Jagiellonian University Medical College

Faculty of Health Sciences

Institute of Public Health

Patricia Lima Pereira

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

1st year Supervisor: Clara Bermúdez Tamayo

2nd year Supervisor: Grazyna Jasienska

Kraków, 2010

2

Acknowledgements

I would like to thank the midwives of the district of Granada for their enthusiastic and

professional collaboration and the expecting parents for their generous participation in this

study. Also I want to thank my supervisors Clara Bermúdez and Grazyna Jasienska for their

patient and dedicated support, José Miguel Morales, Alberto Fernández Ajuria and Maciej

Górkiewicz 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 my

anxieties, and particularly Rodrigo, Abril and Helena for accompanying me in this unexpected

adventure.

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Content

Acknowledgements ...............................................................................................................2

1. ABSTRACT ..........................................................................................................................5

2. THEORETICAL FRAMEWORK...............................................................................................7

Using the Internet as a health information source ..............................................................7

Building parental self-efficacy .............................................................................................8

Maternal education in Spain ...............................................................................................9

3. 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 ..................................................................16

4. ETHICAL CONSIDERATIONS ..............................................................................................18

5. 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

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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 .................................................................................................46

7. CONCLUSION ....................................................................................................................46

BIBLIOGRAPHY .....................................................................................................................48

Appendix 1: Five-pages Questionnaire, translated into English ............................................53

Appendix 2: Template for characterization of maternal education classes ...........................58

Appendix 3: Fact sheet used as intervention ........................................................................60

Appendix 4: Ethical approval from the Health District of Granada ........................................61

Appendix 5: Form of informed consent and information for contact (In Spanish as original) 62

5

Using the Internet for enhancing parental self-efficacy in

infant care. A quasi-experimental study among attendees of

maternal education in district of Granada, Spain

1. ABSTRACT

INTRODUCTION: The Internet is an important source of health information, especially

among women and men in reproductive ages. The Internet could constitute an optimal

environment for developing strategies aimed at health literacy in the area of maternal

education. The aim of this study was to analyze whether midwife’s advice on how to find

information on the Internet could enhance parental self-efficacy in infant care.

OBJECTIVES: Main objectives were: a) To determinate if the perceived usefulness of the

Internet as an information source is related to parental self-efficacy in infant care; and b)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. Secondary objectives were: a) To describe the

use of the Internet as a health information source among participants of maternal education

class in Granada (Spain); b)To calculate the validity of the scale used to determinate parental

self-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 may

confound relationships between Internet use and parental self-efficacy.

METHODS: A quasi-experimental study on group level was carried out for evaluate the effect

of midwife’s advice on searching health information in the Internet. The study population

consisted of women and men who attend maternal education classes in health centers of

Andalusia Health Service in Granada, Spain. The intervention consisted a verbal advice and a

fact sheet designed specifically for this study. Descriptive statistical analysis was conducted

for 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 to

verify the association between studied variables.

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RESULTS: A total of 169 women and 38 men took part of the study. The average age of

participants 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-

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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 of

maternal education classes in Granada, in both men and women. We found a positively

relationship between perceived usefulness of the internet and parental self-efficacy. The

strength of the relationship was increased in those people that received from their midwife

the written advice designed for this study, and followed it. Perceived parental self-efficacy in

infant care was also significantly and positively related with previous deliveries and

advanced pregnancy. Otherwise, older mothers scored statistically significant lower than

younger mothers. Attendants to maternal education classes are open to accessing

information about internet resources suggested by their midwifes and this opportunity

should be exploited for enhancing the usefulness of their internet searches.

2. THEORETICAL FRAMEWORK

Using the Internet as a health information source

The Internet is an important source of health information, especially among women and

men in reproductive ages1-3. Several authors have suggested that motivation of patients to

seek information, managing this information and risks, as well as exchange of information in

the consultation may enhance their empowerment4, increase their health literacy5, and

improve shared clinical decision-making1,6-9. However, most interventions have been

8

implemented to chronic, elderly patients, and therefore less accustomed to using the

Internet10,11.

On the web there are many sites geared to pregnancy, childbirth and motherhood, but many

users are not qualified to assess their quality and reliability6.

Most people seeking health information online did not talk with a health professional about

the information they found during their most recent search, but most would have

appreciated it if their caregiver had suggested relevant web sites. One study showed that, if

patients were ‘prescribed’ how and where to find relevant information about their health

conditions, the patients would adhere to this ‘prescription’7. In a Swedish study with

pregnant women, over half (55%) of participants said that the midwife if they suggested a

site, they would visit it1.

Patients experiment difficulty in interpreting information on the Internet. Therefore, most

appreciate the support of healthcare practitioners in the interpretation and

contextualization of information. The talk about the search on the Internet, with the

recommendation 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 resource

for health and medical information and should be prepared to assist patients in evaluating

quality of information available on the Internet 8.

Building parental self-efficacy

According to social learning theory, self-efficacy is a measure of the confidence an individual

has in their ability to meet the demands and responsibilities of a task within a specific

context12. Perceived parenting self-efficacy is defined as the belief about one`s ability to be

successful in the parenting role. Perceived parenting self-efficacy has found to be related to

positive child outcomes 13.

Four main antecedents to self-efficacy have been articulated, including: (a) prior experience

at the task, (b) experiencing low levels of arousal or stress when engaged in the task, (c) the

opportunity to observe others perform the task, and (d) receiving positive feedback from

others14. In the context of perceived parental self-efficacy , the social support aspects of this

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theory (c and d) may be particularly relevant in affecting parents’ perceptions of their

parenting ability. The accumulated body of research suggests that perceived self-efficacy is a

protective factor and a powerful predictor of competence in caring for children and

subsequent success in health 15.

Various researchers have developed a theoretical framework and tools developed to

measure self-efficacy15,16, but no one has been validated in Spanish.

Maternal education in Spain

In Spain, the antenatal control process is responsible for midwives17. The underlying

philosophy in the care provided by midwives is to develop the birth process is naturally

accompanied by a known and trusted professional. Emphasis is placed on the confidence in

the natural ability of women to experience childbirth with as little intervention as possible. A

systematic review of 2008 suggests that this type of care increases confidence of women

during pregnancy and childbirth18.

Maternal education could constitute an optimal environment for developing strategies

aimed at health literacy1,19-21.

Maternal health literacy is defined as social and cognitive tools that determine the

motivation and the ability of pregnant women to access, understand and use information in

a 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 of

the Internet should have been cleverly engaging for reinforce content covered in childbirth

education classes. They say educators should encourage women to use the Internet, offer

during 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 find

information on the Internet could enhance parental self-efficacy in infant care.

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3. METHODS

3.1 Study population

Women and men who attend maternal education classes in health centers of Andalusia

Health Service in Granada, Spain.

3.2. The intervention: Advice on searching information online

In six of the surveyed groups (55 women and 13 men), participants had received from their

midwife in the preceding classes tips on searching the online information (verbal advice +

factsheet).

The factsheet was developed by a communicational professional based on a quality

assessment for web sites developed by the “Internet and Health Research Group” of

Andalusian Public Health School22. It was reviewed by four midwifes involved in maternal

education. See it in the appendix 3.

Midwifes of the intervention-groups were responsible to deliver the advice on searching the

online information. It took only five minutes at the end of the meeting and consisted of

giving the factsheet to the attendants and suggesting using it.

Participants in the intervention group were surveyed one to two weeks after receiving the

advice.

3.3 The study objectives

MAIN 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.

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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-

efficacy

3.4. The study outcomes and variables

For this study the primary outcome measured, i.e. the dependent variable, was the

perceived 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-type

scale instrument.

The secondary outcome, and independent variable, was the value that future parents give

to the Internet as an information source. It was measured using the followed self-reported

question: “On a scale of 1 (minimum) to 10 (maximum), describe how helpful in solving your

doubts related to pregnancy, childbirth and infant care, the information you read on the

Internet is.”

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To describe the use of the Internet as a health information source among participants of

maternal 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, the

following 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 selected

based 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 questionnaire

Data were collected anonymously using a questionnaire. The questionnaire was created by

the author of this thesis and reviewed by staff of the Andalusian Public Health School and

first year supervisor. Questions addressed a variety of topics related to patient use of the

Internet for gathering health information. The survey also included a nine-question scale for

13

measure of perceived parental self-efficacy and “Background Information” items intended to

gather demographic data.

A pilot testing of the questionnaire was conducted from 26 to 28 May 2009 in 3 health

centers involving 32 participants (30 females and 2 males). Legibility of the questions,

frequency of endorsement, and time required to fill the questionnaire were assessed. Based

on analysis of results some items were modified i.

3.6. Sample size and sampling

The design of our study required a relatively large sample. As it is known, of all the

parameters that have to be specified before attempting to determine the sample size, the

effect size is the most critical24. The expected effect size of our intervention –midwife’s

advice on how to improve internet search- was quite small25. The estimated outcome used

for calculate sample size in our study was the difference in the mean of parental self-efficacy

scores between groups that do receive advice and those that do not. We were expecting

that 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 significance

level 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, the

allocation ratio was 10:1. To maintain the power of 80% it would had been necessary to

multiply the sample by 5. With these considerations, the ideal study should have a sample of

1970 participants in control group (those who do not use Medline) and 197 participants

i The parental self-efficacy scale was modified. The sensibility of 5-value scale seemed insufficient, thus it was replaced

with a 10-value scale. In addition, the option “other information sources” in question number 1 was excluded. A question on “perceived ability to use the internet” was included. The topic “Vaccines” was included within sought items. (It is necessary to mention that a mistake in the design of the questionnaire was noticed at the time of loading data: the check square was missing, thus most of the participants haven’t filled in this option). In the question related to feelings that people experienced while browsing the internet questions were separated in two groups: Four questions inquired about positive feelings and the other four about negative feelings. In question: “Would you like to receive instruction on internet sources from your midwife?”, number of answers offered were reduced from five to three: No / Maybe / Yes

14

users of Medline. Therefore, it should be noted that our study that consisted a sample of

190 participants who do not use Medline and 19 participants who use it, had the power of

12%.

3.7. Participants

A total of 169 women and 38 men took part of the study. For presenting flow of groups and

individual participants through each stage the revised CONSORT statement was used,

including the extensions for clusters analysis and non-pharmacologic interventions26-28. The

flow chart can be seen in figures 1 and 2.

3.8. Implementation of the intervention

The 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 health

information on the Internet29,30. The interventions were carried on by midwifes, without the

presence of researchers. A total of 73 participants took part in the intervention.

The fact sheet was designed by a communicational professional based on a quality

assessment for web sites developed by the Andalusian Public Health School22. It was

reviewed 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 searching

the online information. It took five minutes at the end of the meeting and consisted of giving

the factsheet to the attendants and suggesting using it.

Participants in the intervention group were surveyed one to two weeks after receiving the

advice.

15

Groups assessed for eligibility during the period of the

study (16 groups of 7 health centres) A

lloca

tion

Allocated to control (according to assistance records):

10 groups, median groups size = 18, range 5 – 34

181 participants

Allocated to intervention (according to assistance records)

6 groups, median groups size = 16, range 6 - 26 93 participants

Attended a class the day of assessment

(10 groups, median groups size = 12, range 2 – 22)

117 participants

Attended a class the day of assessment

(6 groups, median groups size = 11, range 5 - 20)

70 participants

Inte

rven

tion

Responded to control questionnaire

(10 groups, median groups size = 11, range 2 – 18) 102 (87,2%) women responded to questionnaire 25 men responded to the questionnaire

Responded to intervention questionnaire

(6 groups, median groups size = 11, range 5 - 18) 66 (94,3%) women participants responded to questionnaire 13 men responded to the questionnaire

Ass

iste

nce

to t

he c

lass

the

day

of

asse

ssm

ent

Received intervention 6 groups, median groups size = 12, range 5 - 20 73 participants were presented the day of intervention

20 participants were not

presented the day of intervention

64 participants were not presented the day of submission questionnaire

2 participants who received intervention were not presented the day of submission

questionnaire

Res

pond

ence

rat

e of

que

stio

nnai

re 4 participants did not respond to

questionnaire for refused to participate

or not read in Spanish

15 participants did not respond to questionnaire for refused to participate

or not read in Spanish

Analysed

(10 groups, median groups size = 11, range 2 – 18) 102 (87,2%) women responded to questionnaire 25 men responded to the questionnaire

Analysed

(6 groups, median groups size = 11, range 5 - 18) 55 women and 13 men who received the intervention and responded to

questionnaire

Ana

lysi

s 12 women who did not received the intervention but responded to

questionnaire

Figure 1. Flow of groups and individual participants through each stage.

16

3.9. Data management and statistical analysis

First, distribution of all quantitative variables was examined with Shapiro-Wilk Test to

determinate if they were normally distributed, and Levene Test, to check the homogeneity

of variances. Factors that do not meet these criteria were analyzed using non parametric

tests.

We used χ2, t tests for independent samples to compare differences in demographic and

other 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 an

information source –independent variable- and parental self-efficacy in infant care-

dependent variable-) was determined using Spearman’s coefficient.

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 factsheet

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 the

control group on four outcome variables (e.g., preference of the Internet as a health

information 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 with

the perceived parental self-efficacy as the dependent variable. Other potential confounders

such as gender, age, education level, number of children, quality of relationship with the

partner 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 groups

were 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 Cronbach's alpha coefficient of the scale was calculated and a factorial analysis was

conducted.

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 health

centers were compared using χ2 and t tests for independent samples or the Mann-Whitney

test.

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Objective B.4: To identify factors that may confound relationships between internet

use and self-efficacy

Linear 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 health

center).

The data were analyzed using Statistical Package for the Social Sciences (SPSS) version 11.

4. ETHICAL CONSIDERATIONS

Considering Bill of 41 of November 2002 of Spain, which regulates the information and

clinical 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 the

guidelines quoted in the latest modification of the Declaration of Helsinki, World Medical

Association (Seoul, October 2008), which considers ethical principles for research involving

human subjects. Prior to any data being gathered, ethical approval from the Health District

of Granada was obtained. Additionally, all participants signed an informed consent form. See

appendix 4 and 5.

5. RESULTS

5.1. Dates of recruitment and follow-up

The survey was conducted in 16 separate groups in 7 centers of Granada city from 29th May

to 25th September 2009. The distribution was as following: Gran Capitán (3 groups, 49

samples, 23.7%), Gongora-Mirasierra (2 groups, 47 samples, 22.7%), Chana (3 groups, 38

samples, 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 months

period of the study.

19

The self-administered questionnaires were administrated at the beginning of the class. The

filling of the questionnaire lasted approximately 15-20 minutes. The total number of persons

attending the courses during days when this research was conducted was 229, including 187

women and 42 men. Four women were excluded for not being able to read in Spanish. Those

who 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 participated

in 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 questionnaire

were originally assigned to control group and did not receive the intervention. A total of 55

women 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 analyses

as part of control group.

5.1.1. Characterization of maternal education classes

Given the variability found among the courses offered by the different centers, we decided

to make a description of the different classes. It employed a template that was designed

based on the literature, and the answers of interviewed midwives responsible for each class.

Moreover, the method of observation was used. The complete questionnaire and template

are included in the appendix 1 and 2.

5.2. Baseline demographic and clinical characteristics of groups

Among those who completed the survey, 83.3% of respondents were women (N = 169) and

16.7% were men (N = 34). The average age of participants was 31.3 (sd 5.98), median age

was 32 years. For women, the mean age was 30.96 (sd 5.71) (minimum 15 and maximum

42). 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 30

weeks, and the median was 32 weeks.

20

With respect to the number of maternal education classes attended, 10.1% had not

attended any at the time of the survey (8.5% of women and 18.2% of men), 27.3% had

attended 1 or 2 classes, 49.5% had participated in 3 or 4 classes and 13.1% had attended 5 or

more classes.

86.6% were expecting their first child. Among those who already had children, 77.8% were

expecting 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 of

study equivalent to complete primary education or lower. 34.7% had achieved a complete

secondary education and 58.9% had college or graduate level. No significant difference was

noted between men and women.

Table 1 presents baseline comparisons between participants of usual antenatal program

and those that received the intervention.

21

5.3. Outcomes

5.3.1. 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 use

The Internet is a frequent source of

information among participants of maternal

education classes in Granada. We measured

frequency and ability of use among

participants that did not receive advice. The

94.5% reported using the Internet usually.

See it in table 2. It is widely used by both men

and women. No significant difference was

found among genders (Chi squared test,

p=0.56).

Among those internet users, 97.4% have ever

sought information on pregnancy. One out of

four participants (25%) did seek information Table 2. Frequency of use the internet as an

information source among future parents

22

in the last 24 hours before the survey. 62% of respondents had sought information in the

course of the week and 84.6% had done that in the last month. The use of the Internet was

common, regardless of education level, but was greater in the group with mid-level

education. 65.2% of the participants with secondary education, 58.9% with tertiary

education level and 50% with primary education level used the Internet for information on

pregnancy within the last week (Chi squared test , p = 0.04). 85.8% of the Internet users

self-assessed their ability to use the Internet as good or very good, the 12.5% as regular and

1.7% as bad.

b. Place and way of use

95% of internet users access it usually at home. Among the 5% that do not have access to

internet at home, 34.8% use it at work, 47.8% at the home of some relatives, and 34.8% in a

public place (library, university, internet café).

The most common way to starting browsing the Internet is using Google. 93.1% reported

used this way for searching information about pregnancy. Moreover, 25.4% of participants

of maternal classes visited websites that were recommended by the media, 18.5% went to

those 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 the

intervention), 48.3% said that they would like to receive guidance on how to find

information on the Internet, 41.2% replied that "perhaps" and 10.3% said that they were not

interested in receiving such guidance (8.5% of internet users and 42.9% of non-users).

c. Topics and websites of interest

The six topics related to pregnancy most frequently searched by both women and men

were: 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% more

than women), information about health care (38% more than women), care of women after

childbirth (37% more than women), relationship/ sexuality/ emotional support (12% more

than women), baby names and stages of childbirth. See in table 3.

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 statistically

significant.

Commercial websites are most frequently used by people looking for information on

pregnancy. In this study we presented to the participants a list of eight websites related to

pregnancy and asked them to report whether they have visited them. The four commercial

pages 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% and

17.1%, respectively.

Finally, the two websites developed by state’s or nonprofit organizations were visited only

by 14.6% and 6.5% of the participants, before the intervention was implemented. These

latest were the sites suggested to be visited.

24

d. First sources of information

Among 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 of

information. 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%) and

friends (26.6%)

Physician was selected most frequently as the first source of information: 54.8% of women

and 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 of

consultation on pregnancy topics. It is used by 18.5% of the women and 25.8% of men as a

primary source of information (increased to 41.7% for 12 men who received the advice

about 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 women

and 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 of

information. Not significant difference is noticed between persons that received advice and

those that do not.

Comparing groups, among those women that did not receive advice, 31% choose the

Internet 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 that

received 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 of

information, 34.2% of women and 31% of men as a second source 15.1% of women and

6.9% of men as third source 5.5% of women and 17.2% of men chose the family as the first

source of information, 15.8% of women and 13.8% of men chose as second, 24% of women

and 10.3% of men as third.

25

Magazines, books and brochures are used by 12.6% of women and 3.2% of men as first

source of information, by 17.9% of women and 22.6% of men as second source, and by

21.9% 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% of

women and 14.8% of men as third source.

e. Positive and negative feelings generated when browsing the Internet

Browsing the Internet generated some positive feelings among the users. 77.7% fully or

partially 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 share

information they have found.

Nevertheless, 9.8% did not feel satisfied with what they found into the Internet, 4.3% did not

feel confidence and 2.7% did not want to share their information.

The Internet search also produces some negative feelings. 56.5% agreed they feel somehow

overwhelmed with the amount of information, 29.1% feel frustrated for not finding what

they were looking for, 45.3% feel confused and 54.4% feel slightly frightened by information

received 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.

26

a. Scale generation, content validity and pilot study

Nine items were generated for measuring the perceived parental self-efficacy, based an

adaptation of the PMP S-E tool16, according to the Bandura’s self-efficacy theory. Items are

referred to activities and tasks related to the baby’s basic needs, which could be found on

the 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 this

scale indicates a low parental self-efficacy.

To assess the content validity of the scale, the items were presented to 2 specialists in

prenatal care, who were asked whether they thought each item related to infant care and

whether it was clear and easy to understand. All of the items were reported to fulfil these

criteria.

A pilot testing of the whole questionnaire of the present study, including the scale

containing 9 items (each one was firstly ranged from 1 to 5), was conducted from 26 to 28

May 2009 in 3 health centers involving 32 participants (30 females and 2 males). Legibility of

the questions, frequency of endorsement, and time required to fill the questionnaire were

assessed. According to analysis of results the parental self-efficacy scale was modified. The

sensibility of former 5-value scale seemed insufficient, thus it was replaced with a 10-value

scale. No further work was carried out with this sample of responders and a larger study was

initiated using the modified version of questionnaire and scale.

b. Reliability and validity testing of our scale

As part of this research, we have proposed to assess reliability and validity of the scale that

we have used. For this purpose we used the sample of non-intervention groups of 139

participants (114 females and 25 males), since we had expected to find some change with

the intervention. The characteristics of the study sample are summarized above.

Independent samples t-test indicated that female and male participants did not significantly

differ 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).

27

Thus the sample was not pooled, but analysed independently. Only the 114 cases of women

were included in analysis.

Five mothers did not complete the scale, leaving an overall total of 109 cases that were used

to test the construct validity and internal consistency reliability of the instrument. Neither a

second assess nor any comparison test was conducted, so it was not possible to measure

neither retest reliability nor divergent validity.

c. Data analyses for assessing the scale

Data were analysed using an independent samples t-test, Cronbach’s coefficient alpha and

factor analysis in SPSS version 11.

d. Degree of discrimination of the scale

Overall, there large variability was found in parental self-efficacy, with scores on the scale

ranging from the minimum possible of 9 to the maximum possible of 90.

Figure 3 shows the distribution of

scores. The overall study sample

mean self-efficacy score was 54.5

(s.d. 17.03), the median was 55 and

the mode was 45. The degree of

spread of the scores suggests that

the tool has a reasonable degree of

discrimination despite a slight

negative skew (skewness -0.15;

standard error of skewness 0.23).

Shapiro-Wilks Test confirmed a normal

distribution (P=0.09).

Figure 3. Frequency’s distribution of responses. N=197

28

e. Internal consistency reliability

Cronbach’s coefficient alpha was used to calculate internal consistency reliability estimates

for the scale; this reached 0.95, that is desirable for new instruments31. The tool

demonstrated 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).

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 Andalucía

for three decades and since 1990 the percentage of involved women have been considered

an indicator of quality in prenatal care. In 1993 more than 40% of pregnant women in

Andalucía attended this kind of classes17. In 2008, according to administrative data from the

Sanitary District of Granada, maternal education achieved 1350 women, that represents

46.5% of the 2903 pregnancies registered that year32.

Despite its dissemination, the programme of attention of the childbirth does not have

developed indicators for measuring quality and impact of the antenatal education. There is

no official guidance, and each midwife in charge of courses decides how to implement the

antenatal education. Content, methodology, duration of classes vary broadly between

different health centres. A resume of this diversity is summarized in table 3.

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.

31

We asked whether women and men who received advice on how to find information on the

Internet from their midwife would, firstly, follow this advice, and furthermore, give higher

importance to the Internet at a source of health information.

Primary hypotheses stated that the intervention group would differ with respect to the

control group on four outcome variables (e.g., preference of the Internet as a health

information source, value that give to the Internet as an information source, amount of sites

visited, feelings related to browse the web).

a. Preferences of using the Internet

Frequency of using the Internet remained unchanged between those who received advice

and those who did not. Only the 54.4% of participants from the intervention group browsed

the 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 fifteen

proposed topics between persons in the intervention and control group.

Although choosing the Internet among the top three sources of information during

pregnancy seems more frequent among the intervention group (58.8%) in comparison with

the 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 that

received 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 it

useful, 3 persons though that they would not use it, and 4 persons (8.3%) said that they did

not use it because they had already known the proposed websites.

32

b. Perceived usefulness of the Internet

The value that expectant parents give to the Internet as an information source did not show

significant difference between groups. Among participants that did not receive an advice the

mean 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 websites

Results suggest that participants of intervention groups have followed the advice given by

midwifes. Statistically significant differences were found in the prevalence of visiting the

two recommended websites.

In the control group, only 5.8% had visited “Medline Plus”, while among the intervention

group this percentage was 17.5%. (Chi squared test, p=0.007). The OR was 3.5 (Interval

confidence (IC) of 95%: 1.36 – 9.05)

Visits to “Nacer Sano.org” were also much frequent in the intervention group (36.8%) than in

the 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 of

looking for some website into the Internet was higher in the intervention group (36.8%) than

in 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)

33

d. Feelings related to browse the web

Most negative and positive feelings related to browsing the Internet were similar in both

groups. No statistically significant differences were found. Nevertheless, more people in the

intervention group said that had felt slightly anxious because of something they had read on

the 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 websites

The two websites that were used in the intervention (Medline Plus and Nacer Sano.org) had

been selected based on consensus criteria of quality in internet sites (33) (22). When the

present study was designed we assumed that users of these websites would have higher

parental self-efficacy. But this assumption was not tested anywhere.

As an additional outcome of our study, we assessed whether using those websites really is

associated with enhanced parental self-efficacy. The sample used for this specific analysis

included all cases that completed the scores (n=195), without taking into account whether

they 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 the

web. 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; IC

95% 1.13 – 9.26).

Using “Medline” or “Nacer Sano.org” was not associated neither with perceived usefulness

of the Internet as an information source nor with self-efficacy. For the variable that was

normally distributed in both groups, we used the T-test to compare means, for the one that

was not, we used the Mann-Whitney test, and no results were statistically significant.

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 squared

test, p=0.033; OR 2.53; IC 95% 1.05 – 6.04); feeling satisfaction (83.7% among visitors and

54.3% among non visitors; Chi squared test, p<0.001; OR 4.33; IC 95% 1.82 – 10.30); and

willingness 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. While

23.2% of people that did not visit Nacer Sano reported felling at least slightly frustrated

when browsing the Internet, this percentage was 37.2% among Nacer Sano’s visitors. The

difference 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; IC

95% 1.11 – 4.32) and feeling of fear because of something they had read (67.4% among

visitors 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 parental

self-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).

35

Our hypothesis was that the higher the value

given to the Internet the higher would be self-

efficacy in infant care score. This idea would

seem confirmed in the total sample (n=194),

however the strength of the relationship

remained low. (Spearman’s coefficient 0.158,

p=0.028). For analysing these variable we used

a non-parametric test because one of them did

not have a normal distribution. See figure 4.

We selected the Medline’s web site as one of

the recommended sites for future parents. We

would expect that among Medline’s users the

correlation between self-efficacy and perceived

usefulness of the Internet would be most

evident. That was correct. Among Medline’s

users (n= 19), the intensity of correlation was

sharper. (Spearman’s coefficient 0.515,

p=0.024). See figure 5.

Finally, we found that the relationship between

the two variables remained statistically

significant and with a higher value of correlation

if we considerer just the group of Medline’s users

that received advice from their midwife

(intervention group). (Spearman’s Correlation

Coefficient= 0.62, p=0.024). See figure 6 .

Figure 4. Correlation between self-efficacy and

value given to the internet. Total sample n=194.

Figure 5. Correlation between self-efficacy and

value given to the internet. Medline’s users n=19.

Figure 6. Correlation between self-efficacy and

value given to the internet. Medline’s users in

intervention group n=12.

36

5.3.6. OUTCOME 6: Factor associated with parental self-efficacy in

infant 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 parental

self-efficacy in infant care. For this objective, firstly, we analyzed each potential factor

independently. Then, we included those that were statistically significant into a linear

regression model, where parental self-efficacy in infant care was the dependent variable.

To analyze each factor independently, we transformed the parental self-efficacy scale and

other variables in dichotomous variables using the median as split point, so we were able to

analyze data with chi squared test. The total sample, 169 women and 34 men, were included

in this part of analysis.

37

Enhanced parental self-efficacy was clearly related to parity. 92.6% of women who had

previously given birth had high parental self-efficacy comparing with 41.0% of primiparous

women (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 those

with 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 was

29.6 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-efficacy

were 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 of

assisted antenatal classes, frequency and ability of use the Internet as an information source

38

and features of antenatal classes (teacher's experience, total hours of classes, incluying

physical exercise in teaching programme or use of audiovisual support).

a. Multivariate analysis

Before conducting the linear regression analysis we checked that all statistically assumptions

were met. Then we built a regression model with all factors that were statistically

significantly 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 of

pregnancy and living in the city were associated with higher scores of self-efficacy.

39

People who attended university studies were statistically significant more likely to have

lower 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 lower

parental 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 8.2

points higher in self-efficacy scale than people who do use it. This result was no statistically

significant as well.

The introduction into the regression model of the two variables that we consider outcomes

of our study (use of Medline and the perceived value of internet) gave small, 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 (Table 6).

40

6. DISCUSSION

The presented study yielded useful insights. We found a positive relationship between

internet use and parental self-efficacy that seem to confirm our initial hypothesis: the higher

the value given to the Internet the higher would be self-efficacy in infant care score. Other

researcher has also found that internet use has a positive influence on self-concept

dimensions34.

Furthermore, the study provides a comprehensive overview of the use of the Internet as a

source of information during pregnancy for a specific group of pregnant women and their

partners. The 97% of our sample have ever sought information on pregnancy, and 3 out of 5

did that during the last week. This percentages were fairly higher than those obtained from

surveys about internet seeking behaviour among the general population. It has been

estimated the percentage of the population that has used the Internet for health purposes

increased from 42.3% in 2005 to 52.2% in 200735. Other studies in developed countries

found similar rate of use, higher than 50%36-41. Only one study, in Atlanta, found prevalence

of internet medical information seeking lower than 20% in general population42.

The high frequency of using the Internet for retrieved health information in our sample are

in correspondence with similar studies among pregnant women1,5. Data indicate that

couples 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 be

generalized is necessary take a look into the sample population. We addressing women and

men who attend maternal education classes in health centers of Andalusia Health Service in

Granada, Spain. Appropriately, everyone who attended classes within a certain period was

approached 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 gathering

of data was limited to four months (June to September 2009), which, in addition, coincided

with the summer holiday period. This resulted in having groups with less numbers of

participants than it was expected.

41

We are aware that the external validity of our study is relatively low, taking into account that

this specific group even do not represent the parents expecting a child in the city of

Granada. Just the 46% of pregnant woman attend this kind of classes17. To assess how

representative 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 in

Spain. If we consider only women over 29 years old (n=104), the rate of women with college

education in our sample was 71%. This is almost twice as high as the national rate of tertiary

education registered. In Spain, according to the National Institute of Statistics (2007), level of

training for higher education in the group of women aged 30 to 44 years reaches barely

38%2. Women with the lowest level of education probably are less inclined to participate in

antenatal group education, but no research was found that analyze the demographic

composition of participants. Further research should be done to evaluate if resources and

effort are putting only in preparing for motherhood some specific, well educated groups of

women, leaving aside those who would most need it.

Altogether, we consider our sample representative for those women and men normally

reached by antenatal education in Granada.

6.1. Differences in antenatal education programmes

The study allows the readers to become aware of the broad range of variability between

different antenatal education providers in the city of Granada, and presents the

demographic characteristics of women and men that attend this kind of classes. Although

antenatal 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 different

contents and methods in the Andalusian region. In fact, worldwide, only a few studies have

assessed antenatal programmes’ effectiveness, and no consistent effect on main childbirth

and parenting outcomes was found44. Despite large divergences in methodology and

theoretical models, only tendencies towards better parental knowledge, confidence, and

competence were observed in small studies45. The effects of general antenatal education for

childbirth or parenthood, or both, remain largely unknown45-48. We did not find any

42

differences in self-efficacy scores, neither regarding programmes characteristics of the

classes nor instructor’s features.

6.2. An original idea

Together with its strengths, the design of our study faces limitations that should be

acknowledged, and taken into account for an appropriate interpretation of results. We will

refer to them below.

Basically, the first problem resulted from the difficulty to precisely define and measure our

factors of interest. Decision on how to assess the quality of internet skills among participants

and what instrument would be used to appraise parental self-efficacy in infant care would

become the key issue.

There was no tool for measuring parental self-efficacy translated into Spanish and validated

for this population, therefore, after the literature review we decided to adapt one,

specifically for our study, based on the Social Cognitive Theory12,14,49 and review of the

literature15,16,23. Albert Bandura, father of this theory, stated that "self-efficacy scales should

measure people's beliefs in their abilities to fulfil different levels of task demands within the

psychological domain selected for study " 49(p.44).

Aware of the methodological requirements that involve producing a new instrument, several

means for increasing validity and reliability of the scale were included in the methodology: a

pilot study was carried out and statistical analysis suggested for this kind of tool was

performed50.

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 scale

within the study. What is more, the developed instrument might be proposed for being

further tested and use to measure parental self-efficacy within the Spanish speakers

population in further research.

It should be noted that our principal hypothesis involves an original idea, not previously

addressed in the literature. We were not interested neither in evaluating the use of any

specific website51-54 nor in delivering any intervention via the Internet55-57, but to determine

43

if the process of gathering information online itself could, independently of the real quality

of this information, be connected with the self-efficacy.

This hypothesis had fundamentally most theoretical than empirical-proved base, and was

grounded 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 on

how sociostructural influences operate through psychological mechanisms to produce

behavioral 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 personal

satisfaction of the participants with their ability to find what they were looking for on the

Internet. Although all others variables related to frequency were included in the

questionnaire, it was decided to use the following direct, subjective question as the

independent variable: “On a scale of 1 to 10, describe how helpful in solving your doubts

related to pregnancy, childbirth and infant care, the information you read on the Internet

is”. According to our theoretical background we found that this personal appreciation of the

utility 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 a

particular means of gathering information in a proactive way, is related with the four

principal sources of self-efficacy beliefs49(p.81-114): 1) Enactive mastery experiences the most

important factor deciding a person's 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.

People's shared belief in their collective power to produce desired results is a key ingredient

of collective capability to change their environment14. The Internet is a pool of social

knowledge. So, if people feel themselves competent in finding the type of information they

are looking for, it should enhance their confidence in developing specific tasks. Different

44

than their habitual role of passive receptor of information, through internet searches they

become active actors in enhancing their own knowledge. If they are being capable to identify

what information they are lacking for performing a task, they might be capable to develop it

after 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 intervention

Our study included an intervention and the measurement of its effect. The assessment of

pros and cons of the intervention itself require an independently analysis. For encouraging

participants to use the Internet, the midwifes in charge of classes were provided of a

factsheet especially elaborated for this study (Appendix 3). It was reviewed by

communicational and research professionals and approved by midwifes involved in maternal

education, but was not tested on validity in the target audience29.

We were aware that the use of brochure within the health services generates divergent

opinions, ranging from those that hold it does not serve any real purpose and clients seldom

looked through it at home60, to those who reported that the combination of verbal and

written patient education enhances levels of knowledge, understanding, satisfaction,

compliance and retention of information in clients, and decreases stress and anxiety61.

As an attempt to learn about the reception of the material among participants, a subjective

question about the usefulness of the leaflet was included into the questionnaire for those

who had received it. We found out that almost 40% of those who had been given the

information 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 after

receiving the advice. A follow-up study would be required to confirm the real impact of the

intervention.

An advantage of the design was that midwifes themselves were responsible for delivering

the advice on searching the online information, because it has been described as a means of

enhancing patient-practitioner relationships62. After several personal meetings with each

professional, the way to provide the intervention was agreed upon. In each case it took only

five minutes at the end of one of the classes and consisted of giving the fact sheet to the

45

attendants, informing that it was designed under the framework of an university study and

suggesting using it. Other study had found that women who were advised to read a

particular brochure (procedures in the midwifery practice) followed this advice60. It has been

reported that patients are open to accessing information prescribed by their physicians and

were much more likely to trust it63.

This fact might support the practical application of our intervention, taking into

consideration that the staff became familiar with the material and considered the possibility

to incorporate it in their program afterward64,65.

However, it is necessary to highlight that our study, although cautiously designed and

executed, faced problems that commonly appear in development and evaluation of similar

type of interventions66,67. It have been proposed that “investigators often move too rapidly

from an idea for an intervention to a proposal for an efficacy trial. Often lacking is sufficient

preliminary work to develop and refine the intervention, to test it for preliminary evidence

of 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 asses

intervention feasibility and acceptability, to test the new intervention in a small group-

randomized trial powered to detect differences on intermediate outcomes or mediators, and

specially 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 the

lack of previous empirical trials by using a strong theoretical model. The fact that our effect

size was supposed to be low (5%) a much larger sample would have required. In general, our

power to explain variation remained fairly low of barely 12%24,25.

The continuous learning is a fundamental part of intellectual training, and the complexity of

this work allowed me to experience the whole process of an academic research, including

the developing and application of a questionnaire, the validation of an scale and the

developing and the conduction of an intervention. If I had to deal with a similar work in the

future, I would tackle it differently. I would split objectives into more modest ones, and I

46

would be assured to have more clearly defined units of analysis. However I do not regret the

way this work have been developed, because it has been a wealthy source of learning.

6.4.Methodological issues

We have analysed data of individuals in spite of the fact that intervention was given to

groups of individuals. This increases the risk of cluster effects, i.e., that certain common

attitudes are adapted within a group or that some individuals affect the group climate and

the participants68. Nonetheless to adjust for cluster effects in the analyses was considered

not necessary, because the fact of low power of statistical analysis due to relatively small

sample size.

6.5. Practical implications of the work

Worldwide, midwifes are aware of the increased use of the Internet among pregnant

women and most of then considered the need to keep up-to-date with the latest

knowledge69.

Developing and providing midwife of materials and training oriented to internet search can

enhance their own internet competence70 and improve the patient-health professional

relationship71. Internet prescription, that is guiding patients to reliable health information

websites, is becoming a new challenge72. Antenatal education is a invaluable setting for

developing health literacy, that nowadays includes knowing where to go for further

information, and the ability to analyse information critically73.

7. CONCLUSION

The Internet is a widespread source of information among participants of maternal

education classes in Granada, in both men and women. More than 95% have ever used it for

retrieving information during their pregnancy. One out of five women and one out of four

men preferred the internet as their first source of information. The great majority access to

47

it at home and the frequency of use was slightly higher in people with secondary and tertiary

degree, than in those with primary education level.

As part of this study, a tool for measuring parental self-efficacy in infant care within the

Spanish speaker population was developed. Its reliability and validity suggested a sufficiently

strong base for accepting its use within the study, and might be proposed for being tested in

further researches.

Great differences in years of professional practice and ability in the use of the Internet

between midwifes in charge of the maternal education classes in Granada, Spain, have been

found. There was no consensus on techniques, exercises or use of audiovisual support in

class, neither in the duration of the programme. Nonetheless, no effects of these differences

have been detected in the rate of parental self-efficacy in infant care.

Perceived parental self-efficacy in infant care was significantly and positively related with

previous deliveries and advanced pregnancy. Otherwise, older mothers scored statistically

significant lower than younger mothers.

We found a positively relationship between perceived usefulness of the internet and

parental self-efficacy. The strength of the relationship was increased in those people that

received 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 useful

and other 44% said that they would use it in the future. More people visited the suggested

websites among those who received the guidance. These facts seem to show that

attendants to maternal education classes are open to accessing information about internet

resources suggested by their midwifes and this opportunity should be exploited for

enhancing the usefulness of their internet searches.

48

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Appendix 1: Five-pages Questionnaire, translated into English

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55

56

57

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Appendix 2: Template for characterization of maternal

education classes

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Appendix 3: Fact sheet used as intervention

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Appendix 4: Ethical approval from the Health District of

Granada

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Appendix 5: Form of informed consent and information for

contact (In Spanish as original)