The effect of psychoeducation on preoperative anxiety and parental self-efficacy in mothers of children undergoing surgery 

The effect of psychoeducation on preoperative anxiety and parental self-efficacy in mothers of children undergoing surgery | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The effect of psychoeducation on preoperative anxiety and parental self-efficacy in mothers of children undergoing surgery Maryam Hafez, Seyed Mohsen Hosseini, Mohammad Mahdi Khazravi, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8703884/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Preoperative parental anxiety is a major clinical concern, affecting up to 74% of parents and serving as a primary predictor of adverse child outcomes, including increased postoperative pain and delirium. While information transfer is common, there is a critical gap in interventions that simultaneously target anxiety reduction and the enhancement of Parental Self-Efficacy (PSE). This study evaluated the effect of a dual-target psychoeducational program on preoperative anxiety and PSE in mothers of children undergoing surgery. Methods This parallel-group randomized controlled trial included 70 mothers (35 intervention, 35 control) of children aged < 7 years scheduled for first-time elective urological surgery at a specialized pediatric center in Iran. The intervention group received a three-session, CBT-based psychoeducation program integrating structured surgical information, cognitive restructuring, and progressive muscle relaxation. The control group received standard care plus a brief informational session. Outcomes were measured using the Spielberger State-Trait Anxiety Inventory (STAI) and the Dumka Parental Self-Efficacy Measure (PSAM) at baseline and immediately before surgery. Data were analyzed using ANCOVA, adjusting for baseline scores. Results The intervention group demonstrated significantly greater reductions in State Anxiety (adjusted mean difference = − 12.34, P < 0.001, Cohen’s d = 0.71) and Trait Anxiety (adjusted mean difference = − 11.26, P < 0.001, d = 0.72) compared to the control group. Furthermore, mothers in the intervention group showed a significantly greater increase in Parental Self-Efficacy (adjusted mean difference = + 7.80, P = 0.024, d = 0.48)1617. Within-group improvements were significant for both groups (all P < 0.001), though the structured program was statistically superior in all domains. Conclusion This study demonstrates that our brief, structured psychoeducational intervention—integrating cognitive restructuring, progressive muscle relaxation, and structured information—robustly addresses both negative emotional states and positive adaptive resources in mothers. The dual-target approach significantly enhances maternal psychological competence and self-efficacy. Given its efficacy, low cost, and non-pharmacological nature, we recommend its integration into routine family-centered preoperative care to improve maternal well-being and optimize pediatric surgical outcomes. preoperative anxiety Parental self-efficacy Psychoeducation Pediatric surgery Cognitive behavioral therapy Figures Figure 1 Introduction The period surrounding a child's elective surgical procedure is universally recognized as a significant emotional stressor, with high levels of preoperative parental anxiety highly prevalent(1), affecting up to 74% of parents, particularly mothers, whose emotional state is highly correlated with that of their child(2-5). High maternal anxiety is a serious clinical concern because it is directly linked to adverse outcomes in the child, including heightened preoperative agitation, increased postoperative pain, and maladaptive behavioral recovery(6-13). Key parental risk factors for elevated anxiety include fear of postoperative pain, having a younger child, and a lack of adequate information regarding the surgical processes(14-18). Concurrently, this emotional distress can undermine a mother's Parental Self-Efficacy (PSE), defined as the parents’ belief in their capacity to successfully perform the caregiving role and provide effective support during challenging situations, such as hospitalization and surgery(19-21). High PSE is a vital protective factor, correlated with lower levels of parental stress and anxiety, whereas low PSE can impair caregiving practices and increase anxiety(22-25). The transactional relationship between these constructs is affirmed by research such as the descriptive and relational study by Arpaci and ÇİL (2025), which found a negative association between parental self-efficacy and children's preoperative fear and anxiety(2). To mitigate these psychological challenges, non-pharmacological preparation strategies are extensively researched(26-30). Recent systematic reviews show that educational interventions generally reduce parental anxiety, though the certainty and scope of these effects are nuanced(31-36). For instance, a 2025 Network Meta-Analysis by Priyadarshini et al. identified that web-based education was the most effective method for reducing parental anxiety (compared to information booklets), with multimedia approaches also showing highly significant benefits(37). Furthermore, Fonseca et al.(2024) demonstrated the viability of high-tech psychological interventions, finding that Virtual Reality (VR)-assisted mindfulness significantly reduced caregiver state anxiety in a pragmatic RCT(38). Similarly, Díaz Luengo et al. (2023) confirmed that providing information via videos and storybooks reduced state anxiety in parents of surgical patients(39). However, the literature also shows significant contradictions; simpler, non-interactive methods like information booklets alone result in a slight, non-significant anxiety reduction(37), and studies such as Carlsson et al. (2017) found that a preoperative visit to the operating theatre did not decrease parental anxiety(40). Complementing anxiety research, interventions targeting PSE are crucial as they address the adaptive skills necessary for coping, often framed by Bandura’s self-efficacy theory (41-43). The development of an intelligent digital solution (ICory-Circumcision) by Kwa et al. (2024) explicitly adopted this theoretical framework to enhance parental competence in perioperative care, demonstrating the potential of theory-driven interventions in the surgical context(3). Similarly, the protocol by Dai et al. (2025) outlines a nurse-led program specifically designed to promote PSE in parents of children with Autism Spectrum Disorder by targeting the four sources of self-efficacy(10) . Success in enhancing PSE through theory-based programs has been reported in chronic care, as seen in the RCT by Cheng et al. (2021), which demonstrated significant improvement in parental self-efficacy and disease management following an education program for managing child’s eczema(44-46). Yet, this area is not without inconsistencies; some studies have reported non-significant changes in self-empowerment post-intervention even when online platforms were utilized to enhance parental self-efficacy(47). The synthesis of contemporary literature reveals a critical dual-target knowledge gap: while ample evidence exists for anxiety reduction, and separate programs aim to build PSE, there is a lack of rigorous, integrated trials evaluating a single, unified psychoeducational program that systematically combines cognitive behavioral techniques (CBT) and structured information delivery to address both the mother's negative emotional distress (anxiety) and her positive psychological resource (PSE) simultaneously(48). Psychoeducational interventions, grounded in the premise of reducing uncertainty and teaching practical coping skills (mastery experience), offer a theoretically strong approach to bridging this dual need(49, 50). Grounded in cognitive-behavioral principles, psychoeducation operates on the premise that providing knowledge demystifies the surgical process, thereby reducing anxiety rooted in uncertainty (51). Simultaneously, teaching practical coping skills directly builds a mother's competence and confidence, which is the foundation of self-efficacy (36, 52). By equipping mothers with both knowledge and tools, such interventions aim to foster a greater sense of control, potentially mitigating anxiety while concurrently empowering mothers (53). Thus, the current study aimed to test the hypothesis that mothers receiving a structured, cognitive-behavioral psychoeducation program would demonstrate significantly greater reductions in anxiety and greater increases in self-efficacy compared to those receiving standard care alone. Materials and Methods Study design and setting This was a single-center, parallel-group, randomized controlled clinical trial (RCT) with blinded outcome assessment conducted from May 2025 to Aguast 2025 in the Department of Pediatric Urology at Imam Ali University Hospital (Alborz University of Medical Sciences), Karaj, Iran. The trial utilized a randomized design to compare the effects of a structured psychoeducation program versus standard care on maternal psychological outcomes. The selection of this location was based on its specialized capacity, as this hospital serves as the only specialized pediatric treatment center in Karaj and covers the majority of specialized pediatric referrals in Alborz Province. The trial was prospectively registered in the Iranian Registry of Clinical Trials (IRCT) on April 6, 2025, before the enrollment of the first participant. The trial registration number is IRCT20250222064815N1. The registration was performed by Maryam Hafez.The study protocol was reviewed and approved by the Ethics Committee of Isfahan University of Medical Sciences (Approval Code: IR.MUI.MED.REC.1403.394). All procedures were performed in accordance with the ethical principles of the Declaration of Helsinki and the Consolidated Standards of Reporting Trials (CONSORT) guidelines. Written informed consent was obtained from all participating mothers prior to randomization. Participants and Eligibility Criteria Study Population The study population consisted of mothers who were the primary caregivers of children aged less than 7 years scheduled for first-time elective urological surgery under general anesthesia at Imam Ali University Hospital, Karaj, Iran. A total of 161 mothers were initially screened for eligibility, of whom 70 met all criteria and were subsequently randomized. Inclusion Criteria Mothers were eligible for inclusion if they met all of the following criteria: Being the primary caregiver of a child aged less than 7 years undergoing first-time elective urological surgery No self-reported history of diagnosed psychiatric disorders in themselves or their child Demonstrating at least moderate-to-severe preoperative anxiety as confirmed by a score higher than 43 on the State Anxiety subscale of the Spielberger State-Trait Anxiety Inventory (STAI) at baseline screening(54, 55) Ability to read and write in Persian Providing written informed consent Exclusion Criteria Participants were initially excluded at the screening stage if they did not meet any of the above inclusion criteria, or if the child had previously undergone any surgery requiring general anesthesia After randomization, participants were withdrawn from the per-protocol analysis if they: Attended fewer than two of the three scheduled intervention sessions Voluntarily withdrew consent at any time The child’s surgery was cancelled brfore the scheduled post-intervention assessment time point (insert figure 1 here) Sample Size Calculation The sample size, considering a confidence level of 95%, a power of 80% based on a previous study(56) and a precision of 5, including a 10% dropout rate equal to 35 people for each group (total n = 70). This resulted in a total sample size of 70 participants, allocating 35 mothers to the psychoeducation group and 35 mothers to the control group Randomization and Blinding Randomization Procedure The allocation process was managed via a pre-generated, simple randomization sequence designed to assign participants consecutively as they enrolled. 1. Sequence Generation: Before the initiation of participant enrollment, an unrestricted, simple randomization sequence was generated using a web-based randomizer. This sequence determined the assignment for 70 hypothetical slots in a 1:1 ratio, resulting in 35 allocations to the Intervention Group and 35 allocations to the Control Group, ensuring numerical balance. 2. Allocation Implementation (Consecutive Assignment): As eligible mothers presented to the clinic and provided informed consent, they were consecutively assigned to the intervention or control group based on their order of entry into the study. The first mother enrolled received the assignment from slot 1 in the pre-generated list, the second mother received the assignment from slot 2, and so forth. This process ensured that every eligible mother was immediately allocated to a study group based strictly on the pre-determined, balanced sequence, circumventing the logistical challenge of simultaneous participant recruitment. Allocation Concealment Due to the sequential, open nature of applying the pre-generated list based on the order of enrollment, allocation concealment was not employed. The research team member responsible for enrollment was aware of the sequence of group assignments. Blinding While complete blinding was not possible due to the nature of the educational intervention, partial blinding procedures were maintained: 1. Interventionist Blinding: Blinding of the health psychology student who delivered the sessions was not feasible due to the requirement for active participation and skills training specific to the intervention group. 2. Participant Blinding (Partial): Mothers in both groups were deliberately informed only that they would receive "preoperative educational support," without specific details regarding the differences in content, duration, or components (i.e., cognitive restructuring vs. standard information). This was intended to maintain partial participant blinding regarding the superiority of one program over the other. 3. Outcome Assessor Blinding: The statistician responsible for data analysis was kept blinded to the group assignment (Intervention vs. Control). Intervention and Control Conditions Both groups received the routine standard preoperative care provided by the hospital, which involved general medical and administrative preparations. The study intervention was delivered by a trained health psychology student. All sessions were conducted individually and online, and took place in the period spanning from ten days to one week before the scheduled surgery. Outcome questionnaires were completed by all mothers at two time points: baseline (after randomization) and post-intervention (immediately after the completion of the final session for both groups). Intervention group(Structured Psychoeducation Program) Mothers randomized to the intervention group (n=35) participated in a structured three-session psychoeducational program, with each session lasting approximately 45–60 minutes. This protocol was designed as a comprehensive, dual-target approach, integrating two main components: information-based protocols(56, 57) (to reduce anxiety rooted in uncertainty) and Cognitive Behavioral Therapy (CBT) techniques(58) (to enhance cognitive control and coping skills). The content of each session was as follows: (Insert Table 1 here) Control group (Standard Care Plus Brief Education) Mothers in the control group (n=35) received standard hospital care plus a single brief educational session delivered by the same psychologist before surgery. The content of this single session was strictly informational and focused on operational and administrative aspects related to the hospital stay: Basic preoperative instructions, including the hospital admission process. Fasting guidelines and necessary documentation. General information about the hospital stay duration. Outcome Measures The effectiveness of the structured psychoeducation program was assessed by measuring the mothers' anxiety and parental self-efficacy at two time points: baseline (after randomization) and post-intervention (immediately after completion of the final session for both the intervention and control groups). I. Maternal Anxiety Measures Maternal anxiety was assessed using the Persian version of the Spielberger State-Trait Anxiety Inventory (STAI), a widely utilized 40-item self-report scale. The STAI is composed of two independent 20-item subscales: State Anxiety: which assesses current anxiety. Trait Anxiety, which evaluates the mother's general and relatively stable disposition or tendency to experience anxiety across different situations. Scoring and Interpretation: Items are rated on a 4-point Likert scale, and total scores for each subscale range from a minimum of 20 to a maximum of 80. Higher scores indicate greater anxiety. Critically, only mothers scoring higher than 43 on the State Anxiety subscale at baseline were included in the study, confirming a pre-existing level of moderate-to-severe preoperative anxiety. Psychometric Properties: In the Iranian population the Persian version of the STAI has demonstrated internal consistency (Cronbach’s α = 0.92 for State Anxiety and 0.65–0.86 for Trait Anxiety) and good test-retest reliability(59, 60). II. Parental Self-Efficacy Measures Parental self-efficacy was measured using the Persian version of the Dumka Parental Self-Efficacy Scale (PSAM). Description and Scoring: This 10-item instrument assesses parents’ perceived confidence in their parenting role, particularly during stressful situations, rated on a 7-point Likert scale (1 = strongly disagree, 7 = strongly agree). The total possible score ranges from 10 to 70. Higher scores on the PSAM reflect a greater sense of parental self-efficacy. Psychometric Properties: The Persian version of the PSAM has demonstrated good internal consistency (Cronbach’s α = 0.80) and acceptable validity in Iranian samples(61). Statistical Analysis All data were analyzed using IBM SPSS Statistics version 26.0. Descriptive statistics were expressed as mean ± standard deviation (SD) for continuous variables and as frequency (percentage) for categorical variables. Baseline demographic and clinical characteristics between the two groups(Intervention vs. Control) were compared using independent-samples t-tests for continuous variables (e.g., age) and χ² tests for categorical variables (e.g., education level). This analysis was conducted to confirm the comparability of the two groups and verify the success of the randomization process Statistical Assumptions Before conducting the primary inferential analyses using parametric tests (paired-samples t -tests and Analysis of Covariance [ANCOVA]), the necessary statistical assumptions were rigorously assessed. We confirmed the following for all continuous outcome variables (State Anxiety, Trait Anxiety, and Parental Self-Efficacy): 1. Normality of Distribution: The assumption of normality for the dependent variables was assessed using the Shapiro-Wilk test and visual inspection of Q-Q plots. Data distributions for all outcome measures were found to be approximately normal. 2. Homogeneity of Variances (for ANCOVA): Levene’s test was used to examine the equality of error variances across the intervention and control groups. This assumption was met for the post-intervention scores of State Anxiety, Trait Anxiety, and Parental Self-Efficacy, confirming the suitability of ANCOVA. 3. Homogeneity of Regression Slopes (for ANCOVA): This critical assumption, which mandates that the relationship between the covariate (baseline score) and the dependent variable (post-test score) is the same across both groups, was also confirmed for all three outcome measures. Meeting these conditions validates the statistical power and robustness of the ANCOVA model used to assess the differential effects of the psychoeducation intervention on maternal outcomes. Results Participant Flow and Baseline Characteristics A total of 161 mothers were screened for eligibility between May 2025 and August 2025. Following the application of the inclusion and exclusion criteria, 70 eligible mothers were randomized in a 1:1 ratio, resulting in 35 participants allocated to the psychoeducation group and 35 to the control group. The participant flow is shown in Figure 1. All 70 participants completed the study, with no loss to follow-up or missing data (per-protocol and intention-to-treat samples were identical). Baseline demographic and clinical characteristics of the participants are summarized in Table 1. The mean maternal age was 34.04 ± 5.53 years, and the mean child age was 41.99±28.14 months. There were no significant between-group differences in maternal age, paternal age, child age, age at onset of the child's problem, maternal or paternal education level, number of children, child gender, or family history of surgery, indicating successful randomization. (Insert Table 2 here) Note: Continuous variables are presented as Mean (Standard Deviation). Categorical variables are presented as frequency (percentage). P-values are derived from independent-samples t-tests or chi2 tests as appropriate, demonstrating that there were no significant differences in baseline characteristics between the groups, confirming successful randomization. Outcomes Pre- and post-intervention scores for all outcomes (State Anxiety, Trait Anxiety, and Parental Self-Efficacy) are presented in Table 2, along with the results of the within-group (paired t-test) and primary between-group (ANCOVA) analyses. I. Within-Group Changes Within-group comparisons (paired-samples t-tests) demonstrated significant positive changes in both the intervention and control groups for measured variables: Intervention Group: This group showed significant reductions in both state anxiety and trait anxiety (both P < 0.001) and a significant increase in parental self-efficacy (P < 0.001). Control Group: The control group also exhibited significant reductions in state anxiety and trait anxiety (both P < 0.001) and a significant increase in parental self-efficacy (P < 0.001). This finding confirms that both the structured psychoeducation and the brief standard education provided in the control group were effective in improving maternal outcomes compared to baseline. II. Between-Group Comparison (Intervention Effectiveness) The primary analysis used Analysis of Covariance (ANCOVA), adjusting for baseline scores, to compare the post-intervention means between the two groups. This determined the unique effectiveness of the structured psychoeducation program relative to standard care. A. Maternal Anxiety The intervention group demonstrated significantly lower post-intervention anxiety scores compared to the control group in both subscales: State Anxiety: The psychoeducation group showed a significantly greater reduction in State Anxiety (P < 0.001). The adjusted mean difference was -12.34, and the effect size was large (Cohen’s d = 0.71). Trait Anxiety: The psychoeducation group showed a significantly greater reduction in Trait Anxiety (P < 0.001). The adjusted mean difference was -11.26, and the effect size was large (Cohen’s d = 0.72). These results support the hypothesis that the three-session psychoeducation program produced a significantly greater reduction in both transient (state) and chronic (trait) anxiety compared to the brief educational session alone. B. Parental Self-Efficacy The intervention group achieved significantly higher post-intervention self-efficacy scores compared to the control group: Parental Self-Efficacy: The increase in self-efficacy was significantly greater in the psychoeducation group (P = 0.024). The adjusted mean difference was +7.80, and the effect size was medium (Cohen’s d = 0.48). This finding confirms the hypothesis that the structured intervention significantly enhanced the mothers' perceived competence in their parenting role during the stressful perioperative period. III. Summary of Effect Sizes The between-group comparisons demonstrated large effect sizes for anxiety outcomes (Cohen’s d = 0.71 and 0.72), and a medium effect size for self-efficacy improvement (Cohen’s d = 0.48). IV. Background Variables Analysis of the background variables (including maternal age, child age, and parental education) revealed no significant relationship with the observed changes in anxiety or self-efficacy scores. However, non-significant trends indicated that regardless of grouping, maternal literacy and the extent to which education influenced them may be related, and higher paternal education may be associated with lower maternal anxiety scores. (Insert Table 3 here) Note: P-values marked with an asterisk (*) are statistically significant. Discussion The present randomized controlled trial demonstrated that a brief, structured psychoeducational program integrating cognitive restructuring and progressive muscle relaxation was highly effective in reducing both state and trait preoperative anxiety and enhancing parental self-efficacy in mothers of young children undergoing elective urology surgery. Compared with standard care, the intervention produced large effect sizes for anxiety reduction and a medium effect size for improvement in self-efficacy, with all between-group differences statistically significant. Effectiveness in Reducing Maternal Anxiety (State and Trait) These findings are consistent with extensive prior research confirming that educational and psychological preparation interventions are effective in reducing parental anxiety before their children’s surgery(21, 26-30). Studies utilizing structured educational programs, such as those by Mehdizadeh et al.(34), Amiri et al.(35), and Chang et al.(36), all reported a significant reduction in maternal anxiety following educational intervention. Our observed large effect sizes for anxiety reduction suggest a superior benefit compared to previous studies focused solely on informational transfer. This superior effectiveness is likely due to the incorporation of a structured, cognitive-behavioral approach that targets multiple psychological mechanisms simultaneously. Mechanisms of State Anxiety Reduction The success of the three-session program in mitigating anxiety can be explained through three primary mechanisms: 1. Reduction of Uncertainty and Ambiguity: Preoperative anxiety is often rooted in the ambiguity surrounding anesthesia, surgical outcomes, and postoperative care(62-64). The psychoeducation program provided detailed, structured, and understandable information on every stage of the surgical process, transforming the unknown into the known. This informational clarity eliminates the primary source of state anxiety, allowing mothers to realistically appraise the situation as less threatening(65). 2. Enhancement of Perceived Control: The hospital environment frequently results in a loss of control(66). The intervention countered this by teaching practical coping strategies and problem-solving skills (e.g., using the Dysfunctional Thought Record, probability estimation, and solving problems). This sense of active participation and psychological competence directly contributes to anxiety reduction(67, 68). 3. Correction of Catastrophic Appraisals: Using techniques like decatastrophizing and evidence examination, the intervention directly addressed the tendency toward exaggerated or catastrophic thinking about the surgery, thereby modifying the subjective cognitive appraisal of the threat(69). This is in contrast to simple informational tools, which demonstrate varied effectiveness; for example, the recent Network Meta-Analysis by Priyadarshini et al. (2025) found that while web-based education was highly effective, mere information booklets showed only a non-significant reduction in anxiety(37). Similarly, passive interventions like pre-operative visits to the operating theatre have been shown not to decrease parental anxiety(37). Our study suggests that the addition of active coping skills (cognitive restructuring and progressive muscle relaxation) is essential to achieving superior outcomes compared with passive standard care. Discussion on Trait Anxiety Reduction The significant reduction observed in Trait Anxiety is particularly noteworthy since trait anxiety is theoretically a relatively stable and deep-seated personality characteristic(70). This finding must be interpreted cautiously, considering the immediate post-intervention assessment time point: 1. Modification of the Cognitive-Emotional Framework: The psychoeducational program provided mothers with specific coping tools, such as problem-solving and decatastrophizing techniques, which effectively altered their cognitive framework for interpreting threats. By equipping mothers with these practical tools, the intervention helped calm their internal alarm system, leading to a significant decrease in emotional arousal(71). 2. Mastery Experience and Self-Efficacy: The success of the mothers in acquiring information and preparing for the surgery served as a mastery experience(72). This success strengthened their perceived competence, and as established in research by Amirsardari et al. (2014), there is an inverse relationship between self-efficacy and trait anxiety(73). This enhanced self-efficacy likely decreased the mothers' stable tendency to worry, thereby indirectly lowering their reported trait anxiety scores(73). 3.Desirability and Short-term Relief: It must be acknowledged that the immediate post-intervention timing of the assessments may have introduced a social desirability bias(74), where mothers felt a subconscious tendency to report lower anxiety in all dimensions after receiving professional psychological support. 4. Superiority of Comprehensive Intervention: Nevertheless, the finding that the three-session intervention resulted in a significantly greater reduction in trait anxiety compared to the brief control session emphasizes the superiority of structured psychological support (incorporating skill training) over simple informational transfer. In conclusion, while the reduction in trait anxiety indicates a significant impact of the intervention on the mothers' emotional-cognitive system in the short term, long-term follow-up studies are essential to determine whether these psychoeducational sessions have truly influenced the stable personality structure of the mothers or provided a profound but temporary state of psychological relief. Effectiveness in Enhancing Parental Self-Efficacy The program’s success in significantly increasing Parental Self-Efficacy confirms the study hypothesis. This outcome aligns with Bandura's social cognitive theory, which posits that mastery experiences strengthen competence beliefs(75). Studies such as those by Kwa et al.(3), who explicitly developed an app based on Bandura's self-efficacy theory for perioperative care, support the integration of competence training. Similarly, other research, including studies by Motahari Niya & Hojjati(21) and Razi et al.(48) in the local context, confirms that educational and stress management training significantly enhances parental self-efficacy. The enhanced self-efficacy is explained through a dual-target mechanism addressing both cognitive and emotional factors: 1. Cognitive Mechanism (Mastery Experience): The psychoeducation directly promoted self-efficacy by enhancing knowledge mastery and perceived competence(76, 77). By providing specific training in managing the postoperative period (e.g., distraction and pleasant stimuli for the child), the intervention gave mothers the necessary cognitive tools to successfully execute their caregiving roles. This strengthened belief in their ability forms the core of self-efficacy(78, 79). 2. Emotional Mechanism (Anxiety Reduction): The concurrent significant reduction in anxiety acted as a critical enabling factor(80, 81). Lower levels of anxiety and emotional distress liberate the mother's cognitive resources, allowing her to shift her focus from fear and self-doubt to active, positive caregiving(82). This positive feedback loop—reduced anxiety enabling competence, which in turn boosts self-efficacy—is central to the comprehensive effectiveness of the intervention(83, 84). Interpretation of Control Group Findings It is important to acknowledge that the control group, which received only a brief session of preoperative educational instructions, also demonstrated significant within-group improvements in anxiety and self-efficacy. This finding emphasizes that providing even minimal, factual information helps reduce baseline cognitive ambiguities, which are a major source of anxiety in parents(85). However, the three-session psychoeducation program was statistically significantly superior in all outcomes, confirming that incorporating advanced cognitive and relaxation skills training yields substantially greater psychological benefits than informational transfer alone(21). Finally, the analysis of baseline demographic variables showed no significant relationship between parental/child characteristics (such as age, gender, or parental education) and the change in anxiety or self-efficacy. However, non-significant trends indicated that higher maternal education may be associated with greater effectiveness of the education on them, irrespective of group allocation, and higher paternal education may also be associated with lower maternal stress. This highlights the potential role of health literacy in processing complex information(86, 87), and emphasizes the role of spousal support as a protective factor against maternal anxiety(88, 89). The findings of this randomized controlled trial provide strong evidence that this low-cost, non-pharmacological psychoeducation program is an effective, comprehensive approach to mitigating maternal distress and enhancing competence in the critical perioperative period. Study Limitations The findings of this randomized controlled trial should be interpreted within the context of several limitations, primarily related to scope and generalizability: Generalizability and Sample Scope Single-Center Setting: The research was conducted at a single center (Imam Ali University Hospital in Karaj, Iran) within a specific time frame. This single-center setting limits the generalizability of the findings to different cultural contexts, distinct healthcare systems, or other geographical regions. Specific Surgery Focus: The sample was restricted to mothers of children undergoing first-time elective urology surgery. This specific type of surgery and associated care expectations may limit the generalizability of the findings to mothers of children undergoing different surgical procedures (e.g., cardiac, neurological, or orthopedic surgeries). External Factors The clinical environment itself posed limitations, as certain factors, such as unexpected delays in the surgery schedule or variations in the quality of standard nursing care, were outside the researcher's control and may have exerted an independent influence on the mothers’ reported anxiety levels. Conclusion This randomized controlled trial demonstrates that a brief, structured psychoeducational program—integrating cognitive restructuring, progressive muscle relaxation, and structured information—effectively achieves its dual goal: significantly reducing preoperative maternal anxiety (with large effect sizes, Cohen’s d ≈ 0.71–0.72) and enhancing parental self-efficacy (with a medium effect size, d = 0.48). By simultaneously targeting negative emotional states and building positive adaptive resources, the intervention strengthens psychological competence in mothers facing their child's surgery. Given its low-cost, non-pharmacological nature, this protocol can be readily integrated into routine family-centered preoperative care in pediatric settings to improve maternal well-being and optimize child perioperative outcomes. Declarations Ethical Approval and Consent to participate The study protocol was meticulously reviewed and approved by the Ethics Committee of Isfahan University of Medical Sciences (Approval Code: IR.MUI.MED.REC.1403.394), ensuring all procedures aligned with the ethical principles stipulated in the Declaration of Helsinki. Key ethical considerations were maintained throughout the research process: Informed Consent: Written informed consent was obtained from all participating mothers prior to their inclusion and randomization,,. Confidentiality: Participants were guaranteed the confidentiality of all collected data. Right to Withdraw: Mothers were explicitly informed of their right to withdraw from the study at any stage without consequence to the standard care received by their child. Consent for publication Not applicable. This manuscript does not contain any individual person's data in any form (including any individual details, images, or videos) Availability of data and materials The individual-level, anonymized datasets generated and analyzed during the current study are available from the corresponding author on reasonable request. Participants consented to the use of their anonymized data for research purposes. Competing interests The authors declare that they have no competing interests. Funding This reaserch received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Authors' contributions Authors' contributions: M.H. (Maryam Hafez) contributed to the study's conception and design, methodology development, project administration, data curation, investigation, and wrote the original draft. F.Z. (Fatemeh Zargar) contributed to the study conception and design, supervised the research, and was involved in reviewing and editing the manuscript. S.M.H. (Seyed Mohsen Hosseini) contributed to the methodological and statistical design, performed the formal analysis, and contributed to data visualization. M.Kh. (Mohammad Mehdi Khazravi) contributed to the methodology by providing specialized clinical/surgical expertise and resources (patient samples), and assisted in the investigation. All authors reviewed and approved the final version of the manuscript. Acknowledgements The authors wish to extend their sincere gratitude to all the mothers who participated in this study. We also thank the administration and staff of Imam Ali Hospital in Karaj for their cooperation in facilitating the sample collection process. Additionally, we acknowledge the faculty members of the Health Psychology Department at Isfahan University of Medical Sciences for their general advice during the initial design phase of this work. References Kumari K, Nemani S, Rathod D, Sharma A, Bhatia PK, Goyal S. Prediction of correlation between preoperative parents' anxiety and their child's anxiety before elective surgery under anaesthesia: An observational study. Indian J Anaesth. 2024;68(9):809-14.http://doi.org/10.4103/ija.ija_1269_23 Arpaci T, ÇİL M. Relationship Between Parental Self-Efficacy and Preoperative Fear and Anxiety of Children: A Descriptive and Relational Research. Turkiye Klinikleri Journal of Nursing Sciences. 2025;17:27-35.http://doi.org/10.5336/nurses.2023-99892 Kwa ZY, Li J, Loh DL, Lee YY, Liu G, Zhu L, et al. An Intelligent Customer-Driven Digital Solution to Improve Perioperative Health Outcomes Among Children Undergoing Circumcision and Their Parents: Development and Evaluation. JMIR Form Res. 2024;8:e52337.http://doi.org/10.2196/52337 Lin C-J, Liu H-P, Wang P-Y, Yu M-H, Lu M-C, Hsieh L-Y, et al. The Effectiveness of Preoperative Preparation for Improving Perioperative Outcomes in Children and Caregivers. Behavior Modification. 2019;43(3):311-29.http://doi.org/10.1177/0145445517751879 Cui X, Zhu B, Zhao J, Huang Y, Luo A, Wei J. Parental state anxiety correlates with preoperative anxiety in Chinese preschool children. J Paediatr Child Health. 2016;52(6):649-55.http://doi.org/10.1111/jpc.13176 Moosazad Y, Valizadeh F, Ghasemi F, Karami K. Mothers’ experiences of children undergoing congenital heart disease surgery: A qualitative study. Jundishapur Journal of Chronic Disease Care. 2024;13(4) Franck LS, Wray J, Gay C, Dearmun AK, Lee K, Cooper BA. Predictors of parent post-traumatic stress symptoms after child hospitalization on general pediatric wards: a prospective cohort study. Int J Nurs Stud. 2015;52(1):10-21.http://doi.org/10.1016/j.ijnurstu.2014.06.011 Pomicino L, Maccacari E, Buchini S. Levels of anxiety in parents in the 24 hr before and after their child's surgery: A descriptive study. J Clin Nurs. 2018;27(1-2):278-87.http://doi.org/10.1111/jocn.13895 Re J, Dean S, Menahem S. Infant cardiac surgery: mothers tell their story: a therapeutic experience. World J Pediatr Congenit Heart Surg. 2013;4(3):278-85.http://doi.org/10.1177/2150135113481480 Dai Y, Zou E, Ji Y, Chen X, Chen M, Chen K, et al. A nurse-led parental self-efficacy promotion program in parents of children with autism spectrum disorder: a quasi-experimental protocol. Frontiers in Psychiatry. 2025;Volume 16 - 2025.http://doi.org/10.3389/fpsyt.2025.1411518 Moura LA, Dias IM, Pereira LV. Prevalence and factors associated with preoperative anxiety in children aged 5-12 years. Rev Lat Am Enfermagem. 2016;24.http://doi.org/10.1590/1518-8345.0723.2708 Artemio G. Breastfeeding self-efficacy in Asia and Pacific: Scoping review. Nursing Practice Today. 2020;8(1).http://doi.org/10.18502/npt.v8i1.4489 Karbandi S, Hosseini S, Masoudi R, MAMORI GA. The effect of relaxation training on breastfeeding self-efficacy of mothers with preterm infants: A randomized clinical trial. 2014 Li HC, Lopez V, Lee TL. Psychoeducational preparation of children for surgery: the importance of parental involvement. Patient Educ Couns. 2007;65(1):34-41.http://doi.org/10.1016/j.pec.2006.04.009 Hui WJ, Pikkarainen M, Nah SA, Nah SNJ, Pölkki T, Wang W, et al. Parental Experiences While Waiting For Children Undergoing Surgery in Singapore. J Pediatr Nurs. 2020;52:e42-e50.http://doi.org/10.1016/j.pedn.2020.01.004 Burns-Nader S, Hernandez-Reif M, Porter M. The relationship between mothers' coping patterns and children's anxiety about their hospitalization as reflected in drawings. Journal of child health care : for professionals working with children in the hospital and community. 2013;18.http://doi.org/10.1177/1367493512468361 Curelaru V, Muntele-Hendreș D, Diac G, Duca D-S. Children’s and Mothers’ Achievement Goal Orientations and Self-Efficacy: Dyadic Contributions to Students’ Well-Being. Sustainability. 2020;12(5):1785 Vance AJ, Pan W, Malcolm WH, Brandon DH. Development of parenting self-efficacy in mothers of high-risk infants. Early Hum Dev. 2020;141:104946.http://doi.org/10.1016/j.earlhumdev.2019.104946 Kieslinger K, Wartha O, Pollatos O, Steinacker JM, Kobel S. Parental Self-Efficacy—A Predictor of Children's Health Behaviors? Its Impact on Children's Physical Activity and Screen Media Use and Potential Interaction Effect Within a Health Promotion Program. Frontiers in Psychology. 2021;Volume 12 - 2021.http://doi.org/10.3389/fpsyg.2021.712796 Sirousfard M, Marofi M, Moeini M, Samouie F, Heidari MM. The effect of aromatherapy with Pelargonium graveolens on postoperative pain intensity in hospitalized children: A clinical randomized trial. 2014 Motahari niya H, Hojjati H. The influence of education on anxiety in mothers of children with surgery. Iranian Journal of Pediatric Nursing. 2019;5(4):49-55 Glatz T, Lippold M, Chung G, Jensen TM. A Systematic Review of Parental Self-efficacy Among Parents of School-Age Children and Adolescents. Adolescent Research Review. 2024;9(1):75-91.http://doi.org/10.1007/s40894-023-00216-w Albanese AM, Russo GR, Geller PA. The role of parental self‐efficacy in parent and child well‐being: A systematic review of associated outcomes. Child: care, health and development. 2019;45(3):333-63 Sarabi M. The effectiveness of parent training on self-efficacy of mothers of children with autism. Journal of Fundamentals of Mental Health. 2011;13(49):84-93 Jones TL, Prinz RJ. Potential roles of parental self-efficacy in parent and child adjustment: a review. Clin Psychol Rev. 2005;25(3):341-63.http://doi.org/10.1016/j.cpr.2004.12.004 Aranha PR, Sams LM, Saldanha P. Impact of preoperative education program on parental anxiety: A pilot project. Archives of Medicine and Health Sciences. 2016;4(1):30-4 Kerimaa H, Hakala M, Haapea M, Vähänikkilä H, Serlo W, He H-G, et al. Effectiveness of a Mobile App Intervention for Preparing Preschool Children and Parents for Day Surgery: Randomized Controlled Trial. J Med Internet Res. 2023;25:e46989.http://doi.org/10.2196/46989 Hou H, Li X, Song Ya, Ji Y, Sun M, Wang D, et al. Effect of interactive, multimedia-based home-initiated education on preoperative anxiety inchildren and their parents: a single-center randomized controlled trial. BMC Anesthesiology. 2023;23(1):95.http://doi.org/10.1186/s12871-023-02055-7 Tabrizi JS, Seyedhejazi M, Fakhari A, Ghadimi F, Hamidi M, Taghizadieh N. Preoperative education and decreasing preoperative anxiety among children aged 8-10 years old and their mothers. Anesthesiology and pain medicine. 2015;5(4):e25036 Kim J, Chiesa N, Raazi M, Wright KD. A systematic review of technology-based preoperative preparation interventions for child and parent anxiety. Can J Anaesth. 2019;66(8):966-86.http://doi.org/10.1007/s12630-019-01387-8 Tural Buyuk E, Bolişik B. An Analysis of the Anxiety Levels of Mothers Who Participate in Education and Therapeutic Games About Their Children's Surgeries. J Perianesth Nurs. 2018;33(3):290-5.http://doi.org/10.1016/j.jopan.2016.09.011 Lööf G, Liljeberg C, Eksborg S, Lönnqvist PA. Interactive web-based format vs conventional brochure material for information transfer to children and parents: a randomized controlled trial regarding preoperative information. Paediatr Anaesth. 2017;27(6):657-64.http://doi.org/10.1111/pan.13142 Nytun KL, Moldestad IO, Snibsøer AK, Espehaug B. The effect of web-based preoperative information on parents of children who are going through elective ambulatory surgery: A systematic review and meta-analysis. Patient Educ Couns. 2022;105(12):3389-97.http://doi.org/10.1016/j.pec.2022.09.006 Mahdizadeh M, Nejat Mohammad A, Behnam Vashani H, Reyhani T. Effects of supportive educational program on anxiety of mothers of children undergoing the lumbar puncture (LP). Evidence Based Care. 2016;6(2):29-38 Amiri A, Edraki M, Paran M, Sajjadi S. The impact of educational program on the anxiety and self-efficacy in mothers of the children under glaucoma surgery: a randomized controlled trial. Pharmacophore. 2017;8(0-2017):0- Chang SF, Hung CH, Hsu YY, Liu Y, Wang TN. The Effectiveness of Health Education on Maternal Anxiety, Circumcision Knowledge, and Nursing Hours: A Quasi-Experimental Study. The journal of nursing research : JNR. 2017;25(4):296-303.http://doi.org/10.1097/jnr.0000000000000177 Priyadarshini S, Agarwala S, Priya H, Jain V, Goel P, Dhua A, et al. Easing Parental Worries: A Systematic Review and Network Meta-analysis on Preoperative Education Methods for Reducing Anxiety in Parents of Children Undergoing Surgery. J Indian Assoc Pediatr Surg. 2025;30(4):427-37.http://doi.org/10.4103/jiaps.jiaps_276_24 Fonseca A, Qian D, Forbes T, Li BS, Lee C, Burdsall K, et al. Reducing Preoperative Caregiver Anxiety With Virtual Reality: A Pragmatic, Randomized Controlled Study. J Patient Exp. 2024;11:23743735231220190.http://doi.org/10.1177/23743735231220190 Luengo TD, Rivas AB, Loureido E, Vargas E. Reducing preoperative anxiety in parents of surgical patients. Heliyon. 2023;9(5):e15920.http://doi.org/10.1016/j.heliyon.2023.e15920 Carlsson R, Henningsson R. Visiting the Operating Theatre Before Surgery Did Not Reduce the Anxiety in Children and Their Attendant Parent. Journal of Pediatric Nursing. 2017;38.http://doi.org/10.1016/j.pedn.2017.09.005 Bandura A. Self-efficacy: toward a unifying theory of behavioral change. Psychol Rev. 1977;84(2):191-215.http://doi.org/10.1037//0033-295x.84.2.191 Bandura A. Social foundations of thought and action. Englewood Cliffs, NJ. 1986;1986(23-28):2 Bandura A. Self-efficacy: The exercise of control: Macmillan; 1997. Cheng NS, Chau JPC, Lo SHS, Choi KC, Hon KLE, Lam PH, et al. Effects of a self-efficacy theory-based parental education program on eczema control and parental outcomes. Pediatr Allergy Immunol. 2021;32(3):535-43.http://doi.org/10.1111/pai.13421 Piro SS, Ahmed HM. Impacts of antenatal nursing interventions on mothers' breastfeeding self-efficacy: an experimental study. BMC Pregnancy Childbirth. 2020;20(1):19.http://doi.org/10.1186/s12884-019-2701-0 Tseng JF, Chen SR, Au HK, Chipojola R, Lee GT, Lee PH, et al. Effectiveness of an integrated breastfeeding education program to improve self-efficacy and exclusive breastfeeding rate: A single-blind, randomised controlled study. Int J Nurs Stud. 2020;111:103770.http://doi.org/10.1016/j.ijnurstu.2020.103770 Al-Shorman NA, Atiyeh H, Kassab M, Al-Rjoub SF. Effects of an educational program on self-efficacy towards type 1 diabetes mellitus disease among parents and adolescents in Jordan. J Pediatr Nurs. 2023;71:66-72.http://doi.org/10.1016/j.pedn.2023.03.011 Razi T, Shamsi M, Khorsandi M, Roozbehani N, Ranjbaran M. Education and self-efficacy of mothers regarding alerting signs in children less than five years in Arak, Iran. 2016 Colom F. Keeping therapies simple: psychoeducation in the prevention of relapse in affective disorders. The British Journal of Psychiatry. 2011;198(5):338-40 Chien WT, Lee IY. The mindfulness-based psychoeducation program for Chinese patients with schizophrenia. Psychiatric Services. 2013;64(4):376-9 Moazeni Z, Miri M, Sharifzadeh G, Behdani S. The relationship between self-efficacy, trust in God, and anxiety in mothers of hospitalized children in Valiasr Hospital of Birjand. Modern Care Journal. 2014;11(3) Toosi M, Akbarzadeh M, Ghaemi Z. The Effect of Relaxation on Mother's Anxiety and Maternal-Fetal Attachment in Primiparous IVF Mothers. J Natl Med Assoc. 2017;109(3):164-71.http://doi.org/10.1016/j.jnma.2017.03.002 Ren J, Li X, Chen S, Chen S, Nie Y. The Influence of Factors Such as Parenting Stress and Social Support on the State Anxiety in Parents of Special Needs Children During the COVID-19 Epidemic. Front Psychol. 2020;11:565393.http://doi.org/10.3389/fpsyg.2020.565393 Aroniada P, Gerogianni G, Stamou A, Zaka M, Tsoulou V, Tsami A, et al. State, Trait Anxiety and Insomnia in Hospitalized Patients With Cardiovascular Disease. Acta Inform Med. 2025;33(2):129-34.http://doi.org/10.5455/aim.2025.33.129-134 Brajer-Luftmann B, Mardas M, Stelmach-Mardas M, Lojko D, Batura-Gabryel H, Piorunek T. Association between Anxiety, Depressive Symptoms, and Quality of Life in Patients Undergoing Diagnostic Flexible Video Bronchoscopy. Int J Environ Res Public Health. 2021;18(19).http://doi.org/10.3390/ijerph181910374 Hashemi SB, Amirfakhraei A, Mosallanezhad M, Amiri A. The effect of education on anxiety and self-efficacy in mothers of 1-3-year-old children under cochlear implant surgery, 2018: a randomized controlled clinical trial. Revista Latinoamericana de Hipertensión. 2019;14(1):8-14 Castellano-Rioja C. Investigating the Effect of Providing Required Training to Mothers of Children with Surgery and Its Effect on Mothers' Anxiety. Journal of Integrative Nursing and Palliative Care. 2025;6(1):7-11.http://doi.org/10.51847/m0J08PS92O Han H, Chen C, Sheng R, Wang S. Psychological intervention based on cognitive behavioral therapy for patients with orthopedic surgical anxiety. Medicine. 2024;103(35):e39401.http://doi.org/10.1097/md.0000000000039401 Khanipour H. Thought control strategies and trait anxiety: predictors of pathological worry in non-clinical sample. International Journal of Behavioral Sciences. 2011;5(2):173-8 Mahram B. Standardization of Spielberger’s test anxiety inventory in Mashhad. Tehran: Allameh Tabatabaei University. 1994:76 Ganji K, Niusha, B., Hedayati, F. The effect of creativity training to mothers on creativity of their preschool children. Journal of Innovation and Creativity in Human Science. 2012;2(2):71-93 Brown R, Gerbarg PL. The Healing Power of the Breath: Simple Techniques to Reduce Stress and Anxiety, Enhance Concentration, and Balance Your Emotions: Shambhala; 2012. Olson N. Preoperative anxiety in children and their parents: the parents’ perspective of the anxiety experienced by a child prior to surgery, the emotional effect on the parent and the care a nurse can provide: a qualitative study. 2018 Sarkhel S, Singh OP, Arora M. Clinical Practice Guidelines for Psychoeducation in Psychiatric Disorders General Principles of Psychoeducation. Indian Journal of Psychiatry. 2020;62(Suppl 2):S319-S23.http://doi.org/10.4103/psychiatry.IndianJPsychiatry_780_19 Kumar V, Yadav P, Bangarwa N, Budhwar D, Kumar P, Arora V. A Randomized Controlled Trial to Assess the Efficacy of a Pre-operative Virtual Operation Theatre Tour on Anxiety and Patient Satisfaction in Adults Undergoing Elective Surgery. Cureus. 2022;14(12):e32337.http://doi.org/10.7759/cureus.32337 Abuatiq A. Patients’ and Health Care Providers’ Perception of Stressors in the Intensive Care Units. Dimensions of Critical Care Nursing. 2015;34(4):205-14.http://doi.org/10.1097/dcc.0000000000000121 Mhango W, Crowter L, Michelson D, Gaysina D. Psychoeducation as an active ingredient for interventions for perinatal depression and anxiety in youth: a mixed-method systematic literature review and lived experience synthesis. BJPsych Open. 2023;10(1):e10.http://doi.org/10.1192/bjo.2023.614 Cuesta-Lozano D, Lopez-Alcalde J, Castro Molina FJ, García Sastre M, Maravilla Herrera P, Muriel A, et al. Psychoeducation for the parents of people with severe mental illness: Cochrane Database Syst Rev. 2022 Jun 16;2022(6):CD014532. doi: 10.1002/14651858.CD014532. eCollection 2022. Brosch T, Scherer KR, Grandjean D, Sander D. The impact of emotion on perception, attention, memory, and decision-making. Swiss Med Wkly. 2013;143:w13786.http://doi.org/10.4414/smw.2013.13786 Yamamori Y, Robinson OJ. Computational perspectives on human fear and anxiety. Neurosci Biobehav Rev. 2023;144:104959.http://doi.org/10.1016/j.neubiorev.2022.104959 Brooks SK, Weston D, Wessely S, Greenberg N. Effectiveness and acceptability of brief psychoeducational interventions after potentially traumatic events: A systematic review. Eur J Psychotraumatol. 2021;12(1):1923110.http://doi.org/10.1080/20008198.2021.1923110 Alemany-Arrebola I, Rojas-Ruiz G, Granda-Vera J, Mingorance-Estrada ÁC. Influence of COVID-19 on the Perception of Academic Self-Efficacy, State Anxiety, and Trait Anxiety in College Students. Frontiers in Psychology. 2020;Volume 11 - 2020.http://doi.org/10.3389/fpsyg.2020.570017 Pereyra Girardi C, Mur J, Rivas A, Trueba D. The Relationship between Self-Efficacy, State-Trait Anxiety and Cognitive Test Anxiety: A Study among University Students in Argentina. Psychological Thought. 2022;15:75-94.http://doi.org/10.37708/psyct.v15i2.664 Bispo Júnior JP. Social desirability bias in qualitative health research. Rev Saude Publica. 2022;56:101.http://doi.org/10.11606/s1518-8787.2022056004164 Artino AR, Jr. Academic self-efficacy: from educational theory to instructional practice. Perspect Med Educ. 2012;1(2):76-85.http://doi.org/10.1007/s40037-012-0012-5 Barani M, Hassani L, Ghanbarnejad A, Molavi MA. Effect of Educational Intervention Based on Self-Efficacy Theory on the Caring Behaviour of Mothers Who Have Children With Cancer. J Mother Child. 2023;27(1):93-101.http://doi.org/10.34763/jmotherandchild.20232701.d-22-00065 Carosi Arcangeli I, Ciavatta V, Celia G. Self-efficacy among parents of children and adolescents with type 1 diabetes: a systematic review. Diabetes Research and Clinical Practice. 2025;229:112939.http://doi.org/https://doi.org/10.1016/j.diabres.2025.112939 Wadsworth LP, Hayes-Skelton SA. Exploring perceived control, a low-control task, and a brief acceptance intervention in a low and high transdiagnostic anxiety sample. Neurology, Psychiatry and Brain Research. 2020;35:1-9.http://doi.org/https://doi.org/10.1016/j.npbr.2019.11.001 Keeton CP, Perry-Jenkins M, Sayer AG. Sense of control predicts depressive and anxious symptoms across the transition to parenthood. J Fam Psychol. 2008;22(2):212-21.http://doi.org/10.1037/0893-3200.22.2.212 Bassi G, Mancinelli E, Di Riso D, Salcuni S. Parental Stress, Anxiety and Depression Symptoms Associated with Self-Efficacy in Paediatric Type 1 Diabetes: A Literature Review. Int J Environ Res Public Health. 2020;18(1).http://doi.org/10.3390/ijerph18010152 Elfström S, Rosengren A, Andersson R, Engelbrektsson J, Isaksson A, Meregalli M, et al. Evaluating a program to prevent anxiety in children of anxious parents: a randomized controlled trial. Journal of Child Psychology and Psychiatry. 2025;66(9):1345-56.http://doi.org/https://doi.org/10.1111/jcpp.14151 McLeish J, Redshaw M. Mothers' accounts of the impact on emotional wellbeing of organised peer support in pregnancy and early parenthood: a qualitative study. BMC Pregnancy Childbirth. 2017;17(1):28.http://doi.org/10.1186/s12884-017-1220-0 Léniz-Maturana L, Vilaseca R, Leiva D. Maternal self-efficacy and emotional well-being in Chilean adolescent mothers: the relationship with their children's social-emotional development. PeerJ. 2022;10:e13162.http://doi.org/10.7717/peerj.13162 Buchanan CM, Gangel MJ, McCurdy AL, Fletcher AC, Buehler C. Parental Self-Efficacy and Physiological Responses to Stress among Mothers of Early Adolescents. J Youth Adolesc. 2022;51(4):643-58.http://doi.org/10.1007/s10964-022-01577-6 Vongkiatkajorn K, Brown EA, Donaldson A, Rich V, Paterson R, Kenardy J, et al. The effect of a parental preparation video (Take5) on child and parent anxiety during anaesthetic induction: a protocol for a randomised controlled trial. Trials. 2023;24(1):446.http://doi.org/10.1186/s13063-023-07480-0 Ratzan SC, Parker RM. Health Literacy—Identification and Response. Journal of Health Communication. 2006;11(8):713-5.http://doi.org/10.1080/10810730601031090 Rudd RE, Comings JP, Hyde JN. Leave no one behind: improving health and risk communication through attention to literacy. J Health Commun. 2003;8 Suppl 1:104-15.http://doi.org/10.1080/713851983 Bain M, Park S, Zaidi A, Atif N, Rahman A, Malik A, et al. Social Support and Spousal Relationship Quality Improves Responsiveness among Anxious Mothers. Child Psychiatry Hum Dev. 2024.http://doi.org/10.1007/s10578-024-01702-5 Lebert-Charron A, Wendland J, Vivier-Prioul S, Boujut E, Dorard G. Does Perceived Partner Support Have an Impact on Mothers’ Mental Health and Parental Burnout? Marriage & Family Review. 2022;58(4):362-82.http://doi.org/10.1080/01494929.2021.1986766 Tables Tables 1 to 3 are available in the supplementary files section Additional Declarations An anonymized version of the dataset can be found at https://doi.org/10.5281/zenodo.18494981 . Supplementary Files Tables.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8703884","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":585985139,"identity":"685d11ce-cec0-4267-a8e0-4793a1726837","order_by":0,"name":"Maryam Hafez","email":"","orcid":"","institution":"Isfahan University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Maryam","middleName":"","lastName":"Hafez","suffix":""},{"id":585985140,"identity":"00ae465a-e534-4c58-a68f-2d722de581eb","order_by":1,"name":"Seyed Mohsen Hosseini","email":"","orcid":"","institution":"Isfahan University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Seyed","middleName":"Mohsen","lastName":"Hosseini","suffix":""},{"id":585985141,"identity":"8d63c888-682a-443e-b5b2-8ae0f8d8c951","order_by":2,"name":"Mohammad Mahdi Khazravi","email":"","orcid":"","institution":"Alborz university of medical sciences, Iran","correspondingAuthor":false,"prefix":"","firstName":"Mohammad","middleName":"Mahdi","lastName":"Khazravi","suffix":""},{"id":585985142,"identity":"277dd6ae-af14-46d1-a5ea-3096847aa647","order_by":3,"name":"Fatemeh Zargar","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/UlEQVRIiWNgGAWjYBAC9gYwdQDKrQBiZuYGvFp4DjAjazkD0sJIihbGNjBJQAv7+YOPblTcseefffzi58p5tdH87UAtPyq24dbCk8xsnHPmGbPEuZxiybPbjufOOMzYwNhz5jZOLfYMyWzSuW2H2RjO8CRINm47ltsA1MLM2IZbCw//Y/bfuf8O88if4Un+2TjnWO58glokktmYgSZLGJxhPybZ2FCTu4GwlsfG0jnHDhsYnuFhs2w4diB3I1DLQXx+4eFPfPg5p+awvdwZ9sc3G2rqcuedP3zwwY8K3FqQdRsAicNg5gFi1AMB+wMgUUek4lEwCkbBKBhJAADTfV21kShDugAAAABJRU5ErkJggg==","orcid":"","institution":"Isfahan University of Medical Sciences","correspondingAuthor":true,"prefix":"","firstName":"Fatemeh","middleName":"","lastName":"Zargar","suffix":""}],"badges":[],"createdAt":"2026-01-26 21:23:48","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8703884/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8703884/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":102179811,"identity":"c53f3a08-2b42-4fef-8eac-c071f8dc4c25","added_by":"auto","created_at":"2026-02-09 07:11:19","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":96189,"visible":true,"origin":"","legend":"\u003cp\u003eCONSORT flow diagram of participant progress through the trial. A total of 161 mothers were assessed for eligibility.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8703884/v1/55eec0aedba78f8a17331f5e.png"},{"id":102296710,"identity":"1f8823a9-1069-44b2-a5ba-209b9fdfbf33","added_by":"auto","created_at":"2026-02-10 10:21:00","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1140741,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8703884/v1/6eedec7e-f22e-4220-9065-aba7108a5899.pdf"},{"id":102179971,"identity":"838cbe0b-16a2-4318-ae0d-2a70b16534be","added_by":"auto","created_at":"2026-02-09 07:11:52","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":21249,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-8703884/v1/268f326b4bfcec3e2ba39ac1.docx"}],"financialInterests":"\u003cp\u003eAn anonymized version of the dataset can be found at \u003ca href=\"https://urldefense.com/v3/__https://doi.org/10.5281/zenodo.18494981__;!!NLFGqXoFfo8MMQ!t70LosKwbGrf5jSMN8TKiyC0Cz7KCJyESauQFRzYemqKsAj72zQBP-mMhXtnqc6BdT-OOXvEYL2Q-F6GPpTWs-LgYA$\" rel=\"noreferrer\"\u003ehttps://doi.org/10.5281/zenodo.18494981\u003c/a\u003e.\u003c/p\u003e","formattedTitle":"The effect of psychoeducation on preoperative anxiety and parental self-efficacy in mothers of children undergoing surgery ","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe period surrounding a child\u0026apos;s elective surgical procedure is universally recognized as a significant emotional stressor, with high levels of preoperative parental anxiety highly prevalent(1), affecting up to 74% of parents, particularly mothers, whose emotional state is highly correlated with that of their child(2-5).\u003c/p\u003e\n\u003cp\u003eHigh maternal anxiety is a serious clinical concern because it is directly linked to adverse outcomes in the child, including heightened preoperative agitation, increased postoperative pain, and maladaptive behavioral recovery(6-13). Key parental risk factors for elevated anxiety include fear of postoperative pain, having a younger child, and a lack of adequate information regarding the surgical processes(14-18).\u0026nbsp;Concurrently, this emotional distress can undermine a mother\u0026apos;s Parental Self-Efficacy (PSE), defined as the parents\u0026rsquo; belief in their capacity to successfully perform the caregiving role and provide effective support during challenging situations, such as hospitalization and surgery(19-21). High PSE is a vital protective factor, correlated with lower levels of parental stress and anxiety, whereas low PSE can impair caregiving practices and increase anxiety(22-25). The transactional relationship between these constructs is affirmed by research such as the descriptive and relational study by Arpaci and \u0026Ccedil;İL (2025), which found a negative association between parental self-efficacy and children\u0026apos;s preoperative fear and anxiety(2).\u003c/p\u003e\n\u003cp\u003eTo mitigate these psychological challenges, non-pharmacological preparation strategies are extensively researched(26-30). Recent systematic reviews show that educational interventions generally reduce parental anxiety, though the certainty and scope of these effects are nuanced(31-36). For instance, a 2025 Network Meta-Analysis by Priyadarshini et al. identified that web-based education was the most effective method for reducing parental anxiety (compared to information booklets), with multimedia approaches also showing highly significant benefits(37). \u0026nbsp;Furthermore, Fonseca et al.(2024) demonstrated the viability of high-tech psychological interventions, finding that Virtual Reality (VR)-assisted mindfulness significantly reduced caregiver state anxiety in a pragmatic RCT(38). Similarly, D\u0026iacute;az Luengo et al. (2023) confirmed that providing information via videos and storybooks reduced state anxiety in parents of surgical patients(39). However, the literature also shows significant contradictions; simpler, non-interactive methods like information booklets alone result in a slight, non-significant anxiety reduction(37), and studies such as Carlsson et al. (2017) found that a preoperative visit to the operating theatre did not decrease parental anxiety(40).\u003c/p\u003e\n\u003cp\u003eComplementing anxiety research, interventions targeting PSE are crucial as they address the adaptive skills necessary for coping, often framed by Bandura\u0026rsquo;s self-efficacy theory (41-43). The development of an intelligent digital solution (ICory-Circumcision) by Kwa et al. (2024) explicitly adopted this theoretical framework to enhance parental competence in perioperative care, demonstrating the potential of theory-driven interventions in the surgical context(3). Similarly, the protocol by Dai et al. (2025) outlines a nurse-led program specifically designed to promote PSE in parents of children with Autism Spectrum Disorder by targeting the four sources of self-efficacy(10) . Success in enhancing PSE through theory-based programs has been reported in chronic care, as seen in the RCT by Cheng et al. (2021), which demonstrated significant improvement in parental self-efficacy and disease management following an education program for managing child\u0026rsquo;s eczema(44-46). Yet, this area is not without inconsistencies; some studies have reported non-significant changes in self-empowerment post-intervention even when online platforms were utilized to enhance parental self-efficacy(47). The synthesis of contemporary literature reveals a critical dual-target knowledge gap: while ample evidence exists for anxiety reduction, and separate programs aim to build PSE, there is a lack of rigorous, integrated trials evaluating a single, unified psychoeducational program that systematically combines cognitive behavioral techniques (CBT) and structured information delivery to address both the mother\u0026apos;s negative emotional distress (anxiety) and her positive psychological resource (PSE) simultaneously(48). Psychoeducational interventions, grounded in the premise of reducing uncertainty and teaching practical coping skills (mastery experience), offer a theoretically strong approach to bridging this dual need(49, 50). Grounded in cognitive-behavioral principles, psychoeducation operates on the premise that providing knowledge demystifies the surgical process, thereby reducing anxiety rooted in uncertainty (51). \u0026nbsp;Simultaneously, teaching practical coping skills directly builds a mother\u0026apos;s competence and confidence, which is the foundation of self-efficacy (36, 52). By equipping mothers with both knowledge and tools, such interventions aim to foster a greater sense of control, potentially mitigating anxiety while concurrently empowering mothers (53). Thus, the current study aimed to test the hypothesis that mothers receiving a structured, cognitive-behavioral psychoeducation program would demonstrate significantly greater reductions in anxiety and greater increases in self-efficacy compared to those receiving standard care alone.\u003c/p\u003e"},{"header":"Materials and Methods ","content":"\u003cp\u003e\u003cstrong\u003eStudy design and setting\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;This was a single-center, parallel-group, randomized controlled clinical trial (RCT) with blinded outcome assessment conducted from May 2025 to Aguast 2025 in the Department of Pediatric Urology at Imam Ali University Hospital (Alborz University of Medical Sciences), Karaj, Iran.\u0026nbsp;The trial utilized a randomized design to compare the effects of a structured psychoeducation program versus standard care on maternal psychological outcomes. The selection of this location was based on its specialized capacity, as this hospital serves as the only specialized pediatric treatment center in Karaj and covers the majority of specialized pediatric referrals in Alborz Province. The trial was prospectively registered in the Iranian Registry of Clinical Trials (IRCT) on April 6, 2025, before the enrollment of the first participant. The trial registration number is IRCT20250222064815N1. The registration was performed by Maryam Hafez.The study protocol was reviewed and approved by the Ethics Committee of Isfahan University of Medical Sciences (Approval Code: IR.MUI.MED.REC.1403.394). All procedures were performed in accordance with the ethical principles of the Declaration of Helsinki and the Consolidated Standards of Reporting Trials (CONSORT) guidelines. Written informed consent was obtained from all participating mothers prior to randomization.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eParticipants and Eligibility Criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Population\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study population consisted of mothers who were the primary caregivers of children aged less than 7 years scheduled for first-time elective urological surgery under general anesthesia at Imam Ali University Hospital, Karaj, Iran. A total of 161 mothers were initially screened for eligibility, of whom 70 met all criteria and were subsequently randomized.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInclusion Criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMothers were eligible for inclusion if they met all of the following criteria:\u003c/p\u003e\n\u003col start=\"1\" type=\"1\"\u003e\n \u003cli\u003eBeing the primary caregiver of a child aged less than 7 years undergoing first-time elective urological surgery\u003c/li\u003e\n \u003cli\u003eNo self-reported history of diagnosed psychiatric disorders in themselves or their child\u003c/li\u003e\n \u003cli\u003eDemonstrating at least moderate-to-severe preoperative anxiety as confirmed by a score higher than 43 on the State Anxiety subscale of the Spielberger State-Trait Anxiety Inventory (STAI) at baseline screening(54, 55)\u003c/li\u003e\n \u003cli\u003eAbility to read and write in Persian\u003c/li\u003e\n \u003cli\u003eProviding written informed consent\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cstrong\u003eExclusion Criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants were initially excluded at the screening stage if they did not meet any of the above inclusion criteria, or if the child had previously undergone any surgery requiring general anesthesia\u003c/p\u003e\n\u003cp\u003eAfter randomization, participants were withdrawn from the per-protocol analysis if they:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eAttended fewer than two of the three scheduled intervention sessions\u003c/li\u003e\n \u003cli\u003eVoluntarily withdrew consent at any time\u003c/li\u003e\n \u003cli\u003eThe child\u0026rsquo;s surgery was cancelled brfore the scheduled post-intervention assessment time point\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e(insert figure 1 here)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSample Size Calculation\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe sample size, considering a confidence level of 95%, a power of 80% based on a previous study(56) and a precision of 5, including a 10% dropout rate equal to 35 people for each group (total n = 70). This resulted in a total sample size of 70 participants, allocating 35 mothers to the psychoeducation group and 35 mothers to the control group\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRandomization and Blinding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRandomization Procedure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe allocation process was managed via a pre-generated, simple randomization sequence designed to assign participants consecutively as they enrolled.\u003c/p\u003e\n\u003cp\u003e1. Sequence Generation: Before the initiation of participant enrollment, an unrestricted, simple randomization sequence was generated using a web-based randomizer. This sequence determined the assignment for 70 hypothetical slots in a 1:1 ratio, resulting in 35 allocations to the Intervention Group and 35 allocations to the Control Group, ensuring numerical balance.\u003c/p\u003e\n\u003cp\u003e2. Allocation Implementation (Consecutive Assignment): As eligible mothers presented to the clinic and provided informed consent, they were consecutively assigned to the intervention or control group based on their order of entry into the study. The first mother enrolled received the assignment from slot 1 in the pre-generated list, the second mother received the assignment from slot 2, and so forth. This process ensured that every eligible mother was immediately allocated to a study group based strictly on the pre-determined, balanced sequence, circumventing the logistical challenge of simultaneous participant recruitment.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAllocation Concealment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDue to the sequential, open nature of applying the pre-generated list based on the order of enrollment, allocation concealment was not employed. The research team member responsible for enrollment was aware of the sequence of group assignments.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBlinding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWhile complete blinding was not possible due to the nature of the educational intervention, partial blinding procedures were maintained:\u003c/p\u003e\n\u003cp\u003e1. Interventionist Blinding: Blinding of the health psychology student who delivered the sessions was not feasible due to the requirement for active participation and skills training specific to the intervention group.\u003c/p\u003e\n\u003cp\u003e2. Participant Blinding (Partial): Mothers in both groups were deliberately informed only that they would receive \u0026quot;preoperative educational support,\u0026quot; without specific details regarding the differences in content, duration, or components (i.e., cognitive restructuring vs. standard information). This was intended to maintain partial participant blinding regarding the superiority of one program over the other.\u003c/p\u003e\n\u003cp\u003e3. Outcome Assessor Blinding: The statistician responsible for data analysis was kept blinded to the group assignment (Intervention vs. Control).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIntervention and Control Conditions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBoth groups received the routine standard preoperative care provided by the hospital, which involved general medical and administrative preparations. The study intervention was delivered by a trained health psychology student. All sessions were conducted individually and online, and took place in the period spanning from ten days to one week before the scheduled surgery. Outcome questionnaires were completed by all mothers at two time points: baseline (after randomization) and post-intervention (immediately after the completion of the final session for both groups).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIntervention group(Structured Psychoeducation Program)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Mothers randomized to the intervention group (n=35) participated in a structured three-session psychoeducational program, with each session lasting approximately 45\u0026ndash;60 minutes. \u0026nbsp; This protocol was designed as a comprehensive, dual-target approach, integrating two main components: information-based protocols(56, 57) (to reduce anxiety rooted in uncertainty) and Cognitive Behavioral Therapy (CBT) techniques(58) (to enhance cognitive control and coping skills).\u003c/p\u003e\n\u003cp\u003eThe content of each session was as follows:\u003c/p\u003e\n\u003cp\u003e(Insert Table 1 here)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eControl group\u003c/strong\u003e \u003cstrong\u003e(Standard Care Plus Brief Education)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMothers in the control group (n=35) received standard hospital care plus a single brief educational session delivered by the same psychologist before surgery.\u003c/p\u003e\n\u003cp\u003eThe content of this single session was strictly informational and focused on operational and administrative aspects related to the hospital stay:\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eBasic preoperative instructions, including the hospital admission process.\u003c/li\u003e\n \u003cli\u003eFasting guidelines and necessary documentation.\u003c/li\u003e\n \u003cli\u003eGeneral information about the hospital stay duration.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eOutcome Measures\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe effectiveness of the structured psychoeducation program was assessed by measuring the mothers\u0026apos; anxiety and parental self-efficacy at two time points: baseline (after randomization) and post-intervention (immediately after completion of the final session for both the intervention and control groups).\u003c/p\u003e\n\u003cp\u003eI. Maternal Anxiety Measures\u003c/p\u003e\n\u003cp\u003eMaternal anxiety was assessed using the Persian version of the Spielberger State-Trait Anxiety Inventory (STAI), a widely utilized 40-item self-report scale. The STAI is composed of two independent 20-item subscales:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eState Anxiety: \u0026nbsp;which assesses current anxiety.\u003c/p\u003e\n\u003cp\u003eTrait Anxiety, which evaluates the mother\u0026apos;s general and relatively stable disposition or tendency to experience anxiety across different situations.\u003c/p\u003e\n\u003cp\u003eScoring and Interpretation: Items are rated on a 4-point Likert scale, and total scores for each subscale range from a minimum of 20 to a maximum of 80. Higher scores indicate greater anxiety. Critically, only mothers scoring higher than 43 on the State Anxiety subscale at baseline were included in the study, confirming a pre-existing level of moderate-to-severe preoperative anxiety.\u003c/p\u003e\n\u003cp\u003ePsychometric Properties: In the Iranian population the Persian version of the STAI has demonstrated internal consistency (Cronbach\u0026rsquo;s \u0026alpha; = 0.92 for State Anxiety and 0.65\u0026ndash;0.86 for Trait Anxiety) and good test-retest reliability(59, 60).\u003c/p\u003e\n\u003cp\u003eII. Parental Self-Efficacy Measures\u003c/p\u003e\n\u003cp\u003eParental self-efficacy was measured using the Persian version of the Dumka Parental Self-Efficacy Scale (PSAM).\u003c/p\u003e\n\u003cp\u003eDescription and Scoring: \u0026nbsp;This 10-item instrument assesses parents\u0026rsquo; perceived confidence in their parenting role, particularly during stressful situations, rated on a 7-point Likert scale (1 = strongly disagree, 7 = strongly agree). The total possible score ranges from 10 to 70. Higher scores on the PSAM reflect a greater sense of parental self-efficacy.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePsychometric Properties: The Persian version of the PSAM has demonstrated good internal consistency (Cronbach\u0026rsquo;s \u0026alpha; = 0.80) and acceptable validity in Iranian samples(61).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data were analyzed using IBM SPSS Statistics version 26.0. Descriptive statistics were expressed as mean \u0026plusmn; standard deviation (SD) for continuous variables and as frequency (percentage) for categorical variables. Baseline demographic and clinical characteristics between the two groups(Intervention vs. Control) were compared using independent-samples t-tests for continuous variables (e.g., age) and \u0026chi;\u0026sup2; tests for categorical variables (e.g., education level). This analysis was conducted to confirm the comparability of the two groups and verify the success of the randomization process\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical Assumptions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBefore conducting the primary inferential analyses using parametric tests (paired-samples \u003cem\u003et\u003c/em\u003e-tests and Analysis of Covariance [ANCOVA]), the necessary statistical assumptions were rigorously assessed. We confirmed the following for all continuous outcome variables (State Anxiety, Trait Anxiety, and Parental Self-Efficacy):\u003c/p\u003e\n\u003cp\u003e1. \u003cstrong\u003eNormality of Distribution:\u003c/strong\u003e The assumption of normality for the dependent variables was assessed using the Shapiro-Wilk test and visual inspection of Q-Q plots. Data distributions for all outcome measures were found to be approximately normal.\u003c/p\u003e\n\u003cp\u003e2. \u003cstrong\u003eHomogeneity of Variances (for ANCOVA):\u003c/strong\u003e Levene\u0026rsquo;s test was used to examine the equality of error variances across the intervention and control groups. This assumption was met for the post-intervention scores of State Anxiety, Trait Anxiety, and Parental Self-Efficacy, confirming the suitability of ANCOVA.\u003c/p\u003e\n\u003cp\u003e3. \u003cstrong\u003eHomogeneity of Regression Slopes (for ANCOVA):\u003c/strong\u003e This critical assumption, which mandates that the relationship between the covariate (baseline score) and the dependent variable (post-test score) is the same across both groups, was also confirmed for all three outcome measures.\u003c/p\u003e\n\u003cp\u003eMeeting these conditions validates the statistical power and robustness of the ANCOVA model used to assess the differential effects of the psychoeducation intervention on maternal outcomes.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eParticipant Flow and Baseline Characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 161 mothers were screened for eligibility between May 2025 and August 2025. Following the application of the inclusion and exclusion criteria, 70 eligible mothers were randomized in a 1:1 ratio, resulting in 35 participants allocated to the psychoeducation group and 35 to the control group. The participant flow is shown in Figure 1. All 70 participants completed the study, with no loss to follow-up or missing data (per-protocol and intention-to-treat samples were identical).\u003c/p\u003e\n\u003cp\u003eBaseline demographic and clinical characteristics of the participants are summarized in Table 1. The mean maternal age was 34.04 \u0026plusmn; 5.53 years, and the mean child age was 41.99\u0026plusmn;28.14 months. There were no significant between-group differences in maternal age, paternal age, child age, age at onset of the child\u0026apos;s problem, maternal or paternal education level, number of children, child gender, or family history of surgery, indicating successful randomization.\u003c/p\u003e\n\u003cp\u003e(Insert Table 2 here)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNote:\u003c/strong\u003e Continuous variables are presented as Mean (Standard Deviation). Categorical variables are presented as frequency (percentage). P-values are derived from independent-samples t-tests or chi2 tests as appropriate, demonstrating that there were no significant differences in baseline characteristics between the groups, confirming successful randomization.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOutcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePre- and post-intervention scores for all outcomes (State Anxiety, Trait Anxiety, and Parental Self-Efficacy) are presented in Table 2, along with the results of the within-group (paired t-test) and primary between-group (ANCOVA) analyses.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eI. Within-Group Changes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWithin-group comparisons (paired-samples t-tests) demonstrated significant positive changes in both the intervention and control groups for measured variables:\u003c/p\u003e\n\u003col start=\"1\" type=\"1\"\u003e\n \u003cli\u003e\u003cstrong\u003eIntervention Group:\u003c/strong\u003e This group showed significant reductions in both state anxiety and trait anxiety (both P \u0026lt; 0.001) and a significant increase in parental self-efficacy (P \u0026lt; 0.001).\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eControl Group:\u003c/strong\u003e The control group also exhibited significant reductions in state anxiety and trait anxiety (both P \u0026lt; 0.001) and a significant increase in parental self-efficacy (P \u0026lt; 0.001).\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThis finding confirms that both the structured psychoeducation and the brief standard education provided in the control group were effective in improving maternal outcomes compared to baseline.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eII. Between-Group Comparison (Intervention Effectiveness)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe primary analysis used Analysis of Covariance (ANCOVA), adjusting for baseline scores, to compare the post-intervention means between the two groups. This determined the unique effectiveness of the structured psychoeducation program relative to standard care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eA. Maternal Anxiety\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe intervention group demonstrated significantly lower post-intervention anxiety scores compared to the control group in both subscales:\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003e\u003cstrong\u003eState Anxiety:\u003c/strong\u003e The psychoeducation group showed a significantly greater reduction in State Anxiety (P \u0026lt; 0.001). The adjusted mean difference was -12.34, and the effect size was \u003cstrong\u003elarge\u003c/strong\u003e (Cohen\u0026rsquo;s d = 0.71).\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eTrait Anxiety:\u003c/strong\u003e The psychoeducation group showed a significantly greater reduction in Trait Anxiety (P \u0026lt; 0.001). The adjusted mean difference was -11.26, and the effect size was \u003cstrong\u003elarge\u003c/strong\u003e (Cohen\u0026rsquo;s d = 0.72).\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThese results support the hypothesis that the three-session psychoeducation program produced a significantly greater reduction in both transient (state) and chronic (trait) anxiety compared to the brief educational session alone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eB. Parental Self-Efficacy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe intervention group achieved significantly higher post-intervention self-efficacy scores compared to the control group:\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003e\u003cstrong\u003eParental Self-Efficacy:\u003c/strong\u003e The increase in self-efficacy was significantly greater in the psychoeducation group (P = 0.024). The adjusted mean difference was +7.80, and the effect size was medium (Cohen\u0026rsquo;s d = 0.48).\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThis finding confirms the hypothesis that the structured intervention significantly enhanced the mothers\u0026apos; perceived competence in their parenting role during the stressful perioperative period.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIII. Summary of Effect Sizes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe between-group comparisons demonstrated large effect sizes for anxiety outcomes (Cohen\u0026rsquo;s d = 0.71 \u0026nbsp;and \u0026nbsp;0.72), and a medium effect size for self-efficacy improvement (Cohen\u0026rsquo;s d = 0.48).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIV. Background Variables\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAnalysis of the background variables (including maternal age, child age, and parental education) revealed \u003cstrong\u003eno significant relationship\u003c/strong\u003e with the observed changes in anxiety or self-efficacy scores. However, non-significant trends indicated that regardless of grouping, maternal literacy and the extent to which education influenced them may be related, and higher paternal education may be associated with lower maternal anxiety scores.\u003c/p\u003e\n\u003cp\u003e(Insert Table 3 here)\u003c/p\u003e\n\u003cp\u003eNote: P-values marked with an asterisk (*) are statistically significant.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe present randomized controlled trial demonstrated that a brief, structured psychoeducational program integrating cognitive restructuring and progressive muscle relaxation was highly effective in reducing both state and trait preoperative anxiety and enhancing parental self-efficacy in mothers of young children undergoing elective urology surgery. Compared with standard care, the intervention produced large effect sizes for anxiety reduction and a medium effect size for improvement in self-efficacy, with all between-group differences statistically significant.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEffectiveness in Reducing Maternal Anxiety (State and Trait)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThese findings are consistent with extensive prior research confirming that educational and psychological preparation interventions are effective in reducing parental anxiety before their children\u0026rsquo;s surgery(21, 26-30). Studies utilizing structured educational programs, such as those by Mehdizadeh et al.(34), Amiri et al.(35), and Chang et al.(36), all reported a significant reduction in maternal anxiety following educational intervention. Our observed large effect sizes for anxiety reduction suggest a superior benefit compared to previous studies focused solely on informational transfer. This superior effectiveness is likely due to the incorporation of a structured, cognitive-behavioral approach that targets multiple psychological mechanisms simultaneously.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMechanisms of State Anxiety Reduction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe success of the three-session program in mitigating anxiety can be explained through three primary mechanisms:\u003c/p\u003e\n\u003cp\u003e1. Reduction of Uncertainty and Ambiguity: Preoperative anxiety is often rooted in the ambiguity surrounding anesthesia, surgical outcomes, and postoperative care(62-64). The psychoeducation program provided detailed, structured, and understandable information on every stage of the surgical process, transforming the unknown into the known. This informational clarity eliminates the primary source of state anxiety, allowing mothers to realistically appraise the situation as less threatening(65).\u003c/p\u003e\n\u003cp\u003e2. Enhancement of Perceived Control: The hospital environment frequently results in a loss of control(66). The intervention countered this by teaching practical coping strategies and problem-solving skills (e.g., using the Dysfunctional Thought Record, probability estimation, and solving problems). This sense of active participation and psychological competence directly contributes to anxiety reduction(67, 68).\u003c/p\u003e\n\u003cp\u003e3. Correction of Catastrophic Appraisals: Using techniques like decatastrophizing and evidence examination, the intervention directly addressed the tendency toward exaggerated or catastrophic thinking about the surgery, thereby modifying the subjective cognitive appraisal of the threat(69).\u003c/p\u003e\n\u003cp\u003eThis is in contrast to simple informational tools, which demonstrate varied effectiveness; for example, the recent Network Meta-Analysis by Priyadarshini et al. (2025) found that while web-based education was highly effective, mere information booklets showed only a non-significant reduction in anxiety(37). Similarly, passive interventions like pre-operative visits to the operating theatre have been shown not to decrease parental anxiety(37). Our study suggests that the addition of active coping skills (cognitive restructuring and progressive muscle relaxation) is essential to achieving superior outcomes compared with passive standard care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiscussion on Trait Anxiety Reduction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe significant reduction observed in Trait Anxiety is particularly noteworthy since trait anxiety is theoretically a relatively stable and deep-seated personality characteristic(70). This finding must be interpreted cautiously, considering the immediate post-intervention assessment time point:\u003c/p\u003e\n\u003cp\u003e1. Modification of the Cognitive-Emotional Framework: The psychoeducational program provided mothers with specific coping tools, such as problem-solving and decatastrophizing techniques, which effectively altered their cognitive framework for interpreting threats. By equipping mothers with these practical tools, the intervention helped calm their internal alarm system, leading to a significant decrease in emotional arousal(71).\u003c/p\u003e\n\u003cp\u003e2. Mastery Experience and Self-Efficacy: The success of the mothers in acquiring information and preparing for the surgery served as a mastery experience(72). This success strengthened their perceived competence, and as established in research by Amirsardari et al. (2014), there is an inverse relationship between self-efficacy and trait anxiety(73). This enhanced self-efficacy likely decreased the mothers\u0026apos; stable tendency to worry, thereby indirectly lowering their reported trait anxiety scores(73).\u003c/p\u003e\n\u003cp\u003e3.Desirability and Short-term Relief: It must be acknowledged that the immediate post-intervention timing of the assessments may have introduced a social desirability bias(74), where mothers felt a subconscious tendency to report lower anxiety in all dimensions after receiving professional psychological support.\u003c/p\u003e\n\u003cp\u003e4. Superiority of Comprehensive Intervention: Nevertheless, the finding that the three-session intervention resulted in a significantly greater reduction in trait anxiety compared to the brief control session emphasizes the superiority of structured psychological support (incorporating skill training) over simple informational transfer.\u003c/p\u003e\n\u003cp\u003eIn conclusion, while the reduction in trait anxiety indicates a significant impact of the intervention on the mothers\u0026apos; emotional-cognitive system in the short term, long-term follow-up studies are essential to determine whether these psychoeducational sessions have truly influenced the stable personality structure of the mothers or provided a profound but temporary state of psychological relief.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEffectiveness in Enhancing Parental Self-Efficacy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe program\u0026rsquo;s success in significantly increasing \u003cstrong\u003eParental Self-Efficacy\u003c/strong\u003e confirms the study hypothesis. This outcome aligns with Bandura\u0026apos;s social cognitive theory, which posits that mastery experiences strengthen competence beliefs(75). Studies such as those by Kwa et al.(3), who explicitly developed an app based on Bandura\u0026apos;s self-efficacy theory for perioperative care, support the integration of competence training. Similarly, other research, including studies by Motahari Niya \u0026amp; Hojjati(21) and Razi et al.(48) in the local context, confirms that educational and stress management training significantly enhances parental self-efficacy.\u003c/p\u003e\n\u003cp\u003eThe enhanced self-efficacy is \u0026nbsp;explained through a dual-target mechanism addressing both cognitive and emotional factors:\u003c/p\u003e\n\u003cp\u003e1. Cognitive Mechanism (Mastery Experience): The psychoeducation directly promoted self-efficacy by enhancing knowledge mastery and perceived competence(76, 77). By providing specific training in managing the postoperative period (e.g., distraction and pleasant stimuli for the child), the intervention gave mothers the necessary cognitive tools to successfully execute their caregiving roles. This strengthened belief in their ability forms the core of self-efficacy(78, 79).\u003c/p\u003e\n\u003cp\u003e2. Emotional Mechanism (Anxiety Reduction): The concurrent significant reduction in anxiety acted as a critical enabling factor(80, 81). Lower levels of anxiety and emotional distress liberate the mother\u0026apos;s cognitive resources, allowing her to shift her focus from fear and self-doubt to active, positive caregiving(82). This positive feedback loop\u0026mdash;reduced anxiety enabling competence, which in turn boosts self-efficacy\u0026mdash;is central to the comprehensive effectiveness of the intervention(83, 84).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInterpretation of Control Group Findings\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIt is important to acknowledge that the control group, which received only a brief session of preoperative educational instructions, also demonstrated significant within-group improvements in anxiety and self-efficacy.\u003c/p\u003e\n\u003cp\u003eThis finding emphasizes that providing even minimal, factual information helps reduce baseline cognitive ambiguities, which are a major source of anxiety in parents(85). However, the three-session psychoeducation program was statistically significantly superior in all outcomes, confirming that incorporating advanced cognitive and relaxation skills training yields substantially greater psychological benefits than informational transfer alone(21).\u003c/p\u003e\n\u003cp\u003eFinally, the analysis of baseline demographic variables showed no significant relationship between parental/child characteristics (such as age, gender, or parental education) and the change in anxiety or self-efficacy. However, non-significant trends indicated that higher maternal education may be associated with greater effectiveness of the education on them, irrespective of group allocation, and higher paternal education may also be associated with lower maternal stress. This highlights the potential role of health literacy in processing complex information(86, 87), and emphasizes the role of spousal support as a protective factor against maternal anxiety(88, 89).\u003c/p\u003e\n\u003cp\u003eThe findings of this randomized controlled trial provide strong evidence that this low-cost, non-pharmacological psychoeducation program is an effective, comprehensive approach to mitigating maternal distress and enhancing competence in the critical perioperative period.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Limitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe findings of this randomized controlled trial should be interpreted within the context of several limitations, primarily related to scope and generalizability:\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGeneralizability and Sample Scope\u003c/strong\u003e\u003c/p\u003e\n\u003col start=\"1\" type=\"1\"\u003e\n \u003cli\u003eSingle-Center Setting: The research was conducted at a single center (Imam Ali University Hospital in Karaj, Iran) within a specific time frame. This single-center setting limits the generalizability of the findings to different cultural contexts, distinct healthcare systems, or other geographical regions.\u003c/li\u003e\n \u003cli\u003eSpecific Surgery Focus: The sample was restricted to mothers of children undergoing first-time elective urology surgery. This specific type of surgery and associated care expectations may limit the generalizability of the findings to mothers of children undergoing different surgical procedures (e.g., cardiac, neurological, or orthopedic surgeries).\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cstrong\u003eExternal Factors\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe clinical environment itself posed limitations, as certain factors, such as unexpected delays in the surgery schedule or variations in the quality of standard nursing care, were outside the researcher\u0026apos;s control and may have exerted an independent influence on the mothers\u0026rsquo; reported anxiety levels.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis randomized controlled trial demonstrates that a brief, structured psychoeducational program\u0026mdash;integrating cognitive restructuring, progressive muscle relaxation, and structured information\u0026mdash;effectively achieves its dual goal: significantly reducing preoperative maternal anxiety (with large effect sizes, Cohen\u0026rsquo;s d \u0026asymp; 0.71\u0026ndash;0.72) and enhancing parental self-efficacy (with a medium effect size, d = 0.48). By simultaneously targeting negative emotional states and building positive adaptive resources, the intervention strengthens psychological competence in mothers facing their child\u0026apos;s surgery. Given its low-cost, non-pharmacological nature, this protocol can be readily integrated into routine family-centered preoperative care in pediatric settings to improve maternal well-being and optimize child perioperative outcomes.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical Approval and Consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study protocol was meticulously reviewed and approved by the Ethics Committee of Isfahan University of Medical Sciences (Approval Code: IR.MUI.MED.REC.1403.394), ensuring all procedures aligned with the ethical principles stipulated in the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003eKey ethical considerations were maintained throughout the research process:\u003c/p\u003e\n\u003col start=\"1\" type=\"1\"\u003e\n \u003cli\u003eInformed Consent: Written informed consent was obtained from all participating mothers prior to their inclusion and randomization,,.\u003c/li\u003e\n \u003cli\u003eConfidentiality: Participants were guaranteed the confidentiality of all collected data.\u003c/li\u003e\n \u003cli\u003eRight to Withdraw: Mothers were explicitly informed of their right to withdraw from the study at any stage without consequence to the standard care received by their child.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable. This manuscript does not contain any individual person\u0026apos;s data in any form (including any individual details, images, or videos)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe individual-level, anonymized datasets generated and analyzed during the current study are available from the corresponding author on reasonable request. Participants consented to the use of their anonymized data for research purposes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis reaserch received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; contributions: M.H. (Maryam Hafez) contributed to the study\u0026apos;s conception and design, methodology development, project administration, data curation, investigation, and wrote the original draft. F.Z. (Fatemeh Zargar) contributed to the study conception and design, supervised the research, and was involved in reviewing and editing the manuscript. S.M.H. (Seyed Mohsen Hosseini) contributed to the methodological and statistical design, performed the formal analysis, and contributed to data visualization. M.Kh. (Mohammad Mehdi Khazravi) contributed to the methodology by providing specialized clinical/surgical expertise and resources (patient samples), and assisted in the investigation. All authors reviewed and approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors wish to extend their sincere gratitude to all the mothers who participated in this study. We also thank the administration and staff of Imam Ali Hospital in Karaj for their cooperation in facilitating the sample collection process. Additionally, we acknowledge the faculty members of the Health Psychology Department at Isfahan University of Medical Sciences for their general advice during the initial design phase of this work.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eKumari K, Nemani S, Rathod D, Sharma A, Bhatia PK, Goyal S. Prediction of correlation between preoperative parents\u0026apos; anxiety and their child\u0026apos;s anxiety before elective surgery under anaesthesia: An observational study. Indian J Anaesth. 2024;68(9):809-14.http://doi.org/10.4103/ija.ija_1269_23\u003c/li\u003e\n \u003cli\u003eArpaci T, \u0026Ccedil;İL M. Relationship Between Parental Self-Efficacy and Preoperative Fear and Anxiety of Children: A Descriptive and Relational Research. Turkiye Klinikleri Journal of Nursing Sciences. 2025;17:27-35.http://doi.org/10.5336/nurses.2023-99892\u003c/li\u003e\n \u003cli\u003eKwa ZY, Li J, Loh DL, Lee YY, Liu G, Zhu L, et al. An Intelligent Customer-Driven Digital Solution to Improve Perioperative Health Outcomes Among Children Undergoing Circumcision and Their Parents: Development and Evaluation. JMIR Form Res. 2024;8:e52337.http://doi.org/10.2196/52337\u003c/li\u003e\n \u003cli\u003eLin C-J, Liu H-P, Wang P-Y, Yu M-H, Lu M-C, Hsieh L-Y, et al. The Effectiveness of Preoperative Preparation for Improving Perioperative Outcomes in Children and Caregivers. Behavior Modification. 2019;43(3):311-29.http://doi.org/10.1177/0145445517751879\u003c/li\u003e\n \u003cli\u003eCui X, Zhu B, Zhao J, Huang Y, Luo A, Wei J. Parental state anxiety correlates with preoperative anxiety in Chinese preschool children. J Paediatr Child Health. 2016;52(6):649-55.http://doi.org/10.1111/jpc.13176\u003c/li\u003e\n \u003cli\u003eMoosazad Y, Valizadeh F, Ghasemi F, Karami K. Mothers\u0026rsquo; experiences of children undergoing congenital heart disease surgery: A qualitative study. Jundishapur Journal of Chronic Disease Care. 2024;13(4)\u003c/li\u003e\n \u003cli\u003eFranck LS, Wray J, Gay C, Dearmun AK, Lee K, Cooper BA. Predictors of parent post-traumatic stress symptoms after child hospitalization on general pediatric wards: a prospective cohort study. Int J Nurs Stud. 2015;52(1):10-21.http://doi.org/10.1016/j.ijnurstu.2014.06.011\u003c/li\u003e\n \u003cli\u003ePomicino L, Maccacari E, Buchini S. Levels of anxiety in parents in the 24 hr before and after their child\u0026apos;s surgery: A descriptive study. J Clin Nurs. 2018;27(1-2):278-87.http://doi.org/10.1111/jocn.13895\u003c/li\u003e\n \u003cli\u003eRe J, Dean S, Menahem S. Infant cardiac surgery: mothers tell their story: a therapeutic experience. World J Pediatr Congenit Heart Surg. 2013;4(3):278-85.http://doi.org/10.1177/2150135113481480\u003c/li\u003e\n \u003cli\u003eDai Y, Zou E, Ji Y, Chen X, Chen M, Chen K, et al. A nurse-led parental self-efficacy promotion program in parents of children with autism spectrum disorder: a quasi-experimental protocol. Frontiers in Psychiatry. 2025;Volume 16 - 2025.http://doi.org/10.3389/fpsyt.2025.1411518\u003c/li\u003e\n \u003cli\u003eMoura LA, Dias IM, Pereira LV. Prevalence and factors associated with preoperative anxiety in children aged 5-12 years. Rev Lat Am Enfermagem. 2016;24.http://doi.org/10.1590/1518-8345.0723.2708\u003c/li\u003e\n \u003cli\u003eArtemio G. Breastfeeding self-efficacy in Asia and Pacific: Scoping review. Nursing Practice Today. 2020;8(1).http://doi.org/10.18502/npt.v8i1.4489\u003c/li\u003e\n \u003cli\u003eKarbandi S, Hosseini S, Masoudi R, MAMORI GA. The effect of relaxation training on breastfeeding self-efficacy of mothers with preterm infants: A randomized clinical trial. 2014\u003c/li\u003e\n \u003cli\u003eLi HC, Lopez V, Lee TL. Psychoeducational preparation of children for surgery: the importance of parental involvement. Patient Educ Couns. 2007;65(1):34-41.http://doi.org/10.1016/j.pec.2006.04.009\u003c/li\u003e\n \u003cli\u003eHui WJ, Pikkarainen M, Nah SA, Nah SNJ, P\u0026ouml;lkki T, Wang W, et al. Parental Experiences While Waiting For Children Undergoing Surgery in Singapore. J Pediatr Nurs. 2020;52:e42-e50.http://doi.org/10.1016/j.pedn.2020.01.004\u003c/li\u003e\n \u003cli\u003eBurns-Nader S, Hernandez-Reif M, Porter M. The relationship between mothers\u0026apos; coping patterns and children\u0026apos;s anxiety about their hospitalization as reflected in drawings. Journal of child health care : for professionals working with children in the hospital and community. 2013;18.http://doi.org/10.1177/1367493512468361\u003c/li\u003e\n \u003cli\u003eCurelaru V, Muntele-Hendreș D, Diac G, Duca D-S. Children\u0026rsquo;s and Mothers\u0026rsquo; Achievement Goal Orientations and Self-Efficacy: Dyadic Contributions to Students\u0026rsquo; Well-Being. Sustainability. 2020;12(5):1785\u003c/li\u003e\n \u003cli\u003eVance AJ, Pan W, Malcolm WH, Brandon DH. Development of parenting self-efficacy in mothers of high-risk infants. Early Hum Dev. 2020;141:104946.http://doi.org/10.1016/j.earlhumdev.2019.104946\u003c/li\u003e\n \u003cli\u003eKieslinger K, Wartha O, Pollatos O, Steinacker JM, Kobel S. Parental Self-Efficacy\u0026mdash;A Predictor of Children\u0026apos;s Health Behaviors? Its Impact on Children\u0026apos;s Physical Activity and Screen Media Use and Potential Interaction Effect Within a Health Promotion Program. Frontiers in Psychology. 2021;Volume 12 - 2021.http://doi.org/10.3389/fpsyg.2021.712796\u003c/li\u003e\n \u003cli\u003eSirousfard M, Marofi M, Moeini M, Samouie F, Heidari MM. The effect of aromatherapy with Pelargonium graveolens on postoperative pain intensity in hospitalized children: A clinical randomized trial. 2014\u003c/li\u003e\n \u003cli\u003eMotahari niya H, Hojjati H. The influence of education on anxiety in mothers of children with surgery. Iranian Journal of Pediatric Nursing. 2019;5(4):49-55\u003c/li\u003e\n \u003cli\u003eGlatz T, Lippold M, Chung G, Jensen TM. A Systematic Review of Parental Self-efficacy Among Parents of School-Age Children and Adolescents. Adolescent Research Review. 2024;9(1):75-91.http://doi.org/10.1007/s40894-023-00216-w\u003c/li\u003e\n \u003cli\u003eAlbanese AM, Russo GR, Geller PA. The role of parental self‐efficacy in parent and child well‐being: A systematic review of associated outcomes. Child: care, health and development. 2019;45(3):333-63\u003c/li\u003e\n \u003cli\u003eSarabi M. The effectiveness of parent training on self-efficacy of mothers of children with autism. Journal of Fundamentals of Mental Health. 2011;13(49):84-93\u003c/li\u003e\n \u003cli\u003eJones TL, Prinz RJ. Potential roles of parental self-efficacy in parent and child adjustment: a review. Clin Psychol Rev. 2005;25(3):341-63.http://doi.org/10.1016/j.cpr.2004.12.004\u003c/li\u003e\n \u003cli\u003eAranha PR, Sams LM, Saldanha P. Impact of preoperative education program on parental anxiety: A pilot project. Archives of Medicine and Health Sciences. 2016;4(1):30-4\u003c/li\u003e\n \u003cli\u003eKerimaa H, Hakala M, Haapea M, V\u0026auml;h\u0026auml;nikkil\u0026auml; H, Serlo W, He H-G, et al. Effectiveness of a Mobile App Intervention for Preparing Preschool Children and Parents for Day Surgery: Randomized Controlled Trial. J Med Internet Res. 2023;25:e46989.http://doi.org/10.2196/46989\u003c/li\u003e\n \u003cli\u003eHou H, Li X, Song Ya, Ji Y, Sun M, Wang D, et al. Effect of interactive, multimedia-based home-initiated education on preoperative anxiety inchildren and their parents: a single-center randomized controlled trial. BMC Anesthesiology. 2023;23(1):95.http://doi.org/10.1186/s12871-023-02055-7\u003c/li\u003e\n \u003cli\u003eTabrizi JS, Seyedhejazi M, Fakhari A, Ghadimi F, Hamidi M, Taghizadieh N. Preoperative education and decreasing preoperative anxiety among children aged 8-10 years old and their mothers. Anesthesiology and pain medicine. 2015;5(4):e25036\u003c/li\u003e\n \u003cli\u003eKim J, Chiesa N, Raazi M, Wright KD. A systematic review of technology-based preoperative preparation interventions for child and parent anxiety. Can J Anaesth. 2019;66(8):966-86.http://doi.org/10.1007/s12630-019-01387-8\u003c/li\u003e\n \u003cli\u003eTural Buyuk E, Bolişik B. An Analysis of the Anxiety Levels of Mothers Who Participate in Education and Therapeutic Games About Their Children\u0026apos;s Surgeries. J Perianesth Nurs. 2018;33(3):290-5.http://doi.org/10.1016/j.jopan.2016.09.011\u003c/li\u003e\n \u003cli\u003eL\u0026ouml;\u0026ouml;f G, Liljeberg C, Eksborg S, L\u0026ouml;nnqvist PA. Interactive web-based format vs conventional brochure material for information transfer to children and parents: a randomized controlled trial regarding preoperative information. Paediatr Anaesth. 2017;27(6):657-64.http://doi.org/10.1111/pan.13142\u003c/li\u003e\n \u003cli\u003eNytun KL, Moldestad IO, Snibs\u0026oslash;er AK, Espehaug B. The effect of web-based preoperative information on parents of children who are going through elective ambulatory surgery: A systematic review and meta-analysis. Patient Educ Couns. 2022;105(12):3389-97.http://doi.org/10.1016/j.pec.2022.09.006\u003c/li\u003e\n \u003cli\u003eMahdizadeh M, Nejat Mohammad A, Behnam Vashani H, Reyhani T. Effects of supportive educational program on anxiety of mothers of children undergoing the lumbar puncture (LP). Evidence Based Care. 2016;6(2):29-38\u003c/li\u003e\n \u003cli\u003eAmiri A, Edraki M, Paran M, Sajjadi S. The impact of educational program on the anxiety and self-efficacy in mothers of the children under glaucoma surgery: a randomized controlled trial. Pharmacophore. 2017;8(0-2017):0-\u003c/li\u003e\n \u003cli\u003eChang SF, Hung CH, Hsu YY, Liu Y, Wang TN. The Effectiveness of Health Education on Maternal Anxiety, Circumcision Knowledge, and Nursing Hours: A Quasi-Experimental Study. The journal of nursing research : JNR. 2017;25(4):296-303.http://doi.org/10.1097/jnr.0000000000000177\u003c/li\u003e\n \u003cli\u003ePriyadarshini S, Agarwala S, Priya H, Jain V, Goel P, Dhua A, et al. Easing Parental Worries: A Systematic Review and Network Meta-analysis on Preoperative Education Methods for Reducing Anxiety in Parents of Children Undergoing Surgery. J Indian Assoc Pediatr Surg. 2025;30(4):427-37.http://doi.org/10.4103/jiaps.jiaps_276_24\u003c/li\u003e\n \u003cli\u003eFonseca A, Qian D, Forbes T, Li BS, Lee C, Burdsall K, et al. Reducing Preoperative Caregiver Anxiety With Virtual Reality: A Pragmatic, Randomized Controlled Study. J Patient Exp. 2024;11:23743735231220190.http://doi.org/10.1177/23743735231220190\u003c/li\u003e\n \u003cli\u003eLuengo TD, Rivas AB, Loureido E, Vargas E. Reducing preoperative anxiety in parents of surgical patients. Heliyon. 2023;9(5):e15920.http://doi.org/10.1016/j.heliyon.2023.e15920\u003c/li\u003e\n \u003cli\u003eCarlsson R, Henningsson R. Visiting the Operating Theatre Before Surgery Did Not Reduce the Anxiety in Children and Their Attendant Parent. Journal of Pediatric Nursing. 2017;38.http://doi.org/10.1016/j.pedn.2017.09.005\u003c/li\u003e\n \u003cli\u003eBandura A. Self-efficacy: toward a unifying theory of behavioral change. Psychol Rev. 1977;84(2):191-215.http://doi.org/10.1037//0033-295x.84.2.191\u003c/li\u003e\n \u003cli\u003eBandura A. Social foundations of thought and action. Englewood Cliffs, NJ. 1986;1986(23-28):2\u003c/li\u003e\n \u003cli\u003eBandura A. Self-efficacy: The exercise of control: Macmillan; 1997.\u003c/li\u003e\n \u003cli\u003eCheng NS, Chau JPC, Lo SHS, Choi KC, Hon KLE, Lam PH, et al. Effects of a self-efficacy theory-based parental education program on eczema control and parental outcomes. Pediatr Allergy Immunol. 2021;32(3):535-43.http://doi.org/10.1111/pai.13421\u003c/li\u003e\n \u003cli\u003ePiro SS, Ahmed HM. Impacts of antenatal nursing interventions on mothers\u0026apos; breastfeeding self-efficacy: an experimental study. BMC Pregnancy Childbirth. 2020;20(1):19.http://doi.org/10.1186/s12884-019-2701-0\u003c/li\u003e\n \u003cli\u003eTseng JF, Chen SR, Au HK, Chipojola R, Lee GT, Lee PH, et al. Effectiveness of an integrated breastfeeding education program to improve self-efficacy and exclusive breastfeeding rate: A single-blind, randomised controlled study. Int J Nurs Stud. 2020;111:103770.http://doi.org/10.1016/j.ijnurstu.2020.103770\u003c/li\u003e\n \u003cli\u003eAl-Shorman NA, Atiyeh H, Kassab M, Al-Rjoub SF. Effects of an educational program on self-efficacy towards type 1 diabetes mellitus disease among parents and adolescents in Jordan. J Pediatr Nurs. 2023;71:66-72.http://doi.org/10.1016/j.pedn.2023.03.011\u003c/li\u003e\n \u003cli\u003eRazi T, Shamsi M, Khorsandi M, Roozbehani N, Ranjbaran M. Education and self-efficacy of mothers regarding alerting signs in children less than five years in Arak, Iran. 2016\u003c/li\u003e\n \u003cli\u003eColom F. Keeping therapies simple: psychoeducation in the prevention of relapse in affective disorders. The British Journal of Psychiatry. 2011;198(5):338-40\u003c/li\u003e\n \u003cli\u003eChien WT, Lee IY. The mindfulness-based psychoeducation program for Chinese patients with schizophrenia. Psychiatric Services. 2013;64(4):376-9\u003c/li\u003e\n \u003cli\u003eMoazeni Z, Miri M, Sharifzadeh G, Behdani S. The relationship between self-efficacy, trust in God, and anxiety in mothers of hospitalized children in Valiasr Hospital of Birjand. Modern Care Journal. 2014;11(3)\u003c/li\u003e\n \u003cli\u003eToosi M, Akbarzadeh M, Ghaemi Z. The Effect of Relaxation on Mother\u0026apos;s Anxiety and Maternal-Fetal Attachment in Primiparous IVF Mothers. J Natl Med Assoc. 2017;109(3):164-71.http://doi.org/10.1016/j.jnma.2017.03.002\u003c/li\u003e\n \u003cli\u003eRen J, Li X, Chen S, Chen S, Nie Y. The Influence of Factors Such as Parenting Stress and Social Support on the State Anxiety in Parents of Special Needs Children During the COVID-19 Epidemic. Front Psychol. 2020;11:565393.http://doi.org/10.3389/fpsyg.2020.565393\u003c/li\u003e\n \u003cli\u003eAroniada P, Gerogianni G, Stamou A, Zaka M, Tsoulou V, Tsami A, et al. State, Trait Anxiety and Insomnia in Hospitalized Patients With Cardiovascular Disease. Acta Inform Med. 2025;33(2):129-34.http://doi.org/10.5455/aim.2025.33.129-134\u003c/li\u003e\n \u003cli\u003eBrajer-Luftmann B, Mardas M, Stelmach-Mardas M, Lojko D, Batura-Gabryel H, Piorunek T. Association between Anxiety, Depressive Symptoms, and Quality of Life in Patients Undergoing Diagnostic Flexible Video Bronchoscopy. Int J Environ Res Public Health. 2021;18(19).http://doi.org/10.3390/ijerph181910374\u003c/li\u003e\n \u003cli\u003eHashemi SB, Amirfakhraei A, Mosallanezhad M, Amiri A. The effect of education on anxiety and self-efficacy in mothers of 1-3-year-old children under cochlear implant surgery, 2018: a randomized controlled clinical trial. Revista Latinoamericana de Hipertensi\u0026oacute;n. 2019;14(1):8-14\u003c/li\u003e\n \u003cli\u003eCastellano-Rioja C. Investigating the Effect of Providing Required Training to Mothers of Children with Surgery and Its Effect on Mothers\u0026apos; Anxiety. Journal of Integrative Nursing and Palliative Care. 2025;6(1):7-11.http://doi.org/10.51847/m0J08PS92O\u003c/li\u003e\n \u003cli\u003eHan H, Chen C, Sheng R, Wang S. Psychological intervention based on cognitive behavioral therapy for patients with orthopedic surgical anxiety. Medicine. 2024;103(35):e39401.http://doi.org/10.1097/md.0000000000039401\u003c/li\u003e\n \u003cli\u003eKhanipour H. Thought control strategies and trait anxiety: predictors of pathological worry in non-clinical sample. International Journal of Behavioral Sciences. 2011;5(2):173-8\u003c/li\u003e\n \u003cli\u003eMahram B. Standardization of Spielberger\u0026rsquo;s test anxiety inventory in Mashhad. Tehran: Allameh Tabatabaei University. 1994:76\u003c/li\u003e\n \u003cli\u003eGanji K, Niusha, B., Hedayati, F. The effect of creativity training to mothers on creativity of their preschool children. Journal of Innovation and Creativity in Human Science. 2012;2(2):71-93\u003c/li\u003e\n \u003cli\u003eBrown R, Gerbarg PL. The Healing Power of the Breath: Simple Techniques to Reduce Stress and Anxiety, Enhance Concentration, and Balance Your Emotions: Shambhala; 2012.\u003c/li\u003e\n \u003cli\u003eOlson N. Preoperative anxiety in children and their parents: the parents\u0026rsquo; perspective of the anxiety experienced by a child prior to surgery, the emotional effect on the parent and the care a nurse can provide: a qualitative study. 2018\u003c/li\u003e\n \u003cli\u003eSarkhel S, Singh OP, Arora M. Clinical Practice Guidelines for Psychoeducation in Psychiatric Disorders General Principles of Psychoeducation. Indian Journal of Psychiatry. 2020;62(Suppl 2):S319-S23.http://doi.org/10.4103/psychiatry.IndianJPsychiatry_780_19\u003c/li\u003e\n \u003cli\u003eKumar V, Yadav P, Bangarwa N, Budhwar D, Kumar P, Arora V. A Randomized Controlled Trial to Assess the Efficacy of a Pre-operative Virtual Operation Theatre Tour on Anxiety and Patient Satisfaction in Adults Undergoing Elective Surgery. Cureus. 2022;14(12):e32337.http://doi.org/10.7759/cureus.32337\u003c/li\u003e\n \u003cli\u003eAbuatiq A. Patients\u0026rsquo; and Health Care Providers\u0026rsquo; Perception of Stressors in the Intensive Care Units. Dimensions of Critical Care Nursing. 2015;34(4):205-14.http://doi.org/10.1097/dcc.0000000000000121\u003c/li\u003e\n \u003cli\u003eMhango W, Crowter L, Michelson D, Gaysina D. Psychoeducation as an active ingredient for interventions for perinatal depression and anxiety in youth: a mixed-method systematic literature review and lived experience synthesis. BJPsych Open. 2023;10(1):e10.http://doi.org/10.1192/bjo.2023.614\u003c/li\u003e\n \u003cli\u003eCuesta-Lozano D, Lopez-Alcalde J, Castro Molina FJ, Garc\u0026iacute;a Sastre M, Maravilla Herrera P, Muriel A, et al. Psychoeducation for the parents of people with severe mental illness: Cochrane Database Syst Rev. 2022 Jun 16;2022(6):CD014532. doi: 10.1002/14651858.CD014532. eCollection 2022.\u003c/li\u003e\n \u003cli\u003eBrosch T, Scherer KR, Grandjean D, Sander D. The impact of emotion on perception, attention, memory, and decision-making. Swiss Med Wkly. 2013;143:w13786.http://doi.org/10.4414/smw.2013.13786\u003c/li\u003e\n \u003cli\u003eYamamori Y, Robinson OJ. Computational perspectives on human fear and anxiety. Neurosci Biobehav Rev. 2023;144:104959.http://doi.org/10.1016/j.neubiorev.2022.104959\u003c/li\u003e\n \u003cli\u003eBrooks SK, Weston D, Wessely S, Greenberg N. Effectiveness and acceptability of brief psychoeducational interventions after potentially traumatic events: A systematic review. Eur J Psychotraumatol. 2021;12(1):1923110.http://doi.org/10.1080/20008198.2021.1923110\u003c/li\u003e\n \u003cli\u003eAlemany-Arrebola I, Rojas-Ruiz G, Granda-Vera J, Mingorance-Estrada \u0026Aacute;C. Influence of COVID-19 on the Perception of Academic Self-Efficacy, State Anxiety, and Trait Anxiety in College Students. Frontiers in Psychology. 2020;Volume 11 - 2020.http://doi.org/10.3389/fpsyg.2020.570017\u003c/li\u003e\n \u003cli\u003ePereyra Girardi C, Mur J, Rivas A, Trueba D. The Relationship between Self-Efficacy, State-Trait Anxiety and Cognitive Test Anxiety: A Study among University Students in Argentina. Psychological Thought. 2022;15:75-94.http://doi.org/10.37708/psyct.v15i2.664\u003c/li\u003e\n \u003cli\u003eBispo J\u0026uacute;nior JP. Social desirability bias in qualitative health research. Rev Saude Publica. 2022;56:101.http://doi.org/10.11606/s1518-8787.2022056004164\u003c/li\u003e\n \u003cli\u003eArtino AR, Jr. Academic self-efficacy: from educational theory to instructional practice. Perspect Med Educ. 2012;1(2):76-85.http://doi.org/10.1007/s40037-012-0012-5\u003c/li\u003e\n \u003cli\u003eBarani M, Hassani L, Ghanbarnejad A, Molavi MA. Effect of Educational Intervention Based on Self-Efficacy Theory on the Caring Behaviour of Mothers Who Have Children With Cancer. J Mother Child. 2023;27(1):93-101.http://doi.org/10.34763/jmotherandchild.20232701.d-22-00065\u003c/li\u003e\n \u003cli\u003eCarosi Arcangeli I, Ciavatta V, Celia G. Self-efficacy among parents of children and adolescents with type 1 diabetes: a systematic review. Diabetes Research and Clinical Practice. 2025;229:112939.http://doi.org/https://doi.org/10.1016/j.diabres.2025.112939\u003c/li\u003e\n \u003cli\u003eWadsworth LP, Hayes-Skelton SA. Exploring perceived control, a low-control task, and a brief acceptance intervention in a low and high transdiagnostic anxiety sample. Neurology, Psychiatry and Brain Research. 2020;35:1-9.http://doi.org/https://doi.org/10.1016/j.npbr.2019.11.001\u003c/li\u003e\n \u003cli\u003eKeeton CP, Perry-Jenkins M, Sayer AG. Sense of control predicts depressive and anxious symptoms across the transition to parenthood. J Fam Psychol. 2008;22(2):212-21.http://doi.org/10.1037/0893-3200.22.2.212\u003c/li\u003e\n \u003cli\u003eBassi G, Mancinelli E, Di Riso D, Salcuni S. Parental Stress, Anxiety and Depression Symptoms Associated with Self-Efficacy in Paediatric Type 1 Diabetes: A Literature Review. Int J Environ Res Public Health. 2020;18(1).http://doi.org/10.3390/ijerph18010152\u003c/li\u003e\n \u003cli\u003eElfstr\u0026ouml;m S, Rosengren A, Andersson R, Engelbrektsson J, Isaksson A, Meregalli M, et al. Evaluating a program to prevent anxiety in children of anxious parents: a randomized controlled trial. Journal of Child Psychology and Psychiatry. 2025;66(9):1345-56.http://doi.org/https://doi.org/10.1111/jcpp.14151\u003c/li\u003e\n \u003cli\u003eMcLeish J, Redshaw M. Mothers\u0026apos; accounts of the impact on emotional wellbeing of organised peer support in pregnancy and early parenthood: a qualitative study. BMC Pregnancy Childbirth. 2017;17(1):28.http://doi.org/10.1186/s12884-017-1220-0\u003c/li\u003e\n \u003cli\u003eL\u0026eacute;niz-Maturana L, Vilaseca R, Leiva D. Maternal self-efficacy and emotional well-being in Chilean adolescent mothers: the relationship with their children\u0026apos;s social-emotional development. PeerJ. 2022;10:e13162.http://doi.org/10.7717/peerj.13162\u003c/li\u003e\n \u003cli\u003eBuchanan CM, Gangel MJ, McCurdy AL, Fletcher AC, Buehler C. Parental Self-Efficacy and Physiological Responses to Stress among Mothers of Early Adolescents. J Youth Adolesc. 2022;51(4):643-58.http://doi.org/10.1007/s10964-022-01577-6\u003c/li\u003e\n \u003cli\u003eVongkiatkajorn K, Brown EA, Donaldson A, Rich V, Paterson R, Kenardy J, et al. The effect of a parental preparation video (Take5) on child and parent anxiety during anaesthetic induction: a protocol for a randomised controlled trial. Trials. 2023;24(1):446.http://doi.org/10.1186/s13063-023-07480-0\u003c/li\u003e\n \u003cli\u003eRatzan SC, Parker RM. Health Literacy\u0026mdash;Identification and Response. Journal of Health Communication. 2006;11(8):713-5.http://doi.org/10.1080/10810730601031090\u003c/li\u003e\n \u003cli\u003eRudd RE, Comings JP, Hyde JN. Leave no one behind: improving health and risk communication through attention to literacy. J Health Commun. 2003;8 Suppl 1:104-15.http://doi.org/10.1080/713851983\u003c/li\u003e\n \u003cli\u003eBain M, Park S, Zaidi A, Atif N, Rahman A, Malik A, et al. Social Support and Spousal Relationship Quality Improves Responsiveness among Anxious Mothers. Child Psychiatry Hum Dev. 2024.http://doi.org/10.1007/s10578-024-01702-5\u003c/li\u003e\n \u003cli\u003eLebert-Charron A, Wendland J, Vivier-Prioul S, Boujut E, Dorard G. Does Perceived Partner Support Have an Impact on Mothers\u0026rsquo; Mental Health and Parental Burnout? Marriage \u0026amp; Family Review. 2022;58(4):362-82.http://doi.org/10.1080/01494929.2021.1986766\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 3 are available in the supplementary files section\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"preoperative anxiety, Parental self-efficacy, Psychoeducation, Pediatric surgery, Cognitive behavioral therapy","lastPublishedDoi":"10.21203/rs.3.rs-8703884/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8703884/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003ePreoperative parental anxiety is a major clinical concern, affecting up to 74% of parents and serving as a primary predictor of adverse child outcomes, including increased postoperative pain and delirium. While information transfer is common, there is a critical gap in interventions that simultaneously target anxiety reduction and the enhancement of Parental Self-Efficacy (PSE). This study evaluated the effect of a dual-target psychoeducational program on preoperative anxiety and PSE in mothers of children undergoing surgery.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis parallel-group randomized controlled trial included 70 mothers (35 intervention, 35 control) of children aged\u0026thinsp;\u0026lt;\u0026thinsp;7 years scheduled for first-time elective urological surgery at a specialized pediatric center in Iran. The intervention group received a three-session, CBT-based psychoeducation program integrating structured surgical information, cognitive restructuring, and progressive muscle relaxation. The control group received standard care plus a brief informational session. Outcomes were measured using the Spielberger State-Trait Anxiety Inventory (STAI) and the Dumka Parental Self-Efficacy Measure (PSAM) at baseline and immediately before surgery. Data were analyzed using ANCOVA, adjusting for baseline scores.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe intervention group demonstrated significantly greater reductions in \u003cb\u003eState Anxiety\u003c/b\u003e (adjusted mean difference = \u0026minus;\u0026thinsp;12.34, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001, Cohen\u0026rsquo;s d\u0026thinsp;=\u0026thinsp;0.71) and \u003cb\u003eTrait Anxiety\u003c/b\u003e (adjusted mean difference = \u0026minus;\u0026thinsp;11.26, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001, d\u0026thinsp;=\u0026thinsp;0.72) compared to the control group. Furthermore, mothers in the intervention group showed a significantly greater increase in \u003cb\u003eParental Self-Efficacy\u003c/b\u003e (adjusted mean difference\u0026thinsp;=\u0026thinsp;+\u0026thinsp;7.80, P\u0026thinsp;=\u0026thinsp;0.024, d\u0026thinsp;=\u0026thinsp;0.48)1617. Within-group improvements were significant for both groups (all P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), though the structured program was statistically superior in all domains.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThis study demonstrates that our brief, structured psychoeducational intervention\u0026mdash;integrating cognitive restructuring, progressive muscle relaxation, and structured information\u0026mdash;robustly addresses both negative emotional states and positive adaptive resources in mothers. The dual-target approach significantly enhances maternal psychological competence and self-efficacy. Given its efficacy, low cost, and non-pharmacological nature, we recommend its integration into routine family-centered preoperative care to improve maternal well-being and optimize pediatric surgical outcomes.\u003c/p\u003e","manuscriptTitle":"The effect of psychoeducation on preoperative anxiety and parental self-efficacy in mothers of children undergoing surgery ","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-09 07:08:15","doi":"10.21203/rs.3.rs-8703884/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2b6b171a-7d98-4cf3-aabb-dd1e5fc22174","owner":[],"postedDate":"February 9th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-06T12:24:59+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-09 07:08:15","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8703884","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8703884","identity":"rs-8703884","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}