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Running head: HEALTH & MEDICAL

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Health & Medical
Student’s Name:
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Theories and Models of Individual Health Behavior – Textbook Chapters 4-7
•

Health Belief Model
o

Key constructs

Perceived Susceptibility. Perceived susceptibility refers to beliefs about the likelihood
of getting a disease or condition. For instance, a woman must believe there is a possibility of
getting breast cancer before she will be interested in obtaining a mammogram.
Perceived Severity. Feelings about the seriousness of contracting an illness or of
leaving it untreated include evaluations of both medical and clinical consequences
(for example, death, disability, and pain) and possible social consequences (such as
effects of the conditions on work, family life, and social relations). The combination of
susceptibility

and

severity

has

been

labeled

as

perceived

threat.

Perceived Benefits. Even if a person perceives personal susceptibility to a serious
health condition (perceived threat), whether this perception leads to behavior change
will be influenced by the person’s beliefs regarding perceived benefits of the various
available actions for reducing the disease threat. Other non-health-related perceptions, such as the
financial

savings

related

to

quitting

smoking

or

pleasing

a

family

member by having a mammogram, may also influence behavioral decisions. Thus,
individuals exhibiting optimal beliefs in susceptibility and severity are not expected
to accept any recommended health action unless they also perceive the action as potentially
beneficial

by

reducing

the

threat.

Perceived Barriers. The potential negative aspects of a particular health action—perceived
barriers—may

act

as

impediments

to

undertaking

recommended

behaviors.

A

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kind of non-conscious, cost-benefit analysis occurs wherein individuals weigh the actions expected
benefits with perceived barriers—“It could help me, but it may be expensive, have negative side
effects,

be

unpleasant,

inconvenient,

or

time-consuming.”

Thus, “combined levels of susceptibility and severity provide the energy or force to act
and the perception of benefits (minus barriers) provide a preferred path of action”
(Rosenstock, 1974).
Cues to Action. Various early formulations of the HBM included the concept of cues
that can trigger actions. Hochbaum (1958), for example, thought that readiness to
take action (perceived susceptibility and perceived benefits) could only be potentiated by other
factors,

particularly

by

cues

to

instigate

action,

such

as

bodily

events,

or by environmental events, such as media publicity. He did not, however, study the
role of cues empirically. Nor have cues to action been systematically studied. Indeed,
although the concept of cues as triggering mechanisms is appealing, cues to action
are difficult to study in explanatory surveys; a cue can be as fleeting as a sneeze or
the barely conscious perception of a poster.
Self-Efficacy. Self-efficacy is defined as “the conviction that one can successfully execute the
behavior required to produce the outcomes” (Bandura, 1997). Bandura distinguished self-efficacy
expectations

from

outcome

expectations,

defined

as

a

person’s

estimate that a given behavior will lead to certain outcomes. Outcome expectations
are similar to but distinct from the HBM concept of perceived benefits. In 1988, Rosenstock,
Strecher, and Becker suggested that self-efficacy be added to the HBM as a
separate construct, while including original concepts of susceptibility, severity, benefits, and
barriers.

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Self-efficacy

was

never

4

explicitly

incorporated

into

early

formulations

of

the

HBM. The original model was developed in the context of circumscribed preventive
health actions (accepting a screening test or an immunization) that were not perceived
to involve complex behaviors.
Other Variables. Diverse demographic, sociopsychological, and structural variables
may influence perceptions and, thus, indirectly influence health-related behavior. For
example, sociodemographic factors, particularly educational attainment, are believed
to have an indirect effect on behavior by influencing the perception of susceptibility, severity,
benefits, and barriers.

o

Gaps, strengths, and limitations

Although the HBM identifies constructs that lead to outcome behaviors, relationships between and
among these constructs are not defined. This ambiguity has led to variation in HBM applications.
For example, whereas many studies have attempted to establish each of the major dimensions as
independent, others have tried multiplicative approaches. Analytical approaches to identifying
these relationships are needed to further the utility of the HBM in predicting behavior.
Ambiguity about the relationships among theoretical constructs in the HBM makes
tests of construct validity more difficult. HBM relationships between constructs have not been well
described. It is possible that one of the variables may mediate relationships between the others.
Temporality of relationships is also an issue. When health beliefs and behaviors are measured
concurrently, apparent relationships between them might well turn out to be spurious. These
factors may have contributed to the frequent lack of scientific rigor in measuring HBM constructs.

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Summary results provided substantial empirical support for the model, with findings from
prospective studies at least as favorable as those obtained from retrospective research. Perceived
barriers were the most powerful single predictor across all studies and behaviors. Although both
perceived susceptibility and perceived benefits were important overall, perceived susceptibility
was a stronger predictor of preventive health behavior than sick-role behavior. The reverse was
true for perceived benefits. Overall, perceived severity was the least powerful predictor; however,
this dimension was strongly related to sick-role behavior. As there has not been an updated
evidence review of HBM studies since 1984, this is the most current synthesis available. A new
up-to-date review would help to confirm or modify these conclusions.
One of the most important limitations in both descriptive and intervention research
on the HBM has been variability in measurement of the central HBM constructs. Several important
principles guide development of HBM measurement. Construct definitions need to be consistent
with HBM theory as originally conceptualized, and measures need to be specific to the behavior
being addressed (barriers to mammography may be quite different from barriers to colonoscopy)
and relevant to the population among whom they will be used. To ensure content validity, it is
important to measure the full range of factors that may influence the behavior. Using multiple
items for each scale reduces measurement error and increases the probability of including all
relative components of each construct. Finally, validity and reliability of measures need to be
reexamined with each study. Cultural and population differences make applying scales without
such examination prone to error. Only a few studies using the HBM that have developed or
modified instruments to measure HBM constructs have conducted adequate reliability and validity
testing prior to research.

o

Application in practice

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Association of HBM Constructs with Mammography Behavior. The HBM predicts
that women will be more likely to adhere to screening mammography recommendations
if they feel susceptible to breast cancer, think breast cancer is a severe disease, perceive barriers
to

screening

as

lower

than

perceived

benefits,

have

higher

self-efficacy

for

obtaining mammograms, and receive a cue to action. Mammography-Promotion Interventions
Based on the HBM. A number of mammography-promotion interventions have addressed at least
one HBM construct—usually perceived barriers—and have had significant effects on
mammography outcomes
•

Theory of Reasoned Action
o

Key constructs

The TRA and TPB, which focus on the constructs of attitude, subjective norm, and perceived
control, explain a large proportion of the variance in behavioral intention and predict a number of
different behaviors, including health behaviors.

o

Gaps, strengths, and limitations

TRA and TPB have been used successfully to predict and explain a wide range of health behaviors
and intentions, including smoking, drinking, health services utilization, exercise, sun protection,
breastfeeding, substance use, HIV/STD-prevention behaviors and use of contraceptives,
mammography, safety helmets, and seatbelts

Although

TRA

and

TPB

have

been

criticized,

based

on

whether

correlational

results can explain behavior (Weinstein, 2007), many published intervention study reports show

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that changing TRA or TPB constructs leads to subsequent change in behaviors. It is not clear that
the TRA components are sufficient to predict behaviors in which volitional control is reduced.

o

Application in practice

Findings have been used to develop many effective behavior change interventions.
•
o

Theory of Planned Behavior

Key constructs

The TRA and TPB, which focus on the constructs of attitude, subjective norm, and perceived
control, and personal agency.

o

Gaps, strengths, and limitations

Thus, Ajzen and colleagues (Ajzen, 1991; Ajzen and Driver, 1991; Ajzen and Madden, 1986)
added perceived behavioral control to TRA to account for factors outside individual control that
may affect intentions and behaviors. With this addition, they created the Theory of Planned
Behavior (TPB; see shaded boxes in Figure 4.1). Perceived control is determined by control beliefs
concerning the presence or absence of facilitators and barriers to behavioral performance, weighted
by their perceived power or the impact of each control factor to facilitate or inhibit the behavior.

A strength of TRA/TPB is that they provide a framework to discern those reasons and to decipher
individuals’ actions by identifying, measuring, and combining beliefs relevant to individuals or
groups, allowing us to understand their own reasons that motivate the behavior of interest. TRA
and TPB do not specify particular beliefs about behavioral outcomes, normative referents, or
control beliefs that should be measured.

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Application in practice

RA/TPB has been applied to explain a variety of health behaviors, including exercise, smoking
and

drug

use,

HIV/STD-prevention

behaviors,

mammography

use,

clinicians’ recommendation of and provision of preventive services, and oral hygiene
behaviors. These studies generally have supported perceived control as a direct predictor of both
intentions and behaviors.
•
o

Integrated Behavioral Model

Key constructs

We recommend use of an integrated behavioral model that includes constructs from TRA/TPB, as
well as from other influential theories.

o

Gaps, strengths, and limitations

Again, in contrast to TRA/TPB, motivation to comply with individuals or groups is not specified
in the IBM because, as with outcome evaluations, we have found that there is often little variance
in these measures. However, if variance is found in motivation to comply, this should also be
measured.

Finally,

the

stronger

one’s

beliefs

that

one

can

perform

the

behavior despite various specific barriers, the greater one’s self-efficacy about carrying out the
behavior.

According to the model, behavioral intention is determined by three construct categories listed in
Table 4.1. The first is attitude toward the behavior, defined as a person’s overall favora...