This study consisted of two major phases: (A) an interview survey of public health nurses and (B) a preliminary effectiveness test of the program. However, this is a pilot study with a single-group repeated-measures design and no control group. Therefore, it should be noted that there are limitations in rigorously verifying causal relationships.

1) Objective

The purpose of this study is to explore the points of contrivance and disincentives considered by public health nurses when creating and introducing this program.

2) Target population and survey procedures

Semi-structured interviews were conducted with six public health nurses (one male, five female) who had 3 to 15+ years of experience in maternal and child healthcare activities. The survey took place from September to December 2020. Written consent was obtained before the interviews, explaining the study’s purpose and methods. The interviews were recorded, transcribed verbatim, and similar responses were categorized.

3) Analysis Method

The verbatim transcripts were carefully read. Words related to contrivance and disincentives for program implementation were extracted, and similar semantic contents were grouped and categorized. The analysis was checked by at least two experts in public health nursing and psychology to enhance reliability.

1) Creation policy

Considering the interview suggestions, such as “the program can be implemented in a short time”, “visually easy-to-understand teaching materials” and “a system that allows mothers to reflect on their daily lives”, a series of three sessions was designed. Each session was intended to last 30 to 40 minutes and be conducted using Zoom.

2) Theoretical Basis

The basic model of cognitive behavioral therapy (CBT), based on cognitive therapy [20] , was applied using the framework that events, automatic thoughts, feelings, and actions mutually influence each other [21] . The focus is on exercises in “cognitive reappraisal”, where participants become aware of thinking habits such as perfectionism and victimized cognition and explore more flexible ways of perceiving events.

3) Specific Contents

1st Session

Reflecting on frustrating situations during child-rearing, ask participants to write down “what events occurred” and “what were the feelings and thoughts at that time” (externalization). Next, brainstorm methods (problem-solving lists) that mothers usually use to cope with irritation (coping), and discuss their potential use. Homework has been shown to be effective in parent training aimed at revising the mother’s cognitive framework [22] . Therefore, as homework, ask the mothers to record any frustrating situations again before the next session.

Second Session

Share the frustrating situations recorded for homework to encourage cognitive reappraisal, and discuss the mother’s coping behaviors and thought patterns. Explain the cognitive-behavioral therapy model and how to self-monitor tendencies toward perfectionism (e.g., “thinking I should ~” or “failure is not acceptable”) and victimized cognitions (e.g., “my child is purposely annoying me”). Specifically, ask, “What if we looked at this from a different perspective?” and “What is the intention behind the child’s behavior?”

Third Session

As a summary of the first two sessions, the mothers reflect on “what they noticed” and “what coping strategies they would like to use in the future”. They are assisted in becoming aware of their thought patterns and tendencies to view their children’s actions and words from a victimized perspective. Continued self-monitoring is encouraged after the course, with guidance to connect with local public health nurses and clinical psychologists as needed.

1) Participants

Fourteen mothers with children aged 1 - 6 years living in the Kanto area were asked to participate. Recruitment was conducted by posting notices through childcare support facilities and nursery schools/kindergartens. Written consent was obtained after explaining the study’s purpose and procedures. The survey was conducted online via Zoom from September to December 2021.

2) Measurement Period

a) Immediately before the start of the 1st program (before the course);

b) Immediately after the 3rd program (immediately after the course);

c) One month after the end of the course.

3) Measurement Details

Face sheet: Mother’s age, children’s age and gender, number of siblings, and employment status.

Perfectionism: Four items measuring perfectionism (e.g., “I feel that everything must be perfect”) were adopted from the “Mothers’ Cognitive Style Scale” [23] and measured using a 5-point scale.

Victimized cognitive: The 5-item victim perception scale developed by Aida & Okawara [15] was used (5-point scale). The reliability and validity of this scale have been confirmed [15] .

Irritability: Participants were asked to select the most irritating situations with their children (e.g., eating, going out, crying, sleeping, etc.) and indicate their degree of irritation on a scale from 0 to 10, with 0 being “not at all irritating” and 10 being “very irritating”. Nakagawa and Miyamoto [11] confirmed that mothers’ perfectionism and victimized cognition affect the “irritability” of child-rearing.

4) Analysis Method

Of the 14 participants, missing values were excluded, and the mean scores for each scale (perfectionism, victimized cognition, and irritability) were compared before, immediately after, and one month after the course. A one-way analysis of variance (within-subjects factor) was performed, and the Bonferroni method was used for multiple comparisons. The significance level was set at 5%.

5) Ethical Considerations

Participants were informed of the study’s purpose, objectives, program content, data use, and privacy protection both in writing and orally in advance. Their consent to participate was obtained by returning the consent form. This study was approved by the Ethics Committee of Tsukuba University (approval number: Tsukuba University 2020-44A). Participation was voluntary, and it was assured that no disadvantage would occur if participants withdrew during the study.

6) Reason for Not Establishing a Control Group

As a preliminary practical study, this research adopted a single-arm, before-and-after comparative design because the primary objective was to confirm the program’s acceptability and feasibility. However, a randomized controlled trial (RCT) or quasi-experimental design with a control group should be used to more rigorously examine the program’s effects.

Based on interviews with six public health nurses, the following categories were identified as important considerations when introducing the program.

1) Points of Contrivance

2) Inhibiting Factors

In creating this program, we incorporated these findings as much as possible (e.g., visual materials and short-time structures).

The 14 mothers who participated in the program and survey ranged in age from 29 to 44 (mean 35.3, SD = 4.38), and their children ranged in age from 1 to 6 (mean 3.44). Employment status was “full-time housewife” for 6, “part-time worker” for 5, and “full-time worker” for 3. The number of siblings was “one child” for 7, “two siblings” for 5, and “three siblings” for 2.

Changes in scores before, immediately after, and one month after the course were examined using a one-way ANOVA. The results (n = 13) showed significant differences in perfectionism scores (F = 4.59, df = 1.83, 21.92, p < 0.05). However, multiple comparisons using the Bonferroni method revealed only significant trends immediately after the course (p = 0.07) and one month later (p = 0.06).

The victimized cognition (n = 13) did not show a significant difference at F = 1.05 (df = 2, 24, p = 0.36) before and after the program ( Table 1 ).

*p < 0.05, ***p < 0.001.

The mothers’ scores (n = 12) on a 10-point scale for “most frustrating situations” averaged 4.00 (SD = 1.04) before the program, 2.92 (SD = 0.79) immediately after the program, and 2.17 (SD = 0.72) one month later. A one-way analysis of variance showed a significant difference (F = 18.27, df = 1.80, 19.80, p < 0.001). Multiple comparisons using the Bonferroni method indicated that scores before the course were higher than immediately after taking the course (p < 0.05), immediately after taking the course > 1 month later (p < 0.05), and scores before > 1 month later (p < 0.001). The results showed that the mothers’ irritability decreased stepwise immediately after the course and then one month later.

In this study, based on the cognitive-behavioral therapy model, a public health nurse implemented a program incorporating exercises to review cognitions (perfectionism and victimized cognition) in child-rearing situations. Notably, the mothers’ irritability was significantly reduced and continued after one month.

Similar programs addressing anger and irritability include anger management and stress management training. However, these programs are challenging to disseminate widely due to time and financial constraints [22] . If offered online as a short-time program in a series of three sessions, mothers with infants and toddlers could easily participate from home. Additionally, by reflecting on their own frustrating situations through homework, they could more readily attempt cognitive reappraisal in their daily lives.

In the present study, a weak but significant trend change was observed in perfectionism, but no clear change was observed in victimized cognition. This may be because victimization may be linked to deeper-rooted issues such as individual attachment disorders or past trauma, which are difficult to transform with only a brief, short-term intervention [14] .

Some mothers with entrenched perfectionism and victimized cognition may require long-term follow-up and professional counseling, even if they become aware of these issues through the current program. Therefore, it is important to establish a system where public health nurses are continuously involved and can connect these mothers to clinical psychologists and medical institutions as needed.

The program developed in this study can be completed in a relatively short time and has the advantage of reaching many mothers from a preventive perspective. By setting up a 30-minute session between infants’ and toddlers’ health checkups and childcare lectures, and offering the program on a flexible schedule, such as three consecutive weeks or every other week, it is expected to be effective in preventing the increased risk of abuse.

Furthermore, some mothers may be significantly affected by unique stressors, such as postpartum hormonal imbalance and childcare during the “Terrible 2’s” period. Conducting a detailed analysis of these specific factors and modifying the program to target them would be beneficial. For example, it may be effective to consider variations like “for mothers with 0-year-old children” or “for mothers with multiple siblings”, depending on their needs.

This study was designed as a single-group repeated measures design and did not establish a control group for rigorous comparison of intervention effects. Therefore, we cannot rule out the possibility of a placebo effect due to the passage of time, a change in the mothers’ attitudes, or the influence of other external support.

To demonstrate the program’s effectiveness with higher evidence, it is essential to conduct a randomized controlled trial (RCT) where target and control groups are randomly assigned, or at least a quasi-experimental design with a waiting group. Additionally, increasing the sample size and examining differences in effects due to maternal and child attributes (e.g., maternal age, child age, sibling status, employment status) would clarify the program’s versatility and limitations.

In addition, it is important to follow up on the program over a longer period, such as 6 months to 1 year, to determine if the effects are maintained after the intervention. Long-term follow-up would help understand whether changes of irritability and cognition are temporary or if they increase or decrease with changes in the living environment and the child’s developmental stage.