Challenging Dogma - Spring 2008

...Using social sciences to improve the practice of public health

Thursday, May 7, 2009

England’s Maternal Prenatal Smoking Cessation-Robbie Frank

There are a number of successful smoking cessation interventions based on behavioral theories. Even though many smoking cessation interventions are deemed successful, none of the interventions are without flaws (12). In England, there is a smoking cessation intervention targeting pregnant women. This intervention is based on the theory of planned behavior (TPB). An intervention based on the TPB model is a fundamentally flawed approach to maternal prenatal smoking cessation because it is an individual level based intervention, it asserts that perceived behavioral control is a predictor of actual behavioral control, and assumes that human behavior is the output of rational, linear decision making process.
Intervention
The England Department of Health launched a smoking cessation ad campaign based on the TPB model targeting pregnant women (20). The ad shows an obviously pregnant woman smoking a cigarette. The campaign then goes on to provide information on how cigarette smoke “restricts the essential oxygen supply to an unborn baby, so that their tiny heart has to beat harder every time a pregnant woman smokes.” The campaign reinforces the message that cigarette smoking harms unborn babies, and that stopping smoking is the right thing to do (social norms say smoking when pregnant is bad). The ad also goes on to inform the reader that smoking cessation –no matter how far long the pregnancy is−will immediately benefit the woman and her baby (control belief—the belief in the ability to control the improvement of the health of mother and child will make it easier for the mother to participate in smoking cessation). It then offers information on how pregnant women can take the situation into their own hands and receive professional support to assist them in smoking cessation (perceived power). The offer of assistance in smoking cessation is meant to turn intentions into the desired behavior. This ad presents smoking cessation as a positive, desirable behavior that one can control.
Theoretical Framework of Intervention
To contextualize the flaws of the England smoking cessation intervention, it is important to understand the health behavior model upon which the intervention is fashioned. The TPB model was proposed by Icek Ajzen in 1985 as an extension of the theory of reasoned action (TRA). TRA is an individual level theory based on the concept that individuals go through complex cognitive assessments before making decisions on behavioral intentions. This is then followed by the rational movement from assessment to behavior (15). A person’s intent to perform (or to not perform) a behavior is viewed as the instant determinant of the action (13). TRA includes two determinants to intention: personal (attitude) and social (subjective norm). An attitude is described as a negative or positive evaluation of performing or not performing a desired behavior. Subjective norm indicates a person’s perception of the social pressure exerted by others who think that a given behavior should or should not be performed. This theory lacked because a person can go through the process of assessment and have a behavioral intention, but still not be able to do the behavior (13). To address this issue, a new element called perceived behavioral control was added to TRA. Perceived behavioral control refers to the degree to which someone believes they have control over whether they can take the action (control belief) and the strength of that belief (perceived power). This new element reformulated TRA to TPB. It attempts to explain the relationship between people’s attitudes and their behaviors, based on people’s perceived behavioral control and perceived power (13).
Flaws of Intervention
Individual Level Intervention

The ultimate goal of the ad intervention is to reach a broad target audience of maternal prenatal smokers and convince them to change to the desired health behavior of smoking cessation. This smoking cessation intervention is based on the TPB model. Due to such, this intervention has inherit flaws of the TPB model, one of which being that this intervention functions on the individual level. The ultimate goal of an individual level intervention is to change the knowledge, awareness, and skills of an individual. These types of campaigns focus on changing a specific aspect of an individual’s attitude, belief, and/ or cognition (27). This is a drawback in an attempting to change the health related behavior of a target audience because the enactment or non-enactment of the target audience’s behavior is likely a result of personal individual-level processes that precede the behavior. Because maternal prenatal smokers are not a homogenous group, different women will have different reasons for participating or not participating in the desired health behavior of smoking cessation. England’s individual level smoking cessation interventions does not take into account that being healthy and giving birth to a healthy baby is not a core value for all women. Due to such, a smoking cessation intervention must be able to find a common ground amongst pregnant women and impact those core values in order to effectively promote the behavior change of smoking cessation.
The individual level approach to maternal prenatal smoking cessation is unable to address the social factors that may influence the behavior of continued smoking. Research shows that tobacco use (or non-use) results from a complex mix of influences that range from factors that are directly tied to tobacco use (e.g., beliefs about the consequences of smoking) to those that appear to have little to do with tobacco use (e.g., parenting styles and school characteristics) (22). Thus, there are a number of social factors that attribute to why women continue to smoke during pregnancy. Some women have cited a socio-economic burden as a barrier to smoking cessation. These women are unable to fund smoking cessation aids such as cigarette modification products, thought changing products, and stop smoking educational products (22). In a study conducted by Greaves, research found that some women use cigarettes to “organize” their social interactions in order to build and bond pleasant social and work relationships (24). In other studies, pregnant women cited smoking as a tool of self definition. Continued smoking projected a personal image perceived by the smoker as cool, tough, defiant, adventurous, sexy, young, and slim. Smoking was also cited as a means through which pregnant women are able to suppress emotions or dissipate feelings of fear or pain in preference to expressing negative emotions openly. The behavior of continued maternal prenatal smoking was also influenced by the smoking habits of husbands, partners, family members, and friends. These factors can contribute to the difficulty of smoking cessation (2). An individual-level model is inappropriate in shaping a smoking cessation intervention for pregnant women because it neglects to acknowledge that the decision of smoking cessation is not necessarily made on and individual level and that there are a number of social factors that impact decisions related to health behaviors.
Perceived Behavioral Control is a predictor of Actual Behavioral Control
A fundamental defect of a maternal prenatal smoking cessation intervention based on the TPB is the assumption that perceived behavioral control is a predictor of actual behavioral control. It is postulated that perceived behavioral control serves as a proxy for actual behavioral control, therefore having a direct influence on both intention and the actual behavior (1). On the contrary, perceived behavioral control is fundamentally different from actual behavioral control. Perceived behavioral control is a strong predictor of the strength of a person’s intention to participate in a certain behavior (25), not a substitute or predictor for the actual behavioral control that a person possesses. Actual behavioral control refers to the extent to which a person has the skills, resources, and other prerequisites needed to perform a given behavior (19). Due to the conceptual difference between perceived behavioral control and actual behavioral control, it is inaccurate to assume that perceived behavioral control can predict or impact a person’s actual behavioral control. Whether or not a person perceives that he/she has full control over his/her ability to perform a behavior and also the strength to do so, does not necessarily lead to the person performing the desired behavior (25). The TPB model does not accurately predict how people move from intention to behavior because it inaccurately asserts that perceived behavioral control is a predictor of actual behavioral control.
In a study conducted on the influence of perceived behavioral control, research revealed that perceived behavioral control impacts behavior only through the prediction of a person’s behavioral intentions (8). Perceived behavioral control is a strong predictor of the intent to do a behavior, but not a predictor of the actual behavioral control a person possesses (25). The fulfillment of many health behaviors do not coincide with attitudes towards, or intentions regarding a specific behavior. The England’s maternal prenatal smoking cessation intervention possesses the ability to convince a pregnant woman to develop a strong belief that she has control and power over her ability to stop smoking. However, strong perceived power and control beliefs do not lead to actual behavioral control, which is necessary to act on the desired behavior intention. Strong perceived power and control beliefs lead to strong intentions to do the desired behavior. Strong intentions is not sufficient enough to illicit the execution of a desired behavior. Pregnant women must possess actual behavioral control in order to perform the intended behavior (19). The assertion that the belief of perceived behavioral control is linked to pregnant women’s ability to act on the intention to participate in smoking cessation is inaccurate. Actual behavioral control must be present in order for a person to act upon his/her perceived behavioral control. Without actual behavioral control, the pregnant woman does not possess the skills and resources necessary to enable her to exercise the intended behavior of maternal prenatal smoking cessation. It is therefore difficult to assess how the construct of perceived behavioral control impacts behavior modification without first understanding the role that actual behavioral control plays in the human decision making process.
Human Behavior is Rational and Linear
Due to the fact that this intervention is rooted in the TPB model, its design oversight assumes that behavior is the output of rational, linear cognitive decision making processes (15). Many behavioral theorists and social scientists argue that human behavior is complex and irrational, therefore difficult to predict (18). Irrationality is defined as the tendency that humans possess to behave, express emotions, and think in ways that are inflexible, unrealistic, absolutist and self- and social-defeating and destructive (16). In light of the irrational nature of human behavior, it cannot feasibly be asserted that decision making is a linear, planned process. Human behavior is affected by the broad social or cultural environment surrounding the behavior, the immediate social situation or context in which the behavior occurs, the characteristics or disposition of the person performing the behavior, the behavior itself and closely related behaviors, and the interaction of all these conditions (22). There are a number of factors that can cause a person not to carry out their planned behavior. In smoking cessation, the decision to use or not to use tobacco is linked with a range of factors, some of which have little or not relation with actual tobacco usage (22). The human decision making process is the result of a complex interplay between cognitive, emotional, social, personal, and environmental influences (16) that can often time lead to irrational, self defeating unplanned behavior.
Today, most pregnant women seem to be aware of the health risks associated with maternal prenatal smoking, however, awareness alone is not sufficient enough to prompt women to stop smoking (9.). Studies show that maternal prenatal smoking is not solely the result of a lack of knowledge of health risks associated with the behavior. It is instead the result of the human decision making process which is shaped by external factors that can persuade women to deviate from the planned, desired behavior of smoking cessation (7). The assumption that decision making is a linear process neglects to consider the extraneous factors that might influence the target audience’s behavior. In a study of women’s attitudes toward smoking, it was found that although most of the women in a focus group considered themselves addicted and dislike smoking itself, they liked the social, psycho-logic, and physical effects of the cigarettes (23). Some reasons given by women for maternal prenatal smoking included those related to an inability to cope with psychological issues (i.e., depression, anxiety, irritability, etc.) and their physical addiction to nicotine (the appearance of characteristic withdrawal symptoms when the use of nicotine is suddenly discontinued) (3). Other factors associated with smoking cessation for pregnant women are their level of education and their race. Research reveals that smoking cessation among pregnant women increases as their level of education increases (5.). In 1991, 45.4 percent (±10.5) of women with 16 or more years of education quit smoking during pregnancy. This finding is consistent with previously published studies (6, 11.). Studies also showed that the percentage of smokers who reported having quit smoking for at least one week during their pregnancy was higher among American Indian mothers (64 percent) than among white mothers (57 percent) or black mothers (49 percent) (26). The factors that impact the decision to participate in maternal prenatal smoking cessation are not all rational, nor are they part of a linear decision making process. The previously stated research helps to illustrate the fundamental flaw of a maternal prenatal smoking cessation intervention based on the TPB model because it demonstrates that the human decision making process is irrational and unplanned (10), thus completely contradicts the functioning of the TPB model.
Conclusion
Due to the inherent flaws and shortcomings of all health behavioral theories, there is no one theory able to adequately and accurately predict human behavior. Human behavior is complex and influenced by a number of intrinsic and extrinsic factors (12). When attempting to predict human behavior, it is important to examine behavior decisions in the context of the target audience’s needs, preferences, social and environmental networks, and core values. In regards to such, public health practitioners must design and utilize health behavior modification interventions based on appropriate health behavior models in order to continue to advocate for healthier behavior.
Introduction
In assignment #3, the fundamental flaws of a maternal prenatal smoking cessation intervention based on the theory of planned behavior (TPB) approach was highlighted. This paper addresses the fundamental flaws highlighted in assignment #3 by offering an alternative approach to the maternal prenatal smoking cessation intervention. To address the fundamental flaws of the TPB approach, the new approach is based on the framing theory. Framing theory asserts that an issue can be viewed from a number of different perspectives . These different vantage points can be interpreted as having implications for multiple deeply ingrained core values of a population. Framing refers to the process by which people develop a particular conceptualization of an issue or organize their opinions about an issue (30). Thus, framing theory redefines, repackages, repositions, and reframes behavior modification interventions in a way that addresses the fundamental core values and needs among the target audience (33). The framing theory approach improves upon the flaws of the TPB approach in assignment #3 because it functions on a community level, takes advantage of the fact that human behavior is irrational and decision making can be non-linear, and it understands that perceived behavioral control is not a predictor of actual behavior control because there are external factors that can impact whether or not a person performs a desired behavior.
Functions on Community Level
Unlike the TPB approach, the framing theory functions on a community level by addressing the wide-spread core values of the target audience. This theory does so by speaking to the packaging and positioning of a public health intervention to appeal to deeply ingrained, widely shared core values held by the target audience (33). A community level smoking cessation intervention must be able to address the common ground amongst pregnant women and impact those core values in order to effectively promote the behavior change of smoking cessation. Literature shows that health is generally important to individuals because it impacts their core values by garnering the fundamental need and desire to have a certain degree of personal freedom, independence, autonomy, and control over their lives (33). To market changes in health behavior, public health must redefine, repackage, reposition, and reframe the health behavior intervention in a way that satisfies an existing demand among the target audience (33). By redefining the problem, framing also suggest a new solution to the problem (35). Framing theory moves the maternal prenatal smoking cessation intervention from the individual level to the community level because this approach equips the intervention with the capacity to appeal to the core values of the general public (34).
While the underlying model in assignment #3 tries to change current health behaviors to fit with the suggested health behaviors, the framing theory recognizes that the target audience will only take action when they believe that the suggested behavior aligns with the core values of their community. Thus, the framing theory focuses on appealing to its audience’s widely accepted core values and not the health value of the public health practice (33). For example, if public health practitioners were trying to market a framing theory approach of smoking cessation to pregnant teenaged girls, the intervention should address the core values of this target audience. Research shows that continued smoking during pregnancy projects a personal image perceived by the smoker as cool, tough, defiant, adventurous, and sexy (29). The framing theory approach could use these core values to create an intervention that sends the message that not smoking during pregnancy is cool, tough, defiant, adventurous, and sexy. This repackaging and repositioning of teenaged maternal prenatal smoking cessation speaks to the core values of a large community of people, thus having appeal beyond the individual level.
Takes Advantage of Irrational Human Behavior and Non-Linear Decision Making

The framing theory takes advantage of the fact that human behavior is irrational and that decision making can be non-linear. This theory addresses the flaws from assignment #3 by using irrational human behavior and spontaneous decision making as means through which it can change the perception of a suggested behavior while ultimately changing the audience’s perception of self interest. It does so by altering the relationship between the perception of the behavior and the audience’s self interest. Framing theory does not assume the need to change its audience’s health behaviors to conform to the suggest health behavior. This model redefines the suggested behavior so that it is perceived as being in the audience’s self interest and addresses the audience’s core values (33). This will encourage the audience to participate in the suggested behavior. This is achieved by demonstrating that the intervention will help the audiences to fulfill its fundamental needs and desires.
For example, a maternal prenatal smoking cessation campaign based on the framing theory can use a group of core values; such as freedom, independence, and control, to frame an intervention. Instead of defining a smoking cessation intervention as a behavior that will improve a person’s health, it can be redefined to be perceived as a behavior that will offer smokers freedom from the tobacco industry’s manipulation, independence from the addiction of nicotine, and control over the fate of their lives. In this smoking cessation campaign, the solution to the problem of loss of freedom, independence, and personal control is smoking cessation. The irrational behavior and non-linear nature of human decision making enables the relationship between the perception of the audience’s behavior and the perception of the audience’s self interest to be altered by repackaging and repositioning a smoking cessation campaign to be about empowerment within the target community.
Perceived behavioral control is not a predictor of actual behavior control because there are external factors that can impact a person’s ability to perform a desired behavior

The framing theory accounts for the fact that perception of control over one’s ability to complete a behavior (perceived behavioral control) does not necessarily lead to actually having the power or control to practice that behavior (actual behavioral control). Perceived behavioral control does not lead to actual behavioral control because there are external factors that can limit a person’s ability to perform a behavior in which he/she might have perceived control over (13). Whether or not a person perceives that he/she has full control over his/her ability to perform a behavior and also the strength to do so, does not necessarily lead to the person performing the desired behavior (25). Research shows that tobacco use (or non-use) results from a complex mix of influences that range from factors that are directly tied to tobacco use (e.g., beliefs about the consequences of smoking) to those that appear to have little to do with tobacco use (e.g., parenting styles and school characteristics). Thus, there are a number of social factors that attribute to why women continue to smoke during pregnancy (22).
The TPB approach does not accurately predict how people move from intention to behavior because it inaccurately asserts that perceived behavioral control is a predictor of actual behavioral control. It does not consider the impact of external factors in a person’s ability to have actual behavioral control. The framing theory addresses this flaw by redefining, repackaging, repositioning, and reframing the health behavior intervention in a way that satisfies an existing demand or need within the lives of the target audience, thus, addressing the external needs and desires of the audience to enable them to participate in the desired behavior (33). For example, a group of pregnant women have the desire to stop smoking are offered an opportunity to participate in a free program that will assist them with smoking cessation (perceived behavioral control). Unfortunately, many of the women are unable to attend the weekly program due to transportation issues, lack of appropriate child care, work, etc. This means that these women do not possess actual behavior control to carry out their desired behavior of smoking cessation. A framing theory approach would restructure the health behavior intervention in ways that would satisfy the demands and needs within these women’s lives in order to give them actual behavior control to participate in smoking cessation.
Conclusion
Maternal prenatal smoking is a complex behavior that is influenced by a number of factors. The framing theory is able to addresses the different ways in which situational and personal factors influence a woman’s decision to participate in smoking cessation. The framing theory provides public health practitioners with a means through which they can define, position, and package a smoking cessation intervention in ways that address pregnant women’s core values and help to them to quit smoking.





Works Cited

References
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2.) Brosky, G. Why do pregnant women smoke and can we help them quit? Canadian Medical Association Journal Jan. 15, 1995; 152(2): 163–166.
3.) Draper, E. and Haslam, C. A qualitative study of smoking during pregnancy.
Psychology Health & Medicine 2001; 6, 95−99.
4.) Dutta-Bergman, M. Theory and Practice in Health Communication Campaigns: A Critical Interrogation. Health Communication 2005; 18 (2); 103–122.
5.) Fingerhut, L.; Kleinman, J.; and Kendrick, J. Smoking before, during, and after
pregnancy. American Journal of Public Health 1990; 80 (5):541–4.
6.) Floyd, R et al. A review of smoking in pregnancy: effects on pregnancy outcomes and cessation efforts. Annual Review of Public Health 1993; 14:379–411.
7.) Gillies, P., Madeley, R., and Power, F. Why do pregnant women smoke? Public
Health Sept. 1989; 103 (5): 337-43.
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