Abstract
Introduction:
Many paediatric emergency departments face a significant proportion of non-urgent attendances, leading to problems for both patients and healthcare systems. Our primary aim was to compare the effectiveness of pamphlet versus video in educating caregivers regarding fever management in children. Our secondary aim was to assess caregivers’ sentiments towards these methods.
Methods:
A randomized controlled trial was conducted with 50 participants over a four-week period (May–June 2015) in the KK Hospital Paediatric Emergency Department. The control group was exposed to the standard pamphlet available in the KK Hospital Paediatric Emergency Department, which provided basic information on fever management. The intervention group watched a video produced by our team, containing similar content. The same five-question questionnaire assessing fever management knowledge was issued to participants before and immediately following exposure to intervention.
Results:
The pamphlet group had a mean pre-intervention score=2.8 (out of five), post-intervention score=3.84, amounting to an improvement of 1.04. The video group had a mean pre-intervention score=2.56, post-intervention score=4.12, giving an improvement of 1.36. The study was powered at 80%, with calculated p-value=0.111, hence the results were statistically insignificant. Both groups had increased self-reported awareness post-exposure, found the intervention useful, would rely on it for future management and would recommend it to others.
Conclusion:
While the sample size was limited, this study demonstrates the potential that both pamphlet and video interventions have in educating caregivers, as participants reported favourable sentiments towards the methods. It would be worthwhile to conduct the study on a larger scale to yield statistically significant results.
Introduction
Non-urgent paediatric emergency department (ED) attendances and associated problems
A longstanding issue that paediatric EDs face worldwide is that many of the ED visits are deemed to be non-urgent cases.1–5 In the local context of KK Women’s and Children’s Hospital (KKH), Singapore’s only level one tertiary paediatric centre, patients are triaged into Priority 1 (resuscitation) to Priority 3 (non-urgent), whereby non-urgent Priority 3 patients refer to cases not requiring urgent medical attention, and can be seen in the primary care setting or managed safely at home. KKH receives up to 180,000 paediatric ED visits annually, of which more than half are deemed non-urgent cases. In 2015, the KKH hospital registry data indicated that non-urgent cases accounted for 51.4% of the patients seen in the KKH paediatric ED, and 48.2% of the non-urgent cases were related to fever. The significant representation of non-urgent cases in the ED brings about a myriad of problems to both the patients and the healthcare system. Such problems include longer waiting times, increased medical costs, patient and staff dissatisfaction, and poorer patient outcomes for both urgent and non-urgent cases.6–8
Understanding caregivers’ perspectives
Prior to the current study, we first conducted a qualitative study to understand the reasons behind non-urgent visits from a caregiver’s perspective. 9 In-depth ethnographic interviews with 49 caregivers were conducted, transcribed, coded and analysed using a grounded theory approach, from which major themes were identified (Figure 1).
Reasons for attendances at the emergency department for non-urgent conditions: caregivers’ perspectives. ED: emergency department; KKH: KK Women’s and Children’s Hospital.
Crafting targeted caregiver-focused educational interventions
Equipped with this information, we aimed to move forward by crafting targeted interventions addressing the particular themes we uncovered, so as to improve the knowledge of caregivers, with the aim of improving overall patient outcomes. Through our literature review, we have noted the increasing engagement of social media in the health sector to effectively educate the public.10–12 We came up with several suggestions on how to employ educational methods appropriate for the generation of Internet-savvy young caregivers who are comfortable with seeking answers from social media, and online forums (78% of our participants were young caregivers aged 45 years old or less). Options for educational materials include building websites that are easy to navigate that young parents can identify with, an option which holds much potential given the increasing prevalence of online use. Short video clips not exceeding eight minutes in duration may also be an effective avenue for education, which can be uploaded onto public domains such as YouTube, which has been shown to be a useful platform in health promotion. 13 Previous studies have shown the potential of parent-focused educational interventions in reducing non-urgent ED visits. 14 Our team produced three videos, each targeting a common non-urgent childhood ailment (fever, nosebleed and minor falls) by using typical quotes from our previous qualitative study to reflect the caregiver’s voice, and local experts to improve their medical knowledge. The videos were aimed at empowering the caregivers with the information to differentiate when they should care for their children at home, bring them to their primary healthcare physicians or go directly to the ED. For the purpose of this study, we chose to focus on caregivers managing children with fever, as analysing data for the three different videos of the respective conditions concurrently might potentially confound the results. The video on fever management was selected as nearly half of the non-urgent ED attendances were fever cases. Our primary aim was to compare the effectiveness of pamphlet versus video in educating caregivers regarding fever management in children. Our secondary aim was to assess caregivers’ sentiments towards these methods.
Methods
Design
We conducted a randomised controlled trial over a four-week period from May 2015–June 2015. A random number generator was utilised to assign participants to the two intervention arms at random, such that 25 participants were exposed to the standard pamphlet educational material and 25 participants were exposed to the video intervention, the order of which was randomised to avoid selection bias. Participants were given two sets of printed questionnaires to complete, the first set filled in prior to exposure to the intervention and the second set completed immediately after exposure to the intervention. Our study was approved by the SingHealth Centralised Institutional Review Board (CIRB) before commencement.
Setting
In the KKH, patients are routinely triaged into Priority 1 (resuscitation), to Priority 3 (non-urgent), whereby non-urgent Priority 3 patients are cases not requiring urgent medical attention, and can be seen in the primary care setting or managed safely at home. Caregivers were recruited from Priority 3 cases seen in the Children’s ED at KKH. The questionnaires were conducted immediately after their visits. The location of questionnaires was a quiet discussion room within the ED to minimise inconvenience and discomfort to the caregivers and patients.
Study population
Caregivers were eligible to participate if they were of legal age to consent to participation in the study, were English-literate and their child had been diagnosed by the attending physician in the ED to have typical non-urgent conditions. Non-urgent conditions include conditions such as fever, nosebleed and minor head injury. We used the widely accepted criteria for non-urgent visits, which excluded cases that had abnormal vital signs such as tachycardia or low oxygen saturations, or conditions warranting urgent attention at triage point, additional investigations (such as laboratory tests, X-rays and electrocardiograms) ordered by doctors, and cases that resulted in admission to the hospital. The study was explained to participants and informed consent was gained prior to the commencement of the questionnaire.
Sampling
Consecutive patients that came to the ED were recruited by convenience sampling, as long as patient safety was not compromised. We ensured that members issuing the questionnaires were not scheduled for work during the time of conducting, so as not to disrupt the workflow of the ED or compromise on medical attention provided.
Pilot
Prior to the commencement of the field study, in order to gauge the potential response and effectiveness of our proposed educational video intervention on fever management, as well as to explore other suggestions and options, we conducted a focus group. The video intervention was played for a group of 20 KKH medical staff to gather feedback and comments to ensure that the content portrayed was medically sound and reliable, and the relevant edits were made. The questionnaire was also given to this pilot group with medical background, in order to assess the content and face validity, and improvements were made.
Interventions
Pamphlet
The standard educational pamphlet on managing children with fever, which is available at the KKH ED, was issued. The pamphlet contained important basic information on fever management, and covered all content needed to answer the questionnaire knowledge questions correctly.
Video
The video was produced by our research team after reviewing the major themes and sub-themes uncovered in the qualitative study on caregivers’ perspectives (see Supplementary Material). Participants were quoted verbatim and anonymously in the video dialogue to provide a representative voice to which viewers would be able to relate. The video, as in the pamphlet, covered all the relevant content needed to answer the questionnaire knowledge questions correctly. It was 3.5 min in length and was played on electronic devices, and earphones were provided which where cleaned with alcohol wipes after each use to ensure hygiene.
The participants were designated, and each participant was exposed to only one of the two interventions and was not allowed to view the other intervention. Each participant was given a standardised maximum of five minutes of exposure to the intervention, during which time participants were allowed to review their intervention (i.e. read through the pamphlet again or playback parts of the video).
Questionnaires
There were four parts to the questionnaire. Part A: Demographics data, Part B: Pre-intervention questionnaire, Part C: Post-intervention questionnaire, and Part D: Feedback on intervention. The Pre-intervention and Post-intervention questionnaires comprised of the same five questions to assess the caregivers’ knowledge of proper fever management (see Appendix 1 for a copy of the questionnaire form). The questionnaire was assessed for its readability and obtained a Flesch-Kincaid Grade Level 7.
After obtaining consent from the participants, Parts A and B were then self-administered and completed, after which the questionnaire set was collected back to avoid participants from referring to the questions while being exposed to the intervention. The predetermined randomly assigned intervention was then given to the participant. After a maximum of five minutes had elapsed, the intervention was then handed back and the remaining questionnaire (Parts C and D) was then completed. No clarifications pertaining to the content of the questionnaire was permitted, and participants were reminded to refrain from guessing an answer, but rather, to select the ‘I do not know’ option. Questions of participants were addressed only upon completion of all the questionnaires, so as not to contaminate the results. Part B and C included the same five knowledge questions.
Results
We recruited 50 eligible participants for the study, after the patients had completed their doctor’s consultations for their non-urgent cases. Of the 50 participants, 25 of them were given the pamphlet as their source of intervention, while the other 25 were given the video intervention.
Demographics
Of the 50 participants, 38% were 35 years old or less, 40% were aged 36–45 years old and 22% were above 45 years old. 58% were female and 42% were male, of which 66% had an education level of diploma, university or higher, the rest having an education level of secondary school or lower (Table 1).
Demographics.
Source of information
Regarding their source of information on managing children with fever prior to coming to the paediatric ED, in which they could indicate more than one source, 70% of the participants stated that their knowledge was obtained directly through medical personnel, 46% referred to the Internet, 46% were taught by family and friends, and only 12% referred to pamphlets (Table 2).
Source of information.
Pre-intervention and post-intervention scores
The pamphlet group had a mean pre-intervention score of 2.8, post-intervention score of 3.84, amounting to an improvement from baseline of 1.04. The video group had a mean pre-intervention score of 2.56, post-intervention score of 4.12, giving an improvement from baseline of 1.36. The study was powered at 80%, with calculated p-value=0.111, which is more than 0.05, hence the results were statistically insignificant (Table 3).
Pre- and post-intervention scores.
CI: confidence interval.
Feedback on interventions
Awareness
Out of 25 participants, nine (36%) reported an increased awareness about how to manage children with fever following their exposure to the pamphlet, as opposed to 17 of 25 (68%) participants following the video intervention (Tables 4–6). Using Fisher’s exact test, the calculated p-value is 0.031, which is less than 0.05, hence the results are deemed to be statistically significant.
Awareness: case processing summary.
Awareness on managing children with fever, 1: Pamphlet, 2: Video crosstabulation.
Awareness: chi-square tests.
Six cells (60.0%) have expected count less than five. The minimum expected count is 0.50.
The standardised statistic is 1.606.
The Fisher’s exact test has a significance level of p=0.031. The probability value (p) is less than or equal to 0.05, therefore the result is statistically significant. We reject the null hypothesis and conclude that there is statistical significance of awareness between the Pamphlet and Video groups.
Usefulness
Out of 25 participants, 14 (56%) agreed that the pamphlet was useful in educating them in managing children with fever, while six of 25 (24%) strongly agreed (Tables 7–9). For the video, seven of 25 (28%) agreed that it was useful, while 17 of 25 (68%) strongly agreed. Using Fisher’s exact test, the calculated p-value is 0.019, which is less than 0.05, hence the results are deemed to be statistically significant.
Usefulness: case processing summary.
Usefulness of video/pamphlet, 1: Pamphlet, 2: Video crosstabulation.
Usefulness chi-square tests.
Four cells (50.0%) have expected count less than five. The minimum expected count is 0.50.
The standardised statistic is 2.743.
The Fisher’s exact test has a significance level of p=0.019. The probability value (p) is less than or equal to 0.05, therefore the result is statistically significant. We reject the null hypothesis and conclude that there is statistical significance of usefulness between the Pamphlet and Video groups.
Reliance for future management
For both the pamphlet and the video intervention arms, the majority of the participants responded that they would rely on the given intervention for future management of fever cases in their children (Tables 10–12). For the pamphlet arm, 16 (64%) agreed that they would rely on the pamphlet, while five (20%) strongly agreed. As for the video intervention arm, 15 (60%) agreed that they would rely on the video, while five (20%) strongly agreed. Using Fisher’s exact test, the calculated p-value is 0.023, which is less than 0.05, hence the results are deemed to be statistically significant.
Reliance: case processing summary.
Reliance on video/pamphlet for future use, 1: Pamphlet, 2: Video crosstabulation.
Reliance: chi-square tests.
Four cells (50.0%) have expected count less than five. The minimum expected count is 1.50.
The standardised statistic is 2.800.
The Fisher’s exact test has a significance level of p=0.023. The probability value (p) is less than or equal to 0.05, therefore the result is statistically significant. We reject the null hypothesis and conclude that there is statistical significance of reliance between the Pamphlet and Video groups.
Recommend to others
Out of 25 participants, 20 (80%) would recommend the pamphlet to others, whereas all of the 24 participants (100%) would recommend the video to others (Tables 13–15). Using Fisher’s exact test, the calculated p-value is 0.05, hence the results are deemed to be statistically significant.
Recommendation: case processing summary.
Recommend video/pamphlet to others, 1: Pamphlet, 2: Video crosstabulation.
Recommend: chi-square tests.
Two cells (50.0%) have expected count less than five. The minimum expected count is 2.45.
Computed only for a 2×2 table.
The standardised statistic is −2.288.
The Fisher’s exact test has a significance level of p=0.050. The probability value (p) is less than or equal to 0.05, therefore the result is statistically significant. We reject the null hypothesis and conclude that there is statistical significance of recommendation between the Pamphlet and Video groups.
Discussion
This study has shown that both the educational fever pamphlet and the video on managing fever can help to increase the knowledge of caregivers, as evidenced by the improvement in questionnaire scores after the intervention, with a more marked improvement in the video intervention arm than the pamphlet.
Both interventions also helped caregivers perceive themselves as more aware about managing fever in children. Tying this information in with our findings from our study on understanding caregivers’ perspectives, which uncovered the issue of caregivers’ psychological status of having anxiety and lack of self-confidence in handling the non-urgent conditions on their own, helping caregivers feel that they are more aware of fever management could help reduce non-urgent attendances. 9
Participants responded that the interventions were useful, the video faring better than the pamphlet, and that they would rely on the interventions for future management of fever in children. While the sample size was limited and data was deemed not statistically significant, this study demonstrates the potential both pamphlet and video have in educating caregivers, as participants reported favourable sentiments towards the methods.
Limitations
A shortcoming of our study is that our pre-intervention and post-intervention questionnaires were administered at the same sitting. A better gauge of the effectiveness of the intervention in educating the caregivers would be to allow a lapse in time from exposure to the intervention, so that retention of knowledge can be assessed, which is a more realistic indicator of the intervention’s usefulness. However, given logistical constraints as well as the issue of participants being lost to follow-up, we chose to issue our pre-intervention and post-intervention questionnaire at the same visit.
A larger sample size might provide a more accurate representation. Given the limited sample size, variations in the participants’ demographics between the two intervention arms affect the statistical significance of the results. Furthermore, as the convenience sampling method was utilised, in the context of a wider population, the calculated p-values would be rendered somewhat redundant, as they assume randomness of error.
The study was conducted at a single children’s hospital and the results may not be generalisable to non-urgent attendances at other EDs. However, our hospital, one of two public paediatric emergency departments in the country, is the only level one tertiary hospital providing paediatric care, and sees a majority of the paediatric emergency cases in the nation. Hence, our findings are likely to be a fair representation of Singapore’s paediatric ED setting.
Conclusion
Both the pamphlet and the video have been beneficial in terms of improving the caregivers’ knowledge and increasing their awareness, with the video showing better outcomes.
Our research demonstrates that the majority of caregivers rely on information from medical personnel (70%), hence more conscious efforts can be made on the medical front to convey the relevant information to caregivers. Given caregivers’ significant reliance on the Internet as a source of information (46%) compared to the pamphlet (6%), we can explore the option of making the video available online for ease of reference for caregivers. These videos can also then be played in medical settings such as in the waiting area of the paediatric ED, utilising medical personnel for information provision. Additionally, given their reliance on obtaining knowledge from family and friends (46%), we could host the video on public social platforms such as YouTube for easy access by all, and it can also then be easily shared on social media platforms, hence reaching out to a wider audience.
While the video produced better results and was viewed to be of more use than the pamphlet, both the video and pamphlet have their place in educating caregivers. While the video has the advantage of being more accessible if made available online, the pamphlet has its strength in that it is often administered by a medical personnel at the point of care, and caregivers rely on medical personnel as one of their main sources of information (36%). Providers may want to consider using both the pamphlet and the video to educate caregivers and in so doing, help to capture a wider population. Additionally, there is value in exploring other avenues to further increase the outreach to caregivers, such as educational software applications that can be made available on mobile devices and other platforms.
Footnotes
Appendix 1
Acknowledgements
The authors thank KKH ED for allowing them to carry out the study in the hospital setting. They would also like to show their appreciation to the participants of the study. Regarding availability of data and information, only study team members had access to the data. Login user ID and password were required to access the information. Only authorised research members were issued user ID and password. Patient data was de-identified prior to data entry. This study was conducted in accordance with the ethical principles that have their origin in the Declaration of Helsinki and that are consistent with the Singapore Good Clinical Practice and the applicable regulatory requirements. The study protocol, including the Patient Information and Informed Consent Form, was approved in writing by the Centralised Institutional Review Board (CIRB), prior to enrolment of any patient into the study. Consent was taken after the doctor completed the medical consultation and assessed if the caregivers could be enrolled in the survey. Consent was taken only by nurses, doctors or medical students who held Good Clinical Practices CITI certificates.
Declaration of conflicting interests
The authors declare that there is no conflict of interest.
Funding
The cost of developing the medical portal is borne by the People’s Association.