# Motivation and emotion/Book/2023/Health belief model

* Multimedia presentation (3 min)

## Overview

* Consider this scenario: A 35-year-old woman who has been overweight for several years knows that losing weight would be good for her health, but she struggles to stick to a healthy eating plan or exercise routine. How might the HBM help explain her behaviour? People tend to believe that others are responsible for their actions and therefore blame them for certain health behaviours. Why do people tend to believe this? Is it truly the individuals' fault or can health behaviours be understood through the individual's perspective on health?
The Health Belief Model (HBM) describes how people make decisions about their health.
Have you ever intended to make a healthier choice, but found it difficult to follow through? Perhaps you planned to start exercising regularly, but never made it past a few workouts. Or maybe you tried to quit smoking, but found yourself lighting up again after just a few days.
The HBM is a psychological framework that can help explain why many people struggle to make healthy choices, and how motivation could be enhanced for health-promoting behaviour.
Health behaviours are a major contributor to chronic disease and early mortality. For example, poor diet and lack of physical activity are major risk factors for heart disease, stroke, and type 2 diabetes. By understanding the factors that influence health behaviours, interventions could be developed that are more effective at promoting healthy choices and preventing disease.
The HBM is just one of many theoretical frameworks that can help to understand health behaviours. By testing these models and understanding how they apply to different populations and contexts, researchers can develop more effective interventions to promote healthy behaviours.
This chapter focuses on how the HBM can enhance motivation for health-promoting behaviour.
* Focus questions:
* What is the HBM?
* How can the HBM be applied to specific health behaviours?
* What are the limitations of the HBM?

## What is the health belief model?

The HBM is a psychological framework that explains why people take certain health-related actions. It was first developed in the 1950s by social psychologists Hochbaum, Rosenstock, and Kegels, who were working in the U.S Public Health Service to explain the failure of people participating in programs to prevent and detect disease (Luger, 2013). Later, the model was extended by others to study people's behavioural responses to health-related conditions. The model is based on the idea that people's beliefs and perceptions about their health and the world around them can influence their behaviour (see Figure 2).
According to the HBM, people are most likely to take action to prevent or treat an illness if they believe that:
* they are susceptible to the illness
* the illness is severe and has serious consequences
* taking a particular action will reduce their risk of getting the illness or help them recover from it
* the benefits of taking action outweigh the costs or barriers to doing so
The HBM is often used in public health campaigns to promote healthy behaviours, such as getting vaccinated or quitting smoking. By understanding people's beliefs and perceptions about their health, public health officials can develop more effective health messaging and interventions to promote better health outcomes.

### Theoretical Constructs

The HBM contains several constructs that are hypothesised to predict why people engage in prevention, screening and/or controlling health conditions (see Table 1).
Table 1. The main constructs of the Health Belief Model and their definitions.
| Construct | Definition |
| Perceived Susceptibility | Belief about getting a disease or condition |
| Perceived Severity | Belief about the seriousness of the condition, or leaving it untreated and its consequences |
| Perceived Benefits | Belief about the potential positive aspects of a health action |
| Perceived Barriers | Belief about the potential negative aspects of a particular health action |
| Cues to Action | Factors which trigger action |
| Self-Efficacy | Belief that one can achieve the behaviour required to execute the outcome |
| Modifying Variables | Factors that can affect perceptions |

#### Perceived Susceptibility

* Refers to subjective assessment of risk of developing a health problem (see Table 1). The HBM predicts that individuals who perceive that they are susceptible to a particular health problem will engage in behaviours to reduce their risk of developing the health problem (Rosenstock, 1974).
* Individuals with low perceived susceptibility may deny that they are at risk for contracting a particular illness. Others may acknowledge the possibility that they could develop the illness, but believe it is unlikely. Individuals who believe they are at low risk of developing an illness are more likely to engage in unhealthy, or risky, behaviours.
* Individuals who perceive a high risk that they will be personally affected by a particular health problem are more likely to engage in behaviours to decrease their risk of developing the condition.

#### Perceived Severity

* Refers to the subjective assessment of the severity of a health problem and its potential consequences (Janz & Becker, 1984). The HBM proposes that individuals who perceive a given health problem as serious are more likely to engage in behaviours to prevent the health problem from occurring (or reduce its severity).
* Perceived seriousness refers to an individual's beliefs about the disease itself, such as whether it poses a threat to their life or may cause disability or pain, as well as the broader impacts of the disease on their ability to perform work and social roles (see Table 1). For example, an individual may not consider influenza to be medically serious, but if they believe that being absent from work for several days would result in significant financial consequences, they may consider influenza to be a particularly serious condition.
* In 2019, researchers studying Australians and their self-reported influenza vaccination status found that perceived severity was a determining factor in vaccination likelihood. The researchers measured perceived severity by asking respondents to rate, on a scale of 0 to 10, how severe they thought the flu would be if they contracted it. The results showed that 31% perceived the severity as low, 44% as moderate, and 25% as high. The study also found that individuals with a high perceived severity were significantly more likely to have received the vaccine than those with a moderate perceived severity. However, self-reported vaccination rates were similar for individuals with low and moderate perceived severity of influenza (Trent et al., 2021).
* Perceived susceptibility and severity of a health condition together, have been labelled as "perceived threat".

#### Perceived Benefits

* People's health-related behaviours are also influenced by their perceived benefits of taking action. Perceived benefits refer to how much value or effectiveness an individual believes a health-promoting behaviour will have in reducing the risk of disease (Janz & Becker, 1984)(see Table 1).
* This means that if a person believes a certain action will reduce their susceptibility to a health problem or decrease its severity, they are more likely to engage in that behaviour, regardless of objective facts about its effectiveness (Irwin, 1974).
* For example, individuals who believe that wearing sunscreen prevents skin cancer are more likely to wear sunscreen than those who do not believe it will prevent skin cancer.
* In terms of how perceived benefits interact when applied in the HBM, they help to reduce perceived threat about a health behaviour.

#### Perceived Barriers

* Refers to an individual's perception of the barriers to taking action. Perceived barriers refer to the obstacles that an individual assesses to behaviour change (Janz & Becker, 1984)(see Table 1).
* Even if an individual perceives a health condition as threatening and believes that a specific action will reduce the threat, barriers may prevent engagement in the health-promoting behaviour. In other words, for behaviour change to occur, the perceived benefits must outweigh the perceived barriers (Janz & Becker, 1984).
* Perceived barriers include inconvenience, expense, danger, and discomfort involved in engaging in the behaviour (Irwin, 1974). For instance, lack of access to affordable healthcare and the perception that a flu vaccine shot is painful may act as barriers to receiving the flu vaccine.
* In a study about breast and cervical cancer screening among Hispanic women, perceived barriers such as fear of cancer, embarrassment, fatalistic views of cancer, and language were shown to impede screening (Austin et al., 2002).

#### Modifying Variables

* According to the HBM, an individual's perception of health-related behaviours can be influenced by a range of factors, including demographic, psychosocial, and structural variables (i.e., perceived seriousness, susceptibility, benefits and barriers) of health-related behaviours (Irwin, 1974).
* Demographic variables may include age, sex, race, ethnicity, education, and others, while psychosocial variables may include personality, social class, peer pressure, and reference group pressure, among others (Irwin, 1974).
* Structural variables may include knowledge about a disease and prior experience with it, among other factors (Irwin, 1974).
* The HBM suggests that modifying variables can indirectly affect health-related behaviours by influencing perceptions of the seriousness, susceptibility, benefits, and barriers related to those behaviours.(Irwin, 1974).

#### Cues to Action

* The HBM proposes that a cue, or trigger, is necessary to prompt engagement in health-promoting behaviours.
* Cues to action can be either internal or external. Examples of internal cues include physiological signals such as pain or symptoms, while external cues can come from close others, the media, or healthcare providers.
* Examples of cues to action include a reminder postcard from a dentist, the illness of a friend or family member, mass media campaigns on health issues, and product health warning labels.
* The intensity of cues needed to prompt action varies between individuals based on their perceived susceptibility, seriousness, benefits, and barriers. For example, individuals who believe they are at high risk for a serious illness and who have an established relationship with a primary care doctor may be easily persuaded to get screened for the illness after seeing a public service announcement. Conversely, individuals who believe they are at low risk for the same illness and who lack reliable access to health care may require more intense external cues to be motivated to get screened.

#### Self-Efficacy

* In 1988, self-efficacy was incorporated into the Health Belief Model's four components: perceived susceptibility, severity, benefits, and barriers (Rosenstock et al., 1988).
* Self-efficacy refers to an individual's belief in their ability to perform a behaviour successfully The inclusion of self-efficacy aimed to better explain differences in health behaviours among individuals.
* Originally developed to explain one-time health-related behaviours, such as cancer screening or immunisation, the HBM was later applied to longer-term behaviour changes like diet modification, exercise, and smoking (Rosenstock, 1974; Rosenstock et al., 1988).
* The HBM's developers recognised that self-efficacy was a critical component of health behaviour change.
* Schmiege et al. (2007) found that self-efficacy was a better predictor of calcium consumption and weight-bearing exercise than beliefs about future negative health outcomes.
* Rosenstock et al. (1988) suggested that self-efficacy could be added to the other HBM constructs without elaborating on the model's theoretical structure. However, this was considered shortsighted because studies showed that key HBM constructs have indirect effects on behaviour through their influence on perceived control and intention, which may be regarded as more proximal factors of action (Abraham & Sheeran, 2007).
* In regards to the application of self-efficacy in the HBM, self-efficacy influences perceived threat (perceived susceptibility and severity) and perceived benefits minus perceived barriers, which support initiation of health behaviour change (see Table 1).

## How can the HBM be applied to specific health behaviours?

* The Health Belief Model (HBM) has been utilised to develop efficacious interventions targeting various components of the model's key constructs (Carpenter, 2010).
* Interventions based on HBM may strive to increase perceived susceptibility and seriousness of a health condition through education about incidence and prevalence of diseases, individualised risk estimates, and information about disease consequences (medical, social, and financial).
* Additionally, interventions may aim to modify the cost-benefit analysis of engaging in health-promoting behaviours (i.e., increasing perceived benefits and reducing perceived barriers) by providing information about effectiveness of various behaviours to mitigate disease risks, recognising common barriers, offering incentives for engaging in health-promoting behaviours, and providing social support or other resources to encourage such behaviours (Rosenstock, 1990).
* Furthermore, interventions based on HBM may use cues to action to remind and motivate individuals to engage in health-promoting behaviours.
* Interventions may also aim to promote self-efficacy by providing training in specific health-promoting behaviours, particularly for complex lifestyle changes, such as changing diet or physical activity or adhering to complicated medication regimen (Carpenter, 2010).
* Interventions can be targeted at the individual level (i.e., working one-on-one with individuals (to increase engagement in health-related behaviours) or the societal level (e.g., through legislation, changes to the physical environment, mass media campaigns)(Jones et al., 2015) (See Figure 2).

#### Theoretical Construct Examples

Table 2. The main constructs of the Health Belief Model in examples of application.
* To explore the perceived susceptibility, severity, barriers, and benefits of breast cancer screening/mammography among Vietnamese women over 40 years of age in the U.S., one could utilise the items listed in Table 2.
| Construct | Definition |
| Perceived Susceptibility | Chances of getting breast cancer are high (on a 5 point scale, ranging from "strongly disagree" to "strongly agree") |
| Perceived Severity | My marriage would be endangered if I had breast cancer. (on a 5 point scale, ranging from "strongly disagree" to "strongly agree") |
| Perceived Benefits | Getting a mammogram has brought me peace of mind. A mammogram is a routine part of my check up exam. (on a 5 point scale, ranging from "strongly disagree" to "strongly agree") |
| Cues to Action | Hearing about breast cancer in the news makes me think about getting a mammogram. (on a 5 point scale, ranging from "strongly disagree" to "strongly agree") |
| Self-Efficacy | How sure are you that you know how to arrange an appointment for a mammogram? (on a 5 point scale, ranging from "strongly disagree" to "strongly agree") |
* To explore the self-efficacy and cues that prompt mammography adherence among women aged 50 and over, the items listed in Table 2 may be useful.

#### Study Examples

* In a study, 58 active adult women smokers aged 16 to 30 were analysed to determine the correlation between their intention to stop smoking and their perceived factors in the construction of HBM.
* All variables, except for perceived barriers, had a weak positive correlation.
* Respondents agreed that they were vulnerable to health and social consequences associated with smoking, but did not fully believe that smoking would trigger such severe concerns, resulting in a low desire to quit.
* Similarly, respondents did not perceive their smoking habits as having severe consequences, leading to a low desire to quit.
* Perceived benefits had a weak positive correlation, indicating that individuals saw the adoption of healthy behaviours as beneficial to their overall lifestyle.
* Perceived barriers had a weak negative correlation, implying that the more barriers an individual associated with quitting smoking, the less likely they were to quit.
* Lastly, respondents' perceived self-efficacy was low, contributing to their low desire to quit smoking.
Citation: Pribadi and Devy, 2020
* In 2016, a study was conducted in Hong Kong to investigate the factors influencing physical activity among people with mental illness (PMI).
* The study utilised the HBM as it is one of the most commonly used models to explain health behaviours and provided a framework for understanding the physical activity levels of PMI.
* The survey involved 443 PMI with an average age of 45 years. The results showed that perceived barriers were significant in predicting physical activity among PMI, and that self-efficacy had a positive correlation with physical activity.
* These findings support previous literature which suggests that self-efficacy and perceived barriers play an important role in physical activity and should be considered in interventions.
* The study also found that participants tended to focus more on their psychiatric conditions than on their physical health needs.
* It is noteworthy that this study sheds light on the HBM by demonstrating how culture can influence the model. For instance, some cultures may place greater emphasis placed on fate and the balance of spiritual harmony over physical fitness. As the HBM does not account for these external factors, this limitation underscores how various factors, not just those outlined in the model, can affect health decisions (Johnson et al., 2008; Quah, 1985).
Citation: Mo et al., 2016
Quiz Time!
Linda is a 40-year-old woman who has a family history of heart disease. She is worried that she might also develop heart disease at some point in her life. Which theoretical construct of the Health Belief Model best describes Linda's concern?
Perceived Severity
Perceived Susceptibility
Perceived Benefits
Perceived Barriers :

## What are the limitations of the HBM?

[Provide more detail]

### General

* The HBM seeks to predict health-related behaviours by taking into account an individual's beliefs and attitudes. However, it fails to consider other factors that may influence health behaviours, such as habitual health-related behaviours that become independent of conscious decision-making processes (Janz & Becker, 1984).
* Furthermore, some health-related behaviours may be motivated by reasons unrelated to health, such as exercising for aesthetic reasons (Janz & Becker, 1984).
* Environmental factors that are outside of an individual's control may also prevent them from engaging in desired behaviours, such as living in a dangerous neighbourhood and being unable to go for a jog outdoors due to safety concerns (Janz & Becker, 1984).
* Importantly, the HBM does not account for the impact of emotions on health-related behaviour, despite evidence suggesting that fear may be a key factor in predicting such behaviour (Janz & Becker, 1984).
* Other factors may also be indicative of health behaviour, including the expectation of a positive outcome (Schwarzer, 2001) (i.e., whether the individual believes that their behaviour will result in improved health) and self-efficacy (Seyde et al., 1990) (i.e., the individual's confidence in their ability to engage in preventive behaviour).

### Theoretical Constructs

* The HBM's theoretical constructs are broadly defined and it does not specify how these constructs interact with each other (Carpenter, 2010). As a result, different operationalisations of the constructs may not be comparable across studies (Maiman et al., 1977).
* There is a limited amount of research assessing the role of cues to action in predicting health-related behaviours (Janz & Becker, 1984; Rosenstock, 1984; Carpenter, 2010).
* The difficulty in assessing cues to action has limited research in this area (Rosenstock, 1984).
* For example, individuals may not accurately report cues that prompted behaviour change. Additionally, cues such as a public service announcement on television or billboard may be fleeting, and individuals may not be aware of their significance in prompting them to engage in a health-related behaviour (Rosenstock, 1984).
* Interpersonal influences are also particularly difficult to measure as cues (Rosenstock, 1984).

### Other

* The Health Belief Model (HBM) may not always be supported by research due to the influence of factors other than health beliefs on health behaviour practices.
These factors can include:
* Cultural factors
* Special influences
* Socioeconomic status
* Previous experiences.
Scholars have extended the HBM by proposing the addition of four more variables as potential determinants of healthy behaviour:
* Self-identity
* Perceived importance
* Consideration of future consequence
* Concern for appearance
* Evidence has shown that consideration of future consequences, self-identity, concern for appearance, perceived importance, self-efficacy, and perceived susceptibility are significant determinants of healthy eating behaviour that can be manipulated by the design of interventions for healthy eating (Orji et al., 2012).

## Conclusion

* The HBM is a psychological framework that can be used to enhance motivation for health-promoting behaviour.
* The HBM suggests that individuals' behaviour is determined by their beliefs about the health threat and the effectiveness of the recommended health behaviour.
* HBM has been applied to various health behaviours, such as smoking cessation and medication adherence, and has been shown to be effective in designing interventions for health promotion.
* To design more effective interventions for health promotion, it is important to understand the individual's perception of health threats and the barriers to adopting health-promoting behaviours.
* The HBM can be used to identify these factors and design interventions that address them. Additionally, interventions should be tailored to the individual's beliefs, values, and cultural background to increase their effectiveness.
* The HBM can also be applied to specific health behaviours, such as smoking cessation or medication adherence. By understanding the individual's beliefs about these behaviours and the perceived barriers, interventions can be designed to address these factors and promote behaviour change.
* The HBM has some limitations, including its focus on individual beliefs and attitudes, which may not fully capture the complexity of health behaviour. Additionally, the model does not account for the social and environmental factors that may influence behaviour.
Remember, small changes can lead to big improvements in health. Take control of your health by adopting health-promoting behaviours today!