The Health Belief Model and smoking cessation behaviours

Historical Origins of the Health Belief Model

Irwin M. Rosenstock, Ph.D. School of Public Health University of Michigan

I t is always difficult to trace the historical development of a theory that has been the subject of considerable direct study and has directly or indirectly spawned a good deal of additional research. This is certainly true of the Health Belief Model, perhaps even more than usual because the Model grew out of a set of independent, applied research problems with which a group of investigators in the Public Health Service were confronted between 1950 and 1960. Thus, the theory and development of the Model grew simultaneously with the solution of practical problems. Two classes of circumstances should be described which were largely responsible for the type of model that ultimately emerged. These concern the settings in which research was required and the training and background experiences of those who participated in the development of the Model.

HEALTH SETTINGS

During the early 1950s the Public Health Service was for the most part oriented toward the prevention, not the treatment, of disease. Medical care was largely beyond the pale of what was considered appropriate public health work, although there had been some notable historical exceptions. Thus, problems connected with patients' symptoms, their compliance with medical regimens, or with physician- patient communications were not a focus of public health concern. What was clearly evident a t that time, however, was the widespread failure of people to accept disease preventives or screening tests for the early detection of asymptomatic disease; these included tests or prevention first for T B 1 somewhat later for cervical cancer, dental disease and, still later, rheumatic fever, polio and influenza. I t was also noted that the various preventive measures or tests were usually provided on a demonstration basis, free of charge, or a t very low cost.

The foregoing factors to a large extent influenced the kind of theory that would have to be developed to explain preventive health behavior. Such a theory would have to deal with the behavior of individuals who were not currently suffering disabling disease. I t would have to be oriented to the avoidance of disease. While it could

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not overlook the potential role of barriers to accepting health services, it would have to attempt to explain the behavior of people who were being charged little or nothing for the service.

THE RESEARCHERS

Those of us* who first worked on the several programmatic problems posed by the public health problems described earlier were all trained as social psychologists. As such, we had been influenced in considerable measure by the theories of Kurt Lewin. All of us exhibited a phenomenological orientation, that it is the world of the perceiver that determines what he will do and not the physical environment, except as the physical environment comes to be represented in the mind of the behaving individual. Finally, we early researchers had a strong philosophical commitment toward theory building and not merely solving practical problems one a t a time. We were thus committed toward the gradual accretion of scientific information by building on the work of others.

I t should also be noted that during the period of time discussed there were relatively few behavioral scientists engaged in full-time research on health problems. To be sure, there were some notable exceptions, but for the most part there was little information within health research itself to guide these investigators.

These factors almost foreordained that the early researchers concerned with the Health Belief Model would work cooperatively, build on each other's work, develop theory that would include a heavy component of motivation and the perceptual world of the behaving individual; and that the orientation of the work would be toward developing a theory not only useful in explaining a particular program problem, but also adaptable to other problems. Also, in the Lewinian tradition, the theory could be expected to focus on the current (ahistorical) dynamics confronting the behaving individual rather than on the historical perspective of his prior experiences. The investigators were of the opinion that it is the present state of affairs that determines actions, with history playing a role only insofar a s it is represented in the present dynamics.

THE BELIEFS

The major outlines of what later came to be known as the Health Belief Model are understandable in the light of the historical perspective provided. The implicit conception following Lewin was of an individual existing in a life space composed of regions some of which were positively valued (positive valence), others of which were

'Drs. Codfrey M. Hochbaum, S. Stephen Kegeles, Howard Leuenthal, and Irwin M . Rosenstock.

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negatively valued (negative valence), and still others of which were relatively neutral. Diseases, if they were represented in the life space a t all, would be regions of negative valence which could be expected to exert a force moving the person away from t h a t region, unless doing so would require him to enter a region of even greater negative valence. One’s daily activities were thus conceived of as a process of being pulled by positive forces a n d repelled by negative forces. T h e earliest characteristics of the Model, as they were translated from the foregoing abstraction, were t h a t in order for a n individual to take action to avoid a disease he would need to believe (1) t h a t he was personally susceptible to it, ( 2 ) t h a t the occurrence of the disease would have a t least moderate severity on some component of his life, a n d (3) t h a t taking a particular action would in fact be beneficial by reducing his susceptibility to the condition or, if the disease occurred, by reducing its severity, a n d t h a t it would not entail overcoming important psychological barriers such as cost, convenience, pain, embarrassment. With respect to taking a test for the early detection of a disease, the same factors were deemed necessary, but in addition there was also the requirement t h a t the individual believe he could have the disease even in the absence of symptoms.’-J

Perceived Susceptibility Individuals were believed to vary widely in their acceptance of

personal susceptibility to a condition. At one extreme might be the individual who denies any possibility of his contracting a given condition. I n a more moderate position is the person who may admit to the “statistical” possibility of a disease occurrence, but a possibility t h a t is not likely to happen. Finally, a person may express a feeling that he is in real danger of contracting the condition. I n short, as it has been measured, susceptibility refers to the subjective risks of contracting a condition.

Perceived Seriousness Convictions concerning the seriousness of a given health problem

may also vary from person-to-person. T h e degree of seriousness may be judged both by the degree of emotional arousal created by the thought of a disease as well as by the kinds of difficulties the individual believes a given health condition will create for him.4

A person may, of course, see a health problem in terms of its medical or clinical consequence. He would thus be concerned with such questions as whether a disease could lead to his death, or reduce his physical or mental functioning for long periods of time, or disable him permanently. However, the perceived seriousness of a condition may, for a given individual, include such broader and more complex implications as the effects of the disease on his job, on his family life,

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and on his social relations. Thus, a person may not believe t h a t tuberculosis is medically serious, but may nevertheless believe t h a t its occurrence would be serious if it created important psychological a n d economic tensions within his family.

Perceived susceptibility and severity having a strong cognitive component are a t least partly dependent on knowledge.

Perceived Benefits of Taking Action and Barriers to Taking Action

The acceptance of one’s susceptibility to a disease t h a t is also believed to be serious was thought to provide a force leading to action, but not defining the particular course of action t h a t was likely to be taken.

The direction t h a t the action takes was thought to be influenced by beliefs regarding the relative effectiveness of known available alternatives in reducing the disease threat to which the individual feels subjected. His behavior was thus thought to depend on how beneficial he believed the various alternatives would be in his case. Of course, there must be available to him a t least one action t h a t is subjectively possible. An alternative is likely to be seen as beneficial if it relates subjectively to the reduction of one’s susceptibility to or seriousness of a n illness. Again, the person’s beliefs about the availability a n d effectiveness of various courses of action, a n d not the objective facts about the effectiveness of action, determine what course he will take. I n turn, his beliefs in this area are undoubtedly influenced by the norms and pressures of his social groups. T h e literature on delay in seeking diagnoses for cancer symptoms 5 9 6 may reflect a conflict between (1) a strong feeling of susceptibility to what is regarded as a most serious disease and ( 2 ) a real conviction t h a t there are no efficacious methods of prevention andlor control.

An individual may believe t h a t a given action will be effective in reducing the threat of disease, but a t the same time see t h a t action itself as being inconvenient, expensive, unpleasant, painful or upsetting. These negative aspects of health action serve as barriers to action a n d arouse conflicting motives of avoidance. Several resolutions of the conflict were thought to be possible. If the readiness to act was high and the negative aspects were seen a s relatively weak, the action in question was likely to be taken. If, on the other hand, the readiness to act was low while the potential negative aspects were seen as strong, the negative aspects functioned as barriers to prevent action.

Where the readiness to act was great a n d the barriers to action were also great, the conflict was thought to be more difficult to resolve. T h e individual was highly oriented toward acting to reduce the likelihood or impact of the perceived health danger. He was equally highly

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motivated to avoid action since he saw i t as highly unpleasant or even painful.

Sometimes, alternative actions of nearly equal efficacy might be available. For example, the person who feels threatened by tuberculosis but fears the potential hazards of x-rays may choose to obtain a tuberculin test for initial screening.

But what can he do if the situation does not provide such alternative means to resolve his conflicts? Experimental evidence obtained outside the health area suggested that one of two reactions occur. First, the person might attempt to remove himself psychologically from the conflict situation by engaging in activities which did not really reduce the threat. Vacillating (without decision) between choices may be a n example. Consider the individual who feels threatened by lung cancer, who believes quitting cigarette smoking will reduce the risk but for whom smoking serves important needs. He may constantly commit himself to give up smoking soon and thereby relieve, if only momentarily, the pressure imposed by the discrepancy between the barriers and the perceived benefits.

A second possible reaction was a marked increase in fear or anxiety.' If the anxiety or fear became strong enough, the individual might be rendered incapable of thinking objectively and behaving rationally about the problem. Even if he were subsequently offered a more effective means of handling the situation, he might not accept it, simply because he could no longer think constructively about the matter.

CUES T O ACTION

The variables which were originally described under the heading of perceived susceptibility and severity a s well as the variables that defined perceived benefits and barriers to taking action, have all been subjected to research which will be reviewed in subsequent chapters. However, one additional variable was believed to be necessary to complete the model, but it has not been subjected to careful study.

A factor that serves as a cue, or a trigger, to appropriate action appeared to be necessary. The combined levels of susceptibility and severity provided the energy or force to act and the perception of benefits (less barriers) provided a preferred path of action. However, we believed the combination of these could reach quite considerable levels of intensity without resulting in overt action unless some instigating event occurred to set the process in motion. I n the health area, such events or cues might be internal (e.g., perception of bodily states) or external (e.g., interpersonal interactions, the impact of media of communication, or receiving a postcard from the dentist).

The required intensity of a cue that was deemed sufficient to trigger behavior presumably varied with differences in the levels of

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susceptibility and severity. With relatively little acceptance of susceptibility to or severity of a disease, rather intense stimuli would be needed to trigger a response. On the other hand, with relatively high levels of perceived susceptibility and severity even slight stimuli may be adequate. For example, other things being equal, the person who barely accepts his susceptibility to tuberculosis will be unlikely to check upon his health until he experiences rather intense cues. On the other hand, the person who readily accepts his constant susceptibility to the disease may be spurred into action by the mere sight of a mobile x-ray unit or a relevant poster.

Unfortunately, the settings for most of the research on the Model. have precluded obtaining an adequate measure of the role of cues. Since the kinds of cues that have been hypothesized may be quite fleeting and of little intrinsic significance (e.g., a casual view of a poster urging chest x-ray), they may easily be forgotten with the passage of time. An interview taken months or years later could not adequately identify the cues. Freidson has described the difficulties in attempting to assess interpersonal influences as cues.8 Furthermore, respondents who have taken a recommended action in the past will probably be more likely to remember preceding events a s relevant than will respondents who were exposed to the same events but never took the action. These problems make testing the role of cues most difficult in any retrospective setting. A prospective design, perhaps a panel study, will probably be required to assess properly how various stimuli serve as cues to trigger action in a n individual who is psychologically ready to act

OTHER VARIABLES

In addition to the foregoing set of variables, early abortive attempts were made to include as a motivational variable the concept of salience of health and illness for the individual. The attempts were abortive because no good operational measure of the concept of salience could be devised; we came to believe that the perception of susceptibility to and severity of a particular condition would itself be motivating. It will subsequently be seen that the concept of motivation was later reintroduced into the Mode1.e

Finally, our view of the role of demographic, socio-psychological, and structural variables was that they served to condition both individual perceptions and the perceived benefits of preventive actions, a view we have not substantially modified. Figure 1 portrays the original Health Belief Model.

I t should be noted explicitly that the Model had a clearcut avoidance orientation; diseases were regarded as negatively valent regions to be avoided. This is in contrast to the view that some

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particular state of health might possibly serve as a positively valent region t h a t would pull a person toward it. I t is still not known whether the improvement of health in a n already healthy person does have some motivating force in influencing action. This grows out of the difficulty of giving positive health any operational meaning. Surely, the exercise a n d dietary mania observed over the last decade represent behaviors t h a t could be regarded a s striving toward improved health,. but it is just as easy to explain them (insofar as they are health related a t a l l ) as behavior undertaken to avoid a deleterious situation. Again, there a r e individuals who exercise and engage in other actions having health implications but who do so for reasons quite unrelated to health, perhaps for aesthetic reasons or for the sheer exhileration felt by many by the performance of physical work. Again, the question of whether the avoidance orientation in the Health Belief Model is adequate to account for the so-called positive health actions taken by people remains unresolved.

REFERENCES 1. Hochbaum G: Public Participation in Medical Screening Programs: A

Sociopsychological Stuay. Public Health Serv Publ, No. 572. 2. Rasenstock IM: What research in motivation suggests for public health. Am J Public

Health 50:295-302, ( M a r ) 1960. 3. Rosenstock IM: Why people use health services. Milbank Mem Fund Q 44:94-127,

( J u l ) 1966. 4. Robbins P: Some explorations into the nature of anxieties relating to illness. United

States Department of Health, Education, a n d Welfare, Public Health Service, Genetic Psycho1 Monogr 66:91-141, 1962.

5. Blackwell B: T h e literature of delay in seeking medical care for chronic illnesses. Health Educ Monogr 16:3-31, 1963.

6. Green LW, Roberts B J : T h e research literature on why women delay in seeking medical care for breast symptoms. Health Educ Monogr 2(2):129-177, (Sum) 1974.

7. Miller NE: Experimental studies of conflict. I n Hunt, JMcV: Personality a n d the Behavior Disorders. New York, T h e Ronald Press, 431-465. 1944.

8. Freidson E: Patients’ Views of Medical Practice. New York, Russell Sage Foundation, 1961.

9. Becker MH, Drachman RH, Kirscht .JP: A new approach to explaining sick-role behavior in low-income populations. Am J Public Health 64:205-216, 1974.

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