Health is a central issue and fundamental human right associated with increase in longevity of population ageing. The maintenance of health status and functioning with age is a critical factor impacting upon many other aspects of the lives of aged, their family and communities.

Ageing is a natural process which is inevitable and thus being the end of the human life cycle. Perceiving ageing with fear is recent phenomenon, it seems to be increasing each day, as world become more complex and moreover ageing is associated with decline in functional ability which affects all aged peoples. Aged have limited regenerative abilities and more prone to disease, syndrome and sickness than adults.

“Old age is an incurable disease,

You do not heal old age but

You protect, promote and extend it”. – James Sterling Ross

The number of persons above the age of 60 years is fastly growing, especially in India. India is the second most popular country in the world has 76.6 million people at over the age of 60, constituting above 7.7% of total population. The most obvious manifestations of old age are changes in physical appearance such as wrinkles appearing on the face, graying of hair, restriction of movements and more prone to chronic illness. Too frequently, older adults suffer from the emotional side effects of ageing such as feeling of distress and anxiety regarding their future, loneliness and social isolation. The major area of concern is the health of the aged with multiple medical and psychosocial problems which have an impact on functional ability of aged.

Functional disability in the aged is defined as an acquired difficulty in performing basic everyday tasks or more complex tasks needed for independent living Davidson. (2011).

The most common problem confronting aged people is functional disability that leads to dependency and institutionalization. The functional disability in the aged includes three dimensions: physical, emotional, and mental performance.

The population of functionally disabled aged is growing rapidly. The number of aged who suffered with functional disability due to arthritis, stroke, cognitive impairment, anxiety and emotional distress is expected to increase at least 80 percent by 2049.

Functional disability limits the autonomy of older people, introduces dependence, and reduces the quality of life and increase the risk of nursing home admission. Studies have shown that the proportion of aged persons who cannot move and are confined to their bed or home ranges from 77 per 1000 in urban area and 84 per 1000 in rural areas.

The family and community play a vital role in the care of a functionally disabled aged. The supportive care for aged with functional disability is the major concern which includes early rehabilitation with adequate nutrition, fluids, range of motion exercise, second hourly position changing; skin care and reviewing medical follow up. This will enable to prevent the development of complications such as infection, bed sore, constipation, movement incapability, urinary tract infection, deep vein thrombosis, muscle atrophy and contractures with resultant deformity in the aged.

Studies shown that majority (70%) of the aged over 60 years with functional disability are expecting the need of care by the caregivers to perform their daily activities. Caregivers are the one who is always present with the aged client, satisfying their needs and solving their problems. The caregivers of the aged may be their spouse, childrens or some other paid caregivers. The involvement of caregivers in caring the aged ones has been a help to create a great confidence in the aged to perform some kind of activities of daily living and also it has profound effect on aged reaction to medical treatment, emotional adaptation and rehabilitation. To implement the care for aged it is necessary that caregivers must be aware of functional disability in the aged to provide supportive care.

BACKGROUD OF THE STUDY:

By reviewing the bureau report 2009, globally aged population will increase from 595 million to 2 billion, a four fold rise by 2050, in terms of proportion 10% in 2000, 15% by 2025 and rise to 21.6 % by 2050.

Ageing population is an end product of demographic transition, the number of older adults aged above 60 years is increasing and they are becoming larger percentage of over all population.

In India, it is estimated that the elderly population has grown from 12.6 million in 1901 to 80.93 million in 2010 and India is the second largest country comprising aged in the whole world and is likely to touch 300 million within next half century. Data available from India suggest that almost 50 per cent of the elderly suffer from chronic diseases with the prevalence of diseases increasing with rising age from 39 per cent in 60-64 years to 55 per cent in those older than 70 years.

Research by the National institute of ageing reports that 80% of the aged are living with chronic conditions. Most of them are able to meet their own needs but only 25% of them require a special type of care. More than two third of the aged (22 %) live independently in a family setting. It is estimated that 10% of the aged need some form of long term care in the home.

Prevalence of various functional disabilities gradually increases with advancing age, starts at the age of 60 years and cause a growing need for help especially after the age of 65 years. Ageing process and changes in life style pattern such as chronic alcoholism, smoking, use of tobacco, sedentary life style, obesity, lack of exercise and improper nutrition during the young age has led a risk of chronic disease conditions among elderly population which results in 70% of disability making elderly more dependent on family and caregivers.

Eden. (2000) stated that old age is still perceived as a casual agent for seeking dependence in performing daily activities and the factors frequently causing dependency are age, gender, falls, illness etc.

A large population of today’s ageing is dependent on the family members for their health maintenance. Approximately 54% of the aged above 60 years are dependent, 24% of them are partially dependent and 22% of them are independent in performing their daily activities. The dependence on others for meeting the various needs will generate a felling of physiological and psychological dependence among the aged. The prevalence of unmet needs for functional disability in the aged due to vision problems is about 4.3%, 22.6% due to hearing problem, 32.5% due to immobility, 50% due to cognitive impairment, 62% due to difficulties in activities of daily living, 35% due to chronic illness, 25% due to psychological and social problems among those aged 60 and older.

The involvement of caregivers in caring the aged will help to create a great confidence in aged to perform some kind of activities of daily living. Approximately 4.1 million caregivers are involved in intense care giving. Hence the care giving is not only the responsibility of health professionals but also the family members, relatives, friends and even non- professionals who cares for the aged in home.

NEED FOR THE STUDY:

Advances in technology and the combination of high fertility and declining mortality in twentieth century have resulted in rapid and large number of aged people worldwide especially in developing countries. In every country, the proportion of people aged over 60 years is growing faster than any other age group.

Ageing causes numerous changes in the physiology of human beings which decreases functional ability. This in turn makes them dependent on caregiver. Inadequate care results in falls and depression among older adults.

Among the aged, the focus is not only on reducing disease related morbidity and mortality, but also on promoting optimal health and ensuring disability-free years. The literature states that the effect of functional disability will have an effect on quality of life among aged, as the aged become dependent where the caregivers should play a major role in taking care of such aged person. Caregivers are the one who is always present with the aged client, satisfying their needs and solving their problems. It is necessary that caregivers must be aware of functional disability in the aged to provide supportive care.

Investigator, during her clinical posting and community postings came across many aged with functional disability such as loss of control in body movements, functional immobility and associated coexisting illness who were dependent on their caregivers for their daily activities. While interacting with their caregivers the investigator came to know that they are not having adequate knowledge regarding the effects of functional disability and the care needed for the aged. Investigator felt that, aged with functional disability need some form of long term care in the home. If the caregivers had the knowledge they would help the aged in taking care of their health to prevent further complications. So the investigator felt the need to assess the knowledge regarding functional disability in the aged and its supportive care among caregivers to develop insight on the needs of older adults.

STATEMENT OF THE PROBLEM:

A study to assess the knowledge on functional disability in the aged and its supportive care among caregivers at selected settings in Chennai

OBJECTIVES:

To assess the knowledge on functional disability in the aged and its supportive care among caregivers at selected settings in Chennai.

To associate the knowledge regarding functional disability in the aged and its supportive care with selected demographic variables among caregivers at selected settings in Chennai.

OPERATIONAL DEFINITIONS:

ASSESS: In this study assess refers to the process of gathering information as expressed by the caregivers in response to the semi-structured interview schedule and analyzing it with the statistical method.

KNOWLEDGE: In this study knowledge refers to the awareness about functional disability and its supportive care as expressed by caregivers as response to the semi-structured interview schedule and analyzing to the statistical method.

AGED: In this study the aged refers to the people above 60 years who are available in the hospital and community.

CAREGIVERS: In this study the caregivers refers to the family members, relatives and paid non – professional persons in the age group from 21 years to 65 years who are taking care of the aged.

FUNCTIONAL DISABILITY: In this study the functional disability refers to deviations from the normal or customary function of an individual within any of the three dimensions i.e, physical, emotional or social skills necessary for an independent life.

SUPPORTIVE CARE: In this study the supportive care refers to the care which is provided to support the functionally disabled aged in meeting their daily needs.

SETTINGS: In this study setting refers to the place or type of surroundings from where the sample is collected i.e, community and hospital setting.

ASSUMPTIONS:

The knowledge on the functional disability in the aged and the supportive care among the caregivers will vary from adequate to inadequate.

The knowledge on functional disability in the aged and the supportive care among caregivers will be influenced by the selected demographic variables.

DELIMITATION:

The samples are the caregivers of the aged available in the community setting i.e, Thoraipakkam, Navalur and those admitted to the two hospitals i.e, V.H.S multi speciality and Dr.Kamakshi memorial hospital. Period of data collection is limited to one month.

PROJECTED OUTCOME:

The results of the study will project the knowledge levels of whom regarding various functional disabilities in the aged and the supportive care needed.

The knowledge levels will highlight the need for educating the caregivers on various problems of functional disability

By assessing this need, we can formulate the various methods of educating the caregivers on common problems of functional disability and it supportive care in the aged.

CONCEPTUAL FRAMEWORK

A concept is an image or symbolic representation of an abstract idea. Conceptual frameworks are interrelated concepts or abstractions that are assembled by virtue of their relevance to a common theme Polit and Beck (2001). It is a device that helps to stimulate research and the extension of knowledge by providing both direction and impetus. A framework serves as a spring board for scientific advancement.

A conceptual framework serves as a guide, to identify systematically and precisely defined relationship among the variables. It gives an idea to the main view and common theme of the research that is a visual diagram by which the researcher explains the area of interest.

MODEL:

The conceptual framework adopted for the study is based on “PENDER’S HEALTH PROMOTION MODEL (1987)”.

Health promotion is, “directed towards increasing the level of well being and self actualization in a given individual or group”.

This model focuses on the three aspects,

Modifying factors.

Cognitive perceptual factors.

Participating in health promoting activities.

MODIFYING FACTORS:

It refers to the situational, maturational, socio cultural, personal and biological factors.

In this study, it refers to the demographic variables like age, gender, marital status, educational status, occupational status, family income, type of family, any previous experience of taking care of the aged, relationship with the client, history of any present diseases in aged person, degree of physical dependency, hours spent in the care of the aged person, any previous information on functional disability in the aged and its supportive care.

COGNITIVE PERCEPTUAL FACTORS:

In this model, cognitive perceptual factors have important motivational significance. These variables can be modified through nursing actions.

In this study it refers to the knowledge of caregivers regarding functional disability in the aged and its supportive care in the aspects of disability in the aged, vision problems, hearing problems, loss of control in body movements, memory impairment , functional immobility, activities of daily living, importance of exercises, coexisting illness, psychological problems and family support.

PARTICIPATING IN HEALTH PROMOTING ACTIVITIES:

Participation of caregivers in this study is considered as one of the health promoting behavior as this will help the caregivers to be aware of their existing knowledge on functional disability in the aged and its supportive care, which enhance through the advices given.

CUES FOR ACTION:

The responses of the caregivers regarding their knowledge on functional disability in the aged and its supportive care provide cues for nursing action like reinforcement and also creating awareness in terms of early rehabilitation of functionally disabled aged with adequate nutrition, fluids, range of motion exercise, second hourly position changing; skin care, reviewing medical follow up, providing assistive devices, assisting in daily activities, emotional support, engaging in social activities, promoting comfort and psychological support.

MODIFYING COGNITIVE PERCEPTUAL PARTICIPATING IN HEALTH

FACTORS FACTORS PROMOTING BEHAVIOUR

KNOWLEDGE OF CAREGIVERS REGARDING FUNCTIONAL DISABILITY IN THE AGED AND ITS SUPPORTIVE CARE:

Information regarding health promoting behavior includes,

Disability in the aged

Vision problems

Hearing problems

Loss of control in body movements

Memory impairment

Functional immobility

Activities of daily living

Importance of exercises

Coexisting illness

Psychological problems

Family support

Participation of caregivers in the study and sharing information regarding functional disability in the aged and its supportive care

DEMOGRAPHIC VARIABLES:

Age

Gender

Marital status

Educational status

Occupation

Family income

Type of family

Relationship with the client

Any previous experience of taking care of the aged

Hours spent in the care of the aged person

Any previous information on functional disability in the aged and its supportive care

History of any present diseases in aged person

Degree of physical dependency

Reinforcement

Adequate knowledge

Eliciting the knowledge of caregivers regarding functional disability and its supportive care through semi-structured interview schedule

Moderate knowledge

Inadequate knowledge

Cues for nursing action

FIG.1 CONCEPTUAL FRAMEWORK BASED ON PENDER’S HEALTH PROMOTION MODEL (1987)

CHAPTER II

REVIEW OF LITERATURE

Review of literature aids the researcher to understand what already known in relation to problem of interest and what remains to be known. It helps to plan and conduct the study in a systematic manner. It is defined as reviewing and analyzing the work of literature in relation to the specified topic in research – Simai Haji Mati.

This chapter deals with selected studies and articles which are related to the objectives of the proposed study. For the present study an extensive review of literature relevant to study was undertaken and is presented under the following headings.

Part I: General information about ageing, functional disability in and its supportive care.

Part II: Studies related to functional disability and its supportive care in the aged.

Part III: Studies related to knowledge of caregivers of aged on functional problems and its supportive care.

Part I: General information about ageing, functional disability and its supportive care.

Ageing is the process of optimizing opportunities for health, participation and security in order to enhance quality of life as people age. It applies to both individuals and population groups. Ageing allows people to realize their potential for physical, social, and mental well-being throughout the life course.

According to Stephan John. (2009) Ageing is denoted as,

Young old – 65-74 yrs.

Middle old – 75-84 yrs.

Older old – 85 and older

Darnton. (1995),emphasized that quality of old age people depends mainly on psychological well being, perceived health status with independency in meeting self care needs.

Normal Ageing process:

The ageing process creates profound changes that there will be 1-2% decline in functional ability per year. Normal Ageing brings about the changes in physiological, Social and Psychological well being – Judith A. McCann. (2003)

Physiological aging process:

Changes in body composition, reduction in bone mass and strength, reduction in blood volume, reduced motility of the large bowel, changes in autonomic function, reduced elasticity of eye lens, high tone hearing impairment and reduced motor and sensory function.

Social and psychological aging process:

Feeling of distress, anxiety regarding their future, loneliness, depression, grief, sadness, and social isolation.

However, some of the above effects of ageing can be slowed by engaging in interventions that improves outcome in the health events.

Functional disability in the aged is defined as an acquired difficulty in performing basic everyday tasks or more complex tasks needed for independent living. It is an important health indicator in the aged, jeopardizing quality of life and causing heavy social impact with long-term institutionalization and increased use of medical care.

Reducing functional disability in the aged is a major challenge for public health- Frazil.(2005), performance in functional disability includes three dimensions: physical, emotional, and mental performance. Physical performance relates to the body’s sensory and motor function. Emotional performance is measured through the individuals’ adaptation to various events in their lives. Mental performance is evaluated through tests that measure the individuals’ intellectual and rational capacity.

The causative factors for functional disability are as follows:

Vision problems, hearing problems, loss of control in body movements, memory impairment, functional immobility, difficulties in performing daily activities, lack of physical exercises, coexisting illness, psychological problems and family support.

The effects of fundamental disability include walking, lifting objects, climbing stairs, reading standard-size print and hearing disturbances, short-term memory loss, disturbance in daily activities, disorientation to time and place, reducing mobility and social activities. The care necessary for the effects of functional disability are early rehabilitation with adequate nutrition, fluids, range of motion exercise, second hourly position changing; skin care, reviewing medical follow up, providing assistive devices, assisting in daily activities, emotional support, engaging in social activities, promoting comfort and psychological support.

By over viewing the various informations regarding functional disability in the aged will thereby helps the caregivers to prevent further complications and also provide supportive care for the aged.

Part III: Studies related to functional disability and its supportive care in the aged.

Felix. (2001) stated that disability is systemic; no body system is immune to its effect. From his statement it is evidenced that meeting the self care activities and physical maintenance are essential for managing the effects of disability.

Nandi Manju. (2002) stated that as ageing increases there will be decline in functional ability, which is compromised with good nutrition, assistive support, with psychosocial concerns and with medical care.

Steffen Been. (2005) proposed a statement that there will de decline in cognitive and functional abilities of old age due to continuous degeneration of numerous brain cells which aid them to obtain a fully dependable care from caretakers.

Frey. (2006) stated that decreased level of physical activity and growing number of chronic illness that often increase with age, frequently create vicious circle of illness, and related functional disabilities that has adverse effect on activities of daily living. In this statement, he highlighted that decrease in functional ability makes the individual to become more dependent and need constant support and supervision.

McDougall.(2006) conducted a cohort study to identify the prevalence of memory impairment among 265 older adults by means of survey method and the results showed that 29.4% (78 individuals) of them had memory impairment in the later adult period .He also concluded that those with declining memory are less aware of their deficits in meeting activities of daily living.

Human research center for ageing.(2006) stated that immobilization, loss of control in body movements and falls need not to be the consequence of living to advanced age all this may be prevented through muscle strengthening and range of motion exercise which has reported benefits of spontaneous activity by the old age people.

Stark.et.al.(2007) conducted a correlational study to assess the health status of functionally disabled aged under the supervision of institution and family by means of health indicator assessment scale and the results showed that the older adults who receiving the care such as adequate nutrition, fluids, range of motion exercise, second hourly position changing, skin care, reviewing medical follow up and participating in family activities are in the family are having moderate health status than the older adults in the institutionalized care.

Zbylut j. (2007) conducted a national survey to evaluate the health status of older persons and prevalence of common health problems among elderly above 60 years. The survey results shows that a large number of older persons were suffering from one of more age-associated chronic diseases like osteoporosis, osteoarthritis, dental problems, visual problems, cognitive impairment and depression which may impair their functional ability and quality of life.

Kart berg. et.al (2010) conducted a descriptive study to assess the functional ability among the aged by means of questionnaire in the aspects of physical, mental and social abilities and the study concluded that low functional ability lead to dependency and stressful environment for the aged which again increase the risk of complications.

Lawton and Brody.(2010) described that assessment of functional ability often includes evaluation of individuals ability to carry out activities of daily living which is an early sensitive indicator to promote quality of life of old age people.

From the above studies the investigator identifies the prevalence, impact of functional disability in the aged and the important aspects of supportive care for the aged. It helped to formulate the need for the study and also helped to identify the major areas which should be included while formulating the objectives.

Part IV: Studies related to knowledge of caregivers of aged on selected functional problems and its supportive care.

Skalska.et.al. (2007) conducted a cohort study with the aim to evaluate the knowledge on various areas of functional problems among 62 caregivers of aged at risk by means of questionnaire and the samples are (78% family members and 22% non related) results revealed that only 41% caregivers had knowledge on functional problems such as (vision, hearing, and memory problems in the aged) and 59% were not aware of functional problems mainly in cognitive and social problems.

Chelma.et.al. (2009) conducted a explorative study to identify the measures on management of functional problems of elderly among 629 caregivers by means of check list, the result revealed that 47% of them were aware on the common measures and 53% were unaware on common measures on management of functional problems among elderly.

Through these studies the investigator understands the importance of caregivers awareness on functional disability in the aged and its supportive care which helped me to formulate the tool.

CHAPTER – III

METHODOLOGY

This study was undertaken to assess the knowledge on functional disability in the aged and its supportive care among caregivers at selected settings in Chennai.

This chapter on methodology includes research approach, research design, setting, population, criteria for selection of sample, sample size, sampling technique, data collection tool, development and description of the tool, validity of the tool, pilot study, data collection procedure and plan for data analysis.

RESEARCH DESIGN

A non experimental descriptive design was chosen for this study.

RESEARCH APPROACH

Research approach was descriptive in nature.

SETTING OF THE STUDY

The setting of the study was chosen on the basis of feasibility, in terms of availability of adequate samples from hospitals and community.

Voluntary Health Services Hospital, Adyar, Chennai.

Dr.Kamakshi Memorial Hospital, Pallikaranai, Chennai.

Community- Thoraipakkam and Navalur.

POPULATION FOR THE STUDY

The population of the study consists of the caregivers of the aged in selected hospitals and in the community.

SAMPLE OF THE STUDY

The caregivers of the aged within the selected hospital and in the community who have fulfilled the inclusion criteria.

CRITERIA FOR THE SELECTION OF SAMPLES

Inclusion criteria:

The caregivers who are taking care of the aged with functional disability.

The caregivers in the age group of above 20 yrs.

Both male and female caregivers of aged people.

Caregivers who are willing to participate.

Exclusion criteria:

The caregivers who are included in the pilot study.

The caregivers of the aged who are independent in doing their daily activities.

Care givers who do not understand and communicate in Tamil or English.

SAMPLE SIZE

The sample size of this study is 60 caregivers of the aged people at selected settings, Chennai.

SAMPLING TECHNIQUE

Purposive sampling technique is used in this study.

DATA COLLECTION TOOL

The data was collected from the caregivers using semi-structured interview schedule.

DESCRIPTION OF THE TOOL

The tool prepared in this study was based on the information gathered from the review of literature; objectives of the study and the personal and professional experience of the investigator. It consists of two parts

Part – I: It consists of demographic variables like age, gender, marital status, educational status, occupation, family income, type of family, any previous experience of taking care of the aged, relationship with the client, hours spent in the care of the aged person, any previous information on functional disability and supportive care, history of any present disease in aged person and degree of physical dependency of the aged.

Part – II: It consists of 11 questions which have three parts to assess the knowledge on functional disability in the aged and its supportive care among caregivers using semi-structured interview schedule.

SCORING PROCEDURE:

In part II:

In first question, part (A) the correct option carries one mark; the incorrected option carries zero mark. In part (B) each option carries one mark.

For all other question from (2 to 11), The first part of each question carries one mark for each ‘YES’ option and no mark for ‘NO’ options. And the second and third part of each question carries one mark for each option.

Thus a total of 10×1=10 for first part of question

46×1=46 for second part question

38×1=38 for third part question

Total of 94 marks will be awarded under the knowledge regarding functional disability in aged and its supportive care among caregivers. It is interpreted in percentage as:

Adequate knowledge : Greater than 75%

Moderate knowledge : 50-75%

Inadequate knowledge : Less than 50%

VALIDITY OF THE TOOL

The tool used in this study was validated by the experts in the field of general medicine and Medical surgical nursing.

PILOT STUDY

The pilot study was conducted in Voluntary health service hospital, Dr.Kamakshi memorial hospital, Thoraipakkam and Navalur community area, Chennai from 20.7.12 to 25.7.12 after obtaining the permission from the respective heads of the organization.

Totally 6 caregivers (2 from each of the hospitals and community area) who fulfilled the inclusion criteria were selected purposively, to generalize the study. A

Despite the smoking ban making it illegal to smoke in enclosed public places, introduced in England in 2007, smoking remains one of the single greatest causes of preventable illness and premature death in the UK. (1) There has been a reduction in rates of smoking, but a challenge remains in targeting high risk, hard to reach groups such as pregnant women.

Smoking during pregnancy, or even passive smoking, can cause serious damage to the health of both mother and baby. (21, 3) Indeed, smoking in pregnancy is one of the main causes of premature births and miscarriages. It has been shown that women who smoke during pregnancy have 1.5 to 3.5 times more chance of miscarriage when compared to non-smoking women. (4) Some women continue to smoke due to evidence that smokers have smaller babies. However, this is due to a lack of oxygen, which can severely affect the baby’s growth and development as well as cause numerous health problems in the future.

The implications of smoking during pregnancy go beyond affecting the mother and her baby, creating additional burden to an already overstretched national health service (NHS). It has been estimated that the increased cost to the NHS of smoking during pregnancy is £1,500 per smoker. (5) Thus, it has been recommended by the NHS Centre for reviews and dissemination that pregnant women are offered intensive advice and support to stop smoking. They specify that a combination of prenatal counselling, 10-minute face-to-face contact, and the provision of tailored written material, can double quit rates to about 15%. (6) Furthermore, a systematic review of best evidence, as conducted by the Cochrane Collaboration, indicates that the benefits of smoking cessation programs for pregnant women are great enough to recommend that they become routine within antenatal practice. (7)

The need for routine antenatal smoking cessation programmes is unquestionable. Research conducted by the British Market Research Bureau (BMRB) in 2005 demonstrated that 32% of mothers in England smoked during the 12-months before pregnancy and continued to smoke during pregnancy. (8) Although nearly half (49%) quit smoking before giving birth, three out of ten (30%) started smoking again less than a year after giving birth. It has been proposed that this is because women are usually motivated to stop smoking for the sake of the baby rather than for personal, long-term health reasons. Therefore, not only is there concern for the one in six (17%) women who continued to smoke throughout their pregnancy, there is also a need to promote long-term abstinence within public health initiatives. Of note, rates of quitting are generally lower among heavy smokers who are unmarried, on a low income, and poorly educated. (9) Therefore, meeting this public health challenge is likely to require highly targeted strategies in order to reach some of the most at risk groups of pregnant women.

Helping pregnant women to stop smoking is notoriously difficult due to the stigma attached to smoking while pregnant. The associated shame experienced by many women acts as a barrier to seeking help, as well as openly discussing smoking habits when questioned. This places pregnant women and their babies at increased vulnerability of complications resulting from continuing to smoke. It also increases the pressure on healthcare professionals to communicate the importance of smoking cessation to pregnant women, which can increase workload and also damage the relationship between pregnant women and their healthcare providers. Healthcare professionals are, understandably, keen to encourage pregnant women to stop smoking due to the known dangers; yet this can add to the shame experienced by the pregnant woman as well as be interpreted as confrontational, thus making them defensive.

There is a clear need for a public health intervention targeted not only at pregnant women, but also at their healthcare providers. The healthcare professional is key to educating pregnant women about the impact of smoking on themselves and their baby. Furthermore, it has been found that self-management initiatives related to health behaviours are unlikely to be sustained without the support and endorsement of health professionals. (10) However, there appears to be a skills gap that needs to be addressed in order for healthcare professionals to be able to approach this sensitive topic in a way that empowers the pregnant woman.

The challenges posed by pregnant women who continue to smoke require the establishment of an evidence-based programme of care that is integrated into the routine care delivered throughout their pregnancy. It is proposed that such an initiative would comprise an advanced development programme for the training of healthcare professionals in behaviour change techniques and, more specifically, in motivational interviewing skills. These skills are becoming more popular within the healthcare setting as they provide a brief psychotherapeutic communication style aimed at increasing the likelihood that a person will attempt to change unhealthy behaviours such as, in this case, smoking.

Motivational interviewing is a patient-centred style of communication designed to help people resolve any ambivalence they might have about changing an unhealthy behaviour, thus recognising that even unhealthy behaviours offer perceived benefits to the person carrying them out. It attempts to guide people towards personally choosing to change their unhealthy behaviour, rather than imposing expectations of change upon them, something which is frequently experienced by pregnant women who smoke. (11) This technique is based on the premise that if a person chooses to stop smoking themselves, they are more likely to be successful at any attempts to quit smoking.

The motivational interviewing technique is based on the transtheoretical model of behaviour change. (12) According to this theory, to achieve permanent change people go through a process of five distinct stages: pre-contemplation (i.e. not yet acknowledging an unhealthy behaviour that needs to be changed); contemplation (i.e. acknowledging the unhealthy behaviour, but not yet sure whether one is ready or wants to change); preparation (i.e. getting ready to change, perhaps setting a quit date); action (changing the unhealthy behaviour); and maintenance (i.e. remaining abstinent). In this sense, motivation is something that gradually grows and thus can be assisted by health professionals who are well placed to assess motivation to change. (13) Furthermore, with continued support, relapse prevention strategies can lower the likelihood of women returning to smoking which, as mentioned earlier, does frequently occur when smoking cessation is not motivated by personal reasons.

This model illustrates that approaching the issue of smoking during, for example, a stage where the woman has no intention or desire to change might become a confrontational consultation. However, motivational interviewing can be used to empower pregnant women in a way that encourages progression through the stages of change process. Motivational interviewing techniques that can assist with this include utilising open questions that convey the message that there are no preconceived views or judgments being made about the pregnant woman and her smoking habits. Closed questions, on the other hand, are often leading and thwart with expectation. With motivational interviewing, the primary goal is for the pregnant woman to be an active participant in the conversation and not just a passive recipient of information.

The four core principles to motivational interviewing are: expressing empathy (i.e. reflecting on and expressing an understanding of the pregnant woman’s perspective); developing discrepancy (i.e. exploring discrepancies between attitudes and beliefs and actual behaviour, e.g. believing smoking is unhealthy but continuing to smoke); rolling with resistance (i.e. understanding the barriers to change experienced by the pregnant woman, as well as any resistance to change); and supporting self-efficacy (i.e. working towards increasing the pregnant woman’s confidence in her ability to quit smoking and cope with any setbacks). (14)

These four core principles can be taught to health professionals to enhance their communication skills within health promotion initiatives such as one that targets pregnant women who smoke. Such skills are most often utilised in face-to-face consultations, but can also be used over the telephone; they are not intended for use within group settings. The application of motivational interviewing skills is diverse and yet can be taught to all health professionals over a period of 2-12 hours, usually via workshops. (15, 16)

The training does not have to be overly intensive and once this skill is adopted it can be delivered merely via conversation during regular consultations with the patient. A recommended programme would be to provide healthcare professionals who work with pregnant women with a 2-day training programme and to monitor the integration of these skills into practice. The advanced communication skills gained from the training, after practice, can become second nature and part of everyday practice. Indeed, motivational interviewing skills are transferrable to everyday face-to-face or telephone consultations. (17) Not only will these skills assist pregnant women in changing their behaviour, but they are also likely to prevent confrontations associated with the sensitive issues being addressed.

Evidence for the efficacy of motivational interviewing in helping pregnant women to stop smoking is strong. The most frequently adopted approach has been one in which smokers are provided with feedback, in a non-confrontational manner, intended to develop a discrepancy between their smoking behaviour and their personal goals. (18) Such a discrepancy is likely to lead to the uptake of any support that is offered to the pregnant woman as she commences attempts to quit smoking.

Karatay, Kublay and Emiroglu (2010) examined the effect of motivational interviewing on pregnant women (n=38) taking part in a smoking cessation intervention based on the transtheoretical model. (19) They found that 39.5% of the women were able to give up smoking, whilst 44.7% were able to reduce their rate of smoking by 60%. Rates of passive smoking pre-intervention, which were 86.8%, decreased to 55.3% post-intervention. Interestingly, mean self-efficacy scores increased substantially from 61.36 pre-intervention to 93.34 after the intervention. Not only had the motivational interviewing facilitated smoking cessation in some of the women, but it also reduced passive smoking and increased confidence in one’s ability to stop smoking and remain abstinent.

The important components of this intervention were reported to be the provision of information designed to raise awareness of the dangers of smoking, helping the woman identify and understand her reasons for smoking via a thoughts and feelings diary, and motivating the woman to consider any ambivalence she might have about quitting smoking. Other important components included helping the woman prepare herself for any quitting attempts by facilitating a decision regarding the method and date for quitting and putting in place methods to prevent passive smoking. It was also fundamental that sources of support were identified for helping the pregnant woman overcome any problems associated with giving up smoking so that she can succeed with her goal of being smoke-free.

In another study, where women (n=302) were randomly assigned to receive motivational interviewing or usual care, motivational interviewing was found to be relatively cost-effective. (20) The intervention comprised education about the impact of smoking on themselves and their baby, being helped to evaluate their smoking behaviour, and being taught skills that would increase their self-efficacy for smoking cessation and abstinence. The women were also provided with information on how to reduce passive smoking, as well as supported to set goals that would facilitate smoking cessation. At 6-months postpartum, for smoking cessation, motivational interviewing cost more for no additional benefit when compared to usual care. The motivational intervention did, however, prevent relapse more effectively than usual care, which in turn increased the cost-effectiveness of the initiative.

Some studies have reported low efficacy for using motivational interviewing with pregnant women who continue to smoke, but the majority of the evidence is in favour of the technique. (21) Even in the aforementioned study reporting low efficacy, fewer women in the motivational interviewing intervention reported that they were smoking more, when compared to the control group.

In order to deliver a training programme for health professionals involved in the care of pregnant women, organisational change will be necessary in order for new ways of working to be integrated into everyday practice. This will require the support of organisation Managers as well as commissioners who might fund a pilot study to test the effectiveness of training staff in motivational interviewing skills. In addition, input from the NHS, especially NHS Stop Smoking services, is likely to enhance the long-term effectiveness of such initiatives by acting as a resource for professionals to refer pregnant women for follow-up support.

The first step in the delivery of the initiative would be designing and conducting the initial training, which will be designed to develop communication skills in motivational interviewing during consultations. Importantly, however, according to a systematic review conducted by Soderlund et al. (2010), follow-up training or ‘refresher’ sessions might be necessary at appropriate intervals and this will need to be considered in terms of resource allocation. (22)

Velasquez et al. (2000) describe the process of training healthcare providers to use motivational interviewing with pregnant women, demonstrating that public health nurses and social workers are generally enthusiastic about attending training workshops and rate them as effective in preparing them to utilise motivational interviewing skills in practice. (23)

Hassel and von Rahden (2007), as part of a larger project, developed a 2-day programme of training in motivational interviewing for midwives. (24) The programme was designed around the stages of change model and focused on counselling skills that could be used to facilitate transition through the stages. This has also been referred to as ‘change talk’. (25) For example, techniques like the ‘Importance Ruler’ (used to assess how important smoking cessation or her baby’s health is to pregnant woman) were taught as a tool for progressing a conversation to the contemplation stage. It was found that this training provided the midwives with a greater array of practical tools they could use in their daily work. The skills that motivational interviewing practitioners need are those that are needed for enabling communication in all areas of healthcare: reflection, active listening and open-ended questioning. Therefore, the training is beneficial across all work the healthcare professional might be involved in.

Although motivational interviewing is more sophisticated than health promotion via the provision of written, it still incorporates information provision as a core element. However, the pregnant woman is coached and guided towards finding information and solutions for themselves. This provides the pregnant woman with options, which increases the effectiveness of motivational interviewing in eliciting change behaviour. Choice is seen as an empowering tool that can secure continued commitment to change (i.e. sustained smoking cessation).

A strong feature of skill development and mastery is that coaches continually learn and hone their practice from direct client experience. Reflection on practice in peer, expert and line managerial supervision is possible using motivational interviewing quality audit tools such. (26)

In measuring the effectiveness of this programme of training, a number of outcomes require assessing. The impact of the training on skills development and confidence in utilising these skills requires assessment via interviews or questionnaires with professionals who attended the training. Ideally, this needs to be done pre-training and post-training, as well as 6-12 months later in order to assess the long-term sustainability of any new ways of working.

Patient records will also require examination in order to track the rates of smoking in pregnant women, as well as the number of quit attempts (both successful and unsuccessful). Abstinence can be measured via self-report and tests for carbon monoxide. Furthermore, the monitoring of adverse events related to smoking could provide useful information on the clinical benefits of the programme.

Importantly, patient-reported outcome data can be collected via anonymous questionnaires eliciting information on service user satisfaction with the skills of healthcare workers, the content of consultations, and the usefulness of the support provided for issues such as smoking cessation.

Overall, the design and delivery of a motivational interviewing training programme for healthcare professionals requires a multidisciplinary approach. In turn, the evaluation of the outcomes of the programme requires a whole-systems approach that takes into consideration both objective and subjective short- and long-term benefits to tackling the public health challenge of smoking in pregnancy.

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