Toxoplasmosis prevention: knowledge and practices among pregnant women in Jordan
Intended for healthcare professionals
Evidence and practice    

Toxoplasmosis prevention: knowledge and practices among pregnant women in Jordan

Mohammad Suliman Associate professor, Faculty of Nursing, Al al-Bayt University, Mafraq, Jordan
Kholoud Assmairan Clinical instructor, Faculty of Nursing, Al al-Bayt University, Mafraq, Jordan
Hind Al sheikh Clinical instructor, Faculty of Nursing, Al al-Bayt University, Mafraq, Jordan
Maen Aljezawi Associate professor, Faculty of Nursing, Al al-Bayt University, Mafraq, Jordan
Hanan Abu Musameh Clinical instructor, Faculty of Nursing, Al al-Bayt University, Mafraq, Jordan
Salwa Abu Alrob Clinical instructor, Faculty of Nursing, Al al-Bayt University, Mafraq, Jordan
Mohammed ALBashtawy Professor, Faculty of Nursing, Al al-Bayt University, Mafraq, Jordan

Why you should read this article:
  • To refresh your knowledge about routes of infection and risk factors in toxoplasmosis

  • To learn about toxoplasmosis knowledge and practices among pregnant women in Jordan

  • To understand the preventive practices required from pregnant women to avoid toxoplasmosis

Background Toxoplasmosis is a common zoonotic infection which, in pregnant women, can result in miscarriage, stillbirth or child disability. Prevention and education play a crucial role in reducing the risks of infection and complications.

Aim To assess the knowledge and practices of pregnant women in Jordan in relation to toxoplasmosis and its prevention.

Method A cross-sectional descriptive study was conducted in a convenience sample of 583 pregnant women visiting a health centre, hospital or private gynaecology clinic in the Jordanian governorate of Mafraq. The governorate has the second-largest population of Syrian refugees in Jordan. A structured questionnaire was used to collect data on participants’ knowledge and practices.

Results Of the 583 participants, 75% had never heard of toxoplasmosis. Participants demonstrated, to varying degrees, some adequate knowledge of toxoplasmosis prevention and some adequate use of preventive practices. None of the sociodemographic characteristics of participants was predictive of their level of knowledge of toxoplasmosis, except nationality: Syrian women had a statistically significant lower level of knowledge than Jordanian women.

Conclusion There are gaps in knowledge and practices among pregnant women in Jordan in relation to toxoplasmosis and its prevention. Improved health education, particularly for female Syrian refugees living in Jordan, could enhance knowledge and practices, thereby reducing the risks of infection and complications.

Primary Health Care. doi: 10.7748/phc.2021.e1702

Peer review

This article has been subject to external double-blind peer review and has been checked for plagiarism using automated software

Correspondence

mbarahemah@aabu.edu.jo

Conflict of interest

None declared

Suliman M, Assmairan K, Al sheikh H et al (2021) Toxoplasmosis prevention: knowledge and practices among pregnant women in Jordan. Primary Health Care. doi: 10.7748/phc.2021.e1702

Published online: 05 May 2021

Introduction

During pregnancy, women are more vulnerable to several conditions that can have serious consequences on their health and well-being, on the outcome of their pregnancy and on the health of their future child. One of these conditions is toxoplasmosis, a zoonotic infection caused by the intracellular protozoan parasite Toxoplasma gondii, which is found in mammals such as cats and humans (Tenter et al 2000). Primary prevention plays a crucial role in reducing the risk of infection, thereby preventing the complications of toxoplasmosis in pregnancy (Kriebs 2008). In Jordan, the prevalence of toxoplasmosis in pregnant women is estimated to be around 47% (Jumaian 2005), but despite this high prevalence, there is a lack of studies exploring pregnant women’s knowledge and practices in relation to toxoplasmosis and its prevention. This article reports on a cross-sectional descriptive study conducted among 583 pregnant women in Jordan.

Background

Cats are the primary hosts of Toxoplasma gondii and can excrete the parasite’s oocysts in their faeces. Once released into the environment, these can infect other animals and humans. Humans can acquire the infection through different routes, but the food-borne route is particularly relevant and infection often occurs through the consumption of undercooked meat or unwashed fruit and vegetables (World Health Organization (WHO) 2015).

Toxoplasmosis typically causes no visible signs in adults. Occasionally, infected people may experience a few weeks or months of moderate flu-like symptoms such as aching muscles and tender lymph nodes. A small number of people may also experience sight impairment (Kriebs 2008). However, people with a compromised immune system are at a higher risk of developing a severe form of toxoplasmosis (WHO 2015).

Pregnancy causes changes in immunity that increase the risk of women acquiring infections such as toxoplasmosis (Many and Koren 2006). Toxoplasmosis in women just before or during pregnancy can result in miscarriage, stillbirth or child disability (WHO 2015). In more than 40% of pregnant women who have toxoplasmosis, complications can lead to early miscarriage (Montoya and Liesenfeld 2004). Toxoplasmosis can also cause intrauterine growth restriction, cerebrospinal fluid abnormalities and, in some cases, retinochoroidal scarring – with up to 50% of children who acquire toxoplasmosis in utero born prematurely (Dubey et al 2012). Toxoplasmosis can cause harm to the child’s nervous system, skin, sight and hearing (Kaye 2011).

The global incidence rate of congenital toxoplasmosis has been estimated to be approximately 1.5 cases of per 1,000 live births, with high burdens seen in South America and in some Middle Eastern and low-income countries (Torgerson and Mastroiacovo 2013).

In the UK, Nash et al (2005) found a prevalence of toxoplasmosis of 9% (n=172) among a population of 1,897 pregnant women attending antenatal clinics in east Kent. This contrasts with the prevalence of 47% found in pregnant women in Jordan by Jumaian (2005). Obaidat et al (2015) found a 67% rate of infection among female university students in Jordan, which the authors thought was attributable to a lack of awareness of the disease. Obaidat et al (2015) reported significant associations between toxoplasmosis and income level, use and consumption of spring (untreated) water, housing type and climate.

Adequate knowledge of toxoplasmosis among pregnant women can reduce the risk of infection (Kravetz and Federman 2005). Nash et al (2005) stressed the importance of educating women of childbearing age about the risk factors for toxoplasmosis. In a study conducted in Saudi Arabia to assess the knowledge and practices of pregnant women in relation to toxoplasmosis, many participants correctly identified the role of cats in the spread of infection, but failed to identify risk factors such as consumption of undercooked meat, consumption of unwashed fruit and vegetables, and contact with soil (Amin et al 2013).

The major risk factors for toxoplasmosis are: living in a low-income country, lack of sanitation, presence of cats and rodents, consumption of contaminated food, suboptimal hygiene, and not washing fruit and vegetables (Kravetz and Federman 2005). Jumaian’s (2005) descriptive study in pregnant women in Jordan showed that the consumption of uncooked meat and contact with soil were significant risk factors for toxoplasmosis. In Nash et al’s (2005) study in east Kent, toxoplasmosis was associated with living in a rural area, feeding dogs raw meat, increasing age, and childhood spent in a European country other than the UK.

Aim

To assess the knowledge and practices of pregnant women in Jordan in relation to toxoplasmosis and its prevention.

Method

Design

A cross-sectional descriptive study design was used. This was deemed appropriate since there is little information on the study topic. It enabled the researchers – who are the authors of this article – to gather a large amount of data within a short period of time.

Setting

The study population was recruited in healthcare centres, hospitals and private gynaecology clinics in the Jordanian governorate of Mafraq, which is located in the north east of the country. The Mafraq governorate is the second-largest governate in Jordan and the only one that has borders with three other countries – Saudi Arabia, Iraq and Syria.

Jordan is home to around 659,000 Syrian refugees (United Nations High Commissioner for Refugees (UNHCR) 2020), although their number is estimated to be 1.36 million when counting those who are not officially registered (Ministry of Planning and International Cooperation 2020). The Mafraq governate accommodates the second-largest population of Syrian refugees in Jordan. According to the UNHCR (2020), there were, in September 2020, 163,449 Syrian refugees in the Mafraq governate.

The Mafraq governorate has several public universities, one of which is Al al-Bayt University, where the researchers are based. Al al-Bayt University, which comprises faculties of sciences, health, humanities and arts, plays an important role in providing health and education programmes to Syrian refugees living in Jordan.

Sample

Convenience sampling was used to recruit participants among pregnant women attending four healthcare centres, three hospitals and five private gynaecology clinics in the Mafraq governorate. All pregnant women who attended the 12 study locations on the day of data collection were approached and asked whether they wanted to participate. To participate, they had to be aged ≥18 years. They could be in any trimester of pregnancy and from any nationality. Participation was voluntary.

Data collection

Data collection was undertaken during the summer of 2019. Having obtained ethical approval from Al al-Bayt University and the Jordanian Ministry of Health, the researchers approached potential participants. Pregnant women who agreed to participate were given a consent form to read and sign. They were then asked to complete a data collection sheet and return it to the researchers.

The data collection sheet contained a set of questions about participants’ sociodemographic characteristics and a questionnaire assessing participants’ knowledge and practices in relation to toxoplasmosis and its prevention. The questionnaire had been adapted from previous studies on toxoplasmosis (Amin et al 2013, Obaidat et al 2015, Elsafi et al 2015) to ensure all questions were culturally appropriate and easy to understand. It comprised three parts:

  • General knowledge of toxoplasmosis.

  • Knowledge of toxoplasmosis prevention.

  • Participants’ prevention practices.

Data analysis

Data were analysed using SPSS software. Descriptive statistics such as numbers, percentages, means and standard deviations (SDs) were used to describe the study population’s characteristics. Inferential statistics were used to establish predictors of participants’ knowledge of toxoplasmosis.

Results

Sociodemographic characteristics

A total of 583 pregnant women – 83% of all those approached for the study – agreed to participate and completed the data collection sheet. The mean age of participants was 27.9 years (SD=6.7) and the age range was 18-47 years. Approximately two-thirds of participants (n=366, 63%) were Jordanian and one-third were Syrian (n=214, 37%). The majority of participants were literate (n=570, 98%). Most participants (n=520, 89%) lived in a house or flat, with the remainder living in a tent or caravan (n=63, 11%). Only 118 (20%) lived above the poverty line, which in Jordan is officially defined as 400 Jordanian dinars (approximately £440) per household per month.

Table 1 summarises participants’ sociodemographic characteristics.

Table 1.

Participants’ sociodemographic characteristics (n=583)*

Characteristic n %
NationalityJordanian36663
Syrian21437
Other31
LiteracyIlliterate132
Literate57098
Employment statusUnemployed38065
Employed20335
Residence typeTent or caravan6311
House or flat52089
Income levelBelow the poverty line46580
Above the poverty line11820
Co-morbiditiesNone32556
Anaemia16829
Asthma376
Diabetes mellitus326
Hypertension407
History of miscarriageNone27948
One8715
More than one21737
Pregnancy trimesterFirst17430
Second22839
Third18131
Age group≤20 years8515
21-30 years30653
31-40 years16629
>40 years265

Percentages have been rounded up or down so totals do not always equate to 100%

General knowledge of toxoplasmosis

Among the 583 participants, 75% (n=435) had never heard of toxoplasmosis. Those who had previous knowledge of the disease had gained it from relatives, books and magazines, the media and healthcare providers.

In the first part of the questionnaire, participants were asked to respond to six questions regarding their general knowledge of toxoplasmosis. Table 2 shows the questions and participants’ responses.

Table 2.

General knowledge of toxoplasmosis (n=583)*

phc.2021.e1702_0002_tb1.jpg

Depending on the question, the percentage of correct answers (‘yes’) to the six questions in Table 2 ranged from 14% to 39%, therefore a majority of participants either gave an incorrect answer (‘no’) or did not know the answer (‘do not know’). For example, 60% of participants (n=355) either did not think that toxoplasmosis is an infection (n=135, 23%) or did not know the answer to that question (n=220, 37%).

Knowledge of toxoplasmosis prevention

In the second part of the questionnaire, participants were asked to indicate their level of agreement with five statements regarding the prevention of toxoplasmosis. Table 3 shows the statements and participants’ level of agreement with them.

Table 3.

Knowledge of toxoplasmosis prevention (n=583)*

phc.2021.e1702_0003_tb1.jpg

Depending on the statement, between 29% (n=169) and 59% (n=342) of participants had adequate knowledge of toxoplasmosis prevention; that is, either ‘agreed’ or ‘strongly agreed’ with the statements. The statement that attracted the lowest number of correct answers (n=169, 29%) was ‘eating uncooked meat increases the risk of getting toxoplasmosis’. The other four statements all attracted more than 50% of correct answers.

Participants’ prevention practices

In the third part of the questionnaire, participants were presented with ten toxoplasmosis prevention practices and asked to indicate how often they use them – whether ‘not at all’, ‘some of the time’ or ‘all the time’. Table 4 shows the ten practices and how often participants said they use them.

Table 4.

Participants’ prevention practices (n=583)*

phc.2021.e1702_0004_tb1.jpg

The prevention practice most widely used all the time was ‘teaching children to wash their hands’ (n=323, 55%) followed by ‘drinking clean water’ (n=300, 52%). The prevention practice least widely used all the time was ‘undergoing screening for toxoplasmosis’ (n=49, 8%).

Predictors of toxoplasmosis knowledge

Table 5 shows the outcomes of logistic regression analysis for predictors of participants’ knowledge of toxoplasmosis.

Table 5.

Logistic regression analysis for predictors of toxoplasmosis knowledge

phc.2021.e1702_0005_tb1.jpg

The threshold for statistical significance had been set at P=0.05. Most sociodemographic characteristics – such as literacy, employment status, residence type, income level and age – had no statistically significant effect on participants’ knowledge. Nationality was the only statistically significant predictor, which means that Syrian women had a statistically significant lower level of knowledge of toxoplasmosis than Jordanian women (odds ratio=1.99).

Discussion

The results of this study show an overall lack of knowledge about toxoplasmosis among pregnant women in the Mafraq governorate of Jordan, since 75% of the study population had never heard of toxoplasmosis. Nijem and Al-Amleh (2009) had obtained a similar result in their study about toxoplasmosis prevalence and risk factors in pregnant women in Palestine. In a study conducted in Egypt, Gaheen and Elkazeh (2014) had found that 70% of women had a low level of knowledge about toxoplasmosis.

However, relatively large proportions of participants in this study – between 29% and 59% – appeared to have adequate knowledge of toxoplasmosis prevention. Four out of five statements on toxoplasmosis prevention attracted more than 50% of correct answers; for example, 59% of participants thought that eating unwashed fruit and vegetables increases the risk of toxoplasmosis. This is consistent with a study conducted in Iraq, which had found that a high percentage of pregnant women had adequate knowledge of toxoplasmosis prevention, such as washing hands after working on farms or in gardens (Al-Hellaly and Chyad 2019).

In this study, out of ten prevention practices, around 50% of participants consistently used four: teaching children to wash their hands (55%), drinking clean water (52%), eating meat well cooked (51%) and washing fruit and vegetables (49%). In a study conducted in the US (Jones et al 2003), a high percentage of pregnant women had reported washing their hands after handling raw meat and after gardening and not eating undercooked meat.

A study in Brazil had found that 59% of pregnant women used preventive practices such as cleaning their kitchen utensils with warm water and detergent after contact with raw meat or unwashed vegetables (Moura et al 2019).

Elsafi et al (2015) had found that, among pregnant women in Saudi Arabia, a higher level of education was significantly associated with a higher level of preventive practices. In this study, literacy had no statistically significant effect on participants’ knowledge of toxoplasmosis. The only sociodemographic characteristic that was a statistically significant predictor of participants’ knowledge was nationality, and Syrian women had a statistically significant lower level of knowledge of toxoplasmosis than Jordanian women. This may be because many Syrian women in Jordan are refugees living in camps with limited access to primary healthcare services and therefore to health education. This demonstrates the particular importance of providing primary healthcare and educational programmes to female Syrian refugees in Jordan.

Limitations

The study used a convenience sample of participants recruited among pregnant women in one region of Jordan, which reduces the generalisability of its results.

Conclusion

A lack of knowledge about toxoplasmosis may lead to the suboptimal prevention of this common infectious disease, with potentially serious consequences for pregnant women, the outcome of their pregnancy and their future child. This study has identified gaps in the knowledge and practices of pregnant women in Jordan in relation to toxoplasmosis and its prevention, but participants also demonstrated some adequate knowledge of toxoplasmosis prevention and some adequate use of preventive practices.

Enhanced health education could reduce women’s risk of acquiring toxoplasmosis and of experiencing complications of the disease. It is particularly important to provide female Syrian refugees living in Jordan with health education about toxoplasmosis.

Implications for practice

  • Toxoplasmosis in women just before or during pregnancy can result in miscarriage, stillbirth or child disability

  • Primary prevention plays an important role in reducing the risk of acquiring toxoplasmosis

  • Health education about toxoplasmosis is crucial to avoid potentially serious complications for pregnant women, the outcome of their pregnancy and their future child

Further resources

References

  1. Al-Hellaly EM, Chyad RT (2019) Knowledge of Iraqi pregnant woman about toxoplasmosis and their practice towards its prevention. Journal of University of Babylon for Pure and Applied Sciences. 27, 3, 308-315.
  2. Amin TT, Al Ali MN, Alrashid AA et al (2013) Toxoplasmosis preventive behavior and related knowledge among Saudi pregnant women: an exploratory study. Global Journal of Health Science. 5, 5, 131-143. doi: 10.5539/gjhs.v5n5p131
  3. Dubey JP, Lago EG, Gennari SM et al (2012) Toxoplasmosis in humans and animals in Brazil: high prevalence, high burden of disease, and epidemiology. Parasitology. 139, 11, 1375-1424. doi: 10.1017/S0031182012000765
  4. Elsafi SH, Al-Mutairi WF, Al-Jubran KM et al (2015) Toxoplasmosis seroprevalence in relation to knowledge and practice among pregnant women in Dhahran, Saudi Arabia. Pathogens and Global Health. 109, 8, 377-382. doi: 10.1080/20477724.2015.1103502
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  8. Kaye A (2011) Toxoplasmosis: diagnosis, treatment, and prevention in congenitally exposed infants. Journal of Pediatric Health Care. 25, 6, 355-364. doi: 10.1016/j.pedhc.2010.04.008
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  12. Ministry of Planning and International Cooperation (2020) Jordan Response Plan for the Syria Crisis 2020-2022. http://www.acaps.org/sites/acaps/files/key-documents/files/jordan_response_plan_2020-2022.pdf (Last accessed 30 November 2020.)
  13. Montoya JG, Liesenfeld O (2004) Toxoplasmosis. Lancet. 363, 9425, 1965-1976. doi: 10.1016/S0140-6736(04)16412-X
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