Dissertation patricia lima pereira 2010
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Using the Internet for enhancing parental self-efficacy in infant care. A quasi-experimental study among attendees of maternal education in the district of Granada, Spain. ...

Using the Internet for enhancing parental self-efficacy in infant care. A quasi-experimental study among attendees of maternal education in the district of Granada, Spain.

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  • 1. Jagiellonian University Medical College Faculty of Health Sciences Institute of Public Health Patricia Lima Pereira Using the Internet for enhancingparental self-efficacy in infant careA quasi-experimental study among attendees of maternal education in the district of Granada, Spain 1st year Supervisor: Clara Bermúdez Tamayo 2nd year Supervisor: Grazyna Jasienska Kraków, 2010
  • 2. AcknowledgementsI would like to thank the midwives of the district of Granada for their enthusiastic andprofessional collaboration and the expecting parents for their generous participation in thisstudy. Also I want to thank my supervisors Clara Bermúdez and Grazyna Jasienska for theirpatient and dedicated support, José Miguel Morales, Alberto Fernández Ajuria and MaciejGórkiewicz for their motivating ideas, Víctor, Kalina and Irmina for their always timely help,my colleagues of Granada and Krakow for bearing with either my enthusiasm or myanxieties, and particularly Rodrigo, Abril and Helena for accompanying me in this unexpectedadventure. 2
  • 3. ContentAcknowledgements ...............................................................................................................21. ABSTRACT ..........................................................................................................................52. THEORETICAL FRAMEWORK...............................................................................................7 Using the Internet as a health information source ..............................................................7 Building parental self-efficacy .............................................................................................8 Maternal education in Spain ...............................................................................................93. METHODS.........................................................................................................................10 3.1 Study population .........................................................................................................10 3.2. The intervention: Advice on searching information online .........................................10 3.3 The study objectives ....................................................................................................10 MAIN OBJECTIVES .........................................................................................................10 SECONDARY OBJECTIVES...............................................................................................11 3.4. The study outcomes and variables .............................................................................11 3.5. Study questionnaire ...................................................................................................12 3.6. Sample size and sampling ...........................................................................................13 3.7. Participants ................................................................................................................14 3.8. Implementation of the intervention ...........................................................................14 3.9. Data management and statistical analysis ..................................................................164. ETHICAL CONSIDERATIONS ..............................................................................................185. RESULTS ...........................................................................................................................18 5.1. Dates of recruitment and follow-up ...........................................................................18 5.1.1. Characterization of maternal education classes ..................................................19 5.2. Baseline demographic and clinical characteristics of groups ......................................19 5.3. Outcomes ...................................................................................................................21 5.3.1. OUTCOME 1: Use of the Internet as a health information source ........................21 5.3.2. OUTCOME 2: Validity of the scale for measuring self-efficacy .............................25 5.3.3. OUTCOME 3: Differences in antenatal education programmes ...........................29 5.3.4. OUTCOME 4: Did the proposed intervention work? ............................................30 3
  • 4. 5.3.5. OUTCOME 5: Relationship between the Internet and parental self-efficacy ........34 5.3.6. OUTCOME 6: Factor associated with parental self-efficacy in infant care ............36 6.1. Differences in antenatal education programmes ........................................................41 6.2. An original idea ..........................................................................................................42 6.3. Pros and cons of our intervention ..............................................................................44 6.4.Methodological issues .................................................................................................467. CONCLUSION ....................................................................................................................46BIBLIOGRAPHY .....................................................................................................................48Appendix 1: Five-pages Questionnaire, translated into English ............................................53Appendix 2: Template for characterization of maternal education classes ...........................58Appendix 3: Fact sheet used as intervention ........................................................................60Appendix 4: Ethical approval from the Health District of Granada ........................................61Appendix 5: Form of informed consent and information for contact (In Spanish as original) 62 4
  • 5. Using the Internet for enhancing parental self-efficacy ininfant care. A quasi-experimental study among attendees ofmaternal education in district of Granada, Spain1. ABSTRACTINTRODUCTION: The Internet is an important source of health information, especiallyamong women and men in reproductive ages. The Internet could constitute an optimalenvironment for developing strategies aimed at health literacy in the area of maternaleducation. The aim of this study was to analyze whether midwife’s advice on how to findinformation on the Internet could enhance parental self-efficacy in infant care.OBJECTIVES: Main objectives were: a) To determinate if the perceived usefulness of theInternet as an information source is related to parental self-efficacy in infant care; and b)Todeterminate if midwife’s advice on how to enhance the use of the Internet could have aneffect in parental self-efficacy in infant care. Secondary objectives were: a) To describe theuse of the Internet as a health information source among participants of maternal educationclass in Granada (Spain); b)To calculate the validity of the scale used to determinate parentalself-efficacy in infant care; c) To characterize the maternal education in Granada, Spain,describing factors differing among the health centers; and e) to identify factors that mayconfound relationships between Internet use and parental self-efficacy.METHODS: A quasi-experimental study on group level was carried out for evaluate the effectof midwife’s advice on searching health information in the Internet. The study populationconsisted of women and men who attend maternal education classes in health centers ofAndalusia Health Service in Granada, Spain. The intervention consisted a verbal advice and afact sheet designed specifically for this study. Descriptive statistical analysis was conductedfor all variables in terms of frequencies for qualitative variables and calculating the mean,standard deviation and ranges for the quantity. Also multivariate analysis was performed toverify the association between studied variables. 5
  • 6. RESULTS: A total of 169 women and 38 men took part of the study. The average age ofparticipants was 31.3 (sd 5.98), median age was 32 years. Outcome 1: Use of the Internet as a health information source: The 97.4% of our sample have ever sought information on pregnancy, and 3 out of 5 participants did that during the last week. 18.5% of the women and 25.8% of men chose the Internet as their first source of information. Fetal development, stages and changes during pregnancy and nutrition were the three topics most frequently searched by both women and men. Commercial sites were more frequently visited than organizational sites. Outcome 2: Validity of the self-efficacy scale: The internal consistency was optimal (Cronbach’s coefficient alpha = 0.95), and it had also an acceptable construct validity that explained 71.7% of total variance. Outcome 3: Differences in antenatal education programmes: We found great differences in years of professional practice and ability in the use of Internet between midwifes in charge of the classes. There was no consensus on teaching respiration techniques, physical exercises or use of audiovisual support in class. Total time of classes ranged from 8 to 24 hours. Outcome 4: Effects of midwife’s advice: Among 48 people that were given the factsheet by their midwifes, 19 (39.6%) said that they had used it and found it useful and 21 people (43.8%) said that they would use it in the future. As it was expected, more people visited “Medline Plus” and “Nacer Sano.org” among those who received advice (17.8% and 36.8% vs. 5.8% and 12.9%, respectively) (Chi squared test, p=0.007). Outcome 5: Relationship between internet and parental self-efficacy: We confirmed our hypothesis that the higher the value given to the Internet the higher would be self-efficacy in infant care score. In the general sample the correlation was positive, but relatively low (Spearman’s coefficient 0.16, p=0.028), but the strenght of the relationship increased in those people that received advice and followed it, i.e. intervention group (Spearman’s Correlation Coefficient= 0.62, p=0.024). Outcome 6: Factors associated with parental self-efficacy in infant care: Controlling for all other variables, parity was the factor most strongly related with parental self- 6
  • 7. efficacy. People who had children scored 21.4 points higher than the general mean in self-efficacy scale. When controlling for others variables, also being in the last weeks of pregnancy and living in the city were associated with higher scores of self-efficacy. We found that being older than 30 years was statistically significant associated with perception of lower parental self-efficacy. The introduction into the regression model of the two variables that we consider outcomes of our study (use of Medline and the perceived usefulness of internet) resulted in low, but statistically significant increase in the variability explained by our model. Nevertheless the explained variability remained rather low, with an adjusted R square of 0.29.CONCLUSION: The Internet is a widespread source of information among participants ofmaternal education classes in Granada, in both men and women. We found a positivelyrelationship between perceived usefulness of the internet and parental self-efficacy. Thestrength of the relationship was increased in those people that received from their midwifethe written advice designed for this study, and followed it. Perceived parental self-efficacy ininfant care was also significantly and positively related with previous deliveries andadvanced pregnancy. Otherwise, older mothers scored statistically significant lower thanyounger mothers. Attendants to maternal education classes are open to accessinginformation about internet resources suggested by their midwifes and this opportunityshould be exploited for enhancing the usefulness of their internet searches.2. THEORETICAL FRAMEWORKUsing the Internet as a health information sourceThe Internet is an important source of health information, especially among women andmen in reproductive ages1-3. Several authors have suggested that motivation of patients toseek information, managing this information and risks, as well as exchange of information inthe consultation may enhance their empowerment4, increase their health literacy5, andimprove shared clinical decision-making1,6-9. However, most interventions have been 7
  • 8. implemented to chronic, elderly patients, and therefore less accustomed to using theInternet10,11.On the web there are many sites geared to pregnancy, childbirth and motherhood, but manyusers are not qualified to assess their quality and reliability6.Most people seeking health information online did not talk with a health professional aboutthe information they found during their most recent search, but most would haveappreciated it if their caregiver had suggested relevant web sites. One study showed that, ifpatients were ‘prescribed’ how and where to find relevant information about their healthconditions, the patients would adhere to this ‘prescription’7. In a Swedish study withpregnant women, over half (55%) of participants said that the midwife if they suggested asite, they would visit it1.Patients experiment difficulty in interpreting information on the Internet. Therefore, mostappreciate the support of healthcare practitioners in the interpretation andcontextualization of information. The talk about the search on the Internet, with therecommendation of trusted web sites and criteria for evaluating the quality of a website,could facilitate the exchange of information during the consultation6.Primary care providers should recognize that patients are using the network as a resourcefor health and medical information and should be prepared to assist patients in evaluatingquality of information available on the Internet 8.Building parental self-efficacyAccording to social learning theory, self-efficacy is a measure of the confidence an individualhas in their ability to meet the demands and responsibilities of a task within a specificcontext12. Perceived parenting self-efficacy is defined as the belief about one`s ability to besuccessful in the parenting role. Perceived parenting self-efficacy has found to be related topositive child outcomes 13.Four main antecedents to self-efficacy have been articulated, including: (a) prior experienceat the task, (b) experiencing low levels of arousal or stress when engaged in the task, (c) theopportunity to observe others perform the task, and (d) receiving positive feedback fromothers14. In the context of perceived parental self-efficacy , the social support aspects of this 8
  • 9. theory (c and d) may be particularly relevant in affecting parents’ perceptions of theirparenting ability. The accumulated body of research suggests that perceived self-efficacy is aprotective factor and a powerful predictor of competence in caring for children andsubsequent success in health 15.Various researchers have developed a theoretical framework and tools developed tomeasure self-efficacy15,16, but no one has been validated in Spanish.Maternal education in SpainIn Spain, the antenatal control process is responsible for midwives 17. The underlyingphilosophy in the care provided by midwives is to develop the birth process is naturallyaccompanied by a known and trusted professional. Emphasis is placed on the confidence inthe natural ability of women to experience childbirth with as little intervention as possible. Asystematic review of 2008 suggests that this type of care increases confidence of womenduring pregnancy and childbirth18.Maternal education could constitute an optimal environment for developing strategiesaimed at health literacy1,19-21.Maternal health literacy is defined as social and cognitive tools that determine themotivation and the ability of pregnant women to access, understand and use information ina way that helps they to promote and improve their own health and their children health20.Many authors suggest that rather than ignoring women’s interest in and their current use ofthe Internet should have been cleverly engaging for reinforce content covered in childbirtheducation classes. They say educators should encourage women to use the Internet, offerduring classes links to high-quality sites, and access criteria1,19-21.In this context the aim of this study is to analyze whether midwife’s advice on how to findinformation on the Internet could enhance parental self-efficacy in infant care. 9
  • 10. 3. METHODS3.1 Study populationWomen and men who attend maternal education classes in health centers of AndalusiaHealth Service in Granada, Spain.3.2. The intervention: Advice on searching information onlineIn six of the surveyed groups (55 women and 13 men), participants had received from theirmidwife in the preceding classes tips on searching the online information (verbal advice +factsheet).The factsheet was developed by a communicational professional based on a qualityassessment for web sites developed by the “Internet and Health Research Group” ofAndalusian Public Health School22. It was reviewed by four midwifes involved in maternaleducation. See it in the appendix 3.Midwifes of the intervention-groups were responsible to deliver the advice on searching theonline information. It took only five minutes at the end of the meeting and consisted ofgiving the factsheet to the attendants and suggesting using it.Participants in the intervention group were surveyed one to two weeks after receiving theadvice.3.3 The study objectivesMAIN OBJECTIVES Objective A.1 To determinate if the perceived usefulness of the Internet as an information source is related to parental self-efficacy in infant care. Objective A.2 To determinate if midwife’s advice on how to improve search on the Internet could have an effect on parental self-efficacy in infant care. 10
  • 11. SECONDARY OBJECTIVES Objective B.1 To describe the use of the Internet as a health information source among participants of maternal education class in Granada (Spain). Objective B.2 To calculate the validity of the scale used to determinate parental self-efficacy in infant care. Objective B.3 To characterize the maternal education in Granada, Spain, describing those factors that differ among the health centers. Objective B.4 To identify factors that may confound relationships between internet use and self- efficacy3.4. The study outcomes and variablesFor this study the primary outcome measured, i.e. the dependent variable, was theperceived parental self-efficacy in infant care. Perceived Maternal Parenting Self-Efficacy(PMP SE) tool16 was adapted and used for measuring it. It was a 9-item, 10-point Likert-typescale instrument.The secondary outcome, and independent variable, was the value that future parents giveto the Internet as an information source. It was measured using the followed self-reportedquestion: “On a scale of 1 (minimum) to 10 (maximum), describe how helpful in solving yourdoubts related to pregnancy, childbirth and infant care, the information you read on theInternet is.” 11
  • 12. To describe the use of the Internet as a health information source among participants ofmaternal education class in Granada (Spain) the following variables were used :  Use of the Internet (in general), frequency of use, place of accessing the Internet,  Use of the Internet as source of information about pregnancy,  Preference over other sources of information  Recent history of use, topics searched, websites visited, search strategy  Positive and negative feelings generated when browsing the Internet  Willingness to receive the instruction (advice, guidance, suggestion) on the Internet use from a midwife  Gender, age, number of pregnancies, educational level, assigned health center.To characterize the maternal education in different health center in Granada, Spain, thefollowing questions were asked: Duration of the course, agenda, duration of each session,gestational age of pregnancy when women were invited to participate in the course,teaching methodology, training and experience in maternal education of the course leader,audiovisual devices used, physical exercises, level of course attendance.Confounding factors related with internet use and parental self-efficacy have been selectedbased on literature review8,15,16,23. Factors related to internet used were: gender, age,education level, ability in using the Internet. Factors related with parental self-efficacy were:gender, age, education level, number of children, quality of relationship with the partner,type of health center.3.5. Study questionnaireData were collected anonymously using a questionnaire. The questionnaire was created bythe author of this thesis and reviewed by staff of the Andalusian Public Health School andfirst year supervisor. Questions addressed a variety of topics related to patient use of theInternet for gathering health information. The survey also included a nine-question scale for 12
  • 13. measure of perceived parental self-efficacy and “Background Information” items intended togather demographic data.A pilot testing of the questionnaire was conducted from 26 to 28 May 2009 in 3 healthcenters involving 32 participants (30 females and 2 males). Legibility of the questions,frequency of endorsement, and time required to fill the questionnaire were assessed. Basedon analysis of results some items were modified i.3.6. Sample size and samplingThe design of our study required a relatively large sample. As it is known, of all theparameters that have to be specified before attempting to determine the sample size, theeffect size is the most critical24. The expected effect size of our intervention –midwife’sadvice on how to improve internet search- was quite small25. The estimated outcome usedfor calculate sample size in our study was the difference in the mean of parental self-efficacyscores between groups that do receive advice and those that do not. We were expectingthat people who visited Medline –proposed website- would have a mean score 3 point (5%)higher than people than did not (58 vs. 55), with a standard deviation of 17 points.To have an 80% chance of detecting as significant differences (with a two sided significancelevel of 5%) 394 people in each group were required (788 in total)24.In addition, the unequal distribution of cases in each group should be taken into account.For each participant that visited Medline, there were ten participants who did not. So, theallocation ratio was 10:1. To maintain the power of 80% it would had been necessary tomultiply the sample by 5. With these considerations, the ideal study should have a sample of1970 participants in control group (those who do not use Medline) and 197 participantsi The parental self-efficacy scale was modified. The sensibility of 5-value scale seemed insufficient, thus it was replacedwith a 10-value scale. In addition, the option “other information sources” in question number 1 was excluded. A questionon “perceived ability to use the internet” was included. The topic “Vaccines” was included within sought items. (It isnecessary to mention that a mistake in the design of the questionnaire was noticed at the time of loading data: the checksquare was missing, thus most of the participants haven’t filled in this option). In the question related to feelings thatpeople experienced while browsing the internet questions were separated in two groups: Four questions inquired aboutpositive feelings and the other four about negative feelings. In question: “Would you like to receive instruction on internetsources from your midwife?”, number of answers offered were reduced from five to three: No / Maybe / Yes 13
  • 14. users of Medline. Therefore, it should be noted that our study that consisted a sample of190 participants who do not use Medline and 19 participants who use it, had the power of12%.3.7. ParticipantsA total of 169 women and 38 men took part of the study. For presenting flow of groups andindividual participants through each stage the revised CONSORT statement was used,including the extensions for clusters analysis and non-pharmacologic interventions26-28. Theflow chart can be seen in figures 1 and 2.3.8. Implementation of the interventionThe intervention was implanted in 6 groups from 5 health centres (median groups size = 12,range 5 – 20). It consisted verbal advice and the fact sheet informing how to search healthinformation on the Internet29,30. The interventions were carried on by midwifes, without thepresence of researchers. A total of 73 participants took part in the intervention.The fact sheet was designed by a communicational professional based on a qualityassessment for web sites developed by the Andalusian Public Health School 22. It wasreviewed by four midwifes involved in maternal education. See it in the appendix 3.Midwifes of the intervention-groups were responsible for delivering the advice on searchingthe online information. It took five minutes at the end of the meeting and consisted of givingthe factsheet to the attendants and suggesting using it.Participants in the intervention group were surveyed one to two weeks after receiving theadvice. 14
  • 15. Groups assessed for eligibility during the period of the study (16 groups of 7 health centres) Allocated to control Allocated to intervention (according to assistance records): (according to assistance records) 10 groups, median groups size = 18, range 5 – 34 6 groups, median groups size = 16, range 6 - 26 Allocation 181 participants 93 participants 20 participants were not presented the day of intervention Intervention Received intervention 6 groups, median groups size = 12, range 5 - 20 73 participants were presented the day of intervention 2 participants who received 64 participants were not intervention were not presented presented the day of submission Assistence to the class the day of the day of submission questionnaire questionnaire assessment Attended a class the day of assessment Attended a class the day of assessment (10 groups, median groups size = 12, range 2 – 22) (6 groups, median groups size = 11, range 5 - 20) 117 participants 70 participants 15 participants did not respond to 4 participants did not respond to Respondence rate of questionnaire questionnaire for refused to participate questionnaire for refused to participate or not read in Spanish or not read in Spanish Responded to control questionnaire Responded to intervention questionnaire (10 groups, median groups size = 11, range 2 – 18) (6 groups, median groups size = 11, range 5 - 18) 102 (87,2%) women responded to questionnaire 66 (94,3%) women participants responded to questionnaire 25 men responded to the questionnaire 13 men responded to the questionnaire Analysed Analysed 12 women who did not Analysis (10 groups, median groups size = 11, range 2 – 18) (6 groups, median groups size = 11, received the intervention 102 (87,2%) women responded to questionnaire range 5 - 18) but responded to 25 men responded to the questionnaire 55 women and 13 men who received questionnaire the intervention and responded to questionnaireFigure 1. Flow of groups and individual participants through each stage. 15
  • 16. Figure 2. The number of group and participants that were interviewed in each care centre. Grey chart = Intervention groups * Participants of intervention groups that did not receive the factsheet3.9. Data management and statistical analysisFirst, distribution of all quantitative variables was examined with Shapiro-Wilk Test todeterminate if they were normally distributed, and Levene Test, to check the homogeneityof variances. Factors that do not meet these criteria were analyzed using non parametrictests.We used χ2, t tests for independent samples to compare differences in demographic andother study variables between the groups that do not receive the advice and those that do. Objective A.1: To determinate if the perceived usefulness of the Internet as an information source is related to parental self-efficacy in infant care.Correlation between both factors (value that future parents give to the Internet as aninformation source –independent variable- and parental self-efficacy in infant care-dependent variable-) was determined using Spearman’s coefficient. 16
  • 17. Objective A.2: To determinate if midwife’s advice on how to enhance the use of the Internet could have an effect in parental self-efficacy in infant care.The primary hypothesis was that the intervention group would differ with respect to thecontrol group on four outcome variables (e.g., preference of the Internet as a healthinformation source, perceived usefulness that give to the Internet as a information source,amount of sites visited, feelings related to browse the web).The effectiveness of the intervention was analyzed by means of a regression analysis withthe perceived parental self-efficacy as the dependent variable. Other potential confounderssuch as gender, age, education level, number of children, quality of relationship with thepartner were included in the model. Objective B.1: To describe the use of the Internet as a health information source among participants of maternal education class in Granada (Spain)Differences in demographic characteristics and other study variables between the groupswere compared using χ2 and t tests for independent samples. Objective B.2: To calculate the validity of the scale used to determinate parental self- efficacy in infant care.The Cronbachs alpha coefficient of the scale was calculated and a factorial analysis wasconducted. Objective B.3: To characterize maternal education in Granada, describing factors that differ among the health centers.Differences in level of education and demographic characteristics between the healthcenters were compared using χ2 and t tests for independent samples or the Mann-Whitneytest. 17
  • 18. Objective B.4: To identify factors that may confound relationships between internet use and self-efficacyLinear regression was used to analyze the group of confounding variables (gender, age,education level, number of children, quality of relationship with the partner, type of healthcenter).The data were analyzed using Statistical Package for the Social Sciences (SPSS) version 11.4. ETHICAL CONSIDERATIONSConsidering Bill of 41 of November 2002 of Spain, which regulates the information andclinical documentation, and Act number 14 of July 3th 2007 of Spanish biomedical research,this dissertation meet the legal and ethical guidelines of Spain. Also, this research follows theguidelines quoted in the latest modification of the Declaration of Helsinki, World MedicalAssociation (Seoul, October 2008), which considers ethical principles for research involvinghuman subjects. Prior to any data being gathered, ethical approval from the Health Districtof Granada was obtained. Additionally, all participants signed an informed consent form. Seeappendix 4 and 5.5. RESULTS5.1. Dates of recruitment and follow-upThe survey was conducted in 16 separate groups in 7 centers of Granada city from 29th Mayto 25th September 2009. The distribution was as following: Gran Capitán (3 groups, 49samples, 23.7%), Gongora-Mirasierra (2 groups, 47 samples, 22.7%), Chana (3 groups, 38samples, 18.4%), Zaidín (two groups, 35 samples, 16.9%), Montijo (3 groups, 17 samples,8.2%), Cartuja-Almanjayar (2 groups, 13 samples, 6.3%) and La Caleta (1 group, 8 samples,3.9%). They represent the whole public offer of maternal classes during the four monthsperiod of the study. 18
  • 19. The self-administered questionnaires were administrated at the beginning of the class. Thefilling of the questionnaire lasted approximately 15-20 minutes. The total number of personsattending the courses during days when this research was conducted was 229, including 187women and 42 men. Four women were excluded for not being able to read in Spanish. Thosewho arrived late at classes did not fill the questionnaire and did not participate in the study.A total of 169 women, 34 men, and 4 persons who did not report their gender participatedin the survey. The response rate was 91.8% for women and 80.9% for men.Among the total of participants, 102 women and 25 men that completed the questionnairewere originally assigned to control group and did not receive the intervention. A total of 55women and 13 men who received the intervention, responded to questionnaire. Moreover,12 women surveyed who were in an intervention group did not receive the intervention,because they did not attendee a class this day. These women were included in the analysesas part of control group.5.1.1. Characterization of maternal education classesGiven the variability found among the courses offered by the different centers, we decidedto make a description of the different classes. It employed a template that was designedbased on the literature, and the answers of interviewed midwives responsible for each class.Moreover, the method of observation was used. The complete questionnaire and templateare included in the appendix 1 and 2.5.2. Baseline demographic and clinical characteristics of groupsAmong those who completed the survey, 83.3% of respondents were women (N = 169) and16.7% were men (N = 34). The average age of participants was 31.3 (sd 5.98), median agewas 32 years. For women, the mean age was 30.96 (sd 5.71) (minimum 15 and maximum42). Among men, the mean age was 32.76 (sd 6.96) (min. 20 and max.57).The stage of pregnancy among participants ranged from 24 to 38 weeks. The mode was 30weeks, and the median was 32 weeks. 19
  • 20. With respect to the number of maternal education classes attended, 10.1% had notattended any at the time of the survey (8.5% of women and 18.2% of men), 27.3% hadattended 1 or 2 classes, 49.5% had participated in 3 or 4 classes and 13.1% had attended 5 ormore classes.86.6% were expecting their first child. Among those who already had children, 77.8% wereexpecting their second child, 18.5% their third and 3.7% their fourth child.The participants had the following level of education: 6.4% of respondents had a level ofstudy equivalent to complete primary education or lower. 34.7% had achieved a completesecondary education and 58.9% had college or graduate level. No significant difference wasnoted between men and women.Table 1 presents baseline comparisons between participants of usual antenatal programand those that received the intervention. 20
  • 21. 5.3. Outcomes5.3.1. OUTCOME 1: Use of the Internet as a health information source Summary: An objective of our study was to describe the use of the Internet as a health information source among participants of maternal education class in Granada (Spain). We found a high level of utilization in both, men and women. The 97.4% of our sample have ever sought information on pregnancy, and 3 out of 5 did that during the last week. 18.5% of the women and 25.8% of men chose the Internet as their first source of information The three topics related to pregnancy most frequently searched by both women and men were: fetal development, stages and changes during pregnancy and nutrition during pregnancy. Commercial sites were more frequently visited than organizational websites.a. Frequency and ability of useThe Internet is a frequent source ofinformation among participants of maternaleducation classes in Granada. We measuredfrequency and ability of use amongparticipants that did not receive advice. The94.5% reported using the Internet usually.See it in table 2. It is widely used by both menand women. No significant difference wasfound among genders (Chi squared test,p=0.56).Among those internet users, 97.4% have eversought information on pregnancy. One out offour participants (25%) did seek information Table 2. Frequency of use the internet as an information source among future parents 21
  • 22. in the last 24 hours before the survey. 62% of respondents had sought information in thecourse of the week and 84.6% had done that in the last month. The use of the Internet wascommon, regardless of education level, but was greater in the group with mid-leveleducation. 65.2% of the participants with secondary education, 58.9% with tertiaryeducation level and 50% with primary education level used the Internet for information onpregnancy within the last week (Chi squared test , p = 0.04). 85.8% of the Internet usersself-assessed their ability to use the Internet as good or very good, the 12.5% as regular and1.7% as bad.b. Place and way of use95% of internet users access it usually at home. Among the 5% that do not have access tointernet at home, 34.8% use it at work, 47.8% at the home of some relatives, and 34.8% in apublic place (library, university, internet café).The most common way to starting browsing the Internet is using Google. 93.1% reportedused this way for searching information about pregnancy. Moreover, 25.4% of participantsof maternal classes visited websites that were recommended by the media, 18.5% went tothose recommended by their midwife, and 16.1% to those suggested by someone else.Among participants of the control groups (those who had not received the fact-sheet of theintervention), 48.3% said that they would like to receive guidance on how to findinformation on the Internet, 41.2% replied that "perhaps" and 10.3% said that they were notinterested in receiving such guidance (8.5% of internet users and 42.9% of non-users).c. Topics and websites of interestThe six topics related to pregnancy most frequently searched by both women and menwere: fetal development, stages and changes during pregnancy, nutrition during pregnancy,stages of childbirth, baby names & zodiac, and breastfeeding.Men reported more frequent search on topics such as: childbirth without pain (43% morethan women), information about health care (38% more than women), care of women afterchildbirth (37% more than women), relationship/ sexuality/ emotional support (12% morethan women), baby names and stages of childbirth. See in table 3. 22
  • 23. Women reported more frequent search on topics related to the purchase of products (18%more than men). However, no difference between men and women was statisticallysignificant.Commercial websites are most frequently used by people looking for information onpregnancy. In this study we presented to the participants a list of eight websites related topregnancy and asked them to report whether they have visited them. The four commercialpages were visited by 41.5%, 39.8%, 35% and 28.5% of the participants, respectively.The two websites launched by health worker’s organizations were visited by 18.7% and17.1%, respectively.Finally, the two websites developed by state’s or nonprofit organizations were visited onlyby 14.6% and 6.5% of the participants, before the intervention was implemented. Theselatest were the sites suggested to be visited. 23
  • 24. d. First sources of informationAmong men, 83.3% cited the family doctor within their first three sources of information,64.5% cited the Internet, 51.6% magazines, 51%, the midwife, 41.4 % relatives and 22.2%friends. In the case of women, 80.3% reported the doctor within their first three sources ofinformation. The following source were cited most frequently within the first three options:midwifes (63.7%) followed by magazines (52.3%), the Internet (47.3%), relatives (45.2%) andfriends (26.6%)Physician was selected most frequently as the first source of information: 54.8% of womenand 53.3% of men chose it as first source, 15.3% of women, and 16.7% of men as second,and 10.2% and 13.3% of men as third source.After physician, the Internet was the most frequently selected source as the first choice ofconsultation on pregnancy topics. It is used by 18.5% of the women and 25.8% of men as aprimary source of information (increased to 41.7% for 12 men who received the adviceabout the use of the Internet from midwifes).Also, 13.9% of women and 16.1% of men qualifies it as a second source. 14.6% of womenand 22.6% of men uses it as a third source of information.Conversely, 25.8% of women and 16% of men choose internet as the last source ofinformation. Not significant difference is noticed between persons that received advice andthose that do not.Comparing groups, among those women that did not receive advice, 31% choose theInternet as last source of information. It changed to 15.7% among those that received it.Among men, 21% among those that did not receive advice and 8.3% among those thatreceived it choose the Internet as last source of information.14.4% of women and 13.8% of men chose the nurse or midwife as the first source ofinformation, 34.2% of women and 31% of men as a second source 15.1% of women and6.9% of men as third source 5.5% of women and 17.2% of men chose the family as the firstsource of information, 15.8% of women and 13.8% of men chose as second, 24% of womenand 10.3% of men as third. 24
  • 25. Magazines, books and brochures are used by 12.6% of women and 3.2% of men as firstsource of information, by 17.9% of women and 22.6% of men as second source, and by21.9% of women and 25.8% of men as third source.Friends are preferred by 4.9% of women and 0% of men as primary source of information.7% of women and 7.4% of men select them as second source information and 14.7% ofwomen and 14.8% of men as third source.e. Positive and negative feelings generated when browsing the InternetBrowsing the Internet generated some positive feelings among the users. 77.7% fully orpartially agreed that it improves their tranquility, 67.4% said that it offers confidence, 57.2%feel satisfied with what they have found, and 80.2% reported willingness to shareinformation they have found.Nevertheless, 9.8% did not feel satisfied with what they found into the Internet, 4.3% did notfeel confidence and 2.7% did not want to share their information.The Internet search also produces some negative feelings. 56.5% agreed they feel somehowoverwhelmed with the amount of information, 29.1% feel frustrated for not finding whatthey were looking for, 45.3% feel confused and 54.4% feel slightly frightened by informationreceived from the Internet.5.3.2. OUTCOME 2: Validity of the scale for measuring self-efficacy Summary: A second objective of our study was to calculate validity and reliability of the scale used to determinate parental self-efficacy in infant care. The internal consistency was optimum: Cronbach’s coefficient alpha = 0.95, and it had also an acceptable construct validity that explained 71.7% of variance. These results give encouragement to the use of the scale through the rest of the work. 25
  • 26. a. Scale generation, content validity and pilot studyNine items were generated for measuring the perceived parental self-efficacy, based anadaptation of the PMP S-E tool16, according to the Bandura’s self-efficacy theory. Items arereferred to activities and tasks related to the baby’s basic needs, which could be found onthe Internet.Responses to each item were recorded on a Likert scale ranging from ‘strongly disagree’(score 1) to ‘strongly agree’ (score 5 in the pilot, 10 in the final scale). A low score on thisscale indicates a low parental self-efficacy.To assess the content validity of the scale, the items were presented to 2 specialists inprenatal care, who were asked whether they thought each item related to infant care andwhether it was clear and easy to understand. All of the items were reported to fulfil thesecriteria.A pilot testing of the whole questionnaire of the present study, including the scalecontaining 9 items (each one was firstly ranged from 1 to 5), was conducted from 26 to 28May 2009 in 3 health centers involving 32 participants (30 females and 2 males). Legibility ofthe questions, frequency of endorsement, and time required to fill the questionnaire wereassessed. According to analysis of results the parental self-efficacy scale was modified. Thesensibility of former 5-value scale seemed insufficient, thus it was replaced with a 10-valuescale. No further work was carried out with this sample of responders and a larger study wasinitiated using the modified version of questionnaire and scale.b. Reliability and validity testing of our scaleAs part of this research, we have proposed to assess reliability and validity of the scale thatwe have used. For this purpose we used the sample of non-intervention groups of 139participants (114 females and 25 males), since we had expected to find some change withthe intervention. The characteristics of the study sample are summarized above.Independent samples t-test indicated that female and male participants did not significantlydiffer in: age (means 31.16 and 32.15, mean difference -0.99, p=0.50), weeks of pregnancy(30.66 and 30.65, m.d. 0.01, p=0.99), number of attended classes (2.85 and 2.05, m.d. 0.8,p=0.08), but they differ in self-efficacy total score (56.28 and 47.72, m.d. 8.56, p=0.054). 26
  • 27. Thus the sample was not pooled, but analysed independently. Only the 114 cases of womenwere included in analysis.Five mothers did not complete the scale, leaving an overall total of 109 cases that were usedto test the construct validity and internal consistency reliability of the instrument. Neither asecond assess nor any comparison test was conducted, so it was not possible to measureneither retest reliability nor divergent validity.c. Data analyses for assessing the scaleData were analysed using an independent samples t-test, Cronbach’s coefficient alpha andfactor analysis in SPSS version 11.d. Degree of discrimination of the scaleOverall, there large variability was found in parental self-efficacy, with scores on the scaleranging from the minimum possible of 9 to the maximum possible of 90.Figure 3 shows the distribution ofscores. The overall study samplemean self-efficacy score was 54.5(s.d. 17.03), the median was 55 andthe mode was 45. The degree ofspread of the scores suggests thatthe tool has a reasonable degree ofdiscrimination despite a slightnegative skew (skewness -0.15;standard error of skewness 0.23).Shapiro-Wilks Test confirmed a normal Figure 3. Frequency’s distribution of responses. N=197distribution (P=0.09). 27
  • 28. e. Internal consistency reliabilityCronbach’s coefficient alpha was used to calculate internal consistency reliability estimatesfor the scale; this reached 0.95, that is desirable for new instruments31. The tooldemonstrated no higher alpha values if any further items were deleted from the scale.f. Validity of the scale Construct validity The scale was assessed for construct validity using the exploratory factor analysis. The components analysis in combination with a Varimax rotation yielded a unique factor (communalities ranging from 0.55 to 0.80, Bartlett`s test of sphericity <0.001) that explained 71.67% of variance. The emergence of this unique dimension was congruent with the our objective and had been based on literature review on self- efficacy theory. Comparison of contrasted groups Construct validity of the parental self-efficacy scale was also examined through the procedure known as contrasted group analysis. This is comparing those participants thought to be high in the construct being tested with those believed to be low. Bandura (1997) suggests that self-efficacy derive from four principal sources of information: prior experience at the task, experiencing low levels of arousal or stress when engaged in the task, the opportunity to observe others perform the task (vicarious experience), and receiving positive feedback from others. The first of these is assumed to be the most influential because it provides the most authentic evidence of whether a person has whatever it takes to succeed49. Therefore, we hypothesized that women who had previously given birth would have significantly higher self-efficacy than primiparous women. Independent samples t- test indicated that multiparous women (mean 75.3, s.d. 10.5) rated significantly higher on self-efficacy (p<0.001) than those who had given birth for the first time (mean 52.9, s.d. 16.1). 28
  • 29. 5.3.3. OUTCOME 3: Differences in antenatal education programmes Summary: To characterize antenatal education in Granada and to describe those factors differing among the health centers were both other objectives of our study. We found great differences in years of professional practice and ability in the use of the Internet between midwifes in charge of the classes. Since there was no fixed programme, each responsible person decided how to give classes. Total time of classes ranged from 8 to 24 hours. There was no consensus on teaching respiration techniques, physical exercises or use of audiovisual support in class.Antenatal education has been included into the offers of health care services in Andalucíafor three decades and since 1990 the percentage of involved women have been consideredan indicator of quality in prenatal care. In 1993 more than 40% of pregnant women inAndalucía attended this kind of classes17. In 2008, according to administrative data from theSanitary District of Granada, maternal education achieved 1350 women, that represents46.5% of the 2903 pregnancies registered that year32.Despite its dissemination, the programme of attention of the childbirth does not havedeveloped indicators for measuring quality and impact of the antenatal education. There isno official guidance, and each midwife in charge of courses decides how to implement theantenatal education. Content, methodology, duration of classes vary broadly betweendifferent health centres. A resume of this diversity is summarized in table 3. 29
  • 30. 5.3.4. OUTCOME 4: Did the proposed intervention work? Summary: A main objective of our study was to determinate if midwife’s advice on how to enhance the use of the Internet could have an effect in parental self- efficacy. Among 48 persons that received the advice, 19 (39.6%) said that they had used it and found it useful and 21 persons (43.8%) said that they would use it in the future. As it was expected more people visited “Medline Plus” and “Nacer Sano.org” among those who received advices. (17.8% and 36.8% vs. 5.8% and 12.9%, respectively) (Chi squared test, p=0.007). However no other hypothesis was confirmed. There was no statistically significant difference in frequency of use the Internet, perceived usefulness of the Internet as an information source, amount of sites visited, and feelings related to browse the web, when comparing intervention and control groups. 30
  • 31. We asked whether women and men who received advice on how to find information on theInternet from their midwife would, firstly, follow this advice, and furthermore, give higherimportance to the Internet at a source of health information.Primary hypotheses stated that the intervention group would differ with respect to thecontrol group on four outcome variables (e.g., preference of the Internet as a healthinformation source, value that give to the Internet as an information source, amount of sitesvisited, feelings related to browse the web).a. Preferences of using the InternetFrequency of using the Internet remained unchanged between those who received adviceand those who did not. Only the 54.4% of participants from the intervention group browsedthe Internet the previous week of the survey, while the 60.4% of the control group did so.Difference was no statistically significant (Chi square test, p=0.41).There was no statistically significant difference in the frequency of search any of the fifteenproposed topics between persons in the intervention and control group.Although choosing the Internet among the top three sources of information duringpregnancy seems more frequent among the intervention group (58.8%) in comparison withthe control group (46.8%), this difference was no statistically significant (Chi square test,p=0.10).The number of people that actually used the advice was as followed: Among 48 persons thatreceived it, 19 (39.6%) said that they had used it and found it useful and 21 persons (43.8%)said that they would use it in the future. One person (2.1%) said that she did not find ituseful, 3 persons though that they would not use it, and 4 persons (8.3%) said that they didnot use it because they had already known the proposed websites. 31
  • 32. b. Perceived usefulness of the InternetThe value that expectant parents give to the Internet as an information source did not showsignificant difference between groups. Among participants that did not receive an advice themean score was 6.02, while among participants that received advice it was 5.91(independent samples t-test, p=0.71).c. Visit to the recommended websitesResults suggest that participants of intervention groups have followed the advice given bymidwifes. Statistically significant differences were found in the prevalence of visiting thetwo recommended websites.In the control group, only 5.8% had visited “Medline Plus”, while among the interventiongroup this percentage was 17.5%. (Chi squared test, p=0.007). The OR was 3.5 (Intervalconfidence (IC) of 95%: 1.36 – 9.05)Visits to “Nacer Sano.org” were also much frequent in the intervention group (36.8%) than inthe control group (12.9%). (Chi squared test, p<0.001). The OR was 3.9 (IC 95%: 1.94 – 7.86)The intervention groups had also significantly more visits to “El Embarazo.net”  (48.5% vs.25.2%, p=0.001, OR 2.80 IC 95% (1.52 – 5.16) and “Ser Padres” (51.5% vs. 36.7%, p=0.043,OR 1.83 IC 95% (1.02 – 3.29)The percentage of people that confirmed following midwife’s advice in the moment oflooking for some website into the Internet was higher in the intervention group (36.8%) thanin the control group (17.3%). This difference was statistically significant. (Chi squared test,p=0.002). OR 2.79 (IC 95% 1.44 – 5.40) 32
  • 33. d. Feelings related to browse the webMost negative and positive feelings related to browsing the Internet were similar in bothgroups. No statistically significant differences were found. Nevertheless, more people in theintervention group said that had felt slightly anxious because of something they had read onthe Internet (57.4%) comparing with the control group (43.9%). (Chi squared test, p=0.069).OR 1.72 (IC 95% 0.96 – 3.09)e. Factors associated with visiting the proposed websitesThe two websites that were used in the intervention (Medline Plus and Nacer Sano.org) hadbeen selected based on consensus criteria of quality in internet sites (33) (22). When thepresent study was designed we assumed that users of these websites would have higherparental self-efficacy. But this assumption was not tested anywhere.As an additional outcome of our study, we assessed whether using those websites really isassociated with enhanced parental self-efficacy. The sample used for this specific analysisincluded all cases that completed the scores (n=195), without taking into account whetherthey have received advice or not. Among them, 19 participants had visited Medline and 42,Nacer Sano.Visiting Medline was related with feeling confidence and satisfaction when browsing theweb. High confidence was more common among Medline’s users (85.0%) than non-users(57.8%) (Chi squared test, p=0.018; OR 4.10; IC 95% 1.17 – 14.63). Highly satisfied was 75.0%among Medline’s users and 48.1% among non-users. (Chi squared test, p=0.022; OR 3.23; IC95% 1.13 – 9.26).Using “Medline” or “Nacer Sano.org” was not associated neither with perceived usefulnessof the Internet as an information source nor with self-efficacy. For the variable that wasnormally distributed in both groups, we used the T-test to compare means, for the one thatwas not, we used the Mann-Whitney test, and no results were statistically significant. 33
  • 34. Visiting “Nacer Sano.org” was related with several positive feelings when browsing the web,like feeling confidence (85.0% among visitors and 67.1% among non visitors; Chi squaredtest, p=0.033; OR 2.53; IC 95% 1.05 – 6.04); feeling satisfaction (83.7% among visitors and54.3% among non visitors; Chi squared test, p<0.001; OR 4.33; IC 95% 1.82 – 10.30); andwillingness to share the information (88.4% among visitors and 67.1% among non visitors;Chi squared test, p=0.006; OR 3.73; IC 95% 1.39 – 10.02).However, the use of the Internet was also connected with some negative feelings. While23.2% of people that did not visit Nacer Sano reported felling at least slightly frustratedwhen browsing the Internet, this percentage was 37.2% among Nacer Sano’s visitors. Thedifference was almost significant (Chi squared test, p=0.06; OR 1.97; IC 95% 0.96 – 4.02).There were significant differences between groups when comparing feeling of confusion(55.8% among visitors and 36.6% among non visitors; Chi squared test, p=0.02; OR 2.19; IC95% 1.11 – 4.32) and feeling of fear because of something they had read (67.4% amongvisitors and 43.3% among non visitors; Chi squared test, p=0.005; OR 2.71; IC 95% 1.34 –5.51).5.3.5. OUTCOME 5: Relationship between the Internet and parentalself-efficacy Summary: The second main objective of our study was to determinate if the perceived usefulness of the Internet as an information source is related to parental self-efficacy in infant care. We confirmed our hypothesis that the higher the value given to the Internet the higher would be self-efficacy in infant care score. In the general sample the correlation remained weak (Spearman’s coefficient 0.158, p=0.028), but it increased in those people that received advice and followed it, i.e. intervention group (Spearman’s Correlation Coefficient= 0.62, p=0.024). 34
  • 35. Figure 4. Correlation between self-efficacy and value given to the internet. Total sample n=194.Our hypothesis was that the higher the valuegiven to the Internet the higher would be self-efficacy in infant care score. This idea wouldseem confirmed in the total sample (n=194),however the strength of the relationshipremained low. (Spearman’s coefficient 0.158,p=0.028). For analysing these variable we useda non-parametric test because one of them didnot have a normal distribution. See figure 4. Figure 5. Correlation between self-efficacy andWe selected the Medline’s web site as one of value given to the internet. Medline’s users n=19.the recommended sites for future parents. Wewould expect that among Medline’s users thecorrelation between self-efficacy and perceivedusefulness of the Internet would be mostevident. That was correct. Among Medline’susers (n= 19), the intensity of correlation wassharper. (Spearman’s coefficient 0.515,p=0.024). See figure 5.Finally, we found that the relationship between Figure 6. Correlation between self-efficacy andthe two variables remained statistically value given to the internet. Medline’s users insignificant and with a higher value of correlation intervention group n=12.if we considerer just the group of Medline’s usersthat received advice from their midwife(intervention group). (Spearman’s CorrelationCoefficient= 0.62, p=0.024). See figure 6 . 35
  • 36. 5.3.6. OUTCOME 6: Factor associated with parental self-efficacy ininfant care Summary: The final objective of our study was to identify other factors that were related with parental self-efficacy in infant care. We found that, controlling for all other variables, parity was the factor most strongly related to parental self- efficacy. People who had children scored 21.4 points higher than the general mean in self-efficacy scale. When controlling for others variables, also being in the last weeks of pregnancy and living in the city were associated with higher scores of self-efficacy. We found that being older than 30 years was statistically significant associated with perception of lower parental self-efficacy. Furthermore, persons who attended university studies were more likely to have lower perceived self-efficacy in infant care, when all other factors remained under control. Our data seem to show that woman scored slightly higher in self-efficacy scale than men. Nevertheless these differences in education level and gender were no statistically significant. In addition, we found that people who do not use the Internet would be likely to score 8.22 points higher in self-efficacy scale than people who do use it. The inclusion into the regression model of the two variables that we consider outcomes of our study (use of Medline and the perceived usefulness of internet) resulted in small, but statistically significant increase in the variability explained by our model. Nevertheless the explained variability remained quite low, with an adjusted R square of 0.29.The final objective of our study was to identify other factors that were related to parentalself-efficacy in infant care. For this objective, firstly, we analyzed each potential factorindependently. Then, we included those that were statistically significant into a linearregression model, where parental self-efficacy in infant care was the dependent variable.To analyze each factor independently, we transformed the parental self-efficacy scale andother variables in dichotomous variables using the median as split point, so we were able toanalyze data with chi squared test. The total sample, 169 women and 34 men, were includedin this part of analysis. 36
  • 37. Enhanced parental self-efficacy was clearly related to parity. 92.6% of women who hadpreviously given birth had high parental self-efficacy comparing with 41.0% of primiparouswomen (p<0.001). See figure 7. Figure 7. Factors associated with parental self-efficacy in infant care.Non-well educated participants would seem to rate higher self-efficacy scores than thosewith tertiary studies (69.2% vs. 43.6%, p= 0.079).Moreover, age was inversely related. In the group of higher self-efficacy the mean age was29.6 years, while among those with lower self-efficacy the mean age was 31.6 years.(Independent samples t-test, p=0.02).Other factors with statistically significant differences associated with parental self-efficacywere good economic situation (65.5% vs. 45.2%; p=0.043), confidence in midwife’s work(58.9% vs. 38.6%, p=0.004) and family’s support (63.6% vs. 44.1%, p=0.022).No statistically significant differences were found in groups of different sex, number ofassisted antenatal classes, frequency and ability of use the Internet as an information source 37
  • 38. and features of antenatal classes (teachers experience, total hours of classes, incluyingphysical exercise in teaching programme or use of audiovisual support).a. Multivariate analysisBefore conducting the linear regression analysis we checked that all statistically assumptionswere met. Then we built a regression model with all factors that were statisticallysignificantly associated with parental self-efficacy in infant care (Table 5).Controlling for all other variable, parity was the factor most strongly related to parental self-efficacy. People who had children scored 21.4 points higher than the general mean in self-efficacy scale. When controlling for others variables, also being in the last weeks ofpregnancy and living in the city were associated with higher scores of self-efficacy. 38
  • 39. People who attended university studies were statistically significant more likely to havelower perceived self-efficacy in infant care, when all other factors remained under control.Furthermore, being older than 30 years was also associated with perception of lowerparental self-efficacy.Our data seem to show that woman scored slightly higher in self-efficacy scale than men.Nevertheless this difference was no statistically significant.In addition, we found that people who do not use the Internet would be likely to score 8.2points higher in self-efficacy scale than people who do use it. This result was no statisticallysignificant as well.The introduction into the regression model of the two variables that we consider outcomesof our study (use of Medline and the perceived value of internet) gave small, statisticallysignificant increase in the variability explained by our model. Nevertheless the explainedvariability remained quite low, with an adjusted R square of 0.29 (Table 6). 39
  • 40. 6. DISCUSSIONThe presented study yielded useful insights. We found a positive relationship betweeninternet use and parental self-efficacy that seem to confirm our initial hypothesis: the higherthe value given to the Internet the higher would be self-efficacy in infant care score. Otherresearcher has also found that internet use has a positive influence on self-conceptdimensions34.Furthermore, the study provides a comprehensive overview of the use of the Internet as asource of information during pregnancy for a specific group of pregnant women and theirpartners. The 97% of our sample have ever sought information on pregnancy, and 3 out of 5did that during the last week. This percentages were fairly higher than those obtained fromsurveys about internet seeking behaviour among the general population. It has beenestimated the percentage of the population that has used the Internet for health purposesincreased from 42.3% in 2005 to 52.2% in 200735. Other studies in developed countriesfound similar rate of use, higher than 50% 36-41. Only one study, in Atlanta, found prevalenceof internet medical information seeking lower than 20% in general population42.The high frequency of using the Internet for retrieved health information in our sample arein correspondence with similar studies among pregnant women1,5. Data indicate thatcouples expecting a baby are often choosing the Internet for addressing their doubts,independently their gender, age or educational level43.In order to appraise the validity of the results and determinate to whom the study may begeneralized is necessary take a look into the sample population. We addressing women andmen who attend maternal education classes in health centers of Andalusia Health Service inGranada, Spain. Appropriately, everyone who attended classes within a certain period wasapproached and a high consent rate of 92% for women and 81% for men was obtained.However, it is clear that time constraint constituted a drawback in our study. The gatheringof data was limited to four months (June to September 2009), which, in addition, coincidedwith the summer holiday period. This resulted in having groups with less numbers ofparticipants than it was expected. 40
  • 41. We are aware that the external validity of our study is relatively low, taking into account thatthis specific group even do not represent the parents expecting a child in the city ofGranada. Just the 46% of pregnant woman attend this kind of classes17. To assess howrepresentative the participants were for a group of childbearing women and men in general,we made comparisons with the total population of women in reproductive age in Andalucía2.The education level of the sample was higher than the tertiary enrollment rate registered inSpain. If we consider only women over 29 years old (n=104), the rate of women with collegeeducation in our sample was 71%. This is almost twice as high as the national rate of tertiaryeducation registered. In Spain, according to the National Institute of Statistics (2007), level oftraining for higher education in the group of women aged 30 to 44 years reaches barely38%2. Women with the lowest level of education probably are less inclined to participate inantenatal group education, but no research was found that analyze the demographiccomposition of participants. Further research should be done to evaluate if resources andeffort are putting only in preparing for motherhood some specific, well educated groups ofwomen, leaving aside those who would most need it.Altogether, we consider our sample representative for those women and men normallyreached by antenatal education in Granada.6.1. Differences in antenatal education programmesThe study allows the readers to become aware of the broad range of variability betweendifferent antenatal education providers in the city of Granada, and presents thedemographic characteristics of women and men that attend this kind of classes. Althoughantenatal education programmes have been established in routine health care since the ’90,to our knowledge this is the first work that collected and analyzed data about its differentcontents and methods in the Andalusian region. In fact, worldwide, only a few studies haveassessed antenatal programmes’ effectiveness, and no consistent effect on main childbirthand parenting outcomes was found44. Despite large divergences in methodology andtheoretical models, only tendencies towards better parental knowledge, confidence, andcompetence were observed in small studies 45. The effects of general antenatal education forchildbirth or parenthood, or both, remain largely unknown45-48. We did not find any 41
  • 42. differences in self-efficacy scores, neither regarding programmes characteristics of theclasses nor instructor’s features.6.2. An original ideaTogether with its strengths, the design of our study faces limitations that should beacknowledged, and taken into account for an appropriate interpretation of results. We willrefer to them below.Basically, the first problem resulted from the difficulty to precisely define and measure ourfactors of interest. Decision on how to assess the quality of internet skills among participantsand what instrument would be used to appraise parental self-efficacy in infant care wouldbecome the key issue.There was no tool for measuring parental self-efficacy translated into Spanish and validatedfor this population, therefore, after the literature review we decided to adapt one,specifically for our study, based on the Social Cognitive Theory 12,14,49 and review of theliterature15,16,23. Albert Bandura, father of this theory, stated that "self-efficacy scales shouldmeasure peoples beliefs in their abilities to fulfil different levels of task demands within thepsychological domain selected for study " 49(p.44).Aware of the methodological requirements that involve producing a new instrument, severalmeans for increasing validity and reliability of the scale were included in the methodology: apilot study was carried out and statistical analysis suggested for this kind of tool wasperformed50.Results obtained from factorial components analysis and the fairly high Cronbach’s Alpha(0.95%) suggested a sufficiently strong base for accepting the use of the presented scalewithin the study. What is more, the developed instrument might be proposed for beingfurther tested and use to measure parental self-efficacy within the Spanish speakerspopulation in further research.It should be noted that our principal hypothesis involves an original idea, not previouslyaddressed in the literature. We were not interested neither in evaluating the use of anyspecific website51-54 nor in delivering any intervention via the Internet55-57, but to determine 42
  • 43. if the process of gathering information online itself could, independently of the real qualityof this information, be connected with the self-efficacy.This hypothesis had fundamentally most theoretical than empirical-proved base, and wasgrounded in the realm of inquiry of the Social Cognitive Theory. This theory, in general,addresses the construction of thought and its functional use and, in particular, centers onhow sociostructural influences operate through psychological mechanisms to producebehavioral effects14.No other study had addressed this specific question before. That represents a motivation,but has its disadvantages, especially regarding the difficulty to define “use of the Internet”,our independent variable.As already mentioned, we were not directly interested neither in a quantitative value(frequency of use the Internet)58 nor in visits to any specific websites, but in the personalsatisfaction of the participants with their ability to find what they were looking for on theInternet. Although all others variables related to frequency were included in thequestionnaire, it was decided to use the following direct, subjective question as theindependent variable: “On a scale of 1 to 10, describe how helpful in solving your doubtsrelated to pregnancy, childbirth and infant care, the information you read on the Internetis”. According to our theoretical background we found that this personal appreciation of theutility of the Internet may work as an enhancer for the self-efficacy59.Through a theoretical analysis it is possible to establish that the use of the Internet, as aparticular means of gathering information in a proactive way, is related with the fourprincipal sources of self-efficacy beliefs49(p.81-114): 1) Enactive mastery experiences the mostimportant factor deciding a persons self-efficacy; 2) Vicarious experiences:“If they can do it,I can do it as well”; 3) Verbal persuasions and allied types of social influences; 4)Physiological and affective states.Peoples shared belief in their collective power to produce desired results is a key ingredientof collective capability to change their environment 14. The Internet is a pool of socialknowledge. So, if people feel themselves competent in finding the type of information theyare looking for, it should enhance their confidence in developing specific tasks. Different 43
  • 44. than their habitual role of passive receptor of information, through internet searches theybecome active actors in enhancing their own knowledge. If they are being capable to identifywhat information they are lacking for performing a task, they might be capable to develop itafter learning how to do it. The popularity of videos and social network maximize the“vicarious learning” –important component of the self-efficacy- even more.6.3. Pros and cons of our interventionOur study included an intervention and the measurement of its effect. The assessment ofpros and cons of the intervention itself require an independently analysis. For encouragingparticipants to use the Internet, the midwifes in charge of classes were provided of afactsheet especially elaborated for this study (Appendix 3). It was reviewed bycommunicational and research professionals and approved by midwifes involved in maternaleducation, but was not tested on validity in the target audience 29.We were aware that the use of brochure within the health services generates divergentopinions, ranging from those that hold it does not serve any real purpose and clients seldomlooked through it at home60, to those who reported that the combination of verbal andwritten patient education enhances levels of knowledge, understanding, satisfaction,compliance and retention of information in clients, and decreases stress and anxiety 61.As an attempt to learn about the reception of the material among participants, a subjectivequestion about the usefulness of the leaflet was included into the questionnaire for thosewho had received it. We found out that almost 40% of those who had been given theinformation had, in fact, used it. Another 44% said that they would use it in the future.Participants in the intervention group were surveyed, only once, one to two weeks afterreceiving the advice. A follow-up study would be required to confirm the real impact of theintervention.An advantage of the design was that midwifes themselves were responsible for deliveringthe advice on searching the online information, because it has been described as a means ofenhancing patient-practitioner relationships62. After several personal meetings with eachprofessional, the way to provide the intervention was agreed upon. In each case it took onlyfive minutes at the end of one of the classes and consisted of giving the fact sheet to the 44
  • 45. attendants, informing that it was designed under the framework of an university study andsuggesting using it. Other study had found that women who were advised to read aparticular brochure (procedures in the midwifery practice) followed this advice60. It has beenreported that patients are open to accessing information prescribed by their physicians andwere much more likely to trust it63.This fact might support the practical application of our intervention, taking intoconsideration that the staff became familiar with the material and considered the possibilityto incorporate it in their program afterward64,65.However, it is necessary to highlight that our study, although cautiously designed andexecuted, faced problems that commonly appear in development and evaluation of similartype of interventions66,67. It have been proposed that “investigators often move too rapidlyfrom an idea for an intervention to a proposal for an efficacy trial. Often lacking is sufficientpreliminary work to develop and refine the intervention, to test it for preliminary evidenceof feasibility and efficacy, and to develop the proper estimates to size the efficacy trial” 67.Before attempting to test any original idea, it would have been necessary to assesintervention feasibility and acceptability, to test the new intervention in a small group-randomized trial powered to detect differences on intermediate outcomes or mediators, andspecially for obtaining the parameter estimates necessary to properly size the efficacy trial67.We tried to concentrate all these complex phases in an unique trial and supplemented thelack of previous empirical trials by using a strong theoretical model. The fact that our effectsize was supposed to be low (5%) a much larger sample would have required. In general, ourpower to explain variation remained fairly low of barely 12%24,25.The continuous learning is a fundamental part of intellectual training, and the complexity ofthis work allowed me to experience the whole process of an academic research, includingthe developing and application of a questionnaire, the validation of an scale and thedeveloping and the conduction of an intervention. If I had to deal with a similar work in thefuture, I would tackle it differently. I would split objectives into more modest ones, and I 45
  • 46. would be assured to have more clearly defined units of analysis. However I do not regret theway this work have been developed, because it has been a wealthy source of learning.6.4.Methodological issuesWe have analysed data of individuals in spite of the fact that intervention was given togroups of individuals. This increases the risk of cluster effects, i.e., that certain commonattitudes are adapted within a group or that some individuals affect the group climate andthe participants68. Nonetheless to adjust for cluster effects in the analyses was considerednot necessary, because the fact of low power of statistical analysis due to relatively smallsample size.6.5. Practical implications of the workWorldwide, midwifes are aware of the increased use of the Internet among pregnantwomen and most of then considered the need to keep up-to-date with the latestknowledge69.Developing and providing midwife of materials and training oriented to internet search canenhance their own internet competence70 and improve the patient-health professionalrelationship71. Internet prescription, that is guiding patients to reliable health informationwebsites, is becoming a new challenge72. Antenatal education is a invaluable setting fordeveloping health literacy, that nowadays includes knowing where to go for furtherinformation, and the ability to analyse information critically 73.7. CONCLUSIONThe Internet is a widespread source of information among participants of maternaleducation classes in Granada, in both men and women. More than 95% have ever used it forretrieving information during their pregnancy. One out of five women and one out of fourmen preferred the internet as their first source of information. The great majority access to 46
  • 47. it at home and the frequency of use was slightly higher in people with secondary and tertiarydegree, than in those with primary education level.As part of this study, a tool for measuring parental self-efficacy in infant care within theSpanish speaker population was developed. Its reliability and validity suggested a sufficientlystrong base for accepting its use within the study, and might be proposed for being tested infurther researches.Great differences in years of professional practice and ability in the use of the Internetbetween midwifes in charge of the maternal education classes in Granada, Spain, have beenfound. There was no consensus on techniques, exercises or use of audiovisual support inclass, neither in the duration of the programme. Nonetheless, no effects of these differenceshave been detected in the rate of parental self-efficacy in infant care.Perceived parental self-efficacy in infant care was significantly and positively related withprevious deliveries and advanced pregnancy. Otherwise, older mothers scored statisticallysignificant lower than younger mothers.We found a positively relationship between perceived usefulness of the internet andparental self-efficacy. The strength of the relationship was increased in those people thatreceived from their midwife the written advice designed for this study, and followed it.Almost 40% said that they had used the factsheet given by the midwife and found it usefuland other 44% said that they would use it in the future. More people visited the suggestedwebsites among those who received the guidance. These facts seem to show thatattendants to maternal education classes are open to accessing information about internetresources suggested by their midwifes and this opportunity should be exploited forenhancing the usefulness of their internet searches. 47
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  • 53. Appendix 1: Five-pages Questionnaire, translated into English 53
  • 54. 54
  • 55. 55
  • 56. 56
  • 57. 57
  • 58. Appendix 2: Template for characterization of maternaleducation classes 58
  • 59. 59
  • 60. Appendix 3: Fact sheet used as intervention 60
  • 61. Appendix 4: Ethical approval from the Health District ofGranada 61
  • 62. Appendix 5: Form of informed consent and information forcontact (In Spanish as original) 62