ARTICLE INFO

Article Type

Original Research

Authors

Khani Jeihooni   A. (1*)
Shahidi   F. (1)
Kashfi   S.M. (2)






(1*) Department of Public Health and Nursing, School of Health, Fasa University of Medical Sciences, Fasa, Iran
(2) Research Center for Health Sciences and Department of Public Health, School of Health, Shiraz University of Medical Sciences, Shiraz, Iran

Correspondence

Article History

Received:  January  15, 2014
Accepted:  April 22, 2014
ePublished:  April 22, 2014

BRIEF TEXT


… [1-4]. Cesarean is considered as one of the major surgeries, and like other major surgeries is accompanied with some complications that sometimes the effects of these complications are very dangerous and rarely fatal [5].

… [6-15]. Theory of Reasoned Action is one of the best models and theories that are associated with the reproductive attitudes and behaviors [16]. This model is based on a psychological theory. The assumptions of this theory include firstly: people make decisions based on reasonable and logical investigation of the available information, and secondly, they consider the outcomes and the results of their performance before making a decision [17].

This study aimed to determine the effect of education intervention based on Theory of Reasoned Action in the selection of mode of delivery in pregnant women.

This research is quasi-experimental intervention.

This study was conducted in 2011 among women in their first pregnancy covered by health centers in the city of Fasa.

The two-stage random sampling method was used in the study; that is four urban health care centers were randomly assigned to two groups of control and experimental. Through studying the records of pregnant women, a list of those who were in their third three-months of their pregnancy was specified in each group. Considering the quotas of each group, totally 100 pregnant women (50 cases for control and 50 cases for intervention group) were selected and entered the study. Exclusion criteria consisted of a history of high blood pressure, diabetes, history of abortion, small hips, twining pregnancy diagnosis, gestational diabetes, and preeclampsia.

Data was collected by a written questionnaire in form of self-reporting from the participants in the control and intervention groups before and after the intervention. The questionnaire was based on the variables of Theory of Reasoned Action and consisted of three following parts. The first part included demographic variables such as age, husband`s age, education level, employment status, spouse`s education level, family income, gestational age, and the probably date of delivery. Knowledge of the benefits and disadvantages of cesarean and vaginal delivery was the second part of the study, in the form of 10 questions with three choices that for each correct answer the score of one and for each wrong answers or the answer “I do not know” the score of zero was considered. Higher score indicated greater knowledge of the benefits of vaginal delivery compared to cesarean section. The third part of the questionnaire included questions of the Theory of Reasoned Action variables that the behavioral beliefs to normal delivery, and the evaluation of the outcomes were assessed with 15 and 10 questions respectively with 5-point Likert scale of 1(very disagree) to 5 (very agree). Earning high score was indicator of more positive behavioral beliefs to normal delivery and better outcome evaluation of that. Questions related to normative beliefs and the questions related to important persons for pregnant women in their decision of mode of delivery, and that how much these persons are important for them was measured with five questions in each part in the form of five-point Likert scale from 1 (very disagree) to 5 (very agree). Higher score indicated the existence of persuasive subjective norms in selecting vaginal delivery. Behavioral intention to evaluate the intention of the person to select the type of delivery was examined using one questions with four options (probably cesarean delivery, cesarean definitely, probably normal delivery, and normal delivery definitely). Content validity and structure of the questionnaire were evaluated using the opinions of 10 experts in health education and promotion. The reliability of the questionnaire was assessed in the pilot study on a group of 30 other pregnant women. The internal correlation coefficients (Cronbach`s alpha) for the questions of behavioral beliefs, evaluation of the outcomes of behavior, normative beliefs and motivation to comply were 0.92, 0.85, 0.81, and 0.89 respectively. After selecting the control and intervention groups, and administrating the pretest in both groups, the control group received the normal training from the health care centers. The intervention group received the training based on the components of Theory of Reasoned Action during three sessions in the presences of their mothers and one of their friends. The training sessions included a session for promoting knowledge, a session for general discussion for attitude change, and a session in the last month for emphasis on the attitude and intention of women for normal delivery respectively. The films of normal delivery, and cesarean were shown to the participants. One session was, also, held for the husbands of pregnant women by famous obstetricians, gynecologists and experts in the city (to influence subjective norms). Finally, the post-test questionnaires were completed in both groups. Three months after the trainings, the results of deliveries in two groups were collected by reviewing the health records in health care centers. Statistical analysis: The collected data was statistically analyzed using SPSS version 18 software. In order to compare the mean scores of knowledge, attitude, and subjective norms before and after intervention paired t-test, and to compare the mean scores between the two groups after the intervention, independent t-test were used. Two compared demographic variables between the two groups, as well as the relative frequency of cesarean section, chi square test and Fisher`s exact test were used. The significance level for all tests was less than 0.05.

The age range of the participants was between 16 and 30 years with the mean age of 42.1±2.3, and most of the participants (71%) were in the age range of 20 to 30 years (Table 1). Chi-square test and Fisher’s exact test results showed that there was no significant difference in terms of age, education level, spouse’s education, the income and employment status between the two groups of control and interventional. In addition, the comparison of the scores of Theory of Reasoned Action constructs showed that there was no significant difference between the two groups before the intervention (p>0.05). The mean scores of knowledge and the constructs of Theory of Reasoned Action before and after the intervention between two groups of control and intervention has been compared in Table 2. According to the findings, the mean scores of knowledge, behavioral beliefs, and evaluation of outcomes of behavior were significantly different between the two groups after the intervention (p<0.05). In other words, there was no significant difference between the two groups before the intervention in any of the constructs. However, after the intervention, the mean scores of knowledge, behavioral beliefs, and evaluation of the outcome of behaviors had significant difference between the control and intervention groups that indicates the effect of intervention on the intervention group. With respect to the subjective norms, 60% of mothers in the control group, and 50% of them in the intervention group, reported their doctors as the most important source of information about delivery, and attitude to compliance to doctors was more than other norms in 53% of control group and 56% of intervention group. Table 3 compares the intention of delivery before and after intervention in two groups of control and intervention using Fisher`s exact test. According to the findings, the number of people who had definite intention of normal delivery was increased from 13 to 35 that was statistically significant (p=0.001). In the control group, definite intention of normal delivery was increased from 17 to 19, and this difference was not statistically significant (p=0.188). However, in this group, the number of pregnant women who had definite intention of cesarean was increased from 2 persons (4%) to 17 persons (34%) after the intervention. Finally, based on the results of chi-square test, the performance of women was statistically significantly different between the intervention and control group after the intervention (p=0.001). In this study, 90% (45 persons) of the pregnant women in the intervention group had normal delivery, while this amount was reported 60% (30 persons) in the control group.

… [18-19]. The finding of the study conducted by Tavassoli et al. with respect to the increase of knowledge after the intervention which had been conducted on the effect of training in reducing selective cesarean in the pregnant women were consistent with the results of this study [15]. Also, of the similar research in line with the findings of this study, studies conducted by Rahimikian et al. [20], Ganji et al. [21], Goba et al. [22], and Fathian and Sharafirad et al. [5] can be mentioned. … [23-30].

It is recommended that this model and other systematic training which in addition to personal factors consider the role of social determinants be used. Training and group discussion for the pregnant women`s husbands and mothers are strongly recommended. Also, the role of other effective factors in reducing cesarean such as exercises, the role of hospital environment, and doctors should be examined.

Coordination of the pregnant women and their husband to participate in the classes, coordination with the health center of the city for holding the classes, and the effective role of obstetricians and gynecologists in increasing the rate of cesarean especially in women in their first pregnancy were of the limitations and problems of this study.

It is inferred that the current intervention is effective in increasing the knowledge, the evaluation of the outcome of the results, behavioral intentions, strengthening the intention of pregnant women, and their performance.

Deputy of Research and Technology of Fasa University of Medical Sciences and Health Services, all participated pregnant women in this study, and healthcare staff of Fasa city are appreciated due to their sincere cooperation with research team.

The interests of authors are not related to the results of this study.

This study has been approved in the ethical committee of Fasa University of Medical Science and Health Services, and the researcher was introduced to the covered health centers with the presentation of official permission from the Deputy of Research and Technology of the university. All the participants were assured with respect to anonymity and confidentiality of the questionnaires and information, and the participants were entered the study voluntarily and with written consent.

This study is the result of research project with no. 24421, which was conducted by the financial support of Research and Technology Deputy of Fasa University of Medical Sciences and Health Services.

TABLES and CHARTS

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