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Impacts of online and group perinatal education: a mixedmethods study protocol for the optimization of perinatal health services

Impacts of online and group perinatal education: a mixedmethods study protocol for the... Background: Prenatal education is a core component of perinatal care and services provided by health institutions. Whereas group prenatal education is the most common educational model, some health institutions have opted to implement online prenatal education to address accessibility issues as well as the evolving needs of future parents. Various studies have shown that prenatal education can be effective in acquisition of knowledge on labour and delivery, reducing psychological distress and maximising father’s involvement. However, these results may depend on educational material, organization, format and content. Furthermore, the effectiveness of online prenatal education compared to group prenatal education remains unclear in the literature. This project aims to evaluate the impacts of group prenatal education and online prenatal education on health determinants and users’ health status, as well as on networks of perinatal educational services maintained with community-based partners. Methods: This multipronged mixed methods study uses a collaborative research approach to integrate and mobilize knowledge throughout the process. It consists of: 1) a prospective cohort study with quantitative data collection and qualitative interviews with future and new parents; and 2) a multiple case study integrating documentary sources and interviews with stakeholders involved in the implementation of perinatal information service networks and collaborations with community partners. Perinatal health indicators and determinants will be compared between prenatal education groups (group prenatal education and online prenatal education) and standard care without these prenatal education services (control group). (Continued on next page) * Correspondence: genevieve.roch@fsi.ulaval.ca Faculty of Nursing, Université Laval, 1050 avenue de la Médecine, Québec, QC G1V 0A6, Canada CHU de Québec Research Centre – Université Laval, Hôpital Saint-François d’Assise, 10 rue de l’Espinay, Québec, QC G1L 3L5, Canada Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Roch et al. BMC Health Services Research (2018) 18:382 Page 2 of 8 (Continued from previous page) Discussion: This study will provide knowledge about the impact of online prenatal education as a new technological service delivery model compared to traditional group prenatal education. Indicators related to the complementarity of these interventions and those available in community settings will refine our understanding of regional perinatal services networks. Results will assist decision-making regarding service organization and delivery models of prenatal education services. Protocol version: Version 1 (February 9 2018). Keywords: Prenatal education, Perinatal care, Pregnancy, Childbirth education, Online education, Community health networks, Community health services, Health status indicators, Mixed methods Background education and information remain unknown [31–33]. Prenatal information is a decisive determinant of health There is thus an urgent need to collect robust data on the choices made by pregnant women and their partners as impacts of group prenatal education and online prenatal they move through the continuum of perinatal services [1, education, and to consolidate perinatal information 2]. Considering the myriad of information sources publicly networks with community partners. available and their variable quality [3–7], prenatal educa- The aim of this project is to evaluate the impacts of tion remains a health promotion strategy at the core of group prenatal education and online prenatal education perinatal care and services provided by health and social provided or recommended by health and social services services centers [8–10] [S-10] and is supported by public centers on health determinants and users’ health status, policies [10, 11]. Group prenatal education is one of the as well as on networks of perinatal educational services most common educational models [12]. Various studies maintained with community-based partners. Specific have shown that group prenatal education can be effective objectives are to: 1) document the characteristics of in the preparation for labour and delivery, reducing anx- group prenatal education and online prenatal education iety and maximising partners’ involvement. However, and contribute to their optimization; 2) evaluate the these results depend on the organization, format, and con- impacts of group prenatal education and online prenatal tent of the educational services [13–17]. In order to ad- education on health determinants and the perinatal dress accessibility issues as well as the evolving needs of health status of parents; 3) evaluate characteristics and future parents, some health and social services centers collaborations related to perinatal educational services have opted to recommend or implement online prenatal within which group prenatal education and online education, while still offering group prenatal education. prenatal education are offered, with community-based Decision makers, however, are concerned about the im- partners. pacts of this new educational mode on the efficacy of health services networks. In a restructuring context where Methods the deployment of online education opens the door to This multipronged study uses convergent mixed new complementary prenatal education to group educa- methods through a collaborative research approach to tion, it is important to understand the contribution of integrate and mobilize knowledge [34, 35]. More pre- these two educational modes on health determinants and cisely, it will consist of 1) a prospective cohort study users’ perinatal health [18]. Because of the heterogeneity with quantitative data collection and qualitative inter- of delivery modes [9], evidence of prenatal education ef- views with future and new parents and 2) a multiple case fectiveness and impact is scarce or contradictory for group study integrating documentary sources and interviews prenatal education [12, 14–17, 19] and very limited for with stakeholders involved in the implementation of peri- online prenatal education [20–22], although online educa- natal information service networks and collaborations tion may address the needs of certain users and improve with community partners. The complementarity of the accessibility [23–29]. Within a health promotion context, quantitative and qualitative data will provide a broader prenatal education delivered by health and social services perspective on perinatal information sources and net- centers could be improved by being integrated into a con- works in order to evaluate the impacts of prenatal tinuum of perinatal information in partnership with exist- education. ing community services networks [30]. Several studies show that networking may contribute to health system Participating sites effectiveness, but structural characteristics and collabora- The study will be conducted within the geographic terri- tions with community partners surrounding prenatal tories covered by two health and social services centers Roch et al. BMC Health Services Research (2018) 18:382 Page 3 of 8 located in adjacent regions in the province of Québec, prenatal education trainers from the different participant Canada, with an approximate total area of 34,000 km training sites, in order to ensure that all knowledge and total population of 1,162,000 inhabitants. Cre- items are covered in group and online prenatal ated in 2015, these regional institutions are respon- education. sible for the provision of health care and services The main secondary outcome is psychological distress, within their territories and for binding agreements measured with a validated French version of the 12-item with partner organizations (e.g. community organiza- General Health Questionnaire [42] and considered as tions, medical clinics, network clinics, etc.) [36]. The the most important outcome for perinatal health mea- health and social services centers are providing simi- sures (i.e., main outcome measuring a health determin- lar group prenatal education, with some variations ant). Other secondary outcomes include: breastfeeding related to their resources and specific population self-efficacy, assessed with a French version of the needs. Both are currently using an online prenatal Breastfeeding Self-Efficacy Scale Short-Form [43, 44]; education interface developed by a private provider anxiety, assessed with a validated French version of the [37]. These institutions also have access to a peri- State-Trait Anxiety Inventory [45]; self-efficacy in the natal information source developed by the Ministry parenting role, assessed with a French version of the of Health and Social Services of Québec to maintain Parent Expectations Survey [46, 47]; depression, assessed the harmonization of content [38]. with a validated French version of the Edinburgh Postna- tal Depression Scale [48, 49]; concern about labour and Participants birth, assessed with a French version of the Oxford For the cohort study, women will be eligible if they: a) Worries about Labour Scale [50]; control during child- are at the beginning of their pregnancy (10 to 20 weeks); birth, assessed with a French version of the Labour b) live within the targeted geographic territories; c) are Agentry Scale [51]; personal control in pain relief during fluent in French; d) have not given birth previously and childbirth, assessed with a French version of the e) have a valid email address and access to internet. Personal Control in Pain Relief Scale [52], breastfeeding Male and female partners of women meeting these cri- status and birth weight. A back translation process [53, teria will be eligible as partners. Partners who already 54] will be used to translate English versions of the Ox- had children with another woman will also be eligible. ford Worries about Labour Scale, Labour Agentry Scale For qualitative interviews, parents will be eligible if they: and Personal Control in Pain Relief Scale to French. a) have a 6- to 12-week-old infant; b) attended group Data on sociodemographic characteristics, pregnancy prenatal education or online prenatal education recom- and childbirth history, and prenatal information sources mended by participant sites; c) live within the targeted consulted during pregnancy will also be collected as po- geographic territories; d) are fluent in French. For the tential confounding factors. All questionnaires will be multiple case study, prenatal education stakeholders pre-tested with a test-retest procedure in order to assess (managers and health professionals) will be eligible if their reliability [55]. they: a) are working within the participating sites or re- lated services networks; b) are interested in sharing their understanding of structural characteristics and determi- Data collection nants of collaboration between health and social services Administrative data collection centers and community partners involved in group pre- Throughout the entire duration of the project, administra- natal education and online prenatal education offer; and tive data needed to establish a general portrait of prenatal c) have been in their position for at least 3 months. education use will be collected and updated with health These stakeholders will be identified with the help of and social services centers managers. These data will collaborators from participating sites. include different characteristics of the organization, for- mat and content such as number and duration of group Outcomes prenatal education meetings, health professionals in- Primary and secondary outcomes related to perinatal volved in group prenatal education, themes covered in health and perinatal health determinants were identified group prenatal education and online prenatal educa- from a literature review on group prenatal education tion, mode and fees for accessing group prenatal educa- effects [18, 39]. Based on studies that demonstrated tion and online prenatal education, and sources used significant effects of group prenatal education, the main for the development of group prenatal education and outcome for health determinant is perinatal knowledge online prenatal education. Administrative data will also [13, 40] and will be measured with an adapted version of be obtained from the online prenatal education pro- the Health Pregnancies Knowledge Survey [41]. The vider and will include access data, registration data and questionnaire will be adapted in collaboration with users’ satisfaction data. Roch et al. BMC Health Services Research (2018) 18:382 Page 4 of 8 Table 1 Distribution of outcomes measures through time (T1) 10–20 weeks of pregnancy (T2) 33 weeks of pregnancy (T3) 6 weeks after child birth Pregnant women Partners Pregnant women Partners Mothers Partners Main outcome measure Health Pregnancies Knowledge Survey ✓✓ ✓ ✓ Secondary outcomes measures General Health Questionnaire ✓✓ ✓ ✓ ✓ ✓ Breastfeeding Self-Efficacy Scale ✓✓ ✓ ✓ ✓ ✓ State-Trait Anxiety Inventory ✓✓ ✓ ✓ ✓ ✓ Parent Expectations Survey ✓✓ ✓ ✓ ✓ ✓ Edinburgh Postnatal Depression Scale ✓✓ ✓ ✓ ✓ ✓ Sociodemographics characteristics ✓✓ Pregnancy history ✓ Prenatal information sources ✓✓ Childbirth history ✓ Breastfeeding status ✓ Oxford Worries about Labour Scale ✓✓ Labour Agentry Scale ✓✓ Birth weight ✓✓ ✓Outcome measured Time measurements (cohort study) interviews with prenatal education stakeholders will be Table 1 presents the distribution of outcomes measurements held in the two participating health and social services through time for the cohort study. Time measurements are centers and their related community-based organizations calculated according to the continuum of services of partici- (expected N = 45). The interview guide will be devel- pating institutions. The first questionnaire (T1) will be com- oped from a reference framework inspired by the work pleted between the 10th and 20th week of pregnancy, in of Turrini et al. [31] for efficient network characteristics, order to reach participants before the prenatal education and Lasker et al. [60] for partnerships functioning period. The second questionnaire (T2) will be sent at (Fig. 1). An adaptation of the Social Network Analysis 33 weeks of pregnancy, in order to reach participants after Tool [61] will also be used in order to estimate how the prenatal education period. The third and last question- these characteristics and determinants may consolidate naire(T3)willbesent6weeksafter theexpecteddateof group prenatal education, online prenatal education and birth. All questionnaires will be sent by email and completed perinatal information. Each interview will last approxi- online. mately 45 min. These interviews will be held simultan- eously with the cohort study and will be completed by Qualitative interviews documentary sources provided by the participating sites. Semi-structured individual qualitative interviews with parents will be based on an interview guide developed Recruitment strategies according to the Interactive Quality Health Education For the cohort study, all questionnaires will be com- Outcomes Model [56]. Interviews will be conducted by pleted in electronic format and data kept on a secured phone in order to facilitate participation. Each interview server hosted by the principal investigator’s institution. will last approximately 45 min. Mothers and partners Pregnant women and their partners will be recruited at from each participating site and each prenatal education their first contact point with participating sites, namely mode (group or online prenatal education) will be recruited at their first ultrasound test or prenatal meeting. In according to a stratified sampling until data saturation is ultrasound clinics, a bookmark providing connection reached (expected N =40) [57–59]. Qualitative interviews information will be given by receptionists when parents will be held simultaneously with the cohort study. attend the first dating ultrasound. A research assistant will then be responsible to meet potential participants in Network data collection the waiting room, provide them with the necessary infor- In order to evaluate structural characteristics of efficient mation and give them the opportunity to complete the networks and collaborations, individual qualitative consent form and start answering the questionnaire on Roch et al. BMC Health Services Research (2018) 18:382 Page 5 of 8 Fig. 1 Networks and partnerships effectiveness reference framework. Legend: Adapted from Lasker et al. (2001) and Turrini et al. (2010) an iPad. Potential participants will also be free to keep abandonment. All participants will be eligible for the the bookmark and complete the questionnaire later at drawing of six iPads, with chances to win proportion- home. In prenatal clinics, the bookmark and project in- ately increasing with the number of completed question- formation will be given by nurses to future parents, naires (one to three). which will then be free to complete the online consent form and questionnaire at home. Posters will also be dis- Statistical analysis played in all participating sites, with the possibility for Sample size potential participants to contact the principal investiga- Assuming an effect size of 0.36 (for perinatal knowledge tor or project coordinator directly if they want to partici- with or without prenatal education) and a 1:1:2 alloca- pate. Once participants are registered, follow-up will be tion between groups (group prenatal education: online done by email or phone. prenatal education: without prenatal education) [13], a For qualitative interviews, parents will be recruited at power of 80% and a bilateral test threshold of 0.025, a their first postnatal clinic encounter in participating total of 445 pregnant women and 445 partners (2 groups health and social services centers (e.g. immunization of 111 with prenatal education and 1 group of 223 with- clinics, breastfeeding clinics, etc.). A bookmark with the out prenatal education) is required at the third measure- research team coordinates and project information will ment time. An ongoing longitudinal study conducted by be given by nurses to new parents, who will be invited our research team with new parents in the Québec to contact the research team in order to verify their region allows us to expect a participation rate of 80% for eligibility and participate to the project. partners and a retention rate of 70% at the end of the For the multiple case study, expert stakeholders will three measuring times. An initial sample size of 795 be recruited through a snowball sampling technique pregnant women and up to 795 partners is therefore starting with the health and social services centers’ anticipated. A second power calculation based on decision-makers initially involved in the study. Jakubiec et al. data [40] was done for the most important secondary outcome (psychological distress) and resulted Incentives and retention strategies in a smaller sample size. Births by territory data suggest In order to prevent loss to follow-up during the cohort a sufficient pool to recruit the required sample size study, automatic email reminders will be sent twice after within 3 to 4 months. the sending of T1, T2 and T3 questionnaires. If the questionnaire is not completed after that, the research Quantitative analysis coordinator or a research assistant will call the partici- Descriptive analysis will be conducted at the three time pant as a last reminder or to record the reason for points. For the main outcome (measured twice), Roch et al. BMC Health Services Research (2018) 18:382 Page 6 of 8 difference between prenatal education groups (group will be developed alongside a content analysis [67]. UCI- prenatal education and online prenatal education) and NET software version 6 [68] will be used to view and standard care without these prenatal education services compare perinatal networks structure according to the will be calculated. Bivariate linear regression models will analytical approach described by Scott et al. [69], as then be used to measure the association between this recommended by Provan et al. for the reinforcement of difference and secondary outcomes. Bivariate linear re- efficient collaboration networks [61]. The integration of gression models will be used to compare prenatal educa- different data sources will allow a cross-sectional tion groups (group prenatal education and online validation of results. prenatal education) to the absence of these prenatal edu- cation services for health determinants measured twice. Collaboration with decision-makers Non-multicollinearity, normality of residuals and homo- Decision-makers of the two participating health and geneity of variances will be verified and a variable trans- social services centers have committed to facilitate the formation will be performed if these postulates are not implementation of this project in their respective estab- met. Outcomes measured at the three time points will lishments. Based on the administrative data collected be analyzed with bivariate repeated measures models. and usability of online prenatal education, they will For continuous and categorical outcomes, mixed models standardizeasmuchaspossible their offerofgroup and generalized estimating equation models will be used prenatal education and online prenatal education be- respectively. For the generalized estimating equation fore the recruitment in order to optimize the results models, binomial distribution will be used for binary of the study. Responding to priorities in public health outcomes and multinomial distribution for outcomes and clinical services organization, this engagement with multiple categories. Multiple imputation will be will facilitate a relevant follow-up of the impacts of used for randomly distributed missing data. Depending group and online prenatal education. The study of on the results, sensitivity analysis may be performed for the service delivery models for prenatal education and geographic regions, health establishments providing pre- the associated regional networks providing these ser- natal education, group or online prenatal education for- vices will also promote collaboration between the pol- mat, exposure level to online prenatal education and itical decision-makers of the Ministry of Health and healthcare providers involved in pregnancy follow-up. Social Services of Québec, the National Public Health All statistical models will be adjusted for sociodemo- Institute of Québec, and the Public Health Agency of graphic data, use of other information sources and preg- Canada who have agreed to actively participate in the nancy follow-up data. Analysis will be performed with interpretation of results and mobilization of knowledge Statistical Analysis Software version 9.4 (SAS Institute, strategies. Cary, NC, USA). Qualitative analysis Discussion Data from semi-structured interviews will be recorded, Knowledge translation strategies transcribed, anonymized and analyzed with QDA Miner An advisory committee (composed of all authors, health software version 5 (Provalis Research, Montreal, QC, professionals and managers as expert knowledge users) Canada). Content analysis and integration of quantitative will support the development and operationalization inferences will be conducted based on an adaptation of of the study, notably for data collection follow-up and the Interactive Quality Health Education Outcomes knowledge translation. A monitoring committee Model [56]. Administrative data will be treated in a de- (composed of all authors, decision-makers, parent repre- scriptive manner in order to establish the general and sentatives and policy makers as expert knowledge users) comparative profile of users. Quality and confidentiality will be responsible for sustained knowledge mobilization of data will be rigorously ensured by the use of consoli- throughout all the study in order to support dated criteria and validated qualitative methods [62, 63]. organizational and political decisions related to perinatal education services. This knowledge mobilization approach Multiple case study analysis in its process, reflections, tools and results can be shared Case studies will consist of perinatal information net- with the involved actors in order to disseminate the best works of the two participating health and social services practices in organizational terms for the users, the organi- centers in which local community perinatal information zations, and partners of perinatal services networks. The networks will be embedded. For each study case, matri- use of brief reports, narrated slides and a website intended ces allowing the evaluation of determinants in relation for the users, decision-makers, and partners will make up to networks success factors and collaborative actions the principal knowledge transfer strategies and results presented in perinatal governmental programs [64–66] dissemination. Roch et al. BMC Health Services Research (2018) 18:382 Page 7 of 8 Expected outcomes Competing interests The authors declare that they have no competing interests. This study will be one of the first to consider the im- pacts of online prenatal education on different health determinants and perinatal health status in a Canadian Publisher’sNote Springer Nature remains neutral with regard to jurisdictional claims in context. This will allow for important knowledge acqui- published maps and institutional affiliations. sition regarding the impact of online prenatal education as a new technological service delivery model compared Author details Faculty of Nursing, Université Laval, 1050 avenue de la Médecine, Québec, to an absence of group prenatal education in some QC G1V 0A6, Canada. CHU de Québec Research Centre – Université Laval, health and social services centers settings. Indicators re- Hôpital Saint-François d’Assise, 10 rue de l’Espinay, Québec, QC G1L 3L5, lated to the complementarity of group and online pre- Canada. Centre intégré de santé et de services sociaux de Chaudière-Appalaches, Hôtel-Dieu de Lévis, 143 rue Wolfe, Lévis, QC G6V natal education and those available in a community 3Z1, Canada. Université de Montréal Public Health Research Institute, 7101 setting will refine our understanding of regional peri- avenue du Parc, Montréal, QC H3N 1X9, Canada. Faculty of Nursing, natal services networks. As studies involving future fa- Université de Montréal, 2375, chemin de la Côte-Ste-Catherine, Montréal, QC H3T 1A8, Canada. Department of Nursing, Université du Québec en thers or partners are uncommon, although their Outaouais, 283 boulevard Alexandre-Taché CP 1250, Gatineau, QC J8X 3X7, involvement in perinatal period is strongly recom- Canada. Faculty of Medicine, Université Laval, 1050 avenue de la Médecine, mended [70], results will also indicate how group and Québec City, QC G1V 0A6, Canada. School of Psychology, Université Laval, 2325 Allée des Bibliothèques, Québec City, QC G1V 0A6, Canada. Ingram online prenatal education can contribute to their School of Nursing, McGill University, 680 Sherbrooke West, Montréal, QC H3A well-being and that of their family. This project also has 2M7, Canada. Institut national de santé publique du Québec, 945 av Wolfe, the potential to improve harmonization of group pre- Québec City, QC G1V 5B3, Canada. School of Social Work, Université de Montréal, 3150 rue Jean-Brillant, Montréal, QC H3T 1N8, Canada. natal education and the user-friendliness of online pre- Département de sociologie, Université de Montréal, 3150 rue Jean-Brillant, natal education. This could potentially improve nurses’ Montréal, QC H3T 1N8, Canada. Department of Political Science, Faculty of professional practices, as well as those of other health Social Sciences, Université Laval, 1030 avenue des Sciences Humaines, Québec, QC G1V 0A6, Canada. School of Public Health, Université de professionals and community stakeholders involved in Montréal, 7101 avenue du Parc, Montréal, QC H3N 1X9, Canada. perinatal education. 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Impacts of online and group perinatal education: a mixedmethods study protocol for the optimization of perinatal health services

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Springer Journals
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Copyright © 2018 by The Author(s).
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Medicine & Public Health; Public Health; Health Administration; Health Informatics; Nursing Research
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Abstract

Background: Prenatal education is a core component of perinatal care and services provided by health institutions. Whereas group prenatal education is the most common educational model, some health institutions have opted to implement online prenatal education to address accessibility issues as well as the evolving needs of future parents. Various studies have shown that prenatal education can be effective in acquisition of knowledge on labour and delivery, reducing psychological distress and maximising father’s involvement. However, these results may depend on educational material, organization, format and content. Furthermore, the effectiveness of online prenatal education compared to group prenatal education remains unclear in the literature. This project aims to evaluate the impacts of group prenatal education and online prenatal education on health determinants and users’ health status, as well as on networks of perinatal educational services maintained with community-based partners. Methods: This multipronged mixed methods study uses a collaborative research approach to integrate and mobilize knowledge throughout the process. It consists of: 1) a prospective cohort study with quantitative data collection and qualitative interviews with future and new parents; and 2) a multiple case study integrating documentary sources and interviews with stakeholders involved in the implementation of perinatal information service networks and collaborations with community partners. Perinatal health indicators and determinants will be compared between prenatal education groups (group prenatal education and online prenatal education) and standard care without these prenatal education services (control group). (Continued on next page) * Correspondence: genevieve.roch@fsi.ulaval.ca Faculty of Nursing, Université Laval, 1050 avenue de la Médecine, Québec, QC G1V 0A6, Canada CHU de Québec Research Centre – Université Laval, Hôpital Saint-François d’Assise, 10 rue de l’Espinay, Québec, QC G1L 3L5, Canada Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Roch et al. BMC Health Services Research (2018) 18:382 Page 2 of 8 (Continued from previous page) Discussion: This study will provide knowledge about the impact of online prenatal education as a new technological service delivery model compared to traditional group prenatal education. Indicators related to the complementarity of these interventions and those available in community settings will refine our understanding of regional perinatal services networks. Results will assist decision-making regarding service organization and delivery models of prenatal education services. Protocol version: Version 1 (February 9 2018). Keywords: Prenatal education, Perinatal care, Pregnancy, Childbirth education, Online education, Community health networks, Community health services, Health status indicators, Mixed methods Background education and information remain unknown [31–33]. Prenatal information is a decisive determinant of health There is thus an urgent need to collect robust data on the choices made by pregnant women and their partners as impacts of group prenatal education and online prenatal they move through the continuum of perinatal services [1, education, and to consolidate perinatal information 2]. Considering the myriad of information sources publicly networks with community partners. available and their variable quality [3–7], prenatal educa- The aim of this project is to evaluate the impacts of tion remains a health promotion strategy at the core of group prenatal education and online prenatal education perinatal care and services provided by health and social provided or recommended by health and social services services centers [8–10] [S-10] and is supported by public centers on health determinants and users’ health status, policies [10, 11]. Group prenatal education is one of the as well as on networks of perinatal educational services most common educational models [12]. Various studies maintained with community-based partners. Specific have shown that group prenatal education can be effective objectives are to: 1) document the characteristics of in the preparation for labour and delivery, reducing anx- group prenatal education and online prenatal education iety and maximising partners’ involvement. However, and contribute to their optimization; 2) evaluate the these results depend on the organization, format, and con- impacts of group prenatal education and online prenatal tent of the educational services [13–17]. In order to ad- education on health determinants and the perinatal dress accessibility issues as well as the evolving needs of health status of parents; 3) evaluate characteristics and future parents, some health and social services centers collaborations related to perinatal educational services have opted to recommend or implement online prenatal within which group prenatal education and online education, while still offering group prenatal education. prenatal education are offered, with community-based Decision makers, however, are concerned about the im- partners. pacts of this new educational mode on the efficacy of health services networks. In a restructuring context where Methods the deployment of online education opens the door to This multipronged study uses convergent mixed new complementary prenatal education to group educa- methods through a collaborative research approach to tion, it is important to understand the contribution of integrate and mobilize knowledge [34, 35]. More pre- these two educational modes on health determinants and cisely, it will consist of 1) a prospective cohort study users’ perinatal health [18]. Because of the heterogeneity with quantitative data collection and qualitative inter- of delivery modes [9], evidence of prenatal education ef- views with future and new parents and 2) a multiple case fectiveness and impact is scarce or contradictory for group study integrating documentary sources and interviews prenatal education [12, 14–17, 19] and very limited for with stakeholders involved in the implementation of peri- online prenatal education [20–22], although online educa- natal information service networks and collaborations tion may address the needs of certain users and improve with community partners. The complementarity of the accessibility [23–29]. Within a health promotion context, quantitative and qualitative data will provide a broader prenatal education delivered by health and social services perspective on perinatal information sources and net- centers could be improved by being integrated into a con- works in order to evaluate the impacts of prenatal tinuum of perinatal information in partnership with exist- education. ing community services networks [30]. Several studies show that networking may contribute to health system Participating sites effectiveness, but structural characteristics and collabora- The study will be conducted within the geographic terri- tions with community partners surrounding prenatal tories covered by two health and social services centers Roch et al. BMC Health Services Research (2018) 18:382 Page 3 of 8 located in adjacent regions in the province of Québec, prenatal education trainers from the different participant Canada, with an approximate total area of 34,000 km training sites, in order to ensure that all knowledge and total population of 1,162,000 inhabitants. Cre- items are covered in group and online prenatal ated in 2015, these regional institutions are respon- education. sible for the provision of health care and services The main secondary outcome is psychological distress, within their territories and for binding agreements measured with a validated French version of the 12-item with partner organizations (e.g. community organiza- General Health Questionnaire [42] and considered as tions, medical clinics, network clinics, etc.) [36]. The the most important outcome for perinatal health mea- health and social services centers are providing simi- sures (i.e., main outcome measuring a health determin- lar group prenatal education, with some variations ant). Other secondary outcomes include: breastfeeding related to their resources and specific population self-efficacy, assessed with a French version of the needs. Both are currently using an online prenatal Breastfeeding Self-Efficacy Scale Short-Form [43, 44]; education interface developed by a private provider anxiety, assessed with a validated French version of the [37]. These institutions also have access to a peri- State-Trait Anxiety Inventory [45]; self-efficacy in the natal information source developed by the Ministry parenting role, assessed with a French version of the of Health and Social Services of Québec to maintain Parent Expectations Survey [46, 47]; depression, assessed the harmonization of content [38]. with a validated French version of the Edinburgh Postna- tal Depression Scale [48, 49]; concern about labour and Participants birth, assessed with a French version of the Oxford For the cohort study, women will be eligible if they: a) Worries about Labour Scale [50]; control during child- are at the beginning of their pregnancy (10 to 20 weeks); birth, assessed with a French version of the Labour b) live within the targeted geographic territories; c) are Agentry Scale [51]; personal control in pain relief during fluent in French; d) have not given birth previously and childbirth, assessed with a French version of the e) have a valid email address and access to internet. Personal Control in Pain Relief Scale [52], breastfeeding Male and female partners of women meeting these cri- status and birth weight. A back translation process [53, teria will be eligible as partners. Partners who already 54] will be used to translate English versions of the Ox- had children with another woman will also be eligible. ford Worries about Labour Scale, Labour Agentry Scale For qualitative interviews, parents will be eligible if they: and Personal Control in Pain Relief Scale to French. a) have a 6- to 12-week-old infant; b) attended group Data on sociodemographic characteristics, pregnancy prenatal education or online prenatal education recom- and childbirth history, and prenatal information sources mended by participant sites; c) live within the targeted consulted during pregnancy will also be collected as po- geographic territories; d) are fluent in French. For the tential confounding factors. All questionnaires will be multiple case study, prenatal education stakeholders pre-tested with a test-retest procedure in order to assess (managers and health professionals) will be eligible if their reliability [55]. they: a) are working within the participating sites or re- lated services networks; b) are interested in sharing their understanding of structural characteristics and determi- Data collection nants of collaboration between health and social services Administrative data collection centers and community partners involved in group pre- Throughout the entire duration of the project, administra- natal education and online prenatal education offer; and tive data needed to establish a general portrait of prenatal c) have been in their position for at least 3 months. education use will be collected and updated with health These stakeholders will be identified with the help of and social services centers managers. These data will collaborators from participating sites. include different characteristics of the organization, for- mat and content such as number and duration of group Outcomes prenatal education meetings, health professionals in- Primary and secondary outcomes related to perinatal volved in group prenatal education, themes covered in health and perinatal health determinants were identified group prenatal education and online prenatal educa- from a literature review on group prenatal education tion, mode and fees for accessing group prenatal educa- effects [18, 39]. Based on studies that demonstrated tion and online prenatal education, and sources used significant effects of group prenatal education, the main for the development of group prenatal education and outcome for health determinant is perinatal knowledge online prenatal education. Administrative data will also [13, 40] and will be measured with an adapted version of be obtained from the online prenatal education pro- the Health Pregnancies Knowledge Survey [41]. The vider and will include access data, registration data and questionnaire will be adapted in collaboration with users’ satisfaction data. Roch et al. BMC Health Services Research (2018) 18:382 Page 4 of 8 Table 1 Distribution of outcomes measures through time (T1) 10–20 weeks of pregnancy (T2) 33 weeks of pregnancy (T3) 6 weeks after child birth Pregnant women Partners Pregnant women Partners Mothers Partners Main outcome measure Health Pregnancies Knowledge Survey ✓✓ ✓ ✓ Secondary outcomes measures General Health Questionnaire ✓✓ ✓ ✓ ✓ ✓ Breastfeeding Self-Efficacy Scale ✓✓ ✓ ✓ ✓ ✓ State-Trait Anxiety Inventory ✓✓ ✓ ✓ ✓ ✓ Parent Expectations Survey ✓✓ ✓ ✓ ✓ ✓ Edinburgh Postnatal Depression Scale ✓✓ ✓ ✓ ✓ ✓ Sociodemographics characteristics ✓✓ Pregnancy history ✓ Prenatal information sources ✓✓ Childbirth history ✓ Breastfeeding status ✓ Oxford Worries about Labour Scale ✓✓ Labour Agentry Scale ✓✓ Birth weight ✓✓ ✓Outcome measured Time measurements (cohort study) interviews with prenatal education stakeholders will be Table 1 presents the distribution of outcomes measurements held in the two participating health and social services through time for the cohort study. Time measurements are centers and their related community-based organizations calculated according to the continuum of services of partici- (expected N = 45). The interview guide will be devel- pating institutions. The first questionnaire (T1) will be com- oped from a reference framework inspired by the work pleted between the 10th and 20th week of pregnancy, in of Turrini et al. [31] for efficient network characteristics, order to reach participants before the prenatal education and Lasker et al. [60] for partnerships functioning period. The second questionnaire (T2) will be sent at (Fig. 1). An adaptation of the Social Network Analysis 33 weeks of pregnancy, in order to reach participants after Tool [61] will also be used in order to estimate how the prenatal education period. The third and last question- these characteristics and determinants may consolidate naire(T3)willbesent6weeksafter theexpecteddateof group prenatal education, online prenatal education and birth. All questionnaires will be sent by email and completed perinatal information. Each interview will last approxi- online. mately 45 min. These interviews will be held simultan- eously with the cohort study and will be completed by Qualitative interviews documentary sources provided by the participating sites. Semi-structured individual qualitative interviews with parents will be based on an interview guide developed Recruitment strategies according to the Interactive Quality Health Education For the cohort study, all questionnaires will be com- Outcomes Model [56]. Interviews will be conducted by pleted in electronic format and data kept on a secured phone in order to facilitate participation. Each interview server hosted by the principal investigator’s institution. will last approximately 45 min. Mothers and partners Pregnant women and their partners will be recruited at from each participating site and each prenatal education their first contact point with participating sites, namely mode (group or online prenatal education) will be recruited at their first ultrasound test or prenatal meeting. In according to a stratified sampling until data saturation is ultrasound clinics, a bookmark providing connection reached (expected N =40) [57–59]. Qualitative interviews information will be given by receptionists when parents will be held simultaneously with the cohort study. attend the first dating ultrasound. A research assistant will then be responsible to meet potential participants in Network data collection the waiting room, provide them with the necessary infor- In order to evaluate structural characteristics of efficient mation and give them the opportunity to complete the networks and collaborations, individual qualitative consent form and start answering the questionnaire on Roch et al. BMC Health Services Research (2018) 18:382 Page 5 of 8 Fig. 1 Networks and partnerships effectiveness reference framework. Legend: Adapted from Lasker et al. (2001) and Turrini et al. (2010) an iPad. Potential participants will also be free to keep abandonment. All participants will be eligible for the the bookmark and complete the questionnaire later at drawing of six iPads, with chances to win proportion- home. In prenatal clinics, the bookmark and project in- ately increasing with the number of completed question- formation will be given by nurses to future parents, naires (one to three). which will then be free to complete the online consent form and questionnaire at home. Posters will also be dis- Statistical analysis played in all participating sites, with the possibility for Sample size potential participants to contact the principal investiga- Assuming an effect size of 0.36 (for perinatal knowledge tor or project coordinator directly if they want to partici- with or without prenatal education) and a 1:1:2 alloca- pate. Once participants are registered, follow-up will be tion between groups (group prenatal education: online done by email or phone. prenatal education: without prenatal education) [13], a For qualitative interviews, parents will be recruited at power of 80% and a bilateral test threshold of 0.025, a their first postnatal clinic encounter in participating total of 445 pregnant women and 445 partners (2 groups health and social services centers (e.g. immunization of 111 with prenatal education and 1 group of 223 with- clinics, breastfeeding clinics, etc.). A bookmark with the out prenatal education) is required at the third measure- research team coordinates and project information will ment time. An ongoing longitudinal study conducted by be given by nurses to new parents, who will be invited our research team with new parents in the Québec to contact the research team in order to verify their region allows us to expect a participation rate of 80% for eligibility and participate to the project. partners and a retention rate of 70% at the end of the For the multiple case study, expert stakeholders will three measuring times. An initial sample size of 795 be recruited through a snowball sampling technique pregnant women and up to 795 partners is therefore starting with the health and social services centers’ anticipated. A second power calculation based on decision-makers initially involved in the study. Jakubiec et al. data [40] was done for the most important secondary outcome (psychological distress) and resulted Incentives and retention strategies in a smaller sample size. Births by territory data suggest In order to prevent loss to follow-up during the cohort a sufficient pool to recruit the required sample size study, automatic email reminders will be sent twice after within 3 to 4 months. the sending of T1, T2 and T3 questionnaires. If the questionnaire is not completed after that, the research Quantitative analysis coordinator or a research assistant will call the partici- Descriptive analysis will be conducted at the three time pant as a last reminder or to record the reason for points. For the main outcome (measured twice), Roch et al. BMC Health Services Research (2018) 18:382 Page 6 of 8 difference between prenatal education groups (group will be developed alongside a content analysis [67]. UCI- prenatal education and online prenatal education) and NET software version 6 [68] will be used to view and standard care without these prenatal education services compare perinatal networks structure according to the will be calculated. Bivariate linear regression models will analytical approach described by Scott et al. [69], as then be used to measure the association between this recommended by Provan et al. for the reinforcement of difference and secondary outcomes. Bivariate linear re- efficient collaboration networks [61]. The integration of gression models will be used to compare prenatal educa- different data sources will allow a cross-sectional tion groups (group prenatal education and online validation of results. prenatal education) to the absence of these prenatal edu- cation services for health determinants measured twice. Collaboration with decision-makers Non-multicollinearity, normality of residuals and homo- Decision-makers of the two participating health and geneity of variances will be verified and a variable trans- social services centers have committed to facilitate the formation will be performed if these postulates are not implementation of this project in their respective estab- met. Outcomes measured at the three time points will lishments. Based on the administrative data collected be analyzed with bivariate repeated measures models. and usability of online prenatal education, they will For continuous and categorical outcomes, mixed models standardizeasmuchaspossible their offerofgroup and generalized estimating equation models will be used prenatal education and online prenatal education be- respectively. For the generalized estimating equation fore the recruitment in order to optimize the results models, binomial distribution will be used for binary of the study. Responding to priorities in public health outcomes and multinomial distribution for outcomes and clinical services organization, this engagement with multiple categories. Multiple imputation will be will facilitate a relevant follow-up of the impacts of used for randomly distributed missing data. Depending group and online prenatal education. The study of on the results, sensitivity analysis may be performed for the service delivery models for prenatal education and geographic regions, health establishments providing pre- the associated regional networks providing these ser- natal education, group or online prenatal education for- vices will also promote collaboration between the pol- mat, exposure level to online prenatal education and itical decision-makers of the Ministry of Health and healthcare providers involved in pregnancy follow-up. Social Services of Québec, the National Public Health All statistical models will be adjusted for sociodemo- Institute of Québec, and the Public Health Agency of graphic data, use of other information sources and preg- Canada who have agreed to actively participate in the nancy follow-up data. Analysis will be performed with interpretation of results and mobilization of knowledge Statistical Analysis Software version 9.4 (SAS Institute, strategies. Cary, NC, USA). Qualitative analysis Discussion Data from semi-structured interviews will be recorded, Knowledge translation strategies transcribed, anonymized and analyzed with QDA Miner An advisory committee (composed of all authors, health software version 5 (Provalis Research, Montreal, QC, professionals and managers as expert knowledge users) Canada). Content analysis and integration of quantitative will support the development and operationalization inferences will be conducted based on an adaptation of of the study, notably for data collection follow-up and the Interactive Quality Health Education Outcomes knowledge translation. A monitoring committee Model [56]. Administrative data will be treated in a de- (composed of all authors, decision-makers, parent repre- scriptive manner in order to establish the general and sentatives and policy makers as expert knowledge users) comparative profile of users. Quality and confidentiality will be responsible for sustained knowledge mobilization of data will be rigorously ensured by the use of consoli- throughout all the study in order to support dated criteria and validated qualitative methods [62, 63]. organizational and political decisions related to perinatal education services. This knowledge mobilization approach Multiple case study analysis in its process, reflections, tools and results can be shared Case studies will consist of perinatal information net- with the involved actors in order to disseminate the best works of the two participating health and social services practices in organizational terms for the users, the organi- centers in which local community perinatal information zations, and partners of perinatal services networks. The networks will be embedded. For each study case, matri- use of brief reports, narrated slides and a website intended ces allowing the evaluation of determinants in relation for the users, decision-makers, and partners will make up to networks success factors and collaborative actions the principal knowledge transfer strategies and results presented in perinatal governmental programs [64–66] dissemination. Roch et al. BMC Health Services Research (2018) 18:382 Page 7 of 8 Expected outcomes Competing interests The authors declare that they have no competing interests. This study will be one of the first to consider the im- pacts of online prenatal education on different health determinants and perinatal health status in a Canadian Publisher’sNote Springer Nature remains neutral with regard to jurisdictional claims in context. This will allow for important knowledge acqui- published maps and institutional affiliations. sition regarding the impact of online prenatal education as a new technological service delivery model compared Author details Faculty of Nursing, Université Laval, 1050 avenue de la Médecine, Québec, to an absence of group prenatal education in some QC G1V 0A6, Canada. CHU de Québec Research Centre – Université Laval, health and social services centers settings. Indicators re- Hôpital Saint-François d’Assise, 10 rue de l’Espinay, Québec, QC G1L 3L5, lated to the complementarity of group and online pre- Canada. Centre intégré de santé et de services sociaux de Chaudière-Appalaches, Hôtel-Dieu de Lévis, 143 rue Wolfe, Lévis, QC G6V natal education and those available in a community 3Z1, Canada. Université de Montréal Public Health Research Institute, 7101 setting will refine our understanding of regional peri- avenue du Parc, Montréal, QC H3N 1X9, Canada. Faculty of Nursing, natal services networks. As studies involving future fa- Université de Montréal, 2375, chemin de la Côte-Ste-Catherine, Montréal, QC H3T 1A8, Canada. Department of Nursing, Université du Québec en thers or partners are uncommon, although their Outaouais, 283 boulevard Alexandre-Taché CP 1250, Gatineau, QC J8X 3X7, involvement in perinatal period is strongly recom- Canada. Faculty of Medicine, Université Laval, 1050 avenue de la Médecine, mended [70], results will also indicate how group and Québec City, QC G1V 0A6, Canada. School of Psychology, Université Laval, 2325 Allée des Bibliothèques, Québec City, QC G1V 0A6, Canada. Ingram online prenatal education can contribute to their School of Nursing, McGill University, 680 Sherbrooke West, Montréal, QC H3A well-being and that of their family. This project also has 2M7, Canada. Institut national de santé publique du Québec, 945 av Wolfe, the potential to improve harmonization of group pre- Québec City, QC G1V 5B3, Canada. School of Social Work, Université de Montréal, 3150 rue Jean-Brillant, Montréal, QC H3T 1N8, Canada. natal education and the user-friendliness of online pre- Département de sociologie, Université de Montréal, 3150 rue Jean-Brillant, natal education. This could potentially improve nurses’ Montréal, QC H3T 1N8, Canada. Department of Political Science, Faculty of professional practices, as well as those of other health Social Sciences, Université Laval, 1030 avenue des Sciences Humaines, Québec, QC G1V 0A6, Canada. School of Public Health, Université de professionals and community stakeholders involved in Montréal, 7101 avenue du Parc, Montréal, QC H3N 1X9, Canada. perinatal education. The partnership approach will assist in the development of a measurement culture and sup- Received: 12 February 2018 Accepted: 14 May 2018 port decision-making regarding service organization and delivery models of prenatal education in Québec as well References as other Canadian provinces where online prenatal edu- 1. Martin CJH, Robb Y. Women’s views about the importance of education in cation are provided, in order to optimize perinatal health preparation for childbirth. Nurse Educ Pract. 2013;13(6):512–8. services. 2. Koehn ML. Childbirth education outcomes: an integrative review of the literature. J Perinat Educ. 2002;11(3):10. 3. Edmonds JK, Cwiertniewicz T, Stoll K. Childbirth education prior to Acknowledgements pregnancy? Survey findings of childbirth preferences and attitudes among We thank the Public Health Agency of Canada, the Ministry of Health and young women. J Perinat Educ. 2015;24(2):93–101. Social Services of Québec, the participating health and social services centers 4. McArdle A, et al. How pregnant women learn about foetal movements: and the online prenatal education private provider for their in-kind contribution sources and preferences for information. Women Birth. 2015;28(1):54–9. to the project. We also thank all knowledge users involved in the study for their 5. Criss S, et al. The role of health information sources in decision-making input on its relevance, their commitment to its facilitation and their support for among Hispanic mothers during their Children’s first 1000 days of life. integrated knowledge transfer strategies. Matern Child Health J. 2015;19(11):2536–43. 6. Grimes HA, Forster DA, Newton MS. Sources of information used by Funding women during pregnancy to meet their information needs. Midwifery. This study is funded by the Canadian Institutes of Health Research (CIHR) 2014;30(1):e26–33. and the Fonds de recherche Santé – Québec (FRSQ). 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Published: May 29, 2018

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