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doi:10.1111/jpc.12511
ORIGINAL ARTICLE
Paediatricians’ perceptions of a potential online psychosocial intervention for children with recurrent abdominal pain Mercè Boixadós,1 Eulàlia Hernández Encuentra,1 Ruben Nieto Luna,1 Anna Huguet2 and Eva Aumatell1 1
PSiNET Research Group, Internet Interdisciplinary Institute, Open University of Catalonia, Barcelona, Spain and 2IWK Health Centre, Halifax, Nova Scotia, Canada
Aims: To evaluate paediatricians’ perceived effectiveness of an online psychosocial intervention for children with recurrent abdominal pain (RAP). Also, to explore which elements of this intervention they would consider necessary when applied in the clinical context. Methods: A total of 131 paediatricians affiliated to Catalan and Balearic paediatric societies completed an online survey about how effective they would perceive an online psychosocial intervention for RAP (for reducing pain intensity, reducing disability and preventing chronicity) and how this intervention should be carried out. They were asked about the perceived effectiveness of the standard medical treatments they routinely applied for RAP and also their opinion of face-to-face psychosocial interventions. Results: A face-to face psychosocial intervention was considered better (to reduce pain intensity, reduce disability and prevent chronic pain) than an online psychological intervention and the standard medical treatment. Online and face-to-face psychosocial interventions are considered equally useful for children with mild disability, but a face-to-face psychosocial intervention is considered better for those with moderate and severe levels of disability. Paediatricians considered that an online psychosocial intervention for children with RAP should be simple and consistent; it should provide easy access for users; and its interface should be easy to use and attractive. Conclusions: Paediatricians show a positive attitude towards a potential online psychosocial intervention for children and adolescents with RAP. However, they do not use the Internet for offering health care, and they would prefer a face-to-face psychosocial intervention. Key words:
children; online psychosocial intervention; paediatricians’ perception; recurrent abdominal pain.
What is already known on this topic
What this paper adds
1 Recurrent abdominal pain (RAP) is a common problem in children and affects their daily lives. 2 Psychosocial interventions are effective for the treatment of children with chronic or recurrent pain when compared with standard medical care. 3 The use of technology to deliver these types of treatments may increase their efficiency.
1 Paediatricians have a positive attitude towards using online psychosocial interventions for RAP. 2 Face-to-face interventions for children with RAP are preferred to those delivered online. 3 Ease of use, attractive design and quality of contents are characteristics that online interventions should have in order to be applied in a clinical context.
Recurrent abdominal pain (RAP), usually defined as at least three episodes of abdominal pain severe enough to interfere in a child’s functioning over at least 3 months and without an identifiable cause,1 is considered one of the most frequent pain problems in children.2 The prevalence of RAP varies widely according to different studies. This is may be due to the difficulties associated with diagnosis criteria or with the identification of symptoms that prevent parents from seeking medical attention in the early
Correspondence: Mercè Boixadós, Psychology and Sciences Education, Universitat Oberta de Catalunya, Rambla del Poblenou 156, 08018 Barcelona, Catalunya, Spain. Fax: +34 933 568 822; email: [email protected] Conflict of interest: The authors declare that they have no conflicts of interest concerning this article. Accepted for publication 30 November 2013.
phases of the problem.3,4 RAP frequently appears together with other pain disorders5 and mental health problems (e.g. anxiety and depression),6,7 and parental care givers seem to play an important role in its occurrence and continuation.6,8,9 Moreover, RAP often persists over years10 and it is associated with other pain problems and psychological disorders in later life.11 Because of the prevalence of RAP and the impact on the individual and their family, professionals need to design effective interventions to improve management of the disease and lessen its future consequences.12–14 Psychosocial interventions, based on the cognitive behavioural model, have proven effective for children with RAP15–17 (e.g. reducing pain intensity,18–20 medication consumption18 and contact with the physicians20); however, paediatricians do not prescribe them to children suffering the most severe conditions.21 Information and communication technologies (ICT) bring to health care unequalled opportunities to improve its quality,
Journal of Paediatrics and Child Health 50 (2014) 449–454 © 2014 The Authors Journal of Paediatrics and Child Health © 2014 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
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accessibility and scope of influence, thus resulting in a greater involvement of patients in their own health care.22,23 In this line, some studies suggest the potential of ICT for treating pain problems,24,25 but the evidence is still scarce. This is especially true for children,24 for whom there has only been one online intervention tested in which children with RAP have been included.26 Online interventions can play a complementary role to the standard medical treatments, especially for paediatricians that might feel they have little to offer children with persisting RAP.27 Within a translational framework,28 exploring perceptions is a first step to developing a new intervention and increasing the probability of it being applied. Health professionals’ perceptions about adopting ICT in clinical practice have been described in the literature. The barriers to adoption are related to technical difficulties, familiarity with ICT, confidentiality, and lack of time and reimbursement;29–31 on the other hand, perception of benefits and ease of use seem to be the major facilitators.29 The purpose of the present study is to explore professionals’ perceptions of the effectiveness of a potential online psychosocial intervention addressed to children with RAP and compare it with the current standard medical care and face-to-face psychosocial interventions. In particular, we are interested in exploring perceptions of usefulness and the elements that paediatricians consider this intervention needs in order to be applied in the clinical context. We expect to obtain a positive perception of a potential online psychosocial intervention for RAP but because of the lack of tradition of ICT use in clinical practice in our country,32 we expect that face-to-face interventions will be better valued.
Methods A mixed-method concurrent study design was employed, combining qualitative and quantitative data with equal status33 to obtain complementary information obtained by both strategies (QUAN + QUAL).
Participants A total of 131 paediatricians (128 affiliated to the Catalan and 3 to the Balearic Societies of Paediatrics) participated in the study. A total of 70.2% of them were males, and the mean age was 47.74 years (standard deviation = 11.30). Almost two thirds (62%) worked in primary care services, and 76.3% had more than 10 years’ experience. The patterns of Internet use are in accordance with samples of physicians in Europe30 and in our country.31 Thus, although the majority was daily users of the Internet (90%), they do not mainly use it for clinical practice, but instead for searching for information and contacting colleagues (61.83% and 14.50%, respectively). In relation to their contact with children with RAP, 79.4% had contact with less than 10 children with RAP per month, 14.5% between 10 and 20, and the rest (6.2%) more than 20. Of the children they treated, most of them were considered as having a mild (67.9%) or moderate level of disability (29.8%) and very few a severe level of disability (2.3%). 450
Measures An ad hoc online survey was designed. The survey encompassed 33 items, combining open- and closed-ended questions, grouped into 6 areas related with RAP treatments: 1) socio-demographic and basic professional data; 2) perception of the standard treatments; 3) perception of face-to-face psychosocial interventions; 4) perception of an online psychosocial intervention; 5) paediatricians’ knowledge of and most frequent uses of ICT; and 6) elements that should be included in an online psychosocial intervention for children with RAP. Specifically, for areas 2, 3 and 4, they were asked for three different ratings of perceived effectiveness (for reducing pain intensity, reduce disability and preventing chronic pain) on an 11-point scale. Moreover, for areas 3 and 4, they were also asked to rate the perceived utility (using the same scale) depending on the level of severity of the child’s RAP (mild, moderate and severe disability) and their willingness to recommend an intervention with these characteristics to children with RAP. Additionally, for areas 4, 5 and 6, they were asked in an open format about what kind of children would be most suitable for online psychosocial interventions, characteristics that paediatricians think an online intervention should have, and the advantages and disadvantages of such interventions.
Procedure Paediatricians from the Catalan and the Balearic Societies of Paediatricians were invited to participate. For the first group, the society contacted them, sending two personal emails. For the second group, an advertisement with information about our study was posted on the society’s website. Access to the online survey was open for 4 weeks. Taking into account the members in each society (1272 in the Catalan and 291 in the Balearic), a response rate of 8.3% can be estimated. Participants were informed about the study and asked for their consent. The Research Ethics Board of the Universitat Oberta de Catalunya approved the study.
Data analysis For the quantitative analysis of paediatricians’ perceptions of the effectiveness of an online psychosocial intervention for children with RAP, we carried out a univariate factorial analysis of variance (ANOVA) of repeated measures. We checked for assumptions of sphericity (Mauchly test) and applied the corrections needed in the absence of homogeneity. As part of the qualitative analysis, an inductive content analysis34 was conducted in several stages using data from the openended questionnaire. Through open coding, two researchers (authors MB and RNL) reviewed the written responses, making notes and headings in the text, after which we transcribed the notes and headings onto a coding sheet. After this open coding, we grouped the data and reduced the number of categories by combining similar headings into broader categories. After the categories were defined, the two researchers independently classified the qualitative data into these categories. Any disagreements were debated until agreement was reached. Finally, we calculated the Cohen’s kappa coefficient, and the intercoder agreement was between 80% and 90% for all the categorisations performed.
Journal of Paediatrics and Child Health 50 (2014) 449–454 © 2014 The Authors Journal of Paediatrics and Child Health © 2014 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
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Table 1
Paediatricians’ perception about online
Perceived effects of interventions on different outcomes Standard medical (I1)
Psychosocial intervention (I2)
Online psychosocial intervention (I3)
Pairs comparisons (CI 95% of dif)
Pain intensity
5.04 (2.08)
6.70 (1.72)
5.94 (1.96)
Disability
5.21 (2.89)
6.96 (1.63)
5.99 (1.87)
Prevention
4.20 (2.47)
7.06 (1.76)
5.93 (1.93)
I1 < I2** (−2.12 ÷ −1.19) I2 > I3** (0.35 ÷ 1.17) I1 < I3** (−1.46 ÷ −0.33) I1 < I2** (−2.26 ÷ −1.23) I2 > I3** (0.58 ÷ 1.35) I1 < I3* (−1.37 ÷ −0.19) I1 < I2** (−3.43 ÷ −2.84) I2 > I3** (0.72 ÷ 1.54) I1 < I3**(−2.37 ÷ −1.09)
Mean (SD); pairs comparisons results; *significance degree P < 0.05; **significance degree P < 0.001; confidence interval (CI 95%) of the difference. Number of paediatricians’ treatment, psychosocial intervention and online psychosocial intervention = 114.
Fig. 1
Means of perceived effects of interventions on different outcomes.
Results Quantitative analyses: perceptions of the effectiveness of an online psychosocial intervention Descriptive data showed that an online psychosocial intervention was perceived above the middle range as to be effective for reducing pain intensity, reducing disability and preventing chronic pain. Psychosocial interventions (face to face) received a slightly better assessment, whereas the standard medical care received a slightly worse one (see Table 1 and Figure 1 for specific data). ANOVAs (3 × 3) confirmed that paediatricians attributed different effectiveness for the three variables that we asked for (i.e. pain intensity: F = 34.63, degrees of freedom (df) = 1, 113, P < 0.001; disability: F = 35.67, df = 1, 113, P < 0.001; chronic pain: F = 80.34, df = 1, 113, P < 0.001). A detailed examination of pairs’ comparison showed that psychosocial face-to-face interventions were perceived as significantly more effective than online psychosocial interventions and the standard medical care for helping children with RAP to reduce pain
intensity, reduce disability and prevent chronicity. They also perceived online psychosocial interventions to be more effective than the standard medical treatments for all three outcomes. An ANOVA of repeated measures (2 × 3) was performed to compare the perceived effectiveness of face-to-face and online psychosocial interventions according to three different levels of disability. Table 2 and Figure 2 show a significant interaction effect between the two factors (F = 4.28, df = 1, 113, P < 0.001) Specifically, when exploring the interaction, we found that an online psychosocial intervention was perceived to be less effective than a face-to-face psychosocial intervention for children with a moderate or severe level of disability. However, there were not significant differences for children with a mild level of disability. When we examine each modality of intervention separately, the results show that online psychosocial interventions were perceived to be significantly less effective for children with severe disability than for children with moderate or mild levels of disability; face-to-face psychosocial interventions were perceived to be significantly less effective for children with severe disability compared with those with a moderate level of disability.
Qualitative analyses: characteristics and advantages and disadvantages of recommending an online psychosocial intervention We summarise the main results of the qualitative analyses performed. Taking into account the categories with a percentage above 10% (based on the total responses for each question), an online psychosocial intervention would be more recommended to children with problems in their family functioning (21%) such as ‘inadequate family environment, relationship problems with parents’; with some specific personality characteristics (21%) such as ‘shyness, intelligence, self-critical’; with specific illness features (15%) such as ‘absence of organic cause’; and to those presenting a psychological disorder or distress (14%) such as ‘anxiety, low self-esteem’. Regarding the characteristics that an online psychosocial intervention should have in order to be implemented in a clinical context, paediatricians most frequently suggested that it
Journal of Paediatrics and Child Health 50 (2014) 449–454 © 2014 The Authors Journal of Paediatrics and Child Health © 2014 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
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Table 2 Perceived effects of interventions depending on level of disability
Mild (D1) Moderate (D2) Severe (D3) Pairs comparisons (CI 95% of dif of D)
Psychosocial intervention (I1)
Online psychosocial intervention (I2)
Pairs comparisons (CI 95% of dif of I)
6.62 (2.12) 6.88 (1.52) 6.35 (2.43) D1 = D2 (−0.66 ÷ 0.16) D2 > D3**(0.13 ÷ 0.93) D1 = D3 (−0.43 ÷ 0.97)
6.28 (2.09) 6.13 (1.92) 5.46 (2.17) D1 = D2 (−0.14 ÷ 0.44) D2 > D3**(0.32 ÷ 1.01) D1 > D3*(0.29 ÷ 1.34)
I1 = I2 (−0.29 ÷ 0.71) I1 > I2**(0.43 ÷ 1.06) I1 > I2**(0.53 ÷ 1.24)
Mean (SD); pairs comparisons results; *significance degree P < 0.05; **significance degree P < 0.001; confidence interval (CI 95%) of the difference. n = 114. D, disability; I, intervention.
Fig. 2 Means of perceived effects of interventions depending on level of disability.
should have an easy and attractive design (35%) such as a ‘friendly interface’ and present clear and coherent contents (10.30%) such as being ‘easy to understand’. Finally, the main potential advantages of an online psychosocial intervention were being accessible and comfortable (29.8%) such as ‘better accessibility by the child and family’ and cheap, reduced costs of consultations category (13.3%) such as ‘no waiting list’. On the other hand, the main disadvantages were related especially to depersonalised, lack of personal relationships and verbal communication (24.4%) such as ‘face-to face contact in psychological issues can be very relevant’; neglect, difficulty to control and monitor (18.7%) such as ‘excessive uncontrolled information’; difficulties with access and with the use of ICT (13.4%) such as ‘parents’ lack of resources’; and distrust (11.5%) such as ‘lack of confidence with technology’.
Discussion The integrated findings highlighted that paediatricians perceived a potential online psychosocial intervention for children with RAP as moderately favourable, and they rated it better 452
than the treatment they currently offer. However, a face-to-face psychosocial intervention was considered more effective than a potential online psychosocial intervention, especially for children with moderate or severe level of disability. In general terms, results are congruent with our hypothesis and the available literature showing that psychosocial interventions are effective for children with RAP.15–17 Interestingly, our results showed that the characteristics of the children modulate paediatricians’ perceptions about a potential online psychosocial intervention for RAP. First, as commented above, an online intervention was considered equally effective as a face-toface intervention for those with a mild level of disability. This might be related to their current experience as primary care professionals, as they see only a few children with RAP each month, the majority of them with mild or moderate severity of the disease. The literature does not provide enough evidence to support these results, as previous studies lack segmentation of the severity of pain, and there are no data for online interventions in severe conditions.24,26 Therefore, this is an area deserving future research. Second, besides severity of disease, paediatricians would modulate the prescription of online psychosocial interventions for RAP according to family functioning, some personality characteristics (e.g. shyness or intelligence), specific characteristics related to RAP (e.g. high pain intensity) and the presence of psychological disorders (e.g. anxiety, low self-esteem) or distress. This is supported by the literature, according to which gastro symptoms are not the best predictors for RAP development and management.35 Moreover, regarding paediatric pain problems, socio-demographic factors,2 parental roles6,8,36 and individual variables16,20,30 would help to delineate the most appropriate situations to prescribe a specific intervention. Besides effectiveness, paediatricians highlighted increasing access and reducing health-care costs of online psychosocial interventions for RAP as the most important advantages with respect to face-to-face interventions. However, our sample did not highlight advantages related to the impact on children’s health and well-being, as previous studies suggested regarding online interventions with a wider scope (i.e. in accordance with patients’ wishes;37 ease of chronic disease management38 and beliefs about control providing better psychological well-being, physical functioning and experiencing fewer pain behaviours25,38). More information is needed regarding this aspect.
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From qualitative findings, the most frequent disadvantages regarding online psychosocial interventions for RAP are related to depersonalisation, a lack of personal relationships and verbal communication, difficulties in monitoring the intervention, and difficulties in access, use and distrust of ICT. We can hypothesise that this wide scope of issues reflects hidden concerns about online interventions that may be previously unknown by the participants. Paediatricians in our sample are mostly primary care professionals and, according to our data and to previous literature, the use of ICT for professional purposes is less frequent among professionals involved at this level of care.24,32 Also, even though the literature describes these interventions as being a potential support for the continuity of care and a tool to engage and empower children and their families in the management of pain,31 these concerns may reflect the lack of coherence between paediatricians’ personal use of ICT and their current medical practices.29 Existing studies with samples of paediatricians and other health professionals have highlighted additional disadvantages of online versus face-to-face interventions,29–32 most of them are related to technical difficulties and familiarity with ICT. Altogether, this means that although being effective, the use and prescription of online treatments require previous training of professionals, and it cannot be recommended in all contexts. Actually, according to our results, the most appealing elements that an online psychosocial intervention for RAP should have are an easy and attractive design, and clear and coherent contents. To date, together with effectiveness, ease of use has been identified by health professionals as the main reason for adopting new interventions (in relation to the Theory of Planned Behavior39) and for technology adoption (in relation to the Model of Technology Acceptance29,40). Consequently, developers of online interventions should also direct their efforts towards greater usability and enhanced design.
Conclusions Paediatricians treating children with RAP would be willing to use online psychosocial interventions if certain specific characteristics are taken into account in their design. Within the framework of translational research, studies such as this one have to be carried out prior to developing any intervention. This would enhance the flow along the continuum from basic issues, such as perceptions and attitudes, to clinical practice, and thus contribute to the effective application of online psychosocial interventions. Future research should test a real online psychosocial intervention for children with RAP and examine paediatricians’ perceptions about this specific intervention. Our study is somewhat limited by sample size and a selfselection bias. Together with replicating these findings with a larger sample, it would be interesting to include other professionals that also are in contact with children with RAP (e.g. psychologists or nurses).
Acknowledgements This work has been funded with a grant from the Fundació La Caixa (Recercaixa2012). PSINET is a research group recognised and supported by the Catalan Government (SGR09–197).
Paediatricians’ perception about online
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21 Lynch ME, Campbell F, Clark AJ et al. A systematic review of the effect of waiting for treatment for chronic pain. Pain 2008; 136: 97–116. 22 Cushing CC, Steele RG. Meta-analytic review of eHealth interventions for pediatric health promoting and maintaining behaviors. J. Pediatr. Psychol. 2010; 35: 937–49. 23 Cuijpers P, van Strate A, Andersson G. Internet-administered cognitive behaviour therapy for health problems: a systematic review. J. Behav. Med. 2008; 31: 169–77. 24 Velleman S, Stallard P, Richardson T. A review and meta-analysis of computerized cognitive behaviour therapy for the treatment of pain in children and adolescents. Child Care Health Dev. 2010; 36: 465–72. 25 Bender JL, Radhakrishnan A, Diorio C, Englesakis M, Jadad AR. Can pain be managed through the Internet? A systematic review of randomized controlled trials. Pain 2011; 152: 1740–50. 26 Hicks CL, von Baeuer CL, McGrath PJ. Online psychological treatment for pediatric recurrent pain: a randomized evaluation. J. Pediatr. Psychol. 2006; 31: 724–36. 27 Gieteling MJ, Lisman-Van Leeuwen Y, Passchier J, Koes BW, Berger MY. The course of mental health problems in children presenting with abdominal pain in general practice. Scand. J. Prim. Health Care 2012; 30: 114–20. 28 Drolet BC, Lorenzi NM. Translational research: understanding the continuum from bench to bedside. Transl. Res. 2011; 157: 1–5. 29 Gagnon MP, Desmartis M, Labrecque M et al. Systematic review of factors influencing the adoption of Information and communication technologies by healthcare professionals. J. Med. Syst. 2012; 36: 241–77. 30 Ortega JM, Román MV, Recio M. eHealth usage patterns of European general practitioners: a five-year (2002–2007) comparative study. Int. J. Health Inform 2010; 79: 539–53.
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31 Romano M, Gesualdo F, Pandolfi E, Tozzi AE, Ugazio AG. Use of the internet by Italian pediatricians: habits, impact on clinical practice and expectations. BMC Med. Inform. Decis. Mak. 2012; 12: 23. 32 Castells M, Lupiáñez F, Saigí F, Sánchez J. E-health and society: an empirical study of Catalonia. Barcelona: Universitat Oberta de Catalunya, 2008. 33 Johnson RB, Onwuegbuzie AJ. Mixed methods research: a research paradigm whose time has come. Educ. Res. 2004; 33: 14–26. 34 Elo S, Kyngäs H. The qualitative content analysis process. J. Adv. Nurs. 2008; 62: 107–15. doi: 10.1111/j.1365–2648.2007.04569.x. 35 Dengler-Crish CM, Horst SN, Walker LS. Somatic complaints in childhood functional abdominal pain are associated with functional gastrointestinal disorders in adolescence and adulthood. J. Pediatr. Gastroenterol. Nutr. 2011; 52: 162–5. 36 Walker LS, Williams SE, Smith CA, Garber J, Van-GSlyke DA, Lipani TA. Parent attention versus distraction: impact on symptom complaints by children with a without chronic functional abdominal pain. Pain 2006; 122: 43–52. 37 Patt MR, Houston TK, Jenckes MW, Sands DZ, Ford DE. Doctors who are using e-mail with their patients: a qualitative exploration. J. Med. Internet Res. 2003; 5: e9. 38 Slakey DP, Nowfar S. Factors affecting patient-physician communication via the Internet. J. Healthc. Inf. Manag. 2004; 18: 81–5. 39 Ajzen I. Theory of planned behavior. Organ. Behav. Hum. Decis. Process. 1991; 50: 179–211. 40 Davis FD. Perceived usefulness, perceived ease of use, and user acceptance of information technology. MIS Quarterly 1989; 13: 319–40.
Journal of Paediatrics and Child Health 50 (2014) 449–454 © 2014 The Authors Journal of Paediatrics and Child Health © 2014 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
doi:10.1111/jpc.12511
ORIGINAL ARTICLE
Paediatricians’ perceptions of a potential online psychosocial intervention for children with recurrent abdominal pain Mercè Boixadós,1 Eulàlia Hernández Encuentra,1 Ruben Nieto Luna,1 Anna Huguet2 and Eva Aumatell1 1
PSiNET Research Group, Internet Interdisciplinary Institute, Open University of Catalonia, Barcelona, Spain and 2IWK Health Centre, Halifax, Nova Scotia, Canada
Aims: To evaluate paediatricians’ perceived effectiveness of an online psychosocial intervention for children with recurrent abdominal pain (RAP). Also, to explore which elements of this intervention they would consider necessary when applied in the clinical context. Methods: A total of 131 paediatricians affiliated to Catalan and Balearic paediatric societies completed an online survey about how effective they would perceive an online psychosocial intervention for RAP (for reducing pain intensity, reducing disability and preventing chronicity) and how this intervention should be carried out. They were asked about the perceived effectiveness of the standard medical treatments they routinely applied for RAP and also their opinion of face-to-face psychosocial interventions. Results: A face-to face psychosocial intervention was considered better (to reduce pain intensity, reduce disability and prevent chronic pain) than an online psychological intervention and the standard medical treatment. Online and face-to-face psychosocial interventions are considered equally useful for children with mild disability, but a face-to-face psychosocial intervention is considered better for those with moderate and severe levels of disability. Paediatricians considered that an online psychosocial intervention for children with RAP should be simple and consistent; it should provide easy access for users; and its interface should be easy to use and attractive. Conclusions: Paediatricians show a positive attitude towards a potential online psychosocial intervention for children and adolescents with RAP. However, they do not use the Internet for offering health care, and they would prefer a face-to-face psychosocial intervention. Key words:
children; online psychosocial intervention; paediatricians’ perception; recurrent abdominal pain.
What is already known on this topic
What this paper adds
1 Recurrent abdominal pain (RAP) is a common problem in children and affects their daily lives. 2 Psychosocial interventions are effective for the treatment of children with chronic or recurrent pain when compared with standard medical care. 3 The use of technology to deliver these types of treatments may increase their efficiency.
1 Paediatricians have a positive attitude towards using online psychosocial interventions for RAP. 2 Face-to-face interventions for children with RAP are preferred to those delivered online. 3 Ease of use, attractive design and quality of contents are characteristics that online interventions should have in order to be applied in a clinical context.
Recurrent abdominal pain (RAP), usually defined as at least three episodes of abdominal pain severe enough to interfere in a child’s functioning over at least 3 months and without an identifiable cause,1 is considered one of the most frequent pain problems in children.2 The prevalence of RAP varies widely according to different studies. This is may be due to the difficulties associated with diagnosis criteria or with the identification of symptoms that prevent parents from seeking medical attention in the early
Correspondence: Mercè Boixadós, Psychology and Sciences Education, Universitat Oberta de Catalunya, Rambla del Poblenou 156, 08018 Barcelona, Catalunya, Spain. Fax: +34 933 568 822; email: [email protected] Conflict of interest: The authors declare that they have no conflicts of interest concerning this article. Accepted for publication 30 November 2013.
phases of the problem.3,4 RAP frequently appears together with other pain disorders5 and mental health problems (e.g. anxiety and depression),6,7 and parental care givers seem to play an important role in its occurrence and continuation.6,8,9 Moreover, RAP often persists over years10 and it is associated with other pain problems and psychological disorders in later life.11 Because of the prevalence of RAP and the impact on the individual and their family, professionals need to design effective interventions to improve management of the disease and lessen its future consequences.12–14 Psychosocial interventions, based on the cognitive behavioural model, have proven effective for children with RAP15–17 (e.g. reducing pain intensity,18–20 medication consumption18 and contact with the physicians20); however, paediatricians do not prescribe them to children suffering the most severe conditions.21 Information and communication technologies (ICT) bring to health care unequalled opportunities to improve its quality,
Journal of Paediatrics and Child Health 50 (2014) 449–454 © 2014 The Authors Journal of Paediatrics and Child Health © 2014 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
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accessibility and scope of influence, thus resulting in a greater involvement of patients in their own health care.22,23 In this line, some studies suggest the potential of ICT for treating pain problems,24,25 but the evidence is still scarce. This is especially true for children,24 for whom there has only been one online intervention tested in which children with RAP have been included.26 Online interventions can play a complementary role to the standard medical treatments, especially for paediatricians that might feel they have little to offer children with persisting RAP.27 Within a translational framework,28 exploring perceptions is a first step to developing a new intervention and increasing the probability of it being applied. Health professionals’ perceptions about adopting ICT in clinical practice have been described in the literature. The barriers to adoption are related to technical difficulties, familiarity with ICT, confidentiality, and lack of time and reimbursement;29–31 on the other hand, perception of benefits and ease of use seem to be the major facilitators.29 The purpose of the present study is to explore professionals’ perceptions of the effectiveness of a potential online psychosocial intervention addressed to children with RAP and compare it with the current standard medical care and face-to-face psychosocial interventions. In particular, we are interested in exploring perceptions of usefulness and the elements that paediatricians consider this intervention needs in order to be applied in the clinical context. We expect to obtain a positive perception of a potential online psychosocial intervention for RAP but because of the lack of tradition of ICT use in clinical practice in our country,32 we expect that face-to-face interventions will be better valued.
Methods A mixed-method concurrent study design was employed, combining qualitative and quantitative data with equal status33 to obtain complementary information obtained by both strategies (QUAN + QUAL).
Participants A total of 131 paediatricians (128 affiliated to the Catalan and 3 to the Balearic Societies of Paediatrics) participated in the study. A total of 70.2% of them were males, and the mean age was 47.74 years (standard deviation = 11.30). Almost two thirds (62%) worked in primary care services, and 76.3% had more than 10 years’ experience. The patterns of Internet use are in accordance with samples of physicians in Europe30 and in our country.31 Thus, although the majority was daily users of the Internet (90%), they do not mainly use it for clinical practice, but instead for searching for information and contacting colleagues (61.83% and 14.50%, respectively). In relation to their contact with children with RAP, 79.4% had contact with less than 10 children with RAP per month, 14.5% between 10 and 20, and the rest (6.2%) more than 20. Of the children they treated, most of them were considered as having a mild (67.9%) or moderate level of disability (29.8%) and very few a severe level of disability (2.3%). 450
Measures An ad hoc online survey was designed. The survey encompassed 33 items, combining open- and closed-ended questions, grouped into 6 areas related with RAP treatments: 1) socio-demographic and basic professional data; 2) perception of the standard treatments; 3) perception of face-to-face psychosocial interventions; 4) perception of an online psychosocial intervention; 5) paediatricians’ knowledge of and most frequent uses of ICT; and 6) elements that should be included in an online psychosocial intervention for children with RAP. Specifically, for areas 2, 3 and 4, they were asked for three different ratings of perceived effectiveness (for reducing pain intensity, reduce disability and preventing chronic pain) on an 11-point scale. Moreover, for areas 3 and 4, they were also asked to rate the perceived utility (using the same scale) depending on the level of severity of the child’s RAP (mild, moderate and severe disability) and their willingness to recommend an intervention with these characteristics to children with RAP. Additionally, for areas 4, 5 and 6, they were asked in an open format about what kind of children would be most suitable for online psychosocial interventions, characteristics that paediatricians think an online intervention should have, and the advantages and disadvantages of such interventions.
Procedure Paediatricians from the Catalan and the Balearic Societies of Paediatricians were invited to participate. For the first group, the society contacted them, sending two personal emails. For the second group, an advertisement with information about our study was posted on the society’s website. Access to the online survey was open for 4 weeks. Taking into account the members in each society (1272 in the Catalan and 291 in the Balearic), a response rate of 8.3% can be estimated. Participants were informed about the study and asked for their consent. The Research Ethics Board of the Universitat Oberta de Catalunya approved the study.
Data analysis For the quantitative analysis of paediatricians’ perceptions of the effectiveness of an online psychosocial intervention for children with RAP, we carried out a univariate factorial analysis of variance (ANOVA) of repeated measures. We checked for assumptions of sphericity (Mauchly test) and applied the corrections needed in the absence of homogeneity. As part of the qualitative analysis, an inductive content analysis34 was conducted in several stages using data from the openended questionnaire. Through open coding, two researchers (authors MB and RNL) reviewed the written responses, making notes and headings in the text, after which we transcribed the notes and headings onto a coding sheet. After this open coding, we grouped the data and reduced the number of categories by combining similar headings into broader categories. After the categories were defined, the two researchers independently classified the qualitative data into these categories. Any disagreements were debated until agreement was reached. Finally, we calculated the Cohen’s kappa coefficient, and the intercoder agreement was between 80% and 90% for all the categorisations performed.
Journal of Paediatrics and Child Health 50 (2014) 449–454 © 2014 The Authors Journal of Paediatrics and Child Health © 2014 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
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Table 1
Paediatricians’ perception about online
Perceived effects of interventions on different outcomes Standard medical (I1)
Psychosocial intervention (I2)
Online psychosocial intervention (I3)
Pairs comparisons (CI 95% of dif)
Pain intensity
5.04 (2.08)
6.70 (1.72)
5.94 (1.96)
Disability
5.21 (2.89)
6.96 (1.63)
5.99 (1.87)
Prevention
4.20 (2.47)
7.06 (1.76)
5.93 (1.93)
I1 < I2** (−2.12 ÷ −1.19) I2 > I3** (0.35 ÷ 1.17) I1 < I3** (−1.46 ÷ −0.33) I1 < I2** (−2.26 ÷ −1.23) I2 > I3** (0.58 ÷ 1.35) I1 < I3* (−1.37 ÷ −0.19) I1 < I2** (−3.43 ÷ −2.84) I2 > I3** (0.72 ÷ 1.54) I1 < I3**(−2.37 ÷ −1.09)
Mean (SD); pairs comparisons results; *significance degree P < 0.05; **significance degree P < 0.001; confidence interval (CI 95%) of the difference. Number of paediatricians’ treatment, psychosocial intervention and online psychosocial intervention = 114.
Fig. 1
Means of perceived effects of interventions on different outcomes.
Results Quantitative analyses: perceptions of the effectiveness of an online psychosocial intervention Descriptive data showed that an online psychosocial intervention was perceived above the middle range as to be effective for reducing pain intensity, reducing disability and preventing chronic pain. Psychosocial interventions (face to face) received a slightly better assessment, whereas the standard medical care received a slightly worse one (see Table 1 and Figure 1 for specific data). ANOVAs (3 × 3) confirmed that paediatricians attributed different effectiveness for the three variables that we asked for (i.e. pain intensity: F = 34.63, degrees of freedom (df) = 1, 113, P < 0.001; disability: F = 35.67, df = 1, 113, P < 0.001; chronic pain: F = 80.34, df = 1, 113, P < 0.001). A detailed examination of pairs’ comparison showed that psychosocial face-to-face interventions were perceived as significantly more effective than online psychosocial interventions and the standard medical care for helping children with RAP to reduce pain
intensity, reduce disability and prevent chronicity. They also perceived online psychosocial interventions to be more effective than the standard medical treatments for all three outcomes. An ANOVA of repeated measures (2 × 3) was performed to compare the perceived effectiveness of face-to-face and online psychosocial interventions according to three different levels of disability. Table 2 and Figure 2 show a significant interaction effect between the two factors (F = 4.28, df = 1, 113, P < 0.001) Specifically, when exploring the interaction, we found that an online psychosocial intervention was perceived to be less effective than a face-to-face psychosocial intervention for children with a moderate or severe level of disability. However, there were not significant differences for children with a mild level of disability. When we examine each modality of intervention separately, the results show that online psychosocial interventions were perceived to be significantly less effective for children with severe disability than for children with moderate or mild levels of disability; face-to-face psychosocial interventions were perceived to be significantly less effective for children with severe disability compared with those with a moderate level of disability.
Qualitative analyses: characteristics and advantages and disadvantages of recommending an online psychosocial intervention We summarise the main results of the qualitative analyses performed. Taking into account the categories with a percentage above 10% (based on the total responses for each question), an online psychosocial intervention would be more recommended to children with problems in their family functioning (21%) such as ‘inadequate family environment, relationship problems with parents’; with some specific personality characteristics (21%) such as ‘shyness, intelligence, self-critical’; with specific illness features (15%) such as ‘absence of organic cause’; and to those presenting a psychological disorder or distress (14%) such as ‘anxiety, low self-esteem’. Regarding the characteristics that an online psychosocial intervention should have in order to be implemented in a clinical context, paediatricians most frequently suggested that it
Journal of Paediatrics and Child Health 50 (2014) 449–454 © 2014 The Authors Journal of Paediatrics and Child Health © 2014 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
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Table 2 Perceived effects of interventions depending on level of disability
Mild (D1) Moderate (D2) Severe (D3) Pairs comparisons (CI 95% of dif of D)
Psychosocial intervention (I1)
Online psychosocial intervention (I2)
Pairs comparisons (CI 95% of dif of I)
6.62 (2.12) 6.88 (1.52) 6.35 (2.43) D1 = D2 (−0.66 ÷ 0.16) D2 > D3**(0.13 ÷ 0.93) D1 = D3 (−0.43 ÷ 0.97)
6.28 (2.09) 6.13 (1.92) 5.46 (2.17) D1 = D2 (−0.14 ÷ 0.44) D2 > D3**(0.32 ÷ 1.01) D1 > D3*(0.29 ÷ 1.34)
I1 = I2 (−0.29 ÷ 0.71) I1 > I2**(0.43 ÷ 1.06) I1 > I2**(0.53 ÷ 1.24)
Mean (SD); pairs comparisons results; *significance degree P < 0.05; **significance degree P < 0.001; confidence interval (CI 95%) of the difference. n = 114. D, disability; I, intervention.
Fig. 2 Means of perceived effects of interventions depending on level of disability.
should have an easy and attractive design (35%) such as a ‘friendly interface’ and present clear and coherent contents (10.30%) such as being ‘easy to understand’. Finally, the main potential advantages of an online psychosocial intervention were being accessible and comfortable (29.8%) such as ‘better accessibility by the child and family’ and cheap, reduced costs of consultations category (13.3%) such as ‘no waiting list’. On the other hand, the main disadvantages were related especially to depersonalised, lack of personal relationships and verbal communication (24.4%) such as ‘face-to face contact in psychological issues can be very relevant’; neglect, difficulty to control and monitor (18.7%) such as ‘excessive uncontrolled information’; difficulties with access and with the use of ICT (13.4%) such as ‘parents’ lack of resources’; and distrust (11.5%) such as ‘lack of confidence with technology’.
Discussion The integrated findings highlighted that paediatricians perceived a potential online psychosocial intervention for children with RAP as moderately favourable, and they rated it better 452
than the treatment they currently offer. However, a face-to-face psychosocial intervention was considered more effective than a potential online psychosocial intervention, especially for children with moderate or severe level of disability. In general terms, results are congruent with our hypothesis and the available literature showing that psychosocial interventions are effective for children with RAP.15–17 Interestingly, our results showed that the characteristics of the children modulate paediatricians’ perceptions about a potential online psychosocial intervention for RAP. First, as commented above, an online intervention was considered equally effective as a face-toface intervention for those with a mild level of disability. This might be related to their current experience as primary care professionals, as they see only a few children with RAP each month, the majority of them with mild or moderate severity of the disease. The literature does not provide enough evidence to support these results, as previous studies lack segmentation of the severity of pain, and there are no data for online interventions in severe conditions.24,26 Therefore, this is an area deserving future research. Second, besides severity of disease, paediatricians would modulate the prescription of online psychosocial interventions for RAP according to family functioning, some personality characteristics (e.g. shyness or intelligence), specific characteristics related to RAP (e.g. high pain intensity) and the presence of psychological disorders (e.g. anxiety, low self-esteem) or distress. This is supported by the literature, according to which gastro symptoms are not the best predictors for RAP development and management.35 Moreover, regarding paediatric pain problems, socio-demographic factors,2 parental roles6,8,36 and individual variables16,20,30 would help to delineate the most appropriate situations to prescribe a specific intervention. Besides effectiveness, paediatricians highlighted increasing access and reducing health-care costs of online psychosocial interventions for RAP as the most important advantages with respect to face-to-face interventions. However, our sample did not highlight advantages related to the impact on children’s health and well-being, as previous studies suggested regarding online interventions with a wider scope (i.e. in accordance with patients’ wishes;37 ease of chronic disease management38 and beliefs about control providing better psychological well-being, physical functioning and experiencing fewer pain behaviours25,38). More information is needed regarding this aspect.
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From qualitative findings, the most frequent disadvantages regarding online psychosocial interventions for RAP are related to depersonalisation, a lack of personal relationships and verbal communication, difficulties in monitoring the intervention, and difficulties in access, use and distrust of ICT. We can hypothesise that this wide scope of issues reflects hidden concerns about online interventions that may be previously unknown by the participants. Paediatricians in our sample are mostly primary care professionals and, according to our data and to previous literature, the use of ICT for professional purposes is less frequent among professionals involved at this level of care.24,32 Also, even though the literature describes these interventions as being a potential support for the continuity of care and a tool to engage and empower children and their families in the management of pain,31 these concerns may reflect the lack of coherence between paediatricians’ personal use of ICT and their current medical practices.29 Existing studies with samples of paediatricians and other health professionals have highlighted additional disadvantages of online versus face-to-face interventions,29–32 most of them are related to technical difficulties and familiarity with ICT. Altogether, this means that although being effective, the use and prescription of online treatments require previous training of professionals, and it cannot be recommended in all contexts. Actually, according to our results, the most appealing elements that an online psychosocial intervention for RAP should have are an easy and attractive design, and clear and coherent contents. To date, together with effectiveness, ease of use has been identified by health professionals as the main reason for adopting new interventions (in relation to the Theory of Planned Behavior39) and for technology adoption (in relation to the Model of Technology Acceptance29,40). Consequently, developers of online interventions should also direct their efforts towards greater usability and enhanced design.
Conclusions Paediatricians treating children with RAP would be willing to use online psychosocial interventions if certain specific characteristics are taken into account in their design. Within the framework of translational research, studies such as this one have to be carried out prior to developing any intervention. This would enhance the flow along the continuum from basic issues, such as perceptions and attitudes, to clinical practice, and thus contribute to the effective application of online psychosocial interventions. Future research should test a real online psychosocial intervention for children with RAP and examine paediatricians’ perceptions about this specific intervention. Our study is somewhat limited by sample size and a selfselection bias. Together with replicating these findings with a larger sample, it would be interesting to include other professionals that also are in contact with children with RAP (e.g. psychologists or nurses).
Acknowledgements This work has been funded with a grant from the Fundació La Caixa (Recercaixa2012). PSINET is a research group recognised and supported by the Catalan Government (SGR09–197).
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