Ms. Z, 23 years of age, is a Caucasian full-time employee at a pharmacy and mother of three young children, 5 years old, 3 years old, and 2 months old. She is married and lives on the outskirts of the city. The one health behavior change she would like to make is to exercise more, since it makes her feel better. Ms. Z does not understand why she is often tired, yet regularly gets at least eight hours of sleep at night. She is constantly in motion at home and on her job, which requires her to be on her feet. She believes her husband does not understand her need for time to herself because he works 10-hour shifts. Although her husband does not initiate support, if she asks him to do something specific he will fulfill her request. However, he has difficulty handling more than one child at a time.
She wanted to be involved in the AMP study, but the timing of classes, her work schedule and that of her husband, and her mother's varied availability to watch the children after work hours, prohibited her commitment.
All three women described their responsibilities to their families and expressed the impact the increased efforts with the newborn added to their already busy schedules. There are several common themes in the barriers these women faced that may also be common for other postpartum women.
Limited time for personal health
Ms. X perceived that a program for exercise and behavior changes was an addition to her already packed schedule. The fact that she had already reduced family activities outside the home, and eliminated her own walking program to relieve the time crunch, points to the time barrier many postpartum women experience. Ms.Y found it difficult to find time to eat well during the day, and viewed things that took her away from her children as extra time commitments. Ms. Z knows exercise makes her feel better but found that the classes did not fit into her or her spouse's work schedules. All three women required the interviewer to call after 9:00 pm, when family demands were lower. Clearly, the sense of inadequate time for an intervention aimed at improving health was a significant barrier to participation.
Prioritizing one's children above oneself
Ms. Y felt that her health was not as important as the welfare of her children. Though she perceived herself as overweight, she put her children's needs and her need to spend time with them above her own health concerns. Ms. X shared this barrier, conveying that her health was not poor enough to be actively involved in lifestyle changes. Both Ms. X and Ms. Y would make a commitment to engage in improved health behaviors if they perceived that their health was life-threatening or had immediate, noticeably negative consequences. Thus, they would need to feel threatened by their current behaviors and believe that behavior change would be beneficial with a cost that is acceptable to them [13, 14]. Ms. Z reports being tired despite adequate sleep and improved feeling of well being when she exercises, but fails to make the connection that addressing her health and fitness will improve her fatigue. All three women express that at this point in their lives their personal health was not top priority. As multicaregivers, they have a myriad of responsibilities to others to the point where they typically put themselves last.
Social support – both positive and negative effects
Social support was considered important to all three women. Ms. Z expressed the need for a stronger social network and did not have many social contacts outside of her employment. She did not receive strong support from her husband, and felt uncomfortable asking him to care for more than one child at a time. At work she felt guilty when she missed work due to children's illness, though she appreciated the support when others traded shifts with her. She would have liked to participate in AMP but lacked the social support at home and work. Ms. Y had little contact with adults throughout the day, but received emotional support from telephoning her friend and periodically joining her friend in taking their children to the mall, park, natural science center, or for a walk. Ms. X received reciprocal support from church members by exchanging meals for child care; however, she must often accept unhealthy food in these exchanges. Thus, Ms. X's church members provide needed instrumental support, but that support also enables unhealthy eating behaviors. As postpartum mothers, all three women's support networks could be important motivators to engage in healthy lifestyle behaviors, or barriers to their daily functioning .
For all three women, geography was a barrier to participation. Since time to meet their multitude of priorities is limited, particularly in the presence of a newborn, adding time to drive to the classes, coupled with the unavailability of care for additional children, made it difficult to make a commitment to participate.