The health belief model (HBM) was developed in the 1950’s and 1960’s and is one of the most widely used conceptual frameworks in health behaviour research (Glanz, Rimer, & Viswanath, 2008). In recent decades, the HBM has been expanded and used more widely in health behaviour change interventions.
The model was originally developed by social psychologists, especially Marshall Becker (Becker, Drachman, & Kirscht, 1972; Becker & Maiman, 1975) to explain why people would not participate in public health programs such as immunisation and tuberculosis screening in the United States of America. The model seeks to explain motivation for health behaviour and is based on learning theory, especially Lewin’s value expectancy theory (Becker & Maiman, 1975; Champion &
Skinner, 2008). In value expectancy theory, individual behaviour is influenced by the subjective value of the outcome of behaviour and the subjective likelihood or expectation that a particular action will achieve that outcome (Glanz et al., 2008).
Glanz and colleagues (2008) describe that when value-expectancy concepts were adapted to the context of health behaviours, it was assumed that individuals value avoiding disease/being well, and expect that a specific health action may prevent illness.
Becker and colleagues (1977) in explaining the health belief model, argue that people will not seek preventive care or health screening without motivation and knowledge. Further, an individual must perceive that they are vulnerable to disease, believe that the treatment or preventive action will be effective and not difficult to undertake.
The original dimensions or constructs of the HBM include: perceived susceptibility, perceived severity, perceived benefits, perceived barriers, and cues to action (Becker & Maiman, 1975; Champion & Skinner, 2008).
Perceived susceptibility refers to an individual’s beliefs about how likely they are to get an illness or disease. For example, a woman must believe there is a risk of getting heart disease before she will be motivated to change unhealthy lifestyle behaviours to reduce the risk of disease.
Perceived severity includes beliefs about the personal and social consequences or severity of an illness. Using the same example, a woman may evaluate that the consequences of developing heart disease are serious and include possible early death, disability, or social consequences such as a negative effect on her family life, work life and social life. These two factors (susceptibility and severity) contribute to the perceived threat to the individual.
A person’s response to the perceived threat of an illness like heart disease will be influenced by the perceived benefits of taking preventive action to reduce the threat such as exercising regularly and eating healthy food. Beliefs that preventive actions are likely to be effective and feasible influence how likely action will be taken.
Conversely, perceived barriers are obstacles or impediments to taking action in response to a perceived threat of illness. For example, although an individual may believe exercising regularly will benefit them and reduce their risk of heart disease, they may also perceive that it will be too time consuming, difficult and inconvenient to do so. So while perceived susceptibility and severity of a disease may be high and provide motivation to act, an individual must believe that action will benefit them and that barriers or the ‘cost’ of acting is not too high. To extend the above example,
a woman may believe that she is at risk of developing heart disease and understand that the consequences may be very severe. She may also understand the benefits of regular exercise and healthy eating to reduce her risk of developing heart disease, and while these factors may motivate her to exercise, her busy lifestyle, lack of time and family commitments are barriers preventing her taking action to exercise regularly.
Cues to action can trigger positive health behaviour and can come from a variety of internal or external sources, although these factors are not considered direct causes of health action. Internal sources could include physical symptoms or experience of illness, whereas external sources could include advice from family or friends, interactions with health professionals, public health campaigns or a newspaper or magazine article.
Other demographic variables (age, gender, race, ethnicity, educations, income etc.) and sociopsychological variables (personality, social group, peer and reference group pressure etc.) are thought to influence perceptions and indirectly influence health related behaviour. For example, educational attainment may have an indirect on behaviour by influencing perceived susceptibility, severity, benefits and barriers (Champion & Skinner, 2008; Rosenstock, Strecher, & Becker, 1988). Elements of the original model are illustrated in Figure 2.2 below.
In 1988, Rosenstock, Stretcher and Becker (1988) noted that the HBM is closely related to social cognitive theory having shared origins in value expectancy theory, argued that self-efficacy be added to the model as a separate construct.
Bandura defined self-efficacy as “the conviction that one can successfully execute the behaviour required to produce the outcomes” (Bandura, 1997). Rosenstock and colleagues (1988) emphasised the value of Bandura’s social cognitive theory in further explaining behaviour. They agreed that expectations develop from several sources of information; and further that self-efficacy beliefs (efficacy expectations) are distinct from beliefs about the outcome of a behaviour (outcome expectations) (Rosenstock et al., 1988). The concept of self-efficacy was never formally incorporated into the early HBM, however the expanded HBM with the self-efficacy construct included has been described and used in a number of studies (Bayat et al., 2013; Champion & Skinner, 2008; Champion et al., 2006; Norman & Brain, 2005;
Sullivan et al., 2008; Wdowik, Kendall, Harris, & Auld, 2001).
Individual perceptions Modifying factors Likelihood of action
Demographic &
Psychosocial factors
Perceived benefits minus Perceived barriers
Perceived susceptibility &
Perceived severity of disease
Perceived threat Likelihood of taking
preventive health action
Cues to action (Internal and external)
Figure 2.2. The Health Belief Model Adapted from Becker and Maiman (1975, p. 12)
In a critical review of health belief model (HBM) studies conducted in the 1970’s and 80’s, of all the HBM concepts, perceived barriers was reported to be the single most powerful predictor across all studies, study designs and preventive behaviours (Janz & Becker, 1984). A meta-analysis of the relationships between HBM constructs undertaken using weighted mean effect sizes, found that while effect sizes were small, ranging between 0.01 to 0.30, there were significant positive relationships between HBM dimensions and health behaviours (Harrison, Mullen, &
Green, 1992).
The health belief model has been criticised for the variability in measurement of its constructs (Champion & Skinner, 2008) and for its focus only on cognitive attitudes and beliefs in determining health behaviour (Janz & Becker, 1984). Despite this, there is strong evidence linking HBM dimensions to preventive health actions like breast screening, risky sexual behaviours and immunisation (Champion &
Skinner, 2008; Janz & Becker, 1984).