HEALTH BELIEF MODEL

The Health Belief Model Larry Lizewski Wayne State University Communication Theory Dr. Katheryn Maguire March 31, 2010

HEALTH BELIEF MODEL The purpose of this paper is to examine the health belief model (HBM). In the more than 50 years of its existence, the HBM has been embraced and developed becoming a prolific framework for explaining and predicting preventive health care behaviors. Added dimensions

have furthered its abilities making it a useful framework in the area of sick-role behaviors as well (Tanner-Smith, 2010, p. 95). It has garnered significant support across many types of applications and its use remains strong today. This work will introduce the HBM and review its origins, perspectives, added dimensions and contributions to communication research as well as its shortcomings. It is difficult to convince people they are at risk. Despite a barrage of health campaigns, warnings labels, doctors advice and pleadings from friends and family, people dismiss empirical evidence of health dangers. Furthering this phenomenon of preventive health care is the difficulty of getting the public to adapt long-term goals. Significant numbers of people, though aware of health risks, either ignore preventive actions or adopt programs without proper regiment. The failure to effectively persuade individuals to seek health prevention has frustrated health communication scholars since the 1950s (Burns, 1992; Mikhail, 1981). The Health Belief Model The HBM consists of 4 variables that interrelate. To better understand the HBM, perceived benefits and barriers have each been given their own brief explanation. Perceived Susceptibility. The belief that one is at risk of an illness is subjective. To one extreme is an individual who is in full denial of any risk while the other an individual who feels danger is certain. The area between contains those who admit the statistical possibility of contracting an illness, but do not fully believe they will (Rosenstock, 1966, p. 6).

HEALTH BELIEF MODEL

Perceived Seriousness. The perception of the consequences of a negative health condition is also subjective. Beliefs of an illness causing pain, debilitation, social stigma or death are examples of seriousness perceived (Rosenstock, 1966, p. 6). Perceived Benefits of Taking Action. Deciding on a course of action is shaped by the options accessible to the individual and the belief in their effectiveness. Action is thus dependent on having at least one course of action to prevent an illness from occurring while believing it will produce acceptable results (Rosenstock, 1966, p. 7). Barriers of Taking Action. Despite a belief being established that a particular course of action may reduce a health threat, indecision may still take place. If readiness is low and negative aspects of the course of action are viewed as high, barriers are constructed preventing action. (Rosenstock, 1966, pp. 7-8). Cues to Action. A stimulus that can trigger (Rosenstock, 1966, p. 8) appropriate health behavior. This may be internal such as physical discomfort, or external such as a message communicating the seriousness of a disease. The external is most relevant to communications as it often relies on media and interpersonal interaction (Mattson, 1999, p. 243). Summary of HBM The HBM posits that people will take action to undergo a health prevention behavior when they are ready; they see it as beneficial; and the difficulty is not greater then what is to be gained. Does the end justify the means? Readiness is determined by the degree to which one believes an illness is likely. Perceived susceptibility may be influenced by proximity to an illness. For instance, someone with a family history of diabetes will more likely seek a blood test then someone who has no family history of the disease. Readiness is also determined by the consequences a health risk may impose. When perceived susceptibility is seen as likely and

HEALTH BELIEF MODEL perceived severity of an illness is high, motivation increases. Conversely, motivation decreases as susceptibility seems unlikely and severity is viewed as inconsequential (Rosenstock, 1966). Once concluded that threat is likely and damage may be severe, action to prevent its occurrence is likely taken. The choice of action to reduce the health threat is reliant on the belief

of its effectiveness. Will it work? At least one viable option to prevent illness must be accessible. The individual experiencing a decision process involving these variables is often unconscious of the cognitive process (Rosenstock, 1966). It is Rosenstocks (1966) opinion that emotional factors have more bearing on this event than do the intellectual. Despite a belief in the effectiveness of an action that may reduce the threat of an illness, barriers preventing commitment to the action may arise. If the psychological readiness of an individual is high and the negative aspects of the course of action relatively weak, action is likely taken. Conversely, when readiness is low and negative aspects of the course of action are viewed as high, barriers are constructed preventing action. Considerations such as will it be painful? Will it upset family life? Will it place ones self and loved ones in financial crisis? These questions raise barriers in the decision process. A significantly more difficult circumstance surfaces when both readiness and the negative aspects of the course of action are high (Rosenstock, 1966). In this circumstance, the HBM posits that individuals will demonstrate behavior to both take action and avoid it. As a result, they may review alternatives and choose another action. If no other option is available, one of two reactions may occur. (1) They may psychologically distance themselves from the situation such as declaring intention to change their behavior tomorrow. This allows for temporary psychological relief from the barrier and the perceived benefit. (2) They may experience increased fear and anxiety. If these negative feelings become

HEALTH BELIEF MODEL

great enough irrational behavior becomes possible. At this point the presentation of any effective means ensuring good health may go unanswered (Rosenstock, 1966, pp. 7-8). Even after all variables are in place indicating high likelihood of positive health behavior, people will sometimes still not take action. Rosenstock (1966) proposed that events can trigger (p. 8) individuals to take action toward prevention. Perceived susceptibility and severity are variables that affect readiness. Perceived benefits affect the course of action. However strong these variables may be interpreted, there remains a possibility an individual may still not demonstrate preventive health behavior. A cue to action may be a solution. These cues could be internal such as physical discomfort or external, such as a media communication. If the cues influence matches or exceeds the level of readiness, action is likely to be taken. Therefore, low readiness require more highly intense cues while high readiness require less (Rosenstock, 1966, p. 8). The origins HBM The frustration as to why the public was not responding to federal government offerings of free health prevention programs in the 1950s sparked the research of three psychologists, Irwin Rosenstock, Godfrey Hochbaum and Stephen Kegels (Burns, 1992; Mikhail, 1981). As Hochbaum (1958) stated, Although the public stands to gain most from the success of health programs, its willingness to participate has all too often been disappointing, in spite of wellorganized attempts to arouse popular interest and to make participation easy (Hochbaum, 1958, p. 1). HBM was developed as a result of their endeavor to resolve this. In particular were the preventive health programs of free chest x-rays and Salk vaccine inoculations. This assistance, and subsequent research, was funded by the U.S. Public Health Service in response to epidemics of tuberculosis and polio (Hochbaum, 1958; Rosenstock, Derryberry, & Carriger, 1959).

HEALTH BELIEF MODEL Hochbaums (1958) survey study of the publics response to chest x-rays had already begun to disclose elements of HBM. Psychological readiness, fear of the severity of illness, belief of oneself contracting an illness and cues to action were discussed. Rosenstock, Derryberry, & Carrigers (1959) also found these factors responsible for the publics lack of response to illness prevention. The role of situational factors was also found. This component would later be criticized as a weakness of HBMs effectiveness. In their work, Rosenstock, et al. (1959) analyzed research of poliomyelitis vaccine or, Salk vaccine. As Hochbaum (1958), their analysis of studies conducted on the forgoing of preventive health measures was similar. For example, Rosenstock et al. (1959) found that perceived susceptibility was the cause of adults not seeking vaccination. It was found that adults

thought of polio as a childrens disease and therefore not relevant to themselves. Though both of these works discuss the variables of the HBM, there is no mention of the health belief model outright. No work could be found that cite the title by Rosenstock, Hochbaum or Kegels until Rosenstocks 1966 work. In addition to Rosentoscks article Why People Use Health Services, other privately funded researchers were finding similar variables included in the HBM. In the same year as Rosenstock (1966) was published, so was Kasl & Cobbs work Health Behavior, Illness Behavior and Sick-Role Behavior (Kasl & Cobb, 1966). Rosenstock (1966) gives significant credit to them in his aforementioned piece. In it he states Kasl and Cobbs useful framework for considering the focus and limitations of the present paper (p. I). Burns (1992) also dedicates considerable space ensuring Kasl and Cobbs recognition for the HBM. The significance of Rosenstocks work is his findings on the costs of taking action against health threats. These are mentioned as benefits and barriers in the HBM (Burns, 1992; Rosenstock, 1966). In the effort to

HEALTH BELIEF MODEL balance contribution, Kasl and Cobbs (1966) applied their findings in the area of sick-role behavior. This would later become a popular addition to HBM (Becker, Drachman, & Kirscht, 1974). The importance of communication research in both the 1950s articles by Hochbaum (1958) and Rosenstock (1959) is recognized. Hochbaum (1958) specifies communications role in the external situation, such as posters, articles, TV and radio programs (p. 8). He found these channels of communication in the decision making process of health prevention to be essential. But it is Rosenstock, et al. (1959) that dedicate a heading Communication Research (p. 101-102). Groups, according to them, differ in their choice of channels of communication, types of message and cognition of communication. These mentioned variables continue to be studied by communication scholars today in creating effective messages. Rosenstock, et al. (1959) states the following: It is not to be denied that the mass media have, and always have had, an important role in communication. However, the poliomyelitis and communication studies reviewed here suggest that the assets and liabilities of the traditional approach should be considered. (p. 102)

Rosenstock et al. (1959) base much of this discussion on the work of Katz and Lazarsfeld. Katz and Lazersfeld, however, were not the only familiar names to communication scholars used by these researchers. Kurt Lewins work had significant influence on the development of HBM (Burns, 1992; Mikhail & Petro-Nustas, 2001; Rosenstock, 1966). HBMs Meta-Theoretical Approach Hochbaum (1958) demonstrates his phenomenological perspective (Mikhail, 1981) as he states, In short, we shall be concerned with what people believe, not with the correctness of these belief orientations (Hochbaum, 1958, p. 5). As does Rosenstock (1966), The variables

HEALTH BELIEF MODEL

deal with the subjective world of the behaving individual and not with the objective world of the physician or the physicist (Rosenstock, 1966, p. 5). These interpretive approaches clearly place the knowing in the consciousness of the individual and not the external world (Miller, 2005, p. 54) Recognizing and evaluating the perceived reality of another was important, according to Hochbaum (1958), in understanding their motivation. Focus on imposing an empirical view another cannot perceive is futile. Simply put by Mikhail (1981), People can only act on what they believe to exist (p. 67). Craig (1999) discusses a quality of the phenomenological tradition when he uses an example of how what we observe on the surface may not be what is going on internally of another. Our own perceptions get in the way of what lies beneath. It is the tradition of phenomenology that addresses this experience of otherness (p. 133). Through their leanings toward this concept, the originators of the HBM were drawn toward the ideas of similar thinkers (Burns, 1992; Mikhail, 1981). The missing element may be derived from the work of Kurt Lewin. Behavior may thus be regarded as a function of a person's motive and of his beliefs about various opportunities for action(Rosenstock, 1960, p. 295).These beliefs are important in determining the goals people set.
An individuals view on what is important and how they place themselves in context of a situation determines their success or failure of obtaining a goal (Hochbaum, 1958). This parallels Craigs (1999) explanation of a phenomenological trait as well. Among the paradoxes of

communication that phenomenology brings to light is that conscious goal seeking, however benevolent ones intentions may be, annihilates dialogue by interposing ones own goals and strategies as a barrier against ones direct experience of self and other (p. 139). To alter anothers beliefs, and thus their approach to a goal, we must first understand the variables of the cognitive process of goal assessment. Hochbaum, Rosenstock and Kegels found Lewin, Dembo,

HEALTH BELIEF MODEL Festinger, & Sears (1944) research in Levels of Aspirations valuable to achieve this (Burns, 1992; Mikhail, 1981). The Expanding HBM Kasl and Cobbs (1966) study of the HBMs variables to sick-role behavior was expanded upon in the 1970s (Becker, et al., 1974; Becker & Maiman, 1975; Mikhail, 1981). Becker et al. (1974), determined there was no reason the HBM could not be used to understand

the behavior of those already ill. For example, if perceived susceptibility is conceptualized as the degree one feels likely to acquire an illness why not to the degree one feels likely they will become more ill? (p. 206). Motivation, according to them, could also more fully explain issues in the area of health behavior. In the original HBM, fear of the severity of illness and negative attributions associated with the course of action was the focus. People sought health prevention because they did not want to get sick. Becker et al. (1974) posits that positive aspects can draw people to better health choices. For example, people may seek preventive health care because they perceive it will make them feel better. This counters HBMs position that people seek preventive health care to avoid negative consequences (Rosenstock, 1966). In the first example they move toward comfort. In the second they move away from discomfort (Becker, et al., 1974; Becker & Maiman, 1975). Because of the new role the HBM had in explaining and predicting the behavior of those already ill, opportunity for new dimensions transpired (Rosenstock, Strecher, & Becker, 1988). Previously there was no need to explain long-term behavior change. Prevention was largely a one-time procedure. One gets a chest x-ray. One gets a shot etc... Illness, however, often requires a life-long regiment to sustain health. Banduras (1977) social cognitive theory (SCT) was found to be valuable in explaining long-term goals and motivation.

HEALTH BELIEF MODEL As Rosenstock et al. (1988) simplify SCT, learning results from events (termed reinforcements) which reduce physiological drives that activate behavior (p. 175). Because of this view, Rosenstock, Strecher, & Becker (1988) proposed SCT (Bandura, 1977) had significant relationship with the HBM. It also made sense in that they share the concept of Lewinian value expectancy theory (Rosenstock, et al., 1988, p. 177). SCTs explaining of

10

expectations and incentives were found to be valuable to HBM in two ways (p. 176). First, SCT posits that observations of others influence our own behaviors. We imitate. The second, however, had the most influence in the HBMs advancement. By comparing the variables of SCT to HBMs, it was found that all but one mirrored HBMs (Rosenstock, et al., 1988, p. 177). This variable was Banduras (1977) idea of selfefficacy. It proposed that to change our behavior we must believe we can. It is hypothesized that expectations of personal efficacy determine whether coping behavior will be initiated, how much effort will be expended, and how long it will be sustained in the face of obstacles and aversive experiences (p. 191). Rosenstock (1988) determined this concept could contribute insight and resolve shortcomings of the HBMs variable of perceived barriers. It was proposed and accepted by researchers and is now included as a variable in the HBM (Rosenstock, et al., 1988). HBM and Communication The value of the HBM to communication scholars is its ability to operationalize research. It offers a framework to conceptualize and measure variables. The measured HBM factors are then able to determine the effectiveness of a health message. For example, did the message increase or decrease perceived susceptibility? If increase is shown, individuals will more likely be motivated to change health behavior. The message is successful. Such is the case with determining the health beliefs of an audience following a health related television program.

HEALTH BELIEF MODEL In the research of Chew, Palmer, Slonska, & Subbiah (2002), a survey was conducted

11

following a sample audiences exposure to five half-hour showings of a health series on diet. The survey was designed to measure efficacy (by an index of benefits and barriers), readiness (susceptibility), motivation, salience and cues to action (p. 186-187). To measure efficacy a five item Likert-scale (strongly agree (1)-strongly disagree (5)) was used to measure two benefits and three barriers. A product of operationalization is direction in developing research questions. In a study of communication between counselors and clients during HIV screenings, the HBM variables allowed parsimony. RQ1: Does interpersonal communication between counselors and clients during HIV testing cue clients perceptions of (a) severity (b) susceptibility (c) benefits (d) barriers, and or (e) self efficacy? (Mattson, 1999, p. 245). Survey questions to assess risk, or perceived susceptibility and severity, were also given shape by the components of HBM. For example, If I get HIV or AIDS from my partner, its no big deal because it can be treated (p. 247). As Chew, Palmer, Slonska, & Subbiah (2002), a Likert-scale was implemented. The end result was to determine the best persuasive strategies for counselors recommending safer sex. Critique Despite Hochbaum (1958) and Rosenstocks (1959) call for increased communication research utilizing the HBM, its use is sparse. A search for the HBM in a communication research database retrieved surprisingly few periodical articles. 34 articles were retrieved using a Boolean keyword search of health belief model. A significant portion of these only referenced the model. Subsequent searches using alternative databases and keywords resulted in less success. Tanner-Smith (2010) may explain this.

HEALTH BELIEF MODEL

12

In 39 studies reviewed on the use of the HBM in pap screening behavior, she found none to include the cues to action variable. First, no studies included indicators of cues to action, which was a strong predictor of mammography behavior (Tanner-Smith, 2010, p. 117). Cues to action also have a strong reliance on communication research as it predicts the effects of messages that trigger (Rosenstock, 1966, p. 8) positive health prevention (Hochbaum, 1958; Rosenstock, et al., 1959). If no studies are giving indication of message influence how can it become a topic of discussion amongst communication researchers? The HBM also has shortcomings to explain and predict. Tanner-Smith (2010) concluded weak support for the HBMs ability to explain and predict perceptions of risk. That is, perceived susceptibility and perceived severity. An explanation could reside with the HBMs shortcomings in considering contextual constraints (p. 118). Perceived susceptibility and severity may be high, but if one is struggling with issues such as poverty, additional stressors may supersede actions to assure health (p. 118). In other words, if someone is striving to feed the kids, ones concern to seek medical screening may be secondary. The role of these situational factors was discussed and given consideration early on by Hochbaum (1958) and Rosenstock (1959). The HBM also does not consider repeat behavior. Tanner-Smith (2010) posits there is a perspective change between those undergoing a pap screening or mammogram for the first time and those who have made these visits routine. Perceived risks may influence the first visit but become less so thereafter. Janz and Becker (1984), also discuss issues with perceived severity. According them, an illness such as cancer has a global perception of being very serious. This would account for little variance when measuring the perception of severity of those who comply with preventive health care and those who do not. Both may have similar perceptions (p. 36-37). Norman & Brain

HEALTH BELIEF MODEL (2005) point to these parallels in their application of the HBM in compliance of breast selfexaminations as well. Conclusion

13

The HBM has demonstrated to be an affective model in explaining and predicting health behaviors from its inception. Its four variables interrelate. These variables affect health behavior on two levels. (1) Perceived susceptibility and severity affect ones readiness. (2) The costs of benefit and barriers determine course of action. Through the years the dimensions and variables added have strengthened HBMs capabilities and increased its use. The meta-theoretical foundations of phenomenology and subsequent connection to communication researchs founders, make the model relevant to the communication field. In addition, the HBMs ability to operationalize communication research has also been a valuable tool. This is demonstrated, not only in the area of communications but, of course, many health fields. Though it is often mentioned in health communications it remains underutilized. Interestingly, as he discusses the role of communication in his article introducing the HBM, Rosenstock (1966) states, Recent research suggests the desirability of more intensive study of the role of emotionally arousing factors in education and on the conditions which increase the effects of emotionally arousing messages upon attitude and behavior change (p.28).

HEALTH BELIEF MODEL References

14

Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioral change. Psychological Review, 84(2), 191-215. Becker, M. H., Drachman, R. H., & Kirscht, J. P. (1974). A new approach to explaining sick-role behavior in low-income populations American Journal of Public Health, 64(3), 205-216. Becker, M. H., & Maiman, L. A. (1975). Sociobehavioral determinants of compliance with health and medical care recommendations. Medical Care, 13(1), 10-24. Burns, A. C. (1992). The Expanded Health Belief Model as a basis for enlightened preventive health care practice and research. Journal of Health Care Marketing, 12(3), 32-45. Chew, F., Palmer, S., Slonska, Z., & Subbiah, K. (2002). Enhancing health knowledge, health beliefs, and health behavior in poland through a health promoting television program series. Journal of Health Communication, 7(3), 179-196. Craig, R. T. (1999). Communication theory as a field. Communication Theory, 9(2), 119-161. Hochbaum, G. M. (1958). Public participation in medical screening programs: A socio-psychological study. Public Health Service publication. Washigton, D.C. Kasl, S. V., & Cobb, S. (1966). Health behavior, illness behavior, and sick role behaivior. Archives of Environment Health, 12(2), 246-2066. Lewin, K., Dembo, T., Festinger, L., & Sears, P. S. (1944). Levels of Aspiration. In J. Hunt (Ed.), Personality and the behavior disorders, a handbook based on experimental and clinical research (Vol. 1, pp. 333-378). New York: The Ronald Press. Mattson, M. (1999). Toward a reconceptualization of communication cues to action in the Health Belief Model: HIV test. Communication Monographs, 66(3), 240.

HEALTH BELIEF MODEL

15

Mikhail, B. (1981). The Health Belief Model: A review and critical evaluation of the model, research, and practice. Advances in Nursing Science, 4(1), 65-82. Mikhail, B. I., & Petro-Nustas, W. I. (2001). Transcultural adaptation of Champion's Health Belief Model Scales. Journal of Nursing Scholarship, 33(2), 159-165. Miller, K. (2005). Communication theories: Perspectives, processes, and contexts (2nd ed.). New York: McGraw Hill. Rosenstock, I. M. (1960). What research in motivation suggests for public health. American Journal of Pubic Health, 50(3), 295-302. Rosenstock, I. M. (1966). Why people use health services. Milbank Memorial Fund Quarterly, 83(4), 1-32. Rosenstock, I. M., Derryberry, M., & Carriger, B. (1959). Why people fail to seek poliomyelitis vaccination. Public Health Reports, 74(2). Rosenstock, I. M., Strecher, V. J., & Becker, M. H. (1988). Social Learning Theory and the Health Belief Model. Health Education Behavior, 15(2), 175-183. Tanner-Smith, E. (2010). Evaluating the Health Belief Model: A critical review of studies predicting mammograpohic and pap screening. Social theory and Health, 8(1), 95-125.