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Online Information Review

Online Health Information Seeking among Women: The Moderating Role of Health Consciousness
Ashraf Sadat Ahadzadeh, Saeed Pahlevan Sharif, Fon Sim Ong,
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Online Health Information Seeking among Women:

Moderating Role of Health Consciousness

Abstract

Purpose: The two major aims of this study are: (i) to test the moderating effect of health

consciousness on the influence of attitude towards Internet usage for health information

seeking behavior; and (ii) to examine whether health consciousness moderates the influence
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of perceived health risk on the Internet usage for health information which is mediated by

perceived usefulness of Internet and attitude towards Internet usage in an integrated model

underpinned by health belief model and the technology acceptance model.

Methodology: Data obtained for the current study were collected using convenience

sampling and the sample consisted of women who not only have Internet access but used the

Internet in their daily life. Partial Least Squares-Structural Equation Modeling (PLS-SEM)

method was used to test the research hypotheses developed from a sample of 270

respondents.

Findings: Findings revealed that health consciousness moderates the influence of attitude

towards Internet use for health information seeking. In addition, the results also showed that

the positive indirect effect of perceived health risk on Internet usage for health information

seeking through perceived usefulness of Internet and attitude towards Internet usage is

significant for high level of health consciousness but not for the medium and low levels of

health consciousness.

1
Originality: Major contribution of this study is in the testing of the moderating role of health

consciousness on the mediating effect of perceived usefulness of the Internet and attitude on

perceived health risk and Internet usage for health information seeking.

Keywords: Technology Acceptance Model, Health Belief Model, Online Health


Information Seeking, Health Consciousness, Moderated Mediation Effect.
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Introduction

People have become increasingly reliant on the Internet as a means of obtaining relevant

information to aid decision making in various aspects of their daily lives, including health

matters (Fox & Duggan, 2013; Fox & Jones, 2009; Laurent & Vickers, 2009). Evidence in

the literature suggests that women demonstrate more online health information seeking

behaviour compared to men (Fox & Duggan, 2013; Fox & Jones, 2009). In Malaysia, using

the Internet to manage health and to learn more about diseases has become increasingly
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important (Mohan & Razali Raja Yaacob, 2004) due to the increasing prevalence of chronic

diseases, in particular among women (Amal, Paramesarvathy, Tee, Gurpreet, & Karuthan,

2011). Although the number of male Internet users is higher than female users, women are

the dominant Internet users in terms of health information seeking (Komathi & Maimunah,

2009).

To date, several studies have investigated Internet usage for health information seeking (IHI)

behaviour among women by employing the Technology Acceptance Model (TAM) (Dillard,

Couper, & Zikmund-Fisher, 2010; Lim et al., 2011; Wilson & Lankton, 2004; Wong, Yeung,

Ho, Tse, & Lam, 2012). However, a recent study took one step further and proposed the use

of an integrated model of TAM and Health Belief Model (HBM) to overcome the

parsimonious/limitations of TAM and HBM and also to provide a better explanation of the

mechanism that brings about Internet health information seeking behaviour (Ahadzadeh,

Pahlevan Sharif, Ong, & Khong, 2015). Ahadzadeh et al. (2015) sought to explain the

mechanism and process through which the psychological orientation of perceived health risk

(PHR) influences Internet searching for health information. In this regard, the dimensions of

TAM i.e. the perceived usefulness of the Internet (PUI) for health information and the

attitude towards the Internet (AI) usage for health information could mediate the relationship

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between perceived health risk with two dimensions, i.e. perceived susceptibility to chronic

diseases (HCD) and perceived severity of chronic diseases (SCD), and information seeking

behaviour for better health management.

Although the attitude dimension in TAM could help to explain health information seeking

behavior, it is insufficient in itself since factors that are closely related to a person’s

personality can also play a significant role in their behaviour (Ajzen & Fishbein, 1977).

Health consciousness (HC) as an intrinsic health motivator can be seen as a factor driving
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health-related behaviors such as Internet health information seeking (Dutta-Bergman, 2004a,

2004b). In the integrated model combining both the HBM and TAM constructs, the results

suggested that health consciousness as an antecedent positively contributes to health

information seeking behaviour (Ahadzadeh et al., 2015).

Although informative, the predominant focus on health consciousness as an antecedent of

online health information seeking in the previous research has overlooked the possibility that

it may act as a moderating factor on Internet usage for health information seeking

(Ahadzadeh et al., 2015; Dutta-Bergman, 2004a, 2004b). Health consciousness can be seen as

a moderator impacting on the relationship between attitude and Internet usage for health

information seeking. By including health consciousness in the mediating model proposed by

Ahadzadeh et al. (2015) the mediation model can be extended into a moderated mediation

model. In other words, it can be further hypothesized that the mediation effect of the

perceived usefulness of the Internet and attitude towards Internet usage are moderated by

health consciousness. Table 1 shows the abbreviations for the terms used in the research

model.

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[Insert Table 1 here]

The main aim of this study is to test the moderating effect of health consciousness on the

influence of cognitive belief as measured by the perceived usefulness of Internet and attitude

towards Internet within an integrated model of HBM and TAM. The second major objective
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is to test whether health consciousness acts as a moderator on the effect of perceived health

risk on Internet usage, mediated by perceived usefulness of Internet and attitude towards this

technology.

Literature

Internet Usage for Health Information Seeking Using an Integrated Model

This study employs the integrated model proposed by Ahadzadeh et al. (2015) for health

information seeking behaviour by simultaneously using HBM and TAM. According to HBM,

the likelihood of engaging in a health managing behaviour or preventive health behaviour

such as health information seeking on the Internet is determined by the level of individuals’

perceived health risk which is a function of perceived susceptibility to disease and perceived

severity of disease (Champion & Skinner, 2008; Rosenstock, 1966). Higher health risk

perception is assumed to reflect higher levels of uncertainty regarding health and greater

health information insufficiency (Bond & Nolan, 2011; Burgess, Donovan, & Moore, 2009;

Johnson & Slovic, 1995), which in turn leads to health information seeking behaviour

(Huurne & Gutteling, 2008; Kwon, Kahlor, & Kim, 2011) particularly via the Internet

(Ahadzadeh et al., 2015; Dillard et al., 2010; Yun & Park, 2010).

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From the HBM perspective, Internet health information seeking can be explained merely by

health factors (Ahadzadeh et al., 2015; Yun & Park, 2010), while TAM postulates that the

effect of cognitive beliefs, i.e. the perceived usefulness of the technology, its perceived ease

of use and attitudes towards technology usage in general exercise a decisive influence on

whether a specific technology is adopted or not (Davis, 1989).

According to Davis, perceived usefulness as a core variable of TAM is defined as the belief

that using the technology would bring benefits to the user while perceived ease of use
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addresses the extent of effort which is needed to use a technology (Davis, 1989). By linking

HBM to TAM in an integrated model, the relationship between perceived health risk and

perceived usefulness of Internet is centered on the premise that individuals will use the

Internet to search for health information in order to reduce risk, owing to their sense of

uncertainty over their health status and a perceived health knowledge gap (Ahadzadeh et al.,

2015). Therefore, engaging in Internet searches for information on health can be seen as

beneficial as it reduces the perceived health risk as found in Rains’s study (2014).

Besides perceived usefulness, perceived ease of Internet use (PEI), which measures

perceptions of the ease or difficulty in using a particular technology, is an important and a

powerful variable in predicting patterns of technology usage within the TAM framework

(Davis, 1989). Together with perceived usefulness of Internet, these two variables form the

cognitive belief component of technology usage as they shape individuals’ attitude towards

technology, which in turn affects its usage level (Davis, 1989). Indeed, past studies have

produced evidence in support of the effect of perceived usefulness and perceived ease of

Internet use for health information on attitude towards the Internet (Ahadzadeh et al., 2015;

Kim & Park, 2012; Wong et al., 2012). For example, Yun and Park (2010) found that

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perceived usefulness of disease information seeking on the Internet positively influences

attitude towards looking for disease information on the Internet. Furthermore, Wong et al.

(2012) found that the attitude of older Chinese adults’ towards the Internet as a source of

health information has a significant positive correlation with the intention to use the Internet

for health information seeking, indicating that individuals with more positive and favorable

affective feelings towards the Internet showed greater Internet usage for health information.

Based on the TAM framework and the supporting literature, we are able to develop the
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following hypothesis:

Hypothesis 1: Attitude towards Internet usage for health information has a positive influence

on the Internet usage for health information seeking.

All prior studies mentioned in the relevant literature indicated the positive influence of

attitude towards Internet on Internet usage for health information, the magnitude of this

influence was found to vary from study to study (Ahadzadeh et al., 2015; Kim & Park, 2012;

Yun & Park, 2010). Studies carried out by Wong et al. (2012) and Ahadzadeh et al. (2015)

showed that attitude towards Internet had only a slight influence on Internet health

information seeking behavior, whereas a more substantial influence was discernible in other

studies (Kim & Park, 2012; Yun & Park, 2010). That said, variations in the magnitude of

attitude influence have not been a principal focus for researchers of Internet health

information seeking behavior. Evidence regarding the strength or weakness of attitude

towards Internet has failed to respond to the question of why attitude towards Internet made

different predictions of behaviour for Internet adoption for health information. In addition,

hardly any studies focused on the conditions that could predict the strength of the influence of

attitude on Internet usage behaviour for health information. In other words, do we know when

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to expect attitude to act as a strong influence? Emphasis is now being placed on defining the

conditions under which attitude towards Internet can be expected to exert a significant

positive influence on Internet health information seeking behavior. One possible explanation

might be found is health consciousness level that acts as the factor that accounts for the

strength of influence of attitude on Internet usage behavior. In other words, an individual who

is very conscious of their health could reasonably be expected to have a strong orientation

towards seeking information or knowledge related to health issues. Health consciousness has

often been investigated as an antecedent of health behaviour (Chen, 2011; Wen & Li, 2013),
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particularly regarding Internet usage for health information seeking (Ahadzadeh et al., 2015;

Dutta-Bergman, 2004a; Yun & Park, 2010) and as an outcome variable (Hussain, Ashai, &

Hussain, 2012; Lin, Li, & Lan, 2013). However, little is known regarding health

consciousness as a moderator affecting the influence of attitude on health behavior.

Moderating Effect of Health Consciousness

Different scholars have offered different definitions of health consciousness over the passage

of time (Dutta-Bergman, 2004a; Gould, 1988; Jayanti & Burns, 1998; Kraft & Goodell, 1993;

Moorman & Matulich, 1993). By reviewing studies on health consciousness carried out over

the last two decades, Hong (2009) defined health consciousness as one’s orientation toward

overall health and conceptualized it as a concept comprised of three elements namely self-

health awareness, personal responsibility, and health motivation. Accordingly, health

conscious people are aware of and concerned about their wellbeing, accountable for their

health and motivated to improve and/or maintain their level of health (Dutta-Bergman, 2004a,

2004b; Gould, 1990). Health consciousness could drive a person towards actively seeking for

health-related information because a health conscious person is motivated to engage in health

preventive behaviors such as health information seeking in order to achieve and maintain

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good health (Dutta-Bergman, 2004a, 2004b, 2006). A growing body of literature suggests

that health consciousness is a predictor for the use of communication channels for health

information seeking (Dutta-Bergman, 2006; Gould, 1990; Moorman & Matulich, 1993),

especially the Internet (Ahadzadeh et al., 2015; Dutta-Bergman, 2004a, 2004b; Yun & Park,

2010).

Past research shows that health consciousness increases the amount of health-related

information sought from media sources such as TV, radio programs, books, newspapers,
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magazines, advertising and pamphlets about health (Moorman & Matulich, 1993). Individuals

with a higher degree of health consciousness will tend to have a more positive attitude

towards Internet, consequently being more willing to engage in online health information

seeking behaviour in order to maintain their good health and prevent diseases (Ahadzadeh et

al., 2015; Yun & Park, 2010). On the contrary, it is difficult to expect people who have a low

degree of health consciousness to use the Internet for health information seeking.

Consequently, they rarely use the Internet for health information to maintain, promote, and

manage their health although they may well use the Internet for other purposes. Therefore,

health consciousness can act as a moderator for the relationship between attitude towards

Internet use for health information and the utilization of the Internet for health information

seeking. Depending on the degree of health consciousness, the influence of attitude on

Internet use may vary. It would be reasonable to expect attitude to have a more positive effect

on Internet usage for individuals with high level of health consciousness as opposed to those

who are less health conscious.

To date, no study has examined the moderating role of health consciousness on the influence

of attitude towards Internet, although there have been limited attempts to examine the

9
moderating influence asserted by health consciousness. For example, Chen (2011) examined

the combined moderating influence exerted by health consciousness and healthy lifestyle on

the relationship between attitude and willingness to consume functional foods and found that

“health consciousness and healthy lifestyle exert impact on willingness to use functional

foods”. Thompson and Chambers (2000) found no discernible interaction between self-

consciousness and health consciousness on health behaviors among Africans. While past

studies on health consciousness show conflicting results, it could be argued that health

consciousness is more appropriately hypothesized as producing a moderating effect on health


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behaviour since health consciousness is expected to drive individuals towards seeking for

more health-related information. Thus, the following hypothesis is proposed:

Hypothesis 2: Health consciousness moderates the influence of attitude towards Internet

usage for health information on the Internet usage for health information seeking.

By introducing health consciousness into the integrated model of HBM and TAM

(Ahadzadeh et al., 2015), it could act as a moderator for the influence of Internet usage

through perceived usefulness of Internet and attitude towards this technology. By testing this

moderation effect, it is possible to show the extent to which health consciousness interacts

with perceived usefulness of Internet and attitude towards Internet in such a way that the

extent of the indirect effect of perceived health risk on Internet usage for health information

is based on the subjective assessment of individuals’ degree of health consciousness.

In other words, the impact of perceived health risk on Internet usage for health information

behaviour can be seen as the result of the moderating influence of health consciousness on

the mediation effect of perceived usefulness and attitude. We can achieve this test by

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extending the mediation model of Internet usage for health information seeking into a

moderated mediation model.

This will bridge the existing gap in the body of literature and specifically address the gap in

Ahadzadeh et al.’s study (2015) which focused only on the mediation effect of perceived

usefulness of Internet and attitude for the relationship between perceived health risk and

Internet health information seeking behaviour in the integrated model of HBM and TAM.

Therefore, based on the above, we propose the following hypothesis:


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Hypothesis 3:

Hypothesis 3: Health consciousness moderates the effect of perceived health risk on the
Internet usage for health information seeking which is mediated by Perceived usefulness of
Internet and attitude towards Internet usage for health information.

Method

Sample and Data Collection

The respondents of this study were comprised of Malaysian females living in the state of

Selangor, the most urbanized state in Malaysia. Convenience sampling was used. Women

who were also Internet users were selected as the sample for the purpose of this study since

past research has found that they tend to be educated, married, and resident in urban areas

(Bowen et al., 2003; Choi, 2011). Furthermore, they tend to search for information regarding

health (Fox & Duggan, 2013). Using the drop and collect method, a questionnaire was

distributed only to those who expressed their willingness to be involved as respondents. The

convenience samples were sourced from women working in governmental institutions located

in Selangor state through friends’ contacts.

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Out of 380 questionnaires distributed, 330 completed questionnaires were obtained. From the

330 sets of questionnaires returned, 270 responses were usable after excluding cases that

turned out not to have used the Internet for health-related purposes and also those cases

where the information was incomplete.

The sample consisted of women, a large proportion of whom (45%) were in the age group of

30-39 years old. Those aged 20-29 years made up 39% of the sample while the rest were aged

40 years or older. The majority of them were married, with only one third of them being
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single. As these women worked in the government sector, their educational level was

representative of the Malaysian workforce, with 49% having college or university education.

Those with secondary education made up 46% of the respondents.

Measurement of Variables

Perceived health risk

Perceived health risk comprises two components: perceived susceptibility to chronic diseases

and perceived severity of chronic diseases. Six items adopted from Kim and Park (2012) and

Bryan et al. (1997) were used to measure perceived susceptibility to chronic diseases while

perceived severity of chronic diseases was measured by four items adopted from Kim and

Park’s study (2012). The items were measured on a 1 to 5 point scale ranging from 1

(strongly disagree) to 5 (strongly agree).

Health consciousness

Participants’ health consciousness was evaluated by eleven items developed by Hong (2009)

The items were measured on a 1 to 5 point scale ranging from 1 (strongly disagree) to 5

(strongly agree).

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Perceived usefulness of Internet

Perceived usefulness of Internet for health information seeking was measured using four

items developed by Davis (1989). However, it proved necessary to modify Davis’ items as

they were originally intended to measure the perceived usefulness of computers in job

performance. In the context of this study, computer use was replaced with Internet use and

job performance was replaced with health information seeking. The items were measured on

a 1 to 5 point scale ranging from 1 (strongly disagree) to 5 (strongly agree).


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Perceived ease of Internet use

Four items developed by Davis (1989) were used to measure perceived ease of Internet use.

The items were measured on a 1 to 5 point scale ranging from 1 (strongly disagree) to 5

(strongly agree).

Attitude toward Internet

Attitude toward Internet use for health information searching was measured by 4 items

incorporated from Wong et al.’s study (2012) The items were measured on a 1 to 5 point

scale ranging from 1 (strongly disagree) to 5 (strongly agree).

Internet usage for health information seeking

Internet usage for health information seeking was measured by eleven items adopted from

past studies (Hale, Cotten, Drentea, & Goldner, 2010; Kim & Park, 2012; Yoo & Robbins,

2008). Respondents were asked to indicate how frequently they use the Internet as a resource

for health and medical information. All eleven items were rated on a 5-point Likert-type scale

(5= Always, 4= Often, 3= Sometimes, 2= Rarely, and 1= Never). Higher scores indicated a

higher frequency of Internet usage for health information seeking.

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Data Analysis Method

Generally, there are two approaches to perform Structural Equation Modeling (SEM),

including covariance-based SEM (CB-SEM) and variance-based SEM which is also known

as PLS-SEM. This study used PLS-SEM method and SmartPLS software 2.0 (Smart PLS 2.0

(beta), 2005 ) to test the research hypotheses. PLS-SEM is suitable for both reflective

(perceived usefulness, attitude towards Internet, health consciousness, perceived

susceptibility to disease and perceived severity to disease) and formative constructs (Internet
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usage for health information and perceived health risk). Besides, in contrast to covariance-

based SEM, PLS-SEM does not look at a theoretical model as a whole which makes it

appropriate for assessing the relatively new measurement model of Internet usage for health

information (Ahadzadeh et al., 2015; J. Hair, Hult, Ringle, & Sarstedt, 2014; Henseler,

Ringle, & Sinkovics, 2009; Pahlevan Sharif & Mahdavian, 2015; Yang, Pahlevan Sharif, &

Khoo-Lattimore, 2015). Indeed, when CB-SEM assumptions are violated (in this case, when

there are formative constructs in the model, and data are non-normally distributed), PLS-

SEM is a good methodological alternative for theory testing and is seen as a ‘silver bullet’ for

assessing causal models in many theoretical models and empirical data situations (Hair et al.,

2011; Yang et al., 2015). For the purposes of assessing a model with second-order constructs,

three different approaches are suggested: these being the repeated indicator approach, the

two-stage approach, and the hybrid approach (Becker, Klein, & Wetzels, 2012). For the

model in his research, the two-stage approach is the most appropriate method for assessing

perceived health risk, due to the dissimilar number of indicators for perceived health risk

across perceived susceptibility to and severity of chronic diseases (Becker et al., 2012).

14
RESULTS

Measurement Model Assessment

In order to assess measurement models of reflective constructs, this research evaluates their

reliability as well as their convergent and discriminant validity (J.F. Hair, Black, Babin, &

Anderson, 2010). As reported in Table 2, construct reliability of all reflective constructs

varies from 0.872 to 0.931 which is greater than 0.7 indicating a good level of reliability (J.F.

Hair et al., 2010; Nunnally & Bernstein, 1994). Moreover, average variance extracted (AVE)
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from all reflective constructs is greater than 0.5 (varying from 0.608 to 0.789) and the

construct reliability of each construct is greater than its respective AVE. This shows that

convergent validity has been established. Furthermore, AVE of each construct is greater than

its maximum shared squared variance (MSV; varying from 0.035 to 0.254), and average

shared square variance (ASV; varying from 0.013 to 0.134) which fulfills the necessary

requirements for discriminant validity (Becker et al., 2012; Nunnally & Bernstein, 1994).

[Insert Table 2 here]

In order to evaluate the measurement model of formative constructs (Internet usage for health

information and perceived health risk), this study tests for collinearity among formative

indicators as well as their outer weights and outer loadings (Falk & Miller, 1992; Fornell &

Larcker, 1981). The results of this formative construct assessment are reported in Table 3. As

maximum variance inflation factor (VIF) for Internet usage (3.278) and perceived health risk

(1.036) does not exceed 5 and their indicators do not have high inter-correlation, the tests

indicated an absence of collinearity among indicators of formative constructs (Joe F Hair,

Ringle, & Sarstedt, 2011). Next, the relative and absolute contributions of indicators to

forming respective formative constructs are assessed by evaluating their outer weights and

outer loadings, respectively. As is shown, although only one of the indicators of Internet

15
usage for health information has significant outer weight, all of its outer loadings are

significant at 95% confidence level and make an absolute contribution to forming their

respective construct (outer loadings range from 0.444 to 0.829). Besides this, while perceived

susceptibility to and perceived severity of chronic diseases have significant outer weights

(0.746 and 0.820, respectively) to forming perceived health risk, their outer loadings (0.592

and 0.681) are greater than 0.5. Therefore, perceived susceptibility to and perceived severity

of diseases can be seen as contributing to their higher order construct and are retained in the

model (Joe F Hair et al., 2011).


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[Insert Table 3 here]

Structural Model Assessment


In order to test the research hypotheses, this study estimates the path coefficients of the

research statistical structural model shown in Figure 1.a and Figure 1.b by using a PLS

algorithm and their statistical significance is assessed by using the bootstrapping method with

2000 replications. Table 4 shows the results. The results show that the positive effect of

attitude on Internet usage (β = 0.132, t-value = 1.510) is not significant at 95% confidence

level, thus providing no support for H1, which posited that attitude towards Internet usage for

health information has a positive influence on the Internet usage for health information

seeking. This shows that in this study the effect of attitude on Internet health information

seeking behavior was not significant.

However, research results supported H2 which was developed to test the moderating effect of

health consciousness on the positive effect of attitude on Internet usage for health information

(β = 0.165, t-value = 2.345). This shows that the positive effect of attitude on Internet usage

is significantly stronger for individuals with a greater health consciousness. In other words,

16
individuals who are health conscious will use the Internet to search for health information,

indicating the indirect influence of attitude towards the Internet.

[Insert Figure 1.a. here]

[Insert Figure 1.b. here]

In order to test H3, the total effect of perceived health risk on Internet usage for health
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information is first examined. Next, the mediating model of the effect of perceived health risk

on Internet usage through perceived usefulness of Internet and attitude towards Internet

moderated by Health consciousness is tested. The results showed that the total effect of

perceived health risk on Internet usage (i.e. the model without the mediators and the

moderator) is significant at 95% confidence level (β = 0.285, t-value = 2.161). Next, testing

was conducted for the moderating role of health consciousness on the mediating effect of

perceived usefulness of Internet and attitude towards this technology on perceived health risk

and Internet usage of for health information seeking. The procedure suggested by Hair et al.

(2014) was followed and tests were conducted on the three levels of moderating effect of

health consciousness. The results showed no presence of the positive indirect effect of

perceived health risk on Internet usage for information seeking through perceived usefulness

and attitude for the medium (β = 0.010, t-value = 1.351) and low level of health

consciousness (β = -0.002, t-value = 0.258) as the relationship is not significant at 95%

confidence level. However, if the level of health consciousness gets higher, the mediating

effect of perceived usefulness and attitude was significant (β = 0.022, t-value = 1.739), thus

supporting the positive indirect effect of perceived health risk on Internet usage for health

information. By controlling the mediators, the direct effect of perceived health risk on

Internet usage was not significant (β = -0.047, t-value = 0.351), indicating full mediation

17
effect of perceived usefulness of Internet and attitude towards Internet for a high level of

health consciousness. The results supported H3 which posited the moderating effect of health

consciousness on the mediation effect of perceived health risk on Internet usage through

perceived usefulness and attitude is true for high level of health consciousness.

[Insert Table 4 here]

Discussion and Implications

The attitude-behaviour consistency explored in the present study shows that affective feelings
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towards the Internet fail to act as an accurate predictor of Internet usage for health

information seeking. This shows that women who have a positive attitude towards the

Internet still might not choose to use it for health purposes, further hinting at the influence of

other variables that could be used to explain the attitude-behaviour congruence for Internet

health information seeking behavior. These results do not lend support to past studies, which

indicate a significant positive effect for attitude on health information technology usage

(Ahadzadeh et al., 2015; Wong et al., 2012; Yun & Park, 2010).

In the current study, it was postulated that the attitude-behaviour effect is moderated by

health consciousness. To the best of the researchers’ knowledge, this study was the first

attempt to investigate the moderation effect of health consciousness on the influence of

attitude towards Internet. The hypothesis developed to test the moderating effect of health

consciousness on the positive influence of attitude towards the Internet was supported, with

evidence showing that affective feeling about Internet usage for health information seeking

and Internet usage is contingent upon on one’s level of health consciousness (H2). In this

study, respondents who had a high level of health consciousness tended to have a more

positive attitude towards using the Internet for health information seeking. Indeed, health

18
consciousness plays a significant role in determining the behaviour of individuals in regard to

their use of the Internet for health information seeking.

Another major contribution of this study is in the testing of the moderating role of health

consciousness on the mediating effect of perceived usefulness of Internet as well as attitude

towards Internet on perceived health risk and Internet usage behaviour for health information

seeking. The support for H3 establishes the mechanism that operates to explain how

perceived health risk leads to the search for information about health using the Internet. In
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other words, for individuals who exhibit high levels of health consciousness, the impact of

perceived health risk on Internet health information seeking is fully mediated by perceived

usefulness of the Internet and attitude towards using the Internet. This establishes the

sequential mediation of perceived usefulness of the Internet that in turn influences attitude

positively to result in information seeking behaviour for those who have a high level of health

consciousness. In this study, there are subgroups of women respondents (who are with low or

medium level of health consciousness) for whom a putative causal mechanism does not hold

true.

The results of this study provide a better explanation of the causal mechanism through which

perceived health risk influence Internet usage for health information seeking by using the

moderated mediation test. Compared to Ahadzadeh et al. (2015), this study has made a

further contribution by extending the mediation model into the moderated mediation model

whereby health consciousness moderates the influence of perceived health risk on Internet

usage which is mediated by perceived usefulness of Internet and attitude toward Internet.

19
The research findings revealed that Internet usage for health information seeking is driven by

women’s level of health consciousness. Cognitive beliefs and attitude towards Internet

mediate the influence of perceived health risk on Internet usage for health information and

are motivated by a high level of health consciousness. In fact, the proposed model

appropriately named as health consciousness-driven model of Internet health information

seeking behaviour shows how health consciousness drives health information seeking

behaviour among women. Therefore, Internet usage for health information seeking is a

proactive health behaviour rather than a reactive health behaviour. Health consciousness can
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act to trigger women’s concern about their health, subsequently leading to active engagement

in health behaviors such as Internet health/ disease information seeking. With most health

care systems striving to change people’s attitudes towards health management from

concentrating on seeking post-diagnostic treatment to active prevention of diseases, Internet

usage for health information along with high level of health consciousness could accelerate

the fulfillment of this proactive approach. Therefore, health intervention programs should

target health conscious women as opinion leaders to disseminate information regarding

health, in particular, those programs that can promote good health practices. In here lies the

role of the government in encouraging and promoting health consciousness which will benefit

the government in reducing the costs of health care and the toll on government health care

system. Health-related NGOs could play a more active role in recruiting females to assist in

disseminating information on disease prevention and care provision information for a

healthier society.

Limitations and Directions for Future Studies

The current study has several limitations. First, the small sample size focusing only on

women limits its generalizability to the population of Malaysia. Since health consciousness

20
can be equally applicable to both men and women, future studies should include males and

females of diverse socio-economic backgrounds, ethnicities, and age groups. Despite its

advantages, the drop and collect method tends to attract respondents who feel very strongly

about the topic in question. In addition, it also tends to be limited in geographical coverage.

These limitations provide opportunities for future research. A national study covering both

Peninsular and East Malaysia involving both the rural and urban population to provide a

better understanding on health information seeking behaviour using the Internet is desirable.

The moderating effect of health consciousness could also be tested using different health-
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related theories (e.g. theory of planned behavior, unified theory of acceptance and use of

technology, and theory of social support) with other constructs such as social influence/

social norm, and facilitating conditions to further test the mechanism of health information

technology usage from different perspectives. Besides the Internet, web-based technologies

such as social media are popular among people as sources for satisfying their need for

information. It would be useful to examine the usage of web-based applications such as social

networking sites and blogs as platforms for health-related information seeking.

The use of PLS-SEM is not without limitations. One of the disadvantages of using SEM

methods that has attracted the researchers’ attention recently is controlling for Type I and

Type II errors (Dijkstra & Henseler, 2015; J. F. Hair, Hult, Ringle, & Sarstedt, 2017;

McCoach, Black, & O'Connell, 2007). Indeed, in PLS-SEM that latent constructs are

aggregates of items, the error of the item is reflected in the latent construct which in turn will

influence the path coefficient estimates. This would result in underestimating the

relationships in the structural model and overestimating the relationships in the measurement

model known as “PLS-SEM bias” (J. F. Hair et al., 2017). Although researchers have been

aware of the bias (Dijkstra & Henseler, 2015; Fornell & Bookstein, 1982), due to its

advantages (e.g. estimating the composite models, predictive capabilities, being distribution-

21
free, lack of convergence problems, etc.) numerous researchers have used this method and its

application has been increasing exponentially (J. F. Hair et al., 2017). Dijkstra and Henseler

(2015) suggest that researchers may (i) avoid using PLS-SEM, (ii) use it while acknowledge

its limitations, or (iii) correct its estimates. To correct the PLS-SEM bias, they also introduce

consistent PLS method, known as PLSc, which can be used only for models with reflective

constructs. The current study pursues the second option. There are three reasons for this

choice. First it is because of the undeniable advantages of this method. Second, the model in

the present study consists of both reflective and formative constructs that do not allow the
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authors to apply PLSc in this study. Third, the simulation studies have indicated that the PLS-

SEM bias is at very low level (Reinartz, Haenlein, & Henseler, 2009; Ringle, Götz, Wetzels,

& Wilson, 2009). J. F. Hair et al. (2017) state in most empirical settings the bias is of limited

relevance. Similarly, according to Rigdon (2012, p. 304), “in practice the observed

differences are not substantively important.”

Conclusion

Based on the integrated model of Health Belief Model and Technology Acceptance Model,

this study has provided support for past studies concerning our knowledge about the positive

effect of perceived health risk on perceived usefulness of health information seeking using

the Internet. While the results do not provide a direct support for attitude-behaviour

congruence as explained by TAM, this study is able to explain health information seeking

behaviour using the Internet via the influencing role of health consciousness. With health

consciousness as the moderator, we established that individuals who exhibit a high level of

health consciousness tend to have a more positive attitude to their own health that results in

health information seeking behavior. Furthermore, by performing the moderated mediation

test, this study provides a useful insight into the mechanism through which a better

22
understanding of how perceived health risk influences the Internet usage for health

information seeking is achieved.

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Table 1: Abbreviations of the Terms Used in the Research Model
Technology Acceptance Model TAM
Health Belief Model HBM
Perceived health risk PHR
Health consciousness HC
(i) Perceived susceptibility to chronic disease HCD
(ii) Perceived severity of chronic disease SCD
Perceived usefulness of Internet PUI
Perceived ease of Internet use PEI
Attitude towards Internet AI
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Internet usage for health information seeking IHI


Table 2: Reflective Constructs Assessment
Construct / Measure (Construct Reliability (CR), Average Variance Extracted (AVE), Maximum Shared Outer Loadings
Squared Variance (MSV), Average Shared Square Variance (ASV)) (t-value)

Perceived susceptibility to chronic disease (CR = 0.918, AVE = 0.653, MSV = 0.035, ASV = 0.013)
HCD 1 I have a higher likelihood of getting chronic diseases. 0.857 (7.239)
HCD 2 There is a great chance that I will be exposed to a chronic disease. 0.862 (7.404)
HCD 3 I would say that I am the type of person who is likely to get chronic diseases. 0.870 (7.507)
HCD 4 There is a person with chronic disease among my family members. 0.835 (6.863)
HCD 5 I have a strong possibility of attack or deterioration of chronic disease due to improper daily
habits (drinking, smoking, dietary habit, lack of exercise, etc.). 0.717 (5.723)
HCD 6 It is most likely that I will catch chronic diseases in my lifetime. 0.685 (4.828)

Perceived severity of chronic diseases (CR = 0.907, AVE = 0.711, MSV = 0.035, ASV = 0.015)
SCD 1 I am afraid of facing attack or orientation of chronic diseases. 0.788 (4.543)
SCD 2 If I face attack or deterioration of chronic disease, I will have difficulty with my work life (or
domestic affairs). 0.841 (4.537)
SCD 3 If I face attack or deterioration of chronic disease, it will hinder my personal relationship. 0.895 (5.765)
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SCD 4 If I face attack or deterioration of chronic disease, I will be long haunted by resultant problems. 0.844 (5.734)

Health consciousness (CR = 0.925, AVE = 0.608, MSV = 0.189, ASV = 0.079)
HC 1 I’m very self-conscious about my health. 0.768(5.684)
HC 2 I’m generally attentive to my inner feelings about my health. 0.710 (5.531)
HC 3 I’m concerned about my health all the time. 0.809 (5.952)
HC 4 I notice how I feel physically as I go through the day. 0.854 (6.392)
HC 5 I take responsibility for the state of my health. 0.874 (6.352)
HC 6 Good health takes active participation on my part. 0.681 (5.801)
HC 7 Living life without disease and illness is very important to me. 0.784 (6.137)
HC 8 My health depends on how well I take care of myself. 0.740 (5.767)

Perceived usefulness of Internet (CR = 0.918, AVE = 0.789, MSV = 0.236, ASV = 0.113)
PUI 1 Using the Internet is useful in managing my daily health. 0.882 (45.797)
PUI 2 Using the Internet for health information is advantageous in better managing my health. 0.915 (63.408)
PUI 3 Using the Internet for health information is beneficial to me. 0.868 (38.414)

Perceived ease of Internet use (CR = 0.872, AVE = 0.630, MSV = 0.254, ASV = 0.076)
PEI 1 Learning to use the Internet for searching health information was easy for me. 0.699 (15.551)
PEI 2 My interaction with the Internet for health information is clear and understandable. 0.832 (38.360)
PEI 3 I find the Internet for health information to be flexible to interact with. 0.800 (32.570)
PEI 4 It is easy for me to become skillful at using the Internet for health information.
0.838 (38.151)

Attitude towards Internet use (CR = 0.931, AVE = 0.770, MSV = 0.254, ASV = 0.134)
AI 1 Using Internet for health information and health management would be a good idea. 0.906 (71.233)
AI 2 Using Internet for health information and health management would be a wise idea. 0.881 (56.237)
AI 3 I like the idea of using Internet for health information and health management. 0.859 (37.305)
AI 4 Using Internet for health information and health management would be a pleasant experience. 0.864 (32.972)
t(0.05, 1999) = 1.645616, t(0.01. 1999) = 2.328215, t(0.001, 1999) = 3.094314.
Table 3: Formative Constructs Assessment
Construct / Measure Indicator outer Indicator Outer
Weights Loadings
(t-value) (t-value)

Internet usage for health information seeking (IHI)


(Range of inter-item correlations= 0.212-0.726; Average inter-item correlation: 0.426; Max. VIF= 3.278)
IHI1 I use the Internet to get general health information 0.025 (0.191) 0.444 (3.897)
IHI2 I use the Internet to get information on medicine/drug 0.538 (4.257) 0.829 (11.021)
IHI 3 I use the Internet to be equipped with information before/after doctoral appointment -0.288 (1.296) 0.639 (5.854)
IHI 4 I use the Internet to get description of various diseases 0.224 (1.442) 0.734 (8.374)
IHI 5 I use the Internet to get information on treatments/therapy/ diagnosis 0.124 (0.708) 0.624 (5.957)
IHI 6 I use the Internet to get information on how to care for oneself -0.198 (1.407) 0.596 (6.183)
IHI 7 I use the Internet to decide about how to treat an illness 0.269 (1.486) 0.782 (8.881)
IHI 8 I use the Internet to decide about whether or not visit a doctor 0.120 (0.668) 0.661 (5.619)
IHI 9 I use the Internet to understand how to deal with an illness 0.277 (1.359) 0.731 (7.936)
IHI 10 I use the Internet to get information on hospitals/clinics/other healthcare facilities 0.019 (0.112) 0.515 (4.246)
IHI 11 I use the Internet to get information for health management (exercise, abstinence 0.179 (0.926) 0.563 (3.645)
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from drinking, smoking, diet, nutrition, stress, mental health, etc.)

Perceived Health Risk (PHR)


(Inter-item correlation= 0.187; Average inter-item correlation: 0.187; VIF= 1.036)
HCD Perceived Susceptibility to Chronic Diseases 0.746 (2.129) 0.592 (1.554)
SCD Perceived Severity to Chronic Diseases 0.820 (2.285) 0.681 (1.742)
t(0.05, 1999) = 1.645616, t(0.01. 1999) = 2.328215, t(0.001, 1999) = 3.094314.
Despite its advantages, the drop and collect method tends to attract respondents who feel very strongly about the topic in question. In addition, it
also tends to be limited in geographical coverage. These limitations provide opportunities for future research. A national study covering both
Peninsular and East Malaysia involving both the rural and urban population to provide a better understanding on health information seeking
behavior using the Internet is desirable.
Table 4: Direct, Indirect, and Total Effects

Path Coefficient Percentile 95%


(t-value) confidence
intervals

Total Effect
IHI
(R2 = 10.48%; Q2 = 8.77%)
 PHR 0.285* (2.161) [0.068; 0.502]
 PEI 0.142** (2.648) [0.054; 0.230]

Direct Effect
PUI
(R2 = 3.35%; Q2 = 2.70%)
 PHR 0.212** (2.838) [0.089; 0.335]
AI
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(R2 = 36.92%; Q2 = 27.30%)


 PUI 0.349*** (5.147) [0.237; 0.460]
 PHR 0.041ns (0.833) [-0.040; 0.123]
 PEI 0.386*** (6.646) [0.291; 0.482]
IHI
(R2 = 29.58%; Q2 = 11.58%)
 AI 0.132 ns (1.510) [-0.012; 0.275]
 PUI 0.389*** (3.995) [0.229; 0.549]
 PHR -0.047 ns (0.351) [-0.268; 0.174]
 HC 0.192** (2.405) [0.061; 0.324]
 AI*HC 0.165** (2.345) [0.049; 0.281]
 PEI -0.113 ns (1.230) [-0.265; 0.038]

Moderated Direct Effect


IHI  AI
Low levels of HC (HC = -1 SD) -0.034 ns (-0.294) [-0.222; 0.154]
Moderate levels of HC (HC = 0 SD) 0.132 ns (1.510) [-0.012; 0.275]
High levels of HC (HC = +1 SD) 0.297** (2.698) [0.116; 0.478]

Moderated Indirect Effect


IHI  AI  PUI  PHR
Low levels of HC (HC = -1 SD) -0.002 ns (-0.258) [-0.018; 0.013]
Moderate levels of HC (HC = 0 SD) 0.010 ns (1.351) [-0.002; 0.022]
High levels of HC (HC = +1 SD) 0.022* (1.739) [0.001; 0.043]

IHI  AI  PEI | HC
Low levels of HC (HC = -1 SD) -0.013 ns (-0.296) [-0.085; 0.059]
Moderate levels of HC (HC = 0 SD) 0.051 ns (1.409) [-0.009; 0.110]
High levels of HC (HC = +1 SD) 0.115** (2.461) [0.038; 0.192]
*, **, and *** indicate statistical significance at the 0.05, 0.01, and 0.001 levels respectively. ns indicates not significant at 95% confidence level.
t(0.05, 1999) = 1.645616, t(0.01. 1999) = 2.328215, t(0.001, 1999) = 3.094314.
SCD = Perceived Severity of Chronic Diseases; HCD = Perceived Susceptibility to Chronic Diseases; PHR = Perceived Health Risk; HC =
Health Consciousness; PUI = Perceived Usefulness of Internet; PEI = Perceived Ease of Internet Use; AI = Attitude towards Internet Use; IHI =
Internet Use for Health Information Seeking
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[Figure 1.a. Research Structural Model with Total Effect]

[Figure 1.b. Research Structural Model with Moderated Mediation Effect]