Published online September 1, 2006
PEDIATRICS Vol. 118 No. 3 September 2006, pp. 1157-1166 (doi:10.1542/peds.2006-0209)
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ARTICLE

Improving Pediatric Prevention via the Internet: A Randomized, Controlled Trial

Dimitri A. Christakis, MD, MPHa,b,c,d, Frederick J. Zimmerman, PhDb,c, Frederick P. Rivara, MD, MPHa,c,d and Beth Ebel, MD, MPH, MSca,c

Departments of a Pediatrics
b Health Services
c Child Health Institute, University of Washington, Seattle, Washington
d Children's Hospital and Regional Medical Center, Seattle, Washington


   ABSTRACT
TOP
 ABSTRACT
METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
BACKGROUND. Innovations to improve the delivery of pediatric preventive care are needed.

METHODS. We enrolled children, 0 to 11 years of age, into a factorial, randomized, controlled trial of a tailored, evidence-based, Web site (MyHealthyChild) that provided information on prevention topics before a scheduled well-child visit. There were 2 components of the intervention, namely, parental Web content and provider notification. Parental Web content provided information to parents about prevention topics; provider notification communicated to physicians topics that were of interest to parents. We assigned 887 children randomly to 4 groups (usual care, content only, content and notification, or notification only). Outcomes were determined with telephone follow-up surveys conducted 2 to 4 weeks after the visit. Poisson regression analysis was used to determine the independent effects of each intervention on the number of topics discussed and the number of preventive practices implemented.

RESULTS. Parents in the notification/content group and in the notification-only group reported discussing more MyHealthyChild topics with their provider. Parents in the notification/content group and in the content-only group reported implementing more MyHealthyChild topic suggestions (such as use of a safety device).

CONCLUSIONS. A Web-based intervention can activate parents to discuss prevention topics with their child's provider. Delivery of tailored content can promote preventive practices.

Key Words: Internet • prevention • primary care • child health • outcome

Abbreviations: UWPN—University of Washington Physician Network • OR—odds ratio • CI—confidence interval • IRR—incidence rate ratio

Pediatricians spend <10 minutes of well-child visits discussing preventive care.1,2 There are numerous barriers to delivering pediatric preventive care, including lack of time and knowledge, clinician forgetfulness,3,4 and information overload.5,6 A typical visit can be consumed by a long list of topics deemed pertinent by providers or organizations, leaving minimal time for discussion of concerns most relevant to parents. Moreover, providers may not use adult learning theory in counseling parents, opting instead for a quick run-through of topics.7 Parents may leave confused, overwhelmed, or distracted by the amount of information conveyed during the visit.8 In general, parents help infrequently to set the agenda for well-child visits, and often they leave without the information they sought initially.9–11

Historically, changing provider behavior has proved difficult, especially with respect to preventive health maintenance.12,13 However, patients themselves can motivate provider behavior changes effectively.12 Informing patients which questions to ask their doctor before a scheduled visit has improved the quality of adult diabetes care,14–16 but similar studies among healthy children are generally lacking. Traditional means of activating patients have relied on mailings, telephone calls, or in-person contact. The ability of the Internet to activate parents has not been explored. This oversight deserves correction, because the Internet has the potential to reach a large number of people through a medium that is more interactive and considerably cheaper than mailings and that is vastly cheaper than in-person contact or telephone calls. We conducted a study to test the hypothesis that parental activation could occur through directed use of an Internet site before a well-child visit and that this activation would promote the discussion of evidence-based prevention topics with providers and would result in increased parental and physician adoption of preventive measures.


   METHODS
TOP
 ABSTRACT
 METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
Setting
This study was conducted in 4 nonteaching clinics in the University of Washington Physician Network (UWPN). Staffed by both pediatricians and family physicians, UWPN serves a diverse group of patients. UWPN uses a commercially developed, electronic medical record system, Epic (Epic Systems, Madison, WI). Providers have computers in all examination rooms and look at them routinely before and during patient encounters.

Patients
Between October 2003 and June 2005, we obtained the names and addresses of patients who had been examined in 1 of the 4 participating UWPN clinics in the previous 3 years. Because older children may be seen as infrequently as every 3 years for well-child visits, we chose a 3-year window to ensure that we included all potentially eligible patients. Eligible children were <11 years of age, had parents who spoke English, were patients at a participating clinic, and needed to make a well-child visit during the study period. All potentially eligible families were mailed a letter stating the purpose of the study and were given an opportunity to opt out immediately, either by returning a postage-paid card or by calling a toll-free telephone number. Only 1 child from each family, selected at random, was invited to participate. A telephone survey group contacted families that did not opt out, to obtain consent and to administer a baseline questionnaire. The questionnaire determined eligibility more completely (eg, patient no longer at UWPN). The baseline questionnaire measured demographic characteristics of the family and specific health and behavioral risk factors (eg, parental smoking and gun ownership). Finally, it determined home Internet access and comfort with using the World Wide Web.

For completing the study, parents were given a $20 gift certificate to Toys "R" Us. The University of Washington institutional review board approved this study protocol.

Intervention
We created a Web-based intervention, called MyHealthyChild. Parents enrolled in the trial received a log-on code and password. The site itself was designed to be self-explanatory and had 2 components, namely, provider notification and parental content. The details of each component are described below.

Provider Notification
When parents in the intervention arms logged on to the password-protected MyHealthyChild site, they were presented with a list of relevant topics, tailored on the basis of their child's age and data retrieved from the baseline questionnaire. For example, only parents who identified themselves as smokers on the baseline questionnaire were given an option to learn more about how to quit smoking; only parents whose children would be eligible for the Head Start program, on the basis of their age and family income, were presented with information on the program. The criteria for presenting topics to parents are summarized in Table 1. Parents could select as many topics as they wished.


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  		TABLE 1 Outcomes Measured According to Topic

 
When providers opened the electronic chart for study patients assigned to receive provider notification, either before or during a well-child visit, patient names were highlighted in green. In addition, a "best-practice" icon was red, indicating that there was relevant information for the patient (Fig 1). When providers clicked on that icon, a hyperlink took them to our secure Web site. For technical reasons, it was not possible for us to know which patient's chart was being viewed. Therefore, we listed all study patients for that day who were being seen in the clinic (Fig 2). By clicking on the appropriate patient's name, providers could see quickly which topics were of interest to parents, on the basis of the topics they had selected. If parents had completed screening questionnaires on-line (eg, developmental screening), then providers had access to those results. Providers were not aware of which parent visited the Web site, although, during enrollment, we asked that it be the parent who took the child to the doctor most commonly.


Figure 1
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  		FIGURE 1 Example of Epic screen, with highlighted patient name and best-practice indicator.

 

Figure 2
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  		FIGURE 2 Notification screen for providers.

 
Parental Content
We also developed specific content for each of the studied topics, to which parents were given access before a scheduled well-child visit. The information was presented in stages and interactively, so that parents could obtain answers to the questions they deemed of greatest relevance to their child. Where available, we provided links to other Web sites that provided high-quality pediatric health information.

We derived age-specific recommendations by relying on 4 sources of information, namely, (1) the US Preventive Services Task Force Guide to Clinical Preventive Services, (2) the Bright Futures guidelines for health supervision,17 (3) peer-reviewed systematic reviews of other preventive care interventions, and (4) high-quality, randomized, controlled trials. With these resources, we identified 13 topics for which there was a reasonable evidence base and clear prevention recommendations. The following prevention areas were targeted as part of the intervention. (1) Smoking cessation counseling. Using the office visit to initiate smoking cessation counseling and tobacco quitlines are effective.18,19 (2) Smoke detector use and testing. Working smoke detectors decrease the risk of injury and death resulting from smoke inhalation by 70%.20 Office-based interventions can increase the proportion of homes with working detectors.21 (3) Car seat use and installation. Although car seats are effective in decreasing injuries, >80% of children 4 to 8 years of age are restrained inadequately.22 (4) Hot water heater temperature. Providing information to families about testing water heater temperature and lowering the setting to <125°F reduces the risk of scald burns.23 (5) Tuberculosis screening. Nearly one half of all children are not screened for tuberculosis risk.24,25 (6) Head Start. The benefits of the Head Start program on early child development have been documented extensively.26 Many children are not enrolled because parents and providers lack knowledge about the child's eligibility and the program's benefits. (7) Developmental and behavioral screening. Less than 30% of parents report receiving adequate development/behavior information from their pediatricians.9,10 Structured screening, rather than informal assessments, are recommended but are used rarely by physicians.27 With child development inventories, parental report is as sensitive as formal screening by pediatricians.28–30 (8) Attention-deficit/hyperactivity disorder screening. Effective treatment for attention-deficit/hyperactivity disorder is associated with improved school performance and behavior.31–33 Parents who are concerned about their child's attention span may benefit from screening of their child. (9) Bicycle helmets. Helmets decrease the risk of brain injury by 88%.34,35 Helmet promotion by physicians can increase helmet use.35 (10) Television viewing. Aggression and obesity are affected by television viewing. Current recommendations are that children watch <2 hours per day, that they not have television sets in their bedrooms, and that they not eat in front of the television.36–38 (11) Firearm storage. Safe storage of guns can decrease the risk of unintentional and suicide firearm injury by >70%.39 (12) Influenza vaccination. Annual influenza vaccination is especially recommended for high-risk pediatric populations.40 (13) Sudden infant death syndrome. Well-identified risk factors for SIDS include prone sleeping and the use of fluffy pillows and bed clothes, although many infants are not put to bed in a safe crib environment.41,42

Kiosk Version
We developed a touch-screen kiosk version of the Web site that was available in clinic waiting rooms. The kiosk version worked identically, in terms of content and notification, to the home computer version. Parents without home Internet access were contacted and asked to come early to their child's clinic visit, where a research assistant helped them access the Web site.

Study Design
We conducted a 2 x 2 factorial, randomized, controlled trial in which families were assigned randomly to receive Web content and notification, notification alone, content alone, or usual care. The intervention groups had the following components. (1) Parents in the group that received Web content and notification were able to select and to read about topics in which they were interested. Providers had access to the topics in which the parents were interested and the results of any screening questionnaires they completed. For example, if the parents completed a developmental screen, then providers were able to view the results. (2) Parents in the group that received notification alone were able to select topics of interest to them from the menu presented on the first screen. However, they were not able to access any content or specific advice regarding the topics. Providers were informed which topics the parents were interested in learning more about. (3) Parents in the group that received content alone were able to select topics and to access relevant content. However, their providers received no information regarding their use of the Web site. (4) Parents in the group that received usual care had no access to the Web site and visited their providers as they normally would.

Our rationale for this design was to determine the marginal benefit of the physician notification component of the study. If getting information to providers at the point of care is critical, then electronic medical records may be an essential component of Web-based interventions. If the parental content arm alone demonstrated benefit, however, then any health care delivery system might benefit from using such a system.

Study Procedure
After baseline questionnaires were completed and consent was obtained, patients' names and medical record numbers were stored on a secure server. Each night, the electronic appointment system was queried automatically to determine the next scheduled well-child visit for all enrolled study subjects. The visits could be as far as 365 days in the future. All upcoming appointments were stored in an electronic database. When enrolled subjects had an upcoming appointment in the next 3 to 14 working days, they were assigned randomly to 1 of the 4 study groups, with a computer algorithm. After randomization, parents with e-mail addresses were sent automatically an e-mail containing the Web address, the family's log-on code and password, and a reminder to visit the site before their child's upcoming appointment. A letter with the same information was mailed the next business day. We imposed the 3-day rule to allow parents time to access the site before their visit. We imposed the 14-day restriction to ensure that reviewed topics were fresh in parents' minds at the time of the clinic visit.

Outcomes
Two to 4 weeks after a scheduled well-child visit occurred, participants completed a telephone interview with a research assistant who was blinded with respect to study assignments. The interview included questions about whether topics were discussed at the previous well-child visit and whether parents were practicing the targeted prevention/health promotion behaviors. Each parent was asked, "At your child's most recent checkup (on [date of last visit]), did you and your child's doctor discuss [each topic]?" All parents were asked about all of the relevant prevention topics targeted by MyHealthyChild, regardless of whether they had expressed interest in them. In addition, parents were asked about their preventive practices. In some cases, there was >1 question for each behavior. For example, for smoking, we asked whether parents had quit, had set a quit date, or had contacted the tobacco quitline, all of which are associated with successful smoking cessation.19 We conducted home-visit validation of practices that lent themselves to validation (eg, smoke detector locations, car seats, hot water temperature, and bicycle helmets). For these behaviors, the positive predictive values ranged from 0.75 to 1.0.43 We decided a priori what would constitute compliance with the targeted behaviors, on the basis of the best available evidence. A summary of prevention topics and measured actions is presented in Table 1.

Statistical Analyses
Because the outcome was the number of topics discussed in the visit, power calculations were completed with the assumption that the data would show Poisson distribution. On the basis of previous work, we assumed that patients in the control arm would discuss ~6 of the 13 topics. We calculated that, with a 2-sided {alpha} value of .05 and with 245 patient visits in each arm, we would have 80% power to detect a difference of 8% between the control arm and any intervention arm in the number of topics discussed.

Because our intent was to test whether an Internet-based intervention would increase discussion and implementation overall and not just for a specific topic, the outcome was the number of topics discussed or the number of practices adopted, ranging from 0 to 13. We were not powered to analyze, and did not analyze, the effects of the intervention on individual prevention topics. The level of analysis was the visit, with 1 eligible visit per patient household. With an intention-to-treat approach, we used Poisson regression to test our hypothesis, with the intervention group as the main predictor of interest. We used the Huber-White estimator of variance to adjust for the correlation of outcomes at the provider level. A likelihood ratio test failed to reject the assumption of equidispersion, with high P values (P > .5) indicating that Poisson estimation was as consistent as and more efficient than the alternative negative binomial specification.44

As secondary analyses, we used the subsample of patients in the 3 intervention arms to test the hypotheses that providers would be more likely to discuss topics if parents had indicated previous interest, regardless of intervention arm, and that parents would be most likely to adopt preventive practices in which they had indicated previous interest and that they had discussed with their child's provider, regardless of intervention arm. We used logistic regression analysis to test whether there was an effect of parental interest (together with discussion with the provider, for the action outcome) beyond patient-, visit-, or provider-level characteristics, which we controlled for with fixed effects at the visit level. The main predictors in these analyses were whether a parent endorsed interest in a topic (when the outcome was discussion at the visit) and whether the topic had been endorsed and/or discussed at the visit (when the outcome was action taken on the topic). The results of the first of these subanalyses can be interpreted as the increase in the odds of discussing a particular topic associated with parental endorsement of interest in the topic before the visit. The results of the second of these subanalyses can be interpreted as the increase in the odds of implementing a particular preventive practice associated with discussing that practice, controlling for parental interest in the topic. These analyses provide insight into the relationships between parental interest, discussion with the provider, and prevention implementation. All analyses were conducted with Stata statistical software, version 9.0 (Stata, College Station, TX).


   RESULTS
TOP
 ABSTRACT
 METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
Letters were mailed to parents of 6372 potentially eligible children, and 3182 potentially eligible families (ie, those who spoke English, were still patients in the UWPN, and had not moved without a forwarding address) were identified. Of these, 1876 families (60%) enrolled and completed the telephone baseline questionnaire. This percentage is conservative, because it assumes that all families who could not be contacted would have been eligible (Fig 3). Of these, 887 families were assigned randomly and follow-up data were available for 767 (86%). The rest of the families were not assigned randomly because they did not have a well-child visit scheduled during the study period and therefore were not eligible for inclusion. More than 80% of households had home Internet access (Table 2). Although 25% of families had incomes of more than $75000, ~1 of 5 had incomes of less than $20000 per year. Table 3 summarizes the proportion of parents in each arm of the study who stated that they had discussed or practiced each behavior.


Figure 3
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  		FIGURE 3 Patient flow through the study.

 

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  		TABLE 2 Descriptive Data on Study Participants

 

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  		TABLE 3 Proportions of Parents Endorsing Discussions and Practices, According to Topic and Treatment Group

 
Before their child's checkup, 713 (93%) of 767 parents visited the Web site. Of those, 93 (13%) did so from the kiosk in the waiting room; the rest used a different location before the visit. Providers accessed the site 160 times. Given that there were 348 patients assigned randomly to groups with notification information, a conservative estimate of provider usage of this notification would be 46%. This number could be an underestimate, however, because, in a single session on the Web site, providers could access information for all of the patients who had visits on a given day.

In the Poisson analysis, parents in the notification/content arm and in the notification-alone arm reported discussing 9% and 8%, respectively, more MyHealthyChild topics with their provider (incidence rate ratio [IRR]: 1.09; 95% confidence interval [CI]: 1.00–1.20; and IRR: 1.08; 95% CI: 1.02–1.15; respectively). Differences between the content-only arm and the control arm were not significant (Table 4).


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  		TABLE 4 Poisson Regression Analyses of Discussion and Implementation of MyHealthyChild Topics

 
With respect to changing behavior within the household, parents in the content/notification arm and in the content-alone arm reported implementing 7% and 5%, respectively, more MyHealthyChild topic suggestions (such as use of a safety device) (IRR: 1.07; 95% CI: 1.03–1.11; and IRR: 1.05; 95% CI: 1.01–1.09; respectively). Differences between the notification-only arm and the control arm were not significant (Table 4).

In subanalyses, parents who expressed interest in a topic were more likely to discuss it subsequently with the provider (odds ratio [OR]: 3.5; 95% CI: 2.98–4.11). Both previous interest and physician discussion were associated independently with implementation of preventive practices (OR: 1.77; 95% CI: 1.52–2.04; and OR: 1.98; 95% CI: 1.70–2.32; respectively) (Table 5).


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  		TABLE 5 Logistic Regression Analyses of Whether a Topic Was Discussed and Whether Action Was Taken on a Topic

 

   DISCUSSION
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
We found that an interactive, tailored, evidence-based, Web site could increase the likelihood of discussing prevention topics with a physician and the likelihood that prevention would be practiced. On the basis of our factorial design, we conclude that sharing parental interests promotes discussion during a well-child visit and tailored Web content promotes actions on the part of parents. The effect sizes for our intervention were modest but consistent with those for other interventions designed to change provider behavior, which has proved notoriously difficult to do.12 Compared with interventions requiring face-to-face encounters, ours has several advantages. First, Web sites are fundamentally scaleable; once developed, they can service a large number of families with minimal extra cost. Accordingly, the cost per patient can be so low as to be trivial. Second, information on a Web site can be updated more easily, compared with the effort required to "redetail" providers personally. Third, because the Web site with parental content alone was sufficient to improve preventive practices, these modest effect sizes could be meaningful when effects are assessed over an entire population. Finally, our bivariate results suggested some areas in which potentially large effects might be achievable (eg, smoking and tuberculosis screening). Our study was not designed to study these in isolation, but future studies could.

Furthermore, our subanalyses suggested that emphasizing topics of interest to parents might be a fruitful approach to improving the delivery of preventive care. It may come as no surprise that parents are more likely to change behaviors when they express previous interest in the topic. However, traditional care delivery typically does little to determine parents' interests. The generic checklist approach to pediatric preventive care may be missing opportunities to promote changes in health behavior. Rather than rushing through a list of topics, providers may wish to prioritize (or focus exclusively on) topics of interest to parents. This approach has been used successfully in motivational interviewing.45 Information technology has the capacity to do this efficiently. Although we chose our topics specifically regarding common issues in pediatric prevention, these topics are in a sense proxies for any set of topics that should be a source of discussion; our study can be viewed as a proof of concept, suggesting that the Internet holds promise as a means of informing and modulating the parent-physician dialogue and the delivery of health services.

Our results must be interpreted in light of some limitations. First, we did not confirm whether reported discussions of topics actually occurred. However, if parents could not recall whether they discussed a topic with their provider 2 weeks after a visit, then the discussion would have minimal impact even if it did occur. Second, this study may not be generalizable to other settings, because it was conducted in 1 practice network. However, we enrolled an economically diverse sample of patients, and the nature of the intervention suggests that patient characteristics are as likely to determine outcomes as are network or physician characteristics. Third, because we assigned patients randomly within clinics, it is possible that some contamination occurred, that is, that providers who treated patients in both the intervention and control groups modified their approach to well-child care, perhaps by stressing different topics or even by asking parents what topics interested them. To the extent that this occurred, our results likely underestimated the true effect size. Fourth, we enrolled 60% of eligible subjects successfully. It is possible, although not apparent, that they were in some systematic way different from the subjects who opted not to enroll. Finally, we were surprised by the large proportion of families with home Internet access, including 70% of parents with only high school education.46 Although this level of Internet access may not be representative of the United States as a whole, the "digital divide" is narrowing; current estimates are that 90% of families will have Internet access at home or at work by 2010.47 We share the views of the Institute of Medicine, that the use of Internet technology to improve health care is in its infancy but holds great promise.48

Despite these limitations, we think that our study has important implications. Ours is one of the first studies to evaluate experimentally the potential of a health-related Internet site to improve the quality of health care, and it confirms that this approach holds promise. An estimated 70 million consumers flock to the estimated 20000 medical information Web sites available, in search of medical information.49 Unfortunately, there is limited use of these technologies to enhance patient-provider interactions, and there are almost no empirical data on the potential benefits. Consumers are left to navigate an information system with no quality control and no patient-specific content.50 Additional research that explores robustly the full measure and potential of such technology is needed. Such studies should focus on ways to improve the tailoring of content, by taking into consideration individuals' readiness to change specific behaviors, and to target areas that are not well served by existing preventive care approaches. The possibilities are truly endless.


   ACKNOWLEDGMENTS
 
This project was funded by a grant from the Agency for Healthcare Research and Quality (grant 1 R01 HS013302, to D.A.C.). The funder played no role in the conduct of the study.

We are grateful to all of the families and providers who participated in the study. Danielle Zerr, MD, MPH, provided thoughtful helpful comments on manuscript drafts. Joseph Leonard created the Web interfaces without which this study could not have been performed.


   FOOTNOTES
 
Accepted Mar 2, 2006.

Address correspondence to Dimitri A. Christakis, MD, MPH, Child Health Institute, University of Washington, 6200 NE 74th St, Suite 210, Seattle, WA 98115. E-mail: dachris{at}u.washington.edu

The authors have indicated they have no financial relationships relevant to this article to disclose.


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 METHODS
 RESULTS
 DISCUSSION
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D. A. Thompson, P. Lozano, and D. A. Christakis
Parent Use of Touchscreen Computer Kiosks for Child Health Promotion in Community Settings
Pediatrics, March 1, 2007; 119(3): 427 - 434.
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