peer and professional parenting support on the internet: a systematic review
TRANSCRIPT
Peer and Professional Parenting Support on the Internet:A Systematic Review
Christa C. Nieuwboer, MA,1 Ruben G. Fukkink, PhD,2 and Jo M.A. Hermanns, PhD2
Abstract
The Internet offers many opportunities to provide parenting support. An overview of empirical studies in thisdomain is lacking, and little is known about the design of web based parenting resources and their evaluations,raising questions about its position in the context of parenting intervention programs. This article is a systematicreview of empirical studies (n = 75), published between 1998 and 2010, that describe resources of peer andprofessional online support for parents. These studies generally report positive outcomes of online parentingsupport. A number of recent experimental studies evaluated effects, including randomized controlled trials andquasi-experimental designs (totaling 1,615 parents and 740 children). A relatively large proportion of the studiesin our sample reported a content analysis of e-mails and posts (totaling 15,059 coded messages). The results ofthis review show that the Internet offers a variety of opportunities for sharing peer support and consultingprofessionals. The field of study reflects an emphasis on online resources for parents of preschool children,concerning health topics and providing professional support. A range of technologies to facilitate online com-munication is applied in evaluated Web sites, although the combination of multiple components in one resourceis not very common. The first generation of online resources has already changed parenting and parentingsupport for a large group of parents and professionals. Suggestions for future development and research arediscussed.
Introduction
The Internet, with its many facets and features, offersparents all kinds of support: parents can gather infor-
mation, share experiences, learn new skills, encourage eachother, or request professional advice. Visitor numbers toparenting Web sites run as high as hundreds of thousands permonth.1–3 Following and intensifying the trend that parentsare users of online resources, parenting professionals havebegun to exploit the opportunities afforded by online tech-nology. Several disciplines are involved in providing parentalsupport and advice, such as psychology, counseling, pediat-rics, and nursing, all of which have undertaken initiatives toemploy the Internet as a tool for their work.4 These initiativesgo by different names, for example computer mediated in-terventions, web based therapy, e-health, online counseling,or cybertherapy. Several authors suggest that the Internetcould be a tool for delivering parenting support in an acces-sible and beneficial way.5–9 Parenting support on the Internetis a relatively new domain, and our current knowledge of its
design and outcomes is limited. In spite of its claimedpotential, the position of online support for parents is yetmarginal in relation to traditional parenting training and in-tervention programs. Although previous reports have de-scribed the role of social networking in regard to healthrelated support needs,10,11 they do not show the specificcharacteristics of parenting services offered online, for ex-ample the types of online communication applied, the ratiobetween peer and professional support, and the opportunitiesfor addressing a wide range of topics for a diversity of targetgroups. A systematic review of empirical studies on onlineparenting resources is currently lacking.
Web based programs offer various types of online com-munication, for example chat, confidential chat, e-mail con-sultation, e-mailing list, discussion boards, and informationpages. In ‘‘chat,’’ parents can exchange experiences andopinions, typing short alternating texts in small groups orpairs. A special form is ‘‘confidential chat,’’ whereby a pro-fessional (e.g., a counselor or a therapist) is available forsupport and advice.12,13 There are healthcare/mental
1Fontys School of Pedagogical Studies, Fontys University of Applied Sciences, Sittard, The Netherlands.2Faculty of Social and Behavioural Sciences, University of Amsterdam, Amsterdam, The Netherlands.
CYBERPSYCHOLOGY, BEHAVIOR, AND SOCIAL NETWORKING
Volume 16, Number 7, 2013ª Mary Ann Liebert, Inc.DOI: 10.1089/cyber.2012.0547
518
healthcare providers that offer e-mail consultation services,such as ‘‘ask-a-nurse’’ or ‘‘helpline.’’14,15 Information on spe-cific themes can be distributed among registered groupmembers via e-mailing lists.16,17 Parents who share a specificexperience in childrearing can organize themselves into anonline forum or discussion board, and can exchange mes-sages in groups. Finally, information pages can be seen as adigital library, giving access to all kinds of facts, explanations,and suggestions.18–20 Thus, social networking, static onlineinformation, and professional consultation are all providedin different resources. Information pages and e-mailing listscan be seen as interaction from ‘‘one to many,’’ group forumsand group chat as interaction from ‘‘many to many,’’ andconfidential chat and e-mail consultations as ‘‘one to one’’communication.21
Web based communication can be controlled by peers orprofessionals, or both. For instance, discussion boards typi-cally offer peer support, while e-mail consultations provideprofessional support. Chat and e-mail are text based methodsof delivering advice and support. It is plausible that onlinemethods require skills other than those required for face toface support in order to, for instance, build rapport, interpret,reflect, confront, and summarize.15,22–24 Further, trainedprofessionals can help parents to use online resources byadapting an empowering attitude in designing and deliver-ing online information and support.2,19 Parenting supportprograms have been claimed to be more effective when theyare provided by well-trained practitioners.25,26 For now, wedo not know to what extent professionals, like psychologists,are involved in providing online parenting programs and ifthey have been trained to do so.
One of the advantages of online dissemination of parentingprograms is that many target groups can be reached. Use ofthe Internet has increased rapidly since it became widelyavailable in 1995. Internet World Stats27 reports a penetrationof Internet access by 32.7% of the worldwide population inDecember 2011; access ranged from 13.5% in Africa through78.6% in North America to 89.5% in the Netherlands,mounting each year. Professionally designed parenting pro-grams usually aim to reduce family stress, strengthen par-ents’ advocacy, and improve parenting self-efficacy andparenting competences by delivering resources for mutualsupport, offering professional consultation, and providingparent training. Traditional face to face parenting supportfocuses on the first stages of parenting as a period of transi-tion and support needs28 and on early intervention.29,30
However, other developmental stages of children can beequally challenging to parents.31 It is commonly acknowl-edged32–34 that parenting can be a challenging task, be it atcertain stages of child development (e.g., transition to par-enthood, infancy, adolescence) or in difficult circumstances(e.g., low income, social isolation, divorce, single parenting,illness, disabilities). We do not know yet, however, whichparents are the target groups of current online support.
Interestingly, a number of both large and small scale ap-plications of online parental support have been evaluated.This interesting line of study includes resources with a widevariety of types of online communication and providers. Anoverview of scholarly research on these programs is neededto assess the evidence base in this area, to verify suggestedbenefits, and to describe implications for future interventiondesign.
By reviewing studies on online parenting resources indetail, we aim to answer two main research questions:
RQ1: What are the characteristics of online parenting re-
sources? Which and how many types of online com-
munication do they use? Do they offer peer and
professional support? Which groups do they target on
which topics?
RQ2: What are the outcomes of different types of evaluation
studies for online parenting Web sites?
Method
Selection of studies
To find full text empirical studies on web based parentingservices that were published before 2010, we conducted amultiple field search in the databases of the Social ScienceCitation Index, PsycINFO, and PubMed. The extensive searchstrategy included blocks of various root terms related toparenthood (parent, mother, father, child, famil*, or pediatr*),parental support (counsel, coach, support, empower, advice,or train), and the online context (Internet*, online, mail, chat,computer, Web site). Studies were also subsequently locatedin other sources by searching for additional references in theobtained studies.
There were three inclusion criteria for this review. First, theprimary components of the studied resource were deliveredonline. Second, the primary target group of these resourcesexists of parents who had children aged between - 9 months(pregnancy) and 21 years (adulthood). Finally, studied re-sources were actual sites on the Internet (some requiredregistered login). Two original research reports, which wereprepublished online in 2009, were included. We did not in-clude descriptive articles on online information for parents.Editorials, commentaries, reviews, and conference paperswere also excluded.
After screening for duplicates, 485 studies were rejectedbecause they did not meet the criteria for the target group. Weassessed 115 articles for eligibility. Of these, 40 studies wererejected because they were descriptive articles on onlineparenting information. After screening the studies with ourinclusion and exclusion criteria, 75 research articles publishedbetween 1998 and 2010 comprised the final set of studies.
Coding
We developed a coding scheme to describe resource anduser characteristics of the web based resources and to assessthe methodological characteristics of their evaluations. Twoindependent coders (i.e., the first and the second author)coded each study.
Concerning resource characteristics, we coded types ofonline communication (i.e., e-mail consultation, e-mailing list,confidential chat, group chat, group forum, information pa-ges); facilitation of professional or peer support; combina-tions with offline services; and guidelines for professionalconduct. Further, parent and child demographics and riskfactors were coded (i.e., on the parent level: pregnancy, firsttime parenthood, single parenthood, minority, low income,low social support; on the child level: preterm, physicalhandicaps, mental health problems, illness, preventive healthchecks). Finally, we coded the following methodological
REVIEW OF PEER AND PROFESSIONAL PARENTING SUPPORT ON THE INTERNET 519
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aspects of the research design: type of research (experimental,content analysis, satisfaction); research period; sample size;theoretical framework; allocation and randomization; use ofincentive; and types of tests and experimental results.
Intercoder reliability was estimated by determiningCohen’s kappa in the case of nominal variables and the in-traclass correlation (ICC, two-way random, absolute agree-ment) for continuous variables, using 0.70 as the cut-off scorefor inclusion. Reliability proved satisfactory to excellent forthe majority of the coded variables, with j ranging from 0.72to 1, and ICC ranging from 0.81 to 1. In the case of divergentcodes, final codes were established by discussion.
Results
Since the Internet became available to a broad public in1995, we expected that the first studies would have appearedshortly after that year. The first article in our sample waspublished in 1998. While a quarter of the research articleswere published before 2005, the other studies were publishedmore recently; a quarter were published in 2009 alone.
Types of online communication
Table 1 provides an overview of resource characteristics forthe included studies. The vast majority of the web based re-sources in our sample offered one or two types of onlinecommunication. Information pages are a dominant feature(61.3%), followed by group forums (36%), and e-mail con-sultations between professional and parent (32%). E-mailinglists (13.3%) and chats with peers (13.3%) were less frequentlyreported; in one study, a confidential chat with a professional(1.3%) was examined.
Thus, our sample showed many different features of onlinecommunication. Further analysis revealed that 47 of the 75studies examined web based programs for parents featuring asingle type of online communication (62.6%), while 28 ex-amined resources with multiple components of online com-munication (37.3%). In the latter studies, 15 programsfeatured two components and 11 featured three components.There were two resources that offered a combination of fourtypes of online communication. Seventeen programs (22.6%)used a two layered interaction model, mostly offering acombination of information pages (one to many) and either e-mail consultation (one to one) or a group forum (many tomany). Ten programs (13.3%) used a three layered interactionmodel, combining these three types of online communication.
The online parenting resources make use of a wide range oftypes of online communication. Use of multiple componentsand the facilitation of layered interactions in one online ser-vice are not common.
Professional involvement
Professionals were often involved in online parentingprograms. Exclusively peer orientated online programs madeup nearly one quarter of our studies; combinations of peersupport with professional help were also frequently ob-served. Nineteen resources could be qualified as parentinginterventions, aimed at the improvement of parenting com-petence. A large array of professional backgrounds were re-presented in these programs: clinical psychologists, coaches,developmental specialists, genetic counselors, healthcare
professionals, midwives, nurses, parent coaches, pediatri-cians, physicians, psychologists, researchers, social workers,teachers, or therapists. In 11 studies (14.7%), we found ex-plicit references to guidelines for providing professionalsupport, mostly related to the quality of information pages.We found no clear instructions for professionals on how toprovide text based professional support in confidential chator e-mail consultations. Thus, although professional in-volvement in these resources is high, directives for profes-sional conduct were scarcely reported.
Target groups
To clarify which topics and target groups were defined bythe studies, we identified both parent characteristics (e.g.,gender, specific themes) and child characteristics (e.g., age,health condition).
Many of the articles that specify parents’ characteristics(n = 36) are specifically devoted to services for pregnant par-ents or first time parents. A relatively large proportion of theweb based resources focused on parents with low socialsupport (17.3%) or low income (12%). Parents’ mean age,reported in 34 studies, was 32.3 years.
In addition to the characteristics of parents, we examinedthose of their children in order to describe the target group ofthe included online programs. Children’s health was an im-portant motive for designing online services to parents(54.3%). These were mostly offered in a pediatric hospitalsetting to the parents of children with physical disabilities orillness (28%) such as spina bifida, traumatic brain injury, orcancer, or mental health issues (13%) such as autism orADHD. Ten online services (13.3%) were offered in combi-nation with preventive health checks.
Twenty-four percent of the studies did not report data onthe children’s ages, whereas 15 studies concerned resourcesfor the parents of all children, regardless of their age. In thestudies that did report the age of the children, the minimumand maximum ages ranged from - 9 months (i.e., pregnancy)to 21 years, with a median of 81.1 months (6.7 years). Par-enting adolescent children ( > 12 years) was central in onlyone resource.35
To sum up: most of the resources in our sample were tar-geted at specific groups of parents and/or children. Half ofthem concerned child health topics, and a large part of theresources was designed to support pregnant and first timeparents. A number of Web sites aimed at parents with lowincome or low social support. The majority of the web basedprograms were aimed at parents with preschool children.
Methodological characteristics of the studies
The studies (see Table 2 for an overview) can be dividedinto two main categories: content analytic studies and ex-perimental studies.
Content analytic studies
Two thirds of the content analytic studies coded postingson e-mail lists, discussion boards, and group chatrooms, andthus focused on social networking among parents. Tenstudies coded e-mail consultations and information pagesprovided by professionals. In total 15,059 online texts wereanalyzed. The sample size of evaluated messages differed
524 NIEUWBOER ET AL.
significantly among studies, varying from 2236 to 6,14237
analyzed messages. One third of these studies (30.4%) ana-lyzed peer support combined with professional support,whereby a professional functioned as a moderator of a peergroup, or a professional consultation was offered in additionto peer support. Four studies concerned resources that wereprovided exclusively by professionals (17.3%). Two of thesestudies mentioned the training of practitioners in social sup-port theory and its application in an online chat forum formothers of mentally ill children36 and in e-mail consultationsby nurses.38
Interactive forums and discussion boards often focus on aspecific target group or parenting topic. There is a strongfocus on children under the age of 12 (47.8%); pregnancy isalso a frequent topic (13%) in this line of study.
Most authors were interested in emerging themes andtopics that were frequently discussed online, like day to daychallenges for mothers of young children.38–40 Researchersalso analyzed these peer orientated services for parents inchallenging circumstances, like parenting children with spinabifida,41 autism,37 and mental illness.8,36 They found thatsocial networking was appreciated because it contributedactively in meaningful goals, for instance to be acknowl-edged, be empowered, adjust to changes, seek encourage-ment, seek a sense of belonging, or help others.
Almost half of the content analytic studies coded aspects,derived from theories on social support, providing a firmbasis for the value of social networking in relation to par-enting issues.
Experimental studies
Nineteen studies (25.3% of all studies) evaluated effects ofonline parental support. Twelve of these studies (16%) eval-uated online parent training interventions. These evaluationsshow a wide variety in the effects studied and measures used,as well as in user characteristics and resource characteristics.The topics were highly diverse, including for example healthand mental health, parenting skills, and parenting specificchildren groups with specific factors, such as adolescentsubstance use, newborn care, and social–emotional risks.
The parent and child characteristics of participants in theinterventions that were evaluated, as well as the programfeatures, differ slightly from those in the programs in the totalsample of studies. First, the reported maximum age of chil-dren was 87.2 months (7.3 years) in 14 studies, which repre-sents an even stronger emphasis on the parenting of youngchildren. Further, professional support is a dominant char-acteristic of the evaluated programs (100% in experimentalstudies vs. 77.3% in all studies), which implies that programsthat exclusively facilitate peer support have not been evalu-ated with experimental studies. However, three resources didoffer peer support in adjunction to professional support.Thus, programs with professional support and a focus onrelatively young children predominate in the experimentalstudies.
Although some other types of online communication—such as e-mail consultations (31.6%), group chat (5.3%), orgroup forums (31.6%)—were a part of the evaluated inter-ventions, information pages were a common feature of all ofthem (100% in experimental studies vs. 61.3% in all studies).Two programs offered additional face to face support, and
one offered telephone support in addition to online features;another one offered television broadcasts.42 We found severalcreative uses of online media for online parent training, suchas an animated character on a handheld device that guidesmothers through a problem solving strategy,43 videos dem-onstrating positive parenting behaviors,44 web based trainingsessions,45 multimedia training modules,46,47 and interactivehomework sessions.48,49
Although the number of experimental studies is low andthey are based on small samples, the results are promis-ing. All reports expressed optimism about the feasibility, ac-ceptance, and effectiveness of the online service, often basedon positive satisfaction reports. In total, effects showed amedium effect size. It should, however, be noted that alleffects were self-reported, mostly with the use of validatedinstruments.
Discussion
Parenting has been changed by the Internet. Internet pio-neers have developed web based programs that provide highquality information to enhance parents’ knowledge, easyaccess to peers with whom to share experiences, and profes-sional consultation and training. Parents can now find a hugeamount of information and support on the Internet that isaccessible, anonymous, cost-effective, and convenient.5–7,9
Only a small number of these Internet resources have beenevaluated in a scientific study, and the studies we reviewedrepresent only a fraction of the huge number of online ser-vices that are available to parents on the Internet.
The studies in this review show that, apart from parenting,parenting support has also been changed by the opportuni-ties the Internet has to offer. The studies reported on serviceswith a broad range of types of online communication. Theseprograms vary widely in goals, design, and reach in order torespond to the different needs of parents.
The content analytic studies showed a strong focus ononline exchanges and peer support, whereas informationpages and professional training and support were frequentthemes in the experimental studies. Content analytic studiesof online parenting resources provide a firm theoretical andempirical basis for the value of online social networking.Parents were, without exception, satisfied with the resourcesoffered to them. The experimental studies show some posi-tive effects on parenting skills and child behavior. However,due to the small sample of experimental studies in this re-view, their wide variety, and their mixed outcomes, it is dif-ficult to generalize conclusions to the many resources forparents on the World Wide Web.
This review shows a trend that scholarly interest in thesubject of online resources for parents is growing. The ap-plication of asynchronous types of online communication,professional support, and young children’s health topics aredominant characteristics of the studied resources. Specifi-cally, such online resources may be designed by parentingpractitioners to reach a large population and prevent prob-lems with parenting.
We suggest several directions for future development forthe innovation of traditional parenting programs and to en-hance the quality of this field.
First, future developers may broaden the scope of onlineprograms for parents. Research on online parenting resources
REVIEW OF PEER AND PROFESSIONAL PARENTING SUPPORT ON THE INTERNET 525
currently places a heavy emphasis on mothers, pregnancy,and young children, while less attention is paid to fathers andlater developmental phases of children. The current state ofthe field likely reflects professional parenting support ingeneral.28–30 However, other developmental stages of chil-dren can be equally challenging to parents and, hence, de-veloping online services for parents with older children seemsan interesting and complementary domain to explore in thenear future.31,50 Some inspiring initiatives of online inter-ventions for parents of older children and a variety in topicsare described in this review.
Second, new technologies have recently become availablefor developers and parents. In this review, we found thatinformation pages are currently a dominant format used inthe programs. Combining types of online communicationmay enrich interventions, but the positive effects of layeredinteractions have not yet been demonstrated. Multimediainnovations might offer new ways of supporting parents thatdiffer from traditional programs. New types of online com-munication (e.g., videochat, microblogging, wiki, ping) havebeen introduced, and also new hardware has been developed(e.g., smartphones, digital tablets, personal digital assistants).These technological innovations may inspire practitionersand developers to offer additional highly interactive oppor-tunities for parenting support in combination with socialnetworking.
Further, this review reveals some limitations in the currentknowledge base. First, scientific evaluation of professionallydesigned online parenting interventions for a wide range oftarget groups is essential, and more programs should beevaluated in future research to establish their effects. Al-though large effects are perhaps not to be expected in the fieldof parenting education in general,30 this review shows someinteresting examples of effective parenting support. Promis-ing innovations are interactive technologies, which facilitatesharing experiences, demonstrating parenting behavior andguiding parents through training sessions.
Finally, we found that clear guidelines for professionalskills or conduct were not included in the reports. However,parenting practitioners and healthcare providers are essentialfor disseminating information and providing support onlinein a proactive, professional, and ethical manner.19 Profes-sional training for the text based support of parents shouldtherefore be developed and encouraged, and should be in-cluded in evaluation reports.
To summarize, enhancements to this line of study couldinclude, on the resource level, the application of multicom-ponent and multilayered types of online communication, theprofessionalization of online support, and the disseminationof resources to meet a wider range of parental needs. As aresult, online resources may acquire a firm position in thedomain of parent intervention programs in the near future.On the level of study design, more online parenting inter-ventions should be evaluated to substantiate claims about theefficiency and effectiveness of online support programs andraise their accountability.
Several authors have described online parenting and pa-tient support as a service ‘‘in its infancy.’’4,9,51–53 If one viewsthese interventions as being part of the ‘‘first generation,’’ it isfair to say that research on these interventions is first gener-ation research. With the rapid evolvement of Internet tech-nologies, providing online services seems a given, rather than
a choice, in future intervention design. This review showssome creative examples of online parenting programs after 15years of scientific evaluation in this relatively new domain.
Both the inspiring results of many of the pioneering studieswe reviewed and the high satisfaction rates suggest that thereis much to be gained by exploiting the potential of the In-ternet to provide parents with the best possible support, inconjunction with a more thorough approach to program de-sign, professional training, and evaluation. The studies fromour review have shown that the first generation of onlineresources has changed parenting and parenting support for alarge group of parents and professionals.
Author Disclosure Statement
No competing financial interests exist.
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Address correspondence to:Christa Nieuwboer
Fontys School of Pedagogical StudiesFontys University of Applied Sciences
Mgr. Claessenstraat 46131 AJ SittardThe Netherlands
E-mail: [email protected]
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