Videos and Simple Text to Empower Parents to Handle Their Sick Children

Background:

Each year there are approximately 200.000 calls regarding sick children younger than 12 years (injuries excluded) to the medical helpline 1813 in the Capital Region of Denmark (ref: Rasmussen et al). These children are not so ill that the parents call the emergency helpline 112, but the parents need to contact the health care system outside their general practitioners' opening hours. After contact with the parents, the medical helpline health professionals (primarily physicians or nurses) may either: 1) refer the child to a pediatric department, 2) refer child to assessment in a pediatric urgent care center, 3) guide the parents on how to perform self-care at home or 4) advice the child to the general practitioners next work day. About 40 % of the calls to 1813 regarding children are referred to a hospital. We estimate that 40 % of those presents mild symptoms, which often does not require treatment or paraclinical tests and many could have benefitted from being observed at home.

Purpose:

Reviews conducted in child health related areas, have indicated that quality of health information varies significantly and Internet searches may reveal information that is not evidence-based, or may even be inconsistent with international treatment recommendations (ref: Pehora et al, Fahy et al). Often health information will also focus on diagnosis, not symptoms, which makes it difficult for parents to navigate the health directions. The study objective is to investigate if it is possible by using videos and simple action cards about common symptoms in children - to empower parents and citizens to take better care of sick children with milder symptoms at home including to know when they must call for medical help. This project therefore aims to, by increasing parental knowledge, decrease the number of children admitted to the hospital with mild symptoms, and to decrease the number of children with late arrival to the hospital with symptoms on critical illness.

Method:

Eight videos have been produced, each lasting about 2-3 minutes, about the following common symptoms: 1) vomiting or diarrhea, 2) difficulties in breathing, 3) fever, 4) abdominal pain, 5) sore throat, 6) a red eye, 7) pain in the ears, and 8) exanthemas. The videos will be accompanied by text, action cards, and be accessible on a smartphone. The information is in Danish. The material has been developed in collaboration between pediatricians (medical content) and professional film/app-makers (creative content) and has been approved by the Danish Society of Pediatrics and other relevant scientific societies. We want to study the clinical value of this material before we launch the campaign to the public.

Parents with children aged between 6 months - 11.9 years will, when contacting the medical helpline 1813, be offered to receive a new information material. If they accept, they will be randomized to the intervention group (randomized to the new material composed of 8 videos and corresponding smart cards) or to the control group (randomized to current standard care). The participants will the following day receive a text message with six questions on self-efficacy and satisfaction. If the caretaker does not fill out the electronical questionnaire, they will receive a reminder the next day. All case reports of the included children will be reviewed and if admitted to a hospital in the Capital Region of Denmark within 72 hours of the call, the diagnosis, duration and treatment will be registered. For the intervention group, the use of the material will be logged.

Statistics:

The primary analysis will use Chi-square and a two-sided level of significance of p < 0.05 for the primary outcome and a p<0.025 for the two secondary outcomes. All other outcomes are exploratory and the statistical methods will be adapted as appropriate. The results from these exploratory analyses will not but used to claim clinical efficacy but used to design new studies. This is an important aspect since new studies can be rapidly designed and performed once the project set-up is in place.

Sample size:

We want to be able to detect if the intervention with videos and action cards increases the proportions of parents who expressed high self-efficacy by 5%. We do not know this actual proportion. If it is actually 50%, we want to detect an increase to 55%. We want a p-value of 0.05 and a probability (power) of 80%. It will require data from about 3300 text-messages in total, randomized in two equal groups (http://www.openepi.com/SampleSize/SSCohort.htm). We suggest we have data to answer our research question within 3 months, and the study will be stopped after 6 months.

After the first 400 SMS-answers, we will perform an interim analysis to study the frequency of acceptance, and the frequency of high self-efficacy, as well as how the videos have worked technically. Moreover, we will study if the number of SMS-answers from the two groups of families, those randomized to intervention and those randomized to control, are about the same size.

After the first 1000 SMS-answers, we will also make an interim analysis to study the effect of the videos and the action cards. This will also include an examination of a significant difference is exhibited between the number of children staying at home the day the parents call 1813 after having the possibility to watch the videos and read the action cards.

Ethics and transparency:

The parents are informed about the study by an automatic voice message when contacting the medical helpline 1813. Their acceptance to the study is their informed consent. The project will be described in short at the webpage of the Copenhagen Emergency Service, where it will be possible to access additional information via a link to the study at Clinical Trials. The telephone call will be recorded in the Emergency Medical Services system, based on the actual regular routine. The protocol has been submitted to the Ethics Committee of the Capital Region of Denmark, who considered it outside their mandate.

In the project the data will be completely anonymized and it is in no way possible to link data with actual people. The study will be registered at https://clinicaltrials.gov/ before enrolment of the first patient.

In cases of serious adverse events the study group will consider stopping the study. This will also be the case if the satisfaction with the contact to the medical helpline 1813 drops to a very low level.

Perspectives and possible yield:

In case of positive effect, it must be decided if the videos and action cards will be an integrated option at the medical helpline 1813. Moreover, it may be considered if the material is released to all of Denmark. The material could be accessible at smartphones, iPads, laptops and easy to find on different major national websites.