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Anxiety, Stress, & Coping: An International Journal Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/gasc20
Health-related Internet habits and health anxiety in university students a
a
Karmpaul Singh & Richard J. Brown a
School of Psychological Sciences, University of Manchester, 2nd floor, Zochonis Building, Brunswick Street, Oxford Road, M13 9PL, Manchester, UK Accepted author version posted online: 28 Jan 2014.Published online: 03 Mar 2014.
To cite this article: Karmpaul Singh & Richard J. Brown (2014) Health-related Internet habits and health anxiety in university students, Anxiety, Stress, & Coping: An International Journal, 27:5, 542-554, DOI: 10.1080/10615806.2014.888061 To link to this article: http://dx.doi.org/10.1080/10615806.2014.888061
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Anxiety, Stress, & Coping, 2014 Vol. 27, No. 5, 542–554, http://dx.doi.org/10.1080/10615806.2014.888061
Health-related Internet habits and health anxiety in university students Karmpaul Singh* and Richard J. Brown School of Psychological Sciences, University of Manchester, 2nd floor, Zochonis Building, Brunswick Street, Oxford Road, M13 9PL, Manchester, UK
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(Received 5 April 2013; accepted 2 January 2014) Health-related Internet use has grown rapidly, yet little research has considered how health anxious individuals use the Internet for this purpose. Our aim was to examine the relationships between health anxiety and the extent of, reasons for, and consequences of health-related Internet usage in university students (n = 255). Responses on a purpose-made Internet use questionnaire were correlated with health anxiety scores; multiple regression analyses controlling for depression and anxiety were also conducted. Health anxiety positively correlated with (all ps < .01): frequency of health-related searching (rs = .163), proportion of health-related information sought (rs = .200), time spent online for health purposes (rs = .166), and number of searches for both illness (rs = .453) and wellness (rs = .208) information. Health anxiety further positively correlated with advantages perceived in health-related Internet use (rs = .183), heightened tension (rs = .364) and relief (rs = .174) post-search, and perceived doctor disadvantages (rs = .306), yet a greater likelihood to visit a doctor post-search (rs = .217). Health anxiety also correlated with six measures of possible addiction to using the Internet for health purposes (rs range = .171 to .366, all ps < .01). Some (including several potentially dysfunctional) aspects of health-related Internet use correlate with health anxiety. Research evaluating the possible role of Internet use in the development and maintenance of health anxiety is warranted. Keywords: health anxiety; hypochondriasis; cyberchondria; Internet; hypochondria
Introduction Health-related Internet use has increased significantly in recent years, with an estimated 12.5 million health-related Internet searches conducted daily worldwide in 2009 alone (Bennett & Glasgow, 2009). Two recent polls suggest 50% of Europeans (European Commission, 2013) and 72% of Americans (Fox, 2013) used the Internet for health information in the past year. Despite the apparent value of such resources, the Internet is also a rich source of potentially alarming information about health and illness (sometimes of dubious validity; Gagliardi & Jadad, 2002) with the potential to increase doubt and fear, particularly in people who are already anxious about their health. Health anxiety falls on a continuum, ranging from intermittent worry to a pathological preoccupation with fears of illness that may meet criteria for a diagnosis of hypochondriasis (Hitchcock & Mathews, 1992). The cognitive behavioral model (Warwick & Salkovskis, 1990) suggests that health anxious individuals hold dysfunctional beliefs and *Corresponding author. Email: [email protected] © 2014 Taylor & Francis
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assumptions about health and disease, which lead them to misinterpret triggering stimuli (e.g. bodily sensations) as evidence that they are, or at risk of becoming, seriously ill. According to this model, searching for health information online could contribute to health preoccupation and anxiety in several ways, including as a source of dysfunctional assumptions and beliefs and by providing conflicting information that increases uncertainty (Warwick, 1989). Using the Internet as a form of reassurance seeking (i.e. to prove/disprove the presence of illness) is thought to be common in health anxious individuals (Wells, 1997). Excessive reassurance seeking may be particularly likely to result in disproportionate Internet use for health purposes (so-called “cyberchondria”; White & Horvitz, 2009), due to negative reinforcement and/or exposure to alarming results that prompt further searching. Most research on health-related Internet use has focused on general aspects of how and why people use the Internet for health purposes (Eysenbach & Kohler, 2002; Tustin, 2010; Weaver et al., 2010; White & Horvitz, 2009) and the perceived credibility of online health information (Gagliardi & Jadad, 2002; Gray, Klien, Noyce, Sesselberg, & Cantrill, 2005). Very few studies have considered the relationship between health anxiety and online health behavior. Eastin and Guinsler (2006) found a positive correlation between health anxiety and post-search health utilization. Baumgartner and Hartmann (2011) observed that health anxious participants reported more post-search distress than low anxious controls; no evidence for a reassuring/relief effect of online health information was found, however. Health anxiety was also more likely to arise when the online source was perceived as trustworthy (Baumgartner & Hartmann, 2011; Eastin & Guinsler, 2006). Muse, McManus, Leung, Meghreblian, and Williams (2012) studied health-related Internet use by high and low health anxious university students, using a purpose-made Internet use questionnaire. Areas examined included likelihood and reasons for Internet utilization, frequency and duration of searching, emotional impact, type of information sought and source used, and perceived accuracy of information. They found high health anxious students searched the Internet for health information more frequently and for longer than low health anxious individuals, reported feeling more distressed and anxious post-search, and searched more for diagnosed/undiagnosed medical conditions and personal accounts of illness. The purpose of the current study was to replicate and extend some of Muse et al.’s findings. We also investigated whether health anxiety was correlated with features suggesting possible addiction to using the Internet for health purposes, including unsuccessful attempts to cut back on health-related Internet use, negative feelings associated with actual and anticipated loss of health-related Internet use, adverse impact of health-related Internet use, and increasing health-related Internet use over time.
Method Design The present study utilized a correlational design using online questionnaires to investigate the relationship between health anxiety and health-related Internet usage. Like Muse et al., we studied the relationship between health anxiety and frequency and duration of Internet usage for health purposes, post-search distress, types of information sought, and the perceived accuracy of health information. We extended the study of Muse et al. by assessing the hypothesis that health anxiety would also correlate with the overall proportion of Internet time spent searching for health purposes, use of the Internet as a
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primary source of health information, perceived advantages of the Internet and disadvantages of doctors, and post-search tension, relief, and doctor utilization. We also obtained demographic information and measured somatic symptom reporting, depression, and generalized anxiety to better understand the potential clinical applicability of our findings.
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Participants Two hundred and fifty-five undergraduate and postgraduate students from the University of Manchester completed the survey (76.9% female, mean age 21.24 years, SD ± 3.92 years). All reported Internet usage for health purposes. Data from all eligible participants were used. Participant volunteers responded to adverts on a university research website and posted around the campus. The majority of participants were psychology undergraduates, who received research credit for participation; non-psychology students were entered into a prize draw to win gift vouchers. Measures Short Health Anxiety Inventory (SHAI) The SHAI was used to measure health anxiety (Salkovskis, Rimes, Warwick, & Clark, 2002). The first 14 items measure symptoms of health anxiety; the final four measure the perceived consequences of having a serious disease. Each item consists of four statements and participants pick which apply to them. Each statement carries a score from 0 to 3, with total scores ranging from 0 to 54. There is some debate as to what constitutes clinically significant health anxiety on this scale (Alberts, Hadjistavropoulos, Jones, & Sharpe, 2013), although a score of ≥18 is often used (Improving Access to Psychological Therapies [IAPT] and National Health Service [NHS], 2011; Muse et al., 2012; Rode, Salkovskis, Dowd, & Hanna, 2006). The SHAI has high test–retest reliability, convergent validity (.90 and .85 respectively; Salkovskis et al., 2002) and internal consistency (.89; Abramowitz, Deacon, & Valentiner, 2007). Internal consistency in this study was excellent (.89). Patient Health Questionnaire (PHQ-15) The PHQ-15 was used to measure somatic symptom burden. The PHQ-15 consists of 15 symptoms such as stomach pain, headaches, and so on. Participants indicate if they are not bothered, bothered a little, or bothered a lot for each corresponding symptom, scoring 0, 1, or 2, respectively; total scores range from 0 to 30. It has good internal consistency (.80; Kroenke, Spitzer, & Williams, 2002), criterion validity, and test–retest reliability (.83; van Ravesteijn et al., 2009). Internal consistency in this study was good (.80). Patient Health Questionnaire (PHQ-9) The PHQ-9 was used to measure depression. The scale asks participants to rate how often each of nine aspects of depression bother them, on a scale from 0 (“not at all”) to 3 (“nearly every day”); total scores range from 0 to 27. The PHQ-9 has shown good internal consistency (.89; Kroenke, Spitzer, & Williams, 2001), concurrent validity, and test–retest reliability (.89; Adewuya, Ola, & Afolabi, 2006). Internal consistency in this study was excellent (.90).
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Generalized Anxiety Disorder-7 (GAD-7) The GAD-7 was used to measure anxiety. It asks participants to rate how often each of seven aspects of generalized anxiety bother them on a scale ranging from 0 (“not at all”) to 3 (“nearly every day”); total scores range from 0 to 21. The GAD-7 displays good internal consistency (.89; Löwe et al., 2008), convergent validity, and test–retest reliability (.83; Spitzer, Kroenke, Williams, & Lowe, 2006). Internal consistency in this study was excellent (.91).
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Internet beliefs and behaviors A purpose-made questionnaire was developed to assess participants’ beliefs and behaviors in relation to three general aspects of health-related Internet use: extent of usage; reasons for usage; and consequences of usage. Data on other aspects of health-related Internet usage (e.g. what sources were used to find health information online, whether healthrelated searches were for oneself or for someone else, whether health-related Internet searches were conducted alone or with someone, and whether/why computers or mobile devices are preferred media for accessing online health information) were also collected but will be reported elsewhere (Singh, in preparation). Extent of Internet usage was measured with the following items: How often do you use the Internet to access health-related information? Rated on a seven-point Likert scale ranging from “Never” (0) to “Every few hours or more” (6). Roughly what proportion of your total Internet time is spent on health/illness-related topics? (Rated on a scale from 10% to 100% divided into 10% increments). On average how quickly do you turn to the Internet when you find/notice a physical symptom? Rated on a seven-point Likert scale ranging from “One or more days after” (0) to “Immediately” (6). Each time you go on the Internet for health purposes, on average how long do you stay online? Rated on a seven-point Likert scale ranging from “Few seconds” (0) to “More than an hour” (6). When using the Internet for health-related purposes, how much time do you typically spend on each website on average? Rated on a six-point Likert scale ranging from “Few minutes” (0) to “Several hours” (5). Do you turn to the Internet as a first source when you find/notice a physical symptom? Rated as “Yes” or “No.” Reasons for Internet usage were measured with the following items: Type of information sought: ten items enquired about how often certain types of information were sought. Each question used a five-point Likert scale, ranging from “Never” (0) to “Very often” (4). Separate mean item scores for the illness and wellness items were calculated for the analysis. Six were illness-based: (1) (2) (3) (4)
“Looking “Looking “Looking “Looking
for for for for
information about specific diseases.” pictures of something I am worried about.” survivor stories and/or personal accounts of illness.” information about symptoms I am experiencing.”
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K. Singh and R.J. Brown (5) “Using forums/chat rooms, so that I can ask questions and read other people’s opinions on the problem I am/think I am facing.” (6) “Looking for information about different diseases I think I might have or am scared of getting.” Four were wellness-based (i.e. information pertaining to how to remain well):
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(1) (2) (3) (4)
“Looking “Looking “Looking “Looking
for for for for
information on how to improve my diet.” information on how to lose weight.” information how to exercise properly.” ways to be healthier.”
Perceived advantages of the Internet/disadvantages of doctors: each on a four-point Likert scale ranging from “Disagree a lot” (0) to “Agree a lot” (3). Separate mean scores for the Internet advantages and doctor disadvantages items were calculated for the analysis. Seven items assessed perceived advantages of the Internet for health purposes: (1) “I find that the Internet is more convenient to find information than other places (e.g. books, library, GP surgery).” (2) “I believe that the Internet is a highly credible source of health information.” (3) “The Internet is the fastest access to information that I have.” (4) “The Internet is beneficial because after I have had an appointment with my doctor, I want to go home and learn more about what we talked about.” (5) “The Internet is a good source, because much of the information I get from the doctor, I can easily find online from the comfort of my home.” (6) “I think the Internet is a good source of information that can be a substitute for my doctor.” (7) “The Internet provides me with comfort in relation to my health worries.” Four items assessed perceived disadvantages of doctors: (1) (2) (3) (4)
“My doctor, for the most part is useless.” “I feel my doctors are not giving me adequate support or information.” “My doctor’s appointments are too short to get the information I need.” “It takes too long to see the doctor.”
How would you rate Internet sites as a source of reliable health information? Assessed with one item using a five-point Likert scale ranging from “All unreliable” (0) to “All reliable” (4). Consequences of Internet usage were measured with the following items: Following a search for health information on the Internet, how much more likely are you to visit a doctor? Rated using a four point Likert scale ranging from “Not more likely at all” (0) to “A lot more likely” (3). After searching the Internet how tense do you feel about your health-related question? Measured using a four point Likert scale, ranging from “No more tense than before I searched” (0) to “A lot more tense than before I searched” (3).
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After searching the Internet how relieved do you feel about your health-related question? Measured on a four point Likert scale, ranging from “No more relieved than before I searched” (0) to “Completely relieved” (3). Symptoms of possible addiction to using the Internet for health purposes were assessed with six questions using criteria extrapolated from Young (1998) and modified for health-related searching. Each question used a four-point Likert scale ranging from “Disagree a lot” (0) to “Agree a lot” (3). Responses to these items were analyzed in terms of mean item scores and proportion of participants who endorsed (i.e. rated as “Agree a little” or “Agree a lot”) individual items. (1) “In the past I have unsuccessfully tried to cut back on using the Internet for health purposes.” (2) “If I did not have the Internet available for health purposes, my life would be significantly altered for the worse.” (3) “If I cannot use the Internet to search for health-related purposes, I feel restless and irritable.” (4) “I end up using the Internet longer than I first intended to when I log on to search for health-related purposes.” (5) “I think I use the Internet more and more over time for health-related purposes.” (6) “My use of the Internet for health purposes negatively affects my social, work and/or academic life.” Procedure The study was administered using an online survey system provided by the university. After reading the study information sheet, participants completed a consent form, followed by the PHQ-15, PHQ-9, GAD-7, SHAI, the Internet questionnaire, and demographics measure. Participants were then led to a page where information was provided about available counseling resources. Data analysis Our study questions pertaining to examining the extent of, reasons for, and consequences of health-related Internet use and its relationship with health anxiety were analyzed using Spearman correlations due to the non-normality of the study variables, which could not be normalized through transformation (Tabachnick & Fidell, 2007). In order to establish whether Internet use was a significant source of variation in health anxiety after controlling for depression and anxiety more generally, a series of hierarchical multiple regressions were also conducted. In each case, the SHAI total score was entered as the target variable, GAD-7 and PHQ-9 scores were entered in Block 1 of the regression, and Internet use variables were entered in Block 2. Results Participant characteristics Mean health anxiety of the sample was 14.13 (SD ± 5.80). The sample was 76.9% female; mean age was 21.24 years, SD ± 3.92 years. Health anxiety correlated significantly (all ps < .01) with somatic symptom reporting (rs = .566), depression (rs = .428), and generalized anxiety (rs = .486; Table 1).
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K. Singh and R.J. Brown Table 1. Spearman correlations between health anxiety, somatic symptoms, depression, and generalized anxiety. Variable
Health anxiety (n = 255)
PHQ-15 PHQ-9 GAD-7
.566* .428* .486*
Note: PHQ-15/9 = Patient Health Questionnaire 15 (somatic symptoms) and 9 (depression); GAD-7 = Generalized Anxiety Disorder 7. *p < .001.
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Extent of Internet use for health purposes Health anxiety significantly correlated (all ps < .01) with more frequent use of the Internet for health purposes (rs = .163), a greater proportion of health compared to nonhealth Internet use (rs = .200), and more time spent online for health purposes (rs = .166). No significant correlations were found between health anxiety and how much time was spent per website when searching for health information (rs = .103), how quickly the Internet was turned to after noticing a symptom (rs = .149), and whether the Internet was used as the first source for finding health information (rs = .120; Table 2). Reasons for Internet use for health purposes Health anxiety correlated positively (all ps < .01) with searching for both illness (rs = .453) and wellness information (rs = .208), perceived advantages of the Internet Table 2. Spearman correlations between health anxiety and items pertaining to extent, reasons for, and consequences of health-related Internet use. Variable Frequency Proportion How quickly Time online Time per site First source Illness information Wellness information Internet advantages Doctor disadvantages Perceived reliability Doctor use post-search Tension Relief Unsuccessful attempt to cut back usage Significant negative alteration to life Feel restless and irritable without searching online Stay online longer than intended Increased Internet usage overtime for health purposes Negative effect on social, work, and/or academic life Note: *p < .05, **p < .01.
Health anxiety (n = 255) .163** .200** .149* .166** .103 .120 .453** .208** .183** .306** .115 .217** .364** .174** .187** .245** .366** .344** .340** .171**
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(rs = .183) and perceived disadvantages of doctors (rs = .306). The correlation between health anxiety and the perception of reliability in Internet sources for health purposes was not significant (rs = .115; Table 2). Consequences of Internet use for health purposes Health anxiety correlated positively (all ps < .01) with both tension (rs = .364) and relief (rs = .174) post-search, and the likelihood of utilizing a doctor post-search (rs = .217). Health anxiety also correlated positively (all ps < .01) with all six dimensions concerning possible addiction to using the Internet for health purposes (unsuccessful attempt to cut back usage: rs = .187; significant negative alteration to life: rs = .245; feel restless and irritable without searching online: rs = .366; stay online longer than intended: rs = .344; increased Internet usage overtime for health purposes: rs = .340; and, negative effect on social, work, and/or academic life: rs = .171; Table 2). Multiple regression analysis Results from the multiple regression analyses controlling for anxiety and depression are presented in Table 3. In the majority of cases, both PHQ-9 and GAD-7 scores were unique predictors of health anxiety in the final regression in addition to the Internet use variable. Table 3. Summary of hierarchal multiple regressions controlling for depression and generalized anxiety. Variable Frequency Proportion Time online Illness information Wellness information Internet advantages Doctor disadvantages Doctor use post-search Tension Relief Unsuccessful attempt to cut back usage Significant negative alteration to life Feel restless and irritable without searching online Stay online longer than intended Increased usage overtime for health purposes Negative effect on social, work, and/or academic life
R2 Beta change
F(1,250)
p Value
.298 .340 .256 .090 .077 .090 .102 .402 .492 .489 .386
.062 .073 .068 .316 .133 .099 .142 .150 .273 .161 .112
.004 .005 .005 .084 .017 .009 .018 .022 .072 .026 .012
1.337 1.834 1.615 33.327 6.168 3.358 6.590 7.806 28.365 9.413 4.418
.249 .177 .205 .000** .014* .068 .011* .006** .000** .002** .037*
1.145
.400
.156
.023
8.186
.005**
1.954
.357
.286
.076
30.031
.000**
1.294
.306
.224
.048
17.929
.000**
1.680
.341
.258
.063
24.337
.000**
1.074
.524
.110
.012
4.208
.041*
Unstandardized B
Standard error of B
.344 .461 .325 .520 .191 .166 .262 1.123 2.620 1.499 .812
Note: Each line concerns a separate regression analysis in which PHQ-9 and GAD-7 scores were entered as covariates in Block 1 and the relevant Internet use variable was entered in Block 2. *p < .05, **p < .01.
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Discussion The results of the present study compliment and extend the findings of Muse et al. (2012), suggesting that health-related Internet use is comparatively common in higher health anxious individuals. Health anxiety correlated positively with the frequency of searching for health information online and the proportion of health-related Internet usage vs. non-health-related usage. Correlations also suggested that more time is spent online for health purposes overall in individuals with higher health anxiety. No significant correlations were found between health anxiety and using the Internet as the first source for health information, and with the amount of time spent on each website when searching for health information. In relation to reasons for usage, health anxiety correlated significantly with searching more for illness information, consistent with previous research (Muse et al., 2012; Weaver et al., 2010). Theory suggests that high health anxious participants selectively attune to illness-related information (Barsky & Ahern, 2004), which may render these individuals particularly susceptible to the damaging effects of “query escalation” (i.e. subsequent searches relating to increasingly serious conditions; White & Horvitz, 2009), when using the Internet for health purposes. Analysis also revealed that health anxiety correlated significantly with searching for “wellness” information (i.e. about how to improve health) online. Such wellness information may be sought as an attempt to prevent the onset or spread of a perceived illness or to avoid “tempting fate” (Wells, 1997). Taken together these findings support the idea that a greater emphasis is given to health information overall in those with higher health anxiety. High health anxiety also correlated positively with the tendency to perceive disadvantages in doctors, consistent with previous research suggesting a relationship between health anxiety and doctor dissatisfaction (Guo, Kuroki, Yamashiro, & Koizumi, 2002). The extent to which this dissatisfaction is a cause of health anxiety (e.g. negative experiences with doctors undermining faith in the medical profession) or an effect of it (e.g. excessive reassurance seeking putting strain on the doctor–patient relationship) is an open question. Furthermore, health anxiety correlated positively with the tendency to perceive advantages in using the Internet for health purposes. The cognitive behavioral model suggests a number of possible reasons why higher health anxious people spend more time engaged in online health searching, including the need to obtain reassurance about health worries and/or to engage in anxiety-neutralizing behavior; and to reduce the uncertainty when faced with possible health threat (intolerance to uncertainty; Hart & Bjorgvinsson, 2010; Wells, 1997). The availability of the Internet to aid in all of these may help explain why greater advantages are perceived in those with higher health anxiety. While previous research has found no association between health anxiety and relief post-searching (Baumgartner & Hartmann, 2011), we found health anxiety correlated with greater post-search relief suggesting a possible role for reassurance seeking in health anxious individuals. We also found, however, that those with greater health anxiety experienced significantly greater tension post-search (presumably in relation to different searches to those that conferred relief) and reported being more likely to visit a doctor, consistent with Eastin and Guinsler (2006). As with other forms of reassurance seeking, it appears that attempting to neutralize distress by obtaining information from the Internet leads to a paradoxical increase in health anxiety for some people. Future research might consider whether the problem is due to the type of information obtained during the search (e.g. via query escalation; White
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& Horvitz, 2009) or due to the amount of searching conducted in general (e.g. because additional checking results in additional doubt; Wells, 1997). Similar to Muse et al. (2012), we found no significant correlation between health anxiety and the perception of reliability in online health information. To our knowledge, this is the first study to provide data concerning the relationship between health anxiety and symptoms indicating possible addiction to using the Internet for health purposes. Significant correlations were found between health anxiety and all six areas of possible Internet addiction examined. Those with higher levels of health anxiety were more likely to report: being unsuccessful in their attempts to lower their Internet usage, perceiving significant negative alterations to their life as a result of Internet use, feeling significantly more restless and irritable when not searching the Internet, staying online significantly longer than intended, feeling that their healthrelated Internet use had increased significantly overtime, and reporting that their healthrelated Internet use as having a negative affect on their social, work, and/or academic lives. These findings suggest that using the Internet for health purposes is likely to fuel anxious preoccupation in some people, to the point where their Internet use begins to feel excessive, out of control and symptomatic of their wider difficulties. Although addiction to the Internet in general appears to be a valid construct (Whang, Lee, & Chang, 2003; Young, 1998), there are no validated criteria for assessing health-specific Internet addiction; we studied symptoms that might suggest possible addiction to using the Internet for health purposes, but our results should not be interpreted as evidence for the definite presence of addiction in our health anxious participants. Future research might consider the extent to which health-related Internet addiction is a clinical problem in its own right for health anxious individuals, and the diagnostic criteria that might be used to determine its presence. Although the generalizability of our findings is clearly limited by our use of a nonclinical sample, the higher end (top quarter) of our sample had an average SHAI score of 21.5, that is within the clinical range on this measure according to some systems (Alberts et al., 2013; IAPT & NHS, 2011; Rode et al., 2006). However, we did not enquire whether our participants had sought or received psychological or medical treatment for their symptoms. Multiple regression analysis also revealed that some of the correlations between Internet use and health anxiety might be better accounted for by covariation with generalized anxiety and depression, suggesting that some aspects of health-related Internet use are not specific to health anxiety. Nevertheless, many of the relationships remained significant after controlling for anxiety and depression, suggesting that some aspects of using the Internet for health purposes have a unique relationship with health anxiety. Women composed the majority of our university undergraduate-based sample, perhaps because of the preponderance of psychology undergraduates in our sample, the greater prevalence of health anxiety in women (Faravelli et al., 1997; Marcus & Church, 2003) and/or the increased tendency for women to seek reassurance (potentially from the Internet) for health-related issues (MacSwain et al., 2009). Future research replicating these findings in male/older participants would be beneficial. We also recognize that some health anxious individuals may not use the Internet to search for health information, perhaps as a form of avoidance. Future research may consider the differences between those individuals who do and do not utilize the Internet for health purposes. The study is
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also limited by the use of a correlational design with a quantitative, online self-report measure that requires further psychometric validation. Despite these limitations, our findings suggest that future research on the role of the Internet in the development and maintenance of health anxiety is warranted, preferably using a range of methods such as qualitative and experimental approaches to explore further the extent, nature, consequences, and potential management of Internet use in people with health anxiety. Particular emphasis should be given to aspects of Internet use that are particularly likely to precipitate health anxiety, such as the tendency to progress from searching for information about nonspecific symptoms to searches related to serious diseases that might (but are unlikely to) be the cause of those symptoms (i.e. query escalation; White & Horvitz, 2009). In so doing, it may be possible to improve psychological treatment for individuals experiencing debilitating health anxiety.
Acknowledgments The authors are grateful to Professor Adrian Wells, Dr Sarah Peters and Ms Vasiliki-Maria AgaliotiSgompou for their comments and advice.
References Abramowitz, J. S., Deacon, B. J., & Valentiner, D. P. (2007). The short health anxiety inventory: Psychometric properties and construct validity in a non-clinical sample. Cognitive Therapy and Research, 31, 871–883. doi:10.1007/s10608-006-9058-1 Adewuya, A. O., Ola, B. A., & Afolabi, O. O. (2006). Validity of the Patient Health Questionnaire (PHQ-9) as a screening tool for depression amongst Nigerian university students. Journal of Affective Disorders, 96, 89–93. doi:10.1016/j.jad.2006.05.021 Alberts, N. M., Hadjistavropoulos, H. D., Jones, S. L., & Sharpe, D. (2013). The short health anxiety inventory: A systematic review and meta-analysis. Journal of Anxiety Disorders, 27, 68–78. doi:10.1016/j.janxdis.2012.10.009 Barsky, A. J., & Ahern, D. K. (2004). Cognitive behavior therapy for hypochondriasis: a randomized controlled trial. The Journal of the American Medical Association, 291, 1464– 1470. Retrieved from http://jama.jamanetwork.com/article.aspx?articleid = 198437 Baumgartner, S. E., & Hartmann, T. (2011). The role of health anxiety in online health information search. Cyberpsychology, Behavior, and Social Networking, 14, 613–618. doi:10.1089/ cyber.2010.0425 Bennett, G. G., & Glasgow, R. E. (2009). The delivery of public health interventions via the Internet: Actualizing their potential. Annual Review of Public Health, 30, 273–292. doi:10.1146/ annurev.publhealth.031308.100235 Eastin, M. S., & Guinsler, N. M. (2006). Worried and wired: Effects of health anxiety on information-seeking and health care utilization behaviors. CyberPsychology and Behavior, 9, 494–498. doi:10.1089/cpb.2006.9.494 European Commission. (2013). Managing health data. Retrieved from http://ec.europa.eu/digitalagenda/en/managing-health-data Eysenbach, G., & Kohler, C. (2002). How do consumers search for and appraise health information on the world wide web? Qualitative study using focus groups, usability tests, and in-depth interviews. British Medical Journal, 324, 573–577. doi:10.1136/bmj.324.7337.573 Faravelli, C., Salvatori, S., Galassi, F., Aiazzi, L., Drei, C., & Cabras, P. (1997). Epidemiology of somatoform disorders: A community survey in Florence. Social Psychiatry and Psychiatric Epidemiology, 32(1), 24–29. Retrieved from http://link.springer.com/article/10.1007/BF008 00664 Fox, S. (2013). Pew Internet: Health. Retrieved from http://www.pewInternet.org/Commentary/ 2011/November/Pew-Internet-Health.aspx
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Gagliardi, A., & Jadad, A. R. (2002). Examination of instruments used to rate quality of health information on the Internet: Chronicle of a voyage with an unclear destination. British Medical Journal, 324, 569–573. doi:10.1136/bmj.324.7337.569 Gray, N. J., Klien, J. D., Noyce, P. R., Sesselberg, T. S., & Cantrill, J. A. (2005). Health information-seeking behaviour in adolescence: The place of the Internet. Social Science and Medicine, 60, 1467–1478. doi:10.1016/j.socscimed.2004.08.010 Guo, Y., Kuroki, T., Yamashiro, S., & Koizumi, S. (2002). Illness behaviour and patient satisfaction as correlates of self-referral in japan. Family Practice, 19, 326–332. doi:10.1093/fampra/19.4.326 Hart, J., & Bjorgvinsson, T. (2010). Health anxiety and hypochondriasis: Description and treatment issues highlighted through a case illustration. Bulletin of the Menninger Clinic, 74(2), 122–140. Retrieved from http://guilfordjournals.com/toc/bumc/74/2 Hitchcock, P. B., & Mathews, A. (1992). Interpretation of bodily symptoms in hypochondriasis. Behaviour Research and Therapy, 30, 223–234. doi:10.1016/0005-7967%2892%2990068-R Improving Access to Psychological Therapies (IAPT) and National Health Service (NHS). (2011). The IAPT data handbook. Retrieved May 1, 2011, from http://www.iapt.nhs.uk/silo/files/iaptdata-handbook-v2.pdf Kroenke, K., Spitzer, R. L., & Williams, J. B. W. (2001). The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16, 606–613. Retrieved from http:// www.ncbi.nlm.nih.gov/pubmed/11556941 Kroenke, K., Spitzer, R. L., & Williams, J. B. W. (2002). The PHQ-15: Validity of a new measure for evaluating the severity of somatic symptoms. Psychosomatic Medicine, 64, 258–266. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/11914441 Löwe, B., Decker, O., Müller, S., Brähler, E., Schellberg, D., Herzog, W., & Herzberg, P. Y. (2008). Validation and standardization of the generalized anxiety disorder screener (GAD-7) in the general population. Medical Care, 46, 266–274. doi:10.1097/MLR.0b013e318160d093 MacSwain, K. L. H., Sherry, S. B., Stewart, S. H., Watt, M. C., Hadjistavropoulos, H. D., & Graham, A. R. (2009). Gender differences in health anxiety: An investigation of the interpersonal model of health anxiety. Personality and Individual Differences, 47, 938–943. doi:10.1016/j. paid.2009.07.020 Marcus, D. K., & Church, S. E. (2003). Are dysfunctional beliefs about illness unique to hypochondriasis? Journal of Psychosomatic Research, 54, 543–547. doi:10.1016/S0022-3999% 2802%2900526-3 Muse, K., McManus, F., Leung, B., Meghreblian, T., & Williams, J. M. G. (2012). Cyberchondriasis: Fact or fiction? A preliminary examination of the relationship between health anxiety and searching for health information on the Internet. Journal of Anxiety Disorders, 26, 189–196. doi:10.1016/j.janxdis.2011.11.005 Rode, S., Salkovskis, P., Dowd, H., & Hanna, M. (2006). Health anxiety levels in chronic pain clinic attenders. Journal of Psychosomatic Research, 60, 151–161. doi:10.1016/j. jpsychores.2005.07.005 Salkovskis, P. M., Rimes, K. A., Warwick, H. M. C., & Clark, D. M. (2002). The health anxiety inventory: Development and validation of scales for the measurement of health anxiety and hypochondriasis. Psychological Medicine, 32, 843–853. doi:10.1017/S0033291702005822 Spitzer, R. L., Kroenke, K., Williams, J. B. W., & Lowe, B. (2006). A brief measure for assessing generalized anxiety disorder the GAD-7. Archives of Internal Medicine, 166, 1092–1097. Retrieved from http://archinte.ama-assn.org/cgi/content/abstract/166/10/1092 Tabachnick, B. G., & Fidell, L. S. (2007). Using multivariate statistics (5th ed.). New York, NY: Pearson Education. Tustin, N. (2010). The role of patient satisfaction in online health information seeking. Journal of Health Communication, 15, 3–17. doi:10.1080/10810730903465491 van Ravesteijn, H. V., Wittkampf, K., Lucassen, P., van de Lisdonk, E., van den Hoogen, H., van Weert, H., … Speckens, A. (2009). Detecting somatoform disorders in primary care with the PHQ-15. Annals of Family Medicine, 7, 232–238. doi:10.1370/afm.985 Warwick, H. M. C. (1989). A cognitive-behavioural approach to hypochondriasis and health anxiety. Journal of Psychosomatic Research, 33, 705–711. doi:10.1016/0022-3999%2889% 2990086-X Warwick, H. M., & Salkovskis, P. M. (1990). Hypochondriasis. Behaviour Research and Therapy, 28(2), 105–117. doi:10.1016/0005-7967(90)90023-C
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Weaver III, J. B., Mays, D., Weaver, S. S., Hopkins, G. L., Eroglu, D., & Bernhardt, J. M. (2010). Health information – seeking behaviors, health indicators, and health risks. American Journal of Public Health, 100, 1520–1526. doi:10.2105/AJPH.2009.180521 Wells, A. (1997). Cognitive therapy of anxiety disorders: A practice manual and conceptual guide. Chichester: John Wiley & Sons. Whang, L. S. M., Lee, S., & Chang, G. (2003). Internet over-users’ psychological profiles: A behavior sampling analysis on Internet addiction. CyberPsychology and Behavior, 6, 143–150. doi:10.1089/109493103321640338 White, R. W., & Horvitz, E. (2009). Cyberchondria: Studies of the escalation of medical concerns in web search. ACM Transactions on Information Systems, 27(4), 1–37. Retrieved from http://research.microsoft.com/en-us/um/people/ryenw/papers/WhiteTOIS2009.pdf Young, K. S. (1998). Internet addiction: The emergence of a new clinical disorder. CyberPsychology and Behavior, 1, 237–244. doi:10.1089/cpb.1998.1.237
Anxiety, Stress, & Coping: An International Journal Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/gasc20
Health-related Internet habits and health anxiety in university students a
a
Karmpaul Singh & Richard J. Brown a
School of Psychological Sciences, University of Manchester, 2nd floor, Zochonis Building, Brunswick Street, Oxford Road, M13 9PL, Manchester, UK Accepted author version posted online: 28 Jan 2014.Published online: 03 Mar 2014.
To cite this article: Karmpaul Singh & Richard J. Brown (2014) Health-related Internet habits and health anxiety in university students, Anxiety, Stress, & Coping: An International Journal, 27:5, 542-554, DOI: 10.1080/10615806.2014.888061 To link to this article: http://dx.doi.org/10.1080/10615806.2014.888061
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Anxiety, Stress, & Coping, 2014 Vol. 27, No. 5, 542–554, http://dx.doi.org/10.1080/10615806.2014.888061
Health-related Internet habits and health anxiety in university students Karmpaul Singh* and Richard J. Brown School of Psychological Sciences, University of Manchester, 2nd floor, Zochonis Building, Brunswick Street, Oxford Road, M13 9PL, Manchester, UK
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(Received 5 April 2013; accepted 2 January 2014) Health-related Internet use has grown rapidly, yet little research has considered how health anxious individuals use the Internet for this purpose. Our aim was to examine the relationships between health anxiety and the extent of, reasons for, and consequences of health-related Internet usage in university students (n = 255). Responses on a purpose-made Internet use questionnaire were correlated with health anxiety scores; multiple regression analyses controlling for depression and anxiety were also conducted. Health anxiety positively correlated with (all ps < .01): frequency of health-related searching (rs = .163), proportion of health-related information sought (rs = .200), time spent online for health purposes (rs = .166), and number of searches for both illness (rs = .453) and wellness (rs = .208) information. Health anxiety further positively correlated with advantages perceived in health-related Internet use (rs = .183), heightened tension (rs = .364) and relief (rs = .174) post-search, and perceived doctor disadvantages (rs = .306), yet a greater likelihood to visit a doctor post-search (rs = .217). Health anxiety also correlated with six measures of possible addiction to using the Internet for health purposes (rs range = .171 to .366, all ps < .01). Some (including several potentially dysfunctional) aspects of health-related Internet use correlate with health anxiety. Research evaluating the possible role of Internet use in the development and maintenance of health anxiety is warranted. Keywords: health anxiety; hypochondriasis; cyberchondria; Internet; hypochondria
Introduction Health-related Internet use has increased significantly in recent years, with an estimated 12.5 million health-related Internet searches conducted daily worldwide in 2009 alone (Bennett & Glasgow, 2009). Two recent polls suggest 50% of Europeans (European Commission, 2013) and 72% of Americans (Fox, 2013) used the Internet for health information in the past year. Despite the apparent value of such resources, the Internet is also a rich source of potentially alarming information about health and illness (sometimes of dubious validity; Gagliardi & Jadad, 2002) with the potential to increase doubt and fear, particularly in people who are already anxious about their health. Health anxiety falls on a continuum, ranging from intermittent worry to a pathological preoccupation with fears of illness that may meet criteria for a diagnosis of hypochondriasis (Hitchcock & Mathews, 1992). The cognitive behavioral model (Warwick & Salkovskis, 1990) suggests that health anxious individuals hold dysfunctional beliefs and *Corresponding author. Email: [email protected] © 2014 Taylor & Francis
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assumptions about health and disease, which lead them to misinterpret triggering stimuli (e.g. bodily sensations) as evidence that they are, or at risk of becoming, seriously ill. According to this model, searching for health information online could contribute to health preoccupation and anxiety in several ways, including as a source of dysfunctional assumptions and beliefs and by providing conflicting information that increases uncertainty (Warwick, 1989). Using the Internet as a form of reassurance seeking (i.e. to prove/disprove the presence of illness) is thought to be common in health anxious individuals (Wells, 1997). Excessive reassurance seeking may be particularly likely to result in disproportionate Internet use for health purposes (so-called “cyberchondria”; White & Horvitz, 2009), due to negative reinforcement and/or exposure to alarming results that prompt further searching. Most research on health-related Internet use has focused on general aspects of how and why people use the Internet for health purposes (Eysenbach & Kohler, 2002; Tustin, 2010; Weaver et al., 2010; White & Horvitz, 2009) and the perceived credibility of online health information (Gagliardi & Jadad, 2002; Gray, Klien, Noyce, Sesselberg, & Cantrill, 2005). Very few studies have considered the relationship between health anxiety and online health behavior. Eastin and Guinsler (2006) found a positive correlation between health anxiety and post-search health utilization. Baumgartner and Hartmann (2011) observed that health anxious participants reported more post-search distress than low anxious controls; no evidence for a reassuring/relief effect of online health information was found, however. Health anxiety was also more likely to arise when the online source was perceived as trustworthy (Baumgartner & Hartmann, 2011; Eastin & Guinsler, 2006). Muse, McManus, Leung, Meghreblian, and Williams (2012) studied health-related Internet use by high and low health anxious university students, using a purpose-made Internet use questionnaire. Areas examined included likelihood and reasons for Internet utilization, frequency and duration of searching, emotional impact, type of information sought and source used, and perceived accuracy of information. They found high health anxious students searched the Internet for health information more frequently and for longer than low health anxious individuals, reported feeling more distressed and anxious post-search, and searched more for diagnosed/undiagnosed medical conditions and personal accounts of illness. The purpose of the current study was to replicate and extend some of Muse et al.’s findings. We also investigated whether health anxiety was correlated with features suggesting possible addiction to using the Internet for health purposes, including unsuccessful attempts to cut back on health-related Internet use, negative feelings associated with actual and anticipated loss of health-related Internet use, adverse impact of health-related Internet use, and increasing health-related Internet use over time.
Method Design The present study utilized a correlational design using online questionnaires to investigate the relationship between health anxiety and health-related Internet usage. Like Muse et al., we studied the relationship between health anxiety and frequency and duration of Internet usage for health purposes, post-search distress, types of information sought, and the perceived accuracy of health information. We extended the study of Muse et al. by assessing the hypothesis that health anxiety would also correlate with the overall proportion of Internet time spent searching for health purposes, use of the Internet as a
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primary source of health information, perceived advantages of the Internet and disadvantages of doctors, and post-search tension, relief, and doctor utilization. We also obtained demographic information and measured somatic symptom reporting, depression, and generalized anxiety to better understand the potential clinical applicability of our findings.
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Participants Two hundred and fifty-five undergraduate and postgraduate students from the University of Manchester completed the survey (76.9% female, mean age 21.24 years, SD ± 3.92 years). All reported Internet usage for health purposes. Data from all eligible participants were used. Participant volunteers responded to adverts on a university research website and posted around the campus. The majority of participants were psychology undergraduates, who received research credit for participation; non-psychology students were entered into a prize draw to win gift vouchers. Measures Short Health Anxiety Inventory (SHAI) The SHAI was used to measure health anxiety (Salkovskis, Rimes, Warwick, & Clark, 2002). The first 14 items measure symptoms of health anxiety; the final four measure the perceived consequences of having a serious disease. Each item consists of four statements and participants pick which apply to them. Each statement carries a score from 0 to 3, with total scores ranging from 0 to 54. There is some debate as to what constitutes clinically significant health anxiety on this scale (Alberts, Hadjistavropoulos, Jones, & Sharpe, 2013), although a score of ≥18 is often used (Improving Access to Psychological Therapies [IAPT] and National Health Service [NHS], 2011; Muse et al., 2012; Rode, Salkovskis, Dowd, & Hanna, 2006). The SHAI has high test–retest reliability, convergent validity (.90 and .85 respectively; Salkovskis et al., 2002) and internal consistency (.89; Abramowitz, Deacon, & Valentiner, 2007). Internal consistency in this study was excellent (.89). Patient Health Questionnaire (PHQ-15) The PHQ-15 was used to measure somatic symptom burden. The PHQ-15 consists of 15 symptoms such as stomach pain, headaches, and so on. Participants indicate if they are not bothered, bothered a little, or bothered a lot for each corresponding symptom, scoring 0, 1, or 2, respectively; total scores range from 0 to 30. It has good internal consistency (.80; Kroenke, Spitzer, & Williams, 2002), criterion validity, and test–retest reliability (.83; van Ravesteijn et al., 2009). Internal consistency in this study was good (.80). Patient Health Questionnaire (PHQ-9) The PHQ-9 was used to measure depression. The scale asks participants to rate how often each of nine aspects of depression bother them, on a scale from 0 (“not at all”) to 3 (“nearly every day”); total scores range from 0 to 27. The PHQ-9 has shown good internal consistency (.89; Kroenke, Spitzer, & Williams, 2001), concurrent validity, and test–retest reliability (.89; Adewuya, Ola, & Afolabi, 2006). Internal consistency in this study was excellent (.90).
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Generalized Anxiety Disorder-7 (GAD-7) The GAD-7 was used to measure anxiety. It asks participants to rate how often each of seven aspects of generalized anxiety bother them on a scale ranging from 0 (“not at all”) to 3 (“nearly every day”); total scores range from 0 to 21. The GAD-7 displays good internal consistency (.89; Löwe et al., 2008), convergent validity, and test–retest reliability (.83; Spitzer, Kroenke, Williams, & Lowe, 2006). Internal consistency in this study was excellent (.91).
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Internet beliefs and behaviors A purpose-made questionnaire was developed to assess participants’ beliefs and behaviors in relation to three general aspects of health-related Internet use: extent of usage; reasons for usage; and consequences of usage. Data on other aspects of health-related Internet usage (e.g. what sources were used to find health information online, whether healthrelated searches were for oneself or for someone else, whether health-related Internet searches were conducted alone or with someone, and whether/why computers or mobile devices are preferred media for accessing online health information) were also collected but will be reported elsewhere (Singh, in preparation). Extent of Internet usage was measured with the following items: How often do you use the Internet to access health-related information? Rated on a seven-point Likert scale ranging from “Never” (0) to “Every few hours or more” (6). Roughly what proportion of your total Internet time is spent on health/illness-related topics? (Rated on a scale from 10% to 100% divided into 10% increments). On average how quickly do you turn to the Internet when you find/notice a physical symptom? Rated on a seven-point Likert scale ranging from “One or more days after” (0) to “Immediately” (6). Each time you go on the Internet for health purposes, on average how long do you stay online? Rated on a seven-point Likert scale ranging from “Few seconds” (0) to “More than an hour” (6). When using the Internet for health-related purposes, how much time do you typically spend on each website on average? Rated on a six-point Likert scale ranging from “Few minutes” (0) to “Several hours” (5). Do you turn to the Internet as a first source when you find/notice a physical symptom? Rated as “Yes” or “No.” Reasons for Internet usage were measured with the following items: Type of information sought: ten items enquired about how often certain types of information were sought. Each question used a five-point Likert scale, ranging from “Never” (0) to “Very often” (4). Separate mean item scores for the illness and wellness items were calculated for the analysis. Six were illness-based: (1) (2) (3) (4)
“Looking “Looking “Looking “Looking
for for for for
information about specific diseases.” pictures of something I am worried about.” survivor stories and/or personal accounts of illness.” information about symptoms I am experiencing.”
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K. Singh and R.J. Brown (5) “Using forums/chat rooms, so that I can ask questions and read other people’s opinions on the problem I am/think I am facing.” (6) “Looking for information about different diseases I think I might have or am scared of getting.” Four were wellness-based (i.e. information pertaining to how to remain well):
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(1) (2) (3) (4)
“Looking “Looking “Looking “Looking
for for for for
information on how to improve my diet.” information on how to lose weight.” information how to exercise properly.” ways to be healthier.”
Perceived advantages of the Internet/disadvantages of doctors: each on a four-point Likert scale ranging from “Disagree a lot” (0) to “Agree a lot” (3). Separate mean scores for the Internet advantages and doctor disadvantages items were calculated for the analysis. Seven items assessed perceived advantages of the Internet for health purposes: (1) “I find that the Internet is more convenient to find information than other places (e.g. books, library, GP surgery).” (2) “I believe that the Internet is a highly credible source of health information.” (3) “The Internet is the fastest access to information that I have.” (4) “The Internet is beneficial because after I have had an appointment with my doctor, I want to go home and learn more about what we talked about.” (5) “The Internet is a good source, because much of the information I get from the doctor, I can easily find online from the comfort of my home.” (6) “I think the Internet is a good source of information that can be a substitute for my doctor.” (7) “The Internet provides me with comfort in relation to my health worries.” Four items assessed perceived disadvantages of doctors: (1) (2) (3) (4)
“My doctor, for the most part is useless.” “I feel my doctors are not giving me adequate support or information.” “My doctor’s appointments are too short to get the information I need.” “It takes too long to see the doctor.”
How would you rate Internet sites as a source of reliable health information? Assessed with one item using a five-point Likert scale ranging from “All unreliable” (0) to “All reliable” (4). Consequences of Internet usage were measured with the following items: Following a search for health information on the Internet, how much more likely are you to visit a doctor? Rated using a four point Likert scale ranging from “Not more likely at all” (0) to “A lot more likely” (3). After searching the Internet how tense do you feel about your health-related question? Measured using a four point Likert scale, ranging from “No more tense than before I searched” (0) to “A lot more tense than before I searched” (3).
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After searching the Internet how relieved do you feel about your health-related question? Measured on a four point Likert scale, ranging from “No more relieved than before I searched” (0) to “Completely relieved” (3). Symptoms of possible addiction to using the Internet for health purposes were assessed with six questions using criteria extrapolated from Young (1998) and modified for health-related searching. Each question used a four-point Likert scale ranging from “Disagree a lot” (0) to “Agree a lot” (3). Responses to these items were analyzed in terms of mean item scores and proportion of participants who endorsed (i.e. rated as “Agree a little” or “Agree a lot”) individual items. (1) “In the past I have unsuccessfully tried to cut back on using the Internet for health purposes.” (2) “If I did not have the Internet available for health purposes, my life would be significantly altered for the worse.” (3) “If I cannot use the Internet to search for health-related purposes, I feel restless and irritable.” (4) “I end up using the Internet longer than I first intended to when I log on to search for health-related purposes.” (5) “I think I use the Internet more and more over time for health-related purposes.” (6) “My use of the Internet for health purposes negatively affects my social, work and/or academic life.” Procedure The study was administered using an online survey system provided by the university. After reading the study information sheet, participants completed a consent form, followed by the PHQ-15, PHQ-9, GAD-7, SHAI, the Internet questionnaire, and demographics measure. Participants were then led to a page where information was provided about available counseling resources. Data analysis Our study questions pertaining to examining the extent of, reasons for, and consequences of health-related Internet use and its relationship with health anxiety were analyzed using Spearman correlations due to the non-normality of the study variables, which could not be normalized through transformation (Tabachnick & Fidell, 2007). In order to establish whether Internet use was a significant source of variation in health anxiety after controlling for depression and anxiety more generally, a series of hierarchical multiple regressions were also conducted. In each case, the SHAI total score was entered as the target variable, GAD-7 and PHQ-9 scores were entered in Block 1 of the regression, and Internet use variables were entered in Block 2. Results Participant characteristics Mean health anxiety of the sample was 14.13 (SD ± 5.80). The sample was 76.9% female; mean age was 21.24 years, SD ± 3.92 years. Health anxiety correlated significantly (all ps < .01) with somatic symptom reporting (rs = .566), depression (rs = .428), and generalized anxiety (rs = .486; Table 1).
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K. Singh and R.J. Brown Table 1. Spearman correlations between health anxiety, somatic symptoms, depression, and generalized anxiety. Variable
Health anxiety (n = 255)
PHQ-15 PHQ-9 GAD-7
.566* .428* .486*
Note: PHQ-15/9 = Patient Health Questionnaire 15 (somatic symptoms) and 9 (depression); GAD-7 = Generalized Anxiety Disorder 7. *p < .001.
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Extent of Internet use for health purposes Health anxiety significantly correlated (all ps < .01) with more frequent use of the Internet for health purposes (rs = .163), a greater proportion of health compared to nonhealth Internet use (rs = .200), and more time spent online for health purposes (rs = .166). No significant correlations were found between health anxiety and how much time was spent per website when searching for health information (rs = .103), how quickly the Internet was turned to after noticing a symptom (rs = .149), and whether the Internet was used as the first source for finding health information (rs = .120; Table 2). Reasons for Internet use for health purposes Health anxiety correlated positively (all ps < .01) with searching for both illness (rs = .453) and wellness information (rs = .208), perceived advantages of the Internet Table 2. Spearman correlations between health anxiety and items pertaining to extent, reasons for, and consequences of health-related Internet use. Variable Frequency Proportion How quickly Time online Time per site First source Illness information Wellness information Internet advantages Doctor disadvantages Perceived reliability Doctor use post-search Tension Relief Unsuccessful attempt to cut back usage Significant negative alteration to life Feel restless and irritable without searching online Stay online longer than intended Increased Internet usage overtime for health purposes Negative effect on social, work, and/or academic life Note: *p < .05, **p < .01.
Health anxiety (n = 255) .163** .200** .149* .166** .103 .120 .453** .208** .183** .306** .115 .217** .364** .174** .187** .245** .366** .344** .340** .171**
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(rs = .183) and perceived disadvantages of doctors (rs = .306). The correlation between health anxiety and the perception of reliability in Internet sources for health purposes was not significant (rs = .115; Table 2). Consequences of Internet use for health purposes Health anxiety correlated positively (all ps < .01) with both tension (rs = .364) and relief (rs = .174) post-search, and the likelihood of utilizing a doctor post-search (rs = .217). Health anxiety also correlated positively (all ps < .01) with all six dimensions concerning possible addiction to using the Internet for health purposes (unsuccessful attempt to cut back usage: rs = .187; significant negative alteration to life: rs = .245; feel restless and irritable without searching online: rs = .366; stay online longer than intended: rs = .344; increased Internet usage overtime for health purposes: rs = .340; and, negative effect on social, work, and/or academic life: rs = .171; Table 2). Multiple regression analysis Results from the multiple regression analyses controlling for anxiety and depression are presented in Table 3. In the majority of cases, both PHQ-9 and GAD-7 scores were unique predictors of health anxiety in the final regression in addition to the Internet use variable. Table 3. Summary of hierarchal multiple regressions controlling for depression and generalized anxiety. Variable Frequency Proportion Time online Illness information Wellness information Internet advantages Doctor disadvantages Doctor use post-search Tension Relief Unsuccessful attempt to cut back usage Significant negative alteration to life Feel restless and irritable without searching online Stay online longer than intended Increased usage overtime for health purposes Negative effect on social, work, and/or academic life
R2 Beta change
F(1,250)
p Value
.298 .340 .256 .090 .077 .090 .102 .402 .492 .489 .386
.062 .073 .068 .316 .133 .099 .142 .150 .273 .161 .112
.004 .005 .005 .084 .017 .009 .018 .022 .072 .026 .012
1.337 1.834 1.615 33.327 6.168 3.358 6.590 7.806 28.365 9.413 4.418
.249 .177 .205 .000** .014* .068 .011* .006** .000** .002** .037*
1.145
.400
.156
.023
8.186
.005**
1.954
.357
.286
.076
30.031
.000**
1.294
.306
.224
.048
17.929
.000**
1.680
.341
.258
.063
24.337
.000**
1.074
.524
.110
.012
4.208
.041*
Unstandardized B
Standard error of B
.344 .461 .325 .520 .191 .166 .262 1.123 2.620 1.499 .812
Note: Each line concerns a separate regression analysis in which PHQ-9 and GAD-7 scores were entered as covariates in Block 1 and the relevant Internet use variable was entered in Block 2. *p < .05, **p < .01.
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Discussion The results of the present study compliment and extend the findings of Muse et al. (2012), suggesting that health-related Internet use is comparatively common in higher health anxious individuals. Health anxiety correlated positively with the frequency of searching for health information online and the proportion of health-related Internet usage vs. non-health-related usage. Correlations also suggested that more time is spent online for health purposes overall in individuals with higher health anxiety. No significant correlations were found between health anxiety and using the Internet as the first source for health information, and with the amount of time spent on each website when searching for health information. In relation to reasons for usage, health anxiety correlated significantly with searching more for illness information, consistent with previous research (Muse et al., 2012; Weaver et al., 2010). Theory suggests that high health anxious participants selectively attune to illness-related information (Barsky & Ahern, 2004), which may render these individuals particularly susceptible to the damaging effects of “query escalation” (i.e. subsequent searches relating to increasingly serious conditions; White & Horvitz, 2009), when using the Internet for health purposes. Analysis also revealed that health anxiety correlated significantly with searching for “wellness” information (i.e. about how to improve health) online. Such wellness information may be sought as an attempt to prevent the onset or spread of a perceived illness or to avoid “tempting fate” (Wells, 1997). Taken together these findings support the idea that a greater emphasis is given to health information overall in those with higher health anxiety. High health anxiety also correlated positively with the tendency to perceive disadvantages in doctors, consistent with previous research suggesting a relationship between health anxiety and doctor dissatisfaction (Guo, Kuroki, Yamashiro, & Koizumi, 2002). The extent to which this dissatisfaction is a cause of health anxiety (e.g. negative experiences with doctors undermining faith in the medical profession) or an effect of it (e.g. excessive reassurance seeking putting strain on the doctor–patient relationship) is an open question. Furthermore, health anxiety correlated positively with the tendency to perceive advantages in using the Internet for health purposes. The cognitive behavioral model suggests a number of possible reasons why higher health anxious people spend more time engaged in online health searching, including the need to obtain reassurance about health worries and/or to engage in anxiety-neutralizing behavior; and to reduce the uncertainty when faced with possible health threat (intolerance to uncertainty; Hart & Bjorgvinsson, 2010; Wells, 1997). The availability of the Internet to aid in all of these may help explain why greater advantages are perceived in those with higher health anxiety. While previous research has found no association between health anxiety and relief post-searching (Baumgartner & Hartmann, 2011), we found health anxiety correlated with greater post-search relief suggesting a possible role for reassurance seeking in health anxious individuals. We also found, however, that those with greater health anxiety experienced significantly greater tension post-search (presumably in relation to different searches to those that conferred relief) and reported being more likely to visit a doctor, consistent with Eastin and Guinsler (2006). As with other forms of reassurance seeking, it appears that attempting to neutralize distress by obtaining information from the Internet leads to a paradoxical increase in health anxiety for some people. Future research might consider whether the problem is due to the type of information obtained during the search (e.g. via query escalation; White
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& Horvitz, 2009) or due to the amount of searching conducted in general (e.g. because additional checking results in additional doubt; Wells, 1997). Similar to Muse et al. (2012), we found no significant correlation between health anxiety and the perception of reliability in online health information. To our knowledge, this is the first study to provide data concerning the relationship between health anxiety and symptoms indicating possible addiction to using the Internet for health purposes. Significant correlations were found between health anxiety and all six areas of possible Internet addiction examined. Those with higher levels of health anxiety were more likely to report: being unsuccessful in their attempts to lower their Internet usage, perceiving significant negative alterations to their life as a result of Internet use, feeling significantly more restless and irritable when not searching the Internet, staying online significantly longer than intended, feeling that their healthrelated Internet use had increased significantly overtime, and reporting that their healthrelated Internet use as having a negative affect on their social, work, and/or academic lives. These findings suggest that using the Internet for health purposes is likely to fuel anxious preoccupation in some people, to the point where their Internet use begins to feel excessive, out of control and symptomatic of their wider difficulties. Although addiction to the Internet in general appears to be a valid construct (Whang, Lee, & Chang, 2003; Young, 1998), there are no validated criteria for assessing health-specific Internet addiction; we studied symptoms that might suggest possible addiction to using the Internet for health purposes, but our results should not be interpreted as evidence for the definite presence of addiction in our health anxious participants. Future research might consider the extent to which health-related Internet addiction is a clinical problem in its own right for health anxious individuals, and the diagnostic criteria that might be used to determine its presence. Although the generalizability of our findings is clearly limited by our use of a nonclinical sample, the higher end (top quarter) of our sample had an average SHAI score of 21.5, that is within the clinical range on this measure according to some systems (Alberts et al., 2013; IAPT & NHS, 2011; Rode et al., 2006). However, we did not enquire whether our participants had sought or received psychological or medical treatment for their symptoms. Multiple regression analysis also revealed that some of the correlations between Internet use and health anxiety might be better accounted for by covariation with generalized anxiety and depression, suggesting that some aspects of health-related Internet use are not specific to health anxiety. Nevertheless, many of the relationships remained significant after controlling for anxiety and depression, suggesting that some aspects of using the Internet for health purposes have a unique relationship with health anxiety. Women composed the majority of our university undergraduate-based sample, perhaps because of the preponderance of psychology undergraduates in our sample, the greater prevalence of health anxiety in women (Faravelli et al., 1997; Marcus & Church, 2003) and/or the increased tendency for women to seek reassurance (potentially from the Internet) for health-related issues (MacSwain et al., 2009). Future research replicating these findings in male/older participants would be beneficial. We also recognize that some health anxious individuals may not use the Internet to search for health information, perhaps as a form of avoidance. Future research may consider the differences between those individuals who do and do not utilize the Internet for health purposes. The study is
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also limited by the use of a correlational design with a quantitative, online self-report measure that requires further psychometric validation. Despite these limitations, our findings suggest that future research on the role of the Internet in the development and maintenance of health anxiety is warranted, preferably using a range of methods such as qualitative and experimental approaches to explore further the extent, nature, consequences, and potential management of Internet use in people with health anxiety. Particular emphasis should be given to aspects of Internet use that are particularly likely to precipitate health anxiety, such as the tendency to progress from searching for information about nonspecific symptoms to searches related to serious diseases that might (but are unlikely to) be the cause of those symptoms (i.e. query escalation; White & Horvitz, 2009). In so doing, it may be possible to improve psychological treatment for individuals experiencing debilitating health anxiety.
Acknowledgments The authors are grateful to Professor Adrian Wells, Dr Sarah Peters and Ms Vasiliki-Maria AgaliotiSgompou for their comments and advice.
References Abramowitz, J. S., Deacon, B. J., & Valentiner, D. P. (2007). The short health anxiety inventory: Psychometric properties and construct validity in a non-clinical sample. Cognitive Therapy and Research, 31, 871–883. doi:10.1007/s10608-006-9058-1 Adewuya, A. O., Ola, B. A., & Afolabi, O. O. (2006). Validity of the Patient Health Questionnaire (PHQ-9) as a screening tool for depression amongst Nigerian university students. Journal of Affective Disorders, 96, 89–93. doi:10.1016/j.jad.2006.05.021 Alberts, N. M., Hadjistavropoulos, H. D., Jones, S. L., & Sharpe, D. (2013). The short health anxiety inventory: A systematic review and meta-analysis. Journal of Anxiety Disorders, 27, 68–78. doi:10.1016/j.janxdis.2012.10.009 Barsky, A. J., & Ahern, D. K. (2004). Cognitive behavior therapy for hypochondriasis: a randomized controlled trial. The Journal of the American Medical Association, 291, 1464– 1470. Retrieved from http://jama.jamanetwork.com/article.aspx?articleid = 198437 Baumgartner, S. E., & Hartmann, T. (2011). The role of health anxiety in online health information search. Cyberpsychology, Behavior, and Social Networking, 14, 613–618. doi:10.1089/ cyber.2010.0425 Bennett, G. G., & Glasgow, R. E. (2009). The delivery of public health interventions via the Internet: Actualizing their potential. Annual Review of Public Health, 30, 273–292. doi:10.1146/ annurev.publhealth.031308.100235 Eastin, M. S., & Guinsler, N. M. (2006). Worried and wired: Effects of health anxiety on information-seeking and health care utilization behaviors. CyberPsychology and Behavior, 9, 494–498. doi:10.1089/cpb.2006.9.494 European Commission. (2013). Managing health data. Retrieved from http://ec.europa.eu/digitalagenda/en/managing-health-data Eysenbach, G., & Kohler, C. (2002). How do consumers search for and appraise health information on the world wide web? Qualitative study using focus groups, usability tests, and in-depth interviews. British Medical Journal, 324, 573–577. doi:10.1136/bmj.324.7337.573 Faravelli, C., Salvatori, S., Galassi, F., Aiazzi, L., Drei, C., & Cabras, P. (1997). Epidemiology of somatoform disorders: A community survey in Florence. Social Psychiatry and Psychiatric Epidemiology, 32(1), 24–29. Retrieved from http://link.springer.com/article/10.1007/BF008 00664 Fox, S. (2013). Pew Internet: Health. Retrieved from http://www.pewInternet.org/Commentary/ 2011/November/Pew-Internet-Health.aspx
Downloaded by [Marquette University] at 01:56 19 August 2014
Anxiety, Stress, & Coping
553
Gagliardi, A., & Jadad, A. R. (2002). Examination of instruments used to rate quality of health information on the Internet: Chronicle of a voyage with an unclear destination. British Medical Journal, 324, 569–573. doi:10.1136/bmj.324.7337.569 Gray, N. J., Klien, J. D., Noyce, P. R., Sesselberg, T. S., & Cantrill, J. A. (2005). Health information-seeking behaviour in adolescence: The place of the Internet. Social Science and Medicine, 60, 1467–1478. doi:10.1016/j.socscimed.2004.08.010 Guo, Y., Kuroki, T., Yamashiro, S., & Koizumi, S. (2002). Illness behaviour and patient satisfaction as correlates of self-referral in japan. Family Practice, 19, 326–332. doi:10.1093/fampra/19.4.326 Hart, J., & Bjorgvinsson, T. (2010). Health anxiety and hypochondriasis: Description and treatment issues highlighted through a case illustration. Bulletin of the Menninger Clinic, 74(2), 122–140. Retrieved from http://guilfordjournals.com/toc/bumc/74/2 Hitchcock, P. B., & Mathews, A. (1992). Interpretation of bodily symptoms in hypochondriasis. Behaviour Research and Therapy, 30, 223–234. doi:10.1016/0005-7967%2892%2990068-R Improving Access to Psychological Therapies (IAPT) and National Health Service (NHS). (2011). The IAPT data handbook. Retrieved May 1, 2011, from http://www.iapt.nhs.uk/silo/files/iaptdata-handbook-v2.pdf Kroenke, K., Spitzer, R. L., & Williams, J. B. W. (2001). The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16, 606–613. Retrieved from http:// www.ncbi.nlm.nih.gov/pubmed/11556941 Kroenke, K., Spitzer, R. L., & Williams, J. B. W. (2002). The PHQ-15: Validity of a new measure for evaluating the severity of somatic symptoms. Psychosomatic Medicine, 64, 258–266. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/11914441 Löwe, B., Decker, O., Müller, S., Brähler, E., Schellberg, D., Herzog, W., & Herzberg, P. Y. (2008). Validation and standardization of the generalized anxiety disorder screener (GAD-7) in the general population. Medical Care, 46, 266–274. doi:10.1097/MLR.0b013e318160d093 MacSwain, K. L. H., Sherry, S. B., Stewart, S. H., Watt, M. C., Hadjistavropoulos, H. D., & Graham, A. R. (2009). Gender differences in health anxiety: An investigation of the interpersonal model of health anxiety. Personality and Individual Differences, 47, 938–943. doi:10.1016/j. paid.2009.07.020 Marcus, D. K., & Church, S. E. (2003). Are dysfunctional beliefs about illness unique to hypochondriasis? Journal of Psychosomatic Research, 54, 543–547. doi:10.1016/S0022-3999% 2802%2900526-3 Muse, K., McManus, F., Leung, B., Meghreblian, T., & Williams, J. M. G. (2012). Cyberchondriasis: Fact or fiction? A preliminary examination of the relationship between health anxiety and searching for health information on the Internet. Journal of Anxiety Disorders, 26, 189–196. doi:10.1016/j.janxdis.2011.11.005 Rode, S., Salkovskis, P., Dowd, H., & Hanna, M. (2006). Health anxiety levels in chronic pain clinic attenders. Journal of Psychosomatic Research, 60, 151–161. doi:10.1016/j. jpsychores.2005.07.005 Salkovskis, P. M., Rimes, K. A., Warwick, H. M. C., & Clark, D. M. (2002). The health anxiety inventory: Development and validation of scales for the measurement of health anxiety and hypochondriasis. Psychological Medicine, 32, 843–853. doi:10.1017/S0033291702005822 Spitzer, R. L., Kroenke, K., Williams, J. B. W., & Lowe, B. (2006). A brief measure for assessing generalized anxiety disorder the GAD-7. Archives of Internal Medicine, 166, 1092–1097. Retrieved from http://archinte.ama-assn.org/cgi/content/abstract/166/10/1092 Tabachnick, B. G., & Fidell, L. S. (2007). Using multivariate statistics (5th ed.). New York, NY: Pearson Education. Tustin, N. (2010). The role of patient satisfaction in online health information seeking. Journal of Health Communication, 15, 3–17. doi:10.1080/10810730903465491 van Ravesteijn, H. V., Wittkampf, K., Lucassen, P., van de Lisdonk, E., van den Hoogen, H., van Weert, H., … Speckens, A. (2009). Detecting somatoform disorders in primary care with the PHQ-15. Annals of Family Medicine, 7, 232–238. doi:10.1370/afm.985 Warwick, H. M. C. (1989). A cognitive-behavioural approach to hypochondriasis and health anxiety. Journal of Psychosomatic Research, 33, 705–711. doi:10.1016/0022-3999%2889% 2990086-X Warwick, H. M., & Salkovskis, P. M. (1990). Hypochondriasis. Behaviour Research and Therapy, 28(2), 105–117. doi:10.1016/0005-7967(90)90023-C
554
K. Singh and R.J. Brown
Downloaded by [Marquette University] at 01:56 19 August 2014
Weaver III, J. B., Mays, D., Weaver, S. S., Hopkins, G. L., Eroglu, D., & Bernhardt, J. M. (2010). Health information – seeking behaviors, health indicators, and health risks. American Journal of Public Health, 100, 1520–1526. doi:10.2105/AJPH.2009.180521 Wells, A. (1997). Cognitive therapy of anxiety disorders: A practice manual and conceptual guide. Chichester: John Wiley & Sons. Whang, L. S. M., Lee, S., & Chang, G. (2003). Internet over-users’ psychological profiles: A behavior sampling analysis on Internet addiction. CyberPsychology and Behavior, 6, 143–150. doi:10.1089/109493103321640338 White, R. W., & Horvitz, E. (2009). Cyberchondria: Studies of the escalation of medical concerns in web search. ACM Transactions on Information Systems, 27(4), 1–37. Retrieved from http://research.microsoft.com/en-us/um/people/ryenw/papers/WhiteTOIS2009.pdf Young, K. S. (1998). Internet addiction: The emergence of a new clinical disorder. CyberPsychology and Behavior, 1, 237–244. doi:10.1089/cpb.1998.1.237
