This was a methodological validity study performed in the northeastern region of Brazil. Data were collected from the Public Health System of Brazil services.
This study was approved by the Research Ethics Committee of the Federal University of Rio Grande do Norte (CEP-UFRN) under approval number 1.065.285/2014. All participants were informed about the research objectives and procedures and signed a consent form, in accordance with Resolution 466/12 of the National Health Council of Brazil.
The sample size of this study was based on the recommendation of having a sample size that is five times the number of items on the instrument being validated24. Thus, a sample of 409 volunteers who agreed to participate was selected for this study.
The inclusion criteria in this study were as follows: Brazilian citizen, receiving prenatal care in one of the public health services previously defined, at least 14 years old, and attained minimum level of education, i.e., elementary school. The inclusion criteria were defined according to the ethical requirements and relevant heterogeneity sample for metodological analysis25. Return questionnaires with no response to one or more items of the each PSEQ dimensions were excluded.
Recruitment and data collection
All pregnant women were invited to participate in the study when they were in the waiting room for prenatal consultation. The data collection period was from 2015 to 2020 to adjust the sample size.
The investigators were trained by the research coordinator and received an instruction manual for data collection. The pregnant women received the evaluation instruments and could respond independently or request the researcher’s help in reading and completing the questionnaires.
First, we collected the socio-demographic, clinical, and obstetric characteristics using a questionnaire developed for this study, with the following variables: age, gestational age, occupation (unemployed or employed), family income (≤ 1 MW or > 1 MW), education level (high school or below, college or above), partner (no or yes), parity (primigravida or multigravida), number of appointments with doctors during prenatal care, gestational planning (no or yes), and antenatal care. The Brazilian minimum monthly wage (MW) is defined as the lowest remuneration that workers receive as payment for their jobs per month.
Then, we administered a version of the PSEQ previously translated and culturally adapted to Brazilian populations by Silva et al.17. First, authorization was requested from the author for the translation and validation of the Brazilian Portuguese version of the PSEQ17. Two translators fluent in the English language translated the instrument into Brazilian Portuguese17. The translations were then reviewed by an expert committee composed of four people who agreed on the final version of the instrument. Subsequently, the questionnaire was sent to two different English-speaking translators for backtranslation17. The PSEQ was administered to 36 pregnant women in a pilot study to determine its clarity and coherence17. The pilot showed that 75% of the pregnant women found the questionnaire easy to understand17.
Originally developed in English in 1984, the PSEQ was designed by a North American nurse, Regina Lederman1. This assessment tool is meant for pregnant women and addresses 79 items in seven dimensions of psychosocial adaptation to pregnancy: Well-being of self and baby (items 12, 16, 17, 30, 41, 51, 57, 63, 68, and 71); acceptance of pregnancy (items 1, 3, 9, 22, 32, 58, 61, 62, 66, 69, 74, 76, 77, and 79); identification with motherhood role (items 2, 6, 19, 29, 33, 34, 42, 45, 46, 50, 54, 67, 73, 75, and 78); preparation for labor (items 7, 13, 24, 25, 26, 38, 47, 48, 56, and 72); control in labor (items 8, 11, 15, 18, 27, 39, 49, 52, 53, and 64); relationship with mother (items 14, 20, 21, 28, 31, 37, 44, 55, 59, and 65); and relationship with partner (items 4, 5, 10, 23, 35, 36, 40, 43, 60, and 70). Each item consists of a statement related to the period of pregnancy, childbirth, and maternity to which the respondents need to indicate their degree of agreement using a four-point Likert scale, with the following options: (4) Very much so, (3) Moderately so, (2) Somewhat so, and (1) Not at all. However, the scoring for questions with positive statements (questions 1, 2, 3, 4, 6, 7, 8, 10, 11, 12, 14, 15, 18, 19, 20, 21, 22, 23, 24, 25, 26, 28, 31, 32, 33, 35, 36, 37, 38, 40, 47, 48, 49, 50, 53, 55, 56, 59, 60, 61, 70, 71, 72, 73, 74, 75, 78, and 79) was reversed. High scores indicate poor adaptation, while low scores indicate increased adaptation. The final score allows the assessment of psychosocial adaptation to pregnancy by means of a specific result, with a total score variation of 79 to 316.
The PPP-PV has four subscales, each with 11 items: stress, support received from the partner, support received from other people, and self-esteem, totaling 44 items16. The score ranges from 1 to 4 for stress and self-esteem and 1 to 6 for support received from the partner and support received from other people, with high ratings reflecting positive adaptation and low scores, poor adaptation16.
The participants whose mothers had deceased mother and those who did not have a partner did not respond to the items related to the domains of relationship with mother and relationship with partner or support received from the partner, respectively.
Descriptive statistics were used to characterize the sample through the median and standard deviation of continuous variables and the absolute and relative frequencies of the categorical variables.
To determine the reliability, internal consistency was evaluated by Cronbach’s alpha coefficient. To calculate the intraclass correlation coefficient (ICC), test-retest evaluation was conducted with 24 eligible women with a one-week interval to ensure stability of the analysis. A Cronbach’s alpha higher than 0.7 was considered reliable. However, values ≥ 0.6 are considered acceptable in exploratory research26. An ICC ≥ 0.40 is considered good and ≥ 0.75, excellent27.
Construct validity was assessed using 1) confirmatory factor analysis (CFA), 2) discriminant validity determined by Pearson’s correlation coefficient of the seven domains, 3) internal validity determined by Pearson’s correlation coefficient between domains and the general scores and 4) concurrent validity determined by calculating Pearson’s correlation between the PSEQ and PPP-VP with 34 eligible women, as both instruments evaluate the same constructs. Generally, the goodness of the fit of a model is confirmed by the following indices: root mean square error of approximation (RMSEA) < 0.08, standardized root mean square residual (SRMR) < 0.08, comparative fit index (CFI) ≥ 0.90, and normed chi-square (x²/df) < 5.0028,29. The correlation between the domains of the PSEQ must be analyzed to test the hypothesis1. The strength of the Pearson’s correlation coefficient increases both from 0 to + 1, and from 0 to -1, so, r < 0.40 is considered weak, 0.40 ≤ r < 0.70 moderate, and r ≥ 0.70 strong30. A significance level of 5% was adopted. The participants who did not respond to some items were excluded from the analysis of the said domain. Data analysis was performed using the Statistical Package for Social Sciences (SPSS), version 23 for Windows.