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Medical emergencies such as anaphylaxis may require immediate use of emergency medication. Because of the low adherence of chronic patients (ie, carrying anti-anaphylactic medication) and the potentially long response time of emergency medical services (EMSs), alternative approaches to provide immediate first aid are required. A smartphone-based emergency response community (ERC) was established for patients with allergies to enable members to share their automatic adrenaline injector (AAI) with other patients who do not have their AAI at the onset of anaphylactic symptoms. The community is operated by a national EMS. In the first stage of the trial, children with food allergies and their parents were invited to join.
This study aimed to identify the factors that influence the willingness to join an ERC for a group of patients at risk of anaphylaxis.
The willingness to join an ERC was studied from different perspectives: the willingness of children with severe allergies to join an ERC, the willingness of their parents to join an ERC, the willingness of parents to enroll their children in an ERC, and the opinions of parents and children about the minimum age to join an ERC. Several types of independent variables were used: demographics, medical data, adherence, parenting style, and children's autonomy. A convenience sample of children and their parents who attended an annual meeting of a nonprofit organization for patients with food allergies was used.
A total of 96 questionnaires, 73 by parents and 23 by children, were collected. Response rates were approximately 95%. Adherence was high: 22 out of 23 children (96%) and 22 out of 52 parents (42%) had their AAI when asked. Willingness to join the community was high among parents (95%) and among children (78%). Willingness of parents to enroll their children was 49% (36/73). The minimum age to join an ERC was 12.27 years (SD 3.02) in the parents’ opinion and 13.15 years (SD 3.44) in the children’s opinion.
Parents’ willingness to join an ERC was negatively correlated with parents’ age, child’s age, and parents’ adherence. This can be explained by the
This study examines different factors affecting willingness of patients and parental-caregivers to join a smartphone-based emergency response community (ERC) for patients with allergy at a risk of anaphylaxis.
A medical emergency is “an acute injury or illness that poses an immediate risk to a person’s life or long-term health” [
Emergency medical services (EMSs) are the primary provider of first aid to people in medical emergencies that occur outside medical institutions [
EMS organizations and health policy makers try to achieve faster response times through various approaches. These include the deployment of automatic electronic defibrillators in public places [
An ERC [
Joining an ERC requires adoption of a dedicated mobile health (mHealth) smartphone app. mHealth is defined as “healthcare to anyone, anytime and anywhere by removing temporal and locational constraints” [
ERCs are a type of mutual aid community with members being both potential givers and takers—providers and recipients—of an emergency response. Joining a mutual aid community is a type of volunteerism. Altruism is the most frequently expressed motive for volunteerism. Yet people may volunteer for reasons other than pure altruism. For example, parents may volunteer in an organization from which their children directly benefit [
The phenomenon of
Another important phenomenon that may influence willingness to join an ERC is
There are 2 types of medication sharing: recreational (ie, abusive medication sharing to experience nonmedical effects) and nonrecreational (medication sharing for medical treatment) [
To the best of our knowledge, no study has examined the correlation between parents’ willingness to join an ERC and parenting styles associated with medical decision making [
Autonomy refers to a person’s ability to act on his or her own values and interest. Taken from ancient Greek, the word autonomy means
Some experiences that children and adolescents with food allergies undergo may put them at risk of problems related to the development of their autonomy. Studies show that limiting young children’s opportunities for independent exploration of their environment can interfere with the development of their autonomy [
In this study, we expand the understanding of the sense of autonomy among children with severe allergies. Subsequently, we will refer to autonomy as an agency consisting of 3 components [
EPIMADA is an ERC launched in January 2018 by the Israel National EMS, Magen David Adom (MDA), in cooperation with Bar-Ilan University. EPIMADA comprises patients with allergies who are required to carry an AAI as the first-line treatment against anaphylaxis [
We studied the willingness to join an ERC from different points of view:
Willingness of parents to join an ERC
Willingness of parents to enroll their children in an ERC
Willingness of children to join an ERC
Opinions of parents and children about the minimum age to join an ERC
We used several types of independent variables:
Demographic data (parents’ age, child’s age, parents’ gender, child’s gender, parents’ level of religious observance, and parent’s years of education).
Medical data about the child (time since diagnosis, time since last anaphylactic attack, and the number of anaphylactic attacks in the past) and medical data about the parents (whether they themselves are allergy patients).
Adherence (carrying the AAI) both by parents and by children.
Parenting styles (protective, dismissive, and monitoring).
Children’s autonomy (attitudinal, emotional, and functional).
We used a convenience sample of children diagnosed with severe food allergies and their parents who attended an annual conference of a nonprofit organization of patients with food allergies. All parents were asked to fill out a written questionnaire for parents (
Given that a convenience sample was used, the research is descriptive and does not presume to predict the behavior of the general population.
A total of 23 parent-child pairs attended the conference and answered the parents' and the children's questionnaires (the children had to be at least 8 years old and attend the conference with their parents). All children’s questionnaires were paired with same-family parents’ questionnaires through a coding system that maintained anonymity. A total of 50 parents attended without their children and answered the parents' questionnaires. The response rates were about 95% (2-3 parents arrived too late and were not able to answer the questionnaire because the conference had started. No one refused to answer the questionnaires.). These activities were performed at the start of the conference before participants were informed of the EPIMADA initiative.
In addition to descriptive statistics, we used several analytical tools to explore our data:
Mann-Whitney nonparametric
Chi-square independence test was used to check if there is significant association between 2 nominal variables.
Pearson correlation analysis was used to discover correlations between different variables to plan regression models and to avoid multicollinearity.
One-way analysis of variances (ANOVAs) were used to check whether there are significant differences between multiple samples, for example, 3 clusters.
Intraclass correlation (ICC) tests were used to check the consistency of measures between parents and children in the 3 parenting styles.
Linear regressions were used for scale-dependent variables.
Ordinal regressions were used for ordinal-dependent variables.
Binary logistic regressions were used for binary-dependent variables.
Bootstrapping is a resampling technique that improves the property estimation in small samples. This technique was applied to logistic regressions that initially did not provide significant results.
Principal component analysis (PCA) was used to find the mix of possibly correlated variables for dimension reduction for cluster analysis.
Cluster analysis was used in unsupervised learning to enable identification of homogeneous groups without a target attribute by identifying the similarities between objects for a given number of subgroups [
Classification tree (J48) analysis was used in supervised learning with known target variable to enable identification of the most influential variables.
The research was approved by the Institutional Review Board of Bar-Ilan University and by the Research Committee of MDA.
The data were converted to digital form by the researchers and analyzed using IBM SPSS 24 software and WEKA 3.7.11 software developed by the University of Waikato in New Zealand.
A total of 57 (78%) parents were female and 16 (22%) were male. A total of 15 (20.5%) parents reported that they are religiously observant.
Demographic statistics of parents (n=73).
Parameter | Average | Median | Mode | SD | Min | Max | IQRa |
Age (N=73) | 40.51 | 40 | 39 | 7.15 | 22 | 55 | 9.5 (35.5-45) |
Years of education (N=72b) | 15.74 | 15.5 | 15 | 2.40 | 12 | 25 | 2 (15-17) |
Number of children (N=73) | 2.49 | 3 | 3 | 0.97 | 1 | 6 | 1 (2-3) |
aIQR: interquartile range.
bThese data were missing in 1 questionnaire.
Age of children.
Parameter | Average | Median | Mode | SD | Min | Max | IQRa |
Childrenb (all; N=73) | 9.01 | 8.5 | 14, 17 | 5.52 | 1 | 21 | 10 (4-14) |
Childrenc (attended; N=23) | 13.69 | 14 | 14 | 3.72 | 8 | 21 | 6 (11-17) |
aIQR: interquartile range.
bChildren’s data were provided by all parents about their children.
cA total of 23 children attended the conference and filled out children’s questionnaires. The statistics of these children (part of the total sample of 73 children) are based on data reported by their parents. Participation was limited to children aged at least 8 years.
Gender of children.
Population | Female, n (%) | Male, n (%) |
Children (all, N=73) | 49 (68) | 23 (32) |
Children (attended; N=23) | 7 (30) | 16 (70) |
Medical statistical data of children are provided in
Parents reported who carries their child’s AAI: in 14 (19%) cases, only the parents carried an AAI; in 19 (26%) cases, only the child carried an AAI; and in 38 (52%) cases, both the parents and the child carried an AAI (in 2 cases, no data were provided).
A total of 52 parents who carried an AAI for their children were asked 3 questions about their own adherence, 57 parents whose children carried an AAI were asked 3 questions about their children’s adherence, and 23 children who attended the conference were asked 2 questions about their adherence.
We compared the parents’ answers to their children’s answers. A total of 2 children answered “Yes” to the question “Are you carrying an AAI now?” whereas their parents answered “No” to the question “Is your child carrying an AAI now?” When parents and children answered the question “How many days last week did your child have immediate access to an AAI throughout the day?” in 3 cases, parents reported higher adherence (6 vs 4, 7 vs 6, and 7 vs 5) than their children, and in 3 cases parents reported lower adherence than their children (6 vs 7, 5 vs 7, and 1 vs 7).
Medical statistics of children.
Parameter and N (valida,b) | Average | Median | Mode | SD | Min | Max | IQRc | |
62 | 8.13 | 7 | 2 | 5.59 | 1 | 22 | 9 (3-12) | |
20 | 12.45 | 12 | —d | 5.36 | 1 | 22 | 7.25 (9.25-16.50) | |
52 | 4.85 | 4 | 1 | 3.92 | 1 | 14 | 6 (1-7) | |
21 | 6.62 | 7 | 1 | 4.61 | 1 | 14 | 9.5 (1-10.5) | |
70 | 1.74 | 1 | 1 | 1.77 | 0 | 10 | 2 (1-3) | |
22 | 2.41 | 2 | 1 | 2.15 | 0 | 10 | 2.25 (1-3.25) |
aData for all children are reported in the upper row for each variable and data for the children that attended the conference are reported in the lower row.
bThese data were missing in 1 questionnaire.
cIQR: interquartile range.
dMultiple modes exist.
First question about adherence.
Question | Never, n (%) | Seldom, n (%) | Often, n (%) | Always, n (%) | No answer, n (%) | |
Do you make sure to carry the AAIa? (N=52) | 1 (2) | 1 (2) | 3 (6) | 45 (86) | 2 (4) | |
Does your child make sure to carry the AAI? (N=57) | 2 (4) | 0 (0) | 10 (18) | 43 (75) | 2 (3) |
aAAI: automatic adrenaline injector.
Second question about adherence.
Question | Yes, n (%) | No, n (%) | No answer, n (%) | |||
Are you (parents) carrying an AAIa now? (N=52) | 22 (42) | 30 (58) | 0 (0) | |||
Is your child carrying an AAI now? (N=57) | 53 (93) | 3 (5) | 1 (2%) | |||
Are you (child) carrying an AAI now? (N=23) | 22 (96) | 1 (4) | 0 (0) |
aAAI: automatic adrenaline injector.
Third question about adherence.
Question | 1, n (%) | 2, n (%) | 3, n (%) | 4, n (%) | 5, n (%) | 6, n (%) | 7, n (%) | |
How many days last week did you have immediate access to an AAIa throughout the day?b (N=52) | 9 (17) | 2 (4) | 1 (2) | 2 (4) | 0 (0) | 1 (2) | 37 (71) | |
How many days last week did your child have immediate access to an AAI throughout the day?b (N=57) | 1 (2) | 0 (0) | 0 (0) | 1 (2) | 1 (2) | 3 (5) | 51 (89) | |
How many days last week did you have immediate access to an AAI throughout the day?c (N=23) | 0 (0) | 0 (0) | 0 (0) | 1 (4.3) | 1 (4.3) | 1 (4.3) | 20 (87) |
aAAI: automatic adrenaline injector.
bReports by parents.
cReports by children.
Parenting styles as assessed by the ARCS questionnaires answered by parents and their children are presented in
We performed a paired samples
We compared our findings with the data reported by Van Slyke and Walker [
Results related to attitudinal, emotional, and functional autonomy among children who attended the conference are given in
Parenting styles as assessed by the Adult Responses to Children’s Symptoms questionnaires answered by parents and their children.
Parenting style and respondents | Average | Median | Mode | SD | Min | Max | IQRa | |
All parents (N=73) | 2.39 | 2.4 | 2.4 | 0.69 | 0.87 | 3.67 | 1.06 (1.87-2.93) | |
Parents whose children attended (N=23) | 2.34 | 2.33 | 1.67 | 0.78 | 0.87 | 3.6 | 1.4 (1.67-3.07) | |
Children who attended (N=23) | 2.27 | 2.27 | 2.93 | 0.71 | 1 | 3.47 | 1.2 (1.73-2.93) | |
All parents (N=73) | 0.88 | 0.83 | 0.33 | 0.58 | 0 | 2.67 | 1 (0.33-1.33) | |
Parents whose children attended (N=23) | 0.74 | 0.67 | 0.67 | 0.62 | 0 | 2.17 | 0.67 (0.33-1) | |
Children who attended (N=23) | 0.93 | 0.67 | 0.5 | 0.58 | 0.33 | 2.17 | 1 (0.5-1.5) | |
All parents (N=73) | 2.91 | 3 | —b | 0.61 | 0.88 | 3.88 | 0.88 (2.5-3.38) | |
Parents whose children attended (N=23) | 2.94 | 3.13 | 3.13 | 0.61 | 1.88 | 3.88 | 1.12 (2.38-3.5) | |
Children who attended (N=23) | 2.63 | 2.63 | 2.63 | 0.71 | 1 | 3.63 | 0.87 (2.38-3.25) |
aIQR: interquartile range.
bMultiple modes exist.
Attitudinal, emotional, and functional autonomy among children who attended the conference (n=23).
Autonomy | Average | Median | Mode | SD | Min | Max | IQRa |
Attitudinal (N=23) | 3.53 | 3.4 | 3.4 | 0.496 | 2.8 | 4.4 | 0.6 (3.2-3.8) |
Emotional (N=23) | 3.628 | 3.6 | 3.8 | 0.482 | 2.8 | 4.4 | 0.8 (3.2-4) |
Functional (N=23) | 3.496 | 3.4 | —b | 0.692 | 2.4 | 4.8 | 1 (3-4) |
aIQR: interquartile range.
bMultiple modes exist.
We performed dimension reduction using the PCA technique [
An analysis with 2 clusters of parents identified the 2 groups, which are presented in
The analysis with 3 clusters of parents identified the 3 groups presented in
We performed a one-way ANOVA to check the differences between the parents’ characteristics in the 3 clusters. The following differences were significant at the 5% significance level: parent's age (
An analysis with 4 clusters of parents did not reveal any unique cluster with special characteristics. Specifically, the largest group from the 3-cluster analysis was divided into 2 subgroups with slight differences.
Parent clusters.
Parameter | Cluster 0 | Cluster 1 | ||
Number of cases | 41 | 32 | —a | — |
Parents’ age | 36.88 | 45.16 | <.001 | <.001 |
Child’s age | 5.66 | 13.23 | <.001 | <.001 |
Children who carry AAIb (valid %) | 25 (64)c | 32 (100)d | — | — |
Parents who carry AAI for their children (valid %) | 38 (97)c | 14 (44)d | — | — |
Time since diagnosis (years) | 5.53 | 11.45 | <.001 | <.001 |
Time since the last attack (years) | 3.82 | 6.16 | .002 | .01 |
Adherence of all parents | 2.934 | 1.79 | <.001 | — |
Adherence of parents who carry AAI for their children | 2.97 | 2.46 | <.001 | — |
Adherence of all children | 1.89 | 2.88 | <.001 | — |
Adherence of children who carry AAI. | 2.48 | 2.88 | <.001 | — |
Adherence: number of days in past week parents had access to AAI7 | 5.89 | 4.63 | .03 | .03 |
Willingness to enroll child in the community | 2.04 | 4.66 | <.001 | — |
aTest is irrelevant.
bAAI: automatic adrenaline injector.
cN=39.
dN=32.
Parent clusters.
Parameter | Cluster 0 | Cluster 1 | Cluster 2 |
Number of cases | 42 | 17 | 14 |
Parents’ age | 39.62 | 47.23 | 35.00 |
Child’s age | 8.33 | 14.85 | 3.94 |
Children who carry AAIa (valid %) | 40 (100)b | 17 (100)c | 0 (0)d |
Parents who carry AAI for their children (valid %) | 37 (92)b | 1 (6)c | 14 (100)d |
Time since diagnosis (years) | 7.48 | 13.18 | 3.95 |
Time since the last attack (years) | 4.36 | 6.81 | 3.92 |
Adherence of parents | 2.80 | 1.09 | 2.96 |
Adherence of parents who carry AAI for their children | 2.83 | 1.00 | 3.00 |
Adherence of child (children who carry AAI) | 2.63 (2.66) | 2.82 (2.82) | 0.81 (0.00) |
Adherence: number of days in past week parents had access to AAI7 | 5.79 | 4.22 | 5.36 |
Willingness to enroll child in the community | 3.07 | 4.82 | 1.57 |
aAAI: automatic adrenaline injector.
bN=40.
cN=17.
dN=14.
Correlations between variables.
Variablesa | V1 | V2 | V3 | V4 | V5 | V6 | V7 | V8 | V9 | V10 | V11 | V12 | V13 |
V1 | 1 | 0.143 | 0.291b | 0.828c | 0.793c | 0.098 | −0.115 | 0.029 | 0.502c | 0.277b | −0.267b | 0.086 | −0.292b |
V2 | 0.143 | 1 | 0.017 | 0.039 | 0.087 | −0.248b | 0.099 | 0.38 | 0.204 | −0.299b | −0.054 | −0.280b | 0.099 |
V3 | 0.291b | 0.017 | 1 | 0.326c | 0.316b | 0.022 | –0.009 | −0.215 | 0.131 | 0.237b | 0.052 | 0.060 | 0.011 |
V4 | 0.828c | 0.039 | 0.326c | 1 | 0.91c | 0.163 | −0.048 | −0.086 | 0.481c | 0.455c | −0.187 | 0.202 | −0.249b |
V5 | 0.793c | 0.087 | 0.316b | 0.91c | 1 | −0.021 | −0.091 | −0.095 | 0.529c | –0.039 | 0.26b | −0.102 | 0.487c |
V6 | 0.098 | −0.248b | 0.022 | 0.163 | −0.021 | 1 | 0.200 | −0.091 | 0.011 | −0.012 | −0.114 | 0.034 | 0.027 |
V7 | −0.155 | 0.099 | −0.009 | −0.048 | −0.091 | 0.200 | 1 | 0.199 | −0.035 | −.030 | −0.075 | 0.008 | 0.008 |
V8 | 0.029 | 0.038 | −0.215 | −0.086 | −0.095 | −0.091 | 0.199 | 1 | −0.056 | −0.003 | 0.082 | 0.060 | 0.135 |
V9 | 0.502c | 0.204 | 0.131 | 0.481c | 0.529c | 0.011 | −0.035 | −0.056 | 1 | −0.205 | −0.240 | −0.054 | −0.177 |
V10 | 0.277b | −0.299b | 0.237b | 0.455c | −0.039 | −0.012 | −0.030 | −0.003 | −0.205 | 1 | 0.142 | 0.511c | 0.013 |
V11 | −0.267b | −0.054 | 0.052 | −0.187 | 0.26b | −0.114 | −0.075 | 0.082 | −0.240 | 0.142 | 1 | 0.188 | 0.634c |
V12 | 0.086 | −0.280b | 0.060 | 0.202 | −0.102 | 0.034 | 0.008 | 0.060 | −0.054 | 0.511c | 0.188 | 1 | −0.056 |
V13 | –0.292b | 0.099 | 0.011 | −0.249b | 0.487c | 0.027 | 0.008 | 0.135 | −0.177 | 0.013 | 0.634c | −0.056 | 1 |
aThe list of variables used are as follows: V1, parents’ age; V2, parents’ years of education; V3, number of children; V4, child’s age; V5, time as diagnosis (years); V6, parents’ opinion about the minimum age for a child to join an ERC; V7, number of days in past week parent who had access to AAI; V8, number of days in past week child who had access to AAI; V9, time as last anaphylactic attack; V10, number of anaphylactic attacks in the past; V11, protective parenting style; V12, dismissive parenting style; V13, monitoring parenting style.
bSignificant at the 5% level.
cSignificant at the 1% level.
Parents were asked 2 questions about their willingness to join an ERC. A total of 69 parents (95%) answered “Yes” to the yes-or-no question “Do you intend to join the community?” Because of the very high percentage of affirmative questions, no further statistical analysis (eg, logistic regression) was possible.
Parents were also asked about the probability (0 [very unlikely] to 6 [very likely]) that they would join an ERC. Their answers are presented in
We used an ordinal regression model to analyze the factors that influence the probability of joining an ERC. We used the following independent variables: child’s gender, child’s age, parents’ age, parents’ education, parents’ adherence (number of days in past week parent had immediate access to AAI), child’s adherence (number of days in past week child had immediate access to AAI), time since diagnosis, the number of anaphylactic attacks in the past, time since the last attack, and parenting style. The model fitting was significant (χ213=22.9 with
A 2-tailed t test for independent samples assuming equal variances (according to Levin’s test) and a Mann–Whitney nonparametric U test showed no significant differences in the probability of the parent joining the community by parents’ gender, but a 1-tailed t test revealed that females are more likely to join the community than males at the 5% significance level (P=.04).
A 2-tailed t test for independent samples assuming equal variances (according to Levin’s test) and a Mann–Whitney nonparametric U test showed no significant differences in the probability of the parent joining the community by child’s gender.
Parents’ answers about the probability of them joining the community (N=73).
Answer | n (%) |
0 (very unlikely) | 1 (1.4) |
1 | 2 (2.7) |
2 | 1 (1.4) |
3 | 5 (6.8) |
4 | 7 (9.6) |
5 | 11 (15.1) |
6 (very likely) | 45 (61.6) |
No answer | 1 (1.4) |
Children were asked 2 questions about their willingness to join an ERC. A total of 18 out of 23 children (78%) answered “Yes” to the yes-or-no question “If your parents let you, do you intend to join the community?“
Because of the low number of respondents, a logistic regression was not able to analyze the factors that influence children’s opinions about joining the community.
Children were also asked what the probability was (0 [very unlikely] to 6 [very likely]) that they would join an ERC, assuming that their parents would allow them to join. Their answers are presented in
We used an ordinal regression model to analyze the factors that influence the probability of joining an ERC. We used the following independent variables: child’s gender, child’s age, child’s adherence (number of days in past week child had immediate access to AAI), parenting style, and child’s autonomy. The model fitting was not significant. The goodness of fit was significant at the 5% significance level for the Pearson chi-square test (
Children’s answers about the probability of them joining the community (N=23).
Answer | n (%) |
0 (very unlikely) | 2 (9) |
1 | 1 (4) |
2 | 3 (13) |
3 | 1 (4) |
4 | 9 (39) |
5 | 2 (9) |
6 (very likely) | 5 (22) |
No answer | 0 (0) |
Parents were asked 2 questions about their willingness to enroll their children in an ERC. A total of 36 parents out of 73 (49%) answered “yes” to the yes-or-no question “Do you intend to enroll your child in the community?”
We used a logistic regression to analyze the factors that influence the parents’ decision to enroll their children in the community (dependent variable). We used the following independent variables: parents’ age, parents’ education, number of children, child’s age, time since diagnosis, parents’ adherence (number of days in past week parents had immediate access to AAI), child’s adherence (number of days in past week child had immediate access to AAI), time since the last anaphylactic attack, the number of anaphylactic attacks in the past, and parenting style. Omnibus tests of model coefficients provided significant results with
We performed another analysis of this variable by applying the J48 classification tree to evaluate the influence of different independent variables on the parents’ decision to enroll their children in the community. The tree correctly classifies 71.21% of the cases.
In an attempt to expand the options scale, the parents were also asked the question, “What is the probability (0–6) that you will enroll your children in an ERC?” Their answers are presented in
We used an ordinal regression model to analyze the factors that influence the probability that parents will enroll their child in an ERC. We used the following independent variables: parents’ age, parents’ education, number of children, child’s age, parents’ adherence (number of days in the past week parent had immediate access to AAI), child’s adherence (number of days in the past week child had immediate access to AAI), time since the last anaphylactic attack, the number of anaphylactic attacks in the past, parenting style, and child’s gender. The model fitting was not significant (χ213=19.1 with
The influence of different independent variables on the parents’ decision to enroll their children in the community.
Parents’ answers about the probability (0 [very unlikely] to 6 [very likely]) of enrolling their children in the community (N=73).
Answer | n (%) |
0 (very unlikely) | 19 (26.0) |
1 | 3 (4.1) |
2 | 4 (5.5) |
3 | 5 (6.8) |
4 | 6 (8.2) |
5 | 8 (11.0) |
6 (very likely) | 19 (26.0) |
No answer | 9 (12.3) |
Both parents and children were asked their opinions about the minimum age to join an ERC (see
In a paired samples
We used a linear regression to analyze the factors that influence parents’ opinions about the minimum age to join an ERC. We used the following independent variables: parents’ age, parents’ education, number of children, child’s age, parents’ adherence (number of days in the past week parent had immediate access to AAI), child’s adherence (number of days in the past week child had immediate access to AAI), time since the last anaphylactic attack, parenting style, and number of anaphylactic attacks in the past. A multicollinearity analysis did not reveal any evidence of multicollinearity. The model resulted in
Opinions about minimum age to join an emergency response community (all values in years).
Population | N (valida) | Average | Min | Max | SD | Median | 95% CI |
Parents | 65 | 12.27 | 6 | 18 | 3.02 | 12 | 11.52-13.02 |
Children (attended) | 23 | 13.15 | 6.5 | 20 | 3.44 | 12 | 11.63-14.67 |
aThese data were missing in 8 parents’ questionnaires.
We used a linear regression to analyze the factors that influence children’s opinions about the minimum age to join an ERC. We used the following independent variables: child’s age, child’s adherence (number of days in the past week child had immediate access to AAI), parenting style, and child’s autonomy. A multicollinearity analysis did not reveal any evidence of multicollinearity. The model resulted in
Parents’ willingness to join the community was very high, even for a convenience sample. In the following, we describe the main factors that influence parents’ willingness to join.
Parents’ willingness to join was negatively correlated with parents’ age and parents’ adherence. Parents’ age had a strong positive correlation with child’s age. Parents of younger children carried the AAIs for their children. These findings can be explained by the
Parents’ willingness to join an ERC was positively correlated with child’s adherence. Previous studies have found that parents’ psychological characteristics influence their child’s adherence [
We found that females were more likely to join the community than males. This can be explained both from a giving point of view (females participate more in volunteer activities than males [
Children’s willingness to join the community was lower than that of their parents, but still high. Children’s willingness to join the community was positively correlated with age. This is a straightforward finding both from a giving point of view (age is positively correlated with volunteerism [
About half of the parents expressed willingness that their children join an ERC. Both the logistic regression and the classification tree identified that being the parent responsible to carry an AAI for his child and parent's adherence as significant factors negatively correlated with parent's willingness to enroll their child in an ERC. It seems that parents who are not able to provide their children with an AAI in the event of an anaphylactic attack want to enroll their children to provide them with an additional layer of support in an emergency.
Child’s age was positively correlated with parents’ willingness to enroll their children in the community. From a taking point of view, this can be explained by the transition from a protective parenting style, which is more common in parents of younger children, to a monitoring parenting style, which prevails as children grow older [
The 2 lower levels of the classification tree reveal another interesting effect: whereas parents of a young child want to enroll him if he has less than perfect adherence, parents of an older child want to enroll him only if he carries an AAI at least 3 days a week. The former finding can be explained by the
Cluster analysis with 2 clusters revealed 2 subgroups of 32 and 41 parents. The smaller group is characterized by younger parents, younger children, shorter time since diagnosis, shorter time since last attack, lower percentage of children who carry an AAI, higher percentage of parents who carry an AAI for their children, higher adherence among parents, lower adherence among children, and lower willingness to enroll child in an ERC. Cluster analysis with 3 clusters revealed 3 subgroups:
Cluster 2: 14 parents to very young children. In this group, all parents carry an AAI for their children, and none of children carries the AAI for himself. Parents' adherence is high when compared with other clusters, and the willingness to enroll child in the community is very low.
Cluster 1: 17 parents to adolescents. In this group, only 1 parent carries an AAI for his child, and all children carry an AAI for themselves. Adherence among children is the highest when compared with other clusters, and the willingness to enroll child in the community is very high.
Cluster 0: 42 parents form the third cluster, which is in the middle between the 2 aforementioned clusters. Almost all children already carry an AAI for themselves, but many parents continue to carry an AAI. The adherence is a little bit lower than in cluster 1, but still high. The willingness to enroll a child in the community falls near the midpoint between clusters 1 and 2.
These results are consistent with previously described results obtained by other techniques. Parents’ willingness to enroll their child in the community is positively correlated with child's age and child's adherence.
The minimum age for a child to join an ERC is between the ages of 12 and 13 years in the opinion of both parents and children. This can be explained by the fact that the study was performed in Israel where the ages of 12 years for girls and 13 years for boys are commonly considered the years when a child comes of age. Another possible explanation is that the age of 12 to 13 years is known to be the cutoff for cognitive development [
The parents’ opinion about the minimum age for a child to join an ERC was positively correlated with the age of the parents’ own child. This finding may be related to the well-known cognitive bias of
The parents’ opinion about the minimum age for a child to join an ERC was negatively correlated with the protective parenting style and positively correlated with the monitoring parenting style. These findings can be explained by the desire of parents with a higher protective parenting style to provide their children with an additional layer of support as soon as possible, and the desire of parents with a higher monitoring parenting style to provide their children with tools to cope by themselves when they become more independent.
The parents’ opinion about the minimum age for a child to join an ERC was negatively correlated with the parents’ education, that is, the more the parent is educated, the higher the likelihood she will allow her child to join an ERC at a younger age. Such association may be related to the relationship between the level of education and the exposure to updated technological solutions for treating medical conditions [
The children’s opinion about the minimum age for a child to join an ERC was negatively correlated with the protective parenting style and positively correlated with the monitoring parenting style. These findings are consistent with the findings about the parents’ opinion presented above. Children who have protective parents are prone to anxiety [
Our research used a convenience sample of highly motivated parents of children with food allergies, namely, those parents who decided to attend the annual meeting of a nonprofit organization for patients with food allergies (these attendees represent about 5% of the total membership of the organization).
Our study was limited to a single emergency condition: anaphylaxis. Most of the participants in our study were parents of patients, but not patients themselves. Our study was conducted in a single country: Israel. Cultural differences could lead to different results in different countries [
We observed high adherence levels among parents: 45 out of 50 parents (90%) reported that they always carry an AAI, 37 out of 52 parents (71%) reported that they had immediate access to an AAI every day in the past week, and 22 out of 52 parents (42%) had an AAI when filling out the questionnaire. Adherence was also high among children: 43 out of 57 parents (75%) reported that their children always carried an AAI, 51 out of 57 parents (89%) reported that their children had immediate access to AAI every day in the past week, and 53 out of 57 parents (93%) reported that the child had an AAI with him at the conference. These adherence levels are higher than those reported in 2 previous studies that found that 30% [
Comparison with the recent study by Shaker et al [
Shaker et al [
EPIMADA is a regulated community, and in every event, the volunteers are provided with guidance by phone from experienced EMS dispatchers. This approach can thus alleviate concerns about “harming the patient if it is not a real allergic reaction” that were also identified by Shaker et al [
Our results provide strong support for the creation of ERCs for allergy patients. The willingness to join the community was found to be very high.
We studied a wide range of variables that can affect the willingness to join an ERC and described those variables that we found to be significant in our field study. Our findings can be of interest both to researchers of smartphone-based emergency response communities and to EMS administrators and policy makers who are considering establishing an ERC.
We note that mediation of an ERC by EMSs has the potential to solve several problems:
An ambulance that arrives to the scene can replace the AAI of the community member who responded to the event by administering his own AAI to the patient in distress. This approach can alleviate the concerns about “leaving oneself or one’s child without an AAI” and those about replacement costs and delays.
EMS dispatchers can provide guidance by phone. This approach can alleviate the concerns about “harming the patient” and can improve responders’ chances of providing emergency assistance.
Future research needs to address the following issues:
Rare use of the app may cause users to forget to install it on new phones. Retention strategies should be developed.
It is unclear whether ERC membership incentivizes adherence. On the one hand, a community member may feel responsibility to be ready to respond at any time, which could raise his level of adherence. On the other hand, a free-rider effect may lower his level of adherence.
In this research, we focus on the willingness to join an ERC. Willingness to respond to an event is a different decision and needs to be studied.
Questionnaire for parents.
Questionnaire for children.
automatic adrenaline injector
Adolescent Autonomy Questionnaire
analysis of variance
Adult Responses to Children’s Symptoms
emergency medical service
emergency response community
intraclass correlation
Magen David Adom—the Israeli national EMS
odds ratio
principal component analysis
None declared.