health behavior

THEORETICAL CONCEPT The Health Belief Model (HBM) is by far the most commonly used theory in health education and health promotion (Glanz, Rimer, & Viswanath, 2008; National Cancer Institute [NCI], 2005). The underlying concept of the HBM is that health behavior is determined by personal beliefs or perceptions about a disease and the strategies available to decrease its occurrence (Hochbaum, 1958). Personal perception is influenced by the whole range of intrapersonal factors affecting health behavior, including, but not limited to: knowledge, attitudes, beliefs, experiences, skills, culture, and religion.

THEORETICAL CONSTRUCTS

The following four perceptions serve as the main constructs of the model: perceived seriousness, perceived susceptibility, perceived benefits, and perceived barriers. Each of these perceptions, individually or in combination, can be used to explain health behavior. More recently, other constructs have been added to the HBM; thus, the model has been expanded to include cues to action, motivating factors, and self-efficacy. PERCEIVED SERIOUSNESS The construct of perceived seriousness speaks to an individual’s belief about the seriousness or severity of a disease. While the perception of seriousness is often based on medical information or knowledge, it may also come from beliefs a person has about the consequences an illness might have on him or her personally. For example, most of us perceive seasonal flu as a relatively minor ailment. We get it, stay home a few days, and get better. However, if you have asthma, contracting the flu could land you in the hospital. In this case, your perception of the flu might be that it is a serious disease. Or, if you are self-employed, having the flu might mean a week or more of lost wages. Again, this would influence your perception of the seriousness of this illness. Perception of seriousness can also be colored by past experience with the illness. No doubt, most people would consider skin cancer a serious disease. However, the perception of serious might be diminished in someone who had a cancerous lesion removed and recovered without much more than a sore area and a Band-Aid for a few days.

PERCEIVED SUSCEPTIBILITY

Personal risk or susceptibility is one of the more powerful perceptions in prompting people to adopt healthier behaviors. The greater the perceived risk, the greater the likelihood of engaging in behaviors to decrease the risk. This is what prompts men who have sex with men to be vaccinated against hepatitis B (de Wit, Vet, Schutten, & van Steenbergen, 2005) and to use condoms in an effort to decrease susceptibility to HIV infection (Belcher, Sternberg, Wolotski, Halkitis, & Hoff, 2005). Perceived susceptibility motivates people to be vaccinated for influenza (Chen, Fox, Cantrell, Stockdale, & Kagawa-Singer, 2007) to use sunscreen to prevent skin cancer, and to floss their teeth to prevent gum disease and tooth loss (Figure 4– 1). It is only logical that when people believe they are at risk for a disease, they will be more likely to do something to prevent it from happening. Unfortunately, the opposite also occurs. When people believe they are not at risk or have a low risk of susceptibility, unhealthy behaviors tend to result. This is exactly what has been found with older adults and HIV prevention behavior. Because older adults generally do not perceive themselves to be at risk for HIV infection, many do not practice safer sex (Rose, 1995; Maes & Louis, 2003). This same scenario was found with Asian American college students earlier in the HIV/ AIDS epidemic. They tended to view epidemic as a non-Asian problem; thus, their perception of susceptibility to HIV infection was low and not associated with practicing safer sex behaviors (Yep, 1993). Unfortunately, this lack of perceived susceptibility to sexually transmitted infections (STIs) is still alive and well on campuses, albeit not necessarily because of ethnicity as seen in the previous example. Rather, students under estimate their risk of contracting infections from their partners, because they underestimate their partners susceptibility. (They ignore the old adage that you are sleeping with everyone your partner has ever slept with.) Consequently, they do not protect themselves against STIs, especially when sexual activity is restricted to oral sex. This is particularly evident if they attend schools in a geographic area that has a low incidence of HIV/ AIDS.

What we have seen so far is that a perception of increased susceptibility or risk is linked to healthier behaviors, and perception of decreased susceptibility to unhealthy behaviors. However, this is not always the case. In college students, perception of susceptibility is rarely linked to the adoption of healthier behaviors (Courtenay, 1998), even when the perception of risk is high. For example, even if college students consider themselves at risk for HIV because of their unsafe sex behaviors, they still do not practice safer sex (Lewis & Malow, 1997), nor do they stop tanning even though they perceive themselves to be at increased risk for skin cancer (Lamanna, 2004). Perception of susceptibility explains behavior in some situations, but not all. When the perception of susceptibility is combined with seriousness, it results in perceived threat (Stretcher & Rosenstock, 1997). If the perception of threat is to a serious disease for which there is a real risk, behavior is likely to change. This is what happened in Germany in 2001 after an outbreak of bovine spongiform encephalitis (BSE), better known as mad cow disease. Although mad cow disease does not occur in people, research suggests that eating cattle with the disease can result in variant Creutzfeldt-Jakob disease (CJD). Variant CJD, like BSE, affects the brain, causing tiny holes that make it appear spongelike. Both diseases are untreatable and fatal (National Institute of Neurological Disorders and Stroke, 2007). The perception of threat of contracting this disease through eating beef was one factor related to declining meat consumption in Germany (Weitkunat et al., 2003). People changed their behavior based on the perception of threat of a fatal disease. Another example in which perception of threat is linked to behavior change is found in colon cancer survivors. Colorectal cancer is a very serious disease with a high risk of

recurrence. It is the perception of the threat of recurrence that increases the likelihood of behavior change in people previously treated for this disease. In particular, changes occur in their diets, exercise, and weight (Mullens, McCaul, Erickson, & Sandgren, 2003). We see the same thing when people perceive a threat of developing non-insulin-dependent diabetes mellitus (NIDDM). Among people whose parents had or have the disease, the perception of threat of developing it themselves is predictive of more health-enhancing, risk-reducing behaviors. Most important, they are more likely than others to engage in behaviors to control their weight (Forsyth, 1997), given that obesity is a known risk factor for NIDDM. Just as perception of increased susceptibility does not always lead to behavior change, as we saw earlier in the chapter with college students, neither does a perception of increased threat. This is the scenario with older adults and safe food-handling behaviors. Older adults are among the groups most vulnerable to foodborne illness (Gerba, Row, & Haas, 1996) and are among those for whom it can be particularly serious. Even though they perceive a threat of illness from foodborne sources, they still do not use safe food-handling practices (Hanson & Benedict, 2002) all of the time.

PERCEIVED BENEFITS

The construct of perceived benefits is a person’s opinion of the value or usefulness of a new behavior in decreasing the risk of developing a disease. People tend to adopt healthier behaviors when they believe the new behavior will decrease their chances of developing a disease. Would people strive to exercise if they didn’t believe it was beneficial? Would people quit smoking if they didn’t believe it was better for their health? Would people use sunscreen if they didn’t believe it worked? Probably not. A prime example of this is seen among parents who either do not have their children vaccinated for vaccine preventable diseases (VPD), or delay having them vaccinated. Children whose parents do not see a benefit in vaccination— that is, are more likely to agree vaccines may have serious side effects and that too many vaccines overwhelm the immune system, tend to not to have their children vaccinated. Conversely, parents who see a benefit to vaccination— that is, agree vaccines are effective in preventing diseases and are safe and necessary to protect the health of the child, are more likely to have their children vaccinated. (Smith, et al., 2011). Perceived benefits play an important role in the adoption of secondary prevention behaviors, as well. A good example of this is screening for colon cancer. One of the screening tests for colon cancer is a colonoscopy. It requires a few days of preparation prior to the procedure to completely cleanse the colon: a diet restricted to clear liquids followed by cathartics. The procedure involves the insertion of a very long, flexible tube instrument with a camera on the end into the rectum to view the length of the colon. The procedure itself is done under anesthesia, so it is not uncomfortable, but it does take time afterward to recover, and the preparation is time consuming. Regardless of the inconvenience, this is presently the best method for early detection of colon cancer, the third leading cause of cancer deaths in the United States. When colon cancer is found early, it has a 90% cure rate. However, only 36% of people over age 50 (who are most at risk) have this screening done (New York-Presbyterian Hospital, 2006). What makes some people undergo screening and others not? Among women, those who perceive a benefit from colonoscopy (early detection) are more likely to undergo screening than those who do not see the screening as having a benefit (Frank & Swedmark, 2004).

PERCEIVED BARRIERS

Since change is not something that comes easily to most people, the last construct of the HBM addresses the issue of perceived barriers to change. This is an individual’s own evaluation of the obstacles in the way of him or her adopting a new behavior. Of all the constructs, perceived barriers are the most significant in determining behavior change (Janz & Becker, 1984). In order for a new behavior to be adopted, a person needs to believe the benefits of the new behavior outweigh the consequences of continuing the old behavior (Centers for Disease Control and Prevention, 2004). This enables barriers to be overcome and the new behavior to be adopted (Figure 4– 2). Even though there is much education on college campuses about HIV/ AIDS risk reduction, and even though students demonstrate they are knowledgeable about HIV/ AIDS, condom use among African American college students remains inconsistent (Winfield & Whaley, 2002) leaving them exposed to a greater risk of infection. There is obviously something else at play here. Using the HBM to explain what that something else might be reveals that perceived barriers may be a contributing factor. Barriers such as perceived difficulty in doing the things that need to be done to protect oneself, for example. Further, research has suggested that African American men use condoms more frequently when they perceive there are fewer barriers to their use. This is important to recognize as HIV/ AIDS prevention often focuses on empowering women to negotiate safer sex rather than addressing it as a shared responsibility (Winfield & Whaley, 2002) and addressing the perceived barriers of both men and women.

MODIFYING VARIABLES The four major constructs of perception are modified by other variables, such as culture, education level, past experiences, skill, and motivation, to name a few. These are individual characteristics that influence personal perceptions. For example, if someone is diagnosed with basal cell skin cancer and successfully treated, he or she may have a heightened perception of susceptibility because of this past experience and be more conscious of sun exposure because of past experience. Conversely, this past experience could diminish the person’s perception of seriousness because the cancer was easily treated and cured. In personal health classes on many

campuses, students are required to complete a behavior change project. They choose an unhealthy behavior and develop a plan to change it and adopt a more healthy behavior. The modifying variable behind this is motivation. The motivation is a grade.

CUES TO ACTION In addition to the four beliefs orperceptions and modifying variables, the HBM suggests that behavior is also influenced by cues to action. Cues to action are events, people, or things that move people to change their behavior. Examples include illness of a family member, media reports (Graham, 2002), mass media campaigns, advice from others, reminder postcards from a health care provider (Ali, 2002), or health warning labels on a product (Figure 4– 3). Knowing a fellow church member with prostate cancer is a significant cue to action for African American men to attend prostate cancer education programs (Weinrich et al., 1998). Hearing TV or radio news stories about foodborne illness and reading the safe handling instructions on packages of raw meat and poultry are cues to action associated with safer food-handling behaviors (Hanson &

Benedict, 2002). Having displays on college campuses of cars involved in fatal crashes from drunk driving is an example of a cue to action— don’t drink and drive. SELF-EFFICACY In 1988, self-efficacy was added to the original four beliefs of the HBM (Rosenstock, Strecher, & Becker, 1988). Self-efficacy is the belief in one’s own ability to do something (Bandura, 1977). People generally do not try to do something new unless they think they can do it. If someone believes a new behavior is useful (perceived benefit), but does not think he or she is capable of doing it (perceived barrier), chances are that it will not be tried.

When we look at osteoporosis, exercise self-efficacy and exercise barriers are the strongest predictors of

whether one practices behaviors known to prevent this disease. Women who do not engage in the recommended levels of weight-bearing exercise tend to have low exercise self-efficacy, meaning they do not believe they can exercise, and perceive there to be significant barriers to exercise (Wallace, 2002). As a result, these women do not exercise. In summary, according to the Health Belief Model, modifying variables, cues to action, and self-efficacy affect our perception of susceptibility, seriousness, benefits, and barriers and, therefore, our behavior (Figure 4– 4). THEORY IN ACTION— CLASS ACTIVITY Use the constructs of the HBM to explain your own daily physical activity. Then, think about how those

same constructs might help you to increase your physical activity. Share this insight with others in your class. Now, read the following article and answer the questions at the end.

Hayden, Joanna Aboyoun. Introduction To Health Behavior Theory (p. 82). Jones & Bartlett Learning. Kindle Edition. This is the name of the author