This descriptive-analytic cross-sectional study of the tool assessment type was implemented in public health centers of Babol University of Medical Sciences from June to October 2018. The research tool was a revised pregnancy distress questionnaire (NuPDQ). This self-reporting questionnaire included 17 items evaluating pregnancy distress in women in each trimester of pregnancy. Specifically, 9 questions were dedicated to the first trimester, 12 questions concerned the second trimester, and 17 questions evaluated the third trimester in pregnant women. The respondents would mark each item with zero (not at all), 1 (somewhat), and 2 (very much). Thus, NUPDQ questionnaire for the second trimester contained 12 questions, and NuPDQ for the third trimester consisted of 17 questions. Note that 12 questions of NuPDQ for the third trimester were the same questions of the second-trimester NuPDQ, with 5 questions specifically for the distresses of the third trimester added to them.
After receiving permission from Dr. Lobel, the questionnaire was translated to Persian using the forward-backward method. Initially, two native Persian language translators, expert in the translation of English texts, translated the English questionnaire into Persian. The two translations were then reviewed by the researchers of the project, and a final version was prepared. In the next stage, two other translators, expert in English and Persian, were asked to translate the Persian version back into English. Then, the English translated paper was compared with the original English version by two experts of English language. Finally, the final Persian version the pregnancy distress questionnaire was approved. After verifying the correctness of the concepts, the 17-item questionnaire was qualitatively given to 10 pregnant women who met the criteria for entering the study. Then, the simplicity, clearance, and understandability of the terms used in the questionnaire were evaluated. In addition, in order to assess the content validity, 5 experts in the field of pregnancy and psychology provided the necessary feedback qualitatively. The results were: Content Validity Index (CVI) 0.91 and Content Validity Ratio (CVR) 0.94.
In order to assess the concurrent validity of the NuPDQ, a simultaneous assessment was performed via the Spielberger state-anxiety. The Spielberger State-Trait anxiety questionnaire is a tool widely used in studies to measure general anxiety. The questionnaire consists of 40 questions, 20 of which concern state anxiety, and 20 other questions evaluate trait anxiety.[14 (link)] In this study, the 20 questions capturing state anxiety were used.
In order to use this questionnaire in pregnant women, 2 rural and urban health centers, as well as one university hospital in Babol and Amol cities were randomly selected. Of the 2 teaching hospitals of Babol city which had an obstetrics clinic, one hospital was selected randomly. Further, of all of the 15 rural health centers in Baol city, one center was included randomly in the study. One center out of 17 urban health centers of Amol city was selected randomly. The inclusion criteria were pregnant women with a gestational age of 14 weeks and more, willingness to participate in the study, and age of 18 years or more. Women with less than elementary school education level, as well as mentally retarded people, and patients with severe physical or mental illnesses were excluded from the study. In each health center, a midwife assessed the participants in terms of meeting the criteria for entering the study, recorded the demographic data, and distributed questionnaires among participants. The sample size was calculated as 15 samples per question of NuPDQ. Thus, with the sample drop of 5%, 269 pregnant women entered the study through available sampling method. Of that number, 122 pregnant women in the second trimester (13 to 26 weeks), and 147 pregnant women in the third trimester (27 to 41 weeks) completed the NuPDQ and Spielberger state anxiety questionnaires. The distribution of samples in the second and third trimesters was based on the number of items in each questionnaire – the second trimester (NuPDQ-12) had 12 questions and the third trimester had 17 questions (NuPDQ-17).
All stages of confirming the validity and reliability for the NuPDQ questionnaire were performed separately for the second trimester (12-item NuPDQ) and the third trimester (17-item NuPDQ). In order to assess the reliability of these questionnaires in terms of internal consistency, Cronbach's alpha coefficient was used. The concurrent validity was assessed based on the correlation between NuPDQ tool and Spielberger state-anxiety inventory. In the next step, exploratory factor analysis was used to determine the areas of the pregnancy distress-specific questionnaires. Statistical analysis was performed using SPSS software (version 24.0, IBM, Chicago, IL, USA).
After receiving permission from Dr. Lobel, the questionnaire was translated to Persian using the forward-backward method. Initially, two native Persian language translators, expert in the translation of English texts, translated the English questionnaire into Persian. The two translations were then reviewed by the researchers of the project, and a final version was prepared. In the next stage, two other translators, expert in English and Persian, were asked to translate the Persian version back into English. Then, the English translated paper was compared with the original English version by two experts of English language. Finally, the final Persian version the pregnancy distress questionnaire was approved. After verifying the correctness of the concepts, the 17-item questionnaire was qualitatively given to 10 pregnant women who met the criteria for entering the study. Then, the simplicity, clearance, and understandability of the terms used in the questionnaire were evaluated. In addition, in order to assess the content validity, 5 experts in the field of pregnancy and psychology provided the necessary feedback qualitatively. The results were: Content Validity Index (CVI) 0.91 and Content Validity Ratio (CVR) 0.94.
In order to assess the concurrent validity of the NuPDQ, a simultaneous assessment was performed via the Spielberger state-anxiety. The Spielberger State-Trait anxiety questionnaire is a tool widely used in studies to measure general anxiety. The questionnaire consists of 40 questions, 20 of which concern state anxiety, and 20 other questions evaluate trait anxiety.[14 (link)] In this study, the 20 questions capturing state anxiety were used.
In order to use this questionnaire in pregnant women, 2 rural and urban health centers, as well as one university hospital in Babol and Amol cities were randomly selected. Of the 2 teaching hospitals of Babol city which had an obstetrics clinic, one hospital was selected randomly. Further, of all of the 15 rural health centers in Baol city, one center was included randomly in the study. One center out of 17 urban health centers of Amol city was selected randomly. The inclusion criteria were pregnant women with a gestational age of 14 weeks and more, willingness to participate in the study, and age of 18 years or more. Women with less than elementary school education level, as well as mentally retarded people, and patients with severe physical or mental illnesses were excluded from the study. In each health center, a midwife assessed the participants in terms of meeting the criteria for entering the study, recorded the demographic data, and distributed questionnaires among participants. The sample size was calculated as 15 samples per question of NuPDQ. Thus, with the sample drop of 5%, 269 pregnant women entered the study through available sampling method. Of that number, 122 pregnant women in the second trimester (13 to 26 weeks), and 147 pregnant women in the third trimester (27 to 41 weeks) completed the NuPDQ and Spielberger state anxiety questionnaires. The distribution of samples in the second and third trimesters was based on the number of items in each questionnaire – the second trimester (NuPDQ-12) had 12 questions and the third trimester had 17 questions (NuPDQ-17).
All stages of confirming the validity and reliability for the NuPDQ questionnaire were performed separately for the second trimester (12-item NuPDQ) and the third trimester (17-item NuPDQ). In order to assess the reliability of these questionnaires in terms of internal consistency, Cronbach's alpha coefficient was used. The concurrent validity was assessed based on the correlation between NuPDQ tool and Spielberger state-anxiety inventory. In the next step, exploratory factor analysis was used to determine the areas of the pregnancy distress-specific questionnaires. Statistical analysis was performed using SPSS software (version 24.0, IBM, Chicago, IL, USA).
