The effect of an educational intervention based on the PRECEDE Model on anxiety caused by Covid-19 in pregnant mothers

Abstract

BACKGROUND:

Some pregnant mothers do not perform periodical examinations due to anxiety about the risk of contracting the epidemic of COVID-19 so they may face serious complications for themselves and the health of the fetus. Therefore, the researchers decided to design and implement a study with the aim of “determining the effect of an educational intervention based on the PRECEDE model on the anxiety caused by COVID-19 in pregnant mothers”.

MATERIALS AND METHODS:

In this randomized semiexperimental study, 84 pregnant mothers covered by comprehensive health centers in West Tehran, during the year 2021, were randomly selected, then assigned to two groups (control group (42 people) and intervention group (42 people)). After the pretest, four sessions of 90 minutes, two sessions per week, were held individually for the intervention group based on the PRECEDE model. The anxiety of pregnant mothers in two groups was evaluated 2 weeks after the training, with the Spielberger State-Trait Anxiety Inventory (STAI). Data were analyzed with SPSS21 software and independent t, paired t, Fisher’s exact, and Chi-square statistical tests. In all tests, a significance level of P ≤ .05 was considered.

RESULTS:

Before the intervention, the two groups had no statistically significant difference in terms of demographic characteristics of the PRECEDE model (P < .05). However, 2 weeks after the intervention, there was a statistically significant difference in the anxiety latent (trait) anxiety and manifest (state) anxiety scores between the control group and the intervention group (P < .001). The PRECEDE model significantly reduced the anxiety latent (trait) anxiety and manifest (state) anxiety in the intervention group.

CONCLUSION:

It is recommended to hold educational classes based on the PRECEDE model, a low-cost and accessible method, to reduce the anxiety of pregnant women during epidemics, such as COVID-19, and to increase the number of visits to comprehensive health centers for routine pregnancy care.

Introduction

Anxiety is the most common psychiatric disorder during pregnancy, during delivery, and after delivery, which has different effects on the health of the mother and fetus. Among them, we can mention the maternal side effects of anxiety during pregnancy, severe nausea and vomiting in early pregnancy, fatigue, and pre-eclampsia. Severe and long-term anxiety by stimulating the automatic nervous system of the smooth muscles, constricts the arteries and reduces the uterine-placental blood flow and oxygen supply to the uterus. As a result, the heart rate pattern of the fetus becomes abnormal, and the possibility of premature delivery increases. Hormones that are released in response to fear and anxiety, such as catecholamines, cortisol, epinephrine, and beta-endorphins, can disrupt the progress of cervical dilation. They can also affect the smooth muscles of the uterus and reduce the contraction power of the uterus and its efficiency in the process of childbirth so they eventually cause labor to be prolonged and increase pain and cause more anxiety and fear.[1] Also, the effect of pregnancy anxiety is not only limited to the mother but also affects the fetus. Among the neonatal complications, we can mention the birth of low birth weight babies, the death of the baby, and behavioral and emotional disorders in the baby’s future life. Mother’s anxiety during pregnancy can cause 10-15% of behavioral and emotional disorders in the future life of babies. Among behavioral and emotional disorders, attention deficit, hyperactivity disorder, cognitive problems, mood disorder, and learning and memory loss at the age of 6-8 can be mentioned.[2]

The COVID-19 epidemic that spread all over the world since 2019; It is the cause of increased stress and anxiety in pregnant women.[3,4] Pregnancy is accompanied by an increase in referrals to health centers for examination, sonography, and examination of the condition of the fetus; therefore, due to physiological changes and increased exposure, pregnant women are at greater risk of contracting COVID-19.[5] On the other hand, due to the concern about the risk of contracting the disease, some pregnant mothers do not perform periodical examinations and may become post-term. Because they imagine that the hospital environment is contaminated, and on the contrary, some others are asking for quick termination of pregnancy through cesarean section.[3]

Martins-Filho et al. (2020)[6] reported in their study that healthy pregnant women have higher levels of IL-6 compared to women with COVID-19. Although the role of IL-6 in the pathogenesis of developmental disorders has not been fully clarified, as a systemic anti-inflammatory factor in the mother, it affects the growth of the fetal brain and increases the risk of developing psychiatric disorders. Abedzadeh-Kalahroudi et al. (2020)[7] reported that the level of anxiety and stress of pregnant women during the COVID-19 pandemic was high, and women had many concerns about their own infection and the baby’s infection or seeking prenatal care. On the other hand, increasing the awareness of mothers about the ways of disease transmission counseling helps reduce their anxiety and worry.[8,9,10]

Khorsandi’s study (2007) was conducted to determine the effect of the PRECEDE-PROCEED model to increase natural childbirth in primiparous women. It was reported that educational interventions based on health education theories and models can be effective in reducing the fear of natural childbirth and reducing cesarean delivery and subsequently better perinatal outcomes.[11]

The PRECEDE-PROCEED model is the most popular and common programming model in health education and health promotion.[12] The PRECEDE-PROCEED model focuses on the individual’s behavior in three important areas. The first area is predisposing factors that precede behavior change and provide motivation for behavior (e.g., knowledge, beliefs, attitudes, and values). The second area is the enabling factors that facilitate the occurrence of behavior in a person (e.g., access to resources, rules, and skills). The third area is the reinforcing factors that cause the continuation of the recommended behavior through the provision of rewards or incentives (e.g., family, peers, and teachers).[13]

Considering the fact that a wide range of individual, social, motivational, and economic factors can contribute to the intention and adoption of health behavior, using the theories of behavioral sciences and health education models in predicting the factors influencing the behavior.[14] Existing theories and models in health education serve as a guide for the purpose of designing and implementing various types of educational interventions. Also, through them, it is possible to measure the effects of the intervention and predict the behaviors.[15]

Based on the results of systematic review studies with the aim of investigating the effect of educational interventions on reducing the anxiety of pregnant women, there is not enough evidence to draw conclusions and more studies are needed and Considering the importance of reducing anxiety in pregnant women. Therefore, the present study was designed and implemented with the aim of determining the effect of an educational intervention based on the PRECEDE model on the anxiety caused by COVID-19 in pregnant mothers.

Materials and Methods

Study design and setting

This study was a semiexperimental two-group study that was conducted on 84 pregnant women referring to comprehensive health centers in West Tehran, Iran in 2021.

Study participants and sampling

Continuous sampling method and allocation of people in the intervention and control group was done using the quadruple block method using the site http://randomination.com/. Determining the sample size at the confidence level of 95% and the power of the test at 80% and assuming that the effect of education on the obvious anxiety of pregnant women in the intervention group compared to the control is 5 units to be considered statistically significant (as much as ten percent of the mean grade of the instrument) was estimated with the following formula. The minimum required sample size was calculated to be 35 people in each group, which was estimated to be 46 people in each group, taking into account 20% sample loss. Finally, 84 people were included in the study [Diagram 1]. Sampling was done after obtaining approval from the Ethics Committee of the University of Research Sciences, with ethics code number (IR.IAU.SRB.REC.1400.088).

Diagram 1.

Consort study of the effect of the educational intervention based on the PRECEDE model on the anxiety caused by COVID-19 in the frequency of referrals of pregnant mothers

The criteria for entering the study were as follows: all women with positive pregnancy test results, willingness to participate in the research, no pregnancy care for the previous three months, overt anxiety (manifest (state)) score between 31 and 75 and hidden (latent (trait)) anxiety score between 31 and 72, full alertness and acceptable listening and speaking ability to receive training and answer questions. The exclusion criteria were as follows: unwillingness to continue cooperation, not participating in training classes for more than one session, termination of pregnancy.

Data collection tool and technique

The tools used included three questionnaires that were organized in three sections:

The first part was personal and demographic information, which consists of 15 questions.

The second part was the Spielberger State-Trait Questionnaire (STAI), which includes 20 items for state anxiety and 20 items for trait anxiety. The scoring value of each statement is based on a Likert scale from 1 (very little) to 4 (very much). The minimum and maximum score is 20-80. The classification of state anxiety levels (manifest) was as follows: mild anxiety (20-31), moderate to low (32-42), moderate to high (43-53), moderately severe (54-64), severe (65-75), and very severe (76 and above). The classification of trait anxiety (hidden) was: mild anxiety (20-31), moderate to low (32-42), moderate to high (43-52), moderately severe (53-62), severe (63-72), and very severe (73 and above). This questionnaire was completed before and immediately at the end of the intervention in the intervention and control groups. Mahram conducted a psychometric study of the Spielberger test in 1993.[16] In this study, its Persian version was used. In the present study, its reliability was determined with Cronbach’s alpha coefficient of 0.89%.

The third part of the self-made questionnaire is based on the constructs of the PROCID model and includes predisposing factors (awareness 8 questions, attitude 7 questions), reinforcing factors structure (3 questions), enabling factors structure (6 questions), and behavioral factors (6 questions). To determine the validity (CVR-CVI) of the questionnaire based on the PRECEDE model, the questionnaire was given to 9 professors of health and midwifery education. The minimum acceptable CVR according to Lavache’s table was 0.75, and the questions were re-reviewed, and the CVI obtained in this study was equal to 0.79. The reliability of the prepared questionnaire was also estimated in a survey of 10 samples by Cronbach’s alpha coefficient test. Test-retest reliability was used, and the reliability coefficient was determined by Pearson’s test to be above 0.85%, and for each of the other variables, it was above 0.7.

The analysis of the questions was done as follows. The pregnant women’s knowledge questionnaire contains 8 questions and each question has 3 options with the scales (yes, no, I don’t know), which were assigned a score (1, 0, 0), respectively. The range of scores is between 0 and 6. A higher score indicates a high awareness of factors effective in increasing mental health. The questions related to the attitude of pregnant women have 7 questions and each question has 3 options. The options of this questionnaire have a 3-point Likert scale (I agree, I have no opinion, I disagree), which were given a score of (3, 2, 1) respectively. The range of scores is between 7 and 21 and based on the average scores obtained, higher scores indicate a positive attitude of pregnant women toward pregnancy.

The questions related to the enabling factors contained 6 questions with yes and no answers. The questions related to the strengthening agents contain three questions and each question has 3 options (yes, limited, no), which are assigned a score (3, 2, 1), respectively. The range of scores is between 3 and 9. Based on the average scores obtained, higher scores indicate the use of enhancing agents (the influence of others and family) by pregnant women. After obtaining written informed consent from the research units, the questionnaire based on the PRECEDE model and the Spielberger anxiety questionnaire were completed by pregnant mothers. Then, each participant’s questionnaire was coded and the mothers’ contact numbers were taken for further follow-up. During the phone call, they were informed about the day and time of the first training session. PowerPoint was used to better understand the training. Then, in the intervention group, 4 sessions of 90 minutes, two sessions a week, were held individually (to prevent contamination). The meetings were held in the counseling room of the health center (description of the meetings in Table 1).

Table 1.

Description of the meetings held in the intervention group

First session (90 min)		Time (minutes)
Introduction of the researcher and reference Overview of the content of the meetings A brief history is taken from the reference. Good relationship between mother and researcher		15
Encouragement to express feelings and thoughts about COVID-19 disease and pregnancy problems With open questions, mothers are given the maximum opportunity to identify and tell their anxiety about the COVID-19 disease and pregnancy problems. The mother is allowed to show her anxiety and emotions. The anxiety experiences of the mother in the past are examined. Feedback about mother’s worries and anxiety		15
Providing information The educational content included explanations on the importance, features, benefits, and risks PowerPoint is used for better understanding. Information is repeated several times and in different ways based on the level of knowledge and needs of mothers.		20
Relaxation training		20
Homework of the first session Do gentle exercise		15
End of summary		5
Second session (90 min)		Time (minutes)
Reviewing and checking the homework of the previous session		5
Asking about important aspects to examine feelings and thoughts about contracting the COVID-19 disease The mother’s opinion about all the factors that cause anxiety in her The mother is asked to talk about what she thinks is important. The mother is asked to talk about her views, feelings, and beliefs about COVID-19 and pregnancy.		15
Establishing a relationship between the event (anxiety) and the feelings and behaviors of the mother Separating healthy and unhealthy logic and feelings is done based on the stories that the mother heard. She is asked about his current feelings about the health of the fetus.		15
Resolving ambiguities and training to improve awareness Misconceptions about the cause of anxiety are clarified.		15
Familiarity with the dangers of not visiting on time		15
Homework of the second session Writing fears and worries on paper		10
At the conclusion of the session, it is discussed how thoughts, actions, and bodily processes are connected, how people’s way of thinking affects their feelings, and also only with pleasant mental imagery can one achieve a feeling of comfort and satisfaction.		5
Do relaxation		10
Third session (90 min)		Time (minutes)
Reviewing and checking the homework of the previous session		15
Increasing attitude and acceptance of appropriate behavior Identify thoughts and assumptions		30
Strengthening the mother’s positive thoughts The mother’s positive opinions about the feeling of having a healthy child are strengthened. Disappointing thoughts and expressions are indirectly countered.		20
Homework of the third session Reading educational pamphlets at home		10
Relaxation		10
End of summary		5
Fourth session (90 min)		Time (minutes)
Review and check the homework from the previous session		15
Addressing the issue of self-efficacy and increasing emotional and social support		20
A program to change your thinking and behavior, encouraging continued pregnancy care		20
Feedback		10
Summary and questions and answers		15
Relaxation		10

All subjects in the control group received routine pregnancy care. Then, 2 weeks after the end of the intervention, a questionnaire made based on the PRECEDE model and the Spielberger anxiety questionnaire were completed by pregnant mothers in both groups.

After collecting the data, it was entered into SPSS-21 statistical software. The data were analyzed by means of descriptive statistics, including mean, standard deviation, frequency, and percentage. The normality of the data was checked by the Kolmogorov − Smirnov test. The independent t-test was used for between-group comparisons, while the paired t-test was used for within group comparisons. Chi-square and Fisher’s exact test used. In all tests, a significance level of P ≤ .05 was considered.

Ethical considerations

This article is a part of the thesis approved by Islamic Azad University of Tehran and was carried out in accordance with the provisions of the 2013 Declaration of Helsinki. The aims, procedures, and conditions of the study were fully explained to the potential participants. Written informed consent was obtained from all participants. The confidentiality of the data and the anonymity of the participants during the entire study process was also guaranteed.

Results

Data analysis was done on 84 people (42 people in the intervention group and 42 people in the control group). At first, the results showed that the two groups were homogeneous in terms of demographic and fertility variables [Table 2].

Table 2.

Demographic characteristics in two intervention and control groups

Variable				Intervention (n=42)				Control (n=42)				Test result (P)
				Mean		SD		Mean		SD
Female age (years)				30.37		5.20		31.10		0.032		0.335*
Wife’s age (years)				34.27		5.51		35.30		4.99		0.407*
BMI				32.6		17.8		32.27		17.92		0.935*
Gestational age (weeks)				28.88		3.95		27.66		4.30		0.214*
Number of births				1.38		1.15		1.58		1.31		0.447*
				Number		Percent		Number		Percent
Wife’s job		Freelancer		25		62.5		23		57.5		0.708**
		Office worker		5		12.5		7		17.5
		Unemployed		3		7.5		0		0.0
		Other		2		5.0		10		25.0
		Total		42		100.0		42		100.0
The economic situation		Good		7		17.5		4		10.0		0.276**
		Medium		29		72.5		33		82.5
		Bad		4		10.0		3		7.5
		Total		42		100.0		42		100.0
Female education level		Literacy for reading and writing		0		0.0		0		0.0		0.391**
		Primary school		4		10.0		0		0.0
		Lower secondary school		2		5.0		4		10.0
		Diploma		16		40.0		15		37.5
		Above diploma		18		45.0		21		52.5
		Total		42		100.0		42		100.0
Woman’s job		Housewife		25		42.5		23		57.5		0.132**
		Office worker		5		12.5		7		17.5
		Freelancer		2		5.0		10		25.0
		Student		3		7.5		0		0.0
		Other		5		12.5		0		0.0
		Total		42		100.0		42		100.0
Spouse’s education level		Diploma and subdiploma		10		23.8		18		42.9		0.064**
		University		24		57.1		32		2.76
		Total		42		100.0		42		100.0
Number of household residents		2		31		73.8		38		90.4		0.126***
		3		7		16.7		2		4.8
		4		4		9.5		2		4.8
		Total		42		100		42		100
nationality		Lur		9		21.5		4		9.6		0.093***
		Kurd		3		7.1		6		14.3
		Turkish		9		21.5		6		14.3
		Fars		16		38.0		25		59.5
		Other		5		11.9		1		2.3
		Total		42		100		42		100

*P=independent t **P=Chi-square test. ***P=Fisher’s exact

The average state anxiety score and the average trait anxiety score before and after the intervention was significant with the paired t-test (P < .001) in both of these two scores. Therefore, in the control group, the average state anxiety score and average trait anxiety score increased significantly after the intervention. In the intervention group, the average state anxiety score and average trait anxiety score has decreased significantly after the intervention [Table 3].

Table 3.

Determination and intragroup comparison of the state anxiety score and average trait anxiety score caused by COVID-19 in pregnant women in each of the intervention and control groups before and after the end of training based on the PRECEDE model

State anxiety		Intervention												Control
		Before						After						Before						After
		Frequency				Percent		Frequency				Percent		Frequency				Percent		Frequency				Percent
Mild (20−31)		0				0		10				23.8		0				0		2				4.8
Medium to low (32−42)		0				0		25				59.5		1				2.4		0				0
Medium to high (43−53)		3				7.1		6				14.3		5				11.9		3				7.1
Moderately severe (54−64)		19				45.2		1				2.4		24				57.1		11				26.2
Severe (65−75)		20				47.6		0				0		12				28.6		25				59.5
Very severe (76 and above)		0				0		0				0		0				0		1				2.4
Total		42				100		42				100		42				100		42				100
Mean±SD		63.88±6.34						38.21±9.35						59.90±7.63						66.14±11.35
Minimal−maximum		45−75						26−73						42−73						25−78
Result of the paired t test		P<0.001, df=41, t=17.43												P<0.001, df=41, t=4.07
Trait anxiety		Intervention												Control
		Frequency		Percent				Frequency		Percent				Frequency		Percent				Frequency		Percent
Mild (20−31)		0		0				10		23.8				0		0				2		4.8
Medium to low (32−42)		4		9.5				25		59.5				6		14.3				0		0
Medium to high (43−53)		6		14.3				6		14.3				7		16.7				2		4.8
Moderately severe (54−64)		14		33.3				1		2.4				15		35.7				10		23.8
Severe (65−75)		18		42.9				0		0				14		33.3				20		47.6
Very severe (76 and above)		0		0				0		0				0		0				8		19
Total		42		100				42		100				42		10.00				42		100
Mean±SD		57.76±10.09						36.02±7.49						55.71±11.12						63.97±11.76
Minimal−maximum		32−71						21−59						32−71						22−76
Result of the paired t test		P<0.001, df=41, t=14.06												P<0.001, df=41, t=5.33

According to the probability value obtained by independent t test between groups, in terms of the average score of state anxiety and trait anxiety after the intervention, a statistically significant difference was observed between the two intervention and control groups (P < .001) [Table 4].

Table 4.

Determining and comparing the average score between the state and trait anxiety groups in both the intervention and control groups, after the educational intervention based on the PRECEDE model

Groups Changes		Intervention (n=42)				Control (n=42)				Result of independent t test
		Mean		SD		Mean		SD
Manifest anxiety		5.95		9.77		−25.66		9.59		P<0.001, df=84 t=−15.12
Latent anxiety		7.95		9.9		−21.73		10.01		P<0.001 df=84 t=−13.80

There was no statistically significant difference between the two intervention and control groups regarding the average scores of knowledge, attitude and enhancing agents (the influence of others and family) before the educational intervention (P < .05). However, after the educational intervention, a significant difference was seen between the intervention and control groups after the educational intervention (P < .001) [Table 5].

Table 5.

Comparison of the average scores of knowledge, attitude, and enhancing factors in two intervention and control groups before and after the educational intervention based on the PRECEDE model

		Mean±SD				The result of the intergroup test, independent t
		Intervention		Control
Consciousness variable
Average knowledge score before the intervention		75.75±19.98		69.39±20.97		P=0.341
Average knowledge after the intervention		93.03±10.96		70.90±17.92		P<0.001
The result of the intragroup test paired t-test		P<0.001		P=0.147
Attitude variable
The mean attitude score before the intervention		40.64±20.61		38.57±20.55		P=0.150
The mean attitude score after the intervention		75.45±17.21		40.38±20.30		P<0.001
The result of the intragroup test paired t-test		P<0.001		P=0.495
Strengthening agents
Average score of reinforcing factors before the intervention		25.05±17.00		22.22±21.06		P=0.622
The average score of reinforcing factors after the intervention		58.38±13.39		20.60±20.16		P<0.001
The result of the intragroup test paired t-test		P<0.001		P=0.417

Findings obtained from the enabling factors, in relation to the access to the enabling factors (use of information acquisition resources), a significant increase in the use of educational resources and access to it in the intervention group after the educational intervention. It was observed in the control group. The highest rate of this increase was related to access to sources of information through health workers with 98.2% [Table 6].

Table 6.

Comparison of the frequency distribution of enabling factors (use of resources and educational classes) in two groups of pregnant women, intervention and control, before and after the educational intervention

Agent type		Factor		Intervention								Control
				Before				After				Before				After
				Frequency		Percent		Frequency		Percent		Frequency		Percent		Frequency		Percent
Enabling factors		Family and friends		27		47.4		40		72.7		34		59.6		32		58.2
		Health personnel		4		7		54		98.2		14		24.6		17		30.9
		Newspapers and magazines		3		5.3		5		9.1		5		8.8		5		9.1
		Radio and TV		13		28.1		22		30.9		13		22.8		22		40
		Educational books		6		10.9		6		10.9		6		10.9		6		10.9

Discussion

This research was conducted with the aim of determining and comparing the state (overt) and trait (hidden) anxiety scores caused by COVID-19 after the educational intervention based on PRECEDE in pregnant women. The results showed that there was an increase in the mean trait and state anxiety score changes in the control group at the end of the study, who did not receive any educational intervention based on the PRECEDE model; But in the intervention group after the end of PRECEDE-based training, these changes were negative. In other words, after the intervention, the anxiety score decreased, and this difference was statistically significant in the two groups, and indicated the positive effect of the educational intervention based on the PRECEDE model on reducing the anxiety level of pregnant women during the period of COVID-19.

In the study by Martins-Filho et al. (2020)[6], comparing healthy pregnant women with pregnant women infected with COVID-19, it was reported that pregnant women infected with COVID-19 have higher levels of IL-6, which may have important consequences in fetal growth. It seems that the activation of the mother’s immune system causes an increase in the child’s sensitivity to epigenetic and environmental stressors, and infection before birth and increased cytokine expression increases the risk of autism and schizophrenia. Although the role of IL-6 in the pathogenesis of developmental disorders has not been fully clarified, but as a systemic anti-inflammatory factor in the mother, it affects the growth of the fetal brain and increases the risk of psychiatric disorders.[6] Considering these issues, the increase of cytokines and inflammation in pregnant women infected with COVID-19 may increase the risk of developing neurodevelopmental disorders in newborns, which necessitates interventions to reduce anxiety and improve the mental health of pregnant mothers.[7]

The study of Green et al. (2020)[10] is in line with the present study. This clinical trial study was conducted with the aim of evaluating the effectiveness of cognitive behavioral group therapy protocol on the level of perinatal anxiety. In total, 96 women referred to the specialized clinic were randomly divided into two groups, cognitive behavioral therapy and waiting list. Spielberger State and Trait Anxiety Questionnaire was used to measure the level of anxiety. Treatment sessions include 6 weekly 2-h sessions in the form of a small group (maximum of six participants in each group). The content of the sessions includes the unique challenges that women have experienced during the perinatal period, techniques to reduce anxiety and depression, and learning and exercises assigned on a weekly basis. The progress of the participants was checked in groups every week. The results of the study showed that compared to the waiting group, the participants in the cognitive behavioral therapy group reported a significant decrease in anxiety level.

In Khodakarami et al.’s study (2015),[17] spirituality-oriented counseling reduced the level of depression, anxiety and stress of pregnant women. In the study of Heydarpour and his colleagues (2020),[9] counseling based on mindfulness led to a decrease in the level of pregnancy anxiety and improved physiological parameters of newborns in the intervention group.

In line with the present study, in the systematic review study of Fink (2012), relaxation techniques during pregnancy led to less admission of the mother to the hospital, fewer birth complications, reduced cesarean section and postpartum complications. Fink reported that identifying pregnant women with anxiety and carrying out intervention can have better results of childbirth for the mother.[18] In the study of Vieten (2008), it was reported that stress and negative mood during pregnancy increases the risk of bad birth outcomes and postpartum mood problems and may interfere with mother − infant attachment and child development and the intervention had reduced the stress and anxiety of pregnant women.[19]

The PRECEDE model is one of the planning models in health education, which is used to identify needs and promote health. This model has the following structures: predisposing factors that deal with the forces that create motivation to adopt appropriate behavior; such as knowledge and attitude that act as underlying factors for creating behavior.[20]

Regarding awareness as the most important predisposing factor in the PRECEDE model, the results indicated a significant increase in the average scores of awareness in the intervention group after the educational intervention compared to the control group; These findings are in line with the effect of education based on the PRECEDE-PRECEDE model in other studies, including Chiang et al.’s[21] study on increasing the awareness of children with asthma, Wright et al.[22] in the field of increasing community awareness to improve awareness of mental health and early help seeking to diagnose mood disorders and psychosis among young people, Taghdisi[23] in the field of increasing women’s awareness of type 2 diabetes, Hosseini and colleagues[24] in the field of raising awareness about high blood pressure disease, which all indicate the positive effect of the PRECEDE model on increasing the average awareness.

In the present study, the attitude of patients regarding the disease of COVID-19 was considered as the second predisposing factor. The results indicate a significant increase in the mean attitude scores in the intervention group after the educational intervention compared to the control group. These results are consistent with other studies regarding the effect of training based on the PRECEDE model in improving people’s attitudes, including the study of Taghdisi et al.[23] and Hosseini et al.[24] The present study showed that the design and implementation of the educational program based on the PRECEDE model can create a significant difference in the level of awareness and attitude, and it shows the necessity of using planned educational interventions in order to improve predisposing factors.

In the present study, the possibility of using educational resources regarding the disease of COVID-19, access to educational resources through health care staff, radio, and television were considered as enabling factors. These factors include providing facilities and creating skills to change behavior.[20] The results indicate a significant increase in the use of these factors in the intervention group, which is consistent with Wright et al.,[22] Hosseini et al.,[24] and Zigheymat.[25] The results of the present study on the effect of using the PRECEDE model showed that the enabling factors were able to improve the behavior.

In this study, the verbal and practical persuasion and encouragement of the family, friends, colleagues, health care staff, and the trainer and the relaxation technique were considered as strengthening factors, and the results indicate a significant increase in these factors after the educational intervention; It is consistent with the results of studies by Wright et al.,[22] Hosseini et al.,[24] and Zigheymat.[25] These factors increase the probability of continuing the recommended behavior.

Limitation and recommendation

It is suggested to conduct a supplementary study by examining the effect of training classes based on the PRECEDE model on other psychological complications in pregnant women during epidemics, especially the outbreak of the viral epidemics, such as COVID-19 virus. Other theoretical models including the theory of planned behavior model, health belief model, and cognitive behavioral training should be used in educational interventions to reduce the anxiety level of pregnant women. On the other hand, COVID-19 has had psychological effects on frontline health care providers,[26] and it is suggested to do interventions based on the PRECEDE model to reduce the anxiety of this groups during health crises.

One of the limitations of the present study is the amount of different social support that people receive from family and friends, which can affect their anxiety levels. For this purpose, in the present study, we tried to reduce the effect of confusion as much as possible by randomly assigning people in two groups. On the other hand, different people with different attitudes and different ability to accept trainings may have an effect on reducing their anxiety level. For this purpose, it was tried to control its distortion effect as much as possible by randomly assigning people. Due to the outbreak of the COVID-19 disease, it was not possible to hold classes in groups at the time of the research. According to the type of educational intervention based on the PRECEDE model, pregnant women were included in the study who had the minimum education level of reading and writing, and illiterate pregnant women were excluded. Therefore, caution should be used in interpreting the results of the present study.

Conclusion

Relaxation interventions can reduce maternal anxiety. Antenatal visit is an important opportunity to screen maternal anxiety, using simple and low-cost educational programs. Considering the effects of anxiety caused by COVID-19 infection and lack of routine pregnancy care, training classes based on the PRECEDE model can be useful in reducing the anxiety of pregnant mothers and increasing the number of referrals for pregnancy care in accordance with the health protocol. The current research can provide the basis for future research to reduce the anxiety level of pregnant mothers caused by COVID-19 or any other epidemic in the future and to carry out routine pregnancy care.

Ethics approval and consent to participate

The present study was approved by the Ethics Committee of Islamic Azad University (IAU) of Tehran with ethics code number (IR.IAU.SRB.REC.1400.088) and was carried out in accordance with the provisions of the 2013 Declaration of Helsinki. All participants signed an informed consent form.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

This study was financed by the Research Vice-Chancellor of the University of Medical Sciences and Technologies, Science and Research Unit, Islamic Azad University of Tehran, Iran, and has not received financial support from any other institution.