Pregnancy and Internet: socio-demographic and geographic differences in e-Health practice. Results from an Italian multicenter study.
Authors
G. Scaiolia, F. Berta, V. Galisa, S. Brusaferro Prof b, E. De Vito Prof c, G. La Torred, L.
Manzolie, G. Messinaf, M.V. Torregrossa g, W. Ricciardi h, M.R. Gualanoa*, R. Siliquinia.
Affiliations
a Department of Public Health - University of Turin, Turin, Italy
b Department of Experimental and Clinical Pathology and Medicine, University of
Udine, Udine, Italy
c Department of Health and Sport Sciences, University of Cassino, Cassino, Italy d Department of Public Health and Infectious Diseases, University Sapienza of Rome,
Rome, Italy
e Section of Epidemiology and Public Health, University G. D’Annunzio of Chieti,
Chieti, Italy
f Department of Molecular and Developmental Medicine, University of Siena, Siena,
Italy
g Department of Sciences for Health Promotion G. D’Alessandro, Hygiene Section,
University of Palermo, Palermo, Italy
h Institute of Public Health, Catholic University of Sacred Heart of Rome, Rome, Italy
* Corresponding author
Department of Public Health - University of Turin Via Santena 5/bis – 10126 Torino
Tel: +390116705809 Fax: +390116705889
Abstract
Objectives: Since the new millennium, the number of e-health users has significantly
increased. Among these, a particular category of people who are interested by this phenomenon is the one of pregnant women. The aim of the present study is to assess the socio-demographic and geographic differences existing in a sample of Italian pregnant women who search for information on the web.
Study design: Multicenter cross-sectional survey
Methods: The present study has been conducted from November 2011 to September
2012, in seven Italian cities, located in the North, in the Center and in the South of Italy. Data were collected through an anonymous questionnaire, administered in waiting rooms of outpatient departments by trained medical doctors. Data were analyzed through multivariate logistic regression models.
Results: Overall, 1,347 responders were interviewed. Eighty-six percent of them
declared to surf the internet to retrieve pregnancy-related information. The most searched topics were fetal development (51.3%), healthy lifestyle during pregnancy (48.7%), physiology of pregnancy (39.8%), generic and specific tips/advices during pregnancy (37,2%) and lactation (36.8%). Statistically significant differences (p<0.05) according to geographic origin, age and educational level were found with regard to the most frequently searched information on the Web, the reasons that pushed pregnant women to practice e-health, and the possibility to change lifestyles after e-health.
Conclusions: Our findings suggest that the phenomenon of pregnancy e-health is
widespread and show social and geographic differences, in particular about city of residence, age and educational level. It might encourage healthcare professionals to be more available and exhaustive during routine visit and to be more careful about web
content on this topic, also addressing the different needs into different geographic contexts.
Keywords
Introduction
Since the new millennium, the number of internet users has significantly increased.1
Many are those who seek information to enhance their culture and the amount of information sought especially in relation to health is on the rise.2,3 Several studies
assessed the reasons that lead people to look for health-related information.4-9 An Italian
multicenter study found out that people surf the Web because they can have more and quicker information than consulting traditional channels.7 A UK survey, published in
2011, showed that people surf the Web primarily for reassurance or as a second opinion, or eventually to improve their understanding and/or to overcome the perceived external barriers in accessing information through traditional sources.9 Surfing the internet for
health related information is part of e-health, defined by the World Health Organization as the use of information and communication technologies (ICT) for health.10 Among
the e-health users, a particular category of people who are interested by this phenomenon is the one of pregnant women. Gestation, indeed, is a condition characterized by a greater thirst for knowledge, often related to the anxiety for the newborn, that pushes women to search information for any source, and the web is often the widest available.11,12 There are some recent studies referring to surfing the Internet in
order to search for pregnancy-related information during the gestation.11-19 All these
studies showed a high prevalence of pregnant women who seek information on the internet. The topics most frequently sought are related to nutrition, fetal growth,
physical activity and healthy lifestyle.15 In a survey conducted by Huberty, around 50%
of pregnant women declared to search for information related to physical activity.14 Two
studies, conducted by Gao and Kavlak, showed instead that the two most relevant topics searched are fetal development and nutrition during pregnancy.13,16
Some studies highlighted that this practice could be influenced by socio-demographic and cultural factors that may affect the way of access to the web, the type and the actual use of information found.9,16,20-23 As example, Kavlak demonstrated that educational
level, work status, number of pregnancies and age of child-bearing women might influence the type of information searched.16 In addition, another study conducted by
Laz, regarding the ethnic disparities among young women practice e-health, showed differences between white, black and Hispanic women, both in the use of the internet and in the type of information sought.21 These differences are important, considering
that the e-health practice is not free of consequences. It was demonstrated, indeed, that the information found could cause changes in behaviors or health care choices.7,18,24,25
Despite the importance of pregnancy within the national healthcare landscape,26 no
studies have been carried out so far on the use of internet to search for information by pregnant women in Italy. In order to fill this gap, a multicenter Italian survey, aimed at evaluating the use of e-health practice by pregnant women was conducted in seven Italian cities, located in the north, in the center and in the south of Italy. .27
As part of the above mentioned study, the present paper aims to assess the potential socio-demographic and geographic differences existing in the same sample.
Methods
The multicenter cross-sectional study, approved by the Ethics Committee of the
“Sant’Anna” University Hospital of Turin, was carried out through the administration of a questionnaire, addressed to pregnant women, in seven Italian cities (Cassino, Chieti, Palermo, Rome, Siena, Turin and Udine) representative of the different geographical areas of Italy.11
The context
Italy, although it is a small country, has major geo-cultural differences on the inside. Data from the National Institute of Statistics showed that, for instance, in 2013 around 23% of the Italian citizens living in the north of the Country declared to trust the majority of their fellow citizens, while in the south this percentage drops to 17.6%. Moreover, the 71% of the north-west citizens were somewhat/very satisfied of their lives (seven or more in a scale from one to ten), while in the south only 56%.28
The questionnaire
The number of women interviewed in each city was chosen on the basis of the number of births in the same cities in 2010. Considering the data available in a previous Italian study about the e-health in Italian females (around 37% of the sample were internet users searching for health information),7 it was possible to provide an estimation of the
number of interviews necessary in order to get valid data. We considered a +/- 20% of Internet usage as “Worst Acceptable” for results. The confidence level was set at 95%, with a power of 80%.
Between November 2011 and September 2012, 1,576 pregnant women aged 18-44y, were contacted, and 1,347 were interviewed. The refusal rate was of about 17%, ranking from 13% to 21%. Data about the number of interviews needed and refusal rate for each center are presented as supplementary material (Table S1).
The questionnaire administration, performed by trained medical doctors, took place in the public hospital’s waiting room of out-patient department, while pregnant women were waiting to undergo routine check-up with ultrasounds scan or blood tests. Only
women who were at least 18 years of age were included. All participants were asked to sign an informed consent form.
The questionnaire, previously validated by a pilot study and described in details in previous papers,11,27 consists of 95 questions and is composed of two parts. The first part
investigates socio-demographic information such as age, education, work status and marital status. The second part, instead, is focused on the use of the internet for seeking pregnancy-related information. In particular, this part investigates what kind of
information pregnant women may seek (e.g. fetal development or lactation tips), the reasons of practicing e-health (reported as “to obtain quickly information” and “for deepening the information obtained through traditional channels”) and the impact of e-health practice on behavioral and lifestyle choices. The items used were closed-ended questions (with dichotomous answers yes/no) or evaluation scales for specific outcomes like the perceived health-status or the reliability of the information found of the web.
Statistical analysis
A descriptive analysis of the frequencies distribution of socio-demographic variables of the sample was initially conducted, using percentages and including the chi-square test to assess differences among the seven cites considered regarding the information most frequently sought by pregnant women, the reasons that push women to practice e-health and the impact of the information found on lifestyle choices. A logistic regression was carried out to estimate the potential impact of some socio-demographic variables on the outcomes previously described. The background variables included in the analyses were age, educational level, nationality, work status, marital status, previous deliveries, trimester of pregnancy and perceived health status. The covariates to be included into
the final model were selected using a stepwise forward selection process, with a univariate p-value <0.25 as the main criterium.29 Results are expressed as Odds Ratio
(OR) with 95% Confidence Intervals (CI), and a two-tailed p-value <0.05 was
considered significant for all analyses. All Data were analyzed using StataMP11 statistic program (Stata Corp., College Station, TX, 2011).
Results
Description of the sample
The overwhelming majority of the women interviewed (94.6%) declared to surf the Web, and91.2% of them stated to use the internet to search for pregnancy-related information. Given these high rates of e-health practitioners, we decided to include in our analysis only the women that declared to use internet for searching for information related to pregnancy (n= 1,162).
Our sample was mainly composed by Italian women (89.4%) and the age group most represented was the one between 26 and 35 years (60%). Most women declared to be married (66.9%), primiparous (61.5%), at the third trimester of pregnancy (63.4%) and claimed a good/excellent health status (86.8%). Furthermore, the majority of women declared to be employed (76.9%).
Some differences were found among childbearing women in socio-demographic and health-related variables, according to geographical origin (Table 1). Palermo was the city with the highest percentage of young mothers (22.7% - 18-25years old), while pregnant women older than 35 years were more represented in Turin (42%) and Udine (44.4%) than in the other cities considered. The percentage of foreign women went from 3.3% of Chieti to 16.6% of Siena. In all the cities analyzed, around or more than 85% of
the women declared at least a high school educational level. The only exception was represented by the city of Palermo, with a 57.7% of the sample that stated a high educational level, while a third of the women interviewed claimed to have completed the middle school and 5.2% only the primary school (Table 1). (Insert table 1 here)
The most searched information on the Web
In the overall sample of e-health users (n=1162), the most frequently searched information were related to fetal development (51.3%), healthy lifestyle during
pregnancy (48.7%), physiology of pregnancy (39.8%), generic and specific tips/advices during pregnancy such as medical examinations and tests calendar or prevention
(37,2%) and the different kind of lactation (36.8%).
The analysis of the most frequent searched topics according to geographical origin, age and educational level are showed in Table 2. The distribution of most frequent searched topics was uneven among the cities included in the survey (Figure 1). A high frequency of women looking for information about the fetal development was observed in Palermo (77.7%) while a lower interest in lifestyles advices was noticed in Cassino (30.5%) and Udine (38.6%).
(Insert figure 1 here).
Considering the age of pregnant women, it is important to highlight that older women (≥36 years) were more prone to search for tips about pregnancy than younger ones (18-25 years). Finally, the results show how the educational level may influence the type of information searched: women with low educational level were less interested in
searching for information related to the physiology of pregnancy than those with middle-high educational level (Table 2).
(Insert table 2 here).
Univariate and multivariate analysis on reasons and attitudes towards pregnancy e-health
In the overall sample, the main reasons leading people to seek information on the Web were the rapidity in obtaining the health-related information (59.4%), and the
opportunity of deepening the topics of interest (50.4%), with differences based on geographical location, age and educational level Indeed, the univariate analysis, showed that the women interviewed in the city of Palermo had a lower propensity of surfing the Web for obtaining quicker information if compared with those of Turin (OR 0.44, CI 95% 0.29-0.66), as well as women older than 25 years if compared with younger ones (18-25 years old) (Table 3). These results were partially confirmed in the logistic regression model (Table 3).(Insert table 3 here).
Moreover, in Chieti and Palermo women were more inclined to practice e-health for deepening the information of interest, than women interviewed in Turin (OR 1.87 CI 95% 1.20-2.91 and OR 4.43 CI 95% 2.78-7.04 respectively) Conversely, women aged between 26 and 35 years have a lower likelihood, if compared with younger ones (OR 0.58, CI 95% 0.38-0.86). In these cases, the multivariate analysis strengthen the univariate results (Table 4).
(Insert table 4 here).
Finally, the analysis conducted to verify a potential association between socio-demographic variables and lifestyles choices after the e-health practice, showed that women in Siena and Chieti were more likely to change their lifestyles after e-health, while, women of Cassino, Palermo and Udine had less probability to do it. After
adjusting for nationality, work status, previous deliveries, trimester of pregnancy and perceived health status, only women of had a significantly lower likehood ratio was found for the women living in Cassino and Udine (OR 0.48 CI 95% 0.26-0.87 and OR 0.42 CI 95% 0.23-0.77 respectively), and a significant higher one for Siena and Chieti. (OR 2.24 CI 95% 1.38-3.65 and OR 1.93 CI 95% 1.14-3.26) (Table 5).
(Insert table 5 here).
Discussion
This paper shows the results of a multicenter survey conducted in seven Italian cities, which aimed to investigate topics, reasons and impact on lifestyles choices of health-related information found through the Web, among pregnant women.
Our study demonstrated that a high percentage of Italian pregnant women use the internet to search for information about their condition, and that the type of information searched may vary according to age, educational level and geographical location. Moreover, socio-demographic and geographical differences have been noticed in the percentage of women who surf the internet to obtain quicker information or to deepen information of interest, and who change lifestyle after reading information on the Web. In our study, almost all the interviewed women declared to search for information about pregnancy, and this is not influenced by the socio demographic characteristics of the sample. These data confirm those presented in the literature; as a matter of fact, to date, the percentage of people that use the web to search for health information, including pregnancy, is very high; Gao established that 91.9% of Chinese women have access to the internet and 88.7% use it to retrieve health information.13
The most searched topics resulted physiology of pregnancy, fetal development, lifestyle during pregnancy, things to do before pregnancy and lactation. These data are partially
in agreement with those of the studies conducted by Gao et al. and Kavlak et al. In these cases, the most searched topics were fetal development, nutrition during pregnancy and stages of birth.13,16 On the contrary, the study conducted by Huberty et al. demonstrated
that the most searched topic was physical activity.14 These differences could be
explained by the different methods used in the different studies, in particular regarding the questionnaire. Indeed, to date there are no standardized tools to assess this issue. Nevertheless, it is interesting to notice that all of these could be considered as “routine topics”, which should be explained exhaustively by all the health care givers during the regular pregnancy checkups. This highlights a deficiency in communication between healthcare professionals and pregnant women.30
Furthermore, the data analysis, based on geographical origin, showed some significant differences, proving how, to date, Italy is a variegated country, either about the kind of research done, or the motivations and consequences of the search.7 In particular,
considering the reasons of the search, we can notice that the city of Palermo was the one where the majority of the responders declare to search for information through the web because of the possibility to have information more in depth; on the contrary, very few women, in this city, searched for information through the web because of its quickness. With regards to changing the lifestyle after reading information on the net, it is
interesting to underline that there are a lot of differences from one city to the other: in the cities of Siena and Chieti there was a higher likelihood to change lifestyle, while the women living in Udine and Cassino were the ones with the lowest probability to modify their habits. Perhaps there are cultural reasons that could affect our analysis, such as a higher predisposition to go in depth about important experiences related to health and to life changing.28
Considering the age of women interviewed, it could be noticed that those between 26 and 35 years old are more prone to practice e-health to retrieve quicker information but have a lower probability to surf the Web for deepening the topics of interest, if
compared with younger women. Moreover, there are no statistically significant differences among the three age categories about lifestyle changes after e-health practice. Lastly, educational level seems not to influence the use of internet to seek information about pregnancy, confirming the results of the study conducted by Lagan et al.18
Our data demonstrate that it is important to establish a good relationship between healthcare professionals and patients in order to try to answer in the better way to the doubts and the requests of the citizens. The current scenario demonstrates that the new ways of communication could have positive effects on health, but it is important to monitor the use of these innovative instruments, such as the Internet, in order to avoid some negative effects.31 Indeed, e-health requires ability to seek and understand health
information and apply the knowledge gained to solve a health problem, a concept known as e-health literacy.32
It would also be important that healthcare professionals pay more attention to the content of the web on the topics of their pertinence, ensuring, whenever it is necessary, the production of informative materials, in order to satisfy the needs of their patients.30,33
This study presents strengths and limits. The main strength of our study is represented by the multi-centric design that allows not only to generalize the results and to consider the phenomenon in the overall Country but also to analyze differences related to
geographical origin. This study was conducted in seven Italian cities (Cassino, Chieti, Palermo, Rome, Siena, Turin and Udine), very different in terms of population and
geographical location. Turin, Rome and Palermo are three densely populated towns, the first one located in the north, the second in the center and the third in the south of Italy, while Udine, Siena Cassino and Chieti are smaller cities with a population not
exceeding the 100,000 inhabitants, equally distributed along the whole Italian peninsula (Figure 1).
Moreover, even if the international literature on this topic is on the rise, to our knowledge, this is the first Italian study that sheds light on e-health practice among pregnant women. However, some limitations of our survey must be took into account when interpreting the results. Firstly, the personal predisposition to fill the
questionnaire: people refusing to answer the question may be shy or introspective and therefore a potential e-health user considering the anonymity provided by the Web. This represents the possible loss of part of the sample.34,35 We tried, though, to resize this
problem by using trained physicians in questionnaires administration that enabled us to gain greater compliance and completeness of the questionnaire. Another limitation is due to a potential loss of pregnant women that are under the care of private
gynecologists and then do not attend the public hospital’s waiting room for their routine check-up with ultrasounds scan or blood tests.
Furthermore, we have to consider that the quality of information retrieved through the web is often questionable, because the information are mostly provided by unofficial sources36,37 and the phenomenon of the “digital divide” may lead to a gap between those
who could have access to internet information and those who cannot and this could affect our findings.9, 20-23
In conclusion, our findings highlight a massive use of the web among pregnant women in Italy to retrieve health information, with socio-demographic and geographic
differences. Since these information, such as fetal development, healthy lifestyle during pregnancy and physiology of pregnancy. are routine topics that should be provided by the doctors, our results might encourage healthcare professionals on one hand to be more available and exhaustive during routine visit to pregnant women, and on the other hand to be more careful about web content on this topic. In particular GPs,
gynecologists, obstetrics and all the other health care professionals should consider socio-demographic and geographic differences when dealing with pregnant women.
Acknowledgments
Funding: None
Competing interests: None declared
Ethical approval: the study was approved by the Ethics Committee of the “Sant’Anna” University Hospital of Torino and all the participants gave informed consent to the work.
Figure legend
Figure 1. Cities included in the study and the two most searched topics in each city.
Tables legend
Table 1. Description of the sample according to geographical origin.
Table 2. Overview of characteristics of search: five most frequently searched topics. Table 3. Association between geographical origin, age and educational level and the practice of e-health for retrieving quicker information related to pregnancy.
Table 4. Association between geographical origin, age and educational level and the practice of e-health for deepening the topics of interest about pregnancy.
Table 5. Association between geographical origin and the impact on lifestyles choices after the practice of pregnancy e-health.
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Table 1. Description of the sample according to geographical origin (N = 1,162) e-Health users % Turin (n=219) Rome (n=192) Cassino (n=131) Siena (n=147) Chieti (n=134) Palermo (n=194) Udine (n=145) pa Age 18-25 (n=125) 5.5 7.9 16.8 7.5 6.7 22.7 8.2 <0.01 26-35 (n=695) 52.5 61.1 60.3 74.1 69.4 59.3 47.2 ≥36 (n=339) 42.0 31.1 22.9 18.4 23.9 18 44.4 Nationality Foreign (n=120) 14.4 10.8 5.3 16.6 3.3 6.7 14.9 <0.01 Italian (n=1011) 85.6 89.2 94.7 83.4 96.7 93.3 85.1 Marital status Single (n=89) 8.3 6.8 3.8 8.8 6.0 3.6 17.2 <0.01 Cohabiting (n=274) 27.5 23.6 17.6 34.7 14.3 22.2 22.8 Married (n=775) 60.5 67.5 77.9 55.1 79.7 73.7 56.5 Other (n=21) 3.7 2.1 0.8 1.4 0 0.5 3.5 Educational levelb College Degree (n=419) 42.0 38.2 41.4 37.7 33.1 20.6 42.1 <0.01 High School (n=545) 44.7 53.9 48.5 50 55.6 37.1 42.8 Middle school (n=182) 12.8 7.9 10 12.3 11.3 37.1 14.5 Primary school (n=12) 0.5 0 0 0 0 5.2 0.7 Employment Employed (n=890) 90.9 81.2 69.5 83 83.5 50.5 79.9 <0.01 Student (n=35) 0.9 4.2 6.9 7.5 0.7 0.5 2.1 Housewife (n=178) 6.4 11.5 16.8 7.5 10.5 40.1 12.5 Unemployed (n=54) 1.8 3.1 6.9 2.0 5.3 8.9 5.6 Perceived health status Bad (n=11) 0 1.0 0.8 0 0.8 3.1 0.7 <0.01 Sufficient (n=141) 9.3 8.5 26.7 6.8 7.5 15.5 14 Good/excellent (n=999) 90.7 90.5 72.5 93.2 91.7 81.4 85.3 Trimester of pregnancy I trimester (n=142) 26.8 6.0 17.6 6.4 10.5 11.9 4.1 <0.01 II trimester (n=246) 43.7 10.4 39.7 26.4 17.7 5.7 8.3 III trimester (n=742) 29.6 83.6 42.7 67.1 71.8 82.5 87.6 Previous deliveries None (n=715) 61.9 67.7 55.7 65.1 60.3 62.4 70.3 0.19 One or more (n=412) 38.1 32.3 44.3 34.9 39.7 37.6 29.7
b years of education in Italy are distributed as follows: College Degree: three to six years; High School: five years; Mid-dle school: three years; Primary school: five years.
Table 2. Overview of characteristics of search: five most frequently searched topics (N=1,162).
Topics (% of pregnant women who answered “yes”)
Physiology of pregnancy (n=458) Fetal development (n=590) Lifestyle during pregnancy (n=560) Tips about pregnancy (n=428) Lactation (n=422) Cities Turin (n=219) 40.4 51.8 50.0 48.2 35.8 Rome (n=192) 40.2 40.2 56.1 36.5 39.0 Cassino (n=131) 29.7 38.2 30.5 23.7 25.9 Siena (n=147) 56.5 41.5 53.1 42.9 51.7 Chieti (n=134) 27.1 38.4 51.9 48.1 28.2 Palermo (n=194) 43.1 77.7 54.3 29.8 41.5 Udine (n=145) 37.9 64.1 38.6 27.6 31.7 (p<0.01a) (p<0.01a) (p<0.01a) (p<0.01a) (p<0.01a) Age 18-25 (n=124) 36.3 46.0 36.3 26.6 41.1 26-35 (n=690) 40.6 50.0 52.0 37.5 37.6 ≥36 (n=335) 39.7 55.8 46.3 40.3 33.7 (p=0.05a) (p=0.10a) (p<0.01a) (p=0.02a) (p=0.28a) Educational
levelb Primary School (n=12) 8.3 50.0 50.0 50.0 25.0
Middle School (n=175) 32.6 53.7 34.9 29.1 29.1
High School (n=544) 38.1 48.7 48.5 36.8 38.6
College degree (n=417) 46.3 53.7 54.7 40.8 38.4
(p=0.19a) (p=0.41a) (p<0.01a) (p=0.05a) (p=0.10a)
bchi2 test, significance level p<0.05
b years of education in Italy are distributed as follows: College Degree: three to six years; High School: five years;
Middle school: three years; Primary school: five years.
Table 3. Association between geographical origin, age and educational level and the practice of e-Health for retrieving quicker information related to pregnancy.
Surf the Web for quicker information
City Turin 1 1 Rome 1.26 (0.83-1.91) 1.27 (0.78-2.06) Cassino 1.22 (0.77-1.94) 1.36 (0.83-2.24) Siena 0.68 (0.44-1.05) 0.62 (0.38-0.98) Chieti 0.86 (0.55-1.35) 0.81 (0.48-1.34) Palermo 0.44 (0.29-0.66) 0.48 (0.29-0.78) Udine 0.94 (0.61-1.45) 0.95 (0.58-1.56) Age 18-25 1 1 26-35 1.70 (1.14-2.53) 1.67 (1.05-2.65) ≥36 1.57 (1.02-2.40) 1.37 (0.82-2.28) Educational levelb College Degree 1 1 High School 0.93 (0.71-1.21) 0.99 (0.74-1.31) Middle School 0.66 (0.46-0.95) 1.08 (0.69-1.69) Primary School 0.33 (0.09-1.16) 0.69 (0.18-2.61)
a adjusted for nationality, work status , previous deliveries, trimester of pregnancy and perceived health status.
b years of education in Italy are distributed as follows: College Degree: three to six years; High School: five years;
Middle school: three years; Primary school: five years.
Table 4. Association between geographical origin, age and educational level and the practice of e-Health for deepening the topics of interest about pregnancy.
Surf the Web for deepening the topics of interest
Crude OR (95% CI) Adjusted OR (95% CI) a
City Turin 1 1 Rome 0.88 (0.59-1.31) 0.88 (0.55-1.41) Cassino 1.27 (0.82-1.96) 1.16 (0.72-1.87) Siena 1.31 (0.86-2.01) 1.52 (0.95-2.43) Chieti 1.87 (1.20-2.91) 1.89 (1.14-3.15) Palermo 4.43 (2.78-7.04) 4.81 (2.85-8.12) Udine 1.35 (0.88-2.06) 1.21 (0.75-1.95) Age 18-25 1 1 26-35 0.58 (0.38-0.86) 0.54 (0.33-0.88)
≥36 0.77 (0.50-1.19) 0.81 (0.48-1.38) Educational level b College Degree 1 1 High School 0.95 (0.73-1.23) 0.89 (0.67-1.18) Middle school 0.95 (0.67-1.36) 0.54 (0.34-0.85) Primary school 1.61 (0.46-5.60) 0.49 (0.12-2.03)
a adjusted for nationality, work status, previous deliveries, trimester of pregnancy and perceived health status.
b years of education in Italy are distributed as follows: College Degree: three to six years; High School: five years;
Middle school: three years; Primary school: five years.
Table 5. Association between geographical origin and the impact on lifestyles choices after the practice of pregnancy e-Health.
Lifestyle changes
Crude OR (95% CI) Adjusted OR (95% CI) a
City Turin 1 1 Rome 0.90 (0.59-1.39) 1.06 (0.64-1.75) Cassino 0.42 (0.24-0.75) 0.48 (0.26-0.87) Siena 2.00 (1.28-3.11) 2.24 (1.38-3.65) Chieti 1.99 (1.26-3.14) 1.93 (1.14-3.26) Palermo 0.57 (0.36-0.91) 0.67 (0.38-1.16) Udine 0.38 (0.21-0.66) 0.42 (0.23-0.77) Age 18-25 1 1 26-35 1.27 (0.81-1.98) 1.09 (0.64-1.86) ≥36 1.14 (0.71-1.84) 1.13 (0.63-2.04) Educational levelb College Degree 1 1 High School 1.08 (0.82-1.44) 1.07 (0.78-1.46) Middle school 1.04 (0.70-1.54) 1.21 (0.74-2.00) Primary School 0.24 (0.03-1.92) 0.41 (0.05-3.43)
a adjusted for nationality, work status, previous deliveries, trimester of pregnancy and perceived health status.
b years of education in Italy are distributed as follows: College Degree: three to six years; High School: five years;
Table S1. Number of interviews in the cities included in the study. City Number of interviewes needed Number of interviews realized Refusal rate Cassino 160 147 18% Chieti 180 140 20% Palermo 240 209 16% Rome 240 217 16% Siena 180 168 13% Torino 240 233 15% Udine 210 161 21%
