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Foetal Health Locus of Control and iron

supplementation adherence among

pregnant women in Bali

Luh Put u Lila Wulandari a , Pippa Craig b & Anna Klinken Whelan c

a

School of Public Healt h, Facult y of Medicine, Udayana Universit y, Bali, Indonesia

b

ANU Medical School, Aust ralian Nat ional Universit y, Canberra, Aust ralia

c

School of Public Healt h and Communit y Medicine, Universit y of New Sout h Wales, Sydney, Aust ralia

Published online: 09 Jan 2013.

To cite this article: Luh Put u Lila Wulandari , Pippa Craig & Anna Klinken Whelan (2013) Foet al Healt h Locus of Cont rol and iron supplement at ion adherence among pregnant women in Bali, Journal of Reproduct ive and Inf ant Psychology, 31: 1, 94-101, DOI: 10. 1080/ 02646838. 2012. 751585

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Foetal Health Locus of Control and iron supplementation

adherence among pregnant women in Bali

Luh Putu Lila Wulandaria*, Pippa Craigband Anna Klinken Whelanc

a_{School of Public Health, Faculty of Medicine, Udayana University, Bali, Indonesia;}b_ANU

Medical School, Australian National University, Canberra, Australia;cSchool of Public Health and Community Medicine, University of New South Wales, Sydney, Australia

(Received 25 August 2012;ﬁnal version received 18 November 2012)

Objective: This study aims to explore whether adherence to taking iron supple-mentation is associated with health beliefs as measured by the Foetal Health Locus of Control (FHLC).Background:Anaemia in pregnancy is major health problem in Indonesia. Non-adherence to iron supplement intake has been one factor that hindered the effectiveness of an iron supplementation in reducing anaemia during pregnancy. Insufﬁcient attention has been given to why such a phenomenon occurs.Methods: A cross-sectional study was conducted in South Kuta, Bali, Indonesia. Pregnant women were invited to complete a self-adminis-tered questionnaire comprising questions on the frequency of taking iron supple-ment in addition to the FHLC scale. Results: This study was among the ﬁrst using the FHLC scale in a non-English-speaking background country. Of the 360 pregnant women invited to participate, 299 returned completed question-naires.Conclusion:Using the FHLC scale we learned that Internal and Chance scales were associated with supplementation adherence. It is recommended that health counselling be introduced to improve iron supplementation adherence among pregnant women in Bali taking into consideration these predictors of adherence.

Keywords:pregnancy; health beliefs; locus of control

Background

Anaemia during pregnancy is a major public health problem in developing coun-tries. One of the approaches introduced in Indonesia to alleviate this problem is iron supplementation, in which pregnant women are given iron supplements and are rec-ommended to take iron tablets daily during their pregnancy. Iron supplements com-monly distributed in developing countries contain 200 mg ferrous sulfate. However, low adherence to the iron tablet distribution hinders its effectiveness in combating anaemia.

A study conducted in Bali in 2008 revealed the wide range in health beliefs dur-ing pregnancy and how these beliefs inﬂuence whether women adopt healthy behaviours (Wulandari & Klinken Whelan, 2011). While studies have been con-ducted on the prevalence of failure to take iron supplements, there have been a lack

*Corresponding author. Email: putuwulandari@yahoo.com

Journal of Reproductive and Infant Psychology, 2013

Vol. 31, No. 1, 94–101, http://dx.doi.org/10.1080/02646838.2012.751585

Ó2012 Society for Reproductive and Infant Psychology

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of studies which have focused on whether health beliefs inﬂuence pregnant women behaviours in adhering to their iron supplementation.

This study used the Foetal Health Locus of Control (FHLC) scale (Labs & Wur-tele, 1986) to explore whether adherence to taking iron supplements is associated with beliefs during pregnancy. The FHLC scale, which measures the perceived per-sonal responsibility by the pregnant women regarding the well-being of their babies, is divided into three subscales. The Internal subscale (FHLC-I) measures the extent to which pregnant women perceived that they themselves are responsible for the health of their baby; the Chance subscale (FHLC-C) measures their expectation that it is chance that affects their baby_’s health outcomes; and the Powerful-Others sub-scale (FHLC-PO) measures their expectation that some external powerful other per-son affects their babies’health outcomes.

Several studies have examined the role of these beliefs in health related behav-iours during pregnancy addressing such aspects as attending prenatal classes, smok-ing status, caffeine consumption, folic acid intake, intention to breastfed, prenatal testing and adherence to prenatal health guidelines (Haslam & Lawrence, 2004; Haslam, Lawrence, & Haefali, 2003; Labs & Wurtele, 1986; Tinsley, 1993). In gen-eral the greater the Internal control (i.e. the greater the score in FHLC-I) the more likely it is that women engage in the health recommendations, and vice versa. The Chance subscale has been reported to have either no effect or a negative association with recommended health behaviour; that is, the higher the score in FHLC-C, the less likely women are to adhere to health recommendations. The Powerful-Other subscale has either no effect or a positive association with health compromising behaviour.

In spite of the fact that this scale has been used extensively to predict various health behaviours during pregnancy, few of these studies have been within a non-English-speaking setting. This study is the ﬁrst using the FHLC scale to assess Indonesian pregnant women’s adherence to iron supplement in terms of their health locus of control beliefs.

Methods

The study was conducted in the subdistrict of South Kuta, in Bali, Indonesia. The area is inhabited by 32,796 people with approximately 446 pregnant women in 2007 (Community Healthcare Centre of South Kuta, 2007).

The health service delivery system in this area, as for the rest of Indonesia, is organised on_ﬁve levels: central, provincials, districts, subdistricts and villages. The Community Health Centre (Pusat Kesehatan Masyarakat_–Puskesmas) at the subdis-trict level, along with subhealth centres (Puskesmas Pembantu_–Pustu) at the village level, deliver primary health care services to the community. Maternal and child health care in each village is also provided by private midwife clinics under the super-vision of community health centres. There is one community health centre and six subhealth centres in addition to 14 private midwife clinics in South Kuta subdistrict.

Three hundred and sixty pregnant women from six private midwife clinics and six subhealth centres who were in at least their second trimester and had sought antenatal care for pregnancy at a subhealth centre or from a village midwife clinic on at least two occasions were invited to participate in this study. Pregnant women in their ﬁrst trimester were excluded because they may not have known that they were pregnant and were unlikely to be taking iron supplements.

Journal of Reproductive and Infant Psychology 95

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A survey instrument was developed. This questionnaire asked for information regarding the adherence to iron supplement intake in addition to sociodemographic characteristics and the FHLC scale.

Compared to other more costly measures, self-report was considered the most practical way of measuring adherence (Svarstad, Chewning, Sleath, & Claesson, 1999). In order to avoid recall biases (Coughlin, 1990), participants were asked to report their adherence during the previous week. This method was also used in an iron supplement adherence study in the USA (Jasti, Siega-Riz, Cogswell, Hartzema, & Bentley, 2005).

It is suggested that repeating questions using different phrases provide more reli-able responses (Abramson, 1990). Participants were asked about how many days they have taken iron during the last week. They were then asked how many times they had missed taking iron tablets in the last week. These questions were then ana-lysed for congruency.

Variables around perceived responsibility towards foetal health were included in the questionnaire using the FHLC scale (Labs & Wurtele, 1986). For each item in the scale, answers were scored using a 5-point likert scale from ‘strongly agree’ (scored 5) to‘strongly disagree’(scored as 1). This response method was also used in a study in the UK (Haslam & Lawrence, 2004).

As no prenatal classes were available in the study settings, one item of the FHLC scale was slightly modi_fied. The original version was worded as: _‘Attending prenatal classes taught by competent health professional can greatly influence the odds of having a healthy normal baby_’. This was modified for this study to become ‘Attending the antenatal care clinic for antenatal care visits can greatly influence the odds of having a healthy normal baby_’.

As this research was conducted in Indonesia and the participants_’ native lan-guage is not English, the questionnaire was translated into Bahasa Indonesia. To account for cross-cultural and linguistic issues, especially as the FHLC scale has been validated in English, a back-translation method was used as suggested by Sperber (2004). The questionnaire was ﬁrst translated into Indonesian. The Indone-sian translation, done by the investigator, was then translated back into English by another translator, an Indonesian doctor, who had not seen the original question-naire. These two versions were then compared by the investigator and reﬁnements made accordingly.

After the development and cross-cultural translation process, the questionnaire was piloted and re_fined prior to the _fieldwork. Pilot testing is also useful in provid-ing information regardprovid-ing unanswered items (Abramson, 1990). The pilot study involved women with similar characteristics to the study population. Six Indonesian pregnant women who lived in Sydney and in Bali were invited to participate. Among the six women, one had notfinished primary school and another was doing her PhD. The inclusion of women with both low and high levels of education allowed evaluation of the readability, comprehension of the questions and differ-ences in responses (Abramson, 1990).

A section for recommendations and suggested modification was included at the end of the pilot survey. All six invited women completed and returned the question-naire, with no questions left unanswered. Their recommendations for modifications were taken into account in refining the questionnaire until the questionnaire was confirmed by these participants as being easy to read and understand.

96 L.P.L. Wulandariet al.

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Following the planning process, data collection was conducted between January and April 2007. Written approvals were received from the heads of the Health Centre of South Kuta and of the Health Ofﬁce of Badung, Bali. Ethical approval was obtained from the Human Research Ethics Advisory Panel at the University of New South Wales.

Questionnaires were distributed to the midwives in the subhealth centres and in the private midwife clinics. Participants completed the questionnaires at the clinic. There was no coercion by midwives and women were reassured that whatever they decided to do, it would not have any impact on their relationship with the health staff at the subhealth centres or midwife clinics.

All computer ﬁles and questionnaires were stored securely as required by the University of New South Wales Human Ethics Research Committee regulations.

Data analysis

Analysis was conducted using SPSS for windows version 13.0 (SPSS Inc. 2004). The frequency of taking iron tablets was grouped into < 4 days a week (categorised as non-adherent) and P4 days a week (grouped as adherent). This cut-off point is similar to taking iron supplements at least 65% of the recommended intake and has been used in several studies (Jasti et al., 2005; Suitor & Gardner, 1990; Yu, Keppel, Singh, & Kessel, 1996). It is also in line with the recommendation that compliance with 60 mg daily elemental iron supplements is sufﬁcient to produce maximal hae-moglobin response (Ekström et al., 2002; Sloan, Jordan, & Winikoff, 2002).

A t-test was used to test the differences between the adherent and non-adherent groups. Prior to comparison of participants with regards to their scores on the FHLC scale, the reliability of the scale was checked to ensure that it reﬂected the construct using Cronbach’s alpha (Field, 2005). To estimate predictors of adherence to iron supplement use, multivariate analysis via logistic regression was performed.

Results

Three hundred and sixty questionnaires were distributed through six subhealth cen-tres and six private midwife clinics; one village midwife clinic and one subhealth centre in each of the six villages included in the study. Two hundred and eighty-one questionnaires were included in the analysis.

The participants_’ age ranged from 16 to 40 years old with a mean (SD) of 26.3 (± 4.9) years. Gestational age ranging from 12 to 40 weeks with mean (SD) of 28.7 (± 6.8) weeks. The highest level of education completed by half of the participants was _‘secondary school or below_’. Almost all of pregnant women were married (98.2%). Balinese (65.1%) and Hindu (65.5%) comprised almost twice as many as non-Balinese and non-Hindu. Over half stated that this was not their ﬁrst pregnancy (63.3%) and reported a previous birth (60.1%), while it was theﬁrst pregnancy for 39.9% of the women.

Almost a quarter (20.3%) of participants admitted that they did not take iron tablets in the previous week. Because adherence in this study context was deﬁned as taking iron supplements for at least 4 days a week, almost half of participants, i.e. 130 women (46.3%), were classiﬁed as non-adherent.

Before the analysis, the reliability of the FHLC scale was examined using Cron-bach_’s alpha. The scale was demonstrated to have good internal consistency. The

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Internal subscale, the Chance subscale, and the Powerful-Others subscale had Cron-bach alpha coefﬁcients of 0.63, 0.82, and 0.76, respectively.

Among variables included in the t-test analysis, the adherent and non-adherent group was statistically signiﬁcantly different in terms of FHLC Internal (p= 0.001) and the Chance subscales (p< 0.001) (Table 1).

The model of logistic regression showed (Table 2) that those who had a higher Internal scale were 1.2 times more likely to adhere to take iron tablets (OR = 1.19; 95% CI = 1.07–1.31; p = 0.001); while those who had higher Chance score were less likely to adhere to take iron (OR = 0.84; 95% CI = 0.80–0.89;p< 0.001).

Discussion

This study showed that almost half the pregnant women surveyed (46.3%) were non-adherent according to the definition of adherence used in this study. This was lower than a previous study in South Kuta which revealed that more than 90% of pregnant women in this area did not take iron supplements as recommended (Gunung, Arhya, Wirakusuma, Indraguna, & Supriyadi, 2003). Differences in de_fi -nition of adherence affect any comparisons between the two studies. The current study defines adherence as taking iron supplements at least 4 days a week, while the study by Gunung et al. strictly defined adherence as taking iron supplements seven days a week. However, most of studies on iron intake adherence worldwide supported the current study with adherence rates ranging from 32.3% to 65% (Dairo & Lawoyin, 2006; Ekstrom et al., 1996; Hyder, Persson, Chowdhury, & Ekström, 2002; Knudsen, Hansen, Ovesen, Mikkelsen, & Olsen, 2007; Nordeng, Eskild, Nes-heim, Aursnes, & Jacobsen, 2003; Schultink, van der Ree, Matulessi, & Gross, 1993).

There were differences between pregnant women who were adherent and non-adherent in terms of their score on the FHLC-Internal and FHLC-Chance subscales; those who had a higher Internal score and a lower Chance subscale score of FHLC were more likely to be adherent.

Table 1. Comparison among pregnant women who were adherent and non-adherent with respect to FHLC mean scores.

FHLC Scale

Adherence

tvalue pvalue Non-adherent Adherent

Mean (SD) Mean (SD) (n= 130) (n= 151)

Internal (range = 17–30) 24.9 (2.7) 26.0 (2.2) –3.46 0.001 Chance (range = 9–30) 22.4 (4.2) 18.6 (5.0) 7.06 < 0.001 Powerful-Other (range = 14–30) 22.2 (4.0) 22.6 (3.6) –0.92 0.356

Table 2. Predictors of iron supplementation adherence.

Predictors of adherence OR 95% CI pvalue

FHLC-Internal 1.19 1.07–1.31 0.001

FHLC-Chance 0.84 0.80–0.89 < 0.001

FHLC-Powerful Other 1.03 0.97–1.10 0.355

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The ﬁnding that a higher Internal subscale score correlates with increased adher-ence to supplement intake is consistent with studies in the UK (Haslam et al., 2003) and in the USA (Tinsley, 1993), which revealed that a higher Internal sub-scale score correlated with a higher adherence to several recommended behaviours during pregnancy. Taken together, these _ﬁndings indicate that the greater their per-ceived responsibilities over the health of the baby, the more likely women are to adhere to healthy behaviours, including adherence to iron supplement usage.

This study also found that a lower score on the Chance subscale of the FHLC was correlated with increased adherence. This might indicate that the stronger the belief that nature and fate will determine the baby_’s outcome, the less likely it is that women will adhere to recommended dosages of iron supplements. This finding is inconsistent with a study in the USA by Tinsley (1993), which found no signifi -cant correlation with health behaviour. However, in a qualitative study among Thai women (Rice & Naksook, 1999), the role of beliefs about fate and nature negatively influenced decisions to engage in healthy behaviour during pregnancy. Rice and Naksook found that strong beliefs regarding the role of chance in determining the health of the baby had discouraged pregnant women from undergoing prenatal test-ing. The finding of a negative association between adherence with the Chance sub-scale was also substantiated by findings from the qualitative part of this study regarding beliefs around the role of nature and God in determining the health of the baby (Wulandari & Klinken Whelan, 2011).

Strengths and limitations of the study

Thefindings of this study must be taken cautiously due to the following limitations. First, although it is assumed that the questionnaire responses accurately reflected the pregnant woman_’s behaviour, and a questionnaire measuring adherence to iron supplements is considered to have high validity (Lutsey, Dawe, Villate, Valencia, & Lopez, 2007), systematic distortion is possible. There was no verification of the women’s adherence as based on self-reporting. It is possible that the number of non compliant pregnant women might have been higher, because not all may have admitted that they did not take iron supplements. Hence this method of measuring adherence potentially overestimates the adherence data.

Second, the study sample was chosen among women who sought antenatal care at subhealth centres and village midwife clinics. This was done because under the supervision of the community health centres, these centres are responsible for the maintenance of the mother and foetal well-being in the villages and subdistricts. This responsibility includes implementing the iron tablet distribution by giving iron tablets to all pregnant women who seek antenatal care at these institutions. Involv-ing these women in this study enables evaluation of the existInvolv-ing iron tablet distribu-tion. However, this might limit the generalisability of the study by limiting it to pregnant women who routinely monitor their pregnancy at the subhealth centres and with private midwife clinics.

Recommendation for future research

Further research needs to be performed using more reliable measurements to increase the validity of the data. Dietary assessment and measures of actual iron levels of pregnant women would provide more robust validation of levels of iron

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insufﬁciency in South Kuta. Neonatal screening for iron deﬁciency would further enhance the meaningfulness of the reported research. This study suggests that there is a crucial role of effective communication between healthcare providers and patients in promoting adherence behaviours among pregnant women in Bali.

Acknowledgements

The authors would like to acknowledge the pregnant women who participated in this study, and Community Healthcare Centre of South Kuta, Bali. We would also like to acknowledge Ms Sally Nathan and thank her for her assistance and comments on this study. Thanks to Van Ngu Yen who strengthened the statistical and SPSS expertise to manage the quantitative data. This study was conducted in fulﬁlment of the requirements for the degree of Master of Public Health at the School of Public Health and Community Medicine, the University of New South Wales and supported by Australian Development Scholarship kindly provided by the Government of Australia.

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