Factors influencing the adoption of health promoting behaviors in overweight pregnant women: a qualitative study

This is a study with a content analysis approach [27], which has been conducted to discover factors affecting the various aspects of health promotion behaviors (nutrition, physical activity, spirituality, stress management, accountability, and social interactions) in Tabriz-Iran in 2017 and lasted for 6 months. Participants were selected based on inclusion criteria through purposive sampling among pregnant women referring to health care centers and pregnant women care clinics. These criteria include singleton pregnant women with an age range of 18–40, having the ability to understand and transfer concepts to a researcher, pregnancy of over 10 weeks, and having information about weight and height preconception in the women’s health records whom are defined as overweight according to their BMI (25–29.9). Exclusion criteria consisted of: any illnesses or medical health file indicating the need for special care or relative/absolute rest for the mother, as well as withdrawal and reluctance of the mother to continue participating in the study.

All individual and group interviews were conducted by the first author of the paper (A.FnK) as a faculty member and a Ph.D. student in reproductive health who has a history of participation in the classes of qualitative research methodology and the use of qualitative analysis software. She also has enough experience in the field of caring pregnant mothers. All steps for data recording and data analysis were conducted under the supervision of the author (S.H) as a Ph.D. student in reproductive health and the faculty member with several years of qualitative study.

After selecting the subjects through the history file of pregnant mothers according to the criteria for inclusion in the study, first, the purpose and reasons for the study were explained to each participant and, the times of the face-to-face interviews were set up as desired for the participants. Initially, five pilot interviews were conducted, which were not analyzed, but they helped shape the interview guide and how to do the study. Semi-structured questions were used to conduct interviews. These were formulated by reviewing the texts and based on the experience of the author who is responsible for qualitative studies. In individual interviews and focus groups, open and general questions were first asked to express their individual experiences. In both individual interviews and focus groups, we used the same interview guide Examples of these questions are: “What is your opinion about health?”, “What factors can help improve your health?”, “What factors can affect your attitude in changing your health behaviors?” “In your opinion, what factors force the pregnant woman to leave the healthy behaviors despite of knowing about their benefits?”, “How can these factors affect your health?” To explore the participants’ experiences, the interviews continued on the basis of their answers and questions like “What do you mean?”, “Please explain”, “Can you give us an example” were asked for a better understanding. To document the data, interviews were first recorded and then transcribed at the right time. Field notes were used as much as possible and non-verbal data such as tone and gestures was also recorded. Interviews were conducted at care centers for pregnant women or at the workplace of the participants, in an isolated room without the presence of anyone except the participant. A code and nickname were assigned to each participant. Interviews lasted from 30 min to 60 min. Interviews continued to saturate the data and until a new classification wasn’t created. Data saturation was obtained on the 14th interview. Nevertheless, two other interviews were conducted to ensure that it was completed. A total of 16 individual interviews and 3 Focus groups (two five-member interviews and a six-member interview) were conducted. And 32 people participated in the interviews.

Two of the interviews were discontinued because of the participants’ dissatisfaction with the continuation of the interview. In one case, a 19-year-old participant was excluded from the study due to she’s inability to answer the questions, and in the latter case, because of the mother’s dissatisfaction and frustration to continue the interview. One of the interviews was interrupted due to ambient noise and was repeated a few days later.

Data was analyzed based on content analysis with a conventional approach [28]. The advantage of this method was to collect data from the participants directly without imposing any theoretical views by the interviewer. Data analysis was performed simultaneously with each interview MAXQDA v. 10, after recording on paper using. Identified codes were the result of semantic units of the participants’ comments.

The interviewer tried to establish a friendly relationship with the participants to validate the results. To increase the validity of the data, the interviews were submitted to the participants after transcription in order to affirm their statements, and if necessary, additional statements were added to the data. Authors were reviewed data for several times and revised word -by-word, and the major sentences and concepts in each line or paragraph were specified and a code was assigned to every sentence. Coding was performed using the participant’s own words or based on reasoning that the researcher made according to the concepts which have been contained in the data. The transcriptions were submitted to colleague along with the extracted codes and categories, and his viewpoints were used regularly. Also, external viewpoints were used to increase the reliability; such that by provision of the initial codes which have been derived from the analysis and examples of how the concepts were extracted for the four researchers of the Reproductive health, who acted as the external observers, it was determined whether they also had a similar understanding of the data.

Individual barriers include a main category of individual factors which prevent health promoting behaviors. This main category is extracted from 2 subcategories and 5 sub-sub-categories: inabilities and additional needs in pregnancy (physical inhibitors, psychological inhibitors) and mental barriers (lack of time, lack of motivation and information, internal inhibitors).

In terms of inabilities and additional needs during the pregnancy, most participants referred to the constraints which are resulting from physical and functional changes in the body organs during the pregnancy. They said:

“During pregnancy, walking will be made tougher due to gaining weight, especially if the person is already obese. I think thin people don’t have these problems. During pregnancy, one has lower energy and gets tired soon. Anemia may also lead to lack of energy and weakness. For example, 4 to 5 months after getting pregnant, I found out that my hemoglobin count is on 10, I was very weak. I couldn’t do my house chore.” (p.7).

“Now (during pregnancy), I cannot drink milk. I have not drunk a glass of milk since I got pregnant. I think this is related to being pregnant. I have to consume more of healthy foods.” (p.2).

“I like jogging; however, I feel ache in my womb when I walk.” (p.8).

In terms of psychological changes which prevent from taking healthcare measures, one of the mothers said:

“At the beginning of the pregnancy period, I was a little excited and I ate a lot due to which. I liked eating. I got sensitive during pregnancy. I got angry and discomforted soon and cry a lot.” (p.1).

The interference of the duties which have been assigned at home and at work and the loss of opportunities were the important factors that were mentioned by the working and employed women. Two of the mothers stated:

“When I come back home from work, I have to do the housework and pay attention to my child and husband. So, I don’t have any time for myself. I like to exercise more, to improve my diet, but I have no time for these.” (p.1).

“I think, at the first pregnancy, the mother has more time for herself, but in the next pregnancy she has another baby, she does not have time for herself. Now I have to pay attention for my children also when my husband comes home, I have to pay attention to what he wants, so I don’t have enough time for myself” Among the important barriers of taking health measures, we can mention the lack of motivation and lack of sufficient information. Pregnant women stated that:

“Exercise is necessary for our health, but we are not used to it, we do not take it serious. We do not substitute exercise with our chores.” (p.7).

“I do not know about weight gain and its effects. I do not know anything I and do not ask about it.” (p.8).

“I do not know about the exercises that can be performed during pregnancy.” (p.3).

Among the other personal aspects which have been mentioned by the participants, the intrinsic inhibitors such as feeling embarrassment, fear or worries and negative thoughts can be observed. Pregnant women said:

“I wanted to ask about sexual relationship from my doctor. I liked to have information but I’m embarrassed.” (p.10).

“From the middle of the pregnancy onwards, the belly comes out and you have to cover it with your scarf. I have to stay in home. I can walk less than before.” (p.11).

“because of I have a familial relationship with my wife, and two of my brothers are deaf, for this reason I have a lot of stress that my child may have a problem.” (p.8).

The socio-economic barriers include environmental, social and economic factors that make problems for the pregnant women in taking health measures. This main category is extracted from the subcategories of negative influences of environment, negative influences of relatives, and financial pressures.

Cultural believes and barriers, insufficient facilities and organizational barriers are among the environmental factors that have a negative influence on a healthy lifestyle. In terms of cultural barriers, patriarchal environment and social beliefs are the reasons of non-participant in the health programs and behaviors. Pregnant women said in this regard:

“I like to go to the gym, but my husband is not happy with that. He says he doesn’t like it. If you (pregnant woman) want to go to the park and use exercise facilities, People look at the woman saying that she has come with her big body to exercise and people say that is not sane for the woman so you cannot exercise comfortably.” (p.12).

“My husband doesn’t like sexual relationship in pregnancy. He says I don’t like my child to grow up in an environment with lust. He doesn’t like it so that he rejects sexual relationship altogether.” (p.13).

“I don’t accept food from anyone, specifically those that I have less trust. They say the characteristics of the ones who give you food, will affect your child.” (p.14).

Among the other barriers that were mentioned frequently, we can refer to lack of facilities and inappropriate environmental status.

“There is no good gym in our neighborhood. I like to go to the gym but I cannot. I may have gone to the gym if it existed near us.” (p.8).

“I have to eat vegetables and fruits during pregnancy. Now they use chemical fertilizers to grow these foods. The fertilizers enter the body. Chickens are grown by hormone injection, so we eat less of it because it hurts.” (p.7).

Among the organizational barriers which have been mentioned in the interviews, the planning problems, working problems for the pregnant women, lack of government services the problems of health care staff and political problems were observed. One woman said:

“When I come for the pregnancy care, I get tired of the crowdedness. There is no planning, so I don’t like to go for the pregnancy care. In addition, the health care provider does not guide us very well. They hurry in doing their duties and measuring blood pressure. They prescribe medications and think that they do not need to guide us.” (p.7).

The lack of government support and the existence of political problems have been mentioned as an obstacle to the desired health outcomes by working pregnant women. One of the participants stated:

“It’s very hard for the working women, specifically for those with alternative shifts and those who have night shifts. The government has to have the necessary plans.” (p.2).

In addition to the negative influences of the community, familial problems, lack of family support and lack of awareness among the relatives were mentioned as factors that are affecting the adoption of lifestyle and the health status. Participating women stated that:

“The husband has an important role. I have many problems with my husband. He is an isolated man. He doesn’t like relationship with the relatives. Also he always wants me besides him (laughs) And do not let me be in touch with my family. These irritate me.” (p.1).

“Because I’m away from my family, I feel more needs. I like to have someone to talk to. I like them to be beside me, not for help and assistance, but for talking.” (p.5).

One of the most influential factors in the adoption of health promoting behaviors which was mentioned frequently by pregnant women was economic problems and financial pressures and inadequate income. They said:

“The cost of screening experiments is very high. It’s very hard to pay for all that.” (p.8).

“If my husband had a good job, I didn’t need to work. If he could earn well, I did not need to weave carpets. If he had a good job, I could pay more attention to myself or even exercise.” (p3).

“There’s no job, and no job means no money. That means there’s no good diet, no exercise. These are all achieved by money. I think bad economic situation is what prevents anyone from paying attention to health.” (p.15).

The main category of individual facilitators includes personal factors which facilitate the adoption of health promoting behaviors. This main category includes 2 subcategories and 3 sub-sub-categories: internal incentives (having motivation and will), wealth and personal skills (personal abilities, knowledge and information). The most important issue about the internal incentives is having the interest, will and incentive.

What was described as a contributing factor to health behaviors is to have individual skills, especially in terms of education, financial strength, experience and the ability to plan individually. On this issue, the pregnant women said:

“Nowadays, the women are better off they have higher education levels and most of them are working and earning income. This is helpful, because it helps them if they can get by on their own.” (p. 17).

“We have to try to grow. For example, for exercising, we have to start from a minimum of 5 min and gradually increase the time so that we are used to it.” (p.7).

The main category of socio-environmental facilitators includes factors which are related to family, social and environmental life. This main category was extracted from 2 sub categories and 5 sub-sub-categories included social support (support and appropriate relationship^’s familial and health staff support) and the motivational environment and general awareness (positive environmental influence, organizational factors, public awareness).

Family and social support is one of the facilitators of adopting health promoting behaviors. In this regard, the support which had been received from the husband was emphasized by pregnant women. In addition, the support from other family members and health care providers was also mentioned as facilitators. For example, the women stated:

“It’s true that the infant is carried by me, but my husband has to cooperate with me, he shouldn’t leave me alone and should help me.” (p.18).

“Being around your family and relatives, gives you confidence. We know that someone supports us, someone that we can trust in.” (p.19).

“I think the physiological delivery classes are better, because in these classes, we ask any questions we have. When you have information, you are calm and no anxiety will remain.” (p.20).

Other socio-environmental facilitators are based on choosing a healthy lifestyle, availability and accessing the health facilities and environments, especially those that are specific to pregnant women. For example, several participants said:

“The government has to consider training classes for the pregnant women during the pregnancy period; e.x., the training classes which have been held by the health centers are OK now.” (p.21).

“I am very happy that I could take all my pregnancy tests; it would have been costly if we were not under the coverage of insurance.” (p.21).

“If there is a special park for ladies, women can use the exercise facilities in the parks.” (p.21).

Other aspects that mentioned by pregnant women, including positive effects of the living environment, such as cultural issues and motivating factors in the community, can play a positive role in adopting health promoting behaviors. One pregnant woman said:

“I think now women can do anything they want. In the past there were constraints but this is now getting better and women are very comfortable.” Also, she said that “observing other people’s activity on health behaviors is an important factor”, and added: “when you see the activity of others, you become motivated to do the same.” (p.17).

From the participants’ point of view, public awareness can be a facilitator for health behaviors, and for most of them, media and education are very important factors in raising public awareness. One of the respondents stated:

“Education by the media is very important, and in my opinion, the media is of top priority. Media advertising is even more important than reading a book.” (P.2).

In addition, emphasis on the importance of educating men and raising their awareness of pregnancy-related issues was mentioned by women. They said:

“Men also need to be educated; I wish that there were places for them to be educated just like us.” (p.1).

In this qualitative study, only the experiences and views of overweight pregnant women are included as the factors which are influencing the adoption of health promotion behaviors. It seems that appropriate interventions are needed to review the opinions and experiences of family and health care providers. Also, most participants in this study had uncomplicated pregnancies, which may affect their perceptions and experiences. In addition, women with different body mass index, such as obese and lean, may also mention different experiences.