The Effect of Theory of Planned Behavior-Based Education in Adopting the Urinary Tract Infection Prevention Behavior in Pregnant Women: A Randomized Controlled Trial

Abstract

Background: Urinary tract infection (UTI) is a common infection in women, and it is more likely to occur during pregnancy due to mechanical and hormonal changes in pregnant women. Urinary tract infections can cause many complications for both mother and fetus. Given the roles of health behavior in the prevention of urinary tract infections and the nature of the theory of planned behavior-based education in behavioral change, the present study aimed to determine the effect of the theory of planned behavior-based education in teaching the urinary tract infection prevention behavior in pregnant women.

Methods: The present study was a randomized controlled trial in which 100 pregnant women, who visited the comprehensive health service centers of Zarinshahr City, were randomly divided into two groups, intervention and control, containing 50 individuals. The data collection tools were a urine test and a questionnaire designed based on the theory of planned behavior. Five education sessions were held based on the constructs of the theory of planned behavior. We analyzed the effect of education review and data using independent t-tests, Mann-Whitney test, chi-square test, and repeated measures ANOVA (analysis of variance) one and three months after the educational intervention.

Results: After implementing the educational intervention, the mean scores of knowledge and constructs of the theory of planned behavior significantly increased in the intervention group over time (P <0.001), while the difference was not significant in the control group over time. After the educational intervention, the incidence of urinary tract infections was 4.3 % in the intervention group and 21.3% in the control group.

Conclusion: Given the positive effect of education based on the theory of planned behavior in changing the pregnant mothers' behavior, the theory can be used as a suitable intervention framework for implementing the educational programs to prevent urinary tract infections.

Trial registration: Name: Iranian Registry of Clinical Trials. Registration number: IRCT20170214032575N1. Registration date: 2019-12-12 [retrospectively registered].

Plain English Summary

Urinary tract infections are ranked among the most common infections affecting people of all ages. Globally, it is estimated that 150 million people contract urinary tract infections annually, caused by the presence and proliferation of microorganisms in the urinary tract. This disease is more common in pregnant women than non-pregnant ones due to mechanical and hormonal changes during pregnancy. Some health behaviors, such as not having frequent sexual activity, wearing appropriate underwear, and not delaying urination are behaviors that can prevent urinary tract infections. Despite the importance of these issues, many women do not have enough information about them. The individuals' perceptions that I may also have the urinary tract infection and the belief that urinary tract infections can be prevented by taking preventive behaviors can help prevent urinary tract infections. The individuals' ability to perform certain behaviors, such as sexual behavior habits and personal hygiene, which play important roles in the development of urinary tract infections during pregnancy, is another factor that can affect the urinary tract infections during pregnancy. The role of social support is also important to follow preventive behaviors. Therefore, if mothers feel that the urinary tract infection prevention behaviors are approved and supported by family members, friends, health care staff, and other important people, they will show a greater desire to exhibit the behaviors that prevent urinary tract infections. Education can increase awareness, change attitudes, and create a sense of empowerment in individuals in the field of behaviors for preventing the urinary tract infections.

Background

The urinary tract infection(UTI) is a common gynecological disease as a serious health problem in the world in the 21st century, caused by the presence and proliferation of microorganisms in the urinary tract (1, 2). UTI affect 150 million people worldwide every year (1, 3, 4), and one-third of all women experience urinary tract infections in their lifetime (5). This disease is more common in pregnant women than non-pregnant ones due to mechanical and hormonal changes during pregnancy (6–8). After anemia, UTI is the second most common health problem among pregnant women (9). Escherichia coli is the cause of 80–90% of urinary tract infections (10–12). UTI in pregnancy occurs as symptomatic and asymptomatic bacteriuria among which the latter is the most common infection during pregnancy (13).

The prevalence of asymptomatic urinary tract infections compared to symptomatic infections is reported to be 2–15% in pregnant women (14, 15) and 6–11% in Iran (16).

UTI has various complications on mothers and fetuses, including pyelonephritis, Pre-eclampsia (PE), anemia, septic shock, and Endometritis, premature delivery, and subsequently the fetal death, respiratory failure, low birth weight, mental retardation, intrauterine growth restriction, and IQ reduction (16–19).

Some health behaviors, such as not having frequent sexual activity, wearing appropriate underwear, and not delaying urination are behaviors that can prevent UTI. Despite the importance of these issues, many women do not have enough information about them, and studies indicate that women have low knowledge about the UTI prevention behavior (16, 20, and 21). In addition to knowledge, the individuals' attitudes, and way of thinking are also important factors in the possibility of UTI. For example, the individuals' perceptions that I may also have the urinary tract infection and the belief that urinary tract infections can be prevented by taking preventive behaviors can help prevent UTI (13, 22).

Subjective norms are other issues that can play important roles in UTI, reflecting the individuals' perception of whether or not others approve the behaviors. Therefore, if mothers feel that the urinary tract infection prevention behavior are approved and supported by family members, friends, health care staff, and other important people, they will show a greater desire to exhibit the behaviors that prevent UTI.

The present study emphasized the role of family, especially the husband, in maintaining sexual health (as informal abstract norms) to prevent UTI in pregnancy (13, 23, 24).

Other studies have considered the effective and useful roles of subjective norms, physician, midwife (as formal norms), and family (as informal norms) in preventing disease.

The individuals' ability to perform certain behaviors, such as sexual behavior habits and personal hygiene, which play important roles in the development of UTI during pregnancy, is another factor that can affect UTI during pregnancy. This sense of ability is considered as the perceived behavioral control (10, 25).

Education can increase awareness, change attitudes, and create a sense of empowerment in individuals in the field of behaviors for preventing UTI. The theory of planned behavior is an important theory of behavioral change as the main framework of the present research. This theory is applicable to predict and understand behaviors. According to this theory, the behavioral intention is the most important determinant of behavior; and other main constructs of this theory (attitude, Subjective norms, and perceived behavioral control) affect this theory in special ways (26).

Given that influential factors such as the individuals' attitudes, presence of others, and the sense of control over the behaviors for preventing UTI are main issues in adopting behaviors for preventing the urinary tract infections, and they are constructs of theory of planned behavior, the present study was designed and conducted with an aim to determine the effect of education based on the theory of planned behavior on teaching behaviors for preventing UTI in pregnant women (Fig. 1).

Methods

Sampling Method And Calculation Of Sample Size

Sampling was randomly conducted in accordance with the population. In Zarinshahr, there are five comprehensive health service centers from which 100 pregnant women were randomly and systematically selected according to the list of pregnant women. A computer random-number generator was used to generate the random sequence for group allocation (50 individuals in the intervention group and 50 individuals in the control group). An investigator blinded to participants selection kept the random sequence and allocated the participants to intervention and control groups at a 1:1 ratio.

The sample size was obtained equal to 44 for each group according to the following equation, and 49 individuals in each group with a 10% drop.

Z1: Confidence level of 95% was equal to 1.96.

Z2: The test power factor of 80% was equal to 0.84.

S: Estimation of the mean standard deviation of score for each variable in the two groups.

d: The minimum difference of mean scores of each variable between two groups, indicating a significant differences and was considered to be 0.6 s.

Results

In the study, 46 individuals were examined in the intervention group with an age range of 17 to 42 years, and 47 individuals in the control group with an age range of 17 to 43 years.

Results of statistical tests indicated that two groups did not differ significantly in terms of demographic variables (Table 2).

Repeated-measures ANOVA indicated that scores of knowledge and constructs of the theory of planned behavior increased significantly in the intervention group over time (P < 0.001), while the difference was not significant in the control group over time (Table 3).

Chi-square test indicated that the frequency of urinary tract infections was significantly lower than the control group three months after the educational intervention in women of the intervention group (Fig. 3).

Discussion

The present study aimed to determine the effect of education based on the theory of planned behavior in adopting behaviors for preventing urinary tract infections in pregnant women. In the study, we examined the pregnant women's knowledge by measuring the existing problems before performing an educational intervention based on results of the pre-test, and then the pregnant mothers were received the necessary training in various fields such as recognizing symptoms of urinary tract infection, prevention methods, and testing to prevent urinary tract infections using the educational booklets and pamphlets, indicating an increase in the knowledge score of the intervention group after the program. The research finding was consistent with studies by Gonzalez et al (27), Haider et al (8), Indhumol et al (28). In the present study, the mean attitude score increased after the intervention, indicating the favorable effect of group discussion based on the theory of planned behavior. Therefore, the pregnant women divided into small groups and discussed issues about the ways to prevent the urinary infection. Under the supervision of the researcher, they exchanged views, and thus the individuals expressed their thoughts and ideas in this field and corrected them by the help of the researcher. The result was consistent with a study by Ahmed et al. (20). Since the family support is an important factor in adopting the urinary tract infection prevention behaviors, the husbands were asked to attend one of the training sessions with their wives to attract the family support. Since they were important subjective norms for their wives, their support were attracted properly. In the study, we saw an increase in mean scores of subjective norms in the post-training intervention group, while a meeting was held with the center's physician and midwife to provide counseling and support services and they were asked to provide the necessary support for pregnant women for education. Therefore, it seems that the guidance of health personnel through the theory of planned behavior in training classes will be very valuable and useful to prevent urinary tract infections in pregnant women. The result was consistent with results of studies by Abd El Aziz (7) and Nezhad Sadeghi. (13). The intervention result indicated an increase in mean score of perceived behavioral control in the intervention group. The increase could indicate the desired effect of education through role-playing, so that the behavior such as nutritional behaviors and way of dressing were simply and separately explained by the researcher in a way that each part of the behavior could be easily done by the pregnant woman. The pregnant mothers were then asked to play roles, leading to active thinking and participation and higher self-confidence in the participants. The result was consistent with a study by Song (29). In the study, the mean score of behavioral intention increased after the intervention. The increase in score might be due to the use of practical demonstration techniques in a way that foodstuffs such as barberry, Cornus mas, and water were displayed in the class and used symbolically by the participants to demonstrate proper eating habits. The result was consistent with a study by Conner et al. (30) and Shamsi et al. (22).

Findings of the present study indicated that the mean score of the urinary tract infection prevention behavior increased compared to the pre-intervention. The increase might be due to the use of film and practical screening, for example, a suitable pants for pregnancy was shown and a number of pregnant mothers wore loose and comfortable pants and showed other participants that not only there was no contraindication, but they were also suitable. The result was consistent with a study by Tehrani et al. (31), while it was different from a study by Ahmadi et al. (32) due to the differences between the research groups.

Conclusion

The research results indicated that the theory of planned behavior-based education, including the participants' attitudes and beliefs, had positive functional effects on most behaviors for preventing the urinary tract infections in pregnant women probably due to the fact that the education program sought to identify the participants' weaknesses through group discussion and provide the appropriate training, thereby changing the individuals' attitudes. The study also indicated that the perceived behavioral control as another construct of the theory could be strengthened in participating pregnant mothers and their self-confidence could increase by relying on the role-playing. Using the practical display technique, the behavioral intention as another construct of the theory could be well developed in the learners' mind; and the desired behavior change could be made in learners using the film screening strategy. Therefore, the theory can be an appropriate intervention framework for implementing the educational programs to prevent urinary tract infections.

Limitations

Since the present study was conducted as a pilot in a city of Iran, the necessary precautions should be taken in generalizing the results to other regions.

Abbreviations

Declarations

Ethics approval and consent to participate:

Approval to conduct the study was obtained from the Research Ethics Committee of Isfahan University of Medical Sciences (ID- number: IR.MUI.REC.1396.3.578). Written informed consent was obtained from the participants. Furthermore, the pregnant women were informed that they had the right to withdraw from the study at any time, and were assured of the confidentiality of the study.

Consent for publication:

Not applicable.

Availability of data and materials:

The data that support the findings of this study are available from Deputy of research of Isfahan University of Medical Sciences but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are however available from the authors upon reasonable request and with permission of Isfahan University of Medical Sciences.

Competing interests:

The Authors declare that they have no competing interests.

Funding:

The Isfahan University of Medical Sciences funded this study as a part of a Master Thesis.    However, this grant did not cover the most sections of this study.

Authors' contributions:

Initially conceived and designed the study: Hossein Shahnazi and  Sheida Moradpour

Conducted the analysis: Akbar Hassanzadeh

Wrote the paper and made revisions: Sheida Moradpour and Hossein Shahnazi

Reviewing the manuscript critically: Hossein Shahnazi

The final version of the manuscript has been read and approved by all the authors, and the requirements for authorship have been met.

 Acknowledgements:

The authors want to thank the all the participated pregnant women who are the main owners of this research.

References

1. Singh B, Tilak R, Srivastava R, Katiyar D. Urinary tract infection and its risk factors in women: an appraisal. J Pure Appl Microbiol. 2014;8(5):1–8.
2. Turay A, Eke S, Oleghe P, Ozekhome M. The prevalence of urinary tract infections among pregnant women attending antenatal clinic at Ujoelen primary health care centre, Ekpoma, Edo state, Nigeria. IJBA IR. 2014;3(3):86–94.
3. Flores-Mireles AL, Walker JN, Caparon M, Hultgren SJ. Urinary tract infections: epidemiology, mechanisms of infection and treatment options. Nat rev microbiol. 2015;13(5):269–84. doi:10.1038/nrmicro3432].
4. Abou Heidar NF, Degheili JA, Yacoubian AA, Khauli RB. Management of urinary tract infection in women: A practical approach for everyday practice. Urol Ann. 2019;11(4):339.[ doi. 10.4103/UA.UA_104_19].
5. Oladeinde BH, Omoregie R, Oladeinde OB. Asymptomatic urinary tract infection among pregnant women receiving ante-natal care in a traditional birth home in Benin City, Nigeria. EthiopJ Health Sci. 2015;25(1):3–8. doi:10.4314/ejhs.v25i1.2].
6. Jido TA. Urinary tract infections in pregnancy: evaluation of diagnostic framework. Saudi J Kidney Dis Transpl. 2014;25(1):85. doi:10.4103/1319-2442.124496].
7. Abd El Aziz MS, Ibrahim HA-F, Elgzar WTI. Effect of application of health belief model on pregnant women'knowledge and health beliefs regarding urogenital infections. JNHS. 2016;5(5):34–44. DOI:10.9790/1959-0505013444].
8. Haider G, Zehra N, Munir AA, Haider A. Risk factors of urinary tract infection in pregnancy. JPMA The JPakMed Assoc. 2010;60(3):213.
9. Szweda H, Jóźwik M. Urinary tract infections during pregnancy-an updated overview. Dev Period Med. 2016;20(4):263–72.
10. Amiri F, Rooshan M, Ahmady M, Soliamani M. Hygiene practices and sexual activity associated with urinary tract infection in pregnant women. EMHJ-Eastern Mediterr Health J. 2009;15(1):104–10.
11. Delzell JE Jr, Lefevre M. Urinary tract infections during pregnancy. Am fam physician. 2000;61(3):713–20.
12. Alemu A, Moges F, Shiferaw Y, Tafess K, Kassu A, Anagaw B, et al. Bacterial profile and drug susceptibility pattern of urinary tract infection in pregnant women at University of Gondar Teaching Hospital, Northwest Ethiopia. BMC res notes. 2012;5(1):197. doi:10.1186/1756-0500-5-197].
13. Nezhad Sadeghi E, Solhi M. Effect of education based on health belief model on prevention of urinary infection in pregnant. HealthMED. 2012;6:4211–7.
14. Tadesse E, Teshome M, Merid Y, Kibret B, Shimelis T. Asymptomatic urinary tract infection among pregnant women attending the antenatal clinic of Hawassa Referral Hospital, Southern Ethiopia. BMC res notes. 2014;7(1):155. doi:10.1186/1756-0500-7-155].
15. 10.1111/j.1365-2362.2008.02009.x]
    Schnarr J, Smaill F. Asymptomatic bacteriuria and symptomatic urinary tract infections in pregnancy. Eur J Clin Invest. 2008;38:50 – 7.[ doi: 10.1111/j.1365-2362.2008.02009.x].
16. Noroozi F, Noroozi A, Tahmasebi R. Influencing factors in the health promoting behaviors of Urinary system based on health belief model in pregnant women in Bushehr 2013-14. ISMJ. 2015;18(3):597–606..[in persian].
17. Derese B, Kedir H, Teklemariam Z, Weldegebreal F, Balakrishnan S. Bacterial profile of urinary tract infection and antimicrobial susceptibility pattern among pregnant women attending at Antenatal Clinic in Dil Chora Referral Hospital, Dire Dawa, Eastern Ethiopia. Ther clin risk manag. 2016;12:251.[ doi. 10.2147/TCRM.S99831. eCollection 2016].
18. Emiru T, Beyene G, Tsegaye W, Melaku S. Associated risk factors of urinary tract infection among pregnant women at Felege Hiwot Referral Hospital, Bahir Dar, North West Ethiopia. BMC res notes. 2013;6(1):292. doi:10.1186/1756-0500-6-292].
19. Alidadi A. Evaluation of Knowledge, Attitude and Behavior in the Field of.
20. Urinary Tract. Infection among the Iranian Pregnant Women.
21. Based on the Health Belief. Model (HBM): A systematic review. Int J.
22. 5
    68
    74
    10.22192/ijamr.2018.05.12.007]
    [ DOI
    Adv Multidiscip R. 2018;5(12):68–74.[ DOI: http://dx.doi.org/10.22192/ijamr.2018.05.12.007].
23. Ahmed NM, Khresheh RMH. Impact Of Instructional Program About Prevention Of UTI Recurrence On The Level Of Knowledge And Self-Care Behaviors Among Women With. UTI In Saudi ArabiaJNHS. 2016;5(3):43–51. DOI:10.9790/1959-0503034351].
24. Hassan MHA. Effect of intervention guidelines on self care practices of pregnant women with urinary tract infection. Life Sci J. 2015;12(1):113–24. doi:10.7537/marslsj120115.16].
25. Shamsi M, Roozbehani N, Kabir K. Preventive behaviors of urinary tract infection (UTI) based on the theory of planned behavior among pregnant women in Karaj in 2013. Daneshvar. 2013;21(5):59–66..[in persian].
26. dos Santos Fioravante FF, de Carvalho Queluci G. Online Braz J Nurs. 2017;16(1):28–36.
27. Badran YA, El-Kashef TA, Abdelaziz AS, Ali MM. Impact of genital hygiene and sexual activity on urinary tract infection during pregnancy. Urol ann. 2015;7(4):478.[ doi. 10.4103/0974-7796.157971].
28. Nikpour S, Tabrizian L, D Roodsari M, Haghani H. Study of predisposing factors of urinary tract infections among married women referred to selected hospitals in Tehran city (2003). Razi Journal of Medical Sciences. 2004;11(41):489–97..[in persian].
29. Glanz K, Rimer BK, Viswanath K. Health Behavior And Health Education:Theory,Research,And Practice. 4th ed. United States: John Wiley And Sons; 2008. p. 592.
30. Gonzalez G, Vaculik K, Khalil C, Zektser Y, Arnold C, Almario CV, et al. Women's Experience with Stress Urinary Incontinence: Insights from Social Media Analytics. The J Urol. 2020;203(5):962–8. DOI:10.1097/JU.0000000000000706].
31. Indhumol T, Pavithran S, George LK. Effectiveness Of Structured Teaching Program On Knowledge Regarding Prevention Of Urinary Tract Infection Among Adolescent Girls. Int J Pharm Med BioSc. 2014;3(3):121.
32. Song KJ. The effects of self-efficacy promoting cardiac rehabilitation program on self-efficacy, health behavior, and quality of life. JKAN. 2003;33(4):510–8. doi:10.4040/jkan.2003.33.4.510].
33. Conner M, Higgins AR. Long-term effects of implementation intentions on prevention of smoking uptake among adolescents: a cluster randomized controlled trial. Health Psychol. 2010;29(5):529.[ doi. 10.1037/a0020317].
34. Tehrani FJ, Nikpour S, Kazemi EAH, Sanaie N, Panahi SAS. The effect of education based on health belief model on health beliefs of women with urinary tract infection. Int J community based nurs midwifery. 2014;2(1):2.
35. Ahmadi Z, Shamsi M, Roozbahani N, Moradzadeh R. The effect of educational intervention program on promoting preventive behaviors of urinary tract infection in girls: a randomized controlled trial. BMC pediatr. 2020;20(1):1–10. doi:10.1186/s12887-020-1981-x].