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Content may be subject to copyright.
cns.sciedupress.com Clinical Nursing Studies 2018, Vol. 6, No. 1
ORIGINAL ARTICLE
Effectiveness of a structured teaching program on
anxiety and perception regarding toxoplasmosis among
seropositive pregnant women in Northern Upper Egypt
Hanan Elzeblawy Hassan∗
Faculty of Nursing, Beni-Suef University, Egypt
Received: July 13, 2017 Accepted: October 9, 2017 Online Published: October 20, 2017
DOI: 10.5430/cns.v6n1p1 URL: https://doi.org/10.5430/cns.v6n1p1
ABS TR ACT
Background:
Toxoplasmosis is a major opportunistic infection caused by single-cell protozoan from the Coccidia family.
Up to 95% of infected individuals remain asymptomatic, nevertheless, it may be a leading cause of foodborne illness-related
hospitalisation and death. Primo-infection can cross the placental barrier and cause life-threatening sequelae for the fetus leading
to miscarriage, hydrocephalus and, retinochoroiditis. Moreover, the infection may cause infertility, endometritis, and uterine
atrophy and, impaired folliculogenesis for the mother.
Aim:
To evaluate the effectiveness of an educational program on perception and anxiety level regarding toxoplasmosis among
seropositive pregnant women in Beni-Suef in Egypt.
Subjects and methods:
A quasi-experimental design was used with 50 seropositive pregnant women attending the inpa-
tient/outpatient antenatal care units. Tools: A structured knowledge questionnaire, pre-test/post-test/retained-test knowledge
assessment sheet and Zung’s self-rating anxiety scale.
Results:
Pre-program 96% of women scored poor knowledge and no participants (0.00%) reported severe anxiety; whereas,
immediately post-program 70% of women scored good knowledge and 84% reported severe anxiety. After implementation of the
program, all women (100%) gained a good knowledge score while 48% of them reported severe anxiety. Significant association
between mean knowledge scores and demographic variables (p< .0001) was found.
Conclusions:
Although the program is effective to enhance women’s perception regarding Toxoplasmosis, it exaggerated the
anxiety level for pregnant women. A negative association was found between women’s perception and anxiety level, however,
this relation was not significant.
Recommendations:
Implementation of health education programs aimed at primary prevention of toxoplasmosis is recommended
for all women of childbearing age.
Key Words: Perception, Toxoplasmosis, Anxiety, Structured educational program
1. INTRODUCTION
Toxoplasmosis is a ubiquitous protozoan parasite.
[1]
It is
one of the most common human zoonoses
[2]
and caused by
infection with the obligate intracellular protozoan parasite
Toxoplasma gondii (T. gondii),
[3]
that is estimated to infect
about a third of the world’s human populace causing a wide
range of health implications.
[1]
It is distributed in humans,
all warm-blooded animals including birds and mammals
throughout the world.
[4, 5]
The seroprevalence of human T.
gondii infection varies in different parts of the world and has
∗Correspondence: Hanan Elzeblawy Hassan; Email: nona_nano_1712@yahoo.com; Address: Faculty of Nursing, Beni-Suef University, Egypt.
Published by Sciedu Press 1
cns.sciedupress.com Clinical Nursing Studies 2018, Vol. 6, No. 1
been reported with rates up to 75%.
[6]
The infection is more
prevalent in humid and warm climates.
[7]
The prevalence
rate is also increased with age but doesn’t differ enormously
between the two sexes (females and males).
[2]
Moreover,
the disease is more common among those consuming under-
cooked meat.[7]
Toxoplasma is a single-cell protozoan that affiliates to the
Coccidia family. It is an obligatory intracellular protozoan
with a heterogeneous life cycle in humans and other ver-
tebrates.
[8]
Toxoplasma has double hosts and double life
cycles: (1) definitive hosts; a sexual cycle that take place in
the feline’s small intestine (cat) family;[2,9] (2) intermediate
hosts; an asexual cycle in infected warm-blooded animals,
including humans.
[2]
Most or all mammals and marsupials
can serve as intermediate hosts.
[10]
T. gondii exists in three
infective stages: (1) Tachyzoites, an invasive rapidly dividing
proliferative form of the parasite; (2) Bradyzoites, a slowly
dividing in tissue cysts, which can persist inside human cells
for protracted periods; and (3) Sporozoites, an environmental
stage, and the sporozoite, protected inside an oocyst.[2, 9]
Feline family (domestic and wild cats) are the only definitive
host in which sexual proliferation (oocysts are exclusively
produced) of the parasite occurs in the intestine, resulting in
the shedding of oocysts in their faeces into the environment,
thereby contaminating soil and water resources that become
infective a few days later.
[2, 11, 12]
One cat can shed up to
10 million oocysts/day, for up to 14 days, after the primary
infection. Shedding of oocysts depends on the source of
infection in that feline tainted by tissue cysts; oocysts are
shed by only 30% to 50% of infected cats.
[4]
Closing the
cycle, cats typically become infected when eating rodents
and/or birds that contain cysts.[11, 13]
Humans generally acquire T. gondii infection by four prin-
ciple routes as illustrated in Figure 1. The foodborne
route is important. Ingestion of tissue cysts by eating
raw/inadequately cooked infected meat or eating uncooked
foods that may be unintentionally contacted with contami-
nated meat.
[8, 11, 14, 15]
Also, the transmission of this parasite
occurs by the exposure to contaminated soil, drinking mu-
nicipal/well un-bottled and un-boiled water that contains
Sporozoites inside the oocysts. Exposure of children may
occur during their playtime in sand pits.
[16]
Animals are in-
fected by eating infected animals, by ingestion of or coming
in contact with infected cat faeces.
[9]
Cattle and other herbiv-
orous animals contract the infection from grass and pastures
contaminated with cats’ faeces.
[17]
Moreover, Tachyzoites
may be found in the milk from an intermediate host, includ-
ing cattle, sheep, and goats. Human cases have only been
linked directly to consumption of goat’s milk, although risk
factor studies have suggested an association with drinking
milk in Poland and with camel milk in the Sudan. Tachy-
zoites have been found in spit or sputum, saliva, urine, tears
and semen, and additionally in raw eggs from experimentally
but not naturally infected hens.
[4]
Humans can unintention-
ally ingest oocysts by ingesting water, soil, or food polluted
by feline faeces (cultivating, eating unwashed vegetables and
fruits, or cleaning a feline’s litter box).
[8, 13, 15]
The various
sources of food-borne and environmental contamination of
humans are represented in Figure 1.
[5]
Third, mother-to-child
transmission of the parasite occurs only when infection is
acquired for the first time during or just before to woman’s
pregnancy. Infection is thought to be transmitted to the baby
transplacentally or during vaginal birth.
[8, 13]
Fourth, blood
transfusion, bone marrow transplantation, organ transplanta-
tion or allogeneic stem cell transplantation from previously
infected donor to an uninfected person.
[9, 15]
The transmis-
sion of the T. gondii parasite may occur by sputum, breast
milk, and semen. Consequently, the disease can possibly
be transmitted via both oral and/or vaginal sex, significantly
more frequently from seropositive one to his passive sex
partner than vice-versa.[9]
Up to 95% of the cases of immunocompetent individuals in-
fected with toxoplasma protozoon remain asymptomatic
[14]
or have a subclinical course with minor symptoms because
their immune system keeps this protozoon from causing
illness. It is nevertheless the most common food-borne para-
sitic infection requiring hospital treatment and the third most
common indication for hospital admission due to food-borne
infection.[1, 9]
The vast majority of literature reported that 10% to 20%
of people infected with toxoplasmosis are symptomatic; in
spite of a survey of flare-ups of toxoplasmosis has suggested
that up to a further 50% may experience mild symptoms.
[4]
T. gondii protozoon can be categorized into four symptoms
groups: (1) cervical lymphadenopathy (T. gondii have been
estimated to cause 3%-7% of clinically significant cases
of lymphadenopathy). The infection is characterized by
non-specific symptoms. An infected individual can expe-
rience mild influenza-like symptoms that last for weeks to
months as headache, glandular fever or flu-like illness, sore
throat, low-grade fever, myalgia, and generalised malaise,
with possibility of brief erythematous (maculopapular) rash
and splenomegaly;
[3, 4, 9]
(2) typhus-like exanthematous form
with myocarditis, a typical pneumonia, meningoencephali-
tis, and potentially death; (3) retinochoroiditis, that may be
severe and requires enucleation; (4) central nervous system
(CNS) involvement. In addition, several reports suggest that
T. gondii disease might be responsible for an additional wide
variety of symptoms, and advancement of several clinical
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entities.
[9]
Immunocompromised people can face severe and
fulminating life-threatening symptoms, especially ocular tox-
oplasmosis (retinochoroiditis), pneumonia, and encephalitis.
In immunocompetent non-pregnant women, acute infection
may lead to uveitis, eye lesions, and impaired eyesight.[1,9]
Figure 1. Sources and cycle of Toxoplasma infection in humans[5]
Women who have already acquired their T. gondii infec-
tion before pregnancy, except if the women are immunosup-
pressed, are not at risk for delivering an infected baby.
[3]
Immunity usually prevents access of the pathogen to the
embryo, and it is viewed as defensive. Hence, preventive
efforts concentrate on seronegative women who can be recog-
nised from “immune” women, who will remain seropositive
throughout their childbearing lives.
[11]
Directly, three factors
are correlated with the incidence of congenital toxoplasmosis
in newborns, namely (1) the incidence of primary infection
in pregnant women; (2) the gestational week that the preg-
nant woman acquired the infection; (3) public health pro-
grams implemented for prevention, detection, and treatment
of the infection during pregnancy. However, several cases
of congenital infection are most likely not recognised as:
(1) the primary infection is related to no specific symptoms
in the great majority of individuals; (2) the infection might
be asymptomatic in newborns; (3) symptoms within the baby
might develop gradually and be non-specific; (4) difficulty
in the recognition of toxoplasma protozoa attributed to the
etiologic agent once symptoms eventually appear.[2]
It is crucial to detect infections throughout pregnancy while
they are still acute since it is usually throughout this pe-
riod that the expectant mother runs the risk of transmitting
the disease to her fetus.
[18]
Laboratory diagnosis, i.e. am-
niocentesis for PCR (polymerase chain reaction) and sero-
logic assays, plays the most important role in congenital
toxoplasmosis infection diagnosis as well as confirmatory
diagnosis of toxoplasmic encephalitis and ocular Toxoplas-
mosis.
[2]
Toxoplasma infection mainly relies on serological
tests. Serological tests help to determine whether the in-
fection was acquired in the distant past or recently. Many
serological tests are used for the detection of various antibody
classes, i.e. IgG, IgM, IgA, and IgE, in body fluids, mainly
serum. IgM antibodies are detectable about one week after
the onset of infection and persist for several months, though
they may remain detectable months or even years after the
acute infection. Serological screening of pregnant women
allows the detection of a recently acquired toxoplasma in-
fection and the implementation of chemotherapy in order to
prevent congenital infection and/or prevent sequelae in the
newborn.[2,13, 18] Case definition, proposed by the European
Published by Sciedu Press 3
cns.sciedupress.com Clinical Nursing Studies 2018, Vol. 6, No. 1
Research Network on Congenital Toxoplasmosis, based on
the probability of infection could be used for diagnosis and
serological evaluation of primo-infection (see Table 1).
[19, 20]
Other useful diagnostic tools to determine the infection of
the fetus are the PCR and ultrasound.
[13]
The PCR and/or
culture at 18-20 weeks’ gestation or if
≥
4 weeks after ma-
ternal infection.
[21]
The amplification of T. gondii DNA in
amniotic fluid should be done at 18 weeks of gestation or
later. If done at the 18
th
week, this test has an overall sen-
sitivity of 64%, a negative predictive value of 88%, and a
specificity and positive predictive value of 100%. Its sensi-
tivity and specificity for amniotic fluid obtained before 18
weeks of gestation have not been studied. In addition, the
procedure done early in pregnancy is associated with a higher
risk to the fetus and is likely less useful.
[13]
Concerning the
ultrasound, this procedure is recommended for women with
suspected or diagnosed acute infection acquired during or
shortly before pregnancy. It may reveal fetal morphology,
the presence of fetal abnormalities, including hydrocephaly,
CNS abnormalities, brain or hepatic calcifications, symmet-
ric fetal growth restriction, splenomegaly, ascites, and nonim-
mune hydrops.
[3, 13]
Additionally, placental examination can
aid with diagnosis of congenital toxoplasmosis if parasite
T. gondii has been isolated from specimens or if there are
histopathological findings suggestive of the infection.[18]
Toxoplasmosis may be a leading cause of foodborne illness-
related hospitalisation and death. T. gondii protozoon has an
adverse effect on both mother and fetus. Generally infants of
women who are seropositive before becoming pregnant are
not at risk.
[20]
Primary maternal infection (“primo-infection”)
with T. gondii protozoon during or just before pregnancy is
associated with a lack of protective immunity, the parasite
(T. gondii) might cross the placental barrier and may pass the
infection to the embryo and may cause health-threatening
sequelae for the fetus. The damage and abnormalities to the
unborn fetus depend on the gestational week; complicating
medical conditions are more common amongst seroconverted
women earlier in pregnancy. If the transmission occurs it
can lead to miscarriage, intrauterine fetal death (IUFD), and
stillbirth, pathophysiology of the CNS, such as cerebral and
intracranial calcification, microcephaly, hydrocephalus or a
child born with signs of Toxoplasmosis.
[14, 20, 22]
Although
infants who are infected during pregnancy often show no
symptoms at birth, they may develop symptoms later in their
life with potential retinochorioiditis, vision loss, seizures,
and convulsions. Moreover, psychomotor and mental impair-
ment may develop in the fetus leading to life-long disabilities
in children.[22, 23]
Table 1. The evaluation criteria for maternal serology
–
ӀgG
–
ӀgM
Seronegative patient
+
ӀgG
(< 200 UӀ)
–
ӀgM
Previous infection
+
ӀgG
+
ӀgM
+
IgΑ
ӀgG avidity < 15%
Acute infection
+
ӀgG
(> 300 UӀ)
+
ӀgM
–
IgΑ
Probably recent infection
+
ӀgG
(< 300 UӀ)
+
ӀgM
–
IgΑ
ӀgM chronic carrier
+
ӀgG
(> 300 UӀ)
–
ӀgM
–
IgΑ
ӀgG avidity > 30%
Probably reinfection
–
ӀgG
+
ӀgM
–
IgΑ
Natural ӀgM
Women can also be susceptible with a positive correlation
between chronic toxoplasma infection and infertility that
includes the development of endometritis and fetal rejec-
tion due to local release of T. gondii from latently located
cysts in endometrial tissue on stimulation during placenta
formation.
[24]
Uterine atrophy, impaired folliculogenesis in
the ovaries and reproductive failure due to hypothalamic
dysfunction as a result of chronic toxoplasmosis.[1]
Protozoan parasite Toxoplasma oocysts can be rapidly de-
stroyed by temperatures higher than 151
◦
F (66
◦
C), and can
also be killed with boiling water. The oocysts found in water
are resistant to chlorination but may be eliminated by filtra-
tion or boiling. Tissue cysts and Tachyzoites are inactivated
at PH < 4.0. Tissue cysts remain viable for approximately
10 minutes at 122
◦
F (50
◦
C) or 4 minutes at 140
◦
F (60
◦
C).
Additionally, freezing at 10
◦
F (12
◦
C subzero) for 2-3 days
may destroy a high percentage of the cysts.[10]
Primary prevention of T.gondii during pregnancy occurs
by preventive behavior directed to food hygiene. Women
should take precautions to avoid exposure to toxoplasmo-
sis by following the World Health Organization (WHO)
Five Keys to Safer Food.
[25]
Pregnant women should be
advised to; (1) Wear gloves when gardening, particularly
when handling soil and to wash their hands thoroughly af-
terwards with hot water and soap; (2) Avoid under-cooked
or, raw meat, particularly lamb, including any ready pre-
pared chilled meals. Cook all red meat until no trace of
pinkness remains and the juices run clear, and avoid tast-
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ing meat before it is fully cooked. Hand washing thor-
oughly after handling the raw meat and also all kitchen-
ware should be washed thoroughly after preparing raw meat;
(3) avoid sheep and their newborns during the lambing season
if the woman is at extra risk; (4) All fruits and vegetables, in-
cluding ready-prepared salads, should be thoroughly washed
with clean water before cooking and eating; (5) Avoid un-
pasteurised goat’s milk or products that are made from it;
(6) avoid handling or adopting stray cats; (7) avoid cat faeces
in soil or cat litter and wear gloves during changing a cat
litter tray, and if the woman is immune deficient or pregnant,
she should ask someone else to do this for her, wash hands
thoroughly afterwards, cats should be fed dried, or canned,
cat food, rather than raw meat.[20]
1.1 Significance of the study
Anxiety is common during childbearing years. The hormonal
changes during pregnancy may place additional stress on
women’s emotions, making them more vulnerable to anxiety.
Pregnancy is thus a period of potential stressor and relatively
a high-risk period for women with pre-existing a number of
psychological health problems which arise during or soon
after pregnancy.
[26–28]
Various situations and conditions can
increase the frequency and severity of the anxiety and preg-
nancy can often amplify this anxiety.
[29]
Some women are
worried about whether their babies are healthy (previous
pregnancy losses or fertility problems can make this an espe-
cially overriding worry). Anxiety during pregnancy may be
associated with a variety of adverse consequences in terms
of obstetric complications and pregnancy outcomes.
[27]
Preg-
nant women can become more anxious when an unexpected
threat occurs as invasion of any microorganism or parasite
such as T. gondii which could have an adverse effect on the
pregnancy outcome. As a result, women may experience
mood swings, a surge of energy and walking may become
more difficult.[30]
Worldwide, it is estimated that primary maternal T. gondii in-
fection occurs in 0.1% to 0.8% of pregnancies, resulting in 1
to 120 cases of congenital toxoplasmosis per 10,000 births.
[4]
Additionally, the WHO estimates that every year there are
over a million case of toxoplasmosis in the European region
caused by contaminated food.
[14]
A positive correlation be-
tween infertility and toxoplasmosis is shown. Using ELISA,
infertile women scored higher prevalence (15.9%) of IgG
antibodies than pregnant-puerperal (5.6%) ones. In Egypt, in
Dakhalia governorate, a statistically significant higher preva-
lence (p< .01) of protozoan parasite T. gondii infection was
found in infertile female patients (61.85%) in comparison
with the control group.[1]
1.2 Operational definitions
Perception: The English dictionary defines the word “percep-
tion” as the capacity for knowledge or insight and an insight
or point of knowledge.
[31]
While the definition stated by
the medical dictionary was the mental process of becoming
aware of or recognising an idea; primarily cognitive rather
than the affective or conative.[32]
Anxiety: Anxiety describes a state of the mind and expe-
rience of unpleasant effect which develops depending on
environmental stimulants that are perceived by the individu-
als as being dangerous or threatening when confronted with
specific situations, demands or a particular object or event.
[29]
1.3 Aim of the study
The aim of the current study was to evaluate the effectiveness
of a structured teaching program (STP) on perception and
anxiety levels regarding toxoplasmosis among seropositive
(IgG or IgM antibodies) pregnant women in northern Upper
Egypt. This general aim will be achieved by the following
specific aims:
(1)
Assess the prevalence of Toxoplasmosis (IgM and IgG
antibodies) among pregnant women in northern Upper
Egypt.
(2)
Assess the knowledge of toxoplasmosis among
seropositive (IgG or IgM antibodies) pregnant women.
(3)
Determine the level of anxiety among seropositive
IgG or IgM antibodies pregnant women with Zung’s
self-rating anxiety scale.
(4)
Implement a STP for pregnant women with toxo-
plasma seropositive IgG or IgM antibodies.
(5)
Evaluate the effectiveness of the structured educational
program on the women’s anxiety levels and knowledge
deficit regarding Toxoplasmosis among seropositive
pregnant women.
1.4 Research hypothesis
Hypothesizes formulated by the researcher for the current
study were:
(1)
After implementing the program, women’s percep-
tion regarding Toxoplasmosis will be improved. The
mean post-test/retained post-test knowledge scores of
seropositive (IgG or IgM antibodies) pregnant women
will be significantly higher than their mean pre-test
knowledge scores at a significant level 0.05.
(2)
The women’s anxiety levels will be alleviated after im-
plementing the program. The mean post-test/retained
post-test anxiety scores of seropositive (IgG or IgM
antibodies) pregnant women will be significantly less
than their mean pre-test anxiety scores at a significant
level 0.05.
Published by Sciedu Press 5
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(3)
There will be a significantly statistical association be-
tween knowledge score and anxiety scores, the higher
the knowledge, the lower the anxiety levels, at a sig-
nificant level 0.05.
(4)
There will be a statistically significant association be-
tween knowledge scores, socio-demographic and ob-
stetric variables at 0.05 level of significance.
2. METHODS AND SUBJECTS
2.1 Research design
A quasi-experimental design was used.
2.2 Setting
The data collection for this study took place in the inpatient
antenatal care units and outpatient antenatal clinics affili-
ated with all government hospitals in Beni-Suef city, Egypt,
namely:
(1) The University Hospital.
(2) Ministry of Health Public Hospital.
(3) Health Insurance Hospital.
2.3 Participants
All pregnant women who were positive IgG or IgM in their
serology for toxoplasmosis admitted in the inpatient antena-
tal care unit or attending the antenatal clinic in the previously
mentioned hospitals in Beni-Suef city from September 1
st
2016 to November 30
th
2016 were approached, using pur-
posive sampling technique. Of the invited women (70), 55
women agreed to participate.
(1) All subjects fulfilled the following eligibility criteria:
•
Women of Upper Egypt ethnicity above 18 years of
age.
•
Seropositive (anti-T. gondii or IgG antibodies) toxo-
plasmosis.
•
Pregnancy free from any complications, such as twins
or known congenital anomalies.
•Have not experienced any psychological treatment.
(2) Exclusion criteria:
•Women considering termination of pregnancy.
•
Women having conceived through in-vitro fertilisation.
•Women with significant comorbidities.
•
Women who have any medical, obstetrical or gyneco-
logical disorder associated with pregnancy.
•
Women who are have experienced any previous psy-
chological disturbance or treatment.
2.4 Assessment tools
Three tools were used for collecting the relevant data.
Tool (I): A structured knowledge questionnaire:
After reviewing the academic literature comprehensively
from electronic media, journals, published studies and books,
the researcher designed and developed an interviewing ques-
tionnaire sheet to assess women’s perception through evaluat-
ing knowledge about toxoplasmosis among seropositive (IgG
or IgM antibodies) pregnant women attending governmental
hospitals in Beni-Suef city. It consists of three sections:
Section (1) Demographics Questionnaire: It encompassed
socio-demographic characteristics of respondents containing
seven items (age, residence, type of family, level of edu-
cation, occupational status and if they were involved with
animal breeding including what types of animals).
Section (2): Obstetrical history and as gravidity, parity, num-
ber of previous abortion or stillbirth.
Section (3): Antenatal assessment sheet to assess antenatal
care during pregnancy.
Tool (II): Pre-test/post-test/retained-test knowledge as-
sessment sheet:
This sheet was distributed to all participant pregnant women
three times; before the program implementation (pre-test),
immediately after the program (post-test), and three months
after implementation of the program (retained-test). Knowl-
edge questionnaire of 45 items was designed by the re-
searcher, on two aspects with a total maximum score of
70 (see Table 2).
Table 2. Total scoring
Score
Good
≥ 75 % correct answer
52 to 70 marks
Satisfactory
≥ 50 % to < 75 % correct answer
35 to 52 marks
Poor
< 50 % correct answer
0 to 35 marks
Part (1): The first part was designed to assess the
women’s knowledge regarding Toxoplasmosis as the defini-
tion, causative organism, mode of transmission, risk groups,
life cycle, signs and symptoms, clinical diagnosis, complica-
tions, prevention, and treatment.
Scoring keys: Knowledge questionnaire of 25 items with
maximum score of 50.
0 = incorrect answer or don’t know.
1 = correct answer, but isn’t complete.
2 = complete and correct answer.
Part (2): The second part was designed to assess women’s
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knowledge regarding cultural habits regarding food and ad-
vice to consumers on toxoplasmosis and other foodborne
pathogens.
Scoring keys: Knowledge questionnaire of 20 items with
maximum score of 20.
0 = don’t know.
1 = know.
Tool (III): Zung’s self-rating anxiety scale:[33]
Standardized Zung’s self-rating anxiety scale is used to as-
sess the anxiety level. This scale includes 20 questions with
a total maximum score of 80. Some questions ask for the
information positively (15 positive statements) and others
negatively (5 negative statements). But in all cases, the symp-
toms severity is scored from 1 to 4.
1 = none or little of the time answer.
2 = some of the time answer.
3 = a large part of the time answer.
4 = the most or all of the time answer.
The total raw score was converted to an anxiety index (100-
point scale).
Thereby, Anxiety Index = (the raw score/80 total points)
×
100 OR anxiety index raw = raw score ×1.25
Total scoring of the pregnant women’s anxiety index (100):
< 45: Normal anxiety.
45 to 59: Minimal to moderate anxiety.
60 to 74: Marked to severe anxiety.
> 74 to 100 : Extreme anxiety.
2.5 Methods and phases of data collection
2.5.1 Validity & reliability of the tools
•
The tools were revised for their content validity by 5
experts in the field. They were senior staff members
with experience in obstetric & gynecological medicine,
maternity & gynecological nursing. The recommended
modifications were made.
•
The tool is reliable as reliability was assessed by Cron-
bach’s alpha coefficient test. The result of the test was
0.89.
2.5.2 Administrative approval
Official letters that described the objectives and the aim of our
study were directed from the Faculty of Nursing, Beni-Suef
University to the directorates of all previously mentioned
governmental hospitals in Beni-Suef city to obtain their per-
mission to collect the research subject from hospitals under
their directorate.
2.5.3 Ethical considerations
Verbal consent took from each participant before including
her in the study. They were informed that their participation
is totally voluntary, so they could withdraw from the study
whenever they decided. After taking consent from each par-
ticipant, the researcher introduced, clarified and explained
the purpose and all the objectives of the study. Total confi-
dentiality to obtain information, as well as respect for privacy,
was ensured.
2.5.4 Pilot study
A pilot study was done on five seropositive (IgG or IgM
antibodies) pregnant women. The results of the pilot study
revealed relevance, clarity, and applicability of the study
tools. Women involved in the pilot were excluded from
the study to avoid contamination of the study sample. The
necessarily required modifications were done.
2.5.5 Phases of field work
While 55 women agreed to participate in the program, sub-
sequently five women dropped-out during the study. So,
the study enrolled 50 pregnant women with positive IgG
or IgM serology for toxoplasmosis. Each participant took,
approximately, 15-30 minutes to complete the interview ques-
tionnaire. Four phases were adopted to fulfill the purpose
of the study as following mentioned: (1) assessment phase,
(2) planning phase, (3) implementing phase, (4) evaluation
phase. The four phases of data collection took 6 months
(from September 1, 2016, to February 25, 2017).
(1) Assessment phase:
The pre-test included assessment of perception and the anx-
iety level among the pregnant women with positive IgG or
IgM serology for toxoplasmosis, through structured knowl-
edge questionnaire and standardized Zung’s self-rating anx-
iety scale. The data obtained during this phase constituted
the baseline for further comparison to evaluate the effect
of the educational program. Each woman was interviewed
to collect socio-demographic data and obstetric and ante-
natal history and to assess their baseline knowledge about
toxoplasmosis.
(2) Planning phase:
After comprehensive reviewing of the relevant academic lit-
erature, from journals, magazines, books, bulletins and the
electronic media, the researcher developed a structured edu-
cational program that was administered at the end of the pre-
test. It contained the definition, causative organism, mode
of transmission, risk groups, life cycle, signs and symptoms,
clinical diagnosis, complications, prevention, and treatment.
Additionally, it contained cultural habits instructions regard-
ing food and advice to consumers on toxoplasmosis and other
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foodborne pathogens.
(3) Implementation Phase:
The design of the program was based on the pre-existing
women’s knowledge regarding toxoplasmosis. The program
consisted of five sessions, each session lasting 25-30 minutes.
It was facilitated by the head nurses from within the antenatal
outpatient clinic and inpatient department. They provided the
researcher with educational aid facilities as place and data
show. Additionally, they collected IgG or IgM seropositive
pregnant women and coordinated with them for attending
the program on Monday every week. Sessions were held in
facilities situated at the hospital. Each session provided a
combination of lectures, group discussion, and brainstorm-
ing which was delivered by the researcher (see Table 3). An
educational booklet was distributed to each participant in the
program. During the study period, a total of 5 courses (10-12
women involved in each course) were held once per week.
Table 3. Overview of the elements in the educational program about Toxoplasmosis (duration 2 hours, 30 minutes)
Session
Elements
Objectives
Method
Session no. 1
Opening Ceremony
1. Welcome
2. Presentation of program objectives.
3. Enumerate the participants' expectations.
4. Distribution of pre-test.
Discussion.
Session no. 2
Knowledge regarding
Toxoplasmosis
1. Define Toxoplasmosis.
2. Identify causative organism.
3. Enumerate mode of transmission.
4. Mention risk groups.
5. Describe life cycle.
Brainstorming.
PowerPoint.
Video.
Session no. 3
Knowledge regarding
Toxoplasmosis
1. List signs and symptoms.
2. Describe clinical diagnosis.
3. List complications for the mothers.
4. List complications for the fetus.
5. Identify methods of prevention and treatment.
Brainstorming.
lecture supported by
discussion.
Power Point.
Questions and answers.
Session no. 4
Knowledge regarding
cultural habits
instructions and food
advice to consumers on
toxoplasmosis and other
foodborne pathogens.
A. The recommended advice in relation to consumption and
preparation of food.
B. The recommended advice in relation to food storage.
C. The recommended advice in relation to personal hygiene.
D. The recommended advice in relation to cats care and
gardening.
Power point.
Group discussion.
Session no. 5
Closing
1. Participant’s evaluation of the program.
2. Distribution of Post-test.
Distributing educational
booklet.
Summary & Conclusion.
Thanks to all participants.
(4) Evaluation phase:
During this phase, the program was evaluated by using the
same previously formatted data collection tools. The im-
mediate evaluation after the program was conducted as a
post-test. Another evaluation subsequent follow-up phase
(retained-test) was scheduled; three months later.
2.5.6 Data snalysis
The data collected were categorised, arranged, tabulated,
coded, scored and analysed by the IBM, SPSS statistical
package version 20 (International Business Machines Corp.,
Armonk, NY, USA). The analysis took place after check-
ing data entry and correction for any errors including cat-
egorical variables such as parity, number of abortions and
stillbirths, occupation, educational level, residence and con-
tinuous variables as anxiety score, age, and gestational weeks.
Continuous variables were converted to categorical ones by
the author to achieve better analysis. The next mentioned
statistical tests were used:
Descriptive statistics:
•
Mean and standard deviations (X
±
SD) were used to
express the quantitative data.
•
Percentages and numbers (number and percent) were
used to express the qualitative data.
Inferential statistics: All tests were used as tests of signifi-
cance at p-value < .05.
•Marginal Homogeneity test.
•Student t-test.
•ANOVA test.
•LSD Post Hoc test.
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•Pearson correlation coefficient (r) test.
•
Colum, Pie and Bar chart diagrams were used to ex-
press the graphical presentation of the data.
3. RES ULTS
Based on data from seroprevalence, a total of 70 pregnant
women was positive IgM and IgG serology for toxoplasmosis
throughout three months; this would suggest that, annually,
there will be around 280 cases of seropositivity toxoplas-
mosis pregnant women. As 765 pregnant woman visited
antenatal outpatient clinics or were admitted to the inpatient
unit, seropositive IgG or IgM antibodies prevalence rate was
on average 9.2%. As all (70 positive IgG or IgM antibodies)
pregnant women had been invited, 55 women agreed to par-
ticipate in the program while the remaining ones declined. So
the participation rate was on average 78.6%. Subsequently,
five of interview questionnaires were excluded as it was in-
complete because those women didn’t come back to complete
the evaluation phase. Of the remaining 50 questionnaires, 39
(70.9%) were seropositive IgG, 5 (9.1%) were seropositive
IgM antibodies and 11 (20.0%) were seropositive IgM and
IgG antibodies.
The data presented in Figure 2 indicates that more than half
of the study sample (52.0%) was aged from 20-30 years old.
More than one third (38%) of the study sample had basic ed-
ucation, more than half (58% and 56%) were housewives and
lived in rural locations, respectively. The majority of them
(90%) live with extended family. All of them bred animals
in their houses, 68% bred farm animals such as sheep, cattle,
goats and horses.
Figure 2. Socio-demographic characteristics of the study sample
Figure 3 illustrates the distribution of pregnant women with
seropositive IgM and IgG antibodies regarding to their obstet-
ric history. Fifty-six percent were multigravida and 52.0%
were in the 1
st
trimester, 28.0% in the 2
nd
trimester, while
20.0% in the 3
rd
trimester. Forty percent of the study sample
had no previous history of abortion and/or stillbirth while
more than half (60.0%) of sample had experienced a previous
abortion.
For women’s commitment to antenatal follow-up schedule
appointment and number of visits, Figure 4 illustrates that
all of study sample (100%) didn’t follow the recommended
antenatal schedule. Additionally, the majority (90%) didn’t
follow the recommended number of visits (
≥
5 visits) pre-
scribed by WHO in their pregnancies, only 10% of women
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visited to receive antenatal care unit
≥
5 times. Most (58%)
of the pregnant women took advice and knowledge from
their relatives, while only 22.0% of them took their advice
from medical staff.
Table 4 shows that in the pre-test the majority of the pregnant
women (96%) had poor knowledge and (2%) had satisfactory
and good knowledge scores whereas; in the post-test (70%)
of them had good knowledge and (20%) had poor knowl-
edge. Additionally, in the follow-up test, that assessed re-
tained knowledge, all of studied sample (100%) gained good
knowledge scores. By Marginal Homogeneity test, highly
statistically significant difference was found between the
three evaluations (pre/post, post/retained and pre/retained) of
assessments at p-values < .0001.
Table 5 reveals that in pre-test the majority of pregnant
women (54%) had normal level of anxiety while no one
(0.0%) had marked to severe anxiety scores. On the contrary,
in the post-test the majority of them (84%) had marked to se-
vere anxiety while no one (0.0%) had normal anxiety scores;
whereas in the retained-test, the majority (50%) had mini-
mal to moderate anxiety while 48% had marked to severe
anxiety scores. Marginal Homogeneity test revealed highly
statistically significant difference between the three times
(pre/post, post/retained and pre/retained) of assessments at
p-values < .0001.
Figure 3. Obstetric history of the study sample
Figure 4. Commitment to antenatal follow-up schedule appointment and number of visits
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Table 4. Distribution of knowledge level among the studied seropositive toxoplasma pregnant women
Knowledge level
Studied seropositive toxoplasma pregnant women (n = 50)
Sig
(pre/post)
Sig
(post/retained)
Sig
(pre/retained)
Pre-test
Post-test
Retained-test
No.
%
No.
%
No.
%
Poor (< 50%)
48
96.0
10
20.0
0
0.0
Satisfactory (50%-75%)
1
2.0
5
10.0
0
0.0
< .0001*
< .0001*
< .0001*
Good (> 75%)
1
2.0
35
70.0
50
100.0
Note. Sig: p-value for Marginal Homogeneity test; *significant at p ≤ .05
Table 5. Distribution self-retailing anxiety level among the studied seropositive toxoplasma pregnant women
Self-retailing anxiety
scale
Studied seropositive toxoplasma pregnant women (n = 50)
Sig
(pre/post)
Sig
(post/retained)
Sig
(pre/retained)
Pre-test
Post-test
Retained-test
No.
%
No.
%
No.
%
Normal level of anxiety
27
54.0
0
0.0
1
2.0
Minimal level : moderate
level of anxiety
23
46.0
8
16.0
25
50.0
< .0001*
< .0001*
< .0001*
Marked level : severe
level of anxiety
0
0.0
42
84.0
24
48.0
Note. Sig: p-value for Marginal Homogeneity test; *significant at p ≤ .05
Table 6 presents the correlation between the knowledge score
of the studied seropositive toxoplasma pregnant women and
self-retailing anxiety scores. Pearson correlation coefficient
test (r) revealed that, the high knowledge score result to
higher anxiety level score, despite, no statistically significant
difference was found between the two mentioned variables.
Table 6. Correlation between knowledge and self-retailing
anxiety scores among the studied seropositive toxoplasma
pregnant women
Anxiety score
Pre-program
Post-program
Retained
г
р
г
р
г
р
Knowledge
score
0.248
.083
0.275
.053
- 0.163
.258
Note. r: рearson correlation coefficient
Table 7 reveals that all women achieved better mean
knowledge scores, progression of good scores and regres-
sion of poor ones, after implementing the program (post-
test/retained-test) than before it (pre-test), regarding all men-
tioned items of the demographic characteristics. There is a
statistically significant association between pre-test mean
knowledge scores and demographic (age, education and
occupation) variables. Moreover, a significant association
between post-test knowledge scores and education and oc-
cupation was observed whereas; no significant association
between retained-test knowledge scores and demographic
variables (p-values < .0001).
Relation between knowledge score and obstetrical history
and antenatal visits among the studied seropositive toxo-
plasma pregnant women, is revealed in Table 8. The high-
est mean knowledge scores, in pre-test (25.9
±
14.2), was
observed among 1st trimester pregnant women. While in
post-test (78.6
±
4.2) and retained-test (93.4
±
3.1) the
highest mean score was observed in 3
rd
trimester. ANOVA
test revealed statistically differences between pre-test mean
knowledge scores and women’s gestational weeks (F = 4.47,
p= .017). Moreover, between the women’s history of
abortion/stillbirth and the mean knowledge scores of pre-
test (F = 28.899, p< .0001) and post-test (F = 21.869,
p< .0001). Finally, Student t-test finds no significant relation
between neither gravida, nor number of antenatal visits and
women’s mean knowledge scores at all times during program
(pre/post/retained).
4. DIS CU SS IO N
Many previous studies have shown the adverse effects of ma-
ternal psychological state on pregnancy outcomes. Given the
potentially high prevalence of anxiety during pregnancy,
[34]
trait anxiety arises in response to a perceived threat. Anxiety
is a normal response to threat or danger and part of the usual
human experience, but it can become a mental health prob-
lem if the response is exaggerated and interferes with daily
life.
[28]
In the developing countries, various infectious agents
encountered during pregnancy are important because they
threaten both fetal and maternal health. Pregnancy-related
physiologic changes suppress immunity for a certain pe-
riod and thereby enhance susceptibility to infectious agents.
Among these, the prevalence of T. gondii is a very high and
they may cause congenital malformations (21% of abnormal
embryos) in the fetus by crossing the placental barrier.
[22, 35]
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Table 7. Relation between knowledge score (%) and socio-demographic characteristics among the studied seropositive
toxoplasma pregnant women different timings of the program (n = 50)
Socio-demographic
characteristics
n
Knowledge score (%) seropositive toxoplasma pregnant women (n = 50)
Pre-test
Post-test
Retained-test
Mean ± SD
Significance
LSD Post Hoc test
Mean ± SD
Significance
LSD Post Hoc test
Mean ± SD
Significance
LSD Post Hoc test
Age (years)
(1) Less than 20
10
11.0 ± 3.4
F = 4.469
73.6 ± 24.2
F = 1.023
91.4 ± 3.1
F = 0.239
(2) 20-<30
26
26.0 ± 14.3
p = .017*
67.9 ± 25.4
p = .367
90.4 ± 3.9
p = .788
(3) 30 or more
14
24.6 ± 16.9
1.2* 1.3*
79.6 ± 5.2
90.6 ± 3.2
Educational level
(1) Illiterate or read and write
14
10.1 ± 4.1
F = 28.899
44.6 ± 26.2
F = 21.869
90.7 ± 2.9
F = 0.285
(2) Basic (Primary/preparatory)
19
19.3 ± 10.9
p < .0001*
81.7 ± 6.3
p < .0001*
90.6 ± 3.1
p = .836
(3) Secondary/ Technical
15
33.5 ± 7.5
1.2* 1.3* 1.4*
82.0 ± 6.9
1.2* 1.3* 1.4*
90.5 ± 4.7
(4) University graduate or higher
2
60.0 ± 22.6
2.3* 2.4* 3.4*
93.0 ± 4.2
93.0 ± 1.4
Occupational status
(1) House wife
29
16.9 ± 9.1
F = 15.649
67.2 ± 22.0
F = 4.424
90.8 ± 3.6
F = 0.199
(2) Governmental employee
13
38.2 ± 17.1
p < .0001*
86.8 ± 5.8
p = .017*
90.9 ± 3.0
p = .820
(3) Worker on daily wages
8
17.8 ± 8.9
1.2* 2.3*
64.5 ± 31.7
1.2* 2.3*
90.0 ± 4.4
Note. F: ANOVA test; *significant at p ≤ .05
Table 8. Relation between knowledge score (%) and Obstetrical and antenatal visits among the studied seropositive
toxoplasma pregnant women different timings of the program (n = 50)
Obstetrical characteristics
n
Knowledge score (%) seropositive toxoplasma pregnant women (n = 50)
Pre-test
Post-test
Retained-test
Mean ± SD
Significance
LSD Post Hoc test
Mean ± SD
Significance
LSD Post Hoc test
Mean ± SD
Significance
LSD Post Hoc test
Gestational weeks/Trimester
(1) First Trimester
25
25.9 ± 14.2
F = 4.47
67.8 ± 25.3
F = 1.023
90.8 ± 3.9
F = 0.239
(2) Second Trimester
14
24.6 ± 16.9
p = .017*
74.6 ± 25.2
p = .367
90.5 ± 3.3
p = .788
(3) Third Trimester
11
12.0 ± 4.4
1.3* 2.3*
78.6 ± 4.2
93.4 ± 3.1
History of previous abortion/stillbirth
(1) ≥ 3
3
61.0 ± 22.6
3.4* 1.4* 1.3*
94.0 ± 4.2
94.0 ± 1.4
(2) Twice
13
9.1 ± 4.0
F = 28.899
44.1 ± 25.2
F = 21.869
90.1 ± 2.8
F = 0.285
(3) Once
14
33.5 ± 7.5
2.4* 2.3* 1.2*
82.0 ± 6.8
2.4* 2.3* 1.2*
90.4 ± 4.7
p = .836
(4) Non
20
19.1 ± 10.8
p < .0001*
81.3 ± 6.1
p < .0001*
90.8 ± 3.1
Gravida
(1) Multigravida
28
25.2 ± 14.9
t = 1.430
76.6 ± 18.2
t = 1.730
90.8 ± 3.8
t = 0.173
(2) Primigravida
22
19.3 ± 14.1
p = .159
65.7 ± 26.3
p = .090
90.6 ± 3.2
p = .863
Number of antenatal visits through pregnancy period
(1) < 5 visits
45
22.0 ± 14.4
t = 0.861
71.6 ± 22.8
t = 0.182
90.7 ± 3.5
t = 0.053
(2) ≥ 5 visits
5
28.0 ± 18.3
p = .393
73.6 ± 22.7
p = .856
90.8 ± 4.1
p = .958
Note. t: Stuԁent t-test; F: ANOVA test; *significant at p ≤ .05
Toxoplasmosis is a preventable disease and is becoming a
worldwide health hazard as it infects 30% to 50% of the
human population.[9, 36] It is well documented that toxoplas-
mosis is of crucial importance due to cosmopolitan distribu-
tion and a wide range of diseases it causes. It is known that
toxoplasmosis has an unfavorable impact on the reproductive
capacity of both men and women. Congenital toxoplasmosis
results from maternal exposure to infection for the 1
st
time
during pregnancy may lead to serious complications such
as stillbirth, prematurity, miscarriage (24.2% of stillbirths
and miscarriages have been related to T. gondii) or the birth
of a baby with neurologic defects. Infants with congenital
toxoplasmosis are mostly asymptomatic at birth, but long-
term studies indicate that up to 85% of all infants develop
sequelae including chorioretinitis leading to severe vision
impairment, hearing loss or psychological impairment.[1, 37]
In Egypt, the majority of T. gondii infection studies em-
phasized Lower Egypt (Dakhalia governorate),
[1, 12]
Alexan-
dria governorate,
[38]
Menoufia governorate,
[39]
Zagazig,
[40]
Tanta
[41]
and Qualyobia Governorate,
[42]
and only one dis-
cussed Upper Egypt (El Fayoum Governorate).
[43]
Nearly all
of the previously mentioned studies that addressed toxoplas-
mosis emphasised diagnosis, the prevalence, and complica-
tions of infection, association between it and other health con-
ditions and its determinant factors; while none have reported
related preventive measures. Moreover, studies that assessed
the pregnant women’s perception regarding this opportunis-
tic infection and state of toxoplasmosis-related anxiety level
in Northern Upper Egypt don’t exist, such data are needed
for initiating an educational health program, thereby, helping
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in the control measures against congenital toxoplasmosis,
especially in the absence of a routine serological screening
program. Beni-Suef governorate is a fertile agricultural land,
in addition to that, most of its population working in agri-
culture activities and most of them raise and breed birds and
animals, making it suitable soil for the spread of T. gondii
infection. As toxoplasmosis is a preventable disease by fol-
lowing the WHO Keys to Safer Food and the prevention is
primarily directed towards health education related to avoid-
ing personal exposure to the parasite. Thus, the present study
is very important as it was directed to assess the prevalence
of Toxoplasmosis (IgM and IgG antibodies) and associated
factors as well as anxiety among seropositive IgM and IgG
antibodies pregnant women in Beni-Suef. Consequently, de-
velop and evaluate the effect of attending a structured educa-
tional program for these women to enhance their Perception
and reduce their anxiety level regarding toxoplasmosis.
The overall laboratory findings showing diagnostic evidence
of an anti-T. gondii IgG antibodies of Toxoplasma at a preva-
lence rate of 23%, emphasised the scope of infection in a
community, and it explained the heavy burden of morbidity
due to this parasitic disease.
[3]
The current study illustrated
that 9.2% of pregnant woman, attending antenatal outpa-
tient clinics or admitted in inpatient units, were seropositive
IgM and IgG antibodies. This is similar to the findings of
Saadatnia et al. who reported that as a minimum a third of
the world human population is infected with the protozoan
T. gondii, making it one of the most successful parasitic
infections.
[2]
Advisory Committee on the microbiological
safety of food documented a study in England that yielded
a low rate (0.023%) of seroconversion during pregnancy.
[4]
Based on data from other countries suggesting that transmis-
sion occurs in 30%-40% of cases, this would endorse that
there are around 40 to 60 cases of congenital toxoplasmo-
sis annually.
[4]
Additionally, several studies conducted in
Brazil have found seroprevalence rates varying from 42% to
90%.
[18]
Conversely Tekkesin (2012) reported that, although
congenital toxoplasmosis is not a nationally reportable dis-
ease, extrapolation from regional studies indicates that an
estimated 400: 4,000 cases occur in the United States each
year.
[3]
Additionally, in Australia, primary infection with
toxoplasmosis during pregnancy is rare.[20]
Based on the prevalence rate and history of infection, the
study showed that 20% of the studied sample was seroposi-
tive IgM and IgG antibodies, while 70.9% were seropositive
IgG and 9.1% were seropositive IgM antibodies. These re-
sults are similar to some Egyptian national findings whilst
dissimilar to others. The prevalence of IgG antibodies among
pregnant women in Menoufia was 67.5%.
[39]
This high preva-
lence of anti-toxoplasmosis IgG antibodies may be due to
agricultural activities, women drinking insufficiently treated
water or unboiled milk, and exposure to risk factors includ-
ing contact with cats, eating insufficiently cooked/raw meat
like shawarma (roasted meat, especially when cooked on a
revolving spit and shaved for serving in sandwiches) and
eating raw unwashed vegetables. Another Egyptian gover-
norate recorded a lower percentage of anti-toxoplasmosis
IgG antibodies in pregnant women. The prevalence of IgG
antibodies among pregnant women in Dakhalia governorate,
Mansoura University Hospital was 44%.
[1]
A similar percent-
age (45.8%) was reported by El Fayoum Governorate
[43]
and
Alexandria governorate (46.2%).
[38]
This may be attributed
to the difference in diagnostic tests, sample size, characteris-
tics of the population in each governorate and their exposure
to relevant risk factors.
Seropositive pregnant women’s knowledge about Toxoplas-
mosis showed; the pre-test revealed that the majority (96%)
of women had a poor knowledge score before the impli-
cation the program (pre-test). The majority of the study
subjects were unfamiliar with the definition of toxoplasmo-
sis, causative organism, and mode of transmission, life cycle,
risk groups, clinical picture, maternal/fetal complications,
and preventive measures. This knowledge deficit may be
attributed to the low educational level as most of the study
sample (66.0%) had a low level of education; 28.0% of the
women were illiterate or could just read and write, while
38.0% of them had only acquired a basic level of education.
Moreover, more than half (58.0% and 56.0%) were house-
wives living in rural areas. Such women will usually become
pregnant early in their marriage in Egypt, especially in rural
and upper Egypt. Therefore, they are considered a high-risk
group for congenital toxoplasmosis, if they seroconvert in
the pregnancy period.[44]
While assessing the effectiveness of the structured program
on participants’ perception regarding Toxoplasmosis, data
analysis revealed that 70% of women had good knowledge
scores after implementation of the program (post-test). Addi-
tionally, the entire study sample (100%) gained good knowl-
edge in the retained-test. The results of Marginal Homogene-
ity test showed a significant gain in the women’s knowledge
(p< .0001). This improvement was also maintained by the
follow-up test. This improvement in women’s perception
may be a result of the women’s keenness to attend all pro-
gram sessions and positive reinforcement or the long-term
retention of knowledge. In this respect, Masters
[45]
and Yeh
et al.
[46]
have said that people will remember about 10%
of what they hear, and about 20% of what they read. On
the other hand, higher scores from the post and retained
knowledge tests may be due to wide varieties of educational
methods used such as audiovisual materials, videos, lectures,
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and discussion as well as an Arabic booklet which was dis-
tributed at the end of sessions to be available to them to take
home. This is in line with Edgar Dale’s or the NTL’s Pyramid
of Learning,
[45]
as the pyramid illustrated that individuals
can retain 10% of what they read and 20% of what they
see and hear (audiovisual). People can retain 50% of what
they learn by discussion.
[45, 47]
In the same line, 63% reduc-
tion in toxoplasmosis seroconversion and health education
in a Belgian study, reinforcing the importance of providing
health education as a tool in the prevention of congenital
toxoplasmosis. It is important that the educational materials
be complete and accurate and that they are made available in
a culturally and linguistic appropriate format.[48, 49]
When searching for a relationship between the knowl-
edge score and sociodemographic characteristic criteria for
seropositive T. gondii pregnant women, the study findings
revealed that those pregnant women exhibited higher mean
knowledge scores of post/retained test at all parameters of
sociodemographic (age, level of educational, occupational
status). Moreover, a clear positive relationship between
women’s mean knowledge score and age (pre-test), educa-
tional level (pre-test and post-test) and occupational status
(pre-test and post-test) was found.
In the majority of the human populations, the parasite sero-
prevalence increases with age.
[9]
According to seropreva-
lence results in our study, we found the prevalence of seropos-
itivity T. gondii in the middle age group (20-30 years) was
more than other age groups reporting 52%. Although this
result was similar to Flegr’s findings
[9]
who reported that,
most of the published data (from 88 countries) on seropreva-
lence are in females of childbearing age and/or those who
are pregnant. The findings challenged the results of the study
performed by the Advisory Committee on the microbiologi-
cal safety of food
[4]
who declared the variation in T. gondii
seropositivity with age in a number of countries. In Japan,
seropositivity of anti T. gondii antibodies in (20-29 year)
age group was 3%, increasing to 40% in those over 70 years
of age. In the Netherlands, seropositivity the anti-T. gondii
antibodies range from 20% at 25 years of age to 60% at 50
years. Wales estimated 22% seroprevalence in females of
childbearing age while in East of England it was ranging
from 8%-10%. However, a prevalence of 50% has been
recorded in the over 50s.[4]
In our study, we found that the pregnant women with mid-
dle age group (20-30 years) were more knowledgeable to-
wards toxoplasmosis. Preprogram, the mean score of knowl-
edge (26.0
±
14.3) in women aged 20-30 years was higher
than other age groups. Furthermore, the results illustrated
that, the older the woman, the greater the degree of reten-
tion of the information. The study findings showed that
women aged 30-36 years, both mean retained-test knowl-
edge score (90.6
±
3.2) and post-test knowledge score
(79.6
±
5.2) are higher than the mean pre-test knowledge
scores (24.6
±
16.9). The results revealed that age had an
influence on acquiring knowledge.
It is logical and generally accepted that seropositive cases
for toxoplasmosis are influenced by residence, lifestyle, geo-
graphic and hygiene as well as socioeconomic conditions of
the population because they create an opportunity for women
to be exposed to parasite infection.
[44]
Only 4.0% of the study
sample had university graduate education, 30.0% secondary
or technical and all remaining (66.0%) had unsatisfactory
level of education. Moreover, 56.0% of the women were
living in rural areas and all of them (100.0%) were breeding
birds and animals in their homes. All these characteristics ex-
pose women to risk factors and make them more vulnerable
to infection. Other research has shown that lower levels of
education, poor hygiene, and, a lower socioeconomic status
may contribute to a higher rate of infection.[9]
T. gondii IgG antibodies vary between 1% to 100% depend-
ing on socioeconomic conditions,
[50]
other report indicated
that seropositivity being highest in rural and lowest in urban
areas.
[4]
Seroprevalence toxoplasmosis differences in rural-
urban can be explained by the differential distribution of risk
factors including frequent consumption of non-washed or
raw fruit or vegetables, unfiltered municipal water, unpas-
teurized milk, and soil contact.
[51]
A higher number of cats
in rural areas, especially inside houses, may be responsible
for the higher difference in rural localities.[52]
The study findings illustrated that educational level influ-
enced women’s mean score of knowledge, the higher the
level of education, the higher the degree of information re-
tained. Consequently, by the higher mean score of knowledge
before the program as well as influence women’s perception
and improve women’s mean score of knowledge at dimen-
sions of the post, retained-tests. These findings are similar to
other authors who reported that educational level affects the
learning process, the higher the persons’ level of education
the more likely they were to receive information.[47,53]
Occupational status may also contribute to exposure to cer-
tain strains of Toxoplasma which may also lead to a higher
rate of infection.
[9]
The women’s occupational status re-
vealed that 58.0% of the women were housewives and were
breeding birds and animals in their homes. As mice destroy
crops, most of the families, especially in rural areas and
working in agriculture activity, rear cats to fight rodents and
mice, hence the importance of providing health education
about meat-cat-soil-related hygiene.
[48, 49]
Sixteen percent of
14 ISSN 2324-7940 E-ISSN 2324-7959
cns.sciedupress.com Clinical Nursing Studies 2018, Vol. 6, No. 1
the sample was workers on daily wages (farmers, agriculture
activity and gardening, slaughterhouses). There is an associ-
ation between occupational status and exposure to infection,
as these women were in frequent contact with cat faeces
(directly and/or indirectly through the soil). The women
may also drink contaminated water or eat contaminated raw
vegetables or fruits.
[12, 20]
Another study in Egypt has found
that 19.2% of workers in slaughterhouses at Zagazig were
seropositive for T. gondii antibodies. Moreover, indirect hem-
agglutination test (IHAT) was positive in 52.4% of Tanta
abattoir workers.[37]
There is a relationship between women’s occupation and
their mean knowledge score. Findings showed that the
highest mean score of knowledge was portrayed by em-
ployed women at all parameters of the program; pre-test
(38.2
±
17.1), post-test (86.8
±
5.8) and retained-test
(90.9
±
3.0). It is expected as employees had more chances
for communication and contact as well as exchange knowl-
edge and experience with professional ones. A statistically
significant difference was found among participants’ occu-
pational status and their mean knowledge score in pre-test
(p< .0001) and post-test (p= .017).
Statistical analysis of the results of our study revealed a rela-
tionship between acquired mean knowledge score for women
with seropositive IgG and IgM antibodies and other related
obstetric and antenatal care parameters including gravida,
gestational age, history of previous abortion or stillbirth, and
the number of antenatal visits. Additionally, significant re-
lationship between women’s mean knowledge score and a
gestational age (pre-test), and history of abortion or stillbirth
(pre-test and post-test) was found.
In relation to women’s gestational weeks/trimester, the re-
sults showed that more than half (52%) of the study subjects
were in the first trimester, 28.0% in the second trimester and
20% in the third trimester. As 9.1% of the study subjects
were seropositive IgM antibody and 20.0% consider chronic
carriers (seropositive IgM and IgG antibody), it is very im-
portant to implement the program to protect mother-to-child
transmission through the placenta and prevent complications
of infection.
The level of risk varies depending on the mothers’ gestational
age at which they acquire the infection as the lowest is in the
first trimester and greatest in the third trimester.[18]
The rate of fetal transmission of T. gondii parasite during
frist infection is 60% to 65% in the third trimester, while
the incidence of severe fetal infection falls from 75% to a
negligible risk in late pregnancy, 30% to 54% in the second
and 10% to 25% in the first trimester.[13,44]
The highest mean knowledge score observed among preg-
nant women in the first trimester in pre-test (25.9
±
14.2).
Moreover, in post-test (78.6
±
4.2) and retained-test (93.4
±
3.1) the highest score was observed in the third trimester.
This may due to the fact that, in the first trimester pregnant
women will be more anxious and worry about their preg-
nancy, hence, it gives more opportunities for women to ask,
attend and read about pregnancy. A significant relationship
was observed between mean knowledge score and gestational
age (p= .017).
In the developing countries, many gynecologists considered
toxoplasmosis as the primary cause of bad obstetrical out-
comes; this is viewed by the public and had created a panic
reaction among all population, generally, and women, es-
pecially.
[54]
The seroprevalence of T. gondii infection in
females who have a poor obstetric history (sporadic and/or
habitual abortions) is known to be significantly higher than
those without it.
[8]
The findings illustrated that 60.0% of
seropositive T. gondii women had previous history of abor-
tion or stillbirth (28.0% once, 26.0% twice, and 6.0% had
previous three or more abortions/stillbirth). This result is
similar to another Egyptian study that revealed a significant
IgM and IgG toxoplasma antibody level difference between
the control group and women who had more than three abor-
tions, women aborted once or twice, and women had no
history of abortion.
[55]
At Al-Shifa hospital, a study included
aborted women (312) who attended antenatal clinic revealed,
seropositive IgM antibodies were found to be 12.8% and
Toxoplasma IgG antibodies were found to be 17.9%.
[8]
Ad-
ditionally, a statistical difference between seropositive IgG
antibody levels against toxoplasma in habitual abortions as
compared to normal pregnancies or sporadic abortions was
in an Indian study.[8]
The better mean knowledge scores (pre-test; 61.0
±
22.6, and
post-test; 94.0
±
4.2), was reported by women who aborted
trice or more. This may be attributed to women with poor
obstetrical history attributed abortion, stillbirth and IUFD
to toxoplasmosis and hence ask about causes and seek care
for investigating and even treatment of toxoplasmosis with-
out physician referral. The previous notion may explain the
effect of poor obstetrical history in the form of repeated mis-
carriage and/or stillbirth on the state of women’s perception
as revealed from the current study. Our study revealed a
significant difference between women’s (pre-test; p< .0001
and post-test; p< .0001) mean knowledge score and their
history of abortion or stillbirth.
The results of the current study revealed that more than half
(56.0%) of the study sample was multigravida, while the
remaining (44.0%) was primigravida. Statistical analysis of
Published by Sciedu Press 15
cns.sciedupress.com Clinical Nursing Studies 2018, Vol. 6, No. 1
the results of previous studies revealed no significant relation-
ship between IgM and IgG antibodies and women’s gravidity
(multigravida or primigravida).
[37]
There was no observed
statistically significant difference between the women’s mean
score of knowledge amongst those seropositive T. gondii an-
tibodies pregnant women in relation to their gravidity, the
results showed that, multigravida women scored a higher
degree of knowledge at all parameters of the study; pre-
test (25.2
±
14.9), post-test (76.6
±
18.2), retained-test
(90.8
±
3.8) compared to primigravida women; pre-test
(19.3
±
14.1), post-test (65.7
±
26.3), retained-test
(90.8
±
3.8). This better score among multigravida women
may due to their previous history of abortion or exposure
to infection as well as attendance to antenatal health classes
during antenatal visits.
Regarding antenatal care visits, the results of the study
revealed that all pregnant women (100.0%) did not fol-
low the recommended antenatal schedule visits. Moreover,
only 10.0% of women attended the recommended number
(
≥
5 visits) of antenatal visits from WHO while the majority
(90.0%) did not. Antenatal visits give health care providers
an opportunity for recommended number (
≥
5 visits) of an-
tenatal visits from WHO while the majority (90.0%) did not.
Antenatal visits give health care providers an opportunity for
early diagnosis during pregnancy as well as prompt treatment
to prevent sequelae in the infected fetus and/or minimise their
intensity and frequency.
[18]
If treatment of T. gondii started
within three weeks of seroconversion, it reduced the rate of
maternofetal transmission through the placenta compared
to treatment beginning later than eight weeks of serocon-
version.
[11]
Education about meat-cat-soil-related hygiene
should be provided to all pregnant women at their first pre-
natal visit and to every woman of childbearing age.
[48, 49]
Although there was no statistically significant difference be-
tween the women’s means score of knowledge amongst that
seropositive T. gondii antibodies pregnant women in relation
to their number of antenatal visits at all parameters of the
study; pre-test (p= .393), post-test (p= .856), retained-test
(p= .958). Additionally, women who visited antenatal care
clinic
≥
5 visits scored higher degree of knowledge at all
parameters of the study; pre-test (28.0
±
18.3), post-test
(73.6
±
22.7), retained-test (90.8
±
4.1) compared with
those who had < 5 visits; pre-test (22.0
±
14.4), post-test
(71.6
±
22.8), retained-test (90.7
±
3.5). This better score
was attributed to the screening test performed during; ante-
natal health classes during antenatal visits and these women
(22.0%) took their advice from medical staff while others
(58%) took advice and knowledge from their relatives.
While studying the effectiveness of the STP on the level
of anxiety among seropositive T. gondii pregnant women
throughout the period of study, an unexpected result was
found. Surprisingly, the pre-test, post-test and retained-test
data analysis revealed that the anxiety level ranged from nor-
mal to minimal or moderate before the program, while, in
post and retained-test it ranged from minimal or moderate
to marked and severe anxiety: i.e. 84.0% (in post-test) and
48.0% (in retained-test) of the study sample scored marked to
severe anxiety compared with 0.0% (in pre-test). This means
that marked anxiety scored the highest level immediately
after the program and then decreased over the time (retained-
test) but did not reach preprogram (pre-test level). Results
illustrated a significant increase in anxiety level (p< .0001).
Aggravated and marked anxiety immediately after the pro-
gram may be attributed to the fact that the majority of the
study sample did not know about complications, or did not
expect its seriousness and consequences for the mother and
her infant (intrauterine malformations miscarriage, restricted
intrauterine growth, mental retardation, cardiac and cerebral
anomalies, epilepsy).
[3, 14, 18, 56]
They did not imagine that
a microbe like T. gondii may be a leading cause of hospi-
talisation and death. The individuals might develop uveitis,
retinochoroidal lesions, visual impairment and vision loss
resulting from symptomatic eye disease from Toxoplasma
infection. Immunocompromised individuals can develop en-
cephalitis, or have a further spread of the disease, which
can be life-threatening and fatal.
[4, 15]
Annually, there are an
estimated three-hundred to four-thousand cases of congenital
(mother-to-child) toxoplasmosis.[4]
Severe and marked anxiety decreased later in the retained-
test, this may be due to the improvement of their knowledge
regarding precautions and preventive measures to avoid ma-
ternal exposure to toxoplasmosis and following the WHO
Five Keys to Safer Food.
[25]
Additionally, although, there are
no statistical differences between women’s knowledge and
their self-rated anxiety scores, the analysis of the women’s
questionnaire showed that by recognising and understanding
elements of T. gondii, the women achieved a higher level
of anxiety score (the high knowledge score result to higher
anxiety level score). The impact of an educational program
was positive for women to progress their knowledge, but it
has a negative effect on their anxiety level. Pearson correla-
tion coefficient revealed that the anxiety level of the subset
of expectant mothers whose high mean knowledge score
was non-significantly higher anxiety level than the other of
the group of expectant mothers whose low mean knowledge
score; pre-program (r = 0.248), post-program (r = 0.275)
and retained (r = - 0.163). The elevation in anxiety level
may be due to the women’s place of residence with most
of them (56.0%) living rurally, mostly all of them, exposed
to certain strains of protozoan gondii as breeding animal,
16 ISSN 2324-7940 E-ISSN 2324-7959
cns.sciedupress.com Clinical Nursing Studies 2018, Vol. 6, No. 1
birds, cats lower socioeconomic, poor hygiene which con-
tributes to a higher rate of infection.
[9]
Rural dwellers cannot
stop breeding cats as they are considered the main biological
method to fight rodents, so it is not surprising to find that
women’s level of anxiety is aggravated, especially when they
are informed that Al-Hindi and Lubbad’s
[8]
study reported
that 23.5% of aborted women with Toxpoplasmosis were
found to rear cats. Frequent involvement in agriculture activ-
ity as the main work for rural dwellers and it exposes them
to sources of infection of herbivores (drink insufficiently
treated water unboiled milk, eating raw unwashed vegeta-
bles, and exposure to risk factors including contact with cats’
faeces-contaminated soil).[12]
5. CON CL US IO NS
The study revealed high seropositivity of IgM/IgG antibod-
ies for toxoplasmosis among pregnant women in Beni-Suef,
Egypt. Statistical analysis to find an association between the
pregnant women’s perception and demographic and obstetric
variables reveals that women’s age, educational level, occupa-
tional status, gestational age, and history of abortion or still-
birth history in the pre-test and post-test knowledge scores
are dependent on each other. We postulate that women’s
perception will be enhanced, regarding toxoplasmosis, after
implementing the program. Based on the results of the study,
women became more knowledgeable, after implementing
the program; this is mirrored by the positive effect of the
program. We felt that the program would reduce or alleviate
women’s anxiety, but surprisingly the results of the study
revealed a negative correlation between women’s knowledge
score and anxiety score, however, this relation is not sig-
nificant. Women scored a higher level of anxiety after the
implementation of the program and gained more knowledge
than before. Progression of pregnant women’s perception
towards toxoplasmosis had unfavorable anxiety level out-
comes.
Recommendations
In the light of the findings of this study, the following is
recommended.
(1)
As T. gondii has some unfavorable effects on the repro-
ductive capacity of both men and women, accordingly,
its life cycle should be integrated into Science curricu-
lum at preparatory schools in Egypt.
(2)
Implementation of public health program for preven-
tion, routine screening, early detection, and treatment
of T. gondii should be mandatory for all women in
childbearing age.
(3)
Prenatal health classes should be implemented, at an-
tenatal clinics and MCH centers, regarding Toxoplas-
mosis and its preventive measures according to WHO
Five Keys to Safer Food.
CON FLI CT S OF INTEREST DISCLOSURE
The authors declare they have no conflicts of interest.
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