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Abstract

Purpose:

Although preconception care (PCC) has been integrated into women’s care programmes in the country for more than a decade, it has not yet been welcomed by Iranian women, and the rate of PCC uptake is very low. Therefore, this study aims to determine predictors of uptake of PCC based on the Beliefs, Attitudes, Subjective Norms and Enabling Factors (BASNEF) model among women of reproductive age referred to health centres in Urmia, Northwest Iran, in 2019.

Methods:

This cross-sectional study was carried out on 230 women of childbearing age at Urmia health centres during 2019. Subjects were selected using a multistage sampling method. A valid reliable researcher-made questionnaire, including demographic information, items related to the BASNEF model constructs regarding PCC and items related to PCC behaviour, was used to collect data. Data were analysed using descriptive and inferential statistics (frequencies, means and standard deviations, independent t-test, chi-square test, logistic and linear regression).

Results:

The findings showed that the rate of receiving PCC was 19.6%. Overall, the BASNEF model predicted 42% of the intention to receive health care. Among the model constructs, enabling factors (β=0.32, p<0.001) and attitude (β=0.41, p<0.001) significantly explained women’s behavioural intention towards receiving PCC. In the logistic regression model, intention (β=0.15, p<0.001) and enabling factors (β=0.12, p=0.034) had a significant role in predicting PCC.

Conclusion:

The low uptake of PCC by women of childbearing age in Urmia suggests the need to design and implement interventions based on women’s attitudes, intentions and enabling factors in order to stimulate and maintain women’s health-promoting behaviours during childbearing age.

Keywords

Preconception care BASNEF model women Urmia

Introduction

According to the World Health Organization (WHO), preconception care (PCC) or pre-pregnancy care is ‘the provision of biomedical, behavioral, social, and health interventions for women and couples before conception occurs’.¹ PCC aims to improve maternal and child health by reducing behavioural, individual and environmental risks that could contribute to poor maternal and child health outcomes.² According to the WHO, PCC interventions should be delivered to women with health problems such as nutritional conditions, tobacco use, genetic conditions, infertility/subfertility, interpersonal violence, sexually transmitted infections, human immunodeficiency virus, mental-health problems, vaccine-preventable diseases and female genital mutilation.¹

There is growing evidence that exposure to unhealthy lifestyle behaviours before or during early pregnancy often affects the future health of mothers and their children.^3–5 Due to the high prevalence of unwanted pregnancies in Iran, the importance of the issue is multiplied. A systematic review and meta-analysis in Iran indicated that about one-third of pregnancies are unwanted.⁶

Concerning PCC delivery in Iran, all married women who intend to become pregnant can receive services related to PCC based on a national protocol released by the Ministry of Health. The PCC services are delivered to women through governmental health centres and private clinics, and women can attend clinics in either the public or private sector. PCC in Iran is used for clients based on integrated care for maternal health (the Ministry of Health, Iran 2012). It is offered by midwives and physicians to women who attend the public health centres in Iran and who have planned to become pregnant or do not use any effective contraceptive methods. In this paper, PCC is defined as doing the following three behaviours: (a) taking folic acid, (b) having the PCC file and (c) having blood screening tests.

Although more than a decade has passed since the integration of PCC in the maternal care programmes of all medical universities in Iran,⁷ its use is still remarkably low. Several studies have reported consistently low uptake of PCC services in Iran, highlighting that >50% of women do not engage with PCC.^8–10 Determining the causes and obstacles of using PCC can provide strategies to increase its use and also eliminate the barriers. In addition, it appears that examining the relationship of different factors with receiving PCC is also necessary. In general, studies in this field have identified related factors, and the reasons for the lack of check-ups have been witnessed. The main barriers to PCC mentioned in the various studies include women’s lack of awareness of PCC,¹¹ low and poor education,¹² gender inequality,¹³ high rates of adolescent pregnancy and early marriage,¹⁴ which may be considered as social barriers.

In order to develop, implement and maintain prenatal health policies, the relevant information is required to be used as a standard of care in the health-care system. Yet, such information does not exist in most countries in the world, especially in developing nations.¹⁵ Some experts believe that one of the reasons for the failure of health programmes is the lack of attention to research causes or establish them considering social psychological models as a clear intellectual framework in educational planning. Theories and models are practical tools for solving various problems. The use of models of health education can help researchers recognise the factors affecting health behaviours.¹⁶

In order to change PCC behaviours, understanding and recognising effective factors for these behaviours are necessary. This information may help researchers to design and perform different interventions, such as educational programmes, for improving PCC behaviours. Hubley’s behaviour-change model is suitable for PCC. This model is based on the Theory of Reasoned Action (TRA) and the Predisposing, Reinforcing and Enabling Constructs in Educational Diagnosis and Evaluation (PRECEDE) model.¹⁷ The present study includes the Beliefs, Attitudes, Subjective Norms and Enabling Factors (BASNEF) model.¹⁸ Based on the BASNEF model, the most important determinant of a person’s behaviour is his/her intention. A person’s intention is a combination of his/her attitude and subjective norms. A person’s attitude towards a behaviour includes his/her belief in the consequences of the behaviour and his/her assessment of the behavioural consequences. Subjective norms, as a construct of the model, also affect a person’s behaviour. They include normative beliefs and the motivation to obey. In other words, they are a type of social pressure imposed by people/systems important to the individual (e.g. friends, acquaintances, family, religious leaders and health-care systems).¹⁹ Another important consideration in this model is enabling factors. A person may not be able to perform certain behaviours due to a lack of enabling factors, such as money, time, resources, special skills and available health care.²⁰

To understand the determinants and importance of PCC services provision to all women of childbearing age,²¹ this study was designed to investigate the application of the BASNEF model in order to predict PCC in a sample of Iranian women. The study results may contribute to the existing knowledge of PCC.

Methods

This cross-sectional study was performed on 230 married women with an age range of 15–49 years referred to health centres in Urmia, Northwest Iran, in 2018. The sample size was estimated to be 230 people using the average estimation formula of a variable in the population and the results of a study conducted by Latifnejad-Rordsari et al.²² The inclusion criteria were: the wish to participate in the study, an age range of 15–49 years, Iranian citizenship, married, resident in Urmia, the desire to become pregnant, not using contraception and not involved in health-related education or employment. Refusal to participate in the study was the exclusion criterion.

To collect the study data, multistage sampling was applied. First, the city of Urmia was divided into four geographical areas: north, south, east and west. Then, 24 health centres (six from each region) were randomly selected. To invite women from each centre, a list of all women eligible to take part in the study was extracted using their continuous care files. They were then invited to attend the centre. The study questionnaires were completed by the researcher via an interview with the subjects after approval from the Ethics Committee of Urmia University of Medical Sciences (no.: IR.UMSU.REC.1397.157), obtaining written informed consent from all participants and explaining the objectives and methods of the study to them.

The data-collection tool was a researcher-made questionnaire consisting of three parts. The first part collected information related to demographic and midwifery characteristics, such as age, educational level, family income level (a monthly income of <30,000,000 Rials as insufficient income and of >30,000,000 Rials as sufficient income), number of pregnancies, history of preterm labour, abortion and history of medical disease. The second part comprised 42 items related to the model constructs: 10 items to assess subjects’ attitudes (e.g. ‘In my opinion, preconception care is useful for the mother and the foetus’); five items to measure subjects’ subjective norms (e.g. ‘My husband encourages me to have preconception care’); seven items to examine subjects’ behavioural intention (e.g. ‘I will start taking folic acid at least 3 months before getting pregnant’); four items to evaluate subjects’ enabling factors (e.g. ‘I do not have enough time to take preconception care’); and 16 items to assess subjects’ knowledge (e.g. ‘Women of childbearing age should consume folic acid tablets for 2 to 3 months before pregnancy’). Questionnaire items were scored on a five-point Likert scale (ranging from 1=‘strongly disagree’ to 5=‘strongly agree’). The third part contained items about PCC use. PCC use was assessed using three items: (1) Did you consume folic acid? (2) Did you perform blood tests prescribed by your physician? (3) Did you set up a PCC file with your physician/midwife and update it during regular visits? Women were required to do all three to qualify as utilising PCC. If they did one or two out of the three behaviours, they were not classed as having received care. The content and face validity of the questionnaire were reviewed and verified by 10 health education and reproductive health professionals. In this psychometric, on average, the content validity ratio (CVR) and the content validity index (CVI) of the study instrument were reported as 0.80 and 0.92, respectively. Cronbach’s alpha coefficients for subscales of attitude, subjective norms, behavioural intention, enabling factors and knowledge were reported to be 0.70, 0.81, 0.85, 0.71 and 0.7, respectively. Data analysis was performed using the SPSS for Windows v16.0 (SPSS, Inc., Chicago, IL). Thus, the validity and reliability of the questionnaire and its dimensions were confirmed. Descriptive and inferential statistics (independent t-test and logistic and linear regression) were used to determine the relationships between variables. In multiple linear and logistic regression analyses, predictors of intention towards PCC use and PCC use were explored. The significance level was set at <0.05 in all statistical analyses.

Results

The mean age of the participants in the study was 30.73 years (standard deviation=6.77 years). Most of the subjects (87.7%) were housewives, and 35.6% of all participants had a high-school diploma. The majority of participants (47%) had sufficient income, and 26.9% had no insurance. A significant and positive relationship was found between using PCC and women’s educational level (df=3, p=0.001; Table 1). Only 45 (19.6%) women utilised PCC (the group with PCC), and the majority (n=185; 80.4%) did not use PCC (the group without PCC).

Table 1.

Comparison of women’s demographic and midwifery characteristics in terms of doing preconception care (N=230).

Variable		Doing preconception care		Statistics
Variable		Yes	No	Statistics
Age (years), M±SD		30.09±7.01	30.88±6.72	p=0.48
Educational level	Primary	2 (4.44)	47 (25.40)	df=3p=0.001
	Guidance school	5 (11.11)	27 (14.59)
	High school and diploma	15 (33.33)	67 (36.21)
	University	23 (51.11)	44 (23.78)
Occupational status	Housewife	36 (80)	166 (89.73)	df=1p=0.187
Occupational status	Employed	9 (20)	19 (10.27)	df=1p=0.187
Family income level	Insufficient	14 (31.11)	63 (34.05)	df=1p=0.89
Family income level	Sufficient	31 (66.89)	122 (65.95)	df=1p=0.89
Insurance	Yes	33 (73.33)	135 (72.97)	df=1p=0.96
Insurance	No	12 (26.66)	50 (27.03)	df=1p=0.96
History of abortion	No	34 (75.55)	141 (76.22)	df=1p=0.92
History of abortion	Yes	11 (24.45)	44 (23.78)	df=1p=0.92
History of preterm labour	No	42 (93.33)	159 (85.94)	df=1p=0.18
History of preterm labour	Yes	3 (6.67)	26 (14.06)	df=1p=0.18
Major medical disease	No	35 (77.77)	143 (77.30)	df=1p=0.94
Major medical disease	Yes	10 (22.23)	42 (22.70)	df=1p=0.94

Data shown as n (%) unless otherwise indicated.

The results of the correlation matrix showed that some variables of the BASNEF model were significantly correlated with each other (p<0.01; Table 2). In particular, women’s attitudes (r=0.597) and enabling factors (r=0.557) were highly (r=0.382) correlated with behavioural intention.

Table 2.

Correlation matrix of variables of the study model (n=230).

Variable	Behavioural intention	Knowledge	Attitude	Subjective norm	Enabling factors
Behavioural intention	1.00
Knowledge	0.135*	1.00
Attitude	0.597**	0.169*	1.00
Subjective norm	0.037	0.181*	0.160*	1.00
Enabling factors	0.557**	0.243**	0.573**	0.058	1.00

p<0.05; **p<0.01.

There were statistically significant differences between the two groups (the groups with and without PCC) in terms of the mean score of attitudes, enabling factors and intention regarding PPC use (Table 3). In other words, women with PCC had high score in the mentioned variables compared to those without PCC.

Table 3.

Comparison of the mean score of constructs of BASNEF model regarding doing preconception care among two groups (N=230).

Variable	Performing preconception care		p
Variable	No	Yes	p
Attitude	45.08±4.90	33.60±11/98	0.001
Enabling factors	16.24±2.87	10.44±5.52	0.001
Subjective norms	18.42±3.82	18.35±4.06	0.91
Knowledge	3.73±1.11	3.79±1.29	0.77
Intention	31.81±5.64	18.32±8.86	0.001

Data shown as M±SD unless otherwise indicated.

Linear and logistic regression analyses were applied to determine the relative importance of the variables of the BASNEF model to behavioural intention and actual behaviour (Tables 4). In multiple linear regression analysis, when the attitude towards behaviour, subjective norms, knowledge and enabling factors were regressed to behavioural intention, the model was very significant (p<0.001), explaining 0.42% of the behavioural intention variance. While knowledge and subjective norms were not significant, enabling factors and attitudes were significantly related to the intention to use PCC. Enabling factors and attitudes seem to be the most important predictors of behavioural intent. In logistic regression analysis, intention (β=0.15, p<0.001) and enabling factors (β=0.12, p=0.034) had a significant role in predicting PCC use (Table 5).

Table 4.

Multiple linear regression analysis on women’s behavioral intention toward PCC (N=230).

Variable	β	B	Standard error	p	Adjusted R²
Constant		4.18	3.10	0.2	0.42
Attitude	0.42	0.35	0.05	<0.001
Enabling factors	0.32	0.56	0.11	<0.001
Subjective norm	−0.05	−0.19	0.13	0.35
Knowledge	−0.005	−0.01	0.16	0.93

Table 5.

Logistic regression analysis on women’s PCC behavior (N=230).

Variable	B	Standard error	Wald	p	Exp (B)
Constant	−7.19	1.05	46.38	<0.001	0.001
Intention	0.15	0.03	22.1	<0.001	1.16
Enabling factors	0.12	0.05	4.48	0.03	1.13

Discussion

This study examined the application of the BASNEF model and its constructs in predicting PCC behaviour. The results show that 19.6% of the women studied used PCC. However, other studies have reported a different rate of PCC behaviours. This result is closer to that of China (20.6%),²³ London (27%),²⁴ Saudi Arabia²⁵ and the USA (32%).²⁶

A study in Isfahan reported that 47.7% of Isfahanian women use PCC.⁹ Bayrami et al. highlight that 46.6% of Iranian women, who intend to become pregnant, use PCC.¹⁰ Furthermore, according to a study, 32.6% of women of childbearing age use PCC in the USA.²⁷ These studies report that >50% of women do not use PCC in Iran and the USA, suggesting this is not just a local issue but a global one. These differences can be due to a variety of factors, including: a lack of awareness of PCC; inadequate attention of health-care providers to PCC; the health, cultural and social differences in communities; and different sample sizes in the studied populations. In general, it seems that the coverage of PCC by women is low and is far from the desired level.

The present study showed a significant and positive relationship between the level of women’s education and using PCC. The results of previous studies have shown that women who use PCC are more likely to have a higher level of education.^24,28–33 The findings of all these studies are in line with those of the present study. The results of some investigations, such as Latifnejad et al. in Iran²² and Temel et al. in the Netherlands,³⁴ are in contrast to those of the current research. In other words, these studies showed that there was no relationship between PCC use and women’s educational level. These differences may be attributed to variables such as different sample sizes and the ethnicity, race and education level of the women in the studies.

The results of the present study indicate that enabling factors and attitudes significantly explain women’s intention to utilise PCC services. The results obtained by other studies show that a positive attitude towards pre-pregnancy health care could predict that care in women.^27,35,36 Further, the study conducted by Jalambadani et al. revealed that women with adequate and proper knowledge as well as a positive attitude towards taking folic acid at their discretion in terms of environmental factors (facilities and barriers) intend to use folic acid.³⁷ The results of all of these studies partly support the findings of the present study. However, a study conducted by Latifnejad et al. in Mashhad shows that despite the high level of awareness and attitude of women, the majority ignore PCC.²² The reason for this discrepancy between the results of the present and the mentioned studies can be attributed to the differences in culture and sample size of the communities. The present research showed no significant relationship between PCC and subjective norms. In line with the present study results, Wang’s work, based on the theory of planned behaviour in the USA, indicates that subjective norms did not predict the use of contraception among diabetic girls.³⁸

According to the present work, women’s intention predicts receiving PCC services. The results of some studies are consistent with this part of our study findings. For instance, in the study by Honari et al., the constructs of intention and attitude are identified as important predictors of prenatal care.³⁹ Furthermore, Asadi et al. showed that intention has a positive and significant relationship with health behaviour.⁴⁰ However, a study by Chuang et al., using the logistic regression model for each of the resulting variables, including nutrition (fruit and vegetable consumption), folic acid supplementation, physical activity, alcohol consumption, tobacco use and vaginal douching, showed no relation between intention and health behaviour.⁴¹ This discrepancy could be due to sociocultural differences.

In the present research, enabling factors predicted PCC behaviours; that is, women who knew about services, who had money and who could easily travel to the services were more likely to use PCC services. In some cases, the mother may intend to practice prenatal care behaviours, but negative enabling factors, such as a lack of skills, money, facilities and time, may affect those behaviours. For example, in the study by Harkari et al., most mothers complained about the high cost of prenatal care.⁴² It can be concluded that women’s understanding of the high cost of care can be a deterrent to women’s health behaviour. Overall, the results show a wide gap between the received PCC and the standard. Thus, health planners need to pay more attention to this. This study found that women who knew about PCC services had positive attitudes towards them, and those who had money and transport to access services were more likely to attend. However, only a small percentage of women were using PCC services. The use of these services by women could be increased by training health personnel in PCC, sensitising and raising awareness among families about PCC through health systems and mass media, and government support through community-based insurance coverage.

The use of the behaviour-change model in this study to identify effective factors for prenatal care in women is considered a strength. However, this study, like others, has its limitations. First, only three components of prenatal care (folic acid supplementation, blood screening tests and health records at the health centre) were examined, and other components, such as women’s oral and mental health, women-specific infections, PAP smear and tetanus vaccination, were not considered. Hence, it is suggested that these components be considered by researchers in future studies. Second, this was a cross-sectional study and cannot be used to examine any cause-and-effect relationship. Thus, stronger studies are recommended to be performed for this purpose. Third, the results cannot be generalised beyond the study sample; they can be generalised only to populations with similar features. Finally, the data-collection tool in this study is a self-report questionnaire. Thus, participants may underestimate or overestimate their PCC behaviours, which could affect the study findings.

Conclusion

The present survey applied the BASNEF model to determine factors influencing women’s behavioural intention towards PCC and their performance. The results of this study showed the uptake of PCC among a sample of Iranian women of childbearing age to be low and far from the desired level. Based on the results, attitude was a strongly related factor of intention to use PCC, followed by enabling factors. Further, intention and enabling factors were known as effective constructs on PCC use among women. Therefore, attitude, intention and enabling factors should be considered as essential factors when health professionals design health interventions to target PCC among reproductive-aged women.

Footnotes

Acknowledgements

We greatly appreciate the financial support of Urmia University of Medical Sciences. We also offer our sincere thanks to the women who participated in our study.

Authors’ contributions

All authors contributed to data analysis, drafting or revising the article; gave final approval of the version to be published; and agree to be accountable for all aspects of the work.

Availability of data and materials

Available upon request.

Ethical approval

Ethics committee of Urmia University of Medical Sciences (approval no.: IR.UMSU.REC.1397.157).

Informed consent

Not applicable.

Conflict of interest

The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The authors received no financial support for the research, authorship and/or publication of this article.

ORCID iD

Alireza Didarloo

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Predictors of preconception care behaviour among women of reproductive age using a behaviour-change model

Abstract

Purpose:

Methods:

Results:

Conclusion:

Keywords

Introduction

Methods

Results

Discussion

Conclusion

Footnotes

Acknowledgements

Authors’ contributions

Availability of data and materials

Ethical approval

Informed consent

Conflict of interest

Funding

ORCID iD

References