New health paradigms suggest that being healthy depends on a number of factors. These can be social factors, awareness, and even personality traits. Similarly, quality of life includes all aspects of life, such as health. It can be, therefore, inferred that health promotion behaviours have positive effects on quality of life, and that people with healthy behaviours are generally healthier and will experience lower disease burden and disability (Hasheminasab, 2016). According to Pender's theory, health promotion behaviours refer to any action taken to increase or maintain the health or self-actualisation of an individual or group.
Health promotion behaviour indicates a person's desire for excellence, which leads to optimal wellbeing, individual development, and creative life. It is a multidimensional model of voluntary actions and perception leading to maintaining and enhancing the level of health, self-actualisation and success (Hosseini et al, 2013; Edrisi et al, 2013). Also, based on Walker's point of view, the health promotion model is a multidimensional model of self-efficacy, maintaining or improving the level of wellbeing and complete self-actualisation of individuals, so behaviours promoting the mental and social health and wellbeing of individuals are important determinants of health status (Mazloomi Mahmoodabad et al, 2013).
The Pender's model includes behaviours promoting psychosocial health. The health promotion behaviours section includes the following sets: feeling healthy about personal health, physical activity and eating habits. The psychosocial health sector includes spiritual growth, interpersonal relationship and stress management. Considering the importance of observing these behaviours, research has shown that 70% of diseases are related to one's lifestyle in such a way that heart, lung and musculoskeletal disorders and other human diseases are directly and indirectly derived from and influenced by one's lifestyle (Karimi and Eshrati, 2012). The role of health behaviours such as exercise and proper nutrition or having appropriate social behaviours in reducing the incidence of diseases and deaths has been proven. Also, 1.3% of all deaths are due to the prevalence of several health-threatening behaviours, almost all of which are due to incorrect personal and social lifestyles, such as poor diet, inactivity, lack of physical activity and smoking, which are the main causes of dangerous diseases, such as heart disease, hypertension, obesity, diabetes, stroke and cancer, and control of these risk factors reduces the rate of deaths by about 50% (Mansorian et al, 2009).
Women who are pregnant or breastfeeding are at a unique moment when they are especially motivated to make healthier changes not just for themselves, but also for their children and their entire families (Together, 2016). Mothers are important members of society and their health has a direct impact on the health of their community. The health of the mothers should be examined and improved in all aspects, with physical activity being an important aspect mothers need to learn more about. Previous studies have shown that despite the effect of exercise on health (Streuling et al, 2011), only 25% of American women (Saravanan and Yajnik, 2010) and 36% of Australian women (Arrish et al, 2014) are exercising regularly. This rate decreases in women during pregnancy and even less after childbirth (Kalisiak and Spitznagle, 2009), since they spend more time during the day to take care of children and doing house work (Blum et al, 2004). These studies have also shown that women who increase their physical activity and are doing exercise during and after pregnancy experience a higher rate of physical and mental health compared to other women (Kernot et al, 2013). For example, healthy eating and postpartum exercise increases maternal health in the short- and long-term. A diet high in fruits and vegetables and low in fat reduces the risk of many diseases (Evenson et al, 2009). Studies have indicated that a low-dairy diet increases the risk of non-communicable disease, such as type 2 diabetes, hypertension, cardiovascular disease and some cancers.
Healthy diet, especially after childbirth, is important for breastfeeding. Mothers make enough, good quality milk for their babies, even when they themselves are lacking adequate nutrition (Bull et al, 2004). Studies have revealed that some women, despite having a healthy diet during pregnancy, do not observe the above-mentioned behaviour after childbirth (Symons Downs and Hausenblas, 2004). Each person's personality and behaviour is established and formed during childhood, and the promotion of mothers' health behaviours affects the formation of healthy habits and overall children's health as well as improving the health status of the community. For this reason, promoting the health behaviours of mothers can reduce many health costs in the community. By considering the importance of health promotion behaviours in breastfeeding women and limited studies in this field in Iran, the present study was conducted to investigate the effect of training on health promotion behaviours on breastfeeding mothers.
Methodology
The present study is a quasi-experimental intervention. The statistical population of the present study include breastfeeding mothers referred to the clinics of Fasa city. The sample size of the study was calculated to be at least 48 people in each of the groups based on the study conducted by Ahmadi et al (Karimi et al, 2012) and considering the 95% confidence level and 80% statistical power at the error level of at least a difference of 12 scores between the two studied groups. To control possible random errors, increase the statistical power of the test and compensate for possible dropouts, the authors decided to increase the sample size to 50 people in each group.
n = ( ( Z 1 + Z 2 ) 2 ( S 1 2 + S 2 2 ) ) / d 2
Random cluster method was used for sampling in this study. Accordingly, the samples were selected from four clinics in Fasa city and then randomly selected from the list of clients (even numbers). A health-promotion lifestyle questionnaire was used in this study. This questionnaire has been adopted from a tool designed by Walker et al (1987). Health promotion areas in this questionnaire include nutrition, exercise, social relationships, mental health, mental problems, physical health, spirituality (defined as a purposeful and meaningful situation of human life, which stems from belief in the infinite power, the perfections of God and belief in life after death) and hope. This 52-item questionnaire is designed on a four-point Likert scale ranging from ‘never’ to ‘always’. Walker et al (1987) reported the Cronbach's alpha coefficient of this tool at 0.94.
In the first stage, the questionnaire was distributed among the samples and samples' self-report of their lifestyle was collected. In the next stage in five sessions, the necessary and appropriate training in various areas of healthy lifestyle was held for the sample group. In these sessions, a health expert taught and lectured in the following topics:
- Exercise and its importance on breastfeeding and health
- The importance of sleep and its effects on breastfeeding and health
- Mental health and its importance on breastfeeding and health
- The importance of nutrition and its role on breastfeeding and health
- Spiritual issues and interpersonal relationships and their importance on breastfeeding and health.
The sessions were in the form of lectures. Questions and answers were held between the presenter and the mothers at the end of each session. Then an educational pamphlet was distributed among the mothers. After one month, the samples (case and control) were collected again and in order to evaluate the effectiveness of the provided trainings, the questionnaires were distributed and collected again for analysis. Data analysis was performed using descriptive and inferential statistics through SPSS version 20 software. The results were reported as number (percentage) and mean (standard deviation). A two-sample t-test was used to examine the relationship between variables. In all analyses, the maximum first type error was considered to be 0.05.
Results
This study was performed on 97 breastfeeding mothers who self-referred themselves to the clinics of Fasa city. The mean age of the women was 29.5 years in the case group and 29.77 years in the control group, and the monthly income level in the case group was 13 703 330 Rials and 18 375 210 Rials in the control group (see Table 1).
Table 1. Descriptive characteristics of demographic variables (age and income)
| Variable | N (f) | Mean | SD | |
|---|---|---|---|---|
| Age | Case group | 44 | 59.29 | 03.5 |
| Control group | 42 | 77.29 | 51.8 | |
| Monthly income | Case group | 30 | 33.1370333 | 77.793705 |
| Control group | 33 | 21.1837521 | 14.1060891 | |
Spiritual growth
The scores of case and control groups before training and also after training in the field of spiritual growth were examined. Results showed (see Table 2) the significance of the difference between scores of the two groups after training (p-value=0.019). In the area of spiritual growth, the scores between two groups were also examined (see Table 3). Accordingly, the scores in each of the control and case groups were compared before and after training, and no significant difference was observed in this area.
Table 2. Comparison of spiritual growth, responsibility, stress management, physical activity, interpersonal relationships scores between control and case groups before and after training
| Group | Before training | After training | |
|---|---|---|---|
| Spiritual growth | Case | 73.6±18.23 | 80.6±551.26 |
| Control | 77.5±37.23 | 00.6±09.23 | |
| p-value | 05.0>p-value | 019.0 | |
| Responsibility | Case | 80.5±88.13 | 79.44 |
| Control | 45.5±22.15 | 97.37 | |
| p-value | 05.0>p-value | 19.0 | |
| Stress management | Case | 28.40 | 71.49 |
| Control | 99.37 | 17.35 | |
| p-value | 65.0 | 006.0 | |
| Physical activity | Case | 22.41 | 34.50 |
| Control | 73.41 | 02.35 | |
| p-value | 92.0 | 007.0 | |
| Interpersonal relationships | Case | 82.45 | 26.51 |
| Control | 10.48 | 01.43 | |
| p-value | 67.0 | 13.0 |
Responsibility
The scores between the two case and control groups in the area of responsibility were examined (Table 2) before and after training and the difference between the scores of two groups was not significant. The scores of control and case groups in the area of responsibility were compared (Table 3) before and after training showed a positive effect in the case group (p-value=0.002).
Stress management
The scores of two groups of cases and control in the area of stress management were compared (Table 2) before and after training, and results indicated that a significant difference between these scores in the two groups after training (p-value=0.006). The scores of the control and case groups in the area of stress management were compared (Table 3) before and after training but no significant difference was observed between them.
Physical activity
The scores between the two groups of case and control were in the area of physical activity were examined (Table 2) before and after training, and results indicated a significant difference between the scores of two groups after training (p-value =0.007). The scores of each of the control and case groups in the area of physical activity before and after training were compared (Table 3), and results showed that training had a positive effect in the case group (p-value=0.005).
Interpersonal relationships
The scores of two groups of case and control before and after training were examined (Table 2) in the area of interpersonal relationships and the difference between the scores of two groups was not significant. Scores of interpersonal relationships in each of the control and case groups were compared (Table 3) before and after training, and the training showed the positive effect of training in the case group (p-value=0.024).
Nutrition
The scores of control and case groups in the area of nutrition were compared (Table 3) before and after training, and results showed the positive effect of training in case group (p-value=0.011).
Discussion
Statistical tests were performed on two groups of case and control before and after training. Spiritual growth and responsibility received the highest scores on the questionnaire. Spiritual growth scored (23.29±6.16, respectively, before training and 24.65±6.56 after training) and responsibility scored (14.62± 5.61, respectively, before training, and 15.93±5.70 after training). It is also in line with the results of the studies conducted by Hossein Nejad, Norouzinia, Tol and Emami (Hosseinnejad and Kalantarzadeh, 2013; Norouzinia et al, 2013; Tol et al, 2013; Emami et al, 2015). Hossein Nejad, Nowruzinia, Tol and Emami's studies were investigating the health promoting lifestyle based on the Pender's model among the students.
Spiritual growth received the highest scores in all of these studies (respectively, 3.07±0.58, 2.99±0.56, 22.01±2.22, 23.27±4.2) (Hosseinnejad and Kalantarzadeh 2013; Norouzinia et al, 2013; Tol et al, 2013; Emami et al, 2015). Also, interpersonal relationships and physical activity (4.70±1.57 and 6.71±4.33, respectively, before training, and 5.05±1.76 and 8.65±5.73, respectively, after training) received the lowest scores on the questionnaire. In Hossein Nejad, Norouzinia, Tol and Emami's studies, physical activity (respectively, 2.27±0.60, 2.16±0.64, 17.58±2.9, 17.9±4.2) received the lowest scores on the questionnaire too (Hosseinnejad and Kalantarzadeh, 2013; Norouzinia et al, 2013; Tol et al, 2013; Emami et al, 2015).
There are many factors in maintaining health, with spiritual growth being one of the most important of these factors. Spiritual growth has effects on a person's social and mental health, and because of these effects, it can even improve a person's physical health. In the present study, spiritual growth obtained the highest score among various areas. It could be due to the prevalence of Islamic values and paying attention to spiritual issues in the community. Also, after the intervention and providing of necessary training, a significant difference between the case and control groups was observed, which indicates the positive effect of the training. Institutionalising responsibility in individuals motivates them to increase the level of health in themselves and individuals in society. Mothers are the educators of the next generation of society and the foundation of the personality of the people of society is directly in their hands, so if mothers have concerns and motivations to live healthier, there will be a healthier society. This area gained the highest score after spiritual growth. Also, a significant difference was found between case and control groups in the scores of responsibility area, and the scores increased significantly in the case group after training, which indicates the positive effect on training on this area in the community.
Stress management area was also examined in this study. Compared to other studies conducted in this regard, like Hossein Nejad's study (2013), the population studied in this study, unlike previous studies, had almost desirable levels, which can indicate the greater importance of reducing anxiety and increasing relaxation by breastfeeding mothers in this city, which is very promising. It was further suggested to include stress management training in students' counselling programme with the aim of increasing psychological, social and emotional wellbeing, and as a result more students' health (Hosseinnejad and Kalantarzadeh, 2013). In the present study, the score of the case group in this area increased significantly compared to the control group.
Nutrition plays a vital role in a person's physical health, can prevent many diseases and have a significant effect on adequate breastfeeding. In this regard, both Islam religious teachings and the World Health Organization (2020) have emphasised the necessity of breastfeeding. In this study, in the area of nutrition, training increased the scores of the case group. The results of this study are in line with those of other studies, which showed breastfeeding mothers following a sedentary lifestyle (Al-Kandari and Vidal, 2007; Hosseini et al, 2013; Tol et al, 2013), while physical activity is one of the most important factors affecting health, because it reduces the risk of cardiovascular disease, type 2 diabetes, depression and some cancers (Al-Kandari and Vidal, 2007; Hasheminasab, 2016).
There are several reasons for not paying attention to physical activity in breastfeeding mothers. One of these factors is the presence of a neonate who needs continuous care and attention. Another factor is the lack of suitable, safe and accessible environments for women, and some mothers may believe that the level of exposure that they would to do to feed their baby outside the home environment is not acceptable by Islamic religion. Another reason might be cultural problems and the lack of proper training to reflect the importance of physical activity in women. Although physical activity has a low score in this study and it is in line with other studies, but training in this area also had a significant effect, and after training, the scores in the case group increased significantly. Also, the scores of the case group increased significantly compared to the control group after training. Interpersonal relationships in this study obtained the lowest score. It might be due to the lack of education on breastfeeding mothers, or the fact that these mothers are less likely to engage in interpersonal relationships as they are more engaged in providing care for their infants. In this area, the score of the case increased significantly compared to the control group after training. In Tol's (2013) study, interpersonal relationships in students were introduced as an area that also needs education. However, Norouzinia et al (2013) and Emami et al (2015) reported that interpersonal relationships among students are in good standing. This discrepancy can be due to differences in the populations studied and increasingly indicates that interpersonal relationships in breastfeeding mothers needs to be addressed.
Conclusion
In general, it can be inferred that training has had a significant impact on all six areas of health-promotion behaviours and has improved lifestyles and general health. With this small sample and just one month of training, the researchers demonstrated that it is possible to make changes in all areas of health. This can not only have an immediate effect but also a ‘snowball effect’, down the generations, through mother-child transfer, as well as mother-other family members transfer. In Iran, holding educational classes to train and encourage promotional health behaviours in health clinics during the frequent visits of mothers and infants can expand these behaviours across the community and improve overall public health.
Key points
- Mothers are considered one of the most important members of community and their health has a direct impact on the health of community
- Mothers pay less attention to interpersonal relationships and pay more attention to their infants
- Hosting educational classes to encourage promotional behaviours in health clinics can expand healthy behaviours across the community and improve overall public health
CPD reflective questions
- What are the most important environmental factors affecting breastfeeding?
- What is the role of husbands in supporting breastfeeding women?
- What effect does the culture of the society have on women who breastfeed?