Critique of Qualitative Nursing Paper

Timmermans et al. BMC Pregnancy and Childbirth https://doi.org/10.1186/s12884-020-2786-5 (2020) 20:105 RESEARCH ARTICLE Open Access Socio-ecological determinants of lifestyle behavior of women with overweight or obesity before, during and after pregnancy: qualitative interview analysis in the Netherlands Y. E. G. Timmermans1,2, K. D. G. van de Kant1,3, J. S. M. Krumeich3,4, L. J. I. Zimmermann1,2,5, E. Dompeling1,3, B. W. Kramer1,2, L. L. J. Maassen1, M. A. E. Spaanderman2,6 and A. C. E. Vreugdenhil1,5* Abstract Background: Maternal overweight and obesity are related to several health risks in the periods before, during and after pregnancy including a higher risk of gestational diabetes mellitus, preeclampsia and preterm birth. At the same time, women’s daily life quickly changes in these periods. Therefore, we hypothesize that the value of determinants of lifestyle behavior within different levels of the socio-ecological model differ accordingly and influence lifestyle behavior. These dynamics of determinants of lifestyle behavior in the periods before, during and after pregnancy are unexplored and therefore evaluated in this study. These insights are needed to offer appropriate guidance to improve lifestyle in women of childbearing age. Methods: Individual semi-structured interviews were conducted before, during or after pregnancy in 26 women with overweight or obesity living in the Netherlands. Questions covered all levels of the socio-ecological model, i.e. intrapersonal, interpersonal, institutional and environmental/societal. All interviews were transcribed and coded. Results: Determinants at all levels of the socio-ecological model were perceived as relevant by women of childbearing age. Various determinants were mentioned including knowledge of a healthy lifestyle, social support, access to customized lifestyle guidance, and distance to healthy lifestyle supporting activities. The importance women attributed to determinants differed between the periods before, during and after pregnancy. Before pregnancy, child’s wellbeing as motivator for adopting a healthy lifestyle was mentioned less frequently than during and after pregnancy. Women described that the interplay and balance between determinants varied on a daily basis, and not merely per period. This was often expressed as fluctuation in energy level per day which influences their willingness to put effort in making healthy choices. (Continued on next page) * Correspondence: a.vreugdenhil@mumc.nl 1 Department of Pediatrics, Maastricht University Medical Centre (MUMC+), P. Debyelaan 25, 6229 HX Maastricht, the Netherlands 5 School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, P. Debyelaan 25, 6229 HX Maastricht, the Netherlands Full list of author information is available at the end of the article © The Author(s). 2020 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Timmermans et al. BMC Pregnancy and Childbirth (2020) 20:105 Page 2 of 11 (Continued from previous page) Conclusions: Findings of this study confirm the importance of determinants at multiple socio-ecological levels for shaping lifestyle behavior in women of childbearing age. The findings add to current insights that the perceived importance of determinants and their interplay differ before, during and after pregnancy. They influence lifestyle behavior decisions, not only per period but even on a daily basis, in particular in this phase of life. This perspective can be helpful in optimizing lifestyle guidance for women of childbearing age in order to prevent perinatal complications. Keywords: Lifestyle behavior, Socio-ecological model, Pregnancy complications Background An unhealthy lifestyle in the period before, during and after pregnancy is associated with an increased time to conceive [1, 2] and a broad spectrum of health risks, such as a higher risk of miscarriage, preeclampsia, gestational diabetes mellitus and caesarean section [3–5]. Moreover, maternal obesity due to an unhealthy lifestyle is related to harmful effects on the fetus, such as a higher risk of infants born large or small for gestational age, preterm birth, and admission to the neonatal intensive care unit [6, 7]. In order to change lifestyle in women of childbearing age to improve perinatal outcomes, it is necessary to understand which determinants of lifestyle behavior are important in this period of life. Critique of Qualitative Nursing Paper

When considering determinants of lifestyle behavior, the socio-ecological model is widely used to understand interrelations between personal, social and environmental determinants [8]. The model assumes that appropriate changes in the social environment will support behavioral changes in individuals by suggesting that behavior is determined on four levels: intrapersonal, interpersonal, institutional, and environmental/societal. In a systematic review of qualitative studies among the general adult population considering primary prevention and health-promotion activities, several determinants for participation in these activities were identified within the framework of the socio-ecological model, as summarized in Table 1 [9]. When supporting healthy lifestyle behavior by a lifestyle intervention it is of utmost importance to customize the intervention to the wishes and needs of the specific target population, in order to minimize barriers and maximize facilitators. Knowledge of the (value of) socio-ecological determinants of lifestyle behavior in a specific target population can lead to successful lifestyle behavior improvement [10, 11]. Thus far, lifestyle interventions with the aim to improve perinatal outcomes mainly focused on pregnant women. Although these interventions resulted in limiting gestational weight gain, disappointing effects were found on reducing perinatal complications [12]. It has been suggested that interventions earlier initiated, preferably already before pregnancy, have a higher chance on significantly reducing perinatal complications [13]. Moreover, continuation of a preconceptionally initiated lifestyle intervention during and after pregnancy might support in sustaining lifestyle improvements during a period in which women’s daily life quickly change. To be able to set up an appropriate lifestyle intervention, it is essential to have knowledge on determinants of lifestyle behavior in the specific population of women before, during and after pregnancy. When considering previous studies on determinants of lifestyle behavior conducted in women of childbearing age, survey studies showed that women wishing to become pregnant were interested in lifestyle programs, especially when tailored to the possibilities within the daily life of women [14, 15]. During pregnancy, health of the unborn child was an important motivator for adopting a healthy lifestyle [16–18]. On the other hand, pregnant women mentioned that being pregnant is a justification for not worrying about weight and pregnancy is a time to eat for two [16]. In addition, women reported that pregnancy-related complaints and lack of time and energy due to work commitments restrain from physical activity, and that they have limited knowledge on appropriate physical activity exercises during pregnancy [16, 19–23]. In the postpartum period, lack of time and energy were often mentioned as barriers for adhering to a healthy lifestyle [24–27]. Women with a history of gestational diabetes mellitus or preeclampsia described their limited knowledge about the complication and its consequences and how to deal with that due to lack of follow-up by health care professionals after a complicated pregnancy as a barrier for lifestyle improvement [24–26]. A part of the previous qualitative research on determinants of lifestyle behavior in women during and after pregnancy was based on the socio-ecological model [20, 22, 23, 27]. The majority of these previous studies did only consider determinants of one specific lifestyle habit (for example physical activity or smoking). Critique of Qualitative Nursing Paper

Exploring determinants of multiple lifestyle habits can be useful to increase insight in the complex multifactorial Timmermans et al. BMC Pregnancy and Childbirth (2020) 20:105 Page 3 of 11 Table 1 Determinants influencing lifestyle behavior in the different levels of the socio-ecological model Level Determinant Examples Intrapersonal Motivation to change Threat of disease Patients’ feelings of guilt and sense of responsibility Perception of improvement when performing prevention activities Knowledge and skills Knowledge on risk factors and what is healthy Knowledge on sources of guidance and advice Self-concept Self-esteem Self-confidence Patients’ beliefs and attitudes Prevention is not patients’ responsibility Faith in the effectiveness of prevention strategies Fear of side effects of prevention activities Resources (Lack of) financial resources Interpersonal Family and friends Social and peer support Institutional Health care professionals Having a dog as a pet stimulates physical activity (Lack of) trust in health care provider Judgmental approach Professionals’ lack of time Environment and society System interests Health care providers do not promote prevention activities Built environment Possibility of physical activity in the direct neighborhood, e.g. bike lanes, parks or pedestrian paths Cultural influence Dietary traditions Social norms Impact of (social) media Socio-economic impact (Lack of) balance between work and personal life Determinants influencing participation in primary prevention and health promotion activities adapted from the findings of Moreno-Peral et al. [9] and summarized in this table interplay between these habits resulting into overall lifestyle. Furthermore, in the periods before, during and after pregnancy it is hypothesized that daily life changes continuously. Previous studies did only consider determinants at a specific moment without taking into account the changes in daily life in women of childbearing age. Thereby, knowledge of determinants of making lifestyle choices in the preconception period is limited. Gaining insight in determinants of lifestyle behavior in women before, during and after pregnancy in the same study setting enables the comparison between these three life phases. Therefore, it will be possible to accentuate the specifically important determinants in each life phase. By exploring multiple level determinants, the acceptability and effectiveness of a lifestyle intervention initiated in the preconception period can be optimized. Critique of Qualitative Nursing Paper

Therefore, the aim of this study was to provide a comprehensive study on determinants of multiple lifestyle behaviors within the framework of the socio-ecological model in the periods before, during and after pregnancy among women with overweight or obesity. Methods Study design, participants and setting A qualitative study using individual interviews was performed to explore the determinants of lifestyle behavior in women of childbearing age. Women who wished to conceive within 1 year, pregnant women and women with a child younger than 1 year of age, with overweight or obesity (body mass index (BMI) ≥ 25 kg/m2 [28]), were included in the study. Women were excluded in case of having a hemodynamically significant heart disease, restrictive lung disease, congenital metabolic disease, diagnosis of intellectual disability according to the DSM5 criteria [29], bariatric surgery in the past, and having diabetes type II dependent on medication. Women represented all strata of society, with different educational levels, age groups, life phases and with or without previous (perinatal) health concerns. Table 2 outlines the characteristics of the participating women.

Twenty-six women, aged between 24 and 36 years, participated in this study. Five women had a child younger than 1 year of age and were wishing to conceive within 1 year. Therefore, these women were interviewed about Timmermans et al. BMC Pregnancy and Childbirth (2020) 20:105 Table 2 Participants’ characteristics Characteristic n (%) BMI category Overweight 8 (31%) Obesity 18 (69%) Smoking Yes 4 (15%) No 22 (85%) Ethnicity Western 24 (92%) Non-western 2 (8%) Educational levela Low 2 (8%) Middle 13 (50%) High 11 (42%) Marital status Not married 12 (46%) Married 14 (54%) Parity 0 8 (31%) 1 14 (54%) 2 2 (8%) 3 2 (8%) Pregnancy status Page 4 of 11 to the participants prior to the interviews. The first four interviews were conducted in the presence of the second researcher in order to reach agreement about the communication style, and the manner to approach the women during the interviews. Repeat interviews were not carried out. The mean duration of the interviews was 42 min and 11 s (standard deviation 13 min and 37 s). Audio recordings from the interviews, with permission of the interviewees, were used to collect data. The interview guide was developed and based on the socioecological model. The interview guide consisted of questions on current experiences regarding different aspects of lifestyle; smoking, nutrition and physical activity. In addition, potential barriers and facilitators of smoking cessation, and nutrition and physical activity according to the recommendations of the Netherlands Nutrition Centre and the Health Council of the Netherlands [30, 31] were asked. Questions in the interview guide covered all levels of the socio-ecological model. The full interview guide is presented in Additional file 1. At the moment no new insights could be extracted from the interviews and data saturation was reached participant inclusion stopped. This method was applied on two levels: 1) insights in determinants for lifestyle behavior that were relevant for the entire target group; and 2) for each subgroup; women before, during and after pregnancy.

Recruitment and ethical concerns Preconception 5 (19%) Pregnancy 12 (46%) their experiences in both of these periods. The interviews took place between February and June 2015 at Maastricht University Medical Centre, the Netherlands. Women who wished to conceive within 1 year, pregnant women and women with a child younger than 1 year of age, with overweight and obesity were the most suitable participants to achieve the primary aim of this study [32]. Critique of Qualitative Nursing Paper

Therefore, purposive sampling was used to specifically reach this target group. Subjects were recruited via midwifes, gynecologists or via advertisements in the lay press and social media. After women agreed to be approached by the researchers, the researchers discussed the aim and design of the study with the women by telephone or face-to-face. Twelve women declined to participate or did not meet inclusion criteria. Each woman that agreed to participate, was included in consecutive order. The researchers reinforced that it was not possible to give incorrect answers during the interviews. Critique of Qualitative Nursing Paper

During the interviews, the researchers devoted particular attention on a sympathetic approach of the women, and on not being judgmental. This qualitative study was approved by the ethics committee of the Maastricht UMC+ (METC 14–4-159) and all participants signed informed consent before the interviews took place. Interviews Data analysis Data were collected by using individual semi-structured interviews. Each interview was conducted by either YT or LM, two well-trained researchers who were unknown Directive content analysis as described by Hsieh and Shannon [33] based on the socio-ecological model was applied for data analysis. The socio-ecological model < 26 weeks of gestational age 6 (23%) ≥ 26 weeks of gestational age 6 (23%) Postpartum 4 (15%) Postpartum & preconceptionb 5 (19%) c Pregnancy complication Yes 3 (33%) No 6 (66%) All data are presented as n (% of the whole group of participants) a Educational level was divided in low (completed primary school), middle (completed secondary school or secondary vocational education) and high (completed higher professional education or university) b This group includes women who had a child younger than 1 year of age and were trying to conceive again c These numbers and percentages are related to the women of the postpartum group Timmermans et al. BMC Pregnancy and Childbirth (2020)

20:105 and the four levels that are identified within the framework of this model were the basis for the interview guide. After interviews were performed, audio recordings were converted into transcripts, and participants’ names were coded. Transcripts were reviewed carefully, and all text was highlighted that appeared to describe a determinant of lifestyle behavior. All highlighted text was coded using the four levels of the socio-ecological model wherever possible. Highlighted text that could not be coded into one of these categories was coded with another code that matches with the content of the highlighted text. Critique of Qualitative Nursing Paper

Subcategories within the four levels of the socio-ecological model were defined. In addition, determinants of lifestyle behavior that were relevant for a specific period (before, during or after pregnancy) were categorized separately. Interviews were independently coded by both investigators to control for inter-observer variation. Differences regarding codes were discussed by the two investigators until consensus was reached. Five women were wishing to conceive within 1 year (preconception) and had a child younger than 1 year of age (postpartum). Specific themes in the preconception or postpartum period that arose from the interviews with these women were assigned to the appropriate period. The interviews were transcribed in NVivo (NVivo qualitative data analysis software; QRS International Pty Ltd. Australia; Victoria Version 12). In addition, NVivo was used to code and to organize the data derived from the interviews. Transcripts and findings were not returned to participants. Both researchers kept a self-reflective diary to evaluate their own subjective views on the interpretation of the interviews. In this study, we adhered to the COnsolidated criteria for REporting Qualitative research (COREQ) guidelines [34]. Critique of Qualitative Nursing Paper

Results Analysis of the interviews showed three main themes that affect lifestyle behavior in the participants, which will be further elaborated: 1) determinants within the framework of the socio-ecological model; 2) specific determinants within the preconception, pregnancy and postpartum periods; 3) the dynamic nature and context in which people make choices. Determinants within the framework of the socioecological model In general, the interview data showed different determinants of lifestyle behavior in the target group within each level of the socio-ecological model.

The determinants that are highest valued by the participants are summarized in Table 3. Several examples are further explored below. The term “lifestyle” is defined as a Page 5 of 11 combination of multiple lifestyle behaviors including nutrition, physical activity and smoking habits. On intrapersonal level, participants experienced and believed that their wellbeing, physical fitness, body image and health could be improved by a healthy lifestyle. In turn, women mentioned that these convictions increased their motivation to adopt a healthy lifestyle. Participant 23 (25–29 years of age; parity 1; postpartum) Critique of Qualitative Nursing Paper