Development and preliminary testing of a culturally competent behaviour change intervention framework to enhance utilisation of sexual and reproductive health services among migrant adolescents in Ghana: an intervention design

Despite global efforts, significant knowledge gaps remain in applying cultural competence interventions to strengthen clinical interactions for migrant adolescents in low- and middle-income countries (LMICs). This study sought to develop and preliminarily test a culturally competent behaviour change intervention framework to enhance the utilisation of sexual and reproductive health services among migrant adolescents in Ghana. An intervention development design using the multiple research approaches was used. A COM-B and Campinha-Bacote’s cultural competence models guided the study. It engaged healthcare providers (HCPs), migrant adolescents, gatekeepers, and peers in the Greater Accra Region. Health facilities were selected using criterion purposive sampling, followed by convenience sampling for participants. The study was conducted in three phases: Phase 1 employed qualitative methods to explore problematic behaviours in health-seeking among (10) migrant adolescents and cultural competence delivery among (8) HCPs. Behavioural analysis informed the identification of relevant behaviour change techniques (BCTs) using the Behaviour Change Wheel. Phase 2 used a Delphi study with (10) experts to validate selected BCTs, assessing their feasibility, acceptability, effectiveness, and risk of harm. Experts also reviewed implementation strategies and delivery methods. Phase 3 involved preliminary testing of the cultural acceptability and feasibility of the intervention through workshops with migrant adolescents and HCPs,with the aim of refining the prototype to inform the final intervention framework. Phase 1 revealed the following explanatory factors that are amenable to behaviour change: mistrust and communication challenges among migrant adolescents, and poor self-efficacy to deliver cultural competence among HCPs. To address these, relevant behaviour change techniques (BCTs) were identified, such as instruction on how to perform the behaviour, removing aversive stimuli etc. In Phase 2, experts validated the BCTs as 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 low-risk of harm (4.0[SD=1.3;2.5) forHCPs.Migrant adolescents; feasible (4.3[SD=0.5;4-5]); acceptable (4.1[SD=0.7;3-5]); effective (4.1[SD=0.7;3-5]); low-risk of harm (4.0[SD=0.8;3-5]).Experts further validated the implementation strategies as appriopriate with the need to include who to deliver the intervention. Phase 3 involved testing the cultural acceptability and feasibility of the strategies among the users, with feedback highlighting the need to address contextual factors like traditional communication methods and HCP training. These insights were integrated into the final framework. The behaviour change-informed framework served not only as a conceptual model of the mechanisms of behaviour change but a practical guide for implementing strategies to enhance ASRHs use among migrant adolescents, pending future testing in a randomised control trial. The study developed and tested a culturally competent behaviour informed intervention framework to make sexual and reproductive health (SRH) services more accessible to migrant adolescents in Ghana by improving cultural competence in healthcare. Using the COM-B and Campinha-Bacote models, the research engaged healthcare providers, migrant adolescents, gatekeepers, and peers in three phases. Phase 1 explored challenges such as mistrust, communication barriers, and limited cultural competence among providers, leading to the selection of behaviour change techniques (BCTs). In Phase 2, ten experts validated these BCTs as feasible, safe, effective and refined delivery strategies. Phase 3 tested the intervention with adolescents and providers, confirming cultural acceptability but highlighting the need for context-specific adaptations, including traditional communication methods and provider training. The final framework provides both a model of behaviour change and a practical tool to improve SRH service use among migrant adolescents, ready for future large-scale testing.