Knowledge and Attitude of Women and Nurses regarding Pre-Conception Care: A Comparative Study 111


Hanan Elzeblawy Hassan*

Citation: Knowledge and Attitude of Women and Nurses regarding Pre-Conception Care: A Comparative Study. American Research Journal of Nursing. 2019; 5(1): 1-15.

Copyright This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


Abstract:

Background: Despite the established importance of preconception care (PCC), it is still not a well-established service in many countries, and women’s and nurses’ related knowledge and attitudes need to be assessed.

Aim of the study: To compare the knowledge and attitude of married women and nurses regarding preconception care.

Subjects and methods: This comparative cross-sectional study was carried out on a stratified cluster sample of 106 nurses and 750 women from Maternal and Child Health (MCH) and Primary Health Care (PHC) centers at Minia city. The data collection tools were a self-administered questionnaire measuring nurse’s awareness, knowledge, and attitudes related to PCC, and a similar interview questionnaire sheet for women. The tools were validated by experts’ opinions and pilot-tested. Data collection lasted from June to November 2017.

Results: The majority of the nurses had a diploma (97.2%), 72.6% had training in antenatal care, and 60.4% provided PCC. Women’s age ranged between 17 and 48 years, and 39.5% had an intermediate education. Nurses’ awareness was higher than women (p<0.001). They had higher knowledge scores in most areas and in total knowledge (p<0.001), but women were higher in vaccination (p=0.001). The attitude towards planning for pregnancy was higher among nurses (p<0.001). In multivariate analysis nurses’ higher qualification, longer experience years, and provision of PCC were positive predictors of their knowledge, while age and urban residence were negative predictors. Higher qualification and provision of PCC were positive predictors of nurses’ attitude score, whereas urban residence was a negative predictor. Women’s knowledge was positively predicted by their education, previous pre-term labor, planning pregnancy, having antenatal care, having PCC, and previous counseling, while labor complications and chronic diseases were negative predictors. Their attitude was positively predicted by urban residence, planning pregnancy, having antenatal care, previous counseling, and knowledge score, while education was a negative predictor.

Conclusion and recommendations: Nurses’ knowledge and awareness of PCC is better compared to women, and both have hesitant attitudes. The study indicates the need for the urgent establishment of a formal PCC in PHC and MCH centers.

Keywords: Knowledge, Attitude, Nurses, Pre-Conception Care


Description:

INTRODUCTION

Preconception care (PCC) is a service provided to women planning the pregnancy to ensure having a healthy child [1]. In contrast, the antenatal care is provided during pregnancy, but both are integral parts of women reproductive health [2]. The PCC involves health promotive, preventive and curative interventions covering the physical, social, and psychological aspects of woman’s life [3-5]. It may also involve genetic counseling and interventions [6, 5]. The PCC got increasing importance with the World Health Organization Global Action Plan for the Prevention and Control of Non-Communicable Diseases 2013-2020 [7].

There is mounting evidence that PCC could have an essential role in preventing both short and long-term adverse maternal and fetal outcomes of pregnancy [8]. Risk factors for poor outcomes of pregnancy include deficient nutrition with low folic acid intake, obesity, chronic diseases, and unhealthy habits [9-11]. It is anticipated that proper PCC can contribute to reductions in maternal mortality and morbidity worldwide and in particular in developing countries. Examples are the potentials of reducing the risk of neural tube defects through folic acid supplementation three months before conception, as well as the mitigation of the risks associated with smoking, alcohol and other drug consumptions, and occupational hazards [12-16].

Despite the established importance of PCC, it is still not a well-established service in many countries, especially the low-income ones. Moreover, research demonstrated that women’s, as well as health care providers’ knowledge and practice of PCC, is poor in developing countries [17-20]. This was also demonstrated in developed countries such as the Netherlands [21], although a good PCC program was established in China since 2010 [22]. Knowledge of PCC could be gained by education, training, or experience [23].

SIGNIFICANCE OF THE STUDY

Births resulting from unintended pregnancies are often associated with untoward health outcomes. Hence, the care provided to women should better be before a child is conceived, in order to prevent any birth defects and other adverse outcomes. There are no formal PCC in the local settings, and the related services might be provided during consultations for contraception and follow-up for chronic diseases. Thus, it is expected that the women, as well as the nurses in the study settings, have deficient knowledge and attitudes towards PCC. Moreover, there is a need to investigate the factors affecting such knowledge and attitude in order to set corrective actions.

AIM OF THE STUDY

The study was conducted to compare the knowledge and attitude of married women and nurses regarding preconception care.

RESEARCH HYPOTHESIS

It was hypothesized that nurses’ scores of knowledge and attitudes will be higher compared to women’s scores.

SUBJECTS AND METHODS

Research Design and Setting

A comparative cross-sectional design was used in carrying out this study at the Maternal and Child Health (MCH) and Primary Health Care (PHC) centers at Minia city.

Subjects

The study included two groups of respondents, namely nurses working in the settings and married women attending the settings for vaccination of their infants through the first year of age. Minia city has a total of 19 MCH centers and 309 PHC centers. A stratified cluster sample of these centers was randomly selected. The two strata were the MCH and PHC centers, and the centers represented clusters. Then, from each selected center, one or more nurse with at least six-month experience in the service was recruited. The total numbers of nurses were 33 from MCH centers and 73 from PHC centers. Similarly, from each selected center around ten adults married women with at least one previous pregnancy and delivery. Their numbers were 150 from MCH centers and 600 from PHC centers.

The sample size was calculated to demonstrate any difference of statistical significance between nurses and women’s knowledge or attitude with a risk ratio 0.75, expecting a level of 60% or higher among nurses, at 95% level of confidence and 80% study power. Using the Open-Epi software package for the sample size of a difference between two proportions, and setting a sample ratio of nurses to women at 1-to-7, the required sample size after adjusting for a non-response rate of about 5%, the required samples were 106 nurses and 750 women.

Data collection tools

The researchers used two different tools for data collection, one for nurses and the other for women.

Nurses’ tool

This consisted of a self-administered questionnaire in Arabic language to assess nurse’s awareness, knowledge, and attitudes related to preconception care. It started with a section for personal characteristics as age, marital status, nursing qualification, experience years, residence, training in preconception care, etc. It also included questions about previous personal experience with preconception care and the provision of this service at work.

The second part assessed nurse’s awareness of the elements of preconception care. It consisted of 10 elements such as talking with the doctor about pregnancy, medication advice, exercise, etc. The score of total awareness was computed by simple summation of the elements the respondent was aware of. The score was converted into a percent score, and means, standard deviations, and medians were calculated for quantitative statistical analysis.

The third part was intended to assess nurse’s knowledge of preconception care. It involved 36 True/False questions covering different aspects of preconception care such as its benefits, services/ elements, risk factors, nutrition, vaccination, as well as chronic and infectious diseases during pregnancy. For scoring, each knowledge item with the correct answer was scored one and the incorrect zero. The scores of the items for each area were summed-up and the total divided by the number of items, giving a mean score for the area. These scores were converted into percent scores, and means, standard deviations, and medians were calculated for quantitative statistical analysis.

The fourth part was an attitude towards pre-conception care. It consisted of 17 positive and negative statements covering areas of pre-conception care as “Preconception care has no impact on pregnancy outcomes,” planning for pregnancy such as “Planning for pregnancy is a priority for me,” and pre-conception care services such as “PHC centers are the best settings to provide preconception care.” The response for each statement is on a 3-point Likert scale from “agree” to “disagree.” These were scored from one to three. The scoring was reversed for negative statements so that a higher score indicates more positive attitude. The scores of the statements for each area were summed-up and the total divided by the number of statements, giving a mean score for the area. These scores were converted into percent scores, and means, standard deviations, and medians were calculated for quantitative statistical analysis.

Women’s tool

This consisted of an interview questionnaire sheet in Arabic language to assess women’s awareness, knowledge, and attitudes related to preconception care. It had a section for woman’s personal characteristics as age, marital status, education, job, residence, as well as a full obstetric history and previous use of preconception care. The second part was exactly similar to the corresponding part of the nurses’ questionnaire, with the same scoring system. The third part assessed women’s knowledge of preconception care through 24 True/False questions covering the same areas as in the nurses’ form, and the scoring was similar to it. The fourth part was an attitude scale consisting of 12 positive and negative statements covering the same areas of pre-conception care as in the nurses’ tool, and it had the same scoring system.

Validity and Reliability of Tools

The two tools were reviewed by a panel of three experts in women health and obstetric nursing to examine their face and content validity. Modification of the content and rephrasing of some statements were done according to their recommendations. The reliability of the attitude scales was examined through assessing their internal consistency, and they showed a good level of reliability as shown by their Cronbach alpha coefficients.

Pilot Study

A pilot study was conducted on approximately 10% of the samples of nurses and women to test the clarity and applicability of the data collection tools, and to determine the time required to fill them. The data collection forms were finalized based on the pilot results.

Ethical Considerations

The researchers obtained required ethical and administrative approvals to conduct the study. The aim and process of the study were explained to each potential participant nurse and woman, and their oral informed consent was obtained before any data collection. They were informed about their rights to refuse or withdraw from the study at any time. They were reassured about the confidentiality of any obtained information. Professional help was provided to women when needed.

Fieldwork

Permission to conduct the study was obtained from the directors of MCH and PHC centers. The researchers first met with the nurses individually and handed the data collection tool to those who gave their consent, along with instructions on how to fill it. It took each nurse approximately 45 minutes to be complete the form. Then, around twelve women were recruited from the center, and they were interviewed using the corresponding form after giving their consent. The woman’s privacy was respected during the interview, which took 25-35 minutes. The data collection period lasted for six months from June to November 2017.

Statistical Analysis

Data entry and statistical analysis were done using SPSS 20.0 statistical software package. Data were presented using descriptive statistics in the form of frequencies and percentages for qualitative variables, and means and standard deviations and medians for quantitative variables. Cronbach alpha coefficient was calculated to assess the reliability of the scales through their internal consistency. Quantitative continuous data were compared using the non-parametric Mann-Whitney test. Qualitative categorical variables were compared using chisquare test. In order to identify the independent predictors of the knowledge and attitude scores, multiple linear regression analysis was used, and analysis of variance for the full regression models done. Statistical significance was considered at p-value <0.05.

RESULTS

The study sample of nurses included 106 female nurses whose age ranged between 21 and 59 years, mostly diploma degree nurses (97.2%), with median experience 20 years as illustrated in Table 1. The majorities of these nurses were married (89.6%), had a previous pregnancy (80.2%), and of this 90.6% had antenatal care. More than two-thirds of them (72.6%) had attended training in antenatal care, and 60.4% provided preconception care at their Primary Health Care (PHC) centers.

Table 2 shows that the age of the married women in the study sample ranged between 17 and 48 years, with about two-fifth having an intermediate level education (39.5%). The majority of them were unemployed (85.1%), living in rural areas (80.3%), and having sufficient income (67.5%).

As presented in Table 3, most women in the study sample were gravida 2-4 (63.6%), and para 2-4 (64.4%), and more than one-fourth of them had previous abortions (28.5%), while only 4.9% had previous pre-term labor. The majority of the women reported using contraception (78.7%) and having an antenatal care in current pregnancy (86.8%). Although around two-fifths of the women had previous pre-conception care (41.2%) and counseling (43.1%), a majority (70.1%) were interested in pre-conception care.

Table 4 points to generally low awareness of women about the elements of pre-conception care. This was prominent regarding the elements related to work hazards, chronic diseases, exercise, and vaccination, which were known by only less than one-third of them. Meanwhile, nurses’ awareness was generally high, except for the elements of exercise and vaccination. The table demonstrates that the nurses’ awareness was higher compared with women in all elements, with statistically significant differences (p<0.001). The only exceptions were related to the elements of talking to the doctor about pregnancy and having advice on medications, which were high in both groups.

Table 5 indicates higher scores of knowledge of pre-conception care among nurses compared to women in the areas of chronic diseases (0.008), infectious diseases (p<0.001), and service/elements (p<0.001). Conversely, women knowledge scores were higher in vaccination (p=0.001). However, the total knowledge score was higher among nurses (p<0.001). Similarly, they had a higher total awareness score (p<0.001). As regards the attitude, only the attitude towards planning for pregnancy had a significantly higher score among nurses compared with women (p<0.001). Although the total attitude score tended to be higher among nurses, the difference did not reach statistical significance (p=0.08).