teori hbm

HEALTH BELIEF MODEL 1

The Health Belief Model

Larry Lizewski

Wayne State University

Communication Theory

Dr. Katheryn Maguire

March 31, 2010


The purpose of this paper is to examine the health belief model (HBM). In the more than

50 years of its existence, the HBM has been embraced and developed becoming a prolific

framework for explaining and predicting preventive health care behaviors. Added dimensions

have furthered its abilities making it a useful framework in the area of sick-role behaviors as well

(Tanner-Smith, 2010, p. 95). It has garnered significant support across many types of

applications and its use remains strong today. This work will introduce the HBM and review its

origins, perspectives, added dimensions and contributions to communication research as well as

its shortcomings.

It is difficult to convince people they are at risk. Despite a barrage of health campaigns,

warnings labels, doctor’s advice and pleadings from friends and family, people dismiss empirical

evidence of health dangers. Furthering this phenomenon of preventive health care is the

difficulty of getting the public to adapt long-term goals. Significant numbers of people, though

aware of health risks, either ignore preventive actions or adopt programs without proper

regiment. The failure to effectively persuade individuals to seek health prevention has frustrated

health communication scholars since the 1950s (Burns, 1992; Mikhail, 1981).

The Health Belief Model

The HBM consists of 4 variables that interrelate. To better understand the HBM,

perceived benefits and barriers have each been given their own brief explanation.

Perceived Susceptibility. The belief that one is at risk of an illness is subjective. To one extreme

is an individual who is in full denial of any risk while the other an individual who feels danger is

certain. The area between contains those who admit the statistical possibility of contracting an

illness, but do not fully believe they will (Rosenstock, 1966, p. 6).


Perceived Seriousness. The perception of the consequences of a negative health condition is also

subjective. Beliefs of an illness causing pain, debilitation, social stigma or death are examples of

seriousness perceived (Rosenstock, 1966, p. 6).

Perceived Benefits of Taking Action. Deciding on a course of action is shaped by the options

accessible to the individual and the belief in their effectiveness. Action is thus dependent on

having at least one course of action to prevent an illness from occurring while believing it will

produce acceptable results (Rosenstock, 1966, p. 7).

Barriers of Taking Action. Despite a belief being established that a particular course of action

may reduce a health threat, indecision may still take place. If readiness is low and negative

aspects of the course of action are viewed as high, barriers are constructed preventing action.

(Rosenstock, 1966, pp. 7-8).

Cues to Action. A stimulus that can “trigger” (Rosenstock, 1966, p. 8) appropriate health

behavior. This may be internal such as physical discomfort, or external such as a message

communicating the seriousness of a disease. The external is most relevant to communications as

it often relies on media and interpersonal interaction (Mattson, 1999, p. 243).

Summary of HBM

The HBM posits that people will take action to undergo a health prevention behavior

when they are ready; they see it as beneficial; and the difficulty is not greater then what is to be

gained. Does the end justify the means? Readiness is determined by the degree to which one

believes an illness is likely. Perceived susceptibility may be influenced by proximity to an

illness. For instance, someone with a family history of diabetes will more likely seek a blood test

then someone who has no family history of the disease. Readiness is also determined by the

consequences a health risk may impose. When perceived susceptibility is seen as likely and


perceived severity of an illness is high, motivation increases. Conversely, motivation decreases

as susceptibility seems unlikely and severity is viewed as inconsequential (Rosenstock, 1966).

Once concluded that threat is likely and damage may be severe, action to prevent its

occurrence is likely taken. The choice of action to reduce the health threat is reliant on the belief

of its effectiveness. Will it work? At least one viable option to prevent illness must be accessible.

The individual experiencing a decision process involving these variables is often unconscious of

the cognitive process (Rosenstock, 1966). It is Rosenstock’s (1966) opinion that emotional

factors have more bearing on this event than do the intellectual. Despite a belief in the

effectiveness of an action that may reduce the threat of an illness, barriers preventing

commitment to the action may arise.

If the psychological readiness of an individual is high and the negative aspects of the

course of action relatively weak, action is likely taken. Conversely, when readiness is low and

negative aspects of the course of action are viewed as high, barriers are constructed preventing

action. Considerations such as will it be painful? Will it upset family life? Will it place one’s self

and loved ones in financial crisis? These questions raise barriers in the decision process. A

significantly more difficult circumstance surfaces when both readiness and the negative aspects

of the course of action are high (Rosenstock, 1966).

In this circumstance, the HBM posits that individuals will demonstrate behavior to both

take action and avoid it. As a result, they may review alternatives and choose another action. If

no other option is available, one of two reactions may occur. (1) They may psychologically

distance themselves from the situation such as declaring intention to change their behavior

“tomorrow”. This allows for temporary psychological relief from the barrier and the perceived

benefit. (2) They may experience increased fear and anxiety. If these negative feelings become


great enough irrational behavior becomes possible. At this point the presentation of any effective

means ensuring good health may go unanswered (Rosenstock, 1966, pp. 7-8). Even after all

variables are in place indicating high likelihood of positive health behavior, people will

sometimes still not take action. Rosenstock (1966) proposed that events can “trigger” (p. 8)

individuals to take action toward prevention.

Perceived susceptibility and severity are variables that affect readiness. Perceived

benefits affect the course of action. However strong these variables may be interpreted, there

remains a possibility an individual may still not demonstrate preventive health behavior. A cue to

action may be a solution. These cues could be internal such as physical discomfort or external,

such as a media communication. If the cue’s influence matches or exceeds the level of readiness,

action is likely to be taken. Therefore, low readiness require more highly intense cues while high

readiness require less (Rosenstock, 1966, p. 8).

The origins HBM

The frustration as to why the public was not responding to federal government offerings

of free health prevention programs in the 1950s sparked the research of three psychologists,

Irwin Rosenstock, Godfrey Hochbaum and Stephen Kegels (Burns, 1992; Mikhail, 1981). As

Hochbaum (1958) stated, “Although the public stands to gain most from the success of health

programs, its willingness to participate has all too often been disappointing, in spite of well-

organized attempts to arouse popular interest and to make participation easy” (Hochbaum, 1958,

p. 1). HBM was developed as a result of their endeavor to resolve this. In particular were the

preventive health programs of free chest x-rays and Salk vaccine inoculations. This assistance,

and subsequent research, was funded by the U.S. Public Health Service in response to epidemics

of tuberculosis and polio (Hochbaum, 1958; Rosenstock, Derryberry, & Carriger, 1959).


Hochbaum’s (1958) survey study of the public’s response to chest x-rays had already

begun to disclose elements of HBM. Psychological readiness, fear of the severity of illness,

belief of oneself contracting an illness and cues to action were discussed. Rosenstock,

Derryberry, & Carriger’s (1959) also found these factors responsible for the public’s lack of

response to illness prevention. The role of situational factors was also found. This component

would later be criticized as a weakness of HBM’s effectiveness.

In their work, Rosenstock, et al. (1959) analyzed research of poliomyelitis vaccine or,

Salk vaccine. As Hochbaum (1958), their analysis of studies conducted on the forgoing of

preventive health measures was similar. For example, Rosenstock et al. (1959) found that

perceived susceptibility was the cause of adults not seeking vaccination. It was found that adults

thought of polio as a children’s disease and therefore not relevant to themselves. Though both of

these works discuss the variables of the HBM, there is no mention of the “health belief model”

outright. No work could be found that cite the title by Rosenstock, Hochbaum or Kegels until

Rosenstock’s 1966 work.

In addition to Rosentosck’s article Why People Use Health Services, other privately

funded researchers were finding similar variables included in the HBM. In the same year as

Rosenstock (1966) was published, so was Kasl & Cobb’s work Health Behavior, Illness

Behavior and Sick-Role Behavior (Kasl & Cobb, 1966). Rosenstock (1966) gives significant

credit to them in his aforementioned piece. In it he states Kasl and Cobb’s “useful framework for

considering the focus and limitations of the present paper” (p. I). Burns (1992) also dedicates

considerable space ensuring Kasl and Cobb’s recognition for the HBM. The significance of

Rosenstock’s work is his findings on the costs of taking action against health threats. These are

mentioned as benefits and barriers in the HBM (Burns, 1992; Rosenstock, 1966). In the effort to


balance contribution, Kasl and Cobb’s (1966) applied their findings in the area of sick-role

behavior. This would later become a popular addition to HBM (Becker, Drachman, & Kirscht,

1974).

The importance of communication research in both the 1950’s articles by Hochbaum

(1958) and Rosenstock (1959) is recognized. Hochbaum (1958) specifies communication’s role

“in the external situation, such as posters, articles, TV and radio programs” (p. 8). He found

these channels of communication in the decision making process of health prevention to be

essential. But it is Rosenstock, et al. (1959) that dedicate a heading “Communication Research”

(p. 101-102). Groups, according to them, differ in their choice of channels of communication,

types of message and cognition of communication. These mentioned variables continue to be

studied by communication scholars today in creating effective messages. Rosenstock, et al.

(1959) states the following:

It is not to be denied that the mass media have, and always have had, an important role

in communication. However, the poliomyelitis and communication studies reviewed

here suggest that the assets and liabilities of the traditional approach should be

considered. (p. 102)

Rosenstock et al. (1959) base much of this discussion on the work of Katz and

Lazarsfeld. Katz and Lazersfeld, however, were not the only familiar names to communication

scholars used by these researchers. Kurt Lewin’s work had significant influence on the

development of HBM (Burns, 1992; Mikhail & Petro-Nustas, 2001; Rosenstock, 1966).

HBM’s Meta-Theoretical Approach

Hochbaum (1958) demonstrates his phenomenological perspective (Mikhail, 1981) as he

states, “In short, we shall be concerned with what people believe, not with the correctness of

these belief orientations” (Hochbaum, 1958, p. 5). As does Rosenstock (1966), “The variables


deal with the subjective world of the behaving individual and not with the objective world of the

physician or the physicist” (Rosenstock, 1966, p. 5). These interpretive approaches clearly place

the knowing in the consciousness of the individual and not the external world (Miller, 2005, p.

54) Recognizing and evaluating the perceived reality of another was important, according to

Hochbaum (1958), in understanding their motivation. Focus on imposing an empirical view

another cannot perceive is futile. Simply put by Mikhail (1981), “People can only act on what

they believe to exist” (p. 67).

Craig (1999) discusses a quality of the phenomenological tradition when he uses an

example of how what we observe on the surface may not be what is going on internally of

another. Our own perceptions get in the way of what lies beneath. It is the tradition of

phenomenology that addresses this “experience of otherness” (p. 133). Through their leanings

toward this concept, the originators of the HBM were drawn toward the ideas of similar thinkers

(Burns, 1992; Mikhail, 1981). “The missing element may be derived from the work of Kurt

Lewin. Behavior may thus be regarded as a function of a person's motive and of his beliefs about

various opportunities for action”(Rosenstock, 1960, p. 295).These beliefs are important in

determining the goals people set.

An individual’s view on what is important and how they place themselves in context of a

situation determines their success or failure of obtaining a goal (Hochbaum, 1958). This parallels

Craig’s (1999) explanation of a phenomenological trait as well. “Among the paradoxes of

communication that phenomenology brings to light is that conscious goal seeking, however

benevolent one’s intentions may be, annihilates dialogue by interposing one’s own goals and

strategies as a barrier against one’s direct experience of self and other” (p. 139). To alter

another’s beliefs, and thus their approach to a goal, we must first understand the variables of the

cognitive process of goal assessment. Hochbaum, Rosenstock and Kegels found Lewin, Dembo,


Festinger, & Sears (1944) research in Levels of Aspirations valuable to achieve this (Burns,

1992; Mikhail, 1981).

The Expanding HBM

Kasl and Cobb’s (1966) study of the HBM’s variables to sick-role behavior was

expanded upon in the 1970s (Becker, et al., 1974; Becker & Maiman, 1975; Mikhail, 1981).

Becker et al. (1974), determined there was no reason the HBM could not be used to understand

the behavior of those already ill. For example, if perceived susceptibility is conceptualized as the

degree one feels likely to acquire an illness why not to the degree one feels likely they will

become more ill? (p. 206). Motivation, according to them, could also more fully explain issues in

the area of health behavior.

In the original HBM, fear of the severity of illness and negative attributions associated

with the course of action was the focus. People sought health prevention because they did not

want to get sick. Becker et al. (1974) posits that positive aspects can draw people to better health

choices. For example, people may seek preventive health care because they perceive it will make

them feel better. This counters HBM’s position that people seek preventive health care to avoid

negative consequences (Rosenstock, 1966). In the first example they move toward comfort. In

the second they move away from discomfort (Becker, et al., 1974; Becker & Maiman, 1975).

Because of the new role the HBM had in explaining and predicting the behavior of those already

ill, opportunity for new dimensions transpired (Rosenstock, Strecher, & Becker, 1988).

Previously there was no need to explain long-term behavior change. Prevention was largely a

one-time procedure. One gets a chest x-ray. One gets a shot etc... Illness, however, often requires

a life-long regiment to sustain health. Bandura’s (1977) social cognitive theory (SCT) was found

to be valuable in explaining long-term goals and motivation.


As Rosenstock et al. (1988) simplify SCT, “learning results from events (termed

reinforcements) which reduce physiological drives that activate behavior” (p. 175). Because of

this view, Rosenstock, Strecher, & Becker (1988) proposed SCT (Bandura, 1977) had

significant relationship with the HBM. It also made sense in that they share the concept of

Lewinian “value expectancy” theory (Rosenstock, et al., 1988, p. 177). SCT’s explaining of

expectations and incentives were found to be valuable to HBM in two ways (p. 176). First, SCT

posits that observations of others influence our own behaviors. We imitate. The second,

however, had the most influence in the HBM’s advancement.

By comparing the variables of SCT to HBM’s, it was found that all but one mirrored

HBM’s (Rosenstock, et al., 1988, p. 177). This variable was Bandura’s (1977) idea of self-

efficacy. It proposed that to change our behavior we must believe we can. “It is hypothesized that

expectations of personal efficacy determine whether coping behavior will be initiated, how much

effort will be expended, and how long it will be sustained in the face of obstacles and aversive

experiences” (p. 191). Rosenstock (1988) determined this concept could contribute insight and

resolve shortcomings of the HBM’s variable of perceived barriers. It was proposed and accepted

by researchers and is now included as a variable in the HBM (Rosenstock, et al., 1988).

HBM and Communication

The value of the HBM to communication scholars is its ability to operationalize

research. It offers a framework to conceptualize and measure variables. The measured HBM

factors are then able to determine the effectiveness of a health message. For example, did the

message increase or decrease perceived susceptibility? If increase is shown, individuals will

more likely be motivated to change health behavior. The message is successful. Such is the case

with determining the health beliefs of an audience following a health related television program.


In the research of Chew, Palmer, Slonska, & Subbiah (2002), a survey was conducted

following a sample audience’s exposure to five half-hour showings of a health series on diet. The

survey was designed to measure efficacy (by an index of benefits and barriers), readiness

(susceptibility), motivation, salience and cues to action (p. 186-187). To measure efficacy a five

item Likert-scale (strongly agree (1)-strongly disagree (5)) was used to measure two benefits and

three barriers.

A product of operationalization is direction in developing research questions. In a study

of communication between counselors and clients during HIV screenings, the HBM variables

allowed parsimony. “RQ1: Does interpersonal communication between counselors and clients

during HIV testing cue clients perceptions of (a) severity (b) susceptibility (c) benefits (d)

barriers, and or (e) self efficacy?” (Mattson, 1999, p. 245). Survey questions to assess risk, or

perceived susceptibility and severity, were also given shape by the components of HBM. For

example, “If I get HIV or AIDS from my partner, it’s no big deal because it can be treated” (p.

247). As Chew, Palmer, Slonska, & Subbiah (2002), a Likert-scale was implemented. The end

result was to determine the best persuasive strategies for counselors recommending safer sex.

Critique

Despite Hochbaum (1958) and Rosenstock’s (1959) call for increased communication

research utilizing the HBM, its use is sparse. A search for the HBM in a communication research

database retrieved surprisingly few periodical articles. 34 articles were retrieved using a Boolean

keyword search of “health belief model”. A significant portion of these only referenced the

model. Subsequent searches using alternative databases and keywords resulted in less success.

Tanner-Smith (2010) may explain this.


In 39 studies reviewed on the use of the HBM in pap screening behavior, she found none

to include the cues to action variable. “First, no studies included indicators of cues to action,

which was a strong predictor of mammography behavior” (Tanner-Smith, 2010, p. 117). Cues to

action also have a strong reliance on communication research as it predicts the effects of

messages that” trigger” (Rosenstock, 1966, p. 8) positive health prevention (Hochbaum, 1958;

Rosenstock, et al., 1959). If no studies are giving indication of message influence how can it

become a topic of discussion amongst communication researchers? The HBM also has

shortcomings to explain and predict.

Tanner-Smith (2010) concluded weak support for the HBM’s ability to explain and

predict perceptions of risk. That is, perceived susceptibility and perceived severity. An

explanation could reside with the HBM’s shortcomings in considering “contextual constraints”

(p. 118). Perceived susceptibility and severity may be high, but if one is struggling with issues

such as poverty, additional stressors may supersede actions to assure health (p. 118). In other

words, if someone is striving to feed the kids, one’s concern to seek medical screening may be

secondary. The role of these situational factors was discussed and given consideration early on

by Hochbaum (1958) and Rosenstock (1959). The HBM also does not consider repeat behavior.

Tanner-Smith (2010) posits there is a perspective change between those undergoing a pap

screening or mammogram for the first time and those who have made these visits routine.

Perceived risks may influence the first visit but become less so thereafter.

Janz and Becker (1984), also discuss issues with perceived severity. According them, an

illness such as cancer has a global perception of being very serious. This would account for little

variance when measuring the perception of severity of those who comply with preventive health

care and those who do not. Both may have similar perceptions (p. 36-37). Norman & Brain


(2005) point to these parallels in their application of the HBM in compliance of breast self-

examinations as well.

Conclusion

The HBM has demonstrated to be an affective model in explaining and predicting health

behaviors from its inception. Its four variables interrelate. These variables affect health behavior

on two levels. (1) Perceived susceptibility and severity affect ones readiness. (2) The costs of

benefit and barriers determine course of action. Through the years the dimensions and variables

added have strengthened HBM’s capabilities and increased its use. The meta-theoretical

foundations of phenomenology and subsequent connection to communication research’s

founders, make the model relevant to the communication field. In addition, the HBM’s ability to

operationalize communication research has also been a valuable tool. This is demonstrated, not

only in the area of communications but, of course, many health fields. Though it is often

mentioned in health communications it remains underutilized. Interestingly, as he discusses the

role of communication in his article introducing the HBM, Rosenstock (1966) states, “Recent

research suggests the desirability of more intensive study of the role of emotionally arousing

factors in education and on the conditions which increase the effects of emotionally arousing

messages upon attitude and behavior change” (p.28).


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