Nursing Research

Becker’s Health Belief Model

Every choice that an individual makes throughout his lifetime is guided by certain sets of beliefs. The same is true to health related issues in the person’s life. Health Belief Model attempts to examine and explain people’s health beliefs and perceptions that influence their health behavior.

Health Belief Model was developed in the 1950 by a group of U.S. Public Health Service social psychologists who wanted to examine the reason of low level of participation in programs to prevent and detect a disease (National Cancer Institute, 2005, p.13). The Model is constructed on the basis of psychological and behavioral theories that explain behavior as interrelation of two variables: 1) the value placed on a particular goal and 2) the estimate probability of an action in achieving that goal. In the context of HBM these variables reflect the desire to avoid an illness and belief that a specific health action will prevent an illness (Janz & Becker, 1984, p.2).

In 1974 the HBM was comprehensively reviewed and studied by Marshall H. Becker, a professor of Health Behavior and Health Education at the University Of Michigan School Of Public Health (Clark, 1994, p.1). Describing the Model he highlights that a person may experience threat by a health problem and benefits of actions that will reduce or eliminate it.  If a person feels that he is prone to a disease with serious complications and that the treatments costs are outweighed by its prevention benefits, it will force him to take an action. This readiness of taking an action will be also affected by internal and external stimulus as symptoms, changes in health, physician advice, flyer at the medical office, or an advice from a relative. Although the concept of threat creates pressure to act, it does not clarify the way the person will act.

The HBM was further developed by Irwin Rosenstock, a psychologist in the US Public Health Service, FHP Endowed Professor and Director, Center for Health and Behavior Studies, California State University. He integrated to the Model a concept of self-efficacy. According to that concept for a behavioral change to succeed an individual must also feel himself competent (self-efficacious) to implement that change (Rosenstock et al., 1988, p.179).

Throughout the years, researchers have expanded the HBM. They have identified six main concepts that influence individual’s decision on prevention and management of the disease. National Institute of Cancer (2005) in their publication Theory at a Glance: a Guide for Health Promotion Practice outlines that people are ready to act if they:

1. Believe that they are susceptible to the disease (perceived susceptibility)
2. Believe that the disease has serious consequences (perceived severity)
3. Believe that taking an action will reduce their susceptibility or its severity (perceived benefits)
4. Believe that costs of taking action (perceived barriers) are outweighed by benefits.
5. Are exposed to factors that prompt action (cue to action).
6. Are confident in their ability to successfully perform the action (perceived self-efficacy).

Because the HBM attempts to better understand the decision-making process in regards to health related problems, it is widely used in the studies focused on motivation, intervention and prevention behavior. It is also being used in transcultural studies to enhance health beliefs perceptions of a particular culture: therefore, its concepts are usually adapted to each culture individually. However, once the main concepts of HBM are adjusted to different studies it is also difficult to design a measurable tool for the Model and prohibits cross-study comparisons. Another limitation the HBM encounters is that other factors such as demography, socio-psychology, and culture can indirectly affect the health behavior practice (Janz and Becker, 1984, p.44).

Overall, the Health Belief Model is a valuable framework not only in identification of control points of health behavior but also for designing preventative strategies.

Any theory is better understood when studied on real examples. To understand and examine HBM more closely, two nursing studies with different research approach have been selected.

In the first qualitative, descriptive study Garavalia and colleagues (2009) used HBM as their conceptual framework to identify and understand the reasons of myocardial infarction (MI) patients’ for non-adherence to their heart medications’ (cholesterol lowering therapy (CLT) and Clopidogrel) regimen.

The authors argue that although many studies have been conducted to identify the rates and the consequences of non-compliance to heart medications, a little is known about the reasons of noncompliance. Therefore, there is a need to understand “the barriers to persistence and the personal beliefs that contribute to the problem” (Garavalia et al., 2009, p.372).

A purposive sampling technique was used to choose a sample from 4,500 MI patients that have been drawn from a multi-center, prospective registry, TRIUPH (Translational Research Investigating Underlying disparities in acute Myocardial infarction Patients’ Health status) each of whom also had to comply with the following criteria:

1. The patient experienced an MI, was enrolled in TRIUPH and was discharged on CLT or clopidogrel;
2.  Patient reported discontinuing CLT of clopidogrel in a follow-up interview at 1,6, or 12 months after the MI;
3. Patient could be contacted by phone and consented to a telephone interview.

Based on the abovementioned inclusion criteria, a sample of 11 MI patients who discontinued clopidogrel and 29 MI patients who discontinued CLT, was formed.

Specific procedures were followed to protect subject of the study. First, a personalized letter that had the information about the study purpose, biography of the researchers and interviewers, request for participation, and the instruction for declining participation in the study was mailed to the study participants. Also an approval from the Institutional Review Board was obtained from St. Luke’s Hospital in Kansas City in addition to original approval for the TRIUPH registry (Garavalia et al., 2009, p. 373).

The study has identified that the main reason of MI patients’ to discontinue CLT is side effects that interfered with their daily activities. Also, patients indicated cost, mistrust of health care system and medication, preference of alternative therapies as secondary reasons affecting their choice. For discontinuance of clopidogrel MI patients’ reported duration confusion, side effects, and cost as their chief complaints.

Another important finding of the study was the belief that MI patients had about the CLT and clopidogrel discontinuance. Patients who discontinued CLT were more likely to believe that they did not need the treatment versus patients who discontinued clopidogrel.

The results of this research, while supporting findings from another study of key reasons for stopping heart medications, indicate specifics of only two medications, providing comparative analyses of the reasons pertaining to these medications. This comparative analyses not only helps to identify challenges associated with each one of them but also detects criteria, or in this case reasons of discontinuance that can be excluded for the two medications. For example, other studies have reported that forgetfulness and not thinking the medication is necessary are primary reasons for noncompliance; however, neither the CLT nor the clopidogrel patients described these two reasons.

As the purpose of the study was to expand the insight into the reasons for discontinuance of heart medications in MI patients, the researchers rationalized that the HBM theory is the most appropriate to interpret the patients’ experience and beliefs as the factors that contribute to the decision making process. This model, according to the authors, will provide nurses and physicians with the descriptive framework while interacting with the cardiac patients on a daily basis to understand patients’ challenges regarding their treatment. For instance, belief of low susceptibility to the heart disease in the absence of pain or other symptoms could be revealed and addressed. High perceived severity of the illness, on the contrary, could be exposed during the interaction with the patient who believes that her sister having coronary artery bypass surgery increases her chances of having the heart diseases.  Also HBM, prior to prescription of CLT or clopidogrel, allows to identify perceived barriers, both actual and potential, for each patient. The action of addressing the side effects of CLT or clopidogel and lifestyle modification that helps to reduce risks of heart diseases is another HBM domain, high perceived benefits of taking preventative action.

The second nursing research used to examine HBM in practice is a quantitative correlational, longitudinal study conducted by Moore and co-researchers (2013). The authors chose the Health Belief Model as a framework to better understand and explain smoking cessation (SC) behavior in women with coronary heart disease (CHD) who have experienced an invasive cardiovascular (CV) treatment. The goal of the current research was to identify which factors predict SC in women after an invasive CV procedure.

According to the researchers, the benefits of SC for women with CHD are immediate and efforts to increase the rates of SC in women are greatly needed. One way to influence the raise of SC’s rate is lifestyle changes during CV interventions (Moore et al., 2013, p.525).

Moore and colleagues (2013) formed a sample that have included 40 to 80 years old female smokers undergoing either coronary artery bypass grafting (CABG) surgery or percutaneous coronary intervention (PCI) with a diagnosis of CHD.

Other inclusion criteria defined for the sample contained the following:

1. Current smokers with a diagnosis of CHD;
2. Undergone invasive CV intervention (CABG OR PCI) within the past week;
3. Able to provide contact information for 3 month follow-up;
4. In a stable medical condition;
5. Able to read and to speak in English without assistance.

To avoid ethical misconduct and bias, women with severe mental illness, who could not provide informed consent, were excluded from the sample.

Study participants were provided with the information about the study and its procedures only after they were in a stable condition after CV interventions. Moreover, approvals from the institutional review boards were obtained from the university and the hospital where participants were recruited.

As Health Belief Model has been used in numerous studies to explain smoking behaviors, the authors rationalized that application of this Model for SC behavior’s examination in women with CHD who have experienced an invasive CV treatment would be also appropriate (Moore et al., 2013, p.525).

Hereafter, HBM constructs were conceptualized into three categories:

1. CHD and future CV intervention’s susceptibility and their seriousness were viewed as a perceived threat;
2. Motivation to quit smoking as a cue to action;
3. Commitment to stop smoking considering the barriers and the benefits as likelihood of action.

Based on measurement of these constructs, the research has revealed that although women with CHD recognized the threat of future CV interventions and perceived benefits of SC; had motivations and willingness to quit, only few women (8 out of 54) had stopped smoking 3 months after an invasive procedure. The perceived barriers to SC were anxiety and depression which, according to the researchers, should be addressed long after the cardiac procedure (Moore et al., 2013, p.531).

Nevertheless, recognition of confidence in one’s ability to stop smoking after CV procedures in women with CHD as a major predictor of SC let the authors to suggest health care providers to focus on increasing this confidence by establishing individualized SC plan for these women.

Although, the researchers came to conclusion that HBM might not be the best model to explain SC behavior for it does not address physiological components of health behavior, such as addiction (nicotine addiction in this case); it still helps to explain physiological predictors of SC and therefore, gives opportunities to improve clinical practice.

Summary

As mentioned earlier, a person makes health related decisions under influence of his or her beliefs. These beliefs, in turn can be influenced by a complex of psychological factors, which makes it even harder for health care providers to rationalize certain health seeking behavior. Here, when psychological components of the Health Belief Model come for assistance.  These components help to construct the decision making process into stages and follow these stages one by one, giving the health care providers opportunity to identify the area or areas that need intervention. For instance, in the qualitative study of Garavalia and colleagues (2009) when exploring the threat of discontinuance of heart medications it was revealed that, besides CLT being used to lower cholesterol level and clopidogrel “keeps the pipes open,” patients had very little knowledge about the medications. The intervention, at this point, would be provision of detailed information and comprehensive literature on these medications.

Another example could be drawn from the quantitative study of Moore and co-researchers (2013) who, while analyzing self-efficacy construct of HBM, discovered that women with CHD made multiple attempts to quit smoking at the time of invasive cardiovascular procedure and at follow-up. The researchers, therefore, imply that a thorough screening surrounding the time of these invasive procedures could be valuable in identification of patients who are willing to stop smoking.

Rationalization of human behavior helps health care providers to predict certain health behavior and design focused individualized preventative and motivational programs. HBM as a framework through it constructs helps health care providers to identify population at risk (perceived susceptibility); delineate magnitudes of that risk (perceived severity); outline the action that should be taken (perceived benefits); specify barriers and required assistance in their reduction (perceived barriers); promote awareness (cue to action) and guidance (self-efficacy) in performing the action; and hence, allows them to tailor their care to the specific needs of a certain group which not only maximizes the quality of care provided, but also in a long term minimizes the cost.

 

 

References

 

Clark, N. M. (1994). In Memoriam: Marshall H.Becker, PhD, MPH 1940-1993. Health Education & Behavior, 2(1), 1–2.

 

Garavalia, L., Garavalia, B., Spertus, J.A., Decker, C. (2009). Exploring Patient’s Reasons for Discontinuance of Heart Medications. Journal of Cardiovascular Nursing, 24 (5), 371-379.

 

Janz, N. K., & Becker, M. H. (1984). The Health Belief Model: A Decade Later. Health Education Quarterly, 11 (1), 1-47.

 

Moore, L.C., Clark, P.C., Lee, S. Y., Eriksen, M., Evans, K., Smith, C. H. (2013). Smoking Cessation in Women at the Time of an Invasive Cardiovascular Procedure and 3 Months Later. Journal of Cardiovascular Nursing, 28 (6), 524-533.

 

National Cancer Institute. (2005). Theory at a Glance: A Guide for Health Promotion Practice. Retrieved from: http://www.cancer.gov/cancertopics/cancerlibrary/theory.pdf

 

Rosenstock, I., Strecher, V., Becker, M. (1988). Social Learning Theory and Health Belief Model. Health Education Quarterly 15 (2), 175-183.