Academic Journal of Nursing and Health Education

Vol.7, No.3, 2018;

ISSN (5733 – 7155);
p –ISSN 4056 – 7396X
Impact factor: 2.91

APPLICATION OF NEST-S PROGRAM AS NURSING

INTERVENTION STRATEGY : ITS IMPACT ON OVERCOMING
ANXIETY AND DEPRESSION DURING PREGNANCY

Marwa. A. Shahin1 and Rasha Kamal Sowelm2

1
Lecturer Maternal and Newborn Health Nursing, Faculty of Nursing, Menoufia University, Egypt
2Lecturer Psychiatric & Mental Health Nursing, Faculty of Nursing, Menoufia University, Egypt

Abstract: Anxiety and depression in pregnancy are risk factors for adverse outcomes for mothers' and children.
The study aimed to evaluate the impact of NEST-S program as nursing intervention strategy on overcoming
anxiety and depression during pregnancy. Quasi experimental design was used to achieve the aim of the study. A
convenience sample of 112 pregnant woman who attended at study settings and agreed to participate in the study.
The study was conducted at three Maternal and Child Health care centers in Shebin Elkom& El-Bagoor city,
Menoufia Governorate. Three different tools were used in this study: tool (1): Semi-structured interviewing
questionnaire, tool (2):Tylor anxiety scale, tool (3): Beck Depression Inventory scale. All studied women
complained from anxiety during pregnancy, moderate type of anxiety took the upper hand of it (42.9%) and
nearly half of women suffered from anxiety at third trimester, meanwhile 64.3 % of pregnant women suffered
from depression during pregnancy and most common type was mild one (47.2%) and nearly one third of women
suffered from depression at third trimester. This study concluded that there was highly statistical significant
reduction of the mean score of anxiety and depression level post program than preprogram, there was highly
statistical significant relation between anxiety disorder and depression disorder pre and post program.
Incorporating screening for anxiety and depression in antenatal programs ,Integrating education about NEST-S
program within existing maternal and child health program to ensure the health of both mother and baby was
recommended
Keywords: anxiety, depression, pregnancy, NEST-S program

1. Introduction pleasure, feelings of guilt or low self-worth, disturbed sleep or

According to the World Health Organization (WHO) appetite, feelings of tiredness and poor concentration”. It can
(2016)(1), mental, neurological, and substance abuse (MNS) be long lasting or recurrent and thus hinders normal
disorders are responsible for 14 % of the global burden of functioning of life, in the most severe cases potentially leading
disease in both men and women, especially during pregnancy. to suicide(1).
Anxiety and depression are highly prevalent and are known Anxiety and depression have been associated with insecure
to have a range of serious negative consequences for both mother-child attachment, preterm birth, low birth weight,
mother and her child. Experiencing symptoms of anxiety and emotional, cognitive, and behavioral problems in the
depression during pregnancy is the most crucial risk factor offspring. Ultimately, psychosocial complaints in pregnancy
for having these symptoms in the postpartum period. have also been related to increased maternal mortality (3).
Anxiety in pregnancy is normal but when anxiety in Psychiatric morbidity is common amid pregnancy with 18.4%
pregnancy is significant enough to cause physical, emotional, of women encountering depressive symptoms during
and cognitive distress, a perinatal anxiety disorder might be pregnancy, and 12.7% having an episode of major
happening and pregnant women need help. Anxiety as defined depression(4). Furthermore, prevalence of anxiety disorders
by American Psychological Association is an emotion during pregnancy ranges from 12.2% to 39% with panic
characterized by feelings of tension, worried thoughts and disorder being three times more common among pregnant
physical changes like increased blood pressure(2).The World women than in the general population. Besides, generalized
Health Organization (WHO) defines depression as “a common anxiety and depressive disorder due to medical condition were
mental disorder characterized by sadness, loss of interest or

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 Academic Journal of Nursing and Health Education
Vol.7, No.3, 2018;
ISSN (5733 – 7155);
p –ISSN 4056 – 7396X
Impact factor: 2.91
found to be twice as common during pregnancy than in non- 2.3. Subjects: -A convenience sample of 112 pregnant women
pregnant women(5). who attended the previous mentioned settings and who agreed
Findings from some studies demonstrated that anxiety is to participate in the study, during a period from February 2017
more common amid pregnancy than depression and often to August 2017.
co-morbid with depression, even related to the occurrence of
2.3.1 Sample size
postnatal depression across numerous countries(6). In
developing countries, mental health has not gotten much Calculating sample size for evaluating the impact of NEST-S
consideration from the research community. Research is Program as nursing intervention strategy on overcoming
limited regarding treatment of perinatal mood disorders. anxiety and depression during pregnancy through DSS
Psychological therapies have been shown to successfully research.com sample size calculator software, at 5% ∞error
diminish anxiety among the general population of patients (95.0% significance) and 20.0 β error (80.0% power of the
with anxiety disorders(7). study), assuming the average Beck scale of depression in the
Women’s hesitance to take medication when pregnant or intervention group after the intervention is (11.84 ±3.17). The
during the postpartum period, along with potential concerns calculated sample size is 112.
about fetal and infant health outcomes, makes non- 2.3.2. Inclusion criteria include:-
pharmacological treatment options imperative in the perinatal
period (8). Nurses are in key position to screen women, provide  Ready and accepted to participate in the study.
education regarding perinatal mood and anxiety disorders to 2.3.3. Exclusion criteria include:-
pregnant and postpartum women and their families, and
guarantee appropriate treatment referrals(9).  Have a history of post-traumatic stress disorder.
The NEST-S Program is an important part of mental and  Have a history of substance abuse.
physical wellness for all new or soon to-be mothers. This  Undergoing medical treatment for psychiatric disorders
program provide women with information on key areas of 2.4. Tools of the study: -
self care and give suggestions for changes in women life to Three tools were used in this study:
help women improve her self-care and lessen her anxiety and Tool (1): Semi-structured interviewing questionnaire: This
depression . The NEST-S program includes five important questionnaire was developed by the researchers after extended
areas of self care and provides an easy way to remember the review of literature.
basic ingredients. N E S T S includes nutrition, exercise, sleep, This tool included socio-demographic characteristics of the
and rest time for pregnant women and support(10). pregnant woman as age, occupation, residence, it also
involved data about past medical history, obstetric history,
1.1. Aim of the study:-
family history of anxiety and depression, causes of anxiety
The aim of the current study was to:
and depression during pregnancy, etc..This tool was tested for
Evaluate the impact of NEST-S program as nursing
its content validity by 5 experts in the field of psychiatric
intervention strategy on overcoming anxiety and depression
nursing and obstetric nursing to ascertain relevance and
during pregnancy
completeness. The tool proved to be valid.
1.2. Research Hypothesis:-
Anxiety& depression level will be decreased among pregnant Tool (2) Tylor anxiety scale (Arabic version) (11):-This scale
women after program implementation than before program was developed by J.A. Tylor and translated & validated by
implementation. Mostafa Fahmi&Mohamed Ahmed, 2010. It consists of fifty
items in the form of two points Likert scale ranging as 1= yes,
2. SUBJECTS AND METHODS
2= no.
2.1. Research design:-
The score of each domain
Quasi experimental design was used to achieve the aim of the
0-16 no anxiety
study.
17-20 mild anxiety
2.2. Research Setting:-
21-26 moderate anxiety
The study was conducted at three Maternal and Child Health 27-29 severe anxiety
care centers in Shebin Elkom &El-Bagoor city , Menoufia 30-50 very severe anxiety
Governorate
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 Academic Journal of Nursing and Health Education
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ISSN (5733 – 7155);
p –ISSN 4056 – 7396X
Impact factor: 2.91
Tool (3):- Beck Depression Inventory (Arabic version) (12): A comfortable, private place was chosen for the interviewers.
This scale was developed byAaron T. Beck, Robert A. Steer, Orientation was done about the purpose of the study and
and Gregory K. Brown, translated and validated by Abd content of the study. Each woman was individually
Elsatar Ibrahim. It includes a 21-item self-report instrument interviewed where pre assessment was done using a structured
intended to assess the existence and severity of symptoms of interviewing questionnaire, b) Tylor anxiety scale c) Beck
depression. Depression Inventory
2.8.2. Implementation phase:-
Scoring: Each of the 21 items corresponding to a symptom of
Anxiety& depression will be decreased among pregnant
depression is summed to give a single score. There is a four-
women after program implementation than before
point scale for each item ranging from 0 to 3. On two items
intervention. This program has a general objective and divided
(16 and 18) there are seven options to indicate either an
into 7 sessions. Each session lasted about one hour and has a
increase or decrease of appetite and sleep. Total score of 0-13
set of specific objective. This was achieved through several
is considered minimal range, 14-19 is mild, 20-28 is moderate,
teaching methods as lecture, group discussion, picture and
and 29-63 is severe.
booklet were used as media. At the end of each session,
2.4.1. Reliability of the tools: - Reliability was applied by summary, feedback, further clarification was done for vague
the researchers for testing internal consistency of the tools by items.
administration of the same tools to the same subjects under General objective of the program:-
similar conditions. Answers from repeated testing were Evaluating the impact of the NEST-S program as nursing
compared (test- retest reliability) the tools revealed reliable at intervention strategy on overcoming anxiety and depression
0.81 for tool (2) and at 0.85 for tool (3) during pregnancy
2.5.An administrative approval was obtained from dean of This aim will be fulfilled through the following objectives
the Faculty of Nursing, Menoufia University and the manager -Assess anxiety& depression among pregnant women
of Maternal and Child Health care centers, Menoufia -Develop and implement nursing intervention (NEST-S
Governorate after explaining the purpose of the study. Program) for pregnant women.
2.6. Ethical consideration: The women were informed about -Evaluate the effect of nursing intervention on anxiety&
the purpose of the study and encouraged and gave full depression of pregnant women
informed verbal consent to participate, women were informed Content of the program:-
about the privacy of their information, the study was Short description of the interviewing program sessions
voluntary, harmless, and anonymous and confidentiality of employed in the study are discussed below
responses would be respected and they had the full right to Session 1: involved developing a trusting relationship with the
refuse to participate in the study at any time and they informed pregnant women& encouraging them to discuss their opinion,
that the data would be used only for scientific purpose. expectations, specific needs and problems.
2.7. Pilot study: It was carried out on 11 women"10"% of the Session2, 3: included information about anxiety &depression
sample to test the clarity, feasibility, consistency of the study such as its definition, signs& symptoms and causes of it.
tools, and time needed for data collection. No modifications Session 4: included information about effect of depression &
were needed as revealed from the pilot study. The sample of anxiety (maternal and fetal outcomes).
pilot study was excluded from the total sample to assure the Session 5: included information about components of NEST-S
stability of the results. Program and give information about nutrition (N) during
2.8.: Field Work: pregnancy especially that reduces anxiety and depression
The study was carried out in the period from February 2017 to during pregnancy as vitamins, minerals, and omega-3 fatty
August 2017.Over a period of six months. The researchers acids.
divided the women into eight groups; each group consisted Session 6: included information about importance and how to
from 14 pregnant women. The researchers collected the data do exercises correctly during pregnancy (E).
during the morning 2 days per week .The implementation of Session 7: included information about importance of sleep (S),
the study passed into three phases (pre assessment phase, required hours for sleeping, right position for sleeping and
implementation phase, and post assessment phase) also included information about importance of taking rest and
2.8.1. Pre assessment phase:-

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 Academic Journal of Nursing and Health Education
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ISSN (5733 – 7155);
p –ISSN 4056 – 7396X
Impact factor: 2.91
relaxation techniques used by pregnant women to deal with 41.1% of the studied women were mutigravida (1-3 times)
stress during pregnancy (T). and 5.4 % of them had abortion. Regarding pregnancy
Session 8: Included information about importance of receiving complications, 16.1 % of studied women had complications at
support (S) during pregnancy and its source &Summary for all previous pregnancy and the most common complications was
previous sessions PIH .
Table (4) represented the distribution of the studied women
2.8.3 Post assessment phase:- according to current obstetric history. Regarding to gestational
Evaluation was done using Tylor anxiety scale & Beck age of current pregnancy, the mean gestational age was 24.6
Depression Inventory scale to evaluate the effectiveness of the ± 13.2 , regarding planning to pregnancy; only 25 % of
program after 1 month of giving program women were un planned to be pregnant .The same table also
2.9.Data Analysis: showed that 21.4% of women experienced pregnancy
Data was coded and transformed into specially designed form complications and the most common complications (10.7%)
to be suitable for computer entry process. Data was entered was PIH .
and analyzed by using SPSS version 16. Quantitative data Table (5) showed that all studied women complained from
were presented by mean (X) and standard deviation (SD). anxiety during current pregnancy, moderate type of anxiety
Friedman test p was performed to differentiate changes in took the upper hand of it (42.9%) and nearly half of pregnant
different follow up results of different studied variables. women suffered from anxiety at third trimester (48%),
Qualitative data were presented in the form of frequency meanwhile 64.3 % of pregnant women suffered from
distribution tables as number and percentage. It was analyzed depression during pregnancy and the most common type was
by chi-square (χ2) test. Level of significance was set as P mild one (47.2%) and nearly one third of women suffered
value < 0.05 for all statistical tests. from depression at third trimester (34%) , the same table also
3. Results showed that 26.8% of studied women complained from both
Table (1) represented socio-demographic characteristics of the anxiety and depression. The table revealed that the most
studied women: This table revealed that more than half of the common cause of anxiety and depression was fearing from
studied sample (62%) were housewife, and had enough pregnancy's complications (26.8%).
income (51.8%). The same table also showed that 14.3 % of Table (6) displayed that there was highly statistical significant
them completed university education. reduction of the mean score of anxiety and depression level at
Table (2) showed that 16.1% of studied woman had history of 0.001 post program than preprogram.
family depression, 57.1% of them complained from anxiety Table (7) revealed that there was highly statistical significant
during previous pregnancy and mild type of anxiety had relation between anxiety disorder and depression disorder pre
highest percentage (37.5%) mean while 19.6 % of them and post program P<0.001 .
complained from previous pregnancy depression and 8.9% of As noticed from Table 8, there was significant positive
them complained from both anxiety and depression during correlation between anxiety disorder level pre and post
previous pregnancy intervention program, correlation coefficient r=0.739
Table (3) displayed the distribution of the studied women
regarding past obstetric history. Regarding previous pregnancy

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 Academic Journal of Nursing and Health Education
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ISSN (5733 – 7155);
p –ISSN 4056 – 7396X
Impact factor: 2.91

Table (1): Socio demographic characteristics of the

studied women (N=112) Table (3): Past obstetric history data of the studied
Socio-demographic No. % pregnant women (N=112).
characteristics Variables The studied pregnant
Age / years: women (N=112)
- 20 - 25 14 12.5 N %
- 26-30 48 42.9 Number of previous
- 31-35 38 33.9 pregnancies:
- 36-40 12 10.7 -0 36 32.1
Education: - 1-3 46 41.1
- Read and write 20 17.9 - 4-6 30 26.8
- Preparatory 16 14.3
56 50.0 History of previous
- Secondary
16 14.3 abortion:
- University 4 3.6 -Yes 6 5.4
- Post graduate -No 106 94.6
Occupation:
- Housewife 70 62.5 History of pregnancy
- Employee 26 23.2 complications:
16 14.3 -Yes 18 16.1
- Others -No 94 83.9
Income:
- Not enough 42 37.5 -If yes, mention the
- Enough 58 51.8 complications:
12 10.7 -PIH 10 8.9
- Enough and more
Residence: -Gestational diabetes 2 1.7
- Rural 80 71.4 -Anemia 6 5.4
- Urban 32 28.6

Table (2):Family and psychological history of the studied

women (N=112) Table (4): Current obstetric data of the studied pregnant
women (N=112).
Psychological History No. %
Family history of depression and anxiety Variables The studied pregnant
during pregnancy : women (n=112)
18 16.1 N %
- Yes
94 83.9 Gestational age of current X ±SD
- No
pregnancy (weeks): 24.6 ± 13.2
Previous y history of anxiety during
pregnancy 64 57.1
Pregnancy status:
- Yes 48 42.9
- Planned 84 75.0
- No 28 25.0
Level of anxiety :
- Unplanned
History of current
- Mild 24 37.5
pregnancy complications:
- Moderate 18 28.1
- Yes 24 21.4
22 34.4
- Severe - No 88 78.6
Previous pregnancy depression : -If yes, mention the
- Yes 22 19.6 complications:
- No 90 80.4
Previous history of both anxiety and - Hypertension 12 10.7
depression 10 8.9
- Anemia
-Yes 10 8.9 1.7
- Diabetes 2
-No 102 91.1

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Impact factor: 2.91

Table (5): Current psychological data of the studied Table (6): Comparison between mean score anxiety and
pregnant women (N=112). depression of studied women pre and post nursing
Psychological History No. % intervention program .
Anxiety during current pregnancy : Parameters Pre Post Paired P
- Yes 𝐗 ±SD 𝐗 ±SD t-test value
- No 112 100% Anxiety level (N =112) 20.7±2.62 15.24±2.01 17.8 0.001
0 0% Depression level 16.1±4.40 8.5±1.32 11.9 0.001
Level of anxiety : (N=72)
- Mild 34 30.4
- Moderate 48 42.9
Table (7): Relation between anxiety and depression level
30 26.7
- Severe pre and post nursing intervention program .
Trimester of anxiety ( total=112)
Parameter Level (Pre) (post) χ2 P-
value
- First 28 25
No. % No. %
- Second 36 32.1
48 42.9 Anxiety: (N 112)
- Third
Current pregnancy depression :  No 0 0.0 50 44.6 13.3 <0.01*
 Mild 34 30.4 36 32.1
 Moderate 48 42.8 20 17.9
- Yes 72 64.3
 Severe 30 26.8 6 5.4
- No 40 35.7
Level of depression( total=72): Depression (N=
- Mild 34 47.2 72):
- Moderate 20 27.8  No 0 0.0 42 58.3 13.3 <0.01*
18 25  Mild 20 27.8 20 27.8
- Severe
Trimester of depression ( total=72)  Moderate 34 47.2 10 13.9
- First  Severe 18 25 0 0.0
- Second 12 16.7
26 36.1 Table (8): Correlation between Anxiety level pre and
- Third
34 47.2 post intervention.
Both anxiety and depression Anxiety disorder
- Yes 30 26.8
Items R P value
- No 82 73.2
Pre
Reason of depression and anxiety
Post 0.739 <0.001*
Complications of 30 26.8
Pregnancy 28 25.0
Complications of labor 28 25.0
Fear from giving birth 26 23.2

4 .Discussion maternal anxiety in pregnancy in China and found that the

The current study aimed at evaluating the impact of the mean age of studied women was 28.9 years and nearly half
NEST-S Program as nursing intervention strategy on of pregnant women reported technical secondary school
overcoming anxiety and depression during pregnancy. degree followed by college or above degree ,on the same
The present study showed that nearly half of the studied line , Niloufer S. et al , (2012)(13) who studied frequency
sample aged 26-30 years , most of them were housewife and and associated factors for anxiety and depression in
had secondary education, The findings of the present study pregnant women reported that several studies had revealed
were congruent with study conducted byYu-ting K etal that young maternal age , lower women’s educational level ,
(2016)(6) who studied prevalence and risk factors of

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 Academic Journal of Nursing and Health Education
Vol.7, No.3, 2018;
ISSN (5733 – 7155);
p –ISSN 4056 – 7396X
Impact factor: 2.91
and unemployment are associated with antenatal anxiety and comprehensive information on childbirth preparation
depressive symptoms. contributed to increased anxiety and depression related to
Concerning obstetric history nearly one third of the studied pregnancy
sample was primigravida, In accordance with current study The present study findings revealed highly statistical
findings, A study conducted by Nagandla K etal (2016)(14)who significant reduction of the mean score of anxiety and
studied prevalence and associated risk factors of depression, depression level after application of N E S T S(nutrition,
anxiety and stress in pregnancy at Malaysia reported that half exercise, sleep, , rest and support)program (self care) than
of studied women were primigravida. This result might be due preprogram, the present study findings was congruent with
to lack of experience and lack of knowledge concerning Haring M(2011)(10) who studied coping with depression
pregnancy which may cause anxiety and depression during during pregnancy and after birth and stated that self care is
pregnancy. often neglected by women in the perinatal period and added
The present study findings revealed that one fourth of studied that self care making positive change in pregnant women life
sample had unplanned pregnancy, the findings of the present that help in reducing anxiety and depression
study was similar to findings of study conducted by Nagandla On the same line Angelo et al (2012) (18) who studied effect of
K. etal (2016)(14)who documented that thirty five percent of aerobic exercise training during pregnancy on reduction of
studied sample had unplanned pregnancy as the major depressive symptom reported that primarily aerobic exercise
concern of unplanned pregnancy is its potential effect on during pregnancy reduces depressive symptoms, also Monire
women's psychological health and well-being resulting in et al (2014) (19) who studied the effect of relaxation training in
profound ambivalence and negative emotion that precipitates primigravida women on anxiety and improved maternal
the development of depression(15) attachment to fetuses and neonates reported that relaxation
The present study findings revealed that the most common training reduces anxiety during pregnancy as exercise and
pregnancy related complications was pregnancy induced other physical activity produce endorphins — chemicals in
hypertension, The current study findings coincided with Yu- the brain that act as natural painkillers, which in turn improve
ting K. etal (2016)(6)who studied prevalence and risk factors mood, reduces stress, anxiety and depression(7).
of maternal anxiety in pregnancy in China and found that Nutrition has important role in reducing pregnant women
women with pregnancy-induced hypertension had higher anxiety and depression, Studies have indicated that daily
prevalence of antenatal anxiety and depression as pregnant supplements of vital nutrients (vitamins, minerals, and omega-
women with preeclampsia intended to suffer from high 3 fatty acids) are often effective in reducing anxiety and
anxiety and depression due to fear of babies’ prematurity, loss depression (Shaheen , 2008) (20) .
and guilt. Conclusion: anxiety and depression level decreased among
Podvornik N &Velikonja V (2015)(16) who studied depression pregnant women after program implementation than before
and anxiety in women during pregnancy in Slovenia reported intervention
that nearly one fifth of pregnant women were identified as Recommendations
suffering from elevated depression and half pregnant women 1- Incorporating screening for anxiety and
reported high anxiety state, on the same line, The present depression in antenatal programs and providing practical
study revealed that nearly one fourth of studied sample support to women during pregnancy, particularly those with a
suffering from severe anxiety and depression, this is may be previous history of depression and who have poor family
due to lack of support from surrounding family members and relationship.
sometimes unwanted sex of the baby and fear of labor. 2- Integrating education about NEST-S program
Kalayil G, Sheila M, NailyK (2015)(17) who studied within existing maternal and child health program to ensure
prevalence of pregnancy anxiety and associated factors found the health of both mother and baby.
that highest prevalence of pregnancy anxiety and depression 3- Implementation of a structured childbirth
was reported during the third trimester of pregnancy, Kalayil education for pregnant women as part of the routine antenatal
et al (2015)(17) study findings was matching with present study care both in public and private hospitals to ensure well-
findings which revealed that nearly half of studied sample informed and empowered expectant mothers, which would
reported anxiety and depression during third trimester.This reduce their pregnancy related anxiety and depression.
may be due to high childbirth fear and lack of scientific and

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Impact factor: 2.91

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An official Publication of Center for International Research Development
Double Blind Peer and Editorial Review International Referred Journal; Globally index
Available www.cird.online/AJNHE: E-mail: [email protected]
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