
==== Front
J Educ Health Promot
J Educ Health Promot
JEHP
J Edu Health Promot
Journal of Education and Health Promotion
2277-9531
2319-6440
Wolters Kluwer - Medknow India

JEHP-13-183
10.4103/jehp.jehp_505_23
Original Article
The effect of single-child couples' education based on the theory of planned behavior on their intention to have next child
Sahraei Mina
Kohan Shahnaz 1
Mohebbi-Dehnavi Zahra 2
AbdiShahshahani Mahshid 3
Faculty of Health, Isfahan University of Medical Sciences, Isfahan, Iran
1 Reproductive Sciences and Sexual Health Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
2 Department of Midwifery and Reproductive Health, Nursing and Midwifery Care Research Center, School of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran
3 Nursing and Midwifery Care Research Center, School of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran
Address for correspondence: Mrs. Zahra Mohebbi-Dehnavi, Department of Midwifery and Reproductive Health, Nursing and Midwifery Care Research Center, School of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran. E-mail: zahra.midwife@yahoo.com
2024
05 7 2024
13 18312 4 2023
26 6 2023
Copyright: © 2024 Journal of Education and Health Promotion
2024
https://creativecommons.org/licenses/by-nc-sa/4.0/ This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.
BACKGROUND:

In today’s society, for many reasons, families have tended toward selective single-child upbringing. Single-child couples’ decisions about continuing to have children depend on their attitudes about the consequences of having the next child, perceived norms about it, and perception of control over childbearing behavior. Therefore, this study was conducted with the aim of determining the effect of single-child couples' education based on the theory of planned behavior on their intention to have next child.

MATERIALS AND METHODS:

This study is a field trial that was conducted in 2022. Eight girls’ and boys’ primary schools in Golpayegan City, Isfahan Province, were randomly selected for sampling the intervention and control groups. Parents of 70 first-grade students who were single children were selected and placed in groups. 35 couples in the intervention group received education about parenting based on the constructs of the theory of planned behavior during 4-weekly sessions. The questionnaire for the evaluation of childbearing behavior intention was completed by the research samples before the intervention, immediately, and three months after the intervention. Data were analyzed using analysis of variance (ANOVA), independent-samples t-test, and Mann–Whitney statistical tests.

RESULT:

Demographic and fertility characteristics were homogeneous in the intervention and control groups. The results showed that the changes in the average score of the attitude toward childbearing (P = 0.004), abstract norms (P = 0.001), perceived behavioral control (P = 0.01), behavioral intention (P = 0.003), and the overall score for the evaluation of childbearing behavior intention (P = 0.001) were significant in the intervention group. Comparing the intervention and control groups, the abstract norms immediately after the intervention (P = 0.002) and three months after the intervention (P = 0.002), behavioral intention immediately after the intervention (P = 0.006) and three months after the intervention (P = 0.009), and the overall score of the questionnaire to evaluate the intention to have children immediately after the intervention (P = 0.004) and three months after the intervention (P = 0.008) had significant differences. However, the two groups did not have significant differences in the dimensions of attitude toward having children and perceived behavioral control, immediately and 3 months after the intervention.

CONCLUSION:

The results obtained from this study showed that parenting education based on the theory of planned behavior generally improved couples’ intention to have children, abstract norms, and also the intention to have children later, but it had no effect on the attitude of couples toward having children and controlling their perceived behavior in having children. It seems that couples having only one child are rooted in environmental conditions, such as the economic and social status of society, rather than being under the control and desire of the couple. Therefore, other environmental conditions should also be taken into consideration in fertility promotion policies. Adaptation and implementation of theory of planned behavior (TPB)-based intervention by health policymakers and healthcare providers achieve a better understanding of childbearing.

Behavioral intention
education
Iran
single child
theory of planned behavior
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pmcIntroduction

The family is one of the important social institutions and the function of childbearing, and fertility is one of the important functions of the family.[1] Many economic, social, and demographic factors such as employment, income, education level, and age of marriage influence the pattern and level of fertility, and couples decide to have children according to their economic and social situation.[2] Also, couples’ decision-making about having children is started with the aim of meeting or reducing some perceived needs and depends on their attitude about the consequences of having another child and the perceived norms in this regard.[3] Finally, they make a decision in this field by taking into account the costs and benefits of their children and considering their conditions.[2]

In today’s society, the attitude of families toward having children and the number of children has changed, and families have become inclined to have only one child. In this type of single child, parents are content to have one child voluntarily and as they wish. This structural change affects the relationships within the family and the quality of life of the only child[2,3,4] and has a decisive effect on the rate of growth, composition, and structure of the population.[5] However, in the Iranian cultural and religious context, the existence of a child is a factor in increasing the satisfaction of parents and strengthening the marital bond,[6] so that the ability of couples to have children is accepted as a value.[7] The attitude toward having children is considered one of the most important factors in couples’ decision-making. A positive attitude toward a child causes early childbearing and also more childbearing.[6,7,8] Therefore, it seems that interventions that can affect the attitude toward the child can also change the childbearing behavior. One of the models of attitude and behavior change is the theory of planned behavior. According to this theory, a combination of attitude toward “behavior,” “abstract norms,” and “perceived behavioral control” can lead to the formation of behavioral intention and ultimately desired behavior. Attitude toward the behavior depends on the individual’s judgment about the effects and consequences of the behavior, and abstract norms represent the social pressure perceived by the individual to perform the behavior. Perceived behavioral control is a person’s feeling about the amount of voluntary control to perform or not perform a behavior.[8,9] In the last few decades, total fertility in Iran has been decreasing, so that currently all provinces have fertility below the replacement level. One of the consequences of continued fertility below the replacement level is the prevalence of single-child families. So, in 2019, 20% of couples aged 30 and above had only one child and 10% of them wanted only one child.[10] The occurrence of decreasing fertility rate and disrupting in the balance of the age pyramid during the last decade in Iran can be considered. The consequence of these changes will be the reduction in the young and efficient population, with today’s young population entering old age in the not-so-distant future, which can cause irreparable economic and social damage to the country. This decrease in fertility has been the result of many social and economic developments and direct and indirect policies of the government, and it seems that the pattern of low fertility has reached the stabilization stage and people tend to have low fertility.[8,9,10] Also, this low fertility has become a value and it is feared that this fertility pattern will spread in the big and small cities of the country and become a fertility practice.[9,10,11,12] However, Isfahan Province has a demographic rank of 25 in terms of overall fertility and is especially facing a higher prevalence of single children. In this regard, during years of work experience and providing services in the midwifery and family planning counseling unit of Golpayegan City, the researcher observed that people have different reasons for wanting to have only one child. Also, the single-child fertility pattern is increasing among different classes of society due to various reasons, voluntarily or involuntarily. This issue led to a question in the mind of the researcher to consider the effect of training methods to encourage single-child couples to reconsider their childbearing planning. Therefore, this study was conducted with the aim of determining the impact of training based on the theory of planned behavior on the value of having children and the behavioral intention of single-child couples.

Materials and Methods

Study design and setting

This study is a field trial with two intervention and control groups, which was conducted in 2022. The samples included 70 couples who had only one 7-year-old child studying in the first grade of primary school. After obtaining permission from the Ethical Committee of Isfahan University of Medical Sciences (IR.MUI.RESEARCH.REC.1400.239), the researcher referred to Golpayegan Education, and after explaining the objectives of the research, sampling began.

Study participants and sampling

First, all the schools in the central and outskirts of the city were listed and eight girls’ and boys’ schools were randomly selected by lottery. Then, for each group, two schools (girls and boys) in the center of the city and two schools (girls and boys) in the outskirts of the city were randomly assigned. The researcher visited the selected schools with a letter of introduction from the education department, and the objectives of the research were explained to the principal and assistants. After identifying the parents of single children and contacting them, the objectives of the study and the working method were explained. Couples who met the inclusion criteria and agreed to participate in the study were selected. This continued until 70 volunteer couples participated in the research in two intervention and control groups. First, all the samples completed the parenting behavior evaluation questionnaire online in Google Forms. Then, the researcher contacted the couples of the intervention group and arranged an in-person meeting with them at the child’s school. In this 90-minute meeting, which was held in the presence of both parents, the researcher first thanked the parents for their cooperation and obtained written consent from them. Then, the researcher asked for a short interview with open-ended questions about their experience of being a single child, obstacles, and facilitators in adopting the next child. Then, they were given questions about the beliefs and attitudes of having children so that they could address them in more time and send the results to the researcher. By analyzing the interviews, educational needs were extracted and used in the design of educational content. Also, 35 couples of the intervention group were placed in small groups of five couples and participated in four 90-minute weekly training sessions. The educational program was designed based on the constructs of the theory of planning behavior and was conducted using lectures, group discussions, film screenings, and questions and answers. To strengthen the structure of the attitude toward childbearing, couples wrote down their beliefs and attitudes toward the next childbearing before starting the sessions and sent it to the researcher. Then, based on the obtained data and using group discussions, film showings and questions and answers in educational sessions, common beliefs about having children, and the value of children and fertility intentions were discussed. Real scenarios about single-child families were presented, and the discussion and exchange of thoughts were directed by the teacher in such a way that people’s beliefs and attitudes were determined. To reinforce abstract norms, participants were asked to attend meetings with key family members or to discuss the content of the meeting with them. To help the couples to control their perceived behavior, they were asked to extract the obstacles and facilitating factors of their childbearing and discuss them in a group and narrate and analyze scenarios from people around them who have similar conditions. In addition, to strengthen the intention of the couple’s behavior to have children, the couple was asked to each of them prepare action solutions for the next hypothetical pregnancy separately and then discuss the solutions together. Then, they reported the result privately to the researcher and the researcher provided the necessary guidance. Also, some real scenarios were discussed about the reasons for delaying the next childbearing and its solutions. Strategies to strengthen people’s will to have children were taught. If they needed prepregnancy care, this care was provided to the couples during the coordination of the researcher [Table 1]. Immediately after the intervention and 3 months later, the intervention and control groups completed the questionnaire online again.

Table 1 Program and outline of parenting training sessions based on the theory of planned behavior

Meeting	Content, teaching methods, and assignments	
First session: Emphasis on improving the awareness and attitude of couples about the consequences of the country’s population decline and responsibility toward society, the attitude, and value of the child	An introduction was presented regarding the state of the country’s population, single childhood, the value of children, reproductive health, and attitudes toward fertility and children, and the discussion about population decline on society and individuals, and the impact of single childhood on children, families, and society, etc. Then, the importance of population and the need to have children were presented through group discussion. Then, each couple discussed their opinions and beliefs. Task or exercise: Before the start of the first session, the couples were asked to write down their beliefs and opinions about childbearing and the reasons for stopping childbearing and then discuss it together and send the result privately to the researcher.	
Second session: Economic and social factors of population and fertility decline and how to negotiate and overcome norms	In addition to providing offline content (via WhatsApp), PowerPoint files containing economic and social factors of population decline and fertility at the community and family levels were explained. The consequences of delay in having children, single children, and population decline were discussed. Then, the role of abstract and social norms is discussed so that couples can be trained to negotiate in this direction. Task or exercise: Couples with key family members studied offline materials and many key family members discussed and negotiated in a face-to-face meeting about childbearing and the state of the country’s population.	
Third session: Controlling the child’s behavior and value	The importance of children in the health of women, family, and society was expressed. Obstacles to childbearing and factors facilitating childbearing were presented by presenting common scenarios and solving scenario problems step by step with the help of couples. Task or exercise: Each couple discussed and negotiated their obstacles and facilitators to have the next child and sent it to the researcher.	
Fourth session: Reinforcement of behavioral intention	Methods to help couples to increase fertility and prevent single children were explained. Facilitators in this direction were discussed, and guidance was provided as much as possible. Necessary care and preparations before pregnancy were explained and presented to the couple. Task or exercise: Each couple extracted their facilitators and needs for fertility, and the researcher designed possible solutions with the research team and sent them privately.	

The data were collected with the help of a questionnaire to evaluate the intention to have children. This questionnaire was designed by Alami et al. (2020) and has 27 questions that are graded on a 5-point Likert scale from 1 completely disagree to 5 completely agree. The questionnaire has four dimensions, which are attitude toward having children (questions 1 to 8), abstract norms (questions 9 to 16), perceived behavior control (questions 17 to 23), and behavioral intention (questions 24 to 27). Its validity and reliability have been confirmed with alpha of 0.94.[8] In this study, Cronbach’s alpha coefficient was calculated as 0.85. The control group received the training package after the end of the intervention. The data were analyzed with the help of Statistical Package for the Social Sciences (SPSS) software version 22 (IBM, SPSS Inc., Chicago, Illinois, USA) and using analysis of variance (ANOVA), independent-samples t-test, and Mann–Whitney statistical tests. The method of doing the work is described in Figure 1.

Figure 1 Study diagram

Ethical consideration

This study was conducted after approval by the Ethical Committee of Isfahan University of Medical Sciences (IR.MUI.RESEARCH.REC.1400.239). Written informed consent was obtained from all participants. They were also assured that their information would be kept confidential and that final research information would be provided if they so wished.

Results

Data analysis was performed on 61 questionnaires (31 couples of the intervention group and 30 couples of the control group). Initially, 35 couples were included in the study in each group, four couples in the intervention group were excluded from the study due to not participating in more than 50% of the sessions, and five couples in the control group were excluded from the study due to not completing the questionnaires at the end of the study. The results showed that the current average age of women was 34 ± 5.2 years and that of their husbands was 38 ± 5.7 years, and the average age of women at marriage was 22.8 ± 3.1 and men was 26.2 ± 3.6 years. In most couples, there was a gap of more than 3.5 years between marriage and the birth of the first child. Most of the women in both the intervention and control groups were housewives and had bachelor’s degree. Most of the men had a diploma education. Most of the couples reported moderate economic level and favorable life stability. At the beginning of the study, the two groups were homogeneous in terms of individual variables and fertility [Tables 1 and 2].

Table 2 Description of individual characteristics and quantitative fertility of research units in two intervention and control groups

Group Variable	Mean±standard deviation	Mann–Whitney test	
	Control group	Intervention group	P	Z	
Woman’s age	33/16±4/62	34/76±5/32	0/27	-1/08	
Spouse’s age	37/20±4/08	38/29±5/32	0/46	-0/73	
Woman’s age at marriage	22/80±3/48	22/80±3/14	0/87	-0/15	
Spouse’s age at marriage	26/30±3/63	26/12±3/44	0/86	-0/17	
Child’s age	6/60±0/56	7/16±0/45	0/32	-3/82	

Changes in the average score of attitude toward childbearing, abstract norms, perceived behavioral control, intention to have children, and the overall score of the questionnaire to evaluate the intention to have children were significant in the intervention group. In the comparison between the two intervention and control groups, there were significant differences in abstract norms, behavioral intention, and the overall score of the childbearing intention evaluation questionnaire immediately after the intervention and three months after the intervention. The two groups did not have significant differences in the dimensions of attitude toward having children and perceived behavioral control, immediately and 3 months after the intervention [Table 3].

Table 3 Individual and fertility characteristics of research units in two intervention and control groups

Group Variable	Number (percentage)	Chi-square test	
	Control group	Intervention group	df	P	
Female education level		
    Illiterate up to fifth grade	2 (6/7)	2 (6/5)	1	0/07	
    Diploma and sub-diploma	10 (33/3)	8 (25/8)			
    Associate degree	4 (13/4)	5 (16/1)			
    Bachelor’s degree	12 (40/0)	12 (38/7)			
    Master’s degree and higher	2 (6/6)	4 (13)			
Woman’s job		
    Free	1 (3/3)	1 (3/2)	2	0/32	
    Housewife	22 (73/3)	22 (71/0)			
    Employee	7 (23/3)	8 (25/8)			
Spouse’s educational level		
    Illiterate and fifth grade	2 (6/7)	0 (0/0)	1	0/56	
    Middle school	6 (20/0)	3 (9/7)			
    Diploma and sub-diploma	15 (50/0)	13 (41/9)			
    Associate degree	2 (6/7)	0 (0/0)			
    Bachelor’s degree	4 (13/3)	10 (32/3)			
    Masters and Ph.D	1 (3/3)	5 (16/1)			
Spouse’s job		
    Free	12 (40/0)	11 (35/5)	1	0/09	
    Employee	4 (13/3)	6 (19/4)			
    Manual Worker	9 (30/0)	11 (35/5)			
    Other	5 (16/7)	3 (9/7)			
The economic situation		
    Very Desirable	0 (0/0)	1 (3/2)	1	0/13	
    Optimal	7 (23/3)	11 (35/5)			
    Medium	23 (79/7)	18 (58/1)			
    Undesirable	0 (0/0)	1 (3/2)			
Strength of life		
    Excellent	14 (46/6)	14 (45/2)	3	0/27	
    Optimal	15 (50/0)	16 (51/6)			
    Undesirable	1 (3/4)	1 (3/2)			
Nuclear family		
    Yes	26 (69/7)	26 (83/9)	2	0/45	
    No	4 (13/3)	5 (16/1)			
Gender of the current child		
    Girl	16 (53/3)	18 (58/1)	2	0/06	
    Boy	14 (46/7)	13 (41/9)			
History of stillbirth		
    Yes	0 (0/0)	0 (0/0)	0	0/70	
    No	30 (100/0)	31 (100/0)			
History of abortion		
    Yes	7 (23/3)	8 (25/8)	6	0/25	
    No	23 (76/6)	23 (74/2)			
History of child’s death		
    Yes	1 (3/3)	0 (0/0)	1	0/42	
    No	29 (96/7)	31 (100/0)			
History of unwanted pregnancy		
    Yes	1 (3/3)	2 (6/5)	1	0/61	
    No	29 (96/7)	29 (93/5)			

The least significant difference (LSD) post hoc test showed that there is no significant difference between the average score of the intention to have children and its dimensions, immediately after the intervention and 3 months after the intervention [Table 4].

Table 4 Comparison of the average score of intention to have children and its dimensions between the two intervention and control groups before, immediately, and 3 months after the intervention

Variable	Before intervention	Immediately after the intervention	3 months after the intervention	P-value, ANOVA	
Attitude to having children		
    Intervention group	24/22±6/80	25/77±5/93	25/90±5/66	P=0/004, F=0/93	
    Control group	25/43±5/97	25/70±5/78	25/90±5/61	P=0/32, F=4/80	
    P between two groups	P=0.96*, t=-0/04	P=0/34*, t=0/94	P=0/40*, t=0/83		
Abstract norms		
    Intervention group	25/00±4/22	27/77±3/96	27/87±3/87	P=0/000, F=2/36	
    Control group	25/06±3/12	25/33±3/32	25/30±3/25	P=0/90, F=1/15	
    P between two groups	P=0/64, t=0/45	P=0/002*, t=3/26	P=0/002*, t=3/29		
Perceived behavioral control		
    Intervention group	22/35±5/40	24/61±4/52	24/70±4/56	P=0/01, F=2/74	
    Control group	23/30±6/17	23/56±6/01	23/76±5/99	P=0/84, F=3/82	
    P between two groups	P=0/98**, Z=-0/14	P=0/07**, Z=-1/77	P=0/08**, Z=-1/74		
Behavioral intention		
    Intervention group	11/09±4/79	14/22±3/35	14/35±3/24	P=0/003, F=1/30	
    Control group	11/22±3/88	11/50±3/78	11/66±3/54		
    P between two groups	P=0/97**, Z=-0/02	P=0/006**, Z=-2/75	P=0/009**, Z=-2/61		
The average overall score of the questionnaire for the evaluation of the intention to have children		
    Intervention group	87/67±16/94	92/38±12/71	92/93±12/56	P=0/000, F=0/05	
    Control group	88/03±16/64	89/10±16/36	89/66±15/80	P=0/41, F=0/34	
    P between two groups	P=0/93*, t=0/07	P=0/004*, t=2/99	P=0/008*, t=2/73		
*Independent t-test; **Man–Whitney

Discussion

The present study was conducted with the aim of determining the effect of parenting education based on the theory of planned behavior on the behavioral intention of single-child couples in Golpayegan City in 2022. The two groups did not differ in terms of individual characteristics and fertility. The two intervention and control groups showed a significant difference in terms of the average score of abstract norms, the intention to have children, and the overall score of the evaluation questionnaire of the intention to have children immediately and three months after the intervention, but there was no significant difference in the average score of attitude toward having children and control of perceived behavior.

The results of this study showed that the changes in the average score of the attitude toward childbearing in the intervention group were significant before, immediately, and three months after the intervention, and the mean score of the attitude toward childbearing was not significantly different between the two intervention and control groups, while it was expected that training based on the theory of planned behavior can create a positive attitude toward a specific behavior.[11] Vatanparast et al.’s study did not show a significant difference in the attitude score of single-child women between the intervention and control groups.[12] However, the study of Ansari Majd et al. showed a significant difference in the mean scores of women’s attitudes in the test group in the previous stage, 3 months and 6 months after the training.[13] Also, the results of Kariman et al.’s study showed that there was a significant difference between the intervention and control groups after the intervention in the attitude dimension.[11]

Akbarian Moghaddam et al.’s study showed that immediately after the educational intervention, there was no significant difference in the attitude score between the groups, but one month after the training, the score in the intervention group increased significantly compared with the control group.[14] Alami et al.’s study showed that there is a significant difference in the attitude score between the intervention and control groups after training.[8] As the results showed, the intervention of planned behavior training in the current study could not increase the attitude of couples toward having children immediately and 3 months after the intervention. This lack of attitude improvement may have occurred for several reasons, including the presence of husbands in the training sessions and the joint response of the couple to the questionnaire questions (in other studies, only women participated), the insufficient number of training sessions, or the content and group discussions to change attitudes. However, it seems that the couples had decided to have only one child under the influence of external factors such as economic and social conditions when planning to have children.

In the current study, the changes in the average score of abstract norms regarding having children in the intervention group before, immediately, and three months after the intervention were significant, but these changes were not significant in the control group. Also, the two intervention and control groups showed a significant difference in terms of the score of abstract norms immediately after the intervention and three months after the intervention. In this regard, the study of Akbarian Moghaddam et al. showed that there was a significant difference between the intervention and control groups in terms of mental norms immediately and one month after the training,[14] but the results of some studies showed that there is no significant difference between the two intervention and control groups after training in terms of abstract norm score.[8,12] The significant increase in the score of abstract norms immediately and 3 months later in the current study may be due to the presence of the spouse and key members of the family in the meetings, or it may indicate the superiority of the traditional fabric of Golpayegan on the couple’s childbearing. It seems that in small towns, it is possible to encourage more fertility through key members of the family.

In the present study, the changes in the average score of perceived behavioral control in the intervention group were significant before, immediately, and three months after the intervention, but these changes were not significant in the control group. The mean score of perceived behavioral control was not significantly different between the intervention and control groups. Perceived behavioral control is a person’s understanding of internal and external limitations, the ease or difficulty of performing a behavior, and his understanding of the skills, resources, and opportunities needed to perform that behavior.[11] Several studies in Iran showed a significant difference between the intervention and control groups.[8,11,14] However, the results of Vatanparast et al.’s study showed that there is no significant difference in the perceived behavioral control score on the intention to have children in single-child women between the intervention and control groups.[12] As the results showed, the intervention of the current study did not create a significant difference in the perceived behavioral control score of couples toward childbearing, which may be an indication of the couples’ understanding of the inability to overcome childbearing barriers. In other words, single-child couples, trying to plan a second child, face many obstacles that they cannot overcome alone. Therefore, these couples should receive comprehensive and continuous support to overcome these obstacles.

The results showed that the two intervention and control groups showed a significant difference in terms of the average score of behavioral intention immediately after the intervention and three months after the intervention. In this regard, other studies also showed a significant difference between the intervention and control groups.[8,11,14] Based on the results of Williamson’s study, it seems that the education of women in the field of fertility has had an effect on women’s fertility intention.[15] The results of the Yekaninejad study also showed that the educational intervention based on the theory of planned behavior caused a significant increase in the average behavior intention in the intervention group.[16] According to studies, educational intervention based on TPB can significantly empower women. The adaptation and implementation of the TPB-based intervention by health policymakers and healthcare providers are helpful to achieve a better understanding of childbearing.[17,18]

Conclusion

The results obtained from this study showed that parenting education based on the theory of planned behavior improved the abstract norms and behavioral intention of the intervention group for parenting, but failed to change the attitude of couples toward parenting and controlling their perceived behavior. It seems that couples’ long single childhood rather than being under the control and desire of couples is rooted in conditions beyond their control, such as the economic and social status of society, so the improvement of other environmental conditions should also be taken into consideration in fertility promotion policies.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Acknowledgment

The present study is in the form of a virtual master’s thesis on community-oriented education approved by the ethics committee of Isfahan University of Medical Sciences with the code IR.MUI.RESEARCH.REC.1400.239. For this purpose, the research assistant of Isfahan University of Medical Sciences and all the participants in this research are appreciated and thanked.
==== Refs
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