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Information systems and patient empowerment

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Title:
Information systems and patient empowerment role of infomediaries in health decision making
Creator:
Permwonguswa, Sumate ( author )
Place of Publication:
Denver, Colo.
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University of Colorado Denver
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English
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1 electronic file (94 pages) : ;

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Doctorate ( Doctor of philosophy)
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University of Colorado Denver
Degree Divisions:
Department of Computer Science and Engineering, CU Denver
Degree Disciplines:
Computer science and information systems

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Infomediaries ( lcsh )
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bibliography ( marcgt )
theses ( marcgt )
non-fiction ( marcgt )

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Review:
Information technology (IT) is playing a key role in health care improvement. IT artifacts enable better reach and access to health, allowing patients to manage care more effectively. Amongst various IT artifacts, a health infomediary is an online health platform that connects patients and providers with the purpose of sharing experience and knowledge for health management. Health infomediary has a potential to facilitate patient empowerment, which is an important concept leading to a better health. A number of health infomediaries have emerged with the attempt to share health knowledge and to increase patient's access to care delivery. However, how these infomediaries are useful in patient empowerment remains a research gap to be addressed. This dissertation focuses on this phenomenon and is comprised of two essays that delve into the issue of patient empowerment using infomediaries. The first essay explores the effect of doctor rating systems on willingness to take health-related action in the context of health infomediary specialized in medical tourism. The study is extended to investigate the effect of trust in infomediary and information quality on willingness to travel abroad for treatment, as well as how doctor rating systems moderate these relationships. The second essay investigates the effect of self-concept and emotional empowerment on knowledge sharing behavior in a health infomediary specialized in reconstructive surgery. The combination of these two essays sets the foundation for the argument that health infomediary is an IT tool that can facilitates patient empowerment through different mechanisms. ( , )
Review:
These two studies have the potential to contribute to the existing literature in exploring how health IT can positively impact healthcare, and how particular health IT features and attributes enhance the efficiency of healthcare delivery. Additionally, we highlight managerial implications to support the development and design of health IT with the goal of providing more efficient and sustainable healthcare delivery and services. This dissertation also includes research and practical implications that are paramount to the formulation of the strategies to enhance the design of health IT artifacts, which can potentially increase the overall effectiveness of healthcare delivery.
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Includes bibliographical references.
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System requirements: Adobe Reader.
Statement of Responsibility:
Sumate Permwonguswa.

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University of Colorado Denver
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Auraria Library
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All applicable rights reserved by the source institution and holding location.
Resource Identifier:
on10230 ( NOTIS )
1023030701 ( OCLC )
on1023030701
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LD1193.B34 2017d P47 ( lcc )

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Full Text
INFORMATION SYSTEMS AND PATIENT EMPOWERMENT: ROLE OF
INFOMEDIARTES IN HEALTH DECISION MAKING
by
SUMATE PERMW ONGU SWA B.B.A., Assumption University, 1992 M.B.A., Assumption University, 1994 M.S. CIS, Assumption University, 2002
A dissertation submitted to the Faculty of the Graduate School of the University of Colorado in partial fulfillment of the requirements for the degree of Doctor of Philosophy
Computer Science and Information Systems Program
2017


This dissertation for the Doctor of Philosophy degree by
Sumate Permwonguswa has been approved for the
Computer Science and Information Systems Program
by
Dawn Gregg, Chair Jiban Khuntia, Advisor Ronald Ramirez Ilkyeun Ra
Date: December 16, 2017


Permwonguswa, Sumate (Ph.D., Computer Science and Information Systems Program)
Information Systems and Patient Empowerment: Role of Infomediaries in Health Decision Making
Dissertation directed by Assistant Professor Jiban Khuntia
ABSTRACT
Information technology (IT) is playing a key role in health care improvement. IT artifacts enable better reach and access to health, allowing patients to manage care more effectively. Amongst various IT artifacts, a health infomediary is an online health platform that connects patients and providers with the purpose of sharing experience and knowledge for health management. Health infomediary has a potential to facilitate patient empowerment, which is an important concept leading to a better health.
A number of health infomediaries have emerged with the attempt to share health knowledge and to increase patients access to care delivery. However, how these infomediaries are useful in patient empowerment remains a research gap to be addressed. This dissertation focuses on this phenomenon and is comprised of two essays that delve into the issue of patient empowerment using infomediaries. The first essay explores the effect of doctor rating systems on willingness to take health-related action in the context of health infomediary specialized in medical tourism. The study is extended to investigate the effect of trust in infomediary and information quality on willingness to travel abroad for treatment, as well as how doctor rating systems moderate these relationships. The second essay investigates the effect of self-concept and emotional empowerment on knowledge sharing behavior in a health infomediary specialized in reconstructive surgery. The combination of these two essays sets the foundation for the argument that


health infomediary is an IT tool that can facilitates patient empowerment through different mechanisms.
These two studies have the potential to contribute to the existing literature in exploring how health IT can positively impact healthcare, and how particular health IT features and attributes enhance the efficiency of healthcare delivery. Additionally, we highlight managerial implications to support the development and design of health IT with the goal of providing more efficient and sustainable healthcare delivery and services. This dissertation also includes research and practical implications that are paramount to the formulation of the strategies to enhance the design of health IT artifacts, which can potentially increase the overall effectiveness of healthcare delivery.
The form and content of this abstract are approved. I recommend its publication.
Approved: Jiban Khuntia
IV


TABLE OF CONTENTS
CHAPTER
I. DISSERTATION OVERVIEW.................................................1
1.1 The Role of IT in Patient Empowerment...........................4
1.2. Health Infomediary and Patient Empowerment.......................5
1.3. Objectives of the Studies in This Dissertation.................7
II. TRUST AND INFORMATION QUALITY ON WILLINGNESS TO TRAVEL
FOR MEDICAL TOURISM INFOMEDIARY......................................12
2.1. Abstract........................................................12
2.2. Introduction....................................................13
2.3. Literature Review...............................................16
2.3.1. Reputation Systems......................................16
2.3.2. Information Quality.....................................17
2.3.3. Trust...................................................19
2.3.4. Medical Portals.........................................21
2.4. Theory and Hypotheses...........................................24
2.5. Research Method.................................................28
2.5.1. Development of the Rating System from Existing Practice.28
2.5.2. Sample and Data Collection..............................29
2.5.3. Operationalization of Variables.........................30
2.6. Results.........................................................32
2.7. Discussion and Conclusions......................................34
v


III. KNOWLEDGE SHARING IN HEALTH INFOMEDIARY: ROLE OF
EMOTIONAL EMPOWERMENT AND SELF-ESTEEM................................37
3.1. Abstract........................................................37
3.2. Introduction....................................................38
3.3. Prior Work and Theoretical Background...........................42
3.4. Research Methodology............................................53
3.4.1. Data Collection and Research Method.....................53
3.4.2. Data Analysis and Results...............................55
3.4.3. Validity and Reliability Tests..........................57
3.4.4. Robustness and Sensitivity Tests........................58
3.4.5. Econometric Analysis and Results........................59
3.5. Discussion......................................................65
3.5.1. Implications of this Study..............................65
3.5.2. Theoretical Contributions of this Study.................69
REFERENCES..............................................................71
APPENDIX................................................................84
A. Health Infomediaries Widely Accessed through Internet.............84
B. Representative Literature on Health Infomediaries.................85
C. Coding Scheme of Variables from the Survey Questionnaire..........87
vi


CHAPTERI
DISSERTATION OVERVIEW
Information technology has provided several tools and applications for information processing. One of the information processing tools that facilitates effective decision making is an online infomediary. An infomediary, first coined by Hagel III, is an agent that gathers information regarding a specific topic and provides it in one place (Hagel III and Rayport 1997; Zahedi and Song 2008). An online infomediary is hence an online information provider, which can take various forms including online discussion forums and web portals (Zahedi and Song 2008). A health infomediary then refers to an online health platform that connect patients and providers with the purpose of sharing experience and knowledge for health management (Koch-Weser et al. 2010; Schwartz et al. 2006).
While general-purpose infomediaries like answers.com and ask.com serve a wide range of purposes, some infomediaries exist to serve more specific purposes such as mechanics, travel, food. Health infomediaries are among the specific purpose infomediaries and serve the health issues by providing a conduit of connection between patients and providers. When compared to other types of infomediaries, health infomediaries are unique in several ways: (1) The nature of information shared, (2) the importance of information quality, (3) factors driving the information sharing.
The knowledge being shared on health infomediaries is uniquely different in that people are often sharing their personal information including their private and sensitive information. In general-purpose infomediaries, people may be sharing information on miscellaneous topics (Adamic et al. 2008). For instance, on Yelp, people share rating and
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reviews about their favorite restaurants. On car forums, people may be sharing mechanic knowledge and how to fix the engine problems. The knowledge being shared on these infomediaries is in no way as personal as the story of a woman going through breast cancer or a man asking questions about his erectile dysfunctionvery personal and sensitive topics (Yim et al. 2015). This essentially distinguishes a health infomediary from other online infomediaries.
The quality of the shared information is extremely important on health infomediaries since it can lead to life or death situation (Sharma et al. 2006). The information being shared on health infomediaries is certainly related to health issues such as diagnoses, diseases, conditions, and physicians. For example, when a cancer patient is making decision whether to undergo chemotherapy, this can be a life-changing decision and if made with wrong or incomplete information, could result in death. The same is true for limb amputation decision for a patient with diabetes. The consequences of wrong decision can ruin the patients life. In contrast, good decision can relieve patients prolonged suffering and affliction.
Since health infomediaries are unique, the factors driving information sharing are likely to be different from the drivers on other infomediaries, at least in the magnitude of the effects. For example, trust is known to be one of the factors influencing information sharing on online infomediaries (Zahedi and Song 2008). However, much higher trust may be required for a person to share private and sensitive information on health infomediaries. Hence, there can be a difference in magnitude of the effect of trust on knowledge sharing in the context of health infomediaries. It is also possible that the magnitude change goes in different direction. For example, the expertise of the
2


information sharer may not be as important on health infomediaries as on other infomediaries. When people are looking for advice on car issues, the advice from mechanics and engineers may be more weighted more heavily than the advice from peer drivers. The most viewed Youtube clips for how to replace a part for a car are always from mechanics and engineers (i.e. Car & Driver Magazine, ChrisFix, Leekautorepair). On health infomediaries, the information from patients with the same diseases or conditions may be more valuable than the information from doctors or nurses (Khuntia et al. 2017). In other words, there exists a strong user based peer-to-peer learning, information sharing and knowledge exchange in health infomediaries. In addition, it is also possible that there are some unique factors driving the information sharing on health infomediaries that are not contributing factors on other infomediariesfor example, motivation of a patient to share personal data with other patients such as ones disease condition, the pain undergoing a surgery, the emotional trauma associated with highly stigmatized diseases (i.e. breast cancer, HIV infection). Therefore, it is important that the dynamics of the information sharing process in health infomediaries are investigated as well as how they influence patient empowerment.
Keeping in mind the importance of health infomediaries, it is only one side of the equation. Another important factor in healthcare industry in the United States is the accessibility to healthcare delivery (HealthyPeople.gov 2017). This is especially true when the current administration is pushing towards cutting the healthcare budget and repealing the Affordable Care Act (ACA) commonly known as ObamaCare (Fox and Mattingly 2017; Porter 2017). A large number of people in the U.S. do not have access to traditional healthcare services due to inability to get health insurance (Thomas 2017).
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Some are rejected from health insurers due to some existing conditions; many cannot afford to pay for the high premiums (CDC 2006). This crisis leads some patients to seek for an alternative healthcare service in foreign countries; hence motivating us to investigate the dynamics of medical tourism infomediary, a specialized category of health infomediary.
1.1 The Role of IT in Patient Empowerment
Patient empowerment is the process of enhancing the ability of patients to actively manage their own health (Samoocha et al. 2010). The concept of empowerment refers to a process by which people gain control over their lives (Perkins and Zimmerman 1995; Rappaport 1987). Information systems research has adopted this definition and extended the concept of empowerment to work contexts. However, patient empowerment with IT is a relatively new concept, with only a few studies in this area (Khuntia et al. 2017). In this context of IT enabled patient empowerment, studies have highlighted different attributes, such as psychological empowerment, emotional empowerment. Psychological patient empowerment is an individual level concept of empowerment (Deng et al. 2013), but consists of multiple components with emotional empowerment as one of its components (Christens et al. 2013; Zimmerman 2000).
IT-enabled patient empowerment may consist of programs designed by a provider used to educate and encourage patients with chronic diseases to manage their own health (Elzen et al. 2007; Funnell et al. 2005). Face-to-face empowerment has been found to be effective in improving patients health (Anderson 2007). However, with the increasing importance of IT and internet, it is believed that patient empowerment can be facilitated in the online setting and can be as effective as or even more effective than traditional
4


face-to-face setting (Samoocha et al. 2010). Increasingly, information technology is perceived to provide access and delivery of healthcare to patients rather than limiting the care delivery to hospitals and clinics. For example, using telemedicine or telehealth, an IT platform enabled by synchronized audio and video connections, patients can visit a doctor online (Chau and Hu 2002). Patients can discuss their symptoms with a doctor and the doctor can prescribe medicine or treatment without a need for physical visit. Many recent clinical studies have found that online intervention for patient empowerment contributes to better health outcomes (Glasgow et al. 2012; Nguyen et al. 2013; Warmerdam et al. 2008). Some studies have reported technical issues (i.e. Internet connection stability, slow loading time) as barriers to web-based interventions supporting patient empowerment but no research has investigated the factors facilitating patient empowerment in online settings (Kuijpers et al. 2013).
1.2. Health Infomediary and Patient Empowerment A health infomediary not only helps patients gain health-related information more easily, but also it helps patients gain higher control over their own health (Khuntia et al. 2017). Health infomediaries or IT-enabled platforms such as WebMD or Healthgrade.com can help patients gain more information about their diseases, and, in turn, become knowledgeable in managing their own diseases. Many countries have realized the potentials of health infomediaries and plan to integrate health infomediaries into the government initiated electronic platform of healthcare delivery at the national level (i.e. National Health Service of the United Kingdom) (Currie 2009; Currie and Guah 2006).
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The dynamics and the flow of information in peer-to-peer health infomediaries like PatientsLikeMe or RealSelf go beyond mere health information. This form of health infomediary allows patients to talk and connect to each other (Yim et al. 2015). The discussions and connections on PatientsLikeMe provide an opportunity for patients who are suffering with some type of diseases to learn from the experience and knowledge of patients who had suffered the same disease or have been suffering for longer time (Khuntia et al. 2017). Some patients may have found ways to relieve or cure the affliction. Others may have found a way to live with it. This provides patient empowerment to both parties (Deng et al. 2013). First, patients who receive guidance and use it to manage their own health are empowered to fight the disease and to take necessary actions to improve their health (Samoocha et al. 2010). Second, patients who provide guidance to others also feel empowered by their own actions. The feeling that their knowledge and experience is important in helping others towards better health provides the knowledge sharers with self-empowerment (Deng et al. 2013; Tajfel and Turner 2004).
Despite the increasing importance of health infomediaries, literature on how health infomediaries are used for patient empowerment is scarce. Existing literature has investigated the dynamics of trust on health infomediaries proposing that information quality has significant effect on trust and suggesting how trust evolves over time on health infomediaries (Song and Zahedi 2007; Zahedi and Song 2008). However, past research has not investigated the dynamics of patient empowerment in health infomediaries.
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1.3. Objectives of the Studies in This Dissertation
The two essays in this dissertation focus on two key research questions, with a common theme of exploring how the participation on health infomediaries is helpful in health-related decision making. The studies investigate the perspective of patients in different ways. The first study is dedicated to the information quality on health infomediaries and how it affects the patients treatment decision while the second study puts more focus on patients intrinsic perception of themselves and how different perception impacts their behaviors in the infomediaries. Both essays explore the dynamics of health infomediaries but focus on different areas and slightly different contexts.
Essay I investigates whether the use of a medical tourism infomediary impacts the patients health-related decision making. The cost of healthcare in the United States is high and is not affordable to many people, especially when it comes to elective procedures which are not covered by many health insurance plans. At the same time, the cost of healthcare in many developing countries is much more affordable while the quality of care is about the same level. As a result, medical tourism has become an alternative for those who do not have access to health insurance or do not want to wait for a long time for the treatment. However, gathering information regarding medical treatment in other countries is not easy. It requires a lot of effort and time to evaluate disparate information about treatment options and to evaluate the credibility of those information. This is often a barrier to the decision to participate in medical tourism.
Prior literature suggests that trust and information quality have an impact on the decision making. Therefore, in the context of medical tourism infomediary, Essay I
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explores the influence of trust in infomediary and information quality on the willingness to travel abroad for medical treatment. Prior literature also suggests that different types of rating systems can have different impact on decision making. Hence, Essay I also investigates the influence of doctor rating systems on the willingness to travel abroad for treatment. The study includes the design of a standard criteria for doctor rating systems using a design science research approach and then incorporates them into a prototype infomediary to investigate both direct and indirect effects of the doctor rating systems on the decision to travel abroad for treatment.
Essay II of this dissertation addresses the research question: How does empowerment and self-esteem motivate patients to share knowledge in health infomediaries. We anchor the study to health belief model and self-related concepts, and propose a two-stage research model focusing on the context of reconstructive surgery infomediary. The first stage of the model investigates the influence of self-efficacy, social identity, and internalized self-stigma on patient empowerment and appearance-contingent self-esteem. The second stage of the model investigates the influence of patient empowerment and appearance-contingent self-esteem on knowledge sharing behavior on health infomediaries. Table 1 summarizes key points in both essays.
Tal Die 1. Summary of key points in essay I and essay II
Study 1 Study 2
Title Trust and information quality on willingness to travel for medical tourism infomediary Knowledge sharing in health infomediary: role of emotional empowerment and self-esteem
Motivation Rapid growth of medical tourism Cost, safety and concerns associated with medical tourism Impact of patient empowerment on health outcome Popularity of health infomediaries
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Table 1 contd
Study 1 Study 2
Research question How does the use of medical tourism infomediary impact the patients health-related decision making? How do empowerment and selfesteem motivate patients to influence knowledge sharing in health infomediaries?
Context Medical tourism infomediary Reconstructive surgery infomediary
Health-Related Decision To travel abroad for medical treatment To share knowledge on health infomediary
Independent Variables Trust in Infomediary Information Quality Doctor Rating Systems Stage 1: Self-Efficacy Social Identity Internalized Self-Stigma Stage 2: Emotional Empowerment Appearance-Contingent Self-Esteem
Dependent Variables Willingness to travel abroad for treatment Stage 1: Emotional Empowerment Appearance-Contingent Self-Esteem Stage 2: Knowledge sharing behavior
Data Collection Primary survey Archival survey
Analysis Structural Equation Modeling (Partial Least Square) Structural Equation Modeling (Partial Least Square) Seemingly Unrelated Regression 3-Stage Least Square Ordered Probit
Sample Characteristics Random sampling of population Random sampling of patients participating in a health infomediary
Results There exists no standard doctor rating across various doctor rating websites including medical tourism infomediaries Patients perceive the infomediaries with comprehensive doctor ratings to have higher information quality Those infomediaries gain higher trust and patients are more likely to use their medical tourism services All self-concepts in the research model play an important role in health infomediaries Self-concepts significantly influence knowledge sharing either through emotional empowerment or appearance-contingent selfesteem Some self-concepts have negative impact on emotional empowerment and appearance-contingent selfesteem
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Table 1 contd
Study 1 Study 2
Collective Results across Studies There are variations of health infomediaries; some of which involve inherently risky decision while some attempt to get patients involved to improve overall health of the community members In the context of medical tourism where decisions usually involve high risks, not only individual trust, but trust in infomediary can be equally important In the context of reconstructive surgery where lower risk is involved, various self-concepts have different impacts on patient engagement in the infomediaries The impacts can be mediated by either emotional empowerment or appearance-contingent self-esteem Appearance-contingent self-esteem plays an important role in reconstructive surgery specific infomediaries as the information on the infomediaries and related decisions are highly contingent on appearance
Theoretical Contributions A set of standard criteria for doctor ratings consisting of an overall rating and 7 criteria in 2 main categories Verification of a research model that combines together the domain knowledge of reputation systems, information quality, and trust to explain the decision making process on medical tourism infomediary The first study to combine self-concepts and empowerment to explain online knowledge sharing behaviors Existing IS literature focuses on internal self-esteem, which can hardly (if not impossible) be manipulated This study focuses on contingent (external) self-esteem, which is more volatile and can be manipulated more easily
Practical Contributions Comprehensive doctor rating provides clearer idea on what to rate and how to interpret (e.g. bedside manner, expertise) Infomediaries with comprehensive doctor rating will be perceived as having higher information quality The proposed doctor rating system can be incorporated into the medical tourism infomediary to gain higher trust from patients Knowledge sharing can be better fostered through empowerment Self-stigma is inhibitor to the process of empowerment Infomediary may alleviate internalized self-stigma by fostering social support for those with self-stigma, and by taking immediate action to intervene when the discussion may lead to self-stigma The higher the self-esteem is tied to appearance, the less likely the patients will share knowledge
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Table 1 contd
Study 1 Study 2
Practical Contributions Infomediary needs to provide accurate, relevant, timely, and easy to interpret information Overall doctor rating is ambiguous and can be interpret differently by different patients The signals from the senders may be confounded by the overall doctor rating and can be misinterpreted by the receivers However, as patients gain higher self-efficacy, their self-esteem tends to be less contingent on appearance, and they are more likely to share their knowledge Hence, infomediary may be able to boost knowledge sharing by increasing members self-efficacy Knowing this, infomediary may pose some screening questions during the registration process to categorize patients and to customize the intervention based on patients self
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CHAPTER II
TRUST AND INFORMATION QUALITY ON WILLINGNESS TO TRAVEL FOR
MEDICAL TOURISM INFOMEDIARY
2.1. Abstract
Lack of information prior to medical tourism visits is a significant issue in meeting the expectations of patients. A global portal or health infomediary with doctor rating systems plausibly can bridge this gap. A health infomediary gathers information relevant to medical tourism and makes them available in one place. Patients can visit this health infomediary and get all the necessary information that will be used to make decision whether to go for an alternative treatment in foreign countries, which country and which provider to go to, and how much will it cost. This information is necessary for a patient to make a decision about having treatment abroad but it is not easily accessible without a health infomediary. Despite the availability of the information, the trust in the infomediary and the quality of information presented on the infomediary are important factors of patient decision making. Doctor ratings can help to reduce information asymmetry; however, different doctor rating websites provide different doctor rating schemes and some have unclear rating schemes. This study proposes a set of standards for doctor rating criteria for a medical tourism portal. The proposed doctor rating criteria have been developed following the steps in design science research. A model has been developed to investigate the relationship between information quality, doctor rating systems, trust in an infomediary, and willingness to travel abroad for treatment. The proposed doctor rating systems have been incorporated into a survey-based experiment
12


used to test the hypotheses and evaluate the model. Analysis of data is presented. Implications and contributions of the study are discussed.
Keywords: Medical Tourism, Online Portal, Doctor Rating System, Medical Tourism Platform.
2.2. Introduction
Medical tourism has emerged as an important option to manage health and wellbeing. Medical tourism refers to the travel of patients to foreign countries, mostly from developed countries to developing countries, with the primary purpose of having a medical treatment (Cortez 2008; Crooks et al. 2010; Horowitz et al. 2007). People seek treatments in foreign countries due to the high cost of treatment in host countries, long waiting lists for the procedures, and cost-effectiveness resulting from economic disparities resulting in saving up to 25-75% (Patients Beyond Borders 2015), and the drive to achieve better health irrespective of the location of treatment (Connell 2006; Garcia-Altes 2005). In addition, some medical procedures such as cosmetic dental surgery, are not covered by insurance in countries like the UK and Australia, leading to the growth of medical tourism (Smith et al. 2011). Some patients are also seeking information about and prefer alternative non-invasive procedures to the evidence-based care provided in their own countries. Moreover, the availability of the Internet, and globalization trends make both patients and providers aware of the medical facilities available in other countries, providing options to avail the alternative care (Smyth 2005). As a result, the medical tourism has grown rapidly with patients from developed countries, such as the United States, spending $38.5 billion in 2014 and projected to be over $58.6 billion in 2017 (Patients Beyond Borders 2015).
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Irrespective of the growth in the medical tourism industry, a number of concerns lead to perceptions that medical tourism is highly risky (Smith et al. 2011). The main risk is the disparity in the quality of care across countries. Second, after the procedure is performed, a lack of follow-up care if there are complications is a major challenge. Current physicians and providers across countries do not share medical reports, nor do they communicate to mitigate the follow-up concerns (Dunn 2007; Turner 2007). The third concern is that there is no set of bi- or multi-lateral laws or systems to address claims related to errors during the procedures (e.g. malpractice). Finally, the lack of information flow between doctors across countries makes continuity of care more difficult (MacReady 2007). These concerns lead to the criticism that the medical tourism industry is only driven by cost-arbitrage rather than a real information- or systemic-care based strategy that is needed by patients (Turner 2007).
Although in the long term bi- or multi-lateral agreements or regulations may be solutions to problem associated with quality, accountability and continuity of care, in the short term such widespread agreements are unlikely (MacReady 2007). Instead, online health platforms can be used to reduce the information asymmetry in medical tourism by collecting and comparing procedure-based information and making it available to patients to support informed decisions (Martinez et al. 2008).
One feature of a medical tourism portal is likely to be an online rating and review system which can be used to document quality of care. Comparison of online ratings and reviews is not new to healthcare systems, although they have not been implemented in a global scale. Portals such as RateMDs.com, healthgrades.com, do rate and review doctors. Some report that 72% of Internet users have searched for health information
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online during 2011-2012 and that the online search and information consumption behaviors of Americans are increasing (PEW Research Center 2015). The availability of prior information is becoming a pre-requisite for patients to make an informed choice on treatment avenues. For example, much of the information on doctors background and details on practice are available across websites and portals, and patients are making their choices of a doctor based on this information. The examples of success in other sectors show that people choose restaurants, movies, consumer products, and books based on what they read on the Internet (Chevalier and Mayzlin 2006; Godes and Mayzlin 2004; Jin and Leslie 2003; Mudambi and Schuff 2010), and therefore, it is likely that many will research their doctors on the Internet as well. Furthermore, doctor report cards implemented in the past echo that patients would like to weigh the ratings in their decision making process (Dranove and Sfekas 2008; Jin and Sorensen 2006).
Although systems do exist to rate doctors and hospitals, they are typically country specific and targeted at patients that understand the norms of medical care within the specific local medical system, There is no standard doctor rating system that provides all relevant and useful information for patients seeking care across international boundaries (e.g. doctor, clinic, hospital). The objective of this study is to develop an appropriate set of doctor rating criteria to reduce information asymmetry in medical tourism. A proposed doctor rating system has been designed, developed, and evaluated through sorting and categorization procedures. The resulted doctor rating criteria were then used as a component in a survey-based experiment, designed to investigate the direct effect of doctor rating systems on trust in infomediary as well as the moderating effect of doctor
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rating systems on the relationship between trust in infomediary and willingness to travel abroad for treatment. Result, implications, future research and limitations are discussed.
2.3. Literature Review
2.3.1. Reputation Systems
Reputation systems can help mitigate the risks associated with having a medical procedure performed by an unknown medical tourism provider. Reputation systems can improve patient decisions by making providers accountable for their actions [21], Reputation systems build a meaningful history of the provider by gathering and disseminating data related to past provider behavior, which can allow potential patients to decide whether to trust a health care provider (Resnick and Zeckhauser 2002).
Many online providers implement rating or review systems where consumers evaluate products and/or services after a transaction is completed. These online reputation systems aid in the formation of initial trust in environments where individuals and service providers have no prior interaction or firsthand knowledge of each other, and where direct experience is not readily available (McKnight et al. 1998; Pavlou and Gefen 2004; Zucker 1986). Nielsen.com found that consumer ratings and reviews are viewed as the most trustworthy and influential source of information on products and services, after family members and friends (Grimes 2012), suggesting that people view online ratings and reviews as more reliable and less biased than any other information available on products and services (Lee and Youn 2009)
Reputation systems have been shown to improve consumer satisfaction and to improve quality in the absence of the traditional cues to trust and reputation in the physical world (Josang et al. 2007). Consumer satisfaction occurs when the performance
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of a product or service matches the consumers' expectations (McFarland and Hamilton 2005; Stark and Meier 2001). Reputation systems serve to improve consumer satisfaction because they provide additional information to support decision making and increase the likelihood that the transaction will end successfully. Finally, reputation systems extend the ability of users to share information regarding trust and reputation on a global scale (Josang et al. 2007). Online users usually select products and services by referring to peers ratings.
Despite the success of reputation systems across a wide range of applications, their trustworthiness can still be questionable (Oh et al. 2015). For example, there is a risk that users might be misled by biased spam ratings (Liao et al. 2014). Many scholarly articles address this concern (Chong and Abawajy 2012; Gefen and Carmel 2013), which suggests that reputation systems still can be improved.
Prior studies have found that reputation profiles are predictive of future performance (Gregg and Scott 2006; Resnick and Zeckhauser 2002), and that consumers use reputation systems when making purchase decisions (Ba and Pavlou 2002; Lee and Youn 2009; Standifird 2001; Standifird 2002). However, prior studies have also found that not all reputation systems provide information in a way that it can be used to best estimate the risk associated with a particular provider (Gregg 2009). Thus, the nature (or quality) of the information contained within a reputation system contributes to the usefulness of a particular system for decision making.
2.3.2. Information Quality
Information quality is typically defined across four dimensions: intrinsic, contextual, representational, and accessibility (Lee et al. 2002; Petter and McLean 2009;
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Wang and Strong 1996). Studies have demonstrated the importance of information quality in decision making and intention to use a wide variety of information systems (Wang et al. 2017).
Intrinsic information quality includes the accuracy and objectivity of the information as well as the believability of the information and reputation of the author or source of the information (Klein 2017; Wang and Strong 1996). All of these attributes contribute to an end user's ability to evaluate the intrinsic quality of a given set of information. For example, most medical tourism information is provided through commercial websites limiting believability of the information (Horsfall et al. 2013; Lunt et al. 2014). Commercial websites may be reluctant to disclose negative information about providers, including poor ratings and reviews, because of its potential impact on future business (Horsfall et al. 2013). Finding believable information about the reputation of the health providers abroad or sometimes even information about the country itself can be challenging for potential medical tourism patients. With the inherent risk of any medical procedure, patients may be reluctant to make a decision to travel abroad for treatment if they do not have access to believable information.
Contextual information quality depends on the context of the task at hand. It includes completeness and timeliness as well as value-added, relevancy, and appropriate amount of data (Klein 2017; Lee et al. 2002; Wang and Strong 1996). In the context of medical tourism, websites must include information necessary for patients to decide whether to undertake treatment abroad. Such information may include the reputation of the providers, the risks associated with the procedure itself, treatment costs, transportation, lodging, and much more (Connell 2006). The quality of these data
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depends on the accuracy and currency of the data as treatment alternatives and prices change over time.
Representational information quality includes aspects related to the format of the data and the meaning of the data. It includes criteria like representational consistency, concise representation, interpretability, and understandability (Klein 2017; Wang and Strong 1996). In the context of medical tourism, the information should be presented in the manner that all aspects of the medical tourism experience can easily be evaluated. Rating systems can facilitate the representational aspect of information quality by summarizing the information and presenting it using visualization (i.e. star ratings, scales, categories). As an example, showing 5 stars rating for the experience of a doctor can be interpreted and understood more easily than showing the qualifications and expertise of the same doctor in a few paragraphs of text (Gregg 2009).
Accessibility information quality refers to end users' ability to find and use a given information resource. It includes how the resource can be accessed and any access security constraints for the resource (Klein 2017; Wang and Strong 1996). In the context of medical tourism, accessibility can be provided using health infomediaries that provide information on the expertise of doctors in foreign countries, the treatment options and costs via the Internet (Cortez 2008). Health infomediaries further reduce the accessibility issue by gathering the information and making it available in one place (Harwell et al. 2015).
2.3.3. Trust
Trust is essential in situations, like medical tourism, where there is risk or exposure to danger. Trust has been described a trustors willingness to be vulnerable to a
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trustee in an environment of uncertainty (Gefen et al. 2003). Several studies related to trust and the Internet have found that concerns about a website trustworthiness is a major obstacle to a consumers willingness to share personal information or engage in on-line transactions (Dinev and Hart 2005; Dinev and Hart 2006).
Three essential trusting beliefs are ability, benevolence, and integrity (Mayer et al. 1995). Ability refers to a trustors determination of a trustees ability to provide the goods or services (or information) they offer in a safe and efficient manner, and to provide assistance if required (i.e., to get additional unbiased information on a medical tourism provider), and to manage competently any personal and financial information the user provides. Benevolence describes trustors perceptions of a trustees intentions to act in the best interests of both parties and refrain from engaging in opportunistic behaviors. Integrity is a belief that a party will abide by the rules of an agreement. Several empirical investigations have supported the internal and discriminant validity of the trusting beliefs model (Casalo et al. 2007; McKnight et al. 2002a), as well as the influence trusting beliefs have on purchase intentions and other online activity (Bart et al. 2005). In the context of medical tourism infomediaries, trust signals include various components of a websites design, information content, functionalities, and even the rating systems that build or degrade sources of trust, or which otherwise influence trusting beliefs, intentions, or behaviors (Ba and Pavlou 2002; Hong 2006; Schlosser et al. 2006).
Another type of trust being studied in online environments is the institution-based trust (Lee and Turban 2001; Tan and Thoen 2000). Institution-based trust is trust that utilizes third party guarantees or recommendations to enable one to act in anticipation of a successful future endeavor (Zucker 1986). Hence, institution-based trust includes trust
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in marketplace and trust in infomediary. In the context of online marketplaces, trust in an infomediary increases trust in the seller community as a whole and facilitates online transactions (Pavlou and Gefen 2004). For example, people may not trust small online vendors as much as they trust a large and well-known vendor. However, when the small online vendors are on a well-known marketplace like Amazon and Ebay, they are more likely to be trusted (Pavlou and Gefen 2004). Similarly, in the context of medical tourism, institution-based trust would allow patients to trust unknown medical tourism providers if they had a high level of trust in the medical tourism infomediary.
2.3.4. Medical Portals
In the healthcare industry, there are numerous healthcare social networking portals which create a vast amount of online information about doctors and healthcare options but do little to reduce information asymmetry. Table 2 lists some examples of healthcare web portals and social media sites that help reduce information asymmetry. Some websites (i.e. BoardCertified.com, Healthcare.com) report the overall doctor rating while others report multiple ratings (i.e. HealthGrades.com, RateMDs.com, Vitals.com). For those presenting multiple ratings, different rating criteria are often used. In medical tourism, where patients seek for medical treatment across geographical boundaries, the information asymmetry becomes more complicated as there are international issues in addition to medical concerns.
Table 2. Samp e health infomediaries to reduce information asymmetry
Website Name & URL Focus Communication Methods Content Categories
Steady Health www.steadyhealth.com How to live healthily under different categories. Covers disease treatments and diets. Information Center; Articles; Discussions; Videos; Slideshows; Medical Answers; Applications Categorized by: Well Beings (purposes); Health Conditions (disease types); Family Heath (Sex and Age); Therapies & Treatments; Emotional & Mental Health
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Table 2 contd
Website Name & URL Focus Communication Methods Content Categories
Wellness www.wellness.com How to live healthy under different categories. Covers disease treatments and diets. Also, information about fitness and beauty. Blogs; Forum; Articles Popular Topics; Facilities; Fitness & Beauty; Dental Care; Stores; Insurances; Doctors; Mental Health; Counseling; Provider Program; Community
Everyday Health www.everydayhealth.com Diseases, drag information, living healthily (food & diet). Articles; Videos; Twitters; Facebook; Blogs; Applications Conditions (diseases); Drags; Health Living; Food & Recipes; Advices & Support
Find a doc www.fmdadoc.com Devised a unique proprietary rating system that helps patients choose from among the 720,000 practicing physicians in the U.S. NA Contact Information Search by Categories
My doc hub www.mydochub.com Offers doctors' information, hospital information and diseases information. Articles; Discussions; Blogs; Applications Doctors; Reviews; Dentists; Blog; Answers; Chiropractors; Hospitals; Vets; Health; News; Health A-Z; Articles
Spark People www.sparkpeople.com Focused on living healthily depending on food and exercises. Information Center; Articles; Discussions; Videos; Boards; Applications Eat Better; Feel Better; Look Better
Physician Data Query www.cancer.gov/cancertopics/ pdq PDQ (Physician Data Query) is NCI's comprehensive cancer database. Search Engine NA
Health grades www.healthgrades.com Doctors' information, hospital information and dentists' information. NA Find Doctors; Find Dentists; Find Hospitals
Vitals www.vitals.com Find and review doctors, make an appointment and prepare for the doctor visit. NA Patient Education; Write a Review
RateMDs.com www.ratemds.com Find and review doctors and hospital information. FAQ; Forums; Tweeters Find a Doctor; Find a Doctor; Browse Doctors; Hospitals; Top Local Doctors; FAQ; Forums
Drscore.com www.drscore.com Find doctors information. Email Find a doctor; Score your doctor; For Patients
Doctortree.org www.doctortree.org Find doctors information. NA Search Engine by Categories
Suggest a doctor www.suggestadoctor.com It helps to find doctors information. Customers' Evaluations Search Engine by Categories
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Table 2 contd
Website Name & URL Focus Communication Methods Content Categories
Healthcare.com www.healthcare.com Information about health insurances. NA NA
Vimo www.vimo.com Information about health insurances. NA NA
HealthDay www.healthday.com/health- portal.html Provide daily health news for both consumers and medical professionals. Phone, Email Hospital Systems; Managed Care; Government; Retail; Physicians Briefing; International Editions; HealthDay TV.
iHealthBeat www.ihealthbeat.org Provide daily news digest reporting on technology's impact on health care. Article Feedback, Suggest a Story, Submit an Event, Twitter, Facebook Meaningful Use; Telehealth; ICD 10.
Healthy People 2020 www.healthypeople.gov/ Provide science-based, 10-year national objectives for improving the health of all Americans. Email Topics and Objectives; Data2020; Evidence-based Resources; Stories from the Field; Leading Health Indicators.
Health Finder http ://healthfinder. gov/ Find information to help you and your loved ones stay healthy. Email, Facebook, Twitter Gender, Age, Health Topics, A-Z, Health News.
WebMD www.wbmd.com/index.shtml Provide quality health information and services. Phone, Email. Consumer Network; Professional Network; Private Portal Services; Magazine.
HealthLinks www.healthlinks.net/ A worldwide directory for healthcare consumers and professionals providing links to health services and products, alternative health, education, dental and medical resources, hospitals, employment, healthcare publications, mental health, etc. Forums, Email. Disease; Provider; Gender.
Existing literature points to several limitations of electronic portals or social websites for health care related communications. A prior study points out that quality concerns, lack of reliability of information, and blurred lines between content producer and user are three major limitations of current health care portals (Moorhead et al. 2013) In addition, information overload and a lack of validity of the information are also cited as big challenges to the use of the social media for meaningful purposes (Adams
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2010). Finally, a lack of guidelines may lead to the public to incorrectly apply information found online to their personal health situation, possibly leading to adverse health impacts or consequences (Freeman and Chapman 2007). Therefore, guidelines for creating effective doctor rating criteria are needed to address these issues.
2.4. Theory and Hypotheses
We propose a conceptual model for this study which suggests that the rating type interacts with trust in the infomediary and information quality to influence willingness to travel abroad for treatment. The conceptual model is presented in figure 1.
Figure 1. Conceptual model
In online environments, reputation systems support both individual trust and institution-based trust (trust in infomediary) (Lee and Turban 2001; Tan and Thoen 2000). First, according to signaling theory (Spence 1973), in situations where there is information asymmetry, the reputation of the product or provider can function as a signal of quality. The reputation signals provided by reputation systems help people relying on online information to decide whom to trust, encourage trustworthy behavior, and deter participation by those who are unskilled or dishonest (Resnick et al. 2000). Secondly, reputation systems help build institution-based trust by providing a mechanism that allows consumers to trust the marketplace as a whole. Focusing on the latter, studies show that Ebay and Amazon have been successful in gaining trust from both buyers and sellers through the use of reputation systems (Resnick and Zeckhauser 2002). Ebay has gradually modified and improved their reputation systems to include combination of rating scores, badges, and relevant information. No matter what the reputation systems
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looks like, the buyers are more likely to trust the sellers who score highly on the reputation systems as compared to those who have a low score. One of the most popular travel infomediaries, TripAdvisor, has also adopted a reputation system by adding review and rating systems on their site.
Nowadays, rating systems are common in various eCommerce websites and infomediaries. These rating systems not only help increase trust in specific products, services, and brands, they also have an impact on the trust in marketplaces, and infomediaries. This is known as institution-based trust. A marketplace like Amazaon and Ebay may gain higher trust from implementing the star rating system on their websites. Even a standalone website implementing a star rating system for each product may also gain higher trust from consumers.
In the context of medical tourism infomediary, we argue that the same mechanism can be extended to the influence of rating systems on trust in infomediary. We argue that when an infomediary implements an overall quality rating for each healthcare provider within the infomediary, the presence of such rating system helps increase trust in infomediary. Furthermore, when an infomediary implements more detailed rating systems, the infomediary can gain higher trust from patients. This leads to the hypothesis that:
HI: Type of rating systems positively influences trust in infomediary.
Previous studies consistently suggest a positive relationship between information quality and trust in various contexts (Elliot et al. 2013; Gregg and Walczak 2010; Kim and Noh 2012; McKnight et al. 2002b). Perceived information quality leads to perceived trust, which in turn leads to intention to transact online (Kim et al. 2008; Nicolaou and
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McKnight 2006). In other words, perceived trust acts as a mediator between perceived information quality and intention to purchase. High information quality on a website means the information is relevant, complete, understandable, and accurate (Webb and Webb 2004). When buyers visit an e-Commerce website (i.e. Amazon) and feel that the website contains high information quality, it is more likely that the buyers will have high trust on the website. In the context of medical tourism, when patients visit a medical tourism infomediary and feel that the infomediary contains high quality of information, they will be more likely to have higher trust on the infomediary, regardless of whether they trust the health providers in foreign countries.
In medical tourism where patients travel to receive medical treatment in other countries, it involves much higher risk than buying something from Amazon. Medical procedures are inherently risky and as such it is likely that information quality will influence trust in infomediary in such a risky situation. Web site quality is found to help reduce the effect of negative perceptions and risk of online transactions (McKnight et al. 2002b). Thus, as the medical tourism infomediary contains high information quality, high trust on the infomediary can be expected from patients or visitors; hence we hypothesize that:
H2: Information quality positively influences trust in medical tourism infomediary.
Trust is needed in uncertain and risky situations (Grabner-Krauter and Kaluscha 2003), especially in online environments (Gefen and Straub 2004) where individual trust has been found to increase willingness to transact (Bhattacheijee 2002; Lim et al. 2006). In traditional transactions where buyers and sellers interact with each other in person,
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trust is important (Grabner-Krauter and Kaluscha 2003). However, in online transactions where sellers are unknown to buyers and vice versa, trust becomes even more important (Bhattacherjee 2002). Most of the time, buyers dont see the real products, dont know the sellers, and have to pay in advance and receive the products. This increases the risk that they will not receive the products or that they may receive defective or different products (Lim et al. 2006).
In the context of eCommerce, when small online vendors are listed on a well-known marketplace like Amazon and Ebay, they are more likely to be trusted even though they are not trustworthy on their own websites (Pavlou and Gefen 2004). Similar mechanism can be expected in the context of medical tourism, when patients have trust in a medical tourism infomediary, they are more likely to have higher trust in the providers listed on the infomediary. In this case, the medical tourism infomediary acts as a marketplace for health providers from various countries to provide their treatments or medical services. Analogous to the buyers, patients come to the medical tourism infomediary with the purpose of exploring information about the services available in foreign countries, the quality of services, and other related information. These providers may be well-known in their own countries, but patients overseas may have no idea about their reputations and may not trust these providers. Similar to other online marketplaces, if patients have high trust on the medical tourism portal, it is more likely that the patients will have higher trust in these providers. In contrast, low trust in the medical tourism would undermine the trust in the providers listed on the portal. Therefore, we hypothesize that:
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H3: Trust in the infomediary is positively associated with willingness to travel abroadfor treatment.
2.5. Research Method
2.5.1. Development of the Rating System from Existing Practice
The focus of the rating system in this study is to fulfil the information asymmetry gap by providing both objective and subjective ratings for clinical, administrative and overall care of the providers. To design an appropriate rating system for medical tourism context, we followed a structural approach involving five steps: (1) reviewing 52 existing rating sites in healthcare context, (2) screening of the sites to finalize 42 sites with 169 rating criteria, (3) removing duplicate rating criteria to reach 117 criteria, and categorizing them into 14 categories, (4) judging the criteria through a systematic process to reach an intermediate categorization (details are omitted here for brevity), and (5) refining the categories and sub-categories to come up with the final rating system (see Figure 2). The final outcome was a totally agreed upon 21 criteria by 2 judges and 6 differently categorized criteria by all judges. Fleiss Kappa was calculated instead of Cohens Kappa as the former supported more than 2 raters while the latter supported only 2 raters (Fleiss 1971; Zaiontz 2014). Fleiss Kappa was 0.8 indicating that there was substantial agreement among the judges (Landis and Koch 1977).
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Bedside Manner
Clinical Rating Experience
- Trust
Overall rating Office
Environment
Scheduling
Administrative
Rating Staff
Professionalism
Wait Time
Figure 2. Rating categories
2.5.2. Sample and Data Collection
In order to evaluate the proposed rating system, data were collected using a scenario-based experiment (Rosenthal and Rosnow 1991). We first developed a prototype of a website to illustrate the proposed rating system on the medical tourism portal. Prototype screens have been created for a fictitious doctor, Dr. Pat. The name Pat has been chosen because it may be male or female so that we can minimize gender bias. Generally, the screen displays the doctors name, specialty, gender (shown as unknown), hospital, address, contact information, languages spoken, a short biography, and rating. The page included ratings by prior patients. The hospital name and address were also fictitious and located in Costa Rica as, it is among the most popular destinations for medical tourism (Medical Tourism Index 2014). Two variations of rating systems have been created; one with single overall rating and another with the proposed detailed rating system consisting of all rating categories in Figure 2.
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The target population for this study were people who have considered medical travel but may or may not have done so. The sample was recruited from social networks. The survey link was shared on authors and co-authors walls on Facebook and all friends were asked to share the survey link on their walls. This recruitment method a variation of the snow ball technique. Almost all responses (96.92%) were from the United States (as can be identified by their IP addresses) while 2.2% were from Thailand and 0.88% from Taiwan. The target markets for medical tourism are varied and cover wide range of ages. Four out of eight top specialties sought by medical travelers are cosmetic surgery, dentistry, reproductive, and weight loss (Patients Beyond Borders 2015), with the dentistry as the most popular followed closely by cosmetic surgery (Pollard 2007) and fertility as the fast-growing market (Pollard 2015). Patients seeking these specialties can be of any age, as such, social networks represent a suitable method to recruit a representative set of subjects. 97.8% of the sample are between 18 to 50 years old, which is a good representation of the target population. To prevent selection bias, the subjects were randomly assigned into control and treatment groups using a single web address (URL) which evenly redirected to either the page with single overall rating or the page with detailed ratings. The group exposed to a page containing the doctors information with single overall rating is the control group and the group exposed to a page containing the doctors information with detailed ratings is the treatment group. Manipulation checks were also included in the survey and demographic information were collected.
2.5.3. Operationalization of Variables
Measurement items from prior research were adopted and slightly adapted to fit the context of our study. Table 3 summarizes the measurement items and sources. All
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items were measured using seven-point Likert scales. Trust in the infomediary was measured using five items adapted from prior studies (Awad and Ragowsky 2008; Pavlou and Gefen 2004). Information quality was also measured using five items adapted from prior studies (Gregg and Walczak 2008; McKinney et al. 2002). Willingness to travel abroad for treatment is actually the willingness to transact in medical tourism transaction. While the term willingness to transact can be applied to any context, willingness to travel abroad for treatment is specific to medical tourism context. Therefore, willingness to travel abroad for treatment was measured using four items adapted from prior studies (Bhattacherjee 2002; Lim et al. 2006). Furthermore, rating system was directly controlled to be either single overall rating or detailed ratings.
Table 3,____Summary of Measurement Items and Sources
Measure Question Sources
Information quality The rating on this portal is adequate for me to pursue treatment abroad. (Gregg and Walczak 2008; McKinney et al. 2002)
The rating on this portal is pretty much what I need to pursue treatment abroad.
The rating on this portal is sufficiently detailed.
Trust in infomediary As a medical tourism portal, this portal can be trusted at all times. (Awad and Ragowsky 2008; Pavlou and Gefen 2004)
As a medical tourism portal, this portal has high integrity.
Based on my experience with the rating web site, I know these ratings are trustworthy.
Willingness to travel abroad for treatment I am likely to go abroad for treatment in the future. (Bhattacheij ee 2002; Lim et al. 2006)
I am considering having treatment abroad in the future.
It is likely that I am going to go abroad for treatment.
I am inclined to have treatment abroad in the future.
The survey also captured demographic data and other factors including gender, age, education, ethnicity, experience with treatment abroad, frequency of using Internet, and experience with doctor rating web sites. We control for the ethnicity of doctor being
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used in the experiment by including fictitious Latino and Indian doctor names in the experiment. Obviously, Americans are so familiar with Latino/Hispanic culture as the U.S. Hispanic population is as large as 57 million (PEW Research Center 2016) while Indian culture is much more distant to Americans. Indian Americans population was only 3.2 million in 2010 and most of them are recent arrivals (Pew Research Center 2014). We also conducted a pilot with 16 respondents to ensure the instructions and items were clearly understood. We then made appropriate modifications to the survey accordingly.
2.6. Results
The minimum sample size requirement for PLS is 10 times the number of items (indicators) in the most complex model (Gefen et al. 2000b). Our most complex model consists of 15 indicators, and hence the minimum sample size is 150. As such, our sample size of 227 is adequate for testing the model. From the descriptive statistics shown in table 4, univariate normality can be assumed from the data set. In addition, the intercorrelation between all variables are below 0.7. Table 5 shows cross-loadings and internal consistencies (Cronbachs Alphas) of the model. The Cronbach Alpha is 0.92 for information quality (IQ), 0.93 for trust in infomediary (TR), and 0.95 for willingness to travel abroad for treatment (WT). All of which are higher than the suggested threshold of 0.7 (Gefen et al. 2000b; Zhu et al. 2004). Table 5 also shows that loadings of the indicators on their underlying constructs are higher than the suggested threshold of 0.7(Goodhue et al. 2006). Discriminant validity can be observed in two ways: (1) when the indicators load much higher on their underlying construct than on the others, and (2) when average variance extracted (AVE) is higher than 0.5 and the square root of AVE is higher than inter-correlations between the underlying construct and all other
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constructs(Chin 1998; Karahanna et al. 2006; Pavlou 2003). The two conditions for AVEs for all constructs are satisfied as shown in table 4. Hence, discriminant validity can be observed. Crossloadings from table 5 also shows that all indicators load highly on their underlying constructs and not on other constructs. This pattern demonstrates high convergence validity and high discriminant validity.
Table 4,________Descriptive statistics and inter-correlations
AVE Min Max Mean S.D. Skew ness 1 2 3 4
1. RT 1.00 0.00 1.00 0.43 0.50 0.28 1.00
2. IQ 0.86 1.00 7.00 4.32 1.38 -0.32 0.37 0.93
3. TR 0.88 1.00 7.00 4.00 1.41 -0.04 0.49 0.60 0.94
4. WT 0.88 1.00 7.00 3.78 1.66 -0.05 0.32 0.56 0.53 0.94
Number of observations = 227 The elements in the matrix diagonals represent the square root of AVEs
Table 5,______Crossloadings and internal consistencies
RT IQ TR WT Alpha
RT RT 1.00 0.37 0.49 0.32 1.00
IQ IQ1 0.35 0.94 0.55 0.53 0.92
IQ2 0.38 0.91 0.57 0.46
IQ3 0.31 0.94 0.56 0.57
TR TR1 0.51 0.55 0.93 0.53 0.93
TR2 0.47 0.58 0.96 0.52
TR4 0.40 0.57 0.93 0.44
WT WT1 0.31 0.54 0.50 0.95 0.95
WT2 0.32 0.49 0.49 0.94
WT3 0.28 0.48 0.42 0.94
WT4 0.30 0.56 0.55 0.92
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The model was first estimated without controls; the effect of rating systems on information quality was 0.37 and the effect of information quality on trust in infomediary was 0.60 while the effect of trust in infomediary on willingness to travel abroad for treatment was 0.53; all were significant at p < 0.01. Then control variables were added into the model. All coefficients remained unchanged except a trivial change from 0.53 to 0.52 for the effect of trust in infomediary on willingness to travel abroad for treatment; all were still significant at p < 0.01. Among the control variables, only education and ethnicity were significant. The R2 of information quality, trust in infomediary, and willingness to travel abroad for treatment were 0.14, 0.37, and 0.37 respectively. All hypotheses are supported and the estimate model is shown in Fig. 3. The final results of the analysis are summarized in table 6.
Table 6,___Summary of the Results
Hypothesis Estimate Value Supported
HI q 27*** Yes
H2 0.60*** Yes
H3 0.52*** Yes
Note: p < 0.10, ** p < 0.05, ***p < 0.01
2.7. Discussion and Conclusions
The objective of the analysis is to investigate and verify the relationships between information quality, doctor rating systems, trust in an infomediary, and willingness to
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travel abroad for treatment in a medical tourism context. The findings show that all hypotheses are strongly supported and the coefficients and other statistics remained unchanged after control variables were added to the model. The findings are congruent with other similar research in a more general context (Lim and Kim 2012; Song and Zahedi 2007; Zahedi and Song 2008). This finding supports the inclusion of the information rich doctor rating system into medical tourism portals.
The results also have practical implications. Today, many doctor rating web sites have only overall single rating system while some sites have multiple rating systems covering more details about the same doctor. The results of this study suggest that sites that adopt a more comprehensive rating scale will be more likely to engender trust in their users and will increase their willingness to transact. The results of this study provide insight to medical tourism agencies, portals, and providers for what patients are expecting from the doctor rating systems on their sites. Patients benefit from sites that adopt a comprehensive doctor rating system because it allows them to gain a comprehensive view of the doctor over all aspects of the medical experience.
This study has made two contributions to the theory. The first and main theoretical contribution of this study is the design of the standard doctor rating system strictly following the design science research approach. The second contribution is empirical verification of a research model that puts together the domain knowledge of reputation systems, information quality, and trust to explain the dynamics of decision making on medical tourism infomediary. Although these relationships have been investigated in prior literature, they were investigated separately and in different contexts.
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This study takes it further to investigate these constructs and their relationship in a more comprehensive research model in a different context, medical tourism context.
There are some limitations to this study. The limited sample size was largely drawn from the general U.S. population. This may pose limitation to the generalizability of the results. Further studies should be designed to include medical tourism patients and sample from other countries in order to strengthen the generalizability of the findings. In addition, the practical validity of findings of this study need to be tested using a real implemented project. It is possible that although detailed ratings are desirable but that patients may be unwilling to spend the time necessary to rate doctors and medical tourism sites on all of the dimensions proposed in this doctor rating scale. Future research is needed to optimize the scale in terms of information comprehensiveness vs willingness to complete the survey.
To conclude, there has been a strong need to reduce the challenge of information asymmetry in medical tourism process. Till now, mediation services have been rare in this space; those currently available do not meet the demand of providing accurate and reliable information. By using the rating system proposed in this paper, providers can help patients get accurate and reliable information, and as a consequence, patients can make informed decision about their treatment options before making a commitment to travel abroad for treatment. Results of this study suggests that a platform that incorporates detailed doctor and administrative ratings will improve a patients trust in the medical tourism portal and their willingness to travel abroad for treatment. The results from this study are expected to be generalizable to other contexts as well. However, further research is required to validate the generalizability of the results.
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CHAPTER III
KNOWLEDGE SHARING IN HEALTH INFOMEDIARY: ROLE OF EMOTIONAL EMPOWERMENT AND SELF-ESTEEM
3.1. Abstract
Health infomediaries are emerging as important knowledge sharing platforms that help patients manage their own health outside of the traditional healthcare delivery models. Patients participate in health infomediaries to learn from other patients experience and knowledge. Knowledge sharing, thus, is an important aspect of success of a health infomediary. However, how an individuals self-concept influence knowledge sharing in infomediaries remains unexplored. This study posits that self-efficacy, social identity and self-stigma drive a patients knowledge sharing in an infomediary through patients emotional-empowerment and self-esteem attributes. We anchor to the health belief model to propose a two-stage model and testable hypotheses. We analyze a secondary archival data of 222 patients participating in the health infomediary specialized in reconstructive surgery using structural equation modeling and econometric methods to find support the hypotheses. Findings broadly suggest that the empowerment or selfesteem path-based approaches would be effective to motivate patients for knowledge contribution in the health infomediary. We explain the managerial insights and contributions of our study.
Keywords: self-esteem, knowledge sharing, self-stigma, self-efficacy, social-identity, health infomediary.
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3.2. Introduction
Health infomediaries are online platforms, portals, websites, and discussion forums dedicated to health; with the objective of bringing patient-provider or patient-patient together to inform and to share knowledge for health management (Khuntia et al. 2017; Song and Zahedi 2007). Health infomediaries offer health and wellness related information, including advice, guidance, and health evaluation functionalities (Zahedi and Song 2008), with the broad objectives to improve health outcomes for participating patients on these online platforms (Wimble 2016).
The importance of health infomediaries stem from a major constraint in current health care systems (i.e., directing patients to hospitals and clinics for small issues, suggestions, diagnosis or treatment), and inadvertently necessitate complicated logistical, scheduling and financial prerequisites (Currie 2009; Mays et al. 2009). While the existing models usually work, but they lack just-in-time care delivery at the patients end. Providing better access to health care through information is the objective of most health infomediaries. This objective is achieved by disseminating information and knowledge from other patients and providers, and making it available to prospective patients (Harwell et al. 2015; Yim et al. 2015). Thus, health infomediaries provide avenues for management of ones own health by patients. Furthermore, communication and coordination through infomediaries can grossly undercut operational costs for health delivery. Patients may be able to get help and advice to manage their own disease from a doctor via web-based communications. Consequently, the care delivery process can involve and engage a patient, rather than overly relying on the institutional process (Deng et al. 2013). In other words, health infomediaries, as artifacts of social media oriented to
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healthcare, have a potential to change the health care delivery paradigm, from being provider-oriented, to be patient-oriented, by empowering and engaging patients with their own health management process (Leroy and Harber 2016).
Irrespective of the perceived potential for health infomediaries in health care delivery, not many have been successful. Infomediaries like patientslike.com, realself.com and webmd.com claim to reach to millions of users; whereas others like rxwiki.com, doctorondemand.com, healthboard.com, are struggling to create a widespread user base (see Appendix A for a representative list of several well ranked and struggling health infomediaries). These examples suggest that unless a critical mass is achieved, and too few of the participants engage in activities, the infomediaries will not sustain. On the contrary, the value of infomediaries increase exponentially as more users join and participate, quite like any other two-sided network (Seraj 2012). Recruiting and eliciting continuous participation from users is challenging (Zahedi and Song 2008). In this regard, it is important that infomediaries fulfill patient-oriented goals that can attract users, such as providing engaging platforms for knowledge discussions, or sharing of patient-patient experiences. Involved and motivated user participation and engagement leads to the creation and accumulation of a knowledge repository, which in turn serves as part of a system that attracts and benefits a patient community (Sherer 2014). Once a user base is created, physicians and other vendors are more likely to participate and may provide financial resources for the infomediaries. Overall, for health infomediaries to be sustainable, user engagement and knowledge exchange are essential (Khuntia et al. 2017; Yim et al. 2015). This process underscores the need for a motivation-oriented approach,
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i.e., motivating patients to participate and contribute to the knowledge base of an infomediary.
Regardless of the importance of knowledge sharing in health infomediaries, there is a gap in existing literature regarding what leads patients to contribute knowledge in infomediaries. Prior studies note that it is important to understand the factors related to knowledge sharing on health infomediaries; which would help to manage the infomediary effectively from the initiation to development (Iriberri and Leroy 2009). Some suggest that health infomediaries can play a role in the patients self-motivation and self-empowering process being helpful in sharing discuss issues that may be difficult in current face-to-face (e.g., clinics, doctor offices) institutional settings of healthcare systems (Corrigan 2004; Wills and DePaulo 1991). For instance, HIV-discussions carry a stigma, and patients may not feel comfortable discussing it with doctors (Emlet 2006). Health infomediaries can help in this process by enabling discussions while keeping a patients privacy or identity secured. In addition, health infomediaries can use automated design schemas that can lead patients to ask questions, seek answers or solutions and in turn be able to self-manage a disease (Deng et al. 2013). To achieve this end, patients need to feel that asking such question in the infomediary is helpful to him or her, or that sharing such knowledge is valuable. Empirical investigation of this role of empowerment on knowledge sharing in health infomediary remains a gap that this current study tries to fulfil.
We ask the research question: How do empowerment and self-esteem motivate patients to share knowledge in health infomediaries? We anchor to the health belief model and the concepts of self and empowerment in social-psychology literature to
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conceptualize and test a two-stage model. The first stage suggests that three dimensions of self-concept, i.e., self-efficacy, social identity and self-stigma, influence patient empowerment and self-esteem. The second stage predicts how empowerment and selfesteem shape the knowledge sharing behavior.
We used a secondary archival dataset of a sample of 222 reconstructive surgery patients participating in a health infomediary for the empirical analysis of this study. Reconstructive surgery is performed to treat structures of the body affected aesthetically or functionally by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. The common feature is that the operation attempts to restore the anatomy or the function of the body to normal. It is generally done to improve function and ability, but may also be performed to achieve a more typical appearance of the affected structure. It is reported that the current reconstructive surgery market is more than $20 billion and is expected to reach over $27 billion by 2019 (PRNewswire Research and Markets 2015). In addition, many patients avail such services out of their host country, to save money, for privacy and/or faster service availability. In this context, prior- and post-information and knowledge associated with the surgery plays an important role in reducing information asymmetry, and supporting the patients decision making and post-operative management process. Thus, the reconstructive surgery context is a rich one and is appropriate for this study.
We used both structural equation modeling and econometric approaches for our empirical analysis. The findings highlight the importance of self-concept on knowledge sharing, mediated through the empowerment and self-esteem paths. Comparative analysis of the two mediated paths reveal that self-esteem path may be better for self-efficacy and
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internalized self-stigma to knowledge sharing, the emotional empowerment path is better from social identity to knowledge sharing. These findings contribute to understanding the factors as well as mechanisms for knowledge sharing in the infomediary. We discuss the results of our analysis from the health infomediary growth and sustainability perspectives, and provide managerial implication and theoretical contributions that can be extended to other studies in future.
3.3. Prior Work and Theoretical Background
This study is focused on how a feeling of self-worth (e.g., self-esteem), and a control-perception regarding ones health (e.g., empowerment) motivates an individual (manifested through a self-concept consisting of three attributes of self-efficacy, self-identity, and self-stigma) and influences the process of knowledge sharing in the health infomediary.
Prior work on health infomediaries include establishing definitions for health infomediaries or the attributes of health infomediaries (Vega et al. 2011b), qualitatively exploring inhibitors and motivators (Ambrose and Basu 2012), classification of user categories (Yim et al. 2015), and trust, privacy and information use issues within infomediaries (Bansal et al. 2010; Lim and Kim 2012; Zahedi and Song 2008) (see Appendix B for a review of representative literature). Existing studies allude to the need for knowledge sharing and the role of user empowerment in this process (Khuntia et al. 2017; Marabelli etal. 2014).
The concept of self is highly relevant to health and health infomediaries. Studies note that understanding the self-related factors that can motivate users knowledge sharing is a key to the initiation or development of the community (Iriberri and Leroy
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2009). Social-psychology literature has established self-concept as a multi-dimensional concept that integrates a collection of beliefs about oneself (Greenwald et al. 2002); and consists of at least three aspects: (1) self-efficacy, (2) social-identity, and (3) internalized self-stigma. Self-efficacy refers to the confidence in one's ability to complete a task within a particular context (Bandura 1997). Social-identity is the acknowledgement of ones position in a social milieu or group that a person can connect to or belong to (Abrams and Hogg 2006; Tajfel and Turner 2004), where a social group is a set of persons having a common social identification (Morgan 2016; Stets and Burke 2000). Ones social identity is gradually formed during a persons growth, and is integral to the process of forming ones esteem. Finally, internalized self-stigma is the change in or deterioration of ones self-esteem or self-worth as the result of labeling oneself as socially unacceptable (Corrigan 2004; Goffman 2009).
Self-esteem refers to the feeling of self-worth. More specifically, when ones selfesteem is dependent on the outcomes within a single domain, it is referred to as contingent self-esteem (Crocker et al. 2003). In other words, contingent self-esteem refers to the situation when ones self-esteem can be affected by, or is staked to the outcomes of events within a specific domain (Crocker and Park 2004). Self-esteem is gradually developed from childhood through adolescence, and may change depending on change in understanding of self-worth, or the feeling of self-worth.
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Figure 4. Conceptual model
Empowerment refers to a process by which individuals, groups, or organizations gain control over matters that are of interest to them (Perkins and Zimmerman 1995). Prior studies also note that empowerment may vary in different contexts (Robert et al. 2000). In the context of a health infomediary, empowerment may include tools that support patients ability to manage and monitor their health, thus helping them to feel better (Grando et al. 2015; Khuntia et al. 2017). Patient empowerment, a relatively new concept, includes support in developing treatment strategies and exchanging knowledge, as well as encouraging patients to take responsibility for their own health (Salmon and Hall 2003). Empowerment can have multiple dimensions, however, emotional empowerment (as used in this study) captures the underlying psychological state of being empowered, and is relevant to patients contexts in shaping their state of mind towards health management (Deng et al. 2013).
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The conceptual model for this study (see Figure 4) anchors to the health belief
model which suggests that people's beliefs about health problems, perceived benefits of action, barriers to action, and self-efficacy explain engagement (or lack of engagement) in health-promoting behavior (Janz and Becker 1984). Individuals will act regarding health outcomes when they believe that such action can lead to better outcomes. This health-promoting behavior must be triggered by a cue to action. We posit that self-esteem and empowerment are two enablers for the cue to action process, and map the health belief model to suggest the two-stage conceptual model. The first stage suggests that the belief about ones health management is manifested through the three dimensions of the self-concept, e.g., self-efficacy, self-identity, and self-stigma. We hypothesize that the belief factors related to self-efficacy, social identity, and internalized self-stigma impact appearance-contingent self-esteem and emotional empowerment (stage 1 of the conceptual model), which in turn will influence the patients knowledge sharing on the health infomediary (stage 2 of the conceptual model). Table 7 provides a summary of our hypotheses and arguments to link the constructs in the conceptual.
Table 7.
Theoretical Mechanisms Linking the Constructs in the Conceptual Model
Relationships Hyp. Linking Mechanisms/ Arguments Association
Self-Efficacy Emo. Emp. Hla Inhibition overriding Sense of improvement in belief Positive
Self-Efficacy Self Esteem Hlb Negative
Social Identity Emo. Emp. H2a Positive distinctness Achievement motivation Social value orientation Positive
Social Identity Self-Esteem H2b Positive
Self-Stigma Emo. Emp. H3a Awareness of stereotypes Identification of stereotypes Efficacious evaluation Negative
Self-Stigma Self Esteem H3b Positive
Emo. Emp. Knowledge Share H4a Pursuance or lack of innovative actions Monitoring and forward influence Positive
Self-Esteem Knowledge Share H4b Negative
Emo. Emp.: Emotional Empowerment
The first set of hypotheses (HI a and Hlb) propose that self-efficacy influences
emotional empowerment and self-esteem. The self-efficacy concept notes that as a
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person feels skillful in managing a task, process, or situation, he or she feels enabled, empowered, and less inhibited (Bandura 1997). Higher self-efficacy or confidence in managing health involves the overriding of inhibitions related to the disease management process (Bong and Clark 1999). Conversely, lack of self-belief or self-control can lead to a sense of powerlessness and subsequent ill-health (Graffigna et al. 2013; Tengland 2008). Similarly, feeling a sense of empowerment can lead to the execution of actions required in care treatment or management (Aujoulat et al. 2007). The outcomes in health-focused motivation include a goal-directed approach and willingness to engage in behaviors to reach these goals, such as adhering to medication regimes, seeking and following treatment procedures, and other health-related behavior adjustments or lifestyle changes (Janz and Becker 1984; Moorman and Matulich 1993). Thus, we argue that with higher self-efficacy, a patients feeling of increased power with respect to managing his or her health situation may increase (Deng et al. 2013), thereby leading to higher empowerment. Based on these arguments, we hypothesize that:
Hla: Self-efficacy of reconstructive surgery patients participating in the health infomediary is positively associated with emotional empowerment.
Along with the influence of self-efficacy on empowerment, we also argue that self-efficacy may reflect a gap on the patients part. As much as self-efficacy motivates a person to use available avenues to find solutions to problems, the process of enabling self-efficacy may lead a person to discover or explore the problems with his or her body or appearance (Aujoulat et al. 2007). In other words, higher self-efficacy should result in a person discovering that there are external ways and means to address appearance or body related challenges. Hence, his or her self-esteem is less likely to
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fluctuate with appearance problems; or to put it simply, higher self-efficacy might result in a reduction of the dependency of self-esteem on appearance. Thus, we hypothesize:
Hlb: Self-efficacy of reconstructive surgery patients participating in the health infomediary is negatively associated with appearance-contingent self-esteem.
The second set of hypotheses (H2a and H2b) propose that social-identity influences emotional empowerment and self-esteem. We argue that these relationships are based on three underlying concepts relevant to positive distinctness, achievement motivation, and social value orientation. First, social identity provides a positive distinctness that an individual belongs to a group. Being in a group is distinct from others who are either not part of the group, or part of other groups (Hogg et al. 1995). With a higher sense of belonging to the group, an individual derives a positive vibe that people accept him or her, and promoting good appearance related feelings (Tajfel and Turner 2004). For instance, individuals who are exposed to others who have the same issue on the health infomediary will develop a sense of belonging and feel better about his or her appearance. If he or she feels that people accept how he or she looks, it increases confidence in his/her appearance. This leads to a higher appearance related selfesteem and empowerment regarding his or her overall health.
Second, higher social identity means that people have higher motivation or desire to achieve, maintain or enhance aspects of their life. Group affiliations provide people with an increase in their motive for achievement, and subsequent positive vibes (Abrams and Hogg 2006). A group of similar patients participating in a health infomediary usually motivates each other to overcome their fears, to ignore criticism, and to see their real value. That enhances their feeling of self-worth, which can contribute to a desire to feel
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and look better. As a result, they increase their appearance-contingent self-esteem and
empowerment.
Third, high group affiliations or social identity of individuals can be classified as possessing either prosocial or competitive social value orientations (Balliet et al. 2009). Behavior that is congruent with one's social value orientation increases social worth related confidence. This then becomes the source of self-esteem. For example, pro-socials may gain higher confidence through helping others on the health infomediary because they value the benefits of the group more than their own benefits. On the other hand, individuals with a competitive social value orientation tend to be more concerned about themselves rather than the benefits of society (van Lange et al. 2013). They would take actions that make them look better and allow them to gain recognition from other group members, which in turn will make the person to look and feel better to increase appearance related self-esteem. In other words, social identity drives prosocial or competitive social value orientations that convert into better appearance related confidence, an increase in self-worth or self-esteem, and an increase in confidence in their ability to manage their own health. Based on these arguments, we hypothesize:
H2a: Social identity of reconstructive surgery patients participating in the health infomediary is positively associated with emotional empowerment.
H2b: Social identity of reconstructive surgery patients participating in the health infomediary is positively associated with appearance-contingent self-esteem.
The third set of hypotheses (H3a and H3b) propose that internalized self-stigma influences self-esteem and emotional empowerment. We argue that these relationships are based on three mechanisms: awareness of stereotypes, identification with stereotypes,
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and efficacious evaluation. The underlying concept behind self-stigma is that it occurs when individuals buy into societys conceptions or misconceptions about ones condition (stereotyping), and is further aggravated by an individuals internalization of negative feelings (internalized self-stigma) (Ritsher et al. 2003). Subsequently, this leads to feelings of shame, anger, hopelessness, or despair that keep them from seeking social support, employment, or treatment for their health conditions (Ritsher et al. 2003; Vauth et al. 2007).
Higher self-stigma involves awareness and identification of stereotypes in the society (Major and O'Brien 2005). For example, stereotypes about mental illness include blame, dangerousness, and incompetence (Corrigan and Kleinlein 2005). Being aware of the stereotypes, the individual may ignore or identify with the stereotyping. Identification with the stereotyping can lead to a feeling of inadequacy and subsequent depression (Cox et al. 2012). Such a depressive state lingers and interferes with daily life and health management; affecting energy and empowered feelings (Brohan et al. 2011; Goldstein and Rosselli 2003; Timulak and Elliott 2003). The individual would then need professional help rather than a self-empowering path to improved feelings (Timulak and Elliott 2003).
Agreement or disagreement with existing stereotypes may not be sufficient to produce self-stigma. Internalization of self-stigma requires a person to apply stereotypes to one's self (I am not good looking, and so I am the one to be blamed for my disorder; or, I am responsible for my mental disorder) (Watson et al. 2007). This is a process of efficacious evaluation on the part of an individual, and may generate positive or negative reactions. As an individual internalizes self-stigma, it can be difficult for him or her to
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fight the reactions or elements of the reactions to the stereotyping (Corrigan 2004;
Ritsher et al. 2003). In addition, individuals who internalize self-stigma related to their appearance (i.e. body image, facial attributes, obesity) are ashamed of their attributes or appearance (Franklin et al. 2006; Smolak 2004). The shame of their appearance means lower feeling of self-worth because of their appearance or higher appearance-contingent self-esteem (Franklin et al. 2006; Strauss 2000). The implications of this argument are two-fold: (1) internalized self-stigma lowers self-esteem when ones self-esteem is highly contingent on appearance; hence (2) higher internalized self-stigma will have higher impact on persons with high appearance-contingent self-esteem.
High self-stigma is usually associated with high anxiety (Lysaker et al. 2010). Knowing that one has some inferior attributes, a person would often remind oneself of the inferior quality and would result in anxiety. This is especially the case when a person has low efficacy. A person with low self-efficacy will be more likely to concern with ones inferior attributes or quality whereas a person with high self-efficacy tends to be more confident in ones ability and less worried about ones inferior attributes (Corrigan et al. 2006).
Two examples would substantiate our arguments. An unattractive individual may be bullied from early childhood and might associate the bullying experiences with being unattractive. The feeling of being unattractive is highly internalized, and is stereotyped as ugly. This internalized self-stigma would lead to a situation of being embarrassed about their identity, capability, or attributes (i.e. appearance) because they had a bad experience and developed self-stigma based on it. Such process may lead the person to feel that he or she cannot do anything about it, thereby reducing empowering feelings (Ilic et al. 2013).
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As another example, being labeled as oversized or obese also tends to impose stigma on that person and influence ones self-esteem, especially when ones self-esteem is highly dependent on appearance. As an obese person internalizes self-stigma, self-esteem is more likely to fluctuate with one's appearancethereby increasing the degree of appearance-contingent self-esteem. Based on these discussions, we hypothesize:
H3a: Internalized self-stigma of reconstructive surgery patients participating in the health infomediary is negatively associated with emotional empowerment.
H3b: Internalized self-stigma of reconstructive surgery patients participating in the health infomediary is positively associated with appearance-contingent self-esteem.
The fourth andfinal set of hypotheses (H4a and H4b), relevant to the second stage of the conceptual model, propose that appearance-contingent self-esteem and empowerment influence knowledge sharing behavior. The underlying concept behind psychological or emotional empowerment is that it energizes and sustains individual behaviors (Thomas and Velthouse 1990). Conger and Kanungo (1988) posit that empowerment stimulates and manages innovativeness, and they are inextricably linked. Once empowered individuals are motivated to make a change, they are more likely to take some innovative action to achieve a desired outcome. In the context of health infomediaries, such action will involve seeking and sharing disease or health related information.
The concept of monitoring and forward influence attempts to influence someone else, either peer or higher in a community or team (Gajendran and Joshi 2012; Kirkman et al. 2004). The sense of control and power derived from empowerment leads people to engage in influencing actions (Janz and Becker 1984; Vecchio 2007). Similarly, high
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degree of self-confidence or competence, stemming out of empowerment is a critical predeterminant for influencing actions, such as words, dialogues, convincing actions, and knowledge sharing behaviors (Hsu et al. 2007). Thus, emotional empowerment can also involve encouraging other users or patients about the value of their knowledge and experience and the contribution it makes to other patients. Emotionally empowered patients are confident and they prefer to lead conversations rather than being observers or followers (Khuntia et al. 2017).
In contrast to empowered individuals, individuals with high appearance-contingent self-esteem are less likely to be responsible for innovative behavior oriented action (Crocker et al. 2003; Knee et al. 2008). Thus, we argue that emotional empowerment is the primary enabler for an individual to take a new action or engage in innovative behavior, such as sharing knowledge about health. Appearance contingent self-esteem, on the other hand, does not provide any action oriented push. Rather, appearance-contingent self-esteemed individuals exhibit pride- or ego-centric melancholic behavior (Jung and Lee 2006; Stefanone et al. 2011), which makes them less likely to engage in sharing processes.
Individuals with high self-esteem exhibit more self-monitoring behaviors than forward influencing behaviors (Gajendran and Joshi 2012; Kirkman et al. 2004). Monitoring, in appearance-contingent self-esteem, involves assessing deviations from a desired appearance. This would involve controlling appearance related attributes, in a highly self-oriented process rather than influencing process. Thus, self-esteem based monitoring would be an antithesis of forward-influence or sharing behaviors. Such behavior would be aggravated especially in health infomediaries, as any sharing of
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information by an individual with higher self-esteem may be perceived as sharing something personal and private (Bansal et al. 2010). For example, when discussing reconstructive surgery, one would probably need to show the images of before and after the surgery; that would be perceived as a privacy-intruding activity by an individual with higher appearance-contingent self-esteem. Thus, we posit that empowerment would be positively associated with knowledge sharing, whereas appearance-contingent selfesteem has a negative influence on knowledge sharing:
H4a: Emotional empowerment positively influences knowledge sharing behavior within a health infomediary.
H4b: Appearance contingent self-esteem negatively influences knowledge sharing behavior within a health infomediary.
3.4. Research Methodology
3.4.1. Data Collection and Research Method
This study uses the secondary archival data of 222 patients collected by a consulting firm. The consulting firm has been keeping track of patients with reconstructive surgery issues and their engagement in a health infomediary. The data set is a subset of a much larger dataset as the company continually tracks online behaviors on a health infomediary and occasionally follows up with online surveys.
The data is filtered by treatment for cosmetic and reconstructive surgeries only. The surveys were sent out to 2,542 members with valid email address and who were actively participating in the cosmetic and reconstructive surgery forum between 2014 and 2015. After the incomplete responses were removed, the data contains the responses and demographic data from 222 patients. The response rate was 8.73% and there was no
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significant difference in demographic attributes between responded and non-responded members. These data have already been de-identified by the consulting firm before sending to the researchers. Most of the respondents (87.7%) are female. This is consistent with the prior studies and contextual observation that reconstructive surgery patients are predominantly females (95.6%) (Schlessinger et al. 2010).
The company that provides the data has been providing the data for many academic studies and has been known to be rigid in crafting the survey questions. However, we ensure the validity of the survey questions by mapping them to the equivalent measurement items found in prior literature. Only the survey questions that match with equivalent measurement items for the constructs were included in the analysis. Therefore, these items have already been tested for reliability and validity, and are accepted among academicians. All variables were reflectively coded. Appendix C provides the coding scheme of the variables. Table 8 provides a description of the variables used in this study.
Table 8. Description of Variables
Variable Description
EFF Self-Efficacy: The confidence in one's ability to complete a task within a particular context.
SID Social Identity: One's acknowledgement of a social group that he or she belongs to.
ISS Internalized Self-Stigma: Internalization of negative feelings, shame, anger, hopelessness, or despair.
CSE Contingent Self-Esteem: When ones self-esteem is dependent on the outcomes within a single domain.
EMO Emotional Empowerment: The psychological trait or dimension of empowerment, involving the process through which people and groups gain greater control over their lives.
KSB Knowledge Sharing Behavior: The behavior when a person disseminates his/her knowledge to other members within the community.
AGE Age of the respondent.
EDU Highest education attained by the respondent.
INC Income of the respondent.
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3.4.2. Data Analysis and Results
We employ two-stage estimation procedures to test and validate our empirical model. The first stage tests to what extent the self-concept beliefs (self-efficacy, social identity, and internalized self-stigma) explain the infomediary contingent actions (CSE and EMO), whereas the second stage further examine to what extent the infomediary contingent actions explain knowledge sharing behavior (KSB). We use partial least square (PLS), a component-based structural equation modeling (SEM) technique, to estimate the path coefficients. The PLS is widely used for path modeling especially when there are multiple latent variables in different stages, which makes it difficult for standard regression techniques (Garson 2016). More specifically, PLS makes no prior assumptions about data normality, which makes it ideal for our research setting. Although PLS technique is recommended for an exploratory model rather than a confirmatory model, PLS is accepted when the model specification is supported by prior literature (Garson 2016).
The first set of hypotheses predict the influence of self-efficacy on emotional empowerment and appearance-contingent self-esteem. We find that self-efficacy has a positive and significant effect on emotional empowerment (ft = 0.37, p<0.01), supporting hypothesis HI a. Results show the self-efficacy has a negative and significant effect on self-esteem (ft = -0.17, p 0.01), supporting hypothesis Hlb. Thus, while self-efficacy has a positive association with emotional empowerment, it negatively affects appearance-contingent self-esteem.
In regard to the second set of hypotheses, we find that social identity has a significant positive effect on appearance-contingent self-esteem (ft = 0.15, p 0.05),
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supporting hypothesis H2a. Similarly, hypothesis H2b is also supported with social identity having a positive and significant coefficient in the analysis results (fi = 0.16,
p<0.01).
Stage 1 Stage 2
Figure 5. Results of Partial Least Square Estimation (N=220)
The third set of hypotheses related self-stigma with the empowerment and selfesteem variables. Results show that self-stigma has a negative and significant association with emotional empowerment (fi = 0.11, p<0.1), supporting hypothesis H3a. Furthermore, H3b is also supported, with a positive and significant coefficient (fi = 0.47, p<0.01) for the association between self-stigma and appearance-contingent self-esteem.
Finally, we also find support for the fourth and final set of hypotheses. Emotional empowerment has a positive and significant effect on knowledge sharing behaviour (fi = 0.27, p<0.01). Likewise, appearance-contingent self-esteem is significant, but has a negative effect on knowledge sharing behaviour (fi = 0.40, p<0.01). Therefore, all hypotheses are supported and the results are in line with prior literature and similar
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studies in different contexts (Crocker et al. 2003; Deng et al. 2013; Hsu et al. 2007;
Kirkman et al. 2004; Knee et al. 2008; Lee Endres et al. 2007; Vauth et al. 2007)
3.4.3. Validity and Reliability Tests
Table 9 shows the descriptive statistics for all variables along with the pairwise correlations. The pair-wise correlation between variables is below 0.7 indicating no sign of multicollinearity. Table 9 also shows that internal consistency (Cronbachs Alpha) of all variables are between 0.79 and 0.88. All of which are higher than the suggested threshold of 0.7 (Gefen et al. 2000a). Table 10 shows that loadings of the indicators on their underlying constructs are higher than or equal to the suggested threshold of 0.7. Discriminant validity can be observed in two ways: (1) when the indicators load much higher on their underlying construct than on the others, and (2) when average variance extracted (AVE) is higher than 0.5 and the square root of AVE is higher than intercorrelations between the underlying construct and all other constructs. The two conditions for AVEs for all constructs were very well satisfied as shown in Table 9. Hence, discriminant validity is observed. Cross loadings from Table 10 shows that all indicators loaded highly on their underlying constructs and not on other constructs. This pattern demonstrates high convergence validity and high discriminant validity.
Table 9, Descriptive Statistics and Pair Wise Correlation Among Variables
Obs Mean S.D. Min Max Alpha AVE 1 2 3 4 5 6 7 8 9
EFF 222 5.82 1.17 1 7 0.86 0.71 0.84
SID 222 3.35 1.64 1 7 0.88 0.74 -0.01 0.86
ISS 222 3.00 1.88 1 7 0.91 0.79 -0.29 0.09 0.89
CSE 222 3.99 1.69 1 7 0.87 0.72 -0.32 0.21 0.56 0.85
EMO 222 4.64 1.50 1 7 0.80 0.71 0.40 0.12 -0.22 -0.27 0.84
KSB 222 5.59 1.44 1 7 0.81 0.72 0.59 0.11 -0.56 -0.47 0.37 0.85
AGE 222 3.43 1.40 1 6 1.00 1.00 0.08 -0.04 -0.18 -0.26 0.12 0.22 1.00
EDU 220 4.40 0.73 2 5 1.00 1.00 -0.04 0.08 0.05 -0.07 -0.07 -0.05 -0.15 1.00
INC 220 3.58 2.21 0 9 1.00 1.00 0.00 0.07 0.07 -0.02 -0.02 -0.12 -0.09 -0.21 1.00
Note: Correlations above 0.2 are significant atp<0.05 level; the elements in the matrix diagonals represent the square root of AVEs.
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Table 10. Cross-loadings of Items for Variables
EFF SID ISS CSE EMO KSB
EFF1 0.81 0.01 -0.24 -0.31 0.32 0.54
EFF EFF2 0.85 -0.01 -0.22 -0.23 0.33 0.44
EFF3 0.83 -0.05 -0.25 -0.28 0.41 0.50
EFF4 0.88 0.01 -0.26 -0.26 0.29 0.51
SID1 -0.08 0.83 0.14 0.25 0.00 -0.01
SID SID2 -0.01 0.87 0.01 0.15 0.18 0.13
SID3 0.03 0.86 0.10 0.18 0.08 0.13
SID4 0.03 0.87 0.06 0.12 0.17 0.16
ISS1 -0.29 0.09 0.91 0.54 -0.26 -0.51
ISS ISS2 -0.22 0.11 0.89 0.47 -0.14 -0.48
ISS3 -0.25 0.02 0.90 0.51 -0.22 -0.49
ISS4 -0.28 0.10 0.85 0.48 -0.15 -0.51
CSE1 -0.31 0.16 0.46 0.85 -0.27 -0.42
CSE CSE2 -0.24 0.18 0.48 0.88 -0.21 -0.42
CSE3 -0.27 0.16 0.38 0.81 -0.25 -0.34
CSE4 -0.28 0.19 0.57 0.85 -0.18 -0.41
EMOl 0.32 0.17 -0.16 -0.16 0.87 0.28
EMO EM02 0.31 -0.03 -0.23 -0.25 0.82 0.32
EM03 0.39 0.16 -0.18 -0.26 0.84 0.34
KSB1 0.51 0.11 -0.51 -0.48 0.37 0.90
KSB KSB2 0.51 0.03 -0.48 -0.40 0.30 0.84
KSB3 0.50 0.17 -0.43 -0.28 0.26 0.80
3.4.4. Robustness and Sensitivity Tests
The model is first estimated without control variables and later all control variables are added to the model. The results remain almost unchanged after adding the control variables. Gender is not used as a controlled variable because more than 95% of
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respondents were female, and hence controlling for gender will not yield any useful insights. Consequently, the results may not be generalizable across gender. Among the control variables, only the effect of age on contingent self-esteem is significant with the coefficient of -0.16 atp< 0.01 while the others are not significant.
We tested for multicollinearity by computing condition indices. The mean variation inflation factor (VIF) is less than 7 in our models, indicating that multicollinearity is not a serious concern in our analyses. In addition, because the dependent and independent variables are from the same survey instrument, we conduct Harman's one-factor test to assess the sensitivity of our results to common method bias. The principal component analysis for key variables yields multiple factors, some with eigen-values exceeding one. Because no single factor emerges as a dominant factor accounting for most of the variance, common method variance does not seem to be a serious problem.
3.4.5. Econometric Analysis and Results
In addition to PLS, we use structural econometrics that imposes more restrictions on underlying assumptions to improve causal relations in our model and interpretability of the parameter estimates. We use the 3SLS procedure to derive parameter estimates of the full system of equations in our study. The structural model approach allows us to simultaneously and explicitly account for possible correlations among the disturbance of the specified equations (Greene 2012). In our study, CSE and EMO are simultaneously determined by the first stage model, thus making them endogenous explanatory variables for KSB in the second stage. The 3SLS procedure corrects for the endogeneity issue to derive parameter estimates.
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While the 3SLS offers efficiency gain over other approaches, it can be sensitive to incorrect specification of underlying relationships in the structural model. If any of the structural model equations are misspecified, the resulting parameter estimates are likely to be inconsistent. Thus, we also use a two-stage approach to compare with the 3SLS results for consistency. More specifically, we use seemingly unrelated regression technique to estimate the effect of the self-concept beliefs on CSE and EMO with joint probability of errors, and then, to handle the endogeneity issue, we use predicted probabilities of the two mediating variables to estimate the parameters on KSB.
The equations that we specified for the regression-based methods (SUREG and 3SLS) are:
CSE = acse + Pi Xt+ Ecse (1)
Where acse is a constant, XL is a vector of explanatory variables, /?, is a vector of parameter coefficients, and ecse is the disturbance of the function.
EMO (%emo T Pi X [ + Eemo (2)
Where aemo is a constant, XL is a vector of explanatory variables, /?, is a vector of parameter coefficients, and £emo is the disturbance of the function.
KSB = aksb + Pi Xt eksb (3)
Where aksb is a constant, XL is a vector of explanatory variables, /?; is a vector of parameter coefficients, and eemo is the disturbance of the function.
We also use ordered probit model to derive parameter estimates to complement linear regression procedure used in deriving the estimates from the 2-stage and 3-stage procedures. Since our dependent variables are measured using survey scale that has limits
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on both minimum and maximum values, it is possible that scale limits may violate the distribution assumption in the linear regression framework (Jackman 2009).
The empirical estimation equation for the ordered probit model is:
Pr (CSE = l\Xt) = <$>{Xjf3) (4)
CSE* = Xf Pi + ecse (5)
Where, Pr is probability, Xt is a vector of explanatory variables, is the cumulative distribution function of the standard normal distribution, P a vector of parameter coefficients, and ecse is the disturbance of the function.
Pr (EMO = 1| Xt) = (Xf 0) (6)
EMO* = XfPi + £emo (7)
Where, Pr is probability, Xt is a vector of explanatory variables, is the cumulative distribution function of the standard normal distribution, P a vector of parameter coefficients, and eemo is the disturbance of the function.
Pr (KSB = l\Xd = (Xjfl) (8)
KSB* = Xj + eksb (9)
Where, Pr is probability, Xt is a vector of explanatory variables, is the cumulative distribution function of the standard normal distribution, P a vector of parameter coefficients, and eksb is the disturbance of the function.
The analysis from seemingly unrelated regression (SUREG) shows that the effect of self-efficacy, social identity, and internalized self-stigma on self-esteem are all significant at p < 0.01 with the coefficient of -0.26, 0.14, and 0.44 respectively. The effect of self-efficacy, social identity, and internalized self-stigma on emotional empowerment are also significant with the coefficient of 0.46 (p < 0.01), 0.12 (p < 0.05),
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and -0.10 (p < 0.1) respectively. The effect of self-esteem and emotional empowerment on knowledge sharing behavior are -0.41 and 1.11, both at p < 0.01. Table 11 summarizes the results of econometric analyses and partial least square technique. The results of all these techniques are quite similar, thereby establishing the robustness of findings.
We also compared the R2 values across the PLS and econometric models. The R2 values in PLS model of self-esteem, emotional empowerment, and knowledge sharing behavior are 0.394, 0.203, and 0.287 respectively. In other words, 39.4% of variability in self-esteem, 20.3% of variability in emotional empowerment, and 28.7% of variability in knowledge sharing behavior are explained by the model. In the SUREG model, The R2 of self-esteem (0.396) and emotional empowerment (0.193) are very close to those of PLS while the R2 of knowledge sharing behavior (0.529) is higher than that of PLS.
The analysis from 3-stage least squares analysis is very similar to the analysis from seemingly unrelated regression. The analysis shows that the effect of self-efficacy, social identity, and internalized self-stigma on self-esteem are all significant with the coefficient of -0.25 (p < 0.01), 0.12 (p < 0.05), and 0.45 (p < 0.01) respectively. The effect of self-efficacy, social identity, and internalized self-stigma on emotional empowerment are all significant atp< 0.01 with the coefficient of 0.44, 0.18, and -0.12 respectively. The effect of self-esteem and emotional empowerment on knowledge sharing behavior are -0.41 and 1.11, both atp< 0.01. The R2 of self-esteem (0.394), emotional empowerment (0.178), and knowledge sharing behavior (0.558) are very close to that of seemingly unrelated analysis as they are both regression-based.
The analysis from ordered probit is again similar to the analysis from PLS, seemingly unrelated regression, and 3SLS. The analysis shows that the effect of self-
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efficacy, social identity, and internalized self-stigma on self-esteem are all significant with the coefficient of -0.19 (p < 0.01), 0.11 (p < 0.05), and 0.35 (p < 0.01) respectively. The effect of self-efficacy, social identity, and internalized self-stigma on emotional empowerment are also significant with the coefficient of 0.37 (p < 0.01), 0.09 (p < 0.1), and -0.07 (p < 0.1) respectively. The effect of self-esteem and emotional empowerment on knowledge sharing behavior are -0.17 and 0.16, both atp< 0.01. The effects in the second stage here are not so similar to the regression-based estimations but more similar to the PLS estimations. The estimates before adjusting for biases (residuals) are closer to the PLS estimates (-0.32 and 0.20, as compared to -0.40 and 0.27).
Table 11. Estimation Results of Seemingly Unrelated Regression, Three-Stage SLS,
Ordered Probit, and Partial Least Square
SUREG 3SLS Ordered Probit PLS
First Stage: Health I relevant Actions (EMO and CSE)
CSE EMO CSE EMO CSE EMO CSE EMO
EFF -0.26*** (0.08) Q 46* (0.08) -0.25*** (0.08) q 44*** (0.07) _0 19*** (0.06) q 37*** (0.07) -0 17*** (0.06) q 37*** (0.06)
SID 0.15*** (0.06) 0.12** (0.06) 0.12** (0.05) 0.18*** (0.04) on** (0.05) 0.09* (0.05) 0.16*** (0.05) 0.15** (0.06)
ISS q 44*** (0.05) -0.10* (0.05) 0.45*** (0.05) -0.12*** (0.04) 0.35*** (0.05) -0.07* (0.04) q 47*** (0.06) -0.11* (0.06)
AGE -0.20*** (0.07) 0.01 (0.07) -0.22*** (0.06) 0.06 (0.04) -0.16*** (0.05) 0.00 (0.05) -0.16*** (0.05) 0.06 (0.06)
EDU -0.17 (0.13) 0.09 (0.13) -0.11 (0.12) -0.05 (0.08) -0.12 (0.10) 0.06 (0.11) 0.00 (0.06) -0.05 (0.06)
INC 0.10** (0.04) -0.04 (0.04) 0.07* (0.04) 0.02 (0.03) 0.07** (0.03) -0.03 (0.03) -0.04 (0.06) -0.03 (0.06)
Obs 218 218 218 218 218 218 222 222
R2 0.396 0.193 0.394 0.178 0.084 0.039 0.394 0.203
Chi2 143.03 52.27 143.87 64.37 87.99 39.69
RMSE 1.32 1.34 1.32 1.36
S iecond Stage: Infomediary Contingent Action (KSB)
KSB KSB KSB KSB
CSE -0 41*** (0.08) -0 41*** (0.14) -0 17*** (0.06) -0 40*** (0.06)
EMO Y Yj*** (0.13) Y y i*** (0.23) 0.16*** (0.06) q 27*** (0.06)
Obs 218 218 218 222
R2 0.529 0.558 0.110 0.287
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F (2, 215) 124.10
Chi2 73.97 90.49
RMSE 1.00 1.80
GOF 0.4641
Notes: Standard errors in parentheses ***p<0.01, **p<0.05, *p<0.1 Pseudo R2 are presented for Ordered Probit results. R2and Chi2 are all significant atp<0.01.
When compared to the other statistics, in the first stage, some estimates from PLS are a bit underestimated (i.e. the effects of self-efficacy on contingent self-esteem and emotional empowerment) while some estimates are a bit overestimated (i.e. the effect of social identity and internalized self-stigma on contingent self-esteem). Overall, the estimates are consistent regardless of the methods used. In the second stage, PLS seems to be underestimated when compared to other methods. The effect of emotional empowerment on knowledge sharing behavior estimated by PLS is much lower than the effect estimated by the regression-based methods. However, there is no apparent difference in the results from all methods and the polarity of the results from all methods are consistent.
Given there are two paths in the model (e.g., emotional empowerment (EMO) and appearance-contingent self-esteem (CSE) paths) to arrive at the knowledge sharing outcome from the dimensions of self-concept, we conducted an additional mediation analysis using the suggested procedure by (Baron and Kenny 1986; Sobel 1986). The analysis compared the two paths for each of the independent variables related to self-concept (e.g., self-efficacy, social identity, and internalized self-stigma) on knowledge sharing behavior. The path comparison and mediation results are presented in Table 12. We find that while the appearance-contingent self-esteem (CSE) path provides a better
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outcome from self-efficacy and internalized self-stigma to knowledge sharing, the emotional empowerment (EMO) path is better from social identity to knowledge sharing. We provide insights and discuss these findings in the next section.
Table 12. Mediation Analysis and Path Comparison Tests
Dependent Variable Independent Variable Mediating Variable Direct Effect Coefficient Indirect Effect Coefficient Proportion of Total Effect That Is Mediated Ratio of Indirect to Direct Effect
KSB EFF EMO 0.66*** (0.07) 0.08*** (0.03) 0.11 0.12
KSB EFF CSE 0.63*** (0.06) Q YJ*** (0.03) 0.14 0.17
KSB SID EMO 0.09* (0.06) 0.04* (0.02) 0.28 0.39
KSB SID CSE 0.21*** (0.06) -0.08** (0.03) -0.60 -0.37
KSB ISS EMO -0.38*** (0.04) -0.05*** (0.02) 0.11 0.12
KSB ISS CSE -0 34*** (0.05) -0.08*** (0.03) 0.19 0.23
Note: Sample size: 218 Parameter estimates are based on Sobel-Goodman mediation tests using Stata software Sobel and/or Goodman coefficients are significant atp<0.01 levels; but significant atp<0.1 level for the KSB~Â¥SID~Â¥ EMO path Estimations include age, education and income as controls Standard errors in parentheses Significance levels: *** p<0.01, **p<0.05, *p<0.1
3.5. Discussion
3.5.1. Implications of this Study
The findings of our analysis suggest that while self-efficacy has a positive association with emotional empowerment, it has a negative association with self-esteem. Social identity has a positive association with both emotional empowerment and selfesteem. These findings suggest that people with higher self-efficacy and social identity
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will seek external validation through emotional empowerment. However, individuals with higher self-stigma will try to analyze and reanalyze their internalization and related self-worth to follow an internal self-realization path. This is validated from the finding that self-stigma is negatively associated with emotional empowerment.
Internalized self-stigma also increases appearance-contingent self-esteem. Knowing this, the infomediaries can try to alleviate internalized self-stigma by fostering social support for those with self-stigma, and by taking immediate action to intervene when the discussion may contribute to self-stigma. Developing measures to minimize the feeling of being excluded from the community or the feeling of being labeled as inferior may also help foster emotional empowerment and reduce the effect of appearance-contingent self-esteem. As an example, it may be helpful to make patients believe that the infomediary has a unique value and is a unique community, and that they are important to the community.
These insights suggest that the concept of self in a health management context is highly relevant. How an individual perceives his or her skills in regards to health management, role or identity in the society, and internalization of stigmas, such as guilt, shame or anger, are pre-cursors to the actions that the person takes towards managing his or her health. In other words, beyond the physical health itself, the psychological self has a key role to play in subsequent steps towards action such as seeking empowerment or improving feelings of self-worth.
We also find that emotional empowerment has positive effect on knowledge sharing, whereas appearance-contingent self-esteem has a negative influence on knowledge sharing. Emotional empowerment can help foster active knowledge sharing
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on health infomediaries. When infomediary members or patients are empowered, they are motivated to share their knowledge and personal experiences in the infomediaries. The empowerment can come either from other members or from the act of sharing itself. Therefore, the health infomediaries should focus on the strategies to facilitate emotional empowerment among members. For example, infomediaries could foster empowerment using mechanisms like badges based on the users level of participation.
Patients whose self-esteem is contingent on their appearance are less likely to share their knowledge in the infomediaries. This implies that patients with high selfesteem do not always share their knowledge. Only patients whose self-esteem is not highly contingent on appearance will likely share their knowledge in the infomediaries. However, as patients gain higher self-efficacy, their self-esteem tends to be less dependent on appearance, and they are more likely to share their knowledge. In other words, although the infomediaries cannot change the way the self-esteem is contingent on appearance, the infomediaries may be able to boost knowledge sharing by increasing the members' self-efficacy.
The comparative analysis of the two paths in our conceptual model (e.g., empowerment and self-esteem paths) reveal that while the self-esteem path is better to leverage on self-efficacy and internalized self-stigma on knowledge sharing, but the emotional empowerment path is better for orienting self-identity for knowledge sharing. The implications from these findings is that empowerment is a reinforcing process when a patient has greater confidence in his or her skills. Empowerment is a confidence increasing enabler in this process. Higher social identity implies that a patient has a higher propensity towards external validation, and external validation is required to
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improve ones self-concept perceptions. Whereas, self-stigma and self-efficacy is how one perceives and judges one against ones self. Therefore, these traits are less influenced by external validation and more influenced by self-evaluation. Thus, selfesteem is likely to be better than empowerment because it focuses on improving ones own well-being. On the other hand, social identity links the self with the social context. Which implies that empowerment is more likely to knowledge sharing because one needs some reinforcement from outside. Broadly, these findings suggest that not necessarily a single path is ideal; and both paths are necessary to manage knowledge sharing in infomediaries.
The implications from the path comparisons are that for health infomediaries to design intervention systems, they need to personalize the intervention systems to the patients characteristics. Rather than a panacea for all intervention to suggest that please share your knowledge through emerging chatbots, the intervention systems need to follow an assessment and recommendation system. For example, prior or current assessment using a few questions can provide if the patient has higher social identity. Then the chatbot or intervention system can suggest that by sharing your knowledge with others regarding the procedures or treatments, others will reflect on your importance; because such empowering reinforcement will work well for this patient. For a patient with higher self-stigma, perhaps the words can be framed as by sharing your knowledge with others, you will be recognized for your contribution towards helping others; since these words are intended to make the individual to feel higher self-worth. Thus, from our findings, we provide a strong recommendation towards design of intervention systems (e.g., chatbots, pop-up suggestion, or human call-agents) on the
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health infomediaries that incorporate personalized intervention systems adhering to the individualized attribute of patients; or, design personalized interventions systems.
In addition, the findings of this study may be applied to similar context. Imagine the discussion of some symptoms or diseases may be embarrassing and may be vulnerable to ones self-esteem. Some examples are erectile dysfunction, HIV disease, and sexually transmitted diseases. Self-esteem, social identity, and self-stigma are most likely the important factors influencing the discussion. Therefore, the infomediaries specialized in those diseases may be able to apply the knowledge from this study to help foster knowledge sharing on their informediaries. The knowledge from this study can be applied not only to similar types of infomediaries, but also to vendors of related products or services (e.g. medication or treatment for those diseases). However, the roles of self-concepts may vary in different context. Further research is required to validate the application to other similar contexts.
3.5.2. Theoretical Contributions of this Study
This study contributes to theory by identifying and validating the ideas of self-concept and patient empowerment and providing evidence that it can lead to patient engagement with health infomediaries. While knowledge-based empowerment plays a role in patient responsiveness within a healthcare system, the categorization and operationalization discussed in this study could lead to further discussion on the role of health infomediaries in a patients management of their own health. This is especially critical in chronic disease management, as patients who live alone need constant motivation to manage their disease. The findings also demonstrate the need for an
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effective interface and appropriate incentive structure for knowledge interaction and community engagement within a health infomediary.
In conclusion, this study provides a new perspective relevant to the self-concept (and its dimensions) and mechanisms for patient empowerment and knowledge exchange with a health infomediary. Different dimensions of self-concept and subsequent esteem and empowerment leads to higher knowledge sharing. Data collected from a health infomediary designed for reconstructive surgery patients is used to validate several hypotheses. The findings highlight the role of self-esteem, self-worth and other self-concept tenets in the health infomediary context. Most importantly, fostering self-esteem alone does not encourage knowledge sharing. Instead, the health infomediary should facilitate knowledge sharing through emotional empowerment and minimize the negative effect of appearance-contingent self-esteem through manipulation of self-efficacy, social identity, and self-stigma.
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APPENDIX
Appendix A: Health Infomediaries Widely Accessed through Internet
Name Rank Service
WebMD.com 510 Health information
myfitnesspal.com 1,234 Dietary information
dmgs.com 1,739 Drags information
healtliline.com 1,830 Health information
medicinenet.com 3,242 Health information
weightwatchers.com 4,783 Dietary information
self.com 7,494 Dietary information
realself.com 7,757 Beauty treatment information
sparkpeople.com 9,407 Dietary information
medhelp.org 9,802 Online health community
practo.com 10,634 Medical tourism
steadyhealth.com 14,304 Online health community
healthtap.com 20,985 Immediate access to doctors
healthboards.com 21,055 Online health community
fatsecret.com 22,164 Dietary information
colgate.com 25,436 Dental information
whatclinic.com 25,889 Beauty treatment information
lybrate.com 30,327 Medical tourism
calorieking.com 31,316 Dietary information
acne.org 33,591 Acne information
ehealtlifomm.com 33,990 Online health community
healingwell.com 60,824 Online health community
patientslikeme.com 100,532 Patient network community
nutritionix.com 109,004 Dietary information
medifee.com 113,648 Medical tourism
iodine.com 128,485 Drags information
medigo.com 137,548 Medical tourism
emedtv.com 146,613 Health information
health-tourism.com 147,771 Medical tourism
medbroadcast.com 154,143 Health information
docshop.com 171,478 Beauty treatment information
pdr.net 198,982 Drags information
doctorondemand.com 205,187 Immediate access to doctors
placidway.com 295,355 Medical tourism
treatmentabroad. com 326,919 Medical tourism
rxwiki.com 346,192 Drags information
dmglib.com 514,363 Drags information
MedPlus.com 13,967,152 Health information
healthboard.com 23,916,291 Online health community
healthinfonim. org 26,766,616 Online health community
Note: The websites are sorted by the rank. The rank is calculated by using a combination
of average daily visitors to this site and pageviews on this site over the past 3 months, and is available at www.alexa.com. The site with the highest combination of visitors and page\!iews are globally top ranked.
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Appendix B: Representative Literature on Health Infomediaries
Study Research Question Method, sample, context Key Findings
(Khuntia et al. 2016) How empowerment dimensions influence patient engagement in health infomediaries? Method: Econometric analysis of secondary data Data: More than 65,000 daily activities of 21,715 patients during the first 30 and 60 days Context: Health infomediary for cosmetic surgery Three types of empowerment (leadership, discretionary, and psychological) have positive association with sustained engagement; with leadership empowerment is shown to play a higher role than discretionary or psychological empowerments in sustaining engagements.
(Ambrose and Basil 2012) What is an overarching theoretical framework and key factors that motivate and inhibit patients' use of online health information systems? Method: Conceptual paper (non-empirical) Context: Online health information systems Usefulness is a motivator Inhibitors are privacy and security concerns Usages is essential to develop successful business models
(Yim et al. 2015) What are the classifications of visitors in health infomediaries? Method: Cluster analysis Data: 162,598 activities of 44,350 visitors Context: Health infomediary for cosmetic surgery Identification of 4 user categories: community supporters, experiencer providers, knowledge questors, and expertise contributors.
(Yi et al. 2013) What are the antecedents of initial trust in Web-based health information? Method: Field experiment Samples: 300 voluntary participants Context: Health information website Argument quality and source expertise positively influence perceived information quality, which in turn positively influence trust. Higher perceived information quality also leads to higher trust by reducing perceived risk.
(Lim and Kim 2012) What are the relationships among trust, information quality, and behavior intention to use health infomediaries at different trust level? Method: Survey Sample: 274 undergraduate students Context: Trust, information quality & health infomediaries In the high-trust group, trust has positive mediation effects of information relevance and information reliability on behavior intention. In the low-trust group, trust has positive mediation effects of information adequacy and information usefulness on behavior intention.
(Zahedi and Song 2008) How does trust evolve over time in health infomediaries? Method: Longitudinal lab experiment Sample: 209 students Context: Trust, information quality & health infomediaries Trust changes over time. Information quality is the most important antecedent in trust building in infomediaries. Satisfaction plays an important changing trust belief.
(Song and Zahedi 2007) What factors may impact various trust beliefs in health infomediaries? What are the natures and roles of different trust beliefs in web-users' intention to make health decision based on information from a health infomediary? Method: Survey-based experiment Sample: 494 business school students Context: Trust & health infomediaries Web users' beliefs about the ability and benevolence of the health infomediary critically affect their behavior intentions. User's propensity to trust has a significant relationship with risk related beliefs. Trust and risk beliefs positively influence web users' behaviors.
(Vega et al. 2011a) What is the trust relationship between humans and health websites? Method: Meta-analytical framework Samples: 49 papers Context: Trust in health websites There is little consensus regarding the defining characteristics of the construct of trust in health websites. Further research in this field should focus on collaboratively defining
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trust and what factors affect trust in health websites.
(Baiisal and Gefen 2010) What is the role of personal dispositions in disclosing health information online? Method: Lab experiment Sample: 367 college students Context: Trust, personal disposition & health infomediaries Trust, privacy concern, and information sensitivity influence individuals' intention to disclose health information. Trust, privacy concern, and information sensitivity are determined by personal dispositions.
(Ye 2010) Is personal capital correlated with trust in online health information? Is social capital correlated with trust in online health information? Does trust in health information from traditional media and government health agencies correlate with trust in online health information? Method: Correlation analysis of secondary data Data source: The National Cancer Institutes 2007 Health Information National Trends Survey Samples: 7,674 adults Context: Consumer trust in online health information Consumer trust in online health information did not correlate with personal capital i.e. income, education, and health status. Social capital indicated by visiting social networking Web sites was not associated with trust in online health information. Trust in online health information transferred from traditional mass media and government health agencies to the Internet. Age appeared to be a key factor in understanding the correlates of trust in online health information.
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Appendix C: Coding Scheme of Variables from the Survey Questionnaire
Variable Description and Operationalization Survey items are measured in a 7-point scale: l=highly disagree to 7=highly agree. References
Self-Efficacy (EFF) The confidence in one's ability to complete a task within a particular context. Iam confident that I could deal efficiently with unexpected events. I can always manage to solve difficult problems if I try hard enough. If I am in trouble, I can usually think of a solution. I can solve most problems if I invest the necessary effort. (Luszczynska et al. 2005; Tambs and Roysamb 2014)
Social Identity (SID) One's acknowledgement of a social group that he or she belongs to. Overall, my group memberships have so much effect on how I feel about myself. The social groups I belong to are an important reflection of who I am. In general, belonging to social groups is an important part of my self-image. The social groups I belong to are important to my sense of what kind of a person I am. (Luhtanen and Crocker 1992)
Internalized Self-Stigma (ISS) Internalization of negative feelings, shame, anger, hopelessness, or despair. My physical appearance makes me feel bad. I feel guilty about my physical appearance. Iam ashamed of my physical appearance. My physical appearance has spoiled my life. (Kalichman et al. 2009)
Contingent Self-Esteem (CSE) When ones self-esteem is dependent on the outcomes within a single domain. My self-esteem is influenced by how good looking I think I am. My self-esteem does not depend on whether or not I look good, (r) My self-esteem is not related to how I feel about the way I look, (r) My sense of self-worth suffers whenever I think I dont look good. (Crocker et al. 2003; Rosenberg 1965)
Emotional Empowerment (EMO) Emotional component of psychological empowerment, the process through which people and groups gain greater control over their lives. I would prefer to be a leader rather than a follower in a conversation. I would prefer having someone else as a leader when Im involved in a conversation, (r) Iam often a leader in a conversation. (Speer and Peterson 2000; Vauth et al. 2007)
Knowledge Sharing Behavior The behavior when a person disseminates his/her knowledge to other members within the community. (Oliveira et al. 2015; Xue et al. 2011)
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(KSB) I frequently participate in knowledge-sharing activities on health websites. I usually spend a lot of time conducting knowledge sharing activities on health websites. I usually share my knowledge with the other on health websites.
AGE Age of the respondent. Scale: 1: 18-24 years, 2: 25 34 years, 3: 35 -44 years, 4: 45 54 years, 5: 55 64 years, 6: 65 74 years, and 7. 75 years or older
Education (EDU) Highest education attained: 1: Did not attend school, 2: Pursuing high school, 3: Finished from high school, 4: Pursuing college, 5: Finished from college
Income (INC) Income of the respondent. Scale: 1: $0 $24,999; 2: $25,000 -$49,999; 3: $50,000 $74,999; 4: $75,000 $99,999; 5: $100,000 -$124,999; 6: $125,000 $149,999; 7: $150,000 $174,999; 8: $175,000-$199,999 9: $200,000 and up
Note: (r) = reverse coded.
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Full Text

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INFORMATION SYSTEMS AND PATIENT EMPOWERM ENT: ROLE OF INFOMEDIARIES IN HEA LTH DECISION MAKING b y SUMATE PERMWONGUSWA B.B.A., Assumption University, 1992 M.B.A., Assumption University, 1994 M.S. CIS, Assumption University, 2002 A d issertation submitted to the F aculty of the Graduate School of the University of Colorado in partial fulfillment of the requirements for the degree of Doctor of Philosophy Computer Science and Informatio n Systems Program 2017

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ii This dissertation for the Doctor of Philosophy degree by Sumate Permwonguswa has been approved for the Computer Science and Information Systems Program by Dawn Gregg, Chair Jiban Khuntia Advisor Ronald Ramirez Ilkyeun Ra Date: December 16, 2017

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iii Permwonguswa, Sumate (Ph.D., Computer Science and Information Systems Program ) Information Systems and Patient Empowerment: Role of Infomediaries in Health Decision Making Dissertation directed by Assistant Professor Jiban Khuntia ABSTRACT Information technology (IT) is playing a key role in health care improvement. IT artifacts enable better reach and access to health, allowing patients to manage care more effectively. Amon gst various IT artifacts, a health infomediary is an online health platform that connect s patients and providers with the purpose of sharing experience and knowledge for health management Health infomediary has a potential to facilitate patient empowermen t, which is an important concept leading to a better health. A number of health infomediaries have emerged with the attempt to share health infomediaries are useful in patient empowerment remains a research gap to be addressed. This dissertation focuses on this phenomenon and is comprised of two essays that delve into the issue of patient empowerment using infomediaries. The fir st essay explores the effect of doctor rating syste ms on willingness to take health related action in the context of health infomediary specialized in medical tourism. The study is extended to investigate the effect of trust in infomediary and information quality on willingness to travel abroad for treatme nt, as well as how doctor rating systems moderate these relationships. The second essay investigates the effect of self concept and emotional empowerment on knowledge sharing behavior in a health infomediary specialized in reconstructive surgery. The combi nation of these two essays sets the foundation for the argument that

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iv health infomediary is an IT tool that can facilitates patient empowerment through different mechanisms. These two studies have the potential to contribute to the existing literature in exploring how health IT can positively impact healthcare and how particular health IT features and attributes enhance the efficiency of healthcare delivery. Additionally, we highlight managerial implications to su pport the development and design of health IT with the goal of providing more efficient and sustainable healthcare delivery and services This dissertation also includes research and practical implications that are paramount to the formulation of the strat egies to enhance the design of health IT artifacts, which can potentially increase the overall effectiveness of healthcare delivery. The form and content of this abstract are approved. I recommend its publication. Approved: Jiban Khuntia

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v TABLE OF CONTENT S CHAPTER I. DISSERTATION OVERVIE W ................................ ................................ ............... 1 1.1 The Role of IT in Patient Empowerment ................................ ........................... 4 1.2. Health Infomediary and Patient Empowerment ................................ ................ 5 1.3. Objectives of the Studies in This Dissertation ................................ .................. 7 II. TRUST AND INFORMATIO N QUALITY ON WILLING NES S TO TRAVEL FOR MEDICAL TOURISM INFOMEDIARY ................................ .................... 12 2.1. Abstract ................................ ................................ ................................ ........... 12 2.2. Introduction ................................ ................................ ................................ ..... 13 2.3. Literature Review ................................ ................................ ............................ 16 2.3.1. Reputation Systems ................................ ................................ .......... 16 2.3.2. Information Quality ................................ ................................ ......... 17 2.3.3. Trust ................................ ................................ ................................ 19 2.3.4. Medical Portals ................................ ................................ ................ 21 2.4. Theory and Hypotheses ................................ ................................ ................... 24 2.5. Research Method ................................ ................................ ............................ 28 2.5.1. Development of the Rating System from Existing Practice ............ 28 2.5.2. Sample and Data Collection ................................ ............................. 29 2.5.3. Operationalization of Variables ................................ ....................... 30 2.6. Results ................................ ................................ ................................ ............. 32 2.7. Discussion and Conclusions ................................ ................................ ........... 34

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vi III. KNOWLEDGE SHARING IN HEALTH INFOMEDIARY: ROLE OF EMOTIONAL EMPOWERMEN T AND SELF ESTEEM ................................ .. 37 3.1. Abstract ................................ ................................ ................................ ........... 37 3.2. Introduction ................................ ................................ ................................ ..... 38 3.3. Prior Work and Theoretical Background ................................ ........................ 42 3. 4 Research Methodology ................................ ................................ ................... 53 3.4.1. Data Collection and Research M ethod ................................ ............ 53 3.4.2. Data Analysis and Results ................................ ............................... 55 3.4.3. Validity and Rel iability Tests ................................ .......................... 57 3.4.4. Robustness and Sensitivity Tests ................................ ..................... 58 3.4.5. Ec onometric Analysis and Results ................................ ................... 59 3.5. Discussion ................................ ................................ ................................ ....... 65 3.5.1. Implications of this Study ................................ ................................ 65 3.5.2. Theoretical Contributions of this Study ................................ ........... 69 REFERENCES ................................ ................................ ................................ ............ 71 APPENDIX ................................ ................................ ................................ .................. 84 A Health Infomediaries Widely Accessed through Internet ................................ 84 B Representative Literature on Health Infomediaries ................................ .......... 85 C Coding Scheme of Variables from the Survey Questionnaire .......................... 87

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1 CHAPTER I D ISSERTATION O VERVIEW Information technology has provided several tools and applications for information processing. One of the information processing tools that facilitates effective decision making is an online i nfomediary An infomediary first coined by Hagel III, is an ag ent that gathers information regarding a specific topic and provides it in one place (Hagel III and Rayport 1997; Zahedi and Song 2008) An online infome diary is hence an online information provider, which can take various forms including online discussion forums and w eb portals ( Zahedi and Song 2008) A health infomediary then refers to an online health platform that connect patients and providers with the purpose of sharing experience and knowledge for health management (Koch Weser et al. 2010; Schwartz et al. 2006) While general purpose infomediaries like answers.co m and ask.com serve a wide range of purposes, some infomediaries exist to serve more specific purposes such as mechanics, travel, food. H ealth infomediaries are among the specific purpose infomediaries and serve the health issues by providing a conduit of connection between patients and providers. When compared to other types of infomediar ies health infomediaries are unique in several ways: (1) The nature of information shared, (2) the importance of information quality, (3) factors driving the information sharing. The knowledge being shared on health infomediaries is uniquely different in that people are often sharing their personal information including th eir private and sensitive information. In general purpose infomediaries, people may be sharing information on miscellaneous topics (Adamic et al. 2008) For instance, o n Yelp, p eople share rati ng and

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2 reviews about their favorite restaurants. On car forums, people may be sharing mechanic knowledge and how to fix the engine problems. The knowledge being shared on these infomediaries is in no way as personal as the story of a woman going through br east cancer or a man asking questions about his erectile dysfunction very personal and sensitive topics (Yim et al. 2015) This essentially distinguishe s a health infomediary from other online infomediaries. The quality of the shared information is extremely important on health infomediaries since it can lead to life or death situation (Sharma et al. 2006) The information being shared on health infomediaries is certainly related to heal th issues such as diagnoses, diseases, conditions, and physicians. For example, when a cancer patient is making decision whether to under go chemotherapy, this can be a life changing decision and if made with wrong or incomplete information could result in death. The same is true for limb amputation decision for a patient with diabetes. The consequences of wrong decision can ruin life In contrast good decision can reli e ve prolonged suffering and af fliction Since health infomediaries are unique, the factors driving information sharing are likely to be different from the drivers on other infomediaries, at least in the magnitude of the effects. For example, trust is known to be one of the factors influencing in formation sharing on online infomediaries (Zahedi and Song 2008) However, much higher trust may be required for a person to share private and sensitive information on health infomediaries. Hence, there can be a difference in magnitude of the effect of trust on knowledge sharing in the context of health infomediaries. It is also possible that the magnitude change goes in differe nt direction. For example, the expertise of the

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3 information sharer may not be as important on health infomediaries as on other infomediaries. When people are looking for advice on car issues, the advice from mechanics and engineers may be more weighted mor e heavily than the advice from peer drivers. The most viewed Youtube clips for how to replace a part for a car are always from mechanics and engineers (i.e. Car & Driver Magazine, ChrisFix, Leekautorepair). On health infomediaries, the information from pa tients with the same diseases or conditions may be more valuable than the information from doctors or nurses (Khuntia et al. 2017) In other words, there exists a strong user based peer to peer learning, information sharing and knowledge exchange in health infomediaries. In addition, i t is also possible that there are some unique factors driving the i nformation sharing on health infomediaries that are not contributing factors on other infomediaries for example, motivation of a patient to share personal data with other patients such as disease condition, t he pain undergoing a surgery the emotiona l trauma associated with highly stigmatized diseases (i.e. breast cancer, HIV infection ) Therefore, it is important that the dynamics of the information sharing process in health infomediaries are investigated as well as how they influence patient empower ment Keeping in mind the importance of health infomediaries, it is only one side of the equation. Another important factor in healthcare industry in the United States is the accessibility to healthcare delivery (HealthyPeople.gov 2017) This is especially true when the current administration is push ing towards cutting the healthcare budget and repealing the Affordable Care Act (ACA) commonly known as ObamaCare (Fox and Mattingly 2017; Porter 2017) A large number of people in the U.S. do not have access to traditional healthcare services due to inability to get health insurance (Thomas 2017)

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4 Some are rejected from health insurers due to some existing conditions; many cannot afford to pay for the high premiums (CDC 2006) This crisis leads some patients to seek for an alternative healthcare service in foreign countries; hence motivating us to investigate the dynamics of medical tourism infomediary, a spe cialized category of health infomediary. 1.1 The Role of IT in Patient Empowerment Patient empowerment is the process of enhancing the ability of patients to actively manage their own health (Samoocha et al. 2010) The concept of empowerment refers to a process by which people gain control over their lives (Perkins and Zimme rman 1995; Rappaport 1987) Information systems research has adopted this definition and extended the concept of empowerment to work contexts. However, patient empowerment with IT is a relatively new concept, with only a few studies in this area (Khuntia et al. 2017) In this context of IT enabled patient empowerment, studies have highlighted diffe rent attributes, such as psychological empowerment emotional empowerment. P sychological patient empowerment is an individual level concept of empowerment (Deng et al. 2013) but consists of multi ple component s with emotional empowerment as one of its components (Christens et al. 2013; Zimmerman 200 0) IT enabled p atient empowerment may consist of p rograms designed by a provider used to educate and encourage patients with chronic diseases to manage their own health (Elzen et al. 2007; Funnell et al. 2005) Face to face empowerment has been found to be effective in improving patie (Anderson 2007) However, with the increasing imp ortance of IT and i nternet, it is believed that patient empowerment can be facilitated in the online setting and can be as effective as or even more effective than traditional

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5 face to face setting (Samoocha et al. 2010) Increasingly, information technology is perceived to provide access and delivery of healthcare to patients rather than limiting the care delivery to hospitals and clinics. For example, using telemedicine or telehealth, an IT platform enabled by synchron ized audio and video connections, patients can visit a doctor online (Chau and Hu 2002) Patients can discuss their symptoms with a doctor and the doctor can prescribe medicine or treatment without a need for physical visit. Many recent clinical studies have f ound that online intervention for patient empowerment contributes to better health outcome s (Glasgow et al. 2012; Nguyen et al. 2013; Warmerdam et al. 2008) Some studies have reported technical issues (i.e. Internet connection stability, slow loading time) as barriers to web based intervention s supporting patient empowerment but no research has investigate d the factors facilitating patient empowerment in online settings (Kuijpers et al. 2013) 1 .2. Health Infomediary and Patient Empowerment A health infomediary not only helps patients gain health related information more easily, but also it helps patients gain higher control over their own health (Khuntia et al. 2017) Health infomediaries or IT enabled platforms such as WebMD or Healthgrade .com can help patients gain more information about their diseases, and in turn, be come knowledgeable in managing their own diseases. Many countries have realized the potentials of health infomediaries and plan to integrate health infomediaries into the government initiated electronic platform of healthca re delivery at the national level (i.e. National Health Service of the Unite d Kingdom) (Currie 2009; Currie and Guah 2006)

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6 The dynamics and the flow of information in peer to peer health infomediaries like PatientsLikeMe or RealSelf go beyond mere health information. This form of health infomediar y allows patients to talk and connect to each other (Yim et al. 2015) The discussion s and connection s on PatientsLikeMe provide an opportunity for patients who are suffering with so me type of diseases to learn from the experience and knowledge of patients who had suffered the same disease or have been suffering for longer time (Khuntia et al. 2017) Some patients may have found ways to relieve or cure the af fliction. Others may have found a way to live with it. This provides p atient empowerment to both parties (Deng et al. 2013) First, patients who receive guidance a nd use it to manage their own health are empowered to fight the disease and to take necessary actions to improve their health (Samoocha et al. 2010) Second patients who provide guidance to others also feel empowered by their own actions. The feeling that their knowledge and experience is important in helping others towards better health provides the knowledge sharers with self empowerment (Deng et al. 2013; Tajfel and Turner 2004) Despite the i ncreasing importan c e of health infomediaries, literature on how health infomediaries are used for patient empowerment is scarce Existing literature has investigated the dynamics of trust on health infomediaries proposing that information quality has signi ficant effect on trust and suggesting how trust evolves over time on health infomediaries (Song and Zahedi 2007; Zahedi and Song 2008 ) However, past research has not investigate d the dynamics of patient empowerment i n health infomediaries.

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7 1. 3 Objectives of the Studies in This Dissertation The t wo essays in this dissertation focus on two key research questions, with a common theme of exploring how the participation on health infomediaries is helpful in health related decision making The studies investigate the perspective of patients in different ways. The first study is dedicated to the information quality on health infomediaries perception impacts their behaviors in the infomediaries. Both essays explore the dynamics of healt h infomediaries but focus on different areas and slightly different contexts. Essay I investigates whether the use of a medical tourism infomediary impacts the related decision making. The cost of healthcare in the United States is high an d is not affordable to many people especially when it comes to elective procedures which are not covered by many health insurance plans At the same time, the cost of healthcare in many developing countries is much more affordable while the quality of car e is about the same level. As a result, medical tourism has become an alternative for those who do not have access to health insurance or do not want to wait for a long time for the treatment. However, gathering information regarding medical treatment in o ther countries is not easy. It requires a lot of effort and time to evaluate disparate information about treatment options and to evaluate the credibility of those information. This is often a barrier to the decision to participate in medical tourism. Prior literature suggests that trust and information quality have an impact on the decision making. Therefore, in the context of medical tourism infomediary, Essay I

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8 explore s the influence of trust in infomediary and information quality on the willingness to travel abroad for medical treatment. Prior literature also suggests that different type s of rating systems can have different impact on decision making. Hence, Essay I also investigate s the influence of doctor rating systems on the willingness to travel abroad for treatment. The study includes the design of a standard criteria for doctor rating systems using a design science research approach and then incorporate s them into a prototype infomediary to investigate both direct and indirect effects of the doctor rating systems on the decision to travel abroad for treatment Essay II of this dissertation address es the research question: How does empowerment and self esteem motivate patients to share knowledge in health infomediaries. We anchor the study to health belief model and self related concepts, and propose a two stage research model focusing on the context of reconstructive surgery infomediary. The first stage of the model investigates the influence of self efficacy, social identity, and internalized self stigma on patient empowerment and appearance contingent self esteem. The second stage of the model investigates the influence of patient empowerment and appearance contingent self esteem on knowledge sharing behavior on health infomediaries. Table 1 summarizes key points in both essays. Table 1. Summary of key points in essay I and essay II Study 1 Study 2 Title Trust and information quality on willingness to travel for medical tourism infomediary Knowledge sharing in health infomediary: role of e motional empowerment and self esteem Motivation Rapid growth of medical tourism Cost, safety and concerns associated with medical tourism Impact of patient empowerment on health outcome Popularity of health infomediaries

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9 Table 1 Study 1 Study 2 Research question How does the use of medical tourism infomediary impact related decision making? How do empowerment and self esteem motivate patients to influence knowledge sharing in health infomediaries? Context Medical tourism infomediary Reconstructive surgery infomediary Health Related Decision To travel abroad for medical treatment To share knowledge on health infomediary Independent Variables Trust in Infomediary Information Quality Doctor Rating Systems Stage 1: Self Efficacy Social Identity Internalized Self Stigma Stage 2: Emotional Empowerment Appearance Contingent Self Esteem Dependent Variables Willingness to travel abroad for treatment Stage 1: Emotional Empowerment Appearance Contingent Self Esteem Stage 2: Knowledge sharing behavior Data Collection Primary survey Archival survey Analysis Structural Equation Modeling (Partial Least Square) Structural Equation Modeling (Partial Least Square) Seemingly Unrelated Regression 3 Stage Least Square Ordered Probit Sample Characteristics Random sampling of population Random sampling of patients participating in a health infomediary Results There exists no standard doctor rating across various doctor rating websites including medical tourism infomediaries Patients perceive the i nfomediaries with comprehensive doctor rating s to have higher information quality Those infomediaries gain higher trust and patients are more likely to use their medical tourism services All self concepts in the research model play a n important role in health infomediaries Self concepts significantly influence knowledge sharing either through emotional empowerment or appearance contingent self esteem Some self concepts have negative impact on emotional empowerment and appearance conti ngent self esteem

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10 Table 1 Study 1 Study 2 Collective Results across Studies There are variations of health infomediaries; some of which involve inherently risky decision while some attempt to get patients involved to improve overall health of the community members In the context of medical tourism where decisions usually involve high risks, n ot only individual trust, but trust in infomediary can be equally important In the context of reconstructive surgery where lower risk is involved, various self concepts have different impacts on patient engagement in the infomediaries The impacts can be mediated by either emotional empowerment or appearance contingent self esteem Appearance contingent self esteem plays an important role in reconstructive sur gery specific infomediaries as the information on the infomediaries and related decisions are highly contingent on appearance Theoretical Contributions A set of standard criteria for doctor ratings consisting of an overall rating and 7 criteria in 2 main categories Verification of a research model that combines together the domain knowledge of reputation systems, information quality, and trust to explain the decision making process on medical tourism infomediary The first study to combine self conce pts and empowerment to explain online knowledge sharing behaviors Existing IS literature focuses on internal self esteem, which can hardly (if not impossible) be manipulated This study focuses on contingent (external) self esteem, which is more volatile an d can be manipulated more easily Practical Contributions Comprehensive doctor rating provides clearer idea on what to rate and how to interpret (e.g. bedside manner, expertise) Infomediaries with comprehensive doctor rating will be perceived as having hig her information quality The proposed doctor rating system can be incorporated into the medical tourism infomediary to gain higher trust from patients Knowledge sharing can be better fostered through empowerment Self stigma is inhibitor to the process of empowerment Infomediary may alleviate internalized self stigma by fostering social support for those with self stigma, and by taking immediate action to intervene when the discussion may lead to self stigma The higher the self esteem is tied to appearance, the less likely the patients will share knowledge

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11 Table 1 Study 1 Study 2 Practical Contributions Infomediary needs to provide accurate, relevant, timely, and easy to interpret information Overall doctor rating is ambiguous and can be interpret differently by different patients The signals from the senders may be confounded by the overall doctor rating and can be misinterpreted by the receivers However, as patients gain higher self efficacy, their self esteem tends to be less contingent on appearance, and they are more likely to share their knowledge Hence, infomediary may be able to boost knowledge sharing by efficacy Knowing this, infomediary may pose some screening questions during the registration process to categorize patients and to customize the intervention based

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12 CHAPTER II TRUST AND INFORMATIO N QUALITY ON WILLING NESS TO TRAVEL FOR MEDICAL TOURISM INFO MEDIARY 2.1. A bstract Lack of information prior to medical tourism visits is a significant issue in meeting the expectations of patients. A global portal or health infomediary with doctor rating systems plausibly can bridge this gap. A health infomediary gathers information rel evant to medical tourism and makes them available in one place. Patients can visit this health infomediary and get all the necessary information that will be used to make decision whether to go for an alternative treatment in foreign countries, which count ry and which provider to go to, and how much will it cost. This information is necessary for a patient to make a decision about having treatment abroad but it is not easily accessible without a health infomediary. Despite the availability of the informatio n, the trust in the infomediary and the quality of information presented on the infomediary are important factors of patient decision making. Doctor ratings can help to reduce information asymmetry; however, different doctor rating websites provide differe nt doctor rating schemes and some have unclear rating schemes. This study proposes a set of standards for doctor rating criteria for a medical tourism portal. The proposed doctor rating criteria have been developed following the steps in design science res earch. A model has been developed to investigate the relationship between information quality, doctor rating systems, trust in an infomediary, and willingness to travel abroad for treatment. The proposed doctor rating systems have been incorporated into a survey based experiment

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13 used to test the hypotheses and evaluate the model. Analysis of data is presented. Implications and contributions of the study are discussed. Keywords: Medical Tourism, Online Portal, Doctor Rating System, Medical Tourism Platform. 2.2 Introduction Medical tourism has emerged as an important option to manage health and well being. Medical tourism refers to the travel of patients to foreign countries, mostly from developed countries to developing countries, with the primary purpose of having a medical treatment (Cortez 2008; Crooks et al. 2010; Horowitz et al. 2007) People seek treatments in foreign countries due to the high cost of treatment in host countries, long waiting lists for the procedur es, and cost effectiveness resulting from economic disparities resulting in saving up to 25 75% (Patients Beyond Borders 2015) and the drive to achieve better health irrespective of the location of treatment (Connell 2006; Garcia Altes 2005) In addition, some medical procedures such as cosmetic dental surgery, are not covered by insurance in countries like the UK and Australia, leading to the growth of medical t ourism (Smith et al. 2011) Some patients are also seeking information ab out and prefer alternative non invasive procedures to the evidence based care provided in their own countries. Moreover, the availability of the Internet, and globalization trends make both patients and providers aware of the medical facilities available i n other countries, providing options to avail the alternative care (Smyth 2005) As a result, the medical tourism has grown rapidly with patients from developed countries such as the United States spending $38.5 billion in 2014 and pr ojected to be over $58.6 billion in 2017 (Patients Beyond Borders 2015)

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14 Irrespective of the growth in the medical tourism industry, a number of concerns lead to perce ptions that medical tourism i s high ly risk y (Smith et al. 2011) The main risk is the disparit y in the quality of car e across countries. Second, after the procedure is performed, a lack of follow up care if there are complications is a major challenge. Current physicians and providers across countries do not share medical reports, nor do they communicate to mitigate the follow up concerns (Dunn 2007; Turner 2007) The third concern is that there is no set of bi or multi lateral law s or systems to address claim s related to errors during the procedures (e.g malpractice) Finally, the lack of information flow between doctors across countries makes continuity of care more difficult (MacReady 2007) These concerns lead to the cr iticism that the medical tourism industry is only driven by cost arbitrage rather than a real information or systemic care b ased strategy that is needed by patients (Turner 2007) Although in the long term bi or multi lateral agreements or regulations may be solutions to problem associated with quality, accountability and continuity of care, in the short term such widespread agreements are unlikely (MacReady 2007) Instead, online health platforms can be used to reduce the information asymmetry in medical tourism by collecting and c ompar ing procedure based information and making it available to patients to support informed decisions (Martinez et al. 2008) One feature of a medical tourism portal is likely to be an online rating and review system which can be used to document quality of care. Comparison of online ratings and reviews is not new to healthcare systems, although they have not been implemented in a global scale. Portals such as RateMDs.com, healthgrades.com, do rate and review doctors. Some report that 72% of Internet users have searched for health information

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15 online during 2011 2012 an d that the online search and information consumption behaviors of Americans are increasing (PEW Research Center 2015) The availability of prior information is becoming a pre requisite for patients to make an informed choice on details on practice are available across websites and portals, and patients are making their choices of a doctor based on this information. The examples of success in other sectors show that people choose restaurants, movies, consumer products, and books based on wha t they read on the Internet (Chevalier and Mayzlin 2006; Godes and Mayzlin 2004; Jin and Leslie 2003; Mudambi and Schuff 2010) and therefore, it is likely that many will research their doctors on the Internet as well. Furthermore, doctor report cards implemented in the past echo that patients would like to weigh the ratings in their decision making process (Dranove and Sfekas 2008; Jin and Sorensen 2006) Although systems do exist to rate doctors and hospitals, they are typically country specific and targeted at patients that understand the norms of medical care within the specific local medical system, There is no standard doctor rating system that provides all relevant and useful information for patients seeking care across international boundaries (e.g. doctor, clinic, hospital). The objective of this study is to develop an appropriate set of doctor rating criteria to reduce information asymmetry in medical tourism. A proposed doctor rating system has been designed, developed, and evaluated through sorting and categoriza tion procedures. The resulted doctor rating criteria were then used as a component in a survey based experiment, designed to investigate the direct effect of doctor rating systems on trust in infomediary as well as the moderating effect of doctor

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16 rating sy stems on the relationship between trust in infomediary and willingness to travel abroad for treatment. Result, implications, future research and limitations are discussed. 2.3. Literature Review 2.3.1. Reputation Systems Reputation systems can help mitigat e the risks associated with having a medical procedure performed by an unknown medical tourism provider. Reputation systems can improve patient decisions by making providers accountable for their actions [21]. Reputation systems build a meaningful history of the provider by gathering and disseminating data related to past provider behavior, which can allow potential patients to decide whether to trust a health care provider (Resnick and Zeckhauser 2002) Many online providers implement rating or review systems where consumers evaluate products and/or services after a transaction is completed. Thes e online individuals and service providers have no prior interaction or firsthand knowledge of each other, and where direct experience is not readily available (McKnight et al. 1998; Pavlou and Gefen 2004; Zucker 1986) Nielsen.com found that consumer ratings and reviews are viewed as the most trustworthy and influential source of information on products and services, after family members and friends (Grimes 2012) suggesting that people view online ratings and reviews as more reliable and less biased than any other information available on products and services (Lee and Youn 2009) Reputation systems have been shown to improve consumer satisfaction and to improve quality in the absence of the traditional cues to trust and reputation in the physical world ( Jsang et al. 2007) Consumer satisfaction occurs when the performance

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17 of a product or service matches the consumers' expectations (McFarland and Hamilton 2005; Stark and Meier 2001) Reputation systems serve to improve consumer satisfaction because they provide additional information to support decision making and increase the likelihood that the transaction will end successfully. Finally, reputation systems extend the ability of users to share i nformation regarding trust and reputation on a global scale ( Jsang et al. 2007) Online users usually select products and services by referring to Despite the success of reputation systems ac ross a wide range of applications, their trustworthiness can still be questionable (Oh et al. 2015) For example, there is a (Liao et al. 2014) Many scholarly articles address this concern (Chong and Abawajy 201 2; Gefen and Carmel 2013) which suggests that reputation systems still can be improved. Prior studies have found that reputation profiles are predictive of future performance (Gregg and Scott 2006; Resnick and Zeckhauser 2002) and that consumers use reputation systems when making purchase decisions (Ba and Pavlou 2002; Lee and Youn 2009; Standifird 2001; Standifird 2002) However, prior studies have also found that not all reputation systems provide information in a way that it can be used to best estimate the risk associated with a particular provider (Gregg 2009) Thus, the nature (or quality) of the information contained wit hin a reputation system contributes to the usefulness of a particular system for decision making. 2.3.2. Information Quality Information quality is typically defined across four dimensions: intrinsic, contextual, representational, and accessibility (Lee et al. 2002; Petter and McLean 2009;

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18 Wang and Strong 1996) Studies have demonstrated the importance of information quality in decision making and intention to use a wide variety of information systems (Wang et al. 2017) Intrinsic information quality includes the accuracy and objectivity of the information as well as the believability of the information and reputation of t he author or source of the information (Klein 2017; Wang and Strong 1996) All of these attributes con tribute to an end user's ability to evaluate the intrinsic quality of a given set of information. For example, most medical tourism information is provided through commercial websites limiting believability of the information (Horsfall et al. 2013; Lunt et al. 2014) Commercial websites may be reluctant to disclose negative information about provid ers, including poor ratings and reviews, because of its potential impact on future business (Horsfall et al. 2013) Finding believable information about the reputation of the health providers abroad or sometimes even information about the country itself c an be challenging for potential medical tourism patients. With the inherent risk of any medical procedure, patients may be reluctant to make a decision to travel abroad for treatment if they do not have access to believable information. Contextual informat ion quality depends on the context of the task at hand. It includes completeness and timeliness as well as value added, relevancy, and appropriate amount of data (Klein 2017; Lee et al. 2002; Wang and Strong 1996) In the context of medical tourism, websites must include information necessary for patients to decide whether to undertake treatment abroad. Such information may include the reputation of the providers, the risks associated with the procedure itself, t reatment costs, transportation, lodging, and much more (Connell 2006) The quality of these data

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19 depends on the accuracy and currency of the data as treatment alternatives and pri ces change over time. Representational information quality includes aspects related to the format of the data and the meaning of the data. It includes criteria like representational consistency, concise representation, interpretability, and understandabili ty (Klein 2017; Wang and Strong 1996) In the context of medical tourism, the information should be pre sented in the manner that all aspects of the medical tourism experience can easily be evaluated. Rating systems can facilitate the representational aspect of information quality by summarizing the information and presenting it using visualization (i.e. sta r ratings, scales, categories). As an example, showing 5 stars rating for the experience of a doctor can be interpreted and understood more easily than showing the qualifications and expertise of the same doctor in a few paragraphs of text (Gregg 2009) Accessibility information quality refers to end users' ability to find and use a given information resource. It includes how the resource can be accessed and any access security constraints for the resource (Klein 2017; Wang and Strong 1996) In the context of medical tourism, accessibility can be provided using hea lth infomediaries that provide information on the expertise of doctors in foreign countries, the treatment options and costs via the Internet (Cortez 2008) Health infomediaries further reduce the accessibility issue by g athering the information and making it available in one place (Harwell et al. 2015) 2.3.3. Trust Trust is essential in situations, like medical tourism, where there is risk or

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20 trustee in an environment of uncertainty (Gefen et al. 2003) Several studies related to trust and the Internet have found that concerns about a website trustworthiness is a major obstacle to a line transactions (Dinev and Hart 2005; Dinev and Hart 2006) (Mayer et al. 1995) Abil goods or services (or information) they offer in a safe and efficient manner, and to provide assistance if required (i.e., to get additional unbiased information on a medical tou rism provider), and to manage competently any personal and financial information the in the best interests of both parties and refrain from engaging in opportunisti c behaviors. Integrity is a belief that a party will abide by the rules of an agreement. Several empirical investigations have supported the internal and discriminant validity of the trusting beliefs model (Casalo et al. 2007; McKnight et al. 2002a) as well as the influence trusti ng beliefs have on purchase intentions and other online activity (Bart et al. 2005) In the build or degrade sources of trust, or which otherwise influence t rusting beliefs, intentions, or behaviors (Ba and Pavlou 2002; Hong 2006; Schlosser et al. 2006) Another type of trust being studied in online environments is the institution based trust (Lee and Turban 2001; Tan and Thoen 2000) Institution based trust is trust that utilizes third party guarantees or recommendations to enable one to act in anticipation of a successful future endeavor (Zucker 1986) Hence, institution based trust includes trust

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21 in marketplace and trust in infomediary. In the context of online marketplaces, trust in an infomediary increases trust in the seller community as a whole and facilitates onlin e transactions (Pavlou and Gefen 2004) For example, people may not trust small online vendors as much as they trust a large and well known vendor. However, when the small online vendors are on a well known marketplace like Amazon and Ebay, they are more likely to be trusted (Pavlou and Gefen 2004) Similarly, in the context of medical tourism, institution based trust would allow patient s to trust unknown medical tourism providers if they had a high level of trust in the medical tourism infomediary. 2.3.4. Medical Portals In the healthcare industry, there are numerous healthcare social networking portals which create a vast amount of onli ne information about doctors and healthcare options but do little to reduce information asymmetry. Table 2 lists some examples of healthcare web portals and social media sites that help reduce information asymmetry. Some websites (i.e. BoardCertified.com, Healthcare.com) report the overall doctor rating while others report multiple ratings (i.e. HealthGrades.com, RateMDs.com, Vitals.com). For those presenting multiple ratings, different rating criteria are often used. In medical tourism, where patients seek for medical treatment across geographical boundaries, the information asymmetry becomes more complicated as there are international issues in addition to medical concerns. Table 2 Sample h ealth infomediaries to reduce information asymmetry Website Name & URL Focus Communication Methods Content Categories Steady Health www.steadyhealth.com How to live healthily under different categories. Covers disease treatments and diets. Information Center; Articles; Discussions; Videos; Slideshows; Medical Answers; Applications Categorized by: Well Beings (purposes); Health Conditions (disease types); Family Heat h ( Sex and Age); Therapies & Treatments; Emotional & Mental Health

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22 Table Website Name & URL Focus Communication Methods Content Categories Wellness www.wellness.com How to live healthy under different categories. Covers disease treatments and diets. Also, information about fitness and beauty. Blogs; Forum; Articles Popular Topics; Facilities; Fitness & Beauty; Dental Care; Stores; Insurances; Doctors; Mental Health; Counseling; Provider Program; Community Everyday Health www.everydayhealth.com Diseases, drug information, living healthily (food & diet). Articles; Videos; Twitters; Facebook; Blogs; Applications Conditions (diseases); Drugs; Health Living; Food & Recipes; Advices & Support Find a doc www.findadoc.com Devised a unique proprietary rating system that helps patients choose from among the 720,000 practicing physicians in the U.S. NA Contact Information Search by Categories My doc hub www.mydochub.com Offers doctors' information, hospital information and diseases information. Articles; Discussions; Blogs; Applications Doctors; Reviews; Dentists; Blog; Answers; Chiropractors; Hospitals; Vets; Health; News; Health A Z; Articles Spark People www.sparkpeople.com Focused on living healthily depending on food and exercises. Information Center; Articles; Discussions; Videos; Boards; Applications Eat Better; Feel Better; Look Better Physician Data Query www.cancer.gov/cancertopics/ pdq PDQ (Physician Data Query) is NCI's comprehensive cancer database. Search Engine NA Health grades www.healthgrades.com Doctors' information, hospital information and dentists' information. NA Find Doctors; Find Dentists; Find Hospitals Vitals www.vitals.com Find and review doctors, make an appointment and prepare for the doctor visit. NA Patient Education; Write a Review RateMDs.com www.ratemds.com Find and review doctors and hospital information. FAQ; Forums; Tweeters Find a Doctor; Find a Do ctor; Browse Doctors; Hospitals; Top Local Doctors; FAQ; Forums Drscore.com www.drscore.com Find doctors information. Email Find a doctor; Score your doctor; For Patients Doctortree.org www.doctortree.org Find doctors information. NA Search Engine by Categories Suggest a doctor www.suggestadoctor.com It helps to find doctors information. Customers' Evaluations Search Engine by Categories

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23 Table Website Name & URL Focus Communication Methods Content Categories Healthcare.com www.healthcare.com Information about health insurances. NA NA Vimo www.vimo.com Information about health insurances. NA NA HealthDay www.healthday.com/health portal.html Provide daily health news for both consumers and medical professionals. Phone, Email Hospital Systems; Managed Care; Government; Retail; International Editions; HealthDay TV. iHealthBeat www.ihealthbeat.org Provide daily news digest reporting on technology's impact on health care. Article Feedback, Suggest a Story, Submit an Event, Twitter, Facebook Meaningful Use; Telehealth; ICD 10. Healthy People 2020 www.healthypeople.gov/ Provide science based, 10 year national objectives for improving the health of all Americans. Email Topics and Objectives; Data2020; Evidence based Resources; Stories from the Field; Leading Health Indicators. Health Finder http://healthfinder.gov/ Find information to help you and your loved ones stay healthy. Email, Facebook, Twitter Gender, Age, Health Topics, A Z, Health News. WebMD www.wbmd.com/index.shtml Provide quality health information and services. Phone, Email. Consumer Network; Professional Network; Private Portal Services; Magazine. HealthLinks www.healthlinks.net/ A worldwide directory for healthcare consumers and professi onals providing links to health services and products, alternative health, education, dental and medical resources, hospitals, employment, healthcare publications, mental health, etc. Forums, Email. Disease; Provider; Gender. Existing literature points to several limitations of electronic portals or social websites for health care related communications. A p rior study point s out that quality concerns, lack of reliability of information, and blurred lines between content produce r and user are three major limitations of current health care portals (Moorhead et al. 2013) cited as big challenges to the use of the social media for meaningful purposes (Adams

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24 2010) Finally, a lack of guidelines may lead to the public to in correctly apply information found online to their personal health situation, possibly leading to adverse health impact s or consequence s (Freeman and Chapman 2007) Therefore, guidelines for creating effective doctor rating criteria are needed to address these issues. 2.4. Theory and Hypotheses We propose a conceptual model for this study which suggests that the rating type interacts with trust in the infomediar y and information quality to influence willingness to travel abroad for treatment. The conceptual model is presented in figure 1. Figure 1. Conceptual model In online environments, reputation systems support both individual trust and institution based trust (trust in infomediary) (Le e and Turban 2001; Tan and Thoen 2000) First, according to signaling theory (Spence 1973) in situations where there is information asymmetry, the reputation of the product or provider can function as a signal of quality. The reputation signals pro vided by reputation systems help people relying on (Resnick et al. 2000) Secondly, reputation systems help build institution based trust by providing a mechanism that allows consumers to trust the marketplace as a whole. Focusing on the latter, studies show that Ebay and Amazon hav e been successful in gaining trust from both buyers and sellers through the use of reputation systems (Resnick and Zeckhauser 2002) Ebay has gradually modified and improved their reputation systems to include combination of rating scores, badges, and relevant information. No matter what the reputation systems

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25 looks like, the buyers are more likel y to trust the sellers who score highly on the reputation systems as compared to those who have a low score. One of the most popular travel infomediaries, TripAdvisor, has also adopted a reputation system by adding review and rating systems on their site. Nowadays, rating systems are common in various eCommerce websites and infomediaries. These rating systems not only help increase trust in specific products, services, and brands, they also have an impact on the trust in marketplaces, and infomediaries. Th is is known as institution based trust. A marketplace like Amazaon and Ebay may gain higher trust from implementing the star rating system on their websites. Even a standalone website implementing a star rating system for each product may also gain higher trust from consumers. In the context of medical tourism infomediary, we argue that the same mechanism can be extended to the influence of rating systems on trust in infomediary. We argue that when an infomediary implements an overall quality rating for eac h healthcare provider within the infomediary, the presence of such rating system helps increase trust in infomediary. Furthermore, when an infomediary implements more detailed rating systems, the infomediary can gain higher trust from patients. This leads to the hypothesis that: H1: Type of rating systems positively influences trust in infomediary. Previous studies consistently suggest a positive relationship between information quality and trust in various contexts (Elliot et al. 2013; Gregg and W alczak 2010; Kim and Noh 2012; McKnight et al. 2002b) Perceived information quality leads to perceived trust, which in turn leads to intention to transact online (Kim et al. 2008; Nicolaou and

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26 McKnight 2006) In other words, perceived trust acts as a mediator between perceived information quality and intention to purchase. High information quality on a website means the information is relevant, complete, understandable, and accurate (Webb and Webb 2004) When buyers visit an e Commerce website (i.e. Amazon) and feel that the website contains high information quality, it is more likely that the buyers will have high trust on the website. In the context of medical tourism, when patients visit a medical tou rism infomediary and feel that the infomediary contains high quality of information, they will be more likely to have higher trust on the infomediary, regardless of whether they trust the health providers in foreign countries. In medical tourism where pati ents travel to receive medical treatment in other countries, it involves much higher risk than buying something from Amazon. Medical procedures are inherently risky and as such it is likely that information quality will influence trust in infomediary in su ch a risky situation. Web site quality is found to help reduce the effect of negative perceptions and risk of online transactions (McKnight et al. 2002b) Thus as the medical tourism infomediary contains high information quality, high trust on the infomediary can be expected from patients or visitors; hence we hypothesize that: H2: Information quality positively influences trust in medical tourism infomediary. Trust is needed in uncertain and risky situations (Grabner Kruter and Kaluscha 2003) especially in online environments (Gefen and Straub 2004) where individual trust has been found to increase willingness to transact (Bhattacherjee 2002; Lim et al. 2006) In traditional transactions where buyers and sellers interact with each other in person,

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27 trust is important (Grabner Kruter and Kaluscha 2003) However, in online transactions where sellers are unknown to buyers and vice versa, trust becomes even more important (Bhattacherjee 2002) the sellers, and have to pay in advance and receive the products. This increases the risk that they will not receive the products or that they may receive defective o r different products (Lim et al. 2006) In the context of eCommerce, when small online vendors are listed on a well known marketplace like Amazon and Ebay they are more likely to be trusted even though they are not trustworthy on their own websites (Pavlou and Gefen 2004) Similar mechanism can be expected in the context of medical tourism, when patients have trust in a medical tourism infomediary, they are more likely to have higher trust in the providers listed on the i nfomediary. In this case, the medical tourism infomediary acts as a marketplace for health providers from various countries to provide their treatments or medical services. Analogous to the buyers, patients come to the medical tourism infomediary with the purpose of exploring information about the services available in foreign countries, the quality of services, and other related information. These providers may be well known in their own countries, but patients overseas may have no idea about their reputat ions and may not trust these providers. Similar to other online marketplaces, if patients have high trust on the medical tourism portal, it is more likely that the patients will have higher trust in these providers. In contrast, low trust in the medical to urism would undermine the trust in the providers listed on the portal. Therefore, we hypothesize that:

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28 H3: Trust in the infomediary is positively associated with willingness to travel abroad for treatment. 2 5 Research Method 2. 5 .1. Development of the Rat ing System from Existing Practice The focus of the rating system in this study is to fulfil the information asymmetry gap by providing both objective and subjective ratings for clinical, administrative and overall care of the providers. To design an approp riate rating system for medical tourism context, we followed a structural approach involving five steps: (1) reviewing 52 existing rating sites in healthcare context, (2) screening of the sites to finalize 42 sites with 169 rating criteria, (3) removing du plicate rating criteria to reach 117 criteria, and categorizing them into 14 categories, (4) judging the criteria through a systematic process to reach an intermediate categorization (details are omitted here for brevity), and (5) refining the categories a nd sub categories to come up with the final rating system (see Figure 2). The final outcome was a totally agreed upon 21 criteria by 2 judges and 6 former supported more than 2 raters while the latter supported only 2 raters (Fleiss 1971; Zaiontz 2014) substantial agreemen t among the judges (Landis and Koch 1977)

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29 Figure 2. Rating categories 2. 5 .2. Sample and Data Collection In order to evaluate the proposed rating system, data were collected using a scenario based ex periment (Rosenthal and Rosnow 1991) We first developed a prototype of a website to illustrate the proposed rating system on the medical tourism portal. Prototype screens have been created for a fictitious doctor, Dr. Pat. The name Pat has been chosen because it may be male or female so tha t we can minimize gender bias. hospital, address, contact information, languages spoken, a short biography, and rating. The page included ratings by prior patients. The hospital name and address were also fictitious and located in Costa Rica as it is among the most popular destinations for medical tourism (Medical Tourism Index 2014) Two variations of rating systems have been created; one with single overall rating and another with the proposed detailed rating system consisting of all rating categories in Figure 2.

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30 The target population for this study w ere people who have consider ed medical travel but may or may not have done so. The sample was recruited from social networks. authors were asked to share the survey link on their walls. This recruitment method a variation of the snow ball technique. Almost all responses (96.92%) were from the United States (as can be identified by their IP addresses) w hile 2.2% w ere from Thailand and 0.88% from Taiwan. The target markets for medical tourism are varied and cover wide range of age s Four out of eight top specialties sought by medical travelers are cosmetic surgery, dentistry, reproductive, and weight loss (Patients Beyond Border s 2015) with the dentistry as the most popular followed closely by cosmetic surgery (Pollard 2007) and fertility as the fast gr owing market (Pollard 2015) Patients seeking these specialties can be of any age as such, social networks represent a suitable method to recruit a representative set of subjects 97.8% of the sample are between 18 to 50 years old, which is a good representat ion of the target population. To prevent selection bias, the subjects were randomly assigned into control and treatment groups using a single web address (URL) which evenly redirected to either the page with single overall rating or the page with single overall rating is the control group and the group exposed to a page contai ning M anipulation checks were also included in the survey and demographic information were collected. 2. 5 .3. Operationalization of Variables Measurement items from prior research were a dopted and slightly adapted to fit the context of our study. Table 3 summarizes the measurement items and sources. All

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31 items were measured using seven point Likert scale s Trust in the infomediar y was measured using five items adapted from prior studies (Awad and Ragowsky 2 008; Pavlou and Gefen 2004) Information quality was also measured using five items adapted from prior studies (Gregg and Walczak 2008; McKinney et al. 2002) Willingness to travel abroad for treatment is actually the willingness to transact in medical tourism transaction. While the term willingness to transact can be applied to any context, willingness to travel abroad for treatment is specific to medical tourism context. Therefore, willingness to travel abroad for treatment was measured using four items adapted from prior studies (Bhattacherjee 2002; Lim et al. 2006) Furthermore, rating system was directly controlled to be either single overall rating or detailed ratings. Table 3 Summary of Measurement Items and Sources Measure Question Source s Information quality The rating on this portal is adequate for me to pursue treatment abroad. (Gregg and Walczak 2008; McKinney et al. 2002) The rating on this portal is pretty much what I need to pursue treatment abroad. The rating on this portal is sufficiently detailed. Trust in infomediary As a medical tourism portal, this portal can be trusted at all times. (Awad and Ragowsky 2008; Pavlou and Gefen 2004) As a medical tourism portal, this portal has high integrity. Based on my experience with the rating web site, I know these ratings are trustworthy. Willingness to travel abroad for treatment I am likely to go abroad for treatment in the future. (Bhattacherjee 2002; Lim et al. 2006) I am considering having treatment abroad in the future. It is likely that I am going to go abroad for treatment. I am inclined to have treatment abroad in the future. The survey also captured demographic data and other factors including gender, age, education, ethnicity, experience with treatment abroad, frequency of using Internet, and experience with doctor rating web sites. W e control for the ethnicity of doctor bei ng

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32 used in the experiment by including fictitious Latino and Indian doctor names in the experiment. Obviously, Americans are so familiar with Latino/Hispanic culture as the U.S. Hispanic population is as large as 57 million (PEW Research Center 2016) while India n culture is much more distant to Americans Indian Americans population was only 3.2 million in 2010 and most of them are recent arrivals (Pew Research Center 2014) We also conducted a pilot wit h 16 respondents to ensure the instructions and items were clearly understood. We then made appropriate modifications to the survey accordingly. 2. 6 Results The minimum sample size requirement for PLS is 10 times the number of items (indicators) in the mo st complex model (Gefen et al. 2000b) Our most complex model consists of 1 5 indicators, and hence the minimum sample size i s 1 5 0. As such, o ur sample size of 227 is adequate for testing the model. From the descriptive statistics shown in table 4 univariate normality can be assumed from the data set. In addition, the inter correlation between all variables are below 0.7. Table 5 shows cross loadings and internal consistenc ies s ) of the model. The Cronbach Alpha is 0.92 for information quality (IQ), 0.93 for trust in infomediar y (TR), and 0.95 for willingness to travel abroad for treatment (WT). All of which are higher than the suggested threshold of 0.7 (Gefen et al. 2000b; Zhu et al. 2004) Table 5 also shows that loadings of the indicators on their underlying constructs are higher than the suggested threshold of 0.7 (Goodhue et al. 2006) Discriminant validity can be observed in two ways: (1) when the indicators load much higher on their underlying construct than on the others, and (2) when average variance extracted (AVE) is higher tha n 0.5 and the square root of AVE is higher than inter correlations between the underlying construct and all other

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33 constructs (Chin 1998; Karahanna et al. 2006; Pavlou 2003) The two conditions for AVEs for all constructs are satisfied as shown in table 4 Hence, discriminant validity can be observed. Crossloadings from table 5 als o shows that all indicators load highly on their underlying constructs and not on other constructs. This pattern demonstrates high convergence validity and high discriminant validity. Table 4 Descriptive statistics and inter correlations AVE Min Max Mean S.D. Skew ness 1 2 3 4 1. RT 1.00 0.00 1.00 0.43 0.50 0.28 1.00 2. IQ 0.86 1.00 7.00 4.32 1.38 0.32 0.37 0.93 3. TR 0.88 1.00 7.00 4.00 1.41 0.04 0.49 0.60 0.94 4. WT 0.88 1.00 7.00 3.78 1.66 0.05 0.32 0.56 0.53 0.94 Number of observations = 227 The elements in the matrix diagonals represent the square root of AVEs Table 5 Crossloadings and internal consistenc ies RT IQ TR WT Alpha RT RT 1.00 0.37 0.49 0.32 1.00 IQ IQ1 0.35 0.94 0.55 0.53 0.92 IQ2 0.38 0.91 0.57 0.46 IQ3 0.31 0.94 0.56 0.57 TR TR1 0.51 0.55 0.93 0.53 0.93 TR2 0.47 0.58 0.96 0.52 TR4 0.40 0.57 0.93 0.44 WT WT1 0.31 0.54 0.50 0.95 0.95 WT2 0.32 0.49 0.49 0.94 WT3 0.28 0.48 0.42 0.94 WT4 0.30 0.56 0.55 0.92

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34 Figure 3. Estimated model The model was first estimated without controls; the effect of rating systems on information quality was 0.37 and the effect of information quality on trust in infomediary was 0.60 while the effect of trust in infomediary on willingness to travel abr oad for treatment was 0.53; all were significant at p < 0.01. Then control variables were added into the model. All coefficients remained unchanged except a trivial change from 0.53 to 0.52 for the effect of trust in infomediary on willingness to travel ab road for treatment; all were still significant at p < 0.01. Among the control variables, only education and ethnicity were significant. The R 2 of information quality, trust in infomediary, and willingness to travel abroad for treatment were 0.14, 0.37, and 0.37 respectively. All hypotheses are supported and the estimate model is shown in Fig. 3. The final results of the analysis are summarized in table 6 Table 6 Summary of the Results Hypothesis Estimate Value Supported H1 0. 37 *** Yes H2 0. 60 *** Yes H3 0.52 *** Yes Note: p < 0.10, ** p < 0.05, *** p < 0.01 2. 7 Discussion and Conclusions The objective of th e analysis is to investigate and verify the relationships between information quality, doctor rating systems trust in an infomediary and willingness to

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35 travel abroad for treatment in a medical tourism context. The findings show that all hypotheses are strongly supported and the coefficients and other statistics remained unchanged after control variables were added to the model. The findings are congruent with other similar research in a more general context (Lim and Kim 2012; Song and Zahedi 2007; Zahedi and Song 2008) This finding supports the inclusion of the information rich d octor rating system into medical tourism portal s The result s also have practical implications Today, many doctor rating web sites have only overall single rating system while some sites have multiple rating systems covering more details about the same d octor. The results of this study suggest that sites that adopt a more comprehensive rating scale will be more likely to engender trust in their users and will increase their willingness to transact. The result s of this study provide insight to medical tour ism agencies, portals, and providers for what patients are expecting from the doctor rating systems on their sites. Patients benefit from sites that adopt a comprehensive doctor rating system because it allows them to gain a comprehensive view of the docto r over all aspects of the medical experience. This study has made two contributions to the theory. The first and main theoretical contribution of this study is the design of the standard doctor rating system strictly following the design science research approach. The second contribution is empirical verification of a research model that puts together the domain knowledge of reputation systems, information quality, and trust to explain the dynamics of decision making on medical tourism infomediary Although these relationships have been investigated in prior literature, they were investigated separately and in different contexts.

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36 This study takes it further to investigate these constructs and their relationship in a more comprehensive research mode l in a different context, medical tourism context. There are some limitations to this study. The limited sample size was largely drawn from the general U.S. population. This may pose limitation to the generalizability of the results. Further studies should be designed to include medical tourism patients and sample from other countries in order to strengthen the generalizability of the findings. In addition, the practical validity of findings of this study need to be tested using a real implemented project. It is possible that although detailed ratings are desirable but that patients may be unwilling to spend the time necessary to rate doctors and medical tourism sites on all of the dimensions proposed in this doctor rating scale. Future research is needed to optimize the scale in terms of information comprehensiveness vs willingness to complete the survey. To conclude, there has been a strong need to reduce the challenge of information asymmetry in medical tourism process. Till now, mediation services have been rare in this space; those currently available do not meet the demand of providing accurate and reliable information. By using the rating system proposed in this paper, providers can help patients get accurate and reliable information, and as a consequ ence, patients can make informed decision about their treatment options before making a commitment to travel abroad for treatment. Results of this study suggests that a platform that incorporates detailed doctor and administrative ratings will improve a pa the medical tourism portal and their willingness to travel abroad for treatment. The results from this study are expected to be generalizable to other contexts as well. However, further research is required to validate the generalizability of the results.

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37 CHAPTER III KNOWLEDGE SHARING IN HEALTH INFOMEDIARY: ROLE OF EMOTIONAL EMPOWERMEN T AND SELF ESTEEM 3.1. Abstract Health infomediaries are emerging as important knowledge sharing platforms that help patients manage their own health outside of the traditional healthcare delivery experience and knowledge. Knowledge sharing, thus, is an important aspect of success of a health infomediary. However, how an individ concept influence knowledge sharing in infomediaries remains unexplored. This study posits that self efficacy, social identity and self empowerment and self esteem attributes. We anchor to the health belief model to propose a two stage model and testable hypotheses. We analyze a secondary archival data of 222 patients participati ng in the health infomediary specialized in reconstructive surgery using structur al equation modeling and econometric methods to find support the hypotheses. Findings broadly suggest that the empowerment or self esteem path based approaches would be effective to motivate patients for knowledge contribution in the health infomediary. We explain the managerial insights and contributions of our study. Keywords: self esteem, knowledge sharing, self stigma, self efficacy, social identity, health infomediary

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38 3.2. Introduction Health infomediaries are online platforms, portals, websites, and discussion forums dedicated to health; with the objective of bringing patient provider or patient patient together to inform and to share knowledge for health management (Khuntia et al. 2017; Song and Zahedi 2007) Health infomediaries offer health and wellness rel ated information, including advice, guidance, and health evaluation functionalities (Zahedi and Song 2008) with the broad ob jectives to improve health outcomes for participating patients on these online platforms (Wimble 2016) The importance of health infomediaries stem from a major constraint in current health care systems (i.e., directing patients to hospitals and clinics for small issues, suggestions, diagnosis or treatment), and inadvertently necessitate complicated logistical, scheduling and financial prerequisites (Currie 2009; Mays et al. 2009) While the existing models usually work, but t hey lack just in Providing better access to health care through information is the objective of most health infomediaries. This objective is achieved by disseminating information and knowledge from other patients an d providers, and making it available to prospective patients (Harwell et al. 2015; Yim et al. 2015) Thus, health infomediaries provide avenues for management of own health by patients. Furthermore, communication and coordination through infomediaries can grossly undercut operational costs for health delivery. Patients may be able to get help and advice to manage their own disease from a doctor via web bas ed communications Consequently, the care delivery process can involve and engage a patient, rather than overly relying on the institutional process (Deng et al. 2013) In other words, health infomediaries, as artifacts of social media oriented to

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39 healthcare, have a potential to change the heal th care delivery paradigm, from being provider oriented, to be patient oriented, by empowering and engaging patients with their own health management process (Leroy and Harber 2016) Irrespective of the perceived potential for health infom ediaries in health care delivery, not many have been successful. Infomediaries like patientslike.com, realself.com and webmd.com claim to reach to millions of users; whereas others like rxwiki.com, doctorondemand.com, healthboard.com, are struggling to cre ate a widespread user base (see Appendix A for a representative list of several well ranked and struggling health infomediaries). These examples suggest that unless a critical mass is achieved, and too few of the participants engage in activities, the info mediaries will not sustain. On the contrary, the value of infomediaries increase exponentially as more users join and participate, quite like any other two sided network (Seraj 2012) Recruiti ng and eliciting continuous participation from users is challenging (Zahedi and Song 2008) In this regard, it is important t hat infomediaries fulfill patient oriented goals that can attract users, such as providing engaging platforms for knowledge discussions, or sharing of patient patient experiences. Involved and motivated user participation and engagement leads to the creati on and accumulation of a knowledge repository, which in turn serves as part of a system that attracts and benefits a patient community (Sherer 2014) Once a user base is created, physicians and other vendors are more li kely to participate and may provide financial resources for the infomediaries. Overall, for health infomediaries to be sustainable, user engagement and knowledge exchange are essential (Khuntia et al. 2017; Yim e t al. 2015) This process underscores the need for a motivation oriented approach,

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40 i.e., motivating patients to participate and contribute to the knowledge base of an infomediary. Regardless of the importance of knowledge sharing in health infomediarie s, there is a gap in existing literature regarding what leads patients to contribute knowledge in infomediaries. Prior studies note that it is important to understand the factors related to knowledge sharing on health infomediaries; which would help to man age the infomediary effectively from the initiation to development (Iriberri and Leroy 2009) Some suggest motivation and self empowering process being helpful in sh aring discuss issues that may be difficult in current face to face (e.g., clinics, doctor offices) institutional settings of healthcare systems (Corrigan 2004; Wills and DePaulo 1991) For instance, HIV discussions carry a stigma, and patients may not feel comfortable discuss ing it with doctors (Emlet 2006) Health infomediaries can help in this process by enabling discussions while keeping a privacy or identity secured. In addition, health infomediaries can use automated design schemas that can lead patients to ask questions, seek answers or solutions and in turn be able to self manage a disease (Deng et al. 2013) To achieve this end, patients need to feel that asking such question in the infomediary is helpful to him or her, or that sharing such knowledge is valuable Empirical investigation of this role of empowerment on knowledge sharing in health info mediary remains a gap that this current study tries to fulfil. We ask the research question: How do empowerme nt and self esteem motivate patients to share knowledge in health infomediaries ? We anchor to the health belief model and the concepts of self and empowerment in social psychology literature to

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41 conceptualize and test a two stage model. The first stage sugg ests that three dimensions of self concept, i.e., self efficacy, social identity and self stigma, influence patient empowerment and self esteem. The second stage predicts how empowerment and self esteem shape the knowledge sharing behavior. We used a seco ndary archival dataset of a sample of 222 reconstructive surgery patients participating in a health infomediary for the empirical analysis of this study. Reconstructive surgery is performed to treat structures of the body affected aesthetically or function ally by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. The common feature is that the operation attempts to restore the anatomy or the function of the body to normal. It is generally done to improve function and abil ity, but may also be performed to achieve a more typical appearance of the affected structure. It is reported that the current reconstructive surgery market is more than $20 billion and is expected to reach over $27 billion by 2019 (PRNewswire Research and Markets 2015) In addition, many patients avail such services out of their host country, to save money, for pri vacy and/or faster service availability. In this context, prior and post information and knowledge associated with the surgery plays an important role in reduc ing information asymmetry, and supporting the making and post operative manag ement process. Thus, the reconstructive surgery context is a rich one and is appropriate for this study. We used both structural equation modeling and econometric approaches for our empirical analysis. The f indings highlight the importance of self concept on knowledge sharing, mediated through the empowerment and self esteem paths. Comparative analysis of the two mediated paths reveal that self esteem path may be better for self efficacy and

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42 internalized self stigma to knowledge sharing, the emotional empow erment path is better from social identity to knowledge sharing. These findings contribute to understanding the factors as well as mechanisms for knowledge sharing in the infomediary. We discuss the results of our analysis from the health infomediary growt h and sust ainability perspectives, and provide managerial implication and theoretical contributions that can be extended to other studies in future. 3.3. Prior Work and Theoretical Background This study is focused on how a feeling of self worth (e.g., self esteem), and a control (manifested through a self concept consisting of three attributes of self efficacy, self i dentity, and self stigma) and influences the process of knowledge sha ring in the health infomediary. Prior work on health infomediaries include establishing definitions for health infomediaries or the attributes of health infomediaries (Vega et al. 2011b) qualitatively exploring inhibitors and motivators (Ambrose and Basu 2012) classification of user categories (Yim et al. 2015) and trust, privacy and information use issues with in infomediaries (Bansal et al. 2010; Lim and Kim 2012; Zahedi and Song 2008) (see Appendix B for a review of representative literature). Existing studies allude to the need for knowledge sharing and the role of user empowerment in this p rocess (Khuntia et al. 2017; Marabelli et al. 2014) T he concept of self is highly relevant to health and health infomediaries. Studies note that understanding the self sharing is a key to the initiation or development of the community (Iriberri and Leroy

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43 2009) Social dimensional concept that integrates a collection of beliefs about oneself (Greenwald et al. 2002) ; and consists of at least three aspects: (1) self efficacy, (2) social identity, and (3) internalized self stigma. Self efficacy refers to the confidence in one's ability to complete a task within a particular context (Bandura 1997) S ocial identity is the acknowledgement of (Abrams and Hogg 2006; Tajfel and Turner 2004) where a social group is a set of persons having a common social identification (Morgan 2016; Stets and Burke 2000) Finally, internalized self stigma is the change in or esteem or self worth as the result of labeling oneself as socially unacceptable (Corrigan 2004; Goffman 2009) Self este em refers to the feeling of self esteem is dependent on the outcomes within a single domain, it is referred to as contingent self esteem (Crocker et al. 2003) In other words, contingent self esteem refers esteem can be affected by, or is staked to the outcomes of even ts within a specific domain (Crocker and Park 2004) Self esteem is gradually developed from childhood through adolescence, and may change depending on change in understanding of self worth, or the feeling of self worth.

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44 Figure 4 Conceptual model Empowerment refers to a process by which individuals, groups, or organizations gain control over matters that are of interest to them (Perkins and Zimmerman 1995) Prior studies also note that empowerment may vary in different contexts (Robert et al. 2000) In the context of a health infomediary, empowerment may include tools that better (Grando et al. 2015; Khuntia et al. 2017) Patient empowerment, a relatively new concept, include s support in developing treatment strategies and exchanging knowledge, as w ell as encouraging patients to take responsibility for their own health (Salmon and Hall 2003) Empowerment can have multiple dimensi ons, however, emotional empowerment (as used in this study) captures the underlying psychological state of being health management (Deng et al. 2013)

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45 The conceptual model for this study (see Figure 4) anchors to the health belief model which suggests that people's beliefs about health problems, perceived benefits of action, barriers to action, and self efficacy explain engagement (or lack of engagement) in health promoting behavior (Janz and Becker 1984) Individuals will act regarding health outcomes when they believe that such action can lead to better outcomes. This health promoting behavior must be triggered by a cue to action. We posit that self esteem and empowerm belief model to suggest the two stage conceptual model. The first stage suggests that the self c oncept, e.g., self efficacy, self identity, and self stigma. We hypothesize that the belief factors related to self efficacy, social identity, and internalized self stigma impact appearance contingent self esteem and emotional empowerment (stage 1 of the c health infomediary (stage 2 of the conceptual model). Table 7 provides a summary of our hypotheses and arguments to link the constructs in the conceptual. Table 7 Theore tical Mechanisms Linking the Constructs in the Conceptual Model Relationships Hyp. Linking Mechanisms/ Arguments Association Self E fficacy Emo Emp. H1 a Inhibition overriding Sense of improvement in belief Positive Self E fficacy Self Esteem H1b Negative Social Identity Emo Emp. H2a Positive distinctness Achievement motivation Social value orientation Positive Social Identity Self Esteem H2b Positive Self Stigma Emo Emp. H3a Awareness of stereotypes Identification of stereotypes Efficacious evaluation Negative Self Stigma Self Esteem H3b Positive Emo. Emp. Knowledge Share H4a Pursuance or lack of i nnovative actions Monitoring and forward influence Positive Self Esteem Knowledge Share H4b Negative Emo. Emp.: Emotional Empowerment The first set of hypotheses (H1a and H1b) propose that self efficacy influences emotional empowerment and self esteem. The self efficacy concept notes that as a

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46 person feels skillful in managing a task, process or situation, he or she feels enabled, empowered and less inhibited (Bandura 1997) Higher self efficacy or confidence in managing health involves the overriding of inhibitions related to the disease management process (Bong and Clar k 1999) Conversely, l ack of self belief or self control can lead to a sense of powerlessness and subsequent ill health (Graffigna et al. 2013; Tengland 2008) Similarly, feeling a sense of empowerment can lead to the execution of actions required in care treatment or management (Aujoulat et al. 2007) The outcomes in health focused motivation include a goal directed approach and wil lingness to engage in behaviors to reach these goals such as adhering to medication regimes, seeking and following treatment procedure s and other health related behavior adjustments or lifestyle changes (Janz and Becker 1984; Moorman and Matulich 1993) Thus, we argue that with higher self or her health situation may increase (Deng et al. 2013), thereby l eading to higher empowerment. Based on these arguments, we hypothesize that: H1a: S elf efficacy of reconstructive surgery patients participating in the health infomediary is positively associated with emotional empowerment. Along with the influence of se lf efficacy on empowerment, we also argue that self efficacy motivates a person to use available avenues to find solutions to problems, the process of enabling self efficacy may lead a per body or appearance (Aujoulat et al. 2007) In other words, higher self efficacy should result in a person discovering that there are external ways and means to address appearance or body related challenges. Hence, his or her self esteem is less likely to

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47 fluctuate with appearance problems; or to put i t simply, higher self efficacy might result in a reduction of the dependency of self esteem on appearance. Thus, we hypothesize: H1b: Self efficacy of reconstructive surgery patients participating in the health infomediary is negatively associated with app earance contingent self esteem. The second set of hypotheses (H2a and H2b) propose that social identity influences emotional empowerment and self esteem. We argue that these relationships are based on three underlying concepts relevant to positive distinct ness, achievement motivation, and social value orientation. First, social identity provides a positive distinctness that an others who are either not part of the group, or part of other gro ups (Hogg et al. 1995) With a higher sense of belonging to the group, an individual derives a pos itive vibe that people accept him or her, and promoting good appearance related feelings (Tajfel and Turner 2004) For instance, individual s who are exposed to others who have the same issue on the health infomediary will develop a sense of belonging and feel better about his or her appearance. If he or she feels that people accept how he or she looks, it increases confiden ce in his/her appearance. This leads to a higher appearance related self esteem and empowerment regarding his or her overall health. Second, higher social identity means that people have higher motivation or desire to achieve, maintain or enhance aspects of their life Group affiliations provide people with an increase in their motive for achievement, and subsequent positive vibes (Abrams and Hogg 2006) A group of similar patients participating in a health infomediary usually motivates each other to overcome their fears, to ignore criticism, and to see their real value. That enhances the ir feelin g of self worth, which can contribute to a desire to feel

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48 and look better. As a result, they increase their appearance contingent self esteem and empowerment. Third, high group affiliations or social identity of individuals can be classified as possessing either prosocial or competitive social value orientations (Balliet et al. 2009) Behavior that is congruent with one's social value orientation increases social worth related confidence. This then becomes the source of self esteem. For example, pro socials may gain higher confidence through helping others on the health infomediary because they value the benefits of the group more than their own benefits. On the other hand, individuals with a competitive social value orientation tend to be more concerned about themselves rather than the benefits of society (van Lange et al. 2013) They would take actions that make them look better and allow them to gain recognition from other group members, which in turn will make the person to look and feel better to increase appearance related self esteem. In other words, social identity drives prosocial or competitive social value orientations that convert into better appearance related confidence, an increase in self worth or self esteem, and an incr ease in confidence in their ability to manage their own health. Based on these arguments, we hypothesize: H2a: Social identity of reconstructive surgery patients participating in the health infomediary is positively associated with emotional empowerment H2b : Social identity of reconstructive surgery patients participating in the health infomediary is positively associated with appearance contingent self esteem. The third set of hypotheses (H3a and H3b) propose that internalized self stigma influences se lf esteem and emotional empowerment. We argue that these relationships are based on three mechanisms: awareness of stereotypes, identification with stereotypes,

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49 and efficacious evaluation. The underlying concept behind self stigma is that it occurs when in feelings (internalized self stigma) (Ritsher et al. 2003) Subsequently, this leads to feelings of shame, anger, hopelessness, or despair that keep them from seeking social support, employment, or treatment for their health conditions (Ritsher et al. 2003; Vauth et al. 2007) Higher self stigma involves awareness and identification of stereot ypes in the society (Major and O'Brien 2005) For ex ample, stereotypes about mental illness include blame, dangerousness, and incompetence (Corrigan and Kleinlein 2005) Being aware of the stereotypes, the individual may ignore or identify with the ster eotyping. Identification with the stereotyping can lead to a feeling of inadequacy and subsequent depression (Cox et al. 2012) Such a depressive state lingers and interferes with daily life and health managem ent; affecting energy and empowered feelings (Brohan et al. 2011; Goldstein and Rosselli 2003; Timulak and Elliot t 2003) The individual would then need professional help rather than a self empowering path to improved feelings (Timulak and Elliott 2003) Agreement or disagreement with existing stereotypes may not be sufficient to produce self stigma. Internalization of self stigma requires a perso n to apply stereotypes to one's self (I am not good looking, and so I am the one to be blamed for my disorder; or, I am responsible for my mental disorder) (Watson et al. 2007) This is a process of efficacious evaluation on the part of an individual, and may generate positive or negative reactions. A s an individual internalizes self stigma, it can be difficult for him or her to

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50 fight the reactions or elements of the reactions to the stereotyping (Corrigan 2004; Ritsher et al. 2003) In addition, individuals who internalize self stigma relat ed to their appearance (i.e. body image, facial attributes, obesity) are ashamed of their attributes or appearance (Franklin et al. 2006; Smolak 2004) The shame of their appearance means lower feeling of self worth because of their appearance or higher appearance contingent self esteem (Franklin et al. 2006; Strauss 2000) The implications of this argument are two fold: (1) internalized self stigma lowers self esteem is highly contingent on appearance; hence (2) higher internalized self stigma will have higher impact on person s with high appearance contingent self esteem. High self stigma is usually associated with high anxiety (Lysaker et al. 2010) Knowing that one has some inferior attributes, a person would often remind oneself of the inferior quality and would result in anxiety. This is especially the case when a person has low efficacy. A person with low self efficacy will be more likely to concern with efficacy tends to be more confident in (Corrigan et al. 2006) Two examples woul d substantiate our arguments. An unattractive individual may be bullied from early childhood and might associate the bullying experiences with being unattractive. The feeling of being unattractive is highly internalized, and is stereotyped as internalized self stigma would lead to a situation of being embarrassed about their identity, capability, or attributes (i.e. appearance) because they had a bad experience and developed self stigma based on it. Such process may lead the person to feel that he or she cannot do anything about it, thereby reducing empowering feelings (Ilic et al. 2013)

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51 As another example, being labeled as oversized or obese also tends to impose stigma on that pers esteem is highly dependent on appearance. As an obese person internalizes self stigma, self esteem is more likely to fluctuate with one's appearance -thereby increasing the degree of appearance contingent self esteem. Based on these discussions, we hypothesize: H3a : Internalized self stigma of reconstructive surgery patients participating in the health infomediary is negatively associated with emotional empowerment. H3b : Internalized self stigm a of reconstructive surgery patients participating in the health infomediary is positively associated with appearance contingent self esteem. The fourth and final set of hypotheses (H4a and H4b), relevant to the second stage of the conceptual model, propos e that appearance contingent self esteem and empowerment influence knowledge sharing behavior. The underlying concept behind psychological or emotional empowerment is that it energizes and sustains individual behaviors (Thomas and Velthouse 1990) Conger and Kanungo (1988) posit that empowerment stimu lates and manages innovativeness, and they are inextricably linked. Once empowered individuals are motivated to make a change, they are more likely to take some innovative action to achieve a desired outcome. In the context of health infomediaries, such ac tion will involve seeking and sharing disease or health related information. The concept of monitoring and forward influence attempts to influence someone else, either peer or higher in a community or team (Gajendran and Joshi 2012; Kirkman et al. 2004) The sense of control and power derived from empowerment leads people to engage in infl uencing actions (Janz and Becker 1984; Vecchio 2007) Similarly, high

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52 degree of self confidence or competence, stemming out of empowerment is a critical pre determinant for influencing actions, such as words, dialogues, convincing actions, and knowledge sharing behaviors (Hsu et al. 2007) Thus, emotional empowerment can also involve encouraging other users or patients about the val ue of their knowledge and experience and the contribution it makes to other patients. Emotionally empowered patients are confident and they prefer to lead conversations rather than being observers or followers (Khuntia et al. 2017) In contrast to empowered individuals, individuals with high appearance con tingent self esteem are less likely to be responsible for innovative behavior oriented action (Crocker et al. 2003; Knee et al. 2008) Thus, we argue that emotional empowerment is the primary enabler for an individual to take a new action or engage in innovative behavior, such as sharing knowledge about health. Appearance contingent self esteem, on the other hand, does not provide any action oriented push. Rather, appearance contingent self esteemed individuals exhibit pride or ego centric melancho lic behavior (Jung and Lee 2006; Stefanone et al. 2011) which makes them less likely to engage in sharing processes. Individuals with high self esteem exhibit more self monitoring behaviors than forward influencing behaviors (Gajendran and Joshi 2012; Kirkman et al. 2004) Monitoring, in appearance contingent self esteem, involves assessing deviations from a desired appearance. This would involve controlling appearance related attributes, in a highly self oriented process rather than influencing process. Thus, self esteem based monitoring would be an antithesis of forward influence or sharin g behaviors. Such behavior would be aggravated especially in health infomediaries, as any sharing of

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53 information by an individual with higher self esteem may be perceived as sharing something personal and private (Bansal et al. 2010) For example, when discussing the surgery; t hat would be perceived as a privacy intruding activity by an individual with higher appearance contingent self esteem. Thus, we posit that empowerment would be positively associated with knowledge sharing, whereas appearance contingent self esteem has a ne gative influence on knowledge sharing: H4a: Emotional empowerment positively influences knowledge sharing behavior within a health infomediary. H4b: Appearance contingent self esteem negatively influences knowledge sharing behavior within a health infomed iary. 3. 4 Research Methodology 3.4.1. Data Collection and Research Method This study uses the secondary archival data of 222 patients collected by a consulting firm. The consulting firm has been keeping track of patients with reconstructive surgery issues and their engagement in a health infomediary. The data set is a subset of a much larger dataset as the company continually tracks online behaviors on a health infomediary and occasionally follows up with online surveys The data is filtered by treatment for cosmetic and reconstructive surgeries only. The surveys were sent out to 2,542 members with valid email address and who were actively participating in the cosmetic and reconstructive surgery forum between 2014 and 2015 After the incomplete responses were removed, the data contains the responses and demographic data from 222 patients. The response rate was 8.73% and there was no

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54 significant difference in demographic attributes between responded and non responded members These data have already been de identified by the consulting firm before sending to the researchers. Most of the respondents (87.7%) are female. This is consistent with the prior studies and contextual observation that reconstructive surgery patients are predominantly females (95.6%) (Schlessinger et al. 2010) The company that provides the data has been providin g the data for many academic studies and has been known to be rigid in crafting the survey questions. However, we ensure the validity of the survey questions by mapping them to the equivalent measurement items found in prior literature. Only the survey que stions that match with equivalent measurement items for the constructs were included in the analysis. Therefore, these items have already been tested for reliability and validity, and are accepted among academicians. All v ariables were reflectively coded. Appendix C provides the coding scheme of the variables Table 8 provides a description of the variables used in this study. Table 8. Description of Variables Variable Description EFF Self Efficacy: The confidence in one's ability to complete a task within a particular context. SID Social Identity : One's acknowledgement of a social group that he or she belongs to. ISS Internalized Self Stigma: Internalization of negative feelings, shame, anger, hopelessness, or despair. CSE Contingent Self Esteem: esteem is dependent on the outcomes within a single domain. EMO Emotional Empowerment: The psychological trait or dimension of empowerment, involving the process through which people and groups gain greater control over their lives. KSB Knowledge Sharing Behavior: The behavior when a person disseminates his/her knowledge to other members within the community. AGE Age of the respondent. EDU Highest education attained by the respondent. INC Income of the respondent.

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55 3.4.2. Data Analysis and Results We employ two stage estimation procedures to test and validate our empirical model. The first stage tests to what extent the self concept beliefs (self efficacy, social identity, and internalized self stigma) explain the infomediary co ntingent actions ( CSE and EMO) whereas the second stage further examine to what extent the infomediary contingent actions explain knowledge sharing behavior (KSB). We use partial least square (PLS), a component based structural equation modeling (SEM) tec h nique, to estimate the path coefficients The PLS is widely used for path modeling especially when there are multiple latent variables in different stages, which makes it difficult for standard regression techniques (Garson 2016) More specifically, PLS makes no prior assumptions about data normality which makes it ideal for our research setting Although PLS technique is recommended for an exploratory model rather than a confirmatory model, PLS is accepted when the model specification is supported by prior literature (Garson 2016) The first set of hypotheses predict the influence of self efficacy on emotional empowerment and appearance contingent self esteem. We find that self efficacy has a positive and significant effect on emotional empowerment ( 3 7, p<0.01 ), supporting hypothesis H1a. Results show the self efficacy has a negative and significant effect on self esteem ( 0.17, p<0.01 ), supporting hypothesis H1b. Thus, while self efficacy has a positive association with emotional empowerment, it negatively affects appearance contingent self esteem. In regard to the second set of hypotheses, we find that social identity has a significant positive effect on appearance contingent self esteem ( 0.15 p<0.0 5 ),

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56 support ing hypothesis H2a. Similarly, hypothesis H2b is also supported with social identity having a positive and significant coefficient in the analysis results ( 0.16 p<0.0 1 ). Figure 5. Results of Partial Least Square Estimation (N=220) The third set of hypotheses related self stigma with the empowerment and self esteem variables. Results show that self stigma has a negative and significant association with emotional empowerment ( 0.11, p<0.1 ), supporting hypothesis H3a. Furthermore, H3b is also supp orted, with a positive and significant coefficient ( p<0.01 ) for the association between self stigma and appearance contingent self esteem. Finally, we also find support for the fourth and final set of hypotheses. Emotional empowerment has a pos itive and significant effect on knowledge sharing behaviour ( 0.27, p<0.01 ). Likewise, appearance contingent self esteem is significant, but has a negative effect on knowledge sharing behaviour ( 0.40, p<0.01 ). Therefore, all hypotheses are supported and the results are in line with prior literature and similar

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57 studies in different contexts (Crocker et al. 2003; Deng et al. 2013; Hsu et al. 2007; Kirkman et al. 2004; Knee et al. 2008; Lee Endres et al. 2007; Vauth et al. 2007) 3.4.3. Validity and Reliability Tests Table 9 shows the descriptive statistics for all variables along with the pairwise correlations. The pair wise correlation between variables is below 0.7 indicating no sign of multicollinearity. Table 9 all variables are between 0.79 and 0.88. All of which are higher than the suggested threshold of 0.7 (Gefen et al. 2000a) Table 10 shows that loadings of the indicators on their underlying constructs are higher than or equal to the suggested threshold of 0.7. Discriminant validity can be observed i n two ways: (1) when the indicators load much higher on their underlying construct than on the others, and (2) when average variance extracted (AVE) is higher than 0.5 and the square root of AVE is higher than inter correlations between the underlying cons truct and all other constructs. The two conditions for AVEs for all constructs were very well satisfied as shown in Table 9 Hence, discriminant validity is observed. Cross loadings from Table 10 shows that all indicators loaded highly on their underlying constructs and not on other constructs. This pattern demonstrates high convergence validity and high discriminant validit y. Table 9. Descriptive Statistics and Pair Wise Correlation Among Variables Obs Mean S.D. Min Max Alpha AVE 1 2 3 4 5 6 7 8 9 EFF 222 5.82 1.17 1 7 0.86 0.71 0.84 SID 222 3.35 1.64 1 7 0.88 0.74 0.01 0.86 ISS 222 3.00 1.88 1 7 0.91 0.79 0.29 0.09 0.89 CSE 222 3.99 1.69 1 7 0.87 0.72 0.32 0.21 0.56 0.85 EMO 222 4.64 1.50 1 7 0.80 0.71 0.40 0.12 0.22 0.27 0.84 KSB 222 5.59 1.44 1 7 0.81 0.72 0.59 0.11 0.56 0.47 0.37 0.85 AGE 222 3.43 1.40 1 6 1.00 1.00 0.08 0.04 0.18 0.26 0.12 0.22 1.00 EDU 220 4.40 0.73 2 5 1.00 1.00 0.04 0.08 0.05 0.07 0.07 0.05 0.15 1.00 INC 220 3.58 2.21 0 9 1.00 1.00 0.00 0.07 0.07 0.02 0.02 0.12 0.09 0.21 1.00 Note: Correlations above 0.2 are significant at p<0.05 level; the elements in the matrix diagonals represent the square root of AVEs.

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58 Table 10 Cross loadings of Items for Variables EFF SID ISS CSE EMO KSB EFF EFF1 0.81 0.01 0.24 0.31 0.32 0.54 EFF2 0.85 0.01 0.22 0.23 0.33 0.44 EFF3 0.83 0.05 0.25 0.28 0.41 0.50 EFF4 0.88 0.01 0.26 0.26 0.29 0.51 SID SID1 0.08 0.83 0.14 0.25 0.00 0.01 SID2 0.01 0.87 0.01 0.15 0.18 0.13 SID3 0.03 0.86 0.10 0.18 0.08 0.13 SID4 0.03 0.87 0.06 0.12 0.17 0.16 ISS ISS1 0.29 0.09 0.91 0.54 0.26 0.51 ISS2 0.22 0.11 0.89 0.47 0.14 0.48 ISS3 0.25 0.02 0.90 0.51 0.22 0.49 ISS4 0.28 0.10 0.85 0.48 0.15 0.51 CSE CSE1 0.31 0.16 0.46 0.85 0.27 0.42 CSE2 0.24 0.18 0.48 0.88 0.21 0.42 CSE3 0.27 0.16 0.38 0.81 0.25 0.34 CSE4 0.28 0.19 0.57 0.85 0.18 0.41 EMO EMO1 0.32 0.17 0.16 0.16 0.87 0.28 EMO2 0.31 0.03 0.23 0.25 0.82 0.32 EMO3 0.39 0.16 0.18 0.26 0.84 0.34 KSB KSB1 0.51 0.11 0.51 0.48 0.37 0.90 KSB2 0.51 0.03 0.48 0.40 0.30 0.84 KSB3 0.50 0.17 0.43 0.28 0.26 0.80 3.4.4. Robustness and Sensitivity Tests The model is first estimated without control variables and later all control variables are added to the model. The results remain almost unchanged after adding the control variables. Gender is not used as a controlled variable because more than 95% of

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59 resp ondents were female, and hence controlling for gender will not yield any useful insights. Consequently, the results may not be generalizable across gender. Among the control variables, only the effect of age on contingent self esteem is significant with th e coefficient of 0.16 at p < 0.01 while the others are not significant. We tested for multicollinearity by computing condition indices. The mean variation inflation factor (VIF) is less than 7 in our models, indicating that multicollinearity is not a ser ious concern in our analyses. In addition, because the dependent and independent variables are from the same survey instrument, we conduct Harman's one factor test to assess the sensitivity of our results to common method bias. The principal component anal ysis for key variables yields multiple factors, some with eigen values exceeding one. Because no single factor emerges as a dominant factor accounting for most of the variance, common method variance does not seem to be a serious problem. 3.4.5. Econometri c Analysis and Results In addition to PLS, we use structural econometrics that imposes more restrictions on underlying assumptions to improve causal relations in our model and interpretability of the parameter estimates. We use the 3SLS procedure to derive parameter estimates of the full system of equations in our study. The structural model approach allows us to simultaneously and explicitly account for possible correlations among the disturbance of the specified equations (Greene 2012) In our study, CSE and EMO are simultaneously determined by the first stage model, thus making them endogenous explanator y variables for KSB in the second stage. The 3SLS procedure corrects for the endogeneity issue to derive parameter estimates.

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60 While the 3SLS offers efficiency gain over other approaches, it can be sensitive to incorrect specification of underlying relatio nships in the structural model. If any of the structural model equations are misspecified, the resulting parameter estimates are likely to be inconsistent. Thus, we also use a two stage approach to compare with the 3SLS results for consistency. More specif ically, we use seemingly unrelated regression technique to estimate the effect of the self concept beliefs on CSE and EMO with joint probability of errors, and then, to handle the endogeneity issue, we use predicted probabilities of the two mediating varia bles to estimate the parameters on KSB. The equations that we specified for the regression based methods (SUREG and 3SLS) are: (1) Where is a constant, is a vector of explanatory variables, is a v ector of parameter coefficients, and is the disturbance of the function. (2) Where is a constant, is a vector of explanatory variables, is a vector of parameter coefficients, and is the disturbance of the function. (3) Where is a constant, is a vector of explanatory variables, is a vector of parameter coefficients, and is the disturbance of the function. We also use ordered probit model to derive parameter estimates to complement linear regression procedure used in deriving the estimates from the 2 stage and 3 stage procedures. Since our dependent variables are measured using survey scale that has limits

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61 on both minim um and maximum values, it is possible that scale limits may violate the distribution assumption in the linear regression framework (Jack man 2009) The empirical estimation equation for the ordered probit model is: (4) (5) Where, Pr is probability, is a vector of explanatory variables, is the cumulative distribution function of the standard normal distribution, a vector of parameter coefficients, and is the disturbance of the function (6) (7) Where, Pr is probability, is a vector of explanatory variables, is the cumulative distribution function of the standard normal distribution, a vector of parameter coefficients, and is the disturbance of the function ( 8 ) ( 9 ) Where, Pr is probability, is a vector of explanatory variables, is the cumulative distribution function of the standard normal distribution, a vector of parameter coefficients, and is the disturbance of the function The analysis from seemingly unrelated regression (SUREG) shows that the effect of self efficacy, social identity, and internalized self stigma on self esteem are all significant at p < 0.01 with the coefficient of 0.26, 0.14, and 0.44 respectively. The effec t of self efficacy, social identity, and internalized self stigma on emotional empowerment are also significant with the coefficient of 0.46 ( p < 0.01), 0.12 ( p < 0.05),

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62 and 0.10 ( p < 0.1) respectively. The effect of self esteem and emotional empowerment on knowledge sharing behavior are 0.41 and 1.11, both at p < 0.01. Table 11 summarizes the results of econometric analyses and partial least square technique. The results of all these techniques are quite similar, thereby establishing the robustness of fi ndings. We also compared the R 2 values across the PLS and econometric models. The R 2 values in PL S model of self esteem, emotional empowerment, and knowledge sharing behavior are 0.394, 0.203, and 0.287 respectively. In other words, 39.4% of variability in self esteem, 20.3% of variability in emotional empowerment, and 28.7% of variability in knowledge sharing behavior are explained by the model. In the SUREG model, The R 2 of self esteem (0.396) and emotional empowerment (0.193) are very close to those of PLS while the R 2 of knowledge sharing behavior (0.529) is higher than that of PLS. The analysis fr om 3 stage least squares analysis is very similar to the analysis from seemingly unrelated regression. The analysis shows that the effect of self efficacy, social identity, and internalized self stigma on self esteem are all significant with the coefficien t of 0.25 ( p < 0.01), 0.12 ( p < 0.05), and 0.45 ( p < 0.01) respectively. The effect of self efficacy, social identity, and internalized self stigma on emotional empowerment are all significant at p < 0.01 with the coefficient of 0.44, 0.18, and 0.12 resp ectively. The effect of self esteem and emotional empowerment on knowledge sharing behavior are 0.41 and 1.11, both at p < 0.01. The R 2 of self esteem (0.394), emotional empowerment (0.178), and knowledge sharing behavior (0.558) are very close to that of seemingly unrelated analysis as they are both regression based. The analysis from ordered probit is again similar to the analysis from PLS, seemingly unrelated regression, and 3SLS. The analysis shows that the effect of self

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63 efficacy, social identity, and internalized self stigma on self esteem are all significant with the coefficient of 0.19 ( p < 0.01), 0.11 ( p < 0.05), and 0.35 ( p < 0.01) respectively. The effect of self efficacy, social identity, and internalized self stigma on emotional empowerment ar e also significant with the coefficient of 0.37 ( p < 0.01), 0.09 ( p < 0.1), and 0.07 ( p < 0.1) respectively. The effect of self esteem and emotional empowerment on knowledge sharing behavior are 0.17 and 0.16, both at p < 0.01. The effects in the second stage here are not so similar to the regression based estimations but more similar to the PLS estimations. The estimates before adjusting for biases (residuals) are closer to the PLS estimates ( 0.32 and 0.20, as compared to 0.40 and 0.27). Table 11. Est imation Results of Seemingly Unrelated Regression, Three Stage SLS, Ordered Probit, and Partial Least Square SUREG 3SLS Ordered Probit PLS First Stage: Health Relevant Actions (EMO and CSE) CSE EMO CSE EMO CSE EMO CSE EMO EFF 0.26*** (0.08) 0.46*** (0.08) 0.25*** (0.08) 0.44*** (0.07) 0.19*** (0.06) 0.37*** (0.07) 0.17*** (0.06) 0.37*** (0.06) SID 0.15*** (0.06) 0.12** (0.06) 0.12** (0.05) 0.18*** (0.04) 0.11** (0.05) 0.09* (0.05) 0.16*** (0.05) 0.15** (0.06) ISS 0.44*** (0.05) 0.10* (0.05) 0.45*** (0.05) 0.12*** (0.04) 0.35*** (0.05) 0.07* (0.04) 0.47*** (0.06) 0.11* (0.06) AGE 0.20*** (0.07) 0.01 (0.07) 0.22*** (0.06) 0.06 (0.04) 0.16*** (0.05) 0.00 (0.05) 0.16*** (0.05) 0.06 (0.06) EDU 0.17 (0.13) 0.09 (0.13) 0.11 (0.12) 0.05 (0.08) 0.12 (0.10) 0.06 (0.11) 0.00 (0.06) 0.05 (0.06) INC 0.10** (0.04) 0.04 (0.04) 0.07* (0.04) 0.02 (0.03) 0.07** (0.03) 0.03 (0.03) 0.04 (0.06) 0.03 (0.06) Obs 218 218 218 218 218 218 222 222 R 2 0.396 0.193 0.394 0.178 0.084 0.039 0.394 0.203 Chi 2 143.03 52.27 143.87 64.37 87.99 39.69 RMSE 1.32 1.34 1.32 1.36 Second Stage: Infomediary Contingent Action (KSB) KSB KSB KSB KSB CSE 0.41*** (0.08) 0.41*** (0.14) 0.17*** (0.06) 0.40*** (0.06) EMO 1.11*** (0.13) 1.11*** (0.23) 0.16*** (0.06) 0.27*** (0.06) Obs 218 218 218 222 R 2 0.529 0.558 0.110 0.287

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64 When compared to the other statistics, in the first stage, some estimates from PLS are a bit underestimated (i.e. the effects of self efficacy on contingent self esteem and emotional empowerment) while some estimates are a bit overestimated (i.e. the effect of social identity and internalized self stigma on contingent self esteem). Overall, the estimates are consistent regardless of the methods used In the second stage, PLS seems to be underestimated when compared to other methods. The effect of emotional empowerment on knowledge sharing behavior estimated by PLS is much lower than the effect estimated by the regression based methods. However, there is no apparent difference in the results from all methods and the polarity of the results from all methods are consistent. Given there are two paths in the model (e.g., emotional empowerment (EMO) and appearance contingent self esteem (CSE) paths ) to arri ve at the knowledge sharing outcome from the dimensions of self concept, we conducted an additional mediation analysis using the suggested procedure by (Baron and Kenny 1986; Sobel 1986) The analysis compared the two paths for each of the independent variables related to self concept (e.g., self efficacy, social identity and internalized self stigma) on knowledge sharing behavior. The path comparison and mediation results are presented in Table 1 2 We find that while the appearance contingent self esteem (CSE) path provides a better F (2, 215) 124.10 Chi 2 73.97 90.49 RMSE 1.00 1.80 GOF 0.4641 Notes: Standard errors in parentheses *** p<0.01, ** p<0.05, p<0.1 Pseudo R 2 are presented for Ordered Probit results. R 2 and Chi 2 are all significant at p<0.01.

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65 outcome from self efficacy and internalized self stigma to knowledge sharing, the emotional empowerment (EMO) path is better from social identity to knowledge sharing. We provide insights and discuss these findings in the next section. Table 1 2 Mediation Analysis and Path Comparison Tests Dependent Variable Independent Variable Mediating Variable Direct Effect Coefficient Indirect Effect Coefficient Proportion of Total Effect That Is Mediated Ratio of Indirect to Direct Effect KSB EFF EMO 0.66*** (0.07) 0.08 *** (0.03) 0.11 0.12 KSB EFF CSE 0.63*** (0.06) 0.11*** (0.03) 0.14 0.17 KSB SID EMO 0.09* (0.06) 0.04* (0.02) 0.28 0.39 KSB SID CSE 0.21*** (0.06) 0.08** (0.03) 0.60 0.37 KSB ISS EMO 0.38*** (0.04) 0.05*** (0.02) 0.11 0.12 KSB ISS CSE 0.34*** (0.05) 0.08*** (0.03) 0.19 0.23 Note: Sample size: 218 Parameter estimates are based on Sobel Goodman mediation tests using Stata software Sobel and/or Goodman coefficients are significant at p<0.01 levels; but significant at p<0.1 level for the KSB SID EMO path Estimations include age, education and income as controls Standard errors in parentheses Significance levels: *** p<0.01, ** p<0.05, p<0.1 3. 5 Discussion 3. 5 .1. Implications of this Study The findings of our analysis suggest that while self efficacy has a positive association with emotional empowerment, it has a negative association with self esteem. Social identity has a positive association with both emotional empowerment and self esteem. These findings suggest that people with higher self efficacy and social identity

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66 will seek external validation through emotional empowerment. However, individuals with higher self stigma will try to analyze and reanalyze their internalization and related self that self stigma is negatively associated with emotional empowerment. Internalized self stigma also increases appearance contingent self esteem. Knowing this, th e infomediaries can try to alleviate internalized self stigma by fostering social support for those with self stigma, and by taking immediate action to intervene when the discussion may contribute to self stigma. Developing measures to minimize the feeling of being excluded from the community or the feeling of being labeled as inferior may also help foster emotional empowerment and reduce the effect of appearance contingent self esteem. As an example, it may be helpful to make patients believe that the info mediary has a unique value and is a unique community, and that they are important to the community. These insights suggest that the concept of self in a health management context is highly relevant. How an individual perceives his or her skills in regards to health management, role or identity in the society, and internalization of stigmas, such as guilt, shame or anger, are pre cursors to the actions that the person takes towards managing his has a key role to play in subsequent steps towards action such as seeking empowerment or improving feelings of self worth. We also find that emotional empowerment has positive effect on knowledge sharing, whereas appearance con tingent self esteem has a negative influence on knowledge sharing. Emotional empowerment can help foster active knowledge sharing

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67 on health infomediaries. When infomediary members or patients are empowered, they are motivated to share their knowledge and p ersonal experiences in the infomediaries. The empowerment can come either from other members or from the act of sharing itself. Therefore, the health infomediaries should focus on the strategies to facilitate emotional empowerment among members. For exampl e, infomediaries could foster empowerment Patients whose self esteem is contingent on their appearance are less likely to share their knowledge in the infomediaries. This implies that patients with high self esteem do not always share their knowledge. Only patients whose self esteem is not highly contingent on appearance will likely share their knowledge in the infomediaries. However, as patients gain higher self efficacy, their self e steem tends to be less dependent on appearance, and they are more likely to share their knowledge. In other words, although the infomediaries cannot change the way the self esteem is contingent on appearance, the infomediaries may be able to boost knowledg e sharing by increasing the members' self efficacy. The comparative analysis of the two paths in our conceptual model (e.g., empowerment and self esteem paths) reveal that while the self esteem path is better to leverage on self efficacy and internalized self stigma on knowledge sharing, but the emotional empowerment path is better for orienting self identity for knowledge sharing. when a patient has greater confidence in h is or her skills. Empowerment is a confidence increasing enabler in this process. Higher social identity implies that a patient has a higher propensity towards external validation, and external validation is required to

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68 concept perceptio ns. Whereas, self stigma and self efficacy is how influenced by external validation and more influenced by self evaluation. Thus, self being. On the other hand, social identity links the self with the social context. Which implies that empowerment is more likely to knowledge sharing because tside. Broadly, these findings suggest that not necessarily a single path is ideal; and both paths are necessary to manage knowledge sharing in infomediaries. The implications from the path comparisons are that for health infomediaries to design interve ntion systems, they need to personalize the intervention systems to the to follow an assessment and recommendation system. For example, prior or current assessment using a few questions can provide if the patient has higher social identity. with others regarding the procedures or treatments, others will reflect on your For a patient with higher self your knowledge w ith others, you will be recognized for your contribution towards worth. Thus, from our findings, we provide a strong recommendation towards design of up suggestion, or human call agents) on the

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69 In addition, the findings of this study may be applied to similar context Imagine the discussion of some symptoms or diseases may be embarrassing and may be esteem. Some examples are erectile dysfunction, HIV disease, and sexually tr ansmitted diseases. Self esteem, social identity, and self stigma are most likely the important factors influencing the discussion Therefore, the infomediaries specialized in those diseases may be able to apply the knowledge from this study to help foster knowledge sharing on their informediaries. The knowledge from this study can be applied not only to similar types of infomediaries, but also to vendors of related products or services (e.g. medication or treatment for those diseases). However, the roles o f self concepts may vary in different context. Further research is required to validate the application to other similar contexts. 3. 5 2 Theoretical Contributions of this Study This study contributes to theory by identifying and validating the ideas of s elf concept and patient empowerment and providing evidence that it can lead to patient engagement with health infomediaries. While knowledge based empowerment plays a role in patient responsiveness within a healthcare system, the categorization and operati onalization discussed in this study could lead to further discussion on the role of critical in chronic disease management, as patients who live alone need constant moti vation to manage their disease. The findings also demonstrate the need for an

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70 effective interface and appropriate incentive structure for knowledge interaction and community engagement within a health infomediary. In conclusion, this study provides a new perspective relevant to the self concept (and its dimensions) and mechanisms for patient empowerment and knowledge exchange with a health infomediary. Different dimensions of self concept and subsequent esteem and empowerment leads to higher knowledge sha ring. Data collected from a health infomediary designed for reconstructive surgery patients is used to validate several hypotheses. The findings highlight the role of self esteem, self worth and other self concept tenets in the health infomediary context. Most importantly, fostering self esteem alone does not encourage knowledge sharing. Instead, the health infomediary should facilitate knowledge sharing through emotional empowerment and minimize the negative effect of appearance contingent self esteem thro ugh manipulation of self efficacy, social identity, and self stigma.

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84 A PPENDIX Appendix A: Health Infomediaries Widely Accessed through Internet Name Rank Service WebMD.com 510 Health information myfitnesspal.com 1,234 Dietary information drugs.com 1,739 Drugs information healthline.com 1,830 Health information medicinenet.com 3,242 Health information weightwatchers.com 4,783 Dietary information self.com 7,494 Dietary information realself.com 7,757 Beauty treatment information sparkpeople.com 9,407 Dietary information medhelp.org 9,802 Online health community practo.com 10,634 Medical tourism steadyhealth.com 14,304 Online health community healthtap.com 20,985 Immediate access to doctors healthboards.com 21,055 Online health community fatsecret.com 22,164 Dietary information colgate.com 25,436 Dental information whatclinic.com 25,889 Beauty treatment information lybrate.com 30,327 Medical tourism calorieking.com 31,316 Dietary information acne.org 33,591 Acne information ehealthforum.com 33,990 Online health community healingwell.com 60,824 Online health community patientslikeme.com 100,532 Patient network community nutritionix.com 109,004 Dietary information medifee.com 113,648 Medical tourism iodine.com 128,485 Drugs information medigo.com 137,548 Medical tourism emedtv.com 146,613 Health information health tourism.com 147,771 Medical tourism medbroadcast.com 154,143 Health information docshop.com 171,478 Beauty treatment information pdr.net 198,982 Drugs information doctorondemand.com 205,187 Immediate access to doctors placidway.com 295,355 Medical tourism treatmentabroad.com 326,919 Medical tourism rxwiki.com 346,192 Drugs information druglib.com 514,363 Drugs information MedPlus.com 13,967,152 Health information healthboard.com 23,916,291 Online health community healthinforum.org 26,766,616 Online health community Note: The websites are sorted by the rank. The rank is calculated by using a combination of average daily visitors to this site and pageviews on this site over the past 3 months and is available at www.alexa.com The site with the highest combination of visitors and pageviews are globally top ranked.

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85 Appendix B: Representative Literature on Health Infomediaries Study Research Question Method, sample, context Key Findings (Khuntia et al. 2016) How empowerment dimensions influence patient engagement in health infomediaries? Method: Econometric analysis of secondary data Data: More than 65,000 daily activities of 21,715 patients during the first 30 and 60 days Context: Health infomediary for cosmetic surgery Three types of empowerment (leadership, discretionary, and psychological) have positive association with sustained engagement; with leadership empowerment is shown to play a higher role than discretionary or psychological empowerments in sustaining engagements. (Ambrose and Basu 2012) What is an overarching theoretical framework and key factors that motivate and inhibit patients' use of online health information systems? Method: Conceptual paper (non empirical) Context: Online health information systems Usefulness is a motivator Inhibitors a re privacy and security concerns Usages is essential to develop successful business models (Yim et al. 2015) What are the classifications of visitors in health infomediaries? Method: Cluster analysis Data: 162,598 activities of 44,350 visitors Context: Health infomediary for cosmetic surgery Identification of 4 user categories: community supporters, experiencer providers, knowledge questors, and expertise contributors. (Yi et al. 2013) What are the antecedents o f initial trust in Web based health information? Method: Field experiment Samples: 300 voluntary participants Context: Health information website Argument quality and source expertise positively influence perceived information quality, which in turn positi vely influence trust. Higher perceived information quality also leads to higher trust by reducing perceived risk. (Lim and Kim 2012) What are the relationships among trust, information quality, and behavior intention to use health infomediaries at different trust level? Method: Survey Sample: 274 undergraduate students Context: Trust, information quality & health infomediaries In the high trust group, trust has positive mediation effects of information relevance and information reliability on behavior intention. In the low trust group, trust has p ositive mediation effects of information adequacy and information usefulness on behavior intention. (Zahedi and Song 2008) How does trust evolve over time in health infomediaries? Method: Longitudinal lab experiment Sample: 209 students Context: Trust, information quality & health infomediaries Trust changes over time. Information quality is the most important antecedent in trust building in infome diaries. Satisfaction plays an important changing trust belief. (Song and Zahedi 2007) What factors may impact various trust beliefs in health infomediaries? What are the natures and roles of different trust beliefs in web users' intention to mak e health decision based on information from a health infomediary? Method: Survey based experiment Sample: 494 business school students Context: Trust & health infomediaries Web users' beliefs about the ability and benevolence of the health infomediary critically affect their behavior intentions. User's propensity to trust has a significant relationship with risk related beliefs. Trust and risk beliefs positively influence web users' behaviors. (Vega et al. 2011a) What is the trust relationship between humans and health websites? Method: Meta analytical framework Samples: 49 papers Context: Trust in health websites There is little consensus regarding the defining characteristics of the construct of trust in health websites. Further research in this field should focus on collaboratively defining

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86 trust and what factors affect trust in health websites. (Bansal and Gefen 2010) What is the role of personal dispositions in disclosing health information online? Method: Lab experiment Sample: 367 colle ge students Context: Trust, personal disposition & health infomediaries Trust, privacy concern, and information sensitivity influence individuals' intention to disclose health information. Trust, privacy concern, and information sensitivity are determined by personal dispositions. (Ye 2010) Is personal capital correlated with trust in online health information? Is social capital correlated with trust in online health information? Does trust in health i nformation from traditional media and government health agencies correlate with trust in online health information? Method: Correlation analysis of secondary data Data source: The National Information National Trends Survey Samples: 7,674 adults Context: Consumer trust in online health information Consumer trust in online health information did not correlate with personal capital i.e. income, education, and health status. Social capital indicated by visiting social networking Web sites was not associated with trust in online health information. Trust in online health information transferred from traditional mass media and government health agencies to the Internet. Age appeared to be a key factor in understanding the correlate s of trust in online health information.

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87 Appendix C : Coding Scheme o f Variables f rom t he Survey Questionnaire Variable Description and Operationalization Survey items are measured in a 7 point scale: 1=highly disagree to 7=highly agree. References Self Efficacy (EFF) The confidence in one's ability to complete a task within a particular context. I am confident that I could deal efficiently with unexpected events. I can always manage to solve difficult problems if I try hard enough. If I am in troubl e, I can usually think of a solution. I can solve most problems if I invest the necessary effort. (Luszczynska et al. 2005; Tambs and Rysamb 2014) Social Identity (SID) One's acknowledgement of a social group that he or she belongs to. Overall, my group memberships have so much effect on how I feel about myself. The social groups I belong to are an important reflection of who I am. In general, belonging to social groups is an important part of my self image. The social groups I belong to are important to my sense of what kind of a person I am. (Luhtanen and Crocker 1992) Internalized Self Stigma (ISS) Internalization of negative feelings, shame, anger, hopelessness, or despair. My physical appearance makes me feel bad. I feel guilty about my physical appearance. I am ashamed of my physical appearance. My physical appearance has spoiled my life. (Kalichman et al. 2009) Contingent Self Esteem (CSE) esteem is dependent on the outcomes within a single domain. My self esteem is influenced by how good looking I think I am. My self esteem does not depend on whether or not I look good. (r) My self esteem is not related to how I feel about the way I look. (r) My sense of self (Crocker et al. 2003; Rosenberg 1965) Emotional Empowerment (EMO) Emotional component of psychological empowerment, the process through which people and groups gain greater control over their lives. I would prefer to be a leader rather than a follower in a conversation. in a conversation. (r) I am often a leader in a conversation. (Speer and Peterson 2000; Vauth et al. 2007) Knowledge Sharing Behavior The behavior when a person disseminates his/her knowledge to other members within the community. (Oliveira et al. 2015; Xue et al. 2011)

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88 (KSB) I frequently participate in knowledge sharing activities on health websites. I usually spend a lot of time conducting knowledge sharing activities on health websites. I usu ally share my knowledge with the other on health websites. AGE Age of the respondent. Scale: 1: 18 24 years, 2: 25 34 years, 3: 35 44 years, 4: 45 54 years, 5: 55 64 years, 6: 65 74 years, and 7. 75 years or older Education (EDU) Highest education attained: 1: Did not attend school, 2: Pursuing high school, 3: Finished from high school, 4: Pursuing college, 5: Finished from college Income (INC) Income of the respondent. Scale: 1: $0 $24,999; 2: $25,000 $49,999; 3: $50,000 $74,999; 4: $75,000 $99,999; 5: $100, 000 $124,999; 6: $125,000 $149,999; 7: $150,000 $174,999; 8: $175,000 $199,999 9: $200,000 and up Note: (r) = reverse coded.