Knowledge, attitudes, and health status of childbearing age young women regarding preconception health - an Italian survey.

Answers to the 20 questions regarding knowledge of young women on preconception health. Knowledge regarding preconception health and variables associated to it. Attitudes of participants regarding preconception health. Physical health of young women in childbearing age. Sexual health of childbearing age young women. Mental and emotional health of young women in childbearing age.

The primary objective of this study was to assess the level of knowledge on the preconception health of childbearing age young women in Italy. Secondary objectives included studying factors associated to the level of knowledge, evaluating the amount of folic acid consumption, and assessing physical, sexual, mental, emotional, and social health of childbearing age young women. This was a cross-sectional study, conducted among young women attending secondary grade schools and universities in Italy, from July 2020 until April 2021. Young women of childbearing age from 18 to 25 years were included in the study. This age group was chosen as it represents women’s most fertile period. In addition, such young women generally report a low and uneven level of knowledge on preconception health, being at higher risk for unintended pregnancies [ 6 , 15 , 17 ]. Pregnant women, those that were planning a pregnancy and women who already had a child were excluded. These categories generally have knowledge and behaviours influenced by the presence of a child already born or on the way, which are different from those of women who are not planning a pregnancy [ 11 , 16 ]. The questionnaire used for data collection was structured and validated through a three-step methodology. First, a systematic review was conducted to determine the main topics that needed to be investigated within the questionnaire [ 18 ]. On this basis, the different sections of the questionnaire were structured including socio-demographic information, knowledge (evaluating knowledge on issues like preconception health definition; gynaecological visit best timing; neural tube defects; herbal supplements and teas safety; obesity, overweight, moderate exercise and alcohol impact; infectious diseases, including sexually transmitted; folic acid and vitamins consumption; family and genetic history; medications revision; malformations; endocrine disruptors), attitudes, physical health (sexual, mental, emotional, social, vaccination status) and lifestyles (dietary behaviours, risky behaviours, physical activity; data reported elsewhere). Subsequently, the questionnaire was validated through a two-round Delphi procedure. The 21 experts involved were asked to evaluate each item through a Likert scale ranging from 1 (Totally Disagree: the question is not relevant at all for the purpose of the questionnaire) to 5 (Strongly agree: the question is very relevant for the purpose of the questionnaire). After two rounds, the questionnaire presented a Content Validity Index of 0.93. The final validation step included a pilot study among 20 women who gave feedback on the questionnaire, reporting a Cronbach’s alpha of 0.99. Sample recruitment took place online. The link to the questionnaire was disseminated and publicized through pages linked to schools and universities, subject to their authorization. The link was published on the community pages on the social networks (Facebook) of schools or universities. To calculate the needed sample size, we considered a type 1 error of 5%, an absolute error (accuracy) of 2.5%, and an expected percentage of preconception health knowledge among young women of 67% [ 19 ]. The number obtained was corrected considering an expected response rate of 70%, establishing the need to recruit 485 young women, to reach a final sample size of 340 young women. The data were analysed through descriptive statistical methods using frequencies and percentages (N, %) for all qualitative variables. Quantitative data were summarized by means and standard deviations (M, SD). Correct answers regarding knowledge questions (20) were coded as “1” and incorrect answers as “0”. This allowed us to calculate a total knowledge score for each participant that sums all the scores for each answer. The correct total score was, then, divided by the maximum score (20) and multiplied by 100, to give the correct knowledge mean score (KMS) as a percentage. T-test and Analysis of Variance (ANOVA) were used to determine if there was a statistically significant difference between the KMS (continuous variable) and different variables concerning attitudes and behaviour, with Bonferroni post-hoc analysis. Associations with p-value < 0.05 were considered statistically significant. Statistical analysis was performed using the STATA 15 software. The study protocol was approved by the Ethics Committee of the Fondazione Policlinico Universitario “A. Gemelli” - Università Cattolica del Sacro Cuore, Rome, Italy. The approval was emitted on 12/12/2019, number 50160/19 ID 2902.

The studied population consisted of 340 young women, with a mean age of 21.9 (SD = 1.9) and with 98.2% being of Italian nationality. 83.5% of the participants was attending school/university, of which 48.4% were enrolled in a health sciences university, 42.2% in a non-health sciences university and the rest in high school. Among the participants, only 17.7% had a part time job and 13.5% had a full-time job. 34.7% of women was single, 59.1% was in a stable relationship, 3.8% had an occasional partner and 2.4% chose not to answer. Subjects lived in families composed by an average of 4 people (SD = 1.4). 35.9% of participants had a family income inferior to 35000 €/year, 18.2% higher than 35000 €/year and 45.9% preferred not to answer. Higher knowledge was identified on topics such as which group of women could benefit from preconception health (90.6%), the negative effects of alcohol on pregnancy (85.3%), the importance of weight control before pregnancy (83.5%), the most effective technique to prevent sexually transmitted diseases (93.8%), the impact of regular physical activity on the foetus (96.5%), the revision of medications with a healthcare provider before pregnancy (94.7%). Women had a lower level of knowledge regarding the safety of using herbal supplements during pregnancy (25.9%), the diseases that can be contracted due to raw foods (34.1%), when should the use of vitamin supplements be started (29.1%), the effects of endocrine disruptors on reproduction (32.9%) ( Tab. I ). The mean knowledge score concerning the 20 questions was 67.6% (SD = 18.1). Participants with Italian nationality, enrolled in a health-field university, who had a full-time job and with a family income higher than 35,000 €/year had a significantly higher mean knowledge score. The mean knowledge score was also higher among subjects who had teachers and healthcare professionals as information source and those who were using at least one contraceptive method ( Tab. II ). The vast majority of women (82.1%) had seen a general practitioner in the last year, while only 47.7% had seen a gynaecologist ( Tab. III ). The main reasons for not seeing a gynaecologist were not having any symptoms, because of shame/fear and not having had any sexual intercourse. Even when a gynaecologist visit took place, only in 15.9% of cases, women asked about preconception health. Only few women were currently taking folic acid (5.9%), while 23.2% was taking additional vitamins ( Tab. III ). Women who had had a gynaecological examination in the last year had higher mean knowledge score compared to those who did not have an examination or that had it more than one year before ( Tab. II ). Among the participants, 68.4% had a normal Body Mass Index (BMI), 13.9% was underweight and the rest was overweight (17.8%) ( Tab. IV ). 74.4% of women was not affected by any chronic disease. When a chronic disease was diagnosed, the most frequent were anaemia, asthma and autoimmune diseases and, in 15.9% of cases, a treatment was being followed. The most used therapies were Levothyroxine, the combination Iron + Folic acid and Antiasthmatics. 30% of women suffered from urinary infections, with an average of 2.2 (SD = 1.9; min-max 1-12) episodes in the last year, the majority of whom (88.6%) were treated. A genetic disease in the family was reported by 14.4% of women, among which the most common were diabetes (34.9%), thalassemia (9.3%), coagulopathies (7%), thyroid and cardio-vascular diseases (4.7%, respectively). As for family diseases linked to pregnancy and birth, 51.2% did not report one, while 32.4% did not know and the rest reported at least one disease, the most frequent of which were preterm birth (7.6%), recurrent miscarriage (7.4%) and gestational diabetes (4.4%). Homeopathic substances or natural medicines were being taken by 20.3%. Exposure to Bisphenol A, Pesticides, Solvents and Poly- and Perfluoroalchilic substances had a frequency of 1-4 exposures/month in 45.9%, 25.5%, 28.9% and 25.6% of cases, respectively. Young women reported being vaccinated against Varicella, Measles, Rubella, Mumps, Hepatitis A, Hepatitis B, Meningococcus, Tetanus, Diphtheria, Pertussis, Polio in 47%, 76.5%, 68.5%, 56.2%, 46.8%, 63.5%, 52.6%, 72.9%, 46.2%, 53.3%, 48% of cases, respectively. A vaccine against Human Papilloma Virus (HPV) was administered in 58.8% of cases. Vaccination status was unknown to 24.7% of young women in the sample. A therapy to regulate the menstrual cycle was followed in 23.8% of cases, 96.7% of which used the estroprogestin pill ( Tab. V ). In 67.9% of cases women had sexual intercourses in the last year, using a contraceptive technique in 91.3% of cases. The most used contraceptive methods were Condom (64.6%), Contraceptive Pill (34.1%) and Coitus interruptus (23.6%). A genital tract infection was reported in 28.9% of cases, with an average of 2.1 (SD = 1.3) episodes in the last year, 86.4% of which were treated mainly with antibiotics (33.3%) and vaginal ovules (23.8%). A sexually transmitted disease was diagnosed in 6.3% of women, most frequently being HPV infection (40%), Genital HSV (herpes simplex virus) infection (20%), Chlamydiosis (13.3%), Candidiasis (13.3%), and treated in 86.7% of cases. 15.6% had a gynaecological disease, which was being treated in 57.6% of cases. Participants in the study reported the presence of stressing factors in the living environment in 82.3% of cases ( Tab. VI ). The main strategies to face these stressors emerged to be elaborating stressing factors to not let them become a problem (51.8%) and looking for relatives/friends’ help (23.6%). Most participants (63.7%) had never consulted a mental health specialist in their life. In 16.7% of women a mental disorder was diagnosed, most frequently being anxiety and depression (10.3% and 2.9%, respectively). Only 23.7% of women with a mental disorder diagnosis was under treatment. 38.2% of women experienced, at least, one type of violence during their life, the most common being verbal (26.2%) and psychological (23.8%), for which they chose to talk mainly to their parents (43.2%) and friends (37.5%). Gender-based discrimination at work, school or family was felt by 25.1% of participants, according to which, men have more advantages at work (54.7%), and at school and work (19.4%). Women felt averagely fulfilled at home (3.9 ± 1.1), at school/university and in the social context they live in (3.5 ± 1.0, respectively), and less at work (2.9 ± 1.2).

The present study aimed at assessing the knowledge, attitudes and health status of young women regarding preconception health, considering its importance for women and their offspring [ 9 ], the lack of data in the Italian context and the fact that information on knowledge and associated gaps could serve as starting point for any future intervention. Participants in this study had higher knowledge on topics such as, which group of women could benefit from preconception health, the negative effects of alcohol on pregnancy, the importance of weight control before pregnancy, the most effective technique to prevent sexually transmitted diseases, the impact of regular physical activity on the foetus, the revision of medications with a healthcare provider before pregnancy. However, there are some topics that were less known to young women, such as the safety of using herbal supplements during pregnancy, diseases that can be contracted due to raw foods, when should the use of vitamin supplements be started, the effects of endocrine disruptors on reproduction, in line with the published literature [ 20 ]. In our sample the level of knowledge was significantly associated to Italian nationality, health-field university, job, yearly family income and information source. This asserts the importance of socio-demographic variables on women’s preconception health, as reported also by published literature, to increase health equity and provide the same possibilities also to disadvantaged population groups [ 11 , 21 , 22 ]. Less than half of the participants had seen a gynaecologist in the last year and only few of them had talked about preconception health. Healthcare professionals remain one of the most important sources of information, however a gynaecological visit is not always associated to better knowledge regarding preconception health. Therefore, there is a need to promote the importance of preconception care among health providers, since they play a crucial role in supporting young women and addressing health issues in clinical consultations [ 23 , 24 ]. Only 5.9% of women in our sample were taking folic acid, even if 56.5% knew that folic acid has been shown to be effective in reducing the risk of neural tube defects in the foetus. The vast majority of participants (68.5%) thought that only pregnant women should take folic acid. Based on this, it should be noted that folic acid remains an issue to be addressed within preconception health and there is the need for more targeted interventions which should focus not only on increasing women’s knowledge, but also changing their attitudes and behaviours, since not always higher knowledge translates into improved behaviours. Several participants reported being diagnosed with chronic, genetic or sexually transmitted diseases. Lack of knowledge could perpetuate unhealthy behaviours, as for example, in our sample, a relatively high percentage of women were using coitus interruptus or contraceptive pill which exposes them to sexually transmitted diseases and unplanned pregnancies. Furthermore, almost 1/4 of the sample did not know their vaccination status. This highlights the importance of regularly checking with a healthcare professional to control the health status, and receive the right information not only before planning a pregnancy, but anytime in women’s lifespan [ 25 ]. An important role in the preconception care is played by mental health, which influences pregnancy outcomes, women’s and children’s health and should be addressed. More than 2/3 of women in our sample was living in a stressful environment, in most cases not knowing how to face this stress. Furthermore, more than 1/3 of women experienced at least one type of violence during their life, the most common being verbal and psychological, asking, more often, their parents and friends for support. The results of this study are important since they refer to a particularly vulnerable population, with a higher risk for unhealthy behaviours and unintended pregnancies, and they could be a starting point to provide information for targeted interventions to increase the knowledge and improve attitudes and behaviours of young women concerning preconception health. From a public health point of view interventions implemented in such a young population group could have an even greater impact on preconception health [ 26 ] and would bring a long-lasting positive effect on women’s and children’s health [ 27 ]. Nevertheless, higher knowledge and awareness are not always associated to modified behaviours, which calls for personalized, targeted interventions, based on evidence and women’s preferences, in order to have a greater impact [ 28 ]. In this context this study provides input and could act as impetus for future interventions, which should focus on disseminating knowledge on topics such as diseases that can be contracted due to raw foods, vitamin and herbal supplements be started, endocrine disruptors, the importance of talking to a healthcare provider about preconception health, taking folic acid, controlling health conditions and therapies. As previously reported by women themselves, interventions could include having access to reputable and easily accessible online sources of preconception health information, education at secondary schools and public health campaigns, considering women’s personal preferences for accessible and tailored preconception health information and support at individual, interpersonal, community and organizational levels [ 29 , 30 ]. As reported also by the Centers for Disease Control and Prevention (CDC) recommendations, the goal of preconception care and services should be to improve the knowledge, attitudes and behaviours of women related to preconception health, assure that all women of childbearing age receive preconception care services (i.e., evidence-based risk screening, health promotion, and interventions) that will enable them to enter pregnancy in optimal health and reduce the disparities in adverse pregnancy outcomes [ 8 ]. The results of this study should be interpreted in the light of some limitations. Firstly, the cross- sectional design does not permit to report causality, but only association between the level of knowledge and the different variables. The questionnaire was filled through an online link and only women more attentive to their health in general, and preconception health in particular, may have answered, which could have introduced a bias. Moreover, since all measures were self-reported and health is a sensitive issue, it is possible that there was a response bias. However, this study has several strong points. To the best of our knowledge, it is the first to explore knowledge, attitudes, behaviours and health status of young Italian women. The sample size was calculated for the study to have the appropriate statistical power. The questionnaire used to collect the data was created based on a systematic literature review and validated through a two-round Delphi procedure followed by a pilot study. Hence, the questionnaire could be a useful tool, acting as an impetus for future research in the field, not only in Italy, but also in other countries.

Poor preconception health could create health disparities across the globe or attenuate already existing ones [ 31 ]. That is why promoting preconception care by improving knowledge, attitudes and behaviours is seen as an impactful possibility to reduce inequalities and improve women’s, children’s and communities’ health. Women in our sample lacked knowledge in several issues regarding preconception health, had some unhealthy attitudes and behaviours and needed guide by their healthcare providers on this topic. Healthcare providers, including midwives, gynaecologists, general practitioners, nurses, etc., and teachers play an important role as the main sources of information regarding preconception health. Through information campaigns, it would be advisable to encourage young women to see their health professionals, to check their status health and improve their knowledge, not only before becoming pregnant, but in every moment of their fertile life, in order to avoid unhealthy behaviours. The consumption of folic acid before pregnancy remains an issue of preconception health, and it deserves particular attention in information campaigns. It is important to integrate preconception health promotion into the continuum of women’s healthcare through raising awareness, providing information, improving clinical practice, and providing high quality research to inform policy makers and guidelines [ 32 ].

Preconception health refers to women’s health before they become pregnant. From a public health perspective, the preconception period can relate to a sensitive phase in the life course, such as adolescence, when health behaviours are established, before the first pregnancy [ 1 ]. It has received higher attention in the last years [ 2 , 3 ], considering the importance of knowing how health conditions and risk factors could affect women or their unborn children in the case of a future pregnancy [ 4 , 5 ]. Preconception health is a very broad concept and embraces different topics, such as management of physical and genetic diseases, proper nutrition, body weight control, healthy lifestyles, mental/emotional and social health [ 6 ], all of which could be associated to poorer pregnancy outcomes and could influence offspring’s health extending across two or more generations [ 7 ]. An optimal preconception health could be achieved through accurate preconception care, which is the provision of biomedical, behavioural and social health interventions (i.e., health promotion, screening, etc.) to women of reproductive age before conception occurs, in order to reduce risk factors [ 8 ] and improve woman’s and child’s health [ 9 ]. One of the crucial pillars of promoting preconception health is the knowledge of women, as well as healthcare providers, regarding this topic. In fact, lack of knowledge and awareness could act as barriers for preconception care use [ 10 ]. Nevertheless, to date, women’s knowledge is not satisfying, and little is said in schools and in environments where health care is provided. According to the current state of the literature, women’s knowledge about preconception health is poor, especially if they have never had a pregnancy, do not plan it and are not trying to get pregnant [ 6 , 11 ]. Particular attention is paid to young women, who are more at risk for unintended pregnancies [ 12 ] and generally report a low and uneven level of knowledge on preconception health [ 13 ]. As some studies show, despite the information provided on preconception health, many young women have difficulty understanding some aspects. Due to lacking knowledge and education, young women tend to prolong their unhealthy behaviours over time [ 13 ]. As reported in literature preventive care for young women might promote some aspects of preconception health, but topics related specifically to pregnancy outcomes might be missed [ 14 ]. Hence, the need for targeted strategies to promote preconception health in this population group. The data on preconception health, in the Italian context, concern exclusively women planning a pregnancy [ 15 ]. Nevertheless, as mentioned above, these women have different needs, knowledge and attitudes regarding preconception health than those who are not planning a pregnancy [ 11 , 16 ]. Considering the importance of preconception health for women and their offsprings, and the lack of data in the Italian context, the objective of this study is to evaluate the knowledge, attitudes and health status of young women regarding preconception health.

None.