Structural Inequalities in Online Health Information Seeking: Cross-National Multilevel Study.

Background: Online health information-seeking behavior (OHISB) has become an increasingly common component of contemporary health self-management. Individuals use a wide range of digital sources, including websites, social media platforms, and mobile apps, to obtain health-related information. However, substantial disparities persist in who seeks health information online, and which populations benefit from digital health resources. While previous research has largely focused on individual-level determinants, cross-national evidence on structural influences remains limited. Objective: This study aims to assess between-country variation in OHISB, examine associations between individual-level characteristics and OHISB, and investigate how country-level structural conditions are associated with cross-national differences in OHISB, net of individual-level characteristics. Methods: Data were drawn from the Health and Health Care II module of the International Social Survey Programme (ISSP 2021-2024; n=35,592; 32 countries). OHISB was measured as any use of the Internet to search for health-related information during the past 12 months. Multilevel logistic regression models were estimated. Country-level indicators were reduced using principal component analysis into 4 composite indices. Robustness checks included analyses excluding respondents without internet access and models incorporating survey weights. Results: OHISB varied substantially across countries (intraclass correlation coefficient=0.177). At the individual level, younger age, higher education, female respondents, recent health problems, doctor visits, unmet medical needs, and perceived usefulness of the internet were associated with higher odds of OHISB. At the macro level, the socioeconomic and health development showed the strongest association (odds ratio=1.52 per SD; P=.003) and explained a substantial share of between-country variation. Cultural hierarchy-individualism was associated with OHISB in separate models but attenuated when adjusted for development. Cross-level interactions indicated that the gender gap and the role of perceived usefulness were more pronounced in higher-development contexts, although these findings were exploratory. Conclusions: OHISB is associated with both individual characteristics and broader structural conditions. Socioeconomic and health development appear to play a key contextual role in shaping cross-national differences in digital health engagement, highlighting the importance of addressing both individual and structural dimensions of digital health inequalities.