Health anxiety can be defined by concern about health in the absence of a pathology. The Health Anxiety Questionnaire (HAQ) based on the cognitive-behavioral model can be useful for evaluating the severity and the structure of health anxiety. This study aims to verify the reliability and validity of Korean version of HAQ (K-HAQ).
For reliability, test-retest reliability and internal consistency were analyzed. For construct validity, exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were conducted. Receiver Operating Characteristic (ROC) analysis was performed to identify the optimal cut-off score.
Cronbach’s alpha was 0.92, and r value of test-retest reliability was 0.84. In the EFA, 4- and 5-factor model showed cumulative percentile of variance of 60% or more. In the CFA, the 4-factor model was found to be the most appropriate and simplest (χ2 =397.33, df=187, CFI=0.909, TLI=0.888, RMSEA=0.077). In the ROC analysis, the cut-off score was 20 points.
It is expected that K-HAQ can be helpful to evaluate the severity of health anxiety and make therapeutic plans because K-HAQ can help explore the cognitive, emotional, and behavioral structure of health anxiety by each factor.
What is health anxiety? Health anxiety can be defined by concern about health in the absence of a pathology or excessive worries when there is some degree of pathology. In the light of psychiatric diagnosis, health anxiety can belong to the hypochondriasis based on the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IVTR), or the somatic symptom disorder or the illness anxiety disorder based on the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) [
However, how can we know and measure health anxiety? In general, checking one’s health anxiety can be known through self-report scale related hypochondriasis. Previously developed well-known health anxiety scales include Whiteley Index (WI) by Pilowsky and Illness Attitude Scale (IAS) by Kellner and his colleagues [
Why does the health anxiety scale need the theoretical model? Barsky, Geringer, and Wool consider hypochondriasis as a cognitive and perceptual disability [
The Health Anxiety Questionnaire (HAQ) can be the scale that help to identify cognitive and behavioral structure of the health anxiety and to make the therapeutic plans. Lucock and Morley [
In South Korea, the Korean version of HAQ (K-HAQ) has not been validated yet. In the light of cognitive-behavioral model, we authors expect that the K-HAQ will be useful to check the level of health anxiety and explore the cognitive structure of health anxiety [
The HAQ consists of total 21 items describing health anxiety related symptoms, and it uses a four-point Likert scale. The four points ‘not at all or rarely’, ‘sometimes’, ‘often,’ and ‘most of the time’ were scored from o to 3, respectively. Before starting the validation study for K-HAQ, the authors received the approval for the Korean validation study from the original authors. First, the authors translated the original English version into Korean, and then did back-translation by a bilingual (English and Korean) expert. Next, the authors and three other psychiatrists compared the two versions (original and back-translated one). After considering Korean cultural adaptation, the final version was determined by the authors.
As a normal group, initially total 218 subjects who consist of college students or public servants registered. The inclusion and exclusion criteria for the normal group are as follows. Participants were from 18 to 65 years of age. Through the initial general survey (gender, age, residence, marital status, education level, medical and psychiatric history), those who had psychiatric history or underlying severe and apparent medical history (i.e., brain disease, cancer, heart disease, etc.) were excluded from the data analysis. In addition, participants were those with a Somatic Complaints-Health Concern (SOM-H) Scale score of less than 65 points in the Personality Assessment Inventory (PAI). Finally, data from 189 participants were used to analyze results. The 38 participants of them received the same tests again to investigate test-retest reliability two weeks after the initial test. As a patient group (named as “hypochondriasis group” in this study), the participants are total 43 subjects. The patients are psychiatric outpatients diagnosed Hypochondriasis, Somatic Symptoms Disorder, or Illness Anxiety Disorder based on DSM-IV-TR and DSM-5 by psychiatrists [
To evaluate concurrent validity, two other scales were included below.
The IAS was originally developed by Kellner et al. [
The PAI can assess both personality and psychopathology, and it includes 11 clinical scales to explain psychopathological symptoms such as depression, anxiety, schizophrenia, and so on [
First, both descriptive statistics and frequency analysis were used to analyze all the demographic data. To verify the reliability of the K-HAQ, Cronbach’s alpha as the internal consistency was calculated. It can often be described as “Acceptable” when Cronbach’s alpha is between 0.70 and 0.80, “Good” when it is between 0.80 and 0.90, and “Excellent” when it is above 0.90. As the reliability of test-retest, the Pearson’s correlation analysis was performed. According to Cohen, the effect size is “Low” if the value of r varies around 0.1, “Medium” if r varies around 0.3, and “Large” if r varies more than 0.5 [
The Cronbach’s alpha was 0.92 as an internal consistency, which means “Excellent” internal consistency. For the test-retest reliability, the 38 participants completed the K-HAQ on two occasions with a 2-week interval. The Pearson’s correlation analysis showed “Large” effect size (r=0.840, n=38, p< 0.001).
First, the value of Kaiser-Meyer-Olkin (KMO) and Bartlett’s test of sphericity showed that it was possible enough to conduct factor analysis (The value of KMO=0.94; χ2 (df=210, n=189)=2435.22, p<0.001) [
Therefore, for the 4-factor model (Supplementary Materials in the online-only Data Supplement), the factor 1 consists of questions 1, 2, 3, 4, 6, 7, 8, 9, 10, 11, and 18 and includes questions about health concerns and obsessions. The factor 1 was named as “Health worry and preoccupation” as same in the original. Factor 2 consists of questions 19, 20, and 21, and includes questions about how much of what you are doing is disturbed by these symptoms. The factor 2 was named as “Interference with life” as same in the original. The factor 3 consists of questions 14, 15, 16, 17 and contains questions related to fear of death and illness. The factor 3 was named as “Fear of illness and death” as same in the original. Lastly, the factor 4 consists of questions 5, 12, and 13, and includes questions related to behaviors to test and confirm symptoms. The factor 4 was named as “Reassurance-seeking behavior” as same in the original.
The correlation analysis was performed to examine the relationship between the K-HAQ and other well-known hypochondriasis scales. As a result, the total score of the K-HAQ showed a “Large” effect size in correlation analysis with the K-IAS scale (r=0.798, n=189, p<0.001). Second, the total score of the K-HAQ showed a “Medium” effect size in the correlation analysis with the SOM-H scale of K-PAI (r=0.359, n=189, p<0.001). Additionally, the total score of the K-IAS also showed a “Medium” effect size in the correlation analysis with the SOM-H scale of K-PAI (r=0.356, n=189, p<0.001).
The ROC analysis was performed to find the cut-off score of K-HAQ, which can distinguish between normal adults and hypochondriasis patients. In the Area under the curve (AUC), which indicates the degree to which the scale accurately diagnoses the presence or absence of the disorder, a score of 0.50 or higher means a probability higher than chance, and a diagnosis based on the scale is useful when the value is 0.72–0.92 [
In this study, we aimed to translate HAQ into Korean and evaluate the reliability and validity of K-HAQ, which can measure the level of anxiety for hypochondriasis and be helpful for establishing a therapeutic plan in the clinical practice. The implications of the results are as follows.
First, as to the implications of the reliability test results, internal consistency reliability and test-retest reliability were all at a reliable level (Cronbach’s alpha=0.92, r=0.84). Comparing this with the original study, the alpha coefficient was 0.92 and r value was 0.87 in the original study. These results suggest that the reliability of the K-HAQ measurement is a quite reasonable.
Second, the implication of the validity test results are as follows. In the construct validity testing, we explored 3-factor, 4-factor, and 5-factor structures in the EFA with reference to scree test, cumulative percentile of variance, and original HAQ study results. In the EFA results, the cumulative percentile of variance for both 3-, 4-, and 5-factors was more than 60% and the RMSEA was well below 0.08. Next, the CFA results suggest that the 4-factor model and the 5-factor model are suitable models. However, since the difference of the goodness-of-fit index between the two models was not significant, the simpler 4-factor model was adopted. Comparing the CFA results with the original HAQ study results, the 4-factor model of this study was consistent with the original study results. Therefore, in this study, the authors named the factor names by naming the four factors as same in the original HAQ study. The factor 1 is “Health worry and preoccupation,” the factor 2 is “Interference with life,” the factor 3 is “Fear of illness and death,” and the factor 4 is “Reassurance-seeking behavior.” The factor 1 includes contents related to excessive worry and obsession with health, as seen in the definition of health anxiety. Especially, it includes contents that most people worry about, or worry constantly about, somatic symptoms that can be easily overtaken. The factor 2 includes questions related to the symptoms of the body, such as whether the person is unable to work, concentrate, or enjoy the pleasure. The factor 3 directly addresses the pathologies such as death, cancer, and heart disease, and contains questions about their fear. The factor 4 includes questions such as learning through a person or a book, medical examination, and so on to find out the causes of physical symptoms. The number of factors in this study and the original HAQ study were the same, but there were some differences in the items that constituted the factor 1 and factor 3. In the factor 1, this study included items 1, 2, 3, 4, 6, 7, 8, 9, 10, 11, and 18, but the items 2, 3, and 10 belonging to the factor 3 of the original HAQ study were included (No. 2 items is “Are you ever worried that you may get a serious illness in the future?,” No. 3 item is “Does the thought of a serious illness ever scare you?,” and No. 10 item is “When you hear of a serious or the death of someone you know, does it ever make you more concerned about your own health?.” The reason for this is that the factor 3 asks about “Fear of illness and death” and because questions 15, 16, and 17 more directly ask about the fear associated with illness and death. In other words, Koreans seem to think that questions 2, 3, and 10 are questions about “Health worry and preoccupation” rather than thinking that they are questions about “Fear of illness and death.” The other items that consist of factor 2 and factor 4 are consistent with this study and the original HAQ study (
Next, in the light of clinical utility, the authors investigated the cut-off score that distinguish between normal adults and patients with hypochondriasis by ROC analysis. As a result, when the total score of K-HAQ was greater than 20 points, it was classified as 71% of the patients with hypochondriasis, and 75% of the non-hypochondriasis adults could be classified. The use of cut-off score in a clinical field is expected to help diagnose hypochondriasis and identify the individual severity. In the case of the cut-off score analysis, the ROC result could not be compared with the result of the original HAQ study because the ROC analysis was not performed on the original study. However, if the authors infer the cut-off score from the mean and SD of the normal group (
In addition, in terms of therapeutic implications associated with cognitive-behavioral therapy, one’s cognitive structure regarding health can be inferred through the factor 1 (“Health worry and preoccupation”). The factor 2 (“Interference with life”) can help for the therapist in charge figure out a current level of daily life functioning of the patient. Through the factor 3 (“Fear of illness and death”), the level of negative emotional state can be inferred. Lastly, it can be understood that the style and level of coping behavior is represented by factor 4 factors (“Reassurance-seeking behavior”). It is expected helpful to make a therapeutic plan and practice cognitive behavioral therapy as K-HAQ can provide therapists with one’s cognitive structure and emotional state, and the level of daily life functioning of patients with hypochondriasis depending on each factor of K-HAQ.
Finally, the limitations and future research directions of this study are as follows. Although this study has adapted and validated the original HAQ in Korean, it is required to verify the clinical utility in practical field. Especially, the present study suggested a cut-off point of K-HAQ using the data of patients with hypochondriasis, but the number of patients used in cut-off point analysis seemed to be insufficient. Therefore, future studies will need to check the health anxiety level of patients with hypochondriasis using K-HAQ and re-testify the cut-off point. Second, as K-HAQ is based on the cognitive-behavioral model, it is necessary to conduct research to apply cognitive-behavioral therapy to patients with hypochondria using HAQ and to verify its therapeutic efficacy.
The online-only Data Supplement is available with this article at
This study was supported by Wonkwang University in 2018.
The ROC curve for the K-HAQ to investigate the optimal cut-off score. ROC: receiver operating characteristics, K-HAQ: Korean version of Health Anxiety Questionnaire.
The demographic characteristics and descriptive statistic of the sample by group
Normal group (N=189) | Hypochondriasis group (N=43) | |
---|---|---|
Age, years: mean (SD) | 30.15 (12.51) | 55.76 (16.08) |
Gender | ||
Male: mean (%) | 47 (24.90) | 15 (34.88) |
Female: mean (%) | 142 (75.10) | 28 (65.12) |
Education, years: mean (SD) | 14.58 (1.04) | 11.33 (3.48) |
Total score of K-HAQ: mean (SD) | 12.76 (9.29) | 32.60 (12.08) |
Total score of K-IAS: mean (SD) | 63.72 (14.48) | 82.04 (17.22) |
Total score of SOM-H: mean (SD) | 4.70 (2.33) | 15.35 (4.79) |
K-HAQ: Korean version of Health Anxiety Questionnaire, K-IAS: Korean version of the Illness Attitude Scale, SOM-H: Somatic Complaints-Health concern of Korean version of Personality Assessment Inventory, SD: standard deviation
The goodness-of-fit for the 3-, 4-, and 5-factor model by factor analysis solutions
FAS | Model | Cumulative % of variance explained | χ2 | df | TLI | CFI | RMSEA |
---|---|---|---|---|---|---|---|
EFA | 3-factor | 60.50 | 299.067 | 150 | N/A | N/A | 0.073 |
4-factor | 65.47 | 224.701 | 132 | N/A | N/A | 0.061 | |
5-factor | 69.99 | 161.637 | 115 | N/A | N/A | 0.046 | |
CFA | 3-factor | 60.50 | 432.56 | 189 | 0.871 | 0.895 | 0.083 |
4-factor | 65.47 | 397.33 | 187 | 0.888 | 0.909 | 0.077 | |
5-factor | 69.99 | 384.86 | 184 | 0.891 | 0.913 | 0.076 |
FAS: Factor Analysis Solutions, EFA: Exploratory Factor Analysis, CFA: Confirmatory Factor Analysis, TLI: Tucker-Lewis index, CFI: comparative fit index, RMSEA: root mean square error of approximation
Factor loading of the K-HAQ items for the 4-factor model by exploratory factor analysis
Item | Factor 1 | Factor | Factor 3 | Factor 4 |
---|---|---|---|---|
01. Do you ever worry about your health? | -0.474 | -0.328 | -0.583 | |
02. Are you ever worried that you may get a serious illness in the future? | -0.438 | -0.427 | -0.473 | |
03. Does the thought of a serious illness ever scare you? | -0.479 | -0.497 | -0.448 | |
04. When you notice an unpleasant feeling in your body, do you tend to find it difficult to think of anything else? | -0.406 | -0.473 | -0.458 | |
06. If you have an ache or pain do you worry that it may be caused by a serious illness? | -0.380 | -0.523 | -0.643 | |
07. Do you ever find I difficult to keep worries about your health out of you mind? | -0.522 | -0.478 | -0.537 | |
08. When you notice an unpleasant feeling in you body, do you ever worry about it? | -0.476 | -0.513 | -0.632 | |
09. When you wake up in the morning, do you find you very soon begin to worry about your health? | -0.254 | -0.332 | -0.322 | |
10. When you hear of a serious or the death of someone you know, does it ever make you more concerned about your own health? | -0.366 | -0.567 | -0.503 | |
11. When you read or hear about an illness on TV or radio, does it ever make you think you may be suffering from that illness? | -0.410 | -0.605 | -0.564 | |
18. Do you ever feel afraid that you may have any other serious illness? | -0.501 | -0.492 | -0.508 | |
19. Have your bodily symptoms stopped you from working during the past six months or so? | 0.387 | -0.140 | -0.265 | |
20. Do your bodily symptoms stop you from concentrating on what you are doing? | 0.508 | -0.306 | -0.403 | |
21. Do your bodily symptoms stop you from enjoying yourself? | 0.538 | -0.369 | -0.338 | |
14. Do you ever feel afraid of news that reminds you of death (such as funerals, obituary notices)? | 0.445 | -0.221 | -0.405 | |
15. Do you ever feel afraid that you may die soon? | 0.570 | -0.353 | -0.438 | |
16. Do you ever feel afraid that you may have cancer? | 0.730 | -0.421 | -0.533 | |
17. Do you ever feel afraid that you might have heart disease? | 0.589 | -0.334 | -0.498 | |
05. Do you ever examine your body to find whether there is something wrong? | 0.471 | -0.386 | -0.298 | |
12. When you experience unpleasant feeling in your body, do you tend to ask friends or family about them? | 0.526 | -0.261 | -0.496 | |
13. Do you tend to read up about illness and disease to see if you may be suffering from one? | 0.569 | -0.364 | -0.417 |
K-HAQ: Korean version of Health Anxiety Questionnaire, Factor 1: “Health worry and preoccupation”, Factor 2: “Interference with life”, Factor 3: “Fear of illness and health”, Factor 4: “Reassurance-seeking behavior”
Inter-factor correlations of 4-factor model in the K-HAQ
Factor 1 | Factor 2 | Factor 3 | Factor 4 | |
---|---|---|---|---|
Factor 1 | 1.00 | |||
Factor 2 | 0.56 | 1.00 | ||
Factor 3 | 0.60 | 0.30 | 1.00 | |
Factor 4 | 0.65 | 0.39 | 0.47 | 1.00 |
K-HAQ: Korean version of Health Anxiety Questionnaire, Factor 1: “Health worry and preoccupation”, Factor 2: “Interference with life”, Factor 3: “Fear of illness and health”, Factor 4: “Reassurance-seeking behavior”
Correlation analysis of K-HAQ with other hypochondriasis scales for the concurrent validity (N=189)
K-HAQ | K-IAS | SOM-H | |
---|---|---|---|
K-HAQ | 1.00 | ||
K-IAS | 0.798 |
1.00 | |
SOM-H | 0.359 |
0.356 |
1.00 |
p<0.000.
K-HAQ: Korean version of Health Anxiety Questionnaire, K-IAS: Korean version of the Illness Attitude Scale, SOM-H: Somatic Complaints-Health concern of Korean version of Personality Assessment Inventory
Sensitivity and specificity for a selection of cut-off points on the K-HAQ
Cut-off ≥ | Sensitivity (%) | Specificity (%) |
---|---|---|
15 | 81 | 56 |
16 | 77 | 60 |
17 | 77 | 64 |
18 | 74 | 68 |
19 | 74 | 71 |
20 |
71 |
75 |
21 | 68 | 76 |
22 | 68 | 77 |
23 | 58 | 81 |
24 | 55 | 83 |
25 | 52 | 83 |
suggested optimal cut-off point.
K-HAQ: Korean version of Health Anxiety Questionnaire
Summary of ROC analysis
AUC | SEM | 95% CI | Cut-off score (points) | Sensitivity (%) | Specificity (%) | |
---|---|---|---|---|---|---|
K-HAQ | 0.780 | 0.040 | 0.702–0.858 | 20 | 71 | 75 |
ROC: Receiver Operating Characteristic, K-HAQ: Korean version of Health Anxiety Questionnaire, AUC: area under the curve, SEM: standard error of the mean, CI: confidence interval