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Urgent and emergency care health services are overburdened, and the use of these services by acutely ill infants and children is increasing. A large proportion of these visits could be sufficiently addressed by other health care professionals. Uncertainty about the severity of a child’s symptoms is one of many factors that play a role in parents’ decisions to take their children to emergency services, demonstrating the need for improved support for health literacy. Digital interventions are a potential tool to improve parents’ knowledge, confidence, and self-efficacy at managing acute childhood illness. However, existing systematic reviews related to this topic need to be updated and expanded to provide a contemporary review of the impact, usability, and limitations of these solutions.
The purpose of this systematic review protocol is to present the method for an evaluation of the impact, usability, and limitations of different types of digital educational interventions to support parents caring for acutely ill children at home.
The review will be structured using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) and Population, Intervention, Comparator, and Outcome (PICO) frameworks. Five databases will be systematically searched for studies published in English during and after 2014: Medline, EMBASE, CINAHL, APA PsycNet, and Web of Science. Two reviewers will independently screen references’ titles and abstracts, select studies for inclusion based on the eligibility criteria, and extract the data into a standardized form. Any disagreements will be discussed and resolved by a third reviewer if necessary. Risk of bias of all studies will be assessed using the Mixed-Methods Appraisal Tool (MMAT), and a descriptive analysis will be used to evaluate the outcomes reported.
The systematic review will commence during 2021.
This systematic review will summarize the impact, usability, and limitations of digital interventions for parents with acutely ill children. It will provide an overview of the field; identify reported impacts on health and behavioral outcomes as well as parental knowledge, satisfaction, and decision making; and identify the factors that affect use to help inform the development of more effective and sustainable interventions.
PRR1-10.2196/27504
Uncertainty about the severity of a child’s symptoms has been identified as a key factor prompting parents to seek unscheduled health care and present to emergency departments with acutely ill children or to delay accessing appropriate services [
This demonstrates the need for better access to primary care services or community-based support for acute pediatric illness and efforts to improve parental health literacy and confidence in determining whether, or which, treatment services are appropriate when a child is ill and how best to manage acute childhood illnesses [
Many digital interventions have been developed to provide parents with guidance on how to care for acutely ill children and when it is necessary to seek medical treatment [
The first systematic review to examine this topic was published in 2015 and included educational resources provided in any format: written, verbal, and electronic. It examined a variety of study types and outcome measurements, providing a good overview of the literature [
Conscientious searches of keywords relating to digital intervention, parents, child health, acute disease, and treatment-seeking on PROSPERO [
The planned systematic review will focus on 4 key research questions to provide this overview. The first 2 questions are based on the research questions of a previous systematic review [
How have these digital interventions been developed (eg, what technologies were used, and what steps were taken in their design to ensure accessibility, usability, and acceptability)?
What measures are used to evaluate the impact of these digital interventions at achieving their aim?
How do current digital interventions impact parents’ knowledge of and experience with managing acute illness at home and use of various health care services for acute childhood illness?
What factors influence the usability and user perceptions of these interventions?
The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) [
Parents and representatives of groups of parents (eg, Mothers Instinct, Meningitis Now, and Meningitis Research Foundation) were involved in the development and refinement of the review protocol. This involvement is valuable in ensuring that the review represents parents’ perspectives, focuses on issues and questions that are both relevant and true to their experiences, and includes keywords and terms that the researchers might not otherwise have identified.
The population, intervention, comparator, outcome, and study (PICOS) type framework (
Population, intervention, comparator, outcome, and study type (PICOS) framework.
Framework component | Description |
Population | Parents and carers of children (aged 0-19 years) will be included. This includes any adult responsible for caring for the child, even if they are not the official guardian (eg, child minders, nursery nurses, teachers, extended family). It will exclude any interventions targeting children or adolescents as the primary user. |
Intervention | Any digital intervention (mobile apps, web-based interventions, or smart devices) designed to support parents with acutely ill children by improving knowledge of signs and symptoms of acute childhood illness and decision making about health management and/or treatment-seeking behavior will be included. |
Context | Interventions delivered in a variety of settings will be included. This includes both nonclinical settings (eg, homes, schools, and other community settings) and clinical settings (eg, out of hours, primary care, family medicine, general practitioner, ambulatory care, health helplines, and other health care services). Context can refer to both where the recruitment takes place and where the intervention is accessed by the parent. Interventions that recruit or are accessed online will also be included. |
Outcomes | The primary objective is to identify the types of digital interventions used to support parents’ health literacy and care of acutely ill children and their effectiveness. Therefore, primary outcomes are expected to include, but are not limited to, health literacy (knowledge and decision making), the confidence in making treatment-seeking decisions and caring for their child, levels of anxiety about the child’s health, actual treatment-seeking behavior, levels and length of engagement with the intervention, and patient-reported experience (including measures of acceptability, usability, or satisfaction). Other outcomes that are reported by studies and deemed relevant will also be included (eg, the ability of the tools to identify a seriously ill child). |
Study types | Observational studies (including qualitative studies) and cohort or randomized control trials will be included. Case studies and editorials will not be included. Literature reviews will be included in the search so that their references can be examined to identify any relevant papers not captured by our search terms but will not be included in the final review themselves. Papers describing the development of interventions that are evaluated in one of the studies will also be included. |
Five databases will be searched to find articles for this review: MEDLINE, CINAHL, Embase, PsycNET, and Web of Knowledge. Key terms relating to digital interventions to support parents with acutely ill children were extracted from an initial review of the literature and used to develop the search terms and search strategy. Search terms will include MeSH terms and keywords relating to digital interventions, children, acute illness, and health information. For this study, acute illness will include any short-term illness, whether minor or severe. Digital interventions will include any digital technologies with the aim of supporting parents or caregivers with children experiencing one or more of these short-term illnesses. An official diagnosis is not required, as the focus of the paper is on how the digital interventions enable parents to respond to children with symptoms of illness. The search terms that will be used in this review are grouped into those 4 themes (see
Search terms.
Category | MeSH | Keywords (in title or abstract) |
Digital interventions | Telemedicine OR Mobile Applications OR Internet-based Interventions OR Internet of Things | “mHealth” OR “mobile health” OR “eHealth” OR ((mobile OR phone OR smartphone OR cell) adj3 app*) OR web OR internet OR “online intervention” OR “web-based intervention” OR “digital intervention” OR virtual OR webpage* OR website* OR “smart device*” OR “smart medical devices” OR “smart tech*” OR tool OR resource OR program OR programme |
Family | Child OR Infant OR Newborn OR Preschool Child OR Pediatrics OR Family OR Adolescent OR Adolescent Health OR Parents OR Caregivers OR Pregnant Women | pediatric* OR paediatric* OR child OR children OR kid OR kids OR infant* OR newborn* OR neonate* OR bab* OR babies OR toddler* OR schoolchild OR teen* OR adolescent* OR parent* OR carer* OR caregiver* OR “foster parent” OR childminder* OR “child minder*”) OR pregnan* |
Acute illness | Acute Disease OR Childhood Disease OR Injury OR Fever OR Cough OR Whooping Cough OR Diarrhea OR Earache OR Vomiting OR Respiratory Tract Infections OR Otitis OR Croup OR Bronchiolitis OR Seizures OR Exanthema OR Mucocutaneous Lymph Node Syndrome OR Conjunctivitis OR Chickenpox OR Epiglottitis OR Tonsillitis OR Common cold OR Influenza, Human OR Pharyngitis OR Meningitis OR Status Epilepticus OR Epilepsy OR Sepsis OR Virus Diseases | (acute OR “short term” OR “short-term” adj2 (illness* OR disease* OR sickness*)) OR (minor adj2 (illness* OR disease* OR sickness*)) OR unwell OR fever* OR febril* OR cough* OR diarrh* OR rash* OR vomit* OR earache* OR bronchiolit* OR (respirator* adj2 infection*) OR otitis OR croup OR seizure* OR rash OR rashes OR exanthem* OR kawasaki* OR conjunctivit* OR “chicken pox” OR chickenpox OR epiglottit* OR tonsillit* OR influenza OR flu OR “sore throat*” OR pharyngit* OR meningit* OR epilepsy OR sepsis OR septicemia OR septicaemia OR epilept* OR headache OR “neck pain” |
Health education | Health Education OR Health Literacy OR Help-Seeking Behavior OR Information Seeking Behavior OR Access to Information OR Decision Support Techniques OR Decision Making OR Empowerment OR Prenatal Education OR Health Knowledge, Attitudes, Practice | “Health education” OR “health information” OR “health literacy” OR “information literacy” OR “information resource*” OR “treatment seeking” OR “help seeking” OR educat* OR counsel* OR “consultation behavior*” OR “consultation behavior*” OR (decision adj2 (aid* OR support OR guidance OR help)) OR “parent information” OR “home management” OR empowerment OR confidence OR self-efficacy OR ability OR knowledge OR ?understanding |
The review will include studies published in English (based in any country) that evaluate digital interventions that aim to improve parents’ health literacy and care for acutely ill children. This will include, but will not be limited to, tools to improve parents’ knowledge of signs and symptoms of acute illness and deterioration, their confidence in assessing illness severity, their perceived self-efficacy in caring for their child, and their treatment-seeking behavior. Digital interventions can include mobile or web-based apps and websites. Studies that examine multicomponent interventions will be included given that there is a digital component of the intervention being evaluated.
The interventions will need to target parents with children (including pregnant women and their families) who have at least one acute illness or to provide education, information, or decision support to prepare parents for the event that a child becomes ill. It is expected that the majority of interventions will target parents with younger children, but the age of 19 years was set as the upper boundary to ensure that no relevant studies are missed in the search. In addition to parents, any caregivers responsible for children (for short or long periods of time) will be included. Studies with any or no comparator will be included.
Studies that do not include parents or caregivers responsible for children under the age of 19 years or that target the children (instead of parents or caregivers) as the primary user will be excluded. Depending on the number of eligible references identified in the search, this may be limited to a younger age in the systematic review.
Studies that were published before 2014 will also be excluded for 2 reasons: (1) Digital technology evolves rapidly [
Studies that merely describe an intervention without evaluating it will be excluded, unless they describe the development of an intervention whose evaluation study is included in the review. Studies that are not published in English will be excluded, as there is no capacity for translation.
The citation management software EndNote X9 will be used to store the references and automatically remove any duplicates. References will be uploaded to a meta-analysis software to facilitate initial screening (based on inclusion and exclusion criteria key words), data extraction, and analysis. Two independent reviewers will then screen the remaining titles and abstracts and then conduct a full-text review to determine final eligibility for inclusion. Any disagreements about eligibility will be discussed by the 2 reviewers, and if no consensus can be reached, eligibility will be decided by a third reviewer. The details of the screening and selection process will be recorded using a PRISMA flow diagram to ensure study reproducibility.
The references of any relevant reviews found in the initial search will also be screened to identify any studies that may have been missed by the search. Once the final set of included studies has been determined, their references will be searched for published papers describing the development of those interventions. These linked papers will also be included in the final review.
Two reviewers will independently examine the full texts of the included articles to extract outcomes into a predetermined form (see
General study information
Year of publication
Country of study
Sample demographics (including, but not limited to, any of the following that are reported: age, gender, target population, parental experience, socioeconomic status, health literacy, locality, health conditions)
Initial sample size
Analyzed sample size
Length of follow-up
Intervention
Digital platform
Cost
Development methods addressing accessibility/implementation
Aim of intervention
Intended time and place of use (eg, before seeking help, after seeking help)
Training or guidance needed to use (if any)
Specified age of children (if any)
Specified type of acute illness (if any)
Theory or logic model the intervention is based on (if any)
Patient and public involvement in development (if any)
Evaluation
Outcomes measured
Health literacy (knowledge of illness and decision making); as there are a variety of tools used to measure health literacy [
Skills to manage child illness
Parental treatment-seeking behavior
Parental characteristics (eg, uncertainty, anxiety, knowledge, confidence, reassurance, perceived self-efficacy)
Acceptability
Usability of platform
Accessibility
User experience (participant perceptions or feedback)
Sustainability of use
Other key performance indicators reported (eg, ability of tools to identify a seriously ill child)
Limitations identified
The quality and risk of bias of the included studies will be independently assessed by 2 reviewers, with disagreements discussed and resolved by a third reviewer if necessary. They will be measured using the Mixed-Methods Appraisal Tool (MMAT) [
A meta-analysis is not expected to be feasible, due to the anticipated variety of study designs, measures, and reported outcomes. A descriptive analysis will be used to summarize the extracted data. The studies will also be analyzed separately depending on the age of the children. Where possible, they will be divided into 4 groups (0-4, 5-9, 10-14, 15-19 years) to align with the division used by Public Health England and the World Health Organization [
Our approach reflects best practice in health research [
Parents and representatives of groups of parents will continue to be involved in the review process. We do not expect patient and public involvement (PPI) experts to review individual papers as this is not their area of expertise. However, 2 representatives from meningitis awareness charities (JB, Meningitis Now, and RD, Meningitis Research Foundation) were involved in the revision of this protocol. We will ask parents and PPI representatives to review our findings from the review of included papers to ensure that any factors that may have affected parents’ participation in projects are identified and the interpretation of the findings are grounded in the reality of life as a parent. In this way, we intend to ensure that the review is not biased towards an academic or clinical lens.
The systematic review is expected to start in May 2021 and be completed by December 2021. However, given the current public health emergency, a firm timeline cannot be guaranteed.
A systematic review of the literature about digital interventions to support parental decision-making for, and care of, acutely ill children will contribute to a better understanding of how these interventions can best support parents. Based on the data about impact, usability, and limitations that will be extracted from the studies, this section will explore what conclusions can be drawn, the limitations of the systematic review, and key areas for future research.
A better understanding of the current strengths and areas for improvement of these digital interventions has the potential to promote timely use of primary care services according to the severity of illness of the child. Given the lack of substantial evidence supporting the effectiveness of such interventions identified by previous reviews, the conclusions drawn from this review will help inform the development of improved digital interventions for parents. This will be particularly important for designing interventions to improve access for hard-to-reach populations and others who are vulnerable to digital exclusion.
Sample search.
Accident and Emergency
Medical Subject Headings
Mixed-Methods Appraisal Tool
Population, Intervention, Comparator, and Outcome
patient and public involvement
Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols
The authors would like to thank Professor Ray Jones for his feedback on the draft protocol.
This paper was funded by the Centre for Health Technology, University of Plymouth. ML was supported by the National Institute for Health Research (NIHR) Biomedical Research Centre based at UCL Great Ormond Street Institute of Child Health/Great Ormond Street Hospital NHS Foundation Trust. MB receives funding from the NIHR under the Applied Health Research and Care (ARC) programme for North West London
We would also like to acknowledge the multidisciplinary and multisector team of people who have contributed to the development and activities of the ASK SNIFF Consortium. The contributors are: Wendy Clyne from the Peninsula Medical School, University of Plymouth and the Research Design Service South West; Ron Daniels from the University Hospitals Birmingham NHS Trust and the Global Sepsis Alliance; Linda Glennie from the Meningitis Research Foundation; Matt Halkes, Hugh Kelly, Amy Wyatt-Haines, and Richard Wyatt-Haines from Health and Care Innovations LLP; Joanne Hughes from Mothers Instinct; Alex Leach from the West of England Academic Health Science Network (AHSN); William Lilley from the South West AHSN; Paula Lorgelly from the Department of Applied Health Research, University College; and Lucie Riches from Meningitis Now.
The protocol was drafted by MMI with iterative input and revisions from SN, NB, MB, JB, LB, EC, BC, RD, PD, ML, DR, AT, and EM.
None declared.