Despite the increased use of social media to share health-related information and the substantial impact that complementary and alternative medicine (CAM) can have on individuals’ health and wellbeing, currently, to our knowledge, there is no review that compiles research on how social media is used in the context of CAM. The objective of this study was to summarize what are the ways in which social media is used in the context of CAM.A scoping review was conducted, following Arksey and O’Malley’s five-stage methodological framework. MEDLINE, EMBASE, PsycINFO, AMED, and CINAHL databases were systematically searched from inception until October 3, 2020, in addition to the Canadian Agency for Drugs and Technology in Health (CADTH) website. Eligible studies had to have investigated how at least one social media platform is used in the context of a single or multiple types of CAM treatments.Searches retrieved 1714 items following deduplication, of which 1687 titles and abstracts were eliminated, leaving 94 full-text articles to be considered. Of those, 65 were not eligible, leaving a total of 29 articles eligible for review. Three themes emerged from our analysis: 1) social media is used to share user/practitioner beliefs, attitudes, and experiences about CAM, 2) social media acts as a vehicle for the spread of misinformation about CAM, and 3) there are unique challenges with social media research in the context of CAM.In addition to social media being a useful tool to share user/practitioner beliefs, attitudes, and experiences about CAM, it has shown to be accessible, effective, and a viable option in delivering CAM therapies and information. Social media has also been shown to spread a large amount of misleading and false information in the context of CAM. Additionally, this review highlights the challenges with conducting social media research in the context of CAM, particularly in collecting a representative sample. Over 3.6 billion people worldwide used social media in 2020 . This nuCAM is frequently used across the world and consists of a variety of health care approaches that are not typically part of conventional medicine or completely integrated into the country’s main health care system. CAM includes, but is not limited to, manual therapies such as chiropractic and osteopathy, natural products such as herbal medicines and dietary supplements, and other forms of therapies including naturopathy, homeopathy, and traditional Chinese medicine –16. The Currently, to our knowledge, there is no review that compiles research on the ways in which social media is used in the context of CAM. Due to the increased impact of social media as a form of information sharing in North America, and the significant impact that CAM can have on people’s health and lives, it is important that a scoping review is performed to outline the research on this topic and identify the gaps. The results from this scoping review could help inform various stakeholders such as clinicians, policy makers, patients, and researchers. Thus, the aim of our scoping review is to provide a summary of the research on the ways in which social media is used in the context of CAM.As described above, to our knowledge, there is a lack of review articles on the ways in which social media is used in the context of CAM. Thus, a scoping review methodology was appropriate as it allows for systematic scoping of a broad array of research and the identification of literature gaps . The met1. Social media services are (currently) applications that are Web 2.0 Internet-based2. The lifeblood of social media is user-generated content3. For a site or app designed and maintained by a social media service, individuals and groups create user-specific profiles4. The development of social networks online by connecting a profile with those of other individuals and/or groups is facilitated by social media servicesOur research question is as follows: what are the ways in which social media is used in the context of CAM in the health and medical scholarly literature? For the purpose of this scoping review, we referred to the Cochrane Complementary Medicine group’s operational definition of CAM . For socAfter identifying the research question, we found relevant studies to include in our scoping review using a comprehensive and systematic search strategy. We searched the bibliographic databases MEDLINE, EMBASE, PsycINFO, AMED, and CINAHL. Indexed headings and keywords relating to social media and CAM were used in each of the search strategies where appropriate. Additionally, we searched the Canadian Agency for Drugs and Technology in Health (CADTH) for any grey literature related to our topic. Search terms on CADTH included “complementary and alternative medicine” and “social media”. The search of these various databases and websites included literature from inception until October 3, 2020. A sample search strategy used is shown in Table We included research articles and protocols in this scoping review. While review articles were not eligible, we screened the reference lists of review articles that appeared relevant to our research question to identify eligible articles. Conference abstracts, commentaries, editorials, letters to the editor, opinion pieces, and articles that were not published in the English language were ineligible. Additionally, articles that could not be publicly accessed, found through our library system, or ordered via interlibrary loan were excluded. In order to be eligible, it had to be evident in the record’s title and/or abstract that the study was about how any form(s) of social media is used in the context of any form(s) of CAM. Two authors (JYN and NJV) pilot-screened a subset of titles and abstracts individually and then met to verify their application of the inclusion criteria. Then, all full articles were screened independently in duplicate by JYN and NJV. In the case of disagreement about article eligibility, when discussion between the two authors (JYN and NJV) was not sufficient to resolve the disagreement, a third author (JS) partook in the discussion and a majority vote took place to determine eligibility.Arksey and O’Malley’s descriptive narrative method was used to critically assess articles meeting the inclusion criteria . To charTables were used to summarize charted data and an inductive thematic analysis was performed on descriptive data . The desSearches retrieved 1714 items following deduplication, of which 1620 titles and abstracts were eliminated, leaving 94 full-text articles to be considered. Of those, 28 were not eligible because they did not fit our definition of social media , 18 did not fit our definition of CAM, 7 did not focus on how social media is used in the context of CAM, 6 were an abstract, and 6 were a review. This left 29 articles for inclusion in this scoping review –72. In Fn = 17), Canada (n = 4), Australia (n = 2), France (n = 1), Germany (n = 1), Spain (n = 1), and Taiwan (n = 1). Additionally, one study was conducted by researchers from China, Australia, and the United Kingdom (n = 1), and another study was conducted by researchers from Iraq and Jordan (n = 1). Of these 29 eligible articles, 10 focused on a study population from a single country, meaning that only social media content posted by users from a specified country was included in the study. These countries included the United States (n = 5), Australia (n = 1), Germany (n = 1), Iraq (n = 1), Spain (n = 1), and Taiwan (n = 1). The remaining 19 eligible articles focused on social media content from more than one country, 13 of which focused on an international sample of social media content . While a diverse array of CAM was explored, the most common were yoga (n = 4), medicinal cannabis (n = 4), dance therapy (n = 2), music therapy (n = 2), and spinal manipulation (n = 2). While nutrition is not typically defined as CAM, we included articles such as the one by Chan et al. despite their focus on nutrition because they included CAM representation and discourse, such as the theme of promoting alternative medicine while challenging conventional medicine [n = 6), Facebook (n = 5), and YouTube (n = 4). The articles used a variety of qualitative and mixed methods in their social media research approaches. Of the 29 eligible articles, 24 were described generically as qualitative without naming a specific design or were described in terms of data collection techniques  or analytic techniques . Of the remaining 5 eligible articles, two were identified by the authors as following a case study design, one was identified as following quantitative approaches, and two were identified as mixed methods studies based on its methodology and the presence of a combination of qualitative and quantitative approaches. The details associated with all eligible article characteristics, including study aims, can be found in Table Eligible articles were published from 2012 to 2020 and were conducted by researchers from the United States , thus future work is warranted in this area. Additionally, CAM is an umbrella term that represents a very wide range of therapies that differ widely in nature. Thus, while our search strategy and the definition of CAM we used when determining article eligibility were comprehensive, certain types of CAM may have been missed. Similarly, many types of social media exist. Thus, while our search strategy likely captured the most prominent types, some forms of less well-known social media may have also been missed. We also acknowledge that because our searches were primarily restricted to biomedical and health databases, literature from the fields of marketing, strategic communication, anthropology, sociology, and medical humanities may not have been fully captured in this review.The present scoping review involved a systematic search of the literature to identify the quantity and type of studies investigating the ways in which social media is used in the context of CAM. From 29 eligible articles, we identified three major themes including: 1) social media is used to share user/practitioner beliefs, attitudes, and experiences about CAM, 2) social media acts as a vehicle for the spread of misinformation about CAM, and 3) there are unique challenges with conducting social media research in the context of CAM, specifically regarding collecting a representative sample of data. Additionally, we highlight that while a substantial number of articles are available to practitioners, patients, and researchers, the quality and update frequency for many of these articles vary widely, and until formally assessed, remain unknown. Furthermore, we identify that a need exists to conduct an updated and systematically searched review of CAM-related health care or research resources on social media.


Attention Deficit Hyperactivity Disorder, also known as ADHD, is a neurodevelopmental disorder diagnosed in children. The exact cause of ADHD is not known, but, along with genetic factors, it is possible that environmental factors including toxins and diet may affect symptom severity. Of these dietary components, artificial food coloring (AFC), while approved by the Food and Drug Administration (FDA), has been suspected to be associated with ADHD symptoms. Of the nine FDA-certified food colors, two are used for artificial blue coloring: Blue No. 1 and Blue No. 2. There is limited literature describing the possible role of blue AFC in causing symptoms of ADHD in children. This paper provides a review of the literature surrounding artificial food coloring and its ability to affect the neurodevelopment of children in a way that could increase the behavioral indicators of ADHD. To do this, search criteria were established using a combination of MeSH terms about blue AFCs and ADHD and were entered into PubMed, along with limits on article types and publication dates from January 2000 to June 2022. There was a total of 20 articles that met this search criterion. These articles were reviewed by authors, and the ones not relevant to the topic were excluded. In total, four studies were chosen to be included in this article. After reviewing the literature, it was found that restriction diets, specifically those excluding AFCs, may affect symptom severity. The source of these changes is not known, but possible mechanisms include AFCs causing nutritional deficiencies and allergic reactions or altering neurotransmitter levels. More research is necessary to describe the neurotoxicity of artificial blue dyes in humans. Attention Deficit Hyperactivity Disorder, also known as ADHD, is a neurodevelopmental disorder that is one of the most common disorders of its type in the United States, with a worldwide prevalence of 3.4% . Since tOf the nine FDA-certified food colors, two are used for artificial blue coloring: Blue No. 1, also known as Brilliant Blue FCF, and Blue No. 2, also known as Indigotine. These artificial blue coloring agents are used in beverages, ice cream, candy, and baked goods. Blue No. 1, along with its structural analogs such as Brilliant Blue G, is the only AFC that the blood-brain barrier is known to be permeable to. DespiteFor this review on artificial blue food coloring and ADHD symptoms in children, we established search criteria using a combination of MeSH terms. Those terms consisted of ‘Blue 1’, ‘Blue 2’, ‘Blue No. 1’, ‘Blue No. 2’, ‘brilliant blue FCF’, ‘blue shade’, ‘Indigotine’, ‘indigo carmine’, ‘blue dye’, ‘blue food dye’, ‘blue pigment’, ‘synthetic blue’, ‘synthetic food coloring’, ‘bright blue’, ‘artificial food color’, or ‘food coloring agent’ and the terms ‘ADHD’, ‘attention deficit hyperactivity disorder’, ‘attention deficit’, ‘attention deficiency’, ‘hyperactivity’, ‘inattention’, ‘hyperactivity disorder’, ‘ADD’, ‘attention deficit disorder’, ‘short attention span’, or ‘disordered attention’ , no mention of artificial food coloring (n=6), no mention of ADHD n=1), or no mention of ADHD or artificial blue food coloring (n=1). This process is described in Figure , or no mDiets and ADHDWhile pharmacological intervention is common for children with ADHD, there is an increasing number of parents who would prefer a treatment option that does not require pharmaceuticals, if possible . One of The article by Nigg et al.  looked iAFCs must be approved by the FDA before being used as a food additive in the United States. Data from the FDA shows that consumption of AFCs has been steadily increasing in the United States as more foods are being made to look brighter and more appetizing to consumers . Among sA double-blind placebo-controlled study done by Bateman et al.  specificEffects of blue artificial food coloringIn foods that are artificially colored blue, FDA-approved synthetic additives Blue No. 1 and Blue No. 2 can be found. Blue No. 1, also called Brilliant Blue, Brilliant Blue FCF (for coloring food), and FD&C Blue No. 1, is used to add a bright, neon blue color mainly to food but additionally to drugs and cosmetics. Blue No. 2, also called Indigo Carmine, Indigotine, and FD&C Blue No. 2, is derived from indigo and is also used in food, drugs, and cosmetics to give a darker blue-indigo color. The accepted daily intake (ADI) for Blue No. 1, a value established by the FDA in 1969 that indicates the amount of an AFC that is safe to consume throughout the day, is 12.0 mg/kg/day, and is higher than the ADI for Blue No. 2, which is 2.5 mg/kg/day .The toxicity of artificial blue food coloring has been studied in mice and rats in laboratory settings as questions about the safety of AFCs continue to rise. A study was done in rats to test for the carcinogenicity of Blue No. 2, but the results concluded that while there was an increase in gliomas in the rats given a high dose of Blue No. 2, these changes did not meet the requirements to be considered neurocarcinogenic since the trends were consistent with historical controls . In regaThe effects of artificial blue dyes Blue No. 1 and Blue No. 2 have also been studied in children, along with other AFCs. A study done by Miller et al. , which wMechanism of action/pathophysiologySince ADHD does not have a known etiology, it is not immediately clear how blue AFC could cause increased hyperactivity or inattentiveness in children. One possible explanation is that artificial food coloring could cause nutritional deficiencies that could lead to impaired neuronal development. One study showed that adding yellow AFC to the diets of male children both with and without ADHD resulted in a decrease in zinc levels in serum and blood, along with worsening behavioral symptoms in children with ADHD . Zinc deThe ability of AFCs to alter levels of trace elements in the body like zinc and manganese may also affect people with ADHD because of these elements’ role in the creation and breakdown of neurotransmitters in the central nervous system (CNS). The neurotransmitter dopamine has been thought to be associated with ADHD symptoms because the chemical is involved in the executive functions of the brain that people with ADHD struggle with . MedicatHNMT gene, which codes for a protein involved in the metabolism of histamine, were linked to hyperactive behavior and sensitivity to AFCs in the participants. This shows that the body’s response to histamine could play a role in the extent to which AFCs may affect a child with ADHD, though further testing with only blue AFCs would need to be done to determine its specific effect.Since the link between artificial food coloring and ADHD was made in the 1970s , there hA limitation of studies on blue artificial food coloring is that some food and beverages that contain the dye are high in refined sugar as well, which may also play a role in ADHD symptom exacerbation. A meta-analysis that assessed how ADHD was affected by dietary patterns found that diets high in refined sugar increased the risk of ADHD or hyperactivity . WithoutImplications for treatment and future directionsFor treating children with ADHD, pharmacological intervention is widely used. In many countries, including the United States, the use of psychostimulants to treat ADHD is recommended, sometimes before behavioral management is considered . StimulaThe studies that were reviewed for this article support the suggestion that dietary intervention, particularly the elimination of AFCs, should be considered for children with ADHD. The study by Nigg et al.  concludeThe studies that were reviewed in this article show that diet, especially consumption of artificial food coloring, produces statistically significant increases in ADHD symptoms in children. The mechanism for how AFCs cause such neurological and behavioral changes is not definitively known, but there are a few possible explanations. These include some well-studied hypotheses for the mechanism of ADHD that AFCs could contribute to, such as the dopamine hypothesis, but some less-studied causes like nutritional deficiencies and histamine release may also be possible. While several studies examine the effect of a combination of AFCs on ADHD symptoms in children, there is very little research done on just Blue No. 1 or Blue No. 2 in children. This is illustrated by the low number of studies reviewed in the article after the PubMed search on blue AFC and ADHD, limiting the strength of the conclusions that can be made from the results. In mice and rats, Blue No. 1 specifically has been found to affect neurodevelopment and hyperactive behavior, while Blue No. 2 has not been shown to have any definitive toxicity. There is a need for more research to determine how these individual compounds affect humans, especially because of Blue No. 1’s ability to cross the blood-brain barrier. Understanding how artificial blue food dyes affect the brain and behavior of humans through increased research on the topic could provide alternative treatment options for children with ADHD.


Objective: To conduct a scoping review to determine how past studies have applied the theory of intersectionality, a critical feminist research paradigm, to understand the physical health and mental health outcomes of perinatal people as a step toward addressing maternal health disparities and injustice. The study includes a review of existing research on maternal physical and mental health outcomes, presents the strengths and limitations of existing studies, and provides recommendations on best practices in applying intersectionality in research to address systemic issues and improve outcomes for the perinatal population. Methods: We conducted an extensive literature search across four search engines, yielding 28 publications using the intersectionality framework that focused on the outcomes of perinatal people, with a total sample of 9,856,042 participants. We examined how these studies applied intersectionality and evaluated them based on three areas: conceptualization, research method, and interpretation/findings. Results: Our findings indicate that maternal health researchers have provided good descriptions of the interaction of systemic inequalities and have used analysis that allows for the examination of interlocking and mutually reinforcing social positions or systems. We find that improvement is needed in the areas of conceptualization, reflexivity, and understanding of power structure. Recommendations are provided in the form of a checklist to guide future research toward an impactful approach to addressing perinatal health disparities. Relevance: Our scoping review has implications for improving applied health research to address perinatal health disparities, mortality, and morbidity. Recommendations are given along with references to other tools, and a guidance checklist is provided to support scholars in creating an impactful approach to applying intersectionality in the goal of addressing maternal health disparities. The United States is the only developed country that has seen rapidly rising rates of maternal mortality and morbidity over the last 25 years ; despiteIn addition, our work reviews existing studies and creates a checklist of requirements to help future researchers use intersectionality in maternal health research toward a more impactful approach. The findings provide insights on (1) how previous studies have used a critical approach to understand systemic inequality embedded in the realities of perinatal people, and (2) ways to improve the application of intersectionality toward the development of a checklist of guidelines for perinatal maternal health science. This insight further helps to produce important knowledge on structural inequalities and informs social change to address maternal health disparities in the perinatal period. In addition, our review strictly focuses on maternal physical and mental health outcomes during the perinatal period. We did this because we did not want to assume that the drivers of systemic inequity underlying perinatal health disparities are the same for infant health disparities. We also recognize that an intricate link exists between maternal and infant health disparities , especiaThe initial expression of intersectionality started in the work of the Combahee River Collective 1977/1995), a group of Black feminists who described the simultaneous impact of both sexism and racism . The con77/1995, While intersectionality was coined in the field of law, it has been widely applied to other fields. These include the fields of social science, humanities, business, and industrial organization. Within these areas, the intersectionality framework helps researchers to conceptualize and contextualize the impact of systemic inequity on different individuals and collective experiences. Intersectionality began to gain more traction in health science and population research over the past decade. Notably, it became a common research paradigm for furthering the understanding of the complexity of health inequities. This has helped health researchers to strive toward structural change to address disparities in the healthcare system .Additionally, the intersectionality framework can be applied to many types of research approaches. For example, existing qualitative studies in health science have applied intersectionality to conceptualize and examine researchers’ and participants’ social positioning ,21,22. HThe objective of our scoping review is to examine how existing research in maternal health has applied intersectionality in their study approach and conceptualization. We focus on how the application of intersectionality has been used to explore health disparities in maternal physical health and mental health outcomes during the perinatal period. The goal of our study is to learn about the strengths and limitations of existing works, and to provide recommendations regarding best practices, as well as a checklist for future research, to study maternal health disparities. In our study, we defined the intersectionality framework as a critical constructivist research paradigm with a focus on examining the interactions of multiple systems of oppression, power, and privilege that have shaped the lived experiences of people. To this end, the intersectionality framework also examines power positionalities of the healthcare system and all stakeholders from historical and cultural contexts in the field of perinatal health. To evaluate all studies included in our scoping review, we identified a list of research questions  inspiredBased on our analysis and results, we considered additional questions to determine recommendations for future research. These questions included: what are the strengths and limitations of existing studies? How do we develop a checklist of guidelines for a research approach based on intersectionality to produce empirical evidence, balance research power among stakeholders, and translate learned knowledge into real-life impact rooted in social justice values?The current scoping review followed the framework and method developed by Arksey and O’Malley , as welldepress*” OR “anxiety” OR “anxious” OR “mental” OR “psychological” OR “physical” OR “medical” OR “stress” OR “distress” OR “cardiovascular” OR “cardiomyopathy” OR “cardiac” OR “hypertension” OR “preeclampsia” OR “diabetes” OR “obesity” OR “infection” OR “hemorrhage” OR “eclampsia” OR “abruptio placentae” OR “placenta previa” OR “asthma” OR “respiratory” OR “mortality” OR “morbidity” OR “comorbid” AND “maternal” OR “perinatal” OR “pregnancy” OR “*partum” OR “antenatal” OR “postnatal” OR “prenatal” AND “intersectionality” OR “positionality” OR “positioning” OR “reflexivity”. We used intersectionality and positionality as synonyms in our search strategy to achieve a broader search. Duplicates, dissertations, theses, and/or studies of insufficient relevance were excluded. We included studies with original research that were published in English, and which strictly examined perinatal health outcomes through an intersectional perspective.To identify relevant literature, we conducted a search across four search engines: Google Scholar, EBSCO, PsycINFO, and PubMed. Keywords used to identify studies included combinations of the following terms: “Initially, our search produced 25,517 records. We excluded 204 duplicate articles, and then further excluded articles if their titles did not allude to a focus on perinatal maternal health outcomes. After excluding these titles, 298 pieces of literature remained. Both authors read the abstracts of all remaining articles to determine eligibility. Studies of birth outcomes that focused on preterm birth and low-birth weight were then excluded, as these outcomes overlapped with infant health outcomes. Eligibility criteria for study inclusion included: (1) use of an intersectionality framework in the research approach/design, (2) inclusion of at least one maternal physical or mental health outcome during the perinatal period (from pregnancy to up to one year of birth), (3) written in English, and (4) inclusion of original research and not a review or opinion. After determining eligibility, a total of 32 research papers remained. Certain articles were not directly accessible because they were locked behind a paywall or did not have the full-text version. For articles that were not directly accessible, we attempted to access them through an interlibrary loan or by contacting the authors directly. After discarding inaccessible articles, 28 eligible, original articles remained. Our final sample included 28 published original research articles with a total sample of 9,856,042 participants .We first created a standardized worksheet to evaluate the 28 published research articles and to summarize the data. This worksheet included the findings of each article and the research questions used to evaluate each study individually. We reviewed, analyzed, and summarized the results. To provide a cohesive analysis of the studies, we utilized a standardized form to evaluate the studies based on each research question. There was a column for each research question, and any details about each study that directly answered the research question were extracted and charted under each column by both authors. We determined that if a research study included at least one detail or one step that directly answered our research question, it was considered “satisfied” for our evaluation. Each author evaluated each study independently and we met together seven times to discuss differences and to reach a consensus. Differences in our evaluation were discussed and each reviewer spent additional time revisiting each study. Consensus was reached based on an iterative process of reviewing and evaluating until all differences were resolved. We summarize our results in two tables: n = 16) were conducted in the United States and 12 studies were conducted in other locations . Out of these 28 original research articles, 11 used quantitative methods and 17 used qualitative methods. For this review, we were unable to find any mixed-method studies. For additional study characteristics, please refer to We included 28 published articles conducted on perinatal health outcomes. The majority of the studies  on perinatal health outcomes. This was done in addition to examining the interactions of demographic and social identities among the studied population (n = 5) included structural and contextual variables, such as poverty levels, crime rates, or state policies on reproductive care, to examine macro and meso-level social factors that impacted intersectional positions. For example, Seng et al. [Overall, all 28 studies discussed the effects of multiple systems of oppression and structural inequality on the health outcomes of the perinatal population  did not discuss the social power relations that contextualize health disparities and their roles within the research hierarchy (n = 23) used data collection and analysis to allow a multidimensional understanding of intersectionality rather than relying on an additive approach. However, given that we only evaluated studies based on reflexivity and consideration of addressing power dynamics, only 4of the 28 studies (13%) in our scoping review met the criteria for satisfaction in this section  did not discuss the context of social and structural power or acknowledged the power differential in their research approaches. Further, most studies did not provide a positionality or reflexive description for their chosen methods and resulting interpretation. One quantitative study did include a stakeholder group to account for power imbalances during research design and implementation. For example, Vedam et al. [m et al.  incorporm et al.  did not t-tests), (2) additive and multiplicative scaling, (3) cross-classified variables, and (4) stratification. In addition, leading intersectionality scholars have asserted that the assessment of additive scale interaction is the most relevant for health-related research because it is a representation of intersectional multiplicativity [Furthermore, based on the recent metaanalyses of colleagues ,60,64, qcativity ,9. Additcativity .Qualitative Research. Six of the 17 qualitative studies discussed the context of social and structural power as well as utilized a stakeholder group to account for power differences and to reflect upon the impact of the lived experiences of the researcher on the process of data collection and analysis . These findings are consistent with several recent systemic reviews on quantitative studies ,60,64, wMany scholars across disciplines caution about the methodological issues of misrepresentation and inaccurate interpretation of demographic intersectional effects, especially in quantitative studies ,64,67. IOur results demonstrate that few studies account for broader social power relations within existing hierarchies. Notably, few researchers described their reflexive process on how their lived experiences and identities impacted their selections of research design, implementation, analysis, and interpretation. This finding is not new and is a part of the ongoing discussion about challenges in conducting intersectionality research and the importance of exploring epistemological assumptions made by the researcher when forming the methodology ,10,14,68As a part of recognizing the power dynamics and striving toward larger social and political change, researchers need to pay attention to the power and the assumptions that they hold with regard to the research process. To this end, community-engaged, patient-engaged, or stakeholder-engaged research has been documented to be valued approaches due to their effectiveness in reducing health inequities, creating impact, and challenging the existing power hierarchy ,70. FindTo the best of our knowledge, our work is the first scoping review in the field of perinatal health and mental health which looks at the application of the intersectionality framework. Our review provides a comprehensive understanding of how existing research has incorporated intersectionality in conceptualization and research design in addressing perinatal mortality, morbidity, and disparity. We recognize that a limitation of our study is that we only used published studies written in English. All of the included studies had perinatal women’s physical and mental health outcomes while excluding preterm birth and low-birth weight studies. This represents a limitation in our inclusion criteria as we recognized that birth outcomes were critical to both maternal and infant health disparities. Furthermore, we could not conclude that the results in our review would apply to the fields of infant and child health. We also included studies that only incorporated intersectionality in their conceptualization and research design, so we could not comment on the rest of the research literature on perinatal health outcomes that did not use the intersectionality framework. Additionally, four studies were excluded after all efforts had been made to gain access to them. Our sample also does not include any mixed-method studies, which demonstrates that this approach is lacking. Future research needs to explore these mixed methods more, as mixed methods have the potential to capture more tenets of intersectionality . To address rising health disparities, mortality, and morbidity among perinatal people in the United States, we urge researchers to extend their approaches by incorporating intersectionality and following our checklist to create more impactful knowledge that brings about more meaningful social change. It is our goal that our checklist helps researchers by giving them tangible steps in methodology, and it is a place where resources are consolidated so that researchers can continue to expand their methods. Our overarching goal is to further the production of important knowledge on structural inequalities, which can then inform policy change and create a more meaningful impact in addressing health disparities in the perinatal population.


Jiritsu (autonomy). We go on to identify patterns of meaning that researchers use in medical ethics / bioethics discussions in Japan, namely, Beauchamp and Childress’s individual autonomy, relational autonomy, and O’Neill’s principled autonomy as the three major ways that autonomy is understood. We examine papers discussing these interpretations. We propose using the term ‘a form of autonomy’ first used by Edmund Pellegrino in 1992 and examine the nature of ‘a form of autonomy.’ We finally conclude that the crux of what Pellegrino calls ‘something close to autonomy,’ or ‘a form of autonomy' might best be understood as the minimization of physician paternalism and the maximization of respect for patient preference. Simultaneously, we introduce a family-facilitated approach to informed consent and respond to criticism by Laura Sullivan. Finally, we discuss cross-cultural approaches and global bioethics. Furthermore, we use the term ‘Bioethics across the Globe’ instead of ‘Global Bioethics’, calling for international scholars to write works to provide an in-depth understanding of each country. We conclude that deep understanding of others is pivotal for dialogue to be of value. We hope this article will deepen the reader’s understanding of Japan and will contribute to the progress of bioethics worldwide.This paper analysed the nature of autonomy, in particular respect for autonomy in medical ethics/bioethics in Japan. We have undertaken a literature survey in Japanese and English and begin with the historical background and explanation of the Japanese word  The overarching term ‘autonomy’ emerged in the field of medical ethics/bioethics in the 1970s, when this area of scholarship was developed. Starting in the USA, the field has spread worldwide. Bioethics emerged in Japan in the 1980s. However, foreign researchers have frequently asked Japanese researchers how autonomy is understood in their country. One of the reasons for this is that there are only a small number of English publications from Japan. Thus, we examine the concept of ‘autonomy’ in Japan in the hope that this article will give the readers greater clarity and insight about the meaning of autonomy in Japan.In the mid-nineteenth and early twentieth century, the Western concept of “self-government” was introduced to East Asia along with the spread of European culture. In Japan and China, this concept confronted traditional beliefs and norms dictating these two countries and thus transformed as it was translated, circulated, and institutionalized, not unlike “freedom”, “democracy”, “constitutionalism”, and other notions.Autonomy is a concept used outside the field of medical ethics / bioethics. It will assist readers to introduce Huang’s  article Jichi, the Japanese translation of ‘self-government’, is closely related to ‘freedom’ (Jiyu) and ‘democracy’ (Minshu-shugi). These terms were created alongside other neologisms that conveyed Western concepts. However, these new phrases were by no means modern inventions but originate from ‘wasei-kango’ (Japanese-made Chinese words), a body of words developed from Chinese. We assume that ‘autonomy’ was translated into Jiritsu (自律) because Ji (自) means ‘self’ (autos) and Ritsu (律) means ‘rule’ or ‘law’ (nomos). Although some discussions are still ongoing on how to translate the term autonomy into Japanese, the majority of people in Japan use Jiritsu.“Self-government,” in this sense, referred to the capability of self-management, drawing much inspiration from the ideal of “self-cultivation” in Confucianism. Nevertheless, it intended to foster “the spirit of autonomy” and was therefore quite different from its Confucian counterpart.As Huang , 61 has Ichushi, J-stage, and Medical-online for Japanese literature. The search keywords used were autonomy, Japan, and relational autonomy. There were more than 500 hits, and we went through all abstracts. We then classified the papers and books according to the patterns in which autonomy is used. Although this search was not exhaustive, we think that it is sufficient to lead us to a meaningful conclusion.In what follows, we focus on the discussions in the field of medical ethics/bioethics in Japan. We performed a database search using PubMed, Philpaper, and Philosopher’s index for English literature, In addition, there was discussion about when concept of autonomy and its centrality first emerged in Japanese bioethics. Some believed that that Japan did not need to embrace the concept of respecting autonomy at all, since it was a Western idea. This position is no longer popular.The most popular and frequently used term, especially by healthcare professionals and in health-related papers, is ‘respect for autonomy’ as discussed by Beauchamp and Childress , which iIn Japan, the word autonomy is frequently used without definition. Because only the concept of Beauchamp and Childress’s autonomy was imported into Japan in the 1990s, most Japanese people do not know that there are other types of autonomy.Jiritsu without any specific commentary referring to the English or Japanese literature, it is assumed that the version of autonomy being referred to is that developed by Beauchamp and Childress  is the second most popular term used in papers by Japanese scholars. Since Japan is regarded as a family-oriented society, proponents of relational autonomy often emphasise that autonomy created by individualistic Western countries fits poorly with issues related to medical ethics and bioethics in Japan. Thus, in the fields of nursing, medical treatment and care, palliative care, and other end-of-life issues such as advance care planning (ACP), relational autonomy is highly relevant and used commonly identifyfourshortcomingsofthetraditionalunderstandingofautonomyfromwhichakeyunderstandingofrelationalautonomycanbedeveloped:autonomyentailsmorethanmerelypossessingcognitivecapacity;autonomyisnotexercisedbypatientsexistinginasocialandculturalvoid;autonomyisnotabinary‘all-or-nothing’condition; autonomy isnotexercisedintermsof isolateddiscretediscussions. Autonomyisamultidimensionalcapacitywhichconsistsofemotionsand bodilymediated experiences  besides rationality;autonomy isexercised in asociocultural contextthat shapes us, and the relationships betweenpatients, family, and personal relationships, and healthcare professionals are able toenhance or undermine autonomy;for these reasons, autonomy manifests itselfin a scale, and we can be more or lessautonomous rather than be or not be autonomous;therefore, autonomy is a temporal perspective evolving and unfoldingover time through interactions with others.I argue that it would be beneficial to introduce thisanalysis of autonomy into clinical practice in Japan. I defend my view in relation to the second, third, and fourth points of theshortcomings of individual autonomy suggested by Gomez-Virseda et al.aetal. , 3–5ideAs Asagumo , 61 corrThus, Asagumo uses the almost same definition proposed by researchers in a Western country . Asagumo , 61 arguAs Japan is a family-oriented society, we presume that the relational character of clinical decision-making already prevails. Asagumo’s , 67 concI have laid more emphasis on empathic interaction necessary for the development of relational autonomy (or agency) and its attendant trusting relationship.’ .The Japanese philosopher, Seisuke Hayakawa, who teaches relational autonomy at the University of Tokyo, Faculty of Literature says, ‘We move to Asagumo’s discussion on advance directives (ADs). She Asagumo , 61 statRecently, the Ministry of Health, Labour, and Welfare in Japan has been promoting the Advanced Care Plan (ACP), a concept proposed in the late twentieth century in the USA (Prendergast amae) and village society and critically argue that Japanese people are hesitant to make decisions on this matter. We believe that amae is one of the factors. Amae, which means dependency, is closely associated to the idea of relationality.In what follows we would like to discuss articles that explain why it is still not a common practice to withdraw ventilators from end-of-life patients in Japan, and why physicians still fear being sued . Another one is Hoshikawa’s (Jiritsuteki Kyodousei), relying mainly on Jürgen Habermas’s idea. Judai . He first used the phrases ‘a form of autonomy’ and ‘something close to autonomy’:In many cultures clinicians encounter patients who are fully aware of the gravity of their condition but choose to play out the drama in their own way.This may include not discussing the full or obvious truth.This is a form of autonomy, if it is implicitly and mutually agreed on,between physician and patient.Scholarly discussions on the nature of autonomy in medical ethics/bioethics have a long history. This was sparked by North American bioethicist Edmund Pellegrino , 1735 inAutonomy is still a valid and universal principle because it is based on what it is to be human. The patient must decide how much autonomy he or she wishes to exercise, and this amount can vary from culture and culture. It seems probable that the democratic ideals that lie behind the contemporary North American concept of autonomywill spread and that something close to it will be the choice of many individuals in other countries as well.He continued:[W]hen considering this issue in the international context, the term “autonomy” should be used carefully since it is not a concept with only one meaning. Pellegrino does not specify whether his notion of a North American concept of autonomy refers to the definition of autonomy or the degree of exercise of autonomy, or both. Surbone’s remark that autonomy is often synonymous with isolation in Italy illustrates that the exercise of autonomy differs in Italy and North America.In response, Antonella Surbone , 1662 dePellegrino did not exactly define or give a detailed explanation of ‘a form of autonomy’ or ‘something close to autonomy’. However, his definition is still valuable today, after 30 years. Therefore, the fundamental question remains: What does ‘a form of autonomy' look like in other countries?.In Japan, the nature of autonomy has been a subject of much discussion. Hereinafter, we use the term ‘a form of autonomy’ instead of ‘something close to autonomy’ because the former is closer to the expression used to explain autonomy linguistically, for example, relational autonomy or principled autonomy. However, we assume that Pellegrino uses ‘a form of autonomy’ and ‘something close to autonomy’ in the same way.This section of our paper brings together the earlier sections.A family-facilitated approach to informed consent where the family and the patient function as a single unit differs from the more popular first-person approach. In this paper, we define a family-facilitated approach as a process of informed consent in which a patient’s family communicates with the attending physician and medical staff and often makes treatment-related decisions. This differs from acting as a proxy in that the patient does not officially appoint his or her family. Family-facilitated decision making thus rests on the premise that a patient–family fiduciary relationship exists and that the patient identifies his or her self more as a component of the family unit than as an independent individual.Among the articles published on this topic, we recommend the following, all written in English  article, Akira Akabayashi and Yoshinori Hayashi Akabayashi and Hayashi , 744-745Through this series of three informed consent articles, Akira Akabayashi (AA) has attempted to elucidate what ‘a form of autonomy’ looks like in Japan. There is, nonetheless, wide debate about our position Nagai . Laura SKennedy Institute of Ethics Journal. We will respond to her criticisms as she sets them out.Sullivan’s  criticis[…], at times, disagreement on particular issues becomes so entrenched that understanding seems impossible. In such circumstances, how might bioethicists proceed? In answering this question, this paper considers a particularly significant area of disagreement: the informed consent standards for medical practices in different countries. Since many medical procedures are transnational, it is thought that the informed consent standards forthese procedures should be universal.(Author's emphasis)In the introduction, Sullivan , 47 wrotIn short, Akabayashi values the possibility of dialogue about ethical valuations across cultures, so he does not allow that ethical judgments are predicated on unique cultural values. Rather, ethical justification must have a universal foundation such that individuals in different cultures can engage in dialogue and critique. For Akabayashi, this foundation is a set of common abstract ideals used in moral judgment and justification. While judgment and justification occur in the context of local realities, their content  and methodology  are universal […]Akabayashi recognizes the efforts of Ruiping Fan to ground family-oriented medical practice in Confucian culture as similar to his attempt to accommodate the importance of the family into medical decision-making. Yet he ultimately concludes that Fan’s justification, which relies on particular Chinese or East Asian cultural concepts “incommensurable with the Western principle of autonomy” , differs from his own, which seeks consistency or compatibility with Western autonomy. For Akabayashi, commensurability of ethical concepts across cultures is necessary for successful cross-cultural dialogue, so his defense of the Japanese practice of informed consent in terms of a form of autonomy compatible with Western autonomy achieves two goals: it accounts for the practice in nonculturally relative terms, and it justifies the practice according to nonculturally relative standards.It seems that Sullivan is a universalist. Sullivan , 55 summThe shared goal of Akabayashi’s and Fan’s arguments is to justify their cultures’ practices. Both assume that ethical justification must proceed through the use of principles and both rely on Tom Beauchamp and James Childress’s Principles of Medical Ethics for their methodology. Akabayashi and Fan refer to Beauchamp and Childress repeatedly and rarely cite positions that challenge the methodology of Principles of Medical Ethics. (p.58)Response: AA is well aware that Beauchamp and Childress’s four-principle approach has received much criticism. This is why AA brought up relational autonomy or principled autonomy by O’Neill.Therefore, to attempt a principlist defense of the family-facilitated approach to informed consent, Akabayashi and Fan must either accept Beauchamp and Childress’s principle of respect for autonomy or reject this principle and redefine autonomy to encompass familial relations in East Asia. […] Despite their shared methodology, Akabayashi and Fan rank global dialogue and traditional cultural practices differently. […] Akabayashi is committed to global discourse through universal principles and Fan defends local traditions through relative principles. Their primary commitments to either the global or the local dictate whether they lean towards moral universalism or moral relativism. Their only two options are a universal principle of autonomy or a relative principle of autonomy; Akabayashi chooses the former, and Fan, the latter. (p. 60)AJOB article. Moreover, AA was critical of the opposition between moral universalism and moral relativism. AA is not a universalist. We do not know whether Ruiping Fan regards himself a relativist.Response: AA has rejected Beauchamp and Childress’s principle of respect for autonomy and redefined autonomy to encompass familial relations. Sullivan stressed ‘in East Asia’ but AA has shown that this form of autonomy exists in the USA also, as is discussed in his 2006 Accordingly, relational autonomy cannot stand in as Akabayashi’s theory of autonomy because it cannot account for East Asian practices. Akabayashi then appeals to Onora O’Neill’s conception of “principled autonomy,” where he takes the crucial point to be the absence of coercion. However, it is hard to assess whether the appropriate safeguards for ruling out coercion are in place without further analysis of medical decision-making in Japan, as many of the respondents to his 2006 article argue. So principled autonomy cannot be Akabayashi’s theory of autonomy either, since its application is unclear in the Japanese context. In the end, Akabayashi has no universal theory of autonomy by which to justify his claims. (p. 61)Response: It is correct to say that AA has no universal theory of autonomy. However, a question remains: is there a universal theory of autonomy that exists in current bioethical or philosophical discussions? For example, Kantians claim that their argument is universaliable, although they have received much criticism.Neither Akabayashi nor Fan successfully justifies East Asian informed consent. This is not because the practices they describe violate respect for autonomy, as many critics have suggested. Nor is it because they have misinterpreted the theory of moral generalism or because the theory of moral generalism is necessarily flawed. Rather, the failure of these two arguments highlights a practical problem with how bioethical discourse is pursued across cultures. Akabayashi and Fan both assume that ethical justification must be attempted according to a moral generalist methodology— principlism […]However, this assumption narrows attempted justifications: (1) it focuses the justification on the definition of ethical principles rather than a detailed description of the practices in question, and (2) it requires an explanation of the chosen principles in terms of either moral universalism or moral relativism. (p.62)Response: AA does not assume that ethical justification must be attempted according to a moral generalist methodology—that is, principlism. AA asserts that the moral particularism methodology has an affinity with moral relativism, which AA wants to reject. Moreover, why does Sullivan state that ‘it requires an explanation of the chosen principles in terms of either moral universalism or moral relativism’? Why does one have to choose either universalism or relativism? If AA chooses the position of moral universalism, will the justification therefore be successful? In the next section, AA states his view regarding the conflict between moral universalism and moral relativism.For Akabayashi, the relevant principle is a form of the universal principle of autonomy, the content of which is the obligation to prevent paternalism and respect patient preferences. […] They make their arguments in terms of these principles alone and do not consider other potentially relevant moral properties. As a result, outsiders to these cultures cannot determine whether these practices should be allowed or forbidden, and insiders become distracted by a seemingly irresolvable opposition between universal and relative principles. (p.62)universal principle of autonomy’. However, this term was not used, and the explanation was not clear.Response: AA discusses relational autonomy and principled autonomy. AA concluded that the family-facilitated approach has an affinity with some conceptions of relational autonomy. Moreover, Sullivan stated, ‘For Akabayashi, the relevant principle is a form of the One might counter that the failures of Akabayashi’s and Fan’s arguments should not be blamed on moral principlism because they incorrectly use principlist methodology. […] it is possible that East Asian informed consent practices indicate that a change to the principle of autonomy is necessary. In fact, revision to the principle of autonomy is exactly the argumentative route taken by both Akabayashi and Fan— Akabayashi seeks out alternative conceptions of autonomy, and Fan defines a Confucian form of autonomy. Yet while revision to principles is theoretically possible, it seldom occurs in practice. (p.63)Response: AA is, once again, not using principlist theory. AA agrees with the statement, “[Y]et while revision to principles is theoretically possible, it seldom occurs in practice”. What, then, is the purpose of the revision of the principle?In the cases of Akabayashi and Fan, Akabayashi justifies his form of the principle of autonomy by tethering it to Western theories of autonomy, which he presumes to be theoretically secure. […] The requirement that the principles themselves be justified by moral theory forces Akabayashi and Fan to defend universalism and relativism, respectively. […] Within principlist ethical justification, there is no final reason why universalism or relativism is justified; the two positions are left in a deadlock.(p.67)Response: AA wants to know why Sullivan states, “which he presumes to be theoretically secure”. AA did not tether autonomy because it is secure. AA does not understand why he has to defend universalism. AA agrees that the two positions are left in a deadlock. This will be discussed in the next section.What is valuable, then, is precisely what is absent from many theoretical accounts of autonomy: concrete particulars. Akabayashi’s appeal to the principle of autonomy is at best a distraction and at worst damaging to the practice. (p.69)Response: AA wants to know why his appeal to the principle of autonomy is, at best, a distraction and, at worst, damaging to the practice. Is she supportive of particularism?A set of reasons such as “Japanese physicians know their patients personally, know whether patients expect them to include the family in decision-making, have communication training with families, and Japanese patients have a higher likelihood of adverse psychosocial effects following disclosure of a terminal diagnosis” would better approximate a particularist justification of some Japanese physicians’ informed consent practices, although more detailed consideration would be necessary. However, this does provide a general sketch of what a moral particularist justification might look like and what types of questions should be asked in ethical justification across cultures. Understanding ethical justification in terms of the moral particularism described in this section avoids opposition between universalism and relativism and clarifies the complex of reasons underlying particular decisions and practices. Had Akabayashi and Fan more thoroughly examined the different reasons for East Asian practices of informed consent, including those outside the scope of the principle of autonomy, they would have increased cross-cultural understanding of these practices while avoiding the competing positions of universalism and relativism. (p.73)Response: AA asks whether Sullivan believes that moral particularism solves the conflict between universalism and relativism. He asks: how would moral generalists respond?In a different article, Sullivan  dialogue is important in bioethics. There are international bodies such as the UNESCO International Bioethics Committee. Nonprofit organisations such as the Global Bioethics Initiative are active. A journal, a handbook, and an encyclopaedia of global bioethics have been published. However, global bioethics has not evolved simply or in a linear way.It is important to understand the complexity of global bioethics. Although I have taken the East and the West as examples, even within East Asia, there are national variations, for example, between China, Japan, and Korea. In addition, different cultures exist within each nation or region. When AA refers to cross-cultural dialogue, he is referring to all of these complex relationships.The Future of Bioethics ” in place of “global bioethics.” While I feel that this term  embodies a more universal tone, I also wonder if some would interpret the adjective “global” to mean that BAG is no longer trying to achieve universalism. […].  at the very least, BAG is preferable to the current term, “global bioethics.” The time has come to discard the term “global bioethics,” which will forever imply the opposition between universalism and relativism. (Author's emphasis).When discussing the deadlock between universalism and relativism AA stated that “universalism versus relativism is a long-standing debate in Western philosophy. However, in the 50 years in which global bioethics has evolved, the discussion has not moved forward in a meaningful way. In general, it appears that Western philosophers have agreed that the radical extremes  should be discarded, but that is all” (Akabayashi abayashi , 121 conabayashi , 122 staWe were highly motivated to respond when we found Sullivan’s article . We beliAA has been criticised because he did not fully explain or define the concept of BAG. He attests that in fact a firm definition is not possible at this time. This is consistent with the view of the founder of modern bioethics, Van Rensselaer Potter , 1990 whBeginning with an analysis of the nature of autonomy in Japan, we went on to discuss the opposition between universalism and relativism. It is our view that the two positions remain deadlocked.Once again, we hope that those who read this article will try to engage in works to facilitate an in-depth understanding of all countries and societies in their diversity. When we can come together to engage with these issues a real dialogue is possible. We want to use this engagement to go on to develop other projects, in particular, an anthology on the ethics of war. We contend that understanding the nature of autonomy in different cultures will be invaluable for a discussion about the ethics of war and through this, human survival. Autonomy is closely related to human beings’ intrinsic value, self, authenticity, dignity, and capacity, all fundamental to human flourishing. As bioethics researchers, we should fully understand our mission and then pass over this spirit to the next generation.


When a public crisis such as COVID-19 occurs, factors that affect health-related behaviors, such as compliance with safety precautions, health professionals, and directives from government agencies will become more obvious. This research explores the differences between the people of the United States and China regarding preventive behavioral intentions, perceptions of personal and social risks, seriousness, and other cultural characteristics in the context of the COVID-19 health crisis. The purpose is to provide insights that can be used when global public health events occur in the future. A total of 536 people who lived in the US and China from 12 July to 7 September 2020 were recruited in the survey. Through a web-based survey, differences in the attitudes and perceptions of COVID-19 between the two countries were identified. Overall, the people of China scored higher than Americans on several measures regarding personal risk perception, social risk perception, and seriousness. Chinese citizens also had higher preventive behavioral intentions than their US counterparts. In addition, the relationships between cultural dimensions and health-related variables were also different. Since the global outbreak of COVID-19 began at the end of 2019 to the beginning of 2020, the pandemic has had a tremendous impact on the global economy. While bringing extreme changes to people’s lives, it also has altered the lifestyle and work of many ordinary people [The findings of Zhou, Ghose, and Wang confirm that the Chinese survey participants have a high health awareness of COVID-19 and are optimistic about successfully fighting the epidemic . From a Despite extensive literature delineating different aspects of health cognition in the context of the COVID-19 pandemic, few studies delve into the comparison between China and the United States. In view of this research gap, in this study, we analyze the health perception of COVID-19 in China and the United States from a cultural perspective and explore the differences in American and Chinese public perceptions of individual and societal risk perception, seriousness, and prevention behavioral intentions, in order to guide the future epidemic control of the two countries and provide a reference for future global public health tragedies.The survey was conducted from 12 July to 7 September 2020 in two densely populated cities in China and the United States. The survey respondents are urban residents aged 20–70 who have a basic understanding of the COVID-19 and have a bachelor’s degree or above, covering various occupational fields. The subjects were selected by random sampling and participated voluntarily through online questions using Questionnaire Star, an international research company with a broad client base and extensive research experience. The target comprises 5,331,323 people aged 20–70. Therefore, a sample of at least 384 individuals was estimated to evaluate the selected variables, assuming a 5% margin of error and a response proportion of 50%, with a 95% confidence level ,7.To comply with academic ethics, the consent and approval of the interviewees were obtained in advance of field research and interviews. When referring to individuals, plantations, and companies, we used pseudonyms to protect the anonymity of the respondents.Hofstede’s IBM study is one of the most cited studies explaining cultural differences among countries. This early research involved a survey of IBM employees in the early 1970s . HofstedPower refers to the probability that an individual can realize his will even when he encounters severe resistance from others or organizations . UncertaPeople in higher positions should make most decisions without consulting people in lower positions”; “People in higher positions should not ask the opinions of people in lower positions too frequently”; “People in higher positions should avoid social interaction with people in lower positions”; “People in lower positions should not disagree with decisions by people in higher positions”; and “People in higher positions should not delegate important tasks to people in lower positions”.Five cultural dimensions of Hofstede were measured with the scales from Wang and Zhang . The staIt is important to have instructions spelled out in detail so that I always know what I’m expected to do”; “It is important to closely follow instructions and procedures”; “Rules and regulations are important because they inform me of what is expected of me”; “Standardized work procedures are helpful”; and “Instructions for operations are important”.The statements to measure UA were “Individuals should sacrifice self-interest for the group”; “Individuals should stick with the group even through difficulties”; “Group welfare is more important than individual rewards”; “Group success is more important than individual success”; “Individuals should only pursue their goals after considering the welfare of the group”; and “Group loyalty should be encouraged even if individual goals suffer”.IDV levels were measured by the following statements: “Careful management of money”; “Going on resolutely in spite of opposition”; “Personal steadiness and stability”; “Long-term planning”; “Giving up today’s fun for success in the future”; and “Working hard for success in the future”.To measure LTO, the following statements were used: “It is more important for men to have a professional career than it is for women”; “Men usually solve problems with logical analysis; women usually solve problems with intuition”; “Solving difficult problems usually requires an active, forcible approach, which is typical of men”; and “There are some jobs that a man can always do better than a woman”.The statements to measure MAS were “One of the main factors influencing people’s decision to make the corresponding health protection behavior is the individual’s perception of health . Health Risk perception is formed by judgments on various types of information that estimate the extent to which risks will affect them . In thisThe public tends to evaluate risk based on the seriousness of the results after the risk occurs, and the seriousness of public perception depends on fear . TherefoBehavioral intention explains changes in human social actions and is considered to be the most timely and important determinant of behavior . To formCOVID-19 is important problem for me”; “I am concerned about the damage I will receive from COVID-19”; “I will be damaged by COVID-19”; “I personally feel the risk of COVID-19”. SRP was measured with the following statements: “COVID-19 is important problem for the community”; “The public worry about the damage they will receive from COVID-19”; “The public will be harmed by COVID-19”; and “The public has a high risk of feeling about COVID-19”.Risk perception was measured by the scales of Morton and Duck . PRP forCOVID-19 is a serious risk that someone could die”; “If someone is exposed to COVID-19, it is very likely to cause serious damage”; “COVID-19 is one of the serious diseases”; and “COVID-19 is more deadly than any other disease”.SER was measured by Rimal et al. . In thisI will actively put social distances if necessary”; “I will actively wear a mask if necessary”; and “I will actively participate in hand washing if necessary”.PBI was measured by the following statements: “Both the Chinese and English questionnaires were proofread by professionals who are native speakers of these two languages, which ensured that the contents of the two questionnaires are completely consistent, so they have good intelligibility for both Chinese and Americans. Subjects were asked to answer these questions on a 7-point scale .Based on the discussed cultural dimensions and health perception, we summarized individual definitions of each cultural dimension and traditional differences between the United States and China. However, cultural orientation and health perception could be changed, as the social environments of the two nations are different. In this regard, we proposed 5 research questions exploring the differences between the United States and China . In our methodology, we combined a review of the literature with quantitative analysis, to measure the health perception of the COVID-19 pandemic in China and the United States. One-way ANOVA and regression analysis were used for data analysis, and the statistical package used for the analysis was SPSS. The ANOVA is a parametric statistical technique used for the comparison of group means. In this study, it was used to compare the differences in culture and health perception between American and Chinese subjects. Regression analysis refers to a statistical analysis method to determine the interdependent quantitative relationship between two or more variables. It was used in this study to assess the impact of culture-related variables on health perceptions among American and Chinese subjects.From a demographic perspective, of the 536 total participants, 313 (58.4%) were in the United States, and 223 (41.6%) were in China. There were 267 (49.8%) females and 269 (50.2%) males, with an age range spanning from 20 to 70, and a mean of 40.0 (SD = 11.2) .p = 0.000), and the factor loading value of each dimension was greater than 0.7.Reliability reflects the stability and consistency of measurement. Cronbach’s α coefficient was used to test the consistency of the subjects’ answers to the questions on the previously mentioned scale. The test results showed that Cronbach’s α coefficient of each variable ranged from 0.712 to 0.919, which is higher than the acceptable standard of 0.6. Therefore, the reliability of the scale is relatively high. Validity reflects the authenticity of measurement, and the validity of a scale is measured by content validity and convergent validity. The results showed that the index of the KMO coefficient was 0.876, the result of Bartlett’s test of sphericity was 5754.630  than American subjects .For research question 4, regarding preventive behavioral intention, there was a statistically significant difference between American and Chinese subjects, as determined by a one-way ANOVA. It was found that Chinese subjects had higher scores  than American subjects .p-values of independent variables of LTO  on the dependent variable of PRP was 0.000, meeting the standard value p-value of less than 0.05. Therefore, LTO positively impacted PRP. Moreover, LTO , MAS , PD , and UA  significantly influenced the dependent variable SRP. LTO, PD and UA positively impacted SRP, whereas MAS negatively impacted SRP. When SER was the dependent variable, LTO , PD , and UA  as independent variables affected SER values. LTO, PD, and UA had positive impacts.Regression analysis was employed to identify links between cultural dimension and risk perception, seriousness, and behavioral intention . The p-vp = 0.000), PD , and UA  had positive effects on it, and MAS  negatively influenced PBI.When PBI was the dependent variable, LTO  and PD  positively impacted PRP, whereas LTO  and MAS  influenced SRP. Among these variables, only MAS had a negative influence relationship, and LTO and COL had positive influences. Moreover, LTO  positively impacted SER. Finally, LTO , PD , and UA  affected PBI, and PD had a negative impact. Additionally, both LTO and UA had positive impacts  positively impacted PRP. LTO  and PD  had effects on SRP, of which LTO had a positive impact, and PD had a negative impact. LTO  had a positive effect on SER. LTO  and MAS  influenced PBI—specifically, LTO had a positive impact, and MAS had a negative impact . Overall, the results showed that Chinese subjects had a higher sense of personal risk, social risk, and seriousness of COVID-19 than American subjects (R.Q. 2 and R.Q. 3). In addition, the results found that Chinese subjects had higher preventive behavioral intention than American subjects (R.Q. 4). It was also found that the relationships between cultural dimensions and health perception differed between participants from China and the United States (R.Q. 5).Studies on the cultural dimension have proved that the Chinese have a higher power distance and are more long-term-oriented than Americans. This finding is consistent with the cultural tendency expressed in the existing Hofstede’s cultural dimension index , also alDelving into the influence of the cultural dimension on health-related perceptions, long-term orientation appeared to have the most significant influence. Dependent variables and cultural factors all seemed to have a greater influence on social risk perception than individual risk perception. All cultural dimensions influenced social risk perception and the preventive behavior intention. All cultural dimensions except MAS influenced the perception of seriousness. The analysis of the direction of the variables revealed that MAS had a negative effect, and individuals with individualistic tendencies were active in social risk perception, seriousness perception, and preventive action intention.Moreover, differences between American and Chinese subjects were noted. In both the United States and China, long-term orientation affected all variables despite differences in other cultural dimensions. Only power distance and masculinity were additionally significant in China. Power distance negatively impacted social risk perception; consequentially, people with low power distance had higher social risk perception. Masculinity negatively impacted preventive behavioral intentions. As a result, feminine-oriented people were found to actively participate in preventive behavioral intentions. On the other hand, in the case of the United States, more diverse cultural dimensions exerted an influence. Specifically, collectivism affected social risk perception and seriousness perception, while participants with a feminine tendency had a higher perception of social risk. Those with high uncertainty avoidance tended to have higher preventive behavioral intentions.The research on health perception in this study confirmed that there are fundamental differences in terms of attitude and perceptions regarding COVID-19 between American and Chinese subjects. Chinese subjects had higher personal risk perception, social risk perception, and concern about COVID-19 than American subjects. Chinese subjects also had higher preventive behavioral intentions than American subjects. This result slightly differs from the results of Han et al., as they did not find significant differences in risk perception between China and the United States .The main limitations of this study are as follows: Firstly, the sampling used in this study can be criticized. The United States and China are both large nations; in particular, China’s population is among the largest in the world. Therefore, considering that the overall sample size surveyed is small, it may not be a representative sample of the population in each country. Secondly, in terms of demographic characteristics, factors such as age, occupation, education level, and income of the respondents should be considered against factors that may affect public judgment this may be included in future research. In future research, a larger sample would allow the research and conclusion to be more generalizable. In addition, future research dealing with other countries representing Western or Eastern cultures will be necessary.Based on the above results, we attempted to analyze the reasons behind the differences found in this study from the following aspects:Firstly, the development and changes in cultural dimensions through the research results are conspicuous. China is often classified as a collectivist country and is recognized as possessing an Asian cultural identity . HoweverSecondly, after sorting the results of previous studies, it was found that few studies compared the differences in seriousness and prevention behavioral intentions between China and the United States. Therefore, it is difficult to find the laws of these two variables between the two countries from the existing studies. From the results of this study, it was revealed that there were obvious differences between American and Chinese subjects across these four variables, and the average values of Chinese subjects markedly exceeded those of the American subjects. In the context of COVID-19, Chinese people are very strong in personal risk perception and social risk perception, not only in seriousness but also in prevention behavioral intentions. The reason for this result may be found in the influence of the cultural dimensions on health perception. Since the Chinese are generally long-term-oriented, Chinese subjects in this study had high levels of power distance index and masculinity tendency. During large-scale public health events, people are more sensitive to risk perception and closely consider the seriousness that such events may entail. Therefore, they are more likely to produce corresponding prevention behavioral intentions. Contrastingly, for American subjects in this study, the influence of cultural dimensions on health perception was more dispersed, thereby weakening the influence of a single dimension on health perception to a certain extent. These findings also reflect the characteristics of American cultural diversity.