For the first time in Iran, this study examined the views and experiences of overweight pregnant women about the factors which are affecting the adoption of health promoting behaviors. The results showed that overweight pregnant women who referred to factors that could be an inhibitor or facilitator for choosing and adopting behaviors related to healthy lifestyle.
Evidence from various studies suggests that one of the strong predictors of changing positive behaviors for improving health is understanding the barriers to choose, adopt and adhere to such behaviors. According to the study by Amiri et al., personal and environmental barriers were extracted from interviews - positive understanding of status quo, studying, unwillingness, undesirable results, and low self-esteem were among the most important personal barriers and the lack of family support, culture, inadequate education, and the lack of environmental resources were among the environmental barriers to adopt a healthy lifestyle in adolescents . This is in agreement with the present study. According to the findings of this study, personal factors were expressed by the participants as perceived barriers, such as physiological changes in pregnancy, insufficient opportunities and motivation, internal negative feelings such as shame, fear and anxiety. Various studies indicated the effects of pregnancy-related changes on health-related functions that are consistent with the present study [19, 30, 31]. That is, in several studies, pregnant women reported that heavy weight during pregnancy is the barrier to physical inactivity [31, 32]. In the present study, large abdomen, heavy weight and tiredness during pregnancy were mentioned as factors which have been involved in reducing physical activity. According to Weir et al., obese pregnant women reported physical and mental changes during pregnancy as individual barriers to physical inactivity . Also, African American women who were participating in the study of Befort et al. stated that an increase in eating habits in pregnancy would lead to weight gain . Based on the findings of other studies about pregnant women, they think that they are two people who need more food and rest [33, 34].
In this study, the lack of enough opportunities for behaviors such as physical activity, the preparation of the desired food and being with friends and recreations, were mentioned as important factors especially for the working pregnant women, and those who have children. This finding is in line with the results of other studies. Despite that insufficient time could be due to the culture of the Iranian community, in which, housekeeping and parenting is among the responsibilities of mother, which was more pronounced for the working women, lack of motivation and proper health habits were among the personal factors. One of the important factors was the lack of physical activity. In the study of Geense et al., as stated by the health care providers, lack of motivation is what leads to disregard for the healthy behaviors on the part of the women . It seems that the lack of awareness of the consequences of ignorance of health behaviors is a reason for not participating in these behaviors. As noted in the study by Sue et al., gaining information about the consequences for the fetus led to an increase in motivation .
Connelly et al. (2015) reported that fears and worries of harming the baby were barriers to exercise for the pregnant women . Based on the findings of the present study, participants discussed anxiety, fear and stress during pregnancy, which had an impact on their mental health. They requested for the psychological counseling, which is not mentioned in other studies. One of the other important factors was self-confidence, or self-efficacy, which is also mentioned in other studies.
According to other studies, lack of support or health care providers, and the high living costs are major barriers to perform healthy behaviors, which are consistent with the current study. Cultural factors, lack of facilities and the way of treating pregnant women by health care providers, family problems and lack of awareness of the relatives were the barriers to adopt healthy lifestyle behaviors. Despite that, in other studies, these things are not detailed, but some of them are mentioned. For example, in Edwards et al., one of the factors which is influencing smoking is having a smoker husband . Or, in the study of Nikolopoulos et al., poor relationship with the health care providers and the inappropriate care were the contributing factors, such that care services were only for documenting the vital signs and the weight of pregnant women and, according to pregnant women, they did not receive appropriate counseling . Additionally, in the study by Connelly et al., community culture can be a barrier to adopt a healthy lifestyle that is consistent with this study . According to this study, the existence of patriarchal environment is a factor in not adopting healthy behaviors like participation in collective activities and outdoor activities, which has not been addressed in other studies.
Personal will, higher education, financial power and gaining information have been mentioned as the individual factors which are facilitating the adoption of health-related behaviors. According to the quantitative studies, self-efficacy and personal will have been reported as a significant predictor of health behaviors . Most studies have shown a direct relationship between the level of education of pregnant women and the adoption of health promoting behaviors such as physical activity and nutrition [38,39,40]. However, in the study by Walker et al., employment had no effect on the level of healthy behaviors. Although researchers have not achieved significant results in this quantitative study , but from the viewpoint of the participants in this study, higher education, which is a result of changes in modern life, plays an important role in increasing the level of awareness, employment and financial independence of women. What is important was that pregnant women pointed to university courses regarding family planning and pregnancy methods, which, would lead to an understanding of changes in pregnancy and help in choosing healthy behaviors by increasing their information. This was not directly mentioned in other studies, which can be due to the existence of educational differences.
Family support, especially by the husband, support from health care providers and the existence of an incentive environment, including education from the media, access to health facilities and other facilities specific to pregnant women was among the socio-environmental facilitators for health promoting behaviors. Family and social support is an important factor in enabling people to choose, adopt and keep up with healthy behaviors, which is also mentioned in other studies . The role of mass media in informing and receiving information from the Internet were often emphasized by women in this study. The participants in Edvardsson et al. (2011) found communication channels (face-to-face, telephone and Internet interviews) effective in changing their behaviors . In the qualitative study which has been conducted by Sanchez & Jones, the Internet, mass media (for example, TV), and health service providers have been reported as sources of information for health promotion, which is in agreement with the present study . It seems that by strengthening media education programs and creating valid internet sites for education, pregnant women can be supported in choosing appropriate behaviors.
According to our findings, special facilities, especially stadiums and parks which had been dedicated to pregnant women, were mentioned as facilitators of the adoption of a healthy lifestyle, especially physical activity, and this could be due to the culture of Iranian society. Also, despite that pregnant women emphasized the activities and adherence to group education classes, especially in terms of sharing information and experiences with other pregnant women, but they often sought specific advice, especially in terms of nutrition and psychology. This was not mentioned in other studies.
In general, it can be said that in order to improve the health of women, the use of individualized and aggregate strategies should be considered according to the needs of pregnant women. In this way, the best step can be women’s empowerment through increased levels of literacy and levels of participation in society for access to welfare and health. Increasing social support through training and implementing media plans should also be considered. Promotion and improving the role of men and their participation in women’s health is an important factor in this regard. Another important issue is the use of personalized counseling, in particular on the appropriate diet, physical activity, and psychological counseling for pregnant women. These strategies should be used by policy makers, planners, managers, researchers and healthcare providers to promote women’s health.
Strengths and limitations
In this qualitative study, only the experiences and views of overweight pregnant women are included as the factors which are influencing the adoption of health promotion behaviors. It seems that appropriate interventions are needed to review the opinions and experiences of family and health care providers. Also, most participants in this study had uncomplicated pregnancies, which may affect their perceptions and experiences. In addition, women with different body mass index, such as obese and lean, may also mention different experiences.