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Approximately 42.5 million adults have been affected by mental illness in the United States in 2013, and 173 million people have been affected by a diagnosable psychiatric disorder in China. An increasing number of people tend to seek health information on the Web, and it is important to understand the factors associated with individuals’ mental health information seeking. Identifying factors associated with mental health information seeking may influence the disease progression of potential patients. The planned risk information seeking model (PRISM) was developed in 2010 by integrating multiple information seeking models including the theory of planned behavior. Few studies have replicated PRISM outside the United States and no previous study has examined mental health as a personal risk in different cultures.
This study aimed to test the planned risk information seeking model (PRISM) in China and the United States with a chronic disease, mental illness, and two additional factors, ie, media use and cultural identity, among college students.
Data were collected in both countries using the same online survey through a survey management program (Qualtrics). In China, college instructors distributed the survey link among university students, and it was also posted on a leading social media site called Sina Weibo. In the United States, the data were collected in a college-wide survey pool in a large Northwestern university.
The final sample size was 235 for the Chinese sample and 241 for the US sample. Media use was significantly associated with mental health information–seeking intentions in the Chinese sample (
Cultural identity and media use should be considered when evaluating the process of mental health information seeking or when designing interventions to address mental health information seeking.
In the United States, about 42.5 million adults have been affected by various kinds of mental illness in 2013, which means that 1 in 5 Americans have had a diagnosable mental disorder [
Moreover, Chinese culture has been known as a collectivistic culture, where group members traditionally put group interests and community values ahead of individual interests [
With the ubiquitous use of the internet (eg, used by more than 3 billion people throughout the world) [
There has been a fair amount of studies about health-related information seeking since the 1990s [
When proposing PRISM, Kahlor [
Although PRISM incorporates a number of constructs from various theories, it does not include the construct of media use. Media use can serve as a source of knowledge and provide important information; it can also be affected by knowledge needs and remind information seekers to stay alert. Previous research found media use to be a mediator in PRISM for predicting impersonal risk information seeking, specifically examining climate change [
Demographics, ideology, personality traits, and social persuasive effects influence media use [
The reinforcing spirals framework highlights the potential timeline and mechanisms for how media use might work. For example, a person who has had a family member experience depression might be primed to have certain attitudes and opinions. After seeing a commercial for a medication for depression, the person might be more likely to seek out additional information on signs and symptoms because of their own personal past experiences and also the information they were exposed to through the media.
A number of studies have shown that media use could influence perceived knowledge and intentions within the context of health [
Another factor not included in PRISM is cultural identity, which is identification with a particular cultural group [
Hofstede [
Chinese culture, as a typical Asian culture, is known as highly collectivistic with value placed on group members’ opinions and a focus on cooperation in group settings [
On the basis of the previously discussed literature, we proposed the following research questions and hypotheses to help assess how the additional variables may impact behavioral intentions and the utility of the PRISM model at predicting behavioral intentions in different samples:
Research question (RQ) 1: Is PRISM a good fit for both the Chinese sample and the US sample of young adults on the topic of mental health information seeking?
Hypothesis 1: Media use will be positively related to seeking intention in the Chinese (H1a) and US (H1b) samples.
Hypothesis 2: Cultural identity will be negatively associated with mental health information seeking intentions among participants in the Chinese sample.
Hypothesis 3: Cultural identity will be positively associated with mental health information seeking intentions among participants in the US sample.
RQ2: What are the relationships between media use and perceived knowledge, perceived knowledge insufficiency, affective response, risk perception, attitude, and subjective norms in the PRISM in the mental health information seeking process in both samples?
RQ3: What are the relationships between cultural identity and variables of PRISM in the mental health information seeking process in both samples?
RQ4: Does the extended PRISM account for more variance in seeking intentions than the PRISM in both the Chinese (RQ4a) and US (RQ4b) samples?
Data were collected in both countries using the same online survey through a survey management program (Qualtrics). The studies were similar in all aspects, except during the recruitment phase. Participants in the United States were recruited from a college participation system called Sona, a cloud-based subject pool. Participants in China were recruited from 2 universities in China and a social media site. Although the methods differ, both provided a sample of college students that was obtained as a convenience sample. These differences in recruitment were due, in part, to logistical issues. The researchers did not have access to a participant pool in China but wanted a comparable population of college students in the same age range. The University Institutional Review Board reviewed the study proposal, and the project was determined to be exempt for both samples.
In China, 2 college instructors in 2 different universities distributed the anonymous survey link to their students using online class announcements and the survey link was also posted on a leading social media site called Sina Weibo to ensure an equivalent sample size. Sina Weibo is often seen as the “Chinese Twitter” and is a microblogging website in China. The questionnaire was translated into Chinese and was cross-examined by an English instructor of a university in China to verify whether the 2 survey versions were consistent. Two students volunteered to pretest the survey, and the completion time was around 15 min. Respondents needed to be 18 years or older to participate. One researcher posted the study description including study information, target population, survey link, and incentive information on Sina Weibo, and snowball sampling was used to distribute the survey link. At the beginning of the online survey, students needed to give their consent to participate in the study by selecting “I am 18 or older and agree to participate.” An incentive of CNY ¥260 (US $37.02) or an equivalent prize was provided in the form of a random drawing. At the end of the survey, participants were provided with another link to enter their email address for a chance to win the incentive. The email addresses were only used for the draw, and participants could not be identified by either the researchers or the instructors. The data collection lasted for about a month, and the completion rate was 77.6%. Incomplete questionnaires and surveys that took less than 2 min to complete were not included in the final analysis.
In the United States, the data were collected in a college-wide subject pool (Sona) in a large Northwestern university. Respondents were recruited among undergraduate students from different majors, and participants were offered extra credit for participating in the study. Participants signed up in Sona and then were directed to the survey in Qualtrics. Participants needed to give consent before they could proceed to the main questionnaire. The data collection process lasted less than 2 months. The completion rate was 96.78%. Students had options for alternate assignments to receive similar credit for their courses. Questionnaires that were incomplete and took less than 2 min to finish were not included in the final analysis.
We used the existing measures of attitude toward seeking, subjective norms, perceived seeking control, perceived current knowledge, risk perception, affective response, perceived knowledge insufficiency, and seeking intent from Kahlor [
Seven 7-point scale statements were used to measure respondents’ attitude toward seeking mental health information. Questions asked whether seeking mental health–related information was “bad” or “good,” “unhelpful” or “helpful,” “worthless” or “valuable,” “unproductive” or “productive,” “harmful” or “beneficial,” “foolish” or “wise,” and “not useful” or “useful.” Items were averaged to create a scale (United States: alpha=.95, mean 5.91, SD 1.11; China: alpha=.90, mean 5.56, SD 0.97).
Five 5-point Likert-type items measured the degree of agreement with statements regarding subjective norms (eg, “Most people who are important to me think that I should seek information about risks to my mental health.”) Items were averaged to create a scale (United States: alpha=.92, mean 2.81, SD 1.13; China: alpha=.91, mean 2.62, SD 1.03).
Four 5-point Likert-type items measured the degree of agreement with statements regarding perceived seeking control (eg, “I can readily access all the information about risks to my mental health that I need”). Items were averaged to create a scale (United States: alpha=.90, mean 3.47, SD 0.91; China: alpha=.91, mean 3.23, SD 0.98).
Three 11-point items measured risk perception related to mental health (0=not at all and 10=extremely) with the following statements: “How serious are the current threats to your mental health?” “How likely are you to have some mental health issues in the next year?” and “If you were to have some mental health issues in the next year, how serious do you think it would be?” Items were averaged to create a scale (United States: alpha=.88, mean 3.86, SD 2.31; China: alpha=.88, mean 5.32, SD 2.30).
Two 5-point Likert-type items asked respondents to indicate their degree of worry and fear. The statements were “Current risks to my mental health are scary” and “Current risks to my mental health are worrisome.” The items were averaged to create a scale (United States: alpha=.94, mean 2.39, SD 1.26; China: alpha=.89, mean 2.76, SD 1.14).
A statement measured perceived current knowledge by asking respondents the following: “Rate your mental health risk knowledge on a scale of 0 to 100, where zero means knowing nothing about risks to your mental health and 100 means knowing everything you could possibly know about risks to your mental health” (United States: mean 57.48, SD 24.30; China: mean 64.09, SD 18.06).
The measurement of sufficiency threshold asked the following: “Think of that same 0 to 100 scale again. This time, estimate how much knowledge you need to deal adequately with risks to your mental health. You might feel you need the same, more, or possibly even less information about this topic. Using a scale of zero to 100, how much information would be sufficient for you” (United States: mean 66.14, SD 23.45; China: mean 74.92, SD 17.34).
Five 5-point Likert-type items measured seeking intent (eg, “I plan to seek more information about risks to my mental health in the near future”). Items were averaged to create a scale (United States: alpha=.97, mean 2.90, SD 1.07; China: alpha=.94, mean 2.98, SD 1.01).
We adapted Brossard and Nisbet’s [
We measured cultural identity with Usborne and Taylor’s [
As we wanted to examine a college student sample across both countries, we only used those who were college students in the both samples. As the measurements were used in former studies and have high reliability (high Cronbach alpha), we computed the items to create one variable for each construct and then conducted path analyses in Mplus version 7.11 to evaluate the paths and model fit. The models included gender as a control variable.
After data cleaning, each sample had more than 200 participants complete the survey (United States: N=241; China: N=235). In the US sample, more than one-third of the sample reported being male (n=83) and less than three-quarters, female (n=158). Participants’ ages ranged from 18 to 32 years (mean 20 years, SD 1.97). Almost two-thirds of the respondents (n=160) reported being white and >10.0% (n=27) as Asian. In the Chinese sample, almost 90.0% (n=209) were female. Respondents ranged from 18 to 27 years (mean 21 years, SD 7.98). Basic descriptive results of the variables are shown in
Basic descriptive results.
Variable | United States, mean (SD) | China, mean (SD) | Range |
Attitude toward seeking | 5.91 (1.11) | 5.56 (0.97) | 1-7 |
Seeking-related subjective norms | 2.81 (1.13) | 2.62 (1.03) | 1-5 |
Perceived seeking control | 3.47 (0.91) | 3.23 (0.98) | 1-5 |
Risk perception | 3.86 (2.31) | 5.32 (2.30) | 0-10 |
Affective response | 2.39 (1.26) | 2.76 (1.14) | 1-5 |
Perceived current knowledge | 57.48 (24.30) | 64.09 (18.06) | 0-100 |
Perceived knowledge insufficiency | 66.14 (23.45) | 74.92 (17.34) | 0-100 |
Seeking intentions | 2.90 (1.07) | 2.98 (1.01) | 1-5 |
Media use | 3.34 (1.17) | 3.47 (1.22) | 1-7 |
Cultural identity | 5.68 (1.89) | 5.33 (1.67) | 0-10 |
For the Chinese sample, the replicated PRISM did not have a good fit, whereas the extended model with 2 additional variables, attention to media and cultural identity, had a good model fit. The replicated PRISM of the US participants did not have a good model fit, whereas the extended PRISM of the US sample had an acceptable model fit (see
Summary of model fit.
Model | Chi-square ( |
Root mean squared error of approximation | Comparative Fit Index | Tucker-Lewis Index |
China PRISMa | 55.4 (2.41) | 0.078 | 0.91 | 0.89 |
China Extended PRISM | 57.1 (1.59) | 0.050 | 0.96 | 0.93 |
US PRISM | 90.1 (3.91) | 0.110 | 0.77 | 0.70 |
US Extended PRISM | 75.4 (2.09) | 0.067 | 0.92 | 0.86 |
aPRISM: Planned Risk Information Seeking Model.
Some significant paths of Kahlor’s [
The paths and standardized coefficients of the replicated PRISM of the US sample are presented in
The planned risk information seeking model of the Chinese sample. Dashed lines denote hypothesized nonsignificant paths. The model includes effects of control variables, which are not displayed. (.000) represents significant path coefficients at the .001 level and (.01), at the .05 level.
The planned risk information seeking model of the US sample. Dashed lines denote hypothesized nonsignificant paths. The model includes effects of control variables, which are not displayed. (.000) represents significant path coefficients at the .001 level and (.01), at the .05 level.
The Chinese extended model with media use and cultural identity are shown in
In addition, attitude toward seeking (β=.15;
The replicated Chinese PRISM accounted for 35.9% of the variance in information seeking intention, whereas the extended model in the Chinese sample accounted for 41.4% of the variance in information seeking intention, answering RQ4a.
The extended planned risk information seeking model of the Chinese sample. Dashed lines denote hypothesized nonsignificant paths. The model includes effects of control variables, which are not displayed. (.000) represents significant path coefficients at the .001 level and (.01), at the .05 level.
In the US extended PRISM (see
In addition, media use was significantly associated with subjective norms (β=.20;
In the US sample, the PRISM accounted for 30.6% of the variance in information seeking intention, whereas the extended model accounted for 40.3% of the variance in information seeking intention. So RQ4b, which asked whether the extended PRISM accounted for more variance in seeking intention than the PRISM in the US sample, was answered.
The extended planned risk information seeking model of the US sample. Dashed lines denote hypothesized nonsignificant paths. The model includes effects of control variables, which are not displayed. (.000) represents significant path coefficients at the .001 level and (.01), at the .05 level.
In this study, we tested the PRISM model in a sample of US and Chinese college students in the context of mental health. We then added additional variables to the model and compared results across cultures. In terms of the model, the original PRISM model was not a great fit with our data in either samples. Consistent with the results of Kahlor [
The extended PRISM that we tested included 2 additional variables, ie, media use and cultural identity, and had a better model fit than the PRISM in both the US and Chinese samples. An important finding in this study is the role of media use in PRISM. Our finding is inconsistent with Ho et al’s [
Another contribution of this study was that cultural identity significantly predicted seeking intention, perceived knowledge insufficiency, risk perception, and subjective norms related to information seeking in both samples, which contributes to the extended PRISM in predicting personal risk. However, cultural identity negatively predicted seeking intention in both samples, which indicates that lower levels of identification of the cultural group is associated with higher levels of seeking intention toward mental health information seeking. We predicted that cultural identity would have opposite effects on the Chinese and US participants’ information seeking intentions based on the assumption that mental health problems are stigmatized in China while less so in the United States. However, the results showed that people who are less identified with the cultural values regarding mental health issues in their cultures are more likely to seek mental health information, which suggests that mental health issues are stigmatized to some extent in both samples.
Cultural identity is positively related to self-esteem and well-being [
Overall, we found that media use and cultural identity can be two variables useful for predicting seeking intentions regarding personal risks such as mental health. With 2 additional variables added in the PRISM, variance accounted for in seeking intentions by the models increased in both samples. Owing to the specificity of the context, the 2 samples with different cultural backgrounds have distinguished results in some perspectives, which again emphasize the importance of culture. We believe that the traditional thought of mental health in China played an important role in explaining these findings as mental health is still a stigmatized issue in China. In addition, the mental health counseling system is not as thoroughly developed in China [
These findings can be used in campaigns promoting the seeking of mental health information and can help researchers and practitioners understand the process of personal risk information seeking, especially when the topic has a strong cultural context. The findings also have theoretical implications. Some of the paths are inconsistent from past research regarding personal cancer risk using PRISM [
This study is not without limitation. First, we used a convenience sample for both populations. The results of using the sample of college students may not generalize to other subgroups, although it does allow us to assess relationships between key constructs. Second, this study used cross-sectional data and only measured variables at a specific time point without the ability to decide causality. Third, due to a relatively small sample size, we chose to conduct a path analysis. Further studies could conduct a structural equation model. In addition, as our context is a personal risk and often a stigmatized issue, future studies could use a more general concept to examine the role of media use and cultural identity. Moreover, the spiral role of media use should be explored in the future as media use can also influence risk perception and other variables such as attitudes and subjective norms.
Overall, this study extended the PRISM to include important aspects that could vary based on culture, including cultural identity and media use. We found that both cultural identity and media use were associated with information-seeking intentions regarding mental health topics and including the variables in the PRISM allowed the model to account for additional variance in information-seeking intentions. These results can help researchers and health practitioners as they continue to grapple with sensitive health and risk issues, such as mental health. Potential patients may benefit from the findings, changing the progression of the disease and how it is treated, leading to more appropriate treatment solutions.
planned risk information seeking model
risk information seeking and processing
None declared.