Sudan Journal of Medical Sciences Volume 17, Issue no. 3, DOI 10.18502/sjms.v17i3.12079 Production and Hosting by Knowledge E Research Article Effectiveness of Health Awareness Module on Pregnant Women’s Perception on and Experience of Constipation at Saad Abu Alela – University Hospital, 2017 Faiza Taha Department of Obstetrics and Gynecology, Nursing Faculty of Nursing Sciences, University of Khartoum, Khartoum, Sudan Abstract Background: Pregnancy predisposes women to developing constipation, and hormonal and mechanical factors, sedentary lifestyle, and alteration of diet augments the condition, leading to discomforts experienced by pregnant women. However, this can be controlled through proper education and lifestyle modification. The present study aims to check the effect of health awareness education module on the reduction of constipation among pregnant women. Methods: A quasi-experimental study design was used. One hundred and twenty- five pregnant women were randomly selected from Saad Abu Alela Hospital between January and March 2017), and based on the ROME II criteria, 59 of them were found to have constipation. After obtaining consent from the women, health awareness module (information about constipation, dietary measures, increased fluid intake, and exercise) was offered to them. Data were collected by structured close-ended questionnaire for the knowledge, pre- and post-intervention, and checklists for the practice and follow-up of the weekly outcome over two months. Data were analyzed, and suitable statistical methods was used. P < 0.05 was considered as statistically significant. Results: The overall prevalence of constipation was 47.2% with a prevalence of 4%, 6.4%, and 36.8% in the first, second, and third trimesters of pregnancy, respectively. Pregnant women’s knowledge about constipation increased significantly from 16.9% pre- to 92.9 post-intervention with P = 0.000. The fiber diet intake, fluid intake, and exercise by pregnant women increased from 37.3%, 39%, and 13.6% pre- to 72.9%, 88.1%, and 49.1% post-intervention, respectively) with P = 0.001. Moreover, 46 (78%) women were relieved of constipation post-intervention. Conclusion: The health awareness module was very effective and significantly increased the level of knowledge, practice, and outcomes with respect to constipation in pregnant women. Keywords: constipation, health awareness, pregnancy How to cite this article: Faiza Taha (2022) “Effectiveness of Health Awareness Module on Pregnant Women’s Perception on and Experience of Constipation at Saad Abu Alela – University Hospital, 2017,” Sudan Journal of Medical Sciences, vol. 17, Issue no. 3, pages 292–302. DOI 10.18502/sjms.v17i3.12079 Page 292 Corresponding Author: Faiza Taha; email: fanasr@uofk.edu Received 30 December 2021 Accepted 28 May 2022 Published 30 September 2022 Production and Hosting by Knowledge E Faiza Taha. This article is distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use and redistribution provided that the original author and source are credited. Editor-in-Chief: Prof. Nazik Elmalaika Obaid Seid Ahmed Husain, MD, M.Sc, MHPE, PhD http://www.knowledgee.com https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ Sudan Journal of Medical Sciences Faiza Taha 1. Introduction Constipation is a condition in which a person experiences infrequent bowel move- ments and sensation of incomplete evacuation resulting in passage of hard stool. It is a common complaint among pregnant women and is considered second to nau- sea [1]. Fluctuating hormones, diet short on fluids/fiber, lack of exercise, iron pills intake, mechanical effects of the growing fetus, uterine enlargement causing compression of the rectum, paired with general anxiety can all lead to it. Lack of knowledge about the safe management of constipation may complicate the condition. Hormonal changes and increased progesterone in pregnancy causes decreased muscle tone and (GI) motility, leading to constipation [2]. Hemorrhoids and anal fissures are two most severe complications of constipation [3]. Constipation can be very troublesome and complicated by a range of disturbances that affect patients’ quality of life and physical health [4, 5]. One method for assessing constipation is the Rome II Criteria, which defines constipation as the presence of at least two of the following symptoms for at least one in four defecation – straining, lumpy or hard stools, sensation of incomplete evacuation, sensation of anorectal obstruction, manual removal to facilitate defecation, and less than three time in the week [6]. Interestingly, the prevalence of constipation in pregnant women ranges from 11 to 38% [7], and those affected by it before pregnancy tend to experience more symptoms while being pregnant [8]. Besides, diet short in fiber, inadequate physical activities, stress and anxiety during pregnancy can also be predisposing factors leading to constipation. However, a number of natural ways can help relieve the suffering caused by constipation. WHO recommends sufficient water and nutritional fiber intake to prevent constipation during pregnancy [9]. There is some evidence that suggest dietary factors such as water intake can prevent, or alleviate, bowel problems during and after pregnancy [10]. In addition, results from a Cochrane review support the benefit of fiber in treating constipation during pregnancy. Fiber intake increases the frequency of defecation and has no side effects. Increased fluid intake as an initial measure is not only inexpensive but also easily obtainable and comes with additional benefits [11]. While constipation can cause discomfort and passive body image conception, it can also lead to psychological problems such as mood fluctuations [12]. In India, the incidence of constipation during pregnancy as one of the morbidities was reported to be lower in women from high-income than those from low-income families [13]. Nutritional elements play a crucial role in preventing, or changing, bowel DOI 10.18502/sjms.v17i3.12079 Page 293 Sudan Journal of Medical Sciences Faiza Taha habit problems during and after pregnancy [14]. To manage constipation through non- pharmacological measures, mothers should be encouraged for regular bowel movement and to increase their fiber and water intake through fruits and vegetables and by drinking at least eight glasses of water daily. In addition, daily walks, good posture, good body mechanics, and daily exercise contracting the lower abdominal muscles can support venous circulation and prevent congestion in the large intestine [15]. One study reveals that many women experience constipation mainly during their second and third trimesters because of the slowed digestion. However, with increased intake of raw fruits and vegetables, whole grain cereals, fluids, mainly water, the problem can be relieved [16]. Another study of Chinese population shows that increasing dietary fiber intake was successful in relieving chronic constipation [17]. Justification: Little is known about the information pregnant women need about constipation and the extent to which they have benefited from the knowledge acquired from training modules. The current study was, therefore, conducted on pregnant women from Saad Abu Alela Hospital who reported having constipation to examine their aware- ness level of constipation, its management, and health outcome. Patients’ nutritional history showed inadequate dietary intake of fibrous food and fluid and a general lack of physical activities and exercises. Non-pharmacological means were recommended initially to manage constipation during pregnancy. 1.1. Hypothesis of the study 1. H₀: Training Module has no significant effect on the level of knowledge, practice, and reduction of constipation in pregnant women. 2. H₁: Training Module has a significant effect on the level of knowledge, practice, and reduction of constipation in pregnant women. 2. Materials and Methods A quasi-experimental hospital-based study (pre–post intervention) was conducted at Saad Abu Alela Hospital from January to March 2017. One hundred and twenty-five pregnant women were selected randomly during regular antenatal follow-up. The sample size was calculated as follows: n = Z2 (PQ)/D2 P = 0.2 DOI 10.18502/sjms.v17i3.12079 Page 294 Sudan Journal of Medical Sciences Faiza Taha Q = (1–p) D2 = ( 0.07) The proportion was drown from the findings of the pilot study that revealed 0.2% of pregnant women suffer from constipation. (1.96)2(0.2 × 0.8) / (0.07)2 = 3.846 × 0.16 / o.oo49 = 125 (1.96)2(0.2 × 0.8) / (0.07)2 = 3.84 × 0.16 / o.oo49 = 125 Next, the women were arranged in chronological order and the sample was selected randomly from the primary healthcare center in Saad Abu Alela Hospital. A total of 59 women had reported constipation based on the ROME II criteria. After obtaining partici- pants’ consent, the study was conducted in three phases – pre-intervention (assessment of participants’ knowledge and practices using structured close-ended questionnaire for the knowledge and a checklist for the practice); intervention (offering awareness module on constipation management, non-pharmacological measures, dietary measures, exer- cise, etc. to the participants); and post-intervention (data collection through a structured close-ended questionnaire for knowledge, a checklist for practice and bowel habits, a seven-day stool diary sheet used every week over two months to assess the outcome). Data were analyzed using the SPSS and suitable descriptive and inferential statistical methods were used as paired t-test. P < 0.05 was considered the level of significance. 3. Results Out of 125 pregnant women visiting the antenatal clinic, 59 reporting constipation based on the ROME 11 criteria were studied. Majority of the participants were in the age group of 20–35 years, lived in urban areas, and were housewives. Half of them were university graduates (Table 1). More than two-third women were multigravida and a majority of them were in their third trimester with regular antenatal follow-up. In addition, previous experience of constipation was reported in more than one-third of them (Table 2). However, the knowl- edge level of the women about constipation increased significantly after intervention (Table 3). The ability of women in managing constipation improved significantly after intervention (Table 4). A significant change was seen in women’s overall heath following the intervention (Table 5). Table 1 shows that 78% of the participants were aged 20–35 years, 52.5% were university graduates, and most of them were housewives 79.7% and lived in urban areas 72.9%. DOI 10.18502/sjms.v17i3.12079 Page 295 Sudan Journal of Medical Sciences Faiza Taha Table 1: Demographic data of the participants, n = 59. Data type Frequency Percentage Age (yr) <20 2 3.4 20–35 46 78 >35 11 18.6 Residence Urban 43 72.9 Rural 16 27.1 Occupation Student 2 3.4 Housewife 47 79.7 Working 10 16.9 Education Illiterate 2 3.4 Primary 6 10.2 Secondary 20 33.9 University 31 52.5 Economic status Insufficient 23 39 Sufficient 36 61 Table 2: Obstetrics information of the participants, n = 59. Information type Frequency Percentage Number of pregnancies Primagravida 19 32.2 Multigravida 40 67.8 Follow-up during pregnancy Irregular 15 25.4 Regular 44 74.6 Gestational age (wk) 1–13 5 8.5 14–26 8 13 27–40 46 78 Had experienced constipation before pregnancy 23 38.9 Table 2 shows that the prevalence of constipation was high in women who were multigravida (67.8%) and in their third trimester and the knowledge of the studied par- ticipants about constipation during pregnancy increased significantly post-intervention from 16.9 to 92.9%, P = 0.000. Table 4 shows that the management of constipation with non-pharmacological mea- sures post-intervention increased significantly from 30 to 70% with P = 0.001. DOI 10.18502/sjms.v17i3.12079 Page 296 Sudan Journal of Medical Sciences Faiza Taha Table 3: Knowledge of the study population about causes and management of constipation during pregnancy pre- and post-intervention, n = 59. Pre-intervention Post-intervention P-value Frequency % Frequency % Hormonal changes 16 27.2 59 100 Iron supplementation dur- ing pregnancy 6 9.6 54 91.5 Anxiety 2 3.4 44 74.6 Exercises 4 7.2 54 91.5 Take high fiber diet 25– 30 gram daily 20 34.4 59 100 Take large amount of fluid (10–12 cups daily) 11 19.2 59 ‘100 Average 16.9 92.9 0.000 Table 4: Management of constipation with non-pharmacological measures during pregnancy pre- and post-intervention, n = 59. Items Pre-intervention Post-intervention P-value Frequency Percentage (%) Frequency Percentage (%) Take high fiber diet (25–30 gram daily) 22 37.3 43 72.9 Take large amount of fluid (10–12 cups daily) 23 39 52 88.1 Exercises (walking) 1.5 hr three times/wk 8 13.6 29 49.1 Average 30 70 0.001 Table 5: Health status of the study population post-intervention (reduction of constipation), n = 59. Outcome Number of participants Percentage (%) The condition totally improved within 3 wk 8 13.5 4 wk 20 33.9 6 wk 14 23.7 8 wk 4 6.8 Total percentage of improved cases 78% The condition did not improve and constipa- tion continued 10 17 Constipation continued and led to complications 3 5.1 (Hemorrhoids) Total percentage of cases in which no improve- ment was seen 22 Table 5 shows that the majority of cases improved after intervention but one-fifth of them reported no improvement, while 5% of them developed complication. DOI 10.18502/sjms.v17i3.12079 Page 297 Sudan Journal of Medical Sciences Faiza Taha 4. Discussion Constipation is common in pregnancy, it may be caused due to hormonal, physical, or mechanical changes, and is usually aggravated by sedentary lifestyle, improper diet, and iron supplementation. A number of natural ways can help reduce the suffering caused by constipation and health awareness and education of pregnant women plays a crucial role in it. The prevalence of constipation in our study was 47.2% and found to be more common in the third trimester of pregnancy (36.8%), which was higher than the rate found in another study, where 24% of the pregnant women developed it, and it was more common in the second trimester of pregnancy 34% [18]. In addition, a correlational study found that the prevalence of constipation was 29.6%, 19%, and 21.8% in the first, second, and third trimesters, respectively [19], while it was 24%, 26%, and 16% in the first, second, and third trimesters, respectively in another study [10]. Although previous evidence shows that the prevalence of constipation is higher in the second and third trimesters, in this study, a high prevalence was seen in the third trimester of pregnancy [20]. Additionally, there is a relationship between constipation and gestational age, 36.8% of the study population experience constipation in the third trimester and is generally caused by the pressure of growing uterus which interferes with bowel movement [4]. The knowledge of pregnant women regarding the causes and management of constipation increased significantly from 16.9% pre- to 92.9% post- intervention; this increase may be related to the fact that most of them were young (78%) – 20–35 years old – and more than half (52.5%) were university-educated. The results of the present study shows the adherence of the module by the women, which = are similar to the results of previous studies that have proved that a majority of pregnant women responded to diet and fluid regulation advice [3, 6, 11] and that fiber supplementation may increase the frequency of stools [16] as the increased fibre diet and fluid intake by the participants in this study increased, respectively, from 37.3% and 39% pre-intervention to 72.9% and 88.1% post-intervention). Additionally, it was found that exercise by pregnant women with constipation increased significantly from 13.6% pre- to 49.1% post-intervention but still more than half of them did not practice it, this may be due to their culture and wrong beliefs. Overall, constipation was treated in the majority of women (46; 77.9%) post-intervention, which is consistent with the results of the study that reveal 35 (72.4%) women responded to conservative treatment [18]; study where after there was an increase in the frequency of bowel movements post-intervention [21]; and studies that supported the safe benefit of fiber in managing constipation in pregnancy [7, 8]. However, constipation persisted in 13 (22%) women DOI 10.18502/sjms.v17i3.12079 Page 298 Sudan Journal of Medical Sciences Faiza Taha who were muligravida and in third trimester with previous experience of constipation due to the lack of their muscle tone and growing uterus during the third trimester on the lower part of the (GI) tract and rectum. Three women developed hemorrhoids as a result of constipation, as seen in previous studies [14, 22]. Nutrition and exercise were means for prohibiting constipation and its complication in pregnancy. But the complication can develop due to several other factors [23]. Management of constipation with laxatives appears to be more effective in the improvement of constipation but is accompanied by side effect as an increase in diarrhea and abdominal discomfort [16]. The strength of this study was considering the principles of intervention with weekly follow-ups of participants in order to ensure the correct use of intervention as well as answering questions and determining the outcome. In addition, fortunately, our intervention was safe with minimal side effects, so most participants accepted the type of intervention. 5. Limitations A majority of the participants were in their third trimester of the pregnancy. In addition, the small sample size may not give a clear picture of the results. Besides, since this study has been conducted on apparently healthy pregnant women, the results of the present study cannot be generalized on pregnant women with a complicated pregnancy 6. Conclusion Health awareness of pregnant women about constipation was very effective and sig- nificantly increased the level of knowledge, practice, and women’s health outcomes related to constipation during pregnancy. Constipation is more common in pregnant women, mainly among multigravida women. Recommendation There is an urgent need for regular antenatal classes about self-care and health pro- motion during pregnancy to prevent constipation. DOI 10.18502/sjms.v17i3.12079 Page 299 Sudan Journal of Medical Sciences Faiza Taha Ethical Considerations The study protocol was approved by the Faculty of Nursing Sciences on January 12, 2017. Participants were informed about the nature of the study and the right to withdraw at any time, without giving any reason. Participants’ verbal agreement was obtained and confidentiality was maintained during the gathering, analysis, and interpretation of the participant’s data. Competing Interests None. 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