Introduction

Currently, there is a growing demand for care in Pedi­atric Emergency Services (PES) worldwide. However, this increase is not attributed to a rise in the severity of the illnesses for which children are evaluated⁽¹⁾.

This increase in PES visits is mainly due to low-urgency conditions, classified as triage levels IV (semi-urgent) or V (non-urgent)⁽²⁾. In most cases, these could be adequate­ly managed in primary care pediatric services. Several factors contribute to this situation: younger patient age, low educational level of caregivers, a culture of immedi­acy, or the day of the week^(3–6). Another possible cause is caregivers’ lack of knowledge regarding the signs or symptoms that require urgent hospital care, as opposed to those that can wait to be assessed by their primary care pediatrician^(3–6).

Moreover, this increased demand in PES has negative consequences for the quality and safety of patient care, generating longer waiting times, delays in attending severe cases, and an increase in medication errors^(7,8).

Over the years, multiple studies⁽⁹⁾ have analyzed the best way to provide health education to improve care­givers’ knowledge. This approach can reduce PES visits, shorten hospital stays, and promote a more efficient use of available health resources, thereby decreasing associ­ated costs⁽⁹⁾. In daily clinical practice, information is often transmitted verbally. However, verbal information is easily forgotten and is frequently ineffective^(10,11). Evidence sup­ports including concise and easy-to-understand written resources to reinforce the message being conveyed⁽¹⁰⁾. In addition, patient understanding improves when interac­tive or active learning methods are used, such as short questionnaires, videos, or even digital resources in apps or websites^(12,13).

The hypothesis of this study is that health education delivered through written information, in addition to verbal explanation, is an effective method to improve caregivers’ knowledge regarding the reasons to attend the PES. This, in turn, may lead to better use of resources, ensuring safer and higher-quality care.

The main objective of this study is to analyze whether caregivers’ knowledge about the reasons for consultation in the PES improves after verbally explaining a standard­ized informational leaflet. Secondary objectives were to describe caregivers’ knowledge regarding the reasons for seeking urgent care in a PES and to identify associated fac­tors. Another objective was to evaluate the impact of these factors on the number of PES visits, the need for treat­ment, hospitalization, and re-consultations.

Materials and methods

Study design

A descriptive, quasi-experimental, prospective, single-center observational study conducted in the Pediatric Emergency Service (PES) of a high-complexity hospi­tal in Madrid, Spain, which attends 60,000 emergencies annually.

Study population

The study population included caregivers of patients under 16 years of age who consulted in the PES during the working shifts of one of the principal investigators. Written informed consent was required. Exclusion criteria included withdrawal of consent, language barriers, or clinical situa­tions that prevented delivering the initial questionnaire to caregivers before medical evaluation.

The study was conducted over a month and a half (December 1, 2022 to January 15, 2023) and was approved by the hospital’s Clinical Research Ethics Committee.

Study phases and variables

The study was carried out in three phases: delivery of the written questionnaire before medical evaluation (Phase 1), verbal explanation of the informational leaflet (intervention), and a telephone call one month later (Phase 2):

• Phase 1: Before medical evaluation, one of the principal investigators delivered the written questionnaire (Ap­pendix 1) and written informed consent to the caregiver.

• Intervention: After completing the questionnaire, an investigator provided the informational leaflet “Should I go to the emergency department? Quick guide for par­ents and caregivers”⁽¹⁴⁾, along with a verbal explanation of its content. Guidelines were established beforehand to standardize how verbal information was delivered. During the patient’s stay in the PES, sociodemographic data and clinical variables (medical history, triage level) were collected, as well as information about comple­mentary tests, treatment, hospitalization, and the num­ber of PES visits in the previous month.

• Phase 2: One month after the PES visit, the investi­gator contacted by telephone the caregiver who had completed the initial questionnaire. During the call, the same questionnaire used in Phase 1 was administered, adding questions about clinical evolution and PES visits during the month after inclusion in the study.

Survey design

The survey consisted of 14 yes/no questions. Each item presented a brief clinical scenario involving common reasons for pediatric consultation (Appendix 1). All ques­tions could be answered by consulting the standardized informational leaflet from the Spanish Society of Pediat­ric Emergency Medicine (SEUP), available at: https://seup.org/hojas-informativas/. A focus group was formed with the investigators to review the questionnaire items. Before the start of the study, the questionnaire was tested among healthcare professionals and individuals outside the medi­cal field to ensure adequate comprehension.

Statistical analysis

Convenience sampling was used to recruit all eligible participants.

The estimated sample size was 109 patients, calculat­ed to achieve 80% statistical power with an alpha of 5%, detecting a 3-point difference between questionnaires (based on a clinically relevant 20% difference), and consid­ering a 15% attrition rate between phases.

Parametric quantitative variables were expressed as mean and standard deviation; nonparametric variables as median and interquartile range. Qualitative variables were expressed as frequency and percentage. A 95% confidence interval was used.

For the main objective, the difference in scores be­tween Phase 1 and Phase 2 surveys was calculated and an­alyzed using the corresponding hypothesis test for mean differences (Student’s t test). To analyze the relationship between sociodemographic factors and caregivers’ base­line knowledge, a multivariable linear regression was per­formed. Statistical significance was set at p < 0.05. SPSS® version 25.0 was used for data analysis.

Results

During Phase 1, a total of 3,556 emergency visits oc­curred. A total of 151 participants were recruited, of whom 95 (62.9%) completed Phase 2 (Figure 1).

Sociodemographic characteristics of caregivers and patients are shown in Table 1.

Main objective

Figure 2 shows the mean number of correct responses in Phase 1 compared with Phase 2. In Phase 1, no differenc­es were found between caregivers who completed Phase 2 and those lost to follow-up (mean correct responses: 11 [SD 1.73] vs. 11.63 [SD 1.66]; p = 0.725).

In Phase 1, 13 caregivers (6.8%) answered all questions correctly; this number increased to 28 caregivers (14.7%) in Phase 2 (p < 0.001).

A significant improvement was observed in questions related to fever duration, skin conditions, ear pain, dehy­dration, and neurological warning signs (Table 2).

Secondary objective: caregiver knowledge

As a secondary objective, caregivers’ knowledge about urgent PES consultation reasons was analyzed. In Phase 1, question 7 (skin conditions) had the highest rate of in­correct responses (51.6% correct), followed by question 10 (ear pain) (52.6% correct).

Questions with the highest number of correct answers were question 2 (head trauma) and question 11 (anaphy­laxis), with 98% and 95.8% correct answers, respectively.

In the multivariable analysis, the only factor associated with Phase 1 score was caregivers’ educational level (B 0.41; 95% CI: 0.14–0.68; p = 0.003). No significant differences were found regarding caregiver sex, presence of underlying conditions, or prior primary care consultations (Table 3).

Impact of the intervention

Figure 3 shows the percentage of patients who had vis­ited the PES at least once and at least twice in the previous month in Phases 1 and 2.

At inclusion (Phase 1), only 2 of 151 patients (1.3%) re­quired hospitalization; 28 (18.5%) received pharmacological treatment; and 67 (44.4%) required complementary tests. After the intervention, 33 patients had revisited the PES in the previous month: 7 (21.2%) required hospitalization (p < 0.05), 12 (52.1%) received treatment (p < 0.05), and 14 (42.4%) required complementary tests (p = 0.479).

Discussion

This study evaluates the impact of an educational inter­vention delivered to caregivers, consisting of a verbal ex­planation of a written informational leaflet about reasons for consultation across different care levels. It also analyzes caregivers’ baseline knowledge of common pediatric con­ditions. Our results show that this strategy is generally ef­fective at improving caregiver knowledge.

The literature supports the effectiveness of written infor­mation and interactive methods such as videos and ques­tionnaires^(10,12,13). In our study, the combination of verbal and written information appears effective in providing health education. Both total correct responses and the number of caregivers who answered all questions correctly increased.

Caregivers completed a questionnaire before and after the intervention with two objectives: evaluating the effect of the intervention and encouraging caregiver engage­ment. According to Hoffmann⁽¹⁰⁾, answering short tests after receiving information improves memory. Reviews⁽¹³⁾ suggest interactive methods enhance patient understand­ing. The systematic review by Glaser⁽¹³⁾ assessed how dif­ferent interventions improve patient comprehension in clinical informed consent; interactive interventions, par­ticularly tests or teach-back strategies, appeared superior to written, audiovisual, or digital methods. However, little literature focuses specifically on teaching caregivers when to seek different levels of medical care.

The impact of the intervention varied among individual questions. Significant improvement was noted in questions related to common high-demand pediatric conditions, such as dehydration or neurological warning signs⁽¹⁾. However, some questions showed no significant differences, partic­ularly those involving nonspecific symptoms (abdominal pain, otalgia). Literature supports that understanding the underlying medical condition helps caregivers better assess symptom relevance^(15–17). This may explain why broad, non­specific symptoms are less well understood. Thus, the im­pact of health interventions depends not only on how infor­mation is delivered, but also on the underlying condition⁽¹⁵⁾.

Regarding baseline knowledge, in Phase 1, 10 out of 14 questions had more than 80% correct answers. Only 5 of the 14 showed significant improvement, a relatively small proportion compared with other studies⁽¹¹⁾. This may be due to the high baseline knowledge in Phase 1, or to the method used to explain the information. Evidence on the optimal format for delivering discharge information is in­conclusive. Ismail⁽¹⁵⁾ found that adding video instructions improved understanding, whereas Wood⁽¹⁸⁾ reported that discharge instructions improved caregiver knowledge re­gardless of format.

One secondary objective was analyzing whether so­ciodemographic variables influenced caregiver knowledge. Higher educational level was significantly associated with better scores, consistent with findings by Long⁽⁴⁾ and Mor­rison⁽⁵⁾, who showed that low health literacy and incorrect perception of severity lead to increased PES use. This find­ing highlights the importance of assessing health literacy to tailor educational resources.

Notably, only one-third of respondents had consulted their primary care center beforehand. In our setting, Prima­ry Care is a key pillar of the health system, where the pri­mary care pediatrician should be the first point of contact. The SEUP leaflet⁽¹⁴⁾ includes guidance on where children should seek care. Studies such as Ravi⁽⁶⁾ show that peo­ple view primary care positively, given its accessibility and shorter waiting times. A potential factor in our study is that it was conducted during a primary care strike period, re­ducing caregivers’ possibility of consulting a pediatrician.

Regarding PES utilization, a decrease in visits was observed after the intervention. Previous studies⁽¹⁹⁾ have reported similar findings, showing that health education effectively reduces PES demand. Additionally, patients who visited the PES in the month after the intervention had more severe conditions and clearer indications for emer­gency evaluation, evidenced by increased hospitalization and treatment rates.

Although cost-effectiveness was not analyzed, reduced PES visits after the intervention may imply lower associat­ed healthcare costs.

Several limitations should be noted. We highlight the loss of participants during Phase 2 follow-up, likely related to the holiday season. Nonetheless, the estimated sample size was nearly reached, and baseline results were similar between participants who completed follow-up and those lost. Overall, our results continued to show significant dif­ferences in the main outcome.

Another limitation was variability in the verbal expla­nation delivered by investigators. Standardized guidelines were provided to reduce this bias.

Resource availability may also impact implementation in other settings. Finally, long-term impact on caregiver knowledge and PES use was not assessed, opening ave­nues for future research.

For applicability in other centers, healthcare profes­sionals must be trained both in how to provide information and in the importance of strategies aimed at reducing PES demand. Educational materials should be adapted to each setting.

We conclude that health education delivered through verbal and written explanations regarding reasons to at­tend the PES is a useful tool to improve population knowl­edge. This study may serve as a starting point for analyzing the impact of such interventions on PES demand, with the aim of optimizing available resources.

Funding

This research did not receive any specific grant from public, commercial, or nonprofit funding agencies.

Author contribution

The authors certify that they contributed equally to the conception, design, scientific and intellectual content, and drafting of the manuscript.

Conflict of interest

The authors declare no conflicts of interest.

References

1. García JLM, Orgeira JMF, Peromingo JAD. Demanda asisten­cial de urgencias pediátricas atendidas en un hospital comar­cal. Aten Primaria. 2008;40(6):297–301.
2. Landaluce AF. Triaje de urgencias de pediatría. En: Protocolos diagnósticos y terapéuticos en urgencias de pediatría. 2019.
3. Oterino D, Peiró S, Calvo R, Sutil P, Fernández O, Pérez G, et al. Utilización inadecuada de un servicio de urgencias hospi­talario: una evaluación con criterios explícitos. Gac Sanit. 1999;13(5):361–70.
4. Long CM, Mehrhoff C, Abdel-Latief E, Rech M, Laub­ham M. Factors influencing pediatric emergency depart­ment visits for low-acuity conditions. Pediatr Emerg Care. 2021;37(5):265–8. Available from: https://doi.org/10.1097/PEC.0000000000002297
5. Morrison AK, Chanmugathas R, Schapira MM, Gorelick MH, Hoffmann RG, Brousseau DC. Caregiver low health literacy and nonurgent use of the pediatric emergency department for febrile illness. Acad Pediatr. 2014;14(5):505–9. Available from: https://doi.org/10.1016/j.acap.2014.05.007
6. Ravi N, Gitz KM, Burton DR, Ray KN. Pediatric non-urgent emergency department visits and prior care-seeking at pri­mary care. BMC Health Serv Res. 2021;21(1):466. Available from: https://doi.org/10.1186/s12913-021-06471-y
7. Kulstad EB, Sikka R, Sweis RT, Kelley KM, Rzechula KH. ED overcrowding is associated with an increased frequency of medication errors. Am J Emerg Med. 2010;28(3):304–9. Avail­able from: https://doi.org/10.1016/j.ajem.2008.12.014
8. Moskop JC, Geiderman JM, Marshall KD, McGreevy J, Derse AR, Bookman K, et al. Another look at the persistent moral prob­lem of emergency department crowding. Ann Emerg Med. 2019;74(3):357–64. Available from: https://doi.org/10.1016/j. annemergmed.2019.04.013
9. Hersh L, Salzman B, Snyderman D. Health literacy in primary care practice. Am Fam Physician. 2015;92(2):118–24.
10. Hoffmann T, Worrall L. Designing effective written health edu­cation materials: considerations for health professionals. Dis­abil Rehabil. 2004;26(19):1166–73. Available from: https://doi. org/10.1080/09638280410001724816
11. Friedman AJ, Cosby R, Boyko S, Hatton-Bauer J, Turnbull G. Effective teaching strategies and methods of delivery for pa­tient education: a systematic review and practice guideline recommendations. J Cancer Educ. 2011;26:12–21. Available from: https://doi.org/10.1007/s13187-010-0183-x
12. Jové-Blanco A, Solís-García G, Torres-Soblechero L, Escobar-Castellanos M, Mora-Capín A, Rivas-García A, et al. Video discharge instructions for pediatric gastroenteritis in an emergency department: a randomized, controlled trial. Eur J Pediatr. 2021;180:569–75. Available from: https://doi. org/10.1007/s00431-020-03838-3
13. Glaser J, Nouri S, Fernandez A, Sudore RL, Schillinger D, Klein-Fedyshin M, et al. Interventions to improve patient comprehension in informed consent for medical and sur­gical procedures: an updated systematic review. Med De­cis Making. 2020;40(2):119–43. Available from: https://doi. org/10.1177/0272989X19896300
14. Sociedad Española de Urgencias de Pediatría. ¿Debo acudir a urgencias? Guía rápida para padres y cuidadores [Internet]. 2023 [Consulted: 5 October 2025]. Available from: https://seup.org/pdf_public/pub/hojas_padres/acudir_urgencias. pdf
15. Ismail S, McIntosh M, Kalynych C, Joseph M, Wylie T, Butterfield R, et al. Impact of video discharge instructions for pediatric fever and closed head injury from the emergency department. J Emerg Med. 2016;50(3):e177–83. Available from: https://doi. org/10.1016/j.jemermed.2015.10.028
16. Young M, Ross A, Sheriff A, Deas L, Gnich W. Child health in­terventions delivered by lay health workers to parents: a real­ist review. J Child Health Care. 2021;25(4):628–46. Available from: https://doi.org/10.1177/13674935211001577
17. Belisle S, Dobrin A, Elsie S, Ali S, Brahmbhatt S, Kumar K, et al. Video discharge instructions for acute otitis media in children: a randomized controlled open-label trial. Acad Emerg Med. 2019;26(12):1326–35. Available from: https://doi.org/10.1111/acem.13827
18. Wood EB, Barnett S, Harrison G, Presgrave K, Stinson S, Rov­elli E. Video discharge instructions for Spanish-speaking care­givers in the pediatric emergency department. J Emerg Nurs. 2020;46(2):180–7. Available from: https://doi.org/10.1016/j. jen.2019.09.004
19. Jeong JH, Hwang SS, Kim K, Lee JH, Rhee JE, Kang C, et al. Im­plementation of clinical practices to reduce return visits with­in 72 h to a paediatric emergency department. Emerg Med J. 2015;32(6):426–32. Available from: https://doi.org/10.1136/emermed-2013-202753

Annex 1. questionnaire

Questionnaire for the study “Does the population know the reasons that require urgent pediatric attention?”

The main objective of this study is to analyze whether caregivers’ knowledge about the reasons for attending the Emergency Department improves after providing and verbally explaining an informative standardized sheet on the sub­ject. Before answering, remember that when your kid is ill, you can take him/her to the Primary Care Services or to the Emergency Department at hospitals.