This methodological validity study was conducted in the northeastern region of Brazil. Data were collected from the Brazilian public health system.
Ethical considerations
The study was approved by the Research Ethics Committee of the Federal University of Rio Grande do Norte (CEP-UFRN), Brazil, under approval number 1.065.285/2014. All participants were informed about the research objectives and procedures and provided written informed consent, in accordance with Resolution 466/12 of the National Health Council of Brazil.
Sample size
A sample size that is five times the number of items on the instrument being validated [24] was recommended; this was increased by 10% to take into account possible losses. Thus, a sample of 409 volunteers who agreed to participate was selected for this study.
Study participants
The inclusion criteria in this study were as follows: Brazilian citizens who received prenatal care in one of the public health services mentioned above, age at least 14 years, and having a minimum level of education (elementary school). The inclusion criteria were defined according to ethical requirements and relevant heterogeneity samples for methodological analysis [25]. Return questionnaires with no response to one or more items of each dimension of the PSEQ were excluded. Figure 1 shows a flow diagram for the selection of study participants.
The sample size for test–retest evaluation was determined according to the volunteer's availability to attend the Public Health System services during the reevaluation period. A convenience sample was used to determine which women would complete the PPP-VP in addition to the PSEQ, according to the volunteer's availability to remain in the health service as long as necessary to complete both instruments.
Recruitment and data collection
All pregnant women were invited to participate in the study when they were in the waiting room for prenatal consultation. Initial data collection was performed between October 2014 and July 2015 after obtaining ethical approval for the research, and final data collection was completed between November 2019 and March 2020, as the minimum sample size required for analysis was not reached in the first phase of data collection.
The investigators were trained by the research coordinator and received an instruction manual for data collection. The pregnant women received the evaluation instruments and could respond independently or request the researcher’s help in reading and completing the questionnaires.
First, we collected sociodemographic, clinical, and obstetric data using a questionnaire developed for this study. An additional variable was the Brazilian minimum monthly wage (MW), defined as the lowest remuneration that workers receive as payment for their jobs per month, in addition to variables including age, gestational age, employment status (unemployed or employed), family income (≤ 1 MW or > 1 MW), education level (high school or below, college or above), partner (no or yes), parity (primigravidas or multigravidas), number of appointments with doctors during prenatal care, planned pregnancy (no or yes), and high or low-risk pregnancy based on antenatal care received. Pregnant women were classified as low or high risk according to the criteria used by the Ministry of Health of Brazil [26]. We then administered a version of the PSEQ previously translated and culturally adapted to Brazilian populations by Silva et al. [17]. First, authorization was requested from the author for the translation and validation of the Brazilian Portuguese version of the PSEQ. Two translators fluent in English translated the instrument into Brazilian Portuguese [17]. The translations were then reviewed by an expert committee composed of four people who agreed to the final version of the instrument [17]. Subsequently, the questionnaire was sent to two English-speaking translators for backtranslation [17]. The PSEQ was administered to 36 pregnant women in a pilot study to determine its clarity and coherence [17].
Originally developed in English in 1984, the PSEQ was designed by a North American nurse, Regina Lederman [1]. This assessment tool is meant for pregnant women and includes 79 items in seven dimensions of psychosocial adaptation to pregnancy: Well-being of self and baby (items 12, 16, 17, 30, 41, 51, 57, 63, 68, and 71); acceptance of pregnancy (items 1, 3, 9, 22, 32, 58, 61, 62, 66, 69, 74, 76, 77, and 79); identification with motherhood role (items 2, 6, 19, 29, 33, 34, 42, 45, 46, 50, 54, 67, 73, 75, and 78); preparation for labor (items 7, 13, 24, 25, 26, 38, 47, 48, 56, and 72); control in labor (items 8, 11, 15, 18, 27, 39, 49, 52, 53, and 64); relationship with mother (items 14, 20, 21, 28, 31, 37, 44, 55, 59, and 65); and relationship with partner (items 4, 5, 10, 23, 35, 161 36, 40, 43, 60, and 70). Each item consists of a statement related to the period of pregnancy, childbirth, and maternity to which the respondents need to indicate their degree of agreement using a four-point Likert scale, with the following options: (4) very much so, (3) moderately so, (2) somewhat so, and (1) not at all. However, the scoring for questions with positive statements (questions 1, 2, 3, 4, 6, 7, 8, 10, 11, 12, 14, 15, 18, 19, 20, 21, 22, 23, 24, 25, 26, 28, 31, 32, 33, 35, 36, 37, 38, 40, 47, 48, 49, 50, 53, 55, 56, 59, 60, 61, 70, 71, 72, 73, 74, 75, 78, and 79) was reversed. High scores indicate poor adaptation, whereas low scores indicate increased adaptation. The final score allows the assessment of psychosocial adaptation to pregnancy by means of a specific result, with a total score ranging from 79 to 316.
In 1994, a group of North American nurses developed the Prenatal Psychosocial Profile (PPP) [27], which was adapted and translated in Brazilian Portuguese and then designated the Prenatal Psychosocial Profile-Portuguese Version (PPP-VP) [16]. This tool has four subscales, each with 11 items: stress, support received from the partner, support received from other people, and self-esteem, totaling 44 items [16]. Scores ranges from 1 to 4 for stress and self-esteem and 1 to 6 for support received from the partner and support received from other people, with high ratings reflecting positive adaptation, and low scores poor adaptation [16].
Participants whose mothers were deceased and those who did not have a partner did not respond to the items related to the relationship with mother and relationship with partner or support received from the partner, respectively.
Statistical analyses
Descriptive statistics were used to characterize the sample using medians and standard deviations for continuous variables and absolute numbers and relative frequencies for categorical variables.
To determine reliability, internal consistency was evaluated using Cronbach’s alpha coefficient. To calculate the intraclass correlation coefficient (ICC), a test–retest evaluation was conducted with 24 eligible women with a 1-week interval to ensure the stability of the analysis. A Cronbach’s alpha higher than 0.7 was considered reliable. An ICC ≥ 0.40 is considered good and ≥ 0.75, excellent [28].
Construct validity was assessed using 1) confirmatory factor analysis (CFA), 2) discriminant validity determined using Pearson’s correlation coefficient of the seven domains, 3) internal validity determined using Pearson’s correlation coefficient between domains and the general scores and 4) concurrent validity determined by calculating Pearson’s correlation between the individual domains of the PSEQ and PPP-VP with 32 eligible women, as both instruments evaluate the same construct: prenatal psychosocial adaptation. Generally, the goodness of fit of a model is confirmed by the following indices: root mean square error of approximation (RMSEA) < 0.08, standardized root mean square residual (SRMR) < 0.08, comparative fit index (CFI) ≥ 0.90, and normed chi-square (χ2/df) < 5.00 [29, 30]. Correlations between the domains of the PSEQ were analyzed to test discriminant validity [1]. The strength of the Pearson’s correlation coefficient increases both from 0 to + 1, and from 0 to -1, therefore, r < 0.40 is considered weak, 0.40 ≤ r < 0.70 moderate, and r ≥ 0.70 strong [31]. A significance level of 5% was considered statistically significant. Participants who did not respond to one or more items in a given domain were excluded from the analysis of that domain. Data analysis was performed using Statistical Package for Social Sciences (SPSS), version 23 for Windows.