The preconception period is the most important time to achieve improvements in the health of the next generation. Women entering pregnancy in optimal health are setting their offspring on a path for a healthier life with a lower risk of developing the non-communicable diseases plaguing society today.
So how can we support young women to achieve good health at this critical time of their lives? As a health psychologist and researcher I have a particular interest in the challenges and opportunities this question presents. For instance, how do we bring about the lifestyle changes required to improve diets or physical activity levels – behaviours known to lead to better health and well-being?
One way is to work in collaboration with service providers that have regular contact with young women and their families, to equip frontline practitioners with additional skills to more effectively support such lifestyle changes. It is clear that healthcare information on its own is not enough to bring about change; people need to be empowered to make a change. There’s no point just telling them what to do or giving them an information leaflet – think about the last time someone told you what to do or gave you a leaflet … how did you feel and what did you do? People need to feel the advice is relevant to the lives they are living right now, need to want to make the change, feel capable of making that change, and can find a way to overcome any barriers to such a change. Change is not easy, does not occur in isolation and there are often many barriers within an individual’s world that make it difficult.
Launched by the Infant and Toddler Forum (ITF) in March 2016, “Ten Steps for a Healthy Pregnancy” (Box 1) is an online resource and factsheet designed to offer healthy lifestyle advice for mothers-to-be. It is supported by the National Obesity Forum, the Association for Nutrition and the Pre-school Alliance. The Ten Steps may be accessed online by women themselves or used as a guide by health visitors, midwives and other healthcare professionals (HCPs) during routine visits. Initial feedback on the use of the Ten Steps has been largely positive with HCPs considering the resource a valuable addition to their toolkit and mothers-to-be finding the information relevant, easy to understand and realistic. But how many of them actually implement some or all of the Ten Steps? How can we support them to take their own first steps towards adopting the Ten Steps?
Box 1
Ten Steps for a Healthy Pregnancy
- Take a daily supplement – of 10µg vitamin D throughout pregnancy and 400µg folic acid up until at least the 12th week of pregnancy.
- Keep physically active – aiming for at least 30 minutes of moderate intensity activity on five or more days per week.
- Aim for a healthy weight gain – this will depend on your pre-pregnancy weight and height. Expect to gain only 1-4 pounds (0.5-2kg) in the 1st trimester and the rest over the 2nd and 3rd trimesters.
- Choose nutritious foods, not extra foods. Extra energy (e.g. half a sandwich each day) is only needed during the last trimester.
- Balance your diet – base each meal on wholegrain starchy foods such as bread, rice, potatoes, pasta or breakfast cereals and include:
- 3 servings of milk, hard cheese or yogurt each day for calcium and iodine
- at least 1 vegetable and 1 fruit in both main meals and include fruit (fresh, canned or dried rather than juice) with breakfast
- meat, fish, eggs, nuts or pulses at 2-3 meals each day for iron.
- Eat fish twice a week – eat oily fish for omega 3 fats – if you don’t eat fish take a daily supplement of 200mg DHA but avoid fish liver oil supplements.
- Choose nutritious snacks – such as fruit, nuts, yogurt, a sandwich or toast rather than food or drink high in sugar or fat.
- Drink 6-8 times a day (1½ – 2 litres) – water is best. Limit caffeine to 200mg per day (about 1 shot of espresso or 2 mugs of instant coffee or 2½ mugs of tea).
- Eat safely – thoroughly cook meat, fish and eggs; wash all soil from vegetables and fruit and avoid vitamin A supplements, liver, liver pate, unpasteurised dairy products, soft and blue cheeses, swordfish, marlin and shark; limit tinned tuna to 4 small servings per week.
- Seek support – to stop smoking or misusing drugs or medication and avoid alcohol.
One barrier to greater use of the Ten Steps is the challenge many HCPs have in engaging their clients in sensitive or “difficult” conversations about their lifestyles. Topics such as weight control and obesity can be particularly hard to address. Over 50% of women in their late 20s and early 30s are overweight or obese, which is indicative of poor nutritional status. This applies just as much to the healthcare workforce as it does to their clients, and HCPs may be reluctant to bring up subjects that they struggle to address themselves. It can also be particularly difficult to offer advice to those who need it most. Vulnerable young women on low incomes living in the most deprived areas may be resistant to making lifestyle changes they feel they cannot afford or don’t feel able to put into practice; furthermore cultural or family beliefs and practices may conflict with health recommendations.
At the MRC Lifecourse Epidemiology Unit at the University of Southampton I have been part of a team developing a training course to equip frontline practitioners with “Healthy Conversation Skills” (HCS) (Box 2) to enable them to better support behaviour change to improve public health. This approach prompts people to come up with their own solutions to their lifestyle problems by asking them “Open Discovery Questions” (beginning with how or what) rather than just telling, suggesting or giving advice and information. HCPs are encouraged to take an empathetic person-centred approach and to avoid preaching, judging or providing rules for healthy living. The aim is to explore an individual’s world in order to support them to identify the first steps they feel they can take towards a healthier lifestyle for themselves and their families. Practitioners can then encourage the identification of relevant and realistic goals, and plans to reach these that fit within each individual’s life.
In discussion with the ITF, we developed a training course for frontline HCPs that would not only explain the Ten Steps for a Healthy Pregnancy but also incorporate HCS in order to build confidence in having conversations with families about them. From the outset it was agreed that the training course must be: 1) Accessible – with an emphasis on practical, achievable skills that frontline HCPs could understand and implement in order to support change and engagement with the Ten Steps; and 2) Short – primary care teams and childcare services are overstretched and cannot afford to lose staff to lengthy training courses. The course was therefore designed in two parts, each two hours long, resulting in a single half-day session. The first part concentrated on the Ten Steps themselves, explaining the rationale and evidence behind each one, using practical examples and quizzes to explore practitioners’ existing knowledge; the second part introduced practitioners to HCS and how to use these to engage families with the Ten Steps, using an interactive and participatory training approach.
Box 2
Healthy Conversation Skills
- Use Open Discovery Questions to support individuals to explore issues and identify solutions for themselves
- Reflect on their practice and conversations
- Spend more time listening than giving information or making suggestions
- Use Open Discovery Questions to support someone to make a SMARTER (Specific, Measurable, Action- oriented, Realistic, Timed, Evaluated, Reviewed) plan.
Between September and November 2016, 70 HCPs attended the Ten Steps/HCS course in five centres across the UK. In relation to the HCS training each HCP completed measures of importance, confidence and usefulness before and after training, and these all showed increases post-training. The training was rated at 9 out of 10 on average and feedback included: “Made me see things in a different light & encouraged me to implement this into my practice”, “Will be more aware of techniques when talking with parents/staff”, “Practical exercises & demonstrations were useful”. There were very few negative comments or suggestions for improvements – a few people wanted more time for training, a few wanted less! After all HCS training we collect feedback and suggestions for improvements, so are constantly evaluating the content and mode of delivery to ensure it is fit for practice and suits the range of practitioners with whom we work.
In conclusion, an easily deliverable, short and highly-valued training course in the Ten Steps for a Healthy Pregnancy in conjunction with HCS supports HCPs to engage with women and empower them to make lifestyle changes in line with current recommendations that may have a significant impact on pre-pregnancy health, particularly among the most vulnerable and difficult to reach groups. In my work delivering “Healthy Conversation Skills” training in the UK and around the world, I have found practitioners to be receptive and eager to use these new skills in their work in communities to support people with differing lives, cultures, health issues and challenges. The application of these skills appears to be wide-reaching and universal, fitting with a philosophy of empowerment to build independent thinking and action. I am excited about the potential for this training and up for the challenge of introducing it to practitioners in the UK and beyond. I would love to hear your thoughts.