A qualitative study of pregnant teenagers’ perceptions of the acceptability of a nutritional education intervention

A qualitative study of pregnant teenagers’ perceptions of the acceptability of a nutritional education intervention

A qualitative study of pregnant teenagers’ perceptions of the acceptability of a nutritional education intervention Andrew G. Symon and Wendy L.Wriede...

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A qualitative study of pregnant teenagers’ perceptions of the acceptability of a nutritional education intervention Andrew G. Symon and Wendy L.Wrieden Objective: in order to assess the feasibility of nutritional education intervention sessions for pregnant teenagers, standard dietary assessment schedules were supplemented by a qualitative appraisal. Reported in this paper are the perceptions of pregnant teenagers who attended one or more of these sessions. Design: qualitative study using a phenomenological approach. Data were collected using semi-structured tape-recorded group interviews. Setting: two community centres and one maternity unit inTayside, Scotland. Participants: ten pregnant teenagers aged 16 --18 years. Interventions: all had attended one or more of a series of food preparation sessions led by a midwife. Food to take away was provided, as were supermarket vouchers. Findings: those who attended found the sessions to be social, educational, and practical. These young women appreciated being in a group which did not include ‘older’ pregnant women.To a limited extent they had changed their dietary habits at home. Food to take home was a signif|cant attraction. Some of the teenagers sought maternity-related information from the midwife leading the session. Key conclusions: nutritional education remains an important public health issue. Despite offering a range of incentives, attracting teenagers to these sessions was diff|cult, making their economic feasibility questionable. Implications for practice: with better recruitment, such sessions could form an important part of improving nutrition and overall health for current and future generations. & 2003 Elsevier Science Ltd. All rights reserved. Andrew G. Symon MA (Hons), PhD, RGN, RM Lecturer, School of Nursing & Midwifery, University of Dundee, Dundee DD1 9SY, UK Wendy L.Wrieden BSc (Hons), RPHNutr, PhD Lecturer, Centre for Public Health Nutrition Research, University of Dundee, UK (Correspondence to: AS E-mail: [email protected] dundee.ac.uk) Received 24 July 2002 Revised 4 October 2002; 11th December 2002 Accepted 18 December 2002

INTRODUCTION Healthy eating can reduce or delay the development of the major causes of morbidity and mortality in the UK (DoH 1991, SODoH 1999). Achieving dietary change in the entire population presents a major public health challenge (Scottish Office 1996), particularly in low-income households. Poor levels of disposable income, unemployment, poor housing, sub-optimal mental and physical health, and limited access to a wide variety of reasonably priced foods, all contribute to difficulties in tackling behavioural Midwifery (2003) 19, 140 --147 & 2003 Elsevier Science Ltd. All rights reserved. doi:10.1016/S0266 - 6138(03)00004- 4/midw.2002.0348

change. These factors, in turn, lead to increasing health inequalities (Forsyth et al. 1994, Acheson 1998). One particularly vulnerable group are teenage pregnant women, many of whom are from disadvantaged backgrounds (Social Exclusion Unit 1999). A healthy dietary intake in this group of women is important not just as an influence on maternal and baby health, but also as a blueprint for appropriate eating patterns in the whole family; this may also be an influence on the health of younger and older generations (van Teijlingen et al. 1998). Individual support or

Qualitative study of pregnant teenagers

counselling to motivate dietary change may be particularly helpful in pregnant women (Kafatos et al. 1989). Although midwives see teenage pregnant women on a one-to-one basis for parentcraft education in some parts of the UK (e.g. Cunningham 2002), it is not apparent that specific advice on diet and nutrition forms part of such services. The pilot project reported here was designed to assess the feasibility of offering a food-based educational intervention. The feasibility of any innovation in practice can be assessed in a variety of ways. Reported in this paper are the views of the pregnant teenagers concerning the sessions, since the level of acceptability among the client group is crucial to any such programme. Providing an additional service is likely to have resource implications, and so its economic feasibility must also be evaluated; we are reporting this in a separate paper, along with a formal evaluation of changes to the teenagers’ nutritional intake.

METHODS Ethical approval was obtained from the Tayside Committee on Medical Research Ethics. Costs (including funding for the midwives’ hours) were secured from the Chief Scientist Office in Edinburgh. A research nutritionist provided a training session for the two midwives who were recruited to work on the programme, following which a teaching package was produced collaboratively. This incorporated educational strategies (with information on nutrition in pregnancy, food groups and food hygiene), behavioural approaches (practical ways of incorporating the foods into low-cost meals) and motivational strategies (making the course a group activity exclusively for this age group and providing free food, transport costs and supermarket vouchers). To reinforce the importance of nutrition, written material comprising recipes, and leaflets on topics such as food safety, shopping, and eating well in pregnancy, were provided for the teenagers. Midwives were used in this programme because it was anticipated that the teenagers would find them a useful resource in terms of accessing additional information. The two midwives employed in this study were chosen for their experience in antenatal education for teenagers. Neither had a formal teaching qualification. Community centre venues in Dundee and Perth, Scotland, were secured for the sessions, and the necessary equipment was purchased. Sessions were planned for one afternoon per week, the programme lasting seven weeks in total. The final session was planned as an evaluation, with group interviews being used in

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addition to standard food assessment questionnaires. Three sets of the sessions were run in each of the venues. Food, specified for each session by the nutritionist, was purchased by the midwives using vouchers provided by a local supermarket. In Dundee the research assistant who administered the study questionnaires was also available to help with setting up and clearing away after the cooking sessions. The package was offered to women aged 16-18 years presenting at the booking clinic in their first pregnancy in Perth or Dundee. This age range has been adopted in the past (e.g. Stone & Ingham 2002), and was chosen for two reasons: daily educational provision already exists locally for pregnant teenagers under the age of 16 years, and (more subjectively) it was felt by the research team that 19-year olds were perhaps not in the same need of such an intervention. An explanatory letter and leaflet were prepared and given to each potential respondent when they attended the hospital ‘booking’ clinic in Dundee or Perth. These described the background to and reasons for the study, and explained what would be involved should they choose to participate. It was also stated that the participants could bring a friend or relative if they wished. Those who attended a session completed the locally approved consent form for research. This stated that they had read the relevant information, had had the opportunity to ask questions (and had received satisfactory answers to any questions), and understood that they could withdraw from the study at any time without their care being affected in any way. All bus fares were reimbursed, food was provided at the end of each session, and a d5 voucher provided on completion of interview schedules. A poor initial response led to contact with community midwives who assisted in recruitment, and the midwives running the course also extended personal invitations by telephone or by visiting teenagers whom they had already met. A news item also appeared in the local newspaper (cf. Wray & Gates 1996). Because of low recruitment an additional oneday course was designed and delivered using material from the longer course. Invitations and an information sheet were sent to all pregnant women aged 16--18 years, living within a five mile radius of Dundee and expecting their first baby between July 2001 and January 2002. These letters were sent by the local trust hospital and signed by the midwife running the course on behalf of the Dundee community midwives. The women were invited along with a friend or relative, and a map of the location was provided. Free transport and food to take away were offered, and a d10 supermarket voucher for completing interview schedules. An information

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leaflet was also provided, together with a return slip and stamped addressed envelope.

Response rate Out of a total of 119 teenagers contacted for the series of sessions or the one-day course, only 24 indicated that they would attend, and of these only 16 did so. Some of the cited reasons for not attending were practical, such as distance, work and education commitments. Eleven teenagers attended one or more of the weekly food preparation sessions; however, only five were present at the final session. All had been informed at the start of the sessions that a group interview would take place at the conclusion of the series. A further five attended the one-day course, bringing the total number interviewed to ten. These all indicated that they were prepared to be interviewed, and the interviews took place in three groups. Because of the small numbers involved, teenagers from two sets of sessions were asked to combine, and this interview was, by arrangement with the relevant midwife, conducted in the maternity unit. The other two interviews, including the one for the one-day course, took place in the community centre. The same semi-structured schedule, aimed at eliciting information about the teenagers’ nutritional habits and their perceptions of the organisational aspects of the sessions, was used for each interview.

Analysis Interviews were transcribed verbatim, and were initially read as narrative accounts. We used a phenomenological approach in trying to provide an accurate description of the teenagers’ views (Heidegger 1962). The discussion was allowed to develop gradually over the course of the interviews, which can be described as interactive (Brannen 1988). Because of this we believe that it was not possible to hold prior experiential knowledge in abeyance, and so bracketing was not attempted (Heidegger 1962). An open text analysis produced a sense of the whole, and identified significant statements and themes. We attempted to articulate the insight in each of the meanings of these themes, and synthesise these into a consistent and explanatory statement (Giorgi 1986).

Findings This section reports the teenagers’ responses (respondents have been allocated pseudonyms), together with prompts from the interviewer. Since this was a feasibility study, the intention was to draw out the practical implications of some of these responses. The interviews have been collated to provide a seamless narrative.

Demographic data were incomplete for two of the teenagers. Of the eight for whom data were available, four lived with one or both parents; none lived alone. Type of housing varied: four lived in a flat (apartment), two in a terraced house, and one in a detached house (accommodation for the remaining one was described as ‘Other’). One teenager’s property was owneroccupied, four lived in local council accommodation, and three paid rent to a private landlord. Seven were unemployed, and one had part-time employment. Two had no formal qualifications, the remaining six had achieved Standard Grade (basic school leaving) qualifications. Three themes emerged concerning their views of the running of the classes. These were recruitment and access, nutritional habits and acceptability of the sessions.

Recruitment and access We have acknowledged that recruitment was problematic. Amongst those who attended there was general agreement that they were pleased that they had done so, the small financial remuneration did not appear to have been a major motivating factor. We had heard that some people might have been deterred from going to one of the centres because of its location. One teenager commented: People might be put off by it, because of where it is. (Ailsa) Excepting this, those participating were reluctant to speculate on why more had not attended the sessions. We were concerned about accessibility, and had promised to reimburse bus fares for those who did attend. Some took advantage of this, with one, however, commenting that travel was not a problem: It doesnae [doesn’t] matter to me because the bus stops outside my house. (Heather) Others indicated that they lived close by, and simply walked to the centre. Living nearby may certainly encourage attendance; we can only speculate as to why others did not attend. In order to make the sessions less unfamiliar, we had suggested that the teenagers could bring a friend along: Now, you brought Tracy as a pal, is that right? Did that help the sessions? Would you have come on your own? (Interviewer) Probably no. (Ailsa) Tracy was asked how she felt about being asked to attend: Well, it didna [didn’t] really bother me, because I knew I had to do it to humour

Qualitative study of pregnant teenagers

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her...I’m only joking! But, it disna [doesn’t] bother me. (Tracy)

and puts it in the freezer so you just have to reheat it. She’s a good cook. (Catriona)

One teenager indicated that some influence had been brought to bear, stating ‘I had to come’. When pressed by the interviewer to explain, she continued:

She went on to point out that appetite during pregnancy might be variable:

My boyfriend thinks I don’t eat properly so he kind of, not that he forced us to come, but he kind of urged us towards comingy To make sure I eat properly from now ony I was a bit shy when I came in but it’s OK because we’re all in the same position, we’re all young and we’re all pregnant and in the same position. Just everyone’s dead friendly, and knows what everyone else is going through. (Catriona) Another incentive was the prospect of free food: Really, I just came for the foody it tells you on the letter. They emphasise there will be food and drink available. (Catriona) That was a definite positive. (Mary) When the cupboards were empty, I remembered. (Catriona) It’s the end of the week, it’s Thursday, we don’t go shopping until tomorrow, I’ll have food for today. (Mary) And you get to take food home which is even better. (Catriona) For these two teenagers at least, the food they took home made a significant difference. This begged the question of what they usually ate at home.

Nutritional habits The intention was that the teenagers’ food habits at home would be affected by the sessions. Some indicated that they rarely cooked anything at home, particularly those who still lived with their parents: Well, I live with my mum and dad so they do most of the cookingy I just leave them to do it. (Ishbel) Even living near the parental home meant not having to do much cooking for one: You get dead lonely when you’re pregnant and I always go out. It’s like I can’t bear to stay in the house for any longer than a couple of hours on my own. You’re sitting staring at the wallsy So I just usually go to my Mum’sy she, like, sends me down food which I like,

Sometimes even the thought of cookingy You might stand there cooking and by the time you made it, you don’t really want it. (Catriona) Certainly, motivation to cook was not high among some of the teenagers: I buy a lot of them (TV dinners) that you just put in the microwave for nine minutes. (Fiona) Asked why this was her preference she continued: Because you can’t be bothered, you’ve no confidence in yourself to make something that’ll be good. The lack of confidence in some of the teenagers was striking: I burn boiling watery I mean, I can’t cook anythingy if I can cook anything (after this session), that’s better than nothingy so learning to make macaroni and cheese is like, a really big thing. (Mary) Some had taken food from the sessions and used that to prepare meals at home. Ailsa said that she was making soup ‘every night’ with food she had taken home. This simple recipe seemed to be popular. Asked if her mother had noticed any changes in her eating habits, Tracy responded: Well, she buys more stuff, because I make tomato soup all the time. Remember that pizza we made, that I was eating the stuff out of the pot? Well I made that and I liquidised it and ate it as soup, so she buys the tomato stuff, and the tinned tomatoes and that for me to make. (Tracy) I still make that all the time. That’s about all I make. (Ailsa) Asked if there was anything else that she was eating that she would not have eaten six months earlier, she replied: Not really, well, I eat more vegetables and more potatoes and I never used to eat them. I hardly used to eat anything good, but now I do. I eat more vegetables and things... and fruit. I eat fruit all day. (Tracy) When the interviewer asked if she was going to different shops, or buying different things once

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she was there, Ailsa replied: A wee bit, aye [A little bit, yes]. I’m buying mair [more] fruit and that.. and vegetables. (Ailsa) Asked if she was buying less of other foods now that she was buying more fruit and vegetables, she responded ‘Less chocolate’. Although there was a wide range of options in terms of choosing recipes (each teenager’s pack contained 21 savoury and sweet recipes), it seemed that changes to nutritional habits were limited for most. Shona noted that she had cooked vegetable pasta at home for her boyfriend, and said that she had tried ‘different vegetables, and different sauces and that’ as a way of varying this. Asked if she had tried anything else at home she responded: Nah, like that’s really, like, the only thing I’ve tried. (Shona) Catriona noted quite proudly that she could ‘make fruit salad now’. When asked if she had ever made this before, she replied: Yeah, I made it at school. That’s why I picked it; ‘cos I knew I could do it! Mine’s ended up for like the five thousand, I was only meant to make a wee bit and it ended up in this huge bowl. (Catriona) However, others were more adventurous: I’ve tried a few of themy It just depends on what it was I was making and who liked ity (Heather) They’re simple recipes and easy to cook and like they’re not like recipes you find in magazines or booksy I’ve made them all. I’ve made every single one. (Fiona) Mary echoed this view about the simplicity of the recipes: They are easy recipes and that’s something else is that I know you said earlier is that you look in magazines and they have four pages for this one recipey and it’s like I don’t want to bother. I’ll just eat supernoodle (a prepared food reconstituted with boiling water) for the rest of my life! (Mary) Clearly, attempting to make adjustments to nutritional habits must take account of individual circumstances. It is unlikely that major changes will be achieved with just one intervention, and the chances of having any impact will be affected by the individual’s perceptions of that intervention. This brings us to the acceptability of the sessions.

Acceptability of the sessions Knowing that the atmosphere in the sessions would be crucial if any effect was to be achieved, we had tried to make them as informal as possible. Fiona said that she had studied Home Economics (which includes cookery) at school, but that it was ‘nothing like this’. Asked what the difference was, she replied: I’d say you’ve got more time and it’s more relaxed and you’re allowed to get on with it yourself and instead of having a teacher over you constantly. (Fiona) I thought it would be somebody sitting telling you what you could eat and what you couldn’t eat and telling you what you should be eating. The best thing is that you get to cook all them things and it’s not your kitchen getting messy. (Catriona) And you don’t have to do the dishes. (Ishbel) We were aware that teenagers would probably not respond positively to an atmosphere that reminded them of school, and we also wanted to avoid certain connotations of existing maternity service provision, being mindful that these may not appeal to teenagers either: The reason really I came is that I knew it was people my age; it told you on the letter ‘people aged 16--18 years old’.y it’s like people your own age. It’s like nobody there older than you, like looking down on you and saying like, ‘you shouldn’t be doing that’, ‘you shouldn’t be wearing this’ or’ ‘you shouldn’t be wearing them shoesy’ (Catriona) Asked if there was a chance to go to an antenatal class specifically for younger women, she replied: They’re just all mixed. I know it puts you off. Majority are just older people. (Ishbel) So it’s not the classes as such that put you off, it’s that you’re with older people that will make you feel somehowy (Interviewer) Bad, for doing what you did, basically. (Fiona) When the interviewer pointed out to Fiona that these ‘older’ women were pregnant just as she was, she responded: Yeah. But they’re older and they’re allowed to do it. y they make you feel like you shouldn’t have done it. (Fiona) Yeah, they’re oldery I think a lot of people look down on you when you’re young when you’re pregnant. A lot of people do. Like they

Qualitative study of pregnant teenagers

see you going, like to the hospital for scans and that, when there’s older woman there and she’s like ‘No wonder you’re looking so depressed! What age are you?’ Just like thaty You know what I mean? You do, you get a lot of criticism from people, like actual friends you used to have. Right? Like, ‘How could you fall [become] pregnant at that age?’ but like, I’m not asking them to fall pregnant. (Catriona) And that’s one of the reasons why this is better than going to an antenatal class because it’s for 16--18 year oldsy if you’re young and pregnanty it’s justy dead lonely and you’re on your own. You’ve only got your family, but there are other people like you and this is a good way of meeting. (Fiona) It was clear that there was a distinct social element to the sessions which was perceived as beneficial. Since existing antenatal provision did not seem to be a popular option, we addressed the question of whether it was helpful to have a midwife leading the session: I kept coming back for the reason of the cooking and because I was meeting interesting people, not as in like people that was coming with me, but as in y all the midwives and stuff and it was great. I was getting to speak to all these different people about my pregnancy yand it was just really good. (Fiona) Whilst you’ve been here have you spoken to the midwife about other things related to pregnancy as well? (Interviewer) Yeah, ‘cos I had a lot of questions about like the hospitals and stuff like thaty (Mary) Was it too awkward because there were other people around? (Interviewer) No, ’cos most of the time she would actually approach you and started speaking about ‘have you got anything that you’d like to speak about?’ (Catriona) There appeared to be some benefit in having a midwife involved in such sessions.

DISCUSSION This study has a number of limitations. The small numbers involved make generalisations impossible, and we acknowledge that recruitment was difficult. It was unfortunate that not all those who attended the sessions were available for interview. The two cities in eastern Scotland in which we conducted the study do not have an ethnically diverse population.

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Nutritional research in pregnancy in developed countries has focussed on issues such as minimising the risk of fetal malformations through dietary supplementation (Mathews et al. 1998, Kadir et al. 1999), determining an appropriate weight gain (Wiles 1998), and the relationship between socio-economic factors and birth weight (Spencer & Logan 2002). The main aim of this study was to develop and test the feasibility of a practical, midwife-led nutrition education programme for pregnant teenage women. The Scottish Diet Action Plan (Scottish Office 1996) highlighted Scotland’s unenviable record for poor nutrition, and emphasised the need for practical support for pregnant women on low incomes. This group includes many teenagers (Social Exclusion Unit 1999), but it appears that no studies have specifically addressed this issue. Several studies of interventions for pregnant women have been reported (van Teijlingen et al 1998) but none of them have included the provision of practical food-based courses. The need to establish healthy eating patterns early in life is demonstrated by a growing body of evidence linking childhood obesity and life-long poor health (Gibson et al. 2002).

Recruitment and access Our study was hampered by low recruitment, a problem encountered in other research involving teenagers (Hanna 2000). Similar problems exist in trying to get young people to use health services generally (Little 1997). There were several stated reasons for not attending, including educational and work commitments. At other times there was no explanation, and attempts to contact the individuals, who had said that they would attend, proved fruitless. We decided to recruit as early as possible in the pregnancy so that any improvements in nutritional habits would have the greatest possible effect on the pregnancy. Various suggestions from the literature were adopted in an attempt to improve recruitment, including starting later in the day than originally planned, payment of bus fares, being encouraged to bring a friend, food to take home, and supermarket vouchers. These proved popular with those who did attend. On the whole, these teenagers were enthusiastic about the sessions, but their relatively low numbers indicate caution when trying to draw lessons. It is difficult to assess the suitability of the venues chosen for the study, but we believe that they were preferable to using hospital premises; suitable alternatives were limited. We opted for community centre venues because we wanted to avoid this being seen as ‘just another antenatal class run by the hospital’, or ‘too much like school’ (Cliff & Deery 1997). However, it was clear that community centres, even when fully

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equipped with catering facilities, were not always popular options either. Accessibility is a prerequisite: while most community centres are situated on bus routes, if the potential attender does not have access to transport the venue may be impractical. Given the territorial nature of the different parts of some cities (Raco & Flint 2001) the fact that they are in a certain area can be taken to indicate either that they do not ‘belong’ to people living outside that area, or even that they are ‘undesirable’ (depending on the reputation of the relevant neighbourhood). We encountered suggestions that this was the case in one of our areas: despite extensive refurbishment of the area (including the provision of a wellequipped community centre and a name change for the locality), for some there was an apparent reluctance to travel there despite the distances involved being small (less than a mile). This does not amount to ‘place hate’ (Henrikson 2001), but is evidently sufficient deterrent to make participation/recruitment a problem. Further investigation of these difficulties for health and social care researchers is required.

Nutritional habits Our attempts to investigate possible changes to food habits were inhibited by our low recruitment. In addition, our attempts to triangulate our findings through the use of standard food assessment questionnaires were impeded by the suggestion from several respondents that, as they did not have regular eating habits, many of the questions in these tools were not applicable. The findings from the questionnaires are reported in a separate paper. Nevertheless, it appeared that there was some short-term benefit in relation to the nutritional habits of those interviewed, and it may be that this is beneficial in public health terms (van Teijlingen et al. 1998). Some of the teenagers were very enthusiastic about the takehome recipes; others were simply pleased that they had succeeded in producing a meal or part of a meal. At least in the short-term it appears that sessions such as these can improve the general confidence level of teenagers -- a spin-off benefit also found in a related study (Valentine et al. 2002). We cannot say what the longer-term benefits might be, or indeed whether these immediate changes in food habits or increased confidence would persist for any length of time.

Acceptability of the sessions Bearing these caveats in mind, and that this was a feasibility study, it was evident that those who were persuaded to attend derived significant benefit. We cannot generalise from a sample of this size, but our findings can be taken as the basis for further reflection and research. There

was some indication that food habits at home had improved following attendance at one or more of the sessions, with claims that the boyfriend or other family members had both noticed and appreciated this. It is not known how long these changes may last; we had not planned to conduct a long-term follow-up study to assess whether changes to dietary lifestyle persisted beyond the immediate period. It was evident that the prospect of free food was a significant incentive for some of the young women. Two of them indicated that, when the kitchen cupboards were getting empty, the food they received was welcome. The supermarket vouchers were intended both as a ‘thank you’ for completing fairly lengthy food questionnaires (these are reported elsewhere), and as an incentive to obtain healthy food. However, accessibility to the supermarket in question (as with the community centre) was not always easy. The teenagers certainly appreciated the informality of the sessions and the fact that there were no ‘older’ pregnant women there. Some of them had, unfortunately, experienced disapproval from others while attending hospital clinics (Cliff & Deery 1997), and found the relaxed atmosphere in our sessions more convivial and welcoming. In determining the feasibility of such a programme this is one aspect that we would not advocate changing. It cannot be denied that the sessions may have provided a social forum for these teenagers that was at least as important as the nutritional aspect of the sessions. It was clear from some of the comments made that pregnancy can be a lonely time, a reality exacerbated by losing touch with old friends and encountering apparent disapproval from ‘older’ pregnant women and health-service practitioners. The fact that the sessions provided an incentive to get out of the home, and that they were even something to look forward to because of the social contact involved, suggests that there is a need to provide some sort of forum for these young women. We combined a nutritional education programme (consonant with government directives [Scottish Office 1996, Roe et al. 1997]) with the opportunity for the teenagers to access midwifery knowledge and skill in a non-hospital environment. The two midwives enjoyed being involved in the study, and several teenagers made use of their presence to elicit information. While it may be desirable to have a midwife working in this capacity, it is questionable whether -- from a cost-effectiveness point of view -- it is necessary to employ a midwife to deliver this intervention (this is discussed in a separate paper). There have been concerns that midwives are not always confident about their ability to impart nutritional information (Mulliner et al. 1995, Symon et al. 2002), and the midwives we

Qualitative study of pregnant teenagers

employed were given a certain amount of basic training before the start of the sessions. Our economic evaluation will appear in a separate paper, but it will be evident from this discussion that any such programme would need to ensure better recruitment in order to demonstrate value for money to an employer. Contacting nonattenders proved to be difficult. We asked those who attended why they thought so many of their peers had not done so, sometimes despite assurances that they would attend. There was some reluctance to speculate on this, although one of the venues was cited as a possible reason.

Conclusion Nutritional education has the potential to improve the health of current and future generations, but recruitment from the group under study remains a difficulty. With financial constraints, health employers may insist on a higher degree of cost-effectiveness (our analysis of this will be reported in another paper). However, those who attended our sessions indicated that they derived considerable benefit from a social point of view (they liked being among people from the same age group), and from a practical point of view (the food they took away made a significant difference to the food available at home). They also appeared to have adopted healthier eating habits at home, although we cannot say how long these changes would last. From the point of view of acceptability among the client group, we would claim that this type of educational intervention is feasible, but in any further studies particular attention would need to be paid to recruitment and retention strategies. ACKNOWLEDGMENTS The authors would like to thank Moyra Crichton, nutritionist, who helped devise the sessions; Fiona Little and Joan Chynoweth, midwives, who ran them; the Chief Scientist Office, Edinburgh, for funding the study, and Asda stores for their support through the donation of vouchers to participants.

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