Exploring the Relationship between Parental Worry about their Children's Health and Usage of an Internet Intervention for Pediatric Encopresis

The growth of the Internet has changed the way many people seek health-related information (Allen & Rainie, 2002). More than 80% of US adult Internet users have searched for health-related information (Fox, 2006), with parents being especially likely to use the Internet for this purpose (Allen & Rainie, 2002). Although most health Web sites provide information to the general public, the number of effective Internet interventions for behavioral and psychological health is growing rapidly (Griffiths, Lindenmeyer, Powell, Lowe, & Thorogood, 2006; Marks, Cavanagh, & Gega, 2007; Ritterband, Gonder-Frederick, et al., 2003; Wantland, Portillo, Holzemer, Slaughter, & McGhee, 2004). These online programs are typically interactive, highly structured, behaviorally based treatments that have been operationalized and transformed for delivery via the Internet (Ritterband, Gonder-Frederick, et al., 2003). Despite growth in the number of Internet-based health interventions, little is known about whether certain user and program characteristics lead to greater use, behavior change, and subsequent symptom improvement (Christensen, Griffiths, Groves, & Korten, 2006; Ritterband, 2006). There is some evidence that increased usage of an Internet intervention leads to greater behavior change (Christensen, Griffiths, & Korten, 2002; Tate, Jackvony, & Wing, 2003, 2006; Tate, Wing, & Winett, 2001; Wantland et al., 2004). Greater comfort with the Internet has also been found to be associated with greater engagement with online health resources (Weinert & Hill, 2005). However, a greater understanding of whether specific user characteristics predict intervention use is needed. Determining which user characteristics predict treatment usage and treatment response can provide information in three key areas: (a) which types of interventions best suit and are most effective for which users, (b) how much support is needed within an intervention for various user types, and (c) which treatment components are most effective for intervention usage and success for which users. Within pediatric Internet interventions, learning which user characteristics predict usage (and ultimately behavior change and symptom improvement) will help developers create and ultimately optimize these Internet-based systems. In addition, data on predictors of usage will provide information for further development of a theoretical model for Internet interventions (Ritterband, 2006). One user characteristic that might be considered to be an obvious predictor of treatment utilization is disease severity, meaning one might expect parents to seek and utilize treatment more often when their children are more symptomatic. Some researchers have found that “objective” indices of disease severity predict greater treatment utilization (Grant, Gil, Floyd, & Abrams, 2000). Others have found that only perceptions of disease severity by caretakers predict treatment utilization (Brown, Connelly, Rittle, & Clouse, 2006). While the relationship between disease severity and treatment utilization is complex and may be disease specific, it is, nonetheless, important to examine these user characteristics within Internet interventions. It has long been recognized that some parent characteristics influence the utilization of traditional health services for children (Newacheck & Halfon, 1986; Riley et al., 1993; Starfield et al., 1985). With few exceptions (e.g., Abidin, 1982; Tessler & Mechanic, 1978), general parental mental health or personality constructs (e.g., trait depression and anxiety) have not been found to predict the use of health services for the children (Kelleher & Starfield, 1990; Ward & Pratt, 1996; Watson & Kemper, 1995). However, specific parental mental health and personality constructs, including maternal worry about their children's health, have been found to be associated with the use of children's health services (Brown et al., 2006; Feigelman, Duggan, & Bazell, 1990; Janicke, Finney & Riley, 2001; Spurrier et al., 2000). Further, maternal worry about their children's health has been found to predict usage even more strongly than mothers’ ratings of their children's actual level of health. Greater parental worry about their children's health has been found to predict increased emergency room utilization (Feigelman et al., 1990), parental possession of medications for their children (Maiman, Becker, & Katlic, 1986), and school absences (Spurrier et al., 2000, although see Anthony, Gil, & Schanberg, 2003 for conflicting evidence). It is possible that parental worry may be even more predictive of treatment usage in Internet-based interventions than in face-to-face interventions. One of the frequently cited advantages of Internet interventions is the additional control given to the user over the availability, timing, and pace of treatment (Griffiths et al., 2006). Worried parents may be more able to access and use treatment information in an Internet intervention because more control rests with the user and they can avoid barriers associated with more traditional interventions (e.g., timing of appointments, expense, availability of care). Given previous findings that parental worry had been predictive of traditional health care utilization (e.g., Feigelman et al., 1990), we hypothesized that greater parental worry about their children's health would predict greater usage of an Internet intervention for childhood encopresis. We believed that encopresis severity (as recorded by two indices) would also be predictive, but that parental worry about their children's health would predict intervention usage even after accounting for parent's ratings of encopresis severity. We further hypothesized that current parental treatment of depression would not predict program usage, but expected parent's comfort level using the Internet to be predictive of use. Finally, given that development theories posit that parent attitudes show more of an influence on child self-care behavior at earlier ages (Kopp, 1989), we expected that the families of younger children would show a stronger positive relationship between parental worry about their children's health and program usage than families of older children.