THE HEALTH BELIEF MODEL
Many people with health problems would probably try ways to prevent and treat illness that are different from those most other people would try. This is because of what they believe is healthy for them. Peoples thinking may affect how they feel. Researchers have been interested in the role of health beliefs in people’s practice and non-practice of health behaviors. The most widely researched and accepted theory of why people do and do not practice these behaviors is called the Health Belief Model (Becker & Rosenstock).
According to the Health Belief Model, the likelihood that a person will take preventive action—that is, perform some health behavior—depends directly on the outcome of two assessments he or she makes. One assessment pertains to the threat the person feels regarding a health problem, and the other weighs the pros and cons of taking the action.
What factors go into these assessments?
First, let’s talk about the perceived threats. There are several factors that can influence peoples perceived threat—that is, the degree to which they feel threatened or worried by the prospect of a particular health problem. These factors include:
- Perceived seriousness of the health problem. People consider how severe the organic and social consequences are likely to be if they develop the problem or leave it untreated. The more serious they believe its effects will be, the more likely they are to perceive it as a threat and take preventive action.
- Perceived susceptibility to the health problem. People evaluate the likelihood of their developing the problem. The more vulnerable they perceive themselves to be, the more likely they are to perceive it as a threat and take action.
- Cues to action. Being reminded or alerted about a potential health problem increases the likelihood of perceiving a threat and taking action. Cues to action can take many forms, such as a public service announcement of a dangerous storm approaching or a reminder phone call for an upcoming dental appointment.
In addition, three other factors are implicated in people’s perceived threat of illness or injury.
These factors are:
Demographic variables, which include age, sex, race, and ethnic background;
Socio-psychological variables, including personality traits, social class, and social pressure; and
Structural variables, such as knowledge about or prior contact with the health problem.
Thus, for example, elderly individuals whose close friends have developed severe cases of cancer or heart disease are more likely to perceive a personal threat of illness than young adults whose friends are in good health.
For the second type of assessment, in weighing the pros and cons of taking preventive action, people assess the benefits—such as being healthier or reducing health risks—and the barriers or costs they perceive in taking action.
What barriers might people see in preventive action?
For the health behavior of getting a periodic physical checkup, the barriers might include financial considerations (“Can I afford the bills?”), psychosocial consequences (People will think I’m getting old if I start having checkups), and physical considerations (My doctor’s office is across town, and I don’t have a car’). As these examples suggest, demographic, socio-psychological, and structural variables can affect people’s assessments. Thus, for instance, individuals from lower economic classes are more likely than people from higher classes to feel that affording the bills or getting to the doctor’s office is very difficult.
The perceived threat of illness or injury combines with the assessed sum of perceived benefits and barriers to determine the likelihood of preventive action. Thus, for the health behavior of having a medical checkup, people who feel threatened by an illness and believe the benefits of having a checkup outweigh the barriers are likely to go ahead with it, taking action for primary prevention. But people who do not feel threatened or assess that the barriers are too strong are unlikely to have the checkup.
According to the health belief model, the processes we described for primary prevention also determine people’s symptom-based behavior in secondary prevention, such as going to the doctor when sick, and sick-role behavior in tertiary prevention, such as sticking with a rehabilitation program following a stroke.
The model has generated a great deal of research, much of which has upheld its predictions. Let’s consider the case of primary prevention. Studies have found that compared to people who do not get vaccinations, have regular dental visits, get regular breast and cervical cancer tests, or take part in exercise programs, those who do are more likely to believe that they are susceptible to the related health problem, that developing the problem would have very serious effects, and that the benefits of preventive action outweigh the barriers.
Similar relationships have been found for secondary and tertiary prevention. That is, compared to people who do not take medication as directed or do not stick with prescribed dietary and weight loss programs; those who do are more likely to believe they are susceptible to a worsening of their health, that the resulting illness would have serious effects and that the benefits of protective action exceed the costs.
Furthermore, studies have shown that cues to action, such as reminders to perform breast self-examinations and demographic and sociopsychological variables influence people’s practice of preventive measures.
In 1982, fast-food chains in New Orleans began using a gimmick to reverse a dangerous trend: more and more parents were not having their children vaccinated. The gimmick involved offering discount coupons for meals to parents who had their children immunized before the end of the summer. Other creative approaches by public health agencies have been used in other communities for the same purpose. We will begin our discussion of programs for health promotion by looking at some of the methods they use.
Methods for Promoting Health
Interventions to promote health try to encourage the practice of healthful behavior by teaching individuals what these behaviors are and how to perform them, and by persuading people to change their current unhealthful habits. An important step in this effort is motivating individuals to want to change, and this often requires modifying their health beliefs and attitudes. What methods do these programs use to encourage health behavior?
People who want to lead healthful lives need information—they need to know what to do and when, where, and how to do it. In reducing dietary cholesterol, people need to know what cholesterol is and that it can clog blood vessels, which can produce heart disease. They also need to know where they can have their blood tested for cholesterol level, what levels are high, how much cholesterol is in the foods they currently eat, which foods might be good substitutes for ones they should eliminate from their diets, and how to prepare these foods.
There are several sources for information to promote health. One source for health information is the mass media. Television, radio, newspapers, and magazines can play a useful role in promoting health by presenting warnings and providing information, such as to help people avoid or stop smoking. One such approach simply provides information to the general population about the negative consequences of an activity—smoking, for instance—as public service advertisements often do. This approach has had limited success in changing behavior. One reason for the limited success is that people often misunderstand the health reports they encounter. Another reason may be that they just don’t want to change the behavior at issue.
Other approaches the mass media have used focus on people who already want to stop an unhealthful habit. For example, programs conducted on TV have been effective in getting smokers to take the first steps in quitting by offering free printed materials or kits with hints on how to stop and contact persons at a community agency. A more comprehensive program on TV, called Cable Quit, was successful in helping people stop smoking by showing them how to prepare to quit, helping them through the day they quit, describing ways to maintain their success, and giving them opportunities to call for advice. Of those who started the program, 17% continued to abstain from smoking a year later.
Another source of health promotion information is the computer, particularly via the Internet. People anywhere in the world who are already interested in promoting their health and have access to the Internet can contact a wide variety of websites. Some are huge databases with information on all aspects of health promotion, and others provide detailed information on specific illnesses, such as cancer and arthritis, or support groups for health problems. People can learn how to avoid health problems and if they become ill, what the illness is and how it can be treated.
A third source of health promotion information is medical settings, particularly physicians’ office. There are advantages and disadvantages in using medical settings as sources of health information. Two advantages are that many individuals visit a physician at least once a year; and they respect health care workers as experts. Two disadvantages are that these efforts take up time in already busy practices; and medical personnel may not know how to help people overcome problems they have in following prevention recommendations. Because of the problem of time in busy practices, researchers have developed 5 to 10minute counseling programs that medical staff can be trained to give in person or on the telephone.
Medical professionals now have another avenue for providing health promotion information. They can offer individuals who are at risk for inherited illnesses, such as some forms of cancer, estimates of their chances of getting the disease and opportunities to undergo tests, such as periodic examinations and genetic testing. But even when genetic testing is offered at no cost, more than half of individuals do not request the testing and results.
Maintaining Healthy Behaviors
When people adopt a new behavior in place of one they performed for a long time, their success usually has some setbacks, or lapses. A Lapse is an instance of backsliding—for instance, a person who quits smoking might have a cigarette one day. Lapses should be expected; they do no indicate failure. A more serious setback is a relapse, or falling back to ones original pattern of the undesirable behavior. Relapses are very common when people try to change long-standing habits, such as their eating and smoking behaviors.
Psychologists C. Alan Marlatt and Judith Gordon have proposed that for many individuals who quit a behavior, such as smoking, experiencing a lapse can destroy their confidence in remaining abstinent and precipitate a full relapse. This is called the abstinence-violation effect. Because these people are committed to total abstinence, they tend to feel guilty about any lapses, even with just one cigarette, and see their violation as a sign of a personal failure. They might think, for instance, “I don’t have any willpower at all and I cannot change.” In programs to change behavior, relapses can be reduced by training individuals to cope with lapses and maintain self-efficacy about the behavior and by providing “booster” sessions or contacts. Contacts, even by phone, can reduce relapses substantially by providing counseling on dealing with difficult situations that could lead to lapses.
Health Promotion Programs
Many types of programs have been carried out to promote health in different settings and with a variety of goals, methods, and populations. We will examine different types of interventions, beginning with health education efforts that are designed to reach children and adolescents in schools and establish healthful habits at early ages.
Promoting Health in the Schools
Public and private schools have a unique opportunity to promote health. In developed nations, they have access to virtually all individuals during the years that are probably most critical in the development of health-related behavior. Effective school-based health education teaches children what healthful and unhealthful behaviors are and the consequences of practicing them.
This can produce two benefits. First, children may avoid developing unhealthful habits at the time when they are most vulnerable to these behaviors taking hold. Second, children may acquire health behaviors that become established or habitual aspects of their beliefs and lifestyles that may stay with them throughout their lives.
Studies have found that more children practice safety behavior if they are taught about health and safety in the school than if they are not. But many schools do not provide health education at all, or their programs are poorly designed and funded and taught by teachers whose interests and training are in other areas.
Worksite Wellness Programs
There is a new “epidemic” in the health field—wellness programs are spreading rapidly in workplaces in industrialized countries. A survey of more than 1300 American work sites with 50 or more employees found that nearly two-thirds offered some form of health promotion activity, such as for fitness and weight control. Some programs use incentives, such as prizes or bonuses for losing weight, stopping smoking, or staying well.
By doing this, employers are helping their workers and saving a great deal of money. Workers with poor health habits cost employers substantially more in health benefits and other costs of absenteeism than those with good habits. These savings offset and often exceed the expense of running a wellness program. Psychologists who study or administer such programs are called occupational health psychologists.
Worksite wellness programs vary in their aims, but usually address some or all of the following risk factors: hypertension, cigarette smoking, unhealthful diets and overweight, poor physical fitness, alcohol abuse, and high levels of stress.
Housing these interventions in workplaces has several advantages. Worksite programs are convenient to attend, are fairly inexpensive for employees, can provide participants with reinforcement from the employer and coworkers, and can structure the environment to encourage healthful behavior, such as by making healthy food available in the cafeteria. Unfortunately, worksite programs don’t always attract high levels of participation and employees who do not participate are often the ones who need it most—those who report having poor health and fitness.
Community—Based Wellness Programs
Community-based programs for health promotion are designed to reach large numbers of people and improve their knowledge and performance of preventive behavior. These interventions may use any or all of the methods we have considered. They may, for instance, use a media blitz to warn people of the dangers of drinking and driving, or provide information regarding free blood pressure testing or offer people a chance to win a prize for stopping smoking or getting vaccinations.
From the next lecture, we will begin our new series of Behaviors that can help in Enhancing Health and reducing Health Risks.