Evaluation of the Predictive Power of the Theory of Planned Behavior on the Intention of Pregnant Women to Neonatal Care

Background: Considering that neonatal are the most sensitive group to kind of diseases, the present study aimed to evaluation of the predictive power of the Theory of Planned Behavior on the intention of pregnant women to neonatal care. Method: In this cross-sectional study, 100 pregnant women in trimester of pregnancy were selected by random sampling. Data was collected using valid and reliable questionnaire and interviews conducted with pregnant women. The questionnaire included demographic characteristic of the mothers and theory planned behavior construct. Finally the data were analyzed by SPSS 20 T-test, Chi-square, Correlation, ANOVA and regression. Results: The average age of the sample was 26.12±4.9 and the average duration of marriage age was 3.9 ±2.74 years. There was a high correlation between perceived behavioral control and behavioral intention (r=0.40; p < 0.001). Over 40% of pregnant women were shown to lack overall Knowledge about the items related to neonatal care. The mothers who were better prepared for parenting tended to have a higher level of schooling, perceived control behavior and knowledge. Regression analysis showed that the knowledge and perceived behavior control R 2 =32% in the prediction of neonatal care intentions. Conclusions: Findings of this study show support for the predictive ability of the theory of planned behavior in predicting for neonatal care therefore the design of educational intervention should be based on intention and knowledge as the most important predictors of maternal behavior.


Background
The United Nations' Sustainable Development Goals (SDGs) include reducing the global maternal mortality rate to less than 70 per 100,000 live births and ending preventable deaths of newborns and children under ve years of age, in every country, by 2030. Neonatal death audit and review is widely recommended as an intervention to reduce neonatal morbidity, mortality and to improve quality of care, and could be key to attaining the SDGs. For pregnant mothers, having a child requires the incorporation of new knowledge and performance to develop pro ciency in neonatal and child-care [1].
In fact to save the life of neonates, the based on recommended WHO essential newborn care performance are crucial interventions; in all aspect in neonatal care, mainly care for the low birth weight newborn [2]. Based on UNICEF the medium world-wide rate of 18 deaths per 1000 live births in 2017 that majority appear period the rst week [3]. Whereas infantile mortality rate in Iran 13 deaths per 1000 live births [4][5].
With considering that in the human life cycle the early childhood phase and neonatal period is the most important phase for every human being [6][7] therefor the well-being of children and neonatal depends on the ability of families especially mothers to function effectively. It is important that the capacity of mothers be strengthened and supported to give their children the best possible start in life [8]. For improve the quality of care provided to children it is necessary that identify obstacle to accessing maternal health services and enhance advocate for mothers before and after birth for child health [9]. De ciency of women awareness, attitude and performance perhaps in uence mothers to minimization their child's needs (for example lack seeking information about side effect selfmedication in newborn and children) [10].
For example in studies in Mongolia revealed that parents gave medications to their children without a prescription for different reasons [11]. Also, the result of other studies showed that some parents give drugs to their children to treat an in ammatory bowel disease without consulting a doctor [12]. In another counteries for example in Kenia only 28% , in Ethiopia 18.2% and Himalayas 52% of women had adequate knowledge about neonatal care [13][14][15].
In this study, the Theory of Planned Behavior (TPB) has been used. This theory has been used in many studies of health behaviors such as urinary tract infection in children [16] and during pregnancy [17]. TPB is applied to determine and understand the effect of environmental and individual factors on a behavior. Since the theory measures both direct behavior and intention (they are closely related to each other), through improving the intention the mothers about neonatal care [10].
The levels of pregnant women's knowledge, attitude, construct TPB and performance towards their neonatal care have been previously neither analyzed nor reported in relation to TPB in IRAN. Therefore the aim of this study was determine the relationship between theory of TPB construct with the pregnant women intention about neonatal care.
This study to respond the following questions: What power predictive construct of TPB for neonatal care in pregnant women? what is the level of knowledge, construct of TPB and intention of pregnant women regarding the neonatal care? What is the association between intention construct of TPB and neonatal care? What is the association between mothers' knowledge, attitude, intention and socioeconomic status factors, such as maternal attitudes about neonatal care, level of education, have been found to be better predictors of neonatal care compared to socio-demographic factors?.

Study Design
This is a cross-sectional and analytical study that was carried out on 100 pregnant women referring to health centers in Arak ( A city in Iran IR) in 2019.
According to the study by Ghasemi et al. [18] and to enable provincially representative proportions to be estimated, the sample size was calculated with α (error)=0.05, 1-β (power)=0.90 and d (precision)=0.1 samples was estimated 100 pregnant women were determined to be the nal sample size estimates. Samples were selected by convenience sampling from pregnant mothers who had gone to four health centers in Arak city. A total of 100 pregnant women selected using convenience sampling based on the following inclusion criteria: (1) being a mother -pregnant in trimester of pregnancy and (2) Nulliparous women and (3) Desiring to participate in the study.
Exclusion criteria included having no desire to participate in the study.
In this study, the dependent variable was intentional behavior and demographic variables and other construct TPB were independent variables.
The pregnant women were initially approached by health worker in the health centers and invited to participate in the study. All those who were approached agreed to participate. The study objectives and procedures were explained, con rming the voluntary nature of participation and the participants' right to withdraw from the study at any time.

Measures
The data collection is a reliable and validity researcher made questionnaire and interview conducted by the researcher. The questionnaire was structured in six parts as follows: 1-Socio-economic variables: including mother's age, marriage age, level education mothers and husband, job mother and husband, and so on.
2-General knowledge about neonatal care: consist of 8 items was based on three or four choices questions. For example, "what time the rst baby visit after birth?". In the awareness questions section, for each correct answer, a score of 1 and for each false answer, a score of 0 was considered, and range of scores was from zero to one.
3-Attitude of pregnant women about neonatal care consist of 4items were scored according to the Likert's ve scales: from completely disagree (score 1) to completely agree (score 5) and the range of scores was between 1and 5. 4-Subjective norm of pregnant women about neonatal care was assessed using 6 items with 5-point Likert scale were designed and the range of scores was between 1 and 5. For example, "Health worker or husband encourages me to awareness about neonatal care in my child." 5-Perceived behavioral control in neonatal care: consist of 6 items and the range of scores was between 1 and 5.
6-Behavioral intention in neonatal care was assessed using 3 items and the range of scores was between 1 and 5.
All items were scored on a 5-point Likert scale ranging from 1=totally disagree to 5=totally agree.
To make the results comparable with other scales, in construct of TPB we transformed scores from 1 to 5. In our study, the minimum possible score for each question in construct of TPB was one and range of scores was ve (1 to 5). The total scores for each subscale were calculated by averaging the scores of all questions on that scale, ranging from 1 to 5. To obtain the score of each dimension, the mean scores of all items in that dimension was obtained.
One of the potential sources of bias in this study, neonatal care which was self-reported. Based on valid resource [16,19] when researcher due to some problems in obtaining data with direct observation using the self-report method an accepted.
In this study the questionnaire validity was assessed with using content validity method includes content validity ratio (CVR) and content validity index (CVI) was approved 0.62 and 0.79 respectively. Moreover in the qualitative face validity, participants expressed no problems with reading and understanding the items. Reliability was calculated with internal consistency method based on Chronbach's alpha on pregnant women. In this study, Cronbach's alpha was upper 0.7 in subscale questionnaire.

Statistical methods
The data were analyzed through the SPSS, Vs 20 (Chicago, IL, USA). with descriptive statistics (Mean, Standard deviation and percent), analytical statistics (Pearson correlation, regression logistic). The data had a normal distribution (correction of the Kolmogorov-Smirnov test by Lilliefors).

Ethical Considerations
All the procedures performed in the study involving human participants, were in accordance with the ethical standards. The present study was approved by the Research Council of Arak University of Medical Sciences (Grant Number:2957). Ethics committee approval code number is (IR.ARAKMU.REC. 1397. 169). Moreover informed written consent was obtained from the mothers.

Results
A total of 100 pregnant women participated in the study. The average age of the sample was 26.12 years. Of these, 100 pregnant women responded to the interviewer-administered questionnaire 40% were between the age of 24 and 28 years. 35% of the women had completed higher education and 44% had completed secondary education. The average duration of marriage age was 3.9 years.  Manual employed 17 Unemployed 61 The highest score was obtained for the construct of intention behavior 4.40, while the lowest scores were obtained for the attitude 3.48. Table 3 presents the Knowledge, construct of TPB and intention behavior of pregnant women about neonatal care (Table 3). in order to choose strategic approaches for increasing intention in neonatal care.
There was a high correlation between perceived behavioral control and behavioral intention (r=0.40; p < 0.001). Table 4 shows that the correlation between pregnant mothers intention behavior and neonatal care based on TPB.
( Table 4). In this study regression analysis showed that the predictive knowledge and perceived control behavior for the intention behavior for neonatal care was 32%. ( Table 5).  Table 6 shows that the knowledge scores for each assessment items. (Table 6). To identify the essential or crucial distinguishing of mothers who are enhance prepared for parenting, we analyzed the association between level of knowledge, attitude, intention behavior and the attribute variables such as higher level of education mothers and husband, live with child father, intention to breastfeeding, health worker and midwife as information source to visit in health centers.

Discussion
TPB is considered as a useful model to predict human behavior and widely used in areas of health [16][17][18][19]. In this study the proportion of pregnant women who correctly know about neonatal care showed that knowledge were lacking for some items. Therefore the efforts should be made to increase it, and health workers in health centers should play a leading role.
Similarly in a study in Nepal participants had a moderate level of knowledge on newborn care (56%), and among its four components, participants had lowest knowledge in breastfeeding (44%) and adequate knowledge (78%) of immunization. Maternal education and socioeconomic status had a signi cant, positive association with newborncare knowledge [20]. In another study in Kenia 28%, Ethiopia 18.2% and in Himalayas 52% of women had adequate knowledge about neonatal care [13][14][15]. The results of this study are consistent with our study.
Therefore the health educator and midwife in health centers should be provided for women regarding an importance knowledge and improve women's motivation for neonatal care.

A systematic review of 30 studies by Schaaf et al. indicated that low socioeconomic status have a signi cant
in uence on neonatal care and increased risk of preterm birth [21]. Some causative factors on neonatal care includes de ciency of knowledge, poverty, adverse environmental conditions, access to quality health care, maternal health behaviors such as smoking or illicit drug use, and maternal stress [22].
In this study nding showed that correlation between mothers' knowledge, intention behavior, age and level of education. In this study mother with higher education were more knowledge about neonatal care. Similarly in the study with Memon et al. about knowledge, attitude, and practice among mothers about newborn care in Sindh, Pakistan indicated that among the study sample, more than half of the newborns were bathed within six hours of delivery. Around 50% started breastfeeding after 1 h of birth. A substantial proportion (45%) of mothers gave prelacteal feeding and 44.8% of them did not feed colostrom to their newborns. Mothers with no education had less signi cant KAP score about newborn care as compared to those who had higher education [23].
According to this study health worker and midwife in health center and spouse were the most subjective norm that in uence on the knowledge, attitude of mothers about neonatal care.
This nding is consistent with the results of other studies for example in Vietnam showing that Fathers' support can in uence mothers' breastfeeding decisions and behavior [24].
Therefore health worker and midwife need to gain the knowledge, attitudes, and adequate skills to deliver culturally competent care, including tools on how to effectively communicate with pregnant mothers or families from diverse cultural, socioeconomic, and level of education. Application of culturally appropriate communication is crucial. This will in turn help elicit helpful dialogue with pregnant women and families that will encourage them to ask questions in health centers and communicate their concerns more clearly to ensure the best delivery of the highest quality of neonatal care for every pregnant women. Beside the health worker, delivery health information through Massmedias such as televisions, radio and booklet about neonatal care would change the women's misconception that would improve their service utilization.
This study also revealed that attitude towards neonatal care was positive associated with intention to neonatal care. Respondents who had a positive attitude towards neonatal care more likely to have intention than those who had a negative attitude. A similar result was reported in China which identi ed attitude women towards cervical cancer screening as the most signi cant factor that affects intention [25].
More than half of the mothers interviewed under the present study lacked the necessary knowledge to baby visit after birth, bathing the baby, baby holding temperature. Another study in China observed that 48.2% of the participants reported practicing neonatal care and range of score for each scale was knowledge 0-16 (M = 9.62),  [26].
In this study knowledge about neonatal jaundice 33% had inadequate knowledge but in study Amegan et al. about awareness, perception and preventive practices about neonatal jaundice in mothers in Accra showed that 92.6% did not know the causes of jaundice or had the wrong information and there was no signi cant association with their level of education [27]. In study Goodman et al in Nigeria showed that 68.9% of the mothers had a poor level of knowledge about neonatal jaundice. In this study age and educational quali cation did not show any statistically signi cant relationship with knowledge about neonatal jaundice [28].
With considering neonatal jaundice is a preventable cause of neonatal morbidity and mortality. Therefore an improving pregnant mothers' knowledge will help with early recognition of neonatal jaundice, prompt and appropriate intervention.
According to this study considerable number of mothers lacked knowledge (73%) the proper temperature of the baby's room. These ndings are considered low when compared with a study conducted in North Ethiopia, where 99.3% of the participants had the knowledge about temperature of the baby room [29]. This difference could be related to the difference in study participants in two countries Iran and Ethiopia.
This study revealed that the proportion of mother having adequate knowledge about bene ts of breastfeeding (86%) and colostrum's (74%) which is almost similar with the ndings in study in Jimma (66.4%) [30]. On the other hand, knowledge of the study participants in this study is slightly higher compared with study in Uganda (47%) [31].
This might be due to slight variation in the tools used and socio-economic variable in participant in countries In study of Chhetri et al. about newborn care practices at home nding showed that initiation of breastfeeding was practiced by only 40% of mother. Among neonates, 65% were given colostrums and hand washing was practiced by 62.5% before touching the baby. For thermal care, burning charcoal (75%) was mostly used. The study revealed association between newborn care and mother education and per capita income of family [32].
According this study 40% of pregnant women knowledge about bathing the baby. In the study in Pakistan (32%) and Southern Tanzania (60%) of respondents stated that they bathed their newborns within six hours after birth [33][34].
The results also show that over 47% of mothers did not have any knowledge about take care of the baby's umbilical cord, 60% did not have any knowledge about how to bathing the baby.
In contrast another study in Jordan [35] and Arab society [36] which showed that neonatal care in mothers most lacked knowledge.
The mothers also showed a lack of knowledge about to visit the baby on the days after birth by health care (59%).
Based on this study health workers at health centers must have been knowledge enough to advise pregnant women to have visit neonatal after birth.
In this study intention behavior for neonatal care was 4.4 score. Similarly in study Andre et al. about in uential factors in in uenza vaccination during pregnancy showed that, 76% of pregnant women had received the in uenza vaccination. Intention of women for vaccination was the desire for neonatal protection, the common reasons for not being vaccinated were not receiving information on vaccination or safety concerns [37].
In this study 22% of mothers don't know recognizing danger sign in neonatal. Welay et al in study indicated that a knowledge score of neonatal danger signs was found 32.9%. Mothers educated to secondary level and mothers whose husband educated to college and above were 4.9 times more likely to know about neonatal danger signs [8].
This study tested the applicability of the knowledge and perceived behavior control R 2 = 32% in the prediction of neonatal care intentions. In fact the ndings of this study show partial support for the predictive ability of the theory of planned behavior in predicting intentions in pregnant women for neonatal care.
In Wang study about predicting women's intentions to screen for breast cancer R 2 = 8.3% in the prediction of breast cancer screening intentions [38]. Sun et al in another study about predicting iron consumption intention in women showed that the model explained 35-55% of the variance of behavioral intention [39].
In fact TPB assumes that attitude, subjective norms, and perceived behavioral control lead to the development of a behavioral intention and so the behavioral intention is the immediate antecedent of behavior [40].
Our study ndings re ected that perceived behavior control were signi cant construct of TPB to intention behavior for neonatal care among mothers. The present study had some limitations. The research is a cross-sectional study, and all independent and dependent variables were measured in a single point of time. All variables were selfreported, which may lead to misclassi cation due to recall and reporting bias. This limitation was resolved by allocating su cient time and explicit expression of the objectives of study, and gathering information along with interviewing. Further research with larger and more diverse samples was suggestion.
Regardless of these limitations, this study has advantages. One of the strengths of the present study is that the design of the protocol based on theory center for asses neonatal care.
Cognition is a critical process to practice good health behavior. Theoretical based research can help to understand the cognition elements better. The TPB constructs of perceived control behavior and attitude explain signi cant to increase intention behavior among pregnant women about neonatal care.
Finally, it can be said that this study show support for the predictive ability of the TPB in predicting for neonatal care therefore the design of educational intervention should be based on intention and knowledge as the most important predictors of maternal behavior

Conclusion
Neonatal care is an important fact worldwide as well as Iran and health needs to be concerned as neonatal are the most vulnerable population. Our study provides evidence of potential factors to strengthen intention behavior with improving knowledge, perceived behavior control, and increasing for neonatal care. Thus, efforts should be exerted to improve the attitude of women involving in uential people, which could improve women's intention for neonatal care performance.
According to the results of the study health workers, and midwife play a critically important role in the development of knowledge and attitude mothers about neonatal car. By identifying the lack of knowledge of mothers, the ndings of this study can inform and suggestion the design of educational program for pregnant women by focusing on construct perceived control behavior for health promotion neonatal care. Moreover, behavioral change communication focusing on the constructs of the theory of planned behavior is crucial. Finally the theory of planned behavior constructs is useful to predictive of neonatal care in pregnant women, which may be useful in the future to design interventions for educational mothers in period of pregnancy.