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Providing safety education to parents of young children is important in the prevention of unintentional injuries in or around the home. We developed a Web-based, tailored safety advice module to support face-to-face counseling in the setting of preventive youth health care (E-health4Uth home safety) in order to improve the provision of safety information for parents of young children.
This pilot study evaluated a Web-based, tailored safety advice module (E-health4Uth home safety) and evaluated the use of E-health4Uth home safety to support counseling in routine well-child care visits.
From a preventive youth health care center, 312 parents with a child aged 10-31 months were assigned to the E-health4Uth home safety condition or to the care-as-usual condition (provision of a generic safety information leaflet). All parents completed a questionnaire either via the Internet or paper-and-pencil, and parents in the E-health4Uth condition received tailored home safety advice either online or by a print that was mailed to their home. This tailored home safety advice was used to discuss the safety of their home during the next scheduled well-child visit. Parents in the care-as-usual condition received a generic safety information leaflet during the well-child visit.
Mean age of the parents was 32.5 years (SD 5.4), 87.8% (274/312) of participants were mothers; mean age of the children was 16.9 months (SD 5.1). In the E-health4Uth condition, 38.4% (61/159) completed the online version of the questionnaire (allowing Web-based tailored safety advice), 61.6% (98/159) preferred to complete the questionnaire via paper (allowing only a hardcopy of the advice to be sent by regular mail). Parents in the E-health4Uth condition evaluated the Web-based, tailored safety advice (n=61) as easy to use (mean 4.5, SD 0.7), pleasant (mean 4.0, SD 0.9), reliable (mean 4.6, SD 0.6), understandable (mean 4.6, SD 0.5), relevant (mean 4.2, SD 0.9), and useful (mean 4.3, SD 0.8). After the well-child visit, no significant differences were found between the E-health4Uth condition and care-as-usual condition with regard to the satisfaction with the information received (n=61,
Less than half of the parents accepted the invitation to complete a Web-based questionnaire to receive online tailored safety advice prior to a face-to-face consultation. Despite wide access to the Internet, most parents preferred to complete questionnaires using paper-and-pencil. In the subgroup that completed E-health4Uth home safety online, evaluations of E-health4Uth home safety were positive. However, satisfaction scores with regard to tailored safety advice were not different from those with regard to generic safety information leaflets.
Unintentional injury is a major cause of death among young children in Europe and the United States [
Many countries have installed preventive youth health care, which refers to various activities to improve and protect the health, growth, and development of young people, and also to prevent illness and disability in early life. These activities include a system of maternal and child health care, which serves children from birth to 18 years of age [
With the current strain on health care, greater efficiency is required. Providing health information through the Internet, as an additional source of information, might be beneficial in various ways. For example, tailored safety information can be provided to parents prior to a preventive youth health care visit, and the information gathered by the eHealth module regarding specific safety behaviors can be provided to the physician/nurse to enhance the efficiency of face-to-face counseling, as is done with regard to other health topics, such as nutrition and physical activity [
eHealth is a "broad, emerging field in the intersection of medical informatics, public health, and business, referring to health services and information delivered or enhanced through the Internet and related technologies" [
However, eHealth is currently not extensively applied in preventive youth health care. We developed a Web-based, tailored safety advice module to support face-to-face counseling at preventive youth health care centers (E-health4Uth home safety) to provide safety information for parents of young children [
This pilot study evaluates a Web-based, tailored safety advice module (E-health4Uth home safety) and evaluates the use of E-health4Uth home safety to support counseling in routine well-child care.
Physicians and nurses of 4 preventive youth health care centers situated in the Rotterdam area in the Netherlands participated in this study. These preventive youth health care centers were chosen because of their ongoing collaboration with the Erasmus University Medical Center in Rotterdam. In 2006 and 2007, parents (N=958) were invited to participate in the study one month before their regular well-child visit at the preventive youth health care center at child’s age 11, 14, 18, or 24 months. Parents received written information about the study and provided written or online informed consent (checkbox). The Medical Ethics Committee of the Erasmus Medical Center gave a "declaration of no objection" for this study (MEC-2004-256).
Parents within each participating preventive youth health care center were randomly assigned to a Web-based, tailored safety advice and counseling group (ie, the E-health4Uth condition), or to a group receiving the generic safety information (ie, the care-as-usual condition,
Study design, participant flow and evaluations.
A Web-based, tailored safety advice module (E-health4Uth home safety) was developed. Parents completed a self-report questionnaire (via the Internet or paper-and-pencil) to assess safety behaviors on the following safety topics: falls, poisoning, drowning, and burns [
When parents failed to practice a particular safety behavior (“unsafe behavior”), they received a tailored message on how they can improve their safety behavior (
After completing the safety assessment questionnaire, parents were invited to visit the health care professional of their preventive health care center for their regular well-child visit. All the advice given to parents about safety were copied to the relevant health care professional, in order to enable the discussion of the advice with the parent during the visit. Parents and health care professionals could prepare for the well-child visit by formulating specific questions about the safety situation at home.
Sample page of tailored safety advice.
Parents of the care-as-usual condition completed the same self-administered questionnaire assessing parents’ child safety behaviors, either by using the Internet or paper-and-pencil. However they did not receive any tailored safety advice after completing the questionnaire. After completing the safety assessment questionnaire, parents visited the health care professional of their preventive health care center for a regular well-child visit. Parents received a generic safety information leaflet from their health care professional during their regular well-child visit (care-as-usual) [
Contents and application of the tailored safety advice in the prevention of falls, poisoning, drowning, and burns.
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Applicable if: | Reinforcement with no tailored safety advice, when: | Tailored safety advice when: | |
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Stair gate | The house has a staircase which the child can reach | A stair gate is present and is closed at all times |
No stair gate is present |
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Balcony | The house has a balcony | The child is never left alone on the balcony |
The child is left alone on the balcony |
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Cleaning products | Always |
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Medicines | Always | Stored above adult chest-height or in a locked cupboard |
Stored below adult chest height or in an unlocked cupboard |
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Bath tub | The child takes a bath | Child is never left alone in the bath tub |
Child is left alone in the bath tub |
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Swimming pool | The child swims in the swimming pool | Never left alone in the swimming pool |
Child is left alone in the swimming pool |
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Pond | There is a pond in the garden | Always the advice is to fill up the pond |
A pond is present |
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Thermostat-controlled tap | Always | Thermostat-controlled tap present in the bathroom |
Thermostat-controlled tap not present in the bathroom |
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Hot drinks | Always | Child is never on parent’s lap when drinking hot liquids |
Child on parent’s lap when drinking hot liquids |
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Kitchen | Always | Child is never in the kitchen when the parent is cooking |
Child is in the kitchen when the parent is cooking |
Socio-demographic data and parents’ safety behaviors were collected through a self-administered assessment questionnaire completed by the parents. Immediately after receiving the tailored safety advice, the parents (only those in the E-health4Uth condition who used the Internet to complete the questionnaire) were invited to complete a Web-based evaluation form about the tailored safety advice received and the use of the tailored safety advice module.
When parents attended the scheduled well-child visit, they were invited to complete an evaluation form about the well-child visit. Parents in the E-health4Uth condition were specifically asked about the use of tailored information during the face-to-face counseling. The youth health care professionals were also invited to complete evaluation forms regarding the well-child visit, and, if applicable, the use of the tailored information during the face-to-face counseling.
Evaluation items of the tailored safety advice, the Web-based tailored safety advice module, and the well-child visit, were measured on 5-point Likert scales ranging from 1 (most negative evaluation) to 5 (most positive evaluation), unless stated otherwise.
Parents of the E-health4Uth condition who completed the Internet version of E-health4Uth home safety, were invited to complete a Web-based questionnaire after having read the tailored safety advice. The questions were: (1) reading of the safety advice (ie, having read the advice completely, partly or not at all), (2) the reliability, understandability, relevance, and usefulness of the tailored safety advice, (3) the ease of use of the module, and (4) the pleasantness of the information source.
Characteristics of all parents and by E-health4Uth condition and care-as-usual condition (n=312).
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Total participants |
E-health4Uth |
Care-as-usual |
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Mean age of respondent in years |
32.5 |
32.3 |
32.8 |
.41a | |
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Mother is respondent | 274/312 (87.8) | 139/159 (87.4) | 135/153 (88.2) | .83 | |
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Non-Dutch mother | 83/312 (26.6) | 43/159 (27.0) | 40/153 (26.1) | .83 | |
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Non-Dutch father | 82/312 (26.3) | 45/159 (28.3) | 37/153 (24.2) | .53 | |
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Educational level of the respondent is lowb | 54/312 (17.3) | 32/159 (20.1) | 22/153 (14.4) | .14 | |
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Single parent | 30/312 (9.6) | 15/159 (9.4) | 15/153 (9.8) | .82 | |
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One child in family | 158/312 (50.6) | 84/159 (52.8) | 74/153 (48.4) | .71 | |
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Mean age of child in months |
16.9 |
17.4 |
16.5 |
.14a | |
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Gender child, boys | 154/312 (49.4) | 80/159 (50.3) | 74/153 (48.4) | .73 | |
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Child can crawl | 303/311 (97.4) | 154/158 (97.5) | 149/153 (97.4) | .96 | |
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Child can pull up to standing | 288/311 (92.6) | 145/158 (91.8) | 143/153 (93.5) | .57 | |
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Child can walk independently | 221/311 (71.1) | 117/158 (74.1) | 104/153 (68.0) | .24 | |
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Child can climb | 211/271 (77.9) | 108/137 (78.8) | 103/134 (76.9) | .70 | |
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.27 | |
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Safe behavior | 198/312 (63.5) | 99/159 (62.3) | 99/153 (64.7) |
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Unsafe behavior | 90/312 (28.8) | 44/159 (27.7) | 46/153 (30.1) |
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Not applicablec | 24/312 (7.7) | 16/159 (10.1) | 8/153 (5.2) |
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.62 | ||
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Safe behavior | 198/312 (63.5) | 103/159 (64.8) | 95/153 (62.1) |
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Unsafe behavior | 114/312 (36.5) | 56/159 (35.2) | 58/153 (37.9) |
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.03 | |
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Safe behavior | 190/310 (61.3) | 90/158 (57.0) | 100/152 (65.8) |
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Unsafe behavior | 107/310 (34.5) | 57/158 (36.1) | 50/152 (32.9) |
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Not applicabled | 13/310 (4.2) | 11/158 (7.0) | 2/152 (1.3) |
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.03 | |
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Safe behavior | 14/312 (4.5) | 11/159 (6.9) | 3/153 (2.0) |
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Unsafe behavior | 198/312 (95.5) | 148/159 (93.1) | 150/153 (98.0) |
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aMann-Whitney
bLow educational level: intermediate secondary education or less
cNot applicable on falls; when no staircase and balcony is present
dNot applicable on drowning; when parents do not bath their child, parents do not go swimming with their child, and no pond is present
After the well-child visit, health care professionals reported the duration of the visit for both conditions on their evaluation form.
Furthermore, health care professionals were invited, directly after each face-to-face consultation, to complete items regarding the following topics: (1) adequacy of the generated tailored safety advice, (2) usefulness of the tailored safety advice during the well-child visit, (3) the rating for the application of the tailored safety advice on a scale from 1 (most negative evaluation) to 10 (most positive evaluation), (4) whether the information of the tailored safety advice was in accordance with what the parent indicated (yes/no), (5) health care professionals’ satisfaction with the information given to the parent, and (6) health care professionals’ overall satisfaction with the well-child visit. Health care professionals rated both the use of the tailored safety advice and the well-child visit on a scale from 1 (most negative evaluation) to 10 (most positive evaluation).
In both the E-health4Uth condition and the care-as-usual condition, all parents that attended the scheduled well-child visit, at the end of the visit, were invited to complete items regarding the satisfaction with the safety information they received (tailored or generic), the overall satisfaction with the well-child visit, and the rating for the well-child visit on a scale from 1 (most negative evaluation) to 10 (most positive evaluation). Parents in the E-health4Uth condition completed an additional item on whether discussing the tailored safety advice was a valuable supplement.
Furthermore both parents in the E-health4Uth condition and the care-as-usual condition had to report their intention to change safety in or around the home after the well-child visit (ie, prevention of falls, poisoning, drowning, and burns: yes/no).
Statistical analyses were performed using SPSS 17.0 (SPSS Inc., Chicago, IL, USA).
Frequency tables were used to explore the socio-demographic characteristics of the total study population and of both conditions (E-health4Uth and care-as-usual). The frequency of safe and unsafe behavior on each safety topic was determined. The differences were examined with chi-square tests. Items about the well-child visit and the intention to change safety behavior after the well-child visit were compared between the current method of providing safety information (care-as-usual condition) and the tailored safety advice (E-health4Uth condition). Differences were determined with student’s
A total of 312 parents (312/958, 32.6%) provided informed consent and participated in the study—159 parents were assigned to the E-health4Uth condition and 153 to the care-as-usual condition. The mean age of the parents was 32.5 (range 20-48, SD 5.4) years, 87.8% (274/312) of parents were mothers and 17.3% (54/312) of parents had a low educational level (intermediate secondary education or lower). In this study, 90.4% (282/312) of responding families included both parents and 50.6% (158/312) of families had one child. The age of the children ranged from 10-31 (mean 16.9, SD 5.1) months, 49.4% (154/312) of children were boys. Almost all children could crawl (303/312, 97.4%), and 92.6% (288/312) could pull up to standing (
In the E-health4Uth condition, 38.4% (61/159) completed the online version of the questionnaire (allowing Web-based tailored safety advice), while 61.6% (98/159) preferred to complete the questionnaire via paper (allowing only a hardcopy of the advice to be sent by regular mail).
All of the parents in the E-health4Uth condition who completed the questionnaire via the Internet completed the Web-based evaluation of the safety advice and the safety advice module, directly after receiving the advice (n=61). Of these, 82.0% (50/61) of parents reported having read their safety advice completely, 13.1% (8/61) of parents read the advice only partly, and 4.9% (3/61) of parents (5%) did not read the advice at all (
We received 65 evaluation forms completed by health care professionals with regard to the well-child visits (43 in the E-health4Uth condition, 22 in the care-as-usual condition) and we received 61 evaluation forms from parents who attended the scheduled preventive youth health care visit (31 in the E-health4Uth condition, 30 in the care-as-usual condition).
The mean duration of the well-child visit, as reported by the health care professionals, was 27.2 minutes (SD 11.1) in the E-health4Uth home safety E-health4Uth condition versus 23.7 (SD 8.0) minutes in the care-as-usual condition (
Health care professionals who completed and submitted the evaluation forms regarding the well-child visits found discussing the tailored safety advice with the parents to be adequate (mean 4.0, SD 0.4) and useful (mean 3.9, SD 0.4,
Among parents that attended the scheduled well-child visit and who completed the evaluation forms, parents of both the E-health4Uth condition and care-as-usual condition were satisfied with the information received during the well-child visit (mean 3.7, SD 0.8 and mean 3.4, SD 1.3, respectively). Discussing the tailored safety advice with the youth health care professional was a valuable supplement to the well-child visit (mean 3.4, SD 1.3). No significant difference was found in satisfaction between the E-health4Uth condition and care-as-usual condition (
More parents in the E-health4Uth condition showed intentions to change safety in or around the home with regard to the prevention of falls (43.3% vs 18.5%,
Parents’ evaluation of the tailored safety advice and the Web-based, tailored safety advice module (n=61).
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Have read their advice completely | 50/61 (82.0) |
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Have read their advice partly | 8/61 (13.1) |
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Have not read their advice | 3/61 (4.9) |
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Was the safety advice reliable?a | 4.6 (0.6) |
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Was the safety advice understandable?a | 4.6 (0.5) |
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Was the safety advice relevant?a | 4.2 (0.9) |
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Was the safety advice useful?a | 4.3 (0.8) |
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Was the module easy to use?a | 4.5 (0.7) |
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Was the module a pleasant information source?a | 4.0 (0.9) |
a Scores on a 5-point Likert scale ranging from 1 (most negative evaluation) to 5 (most positive evaluation)
Health care professionals’ and parents’ evaluation of the well-child visit and the use of the tailored safety advice during the well-child visit (if applicable).
E-health4Uth |
Care-as-usual |
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Was discussing the safety at home adequate?a | 4.0 (0.4) | NAc |
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Was the tailored safety advice useful to discuss during the well-child visit?a | 3.9 (0.4) | NAc |
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Rating for the application of the tailored safety adviceb | 7.3 (1.0) | NAc |
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Was the information of the tailored safety advice in accordance with what the parent indicated? n (%) | 29/36 (80.6%) | NAc |
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Satisfaction with information givena | 4.1 (0.6) | 4.3 (0.5) | .31d |
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Overall satisfaction with the well-child visita | 4.2 (0.4) | 4.3 (0.4) | .16e |
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Rating for the well-child visitb | 7.5 (0.9) | 7.8 (0.8) | .23d |
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Satisfaction with information discusseda | 3.7 (0.8) | 3.4 (1.3) | .51d |
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Was discussing the tailored safety advice valuable supplement?a | 3.4 (1.3) | NAc |
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Overall satisfaction with the well-child visita | 4.4 (0.5) | 4.4 (0.5) | .92d |
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Rating for the well-child visitb | 8.0 (1.2) | 8.0 (0.9) | .92d |
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Falls | 13/30 (43.3) | 5/27 (18.5) | .04f |
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Poisoning | 15/28 (53.6) | 8/27 (29.6) | .07f |
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Drowning | 10/28 (35.7) | 4/27 (14.8) | .08f |
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Burns | 16/28 (57.1) | 6/27 (22.2) | .008f |
aScores on a 5-point Likert scale ranging from 1 (most negative evaluation) to 5 (most positive evaluation)
bScores from 1 (most negative evaluation) to 10 (most positive evaluation)
cNot Applicable
dChi square
eStudent’s
fMann-Whitney
In the present pilot study, we evaluated a Web-based tailored safety advice and the application of an eHealth module compared to the use of generic safety information leaflets in well-child visits. This pilot study showed that although the tailored safety advice and the E-health4Uth module turned out to be positively evaluated, the majority of parents declined to complete the online questionnaires that enabled online tailored safety advice, and preferred to use paper-and-pencil to complete the questionnaires. This diminishes the convenience of the use of Internet to deliver online tailored safety information. In the small subgroup of parents that attended the scheduled well-child visits and those that completed the evaluation form after the visit, the ratings regarding satisfaction in the E-health4Uth condition were equal to those in the care-as-usual condition, stating that parents have no preference with regard to the method of providing safety information during the well-child visit. However, among these parents, more parents in the E-health4Uth condition reported a favorable intention to change the safety situation in and around the home compared to parents in the care-as-usual condition.
In this study, the participation rate (312/958, 32.6%) was relatively low. One reason for the low participation rate could be the lack of sending reminders. There is no data available on the characteristics of parents who did not wish to participate in this study. Baseline characteristics show that in the study population, over 90% of children were living in a two-parent home. In the general population of the Netherlands, the percentage of two-parents homes is comparable with the numbers we found in our study [
Slightly more parents in the E-health4Uth condition carried out unsafe behaviors with regard to the risk of drowning compared to the care-as-usual condition and slightly more parents of the care-as-usual condition behaved unsafe with regard to the risk of burns compared to parents of the E-health4Uth condition. Given the random allocation to both conditions, this was a chance finding.
All parents who provided informed consent completed the safety behaviors questionnaire, either by using Internet or by paper-and-pencil; and all parents in the E-health4Uth condition who completed the online questionnaire, provided answers to the evaluation form regarding the online tailored safety advice. However, relatively few evaluation forms from both parents (n=61) and professionals (n=65) were collected after the scheduled preventive youth health care visit. At the time of the study, there was no digital database regarding the preventive youth health care visits; so we were unaware whether the scheduled visits were realized or not. Furthermore, the empty form (that should have been completed) might have been missing in the dossier of the child (due to logistical problems), or the parent/professional did not want to complete the form. There was no significant difference in parent and child characteristics between parents who did and who did not complete the evaluation (
For the present study, since most well-child visits did not involve a vaccination (which is in the Netherlands associated with a high attendance), we might assume that circa 50% of the invited parents attended the scheduled visit. If this was the case, only circa 4/10 evaluation forms after the visits were collected. In future studies, we recommend the use of digital patient files to record attendance to the scheduled visits and the topics that were discussed during these visits. Brief evaluation questions may be integrated in such digital patient files with informed consent from the study participants. In the present study the results with regard to the evaluations after the preventive youth health care visits should be interpreted with utmost care, since non-response bias may have occurred, and given the relatively low numbers of completed forms. Furthermore, the evaluation of the well-child visit could depend on more items than just the ones we measured in this study.
Over 60% of parents preferred completing the safety behavior questionnaire by paper-and-pencil. In the E-health4Uth condition, this meant that less than 40% of participants could benefit from the online tailored safety advice. In this study, a hard copy of the tailored advice was generated after data-entry of the paper-and-pencil questionnaire results and mailed to both parent and health professional. This is however time consuming, costly, and diminishes the convenient nature of using the Internet to deliver online tailored safety information. According to Statistics Netherlands, the number of Internet connections in the Netherlands was 80% during the time of the study, rising to 94% in 2011 [
One element may be to increase the perceived benefits from online tailored advice as opposed to current generic advice (most often provided as leaflets during well-child visits). This study showed, unexpectedly, a lack of difference between levels of satisfaction regarding tailored safety information provided between the E-health4Uth module and the generic safety information leaflet. We saw that parents were highly satisfied with both the current generic version as well as the tailored safety information, which implies that parents might not have a preference for either method. Safety information is only one topic in preventive youth health care. When the E-health4Uth module covers more relevant topics in the future, more advantage may be gained by providing tailored advice. We recommend involving both panels of parents and health professionals in such developments, in order to achieve maximum profit for the target audience of such eHealth tools. The current pilot study shows that a high uptake, let alone higher appreciation of tailored advice compared to high-quality generic advice cannot be taken for granted.
Although the difference was not statistically significant, the well-child visit lasted slightly longer in the E-health4Uth condition compared to the care-as-usual condition. The youth health care professionals reported a significantly longer duration of the visit in the E-health4Uth condition when a Web-based, online tailored information was generated and provided to both parent and professional (n=21, mean 31.4 minutes, SD 11.8) compared to when parents completed the questionnaire online and a hard copy of the advice was generated and provided to both parent and professional (n=22, mean 23.1 minutes, SD 8.8,
The current study, although in a relatively small, and potentially biased subgroup, illustrated that the tailored advice may induce more intention to change behaviors in a favorable direction. This supports favorable results from early initiatives [
There are many potential benefits of gathering health and health behavior data [
Tailored information has the potential to be more effective in realizing favorable health behaviors compared to generic information, but not all potentially effective elements were already included in the prototype in this study. The current Web-based, tailored safety advice module and the use of the safety advice during the well-child visit could be extended using personal cognitive factors, social factors, or parents’ barriers to show safety behavior [
Changing behavior is difficult, requiring time, effort, and motivation. Health care professionals could benefit from techniques to help them motivate parents to change their behavior. Previous research has shown positive effects of motivational interviewing on health behavior [
We propose future effect-evaluations of tailored safety advice, by exploring whether tailored safety advice is more effective on parents’ child safety behaviors compared to generic safety leaflets. When proven to be effective, eHealth combined with personal counseling could also be used in health promotion on multiple other areas relevant for prevention such as nutrition, physical activity, or sleep. It may be useful for parents to prepare themselves for the well-child visit and to formulate specific questions on these topics. Furthermore eHealth could help parents and youth health care professionals to focus on issues that need further attention.
The authors thank the parents and the staff of the preventive youth health care centers in Rotterdam for their participation in this study. This work was supported by the Netherlands Organization for Health Research and Development (ZonMw), Program Healthy Living: grant number 40100033. The publication of this study was supported by a grant of the Netherlands Organization for Scientific Research (NWO). I confirm all patient/personal identifiers have been removed or disguised so the patient/person(s) described are not identifiable and cannot be identified through the details of the story.
None declared.