Fundamentals of Midwifery: A Textbook for Students (31 page)

. . . a state of well-being with physical, cultural, psychosocial, economic and spiritual attributes
, not simply the absence of illness . . . ’ (p. 4). In a maternity care context, there is very clear evidence that health of the mother and the fetus is not only depend- ant on medical conditions, but on environmental conditions and lifestyle choices during preg- nancy. Midwives are providers of care, but are also in a position to facilitate the empowerment of women to increase control over their health to make healthier decisions. There are some key public health issues within contemporary maternity care that are well evidenced to result in poorer health outcomes for mother and/or baby (see Chapter 11: ‘Public health and health promotion’, where these are discussed in further depth). However, despite the apparently clearevidence of harm, women continue to engage in behaviours that are detrimental to their health. It is therefore of value to understand the psychology that underpins healthy versus unhealthy behaviour.‌‌
Further reading activity 65For further information access the GOV.UK website [Available online] https://www.gov.uk/government/topics/public-health
Health beliefs and behaviours
Strong evidence now underpins the belief that health behaviours are important in predictingmorbidity and mortality (Stringhini et al. 2011). In psychology the role of health beliefs have been considered as predictors of behaviour.
Health locus of control
Health locus of control (HLoC) has been suggested as important as to whether or not we change our behaviour and/or adhere to recommendations by a health professional. HLoC proposes that individuals differ in whether they regard their health as controllable (internal HLoC) or uncon- trollable (external HLoC) by them. Wallston and Wallston (1982) developed a measure to evalu- ate HLoC to determine whether an individual believes their health is:

controllable by them (internal)

not controllable by them and down to fate/luck (external chance)

under the control of powerful others, such as healthcare professionals (external powerfulothers).Clearly those with an internal HLoC are more likely to believe that their own behaviours can influence health outcomes. Studies in maternity care have shown links between HLoC and behaviour (for example see, Martin and Jomeen 2004; Jomeen and Martin 2008a).
Unrealistic optimism
Other authors have suggested that the reason people continue to practise unhealthy behav- iours are inaccurate perceptions of risk (Weinstein 1983; 1984). Weinstein called this phenom- enon unrealistic optimism, and proposed four cognitive factors that contribute:

lack of personal experience with the problem

the belief that the problem is preventable by individual action

the belief that the problem has not yet appeared, so it will not appear in the future

the belief that the problem is infrequent.Weinstein suggested that individuals show selective focus, in that they ignore their risk increasing behaviours and focus on risk decreasing behaviour.
Clinical consideration
A pregnant woman who is overweight may think that it is important, but think ,‘At least I have given up alcohol.’ Individuals, as a consequence of egocentricism, then focus on the risk increasing behav- iour of others and ignore the risk decreasing behaviour.
Table 4.1
Summary of the stages of change model
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Pre-contemplationI am happy being overweight and don’t intend to do anything about itContemplationI am pregnant and being overweight can be harmful for my baby, perhaps I will consider losing weightPreparationI will stop eating fattening foods and start to exerciseActionI have started eating more healthily and doing gentle exerciseMaintenanceI have kept my weight gain during pregnancy within recommended levels and intend to maintain my behaviour post birth66
The stages of change model
The stages of change model is a synthesis of 18 therapies, describing processes involved in behavioural change, developed in 1982 by Prochaska and DiClemente (cited in Hewstone et al. 2005). This model of change has been applied to several health related behaviours including smoking, alcohol use and screening. The model suggests the stages shown in Table 4.1.This model suggests behaviour change as dynamic, and highlights that individuals can move backward and forward before reaching the maintenance stage, and may still slip back over time. It examines how individuals weigh up costs and benefits of particular behaviours. The motiva- tion of pregnancy may be an additional factor in weighing up costs and benefits of altering behaviours.
Social cognition models
These different perspectives have been integrated into Social Cognition Models (SCM) whichaims to develop theories to explain the relationship between knowledge, attitudes and behav- iour. It is believed that there is a close relationship between these elements and a person’s intentions to act in a particular way. Two well utilised SCM theories include the Health Belief Model (HBM: Rosenstock 1966; Becker et al. 1977) and the Theory of Planned Behaviour (TPB: Ajzen 1985; 2002a; 2002b).
Health Belief Model
In the Health Belief Model (HBM) a pregnant woman who smoked would be asked to consider:

her own susceptibility to lung cancer and the implications for the baby such as stillbirth, miscarriage and low birth weight

the seriousness of these conditions and consequences

the positive effects and value of giving up smoking

the potential negative consequences of giving up smoking.The HBM also acknowledges the role of cues, which might be internal, such as a smoker’s cough, or external such as meeting someone with lung disease, as well as their own motivation. In pregnancy, it might be evidence that their baby is growth retarded or the placental flow is inadequate, hence, how important to them is their health and the health of their baby. The HBM suggest these core beliefs can successfully predict health behaviours. Following criticism, the
SeverityInformation about smoking in pregnancy increases fear and the individuals perception of risk
Susceptibility 67Increases the belief that they or their baby are likely to come to harm as a consequence of smokingSelf-efficacyConfidence to change their behaviourResponse effectivenessThat the change would have beneficial consequencesBehaviour intentions Report high intentions to change