Although it is important to acknowledge an individual’s attitudes and values in health promotion, and to respect them, it is also essential that a supportive environment be created in which an individual can challenge ideas and question beliefs. The growth of knowledge about ourselves and the outside world aroused by such challenges provides a day-to-day allure in life for the companionship of others, both to confirm our beliefs and, when we feel secure enough, to move on to different levels of knowledge, with which come more complex beliefs and attitudes.
Pregnancy, childbirth and parenting provide a time that requires immense psychological development, when women acquire a great deal of new information, both from the experience of their own pregnancy and from other sources such as family, friends, magazines and health professionals. Although midwives pay great lip service to the importance of giving unbiased information and respecting women’s wishes, we also have a moral role in informing women about health-damaging behaviours when and where they may occur. Common examples include information about the dangers to the woman and fetus of continued smoking, alcohol consumption or drug taking in pregnancy, and making sure that women are aware and able to have the opportunity to discuss the advantages to both mother and baby of breastfeeding over formula feeding. The areas of nutrition and exercise in pregnancy are less clear cut in terms of what is healthy, but nevertheless midwives have a duty to encourage discussion of such topics.
To understand how individuals come to change their health behaviours there is a need to differentiate between a change in attitude and a change in behaviour, and to be aware of the time scale involved. In 1984 Prochaska and DiClemente developed a
‘trans-theoretical approach’. This approach, developed specifically for smoking cessation, looked for the first time at the actual process undertaken by individuals when changing their health behaviour rather than the factors involved in changing health behaviours and, very controversially for the time, it made clear identification of a relapse stage in light of the evidence showing that long-term smokers took three to four attempts over a 7- to 10-year period before finally quitting (Prochaska and DiClemente 1984). The approach identifies seven stages (Figure 6.2).
1. The pre-contemplation stage
At this point in time the woman has no awareness of a need to change her health behaviour. The midwife, to raise the awareness of the woman, can use health advice
72 Attitudes, values and health behaviours
and gentle non-judgemental questions about the negative health behaviour. Once she becomes aware the woman then moves to the next stage of the approach. It is important for the midwife to realize that the woman may be hostile to any attempt to discuss the dangers of her negative health behaviour, suggesting that she has yet to reach the pre-contemplation stage (and may indeed never do so). Realistically, it is unlikely that further attempts to discuss cessation will serve a useful purpose, and may even damage the midwife’s relationship with the woman. Alternatively she may accept anti-smoking arguments but claim to feel quite powerless to stop. A time span on this is difficult because some women may remain in this stage for many years (Prochaska 2005).
2. The contemplation stage
This is where the health behaviour change starts and may take up to 6 months (Prochaska 2005). The woman, now aware of the side effects of her negative health behaviour, is motivated to think about making the change. She now actively seeks information about the negative health behaviour and the benefits that will come by making a change to it. Empowerment is key to moving through this stage and the midwife can use her considerable skills to facilitate this process, as well as assisting the woman with the collection of information. The midwife must also realize that some of her clients may never move beyond this stage.
Pre-contemplation
‘Not interested in changing
lifestyle’
Contemplation
‘Thinking stage’
Relapse
‘Returning to old lifestyle’
(can occur at any time)
Commitment
‘Ready to make the change’
Maintenance
‘Continuation of the change’
Action
‘Making the change’
Exit
‘Continuing the change’
FIGURE 6.2 Prochaska and DiClemente’s stages of behaviour change. (Adapted from Prochaska and DiClemente 1984.)
The transtheoretical approach to health behaviour change 73
3. The commitment stage
A woman entering this stage of the approach is making a serious decision to change her negative health behaviour. The midwife can help the woman by working with her to identify resources and develop action plans, as well as highlighting coping strategies that may help when things get tough. Towards the end of this stage a date on which to commence the change needs to be clearly acknowledged. Prochaska (2005) identifies that this stage usually lasts no more than a month.
4. The action stage
Here the woman is changing the negative health behaviours. She is making explicit modifications to improve her health behaviours and this stage may take up to 6 months (Prochaska 2005). Support during this stage is vital and the midwife can offer support to the woman as well as referral to self-help support groups, and the development of a support group made up of family and friends and identified in the commitment stage of this approach.
5. The maintenance stage
This is when the woman maintains the health behaviour change and prevents a relapse back to her old health behaviour. Here the midwife provides support for the woman by facilitating the woman’s use of her action plans and her coping strategies identified in the commitment stage. The woman gains satisfaction from her main- tenance of the health behaviour change, which will increase her self-esteem and confidence. Prochaska (2005) highlights that this stage can last for 6 months and beyond.
6. The exit stage
This is where the health behaviour has been successfully changed and maintained by the woman. At this stage the woman is not affected by temptation and has 100 per cent self-efficacy. It is important for the midwife to offer support as required, but it is also important for the midwife to realize that only a small number of women will reach this stage. For most women the best that they will achieve is a lifetime in
maintenance stage (Prochaska 2005).
7. The relapse stage
It is important for both the woman and the midwife to realize that this approach will not be successful for everybody at the first attempt. It is also important that relapse is a fact of life when changing health behaviours and it should not be deemed a failure on the part of the woman. Relapse should be evaluated as to its cause and, on starting the approach again, this evaluation can be worked into an action plan and a coping strategy can be developed. This will allow the midwife to offer support, particularly at the point in the approach that the last relapse happened.
74 Attitudes, values and health behaviours
SUMMARY OF KEY POINTS
■ It is vital to understand how beliefs, values, drives and attitudes affect how individuals form their health behaviour.
■ The relationship between attitudes and behaviours is complex. A change within any of the three component parts of attitude may initiate a change in behaviour; however, there is no guarantee that this will be the case.
■ Age, gender, culture, peer support and personality are just some of the multitude of factors that influence attitudes and attitude formation.
■ Health behaviour theories highlight the factors involved when an individual initiates a change in negative health behaviour.
■ Prochaska and DiClemente’s trans-theoretical approach identifies the process that an individual goes through during health behaviour change and shows the midwife where their skills can be used.
■ Pregnancy is often a time when a woman and her partner are open to new ideas and may change their attitudes as they re-evaluate their lives, learn more about themselves and join a new social group of being parents. The midwife needs to bear in mind that those women in socially excluded groups might find this difficult to achieve.
■ Midwives need to be sensitive to the individual’s values, the complex issues of health behaviour and the ethical dimensions of attempting to change an individual’s values and attitudes.
■ Midwives also need to be aware of their own values, beliefs and attitudes, and how that may impact on the care that they give their clients.
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FURTHER READING
Kerr J, Weitkunat R, Moretti M (eds) (2005) ABC of Behavior Change. A guide to successful disease prevention and health promotion.London: Elsevier Churchill Livingstone.
Rollnick S, Mason P, Butler C (1999) Health Behaviour Change –A guide for practitioners.
London: Churchill Livingstone.