PROMOTING PHYSICAL ACTIVITY AMONG POSTNATAL WOMEN

382 Pages·2014·3.44 MB·English

PROMOTING PHYSICAL ACTIVITY AMONG
POSTNATAL WOMEN: THE MORE ACTIVE MUMS
IN STIRLING (MAMMiS) STUDY

by
Alyssa Sara Gilinsky (MSc, CPsychol)

A Doctoral Thesis
Submitted in partial fulfilment of the requirements for the degree of

Doctor of Philosophy

University of Stirling
School of Nursing, Midwifery and Health

2014
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ACKNOWLEDGEMENTS

There are several individuals who I would like to thank for their contribution to this thesis.
Firstly, my supervisors Dr Adrienne Hughes and Dr Rhona McInnes, both of whom provided
excellent support, enthusiasm and encouragement during the whole process of completing my
research and thesis write-up. I wish to thank them for the opportunities and advice they
provided and for generally putting up with me!
There were a number of people who provided time, support or expertise when helping to
develop or conduct this work. This includes, but is not limited to Hannah Dale, Clare
Robinson and Deirdre Holly.
Thank you to Tricia Cummings and other staff and volunteers from the Walk about Stirling
project who provided advice and assistance with route planning for the walking groups.
Thank you to the health visitors and other community group leaders and businesses who were
helpful during the recruitment process.
I am also grateful to the postnatal women (and babies) who participated in the study. Often
surprising, always moving; I discovered a lot more than what is written in this thesis by just
being involved in in their lives in a small way for a small time.
My family and friends have been incredibly supportive during this time. They will no doubt
be relieved to see it at completion. None so much as Andrew Lee, my wonderful boyfriend,
come fiancée, come husband who, despite everything, still married me. Andrew, your
intellectual, emotional and financial support was crucial to my success in this endeavour - I
know you won’t let me forget it either!
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RESEARCH GRANTS

Hughes AR, Gilinsky AS, McInnes RJ & Jepson R. (2011). The Experiences of postnatal
women participating in a physical activity intervention: Process evaluation of the More
Active MuMs in Stirling (MAMMiS) study. Award of £43,168, Chief Scientist’s Office.

PUBLICATIONS/CONFERENCE PRESENTATIONS

Gilinsky A.S., Dale, H., Robinson, C., Hughes, A.R., McInnes, R. J. & Lavelle, D. (2014).
Efficacy of PA interventions in postnatal populations: Systematic review, meta-analysis and
content coding of behaviour change techniques. Health Psychology Review. doi:
10.1080/17437199.2014.899059

Gilinsky, A.S., Hughes, A.R. & McInnes, R.J. (2012). More Active Mums in Stirling
(MAMMiS): a PA intervention for postnatal women. Study protocol for a randomised
controlled trial. BMC Trials, 13:112. doi:10.1186/1745-6215-13-112

Gilinsky, A.S., Hughes, A.R. & McInnes, R.J. (2014). Quantitative and Qualitative Findings
from the More Active Mums in Stirling Trial. Abstract accepted for the American College of
Sports Medicine (ACSM) 61st Annual Scientific Meeting, Orlando, Florida.

Guthrie, W, Gilinsky A. S., Hughes, A. R., McInnes, R. J., Jepson, R. (2012). A qualitative
study exploring the views and experiences of postnatal women participating in the More
Active Mums in Stirling (MAMMIS) RCT. Abstract presented to the UK Society for
Behavioural Medicine 8th Annual Scientific Meeting, Stirling, UK.

Gilinsky, A.S., Hughes, A.R. & McInnes, R.J. (2012). Primary and secondary outcomes
among women participating in the More Active Mums in Stirling (MAMMIS) RCT. Poster
presentation, UK Society for Behavioural Medicine 8th Annual Scientific Meeting, Stirling.

Gilinsky, A.S., Hughes, A.R. & McInnes, R.J. (2012). More Active MuMs in Stirling
(MAMMiS): A randomised controlled trial of a postnatal activity intervention. Interactive
Poster Presentation to the British Heart Foundation National Centre 11th Annual Conference,
Nottingham, UK & European Health Psychology Society Annual Conference, Crete, Greece.

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Gilinsky, A.S, Dale, H. & Robinson, C. (2011). Are postnatal physical activity interventions
reproducible? Problems for Health Psychologists coding behaviour change techniques. Oral
Presentation, European Health Psychology Society Annual Conference, Crete, Greece.

Gilinsky, A.S, Dale, H. & Robinson, C. (2011). Theory-based content of postnatal PA
interventions: Coding behaviour change techniques for a systematic review. Poster
Presentation, European Health Psychology Society Annual Conference, Crete, Greece.
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ABSTRACT
BACKGROUND: Adults benefit from participating in physical activity (PA) for chronic
disease prevention and treatment. Postnatal women are encouraged to commence a gradual
return to PA 4-6 weeks after giving birth, with participation in line with PA guidelines. The
potential benefits of postnatal PA include weight management, improvements in
cardiovascular fitness and psychological wellbeing. There has been limited high-quality
information about the efficacy, feasibility and acceptability of PA interventions in postnatal
women and few studies in the UK. Behavioural counselling interventions informed by
behaviour change theory have been shown to successfully increase PA in low-active adults.
Physical activity consultations (PACs) use structured and individualised behavioural
counselling to enhance individuals’ motivation for change, and improve self-management
skills. This approach may support adoption of PA in low-active postnatal women with
research demonstrating that modifiable socio-cognitive factors influence PA behaviour. This
thesis reports on the efficacy of a postnatal PA intervention, the More Active MuMs in
Stirling (MAMMiS) study on change in PA behaviour. Efficacy of the intervention was tested
in a randomised controlled trial. The effect on secondary health and wellbeing outcomes and
PA cognitions targeted by the intervention and feasibility results are also reported.
METHODS: The intervention comprised a face-to-face PAC of around 35-45 minutes and
10-week group pramwalking programme. Non-attenders to the pramwalking group received a
support telephone call. A follow-up PAC (15-20 minutes) was delivered after three month
assessments. The first PAC involved raising awareness about benefits of PA, developing self-
efficacy for change, setting goals and action planning PA, developing strategies for
overcoming barriers, encouraging self-monitoring, prompting social support and
selecting/changing the environment to support PA. The second PAC involved feedback about
changes and preventing a return to sedentary habits. The pramwalking group met weekly for
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walks of 30-55 minutes at a brisk pace, providing opportunities to demonstrate moderate-
intensity walking and to encourage and support PA behaviour change. The control group
received an NHS leaflet, which encouraged PA after childbirth.
Postnatal women (six weeks to 12 months after childbirth) were identified through a variety
of NHS-based and community-based strategies plus local advertisements and word-of-mouth.
The primary outcome measure was evaluation of PA behaviour change using the Actigraph
GT3X/GT3X+ accelerometer, an objective measure of PA behaviour; self-reported moderate-
vigorous physical activity (MVPA) was measured using a recall questionnaire (Seven-Day
Physical Activity Recall) and cardiovascular fitness using a submaximal step-test (Chester
step-test). Secondary health and wellbeing measures were; anthropometric (i.e. weight and
body mass index (BMI)) and body composition (measured using a bioelectrical impedance),
psychological wellbeing (measured using the Adapted General Wellbeing Index) and fatigue
(measured on a 100-point visual analogue scale). PA cognitions were measured via a
questionnaire with constructs adapted from previous studies. All were taken at baseline (prior
to randomisation), three and six months follow-up from baseline. Process measures were used
to investigate intervention fidelity and feasibility. Acceptability was investigated in a post-
trial interviews, conducted by a researcher not involved in the trial.
RESULTS: Sixty-five postnatal women (average 33 years old with an infant 24 weeks old)
were recruited (77% of those eligible). There was a 91% rate of retention at six months;
participants who missed a follow-up assessment were younger (30 versus 34 years old) and
had younger infants (21 versus 34 weeks old). Participants were less deprived and older
compared with postnatal women in Scotland. Objectively measured PA behaviour did not
change in response to the intervention. There was no between-groups difference in change in
mean counts/minute from baseline to three months (p=0.35, 95% CI -73.50, 26.17, d=0.22) or
three to six months (p=0.57, 95% CI -39.46, 71.18, d=0.13). There was no change in MVPA
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minutes/day in either group from baseline to three (intervention =-0.70, IQR -9.86, 8.36;
control =1.65, IQR -4.79, 8.21) or three to six months (intervention =0, IQR -1.13, 1.10;
control =0, IQR -9.86, 8.23), with no between-groups difference baseline to three (p=0.43;
r=0.10) or three to six months (p=0.75, r=0.09). Results for relative MVPA were similar.
Median steps/day from baseline to three months did not change in the intervention group (0,
IQR –1619.44, 1047.94) and increased by 195.95 (IQR -1519.55, 1691.03) among controls.
The between-groups difference was non-significant (p=0.37, r=0.18). From three to six
month follow-up steps/day increased in the intervention group and not in controls (0, IQR -
1147.50, 1303.52), this between-groups difference was also non-significant (p=0.35, r=0.16).
From baseline to three months self-reported MVPA declined in the intervention group (15
minutes/week; IQR -111, 15) and increased in the control group (30 minutes/week; IQR –68,
75): a non-significant between-groups difference, with a small effect size (p=0.71, r=0.22).
From three to six months a decline in self-reported MVPA was found in controls (53
minutes/week; IQR -41,-101) and no change among the intervention group (0, IQ range -26,
71); a significant between-groups difference with a small effect size (p=0.04, r=0.26). There
were no differences between the groups for the change in aerobic capacity from baseline to
three months or three to six months with no evidence for change over time in aerobic capacity
or fitness category in either group. Change in secondary outcomes did not differ between the
groups from baseline to three or three to six months (although fatigue did improve in the
intervention group relative to controls from baseline to three months). Considering PA
cognitions, outcome expectancies declined in both groups from baseline to three months and
continued to decline only in the intervention group from three to six months, a between-
groups difference with a small effect size (p=0.03, r=0.26). Self-efficacy increased in the
intervention group from baseline to three months and declined in the control group with a
small effect size for the between-groups difference (p=0.03, r=-0.27). An increase in action
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planning was seen among the intervention group but not controls from baseline to three
months (p<0.01, r=-0.34). Both groups showed an increase in coping planning and action
control; the change was larger among the intervention group relative to controls (i.e. p<0.01,
r=0.44, r=0.43, respectively). Increased self-efficacy and action control were maintained
from three to six months in the intervention group. Coping planning increased relative to
controls (p<0.01, r=0.41) and action planning increased among controls from three to six
months (p<0.01, r=0.39). Intervention fidelity and feasibility was good. All intervention
participants received the initial PAC and adoption of self-management strategies was high for
‘thinking about the benefits of PA’, ‘action planning’ and ‘self-monitoring’, between baseline
and three months. Most participants attended at least one walk (61% attended five or more),
89% of planned walks were conducted with no evidence of poor attendance due to season.
Walks were conducted at a brisk pace and met moderate-intensity thresholds.
DISCUSSION: MAMMiS aimed to recruit low-active healthy postnatal women to test the
efficacy of a PAC and group pramwalking intervention. There was no evidence for an
intervention effect on PA or on secondary health and wellbeing outcomes. Compared to
previous postnatal studies the study sample were relatively active at baseline, there was large
variability in accelerometer-measured PA and evidence for fluctuating PA habits. There were
positive impacts of the intervention on PA cognitions, which published studies have shown
mediate PA behaviour change and postnatal women perceived benefits from taking part. The
intervention was feasible, although due to the sample being older and more affluent compared
with the general population of postnatal women in Scotland, this would need to be considered
if implementing the intervention. Given the importance of PA for health and the challenges of
both engaging postnatal women and for postnatal women wanting to be physically active, the
findings from MAMMiS provides important evidence to inform future choices about trial
design and intervention approach in postnatal PA promotion trials.
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TABLE OF CONTENTS
Page
INTRODUCTION 27
Structure of this thesis 32
CHAPTER ONE
1. LITERATURE REVIEW: PART ONE
1.1 Chapter Preface 33
1.2 Physical activity 33
1.2.1 Physical activity recommendations for health and wellbeing in adults 35
1.2.1.1 Recommendations for postnatal populations 36
1.3 Benefits of postnatal physical activity 37
1.3.1 Postnatal weight management 37
1.3.1.1 Role for physical activity in supporting postnatal weight management 38
1.3.2 Postnatal cardiovascular fitness 40
1.3.3 Physical activity for postnatal psychological health and wellbeing 42
1.4 Measuring physical activity 44
1.4.1 Physical activity measured via physiological proxy 45
1.4.1.1 Measuring cardiovascular fitness 46
1.4.1.1.1 Submaximal fitness tests 47
1.4.2 Methods that subjectively measure physical activity 48
1.4.2.1 Daily diaries 48
1.4.2.2 Recall questionnaires 49
1.4.3 Methods that objectively measure physical activity 50
1.4.3.1 Doubly labelled water 50
1.4.3.2 Heart-rate monitors 51
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1.4.3.3 Motion sensors 52
1.4.3.3.1 Accelerometers 54
1.4.3.3.1.1 Types of accelerometers 54
1.4.3.3.1.2 Reliability and validity of accelerometer activity counts 55
1.4.3.3.1.3 Accelerometer estimated energy expenditure 57
1.4.3.3.1.4 Cutpoints for measuring intensity of physical activity behaviour 58
1.4.3.3.1.5 Acceptability/feasibility for measuring physical activity in the field 60
1.5 Participation in physical activity during the postnatal period 60
1.5.1 Postnatal physical activity participation compared with prepregnancy 61
1.5.1.1 Effect on leisure-time physical activity participation 61
1.5.1.2 Effect on total physical activity participation 62
1.5.1.3 Effect on walking participation 63
1.5.2 Are women active enough in the year following childbirth? 64
1.5.2.1 Adherence to physical activity guidelines during the postnatal period 64
1.5.2.2 Intensity of postnatal physical activity participation 65
1.6 Modifiable factors influencing postnatal physical activity participation 65
1.6.1 Beliefs about the benefits of being active/outcome expectancies 68
1.6.2 Barriers, social support and self-efficacy 69
1.6.3 Self-regulatory self-efficacy 70
1.6.4 Modifiable factors and health behaviour change theory 70
1.6.4.1 Theory of Planned behaviour 71
1.6.4.2 Socio-cognitive theory 73

1.6.4.3 Transtheoretical model 74
1.6.4.3.1 Decisional balance, processes of change and self-efficacy 76
1.6.4.4 Health Action Process Approach 79
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