Videos and Simple Text to Empower Parents to Handle Their Sick Children
Condition: Pediatrics; Efficacy, Self; Triage
Study type: Interventional

Summary: 
      Background:

      The Medical Helpline 1813 (Capital Region, Denmark) handles acute, non-life-threatening
      medical emergencies. Approx. 200,000 calls/year concern children (ref: Rasmussen et al), and
      about 30% are referred to a pediatric urgent care center. However, many of these children
      presents very mild symptoms, which require neither treatment nor paraclinical tests, merely
      parental guidance.

      We want to empower the parents when handling their sick children by videos and simple text
      accessible from their smartphone. We want the parents to handle mild symptoms at home and to
      know when they must contact the medical helpline 1813 or a general practitioner.

      We have produced 8 short videos and simple texts about the most common symptoms in sick
      children. The material covers about 70% of the symptoms in acute sick children. The material
      is developed in collaboration between pediatricians and professional movie producers and is
      approved by the Danish Society of Pediatrics and other relevant medical societies.

      Purpose:

      It will be studied if the new material about symptoms in sick children result in 5% higher
      parental self-efficacy among the parents who were allowed to watch the material.

      Moreover, it will be studied if the new material resulted in less children examined by a
      doctor, and satisfied parents.

      Method:

      Parents who call the medical helpline about a medically ill child aged 6 months to 12 years
      will be offered to try the new material. If they accept, every second parent will be allowed
      given access to the new material, and every other parent will receive the usual triage by
      telephone. The results of these otherwise similar groups will be compared. Parents answer
      surveys about their experiences.

      Yield:

      Videos and simple text may empower parents to handle their sick children. The study may
      result in fewer children referred to hospitals, more appropriate use of resources and better
      experiences for the families.
    

Detailed description: 
      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.
    

Intervention name(s): Intervention Group
Intervention type(s): Behavioral
Intervention description(s): Empowerment of parents. When calling the medical helpline 1813 the parents will be offered to access the new material about sick children, compared to not getting this possibility.
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: The parents of children aged 6 months to 11.9 years who calls 1813 about a medical condition will be offered to participate in the study. They will hear a recorded instruction, explaining the study. If they accept to participate they will be allocated to the intervention group and the control group 1:1.
Masking: Double (Care Provider, Investigator)
Primary purpose: Health Services Research
Keywords: education in medical conditions