Factors associated to toxoplasmosis-related knowledge among pregnant women attending public health services in the municipality of Niterói, Rio de Janeiro, Brazil, 2013-2015

Abstract

OBJECTIVE:

to analyze the factors associated to toxoplasmosis-related knowledge among pregnant women attending public health services in the municipality of Niterói, Rio de Janeiro, Brazil.

METHODS:

this is a cross-sectional study conducted with pregnant women assisted in eight health care units; data was collected using a standardized questionnaire, from April 2013 to February 2015.

RESULTS:

among the 405 pregnant women interviewed, 173 (42.7%) knew about toxoplasmosis and, of those, 24.3% knew about it through friends; the proportion of pregnant women with toxoplasmosis-related knowledge increased with age (p<0.001), education level (p<0.001) and the number of pregnancies (p=0.031); the history of abortion was also associated with toxoplasmosis-related knowledge (p=0.019).

CONCLUSION:

the variables 'age', 'education level', 'number of pregnancies' and 'abortion history' were important factors for toxoplasmosis-related knowledge among pregnant women assisted in the public health care sector of Niterói.

Key words:
Toxoplasmosis, Congenital; Pregnant Women; Primary Prevention; Cross-Sectional Studies

Resumo

OBJETIVO:

analisar os fatores associados ao conhecimento sobre a toxoplasmose entre gestantes atendidas na rede pública de saúde do município de Niterói, Rio de Janeiro.

MÉTODOS:

trata-se de um estudo transversal, realizado com gestantes atendidas em oito unidades de saúde; os dados foram coletados por meio de questionário padronizado, no período de abril de 2013 a fevereiro de 2015.

RESULTADOS:

entre as 405 gestantes entrevistadas, 173 (42,7%) conheciam a toxoplasmose e destas, 24,3% receberam informações por amigos; a proporção de gestantes com conhecimento sobre toxoplasmose aumentou com a idade (p<0,001), a escolaridade (p<0,001) e o número de gestações (p=0,031); a história de aborto também esteve associada com o conhecimento sobre toxoplasmose (p=0,019).

CONCLUSÃO:

as variáveis 'faixa etária', 'escolaridade', 'número de gestações' e 'história de aborto' foram importantes para o conhecimento sobre toxoplasmose entre as gestantes da rede pública de Niterói.

Palavras-chave:
Toxoplasmose Congênita; Gestantes; Prevenção Primária; Estudos Transversais

Resumen

OBJETIVO:

analizar los factores asociados con el conocimiento sobre toxoplasmosis en mujeres embarazadas en el sistema de salud pública en la ciudad de Niterói, Rio de Janeiro, Brasil.

MÉTODOS:

estudio transversal con mujeres embarazadas de ocho centros de salud; los datos se recogieron mediante un cuestionario estandarizado, entre abril de 2013 y febrero de 2015.

RESULTADOS:

entre las 405 mujeres entrevistadas, 173 (42,7%) conocían la toxoplasmosis y, de estas, 24,3% recibieron esta información de amigos; la proporción de mujeres embarazadas con conocimientos sobre toxoplasmosis aumentó con la edad (p<0,001), la educación (p<0,001) y el número de embarazos (p=0,031); historia de aborto también se asoció con un mayor conocimiento sobre toxoplasmosis (p=0,019).

CONCLUSIÓN:

las variables 'edad', 'educación', 'número de embarazos' y 'historia de aborto' fueran importantes para el conocimiento sobre toxoplasmosis en mujeres embarazadas en el sector público en Niterói.

Palabras-clave:
Toxoplasmosis Congénita; Mujeres Embarazadas; Prevención Primaria; Estudios Transversales

Introduction

The congenital Toxoplasma gondii infection is a Public Health problem, and if pregnant women are not treated, it can bring severe consequences to the fetus.^1-4 The fetal infection happens when the mother is infected during pregnancy,⁵ and chronic infections reactivation³ or reinfection by the protozoan take place.⁶

There is no commercial vaccine against toxoplasmosis for pregnant women yet, so the adoption of preventive measures is highly important.⁷ The primary prevention is conducted through health education programs, mainly to women who are seronegative for toxoplasmosis, in order to avoid seroconversion.^8,9 Secondary prevention is the serologic tracking for detecting seroconversion, so the treatment can start as soon as possible to avoid vertical transmission.⁸ Tertiary prevention acts in the infected newborn, aiming to treat and prevent complications.¹⁰

In Brazil, there is a lack of notification of congenital toxoplasmosis in many regions, impairing the disease surveillance.^11,12 Many women do not attend prenatal care or look for it too late,¹³ which can also contribute to the difficulty in controlling toxoplasmosis.

The infection by T. gondii during pregnancy has been reported in different regions of the country, with findings of seroprevalence of 2% for IgM antibodies anti-T. gondii in pregnant women from São José do Rio Preto-SP,¹⁴ 3.6% in the region of Alto Uruguai-RS,² 2.4% in Porto Alegre-RS,¹⁵ 0.25% in Niterói-RJ,16 5.33% in Gurupi-TO⁴ and 0.9% in Caxias-MA.¹⁷ More than one decade ago, studies showed that the incidence rates of congenital toxoplasmosis in Brazil were from 0.2 to 5.0/1,000 live births.^2,18,19 However, it is difficult to compare those studies, due to the wide regional and methodological variations.²⁰

Considering that the primary prevention is the only available way of avoiding maternal infection by the Toxoplasma gondii and that many pregnant women are not aware of the disease, this study aimed at analyzing the factors associated to toxoplasmosis-related knowledge among pregnant women attending public health services in the municipality of Niterói, Rio de Janeiro, Brazil.

Methods

A cross-sectional study was conducted with data collected through personal interviews, using standardized questionnaires that were validated in previous studies.^16,21

Data collection was conducted from April 2013 to February 2015, with the participation of pregnant women who attended the Regional Polyclinic of Largo da Batalha and in seven units of the Family Doctor Program (FDP) of the Municipal Health Foundation of Niterói-RJ, located in the following neighborhoods: Ititioca, Atalaia, Vila Ipiranga, Lagoinha, Maceió, Grota I and Preventório II.

The participants were selected by convenience sampling. All the pregnant women who went to one of the research units during the study period were invited to participate, by answering to the questionnaire; the women who refused to participate, those with dementia and those with hearing loss or cognitive deficits were not included in the sample. After answering to the questionnaire, all of them received a leaflet and information on toxoplasmosis.

The descriptive statistics was used for data analyses, being expressed in absolute and relative frequencies. The association was analyzed through Pearson chi-square test, with significance level of 5%. Cramér's V was used to quantify the degree of association between the variables: 0=V<;0.1 for weak or no association; 0.1<;V<;0.3 for low association; 0.3£;V<;0.5 for moderate association; and V≥0.5 for strong association. The results for multiple logistic regression were expressed by odds ratio (OR) and 95% confidence interval (95%CI).

The data was typed in Microsoft(r) Excel 2010(r) spreadsheets and analyzed using IBM(r) Statistical Package for Social Sciences (SPSS)(r) version 17.0.

The interviews were conducted individually, after the explanation by the researchers on the objectives of the study, and after the pregnant women had read and signed the Free Informed Consent Term. The study project was approved by the Research Ethics Committee of Oswaldo Cruz Foundation - Report No. 110.045, in 28 September 2012 - and conducted according to the recommendations of the National Health Council Resolution No. 466, dated 12 December 2012.

Results

A total of 405 pregnant women were interviewed. They were between 13 and 43 years old, and presented education level from illiterate to higher education degree - 28.9% of them had complete high school -; 25.9% of the women were interviewed during the first trimester of pregnancy, 45.2% were in their first pregnancy, 34.3% were there for their first prenatal care appointment and 19.5% reported abortion history (Table 1).

Table 1
- Distribution of pregnant women assisted in the public health care services according to age group, education level, gestational age, number of pregnancies, number of prenatal care appointments, abortion history and toxoplasmosis-related knowledge in the municipality of Niterói, Rio de Janeiro, Brazil, 2013-2015

• a) Pearson chi-square test

Most of the surveyed women (57.3%) did not know about the disease (Table 1). The toxoplasmosis-related knowledge increased with age (p<;0.001). The chance of toxoplasmosis-related knowledge was higher among the older women: 4.38 times (95%CI 2.39;8.01) among pregnant women aged 31 to 43 years, comparing with the same chance among pregnant women from 13 to 20 years old (Table 1).

Pregnant women with higher education levels had more chance of toxoplasmosis-related knowledge (p<;0.001), mainly women with complete high school (OR=6.26; 95%CI 3.51;11.19), incomplete higher education (OR=27.3; 95%CI 5.85;127.40) and complete higher education (OR=8.49; 95%CI 2.05;35.24), when comparing to those with incomplete elementary school (Table 1).

The number of pregnancies was associated to toxoplasmosis-related knowledge. Mothers with three or more pregnancies history had 1.87 (95%CI 1.16;3.02) more chances of knowing about toxoplasmosis than first-time mothers (Table 1).

Toxoplasmosis-related knowledge was higher among pregnant women with abortion history (p=0.019; OR=1.80; 95%CI 1.10;2.96).

The association degree between the analyzed variables and the toxoplasmosis-related knowledge varied from low to moderate (Cramér's V of 0.1 to 0.5).

The gestational age and the number of prenatal care appointments were not associated to toxoplasmosis-related knowledge (p>0,05).

Among the pregnant women that knew about toxoplasmosis, the information was received, mainly, during conversation with friends (24.3%) and from doctors (19.6%) (Table 2).

Table 2
- Source of information on toxoplasmosis reported by pregnant women assisted at the public health services in the municipality of Niterói, Rio de Janeiro, Brazil, 2013-2015

On Table 3, we present the distribution of pregnant women according to the number of prenatal care appointments per pregnancy period. It is important to highlight that among the interviewed women who were in their first prenatal care appointment (n=139), 40.3% (n=56) had 13 weeks or more of pregnancy, that is, they were starting a late prenatal care.

Table 3
- Distribution of pregnant women according to the number of prenatal care appointments divided by gestational age in the municipality of Niterói, Rio de Janeiro, Brazil, 2013-2015

Discussion

This study revealed that factors such as age and education level, higher number of pregnancies and abortion history can influence on toxoplasmosis-related knowledge, which possibly has an important role in the primary prevention among the studied population.

Previous studies, conducted with pregnant and postpartum women in Niterói-RJ, from 2010 to 2011,^16,21 showed that the risk of infection by the T. gondii increases with age and the higher education level can be a protection factor against the infection.

No association was found between toxoplasmosis-related knowledge and gestational age of the participants; however, it would be expected that women in a more advanced gestational age should know more about the disease. This fact can be explained by the late start of prenatal care and, consequently, by the reduced number of prenatal care appointments observed in the research. A study conducted in the United States of America in 2003²² did not find any difference in the toxoplasmosis-related knowledge connected to gestational age or number of pregnancies.

This study's results showed that a higher number of pregnancies was associated to Toxoplasmosis-related knowledge, as well as abortion history. Those findings were already expected. During the interviews, we observed that pregnant women under those conditions searched for more information on diseases that could cause severe problems in the fetus. Pregnant women being tested positive is also a variable that explains the toxoplasmosis-related knowledge.

No association was observed between the number of prenatal care appointments and toxoplasmosis-related knowledge, which suggests that this topic has not been treated during prenatal care, and this can be related to the delay on exams results, or to a big number of patients for a small number of health professionals.¹²

A study published in 2012,²³ with pregnant teenagers from Ceará State, showed positive association between the adoption of preventive measures and two or more prenatal care appointments. During this research, many factors capable of explaining the reduced number of prenatal care appointments in the population studied could be observed, such as, late suspicious and confirmation of pregnancy, postponement to schedule a prenatal care appointment and the fact that many women were being assisted in the private health care, but searched for public services for not having financial condition for paying the labor costs, thus, getting to the public health care during the third trimester of pregnancy - according to the narrative of the women during the interviews. Studies conducted in Europe, in 2001²⁴ and 2008,²⁵ proved the positive effect of primary prevention of toxoplasmosis on the knowledge and exposition to the risk factors for the disease. However, in Niterói and other Brazilian municipalities, this practice is still unappreciated, according to previous studies.^{9,12,17,21,23,26,27}

It was clear the lack of toxoplasmosis-related knowledge, which represents a challenge for health professionals to conduct primary prevention of congenital toxoplasmosis, an action that requires a change in behavior and eating habits by the pregnant women. It is highly important that the health professionals are well trained, and the education measures must be conducted continuously, so the primary prevention of congenital toxoplasmosis can be effective.

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• *
  Article based on the PhD thesis by Fernanda Loureiro de Moura, entitled 'Occurrence of congenital toxoplasmosis, toxoplasmosis-related knowledge and serological monitoring of pregnant women and implementation of prevention measures in the prenatal care of the public health services in the municipality of Niterói-RJ', presented to the Post-graduation Program in Tropical Medicine of Oswaldo Cruz Foundation (Fiocruz), in a partnership between Fiocruz and the Coordination for the Improvement of Higher Education Personnel (Capes)/Ministry of Education (ME): Brazil no Misery Plan. The thesis was developed under guidance of Dr. Maria Regina Reis Amendoeira and supervision of Dr. Patrícia Riddell Millar Goulart. It was defended in 2016. Grant by: Capes/ME. Scholarship by the Brazil without Misery Plan: Fernanda Loureiro de Moura.

Publication Dates

• Publication in this collection
  Jul-Sep 2016

History

• Received
  29 Jan 2016
• Accepted
  17 May 2016