A cross-sectional observational study was conducted within the context of the COVID-19 pandemic to evaluate the usefulness of QR codes with information to promote women’s health during the pandemic. The QR codes were available in the gynecology and obstetrics outpatient clinics’ waiting rooms at the Torrecardenas University Hospital. This hospital is the reference for the province of Almeria, Spain, located in the southeast of Spain, with a population size of 731,792 inhabitants as of January 1, 2022, according to the Spanish National Statistics Institute [15].

The questionnaire was developed from scratch on the basis of data obtained from a review of the literature and the authors’ experience. The questionnaire collected 5 demographic aspects (age, educational level, the reason for consultation, whether QR codes had been used previously, and the topic consulted through the available QR codes). It also collected 8 qualitative items that assessed the experience of using QR codes and the perceived usefulness in providing health information for women. Likert scales were used, with answers that ranged from “nothing” to “a lot.”

The sample size was estimated using the Epi Info app (Centers for Disease Control and Prevention, Atlanta, Georgia, United States) with the following parameters: population size 358,656 (female population in the province of Almería, as of January 1, 2022) [15]; 80% CI, and a level of precision of 5%. These parameters revealed a required sample size of 164 participants. The authors determined to collect at least 180 answers to diminish potential auto-selection bias—this value was in accordance with the guideline specified by Kline et al [16] of using 2-20 subjects for each questionnaire item for the factorial analysis.

The eligible population comprised women aged 18 or older who attended gynecology and obstetrics outpatient clinics and were offered to participate. The inclusion criteria were as follows: being women, 18 or older, speaking and understanding Spanish, and being recruited in the waiting room of gynecology and obstetrics clinics. The exclusion criteria were as follows: not meeting any of the referred inclusion criteria and not wishing to participate in the study, despite meeting the criteria.

The adequacy of the exploratory factor analysis was determined using the Bartlett test and the Kaiser-Meyer-Olkin measure. To evaluate construct validity, the 8 qualitative items of the questionnaire were assessed through exploratory factor analysis. The tool’s reliability was measured using Cronbach α [17]. The split-half method was used to assess stability because the questionnaire could not be retested with the same users [18].

Statistical analyses were conducted using SPSS (version 28; IBM Corp). Univariant and bivariant analyses were performed. The scoring of each domain was the sum of the scores provided by the participants when answering the questions. These scores could range from 1 to 4 points in each question. Thus, the score range for the first domain was 4-16 and that for second domain was 2-8. The scores of each domain were used to perform bivariate analyses regarding different aspects of the participants. Informed consent was shown at the beginning of the questionnaire. Personal data were not collected.

This study was approved by the Research and Ethics Committee of Nursing, Physiotherapy, and Medicine Department of the University of Almeria, Spain, (EFM 200/2020). The questionnaire did not collect personal information.

In total, 186 women took part in the research, with completed questionnaires with valid responses. Their mean age was 34.3 (SD 7.5) years. In total, 124 (67.7%) participants had nonuniversity studies (Table 1), and 171 (91.9%) were waiting for consultations regarding pregnancy, assisted reproduction, general gynecology, and emergencies. In total, 136 (73.1%) had used QR codes before.

Among the QR codes available in the waiting room, the most consulted ones were pregnancy physical activity, contraceptive methods, and pregnancy nutrition, for 149 (80.1%) women (Table 2). The least consulted topic was gender violence, consulted by 4 (2.1%) women.

The Kaiser-Meyer-Olkin measure of sampling adequacy was 0.779, and the Bartlett test for sphericity was 368.6 (P<.001). These results indicate the model’s suitability for exploratory factor analysis, which excluded 2 of the 8 items from the questionnaire, identifying 2 domains that explained 68.6% of the variance (Table 3). The first domain was defined by 4 items; the second one, by 2 items (Table 4).

These domains were interpreted by analyzing the items within each domain (Textbox 1). Thus, the first domain defined usability and the second one defined applicability in medical practice.

The Cronbach α of the questionnaire was .81. The Cronbach α value for the first domain was .77, while that of the second domain was .80. The split-half method did not reveal significant differences in the domains or the global evaluation (Table 5).

Regarding the evaluation of the domains defined by the questionnaire (Table 6), 83.7% of the answers to the questions that defined the first domain (usability) and 56.4% of the answers to the questions of the second domain (applicability in medical practice) were favorable (responses being “something,” “quite,” and “a lot”).

When analyzing the score of the domains for different aspects, no differences were found regarding the age of the participants in the first domain (P=.13, Spearman ρ) or in the second domain (P=.25, Spearman ρ). Regarding education level (Figure 1), statistically significant differences were found in the scores of the first domain, where the participants with university education scored higher than those with primary school education (P=.01, Kruskal-Wallis test for independent samples). No differences were found with regard to education level when analyzing the second domain (P=.10, Kruskal-Wallis test for independent samples).

When analyzing the score of both domains regarding the medical consultations of the patients (Figure 2), no differences were found (first domain, P=.55; second domain, P=.44; Kruskal-Wallis test for independent samples).

When analyzing the score of both domains regarding if the participants had used QR codes before (Figure 3), those who had used QR codes before scored higher in the first domain (P=.003, Mann-Whitney U test). However, no differences were found in the scores of the second domain regarding previous use of QR codes (P=.13, Mann-Whitney U test).

When analyzing the score of the domains regarding the topic consulted using the available QR codes (Figure 4), higher scores of the first domain were achieved by women who consulted the Breastfeeding, Pregnancy Nutrition, and Emergency Contraception topics (P<.001, Kruskal-Wallis test for independent samples). In the second domain, higher scores were achieved by women who consulted the Breastfeeding and Pregnancy Nutrition topics (P<.001, Kruskal-Wallis test for independent samples).

This research has some limitations. The most important is the selection bias due to various factors. Our sample was obtained from the waiting room of the gynecology clinic of a reference hospital, but it may not be representative of other regions or countries. Women who did not speak or read in Spanish or were younger than 18 years were excluded. We must also consider that the questionnaire and the study were in Spanish. Thus, the final validated questionnaire could be applied in other hospitals or translated and culturally adapted to other languages or countries for future research. Although the sample size in our study was larger than that in another similar study [36], larger sample sizes could also help increase the CI. These aspects must be considered when assessing the external validity of our conclusions. Finally, the potential security issues of familiarizing people to scan random signs in the waiting rooms of medical practices should be considered. For instance, malicious individuals could quite easily place signs in public places. While this is beyond the scope of this study, it is an important consideration that needs to be considered when the use of QR codes.

This study also has some strengths. The most important one is that the questionnaire yielded favorable results in the exploratory factor analysis and the value of Cronbach α. These aspects provide validity to the final questionnaire and the results obtained. Another important strength is that the study has been performed with actual patients from the waiting rooms of gynecology clinics. Considering the demographic characteristics of the sample, it seems to be more representative of actual women who can benefit from using QR codes to improve their health in real life. Thus, our findings can be helpful for current clinical practice and future research.

The questionnaire developed here has been demonstrated to be a helpful tool to measure the perception of the usability of QR codes and the applicability of the information offered even before entering the medical consultations. Thus, considering the answers provided by the participants, we can conclude that using QR codes in the consultations’ waiting rooms can help promote women’s health during a pandemic, regardless of their age, education level, or whether they have previously used QR codes. These last findings are essential because the applicability can be similar for every woman. These findings are crucial for current clinical practice. Finally, this research can be adapted to be performed in other ambits, specialties, or even different countries, and compare the results obtained, so the focus of this method can be widened and extended.