This paper describes Internet use for health information and the online behaviors and skills among college students in Guangdong—the most populous province of China. Our study revealed the most popular search engines, websites, and social media among Chinese college students; their perceived OHI literacy; their OHI seeking behaviors including their motivation and reasons for seeking OHI, health decision making and information management; and the benefits and risks from seeking OHI.
There are some studies recently published on OHI in China. One focus group qualitative study with 27 college students in a mid-sized university in Shanxi Province [
16] reported the sources of health information and the search behaviors of Chinese undergraduate students. Another study with Chinese college students focused on online mental health information seeking [
17] and showed that the participants were sensitive to the quality of search platform service, rather than the information quality. Although the findings of these studies have partially exposed the OHI-seeking behaviors of college students, with their sample size and study topic limitations, they could not reflect the real situation in a larger population of Chinese college/university students like in this study.
OHI-seeking behaviors
College students in English-speaking countries seek health information via two common platforms —via multiple search engines (e.g. Google, Bing, or Yahoo) or social media (e.g. Facebook or Twitter) [
18]. Chinese college students in this study, however, mainly used Baidu search engine and WeChat social media application exclusively in Chinese, which illustrates that regardless of differences in language and search platforms, search strategies among university students are similar [
16,
19,
20]. As reported in previous studies [
11,
12], among Chinese college students, females were more likely to go online for health information.
Reasons for Chinese college students seeking OHI are varied. More than 60% of the respondents went online for self-diagnosis or self-medication. Self-diagnosis is not encouraged as it causes undue anxiety in the patients especially if they are cyberchondriacs (individuals who compulsively search for health information, triggering undue health anxiety) [
21], interferes with doctor-patient relationships [
22], and is potentially subject to financial exploitation by e-health organizations and pharmaceutical companies [
21,
22]. Self-diagnosing prodromal or early symptoms, however, may be helpful for those who would later consult their physicians to receive proper diagnosis and treatment. But many of our respondents intended to self-medicate themselves without a physician’s assistance, which is consistent with our previous findings that self-medication is prevalent among Chinese university students [
23,
24].
Self-medication has become a global health problem for its risks, such as treatment of misdiagnosed medical problems with over-the-counter medicines, adverse drug effects, drug interactions, dosage or treatment duration errors, and drug addiction or abuse [
24,
25].
More than 90% of respondents reported that they turned to online sources of health information for themselves as well as for others. This rate of proxy information seekers is extremely high compared to 50% in American health information seekers [
3]. One likely reason is that Chinese college students are more acquainted with technology than are their families and relatives.
The most concerning issue in China is that most health information hosted on the Chinese websites or social media is translated and doctored versions of primary information in English with translational errors, personal opinions, and commercial interest links to drug companies, health-related vendors and suppliers, hospitals, and physicians, rarely providing the primary source of information (unpublished data from our investigation on the evidence quality of two most sought health issues—H1N1 influenza prevention and hypertension treatment—in the 20 websites visited by the respondents); therefore, it is impossible, even for experienced medical professionals, to verify the quality (accuracy, completeness, reliability, currency) and authenticity of the information.
Without having sufficient knowledge and skills to judge the quality of OHI, which was reflected in their self-assessment, more than half of the respondents still would not only accept the information they retrieved but also share it with or recommend it to others. Since information seekers’ judgment on the OHI quality is reportedly highly subjective and influenced by personal beliefs [
7], college students involved in various OHI could become providers of medical misinformation [
26] or even online opinion leaders. These altogether suggest that the impact of any misinformation or disinformation shared or exchanged online can be exponential and thus significant for public health.
Another concern is cybersafety. Even though the Internet is a known place of hackers and fraudsters [
27], nearly 30% of the respondents were not cautious about hacking attacks or Internet frauds when browsing websites, and 20% of the respondents having fallen victim to cyber frauds, indicating their poor attitude towards cyber safety and lack of cybersecurity literacy (i.e., knowledge, skills, and attitudes towards recognizing cybersecurity risk).
OHI literacy competency
Health information literacy is conceived as a combination of health literacy and information literacy [
8]. The US Institute of Medicine (IOM) defines health literacy as “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions”. The health literacy rate of Chinese citizens in a nationwide study was only 14% in 2017 [
28], which was conducted after the Ministry of Public Health of China had launched Health Literacy Promotion Initiatives with “Health Literacy 66”, i.e., 66 health literacy goals for Chinese citizens, in 2016 [
29].
With such considerably low China’s health literacy rate, it is not surprising to observe inadequate health information literacy competency in this study, which is reflected by the fact that the majority of students were neither confident in the quality and trustworthiness of the online information nor satisfied with the searched results, and yet they would share the information with or recommend it to others. Those with poor OHI are at risk of succumbing to unsubstantiated misinformation and disinformation on unregulated websites. Even for health information literacy-competent information seekers, infodemic—an overabundance of information including misinformation—on the Internet could be overwhelming, confusing, and misleading.
Benefits and risks
Unquestionably, there are benefits and risks of OHI [
6]. While a mere minority of respondents in this study found the Internet unhelpful, the sought information appeared to be beneficial for many respondents at least regarding adopting a healthy living style and health-seeking behavior. On the other hand, with their heavy reliance on online information, many respondents were at high risk of health mismanagement, especially self-diagnosis and self-medication among those with perceived competency in OHI literacy (Fig.
3). Chinese female college students had a higher risk as they were more likely to seek OHI for self-diagnosis and self-medication.
One noteworthy aspect of OHI is its impact on the risk perception and health behaviors of information seekers with poor health information literacy. As reported in media outlets across the world, the current pandemic coronavirus disease 2019 (COVID-19) has seen incompliant and irrational public responses towards infection control and prevention measures in various countries. One of the likely reasons could relate to inadequate health literacy across the globe, which is represented by the fact that the health literacy rate of nearly half of all Europeans in 2013 [
30], 57% of American adults in 2016 [
31], and 86% of mainland Chinese in 2017 was inadequate [
28].
Need for effective interventions
Even with decade-long efforts to address citizen’s health literacy in many countries [
29], poor health literacy remains one of the most pressing public health issues globally. Therefore, some countries have taken enhanced actions to improve the situation; for example, the US’s Healthy People 2020 [
32] and the eHealth Action Plan 2012–2020 by the European Commission outline approaches to provide accurate, assessable, and actionable health information and promote OHI literacy [
4]. Chinese government as well launched Healthy China 2030 [
33], but specific actions or guidance for the netizens and authorities concerned are yet to come.
Despite its formidable task, monitoring and regulation of unsubstantiated OHI is an inevitable public health measure for any country. Given that OHI on Chinese websites is not firsthand and also unregulated, offering an official guide on how to find reliable health information by government agencies such as the one sponsored by the US Department of Health and Health Services [
34], promoting the Health on the Net Foundation Code of Conduct (HONcode) certification [
35], or providing a user-friendly and trustworthy OHI resource, similar to MedlinePlus [
36], for the general public and healthcare providers is required in China for its 829 million netizens [
1].
Limitations
This study had some limitations intrinsic to self-reported online surveys and specific to the complex nature of the Chinese Internet and netizen behaviors. Even though popular search engines, websites, and social media such as Google, YouTube, Facebook, Twitter, Instagram, and Snapchat are not available in China, Chinese netizens still can access them using illegal virtual private networks (VPNs). Therefore, our findings may not reflect their true online behaviors. It should also be cautious in interpreting the information-seeking behaviors of college students because only those with experience of searching OHI participated in this study.