The booking appointment is the first antenatal appointment a woman has with her midwife. At this appointment, women are offered screening for numerous conditions, including Down syndrome. It is vital that women understand screening information because of the implications of the decisions they make. However, research has documented that women are not making informed decisions and undergo screening not realising the implications and subsequent decision-making required (Hall et al, 2009; Bangsgaard and Tabor, 2013). The current research aimed to investigate what factors influence women's understanding of Down syndrome screening information.
Cognitive status plays a role in how we process information in the world around us. Consequently, it may influence women's understanding of screening information. Cognitive ability encompasses a set of mental processes, including attention, memory, intelligence, problem solving, and reasoning.
Piaget (1972) proposed a theory of cognitive development from childhood to adulthood and distinguished between concrete and abstract thought. As humans age, their cognitive development becomes increasingly abstract and logical. Concrete terms and items, which are observable, tend to be acquired at an earlier age than abstract terms, which are not observable (Della Rosa et al, 2010). Abstract thinking forms the basis of logic; it allows individuals to solve problems correctly by imagining alternative solutions and apply knowledge to novel situations (Stern and Prohaska, 1996; Campbell and Ritchie, 2002; Tennant, 2005). The speed of cognitive development can vary between individuals, and it has been suggested that some adults may never gain abstract reasoning and abstract thought might only manifest itself in particular activities in which their strengths lie (Piaget, 1972; Keating, 1979; Cole, 1990; Lehman and Nisbett, 1990; Goldwater and Gentner, 2015).
The capacity to solve novel problems in unfamiliar settings is essential for success in everyday situations (Matthew and Stemler, 2013). At a booking appointment, women are presented with new, and sometimes complex, information which requires reasoning skills to understand it. Abstract reasoning can be assessed by verbal and non-verbal reasoning since learning relies on the ability to process both linguistic and perceptual information (Della Rosa et al, 2010). Verbal reasoning is the ability to understand problems or ideas framed using words, whereas non-verbal reasoning is the ability to solve problems visually, such as identifying relationships or sequences between patterns. Individuals with non-verbal reasoning skills possess abstract reasoning ability (Coaley, 2009).
Abstract and concrete reasoning can be placed on a continuum where levels of ‘abstractness’ can be measured (Wiemer-Hastings et al, 2001). Within this study, women who have high abstract cognitive status are expected to have a better understanding of Down syndrome screening information. This could have implications for midwifery guidelines, where women with more concrete reasoning skills will need to be identified and supported to ensure that they make informed decisions.
Need for cognition
Need for cognition (NfC) is ‘the tendency for an individual to engage in and enjoy thinking’ (Cacioppo and Petty, 1982). It is a form of cognitive motivation that relates to the extent that people engage in thinking to increase their knowledge (Cohen et al, 1955; Haugtvedt et al, 1992). Individuals with high NfC are more likely to be active in discussions, enjoy critical thinking, seek information and ask questions than those with low NfC (Cacioppo et al, 1996; Barbaro et al, 2015). Individuals with low NfC find little enjoyment in exerting cognitive effort, only think as hard as they have to and may avoid situations that involve a lot of thought (Gray et al, 2015). Individuals can fall anywhere on the distribution of low to high NfC (Petty et al, 2009).
Tailoring communication
Information may be tailored by the midwife to suit each woman's cognitive requirements. Patient education is often unsuccessful and it has been suggested that this is due to healthcare professionals' inability to tailor information (Adams et al, 2009). A one-size-fits-all approach is insufficient and information should be individualised (Kreuter et al, 1999; Potter et al, 2015).
In Australia, Wilmore et al (2015) interviewed antenatal staff (n=21) and found that midwives did not feel they have enough time in an appointment to gain an understanding of women's education level and skills, consequently their tailoring was inconsistent.
Another challenge is that each woman has different information needs to gain sufficient understanding (Bensing et al, 2013; Hewison, 2015). Some women require specific information, such as facts and figures (Harper, 2004), whereas others have expressed feeling over-informed and are happy with brief, accurate information (Hargreaves et al, 2005; Davis et al, 2006; Carolan, 2007). If too much information is presented, key information, such as risk messages, may be overlooked (Potter et al, 2015). Clients themselves have expressed a preference for tailored information (Department of Health, 2010; Martin et al, 2013).
While healthcare professionals may tailor information based on women's cognitive status, women themselves may influence midwife communication. For instance, individuals with high NfC are more likely to be more active in discussions, ask questions and speak for longer than those with low NfC (Shestowsky and Horowitz, 2004; Barbaro et al, 2015). When questions are asked, healthcare professionals provide more information (Cegala et al, 2007).
This is the first study of its kind; cognitive status, in terms of abstract-concrete reasoning and NfC, has not previously been investigated as an influence on how women understand Down syndrome screening information (Piaget, 1972; Cacioppo and Petty, 1982). Furthermore, it has not been considered as a factor that could influence the midwife's presentation of information. Whether midwives tailor oral Down syndrome screening information in booking appointments, or whether they offer rote or ‘favourite’ explanations, is unknown.
Methods
Design
The study employed a mixed-methods approach; audio recording and transcribing consultations to capture midwife communication and questionnaires were administered to assess women's demographics, cognitive status and their understanding of the presented Down syndrome screening information.
Study participants
Midwives (n=16) and women (n=100) were recruited from a regional NHS unit in the UK and were required to satisfy inclusion criteria to be considered for the study. Midwives were required to be registered and employed by the Health Board in NHS Wales; providing booking appointment services to women where antenatal screening options are discussed; and be English speaking in accordance with the requirements of the employer.
Women were included if they made their booking appointments with participating midwives, were over the age of 16 years, had capacity to consent and had adequate understanding of verbal and written communication in English.
Data collection
Midwives were sent an email containing invitation letters, information sheets and consent forms. Consenting midwives sent invitation letters, information sheets and consent forms to women who met the inclusion criteria and made their booking appointment with them.
When consenting women attended their booking appointments, an audio recording was started and then the researcher withdrew. Only the information provided on Down syndrome screening was transcribed and analysed. Once the booking appointment was complete, the women completed a questionnaire.
Data analysis
The audio recordings were transcribed and five different aspects of midwife communication were measured (Table 1). The new measuring understanding of screening information and communication (MUSIC) framework has been used in a parallel study that discusses midwife communication further (John et al, 2019). The questionnaire included multiple-choice questions regarding Down syndrome screening information that would normally be covered in a booking appointment to assess women's understanding of provided information. A range of closed and open questions were utilised to gather demographics.
| Language complexity |
Number: word count and sentences |
|
| Score | Difficulty | |
| 0–40 | Very difficult to difficult | |
| 40–80 | Average | |
| 80+ | Easy to very easy | |
| Flesch-Kincaid Grade Level should aim for a score of 4.0–5.0. |
||
| Dynamics |
Interactivity: number of speaking turns in a session per minute |
|
| Check knowledge/understanding |
Knowledge check: do midwives check women's current knowledge levels when they commence the appointment? |
|
| Resources | Are additional resources used to aid explanations, eg pictograms? | |
| Abstract language | The linguistic category model (LCM): the higher the score the more abstract the text. Four-word categories are distinguished to produce an ‘abstract score’, computed as follows: | |
| Word type | Score | |
| Descriptive action verbs (eg yell, hit, walk) | 1 | |
| Interpretative action verbs and state action verbs (eg help) | 2 | |
| State verbs (eg think, admire, hate, appreciate) | 3 | |
| Adjectives (eg social, aggressive, honest, reliable) | 4 | |
Scoring matrix for these measures is set out in Appendix 1
Verbal reasoning was assessed using five proverbs from Gorham's (1956) standardised ‘Best Answer’ proverb interpretation test. Correct interpretation of a proverb demonstrates good reasoning skills (Gibbs and Beitel, 1995; Gibbs, 2001). Individuals who have not developed abstract reasoning skills are likely to provide concrete answers to proverbs (Stern and Prohaska, 1996). If individuals are unfamiliar with a proverb, this truly tests their abstract reasoning skills. Therefore, women's familiarity with the proverbs was established. While proverbs can provide an overall view of individuals' ability on the abstract-concrete continuum (Campbell and Ritchie, 2002), on their own, correct interpretation of proverbs typically does not lead to definitive conclusions regarding individuals' higher cognitive ability (Campbell and Ritchie, 2002). Therefore, they should be accompanied by non-verbal reasoning tests.
Raven's standard progressive matrices (RSPM) were used to assess women's non-verbal abstract reasoning skills (Raven, 1938). RSPM involves visual-spatial processing where participants choose missing elements from options provided to complete a pattern. The original matrices consist of 60 items with five sets containing 12 items each. Each set represents a different conceptual theme and increases in difficulty (Ramsey and Wright, 1968). Therefore, each set requires a different thought process (Jones, 2010). Due to time constraints and attrition concerns, a shorter nine-item version was employed which has the same predictive power, reliability and validity as the 60-item matrices (Bilker et al, 2012).
Cacioppo et al (1984) developed a scale to assess NfC which was utilised within this research. The scale was tested on different populations and reported a reliability coefficient of a=0.90 (Cacioppo et al, 1996). The scale has high internal consistency and test-retest reliability (Petty et al, 2009).
A demographics section was included in the questionnaire to ascertain whether women's understanding and cognitive status was related to their demographics. Questionnaire responses were entered into ‘Statistical Package for the Social Sciences’, version 23. Descriptive statistics were used to analyse demographics. Pearson's correlation-and-enter method, multiple regression analysis were used to answer research questions. T-tests and analysis of variance were conducted to investigate any differences in women's cognitive ability and understanding of Down syndrome screening information depending upon their demographics or characteristics.
Findings
Demographics
The women's age range was 17–42 years, with an average age of 27.6 years. One woman did not provide her age. While women's verbal reasoning (proverbs score) and NfC significantly positively correlated with age, women's non-verbal reasoning (RSPM score) and age were not correlated. Age accounted for 14.9% variance in women's understanding.
The number of years women spent in education ranged from 7–25 years, with an average of 14 years. Five women were currently in education and another woman stated that she was last in education 20 years ago. The average amount of time women had been out of education was 7.7 years. Three women left this question blank.
There was a significant positive correlation between the number of years women spent in education and their understanding of Down syndrome screening information (r=0.229, n=96, p<0.05), ie more educated women had a better understanding of Down syndrome screening information. The number of years women spent in education accounted for 5.2% of the variance in women's understanding of Down syndrome screening information.
There was not a significant correlation between the number of years women spent in education and their verbal reasoning or non-verbal reasoning. However, a significant positive correlation was evident between the number of years women spent in education and their NfC score (r=0.267, n=96, p<0.01). The number of years since women left education was not significantly related to women's understanding or cognitive ability. Of the women sampled, 80% had obtained a GCSE in English, with the majority obtaining a C grade. Nine participants did not answer this question. An independent samples t-test revealed that women who had a GCSE in English had a significantly higher mean Down syndrome understanding score (M=7.15, SD=2.063) than those who did not have a GCSE in English (M=5.16, SD=2.243), (t(97)=3.722, p<0.01). Women with a GCSE in English had significantly higher verbal reasoning (M=6.65, SD=2.176) than those who did not have a GCSE in English (M=4.39, SD=2.304), (t(96)=3.94, p<0.01). There was also a significant difference for women's NfC for those who did (M=57.3, SD=10.924) and did not (M=43.16, SD=11.654) have a GCSE in English (t(97)=5.013, p<0.01).
Cognitive status
Verbal reasoning
A significant moderate-positive correlation was found between proverbs score and understanding (r=0.49, n=99, p<0.01). Verbal reasoning accounted for 24% of variance in Down syndrome understanding. There was not a significant correlation between proverbs score and familiarity.
Non-verbal reasoning
A significant positive correlation was evident between women's non-verbal reasoning and their understanding of Down syndrome information (r=0.317, n=100, p<0.01). Non-verbal reasoning accounted for 10% of the variance in Down syndrome screening understanding. There was a significant positive correlation between women's cognitive ability overall and their understanding of Down syndrome screening information.
Need for cognition
A moderate significant positive correlation between NfC and understanding of Down syndrome screening information was evident (r=0.398, n=100, p<0.01). NfC accounted for 15.9% of the variance in women's understanding.
Using enter method regression, it was found that women's cognitive status explained a significant amount of the variance in their understanding of Down syndrome screening information (F(3,95)=14.501, p<0.01, r2=0.314, r2 adjusted=0.292). Women's verbal reasoning skills (proverbs score, beta=0.371, t=3.959, p<0.01) and NfC (beta=0.193, t=2.014, p<0.05) made significant unique contributions to the prediction of the outcome (women's understanding), with verbal reasoning contributing most to the outcome. Women's non-verbal reasoning (RSPM score) did not make significant unique contributions to the prediction of the outcome (beta=0.175, t=1.949, p>0.05).
Pearson's correlation coefficient was computed to assess the relationship between women's NfC and their abstract-concrete reasoning score. There was significant positive correlation between each of the measures of cognitive status; proverbs and RSPM (r=0.229, p<0.01, n=99), Proverbs and NfC (r=0.408, p<0.01, n=99), RSPM and NfC (r=0.301, p<0.01).
Overall, women's proverbs score accounted for the most variance in their understanding of Down syndrome screening information.
Tailoring information
Midwives did not alter their language complexity (r=−0.148, p>0.05, n=99), dynamics (r=−0.132, p>0.05, n=99) or abstract language (r=−0.005, p>0.05, n=99) based on women's verbal reasoning. However, there was a significant negative correlation between the number of times midwives assessed women's knowledge/understanding and women's proverb scores (r=−0.224, n=99, p<0.05).
No significant multiple regression results were found for any of the communication measures against women's verbal reasoning, non-verbal reasoning or NfC.
Discussion
Cognitive status
Verbal reasoning
Women with more abstract verbal reasoning skills had a better understanding of Down syndrome screening information. Proverb interpretation and familiarity were not related, therefore, the correct interpretation of the proverb was reliant upon abstract interpretation and cognitive ability, since the proverb requires additional processing beyond what is required to understand a familiar proverb (Gibbs and Beitel, 1995).
Individuals' characteristics can influence their interpretation of proverbs, and women who had spent longer in education had enhanced proverb interpretation, supporting earlier findings (Nippold et al, 1997; Wachholz and Yassuda, 2011). It is difficult to assess whether higher education leads to superior abstract reasoning skills or whether advanced abstract skills allow individuals to reach higher levels of education. Individuals with higher levels of general intelligence are usually better at understanding health information, due to their increased capacity for reasoning and problem solving (Gottfredson, 2004; Der et al, 2009).
As would be expected, women who had a GCSE in English had higher abstract verbal reasoning. Women's age also had a significant influence on their proverb interpretation. As women's age increased, their verbal reasoning and NfC significantly increased. This is in line with previous findings where, as age increased, an increased performance in vocabulary tasks was also evident (Schroeder and Salthouse, 2004).
Non-verbal reasoning
On average, half of the questions on the RSPM were answered correctly and thus were answered in an abstract way. Women with higher non-verbal abstract reasoning had a better understanding of the Down syndrome screening information. Psychologists have highlighted that choosing incorrect answers in the matrices could be caused by a number of different errors: individuals may not use all the information available, individuals use alternate reasoning to that required by the problem, individuals cannot distinguish between relevant and irrelevant features of the pattern and instead combine many features of each pattern, and individuals choose a pattern that has already been presented (Jones, 2010).
Need for cognition
Each individual has different drives to gain new information. In line with this, women's NfC was significantly associated with their understanding of Down syndrome screening information. Older women and those who had spent more years in education had a significantly higher NfC. This is possibly because individuals with high NfC are more likely to seek further education to increase their knowledge. Women with higher NfC were also significantly more likely to have a GCSE in English.
As predicted, there was a significant positive relationship between women's cognitive status and their NfC, supporting the view that the best predictor of abstract reasoning skills is NfC (Stuart-Hamilton and McDonald, 2001; Parry and Stuart-Hamilton, 2010). The higher women's abstract score on the reasoning measures, the higher their NfC score. The lower women's abstract score, the lower their NfC score. RSPM is a good test of Spearman's general intelligence (Raven, 2000). However, women's verbal reasoning contributed most to the variability in women's understanding of Down syndrome screening information. This finding implies that women's intelligence is not accountable for their understanding of Down syndrome screening information.
Women require sophisticated, abstract verbal reasoning skills to interpret information provided by the midwife. Thus, midwives should not stereotype women based on their perceptions of how intelligent women are, because this is not predictive of how well they will understand Down syndrome screening information.
What is concerning from these findings is that women with more concrete cognitive status and lower NfC were leaving appointments not fully informed, although they had made decisions to accept or reject screening.
Tailoring information
Midwives did not display different communication methods when faced with women of different non-verbal reasoning and NfC abilities. Although, midwives checked women's knowledge/understanding less for women who had higher verbal reasoning skills. This may be because they recognised that these women had a better understanding due to their advanced verbal skills, and did not feel the need to assess their knowledge and understanding as much as women who had lower verbal reasoning skills.
Tailoring information may be difficult for midwives to achieve when they have not met the woman previously. The challenge of these findings is to seek an approach whereby the midwives could assess women's cognitive status quickly in order to tailor information appropriately. Overall, both the age and ethnicity of women included in this research does not generalise to the wider pregnant population. Therefore, care must be taken with generalising findings and a larger study is required.
Conclusion
It is important that midwives are sensitive to individuals with differing cognitive abilities and information requirements. This has implications for midwifery education and for service provision in terms of time available within booking appointments to sufficiently discuss and tailor Down syndrome screening information.
The ability to tailor information is a challenge for midwives, other healthcare providers and communication researchers, since each individual has different needs (Bensing et al, 2013). Core midwifery concepts need to be taught in combination with communication skills. In cases where midwives have sufficient knowledge of genetics and screening, they may not have received training to communicate this information effectively.
The research extends the field by being the first study to introduce cognitive status as a significant influence on women's understanding of Down syndrome screening information. The study had limitations, but this does not lessen the importance of the finding that women with more concrete cognitive ability and low NfC were not making well-informed decisions. While women with abstract reasoning skills could understand information sufficiently, women with more concrete skills require further explanation from the midwife in order to reach an informed decision. The role that abstract reasoning and NfC plays has been outlined and these findings could be developed to contribute to a more informed approach to screening.