2. Approaches to Designing New Interventions
2.1. The Medical Research Council’s Framework
- Identifying the desired outcome
- Identifying how to bring about change based on theory and evidence
- Testing the feasibility of the intervention to ensure that it is acceptable and can be delivered as intended
- Evaluation of the intervention through both impact and process evaluations
2.2. Behaviour Centred Design
3. Case Studies
3.1. Case Study 1: Designing an Intervention to Improve Uptake of Referral for Ear and Hearing Services for Children in Malawi
3.1.1. Study Aim and Setting
3.1.2. Assess: Systematic Review
3.1.3. Build: Formative Research
- Fear and uncertainty about the referral hospital
- Procedural problems within the camps leading to lack of understanding about the referral
- Distance to the hospital
- Low awareness and understanding of hearing loss
- Lack of and cost of transport
3.1.4. Create: Designing the Intervention
(1) Focus Group Discussion and Theory of Change Development
- Developing a long-term goal for the project
- Backwards mapping from the long-term goal to outcomes and intermediate outcomes required to reach the long-term goal
- Discussing possible activities (interventions) to achieve the prioritised outcomes
- Prioritisation of suggested activities (interventions) in terms of cost, feasibility, acceptability and sustainability
(2) Proposed Interventions
- A photograph/pictorial information booklet providing information about the process of going to the hospital for ear and hearing services
- Counsellors trained to deliver information booklet in camp settings, including one “expert” mother (i.e., mother of a child with ear and/or hearing issue who has attended QECH for referral previously) who would provide peer support and a community health worker
- Text message reminders for caregivers who had been referred to QECH
(3) Engagement with Creative Team
- Draft 1 and 2 reviewed by LSHTM researchers
- Draft 3 reviewed by eight stakeholders from Malawi (six from original ToC workshop)
- Draft 4 reviewed by target population (caregivers of children with ear and hearing issues from Thyolo district) through a focus group discussion). Caregivers were asked to reflect on suitability of the images, comprehensibility of the text, and usefulness of the components of the booklet.
- A booklet with three main parts (Figure 2): (1) An illustrated storyline of “The Banda Family” going through the process of being referred and attending the referral at QECH; (2) Information on how to get to the hospital including photographs of key landmarks that caregivers would see on the way to the ENT department; (3) Action planning stage that was tailored to each caregiver—including how they plan to go, how much money they need, and what they need to take with them. This booklet would be delivered by a trained “expert mother” (i.e., mother of a child with ear and/or hearing issue who has attended QECH for referral previously) at the point at which the referral was made (in camps).
- A text-message reminder to be sent two weeks after the referral (Figure 3).
3.1.5. Deliver: Feasibility Studies
3.2. Case Study 2: Designing an Intervention to Improve Menstrual Hygiene Management of People with Intellectual Impairments in Nepal
3.2.1. Study Aim and Setting
3.2.2. Assess: Systematic Review
3.2.3. Build: Formative Research
- Limited MHM training, information and support. MHM information is often withheld from people with an intellectual impairment because of perceived levels of understanding. Carers have no support, information or guidance on how to manage another person’s menstrual cycle, leading many to feel overwhelmed.
- Limited ability to communicate verbally, understand menstruation and related social norms. Some people with intellectual impairments are unable to communicate verbally that they have pre-menstrual symptoms and may not understand the reason for these. Carers do not always provide pain relief for menstrual cramps. During menstruation some participants are frightened, withdrawn, or refused to eat. Some showed their menstrual blood or hygiene products to others and are abused for doing so.
- Poor access to existing MHM interventions. In Nepal, MHM interventions are predominantly delivered through school and community mechanisms. Many research participants with an intellectual impairment do not attend school so cannot access these. Some carers are unable to leave their home because of caring duties, so are unable to access the MHM information delivered through the community.
3.2.4. Create: Designing the Intervention
(1) Focus Group Discussion and Theory of Change Development
(2) Engagement with Creative Team
(3) Intervention Concept
3.2.5. Deliver: Feasibility Study
3.2.6. Comparison of Intervention Design Processes
4.1. Key Lessons, Implications for Research and Practice
Conflicts of Interest
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|Step 1||Assess and build||Identifying the desired outcome|
|Step 2||Create||Identifying how to bring about change based on theory and evidence|
|Step 3||Deliver||Testing the feasibility of the intervention to ensure that it is acceptable and can be delivered as intended;|
|Step 4||Evaluate||Evaluation of the intervention through both impact and process evaluations.|
|1||Fear and uncertainty about the referral hospital||Reduced fear about hospital||Peer support/counseling|
Information about hospital procedures communicated effectively during outreach
|2||Procedural problems within the camps leading to lack of understanding about the referral||Sufficient information about referral||Information provided through:|
|3||Low awareness and understanding of hearing loss/hearing loss is not prioritised||Improved awareness and understanding about ear and hearing health; hearing loss is prioritised||Ear/hearing day advocacy event|
Education of “gatekeepers” in the community (e.g., community leaders)
|4||Distance to the hospital||Service available closer to the community||Expand outreach camps in the community|
|5||Lack and cost of transport||Transport is available||Group transport provided with community escort|
|Relevant Intervention Component||Target Group||Target Behaviour||Human Motive||Relevant Intervention Training Activity|
|Menstrual storage and shoulder bag, menstrual bin||Person with an intellectual impairment||Use a menstrual product||Comfort, dignity||Bishesta doll, role play|
|Pain symbol bangle||Use pain relief for menstrual cramps||Comfort, reward|
|Menstrual shoulder bag, visual stories||Does not show menstrual blood in public||Affiliate, dignity||Bishesta doll, role play|
‘Reading’ visual stories with carers
|Menstrual storage and shoulder bag, menstrual bin||Carer||Provide enough menstrual products||Nurture, affiliate, reward||Emo-demos (surprising and motivating demonstrations and activities), peer-to-peer support, competition to become ‘Bishesta households’, guiding the person they care for through Bishesta doll role play and ‘reading’ visual stories, household monitoring visits/ad-hoc support|
|Menstrual calendar, visual stories||Provide pain relief for menstrual cramps||Nurture, reward|
|Menstrual calendar, visual stories||Provide emotional support||Nurture, reward|
|Assess||Systematic review of relevant literature||Systematic review of relevant literature|
|Build||Formative research:||Formative research:|
|Deliver||Feasibility study||Feasibility study|
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