On average, 5% to 18% of births worldwide are preterm [1]. Spontaneous premature labor is the most common cause of premature birth, accounting for 40% to 45% of cases, followed by premature labor after preterm premature rupture of membranes (25% to 30%) and various health problems in pregnant women and fetuses for which premature delivery is the best option rather than maintaining pregnancy [2]. In South Korea (hereafter, Korea), the proportion of patients receiving medical treatment for premature labor, relative to all births in the corresponding year, increased steadily from about 5.86% in 2016 to 6.61% in 2018 and 6.75% in 2020 [3-6]. In addition, medical expenses also increased from 37 billion Korean Won (KRW) (approximately 33 million US dollars) in 2016 to 46.5 billion KRW (roughly 42 million US dollars) in 2018 and 48.3 billion KRW (roughly 43 million US dollars) in 2020, despite the continuing decrease in the number of births [3-6].

Premature labor refers to the onset of uterine contractions before 37 weeks of pregnancy. A clinical diagnosis is made when cervical dilatation and effacement have progressed along with regular uterine contractions [7]. Premature labor can have a single cause, such as an infection in the amniotic fluid, but it can also result from multiple pathological processes involving multiple causes [8]. Premature labor does not always lead to premature birth, and full-term delivery is often possible with good prevention, early detection, and prompt management [7]. Since prepregnancy health status affects pregnancy outcomes, preventive management is necessary before pregnancy to improve pregnancy outcomes and reduce health care expenditures for mothers and newborns [9,10]. It is also necessary to identify risk factors for premature labor before pregnancy and manage them according to the degree of risk [7]. In other words, prepregnancy health care to prevent premature labor should not be limited to women who are already aware of and manage an underlying disease, but should also be received by women who are unaware of an underlying disease, have high-risk factors such as obesity and smoking, and have a history of premature labor and cervical surgery [9]. If a woman with high-risk factors becomes pregnant, she should receive regular, early prenatal care and proactive preventive treatment [9]. When receiving preconception care or after childbirth, it is an appropriate time to educate women who have high-risk factors for premature labor to control those factors [11]. In addition, even women at low risk for premature labor can prevent premature birth if they are aware of the symptoms of premature labor in advance and know how to respond appropriately [11]. Women of childbearing age should be able to learn about the risk factors of premature labor before conception in a self-directed way, to manage their health according to these risk factors and develop their preventive self-management capabilities.

Since the incidence of premature birth due to premature labor in developed countries is low, around 9% [1], most women expect and imagine only a normal pregnancy [12,13]. If women are not aware of the term “premature labor” in advance, they might first hear this phrase from a medical professional when they visit a hospital with abnormal symptoms of premature labor [12,13]. Therefore, the opportunity for an early and appropriate response may be missed at the time of symptom onset. A previous study found that women of childbearing age desired individually tailored prepregnancy health information, preferred sources of prepregnancy health information, and learned through the experiences of other women when planning pregnancy [14]. Education using webtoons, a type of digital comics that readers can access via computer or smartphones, can present various stories of women’s experience of premature labor and offer an alternative to personalized learning from others’ experiences.

The term “webtoon” was first used in Korea in 2000 [15] to refer to cartoons published online; these are also called digital comics or website cartoons [16,17]. Webtoons emerged as a comics genre unique to Korea and have now become a representative form and medium of the comics industry [15]. Webtoons are representative areas of the “snack culture” trend, and unlike printed comics, webtoons can be viewed conveniently in a short period of time, regardless of time and place, as long as the user has a device capable of accessing the internet [15]. Therefore, webtoons can be used as a medium for health education that can be easily spread in daily life [18]. In addition, webtoons were reported to have potential educational and cultural value due to their visual stimulation, narratives that can be practical and realistic. In other words, webtoons can provide a better understanding of factual information and give readers a greater understanding of the social and psychological aspects of the illness through the use of narrative, characterization, and images [18]. A prior study reported that using cartoons in the educational process provided learners with an educational environment that was enjoyable, interesting, and motivating to learn, and also facilitated comprehension, developed intelligence, ensured permanent learning, and facilitated evocatory [19]. In addition, webtoons were reported to have interactivity that draws upon their characteristics of openness, participation, and sharing [20,21]. Korean women of childbearing age are familiar with the use of internet devices and webtoons [15]. Furthermore, Korean women use the internet almost every day [22], and about 74% reportedly view webtoons at least once a week [23]. Therefore, Korean women of childbearing age may be open to webtoon learning, done on their own initiative at a time and place that is suitable for them.

To date, premature labor intervention studies have focused on early labor assessment and support at home [24], uterine monitoring for the detection of premature labor at home [25], support for women hospitalized for premature labor [26,27], and relaxation therapy for women hospitalized for premature labor [28-32]. These studies were all conducted among women hospitalized for premature labor, and most of them explored the use of relaxation therapy as a psychological intervention. No studies have yet targeted women at high risk of premature labor before pregnancy and before the onset of premature labor, and to our knowledge, no webtoon-based education on premature labor has been developed. Just as health care before pregnancy is recommended because prepregnancy health care affects pregnancy outcomes [9,10], preventive health education for women with high-risk factors for premature labor can affect pregnancy outcomes.

Therefore, this study developed a webtoon education program for preventive self-management related to premature labor (PSM-PL) for women of childbearing age and evaluated its effectiveness and usability to determine the future potential for wider applicability. The primary hypothesis of this study is as follows: the experimental group participating in the PSM-PL webtoon education program would have significantly higher levels of preventive health management self-efficacy related to premature labor (PHMSE-PL) than the control group immediately after education and at 2 weeks after baseline. The secondary hypothesis is that the experimental group participating in the PSM-PL webtoon education program would have significantly higher levels of preventive self-management knowledge related to premature labor (PSMK-PL) than the control group immediately after education and at 2 weeks after baseline.

This webtoon education program consists of a total of six episodes and 200 number of squares, telling the story of five pregnant women with premature labor. The risk factors for premature labor in these women were selected as the most common cases based on the literature and expert opinions, and the risk factors were different for each woman. This webtoon education program included risk factors of premature labor, preventive risk factor management, preventive daily life management, symptoms of premature labor, early response methods when symptoms appear, and support from family and self-help groups. Because webtoons can be accessed easily through smartphones, computers, and laptops through the internet, they have the advantage of being conveniently viewed in a short time [17]. Thus, webtoons are a valuable medium for health education in places where the internet is easy to access, such as in Korea [18]. Humans most naturally organize their experiences and knowledge through the narrative form [37]. Narrative learning helps students to obtain learning results through the process of exploring and solving problems at the individual or social level in various stories that already exist in the real-life context [37]. Webtoons not only deliver story-based learning content, but also foster self-awareness, reassurance, empathy, and companionship due to the cartoon elements of characters and images [18]. Webtoons are also a valuable health information medium [18] because they facilitate improvements in academic interest, immersion, learning [20,38], and metacognition [20]. Therefore, as a narrative medium based on realistic stories, webtoons help readers naturally organize the delivered knowledge [37]. It is also possible to create metacognitive sensitivity that can be applied in close connection with the real-world context of one’s life through the narrative learning method [37]. The present study developed and administered a webtoon-based intervention because of its advantages in terms of both learning effects and the delivery method. Since the main characters were ordinary women who presented their individual experiences of premature labor as a story, indirect experiential learning was naturally induced while participants read the story, instead of a one-sided method of passively receiving information from the educator. Many educational materials have been developed using cartoons, but these have not generally presented realistic stories; instead, they have generally used formats such as an educator character presenting one-sided explanations [39], story-based comic books [38,39], cartoon media characters presenting information [40], and video formats [41]. Unlike the passive nature of these formats, webtoons allow posting opinions and “likes” which encourage bidirectional engagement, while presenting stories that readers can relate to. A recent study used a webtoon to provide education on COVID-19 infection prevention and reported that webtoon education had an educational effect on knowledge development and positive attitude formation through emotions and inducing preventive behavior [42]. Meanwhile, another study reported that women of childbearing age wished for individually tailored prepregnancy health information, preferred sources of prepregnancy health information, and preferred learning through the experiences of other women when planning pregnancy [14]. In medical education, both instructors and students preferred cartoons because they believed that cartoons create a positive learning environment, support students’ thinking, and help promote verbal communication between instructors and students [43]. Therefore, since the webtoon education program presented in this study was personalized in time and place and involved learning through case experiences, it aligns with what is expected as a preferred source of health information.

In this study, the experimental group had statistically significantly higher PHMSE-PL than the control group immediately after participating in the education program and after 2 weeks. In previous studies, prenatal education using comics was found to be partially effective in improving the environmental health behaviors of pregnant women [39]. Narrative-based educational information from comic books was more effective than traditional information-based education on pregnant women’s self-efficacy in reducing climate change-related health risks [44]. Because the participants of this study participated in story-based narrative learning using webtoons, we can posit that their learning was internalized by considering high-risk factors of premature labor in the context of an individual’s life and how to seek solutions [37]. The visual images of the webtoon and the personalities of the main characters also likely contributed to enhancing the learning effect [20,38].

Furthermore, in this study, the experimental group had a statistically significantly higher PSMK-PL than the control group immediately after participation in the educational program and after 2 weeks. In previous studies, narrative-based educational information from comic books had an effect on pregnant women’s knowledge of health risks related to climate change [44] and on knowledge about the prevention and management of COVID-19 [42]. Cartoons were found to be valuable as a health information medium [18] and had an effect on students’ academic achievement in social studies [21]. It has also been argued that cartoon mnemonics are time-efficient for medical students who must memorize many facts [45]. Therefore, webtoons are thought to improve knowledge by increasing learning interest and learning immersion, making information easier to remember [20,38].

A meaningful aspect of this study is that it evaluated the usability of the webtoon health education related to premature labor based on stories, since this is one of the first studies to use a webtoon-based study to provide health information to women of childbearing age. The average score for usability of webtoon education in this study was high at 4.52 points, with generally high scores ranging from 4.43 to 4.57 across the subcategories. Particularly high scores were found for usefulness, valuableness, and merit for the future of webtoon education, reflecting the recognition that this webtoon presented effective educational material. Since the material was published as a webtoon and only one participant did not view it within the given time, it is presumed that it was convenient and accessible. In this webtoon, however, only four colors (including black and white) were used, and digital effects were not used [46], which may explain why desirability had the lowest score.

In this study, webtoon scenarios describing five cases of premature labor were composed, and their effects were confirmed. In the future, it will be necessary to develop various cases, create a program that can induce behavioral changes as well as improve self-efficacy and knowledge, and conduct evaluation studies. Another point worth noting is that the characters in the webtoons were portrayed realistically to enhance empathy and immersion. However, there are limitations in interpreting the effects of the webtoons in terms of empathy and immersion, because it was not confirmed which specific characteristics of the webtoons affected participants’ learning modalities. The webtoons developed in this study could be individually tailored in terms of time and place, but the educational content was not specifically personalized.

Some possible options for creating a truly personalized online webtoon education program and deepening virtual experiential learning could include developing an interactive webtoon story in which the user directly selects relevant options of risk factors for premature labor and creates the story, using movement technology for characters, or applying the technology of a three-dimensional spatial experience in which the user enters the story [16].

Blinding was not performed due to the characteristics of the webtoon education program in this study, and it was not possible to confirm long-term effects such as preventive health management practices for premature labor during actual pregnancy and indicators related to the direct occurrence of premature labor. Future research to confirm long-term, practical effects are suggested. The time of retest in this study was as short as 2 weeks after the intervention. In future studies, it is suggested to measure the effect by extending the time of the retest. Since there was no pre-existing measurement tool suitable for evaluating the effectiveness of this program, the measurement tools used in this study were not widely utilized. The interpretation of the research results is limited because these tools have not been applied to various groups or sufficiently tested for validity and reliability. It is meaningful that this study evaluated the effectiveness of the webtoon education program on PSM-PL for the first time in nursing. Unlike animation-based educational materials containing stories, which require substantial investments of time and money, webtoon educational materials are relatively time- and cost-effective. No study has yet compared the educational effectiveness of animations and webtoons, so it is expected that a comparative study on time, cost, and educational effects will be conducted in the future.

In conclusion, this study confirmed that a webtoon education program could potentially improve self-efficacy and knowledge of health management related to premature labor in women of childbearing age. As this webtoon education program was also feasible and evaluated as useful, clinicians can use it at various health education sites in the future to enhance the self-management capacity of women of childbearing age to prevent premature labor.