Supportive Counseling and Its Impact on Expecting Mothers

by Layla Langdon, Doctor of Pharmacy Student, University of Mississippi School of Pharmacy

Summary and Analysis of: Esfandiari M, Faramarzi M, Nasiri-Amiri F, et al. Effect of supportive counseling on pregnancy-specific stress, general stress, and prenatal health behaviors: A multicenter randomized controlled trial [Internet]. Patient Education and Counseling 2020;103 (11): 2297-2304 

This article caught my attention because we have been studying women’s health and the impact of the mother’s behaviors and stress on a developing baby. Also, as a student pharmacist, I am very interested in pursuing a career in pediatrics, and a child’s health really starts in the womb. This study attempted to demonstrate the impact of an educational support program on a woman’s pregnancy-related and general stress as well as prenatal health behaviors. Pregnancy-related stress is often the result of worrying about maternal and fetal health, parental responsibility, physical symptoms, labor pain, childbirth, and the cost of raising a child.¹ All of these factors weigh on a woman and starts to take a toll on her health and can lead to a poor pregnancy outcome. Using supportive counseling to supplement usual antenatal care, this study aimed to reduce maternal stress and promote healthy behaviors that would benefit the mother and the developing child.

To test this theory, pregnant women between gestational age 6 and 32 weeks with no comorbidities were recruited to participate in this randomized, control study. The participating women were divided into two groups with 40 participants each. Women in both groups completed four questionnaires at baseline including the Revised Prenatal Distress (NUPDQ), Spielberger State-Anxiety Inventory (STAI-Y), Prenatal Health Behaviors Scale (PHBS), and the Perceived Stress Scale (PSS-14).  In addition, all of the women provided a saliva sample to measure salivary cortisol concentration. Each participant was advised to fast and avoid alcohol for at least 24 hours before the salivary sample was taken. Changes in the NUPDQ, STAI-Y, and PHBS were the primary outcomes for this study, and the PSS-14 and the salivary cortisol assay were considered secondary outcomes.

The control group received only usual antenatal care based on Iranian national guidelines. Each participant in this group received midwifery examinations, assessments of the mother’s and fetus’s health, and education about personal hygiene, sexual activity, signs of a high-risk pregnancy, common pregnancy complaints, nutritional and medicinal supplements, and use of fertility health services. In addition to usual antenatal care, the intervention group received weekly supportive counseling conducted by a female expert psychologist. These supportive counseling sessions consisted of face-to-face instruction with 12 to 14 women in each group. This gave the women the opportunity to interact with one another.  During these sessions, they discussed their stress and anxiety.  The instructor also designed group work and guided exercises to address unhealthy behaviors. The program targeted pregnancy-related worries such as health problems and costs, parental responsibility, physical symptoms, infantile health, parenting, labor pain, and childbirth phobia. Six weeks after completing the educational program, all participants in both groups again completed the four questionnaires and provided a salivary sample to measure their cortisol.

The results revealed there were significant improvements in the mean NuPDQ, STAI-Y, PHBS, and PSS-14 scores in the intervention group, including in the subscales of these instruments, when compared to the control group. Specifically, there were large effect size improvements in the medical and financial problems, infant health, physical symptoms, and labor and delivery subgroups of the NuPDQ and the four subgroups of the PHBS (See Table 1). The salivary cortisol levels improved in both the intervention and control groups but there were no significant differences in the mean change observed. 

Table 1. Mean Pre (T0) and Post (T1) Scores and Differences for Selected Outcomes Following an Educational Support Program for Pregnant Women

	Intervention			Control
	T0 Mean	T1 Mean	Change	T0 Mean	T1 Mean	Change
Primary Outcomes
NuPDQ	11.85	5.6	-6.97	9.42	11.32	2.62
STAI-Y	44.4	35.8	-7.2	40.65	41.82	.52
PHBS
Harmful Behavior of Health	4.17	2.42	-1.72	4.37	4.82	0.42
Health Promoting Behavior	20.2	23.67	3.53	20.45	20	-0.51
Harmful Physical activity of Health	5.52	3.6	-1.91	5.57	5.62	0.03
Health Promoting Physical activity	3.97	7.07	2.88	3.1	2.95	0.06
Secondary Outcomes
PSS-14	23.45	16.82	-7.20	21.82	21.77	-0.53
Serum Cortisol	23.32	20.25	-3.32	17.57	14.98	-2.61

One of the strengths of this study was the use of four different questionaries to evaluate the effect of supportive counseling on pregnancy-specific, general stress, and healthy behaviors. Another strength of this study is that the supportive counseling provided to the experimental group was provided in small groups with only 12 to 14 participants per group. This allowed each participant to develop relationships with other pregnant women who may be experiencing the same struggles. This study also aimed at improving each participant's self-esteem and maximizing their adaptive skills. These are important objectives because pregnant women often feel incapable of birthing and raising a child. The weaknesses of this study are that the questionnaires used were all based on self-evaluation. The authors do not discuss the sustainability of the program and don’t report outcomes after delivery – so the health outcomes of the babies is unknown. The findings of this study probably should not be generalized to complicated pregnancies.  While salivary cortisol was included as a measurement of stress, it does not correlate well with psychological stress.

In future studies, it would be helpful for each participant to complete a session with a mental health professional. This would allow a more personalize assessment and help the participants identify and analyze the specific stressors they are experiencing. Also, the addition of this session could be used as an external evaluation. Although this is a subjective measurement similar to the self-evaluations, an assessment performed by a mental health professional would be consistent for all participants. Future studies should gather data through the entire pregnancies, including delivery, plus three months postpartum.  This is important to truly determine the long-term effect of supportive counseling on pregnancy-related stress and outcomes.

A similar study analyzed the effect of a supportive intervention in pregnant women who were depressed using the Postnatal Depression Scale (EPDS >12).³ In this study, the intervention group received the same number of counseling sessions, six visits, but over eight weeks. That study also concluded that supportive counseling in addition to usual prenatal care improved outcomes. Specifically, the participants reported improvements in depressive symptoms, depressive severity, and quality of life. Another study found that supportive counseling improved the patient’s satisfaction during delivery.⁴ Although these studies had minor differences in terms of the number of counseling sessions provided, the program duration, and the number of participants, they all concluded that supportive counseling subjectively improved pregnancy-related stress 

While the supporting counseling program appears to have been effective, it would have been helpful if the intervention were described in more detail. This would allow other health professionals, such as pharmacists and nurses, to implement a similar program. However, this study is important because it demonstrated the benefits of adding supportive counseling to usual prenatal care. This may also improve the health of the fetus and allow for a smoother birthing experience. Overall, I believe that providing supportive counseling to pregnant women should be the standard of care during all pregnancies.

 

References

1. Esfandiari M, Faramarzi M, Nasiri-Amiri F, et al. Effect of supportive counseling on pregnancy-specific stress, general stress, and prenatal health behaviors: A multicenter randomized controlled trial [Internet]. Patient Education and Counseling 2020;103 (11): 2297-2304.
2. Nast I, Bolten M, Meinlschmidt G, Hellhammer DH. How to Measure Prenatal Stress? A Systematic Review of Psychometric Instruments to Assess Psychosocial Stress during Pregnancy. Paediatric and Perinatal Epidemiology. 2013;27(4):313–22.
3. Neighmond P. To Prevent Pregnancy-Related Depression, At-Risk Women Advised To Get Counseling [Internet]. National Public Radio. NPR; 2019 [cited 2020Oct19].
4. Segre LS, Brock RL, O'Hara MW. Depression treatment for impoverished mothers by point-of-care providers: A randomized controlled trial. J Consult Clin Psychol 2015; 83 (2): 314-24.
5. Pasha H, Basirat Z, Hajahmadi M, Bakhtiari A, Faramarzi M, Salmalian H. Maternal expectations and experiences of labor analgesia with nitrous oxide.. Iranian Red Crescent Med J 2012; 14 (12): 792-7.

Understanding Patient Medication Experiences through Theater

by Alexandra Frazier, Doctor of Pharmacy Candidate, University of Mississippi School of Pharmacy

Summary and Analysis of: Cernasev A, Kuftinec S, Bortz R, Schommer JC, Ranelli PL. Using Theater as an Educational Tool for Understanding Medication Experiences from the Patient Perspective [Internet]. Am J of Pharm Educ. 2020; 84(4): Article 7606. doi:10.5688/ajpe7606

As student pharmacists, a great deal of our education is dedicated to learning how to provide medication counseling and handle patient interactions in various pharmacy practice settings. This training not only involves learning how to provide the essential information patients need to use medications wisely but also delivering that information with empathy, listening actively to patients, and applying motivational interviewing techniques. Though pharmacy students are trained on how to assist patients struggling to acquire medications, students in other healthcare professions do not always receive formal instruction about how to assist patients experiencing access barriers. Healthcare professionals should be knowledgeable about the issues that may arise when medications are prescribed to patients, be prepared to handle these situations efficiently, and be able to express empathy for patients in difficult situations.

This unique study examined the effectiveness of theater as an educational tool for healthcare professionals.¹ The American Alliance for Theatre and Education (AATE) defines drama-based learning strategies as “an improvisational, non-exhibitional, process-centered form of drama in which participants are guided by a leader to imagine, enact, and reflect upon human experiences.”² I was captivated by this study because it allowed healthcare practitioners to gain perspective into patients’ experiences in an innovative way.¹

From April 2015 to March 2016, adults in the U.S. completed the self-administered the National Consumer Surveys on the Medication Experience and Pharmacist Roles. Comments from this survey were compiled detailing participants’ medication experiences. These comments were then used as the inspiration for a theatrical script written by Syl Jones and performed by Mixed Blood Theatre. The play, Go Ask Alice, included a total of seven scenes that explored multiple patient scenarios as well as a mock drug advertisement. There were two performances of Go Ask Alice – one in Minneapolis, Minnesota on November 29, 2016, and the other in Duluth, Minnesota on November 30, 2019. The play lasted ~60 minutes and was followed by a talk-back session facilitated by one of the authors that lasted ~30 minutes. These talk-back sessions were not led by any guided questions but instead allowed audience members to discuss the play openly with one another. Members of the audience were asked to complete a survey before the performance, immediately after the talk-back session, and then three weeks later. These assessments each contained the same seven statements regarding patient medication experiences and asked participants to rate their agreement with each statement. The two additional questionnaires were administered after the play which contained demographic questions and open-ended questions asking for feedback on the experience. The findings from the seven statements were summarized with descriptive statistics and inductive thematic analysis was performed on the open-ended questions.¹

A total of 225 health professions students attended the two performances; 161 participants completed the post-performance survey and only 58 completed the 3-month follow-up survey. There was a significant increase in the survey scores before vs. after the performance. Some of the key results of this survey are detailed in Table 1. During the qualitative analysis, the responses to the open-ended questions were merged into six categories then ultimately two themes: 1) barriers faced by patients when seeking health care services and 2) major hindrances and contributors to the patients’ medication experience. Overall, the results show that theatrical performance may be an effective educational tool to understand the human experience from a patient’s perspective.¹

Table 1: Pre- and Post-Performance Survey Results

Survey Item	Before Performance, Mean (SD)	After Performance, Mean (SD)	P-value
I am able to fully empathize with patients	3.6 (0.9)	3.9 (0.9)	<.001
I am fully aware of all the challenges patients experience with taking their medications	3.0 (1.1)	3.4 (1.1)	<.001
I am fully aware of the attitudes patients hold toward their medications	2.8 (0.9)	3.5 (1.0)	<.001
I am fully aware of all the challenges patients experience with filling their medications	3.0 (1.0)	3.6 (1.1)	<.001
I am fully aware of the roles of medications in society	3.3 (0.9)	3.6 (0.9)	<.001
I fully understand the process of prior authorizations	2.9 (1.2)	3.5 (1.1)	<.001
I fully understand the effect of the medication experience on a patient’s family	2.9 (0.9)	3.5 (1.1)	<.001

 

One of the biggest strengths of this study is the longitudinal assessment of audience members’ perspectives before and after the performance as well as three months following the play. This was an effective way to discern the audience’s initial perceptions and how Go Ask Alice affected their understanding of patients’ medication experiences. The post-performance talk-back session could be seen as both an advantage and disadvantage. The session allowed audience members to explore their feelings and reactions to the play, which would be advantageous for learners. However, this discussion could have influenced the results of the surveys by emphasizing all the aspects of patient experience that audience members were supposed to get from the play but did not. Another disadvantage of this study is the cost and access! The two performances cost roughly 25000.  Only 225 were in attendance and the two plays were held in a relatively small geographical area (both in Minnesota). Because of this, Go Ask Alice was not widely available. A wider audience (from different geographic areas) may not have the same of reaction to the play. There was also some concern from the audience that too much medical jargon was used in the script.

I feel like the analysis method used to evaluate the rate of agreement with the seven statements was appropriate, as was the use of a thematic analysis for the evaluation of the open-ended questions. For this qualitative analysis, one researcher read the comments several times and identified the main codes and categories. After this, a second researcher evaluated the codes and categories.  If needed, the second researcher debated the coding and classifications with the first researcher.  Based on both the results of this study and my personal experience with drama-based educational techniques, I do believe theater is an effective way to teach healthcare providers to see experiences from patients’ perspective. Moreover, this is an entertaining way to present information when real-life experience may not be a practical option.

Another study explored the negative impact of medication-related burden (MRB) and patients’ lived experience with medication (PLEM) therapies or medical conditions.³ This study concluded that because of the impact MRB has on patients’ beliefs and behaviors toward medications, healthcare practitioners need to have better insights into PLEM to improve patients’ medication therapy and outcomes.³ Though theatre models have been used to educate healthcare students in various situations, there is little literature on the appeal of such techniques to trainees.⁴ Another study concluded that the drama-based learning technique used had a generally positive influence on medical students’ perceptions.⁴

Because patient-centered care has the potential to strongly impact patient health outcomes, healthcare providers need to understand the struggles patients might face and be able to express empathy.⁵ This study explored an innovative teaching method that allowed audience members to understand and experience medication issues from a patient perspective.¹ Based on the feedback received from the audience, it seems that the educational tool was successful in achieve its goal but it’s impact was limited to a small audience.¹ In the future, such plays could be recorded for mass viewing or even adapted into active learning exercises for re-enactment by students in the health professions. Future healthcare professionals may benefit from the incorporation of drama-based learning strategies into their curricula, especially in areas where understanding the patient’s perspective is critically important.

References:

1. Cernasev A, Kuftinec S, Bortz R, Schommer JC, Ranelli PL. Using Theater as an Educational Tool for Understanding Medication Experiences from the Patient Perspective [Internet]. Am J of Pharm Educ. 2020; 84(4): Article 7606.
2. DBI Network: Activating learning through the arts [Internet]. Austin: The University of Texas at Austin; c2020. Drama-based Pedagogy; 2020. Available from: https://dbp.theatredance.utexas.edu/about
3. Mohammed MA, Moles RJ, Chen TF. Medication-related burden and patients’ lived experience with medicine: a systematic review and metasynthesis of qualitative studies [Internet]. BMJ Open. 2016; 6: e010035. doi: 10.1136/bmjopen-2015-010035
4. Keskinis C, Bafitis V, Karailidou P, Pagonidou C, Pantelidis P, Rampotas A, Sideris M, Tsoulfas G, Stakos D. The use of theatre in medical education in the emergency cases school: an appealing and widely accessible way of learning [Internet]. Perspect Med Educ. 2017; 6: 199-204.
5. Stewart M, Brown JB, Donner A, McWhinney IR, Oates J, Weston WW, Jordan J. The Impact of Patient-Centered Care on Outcomes [Internet]. J of Fam Prac. 2000; 49(9): 796-804.