Evaluation of a didactic toolkit for promoting preconception health among nursing and midwifery students

ABSTRACT

Ever higher rates of infertility among the population add to the importance of promoting fertility awareness. A digital didactic toolkit was therefore developed for use as educational material. The cross-sectional observational study aimed to test and evaluate a didactic toolkit on reproductive health in the context of nursing and midwifery students. A convenience sample consisted of 88 nursing and 61 midwifery students, all studying full-time. An evaluation questionnaire was developed based on a literature review. The evaluation included 36 didactic tools within the toolkit, divided into 6 categories: Age and Fertility (n = 3), Understanding Reproduction (n = 2), Lifestyle Factors Affecting Fertility (n = 13), Infection Risks (n = 4), Environmental Hazards (n = 1), and Social Environment Issues (n = 13). MATLAB R2017b and SPSS v.26 were used to organize and analyze the data. A web platform providing information on preconception health received positive feedback and was reported to be ‘very good’ for 5 statements and ‘excellent’ for 3 items. The participants identified several groups that could be interested in the didactic toolkit, such as their peers, students, and couples planning a family. The participants already possessed a considerable amount of information about preconception health when they assessed the didactic tools, hence they focused more on its form and design than its content. Social media should be considered as a platform for the ongoing development of the toolkit. To ensure the content is comprehensible, future studies should include participants who are not healthcare professionals.

KEYWORDS:

• Fertility awareness
• educational material
• preconception care
• competence
• health promotion

Introduction

Health-related behaviors prior to conception impact fertility, pregnancy, and birth outcomes, and have been a strong impetus for promoting healthy behaviors during the reproductive years, with preconception care being seen as a related area. The World Health Organization (2013) states that preconception care is ‘the provision of biomedical, behavioral, and social health interventions to women and couples before conception occurs and aims to improve their health status and reduce behaviors and individual and environmental factors that contribute to poor maternal and child health outcomes in both the short and long term’.

Preconception care may be seen as a package of preventive services (health promotion, screening, counseling, management of risk factors) intended to reduce modifiable risk factors in the pre-conception period with a view to optimizing conception, pregnancy outcomes, neurodevelopmental outcomes, chronic childhood conditions as well as maternal and child health (Bortolus et al. 2017). Many countries have developed recommendations and guidelines for preconception care that include a range of preventive, therapeutic, and behavioral interventions (Bortolus et al. 2017; Nypaver, Arbour, and Niederegger 2016). However, for these efforts to be effective, the target population and technological advances available to current generations must be carefully considered while developing appropriate ways to communicate information about preconception health.

Reproductive health is one of the most important components of human health and thus associated with several important preventive aspects like reproductive information, education, and counseling, and the creation of responsibility in both sexes, taking account of the cultural conditions of society (Pourkazemi et al. 2020). In this effort, healthcare professionals play a central role in promoting reproductive health and implementing policies that impact individual and collective health. The primary focus of reproductive health strategy is usually on adolescence and adolescents. However, this is often a critical and complex period with rapid physical, psychological, and cognitive changes that make health promotion, and thus knowledge translation challenging.

Knowledge translation may be defined as a complex process of knowing what knowledge users should do with the shared knowledge to influence health and clinical care, whether through increased awareness, knowledge sharing, or by facilitating behavioral or practice change (Barac et al. 2014; Wilschut et al. 2021; Zidarov, Thomas, and Poissant 2013). Different knowledge translation strategies have emerged, such as printed educational materials (e.g. individual interventions or multifaceted knowledge translation interventions in the form of toolkits), educational sessions, educational outreach, local opinion leaders, audit and feedback, and reminders (Barac et al. 2014; Yamada et al. 2015).

Educational materials tend to be the most commonly used knowledge translation strategies in health and care settings because they are simple, well-known, economical, and feasible in many situations (Barac et al. 2014; Zidarov, Thomas, and Poissant 2013). Educational materials are often called ‘toolkits’, a term coined in the 1980s and seeing frequent use since then. In some ways, toolkits are a variant of multi-level knowledge transfer interventions and are considered to be more effective than single knowledge transfer interventions (Barac et al. 2014). Toolkits allow greater flexibility in application and entail a combination of the grouping of multiple knowledge translation tools and strategies that codify explicit knowledge and are used to educate and/or facilitate health behavior change (Yamada et al. 2015).

Toolkits have become popular as a knowledge translation strategy, particularly in the health and care sectors, while the Internet has become an ideal platform for disseminating toolkits and delivering tailored and targeted messages to a large global population. Although educational materials are in wide use, evidence is lacking as to their effectiveness or how their content, design, and delivery can be optimized to make them more effective. Given that educational materials, at least in health promotion, are expected to remain the dominant mode of knowledge transfer and health behavior/practice change, research into their use and effectiveness should be a priority (Álvarez-Nieto et al. 2018; Barac et al. 2014; Campbell et al. 2019; Yamada et al. 2015; Zidarov, Thomas, and Poissant 2013).

The aim of this study was to test and evaluate digital educational materials on preconception health in the context of future healthcare professionals’ (nursing and midwifery students’) competencies in relation to preconception care. The evaluation research more broadly concentrates on developing useful information about a program, policy, or similarly developed product that decision-makers need to determine whether to adopt, modify, or abandon that being evaluated (Polit and Tatano Beck 2018).

Materials and methods

Study design

A cross-sectional observational study was conducted. Data were collected using a self-report questionnaire.

Participants

The didactic toolkit was evaluated by nursing (n = 92) and midwifery (n = 63) students at two faculties of health sciences located in Western and Central Slovenia. The convenience sample comprised 88 full-time, 3rd-year nursing students (response rate: 96%) and 61 full-time midwifery students (30 from year 1; 13 from year 2; 18 from year 3) enrolled in the 2020/2021 academic year (response rate: 96%). The target population was selected due to their role as future health promoters and reproductive health counselors, and because they constitute a particularly relevant population age group for whom preconception health is becoming an important topic in the near future.

PCHC Toolkit

The Preconception Health and Care (PCHC) toolkit is based on the PCHC model developed as part of the EU-funded project ‘PRECONCEPTION HEALTH OF YOUTH, bridging the gap in and through education – PreconNet’ (grant no. 2018-1-FI01-KA203-047245). The PCHC model frames the content and defines the elements of preconception health and care that can be used to promote reproductive health. The elements describe the latest evidence-based information in the field of preconception health and care, including biological, as well as psychological, social, ethical, and cultural perspectives. The model is designed as a honeycomb model to guide the specific elaboration of the content, didactic approach, and learning outcomes related to preconception, preconception health, and care. The model and its elements form a toolkit available on the web platform (https://preco.tamk.fi/tools/). The content of the PCHC model (also called Honeycomb) describes many factors that influence fertility. Research is constantly revealing new information that should be shared with adolescents and adults to ensure they know how to protect their fertility and to help them make good choices.

As part of the digital toolkit, further didactic tools for PCHC were developed for use either in the education of health students and health professionals, or as promotional material for healthy reproductive lifestyles among laypeople. At the time of the evaluation study, 36 didactic tools within the toolkit were available: 3 in the ‘Age and Fertility’ category, 2 in the ‘Understanding Reproduction’ category, 13 in ‘Lifestyle Factors’, 1 in ‘Environmental Factors’, 4 in ‘Infection Risk’, and 13 in ‘Social Environment’. A test/quiz on reproductive health was also developed to assess knowledge on the topic. The PCHC didactic toolkit then consisted of 9 animations, 4 quizzes, 2 games for couples, 1 video, 12 scenario-based contents, 3 games with dialogue cards, 2 study case templates, and 3 posters.

Evaluation instrument

The evaluation instrument was developed following an extensive literature review since the authors were unaware of any suitable instrument tailored to researched content for evaluating didactic educational materials. A thorough review helped the research team identify key components of evaluation: content, structure, and delivery. The items surrounding these three concepts were developed together by all authors and reviewed several times before the final selection of items included in the instrument.

The instrument in the first section asked for the participants’ demographic data. The second section, ‘Evaluation of a didactic toolkit’, included items that evaluated the content and structure of a didactic toolkit. This section had 14 items based on 4-point Likert response options, ranging from strongly disagree (1) to strongly agree (4). The third section assessed the project’s web platform, which included didactic tools and thus focused mainly on the delivery. Participants had to rate eight features of this platform on a 7-point scale, from unacceptable (1) to unsurpassable (7). The type of rating scale was chosen after considerable consideration by the authors and a review of the evidence on the use of different types of scales (Krosnick and Presser 2010; Revilla, Saris, and Krosnick 2014).

The final version of the instrument underwent a face validity assessment. This was done in two steps. The instrument was peer-reviewed by three experts in the field of health promotion and later tested on a sample of 13 nursing students. In both instances, the evaluators had to assess the quality of each item in terms of the relevance and clarity. The face validity assessment revealed no specific issues with regard to relevance or clarity.

Data collection and data analysis

The PCHC model and toolkit were initially introduced to undergraduate nursing students as part of the course ‘Women’s health nursing’ and undergraduate midwifery students as part of the course ‘Midwifery and midwifery practice’, as this content fit well with the course topics. The evaluation questionnaire was sent individually to every student taking the course using their university email address along with an invitation to evaluate the PCHC toolkit and then complete the questionnaire. Data were collected between 23 October 2020 and 20 January 2021 with the web survey tool OneClick Survey (1KA 2017).

MATLAB R2017b and SPSS v.26 were used to organize and analyze the data exported from the OneClick Survey (1KA 2017). Based on ordinal scales, frequencies, and relative frequencies, we calculated the median values (Me), revealing the central tendency of the responses, and quartiles 1 and 3 (Q₁, Q₃), representing the responses’ variability.

Ethical considerations

Nursing and midwifery students were invited to take part in the evaluation study at the beginning of the course when they were also informed about the aims and research methods. Participation was voluntary and the anonymity of student responses was guaranteed. All students taking the course were emailed a link to the questionnaire. Those who decided to participate began filling out the questionnaire. The students were informed there would be no repercussions for not engaging in the study. Several email reminders were sent to the students after the study had commenced to improve the response rate. The study was reviewed and approved by the Institutional Review Board.

Results

Analysis shows that the participants find the didactic tools within the digital toolkit in all categories useful and that the didactic toolkit being considered presents the issue systematically. Table 1 displays the median values (Me) with the corresponding quartile range (Q1, Q3) of the participants’ responses to the items (rows) for each category (columns), separately. All median scores of their responses were 3 or above, showing agreement with the corresponding items. The only exception are the responses to item 11 (‘Navigating through the didactic tool is too complex’) regarding which the median value is 2 and below, showing disagreement or strong disagreement with the corresponding item. This indicates the majority of participants were generally satisfied with the didactic toolkit content. However, some of the results discussed below raise issues in need of addressing.

Table 1. Student evaluation of didactic toolkit

Item	DT category (no. of DT tools)
	Age and fertility (3)	Understanding reproduction (2)	Lifestyle factors (13)	Infection risks (4)	Environmental factors (1)	Social environment (13)
	Me (Q1, Q3)	Me (Q1, Q3)	Me (Q1, Q3)	Me (Q1, Q3)	Me (Q1, Q3)	Me (Q1, Q3)
1. The DT’s content is meaningful.	3 (3, 4)	3 (3, 4)	4 (3, 4)	3 (3, 4)	4 (4, 4)	3 (3, 4)
2. The DT presents the subject systematically.	3.5 (2.5, 4)	3 (3, 4)	4 (3, 4)	3 (3, 4)	3,5 (3, 4)	3 (3, 4)
3. The DT includes sufficient information.	3 (2, 3.5)	3.5 (3, 4)	4 (3, 4)	3 (3, 4)	4 (3, 4)	3 (3, 3)
4. The DT is useful for healthcare professionals.	3 (2, 3)	3 (2, 4)	3 (3, 4)	3 (2, 4)	3 (3, 3.5)	3 (2, 3)
5. The DT considers my previous knowledge.	3 (2, 3)	3 (2, 3.5)	3 (3, 4)	3 (3, 3)	3.5 (3, 4)	3 (3, 3)
6. I learned new things by reviewing the DT.	3 (2, 4)	3 (3, 3)	4 (3, 4)	3 (2, 3.75)	4 (3.5, 4)	3 (2, 3)
7. I can use the information acquired by reviewing the DT in my future profession.	3 (2, 4)	3 (3, 4)	4 (3, 4)	3 (3, 4)	4 (3, 4)	3 (2, 3)
8. The DT’s contents will impact my future behavior.	3 (2, 3)	3 (2, 3.5)	4 (3, 4)	3 (3, 3.75)	3 (3, 4)	3 (2, 3)
9. The DT is better suited to laypeople than to healthcare professionals.	3 (2, 3)	3 (3, 3.5)	3 (3, 3)	3 (2.25, 4)	3 (3, 4)	3 (3, 4)
10. I like the DT’s design.	3 (2, 4)	3.5 (3, 4)	4 (3, 4)	3 (3, 4)	3,5 (3, 4)	3 (2.75, 3.25)
11. Navigating through the DT is too complex.	2 (1, 2.5)	2 (1, 2.5)	1 (1, 2)	2 (1, 2)	2 (1.5, 2)	2 (1, 3)
12. The DT’s content is illustrative.	3 (2, 3)	3 (3, 3.5)	4 (3, 4)	3 (2.25, 3)	3 (3, 3.5)	3 (3, 3)
13. The DT’s content is understandable by the target population.	3 (2.5, 4)	3 (3, 3)	4 (3, 4)	3 (3, 4)	3.5 (3, 4)	3 (3, 4)
No. of evaluations	20	12	38	27	8	37

Legend: Me – Median, Q₁ – Quartile 1, Q₃ – Quartile 3; DT – Didactic tool

While looking at the quartile ranges (Q₁, Q₃) in Table 1, one sees the majority of items for the didactic tools in the ‘Age and fertility’ category had a Q₁ score of 2, revealing that at least 25% of the participants disagreed with the items. Only the meaningfulness (item 1) of the didactic tools had a Q₁ score of 3, while systematical representation (item 2) and understandable (item 13) scored 2.5 for Q₁. A similar phenomenon (Q₁ score below 2.5) was observed in the didactic tools in the category ‘Understanding reproduction’ for items 4 (‘The didactic tool is useful for healthcare professionals’), 5 (‘The didactic tool considers my previous knowledge’), and 8 (‘The didactic tool contents will influence my future behavior’). The same occurred for didactic tools in the category ‘Infection risks’ for items 4, 6 (‘I learned new things by reviewing the didactic tool’), 9 (‘The didactic tool is better suited to laypeople than to healthcare professionals’), and 12 (‘The didactic tool content is illustrative’). In the ‘Social Environment’ category, items 4, 6, 7 (‘I can use the information acquired by reviewing the didactic tool in my future profession’), and 8 had the lowest Q₁ scores of 2. The didactic tools in the ‘Lifestyle Factors’ category attracted the highest evaluation, with all median and Q₁ scores being 3 or above, except for item 11.

Item 4 (‘The didactic tool is useful for healthcare professionals’) had a Q₁ score of 2 (disagreement) in four out of six categories. Further, item 9 (‘The didactic tool is better suited to laypeople than to healthcare professionals’) also had a low Q₁, but only in two categories: ‘Age and fertility’ (Q₁ = 2) and ‘Infection risks’ (Q₁ = 2.25). Similarly, item 6 (‘I learned new things by reviewing the didactic tool’) received the same Q₁ score of 2 in three out of six categories (‘Age and fertility’, ‘Infection risks’, and Social environment’). In addition, item 8 (‘The didactic tool’s content will impact my future behavior’) scored 2 for Q₁ (disagreement) in three out of six categories (‘Age and fertility’, ‘Understanding reproduction’ and ‘Social environment’).

The rating of the web platform as a whole is shown in Table 2. Participants’ views on the PreconNet web platform were measured using 8 items. Items 1 (‘Design of the web platform’), 2 (‘Up-to-date information’), 3 (‘Web platform navigation’), 4 (‘Web platform accessibility’), and 6 (‘Interactivity’) had a median score of 5, showing that at least 50% of the participants considered these items to be very good, excellent, or unbeatable. Items 5 (‘Graphics’), 7 (‘Usefulness’), and 8 (‘Innovation’) had a median score of 6, meaning that at least 50% of the participants considered these items to be excellent or unbeatable.

Table 2. Student opinion on the PreconNet web platform

Opinion on the PreconNet web platform	f (%)							Me (Q1, Q3)
	1 Unacceptable	2 Needs improvement	3 Satisfactory	4 Good	5 Very good	6 Excellent	7 Unbeatable
Design of the web platform	1(0.7)	5(3.5)	10(6.9)	25 (17.4)	48 (33.3)	50(34.7)	5(3.5)	5 (4, 6)
Up-to-date information	1(0.7)	4(2.8)	9(6.3)	29(20.1)	39(27.1)	58(40.3)	4(2.8)	5 (4, 6)
Web platform navigation	1(0.7)	12(8.3)	17(11.8)	30(20.8)	29(20.1)	49(34.0)	6(4.2)	5 (4, 6)
Web platform accessibility	1(0.7)	11(7.6)	17(11.8)	35(24.3)	19(13.2)	55(38.2)	6(4.2)	5 (4, 6)
Graphics	1(0.7)	4(2.8)	8(5.6)	23(16.0)	34(23.6)	60(41.7)	14(9.7)	6 (4.2, 6)
Interactivity	1(0.7)	4(2.8)	5(3.5)	27(18.8)	36(25.0)	54(37.5)	17(11.8)	5 (4, 6)
Usefulness	2(1.4)	1(0.7)	7(4.9)	24(16.7)	33(22.1)	54(37.5)	23(16.0)	6 (5, 6)
Innovation	2(1.4)	2(1.4)	8(5.6)	15(10.4)	29(20.1)	57(39.6)	31(21.5)	6 (5, 6)

Legend: f – Frequency, Me – Median, Q₁ – Quartile 1, Q₃ – Quartile 3

The majority of participants use digital tools for study sometimes (39.6%) or rarely (37.5%). Frequent use of digital tools was made by 12.5% of the participants, while 9.0% never did so. Only 1.4% of the participants always use digital tools for studying. Most participants (93.1%) would recommend the digital toolkit published on the PreconNet web platform to their peers. Figure 1 shows the participants’ opinions regarding for which segments of the population the PreconNET web platform would be useful, with respect to which the participants had several options to choose from. Accordingly, they stated the web platform would be particularly useful for three groups of potential users: laypeople (132 responses), teachers in the area of health promotion (121 responses), educators at primary and secondary schools (120 responses), students of health (118 responses) and other, non-health sciences (101 responses). Only 82 students believed that social workers (82 responses) and health professionals in practice (n = 61) would benefit from the PreconNet platform. Of the 13 participants who selected the response ‘other’: 5 recommended the platform for elementary and high school students, 2 for people planning a family, and 3 for anyone wishing to know more about preconception health and care. Another participant recommended this platform for parents, while a further one for personal trainers and a last one for the general population. The majority of the participants (73.9%) agreed the didactic toolkit should also be available in the Slovenian language.

Figure 1. Students’ views on who would benefit from the PreconNet web platform.

Discussion

Fertility awareness is becoming ever more important in the face of increasing rates of infertility among the population (Sun et al. 2019). This led the World Health Organization (2013) and other relevant health institutions (American College of Obstetricians and Gynecologists 2005; International Confederation of Midwives 2019) to emphasize the need to address the preconception health of individuals, with some referring to it as the pre-pregnancy period, others more narrowly as family planning, while others still referring to it under the broad umbrella of reproductive health. Yet, the clear message is always the same – adolescents and young adults must be given credible information about fertility as knowing reproductive facts can reduce many negative effects and underpin the making of wise decisions to ensure a healthy lifestyle. Since the affordances of technology have replaced traditional sources of information (Pollard et al. 2015), it seemed very appropriate to disseminate information about preconception health through a didactic toolkit on an interactive web platform.

The aim of the didactic toolkit presented at the website preco.tamk.fi is therefore to provide evidence-based, freely-accessible information in an interactive, innovative, descriptive, and thus attractive way, just like toolkits are meant to be (Barac et al. 2014). In the evaluation, the web platform achieved very good ratings – a median score of very good (5) or excellent (6) (out of 7) for all criteria listed. The didactic toolkit also attracted high scores, with only a few exceptions. The didactic tools in the Age and Fertility category must be re-evaluated as they scored lowest (Q1) on several criteria listed in the evaluation questionnaire, suggesting they need further attention.

Items with the most frequent low scores for Q1 were ‘The didactic tool is useful for healthcare professionals’ (disagreement for didactic tools in four out of six categories) and ‘I learned new things by reviewing the didactic tool’ (disagreement for didactic tools in three out of six categories). It must be recalled that the didactic toolkit was developed for laypeople, whereas most of the participants were 3rd-year midwifery and nursing students. They possessed some prior knowledge of the topics presented, as acquired in their studies, and therefore estimated they had not obtained any new information. This might also explain why the item ‘The didactic tool’s contents will impact my future behavior’ for didactic tools in three out of six categories was met with disapproval. If participants know the facts, they might already be living by sound principles, making it unnecessary to change their behavior.

The main limitation of the study was the selection of the participants, namely, future healthcare professionals. However, these are the very professionals who are expected to promote fertility awareness among the public once they graduate and must know the information presented in the tested didactic toolkits. Moreover, they are in the age group of our target population. Since they already know the content, they might be the best critics of the design method and form (Yamada et al. 2015). Still, further studies should include youth without a background in nursing or midwifery.

The study participants also identified their peers as one group that may be interested in information about preconception health. Other groups mentioned included high school students and young couples planning to have children soon. In order for relevant information to be effectively disseminated to them, three-quarters of the participants suggested that all didactic tools be translated into the Slovenian language. Currently, all didactic tools published on the platform are in English, with some translated into Slovenian, Italian, German, Croatian, and a few into Vietnamese. As noted by Jacobs, Amuta, and Jeon (2017), it is important that everyone have access to health information resources, while we should also not underestimate the use of alternative health information sources. Yet, since both our target population and the participants in this study are information and communications technology (ICT) literate, we consider the ICT approach selected for communicating preconception health issues to be appropriate for the intended population. A possible limitation is that the study was performed only among Slovenian-speaking participants. Since the didactic toolkit was created by European healthcare professionals, it may be that the didactic toolkit is not suitable for all individuals around the world. Future studies should test the didactic toolkit’s cultural sensitivity and consequently perform a cross-cultural adaptation of the toolkit.

The rapid development of ICT requires that the web platform be a ‘live tool’, one that constantly responds to the target population’s needs. Social media are one tool currently showing an effective response from young people while providing a cost-effective source of information (Jane et al. 2018), thus making the idea of transferring the didactic toolkit of our web platform to social media seem reasonable. Further, transferring them to mobile health interventions could lead to adolescents also (Fedele et al. 2017) engaging more strongly with preconception health. The didactic toolkit should also be disseminated through schools after being adapted to the needs of specific age groups in the population. Stakeholders should be involved in disseminating the preconception health promotion by developing guidelines, policies, and national programs with the goal of raising awareness of this extremely important topic.

Conclusion

This study evaluated digital educational materials (a didactic toolkit) on preconception health in the context of the competencies of future healthcare professionals (nursing and midwifery students). Today’s declining levels of fertility underscore the great importance of making younger generations aware of their preconception health. The study results show that the didactic toolkit developed on preconception health is an appropriate form for promoting fertility awareness among young adults. The web platform preco.tamk.fi was found to be useful with the students participating in this study having evaluated most of the didactic tools with high scores. Didactic tools were scored the lowest in the categories Age and Fertility and Understanding Reproduction, although this might be because our participants were health students who may know and study the topics more than young people studying other disciplines. Accordingly, future studies should also examine a population of non-health students. We may conclude that use of the didactic toolkit on the web platform constitutes a good tool for promoting health among young adults.

Author contributions

Mirko Prosen: Study design, data collection, writing original draft, revising the article

Boštjan Žvanut: Analysis and interpretation of data, writing original draft, revising the article

Patrik Pucer: Analysis and interpretation of data, writing original draft, revising the article

Petra Petročnik: Data collection, writing original draft, revising the article

Ana Polona Mivšek: Study design, data collection, writing original draft, revising the article

Acknowledgments

The authors would like to thank all the students who participated in this research.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

The authors confirm that the data supporting the findings of this study are available within the article or its supplementary materials. https://webpages.tuni.fi/preco/tools/

Additional information

Funding

This work was supported by the Erasmus+ Programme of the European Union ‘Preconception health of youth, bridging the gap in and through education – PreconNet’ (https://preco.tamk.fi/; grant number 2018-1-FI01-KA203-047245). The funding source had no role in: study design; the collection, analysis and interpretation of data; the writing of the manuscript; and in the decision to submit the manuscript for publication.