Introduction

Modern life and environmental pressure have increased the incidence of postpartum depression.1 Especially in the case of puerperal primipara, due to the lack of reproductive experience and high stress, women are under high physical and mental pressure, which might cause a series of emotional reactions.2,3 A cross-sectional study found that the postpartum social support and life satisfaction of spouses influenced postpartum depression.4 This indicated that the maternal psychological state is affected by the behavior and psychology of the spouse. Although the stress level of the spouse is lower than that of the new mother, their psychological history is similar to that of the mother and child. They undertake the task of taking care of the mother and child and bear the burden related to physical, psychological, and social aspects.5 Therefore, managing the mental health of the spouse is crucial.6 A study found that about 10% of the spouses of first-time mothers showed significant prenatal and postnatal depression.7 About two decades ago, the International Conference on Population and Development (ICPD) and the Fourth World Conference on Women discussed the role of spouses in the reproductive health of women.8,9 However, although spouses strongly influence the reproductive health of women, they have received less attention from researchers, which has led to many direct and indirect negative effects.10 In addition, other studies have found that the loss of paternal role function during breastfeeding will affect the growth of children.11 Therefore, more attention should be paid to the role of fathers in breastfeeding, and questions need to be asked about the extent to which health professionals can support fathers in adapting to different roles and facing challenges.

The PRECEDE-PROCEED (Predisposing, Reinforcing, and Enabling Causes in Educational Diagnosis and Evaluation-Policy, Regulatory, and Organizational Constructs in Educational and Environmental Development) model (PPM) was developed by the American epidemiologists Kreuter and Lawrence Cew. In the 1980s, PRECEDE-PROCEED integrated multiple theories and perspectives on changes in health-related behaviors. A planned intervention mode that promotes behavioral changes through knowledge acquisition, proposed by combining external environmental factors and psychological factors, is often used in health promotion programs.12 PPM consists of the PRECEDE phase and the PROCEED stage.13,14 This model is widely used in many aspects, such as recommending healthcare techniques,15,16 chronic disease management,17,18 and teaching nursing skills.19 The application of this model in maternal health management, infant feeding, and other aspects of maternal and child health has become a popular area of research;20 however, studies on the application of this model in the mental health management of husbands are limited. Using the PPM, in this study, we investigated the psychological state of paramaternal spouses and the effect of maternal breastfeeding, based on multiple disciplines and perspectives. Intervention strategies can be adjusted at any time by evaluating the process of implementing the intervention and assessing the impact and result to help in the construction of health programs based on evidence.

Materials and Methods Research Participants

In total, 310 spouses of primigravid women who gave birth at The Affiliated Wuxi People’s Hospital of Nanjing Medical University from March 2022 to March 2024 were included in this study.

The inclusion criteria were as follows: (1) the mothers had full-term singleton pregnancies and were giving birth for the first time; (2) the mothers and their spouses were married; (3) the mothers and their spouses were conscious, had no cognitive impairment, and agreed to complete the survey and participate in the health education program; (4) they provided informed consent to voluntarily participate in this study.

The exclusion criteria were as follows: (1) mothers with serious obstetric complications or comorbidities; (2) newborns with serious birth injuries or congenital diseases (Figure 1).

Figure 1 Flow chart of patient selection.

We conducted a retrospective study, and according to the group’s previous research and relevant literature, approximately 70% of spouses in the conventional education group and 50% of spouses in the health education group based on Grimm’s model experienced negative emotions. Assuming a specified alpha of 5% and a confidence level of 0.90, the sample size to be surveyed was calculated using the PASS 15 software and was found to be N1 = N2 = 124 cases. Assuming a non-response rate of the study population of 10%, the required sample size was N = 124 ÷ 0.9 = 137 cases. Therefore, the planned sample size for this study was 330 cases, with 165 cases in each group. The total number of attrition and lost cases was 20, and the final count was 310 cases. Among them, 154 cases were in the conventional education group and 156 cases were in the health education group based on the Grimm model.

General Information Questionnaire

The general information questionnaire included demographic data (eg, maternal age, mode of delivery, age of spouse, education level of spouse, family income, residence, whether planning pregnancy, whether participating in prenatal health education, degree of understanding of infant care (determined by the infant care questionnaire developed by the research group; a total of 20 questions are defined as Proficiency and Mastery level at a correct rate of 60%), whether the spouse received a paternity leave, and maternal combined postpartum complications).

Construction of the Health Education Intervention Program Formation of the Research Team

The research team consisted of six members, including one deputy chief physician from the obstetrics ward, one head nurse from the obstetrics ward, two outpatient nurses, and two ward nurses. Six healthcare workers had a work experience of >5 years. The main tasks of the research team members were to prepare the first draft of the program, identify the selected experts, organize the expert group meeting, revise and improve the program according to the opinions and suggestions of the experts, and form the final draft of the program.

Health Education Implementation Program

The health education intervention program for spouses was developed based on the literature review and preliminary investigation, along with the suggestions provided by the experts. While developing the program, the PPM was used as the theoretical framework (Figure 2), and the theory of knowing, believing, and acting was considered. The main content of the program included three aspects: predisposing factors, contributing factors, and reinforcing factors affecting the psychological state of the spouses. The subject content and measures of the intervention program are listed in Table 1.

Table 1 Program of Educational Interventions on the Mental Health of Spouses

Figure 2 PRECEDE-PROCEED model frame diagram. Color coding: (RGB 134,134,134; 101,21,10; 72,99,146; 136,71,77; 76,101,98; 130,79,132; 48,60,48; 250,252,247; 227,242,239; 111,134,90; 255,247,248; 237,244,252; 254,239,244; 252, 238,238; 237,245,253).

Assessment Methodology Negative Emotion Assessment

The anxiety self-assessment scale (SAS) and depression self-assessment scale (SDS) were used to evaluate the negative mood of the participants at different time points before and after the intervention. SAS consists of 20 items, with four points for each item, and a cut-off value of 50 points; ≤50 points indicates no anxiety, whereas >50 points indicates anxiety, and the higher the score, the more severe the anxiety. SDS consists of 20 items, with a cut-off value of 53 points; ≤53 points indicate no depression, whereas >53 points indicate depression, and the higher the score, the more severe the depression. The spouses were assessed using the SAS and SDS in the 28th week of gestation and three days after delivery, respectively. The health education group based on the PRECEDE-PROCEED model was defined as Group A, while the regular health education group was defined as Group B.

Based on the SAS and SDS scores, patients were considered to be in the negative mood group if they had anxiety and/or depressive symptoms.

Symptom Check List 90 (SCL-90 Score)

This scale was developed by Derogatis L.R. in 1975 based on the Hopkins Symptom Inventory developed by himself.21 The scale contains 90 items divided into nine factors; each factor reflects some aspect of symptom distress among the participants of the survey, and the factor scores provide insights into the characteristics of the distribution of symptoms. The score is based on a 1–5 scale and indicates 1: no, 2: mild, 3: moderate, 4: severe, and 5: very severe problems. A higher score indicates a lower level of mental health. The subgrouping of all items in the scale was as follows: somatization (12 items), obsessive-compulsive issues (10 items), interpersonal sensitivity (nine items), depression (13 items), anxiety (10 items), anger-hostility (six items), phobic-anxiety (seven items), paranoid ideation (six items), and psychoticism (10 items). Additionally, seven items were not grouped into any factor and could be treated as a 10th factor, which was not analyzed in this study.

The SCL-90 is a widely used self-assessment scale in the field of mental health around the world and contains several psychiatric symptomatology components, such as thinking, emotion, behavior, interpersonal relationships, and life habits. It is a highly standardized scale and widely used in China. It has good reliability and validity. In this study, the spouses were scored three days after delivery.

Data Collection Related to the Feeding Situation

In this study, the time of first lactation and the lactation volume were measured in the postpartum period, and the feeding mode was recorded. The height, weight, BMI, head circumference, and other data of the infants were collected when they were six months old to assess the relationship of their growth and development with different education modes and feeding modes.

Statistical Analysis

The results and scores for each scale were entered into a computer for score conversion and statistically analyzed using SPSS 26 (IBM SPSS, USA). Continuous data were expressed as the mean ±standard deviation, and count data were expressed as frequencies and percentages. The differences between groups were determined by performing t-tests and chi-square tests, and the factors influencing the negative emotions of the spouses of primiparous women during puerperium were evaluated by binary logistic regression analysis. All differences were considered to be statistically significant at p < 0.05 (two-sided).

Results Baseline Data

In total, 310 spouses of primiparous women were included in this study. Among them, 87 (55.8%) spouses in Group A showed negative emotions three days after delivery, while 113 (73.4%) spouses in Group B showed negative emotions. The differences between the two groups were not significant in terms of age and negative emotions of the mother, sex of the newborn, mode of delivery, age of the spouse, education level of the spouse, family income, place of residence, whether the pregnancy was planned, whether they participated in prenatal health education, the level of knowledge about infant care, and whether the spouse had paternity leave (P > 0.05) (Table 2).

Table 2 Baseline Data of Two Groups

Comparison of the SAS and SDS Scores of the Spouses of Primiparous Women in the 28th Week of Gestation and Three Days Postpartum

The results of independent t-tests showed no significant difference in SAS and SDS scores between the two groups in the 28th week of pregnancy (P > 0.05), but the differences between the groups were significant on the third day after delivery (P < 0.05). Spouses in Group A had significantly lower SAS and SDS scores than those in Group B (Table 3).

Table 3 SAS and SDS Score of Two Groups

Binary Logistic Regression Analysis of the Negative Emotions of the Spouses

The results of the binary logistic regression analysis showed that several factors, including whether health education was provided, the maternal psychological status, the education level of the spouse, monthly family income, expertise in infant care, and whether there was paternity leave, acted as independent factors for negative emotions among the spouses of puerperal primiparous women (Table 4 and Figure 3).

Table 4 Binary Logistic Regression Analysis of Maternal Spouse’ Negative Emotion

Figure 3 Binary logistic regression analysis of maternal spouse’ negative emotion. Color coding: (Orange: RGB 255,153,0; black: RGB 0,0,0;).

Comparison of SCL-90 of Spouses with Domestic Norms

The results of independent t-tests showed that somatization, interpersonal sensitivity, depression, anxiety, and total points in the SCL-90 (symptom checklist 90) scale of the spouses of primiparous women in Group A were significantly lower than those of the spouses of primiparous women in Group B (P < 0.05). However, the scores of somatization, depression, anxiety, phobic anxiety, and total points in Groups A and B were significantly higher than those of the domestic norm (P < 0.05). Additionally, the scores in terms of interpersonal sensitivity in Group A were also significantly higher than the domestic norm (P < 0.05) (Table 5).

Table 5 Comparison of SCL-90 of Spouses with Domestic Norms

Comparison of Breastfeeding and Growth of Children Between the Two Groups

The results of the chi-square test showed that 98 children (62.8%) in Group A and 87 children (56.5%) in Group B were exclusively breastfed. The difference in the feeding methods between the two groups was not significant (P > 0.05). The results of independent t-tests showed that the onset time of lactation in Group A was significantly shorter than that in Group B, and the three-day lactation volume in Group A was significantly higher than that in Group B (P < 0.05). After six months, infants in Group A were also significantly taller and heavier than those in Group B (P < 0.05) (Table 6).

Table 6 Comparison of Breast-Feeding and Growth of Children Between the Two Groups

The Growth of Children Under Different Feeding Regimens

The results of independent t-tests showed that among exclusively breastfed infants, infants in Group A were significantly heavier than those in Group B (P < 0.05); among mixed-fed infants, infants in Group A were significantly heavier than those in Group B (P < 0.05). In the exclusively breastfed group, the difference in growth between the two groups of infants was not significant (P > 0.05) (Table 7).

Table 7 Comparison of Growth of Children Between the Two Groups Under Different Feeding Patterns

Discussion

Childbirth causes severe stress among women, especially first-time mothers, who are more likely to have adverse emotional reactions, along with their spouses.22 The mood of the spouse also affects the mother, forming a cycle of negative emotions. Therefore, ways to manage the mental health of the spouses also need to be developed.

In this study, we found that health education based on PRECEDE-PROCEED model can significantly reduce anxiety and depression in spouses and can prevent the development of negative emotions in spouses of puerperal primiparous women. We also found significant differences in somatization symptoms, interpersonal sensitivity, depression, and anxiety factor scores, and total mean scores between the two groups of spouses. These results indicated that health education greatly improved the psychological status of spouses, which occurred probably because of the following reasons: (1) Traditionally, mothers play the dominant role in parenting, which decreases the importance of the father’s role. Thus, their parenting participation is low, and their responsibilities and alienation give rise to anxiety and depression.23 In this study, we implemented a health education intervention program based on the PRECEDE-PROCEED model to provide parenting knowledge and skills to the spouses of primiparous women through multiple paths. We also introduced them to the methods and significance of participating in parenting, used various means to motivate spouses to adapt and assume their role as a father at the earliest, make adequate practical and ideological preparations to take care of postpartum infants, overcome their perception of being “outsiders”, improve their participation in parenting, reduce their fear and anxiety of unknown situations, and allow them to better cope with upcoming changes and challenges, which can greatly decrease the sense of anxiety and powerlessness of first-time fathers. (2) Health education based on PRECEDE-PROCEED model usually includes training the spouses of primiparous women on the corresponding psychological support and coping strategies and allows them to deal more effectively with stress and mood swings. This helps reduce the risk of developing anxiety and depression. (3) Through health education, spouses of primigravid women can learn how to better communicate and support their partners. This effective communication can improve the understanding and support between husband and wife and reduce emotional burden. Additionally, this health education system can establish a strong social support network, which can provide emotional support and practical guidance to parturients and their spouses, and also reduce their anxiety and depression. We also found that maternal negative emotions, high education level of the spouse, low family income, low understanding of how to care for infants, lack of paternity leave, and maternal postpartum complications are risk factors for the development of negative emotions in the spouses of primiparous women. This finding matched those of another study,24 in which it was reported that people with high educational levels are more likely to have negative emotions. Highly demanding jobs and those with a lot of responsibilities may be accompanied by status quo, such as prolonged work, stressful work environment, and major occupational decision-making pressures, as well as, no paternity leave. Additionally, people with a high educational level pay special attention to the education problems of children and it has an important impact on the growth of children.25 Fostering a good educational environment often requires a lot of effort and resources, which can greatly challenge the economic condition of the parents. Such an economic burden can also lead to negative emotions in people with a low income.26

In this study, we also found that the somatization symptoms, interpersonal sensitivity, depression, and anxiety factor scores of the spouses who did not receive training and education were significantly higher than the domestic norm. Although the scores of some factors of the spouses who received health education were lower, some of the scores were higher than the domestic norm, and some of them were similar to the domestic norm. This showed that the mental health status of the spouses of primiparous women is generally poor, and their psychological problems are scattered. These problems mainly manifest as somatization symptoms, interpersonal sensitivity, depression, and anxiety, indicating that the spouses are more likely to have physical and psychological problems than the general population. This might be related to an increase in the level of postpartum stress in these men, a decrease in their social activities, lesser social support, introversion of their personality, an increase in sensitivity, emotional instability, and unmet psychological needs; they may also fail to adapt to their roles on time. A recent study suggests that some spouses may not even be aware of the changes in their own psychological status, and have the same perceptual difficulties as pregnant women.27 Nursing staff should pay full attention to the mental health status of primiparous women after delivery, monitor the mental health status of their spouses, implement effective psychological nursing intervention based on the factors affecting their mental health status, assist them in establishing a healthy and effective coping style, reduce or eliminate their negative emotions, such as anxiety and depression, and promote the health of the mother and child.

The effect of maternal breastfeeding can also strongly affect the growth and development of children, mainly their height and weight. This might occur because there is more protein and less fatty lactose in breast milk, which can be easily absorbed and digested by premature infants, facilitate newborns to obtain more adequate nutrition from breast milk, supplement the nutrients required by the body, and facilitate their growth and development.28 In the breastfeeding period, infants in the health education group also had better growth status than those in the usual care group. This occurred probably because health education allows individuals to understand the importance of breastfeeding, allows parturients to learn how to perform healthy breastfeeding, and improves cooperation. Additionally, the physical health and emotional stability of parturients strongly affect the quantity and quality of breast milk.29 Health education can provide parturients and their spouses with information on physical and mental health problems, and give corresponding measures and psychological counseling on time so that parturients can maintain a better state of physical and mental health, which can help them produce high-quality breast milk.

Limitations

The main shortcoming of this study is that the number of patients included was limited due to the shortage of time and manpower. Additionally, this was a single-center study, and only the short-term effects of breastfeeding on infants were recorded. Thus, multicenter studies need to be conducted and the long-term effects on the growth and development of children need to be monitored.

Conclusion

In this study, we investigated the effect of health education based on PRECEDE-PROCEED model on the psychological status of spouses of puerperal primiparous women, as well as, the risk factors affecting the psychological status of the spouses. Our findings might provide valuable information for the nursing staff to provide postpartum care and reduce stress in the family of primiparous women. This study showed that breastfeeding can contribute to better growth and development of infants.

Ethical Statement

The study was conducted in accordance with the Declaration of Helsinki. The study was approved by Ethics Committee of The Affiliated Wuxi People’s Hospital of Nanjing Medical University. Informed consent was obtained from all patients.

Disclosure

The authors have no conflicts of interest to declare.

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