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Health information seeking in the Web 2.0 age: Trust in social media, uncertainty reduction, and self-disclosure
Computers in Human Behavior 56 (2016) 289e294
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Health information seeking in the Web 2.0 age: Trust in social media, uncertainty reduction, and self-disclosure Wan-Ying Lin a, *, Xinzhi Zhang b, Hayeon Song c, Kikuko Omori d a
City University of Hong Kong, Hong Kong School of Professional Education & Executive Development, The Hong Kong Polytechnic University, Hong Kong c University of Wisconsin-Milwaukee, United States d St. Cloud State University, United States b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 12 January 2015 Received in revised form 24 August 2015 Accepted 28 November 2015 Available online xxx
Self-disclosure is purposeful disclosure of personal information to other people, and online selfdisclosure on health-related issues is important in promoting a safe and sound online health environment. The present study investigates the ways in which youths engage in online self-disclosure of healthrelated issues in the Web 2.0 age. We examine how self-disclosure is driven by the level of trust in social media and uncertainty reduction actions, i.e., seeking information to verify and challenge the prescription after visiting medical professionals. Comparative surveys were conducted in Hong Kong, South Korea, and the U.S., respectively. Compared to their counterparts in South Korea and the U.S., youths in Hong Kong were significantly more likely to disclose personal health issues with peers online. Hong Kong youths also held the highest level of trust towards health-related information on social media. Meanwhile, both the level of trust in social media and uncertainty reduction actions were positively associated with online self-disclosure. © 2015 Elsevier Ltd. All rights reserved.
Keywords: Social media Online self-disclosure Trust Uncertainty reduction Online health information seeking
1. Introduction New media have become important channels for seeking and sharing health-related information. Scholars believe that new media, especially social media, have great potentials to support information searching and decision-making on self-care and health-related issues (Miller & Bell, 2012). A recent report suggests that more than a third of U.S. adults would turn to the internet to search the medical condition they or someone else might have (Fox & Duggan, 2013). Nonetheless, the proliferation of new media in health care also poses several problems and challenges. First, the quality of the health-related information on social media is far from perfect, which are often inconsistent, misleading, and not trustworthy (Pant et al., 2012). A few studies have indicated that peoples' trust of online health information is a major factor that influences their follow-up actions after information search, for example, to further discuss health-related topics, or to be willing to share health information (Hou & Shim, 2010; Metzger & Flanagin,
* Corresponding author. Department of Media and Communication, City University of Hong Kong, 83 Tat Chee Avenue, Hong Kong. E-mail address: [email protected] (W.-Y. Lin). http://dx.doi.org/10.1016/j.chb.2015.11.055 0747-5632/© 2015 Elsevier Ltd. All rights reserved.
2011; Ye, 2011; Yun & Park, 2010). Second, people are now more likely than before to engage in online health information seeking to verify or even challenge the prescriptions offered by medical professionals, especially when they experience incongruence or uncertainties about a certain prescription. Based on a national survey of 3,014 adults living in the U.S., the Pew research report indicated that 60% of the so-called “online diagnosers” (i.e., those who consulted online media for health-related issues) living with chronic conditions ever talked with a medical professional about the information they found online, and about one in five of this group of people reported that the clinician offered a different opinion (Fox, Duggan, Rainie, & Purcell, 2013). Therefore, in order to promote a friendly online health environment, it is important that users feel comfortable to engage and disclose themselves in the cyberspace. Focusing on the concept of self-disclosure, the present study seeks to examine the extent to which trust in social media and uncertainty reduction strategies would lead to self-disclosure. Self-disclosure is purposeful disclosure of personal information to another person. Self-disclosure on health issues is important because it is a strategy that helps consumers to manage health-related information (Checton & Greene, 2015). As proposed by Frattaroli (2006), self-disclosure has health benefits and is closely associated with physical and mental well-
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being. Hence, we ask: To what extent would people disclose their personal health issues with others online? How do trust in online health information sources and uncertainty reduction actions influence online self-disclosure of health-related issues? 2. Self-disclosure in the cyberspace Self-disclosure is defined as an “act of making yourself manifest, showing yourself so others can perceive you” (Jourard, 1971, p. 19). It can be considered as one of the strategies for individuals to manage the information acquired (Checton & Greene, 2015). Selfdisclosure was found to play an important role in the online communication process. For instance, in the development of a romantic relationship, self-disclosure helped individuals to collect information about the communicators and to project future interactions (Gibbs, Ellison, & Lai, 2011). Meanwhile, Wang, Jackson, and Zhang (2011) found that online communication via instant messaging was positively correlated to online self-disclosure for adolescents. They also discovered that for boys and for those who experienced high social anxiety, online communication via instant messaging had a greater impact on online self-disclosure. The proliferation of social media provides new channels for sharing and self-disclosing health-related information (Rutsaert et al., 2013). As noted by Checton and Greene (2015), to take care of a chronic illness, one needs to manage information on the illness, while sharing health information with others is a crucial part of such information management strategies. The reason is that, as argued by Walton and Rice (2013), self-disclosure was a reciprocal benefit-exchanging process where, after one's disclosure, an equal or greater disclosure from the others was expected. Other studies found that people disclosed themselves to others because they believed the disclosure would bring returns in terms of encouragement and empowerment (Zolowere et al., 2008). Self-disclosure generates pre-commitment between the people, which in turn encourages “a leap of faith and reciprocal self-disclosure” (Henderson & Gilding, 2004, p. 487) and facilitates interpersonal communication. A recent survey suggested that, of the 8% of internet users in the U.S. who indicated that they had made healthrelated posts online, nearly half of them said they were sharing their personal health experience (Fox, 2014). For those who had two or more chronic conditions, they were more likely to post a health-related question or share their own personal health experience online in any way, compared to their counterparts who had fewer chronic conditions. Hence, self-disclosure plays an important role in the online health information seeking process. 3. Trust in social media, self-disclosure, and health outcomes The level of trust in communication channels and institutions has been found to be an important predictor of self-disclosure, as trust reduces perceived risks and costs associated with disclosing private or sensitive information (Chen & Sharma, 2013). For example, a secondary data analysis of the 2009 Pew survey in the U.S. revealed that the level of trust in individuals and institutions was associated with the level of trust in the internet, whereas trust of the internet positively predicted one's disclosure of identifiable information online (Mesch, 2012). Similar findings were shown in Dutch internet users, where trust in government organizations strongly influenced individuals' disclosure of personal data among the users (Beldad, van der Geest, de Jong, & Steehouder, 2012). In a similar vein, scholars discovered that self-disclosure of health-related issues was promoted by trust, a feeling of safety, and an obligation to others (Zolowere et al., 2008). Paiva and colleagues (2011) found that self-disclosure on sensitive health issues, i.e., the HIV-related issue, required a high level of mutual trust, and the
disclosure happened more frequently among close partners and those who were also HIV-positive (Paiva, Segurado, & Ventura Filipe, 2011). A study carried out in rural China suggested that trust was rated as the first reason for people to disclose sensitive issues, followed by a feeling of needing help, and a feeling of close friendship (Ding, Li, & Ji, 2011). Using the data from the 2007 Health Information National Trends Survey, Hou (2010) found that trust in online health information was a significant predictor of conducting health-related activities via the internet. Similarly, Huh, DeLorme, and Reid (2005) discovered that the higher level of trust in online drug-related information, the more likely one would engage in three types of behaviors, including communicating doctors, talking with others, and seeking more health-related information. Additionally, Chen and Sharma (2013) drew upon the social capital theory and concluded that the level of trust in other users on social networking sites was positively associated with the degree of selfdisclosure. Hence, based on the above discussion, we propose that: H1: Trust in social media is positively associated with selfdisclosure online. 4. Uncertainty reduction and self-disclosure As stated earlier, the trend of consumer-centered health services would lead to an increasing number of health-related consumers via new media (Yun & Park, 2010). For example, nearly one-third of internet users reported that they had consulted online reviews or rankings of health care services or treatments (The Internet and Health, 2012). When there is a lack of sufficient information from traditional medical professionals, uncertainties arise and online media provide individuals with an opportunity for further information seeking and sharing so as to evaluate, verify, or even challenge the prescriptions (Fox et al., 2013). Theoretically, cross-checking health information through both online and offline channels is similar to the “online disinhibition effect” (Suler, 2004). The disinhibition effect states that people would “say and do things in cyberspace that they would not ordinarily say and do in the face-to-face world. They loosen up, feel less restrained, and express themselves more openly” (Suler, 2004). Uncertainties lead to communication practices such as informationseeking behaviors, while people tend to observe and check other people's behaviors by participating in a number of strategies to seek more information about others (Berger, 1979). In other words, uncertainty reduction actions are likely to generate self-disclosure. As researchers discovered in studying the online dating process, “online daters may be more likely to seek confirmatory information about potential partners early in the process, as a basis for calibrating their own self-disclosure” (Gibbs et al., 2011). Similarly, Courtois and colleagues (2012) found that both passive uncertainty reduction strategies (i.e., passively looking at acquaintances' online profile to get more information) and active uncertainty reduction strategies (i.e., actively communicating with the acquaintances) were positively associated with the degree of self-disclosure to the acquaintances (Courtois, All, & Vanwynsberghe, 2012). Meanwhile, their studies found that uncertainty reduction actions positively mediated the effect of social anxiety on the level of certainty about the respondents' friends (Courtois et al., 2012). Gibbs and colleagues (2011) also found that the frequency of taking uncertainty reduction actions were affected by concerns of online dating, such as security and privacy, whereas uncertainty reduction actions were positively linked to self-disclosure (Gibbs et al., 2011). Informed by the above empirical findings, we argue that, if an individual experiences uncertainties after visiting a doctor, he/she is more likely to open up him/herself to discuss personal healthrelated issues. As mentioned earlier, self-disclosure is a benefitdriven activity. If one has experienced inconsistencies with the
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medical services, i.e., having high frequency of alternative information seeking behaviors, one will be more likely to disclose oneself in the cyberspace in order to gain or exchange for more health-related information to reduce the uncertainty. Hence, we propose that: H2: Uncertainty reduction actions are positively associated with self-disclosure online. 5. Research contexts Three societies are chosen for this study, i.e., Hong Kong, South Korea, and the U.S., where internet penetration rates are among the highest in the world, and an East-West comparison is possible. Statistics show that people's online health information seeking behaviors are different in these societies. For example, 59% of the U.S. internet users reported that they ever looked online for health information in the past year (Fox & Duggan, 2013). In Hong Kong, barely a third of a representative sample responded that they had sought health information via the internet, while the figure was far lower than conventional media such as print media (66.2%) and television (61.4%) (Wang, Viswanath, Lam, Wang, & Chan, 2013). In South Korea, while people are actively seeking health information in general, studies suggest that “health-related information and services have a lower profile than other services due to a perceived lack of librarian expertise in searching and evaluating health resources” (Oh, Lauckner, Boehmer, Fewins-Bliss, & Li, 2013, p. 2072). Despite of the discrepancies, several recent reports clearly point out that the type of peer-to-peer healthcare has become a trend. Particularly, in the U.S., the Pew research report showed that, among online health information seekers, 16% in the past year tried to find others who might share similar health concerns. Over one quarter of internet users had read or watched someone else's experience about health or medical issues in the past year (The Internet and Health, 2012). While comparative statistics in South Korea and Hong Kong are fairly limited, we propose a research question to address the cross-society differences in the healthrelated communication practices: RQ1: What is the relationship between trust, uncertainty reduction actions, and self-disclosure across three societies? 6. Data and method
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6.2.2. Predictor variables 6.2.2.1. Trust in social media. The measurement of the trust of social media-based health information sources followed previous studies on how individuals evaluated the trustworthiness of health information online (Richardson et al., 2012). It included how much trust one had on blogs, BBS, and social networking sites, with each measured by a seven-point scale ranging from “very trustful” to “not trustful at all” (M ¼ 3.34, SD ¼ 1.13, Cronbach's Alpha ¼ .82). 6.2.2.2. Uncertainty reduction actions. To measure uncertainty reduction strategies, we adopted the findings by Brashers et al. (2000) that how individuals coped with uncertainties in health information seeking. We constructed an index of five informationseeking or information-appraisal strategies that online health information seekers might use to verify or challenge the diagnosis or prescription after visiting the medical professionals. The respondents were asked a set of five questions ranging from 1 ¼ never, and 7 ¼ always below a leading question: “when would you use the internet,” followed by “after seeing my doctor to validate consultation,” “to find different options for treatment,” “to find alternative health options that may be less invasive than what they do,” “to see if my prescribed medicine has any side effects that were not discussed at,” and “to seek alternative treatment or medicinal information (e.g., herbal medicine).” They were therefore averaged to form an index that represented the amount of disagreement experienced after visiting the professional medical services (Cronbach's Alpha ¼ .91). We also performed a factor analysis for the items. The factor analysis indicated that all the items were loaded on one single factor (Eigenvalue ¼ 3.73, variance explained ¼ 74.52%, Х2 ¼ 2292.33, df ¼ 10, p < .001). These tests suggest that the scale is reliable and robust. The scale has a mean score of 3.16 (SD ¼ 1.40). 6.2.3. Control variables We also included age, gender, and perceived general health condition, as control variables. The reason was that previous studies suggested that these individual characteristics would lead to self-disclosure as well (Dindia, 1992; Gard, 1990; Papini et al., 1990). By including these variables, we limited the possibility that the relationships among our focal predictors and the dependent variable would be spurious.
6.1. Survey instruments and participants 7. Results The 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 then administered among college students living in the metropolitan areas in three different regions: the United States, South Korea, and Hong Kong in 2012. Participants were solicited from large lectures in each selected university using a standardized recruitment strategy and a data collection method. Participation was voluntary (n ¼ 789). 6.2. Measurements 6.2.1. Dependent variable 6.2.1.1. Online self-disclosure. Online self-disclosure was modified from the Self-Disclosure Amount subscale of the Revised Self Disclosure Scale (Wheeless & Grotz, 1976). It was measured by three items, each with a 7-point Likert-type scales (7 ¼ always; 1 ¼ never). The items read: “I do not discuss my health issues with others online” (reversely coded in later analysis), “I share my personal health information on the internet,” and “I offer my health experiences on the Internet to help others” (M ¼ 2.59, SD ¼ 1.20, Cronbach's Alpha ¼ .71).
7.1. Descriptive statistics A total of 789 participants (289 participants from the U.S., 172 participants from South Korea, and 328 participants from Hong Kong) were collected for the study. Among 789 participants, 39.29% were female. For the U.S. participants, 43.60% were female. For the South Korean sample, 59.88% were female. For the Hong Kong participants, 24.70% were female. Overall the participants' age ranged from 17 to 33, with an average of 20.80 and a standard deviation of 2.21. Comparatively, participants from Hong Kong were slightly younger (M ¼ 20.10, SD ¼ 1.67) than those in the other two societies (the U.S.: M ¼ 20.91, SD ¼ 2.50; South Korea: M ¼ 21.96, SD ¼ 2.10). In the U.S. sample, the majority of participants (83.39%) were Caucasians, followed by African Americans (5.88%), Asians (3.81%), and Hispanics/Latinos (2.42%). For Hong Kong and South Korea, local residents were nearly 100%. When asked about their health conditions, American participants were the least to report healthy (M ¼ 2.19, SD ¼ .89), followed by South Korea (M ¼ 2.84, SD ¼ 1.08), and Hong Kong (M ¼ 3.04, SD ¼ .99), where the answer option 1
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H2 stated that the frequency of uncertainty reduction actions after visiting the medical professionals is positively related to online self-disclosure. The results support H2 in all the sub-samples. Regarding our research question that addresses the crosssociety comparison, there are significant societal differences on the level of health-related self-disclosure online. Compared to their counterparts in Korea and the U.S., youths in Hong Kong were significantly more likely to disclose personal health issues with peers online (F (2,684) ¼ 31.21, p < .05). Particularly, the average level of online self-disclosure for the Hong Kong participants was 3.02 (SD ¼ 1.16), followed by South Korean (M ¼ 2.45, SD ¼ 1.08) and American respondents (M ¼ 2.24, SD ¼ 1.18). Meanwhile, trust in social media also varied across the three societies significantly (F (2,696) ¼ 74.13, p < .001), where Hong Kong youths held the highest level of trust towards the health information on social media (M ¼ 3.82, SD ¼ .88), followed by Korean (M ¼ 3.47, SD ¼ .88) and the U.S. respondents (M ¼ 2.75, SD ¼ 1.23). In terms of the uncertainty reduction actions, however, there was no significant cultural difference (F (2,678) ¼ 1.12, n.s.). The Hong Kong participants rated an average score of 3.23 (SD ¼ 1.37) in terms of uncertainty reduction actions, followed by the U.S. participants (M ¼ 3.18, SD ¼ 1.47) and South Korean participants (M ¼ 3.02, SD ¼ 1.32).
indicated a poor health condition and the answer option 5 indicated an excellent condition. In terms of internet access through smartphones, the majority of participants from South Korea (99.43%) and Hong Kong (95.25%) reported that they had smartphones with internet connections, but only 58.90% of the U.S. samples reported so. Among the samples, a large proportion of them (86.74%) reported that they had ever searched health information online whereas the rest did not. Particularly, 90.31% of the U.S. samples reported that they had ever searched health information online, whereas the percentage was 93.26% for the South Korean participants and 80.00% for the Hong Kong participants. The descriptive statistics of all variables for three sub-samples are presented in Table 1. 7.2. Hypothesis testing H1 predicts that the level of trust of health information sources on social media, i.e., BBS, blogs, social media, is positively associated with self-disclosure via online channels. The results from the OLS regression analysis predicting online self-disclosure are summarized in Table 2. Model 1 presents the regression analysis in all three societies, whereas Models 2 to 4 present results from the U.S., the South Korea, and the Hong Kong sub-sample, respectively. Models 1 to 3 reveal that the trust in social media was positively associated with self-disclosure online. H1 is supported. Specifically, a positive link between trust in social media and self-disclosure was found in the U.S. and the South Korean sub-samples, but not in the Hong Kong sample.
8. Discussion and conclusions Our major findings and contributions are three-fold. First, the study demonstrates that, even in the era of “Health 2.0,” when most people are switching to online sources for information, the
Table 1 The Descriptive Statistics of Key Variables in Three Societies (Mean with standard deviation in the parentheses). Overall sample (n ¼ 789) M Female (%) Age Perceived health condition Online Self-disclosure Trust in social media Uncertainty Reduction
39.29% 20.80 2.69 2.59 3.34 3.16
The U.S. Sub-Sample (n ¼ 289) S.D.
M
2.21 1.05 1.20 1.13 1.40
43.60% 20.91 2.19 2.24 2.75 3.18
The S. Korea sub-sample (n ¼ 172)
S.D.
M
2.50 .89 1.18 1.23 1.47
59.88% 21.96 2.84 2.45 3.47 3.02
The Hong Kong sub-sample (n ¼ 328)
S.D.
M
S.D.
2.10 1.08 1.08 .88 1.32
24.70% 20.10 3.04 3.02 3.82 3.23
1.67 .99 1.16 .88 1.37
Note: M. for Mean, S.D. for Standard Deviation.
Table 2 Standardized OLS regression coefficients predicting online self-disclosure in three societies.
Female Age Perceived health condition Trust in social media Uncertainty Reduction Actions U.S. (versus Hong Kong) S. Korea (versus Hong Kong) Observations Adjusted R2 R2 F Value
Model 1
Model 2
Model 3
Model 4
Overall sample
The U.S. Sub-Sample
The S. Korea sub-sample
The Hong Kong sub-sample
.044 (.091) .071 (.021) .034 (.044) .18*** (.045) .27*** (.033) .25*** (.12) .11** (.12) 634 .228 .237 F (7, 626) ¼ 27.76***
.073 (.14) .016 (.029) .049 (.076) .24*** (.063) .34*** (.050) e
.069 (.18) .17* (.043) .20** (.077) .17* (.11) .21* (.068) e
.030 (.17) .10 (.044) .0093 (.076) .092 (.083) .27*** (.056) e
e
e
e
234 .242 .258 F (5, 228) ¼ 15.84***
151 .149 .177 F (5, 145) ¼ 6.25***
249 .082 .101 F (5, 243) ¼ 5.43***
Standardized beta coefficients; Standard errors in parentheses; *p < .05,
**
p < .01,
***
p < .001.
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dynamics with professional medical services still plays an important role in facilitating one's self-disclosure of health concerns. While previous research reveals that both online and offline health information seekers would rely on traditional health care professionals (Cotten & Gupta, 2004), our study shows that real-world uncertainties would be offset by online self-disclosure and information seeking. Our study also provides a clearer picture of the dynamics between the offline professionals and online healthrelated communication practices. Second, while it is generally believed that the information provided on social media by peers, rather than by medical experts, might be misleading and less trustworthy (Pant et al., 2012), our study suggests that trust in social media-based information is a significant predictor of further health-related behavioral engagement. Earlier studies found that peer-to-peer videos were more effective in influencing peoples' attitudes and issue importance (Paek, Hove, Jeong, & Kim, 2011). In other words, information circulated among peers on social media generated larger cognitive effects. The reason is that “perceived similarity seems to be a more influential attribute than perceived expertise” (Paek et al., 2011). Even though we did not ask the respondents whom they shared information with for validation, findings from our study highlight the relationship between the evaluation of information and information seeking behaviors in the Web 2.0 environment. Third, from a comparative perspective, our study found that, while it is popular for the U.S. internet users to check out others' experiences about health-related issues (The Internet and Health, 2012), our respondents from two digital societies in Asia, i.e., Hong Kong and South Korea, ranked higher than those from the U.S. in the level of online self-disclosure. The finding is perplexing as Americans are generally believed to favor direct communication and tend to disclose more in the face-to-face interaction (Kim, 1994), whereas Confucian Asians prefer to keep things to themselves. The online disinhibition effect may offer an explanation. In other words, people may say or do things in the cyberspace that they would not ordinarily say or do in the face-to-face world (Suler, 2004). Previous research has suggested that computer-mediated communication, such as the internet, provides an alternative forum and opens up opportunities for users to express themselves that may be otherwise discouraged in the real world (Lin, Cheong, Kim, & Jung, 2010). Nevertheless, future studies may consider to investigate the extent to which cultural or structural contexts may affect the relationship between the evaluation of online information and one's self-disclosure, online and offline. Limitations exist. Firstly, while the present study focuses on the extent to which one discloses him/herself, it will be intriguing for future studies to examine what has been disclosed through the online platform. For example, Jamison-Powell et al. (2012) conducted a content analysis of Twitter messages on one particular type of health-related issue, i.e., insomnia, and found that Tweets with the word “insomnia” contained more negative health information than a random sample of Tweets. Meanwhile, Attrill and Jalil (2011) raised the concerns on the quality of self-disclosure. They found that CMC-based self-disclosure was merely superficial information, rather than information containing intimacy and personal details. Hence, a closer look into the contents of selfdisclosure would provide a better understanding of such benefit exchanging activities. Secondly, admittedly the explanatory power of the predictors in this study is moderate; it could be that other factors play a role in influencing one's decision to disclose him/ herself online. Scholars may consider to investigate the effect of other factors, especially psychological predispositions, in the process. For example, a lower concern for privacy may suggest more self-disclosure online (Taddei & Contena, 2013). Thirdly, while our study focused on university students, who are among the most
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active internet users, this sample selection limits the generalizability of our results. Future research may consider to study health information seeking behaviors by other populations, such as the elderly or high-risk groups (Flynn, Smith, & Freese, 2006; Miller & Bell, 2012). Lastly, the relationship between online self-disclosure and offline self-disclosure warrants more investigation in future studies. For instance, Skinner and colleagues (2006) found no differences in the style of self-disclosure between online support groups and face-to-face therapy users (Skinner & Latchford, 2006). However, Valkenburg and associates (2011) suggested that selfdisclosure online was used to rehearse offline self-disclosure skills (Valkenburg, Sumter, & Peter, 2011). More sophisticated research is needed before a conclusion can be drawn. Despite of the above limitations, our findings are important in advancing a better understanding of the relationship between trust in different sources of information, experiences with institutional professionals, and health-related behavioral outcomes. Author notes Wan-Ying Lin (Ph.D., University of Southern California) is an Associate Professor at the Department of Media and Communication, City University of Hong Kong. Xinzhi Zhang (Ph.D., City University of Hong Kong) is a Lecturer at the School of Professional Education and Executive Development at the Hong Kong Polytechnic University. Hayeon Song (Ph.D., University of Southern California) is an Associate Professor at the Department of Communication, University of WisconsineMilwaukee. Kikuko Omori (Ph.D., University of WisconsineMilwaukee) is an Assistant Professor at the Department of Communication Studies, St. Cloud State University. Disclosure This manuscript and all the authors have no conflict with any manufacturer of a product discussed in the manuscript to disclose. Acknowledgment Part of this work was supported by City University of Hong Kong under the Grant no. 9610224. References Attrill, A., & Jalil, R. (2011). Revealing only the superficial me: Exploring categorical self-disclosure online. Computers in Human Behavior, 27(5), 1634e1642. http:// dx.doi.org/10.1016/j.chb.2011.02.001. Beldad, A., van der Geest, T., de Jong, M., & Steehouder, M. (2012). Shall I tell you where I live and who I Am? factors influencing the behavioral intention to disclose personal data for online government transactions. International Journal of Human - Computer Interaction, 28(3), 163. Berger, C. R. (1979). Beyond initial interaction: Uncertainty, understanding, and the development of interpersonal relationships. Language and Social Psychology, 122e144. Brashers, D. E., Neidig, J. L., Haas, S. M., Dobbs, L. K., Cardillo, L. W., & Russell, J. A. (2000). Communication in the management of uncertainty: The case of persons living with HIV or AIDS. Communications Monographs, 67(1), 63e84. Checton, M. G., & Greene, K. (2015). Elderly patients' heart-related conditions: Disclosing health information differs by target. Psychology, Health & Medicine, 20(5), 594e604. Chen, R., & Sharma, S. K. (2013). Self-disclosure at social networking sites: An exploration through relational capitals. Information Systems Frontiers, 15(2), 269e278. http://dx.doi.org/10.1007/s10796-011-9335-8. Cotten, S. R., & Gupta, S. S. (2004). Characteristics of online and offline health information seekers and factors that discriminate between them. Social Science & Medicine, 59(9), 1795e1806. http://dx.doi.org/10.1016/j.socscimed.2004.02.020. Courtois, C., All, A., & Vanwynsberghe, H. (2012). Social network profiles as information sources for adolescents' offline relations. Cyberpsychology Behavior and Social Networking, 15(6), 290e295. http://dx.doi.org/10.1089/cyber.2011.0557. Dindia, K., & Allen, M. (1992). Sex differences in self-disclosure: A meta-analysis. Psychological Bulletin, 112(1), 106e124. http://dx.doi.org/10.1037/0033-
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Full length article
Health information seeking in the Web 2.0 age: Trust in social media, uncertainty reduction, and self-disclosure Wan-Ying Lin a, *, Xinzhi Zhang b, Hayeon Song c, Kikuko Omori d a
City University of Hong Kong, Hong Kong School of Professional Education & Executive Development, The Hong Kong Polytechnic University, Hong Kong c University of Wisconsin-Milwaukee, United States d St. Cloud State University, United States b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 12 January 2015 Received in revised form 24 August 2015 Accepted 28 November 2015 Available online xxx
Self-disclosure is purposeful disclosure of personal information to other people, and online selfdisclosure on health-related issues is important in promoting a safe and sound online health environment. The present study investigates the ways in which youths engage in online self-disclosure of healthrelated issues in the Web 2.0 age. We examine how self-disclosure is driven by the level of trust in social media and uncertainty reduction actions, i.e., seeking information to verify and challenge the prescription after visiting medical professionals. Comparative surveys were conducted in Hong Kong, South Korea, and the U.S., respectively. Compared to their counterparts in South Korea and the U.S., youths in Hong Kong were significantly more likely to disclose personal health issues with peers online. Hong Kong youths also held the highest level of trust towards health-related information on social media. Meanwhile, both the level of trust in social media and uncertainty reduction actions were positively associated with online self-disclosure. © 2015 Elsevier Ltd. All rights reserved.
Keywords: Social media Online self-disclosure Trust Uncertainty reduction Online health information seeking
1. Introduction New media have become important channels for seeking and sharing health-related information. Scholars believe that new media, especially social media, have great potentials to support information searching and decision-making on self-care and health-related issues (Miller & Bell, 2012). A recent report suggests that more than a third of U.S. adults would turn to the internet to search the medical condition they or someone else might have (Fox & Duggan, 2013). Nonetheless, the proliferation of new media in health care also poses several problems and challenges. First, the quality of the health-related information on social media is far from perfect, which are often inconsistent, misleading, and not trustworthy (Pant et al., 2012). A few studies have indicated that peoples' trust of online health information is a major factor that influences their follow-up actions after information search, for example, to further discuss health-related topics, or to be willing to share health information (Hou & Shim, 2010; Metzger & Flanagin,
* Corresponding author. Department of Media and Communication, City University of Hong Kong, 83 Tat Chee Avenue, Hong Kong. E-mail address: [email protected] (W.-Y. Lin). http://dx.doi.org/10.1016/j.chb.2015.11.055 0747-5632/© 2015 Elsevier Ltd. All rights reserved.
2011; Ye, 2011; Yun & Park, 2010). Second, people are now more likely than before to engage in online health information seeking to verify or even challenge the prescriptions offered by medical professionals, especially when they experience incongruence or uncertainties about a certain prescription. Based on a national survey of 3,014 adults living in the U.S., the Pew research report indicated that 60% of the so-called “online diagnosers” (i.e., those who consulted online media for health-related issues) living with chronic conditions ever talked with a medical professional about the information they found online, and about one in five of this group of people reported that the clinician offered a different opinion (Fox, Duggan, Rainie, & Purcell, 2013). Therefore, in order to promote a friendly online health environment, it is important that users feel comfortable to engage and disclose themselves in the cyberspace. Focusing on the concept of self-disclosure, the present study seeks to examine the extent to which trust in social media and uncertainty reduction strategies would lead to self-disclosure. Self-disclosure is purposeful disclosure of personal information to another person. Self-disclosure on health issues is important because it is a strategy that helps consumers to manage health-related information (Checton & Greene, 2015). As proposed by Frattaroli (2006), self-disclosure has health benefits and is closely associated with physical and mental well-
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being. Hence, we ask: To what extent would people disclose their personal health issues with others online? How do trust in online health information sources and uncertainty reduction actions influence online self-disclosure of health-related issues? 2. Self-disclosure in the cyberspace Self-disclosure is defined as an “act of making yourself manifest, showing yourself so others can perceive you” (Jourard, 1971, p. 19). It can be considered as one of the strategies for individuals to manage the information acquired (Checton & Greene, 2015). Selfdisclosure was found to play an important role in the online communication process. For instance, in the development of a romantic relationship, self-disclosure helped individuals to collect information about the communicators and to project future interactions (Gibbs, Ellison, & Lai, 2011). Meanwhile, Wang, Jackson, and Zhang (2011) found that online communication via instant messaging was positively correlated to online self-disclosure for adolescents. They also discovered that for boys and for those who experienced high social anxiety, online communication via instant messaging had a greater impact on online self-disclosure. The proliferation of social media provides new channels for sharing and self-disclosing health-related information (Rutsaert et al., 2013). As noted by Checton and Greene (2015), to take care of a chronic illness, one needs to manage information on the illness, while sharing health information with others is a crucial part of such information management strategies. The reason is that, as argued by Walton and Rice (2013), self-disclosure was a reciprocal benefit-exchanging process where, after one's disclosure, an equal or greater disclosure from the others was expected. Other studies found that people disclosed themselves to others because they believed the disclosure would bring returns in terms of encouragement and empowerment (Zolowere et al., 2008). Self-disclosure generates pre-commitment between the people, which in turn encourages “a leap of faith and reciprocal self-disclosure” (Henderson & Gilding, 2004, p. 487) and facilitates interpersonal communication. A recent survey suggested that, of the 8% of internet users in the U.S. who indicated that they had made healthrelated posts online, nearly half of them said they were sharing their personal health experience (Fox, 2014). For those who had two or more chronic conditions, they were more likely to post a health-related question or share their own personal health experience online in any way, compared to their counterparts who had fewer chronic conditions. Hence, self-disclosure plays an important role in the online health information seeking process. 3. Trust in social media, self-disclosure, and health outcomes The level of trust in communication channels and institutions has been found to be an important predictor of self-disclosure, as trust reduces perceived risks and costs associated with disclosing private or sensitive information (Chen & Sharma, 2013). For example, a secondary data analysis of the 2009 Pew survey in the U.S. revealed that the level of trust in individuals and institutions was associated with the level of trust in the internet, whereas trust of the internet positively predicted one's disclosure of identifiable information online (Mesch, 2012). Similar findings were shown in Dutch internet users, where trust in government organizations strongly influenced individuals' disclosure of personal data among the users (Beldad, van der Geest, de Jong, & Steehouder, 2012). In a similar vein, scholars discovered that self-disclosure of health-related issues was promoted by trust, a feeling of safety, and an obligation to others (Zolowere et al., 2008). Paiva and colleagues (2011) found that self-disclosure on sensitive health issues, i.e., the HIV-related issue, required a high level of mutual trust, and the
disclosure happened more frequently among close partners and those who were also HIV-positive (Paiva, Segurado, & Ventura Filipe, 2011). A study carried out in rural China suggested that trust was rated as the first reason for people to disclose sensitive issues, followed by a feeling of needing help, and a feeling of close friendship (Ding, Li, & Ji, 2011). Using the data from the 2007 Health Information National Trends Survey, Hou (2010) found that trust in online health information was a significant predictor of conducting health-related activities via the internet. Similarly, Huh, DeLorme, and Reid (2005) discovered that the higher level of trust in online drug-related information, the more likely one would engage in three types of behaviors, including communicating doctors, talking with others, and seeking more health-related information. Additionally, Chen and Sharma (2013) drew upon the social capital theory and concluded that the level of trust in other users on social networking sites was positively associated with the degree of selfdisclosure. Hence, based on the above discussion, we propose that: H1: Trust in social media is positively associated with selfdisclosure online. 4. Uncertainty reduction and self-disclosure As stated earlier, the trend of consumer-centered health services would lead to an increasing number of health-related consumers via new media (Yun & Park, 2010). For example, nearly one-third of internet users reported that they had consulted online reviews or rankings of health care services or treatments (The Internet and Health, 2012). When there is a lack of sufficient information from traditional medical professionals, uncertainties arise and online media provide individuals with an opportunity for further information seeking and sharing so as to evaluate, verify, or even challenge the prescriptions (Fox et al., 2013). Theoretically, cross-checking health information through both online and offline channels is similar to the “online disinhibition effect” (Suler, 2004). The disinhibition effect states that people would “say and do things in cyberspace that they would not ordinarily say and do in the face-to-face world. They loosen up, feel less restrained, and express themselves more openly” (Suler, 2004). Uncertainties lead to communication practices such as informationseeking behaviors, while people tend to observe and check other people's behaviors by participating in a number of strategies to seek more information about others (Berger, 1979). In other words, uncertainty reduction actions are likely to generate self-disclosure. As researchers discovered in studying the online dating process, “online daters may be more likely to seek confirmatory information about potential partners early in the process, as a basis for calibrating their own self-disclosure” (Gibbs et al., 2011). Similarly, Courtois and colleagues (2012) found that both passive uncertainty reduction strategies (i.e., passively looking at acquaintances' online profile to get more information) and active uncertainty reduction strategies (i.e., actively communicating with the acquaintances) were positively associated with the degree of self-disclosure to the acquaintances (Courtois, All, & Vanwynsberghe, 2012). Meanwhile, their studies found that uncertainty reduction actions positively mediated the effect of social anxiety on the level of certainty about the respondents' friends (Courtois et al., 2012). Gibbs and colleagues (2011) also found that the frequency of taking uncertainty reduction actions were affected by concerns of online dating, such as security and privacy, whereas uncertainty reduction actions were positively linked to self-disclosure (Gibbs et al., 2011). Informed by the above empirical findings, we argue that, if an individual experiences uncertainties after visiting a doctor, he/she is more likely to open up him/herself to discuss personal healthrelated issues. As mentioned earlier, self-disclosure is a benefitdriven activity. If one has experienced inconsistencies with the
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medical services, i.e., having high frequency of alternative information seeking behaviors, one will be more likely to disclose oneself in the cyberspace in order to gain or exchange for more health-related information to reduce the uncertainty. Hence, we propose that: H2: Uncertainty reduction actions are positively associated with self-disclosure online. 5. Research contexts Three societies are chosen for this study, i.e., Hong Kong, South Korea, and the U.S., where internet penetration rates are among the highest in the world, and an East-West comparison is possible. Statistics show that people's online health information seeking behaviors are different in these societies. For example, 59% of the U.S. internet users reported that they ever looked online for health information in the past year (Fox & Duggan, 2013). In Hong Kong, barely a third of a representative sample responded that they had sought health information via the internet, while the figure was far lower than conventional media such as print media (66.2%) and television (61.4%) (Wang, Viswanath, Lam, Wang, & Chan, 2013). In South Korea, while people are actively seeking health information in general, studies suggest that “health-related information and services have a lower profile than other services due to a perceived lack of librarian expertise in searching and evaluating health resources” (Oh, Lauckner, Boehmer, Fewins-Bliss, & Li, 2013, p. 2072). Despite of the discrepancies, several recent reports clearly point out that the type of peer-to-peer healthcare has become a trend. Particularly, in the U.S., the Pew research report showed that, among online health information seekers, 16% in the past year tried to find others who might share similar health concerns. Over one quarter of internet users had read or watched someone else's experience about health or medical issues in the past year (The Internet and Health, 2012). While comparative statistics in South Korea and Hong Kong are fairly limited, we propose a research question to address the cross-society differences in the healthrelated communication practices: RQ1: What is the relationship between trust, uncertainty reduction actions, and self-disclosure across three societies? 6. Data and method
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6.2.2. Predictor variables 6.2.2.1. Trust in social media. The measurement of the trust of social media-based health information sources followed previous studies on how individuals evaluated the trustworthiness of health information online (Richardson et al., 2012). It included how much trust one had on blogs, BBS, and social networking sites, with each measured by a seven-point scale ranging from “very trustful” to “not trustful at all” (M ¼ 3.34, SD ¼ 1.13, Cronbach's Alpha ¼ .82). 6.2.2.2. Uncertainty reduction actions. To measure uncertainty reduction strategies, we adopted the findings by Brashers et al. (2000) that how individuals coped with uncertainties in health information seeking. We constructed an index of five informationseeking or information-appraisal strategies that online health information seekers might use to verify or challenge the diagnosis or prescription after visiting the medical professionals. The respondents were asked a set of five questions ranging from 1 ¼ never, and 7 ¼ always below a leading question: “when would you use the internet,” followed by “after seeing my doctor to validate consultation,” “to find different options for treatment,” “to find alternative health options that may be less invasive than what they do,” “to see if my prescribed medicine has any side effects that were not discussed at,” and “to seek alternative treatment or medicinal information (e.g., herbal medicine).” They were therefore averaged to form an index that represented the amount of disagreement experienced after visiting the professional medical services (Cronbach's Alpha ¼ .91). We also performed a factor analysis for the items. The factor analysis indicated that all the items were loaded on one single factor (Eigenvalue ¼ 3.73, variance explained ¼ 74.52%, Х2 ¼ 2292.33, df ¼ 10, p < .001). These tests suggest that the scale is reliable and robust. The scale has a mean score of 3.16 (SD ¼ 1.40). 6.2.3. Control variables We also included age, gender, and perceived general health condition, as control variables. The reason was that previous studies suggested that these individual characteristics would lead to self-disclosure as well (Dindia, 1992; Gard, 1990; Papini et al., 1990). By including these variables, we limited the possibility that the relationships among our focal predictors and the dependent variable would be spurious.
6.1. Survey instruments and participants 7. Results The 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 then administered among college students living in the metropolitan areas in three different regions: the United States, South Korea, and Hong Kong in 2012. Participants were solicited from large lectures in each selected university using a standardized recruitment strategy and a data collection method. Participation was voluntary (n ¼ 789). 6.2. Measurements 6.2.1. Dependent variable 6.2.1.1. Online self-disclosure. Online self-disclosure was modified from the Self-Disclosure Amount subscale of the Revised Self Disclosure Scale (Wheeless & Grotz, 1976). It was measured by three items, each with a 7-point Likert-type scales (7 ¼ always; 1 ¼ never). The items read: “I do not discuss my health issues with others online” (reversely coded in later analysis), “I share my personal health information on the internet,” and “I offer my health experiences on the Internet to help others” (M ¼ 2.59, SD ¼ 1.20, Cronbach's Alpha ¼ .71).
7.1. Descriptive statistics A total of 789 participants (289 participants from the U.S., 172 participants from South Korea, and 328 participants from Hong Kong) were collected for the study. Among 789 participants, 39.29% were female. For the U.S. participants, 43.60% were female. For the South Korean sample, 59.88% were female. For the Hong Kong participants, 24.70% were female. Overall the participants' age ranged from 17 to 33, with an average of 20.80 and a standard deviation of 2.21. Comparatively, participants from Hong Kong were slightly younger (M ¼ 20.10, SD ¼ 1.67) than those in the other two societies (the U.S.: M ¼ 20.91, SD ¼ 2.50; South Korea: M ¼ 21.96, SD ¼ 2.10). In the U.S. sample, the majority of participants (83.39%) were Caucasians, followed by African Americans (5.88%), Asians (3.81%), and Hispanics/Latinos (2.42%). For Hong Kong and South Korea, local residents were nearly 100%. When asked about their health conditions, American participants were the least to report healthy (M ¼ 2.19, SD ¼ .89), followed by South Korea (M ¼ 2.84, SD ¼ 1.08), and Hong Kong (M ¼ 3.04, SD ¼ .99), where the answer option 1
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H2 stated that the frequency of uncertainty reduction actions after visiting the medical professionals is positively related to online self-disclosure. The results support H2 in all the sub-samples. Regarding our research question that addresses the crosssociety comparison, there are significant societal differences on the level of health-related self-disclosure online. Compared to their counterparts in Korea and the U.S., youths in Hong Kong were significantly more likely to disclose personal health issues with peers online (F (2,684) ¼ 31.21, p < .05). Particularly, the average level of online self-disclosure for the Hong Kong participants was 3.02 (SD ¼ 1.16), followed by South Korean (M ¼ 2.45, SD ¼ 1.08) and American respondents (M ¼ 2.24, SD ¼ 1.18). Meanwhile, trust in social media also varied across the three societies significantly (F (2,696) ¼ 74.13, p < .001), where Hong Kong youths held the highest level of trust towards the health information on social media (M ¼ 3.82, SD ¼ .88), followed by Korean (M ¼ 3.47, SD ¼ .88) and the U.S. respondents (M ¼ 2.75, SD ¼ 1.23). In terms of the uncertainty reduction actions, however, there was no significant cultural difference (F (2,678) ¼ 1.12, n.s.). The Hong Kong participants rated an average score of 3.23 (SD ¼ 1.37) in terms of uncertainty reduction actions, followed by the U.S. participants (M ¼ 3.18, SD ¼ 1.47) and South Korean participants (M ¼ 3.02, SD ¼ 1.32).
indicated a poor health condition and the answer option 5 indicated an excellent condition. In terms of internet access through smartphones, the majority of participants from South Korea (99.43%) and Hong Kong (95.25%) reported that they had smartphones with internet connections, but only 58.90% of the U.S. samples reported so. Among the samples, a large proportion of them (86.74%) reported that they had ever searched health information online whereas the rest did not. Particularly, 90.31% of the U.S. samples reported that they had ever searched health information online, whereas the percentage was 93.26% for the South Korean participants and 80.00% for the Hong Kong participants. The descriptive statistics of all variables for three sub-samples are presented in Table 1. 7.2. Hypothesis testing H1 predicts that the level of trust of health information sources on social media, i.e., BBS, blogs, social media, is positively associated with self-disclosure via online channels. The results from the OLS regression analysis predicting online self-disclosure are summarized in Table 2. Model 1 presents the regression analysis in all three societies, whereas Models 2 to 4 present results from the U.S., the South Korea, and the Hong Kong sub-sample, respectively. Models 1 to 3 reveal that the trust in social media was positively associated with self-disclosure online. H1 is supported. Specifically, a positive link between trust in social media and self-disclosure was found in the U.S. and the South Korean sub-samples, but not in the Hong Kong sample.
8. Discussion and conclusions Our major findings and contributions are three-fold. First, the study demonstrates that, even in the era of “Health 2.0,” when most people are switching to online sources for information, the
Table 1 The Descriptive Statistics of Key Variables in Three Societies (Mean with standard deviation in the parentheses). Overall sample (n ¼ 789) M Female (%) Age Perceived health condition Online Self-disclosure Trust in social media Uncertainty Reduction
39.29% 20.80 2.69 2.59 3.34 3.16
The U.S. Sub-Sample (n ¼ 289) S.D.
M
2.21 1.05 1.20 1.13 1.40
43.60% 20.91 2.19 2.24 2.75 3.18
The S. Korea sub-sample (n ¼ 172)
S.D.
M
2.50 .89 1.18 1.23 1.47
59.88% 21.96 2.84 2.45 3.47 3.02
The Hong Kong sub-sample (n ¼ 328)
S.D.
M
S.D.
2.10 1.08 1.08 .88 1.32
24.70% 20.10 3.04 3.02 3.82 3.23
1.67 .99 1.16 .88 1.37
Note: M. for Mean, S.D. for Standard Deviation.
Table 2 Standardized OLS regression coefficients predicting online self-disclosure in three societies.
Female Age Perceived health condition Trust in social media Uncertainty Reduction Actions U.S. (versus Hong Kong) S. Korea (versus Hong Kong) Observations Adjusted R2 R2 F Value
Model 1
Model 2
Model 3
Model 4
Overall sample
The U.S. Sub-Sample
The S. Korea sub-sample
The Hong Kong sub-sample
.044 (.091) .071 (.021) .034 (.044) .18*** (.045) .27*** (.033) .25*** (.12) .11** (.12) 634 .228 .237 F (7, 626) ¼ 27.76***
.073 (.14) .016 (.029) .049 (.076) .24*** (.063) .34*** (.050) e
.069 (.18) .17* (.043) .20** (.077) .17* (.11) .21* (.068) e
.030 (.17) .10 (.044) .0093 (.076) .092 (.083) .27*** (.056) e
e
e
e
234 .242 .258 F (5, 228) ¼ 15.84***
151 .149 .177 F (5, 145) ¼ 6.25***
249 .082 .101 F (5, 243) ¼ 5.43***
Standardized beta coefficients; Standard errors in parentheses; *p < .05,
**
p < .01,
***
p < .001.
W.-Y. Lin et al. / Computers in Human Behavior 56 (2016) 289e294
dynamics with professional medical services still plays an important role in facilitating one's self-disclosure of health concerns. While previous research reveals that both online and offline health information seekers would rely on traditional health care professionals (Cotten & Gupta, 2004), our study shows that real-world uncertainties would be offset by online self-disclosure and information seeking. Our study also provides a clearer picture of the dynamics between the offline professionals and online healthrelated communication practices. Second, while it is generally believed that the information provided on social media by peers, rather than by medical experts, might be misleading and less trustworthy (Pant et al., 2012), our study suggests that trust in social media-based information is a significant predictor of further health-related behavioral engagement. Earlier studies found that peer-to-peer videos were more effective in influencing peoples' attitudes and issue importance (Paek, Hove, Jeong, & Kim, 2011). In other words, information circulated among peers on social media generated larger cognitive effects. The reason is that “perceived similarity seems to be a more influential attribute than perceived expertise” (Paek et al., 2011). Even though we did not ask the respondents whom they shared information with for validation, findings from our study highlight the relationship between the evaluation of information and information seeking behaviors in the Web 2.0 environment. Third, from a comparative perspective, our study found that, while it is popular for the U.S. internet users to check out others' experiences about health-related issues (The Internet and Health, 2012), our respondents from two digital societies in Asia, i.e., Hong Kong and South Korea, ranked higher than those from the U.S. in the level of online self-disclosure. The finding is perplexing as Americans are generally believed to favor direct communication and tend to disclose more in the face-to-face interaction (Kim, 1994), whereas Confucian Asians prefer to keep things to themselves. The online disinhibition effect may offer an explanation. In other words, people may say or do things in the cyberspace that they would not ordinarily say or do in the face-to-face world (Suler, 2004). Previous research has suggested that computer-mediated communication, such as the internet, provides an alternative forum and opens up opportunities for users to express themselves that may be otherwise discouraged in the real world (Lin, Cheong, Kim, & Jung, 2010). Nevertheless, future studies may consider to investigate the extent to which cultural or structural contexts may affect the relationship between the evaluation of online information and one's self-disclosure, online and offline. Limitations exist. Firstly, while the present study focuses on the extent to which one discloses him/herself, it will be intriguing for future studies to examine what has been disclosed through the online platform. For example, Jamison-Powell et al. (2012) conducted a content analysis of Twitter messages on one particular type of health-related issue, i.e., insomnia, and found that Tweets with the word “insomnia” contained more negative health information than a random sample of Tweets. Meanwhile, Attrill and Jalil (2011) raised the concerns on the quality of self-disclosure. They found that CMC-based self-disclosure was merely superficial information, rather than information containing intimacy and personal details. Hence, a closer look into the contents of selfdisclosure would provide a better understanding of such benefit exchanging activities. Secondly, admittedly the explanatory power of the predictors in this study is moderate; it could be that other factors play a role in influencing one's decision to disclose him/ herself online. Scholars may consider to investigate the effect of other factors, especially psychological predispositions, in the process. For example, a lower concern for privacy may suggest more self-disclosure online (Taddei & Contena, 2013). Thirdly, while our study focused on university students, who are among the most
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active internet users, this sample selection limits the generalizability of our results. Future research may consider to study health information seeking behaviors by other populations, such as the elderly or high-risk groups (Flynn, Smith, & Freese, 2006; Miller & Bell, 2012). Lastly, the relationship between online self-disclosure and offline self-disclosure warrants more investigation in future studies. For instance, Skinner and colleagues (2006) found no differences in the style of self-disclosure between online support groups and face-to-face therapy users (Skinner & Latchford, 2006). However, Valkenburg and associates (2011) suggested that selfdisclosure online was used to rehearse offline self-disclosure skills (Valkenburg, Sumter, & Peter, 2011). More sophisticated research is needed before a conclusion can be drawn. Despite of the above limitations, our findings are important in advancing a better understanding of the relationship between trust in different sources of information, experiences with institutional professionals, and health-related behavioral outcomes. Author notes Wan-Ying Lin (Ph.D., University of Southern California) is an Associate Professor at the Department of Media and Communication, City University of Hong Kong. Xinzhi Zhang (Ph.D., City University of Hong Kong) is a Lecturer at the School of Professional Education and Executive Development at the Hong Kong Polytechnic University. Hayeon Song (Ph.D., University of Southern California) is an Associate Professor at the Department of Communication, University of WisconsineMilwaukee. Kikuko Omori (Ph.D., University of WisconsineMilwaukee) is an Assistant Professor at the Department of Communication Studies, St. Cloud State University. Disclosure This manuscript and all the authors have no conflict with any manufacturer of a product discussed in the manuscript to disclose. Acknowledgment Part of this work was supported by City University of Hong Kong under the Grant no. 9610224. References Attrill, A., & Jalil, R. (2011). Revealing only the superficial me: Exploring categorical self-disclosure online. Computers in Human Behavior, 27(5), 1634e1642. http:// dx.doi.org/10.1016/j.chb.2011.02.001. Beldad, A., van der Geest, T., de Jong, M., & Steehouder, M. (2012). Shall I tell you where I live and who I Am? factors influencing the behavioral intention to disclose personal data for online government transactions. International Journal of Human - Computer Interaction, 28(3), 163. Berger, C. R. (1979). Beyond initial interaction: Uncertainty, understanding, and the development of interpersonal relationships. Language and Social Psychology, 122e144. Brashers, D. E., Neidig, J. L., Haas, S. M., Dobbs, L. K., Cardillo, L. W., & Russell, J. A. (2000). Communication in the management of uncertainty: The case of persons living with HIV or AIDS. Communications Monographs, 67(1), 63e84. Checton, M. G., & Greene, K. (2015). Elderly patients' heart-related conditions: Disclosing health information differs by target. Psychology, Health & Medicine, 20(5), 594e604. Chen, R., & Sharma, S. K. (2013). Self-disclosure at social networking sites: An exploration through relational capitals. Information Systems Frontiers, 15(2), 269e278. http://dx.doi.org/10.1007/s10796-011-9335-8. Cotten, S. R., & Gupta, S. S. (2004). Characteristics of online and offline health information seekers and factors that discriminate between them. Social Science & Medicine, 59(9), 1795e1806. http://dx.doi.org/10.1016/j.socscimed.2004.02.020. Courtois, C., All, A., & Vanwynsberghe, H. (2012). Social network profiles as information sources for adolescents' offline relations. Cyberpsychology Behavior and Social Networking, 15(6), 290e295. http://dx.doi.org/10.1089/cyber.2011.0557. Dindia, K., & Allen, M. (1992). Sex differences in self-disclosure: A meta-analysis. Psychological Bulletin, 112(1), 106e124. http://dx.doi.org/10.1037/0033-
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