The aim of this study was to evaluate knowledge, attitude and self-efficacy among PHPs in PCCs in north-eastern Thailand after they had participated in a KAS-program for identification and management of perinatal depressive symptoms.
Study setting and design
Data were collected in Sakonnakhon, a northeastern province of Thailand. Sakonnakhon has about 300 PHPs, with a bachelor’s degree in public health, working at 168 PCCs. The number of childbirths annually is high . This quasi-experimental study utilized mixed methods approach [32, 33] in which quantitative method was used to demonstrate the changes of knowledge, attitude and self-efficacy scores of PHPs for identification and management of perinatal depressive symptoms during the KAS-program, while qualitative method provided a rich source of information to understand the process during and after implementation of the KAS-program.
nowledge, Attitude, and Self-efficacy (KAS) program for identification and management of perinatal depressive symptoms
The KAS-program was developed by the authors (NP and PCL) on the basis of the theory of self-efficacy . It contained two parts: (1) a full day (eight hours) of theory and (2) a four-week period of field practice. See Figure 1.
The day of theory included interactive lectures provided by three experts in the fields of public health, behavioral science and psychiatric nursing. It focused on knowledge of, attitude towards and self-efficacy for identification and management of perinatal depressive symptoms. Two guidelines were used. One from the World Health Organization , translated into Thai language by NP, dealt with psychosocial management. Another, constructed by the authors, was devoted to identification and management of perinatal depressive symptoms. A questionnaire used among north-eastern Thai women, was also included. It comprised four parts: (1) the Thai EPDS part for screening women during the perinatal period [1, 5, 35-36], (2) the psychological well-being question part , (3) the self-esteem question part , and (4) the sense of coherence question part [1, 39]. The participants were given the guidelines and a copy of the questionnaire for practice.
The four-week period of field practice started immediately after the day of theory. During four weeks, the participants were asked to practice with two women or more (one pregnant woman and one woman after childbirth) visiting the ANC clinic at their PCC. For this practice they used the guidelines and the questionnaire presented in the day of theory. In order to assist the participants, NP supervised them by use of mobile applications (Line and Facebook). Each participant was also contacted once by telephone. Face-to-face visits were arranged by NP for those who requested.
The participants were PHPs employed at PCCs in six selected districts of Sakonnakhon (N=18) with large numbers of childbirths in Sakonnakhon in recent years . There was no specific criteria for selecting the participants in this study. We calculated the sample size . Mean differences and standard deviations (SDs) (based on our pilot study in a province near Sakonnakhon) were: knowledge score = 1.2 and 1.12, attitude score = 4.0 and 3.11, and self-efficacy score = 4.0 and 4.3; β was 80% and α was 0.05. After some losses, the final number of participants was 33.
After the four-week period of field practice, we invited by telephone all participants from the KAS-program to take part voluntarily in four focus group discussions (FGDs). Twenty-three PHPs agreed to participate in focus groups as follows: FGD1 (n=8), FGD2 (n=6), FGD3 (n=5), and FGD4 (n=4). Ten participants could not participate in the FGDs because of, e.g., urgent tasks when the FGDs were held.
We submitted the proposed research study to the Ethics Committee for approval, while the heads of the Health Promotion Department of Sakhonnakhon Provincial Public Health Office and of the District Public Health Offices approved the KAS-program and the data collection. Thereafter we sent, by ordinary post, invitation letters together with socio-demographic characteristics questionnaires (concerning age, gender, marital status, level of education, training experience in mental health field, size of workplace, and working experience in PCCs) and documents about the study to PHPs in PCCs in the six selected districts of Sakonnakhon. One hundred and thirty-four PHPs agreed to participate in the KAS-program and signed a consent form. Later, PHPs who had agreed were selected to participate in the KAS-program using a simple randomization method. The selected PHPs were informed about their participation in the day of theory at the Sakhonnakhon Provincial Public Health Office.
On the day of theory, the authors informed the participants about the aims of the study, their rights as participants in the KAS-program and their option to withdraw from the KAS-program. The participants were asked to three times complete a questionnaire about knowledge, attitude, and self-efficacy for identification and management of perinatal depressive symptoms: (T1) before the first lecture in the day of theory, (T2) after the last lecture in the day of theory, and (T3) immediately after finishing the field practice before the FGDs or on a day close to the last FGD (in any FGD in cases of non-participation). See Figure 2.
The FGDs were conducted in district public health offices in Sakonnakhon at a time and date the participants preferred. Each FGD, with NP and PCL present, was audio-recorded and lasted approximately two hours. After this time, no new information emerged. NP, male author with a degree in public health and experience of qualitative research, served as moderator. PCL, female author, nurse/midwife and PhD with experience of qualitative research, took notes and clarified answers from the participants when needed. The authors had no previous relation to the participants. After each FGD, NP transcribed the recordings verbatim and checked the accuracy of the transcripts. All transcripts were coded without name identification.
A questionnaire was developed for this study by the authors. It consisted of three parts related to perinatal depressive symptom identification and management: (1) knowledge of, (2) attitude towards, and (3) self-efficacy for such activities in their profession. Three experts approved the content of the questionnaire (Content Validity Index: CVI > 0.80). Internal consistency of the questionnaire was tested with 30 PHPs who worked in PCCs nearby Sakonnakhon (the Cronbach’s alpha coefficient for the whole questionnaire was 0.96).
The knowledge and attitude parts were based on a questionnaire intended to train Thai PHPs and public health assistants . Adjustments for the purpose of this study were made by the authors. Twelve questions concerned knowledge of perinatal depressive symptom identification and management. Each question could give a score of zero or one if the answer was incorrect or correct, respectively. Thus, the total score of this part could be 0-12, and a higher score meant more knowledge. Ten questions concerned attitude towards identification and management of perinatal depressive symptoms. Each question had a four-level Likert-scale: Strongly agree, agree, disagree, and strongly disagree, and could be scored between one and four. Thus, the total score could be 10-40, and a higher score meant more positive attitude.
The self-efficacy part was based on Thai validated version  of the Generalized Self-Efficacy Scale . Adjustments for the purpose of this study were made by the authors. It had ten items, each with four options (not at all true, hardly true, moderately true, and exactly true), providing a score 1-4. Thus, the total score could be 10-40, and a higher score meant higher self-efficacy.
An interview guide for use in the FGDs was developed for this study by the authors. The interview guide contained eight open-ended questions letting the participants in the FGDs describe and discuss their knowledge of, attitude towards, and self-efficacy for identification and management of perinatal depressive symptoms after participation in the KAS-program. It was tested in the first FGD and adjusted before use in the remaining FGDs. The first FGD was involved in the qualitative analysis. Example questions were: (1) “How has your knowledge changed after you participated in the KAS-program?” and (2) “Please share your experiences from participating in the four-week period of field practice of the KAS-program”.
Different statistics were used for analyses of the questionnaire. Descriptive statistics were applied to summarize socio-demographic characteristics of the participants using frequency, percent, mean, SD, and range. Assumptions for paired-sample T test were satisfied (i.e., continuous variables, independent observations, normal distribution shown by skewness values was between -0.7 and 0.5, and no outliners defined by kurtosis values were less than 2). Therefore, Chi-square test for trend analysis was used to determine changes of mean scores of the knowledge, attitude and self-efficacy over three time points, and paired-sample T test was used to compare the mean scores between times. The significance level was set at 0.05, and 95% confidence interval was used.
Data from FGDs were analyzed using qualitative content analysis . It focused on meaning units (words or sentences), condensed meaning units, codes, sub-categories and categories, where the categories represented the processes during and after implementation of the KAS-program. First, the authors read all transcripts separately. Thereafter, they discussed categories until agreement was reached. The categories were reported to the participants, and the feedback from them did not result in any adjustments. Example quotations were translated from Thai to English and back by the authors who were Thai natives with good knowledge of English. They are shown in the result section with indication of the focus group (FGD1-4).