Health belief model BY LILLIAN NALUWEMBA MAYANJA & FRED MBUGA outline Definition and Rationale for the Health Belief Model, including: Major Concepts How the Health Belief Model was Developed The Health Belief Model and Sexuality Education How Can we Use the Health Belief Model in our Setting? Challenges and Considerations in Applying the Health Belief Model, and Resources Definition and Rationale for the HBM The Health Belief Model (HBM) is one of the most widely used conceptual frameworks for understanding health behavior. Developed in the early 1950s, the model has been used with great success for almost half a century to promote greater condom use, seat belt use, medical compliance, and health screening use, to name a few behaviors. The HBM is based on the understanding that a person will take a health-related action (i.e., use condoms) if that person: 1. feels that a negative health condition (i.e., HIV) can be avoided, 2. has a positive expectation that by taking a recommended action, he/she will avoid a negative health condition (i.e., using condoms will be effective at preventing HIV), and 3. believes that he/she can successfully take a recommended health action (i.e., he/she can use condoms comfortably and with confidence). How the HBM works The Health Belief Model is a framework for motivating people to take positive health actions that uses the desire to avoid a negative health consequence as the prime motivation. E.g. HIV is a negative health consequence, and the desire to avoid HIV can be used to motivate sexually active people into practicing safe sex. Similarly, the perceived threat of a heart attack can be used to motivate a person with high blood pressure into exercising more often. It's important to note that avoiding a negative health consequence is a key element of the HBM. E.g. a person might increase exercise to look good and feel better. That example does not fit the model because the person is not motivated by a negative health outcome — even though the health action of getting more exercise is the same as for the person who wants to avoid a heart attack. The HBM can be an effective framework to use when developing health education strategies. Health Belief Model: Major Concepts HBM is based on six key concepts. The following table, excerpted with minor modifications from "Theory at a Glance: A Guide for Health Promotion Practice" (1997), presents definitions and applications for each of the six key concepts. Examples of the concepts as they apply to sexuality education are presented after this table. HBM Application For examples of what the six key concepts look like when applied to two sexual health actions, review the following table: Historical Origins of the Model Lewin’s Field Theory (1935) ◦ Introduced the concept of barriers to and facilitators of behavior change U.S. Public Health Service (1950’s) ◦ Group of social psychologists trying to explain why people did not participate in prevention and screening programs. ◦ Two major influences from learning theory: ◦ Stimulus Response Theory ◦ Cognitive Theory Stimulus Response Theory Learning results from events which reduce the psychological drives that cause behavior (reinforcers) In other words, we learn to enact new behaviors, change existing behaviors, and reduce or eliminate behaviors because of the consequences of our actions. Reinforcers, punishments, rewards Cognitive Theory Emphasize the role of subjective hypotheses and expectations held by the individual. Beliefs, attitudes, desires, expectations, etc. Influencing beliefs and expectations about the situation can drive behavior change, rather than trying to influence the behavior directly. Value-Expectancy Theory Vroom! Expectancy: person believes that increased effort leads to improved performance Instrumentality: person believes that improved performance leads to a certain outcome or reward Outcomes: person values that reward or outcome How the HBM was Developed cont… The model was first presented with only four key concepts: Perceived Susceptibility, Perceived Severity, Perceived Benefits, and Perceived Barriers. The concept of Cues for Action was added later to "stimulate behavior.“ Finally, in 1988, the concept of Self-Efficacy was added to address the challenges of habitual unhealthy behaviors such as smoking and overeating. The HBM and Sexuality Education The Health Belief Model (HBM) has been applied to a variety of health education topics including sexuality education. Since the HBM is based on motivating people to take action, (like using condoms) it can be a good fit for sexuality education programs that focus on: Primary prevention — for example, programs that aim to prevent pregnancy, sexually transmitted diseases (STIs) and HIV by increasing condom use, and Secondary prevention — for example, programs that aim to increase early detection of STIs or HIV to reduce their spread via unprotected intercourse and to ensure the early treatment of the conditions. Where HBM is not Applicable In comprehensive sexuality education programs that cover a variety of information related to sexuality but are not specifically action-oriented. Applying the HBM to abstinence education is possible but is not necessarily a good fit. Youth abstain from sex for many reasons — personal reasons, religious reasons, logistical reasons — not always primarily to avoid a perceived threat of a negative health outcome. Using HBM's threat-logic model to promote abstinence could be unduly "sex negative." How Can we Use the HBM in our Setting? Limitations of the HBM There are several limitations of the HBM which limit its utility in public health. It does not account for a person's attitudes, beliefs, or other individual determinants that dictate a person's acceptance of a health behavior. It does not take into account behaviors that are habitual and thus may inform the decision-making process to accept a recommended action (e.g., smoking). It does not take into account behaviors that are performed for non-health related reasons such as social acceptability. It does not account for environmental or economic factors that may prohibit or promote the recommended action. It assumes that everyone has access to equal amounts of information on the illness or disease. It assumes that cues to action are widely prevalent in encouraging people to act and that "health" actions are the main goal in the decision-making process. Other considerations of the HBM The HBM focuses on beliefs and attitudes and, as such, may be less appropriate for dealing with habitual behaviors like smoking, dieting, or other emotionally motivated health behaviors. These behaviors should be addressed separately. In addition, economic and environmental factors are not addressed with the Health Belief Model since these may be out of an individual's control. The HBM is a good fit for prevention-focused programs because these programs generally promote specific actions, and the HBM helps participants to take action. However, HBM is not always a good fit for comprehensive family life education programs which tend to be more information-based and wider in scope of topics. To help build self-efficacy, encourage youth to set short-term goals, which are generally easier to achieve and receive reinforcement for than long-term goals, which may not be realized for months or years. Grant support for programs which are based on the HBM may be easier to get from funding agencies. Funders generally prefer supporting programs that are carefully crafted and grounded in well-researched approaches and models such as the HBM. Other considerations of the HBM 1. It is more effective to combine the HBM with other learning theories (e.g., Social Learning Theory) than to offer specific guidelines for teaching skills. 2. Be aware that the HBM uses "appropriate fear-based messages" in order to facilitate youths' perceived susceptibility and severity. Be careful not to overdo it. When fear levels are too high, youth may feel helpless. 3. The HBM is much more effective for a multiple layer intervention. The combination of multiple interventions (e.g., a school health event, classroom instruction, and an educational ad campaign) is more effective than any single intervention. 4. The HBM is best used for a relatively short intervention to achieve a specific change. It may be less effective in achieving long-term change. References Books Health Behavior and Health Education: Theory Research and Practice, Karen Glanz, Frances Marcus Lewis, Barbara K. Rimer, Jossey-Bass Publishers, 1990. Theory at a Glance: A Guide for Health Promotion Practice, Karen Glanz and Barbara Rimer, National Institute of Health, 1997. Web Sites University of South Florida — Health Behavior Change: Theories and Models http://www.med.usf.edu/~kmbrown/hlth_beh_models.htm http://www.med.usf.edu/~kmbrown/HBM_Interactive_Handout.htm American School Health Association — Behavioral Theories http://www.cast.ilstu.edu/temple/behthe.htm Articles Marvin Eisen, et.al. A Health Belief Model — Social Learning Theory Approach to Adolescents' Fertility Control: Findings from a Controlled Field Trial. Health Education Quarterly. Vol. 19, 1992. Irwin Rosenstock. Historical Origins of the Health Belief Model. Health Education Monographs. Vol. 2 No. 4, 1974. M.H. Becker. The Health Belief Model and Personal Health Behavior. Health Education Monographs. Vol. 2 No. 4, 1974.