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The Internet has increasingly become a popular source of health information by connecting individuals with health content, experts, and support. More and more, individuals turn to social media and Internet sites to share health information and experiences. Although online health information seeking occurs worldwide, limited empirical studies exist examining cross-cultural differences in perceptions about user-generated, experience-based information compared to expertise-based information sources.
To investigate if cultural variations exist in patterns of online health information seeking, specifically in perceptions of online health information sources. It was hypothesized that Koreans and Hongkongers, compared to Americans, would be more likely to trust and use experience-based knowledge shared in social Internet sites, such as social media and online support groups. Conversely, Americans, compared to Koreans and Hongkongers, would value expertise-based knowledge prepared and approved by doctors or professional health providers more.
Survey questionnaires were developed in English first and then translated into Korean and Chinese. The back-translation method ensured the standardization of questions. Surveys were administered using a standardized recruitment strategy and data collection methods.
A total of 826 participants living in metropolitan areas from the United States (n=301), Korea (n=179), and Hong Kong (n=337) participated in the study. We found significant cultural differences in information processing preferences for online health information. A planned contrast test revealed that Koreans and Hongkongers showed more trust in experience-based health information sources (blogs:
This research found significant cultural differences in information processing preferences for online health information. Further discussion is included regarding effective communication strategies in providing quality health information.
The Internet has increasingly become a popular source of health information by connecting individuals with health content, experts, and support. According to the Pew Internet & American Life Project [
Research identifies two types of health information: expertise-based information produced by medical professionals and experience-based information based on laypersons’ subjective first-hand experiences of health and illness [
Limited studies exist explaining such inconsistent findings—a gap remains in research examining possible factors affecting trust in expertise- versus experience-based health information available online. Further, it remains unknown whether clear cultural differences exist in perceptions about experience-based health information compared to expertise-based information sources. Because online health information seeking occurs worldwide [
Although various factors may affect differences across the United States, Korea, and Hong Kong, cultural theories provide a useful framework for understanding differences in the perception and seeking behaviors of online health information. According to Nisbett [
Several empirical studies have demonstrated Americans and Europeans are more likely to use logical, analytic, and rule-based reasoning, whereas East Asians are more likely to use intuitive, experience-based, and holistic reasoning [
Although not directly studied within a health-related context, extant research has demonstrated how cultural orientation influences people’s preferences for online information and trust building on the Internet across cultures. Access to experience-based information through word-of-mouth has been deemed an influential factor affecting consumer behaviors. Many marketing scholars have demonstrated the important role of customer reviews (ie, experience-based information) in e-commerce among various cultures [
Taken together, the previously mentioned studies imply that experience-based information shared online is becoming important across cultures and that Easterners rely more on it compared to Westerners. Particularly, findings imply that Easterners tend to show stronger trust toward those within their network (a whole), which is relevant to one of the core aspects of holism [
Based on the previous empirical studies and the theoretical arguments that examine cultural differences in trust of online information, the goal of this study is to investigate cultural differences in trust of online health information. Specifically, we predict that Koreans and Hongkongers, compared to Americans, would be more likely to trust and use experience-based information shared in social Internet sites such as social media and online support groups. Conversely, Americans would be more likely to value health information prepared or approved by doctors or professional health providers (expertise-based information) than Koreans and Hongkongers.
Therefore, hypothesis 1a is Koreans and Hongkongers, compared to Americans, will report higher levels of trust in experience-based online health information sources (eg, social networking sites [SNS], blogs, online support groups). In contrast, hypothesis 1b is Americans, compared to Koreans and Hongkongers, will report higher levels of trust in expertise-based online health information sources (eg, WebMD).
Hypothesis 2a is Koreans and Hongkongers, compared to Americans, will use experienced-based sites more frequently. In contrast, hypothesis 2b is Americans, compared to Koreans and Hongkongers, will use expertise-based sites more frequently.
In addition, we investigated cultural differences in the goals of online health information-seeking behavior to better understand preferences for experience-based and expertise-based information. Studies have suggested that several goals of online health information-seeking behavior differ before and after seeing a physician. Before meeting their doctor, patients go online mainly to (1) assess the need for consultation, (2) decide which physician to see, or (3) prepare for consultation [
Individuals seek, find, and share health information online not only for themselves, but also for others, such as friends and family. Surprisingly, approximately half of all online health searches are performed on behalf of someone else [
Although not much is known about the social aspects of online health information-seeking behaviors among Asians, some evidence suggests Asians may seek online health information on behalf of family members more frequently compared to Americans. Studies have found Asian and Latin American adolescents possess greater responsibilities in assisting, respecting, and supporting their families than their European counterparts [
The survey questionnaire for this study was developed in English first and then translated into Korean and Chinese. The back-translation method ensured the standardization of questions. In 2012, surveys were distributed to college students living in metropolitan areas of three different countries: the United States (Milwaukee, WI), South Korea (Seoul), and Hong Kong. Participants were solicited from large lectures at each university (University of Wisconsin-Milwaukee, Yonsei University, and City University of Hong Kong) using a standardized recruitment procedure and data collection method. Participation was voluntary. Required IRB documents were prepared and approved. An informed consent form was provided at the beginning of the survey.
The frequency of using particular health information sources—blogs, support groups, SNS (eg, Facebook, Twitter), and professional health information websites (eg, WebMD, Centers for Disease Control and Prevention [CDC])—was measured with a range from 1 (never) to 7 (every day). Health information sources were modified for each country, allowing the list to reflect the most popular and representative sources, and subsequently verified by media statistics and media researchers living in each country. The level of trust in each health information source was also based on a 7-point Likert scale ranging from 1 (not at all) to 7 (completely).
Four major goals of seeking online health information were developed and assessed based on a study by Caiata-Zufferey et al [
The extent to which participants sought information on behalf of family members was measured by the level of agreement with the following statement: “Searching information for sick family members is an important family responsibility.” Responses were obtained using a 7-point Likert-type scale (1=strongly agree, 7=strongly disagree).
To test the hypotheses and research question, a series of 1-way ANOVAs were conducted followed by a planned contrast test. Before ANOVA testing, Levene’s test was conducted to check whether or not equal variance could be assumed. When the group variances were statistically equal, ANOVA
A total of 826 native residents (301 in the United States, 179 in Korea, and 337 in Hong Kong) were included in the analysis (see
Descriptive statistics of the participants.
Characteristics | United States |
South Korea |
Hong Kong |
Total |
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Male | 168 (56.4) | 69 (39.9) | 245 (74.9) | 482 (60.4) |
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Female | 130 (43.6) | 104 (60.1) | 82 (24.9) | 316 (39.6) |
Age (years), mean (SD) | 21.56 (4.66) | 22.05 (2.36) | 20.24 (2.88) | 21.11 (3.63) | |
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Has Internet access | 294 (98.0) | 176 (100)) | 331 (98.2) | 801 (98.5) |
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Internet access through smartphone | 177 (58.8) | 176 (99.4) | 321 (95.3) | 674 (82.8) |
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Daily Internet use, n (%) | 296 (98.7) | 175 (98.9) | 330 (97.9) | 801 (98.4) |
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Hours using Internet/day, mean (SD) | 4.44 (0.16) | 2.92 (0.31) | 4.38 (0.16) | 4.23 (2.82) |
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Ever used Internet for health information, n (%) | 270 (90.6) | 167 (93.3) | 261 (80.6) | 698 (87.1) |
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Frequency of online health information seeking, mean (SD)a | 3.56 (1.11) | 3.69 (1.13) | 3.20 (0.89) | 3.45 (1.06) |
a Frequency of online seeking measured with 7-point scale (1=never, 2=once a year, 3=couple of times a year, 4=once a month, 5=once a week, 6=2-3 times a week, and 7=every day).
A majority of individuals from each country had Internet access at home or at their primary place of residence, such as a dorm (United States: 98.0%, 294/300; Korea: 100%, 176/176; Hong Kong: 98.2%, 331/337). A majority of participants from Korea (99.4%, 176/177) and Hong Kong (95.3%, 321/336) reported they had mobile phones with an Internet connection, whereas only 58.8% (177/301) of the US sample reported having mobile phones with an Internet connection. Regardless of cultural background, most participants used the Internet daily (United States: 98.7%, 296/300; Korea: 98.9%, 175/177; Hong Kong: 97.9%, 330/337). In terms of the hours spent on the Internet each day, American university students used the Internet most often (mean 4.44, SD 0.16 hours) followed by students from Hong Kong (mean 4.38, SD 0.16 hours) and Korea (mean 2.92, SD 0.31 hours). Most participants reported using the Internet for health information and the frequency of online heath information seeking was from a couple of times a year to once a month.
The first hypothesis tested whether cultural differences exist in trust associated with the types of online health information sources, in particular experience-based online health information and expertise-based sites (see
Cultural differences of the trust level in each source of online health information.
Internet sites | Country, mean (SD) | Brown-Forsythea | Planned contrast | ||||||
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United States | Korea | Hong Kong |
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Level 1: US vs KOR/HK | Level 2: KOR vs HK | ||
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SNS | 2.30 (1.43) | 3.16 (1.18) | 3.79 (1.04) | 101.21 (2, 621) | 001 | 11.36 (467) | .001 | 5.76 (316) | .001 |
Blog | 2.86 (1.39) | 4.04 (1.04) | 3.90 (1.04) | 74.91 (2, 652) | .001 | 11.21 (452) | .001 | 1.29 (352) | .20 |
Online support groups | 3.34 (1.49) | 3.34 (1.18) | 5.32 (1.06) | 210.48 (2, 627) | .001 | 9.30 (456) | .001 | 17.78 (323) | .001 |
Online professional heath sitesb | 5.54 (1.25) | 5.39 (1.10) | 5.61 (1.13) | 1.82 (2, 654) | .16 | .42 (511) | .68 | 1.98 (355) | .05 |
a For 1-way ANOVA test, we used Brown-Forsythe because equal variances could not be assumed. Thus,
b Expertise-based source.
Cultural differences in the frequency of using each source of online health information.
Internet sites | Country, mean (SD) | Brown-Forsythea | Planned contrast | ||||||
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United States | Korea | Hong Kong |
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Level 1: US vs KOR/HK | Level 2: KOR vs HK | ||
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SNS | 2.16 (1.51) | 2.27 (1.21) | 3.07 (1.52) | 32.25 (2, 697) | .001 | 4.51 (529) | .001 | 6.06 (405) | .001 |
Blog | 2.50 (1.47) | 3.61 (1.37) | 2.85 (1.25) | 34.61 (2, 622) | .001 | 6.67 (515) | .001 | 5.82 (326) | .001 |
Online support groups | 2.26 (1.54) | 2.15 (1.16) | 2.74 (1.46) | 12.40 (2, 698) | .001 | 1.64 (497) | .10 | 4.70 (409) | .001 |
Online professional heath sitesb | 4.68 (1.62) | 2.66 (1.37) | 3.08 (1.45) | 122.57 (2, 664) | .001 | 15.02 (508) | .001 | 360.02 (360) | .003 |
a For 1-way ANOVA test, we used Brown-Forsythe because equal variances could not be assumed. Thus,
b Expertise-based source.
Hypothesis 2a-b investigated a usage pattern of each online health information source, in particular experience-based sites and expertise-based sites (see
Cultural differences in the frequency of using each source of online health information.
Source and value labela | United States | Korea | Hong Kong | ||||
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n (%) | Cumulative % | n (%) | Cumulative % | n (%) | Cumulative % | |
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1 | 132 (48.5) | 48.5 | 55 (33.1) | 33.1 | 51 (18.6) | 18.6 |
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2 | 64 (23.5) | 72.1 | 53 (31.9) | 65.1 | 59 (21.5) | 40.1 |
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3 | 17 (6.3) | 78.3 | 25 (15.1) | 80.1 | 52 (19.0) | 59.1 |
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4 | 31 (11.4) | 89.7 | 24 (14.5) | 94.6 | 64 (23.4) | 82.5 |
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5 | 19 (7.0) | 96.7 | 9 (5.4) | 100.0 | 33 (12.0) | 94.5 |
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6 | 5 (1.8) | 98.5 |
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10 (3.6) | 98.2 |
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7 | 4 (1.5) | 100.0 |
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5 (1.8) | 100.0 |
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1 | 92 (17.8) | 17.8 | 9 (2.4) | 2.4 | 38 (2.6) | 2.6 |
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2 | 67 (27.5) | 45.4 | 37 (4.8) | 7.2 | 85 (9.2) | 11.7 |
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3 | 39 (22.7) | 68.0 | 27 (18.6) | 25.7 | 60 (13.2) | 24.9 |
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4 | 45 (19.0) | 87.0 | 40 (39.5) | 65.3 | 64 (48.4) | 73.3 |
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5 | 20 (9.7) | 96.7 | 45 (30.5) | 95.8 | 21 (23.8) | 97.1 |
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6 | 7 (2.2) | 98.9 | 9 (4.2) | 100.0 | 5 (2.9) | 100.0 |
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7 | 2 (1.1) | 100.0 |
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1 | 123 (45.7) | 45.7 | 59 (35.3) | 35.3 | 64 (23.5) | 23.5 |
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2 | 57 (21.2) | 66.9 | 59 (35.3) | 70.7 | 76 (27.9) | 51.5 |
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3 | 30 (11.2) | 78.1 | 21 (12.6) | 83.2 | 46 (16.9) | 68.4 |
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4 | 32 (11.9) | 90.0 | 21 (12.6) | 95.8 | 52 (19.1) | 87.5 |
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5 | 12 (4.5) | 94.4 | 7 (4.2) | 100.0 | 24 (8.8) | 96.3 |
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6 | 12 (4.5) | 98.9 |
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6 (2.2) | 98.5 |
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7 | 3 (1.1) | 100.0 |
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4 (1.5) | 100.0 |
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1 | 11 (4.1) | 4.1 | 41 (24.8) | 24.8 | 41 (15.0) | 15.0 |
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2 | 17 (6.3) | 10.3 | 45 (27.3) | 52.1 | 66 (24.1) | 39.1 |
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3 | 35 (12.9) | 23.2 | 29 (17.6) | 69.7 | 62 (22.6) | 61.7 |
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4 | 58 (21.4) | 44.6 | 32 (19.4) | 89.1 | 59 (21.5) | 83.2 |
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5 | 53 (19.6) | 64.2 | 15 (9.1) | 98.2 | 33 (12.0) | 95.3 |
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6 | 59 (21.8) | 86.0 | 3 (1.8) | 100.0 | 8 (2.9) | 98.2 |
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7 | 38 (14.0) | 100.0 |
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5 (1.8) | 100.0 |
a For value label: 1=never, 2=rarely, 3=sometimes, 4=moderately, 5= fairly often, 6=often, and 7=always.
b “Professional” indicates professional online health sites, such as WebMD and CDC. This is also an expertise-based source.
The result of the overall test for expertise-based information was significant (Brown-Forsythe
Regarding the third hypothesis, the result of the 1-way ANOVA test for online health information–seeking behavior on behalf of family was significant (Brown-Forsythe
Research question 1 asked whether cultural differences existed in the goals of online health information–seeking behaviors. Findings indicated significant cultural differences in the goals of health maintenance (Brown-Forsythe
More individuals are turning to social media to share health information and experiences these days. While online, individuals can easily and efficiently find other individuals who have similar health concerns or experiences. This study sheds light on the experience-based health information commonly shared on social sites, such as blogs, SNS, and online health support groups. Specifically, we examined individuals’ trust in experience-based health information presented on social sites compared to their trust in expertise-based health information found on professional sites. As expected, peer-to-peer exchange of experience-based health information online was popular: 51.5% of Americans, 76.9% of Koreans, and 81.4% of Hongkongers reported using SNS for health information, whereas 66.2% of Americans, 94.6% of Koreans, and 86.1% of Hongkongers reported using blogs for health information.
Although social Internet sites function as important online health information sources across cultures, we found significant cultural differences in preferences for types of information found and shared on the Internet. Based on theoretical underpinnings of Nisbett’s cultural theory, we hypothesized Koreans and Hongkongers, compared to Americans, would be more likely to trust and use social Internet sites, such as blogs, social support groups, and SNS. The hypothesis was supported. In addition, as we expected, the study’s findings indicate that expertise-based health information sites are used more frequently by Americans than Koreans and Hongkongers (no country-level differences were detected in terms of trust in expertise-based health information sites). The findings resonate with previous studies demonstrating that Asian cultures, which are predominantly holistic, are more likely to value experience-based information, whereas Western cultures are more likely to value logical expertise- and rule-based information. In addition, we also observed cultural differences in searching for information on behalf of family members. As expected, participants from holistic cultures (Korea and Hong Kong) sought information for family members more than participants from an analytic culture (United States) did.
Regarding information-seeking behaviors in the offline context, Americans generally trusted and used offline sources, including both experience- and expertise-based sources. Further, pairwise comparison revealed that Hongkongers trusted information from laypersons, such as family and friends, more strongly than Americans did, whereas Americans trusted information from health professionals more significantly than Hongkongers. However, no differences were found between Americans and Koreans. When engaging in actual information seeking, Hongkongers consulted both family/friends and health professionals significantly less than did both Americans and Koreans. This finding may suggest the Internet’s strengths in tailoring to meet individual needs and cognitive preferences. The Internet is a proficient medium for audience segmentation in that it efficiently finds people who hold similar interests or concerns [
This study offers several practical implications for the dissemination of health information online. First, our study confirms that experience-based health information is widely used across countries; therefore, professional health information providers should consider actively taking advantage of social media and similar applications when sharing information with patients (eg, providing examples of patients’ experiences). Leveraging social media or similar tools as the source of experience-based information can “increase access to, enliven users’ experiences with, and enrich the quality of the information available” [
Second, online health interventions targeting individuals from different cultural orientations should not discount differential cognitive preferences in locating effective communication strategies for providing health information online. Experience-based information can be strategically and differentially incorporated into expertise-based health information to target audiences from diverse cultures. For example, when designing health-related social media forums with expert moderators, stronger focus on rich, experience-based information should be included for Korean and Hong Kong audiences, whereas the expert role should be more pronounced for American audiences. Because perceived credibility is related to intentions to revisit websites [
Third, the current findings about cultural differences may also inform interactions in the offline context. Previous research with Korean participants illustrates that even though participants indicated a preference for physician interactions, only 10.9% of respondents with a health concern actually went to the physician first, whereas 48.6% indicated they consulted the Internet [
Lastly, we found, across cultures, Internet users possess different motivations for seeking health information online based on differing goals for the outcome of the search. Koreans and Hongkongers seek online health information primarily to make critical health decisions, such as whether to follow doctor’s instructions, whereas the primary goal of health information seeking for Americans is health maintenance and preparation for the medical consultation. In other words, inaccuracy or the incorrect application of information may be more critical among Koreans and Hongkongers than Americans due to goal differences. Incorporating health professionals’ comments in health-related blogs, SNS, and support group sites may be imperative for East Asian populations. To address Americans’ concerns related to health maintenance and medical consultation, key messages related to preventive health can be beneficial in promoting quality of life and cutting medical costs for Americans [
Although the study offers several significant contributions, some limitations exist. First, although this study presents data gathered from three different countries, research should focus on extending this work to other countries. Even though both Korea and Hong Kong are considered to be holistic cultures, significant differences still exist. This finding suggests that even though a dichotomous approach to culture bears differences, the cultural separation in beliefs extends beyond two categories. Future studies should include individual-level comparisons in addition to a country-level investigation. Additionally, factors affecting national differences, such as the level of institutional trust [
Second, the sample consisted of participants who were relatively young, with a mean age of 21 years (SD 3.63); participants in all three countries were university students. Given that young people remain less likely to encounter serious health problems, the patterns observed in online health information-seeking behaviors may not replicate in older age groups. Similarly, because a sample of university students represents a highly educated group, individuals with different education levels or technology efficacy may demonstrate different perceptions and behaviors. For example, previous research indicates that individuals who have lower education levels are not as likely to search for health information online [
Lastly, in addition to a theory-based explanation for cultural differences between the East and West, other factors might influence individual’s perceptions of online health information credibility and trust across cultures. For example, given the higher degree of ethnic homogeneity of the population in Korea and Hong Kong compared to the United States, it is plausible that individuals in these countries are more likely to be exposed to online health information generated by “people like them.”
In conclusion, this study contributes to the literature on online health information–seeking behaviors by demonstrating a tendency for Koreans and Hongkongers to trust and use experience-based knowledge to a greater extent than Americans. Additionally, Koreans and Hongkongers are more likely to search for health information on behalf of family members, resonating with a holistic worldview. Cultural differences also exist in the goals associated with online health information. Asians engage in health information–seeking behavior to make health care decisions, an extremely important finding to consider when evaluating the credibility and trust of health information online. To achieve health and facilitate positive, peer-to-peer communication of health information, clinicians and scholars should continue to be aware of online health information–seeking behaviors before and after medical consultation and provide patients with avenues to navigate online sources. Similarly, health messages should also focus on cultural orientation to provide quality health care.
social networking site
None declared.