The paradox of source preference, online seeking, and timing of seeking
This study indicated that the offline was the primary source of medical information for more than half of Chinese urban patients. It was consistent with the finding of a previous study that used the China 2017 HINTS data . However, Guangzhou Community Health Survey 2013 showed that 26.2% of the urban population used health practitioners as their primary source of health information . The share of the internet option was the highest for female adults  and middle-aged urban residents in eastern China  when they could choose more than one health information source channel. Therefore, the findings on health information source preference in China were inconsistent. The inconsistency could be explained by the differences in where and when the survey was conducted, who was surveyed, and how the question was measured. Despite the inconsistency in China, previous studies conducted in many other countries like the U.S. indicated that the internet was their primary source of health information [7, 20, 41].
This study also indicated a difference in the timing of medical information seeking between China and many other countries. More than half of Chinese patients (54.54%) sought medical information online before and after the medical visit. It was concluded that most Chinese had sought medical information online before the medical visit (91.35%) rather than after the visit (63.19%). However, more online health information seekers in foreign countries sought information after the visit rather than before the visit [30, 34].
Despite the differences in source preference and the timing of information seeking, there was no significant difference in online health information seeking. It was found that in each HINTS survey year (2007–2018), the majority of the U.S. adults (a range of 69.8%–81.5%) had ever sought health or medical information, and 68.9% across survey years reported using the internet first in their most recent health information seeking . This study found that 78.19% of urban adults had ever sought medical information online. A cross-sectional survey conducted on rural adults in Zhejiang Province in 2015 showed that 40.60% of internet users had sought health information via the internet during the past year . This inconsistency could be explained by the difference in when the survey was conducted and who was surveyed. This study indicated a paradox in source preference, online medical information seeking, and the timing of online seeking between China and many other countries.
The special characteristics of China’s health information technology industry
The paradox of findings on source preference, online information seeking, and the timing of seeking, could be explained by the special characteristics of China’s health information technology industry. There are structural differences in the health information technology industry in China and Western countries. Website/app/WeChat public accounts are three primary modalities through which China’s health-related entities deliver their online health services to their consumers. China’s health websites/apps/WeChat public accounts primarily provide online service types such as health information and knowledge, in-person medical visit appointment scheduling, virtual consultation, and virtual visits.
Virtual consultations differ from virtual visits in service scope and health coverage in China . China’s direct-to-consumer telemedicine development lagged behind many Western countries, especially the United States. Only after the National Health Commission of China issued specific regulation schemes for online medical diagnosis and treatment (the equivalent of virtual visits) and internet hospitals in 2018 , did virtual visits and internet hospitals grow tremendously. Before the issuing of the regulation schemes, virtual consultation was one of the most prevalent service types of direct-to-consumer telemedicine in China. The Communication Administration-licensed health websites/apps deliver virtual consultation services to users. However, they are not allowed to diagnose and prescribe treatments for patients. The Health Commission-licensed internet hospitals and virtual visit service providers deliver virtual visit services for non-first-visit patients.
With the help of telemedicine technology, patients can consult with the physician virtually and visit the physician virtually. Consequently, the online source was more likely to become the primary source of health information for internet users in Western countries such as the United States. Due to the development lag of virtual consultations and virtual visits, the offline source was still the primary source of health information for Chinese internet users. Meanwhile, as the offline source (primarily referred to as doctors) was the primary source of health information, in-person visits were the essential way for Chinese patients to obtain medical information.
There were structural differences in the health website/app service composition between China and Western countries. In-person visit online appointment scheduling was the core service type delivered by almost all medical websites/apps/WeChat public accounts in China. Due to the absence of an effective referral system, Chinese patients usually bypassed primary hospitals and directly accessed higher-level hospitals . Previous research has also found that Chinese patients had the highest awareness and usage of in-person medical visit appointments and medical fee payments, among all types of online health information services . The finding that 91.35% of Chinese patients had sought medical information before the visit indicated that preparing for a visiting appointment was one of the most important motivations for China’s online medical information seekers.
In addition to providing in-person visit online appointment scheduling, most of China’s medical websites/apps also provided health/medical information and knowledge for laypersons. However, the health/medical information most of China’s medical websites/apps/WeChat public accounts offered was much less comprehensive and systematic than those of their foreign counterparts, since many of their counterparts provided medical encyclopedia for laypersons according to health topics. Very few of China’s health websites provided medical encyclopedias for their consumers. Comprehensive and systematic health information and knowledge primarily satisfied the consumer’s need to expand knowledge and improve the understanding of the information received after a medical visit and the symptom checks before the medical visit. The underpinning role of in-person visit online appointment scheduling and the limited provision of health/medical information and knowledge have demonstrated that most of China’s health website/app service composition primarily aimed to solve the problems of in-person visit accessibility and convenience.
The abovementioned structural differences could explain the paradox of source preference, online information seeking, and the timing of online seeking between China and other countries. Due to the development lag of virtual visits and virtual consultations, the offline source was still China’s patients’ primary source of medical information, and in-person visits were still the essential way for them to access medical information. In-person visit online appointment scheduling was consequently a core service of most of China’s health websites/apps. In-person visit online appointment scheduling empowered Chinese patients to access the in-person visit conveniently, so the proportion of Chinese who had ever sought medical information online was very close to that of the United States. However, China’s online health information seekers’ motivations differed from the U.S. seekers. The United States’ online health information seekers had various motivations, such as preparing for the visit and expanding the understanding of the information received after the visit. China’s health information seekers went online primarily to prepare for an in-person visit appointment.
Predictors of online medical information seeking behavior
This study indicated that China’s adults with a higher education level, higher income level, young, active in internet use, living in high-income cities were more likely to be active online medical information seekers (using the online as their primary source of medical information) and online medical information seekers (having ever sought medical information online). Most predictors were consistent with the findings of prior research. A systematic literature review and network analysis identified that the most central predictors of HISB were education, age, gender, financial income, and health condition . A meta-analysis found that internet use and demographic factors such as age, gender, education, income, and race were significant predictors of OHIS .
Individuals with higher income and education levels usually had higher demands for high-quality and diverse health information and services; therefore, they were more likely to be active online medical information seekers and online medical information seekers. Information technology, including health information technology, was usually more friendly to young generations and active internet users; therefore, they were more likely to be active online medical information seekers and online medical information seekers. Females were more likely to be family caregivers , and therefore, they were more likely to seek health information online for themselves and their family members.
This study indicated that China’s patients in medium-income and low-income level cities were less likely to be active online medical information seekers and online medical information seekers. By dividing the literature into two subgroups of high-income countries/areas and low-income countries/areas, Zhao et al. used a meta-analysis to confirm that national economic development level differences had a moderating effect on users’ adoption behavior of online health . Lu et al. also confirmed the differences in health information seeking behaviors and source preferences between China population and the U.S. population . However, few previous studies have examined the direct effect of regional economic development differences on health information seeking behavior.
The significant direct impact of regional economic development on health information seeking behavior showed that the development of the online health information technology industry was limited by national/regional economic development. The literature indicated that a wider economic environment was one of the factors associated with the effective implementation of large-scale health information technology . Compared with high-income regions, low-income and medium-income regions were less likely to have sufficient financial resources to develop health information technologies.
This study indicated that most sociodemographic factors were not significantly associated with the timing of online medical information seeking. Females were more likely to seek medical information online before and after the visit. As females were more likely to be family caregivers, they were more likely to prepare for the visiting appointment and expand their knowledge of the treatment and the care for themselves and their family members. Individuals aged 56–65 were more likely than those aged 18–29 to seek medical information online after the visit. One possible explanation was that they were more likely to have information overload problems during the visit, so they needed to expand their understanding of the information received after the visit.
Limitations and future studies
This study has several limitations. First, as the survey was conducted in cities of Zhejiang Province, it was not a nationally representative survey. There are significant provincial differences in China, and I will further the study by conducting surveys in provinces with different income levels in the future. Second, there are significant urban-rural divide in China, and I will extend the research by surveying the rural population. Third, the survey was conducted before the outbreak of COVID-19, while the outbreak brought structural changes to China’s health information industry and consumer behavior toward virtual visits and virtual consultations. Future research should measure the effect of the outbreak of COVID-19 on the direct-to-consumer telemedicine development and health information seeking behavior in China.