‘Program Proposal: Health
behavior change in prenatal smoking among teenage mothers’
By Aysha
Siddiqui
Final Project -Changing Health
Behavior
Walden University
Abstract
This
program proposal is designed to help young teenage mothers who are pregnant and
indulge into the negative health behavior of prenatal smoking. This program is
aimed at the population that mainly is found in low income groups, but not
necessarily limited to low income. The populations of teenage pregnant women
who are unable to understand the dangers of prenatal smoking to their unborn
babies are also present among the middle class or even upper class. There are
also many cases of prenatal smoking present in women over their teenage and in
their young adult life.
We
look at the dangers of prenatal smoking to the unborn child, the long term
health conditions that the newborn could be born with or capable of developing
as a result of prenatal smoking. It is observed in research that either these
pregnant teenagers are unaware of the dangers of their behavior or they are not
emotionally invested enough to make a deliberate effort in changing their
behavior. This is mostly valid in case of unexpected pregnancies and teenagers
dealing with it without family, social support.
The program proposal is
designed to intervene with the primary intention of safeguarding the future
health of the unborn child. The program uses techniques to appeal to the young
and stressful minds of young women, who may or may not be prepared for having a
baby. Case studies, visual arts techniques, presentations and support groups would
be the major tools to make the intervention effective. Looking at various
racial, cultural, non English speaking groups and varying income groups are
helped with customized programs that would cater to their language, cultural
and other social needs.
Introduction
Prenatal smoking is described
as smoking by pregnant women during the time before the birth of their child
while they are pregnant. This is a negative health behavior that can cause
major harm to the unborn fetus while it’s unborn and its later life with health
conditions arising out of this exposure. Prenatal smoking is also harmful to
the pregnant mother and her health.
According to the CDC
and the 2008 Pregnancy Risk Assessment and Monitoring
System (PRAMS) data from 29 states shows that 13% of women reported smoking
during the last three months of pregnancy. PRAMS is the surveillance branch of
CDC that collects data on maternal behavior before, during and after pregnancy.
Looking at the data collected and shown by PRAMS, we understand that, though
the number prenatal smoking cases have decreased, still there is a large
population still indulging in this negative health behavior. When collecting
data on smoking during pregnancy, PRAMS used two ways of reporting.
First includes self reporting by the expectant mothers and second
through a questionnaire filled out during birth certificate information. In
2005 the data collected from these two sources showed that the percentage of
women who did prenatal smoking was much higher than estimated by PRAMS. Data
was collected from 31 sites all over the USA. Andreka et al (2010) did a study
on 4,667 mothers to understand the behavior of pregnant women with smoking
during pregnancy and the risk assessments of this behavior. Their results
showed that 43.7% of the women continued to smoke during pregnancy and low
birth weight and preterm delivery cases were the highest among this group of
the population selected.
Background of the Issue
Ventura et al (2003) worked on looking at the trends of
prenatal smoking and the numbers that varied between 1990 and they year 2000. Their
purpose was also to look at the method of using birth certificates to monitor
prenatal smoking. The method of study was to analyze birth certificates from
all states (except California) and study the data provided on the birth
certificates. Their results showed that the numbers had gone down by 37% from
1989 to 2000 and smoking was highest among older teenagers and women in their
early 20’s.
The study concluded that the use of birth certificate data is a helpful
tool, however some changes need to be implemented that did happen in 2003 and
will make this tool even more effective now. However, relying on the data
collected from birth certificates mostly depends on self reporting and when
looking at our target population of teenagers and young women, then the
questions arises of reliability on self reporting.
Shipton et al (2009) debated over the same issue when they studied the
impact of self reporting on the data collected among teenage smoking girls who
were pregnant in Scotland. They concluded that if relying on self reporting to
identify pregnant smokers, then the numbers can significantly underestimated
and in Scotland ‘over 2400 smokers go undetected’ who are not able to then
participate in ‘smoking cessations services’.
Purpose of the Program
The need for a program arises from the fact that this
behavior is harmful to the mother, but much more harmful to the unborn child.
Prenatal smoking is still going undetected and being the basis for health
conditions in children after birth, in toddler hood and early childhood as
well.
Low Birth Weight (LBW): Research has shown a direct connection between Low birth
weight (LBW) and prenatal smoking. In fact, prenatal smoking has been now
labeled as one of the major reasons for low birth weight among certain groups,
communities. Windham et al (2000) interviewed 4,454 pregnant women to examine
the effect of smoking during pregnancy and birth weight. The method used was interviewing
by telephone and 99% of the sample was able to provide data. The results
confirmed increased risk of preterm birth and low birth weight with ‘heavier
maternal smoking’. These results were more among the non-white population
compared to the white population sample. The link between low birth weight and
prenatal smoking is a research that’s been done since a while now. Alexander et
al (1995) studied prenatal care and risks of delivering preterm and growth
retardation among infants. They found that prenatal smoking was the first
factor to control and target for prenatal interventions to prevent low birth
weight, along with other factors like nutrition and psychosocial health that
are still considered secondary.
Risks in later life of infants: Prenatal smoking is linked to many other health
conditions that can develop in later life of the infants that are born to
mothers who smoked during pregnancy. These conditions can vary from infant
retardation to development of ADHD (attention deficit hyperactivity disorder),
from lung function to weight problems and many other behavioral issues.
ADHD and Prenatal Smoking: Thapar et al (2003) study was intended to understand the
link between ADHD and smoking during pregnancy, and if this cause can be
combined with genetic factors as well. A sample of 1,452 twin pairs, ages 5-16
were selected and parents were presented with a questionnaire. The results
showed that though genetic factors were most important, but maternal smoking
during pregnancy was significantly related to development of ADHD among these
kids.
Infant Retardation and
Prenatal Smoking: Infant retardation can
be connected to prenatal smoking as well, though not a common condition to be
considered. Smoking has been in most research connected with compromise of cognitive
and achievement abilities, but some research connects it with prevention of
mental retardation as well. A study by Drews et al (1996) showed the connection
between mental retardation (MR) and smoking during pregnancy when 221 mothers
of children, suffering from MR and 400 mothers of children attending public
schools were interviewed face to face.
The effects of prenatal smoking are also related to
physical disabilities developed by the children. This includes breathing or
respiratory conditions and the health of organs like lungs and other repertory
organs. This was found by Hanrahan et al (1992) when they looked at the
Pulmonary function (PF) of infants born to mothers who admitted to having
smoked during pregnancy. Their study results showed that ‘maternal smoking
during pregnancy may impair in
utero airway development
and/or alter lung elastic properties’. The study ended hypothesizing that
prenatal smoking maybe linked to these infants developing ‘wheezing illnesses’.
All research like the some mentioned above confirm the fact
that prenatal smoking has effects of the health condition of the unborn child.
There is a need for more research on the issue and for development of
interventions plans that may or may not involve self reporting to improve
future health of children born to mothers who smoke.
Challenges to the Intervention Program
Among the population that is found to be the largest for
prenatal smoking mothers, Hispanic and African American teenagers are the most
common. The highest number still remains that of teenage or younger mothers in
their 20’s, from 1993 to until at least 2004 (PRAMS surveillance results,
2004).
Teenage attitude and behavior: This will be one challenge when the intervention is planned
because teenagers are the most challenging when planning a health behavior
change. Teenagers are full of such energy and defiant attitude, and there can
be a connection made between teenage pregnancies to a rebellious attitude. This
population is hard to convince and interventions are possible to give poor
results or even have no success. Mitsuhiro et al (2006) study on teenage
pregnancies and use of tobacco due to psychiatric disorders showed that there
were unfavorable conditions like ‘unstructured families, dropping out of
school, unemployment’ and more like these that contributed to high prevalence
of drug and tobacco use. These teens are facing so many other challenges,
risks, stressors in their lives and added to that is the very stressful
incident of pregnancy (almost all teenage pregnancies are unplanned). In such a
circumstance to have some defiant, self centered teenagers to comply with a
program that requires them to practice self control and change of habit of
smoking, can be a major challenge.
To overcome this challenge would need strategic planning of
approaching the teenage mothers through ways and mediums that are appealing to
their age, their attitudes. Peer pressure is a very vital factor in teenage
life and influence on teenagers. Peers and friends as a positive influence to
deter harmful health behavior have been observed among White teenagers who are
pregnant (Abrahamse, 1988)
and a strong community effect is seen on Hispanic teenagers. This would be a
helpful step in overcoming the challenge of getting the point through to the
teenagers.
Language barriers: Language can be a challenge when dealing with non English
speaking teenagers or young mothers. This would be valid among the high number
of Hispanic population living in the US and faced with teenage pregnancies. There
is a large number of non English speaking Hispanic who are also a major group
among the high school drop outs (Pew Hispanic center, 2003).
To overcome this challenge use of interpreters if the
teenagers are at school or most importantly at the care provider’s office is
very important. Our program would need to take into account the non English
speaking population and ay questionnaire or printed material involved will need
to be bilingual catering to the needs of Hispanic population that makes up a
part of the teenage population aimed for the intervention.
When considering the challenges of logistics then the
African American population living in low economic conditions would be hard to
reach. This would be hard if the volunteers involved are not familiar with the
culture and structure of the social psychology of these groups.
A training
program would be an integral part of this intervention program that would
include training in verbal communication, avoidance of certain topics and
provide preliminary counseling to troubled teens.
Theoretical Rationale of the Program
Self-efficacy theory: Self-efficacy theory would be the most active and
relevant theory in this program. Self-efficacy is a health behavior model and
also an important part of the Protection motivations theory and the Health
Belief Model. Self-efficacy is a measure of an individual’s confidence and
belief in his ability to change his behavior and reach goals. The teenagers are
young and feel strong about things around them, about their lives and to make
them believe that they are capable of giving up the habit of smoking would be
hard work, but it is possible and maybe the best way to motivate the teenagers.
After making them aware of the dangers prenatal smoking poses to their unborn
child, an approach of making them aware of their abilities to deal with the
problem would be part of the program.
Most groups are found in low income conditions and suffer
from psychological issues of self esteem, PTSD (unplanned pregnancy) and
depression. Group and individual therapy would be the first step to be offered
and helping develop self-efficacy would be an integral part of these therapy
sessions.
Social Cognitive Theory: Another theory that would be incorporated into this
program is that of Social Cognitive theory. This theory is based on the concept
that observed behavior of others in a social setting, experiences and
interactions can be the basis for altering an individual’s behavior. This
theory puts forward that individuals not only learn by trying different
behaviors, but they ‘replicate’ the behavior of others. A main idea in this
theory is of ‘vicarious learning’ which means the process of learning from
other’s behaviors. This means that individuals observe the behavior of others
and then copy that behavior if they observe good results from it. Otherwise,
they learn from the behaviors of others and then avoid that behavior.
This model would be the best way to create a valid program
of intervention for our target population of teenage and young mothers. There
could be presentations and support groups could include such mothers who have
had babies with LBW as a result of prenatal smoking. We could even invite such
mothers who have infants or children diagnosed with conditions, physical or
psychological as result of prenatal smoking. Introducing mothers and their case
studies as an observation for pregnant teenagers would be on the same idea as
‘vicarious learning’.
Marketing the program
As mentioned earlier in the part about challenges, the
communication gap with this population would be with the non English speaking
group, mostly Hispanic or Latino immigrants or not born in the US. This issue
could be handled with ways like hiring or having an interpreter be part of the
program, bilingual printing of all printed matter. If it’s not possible to have
all material translated at all times, then at least a few copies printed for
neighborhoods having a major Hispanic population.
Marketing of the program would concentrate mostly towards:
a)
Areas that are high numbers of unplanned pregnancies, irrespective of age since most of the unplanned
pregnancies do happen at a young age susceptible unhealthy behavior like
prenatal smoking.
b)
Low income groups and neighborhood with a high number of
teenagers and possibly high school
dropouts. This would also include places with more high school drop outs
altogether, since research has shown a relation between lack of education and
indulgence in prenatal smoking.
c)
High schools where in
the past teenage pregnancies have been counted and are rising. This program
could be incorporated into the sex education or physical education class.
d)
Printed information
and workshops could be offered at locations of non profits that are aimed at helping young mothers who are
pregnant and in a financial, emotional crisis. (These locations would also be
good sites for survey and data collection for the program).
e)
Labor and delivery sections of hospitals and if data is collected from a hospital that shows a high
number of mothers with prenatal smoking habit, then those health settings could
be the concentration for a more extensive intervention. This would include
adding printed material on the topic to the ‘post delivery’ phase and to the
material or the hospital bag handed to the new mother when leaving the hospital
with the baby.
Name for the program: The
name would need to be simple and
direct to get attention of the young people. It also needs to bring positive
energy and a positive aspect out of the current situation the teenagers or the
young mothers are finding themselves into.
The suggested name of the
program is:
‘Smoking
Cessation, You first step to motherhood’
Evaluation of the program
Program evaluation would be done by collecting data from
hospitals where the program was used and looking at neonatal lung or
respiratory cases of newborn babies.
It would
also be conducted by data collected from questionnaires presented to pregnant
teens and women present at the non profits where this program is being
introduced.
Evaluation would need to be in phases, where first
evaluation would be a few months after to check validation of the program.
After initial validations of the program is obtained, the next evaluation phase
may come after at least six months which could include the collection of data
on the health birth conditions like LBW, preterm labor and other neo natal
conditions of the newborns whose mothers were introduced the program during
their pregnancies or last trimester.
This could be treated as process evaluation and full or
outcome evaluation could come at about one year when we would follow up with
the health conditions of the infants that were born to the moms who actually
deter smoking during prenatal phase.
Resources for the Program
Resources needed for the implementation of this program
would be:
a)
The first and foremost
would need to be the primary and OB care providers to the teenage and young
mothers population we are going to target.
b)
Social services and
customer service management at hospitals where the program intervention printed
material will be presented or distributed.
c)
We would also need to
include services from an accounting or data collection firm, volunteers to
evaluate data.
d)
Neonatal staff and
care providers to the newborn babies of mothers who were target for the
intervention.
e)
The tobacco control
nonprofit of the local area would be a very good resource to find a more exact
population, neighborhood to target.
Conclusion
The program for prenatal smoking cessation is an optimal
way to improve the health of newborn babies born to mothers who have been or
are smokers. This program will help prevent physiological and psychological
conditions of infants, kids who were exposed to tobacco at a young age. The
cessation program incorporates tools like therapy, group support, service of interpreters
and aiming at the health of the mother and baby. This program is not only an
intervention for prenatal smoking cessation, but can also contribute to the
overall improvement of health, status and health behavior of teenage and young
pregnant women.
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