Introduction
ccording to the 2020 World Health Organization report, there are currently 466 million people in the world with hearing impairment, of whom 34 million are children [1]. Newborn hearing loss has profound effects on the family members and parents [2]. Mothers have an essential and pivotal role in raising their children. So facing any disability of the child, including hearing loss, is more challenging for them, and they are less prepared for it [4, 3]. Studies on the mental health of mothers of hearing-impaired children have shown that the mental health of these mothers is lower than that of mothers with normal children [5, 6, 7, 8, 9, 10]. Maternal mental health problems have several consequences [11, 12, 13, 14]. One of the most critical issues affecting mothers’ mental health is the parent-child relationship [15, 16]. A warm, intimate, and trusting relationship between parent and child is an essential factor in child development, and problems in this regard cause problems in the cognitive and emotional-behavioral development of the child [17, 18, 19, 20]. Mothers of hearing-impaired children have difficulty building a positive mutual relationship between themselves and their children due to a lack of awareness of the new situation, the nature of the hearing loss, and the resulting psychological stress [21, 22, 23, 24, 25, 26]. It is difficult for them to have supportive behaviors, accept the child’s disease and provide parenting intimacy and warmth [23]. Since the effects of early interventions are high when parents, especially mothers, are responsive to their child’s needs as primary caregivers [27, 28, 29 ,30], it is necessary to address the emotional dimension of the family and psychological status of mothers in rehabilitation programs along with providing routine services for hearing-impaired children [9, 31].
One of the interventions that can be supportive for mothers of hearing-impaired children is Baby Triple P Program. This program is a new intervention that aims to improve the quality of the parent-child relationship and improve the mental health of parents, especially mothers [32, 33]. It was designed based on level 4 of the positive parenting program. The purpose of this program is to cover the needs of parents of children under 3 years of age who face mental health problems such as anxiety, depression, and stress and are challenged in establishing a relationship with their babies [32]. Studies on the effectiveness of the Baby Triple P Program have shown that this program has been helpful in reducing the mental health problems of parents, especially mothers, and has had a positive effect on the parent-child relationship and the management of behavioral problems in children [33, 34, 35, 36]. Because there is a tremendous need for early intervention in Iran that emphasizes the psychological support of parents of hearing-impaired children, this program may be an effective method for hearing-impaired children and their parents. The present study aims to determine the effect of Baby Triple P positive parenting program on mental health and mother-child relationship in mothers of hearing-impaired children.
Materials and Methods
This research is a quasi-experimental study with a pretest-posttest design using a control group. The study population consists of all mothers of hearing-impaired children aged less than 3 years in Tehran Province, Iran, who received services in centers for families and children with hearing disabilities in 2019. After obtaining ethical approval and permissions from the University of Welfare and Rehabilitation Sciences and referring to the clinics, 24 mothers were selected based on the inclusion and exclusion criteria using a convenience sampling method. The mothers were then randomly divided into the intervention and control groups. The inclusion criteria were having a hearing-impaired child under 3 years of age and having at least a high school diploma. The exclusion criteria were having a chronic physical disease, participation in the same intervention simultaneously, and being absent from more than 3 sessions. The mothers in the intervention group received the Baby Triple P program for 13 1-h sessions, one session per week. In both groups, symptom checklist-90-revised was used to measure subjects’ mental health, and a Mother-Child Relationship Evaluation (MCRE) questionnaire to measure their mother-child relationship quality at pretest and posttest phases.
The Baby Triple P parenting program has been developed by the Parenting and Family Support Center at the University of Queensland in Australia to enhance the knowledge, skills, and self-confidence of parents who have recently had a baby. Because of the valuable experience of applying the Positive Parenting Program (Triple P) in Iran, correspondence was made with Prof. Sanders, Director of the Parenting and Family Support Center, to obtain his permission to apply to the Baby Triple P parenting program in Iran. Then, due to the cultural differences between Iran and Australia, following the opinion of experts, some changes were made in the way of presenting the contents and in the number of sessions. The main content of the program was adapted from Sanders et al.’s study [33]. To adapt this protocol to the needs of mothers of hearing-impaired children, the resources and workshops that existed in this field were used. Besides, before starting the study, we were in contact with the mothers in one of the centers for families and children with hearing disabilities for 6 months. After collecting data from the subjects, the Shapiro-Wilk test was used to check the normality of data distribution. To examine whether the differences between the two study groups were significant, the Mann-Whitney U test was used for the mental health variable and the MCRE questionnaire’s component of rejection due to abnormal data distribution. Also, the independent t-test was used for the other three components of acceptance, overprotection, overindulgence due to their normal distribution.
Results
The mothers in this study had a normal hearing with a Mean±SD age of 38.8±4.55 years. Also, 70.8% of them had a high school diploma, 4.2% had a postgraduate degree, and 25% had a bachelor’s degree. Besides, 20.8% of them had poor, 50% moderate, and 29.2% good socio-economic status. The Mean±SD age of their children was 22.13±1.346 weeks. All of them were using a hearing aid, except one who had a cochlear implant. The results of the Mann-Whitney U test presented in Table 1 indicate that mental health in the intervention group was not significantly different from that in the control group.


Therefore, the Baby Triple P parenting program did not affect the mental health of mothers of hearing-impaired children. The results of the independent t-test (Table 2) indicate that the difference between the two groups was significant only in the overprotection component of the MCRE questionnaire.


The differences between the two groups in acceptance and overindulgence components were not significant. Thus, the Baby Triple P parenting program affected only the overprotection component. The results presented in Table 3 indicate that the difference between the two study groups was not significant in terms of the rejection component.


Therefore, parenting education did not affect the rejection component, either.
Discussion and Conclusion
This study aimed to investigate the effect of the Baby Triple P parenting program on mental health and mother-child relationship in mothers of hearing-impaired children aged less than 3 years. Findings showed that the Baby Triple P parenting program could not affect the mental health of mothers. It could only affect one of the components of the mother-child relationship (overprotection). Some studies on the effect of the Baby Triple P parenting program on mothers with mental health problems and the parent-child relationship have confirmed the positive effect of this program [33, 34, 36], while some have not [34, 35]. Regarding the mental health variable, our results are against the results of some previous studies [33, 34, 36]. One of the possible reasons why the intervention in the present study did not affect mothers’ mental health was the novelty of the Baby Triple P program for mothers. This intervention has previously been performed only on mothers of normal-hearing children, and the present study is the first study to evaluate its effectiveness in mothers of hearing-impaired children. The needs and concerns of mothers of normal-hearing and hearing-impaired children are very different. Although efforts have been made to tailor and implement this program based on the needs of mothers of hearing-impaired children, this program was been effective for this group of mothers, and further research is needed. Moreover, mothers in previous studies had children under two years of age or had psychological disorders such as depression, anxiety, and postpartum depression. While in the present study, the age of children ranges from newborn to 3 years, and mothers had no psychological disorders. They were mothers who did not expect the birth of a baby with hearing impairment, and this problem faced them with new challenges.
On the other hand, the insufficient content of the intervention and its low focus on solutions to deal with mental health problems and acceptance of hearing impairment has affected the results. Although the number of intervention sessions was increased, it seems that the content of the sessions needs to be enriched and deepened. Furthermore, one of the most critical issues that should be included in the intervention is accepting the child’s hearing loss, because the non-acceptance of a child’s hearing loss can be an obstacle to benefiting from psychological interventions [37], and the mothers in this study had a problem in this regard.
Among the mother-child relationship components, the Baby Triple P parenting program significantly affected the overprotection components. It did not affect acceptance, rejection, and overindulgence components. This result is consistent with the results of some previous studies [34, 35]. Although the Baby Triple P parenting program is useful and positively affects the parent-child relationship, its lack of impact on most components of the mother-child relationship in our study may result from mothers’ not receiving complete and sufficient information from the intervention. The content of the program needs to be enriched to promote the mother-child relationship and to address more coping strategies for negative emotions such as depression, stress, and anxiety that can affect the quality of the parent-child relationship [34, 35]. Mothers need to learn more about hearing loss, the needs of hearing-impaired children, and how to communicate with them.
It should be noted that the two components of acceptance and rejection are very much affected by the parent’s mental health [38]. Since the intervention could not affect mothers’ mental health for the reasons stated, the components of acceptance and rejection were not affected. In explaining the ineffectiveness of the intervention on the overindulgence component, the role of the wrong attitude towards and lack of awareness about the hearing loss should also be mentioned. Usually, parents of hearing-impaired children have little information about the hearing loss and the needs of a hearing-impaired child. On the other hand, they believe that since the child is suffering, the child should be allowed to do what s/he wants [39, 40]. Mothers in our study have recently found out about their children’s hearing loss and had no information about the hearing loss and the needs of their hearing-impaired children. That little information caused the mothers to allow their children to do what they wanted. Finally, it should be noted that the mental health of the parent and the parent-child relationship are highly influenced by social and economic factors [41, 42]. The purpose of this study was not to investigate these factors and control their effects, and their measurement was limited to self-reporting. However, mothers acknowledged the effect of economic and social factors on their attitudes and behaviors in several meetings and referred to them as an obstacle to their management and their relationship with their children, so the effect of these factors cannot be ignored.
There is a high need for early intervention focusing on the mental health and mother-child relationship for mothers of hearing-impaired children. Although the Baby Triple P positive parenting program is useful, further research should be done on it, considering the unique needs of hearing-impaired children aged under 3 years. Also, the program’s content should be enriched for the mothers of hearing-impaired children to explore further the various aspects of the program.

Ethical Considerations
Compliance with ethical guidelines
Mothers were informed about the study objectives, methods, and duration, and informed consent was obtained. All ethical principles are considered in this article. The participants were informed about the purpose of the research and its implementation stages. They were also assured about the confidentiality of their information and were free to leave the study whenever they wished, and if desired, the research results would be available to them.

Funding
This study was extracted from the MA. thesis of the first author at the Department of Psychology and Education of Exceptional Children, University of Social Welfare and Rehabilitation Sciences, Tehran.

Authors' contributions
Conceptualization, editing, and review: Guita Movallali; Data collection: Arezoo Abaszadeh; Methodology: Masoume Pourmohamadreza-Tajrishi; Data analysis: Mohsen Vahedi.

Conflict of interest
The authors declared no conflict of interest.


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