This study used a mixed methods approach for scale development [22], involving feedback and inductive and deductive information in a strictly online setting. Items for the developed Attitudes Toward Seeking Online Health Information (ATSHIO) scale were established in previous studies [23-25]. A qualitative pilot study found that participants were using online peer-to-peer–provided health information to decide whether they would seek health care [23]. The scale was then developed based on the pilot study results and a review of the literature. Subsequent studies then focused on investigating the constructs and gaining feedback on the scale [24,25]. Participants provided feedback on the wording of the items; thus, the scale used in this study included the edited and refined items based on this feedback.

Participants were eligible for the study if they met the following criteria: (1) 18 years or older, (2) identifying as a member of the DOC, and (3) having been diagnosed with T1D by a doctor. Participants were recruited from the DOC via Facebook posts; tweets using the hashtags #doc, #type1 diabetes, and #dsma; and peer-to-peer referrals.

This study was approved by the Institutional Review Board at the University of Texas at El Paso (1216875-1). Participants received a US $10 tango gift card upon completing the study.

Participants were provided access to a link to the Qualtrics survey where they responded to questions on demographics, a health questionnaire, the eHealth Literacy scale [26], the Social Provisions scale [27], the Treatment Adherence scale [28], and the Diabetes Distress scale [29]. Participants also provided qualitative feedback on the clarity, esthetics, relevancy, tone, and cultural competence of the ATSHIO scale, along with the length of time needed to respond. The scale items are provided in Table 1.

Confirmatory factor analysis (CFA) was performed using Mplus 7.11 [30]. Following the suggestions of Brown [31], a variety of plausible models were tested, including a 3-factor model and a 2-factor CFA model, each with 16 items. Robust maximum-likelihood estimation was used in these models. The absolute fit indices included the Satorra-Bentler scaled χ² statistic and the standardized root mean square residual (SRMR). The relative fit indices included the Tucker-Lewis index (TLI) and the comparative fit index (CFI). Following factor analysis and model fit comparison guidelines [32], the CFA results were compared to assess the model fit according to a threshold of SRMR<0.09 in combination with either a TLI or CFI<0.96 or root mean square error of approximation (RMSEA)>0.06.

A total of 175 people with T1D agreed to participate in the study. Nine participants were excluded due to not meeting the inclusion requirements. Of the 166 participants included in this sample, 89.8% (n=149) identified as female with an average age of 34.33 (SD 11.249) years. The majority (149/166, 89.8%) of sample participants were living in the United States. Approximately 86.1% (143/166) of participants identified their race as White. The average household income was US $85,425.28 (median US $74,500). Most participants (133/166, 80%) reported obtaining additional education after high school. The average hemoglobin A_1c was 7.3% (SD 1.36%) and more than half of the participants (88/166, 53%) reported using an insulin pump. Of note, 81.9% (136/166) of the participants indicated that they take additional medications beyond insulin. Table 2 summarizes the main demographic and health-related characteristics of the sample.

Participants provided many detailed responses from questions that should be added to the ATSHIO scale and overall general comments for improvement:

Participants were also asked to address the cultural competency of the ATSHIO scale: “Each question was something someone living with type 1 diabetes could answer or relate to” [ID 129]. One participant identified how the items correctly reflected what individuals with T1D experience: “They understood the DOC is able to help through the disease, especially to avoid an appointment with the endo since those are hard to get sometimes” [ID 179]. Participants stated that the survey used participant-endorsed terminology and that questions seemed to indicate that the research team had knowledge of T1D, largely due to the level of detail.

Importantly, several factors of diabetes distress were correlated with factors of the ATSHIO (Table 6): powerlessness and factor 1 (r=0.198, P=.01), hypoglycemia distress and factors 1 and 2 (r=0.153, P=.05 and r=0.158, P=.04, respectively), management distress and factor 2 (r=0.169, P=.03), physician distress and factor 1 (r=0.204, P=.008), and family distress and factor 2 (r=0.219, P=.005).

In this study, a scale examining online health information–seeking for individuals with T1D was developed and validated. This scale measures multiple types of peer-provided social support and examines how peers broker health information. Scale development was necessary due to the lack of existing scales addressing real-world experiences of seeking chronic disease–related information. We developed a reliable 2-factor, 16-item scale. Furthermore, this project examined the relationships between the measure of seeking health information online and the scale items of eHealth literacy, social provisions, and diabetes distress to establish validity by demonstrating the magnitude of these relationships.

Regarding CFA model comparison, the 2-factor, 16-item scale had small standardized residuals [32] and provided a good model fit. The majority of the project’s scales had excellent reliability, whereas a few scales used to validate the measure demonstrated adequate reliability, as indicated by the Cronbach α coefficient, including Social Provisions-Social Integration, Social Provisions-Reassurance of Worth, Diabetes Distress-Management Distress, Diabetes Distress-Eating Distress, and Attitudes Toward Seeking Health Information Online (factor 1), and fair reliability for Attitudes Toward Seeking Health Information Online (factor 2). The findings from this study will contribute to the knowledge base of the health care of adults with T1D. Participants were forthcoming about the items of the scale and provided recommendations, as they are a very active and communicative population in the context of social media.

As expected, both factors were positively related to eHealth literacy. Additionally, the Trusting and Evaluating Online Health Information factor was positively related to the Social Provisions factors (Attachment, Social Integration, Reassurance of Worth, Reliable Alliance, Guidance, and Opportunity). Thus, this study extends what is known about informational support, as a type of social support, in the context of online health information–seeking. The factor Engaging with Online Health Information in the DOC was also found to be positively related to several Social Provisions items (Attachment, Social Integration, Reassurance of Worth, Reliable Alliance, Guidance, and Opportunity for Nurturance). These relationships are to be expected, as informational support is a type of social support.

Of interest, Trusting and Evaluating Online Health Information (factor 1) was positively related to multiple types of Diabetes Distress items (Powerlessness, Hypoglycemia Distress, Physician Distress). These findings are a unique contribution to the T1D literature because they provide support that key diabetes-related constructs impacting health behaviors also impact health information–seeking. These findings are significant because, to the best of our knowledge, this study is the first to assess these relationships. These findings are a unique contribution to the T1D literature because they provide support that with more feelings of distress toward managing T1D, hypoglycemia-related distress, and diabetes-related distress related to friends and family, individuals are engaging more with online health information in the DOC. With more diabetes-related distress comes more engagement in the DOC and more trust in the information found online.

This study highlights that with more distress toward managing T1D, hypoglycemia-related distress, and diabetes-related distress related to friends and family, people with T1D are engaging more with online health information in the DOC. This is important because instead of seeking support from their health care team, they are seeking support from the DOC (which is available 24 hours a day, 7 days a week). Clinicians may be able to use this scale as a starting point for a discussion with their patients with T1D about how they seek information online and how their clinicians can better support them when they need information quickly. This is especially poignant for the current generation of clinicians who are using telehealth.

Although this study provides an innovative, valid, and reliable scale, there are a few important limitations from which future research may build upon. The sample mostly comprised female participants of White race who were well-educated. Future research in this area should also seek to collect data from minority populations because much of the existing DOC research does not represent the diversity that exists in the online community. Similar research considering and incorporating caregivers for adolescents with T1D would be beneficial because these individuals also engage in the DOC. The developed ATSHIO scale was created for the T1D community but could be tailored for other chronic disease groups who seek health information online.

Future research should be performed based on the feedback provided in this study for the ATSHIO scale to further confirm the findings, further validate its factor structure, and establish reliability of those factors. Future research should also aim to increase the reliability of both factors of the ATSHIO scale. Due to the nature of potential biases inherent to self-reported data, future research should seek to incorporate other sources of data beyond self-reported data, including electronic medical record data.

These findings provide support for the relationships between ATSHIO, social provisions, diabetes distress, and T1D-related health outcomes and behaviors. With a better understanding of the roles of online social support and seeking health information online on disease management, this project serves as the first of several series of studies to improve use of the DOC and facilitate constructions of interventions that encourage or discourage specific aspects of each behavior. From these results, clinicians may encourage people with diabetes to seek social and informational support online. People with diabetes should be educated on health literacy to safely navigate the diabetes online community.