The effect of a prior e‐learning tool on genetic counseling outcomes in diverse ethnic couples with abnormal Down syndrome screening tests: A randomized controlled trial

Genetic counseling (GC) following abnormal Down syndrome (DS) screening tests aims to ensure learning of complex medical concepts and discussion of counselees' personal desires. Pre‐GC use of electronic learning tools (e‐learning tools) can facilitate GC sessions by allowing more time for dialogue rather than learning medical and genetic concepts, enabling greater focus on the counselee's decisional, psychological, and personal needs. Few studies have investigated such tools for DS screening tests and those who have focused on screening uptake rather than abnormal results and implications. This study evaluated prenatal GC outcomes following implementation of an e‐learning tool utilizing an educational animated movie for couples of varied ethnic backgrounds in northern Israel, with abnormal DS screening tests. E‐learning tool impact was assessed as knowledge level, informed choices, satisfaction with the intervention and GC process, the state of anxiety and duration of the GC meeting. The 321 study participants were randomized to three groups: animation movie, booklet, and control. All participants had been asked to complete pre‐ and post‐counseling questionnaires. Outcome scores were compared between the research groups. Results showed increased knowledge level in general among participants in the animation group; among minority participants, the highest knowledge level was in the animation group. Anxiety levels and informed choices were not statistically different among the groups. However, watching the animation, Jewish ethnicity, good level of genetic literacy, and academic degree were significant predictors of informed choice, and those who watched the animation were three times more likely to make an informed choice than the control group. Our findings suggest that this e‐learning tool is efficient and acceptable for the general population. Special attention is needed for minorities with lower genetic literacy and education.

Israeli women is about 60%-70% (Sagi-Dain et al., 2021).Currently, the NIPS (non-invasive prenatal screening) test is offered in Israel on a large scale.However, it has not yet been included in the 'basket' of free services.Sagi-Dain et al. (2021) showed that 13% of the live births between 2011 and 2019 underwent invasive prenatal tests while only 4.3% underwent NIPS.
Couples who receive abnormal screening DS results are routinely referred to a genetic counseling (GC) meeting.Traditionally, these sessions include face-to-face discussion of several topics: a medical explanation of the findings' implications and the estimated risk for DS, as well as a discussion of further available tests such as detailed fetal scans and invasive tests for genetic analysis (i.e., chorionic villus sampling [CVS] or amniocentesis), as well as their associated risks.The genetic counselor emphasizes that these tests are recommended for reaching a definitive diagnosis, yet they are optional.A substantial proportion of Israeli couples are interested in chromosomal diagnostic tests in high-risk pregnancies; the rate of uptake differs between the ethnic and religious communities (Romano-Zelekha et al., 2014).
Based on the information delivered during the GC session, counselees are expected to make informed choices.Hence, in addition to the complex and even abstract concepts, the counselor's role includes discussing personal desires and conflicts.The situation can be overwhelming and challenging for most couples, and the process usually involves deep emotional and decisional conflicts about the familial consequences of having an affected child.The most definitive preventive measures such as termination of the pregnancy are considered to be among the most complex ethical issues that couples face.
In addition to those challenges, other factors have influenced the GC process in recent years, such as advanced technologies in genetic testing and increased public awareness of genetic issues.The upshot is a greater need for GC in an already-overloaded health care system (Stoll et al., 2018).This poses a growing need to enhance traditional GC by developing new approaches that can facilitate meetings with care providers and allow greater focus on counselees' decisional, psychosocial, and personal needs (Birch, 2015;Redlinger-Grosse et al., 2016).The Covid-19 pandemic introduced another urgent need: to develop remote counseling (Voils et al., 2018).Perhaps, medical and technical explanations prior to a face-to-face GC session can improve patients' preparedness.
Many studies have been conducted on the potential of various learning tools and methods such as informative websites, web-based computer and CD-ROM programs, videotapes, audiovisual tapes, and leaflets.The utilization of interactive electronic tools (e-learning tools) in the GC process has been named 'E-counseling'.Some studies of E-counseling have been conducted where general health care providers were responsible for the GC component, rather than a genetic counselor or clinical geneticists.Notably, most of these studies did not compare populations from diverse ethnic backgrounds and some were not randomized controlled trials.The majority of e-counseling research has focused on GC for breast or ovarian cancer, and only a few dealt with Cystic Fibrosis, Tay Sachs, exome sequencing, and/or DS screening tests (Birch, 2015;Conijn et al., 2020;Dugger et al., 2021;Fan et al., 2018;Hernan et al., 2020;Stefansdottir et al., 2020;Temme et al., 2015).Most of the studies on DS screening referred to the test itself and whether or not to undertake it, rather than with its abnormal results and implications (Beulen et al., 2016; decision-making, Down syndrome screening, e-learning tool, genetic counseling, prenatal diagnosis, various ethnic populations

What is known about this topic
Many studies have conducted the utilization of interactive electronic tools (e-learning tools) in the genetic counseling process in many fields.However, the majority have focused on genetic counseling for breast or ovarian cancer, and only a few dealt with Cystic Fibrosis, Tay Sachs, and/or Down syndrome screening tests.Additionally, most of the studies on Down syndrome screening referred to the test itself and whether or not to undergo it, rather than with its abnormal results and implications.Most of these studies did not compare populations of diverse ethnic backgrounds and some were not randomized controlled trials.

What this paper adds to the topic
In this study, we examined the use of an e-learning tool on genetic counseling outcomes in diverse ethnic couples with abnormal Down syndrome screening tests, focusing on its abnormal results and implications.We also had the opportunity to test the usefulness of this tool in various ethnic and cultural populations.Nagle et al., 2008;Skjøth, Draborg, Lamont, et al., 2015;Skjøth, Draborg, Pedersen, et al., 2015;Yee et al., 2014).In general, the use of e-learning tools was equivalent or superior to the traditional GC face-to-face meeting in terms of knowledge acquisition, and most of the users expressed satisfaction with the e-learning tools.For some users, the tools were less effective especially regarding psychological conflicts.Moreover, the state of anxiety, informed choices, and decisional conflict outcome results were varied in the studies.Conclusions from these studies were limited, and comparing between them is difficult due to the vast differences in their design, intervention, and measure outcomes (Beulen et al., 2016;Birch, 2015;Dugger et al., 2021;Hernan et al., 2020;Nagle et al., 2008;Skjøth, Draborg, Lamont, et al., 2015;Skjøth, Draborg, Pedersen, et al., 2015;Stefansdottir et al., 2020;Yee et al., 2014).
In our study, we decided to examine the use of an e-learning tool entailing an educational animated movie (AM), as a supportive measure in prenatal GC.The aim was to evaluate the impact of this tool on GC outcomes in pregnant couples with abnormal DS screening tests, belonging to various ethnic and religious populations in northern Israel.A number of studies indicated that the use of animation generally improves a viewer's level of knowledge and understanding; specifically, its depiction of concepts may result in better learning outcomes, especially for those with low-level health literacy (George et al., 2013;McElhaney et al., 2015).We hypothesized that an elearning tool such as an AM, when coupled with a GC session, would enhance the efficiency of prenatal GC in terms of knowledge, satisfaction with the tool and the GC process, state of anxiety, promotion of informed choice, and reducing the duration of GC meetings.The opportunity to test the usefulness of this tool in diverse populations might elucidate the 'fine-tuning' needed to address specific factors in various ethno-cultural populations.

| Study participants
Participants were recruited from November 2018 to April 2020.
They had been referred to the Emek Medical Center Genetics Institute because of abnormal DS screening test results in the first trimester, second trimester, or sequential tests, as shown in Figure S1.
The participants were residents of northern Israel whose population includes a Jewish majority and a substantial representation of Israeli minorities: Muslim and Christian Arabs and Druze (Table 1).All participants signed a written informed-consent form.Eligibility criteria included pregnant couples older than age 18 years and with reading and writing abilities in Hebrew or Arabic.

| Randomization and study design
The study was a randomized controlled trial using a computergenerated random number table with allocation into three groups.
The participants in the AM group were presented with an animated movie and those in the educational booklet (EB) group received written material with very similar content.Participants in the control (C) group met counselors for a conventional session, without prior intervention.Eligibility criteria required that both members of each couple consented to participate, but were randomized once as a couple, assigned to the same study group.The participants were asked to answer baseline and post-counseling questionnaires (Figures 1 and 2).The GC face-to-face meeting was held immediately after the intervention use.
Seven certified genetic counselors participated in this study and only one of them conducted the GC session.They did not know F I G U R E 1 Research stages.a Cronbach's alpha is calculated for 21 items.This questionnaire had the same 12 items (as the pre-GC knowledge) and nine additional items.b The questionnaire had the same five items (as the pre-GC anxiety questionnaire).AM, animated movie; C, control; EB, educational booklet; GC, genetic counseling; TOP, termination of pregnancy; α, Cronbach's alpha.

| Interventions
Animation and booklet were developed by the first author specifically for this study; they were created in both the Hebrew and Arabic languages, and last 7.5 and 10 min, (https://youtu.be/jkeyGRmPZJg and https://youtu.be/SxEo8L4ZNHY), respectively.The Arabic version is longer than the Hebrew due to the need to provide longer explanations for some medical terms which did not have an accurate translation into Arabic.The AM was developed using the Go-Animate (Vyond) computer program and the five-paged A5-size booklet was graphically designed by Illustrator Cs4 program (https://tinyu rl.com/ta3xxt5p).
Scripts were written based on the content of the traditional GC session.These included basic concepts in genetics, a medical explanation and risk assessments for DS, and recommendations for further evaluation in pregnancy such as invasive tests, including TA B L E 1 Characteristics of the participants between-group comparisons were assessed using CVS or amniocentesis, their associated risks, and available genetic tests such as Chromosomal Microarray Analysis (CMA).Participants could replay the movie or read the booklet as many times as they wished, spending as much time as they felt they needed; they were later asked how many times they had watched the movie or read the booklet?The EB included the information narrated in the AM, as well as the main figures and photos, charts, and colorful images.
An expert validation approach was used to validate the content of the study questionnaires and the intervention scripts.Panels of seven genetic experts discussed, reviewed, and revised the scripts and the study questionnaires concerning content validity, clarity, and relevance.
In a pilot study, we used the cognitive interview methods and the verbal probing technique to assess how participants interpreted the items on the study questionnaire and whether their interpretation matched our intention (Artino et al., 2014).Finally, we used the 'back-translation' approach for all translation validations (Sperber, 2004).A panel of translation-reviewers, composed of native Arabic speakers from the Emek Medical Center Genetics Institute team, assessed the potential cultural differences of several terms, and some adaptations were made.

| Outcome measures-study questionnaires
The aim of the questionnaires was to evaluate levels of knowledge and understanding, ability to make informed choices, emotional assessment and degree of counselee's satisfaction.In light of the medical content, we examined personal attitudes toward genetic tests of their fetus (chromosomal test by CMA technology), and personal attitudes concerning termination of pregnancy.The study questionnaires can be found in the Appendix S1.

| Knowledge about abnormal DS screening test results
We developed a 21-item questionnaire to assess participants' knowledge regarding abnormal DS screening test results.The items addressed information that had been provided in the GC session, as part of our routine practice.Study participants were asked to complete the GC knowledge questionnaire (12 items) at baseline.
They were also asked to complete the same questionnaires after the counseling session; but this time the baseline GC knowledge questionnaire had nine additional items, making it a 21-item questionnaire.Each item had three options: true/false/not sure (do not know).A correct answer for each item was coded as 1, and an incorrect answer, no response or not sure/do not know, were all coded as 0. For each participant, we calculated the final score (0-100) as the fraction of the correct answers and the total number of questions multiplied by 100.Knowledge was defined as 'good' if the mean scores were ≥47 and ≥66, for the baseline and post-GC knowledge questionnaires, respectively.

| Attitudes toward fetal genetic test (chromosomal test by CMA technology)
Three items: important/unimportant, beneficial/harmful, bad idea/ good idea, on a scale of 1 to 7 were adapted from the attitude questionnaire by Marteau et al. (2001)

| Informed choices to perform a fetal genetic test
To assess whether couples made an informed or uninformed choice following the counseling, we used the validated Multidimensional Measure of Informed Choice (MMIC), which has been used in several studies with respect to prenatal GC and DS screening (Ames et al., 2015;Lewis et al., 2016;Marteau et al., 2001;Michie et al., 2002;van der Steen et al., 2018).
To assess whether the medical choices of the participants were based on sufficient medical knowledge and realistic assessment of their situation, three different parameters were checked, according to the concept of the MMIC model: background knowledge, attitude toward performing a fetal genetic test, and the outcome-whether or not the genetic test was carried out.Informed choice was defined as a consistently coherent approach: for instance, a combination of positive attitude, good knowledge and uptake of the genetic test, or negative attitude, good knowledge, and no uptake of the genetic test.The mean score of ≥66 (based on the post-GC knowledge questionnaire scores) defined good knowledge.

| Genetic literacy
Genetic literacy was assessed using eight items adapted from the University of North Carolina Genomic Knowledge Scale (UNC-GKS; Langer et al., 2017).A correct answer for each item was coded as 1, and an incorrect response, no answer or not sure/do not know, were all coded as 0. For each participant, we calculated the final score (0-100) as the fraction of the correct answers and the total number of questions multiplied by 100.A good genetic literacy score was defined as a mean score of ≥55.

| Anxiety
Assessment of the state of anxiety was based on the shortened form of the State Anxiety subscale of the Spielberger State-Trait Anxiety Inventory (STAI) questionnaire (Marteau & Bekker, 1992).
It included five items in a Likert scale ranging from 1 to 6.The same form was given to the participants prior to the GC session and immediately after.Scores higher than 13 (adjusted to the threshold set in the literature) indicated a higher state of anxiety (Annema et al., 2017).

| Satisfaction
Satisfaction with the genetic counseling process was assessed by four items in a Likert scale ranging from 1 to 6.The items were based on two validated questionnaires: Perceived Personal Control (PPC) questionnaire (Berkenstadt et al., 1999) and Genetic Counseling Satisfaction Scale questionnaire (GCSS; DeMarco et al., 2004).
Satisfaction with the genetic counselor was assessed by three items in a Likert scale ranging from 1 to 6.This questionnaire was based on the validated Genetic Counseling Satisfaction (GCS; Zellerino et al., 2009).
Satisfaction with the interventions was assessed by eight originally formulated items that had been developed in a Likert scale ranging from 1 to 6.In these three questionnaires, higher scores (≥4 for each item) indicated higher satisfaction with the mode of intervention.

| Personal attitudes toward termination of pregnancy
The questionnaire contained five original items in a Likert scale ranging from 1 to 6. Thus, scores lower than 17 (the midpoint of the scale) indicated acceptance of termination of pregnancy (TOP).
The duration of the face-to-face GC meeting was measured (in minutes) by the counselor.

| Statistical analyses
Descriptive statistics for all the variables were computerized.Differences between the groups were examined by Kruskal-Wallis rank sum test for non-parametric variables and by mixed-design ANOVA for parametric variables.Multivariable logistic regression was used to determine which variables were significant predictors of informed choice.We used Pearson's chi-square test for assessing association between the groups and other categorical variables.p < 0.05 was considered significant (two-tailed).All statistical analyses were performed using SPSS software version 24 (IBM corp.).

| RE SULTS
In total, 362 participants were approached for this study and 321 were enrolled (Figure 2).The three groups were not significantly different in their demographic characteristics, except for ethnicity (Table 1).In the AM group, there were fewer Jewish and more Arab Muslim participants, compared with the other groups.The participants' ethnic profile reflected the various groups living in northern Israel; 60.1% were Jewish and 36.1% were Arabs.Fifty-four percent of the participants held an academic degree (Bachelor's degree minimum) including 41.6% with Bachelor's degree.Of the Jewish participants, 67.2% had an academic degree vs. 35.9% of the minority communities (X 2 (1) = 30.26,p < 0.001).About half of the women (52.6%) were 35 years old and above.Nearly half of the participants 46.3% (n = 147) shared that they searched for information about the GC topic prior to the GC meeting, with the internet as the main source for obtaining that information, 95.1% (n = 136).However, only half, 47.3% (n = 61), of those who used the internet thought that this information was reliable, and 45.3% (n = 58) thought it was understandable.

| Knowledge about abnormal DS screening test results
As shown in Table 2, there were no significant differences in the knowledge scores between the three groups at baseline (p = 0.204).However, participants who were randomized into the AM group had a higher rate of correct responses to questions after the GC meeting (p = 0.045).Pairwise comparisons with adjusted p-values showed a significant difference between the AM and C groups (p = 0.044) but no significant difference between the AM and EB groups (p = 0.314) or between the EB and C groups, (p = 1.0).Moreover, knowledge scores were improved in all the study groups after the GC meeting, but the highest significant improvement was found in the AM group.
Interestingly, we found that for low genetic literacy participants the highest rate of post-GC knowledge scores was in the AM group 55.2% (n = 32) compared to 34.7% (n = 17) in the EB and 35.7% (n = 20) in the C groups (χ 2 (2) = 6.09, p = 0.048).
Moreover, our results showed a significant association between ethnicity and level of post-knowledge scores (χ 2 (1) = 55.44,p < 0.001).The majority 79.3% (n = 153) of Jewish participants had good knowledge scores compared to 38.3% of minority group participants.However, we found that of those who had good postknowledge scores in the minority groups (n = 49), about half of them belonged to the AM group compared to 25% (n = 10) in the EB and 35% (n = 12) in the C groups (χ 2 (2) = 6.25, p = 0.004).Additionally, 92.7% (n = 51) of the Jewish group with a good-knowledge score belonged to the AM group compared to 80.6% (n = 54) of the EB group and 67.6% (n = 48) of the C group (χ 2 (2) = 12.01, p = 0.002).

| Informed choice
Most of the participants (60.1%) made informed choices; the majority of whom were in the AM group (67.3%;Table S1), but the differences between the groups were not significant (χ 2 (2) = 3.52, p = 0.172).Informed choice was significantly associated with ethnicity.About three quarters, 76% (n = 139) of the Jewish participants made an informed choice compared to 34.5% (n = 39) of the non-Jewish participants (χ 2 (1) = 50.05,p < 0.001).Multivariable logistic regression analysis identified ethnicity (Jewish), academic degree, good level of genetic literacy, and watching the AM (vs. the control group) as significant predictors of informed choice (Table 3), while reading the EB, age, gender, searching for information about the GC topic before the meeting and religiosity were not significant predictors.

| Genetic literacy
There were no significant differences in genetic literacy among the study groups (mean = 52.7 ± 27, 58.5 ± 30.5, 54.7 ± 28.5)  Note: b,c Followed up by multiple comparisons adjusted with Bonferroni correction, a significant difference between the groups.a Between-group comparisons were assessed using Kruskal-Wallis tests.

TA B L E 3
Multivariable regression analysis for predicting informed choice.b Compared to the control group.

| State of anxiety
All the study groups had high scores of anxiety at baseline, with no significant differences among them (p = 0.088).The state of anxiety did not significantly change after the GC session.Data were analyzed using a mixed-design ANOVA.The analysis revealed a nonsignificant effect between the state of anxiety before and after the GC meeting, (F (1,306) = 1.552, p = 0.214) as well as between the study groups, (F (2,306) = 2.448, p = 0.088; Figure S2).

| Satisfaction with the genetic counselor and the GC process
A large majority of the participants in all the study groups were pleased with the counselor (97.2% of the AM group vs. 94.3% and 98% of the EB and the C groups, respectively, with no significant differences H(2) = 0.17, p = 0.92).Most of the participants (90.8% of the AM group, 90.7% of the EB group and 92.4% of the C group) were also satisfied with the GC process, with no statistical differences (H(2) = 0.19, p = 0.91).

| Satisfaction with the intervention
In order to neutralize personal bias of preferred mode of learning, we asked about personal satisfaction with the AM and the EB.We found that the participants enjoyed and understood the explanations in both interventions.All participants declared that they used it once and they also recommended the preliminary explanation (by booklet or animation) for anyone referred to genetic counseling.Additionally, the participants in both interventions were satisfied with the duration/length and the physical conditions for watching the movie or reading the booklet.However, the AM participants declared their intervention as being interesting and inclusive of topics important for decision-making, more than the EB participants did (Table S2).

| Personal attitude toward termination of pregnancy
TOP was one of the key factors affecting personal decisions, since refraining from genetic tests in our population often stems from a fundamental, personal objection to pregnancy termination.Of the 264 participants who completed this questionnaire, more than half, 63.6% (n = 168), declared that in certain circumstances, they accept the idea of TOP.It should be noted that 57 participants did not complete all the items of this questionnaire.Their attitude was affected by various parameters: the fetus's medical status, the mother's medical status or associated risks, ethical, moral, and religious factors, and the pregnancy's week of gestation.There was a positive association between personal attitude toward TOP and making informed choices; 77.6% (n = 111) of those who made an informed choice would perform TOP in certain circumstances (χ 2 (1) = 20.85,p < 0.001).It should be noted that 80.8% (n = 126) of the Jewish participants declared that TOP in certain circumstances was acceptable vs. 38.9% (n = 42) of minority-group participants (χ 2 (1) = 48.4,p < 0.001).Additionally, there was an association between personal attitudes toward TOP and self-described religiosity.Most participants who did not accept the idea of TOP 83.5% (n = 86) defined themselves as either 'traditional' or 'religious' (χ 2 (1) = 29.8,p < 0.001

| DISCUSS ION
The field of genetics has been developing rapidly and the need for an innovative service-delivery model has become apparent (Stoll et al., 2018).Many studies have conducted the utilization of interactive electronic tools (e-learning tools) in the genetic counseling (GC) process in many fields.However, most of the studies on Down syndrome (DS) screening referred to the test itself and whether or not to undergo it, rather than with its abnormal results and implications.Most of these studies did not compare populations of diverse ethnic backgrounds and some were not randomized controlled trials (Beulen et al., 2016;Birch, 2015;Conijn et al., 2020;Dugger et al., 2021;Fan et al., 2018;Hernan et al., 2020;Stefansdottir et al., 2020;Yee et al., 2014).
In this study, we investigated the value of a pre-counseling electronic learning tool, an animated movie (AM) for enhancing GC in cases of abnormal screening tests for (DS) in various ethnic populations in northern Israel.The counselee's level of genetics knowledge is considered a key factor in GC outcome and a primary component of the GC process goal (Redlinger-Grosse et al., 2016).In the prenatal GC session, a wide range of complicated medical and genetic data must be delivered in the limited GC-session time.Therefore, the counselors face a challenging task, especially for counselees with different educational backgrounds and learning skills, and various cultural backgrounds, personal beliefs, and values.Based on this information, the counselees are expected to make informed decisions about the recommended testing related to their pregnancy, its fate, and family planning in general (Dugoff et al. 2016).In accordance with previous studies in this field, our study results showed that using an e-learning tool positively influenced knowledge acquisition (Birch, 2015;Rupert et al., 2013;Yee et al., 2014).The minority participants in the AM group succeeded in gaining the highest postknowledge level compared to the other study groups.
These results indicate that using an animated movie is teachable and efficient, and that its advantages are especially evident in minority communities with a weaker educational background, and therefore worth the attention of policy-makers.Medical services must be tailored to these populations (Kfir et al., 2021) and diverse policies should be developed accordingly with e-learning tools adapted and culturally adjusted to each population.Our results support previous studies which indicated that an animated medium generally improves a viewer's level of knowledge and understanding; specifically, its depiction of concepts may result in better learning outcomes, especially for those with low health and genetic literacy (George et al., 2013;McElhaney et al., 2015).
Contrary to our expectations, the study results show a relatively large number of individuals who declared that they did not obtain information before the GC session and probably they would have benefited from prior e-learning tools.Importantly, the counselee's knowledge acquisition prior to the GC session allowed the counselor to develop a more purposeful and meaningful interaction during the GC session rather than educating the counselees in basic medical and genetic concepts which must then be appropriately absorbed and 'digested' by the listeners.The counselors had more time for discussion and dialogue, and 'translating' the scientific data to personal considerations, desires, and decisions.
Interestingly, about one-third of the counselees declared that the questions they asked during the GC session were due to the material they had absorbed by watching the animation movie.
Considering the goals of GC, this statistic is a major validation for using an e-tool such as the AM, which encourages and guides the patient in gaining knowledge prior to their medical appointment so that they may be more prepared and involved in their care options and treatment.
There are several factors that may have skewed the participants' post-educational knowledge scores and confounded the inter-group comparisons: first, the genetic counselors knew the questions listed in the surveys and this may have influenced the information they emphasized in GC meetings, thus positively biasing the participants' scores.Second, the study team included seven certified counselors who followed the same counseling guidelines but each one, naturally, has her/his own interpersonal variations on how to deliver information.Therefore, a counselee's score may have been biased by the specific counselor with whom they met.Finally, the questions in the pre-and post-GC meeting questionnaire were identical and may have primed participants to pay attention to certain key points.
In addition, we assessed the level of informed choice using the well-validated MMIC model.Our results revealed that there were no significant differences between the study groups, similar to Skjøth, Draborg, Lamont, et al. (2015), who found that using an interactive website with information about DS screening tests had no direct effect on making an informed choice on whether or not to undergo the test.However, when we examined our data in a higher resolution, we found that the rate of informed choice was higher among the Jewish than among minority participants, possibly due to their higher level of knowledge which may be attributed to a higher educational background also expressed by higher scores in the genetic literacy questionnaire.Thus, our results showed that a more significant educational investment in minority ethno-cultural groups is required to enable them to make informed decisions in significant medical issues, as shown in previous studies (Allford et al., 2014;Dormandy et al., 2007).
We were interested in knowing whether the mode of obtaining information affected the net outcome of the intervention and found that, although the participants enjoyed both interventions, they found the AM to be more interesting and inclusive of topics more important for decision making than the educated booklet.Notably, the state of anxiety in our study remained constant before and after the interventions, meaning that the animated movie did not increase anxiety or worry.Since the participants were diverse in gender, educational level, genetic literacy level, and ethnicity, we can conclude that AM is acceptable to a wide range of counselees.
We wondered to what extent the personal attitude to TOP in certain circumstances would influence learning quality and informed choice.Most study participants who had good knowledge scores and informed choice accepted the concept of TOP, but even some of those who refrained from any interventions during pregnancy did undergo screening tests, perhaps because this test is routine, noninvasive, and inexpensive, or because women expect to receive reassuring results.Moreover, we found that women who refrain from terminating pregnancies still chose to undergo the invasive test.This may reflect the desire to 'know', to prepare themselves psychologically for the birth of an affected child, or to hope for normal results.
About one-third of the participants were adamantly opposed to TOP in any situation; most of these belonged to the minority population and associated themselves with a high degree of religiosity.These findings are similar to previous studies in Israel, where the rates of TOP among Arabs were lower than among Jews.For Jewish couples, the critical decision factor for TOP was the severity of the fetal medical condition, whereas among the Arab couples (especially Muslim Arabs) the gestational age was the most critical factor in the decision (Sharkia et al., 2015;Zlotogora et al., 2010).
In conclusion, our findings suggest that using animated movies as an educational device facilitated prenatal GC outcomes by improving levels of knowledge and satisfaction, with no negative effect on the counselees' anxiety level.Hence, developing validated sources of educational information such as the e-learning tools we used and referring the counselees to them prior to the GC meeting is recommended.Many countries worldwide have majority and minority populations, as does Israel; special attention should be given to minority populations with lower genetic literacy and education.
More educational investment is required to enable them to improve their knowledge and make informed decisions concerning significant medical issues.We believe that such tools will serve as an important foundation for a more general transition to digital communication that had already begun to increase dramatically in the medical field prior to the Covid-19 pandemic, which introduced another urgent reason for using e-learning tools to educate care-receivers and patients.

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| INTRODUC TI ON In Israel, maternal serum screening for Down syndrome (DS) is a well-established component of routine prenatal care.Since 2013, routine prenatal care has included sequential tests for DS screening in the first and second trimesters.First trimester screening includes ultrasonic nuchal translucency measurement (NT), maternal blood tests of plasma protein A (PAPP-A), and free beta human chorionic gonadotropin (Free beta HCG).Second trimester screening (triple test) includes maternal serum tests of alpha-fetoprotein (AFP), HCG, and unconjugated Estriol 3 (UE3).Figure S1 shows the flowchart of the current DS screening tests in Israel.These tests are offered to all pregnant couples and are covered by the health maintenance organizations (HMOs).The uptake rate of these tests by pregnant the counselor & measuring the duration of the GC meeting (by the counselor) Completing the post GC study questionnaires, including: -Knowledge (α= 0.88) a -State of Anxiety (α= 0.86, 5 items b )Attitude toward fetus' genetic test (α= 0.67, 3 items) ersonal attitudes towards TOP (α= 0.67, 5 items) -Satisfaction (with the counselor (α= 0.83, 3 items), intervention (α= 0.70, 8 items) and the GC process (α= 0.79,4 items) had received prior information.The participants completed the questionnaire in a dedicated room without the counselor.
a,b .
a Kruskal-Wallis rank sum test.b Pearson's Chi-squared test.
Study participants and flow.AM, animated movie; C, control; EB, educational booklet.
. Possible scores ranged from 3 to 21. Positive or negative attitudes were defined by the midpoint of the scale, with scores of 12 and below attributed to a positive attitude toward a fetal genetic test.F I G U R E 2 Knowledge level according to the study groups a .