The rapid increase in, and use of, online health information has no corresponding increase in the quality of available material which can be biased and there is little control over the timeliness of updates [6-8]. For example, a systematic review of websites offering advice on acute otitis media treatments identified 41% of sites still recommending antibiotics while only 31% recommended the updated guideline of ‘watch and wait’ [9]. Receiving conflicting information makes it difficult for parents to know how to care for their child, creating confusion, uncertainty, and anxiety about best practice [2]. Considering the dubious quality of some available online information, parent-reported actions following accessing online health information are potentially concerning. Parents diagnose (43%) and treat (33%) child health care using online information, with 18% of Australian parents altering their child’s health management to align with online information [10]. Younger persons, aged between 20 and 35 years, are more likely to report these behaviours, with more women than men likely to engage in seeking health information online [11]. A more recent Australian study found the Internet to be the least trusted child health information source, reported by 9% of parents [1]. The incongruence in these studies requires further exploration.

People use online health information for a range of reasons. These include feeling rushed and receiving limited general lifestyle guidance when seeking advice from doctors; finding information that is more up-to-date, readily accessible, finding alternative treatment options, and to extend their understanding of a health issue before or after a medical consultation [1,12,13]. In particular, the empirical literature provides some evidence describing parents’ reasons for searching and seeking online health information. These include worrying about their child’s health [14], seeking specific information about their child’s health issues (e.g., [15-17] and for self-diagnosis for themselves and their children [18]. However, rather than the previous focus on identifying differences between users and non-users, sites explored, and types of information sought, there is a need to examine systematically the processes underlying parents’ decisions to use online health information for their child’s health care. This study addresses this gap in the literature by using the Theory of Planned Behaviour (TPB) [19] to understand the determinants of parents’ decisions to use online health information to diagnose and/or treat their child’s health issues and to increase understanding about their child’s diagnosis or treatment.

More specifically, the study has revealed that parents were more likely to use online information to increase their understanding about a diagnosis or treatment (than to diagnose and/or treat their child’s health issues. Interestingly, the same pattern of results was revealed for both target behaviours with the TPB variables of attitude, subjective norm, and PBC predicting intention (supporting H1); and intention, but not PBC, predicting behaviour (partially supporting H2). In general, the findings are consistent with other TPB-based studies examining parent–child health care behaviours [21,30]. The finding that PBC was not a significant predictor of parents’ behaviour is consistent with Ajzen’s [19] proposal that PBC becomes less useful in predicting behaviour as volitional control over behaviour increases. It is possible that parents are not accurate in judging how much control they actually have over using online information for their child’s health issues due to factors outside of the parents’ control, such as the information requested not being available or easy to comprehend.

The additional variables of perceived risk and group norm predicted intentions (supporting H3). In support of these findings, despite the dearth of literature exploring factors predicting parents’ internet use, some studies have found worry to be a predictor of internet use in parents of a child with encopresis [37]. Further, parents of a child who had suicided who were internet users or experiencing greater depression who experienced greater stigmatisation from their families, obtained valuable support from online groups [38]. The current study revealed also that parents who did not have a medical background were more likely to intend to engage in these behaviours (partially supporting H 4). For intention to diagnose/treat, those parents reporting using the Internet more were also more likely to intend to use child health information. Overall, the psychosocial determinants identified in this study help to understand parents’ decisions to use online information for their child’s health care. Parents with a more positive attitude toward using online information, who perceive greater social pressure/support to use this information, believe they have greater control and that there are lower risks associated with the behaviours, perceive other mothers have similar attitudes and behaviours and have limited medical experience will have stronger intentions to use online information for child health care. Furthermore, parents with stronger intentions to use online information to diagnose/treat their child’s health issues and to increase understanding about their child’s diagnosis/treatment are more likely to actually do so.

These findings can direct the development of methods for informing parents about appropriate websites and developing educational resources to guide appropriate online help-seeking actions among parents. Initially, there is a need to challenge parents’ attitudes toward accessing online child health information, alert them to the need for caution before acting on online information. There are developed methods for evaluating online health information. For example, Golterman and Banasiak [39] report a framework for evaluating the quality of online health information with strategies for accessing reliable child health sources. They report the importance of alerting Internet users, parents in this instance, to look for the HONCode on child health sites, a Code of Conduct for Medical and Health Web Sites developed by the Health On the Net Foundation [40]. Or search through the toolbar on their website http://www.hon.ch/ to find credible, reliable child health information. Alerting parents and colleagues to the existence of this code and to recommend parents to check for it and/or search for child health information from government, hospital and educational institutions is an important aspect of care in the 21^st Century where health consumers can be more informed that health care providers. Additionally, it is important to establish the E-Health literacy of parents prior to referring them to a website; the internet is not an appropriate health information resource for all [13].

Additionally, normative factors were important in informing intentions. Thus, challenging normative beliefs about the perceptions of the approval of important others (such as partners, doctors) and the support from other mothers (mother’s group) for engaging in these target behaviors may also be useful. Parents reported approval toward their intentions to search online; however, normative beliefs were not an independent predictor of behaviour. Mass media campaigns have successfully challenged and changed Australian parents’ sun protective [41] and smoking behaviours [42]. There is a need for a similar approach to child health information that could challenge normative influences toward online child health information. Producers and managers of credible, reliable online child health information, such as hospital and government sites, must be challenged to ensure their sites are the first to appear through Google and/or similar search engines.

Despite parents’ perception of control over using online child health information it had little impact on the variance of their intentions or behaviours. Poor website design or content and the number of advertisements and/or distractors were identified as barriers to using these sites. Online information can be frightening, as described by parents of children with cancer who were afraid of what they may find out [43]. Interestingly, these parents sought online social support rather than information. Health professionals, highlighting the questionable quality of information from sites such as these, can use these factors as a tool when guiding parents toward reputable and appropriate child health websites.

Finally, health professional and media focus on evaluations of the risk involved may help combat any undesired consequences on a child’s health as a result of using online information for child health care. For example, media reports of meningococcal disease send parents to seek online and medical advice for childhood rashes. Medical reports and testimonials from parents, and evidence from the empirical literature, of the consequences of a misdiagnosis based on online information on health outcomes may prompt parents to question their use of Internet-based information to self-diagnose their child’s health issues.

The research has a number of strengths including the use of a well-validated theoretical framework to prospectively examine an important and topical parental behaviour, a consideration of the impact of a range of covariates, and a reasonable sample size. The current study has a number of limitations. The use of self-report data may facilitate socially desirable responses. Further, given that almost one fifth of the sample reported having a medical background, self-selection basis may be an issue to consider as these participants are perhaps more likely to be aware of the limitations of online health information and have a greater ability to find high quality information thus negating some of the risks outlined as a result of the study’s findings. In addition, as no response rate was able to be obtained, it could be presumed that the study recruited a biased sample of respondents; thus, caution should be undertaken in interpreting the generalizability of the findings of the study. Another potential limitation is the use of the self-report behaviour items which may not be the most appropriate measure to determine how often the internet was used to look for information to manage a child’s health care or diagnose/treat. As such, a more objective way to measure internet usage in this context may be a consideration for future investigations. The sample was predominately female and, hence, the relevance of the findings to fathers and extended family and carers is uncertain, although women rather than men are more likely to engage in seeking health information online [11] and are usually the primary caregivers for their child’s health. Finally, although the models in the current study explained a substantial amount of variance in parents’ intentions, a large proportion of variance in the target behaviours remains unexplained.

Future research, then, should consider other variables which might predict parental use of online information seeking behaviour for child health care, such as a consideration of different aspects of risk (e.g., perceived vs. objective risk) in the decision-making process (see [34]). It may be useful for future research, in addition to investigating other variables of interest in this context, to investigate also how information seeking behaviours and use patterns are determined based on condition. For example, the information sought for cancer might be different than asthma, thus highlighting the need for a more targeted approach based on the information being sort for a particular medical condition.