July 20, 2024

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eHealth usage among Chinese college students: qualitative findings | BMC Public Health

eHealth usage among Chinese college students: qualitative findings | BMC Public Health

Qualitative data were organized through interviews and analyzed by conventional content analysis method. At the very first stage, data of students from different majors were mixed up to be coded, through which the whole picture of eHealth usage across college students from different majors was obtained. The whole picture of eHealth usage included five elements: information obtaining (i.e., problem identifying, filtering, choosing, searching, self-data recording, etc.), information evaluating (i.e., cross-checking, distinguishing, appraising, etc.), online socializing (i.e., problem descripting, responding, information communicating, peer competing, posting, sharing, etc.), information applying (i.e., self-tracking, self-managing, decision-making, etc.), and risk-handling (i.e., evaluating potential risks, dealing with the online critics, avoiding being misled or injured, protecting personal information, maintaining orders of internet environment, etc.). Afterwards, we looked into the obtained information (i.e., the eHealth usages) and found the diversity of different major students. The diversity was verified by the two coders as well as a researcher who helped review our data analysis as a ‘critical friend’ [52]. Therefore, the current authors decided to separately profile the eHealth usage of students from different major, and present the result in the current way. Three themes were identified to provide insight into college students’ eHealth: the Expectance, the Usage pattern, and the Perception on eHealth usage. The Expectance referred to information obtaining behaviors, for behaviors mentioned under this sub-theme were driven by specific expectances; the Usage pattern was linked to the evaluating and socializing behaviors; and the Perception referred to behaviors of applying and risk-handling, this is because different perceptions on eHealth tools oriented students to apply eHealth information in different degree, and to have different focus or worries about the potential risks (See Fig. 1).

Fig. 1
figure 1

Themes and sub-themes of the current study

The eHealth tools used widely at present were also identified through interview data (see Table 3). In general, they could be categorized into three main segments: 1) the traditional web-based read-only (or mainly for reading and receiving information) tools (web 1.0 tools), 2) the ones with social networking function to enable users’ interpersonal communication (web 2.0 tools), and 3) the ones based on mobile internet technology, collecting personal health data and provide personalized services (web 3.0).

Table 3 The most widely used eHealth tools

Expectance—stopgap vs monitor vs database

It was found that, students from different majors have different attitudes toward their health. Those attitudes orienting them to have different expectances for the existing eHealth tools.

Non-health major students – stopgap

For six students from non-health major, five of them admitted that they cared less on health because they did not perceive it severe. They also thought that daily-care behaviors such as skincare or dieting were not counted as “health managing”. Most of the time, they held a primitive knowledge on the definition of health, which is equal to “not getting sick”. The non-health major students reported that they might engage health behaviors for body-shape-building, entertainment, or social purpose, but usually health was not the primary concern. Even about personal health caring, they were not sure what and how to do.

“I won’t pay attention to health issues until I am troubled by it.” (Interviewee 3).

Because of their attitude on health caring, half of the non-health major students seldomly interacted with eHealth tools until they had health issue. Interviewee 4 and 9 said that sometimes they would get fragmented daily-care information from influencers they followed, but both of them were passive recipients, not yet actively seeking opportunities to access health information. Meanwhile, the non-health major students did not fully believe in what they obtained online, in that case, they usually took eHealth tools as a stopgap – a tool that serves their urgent or temporary health purpose for a short time. The eHealth tools were expected to provide a “general picture” rather than the exact answer. The non-health major students were found to mostly rely on search engine to solve their health problems.

Sport major students – monitor

All six sport major interviewees reported that they have been conditioned strongly to their very physical active life and got used to pay attention to manage their health. They perceived that the requirement of their major and the environment of their school did impact their attitude and behaviors on health maintenance, especially physical activity participation. Specifically, two of them reported that they perceived being sub-healthy (a state between healthiness and disease) those days (interviewee 11 perceived overweight and 15 perceived sleeping-late), and they were actively adjusting their daily routine.

Corresponding to their attitude in keeping health, half of sport major students had browsed through the posts of fitfluencers at their leisure actively. Every one of them reported consciously making use of health apps. This is because the Web 3.0 tools, such as health apps and intelligent devices, provide the service for users to “real-timely” track and quantify their own health behavior and body data. Therefore, students usually used eHealth tools as the monitor of their own health behavior, by which students perceived more convenience in self-health-management and gained greater insight into their own fitness indexes. Although some index or information might be inaccurate, the sport major students still found those apps helpful.

“I want to know my heart rate and pace, although it may not be accurate, the data provides me the sense of security and control.” (Interviewee 16).

Medical major students – database

The medical major students showed high intention in keeping health similar to the sport major students, but in a medical way. They all had tried to self-treat some minor ailments. Moreover, they all reported that they had accessed to health information actively. Interviewee 1 and 14 said it was driven by requirement of the major, while interviewee 13 also mentioned about the responsibility of being a future medical doctor in practice. Four of them claimed that they often took the medical information online as references when solving health problem. Three informants said they had browsed the eHealth consulting platform for studying actual cases. The eHealth tools were treated as the databases by the medical major students. In addition to that, it was reported that the smart push technology in different apps, forums, and websites had pushed related health information to them based on their reading tendency.

“Being able to get access to online health information provided me a sese of security.” (Interviewee 13).

Compared with the sport major students, the medical major students interacted with Web 1.0 eHealth tools more, but seldomly used the Web 3.0 ones. Five of them declared that they rarely pay attention to other users’ records on health apps or WeRun, and their own exercise routine had never been impacted by the records. Meanwhile, two of them used health apps to record their exercise patterns and menstrual cycles, and both took their records as references to managing their health.

Usage pattern—personal vs practical vs theoretical

Non-health major students – personal

As mentioned previously, non-health major students mainly use eHealth tools to solve a specific health problem, their usage pattern thus worked in a personal way, trying to find the information targeted to their health issues.

Information evaluating

Compared to the other two major groups, when searching health issue online, some of the non-health major students (interviewee 4, interviewee 17) perceived difficulty in identifying keywords, and rarely (2/6) knew any trustworthy web sites for searching in-depth health information. Since the reliability of online health information is uncertain, they showed preference on the information provided by famous people, which included some influencers. For the doubtful information, most non-health major students chose to skip them. The writing style of information would also affect their choice.

“If the headline (web title) is too dramatic or cliche, I would definitely not click in.” (Interviewee 4).

After narrowing the scope down, the credibility and feasibility of health information were subsequently judged. The judgement was made based on common sense (3/6), experience (3/6), and sometimes intuition (interviewee 4). Only interviewee 7 and 18 mentioned about checking different websites to verify the information. For the online-to-offline cross-checking behaviors, half of the six interviewees had consulted offline professionals for uncertainty online health information. None of the non-health major students had ever done online verification for the health information provided by offline professionals.

Online socializing

Most of the non-health major students (except interviewee 7 and 9) said they never used eHealth tools to socialize with strangers or make new friends. They usually used the tools to interact in a small scope, for instance, close friends or family, kept it in a personal way.

“When using the APP, I will only follow the friends I know in the real world.” (Interviewee 4).

As new users, students from the non-health major preferred to transfer their existing relationships to eHealth tools rather than build up a new network from scratch. Even for those who were willing to build a new eHealth-based network, the relationship was usually very fragile unless being transferred to some popular instant messaging sites (i.e., WeChat or QQ).

“I know someone on a forum who is very knowledgeable in body-building. After we became friends, most of the time we contact each other through WeChat. All in all, instant massaging is not the core function of the forum.” (Interviewee 7).

Sport major students – Practical

Unlike the non-health major students, the sport major ones performed a practical pattern in eHealth usage. Compared with the other two groups, the sport major students could be categorized as active tryers and social players.

Information evaluating

Most sport major students believed that knowledge could come from practice. Half of them reported that they had tried the online health suggestions several times. Interviewee 16 expressed that his trust on eHealth tools sometimes were built on the basis of previous effective trial usage.

“Some of my peers had searched online for better weight-control, then did not even have a try. It is meaningless. People cannot lose weight by just reading.” (Interviewee 10).

Compared to the non-health major students, the students from sport major showed stronger demand for information of higher quality. Two informants said they would use specialized eHealth apps as an ‘advanced’ searching engine to obtain information. The sport major students were also the only group who showed willingness to pay for better information (3/6). Meanwhile, they demonstrated the strongest intention to try eHealth tasks with reward provision (i.e., subsidy or opportunity of doing charity).

“I bought a critical illness insurance, the insurance company promise that if I can keep 10,000 steps per day, I could have a discount on the insurance fee. And I am working on it to save money and keep healthy.” (Interviewee 16).

Sport major participants were clear about their purpose on tool-using. For better satisfying their health needs, some of them (2/6) used several apps of the same type simultaneously to fit their needs (i.e., use JoyRun and NikeRun at the same time), while some would expect e-tools to play a supplementary role.

“It is fine enough as an assistant…But I won’t fully rely on it to help me do my specialist training.” (Interviewee 10).

Online socializing

Compared with the other two groups, sport major students’ usage of eHealth tools was not only more active, but also more sociable. All of them reported that they had used eHealth tools to socialize with others. Besides, they were much more willing than the other groups to post personal record online. Interviewee 15 admitted that the motivation for posting her personal records was intended for social interaction rather than self-recording because it made her visible to the public. Some of the sport major students also perceived that online interpersonal eHealth communication could provide novel ways for social interaction. Specifically, they mentioned that with the help of web 2.0 tools, relationships were created and strengthened, or getting healthier.

“One of my friends has a feeling on a girl but he is too shy to express it, and every time when this girl posting her jogging map tracking, my friend would give a thumb up to kind of give a signal.” (Interviewee 5).

Sometimes, students from sport major perceived more comfortable in communicating health behavior with strangers than with their family or peers.

“My APP usage records will be posted on Weibo because most of my followers on Weibo are strangers…I feel a little uncomfortable to post my physical activities to my friend in real world.” (Interviewee 10).

Beyond eHealth-based socializing, the sport major students’ usage of eHealth tools was more likely to be influenced by their social network. The interview data showed that eHealth-based relationship (i.e., offline relations who have similar health concerns, or new friendship made via eHealth tools) deeply influenced the sport major students’ choice on eHealth tools, and their health decision-making as well. Even the comments or recommendation from other users (who the interviewees may never have been in contact with) would have a strong impact.

“I know that the app ‘go ski’ is more professional and could track my movement better, but most of my ski-friends are using ‘Huabei’. In order to have more fun to go ski with them, I am using ‘Huabei’ instead of ‘go ski’.” (Interviewee 11).

“When purchasing new eHealth tools, I would visit some fans-forum and check other buyers’ comments and perceptions. The software data is difficult to understand, but users’ comments not.” (Interviewee 16).

Beside of the fruitful contents created by strangers, the number of strange users, which means the popularity, was also an important indicator for the sport major students to use eHealth tools. All six sport major students reported their willingness to reply another netizen/stranger’s post on health forums, and said they were not hesitated to seek help online if needed. Two of them had posted their health issues on apps and forums for seeking help. Four of them had tried the online health suggestions.

“I prefer to choose the platform with more users, so there would be more information in that platform.” (Interviewee 10).

Medical major students – theoretical

With expertise in health knowledge, most of the medical major students were skillful information accessor, frequently obtained in-depth health information online. However, they seldomly socialized online. A theoretical eHealth usage pattern was found existed in this group.

Information evaluating

Information evaluating

All of the six medical major interviewees knew several trustworthy web sites or apps for checking health information, and they all claimed that they had ever double-check uncertain health knowledge via the internet. They were also very picky on the e-source of the health information. Four of the six medical-major students expressed that they would search more in-depth health information through academic databases, medical forums, disclosed online doctor-consulting when encountering a health issue. Two participants (Interviewee 12, 13) mentioned that the interaction among users may also influence the quality and future development of the health information sources. Interviewee 18 specifically explained that he often checked the qualification of information providers, even he was browsing a qualified e-source.

“On Dingxiangyuan (a Chinese professional forum only accessible for medical practitioners) there would be detail descriptions and cases, and doctors would explain how they diagnose the patients. Those are very helpful, and hard to get through searching engine.” (Interviewee 9).

The medical major students showed skillful filtering strategies during interview, including to directly skip the information with advertising tag, to browse the page excerpts first to exclude the irrelevant ones, and to preferentially view the information provided by qualified sources (e.g., Baidu Dataset and Doctor consulting platforms). Those strategies helped them improve the efficiency of information searching, while not to miss the helpful ones. Interviewee 8 also perceived that assessment reports published online more trustworthy than other netizen’s comments and experience, even if it was provided by the eHealth service provider, which, contrasted with some sport major students’ opinion.

Besides, the medical major students were the only group that specifically mentioned lots of triangulation ways to verify the reliability of information – they not only cross-checked the information among different eHealth websites and tools (Online-to-online checking) (6/6), but also validated online information from offline professionals (Online-to-offline checking) (mainly discussed the online clinical cases with classmates) (4/6). Moreover, they all had sought online information to validate offline ones (Offline-to-online checking).

“I once had helped my family to check doctors’ advice online because I want to make sure the doctor had told us every side-effect.” (Interviewee 1).

Online socializing

The medical major students were inactive in eHealth-based communication, except with acquaintances. Four of them admitted that they often shared health information via internet within acquaintances that they trusted. They felt good when using their knowledge to help people they care without considering the limitation of time and space. Interviewee 13 told the interviewer that, when sharing health information, he preferred to forward the link directly to others rather than explain it in his own words, so that the information transferred could be more accurate and avoid the misunderstanding. Also, interviewee 2 said that he would avoid any recommendation for specific drugs or tools when sharing. All six respondents reported that their focus of health information could be influenced by acquaintances, for example, if acquaintances come to them for seeking health-related help, they would pay extra attention on the related field and rigorously help find the related information.

Perception—fear vs curiousness vs skepticism

Non-health major students – fear

When talking about the perception on using eHealth tools, the students of non-health major expressed their fear on being misled, being criticized and personal data being leaked.

Information applying

All the non-health major students had expressed their concern about the credibility of eHealth information and their limited confident in evaluating eHealth information. Four of them mentioned that they perceived barriers in finding the “exact answer”. All of them showed a degree of distrust on online health resources, and admitted that negative news on information credibility would influence their attitude toward online health information.

“I always have uncertainty in evaluating the credibility of health information, thus I often with low sense of security when applying eHealth information.” (Interviewee 17).

Nevertheless, the non-health major students took online searching as the first choice whenever they are facing health issues. As mentioned before, they were not expecting the exact answer. In that case, most of them (4/6) perceived the existing eHealth tools were fit to their expectation and helpful enough, while the other two (Interviewee2, 7) agreed that the eHealth tools were playing a supplementary role in daily life for it usually cannot fully fit their health need, and sometimes troublesome to use.

“Mobile phone is a boundary for me when doing exercise. With it I cannot move comfortably, I may worry about drop and break it.” (Interviewee 7).

Risk handling

Considering the risk of misled by online health information, the non-health major participants indicated that they tend to trust and have a try on the daily-care information or fitness ones because of having low risk to try them, while dare not to trust the clinical-related ones – being perceived as the high risk makes it unworthy for the respondents to have a try.

“I think knowledge of health maintenance has no risk. Even if we mis-used it, or it is a fake one, this kind of try would do no harm to health. Thus, I feel it is fine to try or share it.” (Interviewee 18).

When it comes to the clinical issues, most students from the non-health major (5/6) perceived that the offline information was more trustworthy than the online ones. Two non-health major interviewees (Interviewee 1, 9) mentioned about the perception when facing the online critic and even trolls, which, the authors had not yet found in previous academic articles.

“I won’t actively share health information, because my friends and family may doubt my ability and show distrust, I am a little scared of being denied…I guess the ability of handling online critics should be acquired for every internet user”. (Interviewee 1).

Participants also mentioned the concern about data security. To make use of the eHealth service, internet users must provide some personal data, which may lead to personal data disclosure. All the non-health major students were aware of this risk, but only interviewee 17 held the idea that users should be extra careful when providing personal data, all the others showed a “let-it-go” attitude, felt that the leakage of personal data was inevitable.

“If you choose to accept the service, you must provide your personal data, otherwise the app cannot be used. For example, if I order a meal online, I have to enter my phone number and my address, and then, my important personal data leaked. I think I may just accept it and stop worry about it.” (Interviewee 7).

Sport major students – curiousness

Sport major students had a positive perception on their knowledge on health and their ability to control risks, so most of the time they are curious about eHealth tools and information.

Information applying

It was found that the perception of novelty motivated the sport major students to try new eHealth tools, although the interest may not last long. Four of them admitted that they would love to try novel devices related to health. Two participants bought new intelligent devices because of novelty. Additionally, all of the sport major students reported being literate in their self-health-data collected by the health apps, and perceived being able to make use of the personal data or exercise record.

For the credibility of eHealth information, it was reported not being a problem for sport major students. Five of them said that they had the proper e-channels or persons to consult for health issues (e.g., clinic, pharmacy, a medical major student, coach in a gym or their teachers). They also had confidence to evaluate the health information and apply them well. Half of them said that negative comments on eHealth information credibility could not influence their confidence. About the accuracy of eHealth tools/devices, they perceived it was acceptable for general public.

In addition, the sport major was the most warm-hearted group in responding to help-seeking requests online. They perceived that a fruitful interaction between online “hobby friends” could raise a higher demand toward the professionalism of health information, and may promote the development of knowledgeable forums for health and sport.

“When I was firstly fond of doing gym in 2012, there was little channels for me to know more about it, but now there are thousands of fitness apps and fans forums to self-learn and discuss it.” (Interviewee 11).

It is worth to mention that Interviewee 16 also admired the anonymity of eHealth tools.

Meanwhile, sport major students expected further improvement of eHealth tools. Interviewee 11 sometimes posted his training plan online, but was bothered by plagiarism. Thus, he specially insisted on the originality of ideas and information, expected a no-plagiarism-or-misappropriation environment could be built in the near future. Meanwhile, Interviewee 10 expected the eHealth tools could be developed for more sports, for example, basketball or table tennis, and a relevant index, such as reflex and movement speed, could be collected.

Risk handling

It should be mentioned that the students from sport major reported trying on the health information related to sports only. Although informants from this group were suggesting the bravery of taking action, the ability of controlling risk when trying was specially mentioned. They explained that their dare to undertake the risk of trying something new was because they had the confident in controlling their muscles to avoid injury and recognizing the fake health information. The self-cognition on health and ability was suggested to be continued through the beginning of information access to the very end (Interviewee 6), so that users could adjust the application on time according to the changes of physical condition.

“I felt that some beginners would follow the online suggestions blindly and easily trust some cyber celebrities, that may lead to some potential health risk.” (Interviewee 15).

The sport major students were not troubled by the personal data security issue. Some of them felt that those data exposed by the eHealth tools were nothing serious even if they were leaked. Some thought posting personal information should be an individual’s choice and one had the right to do so.

“Sometimes you just want to post some of your personal data, for example, your running record. Although that may cause threat, I guess we should respect this kind of behavior”. (Interviewee 6).

Medical major students – skepticism

The students from the medical major expressed the motive of self-protection regarding to the eHealth environment from potential criticism or abuse, and had a cautious view on eHealth usage. The current research outlined it as skepticism.

Information applying

None of the medical major students perceived that health information on websites had met their needs. They felt that the online health information was mostly inadequate in freshness. Interviewee 2 pointed out that it was usually hard to find the newly updated cases or the earliest ones online when it came to a not-generally-recognized disease. Also, eHealth tools were accused of being lack of specificity or professionalism. In addition, the credibility of health information on the web or collected by devices was questioned. Interviewee 12 specially mentioned that health information from qualified sources might also be misunderstood and would lead to some adverse impact on health. In that case, the medical major students suggested every eHealth user should obtain some common knowledge on health, find the trustworthy resources which was comparable to the users’ knowledge level, and build up the ability of cross-checking. Half of them believed that the truth or the right answer can be organized through rigorous verification, while the other ones suggested people with lower health literacy need to keep contact with one or two experts in health.

Although the medical major students were suspicious on the quality of eHealth information environment, their self-efficacy in evaluating online health information was persistent. All of them expressed that the negative views on information credibility would hardly affect their attitude toward online health information.

“I feel like that people with certain knowledge of health will have their own judgment and be less affected by varies information, for example, the news of Putian Hospital1 did little impact on me.” (Interviewee 12).

Risk handling

As mentioned before, the medical major students were skeptical about being active online. They showed strong awareness on self-protection and mostly had a state of alert when giving advice or posting personal data. Most of them (4/6) indicated that they rarely shared or posted their own data online. Two of them (Interviewee 12, 13) thought it might cause potential safety risk, for example, provide location information for possible stalkers. All of them were very mindful when sharing health information or suggestions online and admitted that they would not volunteer giving health information to other strangers.

“I rarely post or share information online for the purpose of protecting myself…most of the medical-related issues is serious, I don’t want to make mistakes or get into trouble.” (Interviewee 2).

Two respondents (Interviewee 8, 13) explained deeper about the reasons why medical students expressed cautious on sharing health information. The first one was that most people could not describe their symptom correctly and in detail, which probably might cause misdiagnosis.

“It is very hard to give suggestion if the help seeker online doesn’t know how to describe his/her symptom, for example, how is the pain feels like? Is it sharp or dull? Is it persistent or intermittent? But most people cannot tell it like this.” (Interviewee 13).

The second reason is that, in recent years, doctors in China have been abused, injured, and even murdered by patients or their relatives in hospitals and clinics across the country [43], which led Chinese doctors of the new generation feels lost. The participants believed that, the fear of potential violence might negatively influence practitioners’ sharing of clinical information, and might lead to a lack of high-quality medical information online. In that case, all the medical major students had never done online help-seeking, for they perceived not only waiting for responses from strangers was a waste of time, but also the quality of the answer was uncertain.

All the interviewees of the medical major agreed that people should try their best to protect the privacy of personal information and choose those tools ran by responsible companies. Although it was hard, those medical students insisted that avoiding information leakage should be treated seriously, with smart strategies, such as posting as little personal information as possible on strangers’ network, setting a blocked list for those untrustworthy netizens or even friends, setting the viewable scope of the posts, and selecting quality eHealth servicers to avoid information leakage. Moreover, the medical major group strongly believed that the government should make an effort to better manage the internet environment and should require companies to take the responsibility of information protection. Guidance for overcoming online scams and online stalking was also suggested to be provided by school or the government.