Question

How can nurses use change theory to empower ACTIVITIES pregnant women to stop or at least reduce the use of tobacco?

Answer 1

“Smoking is the single most important modifiable cause of poor pregnancy outcomes. Smoking during pregnancy has been shown to contribute to adverse outcomes including miscarriage, placental abruption and separation, premature rupture of membranes, preterm delivery, low birth weight, increased prenatal mortality, still birth, and sudden infant death syndrome (SIDS).

Women who smoke during their pregnancy or even through a portion of the pregnancy, put their unborn child at risk for many complications during pregnancy and after delivery. Smoking accounts for 10% of infant mortality, 20%-30% of low birth weight and increased risk for spontaneous abortion and complicated birth. Tobacco smoke introduces greater than 4000 potentially teratogenic chemicals into cardiovascular circulation. Nicotine from cigarettes has a dose-dependent effect that causes vasoconstriction and decreases the amount of blood and oxygen that reaches the fetus. Women who smoke have a 30% higher chance of delivering prematurely. Nicotine readily crosses the placenta and can enter the amniotic fluid, fetal circulation and can be absorbed through the skin of the fetus. Long-term nicotine exposure during
gestation may reduce nutrient supply and have a direct effect on the cell disposition for genetic instability. This oxidative stress can cause a nicotine induced reactive oxygen species (ROS) which can result in mitochondrial DNA damage making the fetus more prone to have genetic instabilities such as developing lung cancer. Studies have shown that between 25% and 60% of pregnant smokers quit smoking spontaneously when they learn they are pregnant. With this said, teaching smoking cessation is vital to women of childbearing age. Smoking cessation provides immediate and long-term benefits for pregnant women and their young children. Care priorities emphasize patient and family education, patient participation in their self-care, promotion of optimal health, provisions of continually competent care, facilitation of entry into the health care system, and the promotion of a safe environment. Counseling by a trained provider lasting only 5-15 min is associated with modest but clinically significant effects on cessation rates for pregnant women.

The ‘5 A’s Smoking Cessation Clinical Practice Guideline which is a brief smoking cessation counselling by antenatal care providers. The guideline recommends that a 10-15 minute counselling session by trained providers and the provision of self-help education materials designed for pregnancy become a standard component of routine antenatal care. Such interventions are expected to increase the usual quit rate to about 15%. The guideline also outlines the five A’s approach which means that the counsellor should Ask about smoking at every patient visit, Advise every smoker to stop, Assess the client’s readiness to quit, Assist clients to assess whether they’re ready to quit or not, Arrange for follow-up visits and discuss the subject of smoking at every subsequent visit.

Theoretical framework
Health behaviour theories are useful tools when planning an intervention study. They provide valuable insight into the key factors that influence behaviour and give
theoretical guidance on what data that is needed for deciding the most suitable design for the targeted behaviour. The Smoking Cessation in Pregnancy Project was informed by several health behaviour theories; the transtheoretical model, which incorporates stages of change theory, and builds on the Health Belief model; the social leaning theory and the theory of planned behaviour. The trans-theoretical model will be described in detail with indications of how the other theories informed the design, the analysis and the evaluation of the project. The theoretical basis for using motivational interviewing as a person centred communication approach will be presented as well as some theoretical assumptions about gender roles and female smoking.

The Trans-theoretical Model of Change
Stages of Change
The first construct of the trans-theoretical model assumes that behaviour change is a dynamic process involving five distinct motivational/behavioural stages.

Process of change
The second construct of the Trans-theoretical model looks at the process of change, which includes the following overt and covert activities people use to progress through the five stages of change described earlier. These activities comprise;

• conscious raising – involves becoming aware of the harm in smoking and its consequences
• self-re-evaluation – assessing one’s feelings about smoking and quitting
• self-liberation – choosing and committing to change a behaviour counter
• conditioning – substituting smoking with healthier behaviours
• stimulus control – avoiding places, people and events that elicit smoking
• contingency management - rewarding oneself or being rewarded by others for making a behaviour change.
• helping relationships – involves developing therapeutic alliance with someone in order to talk about the difficulties of quitting. This process involves being open and trusting about smoking and quitting
• emotional relief – expressing one’s feelings about the experience of quitting. This allows the individual to vent frustrations and anger related to the difficulties associated with the quitting, but also to express how good one feels about achievements
• environmental re-evaluation – assessing how smoking affects one’s physical environment
• interpersonal control – involves making efforts to avoid people or social situations that encourages smoking.

Decisional balance
The third construct of the Trans-theoretical model looks at the individual’s weighing of the pros and cons of changing behaviour. If the pros of changing behaviour significantly outweigh the cons, individuals are more inclined to change. This is also illustrated by the Theory of Planned Behaviour’s construct of ‘subjective norms’. Intentions to change behaviour are often also influenced by the individuals’ beliefs about how significant people in their lives view the behaviour and
how strongly individuals are motivated to either comply with the norm, or reject the expectations of society.

Self-efficacy
The last construct, self-efficacy, has two parts in the Trans-theoretical Model, confidence and temptation. If people are able to resist their temptation to relapse
into the problem behaviour, it increases their confidence in being able to cope with the changed behaviour. Similarly, if they have low self-confidence in their ability to change their behaviour for good, they are more likely to give into temptation. This construct is strongly influenced by the Health Belief Model and the Theory of Planned Behaviour, which describe the ‘perceived behavioural control’. These are the factors outside the individual’s control that may affect her behaviour and intention to make a change. These theories state that individuals are more committed to make a behaviour change when their perceptions of behavioural control are high.