Predictors of engagement in postpartum weight self-management behaviours in the first 12 weeks after birth

Breast cancer survivors' experiences of barriers and facilitators to lymphedema self-management behaviors: a theory-based qualitative study

PURPOSE

Lifelong self-management plays a critical role in the prevention and management of lymphedema among breast cancer survivors. However, adherence to lymphedema self-management behaviors has remained suboptimal. Hence, we adopted a theory-informed method to elucidate the facilitators and barriers of lymphedema self-management for breast cancer survivors.

METHODS

In-depth semi-structured interviews were conducted between August and October 2022 in the lymphedema nursing clinic of a tertiary cancer hospital. The maximum variation sampling technique was used to ensure a diverse sample. The ITHBC (Integrated Theory of Health Behavior Change) framework was used to inform the interview outline and data analysis. Interview transcripts were coded line-by-line and mapped to domains in accordance with the ITHBC, using both deductive and inductive content analysis.

RESULTS

A total of 16 participants were interviewed (aged 35 to 67). Twenty-three themes (12 facilitators and 11 barriers) were mapped onto the three domains (knowledge and belief, social facilitation, and self-regulation skill and ability) of ITHBC as facilitators and barriers to lymphedema self-management. Three additional themes including limited treatment resources for lymphedema, inconvenience of lymphedema management, boredom and tedium of lymphedema self-management were categorized under the domain of other barriers.

CONCLUSIONS

Incorporating these findings into the ITHBC framework allows for a more systematic selection of theory-based strategies that may improve the design of effective lymphedema self-management interventions for breast cancer survivors.

IMPLICATIONS FOR CANCER SURVIVORS

Elucidating impact factors, especially facilitators and barriers, for lymphedema self-management adherence is essential for developing effective intervention programs to enhance breast cancer survivors' lymphedema self-management behaviors.

"Listening to understand," exploring postpartum women's perceptions of their social networks and social support in relation to their health behaviors and weight: A qualitative exploratory study

BACKGROUND

Postpartum is a critical period to interrupt weight gain across the lifespan, decrease weight-related risk in future pregnancies, promote healthy behaviors that are often adopted during pregnancy, and improve long-term health. Because the postpartum period is marked by unique challenges to a person's ability to prioritize healthy behaviors, a multi-level/domain approach to intervention beyond the individual-level factors of diet and activity is needed.

OBJECTIVES

The purpose of this study was to understand postpartum people's perceptions about the relationship between their social networks and support, and their health behaviors and weight.

DESIGN

We used a qualitative descriptive approach and in-depth interviews.

METHODS

Participants (aged 18+, 12-15 months postpartum, who had a pre-pregnancy body mass index ⩾25) engaged in one-on-one, in-depth interviews conducted via Zoom (n = 28). Additional qualitative data came from open-ended responses to an online survey (n = 84) and a personal social-network survey (n = 84). Qualitative analysis used content and thematic analysis in stages of deductive coding applying codes derived from social-network and support theories, followed by inductive coding.

RESULTS

Thirty-eight participants (38.4%) returned to or weighed less than pre-pregnancy weight. We identified two overarching themes grounded in social-network and support theories. They were: (1) normative influence impacts health behaviors, body image, and experiences of weight stigma, and (2) network social support is related to health goals and overall postpartum health. Postpartum networks/support hindered and supported participants' goals. Partners provided an important source of accountability but were often associated with barriers to healthier behaviors.

CONCLUSION

Our findings reinforce the importance of the social context when considering how to support healthy behaviors and weight during the postpartum period. Healthcare providers should focus on health indicators other than maternal weight, and those wishing to support healthy postpartum behaviors could focus on child and family health, rather than solely on maternal weight and health behaviors.

Effect of mode of delivery on postpartum weight retention: A systematic review and meta-analysis

OBJECTIVE

Retention of weight gained over pregnancy increases the risk of long-term obesity and related health concerns. While many risk factors for this postpartum weight retention have been examined, the role of mode of delivery in this relationship remains controversial. We carried out a systematic review and meta-analysis to determine the effect of mode of delivery on postpartum weight retention.

METHODS

Ten electronic databases including PubMed, Cochrane Library, EMBASE, Web of Science, MEDLINE, CINAHL, China National Knowledge Infrastructure (CNKI), Wan-Fang database, the VIP database and China Biology Medicine Database (CBM) were searched from inception through November 2022. Review Manager 5.4 was used to pool the study data and calculate effect sizes. For dichotomous data, the odds ratio and 95 % confidence interval were used to report the results. For continuous data, the mean difference (MD) and 95 % confidence interval were used to report the results. The outcomes were the amount of postpartum weight retention and the number or proportion of women who experienced postpartum weight retention. The Newcastle- Ottawa Scale (NOS) and GRADE Guidelines were used to assess the methodological quality of the included studies.

FINDINGS

A total of 16 articles were included in the systematic review and 13 articles were included in the meta-analysis. The results showed that the mode of delivery had a significant effect on postpartum weight retention, women who delivered by caesarean section were more likely to experience postpartum weight retention compared to those who delivered vaginally. Sensitivity analysis showed that the results were stable and credible.

CONCLUSION

Due to the limitations of this study, the findings need to be treated with caution. And, to better prevent the postpartum weight retention, future practice and research need to further focus on upstream modifiable factors.

Predicting lymphedema self-management behaviours in breast cancer patients: A structural equation model with the Integrated Theory of Health Behaviour Change

AIMS

To explore predictors of lymphedema self-management behaviours among Chinese breast cancer survivors based on the Integrated Theory of Health Behaviour Change, and to clarify the interrelationship among these variables.

DESIGN

Further analysis of a multicentre cross-sectional and survey-based study.

METHODS

A total of 586 participants with breast cancer were recruited from December 2021 to April 2022 in different cities in China. We used self-reported questionnaires to collect data. Descriptive analysis, bivariate analysis and structural equation model were performed.

RESULTS

The Integrated Theory of Health Behaviour Change is suitable for predicting lymphedema self-management behaviours. The final structural model showed good model fit. Social support, self-efficacy and lymphedema knowledge positively affected lymphedema self-management behaviours, directly and indirectly. Self-regulation acted as a crucial mediator between these variables and self-management. The direct path between social support and self-regulation was not significant. Lymphedema knowledge and social support also influenced self-management via illness perception, self-efficacy and self-regulation, sequentially. These variables explained 55.9% of the variance in lymphedema self-management behaviours.

CONCLUSIONS

The modified model based on the Integrated Theory of Health Behaviour Change fitted well in predicting lymphedema self-management behaviours among breast cancer patients. Lymphedema knowledge, illness perception, self-efficacy, social support and self-regulation directly and indirectly influenced lymphedema self-management behaviours.

IMPACT

This study provides a theoretical basis for the assessment and interventions of lymphedema self-management behaviours in breast cancer patients. Lymphedema self-management behaviours should be assessed regularly and comprehensively, taking these predictors into consideration to identify potential barriers. Further research is needed to explore effective interventions integrating these significant predictors.

REPORTING METHOD

This study was reported following Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist for cross-sectional studies.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contributed to the design or conduct of the study, analysis or interpretation of the data, or in the preparation of the manuscript. WHAT DOES THIS PAPER CONTRIBUTE TO THE WIDER GLOBAL CLINICAL COMMUNITY?: This study focused on identifying and predicting mechanism of self-management based on a theory of behaviour change. The results can be applied among patients with other chronic diseases or high-risk populations, and inspire the assessment and interventions facilitating self-management behaviours.

STUDY REGISTRATION

This study was registered as an observational study at Chinese Clinical Trial Registry: http://www.chictr.org.cn (ChiCTR2200057084).

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

For breast cancer patients with poor lymphedema self-management behaviour, attention should be raised among nurses and involved healthcare staffs that lymphedema self-management is multi-faced. Strategies targeted at improving social support, self-regulation, knowledge, self-efficacy and illness perception should be also addressed in lymphedema self-management programs, to facilitate more effective improvement of lymphedema self-management behaviours.

Factors associated with lymphedema self-management behaviours among breast cancer survivors: A cross-sectional study

AIMS AND OBJECTIVES

The purpose of this empirical study was to explore the current status and associated factors of lymphedema self-management behaviours among Chinese breast cancer survivors.

BACKGROUND

Breast cancer-related lymphedema is a lifetime concern for survivors and is currently incurable. Lifetime lymphedema self-management takes a significant role in preventing development and progression of lymphedema. Understanding influencing factors of lymphedema self-management behaviours can help to develop targeted intervention programs.

DESIGN

A multicentre cross-sectional study.

METHODS

From December 2021 to April 2022, a convenience sample of 586 participants were recruited at four tertiary hospitals in four cities in China. Self-reported questionnaires were used to measure socio-demographic characteristics, disease-and treatment-related characteristics, lymphedema self-management behaviours, lymphedema knowledge, illness perception, self-efficacy, self-regulation and social support. Descriptive analysis, bivariate analysis and hierarchical multiple regression were conducted. This study was registered at Chinese Clinical Trial Registry (ChiCTR2200057084), and was reported followed the STROBE checklist.

RESULTS

Breast cancer survivors reported moderate level of lymphedema self-management behaviours. Promotion of lymph reflux management was ranked the least performed self-management behaviours, while the affected limb protection management ranked the most. 36.2% of self-management behaviours was explained by exercise regularly, level of attention on lymphedema prevention, unclear about the tumour stage (vs. stage I), knowledge, self-efficacy, emotional illness representation and social support.

CONCLUSIONS

Lymphedema self-management behaviours of breast cancer survivors was insufficient. Performance of lymphedema self-management varied with different socio-demographic characteristics, along with different levels of knowledge, self-efficacy, perception and social support. All these identified predictors should be reckoned in assessment and intervention of lymphedema self-management behaviours.

RELEVANCE TO CLINICAL PRACTICE

This study addressed that breast cancer survivors' lymphedema self-management behaviours should be promoted. Focusing on identified predictors, further lymphedema surveillance, knowledge education or social facilitation programs are recommended to enhance their self-management performance and adherence.

Associations between social support and physical activity in postpartum: a Norwegian multi-ethnic cohort study

BACKGROUND

Social support is associated with higher self-reported physical activity (PA) in postpartum women, but it is unknown if similar association occur when using objective PA data. The aim was to explore the associations between social support and objectively recorded moderate-to-vigorous physical activity (MVPA) postpartum, and if associations differed across ethnic groups.

METHODS

We used data from 636 women who participated in the STORK Groruddalen cohort study (2008-2010). MVPA minutes/day in bouts of ≥ 10 minutes was recorded by SenseWear Armband™ Pro³ (SWA) over 7 days, 14 weeks postpartum. Social support for PA from family or friends was measured by a modified 12-item version of the Social Support for Exercise Scale. We used single items, family support mean score (6 items) and friends' support mean score (6-items) in four separate count models, and adjusted for SWA week, age, ethnicity, education, parity, body mass index and time since birth. We tested interactions between social support and ethnicity. Analyses were performed on complete cases and imputed data.

RESULTS

Based on imputed data, we observed that women who reported low and high support from family accumulated 16.2 (IQR: 6.1-39.1) and 18.6 (IQR: 5.0-46.5) MVPA minutes/day, respectively. Women who reported low and high support from friends accumulated 18.7 (IQR: 5.9-43.6) and 16.8 (IQR: 5.0-45.8) MVPA minutes/day. We observed a 12% increase in MVPA minutes/day for each additional increase in mean family support score (IRR = 1.12, 95% CI: 1.02 to 1.25). Women reporting high level of support from family on 'discuss PA', 'co-participation' and 'take over chores' accumulated 33%, 37% and 25% more MVPA minutes/day than women reporting low level of support respectively ('discuss PA': IRR = 1.33, 95% CI: 1.03 to 1.72, 'co-participation': IRR = 1.37, 95% CI: 1.13 to 1.66 and 'take over chores': IRR = 1.25, 95% CI: 1.02 to 1.54). Associations were not modified by ethnicity. No statistically significant association between support from friends and MVPA was observed. Similar results were found in complete case analyses, with a few exceptions.

CONCLUSION

Overall family support and specific forms of support from family were associated with MVPA across ethnic groups, while support from friends was not associated with MVPA postpartum.

Barriers and facilitators to a healthy lifestyle in postpartum women: A systematic review of qualitative and quantitative studies in postpartum women and healthcare providers

A healthy postpartum lifestyle is vital for the promotion of optimal maternal health, return to pre-pregnancy weight and prevention of postpartum weight retention, but barriers exist. We performed a systematic review that aimed to describe the barriers and facilitators to a healthy lifestyle in the first 2 years postpartum from the perspectives of women and healthcare providers. Databases were searched for eligible studies published up to 26 August 2019. Following thematic analysis, identified themes were mapped to the Theoretical Domains Framework and the Capability, Opportunity, Motivation and Behaviour model. We included 28 qualitative and quantitative studies after screening 15,643 citations and 246 full texts. We identified barriers and facilitators relating to capability (e.g., lack of knowledge regarding benefits of lifestyle behaviours; limitations in healthcare providers' skills in providing lifestyle support), opportunity (e.g., social support from partners, family, friends and healthcare providers; childcare needs) and motivation (e.g., identifying benefits of exercise and perception of personal health; enjoyment of the activity or food). We suggest intervention components to include in lifestyle interventions for postpartum women based on the identified themes. Our findings provide evidence to inform the development of interventions to support postpartum women in adopting and maintaining a healthy lifestyle.

Preventing Type 2 Diabetes in Women with Previous Gestational Diabetes: Reviewing the Implementation Gaps for Health Behavior Change Programs

Gestational diabetes mellitus (GDM) places a woman at high risk of developing subsequent type 2 diabetes mellitus (T2DM), particularly in the first 5 years postpartum. Engaging women in health behavior change during this period is challenging and current diabetes prevention programs were developed for middle-aged adults, all of which have limited the evidence on successful implementation for this high-risk population. In this review, we will first summarize the effects of existing diabetes prevention programs in women with a history of GDM. Second, we suggest that the programs need to be modified according to the facilitators and barriers faced by this population. Third, we propose that improving program penetration, fidelity, and participation is critical for population-level success. Finally, we outline the research priorities to improve the implementation of diabetes prevention programs for postpartum women with a history of GDM.

Decision-tables for choosing commonly applied inferential statistical tests in comparative and correlation studies

BACKGROUND

Nurse researchers are increasingly using a wide variety of inferential statistical tests. However, novice researchers might find choosing tests for their studies difficult, as a result of this variety.

AIM

To present structured decision-tables to help choose which statistical tests to use in comparative and correlation studies.

DISCUSSION

The wide spectrum of statistical techniques the authors identified in nursing research helped them to construct overview tables that researchers could use as a simple tool to help choose appropriate statistical tests for their studies.

CONCLUSION

The decision-tables provided in this paper are unique in that they are composed of commonly applied statistical techniques identified in nursing studies and structured to simplify the pathway to statistical test decision-making for a broad spectrum of study designs.

IMPLICATIONS FOR PRACTICE

Novice nurse researchers can use the decision-tables presented in this paper as a starting point to explore with research colleagues or supervisors the appropriate choice of statistical techniques.

Applying the chronic care model to prenatal care: Patient activation, productive interactions, and prenatal outcomes

OBJECTIVE

To demonstrate how the chronic care model can be applied in prenatal care.

METHODS

This study was conducted through analysis of data generated in the women's health and family medicine departments of one community hospital and two medical centers across three states (Georgia, Nevada, and Virginia). 159 low-risk obstetric patients were monitored throughout their pregnancy for patient activation and biometric measures including: blood pressure at each appointment, baby's gestational age at birth, and mode of delivery. Patient activation was assessed with the validated, licensed patient activation measure.

RESULTS

Patient activation was strongly associated with the Prenatal Interpersonal Processes of Care metric (F (2, 155) = 3.41, p < .05). Also, increased age, decreased Prenatal Interpersonal Processes of Care, fewer pregnancies, and increased diastolic blood pressure were associated with an increased likelihood of cesarean delivery and the model correctly predicted 81% of cases.

CONCLUSION

Women who identified as feeling more activated reported more positive pregnancy experiences, and women who reported more positive pregnancy experiences were more likely to experience a vaginal delivery.

PRACTICE IMPLICATIONS

Activated patients, more positive prenatal experience, and improved delivery outcomes can be achieved through applying the chronic care model.

Unexpected Effects of a System-Distributed Mobile Application in Maternity Care: A Randomized Controlled Trial

BACKGROUND

As pregnant mothers increasingly engage in shared decision making regarding prenatal decisions, such as induction of labor, the patient's level of activation may influence pregnancy outcomes. One potential tool to increase patient activation in the clinical setting is mobile applications. However, research is limited in comparing mobile apps with other modalities of patient education and engagement tools.

AIM

This study was designed to test the effectiveness of a mobile app as a replacement for a spiral notebook guide as a patient education and engagement tool in the prenatal clinical setting.

METHOD

This randomized controlled trial was conducted in the Women's Health Clinic and Family Health Clinic of three hospitals. Repeated-measures analysis of covariance was used to test intervention effects in the study sample of 205 patients.

RESULTS

Mothers used a mobile app interface to more frequently record information about their pregnancy; however, across time, mothers using a mobile app reported a significant decrease in patient activation.

DISCUSSION

The unexpected negative effects in the group of patients randomized to the mobile app prompt these authors to recommend that health systems pause before distributing their own version of mobile apps that may decrease patient activation.

CONCLUSION

Mobile apps can be inherently empowering and engaging, but how a system encourages their use may ultimately determine their adoption and success.

Women's Perceived Reasons for Their Excessive Postpartum Weight Retention: A Qualitative Interview Study

Introduction

Obesity in Sweden has doubled to 14% over the last 20 years. New strategies for treatment and prevention are needed. Excessive gestational weight gain has been found to contribute substantially to obesity, and there is a consistent association between postpartum weight retention and obesity later in life. We aimed to explore what factors women perceive as reasons for having substantial postpartum weight retention, to identify areas for new and improved interventions.

Methods

Qualitative interview study (semi-structured) using an emergent design. Fifteen women, with a postpartum weight retention ≥ 10 kg, were interviewed by a trained cognitive therapist. Eight women had pre-pregnancy BMI below 30 kg/m². Interviews were transcribed verbatim and data analysed using inductive manifest content analysis. Salient text passages were extracted, shortened, coded and clustered into categories.

Results

Participants reported no knowledge of current gestational weight gain recommendations or of risks for adverse pregnancy outcomes with excessive weight gain or postpartum weight retention. Excessive eating emerged as a common strategy to provide relief of psychological, emotional and physical discomfort, such as depression and morning sickness. Women perceived medical staff as being unconcerned about weight, and postpartum weight loss support was scarce or absent. Some women reported eating more due to a belief that breastfeeding would automatically lead to weight loss.

Conclusion

There is a need to raise awareness about risks with unhealthy gestational weight development and postpartum weight retention in women of childbearing age. The common strategy to cope with psychological, emotional or physical discomfort by eating is an important factor to target with intervention. The postpartum year is a neglected period where additional follow-up on weight and weight loss support is strongly indicated.