Understanding Patient Attitudes: The Health Belief Model

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Cardiovascular

Cardiovascular

Understanding Patient Attitudes: The Health Belief Model

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How do people think about their health?

Why do people engage in behavior they know is detrimental to their health?  With the emergence of modern public healthcare policy after World War II, healthcare professionals began to examine new ways to understand patient behavior. Queries into patient behavior are at the center of the first systematic, theory-based health behavior research and the development of the Health Belief Model (HBM) in the early 1950s.

 

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The HBM premise

The Health Belief Model grew out of the work of early social psychology pioneers, such as Kurt Lewin, who wanted to understand how best to guide the new domain of public health policy and communications. Early versions of the HBM, based on research investigating attitudes towards health screening, appeared in the 1950s.1 As it is typically used today, the HBM was formalized by Rosenstock in 1974,2 and it is the foundation of most models for understanding human health behavior.

The HBM characterizes health decision making as cost-benefit analyses, or in the language of social science, an “expectancy-value” model. That is, people consider the value of behavioral change in terms of the perceived benefit or risk reduction and compare that to the perceived costs, i.e., effort, time, money, and other negative impacts on their life. If the perceived benefits of adopting a new behavior outweigh the costs, then the expected value is sufficient to prompt action or make a behavioral change, e.g. submit to x-ray screening, quit smoking, or adhere to a treatment plan.

The HBM characterizes health decision making as cost-benefit analyses, or in the language of social science, an “expectancy-value” model. That is, people consider the value of behavioral change in terms of the perceived benefit or risk reduction and compare that to the perceived costs, i.e., effort, time, money, and other negative impacts on their life. If the perceived benefits of adopting a new behavior outweigh the costs, then the expected value is sufficient to prompt action or make a behavioral change, e.g. submit to x-ray screening, quit smoking, or adhere to a treatment plan.


Part 1: Understanding the condition

According to the HBM, the two key components of an individual’s understanding of their condition are their perceptions of the seriousness of their condition’s consequences and their susceptibility to those consequences. For example, when considering whether to quit, a person who smokes will first decide how serious the consequences of smoking are, e.g. lung cancer or premature death, and then determine how likely it is that the consequences will manifest.

It is important to remember that the key point here is the patient’s perception of both seriousness and susceptibility – not necessarily what clinical and epidemiologic studies might suggest. For example, while premature death is objectively quite serious, not everyone will be motivated to modify their behavior by a fear of premature death. To a 30-year-old who smokes, the possibility of dying at age 75 instead of 82 may not seem particularly serious, and if they have a relative who smoked their whole life and died at 90 of other causes, they may minimize or dismiss their own susceptibility to premature death. (This is an example of the availability heuristic we discussed in the previous article, << Heuristics and decision-making: What are the effects on adherence for patients with cardiovascular disease? >>). Taken together, these considerations of seriousness and susceptibility form the patient’s perceived risks of their condition or of continuing with current behaviors, e.g. smoking, not getting tested, not taking medication, etc.

 

Part 2: Understanding the treatment

The other half of the equation is the patient’s understanding of the proposed behavior changes needed to manage their condition. This can be further broken down into perceived barriers to the new behavior and the treatment’s perceived benefits. 

Before quitting tobacco, the same 30-year-old will have to determine whether quitting will reduce the possibility of premature death or if that benefit will no longer be available to them even if they now modify their behavior. And in terms of barriers, the perception that it is difficult to quit tobacco is ubiquitous, and there may be other fears, like weight gain, preventing a change in behavior. 


The HBM illustrated

The patient’s combined perceptions and beliefs will determine whether there is value in changing the current behavior in favor of suggested behaviors or treatments.

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The HBM and adherence in cardiology

The Health Belief Model has been amply studied in cardiology, both in terms of predicting patient behavior and in effective patient education. Studies have used the HBM to predict compliance with cardio rehabilitation treatments3 and commitment to regular exercise regimens for cardiac patients.4 The model has also proven to be a useful indicator of risk reduction among patients susceptible to stroke,5 as well as predictive of treatment adherence for patients with hyperlipidemia.6 These and other studies indicate that 30% to 60% of health decision making can be explained by this model.

While the HMB’s predictive utility is helpful, more important is the model’s success in helping patients to understand their conditions and their treatments and to ultimately modify their behavior and adhere to their treatment plans. The model has proven to be useful both as a way of structuring interventions and measuring success within cardiology7, 8 and in related fields of chronic disease management such as diabetes care.

 

Influencing the patient using the HBM 

The HBM allows healthcare professionals to access and assess the patient’s potential behavior by breaking down their beliefs. Following the HBM, a healthcare provider should:

  • Assess the patient’s understanding of the potential consequences of their disease.
  • Make sure the patient knows that:
    (1) they are susceptible to those consequences, and
    (2) that they have a degree of control over the outcome if they follow the treatment.
  • Assess the patient’s understanding of the benefits of the treatment to ensure that they fully understand those benefits.
  • Make sure that the patient has a realistic understanding of side effects to ensure that if side effects manifest, they do not undermine the perceived value of the behavior change.

 

Using the HBM in cardiology: An example

Consider a patient with hypertension. Hypertension is generally an asymptomatic disease (as are many other cardiology ailments, such as hyperlipidemia). Absent symptoms, the patient’s perception of the health risk may be quite low. This makes it easy for the patient to underestimate their susceptibility to negative consequences in the future. The ubiquity of treatment with lipid-lowering and hypertension medications may lead to a certain degree of apathy with respect to treatment adherence, and ironically, the lack of side effects from these medications can contribute to the perception that the medications are not having an effect, thereby reducing the perceived risks, and discouraging adherence to a treatment plan.

The prescriber should also be mindful that a daily pill may be a perceived barrier to disease management. While it may seem easy to take a pill once a day, this can be a challenge for many patients; some may simply be forgetful, while others who dislike being reminded of their condition may avoid their medication based on what it represents. When additional lifestyle changes are suggested or incorporated into a treatment plan, e.g. exercise and diet modification, the patient’s perception of the barriers to treatment compliance can grow exponentially.

A prescriber’s approach that significantly influences a patient’s understanding can have a dramatic effect on behaviors. By asking careful questions, such as those outlined above, a provider can ensure that the patient has the understanding needed to modify their behavior and adhere to treatment. Rudimentary explanations of the disease or treatment, or worse, an assumption that the patient will simply do as they are told, reduce the likelihood that the patient will engage in the desired behavior. Incorporating the HBM can help providers effectively structure the crucial conversations that must take place to help patients adopt healthy behaviors and adhere to treatment.

 

Final thoughts

The Health Belief Model does have limitations. It assumes patients will engage in rational behavior, which is not always the case. It also does not adequately address the fact that many of the behavior changes in a treatment plan, like medication adherence, diet, and exercise, are not one-time decisions, but rather a series of daily decisions that must be made over an extended period of time, often for many years. 

The HBM is an excellent starting point, however, newer behavioral models have emerged since the development of the HBM to address the complicated structure of human cognition to assist patients with treatment adherence.9 As part of its limitations, the HBM gives only tangential consideration to the patient’s assessment of their ability to change behavior, otherwise known as self-efficacy. Self-efficacy and more detailed psychological considerations addressing the question of overall health motivation have led to the elaboration of protection-motivation theory,10 and paved the way for additional frameworks which will be presented in future articles. 

References

1. Godfrey M. Hochbaum GM (1956). “Why people seek diagnostic x-rays.” Public Health Reports, (71):4, pp. 377–380.

2. Irwin M. Rosenstock (1974). “The Health Belief Model and preventive health behavior,” Health Education Monographs. (2):4, pp. 354–386. https://doi:10.1177/109019817400200405

3. Neil B. Oldridge & Davild L. Streiner (1990). “The Health Belief Model: Predicting compliance and dropout in cardiac rehabilitation,” Medicine & Science in Sports & Exercise, (22):5, pp. 678–683. https://doi:10.1249/00005768-199010000-00020

4. Nahla Al-Ali & Linda Haddad (2004). “The effect of the Health Belief Model in explaining exercise participation among Jordanian myocardial infarction patients,” Journal of Transcultural Nursing, (15):2, pp. 114–121. https://doi:10.1177/1043659603262484

5. Karen A. Sullivan, Katherine M. White, Ross Young, Anne Chang, Collette Roos, & Clinton Scott (2008). “Predictors of intention to reduce stroke risk among people at risk of stroke: An application of an extended Health Belief Model,” Rehabilitation Psychology, (53):4, pp. 505–512. https://doi:10.1037/a0013359

6. Leah L. Zullig, Linda L. Sanders, Steven Thomas, et al. (2016). “Health beliefs and desire to improve cholesterol levels among patients with hyperlipidemia,” Patient Education and Counseling, (99):5, pp. 830–835. https://doi:10.1016/j.pec.2015.11.025

7. Mohammad Hosein Baghianimoghadam, Golamreza Shogafard, Reza Sanati Hamid, Behnam Baghianimoghadam, Seyed Saeed Mazloomy, & Mohsen Askarshahi (2013). “Application of the Health Belief Model in promotion of self-care in heart failure patients,” Acta Medica Iranica, (51):1, pp. 52–58. 

8. Zhao Yue, Chen Li, Qi Weilin, & Wang Bin (2015). “Application of the Health Belief Model to improve the understanding of antihypertensive medication adherence among Chinese patients,” Patient Education and Counseling, (98):5, pp. 669 –673. https:// doi:10.1016/j.pec.2015.02.007

9. John Weinman, Keith J. Petrie, Rona Moss-Morris, & Rob Horne (1996). “The illness perception questionnaire: A new method for assessing the cognitive representation of illness,” Psychology and Health, (11):3, pp. 431–445.

10. Steven Prentice-Dunn & Ronald W. Rogers (1986). “Protection Motivation Theory and preventive health: Beyond the Health Belief Model,” Health Education Research, (1):3, pp. 153–161. https://doi:10.1093/her/1.3.153

 

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