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Internet Survey of Childhood HypothyroidismEric Chen BS1, Samantha Madala2, Steven Young BS3, Vinna Nam BS4, Anh N. Tran BA4, Gloria Wu MD5
1University of British Columbia; 2Harker School, San Jose, CA; 3University of California, Irvine; 4University of California, Berkeley; 5Tufts University School of Medicine
Abstract Through the use of surveys, we can assess public health education and interests. Standard telephone and face-to-face interviews are often time consuming and expensive while Internet surveys are more cost effective; surveys can be easily distributed on high traffic internet forums. Hypothyroidism affects approximately 4.6% of the American population and 3.9% of the Indian population. With an even higher estimation of subclinical hypothyroidism in both countries, this disease should be of concern to the global endocrinology community. Purpose: Using an internet questionnaire, we tested the hypothesis that knowledge of childhood hypothyroidism differed by country and gender. Methods: We created an internet questionnaire designed to test the public’s knowledge of childhood hypothyroidism. The questionnaire was posted online through social media platforms like Facebook and through other online distribution services over a three-month period in 2012. Respondents (RE) were required to be ≥ 18 years of age. Results: Total of 2430 RE: 1,194 from US and 1,236 from India. Age: US RE were in the age range of 31 yrs to ≥ 51 yrs: Males (M) (76.5%,231/302) vs Females (F) (80.9%,724/895). In contrast, the majority of respondents from India were younger: M (70%,492/702) and F (52.2%,279/534) in India were in the age range of 18-30 yrs vs in US, only M (23.5%,71/302), F (17.9%,161/895). Education: In the US, college or post graduate education: M (88.1%,266/302) vs F (91.3%,817/895); India: M and F have similar education: M (94.3%,662/702) vs F (91.2%,487/534). Questionnaire: RE answered yes/no to a list of signs and symptoms of childhood hypothyroidism: tiredness, reading problems, anxiousness, unable to complete homework, disorganized, tiredness, too focused, forgetfulness. Chi sq analysis was used. US vs India: Anxiousness: M (47.9%,283/1197) of the US RE vs F (23.6%,592/1236) of the India RE identified "anxiousness" as a symptom (p<0.0001). Tiredness: US M (59.1%,621/1197) vs F (51.8%,731/1236) in India identified "tiredness" as a symptom (p<0.0003). Gender Difference: In India, there is a gender difference with “reading,” M (15.4%,107/702) vs F (20.2%,108/534) (p=0.02); “anxiousness:” M (44.7%,314/702) vs F (52.1%,278/534) (p=0.01); “disorganized behavior:” M (23.6%,166/702) vs F (35.7%,191/534) (p<0.01). Indian females show more knowledge than their male counterparts. There is gender difference in the US, with “tiredness:” M (44.7%,135/302) vs F (54.3%,486/895) (p<0.01); “forgetfulness:” M (28.15%,85/302) vs F (34.4%,308/895) (p=0.05). Females know more in both US and India than their male counterparts despite similar educational backgrounds. For both countries, gender plays a role: with respect to “developmental problems:” in US, M (28.8%,87/302) vs F (17.9%,161/895) (p=0.001) and in India, M (39.4%,277/702) vs F (47.3%,253/534) (p=0.005). Indian Females know more about this than Female counterparts in the US. Conclusions: Overall knowledge about childhood hypothyroidism in the US and India is low in our internet questionnaire. In our sample, gender differences in knowledge about hypothyroidism exist more in India than in US. This may be a result of overall lower age and education in the India sample or the self-selected nature of the Internet survey sample. Nonetheless, more health education about causes and symptoms of hypothyroidism is needed.
Commercial Relationships: NoneAcknowledgement: None
Questionnaire[1] What is your gender? [2] How old are you? [3] What is your education? Grade 1-6; 7-8; 9-12; College; More than college[4] What is your ethnicity? Native American; Asian; South Asian; Pacific Islander; African American; Caucasian; Hispanic; Other[5] Do you know that there might be a connection between hypothyroid disorder and autism? Yes; No (no connection); Unsure [6] Are you a parent of someone with hypothyroidism? Yes; No (not a parent); Unsure (about my child/children)[7] Do you or any of your children show any symptoms of fatigue, constipation, depression, weight gain, or constant coldness? Yes; No; Unsure[8] Do you or any of your children show any signs of bulging eyes, large throat gland, or hair loss? Yes; No; Unsure[9] (If you answered yes to [7] and/or [8]) has your pediatrician discussed thyroid gland disorders with you? Yes; No; Not sure; N/A (no children)[10] (If you answered yes to [7] and/or [8]) has your doctor felt you or your child’s neck for thyroid problems? Yes; No; Not sure; N/A (no children)
Question 13: Recognition of Hypothyroid SymptomsGender Difference vs. Country
Results3043 total responses from 22 countries: India, United States, Canada, United Kingdom, Ireland, Iceland, Australia, South Africa, Korea, etc.
2447 responses from US and India
SAT-286
Background
Google Trends: Hypothyroidism
Country Symptoms Male (%) Female (%) P-value§
India Difficulty Reading 107 (15.2) 108 (20.1) 0.02
Anxiousness 314 (44.5) 279 (52.0) 0.009
Disorganized 166 (23.5) 191 (35.6) <0.001
US Tiredness 136 (44.9) 491 (54.5) 0.004
Forgetfulness 85 (28.1) 313 (34.7) 0.03
PurposeUsing an internet questionnaire, we tested the hypothesis that knowledge of childhood hypothyroidism differed by country and gender.
Methods
College and Post-College: US Male 88.1% US Female 91.3%India Male 94.3% India Female
91.3%
Mean Knowledge Score* Comparison by Country
Comparison by Gender in US
Comparison by Gender in India
§ Pearson’s Chi-squared test for statistical analysis
*Knowledge Score is total number of correct responses to answer choices (max score 11)Q13. In children, what are the symptoms of hypothyroidism? (always tired, reading problems, anxious/nervous, unable to complete homework, disorganized, forgetfulness) Q16. What is an endocrinologist? (doctor that treats diabetes, thyroid disease, and glandular disease)Q17. What is hypothyroidism? (underactive thyroid gland)Q18. What is hyperthyroidism? (overactive thyroid gland)
Conclusions
References
§ Pearson’s Chi2 test for statistical analysis
Question 16 Score: What is an endocrinologist?
Comparison by Country
Comparison by Gender in US
Comparison by Gender in India
§ Pearson’s Chi-square test for statistical analysis
*Q16 score is total number of correct responses to answer choices (max score 3):Q16: What is an endocrinologist? (doctor who treats diabetes, thyroid disease and glandular disease)
• Despite the high level of education of the survey respondents, health literacy about hypothyroidism is low globally.• In our questionnaire, correct answers about hypothyroidism ranged from 15%-54% for some questions, suggesting limited knowledge about the disease. • The definition of "Endocrinologist" elicited low numbers of correct answers in both US and India. • In our sample, more females from US and India answered the questionnaire, correlating to female preponderance of hypothyroidism.• Internet surveys and social media can be a tool in the assessment of global health literacy.
US Male(n=303)
US Female(n=901)
Pearson’s χ² Coefficient
df P-value§
High School 1.97 ± 0.37 < 2.87 ± 0.23 16.78 7 0.033
College 3.24 ± 0.21 < 3.85 ± 0.11 25.30 9 0.005
Post College 4.43 ± 0.19 > 4.22 ± 0.10 21.35 10 0.03
All Education 3.73 ± 0.14 < 3.96 ± 0.07 28.22 10 0.003
India Male(n=706)
India Female (n=537)
Pearson’s χ² Coefficient
df P-value§
High School 2.15 ± 0.24 < 2.83 ± 0.46 21.04 7 0.004
College 3.14 ± 0.10 < 3.76 ± 0.10 73.79 9 <0.001
Post College 3.34 ± 0.14 < 4.35 ± 0.18 32.83 10 0.001
All Education 3.16 ± 0.08 < 3.84 ± 0.09 85.95 10 <0.001
US (n=1204)
India(n=1243)
Pearson’s χ² Coefficient
df P-value§
High School 2.59 ± 0.20 > 2.52 ± 0.27 27.84 7 0.001
College 3.71 ± 0.10 > 3.42 ± 0.07 37.10 9 <0.001
Post College 4.28 ± 0.09 > 3.72 ± 0.11 32.97 10 0.001
All Education 3.90 ± 0.06 > 3.45 ± 0.06 51.21 10 <0.001
US Male (n=303)
US Female(n=901)
Pearson’s χ² Coefficient
df P-value§
High School 0.44 ± 0.10 < 0.86 ± 0.10 6.70 3 0.082
College 0.74 ± 0.08 < 1.22 ± 0.05 22.58 3 <0.001
Post College 1.30 ± 0.07 > 1.28 ± 0.04 0.72 3 0.868
All Education 1.00 ± 0.05 < 1.22 ± 0.03 16.09 3 0.001
India Male (n=706)
India Female (n=537)
Pearson’s χ² Coefficient
df P-value§
High School 0.38 ± 0.11 < 0.87 ± 0.19 15.00 3 0.002
College 0.87 ± 0.04 < 1.11 ± 0.04 45.98 3 <0.001
Post College 0.67 ± 0.04 < 0.97 ± 0.06 19.66 3 <0.001
All Education 0.77 ± 0.03 < 1.04 ± 0.03 64.31 3 <0.001
US (n=1204)
India (n=1243)
Pearson’s χ² Coefficient
df P-value§
High School 0.73 ± 0.08 > 0.64 ± 0.12 27.26 3 <0.001
College 1.12 ± 0.04 > 0.98 ± 0.03 103.33 3 <0.001
Post College 1.29 ± 0.04 > 0.78 ± 0.04 83.24 3 <0.001
All Education 1.17 ± 0.03 > 0.89 ± 0.02 140.70 3 <0.001
• Survey hosted on freeonlinesurveys.com from Oct 2012-Apr 2013• Social media used: Facebook and Facebook ads, Wordpress, Reddit, Craigslist, and blogs (missyusa.com, sfkorean.com)• Analysis of questionnaire (QN): Creation of “Knowledge Score” calculated as total number of correct responses to questions 13, 16, 17 and 18.• Statistical analysis: Pearson’s Chi-squared test, Student t-test, Stata 12 software
[11] Has a doctor referred you or your child to conduct a thyroid blood test? Yes; No; N/A (no and don’t have
children)
[12] Do you and/or your family members have hypothyroidism? Yes; No; Unsure
[13] In children, what are the symptoms of hypothyroidism? (Check all that apply) Always tired; Reading problems;
Anxious/nervous; Unable to complete homework; Disorganized; Too focused; Forgetfulness; (not sure)
[14] Which of these glandular disorders have you heard of? (Check all that apply) Diabetes; Pituitary disorder;
Thyroid disorder; None
[15] In children, what causes the thyroid gland to be under-active? (Check all that apply) Family history of
hypothyroidism; Developmental problems; Gender; Physical environment; Diet; Autism; Unknown cause; Unsure
[16] What is an endocrinologist? (Check all that apply) Doctor that treats diabetes; Psychiatrist that treats obesity;
Doctor that treats thyroid disease; Brain surgeon; Doctor that treats glandular disease; Unsure
[17] What is hypothyroidism? Overactive thyroid gland; Underactive thyroid gland; Cancer; Diabetes; Unsure
[18] What is hyperthyroidism? Overactive thyroid gland; Underactive thyroid gland; Obesity; Heart disease; Unsure
[19] Thyroid problems can be diagnosed with a simple test. Do you think children with learning issues should be
screened for thyroid problems? Yes; No
[20] How did you hear about this survey?
US (%) India (%) Chi-squared df P-value
Q6 Yes 24 (2.00) 73 (5.90) 24.18 1 <0.001No 1180 (98.00) 1170 (94.12)
Q7 Yes 350 (29.07) 413 (33.15) 4.92 1 0.02No 854 (70.93) 830 (66.77)
Q8 Yes 114 (9.47) 211 (16.98) 29.92 1 <0.001No 1090 (90.53) 1032 (83.02)
Q9 Yes 85 (7.06) 143 (11.5) 14.30 1 <0.001No 1119 (92.94) 1100 (88.50)
Q10 Yes 169 (14.04) 95 (9.64) 25.98 1 <0.001No 1035 (85.96) 1148 (92.36)
Q11 Yes 214 (17.77) 189 (15.21) 2.93 1 0.087No 990 (82.22) 1054 (84.79)
Q12 Yes 230 (19.10) 137 (11.20) 31.33 1 <0.001No 974 (80.90) 1106 (89.98)
Q14 Diabetes 1120 (93.02) 1108 (89.14) 11.32 1 <0.001Pituitary dz 727 (60.38) 281 (22.61) 360.27 1 <0.001Thyroid dz 1059 (87.96) 898 (72.24) 94.28 1 <0.001None 37 (3.07) 50 (4.02) 1.61 1 0.20
Q19 Yes 1032 (85.71) 1064 (85.6) 0.0066 1 0.94No 172 (14.29) 179 (14.40)
Respondent Experience with Hypothyroidism
An estimated 14.4 million (4.6%) people in the United States have hypothyroidism,1 compared to 48.4-116.6 million (3.9%-9.4%) in India.2
1. Golden SH, Robinson KA, Saldanha I, Anton B, Ladenson PW. Prevalence and incidence of endocrine and metabolic disorders in the United States: a comprehensive review. J Clin Endocrinol Metab. 2009;94(6):1853–1878.
2. Unnikrishnan AG, Menon UA. Thyroid disorders in India: An epidemiological perspective. Ind J Endocrinol Metab. 2011; 15(2): 78-81.
3. Wu G, Tran A. The Internet and Medicine, 2nd ed. Saratoga:Gratak Media, 2013:3-6.
Max Score 11
Max Score 3
