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Influence of education and residence on the parental search for pediatric surgical information on the internet

BACKGROUND The internet is a valuable tool for access to health-related information. There is limited literature regarding its use by parents of children with surgical conditions. AIM To investigate internet usage by parents seeking information about the surgical conditions of their offspring in relation to epidemiological factors such as family residential area and parental educational level and to subsequently review the literature regarding this topic. METHODS An anonymous questionnaire about internet usage was completed by eligible parents of children who were admitted to our clinic for minor surgical procedures during a six-month period. RESULTS Our results demonstrated that the internet has been mostly used by mothers for children’s health information. Google was the most commonly used search engine, while pediatricians were the first parental choice for ‘live’ information. Only one-quarter of the parents informed their doctor about the information found online. Nine of ten parents had a positive opinion of an official website managed by the doctors of our clinic. Our results mostly agreed with the international literature. CONCLUSION In conclusion, the establishment of official websites (designed and managed by specialists) that parents can access to receive appropriate health information is mandatory in the internet era.


INTRODUCTION
Fifty years have passed since the onset of the internet, and the increase in numbers of people who access it worldwide is remarkable. According to the hellenic statistical authority, the last decade (2009-2018) saw a 100.8% increase in internet access at home. In Greece, more than 76.5% of homes accommodate internet access. The vast majority of adults (96.6%) use the internet more than once a week, and the internet is a popular source of health-related information [1]. Recent studies have demonstrated that up to 91% of adults access online sources of health information [2][3][4]. In Greece, the proportion of internet health users increased from 23% in 2007 to 65.2% in 2018 [1,5]. Parents of children with chronic medical conditions are motivated by a desire to increase their knowledge and relieve their anxiety [6][7][8][9][10][11][12][13]. Nevertheless, there is limited literature regarding the use of the internet for pediatric surgical conditions [4,[14][15][16][17]. Previous studies in Europe have shown that the use of the internet for health information varies significantly in different parts of the continent [5,18]. No similar studies have been recorded in South Europe, a region with diverse cultural and socioeconomic environments. Previous studies on parental internet exploration have mostly focused on three parameters: (1) Identification of the websites used; (2) Evaluation of the information found in relation to its readability and accuracy; and (3) The influence of the information on the parents' decisions to visit the emergency department when their child is sick [6][7][8][9]. The objectives of this study were first to evaluate the epidemiological characteristics of parents in relation to the magnitude of internet usage for health-seeking information and second to review the literature regarding this topic.

Participants
The survey was conducted from January 2018 to June 2018 in the Department of Pediatric Surgery, Alexandroupolis University Hospital, Greece. Eligible participants were parents of children (ages: 0-14 years) who were admitted to our clinic for minor elective surgical treatment (herniotomy, orchidopexy, hypospadias repair, circumcision) or emergency surgery (appendectomy, gonadal torsion, traffic accident, or fallrelated injuries) and lived in the regions of Eastern Macedonia and Thrace. We excluded illiterate parents and parents who had already been included in the study group. Additionally, we excluded parents of children with chronic health problems and those of children who were admitted for major surgical procedures due to their increased anxiety. If both parents were present, only one of them could complete the questionnaire. In this cohort study, parents were divided into two categories according to their residency (urban or rural).

Questionnaire
The questionnaire was designed by MA and KK (authors) and was anonymous and voluntary. The questionnaire was designed and adjusted according to the characteristics and needs of people of our region regarding the difficulties they confront in communicating with a hospital doctor to accomplish sufficient and satisfactory medical information. In this region, with many scattered and isolated villages, the inhabitants form a multicultural society with different habits. The questionnaires were designed to be simple, unintimidating and easy to complete. There was no need for stratification, and the questionnaire consisted of a paper that required approximately 4 to 6 min to complete. It included 17 questions addressing three areas: (1) The use of the internet and its accessibility at home/work/elsewhere. Personal computers (PCs) at home, frequency of internet use, engagement in social media, parental engagement in social media and parental groups; (2) The use of the internet for access to medical information by family members, the use of the internet on a regular basis and 24 h prior to admission and which search engines were used; and (3) The use of the internet by parents addressing information for a specialist pediatric surgeon, other sources of information and the need for an official website with online, up-to-date medical information. In addition, there were questions about demographic data [gender, age and parental educational level, family income, residence, child insurance, type of admission (elective or emergency)]. The questionnaire was in Greek. Nevertheless, the option for a questionnaire written in Turkish was offered for some parents who were more fluent in that language. To reduce bias from the influence of medical staff of our clinic on the participants, a team consisting of two doctors and two medical students from the university was responsible for distributing these questionnaires (in paper) to the parents. The parents, if they agreed to participate, were asked to complete and return the questionnaires up to the day after their child's admission.

Sample size derivation and statistical analysis
With 600 admissions for minor surgical treatment in the University Pediatric Surgery Clinic annually, 234 completed questionnaires were required to achieve a 5% margin of error with a 95% confidence interval [19]. The main emphasis was on parents who searched the internet for children's health-related information in the past (202/235, 86%). Two parameters were analyzed: (1) The residence of the family; and (2) The educational level of the parent who searched the internet for child-related medical information. Descriptive statistics such as frequency, proportions, chi-squared test for categorical variables, and Mann-Whitney U test [nominal scale, when the point of interest was the residence (urban or rural)] or Kruskal-Wallis H (nominal scale, when the point of interest was the education level of the parent; categorized into three groups: (1) Completed high school or less; (2) Completed college or some college; or (3) Advanced degree or beyond) were employed to analyze data. We used R software (version 3.4.1), and a P value < 0.05 was considered statistically significant. The study was completed with a review of the existing literature on this topic. September 9, 2021 Volume 10 Issue 5

Study design and inclusion criteria:
The inclusion and exclusion criteria were defined before the initiation of the research. Only research studies were included. Commentaries, conference abstracts, any type of review, editorials, letters to the editor, case series, and case reports were not considered. The selection criteria were defined by applying the problem/population, intervention, comparison, and outcome framework. Participants included parents or guardians of children who required pediatric surgeon management. Intervention consisted of telephone interviews, live interviews, questionnaires or surveys. Any comparison between different populations was acceptable. Desired outcomes were socioeconomic status; residence (urban or rural area); internet usage; internet search platforms; internet sites and any other result reported in the questionnaire, survey or interview.
Literature search strategy and study selection: A literature search was performed based on the PubMed and Cochrane libraries using the following search terms: Internet health service; internet health information; internet; network; net; search; Ehealth; e-mail; mail; parents; guardians; family; questionnaire; survey; interview; pediatric; pediatric; and pediatric surgery. Articles published in English were retrieved from inception to October 2020. The records found were checked for duplicates. Then, the remaining articles were screened. Any article that met our criteria was included.

Demographics
All parents completed the questionnaire (235 of 235, 100%). Two hundred two (86%) parents searched the internet for children's health-related information. Descriptive data for all participants are presented in Table 1.

Family residence and parental internet usage
Internet usage and accessibility. There was a statistically significant difference between parents living in urban and rural areas regarding several parameters ( Table 2): (1) Internet access according to the location of the participants. Most of the parents in urban and rural districts (95.2% and 86.6%, respectively) had internet access at home. Nevertheless, only 1.9% of urban residents used the internet elsewhere as well (library, internet cafes, friend's home), and 9.3% of rural residents used the internet elsewhere (P = 0.022); (2) Ownership of PC at home. Only 7.6% of the city homes did not possess a PC in comparison to 27.8% of rural homes (P = 0.0001); (3) Frequency of internet usage. The usage of the internet was more than once a week among 94.3% and 85.6% of parents in urban and rural areas, respectively. However, the relevant percentages for internet usage less than three times per month were 5.7% and 14.4%. (P = 0.038); and (4) Participation in parents' groups on social media. Participation in parental social media groups varied significantly in the two groups: 66.7% in urban areas and 34% in rural areas (P < 0.0001).
Internet usage to access medical information. Almost half of the parents (42.1%) searched for medical information 24 h prior to admission, but 49.5% had doubts about this information. There was a statistically significant difference between parents living in urban or rural areas with respect to several parameters, as shown in Table 3: (1) Regular internet search activity for basic medical information in the past. Almost nine of ten parents (86.7%) from urban areas searched the internet for medical conditions on a regular basis, in contrast to 67% of parents from rural areas (P = 0.0009); and (2) Search engines. Multiple answers were possible. Google was the most frequently used search engine by both groups. Parents from urban districts used Wikipedia more often (23.8%) than those from rural areas (12.4%). Rural area participants (12.4%) searched through other unspecified engines, while only 2.9% of the urban area participants used other unspecified engines (P = 0.0078).
Internet usage and examination by a pediatric surgeon. Comparing online sources of information with the information provided by a pediatric surgeon, 67.8% of the parents found both sources to be consistent. There were statistically significant differences between parents living in rural and urban areas with respect to several parameters, as shown in Table 4: (1) Searching the internet for a specialist before an appointment. Half the parents from rural areas (50.5%) searched for a specialist before their decision for an appointment, while only 32.4% of those from urban areas did so (P = 0.008); (2) Informing the doctor about the internet search. A great percent of parents from urban sites (29.5%) communicated with the specialists regarding their September 9, 2021 Volume 10 Issue 5 results from their internet search, in contrast to only 17.5% of parents from rural areas (P = 0.045); and (3) The need for an official website. Parents (97.1%) from urban sites believed that an official website managed by doctors from the clinic would be helpful, while 85.6% of parents from rural areas agreed with this opinion (P = 0.003).

Educational level of parents who performed research for medical information
Internet usage and accessibility. Regardless of education level, 90.1% of all parents used the internet more than once a week. There were statistically significant differences when comparing the results between parents from rural and urban areas with respect to several parameters, as shown in Table 5: (1) Ownership of a PC at home. All participants (100%) with an advanced degree owned a PC, in contrast to 92.1% of the parents with a college degree and 70.9% of the parents with a high school diploma (P < 0.0001); and (2) Participation in parental groups on social media. Participation in parental groups on social media was higher among parents with college degrees (71.4%) than among those with high school degrees (37.9%) and university Internet usage to access medical information. Google was the most commonly used search engine by the three groups (85.6%), followed by Wikipedia (18.3%). There was a statistically significant difference between parents living in urban and rural areas with respect to several parameters, as shown in Table 6: (1) Regular internet search activity for basic medical information in the past. One of three parents (35.9%) from the lower education level never previously searched the internet for medical information, in contrast to parents with a college (6.3%) or an advanced degree (13.9%) (P < 0.0001); (2) Internet usage the day before admission. Parents with a higher education level were less likely to search the internet prior to admission (19.4%) than parents with medium (54%) and lower (42.7%) education levels (P = 0.004); and (3) Website validity. Most parents from the higher education levels (77.8%) negatively evaluated the websites in terms of validity. The evaluation from the two other groups was not decisive (P = 0.0009).
Internet usage and examination by a pediatric surgeon. Regardless of the education level of parents, 41.1% of all participants searched for a specialist on the internet. There was a statistically significant difference in parents living in urban and rural areas with respect to several parameters (Table 7): (1) Informing the doctor about the internet search. We noticed that parents from higher education levels (advanced degree or higher) were less likely to inform doctors about the medical information they found online (8.3%), in contrast to parents who had college degrees (23.8%) and high school diplomas (29.1%) (P = 0.041); (2) Agreement between information provided by the doctor and that from the internet. A total of 55.3% of the parents from the lower, 85.7% from the medium and 72.2% from the higher educational level thought information found on the internet and that provided by the doctor were compatible (P = 0.0002); and (3) The need for an official website. All parents from all educational groups consisting of an advanced degree or higher and who completed college or some college (100%) agreed that an official website is necessary for reliable information, while 83.5% of parents from the lower education level agreed with this opinion (P = 0.0001).

Other interesting results
Regardless of the education levels and the residence of the parents, several factors were generally applicable: (1) Most parents (81.7%) were actively engaged in social media (Facebook, Twitter, Instagram); (2) The family member most likely to search the internet for children's health information was the mother (73.8% when the comparison was according to residence and 68.3% when the comparison was according to the educational level of the parent who searched the internet); (3) Evaluation of the websites in terms of comprehension. Most parents (72.3%) stated that they understood completely, or they thought they understood, the information provided; (4) Level of satisfaction with medical information. Only two of ten parents (22.8%) were satisfied/very satisfied with the medical information they found; and (5) Other resources for health information. Multiple answers were possible. Most parents (97.5%) approached a pediatrician or a general practitioner (GP) for health information about their child's condition. The next most popular source of information consisted of friends and family (37.6%).

Review of the literature
The combined search identified 12 articles that matched our criteria[4,6-8,10-13,16,17, 20,21]. In the recent literature, it is stated that highly educated parents are more likely to search online for child-related information on a regular basis (52.2%-97.7%) and less likely to search 24 h prior to admission of their child (11.8%-21%). Although parents from lower education levels were less likely to search the internet on a regular basis (64.1%), they were more likely to use the internet for health-related information 24 h prior to the child's admission (47.2%). In contrast, the proportion of parents from the higher education levels was 86.1% and 19,4% regarding searching on a regular basis and searching 24 h prior to child admission, respectively. It was also reported that lower rates of internet accessibility and PC ownership in rural districts made parents from these areas less likely to search the internet on a regular basis (67%) than parents from urban sites (86.7%) [7,8,10,11,16]. Russo et al [20] reported that parents who lived more than 44 km from the hospital were twice as likely to search online for information about their child's surgery than those who lived closer to the hospital [20]. September 9, 2021 Volume 10 Issue 5 Regarding search engines, parents mostly used Google and Wikipedia to locate medical websites [4,8,11,12,16,21]. The evaluation of the websites in terms of validity and general level of satisfaction of the information provided was low, especially when the education level of the parents was higher. Several authors have also reported that the quality of medical information found on the internet was poor, which may cause misinformation [6,[11][12][13]. In contrast, Semere et al [16] reported that 98% of parents agreed or somewhat agreed that the information was comprehensible [16]. Regarding other sources of medical information, it was reported that pediatricians and GPs were mainly consulted according to several authors who studied the health information seeking behavior of parents [8,11,12,17]. Some studies conclude that there is a predominance of friends and family instead of pediatricians [4,10,13]. Wong et al [4] reported a similar conclusion that only 35.5% of the parents informed the doctor about online medical information because the doctor had already included it in his consultation [4]. Another reason why they were hesitant to discuss the information they found with their doctor might have been the warnings from doctors about the validity of the health-related webpages [21]. A consistency rate of 95.2% was reported when the information found on the internet and the information provided by the doctor were compared [4]. Furthermore, several authors pointed out the overwhelming interest of parents on websites provided by doctors or hospitals [8,[10][11][12]16].

DISCUSSION
The results of this study confirm that the internet is a rapidly growing source of medical information, and parents are using it for child-related health information to make significant decisions regarding their child's health [4,11,12,16]. Parental internet access at home ranged from 84.5% to 100% and 86.6% to 95.2% in relation to education level and location of residence, respectively. The vast majority (82.7%) owned a PC at home. They used the internet more than once a week in 90.1% of the sample, while 81.7% participated in social media. Half the study group (51%), mostly parents in urban sites with college and university degrees, were members of health-related support and parental support groups. Our study was in contrast to a study concluding that parents of children living a long distance (≥ 44 km) from a hospital were twice as likely to search online for information about their child's forthcoming surgery than those who lived closer to a hospital [20]. In our study, this result probably occurred because families that live far from a hospital are those from rural areas where the parents are simpler and trust without doubt the hospital doctors, and additionally, the internet in their areas is not easily accessible. In our study, most mothers searched the internet regardless of their education level (68.3%) or residence (73.8%). Nevertheless, this result is in line with findings from previous studies [4,5,8,10]. Our questionnairebased study found that the most commonly used search engines by parents were Google (85.6%) and Wikipedia (18.3%), who are less familiar with child-specific websites managed by specialists and hospitals or because they are not aware of what constitutes good health information. These results coincide with previous studies [4,8,11,12,16,21]. On the one hand, the evaluation of websites in terms of comprehension in our study was high since 72.3% of the parents understood or thought that they understood the online medical information. This finding agrees with the results from a study by Semere et al [16] in which 98% of parents agreed or somewhat agreed that the information was comprehensible [16]. In contrast, several studies have shown that the quality of medical information found on the internet is poor and that the results are misleading [6,[11][12][13]. In addition to the internet, other resources for medical information according to our study were mainly pediatricians and GPs (97.5%) regardless of the education level or residence of the parents, while friends and family members were the next most frequently used resources, mostly from urban residents (46.7%), with lower EL (43.7%). The same conclusions were reported by several authors who studied the health information-seeking behavior of parents [5,8,11,12,17], in contrast to other studies in which there was a predominance of friends and family instead of pediatricians [4,10,13]. One study reported that nearly one-third of the parents discussed the information that they found online with their doctors [4]. Our study showed that the higher the education level of the parents, the less likely they were to inform the doctor about their internet searches. Additionally, urban residents discussed the child's health-related information more often (29.5%) than parents from rural sites (17.5%). When comparing the information found on the internet and that provided by the doctor, only half the parents from the lower education level (55.3%), 85.7% with college degrees, and 72.2% with advanced degrees found both sources to be consistent. Wong et al [4] reported a consistency rate of 95.2% [4]. Several authors have noted the overwhelming interest of parents on websites provided by doctors or hospitals [8,[10][11][12]16]. Our study demonstrated that the vast majority of parents (91.6%) supported the idea of an official website designed and managed by the doctors of our clinic in which they would be able to find reliable and accurate child-related infor-mation.

Limitation
Our study included parents of children who were admitted to our clinic but excluded those who were not. It would be interesting to determine parent behaviors when they are not stressed out by their child's hospitalization.

CONCLUSION
Our study is in line with the international literature with some minor deviations. This demonstrates that most parents use the internet to query child-related surgical problems. Internet access is difficult in rural areas of northeastern Greece, probably because many of these regions are isolated mountainous areas where the majority of the population is engaged in agricultural work and has different cultural habits. After this survey and this review, the next developmental step that the medical community must support is clear. This is the creation of an easy-to-use (even by people with a low educational level) official website from which the parents could access appropriate health information to give substantial answers to their questions and by which they could contact online medical staff and address their questions. Parents will be reassured about their decisions regarding the right time to visit the hospital and consult the doctor they choose for their child's conditions.

Research background
The internet is a valuable tool for access to health-related information. There is limited literature regarding its use by parents of children with surgical conditions.

Research motivation
Our study describes the influence of education and residence on the parental search for pediatric surgical information on the internet in a multicultural region of northern Greece, and we compare our results with the recent literature.

Research objectives
The objectives of this study were first to evaluate the epidemiological characteristics of parents in relation to the magnitude of internet usage for health-seeking information and second to review the literature regarding this topic. September 9, 2021 Volume 10 Issue 5

Research methods
In this study, an anonymous questionnaire about internet usage was completed by eligible parents of children who were admitted to our clinic for minor surgical procedures during a six-month period. And the literature was reviewed.

Research results
The results of this study demonstrated that the internet has been mostly used by mothers for children's health information. Google was the most commonly used search engine, while pediatricians were the first parental choice for 'live' information.

Research conclusions
The establishment of official websites that parents can access to receive appropriate health information is mandatory in the internet era.

Research perspectives
It would be interesting to determine parent behaviors when they are not stressed out by their child's hospitalization in the future.