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Laypeople’s Online Health Information Search Strategies and Use for Health-Related Problems: Cross-sectional Survey

Laypeople’s Online Health Information Search Strategies and Use for Health-Related Problems:... Background: With the increase in the use of the internet to search for health information about health-related problems, there is a need for health care professionals to better understand how their patients search for and use the online health information that may influence their medical decision making. Objective: The aims of this study are to explore laypeople’s online health information search strategies and examine the relationships between their search strategies and utilization behavior of online health information. Methods: Two scales, namely match and elaboration, were used to measure patients’ basic search strategies (ie, simple approach) and advanced search strategies (ie, integrative approach), respectively. In addition, the consultation scale was used to evaluate the participants’ use of online health information to consult doctors and others. A total of 253 outpatients without university education were purposely selected and surveyed. The participants were outpatients at a university-affiliated teaching hospital. Partial least squares-structural equation modeling (PLS-SEM) was performed to analyze the measurement model to specify the measurement validation. In addition, the structure model of PLS-SEM was evaluated to examine the path correlations between variables and to execute interaction effect and curvilinear relationship analyses. Results: The results of the path correlation analysis by PLS-SEM showed that both elaboration strategy (path coefficient=0.55, P<.001) and match strategy (path coefficient=0.36, P<.001) were positively correlated with consultation on online health information with doctors and others. In addition, interaction effect and curvilinear relationship analyses indicated that there was a significant interaction effect between elaboration and match on consultation (path coefficient=–0.34, P<.001) and a significant curvilinear relationship between match and consultation (path coefficient=–0.09, P=.046). Conclusions: Increasing patients’ exposure to online health information through both a simple search approach (ie, match strategy) and a complex search approach (ie, elaboration strategy) may lead them to appropriately use the information to consult doctors and others. However, the results of interaction effect and curvilinear relationship analyses highlighted the essential role of the elaboration strategy to properly locate, evaluate, and apply online health information. The findings of this study may help health care professionals better understand how to communicate with their patients through the health information on the internet. (J Med Internet Res 2022;24(9):e29609) doi: 10.2196/29609 KEYWORDS decision making; eHealth literacy; information search strategy; internet; patient; information-seeking behavior; laypeople; online health information; patient communication https://www.jmir.org/2022/9/e29609 J Med Internet Res 2022 | vol. 24 | iss. 9 | e29609 | p. 1 (page number not for citation purposes) XSL FO RenderX JOURNAL OF MEDICAL INTERNET RESEARCH Chiu et al results provided by the search engine, the need to check certain Introduction information against other information sources while searching for online information about medical problems has been strongly Background recommended [21,22]. The impacts of internet search strategies With its convenient and widespread access to abundant on information retrieval and how patients use online health information, the internet has become the major source for information have been of great concern; however, the patients and the general population to retrieve health information information search strategies for health-related problems have [1]. As reported by the Pew Research Center, approximately seldom been studied [7,23]. As suggested, there is a need to 80% of American internet users search the internet for online conduct more in-depth surveys to better understand how online health information [2]. In Taiwan, it is estimated that 83.4% of health information–seeking behaviors influence the use of residents aged 12 years and above have internet experience [3]. information in health-related decision making [24]. As reported by the Taiwan National Health Interview Survey, With respect to the role of education in the use of the internet 1766 (64.4%) of the 2741 surveyed individuals used the internet for health information searching, it was reported that higher to search for online health information or services [4]. The issues education is significantly connected to a higher probability of regarding online health information–seeking behaviors of using the internet as the first source of health information [1]. patients have attracted a great deal of attention, since the health The results of a population-based survey showed that information located on the internet obviously influences patients’ respondents with lower education levels less frequently access medical decision making [5-7]. health information from internet websites, while individuals Having better access to health information on the internet with university or higher education more frequently search the provides internet users with more possibilities to actively internet for health information [10,25]. Regarding the use of manage their own health and medical utilization behaviors [8]. online health information, the role of education has been linked The internet is regarded as a powerful and influential tool to the use of credible information in health-related decision through which retrieving online health information may benefit making [26]. While looking for health care providers to solve patients’ empowerment, well-being health change, and healthier their medical problems, adult individuals with less formal behaviors [9,10]. Compared to infrequent users, frequent internet education are less likely to use online resources to consult online users prefer more health-related information and decision rankings and reviews of doctors, hospitals, drugs, and medical making and the internet enables them to make more informed treatments [27]. In a study on health information–related seeking medical decisions [11]. In addition to medical decision making, and sharing behaviors among baby boomers and older adults, online health information influences patients’ communication the results showed that college graduates and postgraduates are with physicians [12]. The result of a systematic review study more likely than non-high-school graduates to seek and share showed that online health information improves health information over the internet [24]. patient-physician relationships as patients gain better access to According to a systematic review on studies that measured online health information and discuss it with their physicians online health information usage, it was found that online health [13]. information can support desired health decisions, including Despite the use of the internet to search for health information increasing professional visits, asking questions during medical making internet users more knowledgeable, patients seldom consultations, and adhering to physicians’ advice [28]. This discuss the information they find on the web with their doctors review paper suggested that future studies strictly validate [14]. The credibility of the diverse range of health information instruments for investigating online health information–seeking on the internet has been of great concern, as its inappropriate behaviors and carefully examine their impacts on health use may be potentially harmful to patients’ health and waste decisions. Using the concept analysis methodology, 1 study medical resources [15,16]. In sum, online health information conducted a systematic review on the past 10 years of research without verification by experts could generate misinformation to analyze the concept of health information–seeking behavior. and inappropriate health behaviors and hinder the The concept analysis results pointed out that the internet has physician-patient relationship [16,17]. become a common and preferred channel for retrieving health information. In addition to the importance of investigating how According to systematic review studies, it has been concluded individuals from different communities seek information on the that the overall quality of online health information remains internet, the results of this study highlighted the lack of scales problematic and should be considered [18,19]. However, a high that can further measure and understand health percentage (77%) of internet users tend to search for health information–seeking behaviors. They also concluded that there information through search engines due to the decentralized is a need to advance individuals’ ability to adequately acquire nature of the internet [2]. An observational study on health online health information and properly act on the acquired information–seeking behaviors showed a high tendency of using information to make health decisions [29]. search engines to look for health information [20]. As indicated by an experiment, the most popular method for seeking health Research Purposes information was to rely on the results of only 1 search engine Low levels of education have been correlated with undesirable page and to use unaccredited information to answer health online health information–seeking behaviors [24,27]. Research questions without comparing and justifying them with other on the health information–seeking behaviors of the general sources [5]. Because of the high heterogeneity of online health population without a university education has been an issue of information sources, rather than merely relying on the first few https://www.jmir.org/2022/9/e29609 J Med Internet Res 2022 | vol. 24 | iss. 9 | e29609 | p. 2 (page number not for citation purposes) XSL FO RenderX JOURNAL OF MEDICAL INTERNET RESEARCH Chiu et al concern [22]. In addition, it was indicated that laypeople without respect to the theoretical aspect, 2 measurements, the a university background may receive less training in information Information Commitment Survey (ICS) and Online Health search strategies and have difficulties searching for health Information Utilization (OHIU), were adopted from previous information on the internet [5]. However, it was argued that works that have involved clearly conceptual definitions and a either simple or complex search strategies would benefit general theoretical basis for these measurements [7,35]. After receiving health information seekers to gather useful health information permission from the corresponding authors of these studies, the [5,20]. However, it was reported that those with low educational Chinese versions of the ICS and the OHIU were obtained and levels may not benefit from online health information, since used in this study. Next, the wording of the items relating to the they do not access alternative health information from health elaboration strategy, match strategy, and consultation were care providers [30]. As suggested, it is a major topic to explore carefully modified to assess individuals’ opinions on searching how laypeople conduct either basic or advanced search strategies for and using online health information. To ensure content to obtain online health information to investigate and solve their validity, we requested 2 medical experts and 1 expert in health problems [20,31]. information science to evaluate the correspondence between the individual item and its theoretical construct. In addition, we Therefore, this study examined in which manners patients purposively recruited 10 representative participants in a pilot without a university degree search for health information over test to subjectively check whether the wording and readability the internet and how they use that information to answer their of the ICS and OHIU were appropriate. Finally, we conducted health-related questions. Thus, the correlations between patients’ partial least squares-structural equation modeling (PLS-SEM) health information search strategies and utilization behaviors to analyze the measurement model and examine the reliability, were explored. Since the variables of search frequency, age, discriminant validity, and convergent validity of the and sex were regarded as influential demographics in patients’ measurements. health information–seeking behaviors as well as doctor-patient consultations [32,33], these variables were also measured and Demographic Variables recruited in the analyses and treated as control variables. Based Demographic variables, including age, sex, and search on the aforementioned objectives, this study aimed to examine frequency, were measured and recruited in the statistical the following research questions: analyses. Age was the participants’ actual age. For sex, males were coded as 1, while females were coded as 2. The search • Question 1: Are there correlations between laypeople’s frequency, that is, the patients’ frequency of using the internet health information search strategies and their health to search for health information for health-related problems, information utilization? was measured with a 6-point scale ranging from 1 (rarely) to 6 • Question 2: Are there interaction relationships between (always). health information search strategies and health information utilization? Information Commitment Survey • Question 3: Are there curvilinear relationships between Two constructs retrieved from the ICS signified web users’ health information search strategies and health information information search strategies, namely the elaboration strategy utilization? and the match strategy [34,35]. These 2 constructs were modified and used to assess patients’ online information search Methods strategies for answering their health-related questions. These measurements were evaluated with a 6-point Likert scale ranging Recruitment from 1 (strongly disagree) to 6 (strongly agree), indicating To examine laypeople with a low-level education background, participants’ opinions on each item of the search strategy. The a probable sample of outpatients without university education details of the elaboration and match strategies are as follows. was purposefully selected and surveyed in a large-scale, university-affiliated teaching hospital. The criterion for • Elaboration as a search strategy (elaboration): evaluating recruiting participants was having experience of searching for the extent to which web users have metacognitive thinking online health information. All the participants surveyed were and integrate information from diverse websites to find the patients who visited an outpatient clinic for health-related best solution to fulfill their purposes. Example item: I can problems and consulted a doctor about their problems. All the integrate the information retrieved from various websites. participants voluntarily participated in this study by responding • Match as a search strategy (match): assessing the extent to to the survey. Informed consent for the survey was obtained which web users wish to find a few websites containing from individual participants. In addition, their privacy has been fruitful and relevant information to match their searching strictly protected. purposes. Example item: I wish to find a single website containing the most fruitful information. Instruments Online Health Information Utilization Procedure for Developing and Validating the The online health information consulting scale, named Measurements consultation, which is a subscale of the OHIU questionnaire, According to the process suggested, the measurement presented patients’ behaviors of using the health-related development of this study was conducted in several steps information retrieved from the web to consult doctors, experts, involving theoretical and practical considerations [34]. With and relatives [7]. The items of consultation were measured with https://www.jmir.org/2022/9/e29609 J Med Internet Res 2022 | vol. 24 | iss. 9 | e29609 | p. 3 (page number not for citation purposes) XSL FO RenderX JOURNAL OF MEDICAL INTERNET RESEARCH Chiu et al a 6-point Likert scale ranging from 1 (strongly disagree) to 6 Research Act of the Ministry of Health and Welfare, Republic (strongly agree), indicating participants’ opinions on their of China (Taiwan) [39], and the “Scope of Human Research consulting behaviors. The definition of consultation is as Cases Exempt from Ethical Review Board Review” announced follows: by Ministry of Health and Welfare, Taiwan on 5 July 2012, pursuant to Wei-Shu-Yi-Zi (#1010265075) [40]. • Consulting scale (consultation): measuring the extent to which patients consult others about the online health The research involved the use of questionnaires and survey information they retrieve. Example item: I will discuss with procedures and was conducted in a public setting. The a physician the issues regarding the medical information information obtained was recorded in such a manner that human retrieved on the internet. subjects cannot be identified, directly or through identifiers linked to the subjects. Informed consent was obtained from all Data Analysis participants involved in the study, and the participants were Statistical software packages for social science SPSS Statistics subjected to no medical interactions or interventions other than version 22 (IBM Corp) and SmartPLS3 (SmartPLS GmbH, ongoing usual care. The study was also conducted in accordance Germany) were used to conduct statistical analyses. Using partial with the ethics standards required by the Declaration of Helsinki least squares-structural equation modeling (PLS-SEM) analysis, issued in 2013. the measurement model of 2 instruments and the structural model of the research hypotheses were examined based on the Results 2-stage procedure recommended by Hair et al [36]. The statistical software SmartPLS3 was used to execute the Participants PLS-SEM procedure. First, this study evaluated the reliability A sample of 253 outpatients without a university academic and validity of the ICS and OHIU instruments, including factor degree was recruited for this study. The participants included loadings, composite reliability (CR), average variance explained 134 (53%) males and 119 (47%) females, who were outpatients (AVE), and the Fornell-Lacker criterion [37]. Next, we executed at a university-affiliated teaching hospital in the northern area path correlation analysis to examine the relationships among of Taiwan. Their average age was 45.73 (range 30-69) years. the participants’ age, sex, search frequency, elaboration, match, Results of Correlation Analysis consultation, moderating term of elaboration and match, quadratic term of elaboration, and quadratic term of match. P Table 1 provides the means and SDs of the variables and the values less than .05 indicated significant loadings and significant Pearson correlation coefficients between them. As shown in correlations between variables. Moreover, CR values greater Table 1, elaboration was linked to age (r=0.17, P<.01) and than 0.7 and AVE values greater than the threshold value of 0.5 search frequency (r=0.24, P<.001) with positive correlation were considered as having adequate construct reliability and coefficients. In addition, both elaboration strategy (r=0.55, acceptable convergent validity, respectively [38]. P<.001) and match strategy (r=0.31, P<.001) were positively correlated with consultation. That is, patients with high intent Ethical Considerations to conduct elaboration and match searches were more likely to This study was exempt from Institutional Review Board consult others about the online health information they retrieved. oversight in accordance with Article 5 of the Human Subjects Table 1. Means (SDs) and correlations of variables. Variables Mean (SD) Correlation Age Search frequency Elaboration Match Age 45.73 (7.70) N/A N/A N/A N/A Search frequency 3.41 (1.07) –0.07 N/A N/A N/A b c Elaboration 4.68 (0.74) N/A N/A 0.17 0.24 Match 4.36 (0.84) 0.11 –0.06 0.09 N/A b c c Consultation 4.38 (1.07) 0.09 0.18 0.55 0.31 N/A: not applicable. P<.01. P<.001. from 0.81 to 0.89. Moreover, the AVE values were larger than PLS-SEM Analysis of the Measurement Model the threshold value of 0.5, ranging from 0.59 to 0.74, showing PLS-SEM analysis of measurement model showed that the 9 acceptable convergent validity [41]. Based on the Fornell-Lacker items of 3 factors (elaboration, match and, consultation) had criterion, the square root of the AVE for each factor (ranging significant and satisfactory factor loadings ranging from 0.60 from 0.77 to 0.86) was higher than the corresponding interfactor to 0.92. The CR value of each construct was fairly good, ranging correlations (ranging from 0.09 to 0.55), suggesting reasonable https://www.jmir.org/2022/9/e29609 J Med Internet Res 2022 | vol. 24 | iss. 9 | e29609 | p. 4 (page number not for citation purposes) XSL FO RenderX JOURNAL OF MEDICAL INTERNET RESEARCH Chiu et al discriminant validity [37]. For details of the measurement model P=.05) showed negative correlations with consultation. analysis, please refer to Multimedia Appendix 1. Regarding demographics, sex, age, and search frequency did not have significant correlation with consultation. Overall, the Path Correlation Analysis of the Structural Model 2 2 R value for consultation was 0.49, while the adjusted R value Combined with main variables, demographic variables, was 0.47. In addition, the f values of elaboration, match, moderating term, and 2 quadradic terms, path correlation moderating term, and quadratic terms ranging from 0.18 to 0.43 analysis was performed using SmartPLS3. The main variables were higher than 0.025, showing large effects of independent containing elaboration, match, consultation, and demographic variables [42]. Moreover, the values of the variance inflation variables, including sex, age, and search frequency, were factor (VIF) for independent variables ranged from 1 to 2.84, involved in the structural model to evaluate the path coefficients indicating that there was no problem of collinearity [41]. between the variables. To further examine the nonlinear effects of elaboration and match on consultation, following the To further illustrate the curvilinear relationship of match with procedure suggested, we used the 2-stage approach to create a consultation, we used the means of latent variables calculated moderating term (interaction effect between elaboration and by PLS to estimate the quadratic equation of consultation on match) and 2 quadratic terms (quadratic effects of elaboration match. The scatter plot with its trend curve is plotted in Figure and match) on the basis of standardized data [42]. 2. As presented, the coefficient of x was positive, while the coefficient of X was negative, indicating a concave downward Figure 1 presents the path coefficients of the structural model. relationship between match and consultation. That is, an increase The elaboration (path coefficient=0.55, P<.001) and match (path in match had an initial positive effect on consultation, but the coefficient=0.36, P<.001) showed positive correlations between effect became weaker and even changed direction when match consultation, while the moderating term (path coefficient=–0.34, reached a high level, suggesting that match has a decrement of P<.001) and quadratic terms of match (path coefficient=–0.09, positive effect on consultation. Figure 1. Path correlations of the structure model. *P<.05, ***P<.001 Figure 2. Nonlinear graph of the match variable. https://www.jmir.org/2022/9/e29609 J Med Internet Res 2022 | vol. 24 | iss. 9 | e29609 | p. 5 (page number not for citation purposes) XSL FO RenderX JOURNAL OF MEDICAL INTERNET RESEARCH Chiu et al To better understand the interaction effect between elaboration Figure 3 shows the plot of interaction between match and and match, we used the standardized latent means of elaboration elaboration. The solid line is for the low-match group (at a value and match calculated by PLS to analyze the regression of of –1), while the dotted line is for the high-match group (at a consultation for representative groups. As suggested, the low- value of 1). The result indicates that elaboration had a positive and the high-match group were chosen at low (–1 SD from the effect on consultation for both the low- and the high-match mean) and high (1 SD from the mean) values of match, group. However, the slopes show that when the match was low, respectively [43,44]. To observe the crossover interaction, the the effect of elaboration on consultation was stronger than that consultation scores for the low- and high-match groups were of a high match. Furthermore, the crossover interaction shows calculated at a low level (–1.5 SD) and a high level (1.5 SD) of that when elaboration was low, the high-match group had a elaboration, respectively [44]. Next, the predicted values for higher consultation score than that of the low-match group. On each group were produced by multiplying the respective the contrary, when elaboration was high, the low-match group unstandardized regression coefficients for each variable at an had a higher consultation extent than that of the high-match appropriate value (eg, high match=1, high elaboration=1.5). group. Figure 3. Interaction effect between match and elaboration on consultation. information search behaviors of those with low educational Discussion backgrounds. Principal Findings Positive Influences of Health Information Searching on Consultations Role of Education in Health Information Seeking As can be seen from the results presented in Table 1, the It has been reported that online health information may correlations between information search strategies and potentially benefit individuals by making them better informed, consultation showed that both match strategy and elaboration resulting in more effective health outcomes; on the contrary, strategy have positive influences on the usage of online health misinformed health information may result in inappropriate use information to consult others. That is, no matter what search of medical resources [15]. In addition, studies have indicated strategy the patients used to gather online health information, that individuals with lower education levels are less likely to they were willing to further discuss the information with medical access websites for health information and show unsuitable experts or others. Despite an advanced search strategy, such as utilization behaviors, while people with university degrees more an analytic approach, being considered an important factor frequently access online health information using complex and connected with accurate search results, it was emphasized that expanded information search strategies [10,25,26]. Therefore, simple strategies, such as the browsing approach, which may the population without university degrees has been regarded as be efficient and successful, need not necessarily be rejected an important target group to examine their online health [23]. As was expected, patients with more exposure to health information navigation behaviors [22]. Accordingly, the results information through information communication technology of this study may provide expanded views on the online health (both advanced and simple approaches) were more likely to https://www.jmir.org/2022/9/e29609 J Med Internet Res 2022 | vol. 24 | iss. 9 | e29609 | p. 6 (page number not for citation purposes) XSL FO RenderX JOURNAL OF MEDICAL INTERNET RESEARCH Chiu et al perform healthier behaviors, suggesting a potential way for seekers have to adopt advanced search strategies to scan and health care professionals to encourage their patients to access justify the search results [47]. As suggested, patients and their online health information and communicate health information relatives were encouraged to conduct more advanced search with them through digital media [10]. strategies to recognize credible and appropriate health information sources [32]. Curvilinear Relationship of Match With Consultation The Importance of eHealth Literacy for Advancing Curvilinear analysis of the match strategy indicated that it was Health-Seeking Behavior positively linked to consultation willingness, but the correlation became weaker and even changed direction as the match strategy In Taiwan, an investigation on health information–seeking reached a high level. That is, accessing online health information behaviors showed that internet users with high educational levels through the match strategy is necessary and helpful for (university and above) are more likely to use the internet for consulting health care professionals about the retrieved health information searching. Regarding the effects of health information, but too much use of this simple approach may information searching, a majority of the respondents used such disadvantage consultation behaviors. Similarly, it was reported health information to ask physicians questions and to make that health information seekers without medical expertise are decisions on disease treatment and whether to consult a more likely to use search engines to perform a simple search; physician [4]. Therefore, online health information seeking can although it would be useful to engage them in the information be regarded as a channel through which health care professionals discovery process, it also may become a barrier to further can enhance patient-physician relationships and help patients obtaining the most suitable solution [20]. by recommending credible health information sources. Based on the theory of planned behavior (TPB), it was indicated In conclusion, there is a need to investigate how to stimulate that abundant information may overload information seekers internet users with low educational levels (without a university and result in their psychological ill-being (eg, depression and education) to use health information to consult health care anxiety), which may discontinue their intention to use the online professionals and to have positive effects on their treatment health information [45]. Accordingly, it may explain why the decisions and health outcomes. Based on the results of this match strategy has a positive influence on consultation behavior, study, health care professionals may better know how implying that gathering relevant information from a few medicine-related information search strategies (ie, match and resources may support information seekers’ continuous use of elaboration strategies) can benefit patients with low educational online health information. Nevertheless, an overwhelming levels when turning to the internet for making health decisions amount of information retrieved by the match strategy without [26]. In sum, this subpopulation (those with less education) may the skills of evaluating and integrating such information may benefit from online information only when they have access to discourage its continuous use. To summarize prior research, alternative health information sources, such as health care there are interesting findings on health information seekers’ providers [30]. health information–seeking behaviors and responses to the When compared with the low-level-eHealth-literate group, gathered information [5,20,31]. Simple lookup search strategies high-level-eHealth literate individuals who have a good ability may have both advantages and disadvantages for individuals’ to seek, locate, evaluate, and apply online health information health information–seeking behaviors [5,20,31]. Furthermore, were recognized as more frequent health information seekers it was demonstrated that multiple health information sources and were better at using effective online health information through an instant search approach can lead to information search strategies to address their health concerns [5]. As overload and result in information avoidance, suggesting the suggested, improving eHealth literacy may promote individuals’ need for training on advanced health information–seeking skills use of effective online information-seeking strategies and to manage and integrate diverse information sources [46]. identify high-quality health information sources. In the case of The Elaboration Strategy Is Essential to Desired this study, for patients in both the low- and the high-match group (in particular, those with a low tendency to adopt the match Health-Seeking Behavior strategy), developing their eHealth literacy may encourage their As laypeople do not have medical expertise, they tend to adopt intent to use the elaboration strategy and consult health care basic search strategies to look up online health information for professionals. retrieving facts and answering health questions [20,47]. However, the correlation analyses in this study showed that the Limitations elaboration strategy has more positive influences on consultation Several limitations of this study should be noted. First, this than the match strategy. In addition, interaction effect analysis study targeted laypeople without a university education in order indicated the important role of the elaboration strategy in to examine their online health information search behaviors reinforcing patients’ willingness to further consult medical rather than other populations with a university degree or higher experts or others with the online health information they have educational background. That is, the results of this study should found, especially patients with a tendency to adopt a low-match be cautiously interpreted and inferences should be made with strategy. In conclusion, the elaboration strategy may be a better care. The second limitation is the sampling method used in this choice than the match strategy through which to encourage study. The participants included in this study were purposefully patients to gather and integrate numerous types of health recruited from 1 university-affiliated teaching hospital rather information and use such information appropriately. To further than from other clinical settings, such as small hospitals or understand and interpret health information, health information https://www.jmir.org/2022/9/e29609 J Med Internet Res 2022 | vol. 24 | iss. 9 | e29609 | p. 7 (page number not for citation purposes) XSL FO RenderX JOURNAL OF MEDICAL INTERNET RESEARCH Chiu et al private clinics. Therefore, the generalizability of the study results patients are using the internet as a medical information source, is limited to other clinic settings and regions in Taiwan. Third, and should be prepared to help patients to carefully identify the instead of objective data, such as log files, the data of this study quality of online health information and appropriately use such were collected from patients’ subjective opinions and attitudes. information [48]. That is, medical professionals must be aware Thus, the self-reported bias should be considered. Finally, a that they are eligible to direct patients’ health information search few predicting factors, including age, sex, search frequency, behaviors and empower them to engage in an informed and and search strategies, were explored in this study and recruited active way in their own medical decision-making process. in the regression analysis model. Although the results of PLS Finally, we recommend that health care providers offer path analysis indicated that a high proportion of variances was high-quality information on well-designed medical websites. explained by the predictors, there is still a need to further To assist patients in adopting simple searches and becoming consider other predictors or confounding factors, such as severity advanced explorers, there is a need to provide better information of illness and accessibility of medical resources, which may tools and quality content for them to surf the internet full of rich influence how patients use online health information. information and many pitfalls [47]. While conducting a heuristic search, patients sometimes reject credible websites with Conclusion high-quality content due to poor visual appeal and unclear Although there are challenges for laypeople, who are not interface design [12]. In other words, well-designed websites medical experts, and who do not have a university degree to built by medical professionals containing a clear interface and properly access and evaluate the credibility and accuracy of quality health information can draw the attention of patients health information retrieved from the internet [10,22], and lead them to access trustworthy information while looking understanding their online health information search strategies up health information on the internet. and use of such information may help health care professionals Meanwhile, the results of the interaction and curvilinear analyses better know how to lead their patients to appropriately search suggested that the elaboration strategy is a more recommendable for and communicate about online health information with approach than the match strategy through which patients are medical experts. Certainly, the internet is an essential tool more likely to use online health information to consult with through which patients may approach the low-cost wealth of their doctors or others about their health-related problems. To health information; however, it is an additional source of health stimulate patients’ online health information search strategies information, which should not necessarily replace traditional in more advanced ways, it has been suggested that advancing health information offered by health care professionals [9]. patients’ eHealth literacy (ie, ability to search, locate, evaluate, Based on the findings of this study, we provided practical integrate, and apply electronic health information) may support suggestions in several aspects. As suggested, the public them to conduct appropriate information search strategies, justify population and patients were encouraged to gather health reliable and useful information, and use such information in an information from multiple sources, including medical experts’ effective manner [5,45]. advice, as well as alternative opinions from the internet [7,25]. In summary, this study acknowledges how patients without a It has been indicated that patients use online medical information university degree search for health information over the internet, to integrate with advice from friends, family, and physicians in how they share the information with doctors and others, and order to confidently make their medical decisions [12]. how to guide them to accurately use the information sources. According to the results of this study, patients without a As patients have better access to additional medical advice over university degree should be supported to obtain more exposure the internet and can discuss such information with health care to online health information through both complex and simple professionals, they are expected to be more involved in search approaches, which in turn may induce them to consult appropriate health information and engaged in their medical medical experts about such information. In addition, it was decision making. suggested that health care providers should recognize that their Acknowledgments This work was, in part, financially supported by the Institute for Research Excellence in Learning Sciences of the National Taiwan Normal University (NTNU) through the Featured Areas Research Center Program within the framework of the Higher Education Sprout Project by the Ministry of Education (MOE) in Taiwan. In addition, the authors are thankful for the research funding offered by the Ministry of Science and Technology (MOST), Taiwan (Grant MOST 110-2628-H-002 -004 -MY2 and MOST 108-2511-H-003 -004 -MY3). We also thank all those involved in this research, including the patients who replied to the questionnaires and the research assistants who helped with collecting the questionnaires. Authors' Contributions Y-LC contributed to the study design, developed the instruments, analyzed the research data, and also drafted the main text of this paper. C-CT contributed to constructing the research model. He also gave opinions and interpretations to explain the results of the statistical analysis. J-CL developed the instruments and contributed to the study design. In addition, he assisted in delivering and collecting the questionnaires and provided opinions on the results of the statistical analysis. https://www.jmir.org/2022/9/e29609 J Med Internet Res 2022 | vol. 24 | iss. 9 | e29609 | p. 8 (page number not for citation purposes) XSL FO RenderX JOURNAL OF MEDICAL INTERNET RESEARCH Chiu et al Conflicts of Interest None declared. Multimedia Appendix 1 Details about the questionnaire and its validation. [DOCX File , 17 KB-Multimedia Appendix 1] Multimedia Appendix 2 Cover letter describing informed consent. [DOCX File , 13 KB-Multimedia Appendix 2] References 1. Prestin A, Vieux SN, Chou WS. Is online health activity alive and well or flatlining? Findings from 10 years of the Health Information National Trends Survey. J Health Commun 2015 Jul;20(7):790-798. [doi: 10.1080/10810730.2015.1018590] [Medline: 26042588] 2. Fox S, Duggan M. Health Online 2013. 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J Gen Intern Med 2002 Mar;17(3):180-185 [FREE Full text] [doi: 10.1046/j.1525-1497.2002.10603.x] [Medline: 11929503] Abbreviations AVE: average variance extracted CR: composite reliability ICS: Information Commitment Survey OHIU: Online Health Information Utilization PLS-SEM: partial least squares-structural equation modeling Edited by G Eysenbach; submitted 15.04.21; peer-reviewed by J Taylor, W Pian; comments to author 28.06.21; revised version received 25.08.21; accepted 06.03.22; published 02.09.22 Please cite as: Chiu YL, Tsai CC, Liang JC J Med Internet Res 2022;24(9):e29609 URL: https://www.jmir.org/2022/9/e29609 doi: 10.2196/29609 PMID: ©Yen-Lin Chiu, Chin-Chung Tsai, Jyh-Chong Liang. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 02.09.2022. 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Laypeople’s Online Health Information Search Strategies and Use for Health-Related Problems: Cross-sectional Survey

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Abstract

Background: With the increase in the use of the internet to search for health information about health-related problems, there is a need for health care professionals to better understand how their patients search for and use the online health information that may influence their medical decision making. Objective: The aims of this study are to explore laypeople’s online health information search strategies and examine the relationships between their search strategies and utilization behavior of online health information. Methods: Two scales, namely match and elaboration, were used to measure patients’ basic search strategies (ie, simple approach) and advanced search strategies (ie, integrative approach), respectively. In addition, the consultation scale was used to evaluate the participants’ use of online health information to consult doctors and others. A total of 253 outpatients without university education were purposely selected and surveyed. The participants were outpatients at a university-affiliated teaching hospital. Partial least squares-structural equation modeling (PLS-SEM) was performed to analyze the measurement model to specify the measurement validation. In addition, the structure model of PLS-SEM was evaluated to examine the path correlations between variables and to execute interaction effect and curvilinear relationship analyses. Results: The results of the path correlation analysis by PLS-SEM showed that both elaboration strategy (path coefficient=0.55, P<.001) and match strategy (path coefficient=0.36, P<.001) were positively correlated with consultation on online health information with doctors and others. In addition, interaction effect and curvilinear relationship analyses indicated that there was a significant interaction effect between elaboration and match on consultation (path coefficient=–0.34, P<.001) and a significant curvilinear relationship between match and consultation (path coefficient=–0.09, P=.046). Conclusions: Increasing patients’ exposure to online health information through both a simple search approach (ie, match strategy) and a complex search approach (ie, elaboration strategy) may lead them to appropriately use the information to consult doctors and others. However, the results of interaction effect and curvilinear relationship analyses highlighted the essential role of the elaboration strategy to properly locate, evaluate, and apply online health information. The findings of this study may help health care professionals better understand how to communicate with their patients through the health information on the internet. (J Med Internet Res 2022;24(9):e29609) doi: 10.2196/29609 KEYWORDS decision making; eHealth literacy; information search strategy; internet; patient; information-seeking behavior; laypeople; online health information; patient communication https://www.jmir.org/2022/9/e29609 J Med Internet Res 2022 | vol. 24 | iss. 9 | e29609 | p. 1 (page number not for citation purposes) XSL FO RenderX JOURNAL OF MEDICAL INTERNET RESEARCH Chiu et al results provided by the search engine, the need to check certain Introduction information against other information sources while searching for online information about medical problems has been strongly Background recommended [21,22]. The impacts of internet search strategies With its convenient and widespread access to abundant on information retrieval and how patients use online health information, the internet has become the major source for information have been of great concern; however, the patients and the general population to retrieve health information information search strategies for health-related problems have [1]. As reported by the Pew Research Center, approximately seldom been studied [7,23]. As suggested, there is a need to 80% of American internet users search the internet for online conduct more in-depth surveys to better understand how online health information [2]. In Taiwan, it is estimated that 83.4% of health information–seeking behaviors influence the use of residents aged 12 years and above have internet experience [3]. information in health-related decision making [24]. As reported by the Taiwan National Health Interview Survey, With respect to the role of education in the use of the internet 1766 (64.4%) of the 2741 surveyed individuals used the internet for health information searching, it was reported that higher to search for online health information or services [4]. The issues education is significantly connected to a higher probability of regarding online health information–seeking behaviors of using the internet as the first source of health information [1]. patients have attracted a great deal of attention, since the health The results of a population-based survey showed that information located on the internet obviously influences patients’ respondents with lower education levels less frequently access medical decision making [5-7]. health information from internet websites, while individuals Having better access to health information on the internet with university or higher education more frequently search the provides internet users with more possibilities to actively internet for health information [10,25]. Regarding the use of manage their own health and medical utilization behaviors [8]. online health information, the role of education has been linked The internet is regarded as a powerful and influential tool to the use of credible information in health-related decision through which retrieving online health information may benefit making [26]. While looking for health care providers to solve patients’ empowerment, well-being health change, and healthier their medical problems, adult individuals with less formal behaviors [9,10]. Compared to infrequent users, frequent internet education are less likely to use online resources to consult online users prefer more health-related information and decision rankings and reviews of doctors, hospitals, drugs, and medical making and the internet enables them to make more informed treatments [27]. In a study on health information–related seeking medical decisions [11]. In addition to medical decision making, and sharing behaviors among baby boomers and older adults, online health information influences patients’ communication the results showed that college graduates and postgraduates are with physicians [12]. The result of a systematic review study more likely than non-high-school graduates to seek and share showed that online health information improves health information over the internet [24]. patient-physician relationships as patients gain better access to According to a systematic review on studies that measured online health information and discuss it with their physicians online health information usage, it was found that online health [13]. information can support desired health decisions, including Despite the use of the internet to search for health information increasing professional visits, asking questions during medical making internet users more knowledgeable, patients seldom consultations, and adhering to physicians’ advice [28]. This discuss the information they find on the web with their doctors review paper suggested that future studies strictly validate [14]. The credibility of the diverse range of health information instruments for investigating online health information–seeking on the internet has been of great concern, as its inappropriate behaviors and carefully examine their impacts on health use may be potentially harmful to patients’ health and waste decisions. Using the concept analysis methodology, 1 study medical resources [15,16]. In sum, online health information conducted a systematic review on the past 10 years of research without verification by experts could generate misinformation to analyze the concept of health information–seeking behavior. and inappropriate health behaviors and hinder the The concept analysis results pointed out that the internet has physician-patient relationship [16,17]. become a common and preferred channel for retrieving health information. In addition to the importance of investigating how According to systematic review studies, it has been concluded individuals from different communities seek information on the that the overall quality of online health information remains internet, the results of this study highlighted the lack of scales problematic and should be considered [18,19]. However, a high that can further measure and understand health percentage (77%) of internet users tend to search for health information–seeking behaviors. They also concluded that there information through search engines due to the decentralized is a need to advance individuals’ ability to adequately acquire nature of the internet [2]. An observational study on health online health information and properly act on the acquired information–seeking behaviors showed a high tendency of using information to make health decisions [29]. search engines to look for health information [20]. As indicated by an experiment, the most popular method for seeking health Research Purposes information was to rely on the results of only 1 search engine Low levels of education have been correlated with undesirable page and to use unaccredited information to answer health online health information–seeking behaviors [24,27]. Research questions without comparing and justifying them with other on the health information–seeking behaviors of the general sources [5]. Because of the high heterogeneity of online health population without a university education has been an issue of information sources, rather than merely relying on the first few https://www.jmir.org/2022/9/e29609 J Med Internet Res 2022 | vol. 24 | iss. 9 | e29609 | p. 2 (page number not for citation purposes) XSL FO RenderX JOURNAL OF MEDICAL INTERNET RESEARCH Chiu et al concern [22]. In addition, it was indicated that laypeople without respect to the theoretical aspect, 2 measurements, the a university background may receive less training in information Information Commitment Survey (ICS) and Online Health search strategies and have difficulties searching for health Information Utilization (OHIU), were adopted from previous information on the internet [5]. However, it was argued that works that have involved clearly conceptual definitions and a either simple or complex search strategies would benefit general theoretical basis for these measurements [7,35]. After receiving health information seekers to gather useful health information permission from the corresponding authors of these studies, the [5,20]. However, it was reported that those with low educational Chinese versions of the ICS and the OHIU were obtained and levels may not benefit from online health information, since used in this study. Next, the wording of the items relating to the they do not access alternative health information from health elaboration strategy, match strategy, and consultation were care providers [30]. As suggested, it is a major topic to explore carefully modified to assess individuals’ opinions on searching how laypeople conduct either basic or advanced search strategies for and using online health information. To ensure content to obtain online health information to investigate and solve their validity, we requested 2 medical experts and 1 expert in health problems [20,31]. information science to evaluate the correspondence between the individual item and its theoretical construct. In addition, we Therefore, this study examined in which manners patients purposively recruited 10 representative participants in a pilot without a university degree search for health information over test to subjectively check whether the wording and readability the internet and how they use that information to answer their of the ICS and OHIU were appropriate. Finally, we conducted health-related questions. Thus, the correlations between patients’ partial least squares-structural equation modeling (PLS-SEM) health information search strategies and utilization behaviors to analyze the measurement model and examine the reliability, were explored. Since the variables of search frequency, age, discriminant validity, and convergent validity of the and sex were regarded as influential demographics in patients’ measurements. health information–seeking behaviors as well as doctor-patient consultations [32,33], these variables were also measured and Demographic Variables recruited in the analyses and treated as control variables. Based Demographic variables, including age, sex, and search on the aforementioned objectives, this study aimed to examine frequency, were measured and recruited in the statistical the following research questions: analyses. Age was the participants’ actual age. For sex, males were coded as 1, while females were coded as 2. The search • Question 1: Are there correlations between laypeople’s frequency, that is, the patients’ frequency of using the internet health information search strategies and their health to search for health information for health-related problems, information utilization? was measured with a 6-point scale ranging from 1 (rarely) to 6 • Question 2: Are there interaction relationships between (always). health information search strategies and health information utilization? Information Commitment Survey • Question 3: Are there curvilinear relationships between Two constructs retrieved from the ICS signified web users’ health information search strategies and health information information search strategies, namely the elaboration strategy utilization? and the match strategy [34,35]. These 2 constructs were modified and used to assess patients’ online information search Methods strategies for answering their health-related questions. These measurements were evaluated with a 6-point Likert scale ranging Recruitment from 1 (strongly disagree) to 6 (strongly agree), indicating To examine laypeople with a low-level education background, participants’ opinions on each item of the search strategy. The a probable sample of outpatients without university education details of the elaboration and match strategies are as follows. was purposefully selected and surveyed in a large-scale, university-affiliated teaching hospital. The criterion for • Elaboration as a search strategy (elaboration): evaluating recruiting participants was having experience of searching for the extent to which web users have metacognitive thinking online health information. All the participants surveyed were and integrate information from diverse websites to find the patients who visited an outpatient clinic for health-related best solution to fulfill their purposes. Example item: I can problems and consulted a doctor about their problems. All the integrate the information retrieved from various websites. participants voluntarily participated in this study by responding • Match as a search strategy (match): assessing the extent to to the survey. Informed consent for the survey was obtained which web users wish to find a few websites containing from individual participants. In addition, their privacy has been fruitful and relevant information to match their searching strictly protected. purposes. Example item: I wish to find a single website containing the most fruitful information. Instruments Online Health Information Utilization Procedure for Developing and Validating the The online health information consulting scale, named Measurements consultation, which is a subscale of the OHIU questionnaire, According to the process suggested, the measurement presented patients’ behaviors of using the health-related development of this study was conducted in several steps information retrieved from the web to consult doctors, experts, involving theoretical and practical considerations [34]. With and relatives [7]. The items of consultation were measured with https://www.jmir.org/2022/9/e29609 J Med Internet Res 2022 | vol. 24 | iss. 9 | e29609 | p. 3 (page number not for citation purposes) XSL FO RenderX JOURNAL OF MEDICAL INTERNET RESEARCH Chiu et al a 6-point Likert scale ranging from 1 (strongly disagree) to 6 Research Act of the Ministry of Health and Welfare, Republic (strongly agree), indicating participants’ opinions on their of China (Taiwan) [39], and the “Scope of Human Research consulting behaviors. The definition of consultation is as Cases Exempt from Ethical Review Board Review” announced follows: by Ministry of Health and Welfare, Taiwan on 5 July 2012, pursuant to Wei-Shu-Yi-Zi (#1010265075) [40]. • Consulting scale (consultation): measuring the extent to which patients consult others about the online health The research involved the use of questionnaires and survey information they retrieve. Example item: I will discuss with procedures and was conducted in a public setting. The a physician the issues regarding the medical information information obtained was recorded in such a manner that human retrieved on the internet. subjects cannot be identified, directly or through identifiers linked to the subjects. Informed consent was obtained from all Data Analysis participants involved in the study, and the participants were Statistical software packages for social science SPSS Statistics subjected to no medical interactions or interventions other than version 22 (IBM Corp) and SmartPLS3 (SmartPLS GmbH, ongoing usual care. The study was also conducted in accordance Germany) were used to conduct statistical analyses. Using partial with the ethics standards required by the Declaration of Helsinki least squares-structural equation modeling (PLS-SEM) analysis, issued in 2013. the measurement model of 2 instruments and the structural model of the research hypotheses were examined based on the Results 2-stage procedure recommended by Hair et al [36]. The statistical software SmartPLS3 was used to execute the Participants PLS-SEM procedure. First, this study evaluated the reliability A sample of 253 outpatients without a university academic and validity of the ICS and OHIU instruments, including factor degree was recruited for this study. The participants included loadings, composite reliability (CR), average variance explained 134 (53%) males and 119 (47%) females, who were outpatients (AVE), and the Fornell-Lacker criterion [37]. Next, we executed at a university-affiliated teaching hospital in the northern area path correlation analysis to examine the relationships among of Taiwan. Their average age was 45.73 (range 30-69) years. the participants’ age, sex, search frequency, elaboration, match, Results of Correlation Analysis consultation, moderating term of elaboration and match, quadratic term of elaboration, and quadratic term of match. P Table 1 provides the means and SDs of the variables and the values less than .05 indicated significant loadings and significant Pearson correlation coefficients between them. As shown in correlations between variables. Moreover, CR values greater Table 1, elaboration was linked to age (r=0.17, P<.01) and than 0.7 and AVE values greater than the threshold value of 0.5 search frequency (r=0.24, P<.001) with positive correlation were considered as having adequate construct reliability and coefficients. In addition, both elaboration strategy (r=0.55, acceptable convergent validity, respectively [38]. P<.001) and match strategy (r=0.31, P<.001) were positively correlated with consultation. That is, patients with high intent Ethical Considerations to conduct elaboration and match searches were more likely to This study was exempt from Institutional Review Board consult others about the online health information they retrieved. oversight in accordance with Article 5 of the Human Subjects Table 1. Means (SDs) and correlations of variables. Variables Mean (SD) Correlation Age Search frequency Elaboration Match Age 45.73 (7.70) N/A N/A N/A N/A Search frequency 3.41 (1.07) –0.07 N/A N/A N/A b c Elaboration 4.68 (0.74) N/A N/A 0.17 0.24 Match 4.36 (0.84) 0.11 –0.06 0.09 N/A b c c Consultation 4.38 (1.07) 0.09 0.18 0.55 0.31 N/A: not applicable. P<.01. P<.001. from 0.81 to 0.89. Moreover, the AVE values were larger than PLS-SEM Analysis of the Measurement Model the threshold value of 0.5, ranging from 0.59 to 0.74, showing PLS-SEM analysis of measurement model showed that the 9 acceptable convergent validity [41]. Based on the Fornell-Lacker items of 3 factors (elaboration, match and, consultation) had criterion, the square root of the AVE for each factor (ranging significant and satisfactory factor loadings ranging from 0.60 from 0.77 to 0.86) was higher than the corresponding interfactor to 0.92. The CR value of each construct was fairly good, ranging correlations (ranging from 0.09 to 0.55), suggesting reasonable https://www.jmir.org/2022/9/e29609 J Med Internet Res 2022 | vol. 24 | iss. 9 | e29609 | p. 4 (page number not for citation purposes) XSL FO RenderX JOURNAL OF MEDICAL INTERNET RESEARCH Chiu et al discriminant validity [37]. For details of the measurement model P=.05) showed negative correlations with consultation. analysis, please refer to Multimedia Appendix 1. Regarding demographics, sex, age, and search frequency did not have significant correlation with consultation. Overall, the Path Correlation Analysis of the Structural Model 2 2 R value for consultation was 0.49, while the adjusted R value Combined with main variables, demographic variables, was 0.47. In addition, the f values of elaboration, match, moderating term, and 2 quadradic terms, path correlation moderating term, and quadratic terms ranging from 0.18 to 0.43 analysis was performed using SmartPLS3. The main variables were higher than 0.025, showing large effects of independent containing elaboration, match, consultation, and demographic variables [42]. Moreover, the values of the variance inflation variables, including sex, age, and search frequency, were factor (VIF) for independent variables ranged from 1 to 2.84, involved in the structural model to evaluate the path coefficients indicating that there was no problem of collinearity [41]. between the variables. To further examine the nonlinear effects of elaboration and match on consultation, following the To further illustrate the curvilinear relationship of match with procedure suggested, we used the 2-stage approach to create a consultation, we used the means of latent variables calculated moderating term (interaction effect between elaboration and by PLS to estimate the quadratic equation of consultation on match) and 2 quadratic terms (quadratic effects of elaboration match. The scatter plot with its trend curve is plotted in Figure and match) on the basis of standardized data [42]. 2. As presented, the coefficient of x was positive, while the coefficient of X was negative, indicating a concave downward Figure 1 presents the path coefficients of the structural model. relationship between match and consultation. That is, an increase The elaboration (path coefficient=0.55, P<.001) and match (path in match had an initial positive effect on consultation, but the coefficient=0.36, P<.001) showed positive correlations between effect became weaker and even changed direction when match consultation, while the moderating term (path coefficient=–0.34, reached a high level, suggesting that match has a decrement of P<.001) and quadratic terms of match (path coefficient=–0.09, positive effect on consultation. Figure 1. Path correlations of the structure model. *P<.05, ***P<.001 Figure 2. Nonlinear graph of the match variable. https://www.jmir.org/2022/9/e29609 J Med Internet Res 2022 | vol. 24 | iss. 9 | e29609 | p. 5 (page number not for citation purposes) XSL FO RenderX JOURNAL OF MEDICAL INTERNET RESEARCH Chiu et al To better understand the interaction effect between elaboration Figure 3 shows the plot of interaction between match and and match, we used the standardized latent means of elaboration elaboration. The solid line is for the low-match group (at a value and match calculated by PLS to analyze the regression of of –1), while the dotted line is for the high-match group (at a consultation for representative groups. As suggested, the low- value of 1). The result indicates that elaboration had a positive and the high-match group were chosen at low (–1 SD from the effect on consultation for both the low- and the high-match mean) and high (1 SD from the mean) values of match, group. However, the slopes show that when the match was low, respectively [43,44]. To observe the crossover interaction, the the effect of elaboration on consultation was stronger than that consultation scores for the low- and high-match groups were of a high match. Furthermore, the crossover interaction shows calculated at a low level (–1.5 SD) and a high level (1.5 SD) of that when elaboration was low, the high-match group had a elaboration, respectively [44]. Next, the predicted values for higher consultation score than that of the low-match group. On each group were produced by multiplying the respective the contrary, when elaboration was high, the low-match group unstandardized regression coefficients for each variable at an had a higher consultation extent than that of the high-match appropriate value (eg, high match=1, high elaboration=1.5). group. Figure 3. Interaction effect between match and elaboration on consultation. information search behaviors of those with low educational Discussion backgrounds. Principal Findings Positive Influences of Health Information Searching on Consultations Role of Education in Health Information Seeking As can be seen from the results presented in Table 1, the It has been reported that online health information may correlations between information search strategies and potentially benefit individuals by making them better informed, consultation showed that both match strategy and elaboration resulting in more effective health outcomes; on the contrary, strategy have positive influences on the usage of online health misinformed health information may result in inappropriate use information to consult others. That is, no matter what search of medical resources [15]. In addition, studies have indicated strategy the patients used to gather online health information, that individuals with lower education levels are less likely to they were willing to further discuss the information with medical access websites for health information and show unsuitable experts or others. Despite an advanced search strategy, such as utilization behaviors, while people with university degrees more an analytic approach, being considered an important factor frequently access online health information using complex and connected with accurate search results, it was emphasized that expanded information search strategies [10,25,26]. Therefore, simple strategies, such as the browsing approach, which may the population without university degrees has been regarded as be efficient and successful, need not necessarily be rejected an important target group to examine their online health [23]. As was expected, patients with more exposure to health information navigation behaviors [22]. Accordingly, the results information through information communication technology of this study may provide expanded views on the online health (both advanced and simple approaches) were more likely to https://www.jmir.org/2022/9/e29609 J Med Internet Res 2022 | vol. 24 | iss. 9 | e29609 | p. 6 (page number not for citation purposes) XSL FO RenderX JOURNAL OF MEDICAL INTERNET RESEARCH Chiu et al perform healthier behaviors, suggesting a potential way for seekers have to adopt advanced search strategies to scan and health care professionals to encourage their patients to access justify the search results [47]. As suggested, patients and their online health information and communicate health information relatives were encouraged to conduct more advanced search with them through digital media [10]. strategies to recognize credible and appropriate health information sources [32]. Curvilinear Relationship of Match With Consultation The Importance of eHealth Literacy for Advancing Curvilinear analysis of the match strategy indicated that it was Health-Seeking Behavior positively linked to consultation willingness, but the correlation became weaker and even changed direction as the match strategy In Taiwan, an investigation on health information–seeking reached a high level. That is, accessing online health information behaviors showed that internet users with high educational levels through the match strategy is necessary and helpful for (university and above) are more likely to use the internet for consulting health care professionals about the retrieved health information searching. Regarding the effects of health information, but too much use of this simple approach may information searching, a majority of the respondents used such disadvantage consultation behaviors. Similarly, it was reported health information to ask physicians questions and to make that health information seekers without medical expertise are decisions on disease treatment and whether to consult a more likely to use search engines to perform a simple search; physician [4]. Therefore, online health information seeking can although it would be useful to engage them in the information be regarded as a channel through which health care professionals discovery process, it also may become a barrier to further can enhance patient-physician relationships and help patients obtaining the most suitable solution [20]. by recommending credible health information sources. Based on the theory of planned behavior (TPB), it was indicated In conclusion, there is a need to investigate how to stimulate that abundant information may overload information seekers internet users with low educational levels (without a university and result in their psychological ill-being (eg, depression and education) to use health information to consult health care anxiety), which may discontinue their intention to use the online professionals and to have positive effects on their treatment health information [45]. Accordingly, it may explain why the decisions and health outcomes. Based on the results of this match strategy has a positive influence on consultation behavior, study, health care professionals may better know how implying that gathering relevant information from a few medicine-related information search strategies (ie, match and resources may support information seekers’ continuous use of elaboration strategies) can benefit patients with low educational online health information. Nevertheless, an overwhelming levels when turning to the internet for making health decisions amount of information retrieved by the match strategy without [26]. In sum, this subpopulation (those with less education) may the skills of evaluating and integrating such information may benefit from online information only when they have access to discourage its continuous use. To summarize prior research, alternative health information sources, such as health care there are interesting findings on health information seekers’ providers [30]. health information–seeking behaviors and responses to the When compared with the low-level-eHealth-literate group, gathered information [5,20,31]. Simple lookup search strategies high-level-eHealth literate individuals who have a good ability may have both advantages and disadvantages for individuals’ to seek, locate, evaluate, and apply online health information health information–seeking behaviors [5,20,31]. Furthermore, were recognized as more frequent health information seekers it was demonstrated that multiple health information sources and were better at using effective online health information through an instant search approach can lead to information search strategies to address their health concerns [5]. As overload and result in information avoidance, suggesting the suggested, improving eHealth literacy may promote individuals’ need for training on advanced health information–seeking skills use of effective online information-seeking strategies and to manage and integrate diverse information sources [46]. identify high-quality health information sources. In the case of The Elaboration Strategy Is Essential to Desired this study, for patients in both the low- and the high-match group (in particular, those with a low tendency to adopt the match Health-Seeking Behavior strategy), developing their eHealth literacy may encourage their As laypeople do not have medical expertise, they tend to adopt intent to use the elaboration strategy and consult health care basic search strategies to look up online health information for professionals. retrieving facts and answering health questions [20,47]. However, the correlation analyses in this study showed that the Limitations elaboration strategy has more positive influences on consultation Several limitations of this study should be noted. First, this than the match strategy. In addition, interaction effect analysis study targeted laypeople without a university education in order indicated the important role of the elaboration strategy in to examine their online health information search behaviors reinforcing patients’ willingness to further consult medical rather than other populations with a university degree or higher experts or others with the online health information they have educational background. That is, the results of this study should found, especially patients with a tendency to adopt a low-match be cautiously interpreted and inferences should be made with strategy. In conclusion, the elaboration strategy may be a better care. The second limitation is the sampling method used in this choice than the match strategy through which to encourage study. The participants included in this study were purposefully patients to gather and integrate numerous types of health recruited from 1 university-affiliated teaching hospital rather information and use such information appropriately. To further than from other clinical settings, such as small hospitals or understand and interpret health information, health information https://www.jmir.org/2022/9/e29609 J Med Internet Res 2022 | vol. 24 | iss. 9 | e29609 | p. 7 (page number not for citation purposes) XSL FO RenderX JOURNAL OF MEDICAL INTERNET RESEARCH Chiu et al private clinics. Therefore, the generalizability of the study results patients are using the internet as a medical information source, is limited to other clinic settings and regions in Taiwan. Third, and should be prepared to help patients to carefully identify the instead of objective data, such as log files, the data of this study quality of online health information and appropriately use such were collected from patients’ subjective opinions and attitudes. information [48]. That is, medical professionals must be aware Thus, the self-reported bias should be considered. Finally, a that they are eligible to direct patients’ health information search few predicting factors, including age, sex, search frequency, behaviors and empower them to engage in an informed and and search strategies, were explored in this study and recruited active way in their own medical decision-making process. in the regression analysis model. Although the results of PLS Finally, we recommend that health care providers offer path analysis indicated that a high proportion of variances was high-quality information on well-designed medical websites. explained by the predictors, there is still a need to further To assist patients in adopting simple searches and becoming consider other predictors or confounding factors, such as severity advanced explorers, there is a need to provide better information of illness and accessibility of medical resources, which may tools and quality content for them to surf the internet full of rich influence how patients use online health information. information and many pitfalls [47]. While conducting a heuristic search, patients sometimes reject credible websites with Conclusion high-quality content due to poor visual appeal and unclear Although there are challenges for laypeople, who are not interface design [12]. In other words, well-designed websites medical experts, and who do not have a university degree to built by medical professionals containing a clear interface and properly access and evaluate the credibility and accuracy of quality health information can draw the attention of patients health information retrieved from the internet [10,22], and lead them to access trustworthy information while looking understanding their online health information search strategies up health information on the internet. and use of such information may help health care professionals Meanwhile, the results of the interaction and curvilinear analyses better know how to lead their patients to appropriately search suggested that the elaboration strategy is a more recommendable for and communicate about online health information with approach than the match strategy through which patients are medical experts. Certainly, the internet is an essential tool more likely to use online health information to consult with through which patients may approach the low-cost wealth of their doctors or others about their health-related problems. To health information; however, it is an additional source of health stimulate patients’ online health information search strategies information, which should not necessarily replace traditional in more advanced ways, it has been suggested that advancing health information offered by health care professionals [9]. patients’ eHealth literacy (ie, ability to search, locate, evaluate, Based on the findings of this study, we provided practical integrate, and apply electronic health information) may support suggestions in several aspects. As suggested, the public them to conduct appropriate information search strategies, justify population and patients were encouraged to gather health reliable and useful information, and use such information in an information from multiple sources, including medical experts’ effective manner [5,45]. advice, as well as alternative opinions from the internet [7,25]. In summary, this study acknowledges how patients without a It has been indicated that patients use online medical information university degree search for health information over the internet, to integrate with advice from friends, family, and physicians in how they share the information with doctors and others, and order to confidently make their medical decisions [12]. how to guide them to accurately use the information sources. According to the results of this study, patients without a As patients have better access to additional medical advice over university degree should be supported to obtain more exposure the internet and can discuss such information with health care to online health information through both complex and simple professionals, they are expected to be more involved in search approaches, which in turn may induce them to consult appropriate health information and engaged in their medical medical experts about such information. In addition, it was decision making. suggested that health care providers should recognize that their Acknowledgments This work was, in part, financially supported by the Institute for Research Excellence in Learning Sciences of the National Taiwan Normal University (NTNU) through the Featured Areas Research Center Program within the framework of the Higher Education Sprout Project by the Ministry of Education (MOE) in Taiwan. In addition, the authors are thankful for the research funding offered by the Ministry of Science and Technology (MOST), Taiwan (Grant MOST 110-2628-H-002 -004 -MY2 and MOST 108-2511-H-003 -004 -MY3). We also thank all those involved in this research, including the patients who replied to the questionnaires and the research assistants who helped with collecting the questionnaires. Authors' Contributions Y-LC contributed to the study design, developed the instruments, analyzed the research data, and also drafted the main text of this paper. C-CT contributed to constructing the research model. He also gave opinions and interpretations to explain the results of the statistical analysis. J-CL developed the instruments and contributed to the study design. In addition, he assisted in delivering and collecting the questionnaires and provided opinions on the results of the statistical analysis. https://www.jmir.org/2022/9/e29609 J Med Internet Res 2022 | vol. 24 | iss. 9 | e29609 | p. 8 (page number not for citation purposes) XSL FO RenderX JOURNAL OF MEDICAL INTERNET RESEARCH Chiu et al Conflicts of Interest None declared. Multimedia Appendix 1 Details about the questionnaire and its validation. [DOCX File , 17 KB-Multimedia Appendix 1] Multimedia Appendix 2 Cover letter describing informed consent. [DOCX File , 13 KB-Multimedia Appendix 2] References 1. Prestin A, Vieux SN, Chou WS. Is online health activity alive and well or flatlining? Findings from 10 years of the Health Information National Trends Survey. J Health Commun 2015 Jul;20(7):790-798. [doi: 10.1080/10810730.2015.1018590] [Medline: 26042588] 2. Fox S, Duggan M. Health Online 2013. 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J Gen Intern Med 2002 Mar;17(3):180-185 [FREE Full text] [doi: 10.1046/j.1525-1497.2002.10603.x] [Medline: 11929503] Abbreviations AVE: average variance extracted CR: composite reliability ICS: Information Commitment Survey OHIU: Online Health Information Utilization PLS-SEM: partial least squares-structural equation modeling Edited by G Eysenbach; submitted 15.04.21; peer-reviewed by J Taylor, W Pian; comments to author 28.06.21; revised version received 25.08.21; accepted 06.03.22; published 02.09.22 Please cite as: Chiu YL, Tsai CC, Liang JC J Med Internet Res 2022;24(9):e29609 URL: https://www.jmir.org/2022/9/e29609 doi: 10.2196/29609 PMID: ©Yen-Lin Chiu, Chin-Chung Tsai, Jyh-Chong Liang. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 02.09.2022. This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on https://www.jmir.org/, as well as this copyright and license information must be included. https://www.jmir.org/2022/9/e29609 J Med Internet Res 2022 | vol. 24 | iss. 9 | e29609 | p. 11 (page number not for citation purposes) XSL FO RenderX

Journal

Journal of Medical Internet Research – JMIR Publications

Published: Sep 2, 2022

Keywords: decision making; eHealth literacy; information search strategy; internet; patient; information-seeking behavior; laypeople; online health information; patient communication

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