SEARCH

SEARCH BY CITATION

Summary

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References
  9. Supporting Information

Background

Inflammatory bowel diseases (IBD) require complex therapeutic decisions and life choices concerning pregnancy, but little is known about patient's knowledge of IBD and its treatment before and during pregnancy.

Aim

To develop a novel tool (Crohn's and Colitis Pregnancy Knowledge Score ‘CCPKnow’) to assess knowledge of pregnancy-related issues in IBD. The validated tool was then applied to determine knowledge in patients.

Method

Discriminate ability of ‘CCPKnow’ was validated in four groups with different levels of IBD knowledge. Reliability and readability were tested by Cronbach-α and Flesch-Kencaid. Construct validity was subsequently assessed against general IBD knowledge (CCKnow) in 145 women with IBD. Associations between patient factors and knowledge were studied.

Results

Median CCPKnow scores differed significantly between the validation groups (< 0.001). CCPKnow displayed excellent internal consistency, reliability (Cronbach-α 0.94), readability (reading age 9 years) and close correlation with CCKnow (Spearman's ρ 0.64; < 0.001). Of 145 patients, 44.8% had poor, 27.6% adequate, 17.3% good and only 10.3% very good knowledge. Better knowledge was associated with Caucasian ethnicity, higher income, having a partner, having children, Crohn's and Colitis Association membership, longer disease duration and Crohn's disease.

Conclusions

Crohn's and Colitis Pregnancy Knowledge Score, a novel knowledge assessment tool of pregnancy and IBD, demonstrated excellent test characteristics. We found that nearly half of the women with IBD had poor knowledge, identifying a pressing need for better education.


Introduction

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References
  9. Supporting Information

Inflammatory bowel diseases (IBD) affect patients of all ages, and are prominent in women of childbearing age. Research into pregnancy-related issues in IBD has, thus far, been conducted on hospital patient populations and focused on the outcomes of pregnancy. Current international guidelines outline the importance of inducing and maintaining disease remission with medication prior to conception and during pregnancy.[1-4] These guidelines are primarily based on studies examining the effects of IBD on fertility, pregnancy outcome and neonatal abnormalities.[1-5] In addition, the effects of medications during pregnancy and nursing have been examined in case-control studies and relevant guidance relating to medication use has been developed based on FDA classification of drug safety.[1-3, 6-8]

Conversely, there has been minimal research into how women with IBD make decisions about planning pregnancies[9] and their attitudes towards medication use during pregnancy and breast feeding.[10, 11] However, women's views on fertility, breast feeding and pregnancy outcome are likely to have a significant influence on their behaviour before, during and after pregnancy. This is exemplified by a recent survey of 169 women with IBD, in which ‘voluntary childlessness’ was reported significantly more frequently by women with Crohn's disease (CD) in the US than the general population (18% vs. 6%, = 0.001).[9] This far outweighs the rate of ‘involuntary childlessness’ in IBD compared to general population, (5% vs. 2.5%, P = ns)[9] and may be explained by concerns held by patients with IBD related to the impact of pregnancy on their disease (or vice versa), the impact of their medication on the pregnancy, and/or concerns about passing their disease on to their offspring.[9] Patients may also harbour beliefs that their disease or its treatment may have an impact on conception. Indeed, an Australian postal questionnaire administered to 225 women with IBD demonstrated a fear of infertility in 42.7%, which represented a significant overestimate of infertility risk.[10] Hence, there is a marked discrepancy between medical evidence and patients' perceptions. This is also apparent for views held on potential harm from medication used to manage IBD; a recent study identified that more than 80% of patients placed concerns regarding harmful medicine effects over the importance of controlling active disease,[11] a view contrary to the advice published in medical guidelines.[1-3]

It is apparent from the few data available that women with IBD may be at risk of making uninformed choices about fertility, pregnancy and medication use that may in turn lead to voluntary childlessness or adverse pregnancy outcomes. It is not clear if a potential lack of knowledge may determine patients' views on pregnancy and their attitudes to medical therapy.

Validated assessment tools can provide useful information relating to patient knowledge. The aim of the study was therefore to develop and validate a novel and reliable self-administered questionnaire (Crohn's and Colitis Pregnancy Knowledge Score; CCPKnow) to assess patient knowledge of pregnancy-related issues in IBD. We further aimed to evaluate its use in a mixed community and hospital-based cohort of women of childbearing age suffering from IBD to test the hypothesis that a large proportion of women with IBD have poor knowledge of pregnancy-related issue in IBD.

Methods

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References
  9. Supporting Information

CCPKnow development

CCPKnow was developed using similar methodology to the previously validated IBD general knowledge tool ‘CCKnow’.[12] The questions to be included in CCPKnow were developed using feedback from a focus group of patients, IBD specialist nurses and gastroenterologists to maximise content validity. Content validity of a test is generally assured by careful selection of items included at the time of design.[13] Questions covering pregnancy-related issues, including inheritance of IBD, conception and medication in the periconceptual period, medication during pregnancy and breastfeeding, mode of delivery and congenital abnormalities in babies to mothers with IBD were reviewed and refined by physicians and specialist nurses. The initial selection included 18 multiple choice questions with one best answer from a choice of five responses.

Validation of CCPKnow

Discriminatory ability was validated by four groups of healthy volunteers with different levels of IBD education (clerical staff, general staff nurses, junior doctors and IBD specialist nurses) and differences between these groups were analysed using a Kruskal–Wallis test for nonparametric data. Cronbach's alpha, a measure of correlation between different items of a test, was used to analyse for internal consistency.[14] Readability was evaluated by two validated assessment tools. ‘Flesch Reading Ease’[15] measures the readability by a score composed of the length of sentences and the number of syllables used in a word. A score of 65 or higher is considered ‘plain English’ and scores of 100 are considered ‘very easy to read’. ‘Flesch-Kincaid Grade Level’ is a translation of the ‘Flesch Reading Ease’ into the United States schooling system.[15] The number derived from this score equals the school grade level required to understand the text. The sensitivity and specificity of ‘CCPKnow’ was analysed using a receiver operating characteristics curve. Construct validity was then assessed against ‘CCKnow’ within a cohort of women with IBD.

Assessment of patients' knowledge

Once the CCPKnow was validated, it was administered to female patients attending tertiary IBD hospital clinics (by direct invitation) and to female patients registered with office based gastroenterologists (by postal invitation). All patients were aged between 18 and 45 years old and gave fully informed consent prior to study participation. Additional information collected included patient demographics (age, marital status, employment status, highest educational level and household income), Crohn's Colitis Association (the Australian patient support group) membership status, disease specifics and information on previous pregnancies. General knowledge of IBD was assessed by correlation with the normally distributed CCKnow.[12] The influence of demographical and disease-related factors was analysed using student's t-test and anova. Multiple linear regression analysis was used to determine independent predictors of knowledge.

Ethical considerations

The study was approved by the Concord Hospital Human Research Ethics Committee (HREC/10/CRGH/119).

Results

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References
  9. Supporting Information

Subject recruitment

‘CCPKnow’ questionnaire validation was performed on four groups of hospital staff comprising 16 administrative staff members, 11 general ward nurses, 15 junior doctors in their first 3 years of postgraduate training and 17 IBD specialist nurses. The testing of validation process in the patient cohort recruited 145 women with IBD [44 from hospital clinics and 101 from office based gastroenterologists (postal return rate 28%)]. Median age was 32 years (range 18–45). The majority (71%) were married or lived with a partner, while 29% were single or divorced (Table 1). A total of 49 (33.8%) women [24 CD, 23 ulcerative colitis (UC), 2 IBD-unclassified] had had a successful pregnancy and delivery since being diagnosed with IBD.

Table 1. Score range CCPKnow and levels of knowledge for the patient cohort of 145 women
Knowledge levelCCPKnow scoren%
Poor0–76544.8
Adequate8–104027.6
Good11–132517.2
Very good≥141510.3

Discriminate ability

Discriminate ability was tested on the four groups of hospital staff. Median CCPKnow scores were 5.5 for administrative staff, 9 for qualified nurses, 10 for junior doctors and 16 for specialist nurses (Kruskal–Wallis test < 0.001). The receiver operating characteristics (ROC, available online) curve, using IBD nurses as the gold standard, revealed an area under the curve of 0.973 demonstrating favourable characteristics of CCPKnow in distinguishing individuals with better from those with limited knowledge. On the basis of the ROC curve, a cut-off was derived at 14, with 94% sensitivity and 95% specificity for very good knowledge (IBD nurse specialist level). The cut-off for at least adequate knowledge (general nurse level) was derived from the ROC curve at 8 with 78% sensitivity and 70% specificity.

Discriminate ability was analysed using threshold scores of 8 (derived by ROC curve analysis), 11 (arbitrary) and 14 (derived by ROC curve analysis) to categorise knowledge into poor, adequate, good and very good. Of the 18 questions (Appendix S1) initially included in the questionnaire, question 4 failed discriminate ability. After discarding that question, the Kruskal–Wallis test analysing the 17-item questionnaire remained statistically significant (< 0.001 (Figure 1).

image

Figure 1. Discriminate ability of CCPKnow median scores for administrative staff, general ward nurses, junior doctors and IBD specialist nurses (IBD N) (P < 0.001).

Download figure to PowerPoint

Internal consistency

Cronbach's alpha was 0.94, which demonstrated high internal consistency. Corrected item – total correlation tested whether a single question correlated with the overall test score and was measured by Cronbach's alpha (table with detailed results available online). Again, Question 4 had a weaker correlation of 0.114.

Readability

Readability assessment with Flesch Reading Ease revealed a score of 84.9 that correlated to a Flesch-Kincaid Grade Level of 3.6 suggesting that readability was at the level of a 9-year-old.

Construct validity

CCPKnow significantly correlated with CCKnow (Spearman's ρ = 0.641, < 0.001; Figure 2).

image

Figure 2. Correlation between CCPKnow (Y-axis) and CCKnow (X-axis) demonstrating as highly significant (ρ = 0.64).

Download figure to PowerPoint

IBD Cohort Testing

The knowledge scores of 145 female IBD patients ranged from 0 to 17 for CCPKnow (median 8) and 2–23 for CCKnow (median 13). Of these patients 65 (44.8%) had poor (CCPKnow 0–7), 40 (27.6%) adequate (CCPKnow 8–10), 25 (17.3%) good (CCPKnow 11–13), and 15 (10.3%) very good knowledge of pregnancy-related issues in IBD (CCPKnow ≥14) (Table 2). Patient source (hospital vs. office based), age, employment status and educational achievements were not associated with level of knowledge. Married women and those with a long-term partner had significantly higher knowledge than single women (8.65 vs. 7, = 0.03). Caucasian women had greater knowledge than those from other ethnic backgrounds (8.62 vs. 6.34, = 0.008). Household income greater than US$87 000 was also associated with better knowledge (9.48 vs. 7.61, = 0.006). Knowledge was higher in women who had given birth since their IBD diagnosis, compared to those who had not (9.16 vs. 7.8, = 0.04). A diagnosis of CD was also associated with better knowledge compared to UC (9.6 vs. 7.2, < 0.001). Patients with a disease duration greater than 5 years, had better knowledge than those with shorter disease duration (8.82 vs. 6.51, = 0.001). Members of the Crohn's and Colitis Association had significantly better knowledge than non-members (10.18 vs. 7.62, < 0.001). Multiple linear regression analysis revealed that Caucasian ethnicity (β = 0.223, = 0.01), Crohn's Colitis Association membership (β = 0.200, = 0.02) and diagnosis of CD (β = 0.223, < 0.001) were independent factors associated with better knowledge.

Table 2. Patient characteristics and CCPKnow knowledge scores
Characteristicsn (%)CCPKnowP-value
Age (years)
Median32 0.97 (Pearson correlation)
Marital status
Single42 (30.0)70.03
Partner/married103 (70.0)8.65 
Ethnicity
Caucasian120 (82.8)8.620.008
Non-caucasian25 (17.2)6.34 
Asian10 
African1  
Aboriginal1 
Others13  
Employment
Yes25 (17.2)8.50.18
No101 (69.7)7.36 
Not stated19 (13.1)  
Highest level of education
High school18 (12.4)7.940.113
College32 (22.1)7.78 
University68 (46.9)8.97 
Postgraduate23 (15.9)7.8 
Others4 (2.7)  
Income (in $USD)
<18 0003 (2.1) 0.008
18 000–36 00010 (6.9) 
36 000–87 00043 (29.7)7.66 
 56 (38.6)9.48 
<87 00060 (41.4)  
≥87 00029 (20.0)  
Not stated   
Children
No73 (50.3)7.80.04
Yes72 (49.7)9.16 
After diagnosis49 (33.8)  
Diagnosis
CD65 (44.8)9.6<0.001
UC65 (44.8)7.2 
IBD-U/unsure15 (10.4)  
Disease duration
0–5 years42 (29.0)6.510.001
>5 years103 (71.0)8.82 
Crohn's colitis association
Member38 (26.2)10.18<0.001
Nonmember99 (68.3)7.62 
Not stated8 (5.5)  

Discussion

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References
  9. Supporting Information

CCPKnow is the first tool to directly assess knowledge of pregnancy-related issues in IBD. The tool was developed analogous to the CCKnow IBD disease-specific knowledge questionnaire, and demonstrated excellent test characteristics of internal consistency, discriminatory ability and readability. Furthermore, CCPKnow displayed a close correlation with the previously validated CCKnow, demonstrating its construct validity. Since nearly half of women with IBD had poor knowledge about pregnancy-related issues, there is a pressing need for better education, so that patients can make informed decisions about having children and the use of medication before and during pregnancy.

Few studies have addressed patient knowledge of pregnancy-related issues in women with chronic conditions. Qualitative studies have suggested that women with diabetes and hypertension have only limited knowledge of pregnancy risks, medication and health optimisation prior to conception.[16] Studies examining patients' views on IBD and pregnancy have demonstrated that many women hold views contrary to medical evidence and may even remain childless voluntarily.[9-11] It has been suggested that poor disease-related knowledge is associated with these contrary views, but in the absence of a validated knowledge assessment tool, this is somewhat conjectural. Knowledge of pregnancy-related issues in IBD may represent the key to explaining behaviour and decisions made by young women with IBD, especially with regard to the use of medical therapies. For both research and clinical care, CCPKnow now offers an easy to use tool that allows quantitative patient knowledge assessment.

Nearly half of the women studied in our cohort had poor knowledge of pregnancy-related issues in IBD. Knowledge assessed by therapy-related questions was equally poor as knowledge from non-therapy questions. However, this may be of more practical importance since patient choice and concordance with therapy may be directly influenced by knowledge, and therefore by education. Selection bias is a potentially inherent problem in questionnaire studies, and the postal return rate of 28% in our study was relatively low. Patients interested in pregnancy-related issues may have been more likely to respond and may therefore be over- rather than underrepresented. This in turn could have affected the distribution of knowledge scores. If any selection bias occurred, the authors would have expected overrepresentation of good knowledge. Our finding of overall poor knowledge is supported by studies from the UK, Iran and Singapore demonstrating poor disease-related patient knowledge with median CCKnow scores of 4–7 out of 24.[17-19] Indeed the median CCKnow score of 13 in our cohort was substantially higher. It is therefore conceivable that knowledge of pregnancy-related issues in unselected women with IBD may be even lower than in our cohort.

Knowledge of pregnancy-related issues is likely to be closely related to the patients' life circumstances, since CCPKnow scores were higher in women with partners and those who already have had children since being diagnosed with IBD. Caucasian ethnicity was associated with significantly better knowledge, as has been demonstrated previously in IBD.[20] This supports the need for language- and culture-appropriate information and education in ethnic minority groups. Women with CD had significantly better knowledge of pregnancy-related issues, but this may reflect better overall disease-specific education and knowledge, since their CCKnow scores were also significantly higher (13.6 in CD vs. 11.4 in UC, = 0.02), a finding in keeping with some[20] but not all[12] previous studies. Education level did not influence CCPKnow, in accord with previous studies of general IBD-related knowledge.[20] This may reflect the ease of understanding CCKnow (low reading age), but also highlights the need for disease-specific education, regardless of patient background. Physicians should not assume that patients with higher educational achievements will be self-sufficient in gaining the desirable level of disease-related knowledge. Crohn's Colitis Association membership significantly increased pregnancy-related knowledge, highlighting that peer support and focused, disease-specific education are important in forming patients' knowledge base. Thus, while there were three independent predictors of knowledge, only Crohn's colitis Association membership is modifiable; patients should therefore be encouraged to join a patient organisation to aid knowledge improvement.

Enabling women with IBD to have children forms an important part of holistic IBD care. However, poor knowledge and widespread patients' views contrary to medical evidence form a substantial hurdle. Education is a cornerstone of quality IBD care as defined by the recently published UK ‘IBD standards’[21] and advice should be routinely provided to patients of childbearing age. On the basis of our findings, there is a pressing need to improve patient education in this field as nearly half of patients have insufficient knowledge, which may lead to patient choices adversely affecting fertility, pregnancy and breast feeding. Educational assessments and interventions should proactively target all women of childbearing age with IBD. Restricting advice to women already pregnant, or to those who specifically seek advice, will leave some patients without vital information on which to base their decision about having children. Furthermore, women with insufficient knowledge might also cease medication inappropriately in early pregnancy, before presenting to their treating physician.

Thus, the routine use of CCPKnow in the clinical setting will allow for identification of young women with IBD who have insufficient knowledge of pregnancy-related issues. Providing these women with the required education may alleviate infertility fears and could therefore reduce voluntary childlessness that arises from unfounded fears and misconceptions. Appropriate education in women with poor knowledge will improve understanding of the role and risks of therapeutic interventions in IBD, which might also improve medication adherence before and during pregnancy and nursing. While CCPKnow addresses multiple aspects that relate to pregnancy in IBD, the questionnaire is designed to generate a single unified score without sub-scores for ease of use in the clinical setting; patients who lack specific areas of knowledge – for example, relating medication use in pregnancy – can then be targeted with dedicated education programmes to address their needs, while the effectiveness of any educational intervention can then also be re-assessed using CCPKnow.

We have described a novel tool that provides reliable and accurate quantification of disease-related knowledge, for ready use in the clinical setting. While CCPKnow can now be readily applied to all healthcare settings to identify patients with poor knowledge of pregnancy and IBD, future applications of the tool include evaluating patient adherence to medication during pregnancy,[22] and comparative studies examining the knowledge of different practitioners (e.g. general practitioners, midwives, obstetricians and gastroenterologists) involved in the care of the pregnant patient with IBD. The development and validation of knowledge assessment tools such as CCPKnow may therefore form an integral part of evolving techniques – for example, web-based or smart phone applications – that are aimed at improving patient education and, in turn, adherence to medication.

Acknowledgements

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References
  9. Supporting Information

Declaration of personal interests: J. A. Eaden has served as a speaker, a consultant and an advisory board member for Tillotts, Ferring and Schering Plough. W. Selby has served as a speaker, a consultant and advisory board member for Abbott Pharmaceuticals, Ferring Pharmaceuticals and Schering-Plough Pty Ltd. P. Katelaris has served as a speaker, a consultant and an advisory board member for AstraZeneca, Janssen and Orphan Australia. R. W. Leong has served as a speaker and an advisory board member for Abbott Australasia, Janssen Cilag Pty Ltd, Ferring Pharmaceuticals, and has received research funding from Nycomed. J. McLaughlin has served as an advisory board member for Shire and Almirall. S. Lal has served as a speaker a consultant and an advisory board member for IBD/Nutrition companies including Baxter, Ferring, Warner-Chilcott, Shire, MSD, and has received research funding from Crohn's Colitis UK, Raynaud's and Scleroderma Association. Christian Selinger has received research funding from Ferring Pharmaceuticals, Shire and Nycomed. Declaration of funding interests: None.

References

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References
  9. Supporting Information
  • 1
    Mahadevan U, Kane S. American gastroenterological association institute medical position statement on the use of gastrointestinal medications in pregnancy. Gastroenterology 2006; 131: 27882.
  • 2
    Mahadevan U, Kane S. American gastroenterological association institute technical review on the use of gastrointestinal medications in pregnancy. Gastroenterology 2006; 131: 283311.
  • 3
    Van Assche G, Dignass A, Reinisch W, et al. The second European evidence-based Consensus on the diagnosis and management of Crohn's disease: Special situations. J Crohns Colitis 2010; 4: 63101.
  • 4
    Habal FM, Huang VW. Review article: a decision-making algorithm for the management of pregnancy in the inflammatory bowel disease patient. Aliment Pharmacol Ther 2012; 35: 50115.
  • 5
    Bortoli A, Pedersen N, Duricova D, et al. Pregnancy outcome in inflammatory bowel disease: prospective European case-control ECCO-EpiCom study, 2003–2006. Aliment Pharmacol Ther 2011; 34: 72434.
  • 6
    O'Donnell S, O'Morain C. Review article: use of antitumour necrosis factor therapy in inflammatory bowel disease during pregnancy and conception. Aliment Pharmacol Ther 2008; 27: 88594.
  • 7
    Nørgård B, Fonager K, Pedersen L, Jacobsen BA, Sørensen HT. Birth outcome in women exposed to 5-aminosalicylic acid during pregnancy: a Danish cohort study. Gut 2003; 52: 2437.
  • 8
    Langagergaard V, Pedersen L, Gislum M, Nørgard B, Sørensen HT. Birth outcome in women treated with azathioprine or mercaptopurine during pregnancy: a Danish nationwide cohort study. Aliment Pharmacol Ther 2007; 25: 7381.
  • 9
    Marri SR, Ahn C, Buchman AL. Voluntary childlessness is increased in women with inflammatory bowel disease. Inflamm Bowel Dis 2007; 13: 5919.
  • 10
    Mountifield R, Bampton P, Prosser R, Muller K, Andrews JM. Fear and fertility in inflammatory bowel disease: a mismatch of perception and reality affects family planning decisions. Inflamm Bowel Dis 2009; 15: 7205.
  • 11
    Mountifield RE, Prosser R, Bampton P, Muller K, Andrews JM. Pregnancy and IBD treatment: this challenging interplay from a patients' perspective. J Crohns Colitis 2010; 4: 17682.
  • 12
    Eaden JA, Abrams K, Mayberry JF. The Crohn's and Colitis Knowledge Score: a test for measuring patient knowledge in inflammatory bowel disease. Am J Gastroenterol 1999; 94: 35606.
    Direct Link:
  • 13
    Anastasi A, Urbina S. Psychological Testing, 7th edn. Upper Saddle River, NJ: Prentice Hall, 1997.
  • 14
    Cronbach L. Coefficient alpha and the internal structure of tests. Psychometrika 1951; 16: 197334.
  • 15
    Kincaid JP, Fishburne RP, Rogers RL, Chissom BS. Derivation of New Readability Formulas (Automated Readability Index, Fog Count, and Flesch Reading Ease Formula) for Navy Enlisted Personnel: Chief of Naval Technical Training. Memphis: Naval Air Station Memphis, 1975.
  • 16
    Chuang CH, Velott DL, Weisman CS. Exploring knowledge and attitudes related to pregnancy and preconception health in women with chronic medical conditions. Matern Child Health J 2010; 14: 7139.
  • 17
    Butcher RO, Law TL, Prudham RC, Limdi JK. Patient knowledge in inflammatory bowel disease: CCKNOW, how much do they know? Inflamm Bowel Dis 2011; 17: E1312.
  • 18
    Rezailashkajani M, Roshandel D, Ansari S, Zali MR. Knowledge of disease and health information needs of the patients with inflammatory bowel disease in a developing country. Int J Colorectal Dis 2006; 21: 43340.
  • 19
    Subasinghe D, Wijekoon NS, Nawarathne NM, Samarasekera DN. Disease-related knowledge in inflammatory bowel disease: experience of a tertiary care centre in a developing country in South Asia. Singapore Med J 2010; 51: 4849.
  • 20
    Leong RW, Lawrance IC, Ching JY, et al. Knowledge, quality of life, and use of complementary and alternative medicine and therapies in inflammatory bowel disease: a comparison of Chinese and Caucasian patients. Dig Dis Sci 2004; 49: 16726.
  • 21
    Standards. Quality Care Service Standards for People Who Have Inflammatory Bowel Disease (IBD). London: The IBD Standards Group, 2009.
  • 22
    Nielsen MJ, Nørgaard M, Holland-Fisher P, Christensen LA. Self-reported antenatal adherence to medical treatment among pregnant women with Crohn's disease. Aliment Pharmacol Ther 2010; 32: 4958.

Supporting Information

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References
  9. Supporting Information
FilenameFormatSizeDescription
apt5130-sup-0001-FigureS1.jpgimage/jpg2172KFigure S1. Discriminate ability of CCPKnow demonstrated by individual data points.
apt5130-sup-0002-FigureS2.docxWord document12KFigure S2. Receiver operator characteristics of CCPKnow demonstrating high sensitivity (Y-axis) and specificity (as 1-specificity on X-axis).
apt5130-sup-0003-TableS1.docxWord document12KTable S1. Cronbach's alpha analysis of individual CCPKnow items.
apt5130-sup-0004-AppendixS1.docWord document47KAppendix S1. IBD-Pregnancy-Knowledge-Score (CCPKnow).

Please note: Wiley Blackwell is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.