":"f98cb334-7092-4358-9811-047963b941d4","order_by":1,"name":"Haizhu Song","email":"","orcid":"","institution":"Duke Kunshan University","correspondingAuthor":false,"prefix":"","firstName":"Haizhu","middleName":"","lastName":"Song","suffix":""},{"id":495524246,"identity":"78e553f0-32f5-48a3-9d0a-655e146b2b17","order_by":2,"name":"Wai Yan Min Htike","email":"","orcid":"","institution":"Duke Kunshan University","correspondingAuthor":false,"prefix":"","firstName":"Wai","middleName":"Yan Min","lastName":"Htike","suffix":""},{"id":495524247,"identity":"e7bc0f85-9a22-4de1-b19f-9c1c719519d5","order_by":3,"name":"Yuxuan Zhou","email":"","orcid":"","institution":"Duke Kunshan University","correspondingAuthor":false,"prefix":"","firstName":"Yuxuan","middleName":"","lastName":"Zhou","suffix":""},{"id":495524248,"identity":"0227b047-e3eb-48e6-89b8-c06b5a4e34c3","order_by":4,"name":"Lu Yang","email":"","orcid":"","institution":"Nanjing University of Posts and Telecommunications","correspondingAuthor":false,"prefix":"","firstName":"Lu","middleName":"","lastName":"Yang","suffix":""},{"id":495524249,"identity":"a523813b-a429-4d7d-90c3-2d11e593fbf1","order_by":5,"name":"Xuejun Yin","email":"","orcid":"","institution":"School of Public Health, Jiangxi Medical College, Nanchang University","correspondingAuthor":false,"prefix":"","firstName":"Xuejun","middleName":"","lastName":"Yin","suffix":""},{"id":495524250,"identity":"54015e3d-1a90-4740-8b91-cf2b04e9d8aa","order_by":6,"name":"Menglu Jiang","email":"","orcid":"","institution":"Global Health Research Center, Duke Kunshan University","correspondingAuthor":false,"prefix":"","firstName":"Menglu","middleName":"","lastName":"Jiang","suffix":""},{"id":495524251,"identity":"1106ed2f-212c-4246-a5dd-3cd33598cf9c","order_by":7,"name":"Yizhou Ma","email":"","orcid":"","institution":"Global Health Research Center, Duke Kunshan University","correspondingAuthor":false,"prefix":"","firstName":"Yizhou","middleName":"","lastName":"Ma","suffix":""},{"id":495524252,"identity":"7dfdd58c-f74b-40be-8ae0-546d8f7a90c5","order_by":8,"name":"Yiyao Shi","email":"","orcid":"","institution":"National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences \u0026 Peking Union Medical College (CAMS \u0026 PUMC)","correspondingAuthor":false,"prefix":"","firstName":"Yiyao","middleName":"","lastName":"Shi","suffix":""},{"id":495524253,"identity":"4cd9dc43-40b9-4acc-bbb1-f24b9786fe6d","order_by":9,"name":"Bingqing Xu","email":"","orcid":"","institution":"Affiliated Kunshan Hospital of Jiangsu University","correspondingAuthor":false,"prefix":"","firstName":"Bingqing","middleName":"","lastName":"Xu","suffix":""},{"id":495524254,"identity":"9b892e66-56f8-4a4a-951f-c77417433b39","order_by":10,"name":"Enying Gong","email":"","orcid":"","institution":"School of Public Health, Jiangxi Medical College, Nanchang University","correspondingAuthor":false,"prefix":"","firstName":"Enying","middleName":"","lastName":"Gong","suffix":""},{"id":495524255,"identity":"56201742-7608-4221-9cf1-fc070e6f4a00","order_by":11,"name":"Bolu Yang","email":"","orcid":"","institution":"Wuhan University","correspondingAuthor":false,"prefix":"","firstName":"Bolu","middleName":"","lastName":"Yang","suffix":""},{"id":495524256,"identity":"0a479b90-b11e-4a00-856a-6bd85d0c62c2","order_by":12,"name":"Susan Michie","email":"","orcid":"","institution":"University College London","correspondingAuthor":false,"prefix":"","firstName":"Susan","middleName":"","lastName":"Michie","suffix":""},{"id":495524257,"identity":"98e884e3-ea64-4e3b-9720-766c83a71f5c","order_by":13,"name":"Lijing L. Yan","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2UlEQVRIiWNgGAWjYBACPmaGhAMQJvMBCQYwMwG/FjaEFrYEIrUgmDwGRGphZ3h4uOAXQ2L/7J6Pt3nO2DDws+cYEHTY4Zl9DIkz7pzdbM1zI41BsucNEVp4exgSG27kbpPm+XCYweAGMbaAtMy/kfMMqOU/gz1RWnh+MCRuuJHDJs1z4wCDgQRRtjRIGG+8kWZsOedMMo/EmWcFeLXw859J/szzx0Z23o3khzfeHLOT429P3oBXCzA6EhgY2yQcG2BcAspBgP0AA8MfBnsiVI6CUTAKRsFIBQCZPUhZAT517QAAAABJRU5ErkJggg==","orcid":"","institution":"Global Health Research Center, Duke Kunshan University","correspondingAuthor":true,"prefix":"","firstName":"Lijing","middleName":"L.","lastName":"Yan","suffix":""}],"badges":[],"createdAt":"2025-04-17 04:08:09","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6467750/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6467750/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":88411262,"identity":"d6487dcd-c01b-4314-8e58-adbb3167ec23","added_by":"auto","created_at":"2025-08-06 08:24:23","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":150595,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eEPIC intervention development process. \u003c/strong\u003eThe BCW stages and steps were adopted (14). The intervention strategies to achieve three lifestyle factors were developed in parallel from stage 1 to 3 and merged into one intervention after all stages were completed.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-6467750/v1/b7798d3ef9859ee00c0a275d.png"},{"id":88411255,"identity":"56265180-73ee-4cf6-8dc5-0d4dc89d8220","added_by":"auto","created_at":"2025-08-06 08:24:20","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":133683,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eConceptual Model of the EPIC intervention. \u003c/strong\u003eThe intervention contents were grouped into two parts based on implementation timing (during and after follow-up visits). Family physician teams will carry out the intervention with support from clinical decision support system (CDSS) and voice bot.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-6467750/v1/83fc1e9134d693943ff85f6f.png"},{"id":88411336,"identity":"6d5a4bc6-d840-41f9-aa59-f39fec9b16f5","added_by":"auto","created_at":"2025-08-06 08:24:32","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":953784,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6467750/v1/1270f818-d8b7-4799-98e8-faf1b98594fe.pdf"},{"id":88411254,"identity":"17ffc1bc-38e7-46b3-bd11-816ce61751a8","added_by":"auto","created_at":"2025-08-06 08:24:20","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":73204,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFileBCWTables.docx","url":"https://assets-eu.researchsquare.com/files/rs-6467750/v1/b5748b1666d6bb9dbe5b5eaf.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Developing an integrated intervention to co-manage diabetes and hypertension in China: an application of the Behaviour Change Wheel Framework","fulltext":[{"header":"Co-management of hypertension and type 2 diabetes in China","content":"\u003cp\u003eChina is on a fast track to become a super-aged society (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Accompanying population aging is a rising burden of multimorbidity, which is defined as the co-occurrence of two or more chronic health conditions (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). In China, about one in three adults aged 60 and above experience multimorbidity, and the co-occurrence of hypertension and type 2 diabetes is among the most common and clinically significant combinations (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). The combined presence of both diseases is associated with increased risks of adverse cardiovascular events and cardiovascular mortality compared to either hypertension or diabetes alone (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Older adults with both hypertension and diabetes face complex treatment regimens, including multiple medications, intricate dosing schedules, and lifestyle modifications (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). These demands contribute to poor adherence, increased risk of side effects, and higher occurrence of catastrophic health expenditure (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eRecognizing the pivotal role of primary health care for managing chronic diseases, China\u0026rsquo;s central government has committed to strengthening the primary health care system since 2009 (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). As part of this effort, the National Essential Public Health Services Standards was introduced in 2009, and it stipulates the national essential public health service package (hereafter referred to as the NEPHSP) delivered at the primary health care level for all residents (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). The screening and routine management of hypertension and type 2 diabetes for all residents aged 35 and above is part of the NEPHSP (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). However, empirical evidence suggests that current care practices remain fragmented, with limited coordination along care cascade from diagnosis to control (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Moreover, a structured co-management approach has not yet been established.\u003c/p\u003e\u003cp\u003eUnder NEPHSP, primary health care providers in China are tasked with routinely following up with and providing evidence-based care to individuals with hypertension and diabetes for tertiary prevention. The promotion of medication adherence and sustained lifestyle changes\u0026mdash;particularly in diet and physical activity\u0026mdash;if achieved, can significantly improve clinical outcomes in older population with both conditions (\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). However, past surveys found lower than 65% adherence to NEPHSP among older adults with hypertension and type 2 diabetes (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). The low adherence indicates barriers in translating evidence-based practices within the primary health care policy framework. The key question is how to effectively address these implementation barriers for improving the adherence to pharmacological treatment and lifestyle recommendations among older adults with hypertension and diabetes. Closing this implementation gap will be essential to realize the full potential of primary health care and improve population health in China and developing countries facing similar challenges.\u003c/p\u003e\u003cp\u003e\u003cb\u003eApplication of Behaviour Change Wheel (BCW) for multimorbidity management\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThere is growing recognition of the need for integrated, patient-centred interventions that go beyond disease-specific management to address the broader behavioural and contextual challenges faced by older adults with multimorbidity. The Behaviour Change Wheel (BCW) framework, underpinned by the COM-B model (Capability, Opportunity, Motivation \u0026ndash; Behaviour), offers a systematic and theory-driven method to design complex health interventions (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). This rigorous approach has been applied to address challenges in managing chronic conditions among older adults, ranging from promoting physical activity to improving cognitive health (\u003cspan additionalcitationids=\"CR16 CR17\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). BCW is appropriate for hypertension and diabetes co-management intervention development where practical feasibility and stakeholder alignment are essential.\u003c/p\u003e\u003cp\u003eWe applied the BCW framework to form an Evidence-based, People-centred, Integrated, Co-management (EPIC) intervention. The EPIC intervention targeted community-dwelling older adults aged 65 years or older who have been diagnosed with both hypertension and type 2 diabetes, with or without other concurrent chronic conditions. The intervention was designed to be pilot in Kunshan, a county-level city in southeastern China with an older population of 257,411 in 2021 (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Kunshan had a primary health care system consisting of 18 community health centres and 100 community health service stations managed by family physicians and allied health workers in 2024 (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn the next sections, we reported the use case of the BCW framework to identify behavioural determinants, link behavioural change solutions, and integrate implementation strategies. Our case report illustrated how BCW, a framework originally developed in high-income countries, can be applied to address the multimorbidity management challenges in China's primary care setting. Our application of the BCW framework focused on three lifestyle factors strongly associated with improved clinical outcomes in our target population: medication adherence, physical activity, and sodium intake literature (\u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). We presented below the stage-by-stage application of BCW for each lifestyle factor, beginning with medication adherence and ending with the overview of EPIC intervention integrating behavioural change strategies for all three lifestyle factors (see Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Full details of the BCW steps and decision criteria are in supplementary file.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eImproving medication adherence\u003c/b\u003e\u003c/p\u003e\u003cp\u003eIn stage 1 of the BCW framework, we set the target behaviour\u0026mdash;namely the behaviour expected following successful change (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e)\u0026mdash;as taking antihypertensive and/or antidiabetic medication at the prescribed time, dose, and duration (see details in supplementary file Table \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e-S3). Following the COM-B model, we identified determinants causing many older adults to mistime their medication, miss doses, or stop treatment without consulting professional (see Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Old age imposed both psychological and physical limitations on older adults\u0026rsquo; capability to remember and clearly read prescriptions. Additionally, many older adults had low literacy and limited health literacy. Since most community-dwelling older adult remain functional, their caregivers or adult children often paid insufficient attention to their medication schedule. Furthermore, certain medications required older adults to purchase from commercial pharmacy as they were difficult to consistently obtain from primary health care facilities. Motivation was also a concern: some participants questioned the need for medication when symptoms were absent, while others held fatalistic beliefs or had not developed consistent medication-taking habits.\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 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCOM-B diagnosis on drivers for target behavioural changes\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"8\"\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\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e\u003cp\u003eCOM-B Categories\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003eMedical Adherence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003eSalt Reduction\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u003cp\u003ePhysical Activity\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eWhat needs to happen?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eChange needed?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eWhat needs to happen?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eChange Needed?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eWhat needs to happen?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eChange needed?\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eCapability\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003ePsychological\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eKnowledge of the importance of adherence and strategies to overcome forgetfulness.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eUnderstand the health benefits of LSSS; Can accurately select LSSS when shopping.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eUnderstand the health benefits of regular physical exercises.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003ePhysical\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAbility to purchase medication and manage doses independently\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eAble to go to shopping and cook or have family support to do so.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eHave the physical ability to perform moderate activities, such as walking or light exercises.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eOpportunity\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eSocial\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eHave family support to take medication as prescribed.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eHave family support to purchase LSSS; Have caregiver cook with LSSS.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eSupport from family, friends, or community members to encourage exercises or exercise together.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003ePhysical\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eConsistent supply of medication at pharmacy or other health facilities\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eAvailability of LSSS in the supermarket.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eAccess to safe, accessible areas or facilities (e.g., parks, community centres) for physical activity.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eMotivation\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eReflective\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eRecognize the importance of medication adherence and willing to commit to habitual compliance.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eWilling to change current cooking/eating habits related to salt.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eWilling to change current sedentary habits and incorporate physical activity into their daily routine.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eAutomatic\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNot applicable.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eNot applicable.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eNot applicable.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eNo.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"8\"\u003eNote: \u003cem\u003eCOM-B\u003c/em\u003e Capability, Opportunity, Motivation\u0026mdash;Behaviour, \u003cem\u003eLSSS\u003c/em\u003e Low sodium salt substitutes\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eIn stage 2, we applied the Affordability, Practicability, Effectiveness, Acceptability, Safety, Equity (APEASE) criteria to select intervention functions, and subsequently policy categories, to address the barriers identified through COM-B analysis (see details in supplementary file Table S4-S5). Education delivered through culturally tailored sessions and printed materials can likely boost health literacy and psychological capability, which in terms can improve motivation. Policy supports in terms of communication campaigns and clinical guidelines can support the delivery of education intervention efforts. Environmental restructuring, such as digital tools that can send reminder or help purchase medications, can likely fill the gap in physical opportunity and social opportunity. These efforts can be supported via policies that regulate or organize the physical environment around older adults\u0026rsquo; medication management routines. Enablement such as one-on-one support from community peer leaders and family members can especially improve adherence among those with limited literacy or social support to understand their medical prescription. Policies initiating changes to health care service provision and to social environment that shape older adults medication use can enhance the delivery of enablement intervention.\u003c/p\u003e\u003cp\u003eIn stage 3, we finalized our intervention design by specifying the active intervention components, known as behaviour change techniques (BCTs) (see details in supplementary file Table S6-S7). The education intervention function was operationalized via three BCTs: information about health consequences, prompts/cues, and feedback on behaviour. The environmental restructuring intervention function was operationalized via BCT of prompts/cues. The enablement intervention function was operationalized via three BCTs: social support (practical), goal setting (outcome), and action planning. The delivery modes of these BCTs included both face-to-face and distance modalities focusing on individual-level interaction.\u003c/p\u003e\u003cp\u003e\u003cb\u003eReducing sodium intake\u003c/b\u003e\u003c/p\u003e\u003cp\u003eIn stage 1, we set the target behaviour as purchasing and consistently using low-sodium salt substitute in home cooking (see details in supplementary file Table S8-S10). Applying the COM-B model, we found multiple barriers preventing the adoption of low-sodium salt substitute among older adults with hypertension and diabetes (see Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Older adults often lack knowledge about the health risks of high sodium intake and the benefits of low-sodium salt substitute. For community-dwelling older adults, food choices and cooking practices are often influenced by family members or caregivers, who may not support the use of low-sodium salt substitutes. For those with low literacy, they are unable to distinguish low-sodium salt substitute from other type of salt when shopping or make such purchase online when they are not available in nearby stores. Moreover, many participants are unwilling to change lifelong cooking or eating habits.\u003c/p\u003e\u003cp\u003eIn stage 2, we selected intervention functions and policy categories to enhance knowledge, build supportive household environments, and reshape attitudes towards sodium and salt consumption (see details in supplementary file Table S11-12). Educational efforts focused on the benefits of low-sodium salt substitutes and the risks associated with sodium intake can fill knowledge gaps and encourage sodium reduction practices. These efforts can be supported via communication/marketing, regulation, and service provision related policies. Environmental restructuring that places the recommendation of low-sodium salt substitute at the centre of sodium reduction health education at primary health care level can further promote widespread adoption. Policy supports such as guidelines on health education components can enhance the delivery of such environmental restructuring intervention. Enablement such as tools supporting older adults and caregivers to identify low-sodium salt substitutes in local supermarkets likely address the opportunity and motivation gap and spark salt reduction discussion in families. Policies initiating changes to health care service provision and to physical environment related to purchase of cooking salt can enhance the delivery of enablement intervention.\u003c/p\u003e\u003cp\u003eIn stage 3, we operationalized these intervention functions by identifying specific BCTs (see details in supplementary file Table S13-14). The education intervention function was operationalized via three BCTs: information about health consequences, prompts/cues, and feedback on outcomes of the behaviour. The environmental restructuring intervention function was operationalized via the BCT of prompts/cues. The enablement intervention function was operationalized via the BCT of social support (practical). These BCTs were planned to be delivered through in both remote and in-person formats, aiming to normalize low-sodium salt substitute use and embed it into daily life.\u003c/p\u003e\u003cp\u003e\u003cb\u003eIncreasing physical activity\u003c/b\u003e\u003c/p\u003e\u003cp\u003eIn stage 1, we set the target behaviour as increasing older adults\u0026rsquo; engagement in moderate-intensity aerobic physical activity to meet World Health Organization\u0026rsquo;s recommendation of 150 minutes of such exercise per week (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e) (see details in supplementary file Table S15-S17). Our COM-B analysis indicated multiple barriers in reaching the target behaviour (see Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Older adults reported not knowing what types of exercises are appropriate or safe for them. They were further constrained by lack of access to community spaces appropriate for physical activity, particularly when weather is hot, cold or rainy. Meanwhile, exercising together with peers or family members was not an option easily available to all older adults. Motivation for increasing physical activity was also low among many older adults as they perceive physical activity as unnecessary or even risky at their age.\u003c/p\u003e\u003cp\u003eIn stage 2, we selected intervention functions and policy categories to increase and sustain engagement in physical activity to the recommended level (see details in supplementary file Table S18-S19). Education efforts that improve knowledge on health benefits and safety of various physical activities can likely address the gaps in psychological capability and motivation. These efforts can be supported via policies encouraging communication campaigns and expanding health care service provision. Environmental restructuring focused on changing the physical or social environment to make physical activity easier or more enjoyable can increase physical and social opportunity. While building new venues for exercises was outside the scope of primary health care, it was plausible to change the social context of physical activity. Regulatory policies can support the implementation of such intervention. Enablement focused on identification of exercise plans, venues and group activities can address the psychological capability and social opportunity gap. Policies expanding health care service provision and changing social or physical environment where older adults choose physical activities can enhance the delivery of enablement intervention. Modelling intervention that demonstrates standard and safe exercises through peers or health care workers may help older adults build confidence to engage in physical activity. The modelling intervention can be supported by social media campaigns with videos or expanding primary health care service provisions.\u003c/p\u003e\u003cp\u003eIn stage 3, we translated the selected intervention functions into specific strategies using BCTs (see details in supplementary file Table S20-S21). The education intervention function was operationalized via three BCTs: information about health consequences, prompts/cues, and feedback on outcomes of the behaviour. The environmental restructuring intervention function was operationalized via the BCT of prompts/cues. The enablement intervention function was operationalized via two BCTs: action planning and social support (practical). The modelling intervention function was operationalized via the BCT of demonstration of the behaviour. The delivery modes of these BCTs included both face-to-face and remote modalities with a primary focus on individual-level interaction.\u003c/p\u003e\u003cp\u003e[Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e here]\u003c/p\u003e\u003cp\u003e\u003cb\u003eOverview of the EPIC intervention\u003c/b\u003e\u003c/p\u003e\u003cp\u003eWe integrated the selected intervention functions, BCTs, and delivery modes to form the EPIC intervention (see Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The intervention cycle begins when each older adult with coexisting hypertension and diabetes presents to a community health service station for a routine follow-up visit. At the initial visit, the older adult receives a lifestyle prescription from their family physician in addition to the standard medication prescription. The family physician personalizes the lifestyle prescription with the aid of clinical decision support system. The clinical decision support system assists family physicians by converting patient data and clinical guidelines into actionable recommendations at the point of care. For example, they could assess a patient's suitability for replacing daily cooking salt with the low-sodium salt substitutes based on prior diagnosis stored in the system. Additional resources such as maps and schedules of community exercise programs are handed to the older adults to facilitate adherence to lifestyle prescriptions.\u003c/p\u003e\u003cp\u003eUnder NEPHSP, routine follow-up visits are scheduled between two weeks and three months apart, depending on the older adult\u0026rsquo;s blood pressure and blood sugar control levels. During the subsequent visit, the family physician and the older adult jointly review the lifestyle prescription to assess progress and determine whether any adjustments or additional support are required. This regular review of lifestyle prescriptions ensures sustained support to lifestyle changes and can meet dynamic needs of older adults with multimorbidity throughout their disease journey.\u003c/p\u003e\u003cp\u003eBetween routine follow-up visits, older adults receive voice messages containing reminders and health education information on all three lifestyle factors. For older adults requiring social support to complete their lifestyle prescription, the family physician would also send the lifestyle prescription and these voice messages to their caregivers. These voice messages will be sent via an automated calling system, known as voice bot. The use of voice messages to facilitate chronic disease management among older adults population with low literacy level has been positively evaluated in the rural context in China (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Lastly, to specifically promote physical activity, community health service stations would periodically organize group exercise events to demonstrate safe and effective exercise routines.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eStrengths of BCW in designing multimorbidity intervention\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe systematic application of the BCW framework allowed the EPIC intervention to be complex, with multiple components accounting for different stakeholders\u0026rsquo; perspectives, yet specific, tailored to primary health care settings and patient-level barriers in Kunshan. Despite the multifaceted barriers to achieving the three target behaviours, the structured process of selecting locally appropriate intervention functions established a unified and coherent strategy for addressing these complexities. Since intervention functions, in conjunction with the APEASE criteria, serve as the foundation for selecting policy categories, BCTs, and delivery modes, their consistency has enabled the seamless integration of three lifestyle interventions into a single, cohesive intervention. While previous multimorbidity intervention development studies have largely focused on conceptual frameworks without specifying implementation strategies (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e), our study demonstrates how BCW and APEASE can bridge the gap between theory and practice. Another strength of the BCW framework is that it helped to establish clear links between behavioural influences, interventions, mechanisms, and the planned implementation outcomes for each component of this complex intervention. Specifically, influences on change, identified through a COM-B diagnosis, informed the selection of intervention functions. These, in turn, signposted BCTs likely to be effective. These clear links may help future intervention developer or practitioner identify which components of the existing intervention are applicable to their context based on local barriers.\u003c/p\u003e\u003cp\u003e\u003cb\u003eLimitations of BCW in designing multimorbidity intervention\u003c/b\u003e\u003c/p\u003e\u003cp\u003eDespite the advantages of the BCW framework, there are limitations that should be addressed in its application. While the APEASE criteria guide the decision-making process in intervention development, it offers dimensions for decision-making rather than a quantifiable scale. This room for subjectivity is a common issue discussed by intervention studies using BCW (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). To minimize bias, we incorporated expert consultation during the design phase, a strategy also employed by other BCW-based studies in China (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). If helpful, the APEASE dimensions can be developed into quantifiable scales to allow comparison of options.\u003c/p\u003e\u003cp\u003eThe behavioural focus of BCW makes it difficult to integrate system- and organization-level factors in the initial stages of intervention design. To address this issue, we prioritized understanding patient-level barriers in steps 1 to 4. Systems-level factors and stakeholder perspectives were then integrated during later stages through focus group discussions with local health authorities. This approach requires an iterative process, where each revision is carefully aligned with the feedback from community members and stakeholders and mapped to the corresponding BCW steps. While this process ensures the intervention is contextually relevant, it is also time-consuming.\u003c/p\u003e\u003cp\u003e\u003cb\u003eUnanswered questions and future research in multimorbidity interventions\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe EPIC intervention proposed the use of digital health tools to enhance the delivery and effectiveness of lifestyle prescriptions. The implementation strategies for this intervention will depend on the particular healthcare context, which raises questions for future research. The EPIC intervention focuses on clinical decision support systems and voice bots as the main digital health solutions to address human resource shortage. There are many other digital technologies worth exploring for improving care for older adults with multimorbidity in primary care settings (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). For example, sharing audio recordings of clinic visits has been found to be feasible and effective in improving understanding, recall, and family engagement in treatment for a U.S. older adult population with hypertension and diabetes multimorbidity (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn the implementation context of EPIC, most older adults had already been diagnosed with diabetes and hypertension for a long time. The time lapse between diagnosis and intervention significantly impacts medication adherence, as chronic conditions tend to feel less life-threatening over time (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). Devising personalized methods to boost motivation of patients is a potential pathway to engage with older adults with distinct levels of motivation for lifestyle changes. Personalization has been found to be key for the success of lifestyle interventions (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). Research suggests that approaches such as motivational interviewing (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e) and just-in-time interventions (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e) have potential for managing multimorbidity among older adults. However, the evidence base for these approaches is limited. Additionally, task-sharing or task-shifting intervention has also proven to be effective in managing individuals with multimorbidity (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eFurthermore, there remains a dearth of evidence that explicitly links mechanisms of change and implementation outcomes in multimorbidity interventions. Future research should consider applying frameworks such as BCW to clarify the mechanisms of changes for advancing the evidence to design, adapt, evaluate, and sustain effective multimorbidity interventions across diverse settings and populations.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThere are enormous opportunities to improve population health and to relieve health system burden via strengthening multimorbidity management delivered at the primary health level. Our case report of BCW application illustrates that behavioural science frameworks can serve as powerful tools to systematically diagnose behavioural barriers, align intervention components, and develop integrated strategies for the co-management hypertension and diabetes multimorbidity. The EPIC intervention proposed restructuring of the standard of care, integration of digital tools and engagement of family caregiver for the effective co-management of hypertension and type 2 diabetes among older adults. To advance implementation science in developing countries, we call on future researchers and practitioners to document their experiences and contribute insights on applying behavioural science frameworks to address multimorbidity challenges across diverse cultural and socioeconomic conditions.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003eAPEASE\u0026nbsp;\u003c/strong\u003eAffordability, Practicability, Effectiveness, Acceptability, Safety, Equity\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBCW\u0026nbsp;\u003c/strong\u003eBehaviour Change Wheel\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBCT\u0026nbsp;\u003c/strong\u003eBehaviour Change Technique\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCOM-B\u0026nbsp;\u003c/strong\u003eCapability, Opportunity, Motivation, and Behaviour\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEPIC\u0026nbsp;\u003c/strong\u003eEvidence-based, People-centred, Integrated Care\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNEPHSP\u003c/strong\u003e National Essential Public Health Service Package \u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe qualitative research led up to this intervention development study was approved by the Duke Kunshan University Institutional Review Board (registration number FWA00021580). All participants provided written consent to participate.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe details on step-by-step application of BCW is provided in the supplementary file 3. The transcripts and other qualitative data are not publicly available to maintain privacy of the participants. They may be made available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was supported by the National Key R \u0026amp; D program of China (Grant No. 2023 YFC3605002) and the Duke Kunshan University Innovation and Entrepreneurship Initiative and the Innovation Incubator Program. The research results of this article are sponsored by the Kunshan Municipal Government research funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMCY, HS, WYMH, YX, MJ, and YM conducted the literature review and analysed the qualitative findings to inform the step-by-step application of BCW. MCY, HS, WYMH and YX wrote the main manuscript, prepared tables and figures and supplementary files. LY, XY, YS, BX, EG, BY provided critical feedback to the design of the intervention design. SM provide critical inputs in revising the manuscript. LLY conceptualized the study and oversaw the project administration. All authors reviewed and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe express our sincere gratitude to the patients, family members and family physicians who participated in this study. Also, we would like to thank student research assistants Xiaoyu Zhou, Chunyuan Li, Li Di, Jingxuan Zhuge, Juntian Shen, Hanting Zhang, Weijing Song, Yitong Su, Fangyu Wu, Chen Zhang, Yunrong Gu, Yilin Wang, Gao Fan for supporting the semi-structured interviews, particularly the translating and transcribing the interviews. We also thank the officials from Kunshan Community Health Centres and Kunshan Health Commission who supported participants\u0026rsquo; recruitment and provided venues for the semi-structured interviews and focus group discussions.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eLuo Y, Su B, Zheng X. Trends and Challenges for Population and Health During Population Aging \u0026mdash; China, 2015\u0026ndash;2050. China CDC Wkly. 2021 Jul 9;3(28):593\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eValderas JM, Starfield B, Sibbald B, Salisbury C, Roland M. Defining comorbidity: implications for understanding health and health services. Ann Fam Med. 2009;7(4):357\u0026ndash;63. \u003c/li\u003e\n\u003cli\u003eXue X, Wang Z, Qi Y, Chen N, Zhao K, Zhao M, et al. Multimorbidity patterns and influencing factors in older Chinese adults: a national population-based cross-sectional survey. J Glob Health. 2025 Feb 21;15:04051. \u003c/li\u003e\n\u003cli\u003eZhang X, Liu T, Li Z, Yang J, Hou H, Hao T, et al. Using primary and routinely collected data to determine prevalence and patterns of multimorbidity in rural China: a representative cross-sectional study of 6474 Chinese adults. Lancet Reg Health \u0026ndash; West Pac [Internet]. 2025 Jan 1 [cited 2025 Mar 2];54. Available from: https://www.thelancet.com/journals/lanwpc/article/PIIS2666-6065(24)00266-9/fulltext?uuid=uuid%3A6ab7c322-135e-4665-b292-513e45373ac7\u003c/li\u003e\n\u003cli\u003eSeidu S, Hambling CE, Kunutsor SK, Topsever P. Associations of blood pressure with cardiovascular and mortality outcomes in over 2 million older persons with or without diabetes mellitus: A systematic review and meta-analysis of 45 cohort studies. Prim Care Diabetes. 2023 Dec;17(6):554\u0026ndash;67. \u003c/li\u003e\n\u003cli\u003eNirmal S, Chowdhury HA. Hypertension in diabetes and the risk of cardiovascular disease. Cardiovasc Endocrinol Metab. 2017 Mar;6(1):33. \u003c/li\u003e\n\u003cli\u003eKwakye AO, Kretchy IA, Peprah P, Mensah KB. Factors influencing medication adherence in co-morbid hypertension and diabetes patients: A scoping review. Explor Res Clin Soc Pharm. 2024 Feb 29;13:100426. \u003c/li\u003e\n\u003cli\u003eTran PB, Kazibwe J, Nikolaidis GF, Linnosmaa I, Rijken M, van Olmen J. Costs of multimorbidity: a systematic review and meta-analyses. BMC Med. 2022 Jul 19;20(1):234. \u003c/li\u003e\n\u003cli\u003eXiong S, Cai C, Jiang W, Ye P, Ma Y, Liu H, et al. Primary health care system responses to non-communicable disease prevention and control: a scoping review of national policies in Mainland China since the 2009 health reform. Lancet Reg Health \u0026ndash; West Pac [Internet]. 2023 Feb 1 [cited 2025 Jul 16];31. Available from: https://www.thelancet.com/journals/lanwpc/article/PIIS2666-6065(22)00009-8/fulltext\u003c/li\u003e\n\u003cli\u003eNotice from the national health and family planning commission on issuing the national basic public health services standards (third edition) [Internet]. 2017. Available from: http://www.nhc.gov.cn/ewebeditor/uploadfile/2017/04/20170417104506514.pdf\u003c/li\u003e\n\u003cli\u003eAbbasnezhad A, Falahi E, Gonzalez MJ, Kavehi P, Fouladvand F, Choghakhori R. Effect of different dietary approaches compared with a regular diet on systolic and diastolic blood pressure in patients with type 2 diabetes: A systematic review and meta-analysis. Diabetes Res Clin Pract. 2020 May 1;163:108108. \u003c/li\u003e\n\u003cli\u003ePark S, Kim J, Lee J. Effects of Exercise Intervention on Adults With Both Hypertension and Type 2 Diabetes Mellitus: A Systematic Review and Meta-analysis. J Cardiovasc Nurs. 2021;36(1):23\u0026ndash;33. \u003c/li\u003e\n\u003cli\u003eAnderson LJ, Nuckols TK, Coles C, Le MM, Schnipper JL, Shane R, et al. A systematic overview of systematic reviews evaluating medication adherence interventions. Am J Health Syst Pharm. 2020 Jan 8;77(2):138\u0026ndash;47. \u003c/li\u003e\n\u003cli\u003eMichie S, van Stralen MM, West R. The behaviour change wheel: A new method for characterising and designing behaviour change interventions. Implement Sci. 2011 Apr 23;6(1):42. \u003c/li\u003e\n\u003cli\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. Front Pharmacol [Internet]. 2019 Jun 21 [cited 2024 Oct 18];10. Available from: https://www.frontiersin.org/journals/pharmacology/articles/10.3389/fphar.2019.00680/full\u003c/li\u003e\n\u003cli\u003eCombes S, Forbes G, Gillett K, Norton C, Nicholson CJ. Development of a theory-based intervention to increase cognitively able frail elders\u0026rsquo; engagement with advance care planning using the behaviour change wheel. BMC Health Serv Res. 2021 Jul 20;21(1):712. \u003c/li\u003e\n\u003cli\u003eNelligan RK, Hinman RS, Kasza J, Bennell KL. Effectiveness of internet-delivered education and home exercise supported by behaviour change SMS on pain and function for people with knee osteoarthritis: a randomised controlled trial protocol. BMC Musculoskelet Disord. 2019 Jul 27;20(1):342. \u003c/li\u003e\n\u003cli\u003eLin R, Yan Y, Chen Z, Huang C, Zhao J, Chen M, et al. A mobile-based multidomain lifestyle intervention using Cognitive Evergreenland for older adults with subjective cognitive decline: a feasibility study. BMC Geriatr. 2025 Jan 20;25(1):41. \u003c/li\u003e\n\u003cli\u003eKunshan Municipal People\u0026rsquo;s Government [Internet]. 2021 [cited 2025 Mar 2]. Results from Kunshan City\u0026rsquo;s Census. Available from: https://www.ks.gov.cn/kss/ttxw/202106/8ff6d2d3e1204b60a157f14815d7bfce.shtml\u003c/li\u003e\n\u003cli\u003eKunshan Municipal People\u0026rsquo;s Government [Internet]. 2024 [cited 2024 Dec 6]. Performance evaluation of Suzhou\u0026rsquo;s 2023 National Basic Public Health Service Program. Available from: https://www.ks.gov.cn/kss/bmdt/202404/60235c3bdb4440c3aadd6aea7c18bd0d.shtml\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Guidelines on physical activity and sedentary behaviour [Internet]. World Health Organization; 2020. Available from: https://www.who.int/publications/i/item/9789240015128\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Adherence to long-term therapies : evidence for action. [Internet]. World Health Organization; 2003. Available from: https://iris.who.int/handle/10665/42682\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Guideline: Sodium intake for adults and children [Internet]. World Health Organization; 2012. Available from: https://iris.who.int/bitstream/handle/10665/77985/9789241504836_eng.pdf\u003c/li\u003e\n\u003cli\u003eMichie S, Lou Atkins, Robert West. The behavioural change wheel: A Guide to designing interventions. Great Britain: Silverback Publishing; 2014. \u003c/li\u003e\n\u003cli\u003eYan LL, Gong E, Gu W, Turner EL, Gallis JA, Zhou Y, et al. Effectiveness of a primary care-based integrated mobile health intervention for stroke management in rural China (SINEMA): A cluster-randomized controlled trial. PLoS Med. 2021;18(4):1\u0026ndash;20. \u003c/li\u003e\n\u003cli\u003ePatton DE, Ryan C, Hughes CM. Development of a complex community pharmacy intervention package using theory-based behaviour change techniques to improve older adults\u0026rsquo; medication adherence. BMC Health Serv Res. 2020 May 13;20(1):418. \u003c/li\u003e\n\u003cli\u003eJayanna K, Swaroop N, Kar A, Ramanaik S, Pati MK, Pujar A, et al. Designing a comprehensive Non-Communicable Diseases (NCD) programme for hypertension and diabetes at primary health care level: evidence and experience from urban Karnataka, South India. BMC Public Health. 2019 Apr 16;19(1):409. \u003c/li\u003e\n\u003cli\u003eMabweazara SZ, Leach LL, Ley C. Development of a context-sensitive physical activity intervention for persons living with HIV and AIDS of low socioeconomic status using the behaviour change wheel. BMC Public Health. 2019 Jun 17;19(1):774. \u003c/li\u003e\n\u003cli\u003eWang H, Blake H, Chattopadhyay K. Development of a School-Based Intervention to Increase Physical Activity Levels Among Chinese Children: A Systematic Iterative Process Based on Behavior Change Wheel and Theoretical Domains Framework. Front Public Health [Internet]. 2021 Apr 27 [cited 2024 Oct 18];9. Available from: https://www.frontiersin.org/journals/public-health/articles/10.3389/fpubh.2021.610245/full\u003c/li\u003e\n\u003cli\u003eChen D, Shao J, Zhang H, Wu J, Xue E, Guo P, et al. Development of an individualized WeChat mini program-based intervention to increase adherence to dietary recommendations applying the behaviour change wheel among individuals with metabolic syndrome. Ann Med. 2023 Dec 12;55(2):2267587. \u003c/li\u003e\n\u003cli\u003eZhang W, Cheng B, Zhu W, Huang X, Shen C. Effect of Telemedicine on Quality of Care in Patients with Coexisting Hypertension and Diabetes: A Systematic Review and Meta-Analysis. Telemed E-Health. 2021 Jun;27(6):603\u0026ndash;14. \u003c/li\u003e\n\u003cli\u003eBarr PJ, Masel M, Bratches RW, Carpenter-Song E, O\u0026rsquo;Malley AJ, Bruce ML, et al. The feasibility of sharing digital audio-recordings of clinic visits online with older adults in primary care settings: A multisite trial. Patient Educ Couns. 2025 Feb 1;131:108574. \u003c/li\u003e\n\u003cli\u003eRaj JP, Mathews B. Effect of behavioral intervention on medication adherence among elderly with select non-communicable diseases (ENDORSE): Pilot randomized controlled trial. Geriatr Gerontol Int. 2020 Nov;20(11):1079\u0026ndash;84. \u003c/li\u003e\n\u003cli\u003eTong HL, Quiroz JC, Kocaballi AB, Fat SCM, Dao KP, Gehringer H, et al. Personalized mobile technologies for lifestyle behavior change: A systematic review, meta-analysis, and meta-regression. Prev Med. 2021 Jul 1;148:106532. \u003c/li\u003e\n\u003cli\u003ePapus M, Dima AL, Viprey M, Schott AM, Schneider MP, Novais T. Motivational interviewing to support medication adherence in adults with chronic conditions: Systematic review of randomized controlled trials. Patient Educ Couns. 2022 Nov 1;105(11):3186\u0026ndash;203. \u003c/li\u003e\n\u003cli\u003eVandelanotte C, Trost S, Hodgetts D, Imam T, Rashid M, To QG, et al. Increasing physical activity using an just-in-time adaptive digital assistant supported by machine learning: A novel approach for hyper-personalised mHealth interventions. J Biomed Inform. 2023 Aug 1;144:104435.\u003c/li\u003e\n\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-global-and-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [BMC Global and Public Health](https://bmcglobalpublichealth.biomedcentral.com/)","snPcode":"44263","submissionUrl":"https://submission.springernature.com/new-submission/44263/3","title":"BMC Global and Public Health","twitterHandle":"@BMC_GPH","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"multimorbidity, primary health care, hypertension, type 2 diabetes, behaviour change wheel","lastPublishedDoi":"10.21203/rs.3.rs-6467750/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6467750/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThe increasing prevalence of multimorbidity and aging society present a major challenge for China\u0026rsquo;s health system. The co-management of hypertension and type 2 diabetes\u0026mdash;one of the most common and clinically significant multimorbidity cluster\u0026mdash;have been placed in the forefront of China\u0026rsquo;s national health policies. Substantial evidence base exists for lifestyle practices and treatment plans for managing this multimorbidity. Yet, implementation challenges persist within the existing structure and resources of primary health care in China. Behavioural science frameworks hold great potential to address these implementation challenges via identifying the behavioural barriers and rendering tailored implementation strategies. However, existing multimorbidity interventions often do not explicitly link behavioural influences with intervention design. This paper presents a case report of applying Behaviour Change Wheel (BCW) framework to guide the rapid development of an intervention for hypertension and diabetes co-management. The resulting evidence-based, people-centred, integrated care (EPIC) intervention restructures the standard of care by delivering three core features: personalized lifestyle prescriptions, digital tool assistance, and caregiver engagement. The BCW enables seamless integration of multiple intervention components and informed context-specific design. Specifically, the EPIC intervention can be readily implemented during the routine follow-up of older adults with hypertension and diabetes at primary health care facilities in a county-level city. Our case highlights the potential of behavioural science frameworks to address the complex challenge of multimorbidity. To fully realize this potential, empirical evidence is urgently needed to link mechanisms of change and implementation outcomes in theory-informed interventions.\u003c/p\u003e","manuscriptTitle":"Developing an integrated intervention to co-manage diabetes and hypertension in China: an application of the Behaviour Change Wheel Framework","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-06 08:23:34","doi":"10.21203/rs.3.rs-6467750/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-11T09:14:11+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-02T04:35:04+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-25T02:50:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"147384814534063301456655134407400425953","date":"2025-09-24T06:54:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"162423944794976802189699664127934543361","date":"2025-09-24T06:42:35+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-21T00:42:47+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"218437659306938354677527078072406408866","date":"2025-08-10T05:23:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"286563624136749155722153523206835419792","date":"2025-08-04T00:19:50+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-01T08:43:32+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-30T14:17:51+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Global and Public Health","date":"2025-07-30T14:14:54+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-global-and-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [BMC Global and Public Health](https://bmcglobalpublichealth.biomedcentral.com/)","snPcode":"44263","submissionUrl":"https://submission.springernature.com/new-submission/44263/3","title":"BMC Global and Public Health","twitterHandle":"@BMC_GPH","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d499a96c-9195-48d6-83c8-68ed478c6e21","owner":[],"postedDate":"August 6th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-11-26T13:23:41+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-06 08:23:34","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6467750","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6467750","identity":"rs-6467750","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}