Introduction
Premature birth is when a baby is born before 37 weeks of pregnancy. So, the baby requires hospitalization and receiving special care [1]. According to the World Health Organization’s (WHO) report, approximately 15 million premature births (about 10%) and 1 million child deaths occur worldwide due to complications of premature birth [2]. The statistics of premature birth in Iran are about 7%-8%, and about 9% of babies need to be hospitalized in the neonatal intensive care unit (NICU) [3].
Babies with neuro-developmental disorders, including cognition, movement, language, social communications, and behavioral disorders, are more at risk than normal babies, and these disorders may develop after childhood [4]. In a meta-analysis study by Adnan T. Bhutta et al., the cognitive scores of mature children were higher than premature children. Also, attention-deficit hyperactivity disorder prevalence is two times more in premature children [5].
Premature birth is also a challenging and anxiety-provoking issue for parents. Premature birth causes the initial separation of mother and baby and disrupts their bonding [5]. Also, the NICU environment is one of the anxiety-provoking factors. Although parents can access the NICU and stay with the baby for a long time, the experience of an unfamiliar environment, the alarm sound of the devices, and the special conditions of this department can lead to increased levels of parental anxiety. On the other hand, some factors cause parents’ anxiety and discomfort, such as the baby’s thin and immature appearance, the inconsistency of the parents’ initial mentality about their baby, and other concerns during hospitalization in the ICU [6]. 
Studies have shown that these cases disrupt the role of parents, prevent proper interaction between the baby and the mother, and affect the growth and development of the baby [5]. Therefore, parents, especially mothers who have the most relationship with their babies, should acquire skills to reduce their anxiety, teach them the correct interaction with their babies, and help them adapt to the problems and challenges of the NICU environment [7].
The focus of most interventions implemented in the NICU has been separately on the baby or the mother so far, so the needs of both audiences are not covered simultaneously. Interventions related to premature babies are focused on their neuro-developmental outcomes, while interventions for mothers are implemented to increase their awareness and capabilities to reduce stress. To fill this gap in the present study, we considered a modified auditory-tactile-vision-vestibular (ATVV) protocol in which the mother and the baby are simultaneously involved. Also, ATVV techniques have been taught to mothers for the first time in the form of playing with the baby so that the activities leading to the growth and development of the baby become meaningful and enjoyable for the mother and the child to have a purposeful interaction. In this study, the effectiveness of this protocol and the introduction of play in mother-infant interaction have been investigated on the anxiety level of mothers.

Materials and Methods 
This pilot study was a randomized clinical trial with two intervention and control groups conducted in the NICU of Hazrat Ali Asghar Hospital in Tehran City, Iran. The sample size was estimated at 20 in each group based on Bastani’s study [9], considering the power of 80% and the confidence level of 95%. The sample subjects were mothers of premature babies born before 37 weeks and hospitalized in the NICU of this hospital. Other inclusion criteria for mothers were 20-35 years old, having at least a diploma education, and lacking a history of abortion and psychiatric diseases. The inclusion criteria for babies were having stable medical conditions, first and second birth rank, lacking congenital disorders and brain damage, and not being a golden baby. The exclusion criteria included acute medical problems in the baby’s condition, parents’ unwillingness to continue cooperation, and failure to complete the considered program by mothers.
 Sampling continued as a convenience sampling method and over time until the required sample volume was completed, and people were randomly assigned to intervention and control groups by the double-block method. Then, if the parents agreed to enter the study and provided informed consent, their information was recorded in the demographic questionnaire. Considering the sensitivities of the NICU, especially during the COVID-19 epidemic, all stages of sampling, randomization, and evaluation of people in this study were performed by the researcher (occupational therapist).
In this study, the Spielberger anxiety questionnaire was used to measure the anxiety of all mothers in two stages. The first stage at the time of entering the research and before receiving training is related to the intervention (in the intervention group), and the second stage is associated with the day of discharge and before leaving the hospital. This questionnaire has two scales: trait anxiety (feelings of the individual at the moment and response time) and state of anxiety (general and normal feelings of the individual).
Babies in the intervention group received the modified ATVV protocol by play, approved by the expert group, and via their mothers. This protocol includes training to recognize the premature baby and his needs and conditions in the NICU environment, training on the concept of infant play, and finally, training ATVV intervention items in the form of play so that mothers can learn to apply appropriate sensory stimuli while playing with the baby. The theoretical parts of the program (Table 1) were taught in one to two sessions in the presence of the researcher and the mother.


The practical part (Table 2) of the program, including 10 minutes of auditory and tactile stimulation (head, back, abdomen, arms, legs, and face), then 5 minutes of vestibular stimulation were given to the mothers of the intervention group in the form of a brochure and short video after practical training.


This program was performed by mothers at least once a day, at least 5 days a week, until the baby was discharged. Each baby’s sleeping and waking time in the day determined the implementation time of the program by the mother. Also, mothers could raise their questions and doubts with the researcher online full-time and face-to-face for at least one hour a day. Babies in the control group received routine medical and nursing care in the NICU, and their mothers did not receive any training before discharge. After the secondary evaluation and discharge, if the mothers wanted, the control group would also be trained, and the researcher would answer their questions and doubts after the discharge of these people.
To describe the demographic characteristics of the samples, the mean, standard deviation, number, and percentage were used in the form of a table, and to investigate the effect of the intervention, analysis of covariance and two independent t test groups were used to compare the two groups before and after the intervention.

Results
In this research, 40 mothers present in the NICU were examined. Table 3 presents the demographic information of mothers and babies for quantitative variables, and Table 4 presents qualitative variables.




The P value related to the independent t test to compare the groups in terms of the three variables of birth age, child’s weight, and mother’s age were 0.378, 0.734, 0.734, respectively, showing that the two groups did not differ significantly in these cases (P>0.05).
Also, the Chi-square test was used to compare the groups in terms of mothers’ education, and according to the result (P=0.519), the distribution of education level in the intervention and control groups was not significantly different.
The anxiety scores of mothers were also evaluated in two groups using the Shapiro-Wilk test. The P values in the three variables of obvious anxiety, hidden anxiety, and total anxiety were 0.725, 0.426, and 0.426, respectively, and it showed that these three variables followed a normal distribution in the present study.
A t test was performed to compare the two groups regarding anxiety scores and their changes. Based on the results (Table 5), no significant differences were observed between the two groups in the scores of obvious, hidden, and total anxiety before and after the intervention.


However, after the difference of the scores before and after in three variables (to control the score before the intervention), a significant difference was observed in the average difference between the scores before and after for total anxiety and obvious anxiety in the two intervention and control groups (P<0.05) but in hidden anxiety, this difference is not significant (P>0.05).
Then, the mothers’ anxiety scores and the intervention’s effect on them were analyzed by the analysis-covariance model (Table 6).


The results of this analysis showed that after controlling the effect of the obvious anxiety score before the intervention, a significant difference was observed in the average obvious anxiety score after the intervention in the two groups, which shows a significant effect of the intervention on the obvious anxiety score (P=0.001); however, no significant difference was between the two groups in the average hidden anxiety score after the intervention, indicating that the intervention cannot have a significant effect on the hidden anxiety score (P>0.05). Finally, examining the average total anxiety in the two groups shows that the intervention was also effective on total anxiety (P=0.004). The intervention’s effect size was 27% and 20% for the two variables of obvious anxiety and total anxiety, respectively.

Discussion
Although the research protocol was developed to affect premature babies and their mothers, this article was conducted to review the findings and results related to mothers’ anxiety. The statistical data research showed that this protocol was effective on the mothers’ obvious and total anxiety levels; however, their hidden anxiety levels did not change significantly. In previous studies, the effect of ATVV intervention has been measured on factors such as mother-infant interaction [11]. However, its impact on the anxiety factor in the NICU has not been studied yet. In a study, Diane Holditch-Davis investigated the impact of two interventions, ATVV and KC, simultaneously on factors of mothers, including obvious anxiety [12].
The results showed that the speed of reducing anxiety is higher in mothers who used ATVV massages, but the time of their assessment was when the baby was two months old and after discharge from the hospital, and the anxiety measured in this study was not related to the NICU situation. While investigating the situational anxiety related to the NICU and trying to reduce it has been one of the crucial factors in the current research. For this reason, the time frame of the anxiety assessment is limited to the duration of the presence of the mother and the baby in this department. H-HOPE is also a program that includes two parts, a part related to the baby, ATVV intervention, and a part related to mothers, including maternal education and social support [13]. This program has also had positive effects on mother-infant interaction; however, it has not been evaluated on the anxiety level of mothers, especially in the NICU situation [11].
Other mother-centered interventions, including supporting and enhancing NICU sensory experiences, have been evaluated on mothers’ anxiety [14]. This intervention is initiated in the NICU environment and teaches parents how to provide appropriate sensory experiences for their premature infant [15]. However, the results show no effect on the anxiety level and depression symptoms of mothers. Of course, mental health, especially the anxiety level, depends on various factors, and the control of conditions, such as a history of psychiatric disorders and challenges, individual factors and social support, etc., can affect it and differentiate the results of different research [14]. In recent years, family-centered care, the new approach in NICU, has become more popular [16]. However, the family and the mother’s participation do not necessarily reduce the anxiety level. Although the intervention implemented by Linda Frank to participate parents in managing the pain of premature babies hospitalized in the NICU effectively increased the satisfaction and cooperation of parents, it could not reduce the stress and anxiety of parents [17]. Therefore, the type of education and the conditions of parents’ participation seems effective in this field.
The lack of effect of this protocol on the hidden anxiety level can be caused by the short duration of the intervention and the lack of a follow-up phase in the research. Of course, two other similar studies have reported results consistent with the results of this research concerning hidden anxiety [14, 18].
The reduction in the level of obvious anxiety in the present study shows that this protocol can help mothers in the situation of the newborn in the NICU and make the stressful, inflexible, and technological environment of the NICU acceptable to them. After training and learning game techniques, the mother can start her parenting role in the NICU environment, have a correct interaction consistent with the growth and development of her baby, and be an influential element in improving her condition. However, the results showed that mothers’ hidden and general anxiety remains. Therefore, this type of anxiety seems to require different interventions in future studies.

Conclusion
Reducing obvious anxiety levels in the present study shows that this protocol is helpful for mothers in the situation of a newborn in the NICU and makes the stressful, inflexible, and technological environment of the NICU acceptable to them. After receiving training and learning play techniques, the mother can start her parenting role in the NICU environment, have a correct interaction in line with the growth and development of her baby, and be an influential element in improving her condition. However, the results showed that mothers’ hidden and general anxiety remains. Therefore, this type of anxiety seems to require different interventions that should be examined in future studies.

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Research Ethics Committee of the University of Social Welfare and Rehabilitation Sciences (Code: IR.USWR.REC.1399.115). After receiving information about the study process, the participants signed a consent form. They were allowed to leave the study at any time.

Funding
This study was extracted from Master thesis of Fatemeh Farrokhian in Occupational Therapy, Faculty of Rehabilitation, University of Social Welfare and Rehabilitation Sciences. 

Authors' contributions
Conceptualization, methodology, Validation, data analysis, investigation, and final approval: All authors; writing the initial draft, editing & review: Fatemeh Farrokhian and Ayda Ravarian.

Conflict of interest
The authors declared no conflict of interest.

Acknowledgments
The authors would like to thank the personnel of Hazrate Ali Asghar Hospital and its management Dr. Abulhasan Choobdar, as well as all the mothers participated in this study for their cooperation.

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