A quantitative cross-sectional study was conducted to gain an understanding of the nurses and midwives intentions to provide FP and MCH services to adolescents. A researcher-developed structured questionnaire was used to obtain information from nurses and midwives in maternal and child healthcare services in the nine provinces in SA. The questionnaire was partly based on constructs derived from Ajzens’ Theory of Planned Behaviour (TPB) [15, 21]. Thus, the questionnaire included questions about attitude, subjective norms, self-efficacy, and intentions to provide FP and MCH services.
The sampling frame consisted of all public health facilities that provide maternity and infant healthcare services in both urban and rural settings of SA. These facilities were stratified into two (2) categories: 1. Public Health Clinics, and 2. Community Day Centres (CDC), Community Health Centers (CHCs) and district hospitals. In this study, CHC is collectively used to group together the CHCs, CDCs and district hospitals as they all conduct secondary level of care compared to clinics which only conducts primary level of care. A representative sample from each stratum was selected using the probability proportional to size approach . The sampling frame consisted of 147 clinics and 34 CDCs, CHCs and district hospitals.
All nine provinces of SA were included in the selection process in order to reflect the diverse demographic and socio-economic profile of the country. Nurses and midwives were recruited at the facility level with the assistance of facility managers. Depending on the size of the facility either all the nurses and midwives or a sample of them were studied. The inclusion criteria for nurses and midwives was: all the nurses whose work included family planning services, caring for pregnant women, delivering babies; and all midwives were eligible to participate in the study. Not all nurses and midwives in these units were available to complete the questionnaire due to the shortage of healthcare professionals in the country, leaving them having to deal with high patient load at the clinics. All nurses and midwives working in MCH and FP units were eligible and recruited to complete the questionnaire. Out of the 250 nurses and midwives that were approached, only 190 agreed to participate, giving a 76% response rate. Work demands and patient overload or the busyness of the clinic were the most common reason for not participating in the study. In other words, the study used a convenience sample of nurses and midwives. The sample size depended on those who were available to participate in the study at the time of data collection in their facility.
Data collection instruments
Nurses and midwives completed a self-administered questionnaire measuring the determinants of MCH services, and family planning health services behaviour, including demographics as described below. The questionnaire was piloted in a non-study sample and necessary adaptations were made before the study was implemented. The final version of the questionnaire can be found in Additional file 1.
Background information: name of the province, district, location, facility and the type of facility were asked. The gender, participants’ date of birth, position at the facility, the number of years in the position, and education was asked. The variables were coded as following: location (1 = Urban, 2 = Rural), gender (1 = Male, 2 = Female), position at the facility (1 = Registered Nurse, 2 = Registered Midwife, 3 = Staff Nurse, 4 = Enrolled Nurse and Other), type of facility (1 = Clinic, 2 = CHC). Education was (1 = Degree in Nursing) and (2 = Diploma in Nursing and Other). For the purposes of this study, position at facility was grouped into (1 = Registered Midwives, 2 = Registered nurses/Enrolled nurse/Staff nurse, and 3 = other: nurses who were neither registered midwives nor registered nurses).
Knowledge of family planning (FP) services
Knowledge of FP services is a 13-item subscale which assesses nurses and midwives’ knowledge of FP services in SA. The statements for the measurement of knowledge of FP services were extracted from the National Contraception Clinical Guidelines: A companion to the National Contraception and Fertility Planning Policy and Service Delivery Guidelines . The statements were provided in the questionnaire where the nurse-midwife was required to confirm whether the statement was true, false or they don’t know. Sample statements are: 1. Combined oral contraceptive pills should be taken at the same time each day, 2. In SA, any female can get an abortion by simply requesting with no reasons given if she is less than 13 weeks pregnant. Scoring options were coded as (1 = True), (2 = False), and (3 = I don’t know) and the total score was calculated based on the number of items answered correctly.
Knowledge of maternal and child healthcare (MCH) services
Knowledge of MCH services is an 18-item subscale which assesses nurses and midwives’ knowledge of MCH services in SA. Knowledge of MCH services questions were extracted from the Guidelines for Maternity Care in South Africa (a confidential draft document then), which is now currently the official manual for clinics, CHC and district hospitals in SA . Similar to the knowledge of family planning services 18 statements were provided to the nurses and midwives and were asked to confirm whether the statement was true, false, or they don’t know. Sample items were: 1. Family planning services are a basic component of MCH services, 2. Tetanus immunization is not compulsory for a pregnant woman in SA. Scoring options were coded as (1 = True), (2 = False), and (3 = I don’t know) and the total score was calculated based on the number of items answered correctly.
Attitudes towards providing FP services
Attitude toward providing FP services is a ten-item subscale which assesses nurses and midwives’ attitudes towards providing FP services to adolescents in SA. Nurse and Midwives were asked how important it is to them to discuss certain family planning topics with the adolescents in their facility. Sample items were: 1. How important is it to you to discuss injectable contraceptives with adolescents? 2. How important is it to you to discuss termination of pregnancy (TOP) and choices on TOP with adolescents? A Likert scale of 1–5 was used to assess the importance of discussing the topics, where (1 = Very unimportant, 2 = Unimportant, 3 = Neutral, 4 = Important, 5 = Very important).
Subjective norms towards providing FP and MCH services
Subjective norms subscale is a six-item (for FP) and 5-item (for MCH) subscale which assesses general norms of the nurses and midwives’ colleagues at the facility they work in. Nurses and Midwives were asked how strongly they agreed with certain FP and MCH statements regarding their colleagues’ views. The items were 6 for FP and 5 for MCH services. A Likert scale was also used to assess their subjective norms for FP and MCH separately. Sample items were: 1. Most of your colleagues think that you should provide female condoms to adolescent girls (for FP services), 2. Most of your colleagues think that you should discuss delivery options with pregnant adolescent girls (for MCH services). Scoring options were 1 = Strongly disagree, 2 = Disagree, 3 = Neutral, 4 = Agree, 5 = Strongly agree).
Self-efficacy to provide FP and MCH services
Self-efficacy is one’s belief in his or her capabilities to perform a recommended behaviour . In this study, self-efficacy is defined as the nurses’ and midwives’ beliefs and confidence in themselves performing a recommended FP and MCH services for adolescents in SA. Nurses and Midwives were asked to indicate how confident they were to provide FP services and MCH services. The total items were 7 for FP and 10 for MCH services. To measure FP self-efficacy a sample question was: how confident are you that you will be able to provide injectable contraceptives to adolescent girls? To measure MCH self-efficacy a sample question was: how confident are that you will be able to provide immunization for diphtheria, tetanus, and pertussis to pregnant adolescents. Scoring options were 1 = Not confident at all, 2 = Not confident, 3 = Unsure, 4 = Confident, 5 = Very confident.
Intention to provide FP and MCH services
Intention is a 16-item (for FP services) and ten-item (for MCH services) which assesses nurses and midwives’ intentions to provide family planning services to adolescents in SA. Nurses and Midwives were asked to indicate whether they intended to provide certain FP and MCH services. Sample items were: the next time an adolescent girl needs TOP, I intend to provide (for FP services), and the next time a pregnant adolescent needs advice on delivery options, I intend to provide the advice (for MCH services). The total number of items was 16 for FP services and 10 for MCH services. The Likert scale scoring options were 1 = Definitely not, 2 = Not, 3 = Unsure, 4 = Yes, 5 = Definitely yes.
Data were analyzed using SPSS version 21 . Descriptive statistics were conducted to get an overview of the sample characteristics. Mean scores were also calculated in order to gain more information about the nurse- midwives’ personal determinants regarding adolescents’ MCH and FP services. Pearson’s correlation analysis was then conducted to determine the association between knowledge, attitude, subjective norms, self-efficacy, and intention variables for FP and MCH services. The strengths for Pearson’s correlation were classified as weak (0.10 ≤ r < 0.30), moderate (0.30 ≤ r < 0.50) or strong (r ≥ 0.50) . All variables, including the demographics were then taken into multiple linear regression analysis to predict the intentions to provide FP and MCH services to adolescents by the nurses and midwives in this study. Intentions to provide FP and MCH services are the outcome variables for the linear regression analysis.
Prior to the linear regression analysis, exploratory factor analysis was conducted to assess the items making up the scales in order to group together items that were closely related . Thirteen items from the knowledge of FP services, and 18 items from the knowledge of MCH services were put through factor analysis in SPSS. Kaiser-Mayer-Oklin (KMO) test for the FP knowledge subscale met the recommended value at 0.6 with the Bartlett’s test reaching the significance level, p < 0.01, and the KMO value for MCH knowledge subscale was more than the recommended 0.6 with a significant Bartlett’s test, p < 0.01 . Ten items of FP attitudes, 6 items on subjective norms for FP and 5 items for MCH, 7 items self-efficacy for FP and MCH services, and 16 items on intentions to provide FP and MCH services were also put through the factor analysis. All these subscales were above the minimum recommended 0.6 value of the KMO with a significant Bartlett’s test p < 0.01 . Kaiser-Mayer-Oklin and Bartlett’s tests were used to assess the suitability of the data for the planned analysis to ascertain that no assumptions were violated, as well as the appropriateness of the factor analysis that was used to assess the items making up the scales used . The KMO values confirmed that the variables used in this study were fit for further analysis, which the study intended to conduct.
A 2-step linear regression analysis was conducted for both FP and MCH services. In step 1, only demographics: Location (urban or rural), position of the staff, education level, and years of experience were added into the FP and MCH regression models. In step 2, demographics and the psychosocial variables: FP knowledge, FP attitude, FP norms, and FP self-efficacy were added into the FP model. MCH psychosocial variables: MCH knowledge, MCH norms, and MCH self-efficacy were added into the MCH model.
Collinearity statistics showed that the variables entered into the linear regression model did not violate the multi-collinearity assumptions. All variables for both FP and MCH services obtained an acceptable variance inflation factor (VIF) that is below 10, the cut off value [28, 29]. Only variables with a p- value of less than 0.05 (p < 0.05) were considered significant variables in this study.