Promoting Lifestyle Change in the Preconception Period: Development of the Begin Better eHealth Intervention

Abstract

Worldwide, half of women begin a pregnancy above the healthy weight range, which increases the risk of pregnancy and birth complications and adversely affects the lifelong health of their baby. Interventions during pregnancy to manage weight have been largely unsuccessful, with research now promoting changes be made before women conceive, to improve health outcomes. This thesis describes the planning, design and development of an evidence-informed eHealth solution – the “Begin Better” app – as part of a complex multi-component intervention to promote health and wellbeing in women prior to conception. Study 1 outlines the elicitation interviews, Study 2 describes the intervention planning and development process used, and Study 3 details the intervention content, delivery methods and interactive elements. The intervention, based on psychological theories and behaviour change techniques, was developed for women with overweight or obesity intending to conceive. The Begin Better eHealth intervention is part of an integrated program currently being evaluated in a randomised controlled trial to assess if improving health and wellbeing, including weight management before pregnancy, can influence clinical outcomes for the woman and her baby. An iterative approach, guided by Intervention Mapping and human-based methods, was used. In Study 1, semi-structured interviews – informed by the Information-Motivation- Behavioural Skills model – were conducted with 23 women in the target group and analysed using reflexive thematic analysis. This elicitation study aimed to understand women’s emotional and social contexts, knowledge, motivations, skills and self-efficacy in making healthy lifestyle changes. In Study 2, the planning process – informed by Intervention Mapping methods – was undertaken. Change objectives were defined for each behavioural determinant, along with theory-based behaviour change techniques and practical strategies based on psychological theory. Persuasive Systems Design principles were also defined to translate these strategies to a digital environment. The resulting intervention comprises nutrition and physical activity content, and psychological strategies, which are notably absent from mainstream health and weight management programs. Study 3 outlines the therapeutic techniques and interactive elements employed throughout the intervention. The Mind modules of the app offer psychological skills to help women initiate and reinforce new behaviours. The intervention integrates aspects of Acceptance and Commitment Therapy, Cognitive Behavioural Therapy, and methods informed by Motivational Interviewing – therapeutic techniques more typically employed in face-to-face therapy. Despite challenges in implementing some techniques in an online environment, this delivery method allows for some personalisation of experience for the participant. App content was delivered in staged-release modules and presented in video and podcast format to engage the target group. Interactive tasks allow a woman to create an individualised program based on personal values, whole-person goals, habits and action planning via repeated small, easily-achievable steps towards positive change. Poor or incorrect knowledge of health risks was addressed with information on the many benefits of health and lifestyle improvements before pregnancy and building healthy heuristics around nutrition and physical activity. Motivation – reported as a key barrier to sustained healthy change – was addressed via in-app messages of praise and encouragement, individual goal setting and feedback, flexible options and consideration of family support. Behavioural skills were fostered via stress reduction techniques, self-care, problem-solving, time management and strategies to increase self-efficacy and relapse prevention. Processes and design decisions about intervention content, format and delivery are often not reported, which can limit the transferability of findings to other projects. This series of studies responds to this gap in the literature by outlining a process that is potentially transferable to the development of other interventions. The Begin Better app delivers a health behaviour change intervention designed to have broad reach, using psychological techniques to promote values-based behaviour and committed action. The intervention encourages cognitive and behavioural flexibility that may predict longer-term lifestyle change and enhanced wellbeing.