The Anderson Behavioral Model, developed by Andersen [11] in 1968, has been widely used to analyze the factors associated with health service use based on 3 dimensions: predisposing, enabling, and need factors [12-14]. Based on the Andersen Behavioral Model, this study also discussed the factors affecting web-based consultations with physicians in China.

The use of web-based consultation has complex influences rather than a single effect. QCA has been applied to explore the different combinations of health care interventions because it bridges qualitative and quantitative methodologies [15]. Based on set theory, QCA compares characteristics of the cases in relation to the outcomes by a scoring system. Moreover, QCA has an advantage in analyzing small samples, which usually requires 10 to 80 cases [16,17]. Crisp-set QCA (csQCA) yields binary scores of 0 and 1, indicating “full out” or “full in” in certain conditions [18].

The semistructured interviews were centered around three broad questions: (1) Do you have experience using internet health care services? (2) If yes, which function do you use and why do you use it? Which function do you never use and why are you are reluctant to use it? and (3) If no, why do you never use internet health care services? When describing their experiences, the participants were asked to share examples and not only feelings about internet health care services.

We conducted interviews with residents of provinces in Eastern, Western, and Central China between September and October 2022.

The initial 5 samples were selected by convenience, and they were patients visiting the China-Japan Friendship Hospital. Subsequently, we asked them to recommend 1 or 2 interviewees, such as their friends, colleagues, or relatives, randomly. We repeated this process until the information on why internet health care services were or were not used was saturated. To obtain representative samples, we analyzed the characteristics of former samples and provided detailed requirements with regard to age, location, income, education, and sex for the following samples.

In total, 70 participants were interviewed, and 5 interviews were excluded owing to a lack of information regarding web-based consultations with physicians. The sample size for QCA should be at least 2^k, where k is the number of conditions [17,19]. The study includes 6 conditions; hence, the sample size should be at least 64. Ultimately, the study included 65 interviews.

We analyzed the transcripts using a team-based inductive approach. First, the audio data were transcribed verbatim by a third-party company specialized in transcriptions in the Chinese language; once transcribed, the audio recordings were subsequently discarded to protect the participants’ confidentiality. Second, the first round of open coding was conducted using NVivo 12 (QSR International), and we coded the transcripts independently. We discussed and resolved discrepancies and then recoded the data to compile the major themes. Finally, based on the Andersen Behavioral Model, both the conditions and the results were identified by the lead author, reviewed by coauthors, and finalized by the corresponding author (see Table 1). In this study, csQCA was conducted using a program for crisp and fuzzy set with the fsQCA3.0 package (Charles C Ragin and Sean Davey).

This study was approved by the China-Japan Friendship Hospital (approval 202-ky-032). We asked the participants whether they would be willing to be interviewed over the phone. Once the participants confirmed that they were interested in participating in the study, we made an appointment with them before the interview. At the beginning of the interview, we reviewed a consent form with the participants and obtained their verbal consent to proceed. Interviews were conducted primarily through phone calls because we aimed to reach more residents from different regions across China. All interviews were recorded and transcribed verbatim for data analysis. No compensation was provided for participation.

Participants were recruited from the provinces of Beijing, Shanghai, Guangdong, and Zhejiang in Eastern China (31/65, 48%); Jilin, Henan, and Jiangxi in Central China (14/65, 22%); and Sichuan, Yunan, and Qinghai in Western China (20/65, 31%). In total, 38% (25/65) of the participants were male and 62% (40/65) were female, and the participants’ average age was 35.4 (range 18-51) years (Table 2).

In total, 31 (48%) out of 65 participants had experience consulting with physicians over the web. During the COVID-19 pandemic, web-based consultations allowed people to avoid going out and minimized the risk of infection. Although web-based consultations were not always feasible with regard to curing diseases, the participants used them as a prediagnosis tool, which helped them make appropriate decisions regarding what to do next about their potential condition. Participant 1 shared his web-based consultation experience with us:

We examined the current status of the use of web-based consultations with physicians and the factors associated with the service among young and middle-aged Chinese individuals. About half (31/65, 48%) of 18- to 60-year-old residents have experienced web-based consultations. Among the factors associated with the use of web-based consultation, perceived convenience, complementary role, and user’s confidence were found to be the most essential factors.

We found that perceived convenience is a necessary condition enabling participants to use web-based consultations. In this study, time saving and avoiding COVID-19 infection, which are conveniences provided by web-based consultations, promote the participants’ use of it. Participants in our study, similar to patients in other countries, strongly wish to spend less time to access the services, both when making appointments and while waiting for the appointment at the location; they prefer web-based access to appointment scheduling, want SMS text messaging services for reminders, and prefer for physicians to be available during evenings and weekends [22]. The web-based consultation system provided patients with time-saving and convenient solutions for their health care needs across all treatment processes. Patients could make appointments according to their own schedule and do not have to spend time traveling to the appointments. These findings concur with the research done in the United States. Almathami et al [23] conducted a survey in Saudi Arabia and found that saving time would increase the motivation toward the use of web-based consultations.

The COVID-19 pandemic positively influenced web-based consultation use. This is in line with findings of past studies. Studies show that internet health care services enable patients to avoid going out, decrease the time spent at hospitals when patients need to visit hospitals, and minimize infection risks [3,22,24]. Thus, it is not surprising that the COVID-19 pandemic catalyzed the development and use of the service. Although the service cannot fully substitute traditional in-person appointments, various patients were willing to use web-based consultations in the post–COVID-19 era in the long term.

In our research, participants remarked about the unclear instructions hampering the use of the service. Prior studies also find that patients who lack basic internet-related knowledge are excluded from internet health care services [25,26]. The web-based consultation environment requires patients to be well versed in using web-based platforms and electronic gadgets, and the skill levels regarding this vary by patient. Those with low literacy or limited internet-related knowledge are reluctant to use the service. This potential situation was highlighted in prior studies [27,28]. In the future, web-based consultation providers could attempt to assist persons with less accessibility to the platforms by creating intuitive instructions or even providing staff to support these people and explain how they can navigate the service step-by-step. They can also train patients on the use of available technologies prior to them making an appointment. For example, a video on how to book a web-based consultation could be provided on the front page to guide patients.

We found that once the participants’ needs were met, they opted to use web-based consultations with physicians.

In the study, although web-based consultations do not have provisions for laboratory tests and physical exams, they serve as a supplement for minor issues and primary suggestions.

Meanwhile, some studies reported that web-based consultations improved outcomes in chronic disease management such as diabetes and hyperactivity disorder [29,30]. Considering patients’ preference and need, applying the service in chronic diseases management and subsequent visits may expand its complementary role and benefit patients to a greater extent.

Our results found that some participants did not regard web-based consultations as complementary due to its cost. This is in line with previous studies that found that the cost is a barrier influencing the use of the service, even in high-income countries [26]. Moreover, similar to Germany and the United States, clear regulations about web-based consultations are lacking in China; accordingly, not only do the costs of web-based consultations vary widely, but expenditures on the service are not yet covered by the social health insurance systems [5,31]. Thus, the economic burden on patients may impede their use of web-based consultations.

Users’ confidence is a sufficient factor influencing the use of web-based consultations in the study. The participants use the service if they feel safe. Several participants expressed concerns about the safety and privacy of web-based platforms, as well as the qualification of physicians. This corroborates the findings of prior studies, wherein participants expressed their concern about such safety and privacy issues and believed that the safety and privacy of users should be guaranteed by clear regulations for such services [32,33]. These regulations should ensure that patient data cannot be misused for purposes other than health care or shared without patients’ informed consent. Best practices and standards should also be created to ensure that providers have the relevant qualifications and service quality to provide web-based consultations.

Because of the COVID-19 pandemic, our semistructured interviews were mostly conducted through phone calls. This hindered our ability to observe the participants’ body language and nonverbal cues. Nonetheless, we contacted the participants to explain the topic and purpose of the interview. We shared the questions with the participants 1-7 days in advance, which the participants deemed as adequate and reasonable, enabling them to provide more comprehensive information.

In conclusion, the Andersen Behavioral Model represents a profound reflection and exploration of the factors associated with web-based consultation use from the user’s perspective. Additionally, the csQCA offers guidance for optimizing the benefits of the service. Perceived convenience, complementary role, and user’s confidence are the essential influencers associated with the use of the service. Clear instructions, comprehensive regulations, and appropriate application can promote the positive development of web-based consultations.