Early life experience is a determinant of social inequalities in physical, mental, and social well-being [1-6]. Children living in poverty are more likely to suffer from developmental and health problems, and childhood interventions can decrease incidence and prevalence of these problems [7-12]. The proposed project is aimed to assess and improve a childhood intervention: the Naître et grandir (N&G) website and newsletter on child development, education, health, and well-being, which includes the Information Assessment Method (IAM) that allows N&G readers to continuously assess, and subsequently the N&G editors to improve, the content shared on the N&G website and newsletter.

Parents with low education and low income, hereafter referred to as parents with low socioeconomic status (SES), typically have a low literacy level (limited ability to acquire, understand, evaluate, and use written information). Low parental literacy level is particularly detrimental to child health: a low literacy level is associated with worse health status, difficulties accessing health care, and poorer preventive health behavior and self-management of health problems [13-23].

Education and income are the most important SES indicators, and together, they are strongly associated with child health status [24,25]. According to research on information-seeking behavior, parents with low SES have greater information needs than parents with high SES [26]. The use of high-quality online information can improve quality of life and have positive family, economic, and social impacts on low-SES parents, including refugee and homeless parents [27-31]. High-quality information and literacy-related interventions can reduce unnecessary calls and visits to health professionals, increase knowledge and self-efficacy, and improve health [16-19,32-47].

N&G [48] is a website independent from industry funding that provides high-quality information (based on research syntheses and validated by experts) on child development, education, health, and well-being. N&G users can access hundreds of information pages (1 page per topic) that are organized in age group categories, ranging from pregnancy to the age of 8 years. N&G also produces a weekly newsletter to support parents, including those with a low literacy level, having children under the age of 8 years.

N&G partnered with investigators from McGill University to validate and implement the IAM to continuously assess and improve content shared on the N&G website and newsletter [49-53]. In line with the Canadian Institutes of Health Research (CIHR)’s definitions [54], the IAM is a knowledge translation tool for monitoring N&G information use, and its impact on parents is measured by expected health/well-being benefits. It is also fostering parent engagement by enabling parents to interact with N&G editors by providing feedback on the information content. The IAM questionnaire includes 7 questions (with clickable answers and 2 comment boxes), allowing users to rate on the situational relevance, cognitive/affective impact, intention to use and expected benefits of specific information content (N&G information page), and write comments.

During our pilot phase (September 1, 2014, to August 31, 2016), we collected 34,021 IAM ratings (completed IAM questionnaires) from parents, relatives, and professionals (education, health, and social services) who read N&G content. In line with studies on social inequalities in Web information use [55-61], the statistical analysis of these ratings revealed a social gradient: low-SES parents underuse N&G and the IAM (Figure 1). Results also indicated that low-SES parents are more likely to report decreased worries and increased confidence as a result of using N&G information [50]. There is a need to understand this gradient to improve N&G content and reach low-SES parents and a need to explore how the use of knowledge translates into health and well-being outcomes for low-SES parents and children.

This study (research protocol) has been recently funded by CIHR. As per CIHR’s definition of knowledge translation (“making people aware of knowledge and facilitating knowledge use to improve health”) [62], our goal is to improve how low-SES parents engage with and use online information about child development, education, health, and well-being; learn how this format for knowledge sharing translates to improved health and well-being outcomes for low-SES parents and their children; and explore their interaction with Web editors to influence content (responsible for websites’ content). On the basis of the N&G team's (the director and 2 coordinators) questions and using the Knowledge-to-Action framework [63], we determined 4 research objectives:

The nominated principal investigator (NPI) led a CIHR-funded systematic review and proposed a comprehensive harmonized typology of (1) outcomes associated with the use of online consumer health information and (2) conditions (network and resources) leading to these outcomes [64-67]. A total of 68 studies were analyzed using framework synthesis [68,69]. This synthesis was based on an initial framework derived from information studies [49,70-78] and led to propose an innovative theoretical model (Figure 2) [66,67]. This model includes positive and negative health outcomes of online consumer health information in a primary care context and is (information) consumer oriented.

The model comprises 13 main concepts (42 factors and outcomes) and will be used in this study to inform data collection and analysis, for example, the phase 1 qualitative interview guide and interpretive thematic analysis. The model will contribute to establish a chain of evidence linking ultimate outcomes of information (such as health outcomes), intermediary outcomes (such as cognitive impact of information), and conditions associated with outcomes (information needs and seeking behaviors and contextual factors).

Our project focuses on all Canadian parents with low SES who acquire (direct or mediated) online information about child development, education, health, and well-being. In Canada, 42% of nonelderly adults [16,17] and 15% of children live in low-income households [86]. In Quebec, 36% of parents report living in poverty [87]. The demand for information is very high, resulting in frequent internet searches; for example, parents search the internet for child-related information on average 1.3 times per week in Quebec, and 73% of parents report that the internet constitutes their first-line source of parenting information [88].

Specifically, our project is important for about half the population of parents of children under 19 years, namely, parents with a low literacy level. Low literacy is a major concern in Canada [16,17,19,20,23]. Results of the 2011 to 2012 survey of a representative sample of 25,267 Canadian parents aged 16 to 65 years showed that 49% of parents have a low literacy level: [89,90] they have difficulty finding, understanding, and using information presented in a dense or lengthy text; navigating complex digital texts; interpreting and evaluating information (constructing meaning); and disregarding irrelevant or inappropriate content when there is competing information (including when correct content is more prominent). Furthermore, our results may help any parent who faces a transitory low literacy level because of a stressful situation. This interdependence between information and emotion is well established in the information literature [91,92].

Our project nevertheless does not focus on the few information-poor parents without access (direct or mediated) to online information. In the United States, only 1% of 18- to 29-year olds did not use the internet in 2015 [93]. The Quebec 2015 survey of a representative sample of 23,693 parents of preschool children showed that only 1.5% of parents never know where to find child information [61]. According to information studies, the information-poor parents (1) perceive themselves as persons who cannot be helped, (2) adopt self- or group-protective behaviors, (3) are secretive and mistrust others, and (4) consider exposure to information as a risk (harm outweighing benefits) [30].

Our project engages a partnership between N&G and AboutKidsHealth (AKH) [94], both popular comprehensive Web-based resources (Table 1). Both resources contain text with a readability level below high school (this level may be higher for disease-related information), visual illustrations, and complementary simple illustrative videos. For each Web page, an audio help system highlights words as they are spoken. In 2016, our librarian did an environmental scan of Canadian parental websites and found multiple specialized resources but only 12 comprehensive resources (including N&G and AKH).

Although this study is a priority in a Canadian context, our results can be important to and applied by all Web editors who provide health information, thereby benefitting all adults with a low literacy level (not only parents). For example, Health Canada policies recommend funding projects that aim to improve access to, and conduct research on, information for Canadians with a low literacy level [23]. Information systems are key components of health systems and crucial to meet human rights and the democratic right to know and communicate [31,95-100]. Among adults, the most frequent searches for information are about health [101]. The demand for high-quality low-literacy health information is, hence, very high.

Our project uses an organizational participatory research (OPR) approach. OPR is a form of integrated knowledge translation that blends action research and organizational learning to undertake research with organizations and improve practice [102-107]. N&G (organization) proposed the research questions and will participate in all research steps. The NPI has OPR experience and expertise. The NPI led a CIHR-funded systematic review on OPR key processes and outcomes [107]. A steering committee composed of the NPI, the coprincipal investigator, the partner (principal knowledge user), another knowledge user (AKH), and 2 low-SES parents will meet before and after each phase for planning and interpreting results, respectively. All team members will be consulted and have the opportunity to influence the steering committee’s decision making.

A mixed-methods multiphase design will be used [108,109]. Ethical approval has been recently obtained from the institutional review board (IRB) of the Faculty of Medicine at McGill University (IRB#A10-E69-17B). Phases 1, 3, and 4 will be informed by our theoretical model (Figure 2).

Any improvement of knowledge translation tools and websites such as IAM, N&G, and AKH can have an important impact as it affects a large population of individuals with a low literacy level. In fact, the effectiveness of childhood education interventions has been demonstrated repeatedly [16-19,23,27-47]. In our 2-year pilot data, parents expected health and well-being benefits (for themselves or their child) from using N&G information in 65.4% of all IAM ratings (n=34,021) [50]. In accordance with knowledge translation and implementation research [62], we will not replicate effectiveness studies and rather focus on improving interventions that work.

Our project can improve engagement (number of visits) with websites providing high-quality low literacy information; in turn, online parenting information improves parents’ knowledge, attitudes, and behaviors [139-145]. Given our integrated knowledge translation (participatory research) approach, N&G and AKH will adapt their content for low-SES users as we generate results. In addition, IAM+ will better support low-SES parents’ interactions with Web editors and empowerment. Thus, our results can immediately benefit millions of information users with a low literacy level (children’s parents and relatives), for example, in Canada (Table 3).

IAM+N&G+ can be seen as an innovative intervention that complements traditional literacy programs (eg, family literacy classes). Indeed, interventions that somewhat compensate for a low literacy level can greatly improve parents’ and children’s health and well-being [23]. Thus, our results can have a positive impact on 55% of the Canadian working age, those who have a low level of health literacy and need compensatory help to manage their health [23,89,90].

Specifically, IAM+N&G+ can help Canadians in francophone minority communities, as 500,000 annual N&G website visits originate from them. Research with these communities is very underfunded, thus a CIHR priority [146]. As stated in the October 2016 report of the Commissioner of Official Languages [147], early childhood development in these communities is hindered by a lack of resources, and the absence of specific funding has left them vulnerable and often incapable of meeting their needs.

Results will inform the development of an open access online tool kit on how to adapt websites and IAM+ for a low literacy audience (a growing consideration of many Web editors). The tool kit will be designed to be generalizable to all types of online consumer health information in Canada. It will include guidance with 3 main messages: (1) how to produce simple information in lay language with audio and visual content, (2) how to better interact with low-SES persons using IAM+, and (3) how to use consumers’ IAM+ ratings and feedback to continuously optimize information content. The tool kit will be freely available to any Web editor via the Quebec SPOR-SUPPORT Unit and IAM websites. The NPI has experience in developing tools and leads the method development platform of the Quebec SPOR- SUPPORT Unit.

Our primary knowledge translation goal for knowledge user audiences will be to raise awareness about our main messages and drive attention to the tool kit. A secondary knowledge translation goal will be to support the implementation of the toolkit by Web editors. Knowledge users will disseminate our work in multiple Canadian organizations. As per reviews on scaling up [148-150], we will update our 2016 environmental scan and contact all Canadian websites targeting parents. A specialized librarian (collaborator) will reach additional health websites through librarian listservs and peer networks. Team members will raise general awareness for the tool kit and deliver our main messages to a variety of academic and nonacademic knowledge user audiences via a range of knowledge translation strategies (conference presentations, open access peer-reviewed publications, plain language summaries and grey literature, social media, and networks). Multiple knowledge translation channels will be used including Twitter (@UniteSoutien) and websites such as the Quebec SPOR-SUPPORT Unit and the IAM websites [151,152].

Our project will advance knowledge on the value of online information for, and interaction with, low-SES persons to strengthen health systems. On the one hand, this project is the first to systematically explore health and well-being outcomes for low-SES parents and children associated with parenting information websites. Most studies focus on discussion forums that can be intimidating to low-SES parents [140,142,143,153,154]. On the other hand, many studies concern relational marketing and website feedback buttons [52,155-158], but we know of none that addresses interactions between low-SES persons and Web editors (such as interaction through IAM+).

Overall, 3 years will be needed to complete this project (Figure 3). Our phases are simple and well defined, and our planning is realistic. In phases 1 and 4, we anticipate no recruitment difficulties. Many parents have already agreed to be contacted for research, and N&G will facilitate the recruitment. Phase 2 is feasible, and the deliverables are realistic given that N&G has already implemented IAM, McGill and N&G have a strong OPR partnership, and N&G is committed to implementing IAM+N&G+. In phase 3, the large number of N&G readers guarantee a large sample. To control for potential seasonal variation in the number of sessions pre- and postimplementation, monitoring will be conducted during the same seasons. To control for contextual changes, variables such as type of device, age, gender, and location are covariates. We have opted for a prospective longitudinal study as monitoring is embedded in N&G routines. In addition, although randomization would provide a higher level of evidence, it was considered unethical to randomly assign low-SES parents to N&G+ or N&G information and impractical for such a popular website (contamination bias) [159]. Moreover, 3 typical potential sources of biases in longitudinal designs may not affect our study: the use of proportions will control for historical events, there will be no respondent fatigue as our 2-year pilot data showed that the monthly number of IAM raters is stable, and the social desirability bias will affect pre- and postimplementation periods in a similar manner.

Considering the commitment, expertise, and networks of our team, we expect no major challenges. This project is highly facilitated by the participatory research approach (a form of integrated knowledge translation). In addition, it is sustainable as our results will be applied and sustained by 2 longstanding organizations. N&G is fully funded since 1998 by the Lucie et André Chagnon Foundation (one of the largest philanthropic agencies in Canada) and is a priority of this foundation. AKH is owned by the Hospital for Sick Children (Toronto) and is fully funded since 2004 by multiple maternal and child health agencies.

The results of this study will provide a deep understanding of how low-SES parents use online child information and interact with Web editors. Following the implementation of IAM+N&G+, results will also elucidate subsequent health outcomes for low-SES parents and children after interaction with Web editors have been optimized. Thus, our results can immediately benefit millions of information users, children’s parents and relatives in particular, with a low literacy level.