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ORIGINAL ARTICLE
Year : 2021  |  Volume : 19  |  Issue : 1  |  Page : 37-41

Knowledge, attitude, and behavior related to secondhand smoke exposure among pregnant women with smoking spouses in Davangere City: A cross-sectional survey


1 Professor, Department of Public Health Dentistry, Bapuji Dental College and Hospital, Davanagere, Karnataka, India
2 Chief Dental Surgeon, CAPFs Composite Hospital, BSF, Patgoan, Guwahati, Assam, India
3 Interns, Bapuji Dental College and Hospital, Davanagere, Karnataka, India

Date of Submission22-Jan-2020
Date of Decision19-Feb-2020
Date of Acceptance11-Jan-2021
Date of Web Publication31-Mar-2021

Correspondence Address:
Puja Chandrashekar Yavagal
Department of Public Health Dentistry, Bapuji Dental College and Hospital, Davangere - 577 004, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaphd.jiaphd_15_20

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  Abstract 


Background: Exposure to secondhand smoke among pregnant women is highly prevalent in India. Secondhand smoke exposure is linked with various serious deleterious health problems. Aim: The aim of this study was to assess knowledge, attitude, and behavior related to secondhand smoke exposure among pregnant women with smoking husbands in Davangere city. Materials and Methods: A descriptive cross-sectional questionnaire survey was conducted among 245 nonsmoking pregnant women with smoking husbands attending two antenatal clinics in Davanagere city using pretested, validated, investigator-administered closed-ended 18 item questionnaire. Responses to items were placed on a 3-point Likert scale. Statistical significance was set at P < 0.05. IBM SPSS Statistics for Windows, version 21 (IBM Corp., Armonk, N.Y., USA) was used for statistical analysis. Descriptive statistics were generated in terms of percentages. Results: The mean age of study participants was 26.22 ± 4.11 years. Majority of pregnant women were unaware of secondhand smoke exposure (>60%). They were unaware of its systemic complications such as cardiac problems, respiratory problems, and cancer. They were unaware of the harmful effects of secondhand tobacco smoke (SHS) on fetus/child (>60%) which indicated poor knowledge of participants toward harmful effects of secondhand smoke exposure majority of participants showed favorable attitude (>50%) and felt the need to get educated regarding SHS. Majority reported positive behavior by refraining themselves from secondhand smoke (>50%). Conclusions: Knowledge regarding secondhand smoke exposure among pregnant women with smoking husbands was poor. Inspite of having favorable attitude and behavior toward avoidance of smoke exposure, majority of women felt helpless in refraining their husbands from smoking.

Keywords: Attitudes, behavior, knowledge, pregnant women, secondhand smoke


How to cite this article:
Yavagal PC, Velangi CS, Desai JM, Gupta H, Sheik FS, Kaushal M. Knowledge, attitude, and behavior related to secondhand smoke exposure among pregnant women with smoking spouses in Davangere City: A cross-sectional survey. J Indian Assoc Public Health Dent 2021;19:37-41

How to cite this URL:
Yavagal PC, Velangi CS, Desai JM, Gupta H, Sheik FS, Kaushal M. Knowledge, attitude, and behavior related to secondhand smoke exposure among pregnant women with smoking spouses in Davangere City: A cross-sectional survey. J Indian Assoc Public Health Dent [serial online] 2021 [cited 2021 Apr 13];19:37-41. Available from: https://www.jiaphd.org/text.asp?2021/19/1/37/312639




  Introduction Top


Tobacco smoking, now and in the past, has been a custom and addiction primarily of men, leaving women and children as the majority of the world's passive, or involuntary, smokers.[1] Secondhand tobacco smoke (SHS) comprises the smoke released from the burning tip of a cigarette (or other smoked tobacco product) between puffs (called sidestream smoke) and the smoke exhaled by the smoker (exhaled mainstream smoke).[2] Sidestream smoke, generated at lower temperatures than mainstream smoke, tends to have higher concentrations of many of the toxins in cigarette smoke.[1] SHS exposure from either maternal or paternal smoking may lead to postnatal health effects among children, including increased risk for Sudden Infant Death Syndrome (SIDS), reduced physical development, decrements in cognition and behavior, and increased risk for childhood cancers.[1] Exposure to environmental tobacco smoke during pregnancy is associated with higher risk of having a small-for-gestation baby.[3] The International Consultation on Environmental Tobacco Smoke and Child Health concluded that maternal smoking during pregnancy is a major cause of reduced birth weight, decreased lung function, and SIDS in newborns.[4]

Pregnant women exposed to passive smoking are likely to have sleep disturbances such as insufficient sleep, difficulty in initiating sleep, short sleep duration, and snoring loudly/breathing uncomfortably.[5] An investigative survey conducted by Bloch et al. to study exposure of pregnant women and their young children to secondhand smoke in developing nations reported that exposure to SHS among pregnant women was common and it varied between 17.1% (Democratic Republic of Congo) and 91.6% (Pakistan). Also, it was seen in the same survey that 90.4% and 83% of pregnant women from sites of Orissa and Karnataka, respectively, lived with one or more than 1 household family member smoking. 19.9% of pregnant women and 27.8% of children aged 5 years and younger in Karnataka were exposed to tobacco smoke indoors.[6]

Pregnancy is theorized as a “teachable moment” for women, when their perception of health risk is heightened.[7],[8] The WHO Framework Convention on Tobacco Control has prompted many countries to implement smoking bans in public places and workplaces to protect the health of non-smokers. These initiatives are a necessary but only partial step toward fully protecting nonsmokers from SHS, as women and children spend a great deal of time in their homes, an environment beyond the reach of regulation.[1] It is important to identify the knowledge, attitude, and behavior of pregnant women in avoidance of exposure to SHS which may contribute to the development of suitable guidelines for protecting the mother and fetus from SHS. A literature search revealed lack of data in this area in India. Hence, this study was conducted to assess the knowledge, attitude, and behavior of non-smoking pregnant women with smoking husbands related to SHS exposure and in the process to create awareness regarding harmful effects of secondhand smoke exposure to study participants. The aim of the study was to assess knowledge, attitudes, and behaviors related to secondhand smoke exposure among pregnant women with smoking husbands in Davangere city.


  Materials and Methods Top


The study design was a cross-sectional, questionnaire survey, conducted among 245 nonsmoking pregnant women with smoking husbands attending the following antenatal clinics in Davangere city: CG hospital, Davangere, and Bapuji Hospital, Davangere, Karnataka. Permission for conducting the study was obtained from concerned authorities. A detailed research protocol of the survey was submitted to the Institutional review board of Bapuji Dental College and Hospital for scrutiny and ethical approval (Ref. No. BDC/Exam/016/2018-19 dated April 16, 2018) was obtained. The questionnaire was administered by the investigators and the responses of the study subjects were recorded at the premises of the outpatient department of antenatal clinics of the above-mentioned hospitals. The sample size was estimated using the formula n = (Z1-a)2 × p (1 − p)/(d)2 and using proportion from previous study.[6] Z2 was 1.96, P = 19.9% - Proportion of pregnant women exposed to SHS indoors in Karnataka based on the previous study,[6] d = 0.05 (precision). The estimated sample size was 236(n) which was made 245. A convenient, consecutive sampling technique was followed to select 245 pregnant women visiting the above-mentioned clinics and fulfilling the inclusion criteria on the scheduled dates of the study. Pregnant women with smoking husbands who visited the outpatient clinics and gave consent for participation in the study were included in the sample in the order of their presentation to the clinic until the sample size was met. Pregnant women who were smokers were excluded.

Designing the questionnaire

An investigator-administered, closed-ended, 18-item questionnaire was used to assess the knowledge, attitude, and behavior related to secondhand smoke exposure among pregnant women with smoking husbands.

The questionnaire consisted of five sections, namely Section I was designed to record sociodemographic details, Section II had four items to record the history of secondhand smoke exposure, Section III contained four questions designed to assess knowledge of pregnant women about secondhand smoke exposure, Section IV contained five items designed to assess the attitude of pregnant women toward secondhand smoke exposure

Section V had five items designed to assess the behavior of pregnant women toward secondhand smoke exposure.

Responses to items assessing the knowledge, attitude, and practices were recorded as Yes, No, and Don't Know.

Validity of the questionnaire

  1. Content validity - Four subject experts (Professor of Public Health Dentistry, Professor of Community Medicine, Reader in Oral medicine and Radiology, Obstetrician and Gynecologist) validated the questions by scoring relevance, clarity, simplicity, and ambiguity of items on four-point rating scale for each item in the questionnaire in order to calculate content validity index (CVI). According to Yaghmale F, the item with CVI score over 0.75 was recommended as acceptable CVI value.[9] A satisfactory level of agreement was found as reflected by every score for each item among the four experts, i.e., CVI score for relevance = 0.97, clarity = 0.86, simplicity = 0.94, and ambiguity = 0.97, respectively. These CVI values suggested that the questionnaire had a good content validity
  2. Face validity - Face validity of the prepared questionnaires was determined by distributing the questionnaires to five pregnant ladies who visited the Department of Oral Medicine and Radiology in Bapuji Dental College and Hospital for routine dental checkup. A satisfactory level of agreement was found among subjects regarding the clarity and understandability of the questions and language of the questionnaire.


Informed consent was obtained from the pregnant women after explaining them about the purpose of conducting the study.

Statistical analyses

The data obtained were compiled systematically in Microsoft Excel sheet and subjected to statistical analyses using the Statistical Package for the Social Sciences software. Descriptive statistics were generated in terms of percentages. Statistical significance was set at P ≤ 0.05.


  Results Top


A total of 245 pregnant women participated in the study. The mean age of the study participants was 26.22 ± 4.11 years. Around 55.1% of women belonged to upper-middle class, followed by the lower middle class (31%) and middle class (13.9%) based on BG Prasad's socioeconomic status classification. Around 41.1% and 40.4% were in the second and third trimesters of pregnancy and 18% of them were in the first trimester. Majority of subjects (50.6%) reported daily exposure to secondhand smoke. 24.5% of them reported occasional/rare; 19.2% reported weekly exposure and 5.7% of them experienced monthly exposure. In 39.6% of homes, smoking was allowed in all parts of home, in 35.5% of homes, it was allowed in some parts of home, and in 24.9% of homes, there was smoking ban. Around 40.4% of women reported that their husbands consumed <5 cigarettes/bidis per day, followed by 34.3% of women whose husbands smoked upto 5–10 per day and 25.3% of pregnant women who reported that their husbands smoked more than 10 cigarettes/bidis daily [Table 1]. Around 25.7% of them reported SHS exposure from family members, 26.9% from relatives, and 25.8% of them from friends and colleagues at workplace. Around 21.6% of them reported no SHS exposure except for exposure from husbands [Table 1]. Around 40.8% of subjects were not aware of what secondhand smoke was and around 47.8% of them were aware that SHS was injurious to health. More than 50% of subjects were aware that SHS was associated with cancer and respiratory problems. Majority of subjects (54.7%) were not aware that SHS was associated with cancer, respiratory and cardiac problems [Table 2]. Majority of pregnant women (more than 60%) were unaware of the association of SHS with low birth weight babies, crib death, spontaneous abortions, preterm delivery, respiratory problems in children, and heart problems [Table 2].
Table 1: Distribution of study population based on secondhand smoke exposure history

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Table 2: Distribution of study population based on responses of knowledge-related questions

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More than 55% of subjects found it unpleasant to be in the vicinity of smoking person. They found SHS to be offensive, felt helpless regarding restraining themselves from husbands who smoked, and felt the need to be educated regarding harmful effects of SHS [Table 3]. More than 60% distanced themselves from SHS exposure and 32.2% never allowed people at their homes to smoke. 51% of them avoided SHS exposure while traveling by asking smoker to stop smoking. However, 47.8% of women occasionally avoided going to places where they sensed the threat of SHS exposure [Table 4].
Table 3: Distribution of study population based on responses to attitude related to secondhand smoking

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Table 4: Distribution of study population based on responses to behavior related to secondhand smoking

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  Discussion Top


A cross-sectional study was done to assess the knowledge, attitude, and behavior of nonsmoking pregnant women with smoking husbands related to SHS exposure revealed that they had poor knowledge regarding the harmful effects of SHS. This result is in line with the results of a study done by Goel et al.[3] and results of the study done among Chinese pregnant women by Yang et al.[10] where majority of pregnant women were unaware about SHS. However, majority of women (80%) were aware of the harmful effects of SHS on the fetus in a study done by Goel et al.,[3] but the present study results indicate that more than 60% were unaware that SHS is linked with low birth weight babies, crib death, spontaneous abortive preterm delivery, respiratory problems in children, and heart problems.

In India, the SHS exposure rate among pregnant women at home was found to be 25% according to a study done by Mistry and Dasika[11] as compared to 50% in the present study who reported daily exposure to SHS due to smoking husbands. Exposure rate was high among socioeconomically disadvantaged pregnant women due to lack of awareness regarding harmful effects of SHS as reported by a study done by Mistry and Dasika.[11] In a study done by Bloch et al.,[6] investigating SHS smoke exposure during pregnancy in developing Nations, it was observed that 10.5% and 19.9% of pregnant women in Orissa and Karnataka reported daily exposure to SHS indoors. In the present study, 75.1% reported that smoking was allowed in the home while a study done by Bloch et al.[6] revealed that around 55.4% and 43.3% in Orissa and Karnataka reported that smoking was allowed in homes. Secondhand smoke is a combination of sidestream smoke that is released from burning beedi or cigarette and mainstream smoke that is exhaled by the smoker. The toxins in secondhand smoke are more than mainstream smoke.[12] SHS has been classified as a class A human carcinogen as it contains toxins like tar, nicotine, benzene, radioactive compounds etc. The effects of second-hand smoke are enhanced by overcrowding and poorly ventilated homes in the low socioeconomic strata of society. Living with smokers has a negative impact on a non-smoker's practical ability to avoid SHS exposure.[12]

Inspite of knowledge on SHS risks, exposure was prevalent among pregnant women in the present study. Considering the social and cultural aspects of Indian society, it was not surprising that pregnant women had difficulty in negotiating for smoking restrictions at home. In lower socioeconomic classes, this is expected to be prominent as families are often more culturally conservative and traditional. The present study revealed poor knowledge among pregnant women regarding the harmful effects of SHS on the general health and health of developing fetus. This is a matter of concern as many studies have shown that SHS exposure during pregnancy may lead to sudden infant death syndrome, increased risk of childhood cancers, low birth weight babies, and preterm births.[13] This study results could not be compared with other studies as on literature search authors could not find any similar study assessing the knowledge of pregnant women toward SHS. However, a study done among employed nonsmoking women where their knowledge regarding SHS was assessed; it was seen that they were knowledgeable about risks of SHS exposure and also in a cross-sectional study done among Chinese nonsmoking.

pregnant women, it was observed that knowledge regarding SHS among rural pregnant women was very low.[10] Although the participants in the present study exhibited favorable attitude and behavior toward avoidance of SHS, majority of them felt helpless in restraining husbands from smoking and smoking was allowed at some or all parts of their homes. This situation reflects the cultural and traditional barrier toward preventing SHS exposure among pregnant women.

With the scarcity of literature about knowledge, attitude, and behavior of pregnant women about secondhand smoke exposure, this could be the preliminary step in understanding the extent of problem. Studies across various populations are needed in order to understand the severity of the problem. Since this study included pregnant women of Davanagere city, results can least be generalized to the study population. Since it was a questionnaire-based study recall bias may have affected the responses.


  Conclusions Top


Knowledge related to secondhand smoke exposure among pregnant women with smoking husbands was found to be poor. Inspite of having favorable attitude and behavior toward avoidance of SHS exposure, majority of pregnant women felt helpless in restraining their husbands from smoking and smoking was allowed at some and all parts of their homes. Evaluation of SHS among pregnant women and steps to avoid it during pregnancy should be part of antenatal care. Gynecologists, primary health-care workers, and nurses should capitalize on adverse maternal and child health effects of SHS in preventive programs and help pregnant women against SHS exposure as the WHO in its recommendations for the prevention and management of tobacco use and SHS exposure in pregnancy has emphasized on the need for effective screening by health-care provider for tobacco exposure among pregnant women during routine antenatal visits.

Acknowledgment

The authors would like to acknowledge all the undergraduate students who have contributed for the collection of data and all the participants. We would also like to acknowledge the Deputy Director, Department of Women and Child Development, Davangere, for giving us this opportunity to conduct the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Jonathan MS, Soon-Young Y & World Health Organization. Gender, Women, and the Tobacco Epidemic/edited by Jonathan M. Samet and Soon-Young Yoon. World Health Organization; 2010. Available from: https://apps.who.int/iris/handle/10665/44342. [Last accessed on 2021 Feb 04].  Back to cited text no. 1
    
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Office of the Surgeon General (US); Office on Smoking and Health (US). The Health Consequences of Smoking: A Report of the Surgeon General. Atlanta (GA): Centers for Disease Control and Prevention (US); 2004. Available from: https://www.ncbi.nlm.nih.gov/books/NBK44695/. [Last accessed on 2021 Feb 04].  Back to cited text no. 2
    
3.
Goel P, Radotra A, Singh I, Aggarwal A, Dua D. Effects of passive smoking on outcome in pregnancy. J Postgrad Med 2004;50:12-6.  Back to cited text no. 3
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Institute of Medicine (US) Committee on the Assessment of Asthma and Indoor Air. Clearing the Air: Asthma and Indoor Air Exposures. Washington (DC): National Academies Press (US); 2000.  Back to cited text no. 4
    
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Ohida T, Kaneita Y, Osaki Y, Harano S, Tanihata T, Takemura S, et al. Is passive smoking associated with sleep disturbance among pregnant women? Sleep 2007;30:1155-61.  Back to cited text no. 5
    
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Bloch M, Althabe F, Onyamboko M, Kaseba-Sata C, Castilla EE, Freire S, et al. Tobacco use and secondhand smoke exposure during pregnancy: An investigative survey of women in 9 developing nations. Am J Public Health 2008;98:1833-40.  Back to cited text no. 6
    
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McBride CM, Emmons KM, Lipkus IM. Understanding the potential of teachable moments: The case of smoking cessation. Health Educ Res 2003;18:156-70.  Back to cited text no. 7
    
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DiClemente CC, Dolan-Mullen P, Windsor RA. The process of pregnancy smoking cessation: Implications for interventions. Tob Control 2000;9 Suppl 3:III16-21.  Back to cited text no. 8
    
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Zamanzadeh V, Ghahramanian A, Rassouli M, Abbaszadeh A, Alavi-Majd H, Nikanfar AR. Design and Implementation Content Validity Study: Development of an instrument for measuring Patient-Centered Communication. J Caring Sci 2015;4:165-78.  Back to cited text no. 9
    
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Yang L, Tong EK, Mao Z, Hu TW. Exposure to secondhand smoke and associated factors among non-smoking pregnant women with smoking husbands in Sichuan province, China. Acta Obstet Gynecol Scand 2010;89:549-57.  Back to cited text no. 10
    
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Mistry R, Dasika A. Antenatal tobacco use and secondhand smoke exposure in the home in India. Nicotine Tob Res 2018;20:258-61.  Back to cited text no. 11
    
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Khattar D, Awasthi S, Das V. Residential environmental tobacco smoke exposure during pregnancy and low birth weight of neonates: Case control study in a public hospital in Lucknow, India. Indian Pediatr 2013;50:134-8.  Back to cited text no. 12
    
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Krishnamurthy AV, Chinnakali P, Dorairajan G, Sundaram SP, Sarveswaran G, Sivakumar M, et al. Tobacco use, exposure to second-hand smoke among pregnant women and their association with birth weight: A retrospective cohort study. J Family Med Prim Care 2018;7:728-33.  Back to cited text no. 13
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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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