The HBM has been used for over half a century to predict health-related behaviors and to frame interventions to change behaviors. As indicated by the reviewed research, it has been useful in predicting and framing cancer screening and HIV-protective behav- iors. Its simplicity has enabled researchers to identify constructs that may be impor- tant, thus increasing the probability that a theoretical base will be used to frame research interventions. Its simplicity, however, also creates some of its major limitations.
Several challenges remain when considering the HBM as a theory to predict health- related behaviors. First, perceived threat is a construct that has great relevance in health-related behaviors. The HBM couples severity with perceived susceptibility—
a strength, compared with models that conceptualize threat as perceived risk alone.
However, the relationship between risk and severity in forming threat is not always clear. A heightened state of severity is required before perceived susceptibility be- comes a powerful predictor. It may be that perceived susceptibility is a stronger pre- dictor of engagement if severity in health-related behaviors is perceived as higher versus lower. If this is true, a multiplicative variable should be computed that com- bines perceived susceptibility and severity, rather than considering each alone.
Relationships among other constructs in the HBM also should be tested more thoroughly. For instance, perceived benefits and barriers may be stronger predictors of behavior change when perceived threat (perceived severity×perceived suscepti- bility) is high than when it is low. Under conditions of low perceived threat, benefits of and barriers to engaging in health-related behaviors should not be salient. This re- lationship, however, may be altered in situations where benefits are perceived to be very high and barriers very low. Threat may not need to be high if perceived barriers
are very low (for example, if flu shots are available at very convenient locations, like grocery stores). Therefore, the predictive power of one concept may depend on val- ues of another.
The HBM is limited, in that it is a cognitively based model and does not consider the emotional component of behavior. Witte considered fear an essential part of a health-related behavior, defined as a negative emotion accompanied by a high state of arousal (Witte, 1992). We have experimented with adding fear to a model that pre- dicts mammography behavior and have found relationships between HBM constructs and fear that might be useful predictors (Champion, Skinner, and Menon, 2005; Cham- pion, Menon, Rawl, and Skinner, 2004). Fear was significantly predicted by perceived risk, benefits, and self-efficacy; fear, together with barriers, then predicted actual be- havior. These findings are consistent with the Protection Motivation Theory (Rogers and Prentice-Dunn, 1997). The most persuasive communications are those that arouse fear while enhancing perceptions central to the HBM—the severity of an event, the likelihood of exposure to that event, the benefits of responses to that threat, and self- efficacy for accessing those benefits (Rogers and Prentice-Dunn, 1997). Inclusion of an emotional construct might help explain relationships among HBM constructs (Rogers and Prentice-Dunn, 1997).
Finally, cues to action are one component of the HBM often missing from re- search. Cues to action will have a greater influence on behavior in situations where perceived threat and benefits are high and perceived barriers are low. We know little about cues to action or their relative impact because this construct has not been iden- tified clearly in research. Cancer screening studies have used reminder letters or post- cards as an intervention and found that, for many participants, this intervention is significant. A reminder postcard may be a cue to action, but it is seldom labeled as such. Researchers have found that simple reminders may be all that is needed for women who have already had a mammogram or are contemplating getting another (Saywell and others, 2003).
SUMMARY
In this chapter we described the origins of the Health Belief Model (HBM), reviewed and defined its key components and their hypothesized relationships, described issues related to measuring HBM constructs, and gave examples of carefully developed meas- ures. This chapter also gave examples of applications of the HBM in descriptive and intervention studies of breast cancer screening and AIDS-related risky sexual behaviors.
The concept of perceived threat, defined as a combination of perceived suscepti- bility and severity in the HBM, has great relevance for many health-related behaviors.
Future challenges to HBM research include more thorough testing of the relationships among constructs beyond perceived thereat. The HBM is a cognitively based model that does not consider the emotional component of behavior—this component, as well as cues to action, should be added to or better incorporated in HBM research. Finally, an updated critical review of the research and findings based on the HBM is warranted and would help to map future directions for researchers and practitioners.
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