Development of a Culturally Competent Behaviour Change Intervention Framework to Enhance Utilisation of Sexual and Reproductive Health Services among Rural- Urban Migrant Adolescents in the Greater Accra Region, Ghana

Abstract

Purpose: The thesis addresses the gap in culturally competent behaviour change interventions to improve sexual and reproductive health service (ASRH) utilisation among rural and urban migrant adolescents in Ghana. Methodology: It employed intervention development design using a mixed-methods approach. Guided by the COM-B model and Campinha-Bacote’s cultural competence theory, the study engaged healthcare professionals (HCPs) working in ASRH facilities and migrant adolescents utilising services as well as gatekeepers and peers in the Greater Accra Region from 2022 to 2023. A criterion purposive sampling technique was first employed to select the healthcare facilities (HCF). Subsequently, convenience sampling was used to select the HCPs and the migrant adolescents within the catchment area of the target health facilities. The study was conducted in 3 phases. In Phase 1, a qualitative research approach was used to understand problematic behaviours of migrant adolescents regarding current pathways for health-seeking and cultural competence of HCPs using behavioural analysis. In total, 25 participants took part in the study after which saturation was reached. This included 10 migrant adolescents, 8 HCPs, 3 gatekeepers, and 4 migrant peers. Following this, through a process of mapping and distillation, the Behaviour change wheel (BCW)framework was used to guide a systematic process of identifying potential culturally competent intervention functions and their corresponding behaviour change techniques (BCTs) drawn from the BCW taxonomy BCTTv1 and supplemented with relevant literature. Phase 2 involved a Delphi study conducted among 10 experts to validate behaviour change techniques (BCTs); ratings for feasibility, acceptability, effectiveness, and risk of harm were analysed to establish a consensus (>/=70%). Experts were also asked to provide feedback on the appropriateness of the identified implementation strategies and mode of delivery. Phase 3 involved preliminary testing of the cultural acceptability and feasibility of implementation strategy and delivery mode among migrants and HCPs in a workshop to refine the intervention framework. Findings: The behavioural analysis conducted in Phase 1 revealed the following explanatory factors that are amenable to behaviour change: mistrust, communication barriers at the migrant level, and lack of cultural competency at the HCP level. For each of these, the BCTs identified included nonspecific reward, removing aversive stimuli, restructuring the social environment at the migrant adolescent level., and instructions on how to perform the behaviour at the HCP level. In Phase 2, experts rated BCTs as appropriate: feasible (4.6 [SD=0.7; 3-5]); acceptable (4.5 [SD=0.7; 3-5]); effective (4.4 [SD=1.2; 1-5]), and risk of harm 4.0 [SD=1.3; 2-5], indicating low risk of harm. At the migrant adolescent level, the experts rated the BCTs as: feasible (4.3 [SD=0.5; 4-5]); acceptable (4.1 [SD=0.7; 3-5]); effective (4.1 [SD=0.7; 3-5]); and risk of harm (4.0 [SD=0.8; 3-5]), indicating low risk of harm. In the final phase of the framework development, the validated BCTs were operationalised into behaviour change strategies, which were then tested among the experts. Suggestions emerged regarding who to implement the strategies and the need to highlight the importance of providing training that emphasises skills and mastery experiences. These suggestions were integrated into the final content. To ensure that these strategies and delivery options are culturally appropriate and effectively address both demand-side barriers and facilitators, the users emphasised the importance of taking contextual factors into account, which were integrated in order to inform the intervention framework development. Conclusion: The behaviour change-informed framework served as a conceptual model of the mechanisms of behaviour change and a practical guide to the implementation of strategies to enhance the utilisation of ASRH among migrant adolescents pending further testing in a future study.