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This article was downloaded by: [University of Leeds]On: 15 June 2013, At: 14:47Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954 Registeredoffice: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK Journal of Reproductive and InfantPsychology Publication details, including instructions for authors andsubscription information:http://www.tandfonline.com/loi/cjri20 Attitudinal ambivalence towardsDown’s syndrome and uncertaintyin prenatal testing and terminationintentions Louise D. Bryant a , Josephine M. Green b & Jenny Hewison ba Leeds Institute of Health Sciences, University of Leeds, Leeds,UK b Mother and Infant Research Unit, Department of HealthSciences, University of York, York, UKPublished online: 28 Jul 2011. To cite this article: Louise D. Bryant , Josephine M. Green & Jenny Hewison (2011): Attitudinalambivalence towards Down’s syndrome and uncertainty in prenatal testing and terminationintentions, Journal of Reproductive and Infant Psychology, 29:3, 250-261 To link to this article: http://dx.doi.org/10.1080/02646838.2011.599063 PLEASE SCROLL DOWN FOR ARTICLEFull terms and conditions of use: http://www.tandfonline.com/page/terms-and-conditionsThis article may be used for research, teaching, and private study purposes. Anysubstantial or systematic reproduction, redistribution, reselling, loan, sub-licensing,systematic supply, or distribution in any form to anyone is expressly forbidden.The publisher does not give any warranty express or implied or make any representationthat the contents will be complete or accurate or up to date. The accuracy of anyinstructions, formulae, and drug doses should be independently verified with primarysources. The publisher shall not be liable for any loss, actions, claims, proceedings,demand, or costs or damages whatsoever or howsoever caused arising directly orindirectly in connection with or arising out of the use of this material. Attitudinal ambivalence towards Down ’ s syndrome anduncertainty in prenatal testing and termination intentions Louise D. Bryant* a , Josephine M. Green b and Jenny Hewison a a Leeds Institute of Health Sciences, University of Leeds, Leeds, UK; b Mother and Infant Research Unit, Department of Health Sciences, University of York, York, UK ( Received 21 May 2010; fi nal version received 15 June 2011 )This study aimed to investigate the relationship between attitudinal ambivalencetowards Down ’ s syndrome (DS) and prenatal testing and termination intentions.Intentions towards using a screening test, a diagnostic test and termination of pregnancy for DS were collected from 140 pregnant women along with their attitudes and attitudinal ambivalence towards the condition. Women who wereunsure about diagnostic testing and termination were more likely to hold ambiv-alent attitudes towards DS than were women who gave a de fi nite yes or noresponse. In particular, a higher level of ambivalence about how a child withDS might impact on parental quality of life was signi fi cantly associated with anuncertain attitude towards termination of pregnancy. Qualitative data suggestedthat ambivalence towards DS was associated with a desire to make diagnostictesting and termination decisions with a signi fi cant other. The fi ndings from thisstudy inform debate on the link between ambivalence and informed choice andhave implications for supporting prenatal testing decisions in women who holdambivalent attitudes towards parenting a child with DS. Keywords: ambivalence; attitudes; informed choice; prenatal testing; Down ’ ssyndrome Introduction Attitudes can be considered as dynamic and temporary constructions that are not independent of the external context, thus a particular situation or object will trigger recall of accessible information that is currently salient to that situation or object (Wilson & Hodges, 1992). An evaluation of the information will determine the typeof attitude to the situation or object; if the information is evaluated consistently as positive or negative in emotional valence then a favourable or unfavourable attitudeis generated, if a mix of both positive and negative evaluations are generated thenthe attitude is said to be ‘ ambivalent ’ (Eagly & Chaiken, 1993). This article consid-ers how attitudinal ambivalence towards people with Down ’ s syndrome (DS) and parenting a child with DS might relate to prenatal testing intentions and behaviours.DS is mainly associated with learning disability, a characteristic facial appearanceand an increased rate of some serious health problems. DS occurs in approximately1 in 700 births, although in many industrialised countries the incidence of *Corresponding author. Email:
[email protected] Journal of Reproductive and Infant Psychology Aquatic Insects Vol. 29, No. 3, July 2011, 250 – 261 ISSN 0264-6838 print/ISSN 1469-672X online 2011 Society for Reproductive and Infant PsychologyDOI: 10.1080/02646838.2011.599063http://www.tandfonline.com D o w n l o a d e d b y [ U n i v e r s i t y o f L e e d s ] a t 1 4 : 4 7 1 5 J u n e 2 0 1 3 pregnancies affected by DS is rising, which can be attributed to the trend for increasing maternal age (Morris & Alberman, 2009). Many Western European coun-tries including the UK now offer some form of prenatal testing for DS. Prenataltests can be characterised as screening or diagnostic tests. Screening tests are usedto identify women at higher risk of having a baby affected by DS; women found to be at higher risk will then be offered invasive diagnostic tests that carry a 0.5 – 2%risk of miscarriage (Al fi revic, Gosden, & Neilson, 2003). If a diagnostic test identi- fi es that the foetus has DS, women have the option to terminate the pregnancy,although legislation varies internationally.Two published studies have formally examined the role of ambivalence in rela-tion to prenatal testing. The fi rst focused on ambivalence towards undergoing ascreening test (Dormandy, Hankins, & Marteau, 2006) and reported signi fi cantlystronger relationships between screening intentions and behaviour in women withlower levels of ambivalence. Other research that has studied ambivalence within theframework of the Theory of Planned Behaviour (Ajzen, 1991) has also generallyfound that ambivalence moderates the attitude-behaviour relationship with attitudeslow in ambivalence being better predictors of attitude consistent behaviour (Cooke& Sheeran, 2004). In a different approach, Sapp et al. (2010) interviewed women who had elected to undergo amniocentesis (a diagnostic test) and identi fi ed ambiva-lence in all participants, which they characterised as a ‘ tension ’ between the desireto gain information about the pregnancy and a desire to protect the pregnancy fromharm. No published research has yet considered how attitudinal ambivalence towardsthe condition being tested for may impact on prenatal testing related decisions. In asample of pregnant women, Bryant, Green, and Hewison (2010) found that attitudestowards people with DS were signi fi cantly associated with screening uptake andwith diagnostic testing and termination intentions. Those who used screening and(hypothetically) intended to use amniocentesis and termination held less-positiveattitudes towards the condition than did those who did not use/did not intend to usethem. However, while attitudes towards people with DS were good predictors of intentions to terminate for the condition, they were only weak predictors of screen-ing behaviour (Bryant et al., 2010). Qualitative data revealed that women did not consider their attitudes towards DS as salient to their screening decision, only todecisions about diagnostic testing or termination; it is also possible that attitudinalambivalence may have been partly responsible for the weak relationship.Ambivalence is associated with strongly held opposing evaluations and is most likely to be experienced when both positive and negative evaluations are madeaccessible at the same time (Cacioppo, Gardner, & Berntson, 1997). This situationoccurs when having to make a ‘ discrete evaluative choice ’ in relation to an attitudeobject about which one holds inconsistent beliefs and/or feelings (van Harreveld,van der Pligt, & de Liver, 2009). For example, someone who holds both positiveand negative beliefs about people with DS may not feel ambivalence when asked todonate money to a related charity. Their motives may be to help others and tomaintain an altruistic self-image for which only their positive evaluations are sali-ent; at this point, their ambivalence is said to be potential (Conner & Armitage,2008). However, the same person faced with a decision regarding a prenatal test for DS might experience a con fl ict between the motive to be altruistic towards disabled people and the motive to bear a healthy child. At this point, negative beliefs andfeelings about DS may also be accessed resulting in an experience of felt Journal of Reproductive and Infant Psychology 251 D o w n l o a d e d b y [ U n i v e r s i t y o f L e e d s ] a t 1 4 : 4 7 1 5 J u n e 2 0 1 3 ambivalence about DS (Conner & Armitage, 2008). This ambivalence towards DSmay make a decision about whether or not to have a prenatal test more dif fi cult than a more straightforwardly positive or negative attitude. The potential conse-quences of this ambivalence are unknown; one possibility is that a decision toundergo testing becomes more likely as a means of gaining more information about the pregnancy, another is that the person may seek direction about what to do froma signi fi cant other, for example partner or health professional.Attitudes towards disability are known to be complex and frequently ambivalent in nature (Söder, 1990) and a clearer understanding of the role of ambivalencetowards DS is relevant to understanding prenatal testing choices. The aims of thisstudy were to characterise attitudinal ambivalence towards people with DS and par-enting a child with the condition and to investigate the role of this ambivalence inthe relationships between prenatal testing and termination intentions. We anticipatedthat those women who expressed uncertainty about their testing and terminationintentions would hold more ambivalent attitudes towards DS than those womenwho expressed certainty about their intentions. The data presented were collected as part of a larger study (Bryant et al., 2010); the presented analyses focus on the rela-tionships between attitudinal ambivalence towards DS and prenatal testing and ter-mination intentions. Method Following approval from Hull and East Riding Local Research Ethic Committee(LREC 04/00/052) a survey was conducted using a self-completion questionnaireadministered to pregnant women. Materials and measures To measure attitudes towards DS, open-ended measures were adapted from thoseused previously to study attitudes towards minority groups. Studies using thesemeasures have assessed the differing contributions of cognitive, affective and behavioural information in predicting attitudes toward people grouped by sexual ori-entation (Haddock, Zanna, & Esses, 1993), race (Donakowski & Esses, 1996; Esses& Dovidio, 2002) and disability (Esses & Beaufoy, 1994; Kiger, 1997). Detail about the development of the open-ended measures can be found elsewhere (Esses& Maio, 2002; Haddock & Zanna, 1998). They have been shown to be reliable andvalid measures of attitudinal components with psychometric properties equivalent tothose of more traditional methods of attitude measurement, for example, semanticdifferential scales (Eagly, Mladinic, & Otto, 1994; Haddock & Zanna, 1998;Krosnick, 1999). This study measured cognitive, affective and behavioural compo-nents of attitudes towards DS. Cognitive component measure (1): Stereotypical beliefs The assessment of stereotypic beliefs has been central to understanding the cogni-tive component of attitudes towards minority groups. Stereotypic beliefs relate tothe characteristics attributed to typical members of a group, for example, the belief that group members are friendly. Respondents were asked to write down words or phrases that they believed describe people with DS. A range of example responses 252 L.D. Bryant et al. D o w n l o a d e d b y [ U n i v e r s i t y o f L e e d s ] a t 1 4 : 4 7 1 5 J u n e 2 0 1 3 generated from a pilot exercise were provided. Respondents were then asked toevaluate each of these descriptive characteristics by allocating a valence using plusor minus signs. The valence is the degree of favourability with which the responseis viewed and options ranged from the very positive to the very negative (from +2to – 2) or +/ to indicate a mixed evaluation. A ‘ stereotypic belief score ’ was com- puted by summing the allocated valences and dividing this value by the number of responses. Cognitive component measure (2): Parental Quality of Life beliefs Previous research has suggested that measuring only stereotypical beliefs may not access important cognitions relevant to attitudes towards disability and that it isimportant to capture more abstract, value-based beliefs when assessing the cognitivecomponent of attitudes towards minority groups (Esses, Haddock, & Zanna, 1993).Value-based beliefs are said to represent the perceived relationship between thegroup and the values and norms esteemed by the respondent. Beliefs about theimpact of having a child with a learning disability on parental and family quality of life (Lawson, 2006) and on important life-goals such as success and relaxation havealso been shown to signi fi cantly relate to intentions to test and terminate for con-genital conditions (Evers-Kiebooms, Denayer, Decruyenaere, & van den Berghe,1993). Respondents were asked to write down aspects of their life that were impor-tant to them, and a range of example responses generated from a pilot exercise were provided (for example, ‘ my family ’ , ‘ my job/career ’ ). Respondents were then askedto evaluate how each valued life aspect would be affected by having a baby withDS by assigning a valence from +2 to – 2 or +/ – to indicate a mixed evaluation.These value-based cognitions were labelled Parental Quality of Life (PQoL) beliefs.The term ‘ quality of life ’ refers to a subjective experience of well-being and lifesatisfaction that encompasses physical, material, social and productive well-being(Felce & Perry, 1997). A PQoL score was computed by summing the allocatedvalences and dividing this value by the number of responses. Affective component measure: Emotions The affective component of the measures considers the emotions that members of the target group elicit in respondents. For example, a typical group member might elicit fear, admiration or both. Respondents were asked to list the feelings theyexperienced when they saw, met, or thought about a person with DS. A range of example responses, generated from a pilot exercise were provided. Respondentswere then asked to give each ‘ feeling ’ an evaluative rating from ‘ very positive ’ to ‘ very negative ’ (from +2 to – 2) or +/ to indicate a mixed evaluation. An ‘ emotionscore ’ was computed as described previously. Behavioural component measure: Experiences Behavioural attitude information, in terms of past experiences with the target group,has been found to uniquely contribute to the prediction of inter-group attitudes over and above cognitive and affective information (Haddock et al., 1993, 1994). Respondents were asked to think about experiences they had of people with DS, towrite down as many as they could and then to evaluate each experience on a scale Journal of Reproductive and Infant Psychology 253 D o w n l o a d e d b y [ U n i v e r s i t y o f L e e d s ] a t 1 4 : 4 7 1 5 J u n e 2 0 1 3
