The Effects of an Empowerment Program on the Knowledge, Self-Efficacy, Self-Esteem, and Attitudes of Mothers of Preterm Neonates

About 9% of neonates, particularly the preterm ones, need intensive care services (1). Almost 19000 neonates die each year in the world due to complications such as preterm birth, low birth-weight, congenital defects, and sepsis. Due to their physiological problems, preterm neonates need quality care for survival, normal growth, and development.

Hospitalization of neonates in neonatal intensive care units (NICUs) makes their parents anxious. Moreover, mothers’ failure to participate in the process of care delivery to their neonates gives them feelings of insufficiency, depression, and anxiety and changes their parental roles. Such feelings and changes may last for long periods of time after hospital discharge (2). Studies show that mothers’ participation in the process of neonatal care improves neonates’ pulmonary function, nutrition, and weight gain, shortens their hospital stay, and reduces healthcare costs and re-hospitalization rate (3-6).

One of the effective methods for preventing hospitalization-associated damages to parents and post-discharge consequences is the empowerment of parents to participate in the process of care delivery. Such an empowerment can shorten hospital stay and reduce healthcare costs, nosocomial infection risk, and re-hospitalization rate (2).

One of the main goals of empowerment is family-centered nursing. This model improves families’ knowledge, self-esteem, self-efficacy, and attitudes and thus, helps them identify their weaknesses and empowers them to change their immediate situations (7-10). Previous studies showed the positive effects of family-centered empowerment model (FCEM) on mothers’ self-efficacy, stress, and depression (11), knowledge and attitudes of mothers who had a child with thalassemia (12), quality of life of children with asthma and their mothers (7), self-efficacy of patients with diabetes mellitus (8, 12, 13) and patients who received hemodialysis (14), iron deficiency anemia among girls (9), mothers’ stress (6), and health-promoting behaviors of women (15).

One of the concepts of FCEM is self-efficacy. Perceived self-efficacy is the individual’s perception of his/her abilities to act and control those events which affect his/her life. It can be quantified through measuring self-management behaviors and their effects. Role playing helps determine self-efficacy. Another concept of the model is self-esteem, i.e. the degree of self-approval, self-acceptance, and self-worth. Self-efficacy and self-esteem are two main components of learning and they are important to parental empowerment (8). The other concept of the model is attitude which includes perceptions and beliefs of a mother about her preterm neonate. Attitude, in turn, is affected by environmental and socio-cultural factors. Attitude promotes mother’s responsibility towards her childrearing behaviors (16).

The first step in attitude change and behavioral modification is to have adequate knowledge about the intended subject (17). De Rouck and Johnson reported that needs of the parents whose neonates were hospitalized in NICU included: precise information about neonatal care; visiting and protecting their neonates; communicating with neonates; recognition or positive perceptions of their attendance in the unit healthcare providers; self-care; therapeutic communication with healthcare providers; and information about nutrition, hypothermia prevention, skin care, respiratory care, and home care (18, 19). They concluded that the length of hospital stay is significantly correlated with the need for information and post-discharge care (18).

Implementing empowerment programs is essential due to the high levels of stress in NICUs (6, 20), parents’ poor communication with their neonates and healthcare providers (1), diversity of their needs, and mothers’ inability to provide neonatal care (4, 18) and cope with the immediate environment (20). The aim of this study was to assess the effects of an empowerment program on the knowledge, self-efficacy, self-esteem, and attitudes of the mothers of preterm neonates.

This pretest-posttest quasi-experimental study was conducted in 2014 in the NICU of Valiasr (PBUH) hospital, Birjand, Iran. 30 mothers whose neonates were hospitalized in the NICU were recruited via convenience sampling. The inclusion criteria were: having basic literacy skills, having good physical and mental health, having no chronic illnesses, having no previous history of preterm birth for mothers and having no congenital defects, having birth weight of less than 2,500 g, having gestational age of 37 weeks, and feeding by breast milk for neonates. Those mothers who voluntarily withdrew from the study or their neonates died during the study were excluded.

The data collection tool was a 5-part questionnaire. The first part was related to the mothers’ demographic characteristics such as age, job, and educational status as well as the birth rank of the preterm neonate. The second part was a researcher-made knowledge questionnaire which contained 10 multiple-choice questions. Correct and wrong answers were scored as 1 and 0, respectively, resulting in a total knowledge score of 0–10. The face and the content validity of this questionnaire were assessed and approved by a panel of experts. For reliability assessment, 10 external mothers who had similar conditions as the participants but were external to the study were asked to complete the questionnaire. Then, Cronbach’s alpha was calculated which gave the value of 0.88.

The third part was a researcher-made attitude questionnaire which contained 8 questions. The questions were answered on a 4-point scale, the points of which ranged from “Completely disagree” (scored 0) to “Completely agree” (scored 3). Therefore, the total attitude score could range from 0 to 24. The face and the content validity of this questionnaire were assessed and approved by a panel of experts, and its reliability was assessed through asking 10 mothers who had similar conditions as the participants to complete the questionnaire. Finally, Cronbach’s alpha was calculated as 0.88.

The fourth part of the study tool was the self-efficacy questionnaire developed by Vahdaninya et al. which was reported to have an acceptable validity and a Cronbach’s alpha of 0.88. This questionnaire contained 12 items which were scored in the same way as the attitude questionnaire. Thus, the total self-efficacy score could range from 0 to 36 (21).

The fifth part of the study tool was the 10-item Rosenberg self-esteem scale. The items of this scale were scored from 0 (“Strongly disagree”) to 3 (Strongly agree), yielding a total score of 0 - 30. The correlation coefficient between the score of each item and the total score of the scale was reported to be 0.44 - 0.73 (22). The total scores of the knowledge, attitude, self-esteem, and self-efficacy were summed and converted into a 0 - 100 score.

On the first day of hospitalization, the aims of the study were explained to the eligible participants and they were asked to complete the study questionnaires under the supervision of one of the NICU staff. After the pretest, the empowerment program was implemented based on the personal empowerment model in seven 30-min personal face-to-face training sessions. In the first step of the program, mothers were taught about the characteristics of preterm neonates in order to improve their knowledge and attitudes about the importance of care-giving to them. The second and the third steps of the program aimed at improving mothers’ self-efficacy and self-esteem through providing them with practical training about how to care for preterm neonates. Accordingly, mothers were personally taught by the NICU staff about procedures such as neonatal care, hand washing, tube feeding, and vital signs monitoring. Then, the mothers were allowed to practice the learned skills for several times in order to attain mastery over them. In the final step, which was taken one week after the last training session, mothers were asked to re-complete the study questionnaires.

The gathered data were entered into the SPSS software (v. 18.0) and the normality of the variables was assessed through the Kolmogorov-Smirnov test. The demographic characteristics of the participants were described using the measures of descriptive statistics (such as mean and standard deviation). Moreover, the paired-sample t test was used to compare the pretest and posttest scores of knowledge, attitude, self-efficacy, and self-esteem at a significance level of 0.05. During the study, we frequently reassured the participants about the confidentiality of their data. The ethics committee of Birjand University of Medical Sciences, Birjand, Iran, approved the study (approval code Ir.BUMS.REC.1394.384).

This study was carried out on 30 mothers whose neonates were hospitalized in an NICU. The means of the mothers’ and the neonates’ ages were 27.93 ± 6.6 years and 10.9 ± 7.54 days, respectively. Most neonates (73.3%) were hospitalized for more than 10 days. About 36.7% of mothers were below diploma, while the others had either a secondary school diploma or university degrees. Moreover, the majority of mothers (96.7%) were housewives and only one of them (3.3%) was a white-collar worker. Table 1 shows the demographic characteristics of the participants.

The results of the paired-sample t test illustrated that the posttest mean scores of mothers’ knowledge, attitude, and self-efficacy were significantly greater than their pretest scores. Moreover, the mean score of empowerment in posttest (69.5 ± 9.25) was significantly greater than the mean score in pretest (60.30 ± 7.61). However, there was no significant difference between the pretest and posttest scores of self-esteem (Table 2).

The posttest mean scores of mothers’ knowledge, attitude, and self-efficacy were significantly greater than the pretest scores. These findings confirmed the effectiveness of the study intervention in empowering mothers of preterm neonates. Previous studies also showed that empowerment programs improved mother-neonate relationships.

Browne and Talmi (2005) indicated the effectiveness of knowledge and self-confidence in improving mother-child relationships (23). Tilokskulchai et al. (2002) also reported that nurses’ education and services were essential to mothers. Moreover, they reported that empowerment strengthened mother-neonate relationship (24). Alaei et al. (2006) found that based on the received educations, mothers had a wide range of behaviors toward their neonates from caring to emotional ones. Their findings denote the dramatic effects of empowerment on mothers’ behavioral patterns (25). Liu et al. (2010) also reported that their empowerment program improved parents’ self-efficacy and alleviated their depression and stress (11). Similarly, Melnyk (2008) demonstrated the effectiveness of an empowerment program in alleviating mothers’ stress, anxiety, and depression (i.e. the emotional outcomes of adaptation), improving mother-neonate relationships (i.e. the scientific outcomes of adaptation), and positively changing their attitudes (26). Borimnejad et al. (2013) also suggested that knowledge transfer from nurses to parents can promote parents’ participation in the care process, strengthen behaviors such as breastfeeding, and hence, improve neonates’ weight gain (16). Sarajarvi et al. (2006) and Lindberg and Ohrling (2008) also reported that their empowerment programs significantly alleviated anxiety and stress of families and mothers who had preterm neonates and highlighted that families need neonatal care education in order to get more involvement in the process of care-giving to their neonates (10, 27). In addition, Jafari-Myanaie et al. (2011) found the positive effects of education on mothers’ anxiety and tension (1).

Our findings revealed an insignificant increase in the mean score of self-esteem after the study intervention. This finding contradicts the findings of previous studies (11, 23, 26). This contradiction may be due to the differences in the cultural context, sample size, empowerment intervention, and participants in these studies. Previous studies reported that FCEM significantly improved parents’ self-esteem, reduced length of hospital stay, healthcare costs, and risk of infection (26), and fulfilled parents’ needs for emotional support, sense of comfort, neonate-related information, closeness to their neonates, therapeutic communication with nurses, and reassurance about neonatal outcomes and protection (18, 28). Yet, it is noteworthy that the type of education and behavioral outcomes can propel mothers into certain types of behaviors and result in getting interested in certain types of reactions (25).