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ORIGINAL ARTICLE
The Role of Health Anxiety in Online
Health Information Search
Susanne E. Baumgartner, M.A.,
1
and Tilo Hartmann, Ph.D.
2
Abstract
This article is one of the first to empirically explore the relationship between health anxiety and online health
information search. Two studies investigate how health anxiety influences the use of the Internet for health
information and how health anxious individuals respond to online health information. An exploratory survey
study with 104 Dutch participants indicates that health anxiety is related to an increase in online health infor-
mation search. Moreover, results suggest that health anxious individuals experience more negative conse-
quences from online health information search. Findings from an experimental study (n=120) indicate that
online health information results in greater worries among health anxious individuals compared to nonhealth
anxious individuals only if the information stems from a trustworthy governmental Web site. Information from
a less trustworthy online forum does not lead to greater worries among health anxious individuals. In sum, the
Internet appears to play a pivotal role in the lives of health anxious individuals.
The Role of Health Anxiety in Online Health
Information Search
The Internet has become an important source of health
information.
1–3
Despite increasing numbers of online
health information seekers,
4,5
little is known about their
psychological characteristics. Most studies focused on socio-
demographic determinants of online health information
seeking,
2,6–10
the expectations, or the health status of
users.
11,12
For example, Rice
12
has shown that medical con-
ditions predict the search for health information online.
However, online health search may be determined not only
by the actual health status of the users but also by their fears of
having a serious illness.
13
Fear of having or developing a
serious illness is known as health anxiety and, in its extremest
form, hypochondriasis.
14
Health anxious individuals are
preoccupied with thoughts about illnesses.
15,16
This preoc-
cupation is commonly associated with a need to search for
health information.
17
The Internet may serve as an easy ac-
cessible source to satisfy this need.
This article is one of the first to empirically explore the
relationship between health anxiety and online health infor-
mation search. Eastin and Guinsler found that health anxiety
moderates the relationship between online health informa-
tion seeking and health care utilization decisions.
13
The
present studies explore if users’ health anxiety predicts online
health information seeking and the psychological conse-
quences associated with obtained online health information.
Health Anxiety and the Use of Online Health Information
Health anxiety refers to fears that arise from misinterpre-
tations of bodily symptoms as indicating severe illnesses.
18,19
To reduce their fears, health anxious individuals tend to
perform safety behaviors.
17
These behaviors are intended to
reassure the individual of being healthy and include the in-
tensive search for health information.
20
Alongside checking
physical symptoms or asking a medical expert, health anx-
ious individuals may search the Internet for information re-
lated to their presumed illness. While every Internet user may
search for health information, we assume that the need to
search for online health information is greater among health
anxious individuals. Not only may health anxious individu-
als search for more health information online, but they may
also more actively engage in health-related activities online,
including posting of health-related messages and responses.
Therefore, we pose the following hypotheses:
H1: Health anxiety is related to increased levels of online
health information search
H2: Health anxiety is related to actively posting health-
related information online
Consequences of Online Health Information
for Health Anxious Individuals
If health anxious individuals search the Internet for health
information more frequently than individuals with normal
1
Amsterdam School of Communication Research, University of Amsterdam, Amsterdam, The Netherlands.
2
Department of Communication Science, VU University Amsterdam, Amsterdam, The Netherlands.
CYBERPSYCHOLOGY,BEHAVIOR,AND SOCIAL NETWORKING
Volume 00, Number 00, 2011
ªMary Ann Liebert, Inc.
DOI: 10.1089/cyber.2010.0425
1
health beliefs, the question remains as to how online health
information affects health anxious individuals. According to
cognitive-behavioral theory of health anxiety,
21
health anx-
ious individuals respond differently to health-related infor-
mation compared to nonhealth anxious individuals. Health
anxious individuals misinterpret illness-related information
as more catastrophic and perceive themselves to be at greater
risk for medical complications than nonhealth anxious indi-
viduals.
22
They also tend to overestimate the seriousness of
an illness when judging ambiguous health-related scripts.
23
Health anxiety is further characterized by an inability to be
reassured by physicians
24
or by information indicating good
health.
25
These findings have implications for online health infor-
mation search. When confronted with health information,
health anxious individuals may not only pay more attention
to this information but may also be more easily worried.
13,26
Further, regardless of what illness they presume to have, they
may find and interpret information online in support of their
anxiety. Therefore, we hypothesize:
H3: Health anxiety is related to more negative responses to
online health information
It may be argued that the effects of online health infor-
mation on health anxious individuals may be moderated by
the credibility of the source. The quality and credibility of
online health information has been criticized in the past.
2,27,28
A majority of online health information has shown to be of
low quality or barely credible.
29
Source credibility has been
shown to moderate the effect of health information. In gen-
eral, online information from a trustworthy source has a
stronger impact than online information from an untrust-
worthy source.
30
It has been argued, however, that health anxious individ-
uals struggle to account for the trustworthiness of an online
source when responding to health information.
31
If this is the
case, health anxious individuals may be equally worried by
online health information from both trustworthy and less
trustworthy sources. Therefore, we propose:
H4: Health anxiety is related to more negative responses to
health information provided by both trustworthy and less
trustworthy sources
More specifically, we expect that under conditions of both
high and low trustworthiness, health anxious individuals will
deem information about a disease more relevant, overesti-
mate the likelihood that they are afflicted, suspect that they
will get the disease in the future, and feel more worried about
the disease.
Study 1
An online survey was conducted to test H1 to H3.
Method
Sample and procedure. To assess the influence of health
anxiety on online health information search in the normal
population, we used a convenience sample of nonclinical
participants. The study was promoted in university classes of
a Dutch university and participants were encouraged to for-
ward the questionnaire to friends and relatives. Participants
ranged from 18 to 30 years of age (M=21.02, SD =2.19). Most
participants were university students (49 percent) or followed
a study in higher professional education (22 percent) or pre-
paratory scientific education (20 percent). Of the final sample
(n=104), 67 percent were females. The majority of partici-
pants (89.5 percent) used the Internet at least 6 days a week.
In sum, the sample consisted of highly educated young adults
with high levels of Internet use.
Measures. Health Anxiety: To measure health anxiety
we used the Whitely Index.
32
This 14-item scale is the most
widely used self-report inventory of hypochondriacal ten-
dencies.
33
Answering categories ranging from 1 (not true at all)
to 4 (absolutely true) were used, instead of the original di-
chotomous answering categories. Health anxieties are pro-
posed to occur along a continuum,
14,16
which may be better
reflected by response categories ranging from 1 to 4 than by
dichotomous response categories. The additive scale resulted
in a good Chronbach’s alpha of 0.89. Participants’ scores
ranged from 1.00 to 3.43 (M=1.74, SD =0.55).
Online health information search: Searching for health
information online was measured with the question, ‘‘How
often do you search the Internet for health information con-
cerning your own health?’’ Response categories ranged from
1(never)to9(every day)(M=2.99, SD =1.42).
Posting of health-related information: To assess respon-
dents’ posting of health information via online forums, we
asked participants, ‘‘How often did you post questions or
answers in an online health forum in the last year?’’ with
responses ranging from 1 (never)to5(very often)(M=1.14,
SD =0.51). A total of 9.6 percent of all respondents reported
having posted at least once in online health forums in the last
year.
Consequences of obtaining health-related information: The
perceived consequences of online health information search
were assessed using six statements (true/not true) (adapted
from the Pew Internet & American Life Project
27
). We asked
participants to indicate how they felt after their last online
health information search: overwhelmed by the amount of
information they found online; confused by the information
they found online; frustrated by a lack of information or an
inability to find what they were looking for online; frightened
by the serious or graphic nature of the information they found
online; relieved or comforted by the information they found
online; reassured that they could make appropriate health
care decisions.
Control variables: Alongside demographic variables, we
included two additional control variables, amount of Internet
use and working in the health sector. Participants indicated
how many days per week they used the Internet. Response
categories ranged from 0 (never)to7(7 days)(M=6.55,
SD =0.90). Participants also indicated how many hours per
day they used the Internet (M=2.54, SD =1.32). Both vari-
ables were multiplied to calculate the number of hours per
week each participant used the Internet (M=16.88, SD =9.42).
Additionally, participants indicated whether or not they
worked in the health sector.
Results
H1 predicted a positive relationship between health anxi-
ety and frequency of online health information search. Like-
wise, H2 stated that health anxiety is related to increased
2 BAUMGARTNER AND HARTMANN
levels of posting information online. Regression analyses re-
vealed that health anxiety was strongly associated with the
search for health information online (b=1.17, b=0.46,
t(96) =5.05, p<0.01) and the active posting of health-related
information online (b=0.42, b=0.45, t(96) =4.92, p<0.01). In
both regressions we controlled for gender, age, education,
amount of Internet use, and working in the health sector. H1
and H2 were supported.
H3 predicted that health anxiety is related to more negative
responses to online health information. A series of logistic
regressions with the six dichotomous consequence items as
dependent variables were conducted. All control variables
were included in the regression. Health anxiety was most
strongly related to feeling frightened by the seriousness of the
information found online (OR =12.52, 95% CI =3.63–43.23,
p<0.01). Moreover, health anxiety predicted feeling over-
whelmed (OR =6.24, 95% CI =1.91–20.38, p<0.01) and con-
fused (OR =4.04, 95% CI =1.49–10.93, p<0.01) by the amount
of information found online. Finally, health anxiety predicted
feeling frustrated by a lack of information (OR =3.13, 95%
CI =1.09–9.02, p<0.05). No relationship between health anx-
iety and the positive consequences of online health informa-
tion search (feeling relieved or reassured) was found. H3 was
supported.
Study 2
To test H4, which stated that health anxiety is related to
negative responses to online health information provided by
both trustworthy and less trustworthy sources, a one-factorial
(trustworthy vs. less trustworthy source) between-subjects
online experiment was conducted.
Method
Sample. Participants were recruited via an online infor-
mation system of a Dutch university. The final sample con-
sisted of 120 participants. About 57 percent of the participants
had obtained their highest degree in higher general continued
education or preparatory scientific education, and about 24
percent in higher professional or scientific university educa-
tion. Participants ranged from 17 to 68 years of age (M=24.17,
SD =8.66), with 65.8 percent females.
Procedure. Initially, participants’ levels of health anxiety
were assessed. Thereafter, participants read an online text
about a fictitious bacterial disease named ‘‘Lienalis.’’ The text
described the case of a Dutch individual who felt tired and
listless, got stomach ache, and was finally diagnosed with
Lienalis. The text continued to provide factual information
about the bacterial disease so that participants learnt that
Lienalis is associated with typical symptoms like stomach
ache, loss of appetite, and changes in frequency of bowel
movements (Appendix).
To manipulate trustworthiness, the text was presented ei-
ther as an official announcement on the Dutch Public Health
Service Web site (trustworthy source) or as a user posting on
a popular Dutch health forum (less trustworthy source). In-
ternet users tend to judge online health announcements from
a knowledgeable expert as most credible.
2,28
Health an-
nouncements by official authorities are thus considered par-
ticularly trustworthy.
29
Participants were randomly assigned
to one of the two conditions. After reading the online
health information, participants were asked about the trust-
worthiness of the online source, and how much they worried
about Lienalis. At the end of the experiment, participants
were debriefed and informed that Lienalis was not a real
disease.
Measures. Health Anxiety: As in Study 1, health anxiety
was measured on a 4-point scale with the 14-items of the
Whitely Index (a=0.86; M=1.79, SD =0.52).
Trustworthiness of online health information: To measure
participants’ trust in the online source, we asked them to
indicate their agreement with eight items taken from a
trustworthiness scale.
2
Participants responded to all items on
a 5-point scale ranging from 1 (do not agree at all)to5(abso-
lutely agree). All items were collapsed into a mean index
(a=0.86; M=3.16, SD =0.65).
Negative responses to online health information: Four
items measured participants’ negative responses to the in-
formation presented online about Lienalis. Participants were
asked to estimate on a 5-point scale the chances that they
were currently suffering from Lienalis (1 (very low chance)to5
(very high chance); M=1.59; SD =0.89) or that they will get
Lienalis in the future (1 (very low chance)to5(very high chance);
M=1.84; SD =0.93). We also asked participants to rate on a 5-
point scale how much they felt worried right now about
Lienalis (1 (not worried at all)to5(very much worried); M=1.9;
SD =0.95) and how relevant they found the information
about the new disease (1 (not relevant at all)to5(very relevant),
M=2.91; SD =0.97).
Results
Treatment check
Confirming a successful manipulation, participants trusted
online health information more when it was presented on the
public health service Web site (M=3.39; SD =0.59) than when
it was presented on the health-related online forum (M=2.9;
SD =0.63; t(118) =4.32; p<0.01).
Hypothesis testing
We tested H4 with four moderated regressions.
34
The four
variables reflecting participants’ negative responses were re-
gressed in separate hierarchical regressions on health anxiety
(mean-centered) and trustworthiness (contrast-coded) in a
first step, and on an interaction term of both variables in a
second step. Results are displayed in Table 1.
In line with H4, we expected significant simple effects of
health anxiety on the dependent variables under both trust-
worthy and less trustworthy conditions. However, in contrast
to our expectations, results showed that health anxiety in-
creased negative responses to health information obtained
from a trustworthy source, but not from a less trustworthy
source. The regression analyses (Step 1, see Table 1) suggest
that health anxiety is a significant positive predictor of par-
ticipants’ perceived relevance of the information (b=0.36,
t(116) =2.10, p<0.05), estimations of being already infected by
Lienalis (b=0.56, t(116) =3.81, p<0.01), perceived risk of be-
ing infected in the future (b=0.63, t(116) =4.14, p<0.01), and
worrying about Lienalis (b=0.59, t(116) =3.66, p<0.01).
However, in all four regressions, the trustworthiness ·health
anxiety interaction term also emerged as an additional
HEALTH ANXIETY AND ONLINE HEALTH INFORMATION 3
significant predictor of participants’ negative responses (see
Table 1). This suggests that the trustworthiness of an online
source moderates the influence of health anxiety on negative
responses to online health information.
To examine this moderation more closely we conducted
simple slope analyses. These analyses revealed that health
anxiety led to more negative responses to online health
information obtained from a trustworthy source (relevance:
b=0.70, p<0.01; chance of being already infected: b=0.94,
p<0.01; chance of getting infected: b=1.02, p<0.01; worry
about disease: b=0.99, p<0.01). However, health anxiety
did not lead to more negative responses to online health
information obtained from a less trustworthy source (for all
four negative response variables bp0.19, pq0.39). Figure 1
illustrates this simple slope pattern for participants’ esti-
mated chance of getting infected with Lienalis. The patterns
obtained for the three other negative response variables
were almost identical. Taken together, participants’ health
anxiety resulted in more negative responses to the pre-
sented health information, but only when this information
stemmed from a trustworthy online source. H4 was thus
not supported.
Discussion
Despite public concerns and speculations concerning the
role of online health information for health anxious individ-
uals,
35
this relationship has rarely been investigated empiri-
cally. We initially fill this research gap by presenting two
studies examining how health anxiety may influence online
health information use and its consequences in a nonclinical
sample.
The studies have three main findings. First, health anxiety
was related to an increased use of online health information.
Individuals who showed tendencies toward health anxiety
utilized the Internet as a means to satisfy their health infor-
mation needs. Individuals with higher levels of health anxiety
were also more likely to actively post health-related questions
and responses via online health forums. This finding, how-
ever, awaits replication because only a few participants in our
sample posted information online.
A second finding of this study was that health anxiety was
related to more negative responses toward online health in-
formation. In general, health anxious individuals appeared
more frightened by the seriousness of online information and
less reassured. This may indicate a reinforcing downward
spiral.
36
Health anxiety may lead individuals to search the
Internet for reassuring information. However, the informa-
tion they find may provide more reasons to be concerned.
Health-related worries may therefore be maintained rather
than diminished by online health information search. This
finding complements past research and suggests that health
anxious individuals follow a threat-confirming strategy
37
that
heightens their responsiveness to alarming information and
makes them relatively immune to reassuring information.
However, the final finding of our studies was that health
anxiety only resulted in more negative responses to online
health information obtained from a trustworthy online
source, and not from a less trustworthy source. This finding
suggests that health anxiety is not triggered by any kind of
online information but only by information stemming from
trustworthy sources. The relationship between trust and
health anxiety in the context of health information search
should be investigated in more detail in future studies. For
instance, which sources are perceived as trustworthy may
differ considerably among individuals as has been shown in
previous research.
38,39
Thus, the Web sites health anxious
Table 1. Results of the Hierarchical Regression Analysis of Trustworthiness
of Online Health Information Regarding a New Disease and Health Anxiety on Negative Responses
(Relevance, Chances of Having Disease, Worrying About Disease) (n=120)
Negative responses
Relevance Chance now Chance future Worry
Variable b SE B B SE B b SE B B SE B
Trustworthiness 0.24** 0.09 0.14
{
0.08 0.13
{
0.08 0.11 0.08
Health anxiety 0.36* 0.17 0.56** 0.15 0.63** 0.15 0.59** 0.16
Trustworthiness ·health anxiety 0.38* 0.17 0.41** 0.14 0.41** 0.15 0.43** 0.16
Coefficients for trustworthiness and health anxiety were obtained in Step 1 of the regression. Coefficients for the interaction term were
obtained in Step 2 of the regression. Relevance =perceived relevance of presented online information regarding Lienalis (R
2
Step 1 =0.09**, DR
2
Step 2 =0.04*), chance now =reported chance of having Lienalis (R
2
Step 1 =0.13**, DR
2
Step 2 =0.06**), chance future =reported chance of getting
Lienalis in the future (R
2
Step 1 =0.14**, DR
2
Step 2 =0.05**), worry =worrying about Lienalis (R
2
Step 1 =0.11**, DR
2
Step 2 =0.06**).
{
p<0.1. *p<0.05. **p<0.01 (two-tailed).
FIG. 1. Influence of health anxiety and trustworthiness of
online source on participants’ estimated chance of being in-
fected with Lienalis.
4 BAUMGARTNER AND HARTMANN
individuals perceive as trustworthy may differ among
subgroups of Internet users. Moreover, in the present exper-
iment, participants were not explicitly searching for infor-
mation regarding their health, but instead were confronted
with information about a specific disease. Trust perceptions
may differ when people are concerned with their own health
and are desperately searching for helpful information online.
In that case, people may also judge information from informal
sources as trustworthy and helpful.
Limitations
The findings must be interpreted within the studies’ limi-
tations. The two studies were conducted with small conve-
nience samples of Internet users. The samples included highly
educated young adults, who are typically characterized as
defining users of the Internet.
40
We cannot exclude the pos-
sibility that health anxious individuals from other samples
(e.g., older individuals) will use different health information
strategies. However, it may be concluded that health anxious
Internet users use the Internet more to gain health-related
information. Moreover, levels of health anxiety in our studies
were rather mild. Replicating these findings with larger
samples and with individuals with more extreme forms of
health anxiety (e.g., clinical hypochondriasis) would be de-
sirable to further advance this new area of research.
Acknowledgments
We thank Annemieke Lamers, Steffie Wozniak, Deborah
van Unen, and Jan-Kees Schep for their research assistance.
Author Disclosure Statement
No competing financial interests exist.
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Address correspondence to:
Susanne E. Baumgartner, M.A.
Amsterdam School of Communication Research
University of Amsterdam
Kloveniersburgwal 48
1012 CX Amsterdam
The Netherlands
E-mail: s.e.baumgartner@uva.nl
Appendix
A New Disease: Lienalis (Stimulus Text About Fictitious
Disease Applied in Study 2 [Translated from Original
Dutch Version])
When Marjolein de Wit (name changed to protect privacy)
woke up in her apartment in Utrecht 3 months ago, she felt
tired, listless, and suffered from stomach pain. ‘‘I’ve been
having an uncomfortable feeling in my stomach for a week,
but that morning I had real pain,’’ said Marjolein. ‘‘Strangely
enough, I could still eat normally during the last week, de-
spite suffering from these pains.’’ At first, Marjolein did not
worry much about the stomach pain. ‘‘I did not think it would
be anything serious and that it was due to stress.’’ That
morning, however, Marjolein discovered traces of blood in
her excrements and decided to see a doctor. This was a good
decision because the doctor diagnosed that Marjolein was
suffering from a recently discovered disease: Lienalis.
This new disease has been discovered recently by the
Dutch Center for Disease Control. In many cases Lienalis is
lethal. Lienalis leads to an intestinal hyperacidity, which in
turn severely decreases the bowel functions.
Further research is still needed to uncover what exactly
causes Lienalis. However, from existing research, it seems
that a typical Western diet—low in fiber and high in animal
fats—may contribute to this disease. Other factors such as
excessive alcohol intake, obesity, and insufficient physical
exercise may also stimulate Lienalis.
Patients who are suffering from Lienalis typically report
the following symptoms:
change in the frequency of passing motion
blood in the excrements
stomach pain
intestinal pain
less appetite
congestion
No cure has yet been discovered for Lienalis, but with the
right medication the intestinal hyperacidity can be deceler-
ated. It is strongly advised to consult a physician whenever
two or more of the above-mentioned symptoms are experi-
enced.
6 BAUMGARTNER AND HARTMANN
