Journal Of Nursing Practice https://thejnp.org/ ISSN: 2614-3488 (print); 2614-3496 (online) Vol.6 No.2. April 2023. Page.113-121 113 Self-Help Group Therapy as Community Nursing Intervention to Reduce Stress Response and Increase Self-Efficacy in High-Risk Pregnant Women Reni Nurhidayah*, Prima Dewi Kusumawati Department of Nursing, Institut Ilmu Kesehatan STRADA Indonesia, Kediri, Indonesia *Corresponding author: reni.nurhidayah@iik-strada.ac.id ABSTRACT Background: Unexpected and unanticipated obstetric problems that can have a direct or indirect impact on the well-being of mothers and babies are considered high-risk pregnancies. Uncertainty in health conditions is felt as a life-threatening event that can threaten the lives of mothers and babies. This condition will trigger various stress responses felt by the mother. Moderate to severe stress during pregnancy greatly increases the risk of developing postpartum depression. One of the important coping sources to deal with stress is self-efficacy. Personal abilities are all aspects of an individual that can be utilized to solve problems. One of the interventions that can be used to improve coping mechanisms is self-help groups. Self Help group is a group approach to help its members solve their problems. Purpose: This study aims to determine the impact of self-help groups as therapy in the community to reduce stress responses and increase self-efficacy in high-risk pregnant women. Methods: The research design used was a quasi-experimental one-group pre-test post-test design. 15 respondents were given intervention in 3 sessions for 90 minutes in each session. Stress response and self-efficacy were measured before and after the intervention. Data analysis was carried out using the paired sample T-test. Results: This study shows that the average assessment stress response and self-efficacy score of mothers before the self-help group therapy is 128 and 35. After the therapy, the average response stress and self-efficacy score of mothers was 86 and 53. The study shows the effect of self-help group therapy on stress response (ρ-value = 0,012) and self-efficacy (ρ-value = 0,021). Conclusion: It was concluded that self-help group therapy was effective in decreasing stress respons and improving self-efficacy for high-risk pregnant women. Keywords: high risk pregnancy, self-efficacy, self-help group, stress response Received February 10, 2023; Revised March 12, 2023; Accepted April 3, 2023 DOI: https://doi.org/10.30994/jnp.v6i2.367 The Journal of Nursing Practice, its website, and the articles published there in are licensed under a Creative Commons Attribution-Non Commercial- ShareAlike 4.0 International License. https://thejnp.org/ mailto:reni.nurhidayah@iik-strada.ac.id https://doi.org/10.30994/jnp.v6i2.365 Journal Of Nursing Practice https://thejnp.org/ ISSN: 2614-3488 (print); 2614-3496 (online) Vol.6 No.2. April 2023. Page.113-121 114 BACKGROUND Pregnancy is one of the most important life events for women. Various physiological and psychological changes occur in this period. This condition makes pregnant women vulnerable to health problems that affect the mother, fetus, or both. Unexpected and unanticipated obstetric problems that can have a direct or indirect impact on the well-being of mothers and babies are considered high-risk pregnancies. Worldwide, the incidence of high- risk pregnancies is 2 million women and more than 800 pregnant women die every day due to complications and pregnancy problems (Holness, 2018; Yusriani & Septiyanti, 2021). High-risk pregnancies in Indonesia are still quite high. Based on data from the Sampling Registration System (SRS) in 2018, around 76% of maternal deaths occurred in the labor and postnatal phases with the proportion of 24% occurring during pregnancy, 36% during delivery, and 40% after delivery. The number of maternal deaths in 2019 was sourced from district/city health profiles reporting as many as 684 problems or 74.19 per 100,000 live births, a decrease of 16 cases compared to 2018 which was 700 cases. The cause of maternal death is still dominated by 33.19% bleeding, 32.16% hypertension in pregnancy, 3.36% infection, 9.80% circulatory system (heart) barriers, 1.75% metabolic barriers and 19.74% triggers another (RI Kemenkes, 2018). Uncertainty in health conditions is felt as a life-threatening event that can threaten the lives of mothers and babies. This condition will trigger various stress responses felt by the mother. Stress is our body's natural response when faced with a problem. The stress mechanism will form when we are faced with a stressor. Pregnancy complications are a serious stressor for pregnant women. Threats to the health of the mother and the fetus, the strict treatment in the hospital, and the bed rest will make pregnant women feel fear and a real threat to the safety of themselves and their babies (Akbarian et al., 2018; Esfandiari et al., 2020; Kinsella & Monk, 2013; Wesley, 2006). Pregnancy complications not only cause physical problems but also psychological problems. The reaction of pregnant women to high risk pregnancy is very much determined by their perception of the problem, starting from the risk, severity, and expectation related to their health condition. The label of high-risk pregnancy will make these pregnant women think negatively about their pregnancy (Ahmadi et al., 2019; Hassan, Mohammed, et al., 2020; Holness, 2018; Kianpour et al., 2018; Yusriani & Septiyanti, 2021). Qualitative research that has been conducted on mothers with high-risk pregnancies shows that all mothers have negative thoughts regarding pregnancy and their health conditions. Pregnant women with high risk often feel that they and their babies are going to die. They are worried about all the possibilities that can happen and are even frustrated with their health and pregnancy conditions. Even pregnant women often think that they fail to maintain their pregnancy and health (Dijkhuis et al., 2020; Harris et al., 2014; Roberts et al., 2017). A high-risk pregnancy is a problem causing maternal and fetal morbidity and mortality. The real threat to safety makes pregnant women often show symptoms of stress related to the problem they are experiencing. Moderate to severe stress during pregnancy greatly increases the risk of developing postpartum depression (Hassan, Gouda, et al., 2020; Hassan, Mohammed, et al., 2020; Kendig et al., 2016). Research has shown the incidence of postpartum depression is much higher in pregnant women with pregnancy problems. Uncertainty in the health condition of pregnant women and the fetus during treatment. Various actions are given during treatment. Various interventions that may be given during childbirth often increase the trauma felt by pregnant women. Trauma that does not go away often increases the risk of postpartum depression experienced by postpartum mothers with a high-risk pregnancy (Abedian et al., 2015; Akbarian et al., 2018; Chen et al., 2019; Mbarak et al., 2019). https://thejnp.org/ Journal Of Nursing Practice https://thejnp.org/ ISSN: 2614-3488 (print); 2614-3496 (online) Vol.6 No.2. April 2023. Page.113-121 115 Stress during pregnancy that is not resolved can trigger mental disorders in pregnant women and postpartum. Pregnant women with severe stress can have emotions or moods such as rollercoasters where suddenly anxiety attacks to panic, depression, and even thoughts of suicide can appear. This is due to their fear of not being able to adapt to the traumatic events during the pregnancy. All of the above conditions greatly affect the mental health of the mother and can trigger depression and even psychosis (Acosta et al., 2013; Caropreso et al., 2019; Nasiri, S., Akbari, H., Tagharrobi, L. and Tabatabaee, A.S., 2018; Verbeek et al., 2015). In adapting to stressors such as high-risk pregnancy, a mother needs an effective coping mechanism that is supported by adequate coping sources (Chapuis-de-Andrade et al., 2021; Kerns et al., 2018). One of the important coping sources to deal with stress is self-efficacy. Personal abilities are all aspects of an individual that can be utilized to solve problems. One of the main factors in personal ability is self-efficacy. Self-efficacy is an individual's ability, strength, and ability to solve certain specific problems. Self-efficacy in pregnant women is usually associated with the mother's readiness to adapt to her pregnancy. Good self-efficacy will help mothers adapt to the conditions of their pregnancy adaptively (Abarashi et al., 2014; Dwairej & Ahmad, 2022; Kim & Suh, 2018; Mohammadpour et al., 2016; Nurhidayah, 2017). One of the interventions that can be used to improve coping mechanisms is self-help groups. Self Help group is a group approach to help its members solve their problems. In a self-help group, each group member shares physical, emotional, or other issues. This group also discussed how to solve these health problems. Self-help groups will form a support system where all pregnant women with high risk can share and not feel alone in living their lives so that they can respond to all existing stressors more adaptively (Saggurti et al., 2018, 2019; Worrall et al., 2018). This study aims to determine the impact of self-help groups as therapy in the community to reduce stress responses and increase self-efficacy in high-risk pregnant women. So it is hoped that this research can provide intervention options in caring for pregnant women with high risk more holistically and optimally. So that the welfare of pregnant women during the process of pregnancy, childbirth, and postpartum can be achieved. METHODS The research design used was a quasi-experimental one-group pre-test post-test design. Respondents in this study were 15 mothers with high risk pregnancy at the Posyandu in Gempolan Village in May 2022. The intervention was given in 3 sessions for 90 minutes in each session. Stress response and self-efficacy were measured before and after the intervention. Data analysis was carried out using the paired sample T-test. RESULTS Respondent Demographics The characteristics of the respondents in this study were general data which included: age, education, occupation and marital status. Table 1. Characteristics of Respondents N=15 No. Characteristics f % Age 1 <20 years old 2 13,4 2 20-35 years old 8 53,3 3 >35 years old 5 33,3 https://thejnp.org/ Journal Of Nursing Practice https://thejnp.org/ ISSN: 2614-3488 (print); 2614-3496 (online) Vol.6 No.2. April 2023. Page.113-121 116 Based on the table above, it is known that more than a half of the respondents were 20- 35 years old (53,3%). Most of the respondents have a high school education (60%), work as housewives (53,3%), and multipara (86,6%) from a total of 15 respondents. High Risk pregnancy are too young mother (13,4%), too old mother (33,3%), hypertension (53,3%), anemia (26,7%), diabetes (13,4%) and twin pregnancy (6,7%). Stress Response Before and After Treatment Table 2. Psychological Well Being in Mothers Before and After Mindfulness-Based Stress Reduction Therapy Based on the table above, it is known that the average assessment stress response score of mothers before the self-help group therapy is 128 with the lowest score is 114 and the highest is 146. After the therapy, the average response stress score of mothers was 86 with the lowest score 78 and the highest 117. Table 3. Results of Paired Sample T-Test The Effect of Self-Help Group Therapy on Stress Response The table above shows the effect of self-help group therapy on stress response in high risk Education 1 Elementary School 1 6,7 2 Junior High School 3 20,0 3 Senior High School 9 60,0 4 University 2 13.3 Profession 1 Housewife 8 53,3 2 Farmer 4 26,7 3 Entrepreneur 2 13,4 4 Private 1 6,7 Pregnancy Status 1 Primipara 2 13,4 2 Multipara 13 86,6 Pregnancy Complication 1 Hypertension 8 53,3 2 Anemia 4 26,7 3 Diabetes 2 13,4 4 Twin Pregnancy 1 6,7 N Min Max Mean Sd Stress Response Pre Test 15 114 146 128 2,052 Stress Response Post Test 15 78 117 86 1,242 https://thejnp.org/ Journal Of Nursing Practice https://thejnp.org/ ISSN: 2614-3488 (print); 2614-3496 (online) Vol.6 No.2. April 2023. Page.113-121 117 The table above shows the effect of self-help group therapy on stress response in high risk pregnancy (ρ-value = 0,012 <0.05, so H0 was rejected). There is an effect of self-help group therapy on stress response in high risk pregnancy at Posyandu Gempolan. Table 4. Self-efficacy in Mothers Before and After Mindfulness-Based Stress Reduction Therapy The table above shows the effect of self-help group therapy on stress response in high risk pregnancy (ρ-value = 0,012 <0.05, so H0 was rejected). There is an effect of self-help group therapy on stress response in high risk pregnancy at Posyandu Gempolan. Self-efficacy before and after treatment Table 5. Results of Paired Sample T-Test The Effect of Self-Help Group Therapy on Self- Efficacy Based on the table above, it is known that the average self-efficacy assessment score of mothers before the mindfulness-based stress reduction therapy is 35 with the lowest score is 13 and the highest is 56. After the therapy, the average score psychological well-being of mothers after treatment was 53 with the lowest score 32 and the highest 71. The table above shows the effect of self-help group therapy on self-efficacy in high risk pregnancy (ρ-value = 0,021 <0.05, so H0 was rejected). There is an effect of self-efficacy in high risk pregnancy at Posyandu Gempolan. DISCUSSION Effect of Self-Help Group Therapy on Stress Response The results showed that self-help groups were able to reduce the stress response of pregnant women with high risk. The self-help group is one of the interventions that can optimize the source of coping that is needed by someone who is experiencing stress. Self-help group has purpose to make pregnant women able to maintain and improve their self and social Pre Test Post Test Paired Sample T Test (t) ρ N Mean SD N Mean SD Self-Efficacy 15 35 13,92 15 53 224,73 -2,70 0,021 Pre Test Post Test Paired Sample T Test (t) ρ N Mean SD N Mean SD Stress Response 15 128 2,052 15 86 1,242 100,347 0,012 N Min Max Mean Sd Self-efficacy Pre Test 15 13 56 35 13,92 Self-efficacy Post Test 15 32 71 53 24,73 https://thejnp.org/ Journal Of Nursing Practice https://thejnp.org/ ISSN: 2614-3488 (print); 2614-3496 (online) Vol.6 No.2. April 2023. Page.113-121 118 functions through cooperation and sharing in dealing with pregnancy problems. Self-help groups understand people that they are not alone, where members help each other and support each other by telling experiences and alternative ways of solving problems. So a self-help group is an informal group with members who experience similar problems so that they can share experiences, cooperate and support in solving problems related to self and society (Saggurti et al., 2018, 2019; Worrall et al., 2018). Self-help groups will provide social support which is an important factor in the adaptation of high-risk pregnant women. Heavy pregnancy can make the mother feel pressured by the health changes she must undergo. So the mother will really need help from others. Support plays an important role in reducing stress responses because good family support will make the mother feel valued, and cared for it can reduce feelings of pressure and helplessness that arise due to pregnancy problems experienced. With an effective support system, pregnant women will feel not alone and have a place to share during pregnancy. This effective support system will increase the ability to cope and reduce the stress response felt by pregnant women with high risk (Esfandiari et al., 2020; Saggurti et al., 2019; Spiegel et al., 2007; Wesley, 2006; Worrall et al., 2018). Effect of Self-Help Group Therapy on Self-Efficacy Self Efficacy is a personal ability to solve problems. So that it can be said that self- efficacy is how a person judges herself to be able to overcome a problem and he shows the ability to overcome the problem. So self-efficacy does not only refer to self-confidence but also refers to one's skills in overcoming the problem. Self-efficacy has an important role in improving the performance of mothers in adapting and solving problems encountered. When mothers are faced with problems with their pregnancy, self-efficacy will help them to take better care of their pregnancy. Poor self-efficacy will make the mother feel incapable, afraid, and failing so pregnant women will focus on their health problems without thinking of solutions that must be done. On the other hand, if the mother has good self-efficacy, she will try to do her best to maintain a healthy pregnancy(Nurhidayah, 2017; Salomonsson et al., 2013; Zarenejad et al., 2020). The results of the study show that self-help group therapy can increase maternal self- efficacy because self-help group therapy will help pregnant women find advice, role models, and solutions to overcome their problems. A self-help group is a group or peer where each member will share with each other the physical and emotional problems they face during pregnancy. Self-help group aims to develop empathy among fellow group members where fellow group members provide reinforcement to each other to form adaptive coping (Saggurti et al., 2018, 2019; Worrall et al., 2018). 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