developing web-based triple p ‘positive parenting programme’ for families of children with...

Developing web-based Triple P ‘Positive ParentingProgramme’ for families of children with asthma

S.-A. Clarke,* R. Calam,* A. Morawska† and M. Sanders†

*Division of Clinical Psychology, University of Manchester, Manchester, UK and†Parenting and Family Support Centre, School of Psychology, The University of Queensland, Brisbane, Qld, Australia

Accepted for publication 17 March 2013

Keywordschildhood asthma,engagement, parentinginterventions, Triple P

Correspondence:Sally-Ann Clarke, PhD,MSc, AFBPsS, HealthPsychologist and TraineeClinical Psychologist,Division of ClinicalPsychology, 2nd Floor,Zochonis Building,University of Manchester,Brunswick Street,Manchester M13 9PL, UKE-mail: [email protected]

AbstractBackground We examined the feasibility of self-directed Triple P ‘Positive Parenting Programme’

for optimizing parents’ management of childhood asthma and behaviour.

Methods Eligible families were invited to access asthma-specific web-based Triple P as part of a

preliminary randomized controlled study.

Results Initial study information and introductory website pages received considerable interest

but intervention uptake was poor with high rates of attrition.

Conclusions Although parents of children with asthma show willingness to access web-based

parenting support, further work is necessary to develop engaging websites and determine barriers

to uptake, and adherence to online parenting interventions with this population.

Introduction

Approximately one in every 11 UK children is affected by child-

hood asthma, a chronic inflammatory disorder of the airways

(Asthma UK 2004). Ineffective asthma management leads to

poor symptom control (McQuaid et al. 2007) and risk of hos-

pital admission (Ordonez et al. 1998) with serious implications

for child health-related quality of life (HRQOL) in physical,

emotional, social and school functioning domains (Bender

1995; Graetz & Shute 1995).

Parenting and child behaviour can impact upon symptom

control and adversely affect health outcomes. Parents, critical to

successful asthma management, frequently report difficulties

with the tasks involved (Gibson et al. 1995; Milgrom et al.

1996), while children with asthma display greater behavioural

difficulties compared with healthy peers (Calam et al. 2003,

2005). Asthma-specific difficulties, such as tantrums in response

to treatment, create additional challenges for parenting and

impair treatment adherence (Morawska et al. 2008).

A review of psychosocial interventions designed to improve

HRQOL among asthmatic children (Clarke & Calam 2011)

identified four of 18 studies reporting significant improve-

ments. Asthma education programmes (72%) dominated

research, yet there is limited evidence that simply educating

families about asthma is sufficient to significantly improve

broad psychosocial outcomes such as HRQOL. One explanation

is that education does not address parents’ ability to put knowl-

edge into practice. Put simply, asthma education tells parents

what to do in order to manage childhood asthma, not how to

do it.

Triple P (Positive Parenting Programme) is a multi-level,

evidence-based, parenting intervention grounded in social

learning theory that aims to increase parents’ self-efficacy

in raising their children. Triple P has prevented behavioural

and emotional problems in many contexts (Sanders 1999).

In preliminary studies of parents of chronically ill children

(F. Doherty, submitted; A. Morawska, in prep.) it has helped

parents develop skills and confidence in managing illness and

bs_bs_banner Child: care, health and developmentOriginal Article doi:10.1111/cch.12073

© 2013 John Wiley & Sons Ltd492

mailto:[email protected]

mailto:[email protected]

behaviour. Online formats offer cost-effective methods for pro-

viding easily accessible and widely available, intensive parenting

support for hard to reach groups, such as families of chronically

ill children. In line with the ‘Every Family’ initiative to improve

access and delivery of preventive parenting interventions

(Sanders et al. 2005), the present study aimed to evaluate the

feasibility of self-directed, web-based (level 4) Triple P with

families of children with asthma in the UK.

Method

Design

A randomized controlled study employing a mixed within-

between-subjects design comparing 8 weeks of web-based

Triple P with a wait-list control group.

Participants

University of Manchester ethics approval was obtained. Eligible

families were parents of children with asthma aged 2–8 years

who could read English. Web-based Triple P has been validated

with this age. Children with significant physical or learning

disabilities were excluded. In order to increase intervention

reach we adopted a broad and wide-reaching recruitment strat-

egy over a 7-month period (June 2010–December 2010) in the

UK. Flyers and emails including brief information about the

study, eligibility criteria and an invitation to participate were

circulated to employees of private companies and public serv-

ices, and through providers of child services and media outlets.

The study website was available to parents over a 20-month

period (June 2010–February 2012).

Intervention

An online self-directed intervention including two components:

1 Asthma-specific tip sheets (n = 2) (Morawska 2008, 2009)

available for the study duration providing brief education

about asthma management and links between asthma, behav-

iour and parenting.

2 Group seminar series Triple P (Sanders 1999; Zubrick

et al. 2005) including weekly video-clips (approximately

10 min) to enhance parental knowledge, skills, confidence,

self-sufficiency and resourcefulness; promote more nurtur-

ing, safe, engaging, non-violent and low conflict environ-

ments for children; and promote children’s social, emotional,

language, intellectual and behavioural competencies through

positive parenting practices.

Procedure

Parents were invited to access the study online via the study

website address and completed stages outlined in Table 1. All

parents were recruited through the same procedure and were

randomly assigned to the intervention or control group after

completing baseline measures.

Measures

Measures (Table 2) took parents approximately 30 min to com-

plete. Children did not complete questionnaires. Where possi-

ble, one-sample t-tests were used to compare baseline scores

with a sample of parents of asthmatic children enrolled in a

similar Triple P study (A. Morawska, in prep.).

Table 1. Stages of participation

Stage 1 Read electronic information sheet with opportunities to ask questions via the researcher’s email address or telephone number.Stage 2 Complete a brief screen to check eligibility criteria was met. Families not eligible did not proceed to stage 3 and were provided with the

researcher’s contact details for any questions.Stage 3 Provide online informed consent.Stage 4 All parents asked to complete baseline measures.Stage 5 Electronic randomization followed by access to the online intervention (intervention group), or a request to wait 8 weeks before

starting the intervention (control group). To test for differential expectancies associated with being randomly assigned to the twotreatments, parents were asked pre and immediately post-randomization to rate ‘how confident are you that your child will benefit fromthe intervention they will receive’ on a Likert-type scale (1–10).

Stage 6 Intervention group asked to complete weekly asthma diary cards and online intervention (prompted by email reminders).Stage 7 All parents asked to complete post-treatment measures online (prompted by email reminders).Stage 8 Control group allowed access to online intervention and sent the Triple P workbook by post.Stage 9 All parents asked to complete follow-up questionnaires online 8 weeks post-baseline assessment (prompted by email reminders).

Triple P for children with asthma 493

© 2013 John Wiley & Sons Ltd, Child: care, health and development, 40, 4, 492–497

Results

Website usage

Log analyser software (http://www.deep-software.com/) was

used to obtain descriptive statistics for website usage between 13

May 2010 and 12 January 2012. Estimates suggest that the home

page was viewed 668 times, the information sheet 195 times and

the consent form 140 times.1

Intervention uptake

Of the 140 views of the consent form, 14 eligible parents

provided consent and registered for the online study. Thirteen

completed baseline questionnaires (intervention group n = 8)

(Tables 3 and 4). No significant differences in baseline scores

were found when compared with the Morawska 2012 sample.

Adherence and attrition

No family completed the intervention and all had discontinued

the study by week four. Families dropped out at week one

(n = 12) and week four (n = 1). One family completed post-

intervention measures.

In the control group (n = 5), all families discontinued the

study after baseline questionnaires with no family logging on

to access the intervention 8 weeks later, despite two email

reminders to inform them that they could start.

All families were contacted by email and invited to give feed-

back about reasons for discontinuing the study and potential

areas for improvement to the website and intervention. One

family responded. Reasons included not having time, no per-

ceived need to change parenting practices, and only moderate

interest in the intervention prior to registering.

Discussion

Statistics for website usage suggest sufficient interest in the

study to warrant further research into online interventions for

this population. Parents initially responded favourably to the

study, by viewing the home page for further information. This

is consistent with suggestions that parents want online inter-

ventions (Sanders & Turner 2002; Sanders et al. 2011) and use

the internet for asthma information (Oermann et al. 2003),

and suggests parents may be interested in obtaining asthma

management and parenting support via the internet.

However, intervention uptake was low with very few parents

(approximately 10% of those who viewed the consent form)

providing consent and registering for the study. Furthermore,

attrition was high with no family adhering to the intervention.

This is perhaps surprising given previous research documenting

prevalent child behavioural and asthma management difficul-

ties within this population (Calam et al. 2003, 2005) and clearly

indicates further work is needed to explore engagement within

this population.

1 It is not possible to provide exact statistics regarding website usage as visits

from web-crawlers were also frequent. Estimates exclude visits from the Univer-

sity of Manchester IP address range (most likely to be members of the research

team) and visits, which were clearly from search engine crawlers. Because of

limitations with the ways in which data are logged it is not possible to detect how

many views were repeat visits from the same person (i.e. a parents who might

have viewed the site several times while deciding to take part would have been

logged as a new ‘view’ each time).

Table 2. Measures

Demographicinformation

Family Background Questionnaire (FBQ); routinely used in Triple P outcome research for demographic information(socio-economic status, ethnic background, marital status, parent and child age and gender and health).

Medical information Information regarding the child’s asthma history (treatment, exacerbation rate, courses of prednisolone, hospital admissions,and accident and emergency attendances).

Weekly asthma diarycard

Information about the child’s symptoms in the previous week.

HRQOL The Juniper Paediatric Asthma Caregiver’s Quality of Life Questionnaire (PACQOL) (Juniper et al. 1996a,b); assessing the impactof asthma, including limitations on daily activity and stress on the parent. There are 13 questions in two domains (activitylimitations and emotional function) selected on the basis of their importance to parents themselves. Items are rated on aseven-point Likert scale. Higher scores indicate positive quality of life (activity limitations maximum score = 28, emotionalfunction maximum score = 63).

Child behaviour Eyberg Child Behavior Inventory (ECBI) (Eyberg & Pincus 1999); a 36-item measure of parental perceptions of disruptive behaviourin children between the ages of 2 and 16. Higher ‘intensity’ scores indicate that the problem occurs with greater frequency.Higher ‘problem’ scores indicate lower parental tolerance for child behaviour problems. Clinical cut-off scores are 127 for theIntensity score and 11 for the Problem score (Eyberg & Ross 1978).

Asthma parentingbehaviours

Asthma Behaviour Checklist (ABC) (Morawska et al. 2008); a 22-item measure of parental efficacy for managing asthma behaviour.Parents rate the extent to which the behaviour has been a problem for them on a seven-point Likert scale, and how confidentthey are that they can successfully deal with the behaviour on a 10-point liker scale.

494 S.-A. Clarke et al.


http://www.deep-software.com/

Despite accessing the home page, most parents did not

register. Consequently information on introductory pages

requires careful consideration in order to attract parents. Our

informed consent process was perhaps too lengthy or complex

for a remote online format. Furthermore, parents may have

responded negatively to requests in our consent form: (1) for

permission to contact the child’s general practitioner (GP)

about study participation; and (2) for parents to contact the GP

should concerns about child behaviour or asthma arise during

the course of the study. This could be addressed by providing

further information about how online data are used, stored and

protected, and offering more formal support for parents in the

form of a helpline or follow-up calls.

In addition to generic Triple P video-clips we provided

written information about asthma and Triple P, and ways in

which Triple P might help parents develop confidence in asthma

management. Feedback from parents who accessed the website

but did not register for the study would have helped identify

Table 3. Baseline measures: family demographic and child asthma information (n = 13)

Family demographic information (n = 13)

Child mean age = 3.65 years (1.70 SD, range 2–7 years)Child gender Parent relationship to child

Male n = 8 Mother n = 13Female n = 5 Father n = 0

Child ethnic group Parent marital statusWhite n = 10 Married n = 7Mixed n = 2 Separated n = 2Pakistani n = 1 Live in partner n = 3

Never married/no partner n = 1

Child asthma information (n = 13)

Severity of symptoms Severity of attacksOccur less than once a week n = 6 Mild (breathless when walking, able to talk in sentences, moderate wheeze) n = 8Occur more than once a week but less than once a day n = 3 Moderate (breathless when talking, talks in phrases, loud wheeze) n = 1Occur daily but night-time symptoms less than once a week n = 1 severe (breathless even when resting, talks in words, loud wheeze) n = 4Occur daily and night-time symptoms are frequent n = 3

Preventer medication prescribed Child ever hospitalized because of asthmaYes n = 11 Yes n = 5No n = 2 No n = 8

Reliever medication prescribed Child ever visited accident and emergency because of asthmaYes n = 11 Yes n = 5No n = 2 No n = 8

Prednisolone prescribed in last 12 monthsYes n = 4No n = 9

Table 4. Means and SD for baseline measures (n = 13) and comparison with A. Morawska (in prep.)

Measures

n = 13 study sample n = 41 asthma sample (A. Morawska, in prep.)

Mean (SD) Range Mean (SD) Range

HRQOL score Not assessed Not assessedPACQOL activity 20.03 (2.64) 15.75–22.75PACQOL emotional 47.70 (6.84) 36.56–56.78

Child behaviour scoreECBI intensity 124.25 (34.29) 69–187 128.17 (33.08) 62–186ECBI problem 13.92 (9.32)* 0–29 15.34 (7.13)* 4–36

Asthma parenting behavioursABC extent 43.30 (11.05) 34–68 43.39 (19.13) 22–91ABC confidence 183.10 (26.26) 139–220 186.97 (36.74) 40–220

*Within clinical range �11.HRQOL, health-related quality of life; PACQOL, Paediatric Asthma Caregiver Quality of Life Questionnaire; ECBI, Eyberg Child Behavior Inventory; ABC, AsthmaBehaviour Checklist.



the acceptability of this message but could not be obtained.

It is possible that parents did not perceive their child’s behav-

iour to be problematic [mean Eyberg Child Behavior Inventory

(ECBI) intensity score was within the normal range although

approaching clinical cut-off], or did not identify an explicit link

between generic parenting practices and asthma-management

behaviour.

The format and content of interventions with this popu-

lation require further pilot work before future attempts at a

full-scale web-based trial. Parents who viewed our inter-

vention mostly disengaged after video-clips at session one,

which introduced parents to generic Triple P principles such

as praise and limit-setting. Additional asthma-specific visual

materials at each session could help promote engagement and

retention to the intervention. This might include video-clips

that complement written asthma-specific tip sheets and dem-

onstrate parents using Triple P strategies with asthma-specific

issues.

Our sample did not differ on baseline measures when

compared with A. Morawska (in prep.), and did not report

substantial difficulties with asthma symptoms, HRQOL,

parental efficacy for managing asthma behaviour, or frequency

(intensity) of child behaviour problems, and so may not

have included those with the greatest difficulties. Interestingly,

the mean ECBI ‘problem’ score (the extent to which beha-

viour is perceived as problematic) was within the clinical

range while the mean ECBI ‘intensity’ score (frequency of

the behaviour) was within the normal range, although

approaching clinical cut-off. This highlights the importance

of parental perceptions of the impact of child behaviour on

the family and resources to manage the behaviour, beyond

simply intensity or frequency with which behaviour occurs.

Parents’ own mental well-being and attributions for child

behaviour, and the wider family context, are therefore likely

to influence engagement and non-completion with parenting

interventions, and could be measured and targeted in future

interventions.

Emotional difficulties, such as parent and child anxiety

about asthma, might also be addressed, while wider contextual

issues related to asthma outcomes, such as smoking in the

family household, could be additional areas for intervention,

or formal assessment at least. Parents might also benefit from

an additional online support forum through which they could

discuss and troubleshoot idiosyncratic issues and obtain peer

feedback.

Feedback from recruitment to similar studies of Triple P

for diabetes (F. Doherty, submitted), and asthma or eczema

(A. Morawska, in prep.), suggests engagement difficulties

are specific to asthma, and that the nature of childhood illness

may lead to different uptake. It is striking that online Triple P

for diabetes (F. Doherty, submitted) encountered no difficulty

with recruitment despite using the same website designer as

our study. One possibility is the intermittent nature of asthma

attacks such that parents are less likely to perceive problems

unless there is a crisis. Conditions with more enduring symp-

toms, and requiring more demanding daily management

routines, such as eczema and diabetes, may create different

challenges for parents and greater awareness that their child’s

behaviour could be a factor in their illness and management.

Other illness-specific factors may include parents’ perceptions

of the seriousness of the condition, threat to health if the child

is non-compliant with treatment, and links between managing

behaviour and managing illness-related activities and health-

care administration. Further work to clarify ways in which to

present links between parenting practices and specific health

conditions are therefore necessary.

Intervention-related factors, including website design,

intervention length and self-directed format may partly

account for attrition. The challenge for researchers is to

facilitate uptake and commitment to online interventions

without face-to-face contact with families. In this study few

parents contacted the researcher for further information, thus

opportunities to allay concerns were limited. Access to testi-

monials from parents with experience of Triple P may be one

strategy for helping parents make informed choices about the

relevance and potential benefits of interventions (Morawska

et al. 2011).

Parenting interventions tailored to the needs of chronically

ill children are not routinely available in the National Health

Service. At a local level clinicians can adapt existing pro-

grammes to meet service users’ needs but few empirical

studies exist. This is a new area of research activity and feasi-

bility studies offer valuable information for clinicians and

researchers planning future interventions. Our data raise

important questions about differences in engagement with

parenting interventions between populations of chronically

ill children. Findings indicate a need for further work with

parents of children with asthma to explore barriers to uptake

of parenting interventions and factors relating to adherence

and attrition, before attempting an outcome study. Future

questions relate to: (1) uptake; ‘what factors affect whether

parents respond to online interventions?’; (2) adherence; ‘what

factors promote intervention completion?’; (3) attrition;

‘where do parents drop out and why?’; and (4) outcome; ‘what

percentage of families who adhere show improvements in

outcomes such as HRQOL and asthma management?’

496 S.-A. Clarke et al.


Key messages

• Parents of children with asthma showed sufficient initial

interest in the online Triple P to warrant further research

into web-based parenting support for this population.

• Despite initial interest, intervention uptake was low and

attrition was high, when compared with other research

with chronically ill populations.

• Engagement with parenting interventions is influenced by

illness-specific factors.

Conflict of interests

We can confirm that there are no conflicts of interests.

Acknowledgements

We wish to acknowledge Austin Lockwood, the website designer

and technician providing technical support for this online

study.

References

Asthma UK (2004) Where do we stand? Asthma in the UK today.

Available at: http://www.asthma.org.uk/document.rm?id=18

(accessed from 19 November 2010).

Bender, B. (1995) Are asthmatic children educationally handicapped?

School Psychology Quarterly, 10, 274–291.

Calam, R., Gregg, L. & Goodman, R. (2005) Psychological adjustment

and asthma in children adolescents: the UK nationwide mental

health survey. Psychosomatic Medicine, 67, 105–110.

Calam, R., Gregg, L., Simpson, B. M., Morris, J., Woodcock, A. &

Custovic, A. (2003) Childhood asthma, behaviour problems and

family functioning. The Journal of Allergy and Clinical Immunology,

122, 499–504.

Clarke, S. A. & Calam, R. (2011) The effectiveness of psychosocial

interventions designed to improve Health-related Quality of

Life (HRQOL) amongst asthmatic children and their families:

a systematic review. Quality of Life Research, 21, 747–764.

Eyberg, S. M. & Pincus, D. (1999) Eyberg Child Behaviour Inventory

and Sutter-Eyberg Student Behaviour Inventory – Revised.

Professional manual. Psychological Assessment Resources,

Odessa, FL, USA.

Eyberg, S. M. & Ross, A. W. (1978) Assessment of child behaviour

problems: the validation of a new inventory. Journal of Child

Clinical Psychology, 7, 113–116.

Gibson, N. A., Ferguson, A. E., Aitchison, T. C. & Paton, J. Y. (1995)

Compliance with inhaled asthma medication in preschool

children. Thorax, 50, 1274–1279.

Graetz, B. & Shute, R. (1995) Assessment of peer relationships in

children with asthma. Journal of Paediatric Psychology, 20, 205–216.

Juniper, E. F., Guyatt, G. H., Feeny, D. H., Ferie, P. J., Griffith, L. E. &

Townsend, M. (1996a) Measuring Quality of Life in parents of

children with asthma. Quality of Life Research, 5, 27–34.

Juniper, E. F., Guyatt, G. H., Feeny, D. H., Ferie, P. J., Griffith, L. E. &

Townsend, M. (1996b) Measuring Quality of Life in children with

asthma. Quality of Life Research, 5, 35–46.

McQuaid, E. L., Mitchell, D. K., Walders, N., Nassau, J. H., Kopel,

S. J., Klein, R. B., Wamboldt, M. Z. & Fritz, G. K. (2007) Pediatric

asthma morbidity: the importance of symptom perception and

family response to symptoms. Journal of Pediatric Psychology,

32, 167–177.

Milgrom, H., Bender, B., Ackerson, L., Bowry, P., Smith, B. &

Rand, C. (1996) Noncompliance and treatment failure in children

with asthma. The Journal of Allergy and Clinical Immunology, 98,

1051–1057.

Morawska, A. (2008) Triple P Tip Sheet – Asthma. Parenting and

Family Support Centre, The University of Queensland.

Morawska, A. (2009) Triple P Tip Sheet – Parenting a child with

Asthma. Parenting and Family Support Centre, The University

of Queensland.

Morawska, A., Stelzer, J. & Burgess, S. (2008) Parenting asthmatic

children: identification of parenting challenges. The Journal of

Asthma, 45, 465–472.

Morawska, A., Faye, N. & Burrows, S. (2011) Do testimonials improve

parental perceptions and participation in parenting programmes?

Results of two studies. Journal of Child Health Care, 15, 85–98.

Oermann, M. H., Gerich, J., Ostosh, L. & Zaleski, S. (2003)

Evaluation of asthma websites for patient and parent education.

Journal of Pediatric Nursing, 18, 389–396.

Ordonez, G. A., Phelan, P. D., Olinsky, A. & Robertson, C. F. (1998)

Preventable factors in hospital admission for asthma. Archives of

Disease in Childhood, 78, 143–147.

Sanders, M. R. (1999) Triple P – Positive Parenting Program: towards

an empirically validated multilevel parenting and family support

strategy for the prevention of behaviour and emotional problems

in children. Clinical Child and Family Psychology Review, 2, 71–90.

Sanders, M. R., Haslam, D. M., Calam, R., Southwell, C. & Stallman,

H. M. (2011) Designing effective interventions for working

parents: a web-based survey of parents in the workforce. Journal

of Children’s Services, 6, 186–200.

Sanders, M. R., Ralph, A., Thompson, R., Sofronoff, K., Gardiner, P.,

Bidwell, K. & Dwyer, S. (2005) Every Family: a public health

approach to promoting children’s wellbeing. Brief Report. The

University of Queensland: Brisbane, Australia.

Sanders, M. R. & Turner, K. M. (2002) The role of the media and

primary care in the dissemination of evidence-based parenting and

family support interventions. Behaviour Therapist, 25, 156–166.

Zubrick, S. R., Ward, K. A., Silburn, S. R., Lawrence, D., Williams,

A. A., Blair, E., Robertson, D. & Sanders, M. R. (2005) Prevention

of child behavior problems through universal implementation of

a group behavioral family intervention. Prevention Science, 6,

287–304.



http://www.asthma.org.uk/document.rm?id=18

developing web-based triple p ‘positive parenting programme’ for families of children with...

Documents