Explaining the Nutritional Behavior of Iranian Pregnant Women with Diabetes: application of Health Action Process Approach model : Across sectional study

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Explaining the Nutritional Behavior of Iranian Pregnant Women with Diabetes: application of Health Action Process Approach model : Across sectional study

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Background: Gestational diabetes mellitus (GDM) is currently the most common medical complication of pregnancy. Evidence suggests that by lifestyle modifications, especially nutritional behaviors, GDM may be preventable. This study aimed to investigate the Health Action Process Approach in predicting behavior and nutrition style in diabetic pregnant mothers referred to health centers under Abadan University of Medical Sciences (southern Iran).

Method: This descriptive cross-sectional study on 82 pregnant women with diabetes referred to an urban health center. The samples were selected using simple random sampling. Data were analyzed using SPSS 25 software through descriptive tests, regression, analysis of variance, and correlation.

Results: Most pregnant mothers (41.5 %) were in the 21-30 age group. 4 3.9% of the subjects were at the moderate economic level. Linear regression test showed among demographic variables, the strongest predictor of HAPA model was income (p<0.01, R=19.9, β=-0.299).The result also showed that none of the model constructs alone predicted nutritional behavior in pregnant women. The HAPA model was able to predict 21% of the variance of the nutritional behavior (p<0.001, r=0.210, β=0.458).

Conclusion: Positive or negative outcomes, pregnant women's behavioral intent, and planning for healthy eating behaviors are effective in educating pregnant women about the prevention and control of diabetes.

HAPA model

pregnancy

Gestational diabetes mellitus

nutrition

behavior

Gestational diabetes mellitus (GDM) is increasing globally at an alarming rate. According to the recent updates 16.2 million live births were affected by hyperglycemia in pregnancy ^{[1, 2]}. GDM is defined as "any degree of glucose intolerance at the onset or first diagnosis during pregnancy"^[3]. Women with a history of GDM are at higher risk for weight gain, preeclampsia and cesarean section ^{[4, 5]}.The increasing prevalence of GDM in Asia depends on demographic characteristics such as maternal age, socioeconomic status, race/ethnicity, body composition, screening approaches, diagnostic criteria, presence of GDM, and genetic factors ^{[6, 7]}. Evidence suggests that a large proportion of the risk of gestational diabetes in women may be prevented by lifestyle modifications, especially nutritional behaviors ^[1]. GDM has several adverse consequences for mother and infant including hypertension, polyhydramnios, preterm delivery, fetal macrosomia, and respiratory distress It is believed that improving the diet of patients can prevent or at least delay the effects of diabetes^[8] . Globally the consumption of healthy foods has increased but the consumption of unhealthy foods has increased more ^[9]^.However, the diet and its trends have been very different throughout the world ^[9]. According to theorists, health-promoting behaviors positively affect the quality of life so that people with healthy habits are healthier. It is easier to prevent and even treat physical and mental problems ^{[10, 11]}.In this regard, the Health Action Process Approach (HAPA) model may be useful . The HAPA model was proposed by Schwartzer in 2008 and is based on Bandura's social cognitive theory. The main hypothesis of the HAPA model is that "for a person to adopt a behavior ^[12-14].Subsequently the individual prepares to accept certain behaviors and related decisions. After forming a behavioral intention, the person enters the voluntary stage, which consists of coping and adaptation planning, action self-efficacy, improvement self-efficacy and maintenance self-efficacy ^[15]. The HAPA is a social cognition psychological model that identifies the determinants of the initiation and maintenance of health behavior. It includes a motivational phase and a volitional phase. A review on previous studies revealed the power of HAPA in predicting health outcomes ^[15]. Recently the findings of one study provide preliminary support for the practical usage of the HAPA model for predicting healthy diet intention and behavior among diabetic patients ^[12]. The model differentiates between two distinct stages or phases each comprising sets of constructs and processes that determine behavioral enactment. The motivational phase includes outcome expectancies, action self-efficacy and risk perceptions which implicates intention formation. Outcome expectancies reflect an individual’s belief about desired outcomes which can be achievable by engaging in the behavior. It encompasses Behavioral intention, Action and coping planning, Maintenance self-efficacy and Recovery self-efficacy which resulting Healthful behavior ^[16]. The HAPA model has been used to predict design, and evaluate educational interventions in many health behaviors ^{[4, 14]}. This study performed in 2014 to investigate the predictive utility of the HAPA model and model-based healthy nutrition intervention test in people with type 2 diabetes Macphail found that the constructs of this model can predict BMI score^[17]. Awareness of risk perception, self-efficacy and intention were also significant predictors of health outcomes^[17]. Due to the use of this model in recent years and the lack of study on the application of the model dimensions for women with gestational diabetes this study aimed to investigate the effect of the Health Action Process Approach in predicting appropriate behavior and nutrition style in pregnant mothers with diabetes who referred to the health centers under the auspices of Abadan University of Medical Sciences (southern Iran). In this study the score of HAPA model constructs and food style in relation to gestational diabetes was determined. Also, the relationship between blood sugar score, blood pressure and eating style with the constructs of the HAPA model was investigated.

Study design

The sampling location of this descriptive cross-sectional study was urban health centers. The study population was pregnant women with diabetes referred to the health centers. The diagnosis was performed using an oral glucose tolerance test (OGTT). The OGTT is used at 24 to 28 weeks of pregnancy. Based on the International Association of Diabetes in Pregnancy Study Groups (IADPSG) 2010 criteria, which were endorsed by the WHO in 2013, Glucose threshold values in the OGTT for a GDM diagnosis at least one of three criteria are necessary) A fasting plasma glucose more than 92 (mg/dl), b) 1-hour glucose 180 (mg/dl) 2-hour glucose more than 153(mg/ dl) [18]. In the present study having at least one of the above criteria was considered a condition for study inclusion.

Sample size

In this study, women were determined as the sample size based on the smple size formula to estimate the ratio of an attribute in a community and consider the prevalence of gestational diabetes in Iran. Rahimi 2017 ^[19]. Reported.The prevalence of GDM among Iranian 6 percent. Based on cochran formula, the lowest required sample size was 85(d=0.05, p=0.06, and q=0.94).

Inclusion and exclusion criteria

Being a positive case for gestational diabetes based on OGTT, Being literate, having satisfaction for participating in the study, and having no cognitive disorder were considered as study inclusion criteria.

Exclusion criteria

Incomplete completion of the questionnaire was considered as the study exclusion criterion.

Sampling method

The subjects were selected by simple random sampling according to the list of electronic health records in urban health centers in Abadan. Eighty-five participants were interviewed. Three participants refused the complete all questionnaires thus their information was not entered in the data analysis.

Data collection:

Demographic questionnaire was information including age, education level, etc. Second questionnaire was HAPA model constructs. The items of the questionnaires were scaled using a 7-point Likert scale. The sum of the scores obtained from the items is calculated as the individual score in all constructs. In order to evaluate the perceived risk, participants were asked to estimate the chance of facing health problems such as heart attack; stroke and cardiovascular for instance “How high do you think your risk of heart attack is because of unhealthy nutrition during pregnancy time or even then.” A seven-point scale [from 1= very unlikely to 7= very likely] was used to rate the items. Outcome expectancies were evaluated by eight items that mothers considered as consequences of nutritional behaviors, for example “I will have a healthy fetus.” To assess the perceived action self-efficacy, we used four different items some obstacles that make it difficult to change eating habits, for example “how confident are you that you can overcome the time limitation to maintain healthy nutritional behavior”. A seven-point scale [from 1= completely disagree to 7= completely agree] was used to rate the items. For assessment of intention about nutritional behaviors, 3 items were applied. One example was “I intend to follow a healthy diet in the next month”. A seven-point scale [from 1= very unlikely to 7= very likely] was used to rate the items. Action planning was assessed with five items that showed whether mothers had made detailed plans regarding their healthy diet, for example “I have planned how to change my eating habits.” A seven-point scale [from 1= definitely false to 7= definitely true] was used to rate the items. Maintenance self-efficacy measured the confidence of mothers in their ability to continue a healthy diet when they were blocked by some barriers. For example “Even if one day I cannot follow a healthy diet, I will resume my diet again.” A seven-point scale [from 1=not confident at all to 7=completely confident] was used to rate the items. Recovery self-efficacy measured the confidence of individuals in their ability to resume a healthy diet when they have stopped the healthy diet because of various obstacles. For example “Even if one day I cannot follow a healthy diet, I will resume my diet again.” A seven-point scale [from 1=not confident at all to 7=completely confident] was used to rate the items. The Nutrition Style Scale, developed by Lippke and Zigelmann in 2006, was used to measure healthy eating behavior. This scale was used in previous study on Iranian diabetic patients, and showed a good reliability and validity. The scale consisted of 14 items, scaled by a 4-point Likert scale (never, to somewhat, very very much). The higher the total scores obtained on this scale indicates the healthier the nutritional style of the person ^[20-22].

Data analysis method

Data were analyzed using descriptive, regression, analysis of variance, and correlation tests.

The present study was conducted on 82 pregnant women with gestational diabetes. Table 1 showed demographic characteristics of study participants. Most pregnant mothers were in the 21-30 group age (n=34, 41.5 %). Most of the subjects and their husbands were in the diploma education level (42%). Most pregnant mothers were housewives (62.2%). 43.9% of the subjects were at the moderate economic level. In this study, 51.2% of the subjects received information on gestational diabetes through a physician or health expert, and 30.5% received information through Web or Social Networks. Also, 34.1% of the subjects have close relatives who had affected by diabetes. Most of the subjects' spouses were employed (25.6%). 34.1% of pregnant women were overweight.

Table 1. Demographics of women Participants (n=82)

Percent	Frequency	Categories	Variable
12.2	10	15-20 Year	Age
41.5	34	21-30 Year
39.0	32	31-40 Year
7.3	6	41-45 Year
12.2	10	Elementary School	Education
26.8	22	Junior High School
40.2	33	Diploma
20.7	17	Academic
7.3	6	Elementary School	Spouse Education
12.2	10	Junior High School
42.7	35	Diploma
37.8	31	Academic
62.2	51	Housewife	Job
6.1	5	Worker
18.3	15	Employee
13.4	11	Self-Employment
13.4	11	Unemployed	Spouse Job
13.4	11	Worker
25.6	21	Employee
23.2	19	Self-Employment
24.4	20	Retired
3.7	2	Very Good	Income Status
19.5	16	Good
43.9	36	Mediocre
19.5	16	Weak
13.4	11	Very Weak
6.1	5	Underweight	Body Mass Index
28.0	23	Normal
31.7	26	Overweight
34.1	28	Obese
6.1	5	Friends and Relatives	Awareness
51.2	42	Health Care Providers
7.3	6	Magazine or Newspaper
4.9	4	TV or Radio
30.5	25	Web or Social Networks
34.1	28	Yes	Family History for Diabetes
65.9	54	No	Family History for Diabetes

The mean scores of weight, gestational age, blood pressure, Nutrition and total HAPA score and its structures are in table 2.

Table 2. Scores of HAPA model constructs and nutrition behavior

variable	Mean	SD	Minimum	Maximum	Range
Weight	77.37	14.15	52	114	62
Gestational Age	25.33	7.28	8	37	29
Systolic Blood Pressure	110.43	10.92	90	140	50
Diastolic Blood Pressure	70.51	10.19	70	90	20
Blood Sugar	116.17	32.19	80	301	221
Risk Perception	26.62	8.70	11	58	47
Action Initiation Self-Efficacy	13.83	5.12	4	28	24
Outcome Expectancies	33.74	8.58	18	56	38
Maintenance Self-Efficacy	12.72	4.01	4	27	23
Action Planning	16.21	5.53	7	35	28
Intention	11.57	4.48	3	21	18
Recovery Self-Efficacy	13.52	4.71	4	28	24
Total HAPA	161.07	21.90	126	259	133
Nutrition	32.85	4.79	19	46	27

The Pearson correlation test showed a positive and significant relation between all constructs of the HAPA model and the total score. The highest correlation was obtained between the total score of the model and the construct of outcome expectations (p<0.001, r=0.651). Behavioral intention had a positive and significant correlation with outcome expectations (p<0.001, r=0.482) and action planning (p<0.001, r=0.448) (Table 3).

Table 3. HAPH Model Construct Correlation

variable

risk perception

action initiation self-efficacy

outcome expectancies

maintenance self-efficacy

Action planning

Intention

Recovery self-efficacy

Total HAPA

risk perception

r= -0.023

P= 0.837

r= -0.184

P= 0.098

r= 0.036

P= 0.747

r= -.020

P= 0.859

r= -0.275

P= 0.012

r= -0.207

P= 0.062

r= -0.158

P= 0..157

action initiation self-efficacy

r= 0.151

P= 0.175

r=.313**

P= 0.004

r= 0.141

P= 0.207

r= 0.079

P= 0.480

r=0.229*

P=0.038

r=0.371**

P< 0.001

outcome expectancies

r=0.217*

P= 0.050

r= 0.193

P= 0.082

r= 0.482**

P< 0.001

r=0.350**

P< 0.001

r=0.676**

P< 0.001

maintenance self-efficacy

r= 0.032

P= 0.775

r=0.014

P= 0.902

r=0.206

P= 0.064

r=0.174

P= 0.117

Action planning

r=0.448**

P< 0.001

r=0.286**

P= 0.009

r=0.491**

P< 0.001

Intention

r=0.350**

P< 0.001

r=0.520**

P< 0.001

Recovery self-efficacy

r=0.461**

P< 0.001

*. Correlation is significant at the 0.05 level (2-tailed).

**. Correlation is significant at the 0.01 level (2-tailed).

Linear regression test showed that demographic variables (education and income) predicted the total score of the HAPA model, while the strongest predictor was income (p=0.01, R=19.9, β=-0.299). Also the blood sugar scores were a good predictor of the HAPA model (p<0.001, R=0.479, β=0.528). In addition blood glucose score predicted action self-efficacy (p=0.03, R=0.056, β=0.237) outcome expectations (p<0.001, R=0.123, β=0.351) behavioral intent (p=0.006, R=0.092, β=0.304), recovery self-efficacy (p=0.002, R=0.117, β=0.341) and predicted the outcome expectations more strongly (p<0.001, R=0.173, β=0.416). (Table 4).

Table 4. Linear Regressions for HAPA model

p	t	β	B	Variables
0.503	0.673	0.068	0.187	Gestational Age
0.193	-1.315	-0.135	-3.453	Age
0.012	-1.325	-0.151	-3.240	Education
0.082	1.765	0.186	4.203	Spouse Education
0.547	-0.605	-0.065	-1.125	Job
0.969	0.039	0.004	0.061	Spouse Job
0.013	-1.088	-0.025	-2.360	Income Status
0.826	0.220	-.024	-0.524	BMI^*
0.395	0.857	0.100	0.184	Systolic blood pressure
0.181	-1.353	-0.156	-0.308	Diastolic blood pressure
0.001	4.228	0.460	0.287	Blood sugar
*Body Mass Index F(7, 81)=3.740, p<0.001 , R²=0.394)

Regression analysis of behavioral intention constructs showed that risk perception, action self-efficacy, maintenance self-efficacy, and improvement self-efficacy could not predict behavioral intention in healthy nutrition. Regression also showed that none of the model constructs alone predicted nutrition behavior in pregnant women. However the total score of the HAPA model was able to predict 21% of the nutritional style (p<0.001, R²=0.210, β=0.458).(Table 5)

Table 5. Linear Regressions for behavioral intention

p	t	β	b	Variables
0.421	0.809	0.094	0.052	Risk Perception
0.551	-0.600	-0.071	-0.066	Action Initiation Self-Efficacy
0.950	-0.62	-0.008	-0.005	Outcome Expectancies
0.128	1.540	0.184	0.219	Maintenance Self-Efficacy
0.841	0.201	0.025	0.022	Action Planning
0.099	1.670	0.257	0.094	Intention
0.436	0.783	0.094	0.257	Recovery Self-Efficacy
F(7, 81)= 1.354, p< 0.001 , R²=0.210)

In this study we examined the Health Action Process Approach in explaining the behavior and nutrition style of diabetic pregnant mothers. The findings showed that some demographic variables were related to the constructs of the HAPA model. There was a relationship between the subjects' education level and their spouses with the outcome expectancy construct, and this result was observed in the subjects with a college education following a study^[23]. Also there was a relationship between the income of pregnant women's spouses and the action self-efficacy and action planning, which was observed in women with moderate, weak, and very poor economic status. It seems that the beginning of any change and planning for it depends on income and if the limitation is in the beginning the adoption of health behavior may be delayed ^[23]. For Iranian women who are often housewives the husband's income by influencing food choices plays a very important role in the nutritional status of pregnant women. In addition Iranian pregnant women rely more on the food knowledge of those around them including their husbands in choosing their food. In the study of Karimi et al. (2015) was well proved only 21% of mothers referred to nutritionists^[24]. In the present study women's blood sugar scores were related to outcome expectations, behavioral intent, and maintenance self-efficacy. Expecting a good outcome seems to have a better commitment ^[25]. People need to know how to adjust their behavior by understanding the possibilities between their actions and the consequences. There was a relationship between the HAPA with neither systolic nor diastolic blood pressure which was slightly surprising; because previous research has shown that self-efficacy is a determinant of health behavior, which is also related to health consequences ^[17]. Pregnant women had a lower risk perception of gestational diabetes. In addition close relatives of pregnant women with type 2 diabetes were associated with risk perception and action planning. Risk perception is a perceived health threat which is necessary to start mobilizing action ^[26]. The findings of this study showed that BMI was only related to outcome expectations. This structure may be useful in weight control and improving BMI ^[17].Some dimensions of the HAPA model were correlated with each other. The more a person believes that the behavior will cause a positive change the more she/he is willing to do this behavior ^[22].In current research none of the constructs could predict the risk of gestational diabetes which was consistent with the results of the previous study in this field ^[27]. The strongest predictors of behavioral intention in pregnant women were outcome expectations and subsequent planning. The results of this study were inconsistent with the study of Rouhani et al ^[28]. Most previous studies on nutritional behaviors have considered outcome expectations as the best predictor of behavioral intention ^{[29, 30]}. this is theoretically significant because people face unforeseen obstacles and may be challenged by temptations, and the more positive the behavior for the individual the more likely the individual is to plan the behavior through self-efficacy mediation ^[31].In another study Karimi et al Showed that fear of the effects of unhealthy nutrition on the fetus and mother was the most important motivator for mothers to maintain a healthy diet ^[24]. When a behavioral intention is formed, the individual enters the voluntary stage of behavior through planning ^[32]. Perhaps the number of research samples is the average self-efficacy of pregnant women in this study The findings of the present study are consistent with MacPhail's study and contradict Scholz's study ^{[17, 33]}. However, in general, the HAPA model can partially (21%) explain the variance of nutrition behavior in pregnant women with diabetes.

The limitation of this study was not addressing all husband factors which probably affect on the nutritional behavior in pregnant women. The strength point of this study is the use of a theoretical framework-based approach to explaining the nutritional behavior of pregnant women.

According to the results the HAPA model was successful in predicting health outcomes. However, these values were limited and healthy nutrition was not predicted by the constructs. However, the Health Action Process Approach is a good model for identifying gaps and weaknesses in healthy nutrition behavior in pregnant women with diabetes and can be useful in designing effective interventions.

HAPA: Health Action Process Approach ; OGTT: oral glucose tolerance test ; GDM: Gestational diabetes mellitus ; BMI: body mass index.

Ethical approval

The present study was approved by the ethics committee of Abadan University of Medical Sciences IR.ABADANUMS.REC.1398.018. Ethical informed written consent form was completed for subjects and informed written consent forms of pregnant women under 18 years of age was obtained from herself and their husbands .By stating that informed consent was obtained, the authors are attesting that the participants were aware of the study purpose, risks and benefits.

All methods were performed in accordance with the relevant guidelines of institutional and Declaration of Helsinki.

Consent for publication

Not applicable.

Data availability

The data generated during the study are not publicly available but this available through the correspondence author.

Declaration of Conflicting Interests

The authors declared no conflicts of interest or publication of this article.

Funding

This research was supported by the Deputy for Research, Abadan University of Medical Sciences, No. 276. As the financial sponsor of this research, the Deputy for Research of Abadan University of Medical Sciences had no role in designing the study, collecting, analyzing, interpreting the data, and writing the article.

Authors’ contributions

MC designed the research and wrote the draft of the manuscript reviewed and analyzed data; HM collected the data. DS supervised this research. All authors approved the final version.

Acknowledgements

The research team appreciates pregnant women participating in the study and health personnel for their cooperation in conducting the study.

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No competing interests reported.

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Explaining the Nutritional Behavior of Iranian Pregnant Women with Diabetes: application of Health Action Process Approach model : Across sectional study

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