Abstract
Purpose
No information exists on the level of internet use among parents of pediatric patients with scoliosis. The internet may represent a medium through which to provide information to augment the outpatient consultation. The aim of this research was to establish the prevalence of internet use amongst a cohort of parents attending a pediatric scoliosis outpatient clinic.
Methods
A previously used questionnaire (Baker et al., Eur Spine J, 19:1776–1779, 2010) was distributed to parents attending a dedicated scoliosis outpatient clinic with their children. Demographic data and details about use of the internet were collected.
Results
Fifty-eight percent of respondents had used the internet to search for information on scoliosis, and 94 % were interested in a local internet provided information provision. A positive history of corrective surgery and possession of health insurance were independent positive predictors of internet use.
Conclusions
As surgeons we need to be aware of our patients’ use of the internet, and there is the opportunity to use this medium to provide additional education.
Keywords: Internet, Pediatric, Scoliosis, Information provision, Outpatient
Introduction
The internet has revolutionized the way we exchange information. Access to an enormous quantity of information on any topic is available to anyone who has a computer connected to the World Wide Web. If one searches for the term ‘scoliosis’ using the Google search engine, 6.87 million results are declared in only 0.1 s (search performed 31 August 2011). This is a remarkable increase in volume of information available in less than a decade [1].
Previously it has been noted that approximately one-quarter of patients attending orthopedic outpatient clinics for spinal related complaints had used the internet to search for information on their condition [2]. While providing accurate and comprehensible information, internet sites can equally provide misleading or difficult to understand information that can cause undue anxiety, appropriately termed ‘cyberchondria’ [1, 3, 4]. This raises concerns for both patient and doctor alike as the patient–doctor relationship can potentially be altered on the basis of the internet search [5–7].
We aimed to ascertain the level of internet use to search for information regarding scoliosis by parents of children attending the outpatient service in our hospital. We hypothesized that the level of use would be greater than that previously reported in other local studies. Secondarily we aimed to determine whether the search for information was useful or otherwise and also whether further information provision via this medium was desired.
Materials and methods
A questionnaire based on a previously used model by Baker et al. [2] was used to collect basic demographic information and information regarding internet use and access. The new questionnaire was initially trialed on 20 parents attending the outpatient clinic to test for readability. Minor modifications were made following this piloting and these questionnaires were discarded (see Appendix 1 for full version of the questionnaire). Ethical board approval was waived.
Questionnaires were distributed over a 3-month period in early 2010 to all parents attending the scoliosis outpatient clinic. Our hospital is a national tertiary referral center for pediatric scoliosis and the population attending can therefore be assumed to be representative national demographics. Three consultant spinal surgeons with a special interest in pediatric spinal deformity staff the clinic. Consecutive parents attending with their child(ren) were invited to participate. Consent was obtained at the time of distribution.
Information gathered included basic demographics, highest level of education, history of corrective surgery and whether the visit was an initial consult or a follow-up visit. Details were sought regarding the possession of insurance, access to the internet at home or at work and whether they had used the internet specifically to search for information on scoliosis. We enquired whether the internet search was helpful; if it induced a greater degree of anxiety and whether it stimulated further questions. Finally, we asked if they were enthusiastic for a local internet site that provided information scoliosis.
Statistics
All data were collated on an Excel spreadsheet and statistical analysis performed using Minitab (ver. 16). Basic descriptive data are used to report results, as are proportions with 95 % confidence intervals when reporting responses to questions regarding internet use. A multiple-regression model was used to determine the relationship between internet use and basic demographical information as well as web access. In order to include categorical variables with more than two levels (e.g. level of education) in the multiple-regression prediction model, additional steps were taken to insure that the results are interpretable. These steps include recoding the categorical variable into a number of separate, dichotomous variables. This recoding is called “dummy coding”.
Results
One hundred and sixty-eight parents attending the outpatient service completed the questionnaire, of which 32 were males. One hundred and sixteen were aged between 35 and 50 years, 11 between 20 and 35 years, 18 below 20 years and 10 were aged over 50 years. The average age of the child attending was 11.9 (SD 4) with a range of 1–18 years.
The highest level of education varied amongst parents: 14 attained a primary education, 93 had either a secondary education or a trade qualification, while 54 achieved tertiary level education. One hundred and eighteen were making a return visit either for scheduled follow-up or to receive results of investigations. Sixty-four respondents (41 %) held private health insurance. Previous corrective surgery had been performed in 34 children (21 %) attending the clinic.
The responses to demographic questions and details regarding access to the internet are displayed in Table 1. Results from questions assessing parental experience of using the internet for seeking information on scoliosis are displayed in Table 2.
Table 1.
Results from demographic details and assessment of parental use of the internet to search for information on scoliosis
| Demographic/question | Responses (N) | Answers | Sample p-value (95 % CI) |
|---|---|---|---|
| Gender | 167 | 32 = male | 0.19 (0.14, 0.26) |
| 135 = female | 0.81 (0.74, 0.87) | ||
| Age | 155 | 18 parents <20 | 0.12 (0.07, 0.18) |
| 11 parents 20–35 | 0.07 (0.04, 0.12) | ||
| 116 parents 35–50 | 0.75 (0.67, 0.82) | ||
| 10 parents 50–65 | 0.07 (0.03, 0.12) | ||
| Age of child | 164 | 11.9 (SD 4), range 1.1–19 years old | |
| Highest level of parent education | 161 | 14 parents = primary | 0.09 (0.05, 0.14) |
| 87 Parents = secondary | 0.54 (0.46, 0.62) | ||
| 6 Parents = trade | 0.04 (0.01, 0.08) | ||
| 54 Parents = third level | 0.34 (0.26, 0.41) | ||
| Visit type | 164 | 18 First visit | 0.11 (0.07, 0.17) |
| 118 Results/investigation | 0.72 (0.64, 0.79) | ||
| 28 Return visit | 0.17 (0.12, 0.24) | ||
| Waiting time to first consultation (months) | 29 | 6.24, range 1–24 months | |
| Has you child had corrective surgery? | 164 | 34 = yes | 0.21 (0.15, 0.28) |
| 130 = no | 0.79 (0.72, 0.85) | ||
| Were there any post-operative complications? | 41 | 36 = no | 0.88 (0.74, 0.96) |
| 5 = yes | 0.12 (0.04, 0.26) | ||
| Do you have private health insurance? | 154 | 90 = no | 0.58 (0.50, 0.66) |
| 64 = yes | 0.41 (0.34, 0.50) | ||
| Do you have internet access at home? | 159 | 152 = yes | 0.96 (0.91, 0.98) |
| 7 = no | 0.04 (0.02, 0.09) | ||
| Is your internet access only at work? | 99 | 93 = no | 0.94 (0.87, 0.98) |
| 6 = yes | 0.06 (0.02, 0.13) | ||
| Have you searched the internet for information on scoliosis? | 165 | 97 = yes | 0.58 (0.50, 0.66) |
| 69 = no | 0.42 (0.34, 0.5) | ||
| Had you searched prior to your first consultation? | 163 | 98 = no | 0.6 (0.52, 0.68) |
| 65 = yes | 0.4 (0.32, 0.48) | ||
| Did you search only after the first clinic visit? | 146 | 114 = no | 0.78 (0.71, 0.85) |
| 32 = yes | 0.22 (0.16, 0.30) |
Test and confidence interval (CI) for one proportion is based on the number of answers (i.e. excludes the number of blank responses)
All sample p values and CI rounded to the nearest two decimal places
Table 2.
Results from questions assessing the way in which parents used the internet and their experiences in doing so
| Demographic/question | Responses (N) | Answers | Sample p (95 % CI) |
|---|---|---|---|
| How did you find websites on scoliosis? | 85 | 12× friend | 0.14 (0.08, 0.23) |
| 2× physician/surgeon | 0.02 (0.00, 0.08) | ||
| 70× search engine | 0.82 (0.73, 0.90) | ||
| 1× another patient | 0.01 (0.00, 0.06) | ||
| Search engine used | 62 | 1× auntminnie.com | 0.02 (0.00, 0.09) |
| 57× Google | 0.92 (0.82, 0.97) | ||
| 1× Google/Yahoo | 0.02 (0.00, 0.09) | ||
| 1× Google scholar | 0.02 (0.00, 0.09) | ||
| 2× Yahoo | 0.03 (0.00, 0.11) | ||
| Was the internet helpful? | 103 | 79 = yes | 0.77 (0.67, 0.84) |
| 24 = no | 0.23 (0.16, 0.33) | ||
| How helpful was the internet? | 97 | Average 58 (range 0–100) | |
| Did the internet search create more anxiety? | 132 | 38 = yes | 0.29 (0.21, 0.37) |
| 94 = no | 0.71 (0.63, 0.79) | ||
| Did you encounter confusing websites? | 104 | 73 = no | 0.70 (0.60, 0.79) |
| 31 = yes | 0.30 (0.21, 0.40) | ||
| Could you recommend sites after your search? | 90 | 53 = no | 0.59 (0.48, 0.69) |
| 37 = yes | 0.41 (0.31, 0.52) | ||
| Did the search prompt more questions for this visit? | 107 | 68 = no | 0.64 (0.54, 0.73) |
| 39 = yes | 0.36 (0.27, 0.46) | ||
| Are you interested in an Irish scoliosis site? | 138 | 8 = no | 0.06 (0.03, 0.11) |
| 130 = yes | 0.94 (0.89, 0.98) | ||
| Were you satisfied with information provided at last clinic visit? | 126 | 10 = neutral | 0.08 (0.04, 0.14) |
| 1 = not satisfied at all | 0.01 (0.00, 0.04) | ||
| 4 = somewhat dissatisfied | 0.03 (0.01, 0.08) | ||
| 41 = somewhat satisfied | 0.33 (0.25, 0.42) | ||
| 70 = totally satisfied | 0.56 (0.46, 0.64) | ||
| Reasons for searching the internet | |||
| To gain a clearer explanation | 56 | 56 = yes | |
| To find additional information | 84 | 84 = yes | |
| To answer further questions | 33 | 33 = yes | |
| To search for a visual explanation | 50 | 50 = yes | |
Test and CI for one proportion is based on the number of answers (i.e. excludes the number of blank responses)
All sample p values and CI rounded to the nearest two decimal places
Fifty-eight percent of those surveyed had used the internet to search for information on scoliosis. Fifty-six parents (34 %) reported that they used the internet to gain a better understanding of their child’s spinal condition, 33 (20 %) used the internet to answer further questions they had encountered after the clinic visit and 50 (30 %) used the internet to find a visual explanation of the condition.
A regression analysis was used to explore if participants’ gender, age group, child age, education, private health insurance, visit type, history of corrective surgery for the scoliosis, post-operative complications or internet access (home or at work) had an impact on whether the parents of children with scoliosis searched the internet (see Table 3). Work only web access and post-operative complications were omitted from the analysis, as there were a number of blank responses—69 and 127, respectively.
Table 3.
Results from the multiple-regression prediction model
| Term | Coefficient | SE Coefficient | T | P |
|---|---|---|---|---|
| Constant | 0.554 | 0.658 | 0.84 | 0.401 |
| Parent gender | 0.022 | 0.106 | 0.21 | 0.832 |
| Parent age group | 0.006 | 0.058 | 0.11 | 0.913 |
| Child age (years) | 0.015 | 0.01 | 1.6 | 0.113 |
| Parent education | −0.029 | 0.041 | −0.71 | 0.48 |
| Visit type | 0.011 | 0.114 | 0.1 | 0.922 |
| Corrective surgery | 0.233 | 0.146 | 1.6 | 0.112 |
| Private health insurance | −0.078 | 0.089 | −0.88 | 0.383 |
| Home internet access | 0.318 | 0.216 | 1.48 | 0.142 |
Work only web access and post-op complications are ‘essentially’ constants in the regression equation as there were a number of blank responses
This regression analysis was used to understand how/if parents searching the internet changes when any one of the independent variables (parent gender, age group, etc.) is varied, while the other independent variables are held fixed
Overall 138 cases were used in the analysis while 30 contained missing values. In order to account for missing values, individual regression analyses were carried out to investigate the specific relationships between internet use and ‘corrective surgery’ (p = 0.039, 164 cases used), ‘post-op complications’ (p = 0.154, 41 cases used) and ‘private health insurance’ (p = 0.017, 154 cases used).
Discussion
The internet has influenced many facets of life. Healthcare has not been immune to this phenomenon with both patients and physicians alike using the internet to their advantage [8]. We first aimed to determine the level of internet use in our cohort of parents of children attending the scoliosis outpatient clinic. Confirming our hypothesis we found that the prevalence of internet use of almost 60 % was much greater than that previously encountered in an adult population with spinal complaints [2]. It was also higher than the 39 % prevalence in a general pediatric outpatient population reported in 2002 [9]. It was, however, still somewhat less than the 84 % prevalence reported by Aslam et al. [10], although it is noted that their response rate to the questionnaire was only 67 %.
A majority of those who used the internet found the exercise useful and the search prompted further questions in a number of parents. This is a consistent finding with Aslam et al. [10] also reporting that most of their study cohorts found the search useful and just over a quarter found that the internet search generated new questions to ask at their next clinic visit.
We noted that almost a third of those who searched the internet found sites either confusing or had a greater feeling of anxiety afterwards. Anxiety after searching the internet for health-related information is not new but is of concern as it can alter the patient–doctor relationship [3]. Potentially it can result in increased time spent in the outpatient setting correcting misconceptions. Increased anxiety may not only be due to inaccurate information but could also be simply due to miscomprehension of the information provided. Badarudeen et al. [4] found that internet-based education materials provided by the Pediatric Orthopaedic Society of North America had readability scores considered too high for the general population.
A notable proportion of parents responded positively to the question on delivery of a locally provided internet site on scoliosis. It has already been determined that the currently available information on the internet about scoliosis is of concerning quality [1]. This represents an opportunity to engage positively with both the pediatric patient and their parent using the internet for greater information provision—a benefit increasingly suggested in the age of the internet [11]. On a European level efforts are already being made to engage patients via the internet to provide the best possible evidence and information available—this includes information specifically on scoliosis [8]. However, we need to be mindful of ensuring that the readability of information provided is suitable for the target audience as often the comprehension level the information is provided at is too high [4].
It appears that visual explanations should be included in any internet-based information effort with almost one-third searching specifically for a visual explanation of their child’s scoliosis condition. This may play a role, especially for those requiring surgery, as this was one of the few independent variables that predicted a parent had searched for information on the internet. We propose that any site development should include and interactive module to explain the deformity and what is involved in correction.
We acknowledge that this study has certain weaknesses, as do many questionnaire-based studies. There is the potential for selection bias when a 100 % response rate is not achieved for a certain question and this can result in an over estimation of a positive or negative result. The search skills of those using the internet and the quality of the internet sites visited is impossible to control—we acknowledge that a more skilled internet user may be more likely to access better quality sites and hence not suffer the same anxiety as a less skilled individual. This clearly has a potential impact on the results. Furthermore, as this is an initial study we have not sought certain information that may be of interest. Subsequent development of a local internet site and auditing of outpatient attendees will determine whether we are able to reduce under anxiety and confusion in our patients.
In conclusion, parents of children attending our scoliosis outpatient clinic reported a higher than average prevalence of internet use to search for information on their child’s condition. There is a clear suggestion that parents desire an internet-based educational tool. We believe that this is an opportunity to improve the patient–doctor relationship and reduce undue anxiety and confusion among our patients.
Conflict of interest
None.
Appendix 1: Scoliosis internet questionnaire
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