International Journal of Nursing Studies 51 (2014) 1524–1537

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International Journal of Nursing Studies journal homepage: www.elsevier.com/ijns

Review

Internet-based peer support for parents: A systematic integrative review Hannakaisa Niela-Vile´n a,*, Anna Axelin a, Sanna Salantera¨ a,b, Hanna-Leena Melender c a b c

Department of Nursing Science, University of Turku, Finland Turku University Hospital, Finland VAMK University of Applied Sciences, Vaasa, Finland

A R T I C L E I N F O

A B S T R A C T

Article history: Received 20 December 2013 Received in revised form 5 June 2014 Accepted 12 June 2014

Objectives: The Internet and social media provide various possibilities for online peer support. The aim of this review was to explore Internet-based peer-support interventions and their outcomes for parents. Design: A systematic integrative review. Data sources: The systematic search was carried out in March 2014 in PubMed, Cinahl, PsycINFO and Cochrane databases. Review methods: Two reviewers independently screened the titles (n = 1793), abstracts and full texts to decide which articles should be chosen. The inclusion criteria were: (1) an Internet-based community as an intervention, or at least as a component of an intervention; (2) the participants in the Internet-based community had to be mothers and/or fathers or pregnant women; (3) the parents had to interact and communicate with each other through the Internet-based community. The data was analysed using content analysis. When analysing peer-support interventions only interventions developed by researchers were included and when analysing the outcomes for the parents, studies that focused on mothers, fathers or both parents were separated. Results: In total, 38 publications met the inclusion criteria. Most of the studies focused on Internet-based peer support between mothers (n = 16) or both parents (n = 15) and seven focused on fathers. In 16 studies, the Internet-based interventions had been developed by researchers and 22 studies used already existing Internet peer-support groups, in which any person using the Internet could participate. For mothers, Internet-based peer support provided emotional support, information and membership in a social community. For fathers, it provided support for the transition to fatherhood, information and humorous communication. Mothers were more active users of Internet-based peer-support groups than fathers. In general, parents were satisfied with Internet-based peer support. The evidence of the effectiveness of Internet-based peer support was inconclusive but no harmful effects were reported in these reviewed studies. Conclusions: Internet-based peer support provided informational support for parents and was accessible despite geographical distance or time constraints. Internet-based peer support is a unique form of parental support, not replacing but supplementing support offered by professionals. Experimental studies in this area are needed. ß 2014 Elsevier Ltd. All rights reserved.

Keywords: Internet Parental support Parents Peer group Peer support Review Social media

* Corresponding author at: Department of Nursing Science, University of Turku, FIN-20014 Finland. Tel.: +358 440 535 433. E-mail address: hmniel@utu.fi (H. Niela-Vile´n). http://dx.doi.org/10.1016/j.ijnurstu.2014.06.009 0020-7489/ß 2014 Elsevier Ltd. All rights reserved.

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What is already known about the topic?  Internet and social media provide multiple possibilities for parenting peer support.  Parents are active users of the Internet and social media.  The number of studies into Internet-based peer support for parents is increasing. What this paper adds  This review demonstrates that the main parental outcomes of Internet-based peer support are informational and emotional support given and received, and parents participating in these communities enjoy interacting with each other.  Internet-based peer support has some effect on parenting skills and mental well-being, but the evidence for this was limited due to the lack of experimental designs.  Internet-based peer support for parents might supplement the guidance given in the health-care system by professionals. 1. Introduction Parents want to share their experiences and receive information from other parents as much as they want to seek information and advice from professionals. Peer support between parents is an important source of emotional and informational support (Rossman, 2007) and it may help them to gain more positive perspectives on parenting (Ritchie et al., 2000). Peer support is defined as social emotional support (Solomon, 2004) which is voluntary, informal, flexible, non-hierarchical and nonmedical (Mead and MacNeil, 2006). Peer support is giving and receiving help and understanding another’s situation through shared experience (Mead et al., 2001). Professional support provided by nurses is an essential component of nursing practice and it contains informational, emotional, instrumental and esteem support (Miles et al., 1999). It partly overlaps with the idea of peer support but nurses are required to have certain skills, knowledge and competencies (Hobbs, 2009) and nurses do not belong to the social network of patients and do not share their experiences (Miles et al., 1999). Peer support is usually related to social support which is a multidimensional and broader concept including support also from, for example, family members and friends, not just peers. Social support is associated with well-being and there might be also a causal relationship (Cohen and Wills, 1985). Today, in the era of social media, the Internet provides various possibilities for online peer support. Social media is here defined as a group of Internet-based applications that are based on the technological foundations of Web 2.0 and are publicly available (Kaplan and Haenlein, 2010). Nieuwboer et al. (2013a) showed in their review that the Internet provides multiple opportunities to provide peer and professional parenting support. Online parenting support utilises a wide range of online communication from one-to-one discussion to open group forums. The transition to parenthood is one of the biggest life changes and parents need support during this time

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(Petch and Halford, 2008; Solmeyer and Feinberg, 2011). ‘Traditional’ peer support has been shown to be an efficient intervention. Successful mother-to-mother peer support associated with breastfeeding, for example, has been conducted within home visits and via the telephone (e.g. Ahmed and Sands, 2010; Kaunonen et al., 2012; Merewood et al., 2006). Breastfeeding rates in Texas also increased after the use of father-to-father peer support; indeed, the attitude of the father has a strong impact on a mother’s decision over feeding methods (Stremler and Lovera, 2004). Parents of children with special health-care needs have received particular benefits, such as increased knowledge, skills and support, from peer-support groups (Kingsnorth et al., 2011). Telephone-based peer support has also been used by mothers suffering from postpartum depression, in which it was shown that it may be effective: at the very least, the mothers reported being satisfied with this peer-support experience (Dennis, 2010; Dennis et al., 2009). Internet-based peer support is available for diverse groups of people, including parents and families, despite geographical distance or time constraints. Peer support for mothers, fathers or pregnant women can be provided in public groups open for all Internet users or in closed groups for a targeted group only. Peer-support groups can be either moderated or not and they can be synchronous or asynchronous. These groups in Internet-based social media are a constantly growing phenomenon. In Yahoo!Groups (www.yahoo.com) alone there are over 20,000 groups for parenting, and in the social media site Facebook (www.facebook.com) – which had over 1.2 billion monthly active users in December 2013 (Facebook, 2013) – there are thousands of groups for such peer support. On average, 77% of the European and 61% of the American population in 2013 use the Internet (ITU, 2013). Young adults are very active Internet users, for example in Finland 98% of people aged between 25 and 34 use the Internet every week and over 70% of this age group visit social media sites at least occasionally. Furthermore, families with children are very active users of the Internet and over 60% of Finnish families use various discussion forums (Taloustutkimus, 2010). Research on parenthood and the use of the Internet has strongly increased after the millennium (Plantin and Daneback, 2009). It has been suggested that new mothers particularly feel more connected with other people by using the Internet than without doing so (McDaniel et al., 2012). In a study by Bartholomew et al. (2012), 58% of new American mothers and 44% of fathers visited their Facebook accounts at least once a day, however, for various reasons, not only parenting issues. In a systematic review on the effects of online peer-topeer interactions, no evidence on the effects of online peer support was found, partly because in many studies included in the review, peer support was only one part of a complex intervention (Eysenbach et al., 2004). Results of the review by Shilling et al. (2013) on peer support for parents of children with chronic disabling conditions suggested that parents benefit from peer support, for example by sharing a social identity or learning practical information, but the evidence of this effectiveness was

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inconsistent. Nieuwboer et al. (2013b) concluded that online interventions can make a positive contribution to parents. All online programmes aiming to improve parenting, in addition to peer support, were included in their review. Nieuwboer et al.’s (2013a, 2013b) reviews approach this phenomenon but with different perspectives such as communication types and online programmes. Indeed, no previous systematic review has purely focused on the outcomes of Internet-based peer support for parents. Our integrative review strives to fill this gap because Internetbased peer support is an easy and accessible channel for almost all parents, and it may be an efficient intervention to promote parents’ well-being. Furthermore, by combining professional nursing support and Internet-based peer support it could be possible to create a cost-effective method of providing additional support for parents. The aim of this review was to explore Internet-based peersupport interventions and their outcomes for parents. The research questions were as follows: 1. What Internet-based peer-support groups/interventions have been provided for parents? 2. What outcomes have been achieved by using these Internet-based peer-support groups/interventions for parents?

2. Methods 2.1. Inclusion and exclusion criteria This integrative review has been conducted based on the framework of Whittemore and Knafl (2005). We searched for papers with diverse methodologies concerning Internet-based peer support for parents. We included studies published in peer-reviewed journals written in English. The inclusion criteria were as follows: first, there had to be an Internet-based community as an intervention or at least as a component of an intervention; second, the participants in the Internet-based community had to be mothers and/or fathers or pregnant women; third, the parents had to interact and communicate with each other through the Internet-based community.

Studies where the Internet-based community was built to be ‘a self-management program’, ‘therapy’, ‘treatment’, ‘education-intervention’ or ‘training’ were excluded, because the main focus of the community in the studies included needed to be participant-directed discussion without a predetermined goal. An Internet-based intervention that focused on teenaged parents was also excluded because the intervention was not targeted at parenting but enhancing participation in the group. In addition, we excluded studies in which parents and children participated in the same Internet-based peer-support group because the particular interest was in parental outcomes, and thus the perspective of children would have broadened the scope. 2.2. Search strategy The search was carried out in March 2014 (4.3.2014) in PubMed, Cinahl, PsycINFO and Cochrane databases. The search terms used are presented in Table 1. All the word variations and MeSH terms were used. No limitation related to the years of publication was applied. The total number of titles, abstracts and full texts found through the search and selection processes are presented in Fig. 1. Two reviewers (HN-V, AA) independently screened the titles to decide which abstracts should be chosen; disagreements were resolved through discussion. The same two reviewers together screened the abstracts (n = 304) with the same criteria to decide whether the full text article should be obtained. After rejecting the duplicates (n = 32) and non-published dissertations (n = 4), 54 full text articles were evaluated. The reference lists of chosen articles were explored and three studies were included based on this search. Finally, 38 publications met our inclusion criteria and were chosen for review (Fig. 1). Over half (n = 25) of the studies were qualitative, ten were quantitative and three studies used mixed methods. 2.3. The quality of the studies All the included studies were evaluated by two reviewers (HN-V, H-LM). Both reviewers independently conducted the quality assessment and following discussion, a consensus

Table 1 Search terms used in the databases. Database

Search terms

PubMed

(‘‘Peer group’’[Mesh] OR ‘‘peer support’’[tiab] OR ‘‘peer counseling’’[tiab] OR ‘‘Social support’’[Mesh]) AND (‘‘Internet’’[Mesh] OR Internet[tiab] OR Online[tiab] OR web[tiab] OR ‘‘social media’’[tiab] OR ‘‘Social media’’[Mesh] OR wiki*[tiab] OR facebook[tiab] OR youtube[tiab] OR chat*[tiab] OR ‘‘Blogging’’[Mesh] OR ‘‘web 2.0’’[tiab]) AND (‘‘Child’’[Mesh] OR ‘‘Family’’[Mesh] OR family[tiab] OR child*[tiab] OR ‘‘Parents’’[Mesh] OR parent*[tiab]) ((MH ‘‘Internet+’’) OR (AB ‘‘Internet’’) OR (AB ‘‘web’’) OR (‘‘Online’’) OR (MH ‘‘World Wide Web+’’) OR (MH ‘‘Blogs’’) OR (MH ‘‘World Wide Web Applications+’’) OR (MH ‘‘Online Systems+’’) OR (AB ‘‘social media’’) OR (AB ‘‘wiki’’) OR (AB ‘‘facebook’’) OR (AB ‘‘youtube’’) OR (AB ‘‘chat’’) OR (AB ‘‘web 2.0’’)) AND ((MH ‘‘Support, Psychosocial+’’) OR (MH ‘‘Peer Counseling’’) OR (MH ‘‘Peer Group’’)) AND ((MH ‘‘Parents+’’) OR (MH ‘‘Child+’’) OR (MH ‘‘Family+’’)) Internet OR Online OR web OR ‘‘Social media’’ OR wiki OR facebook OR youtube OR chat OR Blog AND ‘‘Peer group’’ OR ‘‘peer support’’ OR ‘‘peer counseling’’ OR ‘‘Social support’’ AND family OR child OR parent (((Internet$ or online4 or web$ or ‘‘social media’’ or wiki$ or facebook or youtube or chat$ or blog$) and (‘‘peer group’’ or ‘‘peer support’’ or ‘‘peer counseling’’ or ‘‘social support’’) and (famil$ or child$ or parent$)).mp.) OR ((exp Internet/OR exp Online Social Networks/OR exp Computer Mediated Communication/) AND (exp Peers/OR exp Peer Relations/OR exp Support Groups/OR exp Social Support/OR exp Social Networks) AND (exp Family/OR family members/OR adopted children/OR biological family/OR daughters/OR grandchildren/OR grandparents/OR orphans/OR parents/OR siblings/OR sons/OR stepchildren/))

Cinahl

Cochrane

PsycInfo

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Total of titles screened n = 1793 (Cochrane 79, Cinahl 635, PubMed 636, PsycInfo 443)

Excluded by title n = 1489 Abstracts screened n = 304

Excluded by abstract n = 229 Not fulfilled the inclusion criteria, n = 214 Duplicates, n = 32 Non-published dissertations, n=4

Full texts screened n = 54 Excluded by full text n = 19 Based on full texts, n = 35 and reference lists, n = 3 Included in review n = 38

No peer support, n = 9 No research article, n = 3 Including children, n = 2 Teenaged parents, n = 1 No Internet-based, n = 2 No parents, n = 2

Fig. 1. Flow diagram of search and selection processes.

was reached. The quality of the selected studies was evaluated according to the criteria by Gifford et al. (2007), which provides design-specific quality assessment criteria for quasi-experimental, survey and qualitative studies. Studies using mixed methods were evaluated according to the predominant method. Each criterion was given a score from zero to two; 0 point representing many limitations, 1 point some limitations and 2 points representing excellent quality of the criterion. Quasi-experimental study assessment included eight criteria, survey study six criteria and qualitative study 11 criteria; thus, the highest possible scores were 16, 12 and 22, respectively. According to the total score, the quality of a paper was classified as ‘excellent’, or having ‘some limitations’ or ‘many limitations’. The total score had to be at least 75% of the maximum score to be classified as excellent. In total, 25 of the studies were classified as excellent, 12 had some limitations and one had many limitations (Table 2). All the studies were included in the analysis, despite the result of the quality evaluation, in order to achieve a broad view of the current research and in order to avoid bias. 2.4. Data analysis In the analysis, the data was divided into subgroups (Whittemore and Knafl, 2005). When analysing peersupport interventions (research question 1), only the interventions developed by researchers and for study purposes were included. When reviewing the outcomes for the parents (research question 2), studies focused on mothers, fathers or both parents were separated. The data was analysed using content analysis (Hsieh and Shannon, 2005). The contents of the interventions, evaluation

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methods and essential results from the evaluations were written into a matrix. The data was coded according to the research questions. The codes were sorted by searching for similarities and differences, and then abstracted into categories. This analysis was performed by the first author (HN-V), with close and continuous support from the research group. The author performing the quality evaluation (H-LM) with the first author particularly critically assessed the initiation of the analysis. 3. Results 3.1. Included studies In total, 38 publications met our inclusion criteria and were chosen for the review. Most of the studies (n = 16) were focused on Internet-based peer support between mothers. Seven studies were focused on fathers and 15 on both parents. Although the publication years were not limited, almost all of the papers were published after the year 2000. The oldest included study (Dunham et al., 1998) was published in 1998. Most of the studies were from North America, with 13 from the USA and seven from Canada. Five studies were from Australia and one was conducted in co-operation in Australia and the USA. The European studies were from Sweden (4), Finland (3), the UK (3), Germany (1) and Iceland (1). Detailed methodological characteristics of the studies are described in Table 2. 3.2. Internet-based peer-support interventions and groups for parents 3.2.1. The diversity of the Internet-based peer-support interventions and groups In 16 studies (I–XVI, Roman numerals refer to Table 2), the Internet-based interventions were developed by the researchers. In these studies, the participants were groups of carefully defined individuals. In five studies, the intervention was based on a theory. These theories were: the social support theory (II, IV), transition to parenthood (VII), theory of self-efficacy (XIII) and Lazarus and colleagues’ model of stress and coping (XV). In 11 studies, the intervention was based on previous research and/or other literature. Interventions developed by researchers were divided into two categories: exclusive peer-support interventions (I, VI, VIII, IX, X, XI, XVI), and complex interventions that only included peer support in part (II, III, IV, V, VII, XII, XIII, XIV, XV) (Table 2). Even though the interventions were exclusively peer-support based, the discussion was controlled, for example by a facilitator or moderator. In some cases, prepared questions for participants were used. Peer support was usually conducted through an asynchronous discussion board (II, III, IV, VII, VIII, IX, XII, XIII, XIV, XV) or e-mail list (I, XI); real-time online meetings were used in four interventions (V, VI, X, XVI). In addition to the peer support, complex interventions included 1–3 other elements: in most cases, an information database or library (II, IV, VII, XII, XIII, XIV, XV) or an ask-a-nurse or midwife forum (II, IV, VII, XII, XIV).

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Table 2 Internet-based peer-support interventions (a) and existing Internet-based peer-support groups (b) for parents. Studies included in the review, country of origin and Quality Grade (QG) of the studies

Description of the intervention or peer-support group

(VIII) Nicholas et al. (2012) Canada QG: Some limitations 15/22p

Network for fathers of children with brain tumours; semistructured, asynchronous, led by a facilitator

Exclusive peer support (e)/part of complex intervention (c)

Effectiveness tested and if yes, outcomes measured

Qualitative, web-based focus group, n = 7 pregnant women

e

No

x

Qualitative, postings, n = 19 mothers, 174 posted messages

c

No

x

Mixed methods, measures of online participation, postings, questionnaires, n = 42 mothers

c

Parenting stress (no control group)

x

Qualitative, postings, n = 19 pregnant African American women

c

No

x

Quantitative, online-survey, n = 18 mothers

c (real time chats)

No

x

Qualitative, interviews and diary notes, n = 5 mothers

e (real time videoconference)

No

x

Quantitative, quasiexperimental design with repeated measures, questionnaires, n = 34 fathers, (intervention n = 14, comparison n = 20) Mixed methods, pre- and post-intervention measures, questionnaires, interviews, postings, n = 21 fathers

c

Parenting satisfaction, parenting self-efficacy

x

e

Paternal coping, social support, meaning of illness

x

Focused on Mothers

Fathers

Both parents

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(a) Peer-support interventions developed by researchers Virtual focus group for pregnant (I) Adler and Zarchin (2002) women on home bed rest. A USA closed e-mail loop for QG: Excellent 19/22p participants only New Mothers Network, a web(II) Brage Hudson et al. (2009) based network that consists of: USA (1) an asynchronous discussion QG: Some limitations 15/22p forum, (2) e-mail and (3) an electronic library Based on Social support theory Computer-mediated social (III) Dunham et al. (1998) support network for single Canada young mothers. It permitted: (1) QG: Some limitations 16/22p public message exchanges, (2) private e-mail and (3) text-based teleconferencing Culturally congruent web site (IV) Herman et al. providing information on (2005) pregnancy-related health USA behaviours and other pregnancy QG: Some limitations 16/22p issues: (1) health information, (2) ask-a-nurse, (3) discussion board Based on Social support theory SupportNet for ‘‘at risk’’ (V) Miller (2006) pregnant and parenting women. Canada Includes: (1) secure chats and (2) QG: Many limitations 3/12p e-mail. Chats are prearranged with a professional and coordinator online ¨ hrling (2006) E-meeting portal: real-time (VI) Nystro¨m and O videoconferencing through the Sweden web, group led by a child nurse QG: Excellent 19/22p New Fathers Network: (1) library (VII) Brage Hudson et al. (2003) of information, (2) asynchronous USA QG: Excellent 12/16p discussion forum, (3) e-mail Based on Transition theory

Methodological approach, data collection, number of participants/postings

Table 2 (Continued ) Methodological approach, data collection, number of participants/postings

Exclusive peer support (e)/part of complex intervention (c)

Effectiveness tested and if yes, outcomes measured

Qualitative, postings, n = 25 fathers

e

No

x

Qualitative, interviews, n = 3 fathers

e (real time videoconference)

No

x

Quantitative, one-group, before and after design, questionnaires, n = 11 mothers and n = 10 fathers Qualitative, postings, n = 21 families

e

Anxiety, depression, stress, somatisation

x

c

No

x

Quantitative, pretest– posttest design, questionnaires, n = 9 parents

c

Parental self-efficacy

x

Quantitative, quasiexperimental design with repeated measures, questionnaires, n = 500 mothers and n = 242 fathers Qualitative, postings, n = 6 mothers and n = 1 father

c

Parenting satisfaction, parenting self-efficacy

x

c

No

x

Qualitative, assessment interviews, n = 44 mothers, post-intervention interviews, n = 19 parents

e (real time meetings online)

No

x

Private Internet support group for mothers who had lost a child

Qualitative, postings, n = 4 mothers, 631 postings

e

No

x

Electronic discussion board for breastfeeding support

Qualitative, postings, n = 1614 postings with 206 different user names

e

No

x

Description of the intervention or peer-support group

(IX) Nicholas et al. (2003) Canada QG: Some limitations 14/22p ¨ hrling (2008) (X) Nystro¨m and O Sweden QG: Excellent 19/22p (XI) Bragado´ttir (2008) Iceland QG: Excellent 13/16p

Online group for fathers of children with spina bifida, group facilitated by a social worker E-meeting portal: real-time videoconferencing through the web, group led by a man Computer-mediated support group for parents of children diagnosed with cancer: mailing list with three facilitators NetClinic, Internet-based network for pregnant families: (1) news, (2) e-mail, (3) information bank, (4) discussion forum Web-based platform for parents with children diagnosed with type 1 diabetes: (1) educational materials, (2) discussion threads, (3) links, announcements Based on the theory of selfefficacy Online support for parenting, breast feeding and infant care: (1) information database, (2) discussion forum and (3) ask-anurse/midwife Internet site for parents of mentally ill children: (1) asynchronous discussion board, (2) information pages, (3) links Based on Lazarus and colleagues’ model of stress and coping Peer-support sessions for parents of children with asthma and allergies. Sessions had facilitators

(XII) Kouri et al. (2006) Finland QG: Excellent 17/22p

(XIII) Merkel and Wright (2012) USA QG: Excellent 12/16p

(XIV) Salonen et al. (2011) Finland QG: Excellent 13/16p

(XV) Scharer (2005) USA QG: Some limitations 15/22p

(XVI) Stewart et al. (2011) Canada QG: Excellent 20/22p

(b) Existing peer-support groups (XVII) Aho et al. (2012) Finland QG: Excellent 19/22p (XVIII) Cowie et al. (2011) Australia QG: Excellent 19/22p

Focused on Mothers

Fathers

Both parents

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Studies included in the review, country of origin and Quality Grade (QG) of the studies

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Table 2 (Continued ) Exclusive peer support (e)/part of complex intervention (c)

Effectiveness tested and if yes, outcomes measured

Mixed methods, postings, web-based ‘roll-calls’ for background information, n = 81 mothers Qualitative, postings, n = 512 postings

e

No

x

e

No

x

Qualitative, web-based questionnaire, n = 37 women

e

No

x

Qualitative, postings, n = 40 mothers

e

No

x

Qualitative, listserv messages, n = 447 messages from 80–87 participants, mostly mothers

e

No

x

Mixed methods, web-based survey, n = 155 mothers and virtual group interviews n = 16 Qualitative, postings, n = 120 messages by 112 parents

e

No

x

e

No

x

Qualitative, postings, n = 2042 messages

e

No

x

Public online forum for fathers

Qualitative, postings, n = 1203 pages of data from online forum

e

No

x

Fathers’ chat room in parenting information web site

Qualitative, postings in chat room, n = 24 fathers and n = 22 mothers

e

No

x

Fathers’ chat room in parenting information web site

Qualitative, postings in chat room, n = 23 fathers and n = 22 mothers Quantitative, Internet survey, n = 114 primary care givers

e

No

x

e

No

Description of the intervention or peer-support group

(XIX) Drentea and Moren-Cross (2005) USA QG: Excellent 17/22p

Mothering board in a large parenting website. Cohorts based on the expected month of their child’s birth Online group focused on maternal mood and anxiety disorders E-mail list for women who are or who are hoping to breastfeed an adopted child or attempting to relactate for a biological child Community-based online group for mothers of infants and toddlers Perinatal loss listserv for mothers who had experienced a perinatal loss through miscarriage, stillbirth or neonatal death Babyworld, UK parenting website

(XX) Evans et al. (2012) Canada QG: Excellent 20/22p (XXI) Gribble (2001) Australia QG: Some limitations 13/22p (XXII) Hall and Irvine (2009) Canada QG: Excellent 19/22p (XXIII) Leask Capitulo (2004) USA QG: Some limitations 14/22p (XXIV) O’Connor and Madge (2004) UK QG: Some limitations 5/12p (XXV) Porter and Ispa (2013) USA QG: Excellent 18/22p (XXVI) Sullivan (2008) USA QG: Excellent 18/22p (XXVII) Eriksson and Salzmann-Erikson (2013) Sweden QG: Excellent 17/22p (XXVIII) Fletcher and StGeorge (2011) Australia QG: Excellent 21/22p (XXIX) StGeorge and Fletcher (2011) Australia QG: Excellent 20/22p (XXX) Baum (2004) USA QG: Excellent 9/12p

Two online parenting message boards maintained by popular parenting magazines in the US, infant and toddler categories Online asthma caregivers support group

Internet parent support groups for primary caregivers of children with special health-care needs

Focused on Mothers

Fathers

Both parents

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Methodological approach, data collection, number of participants/postings

Studies included in the review, country of origin and Quality Grade (QG) of the studies

x

Table 2 (Continued ) Exclusive peer support (e)/part of complex intervention (c)

Effectiveness tested and if yes, outcomes measured

Three discussion boards (two USA, one UK) for childhood cancer

Qualitative, postings, n = 487 messages

e

No

x

Three online support groups for family members of children with cancer (N-Blastoma, Ped-All, Ped-Onc) Email discussion list for parents of children with autism

Quantitative, e-mail questionnaire, n = 55 mothers n = 18 fathers

e

No

x

Qualitative, postings, n = 6142 messages from 374 email addresses Quantitative, web-based questionnaire, n = 119 (including 94 mothers, 13 fathers and 12 others) Qualitative, stories in peersupport group, n = 12 online survey, n = 26

e

No

x

e

No

x

e

No

x

Qualitative, postings, n = 775 messages

e

No

x

Quantitative, web-based questionnaire, n = 2030 respondents with children under 18 years Qualitative, postings, n = 1497 individual groups were identified, 25 largest groups were extracted

e

No

x

e

No

x

Description of the intervention or peer-support group

(XXXI) Coulson and Greenwood (2012) UK QG: Some limitations 16/22p (XXXII) Han and Belcher (2001) USA QG: Some limitations 7/12p (XXXIII) Huws et al. (2001) UK QG: Excellent 19/22p (XXXIV) Leonard et al. (2004) Australia QG: Excellent 10/12p (XXXV) Morris and Bertram (2013) USA QG: Excellent 21/22p (XXXVI) Oprescu et al. (2013) Australia and USA QG: Some limitations 15/22p (XXXVII) Sarkadi and Bremberg (2005) Sweden QG: Excellent 11/12p (XXXVIII) Thoren et al. (2013) Germany QG: Excellent 19/22p

E-mail listserv for parents of children with Rett syndrome (neurological disorder) Online support site for parents of premature infants (March of Dimes, Share Your Story, NICU online community) Online support community for parents of children with clubfoot Fo¨ra¨ldraNa¨tet, parenting website including 250 discussion groups

Public English-language Facebook groups focusing on preterm infants

Focused on Mothers

Fathers

Both parents

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Methodological approach, data collection, number of participants/postings

Studies included in the review, country of origin and Quality Grade (QG) of the studies

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Anonymous participation was mentioned in eight studies (III, IV, V, XI, XII, XIII, XIV, XV). Stress, parenting selfefficacy, parenting satisfaction, paternal coping, social support, the meaning of illness, self-efficacy for diabetes, anxiety, depression and somatisation were measured as outcomes when evaluating the effectiveness of peer support or the complex intervention (Table 2). In the remaining 22 studies (XVII–XXXVIII), preexisting Internet peer-support groups were used, in which any person using the Internet could participate. The main interest in these studies was in the contents of the peer discussions. These existing discussions were downloaded from the peer-support groups and the researcher did not influence the discussions or the participants. In seven of these studies, the data was collected with questionnaires from the users of the Internet-based peer-support groups (Table 2). 3.2.2. The topic of peer support in the studies that focused on mothers, fathers or both parents In the studies focused on mothers, general mother-tomother support was explored in five studies (VI, XIX, XXII, XXIV, XXV) and breastfeeding support in two studies (XVIII, XXI). In three studies, the Internet-based peer support was focused on young single mothers after childbirth (II, III, V), and in one study the peer support was targeted to the mothers of children with asthma (XXVI). In addition, peer support was provided during pregnancy (I, IV), after the death of a child or a foetus (XVII, XXIII) or for mothers who suffered postpartum depression (XX). Internet-based peer support for fathers was mainly provided for first-time fathers to enhance their experiences of fatherhood (VII, X, XXVII, XXVIII, XXIX). Two studies were more specific, focusing on the fathers of children with brain tumours (VIII) and the fathers of children with spina bifida (IV). When Internet-based peer support was available for both parents, it was examined during pregnancy (XII) and after childbirth (XIV, XXXVII). The other studies explored the issues of special circumstances in parenthood: that is, when a child was born prematurely (XXXV, XXXVIII) or a child had cancer (XI, XXXI, XXXII), diabetes (XIII), mental illness (XV), asthma (XVI), special health-care needs (XXX), autism (XXXIII), a neurological disorder (XXXIV), or clubfoot (XXXVI). 3.3. The outcomes of Internet-based peer-support interventions for parents 3.3.1. Emotional support, information and social community for mothers Internet-based peer support provided emotional support, information and a social community for mothers. Emotional support was provided most commonly, which included sharing feelings and experiences and expressing and displaying sympathy (II, III, VI, XVII, XVIII, XIX, XX, XXII, XXVI). Informational support was equally common; mothers sought and shared information and referred to their own experiences or different sources (III, IV, XVII, XVIII, XIX, XX, XXI, XXII, XXVI). Some mothers were very stressed because of their concerns related to

parenting and they needed information and advice immediately (XXV). Internet-based information was considered more up-to-date and more convenient than information from the health-care service (XXIV). Membership of a social community was an important part of the Internet-based peer-support group for mothers (I, III, XVII, XIX, XXI, XXII, XXIII, XXIV, XXVI). The basis of the composed community was the members having similar and concise interests. Geographical distance was not a problem in such an Internet community. Moreover, mothers experienced the feeling they were not alone in their situation (I, XXVI). In one ethnographic study (XXIII), the peer-support group was described as a real culture. Mother-to-mother support alleviated isolation within the composed community but also created a sense of normality (XXI) or normalised infants’ developmental and mothers’ parenting experiences (XXII, XXV). In general, mothers’ experiences regarding Internet-based peer support were very positive (I, V, VI). The only negative aspects were some problems related to technology, for example some sound problems in the real-time online meetings (VI). 3.3.2. Supported transition to fatherhood with humour and information For fathers, Internet-based peer support provided affirmation of their fatherhood (IX, X, XXVII, XXVIII, XXIX). The transition to fatherhood demanded resources from new fathers and they felt confused about their roles in the family and the meaning of fatherhood. First-time fathers were particularly insecure about how to balance family and work life (XXIX). In the Internet group, they gave and received mutual support (VII, VIII, IX, X, XXVII, XXVIII, XXIX). The use of humour was characteristic in the conversations between fathers, and was used to describe the reality of being a father (IX, XXVII, XXVIII). One important reason for fathers to participate in Internet-based peer-support groups was the need for information. Fathers shared their experiences and were relieved that they were not alone with their problems (VII, VIII, IX, X, XXVIII), and father-to-father support was encouraging and confirming (XXVII, XXVIII). Fathers also felt that they were forgotten and that the general belief was that ‘normal’ parent–infant interactions belonged more to mothers than fathers (XXIX). 3.3.3. Both parents exchanging information and being connected Internet-based peer support groups were ‘a gateway to other parents’ lives’ for both parents (XII) and provided mutual and emotional support (XI, XII, XV, XVI, XXXI, XXXII, XXXIV, XXXVIII) and encouragement (XXXIII, XXXV) for mothers and fathers. One study (XXXVII) showed high scores of perceived support from other parents in an Internet-based peer-support group. Generally, peer-support groups were used as a forum for knowledge, where parents provided and received information (XII, XV, XVI, XXXI, XXXII, XXXIV, XXXV, XXXVI, XXXVIII). In a grounded theory study (XXXIII), the core category was ‘making sense of autism’ which included many components from using humour to religious explanation. As one parent expressed, it

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was ‘extremely helpful to have others that completely understand what you’re dealing with’ (XXXIV). However, even if the peer support was targeted to both parents, mothers were more active users than fathers (XI, XIV, XV, XXX, XXXVI, XXXVII, XXXVIII). Parents of sick children reported improved coping (XXX) and found assurance from other parents that they were handling the situation with their children well (XVI). Parents of both healthy and sick children were usually very satisfied with these groups and enjoyed interacting with other parents in similar situations and liked being members of these groups (XI, XII, XIII, XIV, XV, XVI, XXX, XXXIV, XXXV). Importantly, the parents in the groups felt that they were not alone (XXXIV, XXXV). In one study (XXX), almost all of the respondents recommended peersupport groups and suggested that other parents of children with special health-care needs should participate in a group as soon as possible. Afterwards, having received peer support from others, some parents noticed that their experiences could enable them to be peer supporters for other parents (XIII, XVI). Some negative elements of Internet-based peer support were reported in three studies: a large volume of e-mail was mentioned (XXXII, XXXIV), as well as postings ‘off topic’ (XXXII) or repetition of topics (XXXIV). Some parents negatively experienced the lack of physical contact (XXXI, XXXII). Other disadvantages were the time taken, misinformation (XXXIV) and a lack of replies (XXXI). 3.3.4. The effectiveness of Internet-based peer support: parenting skills and mental well-being The evidence of the effectiveness of Internet-based peer support was limited and inconclusive. Only four studies had a quasi-experimental design that tested the effectiveness of the intervention: a repeated measures design with a control group was used in two of the studies (VII, XIV) and two studies had one-group pre and post measures (IX, XIII). In addition, two studies (III, VIII) had a pretest– posttest design as part of a mixed method. None of the studies had follow-up for long-term effects.

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Peer support was shown to have some effect on parenting skills. One study (VII) showed that in the intervention group, the fathers’ self-efficacy and parenting satisfaction after childbirth had improved between weeks four and eight. Notably, the baseline measurements were taken at four weeks after childbirth, and both scores were lower in fathers in the intervention group compared to the control-group fathers. The intervention was complex and included peer-support, a library of information and the possibility to e-mail an advanced practice nurse (VII). Maternal parenting stress scores did not change significantly during the intervention, which included peer discussion, e-mail messages and text-based teleconferencing. However, the mothers who more consistently participated in this Internet-based peer-support group reported reduced levels of parenting stress (III). Furthermore, in one quasi-experimental study no significant differences between the intervention and control groups were found in parenting self-efficacy and parenting satisfaction (XIV). Peer support was only a part of this intervention developed for the study parents; the intervention also included an information database and the possibility to ask a nurse or a midwife questions (Table 3). Peer-support also had some effects on the mental wellbeing of parents of sick children. Mothers’ depression and fathers’ anxiety and stress decreased after the peersupport intervention of a mailing list facilitated by three professionals (XI). The intervention was provided for parents whose children had completed cancer treatment in the previous five years. However, in this study the design and small sample size limited the generalisation of the results. In fathers of children with brain tumours, paternal coping was significantly more favourable at the post-intervention measure as compared with the pre-test, but no control group existed. This intervention included semi-structured peer discussions led by an experienced facilitator. No differences were found in the measures of social support or meaning of illness (VIII). Parental selfefficacy in diabetes management increased after online support intervention based on the theory of self-efficacy.

Table 3 Vote-counting of outcomes measured in quasi-experimental and pretest–posttest designs and the main limitations of the studies. Outcome Parenting skills

Mental well-being of parents of sick children

Effectiveness

Parenting stress Parenting satisfaction

+

Parenting self-efficacy

+

Coping Social support Meaning of illness Depression

+

+

Anxiety + Stress Self-efficacy for diabetes

+ +

Mothers/fathers

Study

Main limitations

Mothers Fathers Mothers Fathers Fathers Mothers Fathers Fathers Fathers Fathers Mothers Fathers Mothers Fathers Mothers Fathers Mothers and fathers

Dunham et al. (1998) Brage Hudson et al. (2003) Salonen et al. (2011)

No control group Convenience sample Lack of randomisation

Brage Hudson et al. (2003) Salonen et al. (2011)

Convenience sample Lack of randomisation

Nicholas et al. (2012)

No control group, small sample

Bragado´ttir (2008)

No control group, small sample

Merkel and Wright (2012)

No control group, small sample

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This study also did not have a control group and the sample size was small (XIII) (Table 3). 4. Discussion Internet-based peer groups and interventions have been conducted to support the transition into parenthood or coping during stressful events in parenthood. These interventions have been mainly aimed at mothers or both parents, with a few for fathers only. Mothers and fathers appreciated up-to-date informational support from their peers. Characteristic outcomes for mothers were emotional support and a membership in a virtual community; for fathers these were support for the transition to fatherhood with the help of humour and the feeling of shared experience. The evidence of the effectiveness of Internet-based peer support remained inconclusive due to the limited number of experimental designs. The variety and diversity of Internet-based peer support for parents was clear (Nieuwboer et al., 2013a): they can be synchronous or asynchronous or use real-time videoconference or an e-mail listserv, moderated or non-moderated, open to a wide population or targeted to a certain group. This kind of peer support was provided for parents of both healthy and sick children. The peer-support interventions or groups developed for research purposes were based on theories from sociology and psychology or previous literature. Therefore, the systematic development of an intervention based on nursing theory might emphasise a nursing perspective (e.g. Davidson et al., 2010), to incorporate the holistic approach to individuals found in nursing theory (MarrinerTomey and Alligood, 2006). The role of the peer-support group moderator (a nurse or a midwife) could be determined, for example, through Peplau’s interpersonal relations in nursing (Marriner-Tomey and Alligood, 2006). On the other hand, a layperson’s individual interest was the basis for pre-existing peer-support groups. Based on this review, parents appreciate both kinds of peer-support groups. However, evidence-based support is needed and complex interventions need to be developed systematically, based on appropriate theories and carefully tested (Craig et al., 2008). The sharing of information (Ritchie et al., 2000; Shilling et al., 2013), experiences and emotional support (Rossman, 2007) was strongly present in the Internet-based peer-support groups. Previously, Braithwaite et al. (1999) reported that informational support and emotional support were most commonly offered in computer-mediated groups for people with disabilities. Supporting the transition to parenthood and communality were also important functions of Internet-based peer support. Regardless of gender, the most important function of Internet-based peer support seemed to be informational support, or at least this was provided most often. Information was based on professional sources but also on other parents’ experiences. Parents appreciated the information received from their peers and considered this information to be more tailored to their needs than information provided by professionals. Indeed, peers are in similar positions and thus can perhaps relate to each other’s problems more

easily than professionals. Certainly, professionals have upto-date information, but the delivery of that information may come at the wrong time. In a review by Moorhead et al. (2013), social media provided available and tailored information about health issues. Notably, online discussions are associated with learning achievements at least as good as face-to-face discussions, and more active participation also improves achievement (Campbell et al., 2008). However, although peer support is a unique form of support, it cannot replace professional support (Mead and MacNeil, 2006). Thus, it is important to ensure that professional support is current and based on evidencebased practice, for example by including further education and development work on the basis of the best evidence available. A large proportion of the studied peer-support interventions were targeted at mothers which is consistent with an earlier study (Plantin and Daneback, 2009). Research in general has been concentrated on the maternal view during the transition to parenthood (Solmeyer and Feinberg, 2011). In addition, mothers were more active users of Internet-based peer support than fathers (Moorhead et al., 2013). Based on the review by Mo et al. (2009), Internet-based communication also seemed to be gendered. Women wrote more emotional and personal comments whereas men’s comments were more informative and practical, and typically employed the use of humour. However, computer-mediated communication might decrease some gender differences identified in face-to-face communication (Mo et al., 2009). It is not possible to conclude whether peer support is gendered until more research on fathers is conducted. Both parents enjoyed interacting with other parents and sharing their experiences of parenting, which is consistent with an earlier study result regarding telephone-based peer support (Ritchie et al., 2000). In the future, the challenge is to encourage more fathers to participate in peer-support groups, particularly because the father’s role can be significant, for example in a mother’s decision over the infant feeding method (Stremler and Lovera, 2004). Transition to fatherhood is seen as a passage rather than one event (Draper, 2003). The role of a father has changed significantly during the past few decades and fathers may have difficulties in finding their places in the family, providing both emotional and economic support. Fathers often struggle to reconcile their personal and new family needs (Genesoni and Tallandini, 2009). It would thus be important to ask fathers what kind of support groups they would be motivated to be involved in and what kind of affirmation they need in fatherhood. One important advantage of Internet-based peer support is its independence from the geographical distance between participants (also Moorhead et al., 2013) or from time limitations. Parents may need support at night, or the only possible time for them to read the discussions may be at night. In a study by Hja¨lmhult and Lomborg (2012) new mothers had very little support and information after childbirth and the importance of continuous support was emphasised. Moreover, for the parents of sick children these peer-support groups may be their first opportunity to talk to other parents in the same situation (Ritchie et al.,

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2000). In addition, social media provides an opportunity to develop a close network between other parents and friends without leaving the home (Bartholomew et al., 2012). In social media, it is also possible to participate anonymously with a pseudonym, which was appreciated in many of the studies in this review (also Plantin and Daneback, 2009). It is easier to discuss sensitive topics anonymously, but it may also enable more impulsive statements. However, this was not mentioned in the studies of this review and only a few studies reported negative effects of Internet-based peer support such as misinformation (also in Moorhead et al., 2013), the time taken, a large amount of e-mails, vapid messages or a lack of replies. Further problems such as minor technical problems were reported, which was consistent with a previous review (Eysenbach et al., 2004), and it has also been reported that the relationship between participants is asymmetrical (Embuldeniya et al., 2013). There is also a possibility of security and confidentiality problems when health information is shared online (Moorhead et al., 2013). The moderator of a peer-support group thus performs a key role in preventing malpractice and confirming the validity of information shared within the group. These are important issues to consider when developing a peer-support intervention, and additional research focusing on the positive and negative effects of a professional or layperson moderator is thus needed (Eysenbach et al., 2004; Coulson and Greenwood, 2012). Outcomes associated with parenting skills were mainly measured in parents of healthy children, whereas mental well-being was measured in parents of sick children. It is possible that parents of sick children are burdened because of the demanding care of their children (Fisher, 2001) and more attention is thus paid to their mental well-being. Unexpectedly, despite all the positive outcomes related to Internet-based peer support, its effectiveness could not been shown. One explanation might be insensitive outcome measures. Sometimes, a complex intervention may have effects in many domains and a single primary and a few secondary outcomes do not provide adequate evaluation (Craig et al., 2008). When exploring parenting or the transition to parenthood, the outcome measured is more difficult to determine than when aiming to increase breastfeeding rates (Kaunonen et al., 2012), for example, or decrease depression (Dennis et al., 2009). The other potential, and more probable, explanation might be the lack of randomised controlled studies in the area reviewed. It may be difficult to control for confounding variables in such complex phenomena as parenting and social media. In the future there is a need for high-quality research with experimental methodology (Moorhead et al., 2013). Such research requires a good theoretical understanding of the phenomenon and expertise in developing and evaluating complex interventions (Craig et al., 2008). It has been recommended that different designs should be combined when evaluating the effects of complex interventions (Craig et al., 2008), such as Internet-based interventions with other aspects of support (also Eysenbach et al., 2004). It has also been suggested that adaptation to local settings prefers strict standardisation when implementing complex interventions (Craig et al., 2008). A qualitative

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approach might provide a fresh insight into peer support from the users’ perspective. Both quantitative and qualitative methods are essential for evidence-based nursing (DiCenco et al., 2005). In addition, in each study included in this review, the outcomes measured and the participants were different. In this review, the complex interventions were not more effective than exclusive peersupport interventions. Longer follow-up would have enabled the potential longitudinal effects on the parents to be detected (Craig et al., 2008). The cost-effectiveness of Internet-based peer support for parents should also be determined. Further research about fathers and the gender roles of Internet-based peer support would be necessary. To summarise, social media may be a worthy tool for health promotion (Moorhead et al., 2013; Norman, 2012). Shilling et al. (2013) found in their review that if parents feel pressured by professionals to join peer-support groups, they might feel less satisfied with the support. However, this may be different in the case of Internet-based peer support, when virtual attendance is possible. Not all parents of children with chronic illness considered peer-support to be helpful (Shilling et al., 2013). Thus, Internet-based peer support cannot replace face-to-face support, but it can be a supplemental resource for mothers and fathers in either normal or special situations in parenting. Moreover, social media may provide a channel for health communication at relatively low cost (Moorhead et al., 2013). 4.1. Strengths and limitations The strengths and limitations of this review are discussed based on Whittemore’s (2005) criteria for quality in reviews. First, the study problem was justified and the review method was identified at an early stage because we searched for studies with diverse methodologies. From the beginning, we had two researchers independently screening possible studies based on inclusion and exclusion criteria. All the researchers have worked with parents and families in hospitals or in public health-care settings, and thus can be described as professionals when concerning parental support. The literature search was comprehensive; however, the number of search terms related to the Internet is high. It is thus possible that there are some limitations concerning our search terms and, consequently, only screening titles in the first phase resulted in some relevant articles not being found. We decided to exclude non-published dissertations, so only published studies are included. That might enhance the quality of the data, but then, it is possible that some relevant studies were missed. Including only articles written in English may also be seen as a limitation. The decision to combine the different interventions into one review could also be questioned. However, a broad view of Internet-based peer support between parents was reached. Furthermore, the results of this review highlight the need for additional research into this phenomenon. 5. Conclusions Internet-based peer support provided informational support for both parents, despite geographic distance or

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time constraints. Mothers mostly gained emotional support and fathers found affirmation of their fatherhood. Both parents appreciated being a member of a group with other parents in similar situations, but mothers were more active users of Internet-based peer support than fathers. These above-mentioned elements seemed to be key factors in Internet-based peer support for parents. Internet-based peer support seemed to have some effects on parenting skills and parents’ mental well-being, but the evidence for this was limited. There was a distinction between the parents of healthy and the parents of sick children; parenting skills being focused on the first and mental well-being in the latter group. Internet-based peer support for parents is an increasing phenomenon that provides a unique form of support supplementing other methods of social and emotional support and it should be further developed and tested through research. More experimental studies, with a rigorous design, on the effectiveness of Internet-based peer support are needed. Conflict of interest. The authors declare no conflicts of interest. Funding. Finnish National Doctoral Educational Network in Nursing Science provided the opportunity to conduct this review. References1 *Adler, C.L., Zarchin, R., 2002. The ‘‘virtual focus group’’: using the Internet to reach pregnant women on home bed rest. J. Obstet. Gynecol. Neonatal Nurs. 31 (4), 418–427. Ahmed, A.H., Sands, L.P., 2010. Effect of pre- and postdischarge interventions on breastfeeding outcomes and weight gain among premature infants. J. Obstet. Gynecol. Neonatal Nurs. 39 (1), 53–63. *Aho, A.L., Paavilainen, E., Kaunonen, M., 2012. Mothers’ experiences of peer support via an Internet discussion forum after the death of a child Finland. Scand. J. Caring Sci. 26 (3), 417–426. Bartholomew, M.K., Schoppe-Sullivan, S.J., Glassman, M., Kamp Dush, C.M., 2012. New parents’ Facebook use at the transition to parenthood. Interdiscip. J. Appl. Fam. Stud. 61 (3), 455–469. *Baum, L.S., 2004. Internet parent support groups for primary caregivers of a child with special health care needs. Pediatr. Nurs. 30 (5), 381–401. *Bragado´ttir, H., 2008. Computer-mediated support group intervention for parents. J. Nurs. Scholarsh. 40 (1), 32–38. *Brage Hudson, D., Campbell-Grossman, C., Fleck, M.O., Elek, S.M., Shipman, A., 2003. Effects of the New Fathers Network on first-time fathers’ parenting self-efficacy and parenting satisfaction during the transition to parenthood. Issues Compr. Pediatr. Nurs. 26 (4), 217–229. *Brage Hudson, D., Campbell-Grossman, C., Keating-Lefler, R., Carraher, S., Gehle, J., Heusinkvelt, S., 2009. Online support for single, low-income, African American mothers. Am. J. Matern./Child Nurs. 34 (6), 350–355. Braithwaite, D.O., Waldron, V.R., Finn, J., 1999. Communication of social support in computer-mediated groups for people with disabilities. Health Commun. 11 (2), 123–151. Campbell, M., Gibson, W., Hall, A., Richards, D., Callery, P., 2008. Online vs. face-to-face discussion in a web-based research methods course for postgraduate nursing students: a quasi-experimental study. Int. J. Nurs. Stud. 45 (5), 750–759. Cohen, S., Wills, T.A., 1985. Stress, social support, and the buffering hypothesis. Psychol. Bull. 98 (2), 310–357. *Coulson, N.S., Greenwood, N., 2012. Families affected by childhood cancer: an analysis of the provision of social support within online support groups. Child Care Health Dev. 38 (6), 870–877. *Cowie, G.A., Hill, S., Robinson, P., 2011. Using an online service for breastfeeding support: what mothers want to discuss. Health Promot. J. Austr. 22 (2), 113–118.

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