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WOMBI-445; No. of Pages 5 Women and Birth xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
Women and Birth journal homepage: www.elsevier.com/locate/wombi
ORIGINAL RESEARCH – QUANTITATIVE
Intentions of Muslim Arab women in Israel to attend prenatal classes Merav Ben Natan a,b,*, Maayan Ashkenazi a, Safaa Masarwe a a b
Pat Matthews School of Nursing, Hillel Yaffe Medical Center, Hadera, Israel Department of Nursing, School of Health Professions, Tel Aviv University, Israel
A R T I C L E I N F O
Article history: Received 18 December 2014 Received in revised form 6 April 2015 Accepted 23 July 2015 Keywords: Female Prenatal education Patient acceptance of health care Questionnaires Israel
A B S T R A C T
Background: Prenatal education has many benefits to both mother and child. In Israel, prenatal classes are offered to pregnant women in their third trimester from all cultures and sectors. However, Israeli Muslim Arab women often do not attend these classes. Aim: To explore factors influencing the intention of Muslim Arab women in Israel to attend prenatal classes, using the Theory of Planned Behavior. Methods: The study was a cross-sectional quantitative correlational design. A convenience sample consisting of 200 Arab Muslim women completed a questionnaire based on the literature review and the theoretical model. Findings: The research findings indicate that women’s intention to attend prenatal classes increases with more positive beliefs and attitudes toward prenatal education, greater subjective social pressure to attend classes, and with higher perceived control of attending such classes. The higher a woman’s age and level of education, the greater her intention to attend classes. This study shows that the spouse is the most significant factor influencing women’s decisions on this matter. Conclusion: In order to raise the intentions of Muslim Arab women in Israel to attend prenatal classes, policy makers must design programs to increase the awareness of prenatal education among both women and men in the Muslim Arab sector, emphasizing its benefits for mothers, infants, and families as a whole. Classes should reflect the uniqueness of Israeli Muslim Arab culture and combine traditional and modern outlooks. ß 2015 Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd) on behalf of Australian College of Midwives.
1. Background Prenatal education is common throughout the Western world and recommended by the World Health Organization (WHO) as a preventive measure aimed at promoting the health of mothers and infants.1 The research literature indicates that prenatal education has many benefits to both mother and child, including: reducing anxiety, management and relief of pain during labor and delivery, improving marital relations, encouraging breastfeeding, improving parental skills, and creating a social support network.2–9 In Israel, prenatal classes are offered to pregnant women in their third trimester from all cultures and sectors. Israel’s National Insurance Institute provides universal health coverage and subsidizes the majority of the cost for these courses for all women. Despite the
* Corresponding author at: Pat Matthews Academic School of Nursing, Hillel Yaffe Medical Centre, P.O.B. 169, Hadera 38100, Israel. Tel.: +972 4 6304367/9; fax: +972 4 6304730. E-mail address: [email protected] (M. Ben Natan).
financial coverage, Israeli Muslim Arab women often do not attend these classes. Some attribute this to the traditional approach of Israel’s Muslim Arab society to pregnancy and birth,7 despite modernization processes within Muslim Arab society. In the traditional approach, Muslim Arab women receive most of their prenatal knowledge from their mother or mother-in-law, who are considered to be ‘‘experts’’. Likewise, as Muslim Arab society is traditionally patriarchal, the opinions of Muslim Arab women’s husbands regarding prenatal education are also an important factor affecting these women.10 In Muslim Arab culture, giving birth is considered a natural process attesting to the skills and strength of a healthy mother and close supervision of the pregnancy contradicts this outlook.7 This approach is prevalent in other Arab countries as well.11 Another possible reason that few Muslim Arab women in Israel attend prenatal classes may be the language barrier. A considerable proportion of Muslim Arab women in Israel do not speak Hebrew at all, or their Hebrew level is inadequate and they do not feel sufficiently confident to attend prenatal classes conducted in Hebrew.7 Very few Arabic language prenatal classes are currently
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1871-5192/ß 2015 Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd) on behalf of Australian College of Midwives.
Please cite this article in press as: Ben Natan M, et al. Intentions of Muslim Arab women in Israel to attend prenatal classes. Women Birth (2015), http://dx.doi.org/10.1016/j.wombi.2015.07.009
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offered in Israel. To date, factors associated with the intentions of Muslim Arab women in Israel to attend prenatal classes have not been systematically investigated. While standard prenatal care is available to all Israeli women through the national health system, Muslim Arab women seek prenatal care at lower levels than do Jewish populations in Israel. For example, prenatal diagnostic testing (amniocentesis or chorionic villus sampling) is offered to all women aged 35 and older and fully funded by the national health system. However, a survey conducted in 2007 by the Ministry of Health found that only 15% of Arab women in this age chose to have prenatal diagnostic testing performed during pregnancy, compared to a testing rate of 52.1% for Jewish women aged 35 and older. Following this low acceptance rate for prenatal testing, 81.3% of incidences of Down syndrome in the Muslim Arab population in Israel were only diagnosed after birth, as compared with only 48% of Down syndrome incidences being postnatally diagnosed in the Jewish population. However, in recent years, Muslim Arab society in Israel has been undergoing a process of modernization which encourages young women to be educated and interested in many subjects. Muslim Arab women are more trusting of doctors and their healing ability. Muslim Arab women are now also more likely to believe that unhealthy behaviors such as smoking and poor nutrition contribute to illness and poor health.12 1.1. Theoretical framework This study was based on the Theory of Planned Behavior (TPB), which focuses on the prediction of health and social behaviors.12 According to the theory, one’s behavioral intention affects one’s actual behavior. Behavioral intention is informed by three main factors: behavioral attitude, subjective norms, and perceived control of the behavior. Each of these is governed by one of three types of beliefs: behavioral beliefs, normative beliefs, and control beliefs. Behavioral beliefs refer to one’s overall positive or negative evaluation of the behavior and expectations of the behavior’s consequences. These beliefs create an attitude toward the behavior. Normative beliefs are the beliefs of significant others with regard to the behavior. These beliefs create subjective norms involving perceived social pressure by significant others to perform or not perform the behavior. Control beliefs are comprised of facilitating factors and impeding factors. Control beliefs are one’s perceived control of performing the behavior and the perceived ease or difficulty of this performance. The TPB has been used to explain various women-specific health behaviors.13–15 It has been found applicable to understanding mammography screening behavior among Muslim Arab women in Israel.16 TPB has been found to contribute to understanding women’s health behaviors during pregnancy and post-partum.17–20 To the best of our knowledge, the theory has not been previously used to explore factors related to the intentions of Muslim Arab women in Israel to attend prenatal classes. Therefore, the aim of the study is to explore factors influencing the intention of Muslim Arab women in Israel to attend prenatal classes, using the Theory of Planned Behavior.
Two hundred and twenty participants were allocated to the study on the assumption that 10% would choose to attend prenatal classes in the Muslim Arab sector, with 95% confidence interval and 80% power. Inclusion criteria were married women with no children, literate in Arabic or Hebrew. 2.3. Research tool The research tool was a structured self-administered questionnaire constructed by the researchers based on the literature review and the theoretical model. The questionnaire was comprised of 52 items as follows: 12 items gathering sociodemographic data; 7 items examining behavioral beliefs (for example: ‘‘Attending prenatal classes raises the likelihood of breastfeeding after delivery’’); 4 items examining behavioral attitude (for example: ‘‘To what degree is attendance of prenatal classes embarrassing?’’); 7 items examining normative beliefs (for example: ‘‘My mother believes that it is important for me to attend prenatal classes’’); 7 items examining subjective norms motivating women to attend prenatal classes (for example: ‘‘My spouse’s opinion will influence my intention to attend prenatal classes’’); 9 items examining control beliefs (for example: ‘‘Advertising in Arabic would encourage me to attend prenatal classes’’); 3 items examining perceived control (for example: ‘‘No one but myself will decide whether I will attend prenatal classes’’); 3 items examining behavioral intention (for example: ‘‘I will make every effort to persuade my spouse that we should attend prenatal classes’’). Responses were ranked on a Likert scale ranging from 1 (do not agree) to 6 (strongly agree). Three nurses who are content experts specializing in midwifery inspected the questionnaire and its contents and gave their approval following corrections for clarity of language. The questionnaire was translated into Arabic and externally validated by two Arabic language instructors using backward and forward translation. In order to examine its validity, the questionnaire was pilot tested with 20 Muslim Arab women. The reliability of the subscales (alpha Cronbach) ranged from 0.80 to 0.90. 2.4. Procedure The study was approved by the Ethics Committee of Tel Aviv University. Women were sampled during public lectures on women’s health conducted by the researchers in Muslim Arab towns. The researchers distributed the questionnaire after confirming that the women had not completed the questionnaire in the past and explaining the purpose of the study. Women signed a consent form to participate in the study prior to the questionnaire being distributed. Upon completion the questionnaires were collected by the researchers. Anonymity was preserved. Women completed the questionnaire in a quiet room allocated for this purpose. Two hundred and twenty questionnaires were administered during October through December 2013 and 200 fully completed questionnaires were returned to researchers, for a response rate of 91%.
2. Methods
2.5. Statistical analysis
2.1. Study design
Data analysis was performed using the Statistical Package for Social Sciences (SPSS-PC, version 22, Chicago IL). Descriptive statistics were used to describe the women’s responses to the questionnaire. Pearson correlations were used to determine the relationship between the TPB constructs and the intentions of Muslim Arab women in Israel to attend prenatal classes. A multiple linear regression was performed to examine the ability of the TPB to predict the intentions of Muslim Arab women in Israel to attend prenatal classes. Statistical significance was set at p < .05.
The study was a cross-sectional quantitative correlational design. 2.2. Participants The study included a convenience sample of 200 Muslim Arab women. Sample size was calculated by Power & Precision software.
Please cite this article in press as: Ben Natan M, et al. Intentions of Muslim Arab women in Israel to attend prenatal classes. Women Birth (2015), http://dx.doi.org/10.1016/j.wombi.2015.07.009
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3. Results
3.6. Normative beliefs
3.1. Sociodemographic data
The mean for normative beliefs was medium (M = 3.8, SD = 1.0), indicating that most respondents perceived the opinions of significant others in their life concerning attendance of prenatal classes as reserved. Positive opinions were most frequently attributed to respondents’ primary nurse and spouse. Fifty six percent of respondents agreed that their attendance of prenatal classes would be important to their primary nurse, and 54% agreed that it would be important to spouse.
Two hundred married Muslim Arab women with no children, residing in a wide range of geographic areas of Israel, took part in the study. Their mean age was M = 2.42 (SD = 4.6; range 16–40). They had 10–24 years of education, with a mean of M = 13.3 (SD = 3.2). Most (61.3%) were religious. Of all women sampled, 55.3% were employed (full-time or part-time), and 53% of women reported an average level household income.
3.7. Subjective norms 3.2. Awareness of prenatal classes Sixty one percent of women in the current study knew about prenatal classes before receiving the questionnaire. Of these, 52.9% had heard of prenatal classes from medical sources and the remainder from friends and family. Only 44.5% of respondents reported that at least one of their friends had attended prenatal classes. Only 7% reported that their mother had attended prenatal classes.
The mean for subjective norms was medium (M = 3.83, SD = 1.2), indicating that most respondents experienced moderate pressure by significant others in their life to attend prenatal classes. The most significant elements stated by respondents as influencing their attendance of prenatal classes were their spouse (69.5%) and primary nurse (54%). In contrast, 67% of respondents claimed that the opinion of clerics would have no influence on their decision whether to attend prenatal classes.
3.3. Intentions
3.8. Control beliefs
The research findings indicate that the respondents had a medium-high intention of attending prenatal classes, M = 4.1 (SD = 1.4) (Table 1). Fifty-four percent of respondents strongly agreed that they intend to attend prenatal classes, while only 16% stated that they had no intention of attending classes. Forty-eight percent agreed to make every effort to convince their spouse to attend prenatal classes; however 17% stated that they would not make any effort to convince their spouse. Fifty percent of respondents strongly agreed that they could overcome any obstacle to attending classes. Eighteen percent did not agree that they were capable of overcoming obstacles in order to attend prenatal classes.
The mean for control beliefs was medium-high, M = 4.2 (SD = 1.2). The elements found to have the greatest influence on respondents’ intention to attend prenatal classes were proximity of classes to their place of residence (75.5%) and the consent of their spouse for the women to attend classes (72.5%). Seventy percent of respondents claimed that having the time to attend classes would contribute to their attendance, and 67% agreed that holding classes in Arabic would encourage them to attend.
3.4. Behavioral beliefs
The mean for perceived control was medium-high, M = 4.5 (SD = 1.3). Sixty-seven percent of respondents claimed that they had full control over decisions involving their pregnancy. Sixty four percent claimed that no one would decide for them whether to attend prenatal classes. Sixty-two percent of respondents indicated that the decision whether to attend prenatal classes is theirs alone.
The mean for behavioral beliefs was medium-high M = 4.3 (SD = 1.2), indicating that most respondents believed that attending prenatal classes is a positive behavior. The respondents strongly agreed that prenatal education helps women in labor breath easier (68%) and reduces fear (63%). Respondents were uncertain about prenatal classes’ impact on enhancing the mother’s confidence during labor. 3.5. Behavioral attitudes The mean for behavioral attitudes was medium-high M = 4.3 (SD = 1.2), indicating that most respondents perceived prenatal education as having positive consequences for them. Respondents strongly agreed that the classes are beneficial (62%) and important (56%). Despite this perception, 49% perceived classes as embarrassing and as an uninteresting experience.
Table 1 Distribution of the research variables (n = 200). Research variables
M
SD
Range
Behavioral beliefs Behavioral attitudes Normative beliefs Subjective norms Control beliefs Perceived control Intentions
4.1 4.3 3.8 3.8 4.5 4.5 4.1
1.1 1.2 1.0 1.2 1.2 1.3 1.4
1–6 1–6 1–6 1–6 1–6 1–6 1–6
3.9. Perceived control
3.10. Correlations between the theory’s components Medium positive correlations were found between all the theory’s components. Respondents’ behavioral beliefs and behavioral attitudes toward attending prenatal classes, normative beliefs and subjective norms, control beliefs and perceived control of attending classes were correlated with their intention to attend classes (Table 2). The more positive the women’s beliefs and attitudes toward prenatal classes, the more subjective social pressure they experience to attend classes, and the higher their perceived control of attending classes, the higher their intentions to attend prenatal classes. A medium positive correlation was found between respondents’ age and their behavioral intention to attend prenatal classes (r = .24, p < .05). The higher a woman’s age, the higher her intention to attend classes. A medium positive correlation was also found between years of education and intention to attend prenatal classes. More years of education was correlated with a greater intention to attend classes. The regression’s findings show that the theory’s power of prediction is R2 = 37% (p < .01). The factor with the most influence on respondents decision to attend prenatal classes is subjective
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4 Table 2 Correlations between the theory components (n = 200). Behavioral beliefs Behavioral beliefs Behavioral attitudes Normative beliefs Control beliefs Subjective norms Perceived control * **
Behavioral attitudes .325**
1 .325** .309** .225** .094 .206**
Normative beliefs .309** .356** 1 .056 .249** .098
1 .356** .135 .048 .175*
Control beliefs
Subjective norms
.225** .135 .056
.206** .175* .098 .202** .033
.094 .048 .249** .316**
1 .316** .202**
Perceived control
1 .033
1
Intention .372** .255** .465** .162* .378** .233**
p < .05. p < .01
norms, primarily the influence of their spouse (b = .299; p < .01) (Table 3). 4. Discussion The current study explored factors related to the intentions of Muslim Arab women in Israel to attend prenatal classes, using the TPB.12 The intention of Muslim Arab women in Israel to attend prenatal classes was found to depend on their beliefs and attitudes about prenatal classes, their control beliefs and perceived control, and the influence of significant others. The current study showed that the factor with the greatest impact on the intention of Muslim Arab women in Israel to attend prenatal classes was perceived social pressures applied by significant others. In the current study this refers to their spouse. The strong effect of significant others on Muslim Arab women’s health-related decisions has been documented in previous studies as well.7,10,11,21 The current study found that the most significant opinions influencing Muslim Arab women’s decision whether to attend prenatal classes were those of their spouse and primary nurse. Other factors influencing respondents’ intentions to attend prenatal classes in this study was their age and years of education, which was consistent with findings by Gagnon and Sandall metaanalysis studies looking at a variety of research on the impact of prenatal education courses and factors influencing women’s intention to attend have shown that intentions are higher among women who are older and more educated.5 This might be related to the fact that older pregnant women have more concerns and are more willing to receive medical information and guidance concerning their pregnancy and the baby.22 This is confirmed by a study that examined pregnant women in the UK, which found that young women and teenage girls are less aware of the potential and benefits of prenatal classes.4 Respondents’ perceived control of health decisions influenced their intentions to attend prenatal classes. Most respondents claimed that they have exclusive control over decisions involving their pregnancy, including the decision whether to attend prenatal classes. This is similar to findings by Nikie´ma et al., who performed
Table 3 Summary of regression analyses for variables predicting intentions to attend prenatal classes (n = 200). Variable Behavioral beliefs Behavioral attitudes Normative beliefs Subjective norms Control beliefs Perceived control R2 = 37%.
B
SE B .271 .047 .380 .332 .077 .194
.079 .070 .086 .069 .087 .062
b .218 .043 .286 .299 .056 .187
t
P
3.418 .669 4.404 4.786 .893 3.103
.001 .504 .000 .000 .373 .002
a cross-country analysis on data from the most recent demographic and health surveys of 19 Sub-Saharan African countries which demonstrated that women’s perceived control contribute to their own health and that of their child.22 The current study found several factors which may encourage Muslim Arab women’s intentions to attend prenatal classes. Respondents reported that it would be easier for them to attend prenatal classes if they were provided at an accessible location in their area of residence. At present almost no classes are given in Muslim Arab towns, and classes given in distant locations are not always easily accessible. Holding prenatal classes in Arabic may also encourage Muslim Arab women to attend. Most prenatal classes are conducted only in Hebrew and not in Arabic. This finding is consistent with that of Rassin et al., who studied a total of 126 Jewish and Arab-Muslim pregnant women to compare Jewish and Arab populations regarding pregnancy follow-up, compliance with a health regime and behavioral expressions during labor, delivery and the post-partum period. Their research found that Muslim Arab women do not attend prenatal classes due to language barriers.7 A considerable proportion of Muslim Arab women in Israel are not sufficiently fluent in Hebrew and lack confidence to attend prenatal classes conducted in Hebrew. Due to changes in Muslim Arab culture and society in Israel, many women no longer make do with information provided by their mother or mother-in-law. Instead they seek additional sources of knowledge on pregnancy and labor. The women in the current study stated that receiving information from relatives is not a barrier to attending prenatal classes. This finding indicates that modern views are gradually spreading among Israel’s Muslim Arab society. 4.1. Limitations The study has several limitations. Convenience sampling might limit the generalizability of the findings to Israel’s entire population of Muslim Arab women. In addition, as the study questionnaires were distributed and completed at public lectures on women’s health, only women who already utilized public health services participated in the study. This study examined intentions, and it is not clear whether women who declared their intention to attend prenatal classes would indeed do so. 4.2. Recommendations In order to increase the intentions of Muslim Arab women to attend prenatal classes, it is recommended to raise the awareness of such classes among the Muslim Arab sector, emphasizing their benefits for the mother, baby, and family. The primary nurse, who follows and guides women throughout their pregnancy, may constitute a valuable resource for Muslim Arab women in providing information about prenatal education and encouraging women to attend classes. Factors with the greatest influence on Muslim Arab women’s intention to attend prenatal classes are their
Please cite this article in press as: Ben Natan M, et al. Intentions of Muslim Arab women in Israel to attend prenatal classes. Women Birth (2015), http://dx.doi.org/10.1016/j.wombi.2015.07.009
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significant others, and primarily the spouse. It is recommended that spouses also be approached with regard to encouraging their wife to attend prenatal classes. Classes should be held in Arab towns, in the Arabic language, and should reflect the uniqueness of Muslim Arab culture, with its combination of traditional and modern views. This should be stated in campaigns promoting prenatal classes. Likewise, Arabic language promotional campaigns should be designed to encourage both Muslim Arab women and their partners to participate in prenatal education classes. It is also necessary to further study the attendance of prenatal classes by this unique population. Future studies should use random sampling in order to reach different segments of women within the Muslim Arab sector. Further studies should also be conducted on factors facilitating women’s attendance of prenatal classes, in order to reach a deeper understanding of this practice. Additional recommendations for further study include examining the effect of opening prenatal courses in Arabic at an easily accessible geographical location on Arab Muslim women intention to attend these courses and examining the knowledge, attitudes and barriers of Muslim Arab women’s partners in regards to prenatal education classes. 5. Conclusion Research findings indicate that Muslim Arab women in Israel had relatively high intentions to attend prenatal classes. The influence of tradition on women’s intentions to attend classes remains significant and should not be disregarded, including the important role of the spouse in this decision. Several barriers to Muslim Arab women’s attendance of prenatal classes in Israel, such as geographical distance and language, are notable. Also, it is especially important for nursing and medical staff to develop transcultural sensitivity toward populations from different cultures, especially Muslim Arab women. Acknowledgments There has been no financial assistance with the research. References 1. Murphy Tighe S. An exploration of the attitudes of attenders and non-attenders towards prenatal education. Midwifery 2010;26(3):294–303. http://dx.doi.org/ 10.1016/j.midw.2008.06.005. 2. Escott D, Slade P, Spiby H. Preparation for pain management during childbirth: the psychological aspects of coping strategy development in prenatal education. Clin Psychol Rev 2009;29(7):617–22. http://dx.doi.org/10.1016/j.cpr. 2009.07.002.
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3. Fabian HM, Ra˚destad IJ, Waldenstro¨m U. Childbirth and parenthood education classes in Sweden. Women’s opinion and possible outcomes. Acta Obstet Gynecol Scand 2005;84(5):436–43. http://dx.doi.org/10.1111/j.0001-6349.2005.00732.x. 4. Ferguson S, Davis D, Browne J. Does prenatal education affect labour and birth? A structured review of the literature. Women Birth 2013;26(1):e5–8. http:// dx.doi.org/10.1016/j.wombi.2012.09.003. 5. Gagnon AJ, Sandall J. Individual or group prenatal education for childbirth or parenthood, or both. Cochrane Database Syst Rev 2007;3. http://dx.doi.org/ 10.1002/14651858.CD002869.pub2. 6. Ip WY, Tang CS, Goggins WB. An educational intervention to improve women’s ability to cope with childbirth. J Clin Nurs 2009;18(15):2125–35. http:// dx.doi.org/10.1111/j.1365-2702.2008.02720.x. 7. Rassin M, Klug E, Nathanzon H, Kan A, Silner D. Cultural differences in child delivery: comparisons between Jewish and Arab women in Israel. Int Nurs Rev 2009;56(1):123–30. http://dx.doi.org/10.1111/j.1466-7657.2008.00681.x. 8. Svensson J, Barclay L, Cooke M. The concerns and interests of expectant and new parents: assessing learning needs. J Perinatal Educ 2006;15(4):18–27. http:// dx.doi.org/10.1624/105812406X151385. 9. Svensson J, Barclay L, Cooke M. Effective prenatal education: strategies recommended by expectant and new parents. J Perinatal Educ 2008;17(4):33–42. http://dx.doi.org/10.1624/105812408X364152. 10. Azaiza F, Cohen M. Between traditional and modern perceptions of breast and cervical cancer screenings: a qualitative study of Arab women in Israel. Psychooncology 2008;17(1):34–41. http://dx.doi.org/10.1002/pon.1180. 11. Oweis A, Abushaikha L. Jordanian pregnant women’s expectations of their first childbirth experience. Int J Nurs Pract 2004;10(6):264–71. http://dx.doi.org/ 10.1111/j.1440-172x.2004.00488.x. 12. Ajzen I. The theory of planned behavior. Organ Behav Hum Decis Process 1991;50(2):179–211. http://dx.doi.org/10.1016/0749-5978(91)90020-T. 13. Carter-Parker K, Edwards KA, McCleary-Jones V. Correlates of physical activity and the theory of planned behavior between African American women who are physically active and those who are not. ABNF J: Off J Assoc Black Nurs Fac High Educ Inc 2012;23(3):51–8. 14. Griva F, Anagnostopoulos F, Madoglou S. Mammography screening and the theory of planned behavior: suggestions toward an extended model of prediction. Women Health 2010;49(8):662–81. http://dx.doi.org/10.1080/ 03630240903496010. 15. Jalilian F, Emdadi S. Factors related to regular undergoing Pap-smear test: application of theory of planned behavior. J Res Health Sci 2011;11(2):103–8. 16. Soskolne V, Marie S, Manor O. Beliefs, recommendations and intentions are important explanatory factors of mammography screening behavior among Muslim Arab women in Israel. Health Educ Res 2007;22(5):665–76. http:// dx.doi.org/10.1093/her/cyl132. 17. Ben Natan M, Golubev V, Shamrai V. Smoking during pregnancy: analysis of influencing factors using the Theory of Planned Behaviour. Int Nurs Rev 2010;57(3):388–94. http://dx.doi.org/10.1111/j.1466-7657.2010.00807.x. 18. Mutuli LA, Walingo MK. Applicability of Theory of Planned Behavior in understanding breastfeeding intention of postpartum women. Int J Multidiscip Curr Res 2014;2:258–66. 19. Swanson V, Power KG. Initiation and continuation of breastfeeding: theory of planned behaviour. J Adv Nurs 2005;50(3):272–82. http://dx.doi.org/10.1111/ j.1365-2648.2005.03390.x. 20. Symons Downs D, Hausenblas HA. Exercising for two: examining pregnant women’s second trimester exercise intention and behavior using the framework of the theory of planned behavior. Women’s Health Issues 2003;13(6):222– 8. http://dx.doi.org/10.1016/j.whi.2003.09.004. 21. Rabi U, Rudnitzky A. Women in Israel’s Arab Society. Tel Aviv: Tel Aviv University; 2011. [Hebrew]. 22. Nikie´ma B, Beninguisse G, Haggerty JL. Providing information on pregnancy complications during prenatal visits: unmet educational needs in sub-Saharan Africa. Health Policy Plan 2009;24(5):367–76.
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WOMBI-445; No. of Pages 5 Women and Birth xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
Women and Birth journal homepage: www.elsevier.com/locate/wombi
ORIGINAL RESEARCH – QUANTITATIVE
Intentions of Muslim Arab women in Israel to attend prenatal classes Merav Ben Natan a,b,*, Maayan Ashkenazi a, Safaa Masarwe a a b
Pat Matthews School of Nursing, Hillel Yaffe Medical Center, Hadera, Israel Department of Nursing, School of Health Professions, Tel Aviv University, Israel
A R T I C L E I N F O
Article history: Received 18 December 2014 Received in revised form 6 April 2015 Accepted 23 July 2015 Keywords: Female Prenatal education Patient acceptance of health care Questionnaires Israel
A B S T R A C T
Background: Prenatal education has many benefits to both mother and child. In Israel, prenatal classes are offered to pregnant women in their third trimester from all cultures and sectors. However, Israeli Muslim Arab women often do not attend these classes. Aim: To explore factors influencing the intention of Muslim Arab women in Israel to attend prenatal classes, using the Theory of Planned Behavior. Methods: The study was a cross-sectional quantitative correlational design. A convenience sample consisting of 200 Arab Muslim women completed a questionnaire based on the literature review and the theoretical model. Findings: The research findings indicate that women’s intention to attend prenatal classes increases with more positive beliefs and attitudes toward prenatal education, greater subjective social pressure to attend classes, and with higher perceived control of attending such classes. The higher a woman’s age and level of education, the greater her intention to attend classes. This study shows that the spouse is the most significant factor influencing women’s decisions on this matter. Conclusion: In order to raise the intentions of Muslim Arab women in Israel to attend prenatal classes, policy makers must design programs to increase the awareness of prenatal education among both women and men in the Muslim Arab sector, emphasizing its benefits for mothers, infants, and families as a whole. Classes should reflect the uniqueness of Israeli Muslim Arab culture and combine traditional and modern outlooks. ß 2015 Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd) on behalf of Australian College of Midwives.
1. Background Prenatal education is common throughout the Western world and recommended by the World Health Organization (WHO) as a preventive measure aimed at promoting the health of mothers and infants.1 The research literature indicates that prenatal education has many benefits to both mother and child, including: reducing anxiety, management and relief of pain during labor and delivery, improving marital relations, encouraging breastfeeding, improving parental skills, and creating a social support network.2–9 In Israel, prenatal classes are offered to pregnant women in their third trimester from all cultures and sectors. Israel’s National Insurance Institute provides universal health coverage and subsidizes the majority of the cost for these courses for all women. Despite the
* Corresponding author at: Pat Matthews Academic School of Nursing, Hillel Yaffe Medical Centre, P.O.B. 169, Hadera 38100, Israel. Tel.: +972 4 6304367/9; fax: +972 4 6304730. E-mail address: [email protected] (M. Ben Natan).
financial coverage, Israeli Muslim Arab women often do not attend these classes. Some attribute this to the traditional approach of Israel’s Muslim Arab society to pregnancy and birth,7 despite modernization processes within Muslim Arab society. In the traditional approach, Muslim Arab women receive most of their prenatal knowledge from their mother or mother-in-law, who are considered to be ‘‘experts’’. Likewise, as Muslim Arab society is traditionally patriarchal, the opinions of Muslim Arab women’s husbands regarding prenatal education are also an important factor affecting these women.10 In Muslim Arab culture, giving birth is considered a natural process attesting to the skills and strength of a healthy mother and close supervision of the pregnancy contradicts this outlook.7 This approach is prevalent in other Arab countries as well.11 Another possible reason that few Muslim Arab women in Israel attend prenatal classes may be the language barrier. A considerable proportion of Muslim Arab women in Israel do not speak Hebrew at all, or their Hebrew level is inadequate and they do not feel sufficiently confident to attend prenatal classes conducted in Hebrew.7 Very few Arabic language prenatal classes are currently
http://dx.doi.org/10.1016/j.wombi.2015.07.009
1871-5192/ß 2015 Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd) on behalf of Australian College of Midwives.
Please cite this article in press as: Ben Natan M, et al. Intentions of Muslim Arab women in Israel to attend prenatal classes. Women Birth (2015), http://dx.doi.org/10.1016/j.wombi.2015.07.009
G Model
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offered in Israel. To date, factors associated with the intentions of Muslim Arab women in Israel to attend prenatal classes have not been systematically investigated. While standard prenatal care is available to all Israeli women through the national health system, Muslim Arab women seek prenatal care at lower levels than do Jewish populations in Israel. For example, prenatal diagnostic testing (amniocentesis or chorionic villus sampling) is offered to all women aged 35 and older and fully funded by the national health system. However, a survey conducted in 2007 by the Ministry of Health found that only 15% of Arab women in this age chose to have prenatal diagnostic testing performed during pregnancy, compared to a testing rate of 52.1% for Jewish women aged 35 and older. Following this low acceptance rate for prenatal testing, 81.3% of incidences of Down syndrome in the Muslim Arab population in Israel were only diagnosed after birth, as compared with only 48% of Down syndrome incidences being postnatally diagnosed in the Jewish population. However, in recent years, Muslim Arab society in Israel has been undergoing a process of modernization which encourages young women to be educated and interested in many subjects. Muslim Arab women are more trusting of doctors and their healing ability. Muslim Arab women are now also more likely to believe that unhealthy behaviors such as smoking and poor nutrition contribute to illness and poor health.12 1.1. Theoretical framework This study was based on the Theory of Planned Behavior (TPB), which focuses on the prediction of health and social behaviors.12 According to the theory, one’s behavioral intention affects one’s actual behavior. Behavioral intention is informed by three main factors: behavioral attitude, subjective norms, and perceived control of the behavior. Each of these is governed by one of three types of beliefs: behavioral beliefs, normative beliefs, and control beliefs. Behavioral beliefs refer to one’s overall positive or negative evaluation of the behavior and expectations of the behavior’s consequences. These beliefs create an attitude toward the behavior. Normative beliefs are the beliefs of significant others with regard to the behavior. These beliefs create subjective norms involving perceived social pressure by significant others to perform or not perform the behavior. Control beliefs are comprised of facilitating factors and impeding factors. Control beliefs are one’s perceived control of performing the behavior and the perceived ease or difficulty of this performance. The TPB has been used to explain various women-specific health behaviors.13–15 It has been found applicable to understanding mammography screening behavior among Muslim Arab women in Israel.16 TPB has been found to contribute to understanding women’s health behaviors during pregnancy and post-partum.17–20 To the best of our knowledge, the theory has not been previously used to explore factors related to the intentions of Muslim Arab women in Israel to attend prenatal classes. Therefore, the aim of the study is to explore factors influencing the intention of Muslim Arab women in Israel to attend prenatal classes, using the Theory of Planned Behavior.
Two hundred and twenty participants were allocated to the study on the assumption that 10% would choose to attend prenatal classes in the Muslim Arab sector, with 95% confidence interval and 80% power. Inclusion criteria were married women with no children, literate in Arabic or Hebrew. 2.3. Research tool The research tool was a structured self-administered questionnaire constructed by the researchers based on the literature review and the theoretical model. The questionnaire was comprised of 52 items as follows: 12 items gathering sociodemographic data; 7 items examining behavioral beliefs (for example: ‘‘Attending prenatal classes raises the likelihood of breastfeeding after delivery’’); 4 items examining behavioral attitude (for example: ‘‘To what degree is attendance of prenatal classes embarrassing?’’); 7 items examining normative beliefs (for example: ‘‘My mother believes that it is important for me to attend prenatal classes’’); 7 items examining subjective norms motivating women to attend prenatal classes (for example: ‘‘My spouse’s opinion will influence my intention to attend prenatal classes’’); 9 items examining control beliefs (for example: ‘‘Advertising in Arabic would encourage me to attend prenatal classes’’); 3 items examining perceived control (for example: ‘‘No one but myself will decide whether I will attend prenatal classes’’); 3 items examining behavioral intention (for example: ‘‘I will make every effort to persuade my spouse that we should attend prenatal classes’’). Responses were ranked on a Likert scale ranging from 1 (do not agree) to 6 (strongly agree). Three nurses who are content experts specializing in midwifery inspected the questionnaire and its contents and gave their approval following corrections for clarity of language. The questionnaire was translated into Arabic and externally validated by two Arabic language instructors using backward and forward translation. In order to examine its validity, the questionnaire was pilot tested with 20 Muslim Arab women. The reliability of the subscales (alpha Cronbach) ranged from 0.80 to 0.90. 2.4. Procedure The study was approved by the Ethics Committee of Tel Aviv University. Women were sampled during public lectures on women’s health conducted by the researchers in Muslim Arab towns. The researchers distributed the questionnaire after confirming that the women had not completed the questionnaire in the past and explaining the purpose of the study. Women signed a consent form to participate in the study prior to the questionnaire being distributed. Upon completion the questionnaires were collected by the researchers. Anonymity was preserved. Women completed the questionnaire in a quiet room allocated for this purpose. Two hundred and twenty questionnaires were administered during October through December 2013 and 200 fully completed questionnaires were returned to researchers, for a response rate of 91%.
2. Methods
2.5. Statistical analysis
2.1. Study design
Data analysis was performed using the Statistical Package for Social Sciences (SPSS-PC, version 22, Chicago IL). Descriptive statistics were used to describe the women’s responses to the questionnaire. Pearson correlations were used to determine the relationship between the TPB constructs and the intentions of Muslim Arab women in Israel to attend prenatal classes. A multiple linear regression was performed to examine the ability of the TPB to predict the intentions of Muslim Arab women in Israel to attend prenatal classes. Statistical significance was set at p < .05.
The study was a cross-sectional quantitative correlational design. 2.2. Participants The study included a convenience sample of 200 Muslim Arab women. Sample size was calculated by Power & Precision software.
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3. Results
3.6. Normative beliefs
3.1. Sociodemographic data
The mean for normative beliefs was medium (M = 3.8, SD = 1.0), indicating that most respondents perceived the opinions of significant others in their life concerning attendance of prenatal classes as reserved. Positive opinions were most frequently attributed to respondents’ primary nurse and spouse. Fifty six percent of respondents agreed that their attendance of prenatal classes would be important to their primary nurse, and 54% agreed that it would be important to spouse.
Two hundred married Muslim Arab women with no children, residing in a wide range of geographic areas of Israel, took part in the study. Their mean age was M = 2.42 (SD = 4.6; range 16–40). They had 10–24 years of education, with a mean of M = 13.3 (SD = 3.2). Most (61.3%) were religious. Of all women sampled, 55.3% were employed (full-time or part-time), and 53% of women reported an average level household income.
3.7. Subjective norms 3.2. Awareness of prenatal classes Sixty one percent of women in the current study knew about prenatal classes before receiving the questionnaire. Of these, 52.9% had heard of prenatal classes from medical sources and the remainder from friends and family. Only 44.5% of respondents reported that at least one of their friends had attended prenatal classes. Only 7% reported that their mother had attended prenatal classes.
The mean for subjective norms was medium (M = 3.83, SD = 1.2), indicating that most respondents experienced moderate pressure by significant others in their life to attend prenatal classes. The most significant elements stated by respondents as influencing their attendance of prenatal classes were their spouse (69.5%) and primary nurse (54%). In contrast, 67% of respondents claimed that the opinion of clerics would have no influence on their decision whether to attend prenatal classes.
3.3. Intentions
3.8. Control beliefs
The research findings indicate that the respondents had a medium-high intention of attending prenatal classes, M = 4.1 (SD = 1.4) (Table 1). Fifty-four percent of respondents strongly agreed that they intend to attend prenatal classes, while only 16% stated that they had no intention of attending classes. Forty-eight percent agreed to make every effort to convince their spouse to attend prenatal classes; however 17% stated that they would not make any effort to convince their spouse. Fifty percent of respondents strongly agreed that they could overcome any obstacle to attending classes. Eighteen percent did not agree that they were capable of overcoming obstacles in order to attend prenatal classes.
The mean for control beliefs was medium-high, M = 4.2 (SD = 1.2). The elements found to have the greatest influence on respondents’ intention to attend prenatal classes were proximity of classes to their place of residence (75.5%) and the consent of their spouse for the women to attend classes (72.5%). Seventy percent of respondents claimed that having the time to attend classes would contribute to their attendance, and 67% agreed that holding classes in Arabic would encourage them to attend.
3.4. Behavioral beliefs
The mean for perceived control was medium-high, M = 4.5 (SD = 1.3). Sixty-seven percent of respondents claimed that they had full control over decisions involving their pregnancy. Sixty four percent claimed that no one would decide for them whether to attend prenatal classes. Sixty-two percent of respondents indicated that the decision whether to attend prenatal classes is theirs alone.
The mean for behavioral beliefs was medium-high M = 4.3 (SD = 1.2), indicating that most respondents believed that attending prenatal classes is a positive behavior. The respondents strongly agreed that prenatal education helps women in labor breath easier (68%) and reduces fear (63%). Respondents were uncertain about prenatal classes’ impact on enhancing the mother’s confidence during labor. 3.5. Behavioral attitudes The mean for behavioral attitudes was medium-high M = 4.3 (SD = 1.2), indicating that most respondents perceived prenatal education as having positive consequences for them. Respondents strongly agreed that the classes are beneficial (62%) and important (56%). Despite this perception, 49% perceived classes as embarrassing and as an uninteresting experience.
Table 1 Distribution of the research variables (n = 200). Research variables
M
SD
Range
Behavioral beliefs Behavioral attitudes Normative beliefs Subjective norms Control beliefs Perceived control Intentions
4.1 4.3 3.8 3.8 4.5 4.5 4.1
1.1 1.2 1.0 1.2 1.2 1.3 1.4
1–6 1–6 1–6 1–6 1–6 1–6 1–6
3.9. Perceived control
3.10. Correlations between the theory’s components Medium positive correlations were found between all the theory’s components. Respondents’ behavioral beliefs and behavioral attitudes toward attending prenatal classes, normative beliefs and subjective norms, control beliefs and perceived control of attending classes were correlated with their intention to attend classes (Table 2). The more positive the women’s beliefs and attitudes toward prenatal classes, the more subjective social pressure they experience to attend classes, and the higher their perceived control of attending classes, the higher their intentions to attend prenatal classes. A medium positive correlation was found between respondents’ age and their behavioral intention to attend prenatal classes (r = .24, p < .05). The higher a woman’s age, the higher her intention to attend classes. A medium positive correlation was also found between years of education and intention to attend prenatal classes. More years of education was correlated with a greater intention to attend classes. The regression’s findings show that the theory’s power of prediction is R2 = 37% (p < .01). The factor with the most influence on respondents decision to attend prenatal classes is subjective
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4 Table 2 Correlations between the theory components (n = 200). Behavioral beliefs Behavioral beliefs Behavioral attitudes Normative beliefs Control beliefs Subjective norms Perceived control * **
Behavioral attitudes .325**
1 .325** .309** .225** .094 .206**
Normative beliefs .309** .356** 1 .056 .249** .098
1 .356** .135 .048 .175*
Control beliefs
Subjective norms
.225** .135 .056
.206** .175* .098 .202** .033
.094 .048 .249** .316**
1 .316** .202**
Perceived control
1 .033
1
Intention .372** .255** .465** .162* .378** .233**
p < .05. p < .01
norms, primarily the influence of their spouse (b = .299; p < .01) (Table 3). 4. Discussion The current study explored factors related to the intentions of Muslim Arab women in Israel to attend prenatal classes, using the TPB.12 The intention of Muslim Arab women in Israel to attend prenatal classes was found to depend on their beliefs and attitudes about prenatal classes, their control beliefs and perceived control, and the influence of significant others. The current study showed that the factor with the greatest impact on the intention of Muslim Arab women in Israel to attend prenatal classes was perceived social pressures applied by significant others. In the current study this refers to their spouse. The strong effect of significant others on Muslim Arab women’s health-related decisions has been documented in previous studies as well.7,10,11,21 The current study found that the most significant opinions influencing Muslim Arab women’s decision whether to attend prenatal classes were those of their spouse and primary nurse. Other factors influencing respondents’ intentions to attend prenatal classes in this study was their age and years of education, which was consistent with findings by Gagnon and Sandall metaanalysis studies looking at a variety of research on the impact of prenatal education courses and factors influencing women’s intention to attend have shown that intentions are higher among women who are older and more educated.5 This might be related to the fact that older pregnant women have more concerns and are more willing to receive medical information and guidance concerning their pregnancy and the baby.22 This is confirmed by a study that examined pregnant women in the UK, which found that young women and teenage girls are less aware of the potential and benefits of prenatal classes.4 Respondents’ perceived control of health decisions influenced their intentions to attend prenatal classes. Most respondents claimed that they have exclusive control over decisions involving their pregnancy, including the decision whether to attend prenatal classes. This is similar to findings by Nikie´ma et al., who performed
Table 3 Summary of regression analyses for variables predicting intentions to attend prenatal classes (n = 200). Variable Behavioral beliefs Behavioral attitudes Normative beliefs Subjective norms Control beliefs Perceived control R2 = 37%.
B
SE B .271 .047 .380 .332 .077 .194
.079 .070 .086 .069 .087 .062
b .218 .043 .286 .299 .056 .187
t
P
3.418 .669 4.404 4.786 .893 3.103
.001 .504 .000 .000 .373 .002
a cross-country analysis on data from the most recent demographic and health surveys of 19 Sub-Saharan African countries which demonstrated that women’s perceived control contribute to their own health and that of their child.22 The current study found several factors which may encourage Muslim Arab women’s intentions to attend prenatal classes. Respondents reported that it would be easier for them to attend prenatal classes if they were provided at an accessible location in their area of residence. At present almost no classes are given in Muslim Arab towns, and classes given in distant locations are not always easily accessible. Holding prenatal classes in Arabic may also encourage Muslim Arab women to attend. Most prenatal classes are conducted only in Hebrew and not in Arabic. This finding is consistent with that of Rassin et al., who studied a total of 126 Jewish and Arab-Muslim pregnant women to compare Jewish and Arab populations regarding pregnancy follow-up, compliance with a health regime and behavioral expressions during labor, delivery and the post-partum period. Their research found that Muslim Arab women do not attend prenatal classes due to language barriers.7 A considerable proportion of Muslim Arab women in Israel are not sufficiently fluent in Hebrew and lack confidence to attend prenatal classes conducted in Hebrew. Due to changes in Muslim Arab culture and society in Israel, many women no longer make do with information provided by their mother or mother-in-law. Instead they seek additional sources of knowledge on pregnancy and labor. The women in the current study stated that receiving information from relatives is not a barrier to attending prenatal classes. This finding indicates that modern views are gradually spreading among Israel’s Muslim Arab society. 4.1. Limitations The study has several limitations. Convenience sampling might limit the generalizability of the findings to Israel’s entire population of Muslim Arab women. In addition, as the study questionnaires were distributed and completed at public lectures on women’s health, only women who already utilized public health services participated in the study. This study examined intentions, and it is not clear whether women who declared their intention to attend prenatal classes would indeed do so. 4.2. Recommendations In order to increase the intentions of Muslim Arab women to attend prenatal classes, it is recommended to raise the awareness of such classes among the Muslim Arab sector, emphasizing their benefits for the mother, baby, and family. The primary nurse, who follows and guides women throughout their pregnancy, may constitute a valuable resource for Muslim Arab women in providing information about prenatal education and encouraging women to attend classes. Factors with the greatest influence on Muslim Arab women’s intention to attend prenatal classes are their
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significant others, and primarily the spouse. It is recommended that spouses also be approached with regard to encouraging their wife to attend prenatal classes. Classes should be held in Arab towns, in the Arabic language, and should reflect the uniqueness of Muslim Arab culture, with its combination of traditional and modern views. This should be stated in campaigns promoting prenatal classes. Likewise, Arabic language promotional campaigns should be designed to encourage both Muslim Arab women and their partners to participate in prenatal education classes. It is also necessary to further study the attendance of prenatal classes by this unique population. Future studies should use random sampling in order to reach different segments of women within the Muslim Arab sector. Further studies should also be conducted on factors facilitating women’s attendance of prenatal classes, in order to reach a deeper understanding of this practice. Additional recommendations for further study include examining the effect of opening prenatal courses in Arabic at an easily accessible geographical location on Arab Muslim women intention to attend these courses and examining the knowledge, attitudes and barriers of Muslim Arab women’s partners in regards to prenatal education classes. 5. Conclusion Research findings indicate that Muslim Arab women in Israel had relatively high intentions to attend prenatal classes. The influence of tradition on women’s intentions to attend classes remains significant and should not be disregarded, including the important role of the spouse in this decision. Several barriers to Muslim Arab women’s attendance of prenatal classes in Israel, such as geographical distance and language, are notable. Also, it is especially important for nursing and medical staff to develop transcultural sensitivity toward populations from different cultures, especially Muslim Arab women. Acknowledgments There has been no financial assistance with the research. References 1. Murphy Tighe S. An exploration of the attitudes of attenders and non-attenders towards prenatal education. Midwifery 2010;26(3):294–303. http://dx.doi.org/ 10.1016/j.midw.2008.06.005. 2. Escott D, Slade P, Spiby H. Preparation for pain management during childbirth: the psychological aspects of coping strategy development in prenatal education. Clin Psychol Rev 2009;29(7):617–22. http://dx.doi.org/10.1016/j.cpr. 2009.07.002.
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3. Fabian HM, Ra˚destad IJ, Waldenstro¨m U. Childbirth and parenthood education classes in Sweden. Women’s opinion and possible outcomes. Acta Obstet Gynecol Scand 2005;84(5):436–43. http://dx.doi.org/10.1111/j.0001-6349.2005.00732.x. 4. Ferguson S, Davis D, Browne J. Does prenatal education affect labour and birth? A structured review of the literature. Women Birth 2013;26(1):e5–8. http:// dx.doi.org/10.1016/j.wombi.2012.09.003. 5. Gagnon AJ, Sandall J. Individual or group prenatal education for childbirth or parenthood, or both. Cochrane Database Syst Rev 2007;3. http://dx.doi.org/ 10.1002/14651858.CD002869.pub2. 6. Ip WY, Tang CS, Goggins WB. An educational intervention to improve women’s ability to cope with childbirth. J Clin Nurs 2009;18(15):2125–35. http:// dx.doi.org/10.1111/j.1365-2702.2008.02720.x. 7. Rassin M, Klug E, Nathanzon H, Kan A, Silner D. Cultural differences in child delivery: comparisons between Jewish and Arab women in Israel. Int Nurs Rev 2009;56(1):123–30. http://dx.doi.org/10.1111/j.1466-7657.2008.00681.x. 8. Svensson J, Barclay L, Cooke M. The concerns and interests of expectant and new parents: assessing learning needs. J Perinatal Educ 2006;15(4):18–27. http:// dx.doi.org/10.1624/105812406X151385. 9. Svensson J, Barclay L, Cooke M. Effective prenatal education: strategies recommended by expectant and new parents. J Perinatal Educ 2008;17(4):33–42. http://dx.doi.org/10.1624/105812408X364152. 10. Azaiza F, Cohen M. Between traditional and modern perceptions of breast and cervical cancer screenings: a qualitative study of Arab women in Israel. Psychooncology 2008;17(1):34–41. http://dx.doi.org/10.1002/pon.1180. 11. Oweis A, Abushaikha L. Jordanian pregnant women’s expectations of their first childbirth experience. Int J Nurs Pract 2004;10(6):264–71. http://dx.doi.org/ 10.1111/j.1440-172x.2004.00488.x. 12. Ajzen I. The theory of planned behavior. Organ Behav Hum Decis Process 1991;50(2):179–211. http://dx.doi.org/10.1016/0749-5978(91)90020-T. 13. Carter-Parker K, Edwards KA, McCleary-Jones V. Correlates of physical activity and the theory of planned behavior between African American women who are physically active and those who are not. ABNF J: Off J Assoc Black Nurs Fac High Educ Inc 2012;23(3):51–8. 14. Griva F, Anagnostopoulos F, Madoglou S. Mammography screening and the theory of planned behavior: suggestions toward an extended model of prediction. Women Health 2010;49(8):662–81. http://dx.doi.org/10.1080/ 03630240903496010. 15. Jalilian F, Emdadi S. Factors related to regular undergoing Pap-smear test: application of theory of planned behavior. J Res Health Sci 2011;11(2):103–8. 16. Soskolne V, Marie S, Manor O. Beliefs, recommendations and intentions are important explanatory factors of mammography screening behavior among Muslim Arab women in Israel. Health Educ Res 2007;22(5):665–76. http:// dx.doi.org/10.1093/her/cyl132. 17. Ben Natan M, Golubev V, Shamrai V. Smoking during pregnancy: analysis of influencing factors using the Theory of Planned Behaviour. Int Nurs Rev 2010;57(3):388–94. http://dx.doi.org/10.1111/j.1466-7657.2010.00807.x. 18. Mutuli LA, Walingo MK. Applicability of Theory of Planned Behavior in understanding breastfeeding intention of postpartum women. Int J Multidiscip Curr Res 2014;2:258–66. 19. Swanson V, Power KG. Initiation and continuation of breastfeeding: theory of planned behaviour. J Adv Nurs 2005;50(3):272–82. http://dx.doi.org/10.1111/ j.1365-2648.2005.03390.x. 20. Symons Downs D, Hausenblas HA. Exercising for two: examining pregnant women’s second trimester exercise intention and behavior using the framework of the theory of planned behavior. Women’s Health Issues 2003;13(6):222– 8. http://dx.doi.org/10.1016/j.whi.2003.09.004. 21. Rabi U, Rudnitzky A. Women in Israel’s Arab Society. Tel Aviv: Tel Aviv University; 2011. [Hebrew]. 22. Nikie´ma B, Beninguisse G, Haggerty JL. Providing information on pregnancy complications during prenatal visits: unmet educational needs in sub-Saharan Africa. Health Policy Plan 2009;24(5):367–76.
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