Millions of people throughout the world use the Internet and much of this activity is focused on health [1,2]. The Internet is frequently used for seeking health information and communicating for health-related purposes [3-5]. Information seeking refers to the “purposive seeking for information as a consequence of a need to satisfy some goal” [6]. Individuals seek information to fill gaps between what they know and what they need to know in various fields including health. Health information seeking takes place in an environment where different sources are available [7] and information seekers consciously select 1 or more sources to meet their informational need [8]. Among formal and informal health information sources, however, mass media play a vital role in the dissemination of information: the Internet is a key source for information. The Internet as the largest online medical library contains more than 100,000 health-related websites [9]. Internet-based dissemination of health-related information is often suggested as an optimal way to spread health information [10] because the Internet provides privacy, immediacy, faster and easy access to a wide variety of health information, and a variety of perspectives on health-related issues [11,12].

The Internet not only functions as a rich source of health information, but it also provides interactivity between professionals and health seekers through an electronic or communication tool to gain and convey health information [13]. The interactive features of the Internet, such as emailing, chatting, and discussion forums, provide users with the opportunity to leave their questions related to their health and to contact with others, to share and exchange their experiences about a disease, to ask for the best physicians in the field, and to get and give psychological, emotional, and spiritual support from support groups such as bulletin boards and chat rooms [4,5,14,15]. All these communication-based activities on the Internet are not so easily performed through other media forms such as newspapers, radio, or television [16]. Internet use helps people make key health care decisions by connecting with those who access health information, and interacting with health professionals and social support groups [17].

Such importance placed on the Internet as a health-seeking platform helps people maintain, promote, and manage their health. Past research shows that women are more likely to use the Internet for health-related purposes than men [1,2]. In Malaysia, the use of the Internet to manage health and to learn more about diseases has become increasingly important [18] due to the increase in the incidence of chronic diseases, in particular among urban women [19]. Malaysian women, like women in other parts of the world, live longer than men, but are more susceptible to chronic diseases that are preventable [19]. The Internet can be beneficial for empowering women to take responsibility for their own health, decreasing the incidence of illness, and enhancing well-being. This could possibly explain why women are the dominant Internet users in terms of health information seeking even though the number of male Internet users is higher than that of female users [20].

Although an abundance of research can be found on Internet health care information-seeking behavior, a major focus of these studies tends to concentrate on understanding the use of the Internet for health information-seeking behavior based on the Health Belief Model (HBM). The HBM was initially developed to predict the behavioral reaction of individuals with acute or chronic diseases to the treatment they receive [21], but the model was later employed to predict more general health behavior [22,23]. The basic assumption of the HBM is that, in the absence of any symptoms, individuals will not take health or preventive measures unless that they are psychologically ready (eg, they feel vulnerable to a disease) [21]. The HBM suggests that belief in health risk predicts the likelihood of engaging in health behavior [21]. Perceived health risks consist of 2 dimensions: perceived susceptibility to disease and perceived severity of disease. Perceived susceptibility to disease refers to “beliefs about the likelihood of getting a disease or condition” [21]. Perceived severity of disease, on the other hand, is defined as “feelings about the seriousness of contracting an illness or of leaving it untreated include evaluations of both medical and clinical consequences (eg, death, disability, and pain) and possible social consequences (eg, the effect of the condition on work, family life, and social relations)” [21].

Individuals with higher perceived health risk have greater motivation to change or adopt a health-oriented behavior, including adopting a preventive health behavior such as seeking information and using information and communication channels (eg, the Internet) to satisfy health-related information and communication needs [24-27] (Figure 1).

Results of past studies found that women tend to have a higher perceived health risk than men [28,29]. Moreover, perceived health risk is the most important and noticeable predictor in determining women’s health behavior adoption [30].

As well as perceived health risk, health consciousness is another dimension that influences health-seeking behavior. Health consciousness is defined as “the degree to which health concerns are integrated into a person’s daily activities” [31]. Health-conscious people are aware of and concerned about their wellness; therefore, they are motivated to improve and/or maintain their health.

Health consciousness is a predictor of the use of communication channels for health information seeking [32-34]. Health consciousness increases the amount of health-related information obtained from media sources such as television, radio programs, books, newspapers, magazines, advertising, and pamphlets about health [35]. The positive attitude toward the Internet has made it a primary health information source (Figure 1), in comparison to mass media (eg, television and radio), for learning about health-related issues [4,5,33] as previously discussed. In essence, the Internet has enabled individuals to be proactive in managing their health through seeking, exchanging, and communicating health-related information via the e-platforms.

Other studies that contribute toward the extant literature include those that are based on the Technology Acceptance Model (TAM) [36,37]. Although the HBM perspective explains health-related Internet use via the subjective assessment of an individual’s vulnerability to health risks and one’s consciousness toward health, the TAM views health-related Internet use behavior from the technology perspective (ie, the usefulness and ease of use of the Internet and one’s attitude toward Internet use) [38].

The TAM was developed to enable understanding of the use of technology [38] and is most commonly used for studying technology-related behavior such as the Internet and computer use in different contexts including health. The TAM has 3 dimensions: perceived usefulness, perceived ease of use, and attitude toward technology use. Perceived usefulness is defined “as the belief about using the technology that would bring benefits to the user,” whereas perceived ease of use refers to “the belief about using the technology that involves little effort” [36]. Perceived usefulness and perceived ease of use both affect attitude toward using the technology, which in turn influences behavioral intention to adopt the technology [36]. Attitude involves an individual’s belief about the consequences of performing a behavior (eg, technology use), whether it is good or bad, and the general evaluation influences an individual’s inclination to use or not to use a particular technology [39]. Attitude guides an individual’s behaviors by shaping perception [39].

Using the TAM framework, studies showed that perceived usefulness, perceived ease of use and attitude, positively influence behavioral intention to use health information technologies such as the Internet and mobile phones [36,40]. Furthermore, all studies that applied the TAM in the health care domain included behavioral intention to use health information technology, which is driven by the Internet [24,36,37] (Figure 2).

Although many past studies on Internet use for health-related purposes adopted the TAM or HBM, the use of these theories independently has not been able to explain fully Internet health-seeking behavior. The TAM has been used to predict an individual’s technology use; however, it is an inadequate model for health-related Web use because of its heavy dependence on 2 factors: perceived usefulness and perceived ease of use of technology [38]. The HBM attempts to explain the factors that influence health-related Internet use from purely the health perspective and it does not explain the mechanism or the process that lead to the behavior. Although the TAM has been widely used in explaining behavior that relates to technology [36,38,40], its effect on Internet use for health-related purposes could only be fully understood by incorporating dimensions of the HMB that explain individuals’ belief about health into the model. In short, there is a need to examine health-related Internet use from an integrated perspective that combines cognition, attitude, and behavior as well as the subjective evaluation of the psychological states of individuals regarding their perception of their health status.

By incorporating constructs of technology acceptance based on the TAM and perceived health risk and health consciousness as explained by the HBM, an integrated model of health-related Internet use behavior is proposed whereby perceived usefulness of the Internet and attitude toward the Internet for health purposes mediate the relationship between perceived health risks as well as health consciousness and health-related Internet use behavior (Figure 3). In this model, individuals who perceive their health to be at risk or are motivated to use the Internet when they believe that the Internet is useful for providing information on health and health management would be expected to have a positive attitude toward Internet use for health purposes. In other words, cognitive and affective beliefs toward the Internet become central to a person who perceives his/her health to be at risk or is conscious about health. Therefore, these individuals would have greater technology usage (ie, the Internet).

This study aimed to examine the influence of perceived health risk and health consciousness on health-related Internet use based on the HBM. The model developed for the purpose of this study incorporated the TAM to provide a better understanding of the process that affects the adoption of Internet use for health purposes. Based on the integrated model, this study set out to test the mediating effect of TAM constructs, perceived usefulness of the Internet, and attitude toward Internet use on the relationship between perceived health risk and health consciousness on Internet use for health purposes. Table 1 shows the 4 hypotheses developed for the purpose of this study based on the literature reviewed previously.

The participants in this study consisted of Malaysian females living in the state of Selangor, the most urbanized state in Malaysia. Purposive sampling was used. Women who were Internet users were selected as the sample for the purpose of this study because past research found that they tend to be educated, married, and live in urban areas [15,41,42]. Furthermore, they tend to search for information regarding health [1,2,43]. Using the drop-and-collect method, a questionnaire was distributed to only those who expressed their willingness to be respondents. The purposive samples were sourced from women working in governmental institutions located in Selangor state through friends’ contacts.

Out of 380 questionnaires distributed, 330 completed questionnaires were obtained. From the 330 sets of questionnaires returned, 293 responses were usable after excluding cases that had not used the Internet for health-related purposes and cases with incomplete information.

As shown in Table 2, 127 of 293 respondents (43.0%) were in the 30 to 39 age group, 193 of 293 (66.5%) were married, 138 of 291 (47.5%) reported that they had a college or university degree, and 133 of 288 participants (46.0%) had an income in the range of 3000-5999 Malaysian Ringgit (RM) (US $882-$1764).

This study showed that there is a positive influence of perceived health risk and health consciousness on health-related Internet use, supporting hypotheses 1 and 2. It was also found that the effect of perceived health risk on health-related Internet use is fully mediated by perceived usefulness of the Internet and attitude toward Internet use for health information and health management as hypothesized in hypothesis 3. The study also supported that perceived usefulness of the Internet and attitude toward Internet use for health information and health management partially mediates the influence of health consciousness on health-related Internet use as proposed in hypothesis 4.

This study showed that perceived health risk positively affects health-related Internet use, confirming that perceived health risk is significant in influencing women’s Internet use for health-related purposes. This finding is consistent with Dillard et al’s study [26]. In addition, the results of the present study are in-line with Kim and Park’s study, which found that behavioral intention to use health information technology was influenced by perceived health risk [37]. However, the results of Kim and Park [37] showed a smaller impact of perceived health risk on intention to use health information technology (β=.016) than in this study (β=.135) One explanation for this could be related to the perceived health risk level of the participants, whereby the present study is based on urban women who tend to assess their health as being more at risk, whereas the sample of Kim and Park’s study consisted of both men and women [37].

The results of this study also showed that health consciousness has a significant positive effect on health-related Internet use, supporting the relevance of the HBM, which asserts that health consciousness contributes to health behavior adoption [31]. Additionally, it is consistent with prior research that revealed that health-conscious people engage more in health information-seeking behavior [32,33], prefer health information sources [68] and information oriented on the Internet [33], and tend to take part in both offline and online health communities [69].

The findings show that perceived usefulness of the Internet for health management and attitude toward Internet use for health-related purposes become central to women who perceive their health to be at risk and have the consciousness to seek information on health and health-related issues to manage their health and to stay healthy. Therefore, Internet use for health-related purposes is a process with perceived health risk and health consciousness as antecedents, but for this psychological orientation to translate into health-related Internet use behavior, perceived usefulness of the Internet and perceived ease of Internet use as well as attitude toward Internet use for health purposes provide the mechanism that explains health-related Internet use. In other words, for those who subjectively assess their health as susceptible to diseases and are concerned about their health, cognitive beliefs and positive affective feelings about the Internet come into play in the use of the Internet for health-related purposes.

Additionally, this integrated model shows that as health-related Internet use is predicted more by health consciousness than perceived health risk, it can be said that Internet usage for health purposes is a proactive health behavior driven by consciousness rather than a reactive health behavior. This result suggests that the Internet has become a necessary part of life for women who are health conscious and who prefer to be empowered by seeking health information online. Based on the findings of this study, the implications tend toward further promotion of Internet use for health purposes by individuals, health care service providers, and public policy makers. Knowing that health-related factors (ie, perceived health risk and health consciousness), technology-related cognitive beliefs (ie, perceived usefulness and perceived ease of use), and affective feelings toward Internet usage for health information positively influence Internet usage for searching health information, health care service providers could make greater use of the Internet to disseminate health-related information. Furthermore, health care providers can promote the use of online patient support systems or online self-care for a more seamless operation of their services. Individuals, especially women, would be motivated to seek information about health care by using the Internet, acting as opinion leaders in health and health-related issues for their family members and friends. Since the governments of all countries are keen to promote a healthy lifestyle, public policy makers could make use of the Internet to promote good health behavior, through women as the gatekeepers and as opinion leaders.

The present study has several limitations. First, the sample population focused only on working women living in urban areas. The sample was not representative of the Malaysian female population. Therefore, a more comprehensive future study is suggested to include both men and women with different ethnicities, age groups, household income levels, educational attainment levels, and place of residence for a more representative study. Second, apart from perceived health risk and health consciousness examined in this study, there are other health-related factors such as health locus of control, and health informational and decisional involvement that could be included in the deliberate reasoning process of health-related Internet use as moderator or exogenous constructs. Further, this study did not examine the influence of possible predictors of perceived ease of Internet use for health such as eHealth literacy. Therefore, we suggest that future studies could be devoted to examining the influence of these suggested constructs on health-related Internet use. Finally, based on the commonly known health-related activities that are most often performed on the Internet (namely health information seeking, communicating for health-related purposes, and purchasing drugs and health products), further studies could include purchase of drugs and other health care products as variables to enable better understanding of the use of the Internet for health maintenance activities.

Although the present study supported past research that perceived health risk and health consciousness can operate as determinants of health-related Internet use as underpinned by HBM, the HBM model is insufficient to explain the mechanism for the adoption of the Internet for health purposes. By integrating HBM and TAM, results of this study provided the insight and an understanding that perceived usefulness of the Internet for health information and attitude toward Internet usage for health purposes act as mediators on the effect of health-related factors on health-related Internet use.