The effect of DECO-MOM mobile application for a prenatal environmental health program on environmental health behaviors: a pilot test | BMC Pregnancy and Childbirth

Study design

This study employed a non-randomized controlled pilot design with pre- and post-test assessments for experimental and control groups. This study adhered to the Transparent Reporting of Evaluations with Nonrandomized Designs (TREND) guidelines [12]. The study protocol was registered in the Korean Clinical Research Information Service on September 22, 2022 (KCT0007725:  [13].

Setting

Participants were recruited from three public health care centers in Chuncheon, Jeonju, and Gongju cities (in Gangwon, Jeonrabuk, and Chungcheongnam Provinces, respectively) in South Korea. The public centers provided maternal-child healthcare services, offering birth education to pregnant women. Researchers were permitted for study and data collection from the healthcare centers and participated prenatal education as lecturers. Researchers provided a mobile application QR code of the website address for the experimental group after written consent to participate in the study and treatment as usual (TAU) education program for the control group.

Inclusion and exclusion criteria

The participants were included as follows: 1) pregnant women at gestational ages of 4–36 weeks, 2) age over 20 years, 3) ownership of a smart gadget, and 4) Korean language literacy. The exclusion criteria were 1) hospitalization due to physical or psychological health problems and 2) currently receiving medical treatment due to fetal or maternal disease.

Allocation

Convenience sampling was used to allocate 1:1 parallel allocation. The participants recruited from Chuncheon city were allocated to the control group applied only TAU and the participants from Jeonju and Gongju cities in South Korea were allocated to the experimental group applied mobile application. These three cities were middle-sized urban–rural cities with similar socioeconomic and cultural statuses to avoid potential heterogeneous bias. The researcher contacted the pregnant women and explained the study’s purpose, procedure, and benefits. The pre-test was performed before the mobile application and TAU, the intervention lasted for 4 weeks, and the post-test was administered just after the intervention between September 26 and October 24, 2023 (Fig. 2).

Flow diagram of the research process

Sample size

The G*Power 3.1.4.9 [14] calculated the sample size as 32 and 32 in both groups with designated a one-tailed test, the independent t-test, 0.59 effect size (f), 0.75 power, 0.05 significance level, and a 1:1 allocation ratio [15]. The effect size (Cohen’s d) was calculated by 18.45 ± 13.13 and 9.68 ± 8.24, resulting in a Cohen’s d of 0.59 according to the previous study [6]. The sampling was 35 and 35 participants in both groups considering a conservative rate of 10%. Four participants withdrew from the mobile group due to schedule conflicts involving hospital visits or house chores. In total, 31 participants in the experimental group and 34 in the control group were analyzed. The adherence rates for the experimental and control groups were 88.57% and 97.14%.

Intervention

Intervention group

The DECO-MOM intervention was designed as a four-week program, delivered via a mobile application, aimed at educating pregnant women on environmental toxins and promoting adaptive environmental health behaviors. The Android system was used to develop the application. Grounded in the revised protection motivation theory (rPMT), the program operationalizes the theory’s constructs—severity, susceptibility, response efficacy, self-efficacy, costs, and benefits [11]—into weekly themes that progressively aimed to: enhance understanding of environmental risks, motivate protective health behaviors, balance the perceived benefits against costs of such behaviors, and empower both individual and communal action towards environmental health. This intervention was supported by weekly telephonic follow-ups by a research assistant and facilitated through the widespread KakaoTalk social networking service in Korea, ensuring participant engagement and adherence to the program protocols.

The “DECO-MOM environmental prenatal health program” is structured as a mobile application designed to educate pregnant women on climate change and environmental health over a four-week period. Each week targets different aspects of environmental health through varied educational methods to engage participants.

In the first week, the focus was on raising awareness regarding the reproductive health problems of maternal, fetus, and child (severity). The potential harms from chemicals, electromagnetic waves, and unsafe foods, along with discussing reproductive and general health issues (susceptibility). This was delivered through an orientation session, cartoons for visual learning, explanations for depth understanding, a 5-min video developed by a researcher, and a question-and-answer segment for interaction, each segment lasting 30 min.

The second week aimed to empower women with knowledge on avoiding environmental toxins and enhancing their health and that of their fetus (response efficacy), addressing topics such as empowering preventive judgment and control (self-efficacy). A 5-min video developed by a researcher, cartoons, and explanations were used, followed by a question-and-answer session, mirroring the first week’s duration and teaching methods.

Week three discussed the trade-offs and benefits of making lifestyle adjustments, focusing on the positive (benefits) and negative aspects (costs) of unhealthy environmental behaviors and highlighting the psychological and physical gains from healthier choices. The session used a 5-min video developed by a researcher, cartoons, explanations, and a Q&A format for delivery, each lasting 30 min.

The final week broadens the scope to include changes in personal and community behavior to avoid climate change and exposure to environmental toxins, touching on lifestyle adjustments and community engagement in environmental health practices (motivated health behaviors). It leveraged a 5-min video developed by a researcher, cartoons, explanations, a question-and-answer segment, introduces a trophy system likely for motivation or achievement recognition, and concludes with a wrap-up session. Each method was designed to last for 30 min.

Overall, the program was meticulously designed to educate, engage, and empower pregnant women regarding climate change and environmental health, utilizing a blend of educational methods to cater to different learning preferences and effectively communicate complex information (Table 1).

Control group

For the control group, Treatment As Usual (TAU) was administered through in-person instruction over a four-week period. These sessions took place in the maternity classroom at the public health center, each lasting two hours and led by two professors specializing in women’s health and a midwife. The curriculum covered a range of topics including: 1) comprehension of pregnancy and fetal development; 2) managing pain during childbirth, alongside techniques for relaxation and breathing throughout labor; 3) care after childbirth and breastfeeding practices; and 4) caring for a newborn infant.

Measurements

The questionnaires were distributed via online survey using a Naver Form respectively through the KakaoTalk messenger. The online survey took from 10 to 15 min. Online gift worth 7 dollars was provided to the participants twice after the pre- and post-test. The questionnaire used to measure the primary outcome of this study employed a tool developed and published [16] by the researcher to assess women’s environmental health behaviors (see Appendix 1).

Primary outcomes

Personal environmental health behavior

Personal environmental health behavior was measured using the Women’s Environmental Health Behavior (WEHB) scales [16]. The WEHB consists of four factors: 7 lifestyle, 4 personal hygiene, 3 diet, and 3 dust-related behaviors (total 14 items). The WEHB was measured by a Likert scale, ranging from 1 (not at all) to 5 (strongly agree). Total scores ranged from 14 to 60, the higher score meant the higher personal environmental behavior. The Cronbach’s alpha values for internal consistency reliability were 0.90 for the original scale and 0.88 in this study.

Community environmental health behavior

Community environmental health behavior was measured using the Women’s Environmental Health Behavior (WEHB) scales [16]. The WEHB consisted of four factors with 5 items on reduction, 5 on involvement, 3 on recycling, and 3 on reuse behaviors (total 16 items). The WEHB was measured by a Likert scale, ranging from 1 (not at all) to 5 (strongly agree). Total scores ranged from 16 to 90, the higher score meant the higher community environmental behavior. The Cronbach’s alpha was 0.90 for the original scale and 0.89 in this study.

Secondary outcomes

Quality of life

Quality of life was measured using the EuroQol-5D (EQ-5D) [17], and the Korean version of the EQ-5D was used [18]. The EQ-5D consists of 5 items, assessing mobility, self-care, usual activity, pain/discomfort, anxiety/depression. The EQ-5D was measured using a Likert scale, ranging from 1 (not at all) to 4 (nearly every day). Total scores ranged from 5 to 20, with higher scores indicating lower quality of life. Cronbach’s alpha was 0.61 for the original scale and 0.75 in this study.

Subjective health status

Subjective health status was measured using the EQ-VAS [17], and the Korean version of the EQ-VAS was used [18]. EQ-VAS had one question of ‘The worst health you can imagine’ and numbered from 0 (the worst health respondent can imagine) to 100 (the best health respondent can imagine). When presenting data with the central tendency, the mean value and the standard deviation could be used or, if the data are skewed, it may be preferable to present the median values and the interquartile range (IQR).

Depression

Depression was measured using the ultra-short depression screener Patient Health Questionnaire (PHQ-2) [19], and the Korean version of the PHQ-2 was used [20]. A total score of 3 or greater should prompt administration of the full PHQ-9, as well as a clinical interview to determine whether a mental disorder is present. The PHQ-2 was measured using a Likert scale, ranging from 1 (not at all) to 4 (nearly every day). Total scores ranged from 4 to 8, with higher scores indicating higher depression. Cronbach’s alpha was 0.61 for the original scale and 0.82 in this study.

Anxiety

Anxiety was measured using the General Anxiety Disorder-7 (GAD-7) [21] and the Korean version of the GAD-7 will be used [22]. The GAD-7 had seven items using a Likert scale, ranging from 1 (not at all) to 4 (nearly every day). Total scores ranged from 7 to 28, with higher scores indicating higher anxiety. Cronbach’s alpha was 0.97 for the original scale and 0.85 in this study.

E-learning satisfaction

E-learning satisfaction was measured using the E-Learning Satisfaction Scale (eLSS) (17 items) [23]. The eLSS consisted of three factors with 8 content, 5 interface, and 4 communication items (total 17 items). The eLSS was measured by a Likert scale, ranging from 1 (not at all) to 5 (strongly agree). Total scores ranged from 8 to 40, with higher scores indicating greater content satisfaction. Cronbach’s alpha for internal consistency reliability was 0.93 for the original scale and 0.95 in this study.

General and obstetric characteristics

The general characteristics were elicited self-reported information, including age, present disease, and employment status. The obstetric characteristics included gestational age and number of children.

Ethical consideration

This study was approved by the Institutional Review Board of Jeonju University (jjIRB-231214-HR-2023–1014) and adhered to the Declaration of Helsinki. Informed consent was obtained from all participants in the study.

Statistical analysis

This study used SPSS for Windows version 27.0 (IBM Corp., Armonk, NY, USA). The homogeneity test was performed using t-test and chi-square test between the two groups. Shapiro–Wilk test was used to test normality, linearity, and residual independence. The independent t-test was used to test the study hypothesis.

• Hypothesis 1: The mobile group would have higher scores for personal and community environmental health behaviors than the TAU group.

• Hypothesis 2: The mobile group would have higher scores for quality of life, subjective health status than the TAU group.

• Hypothesis 3: The mobile group would have lower scores for depression and anxiety than the TAU group.

• Hypothesis 4: The mobile group would have higher scores for e-learning satisfaction than the TAU group.