Foetal Health Locus of Control and iron supplementation adherence among pregnant women in Bali.

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Editorial

Atomic bombs and obesity: legacies for perinatal health
Colin R. Martin & Maggie Redshaw
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Foetal Health Locus of Control and iron supplementation adherence
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Journal of Reproductive and Infant
Psychology
Publicat ion det ails, including inst ruct ions f or aut hors and
subscript ion inf ormat ion:
ht t p: / / www. t andf online. com/ loi/ cj ri20

Foetal Health Locus of Control and iron
supplementation adherence among
pregnant women in Bali
Luh Put u Lila Wulandari

a

, Pippa Craig

b

& Anna Klinken Whelan

c

a

School of Public Healt h, Facult y of Medicine, Udayana
Universit y, Bali, Indonesia
b

ANU Medical School, Aust ralian Nat ional Universit y, Canberra,
Aust ralia
c

School of Public Healt h and Communit y Medicine, Universit y of
New Sout h Wales, Sydney, Aust ralia
Published online: 09 Jan 2013.

To cite this article: Luh Put u Lila Wulandari , Pippa Craig & Anna Klinken Whelan (2013) Foet al
Healt h Locus of Cont rol and iron supplement at ion adherence among pregnant women in Bali,
Journal of Reproduct ive and Inf ant Psychology, 31: 1, 94-101, DOI: 10. 1080/ 02646838. 2012. 751585
To link to this article: ht t p: / / dx. doi. org/ 10. 1080/ 02646838. 2012. 751585

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Journal of Reproductive and Infant Psychology, 2013
Vol. 31, No. 1, 94–101, http://dx.doi.org/10.1080/02646838.2012.751585

Foetal Health Locus of Control and iron supplementation
adherence among pregnant women in Bali
Luh Putu Lila Wulandaria*, Pippa Craigb and Anna Klinken Whelanc
a

School of Public Health, Faculty of Medicine, Udayana University, Bali, Indonesia; bANU
Medical School, Australian National University, Canberra, Australia; cSchool of Public
Health and Community Medicine, University of New South Wales, Sydney, Australia

Downloaded by [UNSW Library] at 22:23 19 September 2013

(Received 25 August 2012; final version received 18 November 2012)
Objective: This study aims to explore whether adherence to taking iron supplementation is associated with health beliefs as measured by the Foetal Health
Locus of Control (FHLC). Background: Anaemia in pregnancy is major health
problem in Indonesia. Non-adherence to iron supplement intake has been one
factor that hindered the effectiveness of an iron supplementation in reducing
anaemia during pregnancy. Insufficient attention has been given to why such a
phenomenon occurs. Methods: A cross-sectional study was conducted in South
Kuta, Bali, Indonesia. Pregnant women were invited to complete a self-administered questionnaire comprising questions on the frequency of taking iron supplement in addition to the FHLC scale. Results: This study was among the first
using the FHLC scale in a non-English-speaking background country. Of the
360 pregnant women invited to participate, 299 returned completed questionnaires. Conclusion: Using the FHLC scale we learned that Internal and Chance
scales were associated with supplementation adherence. It is recommended that
health counselling be introduced to improve iron supplementation adherence
among pregnant women in Bali taking into consideration these predictors of
adherence.
Keywords: pregnancy; health beliefs; locus of control

Background
Anaemia during pregnancy is a major public health problem in developing countries. One of the approaches introduced in Indonesia to alleviate this problem is iron
supplementation, in which pregnant women are given iron supplements and are recommended to take iron tablets daily during their pregnancy. Iron supplements commonly distributed in developing countries contain 200 mg ferrous sulfate. However,
low adherence to the iron tablet distribution hinders its effectiveness in combating
anaemia.
A study conducted in Bali in 2008 revealed the wide range in health beliefs during pregnancy and how these beliefs influence whether women adopt healthy
behaviours (Wulandari & Klinken Whelan, 2011). While studies have been conducted on the prevalence of failure to take iron supplements, there have been a lack
*Corresponding author. Email: putuwulandari@yahoo.com
Ó 2012 Society for Reproductive and Infant Psychology

Downloaded by [UNSW Library] at 22:23 19 September 2013

Journal of Reproductive and Infant Psychology

95

of studies which have focused on whether health beliefs influence pregnant women
behaviours in adhering to their iron supplementation.
This study used the Foetal Health Locus of Control (FHLC) scale (Labs & Wurtele, 1986) to explore whether adherence to taking iron supplements is associated
with beliefs during pregnancy. The FHLC scale, which measures the perceived personal responsibility by the pregnant women regarding the well-being of their babies,
is divided into three subscales. The Internal subscale (FHLC-I) measures the extent
to which pregnant women perceived that they themselves are responsible for the
health of their baby; the Chance subscale (FHLC-C) measures their expectation that
it is chance that affects their baby’s health outcomes; and the Powerful-Others subscale (FHLC-PO) measures their expectation that some external powerful other person affects their babies’ health outcomes.
Several studies have examined the role of these beliefs in health related behaviours during pregnancy addressing such aspects as attending prenatal classes, smoking status, caffeine consumption, folic acid intake, intention to breastfed, prenatal
testing and adherence to prenatal health guidelines (Haslam & Lawrence, 2004;
Haslam, Lawrence, & Haefali, 2003; Labs & Wurtele, 1986; Tinsley, 1993). In general the greater the Internal control (i.e. the greater the score in FHLC-I) the more
likely it is that women engage in the health recommendations, and vice versa. The
Chance subscale has been reported to have either no effect or a negative association
with recommended health behaviour; that is, the higher the score in FHLC-C, the
less likely women are to adhere to health recommendations. The Powerful-Other
subscale has either no effect or a positive association with health compromising
behaviour.
In spite of the fact that this scale has been used extensively to predict various
health behaviours during pregnancy, few of these studies have been within a nonEnglish-speaking setting. This study is the first using the FHLC scale to assess
Indonesian pregnant women’s adherence to iron supplement in terms of their health
locus of control beliefs.
Methods
The study was conducted in the subdistrict of South Kuta, in Bali, Indonesia. The
area is inhabited by 32,796 people with approximately 446 pregnant women in
2007 (Community Healthcare Centre of South Kuta, 2007).
The health service delivery system in this area, as for the rest of Indonesia, is
organised on five levels: central, provincials, districts, subdistricts and villages. The
Community Health Centre (Pusat Kesehatan Masyarakat – Puskesmas) at the subdistrict level, along with subhealth centres (Puskesmas Pembantu – Pustu) at the village
level, deliver primary health care services to the community. Maternal and child
health care in each village is also provided by private midwife clinics under the supervision of community health centres. There is one community health centre and six
subhealth centres in addition to 14 private midwife clinics in South Kuta subdistrict.
Three hundred and sixty pregnant women from six private midwife clinics and
six subhealth centres who were in at least their second trimester and had sought
antenatal care for pregnancy at a subhealth centre or from a village midwife clinic
on at least two occasions were invited to participate in this study. Pregnant women
in their first trimester were excluded because they may not have known that they
were pregnant and were unlikely to be taking iron supplements.

Downloaded by [UNSW Library] at 22:23 19 September 2013

96

L.P.L. Wulandari et al.

A survey instrument was developed. This questionnaire asked for information
regarding the adherence to iron supplement intake in addition to sociodemographic
characteristics and the FHLC scale.
Compared to other more costly measures, self-report was considered the most
practical way of measuring adherence (Svarstad, Chewning, Sleath, & Claesson,
1999). In order to avoid recall biases (Coughlin, 1990), participants were asked to
report their adherence during the previous week. This method was also used in an
iron supplement adherence study in the USA (Jasti, Siega-Riz, Cogswell, Hartzema,
& Bentley, 2005).
It is suggested that repeating questions using different phrases provide more reliable responses (Abramson, 1990). Participants were asked about how many days
they have taken iron during the last week. They were then asked how many times
they had missed taking iron tablets in the last week. These questions were then analysed for congruency.
Variables around perceived responsibility towards foetal health were included in
the questionnaire using the FHLC scale (Labs & Wurtele, 1986). For each item in
the scale, answers were scored using a 5-point likert scale from ‘strongly agree’
(scored 5) to ‘strongly disagree’ (scored as 1). This response method was also used
in a study in the UK (Haslam & Lawrence, 2004).
As no prenatal classes were available in the study settings, one item of the
FHLC scale was slightly modified. The original version was worded as: ‘Attending
prenatal classes taught by competent health professional can greatly influence the
odds of having a healthy normal baby’. This was modified for this study to become
‘Attending the antenatal care clinic for antenatal care visits can greatly influence the
odds of having a healthy normal baby’.
As this research was conducted in Indonesia and the participants’ native language is not English, the questionnaire was translated into Bahasa Indonesia. To
account for cross-cultural and linguistic issues, especially as the FHLC scale has
been validated in English, a back-translation method was used as suggested by
Sperber (2004). The questionnaire was first translated into Indonesian. The Indonesian translation, done by the investigator, was then translated back into English by
another translator, an Indonesian doctor, who had not seen the original questionnaire. These two versions were then compared by the investigator and refinements
made accordingly.
After the development and cross-cultural translation process, the questionnaire
was piloted and refined prior to the fieldwork. Pilot testing is also useful in providing information regarding unanswered items (Abramson, 1990). The pilot study
involved women with similar characteristics to the study population. Six Indonesian
pregnant women who lived in Sydney and in Bali were invited to participate.
Among the six women, one had not finished primary school and another was doing
her PhD. The inclusion of women with both low and high levels of education
allowed evaluation of the readability, comprehension of the questions and differences in responses (Abramson, 1990).
A section for recommendations and suggested modification was included at the
end of the pilot survey. All six invited women completed and returned the questionnaire, with no questions left unanswered. Their recommendations for modifications
were taken into account in refining the questionnaire until the questionnaire was
confirmed by these participants as being easy to read and understand.

Journal of Reproductive and Infant Psychology

97

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Following the planning process, data collection was conducted between January
and April 2007. Written approvals were received from the heads of the Health
Centre of South Kuta and of the Health Office of Badung, Bali. Ethical approval
was obtained from the Human Research Ethics Advisory Panel at the University of
New South Wales.
Questionnaires were distributed to the midwives in the subhealth centres and in
the private midwife clinics. Participants completed the questionnaires at the clinic.
There was no coercion by midwives and women were reassured that whatever they
decided to do, it would not have any impact on their relationship with the health
staff at the subhealth centres or midwife clinics.
All computer files and questionnaires were stored securely as required by the
University of New South Wales Human Ethics Research Committee regulations.
Data analysis
Analysis was conducted using SPSS for windows version 13.0 (SPSS Inc. 2004).
The frequency of taking iron tablets was grouped into < 4 days a week (categorised
as non-adherent) and P 4 days a week (grouped as adherent). This cut-off point is
similar to taking iron supplements at least 65% of the recommended intake and has
been used in several studies (Jasti et al., 2005; Suitor & Gardner, 1990; Yu, Keppel,
Singh, & Kessel, 1996). It is also in line with the recommendation that compliance
with 60 mg daily elemental iron supplements is sufficient to produce maximal haemoglobin response (Ekström et al., 2002; Sloan, Jordan, & Winikoff, 2002).
A t-test was used to test the differences between the adherent and non-adherent
groups. Prior to comparison of participants with regards to their scores on the
FHLC scale, the reliability of the scale was checked to ensure that it reflected the
construct using Cronbach’s alpha (Field, 2005). To estimate predictors of adherence
to iron supplement use, multivariate analysis via logistic regression was performed.
Results
Three hundred and sixty questionnaires were distributed through six subhealth centres and six private midwife clinics; one village midwife clinic and one subhealth
centre in each of the six villages included in the study. Two hundred and eightyone questionnaires were included in the analysis.
The participants’ age ranged from 16 to 40 years old with a mean (SD) of 26.3
(± 4.9) years. Gestational age ranging from 12 to 40 weeks with mean (SD) of 28.7
(± 6.8) weeks. The highest level of education completed by half of the participants
was ‘secondary school or below’. Almost all of pregnant women were married
(98.2%). Balinese (65.1%) and Hindu (65.5%) comprised almost twice as many as
non-Balinese and non-Hindu. Over half stated that this was not their first pregnancy
(63.3%) and reported a previous birth (60.1%), while it was the first pregnancy for
39.9% of the women.
Almost a quarter (20.3%) of participants admitted that they did not take iron
tablets in the previous week. Because adherence in this study context was defined
as taking iron supplements for at least 4 days a week, almost half of participants,
i.e. 130 women (46.3%), were classified as non-adherent.
Before the analysis, the reliability of the FHLC scale was examined using Cronbach’s alpha. The scale was demonstrated to have good internal consistency. The

98

L.P.L. Wulandari et al.

Table 1. Comparison among pregnant women who were adherent and non-adherent with
respect to FHLC mean scores.
Adherence

FHLC Scale
Internal (range = 17–30)
Chance (range = 9–30)
Powerful-Other (range = 14–30)

Non-adherent
Mean (SD)
(n = 130)

Adherent
Mean (SD)
(n = 151)

t value

p value

24.9 (2.7)
22.4 (4.2)
22.2 (4.0)

26.0 (2.2)
18.6 (5.0)
22.6 (3.6)

–3.46
7.06
–0.92

0.001
< 0.001
0.356

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Table 2. Predictors of iron supplementation adherence.
Predictors of adherence

OR

95% CI

p value

FHLC-Internal
FHLC-Chance
FHLC-Powerful Other

1.19
0.84
1.03

1.07–1.31
0.80–0.89
0.97–1.10

0.001
< 0.001
0.355

Internal subscale, the Chance subscale, and the Powerful-Others subscale had Cronbach alpha coefficients of 0.63, 0.82, and 0.76, respectively.
Among variables included in the t-test analysis, the adherent and non-adherent
group was statistically significantly different in terms of FHLC Internal (p = 0.001)
and the Chance subscales (p < 0.001) (Table 1).
The model of logistic regression showed (Table 2) that those who had a higher
Internal scale were 1.2 times more likely to adhere to take iron tablets (OR = 1.19;
95% CI = 1.07–1.31; p = 0.001); while those who had higher Chance score were
less likely to adhere to take iron (OR = 0.84; 95% CI = 0.80–0.89; p < 0.001).
Discussion
This study showed that almost half the pregnant women surveyed (46.3%) were
non-adherent according to the definition of adherence used in this study. This was
lower than a previous study in South Kuta which revealed that more than 90% of
pregnant women in this area did not take iron supplements as recommended
(Gunung, Arhya, Wirakusuma, Indraguna, & Supriyadi, 2003). Differences in definition of adherence affect any comparisons between the two studies. The current
study defines adherence as taking iron supplements at least 4 days a week, while
the study by Gunung et al. strictly defined adherence as taking iron supplements
seven days a week. However, most of studies on iron intake adherence worldwide
supported the current study with adherence rates ranging from 32.3% to 65% (Dairo
& Lawoyin, 2006; Ekstrom et al., 1996; Hyder, Persson, Chowdhury, & Ekström,
2002; Knudsen, Hansen, Ovesen, Mikkelsen, & Olsen, 2007; Nordeng, Eskild, Nesheim, Aursnes, & Jacobsen, 2003; Schultink, van der Ree, Matulessi, & Gross,
1993).
There were differences between pregnant women who were adherent and nonadherent in terms of their score on the FHLC-Internal and FHLC-Chance subscales;
those who had a higher Internal score and a lower Chance subscale score of FHLC
were more likely to be adherent.

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Journal of Reproductive and Infant Psychology

99

The finding that a higher Internal subscale score correlates with increased adherence to supplement intake is consistent with studies in the UK (Haslam et al.,
2003) and in the USA (Tinsley, 1993), which revealed that a higher Internal subscale score correlated with a higher adherence to several recommended behaviours
during pregnancy. Taken together, these findings indicate that the greater their perceived responsibilities over the health of the baby, the more likely women are to
adhere to healthy behaviours, including adherence to iron supplement usage.
This study also found that a lower score on the Chance subscale of the FHLC
was correlated with increased adherence. This might indicate that the stronger the
belief that nature and fate will determine the baby’s outcome, the less likely it is
that women will adhere to recommended dosages of iron supplements. This finding
is inconsistent with a study in the USA by Tinsley (1993), which found no significant correlation with health behaviour. However, in a qualitative study among Thai
women (Rice & Naksook, 1999), the role of beliefs about fate and nature negatively
influenced decisions to engage in healthy behaviour during pregnancy. Rice and
Naksook found that strong beliefs regarding the role of chance in determining the
health of the baby had discouraged pregnant women from undergoing prenatal testing. The finding of a negative association between adherence with the Chance subscale was also substantiated by findings from the qualitative part of this study
regarding beliefs around the role of nature and God in determining the health of the
baby (Wulandari & Klinken Whelan, 2011).
Strengths and limitations of the study
The findings of this study must be taken cautiously due to the following limitations.
First, although it is assumed that the questionnaire responses accurately reflected
the pregnant woman’s behaviour, and a questionnaire measuring adherence to iron
supplements is considered to have high validity (Lutsey, Dawe, Villate, Valencia, &
Lopez, 2007), systematic distortion is possible. There was no verification of the
women’s adherence as based on self-reporting. It is possible that the number of non
compliant pregnant women might have been higher, because not all may have
admitted that they did not take iron supplements. Hence this method of measuring
adherence potentially overestimates the adherence data.
Second, the study sample was chosen among women who sought antenatal care
at subhealth centres and village midwife clinics. This was done because under the
supervision of the community health centres, these centres are responsible for the
maintenance of the mother and foetal well-being in the villages and subdistricts.
This responsibility includes implementing the iron tablet distribution by giving iron
tablets to all pregnant women who seek antenatal care at these institutions. Involving these women in this study enables evaluation of the existing iron tablet distribution. However, this might limit the generalisability of the study by limiting it to
pregnant women who routinely monitor their pregnancy at the subhealth centres
and with private midwife clinics.
Recommendation for future research
Further research needs to be performed using more reliable measurements to
increase the validity of the data. Dietary assessment and measures of actual iron
levels of pregnant women would provide more robust validation of levels of iron

100

L.P.L. Wulandari et al.

insufficiency in South Kuta. Neonatal screening for iron deficiency would further
enhance the meaningfulness of the reported research. This study suggests that there
is a crucial role of effective communication between healthcare providers and
patients in promoting adherence behaviours among pregnant women in Bali.
Acknowledgements

Downloaded by [UNSW Library] at 22:23 19 September 2013

The authors would like to acknowledge the pregnant women who participated in this study,
and Community Healthcare Centre of South Kuta, Bali. We would also like to acknowledge
Ms Sally Nathan and thank her for her assistance and comments on this study. Thanks to
Van Ngu Yen who strengthened the statistical and SPSS expertise to manage the quantitative
data. This study was conducted in fulfilment of the requirements for the degree of Master of
Public Health at the School of Public Health and Community Medicine, the University of
New South Wales and supported by Australian Development Scholarship kindly provided by
the Government of Australia.

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