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Original Article
Developing a community-based, multicultural-friendly prenatal education pilot program
EunSeok Cha1orcid, Sojung Lee2orcid, Gui-Nam Kim3orcid, Byung Hun Kang4orcid, Min-Sun Jeon5orcid
Research in Community and Public Health Nursing 2024;35(3):226-239.
DOI: https://doi.org/10.12799/rcphn.2024.00507
Published online: September 30, 2024

1Professor, College of Nursing, Chungnam National University, Daejeon, Korea

2Assistant Professor, Department of Nursing, Korean Bible University, Seoul, Korea

3Instructor, College of Nursing, Chungnam National University, Daejeon, Korea

4Associate Professor, College of Medicine, Chungnam National University, Daejeon, Korea

5Professor, Department of Food and Nutrition, Chungnam National University, Daejeon, Korea

Corresponding author: Min-Sun Jeon Department of Food and Nutrition, Chungnam National University, 99 Daehak-ro, Yuseong-gu, Daejeon, 34134, Korea Tel: +842-821-6836, E-mail: dearms@cnu.ac.kr
• Received: February 27, 2024   • Revised: June 4, 2024   • Accepted: July 10, 2024

© 2024 Korean Academy of Community Health Nursing

This is an Open Access article distributed under the terms of the Creative Commons Attribution NoDerivs License. (https://creativecommons.org/licenses/by-nd/4.0) which allows readers to disseminate and reuse the article, as well as share and reuse the scientific material. It does not permit the creation of derivative works without specific permission.

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  • Purpose
    The purpose of this study was to examine the acceptability, availability and sustainability of a pilot prenatal program developed by an interdisciplinary team.
  • Methods
    Out of 19 multicultural women participated in the 6-session prenatal program, 6 women took part in an exit- focus group interview as a part of formative evaluation. The verbatim transcriptions of semi-structured interview data were analyzed using conventional content analysis.
  • Results
    In general, the participants expressed high satisfaction with program content, educators and education methods. A hybrid model including health professionals and community health workers and using online and offline education modes was suggested as a way to disseminate the program at a national level. Interventions using aesthetic approaches such as music and an integrated method such as the introduction of available social services in pregnancy and during the postpartum period may play a role as the facilitator of the program participation of multicultural women. These approaches may also help them develop healthy coping skills, problem solving skills and empowerment in multicultural childbearing women who need to adjust to life in a new country simultaneously taking a new role as a mother.
  • Conclusion
    An interdisciplinary prenatal program using a holistic approach contributes to enhancing multicultural women’s empowerment to become a mother in a new country.
As of 2022, the number of marriage immigrants in Korea is reported to be 169,633 people, and married immigrant women are reported to take up 80.3% of them [1]. Married immigrant women are women who immigrated to Korea with the intention of marrying a Korean man [2,3]. In general, they get married with little background knowledge about Korean culture, and 80% of them experience the first pregnancy within a year after immigration when they have not yet sufficiently adjusted to Korean language and culture [4,5].
It has been shown that married immigrant women not only experience difficulties due to a lack of information about pregnancy and childbirth, problems in communication with medical staff due to a language barrier, and a lack of support systems in pregnancy and the postpartum period [4,6,7], but also have a hard time adjusting to Korean foods and childbirth culture [5-7]. Many married immigrant women depend on their Korean husbands to overcome language barriers and a lack of information, but they do not receive sufficient help in overcoming the fear of pregnancy and childbirth [7-9]. Rather, they experience problems such as emotional stress, prenatal depression, and nutritional imbalances during the processes of pregnancy and childbirth [7,9-11], which is linked to a high rate of low birth weight and postpartum depression [8,12].
The increase of married immigrant women is directly linked to the growth of multicultural births [8,13], and if married immigrant women fail to adjust appropriately to the new culture and parental roles, it may lead to many health problems related to maladjustment, identity problems, family conflicts, and self-care deficit [4,8]. Therefore, it is necessary to develop and execute a community-based, multicultural-friendly prenatal education program and subsequently implement a full-fledged education program in the community not only for the health promotion of individuals but also for the health promotion of multicultural families and the entire community [3] .
So far, prenatal education for married immigrant women has been carried out by providing the translations of educational materials for Koreans without considering linguistic and cultural differences just with the goal of increasing knowledge about pregnancy and childbirth [4,14,15]. Since the number of married immigrant women is increasing, it is essential to develop a new education program that can help them adjust to a new culture and, at the same time, improve their capabilities to carry out pregnancy, childbirth, and childrearing successfully [4,5,8]. In other words, there is a need to develop a new ‘multicultural-friendly prenatal education program’. This new program is designed as a personalized self-care capacity enhancement program to help married immigrant women settle into a new society and maternal roles through the process of mutual adaptation through respecting various cultural differences among community members and utilizing positive coping mechanisms and acculturation strategies such as assimilation and integration [8,11,16]. Thus, it is necessary to develop a community-based prenatal education program differentiated from existing programs by directly investigating the needs of married immigrant women regarding the educational topics and methods they want through their voices, and by evaluating the appropriateness of educational methods and operation processes of the program rather than simply assessing the efficacy of education.
This study aimed to evaluate the feasibility and operation of a multicultural-friendly prenatal pilot program developed by an interdisciplinary research team through collaboration through community partners [17-19]. To achieve the goal, the research team developed a prenatal education pilot program based on a socioecological model, and performed a pilot operation. Then, the research team examined whether the developed program met the educational needs of married immigrant women and whether the educational methods were appropriate in terms of methodological aspects with group interview feedback. This study eventually derived an appropriate model of multicultural-friendly prenatal education that can be applied to married immigrant women in Korea, and the results of this study can serve as a foundation for providing an effective, innovative, community-based multicultural-friendly prenatal education program nationwide [17].
Study design
This study is a methodological study in which an interdisciplinary research team developed and operated a multicultural-friendly prenatal education pilot program, and conducted an evaluation of the operation of the program to explore improvement directions of the program, based on group interview feedback [20]. The interdisciplinary team was composed of a total of 10 people (three nurses, three nutritionists, a doctor, a social worker, a music therapist, and an international board-certified lactation consultant). This study attempted to repeatedly perform the four phases of Plan, Do, Check, and Act (PDCA) in order to identify problems that may be encountered in a specific situation, and derive measures to solve the problems [21,22]. PDCA is widely used to improve clinical research and practice education in the field of nursing, where the connection between theory and practice is considered important [22,23]. In the ‘Plan’ phase, an intervention for previously set topics is planned, and in the ‘Do’ stage, an intervention is actually executed. In the ‘Check’ stage, an evaluation of the provided intervention, including feedback from participants, is conducted, and in the ‘Act’ stage, improvement measures for the identified problems are suggested, and changes are made to the intervention program to improve it (Figure 1).
Participants
This study was conducted after obtaining approval from the IRB (IRB No: 202209-SB-126). Education participants were married immigrant women who used a multicultural center, an integrated support center for foreign residents, and the obstetrics and gynecology outpatient clinic of a general hospital operating an integrated care center for high-risk pregnancy and neonatal care which were located in the five districts of D City. The participants included pregnant women, and they were recruited through institutional promotion and by snowball sampling. A total of 19 married immigrant women participated in a multicultural-friendly prenatal education pilot program. Afterwards, out of the 19 participants, 6 people who could vividly describe their experience of the program or clearly express their opinions about program improvement participated in a participant group interview. The interview participants were women who participated in the multicultural-friendly prenatal education pilot program, and were able to communicate in Korean. In terms of nationality, they consisted of three Vietnamese, one Uzbek, one Mongolian, and one Thai. According to Krueger & Casey [24], for a group interview that deals with non-commercial topics and requires specialized knowledge, the appropriate number of participants is 6 to 8.
Research procedure

Researcher preparation

In order to conduct a systematic interview, the interview was conducted by the main facilitator and a co-facilitator who had experience in conducting qualitative research, and did not directly participate in the education program. To exclude general societal preconceptions about multiculturalism and multicultural people, the two facilitators discussed with each other several times before starting the interview. To proceed with the interview in an objective, neutral, and permissive atmosphere, the main facilitator, who participated only in education planning, proceeded with the interview, and the co-facilitator, who was in charge of educator recruitment and the general management of program operation, participated in the interview only when there was a need to clarify the meanings of questions or responses or ask additional questions. A research assistant attended the interview, and observed and recorded the nonverbal expressions of the participants, such as their facial expressions, behaviors, and tones of voice, during the group interview.

Development of a prenatal education pilot program

1. Development of a prenatal education pilot program and planning of its operational methods

1) Collaboration with community partners for development of the content of a prenatal education program

To develop an evidence-based multicultural-friendly prenatal education program, an interdisciplinary research team comprised of researchers in the fields of nursing, nutrition, and medicine was created. Also, health education experts actively providing health education to the community, including a music therapist, an international board-certified lactation consultant, and a nurse with 20 years or more of clinical nursing experience in women’s health, were invited to join the research team for collaborative research. A community multicultural program expert working at a local multicultural family support center was additionally recruited to join the research team. In addition, with the help of this multicultural program experts, eight married immigrant women with the experience of pregnancy and childbirth in Korea were joined as the members of an advisory group. Convergence research by a multidisciplinary research team can provide various perspectives for resolving social problems, increase the professionality of a program, provide diverse analyses and interpretations of the collected data, and thereby derive diverse solutions [25].
Individuals’ health behaviors are influenced by intrapersonal, interpersonal, organizational, community, and social and public policy [25,26]. In addition, it has also been suggested that prenatal education for married immigrant women is effective when it is provided as a theory-based intervention including not only medical information about pregnancy and childbirth but also strategies for acquiring psychological support, healthcare accessibility, and social services [3,4,27]. Thus, a socioecological model was adopted as a theoretical basis of program development [11,17,26]. For example, married immigrant women’s ability for prenatal care and acquiring a maternal role may be influenced by intrapersonal factors such as age, period of residence in Korea, language fluency, and cultural differences, interpersonal factors such as the spouse, the family, friends, colleagues, and social networks, organizational and community factors such as neighbors, school, religion, workplace, and the multicultural center, and social and public policy factors such as social norms and interest, law, and health policies [26,28,29]. In this study, a socioecological model was selected as a program development model because the pilot program is thought to allow researchers to identify major uncertainties that may influence prenatal care among married immigrant women, thereby understand their knowledge about prenatal care as well as unmet education needs and identify stakeholders that can help to derive practical and feasible solutions [3,17].
The research team organized the educational content of the prenatal education program under three main topics: healthy pregnancy, healthy childbirth and postpartum period, and healthy family. Subtopics and details of the educational content were selected through repeated meetings mainly by two professors with nursing and nutrition major and community experts with experience in providing multicultural prenatal education and support programs. Also, master’s students who were majoring in nursing or food and nutrition took part in program planning. The students attended meetings to identify appropriate education topics and content and presented evidence corresponding topics they collected (Table 1).
The medical educational content about pregnancy and childbirth provided in the prenatal education program included up-to-date information, and the content was reviewed by an obstetrician-gynecologist to check the accuracy of the content. In addition, since community resources and social welfare services have a great impact on health maintenance and promotion among married immigrant women [3,4,8], information on community services was included under the topic of prenatal education, and community resources and social welfare benefits available to married immigrant women were investigated. The developed material was reviewed by a medical social worker, and after an interview, it was developed as an educational booklet related to community resources and social welfare services, and the copies were distributed free of charge to multicultural centers and obstetrics and gynecology clinics in the community.

2) Collaboration with community partners for the operation of the education program

Based on the feedback from multicultural program experts with practical experience, a prenatal education program was designed as a 6-session program that is conducted for 90 minutes per session over 4 to 6 weeks. To develop educational materials for the improvement of health literacy, after the research team developed educational materials, the materials were reviewed by the multicultural prenatal education advisory group composed of multicultural experts and married immigrant women, who immigrated earlier and had the experience of pregnancy and childbirth in Korea. Afterwards, the materials were shown to second-year nursing students who did not have the experience of pregnancy and childbirth and did not take a course on women’s health nursing in order to receive their feedback about the appropriateness of educational content, used terms, and audiovisual materials. Then, the educational materials were re-shown to the multicultural prenatal education advisory group composed of a total of 8 people to receive their feedback regarding the content and degree of difficulty of the educational materials, the language to be used in education, and operational methods of the education program. The advisory group commented that the inclusion of English translations along with Korean explanations only presents another unfamiliar language and would not be very useful. Therefore, they suggested speaking slowly using succinct, easy-to-understand Korean expressions, and actively including pictures or photos that explain the content. After revising the educational materials based on the feedback from the advisory group, the research team iterative revision until they obtained approval from the advisory group. Afterwards, the research team shared the advisory group’s opinions with second-year nursing students, then actually conducted education for the students, and received their feedback on the lecture speed, words used, and whether images matched the educational content. The final educational materials and program operation methods were determined in consideration of the collected feedback.

2. Program application

1) Recruitment of the participants of multicultural-friendly prenatal education

The inclusion criteria of the study participants were married immigrant women of childbearing age, including pregnant women. The participants were recruited through the following process. First, with the cooperation of multicultural centers and the integrated support center for foreign residents located in the five districts of D City, staff members of the centers contacted eligible participants registered at each center and introduced the education program. Second, a promotion notice of the multicultural-friendly prenatal education program was posted at the webiste of each of the institutions mentioned above. Third, a flyer for recruiting research participants was posted at the obstetrics and gynecology outpatient clinic of a hospital operating an integrated care center for high-risk pregnancy and neonatal care. Fourth, self-referred participants were recruited by the snowball sampling method. During the recruitment process, the staff explained the purpose and procedures of the study in Korean to interested, eligible participants, and only those who understood the purpose and procedures of the study and gave written informed consent were included in the study. Through the above process, a total of 19 married immigrant women of childbearing age were recruited, and they included four pregnant women and 15 non-pregnant women of childbearing age.

2) Operation of the education program

A total of 6 sessions of the program were delivered over a period from December 16, 2022 to January 27, 2023. The topics of each session of the program were as follows: Session 1: Self-care during pregnancy, Session 2: Nutrition in pregnancy; Session 3: Becoming multicultural mothers in Korea; Session 4: Utilizing community and social resources; Session 5: Breastfeeding; Session 6: Self-care in the labor and during the postpartum period.
Each session was designed as a 90-minute session, but when the education program was actually operated, each session took about 130 minutes, including Q&A time. Considering the language barriers of the participants, explanations on how to use a translation app program were provided before the start of each session, and a 10-minute break was given every 15 to 20 minute lecture during each session so that the participants could discuss what they had learned in their native languages and ask questions about the content. As for the education location, education was offered in the lecture room of A Multicultural Family Center in D City according to the opinions of multicultural program experts and the multicultural prenatal education advisory group. Among second-year nursing students who participated in program development, those who wanted to participate were allowed to participate in the education process as assistant educators.

3. Program evaluation

1) Recruitment of group interview participants to collect feedback about the program

To evaluate the operation of the prenatal education program developed by the research team, group interview participants were recruited from the participants of the education program. All of the 19 participants were informed through a notice that the group interview would be performed after the completion of the program, and the information about the purpose, method, date, and location of the interview was also given. A total of 6 people voluntarily expressed willingness to participate in the interview. Among the six interview participants, five people attended all of the six sessions, but one person was absent from one of the six sessions due to an important family event.

2) Interview data collection

To collect interview participants’ opinions in a flexible and systematic manner, two facilitators developed a semi-structured four interview questions (Table 2): 1) The reasons for having participated in the program; 2) Whether this program would be helpful for promoting the perinatal health of married immigrant women or not, and why; 3) Aspects that require improvement regarding the content, method, and mode of education for future education; 4) Matters that need to be considered if the research team conducts a full-fledged program in the community in the future; and 5) Other health education topics that is necessary for married immigrant women and multicultural families. The interview took about 2 hours, and it was conducted in a classroom of the university that is the affiliation of the corresponding author. The entire process of the interview was recorded using two recorders, and an assistant researcher attended the interview and recorded field notes.

③ Data analysis

First, the recorded responses of the participants were transcribed using an AI voice expert program (Naver clova note), and the first author, who participated in the interview as the co-facilitator, checked the accuracy of the transcript data. Afterwards, the first author and corresponding author, who had experience in qualitative research, independently read the transcript data repeatedly several times to analyze the content. Then, peer debriefing was performed, and during this process, all authors reviewed and discussed the analysis results of the content
Sociodemographic characteristics of interview participants
The age of the 6 participants of the group interview ranged from 24 to 44, and the education level ranged from elementary school to graduate school. The period of residing in Korea was 3 to 16 years. All the women who participated in the study were able to communicate in Korean, so the interview was conducted without an interpreter. All the participants had the experience of childbirth and two out of the six participants had their first child and were preparing for the second pregnancy. The other four were multicultural women who immigrated to Korea earlier and had participated as peer mentors referred to as ‘mom’s coaches’ when the multicultural center, a community partner of this study, operated the ‘High-Risk Multicultural Pregnant Women Identification and Crisis Response Program’ from 2020 to 2022 with the support of the Community Chest of Korea (Table 3).
Evaluation of the prenatal education pilot program and suggestions for the implementation of a full-pledged program in the community
To evaluate the prenatal education pilot program and identify major uncertainties that need to be addressed to successfully operate the program in the community in the future, a group interview was conducted, and feedback from the participants was analyzed [17]. Analysis results were used for the evaluation of the program and the modification and complementation of education materials, and the information about community services that the interview participants required was revised and edited into a book titled ‘Social Welfare and Community Resources for Pregnant Women.’ The book was shared with relevant organizations in the community so that the organizations could utilize it when operating a similar program and it would serve as a basis for the organizations’ continuous collaboration with the research team in the future.

Educators

The participants rated the education program carried out by Koren experts as a high-quality program, considered the provided information useful. They showed a high level of satisfaction with the fact that Korean experts provided the education in Korean.
“When I took the instructor’s lecture with professional education materials, I thought they were reliable. I felt somewhat reassured and relieved.”(Participant B) In addition, “I think it’s also good to directly learn (how to communicate with medical staff) and directly listening to the teacher speaking in Korean as I participated in education.” (Participant D)
“I didn’t know there are foremilk and hindmilk when breastfeeding babies, and I didn’t know it’s necessary to alternate breasts, either. There was no one around me who gave me such detailed information.” (Participant C)
Regarding future education programs, the participants showed positive responses about the method of program development in which experts directly select education contents and develop educational materials, as in the case of this education program. In addition, the participants commented that if the educational materials are developed into video materials and trained peer mentors conduct face-to-face education using them, multicultural women can receive high-quality education instead of incorrect information provided by friends and family members, who are not experts, and the education method using peer mentors may also have more advantages than education provided by experts in Korean.
“I think the method in which experts conduct classes through videos or non-face-to-face classes and multicultural women who previously received education participate in education as lecturers could also be used if lecture materials are given in advance. If a senior woman close to multicultural women teaches them giving explanations, it may be better for them than just sitting and listening to lectures when they have difficulty understanding Korean.” (Participant B)

Educational content

The participants said that not only medical information about pregnancy and childbirth and education on self-care but also information about social welfare services and music activities were also very helpful. In addition, when looking back on their own experiences of pregnancy and childbirth, they emphasized that timely education is most important, mentioning that they had not received prenatal education in advance when they needed.
“When I got pregnant for the first time, I knew nothing about pregnancy, so I had great trouble. I participated in this education and received education before having my second child, and now, I’m not worried at all.” (Participant C)
“Actually, I was so afraid of giving birth to a baby without knowing anything about the processes of labor and delivery. I think if I had experienced pregnancy and childbirth after receiving education about the childbirth process from hospital admission to discharge (as in this education, I would have felt much less worried.” (Participant D)
“I think receiving this education was very helpful. I learned about the child support allowance, got detailed information about what benefits (community resources) are available for me when preparing for pregnancy, and it was also good to learn about what benefits I can receive from the public health center.” (Participant E)
“I think this education gave me everything I needed. Pregnant women get depressed. The music activities (with dancing) that the research team provided, first of all, gave me an opportunity to exercise, and secondly, listening (to familiar songs from my native country) helped to relieve stress and relax. I learned useful things and new things that weren’t provided in previous education programs.” (Participant F)

Education method

During the COVID-19 pandemic that persisted for about three years from 2020 to 2022, health education was provided mainly in a non-face-to-face manner, but it was found that non-face-to-face health education was not a preferred educational method for married immigrant women. Although the primary purpose of participating in face-to-face prenatal education was acquiring information about pregnancy and childbirth for the participants, this face-to-face education was meaningful as an officially recognized opportunity for going out that allows them to obtain psychosocial support during the trip, separation from housework, relationship formation, and network expansion and social interactions with peers. Participants addressed that they felt unnecessary anxiety or fear as they learned about things they did not know previously during health education, and suggested that it would be better if education delivers messages emphasizing benefits or positive results rather than emphasizing threats or seriousness.
“For foreigners, we have no places to go. People who previously didn’t know each other can become to know each other and talk about their homelands … I got to know a Kazakh woman through education, and she said to me, “Aren’t you going to come with me when I give birth to my baby?” So, I think face-to-face education is good.” (Participant A)
“In education, teachers told us many (negative) stories about what happens if you do this. I’d like to ask you to provide education to have positive emotions as well.” (Participant D)

Education operation

In general, the participants were satisfied with the program period and session duration that were provided by the research team. Some participants requested long-term education or slightly longer duration for one session. Others suggested that it would be better to avoid summer and winter considering the convenience of activities and attendance.
“For me, I think six weeks is appropriate. … (So far) I have had some trouble because I didn’t have accurate knowledge. Two other women, Vietnamese pregnant women, (who couldn’t attend today) wanted to learn a little more, so I think it could also be fine if it becomes a little longer.” (Participant E)
“(Increasing the time for one session to) 2 hours would also be fine.” (Participant F)
“It’s also necessary consider the weather when education is conducted. A friend of mine wanted to come to group counseling today, but couldn’t come because of the slippery road. Winter (summer) is not good (for education). It’s also necessary to consider the accident prevention and safety..” (Participant B)
The multicultural center, which was used as the education location, was not simply a place of education for married immigrant women, but it also served as an information-sharing space and as a place where they could go out with the official permission of their families. The interview participants addressed the multicultural education for adjustment to life in Korea that is provided by the Immigration Office. They, however, emphasized an education program regardless of content will be useless if the timing or the place is not suitable.
“While living in Korea, I found that there are many places I can get information (health information, social service information, etc.). Before applying for a visa, we need to receive education for about 3 hours, and during this education, they give you a lot of information about life in Korea. However, for married immigrants, they have difficulty understanding the explanations since they are not used to Korean, and their (Korean) husbands pay little attention to the information since they are not interested.” (Participant A)
“At first, people usually hesitate to come to the multicultural center. Even for me, at first, my husband told me not to go to the multicultural center, saying that it is a place like a church. However, after I started to go there, I knew it was completely different from what I had thought. It is a place that offers a program where I can meet people from my native country. The Kazakh woman who participated in this education also hesitated to participate at first, but later, she came by taxi (intentionally) and was very sorry about the education session she had to miss.” (Participant A)
“It is a place where you can relieve stress while getting some fresh air and talking with people comfortably. And in the multicultural center, there is a teacher you can ask questions (when anyone is curious about something).” (Participant C)

Others

The participants addressed that there is a need for a textbook that can be used for them to review the educational content, and it would be good to have lecture videos that can help them to understand education content better with repeated watching.
“I hope there are some instructional materials like a pamphlet that I can carry around with me. I also think it would be good to distribute educational materials on community social services. I don’t know if it’s only my hope or if the professors also think so. But, maybe, if I get pregnant, I would read the book given as a textbook over and over again until it is torn apart. I think if it includes important content, but doesn’t have too many words, have photos, and contains some elements to admire, (like the instructional materials of this education), I would keep reading the book. Also, considering the trend of the increase of multicultural (families), I think it would be great if information on multicultural psychology (support) programs is available.” (Participant B).
“I think if they show videos rather than explaining in words, things would be easier to understand.” (Participant A)
The participants’ trust in and satisfaction with the education provided were linked to their feedback about their needs and wishes regarding a follow-up health education program. The participants wanted to have a vocabulary list that can be used in communicating with medical staff during pregnancy and childbirth. They also mentioned a need of activity-based mental health support programs available for them to be fun and relieve stress. Regarding the development of a follow-up health education program, the participants requested the development of health education that includes how to communicate with medical staff and family education that husband and their parents -in -law can be participated so as to reduce cultural gaps, and thus promote cultural integration and assimilation within family. Information that can be helpful for adjusting to daily life in Korea is also requested.
“I hope there is some education that teaches us exactly how to eat in one meal to maintain our health, … and how much meat we should eat or when we eat vegetables, how much we should eat. I mean education about diet.” (Participant B)
“I am worried because I don’t know what to say to the doctor when I go to hospital. So, I think it would be good if there is a class that teaches what to say when I go to hospital” (Participant D)
“Because we have so different ways of taking care of the baby, I have conflicts with my parents-in-law. I think it would be good if my parents-in-law understand that there are (cultural) differences. I think it would be greatly helpful if you offer an educational program (where I can participate together with my parents-in-law).” (Participant F)
This study used a socioecological model as a theoretical basis to develop a prenatal education program [17]. This is a methodological research that developed and operated a community-based multicultural-friendly prenatal education program as a pilot program and analyzed the results of the program operation by applying PDCA [17,22,29]. Using the feedback of the group interview of the participants, this study examined the degree of satisfaction of needs for prenatal education among married immigrant women, and evaluated the appropriateness of educational methods and the operation of the program. Also, the present study explored how to modify the program in order to implement it in a community and disseminate the program in the community. Through these processes, the following implications were derived.
First, this study suggest that a personalized activity-centered health education program is needed for the multicultural women. Since this study aimed to develop a prenatal education program that can help multicultural women to adjust to a new culture while maintaining their cultural identity in addition to providing medical, nursing, and nutritional information necessary for pregnancy and childbirth, a holistic approach was used [15]. In an attempt to develop a holistic education program, the research team included information on how to use social services as well as music activities in the educational content. To this end, this study conducted a convergence research by inviting experts in the fields of various disciplines, and sought to improve the accuracy and quality of the program content through several consultations with experts [25]. In addition, in planning the program, the education process was designed to be interesting and enjoyable rather than simply focusing on educational effects such as the improvement of prenatal knowledge. As a result, the participants showed a high level of satisfaction with the content, composition, and delivery methods of education. Also, the value of community-based interdisciplinary participatory convergence research and the need for such research in the future were well established [25].
Second, the results of this study suggest that language barriers should be regarded as an obstacle that can be overcome. In the program planning stage, the choice of language to be used in the education for married immigrant women acted as a major methodological factor. Given various nationalities, cultures, and languages of married immigrant women and limited resources such as time, effort, and costs, it was realistically difficult to develop a multicultural-friendly prenatal education program that can meet all the conditions and needs of the participants. Thus, based on the results of the meeting of the research team and the advisory group as well as feedback from the multicultural advisory group, education was carried out in Korean, which was the language commonly used by the participants, despite difficulties in communication. After participating in the education program, the participants gave very positive feedback about education carried out in Korean in that the program provided them with an opportunity to learn various words and expressions that can be used in communicating with medical staff when using a medical institution for pregnancy and childbirth. In addition, the participants addressed it would be helpful to open a special Korean language course as a follow-up program so that they can learn words that can be used when using a medical institution as well as how to communicate with medical staff. These results are consistent with the findings of previous research showing that married immigrant women feel nervous and anxious when they experience pregnancy and childbirth, which are a life transition period. They feel very worried about situations in which they have to make treatment decisions while communicating with medical staff in an unfamiliar language and medical environment [4-6]. In addition to provide patient-centered medical services, it is necessary to develop education designed to strengthen the cultural competence of healthcare professionals from the stage of undergraduate education [30-32]. In a future study on program dissemination, it is necessary to develop strategies to facilitate the overcome of linguistic, cultural, and medical service barriers and decrease the fear of multicultural people about unfamiliar medical environments [4]. For example, it can be a useful approach with high applicability to provide a handbook with a list of words frequently used at hospitals, and develop education materials that present sentences that can be used for simple communication in specific situations along with photos and pictures. A specialized translation and interpretation service program available around the clock in the field of medical care in hospitals is also needed [7,31].
Third, it is necessary to develop a multicultural-friendly prenatal education program considering sociodemographic characteristics [3]. Married immigrant women are reported to give birth at younger ages than Korean women [13]. While 69% of Korean women give birth to their first babies in their 30s or later, 65% of multicultural married immigrant women experience their first pregnancy and childbirth in their 20s [13]. These gaps in the ages of pregnancy and childbirth between Korean and multicultural women may deliver the wrong message that Korean society regards married immigrant women as a tool to support a decreasing birth rate maintaining a society rather than welcoming them as new members of the society [33,34]. This may increase immigration stress and lead married immigrant women to adopt negative acculturation strategies such as isolation and separation. In health education, a health behavior and its consequences are major factors to design message tailoring [35,36]. Since the use of inappropriate strategies may cause negative emotions such as stress, depression, anxiety, and low self-esteem [13,35], behavioral strategies to deliver positive and effective messages to promote health is essential task in a follow-up study targeting for multicultural women..
Fourth, it is suggested to utilize multicultural women who immigrated to Korea earlier to empower community. It has been reported that more than half (52.4%) of married immigrant women feel lonely living in Korea due to cultural differences, and cultural gaps experienced made them isolated and feel outsider. Consequently, many multicultural women ( 62.3%) think they cannot rely on their husbands [12]. During the adjustment period right after immigration, sharing their emotions with fellow married immigrant women with same language and similar culture may help them to choose positive coping mechanisms for adjusting to life in Korea and help them to find their own identity [12]. In addition, multicultural women who immigrated to Korea earlier (e.g., the advisory group of this study) can serve as role models for married immigrant women who have just begun to live their lives in Korea and play an important role to empower interpersonal, organizational, and community factors that influence health behaviors [3,26,29]. Therefore, it is suggested that multicultural women who immigrated earlier and share language and culture with multicultural women who recently immigrated to Korea could be trained as community health workers and be included main members in community prenatal education programs [37]. If multicultural women who immigrated earlier are utilized as community health workers in a health education program for multicultural women, it may have several advantages: the program can give married immigrant women not only simple knowledge but also opportunities for expanding relationships, sharing information about community resources, and receiving social support [38]. In addition, it is believed that such an educational program can be a highly acceptable, effective alternative for improving health equity in married immigrant women and their families [3,38,39].
Fifth, the development of a health education program with good quality through university-community collaboration can contribute to improve not only content quality but also the quality of life of the participants and community empowerment. The participants of this study said that the local multicultural center in the community was a very suitable place for health education. This feedback of the participants regarding the education location is presumed to be the multicultural center, which is the central axis of the multicultural family support project, serves not only as a place to receive Korean language education [40] but also as a familiar space where married immigrant women can meet and interact with other multicultural women. For married immigrant women experiencing significant cultural changes in an unfamiliar country, the prenatal education program provided by multicultural centers is considered to provide psychological stability for them. In addition, participating in the program helps them to share information with other multicultural women and expand their social networks, and increase health information. Given these, this pilot study reminds researchers of the importance of selecting a suitable location for community-based health education. It is possible that an industry-academic collaboration health education program that can increase the content quality and diversity offered by multicultural family support centers can be a linkage between university and community. That is, industry-academic collaboration enable to enhance the self-esteem, cultural competence, and pride as community members in all participants including university members (students, researchers), community experts, and new community members (multicultural community members). Further, as mentioned by the study participants, if experts and community health workers form a team and provide a hybrid education program using both face-to-face and online education modes, it would become a sustainable cost-effective program model meaningful and having greater applicability..
Lastly, there is a need to develop a health education program based on assimilation and integration strategies to help families and community members learn each other’s culture and become assimilar to each other [21]. After having settled in Korea, many married immigrant women experience difficulties adjusting to life in Korea, especially in daily life (e.g., food, housework, and childrearing) [6,12]. According to a previous study, one in four married immigrant women responded that due to cultural maladjustment, they experienced strong sadness and despair that disrupted daily activities for two weeks or more in the past year [12]. Moreover, depression and anxiety rates are high in multicultural women [11]. Therefore, an art-based health education program, which allows individuals to express emotions through art [13,31], allows all the family members to participate together, and offers multicultural women an opportunity to introduce their cultures to the participants rather than forcing them to adjust to Korean culture is necessary to develop to promote mental health and social adaptation. .
A good exemplar to improve mental health in pregnant women would be music therapy [41].This study included music activities as a part of holistic nursing in educational activities. To develop educational activities, we selected songs for children and lullabies of the native countries of the participants with the help of multicultural women who immigrant earlier. Also, music activities using hand bells and boomwackers were included in the education program in consultation with a music therapist in order to allow those who were not able to play an instrument to participate in music activities together. In addition, the research team created colored music notation to allow participants to actively participate in music activities even if they could not read musical notes. After education, the participants showed great interest in music activities and favorable responses toward them. Also, music activities helped the participants to build rapport with the research team, which led to participants’ continuous participation in the program and interest in the follow-up research offered by the research team. Even in the process of the group interview, music activities were frequently mentioned as very interesting activities relieving stress. With regard to the feedback from second-year nursing students who participated in education planning and the development of colored music notation, the program participation process provided them an opportunity to strengthen their cultural competency and realize the importance of learner-centered community health education. In other words, music activities acted as a medium that allowed multicultural participants to change their positions from passive, powerless people that are required to accept Korea culture to active partners , which allows them to have naturally adopted positive acculturation strategies in this process [42]. In addition, these results provided significant implications for nursing research that places importance on human experience and processes [43], and it is believed that music activities can be utilized as an educational medium for the enhancement of cultural competency in nursing students [44]. In the future, it is necessary to develop a prenatal education program for multicultural women as an interdisciplinary, art-integrated health education program to promote health equity, and analyze the effects qualitatively, quantitatively, and in terms of costs.
This study has the following limitations. First, this study evaluated processes rather than outcomes, and although a total of 19 women participated in the 6-week prenatal education program, only six peopleparticipated in the group interview. Also, only one group interview was conducted. Second, to improve the programe, it is essential to collect data and feedback about the perceptions and experiences of all stakeholders, including the program planners and manager, community leaders and study participants. Third, there are limitations in generalizing the results without considering the situations of each organization and the community. Therefore, there is a need to conduct quantitative research to secure the objectivity of research results and evaluate the results before conducting a follow-up study on program dissemination in a community [17].
The multicultural-friendly prenatal education program developed by the research team met the needs of multicultural women in terms of the educator, educational content, and educational methods. Also, it could be a feasible community program according to interview participants reviews. Based on these research results, it is suggested to extensively conduct a full-fledged program, that can help to expand access to healthcare services for married immigrant women and their families and facilitate multicultural women’s positive adjustment as social members in a new country. A health education program according to family situations and life cycle stages is needed to be developed in response to growing needs of this population.

Conflict of interest

The authors declared no conflict of interest.

Funding

This study was supported by Chungnam National University Research Fund (PI: Cha, E).

Authors’ contributions

EunSeok Cha contributed to conceptualization, formal analysis, funding acquisition, methodology, project administration, writing-original draft, review & editing, investigation, resources, supervision, and validation. Sojung Lee contributed to conceptualization, methodology, writing-original draft, review & editing, investigation, and validation. Gui-Nam Kim contributed to conceptualization, project administration, writing - original draft, and validation. Byung Hun Kang contributed to conceptualization, resources, and validation. Min-Sun Jeon contributed to conceptualization, formal analysis, funding acquisition, methodology, writing-review & editing, investigation, resources, supervision, and validation.

Data availability

Please contact the corresponding author for data availability.

Acknowledgments

The authors are grateful to the undergraduate nursing students who took Global Health and Nursing in 2022, Ms. Jihyeon Kwon (Medical Social Worker) and the staff at the Healthy Family Support Center in Daejeon who provided feedback on the educational materials and methods of the pilot prenatal program. The authors appreciate Ms. Hae-Ju Jang, Young-Hee Min, Hae-Jeong Kim, Yu-Bin Park, and Jin-Kyeong Kim for providing lectures to the multicultural women at the community center. In addition, the research team acknowledges the contribution of CareArt, Inc., which provided a carry-on educational booklet adapted from lecture slides for the participants.

Figure 1.
Research process
rcphn-2024-00507f1.jpg
Table 1.
Planning of Prenatal Program
Theme & Title Content Educator Comment
1 Self-care during pregnancy • Self-care in routine days • A retired nurse with more than 20 years of OB/GYN clinical experiences Education materials was reviewed by an OB/GYN doctor
• Situations for a visiting clinic, hospital or ER
2 Nutrition in pregnancy • Significance of balanced Nutrition in pregnancy • A nutritionist attending a graduate program who has community nutrition education experiences Education materials was reviewed by a senior nutritionist
• Nutrition counseling based on individual and cultural differences
3 Becoming multicultural mothers in Korea • Understanding cultures with music activities • An experienced music therapist in medical field and community
(e.g., colored music notation, Boomwhackers, handbells)
• Reducing stress & positive coping related to pregnancy
4 Utilizing social and community resources • Introducing available community resources and referral systems for pregnant women and their families living in Korea • A nurse attending a graduate program Education materials was reviewed by a medical social worker
5 Breastfeeding • Preparing breastfeeding in pregnancy • An international board-certified lactation consultant with nursing license who actively works in a community Education materials was reviewed by a PhD nurse scientist
• Problem solving during breastfeeding
6 Self-care in the labor and postpartum period • Signs for labor • Same educator in session 1 Reviewed by an OB/GYN doctor
• Signs and symptoms in labor process
• Expected medical treatments in admission
• Self-care activities after discharge
Table 2.
Semi-Structured Interview Questions
Q1 Tell me about how you knew the program and what motivated you to participate in it.
Q2 Tell me about whether the program would be helpful for promoting self-care activities in multicultural women who would be in pregnancy, labor, and postpartum period.
(probe) Which content would be helpful or unhelpful? Is there any reason why?
Q3 With regard to education content, mode, and method, are there things or places we can do better in the next time?
Q4 What would be considered and/or need to be improved, if the research team conduct a full-fledged program in a community in a future?
- Which content may need to add/delete/ modify?
- If the research team develops another health promotion program for multicultural women and their families, which program would be appropriate and why?
Table 3.
Socio-Demographics
Participant Age Country of Origin Residing year in Korea Perceived financial condition Education completed Religion Education experience in Korea
A 41 Uzbekistan 13 Moderate High school Muslim X
B 34 Mongolia 10 Affluent Master program Other O
C 24 Vietnam 3 Moderate High school Catholic X
D 34 Vietnam 4 Moderate Elementary school Other O
E 42 Vietnam 13 Moderate College Other O
F 44 Thailand 12 Moderate Master program Buddhism O
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      We recommend
      Developing a community-based, multicultural-friendly prenatal education pilot program
      Image
      Figure 1. Research process
      Developing a community-based, multicultural-friendly prenatal education pilot program
      Theme & Title Content Educator Comment
      1 Self-care during pregnancy • Self-care in routine days • A retired nurse with more than 20 years of OB/GYN clinical experiences Education materials was reviewed by an OB/GYN doctor
      • Situations for a visiting clinic, hospital or ER
      2 Nutrition in pregnancy • Significance of balanced Nutrition in pregnancy • A nutritionist attending a graduate program who has community nutrition education experiences Education materials was reviewed by a senior nutritionist
      • Nutrition counseling based on individual and cultural differences
      3 Becoming multicultural mothers in Korea • Understanding cultures with music activities • An experienced music therapist in medical field and community
      (e.g., colored music notation, Boomwhackers, handbells)
      • Reducing stress & positive coping related to pregnancy
      4 Utilizing social and community resources • Introducing available community resources and referral systems for pregnant women and their families living in Korea • A nurse attending a graduate program Education materials was reviewed by a medical social worker
      5 Breastfeeding • Preparing breastfeeding in pregnancy • An international board-certified lactation consultant with nursing license who actively works in a community Education materials was reviewed by a PhD nurse scientist
      • Problem solving during breastfeeding
      6 Self-care in the labor and postpartum period • Signs for labor • Same educator in session 1 Reviewed by an OB/GYN doctor
      • Signs and symptoms in labor process
      • Expected medical treatments in admission
      • Self-care activities after discharge
      Q1 Tell me about how you knew the program and what motivated you to participate in it.
      Q2 Tell me about whether the program would be helpful for promoting self-care activities in multicultural women who would be in pregnancy, labor, and postpartum period.
      (probe) Which content would be helpful or unhelpful? Is there any reason why?
      Q3 With regard to education content, mode, and method, are there things or places we can do better in the next time?
      Q4 What would be considered and/or need to be improved, if the research team conduct a full-fledged program in a community in a future?
      - Which content may need to add/delete/ modify?
      - If the research team develops another health promotion program for multicultural women and their families, which program would be appropriate and why?
      Participant Age Country of Origin Residing year in Korea Perceived financial condition Education completed Religion Education experience in Korea
      A 41 Uzbekistan 13 Moderate High school Muslim X
      B 34 Mongolia 10 Affluent Master program Other O
      C 24 Vietnam 3 Moderate High school Catholic X
      D 34 Vietnam 4 Moderate Elementary school Other O
      E 42 Vietnam 13 Moderate College Other O
      F 44 Thailand 12 Moderate Master program Buddhism O
      Table 1. Planning of Prenatal Program

      Table 2. Semi-Structured Interview Questions

      Table 3. Socio-Demographics


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