Stronger Together: a community-based intervention using Behaviour Change Wheel to promote healthier lifestyles among women with low socioeconomic status: a feasibility study – International Journal for Equity in Health

Report on the “Stronger Together” Feasibility Study: An Initiative Aligned with the Sustainable Development Goals

A single-arm feasibility study, “Stronger Together,” was executed at the AlNahda Society in Riyadh, Saudi Arabia, to assess an intervention aimed at enhancing physical activity and healthy dietary habits. This initiative directly addresses several United Nations Sustainable Development Goals (SDGs), particularly those focused on health, gender equality, and poverty reduction.

The study’s design, featuring pre- and post-intervention measures, serves as a preparatory phase for a large-scale randomised controlled trial. The project was conducted in partnership with AlNahda Society, a non-profit organisation dedicated to the social and economic empowerment of women, reflecting a commitment to SDG 17 (Partnerships for the Goals). AlNahda’s mission to help low-income households graduate from poverty aligns with SDG 1 (No Poverty) and SDG 8 (Decent Work and Economic Growth) by equipping women with skills for societal contribution. The study’s focus on women from low-income backgrounds is a direct effort to advance SDG 5 (Gender Equality) and SDG 10 (Reduced Inequalities). Ethical approval was secured from the King Saud University Human Research Ethics Committee (KSU-HE-23-482), and reporting adhered to CONSORT guidelines.

Methodological Framework for Sustainable Health Impact

Study Design and Theoretical Foundation

The intervention’s development was guided by the Medical Research Council framework and the Behaviour Change Wheel (BCW), ensuring a robust, evidence-based approach to promoting lasting health improvements in line with SDG 3 (Good Health and Well-being). The theoretical underpinning was the Capability, Opportunity, Motivation – Behaviour (COM-B) model, which posits that behaviour change requires modification in at least one of these three components. This model was used to explore barriers and facilitators to healthier lifestyles among the target demographic.

Intervention Development Process

The intervention was developed through a systematic, three-stage process:

1. Understanding the Behaviour: This stage focused on promoting healthy eating and physical activity. A qualitative study was conducted to identify key factors for behaviour change, ensuring the intervention was culturally and contextually appropriate for the target group.
2. Identifying Intervention Options: Based on the initial findings, intervention functions were selected from the BCW to support behaviour change effectively. These functions included education, training, modelling, enablement, persuasion, and environmental restructuring, all aimed at empowering participants (SDG 5).
3. Identifying Content and Implementation Options: Specific behaviour change techniques were selected from an established taxonomy. The intervention combined face-to-face group sessions with virtual communication, a hybrid model chosen based on participant preference to maximize accessibility and engagement.

Intervention Description and Implementation

Program Structure

The intervention was delivered over five weeks, with a one-month follow-up assessment. The core objective was to help participants adopt sustainable healthy lifestyle changes using readily available resources. Key components included:

• Two-hour weekly sessions (primarily face-to-face, with one virtual session).
• Daily virtual support via a WhatsApp group.
• Assignment of a dedicated health mentor to each participant.
• Provision of Fitbit wearable activity trackers for self-monitoring.

Intervention Team and Support System

The intervention team was structured to provide comprehensive support, contributing to a positive health environment (SDG 3).

• Health Mentors: Professionals with backgrounds in health education or nutrition supported 8–10 participants each, helping them set goals and track progress.
• Intervention Providers: Clinical nutrition and physical activity specialists delivered the weekly sessions.
• Assessors: An independent team conducted assessments to ensure objectivity.

Fidelity to the intervention protocol was monitored by a project manager to ensure consistency and quality of delivery across all participant groups.

Participant Recruitment and Feasibility Measures

Recruitment Strategy

Participants were recruited from AlNahda Society’s beneficiaries, with an enrollment target of at least 30 women, consistent with recommendations for pilot studies. This targeted approach ensures the intervention reaches a key demographic for achieving health equity and reducing inequalities (SDG 10).

Eligibility Criteria

• Women over 18 years of age.
• Registered beneficiaries of AlNahda Society.
• Able to commit to the intervention duration.
• Exclusion criteria included involvement in other lifestyle interventions, pregnancy, or postpartum status.

Adherence and Engagement Monitoring

Feasibility was assessed by monitoring recruitment rates, intervention completion, session attendance, and engagement with virtual components. To mitigate financial barriers, a transportation subsidy was offered, directly addressing an element of poverty (SDG 1) that can impact health access. Engagement in the WhatsApp group was tracked by monitoring the number of posts and weekly sharing of step counts.

Outcome Measures for Assessing Progress Towards SDG 3

Socio-Demographic and Health-Related Outcomes

A comprehensive set of measures was used to evaluate the intervention’s impact on health and well-being. Assessments were conducted at baseline, post-intervention, and at a one-month follow-up.

• Socio-Demographic Information: Data on age, education, marital status, and employment were collected to contextualize findings within the framework of SDG 5 and SDG 10.
• Weight: Weight (kg) and Body Mass Index (BMI) were measured as primary indicators of physical health.
• Physical Activity: The International Physical Activity Questionnaire (IPAQ) was used to assess changes in activity levels.
• Diet: Two 24-hour dietary recalls were analyzed to measure changes in food group intake, particularly fruits and vegetables.
• Mental Health: The Kessler Psychological Distress Scale (K6) was administered to assess psychological distress, a key target of SDG 3.4.
• Quality of Life: The WHOQOL-BREF questionnaire was used to evaluate four domains: physical health, psychological health, social relations, and environment, providing a holistic view of well-being.

Data Analysis

Baseline characteristics were summarized using descriptive statistics. Due to non-normal data distribution, non-parametric statistics were employed. The Friedman test was used to compare outcomes across the three time points, followed by post-hoc Wilcoxon signed-rank tests with Bonferroni correction for pairwise comparisons. All statistical analyses were performed using R version 4.1.2 to ensure rigorous evaluation of the intervention’s potential to contribute to the Sustainable Development Goals.

Analysis of Sustainable Development Goals in the Article

1. Which SDGs are addressed or connected to the issues highlighted in the article?

The article discusses a health intervention study that connects to several Sustainable Development Goals (SDGs) due to its focus on health, poverty, gender, inequality, and partnerships. The following SDGs are addressed:

• SDG 1: No Poverty – The study specifically targets “low-income women” and is conducted in collaboration with the AlNahda Society, an organization that works to help “low-income households in graduating from poverty.”
• SDG 3: Good Health and Well-being – This is the central theme of the article. The “Stronger Together” intervention is designed “to increase physical activity and healthy diet,” directly promoting healthy lifestyles and well-being. It also assesses mental health and quality of life.
• SDG 5: Gender Equality – The intervention focuses exclusively on women and is implemented with a partner, AlNahda Society, which is “dedicated to empowering women socially and economically.” This highlights a commitment to addressing women’s specific needs and empowering them.
• SDG 10: Reduced Inequalities – By targeting a vulnerable and specific demographic group, “low-income women,” the study aims to address health disparities and provide access to health-promoting resources that this group might otherwise lack, thereby reducing health inequalities.
• SDG 17: Partnerships for the Goals – The study is a clear example of a partnership, as it was “conducted in collaboration with AlNahda Society, a non-profit organisation.” This collaboration between an academic institution (King Saud University) and a civil society organization is crucial for achieving the goals.

2. What specific targets under those SDGs can be identified based on the article’s content?

Based on the scope and activities described in the article, the following specific SDG targets can be identified:

1. Target 1.2: By 2030, reduce at least by half the proportion of men, women and children of all ages living in poverty in all its dimensions according to national definitions.
   • Explanation: The intervention is implemented through the AlNahda Society, whose mission is to assist “low-income households in graduating from poverty.” While the health intervention is not a direct anti-poverty program, it supports a vulnerable population, contributing to their overall well-being, which is a key dimension of poverty.
2. Target 3.4: By 2030, reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being.
   • Explanation: The intervention’s primary aim is to “increase physical activity and healthy diet,” which are key preventative measures against non-communicable diseases. Furthermore, the study explicitly measures outcomes related to “mental health, and quality of life,” directly aligning with the promotion of mental health and well-being.
3. Target 5.5: Ensure women’s full and effective participation and equal opportunities for leadership at all levels of decision-making in political, economic and public life.
   • Explanation: The study empowers women by providing them with health education, skills, and support systems (“health mentors,” “online chat group”) to take control of their health. This capacity development and empowerment, facilitated by an organization “dedicated to empowering women socially and economically,” is a foundational step toward fuller participation in public life.
4. Target 10.2: By 2030, empower and promote the social, economic and political inclusion of all, irrespective of age, sex, disability, race, ethnicity, origin, religion or economic or other status.
   • Explanation: The program specifically targets “low-income women,” a group facing economic and social disadvantages. By providing a tailored health intervention, it promotes their social inclusion and empowers them to improve their health outcomes, addressing inequalities faced by this economic group.
5. Target 17.17: Encourage and promote effective public, public-private and civil society partnerships, building on the experience and resourcing strategies of partnerships.
   • Explanation: The article states the study was a “collaboration with AlNahda Society, a non-profit organisation.” This partnership between a university research team and a civil society organization to deliver a community-based intervention is a direct example of the multi-stakeholder partnerships this target aims to foster.

3. Are there any indicators mentioned or implied in the article that can be used to measure progress towards the identified targets?

Yes, the article mentions several specific tools and metrics that serve as direct or implied indicators for measuring progress towards the identified targets.

• Indicators for Target 3.4 (Good Health and Well-being):
  • Physical Activity Levels: Measured using the “International Physical Activity Questionnaire (IPAQ)” and by tracking daily steps with “Fitbit wearable activity trackers.”
  • Dietary Habits: Assessed via “24-hour dietary recalls” and analyzed for the “average intake of food groups such as fruits and vegetables.”
  • Weight and Body Mass Index (BMI): Progress is tracked by measuring “changes in weight (kg) and body mass index (BMI)” at baseline, post-intervention, and follow-up.
  • Mental Health Status: Measured using the “Kessler Psychological Distress Scale (K6)” to assess psychological distress.
  • Quality of Life: Assessed with the “World Health Organisation Quality of Life (WHOQOL-BREF) questionnaire.”
• Indicators for Target 1.2 (No Poverty):
  • Proportion of participants from low-income households: This is an implied indicator, as the recruitment criteria specify that participants must be “AlNahda beneficiaries,” who are from low-income households.
• Indicators for Target 5.5 (Gender Equality):
  • Intervention completion and engagement rates: The article mentions monitoring the “intervention completion rate, and attendance and engagement with the intervention.” These metrics serve as process indicators for women’s participation in empowerment programs.
  • Qualitative assessment of empowerment: The article notes that the “acceptability of the intervention was also assessed using qualitative methods,” which would capture participants’ experiences of empowerment and behavior change.
• Indicators for Target 10.2 (Reduced Inequalities):
  • Targeting of a vulnerable group: The study’s design, which focuses exclusively on “low-income women,” is itself an indicator of an effort to address health inequalities. Improved health outcomes within this group would demonstrate a reduction in this specific disparity.
• Indicators for Target 17.17 (Partnerships for the Goals):
  • Existence and functioning of the partnership: The successful implementation of the “Stronger Together” study through the collaboration between the university researchers and the AlNahda Society serves as a direct indicator of an effective civil society partnership.

4. Table of SDGs, Targets, and Indicators

Source: equityhealthj.biomedcentral.com