Cyberchondria levels in women with human papilloma virus

Abstract

Aim

To investigate the level of cyberchondria in patients with high‐risk human papilloma virus (HPV) positivity.

Methods

One hundred and forty women who applied to our clinic between July 2020 and September 2020 and were diagnosed with high‐risk HPV positivity or abnormal uterine bleeding (AUB) were included in the study. The Cyberchondria Severity Scale (CSS) was administered face‐to‐face to the participants. CSS and subscales scores of both groups of patients were evaluated and compared.

Results

The mean score of the patients on the CSS was 78.54 ± 22.09 and the patients with AUB and HPV(+) was 67.43 ± 19.87 and 84.16 ± 21.08, respectively. The mean subscale scores were as follows, compulsion 13.89 ± 6.49, distress 20.07 ± 7.54, excessiveness 22.40 ± 8.18, reassurance 15.07 ± 6.56, and mistrust of medical professionals 7.26 ± 3.62. The mean scores of the CSS and subscales except for the mistrust of medical professional subscale were higher in patients who were HPV‐positive than in other patients.

Conclusions

Women with HPV have higher levels of cyberchondria. Medical professionals can reduce this anxiety by giving information to patients.

Introduction

With the advent of technology and the increasing use of the internet, people have easy access to health‐related information. The proportion of all online adults who search the internet for health information is 89% and 60% in the past month. ¹ Searching online for health information has many advantages such as easy access, confidentiality, cost‐effectiveness, and the high variety and amount of information. However, in addition to these advantages, it also has disadvantages such as exposure to confusing, unreliable, conflicting, obsolete, or inaccurate information and health anxiety increase. ² , ³ , ⁴

In recent years, the term cyberchondria, related to online health research associated with increased distress and anxiety, has come to be known. Cyberchondria is a type of elevated anxiety concerning distress about one's health status due to online searches for health information. The Cyberchondria Severity Scale (CSS) was developed by McElroy and Shevlin to measure the experienced health anxiety in the face of excessive online health searches. ⁵

Cervical cancer is the fourth most common cancer in women worldwide. ⁶ Cervical cancer has lower incidence and mortality rates compared with uterine corpus cancer and ovarian cancer. However, it remains an important cause of morbidity and mortality in countries with limited access to screening and prevention programs. High‐risk human papilloma virus (HPV) is the main etiologic factor in the development of cervical intraepithelial neoplasia or cervical cancer and is detected in 99.7% of cervical cancer cases. ⁷ HPV is used effectively in cervical cancer screening. Although screening with the HPV test is beneficial in the early diagnosis and treatment of cervical cancer, it can also have some adverse effects. HPV positivity is associated with negative feelings such as fear, anxiety, stress, stigma, shame, and sadness. HPV is a very common sexually transmitted disease. ⁸ Knowing that it is transmitted in this way can have negative social and psychological consequences. In regions where talking about sex is taboo, women are more likely to obtain information from the internet.

The aim of this study was to investigate the level of cyberchondria in patients with high‐risk HPV positivity.

Methods

This study was approved by the ethics committee for clinical studies (approval number: 2020/14) of Zonguldak Bülent Ecevit University, Turkey. The study was conducted with patients who presented to the Zonguldak Obstetrics and Gynecology Hospital, Gynecologic Oncology Surgery outpatient clinic between July 15, 2020, and September 1, 2020, due to HPV positivity or abnormal uterine bleeding (AUB). In Turkey, women aged between 30 and 65 years are invited for HPV‐based screening by primary level health staff every 5 years. Patients who are positive for HPV in the national cervical cancer screening program are examined in gynecology or gynecologic oncology polyclinics. AUB, a term which refers to uterine bleeding of abnormal quantity, duration, or schedule, is a common gynecologic concern. Chronic heavy or prolonged uterine bleeding raise concerns about uterine cancer and can result in anemia and interfere with daily activities. AUB patients also have their examinations in gynecology or gynecologic oncology outpatient clinics.

The participants were administered the CSS. The minimum number of patients required for the comparison of two independent groups at 90% power 0.5 effect size, α = 0.05 is 180 (related calculation was calculated using the G*Power 3.1.97 software).

Patients who do not have internet access, did not use the internet in any way, those who used drugs that might cause mood changes, women with chronic diseases, and those who do not want to participate in the study were not included in the research. Before administering the questionnaire, the purpose of the research was explained to the participants and their verbal consent was obtained. The questionnaire was administered and the responses were recorded by a single researcher.

The CSS is a continuous psychometric scale that was developed by McElroy and Shevlin in 2014 to measure cyberchondria. The scale consists of 33 items and 5 subscales (compulsion, distress, excessiveness, reassurance, and mistrust of medical professionals). Items were evaluated using a five‐point Likert‐type rating (1: Never, 2: Rarely, 3: Sometimes, 4: Often, and 5: Always). The questions constituting the fifth factor were scored in reverse. The total cyberchondria score is calculated by summing the scores obtained from each question. The higher the score, the higher the level of cyberchondria.

Statistical analysis of the study was performed using the R 4.0.3 package program. The descriptive statistics of the quantitative variables in the study are given with their mean, SD, median, minimum and maximum values; qualitative variables are reported as frequency and percentage. The conformity of quantitative variables to normal distribution was examined using the Shapiro–Wilk test. The Mann–Whitney U test was used in the comparisons of two groups of quantitative variables that did not show normal distribution. Results less than p = 0.05 in all statistical analyses were considered statistically significant.

Results

A total of 140 women participated in the research. The average age of the participants was 43.86 ± 7.95 (range, 30–65) years. Seventy‐four (52.9%) participants had completed elementary school, 20 (14.3%) middle school, 34 (24.3%) high school, and 12 (8.6%) higher education. Ninety‐four (67.1%) of the participants had completed primary education, and 46 (32.9%) had high school or higher education. One hundred seven women were unemployed, and 33 women were working. Ninety‐three (66.4%) of the patients were diagnosed as having AUB, and 47 (33.6%) were HPV(+). Women in both groups were similar in terms of factors such as age, education level, and employment status.

The mean score of the patients on the CSS was 78.54 ± 22.09. The mean subscale scores were as follows, compulsion 13.89 ± 6.49, distress 20.07 ± 7.54, excessiveness 22.40 ± 8.18, reassurance 15.07 ± 6.56, and mistrust of medical professionals 7.26 ± 3.62. The mean score of the patients with AUB and HPV(+) was 67.43 ± 19.87 and 84.16 ± 21.08, respectively, and a statistically significant difference was found between them (p < 0.001). The mean subscale scores of patients who were HPV(+) were found to be significantly higher than patients with AUB, except for the “Mistrust of Medical Professionals” subscale score (p < 0.05). Table 1 shows the mean scores of the CSS and subscales and their comparisons according to the sociodemographic characteristics of the participants and the diagnosis at the time of admission.

TABLE 1.

Mean scores of the participants on the cyberchondria severity scale and subscales

	n	Compulsions	p	Distress	p	Excessiveness	p	Reassurance	p	Mistrust of medical professional	p	Total score	p
Education level
Primary education	94	13.0 ± 6.33	0.948	19.67 ± 8.08	0.446	20.80 ± 8.40	0.006	14.39 ± 6.70	0.098	7.93 ± 3.80	0.009	76.35 ± 22.97	0.211
High school or higher education	46	14.02 ± 6.79		20.69 ± 6.64		24.87 ± 7.22		16.13 ± 6.26		6.22 ± 3.06		81.93 ± 20.38
Employment status
Employed	33	14.24 ± 6.56	0.591	21.15 ± 5.93	0.304	25.63 ± 7.02	0.008	17.33 ± 6.21	0.022	6.27 ± 3.07	0.114	84.64 ± 17.19	0.066
Unemployed	107	13.69 ± 6.36		19.84 ± 8.01		21.43 ± 8.36		14.40 ± 6.57		7.51 ± 3.6		76.68 ± 23.31
Diagnosis
HPV	93	14.78 ± 6.51	0.002	21.78 ± 7.46	<0.001	23.98 ± 7.64	0.02	16.85 ± 6.63	<0.001	6.74 ± 3.37	0.027	84.16 ± 21.08	<0.001
AUB	47	12.11 ± 6.14		16.70 ± 6.56		19.28 ± 8.39		11.55 ± 4.80		8.28 ± 3.90		67.43 ± 19.87

Note: Bold indicates significant values (p < 0.005).

Abbreviations: AUB, abnormal uterine bleeding; HPV, human papilloma virus.

Discussion

Cervical cancer is one of the most common malignancies among women worldwide: in 2018 alone, there were approximately 570 000 new cases and 311 000 female deaths. ⁹ Cervical cancer is closely associated with HPV infection. Almost all cervical cancer cases (99%) are linked to infection with high‐risk HPV, an extremely common virus transmitted through sexual contact. Cervical cancer is screened by many methods, including HPV. Although HPV is a very effective method in cervical cancer screening, it can cause adverse social and psychological effects for women who are positive for HPV. The sexual transmission of HPV is mainly responsible for these effects. In studies examining the psychosocial effects of the positivity of other sexually transmitted diseases, it was concluded that the diagnosis had negative psychosocial effects. ¹⁰ , ¹¹

In the study of McCaffery et al., in which the authors examined the social and psychological effects of the HPV test for cervical cancer screening on 74 participants, positive HPV tests were found to be associated with negative psychological and social effects. Participating women stated that they felt, anxious, stigmatized, and stressed. In addition, the women declared that they were worried about their sexual relationships and concerned about revealing their test results to others. The authors stated that these negative effects of HPV were related to women's relationship history and status, social, religious, and cultural norms, sexual experiences, and understanding of HPV. ¹²

Patients with positive HPV screening results use the internet to obtain more information after learning their results, where they can find a significant amount of wrong and misleading information. In previous studies, 50% of women with an abnormal PAP‐smear test or a positive HPV test were afraid of dying of cancer. ¹³

In the PODCAD study, in which 3753 women were surveyed, the effect of HPV positivity or abnormal results detected in PAP‐smears on the psychological stress of women was investigated. Approximately 70% of the participants were afraid of developing cancer and 30% had symptoms of post‐traumatic stress disorder. Abnormal results detected in cervical cancer screening affect the psychology of patients, regardless of the severity of the findings and knowledge. ¹⁴

In studies on HPV screening, short‐term increased distress, anxiety, and concern were found in women who were HPV‐positive, but it was not observed at the 6‐month follow‐up. ¹⁵ , ¹⁶ Also, women with positive HPV screening results had higher anxiety and distress than women with negative results. ¹⁷

The internet affects every aspect of life. It changes people's behavior, communication, and emotions, and also their lifestyles. Lifestyle changes occur in the social field as well as in the medical field. ¹⁸ , ¹⁹ Although the internet is a good source of health information, it can cause increased anxiety and fear in sensitive people. ²⁰ Cyberchondria is a concept that emerged and became popular in the last two decades. Cyberchondria was defined by McElroy and Shevlin as a form of anxiety characterized by excessive online health‐seeking behavior, and they developed a psychometric scale to measure this anxiety, the CSS. ⁵

Sexuality is a difficult topic to talk about in Muslim countries such as Turkey, even though it is a secular country. The sexual transmission of HPV makes it difficult for women to obtain information about this infection from sources such as medical professionals. The internet is an easily accessible and confidential source of information. We observed that women with HPV positivity mostly researched their status on the internet and their anxiety levels were high. In our study, we compared the CSS scores of patients who presented with HPV positivity or AUB. The mean CSS score of patients who were HPV‐positive was 84.16 ± 21.08, whereas it was 67.43 ± 19.87 in patients with AUB, which was statistically significantly different. We have confirmed our observations of cyberchondria in patients with HPV positivity with our study. The mean scores of the four subscales were higher in patients with HPV positivity than in the other patients, and the mean score of the patients in the mistrust of medical professionals subscale was lower.

The CSS is a continuous scale. It has no cut‐off value. The higher the score, the higher the level of cyberchondria. Few studies have been performed using the CSS. In Norr et al.'s study, which was completed online by 526 participants, the average CSS score was 74.9 and subscale scores were compulsion 14.28 ± 7.66, distress 15.79 ± 8.23, excessiveness 21.20 ± 7.51, reassurance 13.21 ± 5.61, and mistrust of medical professionals 10.51 ± 3.51, respectively. The authors stated that unique relations between general and specific cyberchondria factors with lower‐order health anxiety dimensions. ²¹ In Fergus's study involving 539 adults living in the United States, the average CSS score was 69.14 ± 21.28. The mean subscale scores were as follows, compulsion 13.01 ± 6.09, distress 15.65 ± 7.22, excessiveness 20.85 ± 6.73, reassurance 12.61 ± 5.01, and mistrust of medical professionals 7.02 ± 3.14. ²² In the study of Barke et al., in which 500 people living in Germany participated online, the average score was 60 and it was determined that the German version of the CSS possesses very good psychometric characteristics, which were preserved in a short version. ²³ In a study conducted with 337 university students from Turkey, the mean CSS score was found as 74.31 ± 17.57 and it was stated thar CSS is a scale suitable for the Turkish language. ²⁴ The mean scores of the CSS and subscales of all patients in our study and patients with AUB were similar to other studies cited. However, the average CSS score and the subscale scores except for the mistrust of medical professional subscale of women with HPV positivity were higher.

Cervical cancer screening with HPV tests is accepted and used all over the world. It is very important for the early detection of cervical cancer. Compared with other patient groups, patients who are HPV‐positive may experience increased anxiety and health‐seeking behaviors on the internet due to the fear of cancer and the problems that may arise because it is a sexually transmitted disease. This anxiety of patients can be relieved by medical professionals. It should not be forgotten that although the CSS score of this patient group was higher than in the other patient group, the score regarding mistrust of medical professionals subscale was lower.

Author contributions

Anil T. Cakir: Contributed to collecting data, statistics and analyzing data, design, compiling and discussion, conceived the project, and authored the manuscript.

Conflict of interest

The author declares no conflict of interest for this article.

Data availability statement

Data available on request from the authors.