Article
Effect of an educational intervention related to health and nutrition on pregnant women in the villages of Central Java Province, Indonesia
Health Education Journal 2014, Vol. 73(4) 370–381 © The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0017896913485741 hej.sagepub.com
Maria Wijaya-Erhardt, Siti Muslimatun and Juergen G Erhardt
Southeast Asian Ministers of Education Organization – Regional Center for Food and Nutrition (SEAMEO RECFON), University of Indonesia, Indonesia
Abstract Objective: To assess the effects of a health and nutrition educational intervention on maternal knowledge, attitudes and practices. Design: Pre- and post-test design using structured interviews of pregnant women. Setting: Thirty-nine villages in Central Java Province, Indonesia. Method: Pregnant women (N = 252) at 12–20 weeks of gestation were randomly allocated at the village level into education intervention and control groups. Women in the intervention group received health and nutrition education, while those in control group did not. Educational sessions were provided monthly until delivery. Results: After the intervention, women in the education group had better knowledge about the risks and consequences of getting worm infection and the causes, consequences and prevention of anaemia during pregnancy; expressed stronger intentions to feed colostrum (91.9% vs. 78.2%, P = 0.003); to breastfeed within one hour of birth (80.4% vs. 68.9%, P = 0.004); to breastfeed exclusively for six months (77.2% vs. 62.7%, P = 0.014); to breastfeed for 24 months (P = 0.06); and also had better knowledge of practices related to the early initiation of breastfeeding (0.5 hour [25th–75th 0.5–6] vs. two hour [0.5–17.5], P = 0.052); of 24-hour exclusive breastfeeding (51.2% vs. 31.1%, P = 0.006); of giving birth at health facilities (71.9% vs. 58%, P = 0.024); and of birth assisted by skilled birth attendants (90.1% vs. 81.5%, P = 0.057) than their control counterparts. Conclusion: The reported change in knowledge, attitudes and reported practices may be attributable to the health and nutrition education provided during pregnancy.
Keywords Education, Indonesia, intervention, nutrition, pregnant women
Corresponding author: Siti Muslimatun, SEAMEO RECFON, University of Indonesia, Jl. Salemba Raya 6, Jakarta 10430, Indonesia. Email:
[email protected]
Downloaded from hej.sagepub.com at Bibliothekssystem der Universitaet Giessen on October 21, 2015
Wijaya-Erhardt et al.
371
Introduction Appropriate knowledge, attitudes and practices (KAP) on health and nutrition among rural pregnant women remain low, although health-education services have been a part of the national programme in Indonesia. According to the 2007 Indonesia Demographic Health Survey (IDHS), a nationally representative study, about 95% of the infants in Indonesia received any breastfeeding (BF) for some period of time; however, only 44% were put to the breast within one hour of birth. Contrary to World Health Organization (WHO) recommendations, overall the exclusive breastfeeding (EBF) rate at six months was only about 32%.1 Additionally, the subsample of young adults in the 2007 national survey revealed that three in 10 women do not know the cause of anaemia and one in four women do not know how anaemia should be treated.2 Low levels of knowledge and awareness of maternal and child health among pregnant women could be one of several factors that contribute to severe public health problems in Indonesia, as indicated by ≥ 40% anaemia prevalence among pregnant women;3 high rates of BF practices which deviate from international recommendations (53% of children age 4–5 months have started consuming solid or semi-solid food); a large percentage (54%) of deliveries taking place outside of a health facility; and no declining of perinatal mortality rate (24 and 25 per 1000 pregnancies in the year 2002–2003 and in the year 2007, respectively1). It is important that pregnant women strengthen their awareness of health and nutrition information because this is one of the few things that they can apply in their daily lives to protect the health of the foetus.4 With education, knowledge may theoretically improve, having a stronger impact on intentions or attitudes5 and practices. This small-scale study, therefore, aimed to determine the effects of educational intervention on knowledge, attitudes and practices (KAP) about maternal and child health-related issues among pregnant women living in villages in central Java.
Methods Study settings We conducted the study in 39 villages from two districts (Karanganyar and Demak) of Central Java Province, Indonesia. The villages were served by six primary health centres (puskesmas), which were located at the subdistrict level. The study subjects were 252 pregnant women aged 15–49 years at 12–20 weeks of gestation who had participated in a study on food intervention. Detailed results and methodology relating to this study are published elsewhere.6 Throughout the study period, pregnant women (n = 127 from 19 villages) in the intervention (supplementary food) group received education, while those (n = 125 from 20 villages) in the control group did not. Educational intervention integrated with a supplementary food intervention was given until delivery. Prior to study participation, the purpose and procedure of the study were explained to the women. Women were assessed for an estimated gestational age which was calculated from the first day of the last menstruation and confirmed by palpation on fundal height by a coordinator midwife. The Ethics Committee for Studies on Human Subjects at the Faculty of Medicine, University of Indonesia approved the study protocol. The pregnant women who qualified to be part of the study gave written informed consent.
Data collection Assessments included KAP of pregnant women based on the structured questionnaires that were collected at pre- and post-intervention. Trained enumerators conducted the structured interviews
Downloaded from hej.sagepub.com at Bibliothekssystem der Universitaet Giessen on October 21, 2015
372
Health Education Journal 73(4)
Table 1. Selected items accessing maternal knowledge of health and nutrition. Item
Options (multiple answer)
How do you get worm infection?
1. On skin contact with worm’s egg; 2. Hands/nails contaminated with worm’s egg; 3. Consuming unwashed/contaminated food; 4. Drink contaminated water; 5. not washing hands after defecating; 6. Not taking anti-helminthic drugs; 7. Not keeping clean; 8. Being too tired 1. Blood loss; 2. Nutrient loss; 3. Anaemia; 4. Thinness/ undernutrition; 5. Stomach ache 1. Bleeding; 2. Frequently giving birth; 3. Birth spacing is too close; 4. Worm infestation in intestine; 5. Working too hard; 6. Lack of energy/consuming carbohydrate; 7. Lack of consuming meat; 8. Lack of consuming green leafy vegetables; 9. Lack of consuming iron-rich food 1. Mother is not strong enough to work; 2. Small baby; 3. Danger for mother/baby; 4. Mother/neonates can be dead during delivery; 5. Pre-term delivery; 6. Severe bleeding during pregnancy 1. Consuming a variety of dishes; 2. Consuming meat; 3. Consuming a variety of beans; 4. Consuming a variety of dark green leafy vegetables; 5. Consuming vitamin C-rich food; 6. Taking iron tablets; 7. Taking vitamins; 8. Taking medicine; 9. Controlling birth spacing; 10. Control number of pregnancy/ family planning; 11. Take enough rest; 12. Regular meals; 13. Consuming nutritious food 1.Vaginal bleeding; 2. Swollen limb; 3. Early rupture of amniotic membrane; 4. Convulsions; 5. Severe headache; 6. High blood pressure; 7. High fever; 8.Vomiting; 9. Not wanting to eat; 10. Stomach ache 1. The child looks unwell or is not playing normally; 2. The child cannot breastfeed/drink/eat; 3. The child is lethargic/difficult to wake; 4. The child has a high fever; 5. The child has fast/difficult breathing; 6. The child vomits; 7. The child has convulsions; 8. The child has diarrhoea
Worm infestation consequences Causes of anaemia
Anaemia consequences during pregnancy Anaemia prevention during pregnancy
Danger signs of pregnancy requiring immediate medical attention Danger signs of a child requiring immediate medical attention
and observations at home visits, which took approximately 30–45 minutes to complete. At the first visit, enumerators collected information on socioeconomic conditions, family composition, maternal characteristics, and maternal knowledge about health and nutrition. Postpartum, trained enumerators conducted a second interview with all mothers to mainly assess the effect of health and nutrition education activities on maternal knowledge and attitude/intention. The second interviews were similar to the questionnaires at baseline on maternal knowledge and intention aspects and were uniform for both groups. Table 1 contains several questions measuring the knowledge of the women. A coordinator midwife and a trained nutritionist visited the women as soon as possible after birth (at
