Health Belief Model

Imagine that you come down severely with the flu. You have a few options to get yourself back to a healthy state:

1. Buy over-the-counter medicine from your local pharmacy
2. Book an appointment to visit your General Practitioner. 
3. Try a “homemade remedy” your friend swears by.

Which option are you likely to choose? According to the HBM, you’ll probably go with option one. You feel bad enough to take action, there are few perceived barriers (it’s faster and easier than visiting your GP), and you trust in the benefits (more so than your friend’s so-called remedy). 

The Health Belief Model (HBM) suggests that people’s willingness to change their health behaviors is significantly influenced by their perceptions related to health. By examining how individuals perceive the threat of illness, the benefits and effectiveness of changing behavior, and the barriers to making those changes, the HBM helps predict (and design interventions to change) health behaviors. The model identifies six key factors that drive these behaviors.¹: perceived severity, perceived susceptibility, perceived benefits, perceived barriers, cues to action, self-efficacy 

Perceived Severity: How serious a person believes the consequences of their actions are. For example, if someone believes smoking will cause them lung cancer, they are unlikely to smoke.

Perceived Susceptibility: How likely someone believes they are at risk of contracting a disease. For example, if cervical cancer runs in your family, you will believe you are more prone to the disease and will be more likely to take the HPV vaccine. 

Perceived Benefits: The benefits someone associates with a change in health behavior. For example, if you have experienced the positive endorphin release after exercising, you are more likely to engage in exercise than someone who doesn’t recognize those benefits.

Perceived Barriers: The obstacles a person associates with completing a change in health behavior. For example, if you want to get fitter, you may not hire a personal trainer because it would cost you money. 

Cues to Action: A nudge or prompt that motivates someone to change their health behavior(s). This key factor acknowledges that simply wanting to change a health behavior is often not motivating enough to push someone to actually change, and they require a push from an external source. For example, if you watch a shocking advertisement warning against speeding, you would be less likely to engage in that behavior. 

Self-Efficacy: A person’s faith in their personal ability to engage in a health behavior. For example, if you want to run a marathon, running 26.2 miles may feel impossible. If you start with a smaller goal, like running 3 miles, you will have greater belief in your ability to do so, and start engaging in that health behavior.

In the early 1950s, the US Public Health Service prioritized disease prevention over treatment, advocating for preventive behaviors and early screening tests. Preventative behaviors included avoiding tobacco use and excessive alcohol consumption, and getting regular x-rays. Throughout their research, it became clear that most people were neglecting routing screenings, particularly for tuberculosis (TB). In an attempt to make screening for TB easier and more accessible, mobile X-ray vans were created. The idea was that people would be more likely to attend screenings if they didn’t have to make costly and time-consuming trips to the hospital. But, despite this intervention, very few people participated.³

A team of social psychologists comprised of Godfrey Hochbaum, Irwin Rosenstock, Stephen Kegeles, and Howard Leventhal, were all working at the U.S. Public Health Service during the time that the X-ray vans were mobilized. Despite reducing barriers to screening, they observed that people were not using the X-ray vans. They hypothesized that patients’ beliefs, attitudes, and understanding of the illness, and of healthcare in general, influenced how likely they were to seek out preventive treatments and screening.3 This hypothesis formed the basis of the Health Belief Model. Up until this point, researchers had largely focused on how socioeconomic, cultural, and demographic factors (classically, age, gender, and race) influenced the likelihood of seeking out health care, but they had not yet considered the impact that people’s perception had on their behavior.³

When the Health Belief Model was first developed in the 1950s, it only included five main components: perceived severity, perceived benefits, perceived barriers, and cues to action. In 1988, Rosenstock et al. added self-efficacy to the model, accounting for advances made in social learning theory.⁴ Social learning theory had found that self-efficacy, one’s expectation about their ability to perform a behavior, was a big factor in determining whether they engaged in that behavior. 

But the Health Belief Model isn’t just used to figure why people do or don’t engage in a behavior. In fact, it is an important source for informing how public health officials design interventions and nudge people towards a particular behavior. For example, using scary images of damaged lungs on cigarette packets emphasizes the severity of smoking on your health and can dissuade people from smoking. Or, making healthcare easily accessible through mobile health apps, where you can quickly get an appointment with a doctor, reduces barriers and can promote people to seek out treatment. 

Godfrey Hochbaum

An Austrian social psychologist, Godfrey Hochbaum, was well known for his contributions to the study of health behavior and education, applying behavioral science to public health. Hochbaum was one of the first social psychologists hired by the U.S. Public Health Service when they created a Behavioral Science department, it was during his time in this role when he co-devised the Health Belief Model.⁵

Irwin Rosenstock

Rosenstock was an American social psychologist who was considered to be a prominent figure in public health in the 1950s. Rosenstock worked for the U.S. Public Health Service from 1957 to 1967, and later became a professor at the University of North Carolina. Rosenstock led the charge in adding the “self-efficacy” component to the Health Belief Model in 1988.⁶ 

Stephen Kegeles

Kegeles, an Eastern-European social psychologist, began his academic career as a researcher at the Boston Psychopathic Hospital from 1950–1952 prior to working at the U.S. Public Health Service. Throughout his career, Kegeles was focused on health and wellness issues, namely how to promote health with regards to cervical cancer, heart disease, diabetes, and dental decay. He was part of the team that formulated the Health Belief Model.⁷

Howard Leventhal

Leventhal is a Canadian social psychologist well-known for his contributions to consumer behavior and marketing in the public health field. Currently, he is a member of the Institute of Medicine of the National Academy of Sciences, Leventhal is considered one of the most distinguished health psychologists, and helped to create the Health Belief Model.⁸

The Health Belief Model has had a significant impact on public health practices and interventions since its development in the 1950s. Since then, there have been other health behavior theories used to inform intervention designs, such as the Theory of Planned Behavior and the Transtheoretical model, however the Health Belief Model remains one of the most popular theories used to explain health behavior.⁹

By helping to understand why people choose to engage in health-promoting behaviors, the Health Belief Model allows public health professionals to design and tailor interventions for maximum impact. Although ideally, we’d live in a world where people engage in positive health behaviors for their own benefit, the model reveals that more must be done to nudge people in the right direction. Even if health is a priority, we don’t often feel the need or urgency to engage in preventative measures—instead, we tend to take action once we are already sick. 

The Health Belief Model was useful in predicting behavior during the COVID-19 pandemic. During the height of the pandemic, for both individual and collective health to be possible, public health officials needed to promote positive health behaviors to decrease the rate at which the virus spread. 

A meta analysis reviewing 32 studies about health behavior related to the COVID-19 pandemic revealed that perceived benefit was the factor that most influenced people to engage in positive health behaviors, such as wearing a mask, social isolation, and getting vaccinated.10 Self-efficacy was the second most significant predictor of COVID-19 related behaviors, which meant people that believed they were able to follow through on the change were more likely to engage in it. This, in part, may be why there was wide-spread adoption of wearing face masks, where self-isolation was more difficult to sustain. Perceived susceptibility was the third most significant predictor of preventative COVID-19 related behaviors, which provides evidence that highlighting the number of ongoing cases (using tools like the Centers for Disease Control and Prevention’s COVID Data Tracker) is useful in promoting people to engage in positive health behaviors. 

The Health Belief Model primarily focuses on individuals’ perceptions related to health and illness, but does not always adequately factor in other influential factors, such as emotions, habits, social pressures, and economic and environmental factors.

Emotions, for instance, play a significant role in our behavior. Fear can significantly impact the likelihood of engaging in preventive measures. Someone who is very afraid of contracting the flu is more likely to get vaccinated. While this may be a positive result of fear, an individual who is persistently worried about getting sick, such as a hypochondriac, might engage in over-the-top health behaviours. Fear can also deter people from healthcare – someone who has had bad experiences with health care professionals might be fearful of going to the doctor. At times, health care professionals hold explicit or implicit bias towards certain marginalized groups, which can cause groups to lack trust in the system.

Similarly, the model does not address how difficult it is to change habits.If you’re used to having three coffees a day, it’s hard to reduce your caffeine intake even if you know there are health risks associated. 

Additionally, the Health Belief Model assumes that people are rational decision makers who carefully weigh out all the benefits and consequences of engaging in a behavior. However, according to bounded rationality, due to constraints such as time and mental capacity, humans do not weigh out all the pros and cons and instead make decisions that are good enough. Our perception of risks and benefits are often inaccurate. 

While there is a lot of nuance when making health-related decisions, the Health Belief Model is a useful tool that focuses on individual perception of health-related behaviors. By understanding what makes people more or less likely to engage in health behaviors, the model can inform interventions to push people towards smart, healthy decisions.

Promoting Physical Activity in Elderly Nursing Homes

As we get older, it becomes even more important to engage in physical activity to maintain our mental and physical health. Physical inactivity is reported to be the fourth leading risk factor for disease that's not related to infections. However, physical activity is usually low among elderly residents in nursing homes. Using the Health Belief Model, researchers sought to understand the factors that influence physical activity in nursing homes in China.

The researchers examined the level of physical activity that elders in 213 nursing homes engaged in, and distributed surveys to understand their perceptions related to physical activity. They found that there was a correlation between each of the six components of the Health Belief Model and the amount of physical activity participants engaged in. Specifically, they found that self-efficacy was the most likely determinant to positive influence engaging in physical activity. ¹¹

What the results show is that interventions tailored to increase self-efficacy would have the most impact. To promote physical activity in elder nursing homes, public health officials could focus on interventions that increase the confidence of elders to make physical activity seem achievable.

The Stepped Care Approach to Mental Health: How to build digital tools to tackle workplace stigma

Recognizing the economic impact that mental health can have on productivity, many employers have expanded access to mental health benefits. However, many employees are still not taking advantage of these benefits. In this article, The Decision Lab’s writers Ryan McPhredrain and Marielle Montenegro explore how the stigma of mental health makes people hesitant to seek help, and propose methods to counter the stigma, including by making it easily accessible (removing perceived barriers) and encouraging positive discussion around mental health benefits (highlighting perceived benefits and diminishing perceived consequences). 

Dr. Mitesh Patel on Nudging, Tech, and Health Care

There are two things necessary for someone to engage in medical therapies, tests, and treatments: first, a clinician needs to recognize that a patient should engage in that treatment, and second, a patient needs to decide to engage in the behavior. In this article, our writer Sanketh Andhavarapu interviews Dr.Mitesh Patel, the Director of the Penn Medicine Nudge Unit, to explore how behavioral science can help nudge people to engage in health-related behaviors. 

1. Gordon, A. (2020, January 24). Health Belief Model: How it works and how to use it. Verywell Mind. https://www.verywellmind.com/health-belief-model-3132721
2. Leventhal, H., Meyer, D., & Nerenz, D. (1980). The commonsense model of illness danger. In The role of the individual in the understanding and management of health (pp. 7-30). Springer.
3. Rao, N. (2023, January 17). Health Belief Model: An overview of the theory and its components. Positive Psychology. https://positivepsychology.com/health-belief-model/#primary-components-of-the-health-belief-model-theory
4. Rosenstock, I., Stretcher, V., & Becker, M. (1988) Social Learning Theory and the Health Belief Model. In Health Education Quarterly, 15(2), pp. 175-183. https://www.jstor.org/stable/45049256
5. Steckler, A., McLeroy, K. R., & Holtzman, D. (2010). Godfrey H. Hochbaum (1916–1999): From social psychology to health behavior and health education. American Journal of Public Health, 100(10), 1864. https://doi.org/10.2105/AJPH.2009.189118
6. Studylib. (n.d.). Health Belief Model. Retrieved July 19, 2024, from https://studylib.net/doc/8875220/health-belief-model
7. SFGate. (2006, February 27). Kegeles, S. Stephen, PhD. SFGate. https://www.sfgate.com/news/article/KEGELES-S-Stephen-PhD-2636527.php
8. Rutgers Institute for Health. (n.d.). Howard Leventhal. Rutgers University. Retrieved July 19, 2024, from https://ifh.rutgers.edu/faculty_staff/howard-leventhal/
9. Orji, R., Vassileva, J., & Mandryk, R. (2012). Towards an effective health interventions design: An extension of the Health Belief Model. Online Journal of Public Health Informatics, 4(3), ojphi.v4i3.4321. https://doi.org/10.5210/ojphi.v4i3.4321
10. Zewdie, A., Mose, A., Sahle, T., Bedewi, J., Gashu, M., Kebede, N., & Yimer, A. (2022). The Health Belief Model’s ability to predict COVID-19 preventive behavior: A systematic review. SAGE Open Medicine, 10, 20503121221113668. https://doi.org/10.1177/20503121221113668
11. Huang, J., Zou, Y., Huang, W., Zhou, Y., Lin, S., Chen, J., & Lan, Y. (2020). Factors associated with physical activity in elderly nursing home residents: A path analysis. BMC Geriatrics, 20, 274. https://doi.org/10.1186/s12877-020-01676-8