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Health anxiety and cyberchondria among Ege University health science students
Nurse Education Today 71 (2018) 169–173
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Nurse Education Today journal homepage: www.elsevier.com/locate/nedt
Health anxiety and cyberchondria among Ege University health science students
T
Ayse Hilal Batia, , Aliye Mandiracioglub, Figen Govsac, Olcay Çamd ⁎
a
Department of Medical Education, Faculty of Medicine, Ege University, Izmir, Turkey Department of Public Health, Faculty of Medicine, Ege University, Izmir, Turkey c Department of Anatomy, Faculty of Medicine, Ege University, İzmir, Turkey d Olcay Çam, Department of Psychiatry, Faculty of Nursing, Ege University, İzmir, Turkey b
ARTICLE INFO
ABSTRACT
Keywords: Health sciences student Health anxiety Cyberchondria
It is common among health science students to incorrectly believe that they have contracted certain diseases they have recently studied. This can also be seen in the form of health anxiety and investigating health-related information via the internet. Health anxiety, cyberchondria and affecting factors are determined among health science students. The study was conducted at the faculties of Medicine, Pharmacy, Dentistry and Nursing in 2016–2017 with the participation of 874 students. The data were gathered using a questionnaire as well as health anxiety and cyberchondria severity scales. In the presence of a health problem, 14.2% of students seek health information via the internet. 83.7% use mobile phone to access the internet, ¼ of students conduct health scanning once a week or more. To 65.4%, internet information is correct at medium and above level. No statistically significant difference was found with respect to students' gender, high school, places they lived before, parents' education and scales' scores. The cyberchondria scores of students with health problems are higher in the whole scale and in “distress and mistrust of medical professional” subscales. As the frequency of scanning on the internet increases, the scores of cyberchondria also increase significantly. Medical students had significantly higher scores in “distress, excessiveness and reassurance” subscales. Male students' “mistrust of medical professional and compulsion” subscales scores were also higher. It was determined that the presence of the health problem was effective on the cyberchondria. Identification of somatoform problems like health anxiety and cyberchondria may help to regulate the education program.
1. Introduction and Objective Advances in modern technology and the increase in internet usage have enabled greater number of people to access the internet. It was found that 85% of the adult population of the USA was internet users in 2013. According to data released by the Turkish Statistical Institute, 66.8% of Turkey's population is internet users (“Turkish Statistical Institute Household Usage of Information Technologies Survey”, 2017). Internet usage is the highest in the group comprising people between ages of 16 and 24 (91.5% in males and 82.9% in females). According to educational levels, 89.8% of the internet users in Turkey are high school and vocational high school graduates while 97% are graduates of university undergraduate, master's and doctorate programs. The highest percentage of internet usage was observed in professional occupational groups with 99.3% (“Turkish Statistical Institute Household Usage of ⁎
Information Technologies Survey”, 2016). As the widespread and intensive use of the internet have provided people easy and free access to information, the internet has become a popular source of accessing online health information (McElroy and Shevlin, 2014; Yılmaz, 2013). International studies have shown that a great number of people manage their own health based on health-related information they get online. In Turkey, the percentage of seeking personal health related information online was 65.9% during the first three months of 2016. Despite the fact that an online environment provides extensive and easy access to information through a myriad of sources, it often creates problems concerning access to up-to-date, reliable, efficient and accurate information (Lewis, 2006; Singh et al., 2004; “Türkiye İstatistik Kurumu 2016 yılı Hanehalkı Bilişim Teknolojileri Kullanım Araştırması (Turkish Statistical Institute Household Usage of Information Technologies Survey for the year 2016”, 2016) because seeking health information is
Corresponding author at: Ege University, Faculty of Medicine, Department of Medical Education, 35100 Bornova-Izmir, Turkey. E-mail address: [email protected] (A.H. Bati).
https://doi.org/10.1016/j.nedt.2018.09.029 Received 20 March 2018; Received in revised form 4 September 2018; Accepted 25 September 2018 0260-6917/ © 2018 Published by Elsevier Ltd.
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an important coping strategy, people continue to search for information; however, sources they use and how they do this demonstrate variations. Online sources meet the information needs of the patients and their relatives prior to consulting a physician with respect to up-to-date medical information, newly diagnosed diseases and treatment methods, advanced medical devices. Information often obtained using general search engines may be effective in decision making by healthy or sick individuals related to maintaining their health, engaging a physician's assistance concerning diagnosis and treatment, treating an acute illness and coping with chronic problems. Information obtained from official and other reliable sources provides various benefits such as understanding symptoms, deciding on the urgency and necessity of consulting a physician, turning to the correct area of specialty for the health problem and obtaining accurate information. Unofficial and unreliable sources, on the other hand, lead to incomplete and incorrect information; thus aggravating health anxiety depending on the problem being experienced (Doherty-Torstrick et al., 2016; White and Horvitz, 2009; Yılmaz, 2013). It is known that individuals with frequent online medical information seeking demonstrate elevated health anxiety concerns (Norr et al., 2014). These people often investigate rare, uncommon and dreadful medical conditions (Uzun, 2016). When online sources are perceived as reliable, likelihood of developing health concerns increases (Singh and Brown, 2014). Milder form of health concern may direct individuals to get medical assistance but may lead to excessive grief and development of negative social and occupational functions (Pugh et al., 2013). In a review by B. Zülfikar investigating the online health-related attitudes and behaviour, it was determined that more than half of the individuals who scanned online health information had benefited from this procedure which strengthened the process of decision- making concerning certain diseases and helped them in their contacts with their doctors. However, problems related to compulsion and reliability of the information obtained were also observed in the management of some diseases (Zülfikar, 2014). Health anxiety is a psychological state in which somatic and mental concerns are stimulated by health-related threat perceptions. It describes negative interpretation of normal and abnormal somatic sensations and fear. In other words, the individual thinks that s/he has a serious health problem and that this problem will cause negative consequences. Health anxiety is common not only among individuals with somatoform and psychological disorder but also among normal people. Mild health anxiety experienced by many people is a tolerable situation that will go away on its own. Severe health anxiety, on the other hand, indicates basic psychiatric disorders such as hypochondriasis or health phobia. It is thought that health-related unconcern, anxiety and hypochondriasis display successive consistency (Aydemir et al., 2013; Hadjistavropoulos et al., 2012; Ünalan, 2014; Welch et al., 2009; Zhang et al., 2014). Young people starting higher education try to adapt to university environment while coping with problems of adolescence. Especially factors such as living away from the family, adaptation to university life and conditions, new and different friends and financial problems inevitably have an impact on physical and mental health in a period when individual responsibilities and personalities are shaped (Ünalan, 2014). An online environment has become a more frequently-used alternative for sexual and mental problems young people cannot discuss face to face or prefer to keep secret. When health anxiety is high, online environments are used more frequently and concerns increase following the internet search (Singh and Brown, 2014). Furthermore, medical students are under constant stress associated with intense study sessions, heavy work load, a competitive environment and new clinical experiences. This stress intensifies somatic sensations with autonomic activations and causes them to be perceived as symptoms. It is thought that medical students conceptualize some symptoms with new information they learn and interpret them as
medical evidence. Thus, clinical teachers report that they are often faced with fear and symptoms of illness in medical students. Such reactions termed as medical student's disease, nosophobia, or medical student's hypochondria are often conceptualized as a mild form of health anxiety or transient hypochondriasis. Medical students who believe they have contracted a certain disease identify cases more easily and selectively as they readily arouse interest and stay in their mind. It can be considered that this condition may also be true not only for medical students but also for all the students studying in health sciences including nursing, pharmacy and dentistry. Online health information seeking behaviour may become steady with the fear that one has or will develop a serious disease. Studies conducted have shown that this increases health anxiety and may lead to cyberchondria which is described as a severe form of anxiety associated with the escalation of distress and anxiety (Doherty-Torstrick et al., 2016; Muse et al., 2012). Cyberchondria is a form of anxiety characterized by excessive online health research (McElroy and Shevlin, 2014; White and Horvitz, 2009). Following its widespread use in the media, the term cyberchondria emerged in the medical literature in the 2000's (Uzun, 2016). Although the number of related studies is limited, cyberchondria is thought to be quite common in our country as well (Uzun et al., 2017). The aim of the present study is to determine the factors affecting cyberchondria and health anxiety levels in health sciences students. 2. Material and Method 2.1. Research Design and Research Group The present cross-sectional study comprised second-year students enrolled in four health science faculties of Ege University in the academic year 2016–2017. There were totally 1085 second-year students in faculties (498 Medicine, 110 Pharmacy, 182 Dentistry, 295 Nursing) and we tried to reach all of the students. A total of 874 students (412 Medicine, 80 Pharmacy, 144 Dentistry, 238 Nursing) were recruited for participation on a voluntary basis. The response rate was 80.56%. 2.2. Data Collection Devices Research data was collected anonymously, by the faculty members after approval from the Ege University Scientific Research and Publication Ethics Board as well as from the administrations of related faculties was obtained. Prior to this, necessary explanations for the research group were made both verbally and in writing. The Health Anxiety Inventory and the Short Form version of the Cyberchondria Severity Scale as well as a questionnaire form prepared by researchers were used as data collection devices. The questionnaire was composed of 10 items questioning attitudes and behaviour towards checking health information online in the presence of a medical problem in addition to sociodemographic characteristics. Students filled in the data collection tools themselves. 2.2.1. Health Anxiety Inventory The Health Anxiety Inventory was developed by P.M. Salkovskis et al. to measure a broad range of health anxiety symptoms. The inventory is composed of 18 self-report questions. The main section (the first 14 items) associated with excessive sensitivity to somatic symptoms and distress dimension contains four sequential statements questioning the mental state. The negative consequences section (the remaining 4 items) questions people's attitudes towards how awful it would be if they were to develop a serious disease. Each item of the inventory is scored on a 0–3 basis and scores of each item are added together for a total score ranging from 0 to 54. The higher score indicates the higher health anxiety level. The short form can be used in health scanning; furthermore, the inventory can help differentiate hypochondriasis from anxiety disorders and identify actual physical 170
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illnesses. The Health Anxiety Inventory was adapted to Turkish by Aydemir et al., reliability and validity analyses of the Turkish version of the inventory were performed in a sample of out-patients with somatoform disorder and panic disorder and university students (Aydemir et al., 2013; Salkovskıs et al., 2002).
Table 1 Characteristics of the students participating in the study.
Faculty
2.2.2. Cyberchondria Severity Scale Short Form Cyberchondria Severity Scale (CSS) was originally developed by McElroy and Shevlin in 2014 in a sample of university students to assess cyberchondria. A brief version with 15 items was developed (CSS-15) and validated by Barke et al. in 2016. It was adapted to Turkish, and reliability and validity analyses of the Turkish version of the inventory were performed by Uzun et al. in a sample of university students. CSS15 comprises five subscales including compulsion, distress, excessiveness, reassurance, mistrust of medical professional. The scale contained 15 times each consisting of a 5 point Likert-scale indicating frequency (1 ‘Never’, 2 ‘Rarely’, 3 ‘Sometimes’, 4 ‘Often’ and 5 ‘Always’). Scores that can be obtained from the scale range between 15 and 75 (Barke et al., 2016; McElroy and Shevlin, 2014; Uzun, 2016; Uzun et al., 2017).
Gender Education level of parents
Residence
Medium of Internet access
2.3. Data Analysis
Presence of health problem In case of a health problem
SPSS 18.0 statistical software program was used to evaluate data and p < 0.05 was accepted as a significant value. After descriptive statistics were performed, t-test and ANOVA were used to determine the relationship between inter-scale correlation scale scores and sociodemographic characteristics of the students. 3. Findings
Frequency of online health scanning
The mean age of the study group was 20.33 ± 1.4 and 64.2% of them were females. The education level of the family (mothers 57.3% and fathers 69.3%) is generally high school and above. The percentage of students who spent most of their lives in cities and metropolises was 58.7%. 83.7% of the students use mobile phones to access the Internet and ¼ perform health scanning once a week or more frequently. In the presence of a health problem, 40.3% expected it to go away on its own, 25% visited the nearest doctor, and 14.2% reported that they would try to understand the problem by investigating on the internet. The percentage of the students who stated that online health information was not accurate was 34.5% and the mean score was 2.74 ± 0.80 when the validity was rated on a 5 point Likert-scale indicating frequency (1 ‘Never’, 2 ‘Rarely’, 3 ‘Sometimes’, 4 ‘Often’ and 5 ‘Always’). The characteristics of the students are shown in Table 1, and the students' health anxiety and cyberchondria severity scale scores are shown in Table 2. It has been determined that there is a moderate correlation between cyberchondria and health anxiety scales according to a four-point scale (Pearson Correlation: 0.325 p: 0.000). No statistically significant relationship was found between the students' faculty, gender, school they graduated from, previous place of residence, education levels of parents and the total scores from the scale. The health anxiety scale total score (t: 3.882 p: 0.00) and the cyberchondria scale distress score of the students with health problems were higher than the others. As the frequency of online health scanning increased, the health anxiety scores (F: 4.803 p: 0.008) and the cyberchondria scores (F: 19.010 p: 0.00) also showed a significant increase. Excessive sensitivity to somatic symptoms and distress scores (F: 50.891 p: 0.000) and the cyberchondria scale scores (F: 3.927 p: 0.020) of the students who do not believe in the accuracy of the online information they obtain on the internet are comparatively lower. The male students' scores on the subscales of compulsion and mistrust of medical professional were found to be higher. While there was no relationship between the students' faculties and health anxiety scores, cyberchondria scale scores of the medical faculty students were significantly low (F:3.757 p:0.011).
Reliability of online health information a
Medicine Dentistry Pharmacy Nursing Female Male Literate Elementary Secondary High school Faculty City Town Village Metropolitan city Mobile phone Tablet Computer No individual access Yes No I wait for it to go away I apply what I know I check the Internet I consult a friend I visit a physician Others I select one of the above if the problem persists Fewer than once a month Once a month Once a week 2–4 times a week Everyday Few times a day Inaccurate Not sure Accurate
Na
%
412 144 80 238 560 312 Mother N % 50 5.7 238 27.2 83 9.5 209 23.9 292 33.4 333 287 68 180 731 19 166 1 167 705 352 93 124 9 218 24 54
47.1 16.5 9.2 27.2 64.1 35.7 Father N % 14 1.6 158 18.1 95 10.9 187 21.4 417 47.9 38.1 32.9 7.8 20.6 83.7 2.1 18.9 0.1 19.2 80.8 40.3 10.7 14.2 1.0 25.0 2.7 6.1
332 316 122 66 25 9 299 446 121
38.2 36.3 14.0 7.6 2.9 1.0 34.5 51.5 14.0
Total number of students answering the questions.
Table 2 Students' Health Anxiety Inventory and Cyberchondria Severity Scale Scores.
Health Anxiety Scale Health anxiety total points (0–54) Excessive sensitivity to somatic symptoms and anxiety Negative consequences of disease Cyberchondria Severity Scale Cyberchondria total points (15–75) Compulsion Distress Excessiveness Reassurance Mistrust of medical professional a
Na
Minimum
Maximum
Mean
SD
820 827
0 0
44 35
17.85 14.17
6.36 5.27
854
0
12
3.67
2.25
819 859 858 865 856 864
15 3 3 3 3 3
63 15 15 15 15 15
36.98 5.23 7.09 9.91 8.79 5.99
7.69 2.37 2.66 2.54 2.70 2.42
Total number of students answering the questions.
4. Results and Suggestions In this study, online health research habits of university students in medical sciences programs have been established. All the students had internet access and they used it frequently. When they had a health problem, it was understood that 14.2% of them tried to understand the problem by seeking health information on the internet. 25% of the students searched online for health information once a week or more. It was reported that 72% of adults in the United States and 50% in France, 171
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Germany and Japan use the online health information, and internet use was particularly more common among young people (Lewis, 2006; Singh et al., 2004). In the UK, on the other hand, the rate of online health information seeking was higher in individuals in the upper socioeconomic group (Zülfikar, 2014). The rate of online personal health seeking in Turkey was 60.6% for men and 73.2% for women for the first three months of 2016 (“Turkish Statistical Institute Household Usage of Information Technologies Survey for the Year 2016”, 2016). There are few studies on online health information search in Turkey (Uzun, 2016). While 14% of the study group comprising health science students accepted online health information as accurate, 51.5% of them thought they were not sure. This result led us to believe that half of the students had the potential to trust online health information even if they were skeptical about it. Studies examining health-related online resources reported that there were significant problems concerning the quality, accuracy, and efficiency of the information compared to other sources such as brochures and books (Muse et al., 2012). The mean total score for health anxiety scale of the students who participated in the study was 17.85 ± 6.36 (0–54) and It was also determined that the health anxiety levels of these students were not high. The mean score of the cyberchondria scale was calculated as 36.98 ± 7.69 (15–75). It was found that there was a moderate correlation between the scores of these two scales. According to the findings of the present research, students were more concerned about health anxiety and cyberchondria distress than other students in the presence of a health problem. The level of health anxiety has a positively relationship with the distress and anxiety experienced while seeking online health information. It has been shown that frequent online health information seeking decreases the number of doctor visits for people with low or no concern about their health. However, it is thought that this could be harmful to those who are worried about their health (Eastin and Guinsler, 2006; Muse et al., 2012). Increased anxiety sensitivity is inevitable in people who repeatedly search online health sources containing negative comments about experiencing certain somatic sensations (Norr et al., 2014). It was established that 4–6% of patients in American primary care samples exhibited pathologic levels of illness worry of sufficient severity to meet the criteria for the DSM-IV diagnosis of hypochondriasis (Doherty-Torstrick et al., 2016). The findings of the present study also indicate that health anxiety and cyberchondria increase in direct proportion with the frequency of healthrelated online search. For this reason, the main objective of cognitivebehavioral interventions for health anxiety should be to reduce the frequency of repetitive control behaviors. Seeking symptoms on the Internet and avoiding long-duration search appear critical for patients with very moderate-to-severe health anxiety (Doherty-Torstrick et al., 2016). Our research findings indicated that there was no relationship between the faculties of the students and health anxiety levels, and that cyberchondria scores of the medical students were lower than the other students. This could be due to the fact that medical faculty students had easier access to health information resources and services than other students did. Moreover, their working with faculty members, specialists and research assistants in the clinical education environment created an important advantage in solving health problems. There are some studies reporting that psychological distress, which is compatible with the society prior to medical education, has increased in the education process of medical students. Zahid et al. reported that health-related anxiety was an evident finding in 11.9% of medical students. While entering the clinical years, a significant rise was observed in health anxiety and in preoccupation with and fear of illness and death followed by a significant decrease later on. This particular topic is addressed in health psychology classes given in medical faculties in the UK (Azuri et al., 2010; Howes and Salkovskis, 1998; Waterman and Weinman, 2014; Yusoff et al., 2013; Zahid et al., 2016). On the other hand, it is known that young people have developed strategies
enhancing reliability such as obtaining information from well-known institutions (Gray et al., 2005; Ünalan, 2014). Realization of the study in a cross-sectional design has created certain limitations in explaining causation. Another limitation is that it covered students from only one university in the field of health sciences. On the other hand, it provides important clues about health sciences students as it involved a large group of individuals. To conclude, findings show that Internet use is quite widespread among students, and the online environment is a common option for seeking health-related information in the presence of health problems. Health anxiety and cyberchondria are more common among students with health problems. Medical faculty students constitute the group with the lowest cyberchondria score. Scheduling educational programs in the field of health sciences, as in the case of the UK, as well as strengthening easily accessible health services for the students has a particular importance in solving the health problems of young people whose physical and mental sensitivity has increased during the process of adaptation to university life. Acknowledgements The authors of this study would like to thank Mengü Noyan Çengel for constructive comments on English of this article. Grants This work was supported by the Ege University Scientific Research Project Fund (Project 2017-TIP-008). Conflict of interest No conflicts of interest, financial or otherwise, are declared by the authors. References Aydemir, Ö., Kırpınar, İ., Satı, T., Uykur, B., Cengisiz, C., 2013. Sağlık Anksiyetesi Ölçeği'nin Türkçe için Güvenilirlik ve Geçerlilik Çalışması (Reliability and validity of the Turkish version of the Health Anxiety Inventory). Arch. Neuropsychiatr. 50, 325–331. Azuri, J., Ackshota, N., Vinker, S., 2010. Reassuring the medical students' disease – health related anxiety among medical students. Med. Teach. 32 (7), e270–e275. Barke, A., Bleichhardt, G., Rief, W., Doering, B., 2016. The Cyberchondria Severity Scale (CSS): German validation and development of a short form. Int. J. Behav. Med. 23, 595–605. Doherty-Torstrick, E., Walton, K., Fallon, B., 2016. Cyberchondria: parsing health anxiety from online behavior. Psychosomatics 57, 390–400. Eastin, M., Guinsler, N., 2006. Worried and wired: effects of health anxiety on information-seeking and health care utilization behaviors. Cyberpsychology Behav. 9 (4), 494–498. Gray, N., Klein, J., Noyce, P., Sesselberg, T., Cantrill, J., 2005. Health information-seeking behaviour in adolescence: the place of the internet. Soc. Sci. Med. 60, 1467–1478. Hadjistavropoulos, H., Janzen, J., Kehler, M., Leclerc, J., Sharpe, D., Bourgault-Fagnou, M., 2012. Core cognitions related to health anxiety in self-reported medical and nonmedical samples. J. Behav. Med. 35, 167–178. Howes, O., Salkovskis, P., 1998. Health anxiety in medical students. Lancet 351 (May 2), 1332. Lewis, T., 2006. DIY selves? Reflexivity and habitus in young people's use of the internet for health information. Eur. J. Cult. Stud. 9 (4), 461–479. McElroy, E., Shevlin, M., 2014. The development and initial validation of the cyberchondria severity scale (CSS). J. Anxiety Disord. 28, 259–265. Muse, K., McManus, F., Leung, C., Meghreblian, B., Williams, J., 2012. Cyberchondriasis: fact or fiction? A preliminary examination of the relationship between health anxiety and searching for health information on the Internet. J. Anxiety Disord. 26, 189–196. Norr, A., Capron, D., Schmidt, N., 2014. Medical information seeking: impact on risk for anxiety psychopathology. J. Behav. Ther. Exp. Psychiatry 45, 402–407. Pugh, N., Hadjistavropoulos, H., Sharpe, D., 2013. The reassurance questionnaire: comparison of the latent structure in university, community, and medical samples. Psychol. Health Med. 18 (1), 117–124. Salkovskıs, P., Rimes, K., Warwick, H., Clark, D., 2002. The Health Anxiety Inventory: development and validation of scales for the measurement of health anxiety and hypochondriasis. Psychol. Med. 32, 843–853. Singh, K., Brown, R., 2014. Health-related Internet habits and health anxiety in university students. Anxiety Stress Coping 27 (5), 542–554. Singh, G., Hankins, M., Weinman, J., 2004. Does medical school cause health anxiety and
172
Nurse Education Today 71 (2018) 169–173
A.H. Bati et al. worry in medical students? Med. Educ. 38, 479–481. Turkish Statistical Institute Household Usage of Information Technologies Survey for the Year 2016, 2016. Retrieved 09.09.2017, 2017, from. http://www.tuik.gov.tr/ PreHaberBultenleri.do?id=21779 (Türkiye İstatistik Kurumu 2016 yılı Hanehalkı Bilişim Teknolojileri Kullanım Araştırması). Turkish Statistical Institute Household Usage of Information Technologies Survey for the Year 2017, 2017. Retrieved 09.09.2016, 2017, from. http://www.tuik.gov.tr/ HbPrint.do?id=24862 (Türkiye İstatistik Kurumu 2017 yılı Hanehalkı Bilişim Teknolojileri Kullanım Araştırması). Ünalan, E., 2014. Üniversite Öğrencilerinde Ruh Sağlığı, Sağlık Kaygısı ve Sağlık Davranışları Arasındaki İlişkiler (The relationship between Mental Health. Health Anxiety and Health Behaviors in University Students). Unpublished Master's Thesis. Okan University, Institute of Social Sciences, İstanbul. Uzun, S., 2016. Pamukkale Üniversitesi Çalışanlarında Siberkondri Düzeyi ve Etkileyen Etmenler (Cyberchondria Levels and Contributing Factors Among Pamukkale University Employees). Unpublished Specialty Thesis. Pamukkale University, Department of Public Health, Denizli. Uzun, S., Akbay, B., Özdemir, C., Zencir, M., 2017. Siberkondri Ciddiyet Ölçeğinin ve Kısa Formunun Üniversite Öğrencilerinde Geçerlilik-Güvenilirliği (The Validity and Reliability of the Cyberchondria Severity Scale and Brief Symptom Inventory for University Students). (Paper presented at the 19th Public Health Congress, Antalya, 15–19 Mart).
Waterman, L., Weinman, J., 2014. Medical student syndrome: fact or fiction? A crosssectional study. J. R. Soc. Med. Open 5 (2), 1–9. Welch, P., Carleton, R., Asmundson, G., 2009. Measuring health anxiety: moving past the dichotomous response option of the original Whiteley Index. J. Anxiety Disord. 23, 1002–1007. White, R., Horvitz, E., 2009. Cyberchondria: studies of the escalation of medical concerns in web search. ACM Trans. Inf. Syst. 27 (4), 23. Yılmaz, E., 2013. Türkiye'de Hastaların İnternette Tıbbi Enformasyon Arama Davranışlarının Doktor-Hasta İletişimine Etkileri (The Impact of Patients' Medical Information Seeking Behaviours on the Internet on Doctor-Patient Communication in Turkey). İLETİ-Ş-İM, pp. 93–108. Yusoff, M., Rahim, A., Baba, A., Ismail, S., Pa, M., Esa, A., 2013. The impact of medical education on psychological health of students: a cohort study. Psychol. Health Med. 18 (4), 420–430. Zahid, M., Haque, A., Aslam, M., Aleem, N., Hussain, S., Fahad, H., ... Ghias, K., 2016. Health-related anxiety and hypochondriacal concerns in medical students: a crosssectional study from Pakistan. Teach. Learn. Med. 28 (3), 252–259. Zhang, Y., Zhao, Y., Mao, S., Li, G., Yuan, Y., 2014. Investigation of health anxiety and its related factors in nursing students. Neuropsychiatr. Dis. Treat. 10, 1223–1234. Zülfikar, H., 2014. Hastaların İnternet Kullanımı ve Elektronik Ortamdaki Sağlık Bilgilerine Erişim Davranışları (the Internet usage behaviour and access patterns of the patients to the health information on the Internet). F.N. Hem. J. 22 (1), 46–52.
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Nurse Education Today journal homepage: www.elsevier.com/locate/nedt
Health anxiety and cyberchondria among Ege University health science students
T
Ayse Hilal Batia, , Aliye Mandiracioglub, Figen Govsac, Olcay Çamd ⁎
a
Department of Medical Education, Faculty of Medicine, Ege University, Izmir, Turkey Department of Public Health, Faculty of Medicine, Ege University, Izmir, Turkey c Department of Anatomy, Faculty of Medicine, Ege University, İzmir, Turkey d Olcay Çam, Department of Psychiatry, Faculty of Nursing, Ege University, İzmir, Turkey b
ARTICLE INFO
ABSTRACT
Keywords: Health sciences student Health anxiety Cyberchondria
It is common among health science students to incorrectly believe that they have contracted certain diseases they have recently studied. This can also be seen in the form of health anxiety and investigating health-related information via the internet. Health anxiety, cyberchondria and affecting factors are determined among health science students. The study was conducted at the faculties of Medicine, Pharmacy, Dentistry and Nursing in 2016–2017 with the participation of 874 students. The data were gathered using a questionnaire as well as health anxiety and cyberchondria severity scales. In the presence of a health problem, 14.2% of students seek health information via the internet. 83.7% use mobile phone to access the internet, ¼ of students conduct health scanning once a week or more. To 65.4%, internet information is correct at medium and above level. No statistically significant difference was found with respect to students' gender, high school, places they lived before, parents' education and scales' scores. The cyberchondria scores of students with health problems are higher in the whole scale and in “distress and mistrust of medical professional” subscales. As the frequency of scanning on the internet increases, the scores of cyberchondria also increase significantly. Medical students had significantly higher scores in “distress, excessiveness and reassurance” subscales. Male students' “mistrust of medical professional and compulsion” subscales scores were also higher. It was determined that the presence of the health problem was effective on the cyberchondria. Identification of somatoform problems like health anxiety and cyberchondria may help to regulate the education program.
1. Introduction and Objective Advances in modern technology and the increase in internet usage have enabled greater number of people to access the internet. It was found that 85% of the adult population of the USA was internet users in 2013. According to data released by the Turkish Statistical Institute, 66.8% of Turkey's population is internet users (“Turkish Statistical Institute Household Usage of Information Technologies Survey”, 2017). Internet usage is the highest in the group comprising people between ages of 16 and 24 (91.5% in males and 82.9% in females). According to educational levels, 89.8% of the internet users in Turkey are high school and vocational high school graduates while 97% are graduates of university undergraduate, master's and doctorate programs. The highest percentage of internet usage was observed in professional occupational groups with 99.3% (“Turkish Statistical Institute Household Usage of ⁎
Information Technologies Survey”, 2016). As the widespread and intensive use of the internet have provided people easy and free access to information, the internet has become a popular source of accessing online health information (McElroy and Shevlin, 2014; Yılmaz, 2013). International studies have shown that a great number of people manage their own health based on health-related information they get online. In Turkey, the percentage of seeking personal health related information online was 65.9% during the first three months of 2016. Despite the fact that an online environment provides extensive and easy access to information through a myriad of sources, it often creates problems concerning access to up-to-date, reliable, efficient and accurate information (Lewis, 2006; Singh et al., 2004; “Türkiye İstatistik Kurumu 2016 yılı Hanehalkı Bilişim Teknolojileri Kullanım Araştırması (Turkish Statistical Institute Household Usage of Information Technologies Survey for the year 2016”, 2016) because seeking health information is
Corresponding author at: Ege University, Faculty of Medicine, Department of Medical Education, 35100 Bornova-Izmir, Turkey. E-mail address: [email protected] (A.H. Bati).
https://doi.org/10.1016/j.nedt.2018.09.029 Received 20 March 2018; Received in revised form 4 September 2018; Accepted 25 September 2018 0260-6917/ © 2018 Published by Elsevier Ltd.
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an important coping strategy, people continue to search for information; however, sources they use and how they do this demonstrate variations. Online sources meet the information needs of the patients and their relatives prior to consulting a physician with respect to up-to-date medical information, newly diagnosed diseases and treatment methods, advanced medical devices. Information often obtained using general search engines may be effective in decision making by healthy or sick individuals related to maintaining their health, engaging a physician's assistance concerning diagnosis and treatment, treating an acute illness and coping with chronic problems. Information obtained from official and other reliable sources provides various benefits such as understanding symptoms, deciding on the urgency and necessity of consulting a physician, turning to the correct area of specialty for the health problem and obtaining accurate information. Unofficial and unreliable sources, on the other hand, lead to incomplete and incorrect information; thus aggravating health anxiety depending on the problem being experienced (Doherty-Torstrick et al., 2016; White and Horvitz, 2009; Yılmaz, 2013). It is known that individuals with frequent online medical information seeking demonstrate elevated health anxiety concerns (Norr et al., 2014). These people often investigate rare, uncommon and dreadful medical conditions (Uzun, 2016). When online sources are perceived as reliable, likelihood of developing health concerns increases (Singh and Brown, 2014). Milder form of health concern may direct individuals to get medical assistance but may lead to excessive grief and development of negative social and occupational functions (Pugh et al., 2013). In a review by B. Zülfikar investigating the online health-related attitudes and behaviour, it was determined that more than half of the individuals who scanned online health information had benefited from this procedure which strengthened the process of decision- making concerning certain diseases and helped them in their contacts with their doctors. However, problems related to compulsion and reliability of the information obtained were also observed in the management of some diseases (Zülfikar, 2014). Health anxiety is a psychological state in which somatic and mental concerns are stimulated by health-related threat perceptions. It describes negative interpretation of normal and abnormal somatic sensations and fear. In other words, the individual thinks that s/he has a serious health problem and that this problem will cause negative consequences. Health anxiety is common not only among individuals with somatoform and psychological disorder but also among normal people. Mild health anxiety experienced by many people is a tolerable situation that will go away on its own. Severe health anxiety, on the other hand, indicates basic psychiatric disorders such as hypochondriasis or health phobia. It is thought that health-related unconcern, anxiety and hypochondriasis display successive consistency (Aydemir et al., 2013; Hadjistavropoulos et al., 2012; Ünalan, 2014; Welch et al., 2009; Zhang et al., 2014). Young people starting higher education try to adapt to university environment while coping with problems of adolescence. Especially factors such as living away from the family, adaptation to university life and conditions, new and different friends and financial problems inevitably have an impact on physical and mental health in a period when individual responsibilities and personalities are shaped (Ünalan, 2014). An online environment has become a more frequently-used alternative for sexual and mental problems young people cannot discuss face to face or prefer to keep secret. When health anxiety is high, online environments are used more frequently and concerns increase following the internet search (Singh and Brown, 2014). Furthermore, medical students are under constant stress associated with intense study sessions, heavy work load, a competitive environment and new clinical experiences. This stress intensifies somatic sensations with autonomic activations and causes them to be perceived as symptoms. It is thought that medical students conceptualize some symptoms with new information they learn and interpret them as
medical evidence. Thus, clinical teachers report that they are often faced with fear and symptoms of illness in medical students. Such reactions termed as medical student's disease, nosophobia, or medical student's hypochondria are often conceptualized as a mild form of health anxiety or transient hypochondriasis. Medical students who believe they have contracted a certain disease identify cases more easily and selectively as they readily arouse interest and stay in their mind. It can be considered that this condition may also be true not only for medical students but also for all the students studying in health sciences including nursing, pharmacy and dentistry. Online health information seeking behaviour may become steady with the fear that one has or will develop a serious disease. Studies conducted have shown that this increases health anxiety and may lead to cyberchondria which is described as a severe form of anxiety associated with the escalation of distress and anxiety (Doherty-Torstrick et al., 2016; Muse et al., 2012). Cyberchondria is a form of anxiety characterized by excessive online health research (McElroy and Shevlin, 2014; White and Horvitz, 2009). Following its widespread use in the media, the term cyberchondria emerged in the medical literature in the 2000's (Uzun, 2016). Although the number of related studies is limited, cyberchondria is thought to be quite common in our country as well (Uzun et al., 2017). The aim of the present study is to determine the factors affecting cyberchondria and health anxiety levels in health sciences students. 2. Material and Method 2.1. Research Design and Research Group The present cross-sectional study comprised second-year students enrolled in four health science faculties of Ege University in the academic year 2016–2017. There were totally 1085 second-year students in faculties (498 Medicine, 110 Pharmacy, 182 Dentistry, 295 Nursing) and we tried to reach all of the students. A total of 874 students (412 Medicine, 80 Pharmacy, 144 Dentistry, 238 Nursing) were recruited for participation on a voluntary basis. The response rate was 80.56%. 2.2. Data Collection Devices Research data was collected anonymously, by the faculty members after approval from the Ege University Scientific Research and Publication Ethics Board as well as from the administrations of related faculties was obtained. Prior to this, necessary explanations for the research group were made both verbally and in writing. The Health Anxiety Inventory and the Short Form version of the Cyberchondria Severity Scale as well as a questionnaire form prepared by researchers were used as data collection devices. The questionnaire was composed of 10 items questioning attitudes and behaviour towards checking health information online in the presence of a medical problem in addition to sociodemographic characteristics. Students filled in the data collection tools themselves. 2.2.1. Health Anxiety Inventory The Health Anxiety Inventory was developed by P.M. Salkovskis et al. to measure a broad range of health anxiety symptoms. The inventory is composed of 18 self-report questions. The main section (the first 14 items) associated with excessive sensitivity to somatic symptoms and distress dimension contains four sequential statements questioning the mental state. The negative consequences section (the remaining 4 items) questions people's attitudes towards how awful it would be if they were to develop a serious disease. Each item of the inventory is scored on a 0–3 basis and scores of each item are added together for a total score ranging from 0 to 54. The higher score indicates the higher health anxiety level. The short form can be used in health scanning; furthermore, the inventory can help differentiate hypochondriasis from anxiety disorders and identify actual physical 170
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illnesses. The Health Anxiety Inventory was adapted to Turkish by Aydemir et al., reliability and validity analyses of the Turkish version of the inventory were performed in a sample of out-patients with somatoform disorder and panic disorder and university students (Aydemir et al., 2013; Salkovskıs et al., 2002).
Table 1 Characteristics of the students participating in the study.
Faculty
2.2.2. Cyberchondria Severity Scale Short Form Cyberchondria Severity Scale (CSS) was originally developed by McElroy and Shevlin in 2014 in a sample of university students to assess cyberchondria. A brief version with 15 items was developed (CSS-15) and validated by Barke et al. in 2016. It was adapted to Turkish, and reliability and validity analyses of the Turkish version of the inventory were performed by Uzun et al. in a sample of university students. CSS15 comprises five subscales including compulsion, distress, excessiveness, reassurance, mistrust of medical professional. The scale contained 15 times each consisting of a 5 point Likert-scale indicating frequency (1 ‘Never’, 2 ‘Rarely’, 3 ‘Sometimes’, 4 ‘Often’ and 5 ‘Always’). Scores that can be obtained from the scale range between 15 and 75 (Barke et al., 2016; McElroy and Shevlin, 2014; Uzun, 2016; Uzun et al., 2017).
Gender Education level of parents
Residence
Medium of Internet access
2.3. Data Analysis
Presence of health problem In case of a health problem
SPSS 18.0 statistical software program was used to evaluate data and p < 0.05 was accepted as a significant value. After descriptive statistics were performed, t-test and ANOVA were used to determine the relationship between inter-scale correlation scale scores and sociodemographic characteristics of the students. 3. Findings
Frequency of online health scanning
The mean age of the study group was 20.33 ± 1.4 and 64.2% of them were females. The education level of the family (mothers 57.3% and fathers 69.3%) is generally high school and above. The percentage of students who spent most of their lives in cities and metropolises was 58.7%. 83.7% of the students use mobile phones to access the Internet and ¼ perform health scanning once a week or more frequently. In the presence of a health problem, 40.3% expected it to go away on its own, 25% visited the nearest doctor, and 14.2% reported that they would try to understand the problem by investigating on the internet. The percentage of the students who stated that online health information was not accurate was 34.5% and the mean score was 2.74 ± 0.80 when the validity was rated on a 5 point Likert-scale indicating frequency (1 ‘Never’, 2 ‘Rarely’, 3 ‘Sometimes’, 4 ‘Often’ and 5 ‘Always’). The characteristics of the students are shown in Table 1, and the students' health anxiety and cyberchondria severity scale scores are shown in Table 2. It has been determined that there is a moderate correlation between cyberchondria and health anxiety scales according to a four-point scale (Pearson Correlation: 0.325 p: 0.000). No statistically significant relationship was found between the students' faculty, gender, school they graduated from, previous place of residence, education levels of parents and the total scores from the scale. The health anxiety scale total score (t: 3.882 p: 0.00) and the cyberchondria scale distress score of the students with health problems were higher than the others. As the frequency of online health scanning increased, the health anxiety scores (F: 4.803 p: 0.008) and the cyberchondria scores (F: 19.010 p: 0.00) also showed a significant increase. Excessive sensitivity to somatic symptoms and distress scores (F: 50.891 p: 0.000) and the cyberchondria scale scores (F: 3.927 p: 0.020) of the students who do not believe in the accuracy of the online information they obtain on the internet are comparatively lower. The male students' scores on the subscales of compulsion and mistrust of medical professional were found to be higher. While there was no relationship between the students' faculties and health anxiety scores, cyberchondria scale scores of the medical faculty students were significantly low (F:3.757 p:0.011).
Reliability of online health information a
Medicine Dentistry Pharmacy Nursing Female Male Literate Elementary Secondary High school Faculty City Town Village Metropolitan city Mobile phone Tablet Computer No individual access Yes No I wait for it to go away I apply what I know I check the Internet I consult a friend I visit a physician Others I select one of the above if the problem persists Fewer than once a month Once a month Once a week 2–4 times a week Everyday Few times a day Inaccurate Not sure Accurate
Na
%
412 144 80 238 560 312 Mother N % 50 5.7 238 27.2 83 9.5 209 23.9 292 33.4 333 287 68 180 731 19 166 1 167 705 352 93 124 9 218 24 54
47.1 16.5 9.2 27.2 64.1 35.7 Father N % 14 1.6 158 18.1 95 10.9 187 21.4 417 47.9 38.1 32.9 7.8 20.6 83.7 2.1 18.9 0.1 19.2 80.8 40.3 10.7 14.2 1.0 25.0 2.7 6.1
332 316 122 66 25 9 299 446 121
38.2 36.3 14.0 7.6 2.9 1.0 34.5 51.5 14.0
Total number of students answering the questions.
Table 2 Students' Health Anxiety Inventory and Cyberchondria Severity Scale Scores.
Health Anxiety Scale Health anxiety total points (0–54) Excessive sensitivity to somatic symptoms and anxiety Negative consequences of disease Cyberchondria Severity Scale Cyberchondria total points (15–75) Compulsion Distress Excessiveness Reassurance Mistrust of medical professional a
Na
Minimum
Maximum
Mean
SD
820 827
0 0
44 35
17.85 14.17
6.36 5.27
854
0
12
3.67
2.25
819 859 858 865 856 864
15 3 3 3 3 3
63 15 15 15 15 15
36.98 5.23 7.09 9.91 8.79 5.99
7.69 2.37 2.66 2.54 2.70 2.42
Total number of students answering the questions.
4. Results and Suggestions In this study, online health research habits of university students in medical sciences programs have been established. All the students had internet access and they used it frequently. When they had a health problem, it was understood that 14.2% of them tried to understand the problem by seeking health information on the internet. 25% of the students searched online for health information once a week or more. It was reported that 72% of adults in the United States and 50% in France, 171
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Germany and Japan use the online health information, and internet use was particularly more common among young people (Lewis, 2006; Singh et al., 2004). In the UK, on the other hand, the rate of online health information seeking was higher in individuals in the upper socioeconomic group (Zülfikar, 2014). The rate of online personal health seeking in Turkey was 60.6% for men and 73.2% for women for the first three months of 2016 (“Turkish Statistical Institute Household Usage of Information Technologies Survey for the Year 2016”, 2016). There are few studies on online health information search in Turkey (Uzun, 2016). While 14% of the study group comprising health science students accepted online health information as accurate, 51.5% of them thought they were not sure. This result led us to believe that half of the students had the potential to trust online health information even if they were skeptical about it. Studies examining health-related online resources reported that there were significant problems concerning the quality, accuracy, and efficiency of the information compared to other sources such as brochures and books (Muse et al., 2012). The mean total score for health anxiety scale of the students who participated in the study was 17.85 ± 6.36 (0–54) and It was also determined that the health anxiety levels of these students were not high. The mean score of the cyberchondria scale was calculated as 36.98 ± 7.69 (15–75). It was found that there was a moderate correlation between the scores of these two scales. According to the findings of the present research, students were more concerned about health anxiety and cyberchondria distress than other students in the presence of a health problem. The level of health anxiety has a positively relationship with the distress and anxiety experienced while seeking online health information. It has been shown that frequent online health information seeking decreases the number of doctor visits for people with low or no concern about their health. However, it is thought that this could be harmful to those who are worried about their health (Eastin and Guinsler, 2006; Muse et al., 2012). Increased anxiety sensitivity is inevitable in people who repeatedly search online health sources containing negative comments about experiencing certain somatic sensations (Norr et al., 2014). It was established that 4–6% of patients in American primary care samples exhibited pathologic levels of illness worry of sufficient severity to meet the criteria for the DSM-IV diagnosis of hypochondriasis (Doherty-Torstrick et al., 2016). The findings of the present study also indicate that health anxiety and cyberchondria increase in direct proportion with the frequency of healthrelated online search. For this reason, the main objective of cognitivebehavioral interventions for health anxiety should be to reduce the frequency of repetitive control behaviors. Seeking symptoms on the Internet and avoiding long-duration search appear critical for patients with very moderate-to-severe health anxiety (Doherty-Torstrick et al., 2016). Our research findings indicated that there was no relationship between the faculties of the students and health anxiety levels, and that cyberchondria scores of the medical students were lower than the other students. This could be due to the fact that medical faculty students had easier access to health information resources and services than other students did. Moreover, their working with faculty members, specialists and research assistants in the clinical education environment created an important advantage in solving health problems. There are some studies reporting that psychological distress, which is compatible with the society prior to medical education, has increased in the education process of medical students. Zahid et al. reported that health-related anxiety was an evident finding in 11.9% of medical students. While entering the clinical years, a significant rise was observed in health anxiety and in preoccupation with and fear of illness and death followed by a significant decrease later on. This particular topic is addressed in health psychology classes given in medical faculties in the UK (Azuri et al., 2010; Howes and Salkovskis, 1998; Waterman and Weinman, 2014; Yusoff et al., 2013; Zahid et al., 2016). On the other hand, it is known that young people have developed strategies
enhancing reliability such as obtaining information from well-known institutions (Gray et al., 2005; Ünalan, 2014). Realization of the study in a cross-sectional design has created certain limitations in explaining causation. Another limitation is that it covered students from only one university in the field of health sciences. On the other hand, it provides important clues about health sciences students as it involved a large group of individuals. To conclude, findings show that Internet use is quite widespread among students, and the online environment is a common option for seeking health-related information in the presence of health problems. Health anxiety and cyberchondria are more common among students with health problems. Medical faculty students constitute the group with the lowest cyberchondria score. Scheduling educational programs in the field of health sciences, as in the case of the UK, as well as strengthening easily accessible health services for the students has a particular importance in solving the health problems of young people whose physical and mental sensitivity has increased during the process of adaptation to university life. Acknowledgements The authors of this study would like to thank Mengü Noyan Çengel for constructive comments on English of this article. Grants This work was supported by the Ege University Scientific Research Project Fund (Project 2017-TIP-008). Conflict of interest No conflicts of interest, financial or otherwise, are declared by the authors. References Aydemir, Ö., Kırpınar, İ., Satı, T., Uykur, B., Cengisiz, C., 2013. Sağlık Anksiyetesi Ölçeği'nin Türkçe için Güvenilirlik ve Geçerlilik Çalışması (Reliability and validity of the Turkish version of the Health Anxiety Inventory). Arch. Neuropsychiatr. 50, 325–331. Azuri, J., Ackshota, N., Vinker, S., 2010. Reassuring the medical students' disease – health related anxiety among medical students. Med. Teach. 32 (7), e270–e275. Barke, A., Bleichhardt, G., Rief, W., Doering, B., 2016. The Cyberchondria Severity Scale (CSS): German validation and development of a short form. Int. J. Behav. Med. 23, 595–605. Doherty-Torstrick, E., Walton, K., Fallon, B., 2016. Cyberchondria: parsing health anxiety from online behavior. Psychosomatics 57, 390–400. Eastin, M., Guinsler, N., 2006. Worried and wired: effects of health anxiety on information-seeking and health care utilization behaviors. Cyberpsychology Behav. 9 (4), 494–498. Gray, N., Klein, J., Noyce, P., Sesselberg, T., Cantrill, J., 2005. Health information-seeking behaviour in adolescence: the place of the internet. Soc. Sci. Med. 60, 1467–1478. Hadjistavropoulos, H., Janzen, J., Kehler, M., Leclerc, J., Sharpe, D., Bourgault-Fagnou, M., 2012. Core cognitions related to health anxiety in self-reported medical and nonmedical samples. J. Behav. Med. 35, 167–178. Howes, O., Salkovskis, P., 1998. Health anxiety in medical students. Lancet 351 (May 2), 1332. Lewis, T., 2006. DIY selves? Reflexivity and habitus in young people's use of the internet for health information. Eur. J. Cult. Stud. 9 (4), 461–479. McElroy, E., Shevlin, M., 2014. The development and initial validation of the cyberchondria severity scale (CSS). J. Anxiety Disord. 28, 259–265. Muse, K., McManus, F., Leung, C., Meghreblian, B., Williams, J., 2012. Cyberchondriasis: fact or fiction? A preliminary examination of the relationship between health anxiety and searching for health information on the Internet. J. Anxiety Disord. 26, 189–196. Norr, A., Capron, D., Schmidt, N., 2014. Medical information seeking: impact on risk for anxiety psychopathology. J. Behav. Ther. Exp. Psychiatry 45, 402–407. Pugh, N., Hadjistavropoulos, H., Sharpe, D., 2013. The reassurance questionnaire: comparison of the latent structure in university, community, and medical samples. Psychol. Health Med. 18 (1), 117–124. Salkovskıs, P., Rimes, K., Warwick, H., Clark, D., 2002. The Health Anxiety Inventory: development and validation of scales for the measurement of health anxiety and hypochondriasis. Psychol. Med. 32, 843–853. Singh, K., Brown, R., 2014. Health-related Internet habits and health anxiety in university students. Anxiety Stress Coping 27 (5), 542–554. Singh, G., Hankins, M., Weinman, J., 2004. Does medical school cause health anxiety and
172
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A.H. Bati et al. worry in medical students? Med. Educ. 38, 479–481. Turkish Statistical Institute Household Usage of Information Technologies Survey for the Year 2016, 2016. Retrieved 09.09.2017, 2017, from. http://www.tuik.gov.tr/ PreHaberBultenleri.do?id=21779 (Türkiye İstatistik Kurumu 2016 yılı Hanehalkı Bilişim Teknolojileri Kullanım Araştırması). Turkish Statistical Institute Household Usage of Information Technologies Survey for the Year 2017, 2017. Retrieved 09.09.2016, 2017, from. http://www.tuik.gov.tr/ HbPrint.do?id=24862 (Türkiye İstatistik Kurumu 2017 yılı Hanehalkı Bilişim Teknolojileri Kullanım Araştırması). Ünalan, E., 2014. Üniversite Öğrencilerinde Ruh Sağlığı, Sağlık Kaygısı ve Sağlık Davranışları Arasındaki İlişkiler (The relationship between Mental Health. Health Anxiety and Health Behaviors in University Students). Unpublished Master's Thesis. Okan University, Institute of Social Sciences, İstanbul. Uzun, S., 2016. Pamukkale Üniversitesi Çalışanlarında Siberkondri Düzeyi ve Etkileyen Etmenler (Cyberchondria Levels and Contributing Factors Among Pamukkale University Employees). Unpublished Specialty Thesis. Pamukkale University, Department of Public Health, Denizli. Uzun, S., Akbay, B., Özdemir, C., Zencir, M., 2017. Siberkondri Ciddiyet Ölçeğinin ve Kısa Formunun Üniversite Öğrencilerinde Geçerlilik-Güvenilirliği (The Validity and Reliability of the Cyberchondria Severity Scale and Brief Symptom Inventory for University Students). (Paper presented at the 19th Public Health Congress, Antalya, 15–19 Mart).
Waterman, L., Weinman, J., 2014. Medical student syndrome: fact or fiction? A crosssectional study. J. R. Soc. Med. Open 5 (2), 1–9. Welch, P., Carleton, R., Asmundson, G., 2009. Measuring health anxiety: moving past the dichotomous response option of the original Whiteley Index. J. Anxiety Disord. 23, 1002–1007. White, R., Horvitz, E., 2009. Cyberchondria: studies of the escalation of medical concerns in web search. ACM Trans. Inf. Syst. 27 (4), 23. Yılmaz, E., 2013. Türkiye'de Hastaların İnternette Tıbbi Enformasyon Arama Davranışlarının Doktor-Hasta İletişimine Etkileri (The Impact of Patients' Medical Information Seeking Behaviours on the Internet on Doctor-Patient Communication in Turkey). İLETİ-Ş-İM, pp. 93–108. Yusoff, M., Rahim, A., Baba, A., Ismail, S., Pa, M., Esa, A., 2013. The impact of medical education on psychological health of students: a cohort study. Psychol. Health Med. 18 (4), 420–430. Zahid, M., Haque, A., Aslam, M., Aleem, N., Hussain, S., Fahad, H., ... Ghias, K., 2016. Health-related anxiety and hypochondriacal concerns in medical students: a crosssectional study from Pakistan. Teach. Learn. Med. 28 (3), 252–259. Zhang, Y., Zhao, Y., Mao, S., Li, G., Yuan, Y., 2014. Investigation of health anxiety and its related factors in nursing students. Neuropsychiatr. Dis. Treat. 10, 1223–1234. Zülfikar, H., 2014. Hastaların İnternet Kullanımı ve Elektronik Ortamdaki Sağlık Bilgilerine Erişim Davranışları (the Internet usage behaviour and access patterns of the patients to the health information on the Internet). F.N. Hem. J. 22 (1), 46–52.
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