A causal model of eating behaviors among Thai pregnant women working in industrial factories

Over the last decade, the number of female workers in industries has increased steadily. Female factory workers are prone to be stressed due to prolonged working hours and constant fear of dismissal.¹ Moreover, they do not meet their nutritional requirements due to low socioeconomic status, long commute time to work, low wages, domestic problems, less accessibility to healthy food, work constraints, and stringent workplace regulations.² It is essential to pay attention to the eating behaviors of pregnant women working in factories, as it could greatly influence pregnant women and their fetal health.³ According to the World Health Organization, about half of pregnant women have micronutrient deficiencies globally.⁴ It was found that females from developing countries were at risk of malnutrition, ranging from 13% to 38%.^5,6 An estimated 3.5 million deaths occurred due to maternal malnutrition, accounting for 14% of fetuses with intrauterine growth restriction.⁷ In Thailand, 66.43% of pregnant women had unhealthy eating behaviors.⁸ Most pregnant women had poor dietary practices, such as frequent snacking, fast food consumption, low-energy food choice, and higher fat and sugar diet.⁹ Low intake of micro- and macro- nutrients and regular caffeine consumption could lead to deleterious health outcomes, including gestational weight gain, diabetes mellitus and hypertension, anemia, fetal macrosomia, spina bifida, and low birth weight.¹⁰ Around 34.3% of the Thai pregnant women reported of gestational weight gain.⁸ Moreover, pregnant women should be encouraged to consume dense nutrition without exceeding the requirement level.¹¹

The existing literature indicates various influencing factors on eating behaviors. Primarily, pregnancy symptoms itself could influence the food practices of pregnant women. For instance, a study found that physiological changes influence dietary preferences.¹² Apart from that, internal and external factors play a vital role in the eating behaviors of pregnant women. A high social support can promote good mental health and increases the likelihood of healthy behaviors among pregnant women, thereby increasing their well-being.¹³ Accessibility to healthy food and self-efficacy are indicators of dietary habits.¹⁴ Moreover, the unavailability of healthy foods could result in barriers, including a lack of food literacy.¹⁵ Perceived barriers refer to an individual’s evaluation of physical and psychosocial barriers that prevent him or her from adhering to health-related practices.¹⁶ Pregnant women with perceived benefits receive more social support and engage in health-promoting behaviors.¹⁷ In terms of individual factors, self-efficacy in and perceived benefits of behavioral change must be enhanced, along with the interpersonal and situational influences.

Some studies found lifestyle interventions as an effective way to modify dietary patterns and in reducing gestational weight gain.^18,19 In addition, studies on workplace nutrition interventions also exist.^20,21 Most studies have examined the related factors to a person’s health behaviors and dietary patterns of pregnant women,^9,22 although there is limited evidence in industrial environments. Hence, there is an extensive need to identify the influencing factors of eating behaviors among pregnant factory workers. By underpinning Pender’s health promotion model, this study aimed to examine the various factors.²³ Promoting healthy eating behaviors among pregnant women is vital in prenatal care, and understanding various factors may aid in optimizing the maternal diet and reduce pregnancy complications. In Thailand, limited studies exist on the dietary patterns of pregnant female workers in factories. Besides, this study sought to examine the maternal, social, and contextual factors, specifically the pregnancy intention, mothers’ perceptions of eating behaviors, the barriers and benefits of healthy eating, and the accessibility to healthy food. Understanding these factors is significant, as they play an important role in improving women’s eating behaviors during pregnancy and providing them with essential welfare facilities in the workplace. Moreover, this will inform future tailored intervention programs that are more effective for working pregnant women. Therefore, this study aimed to develop and examine the causal model of eating behaviors and their related factors among pregnant women working in industrial factories.

This study found that factors, namely, perceived benefits, perceived barriers, and perceived self-efficacy in healthy eating, social support, pregnancy planning, and accessibility to healthy foods, influenced the eating behaviors among pregnant women working in industrial factories.

In this study, perceived barriers to healthy eating directly and negatively influenced eating behaviors (β = −0.24, P < 0.001) and were consistent with Pender’s health promotion model.²³ This could encourage a person to avoid unhealthy behaviors associated with unreadiness, inconvenience, expenditures, and difficulties.²³ Our findings are in line with previous studies, which revealed that perceived barriers had a negative DE on health-promoting behavior (B = −1.28; β = −0.13),^27,28 the likelihood of healthy eating (β = −0.31),²⁹ and blood pressure controlling behavior (β = −0.49).³⁰ This study also revealed a mediating role of perceived barriers between perceived self-efficacy and health-promoting lifestyle.^23,31

Perceived benefits and perceived self-efficacy, directly and positively, influenced eating behaviors (β = 0.13, P < 0.05 and β = 0.22, P < 0.001, respectively). Perceived benefit is a cognition factor that refers to the belief in positive outcomes resulting from performing health-promoting behavior. This finding could be explained by the fact that if pregnant women realize the benefits of healthy eating, they could more likely practice healthy dietary patterns. This is consistent with previous studies that found that perceived benefits directly and positively influenced the likelihood of healthy eating (β = 0.23),³¹ health-promoting behavior (β = 0.63),²⁷ pregnancy care behavior (β = 0.25),³² and blood pressure controlling behavior (β = 0.62).³⁰ Moreover, perceived benefits of healthy eating had a positive indirect influence through perceived self-efficacy.²⁹ Perceived self-efficacy is a psychosocial factor, in which a person is determined to modify or maintain their health-promoting behaviors.³³ Similarly, another study in the other population found perceived self-efficacy’s direct and positive influence on health-promoting behaviors (β = 0.38),³⁴ self-management behaviors (β = 0.26),³⁴ and the likelihood of healthy eating (β = 0.37).²⁹ Perceived self-efficacy also acted as a mediating factor between social support and health behavior.^34–36

Planned pregnancy positively affected the perceived self-efficacy and eating behavior of pregnant women working in industrial factories (β = 0.21, P < 0.01, and β = 0.28, P < 0.001, respectively). One possible explanation is that pregnant women with planned pregnancies are more likely to have increased perceived self-efficacy, and it may encourage them to adhere to adaptive eating behaviors. Moreover, planned pregnancies could influence women’s thoughts and feelings. They may motivate them to maintain an optimal nutritional status.^37,38 These findings agreed with another study that found pregnant women with planned pregnancies had healthier eating behaviors than those with unplanned or unwanted pregnancies.³⁹

Accessibility to healthy foods in the factory had a direct, positive influence on eating behavior in pregnant women working in industrial factories (β = 0.12, P < 0.05). The availability of healthy foods in the factory canteens, reasonable food prices, and workplace environments could highly promote dietary changes among pregnant women. Also, accessibility to healthy food is a situational factor that directly influences health- promoting behavior.¹⁸ This was consistent with the findings of another study that indicated a positive influence of workplace nutrition environment and administrator’s attitude on eating habits¹ and situational influence on health-promoting behaviors.^28,30 However, food choices vary based on workplace nature and nutrition policy. Most factories have a few healthy food facilities inside, and the policies and plans for nutrition promotion are quite low, thus posing negative health impacts among pregnant workers.⁴⁰

Social support had a positive DE on perceived benefits and perceived self-efficacy (β = 0.27, P < 0.001, and β = 0.29, P < 0.001, respectively) and a positive indirect effect (IE) on eating behaviors to healthy eating. Enhancing favorable environmental conditions and satisfying social relationships could strengthen individuals and create positive attitudes toward healthy eating behaviors. Pregnant women who receive informational support may easily be equipped with knowledge and understanding about appropriate eating behaviors; other supports, such as emotional, instrumental, and appraisal, could help them adjust to physical and psychosocial changes. The influence of social support on eating behavior in pregnant women is supported by previous studies that found an indirect, positive influence on health behavior through self-efficacy.^33,34

The major strength is that this is the first study to examine the simultaneous relationship of multiple factors related to the eating behaviors of pregnant industrial workers. Furthermore, it emphasized the eating behaviors of pregnant workers at the individual, interpersonal, and workplace levels. The limitation is that since the study was conducted in only 1 province in Thailand, it may limit the representativeness of samples and the generalizability of findings. Secondly, some factors were not examined, including demographic characteristics such as types of residential areas (urban or rural), health literacy level, pre-pregnancy healthy lifestyle behaviors, and availability of healthy workplace policies. Exploring the influence of the combination of these factors in future investigations may provide further insights into the eating behaviors of pregnant women. Lastly, the eating behaviors of pregnant female workers in their first and second trimesters warrant further investigation. The findings of this article are imperative, as they enhance our understanding of the situational and social factors that contribute to the wellbeing of pregnant women working in industries. Gaining knowledge regarding the dietary patterns of pregnant women may guide nurses and other healthcare professionals in conducting future educational activities and cultivating awareness about the deleterious effects of unhealthy eating habits that could impede fetal growth and development.

This study revealed that perceived self-efficacy, perceived benefit, planned pregnancy, and accessibility to healthy foods positively influenced eating behaviors, while perceived barriers to healthy eating negatively influenced eating behaviors among pregnant factory workers. The findings of this study will provide baseline information for community-based initiatives. They may guide the healthcare providers in primary health centers in formulating health-related policies and identifying the potential barriers related to healthy eating practices of the workers in industries situated in the eastern province of Thailand. This study suggests that improving canteen facilities and factory nutritional policies could promote pregnant women’s health status. Also, work-based health promotion strategies could also be implemented, such as proper dietary management, improving safety measures, adequate wages, flexible schedules, and paid medical leave. In addition, since social support directly influences self-efficacy, family members or workplace support could increase pregnant women’s beliefs and dietary practices. Furthermore, these findings could guide future experimental studies in designing individual-based interventions among pregnant women working in industrial factories. Lastly, this study, by providing a comprehensive understanding of influencing factors based on health promotion models, could aid in creating various awareness programs for pregnant women who work in industrial settings.