Review
The Short Health Anxiety Inventory: A systematic review and meta-analysis

https://doi.org/10.1016/j.janxdis.2012.10.009Get rights and content

Abstract

Introduction

The Short Health Anxiety Inventory (SHAI) measures health anxiety in medical and non-medical contexts.

Objective

To review the literature pertaining to the psychometric properties of the SHAI in non-clinical, clinical, and medical samples. Meta-analysis was also conducted to examine the strength of associations between the SHAI and other constructs.

Methods

Direct search of digital databases for papers that cited the original SHAI publication.

Results

Seventy-eight papers were identified, with 42 providing relevant information. The SHAI has acceptable Cronbach's alpha scores, strong construct validity, and is sensitive to treatment. Discrepancies have been observed between the findings of factor analytic studies, largely as a result of varying methods used. Overall, there appears to be greatest support for the original two factors, with one factor assessing health anxiety and one factor assessing negative consequences of illness. As expected, individuals with hypochondriasis score higher as compared to non-clinical samples. The strongest association was observed between the SHAI and other measures of health anxiety, followed by measures related to health anxiety vulnerability, and then general anxiety and worry.

Conclusions

The SHAI is a psychometrically sound tool for assessing health anxiety across samples. Future studies are needed, however, to assess test–retest reliability, incremental validity, and cut-off scores as well as use of the SHAI among diverse samples.

Highlights

► Despite widespread use of the Short Health Anxiety Inventory (SHAI), no review of its psychometric properties and use has been conducted. ► We reviewed studies that cited the original SHAI publication and conducted a meta-analysis to examine the strength of associations between the SHAI and other constructs. ► Research supports the psychometric properties of the SHAI and indicates that it is sensitive to treatment effects. ► Future research is needed to examine incremental validity, cut-off scores, and use among more diverse samples.

Introduction

Health anxiety is characterized by excessive fears or beliefs that one has a serious illness often based on the misinterpretation of bodily sensations or symptoms (APA, 2000, Barsky and Ahern, 2004). Some studies suggest that health anxiety is a dimensional construct (Ferguson, 2009, Longley et al., 2010) existing on a continuum with minimal worry about illness at one end and excessive anxiety at the other. Other studies indicate health anxiety is a dichotomous construct with some individuals falling into a high health anxiety group and others in a low health anxiety group (Asmundson et al., 2012). In general, research suggests that high levels of health anxiety are observed in individuals who meet diagnostic criteria for hypochondriasis. In hypochondriasis, health anxiety is severe and maladaptive, unresponsive to reassurance, present for an extended period, and leads to clinical levels of distress or impairment (American Psychiatric Association, 2000). Elevated health anxiety is also often observed among individuals with medical conditions such as chronic pain (Wright & Salkovskis, 2007) and multiple sclerosis (MS; Kehler & Hadjistavropoulos, 2008), compared to non-medical groups (Alberts, Sharpe, Kehler, & Hadjistavropoulos, 2011). Individuals with anxiety disorders also experience higher health anxiety than those in the general population (Asmundson et al., 2001).

Salkovskis, Rimes, Warwick, and Clark (2002) developed the Health Anxiety Inventory (HAI; 64 items) and a shortened version of this scale, the Short Health Anxiety Inventory (SHAI; 18 items), to be sensitive to both normal levels of health concern and severe health anxiety. The SHAI, in particular, has become a popular measure among both clinicians and researchers. Each item of the SHAI consists of a group of four statements in which an individual selects the statement that best reflects their feelings over the past 6 months (1 week in some studies). Item scores are weighted 0–3 and are summed to obtain a total score. To create the main scale of the SHAI, the authors selected 14 items from the HAI with the highest item-total correlations from a sample of patients with hypochondriasis. A four-item subscale was also developed to measure the perceived negative consequences of becoming ill. Although the four item subscale was not developed to directly measure health anxiety, it has frequently been summed with the other items to create a total health anxiety score. As a result, some studies report administering a 14-item version (scored 0–42) or an 18-item version (scored 0–54) of the SHAI to assess health anxiety.

According to Salkovskis et al. (2002), a primary reason for developing the SHAI was to create a measure of health anxiety that could be used in medical contexts. Most previous measures of health anxiety included items concerning the belief that one is physically ill, and the endorsement of such items resulted in elevated scores in individuals who were temporarily sick or diagnosed with a serious illness. The SHAI was designed to reduce this problem as much as possible, making it appropriate for use with both healthy and physically ill individuals. Indeed, Salkovskis and colleagues found that patients undergoing MRI scans and patients consulting a gastroenterology department obtained scores similar to non-medical participants and lower scores than patients with hypochondriasis.

Despite the widespread application of the SHAI and the relevance of health anxiety symptoms to the anxiety disorders and to medical and non-clinical groups, a comprehensive literature review regarding its use has not been conducted. A review of this body of literature is important as it would abridge knowledge generated on the SHAI thus far and would identify questions that remain unanswered. Given this gap in the literature, we undertook a systematic review of the literature pertaining to the psychometric properties of the SHAI, including findings related to its factor structure, internal consistency, construct and predictive validity, cut-off scores, and sensitivity to treatment effects. After this review, we further examined the validity of the SHAI by conducting a meta-analysis of correlations reported between the SHAI total score and other relevant measures. Finally, we examined use of the SHAI in medical, clinical, and non-clinical samples, and provided preliminary estimates of scores that can be expected from these populations. By bringing together knowledge generated on the SHAI thus far, our goal was to present an informative review for both researchers and clinicians in the area of anxiety disorders and hypochondriasis while also identifying limitations of the literature and providing ideas for future research using the SHAI.

Section snippets

Methods

In conducting the current review, we adhered to the reporting guidelines of systematic reviews (Preferred Reporting Items for Systematic Reviews and Meta-Analyses; Moher et al., 2009). During April 2012, three electronic databases (ISI Web of Science; PsycINFO; PubMed) were searched for papers citing the original SHAI paper (Salkovskis et al., 2002). No language or date restrictions were used.

Studies were then selected for inclusion in the review if the authors: (1) published the paper in

Search results

The search strategy identified 79 original titles. Screening resulted in the exclusion of 36 papers; with the main reason for exclusion being that the original SHAI article was cited but the SHAI was not administered (24 papers). In addition, excluded studies did not report the version of the SHAI used (five papers), were not in English (one paper) or used a translated version of the SHAI (two papers), were not peer-reviewed (one paper), reported the same data as another study, but did not

Discussion

Given its widespread use among researchers and clinicians and the relevance of health anxiety symptoms to a variety of populations, the purpose of this paper was to review the growing literature pertaining to the psychometric properties of the SHAI and examine its use among non-clinical, clinical, and medical samples. Through a synthesis of these findings, the current review contributes clarity to knowledge gained thus far using the SHAI and provides a comprehensive picture of health anxiety as

Conflict of interest statement

None to declare.

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