Perceptual Factors (Awareness, Attitude) and Positive, Indeterminate and Negative Nurturing Factors Affecting Physical Activity of Pregnant Women Visiting Health-care Centers in Tehran: Examination and Analyses

The purpose of this study was to examine the effect of perceptual factors (awareness, attitude) and positive, intermediate and negative nurturing factors on physical activity of pregnant women visiting health centers in Tehran. The present research was an applied study in which a quasi-experimental research design (pre-test-post-test) with a control group was employed. The Pregnancy Physical Activity Questionnaire (PPAQ) and a questionnaire designed based on the results of needs assessment and dimensions of the PEN-3 model were used for the purposes of this study. This study is a randomized control trial (RCT). The results indicated that the intervention based on E-learning has a statistically signicant effect on perceptual factors (awareness, attitude) in increasing physical activity of pregnant women in the experimental group. Furthermore, E-learning-based intervention has a signicant effect on increasing physical activity of pregnant women in the experimental group compared to the control group.


Abstract Background
The purpose of this study was to examine the effect of perceptual factors (awareness, attitude) and positive, intermediate and negative nurturing factors on physical activity of pregnant women visiting health centers in Tehran.

Methods
The present research was an applied study in which a quasi-experimental research design (pre-test-posttest) with a control group was employed. The Pregnancy Physical Activity Questionnaire (PPAQ) and a questionnaire designed based on the results of needs assessment and dimensions of the PEN-3 model were used for the purposes of this study. This study is a randomized control trial (RCT).

Results
The results indicated that the intervention based on E-learning has a statistically signi cant effect on perceptual factors (awareness, attitude) in increasing physical activity of pregnant women in the experimental group. Furthermore, E-learning-based intervention has a signi cant effect on increasing physical activity of pregnant women in the experimental group compared to the control group.

Conclusion
Based on the research results, it can be said that there is a statistically signi cant difference between the experimental and control groups in the scores obtained from perceptual factors (awareness, attitude) in the pre-test and the experimental group. Furthermore, it is safe to say that there is a statistically signi cant difference between the experimental and control groups in the scores obtained from physical activity in the pre-test and the experimental group.

Background
Pregnancy is one of the most sensitive and signi cant stages of any woman's life. It is associated with changes in psychological needs (e.g., anxiety and depression) and physical demands (such as weight gain and higher cardiac output). Nevertheless, about 60% of all pregnant women eliminate or reduce their physical activity during pregnancy (1,2). Research shows that reduced physical activity in pregnant women is highly stemmed from their misconceptions and attitudes during pregnancy. It has been proven that regular physical activity in the rst six months of pregnancy reduces the prevalence of cesarean section, shortens the second stage of labor and reduces fetal complications. In Iran, the prevalence of required training in accordance with standard pregnancy care programs is not satisfactory. Women experience unavoidable weight gain during pregnancy, while the role of physical activity during pregnancy with the purpose preventing such problems is signi cant (3). Furthermore, guides speci cally designed with the characteristics of pregnancy in mind are less available. Physical activity is de ned by the World Health Organization as "any physical movement produced by skeletal muscle that requires energy consumption, including activities such as working, playing, doing household chores, traveling, and taking responsibility for recreational activities" (4). Although many studies show the bene cial effects of physical activity on the overall health of mother and fetus and having a healthy pregnancy, about 60% of all pregnant women do not undertake any physical activity during pregnancy (1). Despite the prevalence of awareness on physiological manifestations of exercise during pregnancy, there is still no comprehensive understanding on the effects of exercise with different intensities and intervals during pregnancy on mother and fetus (5). The postpartum period can be introduced as an opportunity to change health-related habits throughout the life. Unfortunately, limited interventions have been proposed based on health education theories and models in this regard (6)(7), and most studies have been descriptive and analytical. Considering the vital role of mothers, their health is signi cantly involved in the health of infants. Maternal factors during pregnancy such ways employed for reducing the concentration of blood in diabetic mothers, reducing back pain, increasing mental activity, improving quality of life and increasing physical function, type of nutrition, strategies used to cope with stress and overall care during this period constitute an important part of the mother's lifestyle during pregnancy (8). Signi cant developments have been achieved in technology and studies related to exercise for pregnant women, but the most optimal methods for encouraging pregnant women to engage in physical activity is yet to be examined and there are no studies on the implementation of an effective E-learning program, one that considers the cultural dimension of society, with the aim of increasing physical activity in pregnant women in Iran. It is also necessary to develop programs for the prevalence of exercises in pregnant women. Given the importance of physical activities during pregnancy and the necessity to implement suitable interventions in line with the improvement of the aforementioned attitude among pregnant women, it is also of paramount importance to use modern methods and technologies to entice women to increase their activity levels during pregnancy, the purpose of which would be to reduce the incidence of pregnancy-related diseases and hence to reduce the rate of cesarean section in Iran and the world. As such, this studied sought to offer an answer for the following question: what are the perceptual factors (awareness, attitude) that increase physical activity in pregnant women referring to health-care centers?

Materials And Methods
This research is an applied study in terms of purpose, which employs mixed method (quantitative and qualitative) design for data collection. The research was conducted in two stages. In the rst stage of the research, the literature was rst reviewed, followed by semi-organized interviews with pregnant women, with the purpose of obtaining the criteria and sub-criteria for increasing physical activity in pregnant women. The method employed at this stage of research was that of qualitative. In the second stage of the research, based on the information obtained from the previous stage, the researcher nally implemented an E-learning program intervention to increase physical activity in pregnant women visiting health centers in Tehran based on the PEN-3 cultural model, and thus, the second stage of the research was a quasi-experimental study which was performed in a quantitative manner. This study was in fact a randomized control trial (RCT). Given the nature of the research, a quasi-experimental research design (pre-test/post-test) with a control group was employed for the purposes of the study.
The study population included all pregnant women aged 18 to 40 years with gestational age of 12-38 weeks visiting health-care centers in Tehran's District 5 out of all 22 districts of the city that had eliminated their physical activity during pregnancy.
In the qualitative stage, the sample size was determined based on the necessity of data saturation, and as such, interviewing continued until it was achieved. Sampling was performed using simple random sampling among those invited to participate in the study in the health center. Thus, after sending invitations to pregnant women who were in their rst pregnancy and conducting telephone follow-ups by an expert and the head of the health center, 23 people were selected from the mothers who visited the health center. This questionnaire was a researcher-made questionnaire, with three categories and 42 items. The categories include perceptual factors with 20 items, nurturing factors with 10 items, and enabling factors with 12 items. The items are scored on a 5-point Likert scale ranging from strongly agree to strongly disagree. The validity of the questionnaire was con rmed using content validity, while its internal reliability was con rmed following a con rmatory study among 250 pregnant mothers with similar traits to that of the study group. The reliability of the questionnaire was con rmed with Cronbach's alpha coe cient (0.85). The results of validity and reliability of the tools were presented.

Pregnancy Physical Activity Questionnaire (PPAQ)
This questionnaire is consisted of two parts, the rst part pertains to the personal characteristics and the second part is consisted of 32 items on physical activity, which itself is divided into four groups of items, namely household/caregiving activities (16 items), transportation (3 items), occupational activities (5 items) and entertainment and sports (8 items). Activity intensity was calculated based on Metabolic equivalent of task (MET), which is a unit for estimating metabolic expenditure in physical activity per unit of time. Its reliability was determined by conducting a preliminary study on 3 eligible pregnant women, attaining a Cronbach's alpha of 0.85.
Validity and Reliability of the questionnaire Face validity: The questionnaires were rst administered among at least 15 pregnant women visiting health centers, then the face validity was determined based on the importance of the items and by calculating the impact score. Items with an impact score higher than 1.5 were deemed appropriate for subsequent analysis.
Content validity: The opinions of the panel of experts were extracted and used accordingly to determine the content validity. To quantitatively evaluate the content validity, two coe cients of content validity ratio and content validity index were used.
Content Validity Ratio (CVR): At least 15 specialists and experts responded to each item through 3 choices for each (i.e., item is necessary, item is useful but not necessary, item is not necessary). Items whose resulting scores were larger than the relevant value of the Lawshe table were considered as necessary items.
Content Validity Index (CVI): To ensure that items were optimally designed to measure structures, three criteria of relevance, clarity, and simplicity were examined using 8-point Likert scale, as each item was examined by at least 15 specialists. CVI scores higher than 0.79 was deemed appropriate.
Reliability test: To determine the reliability of data collection tool, a modi ed questionnaire was distributed among 30 people in the study population and Cronbach's alpha value was calculated. An alpha value higher than 0.7 was considered proper for the purposes of this study.

Data analysis method
In the rst stage, qualitative data were coded immediately after each group discussion and individual interview, and these sessions were continued until data saturation. The main themes and topics were extracted using MAX-QDA software and based on deductive qualitative content analysis. Descriptive statistical methods such as mean and inferential statistics were employed to analyze the data.

Integration through inclusive themes
In the process of thematic analysis, the themes formed in the interviews were integrated under comprehensive themes, and a network of themes, namely "Factors Affecting Physical Activity Based on the PEN-3 Cultural Model" was formed, which is shown in Fig. 1.

Quantitative data analysis
In this section, structural measurement models were employed to examine the accuracy of measuring structures by the corresponding indicators. Table 1 shows that the con rmatory factor analysis of the constructs of the questionnaires on the impact of E-learning program with the aim of increasing physical activity of pregnant women visiting healthcare centers in Tehran based on the PEN-3 cultural model has a suitable t and thus the constructs of the questionnaire measure the relevant variables properly. Given that all signi cance variables of model parameters except the item "doing daily basic exercise will not harm the mother and fetus" is greater than 1.96, the validity of the measurement structures for the relevant variables at a signi cant level is con rmed.
In the research model, the root mean square error of approximation (RMSEA) is 0.038 which is less than 0.1. Moreover, other tness indicators are also listed in the table below. As can be seen, they con rm the signi cance and t of the model.

Descriptive statistics of variables
The results of descriptive statistics on the pre-and post-test of the variables of "awareness" and "attitude" in the experimental and control groups are given in Table 2.  Table 3 and considering that the level of signi cance for all the variables of "awareness", "attitude", "perceptual factors" and "increase in physical activity" is higher than 0.05, it can be concluded that the relevant variable has a normal distribution. Furthermore, according to the same table and considering that the signi cance level of Levene test for all the variables of "awareness", "attitude", "perceptual factors" and "increase in physical activity" is higher than 0.05, it can be argued that the experimental and control groups have homogeneous variances.
Considering that none of the variables of "awareness", "attitude", "perceptual factors" and "increase in physical activity" are signi cant in examining the homogeneity of regression slope (P > .05), we conclude that the assumption of homogeneity of regression slope holds.
Examining the hypotheses 1. Intervention based on E-learning has a signi cant effect on perceptual factors (awareness, attitude) with the purpose of increasing physical activity in pregnant women in the experimental group.
To test Hypothesis 1, multivariate analysis of covariance was performed while controlling the possible effect of pre-tests, the results of which can be seen in Table 4. Covariance analysis is a comprehensive type of analysis of variance in which the effect of one or more control or interfering variables and covariates is excluded from the equation while comparing the means of one or more groups and estimating one or more independent variables. In fact, this analysis is a statistical method that allows the effect of one independent variable on the dependent variable to be examined while eliminating the effect of another variable. The results from Wilkes lambda test indicated that the effect of interventions based on E-learning on the combination of variables of perceptual factors (i.e., awareness and attitude) was signi cant (F = 24.859, p < 0.05). The above test allowed the use of multivariate analysis of variance (MANOVA). The size of the difference effect is proper considering the eta-value (0.202). The results of multivariate analysis of covariance in Table 5 showed that the mean scores of perceptual factors, i.e., awareness (2080.125) and attitude (2284.880) were signi cantly higher in pregnant women in the experimental group than those in the control group, and as such it can be concluded that Intervention based on E-learning has a signi cant effect on perceptual factors (awareness, attitude) that aim to increase physical activity of pregnant women in the experimental group. According to Table 6, pregnant women (F = 320.395, P < 0.05) received a signi cant impact from the intervention based on E-learning in the physical activity variable. As a result, the null hypothesis is rejected and thus the research hypothesis is accepted. In other words, E-learning-based intervention has a signi cant effect on the level of physical activity in pregnant women.  spirit, reduces stress, controls weight and results in tness. Wife, mother and health care workers were the most in uential people (9). To elaborate, it is safe to argue that the very rst step in physical activity training is to improve awareness and attitude on the importance and manner of physical activity, as improving awareness and attitude naturally leads to behavioral changes. In our country today, the amount of training required according to standard pregnancy care programs is not optimal. It seems that mothers are highly concerned about sports during pregnancy owing to their lack of knowledge about permitted sports and the relevant procedures, and since incorrect information is one of the factors affecting their behavior, it causes women to opt for a rather sedentary life during pregnancy (10).
Increasing awareness and readiness during pregnancy allows the mother to go through this stage of life with fewer complications, and as such pregnancy poses a good opportunity to educate pregnant women to be aware of the bene ts of proper physical activity and healthy lifestyle. Increasing women's awareness on physical activity and physical exercises during pregnancy and changing their attitude will naturally lead to behavioral changes their behavior.
Hypothesis 2: Intervention based on E-learning has a signi cant effect on increasing physical activity in pregnant women of the experimental group compared to those of the control group.
Based on the ndings of the study, it is safe to say that there is a statistically signi cant difference between the experimental and control groups in the scores obtained from physical activity in the pre-test has actively sought to follow the standard activity recommendations presented in the training class. In this study, the activity of mothers in the experimental group has improved. Kazemi et al. (2007) concluded that the rate of physical activity in women without gestational hypertension was signi cantly higher than the group with hypertension (11). Shakeri et al. (2012) performed a study to determine the effect of physical activity training during pregnancy on the level of physical activity of pregnant women.
In this interventional and quasi-experimental study, two groups of 140 pregnant women in their rst pregnancy who referred to healthcare centers in Zanjan were selected and randomly divided into experimental and control groups. Based on the results, the amount of physical activity in women in the experimental and control groups before the intervention was not signi cantly different. But after the intervention, the amount of physical activity in the experimental group was signi cantly higher than the control group (12). The results of another study revealed that the administration of pregnancy training classes promotes behaviors related to a healthy lifestyle and leads to increased physical activity. It seems that using the experiences and verbal advices of midwives and studying written training materials can improve the level of physical activity of women during pregnancy. Therefore, it is necessary to recommend physical activity during pregnancy (13). The Research Ethics Committee approved the research of this study. All pregnant women in this trial were informed about participating in the survey and gave written informed consent for the study.

Consent for publication
Not applicable.

Availability of data and materials
All data generated during the process of this research are included in this article.

Funding
This study is funded in part by the Medical Sciences, Tarbiat Modares University, Department of Health Education and Health Promotion. This funding has facilitated the use of websites to support physical activity during pregnancy.

Competing interests
The authors declare that they have no competing.
Authors' contributions LK comprehended the trial, completed the collection, categorized the data. SR presented supervise during data collection and collaborated to temporary and interpretation nal data. SHN performed manage during the development of the study and data collection, participated in the analysis of the data. FSH prepared the draft, and edited the repetitive draft. All researchers read, concluded, and approved the nal draft. Figure 1 Conceptual model of factors affecting physical activity based on PEN-3 cultural model