The document summarizes the results of an internet survey assessing public knowledge of childhood hypothyroidism in the United States and India. The survey found that overall knowledge was low in both countries. It also found some gender differences in knowledge, with females showing more knowledge than males in India, while in the US females knew more about some symptoms but males knew more about others. The study concluded that more public health education is needed about the causes and symptoms of hypothyroidism globally.

1. Internet Survey of Childhood Hypothyroidism
Eric Chen BS1
, Samantha Madala2
, Steven Young BS3
, Vinna Nam BS4
, Anh N. Tran BA4
, Gloria Wu MD5
1
University of British Columbia; 2
Harker School, San Jose, CA; 3
University of California, Irvine; 4
University of California, Berkeley; 5
Tufts 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: None
Acknowledgement: 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 Symptoms
Gender Difference vs. Country
Results
3043 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
Purpose
Using 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 <0.001
No 1180 (98.00) 1170 (94.12)
Q7 Yes 350 (29.07) 413 (33.15) 4.92 1 0.02
No 854 (70.93) 830 (66.77)
Q8 Yes 114 (9.47) 211 (16.98) 29.92 1 <0.001
No 1090 (90.53) 1032 (83.02)
Q9 Yes 85 (7.06) 143 (11.5) 14.30 1 <0.001
No 1119 (92.94) 1100 (88.50)
Q10 Yes 169 (14.04) 95 (9.64) 25.98 1 <0.001
No 1035 (85.96) 1148 (92.36)
Q11 Yes 214 (17.77) 189 (15.21) 2.93 1 0.087
No 990 (82.22) 1054 (84.79)
Q12 Yes 230 (19.10) 137 (11.20) 31.33 1 <0.001
No 974 (80.90) 1106 (89.98)
Q14 Diabetes 1120 (93.02) 1108 (89.14) 11.32 1 <0.001
Pituitary dz 727 (60.38) 281 (22.61) 360.27 1 <0.001
Thyroid dz 1059 (87.96) 898 (72.24) 94.28 1 <0.001
None 37 (3.07) 50 (4.02) 1.61 1 0.20
Q19 Yes 1032 (85.71) 1064 (85.6) 0.0066 1 0.94
No 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