Behavioural change techniques within the intervention

The intervention was designed to engage mothers in discussing their current emotional and psychological context and what they would like to achieve from exercise in order to modify their situation. A series of cognitive behavioural change techniques were utilised to facilitate self-modification of exercise behaviours. The following behavioural change techniques have been categorised by Michie and Johnston in their taxonomy of behavioural change techniques to promote change in physical activity and eating behaviours (184). (Appendix Figure 6)

To increase mother’s knowledge and understanding of the aim of the intervention, they were initially presented with the potential mood related benefits of exercise for women in the postnatal period and the negative consequences of remaining inactive. Mothers were then encouraged to consider their motivation for exercise. There are many potential physical and psychological barriers to exercise for mothers with PND, mothers were therefore encouraged to consider ways of

overcoming these barriers through problem solving. This process was of particular importance in facilitating the initiation of exercise. Restructuring of the participant’s physical environment was explored if, for example, they wished to create an exercise environment at home. Mothers were also encouraged to restructure their social environment by seeking social support within their network of family and friends. This support may have involved seeking informal childcare, support from a partner to exercise together, a friend accompanying the mother to the gym or

80

Goal setting was performed at each contact between the participant and PAF. Mothers were encouraged to define their exercise objectives, making them specific, measurable, action-orientated, realistic and timed. The importance of a goal being realistic was stressed in order to avoid the experience of ‘false hope syndrome’ as described by Polivy and Herman, in which unrealistic expectations result in a loss of control and the eventual failure of the attempted behavioural change (185). Guidance on how to perform exercise behaviours was provided; appropriate

duration and intensity were discussed including the indicators of moderate exercise. Demonstration of moderate exercise in the form of a walk with the PAF was

provided if desired. The use of graded tasks encouraged progression from the goal of 30 minutes of moderate exercise three times a week in the initial weeks of the intervention, to 30 minutes five times a week in the later stages.

Self-monitoring was encouraged with the provision of exercise diaries relating exercise and mood (Appendix Figure 7), and pedometers. Feedback on exercise behaviours was provided by the PAF. Exercise goals were reviewed including possible reasons for changes that had or had not been successfully made. New goals were set in light of how a mother was progressing. The mood related consequences of the behavioural change were discussed at each meeting between the PAF and mother. Encouragement was provided by the PAF, who was supportive of mothers’ attempts to be active, whether goals were achieved or not. Participants were

encouraged to self-monitor their own exercise and associated mood related progress using an exercise diary.

In the initial stages of the intervention mothers were provided with two face to face sessions in their home with the PAF. This contact was reduced to two shorter

81

sessions delivered via phone in the later stages of the intervention, followed by phone contact only if initiated by the participant. Fading of support was used in conjunction with advice on maintenance of exercise behaviours to encourage long term adherence to behavioural change.

3.3.2.2 Motivational interviewing

Motivational interviewing (MI) is communication style that was devised for work between health professionals and patient with addiction issues. MI has been defined as ‘A directive, client-centred negotiating style for helping patients explore and resolve ambivalence about health behaviours’ (186). In preparation for delivering the intervention the PAF attended introduction to MI and intermediate MI courses at Sheffield Hallam University delivered by an MI network trainer. It is recognised that the simple provision of information may be premature for those who are not ready to make a decision regarding a new behaviour, perhaps because they are ambivalent about the benefits of the new behaviour. In this intervention, the techniques of MI were used to help mothers to discuss and resolve their views and concerns regarding the benefits and disadvantages of becoming more active, reducing their ambivalence and increasing the likelihood of exercise behaviours being adopted. Motivational interviewing was felt to be an appropriate method of enhancing the effectiveness of communication between the PAF and the participants, particularly in view of the lack of motivation often reported by people with depression (187, 188).

This method of interviewing is also compatible with the theoretical basis of this intervention, the Transtheoretical Model (111), which recognises that people may be at different stages of readiness to alter their behaviours. Mothers in the

82

present RCT were asked questions such as ‘How important is becoming more active to you?’ and ‘How confident are you that you can become more active?’ in order to gauge their readiness to adopt exercise behaviours. Motivational interviewing provides a range of different communication strategies which are appropriate to people at different stages of readiness to change. Consequently, discussions with mothers who were felt to be in precontemplation began with conversation about their current lifestyle, what a typical day entailed for them, their mental health and any exercise they were currently undertaking. The benefits and disadvantages of exercise and of remaining inactive might be discussed and information provided related to exercise and mood. For those who were in precontemplation who may have been more resistant to change, emphasis was placed on personal choice. For those in the contemplation stage or who were commencing their behavioural change discussion would also focus on what the participant hoped to achieve and why; an exploration of any concerns they had regarding becoming more active; help with decision making and the shared formation of specific exercise plans.

Certain skills were used within all consultations in order to facilitate rapport, including the use of open questions to ensure that the discussion is focused on what is important to the individual mother. Reflective listening was used to indicate the PAFs attention and empathy. Summarising was performed to reflect the PAFs understanding and acceptance of the mothers’ statements and beliefs, whilst the PAF refrained from over representing their own opinions. Affirmation was used to support the mother’s confidence and self-efficacy for decision making. The mother’s self-efficacy for behavioural change was also supported by the PAF assisting them in understanding their own capabilities. Through the use of MI and complementary

83

communication techniques the focus of the intervention remained on supporting the mother to progress from ambivalence to instigating her own behavioural change (186).