Bilag 1: Søgeprotokol s. 1-4.
Bilag 2: Lagan, B. M., Sinclair, M., Kernohan, W. G. 2011 “What Is the Impact of the Internet on Decision-Making in Pregnancy? A Global Study”, BIRTH: Issues in Perinatal Care, 2011, nr. 38:4, s. 336-345.
Bilag 3: Weston, C., Anderson, J. L. 2014 ”Internet use in pregnancy”, British Journal of Mid-wifery 2014, nr. 7, s. 488-493.
Jordemoderuddannelsen. UC Syddanmark Litteratursøgning / søgeprotokol
1
Studie nr. Navn Hold Dato
115 Anna Lindvig Greve JM14V 27/4-17
112 Simone Glerup Jensen JM14V 27/4-17
Jordemoderfaglig problemstilling:
Flere og flere gravide søger graviditetsrelaterede informationer gennem medier. Denne stigende tendens har set at have en påvirkning på de gravide kvinder. Disse påvirkninger kan både være positive, hvor kvinderne får en større viden omkring det emne, de gerne vil vide mere om, samt at de kan være forberedte med spørgsmål, når de kommer i
jordemoderkonsultationen. På den anden side, kan disse søgninger også have nogle
konsekvenser, så som fejlinformation eller misforståelser. Denne aktuelle tendens, berører også jordemoderens arbejde i jordemoderkonsultationen, da hun skal forholde sig til disse informationer, som kvinderne finder ved hjælp af f.eks. internettet eller gennem apps. Ud fra denne problemstilling, ses følgende problemformulering:
Problemformulering:
Hvordan påvirker det gravide at søge graviditetsrelateret information ved hjælp af medier, og hvilken betydning har dette for jordemoderens sundhedsfremmende arbejde i
jordemoderkonsultationen?
Søgeord/emneord:
Søgeord Synonym (er) Oversættelse til
fremmedsprog
Graviditet Gravide kvinder Pregnancy / Pregnant
women / Attitude to Pregnancy / Expectant Mothers
Sociale medier Social Media / Social
Networking / Internet / blog* / newsletter* /
Facebook / Twitter / Tweets
Jordemoderuddannelsen. UC Syddanmark Litteratursøgning / søgeprotokol
2 / Television
Indflydelse Effekt / betydning
/påvirkning
Influence / impact / effect / affect / factor
Informationskilde:
Valg af informationskilder samt kort begrundelse:
(databaser, søgemaskine, internet-hjemmesider mv)
Cinahl Denne database er en international sundhedsfaglig database, som indeholder kvalitative forskningsartikler. Vi valgte at søge i Cinahl, da vi tidligere har erfaring med, at finde brugbare kvalitative
forskningsartikler.
SveMed+ SveMed+ er en nordisk sundhedsfaglig database. Vi valgte at søge på denne database, da der var mulighed for at kunne finde studier udelukkende fra Norden, hvilket var en fordel i forhold til sammenlignelighed med danske forhold.
PubMed PubMed er en international sundhedsfaglig database, som indeholder både kvantitative og kvalitative forskningsartikler. Vi valgte at søge på denne, for at sikre en bred søgning.
Jordemoderuddannelsen. UC Syddanmark Litteratursøgning / søgeprotokol
3 Søgning
Database Fritekst / emneord
AND / OR / NOT Antal hits
Cinahl, d. 31/3-17 "Pregnancy" OR "Attitude to Pregnancy"
OR "Expectant Mothers" (CINAHL Headings)
AND
"Social Media" OR "Social Networking"
OR "Internet" (CINAHL Headings) OR blog* or newsletter* or facebook or twitter or tweets or television (fritekstsøgning)
AND
influenc* or impact* or effect* or affect*
or factor* (fritekstsøgning) AND
Midwives OR midwifery (CINAHL Headings)
38 hits
”Internetuse in pregnancy”
Database Fritekst / emneord
AND / OR / NOT Antal hits
PubMed, d. 2/4-17 Influence (fritekstsøgning) AND
Pregnancy OR Pregnant Women (MeSH-termer)
AND
18 hits
”What Is the Impact of the Internet on Decision-Making in Pregnancy? A
Global Study”
Jordemoderuddannelsen. UC Syddanmark Litteratursøgning / søgeprotokol
4 Social Media OR Internet (MeSH-termer)
Inklusions- og eksklusionskriterier i forhold til problemstillingen Inklusion/eksklusion Begrundelse
Tidsperiode Vores inklusionskriterier for vores søgning var at vi søgte på studier publiceret inden for de sidste 10 år. Dette gjorde vi fordi vi er bevidste om at medier og brugen af denne er i konstant udvikling, og vi ønskede at få den nyeste viden og forskning indenfor området.
Sprog Vi ekskluderede studier som var på andre sprog end dansk, engelsk, svensk og norsk da vi ønskede at kunne læse og forstå de søgte artikler.
Studiedesign Vi søgte med det formål, at vi hovedsageligt ønskede at finde kvalitative forskningsartikler, men udelukkede ikke
bestemte metoder, da vi havde en formodning om at der eksisterede sparsomt materiale omhandlende netop vores problemstilling.
Eks. Geografi
Verden, Europa, Skandinavien
Vi valgte at søge bredt, og anvende Mesh-termer og Cinahl Headings, for at få den mest optimale søgning. Fra start ekskluderede vi ingen lande i vores søgning, for at få en så bred søgning som muligt. Efter de fundne hits, begyndte vi først der at være bevidste om, hvilket land studiet var publiceret fra og valgte dermed nogle forskningsartikler fra.
Dette gjorde vi grundet, at vi ønskede lande som var mest mulige sammenlignelige med Danmark, i forhold til
adgangen til internetbrug, samt opbygning og udøvelsen af svangreomsorgen.
Effektmål/fokus for interviews
Gennem vores søgning fandt vi flere forskningsartikler omhandlende vores ønskede emne, dog havde flere af dem et andet fokus og vi fravalgte derfor disse.
Antallet af personer der Vi har søgt bredt, og ikke fra start forholdt os til antallet at
Jordemoderuddannelsen. UC Syddanmark Litteratursøgning / søgeprotokol
5 indgår i undersøgelsen deltagere i studiet, da vi ønskede kvalitative artikler som
vores empiri. Ved nærmere gennemlæsning var vi opmærksomme på antallet af deltagere.
What Is the Impact of the Internet on
Decision-Making in Pregnancy? A Global Study
Briege M. Lagan, PhD, RM, Marlene Sinclair, PhD, RM, and W. George Kernohan, BSc, PhD
ABSTRACT: Background: Women need access to evidence-based information to make informed choices in pregnancy. A search for health information is one of the major reasons that people worldwide access the Internet. Recent years have witnessed an increase in Internet usage by women seeking pregnancy-related information. The aim of this study was to build on previous quantitative studies to explore women’s experiences and perceptions of using the In-ternet for retrieving pregnancy-related information, and its influence on their decision-making processes. Methods: This global study drew on the interpretive qualitative traditions together with a theoretical model on information seeking, adapted to understand Internet use in preg-nancy and its role in relation to decision-making. Thirteen asynchronous online focus groups across five countries were conducted with 92 women who had accessed the Internet for preg-nancy-related information over a 3-month period. Data were readily transferred and analyzed deductively. Results: The overall analysis indicates that the Internet is having a visible impact on women’s decision making in regards to all aspects of their pregnancy. The key emergent theme was the great need for information. Four broad themes also emerged: ‘‘validate informa-tion,’’ ‘‘empowerment,’’ ‘‘share experiences,’’ and ‘‘assisted decision-making.’’ Women also reported how the Internet provided support, its negative and positive aspects, and as a source of accurate, timely information. Conclusion: Health professionals have a responsibility to acknowledge that women access the Internet for support and pregnancy-related information to assist in their decision-making. Health professionals must learn to work in partnership with women to guide them toward evidence-based websites and be prepared to discuss the ensuing information. (BIRTH 38:4 December 2011)
Key words:decision-making, information seeking, Internet, online focus groups, pregnant women
The ethical need for health professionals to respect autonomy and respond to consumer demands has resulted in extensive international interest to under-stand health care decision-making and strengthen
‘‘shared’’ decision-making within policy and practice developments (1–3). Decision-making is an integral component of maternity care and is supported globally by recommendations that reinforce the importance of informed choice for pregnant women (4–6). To make informed choices, women need access to evidence-based information. The Internet has the potential to
offer consumers of health care an extensive mecha-nism and resource for information. Recent data indi-cate that the growth rate for Internet use in the past decade has increased by almost 500 percent, and 30 percent of the world’s population now has online net-work access (7). With almost 136 million websites currently disseminating pregnancy-related information, online usage by pregnant women is growing rapidly (8–10).
A review of the literature demonstrated limited evi-dence exploring pregnant women’s use of the Internet as
Briege M. Lagan is a Research Fellow, Marlene Sinclair is a Professor of Midwifery Research, and W. George Kernohan is a Professor of Health Research at the Institute of Nursing Research, University of Ulster, Jordanstown, United Kingdom.
This study was supported by a postgraduate studentship award from the Department for Employment and Learning, Belfast, United Kingdom.
Address correspondence to Dr. Briege M. Lagan, PhD, RM, 11 Inisho-wen Park, Portstewart, County Londonderry BT55 7BQ, UK.
Accepted March 7, 2011
2011, Copyright the Authors
Journal compilation2011, Wiley Periodicals, Inc.
336 BIRTH 38:4 December 2011
a source for health information (11). Findings were found within the text of papers investigating other issues, with the Internet only peripherally mentioned.
The ability to seek and exchange Internet information depends both on having access to the medium and also necessary technical skills. It also calls for basic compe-tence in being able to choose, classify, and critically evaluate the information that emerges.
Information seeking is described as a holistic learn-ing process to seek meanlearn-ing (12). For health care practitioners and policy-makers to be able to identify and thus address the information needs of pregnant women, their dependence on the process and their experience within it must be clearly understood.
This study builds on previous quantitative studies (10,13) that investigated pregnant women’s use of the In-ternet in pregnancy and the InIn-ternet’s effect on decision-making. Although quantified evidence can be powerful, it can fail to reveal understanding behind experiences.
This study drew on the interpretive traditions within qual-itative research to explore in-depth women’s experiences and perceptions of using the Internet for retrieval of pregnancy-related information, and the influence this medium had on their decision-making processes.
Methods
The conceptual design was underpinned by a theoretical model of information seeking adapted for the study.
Kuhlthau’s (12) information-seeking process was modi-fied to include work conducted by Kalbach (14) on seeking information on the Internet, and to integrate
‘‘decision-making’’ into the framework.
Setting and Sampling
As Lehoux et al pointed out, focus groups should be conceptualized as social spaces in which participants co-construct the ‘‘patient’s view’’ by acquiring, sharing, and contesting knowledge (15). As a result of the diverse global location of the participants and the topic of study (i.e., ‘‘Internet users’’), it was considered that online would be the most appropriate setting for data collec-tion. Turney and Pocknee also advised using virtual focus groups whenever the populations are difficult to recruit or access (16).
The method of using moderated asynchronous online focus groups was chosen instead of the synchronous ver-sion primarily because managing the logistics of sched-uling and time zones for both researcher and participants can be problematic. In addition, synchronous discussion requires participants to have higher levels of computer literacy (17). Asynchronous communication allowed the geographically separated participants to join the discus-sion at a time convenient to each.
Participants were drawn from a population of 193 women who had participated in a web-based survey, used the Internet as a medium for information in preg-nancy, and expressed a willingness to engage in an online focus group. Demographic details from a previ-ous survey were used to stratify the focus groups by country of residence (13) (Table 1).
Data Collection
Thirteen asynchronous online focus group discussions across five countries were conducted over a 3-month
Table 1. Composition of Focus Groups According to Country, Number Expressed Interest and Invited, Number Responded, and Number Participated
Focus Group
No. of Participants Expressed Interest and Invited
No. Responded to Invitation
No. of Participants in Each Focus Group
Australia 1 15 5 5
Australia 2 15 10 9
Australia 3 15 9 6
Australia 4 15 7 7
Canada 15 7 7
New Zealand 1 14 4 4
New Zealand 2 14 7 7
United Kingdom 1 15 10 9
United Kingdom 2 15 7 7
United Kingdom 3 15 8 7
United Kingdom 4 15 8 7
United States 1 15 8 6
United States 2 15 11 11
Total 193 108 92
BIRTH 38:4 December 2011 337
period. The lead researcher (B. M. Lagan) e-mailed interested participants and set up individual listserve accounts for each of the focus groups, using an Internet service provider. Measures were taken to control access and protect anonymity. The groups were moderated by the researcher (B. M. Lagan), an experienced midwife trained in conducting asynchronous communication.
According to Madge, actually seeing someone’s face can give participants a sense of reassurance (18). In an effort to develop rapport and a trusting relationship with the prospective participants, each group’s home page contained a brief profile of the researcher’s qualifica-tions, her photo, the purpose of the study, and the name of the institution conducting it. Before data collection, the invited participants were provided with detailed instructions on how to access and interact in the online discussion forum and how to unsubscribe from the group if they wished to do so.
Focus Group Guide
The structure of the focus group guide was designed around the theoretical framework and the findings from two previous surveys on Internet use in pregnancy (10,13). Key areas of discussion included: what was the need to search the Internet; why it was used as an infor-mation source; how information was retrieved, appraised, and used; and whether it influenced women’s decisions about how their pregnancy should be man-aged. Within this loose framework, questioning was unstructured and open ended, which allowed the respon-dents to answer from a variety of viewpoints.
Pilot Study
A pilot study was undertaken before the main study to evaluate the interview guide and test the feasibility and effectiveness of using an online medium for qualitative data collection and to verify that the system worked in the actual user environment. After the pilot study, minor modifications were made to the focus group discussion guide. No technical issues were identified.
Ethical Considerations
Potential benefits of the study were deemed to outweigh any risks or inconveniences. Ethics applications were submitted to, and approval granted through, arrange-ments for research governance at the University of Ulster and the Office for Research Ethics Committees in North-ern Ireland. All potential respondents were provided with a focus group protocol and participant information sheet
containing detailed information about the study. A posi-tive response to the e-mail invitation to participate in an online focus group discussion constituted consent. All participants were advised that they could withdraw from the study at any time. Participation by ‘‘invite only’’
allowed the moderator to retain control of who had access and could contribute to the group. To protect partici-pant’s identity and confidentiality, all data went through a de-identification process. Any participant who contrib-uted to the discussion needed only to identify herself to the group by a username of her choice; thus, the partici-pant could retain control over protecting her identity. To further preserve anonymity, pseudonyms have been used in the data presented in this paper.
Data Analysis
All text from each online focus group discussion was made anonymous, copied, and pasted verbatim into the qualitative data management tool, NVivo 7 (19). Analy-sis and data collection were conducted concurrently, commencing as soon as the first posting was entered using Ritchie and Spencer’s five-stage framework (20).
Initially the lead researcher (B. M. Lagan) worked with the transcripts deductively, using the elements of the the-oretical framework as a priori themes. She then worked more inductively with the data to identify comments on other didactic themes relating to women’s experiences and views on use of the Internet as an information source in pregnancy and the effect it had on their decisions about how their pregnancy should be managed.
M. Sinclair and W. G. Kernohan read a subset of the texts to check the credibility and trustworthiness of the developing analysis. Feedback from the participants on the accuracy of the identified categories and themes was also sought. Some comments were selected to represent the breadth and depth of themes, and are reported verbatim.
Results
Quantitative data are reported in the first instance to pro-vide a sense of the overall demographic profile of the focus groups. Of 193 women who initially expressed an interest to participate, 108 (56%) responded to the e-mail invitation, and of these 92 participated in a focus group. The average number of participants for each group was 7, ranging from 4 to 11 (Table 1). Table 2 presents the demographic profile of the participants, pregnancy data, and types of antenatal care.
The central theme identified was a ‘‘need’’ for infor-mation, with four broad themes emerging repeatedly from the focus groups: ‘‘validate information,’’
‘‘empowerment,’’ ‘‘share experiences,’’ and ‘‘assisted
338 BIRTH 38:4 December 2011
decision-making.’’ Within each of these themes, several subthemes were identified, many of which were interre-lated and overlapping (Fig. 1). The themes were com-mon to all the focus groups. The findings are presented under the headings of the theoretical framework and the master themes.
Information Need
Most women attributed their motivation to search for online information because health professionals did not provide enough information to meet their needs:
Health professionals often don’t have the time or inclination to explain things in the detail you would like. (Leah, Australia)
When women met with their doctor or midwife (less frequently than they would have liked), they viewed them as ‘‘busy people.’’ Some women described their appointments being ‘‘tick box’’ exercises for their health professionals ‘‘filling out irrelevant and outdated statis-tics on the maternity notes…rather than chatting about their pregnancy.’’ Others did not want to ‘‘bother’’ their health professionals unnecessarily:
I felt my questions were too ‘‘small’’ for the doctor to answer, and just needed a little info, and felt there was no reason to bother her. (Noelle, Canada)
The infrequency of antenatal visits and time con-straints at appointments appeared to have an influence on Internet use to meet information needs between appointments:
Face-to-face contact — for most of my pregnancy this was only once every 4 to 5 weeks, so wasn’t really enough to satisfy all my questions. (Alexis, Australia)
Between appointments the Internet helped to provide support and reassurance:
Appointments these days seem very few and far between (every 6 weeks, right up to 36 weeks), and I often have concerns and queries in the meantime which can be found out about, and often resolved, using the Internet. Even with such a fab mid-wife, though, appointments are often very short, and although for her pregnancy is a completely everyday matter, for us expectant mothers it is a huge and important part of our lives for 40 weeks. (Kerry, UK)
Identifying the Internet as an Information Source
For all the women the Internet was already a familiar source for information, and many wrote about how they
‘‘use the Internet to search for everything,’’ ‘‘always known it as a source for all types of information.’’ Some used it for work, entertainment, wedding planning, studying, shopping, ‘‘…so why wouldn’t I think of using it for pregnancy information?’’ One woman described how her doctor referred her to specific websites:
He knows that I like to research things on my own before mak-ing decisions so he has told me to use the Internet and gave me specific web pages to look up. (Helen, Canada)
Considerable discussion ensued about the appeal-ing and distinct characteristics the Internet has to offer. Anonymity was a major attribute of online Table 2. Demographic Profile of Online Focus Group
Participants (n= 92)
Characteristics Mean (SD) Range
Age (yr)
Mean (SD) 29.9 (4.88) 19–39
Marital status
Married 80 (87.0)
Single but in steady relationship 11 (12.0)
Divorced 1 (1.1)
Highest level of education completed
Grammar⁄secondary⁄high school 19 (20.7) Technical college⁄diploma 19 (20.7) Undergraduate degree
(Associate or Bachelors)
35 (38.0)
Postgraduate degree 19 (20.7)
Pregnancy status
Pregnant 34 (37.0)
Postnatal 58 (63.0)
First pregnancy
Yes 53 (57.6)
No 39 (42.4)
Pregnancy complications
Yes 38 (41.3)
No 54 (58.7)
Type of antenatal care
Midwife only 23 (25.0)
Obstetric consultant only 21 (22.8) General Practitioner only 3 (3.3)
Shared care* 44 (47.8)
No antenatal care 1 (1.1)
Internet access at home
Yes 89 (96.7)
No 3 (3.3)
Formal Internet training
Yes 27 (29.3)
No 65 (70.7)
Perception of Internet skills
Expert 57 (62.0)
Nonexpert 35 (38.0)
*Antenatal care shared between a midwife and general practitioner (GP); or midwife and consultant obstetrician; or GP and consultant obstetrician; or midwife, GP, and consultant obstetrician.
BIRTH 38:4 December 2011 339
communication, and was particularly important when women wanted confidential advice, to be free to ask questions, and receive support without fear of identifica-tion and judgment:
I didn’t want to announce the pregnancy to my family until after 12 weeks, so in the early weeks it was great to anony-mously get replies to ‘‘stupid questions’’ which you couldn’t ask others in real life. (Louise, Australia)
I also found the anonymity good, especially when I was looking for the answer to a question that I felt ‘too silly’ to ask my midwife. (Jennie, UK)
Flexible Internet access was highly valued and the ability to go online at any time and anywhere was perceived as a benefit:
The Internet is fast and immediate. I didn’t have to wait until office hours or until someone returned my phone call. I didn’t have to go to a library or bookstore. I could look up information while at work or at home, anytime. (Laura, USA)
When compared with other information sources, the Internet had several advantages for these respondents.
They criticized books for being expensive, difficult to search, having a one-sided and limited view, and going out of date very quickly. Magazines and leaflets were also criticized for providing limited detail. Overall, they reviewed the Internet as a valuable source for informa-tion and described it as a ‘‘font of all knowledge’’:
When I was a kid, my parents were big ‘investors’ in encyclo-paedias…Google is the encyclopaedia of this century. The Internet contains so much information that can be accessed in seconds. (Infinity, Australia)
The magazines all seemed to say the same thing…My health professional had only one opinion and appointments are short.
Books go out of date quickly. I found the Internet had different perspectives to offer and more current information. (Jeannie, USA)
Retrieving Information from the Internet
Women used different strategies to retrieve online information, but in the main they commenced their search by entering key words into a search engine such as Google. A desire to critically evaluate a diag-nosis or a problem helped focus their search. Many preferred sites supported by health authorities or well-known medical or academic institutions. Most women recognized the need to distinguish among practices available in different countries. They used more advanced search techniques, such as focusing on their country of residence. Phrases, quotation marks, and extra words helped to narrow their searches. They articulated an understanding of how these techniques helped to focus their search to provide ‘‘authentic’’
choices:
I used Google first of all…limiting my search to NZ pages.
I read through the summaries of the first few hits and chose the first commercial site because I knew that would give me a quick and basic overview, rather than an overly scientific one.
(Chaucey, New Zealand)
Numerous participants shared alternative search strat-egies, which included going directly to websites adver-tised in an information leaflet they had been given or by starting a ‘‘thread’’ on the topic on a discussion forum:
I would visit open discussion forums that were debating the issue or, begin a thread myself and ask for the opinion of others.
(Angie, UK)
Participants reported that when they found websites they liked, they would often ‘‘bookmark the site’’ or
INFORMATION
NEED
Assisted Decision-Making
Empowerment Validate
Information
Share Experiences
Social Support Knowledge
Anonymity
Reassurance Satisfaction Interactivity
Choice
Control
Clarity
Internet use in Pregnancy
Fig. 1. Main themes and subthemes related to online information seeking drawn from focus groups.
340 BIRTH 38:4 December 2011