Comparison of the Effectiveness of Parenting Training with Life Skills Training on the Mental Health of Mothers of Children with Hearing Loss: A Randomized Clinical Trial


 BackgroundHearing loss is one of the most common sensory disorders. The consequences of hearing loss and its effect on the mothers of these children on the one hand and the emphasis of previous research on the effectiveness of educational interventions along with the lack of comparative studies on the other hand prompted us to do this research. Educational interventions have been approved for prevention of unwanted effects between mother and child. One of these interventions is a positive parenting program. This educational program seeks to create a useful relationship between mother and child. Another life skills training intervention enables life skills to cope.MethodsThis study was a randomized clinical trial. The research sample consisting of 46 mothers who have child with hearing loss were divided into two groups: a positive parenting training group and a group that was trained in a life skills program. The workshops of both groups were accomplished online due to the limitations caused by the Covid-19 pandemic. Data collection tools were three questionnaires of parenting, life skills, and general health that were completed in both pre-test and post-test stages. For data analysis, SPSS software version 26 was used.ResultsThe results indicate that parenting education in mothers with children with hearing impairment has significantly reduced anxiety and depression. ConclusionsThis research showed that parenting education has increased the quality of life of mothers with children with hearing impairment and the positive effects of this education are confirmed.Trial registration: IRCT20201014049023N1. Registered 23 October 2020, https://www.irct.ir/trial/51623


Introduction
The global outbreak of Covid-19 has affected everybody's daily life (1). Also, many viral infections have emerged in the world, which has affected the World Health Organization and millions of people around the world (2); the rapid spread and epidemic of the coronavirus, which killed many people in two months, shows the strength of the virus (3). In addition to endangering the physical health of humans, the virus imposes irreversible psychological effects on human societies and causes anxiety, especially in affected countries (4). Separation from loved ones, feelings of uncertainty, fear about getting sick, restricted freedom, and feeling bored are some of the effects of home quarantine that can have signi cant effects in some cases. People in quarantine are afraid of the consequences of this infectious disease. They experience boredom, loneliness, and anger (5). In addition, due to home quarantine, it is not possible to attend community services and enjoy psychological support and rehabilitation (6). In the meantime, home quarantine and the closure of educational institutions are affecting children's lifestyle patterns due to less physical activity, more TV watching, and changes in bedtime. Such negative health effects are exacerbated when children are deprived of activities outside the home and interaction with their peers during an outbreak (7). Therefore, due to social distancing to help eliminate this disease, the authorities put virtual education on the agenda as the main challenge and concern. International institutions and organizations such as the World Health Organization and UNICEF have also been forced to develop curricula and educational guidelines for these crises (8).
Hearing impairment is one of the most common sensory disorders in children. Hearing impairment reduces hearing and thus impairs the development of speech and language skills (9-12). Therefore, a child's hearing impairment puts a lot of stress on parents (13)(14)(15). More than 95% of hearingimpaired children are born to hearing parents (1). In such cases, the expectations that hearing parents have of a hearing-impaired child are often similar to those of a hearing-impaired child. However, there is no harmony between the expectations of hearing parents, especially the mother, and the reactions of a hearing-impaired child. This disrupts the parents' relationship with the deaf child (16).
Among the family members, the mother is the rst person with whom the child has a relationship and is considered the centre of health or illness (17). Thus, the birth of a hearing-impaired child presents the family with challenges that may cause them distress, despair, depression, anger, helplessness, guilt, shame, and humiliation (18). Therefore, if these unpleasant consequences are not resolved logically, it will cause irreparable damage to the psyche of the mother and family (19,20).
In this regard, the results of studies show the important role of parents in reducing and preventing child behavioural problems and in developing interventions in this eld (14,15,21). In general, the parenting style of parents is one of the most important factors affecting the psychosocial development of children (22). The Triple P -Positive Parenting Program was established at the University of Queensland, Australia as a family behavioural intervention aiming at altering children's behavioural problems and improving family environments that maintain and reinforce the child behavioural problems (23). In designing this program, social learning methods such as parent-child interaction models, family-child behaviour therapy, applied behaviour analysis, parenting development research, and child psychological pathology as well as social information data processing models and social and public health perspectives have been used (24). This program, which is considered the most comprehensive support program in the eld of parenting, is a preventive parenting method with a family support strategy that has several levels of intervention with varying degrees of intensity. All levels are used to prevent behavioural, developmental, and emotional problems in children (25).
A positive parenting program promotes a variety of aspects, including (1) parenting skills, knowledge, con dence, and resourcefulness; (2) a more nurturing, safer, more attractive, and nonviolent environment for children, and (3) more social, emotional, linguistic, intellectual, and behavioural abilities of children. Previous research has shown that a positive parenting program reduces parental stress through parenting skills (26). It also reduces disorders such as depression, anger, anxiety, and high levels of stress in parents (27).
In the study of Ashori and Ghaforian, which examined the effect of positive parenting education on the relationship pro le of mothers and hearingimpaired children, it is shown that parenting education leads to improving the pro le of parents with deaf children (21).
In another study, Movallali et al. examined the effectiveness of parenting on the mental health of families with children with hearing impairments. They concluded that educating parents on parenting styles signi cantly reduced the somatic symptoms, anxiety, and interpersonal relationships (18).
Everyone faces problems and obstacles in the course of life that may change his/her quality of life, but the way he/she deals with problems is very different. Some people lack the necessary abilities and skills in facing life problems, and this makes them vulnerable to depression. Having resources and skills helps people cope with their problems in the best possible way (28). Life skills are psychosocial abilities for adaptive and effective behaviour that enable individuals to cope effectively with the needs and challenges of everyday life. The life skills training program is based on the components of life skills of the World Health Organization, including ten skills; decision-making ability, problem-solving ability, creative thinking ability, critical thinking ability, effective communication ability, interpersonal relationship ability, self-awareness ability, empathy ability, ability to deal with emotions, and ability to deal with stress (29). These skills help people in times of intense stress develop the abilities, information, attitudes, and skills necessary for a successful, healthy, and stress-free life. Life skills training helps people, especially mothers with deaf children, know more about themselves and the situation, as well as their strengths and weaknesses, thereby helping them better accept the facts and deal with them more correctly. This increases adaptation and consequently acceptance of conditions, thus reducing stress. Therefore, these trainings cause appropriate changes in attitudes and values, strengthen behaviours appropriate to health problems and barriers, promote mental health, and enable people to face the life's problems. Consistent with these ndings, research also shows that life skills training is a useful intervention and an effective way to improve the self-e cacy for childcare (30)(31)(32). Therefore, according to the above points, the purpose of this study was to compare the effectiveness of parenting education and life skills training for the mental health of mothers with hearing-impaired children in the Covid-19 crisis and quarantine virtually.

Methods
The present study was a randomized clinical trial (RCT), with two groups of parallel and two-stage design (pre-test and post-test). The research protocol was approved by the Ethics Committee of Shiraz University of Medical Sciences, Shiraz, Iran (code: IR.SUMS.MED.REC.1399.369). Also, while pointing out the con dentiality of the participants' information, they have given written consent to participate in the research.
The study population was all the mothers with hearing-impaired children under training at the Family Rehabilitation Center in Soroush, Shiraz.
Criteria for inclusion of mothers in the study were: Persian language, a child with hearing loss in the age range of 3 to 7 years, and no psychiatric disorder requiring medication.
Conventional simple sampling was performed through the available samples. A total of 57 eligible individuals were included in the study.
First, the necessary information about confounding variables about each participant was collected through performing interviews, referring to the child's le, and completing a questionnaire. These variables were: mother's age, mother's level of education, father's level of education, father's role, socioeconomic level of the family, family type, city of residence, number of children, child's age, child's gender, order of birth, comorbid disorders, severity of hearing loss, and type of hearing aid (Tables 1,2).
Participants were randomly assigned and divided into two groups (group A including 29 subjects and group B including 28 participants) using a table of random numbers.
Then, the relevant data were entered into SPSS software, and the means of confounding variables were compared using the independent t-test at a signi cance level of 0.05. According to Table 1, no signi cant difference was observed at the baseline between the two groups. Therefore, the two groups had the same conditions at the baseline concerning the confounding variables.
Also, to collect data related to the study-related variables, including the mother's general health status, authoritative parenting style, careless parenting style, authoritarian parenting style, and life skills, rst the authors sent the relevant questionnaires to be completed by the mother. Then the data were analysed by a psychologist. In this regard, the mother's general health status was determined using the GHQ questionnaire, the mother's parenting style was determined using the PSDQ questionnaire, and life skills were determined using the life skills questionnaire. Then, the relevant data were entered into SPSS software, and the means of dependent variables were compared using the independent t-test at a signi cance level of 0.05. No signi cant difference was observed at the baseline between the two groups. Therefore, the two groups were in the same status at the baseline concerning the dependent variables. (Tables 1, 2) In the next step, the type of intervention in each group was determined randomly, which was the intervention assigned to group A being through parenting education and the intervention assigned to group B being through life skills training. Using the Kiddie Schedule for Affective Disorders and Many times, 5. Always); for each option, a score equal to its number is considered. For analysis of the data of this the questionnaire, at rst, the questions were separated according to parenting style; after calculating the score for each style, they were entered into a comparative analysis.

Life Skills Questionnaire
The life skills of mothers participating in the group were assessed through the life skills questionnaire of Saatchi et al. Its validity and reliability were con rmed, and the data of this questionnaire were entered into the relevant software. This questionnaire contains 40 items that are scored based on a ve-point Likert scale (very low, low, to some extent, high, very high). They are listed in options 1 to 5, respectively, each of which having a numerical value equivalent to its option. As a result, test scores range from 40 to 200.
General Health Questionnaire-28 The level of mental health of the participants in both groups was measured through a general health questionnaire. The validity and reliability of this questionnaire has already been con rmed in Iran, and the relevant data were entered into the software. This questionnaire consists of 28 items for each of the four options. The options have a numerical value of 0 to 3. A lower score indicates a better level of mental health. The scores on this questionnaire also range from 0 to 84.
Due to the implementation of this project during the Covid-19 pandemic and as a result of the impossibility of holding a face-to-face workshop, the training course was held in the form of a virtual workshop online via WhatsApp due to its no-cost, availability, ease of use, and popularity among mothers.
Training in both groups was done by a female psychologist with a master's degree.
The intervention included ten 120-minute workshops held twice a week.
The structure of each session on the appointed day and time was to rst review their assignments of the previous session, extract practice exercises, provide feedback, introduce the content of the current session, teach a new topic, practice, and determine the practice of the next session.
To improve the training process, on days other than the main meetings, if any ambiguity or question arose for any of the members, it was raised in the group and the answer was provided with the participation of others.

Parenting training workshop
Parenting education was done through the Triple P -Positive Parenting Program, in which parents were introduced to parenting techniques, designed by professors at the University of Queensland in Australia, based on a memorandum of understanding between the Cognitive Sciences Research Institute (Iran), the Iranian Child and Adolescent Psychiatric Association, and Triple P International, which is in charge of distributing this program. The license was issued to implement the program in Iran.

Life skills training workshop
The life skills training program was held based on the life skills components of the World Health Organization, including ten skills: decision-making ability, problem-solving ability, creative thinking ability, critical thinking ability, effective communication ability, interpersonal relationship ability, selfawareness ability, empathy ability, the ability to cope with emotions, and stresses.
At the end of the intervention, questionnaires on parenting style, life skills, and general health were completed again by participants in both groups.
After analysing the relevant data by a psychologist, these data were entered into SPSS software and the means of dependent variables were compared by independent t-test at a signi cance level of 0.05.
Exclusion from the study During the course, 8 participants withdrew from the study, 4 of them due to their illness or that of a family member, 2 people due to the death of a family member due to Covid-19, and 2 people left the project due to cancellation. After completing the course, 3 participants were excluded due to uncompleted questionnaires, and after analyzing the data, 2 participants were excluded due to incorrect scores.

Results
In this study, rst the confounding parameters were examined and compared between the two groups, based on the data on the mother's age, mother's level of education, father's level of education, father's role, socioeconomic level, family type, city of residence, number of children, child's age, child's gender, order of birth, accompanying disorders of the child, hearing loss, and type of hearing aid. There was no signi cant difference in the age of mothers in the two groups of life skills and parenting, and only the results of comparing the level of education of fathers were signi cantly different: the fathers of the parenting group had a higher level of education than that of the life skills group (Tables 1, 2). Table 4 shows the standard deviation from the mean. According to Table 5, in within-group comparison, in the group of mothers who had a score higher than 23 in general health before training, after parenting education there was a signi cant improvement in the depression score (P < 0.05). Also, in the group of mothers whose general health score was higher than 23 before training, after life skills training a signi cant change was observed in mental health score (P < 0.05), which was due to the change and improvement in the social factor subgroup (P < 0.05). As can be seen in Table 5, in the parenting group whose general health score was higher than 23, the change in the general health score of mothers after parenting education was signi cant (P < 0.05). This signi cance was due to the improvement of mothers' condition in somatic health variables (P < 0.05), anxiety (P < 0.05), and depression (P < 0.05).
In the life skills group whose general health score was higher than 23, the mothers' general health score was better and therefore signi cant (P < 0.05). This signi cance was due to the improvement in the score of the social factor subgroup (P < 0.01). In other cases, as shown in Tables 4 and 6, no change was made.

Discussion
The present study is innovative in terms of group matching and considering various confounding factors in this group of studies on mothers with children with hearing impairment. Due to the online implementation of training workshops and simultaneously with the prevalence of Covid-19 and its high peak in the world as well as in our country, which has increased the level of stress and anxiety of mothers and children, it is probable that these unique and unprecedented conditions have had an effect on the results obtained in this research.
The results obtained in this research have shown that in the group of mothers with children with hearing impairment who were exposed to life skills education compared to mothers who received parenting education, there was a signi cant improvement in mental health in the social factor (P < 0.01), which had a signi cant effect (P < 0.05) on the overall mental health.
After parenting education in mothers whose general health scores were below 23 (meaning better in their general health), there has been a signi cant reduction in the depression factor (P < 0.05). In mothers who received a general health score above 23 (which means a poorer state of health), parenting education compared to life skills had a signi cant effect in the somatic factor (P < 0.05), anxiety factor (P < 0.05) and depression factor (P < 0.05), and nally the general score of general health (P < 0.05) had a signi cant effect.
Therefore, these results indicate that the effect of parenting education in mothers with children with hearing impairment has been signi cant, and these results indicate that parenting education in mothers with children with hearing impairment has signi cantly reduced anxiety and depression in these mothers. Thus the positive effects of this education are con rmed in this study.
The study conducted by Ashori and Ghafourian on positive parenting education on the relationship between the mothers and deaf children concluded that positive parenting education signi cantly reduced somatic symptoms and anxiety, and their interpersonal and psychological relationships also improved (21). Therefore, the results of our study are consistent with this study. The research carried out by Pakzad et al. examined the effect of mothers' education based on the positive parenting model on the symptoms of deaf students' behavioral disorders and concluded that mothers' education based on the positive parenting model had an effect on reducing their deaf child's behavioral disorders and could be used as an effective interventional method (35). So, our research was to con rm the results of this study.
In another study conducted by Abbaszadeh et al. on the effectiveness of parenting education on mental health and the parent-child relationship in mothers of deaf children, the effect of early intervention to improve maternal mental health was investigated and con rmed(36) .
Movalalli et al. carried out a study on the effectiveness of parenting on the mental health of families with children with hearing impairments. The results showed that educating parents on parenting styles signi cantly reduced somatic symptoms as well as interpersonal and psychological anxiety. Therefore, positive parenting education is an effective program for the mental health of mothers with deaf children, and positive parenting training should be promoted (18).
In this regard, the present research showed that parenting education increased the quality of life and reduced the level of anxiety and depression of mothers with children with hearing impairment, which in itself improved the general health of mothers and increased the level of general health.
Children with hearing impairment are likely to improve the level of verbal development and have reduced behavioural disorders through the mentioned education.

Declarations
Ethics approval and consent to participate Informed consent was obtained from each patient participating in the study, and the research protocol was approved by the Ethics Committee of Shiraz University of Medical Sciences, Shiraz, Iran.

Consent for publication
Not applicable Availability of data and materials Not applicable

Competing interests
The authors have no competing interests to report.

Funding
This study did not receive any nancial support.