Effectiveness of Theory of Planned Behavior-Based Educational Intervention on Newborn Care in Pregnant Mothers: A quasi-experimental study

Background and Purpose: The neonatal period is one of the most sensitive stages of life, requiring proper understanding and attentive care. Accordingly, this study aimed to investigate the effectiveness of theory of planned behavior-based educational intervention on newborn care in pregnant mothers. Methodology: This study was conducted as a quasi-experimental research on 100 pregnant mothers who were randomly assigned to two groups of intervention (N=50) and control (N=50). The data were collected using a theory of planned behavior-based questionnaire. Considering the effective constructs of this theory, the educational intervention was performed in the form of four 60-minute education sessions in one month in the intervention group. One month after delivery, the data were recollected from both groups and analyzed using statistical tests. Findings: The mean and standard deviation of the mothers’ age in both intervention and control groups were 26.14±4.7 and 26.10±5.19, respectively (p=0.48). Before the educational intervention, the behavioral intention of the intervention group was 3.33 (out of 5), which signicantly increased to 4.54 after the educational intervention (p<0.001). In addition, the performance of mothers regarding neonatal care was signicantly enhanced from 2.86 to 4.64 one month after the delivery (p=0.001). Conclusion: The theory of planned behavior-based educational intervention, along with active follow-ups, led to better and more principled behavioral intention and care provided by pregnant mothers to their newborn infants. Therefore, providing theory of planned behavior-based education in other healthcare centers is recommended. on the Kolmogorov-Smirnov test.


Introduction
The neonatal period ( rst 28 days after birth) is one of the most sensitive stages of life, requiring proper understanding and attentive care. Any failure to do so causes irreparable damage and increases infant mortality [1]. Globally, infant mortality is still a critical public health challenge, with the highest mortality rates among children under ve [2]. About 7.7 million children under ve die worldwide every year, out of which approximately 3.1 million infants die during infancy and nearly all of these deaths (99%) occur in developing countries. According to the estimations reported by the World Health Organization, infant mortality makes up 45% of the deaths among children under ve and more than one-third of these mortalities occur during the rst 24 hours of birth [3].
In developed countries, including the United States, two-thirds of all deaths during the rst year of life occur in infancy. The annual mortality rate in the rst year of life exceeds that until the seventh decade of life [4][5]. In Iran, infant mortality rate (IMR( is 12 and mortality rate in children aged 1-4 were estimated to be 14.5 per 1000 live births [6][7].
Genetics and environment are two factors in uencing infants' health. Genetic effects cannot be controlled by the individual, but environmental effects such as motherhood skills in neonatal care can be learned. Accordingly, promoting awareness and ability of mothers, especially the nulliparous pregnant women, in every society regarding the ways of coping with problems of newborns can be effective in enhancing newborns' health [8]. As reported by the World Health Organization, if the knowledge and awareness of parents is promoted properly, the lives of two-thirds of children dying annually because of different reasons will be saved [9][10].
However, it was found that only 37% of mothers in a study in Saudi Arabia [11], 30% of mothers in the study of Uchenna in Nigeria [12], 58% of mothers in the study of Sandberg in Uganda [13] and 20% of mothers in the study of Bulto in Ethiopia [14] were aware of newborn care, and all these studies emphasized on the necessity of educating mothers in this area.
On the other hand, Memon et al. reported the weak performance of Pakistani mothers [15] and Waiswa also revealed weak newborn care methods used by mothers in Eastern region of Uganda [16].
As implementing educational programs for empowering mothers without the need for modern equipment can be very cost-effective in reducing mortality rate and huge costs of mental disabilities resulted from defects in pregnancy and newborn care, the importance of educating mothers is tangible in any society.
Alam [17], Murthy [18] and Wu [19] in their studies conducted in Bangladesh, India and China, respectively, have also emphasized on the necessity of educating pregnant mothers regarding newborn care and conducting more research in this regard.
This study has employed the theory of planned behavior, for it has the appropriate constructs, including behavioral intention, for the purpose of the study. This theory is used when we cannot measure people's actual behaviors and so, we use their equivalents, that is, behavioral intentions. Similarly, we cannot measure the mothers' behavior of newborn care as long as the baby has not been born. However, their behavior of newborn care can be predicted and assessed by measuring the behavioral intention of the pregnant mothers in this regard. Therefore, this theory has been used in this study.
According to this theory, people enact behaviors when they expect a bene t and value out of those behaviors and this expectation is based on individual judgment [20]. Education based on this theory has been positively assessed in various areas of healthcare for vulnerable groups [21][22]. It is worth to note that most of the previous research has been non-interventional and focused on the problems of premature infants and little research is available on healthy newborn care. Accordingly, considering multiple problems of newborn care and the importance of educating mothers on taking care of their newborns, this study was designed and conducted aiming to determine the e ciency of theory of planned behavior-based educational intervention on enhancing newborn care by mothers.

Materials And Methods
This study was an interventional and quasi-experimental research. The study population included all third-trimester pregnant mothers who referred to the health centers located in the city of Arak, Iran. Inclusion criteria were being a nulliparous pregnant woman and willingness to participate in the study.
Exclusion criteria were reluctance to continue participating in the study and being absent more than twothirds of the education sessions.
The sample size required for this study was determined as 100 people. According to the study of Ghasemi et al. [21] and considering type I error of 5% and type II error of 10% based on the performance construct, the sample size of 40 participants was obtained in each group. Finally, considering the sample loss, 50 participants were included in each group of intervention and control.
See formula 1 in the supplementary les.
In order to sample among health centers located in the city of Arak, 4 health centers out of the total of 24 centers were selected based on socioeconomic conditions and were randomly divided into two groups of intervention and control (two centers for each). 50 mothers from the intervention centers and 50 mothers from the control centers were selected through convenience sampling and included in the study according to the family le number available in the health centers.
In the study, the primary outcomes included awareness and constructs of the theory of planned behavior, including attitude, subjective norm and perceived behavioral control. The secondary outcomes included intention and behavior of pregnant mothers regarding their newborn babies.
In this study, rst the information were collected from both intervention and control groups through a reliable and valid questionnaire before the intervention. Then, the intervention group received TPB-based educational intervention for one month and the control group received routine educations provided by the centers. At last, the information were collected from both intervention and control groups one month after delivery.

Data Collection Tool
The data collection tool in this study was a questionnaire composed of the following sections: Demographic Information: including the mother's age, parents' job, parents' education, pregnancy age and the age of marriage The Mothers' Awareness Assessment on Newborn Care: including 8 multiple-choice questions completed by mothers Theory of Planned Behavior Section: including the following constructs: 1. Mothers' Attitudes: including four questions to be answered on a 5-point Likert scale (totally agree: 5 points, agree: 4 points, no idea: 3 points, disagree: 2 points, and totally disagree: 1 point). In this study, the mothers' attitudes towards the bene ts of proper newborn care and the adverse consequences of improper care were measured. The more desirable the attitude toward a behavior is, the more likely the behavior is enacted. 5-Mothers' Performance: including 6 questions to be answered on a 5-point Likert scale. In this study, proper newborn care included keeping the newborn's room temperature at the appropriate level, proper bathing, feeding the newborn with the colostrum, cleaning the umbilical cord, proper reaction to danger signs in the newborn and regular visits to health centers.

Mothers
The questions have been also assessed during pregnancy based on the mothers' perceptions of whether they will enact the desired certain care behaviors if they have a baby.
To score the items in the mothers' awareness assessment on newborn care section, 1 point was given to each correct response and zero to each incorrect response. So, the points ranged from zero to 1. The points in the constructs of the theory of planned behavior ranged from 1 to 5.

Reliabilityand Validity of Data Collection Tool
Content validity was assessed both quantitatively and qualitatively with the help of 10 experts in the elds of health education, midwifery, pediatrics and maternal and child health. To quantitatively assess content, Content Validity Ratio (CVR) and Content Validity Index (CVI) were calculated. Obtaining CVI of at least 0.79 and CVR of at least 0.62 by referring to Lawshe's table and the number of experts in the study, the items' validity was con rmed. To determine the reliability of the questionnaire using the internal consistency, Cronbach's alpha coe cient was obtained as 0.8 for awareness, 0.75 for attitude, 0.7 for perceived behavioral control, 0.7 for behavioral intention, 0.7 for subjective norms and 0.8 for performance.

Educational Intervention
The educational intervention was designed based on the initial needs analysis of the pre-test results and was implemented in the form of 4 sessions as follows: The rst session was held for one hour focusing on enhancing the pregnant mothers' awareness of the neonatal period, newborns' needs and danger signs in newborns.
The second session was held for one hour focusing on changing the pregnant mothers' attitudes and subjective norms. According to the process recommended by Sharma et al. [20], brainstorming and group discussion techniques were used in order to modify and or change incorrect beliefs and strengthening correct ones. To enhance the mothers' belief to the importance of proper newborn care, this session covered the bene ts of proper newborn care and adverse consequences of improper newborn care and its resulting economic costs. Also, in order to address subjective norms, the role of in uential people, especially spouses, and their participation in performing proper newborn care was emphasized and some materials were handed to the participants in the form of educational pamphlets and booklets. In this session, role play, group discussion and critical thinking techniques were used.
The third session was held for one hour focusing on the perceived behavioral control. This session tried to make the mothers familiar with the barriers to proper care and enhancing their con dence in their ability to take care of their newborns. The educational videos were used to show the effects of behaviorfacilitating factors such as providing incentives, reducing and eliminating perceived barriers, breaking behaviors into small steps, practical demonstrations and successful experiences of mothers on perceived behavioral control.
The fourth session was held for one hour focusing on the mothers' behavioral intention and performance. The purpose of this session was making the mothers familiar with proper newborn care. Using educational videos and pictures, certain behaviors such as keeping the newborn's room temperature at the appropriate level, proper bathing, feeding the newborn with the colostrum, cleaning the umbilical cord and proper reaction to danger signs in the newborn were taught.
In order to evaluate the effectiveness of the educational intervention, the questionnaire was completed and the mother's performances were evaluated both before the intervention and one month after delivery.

Data Analysis
The data were analyzed through SPSS 20. First, descriptive statistics of mean and SD were used. Then, non-parametric Mann-Whitney and Willcoxon tests were used in cases where the data distribution was abnormal based on the Kolmogorov-Smirnov test.

Ethical Considerations
This study has been approved and nancially supported by the Faculty of Health of Arak University of Medical Sciences in the form of a master's thesis in the eld of Health Education and Promotion bearing the code No. 2957. Also, the research has been approved in the Committee of Ethics in Research of Arak University of Medical Sciences bearing the ethics code IR.ARAKMU.REC.1397.169.

Results
The average ages of the mothers in the intervention and control group were 26.4±4.76 and 26.1±5.19 years, respectively, which were not signi cantly different based on the results of the Mann-Whitney test (p=0.310). Other demographic characteristics of the studied mothers are listed in Tables 1 and 2. The results showed that before the intervention, there was no signi cant difference between the intervention and control groups in terms of the constructs of the theory of planned behavior. However, Mann-Whitney test showed a signi cant difference between the intervention and control groups in terms of constructs of the theory of planned behavior and proper newborn care behavior after the educational intervention (Table 3). Also, the performance of the intervention group regarding the proper newborn care behavior was signi cantly enhanced from 02.86±0.42 before the educational intervention to 4.64±0.14 after the intervention (p <0.001).

Discussion
According to the ndings of this study, the educational intervention led to a signi cant enhancement of mothers' performance on newborn care. This enhancement can be attributed to the educational methods, including educational videos, booklets, role plays, critical thinking, etc.
In this study, the mothers' awareness was signi cantly enhanced after the educational intervention. As reported by the World Health Organization, if the knowledge and awareness of parents is promoted properly, the lives of two-thirds of children dying annually because of different reasons will be saved [9][10]. This shows the necessity of educating mothers for and enhancing their awareness of newborn care.
However, it was found that only 37% of mothers in a study in Saudi Arabia [11], 30% of mothers in the study of Uchenna in Nigeria[12], 58% of mothers in the study of Sandberg in Uganda [13] and 20% of mothers in the study of Bulto in Ethiopia [14] were aware of newborn care. Also, Tsegay reported weak awareness of 25% of midwives about newborn care [23]. All these studies emphasized on the necessity of educating mothers in this area.
It is noteworthy that the effectiveness of educational intervention in enhancing mother's awareness in the present study is consistent with the results of many other studies. The results of the study by Ghasemi et al. also reported enhanced awareness of mothers regarding the newborn care after an educational program [21]. However, the study by Salem in Saudi Arabia showed no increase in the knowledge of nurses before and six months after an educational program on neonatal growth monitoring, which is not consistent with the results of the present study. Therefore, researchers have recommended new methods of education, active participatory education and practical work, as well as supportive monitoring and evaluation [24].
In this study, the attitude of the mothers in the intervention group was enhanced after implementing the educational intervention. This nding is consistent with those of the studies by In the preset study, this enhancement can be the result of holding educational sessions (playing educational videos, using educational booklets with relevant pictures) about the bene ts of newborn care and the adverse consequences of improper newborn care. However, the study by Abdulkarimi et al. [27] showed thaat pregnant mothers did not have a good attitude toward taking care of their newborns due to being addicted, which is not consistent with the ndings of the present study. The studies by Salem in Saudi Arabia [24], Deng in China [28] and Chia in Melbourne [29] assessed nurses' attitudes toward newborn care as low or average. The reasons can be the staff's heavy workload, insu cient education, lack of organizational support and lack of transparent protocols, especially for low birth weight babies. Also, the study by Berhe et al. in Ethiopia evaluated mothers' attitudes toward newborn care as low in some aspects which were not compatible with their religious beliefs [30].
In another studies indicated that traditional attitudes and methods of newborn care and arbitrary use of drugs for infants are the leading causes of death and high infant mortality rate in some countries [31][32].
Another nding of the present study was an increase in the subjective norm construct in the intervention group after performing the educational intervention. As most of the pregnant mothers mentioned their husbands as subjective norms, the relevant materials in this eld were included in the designed educational booklets and were provided to them.
The study by Rempel in Vietnam on the role of fathers in newborn care found that greater sensitivity and interaction between father and infant could promote the emotional development of the child [33].
The study of Gu et al. on the effectiveness of TPB-based education on promoting exclusive breastfeeding in Chinese nulliparous pregnant women showed that the subjective norms of Chinese women were their husbands and mothers [22], which was consistent with the nding of the present study.
Another nding of this study was an increase in the perceived behavioral control construct in the intervention group, which is consistent with the results of some studies like Ghasemi [21] on premature newborn care. As newborn care is considered as a value among Iranian families, highlighting the value and importance of newborn care in the educational sessions could increase perceived ability of mothers and their self-con dence in this regard.
Tahir et al. also showed that one of the barriers that mothers face in early postpartum period is the low milk supply and telephone counseling for educating breastfeeding can improve breastfeeding methods [34].
In the study by Esan in Nigeria, 75% of mothers had perceived ability in taking care of their underweight newborns, which was due to education provided by clinical staff [35]. However, in the study by Mansourian in Iran, nurses in the neonatal intensive care units found their educational role for the parents to be poor (37%), which was due to staff shortage, heavy workload and lack of time to educate parents [36].
In terms of behavioral intention construct, the nding of the present study showed a signi cant difference in the intervention group before and after the educational intervention. In order to increase behavioral intention of pregnant mothers during the educational intervention, they were informed that they could get any required information from their local health centers. Also, behavioral intention was enhanced by watching educational videos and reading the booklets. This nding was consistent with the some studies like the one by Ghaffari et al. on increasing mothers' intention for behavior of pregnant women related to exclusive breast feeding [37].
However, the results of the present study are inconsistent with those of the study by Ahmadi et al. [38], as the intention of mothers did not show any increase after breastfeeding training. It could be due to the emphasis and propaganda on the bene ts of breastfeeding by the mass media and the increased initial intention of mothers before the intervention.
In their study on increasing mothers' intention to breastfeed in Spain, Bonuck et al. stated that breastfeeding counseling in two sessions before delivery and one session after delivery was effective in promoting mothers' behavioral intention in exclusive breastfeeding [39].
Promoted performance of mothers in the present study could be due to the emphasis of educational intervention sessions on learning newborn care skills by mothers participating in the intervention group.
The newborn care skills emphasized in the educational intervention were cleaning the umbilical cord, bathing, proper breastfeeding, regular visits to health centers, seeing a doctor when noticing danger signs, maintaining the appropriate body temperature, etc., which all were emphasized in training sessions while providing videos and pictures.
This nding is consistent with the results of several interventional studies conducted based on TPB on various health subjects [21][22]. The results of the mentioned studies show that this theory can be effectively used to promote attitude and performance of mothers in various elds.
The positive effects of educational intervention were reported in the studies by Alam in Bangladesh on education via weekly voice messaging [17], Murthy in India on education via mHealth voice messaging service on newborn care [18], Wu in China on education using WeChat social network for improving exclusive breastfeeding [19] and de Jongh on education via SMS for improving self-e cacy skills of patients and vulnerable groups of pregnant mothers [40]. However, According to the researchers, the effectiveness of mHealth interventions need to be studied further.
One of the limitations of the present study was collecting data though self-reporting. However, it was tried to increase the quality of the collected data by providing transparent information to mothers.

Conclusion
Considering the results of the study, the theory of planned behavior could serve as a useful model for promoting the behavior of the intervention group. Therefore, based on the obtained results, it is hoped that we can take an effective step toward the enhanced health of newborns and infants of our country by conducting more studies on this eld and educating other in uential individuals, especially healthcare providers and all those who have an important role in mother and child care, as the importance of the health of infants as future capitals of the country is one of the undeniable facts. Therefore, theory of planned behavior -based educational interventions are recommended to be held for better newborn care in healthcare centers and educating mothers through mass media in studies with a wider scope, longer follow-up and for other groups, including nurses, midwives and physicians.

Declarations Acknowledgment
We would like to thank all mothers who participated in this study. This study was nancially sponsored by Arak University of Medical Sciences with grant number 2957.
Ethics approval and consent to participate All the procedures performed in the study involving human participants, were in accordance with the ethical standards. The present study was approved by the Research Council of Arak University of Medical Sciences (Grant Number:2957). Ethics committee approval code number is (IR.ARAKMU.REC. 1397. 169). Moreover informed written consent was obtained from the mothers and all the procedures performed in the study involving human participants, were in accordance with the ethical standards.

Consent for publication
Not applicable.

Competing interests
The authors have no con ict of interest to declare; the researchers have no personal or nancial a liations with the parties involved with the study.

Availability of data and materials
Upon request, we can offer onsite access to external researchers to the data analyzed at Arak University of Medical Sciences, Arak, Iran.