Health Belief
Model
Person's perception of the threat of a health problem and the appraisal of recommended behaviour(s) f
managing the problem
Theory
Focus
Individual
Level
Stages of Change
Model
Individual's readiness to change or attempt to change toward healthy beh
Health Belief Model
Person's perception of the threat of a health problem and the appraisal o
recommended behaviour(s) for preventing or managing the problem
Interpersonal
Level
Social Learning Theory
Behaviour is explained via a 3-way, dynamic reciprocal theory in which p
factors, environmental influences and behaviour continually interact
Community
Level
Community
Organisation Theories
Emphasises active participation and development of communities that ca
evaluate and solve health and social problems
Organisational Change
Theory
Concerns processes and strategies for increasing the chances that healt
and programmes will be adopted and maintained in formal organisations
Diffusion of Innovations
Theory
Addresses how new ideas, products and social practices spread within a
from one society to another
HEALTH BELIEF MODEL
explaining health behaviors
History and Orientation
The Health Belief Model (HBM) is a psychological model that attempts to explain and predict health behaviors. This is
was first developed in the 1950s by social psychologists Hochbaum, Rosenstock and Kegels working in the U.S. Pub
of a free tuberculosis (TB) health screening program. Since then, the HBM has been adapted to explore a variety of lo
the transmission of HIV/AIDS.
Core Assumptions and Statements
The HBM is based on the understanding that a person will take a health-related action (i.e., use condoms) if that pers
1.
2.
feels th
has a p
action,
condom
believe
health a
with con
3.
The HBM was spelled out in terms of four constructs representing the perceived threat and net benefits: perceived su
barriers. These concepts were proposed as accounting for people's "readiness to act." An added concept, cues to ac
addition to the HBM is the concept of self-efficacy, or one's confidence in the ability to successfully perform an action.
HBM better fit the challenges of changing habitual unhealthy behaviors, such as being sedentary, smoking, or overea
Table from “Theory at a Glance: A Guide for Health Promotion Practice" (1997)
Concept
Definition
Perceived Susceptibility
One's opinion of chances of getting a cond
Perceived Severity
One's opinion of how serious a condition a
consequences are
Perceived Benefits
One's belief in the efficacy of the advised a
to reduce risk or seriousness of impact
Perceived Barriers
One's opinion of the tangible and psycholo
costs of the advised action
Cues to Action
Strategies to activate "readiness"
Self-Efficacy
Confidence in one's ability to take action
Conceptual Model
Source: Glanz et al, 2002, p. 52
Favorite Methods
Surveys.
Scope and Application
The Health Belief Model has been applied to a broad range of health behaviors and subject populations. Three broad
behaviors, which include health-promoting (e.g. diet, exercise) and health-risk (e.g. smoking) behaviors as well as vac
to compliance with recommended medical regimens, usually following professional diagnosis of illness. 3) Clinic use,
Example
This is an example from two sexual health actions. (http://www.etr.org/recapp/theories/hbm/Resources.htm)
Concept
1. Perceived Susceptibility
2. Perceived Severity
3. Perceived Benefits
4. Perceived Barriers
5. Cues to Action
Condom Use Education Example
Youth believe they can get STIs or HIV or create a
pregnancy.
Youth believe that the consequences of getting STIs
or HIV or creating a pregnancy are significant
enough to try to avoid.
Youth believe that the recommended action of using
condoms would protect them from getting STIs or
HIV or creating a pregnancy.
Youth identify their personal barriers to using
condoms (i.e., condoms limit the feeling or they are
too embarrassed to talk to their partner about it) and
explore ways to eliminate or reduce these barriers
(i.e., teach them to put lubricant inside the condom to
increase sensation for the male and have them
practice condom communication skills to decrease
their embarrassment level).
Youth receive reminder cues for action in the form of
incentives (such as pencils with the printed message
"no glove, no love") or reminder messages (such as
messages in the school newsletter).
6. Self-Efficacy
Youth confident in using a condom correctly in all
circumstances.
References
Key publications
Conner, M. & Norman, P. (1996). Predicting Health Behavior. Search and Practice with Social Cognition Models. Ope
Glanz, K., Rimer, B.K. & Lewis, F.M. (2002). Health Behavior and Health Education. Theory, Research and Practice.
Glanz, K., Marcus Lewis, F. & Rimer, B.K. (1997). Theory at a Glance: A Guide for Health Promotion Practice. Nation
Eisen, M et.al. (1992). A Health Belief Model — Social Learning Theory Approach to Adolescents' Fertility Control: Fin
Rosenstock, I. (1974). Historical Origins of the Health Belief Model. Health Education Monographs. Vol. 2 No. 4.
Becker, M.H. The Health Belief Model and Personal Health Behavior. Health Education Monographs. Vol. 2 No. 4.
Champion, V.L. (1984). Instrument development for health belief model constructs, Advances in Nursing Science, 6,
Becker, M.H.,Radius, S.M., & Rosenstock, I.M. (1978). Compliance with a medical regimen for asthma: a test of the h
See also: http://www.comminit.com/ctheories/sld-2929.html
http://www.etr.org/recapp/theories/hbm/
See also: Theory of Planned Behavior/ Reasoned Action, Protection Motivation Theory
See also Health Communication
Using a Health Belief Model
In
Teaching Preventive Health Care Principles
To
Israeli RNs
A Paper for Presentation at the CITA Conference
University of Massachusetts Lowell
November 7, 8, 9, 2002
nn K. Mackey EdD, RN Introduction
The health of individuals and aggregate populations within a given community is
dependent on their ability to identify their risk for specific health problem(s). In addition,
these individuals and groups must be willing to adhere to life style changes in order to
maintain health and wellness. Therefore, the role of nurses and other health care
practitioners is to assess an individual’s health risk and his/her belief that engaging in
specific risk reduction interventions could lead to healthier outcomes.
The purpose of this paper is to explore instructional methods that can be utilized
by faculty to teach nurses about the application of a Health Belief Model (HBM) in any
health care setting. The application of teaching methods will be based upon how Israeli
registered nursing students were taught HBM models or principles for implementation in
their clinical practice. Before presenting specific teaching methods, the health care
system in Israel, the role of nursing, and the future for nursing practice in Israel will be
discussed.
Overview of the Israeli Health Care System and Cultural Background
The current Health Care System in Israel is a result of the National Health
Insurance Law, which was enacted in 1995 and is based on principles of socialized
medicine. The health care system is support by an individual health tax and funding from
general tax revenues. Each citizen has a choice to belong to one of four Health
Maintenance-like Organization (HMOs) or “sick funds.” These HMOs are similar to
American HMOs and all citizens of Israel are required to join a sick fund. Israel’s
national health law determines the types of health services or “basket of services”
provided by the HMOs, the various payments the insured must pay, and how
governmental appropriations will be divided among the HMOs. According to the health
care law ll Israeli citizens must be provided basic health care. However, for improved
access and choice, any individual who can afford it may obtain private supplemental
hospitalization and health care.
In each major city there are large medical centers that have the same departments
that one would see in any hospital or medical center in the United States. Hadassah
Hospital located in Jerusalem, an important research institution, is one of the most well
known medical centers in Israel that provides health care.
Israel has many cultural groups, which have led, the country in becoming a
pluralistic society. The major cultural groups are Arabs and Jews, as well as Russian and
Ethiopian immigrates. Within the Jewish culture are the Ultra-Orthodox Jews who have a
very strong religious faith and rely on governmental support in order to live. Before any
Ultra-Orthodox Jewish member can receive health care treatment, his/her spiritual leader
will provide consultation and approval. Arabic and Hebrew are the principle languages,
while English is an emerging language for many Israelis. Many of the medical and
nursing journals are written in English so the health care practitioner must have some
command of English.
Role of Nursing
Basic nursing education is completed through hospital based nursing programs,
similar to that seen in the early development of nursing education in the United States.
There are baccalaureate-nursing programs at some of the Israeli universities but
enrollment is limited to
students who do not have a nursing background. Nurses who are currently registered
nurses (RNs) have little opportunity in obtaining a baccalaureate in nursing through
Israeli universities. Therefore, nurses must obtain their nursing degrees through a United
States based program that has been contracted by a private Israeli educational brokering
institution. In addition, the Israeli Counsel on Higher Education must approve of the
American nursing program before it can be
3
offered to Israeli RNs. Lack of approval by this counsel would result in non-recognition
of the nursing degree by Israel.
Currently, Israeli nurses view their role as providing treatment (nursing care) to
patients in a variety of practice settings, engaging in patient health education programs,
assisting physicians in carrying out medical treatment regimes, and collaborating with
multi-disciplinary staff. Nurses who work in various sick funds (HMOs) help carry out
physicians’ instructions and supervise patients’ progress. Hospital nurses engage in
complex functions based upon patient acuity and supervise care provided by paraprofessional workers.
Based upon student comments, within the next 5-10 years nurses in Israel would
like to see nursing develop as a profession with greater respect, and that the bachelors
degree will be required for entry into nursing practice. In addition, they want to become
active decision makers in the health care system by having more input into the policies
and strategies that relate to the delivery of health care. One student summed up her future
vision of nursing by saying “nurses must become independent in initiating nursing
interventions and assist patients and families to assume more responsibility for self care.”
Nurses would also like to see higher salaries but recognize that the continuing violence in
the country is draining to the financial resources. Nevertheless these nurses believe that a
solid nursing education at the baccalaureate level will enhance the image of nursing and
increase the quality of health care for all Israeli citizens. Thus, nurses become enrolled in
the approved American nursing program to help actualize their vision for nursing.
Instructional Preparations
A required course in the American nursing program is Health Education in the
Community where part of the course content is the application of a health belief model.
The
4
HBM framework is presented as one of the theoretical approaches to promote and
maintain a life style change that encourages health promotion, health maintenance, and
assist in decreasing complications due to chronic illness.
The implementation of an American based nursing program in a foreign country requires
the nursing faculty to have: (a) a solid back ground in teaching and learning principles,
(b) an extensive experience in academic settings, (c) expertise in the content area, (d)
flexibility in presenting course content that does not compromise academic integrity, and
(e) an understanding of the host country’s culture, health care system, role of nursing, and
strategies used by students to engage in the process of learning.
At the beginning of the Health Education course, a student questionnaire was completed
by the Israeli RNs. The purpose of this questionnaire was to assist the nursing faculty in
understanding the Israeli health care system and the nursing experience of each student.
Results of the questionnaire identified where students worked and how long they had
been nurses; their understanding of the Israeli health care system; identification of at risk
populations and the five major health care problems in Israel today. Because the Health
Education course was taught in English, another outcome of the questionnaire was to
identify the level of student proficiency with the English language. Most of the students
in the nursing course were proficient in a second, third, or even a fourth language.
To ensure that students understood the course content from a language
perspective several strategies were used. Before each class the instructor developed a list
of vocabulary words that were essential for class content and students were required to
look up the definitions in English. During the first few minutes of class, feedback was
elicited from students regarding their understanding of these vocabulary words. When
discussing the class content the instructor
5
used a set of questioning strategies to help ensure the English comprehension. For
example, student were asked to define certain words such as “motivation and
compliance” and then related the concept or definition to health education and expected
health outcomes.. If students were still confused due to the comprehension of the English,
a student who was proficient in tge English language presented the concepts to students
in Hebrew.
Literature Review
Before developing the lecture material and learning activities, the course instructor
conducted a review of the literature to find current research studies related to health belief
models. The purpose for this review was to encourage evidence-based practice in
understanding what may work or not work in using health belief modules in practice
settings. One such study was a meta-analysis conducted by Bennet and Bozionelous
(2000) related to the use of condoms and health belief concepts. The researchers
reviewed 20 studies and found that attitudes were more powerful than social norms in the
use of condoms and self-efficacy judgments were more influential than other perceived
control factors. Another study conducted by Bish, Sutton, and Golombok (2000) focused
on the use of Becker’s Health Belief Model and Ajzen and Fishbien’s Theory of Planned
Behavior in identifying factors that influenced women to complete routine cervical pap
smears. Findings from this study indicated that a positive attitude toward the procedure it
self was more important in having it done than the perceived threat of disease or social
pressure. Mclntosh and Kubena (1996), conducted a study by applying health belief
model components to determine if changes in dietary habits could result in a reduction of
fat and cholesterol intake. Findings from this found that the HBM components help
people make changes in their dietary habits and that the beliefs were subject to influences
by others in particular health care personnel who provided health teaching. An additional
finding from
6
McIntosh and Kubena’s study was the influence of dietary cost in reducing fat and
cholesterol. Although these three studies were only a partial representation of the
literature review completed by the faculty member, the process helped the instructor to
direct students to recent research studies that might be influential in finding the right
combination of assessment factors and interventions to help individuals achieve desired
health outcomes
Health Education and a Health Belief Model
The health care provider drives health education in Israel. Clients and families are
referred to a guidance nurse or social worker where health information is provided.
Community health education classes are offered on specific health issues such as
smoking cessation, effects of diet on cardiac disease, how to control blood pressure, and
the importance of mammography. Age specific health education in the schools focuses on
nutrition, good dental care, protection from the sun, and safe sexual practices. Many
health education classes also have a specific population focus, such as first time mothers
who want to breast feed their infants.
An over-riding theme from Israeli RNs in the health education course was that
patients and families did not always follow the guidance offered by nurses, physicians, or
social workers. Because of the lack of follow through by patients and families an increase
in health care cost was seen through readmissions, proliferation of chronic illness, a rise
in morbidly and mortality rates for specific diseases as well as injures caused by
accidents in particular road accidents. Based upon the referral system, clients were sent to
the guidance nurse for instruction. The philosophical under-pinning here was “we tell
patients what they need to know and expect them to follow through”. To help Israeli
nurses understand that information alone does not lead to client motivation, compliance,
or the desired health care outcome, a six-hour block of instruction about health belief
models was provided. The basic model that was introduced to students was 7
Becker’s health belief model. This model provided the framework in teaching
nurses the importance of putting the focus on the client and not the guidance nurse/nurse
educator.
Becker’s Health Belief Model
Becker (1974) developed the concepts of a health belief model by expanding upon the
works of Reoenstock who studied individuals’ reasons for not participating in healthscreening programs. Health belief from Becker’s point of view is based upon the idea that
an individual must have the willingness to participate in health interventions and believe
that being healthy is a highly valued outcome. Therefore, it was possible to predict if an
individual would engage in positive health behaviors by determining the individuals’
perception of the disease, illness or accident, identification of modifying factors, and the
likelihood that the individual will take some action. The most influential factor within
Becker’s model that might prevent an individual from engaging in healthy behaviors was
the perceived barriers (Barnstable, 1997). Becker’s model can be found in Table 1
Table 1 Becker’s The Health Belief Model
________________________________________________________________________
______
Individuals Perceptions Modifying Factors Likelihood of Action
Perceived Susceptibility Demographic, Socio-psychological Perceived Benefits
Perceived Seriousness and Structural Variables Perceived Barriers
Cues to Action:
Advice from others
Reminders form Primary Care
Articles or TV information
Illness of friend or family member
Perceived Threat of Disease
Likelihood of Taking Recommended
Preventive Health Action
(Copied and modified from Bastable p.135) 8
Instructional Steps
Using concepts of the health belief model developed by Becker the following
steps were used to help students understand the basic components and the application of a
health belief models.
Step 1. Students were broken down into small discussion groups and asked
to define health, illness, and health promotion from their own health perspective.
Then they were to discuss how they envisioned or defined the health of their
clients. At the end of the group discussions, each group presented their findings to
the entire class.
Step 2: An interactive teaching approach, utilizing power-point materials
as a guide, basic concepts and principles related to health belief model developed
by Becker was presented. Included in the presentation were Pender’s Health
Promotion Model, Ajzen and Fishbien’s Theory of Reasoned Action, and
Bandura’s Self-efficacy Model.
Step 3: After the presentation of the basic concepts related to health belief,
the students were ask to break down into their groups and each student was to
identify a behavior tat they would like to see changed in themselves. Students
were asked to look at their current behavior, which intellectually they know need
to be changed; then using the health belief model to guide the assessment, ask
themselves the following questions:
To what extent did the RN students believe being over weight, smoking, lack of
exercise, or not completing a mammogram would lead to the development of
disease? If a problem were to develop how serious would it be? Who would
support them in their quest to change behavior? What are their barriers to change?
Students who smoked were asked the following questions: why do you smoke,
what prevents you from stopping, and how 9
important is smoking to you? The purpose for this part of the class was to help
students view the health issue as if they were the clients.
Step 4: After completing the exercise in Step 3, each student was then
asked to
identify a client situation where a change in client behavior was a desired
outcome. One student presented the problem of diabetic patients who live on a
Kabutz and had difficulty managing their blood sugars and preventing foot ulcers.
In this particular Kabutz meals were prepared and eaten in a central location. The
cost for the care and treatment of diabetic patients was stressing the financial
resources of the Kabutz. Although previous health teaching was conducted on
foot care, the importance of a good diet, exercise, and other principles of diabetic
care, patients continued to have problems. When the nurse was able to assess the
client using health belief model principles, the following was a partial list of
concerns that were discovered from the clients’ perspective:
a. Felt embarrassed because he/she was different from the other
members in the Kabutz.
b. Express difficulty in talking with the individual who cooked the
communal meal.
c. Wanted to be able to participate more fully in the activities of the
Kabutz
d. Wanted to feel valued as a member who could contribute to the
operations of the Kubutz.
Step 5. Evidence-based principles have become an integral part of
baccalaureate nursing education and nursing practice. Therefore, the next steps in
the learning process, students were asked to find primary research articles related
to health belief models and 10
present their findings when completing course assignments. The
application of research findings was evident in the final course papers, through
class discussions, and during their microteaching activities.
Step 6. The final step in the students’ learning process was for them to
attend a health education class and determine if a health belief model or
components from a health belief model were evident in helping clients achieve
better health outcomes. If the presenter did not use a health belief model, and in
most cases this was true, students were then asked to indicate which health belief
model they would use, how would they use it, and why. The learning outcomes
for this assignment were mixed. For example, some of the students identified
principles of Bandura’s Self-efficacy. However, the students did not look at self-
efficacy from the client’s perspective. Instead identified during the teaching
session that the guidance nurse explained to the class participates that their efforts
were essential in achieving positive health outcomes. It was clear in the students
write up that the participants in the health education were passive learners without
the opportunity to discuss their feelings and abilities toward meeting a health
goal. Although the idea of self-efficacy has merit, more work was needed with the
students to understand the difficulties, challenges, and possibilities from the
client’s point of view.
Other students were able to describe the difficulties and possibilities from the client’s
perspectives. In guidance class for diabetic patients stated “ the intensity of the illness,
side effects of the medication, and the length of time needed to be on a therapeutic
mediation” impacted on how well the medication follow-up was continued. In addition,
the same patients felt the lack of family support was a barrier to continued follow-through
in taking medications for diabetes. Some students addressed a health belief model from a
theoretical perspective by 11
explaining how to use the model to help adolescence engage in safe sexual practices. The
model used in this context was Ajzen’s Theory of Planned Behavior. Using the concepts
of attitude, subjective norms, and perceived control, the RNs were able to take these
principles and help the guidance nurse (school nurse) prepare for a lecture on reducing at
risk sexual behavior. An example of how the school nurse approached the young person’s
attitude toward sex was to give students a questionnaire a week before the class. In this
questionnaire the students were to tell how they felt about engaging in sexual activity and
how important was it for them to use or not use a condom. The questionnaire also
addressed social support regarding condoms use. Was it cool to use condoms or not from
the peer group perspective?
As students gained an understanding of health belief model principles, two ideas were
generated. The first idea was related to how to use health belief principles in situations
where illness was not the overriding concern. An example would be to encourage
mothers to breast-feed and couples to participation in childbirth classes. A second idea
presented by the RN students was how to use health belief principles as a change model
for nursing staff. Through class discussions the students were asked to discuss principles
related to health belief and self-efficacy in a non-illness context.
Some of the RN students in the class were managers and supervisors wanted to know if
the health belief module could be used to change behavior in other staff members. One
situation identified by these nurse managers was how to help nursing assistants recognize
a change in a client’s condition and then report findings to the staff nurse. Thus, a
discussion was generated to identify how the nursing assistants might perceive the
importance of their role as care gives and did they feel they could make a difference in
the health outcomes for clients. Questions generated from this discussion were:
12
a. Does the nursing assistant feel that they can make a difference in client
care?
b. Do other members of the health team value their input?
c. Do they feel valued as a member of the team?
d. Did the assistants find that the staff nurses listen to them?
e. Does the staff nurse provide cues to the nursing assistants?
f. Does the nursing assistant feel that they have the knowledge and resources
to make a difference (self-efficacy)?
g. Who supports or recognizes the nursing assistant during their care of
patients?
h. What are the barriers to working with elderly clients as perceived by
nursing assistance?
At the end of the discussion nurses were able to begin to develop realistic approaches,
which involved the nursing assistants that would improve early recognition of signs and
symptoms indicating an elder client may be experiencing a change in health status.
Before any in-service classes an idea that was generated was for the guidance nurse to
talk with the nursing assistants to find out how they felt regarding early recognition of
patient problems requiring immediate attention. It is also important to point out that
understanding the problem from the individual’s perspective whether it is the client, staff
member, or family member may help insure some successes in meeting expected
outcomes.
In the case of mothers who desire to breastfeed, asking the following questions to
determine from the mothers perspective thoughts, experiences, and feelings regarding the
art of breast-feeding, another class discussion was pursued.
a. How important is breast-feeding is to the mother (i.e. breast feeding can be
used as a method of birth control, to have a healthy baby; attitude toward
breast-feeding)? 13
b. Does the mother believe that she has the ability and resources to start and
continue with breast-feeding (i.e. enough milk, prevent sore nipples, able to
eat properly)?
c. Who offers support for breast-feeding (social support)?
d. What barriers have the mother identified that might become an issue related
to breast- feeding (i.e. not able to breast-feed before, seeing friends who had a
difficult time, working, other children to take care of, etc)?
e. What is the mother’s desired outcome (i.e. healthy baby, bonding with the
infant, feeling good about herself as a mother, meeting a cultural and or
religious requirement, etc.)?
Mothers, especially first time mothers, come to breast-feeding classes to learn how to
breast-feed and to feel comfortable with the decision to breat-feed. Assessing a mother
from a health belief perspective will enable nurses gain a more complete insight into the
new mothers’ specific concerns. This assessment information can lead in the
development of a teaching and intervention plan that meets the learning needs of breastfeeding mothers.
Conclusion
Using health belief models can assist nurses in seeing the health concerns from the
client’s perspective. In many cases clients and families are referred or given health
education programs without an assessment of their learning needs and are expected to
follow the treatment plan. Nurses can empower clients to become active participants by
including them in the decision making process through adequate collection of
information from the client’s perspective. Faculty can facilitate the learning process by
teaching in an interactive format that provides an opportunity for students to engage in
learning about the application of health belief principles in clinical practice. Part of the
teaching and learning process is to demonstrate how
14
course content can be applied realistically to clinical practice. Without a realistic
application of course content that can be supported by research outcomes, improvement
in clients’ health may not come to fruition.
Clinical research is the next logical step in determining whether nurses who have been
taught about health belief models actually apply the principles in clinical practice
overtime and if so, do they effect change in the client’s willingness to change behaviors
that result in healthier life styles. In addition, educational research should be conducted to
determine which teaching methodologies best help students learn health belief principles
and concepts. . Therefore, outcome research becomes an important goal whether it is
conducted in the clinical or educational setting.
15
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