Cancer is becoming a critical public health concern in low and middle income countries (LMICs) due to rising obesity rates, increasingly sedentary lifestyles, dietary influences, excessive tobacco and alcohol use, and recurrent carcinogenic infections such as Helicobacter pylori, hepatitis B virus, and human papillomavirus (1). The global cancer burden, morbidity, and mortality is disproportionately higher in LMICs than in high-income countries (HICs), with the LMICs accounting for approximately 81% increase in cancer incidence from 2008 to 2030 (2). Conflicts, poverty, and natural disasters exacerbate the situation, but it is primarily due to socioeconomic and cultural factors that result in late diagnosis, low retention in treatment, and minimal follow-up of cancer survivors (3). The rising cancer burden in LMICs places additional strain on already overburdened healthcare and economic infrastructures, as well as posing unique challenges to this region; as a result, extrapolating cancer experiences from high-income countries (HICs) to LMICs is often inadequate (4). Though individuals living with cancer and their family caregivers in both HICs and LMICs expressed similar needs (5, 6); but those in LMICs expressed these needs in greater numbers (7). Family/social, spiritual, and information needs, for example, may be expressed more in LMICs than in HICs due to socioeconomic challenges and culture (7, 8). These concerns must be addressed by designing a viable and sustainable model of care that addresses the needs of people living with cancer/family caregivers and improve their QoL in resource-poor settings (9).
Brumann, Abu-Lughod (10) define culture as “forms of traditional behaviour which are characteristic of a given society or of a group of societies, or of a certain race, or of certain area, or of a certain period of time”. People in LMICs, particularly in Africa, have a diverse set of cultural and religious beliefs that influence their behaviours and perceptions of cancer care (11). As a result, if cancer management in this region is to improve cultures, traditions, and religious beliefs that influence the behaviour of people living with cancer and their families must be a focus of an intervention (12).
There is some evidence, mostly from HICs, that psychosocial interventions have the potential to improve the QoL of people with cancer and/or families (13-15), but most of these interventions lack concepts that are essential to LMICs. Additionally, there is even knowledge gap in applying those interventions in LMICs where the cancer/caregiving burden is highest and the demand for resources is greatest (16).
In addressing these gaps, it is crucial to design an intervention that integrates information, social, spiritual, and cultural beliefs. Therefore, this study aimed to design an evidence-based intervention to improve the QoL of adults living with cancer and their families in Nigeria and Africa in general.
Theory Based Intervention Design
According to the Medical Research Council (MRC), intervention should be based on a specific and consistent underpinning theory (17). The MRC framework is widely regarded as the “gold standard” for developing and evaluating complex interventions, as well as the most widely used set of guidelines in health science (18-21). The MRC framework, on the other hand, lacks depth and direction as a detailed guide for how to develop an intervention. For example, the MRC framework emphasises the importance of using theory in intervention design (17); however, there is no clear guidance on how to select and apply theory. Consequently, Michie, Van Stralen (22) synthesised nineteen frameworks and developed the Behaviour Change Wheel (BCW), a comprehensive and pragmatic framework for intervention design (BCW).
The BCW has been shown to be extremely effective in developing interventions prior to human clinical trials (23). The BCW is a systematic guide for developing behaviour change interventions that is based on the COM-B. The COM-B model is built around three components: capability, opportunity, and motivation, all of which are necessary to generate or change a behaviour (24). The COM-B model acknowledges that behaviour is part of a broader context that includes a person's or group’s capacity (physical and psychological), opportunity (social and physical), as well as motivation (reflective and automatic). According to COM-B, for any behaviour of an individual, or group to occur, there must be: (1) capacity to perform the behaviour, which can be physical (e.g., having the physical skills, or strength) or psychological (e.g., having the knowledge psychological skills, or stamina) (2) the opportunity for the behaviour to occur, which can be physical (for example, environmental factors that allow or promote behaviour, such as time, resources, stimuli, and so on) or social (e.g. opportunity afforded by interpersonal influences, social cues and cultural norms). (3) motivation to perform the behaviour at the relevant time, which can be reflective (e.g., requiring self-aware planning and evaluation) or automatic (e.g., processes involving wants, needs, desires, impulses, and reflex responses) (22, 24).
The BCW has nine intervention functions in the middle ring and seven policy-level strategies in the outer ring. The BCW is used to link influences on behaviour, identified by the COM-B, to potential intervention functions and policy categories (see Figure 1).