This chapter of the paper would explain on the introduction to this study and issues background. It would consist of problem statement, objectives, research questions, scope, significant of the study, limitations and some important terms that will be use in this research.

Introduction

Healthcare system in Malaysia is one of the crucial sector focus by the government. The healthcare services can be divided into public and private sector. There are many efforts done by the government to increase country healthcare quality such as by including healthcare aspects in formulating 10th Malaysia plan strategies that are:

Strategy 1 : Establish a comprehensive healthcare system & recreational infrastructure

Strategy 2 : Encourage health awareness & healthy lifestyle activities.

Strategy 3 : Empower the community to plan or implement individual wellness programme (responsible for own health)

Strategy 4 : Transform the health sector to increase the efficiency and effectiveness of the delivery system to ensure universal access

It showed government really concern in improving and fulfilling people healthcare necessity. The public healthcare in Malaysia consist of government public hospital and clinics. public and private sector has spend billion of money in providing better healthcare and it will continuing increase align with the increase of Malaysia population. According to country health plan in 10th Malaysia plan for 2011-2015, population of Malaysia has increase till 28.3 million and 2.32 million of it was immigrant and foreign workers. Moreover, 24.4 % from the total immigrants residing in Sabah. It means the number population will keep increasing from year to year. The more higher population would need the more good healthcare providers.

The public and health sector has invest lot of money in ensuring the current healthcare availability is enough in fulfilling people high demand. The table below shown total expenditure on health from 1997 to 2008. Therefore, in 23rd October 2009, prime minister YAB Dato Sri Najib Tun Razak established 1Malaysia clinics under 1Care programme of 1 Malaysia concept. According to the prime minister 1Malaysia concept is define as “…provide a free and open forum to discuss the things that matter deeply to us as a Nation. It provides a chance to express and explore the many perspectives of our fellow citizens. What makes Malaysia unique is the diversity of our peoples. 1Malaysia’s goal is to preserve and enhance this unity in diversity which has always been our strength and remains our best hope for the future. I hope this Website will initiate an open and vital dialogue exploring our Malaysian identity, purpose, and direction. I encourage each of you to join me in defining our Malaysia and the role we must play in its future. Each of us despite our differences shares a desire for a better tomorrow. Each of us wants opportunity, respect, friendship, and understanding” (1Malaysia Booklet). The definition of 1Care Malaysia is national health restructuring system that provide more choice of quality health care, better healthcare coverage that require by the population based on solidarity and equity. This new system should improve old system by providing new effort in enhancing people healthcare quality (Maimunah binti A hamid, 2010).

1Malaysia clinics objective is to provide affordable and quality healthcare treatment to the local residents especially for middle and local income group. It manage by medical assistance and only applicable in handling minor treatment and limited medicine prescription. Currently, there are 100 clinics with additional RM 17.2 Million budget (Nes strait times, 2012). In sabah only there are 20 clinics and 2 (Sulaman sentral kota kinabalu and Bandar Leila, Sandakan) of it has been upgraded to Klinik Kesihatan. The upgraded of 1Malaysia clinic to become Klinik Kesihatan is because the positive response from loal residents and the clinic received more than 100 patients per day. The upgraded is hope to provide better services to the people with extra expertise (Utusan, 2012).

TOTAL EXPENDITURE ON HEALTH, 1997-2008

(RM, NORMINAL VALUE)

Year

Expenditure on Health (RM million)

Expenditure on Health as % of GDP

Total GDP (nominal value) (RM million)

1997

8,213

2.9

281,795

1998

8,966

3.2

283,243

1999

9,743

3.2

300,764

2000

11,516

3.4

342,612

2001

12,520

3.7

334,309

2002

13,620

3.8

360,568

2003

19,164

4.6

418,769

2004

21,378

4.5

474,048

2005

21,915

4.2

519,451

2006

24,788

4.3

572,555

2007

30,228

4.7

641,864

2008

35,149

4.7

740,721

Source: Malaysia National Health Accounts 2007

PROBLEM STATEMENT

Malaysia government has established lot of healthcare effort in order to increase public health quality for example 1Malaysia clinic and klinik kesihatan. These two clinic is related to each other and offer almost the same system of service delivery and purpose. This study conduct to identify the comparison between these two clinics based on certain aspects of effectiveness. There are a few issues arise related to these government healthcare program. The first issues is related to the reliability of 1Malaysia clinics services, the concern shows by president of the Malaysian medical association (MMA), Dr. David Quek. He said that the establishment of 1malaysia clinic provides low healthcare standard system because it operates by medical assistance and nurses only. He also reminded the ministry, the limitation of knowledge among medical assistance and nurses in giving medical advices and medicines would affect the healthcare services in Malaysia (the sun, 2010). It not aligns with the modernization of Malaysia and this kind of system similar with healthcare system during world war. He also showing concern related to 1malaysia legality, according to Medical Act 1971 its illegal for a medical assistance to manage a clinic (the star online, 2009).  The provision referred by Dr David Quek is Medical Act 1971 Section 33. (1) (f), the section stated:

“33(1) Any person not registered or exempted from registration under this Act who – (f) uses the term “clinic” or “dispensary” or “hospital” or the equivalent or any of there terms in any other language in the signboard over his place of practice in purported practice of medicine or surgery as a person registered under this Act; shall be guilty of an offence against this Act.”

It showed that there are some doubt by the public related to the 1Malaysia clinic effectiveness. The effectiveness of 1Malaysia clinics is a major corcern to the public because of the high cost of establishment. Government allocated RM 10 million for 50 clinics in 2010 and RM 7.2 Million in 2012 for adding 20 more clinics, it cost lot of country money allocation for established all clinics for the public (Bernama, 2012). The failure of this clinics can cause loss to the country with the high expenses given. After establishment of 1Malaysia clinic, government came with another idea for improving people healthcare quality especially for middle and low income group by upgrading the 1Malaysia clinic into klinik kesihatan. For those 1Malaysia clinic that exceed 100 patients per day, the clinic would be upgraded to klinik kesihatan and 1 doctor would be provided. Klinik kesihatan as a replacement of 1Malaysia clinics guesting to provide better service and medication compare to before the upgraded.

This study will focusing on comparing between 1Malaysia clinics and Klinik kesihatan in a few effectiveness aspects. It also hope to answer a few main questions related to the improvement of services between before and after upgraded. In Malaysia there is limited proper study done related to the evaluation of this healthcare program especially when it related to the 1Malaysia clinics. it also very difficult to find comparison study between government clinics for such as 1Malaysia clinic and klinik kesihatan.

By conducting this study, it may assist in evaluate whether this program that cost RM 10 Millions is resulting good result for the public. In addition, this study also may help in figuring out the relevant of 1Malaysia clinic implementation and service changes happened through the upgrading process.

Objectives

To identify comparative analysis between 1 Malaysia clinic and Klinik Kesihatan in term of:

Accessibility

Availability

Treatment

Staff services

Environment

Waiting time

Research questions

Comparative analysis between 1 Malaysia clinics with Klinik Kesihatan:

What is the people preference between 1 Malaysia clinic and Klinik Kesihatan? Why?

What are the rationale the establishment of the new healthcare program, 1Malaysia clinics compare to existed government health clinics?

What are the differences between these two clinics:

Which of the clinics provides better accessibility to the patients?

Which of these clinics better in term of availability?

Which of these clinics provides better health treatment to the patients?

Which of these clinics provides friendlier services to the patients?

Which of these clinics provides a better treatment environment?

Which of these clinics provide better waiting time?

Scope Of Study

This study will be conducted at Klinik kesihatan Sulaman sentral, kota kinabalu sabah. The respondents of this study consist of representative of health ministry, both clinics staffs and patients.

SIGNIFICANT OF STUDY

This study is significant as a feedback to the policy maker. The policy maker is refer to government especially ministry of health that responsible in formulating and implementing any healthcare programs. Result of this thesis can be use as one of the feedback especially to 1Malaysia clinics and Klinik Malaysia implementation. Not only that, policy makers also can beneficial from this study by referring to the findings and it can give them some ideas related to the current service quality provided and from the analysis also it can be use as one way to improvise the healthcare practices in the future.

The other beneficial gain from this study is as a contribution to the body of knowledge in this discipline. In Malaysia, there were very limited past research done related to government healthcare services especially comparative study between two government clinics. Most of the past study only focusing on on customer satisfaction and comparison between public and private clinics only. The study conducted can be as one of the reference and source to the future researchers because it rare to find any comparative study related to the two government healthcare services especially related to 1Malaysia clinics. It is because 1Malaysia clinics is still in progress and new programs that established by the prime minister under 1Malaysia concept in 2009.

Besides that, this comparative study between 1Malaysia clinic and Klinik kesihatan can be as one of the information sources for the public. It because public has lack of information related to these clinics and only a few people notice about the upgrading and changes happened. Through this study, it can provide some understanding to the public about the public clinic system and the reason of upgrading of 1Malaysia clinics. Finally, they can realize the government effort in providing better healthcare to the people especially for the middle and low income group.

LIMITATIONS

The first limitation is difficulty in searching for past research. There lack of study done related to healthcare service in Malaysia especially in comparing between government healthcare services. It can be a challenges to the researcher in finding past research related to the 1Malaysia clinics and Klinik kesihatan because of it a new programs and no focus done related to this topics. Result from the difficulty, it hardly to find strong statement to support details in this research.

The second limitation is in analysis the information. This study is a qualitative research and the information gain from interviewing respondents from ministry of health, clinics staff and patients that experienced the services. It means the information gather from the interview, it can be a limitation to the study to observe the body language of interviewee carefully and at the same time make sure all the interview details taken taken into account.Furthermore, it also a challenge for analysis the information received and make ensure the result is based on the actual interviews. In order to overcome this limitation, the researchers has use another way of recording the conversation so at the interviews conducted all the attention can be given in asking, understanding and observing the respondents.

Limitation also exist in finding the right patient respondents, it because the respondents should be someone who has been received treatment from both 1Malaysia clinic and klinik kesihatan so the information given more reliable and convenient if the patients experiencing both clinics treatment. It would be time consuming for search the right respondents to be interview.

Hypertension

Hypertension or increased blood pressure is a major US health problem attracting the attention of public, physicians, and medical organizations. The aim of this thesis is to provide a brief yet a comprehensive review of the problem.

The definition of high blood pressure or hypertension is increase in the pressure exerted by the blood on the arterial walls as it passes through. Blood pressure reads as two numbers (for example 120/80). The nominator expresses the pressure within the arteries as the heart contracts (systolic), while the denominator points out the pressure within the arteries when the heart is in the relaxation phase of the cardiac cycle (diastolic). The normal blood pressure reading is 120/80 (+/- 10) mm Hg, with every increase of 20/10 mm Hg, cardiovascular risks of the disease double. Many believed that rise in the diastolic pressure is more risky than systolic rise. However, physicians know now that rise in the systolic blood pressure especially if sudden and unpredicted, is more risky and associated with strokes and cardiovascular accident especially above 50 years old (JNC report 7, p. 14-17).

Classification of hypertension according to severity considers the measured blood pressure. Normal individuals are those with a reading of 120/80 mm Hg. Individuals with blood pressure levels of 120-139 (systolic) or 80-89 (diastolic) are considered prehypertensive. Patients with stage 1 hypertension read measures of 140-159 (systolic) or diastolic reading of 90-99. In stage 2 hypertension, patients have higher systolic readings of more than 160 or diastolic more than 100 (JNC report 11-12). There are two points to stress in this context; first prehypertension is not a disease category. It means an individual is more prone to the risk of being hypertensive and it may be wise to look at his or her life style and recognize possible risk factors (obesity, smoking, overuse of alcohol…). Second, this classification does not consider the risk of other organs affected by hypertension (kidney, eye…); nor does it consider contributing factors to the disease (diabetes, renal disease) (JNC report 11-12).

Hypertension is also classified according to what causes it into two categories. First is primary or essential hypertension, which is more common with no clinically obvious cause for the disease. There may be some form of rigidity in the arterial wall (arteriosclerosis) because of precipitation of cholesterol plaques in the arteries walls. Genetic factors may play an important role in developing essential hypertension; however, identification of the possible gene(s) is not yet available. Hypertension may be a reflection of an underlying systemic disease. Chronic kidney diseases as renal failure result in renal hypertension. Renal hypertension may also result from an abnormality (narrowing) affecting the renal artery (renal artery stenosis). Diseases of the suprarenal endocrine gland (adrenal) may also cause hypertension. These diseases may be in the form of disturbed function as increased glucocorticoid (cortisone) secretion a disease known as Cushing syndrome. Alternatively, increased secretion of mineralocorticoids (adrenaline and nor-adrenaline) causes hypertension. This occurs mainly in cases of pheochromocytoma (an adrenal gland tumor). Secondary hypertension may also occur because of thyroid gland hypersecretion, or as more recently recognized, because of some sleep disorders (sleep apnea). It may be because of a major blood vessel abnormality as in cases of coarcitation of the aorta, or may be secondary to drug use as in chronic cortisone therapy (as an immunosuppressant drug) (JNC report 22-24).

Hajjar and Kotchen (199-206), performed comparative analysis of three National Health and Nutrition Examination Surveys (NAHNES), 1989-1991, 1991-1994 and 1999-2000 to identify the trends in prevalence, awareness and control of hypertension in the American population. Results of their study showed that nearly 29 percent of adults in USA suffer hypertension (that comes to over 58 million individuals). The results showed an increase of 3.7% in the prevalence of hypertension. The prevalence was highest in non-Hispanic Black American ethnic group (33.5%). As regards age prevalence, hypertension increases with advancing age. In this study, age group over 60 years old showed prevalence of 65.4%. Gender differences showed the disease is more prevalent in females of age group 65-70 years old (38% compared to 31% of males of the same age group). Increased body weight was significantly associated with hypertension. Awareness of the disease has increased by 6% during the period 1989 to 2000 and 58% of participants (total 5448 individuals) were under treatment, however, only 31% were controlled. Three groups showed the least rate of disease control; they were Mexican-Americans, females and individuals aged 60 years or older. Despite advances made in medications and treatment protocols, hypertension remains a major health problem of the American population.

Accurate measurements of blood pressure are the cornerstone of diagnosis and follow up. The device used is the sphygmomanometer; it may be mercury working (like the thermometer), digital or electronic. The risk of mercury escaping from its container led to the frequent use of other types; however, there are concerns about their accuracy. Therefore, these equipments need regular calibration and adjustment. On measuring blood pressure, the patient should be seated with the feet touching the ground, arms supported and with no previous exercise, smoking or drinking beverages for at least 30 minutes before the test. The examiner should take at least two readings and take the average. It is always more accurate to use the stethoscope (auscultation) method rather than feeling the pulse ((JNC report 18-19).

Evaluation of the hypertensive patient in a clinical setting aims at four objectives, first to assess the patient life style, for example types of food the patient eats, practicing exercise, kind of job, and how emotional the patient is. Second, is to assess cardiovascular risk factors as previous cardiac disease, presence of a major blood vessels anomaly, history of previous or chronic medications. Third, is to identify the presence of possible causes of hypertension (secondary hypertension) and the presence of coexistent diseases that may affect the treatment plane. Finally, is to examine the impact of hypertension on other organs as the eye and kidney. In a clinical setting, it is a better practice to measure blood pressure in both arms as significant difference may point to coarcitation of the aorta. General examination and heart examination are performed with eye fundus examination to fulfill the aims of evaluation. Abnormalities of the heart rate (reduced or increased) may signal higher cardiovascular risk. Laboratory testing usually begins by 12 channels electrocardiography to have full information on the patient’s heart. Laboratory testing aiming to assess the kidney condition includes testing for albumin, kidney function tests, and albumin creatinine ratio. Patients usually need blood tests to determine low-density lipoproteins (LDL), lipoprotein cholesterol study, and triglycerides as abnormalities may point to arteriosclerosis (JNC report 20-21).

In dealing with health problems, prevention and prophylaxis are always golden rules. Excess weight, increased dietary intake of sodium and decreased intake of potassium, lack of exercise and reduced intake of fresh vegetables and fruits are factors closely associated with the risk of hypertension. Obstacles to prevention, on individual level, are many. They include cultural reasons as regards the type and amount of food eaten, lack of healthy food choices at schools and working places, larger food serving in restaurants, and lack of exercise programs in schools. Communities serving civil societies are important partners in prevention. The proposal provided by the American Public Health Association to reduce sodium intake by 50% over 10 years to lessen hypertension risk is a good pattern of alerting the public with ways to prevent health problems (JNC report 15-16).

Hypertension is an important predisposing factor for coronary artery disease, congestive heart failure and chronic kidney disease, therefore it deserved the name ‘silent killer’ (Hypertension- ‘The Silent Killer’. Briefing statement of the Faculty of Public Health. The Royal Colleges of Physicians of the United Kingdom). The aim of treating hypertension is to lessen the risk of cardiovascular and kidney complications. All treatments start by modifying the patient life style. Adopting a healthy lifestyle in eating habits, exercise, moderation in alcohol use and stop smoking are essential both in prevention and in treatment. A Latin proverb accurately describes this line of prevention and treatment. It says Optima medicina temperantia est; which means moderation is the best medicine (Post Details: Latin Proverbs about Medicine: Physician, heal thyself (from <http://latin.bestmoodle.net.index.php/proverbia/2006/06/20/proverbia_about_doctors>).

The primary goal of treatment is to achieve a blood pressure level less than 140/90; treatment usually starts by recognizing unhealthy lifestyle behaviors and modifying them, if this fails to bring blood pressure level to normal, pharmacotherapy starts. Thiazide diuretics are the drug of choice to begin with in stage 1 hypertension, if a patient does not respond, a second drug (a bet blocker, a calcium channel antagonist…). In stage 2, it is justifiable to start with a combination of two drugs. More than 60% of hypertensive patients do not respond to one drug treatment, therefore the use of multiple drug therapy may be initially used either on separate prescriptions of in fixed dose combinations. The starting doses are usually below those mentioned in clinical trials, tailoring the dose according to follow up results follow. This is one reason why monthly follow up visits are important, although stage 2 patients may need more frequent initial follow up visits. Other reasons are to evaluate the efficiency of the drug combination used and to check for risk or drug side effects. When the patient reaches aimed blood pressure level, follow up visits can be every three-6 months (JNC report 26-32).

Despite advances in diagnostic techniques and drugs used, there are cases of refractory hypertension (difficult to treat), where drug combinations used do not achieve the treatment goal. Moser and Setaro (385-392) described a case of an obese old female (70 years old) who was receiving a fixed drug combination of three antihypertensive drugs (including a thiazide diuretic). Her blood pressure level was still in stage 2, in addition to these drugs, she received ibuprofen for osteoarthritis. This called for further advanced investigations as repeated blood pressure measuring in non-clinical settings (at home, at work or ambulatory measurements), and echocardiography. Advanced laboratory tests for possible causes of secondary hypertension (hormonal assessment, VMA, Valinyl Mandelic Acid, level for pheochromocytoma, investigating the aorta and renal arteries for abnormalities, and in view of the patient’s overweight, sleep lab studies) were performed. As all tests (except sleep lab studies) were negative, they discontinued ibuprofen, as it may predispose to hypertension, and was replaced by another safer drug (acetaminophen). The patient was seriously encouraged to reduce weight, and the diuretic dose was increased for fear of blood volume overload on the patient’s heart.

Based on the frequency of such refractory cases and because of advances made in diagnosis, pharmacotherapy and clinical trials suggested drug combinations. Moser (9-14), suggested an update to JNC report of 2004 that addresses the advances achieved in the last few years to shape an up to date guidelines.

Hypertension is a serious health hazard as it affects nearly one in four adult Americans. It increases the risk of cardiovascular accidents and stroke (causes number one and three as the common causes of death in the US). Its definition is rise of blood pressure above 140/90. There is a change of epidemiology trends in the last few years, in the form of increased prevalence. This calls for more efforts for prevention and updated guidelines for diagnosis and treatment.

Works Cited

US Department of Health and Human Services. National Institutes of Health. National Heart and Blood Institute. Complete Report: The Seventh Report of Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure. By Chobanian, A V. (Chair). 2004. 19/05/2008 <http://www.nhlbi.nih.gov/jnc7/full/pdf>

Hajjar, I and Kotchen, T A. Trends in Prevalence, Awareness, Treatment and Control of Hypertension in the United States, 1988-2000. JAMA. Vol. 290 (2) 2003. p. 199-206.

Moser, M and Setaro, J F. Resistant or Difficult-to-Control Hypertension. The New England Journal of Medicine. Vol. 355(4) 2006. p. 385-392

Moser, M. Hypertension Treatment Guidelines: Is It Time for an Update. The Journal of Clinical Hypertension. Vol. 9 (1) 2007. p. 9-14

Introduction

The object of this assignment is to critically appraise a health promotion initiative related to midwifery practice. The initiative chosen is a NHS Health Scotland leaflet entitled ‘Smoking: giving up during pregnancy: a guide for pregnant women who want to stop smoking’ (NHS Health Scotland 2003). It will be referred to as the ‘initiative’ or the ‘leaflet’ throughout this assignment.

The World Health Organisation (WHO) identified that health promotion was a way of equipping people to have more power enabling them to make choices in regard to improving their well-being (WHO 1986). Ewles and Simnett (2003) determine from this, that the fundamental elements of health promotion are improving health and empowerment. The Scottish Office paper ‘Towards a Healthier Scotland’ (1999) recommended making more health promotion available for pregnant smokers.

This appraisal will systematically review the literature relating it to the health promotion initiative chosen using Ewles and Simnett (2003) Five Approaches to Health Promotion model. It will furthermore evaluate the midwife’s role in promoting the issue highlighted and conclude with a summary and any proposals to improve future practice.

Critical Appraisal

The Scottish Office paper ‘Towards a Healthier Scotland’ (Scottish Office 1999) recommends reducing the numbers of women smoking during pregnancy from 29% to 20% in the next 5 years. According to the Health Education Authority (1999) the rate for smoking in pregnancy in the UK was 30% however nearly 90% classified smoking as dangerous to their unborn child. Johnston et al (2003) point out that smoking is the main preventable cause of disease and disability in the fetus and newborn. Around 13 000 individuals die from smoking in Scotland each year (NHS Health Scotland and ASH Scotland 2004a). This initiative is based on the normative needs concept as it is influenced by expert opinion and government policies (Ewles and Simnett 2003). Epidemiological evidence in its favour allows the initiative to be evaluated by reduction in the mortality and morbidity (Naidoo and Wills 2000). This is cost effective because the initial resources for implementing the smoking cessation will be significantly less than the cost of hospitalisation later in life (NHS Health Scotland and ASH Scotland 2003).

The leaflet that will be critiqued (appendix 1) is aimed at pregnant women who currently smoke but who want to give up. It is split into five sections titled: pregnancy and smoking; stopping smoking; tips for stopping; stopping smoking is worth it and thinking about your smoking.

The Ewles and Simnett (2003) model comprises of five approaches to health promotion; medical approach; behaviour change approach; educational approach; client-centred approach and societal change approach. The behaviour change approach is the main focus for this initiative, although it does utilise aspects of all approaches.

The behaviour change approach as described by Ewles and Simnett (2003) is a way of encouraging changes in an individual’s attitudes and beliefs to take up a healthier lifestyle. It is, however considered by some, to be more forceful depending on the degree of encouragement and persuasion utilised (Crafter 1997, Norton 1998).

The behaviour change approach uses a number of models to guide health promoters to facilitate clients to achieve a positive outcome. The Stages of Change Model (Prochaska and DiClemente 1984 as cited by Ewles and Simnett 2003) is a five stage cyclical model that has been found to be particularly useful in work with addictive behaviours (Naidoo and Wills 2000).

This cycle incorporates a pre-contemplation stage where the individual is unaware of any need for change or has no interest in changing (Ewles and Simnett 2003). At this stage the midwife would assess whether the woman is genuinely not interested in stopping smoking at present and respect this decision but inform her she will be asked throughout her pregnancy about her smoking status (Crafter 1997, Dunkley 2000). The leaflet may still be issued as having the information readily at hand may prompt the individual to think about stopping smoking. The advantages of leaflets mean they allow individuals to read through them at their own pace (Ewles and Simnett 2003).

The second stage is the contemplation stage where the individual is motivated to consider changing their behaviour, maybe she reads the leaflet and attempts to seek information (Naidoo and Wills 2000). The role of the midwife at this stage would be to determine why the woman smokes and what barriers she may face in stopping smoking (Dunkley 2000). The leaflet facilitates this by allowing the woman to question why she smokes and how she feels about it. It also seeks to establish what the woman feels is good and bad about smoking and how she anticipates changing her behaviour towards smoking. It has been suggested (McLeod et al 2003) that some midwives find it difficult to broach the subject of smoking particularly with women who have no desire to stop and those who are still considering stopping. However McLeod et al (2003) found from their qualitative study that women expected to be asked about smoking during routine antenatal care and indeed they felt it was part of the midwives role to ask.

The preparation stage is where the woman is committed to giving up smoking. She may seek extra help and is likely to attempt change soon (Dunkley 2000). If the woman is in this planning stage she may benefit from smoking cessation services, which the midwife can offer such as Smokeline, or other local services. Within the leaflet is a free phone number for Smokeline (HEBS 2003) who offer advice and issue the booklet ‘Aspire to Stop Smoking’ (HEBS and Action on Smoking and Health Scotland 2001). This supporting information helps the woman to discover what she can do to help herself to stop smoking. NHS Health Scotland and ASH Scotland (2004b) challenge the reliability of answers to questions Midwives and other health promoters may be asking individual’s with regard to their interest in stopping smoking as that individual may feel that agreeing is what is expected. Hesitancy in answering may be indicative of reluctance to commit to stopping at present, so ensuring they understand that there are many options available in the future can enhance the chance of them stopping (NHS Health Scotland and ASH Scotland 2004b).

The midwife would continue to support the individual during this time offering advice and encouragement (Crafter 1997) and also would remind the patient of the importance of social support from partners and friends (NHS Health Scotland and ASH Scotland 2004b). The findings from a study by McLeod et al (2003) concur with the need to have partner involvement. They found that although the women were supported by the midwives there was a failing in educating the partners to the women’s needs while trying to stop smoking (McLeod et al 2003). Moreover Thompson et al (2004) would like to see this expanded out with the antenatal setting. This issue has been addressed in part by the initiative, which encourages the woman to seek partner involvement to support her at this time (HEBS 2003).

The penultimate stage is the making the change stage this is when the woman is taking action (Naidoo and Wills 2000). NHS Lothian (2002) supports making a date to stop and sticking to it. One of the options is nicotine replacement therapy (NRT), which has caused debates over its place in smoking cessation during pregnancy (Dunkley 2000, McNeill et al 2001). McNeill et al (2001) found that using NRT, although not recommended in pregnancy, could be beneficial, as all the pollutants from actual cigarettes would not be delivered to the mother or the fetus.

The final stage is the maintenance stage. It is vital that the midwife maintains good support through the postnatal period as Pollock (2003) found that 60% of women who give up during pregnancy restart smoking within 1 month of birth. Encouragement from the midwife to eat a sensible a diet (Crafter 1997) and use diversionary tactics like regular brushing of teeth and saving cigarette money up for treats (NHS Lothian) helps the woman to stay stopped. The leaflet in its favour mentions how other smokers managed to stop and what they have done to help themselves. In this final stage there is room for relapse or slipping. The leaflet lets individuals know it is ok to relapse but encourages them to learn from this. It also mentions some of the side effects that women may experience from nicotine withdrawal.

The medical approach to health promotion aims to ensure individuals are disease and disability free (Ewles and Simnett 2003). This approach could be viewed as paternalistic, where professionals decide what is best for an individual (Crafter 1997) and as pregnancy is not a state of ill health (Dunkley 2000) it brings into question its validity in midwifery care. However women could jeopardise the health of themselves and their unborn child if they are involved in risk taking behaviour such as smoking during pregnancy. The initiative mentions some of the health risks involved such as miscarriage and low birth weight babies (HEBS 2003) but favourably does not go into detail to avoid victim-blaming. Within the medical approach such initiatives as General Practitioner’s or other health professionals advocating smoking cessation during consultations is found to be more useful than no mention at all (HEBS 1998) resulting in approximately 2% of smokers stopping long term. Recommendation 1.2 of the Smoking Cessation Guidelines for Scotland (NHS Health Scotland and ASH Scotland 2004a) states that a midwife should ascertain a patient’s smoking status and discourage them from smoking at the earliest opportunity. The midwife should also offer support and treatment to aid cessation (NHS Health Scotland and ASH Scotland 2004a). Crafter (1997) identifies the need for midwives to give unbiased information, however justifies the obligation to educate women about damaging behaviour such as smoking during pregnancy. Facts specific to smoking in pregnancy are not included in the leaflet such as smoking in the first 3 months of pregnancy accounts for a quarter of low birth weight babies (Scottish Executive 2001).

An educational approach to health promotion is giving individuals information to discover the health benefits or detriments for themselves (Ewles and Simnett 2003). Crafter (1997) argues that there can be no true educational approach when it comes to smoking in pregnancy because midwives would be unable to remain neutral due to the fact that evidence is available that clearly shows smoking is detrimental. Naidoo and Wills (2000) explain that the educational approach differs from the behaviour change model, as the educational model does not use encouragement to achieve its aims. NHS Health Scotland and ASH Scotland (2004b) concur with this view advocating that it is not the role of the midwife to persuade but to inform. They go on to defend the use of facts in conjunction with the leaflet. The National Institute for Clinical Excellence (2003) also emphasise the need for women to be informed of the risks, which can make a purely educational approach unattainable in relation to smoking cessation. The information could be available to patient who enquire about if for them to discover the advantages and disadvantages for themselves with the midwife advising them of where to find resources. In a study by Pullon et al (2003) it showed how suitable resources helped educate women to stop smoking. Critically however it appeared that the midwives concerned were involved in a more behavioural change role as then conclusion commented on the midwives powerful influence (Pullon et al 2003).

The client-centred approach facilitates health promotion of things that the client feels will be of benefit (Ewles and Simnett 2003), this could mean that an individual may not consider that smoking cessation is an issue they want to address and as such the topic may never be discussed. This model is said to facilitate autonomy (Dunkley 2000) but as such the leaflet may never be looked. If however the client felt that smoking cessation was something she was interested in, the midwife would be able to offer any help that was available to her to empower the woman to achieve her objective (Crafter 1997).

The societal change approach focuses on changing the whole society not just individuals within it (Ewles and Simnett 2003). Implementation of changes at community level or above looks to bring about changes to the attitudes and beliefs about smoking during pregnancy to the population. This would include laws such as that to be introduced in spring 2006 banning anybody smoking in enclosed public spaces in Scotland (Scottish Executive 2004). The majority of pregnant smoker’s are age 16-24 and low socio-economic groups highlighting the important fact that deprivation and inequality increase the incidences of smoking and of teen pregnancy (Lazenbatt et al 2000, NHS Health Scotland and ASH Scotland 2003).

Conclusion

Midwives play an important role in promoting the health and wellbeing of individuals and their families and delivery of health education (Scottish Executive 2001). The initiative appeared to have some weaknesses as a stand-alone leaflet, however as part of a multi-dimensional approach it emerged favourably.

The midwife must endeavour to gain trust and support to deliver the required service and promote empowerment (Dunkley 2000). She must take care not to alienate the women that require her help. There must be a trusting relationship built up between the midwife and the woman to achieve a positive outcome.

Approximately 20% of smoking mums give up during pregnancy and of them over 50% who gave up attributed it to being pregnant (HEA 1999) this indicates further that women want to stop and indeed manage successfully to stop smoking.