Taking a patient-oriented approach in exercise interventions for pregnant women: a commentary

Abstract

Taking a patient-oriented approach to developing lifestyle interventions includes incorporating the patient into the program’s design, delivery, and evaluation. This commentary assumes that a patient-oriented approach has not yet been implemented and tested in exercise-based interventions designed for pregnant women. We outline and define a patient-oriented approach to conduct exercise-based research and review previous physical activity interventions designed for pregnant women to determine whether a patient-oriented approach was applied. In addition, pregnant women living with obesity may have unique barriers to engaging in prenatal exercise interventions that have not been previously addressed, such as having experienced weight stigma before pregnancy in healthcare and fitness settings. We propose suggestions for future trials to effectively take a patient-oriented approach when designing and implementing prenatal exercise interventions to address patient-informed barriers and incorporate suggested facilitators for physical activity. Given that prenatal activity levels are low and pregnant women may have unique barriers to engaging in exercise interventions, a patient-oriented approach may be an effective strategy to improve inclusivity and equity and, as a result, increase uptake and adherence to the intervention.

Introduction

Patient-oriented care incorporates the patient in the delivery of their healthcare by identifying their health-related priorities, and individualizing recommendations, assessments, and treatment options (Canadian Institutes of  Health Research, 2019). Research consistently indicates that patient-oriented care is an effective strategy for improving health outcomes (e.g., prevention of multi-morbidities including hypertension, diabetes, and depression), patient-physician communication, and motivation to meet behaviour change goals (e.g., increasing physical activity levels) (Smith et al. 2016).

Pregnant women represent a population at risk for high levels of sedentary behaviour (Huberty et al. 2016) and may have unique barriers to engaging in prenatal physical activity interventions (Evenson et al. 2014). High sedentary time and physical inactivity during pregnancy increase the risk of complications, such as preeclampsia and macrosomia (Fazzi et al. 2017). As well, women who have an elevated body mass index (BMI) may have additional barriers to participating in physical activity interventions that have not been previously addressed in exercise-based research studies, such as having experienced weight stigma before pregnancy (Myre et al. 2020). This commentary advocates for taking a patient-oriented approach for designing and delivering physical activity interventions for pregnant women, intending to increase uptake and adherence throughout gestation. According to the Strategy for Patient-Oriented Research – Patient Engagement Framework, a patient-oriented approach would include a collaborative effort among patients, researchers, healthcare providers, and decision-makers to inform the design and delivery of the exercise intervention (Canadian Institutes of Health Research 2019).

Adherence to exercise during pregnancy

The 2019 Canadian Guideline for Physical Activity throughout Pregnancy recommends that pregnant women without contraindications to exercise should achieve 150 min of moderate-intensity exercise per week (Mottola et al. 2018). Overall, there is a global consensus that physical activity during pregnancy should be promoted to accrue the many maternal and fetal health benefits (Evenson et al. 2014). Despite the known health benefits of physical activity during pregnancy, most pregnant women do not meet physical activity recommendations, and total sedentary time is particularly high among pregnant women with an elevated BMI (Huberty et al. 2016).

Attributing BMI as a potential causal factor for low prenatal exercise levels and participation in exercise interventions may further perpetuate a common weight stigmatizing perception that individuals living with obesity are not motivated to engage in exercise (Myre et al. 2020). Approximately 56% of pregnant women living with overweight/obesity report receiving limited or no advice on physical activity (Stengel et al. 2012), despite research suggesting that most pregnant women are receptive to learning about exercise during pregnancy irrespective of pre-pregnancy BMI (Smith et al. 2016). In addition to BMI, other maternal factors that can contribute to low adherence to physical activity interventions include having co-morbidities (e.g., prenatal depression, gestational diabetes mellitus), living situation (e.g., rural communities, other children to care for), socio-economic factors (e.g., job requirements, low income), and physical changes throughout gestation (e.g., nausea, fatigue) (Harrison et al. 2018). These social determinants of health may also intersect, and therefore will vary at the individual level for all pregnant women. Thus, a patient-oriented approach for exercise interventions may be able to identify barriers and priority areas, and improve overall uptake for all women.

Patient-oriented approach for prenatal exercise interventions

A patient-oriented approach aims to engage the community (i.e., patients and their network) as partners in the entire research process (Canadian Institutes of Health Research 2019). As such, the Saskatchewan Centre for Patient-Oriented Research (SCPOR) developed a project planning tool outlining seven considerations for investigators to incorporate when taking a patient-oriented approach to their research (SCPOR 2019): (1) patient involvement is essential to ensure that the research is focused on the public interest and concerns; (2) current or former patients, their caregivers, families, and organizations might contribute with ideas for new research areas based on patient necessities; (3) these partners would work on identifying research priorities and can be involved in various stages of a project such as the design, preparation and execution; (4) there are different methods of engaging patient team members (e.g., focus group, surveys, social media); (5) research partners may engage in diverse levels of the project development (e.g., informing the research context, providing feedback on the analysis, guiding the implementation process); (6) an honorarium rate (for patient involvement) may be established depending on the research funding source; and finally (7) the monitoring and evaluation of partner engagement and their contribution to the research project are fundamental to guarantee an effective patient-oriented approach was applied (SCPOR 2019).

For prenatal exercise-based studies, the patient-oriented approach may take the form of selecting which health outcomes are important to evaluate and the inclusion of family members and partners in the study design. Women should be engaged to establish the methods and procedures, and subsequently evaluate the program based on barriers identified and the preferences of the pregnant participants who will be engaged in the study (e.g., type of exercise, frequency of program, intensity level, group-based or individual interventions).

Evaluating previous exercise interventions for patient-oriented strategies

In 2013, Currie et al. published a systematic review exploring the effectiveness of physical activity interventions and behaviour change techniques for pregnant women (Currie et al. 2013). Similarly, Flannery et al. used the same methodology to assess physical activity interventions and the adoption of behaviour change techniques specifically for pregnant women with an overweight or obese BMI (Flannery et al. 2019). Whether studies included in these reviews applied a patient-oriented approach was not recorded.

We evaluated the randomized controlled trials (RCTs) included in the Currie et al. (2013) and Flannery et al. (2019)meta-analyses for whether a patient-oriented approach was used or not. A total of 25 RCTs were assessed, and our appraisal indicates that none adopted a patient-oriented method. A nested randomized trial developed by Szmeja et al. (2014) and an RCT from Gaston and Prapavessis (2009) partially considered a few aspects of a patient-oriented approach (Gaston and Prapavessis 2009; Szmeja et al. 2014). Women randomized to receive the lifestyle intervention were provided with individualized information based on their dietary and exercise history, were encouraged to set behaviour goals they viewed as achievable, and identified potential barriers to achieving their dietary and physical activity goals (Szmeja et al. 2014). There was also a notable section that intended to get women to think about how, when, and where they were going to exercise (Gaston and Prapavessis 2009). Although elements implemented by these studies (i.e., participants’ identification of their personal barriers and intentions) are important attributes for ensuring a more sensitive and acceptable intervention methodology, their studies lacked the up-front involvement of pregnant women to inform the design of the program.

Future direction and recommendations

A patient-oriented approach for prenatal exercise interventions meets the expectation of the philosophy, “Nothing about us, without us”, meaning that pregnant women for whom the exercise intervention is intended, should be involved in the actual design and dissemination (Paul 2016). We offer suggestions for incorporating a patient-oriented approach in future prenatal exercise interventions:

• i.Verify, through a survey or qualitative-based study, the opinions of pregnant women on individual barriers and facilitators to engaging in an exercise intervention, important outcomes that need to be evaluated through exercise and pregnancy research, components of an exercise prescription deemed manageable (e.g., frequency of exercising, intensity of the exercise, timing of the program, and type(s) of exercise), and who women think are the contributors on research teams who can best represent their perspectives (e.g., women with a specific BMI, previous exercise experience, or certain expertise);
• ii.Based on the first step, determine the criteria to engage women in the initial steps of designing an exercise program and develop the intervention accounting for identified priority areas and preferences;
• iii.Test the feasibility and adherence to patient-oriented exercise interventions, where the participant is engaged from the design to the evaluation, on selected health outcomes that were directed by women.

Conclusion

In summary, a patient-oriented approach has not been ardently applied in the design of studies examining the effects of an exercise intervention for pregnant women. Future studies should engage women at the initial stages of the research process, including informing the design, priorities, and dissemination of prenatal exercise interventions. By including pregnant women through a patient-oriented approach, exercise-based interventions can improve inclusivity and equity, resulting in increasing prenatal physical activity levels.

Acknowledgement

TSN is funded by a Mitacs Fellowship supported by the Society of Obstetricians and Gynaecologists of Canada.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.