Study design
This was a descriptive cross-sectional study.
The participants
Participants were 1,051 women of reproductive age (including 536 women aged 19-39 and 515 women aged 40-55) living in the 22 districts of Tehran in 2021.
The inclusion criteria were as follows: residing in Tehran, having no known health problems, and having appropriate mental status and communication to complete the questionnaire. Exclusion criteria were incorrect response to the self-assessment questionnaire.
Sample size
Sampling was carried out in all 22 districts of Tehran through the municipality’s health homes and using a multi-stage sampling method through an online questionnaire (Google form). The link to the questionnaire was sent by the manager of the health home who had access to the participants’ mobile phone numbers. The sample size was obtained by using the following formula to calculate the sample size for each group of women aged 19-39 and 40-55.
$$n\ge \frac{z_{1-\alpha /2}^2\left(1-P\right)}{\varepsilon^2P}$$
The minimum sample size was calculated at 385 samples for each group using the formula for descriptive studies and considering the 50% probability that women take care of themselves and the Type I error of 0 .05 and the absolute error of 0.5.
Sampling method
The study sampling method was similar to our previous study to assess the self-care needs of postmenopausal women (16). A multistage sampling method was used to recruit study participants. The 22 districts of Tehran Municipality were selected as sampling clusters. Then, a simple random sampling method using Excel software was used to select three or four health centers in each district.
Subsequently, using the quota sampling method and depending on the population covered by the center, the sample size for each health home was considered to be 10 to 15 eligible women. Then, the link to the online questionnaire was sent to the participants after contacting them, explaining the objectives and process of the study and obtaining their oral consent. Then, written informed consent electronically was also obtained from all participants and it was only possible to complete the forms after giving the participant’s informed consent. For illiterate women, the questionnaire was completed by the head of the health center through a telephone interview. The sampling for this study was carried out during the Covid-19 pandemic.
Instructions for sample recruitment were provided to the heads of health homes in the selected municipalities. Subsequently, an online workshop was organized by the principal investigator to train heads of health facilities on the sampling procedure. Then, the head of each health facility selects 10 to 15 eligible women of childbearing age. The principal investigator’s contact number was also provided to fellow researchers to answer any questions colleagues may have.
Data collection tools
This online Google form included two questionnaires for data collection, including (1) sociodemographic questionnaires and (2) a questionnaire to assess the health self-care of women of childbearing age (RWSCQ) with 36 questions for women aged 19 to 55.
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(1)
The sociodemographic questionnaire: this questionnaire contained 15 questions on the personal, social, economic and anthropometric characteristics of the participants, including district, age, weight, height, education and occupation of women, marital status, spouse’s employment and education. if married, income adequacy, housing status, number of children, medical history, and health status.
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(2)
Self-Care for Women of Reproductive Age (RWSCQ): This questionnaire was developed with 36 items in 4 domains, including physical health with 14 items, psychosocial health with 6 items, and reproductive and sexual with 12 items, and periodic tests with 4 items. items. The questionnaire assessed the self-care of women aged 19 to 55 years.
This questionnaire was developed using a deductive approach and based on a review of guidelines for women’s health, reproductive health and self-care that have been presented on the website of trustworthy organizations such as the American College of Obstetricians and Gynecologists (ACOG) (17)Royal College of Obstetricians and Gynecologists (18), Medline Plus (19), women’s health from the World Health Organization (20), Centers for Disease Control and Prevention (CDC) (21). Finally, the main questionnaire items were generated based on the “2021 Recommendations for Healthy Women’s Care” updated by the Women’s Preventive Services Initiatives WPSI.22, 23). This table is adapted by members of the WPSI Support Advisory Committee, including ACOG, the American Academy of Family Physicians, and the American College of Physicians (ASP). The items have been selected and modified to be suitable for women of childbearing age and based on guidelines from the reputable organizations mentioned above.
To assess the validity and reliability of the questionnaire, the method described by Pilot and Beck 2010 was used (24). The RWSCQ was evaluated in two age groups: 19 to 39 years and 40 to 55 years. First, face validity (qualitative and quantitative) and then content validity (qualitative and quantitative) were examined.
Face validity
For the qualitative assessment of face validity, five women of childbearing age were asked about item difficulty, irrelevance, and ambiguity. Then, the impact score of each element was calculated and evaluated according to the threshold of > 1.5. The impact score was calculated using the following formula.
$$\textrm{Impact}\ \textrm{score}=\textrm{frequency}\ \left(\%\right)\times \textrm{importance}$$
All items in the questionnaire had a score above 1.5 and were therefore considered important by the participants. The calculated impact scores of the RWSCQ were 2.47 to 4.86.
Content validity
The content validity of the questionnaire was assessed by 12 experts in midwifery, public health, reproductive health and nursing. The content validity of the questionnaire was assessed by calculating the content validity ratio (CVR) and content validity index (CVI). The results showed that the CVR ranged from 0.83 to 1. The modified content validity index of the I-CVI for all items ranged from 0.91 to 1, and the S-CVI/Ave score was of 0.97. An alpha coefficient greater than 0.7 is generally acceptable (25).
Reliability
The reliability of the questionnaire was measured by calculating the Cronbach’s alpha coefficient for the assessment of internal consistency and also calculating the Pearson coefficient to measure the stability of the questionnaire by the test-retest method on 15 women of childbearing age. The results showed the reliability of the questionnaire by A = 0.92 and intra-class correlation coefficient ICC = 0.93. A reliability coefficient greater than 0.7 is acceptable (26).
The notation
Items were scored from 1 to 3 in the responses “No, I haven’t,” “Yes, a little/I intend to,” and “Yes, I have.” , respectively. The score ranges for different dimensions of the questionnaire, including physical, psychosocial, and sexual and reproductive health and screening tests, were 14 to 42, 6 to 18, 12 to 36, and 4 to 16, respectively, and for the entire questionnaire. was 36-108 for RWSCQ-36. Higher scores indicate healthier self-care behaviors among women of childbearing age. The score of each domain and the total score were calculated and then converted to a standardized score from 0 to 100 using the following equation. (X-Min Score / Max-Min Score) × 100. The questionnaire is available in Supplementary file 1.
statistical analyzes
After completing the participants’ Google forms on the Google platform, the data was generated in Excel software in two Google Drives for women aged 19 to 39 and 40 to 55 years. Then the data from the Excel file was converted to SPSS. Then, the data were analyzed using SPSS 24 and Kolmogorov–Smirnov to test the normality of the data, ANOVA, Sheffe, Pearson and Spearman correlation coefficient tests and linear multiple regression analysis. P. values less than 0.05 and a 95% confidence interval were considered statistically significant.
Ethics
The study was approved by the Ethics Committee of Shahid Beheshti University of Medical Sciences, with the code “IR.SBMU.PHARMACY.REC.1398.298”. All methods were carried out in accordance with current guidelines and regulations approved by the Vice President for Research and the Ethics Committee of Shahid Beheshti University of Medical Sciences. Online written informed consent was obtained from all participants.