The Association between Online Health Information ...

The Association between Online Health Information-seeking Behavior and Social Support in Social Networks among Korean Americans Wonsun (Sunny) Kim, PhD Gary L. Kreps, PhD, FAAHB Objectives: The purpose of this study was to examine Korean Americans’ (KAs) access to online health information and social support from personal social networks. Method: A cross-sectional online survey of KAs (N = 202) aged 18-49 was conducted. Results: KAs in large social networks had high access to social support from personal social networks. KA women had higher perceived social support than men and were more likely to seek health information online. Conclusion: This study illustrates high use of personal social networks and online channels as important sources of health information and support among KAs, suggesting the utility of employing these channels for health information dissemination with this at-risk population. Key words: health information, Internet, Korean Americans, social networks, social support Health Behavior & Policy Review. 2014;1(5):381-394 DOI: http://dx.doi.org/10.14485/HBPR.1.5.4

K

orean Americans (KAs) are the fifth largest group of Asian Americans and one of the fastest growing minority groups, with more than 1.7 million KAs living in the US in 2010.1 However, little is known regarding what health needs are unique to KAs and the behaviors they engage in when they seek health information because population-based health surveys, such as the Health Information National Trends Survey conducted by the National Cancer Institute, typically have aggregated health data for more than 60 Asian nationalities into one category. This aggregation of data can mask potential differences regarding health beliefs, behavior, and needs among the many unique ethnic/cultural groups classified as Asian/Pacific Islanders.2,3 KAs have immigrated to the US relatively recently compared with other Asian subgroups, and a majority of the KA population comprises firstgeneration immigrants.4 About 71% of KAs were born in Korea, and about 25% of those arrived in the US in 2000 or later.1 Unlike the earlier Korean immigrant groups, these recent immigrants have a

high level of education, are younger, and hold professional occupations.1,4 However, KAs are regarded as one of the groups that suffers most from serious health disparities and have significant health information needs that often go unmet.5-7 Whereas the number of young and middle-aged KAs is increasing rapidly due to recent immigration, relatively little is known about young and middle-aged Korean immigrants’ access to and use of health information because few studies have examined health information sources, informationseeking behaviors, and information preferences of this population. To improve KAs’ health, effective health communication is necessary to address their current patterns of health information access and use, so that positive changes in knowledge, attitudes, and behavior may follow.8 Researchers have increased interest in the dynamics of health information.9-19 Health information seeking is the purposive acquisition of information from selected information carriers to guide health-related decision making. Patterns of health information seeking can be strongly influenced by

Wonsun (Sunny) Kim, Assistant Professor, College of Nursing and Health Innovation, Arizona State University, Phoenix, AZ. Gary L. Kreps, Professor, Department of Communication, George Mason University, Fairfax, VA. Correspondence Dr Kim; [email protected]

Health Behavior & Policy Review. 2014;1(5):381-394

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Association between Online Health Information-seeking Behavior & Social Support in Social Networks among Korean Americans

different cultural frameworks.20 Multiple factors influence the extent to which health information is accessed by individuals from different immigrant groups.20 For KAs as a recent immigrant group in particular, lack of familiarity with the US healthcare system, language barriers, inadequate health insurance coverage, lack of social support and networks, and unique cultural values and beliefs have been noted as potentially significant factors influencing health outcomes.6,10,21-23 These differences in social and cultural experiences, as well as cultural and language barriers to effective communication within the modern healthcare system, suggest that social support and personal social networks are likely to be important to KA immigrants because social support is a potentially modifiable aspect of their lives that contributes to various health information-seeking behaviors.24-31 As we focus on how people share information with each other and work together in teams seeking answers to questions, evaluating the use of social support and social networks is a concrete way to examine the communication patterns used to seek relevant health information.26 The extent to which individuals expand their social networks has important consequences for how they acquire health information.32 For example, individuals who have extensive access to social support from social networks appear also to have greater access to innovative and relevant health information and endorse healthy behavioral norms.27 KAs need to seek support and help from different sources and personal networks to cope with feelings of inadequacy and frustration in their changed national environment, especially within the US healthcare system which can be both foreign and frustrating for them to navigate.5-7,33,34 When immigrants enter a new cultural environment, building close relationships with home-nation friends in the host culture can help them obtain health information and support.35 The adaptive functions of these shared culture relational networks include providing informational emotional support and giving newcomers a sense of security and well-being, as well as sources of knowledge about their new host culture. Members of shared cultural social groups share similar experiences of living and studying in a new cultural environment and have many of the same concerns about dealing with various dif-

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ficulties in their new countries. A supportive social network is especially critical for KAs because it can expand the range of information available to members of this immigrant population, who may have difficulties seeking health information through traditional available sources in their new country.5,6,36,37 For instance, many KA women have never heard of the Pap smear test, although cervical cancer is a significant health problem for KA women.38 However, if their friends or family members were to recommend or talk to them about the Pap smear, they would become more familiar with this procedure and might be more likely to seek this screening test. Despite the importance of the relationship between health information-seeking behavior and social support and social networks, there are no extant studies that have examine KAs’ access to perceived social support in social networks that have been identified in prior literature to be significant predictors of health information seeking or exposure to health information for KAs. A few studies3,6,39 have examined health information behaviors or exposure among KAs. These available studies found that healthcare professionals have been regarded as a primary source of information, especially for disease-related information.16 However, to immigrants with limited resources and language/cultural barriers, healthcare professionals and other traditional sources are perceived to be inaccessible or unhelpful.40 When access to other sources (eg, interpersonal, mass media) is limited, the Internet may function as a useful alternative to traditional sources of health information, as it can fulfill both interpersonal and informational needs for immigrants such as KAs.3 Individuals utilize this powerful tool to keep in touch with and expand social support networks, keep updated with health news, and search for various types of information to assist them in their daily lives.17 When looking for health information, most people prefer to explore more than one type of information source and to consult multiple sources of information to find the best solutions for their situations.41 When Case et al41 examined the use of sources for genetic information, they found that 63% of their respondents identified at least 2 health information sources, and 34% identified 3 sources. Fox and Rainie42 reported in their study that although respondents considered health pro-

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fessionals as their primary source for information, they also reported heavy use of the Internet before (27%) and after (34%) visiting physicians, as well as for other health questions for which they felt there was no need to consult a physician. Consistent with this finding, although immigrants with high level of access to social support from their social networks already obtain relevant health information through these networks, they may also go to the Internet to find more information to check whether the information from social networks is reliable. The Internet affords users immediate access to a wide variety of information and a variety of perspectives on the same topic with privacy, immediacy, convenience and anonymity.42-46 Acculturation processes often have been examined with respect to study immigrants’ health-related outcomes.33 Immigrants’ beliefs, norms, values, lifestyles, and behaviors are adapted, modified, and changed when they come into contact with their new home culture.47 In this process, each immigrant has a varying level of acculturation depending upon 2 primary factors: language proficiency and length of residence in the US.48 Social support also has been proposed as a possible mechanism to promote successful acculturation.49 In the process of acculturation, individuals need to receive information from various communication channels to adjust to their host society. Depending on their acculturation status, individuals tend to choose different media and information sources. For instance, newcomers lacking a broad social network may rely on family or friends more than highly acculturated immigrants and native residents do. Jeong’s37 qualitative study of Korean international students found that they tended to rely more heavily on fellow Koreans than US mass media for acquiring everyday information because of language barriers and their strong ethnic bonds. The presence of supportive family members, relatives, and friends, as well as church and personal sense of connectedness has been shown to provide social support for immigrants in coping with external challenges in their acculturation process.50,51 Moreover, the length of time in a host country can influence an individual’s use of sources of social support for acculturation.35 This study is guided by social network theory (SNT) to guide the selection of key variables in

this study.52 SNT is concerned with the properties of social networks, social support and resource exchanges among network members. SNT provides an important framework from which to examine the influences of personal social relationships and networks for Korean American immigrants from South Korea concerning the ways that KAs acquire health information. The purpose of this study was to examine how individual characteristics, social support in social networks, and acculturation affect online health information-seeking among KAs. Whereas previous research has begun to investigate the health information-seeking behaviors for KAs,6,53 little is known about how the power of social support and social networks, and how level of acculturation affects health information seeking on the Internet. Also, it is unclear how social support and social networks are related. This study is designed to provide empirical evidence for healthcare providers and policymakers to identify the best sources of health information and social for KAs, who often suffer from serious health disparities, and suggest best strategies for disseminating relevant health information to KAs using both social networks and the Internet. To our knowledge, this is the ﬁrst empirical study that combines these factors to examine how they relate to online health information seeking among KAs. Based on prior research, we hypothesize that the size of social networks and access to social support in social networks are positive correlated. We also hypothesize that KAs with higher accessibility of social support from social networks (ie, family, friends, and significant of others) are more likely to look for a large scope of health information on the Internet. Previous studies have indicated that the length of time in a host country can influence an individual’s use of sources of social support for acculturation.54,55 We hypothesize that the size of social network and access to social support will be associated with the level of time in country (acculturation) for KAs.


DOI: http://dx.doi.org/10.14485/HBPR.1.5.4

METHODS Sample The sample for this study consisted of young and middle-aged adult first-generation KAs, aged 18 to 49. The reason for using this age criterion is that most

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studies with older KAs collected the data at 50 years of age of older.7,21 Because foreign-born individuals have different health beliefs, values, and behaviors than those born in the US, this study included only those who migrated to the US. Because the number of young and middle-aged KAs is increasing due to current immigration patterns, research on this population will make a significant contribution to understanding of the role of social support and social networks among KA immigrant populations. Sampling Method Data for this study were collected using a Webbased online survey from January 2013 to April 2013 in the US. The convenience and snowball sampling method was used to recruit participants. The researchers searched Korean ethnic associations, Korean businesses and organizations, local Korean churches and referrals, which may have online channels to communicate with their members. By using public contact information of communication officers or executive members of the organizations, websites, a recruitment e-mail or an online inquiry asking participation in the online survey as well as forwarding the recruitment message to their members was sent. Although it was hard to measure exactly how many organizations/individuals distributed the message to their members, the researchers received a positive response supporting the distribution or permitting uploading the message on their websites or social network profiles. We also contacted friends to inform them of the study, ask them to participate, and then seek their cooperation in locating additional participants. Participants were asked to click the online survey link to answer the survey and participation was voluntarily. To assist participants’ understanding of the questionnaire items, the survey was provided in Korean. The 2 inclusion criteria listed in the consent letter for the survey stated that participants needed to be: (1) between 18 and 49 years of age at the time of study; (2) a first-generation Korean immigrant to the US; and (3) able to speak and write Korean or English. We excluded persons who were born in the US, ones aged 50 years or older, and ones younger than 18 were excluded. Measures Korean-language versions of the Multidimen-

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sional Scale of Perceived Social Support (MSPSS) and the Lubben Social Network Scale already exist; these scales have been validated in different studies.25,56 The health information-seeking behavior questions were adapted from the Health Information National Trends Survey (HINTS). The original HINTS survey was developed, refined, and validated to represent the American public’s access to, understanding of, preferences for, and uses of cancer-related health information.18 These questions were translated and back-translated by 2 independent, trained bilingual (Korean-English) to ensure equivalent meanings. To measure the outcome variable of our study, online health information-seeking activities, respondents were asked 10 questions: “In the past 12 months, have you done the following things while using the Internet: looked for health or medical information for yourself; looked for health or medical information for someone else; bought medicine or vitamins online; participated in an online support group for people with a similar health or medical issue; used e-mail or the Internet to communicate with a doctor or a doctor’s office; looked for information about physical activity or exercise; looked for information about diet or nutrition; looked for a healthcare provider; kept track of personal health information, such as care received, test results, or upcoming medical appointments; or looked for information on social networking sites. Each question was coded as Yes (=1) or No (=0). If respondents reported “Yes” to seeking online health information, they received a score of 1 for that source; if not, they received a zero. The scores were summed to form an index of online health information-seeking activities (M = 6.82, SD = 2.03). Scores ranged from 0 to 10, with higher scores indicating a large scope of online health information searches. For the measure of health information-seeking behavior, participants were asked the following questions to identify the source: “For the most recent time you looked for information about health or medical topics, where did you go first?’’ Responses were categorized into 7 groups: newspapers/magazines, family/friend/co-worker, healthcare provider, Internet, television, radio, and other. Independent variables included the demographic variables of sex, age, marital status, education, household income, and employment status; and

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acculturation variables of length of US residence, proportion of life spent in the US, and English language proficiency. We also included self-reported health status as a health status variable and healthcare access variables, including health insurance status and number of visits to providers in the last 12 months. We used these “background characteristics” variables as factors for data analysis to see how they influenced health information seeking behavior. Perceived social support was measured with the Multidimensional Scale of Perceived Social Support (MSPSS) developed by Zimet, Dahlem, Zimet, and Farley.57 It has 12 items and measures social support from 3 sources: family, friends, and signiﬁcant others. The responses range from 1 (strongly disagree) to 5 (strongly agree). Kim et al56 reported that this measure was reliable for KAs (Cronbach’s α = .85). Also, the Korean version of MSPSS is validated in Park, Nguyen, and Park’s25 study (Cronbach’s alpha = .90). Sample items include: “My family really tries to help me” and “There is a special person who is around when I am in need.” Cronbach’s alpha was obtained for the scale as well as for each subscale in this study. For the Significant Other, Family, and Friends subscales, the values were .90, .83, and .88 respectively. The reliability for the total scale was .93. An index of perceived social support was created from the mean of the 12 items (M = 4.29, SD = 0.71). Social networks were assessed by the abbreviated version of the Lubben Social Network Scale (LSNS-6).58 The 6-item LSNS-6 assesses the size of 3 different aspects of social network that are attributable to family ties and a parallel set attributable to friendship ties. The 3 aspects are the size of the respondent’s active social network (ie, relatives or friends seen or heard from ≥ 1 times/month), the perceived support network (ie, relatives or friends who could be called on for help), and the perceived confidant network (ie, relatives or friends to whom the respondent could talk about private matters). Each LSNS-6 question is scored on a 0 to 5 scale (0 = none, 1= 1 person, 2 = 2 persons, 3 = 3 or 4 persons, 4 = 5 to 8 persons, and 5 = 9 or more persons). The LSNS-6 is scored by an equally weighted sum of responses to the 6 items. The responses range from 1 (smallest size of social networks) to 30 (largest size of social networks). Recently, Hong,

Casado, and Harrington59 investigated the validity of Korean versions of the LSNS-6 among KAs, and they found them acceptable. The Cronbach α values from this study were .85 for the LSNS-6, .84 for the family subscale, and .80 for the friend subscale. The total score of these 6 items formed an index of the social network (M = 15.02, SD = 5.24).



Statistical Analysis Statistical analyses were performed using the SPSS 21.0 program. Descriptive statistics were used to describe the background characteristics of the study sample. Multiple hierarchical linear regression models were built to test perceived social support, social networks, and online health information seeking to answer the hypotheses, controlling for age, sex, income, and education. Reliability tests and correlation analyses also were performed. Before conducting the main analysis, the missing data and distribution of the data were examined to employ appropriate data analysis techniques. As participants were able to withdraw from participation anytime and skip any questions, some variables had a large number of missing data. To deal with missing data, the multiple imputation technique was used for most analyses. RESULTS A total of 215 responses were collected from an online survey. Of the 215 responses 13 were not used due to not meeting inclusion criteria. A response from a participant who was over 50 years or older and was born in the US was discarded. As a result, 202 responses were retained for analysis. Demographics A summary of the demographic variables is presented in Table 1. The mean age of the 202 participants was 33.1 years (SD = 6.9). A majority of participants fell into the age group 30-40 (N = 94, 51.5%) or 18-29 (N = 60, 32.6%). The number of participants in the age group 40-49 (N = 30, 16.3%) was relatively small. Women (60.3%, N = 113) were more represented in the sample than were men (39.7%, N = 71). All respondents were Korean immigrants, and their native language was Korean. Sociodemographic status, acculturation, and health status are presented in Table 1.

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Table 1 Study Group Characteristics Sociodemographic Sex Age Group

Education (years)

Men

71 (39.7)

Women

113 (60.3)

18-29

60 (32.6)

30-40

94 (51.1)

40-49

30 (16.3)

High school graduate

24 (11.6)

College graduate

95 (45.9)

Post graduate education

59(28.5)

Living arrangement

Alone

28 (13.5)

With spouse/partner

99 (47.8)

With parents

35 (16.9)

With friends/roommates

22( 10.6)

With children

41 (19.8)

75,000

80 (45.7)

Homemaker

26 (14.1)

Unemployed

13 (7.0)

Main Activity

Part time student

3 (1.5)

Full time student

61(33.0)

Full time worker

71 (38.5)

Part time worker

10 (5.4)

Acculturation Length in US (years)

English proficiency

1-10

91 (44.0)

11-20

69 (33.3)

>20

18 (8.7)

Very comfortable

50 (27.9)

Somewhat comfortable

65 (36.3)

Does not speak or a little or not at all

64 (35.8)

Excellent

22 (12.2)

Very good/Good

145 (81.1)

Health Status Self-reported health status

Health insurance Time visits to healthcare

Routine checkup

Note. N = 184 cases included after multiple imputation

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Poor

11 (6.7)

Yes

128 (69.5)

No

56 (30.5)

0

37 (20.6)

1-4

120 (66.7)

>5

23 (12.8)

Yes

79 (43.0)

No

105 (57.0)

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Table 2 Correlations, Means, and Standard Deviations of Variables Social Support Family SS Family

Social Support Friends

Social Support Significant Other

Social Support Total

Social Network Family

Social Network Friends

Social Network Total

.55**

.65**

. 82**

.50**

.31**

.46**

.72**.

.89**

.35**

.52**

.49**

.91

.43

.48**

.52**

.48**

.51**

.56**

.56**

.88**

SS Friends SS Significant Other SS Total SN Family SN Friends

.

.89

M

4.45

4.03

4.43

4.30

7.59

7.47

15.06

SD

0.71

0.89

0.80

0.70

2.94

3.00

5.26

** p < .001

Health Information-seeking Behavior The survey data explored the general health information-seeking behavior for KAs. Respondents identified 6 different sources for health information, with the Internet being the most common. Overall, 68.1% (N = 141) of respondents reported that they most recently looked for information about health or medical topics on the Internet, followed by family/friends (15.9%, N = 33) and healthcare providers (12.1%, N = 25). Of the respondents 94.2% (N = 195) looked for information for themselves, and 75.8% of respondents (N = 170) looked for information for others. Overall, 75.8% of respondents (N = 157) bought medicine or vitamins on the Internet, 89.4% reported using the Internet for information about diet and nutrition (N = 185), 85.5% (N = 177) looked for information about physical activity or exercise, 65.2% (N = 135) looked for healthcare providers on the internet, 62.3% (N = 129) used email or the internet to communicate with a doctor or a doctor’s office, and 55.1% (N = 114) looked for health information on social networking sites. On the other hand, only 21.7% (N = 45) participated in an online support groups for people with a similar health or medical issue. In terms of a specific Internet site to go to for health or medical information, most of the participants reported that they most frequently first visited Google or Naver (a popular search portal in South Korea) when searching for health information. Other web sites participants

mentioned using were Yahoo, Wikipedia, and MissyUSA (the largest online community among Korean immigrants in the United States).



Relationship between the Social Network and Social Support Access to social support in social networks was positively associated with the size of social networks at a significant level, p < .001. Table 2 shows means, standard deviations, and correlations of the variables. Results of the hierarchical multiple regression analyses using a social network index to predict social support are presented in Table 3. The overall model for predicting social networks and social support was statistically significant, F(4,174) = 18.74, p < .001, adj.R2 = .30. Social network (b = 0.70, t = 7.51, p < .001) was positively associated with social support, and age (b = -0.20, t = -3.47, p < .001) was negatively associated with social support. In other words, compared with individuals who had a small social network, those with large social networks tended to have a high level of access to social support from family, friends, and significant others. Also, when individuals get older, they were less likely to have access to social support in social networks. Online Health Information-seeking Behavior and Social Support A hierarchical multiple regression analysis

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Table 3 Hierarchical Multiple Regression Results for Social Support

B

SE

t

CI (95%)

Step 1 Social Network

.07

.01

8.75

.06-.09***

Step 2 Social Network .07 .01 7.51 .05-.08*** Age -.02 .01 - 3 . 4 7 - .04-.-01*** Female .01 .09 . 0 9 - .16-.18 Income - . 01 .03 -.19 - .06-.05 Education .09 .05 .10 -.05-.22 Length of residence in US .01 .01 1.40 -.01-.03 Comfort with English -.01 .05 .06-.09 Notes. 2 2 2 R =.30 for Step 1, R =.36 for Step 2, ΔR = .06 (p < .05) * (p < .001)*** When employing multiple imputation method, the sample size was reduced to N = 184

showed that KAs with higher access to social support in social networks (ie, family, friends, and significant of others) were more likely to look for a large scope of health information on the Internet (Table 4). Within the first block, perceived social support was a significant and positive predictor of the score for online health information seeking (b = .48, t = 2.23, p < .05). Among the predictors in the second block, perceived social support (b = .49, t = 2.11, p = .05) and sex (b = 1.00, t = 3.33, p < .001) were statistically significant. That is, participants who were women and had higher perceived social support were more likely to look for a variety of health information on online.

Acculturation and Social Support/Social Networks The size of the social network and access to social support were not significantly associated with acculturation for KAs. Results of the hierarchical multiple regression analyses using age, sex, income, education, length of residence in the US, and English proficiency to predict access to social support are presented in Table 5. As shown in Table 6, multiple regression results showed that neither length of residence in the US nor English proficiency was statistically significant for social networks. However, an interesting finding was that age was also negatively associated with social support (b =-0.05,

Table 4 Hierarchical Multiple Regression Results for Predicting Online Health Information Seeking

B

SE

t

CI (95%)

Step 1 Social Support

.48

.21

2.23

.06-.91*

Step 2 Social Support Age Female Income Education Length of residence in US Comfort with English

.49 -.01 1.00 -.13 -.01 .05 -.17

.23 .03 .30 .09 .25 .09 .03

2.11 -.25 3.33 -1.34 -.03 -1.34 1.85

.04-.94* -.06-.05 .41-1.58*** -.32-.06 -.50-.49 -.32-.06 -.03-.11

Notes. 2 2 2 R = .03 for Step 1, R = .12 for Step 2, ΔR = .09 (p < .05) * (p < .01)** (p < .001)*** When employing multiple imputation method, the sample size was reduced to N = 184

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Table 5 Multiple Regression Results for Social Support and Acculturation Acculturation Age Sex Income Education Length of residence in US Comfort with English

B

SE

-.05 -.01 -.01 .21 .01 .05

.01 .10 .03 .08 .01 .06

t

CI (95%)

-5.09 -.08 -.23 2.54 1.30 .76

-.06- -.03*** -.21-.19 -.07-.05 .05-.38** -.01-.03 -.07-.16

Notes. 2 Adj. R = .15, p < .001***, p < .01**, p < .05 * When employing multiple imputation method, the sample size was reduced to N = 184

t = -5.09, p < .001) and the size of the social network (b = -0.23, t = -3.16, p < .01). Education was positively associated with social support (b = .21, t = 2.54, p = .01). In other words, when people got older, access to social support and the size of the social network decreased. Also, individuals with higher education are tended to have high access to social support. DISCUSSION Our investigation examined the relationship between social support and social networks and how social support in social networks, and acculturation affect online health information-seeking among KAs. Our findings revealed that compared with individuals with small-sized social networks, those who had larger social networks tended to have high access to social support from family, friends, and significant others. Empirical analyses suggest that social support and social networks can refer

to many social phenomena and processes;60,61 thus, there is a lack of consensus with regard to the definition of social support.62,63 This finding implies that social networks and perceived social support are not 2 distinct concepts, but they are related as social networks give individuals access to social support. It is consistent with Uchino’s nested model of components of social relationships.27 Uchino27 proposed that social networks are embedded within the broad social relationship construct and each captures a facet of the construct of social relationships. Thus, our results suggest that integrating social support and social networks are important for examining KAs’ health behaviors. These findings also yield insights about how social support functions in social networks for Korean immigrants in the US. For example, given that access to social support is important for developing behaviors concerning seeking health information, frequent contact with social network members may

Table 6 Multiple Regression Results for Social Network and Acculturation Acculturation Age Sex Income Education Length of residence in US Comfort with English

B

SE

t

-.23 .07 .14 1.19 .01 -.06

.07 .80 .25 .66 .07 .47

-3.16 .08 .56 1.79 .15 - 14

CI (95%) -.37- -.09** -1.50-1.68 -.36-.64 -.11 -2.48 -.14-.16 -.99-.85

Notes. 2 Adj. R = .07, p < .05 * When employing multiple imputation method, the sample size was reduced to N = 184



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encourage individuals to look for more health-related information. Thus, Korean immigrant households may be able to protect the health of their families and children by relying on their social networks for gathering relevant health information and social support. More in-depth qualitative analysis of social support communication needs to be conducted to improve understanding of the importance of social networks for recent KA immigrants and the specific functions performed by different social support providers within social networks. Additionally, the results indicated that having access to social support and being a woman were positively associated with online health information-seeking activities and with the greater likelihood of seeking health information online. These findings offer empirical evidence for the importance of access to social support when seeking health information and also suggest that KA women may be important intermediaries for gathering and distributing health information. Higher level of access to social support offers a mechanism through which KAs could access resources and obtain health information. One explanation for this finding is that having more social support in social networks diversifies resource. Thus, individuals with more social support in their social networks were more likely to seek additional health information and look for health information on the Internet to confirm the reliability of information. Previous studies also found that many consumers arm themselves with information from multiple sources including the Internet and friends, family, and healthcare providers.64 These findings also mirror previous studies that show women are significantly more likely than men to use the Internet as a resource for health information.42,65 We found that one of the frequently visited websites when searching for health information was MissyUSA (the largest online community among Korean female immigrants in the United States). Understanding how online support communities affect online health information seeking-behaviors among KA women is a potentially important area for future inquiry. Previous studies have indicated that the length of time in a host country can influence an individual’s use of sources of social support for acculturation.54,55 We hypothesized the relationship between the size of the social network and access to social

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support with acculturation for KAs. However, the association of length of residence in the US and English language proficiency were not associated with the size of social networks and access to social support. Thus, hypothesis 4 was not supported by our data. Previous studies have suggested that many KAs tended to rely more heavily on fellow Koreans than on US mass media for acquiring everyday life information because of language barriers and strong ethnic bonds.3,21,37 In our study, almost 65% of participants reported that they were very comfortable or somewhat comfortable with English. If individuals have highly developed English language ability, they may not need to obtain health information from other Koreans. They may have greater access to others outside the Korean community, increasing access to US health information. Given this finding, additional research is needed that examines the interrelationships among social support, social networks, and acculturation. This will help to ascertain interrelationships and causal patterns among these factors and how they may relate to health information seeking among KAs. Age also was negatively associated with social networks and perceived social support among Korean immigrants. Many previous studies66,67 have noted that older people have smaller social networks, less closeness to network members, and less social support compared with younger people among immigrants because of such factors as losing their family members or close friends due to deaths. Future research can examine age-related factors influencing access to health information and social support for KAs. IMPLICATION FOR HEALTH BEHAVIOR AND POLICY This study has important implications for both health behavior researchers and policymakers. This study is the first attempt to investigate young and middle-aged KAs’ use of both social networks and social support in the context of health informationseeking behaviors. Previous studies indicated that older KAs confront many barriers to accessing relevant health information and health services due to their low levels of English language proficiency and their low rates of having health insurance.21 Thus, they suffer from high mortality rates of cancer related to late stage diagnosis and inconsistent access

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to relevant treatments.68,69 Although this group of immigrants was more likely to have health insurance, higher income, better English proficiency, and more education than older Korean immigrants, they still face many barriers in accessing health information and healthcare. This suggests the need to develop culturally sensitive health information dissemination programs to provide these KAs with access to relevant health information and support. Several studies have alluded to the influence that cultural background exhibits on health information seeking.70,71 One study examined the influence of immigration on health information-seeking behaviors among KAs. Compared with Korean national counterparts who have universal healthcare coverage as Korean citizens, KAs have limited access to healthcare due to inconsistent and low levels of health insurance coverage,72 as well as limited access to health information and social support in the US.3,5,7,34 This is consistent with studies that show immigrants tend to obtain lower-quality and less frequent healthcare than their native-born counterparts,73,74 which reinforces the characterization of the Korean American study population as vulnerable. Thus, after moving into the new country, different cultural factors and different environmental constraints may affect immigrant’s health behaviors and their healthcare. Our results provide further insight concerning the importance of social support from personal social networks and use of the Internet to provide access to needed health information and support. Future research on young and middle-aged Korean immigrants can increase understanding about how social support and social networks can be effective disseminating relevant health information and support to these at-risk populations in the US. Ethnic online communities and Korean websites seem to play a critical role for KA Internet users in need of health information, particularly for lowacculturated and uninsured KAs who have limited accessible information resources. The Internet allows them to search for health information online in their native Korean language. Given this finding, targeted educational interventions designed to increase health knowledge through the dissemination of culturally sensitive, relevant, and high-quality health information through the Internet may have great potential to make significant contributions to

promoting health for KAs. This finding also further highlights the importance of educating KAs about reliable healthcare websites, as well as how to interpret and integrate information found online with health information from social support networks.



Limitations This study had several limitations. First, the strategy of convenience and snowball sampling through a community organization or a church did not allow reaching persons who were more isolated. Similarly, online surveys did not allow reaching those who had no Internet access and to control for geographic variations. KAs living in the Washington, DC metropolitan area may have different characteristics than those living in rural areas. Although the survey was anonymous and confidential, they may have been reluctant to disclose information, which resulted in many missing values for background information. It is possible that respondents who answered the survey were more educated and affluent than those who did not answer the survey. Thus, the findings cannot be broadly generalized. Future studies should attempt more rigorous sampling approaches to insure more representative samples. Despite these limitations, this study attempted to illustrate the important role of personal social networks and online information sources in providing relevant health information and support to members of a large ethnic population that confronts distinct cultural challenges when looking for health information in the US. Data from this study and others that examine the cultural factors that influence health information acquisition and access to social support for ethnic minorities can provide practical insights for professionals who provide health information services to immigrants so they can serve these vulnerable populations better. Acknowledgments Gary L. Kreps, PhD, FAAN served as the chair of the dissertation committee and provided primary mentorship for this study. Other committee members Anne Nicotera, PhD, Xiaoquan Zhao, PhD, Carla Fisher, PhD, and Kyeung Mi Oh, PhD, RN also are acknowledged. Recognition also goes to the study participants for their willingness to share their time and experiences with me. This work was

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supported by the George Mason University’s dissertation completion fund. Human Subjects Approval Statement The protocol was reviewed by the George Mason University Institutional Subject Review Board (Application #8532) and was classified as exempt under category 2 and approved in January 31, 2013. References

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