Iran Journal of Nursing

Introduction
Hospitalization at any age, especially during childhood, is considered a stressful experience. Although the death rate of children has decreased in recent decades, the rate of hospitalization in pediatric intensive care units (PICUs) has increased due to the increase in chronic conditions and the need for specialized services. Most of the children admitted to PICUs have life-threatening conditions. Hospitalization of a child is very stressful for the parents. This experience disturbs the physical and mental functioning of the parents. Anxiety, fear, and stress occur after an accident. The results of a study showed that 24% of parents with a child hospitalized in the PICU experienced severe anxiety, 51% experienced severe depression, and 26% experienced decision-making problems. Less attention has been paid to the support given to the parents of children in the PICU by the healthcare team. Providing appropriate interventions to reduce anxiety and stress and support of parents by the healthcare team, especially nurses, is necessary. Mobile applications have recently been used to improve patients’ chronic disease self-management and disease prevention. They have less been used for caregivers. This study aims to investigate the effect of a mobile-based educational intervention on the anxiety and self-efficacy of mothers of children hospitalized in the PICUs.

Methods
This is a quasi-experimental study. The study population consists of the mothers of children admitted to the PICU of hospitals in Shahrekord, Iran. Among them, 60 were selected and included in the study. The sample size was determined 30 per group using the sample size formula, considering the alpha value of 0.05 and the test power of 80%, previous similar studies, and a 10% sample dropout. The selected samples were randomly assigned to intervention and control groups using random number generator software. Inclusion criteria were age over 18 years, having  a child hospitalized in the PICU, no previous experience of child hospitalization in the PICU or the death of the child, no history of any neurological and psychiatric diseases, no use of neuropsychiatric medications, no drug addiction, no history of divorce, reading and writing literacy, not being a member of the healthcare team, having a smart cell phone with access to WhatsApp for one hour a day, and having consent to participate in the study. Mothers of children with a history of hospitalization in the intensive care units, mothers who experienced the death of a hospitalized child, and mothers who experienced a stressful event such as divorce or job loss at the time of the study were excluded from the study. To prevent the exchange of information between the two groups, the mothers in the control group were selected from Kashani Hospital, and the mothers in the intervention group were selected from Hajar Hospital. 
After giving complete explanations about the study objectives to the mothers, a written informed consent was obtained from them. First, a demographic form was completed from the children’s medical files with the help of the mothers in both groups. Then, the Spielberger state-trait anxiety inventory and Schwarzer & Jerusalem’s general self-efficacy scale were completed by the mothers. Then, a WhatsApp group was created separately for the mothers in the intervention and control groups. For the intervention group, education was provided at 4 sessions of 60 minutes for 4 days. The educational content was provided in the form of multimedia files (audio and video) and pamphlets. The educational content was prepared based on the review of related books and articles and was approved by the supervisor and advisor professors and an expert in psychology. For the control group, routine education was provided by the nurses of the PICU. One week after the intervention, the two questionnaires were completed by both groups again.

Results
There was no significant difference between the two groups in terms of age (P=0.81). In both groups, most of the mothers had a high school diploma, and the difference in educational level between the groups was not statistically significant (P=0.83). In both groups, most of the mothers were housekeepers, and the difference in occupation between the groups was not statistically significant (P=0.59). The difference between the groups in terms of the child age was not statistically significant (P=0.66). In both groups, most of the fathers had lower than high school education, and the difference in the father’s educational level between the groups was not statistically significant (P=0.79). In both groups, most fathers were self-employed, and the difference in father’s occupation was not statistically significant (P=0.33). The difference in children’s gender between the two groups was not statistically significant either (P=0.79). In both groups, most of the children had no history of previous hospitalization, and the difference in this regard between the two groups was not statistically significant (P=0.29). 

Conclusion
The present study was conducted to investigate the effect of a mobile-based educational intervention on the anxiety and self-efficacy of mothers of children hospitalized in the PICUs. The education was provided over WhatsApp application. There was no significant difference between the two groups in state anxiety and self-efficacy before and after the intervention. The differences between the pretest and posttest scores of state anxiety and self-efficacy were not significant in any groups, either. 
A study in Brazil in 2018 showed that providing information by the healthcare team to mothers of children in the PICU could empower them. Another study in 2022 in Korea suggested that, for effective communication between mothers and nurses, necessary measures should be taken to provide a suitable strategy for the participation of parents and gain their trust. A qualitative study in Turkey in 2018 showed that mothers with children hospitalized in the PICUs had various needs that the nurses neglected. 
The authors stated that since nurses are responsible for child and family care in the PICU, they should show more attention and provide more support to them, especially mothers. Another study in Egypt in 2019 suggested that the important factors in the satisfaction of mothers of children in PICUs were the participation of parents in child care and the proper communication of the healthcare team with the parents.
To reduce anxiety and increase the self-efficacy of mothers of children in the PICUs, nurses, as important members of the healthcare team, should use other measures along with virtual education, which needs more research.

Ethical Considerations
Compliance with ethical guidelines
All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975. This study was approved by the ethics committee of Shahrekord University of Medical Sciences (Code: IR.SKUMS.REC.1401.050). Informed consent was obtained from the participants in the study. 

Funding
This project was funded by the Shahrekord University of Medical Science (Grant: 3864).

Authors' contributions
All authors contributed to preparing this article.

Conflict of interest
The authors declare no conflict of interest.

Acknowledgments
The authors would like to thank all parents who participated in the study and the Shahrekord University of Medical Sciences for their financial support.


References

1. Delvecchio E, Salcuni S, Lis A, Germani A, Di Riso D. Hospitalized children: Anxiety, coping strategies, and pretend play. Front Public Health. 2019; 7:250. [DOI:10.3389/fpubh.2019.00250] [PMID]
2. Rennick JE, St-Sauveur I, Knox AM, Ruddy M. Exploring the experiences of parent caregivers of children with chronic medical complexity during pediatric intensive care unit hospitalization: An interpretive descriptive study.  BMC Pediatr. 2019; 19(1):272. [DOI:10.1186/s12887-019-1634-0] [PMID]
3. Alisamir M, Mirkarimi M, Mirzaee S, Heidari S, Barouti S, Mohammadi S. Characteristics and outcomes of patients admitted to a pediatric intensive Care Unit in Southwest of Iran.  Acta Med Iran. 2022; 60(10):646-54. [DOI:10.18502/acta.v60i10.11558]
4. Coulthard MG, Varghese V, Harvey LP, Gillen TC, Kimble RM, Ware RS. A review of children with severe trauma admitted to pediatric intensive care in Queensland, Australia. PLoS One. 2019; 14(2):e0211530. [DOI:10.1371/journal.pone.0211530] [PMID]
5. Colville G. The tip of an iceberg? A “big data” study examines the evidence for new mental health problems in parents after PICU. Pediatr Crit Care Med. 2020; 21(11):1002-3.  [DOI:10.1097/PCC.0000000000002588] [PMID]
6. Kastner K, Pinto N, Msall ME, Sobotka S. PICU follow-Up: The impact of missed school in a cohort of children following PICU Admission. Crit Care Explor. 2019; 1(8):e0033.  [DOI:10.1097/CCE.0000000000000033] [PMID]
7. Alzawad Z, Lewis FM, Kantrowitz-Gordon I, Howells AJ. A qualitative study of parents’ experiences in the pediatric intensive care unit: Riding a roller coaster. J Pediatr Nurs. 2020; 51:8-14 [DOI:10.1016/j.pedn.2019.11.015] [PMID]
8. van Benthum MV, van Dijk T, Maas-van Schaaijk NM, van Zwol A. Psychological problems in parents of children with bronchiolitis following paediatric intensive care unit (PICU) admission. Acta Paediatr. 2022; 111(5):1054-5. [DOI:10.1111/apa.16272] [PMID]
9. Stremler R, Haddad S, Pullenayegum E, Parshuram C. Psychological outcomes in parents of critically Ill hospitalized children. J Pediatr Nurs. 2017; 34:36-43. [DOI:10.1016/j.pedn.2017.01.012] [PMID]
10. Vasli P, Dehghan-Nayeri N, Borim-Nezhad L, Vedadhir A. Dominance of paternalism on family-centered care in the Pediatric Intensive Care Unit (PICU): An ethnographic study. Issues Compr Pediatr Nurs. 2015; 38(2):118-35.  [DOI:10.3109/01460862.2015.1035464] [PMID]
11. Debelić I, Mikolčić A, Tihomirović J, Barić I, Lendić Đ, Nikšić Ž, et al. Stressful experiences of parents in the paediatric intensive care unit: Searching for the most intensive PICU stressors.  Int J Environ Res Public Health. 2022; 19(18):11450. [DOI:10.3390/ijerph191811450] [PMID]
12. Motahari Niya H, Hojjati H. The impact of General Psychological Training on the self-efficacy of Mothers whose Children Undergoing Surgery in Taleghani Pediatrics Hospital in Gorgan, Iran. J Res Dev Nurs Midw. 2019; 16 (1):43-50. [DOI:10.29252/jgbfnm.16.1.44]
13. Foster CC, Blackwell CK, Kan K, Morales L, Cella D, Shaunfield S.“Parental self-efficacy managing a child’s medications and treatments: Adaptation of a PROMIS measure.”J Patient Rep Outcomes. 2023; 7(1):10. [DOI:10.1186/s41687-023-00549-z] [PMID]
14. Boeschoten SA, Dulfer K, Boehmer ALM, Merkus PJFM, van Rosmalen J, de Jongste JC, et al. Quality of life and psychosocial outcomes in children with severe acute asthma and their parents. Pediatr Pulmonol. 2020; 55(11):2883-92. [DOI:10.1002/ppul.25034] [PMID]
15. Waak M, Harnischfeger J, Ferguson A, Gibbons K, Nguyen KH, Long D.  Every child, every day, back to play: The PICUstars protocol-implementation of a nurse-led PICU liberation program. BMC Pediatr. 2022; ;22(1):279. [DOI:10.1186/s12887-022-03232-2] [PMID]
16. Johanna B, Noora G, Kaisa M, Heikki E, Mari L. Nurses’ and patients’ perceptions about psychiatric intensive care-an integrative literature review. Issues Ment Health Nurs. 2022; 43(11):983-95. [DOI:10.1080/01612840.2022.2101079] [PMID]
17. Bruyneel A, Tack J, Droguet M, Maes J, Wittebole X, Miranda DR, et al. Measuring the nursing workload in intensive care with the Nursing Activities Score (NAS): A prospective study in 16 hospitals in Belgium. J Crit Care. 2019; 54:205-11. [DOI:10.1016/j.jcrc.2019.08.032] [PMID]
18. Slusher TM, Kiragu AW, Day LT, Bjorklund AR, Shirk A, Johannsen C, et al. Pediatric critical care in resource-limited settings-overview and lessons learned.  Front Pediatr. 2018; 6:49. [DOI:10.3389/fped.2018.00049] [PMID]
19. Hill C, Knafl KA, Santacroce SJ. Family-centered care from the perspective of parents of children cared for in a pediatric intensive care unit: An integrative review.  J Pediatr Nurs. 2018; 41:22-33. [DOI:10.1016/j.pedn.2017.11.007] [PMID]
20. Coats H, Bourget E, Starks H, Lindhorst T, Saiki-Craighill S, Curtis JR, et al. Nurses’ reflections on benefits and challenges of implementing family-centered care in pediatric intensive care units. Am J Crit Care. 2018; 27(1):52-8. [DOI:10.4037/ajcc2018353] [PMID]
21. Matricardi PM, Dramburg S, Alvarez-Perea A, Antolín-Amérigo D, Apfelbacher C, Atanaskovic-Markovic M, et al. The role of mobile health technologies in allergy care: An EAACI position paper. Allergy. 2020; 75(2):259-72. [DOI:10.1111/all.13953] [PMID]
22. Longacre M, Grande S, Hager A, Montan M, Bergquist RP, Martensson M, et al. Clinical adoption of mHealth technology to support pediatric cystic fibrosis care in Sweden: Qualitative case study. JMIR Pediatr Parent. 2018; 1(2):e11080. [DOI:10.2196/11080] [PMID]
23. Siebert JN, Gosetto L, Sauvage M, Bloudeau L, Suppan L, Rodieux F, et al. Usability Testing and Technology Acceptance of an mHealth App at the Point of Care During Simulated Pediatric In- and Out-of-Hospital Cardiopulmonary Resuscitations: Study Nested Within 2 Multicenter Randomized Controlled Trials. JMIR Hum Factors. 2022; 9(1):e35399.[DOI:10.2196/35399] [PMID]
24. Shorey S, Ng YPM, Ng ED, Siew AL, Mörelius E, Yoong J, et al. Effectiveness of a technology-based supportive educational parenting program on parental outcomes (part 1): Randomized controlled trial. J Med Internet Res. 2019; 21(2):e10816. [DOI:10.2196/10816] [PMID]
25. Spielberger CD, Gonzalez-Reigosa F, Martinez-Urrutia A, Natalicio LF, Natalicio DS. The state-trait anxiety inventory. Revista Interamericana de Psicologia/Interam J Psychol. 1971; 5(3 & 4). [Link]
26. Hedayati E, Hazrati M, Momen Nasab M, Shokoohi H, Afkari F. [The relationship between spiritual well-being and anxiety of aged people admitted in coronary care units (Persian)]. Iran J Ageing. 2016; 11(3):432-9. [DOI:10.21859/sija-1103432]
27. Schwarzer R, Jerusalem M. Generalized self-efficacy scale. J. Weinman, S. Wright, & M. Johnston, Measures in health psychology: A user’s portfolio. Causal and control beliefs. 1995; 35:37.
28. Ebrahimi Moghaddam H, Mahmodi A. [The relationship between quality of life and self-efficacy among students with mental health component (Persian)]. J Couns Res. 2017; 16(63):67-80. [Link]
29. Azevedo MSN, Oliveira ICDS, Souza TV, Moraes JRMM, Martinez EA, Araújo BDS. Empowerment of the mothers of children in a pediatric intensive care unit. Rev Bras Enferm. 2018; 71(3):998-1006. [DOI:10.1590/0034-7167-2016-0689] [PMID]
30. Park B, Oh WO. Differences in the perceptions of partnership between nurses and mothers of children in a pediatric intensive care unit in South Korea: A qualitative study. Child Health Nurs Res. 2022; 28(3):197-207. [DOI:10.4094/chnr.2022.28.3.197] [PMID]
31. Beytut D, Özalp Gerçeker G, Karayağız Muslu G. A qualitative study exploring the needs of Turkish mothers in the Pediatric Intensive Care Unit. J Pediatr Res. 2018; 5(4):187-93. [DOI:10.4274/jpr.37232]
32. Sauers-Ford HS, Hamline MY, Gosdin MM, Kair LR, Weinberg GM, Marcin JP, et al. Acceptability, usability, and effectiveness: A qualitative study evaluating a pediatric telemedicine program. Acad Emerg Med. 2019; 26(9):1022-33. [DOI:10.1111/acem.13763] [PMID]
33. Sukhov R, Asante A, Ilizarov G. Telemedicine for pediatric physiatry: How social distancing can bring physicians and families closer together.  J Pediatr Rehabil Med. 2020; 13(3):329-38. [DOI:10.3233/PRM-200747] [PMID]
34. Marcano Belisario JS, Huckvale K, Greenfield G, Car J, Gunn LH. Smartphone and tablet self management apps for asthma. Cochrane Database Syst Rev. 2013; 2013(11):CD010013. [DOI:10.1002/14651858.CD010013.pub2] [PMID]
35. Salvador Á, Crespo C, Barros L. The benefits of family-centered care for parental self-efficacy and psychological well-being in parents of children with cancer.  J Child Fam Stud. 2019; 28(7):1926-36. [DOI:10.1007/s10826-019-01418-4]
36. Rodríguez-Rey R, Alonso-Tapia J, Colville G. Prediction of parental posttraumatic stress, anxiety and depression after a child’s critical hospitalization. J Crit Care. 2018; 45:149-155. [DOI:10.1016/j.jcrc.2018.02.006] [PMID]
37. Verma K, Dharni IT. A mixed method research on experience of stress among mothers of children admitted in Pediatric Intensive Care Unit of Indira Gandhi Medical College and Hospital, District Shimla (Himachal Pradesh). Int J Adv Res Ideas Innov Technol. 2019; 5(3):1887-99. [Link] 
38. Gholami S, Reyhani T, Beiraghi M, Behnam Vashani H. Effect of a supportive educational program on self-efficacy of mothers with epileptic children.  Evidence Based Care Journal. 2016; 6(2):49-56. [DOI:10.22038/EBCJ.2016.7321]