Engagement in “My Child's Asthma”, an interactive web-based pediatric asthma management intervention

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Abstract

Purpose

The Internet is a promising tool for delivering health behavior change programs although such interventions raise questions about participant engagement in this medium. In this study we sought to determine the characteristics of parents who engage in an Internet-based health intervention for their children (with asthma) and to distinguish parents who engage at the prescribed intervals versus those who engage less often.

Methods

N = 283 parents with children who had asthma were recruited and randomized to receive a web-based intervention. Participants filled out six surveys over a 6-month period asking them about demographic and clinical characteristics, outcome expectations and self-efficacy beliefs regarding asthma control for their child, and attitudes about computers and the Internet. Descriptive statistics were used to describe the population and analyze associations.

Results

Controller use and being adherent to this medication as well as positive outcome and self efficacy expectations were associated with increased engagement. Parents who logged on only once reported significantly less frequent use of the Internet than parents who logged on to all sessions.

Discussion and conclusion

The results of this study suggest that it is important to find ways to increase engagement in a web-based intervention for parents who are not yet engaging in the recommended behaviors and/or who report less positive outcome and efficacy expectations around asthma management.

Introduction

Over the past decades, web-based delivery of health promotion programs has received a great deal of attention and evaluation [1]. As Internet access continues to increase opportunities to reach broad audiences make this technology a promising tool for health behavior change programs [2]. Web-based interventions have become increasingly popular as a way of reaching clinical and general population audiences [1], [3], [4], [5], [6], [7], [8], [9], [10] due to features of web-based communication that facilitate message delivery such as, tailoring of messages, instant feedback and ability to track progress over time. Internet-based interventions are capable of providing all of these features, and hold promise for effective and efficient delivery of health behavior change programs. However delivering such interventions via the Internet also raises questions about participant engagement in this medium.

Two issues detract from the enthusiasm for web-based interventions. First, Internet-health information seekers are usually more health-oriented than those who do not use this medium for health information [11], thus limiting the reach of Internet-based interventions. Second, program engagement is often less than what was envisioned [12] and little research is available on characteristics that predict engagement in web-based interventions [13]. Although some web-interventions are designed for a one-time interaction, others, particularly those dealing with a chronic disease or problem, are designed to track progress and provide feedback over time. As such, efforts to engage people in continued exposure to a website that needs to be accessed periodically is key to success of such interventions.

In some recent studies, demographic variables, as prior health behaviors and health motivation were associated with engagement in health related web-based interventions. For instance, Strecher et al. [14], showed that older, more educated female study participants were more likely to engage in a web-based smoking cessation intervention than younger, less educated, male counterparts, as measured by the number of web-based sections opened. Another study of engagement in an Internet-based weight loss program also showed that males were less likely to be or continue to be engaged both in the initial exposure to intervention content as well as in the follow-up electronic newsletter [15]. Implementation of a worksite self-help web-based program for stress management showed that being a woman, having a secondary education, regular physical exercise habits and having positive expectations of the program were significant predictors of high use of the program [16]. Similarly, being female and having a strong motivation to be healthy was associated with continued usage of an online health communication program for physical activity [17]. In summary, gender, education, health motivation, and health behaviors appear associated with engagement in web-based programs targeted at adult individuals. It is not clear if these same factors are related to engagement in a web-based program that focuses on chronic illness management for a pediatric population.

In this study we explored factors that predict engagement over a 6 months period among parents who joined a web-based intervention study for asthma management of their young children (2–10). The study design included monthly visits to the site. Our main interest was in the group of parents who followed the recommended engagement schedule and log on every month. We sought to determine:

  • 1.

    characteristics of parents who engage in the Internet-based health intervention for their children (with asthma),

  • 2.

    characteristics that distinguish parents who engage at the prescribed intervals over 6 months vs. those who engage less often than prescribed,

  • 3.

    characteristics that distinguish those who engage one time only vs. those who engage in all five visits (super-engagers),

  • 4.

    factors predicting engagement among participants with children whose asthma was not well controlled at baseline—a key target group for this intervention.

We explored socio-demographic variables, level of severity of child's asthma, current asthma management behaviors, positive and negative outcome expectations regarding daily controller use, and self-efficacy beliefs about asthma management of child's asthma. We also included variables related to comfort/attitude with computers and Internet access and use. We hypothesized that younger age, male gender of parent and lower educational attainment would be negatively associated with engagement. In addition we hypothesized that positive health beliefs around asthma management (i.e. reflecting a greater health orientation) and positive health behaviors (i.e. engaging in asthma management behaviors) would be positively associated with engagement in this intervention. Last, we wanted to explore if prior experience with the Internet and attitudes toward Internet use would be associated with engagement with this medium.

Section snippets

Overview of the My Child's Asthma study

This study was a sub-analysis of participants’ engagement in the intervention arm of a randomized controlled trial testing the effectiveness of a web-based intervention to improve asthma control among 2–10-year olds. The main objectives of the intervention were to: (1) increase controller medication use for children who are currently not on controller medication but for whom controllers are indicated, according to treatment guidelines and based on symptom severity and (2) increase adherence to

Results

Table 1 portrays the sample characteristics for participants randomized to the My Child's Asthma website. Most of the participants in the study were female (and the mother of the child), Caucasian, between 35 and 45 years of age and with at least some college education. Most of the children were classified as “mild intermittent” and on controllers. Only about one-third of children who were on controllers were classified as “adherent” to this medication. A slight majority of parents returned to

Discussion

The objective of this study was to describe the parents of children with asthma who engaged with a web-intervention to improve asthma control at the recommended intervals and compare them with their less engaged counterparts. The results show that having a child on controller medication and adherence to this medication was an important predictor of being a super-engager in the My Child's Asthma web-based intervention. Positive outcome expectations and high self-efficacy beliefs regarding

Limitations

Engagement was measured by adding the number of visits parents returned to the My Child's Asthma website. This does not include a measure of understanding of the material or a measure of engaging with additional web-based content. However, the visit was only recorded into the database if parents filled out the requested information and read through the feedback sheet (which was created each month based on the responses to the survey). As such, all visits included exposure to minimal

Conclusion

The objective of this paper was to explore factors that are related to engagement over time with an interactive web-program designed to help parents manage their child's asthma. The “super engagers” (those who logged on for all five follow-up sessions) were more likely at baseline to be adherent to asthma medication and had positive outcome and self-efficacy beliefs around asthma management. Maybe more interesting than that is that none of the demographic or computer/Internet related variables

Authors’ contributions

Drs. Meischke, Christakis, Lozano and Garrison have participated in the conception and design of the study, data collection, drafting and/or revising of the article and given final approval for the submission of this manuscript. Dr. Chuan has participated in analysis and interpretation of the data, and revising the article. He has also given final approval for submission of this article.

Conflict of interest

None of the authors on this paper have any conflict of interest to report regarding this study.

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