The Health Belief Model (HBM)

THEORETICAL FRAMEWORK

2.2 Individual-level behaviour change theories

2.2.1 The Health Belief Model (HBM)

The Health Belief Model (HBM), one of the first theories of health behaviour, is a psychological model formulated to explain and predict why individuals engage in health-related actions that may or may not compromise their health. It remains one of the most widely recognized theories in the field of prevention. It was initially developed in the 1950’s to explain the widespread failure of people to participate in prevention programmes against diseases (vaccination) and later applied to people’s responses to diagnosed symptoms of illness and compliance with medical regimens (Rosenstock, Strecher & Becker, 1994). It suggests that health-related behaviours depend on four individual attitudes or perceptions about an illness:

1) the potential seriousness of an illness, 2) the person’s feeling of risk from that illness, 3) the benefits they feel they will receive for taking a preventive action and 4) the barriers to taking that action. The extension of the HBM to include Bandura’s concept of self-efficacy to strengthen its utility and explanatory power for a wider variety of health behaviours was proposed by Rosenstock, Strecher and Becker.

The focus of the comprehensive HBM is on disease prevention and has the following key variables:

 Perceived threat, which consists of two components:

o Perceived susceptibility: An individual’s subjective perception of being vulnerable to a health condition;

o Perceived severity: An individual’s evaluation of the seriousness of the illness or leaving it untreated within the context of medical and clinical consequences and possible social consequences.

 Perceived benefits: The beliefs about the effectiveness of strategies available to reduce threat of contacting a disease.

 Perceived barriers: The possible negative consequences of taking particular health actions, including physical, psychological, and cost effectiveness.

 Cues to action: Events that trigger action, which can either be bodily (e.g. symptoms of onset of a disease) or external (e.g. medical publicity, mass media campaigns, or a reminder from one’s physician) that motivate the individual to take actions.

 Other variables: These include demographic (age, sex, ethnicity/race), socio-psychological (social class, peers, religion) and structural (knowledge, publicity) variables that affect an individual’s perceptions and indirectly influence health-related behaviour.

 Self-efficacy: An individual’s confidence in being able to execute successfully the behaviour change required to produce the desired outcomes. The likelihood of an individual taking an action is related to the perceived benefits of such action weighed against the perceived barriers. This was a later addition to the HBM.

The HBM has been proposed as a framework to conceptualize HIV/AIDS preventive behaviours because of its success in explaining health conditions and health related behaviours (Rosenstock, Stretcher, & Becker, 1994). The HBM is therefore built on these four core components (perceived susceptibility, perceived severity, perceived benefits, and perceived barriers). Evidently since health motivation is the central focus of HBM, the model should be a good fit for addressing problem behaviours that could evoke health concerns like high-risk sexual behaviour and the possibility of contracting HIV. The six constructs above could provide a useful framework for designing both long-term and short-term change strategies. The framework is presented in Table 1.1 (Source: NIH, 2005) and the schematic representation in Figure 1.

‘Cues of action’, which refers to stimuli necessary to trigger the process of healthy actions, could come from mass media campaigns (TV, newspapers or magazine articles), illness/death of a family member or friend from a particular disease, advice from others, reminder postcard from one’s physician or dentist or text messages sent to cell phones. The demographic (e.g., age, sex, race, ethnicity), socio-psychological (e.g., personality, social economic factors), and structural (e.g., knowledge about the disease, personal experience with condition) variables directly/indirectly influence health-related behaviours by affecting a person’s perception of susceptibility, severity, benefits, and barriers.

Table 1.1: Framework for adoption of Health Belief Model

Concept Definition Potential Change Strategies

Perceived susceptibility

Belief about the chances of getting a condition

 Defining what population(s) are at risk and their level of risk

 Tailor risk information based on an individual’s characteristics or behaviours

 Help the individual develop an accurate perception of his/her own risk

Perceived benefits Beliefs about the seriousness of a condition and its consequences

 Specify the consequences of a condition and recommend action Perceived benefits Beliefs about the effectiveness of

taking action to reduce risk or seriousness

 Explain how, where, and when to take action and what the potential positive results will be

Perceived barriers Beliefs about the material and psychological costs of taking action

 Offer reassurance, incentives, and assistance; correct misinformation Cues to action Factors that activate ‘readiness

to change’

 Provide ‘how to’ information, promote awareness, and employ reminder systems

Self-efficacy Confidence in one’s ability to take action

 Provide training and guidance in performing action

 Use progressive goal setting

 Give verbal reinforcement

 Demonstrate desired behaviours

Most of the studies have, however, not employed the comprehensive version of the model except that of Winfield and Whaley (2002). One consistent finding from most of the studies carried out in the USA is that knowledge of HIV/AIDS does not predict condom use.

Consequently HIV/AIDS knowledge is a necessary, but not sufficient, factor for health preventive behaviours.

Sociodemographic factors

e.g. education, age, sex, race and ethnicity

BACKGROUND

PERCEPTIONS

ACTIO NS

Expectations

.

Perceived benefits of action (minus)

.

Perceived barriers to action

.

Perceived self-efficacy to perform action

Threats

.

Perceived susceptibility (or acceptance of the diagnosis)

.

Perceived severity of ill health condition

Cues of action

.

^Media

.

Personal influence

.

^Reminders

Behaviour to reduce threat based on expectations

Source: Rosenstock, Strecher & Becker (1994) Figure 1.1: The schematic representation of HBM

Winfield and Whaley (2002) found that only perceived barriers was a significant predictor of condom use among African American students and the comprehensive HBM did not explain significantly more variance in condom use than the core components of the model. This finding is in agreement with similar studies in Africa (e.g., Hounton, Carabin & Henderson, 2005).

One of the criticisms that the HBM has received is the argument that the model is based on rationalistic assumptions. The argument has been that direct personalized information about

vulnerability should, when combined with information about preventive behaviours, induce behaviour change. However, HIV prevention has shown that human beings are not always rational in a concept that is best understood by the individual at the point of decision making.

The decision to have sex by a young African girl is not driven only by the fear of the consequences but could be by positive motivations, such as the need for affection, and establishing a strong personal relationship, which may be absent at home or which could have been missing in her life by circumstances beyond her control. Hence as far as she is concerned she is being rational (Gage, 1998).

Researchers have been consistent in ignoring the importance of the social environment in behaviour and the strong influence socio-cultural context exerts on decision-making as major weaknesses of the HBM. Romer and Hornick (1992) provided a repository of social meaning and norms for behaviour, including sexual behaviour, to include images and interpretations that groups attach to behaviour. Norms are the social expectations that groups maintain to define appropriate behaviour. The inability of the HBM to make tangible provision for social environment where behaviour takes place has created a gap concerning its application in Africa where traditions are held in high esteem (Odutola, 2005).

Most of the other psychological theories, like HBM, are based on the assumption of a linear relationship from information to knowledge and behaviour change. However, the theory of reasoned action (e.g. Bosompra, 2001) provides a framework for linking individual beliefs, attitudes, intentions and behaviours.