The effect of DECO-MOM mobile application for a prenatal environmental health program on environmental health behaviors

The effect of DECO-MOM mobile application for a prenatal environmental health program on environmental health behaviors | 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 DECO-MOM mobile application for a prenatal environmental health program on environmental health behaviors Haekyung Jo, Hyun Kyoung Kim This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4303622/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 04 Mar, 2025 Read the published version in BMC Pregnancy and Childbirth → Version 1 posted 4 You are reading this latest preprint version Abstract Background: The DECO-MOM mobile program was developed to enhance prenatal environmental health behaviors among pregnant women, addressing the challenges of climate change and environmental pollution. This study aimed to explore the effects of the DECO-MOM app on personal and community health behaviors, quality of life, subjective health status, depression, anxiety, and e-learning satisfaction, guided by the revised protection motivation theory. Methods/Design: This non-randomized controlled study employed a pre-post-test design with experimental and control groups. The study analyzed data from 31 participants in the experimental group and 34 in the control group after a four-week mobile application intervention conducted from September 26 to October 24, 2023, in three cities in South Korea. Results: The experimental group demonstrated significant improvements in personal environmental health behaviors (p = .003), community environmental health behaviors (p = .001), quality of life (p = .043), and e-learning satisfaction (p = .005) compared to the control group. Significant increases were observed in subcategories such as lifestyle (p = .005), dust management (p < .001), reduction efforts (p = .001), involvement (p = .007), recycling (p = .005), reuse (p = .035), content satisfaction (p < .001), and communication satisfaction (p = .039). However, no significant increases were found in subjective health status, depression, or anxiety. Discussion: The integration of tailored educational content delivered via mobile technology presents a viable strategy for prenatal health promotion. Future studies should explore the long-term impacts and scalability of such mobile-based interventions. Trial registration : Trial registration Number: KCT0007725, Registered September 22, 2022. Prospectively registered. Environmental health Women Pregnancy Health behaviors Mobile application Figures Figure 1 Figure 2 Background The unfolding crisis of climate change presents unprecedented challenges to public health, particularly for vulnerable populations such as pregnant women. The American National Association for Environmental Health has recognized environmental health as encompassing the effects of physical, chemical, biological, and psychosocial factors on human health, a definition that becomes increasingly pertinent as we face escalating environmental risks [ 1 ]. Pregnant women are of particular concern due to their heightened vulnerability to adverse outcomes from environmental exposures [ 2 , 3 ]. Climate change exacerbates the spectrum of environmental hazards, from pollution to heatwaves, posing significant threats to maternal and fetal health including neonatal stress and preterm birth [ 4 ]. The need for effective interventions is underscored by a growing body of evidence linking environmental pollutants with adverse pregnancy outcomes, including preterm birth, low birth weight, and developmental issues in offspring [ 2 , 3 ]. Environmental pollution and environmental health factors such as fine particulate matter, air pollution, heavy metals, and chemicals have been shown to contribute to depression, anxiety, and stress in pregnant women [ 5 ]. This situation calls for innovative solutions that can empower pregnant women to navigate physical and psychological risks effectively. Awareness of harmful substances during pregnancy motivates environmental health behaviors [ 6 ]. Research on environmental health interventions for pregnant women is scarce. Providing information about exposure to endocrine disruptors in pregnant women's diets increased environmental behaviors [ 7 ]. In-person environmental health childbirth classes increased environmental awareness, intention, and behavior among pregnant women [ 6 ]. Childbirth education using virtual Zoom meetings and cartoon booklets also increased environmental health vulnerability awareness, self-efficacy, and community health behaviors [ 8 ]. It is imperative to consider the potential of mobile health (mHealth) interventions in bridging the gap between environmental health risks and protective health behaviors from environmental hazards. The advent of mHealth offers a promising avenue for enhancing health literacy and facilitating proactive health management, especially in contexts where traditional healthcare access may be limited or where environmental risks are under-recognized [ 9 ]. A mobile application, the quintessential mHealth, is needed to leverages the ubiquity and accessibility of mobile technology to educate pregnant women about environmental toxins and promote adaptive health behaviors. However, we could not found any mobile application for pregnant women regarding climate change and environmental health. Therefore, the protocol for mobile application named Deep ECOlogy MOM application (DECO-MOM app) interventions was developed by draws upon the revised protection motivation theory (rPTM) as the theoretical foundation [ 10 ]. Rogers suggests that perception of the severity, susceptibility, response efficacy, self-efficacy, costs, and benefits to health threats can motivate protective health behaviors [ 11 ]. By situating the DECO-MOM app within the broader discourse on environmental health, climate change, and digital health innovations, this introduction sets the stage for a nuanced exploration of how technology-driven interventions can make a tangible difference in the lives of pregnant women, offering them tools to safeguard their health and that of their fetus in an increasingly complex environmental landscape. Therefore, this study aimed to explore the effects of DECO-MOM app on environmental health behavior (personal and community health behavior), psychological health (quality of life, subjective health status, depression, and anxiety,), and e-learning satisfaction (Fig. 1 ). Methods Study design This study was non-randomized controlled study with experimental and control group pre-post-test design. This study adhered to the Transparent Reporting of Evaluations with Nonrandomized Designs (TREND) guidelines [ 12 ]. The study protocol was registered in the Korean Clinical Research Information Service at September 22, 2022 (KCT0007725: https://cris.nih.go.kr/cris/search/detailSearch.do?seq=22378&status=5&seq_group=22378&search_page=M ) [ 13 ]. Setting Participants were recruited from three the public health care centers of Chuncheon, Jeonju, and Gongju cities in Gangwon, Jeonrabuk, and Chungcheongnam Province respectively in South Korea. The public centers provided maternal-child healthcare service operating birth education to pregnant women. Researchers were permitted for study and data collection from the healthcare centers and participated prenatal education as lecturers. Researchers provided a mobile application QR code of website address for experimental group after written consent to participate the study and treatment as usual (TAU) education program for the control group. Inclusion and exclusion criteria The participants were included as follow; 1) pregnant women in the gestational aged 4–36 weeks 2) aged over 20 years, 3) have a smart gadget, and 4) Korean language literacy. The exclusion criteria were 1) hospitalized due to physical or psychological health problems and 2) currently receiving medical treatment due to fetal or maternal disease. Allocation The convenience sampling was used allocate 1:1 parallel allocation. The participants recruited from Chuncheon city were allocated to the control group applied only TAU and the participants from Jeonju and Gongju cities in South Korea were allocated to the experimental group applied mobile application. These three cities were middle sized urban-rural cities and similar socioeconomic and cultural status to avoid potential heterogeneous bias. The researcher contacted the pregnant women and explain the study's purpose, procedure, and benefits. The pre-test was performed before mobile application and TAU, intervened for 4 weeks, and post-test just after intervention between September 26 and October 24, 2023 (Fig. 2 ). Sample size The G*Power 3.1.4.9 [ 22 ] calculated the sample size as 32 and 32 in both groups with designated a one-tailed test, the independent t-test, 0.59 effect size (f), 0.75 power, 0.05 significance level, and a 1:1 allocation ratio [ 23 ]. The effect size (Cohen’s d) was calculated by 18.45 ± 13.13 and 9.68 ± 8.24, resulting in a Cohen’s d of .59 according to the previous study [ 6 ]. The sampling was 35 and 35 participants in the both group considering conservative rate of 10%. Four participants among the mobile group the reasons of another schedules of hospital visit or house chores. The participants of 31 in the experimental group and 34 in the control were analyzed. The adherence rates for experimental and control group were 88.57% and 97.14%. Intervention Intervention group The DECO-MOM intervention was designed as a four-week program, delivered via a mobile application, aimed at educating pregnant women on the environmental toxins and promoting adaptive environmental health behaviors. the Android system was used to develop the application. Grounded in the revised protection motivation theory (rPMT), the program operationalizes the theory’s constructs—severity, susceptibility, response efficacy, self-efficacy, costs, and benefits [ 11 ]—into weekly themes that progressively aimed to: enhance understanding of environmental risks, motivate protective health behaviors, balance the perceived benefits against costs of such behaviors, and empower both individual and communal action towards environmental health. This intervention was supported by weekly telephonic follow-ups by a research assistant and facilitated through the widespread KakaoTalk social networking service in Korea, ensuring participant engagement and adherence to the program protocols. The "DECO-MOM environmental prenatal health program" structured as a mobile application designed to educate pregnant women on climate change and environmental health over a four-week period. Each week targets different aspects of environmental health through varied educational methods to engage participants. In the first week, the focus was on raising awareness regarding the reproductive health problems of maternal, fetus, and child (severity). The potential harms from chemicals, electromagnetic waves, and unsafe foods, along with discussing reproductive and general health issues (susceptibility). This was delivered through an orientation session, cartoons for visual learning, explanations for depth understanding, a 5-minute video developed by a researcher, and a question-and-answer segment for interaction, each segment lasting 30 minutes. The second week aimed to empower women with knowledge on avoiding environmental toxins and enhancing their health and that of their fetus (response efficacy), addressing topics such as empowering preventive judgment and control (self-efficacy). A 5-minute video developed by a researcher, cartoons, and explanations were used, followed by a question-and-answer session, mirroring the first week's duration and teaching methods. Week three discussed the trade-offs and benefits of making lifestyle adjustments, focusing on the positive (benefits) and negative aspects (costs) of unhealthy environmental behaviors and highlighting the psychological and physical gains from healthier choices. The session used a 5-minute video developed by a researcher, cartoons, explanations, and a Q&A format for delivery, each lasting 30 minutes. The final week broadens the scope to include changes in personal and community behavior to avoid climate change and exposure to environmental toxin, touching on lifestyle adjustments and community engagement in environmental health practices (motivated health behaviors). It leveraged a 5-minute video developed by a researcher, cartoons, explanations, a question-and-answer segment, introduces a trophy system likely for motivation or achievement recognition, and concludes with a wrap-up session. Each method was designed to last for 30 minutes. Overall, the program was meticulously designed to educate, engage, and empower pregnant women regarding climate change and environmental health, utilizing a blend of educational methods to cater to different learning preferences and effectively communicate complex information (Table 1 ). Control group For the control group, Treatment As Usual (TAU) was administered through in-person instruction over a four-week period. These sessions took place in the maternity class room at the public health center, each lasting two hours and led by two professors specializing in women's health and a midwife. The curriculum covered a range of topics including: 1) comprehension of pregnancy and fetal development; 2) managing pain during childbirth, alongside techniques for relaxation and breathing throughout labor; 3) care after childbirth and breastfeeding practices; and 4) caring for a newborn infant. Measurements The questionnaires were distributed via online survey using a Naver Form respectively through the KakaoTalk messenger. The online survey eook from 10 to 15 minutes. Online gift worth 7 dollars was provided to the participants twice after the pre- and post-test. Primary outcomes Personal environmental health behavior Personal environmental health behavior was measured using the Women's Environmental Health Behavior (WEHB) scales [ 14 ]. The WEHB consists of four factors: 7 lifestyle, 4 personal hygiene, 3 diet, and 3 dust-related behaviors (total 14 items). The WEHB was measured by a Likert scale, ranging from 1 (not at all) to 5 (strongly agree). Total scores ranged from 14 to 60, the higher score meaned the higher personal environmental behavior. The Cronbach’s alpha values for internal consistency reliability were .90 in original scare and .88 in this study. Community environmental health behavior Community environmental health behavior was measured using the Women's Environmental Health Behavior (WEHB) scales [ 14 ]. The WEHB consisted of four factors with 5 reduction, 5 involvement, 3 recycling, and 3 reuse behaviors (total 16 items). The WEHB was measured by a Likert scale, ranging from 1 (not at all) to 5 (strongly agree). Total scores ranged from 16 to 90, the higher score meaned the higher community environmental behavior. The Cronbach’s alpha was .90 in original scare and .89 in this study. Secondary outcomes Quality of life Quality of life was measured using the EuroQol-5D (EQ-5D) [ 15 ] and the Korean version of the EQ-5D was used [ 16 ]. The EQ-5D consists of 5 items with mobility, self-care, usual activity, pain/discomfort, anxiety/depression. The EQ-5D was measured using a Likert scale, ranging from 1 (not at all) to 4 (nearly every day). Total scores ranged from 5 to 20, with higher scores indicating lower quality of life. Cronbach’s alpha was .61 in original scare and .75 in this study. Subjective health status Subjective health status was measured using EQ-VAS was used [ 15 ] and the Korean version of the EQ-VAS was used [ 16 ]. EQ-VAS had one question of ‘The worst health you can imagine’ and numbered from 0 (the worst health respondent can imagine) to 100 (the best health respondent can imagine). When presenting data had the central tendency, it could be the mean value and the standard deviation or, if the data was skewed, the median values and the interquartile range (IQR). Depression Depression was measured using ultra short depression screener Patient Health Questionnaire (PHQ-2) [ 17 ] and the Korean version of the PHQ-2 was used [ 18 ]. A total score of 3 or greater should prompt administration of the full PHQ-9, as well as a clinical interview to determine whether a mental disorder is present. The PHQ-2 was measured using a Likert scale, ranging from 1 (not at all) to 4 (nearly every day). Total scores ranged from 4 to 8, with higher scores indicating higher depression. Cronbach’s alpha was .61 in original scare and .82 in this study. Anxiety Anxiety was measured using the General Anxiety Disorder-7 (GAD-7) [ 19 ] and the Korean version of the GAD-7 will be used [ 20 ]. The GAD-7 had seven items using a Likert scale, ranging from 1 (not at all) to 4 (nearly every day). Total scores ranged from 7 to 28, with higher scores indicating higher anxiety. Cronbach’s alpha was .97 in original scare and .85 in this study. E-learning satisfaction E-learning satisfaction was measured using the E-Learning Satisfaction Scale (eLSS) (17 items) [ 21 ]. The eLSS consisted of three factors with 8 content, 5 interface, and 4 communication (total 17 items). The eLSS was measured by a Likert scale, ranging from 1 (not at all) to 5 (strongly agree). Total scores ranged from 8 to 40, with higher scores indicating greater content satisfaction. Cronbach’s alpha for internal consistency reliability was .93 in original scare and .95 in this study. General and obstetric characteristics The general characteristics were elicited self-reported information, including age, present disease, and employment status. The obstetric characteristics included gestational age and number of children. Ethical consideration This study was approved by the Institutional Review Board of Jeonju University (jjIRB-231214-HR-2023-1014) and adhered to the Declaration of Helsinki. Statistical analysis This study used SPSS for Windows version 27.0 (IBM Corp., Armonk, NY, USA). The homogeneity test was performed using t-test and chi-square test between the two groups. Shapiro-Wilk test was used to test normality, linearity, and residual independence. The independent t-test was used for test the study hypothesis. Hypothesis 1 The mobile group would have higher scores for personal and community environmental health behaviors than the TAU group. Hypothesis 2 The mobile group would have higher scores for quality of life, subjective health status than the TAU group. Hypothesis 3 The mobile group would have lower scores for depression and anxiety than the TAU group. Hypothesis 4 The mobile group would have higher scores for e-learning satisfaction than the TAU group. Results Homogeneity Between Groups The characteristics compared include age, gestational age, number of children, present disease, employment status, personal environmental health behavior (with subcategories: lifestyle, personal goods, diet, dust), community environmental health behavior (with subcategories: reduction, involvement, recycle, reuse), quality of life, subjective health status, depression, anxiety, and e-learning satisfaction. The results indicate no significant differences between the control and experimental groups across most variables, suggesting homogeneity in terms of demographics and baseline measures (Table 2 ). Table 2 Analysis of homogeneity between groups (N = 65) Characteristics Control group (n = 34) Experimental group (n = 31) t/χ² p n (%) / M (SD) n (%) / M (SD) Age (years) 34.35 (4.22) 33.06 (4.36) 1.20 .231 Gestational age (weeks) 24.35 (7.45) 28.03 (7.79) -1.94 .057 Number of children 0.50 (0.62) 0.77 (0.96) -1.38 .170 Present disease Yes† No 9 22 11 23 0.84 .772 Employment Employed‡ Unemployed 14 17 14 20 0.11 . 746 Personal environmental health behavior Total Lifestyle Personal good Diet Dust 55.74 (13.47) 22.56 (5.36) 14.21 (4.72) 7.53 (2.57) 11.44 (3.21) 57.10 (8.35) 23.58 (3.68) 13.94 (3.49) 7.81 (2.12) 11.77 (1.27) -0.48 -0.88 0.26 -0.47 -0.51 .629 .378 .759 .639 .609 Community environmental health behavior Total Reduction Involvement Recycle Reuse 51.50 (12.01) 14.08 (3.88) 14.88 (4.10) 10.82 (3.81) 10.26 (2.64) 55.74 (10.12) 16.39 (3.93) 15.84 (3.89) 12.06 (2.11) 11.45 (2.16) 0.38 0.86 0.75 -0.62 -0.14 .705 .389 .452 .537 .888 Quality of life 7.51 (1.79) 6.65 (1.47) 1.22 .225 Subjective health status 73.12 (11.51) 67.42 (17.02) 1.36 .176 Depression 10.32 (3.85) 10.45 (3.50) -0.14 .889 Anxiety 2.76 (0.92) 3.10 (1.32) -1.18 .242 E-learning satisfaction 32.15 (6.40) 29.90 (6.08) 1.44 .153 † Anemia, cystitis, cough, gestational diabetes, headache, hemorrhoid, hyperthyroidism, hypothyroidism, hypertension, hypotension, rhinitis M, mean; SD, standard deviation. Effects of the “DECO-MOM” Prenatal Mobile Program The total score of personal environmental health behavior was significantly increased from 55.85 (SD = 6.48) in the control group to 62.32 (SD = 10.38) in the experimental group (p = .003). Subcategories as lifestyle (p = .005) and dust (p < .001) also showed significant improvements. Total scores of community environmental health behavior was significantly improved from 54.18 (SD = 5.58) in the control group to 60.48 (SD = 9.27) in the experimental group (p = .001). Improvements were noted across all subcategories; reduction (p = .001), involvement (p = .007), recycle (p = .005), and reuse (p = .035). Score of quality of life was increased in the experimental group (M = 7.53, SD = 2.03) compared to the control group (M = 6.55, SD = 1.76) (p = .043). Total score of e-learning satisfaction was increased from 57.76 (SD = 11.71) to 65.10 (SD = 8.13) significantly (p = .005). Subcategories as content satisfaction (p < .001) and communication satisfaction (p = .039) increased significantly in the experimental group compared to the control group. There were no significances in subjective health status, depression, and anxiety (Table 3 ). Table 3 Effects of “DECO-MOM” prenatal mobile program on environmental health behaviors, quality of life, depression, anxiety, and satisfaction (N = 65) Characteristics Control group (n = 34) Experimental group (n = 31) t/χ² p n (%) / M (SD) n (%) / M (SD) Personal environmental health behavior Total Lifestyle Personal good Diet Dust 55.85 (6.48) 22.68 (3.96) 14.35 (2.76) 8.24 (1.72) 10.59 (1.50) 62.32 (10.38) 25.82 (4.77) 15.00 (3.52) 9.03 (2.47) 12.48 (1.98) -3.04 -0.82 0.26 -1.51 -4.37 .003 .005 .411 .134 < .001 Community environmental health behavior Total Reduction Involvement Recycle Reuse 54.18 (5.58) 16.03 (1.56) 15.74 (2.71) 11.38 (1.81) 11.03 (1.66) 60.48 (9.27) 17.71 (3.35) 18.00 (3.82) 12.81 (2.12) 11.97 (1.85) -3.38 -2.62 -2.77 -2.92 -2.15 .001 .011 .007 .005 .035 Quality of life 6.55 (1.76) 7.53 (2.03) -2.06 .043 Subjective health status 71.29 (20.54) 77.42 (21.12) -1.18 .241 Depression 10.85 (3.06) 9.77 (2.85) 1.45 .151 Anxiety 2.62 (0.95) 2.97 (1.27) -2.25 .213 E-learning satisfaction Total Content Interface Communication 57.76 (11.71) 26.35 (5.62) 17.85 (4.40) 13.56 (3.11) 65.10 (8.13) 31.10 (3.78) 18.97 (3.06) 15.03 (2.44) -2.90 -3.94 -1.17 -2.11 .005 < .001 .245 .039 M, mean; SD, standard deviation. Discussion In this study, the application of the DECO-MOM app for environmental health of pregnant women increased environmental health behaviors in personal and community aspects, quality of life, and increased satisfaction with the app, while psychological health, such as quality of subjective health status, depression, and anxiety, did not show statistically significant changes. Therefore, study hypothesis 1 and 4 were supported, however, hypothesis 2 and 3 were not supported. The DECO-MOM application, by effectively enhancing personal and community environmental health behaviors, illustrated the viability of leveraging technology to disseminate critical health information and foster behavioral change at a personal and communal level. Furthermore, this study's findings on e-learning satisfaction provided insights applicable to health education contexts, including the elements critical to user satisfaction and engagement in digital learning environments. The effectiveness of this study is attributed to the rPMT, which recognizes that pregnant women are vulnerable to climate change and environmental pollution and perceive real risks to their health [ 11 ]. Personal lifestyle and health behaviors to prevent micro dust triggered health behavior response efficacy, and community environmental health behaviors of reducing, engaging, recycling, and reusing stimulated self-efficacy to respond to climate change [ 11 ]. Climate change encompasses a broad spectrum of environmental alterations, including rising temperatures, increased exposure to pollutants, and the proliferation of vector-borne diseases, all of which pose significant health risks. For pregnant women, these environmental stressors can lead to adverse pregnancy outcomes, such as preterm birth, low birth weight, birth defects [ 24 ], and developmental issues in children [ 25 ]. The susceptibility of pregnant women to these environmental factors was attributed to physiological changes during pregnancy that can alter their response to heat, pollutants, and infectious agents. The intrauterine environment, crucial for fetal development, was sensitive to external environmental conditions, making it imperative to protect maternal health from the adverse effects of climate change [ 25 ]. The results of positive e-learning satisfaction reported by participants further validate the design and content delivery approach of the DECO-MOM program. This satisfaction is indicative of the program's ability to engage users effectively, a critical factor in the success of any health intervention [ 26 ]. This study showed that content satisfaction and communication satisfaction were effective, but interface satisfaction was not, suggesting that it is necessary to use more convenient and attractive technologies for users when developing environmental health apps. The positive reception of the app's content and communication suggests that user-centered design principles, which prioritize the needs and preferences of the target population, are essential in the development of effective mHealth interventions. While previous studies in digital healthcare for pregnant women have shown benefits on depression [ 28 ], anxiety [ 28 , 29 ], and subjective well-being [ 30 ], this study did not show significant psychological effects. The lack of effect on psychological health outcomes in this study could be attributed to the lack of social support during app use. Communication was noted as a key factor affecting the sustainability of mobile apps, so future research should incorporate this factor into the design and evaluation of tools [ 28 ]. Mental health experts ought to be strategically involved in mitigating the adverse effects of climate change by delivering essential psychological assistance and incorporating mental health aspects into the broader framework of climate resilience strategies [ 31 ]. The low levels of subjective well-being and happiness globally were linked to exposure to environmental factors during pregnancy [ 32 ]. Implementing mobile health interventions that focus on environmental health during pregnancy could enhance healthcare quality. Additionally, these interventions can encourage women to take a more active role in managing their own health, ultimately leading to empowered attitudes, healthier environmental health behaviors [ 32 ]. This study had several limitations. Firstly, this study was a small-sized experimental study of pregnant women in three Korean cities the generalizability of the study is limited. There was risk of selection bias of a quasi-experimental study due to difficulties in randomizing subjects as planned in the protocol. Secondly, this study did not consider health equity because it did not include digital literacy or migrant women, because the study only selected participants who could use digital devices and speak Korean. Thirdly, the researchers provided a mobile app and encouraged participation with social networking services, but were unable to provide individualized social support, which did not have a positive impact on mental health. Fourthly, we measured outcomes immediately after the 4-week app implementation, but did not follow up to measure the long-term impact of the app. The DECO-MOM study, through its focus on leveraging a mobile application for prenatal environmental health education, offers several important implications for public health policy, and future research in the domain of environmental health and mHealth interventions. The DECO-MOM study underscore the critical need for incorporating environmental health solutions into public health strategies, especially those aimed at vulnerable populations like pregnant women. The study also indicates that discussing environmental health risks and mitigation strategies should be an integral part of prenatal care. The DECO-MOM study lays the groundwork for future research in key areas. There is a need for further studies to explore the long-term effects of prenatal environmental health interventions on maternal and neonatal outcomes. Such research could provide deeper insights into the potential for mHealth tools to contribute to reducing adverse birth outcomes associated with environmental exposures. In conclusion, the DECO-MOM study not only demonstrates the effectiveness of a mobile application in improving environmental health behaviors and e-learning satisfaction among pregnant women but also reflects the potential of digital health interventions in enhancing environmental health outcomes. Trial status Registered before recruiting. Abbreviations DECO-MOM: DEep Ecology-MOM GAD-7: general anxiety disease e-LSS: e-learning satisfaction scale EQ-5D: European quality of life 5-dimension EQ-VAS: European quality of life Visual Analogue Scale PHQ-2: Patient Health Questionnaire-2 QR: quick response rPMT: the revised protection motivation theory TAU : Treatment As Usual TREND: Transparent Reporting of Evaluations with Nonrandomized Designs WEHB: women's environmental health behavior Declarations Ethics approval This study was reviewed by the Institutional Review Board of Institutional Review Board of Jeonju University (jjIRB-231214-HR-2023-1014) and adhered to the Declaration of Helsinki. Consent to participate Participants completed written consent. Consent for publication Not applicable. Availability of data and materials The data that support the findings of this study are available from the corresponding author upon reasonable request. Competing interests The author declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Funding This work was supported by the National Research Foundation of Korea (NRF) Grant funded by the Korea government (MIST) (RS-2023-00239284). Author contributions HKK participated in the conception, design of the study HKK and JHK the acquisition of data, drafted the first and final manuscript. Acknowledgements Not applicable. Author details First author: Hae Kyung Jo, Ph.D., RN. Associate Professor, Department of Nursing, Jeon Ju University, Jeonju, South Korea Tel: +82-63-220-2025, , Fax: +82-63-220-2054 [email protected] https://orcid.org/0000-0002-0450-4308 *Corresponding author: Hyun Kyoung Kim, Ph.D., RN. 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Annals of Medicine. 2001;33(5):337-43, https://doi.org/01-07-2001 Korean Centers for Disease Control and Prevention. The report of quality weighted health related quality of life. Seoul: Korean Centers for Disease Control and Prevention; 2007. Spitzer RL, Kroenke K, Williams JB; Patient Health Questionnaire Primary Care Study Group. Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. JAMA. 1999;282(18):1737-44. Patient Health Questionnaire. Korean version of PHQ-2. (Online), May 15, 2023 retrieved. Denver. Retrieved form www.phqscreeners.com Spitzer RL, Kroenke K, Williams JBW, Löwe B. A brief measure for assessing generalized anxiety disorder: The GAD-7. Archives of Internal Medicine. 2006;166(10):1092–7. https://doi.org/10.1001/archinte.166.10.1092 Kim YS, Park YS, Cho GC, Park KH, Kim SH, Baik Y, et al. Screening Tool for Anxiety Disorders: Development and Validation of the Korean Anxiety Screening Assessment. Psychiatry Investigation. 2018;15:1053-63. https://doi.org/10.30773/pi.2018.09.27.2 SW Hwang, HK Kim. Development and validation of the e-learning satisfaction scale (eLSS), Teaching and Learning in Nursing. 2022;17(4). https://doi.org/10.1016/j.teln.2022.02.004 Faul F, Erdfelder E, Buchner A, Lang A. Statistical power analyses using G*Power 3.1: Tests for correlation and regression analyses. Behavior Research Methods. 2009;41(4):1149-60. https://doi.org/10.3758/BRM.41.4.1149 Cohen J. A power primer. Psychological Bulletin. 1992;112(1):155–9. https://doi.org/10.1037/0033-2909.112.1.155 Demelash Enyew H, Bogale BG, Hailu AB, Mereta ST. Environmental exposures and adverse pregnancy outcomes in Ethiopia: A systematic review and meta-analysis. PLoS ONE. 2023;18(7):e0288240. https://doi.org/10.1371/journal.pone.0288240 Shah S, Jeong KS, Park H, Hong YC, Kim Y, Kim B, et al. Environmental pollutants affecting children's growth and development: Collective results from the MOCEH study, a multi-centric prospective birth cohort in Korea. Environment International. 2020;137:105547. https://doi.org/10.1016/j.envint.2020.105547 Roos N, Kovats S, Hajat S, Filippi V, Chersich M, Luchters S, Scorgie F, Nakstad B, Stephansson O; CHAMNHA Consortium. Maternal and newborn health risks of climate change: A call for awareness and global action. Acta Obstet Gynecol Scand. 2021 Apr;100(4):566-570. https://doi.org/10.1111/aogs.14124 Mazaheri Habibi MR, Moghbeli F, Langarizadeh M, Fatemi Aghda SA. Mobile health apps for pregnant women usability and quality rating scales: a systematic review. BMC Pregnancy Childbirth. 2024 Jan 5;24(1):34. https://doi.org/10.1186/s12884-023-06206-z Hussain-Shamsy N, Shah A, Vigod SN, Zaheer J, Seto E. Mobile Health for Perinatal Depression and Anxiety: Scoping Review. J Med Internet Res. 2020;22(4):e17011. Published 2020 Apr 13. https://doi.org/10.2196/17011 Shorey S, Ng YPM, Ng ED, Siew AL, Morelius E, Yoong J, et al. Effectiveness of a technology-based supportive educational parenting program on parental outcomes (Part 1): Randomized Controlled Trial. Journal of Medical Internet Research. 2019;21(2):Article e10816. https://doi.org/10.2196/10816 Moise IK, Ivanova N, Wilson C, Wilson S, Halwindi H, Spika VM. Lessons from digital technology-enabled health interventions implemented during the coronavirus pandemic to improve maternal and birth outcomes: a global scoping review. BMC Pregnancy Childbirth. 2023 Mar 20;23(1):195. https://doi.org/10.1186/s12884-023-05454-3 Li C, Lawrance EL, Morgan G, Brown R, Greaves N, Krzanowski J, Samuel S, Guinto RR, Belkin G. The role of mental health professionals in the climate crisis: an urgent call to action. Int Rev Psychiatry. 2022 Aug;34(5):563-570. https://doi.org/10.1080/09540261.2022.2097005 Ortega-García JA, Sánchez-Sauco MF, Zafra-Rodríguez JA, et al. Subjective well-being, happiness, and environmental health factors related to women planning a pregnancy or pregnant, using mobile health intervention. DIGITAL HEALTH. 2023;9. https://doi.org/10.1177/20552076231177146 Table 1 Table 1 is available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Table1.docx Cite Share Download PDF Status: Published Journal Publication published 04 Mar, 2025 Read the published version in BMC Pregnancy and Childbirth → Version 1 posted Editorial decision: Revision requested 09 May, 2024 Editor assigned by journal 09 May, 2024 Submission checks completed at journal 26 Apr, 2024 First submitted to journal 22 Apr, 2024 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-4303622","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":295937859,"identity":"d73de662-8e32-40ee-93a2-02fe9b92dbc3","order_by":0,"name":"Haekyung Jo","email":"","orcid":"","institution":"Jeonju University","correspondingAuthor":false,"prefix":"","firstName":"Haekyung","middleName":"","lastName":"Jo","suffix":""},{"id":295937862,"identity":"4ef6c719-6e6b-4c0a-aadc-7d98f0453af5","order_by":1,"name":"Hyun Kyoung Kim","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAwklEQVRIiWNgGAWjYBACAx42xocNQAZjA5ifQJQWZkOStbBJNiD4RGgx5zmWVjmj4o5d84wExg8/GNLyCWqx7G07dnPDmWfJjTMSmCV7GHIsGwhpMTjP3nbzYdvhZMYZCQzSDAwVBgRtAWkphGph/k2clrNtxxg3th22A2phA9qSQ4SWM8eSJWecOZzA2POwzbLHII0YLWmGH3sqDtsbticfvvGjIpmwFhhI3NgAikziNTAw2MuToHgUjIJRMApGGAAAxPE/Fgfx/yoAAAAASUVORK5CYII=","orcid":"","institution":"Kongju National University","correspondingAuthor":true,"prefix":"","firstName":"Hyun","middleName":"Kyoung","lastName":"Kim","suffix":""}],"badges":[],"createdAt":"2024-04-22 06:38:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4303622/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4303622/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12884-025-07361-1","type":"published","date":"2025-03-04T15:57:22+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":55767678,"identity":"488c5694-88dc-4678-ad01-28466f8bd2d7","added_by":"auto","created_at":"2024-05-02 20:20:17","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":320305,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eTheoretical framework of revised protection motivation theory.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"fig1.png","url":"https://assets-eu.researchsquare.com/files/rs-4303622/v1/e822c789eebc54871c951120.png"},{"id":55767677,"identity":"7423f65e-401c-4193-94f7-3e0f7543a405","added_by":"auto","created_at":"2024-05-02 20:20:17","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":54575,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFlow diagram of the research process.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"fig2.png","url":"https://assets-eu.researchsquare.com/files/rs-4303622/v1/65c90eb8acef9c5e163505be.png"},{"id":78190351,"identity":"ba9fd16a-2379-4d10-8549-07c00c1bea7f","added_by":"auto","created_at":"2025-03-10 19:48:36","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1348046,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4303622/v1/de0df337-b1ca-4930-818a-392f95161d65.pdf"},{"id":55767680,"identity":"2227828e-c974-406d-8c0c-b63faeb390d1","added_by":"auto","created_at":"2024-05-02 20:20:18","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":222391,"visible":true,"origin":"","legend":"","description":"","filename":"Table1.docx","url":"https://assets-eu.researchsquare.com/files/rs-4303622/v1/28010435da34f62fd80e5879.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"The effect of DECO-MOM mobile application for a prenatal environmental health program on environmental health behaviors","fulltext":[{"header":"Background","content":"\u003cp\u003eThe unfolding crisis of climate change presents unprecedented challenges to public health, particularly for vulnerable populations such as pregnant women. The American National Association for Environmental Health has recognized environmental health as encompassing the effects of physical, chemical, biological, and psychosocial factors on human health, a definition that becomes increasingly pertinent as we face escalating environmental risks [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Pregnant women are of particular concern due to their heightened vulnerability to adverse outcomes from environmental exposures [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eClimate change exacerbates the spectrum of environmental hazards, from pollution to heatwaves, posing significant threats to maternal and fetal health including neonatal stress and preterm birth [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The need for effective interventions is underscored by a growing body of evidence linking environmental pollutants with adverse pregnancy outcomes, including preterm birth, low birth weight, and developmental issues in offspring [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Environmental pollution and environmental health factors such as fine particulate matter, air pollution, heavy metals, and chemicals have been shown to contribute to depression, anxiety, and stress in pregnant women [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. This situation calls for innovative solutions that can empower pregnant women to navigate physical and psychological risks effectively.\u003c/p\u003e \u003cp\u003eAwareness of harmful substances during pregnancy motivates environmental health behaviors [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Research on environmental health interventions for pregnant women is scarce. Providing information about exposure to endocrine disruptors in pregnant women's diets increased environmental behaviors [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. In-person environmental health childbirth classes increased environmental awareness, intention, and behavior among pregnant women [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Childbirth education using virtual Zoom meetings and cartoon booklets also increased environmental health vulnerability awareness, self-efficacy, and community health behaviors [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. It is imperative to consider the potential of mobile health (mHealth) interventions in bridging the gap between environmental health risks and protective health behaviors from environmental hazards. The advent of mHealth offers a promising avenue for enhancing health literacy and facilitating proactive health management, especially in contexts where traditional healthcare access may be limited or where environmental risks are under-recognized [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA mobile application, the quintessential mHealth, is needed to leverages the ubiquity and accessibility of mobile technology to educate pregnant women about environmental toxins and promote adaptive health behaviors. However, we could not found any mobile application for pregnant women regarding climate change and environmental health. Therefore, the protocol for mobile application named Deep ECOlogy MOM application (DECO-MOM app) interventions was developed by draws upon the revised protection motivation theory (rPTM) as the theoretical foundation [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Rogers suggests that perception of the severity, susceptibility, response efficacy, self-efficacy, costs, and benefits to health threats can motivate protective health behaviors [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBy situating the DECO-MOM app within the broader discourse on environmental health, climate change, and digital health innovations, this introduction sets the stage for a nuanced exploration of how technology-driven interventions can make a tangible difference in the lives of pregnant women, offering them tools to safeguard their health and that of their fetus in an increasingly complex environmental landscape. Therefore, this study aimed to explore the effects of DECO-MOM app on environmental health behavior (personal and community health behavior), psychological health (quality of life, subjective health status, depression, and anxiety,), and e-learning satisfaction (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n \u003ch2\u003eStudy design\u003c/h2\u003e\n \u003cp\u003eThis study was non-randomized controlled study with experimental and control group pre-post-test design. This study adhered to the Transparent Reporting of Evaluations with Nonrandomized Designs (TREND) guidelines [\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e]. The study protocol was registered in the Korean Clinical Research Information Service at September 22, 2022 (KCT0007725: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://cris.nih.go.kr/cris/search/detailSearch.do?seq=22378\u0026amp;status=5\u0026amp;seq_group=22378\u0026amp;search_page=M\u003c/span\u003e\u003c/span\u003e) [\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\n \u003ch2\u003eSetting\u003c/h2\u003e\n \u003cp\u003eParticipants were recruited from three the public health care centers of Chuncheon, Jeonju, and Gongju cities in Gangwon, Jeonrabuk, and Chungcheongnam Province respectively in South Korea. The public centers provided maternal-child healthcare service operating birth education to pregnant women. Researchers were permitted for study and data collection from the healthcare centers and participated prenatal education as lecturers. Researchers provided a mobile application QR code of website address for experimental group after written consent to participate the study and treatment as usual (TAU) education program for the control group.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n \u003ch2\u003eInclusion and exclusion criteria\u003c/h2\u003e\n \u003cp\u003eThe participants were included as follow; 1) pregnant women in the gestational aged 4\u0026ndash;36 weeks 2) aged over 20 years, 3) have a smart gadget, and 4) Korean language literacy. The exclusion criteria were 1) hospitalized due to physical or psychological health problems and 2) currently receiving medical treatment due to fetal or maternal disease.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\n \u003ch2\u003eAllocation\u003c/h2\u003e\n \u003cp\u003eThe convenience sampling was used allocate 1:1 parallel allocation. The participants recruited from Chuncheon city were allocated to the control group applied only TAU and the participants from Jeonju and Gongju cities in South Korea were allocated to the experimental group applied mobile application. These three cities were middle sized urban-rural cities and similar socioeconomic and cultural status to avoid potential heterogeneous bias. The researcher contacted the pregnant women and explain the study\u0026apos;s purpose, procedure, and benefits. The pre-test was performed before mobile application and TAU, intervened for 4 weeks, and post-test just after intervention between September 26 and October 24, 2023 (Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\n \u003ch2\u003eSample size\u003c/h2\u003e\n \u003cp\u003eThe G*Power 3.1.4.9 [\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e] calculated the sample size as 32 and 32 in both groups with designated a one-tailed test, the independent t-test, 0.59 effect size (f), 0.75 power, 0.05 significance level, and a 1:1 allocation ratio [\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e]. The effect size (Cohen\u0026rsquo;s d) was calculated by 18.45\u0026thinsp;\u0026plusmn;\u0026thinsp;13.13 and 9.68\u0026thinsp;\u0026plusmn;\u0026thinsp;8.24, resulting in a Cohen\u0026rsquo;s d of .59 according to the previous study [\u003cspan class=\"CitationRef\"\u003e6\u003c/span\u003e]. The sampling was 35 and 35 participants in the both group considering conservative rate of 10%. Four participants among the mobile group the reasons of another schedules of hospital visit or house chores. The participants of 31 in the experimental group and 34 in the control were analyzed. The adherence rates for experimental and control group were 88.57% and 97.14%.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n \u003ch2\u003eIntervention\u003c/h2\u003e\n \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e\n \u003ch2\u003eIntervention group\u003c/h2\u003e\n \u003cp\u003eThe DECO-MOM intervention was designed as a four-week program, delivered via a mobile application, aimed at educating pregnant women on the environmental toxins and promoting adaptive environmental health behaviors. the Android system was used to develop the application. Grounded in the revised protection motivation theory (rPMT), the program operationalizes the theory\u0026rsquo;s constructs\u0026mdash;severity, susceptibility, response efficacy, self-efficacy, costs, and benefits [\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e]\u0026mdash;into weekly themes that progressively aimed to: enhance understanding of environmental risks, motivate protective health behaviors, balance the perceived benefits against costs of such behaviors, and empower both individual and communal action towards environmental health. This intervention was supported by weekly telephonic follow-ups by a research assistant and facilitated through the widespread KakaoTalk social networking service in Korea, ensuring participant engagement and adherence to the program protocols.\u003c/p\u003e\n \u003cp\u003eThe \u0026quot;DECO-MOM environmental prenatal health program\u0026quot; structured as a mobile application designed to educate pregnant women on climate change and environmental health over a four-week period. Each week targets different aspects of environmental health through varied educational methods to engage participants.\u003c/p\u003e\n \u003cp\u003eIn the first week, the focus was on raising awareness regarding the reproductive health problems of maternal, fetus, and child (severity). The potential harms from chemicals, electromagnetic waves, and unsafe foods, along with discussing reproductive and general health issues (susceptibility). This was delivered through an orientation session, cartoons for visual learning, explanations for depth understanding, a 5-minute video developed by a researcher, and a question-and-answer segment for interaction, each segment lasting 30 minutes.\u003c/p\u003e\n \u003cp\u003eThe second week aimed to empower women with knowledge on avoiding environmental toxins and enhancing their health and that of their fetus (response efficacy), addressing topics such as empowering preventive judgment and control (self-efficacy). A 5-minute video developed by a researcher, cartoons, and explanations were used, followed by a question-and-answer session, mirroring the first week\u0026apos;s duration and teaching methods.\u003c/p\u003e\n \u003cp\u003eWeek three discussed the trade-offs and benefits of making lifestyle adjustments, focusing on the positive (benefits) and negative aspects (costs) of unhealthy environmental behaviors and highlighting the psychological and physical gains from healthier choices. The session used a 5-minute video developed by a researcher, cartoons, explanations, and a Q\u0026amp;A format for delivery, each lasting 30 minutes.\u003c/p\u003e\n \u003cp\u003eThe final week broadens the scope to include changes in personal and community behavior to avoid climate change and exposure to environmental toxin, touching on lifestyle adjustments and community engagement in environmental health practices (motivated health behaviors). It leveraged a 5-minute video developed by a researcher, cartoons, explanations, a question-and-answer segment, introduces a trophy system likely for motivation or achievement recognition, and concludes with a wrap-up session. Each method was designed to last for 30 minutes.\u003c/p\u003e\n \u003cp\u003eOverall, the program was meticulously designed to educate, engage, and empower pregnant women regarding climate change and environmental health, utilizing a blend of educational methods to cater to different learning preferences and effectively communicate complex information (Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec10\" class=\"Section3\"\u003e\n \u003ch2\u003eControl group\u003c/h2\u003e\n \u003cp\u003eFor the control group, Treatment As Usual (TAU) was administered through in-person instruction over a four-week period. These sessions took place in the maternity class room at the public health center, each lasting two hours and led by two professors specializing in women\u0026apos;s health and a midwife. The curriculum covered a range of topics including: 1) comprehension of pregnancy and fetal development; 2) managing pain during childbirth, alongside techniques for relaxation and breathing throughout labor; 3) care after childbirth and breastfeeding practices; and 4) caring for a newborn infant.\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n \u003ch2\u003eMeasurements\u003c/h2\u003e\n \u003cp\u003eThe questionnaires were distributed via online survey using a Naver Form respectively through the KakaoTalk messenger. The online survey eook from 10 to 15 minutes. Online gift worth 7 dollars was provided to the participants twice after the pre- and post-test.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n \u003ch2\u003ePrimary outcomes\u003c/h2\u003e\n \u003cdiv id=\"Sec13\" class=\"Section3\"\u003e\n \u003ch2\u003ePersonal environmental health behavior\u003c/h2\u003e\n \u003cp\u003ePersonal environmental health behavior was measured using the Women\u0026apos;s Environmental Health Behavior (WEHB) scales [\u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e]. The WEHB consists of four factors: 7 lifestyle, 4 personal hygiene, 3 diet, and 3 dust-related behaviors (total 14 items). The WEHB was measured by a Likert scale, ranging from 1 (not at all) to 5 (strongly agree). Total scores ranged from 14 to 60, the higher score meaned the higher personal environmental behavior. The Cronbach\u0026rsquo;s alpha values for internal consistency reliability were .90 in original scare and .88 in this study.\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\n \u003ch2\u003eCommunity environmental health behavior\u003c/h2\u003e\n \u003cp\u003eCommunity environmental health behavior was measured using the Women\u0026apos;s Environmental Health Behavior (WEHB) scales [\u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e]. The WEHB consisted of four factors with 5 reduction, 5 involvement, 3 recycling, and 3 reuse behaviors (total 16 items). The WEHB was measured by a Likert scale, ranging from 1 (not at all) to 5 (strongly agree). Total scores ranged from 16 to 90, the higher score meaned the higher community environmental behavior. The Cronbach\u0026rsquo;s alpha was .90 in original scare and .89 in this study.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\n \u003ch2\u003eSecondary outcomes\u003c/h2\u003e\n \u003cdiv id=\"Sec16\" class=\"Section3\"\u003e\n \u003ch2\u003eQuality of life\u003c/h2\u003e\n \u003cp\u003eQuality of life was measured using the EuroQol-5D (EQ-5D) [\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e] and the Korean version of the EQ-5D was used [\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e]. The EQ-5D consists of 5 items with mobility, self-care, usual activity, pain/discomfort, anxiety/depression. The EQ-5D was measured using a Likert scale, ranging from 1 (not at all) to 4 (nearly every day). Total scores ranged from 5 to 20, with higher scores indicating lower quality of life. Cronbach\u0026rsquo;s alpha was .61 in original scare and .75 in this study.\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\n \u003ch2\u003eSubjective health status\u003c/h2\u003e\n \u003cp\u003eSubjective health status was measured using EQ-VAS was used [\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e] and the Korean version of the EQ-VAS was used [\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e]. EQ-VAS had one question of \u0026lsquo;The worst health you can imagine\u0026rsquo; and numbered from 0 (the worst health respondent can imagine) to 100 (the best health respondent can imagine). When presenting data had the central tendency, it could be the mean value and the standard deviation or, if the data was skewed, the median values and the interquartile range (IQR).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\n \u003ch2\u003eDepression\u003c/h2\u003e\n \u003cp\u003eDepression was measured using ultra short depression screener Patient Health Questionnaire (PHQ-2) [\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e] and the Korean version of the PHQ-2 was used [\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e]. A total score of 3 or greater should prompt administration of the full PHQ-9, as well as a clinical interview to determine whether a mental disorder is present. The PHQ-2 was measured using a Likert scale, ranging from 1 (not at all) to 4 (nearly every day). Total scores ranged from 4 to 8, with higher scores indicating higher depression. Cronbach\u0026rsquo;s alpha was .61 in original scare and .82 in this study.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\n \u003ch2\u003eAnxiety\u003c/h2\u003e\n \u003cp\u003eAnxiety was measured using the General Anxiety Disorder-7 (GAD-7) [\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e] and the Korean version of the GAD-7 will be used [\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e]. The GAD-7 had seven items using a Likert scale, ranging from 1 (not at all) to 4 (nearly every day). Total scores ranged from 7 to 28, with higher scores indicating higher anxiety. Cronbach\u0026rsquo;s alpha was .97 in original scare and .85 in this study.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\n \u003ch2\u003eE-learning satisfaction\u003c/h2\u003e\n \u003cp\u003eE-learning satisfaction was measured using the E-Learning Satisfaction Scale (eLSS) (17 items) [\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e]. The eLSS consisted of three factors with 8 content, 5 interface, and 4 communication (total 17 items). The eLSS was measured by a Likert scale, ranging from 1 (not at all) to 5 (strongly agree). Total scores ranged from 8 to 40, with higher scores indicating greater content satisfaction. Cronbach\u0026rsquo;s alpha for internal consistency reliability was .93 in original scare and .95 in this study.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\n \u003ch2\u003eGeneral and obstetric characteristics\u003c/h2\u003e\n \u003cp\u003eThe general characteristics were elicited self-reported information, including age, present disease, and employment status. The obstetric characteristics included gestational age and number of children.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\n \u003ch2\u003eEthical consideration\u003c/h2\u003e\n \u003cp\u003eThis study was approved by the Institutional Review Board of Jeonju University (jjIRB-231214-HR-2023-1014) and adhered to the Declaration of Helsinki.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec23\" class=\"Section2\"\u003e\n \u003ch2\u003eStatistical analysis\u003c/h2\u003e\n \u003cp\u003eThis study used SPSS for Windows version 27.0 (IBM Corp., Armonk, NY, USA). The homogeneity test was performed using t-test and chi-square test between the two groups. Shapiro-Wilk test was used to test normality, linearity, and residual independence. The independent t-test was used for test the study hypothesis.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eHypothesis 1\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eThe mobile group would have higher scores for personal and community environmental health behaviors than the TAU group.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eHypothesis 2\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eThe mobile group would have higher scores for quality of life, subjective health status than the TAU group.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eHypothesis 3\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eThe mobile group would have lower scores for depression and anxiety than the TAU group.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eHypothesis 4\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eThe mobile group would have higher scores for e-learning satisfaction than the TAU group.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec25\" class=\"Section2\"\u003e \u003ch2\u003eHomogeneity Between Groups\u003c/h2\u003e \u003cp\u003eThe characteristics compared include age, gestational age, number of children, present disease, employment status, personal environmental health behavior (with subcategories: lifestyle, personal goods, diet, dust), community environmental health behavior (with subcategories: reduction, involvement, recycle, reuse), quality of life, subjective health status, depression, anxiety, and e-learning satisfaction. The results indicate no significant differences between the control and experimental groups across most variables, suggesting homogeneity in terms of demographics and baseline measures (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAnalysis of homogeneity between groups (N\u0026thinsp;=\u0026thinsp;65)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003cp\u003egroup\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;34)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExperimental group\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;31)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003et/χ\u0026sup2;\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en (%) / M (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003en (%) / M (SD)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e34.35 (4.22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e33.06 (4.36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.231\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGestational age (weeks)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e24.35 (7.45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e28.03 (7.79)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-1.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.057\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of children\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.50 (0.62)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.77 (0.96)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-1.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.170\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePresent disease\u003c/p\u003e \u003cp\u003eYes\u0026dagger;\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11\u003c/p\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.772\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmployment\u003c/p\u003e \u003cp\u003eEmployed\u0026Dagger;\u003c/p\u003e \u003cp\u003eUnemployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14\u003c/p\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.\u003c/p\u003e \u003cp\u003e746\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePersonal environmental health behavior\u003c/p\u003e \u003cp\u003eTotal\u003c/p\u003e \u003cp\u003eLifestyle\u003c/p\u003e \u003cp\u003ePersonal good\u003c/p\u003e \u003cp\u003eDiet\u003c/p\u003e \u003cp\u003eDust\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55.74 (13.47)\u003c/p\u003e \u003cp\u003e22.56 (5.36)\u003c/p\u003e \u003cp\u003e14.21 (4.72)\u003c/p\u003e \u003cp\u003e7.53 (2.57)\u003c/p\u003e \u003cp\u003e11.44 (3.21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e57.10 (8.35)\u003c/p\u003e \u003cp\u003e23.58 (3.68)\u003c/p\u003e \u003cp\u003e13.94 (3.49)\u003c/p\u003e \u003cp\u003e7.81 (2.12)\u003c/p\u003e \u003cp\u003e11.77 (1.27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.48\u003c/p\u003e \u003cp\u003e-0.88\u003c/p\u003e \u003cp\u003e0.26\u003c/p\u003e \u003cp\u003e-0.47\u003c/p\u003e \u003cp\u003e-0.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.629\u003c/p\u003e \u003cp\u003e.378\u003c/p\u003e \u003cp\u003e.759\u003c/p\u003e \u003cp\u003e.639\u003c/p\u003e \u003cp\u003e.609\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCommunity environmental health behavior\u003c/p\u003e \u003cp\u003eTotal\u003c/p\u003e \u003cp\u003eReduction\u003c/p\u003e \u003cp\u003eInvolvement\u003c/p\u003e \u003cp\u003eRecycle\u003c/p\u003e \u003cp\u003eReuse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e51.50 (12.01)\u003c/p\u003e \u003cp\u003e14.08 (3.88)\u003c/p\u003e \u003cp\u003e14.88 (4.10)\u003c/p\u003e \u003cp\u003e10.82 (3.81)\u003c/p\u003e \u003cp\u003e10.26 (2.64)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55.74 (10.12)\u003c/p\u003e \u003cp\u003e16.39 (3.93)\u003c/p\u003e \u003cp\u003e15.84 (3.89)\u003c/p\u003e \u003cp\u003e12.06 (2.11)\u003c/p\u003e \u003cp\u003e11.45 (2.16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.38\u003c/p\u003e \u003cp\u003e0.86\u003c/p\u003e \u003cp\u003e0.75\u003c/p\u003e \u003cp\u003e-0.62\u003c/p\u003e \u003cp\u003e-0.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.705\u003c/p\u003e \u003cp\u003e.389\u003c/p\u003e \u003cp\u003e.452\u003c/p\u003e \u003cp\u003e.537\u003c/p\u003e \u003cp\u003e.888\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQuality of life\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7.51 (1.79)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6.65 (1.47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.225\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSubjective health status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e73.12 (11.51)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e67.42 (17.02)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.176\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDepression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10.32 (3.85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10.45 (3.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.889\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnxiety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.76 (0.92)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.10 (1.32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-1.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.242\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eE-learning satisfaction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e32.15 (6.40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e29.90 (6.08)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.153\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e\u0026dagger; Anemia, cystitis, cough, gestational diabetes, headache, hemorrhoid, hyperthyroidism, hypothyroidism, hypertension, hypotension, rhinitis\u003c/p\u003e \u003cp\u003eM, mean; SD, standard deviation.\u003c/p\u003e \u003cdiv id=\"Sec26\" class=\"Section3\"\u003e \u003ch2\u003eEffects of the \u0026ldquo;DECO-MOM\u0026rdquo; Prenatal Mobile Program\u003c/h2\u003e \u003cp\u003eThe total score of personal environmental health behavior was significantly increased from 55.85 (SD\u0026thinsp;=\u0026thinsp;6.48) in the control group to 62.32 (SD\u0026thinsp;=\u0026thinsp;10.38) in the experimental group (p\u0026thinsp;=\u0026thinsp;.003). Subcategories as lifestyle (p\u0026thinsp;=\u0026thinsp;.005) and dust (p\u0026thinsp;\u0026lt;\u0026thinsp;.001) also showed significant improvements. Total scores of community environmental health behavior was significantly improved from 54.18 (SD\u0026thinsp;=\u0026thinsp;5.58) in the control group to 60.48 (SD\u0026thinsp;=\u0026thinsp;9.27) in the experimental group (p\u0026thinsp;=\u0026thinsp;.001). Improvements were noted across all subcategories; reduction (p\u0026thinsp;=\u0026thinsp;.001), involvement (p\u0026thinsp;=\u0026thinsp;.007), recycle (p\u0026thinsp;=\u0026thinsp;.005), and reuse (p\u0026thinsp;=\u0026thinsp;.035).\u003c/p\u003e \u003cp\u003eScore of quality of life was increased in the experimental group (M\u0026thinsp;=\u0026thinsp;7.53, SD\u0026thinsp;=\u0026thinsp;2.03) compared to the control group (M\u0026thinsp;=\u0026thinsp;6.55, SD\u0026thinsp;=\u0026thinsp;1.76) (p\u0026thinsp;=\u0026thinsp;.043). Total score of e-learning satisfaction was increased from 57.76 (SD\u0026thinsp;=\u0026thinsp;11.71) to 65.10 (SD\u0026thinsp;=\u0026thinsp;8.13) significantly (p\u0026thinsp;=\u0026thinsp;.005). Subcategories as content satisfaction (p\u0026thinsp;\u0026lt;\u0026thinsp;.001) and communication satisfaction (p\u0026thinsp;=\u0026thinsp;.039) increased significantly in the experimental group compared to the control group. There were no significances in subjective health status, depression, and anxiety (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eEffects of \u0026ldquo;DECO-MOM\u0026rdquo; prenatal mobile program on environmental health behaviors, quality of life, depression, anxiety, and satisfaction (N\u0026thinsp;=\u0026thinsp;65)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003cp\u003egroup\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;34)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExperimental group\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;31)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003et/χ\u0026sup2;\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en (%) / M (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003en (%) / M (SD)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePersonal environmental health behavior\u003c/p\u003e \u003cp\u003eTotal\u003c/p\u003e \u003cp\u003eLifestyle\u003c/p\u003e \u003cp\u003ePersonal good\u003c/p\u003e \u003cp\u003eDiet\u003c/p\u003e \u003cp\u003eDust\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55.85 (6.48)\u003c/p\u003e \u003cp\u003e22.68 (3.96)\u003c/p\u003e \u003cp\u003e14.35 (2.76)\u003c/p\u003e \u003cp\u003e8.24 (1.72)\u003c/p\u003e \u003cp\u003e10.59 (1.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62.32 (10.38)\u003c/p\u003e \u003cp\u003e25.82 (4.77)\u003c/p\u003e \u003cp\u003e15.00 (3.52)\u003c/p\u003e \u003cp\u003e9.03 (2.47)\u003c/p\u003e \u003cp\u003e12.48 (1.98)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-3.04\u003c/p\u003e \u003cp\u003e-0.82\u003c/p\u003e \u003cp\u003e0.26\u003c/p\u003e \u003cp\u003e-1.51\u003c/p\u003e \u003cp\u003e-4.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.003\u003c/p\u003e \u003cp\u003e.005\u003c/p\u003e \u003cp\u003e.411\u003c/p\u003e \u003cp\u003e.134\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCommunity environmental health behavior\u003c/p\u003e \u003cp\u003eTotal\u003c/p\u003e \u003cp\u003eReduction\u003c/p\u003e \u003cp\u003eInvolvement\u003c/p\u003e \u003cp\u003eRecycle\u003c/p\u003e \u003cp\u003eReuse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54.18 (5.58)\u003c/p\u003e \u003cp\u003e16.03 (1.56)\u003c/p\u003e \u003cp\u003e15.74 (2.71)\u003c/p\u003e \u003cp\u003e11.38 (1.81)\u003c/p\u003e \u003cp\u003e11.03 (1.66)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60.48 (9.27)\u003c/p\u003e \u003cp\u003e17.71 (3.35)\u003c/p\u003e \u003cp\u003e18.00 (3.82)\u003c/p\u003e \u003cp\u003e12.81 (2.12)\u003c/p\u003e \u003cp\u003e11.97 (1.85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-3.38\u003c/p\u003e \u003cp\u003e-2.62\u003c/p\u003e \u003cp\u003e-2.77\u003c/p\u003e \u003cp\u003e-2.92\u003c/p\u003e \u003cp\u003e-2.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.001\u003c/p\u003e \u003cp\u003e.011\u003c/p\u003e \u003cp\u003e.007\u003c/p\u003e \u003cp\u003e.005\u003c/p\u003e \u003cp\u003e.035\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQuality of life\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6.55 (1.76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7.53 (2.03)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-2.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.043\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSubjective health status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e71.29 (20.54)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e77.42 (21.12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-1.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.241\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDepression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10.85 (3.06)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9.77 (2.85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.151\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnxiety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.62 (0.95)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.97 (1.27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-2.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.213\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eE-learning satisfaction\u003c/p\u003e \u003cp\u003eTotal\u003c/p\u003e \u003cp\u003eContent\u003c/p\u003e \u003cp\u003eInterface\u003c/p\u003e \u003cp\u003eCommunication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57.76 (11.71)\u003c/p\u003e \u003cp\u003e26.35 (5.62)\u003c/p\u003e \u003cp\u003e17.85 (4.40)\u003c/p\u003e \u003cp\u003e13.56 (3.11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e65.10 (8.13)\u003c/p\u003e \u003cp\u003e31.10 (3.78)\u003c/p\u003e \u003cp\u003e18.97 (3.06)\u003c/p\u003e \u003cp\u003e15.03 (2.44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-2.90\u003c/p\u003e \u003cp\u003e-3.94\u003c/p\u003e \u003cp\u003e-1.17\u003c/p\u003e \u003cp\u003e-2.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.005\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003cp\u003e.245\u003c/p\u003e \u003cp\u003e.039\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eM, mean; SD, standard deviation.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, the application of the DECO-MOM app for environmental health of pregnant women increased environmental health behaviors in personal and community aspects, quality of life, and increased satisfaction with the app, while psychological health, such as quality of subjective health status, depression, and anxiety, did not show statistically significant changes. Therefore, study hypothesis \u003cspan refid=\"FPar5\" class=\"InternalRef\"\u003e1\u003c/span\u003e and \u003cspan refid=\"FPar8\" class=\"InternalRef\"\u003e4\u003c/span\u003e were supported, however, hypothesis \u003cspan refid=\"FPar6\" class=\"InternalRef\"\u003e2\u003c/span\u003e and \u003cspan refid=\"FPar7\" class=\"InternalRef\"\u003e3\u003c/span\u003e were not supported. The DECO-MOM application, by effectively enhancing personal and community environmental health behaviors, illustrated the viability of leveraging technology to disseminate critical health information and foster behavioral change at a personal and communal level. Furthermore, this study's findings on e-learning satisfaction provided insights applicable to health education contexts, including the elements critical to user satisfaction and engagement in digital learning environments.\u003c/p\u003e \u003cp\u003eThe effectiveness of this study is attributed to the rPMT, which recognizes that pregnant women are vulnerable to climate change and environmental pollution and perceive real risks to their health [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Personal lifestyle and health behaviors to prevent micro dust triggered health behavior response efficacy, and community environmental health behaviors of reducing, engaging, recycling, and reusing stimulated self-efficacy to respond to climate change [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Climate change encompasses a broad spectrum of environmental alterations, including rising temperatures, increased exposure to pollutants, and the proliferation of vector-borne diseases, all of which pose significant health risks. For pregnant women, these environmental stressors can lead to adverse pregnancy outcomes, such as preterm birth, low birth weight, birth defects [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], and developmental issues in children [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. The susceptibility of pregnant women to these environmental factors was attributed to physiological changes during pregnancy that can alter their response to heat, pollutants, and infectious agents. The intrauterine environment, crucial for fetal development, was sensitive to external environmental conditions, making it imperative to protect maternal health from the adverse effects of climate change [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe results of positive e-learning satisfaction reported by participants further validate the design and content delivery approach of the DECO-MOM program. This satisfaction is indicative of the program's ability to engage users effectively, a critical factor in the success of any health intervention [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. This study showed that content satisfaction and communication satisfaction were effective, but interface satisfaction was not, suggesting that it is necessary to use more convenient and attractive technologies for users when developing environmental health apps. The positive reception of the app's content and communication suggests that user-centered design principles, which prioritize the needs and preferences of the target population, are essential in the development of effective mHealth interventions.\u003c/p\u003e \u003cp\u003eWhile previous studies in digital healthcare for pregnant women have shown benefits on depression [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e], anxiety [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e], and subjective well-being [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], this study did not show significant psychological effects. The lack of effect on psychological health outcomes in this study could be attributed to the lack of social support during app use. Communication was noted as a key factor affecting the sustainability of mobile apps, so future research should incorporate this factor into the design and evaluation of tools [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Mental health experts ought to be strategically involved in mitigating the adverse effects of climate change by delivering essential psychological assistance and incorporating mental health aspects into the broader framework of climate resilience strategies [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. The low levels of subjective well-being and happiness globally were linked to exposure to environmental factors during pregnancy [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Implementing mobile health interventions that focus on environmental health during pregnancy could enhance healthcare quality. Additionally, these interventions can encourage women to take a more active role in managing their own health, ultimately leading to empowered attitudes, healthier environmental health behaviors [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis study had several limitations. Firstly, this study was a small-sized experimental study of pregnant women in three Korean cities the generalizability of the study is limited. There was risk of selection bias of a quasi-experimental study due to difficulties in randomizing subjects as planned in the protocol. Secondly, this study did not consider health equity because it did not include digital literacy or migrant women, because the study only selected participants who could use digital devices and speak Korean. Thirdly, the researchers provided a mobile app and encouraged participation with social networking services, but were unable to provide individualized social support, which did not have a positive impact on mental health. Fourthly, we measured outcomes immediately after the 4-week app implementation, but did not follow up to measure the long-term impact of the app.\u003c/p\u003e \u003cp\u003eThe DECO-MOM study, through its focus on leveraging a mobile application for prenatal environmental health education, offers several important implications for public health policy, and future research in the domain of environmental health and mHealth interventions. The DECO-MOM study underscore the critical need for incorporating environmental health solutions into public health strategies, especially those aimed at vulnerable populations like pregnant women. The study also indicates that discussing environmental health risks and mitigation strategies should be an integral part of prenatal care. The DECO-MOM study lays the groundwork for future research in key areas. There is a need for further studies to explore the long-term effects of prenatal environmental health interventions on maternal and neonatal outcomes. Such research could provide deeper insights into the potential for mHealth tools to contribute to reducing adverse birth outcomes associated with environmental exposures. In conclusion, the DECO-MOM study not only demonstrates the effectiveness of a mobile application in improving environmental health behaviors and e-learning satisfaction among pregnant women but also reflects the potential of digital health interventions in enhancing environmental health outcomes.\u003c/p\u003e \u003cdiv id=\"Sec28\" class=\"Section2\"\u003e \u003ch2\u003eTrial status\u003c/h2\u003e \u003cp\u003eRegistered before recruiting.\u003c/p\u003e \u003c/div\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eDECO-MOM: DEep Ecology-MOM\u003c/p\u003e\n\u003cp\u003eGAD-7: general anxiety disease\u003c/p\u003e\n\u003cp\u003ee-LSS: e-learning satisfaction scale\u003c/p\u003e\n\u003cp\u003eEQ-5D: European quality of life 5-dimension\u003c/p\u003e\n\u003cp\u003eEQ-VAS: European quality of life Visual Analogue Scale\u003c/p\u003e\n\u003cp\u003ePHQ-2: Patient Health Questionnaire-2\u003c/p\u003e\n\u003cp\u003eQR: quick response\u003c/p\u003e\n\u003cp\u003erPMT:\u0026nbsp;the revised protection motivation theory\u003c/p\u003e\n\u003cp\u003eTAU : Treatment As Usual\u003c/p\u003e\n\u003cp\u003eTREND: Transparent Reporting of Evaluations with Nonrandomized Designs\u003c/p\u003e\n\u003cp\u003eWEHB: women\u0026apos;s environmental health behavior\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was reviewed by the Institutional Review Board of Institutional Review Board of Jeonju University (jjIRB-231214-HR-2023-1014) and adhered to the Declaration of Helsinki.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants completed written consent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by the National Research Foundation of Korea (NRF) Grant funded by the Korea government (MIST) (RS-2023-00239284).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHKK participated in the conception, design of the study\u003c/p\u003e\n\u003cp\u003eHKK and JHK the acquisition of data, drafted the first and final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor details\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFirst author:\u003c/p\u003e\n\u003cp\u003eHae Kyung Jo, Ph.D., RN. Associate Professor, Department of Nursing, Jeon Ju University, Jeonju, South Korea Tel: +82-63-220-2025, , Fax: +82-63-220-2054\u0026nbsp;\u003c/p\u003e\n\u003cp\[email protected]\u003c/p\u003e\n\u003cp\u003ehttps://orcid.org/0000-0002-0450-4308\u003c/p\u003e\n\u003cp\u003e*Corresponding author:\u003c/p\u003e\n\u003cp\u003eHyun Kyoung Kim, Ph.D., RN. Associate Professor, Department of Nursing, Kongju National University, Gongju, South Korea Tel: +82-41-850-0308, Fax: +82-41-856-0740\u003c/p\u003e\n\u003cp\[email protected]\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ehttps://doi.org/0000-0003-2782-108X\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eNational Environmental Health Association (NEHA), Definitions of environmental health. (Online), September 11, 2021 retrieved. Denver. Retrieved form https://www.neha.org/about-neha/definitions-environmental-health.\u003c/li\u003e\n\u003cli\u003eNyadanu SD, Dunne J, Tessema GA, Mullins B, Kumi-Boateng B, Lee Bell M, et al. Prenatal exposure to ambient air pollution and adverse birth outcomes: An umbrella review of 36 systematic reviews and meta-analyses. Environ Pollut. 2022 Mar;306:119465. https://doi.org/10.1016/j.envpol.2022.119465.\u003c/li\u003e\n\u003cli\u003eKamai EM, McElrath TF, Ferguson KK. Fetal growth in environmental epidemiology: mechanisms, limitations, and a review of associations with biomarkers of non-persistent chemical exposures during pregnancy. Environ Health. 2019;18(1):43. https://doi.org/10.1186/s12940-019-0480-8.\u003c/li\u003e\n\u003cli\u003eKuehn L, McCormick S. Heat Exposure and Maternal Health in the Face of Climate Change. International Journal of Environmental Research and Public Health. 2017; 14(8):853. https://doi.org/10.3390/ijerph14080853\u003c/li\u003e\n\u003cli\u003eBastain TM, Chavez T, Habre R. Hernandez-Castro I, Grubbs B, Toledo-Corral CM., et al. Prenatal ambient air pollution and maternal depression at 12\u0026thinsp;months postpartum in the MADRES pregnancy cohort. Environmental Health. 2021;20:121, https://doi.org/10.1186/s12940-021-00807-x\u003c/li\u003e\n\u003cli\u003eKim HK, Jeong GH. Effect of pro-environmental prenatal education program on pregnant women\u0026apos;s environmental health awareness and behaviors based on the protection motivation theory. Inquiry. 2022;59:469580211047045. https://doi.org/10.1177/00469580211047045\u003c/li\u003e\n\u003cli\u003eBarrett ES, Velez M, Qiu X, Chen SR. Reducing Prenatal Phthalate Exposure Through Maternal Dietary Changes: Results from a Pilot Study, Maternal and Child Health Journal, 2015;19(9):1936\u0026ndash;1942. https://doi.org/10.1007/s10995-015-1707-0\u003c/li\u003e\n\u003cli\u003eKim HK, Kim HK, Kim M, Park S. Development and evaluation of prenatal education for environmental health behavior using cartoon comics. Journal of Korean Academy Nursing. 2021;51(4):478-488. https://doi.org/10.4040/jkan.21083\u003c/li\u003e\n\u003cli\u003eIribarren SJ, Akande TO, Kamp KJ, Barry D, Kader YG, Suelzer E. Effectiveness of Mobile Apps to Promote Health and Manage Disease: Systematic Review and Meta-analysis of Randomized Controlled Trials. JMIR Mhealth Uhealth 2021;9(1):e21563 https://doi.org/10.2196/21563 \u003c/li\u003e\n\u003cli\u003eKim HK. The protocol of DECO-MOM: a clinical trial testing the effectiveness of a mobile application for an environmental health intervention among pregnant women. BMC Med Inform Decis Mak. 2023;23:154. https://doi.org/10.1186/s12911-023-02258-5\u003c/li\u003e\n\u003cli\u003eRogers RW. Cognitive and physiological processes in attitude change: A revised theory of protection motivation, Guilford Press. 153-76. 1983.\u003c/li\u003e\n\u003cli\u003eDes Jarlais DC, Lyles C, Crepaz N, the TREND Group. Improving the reporting quality of nonrandomized evaluations of behavioral and public health interventions: The TREND statement. American Journal of Public Health. 2004;94:361-6.\u003c/li\u003e\n\u003cli\u003eKorean research information service for trial registration. National Center for Medical Information and Knowledge. Osong. (Online), 12 March, 2024. Retrieved form https://cris.nih.go.kr/cris/index/index.do\u003c/li\u003e\n\u003cli\u003eKim HK. Kim HK. 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JAMA. 1999;282(18):1737-44.\u003c/li\u003e\n\u003cli\u003ePatient Health Questionnaire. Korean version of PHQ-2. (Online), May 15, 2023 retrieved. Denver. Retrieved form www.phqscreeners.com\u003c/li\u003e\n\u003cli\u003eSpitzer RL, Kroenke K, Williams JBW, L\u0026ouml;we B. A brief measure for assessing generalized anxiety disorder: The GAD-7. Archives of Internal Medicine. 2006;166(10):1092\u0026ndash;7. https://doi.org/10.1001/archinte.166.10.1092\u003c/li\u003e\n\u003cli\u003eKim YS, Park YS, Cho GC, Park KH, Kim SH, Baik Y, et al. Screening Tool for Anxiety Disorders: Development and Validation of the Korean Anxiety Screening Assessment. Psychiatry Investigation. 2018;15:1053-63. https://doi.org/10.30773/pi.2018.09.27.2\u003c/li\u003e\n\u003cli\u003eSW Hwang, HK Kim. Development and validation of the e-learning satisfaction scale (eLSS), Teaching and Learning in Nursing. 2022;17(4). https://doi.org/10.1016/j.teln.2022.02.004\u003c/li\u003e\n\u003cli\u003eFaul F, Erdfelder E, Buchner A, Lang A. Statistical power analyses using G*Power 3.1: Tests for correlation and regression analyses. Behavior Research Methods. 2009;41(4):1149-60. https://doi.org/10.3758/BRM.41.4.1149\u003c/li\u003e\n\u003cli\u003eCohen J. A power primer. Psychological Bulletin. 1992;112(1):155\u0026ndash;9. https://doi.org/10.1037/0033-2909.112.1.155\u003c/li\u003e\n\u003cli\u003eDemelash Enyew H, Bogale BG, Hailu AB, Mereta ST. Environmental exposures and adverse pregnancy outcomes in Ethiopia: A systematic review and meta-analysis. PLoS ONE. 2023;18(7):e0288240. https://doi.org/10.1371/journal.pone.0288240\u003c/li\u003e\n\u003cli\u003eShah S, Jeong KS, Park H, Hong YC, Kim Y, Kim B, et al. Environmental pollutants affecting children\u0026apos;s growth and development: Collective results from the MOCEH study, a multi-centric prospective birth cohort in Korea. Environment International. 2020;137:105547. https://doi.org/10.1016/j.envint.2020.105547\u003c/li\u003e\n\u003cli\u003eRoos N, Kovats S, Hajat S, Filippi V, Chersich M, Luchters S, Scorgie F, Nakstad B, Stephansson O; CHAMNHA Consortium. Maternal and newborn health risks of climate change: A call for awareness and global action. Acta Obstet Gynecol Scand. 2021 Apr;100(4):566-570. https://doi.org/10.1111/aogs.14124 \u003c/li\u003e\n\u003cli\u003eMazaheri Habibi MR, Moghbeli F, Langarizadeh M, Fatemi Aghda SA. Mobile health apps for pregnant women usability and quality rating scales: a systematic review. BMC Pregnancy Childbirth. 2024 Jan 5;24(1):34. https://doi.org/10.1186/s12884-023-06206-z \u003c/li\u003e\n\u003cli\u003eHussain-Shamsy N, Shah A, Vigod SN, Zaheer J, Seto E. Mobile Health for Perinatal Depression and Anxiety: Scoping Review. J Med Internet Res. 2020;22(4):e17011. Published 2020 Apr 13. https://doi.org/10.2196/17011\u003c/li\u003e\n\u003cli\u003eShorey S, Ng YPM, Ng ED, Siew AL, Morelius E, Yoong J, et al. Effectiveness of a technology-based supportive educational parenting program on parental outcomes (Part 1): Randomized Controlled Trial. Journal of Medical Internet Research. 2019;21(2):Article e10816. https://doi.org/10.2196/10816\u003c/li\u003e\n\u003cli\u003eMoise IK, Ivanova N, Wilson C, Wilson S, Halwindi H, Spika VM. Lessons from digital technology-enabled health interventions implemented during the coronavirus pandemic to improve maternal and birth outcomes: a global scoping review. BMC Pregnancy Childbirth. 2023 Mar 20;23(1):195. https://doi.org/10.1186/s12884-023-05454-3\u003c/li\u003e\n\u003cli\u003eLi C, Lawrance EL, Morgan G, Brown R, Greaves N, Krzanowski J, Samuel S, Guinto RR, Belkin G. The role of mental health professionals in the climate crisis: an urgent call to action. Int Rev Psychiatry. 2022 Aug;34(5):563-570. https://doi.org/10.1080/09540261.2022.2097005\u003c/li\u003e\n\u003cli\u003eOrtega-Garc\u0026iacute;a JA, S\u0026aacute;nchez-Sauco MF, Zafra-Rodr\u0026iacute;guez JA, et al. Subjective well-being, happiness, and environmental health factors related to women planning a pregnancy or pregnant, using mobile health intervention. DIGITAL HEALTH. 2023;9. https://doi.org/10.1177/20552076231177146\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Table 1","content":"\u003cp\u003eTable 1 is available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Environmental health, Women, Pregnancy, Health behaviors, Mobile application","lastPublishedDoi":"10.21203/rs.3.rs-4303622/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4303622/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eThe DECO-MOM mobile program was developed to enhance prenatal environmental health behaviors among pregnant women, addressing the challenges of climate change and environmental pollution. This study aimed to explore the effects of the DECO-MOM app on personal and community health behaviors, quality of life, subjective health status, depression, anxiety, and e-learning satisfaction, guided by the revised protection motivation theory.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods/Design: \u003c/strong\u003eThis non-randomized controlled study employed a pre-post-test design with experimental and control groups. The study analyzed data from 31 participants in the experimental group and 34 in the control group after a four-week mobile application intervention conducted from September 26 to October 24, 2023, in three cities in South Korea.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eThe experimental group demonstrated significant improvements in personal environmental health behaviors (p = .003), community environmental health behaviors (p = .001), quality of life (p = .043), and e-learning satisfaction (p = .005) compared to the control group. Significant increases were observed in subcategories such as lifestyle (p = .005), dust management (p \u0026lt; .001), reduction efforts (p = .001), involvement (p = .007), recycling (p = .005), reuse (p = .035), content satisfaction (p \u0026lt; .001), and communication satisfaction (p = .039). However, no significant increases were found in subjective health status, depression, or anxiety.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiscussion: \u003c/strong\u003eThe integration of tailored educational content delivered via mobile technology presents a viable strategy for prenatal health promotion. Future studies should explore the long-term impacts and scalability of such mobile-based interventions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial registration\u003c/strong\u003e: Trial registration Number: KCT0007725, Registered September 22, 2022. Prospectively registered.\u003c/p\u003e","manuscriptTitle":"The effect of DECO-MOM mobile application for a prenatal environmental health program on environmental health behaviors","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-05-02 20:20:12","doi":"10.21203/rs.3.rs-4303622/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-05-09T07:06:50+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-05-09T04:18:49+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-04-26T16:52:20+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2024-04-22T06:35:59+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5989085d-5604-44a8-96cd-2df9b846e83d","owner":[],"postedDate":"May 2nd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-03-10T19:45:07+00:00","versionOfRecord":{"articleIdentity":"rs-4303622","link":"https://doi.org/10.1186/s12884-025-07361-1","journal":{"identity":"bmc-pregnancy-and-childbirth","isVorOnly":false,"title":"BMC Pregnancy and Childbirth"},"publishedOn":"2025-03-04 15:57:22","publishedOnDateReadable":"March 4th, 2025"},"versionCreatedAt":"2024-05-02 20:20:12","video":"","vorDoi":"10.1186/s12884-025-07361-1","vorDoiUrl":"https://doi.org/10.1186/s12884-025-07361-1","workflowStages":[]},"version":"v1","identity":"rs-4303622","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4303622","identity":"rs-4303622","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}