Interactive and non-interactive e-learning in prenatal care

Midwives are known as the main care providers during pregnancy, and play a key role in providing pregnant women with consultation and training about pregnancy complications (Murray-Davis et al, 2019; Owili et al, 2019). A healthy diet during pregnancy can reduce excess weight gain and such complications as pregnancy hypertension, preeclampsia, gestational diabetes mellitus, likelihood of a caesarean section, large for gestational age and childhood obesity (Timur et al, 2018). Regular exercise during pregnancy can mitigate complications such as preeclampsia, back pain, vomiting, cramps, anxiety, and insomnia (Perales et al, 2017). It is estimated that a large number of pregnant women have low levels of knowledge on pregnancy-related exercises and do not pursue these activities (Savvaki et al, 2018).

The presence of professional midwives and availability of high-quality prenatal care is a prerequisite for supporting safe motherhood (Nguyen et al, 2020). Nowadays, midwives should improve their professional skills along with their knowledge, making in-service education courses necessary (Belowska et al, 2015). These courses enhance midwives' knowledge and skills to undertake their tasks (Gavine et al, 2019). In-service education includes a series of activities developed to maintain and promote the qualifications and capabilities of working staff in their assigned tasks and help organisations to achieve their objectives (Taheri et al, 2017). It can also improve collaboration, discipline, job satisfaction, and innovation and mitigate job errors (Belowska et al, 2015). Studies have shown that midwives tend to participate in in-service programs with different educational approaches to constantly promote their positions (Gavine et al, 2019).

The ongoing development of professional skills, especially in medicine, is now changing and improving (Kim and Kim, 2019; Mahmoudi et al, 2021). The most significant constraint on midwives' tendency to participate in-service education is insufficient time to study novel and valid educational material (Gavine et al, 2019). As a result of their high workloads, midwives are often unable to participate in full-time, part-time, and ongoing educational programs. It might be more accessible for them if some parts of the training programs were done online. E-learning courses can eliminate this barrier and make learning more efficient in comparison with the conventional approaches (Walsh et al, 2018; Rouleau et al, 2019).

Providing textual content via a mobile application is the simplest and most common e-learning approach (Golenhofen et al, 2020). Smartphones are now extensively utilised by health providers to communicate, manage patient care information, and prepare education (Klímová, 2018; Zhou et al, 2018). The main advantage of this technology is its unlimited accessibility, as smartphones can be used at any time and in any place (Badiei et al, 2016; Safdari et al, 2018).

Education through interactive content is another approach to e-learning. In this approach, a topic is presented to the learner and a question is then asked accordingly. Through education, feedback is provided for the learner's responses, and more information and educational topics are then presented until the education process is completed. The aim of interaction in education is to lead learners towards the point in which they can initially assess assumptions and then accept or reject new information (Mahdiyoun et al, 2015; Donkin et al, 2019).

Face-to-face training is more suitable for learning psychomotor skills. There is also the possibility of more interaction between trainees and trainers in this approach. As a result of certain challenges, such as the COVID-19 pandemic, that reduced the possibility of attendance at in-person classes, as well as the new generation's tendency to use e-learning, educators have become more interested in adopting new and state-of-the-art methods such as virtual learning and conducting relevant studies (Rezamahaleh et al, 2020). According to the results of a study comparing the effects of interactive and non-interactive e-learning, both methods enhance the knowledge of intensive care unit nurses in terms of brain death and organ transplant; however, they were more satisfied with interactive courses (Mahdiyoun et al, 2015). According to another study drawing a comparison between smartphone-based and booklet-based educational courses among dentistry students, smartphone-based educational software applications were more efficient in knowledge promotion (Sarabadani et al, 2019). Furthermore, a systematic review concluded that smartphone-based education was more effective, although there are some constraints on the use of smartphones in the clinical setting (Chase et al, 2018).

The bulk of studies on e-learning have compared e-learning methods with conventional approaches (Yazdannik et al, 2018; Rouleau et al, 2019); however, there are still scant studies comparing different e-learning approaches with each other. Therefore, this paper demonstrates and compares the effects of interactive and non-interactive e-learning courses on the knowledge and self-efficacy of working midwives in prenatal care in health centres.

Methods

This quasi-experimental study included two groups that were analysed in pre- and post-intervention phases. The research sample consisted of 76 midwives working in treatment centres affiliated with the Iran and Tehran Universities of Medical Sciences. The study aimed to compare the effects of interactive (computer-based) and non-interactive (smartphone-based) e-learning on the knowledge and self-efficacy of midwives in terms of nutrition, exercise, and weight control during pregnancy.

Convenience sampling was used to select participants. The inclusion criteria were being a computer user, having a smartphone, and not having participated in any educational courses similar to the one implemented in this study. The exclusion criteria included withdrawal from the study and not participating in the post-test phase. The participants were divided randomly into the computer e-learning and smartphone e-learning groups. To minimise encounters between the participants of the two groups, the midwives of one centre were assigned to one group. During the study, two participants of the computer group and two participants of the smartphone group were excluded from the study as they lacked sufficient time to complete it.

The participants joined their own channel on the app ‘Telegram’ where guidance and explanation on how to respond to the pre-and post-test questionnaires, how to use the application, and how to become a member of the website was provided. The participants were also provided with a phone number to ask questions if needed.

Educational content

The educational content created by the researchers was studied, assessed, and approved by 10 midwifery professors from the Tehran University of Medical Sciences. The content was credited by the university to comply with the Educational Office website, and valid certificates were then issued for all the participating midwives. The educational content on nutrition had 11 main items, the content on exercise had 21 items and the content on pregnancy weight control had seven items, which are outlined in Box 1.

Box 1.Items included in educational contentNutrition

• Topic importance
• Taking history
• Nutritional pyramid
• Macronutrients
• Vitamins
• Foods with limited use in pregnancy
• Insufficient nutrition adverse effects
• Consultation with nutritionist in specific situations
• Nutritional instructions in common pregnancy complications
• Nutritional instructions in high-risk pregnancies
• Resources.

Exercise

• Importance
• Advantages
• Risks
• Absolute and partial counter-indications
• Exercise plan
• Exercise intensity
• Frequency of exercise
• Hyperthermia
• Hydration
• Energy
• Complication signs during exercise
• Exercise in high altitudes
• Professional exercise
• Women at risk of gestational diabetes mellitus
• Obese women
• Women at risk of abortion and preterm delivery
• Women at risk of fetus insufficient growth
• Stretching and aerobic exercises
• Exercise in a sitting position
• Exercise in a lied-down position
• Resources.

Pregnancy weight control

• Importance
• Pregnancy weight changes
• Body mass index demonstration methods
• Gaining weight of mothers with single fetus
• Gaining weight of mothers with twin fetus
• Gaining weight of teenage mothers
• Resources.

In the interactive e-learning group, the online database was available at a web link provided to the participants. After joining the database, the participants received usernames and passwords to access the educational content in their accounts. An introduction was provided for each topic and a question form was provided in the next step to provoke the curiosity of participants. The questions were ‘patient management problems’, in which a brief description of a clinical situation was given, followed by a series of multiple choice questions. When the correct answer was selected, participants were shown more information on the topic of the question. If an incorrect answer was selected, the reason why the answer was not correct was explained and the participant was then redirected to a page to select the correct response. The position of answers in the list changed automatically between attempts. The questions remained visible on screen at the same time as the educational content was displayed. The questions were solely for self-examination and did not affect the final assessment. There was a time limit, at the end of which the educational content was summarised and presented to the participants in PDF format so that they could download and read it offline.

For non-interactive e-learning, a mobile Android-compatible application for educational content was designed by an IT engineer and installed on the participants' smartphones. On the homepage, main items were shown, which displayed sub-items when selected. This divided the content into smaller sections that were linked to one other, allowing the participants to read the items whenever they wanted.

Evaluating knowledge and self-efficacy

A researcher-made questionnaire was used to evaluate the knowledge and self-efficacy of midwives in terms of educational content. The two sections of the questionnaire, assessing knowledge and self-efficacy respectively, were presented to 10 midwifery professors at the Tehran University of Medical Sciences who assessed the content validity.

Cronbach's alpha was employed to assess the reliability of the self-efficacy and knowledge scales in terms of internal consistency, and Kuder–Richardson formulas were used to evaluate the reliability of the knowledge scale. The questionnaire containing both scales was presented to 15 midwives from the Qazvin Province who did not participate in the study. Cronbach's alphas of self-efficacy and knowledge were 0.832 and 0.712 respectively. After reliability assessment for repeatability, the questionnaire was presented to the same 15 midwives 10 days later. The Pearson internal consistency rates were reported as 0.981 and 0.734 for self-efficacy and knowledge respectively.

The questionnaire was sent to the participants, who gave their responses to the researcher via e-mail. After the questionnaires were completed, the participants were allowed to access the educational content for a month. The questionnaire was designed to let the participant fill it once before accessing the educational content and once after. Immediately after the intervention, the questionnaire was presented to the participants. The questionnaire had three sections, the first of which concerned demographics (6 questions), the second (25 questions; minimum score: 0, maximum score: 25) assessed participants' knowledge of nutrition, exercise, weight control, and overall care during pregnancy, and the third section (15 questions; minimum score: 15, maximum score: 75) examined participants' self-efficacy in nutrition, exercise, weight control, and overall care during pregnancy.

Finally, data were collected and analysed using the statistical package for social sciences, and descriptive statistics were used to illustrate the data in tables. Independent and paired t-tests were use to analyse the data, with P=0.05 considered significant.

Results

In total, 76 midwives working in in prenatal care at health centers were compared in two groups that used interactive (computer-based) and non-interactive (smartphone-based) education respectively. According to a one way analysis of variance for age and a chi-squared test for all other characteristics, both groups were homogenous in terms of age, job experience, years of education, in-service e-learning, employment type, and interest in e-learning (P>0.05). The sociodemographic characteristics of the participants are shown in Table 1.

The average age of participants in the interactive group was 33.07±1.43 years old and 32.98±1.02 years old in the non-interactive group. The average job experience of participants in the interactive group was 9.7±7.55 years, and 7.19±6.7 years in the non-interactive group. According to the independent t-test, the two groups had no significant differences in terms of knowledge or self-efficacy in nutrition, exercise, weight control, and overall care during pregnancy before the intervention (P≥0.05).

The results of the paired t-test revealed that the knowledge of midwives on nutrition (P<0.00), exercise (P=0.01), and overall care (P<0.00) increased significantly in the post-intervention phase in the interactive group. However, the increase was not significant in terms of knowledge on weight control (P=0.06). The results of the comparison of knowledge scores are shown in Table 2. The self-efficacy of midwives from the interactive group increased significantly in the post-intervention phase in exercise (P=0.003) and overall care during pregnancy (P=0.004), whereas self-efficacy in weight control (P=0.18) and nutrition (P=0.055) did not increase significantly. The results for self-efficacy are shown in Table 3.

In the non-interactive group, the knowledge of midwives on nutrition (P=0.04), exercise (P<0.00), and overall care (P<0.00) during pregnancy increased significantly in the post-intervention phase; however, the increase was not significant in weight control (P=0.26) (Table 2). Self-efficacy in nutrition (P=0.03), weight control (P=0.01), exercise (P<0.00), and overall care during pregnancy (P<0.00) improved significantly in the post-intervention phase (Table 3).

The independent t-test showed were no significant differences in the knowledge and self-efficacy of midwives in terms of nutrition, exercise, and overall care during pregnancy between the two groups in the post-intervention phase (P<0.05) (Tables 2 and 3).

Discussion

This study compared the knowledge and self-efficacy of 76 midwives in terms of nutrition, exercise, weight control, and overall care during pregnancy between two groups, one who used interactive e-learning (computer-based) and one who used non-interactive e-learning (smartphone-based). In general, interactive learning has been found to be more engaging for students, and increases efficacy, motivation and student-centred learning (Herianto and Wilujeng, 2021).

Both methods significantly improved the knowledge of midwives on nutrition, exercise, and overall care during pregnancy. Similarly, studies have found that computer-based interactive e-learning significantly increased knowledge and attitudes of medical students in terms of patient care (Gaupp et al, 2016), and that the use of smartphone applications and participation in workshops increased the knowledge of emergency unit nurses (Yazdannik et al, 2018). According to the results of a study that compared oral learning, e-learning, and in-home educational packages, all forms of education were equally efficient in increasing levels of knowledge among nurses (Soper, 2017). Despite differences in methodology, educational content, and tools in these studies, all of them emphasised the positive effects of e-learning on knowledge improvement.

The present study found no significant differences between the two methods in promoting knowledge among midwives. Another study investigating nurses' knowledge on brain death and organ transplantation found that both interactive and non-interactive e-learning groups demonstrated increased knowledge (Mahdiyoun et al, 2015). In Taiwan, Sun and Hsu (2013) conducted a study to compare three e-learning methods with different layers of interaction. Their results showed that the three methods managed to equally improve the students' knowledge of IT.

However, a study of nurses' knowledge in 2016 found that interactive e-learning significantly increased nurses' knowledge, more than that of educational booklets (Badiei et al, 2016). Similarly, Babajani-Vafsi et al (2019) compared virtual learning through smartphone-based social media with interactive oral learning and showed that the mean of knowledge scores increased significantly in interactive oral learning. The differences in results between these studies and the present study could be because of the different educational methods under study.

More recently Golenhofen et al (2020) found that smartphone-based e-learning was more effective than computer-based e-learning in educating medical students. In the authors' experiences, participants are more likely to use mobile phones, which would account for the discrepancy with the results of Golenhofen et al (2020). The interactive nature of e-learning in the computer-based grooup and the absence of this interaction with participants in the smartphone-based group meant that relatively similar results were achieved in both research groups in the present study. Lee and Shin (2016) reported that knowledge scores improved more in an interactive e-learning group than a non-interactive group among nurses. This could be the result of the type of interaction and different educational content.

The results of the present study emphasise the importance of increasing midwives' knowledge on prenatal care through different types of in-service e-learning methods, as it appears that both interactive and non-interactive methods are equally effective in significantly improving midwives' knowledge.

The findings show that self-efficacy did not improve significantly in nutrition and weight control in the interactive e-learning group after the intervention. Part of a midwife's role is to help women manage weight gain. In cases where there is concern related to a patient's body mass index, a midwife should refer them to a gynecologist (Lauridsen, 2020); therefore, it can be concluded that the midwives need to be highly capable and self-efficient.

Both methods (interactive and non-interactive) were comparatively effective in improving the self-efficacy of midwives. Similarly, Lee and Shin (2016) reported that the self-efficacy of nursing practitioners increased in cases of interactive and non-interactive learning, with no difference 1 week after a learning intervention. The intervention involved giving nursing students feedback on their practice of particular procedures following education, one group via video taken during self-directed practice and one without video. Their findings also found that interactive and non-interactive methods of e-learning were effective in improving the self-efficacy of working personnel.

Conclusions

The findings of this study showed the effect of both interactive (computer-based) and non-interactive (smartphone-based) e-learning in improving the knowledge and self-efficacy of midwives in prenatal care. Interactive learning has previously been found to be more engaging than non-interactive learning for students. Therefore, interactive methods are thoguht to lead to higher levels of motivation for learning and active participation than non-interactive methods. However, in the present study, both methods were found to be similarly effective in improving midwives' knowledge and self-efficacy. This may be because in the non-interactive e-learning group, more access was provided to educational content with no spatiotemporal limitations, as it was accessible via smartphone.

To achieve effective outcomes and improve midwives' knowledge, the authors recomment that novel educational methods are more frequently used. People vary in motivation levels and interests, which necessitates different types of educational techniques and access to various novel methods, meaning facilitating health personnel's access to new educational material plays an important role in improving their knowledge. At the same time, it seems essential to accurately demonstrate objectives, utilise novel and proper educational contents, and adopt state-of-the-art, effective, and objective-oriented methods in designing educational programs to achieve positive outcomes in training health personnel.

Key points

• Continuous education of midwives with efficient and novel techniques is vital to improve the quality of prenatal care and women's health.
• E-learning was found to have a positive effect on the knowledge and self-efficacy of midwives
• The authors recommend the use of e-learning approaches alongside conventional in-service training methods

CPD reflective questions

• Why are midwives more interested in e-learning today?
• What are the limitations of e-learning in midwifery education?
• How can the limitations of e-learning be reduced?