Investigation the effectiveness of self-care education based on the Seven-Step Learning Cycle (7E) on health literacy, distress, and self-concept of pregnant women referring to health care centers

Investigation the effectiveness of self-care education based on the Seven-Step Learning Cycle (7E) on health literacy, distress, and self-concept of pregnant women referring to health care centers | 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 Investigation the effectiveness of self-care education based on the Seven-Step Learning Cycle (7E) on health literacy, distress, and self-concept of pregnant women referring to health care centers Fatemeh Parimi, Fereshteh Javaheri Tehrani, Shabnam Shariatpanahi, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6230605/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction: The aim of the study was to investigate the effect of self-care education based on the seven-step learning cycle on pregnancy health literacy, pregnancy concerns, and self-concept of pregnant women referring to health care centers Methods The present study was a quasi-experimental study with two test and control groups using a pre-test and post-test method. The research sample consisted of 100 healthy mothers referring to health care centers. All the participants completed demographic, Maternal Literacy, Pregnancy Distress and the Beck Self-Concept Questionnaires before and after the intervention. The intervention was conducted based on the Seven-step Learning Cycle on the test group. Results The results showed a statistically significant difference in the mean score of distress, self-concept and health literacy in the test group (p-value = 0.000). however, there was no statistically significant difference between the scored before and after the intervention of this group in the distress questionnaire (p value = 0.803) and self-concept (p-value = 0.553), but this difference was also significant in the health literacy of the control group (p-value = 0.005). Conclusion According to the results, it is necessary to hold educational classes and workshops using new educational models for pregnant mothers. Introduction Pregnancy is a transformative period in women’s lives that affects their attitudes and experiences. This period is known as one that can cause psychological, biological and emotional changes (1). Some perspectives consider pregnancy as a period during which the mother gains positive emotions and mental strength, while other perspectives consider it a natural event, and in most cases, a positive development experience (2). This personal experience can range from positive to negative and have significant short- and long-term effects on women’s health, well-being, and social roles (3). Pregnancy is accompanied by physiological and psychological changes that affect the health of the mother and fetus (4–6), 90% of women become pregnant at least once in their lives, so it is essential to examine the psychological changes during this period (1–3). These changes often lead to emotional instability and stress in pregnant women (7). Hans Selye divides stress into two types: eustress (good stress) and distress (bad stress or turmoil). Eustress increases energy and motivation in individuals, but distress can lead to adjustment problems and long-term psychological stress (8). The distress of pregnancy can disrupt the body’s physiological balance leading to cardiovascular problems and a weakened immune system (7, 9). Activation of the HPA axis during pregnancy leads to adverse outcomes such as preterm labor and low birth weight (10–13). About 75% of pregnant women experience significant distress during pregnancy, the most important reason is concern about the health of the fetus (14–16). Excessive distress during pregnancy may delay the baby’s mental and motor development (17). Complications of prenatal distress include miscarriage, low birth weight, and postpartum mental disorders (18). Managing distress during pregnancy has a positive impact on the quality of pregnancy and parenting (19). Despite psychological advances in pregnancy, the mental health of pregnant mothers has received less attention (20, 21). The American College of Obstetrician and Gynecologists (ACOG) emphasizes the importance of screening for distress and providing education on its management of expectant mothers (22–25). Pregnant mothers with lower socioeconomic status are more likely to experience distress, which can lead to more negative outcomes (24). Several ways to manage distress during pregnancy have been suggested, one of which is the use of appropriate educational interventions that can enhance self-concept in pregnant mothers (26). Self-concept is associated with personal well-being, happiness, adaptability, life satisfaction, and reduced anxiety and depression (27). Self-concept is a dynamic system of beliefs, attitudes, and opinions that an individual uses to interpret their identity (28). Positive self-concept is a key factor for individual and social growth and influences an individual’s attitude and evaluations of life (29). Research shows that nurses can help improve self-concept in pregnant mothers through educational programs (30). High-risk pregnancy may cause poor self-concept in pregnant mothers, and training of health personnel in this regard can be useful (31). Distress management is an example of self-care and contributes to a safe pregnancy (32). Self-care includes activities that individuals, families, and communities undertake to maintain health, treat, and prevent disease (33). Self-care can have positive outcomes such as reduced distress and anxiety, increased resilience, and improved mental health (34, 35). Self-care refers to the decisions and activities that a pregnant mother makes to improve her health (36). Conscious self-care activities can help maintain maternal and fatal health during and after pregnancy (37). pregnant mothers should receive the necessary information, skills, and social support for better self-care effectiveness (36, 37). Minor discomforts during pregnancy occur in almost all pregnant mothers, and nursing interventions during this period focus on monitoring, support, and education. So that the nurse should monitor the health status of the mother and fetus, provide emotional support and design and implement her training based on physiological changes during pregnancy, fetal development, childbirth, postpartum care, and newborn care. Educational interventions during pregnancy improve pregnancy and delivery outcomes in both mother and baby (38). Therefore, nurses play a vital role in maternal and newborn health-care and can improve health literacy and ultimately promote health in the generational population of society (39–41). Health literacy includes the skills of reading, listening, analyzing, making decisions, and applying these skills in health issues, and inadequate health literacy has become a global problem (42). Health literacy is particularly important in pregnant mothers, as pregnancy may be the first experience of interacting with a complex health care system that poses challenges (27–29). Inadequate health literacy in pregnant mothers can lead to difficulty in obtaining information and following instructions, and creating adverse consequences for maternal and family health (38, 42). Various educational methods, including traditional, art-based, active learning, and technology-based interventions, have been proposed to promote health literacy and health behaviors (43). The seven-step learning cycle model as a constructive approach, emphasizes active inclusive participation in the learning process (44). The above model consists of seven stages, which is why it is also called the seven-step model. The seven steps of this model are: elicit, engage, explore, explain, elaborate, extend and evaluate. The seven-step learning cycle is simpler than other models and provides an opportunity for effective assessment of learners, which can promote their motivation, knowledge, and critical thinking (44, 46). Based on the researcher’s initial research, this model has been mostly conducted on students in domestic and international studies, for example, various studies have examined the effect of seven-stage learning cycle on students’ critical thinking (47, 48), also in another study, the effect of this cycle on two variables of critical thinking and self-efficacy has been examined (49, 50). In addition, a study titled The Effect of Training on the Seven-Step Learning Cycle on the knowledge of Diabetic Foot Ulcer Prevention, Critical Thinking, and Self-Efficacy of Nursing Students has also been conducted (51). However, as far as the researcher has searched, no study has been conducted that examined the use of the seven-step learning cycle on health literacy, pregnancy concerns, and self-concept of pregnant women. Accordingly, it was decided to conduct a study to investigate the effect of self-care education based on the seven-step learning cycle on pregnancy health literacy, pregnancy concerns, and self-concept of pregnant women referring to health care centers. Research method The present study was a quasi-experimental study with two test and control groups using a pre-test and post-test method. The intervention was conducted in the form of three sessions of self-care training during pregnancy based on a seven-step learning cycle. The research sample consisted of 100 healthy mothers referring to health care centers under the coverage of Shahid Beheshti University of Medical Sciences, who were selected from the research population through random sampling and randomly assigned to two test and control groups. Thus, in the present study, one cluster was randomly selected from among the three main clusters (healthcare networks), and in the second stage, ten health care centers were randomly selected as sub-clusters from among all health centers covered by the cluster, and finally, 5 centers were randomly selected as the test group and 5 centers as the control group. Therefore, among the three main healthcare networks in Tehran (East health center, north health center, and Shemeranat health center), the East Health Center and among the 23 health care centers covered by East health network, Besat-al-nabi, Safdari, Salavati, Mohamadian, seyyed Abdollah centers were randomly selected as the test group and the Taqavi, Jalali, Shabir, Lailatolghadr, and Heffdah Shahrivar centers were randomly selected as the control group. The intervention was implemented in three sessions based on a seven-step learning cycle for the test group. In this study, research tools including demographic questionnaire, pregnancy health literacy questionnaire, pregnancy distress questionnaire, and Beck self-concept questionnaire were used, which were answered before and two weeks after training by both the test and control group. Inclusion and exclusion criteria: Inclusion criteria age range of women between 18 and 45 years’ old Willingness to participate in the study Pregnancy before 32 weeks (at least 6 weeks until the end of the pregnancy period to implement the intervention and conduct the pre-test and post-test) Absence of high-risk pregnancy conditions Absence of underlying physical and mental diseases diagnosed by a doctor Exclusion criteria Unwillingness to continue participating in studies or other educational classes Diagnosis of high-risk pregnancy after entering the study Termination of pregnancy before completing the training classes and conducting post-tests Non-completion or incomplete completion of questionnaires Research tools Demographic information questionnaire The demographic information questionnaire in the present study was researcher-made and included personal information of the participants, including age, occupation, education, spouse’s occupation, age at marriage, household income, number of children, number of pregnancies, history of abortion, history of stillbirth, history of high-risk childbirth, history of high-risk pregnancy in immediate families, and week pregnancy. Mojoyinola Maternal Health Literacy Questionnaire This questionnaire was designed by Mojoyinola in 2011 with the aim of measuring pregnancy and maternal health literacy in the form of self-report for pregnant and lactating mothers (52). This questionnaire has 26 items (14 questions related to maternal health literacy and 12 questions related to pregnancy outcomes) and a five-point Likert response model, was translated into Persian by Kharrazi et al. (2016), and its validity and reliability, have been confirmed with Cronbach’s alpha above 0.7 (53). A higher score on this questionnaire indicates more health literacy. It should be noted that in the present study, only the first part of the questionnaire, which is related to health literacy, was used. The internal correlation of this questionnaire was examined before conducting the study, and Cronbach’s alpha in the heath literacy section was obtained (@=0.880). Aldersey and Lane Pregnancy Distress Questionnaire The pregnancy distress questionnaire was designed and developed by Alderdey and Lane (2011) to measure pregnancy distress (54). This questionnaire was translated into Persian in Iran by Sarmad et al. (2011) and was subjected to psychometric testing, and the content, face and criteria validity of this questionnaire were evaluated and the calculated Cronbach’s alpha coefficient of this questionnaire was estimated to be above 0.7 (55). Currently, this questionnaire has 12 questions and includes 3 components of concerns about birth and newborn, concerns about Wight, body image, and emotional and relationship emotions, which has a five-point Likert response pattern. The range of scores of this questionnaire will be between 12 and 60 and the higher the score of this questionnaire, the greater the level of anxiety during pregnancy. The internal correlation of this questionnaire was examined before conducting the study, and Cronbach’s alpha was obtained (@=0.908). Beck Self-Concept Questionnaire The self-concept theory is a self-report measure of negative attitude toward oneself, or in other words, part of the cognitive trinity of depression. This questionnaire differs from self-esteem and self-concept questionnaires because it asks the respondents to compare themselves with others they know rather than with vague standards (56). This questionnaire was translated into Persian by Namyar (1996) in Iran, and was studied in a group of 480 people, and its validity and reliability criteria, as well as its desired Cronbach’s alpha, were measured. Data collection method Before the training began, all participants completed demographic information questionnaires, the Mojoyinola Maternal Literacy Questionnaire, the Aldersey and Lane Pregnancy Distress Questionnaire, and the Beck Self-Concept Questionnaire. Participants in the test group, participated in three 45 to 60 minute in-person sessions, one self-care training session per week based on the seven-step learning cycle (elicit, engage, explore, explain, elaborate, extend and evaluate), and participants in the control group participated in common pregnancy-related educational classes held by health care centers. All participants completed the questionnaires again, two weeks after the sessions ended (59). At the end of the study, in order to comply with ethical principles in research, educational content was prepared from what was explained in the sessions and was provided to all participants (test and control group). Then, the data were analyzed. Intervention program The educational intervention was conducted in three in-person sessions with an emphasis on elicit, engage, explore, explain, elaborate, extend and evaluate. All seven steps were repeated in each of the three sessions. Three training sessions based on the seven-step cycle were conducted for 45 to 60 minutes (Table 1 ). Table 1 – Educational intervention through the seven-step learning cycle for pregnant mothers Learning steps Purpose Content Teaching method Evaluation method elicit Stimulating the basic knowledge of pregnant mothers to help generate new knowledge The instructor asked simple questions about the importance of self-care during pregnancy to determine their initial knowledge about self-care during pregnancy Question and answer Answering oral questions and feedback engage Making the teaching and learning process enjoyable The instructor began teaching about self-care, pregnancy stress, health literacy and self-concept. She used images and videos about healthy and unhealthy pregnancies. Show videos and photos explore Taking learning out of passive mode By presenting a scenario of a pregnant mother, the researcher attempted to provide pregnant mothers with opportunities to design care plans, formulate hypotheses about the proposed plan, and test the hypothesis. Scenario presentation Group discussion explain Interactive learning between learners and the teacher and its impact on emotions and motivation for inclusive learning At this stage the mothers summarized the results of the hypothesis and drew conclusions and interpretations through group discussion Group discussion Trouble shooting elaborate Solving new problems using what has been learned At this stage, the mothers discussed the summarized findings and resolved each other’s problems. The researcher was responsible for managing and summarizing the discussion at this stage. Group discussion Trouble shooting extend Evaluating the learning accuracy In this stage, to evaluate the level of understanding of pregnant mothers after learning, several oral questions were used to clarify the learning accuracy of pregnant mothers for them and also for the researcher Oral questioning evaluate Extending the learned concepts to personal life At this stage, pregnant mothers were encouraged to explain the learned concepts to themselves so that they could learn and implement a proper self-care program Group discussion Data analysis method The collected data were analyzed using SPSS version 20 software, and the Chi-square and Fisher’s tests were used to examine descriptive statistics. The normality of data distribution was checked using the Kolmogorov-Smirnov test, and based on the results of this test, independent t-tests and Mann-Whitney tests were used to compare the means between the two groups, and paired t-test and Wilcoxon tests were used to compare the means between the two groups (before and after). A significance level of less than 0.5 was considered for comparing means. Results Participants in the present study were on average 29.75 ± 5.05 years old with an average age of marriage of 6.93 ± 4.48 years and were on average 20.21 ± 7.81 weeks pregnant (Table 2). The results of Mann-Whitney, Chi-square, and Fisher’s exact tests, did not show statistically significant differences in terms of demographic and background variables of the two test and control groups (p-value>0.05). The results of Spearman correlation test also showed no statistically significant relationship between demographic variables and mean score of distress, self-concept, and health literacy questionnaires (p-value>0.05). Before the intervention, the scores of the questionnaire were checked using the Mann-Whitney test. The results of the Mann-Whitney test showed no statistically significant difference between the test and control groups before the intervention (p-value>0.05) (Table 3). While, the Mann-Whitney test showed a statistically significant difference between the two test and control groups after the intervention (p-value = 0.000) (Table 4). The results of the Kruskal-Wallis test for within-group comparison or before and after the intervention showed a statistically significant difference in the mean score of the test group (p-value = 0.000). the Kruskal-Wallis test comparing test scores before and after the intervention of the control group showed that there was no statistically significant difference between the scored before and after the intervention of this group in the distress questionnaire (p value=0.803) and self-concept (p-value= 0.553), but this difference was also significant in the health literacy of the control group (p-value= 0.005) (Table 5). Discussion and conclusion The results of this research indicate an increase in the total health literacy score in both the test and control groups over time, but after the intervention, the increase in the health literacy score in the test group was greater than in the control group. The results of our study were consistent with the research of Karbalayi et al. (60). In Karbalayi’s study, there was no significant differences between the test and control groups in terms of perceived stress, health literacy, and self-care behaviors in the pre-test phase, but there were significant differences in terms of all three variables, in the post-test phase. Therefore, self-care education significantly reduced perceived stress and significantly increased health literacy and self-care behaviors in women with gestational diabetes (p-value < 0.001). One reasons for the similarity of the results is the way of presenting educational materials, which used group instruction, group discussion and video presentation in both studies. The results of our study were inconsistent with the research of Sakai et al. The research findings show that before the intervention, the three groups did not have a significant difference in terms of the mean score of the total health literacy and the subscales (functional health literacy, communicational health literacy, and critical health literacy) and were homogeneous, and after the intervention, the total score of the subscales (functional health literacy, communicational health literacy, and critical health literacy) in all three groups did not differ significantly from before the intervention (although in some cases a slight improvement was observed) (61), which is contrast to the current research and the reasons for this can be attributed to the difference in the level of education and literacy of the samples (illiterate people also participated in the mentioned study, but in the present study, all the participants were literate and most of them had at least a diploma), difference in the content provided, difference in the person provided the educational content, difference in total training hours (in the aforementioned study, the material was taught in three 10-minute sessions, but in the present study, the material was taught in three 45-to 60-minutes sessions), difference in the style and model of presenting the material (unlike the present study, questions and answers, group discussions, feedbacks, and active learning in general were not used in the aforementioned study), cultural differences, and different societies. Also, in our study, the results of the Mann-Whitney U test showed that before the intervention, there was no statistically significant difference between the two test and control groups in terms of the mean score of pregnancy distress, but after the intervention, there is a statistically significant difference between the two test and control group in terms of the mean score of pregnancy distress, and pregnancy distress in the test group was significantly lower than the control group after the intervention. The results of our study are consistent with the research of Derya YA et al. the results of this study show that pregnancy-related distress and anxiety can be reduced by providing distance education to pregnant mothers (62), and the reasons for this similarity include the use of random sampling method, the homogeneity of the test and control groups in terms of demographic information, and the use of educational intervention in both studies. The results of our study are inconsistent with the research of Ayraler et al. the results of this study show that after the intervention in two test and control groups, no significant difference was observed between the pregnancy distress and anxiety scores (inconsistent with the present study), but the score of trait anxiety in the test group was reported to be lower than in the control group (63). One of the reasons for inconsistency of the aforementioned study with the present study is the heterogeneity of the demographic characteristics of the two test and control groups. Also, the frequency of the primary gravida (prim parous) women in the test group was significantly higher than the control group. 90.9% of the test group members were prim gravid, and it is possible that the effect of training was not observed in the test group due to the high baseline stress of prim gravid women. Also, in the mentioned study, samples were collected from only one hospital and the selection of the hospital was not random, while in the present study, all the stages of selecting health care centers and samples are random, which can be considered as confounding factors in the study. Also, the results of the present study showed that before the intervention, there was no statistically significant difference between the two test and control groups in terms of the mean scores of the self-concept questionnaire, but after the intervention, there was a statistically significant difference between the two test and control group in terms of the mean score of the self-concept. In general, the results of this study indicate an increase in self-concept scores in the test group and a decrease in self-concept score in the control group over time. The results of our study are inconsistent with the research of Sholevar et al. the results of this study show that before the intervention, the mean scores of Rogers’s self-concept in the test group and control groups did not differ significantly from each other, and after the intervention, the mean scores of Roger’s self-concept in the test group were slightly better than before the intervention, however, the mean scores of self-concept still reported a negative self-concept. While, in the present study, unlike the aforementioned study, the changes in the mean score of self-concept after the intervention in the test group increased significantly, and the mean scores reported a positive self-concept (64). Therefore, these two studies could be different. the reasons for this difference include the different statistical population, the physical, mental, and psychological conditions of the research samples in two studies, the different teaching methods in two studies, the active participation of learners (pregnant mothers) in the teaching process, and the creation of appropriate opportunities for discussion and interaction with each other, as well as the display of videos and photos appropriate to the educational content of the current research. The results of our study are consistent with the research of Nekoui et al. the results of this study showed that the mean score of knowledge on diabetic foot ulcer prevention, critical thinking, and self-efficacy in the test and control groups were significantly different from each other, after training based on the seven-step learning cycle. In the above study, this comparison was performed immediately and one month after training, and a significant difference was observed between the test and control groups in both stages (51). Nekoui’s study is similar to the present study in terms of using a seven-stage learning cycle, and based on this, it can be concluded that holding educational sessions based on the seven-step learning cycle model can have a positive impact on health knowledge or health literacy and self-efficacy of individuals. Conclusion Every study has its strengths as well as limitations. In this study, due to the use of self-report questionnaires, there was a possibility that people might avoid providing truthful answers, so the researcher provided them with sufficient explanations before conducting the study. Based on the general purpose of the study, the findings showed that holding self-care training sessions based on the seven-step learning cycle has an impact on health literacy, distress, and self-concept of pregnant women referring to health care centers. Choosing the right teaching method in nursing education is of great importance because of the interaction learners and can make learning enjoyable for them. According to the results of this study, it is necessary to hold educational classes and workshops using new educational models for pregnant mothers, and further researches is needed to determine the effectiveness of educational interventions based on the seven-step learning model. Declarations Ethics approval and consent to participate The study was approved by The SBMU [1] Research Ethics Committee with code IR.SBMU.PHARMACY.REC.1403.007 . we clarified that our study adhered to the Declaration of Helsinki. Participants signed an informed consent form before entering the study and after being informed of the study's goals. Participants were free to enter or leave the study. All rights of the participants, including anonymity, autonomy, and confidentiality of information, have been respected in this study. [5] Shahid Beheshti University of Medical Sciences Consent for publication All the authors have read the manuscript and accepted to publish it. Availability of data and materials Data available on request / reasonable request of the readers. Competing interests The authors of this article confirm that there is no conflict of interest between them. Funding There is no more financial support for this research. Authors' contributions F.J.T supervised all the process of the study. Sh.Sh and M.M counseled the process of the research and F.P gathered and analyzed the data. All the authors have read and confirmed the manuscript. 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Patient education and counseling. 2019;102(1):119-25. García-Acosta JM, San Juan-Valdivia RM, Fernández-Martínez AD, Lorenzo-Rocha ND, Castro-Peraza ME. Trans* pregnancy and lactation: A literature review from a nursing perspective. International Journal of Environmental Research and Public Health. 2020;17(1):44. Meherali S PN, Mevawala A. Health literacy interventions to improve health outcomes in low-and middle-income countries. HLRP: Health Literacy Research and Practice. 2020;11;4(4):e251-66. Sari NI, Meilinda M, Anwar Y. The Effect of 7E Learning Cycle Model on the Students’ Critical Thinking Skills. Sriwijaya International Journal of Lesson Study. 2020;1(2):23-30. Nurochmah N, Arifin S, Surgandini A, editors. The application of learning cycle 7E model to improve a mathematics communication skills of junior high school students. AIP Conference Proceedings; 2021: AIP Publishing. Mustafa LK, editor Exploring Students’ Integrated Ability and Creativity: Using 7e Learning Cycle Model in Chemistry Learning. Journal of Physics: Conference Series; 2019: IOP Publishing. Ngozi O, Hyacinth N. Promoting critical thinking skills of secondary school chemistry students’ through 7e-learning cycle model. Tropical Journal of Education. 2021;3(1/2):16-27. Suardana IN, Redhana IW, Sudiatmika A, Selamat IN. Students' Critical Thinking Skills in Chemistry Learning Using Local Culture-Based 7E Learning Cycle Model. International Journal of Instruction. 2018;11(2):399-412. Farhadi Varmerzabadi sMG, A. Salimi, M. The effectiveness of expression expression on the cycle pattern Eisencraft's seven steps to improve your skills Self-efficacy and critical thinking of students in district 1 of Karaj. 2018. Liu T, Yu X, Liu M, Wang M, Zhu X, Yang X. A mixed method evaluation of an integrated course in improving critical thinking and creative self-efficacy among nursing students. Nurse Education Today. 2021;106:105067. Nekouei M, Tehrani FJ, Vasli P, Nasiri M. The effect of seven-step educational strategy on knowledge of diabetic foot ulcer prevention, critical thinking and self-efficacy of nursing students: A randomized controlled trial. Nurse Education Today. 2024;137:106164. Mojoyinola J. Influence of maternal health literacy on healthy pregnancy and pregnancy outcomes of women attending public hospitals in Ibadan, Oyo State, Nigeria. African Research Review. 2011;5(3). Kharazi SS, Peyman N, Esmaily H. Effect of an educational intervention based on self-efficacy theory and health literacy strategies on pregnancy outcomes: a randomized clinical trial. The Iranian Journal of Obstetrics, Gynecology and Infertility. 2018;21(5):33-46. Alderdice F, Lynn F. Factor structure of the prenatal distress questionnaire. Midwifery. 2011;27(4):553-9. Yousefi R. Psychometric properties of Persian version of renataldistressquestionnaire (PDQ). Nursing and Midwifery Journal. 2015;13(3):215-25. Beck AT, Steer RA, Epstein N, Brown G. Beck self-concept test. Psychological Assessment: A Journal of Consulting and Clinical Psychology. 1990;2(2):191. HOOMAN H, DEHABADI S. PSYCHOMETRIC PROPERTIES OF THE SELF-CONCEPT AND ITS RELATION TO SOCIAL ADJUSTMENT IN SABZEVAR CITY'S HIGH SCHOOL STUDENTS. 2013. Masoud Namyar HAH. A preliminary investigation of practicality, validity, psychology, and self-concept test software for high school students in Tehran 1995. Montazer-Zohouri EMANMNM. The Effects of e-Learning about Fetal Screening Tests on the Level of Anxiety and Worry in Pregnant Women. 2021. Fatemeh soghra Karbalai Harafteh ZKM, Samaneh Kia The Effect of Self-care Training on Perceived Stress, Health Literacy, and Self-care Behaviors in Women with Gestational Diabetes. 2020. Sakai H, Kawata R, Adhikari R, Thapa YO, Bhandari TR. Effectiveness of art-based health education on anemia and health literacy among pregnant women in Western Nepal: A randomized controlled trial. Plos one. 2024;19(9):e0281789. Derya YA, Altiparmak S, Emine A, GÖkbulut N, Yilmaz AN. Pregnancy and birth planning during COVID-19: The effects of tele-education offered to pregnant women on prenatal distress and pregnancy-related anxiety. Midwifery. 2021;92:102877. Ayraler A, Tosun ŞA, Özkök S. Pregnancy school education program in mother friendly training and research hospital impact on stress and anxiety. Revista da Associação Médica Brasileira. 2023;69:e20230279. Saber Sholehvar M RZ, Nejati S, Haqani S. The effect of self-care education on self-concept in patients with multiple sclerosis: A randomized clinical trial. IJNR 2021; 16 (1) :108-118. Footnotes Shahid Beheshti University of Medical Sciences Table 2 To 5 Table 2 To 5 are available in the Supplementary Files section. Additional Declarations No competing interests reported. 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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-6230605","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":451736150,"identity":"bce44506-e050-4a83-95cc-5ce95645cfce","order_by":0,"name":"Fatemeh Parimi","email":"","orcid":"","institution":"Shahid Beheshti University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Fatemeh","middleName":"","lastName":"Parimi","suffix":""},{"id":451736151,"identity":"6b91fea0-f598-43bf-8fd8-7731a95857fa","order_by":1,"name":"Fereshteh Javaheri Tehrani","email":"data:image/png;base64,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","orcid":"","institution":"Shahid Beheshti University of Medical Sciences","correspondingAuthor":true,"prefix":"","firstName":"Fereshteh","middleName":"Javaheri","lastName":"Tehrani","suffix":""},{"id":451736152,"identity":"77205ca1-cbd5-4e2c-8e66-9d11d0892218","order_by":2,"name":"Shabnam Shariatpanahi","email":"","orcid":"","institution":"Shahid Beheshti University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Shabnam","middleName":"","lastName":"Shariatpanahi","suffix":""},{"id":451736153,"identity":"fb9daed3-cbeb-4ccd-a606-b6c2f759098d","order_by":3,"name":"Mahsa Matbouei","email":"","orcid":"","institution":"Shahid Beheshti University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Mahsa","middleName":"","lastName":"Matbouei","suffix":""}],"badges":[],"createdAt":"2025-03-15 05:38:08","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6230605/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6230605/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":96274951,"identity":"1a95268e-f4cc-4fe1-8301-672d2467b073","added_by":"auto","created_at":"2025-11-19 09:54:24","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":795732,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6230605/v1/22029701-fb09-4111-a9a3-167c9e8a9667.pdf"},{"id":82178698,"identity":"f4aeab46-523d-4e84-a55c-5888bbfe841d","added_by":"auto","created_at":"2025-05-07 11:26:02","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":25544,"visible":true,"origin":"","legend":"","description":"","filename":"Table2to5.docx","url":"https://assets-eu.researchsquare.com/files/rs-6230605/v1/99046b26a9d7a55ea45e494f.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Investigation the effectiveness of self-care education based on the Seven-Step Learning Cycle (7E) on health literacy, distress, and self-concept of pregnant women referring to health care centers","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePregnancy is a transformative period in women\u0026rsquo;s lives that affects their attitudes and experiences. This period is known as one that can cause psychological, biological and emotional changes (1). Some perspectives consider pregnancy as a period during which the mother gains positive emotions and mental strength, while other perspectives consider it a natural event, and in most cases, a positive development experience (2). This personal experience can range from positive to negative and have significant short- and long-term effects on women\u0026rsquo;s health, well-being, and social roles (3).\u003c/p\u003e \u003cp\u003ePregnancy is accompanied by physiological and psychological changes that affect the health of the mother and fetus (4\u0026ndash;6), 90% of women become pregnant at least once in their lives, so it is essential to examine the psychological changes during this period (1\u0026ndash;3). These changes often lead to emotional instability and stress in pregnant women (7). Hans Selye divides stress into two types: eustress (good stress) and distress (bad stress or turmoil). Eustress increases energy and motivation in individuals, but distress can lead to adjustment problems and long-term psychological stress (8).\u003c/p\u003e \u003cp\u003eThe distress of pregnancy can disrupt the body\u0026rsquo;s physiological balance leading to cardiovascular problems and a weakened immune system (7, 9). Activation of the HPA axis during pregnancy leads to adverse outcomes such as preterm labor and low birth weight (10\u0026ndash;13). About 75% of pregnant women experience significant distress during pregnancy, the most important reason is concern about the health of the fetus (14\u0026ndash;16). Excessive distress during pregnancy may delay the baby\u0026rsquo;s mental and motor development (17). Complications of prenatal distress include miscarriage, low birth weight, and postpartum mental disorders (18). Managing distress during pregnancy has a positive impact on the quality of pregnancy and parenting (19).\u003c/p\u003e \u003cp\u003eDespite psychological advances in pregnancy, the mental health of pregnant mothers has received less attention (20, 21). The American College of Obstetrician and Gynecologists (ACOG) emphasizes the importance of screening for distress and providing education on its management of expectant mothers (22\u0026ndash;25). Pregnant mothers with lower socioeconomic status are more likely to experience distress, which can lead to more negative outcomes (24). Several ways to manage distress during pregnancy have been suggested, one of which is the use of appropriate educational interventions that can enhance self-concept in pregnant mothers (26).\u003c/p\u003e \u003cp\u003eSelf-concept is associated with personal well-being, happiness, adaptability, life satisfaction, and reduced anxiety and depression (27). Self-concept is a dynamic system of beliefs, attitudes, and opinions that an individual uses to interpret their identity (28). Positive self-concept is a key factor for individual and social growth and influences an individual\u0026rsquo;s attitude and evaluations of life (29). Research shows that nurses can help improve self-concept in pregnant mothers through educational programs (30). High-risk pregnancy may cause poor self-concept in pregnant mothers, and training of health personnel in this regard can be useful (31).\u003c/p\u003e \u003cp\u003eDistress management is an example of self-care and contributes to a safe pregnancy (32). Self-care includes activities that individuals, families, and communities undertake to maintain health, treat, and prevent disease (33). Self-care can have positive outcomes such as reduced distress and anxiety, increased resilience, and improved mental health (34, 35). Self-care refers to the decisions and activities that a pregnant mother makes to improve her health (36). Conscious self-care activities can help maintain maternal and fatal health during and after pregnancy (37). pregnant mothers should receive the necessary information, skills, and social support for better self-care effectiveness (36, 37).\u003c/p\u003e \u003cp\u003eMinor discomforts during pregnancy occur in almost all pregnant mothers, and nursing interventions during this period focus on monitoring, support, and education. So that the nurse should monitor the health status of the mother and fetus, provide emotional support and design and implement her training based on physiological changes during pregnancy, fetal development, childbirth, postpartum care, and newborn care. Educational interventions during pregnancy improve pregnancy and delivery outcomes in both mother and baby (38). Therefore, nurses play a vital role in maternal and newborn health-care and can improve health literacy and ultimately promote health in the generational population of society (39\u0026ndash;41). Health literacy includes the skills of reading, listening, analyzing, making decisions, and applying these skills in health issues, and inadequate health literacy has become a global problem (42). Health literacy is particularly important in pregnant mothers, as pregnancy may be the first experience of interacting with a complex health care system that poses challenges (27\u0026ndash;29). Inadequate health literacy in pregnant mothers can lead to difficulty in obtaining information and following instructions, and creating adverse consequences for maternal and family health (38, 42). Various educational methods, including traditional, art-based, active learning, and technology-based interventions, have been proposed to promote health literacy and health behaviors (43).\u003c/p\u003e \u003cp\u003eThe seven-step learning cycle model as a constructive approach, emphasizes active inclusive participation in the learning process (44). The above model consists of seven stages, which is why it is also called the seven-step model. The seven steps of this model are: elicit, engage, explore, explain, elaborate, extend and evaluate. The seven-step learning cycle is simpler than other models and provides an opportunity for effective assessment of learners, which can promote their motivation, knowledge, and critical thinking (44, 46). Based on the researcher\u0026rsquo;s initial research, this model has been mostly conducted on students in domestic and international studies, for example, various studies have examined the effect of seven-stage learning cycle on students\u0026rsquo; critical thinking (47, 48), also in another study, the effect of this cycle on two variables of critical thinking and self-efficacy has been examined (49, 50). In addition, a study titled The Effect of Training on the Seven-Step Learning Cycle on the knowledge of Diabetic Foot Ulcer Prevention, Critical Thinking, and Self-Efficacy of Nursing Students has also been conducted (51). However, as far as the researcher has searched, no study has been conducted that examined the use of the seven-step learning cycle on health literacy, pregnancy concerns, and self-concept of pregnant women. Accordingly, it was decided to conduct a study to investigate the effect of self-care education based on the seven-step learning cycle on pregnancy health literacy, pregnancy concerns, and self-concept of pregnant women referring to health care centers.\u003c/p\u003e"},{"header":"Research method","content":"\u003cp\u003eThe present study was a quasi-experimental study with two test and control groups using a pre-test and post-test method. The intervention was conducted in the form of three sessions of self-care training during pregnancy based on a seven-step learning cycle. The research sample consisted of 100 healthy mothers referring to health care centers under the coverage of Shahid Beheshti University of Medical Sciences, who were selected from the research population through random sampling and randomly assigned to two test and control groups. Thus, in the present study, one cluster was randomly selected from among the three main clusters (healthcare networks), and in the second stage, ten health care centers were randomly selected as sub-clusters from among all health centers covered by the cluster, and finally, 5 centers were randomly selected as the test group and 5 centers as the control group. Therefore, among the three main healthcare networks in Tehran (East health center, north health center, and Shemeranat health center), the East Health Center and among the 23 health care centers covered by East health network, Besat-al-nabi, Safdari, Salavati, Mohamadian, seyyed Abdollah centers were randomly selected as the test group and the Taqavi, Jalali, Shabir, Lailatolghadr, and Heffdah Shahrivar centers were randomly selected as the control group. The intervention was implemented in three sessions based on a seven-step learning cycle for the test group. In this study, research tools including demographic questionnaire, pregnancy health literacy questionnaire, pregnancy distress questionnaire, and Beck self-concept questionnaire were used, which were answered before and two weeks after training by both the test and control group.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eInclusion and exclusion criteria:\u003c/h2\u003e \u003cdiv id=\"Sec4\" class=\"Section3\"\u003e \u003ch2\u003eInclusion criteria\u003c/h2\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eage range of women between 18 and 45 years\u0026rsquo; old\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eWillingness to participate in the study\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ePregnancy before 32 weeks (at least 6 weeks until the end of the pregnancy period to implement the intervention and conduct the pre-test and post-test)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eAbsence of high-risk pregnancy conditions\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eAbsence of underlying physical and mental diseases diagnosed by a doctor\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e\n\u003ch3\u003eExclusion criteria\u003c/h3\u003e\n\u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eUnwillingness to continue participating in studies or other educational classes\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eDiagnosis of high-risk pregnancy after entering the study\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eTermination of pregnancy before completing the training classes and conducting post-tests\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eNon-completion or incomplete completion of questionnaires\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e\n\u003ch3\u003eResearch tools\u003c/h3\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eDemographic information questionnaire\u003c/h2\u003e \u003cp\u003eThe demographic information questionnaire in the present study was researcher-made and included personal information of the participants, including age, occupation, education, spouse\u0026rsquo;s occupation, age at marriage, household income, number of children, number of pregnancies, history of abortion, history of stillbirth, history of high-risk childbirth, history of high-risk pregnancy in immediate families, and week pregnancy.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eMojoyinola Maternal Health Literacy Questionnaire\u003c/h2\u003e \u003cp\u003eThis questionnaire was designed by Mojoyinola in 2011 with the aim of measuring pregnancy and maternal health literacy in the form of self-report for pregnant and lactating mothers (52). This questionnaire has 26 items (14 questions related to maternal health literacy and 12 questions related to pregnancy outcomes) and a five-point Likert response model, was translated into Persian by Kharrazi et al. (2016), and its validity and reliability, have been confirmed with Cronbach\u0026rsquo;s alpha above 0.7 (53). A higher score on this questionnaire indicates more health literacy. It should be noted that in the present study, only the first part of the questionnaire, which is related to health literacy, was used. The internal correlation of this questionnaire was examined before conducting the study, and Cronbach\u0026rsquo;s alpha in the heath literacy section was obtained (@=0.880).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eAldersey and Lane Pregnancy Distress Questionnaire\u003c/h3\u003e\n\u003cp\u003eThe pregnancy distress questionnaire was designed and developed by Alderdey and Lane (2011) to measure pregnancy distress (54). This questionnaire was translated into Persian in Iran by Sarmad et al. (2011) and was subjected to psychometric testing, and the content, face and criteria validity of this questionnaire were evaluated and the calculated Cronbach\u0026rsquo;s alpha coefficient of this questionnaire was estimated to be above 0.7 (55). Currently, this questionnaire has 12 questions and includes 3 components of concerns about birth and newborn, concerns about Wight, body image, and emotional and relationship emotions, which has a five-point Likert response pattern. The range of scores of this questionnaire will be between 12 and 60 and the higher the score of this questionnaire, the greater the level of anxiety during pregnancy. The internal correlation of this questionnaire was examined before conducting the study, and Cronbach\u0026rsquo;s alpha was obtained (@=0.908).\u003c/p\u003e\n\u003ch3\u003eBeck Self-Concept Questionnaire\u003c/h3\u003e\n\u003cp\u003eThe self-concept theory is a self-report measure of negative attitude toward oneself, or in other words, part of the cognitive trinity of depression. This questionnaire differs from self-esteem and self-concept questionnaires because it asks the respondents to compare themselves with others they know rather than with vague standards (56). This questionnaire was translated into Persian by Namyar (1996) in Iran, and was studied in a group of 480 people, and its validity and reliability criteria, as well as its desired Cronbach\u0026rsquo;s alpha, were measured.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eData collection method\u003c/h2\u003e \u003cp\u003eBefore the training began, all participants completed demographic information questionnaires, the Mojoyinola Maternal Literacy Questionnaire, the Aldersey and Lane Pregnancy Distress Questionnaire, and the Beck Self-Concept Questionnaire. Participants in the test group, participated in three 45 to 60 minute in-person sessions, one self-care training session per week based on the seven-step learning cycle (elicit, engage, explore, explain, elaborate, extend and evaluate), and participants in the control group participated in common pregnancy-related educational classes held by health care centers. All participants completed the questionnaires again, two weeks after the sessions ended (59). At the end of the study, in order to comply with ethical principles in research, educational content was prepared from what was explained in the sessions and was provided to all participants (test and control group). Then, the data were analyzed.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eIntervention program\u003c/h2\u003e \u003cp\u003eThe educational intervention was conducted in three in-person sessions with an emphasis on elicit, engage, explore, explain, elaborate, extend and evaluate. All seven steps were repeated in each of the three sessions. Three training sessions based on the seven-step cycle were conducted for 45 to 60 minutes (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u0026ndash; Educational intervention through the seven-step learning cycle for pregnant mothers\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=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" 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\"\u003e \u003cp\u003eLearning steps\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePurpose\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eContent\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTeaching method\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eEvaluation method\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eelicit\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStimulating the basic knowledge of pregnant mothers to help generate new knowledge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThe instructor asked simple questions about the importance of self-care during pregnancy to determine their initial knowledge about self-care during pregnancy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eQuestion and answer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"6\" rowspan=\"7\"\u003e \u003cp\u003eAnswering oral questions and feedback\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eengage\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMaking the teaching and learning process enjoyable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThe instructor began teaching about self-care, pregnancy stress, health literacy and self-concept. She used images and videos about healthy and unhealthy pregnancies.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eShow videos and photos\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eexplore\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTaking learning out of passive mode\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBy presenting a scenario of a pregnant mother, the researcher attempted to provide pregnant mothers with opportunities to design care plans, formulate hypotheses about the proposed plan, and test the hypothesis.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eScenario presentation\u003c/p\u003e \u003cp\u003eGroup discussion\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eexplain\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInteractive learning between learners and the teacher and its impact on emotions and motivation for inclusive learning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAt this stage the mothers summarized the results of the hypothesis and drew conclusions and interpretations through group discussion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGroup discussion\u003c/p\u003e \u003cp\u003eTrouble shooting\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eelaborate\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSolving new problems using what has been learned\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAt this stage, the mothers discussed the summarized findings and resolved each other\u0026rsquo;s problems. The researcher was responsible for managing and summarizing the discussion at this stage.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGroup discussion\u003c/p\u003e \u003cp\u003eTrouble shooting\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eextend\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEvaluating the learning accuracy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIn this stage, to evaluate the level of understanding of pregnant mothers after learning, several oral questions were used to clarify the learning accuracy of pregnant mothers for them and also for the researcher\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOral questioning\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eevaluate\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExtending the learned concepts to personal life\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAt this stage, pregnant mothers were encouraged to explain the learned concepts to themselves so that they could learn and implement a proper self-care program\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGroup discussion\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eData analysis method\u003c/h2\u003e \u003cp\u003eThe collected data were analyzed using SPSS version 20 software, and the Chi-square and Fisher\u0026rsquo;s tests were used to examine descriptive statistics. The normality of data distribution was checked using the Kolmogorov-Smirnov test, and based on the results of this test, independent t-tests and Mann-Whitney tests were used to compare the means between the two groups, and paired t-test and Wilcoxon tests were used to compare the means between the two groups (before and after). A significance level of less than 0.5 was considered for comparing means.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eParticipants in the present study were on average 29.75\u0026thinsp;\u0026plusmn;\u0026thinsp;5.05 years old with an average age of marriage of 6.93\u0026thinsp;\u0026plusmn;\u0026thinsp;4.48 years and were on average 20.21\u0026thinsp;\u0026plusmn;\u0026thinsp;7.81 weeks pregnant (Table 2).\u003c/p\u003e\n\u003cp\u003eThe results of Mann-Whitney, Chi-square, and Fisher\u0026rsquo;s exact tests, did not show statistically significant differences in terms of demographic and background variables of the two test and control groups (p-value\u0026gt;0.05). The results of Spearman correlation test also showed no statistically significant relationship between demographic variables and mean score of distress, self-concept, and health literacy questionnaires (p-value\u0026gt;0.05).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBefore the intervention, the scores of the questionnaire were checked using the Mann-Whitney test. The results of the Mann-Whitney test showed no statistically significant difference between the test and control groups before the intervention (p-value\u0026gt;0.05) (Table 3). While, the Mann-Whitney test showed a statistically significant difference between the two test and control groups after the intervention (p-value = 0.000) (Table 4). The results of the Kruskal-Wallis test for within-group comparison or before and after the intervention showed a statistically significant difference in the mean score of the test group (p-value = 0.000). the Kruskal-Wallis test comparing test scores before and after the intervention of the control group showed that there was no statistically significant difference between the scored before and after the intervention of this group in the distress questionnaire (p value=0.803) and self-concept (p-value= 0.553), but this difference was also significant in the health literacy of the control group (p-value= 0.005) (Table 5).\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion and conclusion","content":"\u003cp\u003eThe results of this research indicate an increase in the total health literacy score in both the test and control groups over time, but after the intervention, the increase in the health literacy score in the test group was greater than in the control group. The results of our study were consistent with the research of Karbalayi et al. (60). In Karbalayi’s study, there was no significant differences between the test and control groups in terms of perceived stress, health literacy, and self-care behaviors in the pre-test phase, but there were significant differences in terms of all three variables, in the post-test phase. Therefore, self-care education significantly reduced perceived stress and significantly increased health literacy and self-care behaviors in women with gestational diabetes (p-value \u0026lt; 0.001). One reasons for the similarity of the results is the way of presenting educational materials, which used group instruction, group discussion and video presentation in both studies. The results of our study were inconsistent with the research of Sakai et al. The research findings show that before the intervention, the three groups did not have a significant difference in terms of the mean score of the total health literacy and the subscales (functional health literacy, communicational health literacy, and critical health literacy) and were homogeneous, and after the intervention, the total score of the subscales (functional health literacy, communicational health literacy, and critical health literacy) in all three groups did not differ significantly from before the intervention (although in some cases a slight improvement was observed) (61), which is contrast to the current research and the reasons for this can be attributed to the difference in the level of education and literacy of the samples (illiterate people also participated in the mentioned study, but in the present study, all the participants were literate and most of them had at least a diploma), difference in the content provided, difference in the person provided the educational content, difference in total training hours (in the aforementioned study, the material was taught in three 10-minute sessions, but in the present study, the material was taught in three 45-to 60-minutes sessions), difference in the style and model of presenting the material (unlike the present study, questions and answers, group discussions, feedbacks, and active learning in general were not used in the aforementioned study), cultural differences, and different societies.\u003c/p\u003e\u003cp\u003eAlso, in our study, the results of the Mann-Whitney U test showed that before the intervention, there was no statistically significant difference between the two test and control groups in terms of the mean score of pregnancy distress, but after the intervention, there is a statistically significant difference between the two test and control group in terms of the mean score of pregnancy distress, and pregnancy distress in the test group was significantly lower than the control group after the intervention. The results of our study are consistent with the research of Derya YA et al. the results of this study show that pregnancy-related distress and anxiety can be reduced by providing distance education to pregnant mothers (62), and the reasons for this similarity include the use of random sampling method, the homogeneity of the test and control groups in terms of demographic information, and the use of educational intervention in both studies.\u003c/p\u003e\u003cp\u003eThe results of our study are inconsistent with the research of Ayraler et al. the results of this study show that after the intervention in two test and control groups, no significant difference was observed between the pregnancy distress and anxiety scores (inconsistent with the present study), but the score of trait anxiety in the test group was reported to be lower than in the control group (63). One of the reasons for inconsistency of the aforementioned study with the present study is the heterogeneity of the demographic characteristics of the two test and control groups. Also, the frequency of the primary gravida (prim parous) women in the test group was significantly higher than the control group. 90.9% of the test group members were prim gravid, and it is possible that the effect of training was not observed in the test group due to the high baseline stress of prim gravid women. Also, in the mentioned study, samples were collected from only one hospital and the selection of the hospital was not random, while in the present study, all the stages of selecting health care centers and samples are random, which can be considered as confounding factors in the study.\u003c/p\u003e\u003cp\u003eAlso, the results of the present study showed that before the intervention, there was no statistically significant difference between the two test and control groups in terms of the mean scores of the self-concept questionnaire, but after the intervention, there was a statistically significant difference between the two test and control group in terms of the mean score of the self-concept. In general, the results of this study indicate an increase in self-concept scores in the test group and a decrease in self-concept score in the control group over time. The results of our study are inconsistent with the research of Sholevar et al. the results of this study show that before the intervention, the mean scores of Rogers’s self-concept in the test group and control groups did not differ significantly from each other, and after the intervention, the mean scores of Roger’s self-concept in the test group were slightly better than before the intervention, however, the mean scores of self-concept still reported a negative self-concept. While, in the present study, unlike the aforementioned study, the changes in the mean score of self-concept after the intervention in the test group increased significantly, and the mean scores reported a positive self-concept (64). Therefore, these two studies could be different. the reasons for this difference include the different statistical population, the physical, mental, and psychological conditions of the research samples in two studies, the different teaching methods in two studies, the active participation of learners (pregnant mothers) in the teaching process, and the creation of appropriate opportunities for discussion and interaction with each other, as well as the display of videos and photos appropriate to the educational content of the current research.\u003c/p\u003e\u003cp\u003eThe results of our study are consistent with the research of Nekoui et al. the results of this study showed that the mean score of knowledge on diabetic foot ulcer prevention, critical thinking, and self-efficacy in the test and control groups were significantly different from each other, after training based on the seven-step learning cycle. In the above study, this comparison was performed immediately and one month after training, and a significant difference was observed between the test and control groups in both stages (51). Nekoui’s study is similar to the present study in terms of using a seven-stage learning cycle, and based on this, it can be concluded that holding educational sessions based on the seven-step learning cycle model can have a positive impact on health knowledge or health literacy and self-efficacy of individuals.\u003c/p\u003e\n\u003ch3\u003eConclusion\u003c/h3\u003e\n\u003cp\u003eEvery study has its strengths as well as limitations. In this study, due to the use of self-report questionnaires, there was a possibility that people might avoid providing truthful answers, so the researcher provided them with sufficient explanations before conducting the study. Based on the general purpose of the study, the findings showed that holding self-care training sessions based on the seven-step learning cycle has an impact on health literacy, distress, and self-concept of pregnant women referring to health care centers. Choosing the right teaching method in nursing education is of great importance because of the interaction learners and can make learning enjoyable for them. According to the results of this study, it is necessary to hold educational classes and workshops using new educational models for pregnant mothers, and further researches is needed to determine the effectiveness of educational interventions based on the seven-step learning model.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by \u003cstrong\u003eThe SBMU\u003cstrong\u003e[1]\u003c/strong\u003e Research Ethics Committee\u0026nbsp;\u003c/strong\u003ewith code \u003cu\u003eIR.SBMU.PHARMACY.REC.1403.007\u003c/u\u003e. we clarified that our study adhered to the Declaration of Helsinki. Participants signed an informed consent form before entering the study and after being informed of the study\u0026apos;s goals. Participants were free to enter or leave the study. All rights of the participants, including anonymity, autonomy, and confidentiality of information, have been respected in this study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e[5] \u003cstrong\u003eShahid Beheshti University of Medical Sciences\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll the authors have read the manuscript and accepted to publish it.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData available on request / reasonable request of the readers.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors of this article confirm that there is no conflict of interest between them.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eFunding\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere is no more financial support for this research.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eF.J.T supervised all the process of the study. Sh.Sh and M.M counseled the process of the research and F.P gathered and analyzed the data. All the authors have read and confirmed the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eAcknowledgement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank all the pregnant mothers who participated in this study.\u003c/p\u003e\n\u003cp\u003e\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003e\u003cstrong\u003eClinical Trial Number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eThorpe KJ, Dragonas T, Golding J. The effects of psychosocial factors on the emotional well-being of women during pregnancy: a cross-cultural study of Britain and Greece. Journal of Reproductive and Infant Psychology. 1992;10(4):191-204.\u003c/li\u003e\n\u003cli\u003eBrown MA, Lindheimer MD, de Swiet M, Assche AV, Moutquin J-M. 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Pregnancy school education program in mother friendly training and research hospital impact on stress and anxiety. Revista da Associa\u0026ccedil;\u0026atilde;o M\u0026eacute;dica Brasileira. 2023;69:e20230279.\u003c/li\u003e\n\u003cli\u003eSaber Sholehvar M RZ, Nejati S, Haqani S. The effect of self-care education on self-concept in patients with multiple sclerosis: A randomized clinical trial. IJNR 2021; 16 (1) :108-118.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Footnotes","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003e\u003cb\u003eShahid Beheshti University of Medical Sciences\u003c/b\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Table 2 To 5","content":"\u003cp\u003eTable 2 To 5 are available in the Supplementary Files section.\u003c/p\u003e\n"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-6230605/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6230605/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction:\u003c/h2\u003e \u003cp\u003eThe aim of the study was to investigate the effect of self-care education based on the seven-step learning cycle on pregnancy health literacy, pregnancy concerns, and self-concept of pregnant women referring to health care centers\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThe present study was a quasi-experimental study with two test and control groups using a pre-test and post-test method. The research sample consisted of 100 healthy mothers referring to health care centers. All the participants completed demographic, Maternal Literacy, Pregnancy Distress and the Beck Self-Concept Questionnaires before and after the intervention. The intervention was conducted based on the Seven-step Learning Cycle on the test group.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe results showed a statistically significant difference in the mean score of distress, self-concept and health literacy in the test group (p-value\u0026thinsp;=\u0026thinsp;0.000). however, there was no statistically significant difference between the scored before and after the intervention of this group in the distress questionnaire (p value\u0026thinsp;=\u0026thinsp;0.803) and self-concept (p-value\u0026thinsp;=\u0026thinsp;0.553), but this difference was also significant in the health literacy of the control group (p-value\u0026thinsp;=\u0026thinsp;0.005).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eAccording to the results, it is necessary to hold educational classes and workshops using new educational models for pregnant mothers.\u003c/p\u003e","manuscriptTitle":"Investigation the effectiveness of self-care education based on the Seven-Step Learning Cycle (7E) on health literacy, distress, and self-concept of pregnant women referring to health care centers","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-07 11:25:58","doi":"10.21203/rs.3.rs-6230605/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"36bea588-f808-4551-9ffe-90596e417d26","owner":[],"postedDate":"May 7th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-11-19T09:54:05+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-07 11:25:58","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6230605","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6230605","identity":"rs-6230605","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}