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Introduction Mental health promotion is an important step to improving quality of life, it aims to enhance positive mental health and to reduce the burden of mental health problems and disorders (Ip, 2002). Pregnancy can be a difficult period presenting physiological and psychological challenges for women (Van den Bergh et al. , 2005).

Many pregnant women may experience a variety of emotions such as fear regarding their ability to cope with the pregnancy, an inability to adapt to the pregnancy and anxiety over their baby’s physical health and pending lifestyle changes (Hayes et al., 2001, Cantwell & Cox, 2003).

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When psychological problems arise during pregnancy, the safety of pharmacological treatment in terms of the risks to the fetus and the mother must be considered. In light of these risk assessments, non-pharmacological preventive intervention for antenatal stress, anxiety and depression should be considered of significant importance (Cunningham & Zayas, 2002; Field et al. , 2003; Lee et al. , 2004; Van den bergh et al. , 2005). Music has been used for healing for hundreds of years.

In the early nursing history, Florence Nightingale used music as a nursing intervention (Olson, 1998; Biley, 2000). Music maintains harmony between the body and soul and is an effective therapeutic modality within holistic or integrative medicine (Olson, 1998). As an effective and non-pharmacological therapeutic modality, music can assist nurses in creating a healing environment that promotes physical, emotional and spiritual well-being (MCloskey & Bulechek 1996). Moreover, music is easily used in most environments and it can be tailored to personal preferences to enhance relaxation (Ip, 2002).

This issue aim as discuss the definition of health and mental health, the common mental illness which pregnancy women will be encountered, the importance of mental health promotion in pregnancy and the musical therapy intervention. A health promotion session for pregnancy women will also be proposed. Definition of Health and Mental Health Health is described as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (WHO 1948). This definition stresses health as a positive state of well-being.

People in a state of emotional, physical, and social well-being fulfill life responsibilities, function effectively in daily life, and are satisfied with their interpersonal relationships and themselves (Videbeck, 2009). No single universal definition of mental health exists. Generally, a person’s behavior can provide clues to his or her mental health. Because each person can have a different view or interpretation of behavior, the determination of mental health may be difficult. Mental health has many components, and a wide variety of factors influence it.

These factors interact; thus, a person’s mental health is a dynamic or ever-changing state. Factors influencing a person’s mental health can be categorized as individual, interpersonal, and social or cultural (Videbeck, 2009). The American Psychiatric Association (APA, 2000) defines a mental disorder as “a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and is associated with present distress or disability or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom (Videbeck, 2009).

Mental status during the pregnant period Globally, women’s health is seen as a particular issue of need (WHO, 2000). In the context of women’s health, it includes women’s lives such as spiritual, emotional, physical, political, economic and social dimensions (McDonald & Thompson, 2005). However, it is suggested that a major depressive disorder is experienced by around 7-13% of women worldwide (Bennett et al, 2004). Moreover, pregnancy is an episode of great adjustment which includes emotion, social, family, financial and physical demands (Hurklock, 1990).

It has been suggested that around 30% of pregnant women may experience depression (Bennett et al, 2004). While the apparent physical problems associated with pregnancy such as weight gain, morning sickness, constipation, back pain and swollen feet and ankles are often addressed, the psychological challenges related to mental health and pregnancy are unheeded (Solanki, 2010). There are various factors affect the mental statuses of women during pregnancy to be discuss as follow. Firstly, perinatal mood disorder is a result of the physiological and hormonal changes the body undergoes and the stressors involved in pregnancy.

Anxiety and depression constitute the major emotional disturbances in the perinatal stage. Moreover, there are various gestational disorders that affect women during pregnancy and postnatal mood disorders that occur after pregnancy (Solanki, 2010). Secondly, body image, an internalized perception of the individual’s own height, weight and shape is inevitably linked with self-esteem in which the individual evaluates her attractiveness, desirability and social worth or value (Garner & Garfinkel, 1980).

During pregnancy, women experience substantial changes in their body shape and weight that result in significant alterations of their body image (Lederman 1984; Moore 1978; Strang & Sullivan 1985). Many pregnant women find themselves falling further from the cultural ideal of beauty. In this way, body image satisfaction may decline, the consequences of a negative body image may include such behaviors as dieting, starving or purging (Lavender, 2007). Generally, the expectation of weight gain during pregnancy is normalized.

Nonetheless, it can be presumed that for some women, satisfaction with body image may further decline during their pregnancy (Lavender, 2007). Thirdly, body image during pregnancy is influenced by the way in which women conceptualize and represent their relationship with their fetus. The experience of pregnancy, with all the physical and emotional changes involved raises questions for women about their sense of identity and embodiment. Lupton (1999) presents these questions such as “is the fetus part of myself? ”, “Where do I begin and the fetus end? ”, “how much control do I have over this fetus as it grows inside my body?”.

The majority of the research concerning the relationship between a pregnant woman and her unborn baby has tended to focus on questions of the nature of attachment in relation to the development of maternal behaviors and attitudes following the birth (Lavender, 2007). Ballou (1978), Lumley (1980,1982), Cranley (1981) and Stainton (1990) present four distinctive phases in women’s developing awareness of the fetus; incorporating the fetus into the body and self image, differentiation of the fetus from self, gaining a sense of the child and finally attachment.

There is an emphasis on the importance and the need for women to move through these stages progressively in their efforts to resolve the questions concerning identity and embodiment (Lavender, 2007). Finally, pregnancy is a normal life event that necessitates adjustments for the expectant mother as well as her partner and other family members (Yang et al. , 2009).

However, a range of psychosocial factors have been associated with depression in pregnancy (Pajulo et al., 2001) including having an unwanted or unplanned pregnancy, having low family income, having insufficient support from the partner and his family and past experience of pregnancy loss. Most women suffer from mood disorders during pregnancy are still unaware of the devastating effect of these conditions, it will cause significant morbidity for the mother as well as the child (Solanki, 2010).

The importance of health promotion to mental illness pregnancy women Health promotion is the process of enabling individuals and communities to increase control over the determinants of health and thereby to improve their health (WHO, 1986).

The definition of health demonstrates the need to have a holistic understanding of people’s needs in order to provide the most appropriate care and to promote health (Hall, 2007). With a holistic approach, it should be remembered that anything that may affect the well-being of the woman prior to pregnancy or in the antenatal period will subsequently have an effect during labour and in the postnatal continuum. Research has shown that antenatal psychological disturbance may have a long-term effect on a child’s behavior (O’Connor et al, 2002).

Therefore, promotion of well-being should take place at all times for the potential effect it may have in the future on the well-being of the whole family (Hall, 2007). Music therapy “Music therapy is a systematic process of intervention wherein the therapist helps the client to promote health, using music experiences and the relationships that develop through them as dynamic forces of change” (Bruscia, 1998). The use of music to treat health problems can be traced to ancient cultures (Boxberger, 1962).

It uses to promote human health and well-being has grown the discipline of music therapy. It also uses to facilitate relaxation which is one of the most important therapeutic aspects (Scartelli, 1989). Medical applications of music therapy have burgeoned during the past 20 years, clinical conditions for which music therapy is used such as Autism (Gold & Wigram, 2003; Thaut, 1992).

Developmental Disabilities (Gfeller, 1999; Jellison, 2000), and Stress (Dileo & Bradt, 2005; Pelletier, 2004), medical specialties within which music therapy is used such as Pediatrics (Malone, 1996; Robb, 2001), Hospice (Dileo & Loewy, 2005; Hilliard, 2003), and Obstetrics and Gynecology (Davis, 1992; Liebman & MacLaren, 1991).

Research indicates that both music and music therapy elicit physiological, psychological, cognitive, social, and spiritual responses (Dileo & Bradt, 2005), and these effects can clearly support a rationale for the use of music and music therapy in stress management (Dileo, & Bradt, 2007). The full range of possible experiences within music is used in music therapy.

They are including listening experiences, performing music or learning practicing on an instrument, improvisational experiences, music composition, and combined arts experiences (Dileo, & Bradt, 2007). Music therapy may be offered to the client at various level of practice depending on his or her needs. At the basic levels of music therapy practice, music therapy activities may be used as a distraction from stress and anxiety; music may be used in combination with other, traditional approaches to stress management; and may be used in an attempt to palliate the client’s symptoms of stress.

In addition, music may be used within a psychoeducational approach to stress management. At more advanced levels of music therapy practice, the therapist addresses the full range of the client’s issues besides those that cause anxiety and utilizes methods that will enhance insight into these issues and support change (Dileo & Bradt, 2007). However, as identified in the literature, a number of individual factors may influence responses to music such as age, gender, cognitive function, severity of stress, preference for the music, culture and personal associations with the music (Pelletier, 2004; Standley, 1986, 2000).

Music therapy intervention Music elevates the stress threshold, harmonizes inner processes, helps people attain an advanced state of relaxation and reduces stressful situations (Hoffman, 1997, Field, 1998, Sidorenko, 2000). Music therapy demonstrated a powerful anti-stress effect in high-risk pregnancies (Sidorenko, 2000), and a reduction in anxiety according to the Spilberger scale. Moreover, Chang et al (2007) showed that music therapy significantly reduced the intensity of stress, anxiety and depression in lower risk pregnant women.

Besides, Music has the ability to be transferred into the client’s own environment. Relevant music therapy sessions may be tape-recorded for the client for follow-up use. It can be portable, via a Walkman, iPod, or similar devices, and thus may be used in a variety of non clinical settings. Following will be proposed a music therapy sessions and the learning of skills is included, clients are given detailed instructions on how to transfer skills to their own situations and use them most efficiently for their own needs (Dileo & Bradt, 2007).

One day Mental Health promotion program in pregnancy women Aim This program aims to promote the concepts of normal & abnormal health status in physical & mental aspect respectively in pregnancy. Objective: i) To enrich the knowledge about normal signs of pregnancy, as well as early signs of mood disorder. ii) To introduce Music Therapy as a non-pharmaceutical & voluntary basic program to reduce stress, anxiety and depression during pregnancy. iii) To demonstrate the skills of music therapy and relaxation exercise. iv) To maintain physical and mental well being in pregnancy.

Resources i) Pamphlets: Minor ailments in Early Pregnancy and their Management (Appendix 1) Minor ailments in Middle and Late Pregnancy and their Management (Appendix 2) Postnatal Mood Disorders (Appendix 3) ii) Educational compact discs (CD) : women health in pre & post natal period. iii) Four types of pre-recorded Music (CD) were created for this program. Each CD contained approximately 30 minutes of music consisting of lullabies, classical music, nature sounds or crystal music performing Chinese children’s rhymes and songs.

Those sons have the same characteristic that the tempo of the music was selected to mimic the human heart rate. iv) Pre & post Perceived Stress Scale (PSS) & Edinburgh Postnatal Depression Scale (EPDS) assessment questionnaires (Appendix 4, 5) Strategies The occurrence of depression during the different trimesters of pregnancy varied in different studies. Unattended mental disorder in pregnancy will lead to postpartum blue & women suffer postnatal depression will have a chance to develop psychotic illness in the puerperium, which may be complicated by a danger of suicide or infanticide (Cox et al., 1982).

It is a well known fact that prevention or early intervention is much better and cost effective than cure. Therefore we would choose pregnant women of 1 & 2 trimesters as our target group of the program. We will first invite pregnant women to fill in a questionnaire (Appendix 4) in voluntary basis. Then we will select those women with early signs of mental disorders with reference to PSS score. They will be given the prerecorded CD and asked to listen to at least one disc (30 minutes) a day for two weeks at any time during the day.

To determine the type and volume of music listening, they are asked to maintain two-week diary that stated which CD they have listened to and what they are doing while they listen to the music. Venue: The sessions are proposed to hold in a large room with comfortable chairs placed in a circle. Seminar Room in day hospital or clinical setting would be preferred. Time Frame: Since one day program is not realistic for pregnant women, therefore, we prefer to hold 2 sessions of a 2-hours program for two groups of pregnant women.

|Timeframe |Action plan | |10:00 – 10:05 |Introduction | |10:05 – 10:30 |Minor ailments in Pregnancy and their Management (Appendix 1, 2) | |10:30 – 10:45 |Break | |10:45 – 11:30 |Introduction, demonstration and practice of Music Therapy. | | |Sharing the feeling after listening to music; Music therapy at home. | |11:30 – 11:50 |Introduction of Relaxation Exercise | |11:50 – 12:00 | Q & A | Role of Nurse In the above health education plan, nurses act as an Educator, Advocator and Information giver to teach the pregnant women about the normal discomforts they would be faced and mental illness may occur.

Also, nurses create an environment & provide an opportunity for group members to learn the relaxation exercises, as well the alternate music therapy so that they may use the technique at home. Evaluation Evaluate the effectiveness of the music therapy to reduce stress & degree of anxiety or depression by pre & post PSS (Appendix 4) & EPDS (Appendix 5) assessment questionnaires that will be given before seminar and 2 weeks after. Conclusion Pregnancy is a miracle and amazing journey of women.

However, there are a host of physical as well as mental challenges such as depression, anxiety and low self-esteem among pregnancy women. Therefore, a well-plan mental health promotion program should be able to strengthen the pregnancy women to cope with the challenges and maintain the mental well-being during the pregnant period. Undoubtedly, music therapy is one of the most effective, non-invasive, and low-priced tool for pregnant women to release their emotion. It would be benefited to both mother and fetus in this golden period.

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