The objective of this feasibility study was to gain insight into occupational physicians' (OPs) and employees' use of, and attitudes towards, 'Snelbeter' (Get Well Fast), a new web-based counselling program for employees on sick leave due to non-specific back or neck pain and their OPs.Registered user information was collected from the website to get insight in the use of the program by employees (n = 24). Qualitative information was obtained through semi-structured in-depth interviews with 19 OPs and nine employees in order to get insight in the actual use of the provided information, the attitudes towards the program and possible improvements of the program.Actual use of the program among OPs was low. The majority of OPs, eight out of 11 (73%), never or only occasionally signed in. The greatest obstacle for OPs to use the program was the low number of eligible employees involved. Employees appreciated the program but their use was moderate. A small majority of the employees who used the program, 14 out of 24 (58%), opened 50% to 100% of the provided documents, a majority of the interviewed employees, seven out of nine (78%), used the provided information sometimes or regularly. The absence of personal contact was found to be a major barrier towards use of the program by employees.Although both OPs and employees appreciated the idea of the program and employees appreciated using it, program utilization was moderate to low. The discussion section reveals that before implementation can be started to any extent, the program will need adaptations that make it more attractive to use. The program should be considered for both return to work (RTW) and the prevention of sick leave. Adding personal contact (e.g. involving physiotherapists) to the program may also be promising. The most prevalent musculoskeletal symptom in the Netherlands is low back pain , followed by neck pain  . ObviousTo incorporate these factors in the usual care of employees on sick leave due to non-specific back or neck pain, a web-based counselling program named 'Snelbeter' (Get Well Fast) was developed. The purpose of this web-based counselling program  is twofold: 1) to stimulate the self-efficacy of employees, and 2) improve the knowledge and capacity of OPs to deliver individualized care and support their referral process. The program was developed by two experts, an OP and a physiotherapist, after several discussions in the multidisciplinary research team. Before OPs could start, they had to follow a training in the purpose and use of the program.The objective of this feasibility study is to gain insight into OPs' and employees' use of and attitudes towards the program. This paper answers the following questions:1. To what extent did OPs and employees use the program?2. What did OPs and employees appreciate about the program?3. Did anything prevent the OPs and employees' from using the program?4. How do OPs and employees think the program could be improved?http://www.snelbeter.nl[The program is accessible for the employee and his OP by lbeter.nl. The empThe feasibility study was conducted by gathering registered user information of the web-based program and interviewing both OPs and employees. The study population consisted of OPs working for either KLM or National Railways and employees of both companies absent due to back or neck pain. In the Dutch system, all employees are attached to an occupational health service which requires those on sick leave for longer than a fortnight to see their OP. During the first consultation, employees who met the inclusion criteria . Themes included the opinions and issues mentioned by one or more respondents as summarized by the researcher. Themes were identified through a crystallization process. Various key words were linked to the answers from OPs and employees. Then these were categorized into the themes. Simple counts were used to provide a summary of the results. The results are illustrated by quotations from participants.All 11 OPs who recruited employees participated in the interviews. Of the 15 OPs who did not recruit employees, eight participated in the interviews. Lack of time and personal considerations were reasons given for non-participation. We obtained registered user information for all 24 employees who used the program but only nine were available for an interview. Fifteen employees were unavailable for an interview even after several attempts had been made to reach them. Reasons for non-participation ranged from 'no time' to 'insufficient use of the program' and 'problems with recalling experiences'. The interviewed employee population consisted predominantly of men (67%) between 40 and 50 years suffering from low back pain (75%). Both white and blue collar workers with various levels of education were recruited. Sick leave duration due to back or neck pain including partial absenteeism ranged from seven weeks to six months.Use of the program by OPs was low. Three of the 11 OPs never logged in to the website to follow the information or instructions. Five OPs signed in occasionally and only three did so regularly. Six of the 11 OPs tracked the employee's personal diary and read the employee reports based on the questionnaire data at least one time, which included specific recommendations for RTW and referral to secondary care. Only one OP used these recommendations in practice.Both the registered and actual use of the program was moderate among the employees. Registered data revealed that seven employees, out of 24 employees who used the program, filled in all four questionnaires. Another 12 filled in two or three questionnaires and the remaining five just one questionnaire. Ten employees opened less than 50% of the documents provided. Six employees opened between 50-75% of the documents, four employees opened almost all of them and four employees did indeed open them all. The majority (n = 7) of the nine interviewed employees reported that they read the provided documents sometimes or regularly and performed one or more of the exercises.Most OPs believed that the program is useful for employees. Some stressed that it would be most useful for employees who did not know how to cope with pain or were experiencing pain for the first time. Only half of the OPs indicated that the program had added value for themselves. Some OPs mentioned that the program offered additional support for them especially when an employee's recovery was making no progress. About half of the OPs indicated that a website is a good medium for the counselling of employees with back or neck pain. More than half of the OPs were positive about the content . It was suggested that the program could be useful as a reference source as it provides a good overview of information for OPs. It also supports the taking of systematic action. Finally, almost all OPs were positive about the user-friendliness and design of the program.The majority of employees replied affirmatively to 'Did the program add value to the treatment of your back or neck pain?' Overall, employees experienced the program as a supportive tool. The program stimulated them to perform exercises at home, helped them give structure to their daily life and gave them the feeling that they could take an active approach to their pain and RTW process. Furthermore, employees felt their situation was gaining attention. They were positive about the content, user-friendliness and web-based design of the program. They said the information was easy to understand, to the point, and conveniently arranged. About half of the interviewed employees said that the program extended their knowledge of coping with pain and enhanced communication with their OP. A few employees reported that the program helped them to return to work faster.Of all the available information, the neck and back exercises were appreciated the most. Some employees involved their physiotherapist in the RTW program. One discussed the exercises with his therapist. In contrast, other employees noted that the program was most useful when they received no additional treatment. The program was perceived as useful if employees lacked knowledge, were experiencing pain for the first time or had less severe pain. This outcome was supported by comments from the OPs.Although about half of the OPs were positive about the added value, content and user-friendliness of the program, all encountered obstacles which limited their use of the program in actual practice. The greatest barrier for OPs was the low number of employees who met the inclusion criteria, especially for those who did not recruit employees. Several OPs mentioned that employees' fast recovery also had an impact on the low numbers involved. Furthermore, many employees were contacted later than the official term, about two weeks after the employee has become absent from work. By this stage employees may already be under treatment by their general practitioner or another therapist. Because of the low number of employees involved, OPs did not get round to using the program with any routine. As one OP said, 'It takes time to get used to the recruitment process and to using the program.' More than half of all OPs did not keep the program in mind during consultations and some had difficulty providing employees with accurate information about the program.A second important barrier for OPs was the limited time available for introducing employees to the program and working with it as well. As another OP pointed out, 'We lack the time to do this kind of projects.' Several OPs mentioned that since they were already burdened by many administrative tasks they found the program more of an extra duty than something that offered added value. As well as these major barriers, OPs indicated other aspects which discouraged their use of the program. One OP explained that he was quite capable of managing the RTW process himself and did not need a program for additional support. Many preferred the more familiar therapies (e.g. physiotherapy) for their employees despite the fact that the program can work as a supportive tool. They preferred having personal contact with employees. One OP stated that he did not use the program because he did not believe in 'computer-based treatment' of physical pain. He explained, 'The ability to touch people is an essential element in the treatment of people with back or neck pain.' Some OPs had no affinity with the use of a web-based program in general and therefore preferred not to use this method. Finally, some OPs faced practical obstacles, such as log-in problems or no access to a computer or the internet in their consulting rooms.The greatest barrier for employees against using the program was the availability of other treatment such as physiotherapy, which involves personal contact. Employees perceived the program as less relevant because they were already getting exercises from their physiotherapist. For some employees the exercises suggested by the program conflicted with the exercises given by the physiotherapist. They felt that some exercises would be performed better after consultation with a physiotherapist. In addition, because some of the advice and exercises were not specific enough, they did not apply to the employee's situation. It was remarkable that almost no employees talked about the outcome of the program with their OPs. The program was not a subject of discussion during consultations; no OPs actually referred to the program. One employee said, 'I expected more commitment from my OP". This did not encourage employees to use the program. Only a few employees considered the large amount of information as a barrier. One employee mentioned that the back or neck pain they were suffering from may have prevented them from sitting at a computer. A small number of employees either had 'problems with logging in' into the program or had 'no affinity with computers'.Although OPs were generally positive about the user-friendliness and design of the program, some felt that further improving user-friendliness  might enhance its use. For example, it was suggested that it would be useful if the program was able to sort a list of employees in the same way as the OP's company system does. It should also be easier to register employees in the program. A helpdesk or some additional support would be helpful in case the OP had practical questions. Alternative tools, instead of the program, were also suggested. According to one OP, a website with a practical overview of information would be sufficient to satisfy the needs of OPs and employees. Some questioned whether the OP should be involved in the program at all. For example the direct supervisor or the physiotherapist might have a more prominent role in the promotion and use of the program. One OP mentioned the importance of focussing on the prevention of sick leave due to back or neck pain, in addition to focussing on the RTW process. This broader focus should not only be on sick leave prevention but also on how to work with pain. Additional content should be provided for this purpose. OPs also meet employees at an earlier stage, for example during an open consultation or during a general medical assessment. According to one OP, this would be a good starting point for recruiting employees to the program. OPs put forward that the direct supervisors should be more involved in the prevention of sick leave due to back or neck pain since their support is important.A couple of employees mentioned the importance of customizing the advice to an employee's personal needs. Circumstances can change over time; therefore it is important that the advice fits the employee's current situation. Employees mentioned that a feedback function on the program would be helpful, which was also mentioned by OPs. For example, it would give the employee the opportunity to contact a professional by telephone or e-mail. According to one employee, a personal meeting a couple of weeks after the program is finished would be useful for evaluating recovery. It was suggested that combining hands-on treatment by a physiotherapist with the web-based counselling program would provide optimal support. Increasing the involvement of OPs or physiotherapists may stimulate employees to use the program. Employees also suggested other improvements related to the program content and user-friendliness (e.g. shortening the questionnaires and adding illustrations and cartoons). A link on the company website would also enhance use of the program. One employee felt that more attention should be paid to the psychological distress experienced by employees suffering from back or neck pain. He explained, 'I missed information on how to deal with it mentally.' Another employee felt that more attention should be paid to the prevention of sick leave due to back or neck pain. For example, preventive exercises could be made available on the company's website.The perceived barriers and possible improvements of the program are summarized in table The results of this feasibility study showed that although OPs and employees are generally positive about the web-based counselling program in terms of content and user-friendliness, in practice usage was low, particularly among OPs. Some employees returned to work during the program which may have been why they stopped using it. Some barriers limited the use of the program. For example, both OPs and employees mentioned that they prefer therapies with personal contact. This finding is in line with results reported by Steele et al. . Their pAn issue mentioned by OPs and one employee is to focus on the prevention of sick leave as well. Broadening the program's focus to the prevention of sick leave and working with back or neck pain would increase the target population and could improve usage by OPs and employees.To our knowledge, our study is the first to use a customized web-based program in occupational health care for non-specific back or neck pain. A strength of the study was that the program was applied in a real-life occupational healthcare setting. Therefore, the generalizability of the results is good. A second strength is that the web-based content conforms to the Dutch practice guidelines for employees with back and neck complaints ,18. FinaThis study also has limitations. First, the value of the results derived from interviews with OPs who only received training without including any employees is questionable since their answers were based on their opinions, not on their use of the program. Furthermore, since we interviewed only a limited number of employees and OPs, we may have missed relevant information. We possibly did not achieve full saturation, especially among employees. A recollection bias also needs to be taken into account, since the interviews took place more than six months after the intervention. We controlled for this partly by giving the respondents the opportunity to look at the website before the interview. There may have been some response bias during the interviews as well. Participants may have provided more desirable feedback about the program when faced by the interviewer. However, prior to starting the interview, we stressed that it was of great importance to be honest. A selection bias may have occurred if the only participants were those people who were positive about the program. However, we included OPs and employees who used the program to different extents (i.e. based on the number of filled in questionnaires and opened documents).Overall, our study stresses the importance of assessing needs of both employees and OPs in preparation for intervention development. Needs assessment and context analysis is a systematic study of the discrepancy between what is and what should be needed in a group and situation of interest. A program can only be effective if there is a real problem or need . A rigorMore general research on the use of web-based programs for musculoskeletal disorders in occupational health care is desirable. Since our intervention study was limited to OPs and employees from two transport companies it would be interesting to apply the web-based program to other target groups, for example, in the health care sector.The results of this study showed that the use of the program was low among OPs. The majority of OPs, eight out of 11 (73%), never or only occasionally signed in. Only one OP used the provided recommendations for OPs about RTW and referral to secondary care of employees in practice. Although the majority of OPs appreciated the value of the program for employees, only half of the OPs experienced added value personally. All OPs perceived barriers against using the program in practice. The low number of employees involved, lack of time and a preference for usual care were reasons why the program was hardly ever used in consultations. According to OPs some adaptations might improve its user-friendliness (e.g. simplifying registration of employees and adding a helpdesk function). However, because of their limited use of the program we questioned whether the OPs should be extensively involved in the program. Therapeutic involvement of a therapist does seems important, but perhaps someone else could fill the role played by the OP, for example a physiotherapist.The employees used the program to a moderate extent. A small majority of the employees who used the program, 14 out of 24 (58%), opened 50% to 100% of the provided documents, a majority of the interviewed employees, seven out of nine (78%), used the provided information sometimes to regularly. Most employees confirmed that the program offered added value in their consultations for back or neck pain. They also appreciated the content and design of the program. However, as for OPs, the availability of usual care was a barrier against using the program. Employees indicated that the involvement of a therapist, more opportunities for feedback, the ability to customize the program, more emphasis on emotional factors, and a link to the company website were all factors that would improve the program.OPs and an employee mentioned the importance of focussing on the prevention of sick leave due to back or neck pain We concluded that broadening the program's focus to the prevention of sick leave and working with back or neck pain would increase the target population and could improve usage by OPs and employees.The authors declare that they have no competing interests.TJ conceived the study, participated in the design and coordination of the study, performed the data analysis and drafted the manuscript. JH conceived the study, participated in its design and coordination and drafted the manuscript. BMB, JRA and AJB conceived the study and helped to draft the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6947/9/46/prepub


There have been no previous studies of the variables that predict adherence to online depression and anxiety intervention programs among adolescents. However, research of traditionally delivered intervention programs for a variety of health conditions in adolescence suggests that health knowledge, type and level of symptomatology, race, socioeconomic status, treatment setting, and support may predict adherence.The aim was to compare adherence rates and identify the predictors of adherence to a cognitive behavior therapy website in two adolescent samples that were offered the program in different settings and under different conditions of support.The first adolescent sample consisted of 1000 school students who completed the MoodGYM program in a classroom setting over five weeks as part of a randomized controlled trial. The second sample consisted of 7207 adolescents who accessed the MoodGYM program spontaneously and directly through the open access URL. All users completed a brief survey before the start of the program that measured background characteristics, depression history, symptoms of depression and anxiety, and dysfunctional thinking.t                        1088.62 = −28.39, P < .001). A multiple linear regression revealed that school-based setting (P < .001) and female gender (P < .001) were predictive of greater adherence, as were living in a rural area (P < .001) and lower pre-test anxiety (P = .04) scores for the school-based sample and higher pre-test depression scores (P = .01) for the community sample. A history of depression (P = .33) and pre-test warpy thoughts scores (P = .35) were not predictive of adherence in the school-based or community sample. Adolescents in the school-based sample completed significantly more online exercises  than adolescents in the open access community sample (mean = 3.10, SD = 3.85;  Adherence is greater in monitored settings, and the predictors of adherence differ between settings. Understanding these differences may improve program effectiveness and efficiency. A number of early intervention and prevention programs have been developed to address the prevalence of anxiety and depressive disorders in children and adolescents ,2. HowevKnowledge about the predictors of adherence to intervention programs in adolescent populations is largely based on research targeting physical health or smoking behaviors. Kyngäs , for insProgram adherence for medical conditions among adults and children has also been found to depend on the type of treatment and program factors such as reminders, rewards, and monitoring . System Previous research on program adherence has been hampered by imperfect data collection methods, using retrospective self-reports (which rely on good memory), and absence of social desirability bias ,12. BehaThe current study was designed to investigate adherence, with the level of activity on the website serving as the primary measure of this construct. A specific objective of the study was to compare the module and exercise completion rates of adolescents for a mental health website (MoodGYM) in two distinct settings. The first sample constitutes a group of users who completed MoodGYM within a classroom, where teachers provided encouragement, support, and guidance in the use of the program as part of the curriculum. Teachers did not receive specific reports on student progress through the program. The second sample consisted of community adolescent users who spontaneously logged on to the open access site. In both settings, the website program was fully automated and participant progress within the program was self-directed, with the exception that the school-based participants were directed to a different module each week. We predicted that adherence rates would be greater for the monitored classroom setting compared to the community setting. The current study also aimed to identify the demographic, setting, and symptom-related factors that contribute to adherence in the two samples.The school sample comprised 1000 students who completed the MoodGYM program as part of the YouthMood Project during 2006 and 2007. The YouthMood Project is a randomized controlled trial evaluating the effectiveness of the MoodGYM program among adolescents aged 13 to 17 years. Thirty schools from across Australia took part in the project. During a designated class period of 50 minutes, once a week for five weeks, students were instructed to log on to the program and individually undertake the self-directed program. Using the teacher manual, the classroom teacher provided information, support, and referral advice, if required, and maintained classroom order. No psychological intervention was provided. Approximately 60% (597/1000) of the students participating in the YouthMood Project were female, 19% (193/1000) reported living in a rural area, and 29% (287/1000) had previously been depressed.The community sample consisted of 7207 adolescents from Australia who registered on the MoodGYM public site between January 2006 and November 2007. Adolescent users were identified as users who selected the age category “19 or under” when registering on the website. Approximately 72% (5223/7207) of the adolescent community users were female, with 66% (4734/7207) reporting a previous history of depression and 19% (1396/7207) indicating that they lived in a rural area.The MoodGYM program is an interactive, Internet-based CBT program designed to prevent and decrease symptoms of anxiety and depression. MoodGYM aims to modify dysfunctional thoughts and beliefs, improve self-esteem, and teach important life skills such as problem solving and relaxation. The MoodGYM program consists of five interactive modules, each of which includes information, animated demonstrations, quizzes, and “homework” exercises. A user’s answers to the quizzes and exercises in the MoodGYM program are recorded in his or her own personal MoodGYM Workbook, which he or she can access any time throughout the program. Upon registering, all users consent to their data being collected and stored in a secure database for analysis. The anonymity of users is protected through the use of a pseudonym.Users completed a number of measures prior to beginning the MoodGYM program, including the Goldberg Depression and Anxiety Scales  and the Anxiety and depressive symptoms were measured using the Goldberg Depression and Anxiety Scales . Each ofThe 42-item Warpy Thoughts Scale  was usedThe number of modules and exercises completed on the MoodGYM website were the primary outcome measures in the current study. The MoodGYM program automatically tracks and records a user’s activity on the website, including the number of log-ons and the number of modules and exercises started and completed. While the school-based users were encouraged to complete all modules of the program, the completion of exercises within the modules was optional, making this variable a good measure of adherence to, and level of engagement with, the treatment program. Since there were 28 exercises, the number of exercises completed could range from 0 to 28, while the number of modules completed could range from 0 to 5.t test were conducted to compare the adherence rates of the two adolescent samples. A hierarchical multiple linear regression was conducted on the combined sample to explore the predictors of adherence. In this model, the setting was entered first, followed by gender and location in the second step. Depression history was added in the third step, followed by the pre-test symptom variables of anxiety, depression, and warpy thoughts in the fourth step. In the final step, the interaction between setting and the other predictor variables was added to explore differences in adherence predictors between settings. All analyses were performed using SPSS v15 .Exploratory descriptive analyses and an independent samples The mean depression pre-test score for school-based participants was 2.62 (SD = 2.42), while mean pre-test anxiety and warpy thoughts scores were 2.51 (SD = 2.44) and 2.58 (SD = .65), respectively. The mean depression pre-test score for community users was 5.46 (SD = 2.42), while mean pre-test anxiety and warpy thoughts scores were 5.50 (SD = 2.59) and 3.16 (SD = .71), respectively.                                                            t                    1088.62 = −28.39, P < .001). Mean exercise completion rates also varied between schools in the school-based sample .Adolescents in the school-based sample completed significantly more exercises  than adolescents in the community sample , suggesting that other factors may also be predictive of adherence to the MoodGYM program. Future research, therefore, should focus on measuring other potential predictors of adherence such as motivation to change, stage of change, computer savviness, perceived efficacy of computer-based programs, level of support, and personal expectations.The variability in the exercise completion rates between schools in the school-based sample should also be investigated further. School-level predictors might include the gender distribution of students , type of school (private vs public), and the socioeconomic status of the school. In addition to this, future studies should also explicitly measure the extent to which users implement the techniques taught in the MoodGYM program as a means of identifying if people actively engage with the material on the website or are simply passive browsers. This would enable a user’s engagement with the program to be more closely assessed.We also acknowledge that there are many measured and unmeasured differences between our direct open access users and school students. It is clear that the open access adolescents had higher levels of anxiety and depression than the sample of adolescents in school classrooms. The motivation and context in which the program is likely to be undertaken is also very different. Open access users are likely to be seeking immediate help for mental health problems, while the average attendee at school may have no need for the website. These factors are likely to impact adherence rates and to confound differences between the adherence rates of the two samples described here. Nevertheless, our analyses, while identifying the importance of the difference between settings, control for this factor and provide additional information about the impact of other variables on adherence in both settings.The clarification and identification of further predictors of adherence would enable appropriate strategies to be developed that could help improve adherence to automated Internet applications . Such st


Integrative medicine  with conventional medicine) is becoming increasingly popular.The objectives of this paper are to compare and contrast the development of two teams that set out to establish integrative medical clinics, highlighting key issues found to be common to both settings, and to identify factors that appear to be necessary for integration to occur.At St Michael's Hospital , a total of 42 interviews were conducted between February 2004 and August 2006 wi18 key participants . At the CARE (Complementary and Alternative Research and Education) Program at Stollery Children's Hospital, Edmonton, Canada, 44 interviews were conducted with 24 people on four occasions: June 2004, March 2005, November 2006, and June 2007. Basic content analysis was used to identify the key themes from the transcribed interviews.Despite the contextual differences between the two programs, a striking number of similar themes emerged from the data. The five most important shared themes were: 1) the necessity of "champions" and institutional facilitators to conceive of, advocate for, and bring the programs to fruition; 2) the credibility of these champions and facilitators (and the credibility of the program being established) was key to the acceptance and growth of the program in each setting; 3) the ability to find the "right" practitioners and staff to establish the integrative team was crucial to each program's ultimate success; 4) the importance of trust (both the trustworthiness of the developing program as well as the trust that developed between the practitioners in the integrative team); and 5) the challenge of finding physical space to house the programs.The programs were ultimately successful because of the credibility of the champions, institutional facilitators and the staff members. Selection of excellent clinicians who were able to work well as a team facilitated the establishment of trust both within the team itself as well as between the team and the host institution. For example, Hsiao et al.'s interviews with a wide range of practitioners show that successful integration is related to provider attitudes toward integrative medicine, knowledge of integrative medicine, readiness to refer to other practitioners and ability of clinicians to practice more than a single modality.  This worThere are also a number of critiques that the type of medicine being practiced by those claiming to provide "integrative medicine" are not in actuality integrated according to many definitions of the concept. ,9 For exThere is an increasing number of accounts of integrative medicine program developments in the literature. i.e. -14) Thes Thes14])In this paper we compare the findings from two different applied ethnographies ,17 of inAt SMH, a total of 42 interviews were conducted between February 2004 and August 2006 with 18 key participants . All participants were interviewed at least twice, with the exception of two administrators and three family physicians who were only interviewed once. All interviews included questions about perceptions of, and involvement in, the integration of chiropractic services at SMH. At CARE, 44 interviews were conducted with 24 people on four occasions: June 2004, March 2005, November 2006, and June 2007. Five participants were interviewed only once due to staff turnover. Eighteen participants were interviewed 2 – 3 times. Only 1 participant was interviewed at all four visits. During the interview, the participants were asked to reflect on their experience of working in the CARE program; specifically, what seemed to be working well, what was not working, and what had changed since the authors' previous visit.All interviews were audio recorded and transcribed verbatim. The initial 10 interviews at each site were coded individually by both authors using basic content analysis -20 to idBoth programs described themselves as providing integrative medicine by which they meant combining CAM and conventional medicine therapies in an evidence-based approach to providing patient care. For instance, one of the stated goals of the CARE program was to:...create a supportive and collaborative environment where conventional health care providers, CAM practitioners, and trainees can investigate and learn about CAM therapies and products from a rigorous evidence-based perspective was very, very effective in advocating with the [provincial ministry of health] and using her relationship with people at the Ministry to push that forward...I think [Champion] was extremely effective with her strategy. There are a lot of people who are interested... but I think having an interest alone is not going to be enough to get a clinic up and running. You need someone to champion it, and who has knowledge as well as the motivation. And we have that. The services only became reality when these champions were able to mobilize support at a variety of different levels throughout the conventional medicine hierarchy within the institution with which they were affiliated. In both cases, the facilitators within the host institutions played essential roles in this stage.Respondents recognized that potentially controversial programs such as these require champions who are stellar in terms of their personal and professional credibility. "Credible" champions were identified as one of the key success factors for these programs:She [champion] is passionate about what she does, but her personal presentation I think is astute and conciliatory and not over-zealous and she is willing to listen. She has years of experience, both practically and politically, and that really comes across. I am sure that she has heard these arguments and criticisms a million times, but she deals with them graciously and politely and patiently and that kind of presentation is critical I think. It gave her a personal level of credibility.... She is very adept at getting money and convincing the powers that be, both at the hospital and ministry level, to go along with this. The adjectives used to describe the characteristics of both champions were strikingly similar. According to participants, each champion had vision, inspired both trust and confidence, and were able to mobilize many different types of people to work together. Participants also talked about the champions' energy and confidence in what they were trying to achieve, as well as their ability to include others in their plans:...good credentials, successful, driven, very ambitious, is able to articulate a vision. It was her vision. And her energy and her positivism. She really gives us all a sense of equality and tries to get us involved, open minded, happy. We trust [Champion] The champions, aided by the institutional facilitators, spent a great deal of time and energy laying the groundwork for the CARE and SMH programs within their respective institutions. This groundwork was instrumental in preparing clinicians and administrators at all levels of each home institution  to ensure that the integrative medicine program would be able to survive and thrive once it was introduced. Given the scarcity of resources and the range of opinions  about CAM therapies in general, it was essential that the champions and institutional facilitators were diligent in laying this groundwork prior to the initiation of the integrative medicine programs. This preliminary work made it clear that the programs were supported by senior level administration and physicians throughout the conventional medicine organization, which in turn sent the message to other clinicians throughout the institutions that these programs were safe, legitimate options for providing care for patients:It's important with any new service. We need to pave the way, we need to market it. We need to send positive messages to the potential referral services. Physicians and family physicians tend to be somewhat conservative about where they're going to send their patients. They're protective, and they're not just going to send them anywhere. So they want to know that it's supported and endorsed and has credibility and it's going to be a safe service....And also again sending the message that senior levels of program administration supported it and had confidence in it....We've also done a survey of all the divisions, like everyone who's a member of the Department of Pediatrics. That was to find out who was going to be sending patients to us. Because we wanted to be able to prepare in advance for what their clinical needs will be.... So the clinicians have an understanding that there is a need, they have a need for this knowledge, their patients have a need for this knowledge, they would love to have a place that they could send patients. It was a lot of work up front, but it's paid off. Participants interviewed for both projects explained how acquiring credibility within the host institutions was crucial to the success of the programs. For example, the SMH project had to overcome a history of distrust and, in some cases animosity, between chiropractors and physicians. -28 PhysiI know their names, I know who they are, I know they're good and well trained, that makes it [referring to the service] a little easier.6 SMH)I think that having a reliable, credible source is very important. It's the same with anything. I don't refer to all the gastroenterologists in the city either, right. So having a reliable, quality source that's actually in the hospital, and in the hospital context, makes a huge difference.... So would I refer to every chiropractor in the city the same way? No. I don't refer to every doctor in the city the same way. (HCP9 SMH)One of the key ways the SMH program built credibility and trust among the physicians of the host institution was by voluntarily limiting the scope of chiropractic practice to musculoskeletal complaints for which there existed a basis in scientific evidence. In addition, the chiropractors' practices were limited to referrals from physicians in the family practice unit and two other units in the hospital. Thus patients treated by the chiropractors were initially screened by physicians. These restrictions on the normal practice of chiropractic were key to creating the level of comfort necessary to initiate the chiropractic service; however, it was the competence and skill of the chiropractors working in the service that led to high levels of trust as the program evolved over time:It's hard to know who to send your patients to. You don't always know you if can trust the person you're sending your patient to, but in this case, we don't have this problem. CARE program members also identified establishing credibility for the program as being key to the program's success. One of the big challenges for CARE was that fact that they were a pediatric service and thus had to deal with the fact that there was relatively little scientific evidence about the safety or efficacy of most CAM therapies for children. Further, CARE members were conscious of the fact that their very existence might be seen as supportive of all CAM therapies. Respondents were clear in their assertion that, in order to achieve credibility, they were striving to provide a service that is based on what evidence does exist combined with the extensive clinical experience of their team. The team also had a stated focus on collecting data to generate evidence to facilitate recommendations for future patients.I think the fact that we are here in an academic setting gives the sceptics a little bit of comfort and sends the message that probably it is a safe program.... It gives us credibility. We include CAM providers, we listen to what they say, we respect them, we've created a home where they could be part of the team. That is in its very essence a form of advocacy because the system before didn't have room for that.... we do what we say we do, which is to walk that really difficult path down the middle because sometimes the evidence comes out against a particular (CAM) therapy and then we need to say so. And sometimes it comes out in favour of us and we need to say that too. CARE also began by limiting the service they provided to consultation services. No CAM therapies were provided by the CAM practitioners of the CARE team; instead, they offered their expert clinical opinions to help inform what treatment options might be helpful. In addition, although the CARE team was composed of a wide variety of practitioners, it did not include a chiropractor due to the historical concerns and political controversy surrounding chiropractic treatment for children.  Thus, liI think doing this research in an academic setting...gives credibility to a field that some perceive to be soft and fluffy. And so it brings science and a language of science, questioning, using evidence, and having hypotheses and so on to the use of CAM, which has helped us expand our scope within this setting. Participants interviewed from both teams stressed the importance of finding exactly the right kind of staff. For both programs, choosing staff was not always an easy task. The "right" people had to have very strong clinical qualifications, but also be able to participate and enhance the team as a whole:For instance, we do the 'tell us about a time you had a difference with a colleague and how you resolved it' – the question that everybody gets in every job interview. But I think it's an important question because it's a fact of life and you can tell when people answer that question if it sounds rehearsed or not. What we want is for them to come up with something really specific like 'I just didn't see eye to eye with my director on this, and we just couldn't resolve it and then I just decided that I was going to write out my piece and solve it creatively'...that's one of the things that we were looking for. This direct honesty, face to face honesty. That's when we know we have a good fit. And from the first time I met them I found both (chiros) very friendly and open and not defensive and not pushy, just very collaborative. Anxious to make this project work and very positive about it, but very respectful of the fact that many people here probably were not very familiar with chiropractic. I think also the fact that they are both very experienced chiropractors helped, and on staff at the [chiropractic college], because as a person myself who knew relatively little about chiropractic in the past, I could relax about their clinical competence. I didn't have to worry about that at all, whereas somebody who was much younger and on a learning curve in their practice, not only in terms of the techniques and treatment things of chiropractic but also with dealing with difficult patients. So these individuals as choices of staff for the program was obviously a hugely important consideration. I don't know how we would be doing without them. Finding space for both programs within the larger institutions was a huge issue for both initiatives. With the SMH program, the chiropractors were promised a renovated space containing two treatment rooms and a rehabilitation gym. This renovation did not get underway until more than halfway through the time allotted to the research phase of the program. While this problem was ultimately solved, space issues continued to be a factor throughout most of the pilot period and definitely slowed the development of the program:I think one of our major limitations is going to be that we don't have enough space... and that's limited like how much patient volume we can see and our ability to practice more efficiently. Right now, I have an office on another floor and I have to run up the stairs to work on my computer and then run downstairs to see my patients. It's very limiting. We call "space" the five-letter word! Similarly, in the case of CARE, space was identified as one of few, and most significant, barriers to the growth of the program:So what are our barriers right now? I'd say the first is space: physical space. I had not anticipated this...We have had such rapid expansion that finding physical space to put people: where will their desk be? Where is their computer? Do they have a phone? [These] are issues that you don't need that when you only have an idea. But suddenly when that becomes a reality, these people need stuff. So finding them a physical home has been really, really difficult. Perhaps the most interesting finding to emerge from these data was the high degree of similarity between the themes associated with each program. Both programs have been successful at integrating the services of CAM and conventional medicine providers on many levels. They continue to struggle with some of the factors previously identified in the literature, including communication among team members, which in both cases is exacerbated by the large number of part-time staff, and challenges finding appropriate space where the entire team can be housed together. The preponderance of part-time practitioners is partially driven by economic incentives and is related to the fact this study tracked two integrative medicine programs from their inception. Both continue to evolve and expand, and it is likely that the number of full-time team members will increase and space issues will be more permanently resolved as the programs mature.Our results suggest that a highly respected champion is necessary for the development of a new integrative medicine program. Both these programs were highly dependent on the efforts of champions with visions who were able to mobilize a wide range of individuals at many different levels within the health care system in order to facilitate the actualization of these integrative medicine programs. Previously, Vohra et al. identified the necessity of a "motivated champion" to initiate an integrative medical centre.  However,The findings of this study highlight another necessary factor for new academic integrative medicine programs. Both evolving clinics were flexible in implementing their visions to address issues and concerns related to their unique contexts. CARE began with only a consult service and to date does not include a chiropractor among the team members despite the high use of chiropractic among children.  SimilarlIn both settings, it appeared that time was needed to establish the level of trust necessary to fully integrate the CAM services into the host institutions. This was facilitated by the demonstrated competency of the CAM providers and highlights how important the choice of these individuals was in each instance. Launsø identifies a range of competencies that facilitate integrative team work including: the ability to "think as a team", including the ability to cooperate, openness to working together, respectful attitude toward others and willingness to solve tasks as a group.  These weLike all research projects, this study has limitations. Data from only two clinics are compared. However the high degree of similarity among the key themes despite the large differences in context suggests that study of other teams will not add many additional themes. Both integrative medicine clinics were followed from their inception to stable functioning; however, it is not possible to infer the long term success of either program at this time and thus, we cannot be sure the common themes we describe are in fact "success" factors.Despite the wide contextual difference in the two clinical settings under study, there was a large overlap in the key characteristics of these integrative medicine programs which have allowed them to succeed so far. Our data suggest that champions with vision and energy supported by institutional facilitators who were able to mobilize a range of others are necessary to establish an integrative medical program. The programs arose in host institutions  that were open to trying new care-delivery programs, as is evidenced by the very fact that these programs were allowed to become firmly established and thrive within their walls. The programs were ultimately successful because of the credibility of both the champions, facilitators and the staff members. Selection of excellent clinicians who were able to work well as a team facilitated the establishment of trust both within the team members as well as between the team and the host institution.The abbreviations used in this article were: CAM: Complementary and alternative medicine; CARE: Complementary and Alternative Research and Education program; SMH: St. Michael's Hospital; and HCP: Health care practitioner.The authors declare that they have no competing interests.HSB conceptualized the study, participated in data collection, analysis and interpretation, helped to draft the paper and approved the final manuscript. NK participated in data collection, analysis and interpretation, helped to draft the paper and approved the final manuscript.The pre-publication history for this paper can be accessed here:


The Big Brothers Big Sisters (BBBS) program matches vulnerable young people with a trained, supervised adult volunteer as mentor. The young people are typically seriously disadvantaged, with multiple psychosocial problems.Threshold analysis was undertaken to determine whether investment in the program was a worthwhile use of limited public funds. The potential cost savings were based on US estimates of life-time costs associated with high-risk youth who drop out-of-school and become adult criminals. The intervention was modelled for children aged 10–14 years residing in Melbourne in 2004.If the program serviced 2,208 of the most vulnerable young people, it would cost AUD 39.5 M. Assuming 50% were high-risk, the associated costs of their adult criminality would be AUD 3.3 billion. To break even, the program would need to avert high-risk behaviours in only 1.3%  of participants.This indicative evaluation suggests that the BBBS program represents excellent 'value for money'. Mentoring involves the commitment of time and specific efforts by a more experienced person to the development of a mutually beneficial, supportive and nurturing relationship with a less experienced person. Big Brothers Big Sisters (BBBS) is a world wide organisation which has operated in Melbourne (BBBS-M), Australia since 1980. Its program matches vulnerable young people (termed "Littles"), who are aged between 7 and 17 years, living in complex social predicaments, are isolated and in need of additional support and friendship, with adult volunteers (termed "Big Brothers" or " Big Sisters" or "Bigs"). The program aims to reduce marginalisation and/or self-destructive behaviours in young people and to foster optimal development and the establishment of confident adult identities.As at November 2003, there were 439 Littles on the database of BBBS-M. Of these, 109 were in active matches with a Big, whilst a further 189 were on the waiting list for a match, and 141 were classified as 'non-active'   appears to be relatively inexpensive for a social policy intervention....... little is known about the cost of mentoring and how this relates to program features".Few mentoring programs for young people "at-risk" have been rigorously evaluated in terms of their effectiveness in promoting maturity and positive social adjustment in young people and there is a dearth of evidence about their cost-effectiveness. Grossman & Furano, 1999  note thaFountain & Arbreton, 1999  endeavouA number of studies have examined the relationship between the effectiveness and costs of youth mentoring programs. A rate of return analysis of BBBS-America conducted by Belfield, 2003  considerA cost-benefit analysis of prevention and early intervention programs for at-risk youth conducted by the Washington State Institute for Public Policy 2004  concludeIn order to begin to build an evidence base to practice, the aim of our study was to prepare an economic case for the public worth of the BBBS-M program, by investigating whether the current program represents 'value for money'. The specific objective was to establish whether an investment in the program is likely to be a worthwhile use of limited public health and welfare resources? In establishing the economic credentials of the program, the focus is on allocative efficiency.The BBBS-M program offers formal supervised mentoring on a one-on-one basis as the sole focus of a stand-alone program, in contrast to other programs where mentoring is offered on a group basis or where it is one of multiple activities within an integrated youth program .To ascertain whether the program provides 'value for money", economic evaluation using "threshold analysis"  was usedIt is important to specify the viewpoint of the economic evaluation since an item may be a cost from one point of view, but not from another . A tradiThe comparator was a scenario in which participants did not receive the BBBS-M intervention.The reference year for the evaluation was the calendar year ending June 2004.The population of interest was young people living in the Melbourne metropolitan area aged 10–14 years, which is within the age range for eligibility for the BBBS-M program.The costs included all the resource use associated with the delivery of the program during the reference year. The costs of BBBS-M include labour, office accommodation and associated costs, transport and other administrative infrastructure costs (such as telephone and printing) . For this reason, volunteer time was valued at AUD16 per hour, which is the average hourly rate paid by other Australian mentoring programs which pay mentors a stipend [The program uses a range of resources for which it incurs no costs, examples of which are 'pro bono' legal and public relations advice and administrative assistance; free rental accommodation, and the time which Bigs donate to the program. Given that this evaluation is concerned to identify the real economic costs associated with the operating the service, the costing included both 'budgeted' and 'off-budget' items, with market values being imputed for the latter. Mentors are required to commit to between two to six hours per week of contact with their Little during the first year of the match. Time is an important resource, and has an opportunity cost  were factored into the costing, no costs to Littles and their families were included. Young people actively matched with a mentor are likely to incur limited costs as a result of their participation in the program. Any expenses associated with contact visits with their mentors are likely to be minor and are usually borne by the Big. These expenses were not included. Likewise, the time foregone by Littles to other activities as a result of their participation in the program was not costed.In calculating the full economic cost of running the BBBS-M program in 2003–04, the program was assumed to be operating in 'steady state' or at its full effectiveness with no workforce or unmet training needs. It was assumed that an appropriate workforce was available to deliver the intervention to the recruited population, meaning that no provision was made for costs associated with the recruitment, orientation and training of more staff.The potential benefits of youth mentoring programs include gains of a diverse nature ,15,16, rA search of the published literature for Australian data about the costs of marginalised youth who become involved in crime identified a number of studies which report unit cost estimates per different categories of crime -24. The Of more relevance for the purposes of this investigation is a US study by Cohen, 1998  which se. These values were inflated to 2002–03 equivalent values using the relevant Australian health price deflator. It was assumed that the benefits started to apply at age 18 years; they were then discounted at 5% back to age 10 years (the age of many children in the program) to be consistent with costs.The Cohen costs  were conThe measurement of the costs-offsets arising from the BBBS-M program averting young people from a life of crime required evidence about the probability of children in the program target group following such a pathway, and secondly, the likelihood of such activity being reduced by participation in the program.For the purposes of this study, it was conservatively estimated that 1% of children aged 10–14 years living in Melbourne displayed characteristics which would make them a potential candidate for the BBBS-M program. The task then was to estimate the proportion of these children who were likely, in the absence of an intervention, to become a criminal.The overview by the Australian Attorney-General's Department of mentoring programs for youth at risk of offending  indicateWhilst it is not possible to predict individual propensity for adult criminality or substance abuse, many in the client group either currently displayed the characteristics or were from social and economic backgrounds that are common among adolescents who later pursue such high-risk behaviour. For the purposes of the modelling, it was assumed that half of the youths enrolled in the program were in the 'high-risk' category, i.e. equivalent to 0.5% of Melbourne children in the eligible age group.BBBS-M had not consistently collected outcome data, which enabled a comparison of the behaviour of program participants and non-participants (such as those in a waiting-list control group). Therefore, it was necessary to rely on published evidence to provide the link between participation in youth mentoring programs and consequent reductions in high-risk behaviours.A number of studies have reported benefits of youth mentoring in reducing negative behaviours ,19-21. TThe total cost of providing the BBBS-M mentoring service to currently matched youth in 2004 was AUD689,093, which equates to an annual cost of AUD 6,264 per each of the 110 young people currently in an active match. As at June 2000, there were an estimated 220,755 children aged 10–14 years resident in the Melbourne Statistical Division , which iAssuming that half of the youths enrolled in the program  are in the 'high-risk' category, the associated costs of juvenile and adult criminal behaviour would be AUD 3.3 billion (based on an average cost of AUD 3 M per youth).The threshold analysis Table  shows foThe analysis suggests that the BBBS-M program represents very good 'value for money' in that it offers the potential to provide long-term cost savings of much greater value than the costs of delivering the program. This is essentially because the program is relatively inexpensive to deliver, yet it affords the likely prospect of assisting young people at 'high-risk' of antisocial adult behaviours to avoid criminality and substance abuse, thereby saving the associated high costs to society.The annual calculated cost of the BBBS-M program per match of AUD6,264 is reasonably close to the equivalent cost for BBBS-A reported by the Washington State Institute for Public Policy 2004 . The AmeWhilst it is reasonable to conclude that the benefits of the program exceed its costs, the evaluation results should be considered indicative given both the lack of outcome data on the BBBS-M program's effectiveness, and the limited existing evidence of the value of its potential benefits. The economic modelling necessarily relies on a number of assumptions, which whilst conservative, require verification. Given the absence of more rigorous evidence, this economic evaluation is necessarily characterised by a number of uncertainties. These include the proportion of the age cohort meeting the eligibility criteria for the BBBS-M program, the cost estimates for saving a high-risk young person, the proportion of young people who without an intervention are likely to embark on a high-risk pathway, and in particular, the effectiveness of the BBBS-M program in diverting participants from such a lifetime pathway. The costs associated with operating the program are the subject of less uncertainty in that they have been developed by a 'bottom-up' costing approach. A number of variations in assumptions were tested and were found to have little impact on the overall conclusions Table ."How many career criminals must be prevented before the program pays for itself?" It is recognised that there are questions about the transferability of lifetime costs presented by Cohen from the USA to the Australian context. Cost structures are likely to differ . The target population is also likely to be different. Nevertheless, these estimates are useful in providing some indicative data on the benefits which need to be forthcoming from the BBBS-M program to make it a worthwhile investment. Even if the cost of saving a high-risk youth was substantially reduced to a very conservative estimate of AUD 1 M , the intervention would still break even when a not unrealistic 4% of cases (one in 25) was saved.The Cohen paper  was of kIn adopting a comparison of children receiving the BBBS-M program with those not receiving the program, it is acknowledged that children in the latter group are likely to be in receipt of some other support services which have not been costed. Given that many BBBS Littles display problematic social behaviour, there is likely to be some involvement from youth justice or social care services.Our analysis estimated that 1% of children in the target age group in Melbourne were likely to display characteristics which would make them a potential candidate for the BBBS-M program. This is a very conservative assumption, given data from the report on the mental health of young Australians . The latWhilst the BBBS-M mentoring program is not geared specifically to young offenders or children/adolescents at risk of offending, the profile of its youth participants parallels closely the characteristics typical of young offenders including parental drug or alcohol abuse, problems at school, poor family relationships, family violence, behavioural problems, low educational achievement and drug use ,34. WhilFurther research is required to estimate the true effectiveness and cost offsets of the intervention. The need to resort to threshold analysis as the form of economic evaluation was a consequence of the absence of outcome data for the BBBS-M program. A full cost-effectiveness analysis relies on the availability of both good costing data and measurable outcomes on the effectiveness of the program. Appropriate outcomes need to be identified and their measurement built-in to the ongoing data collection procedures of this and other non-government organisations providing essential social services.Despite these study limitations, even modest reductions in the prevalence rates of high-risk behaviour were shown to be sufficient to make the BBBS-M program a "dominant" intervention, . Nevertheless, whilst the program has been shown to "break-even" when it averts or "saves" around 2% of its high-risk youth participants, it may be that such a low proportion would not be acceptable to program management or funding bodies. However, focussing on the very small proportion of youth who may be saved from a high-risk lifetime  neglects the potential for other youth to be averted from lesser high-risk pathways (from being a high-school drop-out without the life of crime), thereby further adding to the net benefits of the program. It is fair to conclude that the BBBS-M program would appear to offer excellent "value-for-money", and represents a highly cost-effective use of public health or welfare resources.Author, Jane Fisher, was a member of the Board of Directors of BBBS-M from 2002 to 2007. The authors declare that they have no competing interests.MLM developed the study protocol, undertook the data collection and analysis and wrote the manuscript. JF made a substantial intellectual contribution to the conception and design of the study, and to the critical review of the manuscript.The pre-publication history for this paper can be accessed here:Annual costs of implementing the BBBS-M program and data sources. The table shows the itemised costs of implementing the BBBS-M program and the sources from which the data was obtained.Click here for file


The Internet is a significant source of medical information and is now being shown to be an important conduit for delivering various health-related interventions. This paper aimed to examine the utility and impact of an Internet intervention for childhood encopresis as part of standard medical care in a “real world” setting. Patients diagnosed with encopresis were given a Web-based information prescription to use an Internet intervention for pediatric encopresis. A total of 22 families utilized the intervention between July 2004 and June 2006. A chart review and phone interview were undertaken to collect user characteristics; defecation-related information, including frequency of soiling, bowel movements (BMs) in the toilet, and amount of pain associated with defecation; and information on computer/Internet usage. Three questionnaires were used to examine the utility of, impact of, and adherence to the Internet intervention. Program utilization was obtained from a data tracking system that monitored usage in real time. Overall, parents rated the Internet intervention as enjoyable, understandable, and easy to use. They indicated that the Internet intervention positively affected their children, decreasing overall accidents and increasing child comfort on the toilet at home. Of the 20 children who initially reported fecal accidents, 19 (95%) experienced at least a 50% improvement, with a reduction of accident frequency from one fecal accident per day to one accident per week. Although it is not clear whether this improvement is directly related to the use of the Internet intervention, patient feedback suggests that the program was an important element, further establishing Internet interventions as a viable and desirable addition to standard medical care for pediatric encopresis. To our knowledge, this is the first time a pediatric Internet intervention has been examined as part of a “real world” setting. This is an important step toward establishing Internet interventions as an adjunctive component to treatment of pediatric patients in a clinical setting, particularly given the positive user feedback, possible cost savings, and significant potential for large-scale dissemination. The Internet has become a vital source of health care and medical information. Approximately 113 million Americans have searched for health-related information on the Internet . ParentsThere is a growing literature on the feasibility and efficacy of Internet interventions for a variety of pediatric disorders, including body image/disordered eating -11, weigIn the real world, Internet interventions will likely be sought out directly by consumers or prescribed by a clinician. Clinicians can direct patients and families to Internet interventions using a Web-based information prescription. An information prescription is a “prescription of focused, evidence-based information...to manage a health problem” . We haveBetween 1.5% and 7.5% of children suffer from encopresis ; 25% of Patients included families with an encopretic child seen at the Pediatric Gastroenterology Clinic at the University of Virginia Children’s Hospital. All children had a documented diagnosis of encopresis, as noted in their medical record, and had been given access to the pediatric encopresis Internet intervention as part of treatment.As part of treatment, the pediatric gastroenterologist seeing the children (SB or JS) provided families with a Web-based information prescription directing them to U-CAN-POOP-TOO, an Internet-based intervention for childhood encopresis (described below). The family provided the gastroenterologist with their email address, and an email message was sent to them with instructions on how to begin using the program.Patients were seen between July 2004 and June 2006 and were contacted for an interview between June and August 2006 (conducted by KA). This interview occurred anywhere from 2 months to 2 years following their appointment. Relevant patient data were available from the Internet intervention data tracking system (usage data) and medical charts. Consent was obtained at the beginning of the phone interview. This protocol was approved by the University of Virginia Health System Institutional Review Board.Data came from three sources: (1) medical charts, (2) the U-CAN-POOP-TOO data tracking system, and (3) a phone interview. The medical chart provided basic demographic and descriptive information, including patient characteristics, contact information, and diagnoses. It also provided history and frequency of soiling, frequency of bowel movements (BMs) in the toilet, and amount of perianal pain the child experienced during defecation. The U-CAN-POOP-TOO data tracking system contained usage statistics of the Internet intervention for each patient, including the number of completed program components.During the phone interview, the parents were asked questions about the following: additional user characteristics , retrospective and current bowel-related information , and computer/Internet use . Three structured questionnaires were completed during the interview. The phone interview also included open-ended questions about what parents believed were the most helpful and least helpful components of the program. The three questionnaires, developed mostly for this interview, included the following:U-CAN-POOP-TOO Utility Questionnaire: This inquired about the extent to which the parent and child found the program useful, enjoyable, understandable, and easy to use. There are 10 items, 8 requiring responses on a 5-point scale from 1  to 5 (“very”), and 2 items asking what the most and least helpful aspects of the Internet program were. For the 8 Likert scale items, the alpha coefficient was .69, indicating good internal reliability. It was administered to all parents who had used the U-CAN-POOP-TOO program.U-CAN-POOP-TOO Impact Questionnaire: This asked parents to rate how much they perceived the program helped their child. There are 25 items, and responses are on a 5- point scale from 1  to 5 (“very”). Parents could also respond with a 0 to indicate that the item was not relevant to them. To establish internal reliability, the items were broken down into five categories, including physical symptoms , comfort , worry/mood , school/social support , and cost/time .The questionnaire was administered to all parents who had used the U-CAN-POOP-TOO program.Internet Intervention Adherence Measure: This measure attempts to identify obstacles that interfered with the patient completing the program. Obstacles are categorized as Internet/computer/technical issues, personal/family issues, intervention-general issues, and intervention-specific issues. Patients are asked to respond to the 35 items on a 3-point scale from 1 to 3, indicating whether that obstacle had “no part,” “a little part,” or “a major part” in why they stopped using the program. The measure was administered to patients who stated that they stopped using the U-CAN-POOP-TOO program for some reason other than that their problem was “resolved.” This is an expanded and more detailed measure to the one we used in a previously published paper examining barriers to following through with a Web-based information prescription .The U-CAN-POOP-TOO program  was deve                                        z score was created for each patient by combining the patient’s email and Internet usage. This composite z score was generated by computing a z score for each patient by comparing him or her to the overall group mean on each variable . The email and Internet z scores for each person were then averaged to calculate the composite score. Pearson correlations were computed between the computer/Internet usage z scores and the initial to follow-up change scores. Descriptive statistics were calculated based on parents’ responses to the measures of perceived utility and helpfulness of the program, as well as perceived obstacles to completing the program. Finally, responses to the open-ended questions about the least and most helpful aspects of the program were reviewed for clear themes.Descriptive statistics of the 22 subjects included in the data analysis were first computed, including gender, race, age, and education as well as developmental delays, accident history, and the age of the child when toilet training was completed. Repeated-measures analysis of variance and correlations were calculated to examine changes in the main bowel-related variables of interest. Cure and success rates were also computed. Additional descriptive statistics were computed to explore program usage patterns by patients. To examine the impact of computer/Internet usage specifically, a composite Between July 2004 and June 2006, 46 patients seen in the pediatric gastroenterology clinic for encopresis were provided the U-CAN-POOP-TOO Web-based information prescription.                     Three main bowel-related variables were examined for the initial period and the follow-up period: (1) the number of fecal accidents over a 2-week period, (2) the number of BMs passed in the toilet over a 2-week period, and (3) the average amount of perianal pain experienced during defecation over a 2-week period, based on a 3-point Likert scale from 0 (“none”) to 2 (“a lot”). The initial period was the 2 weeks before the children were enrolled in the program, and the follow-up period was the 2 weeks immediately before the phone interview.1,21 = 27.29, P < .001). No significant changes were found for the number of BMs in the toilet  or the amount of pain the child experienced during defecation . These results are summarized in The number of accidents decreased from 13.86  during the initial period to 2.14  during the follow-up period  reported having no more than one accident in the 2 weeks prior to the phone interview. Four patients (20%) were considered “cured” by indicating that they had no accidents during the follow-up period. All but one of the 20 patients (95%) had at least a 50% reduction in accident frequency from the initial to interview period. The median reduction was 7.5 accidents in 2 weeks, supporting the notion that these were substantive improvements.r = .05, P < .84, N = 22), BMs passed in the toilet , or amount of pain with defecation , suggesting that the severity of the symptoms at the time of enrollment did not relate to how much the patient benefited from treatment.The number of fecal accidents in the 2-week initial period did not predict the number of accidents at the follow-up period. That is, there were no significant correlations between initial and follow-up periods for accident frequency  completed all three assigned cores (main treatment components). All 22 patients completed the Anatomy Core; 20 completed the Medication Core; and 18 completed the Behavior Core. A total of 12 patients (55%) completed one follow-up, four (18%) completed a second and third follow-up, and two of these four (9%) completed more than three follow-ups. Modules were individually assigned based on responses to follow-ups; however, patients had access to all the modules. The average number of modules completed was 7.23 (SD 9.64); 14 patients (64%) completed at least one module.2,19 = 1.93, P < .18), BMs in the toilet , or pain experienced during defecation .There was significant variability in the amount of time elapsed between when patients were initially given access to U-CAN-POOP-TOO (between July 2004 and June 2006) and the time the phone interview was conducted (between July and August 2006). To examine whether time alone may have been a significant factor in terms of reported encopretic symptoms, patients were divided into three time-based groups with an attempt to make cell sizes roughly even: (1) those enrolled between July 2004 and June 2005 (N = 5), (2) those enrolled between July 2005 and December 2005 (N = 7), and (3) those enrolled between January 2006 and June 2006 (N = 10). No differences were found among these three time groups for changes in accident frequency , BMs passed in the toilet , or amount of pain associated with defecation . Internet comfort and connection speed were also not significantly correlated to changes in any of the bowel-related outcome variables .The 22 families reported checking their email 13.18 times per week (SD 14.03) and using the Internet 10.39 hours per week (SD 10.15). On average, they indicated their comfort level using the Internet to be 2.64 (SD .73) on a 5-point scale ranging from 0  to 4 (“I’m an expert”). A total of 15 of the 22 families (68%) had high-speed Internet access at home, six (27%) had dial-up access, and one was unsure about the connection speed. The above variables  were examined to determine whether they affected outcome. No significant correlations were found between computer/Internet usage and the change from initial to follow-up period for accident frequency  and found it understandable  and easy to use . They also believed that their child liked the program  and found it understandable  and easy to use . Those who responded “not applicable” to items on the U-CAN-POOP-TOO Utility Questionnaire were not included in the analysis for that item (explaining the varying sample sizes). In addition to questions about enjoyment, comprehension, and ease of use, parents were also asked what they believed were the most helpful and least helpful components of the program. They found the tutorials about anatomy and pathophysiology to be one of the most helpful aspects of the program. They also liked that the program was geared toward the child, but that it was comprehensive and nonjudgmental. No clear themes emerged from the “least helpful” question.The U-CAN-POOP-TOO Impact Questionnaire was administered to examine how much the parents believed the program affected outcome. Those who responded “not applicable” were not included in the analysis for that item. On average, 19 out of 25 items (76%) were rated at least “somewhat helpful,” and no item was described as “not at all helpful.” On the 1- to 5-point scale, average responses ranged from a low of 2.33 (the program helped reduce the number of times parents had to remind their child to use the bathroom) to a high of 4.2 (the program helped the child feel more comfortable using the toilet at home). See Of the 22 patients examined, 16 indicated that they stopped using the program for some reason other than that their problem was “resolved.” They were administered the Internet Intervention Adherence Measure, the questionnaire used to identify obstacles to using the program. Based on the responses, only two items had a mean score of 2 or greater . They were “I just forgot [to go to the website]”  and “I didn’t have time in my schedule” . Notably, these were the same top two obstacles identified in our previous study examining the use of Web-based information prescriptions .This paper examined the utility and impact of an Internet intervention for childhood encopresis provided as a Web-based information prescription in a “real world” situation. Based on parent participant report, there was an almost universal belief that the system had a substantive and positive effect on their child. When parents were asked to rate their perception of the impact of the Internet intervention, they indicated that the Internet program helped decrease the number of accidents and increase the child’s comfort in using the toilet at home. Parents also believed that the system helped reduce their child’s physical symptoms of encopresis and level of worry, improved their child’s mood, and increased and improved their child’s school and social activities. Additionally, parents believed that U-CAN-POOP-TOO helped reduce the number of calls and visits to their doctor, implying that there may be cost reductions with the use of the program.Accompanying improvements in defecation-related variables were reported, including a marked decrease in fecal accident frequency from the initial to follow-up period in this sample of patients. However, it cannot be determined if this improvement is directly attributable to the Internet intervention due to the major limitation of not having a control group. This precludes reaching a definitive conclusion as to whether the Internet intervention caused the improvement. Yet, while the lack of a control group makes it impossible to state that the intervention led to the observed improvements, parents clearly indicated that they believed the program played an important and substantive role in their child’s success.In addition to the lack of the control group, there are some other limitations with this “real-world” analysis that should be considered when interpreting these results. Parents articulated two difficulties in answering certain questions during the phone interview. Parents frequently stated that they had difficulty differentiating whether or not a certain outcome  was due to the medications/laxatives their child was taking or due to U-CAN-POOP-TOO. More often than not in these cases, parents tended to assign most or all of the credit to the medication, making the findings reported here more conservative. Parents also noted that the questions did not take into account a change (decrease) in the volume of the accidents. Some parents stated that there was improvement but that this was not reflected in their answers as their child was still having accidents .Another limitation of this paper relates to who was given the Web-based information prescription and the patients who were ultimately included in the analyses. Patients were not systematically identified or consecutively selected; instead, the physician used his own judgment as to whether a patient would be appropriate for receiving the Web-based information prescription. This judgment was based on the presentation of the family related to issues such as disorganization, apparent motivation, and readiness to change. This certainly limited the number of patients included but fits more appropriately with the notion of a “real world” prescription in that clinicians will likely provide Web-based information prescriptions to those whom they believe would benefit as opposed to providing it to everyone. It is not known what proportion of the overall clinic might have been deemed to benefit.The final group used in the analyses was relatively small and all were Caucasian. These issues make it inappropriate to generalize these findings to a larger or more diverse population. Also, two of the 22 patients were not actually having accidents in the 2 weeks immediately prior to using the Internet intervention. They did, however, have a diagnosis of encopresis and reported accidents prior to this 2-week period. There is also an issue regarding the difference in time when patients used the program. Some patients accessed U-CAN-POO-TOO as long as 2 years before the interview, while others accessed it as recently as 2 months prior. However, in all the subanalyses conducted to examine this issue, no differences were found in any of the primary variables among groups of patients separated by varying enrollment dates.Finally, not everyone who was given access to U-CAN-POOP-TOO used the program. Those who stopped using it for reasons other than resolution of their child’s encopresis identified lack of time and forgetfulness as two of the main barriers. This is consistent with our previous findings showing these as two of the most common barriers to families following through with Web-based information prescriptions . HoweverThis paper has important implications for the treatment of pediatric health problems using Internet interventions. These results indicate that parents believe Internet interventions can be helpful to their children outside of clinical trials. Although an increase in the development, testing, and use of Web-based applications is already occurring -34, this