The development of an online-based rural community of practice framework for addressing health issues among rural citizens: a grounded theory approach

Abstract

Background

Health literacy facilitates an individual’s ability to interpret and utilize medical information, thereby influencing their quality of life. Despite the benefits, the current oversaturation of information necessitates the support of healthcare professionals. Help-seeking behavior (HSB) is a term that describes the actions taken to assuage health concerns, and timely medical consultations are critical, especially for older individuals in rural areas who often face barriers to accessing care. These challenges are exacerbated by the perceived psychological distance from medical services in rural settings due to past negative experiences; however, the emergence of social media has helped form a bridge, allowing for direct communication with physicians. While consultations with artificial intelligence (AI) do occur, interaction with human physicians remains the gold standard. Thus, this study sought to understand social media’s role in facilitating health consultations in rural areas and the implications for primary care education among physicians.

Methods

This qualitative study, conducted from September 2022 to June 2023, employed a grounded theory approach to analyze information about a social network-based consulting system that utilized the LINE application. Residents posted anonymous health-related concerns, and comments were extracted. Two researchers coded and assessed the data; another specialist reviewed the findings.

Results

A total of 621 citizens participated, generating 10,432 posts. The grounded theory approach identified five major themes regarding health-related social networking in rural settings: (1) mutual exploration for information sharing highlighted distrust toward primary care physicians; (2) temporary collaboration resulted in superficial health discussions and relationship-building through empathy; (3) conflicts arising from differing health perspectives and misinformation sharing led to intense debates; (4) anxiety was resolved through shared illness experiences and increased empathy, enhancing psychological safety; and (5) a mutual assistance community was created, characterized by improved health dialogues and HSB among participants.

Conclusions

The high engagement with the social network-based consulting system in rural Unnan City highlights technology’s pivotal role in facilitating health dialogue and community engagement, despite challenges related to misinformation and health literacy complexities. As a reflection of the community’s health perceptions and dynamics, future adaptations should incorporate strategies to combat these challenges while preserving collaboration and support.

Background

Effective symptom management can help sustain an individual’s quality of life (QOL), and high health literacy can be a critical factor. Health literacy refers to the ability to identify, comprehend, and utilize medical information and services to make informed health-related decisions and take actions for the benefit of oneself and others [1]. Those with high health literacy are capable of acquiring the information needed to improve their knowledge and skills for managing various health conditions [2, 3], and some reports have suggested that high health literacy is associated with a high QOL [4]. However, the oversaturation of information in the present era has made it difficult for people to judge the validity and reliability of medical information without the support of medical professionals, regardless of their level of health literacy [5].

Consultations with medical professionals can bolster one’s health literacy, leading to better help-seeking behaviors (HSBs), which are concrete behaviors that people engage in when experiencing symptoms and anxieties, such as those related to self-management, self-medication, and medical care [6]. Effective HSBs performed with self-efficacy and intent can lead to a better QOL [7, 8], as can effective self-management [9]. However, ensuring timely medical care is vital, as delays in the receipt of care for critical diseases can increase the likelihood of morbidity and mortality [10], and health literacy is limited to assessing symptoms and seeking adequate medical consultations [11]. Persistent symptoms require consultation with medical professionals, especially physicians, for effective diagnosis and treatment, which could also reveal hidden symptoms that may have been overlooked.

Rural environments play a significant role in shaping people’s HSBs. In rural settings, geographical isolation, limited access to healthcare services, and a shortage of medical professionals often create barriers to timely medical consultations [12, 13]. As a result, rural residents frequently face challenges in accessing healthcare, leading to delays in seeking treatment for potentially serious conditions [14, 15]. These factors contribute to a tendency for individuals to rely on self-management, where they attempt to treat or manage symptoms without professional guidance [16, 17]. Cultural and social factors may also influence the self-management behaviors in rural populations. Rural communities often value self-reliance and may perceive seeking medical help as unnecessary or a sign of weakness [18].

Additionally, trust issues with healthcare providers, rooted in past negative experiences or perceived dismissive attitudes from physicians, can further discourage people from seeking timely care [19, 20]. This combination of geographic, cultural, and systemic barriers affects how rural residents interpret their symptoms and make health decisions, often favoring self-care over professional consultation. Given these challenges, it is important to understand how rural residents engage with healthcare systems and digital platforms like social media [21, 22]. By examining how they communicate health concerns in a network-based environment, we can better address the barriers that limit their access to professional medical advice and support.

Social networking is a useful tool, allowing for direct and easy access to physicians before in-person consultations, facilitating HSBs to achieve better health outcomes [23]. The terms “social media” and “social network” refer specifically to digital platforms that allow individuals to communicate, share information, and form communities online. Social media is a broad term encompassing various online platforms that enable users to create, share, and exchange content, such as text, images, and videos. It facilitates real-time interactions across geographical boundaries, enabling users to engage in discussions on topics of common interest [23]. The idea of face-to-face consultations with physicians may actually prevent some people from seeking medical care in rural settings [21]; social networks can effectively mitigate such negative perceptions [24]. Artificial intelligence (AI) may facilitate HSBs, depending on the questions posed by patients [25]; for example, some patients may turn to programs such as ChatGPT for health consultations. However, one study demonstrated that the degree of patient satisfaction was higher when advice was provided by an actual physician rather than through AI suggestions [26].

Interactions between physicians and laypeople on social media can lead to the creation of healthcare communities with distinct characteristics, as different people may have conflicting ideas, which can lead to disagreements. Clarifying the processes required for the development and advancement of social network-based communities to provide information on health-related issues and improve HSBs in rural settings can help improve medical care in such areas and those lacking adequate healthcare resources. However, the current status and characteristics of social media-based dialogue regarding health issues and HSBs remain unknown. A better understanding of the process required to facilitate such dialogue and improve HSBs in rural contexts would be beneficial, and implementing systems to educate primary care physicians could be effective. Therefore, this study aimed to clarify the themes for the development and advancement of social networking-based strategies for consultations on health issues and the improvement of HSBs in rural contexts using a grounded theory approach.

Methods

This qualitative study used a grounded theory approach to understand the development and growth of a social network-based consulting system. Grounded theory is a research method used to develop theories based on data collected during the study. Instead of starting with a fixed theory or framework, the researchers allow the themes and patterns to emerge from the data itself [27]. This makes grounded theory useful when exploring new or complex social phenomena, such as online health consultations in rural areas, where there may not be existing theories to explain the situation.

In this study, we collected data from the posts made by participants on the social network-based consulting system. The researchers reviewed these posts to identify common themes and patterns. After coding the data into different categories, the research team discussed and refined these categories to form more significant concepts. This process involved reading and re-reading the data to ensure the findings were based on the participants’ actual experiences rather than on preexisting ideas.

Grounded theory was especially suitable for this study because it allowed us to develop a framework for understanding how rural citizens use social networks to share health information and seek medical advice based on their own words and actions. The goal was to create a theory explaining how the social network helped or hindered the community’s health-seeking behaviors rather than testing a pre-defined hypothesis.

Setting

This study was conducted in Unnan City, Shimane Prefecture, Japan. Unnan City is located in the eastern part of Shimane and borders Hiroshima Prefecture to the south. Its total land area is 553.1 km², accounting for 8.3% of that of Shimane, most of which is forested. A survey conducted in 2020 revealed that the total population of Unnan City was 36,007 (17,316 men and 18,691 women), with 40.01% of the population being older than 65 years. There are six towns and 30 multifunctional autonomies in Unnan City, each of which varies in the functional approach to managing respective social issues. In the traditional protocols, multiple community groups are responsible for carrying out specific functions. Thus, each autonomous community organization comprises a director, sub-directors, and clerks whose activities are classified into three main categories, including community organization, healthcare, and social/environmental development. Community organization refers to citizen empowerment, effective utilization of local resources, and the resolution of community problems through the efforts of local actors [28]. Unnan City was chosen as the setting for this study because its characteristics are representative of typical Japanese rural conditions and are generalizable to other rural conditions in developed countries.

Rural populations in Japan, including those in Unnan City, often need help obtaining health information and healthcare services, including geographical distance from medical facilities, limited availability of healthcare providers, and insufficient health infrastructure. These factors can contribute to difficulties seeking timely medical consultations and managing health conditions. Previous research has shown that rural populations may need more opportunities to develop health literacy due to reduced access to healthcare resources and professional guidance [29]. As a result, rural residents may rely more heavily on self-management and informal sources of health information, including social media and online platforms [30].

While we did not directly measure the health literacy levels of the participants in this study, it is essential to recognize that limited access to reliable health information and professional healthcare services in rural areas can influence people’s ability to interpret and apply medical information. This may lead to challenges in making informed health decisions and can contribute to the spread of misinformation, as observed in the early stages of the social network-based consulting system. However, any assumptions regarding health literacy must be approached cautiously, as the specific literacy levels of the participants were not assessed in this study [30].

Future research could explore the health literacy levels of rural populations more directly. Still, for this study, we focused on how rural citizens engaged with an online health consultation platform to address their health concerns without assuming a specific baseline of health literacy.

Establishment of the rural community social network-based consulting system

The social network-based consulting system used in this study was established by rural family physicians at Unnan City Hospital, a general hospital in Unnan City. This system utilized the LINE social networking application, which is a popular messaging and communication application developed by the Japanese LINE Corporation. The application was first released in 2011 and has since become one of Asia’s most widely used communication platforms, particularly in Japan, Taiwan, Thailand, and Indonesia. LINE allows users to send messages, make voice and video calls, share photographs and videos, and play games with each other. LINE is available on multiple platforms, including smartphones, tablets, and desktop computers, with over 200 million active monthly users worldwide [31].

The social network-based consulting system allowed the participants to post anonymously about their anxieties and symptoms in a group chat. The notice board provided posting instructions, which stated that the participants should post their anxieties and symptoms anonymously, that they might not receive rapid responses from physicians, that they should not post about medical emergencies, and that no medical institution authorized the responses they may receive. Hence, the participants were responsible for their own actions. The contents of the posts were related to the symptoms experienced by the participants and their relatives, as well as general questions about health and diseases.

Participants

The study commenced with the launch of the social network-based consulting system in September 2022 and concluded in June 2023. Participants were rural residents of Unnan City, Shimane Prefecture, Japan. Access to the system was provided via a password distributed to community workers in each autonomous community organization. These workers were instructed to offer the password to individuals who expressed difficulties in managing their health conditions. Participation was entirely voluntary, and participants were informed that they could withdraw from the social network-based consulting system at any time.

Inclusion criteria were: (1) residents of Unnan City or the surrounding rural areas, and (2) individuals experiencing health-related concerns who were interested in engaging in discussions or seeking advice through the platform. No restrictions were placed on gender, medical history, or health literacy levels, as the objective was to capture a wide range of health-related experiences and behaviors. Exclusion criteria included individuals unable to provide informed consent, those who were not fluent in Japanese, or those experiencing acute medical emergencies requiring immediate attention. Participants were explicitly advised not to post about urgent medical issues, as the platform was not intended for emergency care.

Recruitment process

Participants were recruited through various channels. Community workers at local autonomous organizations were provided with detailed information about the social network-based consulting system and distributed passwords to eligible individuals. Additionally, recruitment materials, including posters and flyers, were placed in community centers, public health facilities, and at Unnan City Hospital. These materials explained the study’s purpose, the anonymous nature of the platform, and provided instructions on how to participate. Community healthcare workers also conducted informational sessions to address questions and further clarify how the platform operated. All participants were informed that their participation in the study was voluntary, and they had the option to withdraw at any time. Informed consent was implied through participation in the system, in line with the ethical guidelines approved by the Institutional Review Board.

Measurements

All posted comments were extracted from the social network-based consultation system during the study period for analysis using a grounded theory approach, and the total numbers of participants and posts were calculated.

Analysis

The grounded theory approach was adopted to identify how social networking-based consultations for addressing health issues and promoting HSBs in rural contexts have developed and advanced [27]. After extracting the contents of the network-based consultation system as transcripts, RO and TY carefully read the transcripts independently. Subsequently, RO and TY coded the data, and RO developed and revised the codebooks based on repeated readings of the transcripts. After coding each participant’s data, RO and TY discussed the coding based on the codebooks until a mutual agreement was reached. The two authors introduced, merged, deleted, and refined the codes, which enabled them to develop the concepts and overarching themes by comparing the research materials and codes. Discussions regarding the data and coding continued until a mutual agreement was reached and no new concepts or themes were developed. Finally, CS, a community care specialist at the university, participated in the discussion of the coding concepts and themes and reached an agreement on them. The results were translated from Japanese into English.

Reflexivity

This study was conducted collaboratively through interactions between the researchers and participants. The research team had diverse expertise in and perspectives on rural community care. RO is a family physician and public health professional who graduated with a master’s degree in public health and family medicine and had experience working in and conducting research related to rural community healthcare. TY is a director of a non-profit organization who has worked in isolated communities and served their residents for 20 years. CS is a medical educator and professor at a medical university who graduated from a medical university and specializes in community healthcare management and education. To minimize bias, each idea related to community care was discussed by analyzing the research content of the individual data analyses. Alternative viewpoints were explored during the data interpretation stage.

Ethical consideration

The Unnan City Hospital Clinical Ethics Committee approved the study protocol (No. 20230003).

Results

A total of 621 citizens participated in the network-based consultation system, generating 10,432 posts during the study period. Through the grounded theory approach, the following five themes were identified: mutual exploration for information sharing; temporary collaboration based on a superficial understanding of health; conflict arising from differing perspectives among participants; resolution of anxiety through participants’ cooperation and empathy; and the creation of a community for mutual assistance (Fig. 1).

Fig. 1.

Conceptual framework for social networking-based consultation systems for rural health issues and HSBs. HSBs, help-seeking behaviors

During the mutual exploration for information sharing stage, the participants posted non-stimulative information in the feed, with the goal of understanding the characters of the other participants. In addition, a lack of health literacy led to the sharing of incorrect health information, most of the dialogues were simplistic, with little interaction, and the content mostly concerned the distrust some participants felt toward primary care physicians and the symptoms caused by disrupted lifestyle habits. During the temporary collaboration based on a superficial understanding of health stage, continual superficial discussions about health and symptoms reinforced a superficial understanding of HSBs but led to the formation of relationships through empathy based on other people’s descriptions of their illness-related experiences. During the stage in which conflicts arose from differing perspectives among the participants, their ideas about health and primary care physicians diverged. In addition, the increased sharing of misinformation about health, such as that related to the administration of vaccines and the use of home remedies, led to intensive discussions among the participants. In the resolution of anxieties through cooperation and empathy stage, an increase in the sharing of information about experiences with illness led to greater empathetic attitudes toward the experiences of others, thereby reducing the participants’ anxieties. The continual dialogues between the participants reduced the number of conflicts as a result of an increased perception of psychological safety when asking everyday questions. In the final stage involving the creation of a community for mutual assistance, empathy continued to increase through the sharing of illness-related experiences, and stabilization was achieved by learning about the anxieties of the other participants through the continual health dialogues, which also improved the quality of such engagements and the understanding of health, encouraging the participants to seek out medical treatment. Sample dialogues for each of the five themes follow.

Mutual exploration for information sharing

During the mutual exploration for information sharing stage, the participants posted non-stimulative information on the site in an effort to understand the other participants’ characters, with most of the posts containing superficial information and little engagement with other participants. One interaction between two of the participants was as follows:

Participant A: “COVID-19 is scary; teach me how to approach it.”

Participant B: “I feel the same. It is too bad; I hope the pandemic ends.”

The following is another interaction that occurred between two participants:

Participant C: “Every day my back pain is bringing me down…”.

Participant D: “I understand that. The pain is always depressing.”

The lack of health literacy also frequently led to the sharing of incorrect health information, such as logical fallacies related to vaccination. Initially, there were a few accusations of the sharing of incorrect information and instances where another person supported this information; for example:

Participant E: “Did you get vaccinated against COVID-19? The situation is hectic; they cannot be effective, and there are many complications.”

Participant F: “I think the same! Therefore, we must avoid vaccinations.”

Most dialogues were simplistic, with very little interaction, and the contents mostly concerned the distrust some participants felt towards primary care physicians and the symptoms caused by disrupted lifestyle habits; for example:

Participant G: “I cannot ask my doctor about my anxiety and concerns. They do not listen to me seriously because they seem to be preoccupied with other duties.”

Participant H: “I agree with you. Physicians do not suggest concrete lifestyle modifications. My symptoms could be caused by my lifestyle, but I cannot change the habits by myself.”

Temporary collaboration based on a superficial understanding of health

During the stage involving temporary collaboration based on a superficial understanding of health, continual simplistic discussions about health and symptoms led to a superficial understanding of HSBs. The participants hoped to get one-size-fits-all answers to their health conditions and issues, and they refused to engage in a deep discussion about their health conditions. One of the dialogues went as follows:

Participant I: “How can I deal with a cough I have had for several days?”

Doctor: “You can continue to assess your symptoms if they are not severe. Your symptoms may persist for several weeks, in which case you should visit your primary care doctor. How long has your cough persisted?”

Participant I: “I got it! I will try it.”

Another dialogue occurred as follows:

Participant J: “I cannot sleep well lately. This may be due to stress. Does stress affect sleep?”

Doctor: “Yes, it does. Stress can reduce your quality of sleep. How long have you experienced these symptoms? You should visit a primary care doctor if the situation continues for over a month.”

Participant J: “I understand my condition. I monitor my sleeping conditions and stress!”

Continual discussions, however, gradually created superficial relationships among the participants, leading several of them to share their illness-related experiences to help find solutions to other participants’ health issues. One of the dialogues was as follows:

Participant K: “My hands are tingling; from the elbows down on both hands, particularly from the middle finger to the pinky. It started when I first became pregnant with my oldest child, and when I use force when doing fine tasks such as sewing, my hands tingle and lose sensation. I have not done anything about it because it has not gotten better or worse, but now I feel a tingling similar to when I sit on my feet, just from holding my mobile phone. It eases to some extent when I relax, but there is always a nagging itchiness like frostbite.”

Participant L: “I understand. I have also been experiencing numbness in both of my hands for a while now, and it is increasing the number of things I cannot do. It is quite difficult, is it not? The tingling sensation is persistent. It would be nice if there was a good treatment option for it.”

Conflict arising from differing perspectives among participants

During the stage in which conflicts arose from discrepancies among participants, differing perspectives or opinions about health and primary care physicians began to appear in the discussions. Various participants shared their ideas about health and diseases, which induced negative sentiments in others, sometimes leading to arguments. The initial conflicts between participants were slowly resolved after such differences were clarified. For example, one of the dialogues was as follows:

Participant M: “I have become lethargic lately and cannot seem to cheer up. I also have occasional headaches and do not seem to enjoy my life. What could be the cause of this?”

Doctor: “This sounds difficult. There is a possibility of an internal disease; therefore, if this has been ongoing for more than a month, please consult your family doctor.”

Participant N: “Fatigue can be caused by anything. If there is no significant weight loss, this may be psychological. It will get better if you rest.”

Participant M: “I do not want you just to assume that it is psychological. I have been trying to distract myself daily to avoid thinking about it.”

Participant O: “It is not good to presume that it is psychological, nor is it good to deny that possibility. I think that both psychological and physical issues can occur; therefore, please undergo a thorough examination at the hospital.”

A similar dialogue went as follows:

Participant P: “I am troubled with constipation. Recently, the frequency of bowel movements has decreased; it is now down to two or three times a week. Please advise me on how to improve my constipation.”

Doctor: “This sounds difficult. Constipation can be influenced by your diet and exercise habits. However, as you age, we cannot rule out the possibility of malignant tumors. Therefore, if you have not undergone a checkup, please consult your family doctor.”

Participant P: “Thank you!”

Participant Q: “This is probably just a matter of diet. If you start living regularly and get enough sleep, you should be fine.”

Participant P: “It is not always that simple. It is not that easy to change my lifestyle.”

Participant Q: “If you want to improve your symptoms, you should change it immediately. I believe that it is a matter of awareness.”

In addition, the increased sharing of health-related misinformation, such as that associated with vaccines and home remedies, led to intensive discussions among the participants. Such dialogues and conflicts developed based on the poor existing relationships between the participants and their primary care physicians. For example, one of the dialogues was as follows:

Participant R: “Vaccines are not really good to get, right? I heard that they mostly just cause side effects and have barely any effect.”

Doctor: “Please, you should definitely get vaccinated. For COVID-19, especially, there are high preventive effects of getting vaccinated, which can protect yourself and those around you.”

Participant R: “The internet does not say that. Everyone says it is pointless.”

Participant S: “It is better not to believe internet information because it is full of lies. It is better to trust what medical professionals say and to act accordingly.”

Participant R: “My primary care doctor does not give me much information, and the internet, which does provide a lot of information, is important.”

Another dialogue occurred as follows:

Participant T: “There are so many over-the-counter medications available now, and various ones can be obtained on the internet, so it is faster and better to buy drugs and handle things myself if I have any symptoms.”

Doctor: “It depends on the symptoms. Over-the-counter drugs may be ineffective or may not provide a fundamental solution. Casually continuing to use over-the-counter drugs can delay the diagnosis of important illnesses and ultimately cause harm to your health. When symptoms persist, please consult your primary care doctor and use over-the-counter drugs as directed.”

Participant U: “That’s right. I also try to ask my primary care doctor first, and I want to maintain this attitude in the future.”

Participant T: “Do you never feel like your primary care doctor does not tell you anything important? Sometimes, I feel like I am being deceived, and I cannot really trust them. In this case, I think it might be better to read the descriptions of over-the-counter drugs and manage my health myself.”

Resolution of anxiety through mutual cooperation and empathy

During the stage involving resolution of anxiety through cooperation and empathy among the participants, the increased sharing of information about experiences related to illness and the continual development of empathetic attitudes led to a reduction in the participants’ health anxieties. One such dialogue was as follows:

Participant V: “Currently, I am undergoing chemotherapy for breast cancer. It is difficult because I have to take approximately four different types of medications daily. My hands and feet are numb; is this a side effect of the medication? Somehow, I feel like my daily life is getting more and more depressing, and there are times when I get fed up. Is this the life I will continue to lead?”

Doctor: “I understand how difficult it is. Chemotherapy often has side effects, and many people are troubled by them. Please manage your illness slowly, with symptomatic therapy, if possible, while consulting your primary care physician.”

Participant W: “I understand how you feel. I have been taking medications for a different illness, and there are times when it is difficult to take them. It is unclear whether I am getting better, and there are side effects; therefore, my medication has been changed several times. I think of my illness as something I have to live with, and I am managing it slowly. It is tough, but I think we need to do what we can, one day at a time.”

Participant V: “Thank you. Thank you for listening. I feel somewhat relieved. I am happy that I posted honestly. I will contact you again.”

Furthermore, the continual dialogue among the participants about their health conditions gradually resolved the number of conflicts through the increased perception of psychological safety when asking everyday questions. One of the related dialogues occurred as follows:

Participant X: “Being able to post here helps calm my mind. I usually have various health concerns, but I feel I can resolve many issues by sharing them here. Thank you for always listening so sincerely.”

Doctor: “If you have any other concerns, please let us know.”

Participant Y: “It is really helpful that I can share things here that I cannot usually ask a doctor about. The comments from the doctor are helpful, but it is also very comforting that the other participants listen kindly and provide answers.”

A similar dialogue went as follows:

Participant Z: “I like the feeling of safety here. Being anonymous and having everyone listen without denying or responding, I feel at ease talking about myself.”

Doctor: “Thank you. It would be nice to have a place where everyone can comfortably share and discuss their health concerns as much as possible.”

Creation of a community for mutual assistance

During the stage involving the creation of a community for mutual assistance, empathy continued to increase through the sharing of illness-related experiences, and stabilization was achieved by acknowledging the anxieties of other participants through the health dialogues. These changes were accompanied by improvements in manners and etiquette through repeated and continual discourse. For example, one exchange was as follows:

Participant α: “Thank you for listening to my worries. I would like to continue to post occasionally in the future.”

Doctor: “Please feel free to post whenever you have any concerns.”

Participant β: “When posting, I think it would be smoother if you could post in accordance with the guidelines as much as possible. As there are others who would like to post as well, if we proceed by adhering to the rules, I think it can become a place where various people can post and share their health concerns with less conflict.”

Participant α: “Thank you. I will proceed in that way.”

Another exchange was as follows:

Participant γ: “It seems that when many posts overlap, there are often cases in which a response from a doctor to questions from previous posts cannot be obtained.”

Doctor: “That is indeed true. Occasionally, it becomes unclear which posts should be responded to.”

Participant δ: “If possible, how about tagging the posts as a question to the doctor when you want a reply from them; would that ensure that a response could be received from the doctor?”

Participant γ: “That sounds good. I will try it right away.”

In addition, the continual dialogue improved the participants’ understanding of health and their QOL through the increased motivation to seek medical treatment. The participants began to review the previous posts made by others and revised their HSBs to receive better care to address their usual symptoms. For example, one of the dialogues was as follows:

Participant ε: “I am reviewing the previous posts, and I have found several that match my symptoms, which is very educational. When you are experiencing dizziness, it is important to first distinguish whether it occurs when you are moving or even when you are still. In addition, the duration matters. In my case, I am a middle-aged woman, and the dizziness starts when I shake my head and stops quickly when I remain still. Therefore, could it be something related to my ears after all?”

Doctor: “Yes, that is likely to be the case. It is wonderful that you understand your symptoms so well; if they persist and interfere with your daily life, please consult a medical institution.”

Another exchange occurred as follows:

Participant ζ: “I am unsure what to do about my health checkup. I am middle-aged and do not have any particular symptoms, but there are things that concern me, such as slight weight loss. From previous posts and conversations with everyone, I learned that cancer screenings, for example, are based on evidence, and that the frequency and timing of the tests are determined accordingly. Regarding colorectal cancer screening, since the disease is common in Japan, it is my understanding that simply having a fecal occult blood test every year can lead to the early detection of colorectal cancer, is that correct?”

Doctor: “Yes, that is a good approach. If the fecal occult blood test is positive, you can proceed to the next step in cancer screening by undergoing a colonoscopy.”

Discussion

This study clarified the concrete themes related to the growth of network-based consultation systems through interactions between participants and family physicians. In developing and advancing such consultations to address health issues and improve HSBs in rural contexts, mutual exploration for information-sharing was initially performed to develop a better understanding of the other participants’ characters. Also, due to the lack of health literacy, the sharing of incorrect health information occurred frequently at the beginning of the study. Temporary collaboration based on a superficial understanding of health also led to a superficial understanding of HSBs; however, relationships began to be established through empathy based on other people’s experiences of illness. In the early stages, conflict arose from differences in perspective or opinions among the participants. The increased sharing of illness-related experiences and the development of more empathetic attitudes toward the experiences of others helped resolve the health anxieties of the participants. Finally, the continual dialogue among the participants gradually led to a reduction in the number of conflicts through the increased perception of psychological safety when asking everyday questions, leading to a community for mutual assistance and improving the QOL of the participants as they felt increasingly comfortable seeking medical treatment.

The initial stage of the development of network-based consultation systems can begin with mutual exploration that allows for information sharing and conflict avoidance, a process that can be affected by cultural factors. In team- and community-building scenarios, participants tend to mask their true opinions, explore the information held by others, and share superficial information; this is known as the formation stage in team-building frameworks [31]. As the present study shows, during the development of the network-based consultation system, the participants shared only superficial anxieties about health, referencing topics that were relevant in the current social conditions, such as the use of vaccines and the prevalence of infectious diseases. During the formation phase, participants may begin to recognize their own involvement in their communities, they try to “read the room”, and they gauge other people’s attitudes toward their communities [32]. Fitting in with others is a cultural issue in Japan and other Asian countries [33]. As this study shows, the participants were conscious of the others’ ideas and did not insist on making their own opinions known, instead co-opting the opinions of others from news media. In Japanese culture, people try to respect others’ opinions and do not insist on different ideas to avoid disrupting the community [34]. This study confirmed that the initial stage of the building of a network-based consultation system was affected by the culture and background characteristics of the participants; it also confirmed that superficial discussions on medical issues, including symptoms, on network-based consultation systems can lead to temporary collaboration and a superficial understanding of health and HSBs, highlighting the limitations of current practices. This can be seen as a direct call for health platforms to review and potentially revise their communication strategies [35]. However, because this is qualitative research, the term “superficial” is inherently subjective, and the absence of clear parameters for defining a “superficial discussion” can lead to some ambiguity in the interpretation of the results. Previous research has focused more on the technical feasibility and accessibility of network-based consultation systems [36, 37], whereas the present study focused on the quality of the discussions taking place on the platform, which is a more nuanced approach. To mitigate such ambiguity related to the subjective nature of terms like “superficial,” it would be beneficial to agree on operational definitions. While temporary collaboration is a valuable metric, future studies should broaden the scope to quantitatively assess other outcomes.

Superficial and cursory discussions of health on network-based consultation systems can lead to conflicts due to discrepancies in the perspectives of participants. With the rapid proliferation of online platforms and consultation systems, an understanding of the dynamics of health discussions has become crucial [38]. This study highlights an essential aspect of these discussions that could have detrimental effects on the quality and efficacy of such platforms if not adequately addressed. In the early superficial and cursory discussions of health, the participants gradually began to insist that their own opinions about health and diseases were more valid than those of others, which can irritate and offend other participants and cause conflict; this phenomenon occurs during the storming stage of team-building [32]. Conflict and discussions can create established goals, as well as new roles and responsibilities for each participant [32]. Previous studies have shown that the quality of discussions occurring on online platforms can affect user satisfaction and outcomes [39]. By highlighting the conflict that resulted from superficiality, our research provides a unique perspective that could lead to more in-depth, meaningful, and constructive health discussions on online platforms and improve the quality of network-based consultation systems, thereby improving the overall user experience and, potentially, health outcomes. Some research has suggested that users prefer shorter and more concise discussions that allow for quicker information dissemination, although this may be platform- and context-specific [40]. Depending on the needs of the users of an online platform, this study suggests that the initial phases require oversight to facilitate conflict management. When building upon these findings, it will be vital to ensure that network-based consultation platforms remain effective and constructive through continual management.

On network-based consultation platforms, continual cooperation and the establishment of empathy through the facilitation of physicians can help resolve participants’ anxiety and effectively deepen discussions on health-related issues; thus, this study underscores the fundamental human aspects of such interactions, even in digital environments. These results could pave the way for the development of more effective and user-friendly systems, as conflicts and anxiety on online platforms can derail conversations and degrade user experience [41]. This study indicates that cooperative and empathetic behaviors, as well as the continual responses from physicians can resolve or mitigate conflicts, providing actionable insights for designers and moderators. As online consultations continue to become increasingly ubiquitous, an understanding of interpersonal dynamics is essential [42]. The present findings resonate with foundational social and psychological theories, which posit that empathy and cooperation foster positive social interactions and reduce conflict [43]. Some studies have indicated that online interactions sometimes lack the depth and nuance of face-to-face conversations, leading to misunderstandings [44]. Other research has focused on technical solutions to conflicts occurring on online platforms [45], whereas this study adopted a more human-centric approach, potentially offering a new perspective on network-based consultation systems. Given the positive outcomes from increased empathy and cooperation, it may be valuable to explore how these behaviors can be organically nurtured and integrated into digital platforms, as addressing human elements in digital interactions can significantly enhance the user experience and the efficacy of network-based consultation systems.

Continual dialogue, including that related to experiences of illness, can foster a community for mutual assistance on network-based consultation systems. By focusing on such shared experiences, this research underscores the power of personal narratives in building community ties in digital spaces. For many individuals with illnesses, particularly rare or chronic ones, the sense of isolation can be overwhelming [46]. This research suggests a potential avenue to combat this isolation. The establishment of communities of mutual assistance can promote peer-to-peer support, which positively influences psychological well-being [47]. As healthcare and patient communities migrate online, understanding the dynamics of community formation becomes imperative [48]. Many psychosocial theories assert that shared experiences, particularly challenging ones, can foster tight-knit communities [42, 49], which is consistent with the present results. Some research has explored ways of building online communities by focusing either on the technical aspects of the system [50] or the importance of casual interactions or shared interests [51]; however, this study emphasized the organic, deeper, and more profound human-centric nature of online community formation through the sharing of anecdotes and illness-related experiences, providing crucial insights into the potential of shared narratives. Embracing these findings could lead to an enrichment of the landscape of network-based consultation systems, offering the solace and support sought by many.

AI has been integrated into online health platforms, such as virtual assistants and chatbots, to provide basic information and symptom checking [25, 26]. However, its role in promoting meaningful discussions is limited compared to human-driven consultations, especially in rural communities where trust in healthcare providers is crucial [22, 25]. Participants in this study preferred real-time interactions with physicians over AI consultations, likely due to trust issues and the need for emotional support [22]. Studies indicate that patients feel more comfortable sharing personal information with human providers, believing that doctors provide more reliable, empathetic care [26]. While AI can reduce healthcare professionals’ workload, it is essential to maintain human involvement for personalized and trustworthy consultations [23, 25]. Although AI can handle routine inquiries, building a community of practice in healthcare still relies heavily on human interactions [25, 26]. Future research should explore how AI can complement, rather than replace, human physicians in online health consultations.

This study had several limitations. First, it was conducted exclusively on the LINE social networking platform. Although LINE is prevalent in certain Asian countries, this potentially limits the generalizability of the results to populations or regions where LINE may not be a preferred or accessible platform. Given that the study relied on participants who voluntarily chose to engage with others on the consulting system, there may have been a self-selection bias; for example, those who were more tech-savvy, health-conscious, or familiar with LINE might have been overrepresented, whereas the experiences of others in the rural community who did not meet those description may have been underrepresented. While the anonymous nature of posting online might encourage more open sharing, it could also lead to potential misinformation or misrepresentation of the participants’ symptoms and experiences. Given that incorrect health information was frequently shared at the start of the study, the lack of a mechanism to verify or correct misinformation could potentially lead to the propagation of harmful advice or beliefs. It is important to note that the results were also translated from Japanese into English, which could introduce an interpretation bias, with the potential to overlook cultural nuances. Due to its qualitative nature, the grounded theory approach, although rigorous, relies on researchers’ interpretations. While the diverse backgrounds of the researchers could be viewed as a strength of the study, it could also have introduced subjective biases into the identification and interpretation of the themes. Finally, the study was conducted over a period of just one year, and the long-term implications, sustainability, and evolution of such systems remain unexplored.

Furthermore, the lack of measuring health literacy among participants is one of the limitations of the studies. This study identified several themes related to developing network-based consultations for addressing health issues and promoting HSBs in rural contexts. A key observation was sharing incorrect or misleading health information early in the consultation process. Initially, we hypothesized that this behavior might be tied to low health literacy levels, as health literacy is often linked to individuals’ ability to interpret and apply medical information accurately. However, it is essential to note that we did not directly assess the health literacy levels of the participants in this study. Therefore, we cannot definitively attribute the sharing of incorrect information to low health literacy.

Instead, we can infer that misinformation in the discussions may have been influenced by various factors, including participants’ access to inaccurate online information, their trust in non-expert sources, and, potentially, a general unfamiliarity with medical or scientific terminology. These factors, rather than health literacy per se, may have contributed to the propagation of incorrect information within the online community.

In future studies, measuring participants’ health literacy levels could provide more precise insights into the relationship between health literacy and the accuracy of shared information. For this study, our focus remained on how participants interacted with one another and sought to resolve their health-related anxieties through the consultation system. The observed behaviors of misinformation sharing, conflict, and later cooperation suggest a need for improved health communication strategies, but without the assumption that health literacy levels were directly responsible for these early interactions.

Conclusions

The introduction and study of a social network-based consulting system for patients in rural Unnan City provided unique insights into the roles of technology in addressing health concerns and fostering community-based dialogue. With over 10,000 posts from 621 participants, the system demonstrated a strong demand for an online platform where rural citizens could discuss health anxieties and seek mutual assistance from other patients.

While the system effectively facilitated health discussions, it also revealed several challenges, particularly around sharing health information. The early stages of the platform were marked by the circulation of misinformation, which highlights the complexities associated with health communication in online environments. Although we did not assess participants’ health literacy levels directly, misinformation and the need for more accurate health information reflect the broader challenges rural populations face in accessing reliable health resources.

The consulting system served as both a tool for community engagement and a mirror that reflected broader health concerns and interpersonal dynamics within the community. As such, future implementations of similar systems should consider strategies to mitigate misinformation and promote accurate health literacy while maintaining the spirit of community engagement and mutual assistance. These strategies will be crucial for enhancing the effectiveness of online health platforms, especially in rural contexts where access to healthcare is limited.

Abbreviations

AI

Artificial intelligence

HSBs

Help-seeking behaviors

QOL

Quality of life

Author contributions

Conceptualization, R. O. and T. Y.; methodology, R. O.; validation, R. O. and C. S.; formal analysis, R. O., T. Y., and C. S.; investigation, R. O. and T. Y.; data curation, R. O. and T. Y.; writing—original draft preparation, R. O. and C. S.; writing—review and editing, R. O. and C. S.; visualization, R. O.; supervision, C. S.; project administration, R. O. and T. Y. All authors have read and agreed to the published version of the manuscript.

Funding

This study received no external funding.

Data availability

The datasets used and/or analyzed during the current study may be obtained from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

This study was conducted in accordance with the guidelines of the Declaration of Helsinki and approved by the Institutional Ethics Committee of Unnan City Hospital (protocol code No. 20230003). Informed consent was obtained from all participants involved in the study.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.