Despite severe health and economic consequences that women face because of the negative attitude of healthcare providers towards safe abortion and post-abortion care (SA/PAC), no psychometric tool has yet been validated for assessing the attitude towards SA/PAC. Only a handful of studies have attempted to assess healthcare providers’ attitude towards safe abortions in Pakistan. Therefore, this study aimed to develop and validate a psychometric scale to assess attitude towards safe abortions in Pakistan. The study collected data from 106 workers of an NGO that provides SA/PAC through an online and anonymous survey using the organisation’s network. The study used factor analytic techniques and structural equation modelling to validate the factor structure and a final hierarchical model. A final scale of seven items relating to attitude towards elective abortions and moral attitude towards safe abortions was validated. The scales were highly reliable with both factors having reliability indicators greater than 0.7. The scale can be easily implemented to assess providers’ attitude towards safe abortions. This will allow programmers to screen healthcare providers with a negative attitude, and evaluate the efficacy of their Value Clarification and Attitude Transformation (VCAT) programmes that are aimed at transforming providers’ attitude towards safe abortions.
Keywords: Structural equation modelling, factor analysis, post-abortion care, scale development, elective abortions.
With a high fertility rate of 3.6 and only 25% of the population using modern contraception, Pakistan is marred with one of the highest rates of unintended pregnancies in the world at 93 per 1,000 women aged 15-49.1-3 This results in 4.4 million annual unintended pregnancies, of which 54% are resolved through, predominantly, unsafe abortions.2 Majority of these abortions are clandestine and are performed under poor safety conditions, thereby posing a serious risk to the health and lives of the women.4 This can be seen in the high rate (14 per 1,000) of women who are treated for post-abortion complications due to poor conditions and unsafe procedures.2 The Pakistan Penal Code 1948 states that an abortion can be legally sought and performed to save the mother’s life or to provide “necessary treatment”.4 However, the ambiguity in the statement leaves a lot of room for varying, and mostly restrictive, interpretation by both healthcare providers (NGOs, and public and private providers) and the women concerned.4,5 Women feel reluctant to approach qualified professionals to procure a safe abortion due to lack of knowledge of the practice, or the possibility of committing a criminal offence, while medical professionals may be averse to the practice due to their beliefs and the fear of being labelled an “abortionists”.5
This refusal to provide a medical service that women are entitled to stems from an extremely negative attitude of service providers towards safe abortions and incorrect knowledge about the legality of abortions under the Penal code as well as Islamic jurisprudence.5 No psychometric tool has yet been validated for assessing providers’ attitude, and only a handful of studies have attempted to assess the attitude of healthcare providers towards safe abortions in Pakistan.2,4,5 Accurate assessment of attitude is critical for screening providers with a negative attitude and developing Values Clarification and Attitude Transformation (VCAT) programmes for transforming their attitudes. Healthcare providers’ attitude towards safe abortion and post-abortion care (SA/PAC) is critical for creating a cordial environment for women to avail services.
Methods and Results
Since there is no precedent for a psychometric scale to measure attitude towards SA/PAC in Pakistan, we adapted and refined an existing scale.6 Twenty-six culturally-congruent items, that focussed on multiple dimensions around attitude towards SA/PAC,7,8 were developed on a seven-point Likert scale. Data was collected through a cross-sectional survey of NGO workers from June to July 2017. Respondents were primarily based in the Karachi office of an NGO that provides SA/PAC services in Pakistan. A-priori sample size calculation for structural equation models determined the minimum sample to be 113 with an anticipated effect size of 0.3, desired statistical power of 0.8, five latent variables, and 26 observed variables.9 Data were collected through an online survey disseminated through the NGO’s email network, and, with a response rate of 93%, a sample of 106 was achieved. Data were also collected on sociodemographic characteristics, and legal and contextual knowledge of SA/PAC in Pakistan. Statistical analyses were performed using LISREL Version 8.8 and Stata MP Version 13.1. DeVellis’ scale development guidelines were utilised for data analysis.10
Exploratory factor analysis (EFA) was used to identify a parsimonious set of factors to assess attitude towards SA/PAC. Since scale items were ordinal, unweighted least squares estimation with polychoric correlations was used. The Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy determined the sample size to be average for factor analysis by providing a value of 0.75.11 EFA revealed the two-factor solution as the optimal solution with one factor pertaining to Attitude towards Elective Abortions (EA) and the other to Moral Attitude (MA) towards SA/PAC. Seven items with loadings greater than 0.5 and conceptual underpinnings were retained in the final scales (Table-1).12
Factors’ reliability and validity was established through Average Variance Extracted (AVE), Coefficient H, and Ordinal Alpha.13,14 AVE for both factors exceeded 0.5 while Ordinal Alpha and Coefficient H for both factors exceeded 0.75. (Table-1) A subjects-to-variables (STV) ratio approach was used to provide an estimate of whether this sample size would suffice. An STV ratio of ≥ 20 is recommended.10 The final scale consisted of seven items and thus provided with an STV ratio of 15.
Descriptive statistics (Table-2) were used to review the sample’s characteristics. There were 73 (69%) men and 32 (30%) women in the sample; mean age of the sample was 33.9±9.4 years with 82 (77%) respondents holding graduate degrees, and 81 (76%) respondents were married. Mean number of years of professional experience was 12.3±6.4 years, while the respondents had been working for the NGO for an average of 5.5±4.3 years. Furthermore, 48 (36%) respondents felt their religious beliefs influenced their view towards SA/PAC and 33 (31%) respondents thought that it is not legal for women to access SA services in Pakistan. Moreover, only 23 (22%) respondents were able to correctly answer the number of pregnancies terminated through abortions in Pakistan which was reflective of low contextual knowledge.
Structural Equation Modelling (SEM) was undertaken to validate the factor structure and explore relationships between the two factors.15 Satorra-Bentler (SB) c2, Comparative Fit Index (CFI), Standardised Root Mean Square Residual (SRMR), Akaike Information Criterion (AIC), and Root Mean Square Error of Approximation (RMSEA) were used to test the fit of the models.16 A measurement model of seven items with two factors was run through SEM using Diagonally Weighted Least Squares (DWLS) estimation fitted to polychoric correlations and asymptotic covariances.17 The model yielded a good fit [SB c2 (13, 106) = 17.47 (p=0.18), CFI = 0.993, SRMR = 0.058, AIC = 47.47, RMSEA = 0.057 (0.000; 0.120)]. Both factors were highly correlated (r= 0.83, p<0.001) indicating the presence of a hierarchical factor of attitude towards SA. A hierarchical model (Figure) was tested, which yielded a marginally better fit [SB c2 (12, 106) = 14.86 (p=0.25), CFI = 0.996, SRMR = 0.058, AIC = 46.86, RMSEA = 0.048 (0.000; 0.116)]. Since the hierarchical model fit better, it was accepted as the final model. The hierarchical factor explained 91% of the variance in EA and 76% of the variance in MA. (Figure)
Overall attitude towards SA/PAC was negatively correlated with the belief that attitude is influenced by religion (r = -0.45, p<0.001), and positively correlated with correct legal knowledge (r = 0.47, p<0.001) and correct contextual knowledge (r = 0.26, p<0.001).
This scale was developed through rigorous latent variable methodology and has reduced measurement bias. Furthermore, confirmation of a hierarchical factor indicates that the scores of the scales can be simply summed up to create a composite variable for attitude towards SA/PAC. This scale can be implemented routinely to recruit providers and implementers with a pre-existing positive attitude towards SA/PAC, and screen providers with a negative or neutral attitude towards SA/PAC. Moreover, Value Clarification and Attitude Transformation (VCAT) for SA/PAC programmes can be developed and tailored in accordance with the dilemma of the providers (i.e. dilemma with morality of SA/PAC versus dilemma with the element of choice). The study further highlights the importance of legal and contextual knowledge as it has a direct impact on individuals’ attitude.
The study had a small sample taken from one NGO in Pakistan; however, all the respondents were implementers or had significant exposure to the operational environment of providing SA/PAC services. The questionnaire was prepared in English, and would require a subsequent validation for implementation in Urdu with service providers. Future studies should test this scale with different subpopulations within the health sector and test its application with the development of VCAT programmes.
Conflict of Interest: None.
Funding disclosure: None.
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