Parental use of the Internet to seek health information and primary care utilisation for their child: a cross-sectional study

Using the Internet to seek health information is becoming more common in Europe [1] as well as in the USA [2]. In France little data is available on the proportion of people who have ever used the Internet to seek health information [3] but this proportion seems to be increasing rapidly (from 15% in 2002 [1] to 37% in 2005 [4]).

People use the Internet to seek health information because of its advantages. The Internet is widely available (home, work, libraries), convenient (24 h a day) and anonymous. A recent review highlighted the main reasons of using the Internet to seek health information: to gather additional information after a consultation, to access more complex information about a symptom, a disease or a treatment, to look for information about healthy lifestyles or healthcare services, to participate in an online support group and to be aware of other treatment alternatives [5]. Specific surveys have been carried out in samples of parents looking for health information. Many studies asked parents attending a paediatric hospital whether and why they used the Internet to seek heath information. A high proportion of parents attending outpatient departments seek health information online (from 53% to 64% in the most recent articles) [6–8]. This proportion is even higher for parents of children with a chronic disease or condition (from 58% to 89%) [9–11]. The authors highlighted that health professionals should advise a few selected websites to parents. Population-based surveys pointed out that mothers are high information seekers [12], especially during pregnancy and during the first few years following delivery look to find parenting advice and online clinical health information [12–14].

The widespread utilisation of the Internet raises some questions about its impact on health behaviour, health services utilisation and finally on health outcomes. Although some characteristics of Internet users who seek health information have been well identified [3, 15–17], no sufficient data is available to answer the above questions, in particular on the relation between seeking health information on the Internet and health care utilisation.

Some observers have suggested that use of the Internet might actually decrease the cost of primary care services in systems with universal health care [18]. In that case, one might expect a negative relationship between use of the Internet and primary care utilisation. Others might speculate that Internet usage represents just another channel for activated, information-seeking behaviour, in which case the prediction might be for a positive relationship with primary care utilisation. Results from the studies about the impact of the Internet on health care utilisation are heterogeneous, showing a positive relationship between Internet use and service utilisation [19], a negative relationship [20, 21] or no relationship at all [22, 23]. All these studies but one [21] were carried out within an adult population and none have been conducted elsewhere than in the USA.

Since the health of young children is of particular concern to parents, we assume that parental use of the Internet to seek health information would be related to primary care utilisation for their children. As we previously stated, results from studies available in the literature were heterogeneous [19–23]. Thus, we did not initially presume a positive or negative association.

To test this association, we designed a cross-sectional study in a population of parents of pre-school children. In this paper, we examined the relationship between parental use of the Internet to seek health information and self-reported primary care consultation frequency for their children.

We did not find any relationship between parental use of the Internet to seek health information and the number of self-reported consultations for their child. This finding runs counter to our initial assumption that parental use of the Internet to seek health information would be related to primary care utilisation, either in a positive or in a negative way.

To our knowledge, this is the first study carried out elsewhere than in the USA to assess this relationship. Our results are consistent with an interventional study on mental health services utilisation, which did not find any significant difference in the number of mental health visits between a group that had Web site access and the control group [22]. A quasi-experimental study carried out by Wagner et al. found a null association for parents [23] and a negative association for children [21]. Data from this study are not fully comparable with our study because the intervention was complex and not entirely Internet-based (self-care books, telephone advice nurses and computers). Within a population of Internet users, Eastin and Guinsler found an interaction between anxiety and Internet use to seek health information [20]. Anxious individuals who used the Internet to seek health information had fewer consultations than anxious non-users, whereas such a difference was not found for less anxious individuals. Our findings do not corroborate this interaction, since we did not find any interaction between stress levels and parental use of the Internet to seek health information. Another American study conducted in 1999–2000 found a positive association with an increase of 1.6 consultations for women using computer-based resources [19]. Differences in time period (1999–2000), geographical area (Baltimore metropolitan area, USA) and potential selection bias in both studies are likely to explain the differences between these results and our findings. Finally, findings from a cross-sectional study in seven European countries that investigated patterns of health-related Internet use and its consequences support our results. Only 6% of the sample claimed that they had made, cancelled or changed a doctor's appointment based on health related Internet activity [28]. Even if the number of consultations was not collected in this study, only 6% of the sample claimed that they have made, cancelled or changed a doctor's appointment based on health related Internet activity.

The association that we found between primary care utilisation and the child's age [29–31], child's medical condition [29], familial socio-economic position [32] and psychological factors [33] are consistent with previous findings. However, in most studies performed in the USA [29, 30, 34], lower socio-economic position was associated with less frequent primary care utilisation, which is contrary to our results. Explanations are likely to come from the differences between the French and the American health insurance coverage for children. In France, health insurance coverage is nearly universal [35]. In the USA, most of the studies have been carried out in the 1990's or before, when the problem of uninsured children was raised [29, 30, 34]. At that time, children from the poorest families were more likely to be uninsured resulting in a lower number of primary care consultations. A few new factors associated with the number of primary care consultations have been identified in our study. Taking advice from a pharmacist, using relatives or friends as a health information source or using homeopathy for one's child could be explained by increased parental consciousness of health issues. These findings might reflect the "familial context" mentioned by Cardol [36] which would explain about 20% of the variability of the number of consultations in primary care.

The first limitation of our study was the overall response rate of 49%. However, details of response rates of each school gave us information to identify the bias due to non-responses. We found that response rates were lower in schools with a higher proportion of families of low socio-economic position and with a higher proportion of non-French speaking families. We therefore probably over-estimated the proportion of families who used the Internet to seek health information, and possibly under-estimated the mean number of consultations. The second limitation was that data on race/ethnicity was not asked in the questionnaire. According to the French population statistics, less than five percent of the inhabitants of the department of Vienne are non native French. In this context, race/ethnicity is not so important even if it is well established in the American context that disparities in Internet use for health information exist according to race/ethnicity [37, 38].

Another limitation was that the number of consultations was self-reported by the parents. Many studies have shown a tendency for underestimation when people were asked to report the frequency of their health care utilisation. Since we found a mean of 5.9 consultations per child within the last 12 months, which is consistent with the data of health care utilisation from the provider [39], the bias may be small. Missing data for parental income was another limitation, with 119 (11%) parents who did not report their annual family income. This omission in reporting annual family incomes is information probably not missing at random because it is more likely to occur when the income level is relatively high [40].

Even if our study had some limitations, we demonstrated that there was no relationship between parental use of the Internet to seek health information and primary care consultation of their children. The Internet seems to be used as a supplement to health services for some rather than as a replacement. Individuals are increasingly involved in the management of their own health and using the Internet to seek health information is one way to be involved actively. Some authors suggested that this would lead to saving in health costs [18]. According to our findings, this may not be true from a short-term perspective. In our opinion, what is more likely to occur is an improvement in the health of those who use the Internet to seek health information, which, from a long-term perspective, would eventually lead to saving in health costs.