Complex physiological changes during pregnancy have a significant impact on almost every organ on the body system including the oral cavity — these changes are due to hormonal changes. Estrogen causes increased blood flow to the oral cavity, making the gums friable and easy to bleed, contributing to gingivitis. Pregnancy-associated gingivitis is highly prevalent. It affects approximately 30%-75% of pregnant women and resolves after delivery. Nausea and vomiting during pregnancy can also increase the risk of extensive erosion (Varney, Kriebs, & Gegor, 2004; Barak, Oettinger, Machetie, Peled, & Ohel, 2003). In addition, changes in diet, such as increased consumption of carbohydrates, increased acid from vomiting, and changes in oral hygiene may increase the risk of tooth decay during pregnancy (Russel & Mayberry, 2008).
Current research and evidence shows the importance of maintaining good oral health during pregnancy. Evidence supports that periodontal infections during pregnancy increases the risk of adverse birth outcomes such as premature deliveries, low birth weight, still birth, miscarriage, and pre-eclampsia (Russell & Mayberry, 2008; Jeffcoat, Geurs, Reddy, Cliver, Goldenberg & Hauth, 2001). Preterm birth is a significant public health problem, as the prematurity rate at in the United States was 12.7% in 2007. Preliminary data for 2008 indicates a slight decline to about 12.3% (Martin, Hamilton, Sutton, Ventura, Mathews, Kirmeyer, & Osterman, 2010).
Behrman & Butler (2007) reported that annual societal preterm births cost more than $26.2 billion in 2005, or $51,600 per infant born preterm, including maternal delivery, medical care, early intervention services, and loss of household and labor market productivity. As a midwife, one main goal during antenatal care is to improve pregnancy outcomes. Part of this can be accomplished is by promoting oral health care and healthy behaviors. It is important to provide oral health education before and during the current pregnancy, as well as educate our clients about the association between poor maternal oral health and adverse pregnancy outcomes. In addition, we must encourage them to see a dentist during pregnancy.
To choose a theory to apply to the practice problem, relevant theories must be critically evaluated based on a set of criteria. The author used the three questions posed by Fawcett and Associates (1992) as described by Kenny (2006): “(1) Does the theory or model address the client problems and health concerns?; (2) Are the nursing interventions suggested by the model consistent with client’s expectations for nursing care?; and (3) Are the goals of nursing actions, based on the model or theory, congruent with the client’s desired health outcomes?” (Kenny, 2006, p.305). Several middle range theories can be used and applied to maximize oral health during pregnancy, as well as the prevention of adverse outcome related to oral problems.
The Theory of Reasoned Action and Theory of Planned Behavior focuses on and explores the relationship between behavior and beliefs, as well as attitudes and intention (Montano & Kasprzyk, 2008). The Diffusion of Innovations Theory has been used to study the adoption of health behaviors and programs (Tiffany & Lutjens, 1998). The Precaution Adoption Process Model has been applied to behaviors which require deliberate action and initiating new behaviors (Weinstein, Sandman, & Blalock, 2002).
The Transtheoretical Model and Stages of Change are used to guide the individual through the stages of change to action and maintenance (Prochaska, Redding, & Evers, 2002). The Health Belief Model is used to predict and explain health behaviors and promote individuals in engaging health behavior (Champion & Stretcher & Janz, 2002). The best theory that fits this practice problem and author’s values and beliefs about client, health and nursing practice is Health Belief Model.
Health Belief Model
The Health Belief Model (HBM) was developed by a group of social psychologists at the U.S. Public Health Service in the 1950s in an attempt to understand “the widespread failure of people to participate in programs to prevent and detect disease.” It was later applied to patient responses to symptoms and to compliance with prescribed medical regimens (Champion, Stretcher, & Janz, 2002, p. 46). The HBM has four major constructs: Perceived susceptibility, perceived severity, perceived benefit, and perceived barriers. The model has been expanded to include cues to action and self efficacy (Champion, Stretcher, & Janz, 2002). ‘‘Perceived susceptibility” refers to “one’s subjective perception of the risk of contracting a health condition.” (Champion, Stretcher, & Janz, 2002, p.48). “Perceived severity” refers to “feelings concerning the seriousness of contracting an illness or of leaving it untreated includes evaluations of both medical and clinical consequences (death, disability and pain) and possible social consequences (such as effects of the conditions on work, family life, and social relations).” (Champion, Stretcher, & Janz, 2002, p.48).
“Perceived benefits” are beliefs and opinions of the value regarding the effectiveness of the various actions available in reducing the disease threat.” (Champion, Stretcher, & Janz, 2002, p.48). “Perceive barrier” is a person’s perception of both the difficulties in performing the specific behaviors of interest and the negative things that could happen from performing those behaviors.” (Champion, Stretcher, & Janz, 2002, p.49). “Cues to action are strategies to activate the one’s readiness.” And finally, “self efficacy” is “one’s confidence in one’s ability to take action.” (Champion, Stretcher, & Janz, 2002, p.49). The Health Belief Model is one of the conceptual frameworks for understanding health behavior. Also, the HBM is used for explaining and predicting acceptance and adherence to medical care recommendations (Champion, Stretcher, & Janz, 2002).
The Model hypothesis “that an individual’s decision to change behavior is determined by two elements: (1) One’s perception of a threat to personal health which is determined by two underlying belief, namely perceived susceptibility of the disease and the perceived severity and seriousness of the disease. And (2) Ones perception of the efficacy of treatment proposed to reduce the threat”. (Ramseier, Suvan, 2010). This theory is indicated as a mid-range theory because it is narrow in scope, less abstract, and more applicable directly to practice for explanation and implementation.
The early applications of HBM were focused on tuberculosis screening test, and then MBM extended to lifestyle behavioral changes such as condoms use, obtaining vaccination against infectious disease such as influenza vaccine (Baranowski, Cullen, Nicklas, Thompson, & Baranowski, 2003; Janz & Becker,1984). The HBM model also has been used on screening behaviors such as: mammography screening behaviors for detecting breast cancer, screening program for Tay Sachs disease, as well as in AIDS and high-risk behavior research (Janz & Becker, 1984)
Plan for Practice Integration
To initiate the use of the Health Belief Model in promoting and maximizing oral health during pregnancy, we might begin with distributing a survey or questionnaire for each woman during the prenatal visit. The purposes of questionnaire are: (1) To explore oral health practices and utilization of dental care; and (2) To examine women’s use of dental service and frequency of dental visits during pregnancy. The questionnaire includes demographic data (i.e., age, marital status, educational level, annual house hold income, and dental insurance). It also includes questions regarding oral health hygiene practices (i.e., frequency of brushing and flossing). In addition, the frequency of dental visits before and during pregnancy, reason for dental visit, questions regarding any instructions received from health care providers about oral health care, safety of oral treatment during pregnancy, knowledge of common oral health problem during pregnancy, and associations between poor maternal oral health and adverse pregnancy outcomes would also be covered.
Questions about barriers to dental care or reasons they do not visit the dentist would be explored. After collecting the survey from the women, the midwife or health care provider should discuss and provide teaching about oral health practices, the importance and safety of dental visits, and provide knowledge of oral health and pregnancy outcomes associated with poor oral health. This information should be provided at every prenatal visit. The Health Belief Model would be explained in an educational session for midwife and health care provider (MD and dentist) using visual aids, including posters and handouts of the HBM construct. This educational session includes information about the theory in general, constructs and its relationships, also how this model was used in research and practice previously, and then how this model might be used and applied in maximizing and promoting oral health during pregnancy.
A better understanding of the HBM from the midwife will enable them to use it in predicting and screening a patient’s oral health and related behaviors. In-person counseling could address each woman’s baseline belief regarding susceptibility to oral infection (i.e., gingivitis, peridonitis and dental caries), as well as benefits and barriers to the dental clinic visit and screening. By the end of the educational session, certain outcome objectives should be assessed. These outcome objectives would be: (1) By the end of the session, 100% of the midwives and health care providers will be able to describe the HBM and its constructs in their own words; and (2) By the end of the session, 100% of the health care providers and midwives will be able to assist individual clients to develop and maintain oral hygiene behaviors.
These objectives could be measured by assessing learner expectations regarding the sessions, asking questions, and having each one state their answers, as well as provide effective feedback to each answer from the participants. Several factors influencing the practice issues were understood by using the HBM in this practicum situation. The concept of “perceived susceptibility” includes all pregnant women because of the hormonal fluctuations that occur during pregnancy, in addition to personal characteristics related to income, poor habits, inadequate dental hygiene and related behaviors. The concept of “perceived severity” is important in that if woman are made aware of poor pregnancy outcomes related to poor oral health, they may be more inclined to engage in healthy behaviors.
The concept of “perceived benefits” are instrumental and correlate with healthy behaviors and healthy outcomes, which is the desire of most pregnant women. The concept of “perceived barriers” is important to address. While the cost of dental care may be discouraging and many may fear the pain involved in dental health (i.e., injections, fillings), the cost and disappointment of poor pregnancy outcomes may far exceed these perceived barriers. “Cues to action” are employed through education and counseling the patient regarding the many benefits and risks regarding adequate and a lack of oral hygiene, as it affects their pregnancy outcome. The concept of “self-efficacy” is important, as women become empowered to make positive life-style behavioral changes which positively impact their pregnancies.
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