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Table of Contents
ORIGINAL ARTICLE
Year : 2020  |  Volume : 52  |  Issue : 1  |  Page : 24-29

To Analyze the effect of person-environment-occupation intervention model on stress and breast-feeding efficacy on mothers of preterm neonates: A randomized controlled study


Occupational Therapy Training School and Center, L.T.M.M.C and G.H, Mumbai, Maharashtra, India

Date of Submission03-Jan-2020
Date of Decision18-Mar-2020
Date of Acceptance18-Mar-2020
Date of Web Publication30-Mar-2020

Correspondence Address:
Dr. Shrutika Surendra Patil
66/2, Ramnagar CHS, B.B. Khedekar Road, Wadala, Mumbai - 400 031, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijoth.ijoth_1_20

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  Abstract 


Background: Mothers of infants admitted to the neonatal intensive care unit (NICU) are believed to experience high levels of distress, which affects breastfeeding ability in nursing mothers. The Person-Environment-Occupation (PEO) model based on environmental behavior approach was used as a tool to enhance coping behavior in mothers of preterm infants. Mothers were assessed for their stress levels and breastfeeding abilities and for environmental barriers and coping skills. Objectives: The objectives of this study were to assess the effect of PEO model as a tool in the intervention of postpartum mothers of preterm infants and on parental stress levels and breastfeeding efficacy. Study Design: A randomized, intervention-controlled study design was chosen for the research. Methods: A total of 52 postpartum mothers of preterm infants of gestational age 28 weeks to 36 weeks from NICU were included using a convenient sampling method using a lottery method for random allocation into two groups. The control group was given counseling regarding breastfeeding, handling, and positioning of infants, and the experimental group received intervention considering their individual environmental barriers and then implementing appropriate solutions with client agreement. The baseline scores were obtained on the Edinburgh Postnatal Depression Scale (EPDS), Parental Stress Scale: NICU (PSS:NICU), Breastfeeding Self-Efficacy Scale (BFSES) and followup was taken after 15 day. Results: The experimental group showed a significant reduction in PSS score at 95% confidence interval [CI]: 143.86-158.57 to 95% CI: 124.88-144.95, whereas the control group showed a PSS score at 95% CI: 135.16-151.19 to 95% CI: 127.45-144.62, with P = 1.23. On EPDS, the experimental group showed a score at 95% CI: 15.99-20.22 to 95% CI: 13.16-16.19 and the control group showed a minimal reduction at 95% CI: 14.18-18.81 to 95% CI: 13.75-17.64, with P = 0.65. No infant was able to receive breastfeed preintervention; however, some of them had shown the ability to attach while feeding. This has given the confidence of breastfeeding ability to mothers. Postintervention, the experimental group showed a significant difference in breastfeeding efficacy, with P = 0.0003. Conclusions: PEO intervention model can be recommended for improving mothers' breastfeeding capabilities in preterm neonates.

Keywords: Breastfeeding, Occupational Therapy, Parent, Person-Environment-Occupation Model, Preterm Infant, Stress


How to cite this article:
Jaywant SS, Patil SS, Shrivastav DS. To Analyze the effect of person-environment-occupation intervention model on stress and breast-feeding efficacy on mothers of preterm neonates: A randomized controlled study. Indian J Occup Ther 2020;52:24-9

How to cite this URL:
Jaywant SS, Patil SS, Shrivastav DS. To Analyze the effect of person-environment-occupation intervention model on stress and breast-feeding efficacy on mothers of preterm neonates: A randomized controlled study. Indian J Occup Ther [serial online] 2020 [cited 2020 May 25];52:24-9. Available from: http://www.ijotonweb.org/text.asp?2020/52/1/24/281634




  Introduction Top


A potentially stressful life event is a birth of preterm neonates and admission in a neonatal intensive care unit (NICU).[1] The thoughts provoking anxiety may be related to an infant's prematurity and the NICU environment, as well as isolation, physical and emotional, from their infants. [2,3] The family-centered care may be beneficial to reduce stress in parents and enhance the nurturing of preterm infants. The Person-Environment-Occupation (PEO) model can be used to direct occupational therapy practice to incorporate a focus on family-centered care and the development of an occupation-based approach. This can enhance the occupational therapy practice, ensuring that both the infant's and the family's needs are recognized and addressed.[4]

While using the above concept, the PEO model was used in the present study to enhance coping behavior in mothers of preterm infants.

The study was conducted to analyze the effect of PEO intervention model on stress, depression, and breastfeeding efficacy on mothers of preterm neonates. The objective of our study was to assess how mothers' physical, social, and cultural environment affects the primary occupation of breastfeeding the infant and the effect of PEO model as a tool for occupational therapy intervention and on parental stress levels and breastfeeding self-efficacy of postpartum mothers of preterm infants.


  Methods Top


A randomized, intervention-controlled study design was chosen for our research. An institutional ethics committee approval was sought before the initiation of the study. A convenient sampling method was used to derive a sample of 54 mothers of preterm neonates from NICU of a tertiary care hospital, of which 27 mothers each were recruited to the experimental and control groups, respectively, by random allocation using a lottery method. Mothers who could understand Marathi, Hindi, or English languages were included in the study. Mothers of infants with cardiovascular and neurological disorders and psychosis were excluded from the study. These mothers were first assessed on the Edinburgh Postnatal Depression Scale (EPDS), Parental Stress Scale:NICU (PSS:NICU), and Breastfeeding Self-Efficacy Scale (BFSES) at baseline.

Edinburg Postnatal Depression Scale

EPDS was used as a pre- and postintervention measure. It is a 10-item screening tool questionnaire that was developed to identify women who have postpartum depression. In their studies, many addressed concurrent validity of the scale (47.4%), predictive validity (51%), and internal consistency (52.6%). The maximum score was 30 and possible depression of 10 or greater. Always check for the scoring of item 10 which may suggest suicidal thoughts in mothers. The scale can be used postpartum mothers up to 6-8 weeks postpartum.[5]

Parental Stress Scale:Neonatal Intensive Care Unit

PSS:NICU was used as a pre- and postintervention measure. It is designed to measure the parental perception of stressors arising from the physical and psychosocial environment of the NICU. Miles et al., 1991, stated satisfactory construct validity. Inter-item correlations according to each PSS:NICU subscale were high. Internal consistency was good with alpha coefficients of 0.70 for each subscale (Franck et al., 2005; Miles et al., 1993; and Reid and Bramwell, 2003). This finding indicates a good reliability of the PSS:NICU in the form of internal consistency. The responses to the PSS:NICU are scored on a 5-point Likert scale on which the parents can rate the level of stress for each item from 1 (not at all stressful) to 5 (extremely stressful). There is also a not applicable (N/A) option, which is scored 0 when using one of the scales' scoring methods.[1]

Breastfeeding Self-Efficacy Scale

BFSES was used as a pre- and postintervention measure. This scale is a 33-item, self-administered scale, where items are preceded by the phrase “I can always” and scored on a 5-point Likert scale ranging from 1 (not at all confident) to 5 (always confident). The total score ranges from 33 to 165. The higher scores reflecting better breast feeding self-efficacy.[5] As such, scores can range from 33 to 165. The scale was performed on 165 breastfeeding women, the Cronbach's α coefficient was 90, and evidence for predictive validity was demonstrated through exclusively breastfeeding mothers at 4 weeks postpartum having significantly higher in hospital BFSES scores (M = 49.4, standard deviation = 12.9). This study builds upon previous research and provides additional evidence, suggesting that the BFSES has sound psychometric properties and can be utilized among diverse samples, including Southeast Asian mothers.[6]

All the scales were translated into Hindi and Marathi languages. Before administering on the mothers, translated versions were evaluated for validity and reliability. The content validity of EPDS in Marathi (0.9) and in Hindi (0.8); the content validity of PSS:NICU in Marathi (0.86) and in Hindi (0.8); and the content validity of BFSES in Marathi (0.9) and in Hindi (0.76) were found.

For EPDS, the inter-rater reliability in Marathi (0.72) and Hindi (0.73) and intra-rater reliability in Marathi (0.76) and Hindi (0.69); for PSS:NICU, the inter-rater reliability in Marathi (0.61) and Hindi (0.56) and intra-rater reliability in Marathi (0.71) and Hindi (0.61); and for BFSES, the inter-rater reliability in Marathi (0.76) and Hindi (0.61) and intra-rater reliability in Marathi (0.63) and Hindi (0.74) were found.

Study Procedure

After obtaining written informed consent, the mothers obtaining EPDS scores >10 were included in the study. None of them were on antidepressants, as they showed borderline depression, which generally did not show obvious symptoms to start pharmacotherapy. Other outcome measures were administered, as stated above, on all mothers included in the study. The control group received conventional intervention and the experimental group mothers received therapy using PEO model as a tool daily for 15 days.

The PEO model tool includes an initial evaluation of mothers' perception about child problem and mothers' problem of handling through an unstructured interview. Therapists demonstrated an alternate way of handling, the best way of breastfeeding after understanding their environmental barriers. Mothers were guided about appropriate handling, identifying infant's clues through neonatal individualized development care assessment and program. The family preferences were given priority in planning program. Mothers were taught to observe infant's sleep cycle, feeding needs and stress signals, modifying handling, feeding techniques, etc.[7],[8]

The control group mothers received therapy daily for 15 days of protocol as follows: containment hold and body flexion, positive oral stimulation, passive range of motion and positioning, demonstration of handling techniques, and general stress clues given by infants.[7]

Follow-up assessments were done after 15 days on all outcome measures.

Data Analysis

The SPSS 16 version of IBM Watson company, New York, USA was used for statistical analysis. The results were analyzed using Mann-Whitney U-test. The level of significance was set as P ≤ 0.05 at the outset of the study, and 95% confidence interval values were computed.


  Results Top


A total of 54 mothers were recruited in the study, and there were two dropouts from the control group. Hence, the scores of only 52 mothers were analyzed. As seen in [Table 1], majority of them were between the age groups of 20 and 25 years, with 28-30 weeks of gestational age. Only one mother was above 30 years of age. Furthermore, most of the mothers were gravida 1, para 1, followed by gravida 2, para 2. The results were analyzed to study the effect of both interventions on EPDS, PSS:NICU, and BFSES scales at baseline and at 15 days.
Table 1: Demographic Characteristics of Mothers

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As seen in [Table 2], postintervention scores on outcome measures, the experimental group showed a significant improvement.
Table 2: Scores in Control and Experimental Groups

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On EPDS, the difference between preintervention scores between the groups was insignificant, which further showed a similar trend postintervention. On EPDS score, there was a significant difference in the mean scores from pre- to postintervention in the experimental group, whereas the control group has dropped by minimal values.

PSS score in the experimental group jumped significantly, with P = 0.020. In the control group, PSS score showed a varied range of improvement, which is statistically not significant. Thus, parental stress was decreased markedly in the experimental group. In the control group, the intervention has shown a minimal effect. When mothers were included in the study, they had not started breastfeeding. Hence, PSS score was very low. Postintervention in the experimental and control groups showed a significant difference, with P ≤ 0.00001 and P ≤ 0.0001, respectively.

When compared the pre- and postintervention scores between the two groups as seen in [Table 3], EPDS showed no significant difference in both the scores, with P = 0.231 at preintervention and P = 0.522 at postintervention, but the mean value in the experimental group has decreased markedly. In PSS score, a similar trend was observed, i.e., difference in scores of pre-intervention and post-intervention are P = 0.183 and P = 0.972 respectively, but the experimental group mothers showed a marked decrease in stress levels though the difference is not significant. On BFSES, initially, both the groups had an insignificant difference in scores, with P = 0.9124, but postintervention, the difference in BFSES score was very significant, with P < 0.0003. This showed the effects of PEO on confidence and coping abilities of mothers in the experimental group.
Table 3: Scores of Control versus Experimental Groups

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  Discussion Top


As per the demographical data, most of the mothers were in early adulthood phase, which were found to be very keen to learn new techniques of parenting along with some anxiety. Around 30 mothers in this study were gravida 1, para 1 and 32 mothers had a strong family support. While reporting on PSS during unstructured interviews, the mothers reported that in spite of strong support, new mothers felt unpreparedness in the role of mothers, due to early arrival/birth of their infants (especially women having their first baby). The sounds of scary equipment also made mothers more anxious and stressful. As occupation is multifaceted and complex, it becomes more challenging in NICU setup for mothers of preterm infants.[8] This study was designed to explore the parenting occupations which are both meaningful to mothers and aims to support the process of adjustment to parenting a preterm infant in the NICU. This study has also analyzed the effect of the use of PEO tool on parents on mood (using EPDS), stress level (using PSS-NICU), and basic parental occupation of breastfeeding (through BFSES).

On EPDS, the difference between preintervention scores between the groups was insignificant, which further showed a similar trend postintervention. In the present study, the use of EPDS has led to the identification of probable postpartum depression symptoms. These mothers did not receive any medical intervention for their probable symptoms. The authors of this study identified their sense of lack of control over their life and incomplete maternal feelings. In the experimental group, they received counseling and problems were addressed personally by the therapist, whereas the control group mothers were given insight about various equipment, which were causing anxiety and handling techniques of their infants. This may have resulted in a decrease in depressive symptoms in mothers of both the groups. These mothers from both the groups showed an improvement in their probable symptoms of depression, but targeted intervention for the experimental group showed better scores on EPDS. Most of the postpartum depression symptoms go vastly undetected and untreated.[9]

The experimental group parents were given required environmental support and counseling to reduce their stress. Some mothers in control group were unable to appreciate reduction in their stress. This resulted in statistically minimal changes.

The parents in the experimental group received family-centered care and opportunities to determine how the occupational efforts of parents and preterm infants can be best supported. As stated by Deanna Gibbs, the PEO model can be used as a framework for illuminating the acquisition of parenting occupation in NICU.[4]

The parents from the control group received conventional treatment, i.e., positioning and handling of preterm neonates using fundamental concepts of positioning. This has led to an improvement in parents' knowledge, but parental difficulties such as lack of parental support, lack of family support, or mothers' anxiety were not considered in the control group intervention.

The therapist has explained the parents and has assisted in building up parental confidence in understanding the purpose of technological support. While using PEO as a tool, the therapist also worked on increasing awareness in all NICU staff about the importance of parent involvement and modeling caregiving behavior, which helped in facilitating active involvement of mothers in caregiving. This has resulted in lowering mothers' depression in the experimental group. The Newborn Individualized Developmental Care and Assessment Program (NIDCAP) approach has been used while considering PEO model. As stated in Als and McAnulty study, “The Newborn Individualized Developmental Care and Assessment Program (NIDCAP) with Kangaroo Mother Care (KMC): Comprehensive Care for Preterm Infants” can prove pivotal in supporting parental care for preterm infants.[10]

On PSS score, there was a significant difference in the mean scores of pre- and postintervention in the experimental group, whereas the control group has dropped by minimal values (143-136). While using PEO as a tool, the parental efforts were positively directed toward engaging in their new occupation by direct intervention (support counseling and demonstration). As stated in “Occupational adaptation of parents of preterm infants in the neonatal intensive care unit: An interpretive descriptive study,” the promotion of opportunities for co-occupations can also promote the early establishment of family roles and routines.

The therapist educated parents to participate in meaningful touch and nurturing of their infants and early caregiving based on the infant's stability, which helped the mothers to provide mothers with opportunities early in their NICU experience to begin to establish their role as a parent to their preterm infant within the environmental restrictions.[4]

During the study, the promotion of opportunities for family roles and routines was also done by active discussion about adjustments. The similar trends were noted during the study on “Occupational adaptation of parents of preterm infants in the neonatal intensive care unit: An interpretive descriptive study.” Thus, the support provided for total adjustment to the social environment of NICU and social environment outside NICU, i.e., society and family, has led to steep decline in parental stress in the experimental group. The mothers from the control group may have adjusted to the stressful NICU environment due to the conventional training received for handling and nurturing the infants,[11] thus showing a decrease in PSS score resulting in minimal difference between the scores of the two groups.

BFSES score increased significantly in both the groups. In the control group, mothers received breastfeeding education from the therapist. In a study by Froozani et al. on “effect of breastfeeding education on feeding pattern and health of infants in their first 4 months in Islamic Republic of Iran,” a similar observation has been mentioned that face-to-face breastfeeding education increases mothers' exclusive breastfeeding rate and confidence.[12]

The experimental group in the study received social support analysis and support person education, along with breastfeeding education to mothers. This has shown a positive impact. In a systemic review on the role of social support in breastfeeding promotion done by Raj and Plichta, the authors have stated that social support that increases breastfeeding includes emotional, tangible, and educational components from social network including family and friends. In the absence of this support, the breastfeeding program may not be successful.[13]

Breastfeeding self-efficacy score showed a significant difference in the experimental group as compared to the control group. The individual difference and difficulties were discussed with parents to analyze breastfeeding difficulties, and optimal support was provided to individual mothers for breastfeeding promotion in the experimental group. Whereas, the control group received a health system-based breastfeeding promotion program. This may have resulted in improving the self-efficacy in this primary occupation of mothers. This observation is supported by the study “the impact of hospital and clinic based breastfeeding promotion program in a middle class urban environment” by Valdés et al. The findings in the study state that there was a significant increase in the duration of full breastfeeding in the intervention group.[14]

In the study conducted by Chrásková and Boledovičová in 2015, the similar results were observed. Where they conducted postnatal education sessions, the knowledge of women from the intervention group after 2 and 6 weeks after giving birth was better than the corresponding score in the control group. In their study, the authors stated that postnatal education and support of breastfeeding 3 days after giving birth at home were successful.[15]

In the present study, the mothers have reported increased stress during intervention due to their ignorance on an infant's ability on thermoregulation, respiratory complication, and reported sound of equipment. This was more observed in mothers with less education and lack of family support. The socioeducational background was not considered during the analysis in this study.

During the study, the therapist developed a special understanding about co-occupations of mothers along with present responsibilities of mothers, for example, an elder sibling of preterm neonates being cared by someone was stressful to mothers. The therapist helped them find feasible solutions considering their values and culture. This also may be a confounding factor while considering stress in parents. It is very important to state that during the study, it was observed that mothers sharing their problems with other mothers and sharing good rapport with each other gave them emotional support. The therapist in this study facilitated the communication between the mothers to enhance their occupational performance.

As stated in “Occupational adaptation of parents of preterm infants in the neonatal intensive care unit: An interpretive descriptive study,” occupational therapy practice has the potential to serve to bridge the gap between the parents' efforts to engage in occupation and the physical environment of the NICU.[4]

Some of the mothers in the present study exhibited more maturity as compared to others, thus gaining the confidence in handling babies in NICU.

In the present study, breastfeeding self-efficacy has improved significantly. The PEO model is more effective in improving mothers' stress and breastfeeding efficacy in mothers of preterm neonates, as compared to conventional approach. Intervention was carried by the therapist; bias by the therapist while scoring mothers was taken care of, as questionnaires were filled by the mothers/participants in intervention.

Advantages

In the study, consideration was given to the availability of opportunities for mothers to be engaged in caregiving activities that are meaningful to them. The strategies were developed to improve mothers' confidence and self-efficacy through PEO tool. Each person in environment was considered as a different unit for planning appropriate intervention. The supporting family members were considered as a unit for nurturing preterm infants.

The PEO model can be used to direct an occupation-based approach, ensuring that both the infant's and the family's needs are recognized and addressed.

Recommendations

Further research is required on a larger sample size. The family support for mothers should be given special consideration. Mother's Educational and sociocultural background can be used for further analysis.


  Conclusions Top


PEO intervention model can be recommended for improving mothers' breastfeeding capabilities in preterm neonates. When this tool is used as an intervention for mothers, it further improves the handling and nurturing of preterm neonates, due to reduced stress in mothers.

Financial Support and Sponsorship

Nil.

Conflicts of Interest

There are no conflicts of interest.



 
  References Top

1.
Musabirema P, Brysiewicz P, Chipps J. Go to: Parents perceptions of stress in a neonatal intensive care unit in Rwanda. Curationis 2015;38:1499-1506.  Back to cited text no. 1
    
2.
Obeidat HM, Bond EA, Callister LC. The parental experience of having an infant in the newborn intensive care unit. J Perinat Educ 2009;18:23-29.  Back to cited text no. 2
    
3.
Frances K. Breastfeeding self-efficacy and alternative techniques to overcome maternal or infant breastfeeding challenges: A retrospective descriptive study. Australia: Queensland University of Technology; 2011. Available from: https://eprints.qut.edu.au/47144/1/Frances_Keemer_Thesis.pdf. [Last accessed on 2018 Dec 12; Last updated on 2017 Jun 21].  Back to cited text no. 3
    
4.
Gibbs D, Boshoff K, Lane A. Understanding parenting occupations in neonatal intensive care: Application of the person-environment-occupation model. Br J Occup Ther 2010;73:24-27.  Back to cited text no. 4
    
5.
Kheirabadi GR, Maracy MR, Akbaripour S, Masaeli N. Psychometric properties and diagnostic accuracy of the Edinburgh Postnatal Depression scale in a sample of Iranian women. Iran J Med Sci 2012;37:32-38.  Back to cited text no. 5
    
6.
Dennis CL, Faux S. Development and psychometric testing of the Breastfeeding Self-Efficacy Scale. Res Nurs Health 1999;22:399-409.  Back to cited text no. 6
    
7.
O'Brien CS. Occupational Therapy for Children and Adolescents. 6th ed. Missouri: Mosby Elsevier; 2010. p. 650-677.  Back to cited text no. 7
    
8.
Cardin AD. Parent and Infant Occupational Performance in the Neonatal Intensive Care Unit. Minnesota: St. Cathedrine University; 2015. Available from: https://sophia.stkate.edu/. [Last accessed on 2018 May 15; Last updated on 2015 May 03].  Back to cited text no. 8
    
9.
Tahirkheli NN, Cherry AS, Tackett AP, McCaffree MA, Gillaspy SR. Postpartum depression on the neonatal intensive care unit: Current perspectives. Int J Womens Health 2014;6:975-987.  Back to cited text no. 9
    
10.
Als H, McAnulty GB. The Newborn Individualized Developmental Care and Assessment Program (NIDCAP) with Kangaroo Mother Care (KMC): Comprehensive care for preterm infants. Curr Womens Health Rev 2011;7:288-301.  Back to cited text no. 10
    
11.
Chrásková J, Boledovičová M. The importance of breastfeeding education. Profese Online 2015:8:39-46.  Back to cited text no. 11
    
12.
Froozani MD, Permezadeh K, Motlagh AR, Golestan B. Effect of breastfeeding education on feeding pattern and health of infants in their first four months in Islamic Republic of Iran. Bull World Health Organ 1999;77:381-385.  Back to cited text no. 12
    
13.
Raj VK, Plichta SB. The role of social support in breastfeeding promotion: A literature review. J Hum Lact 1998;14:41-45.  Back to cited text no. 13
    
14.
Valdés V, Pérez A, Labbok M, Pugin E, Zambrano I, Catalan S. The impact of a hospital and clinic-based breastfeeding promotion programme in a middle class urban environment. J Trop Pediatr 1993;39:142-151.  Back to cited text no. 14
    
15.
Occupational Therapy Intervention in Neonatal Intensive Care Units: Position Paper. Israeli: The Israeli Society of Occupational Therapy. Available from: https://www.health.gov. [Last accessed on 2018 Jun 05].  Back to cited text no. 15
    



 
 
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