Sarah K. Burns

Background: Reliable internet connectivity is crucial for family participation in pediatric digital health care, including telehealth. Lack of internet connectivity is a barrier to pediatric telehealth access. While surveys commonly inquire about metrics, such as internet plan or device ownership, fewer measures exist for the reliability of internet connectivity when needed. There is limited knowledge of the national prevalence of reliable internet connectivity among households with children and how reports of reliable internet connectivity are associated with use of internet plans and devices. Objective: We examined the prevalence of reliable internet connectivity among households with children and its association with digital technology access and sociodemographic factors. Methods: We performed a secondary data analysis of a US national cross-sectional survey examining parents’ health-seeking decisions for children younger than 18 years old. The respondent panel was hosted by the National Opinion Research Center (NORC) AmeriSpeak. This analysis focused on survey items on reliable internet connectivity, digital technology access (internet plan type and device ownership type), and sociodemographic characteristics (education, employment, geographic region, race and ethnicity, and disability) of parent respondents and their children. The dependent variable was a binary indicator of household reliable internet connectivity. Respondents were categorized as having unreliable internet connectivity if they self-reported internet worry or unreliable internet experience. Unadjusted Rao-Scott chi-square tests and adjusted multivariable logistic regressions with sampling weights were applied. Results: The final survey sample (N=1158) comprised 753 (55%) females, 614 (57%) non-Hispanic White, and 948 (81%) metropolitan respondents. There were 125 (12%) parents who reported internet worry, 152 (13%) parents who reported unreliable internet experience, and 76 (7%) parents who reported both. Combining these measures, we identified 201 (19%) parents with unreliable internet connectivity, defined as reporting either internet worry or unreliable internet experience. In contrast, 957 (81%) parents reported reliable internet connectivity in the household. In adjusted analysis, reliable internet connectivity was significantly associated with owning both nonmobile and mobile internet plans combined (86% reliable internet connectivity) versus nonmobile internet plan-only (67%; P =.001); postgraduate (94%) versus high school education (75%; P <.001); employment (84%) versus unemployment (76%; P =<.01); racial and ethnic marginalized status (77%) versus nonmarginalized (85%; P =<.01); and disability (70%) versus without disability (85%; P <.001), but not with device ownership, geographic region, race and ethnicity as separate groups, or parent sex. Conclusions: One-fifth of families with children experienced unreliable internet connectivity, highlighting an important dimension of the digital health divide that appears distinct from internet plan use or device ownership alone. Future research is needed to derive consensus on measuring reliable internet connectivity as a separate metric, including specifying the definition, survey questions, response options, and time frame of unreliability experience. Since reliable internet connectivity is needed for the growing field of digital health care, it is a critical issue for equitable pediatric health care access and delivery.

Background: Since 2020, parents have had increasing opportunities to use telemedicine for their children, but how parents decide whether to use telemedicine for acute pediatric care relative to alternative sites of care is not clear. One of the most common reasons parents seek acute care for their children is for acute respiratory tract infections (ARTIs). Objective: This study aims to examine parental expectations of care via telemedicine for pediatric ARTIs, contrasting expectations of care delivered via primary care telemedicine and direct-to-consumer (DTC) telemedicine. Methods: We performed a sequential mixed methods analysis to examine how parents assess telemedicine for their children’s acute care. We used ARTIs as a case study for examining parent perceptions of telemedicine. First, we analyzed semistructured interviews focused on parent responses about the use of telemedicine. Each factor discussed by parents was coded to reflect whether parents indicated it incentivized or disincentivized their preferences for telemedicine versus in-person care. Results were organized by a 7-dimension framework of parental health care seeking that was generated previously, which included dimensions related to care sites (expected access, affordability, clinical quality, and site quality) and dimensions related to child or family factors (perceived illness severity, perceived child susceptibility, and parent self-efficacy). Second, we analyzed responses to a national survey, which inquired about parental expectations of primary care telemedicine, commercial DTC telemedicine, and 3 in-person sites of care (primary care, urgent care, and emergency department) across 21 factors identified through prior qualitative work. To assess whether parents had different expectations of different telemedicine models, we compared survey responses for primary care telemedicine and commercial DTC telemedicine using weighted logistic regression. Results: Interview participants (n=40) described factors affecting their perceptions of telemedicine as a care modality for pediatric ARTIs. Generally, factors aligned with access and affordability (eg, decreased wait time and lower out-of-pocket cost) were discussed as potential incentives for telemedicine use, while factors aligned with perceived illness severity, child susceptibility, and clinician quality (eg, trustworthiness) were discussed as potential disincentives for telemedicine use. In survey responses (n=1206), primary care and commercial DTC telemedicine were rated similarly on items related to expected accessibility and affordability. In contrast, on items related to expected quality of care, primary care telemedicine was viewed similarly to in-person primary care, while commercial DTC telemedicine was rated lower. For example, 69.7% (weighted; 842/1197) of respondents anticipated their children would be comfortable and cooperative with primary care telemedicine versus 49.7% (weighted; 584/1193) with commercial DTC telemedicine (P<.001). Conclusions: In a mixed methods analysis focused on telemedicine for ARTIs, parents expressed more concerns about telemedicine quality in commercial DTC models compared with primary care–based telemedicine. These results could help health systems better design telemedicine initiatives to support family-centered care.

BACKGROUND Since 2020, parents have had increasing opportunities to use telemedicine for their children, but how parents decide whether to use telemedicine for acute pediatric care relative to alternative sites of care is not clear. One of the most common reasons parents seek acute care for their children is for acute respiratory tract infections (ARTIs). OBJECTIVE This study aims to examine parental expectations of care via telemedicine for pediatric ARTIs, contrasting expectations of care delivered via primary care telemedicine and direct-to-consumer (DTC) telemedicine. METHODS We performed a sequential mixed methods analysis to examine how parents assess telemedicine for their children’s acute care. We used ARTIs as a case study for examining parent perceptions of telemedicine. First, we analyzed semistructured interviews focused on parent responses about the use of telemedicine. Each factor discussed by parents was coded to reflect whether parents indicated it incentivized or disincentivized their preferences for telemedicine versus in-person care. Results were organized by a 7-dimension framework of parental health care seeking that was generated previously, which included dimensions related to care sites (expected access, affordability, clinical quality, and site quality) and dimensions related to child or family factors (perceived illness severity, perceived child susceptibility, and parent self-efficacy). Second, we analyzed responses to a national survey, which inquired about parental expectations of primary care telemedicine, commercial DTC telemedicine, and 3 in-person sites of care (primary care, urgent care, and emergency department) across 21 factors identified through prior qualitative work. To assess whether parents had different expectations of different telemedicine models, we compared survey responses for primary care telemedicine and commercial DTC telemedicine using weighted logistic regression. RESULTS Interview participants (n=40) described factors affecting their perceptions of telemedicine as a care modality for pediatric ARTIs. Generally, factors aligned with access and affordability (eg, decreased wait time and lower out-of-pocket cost) were discussed as potential incentives for telemedicine use, while factors aligned with perceived illness severity, child susceptibility, and clinician quality (eg, trustworthiness) were discussed as potential disincentives for telemedicine use. In survey responses (n=1206), primary care and commercial DTC telemedicine were rated similarly on items related to expected accessibility and affordability. In contrast, on items related to expected quality of care, primary care telemedicine was viewed similarly to in-person primary care, while commercial DTC telemedicine was rated lower. For example, 69.7% (weighted; 842/1197) of respondents anticipated their children would be comfortable and cooperative with primary care telemedicine versus 49.7% (weighted; 584/1193) with commercial DTC telemedicine (P<.001). CONCLUSIONS In a mixed methods analysis focused on telemedicine for ARTIs, parents expressed more concerns about telemedicine quality in commercial DTC models compared with primary care–based telemedicine. These results could help health systems better design telemedicine initiatives to support family-centered care.

Background: Telemedicine delivered from primary care practices became widely available for children during the COVID-19 pandemic. Objective: Focusing on children with a usual source of care, we aimed to examine factors associated with use of primary care telemedicine. Methods: In February 2022, we surveyed parents of children aged ≤17 years on the AmeriSpeak panel, a probability-based panel of representative US households, about their children’s telemedicine use. We first compared sociodemographic factors among respondents who did and did not report a usual source of care for their children. Among those reporting a usual source of care, we used Rao-Scott F tests to examine factors associated with parent-reported use versus nonuse of primary care telemedicine for their children. Results: Of 1206 respondents, 1054 reported a usual source of care for their children. Of these respondents, 301 of 1054 (weighted percentage 28%) reported primary care telemedicine visits for their children. Factors associated with primary care telemedicine use versus nonuse included having a child with a chronic medical condition (87/301, weighted percentage 27% vs 113/753, 15%, respectively; P=.002), metropolitan residence (262/301, weighted percentage 88% vs 598/753, 78%, respectively; P=.004), greater internet connectivity concerns (60/301, weighted percentage 24% vs 116/753, 16%, respectively; P=.05), and greater health literacy (285/301, weighted percentage 96% vs 693/753, 91%, respectively; P=.005). Conclusions: In a national sample of respondents with a usual source of care for their children, approximately one-quarter reported use of primary care telemedicine for their children as of 2022. Equitable access to primary care telemedicine may be enhanced by promoting access to primary care, sustaining payment for primary care telemedicine, addressing barriers in nonmetropolitan practices, and designing for lower health-literacy populations.