The Health Belief Model of Behavior Change

Summary / Explanation

The health belief model (HBM) is a foundational framework in health behavior research. It was conceptualized in the 1950s to help understand preventative health behavior by social psychologists working in the United States Public Health Service (USPHS), specifically "the widespread failure of people to accept disease preventatives or screening tests for the early detection of asymptomatic disease." The model focuses on how individuals perceive health threats and decide to act based on the value individuals place on a particular goal and the likelihood that actions taken toward that goal will be successful in achieving the goal. It consists of 6 primary cognitive constructs, or "dimensions" that influence behavior: perceived susceptibility, perceived severity, perceived benefits, perceived barriers, self-efficacy, and cues to action.

The model has been applied in diverse contexts, from chronic disease prevention to health education and promotion to evaluation of the effectiveness of community-based interventions. Critics argue that the HBM overly emphasizes cognitive constructs, neglecting emotional and social factors. It often overlooks cultural and social influences on health behaviors and assumes rational decision-making, ignoring emotional complexities. Some reviews highlight its static nature and limited predictive power, which can be as low as 20% to 40% compared to other models that incorporate social, economic, and environmental factors.

Technology integration, specifically leveraging technology for tailored health messaging, can modernize interventions and adapt to evolving lifestyles. Focusing on key constructs—prioritizing perceived susceptibility, severity, and self-efficacy—can strengthen health promotion efforts. While the HBM remains a foundational framework for understanding health behaviors, ongoing adaptation and refinement are crucial for its continued relevance and effectiveness in promoting health and preventing disease.

The Health Belief Model of Behavior Change 

The USPHS created the HBM, a widely used conceptual framework of health behavior, in the 1950s. The main contributors to the development of the model were Irwin M. Rosenstock, Godfrey M. Hochbaum, S. Stephen Kegels, and Howard Leventhal. The model responded to the challenges of tuberculosis screening using chest x-rays, the need for immunization, and the community's underutilization of services. The model is based on the psychologists' hypothesis that the community perceives health threats when undergoing chest x-rays for diagnosis and anticipates fear reduction from immunization as a perceived benefit.[1]

In practical terms, individuals assess the benefits of changing their behavior to mitigate health threats and decide to act based on their evaluation. This model is commonly applied to explore interpersonal decision-making on various health behaviors such as screening, vaccination, surgery, and the cessation of any unhealthy behaviors.[2][3][4] 

Key Cognitive Constructs

As a theoretical framework, the HBM comprises 4 primary cognitive constructs: perceived susceptibility to illness, perceived severity of illness, perceived benefits of behavior change, and perceived barriers to action.[5] Over time, and due to evolving research, psychologists have recognized the significance of self-efficacy as a critical aspect of health behavior decision-making and have accordingly incorporated it into the model.[6] In the 1970s, the "cues to action" construct was added to the model to include the stimuli of initiating the action for the change. This addition enhanced the model's predictive power by addressing the factors that motivate individuals to act on their beliefs about health behaviors.

The HBM consists of the following:

• Perceived susceptibility: assessing the probability of acquiring an illness or encountering an undesirable outcome. For instance, the individual susceptibility to viral infection increases if in a crowded public space during a respiratory pandemic.                                                                                                                        
• Perceived severity: understanding the severity of the illness, condition, or unfavorable outcome and what could happen if no additional action is taken. There is a considerable range in how people perceive the severity of an illness, and they often consider both the medical and social implications when assessing its severity. The COVID-19 pandemic is an excellent example, with a wide range of behaviors based on differing perceptions of the consequences of becoming infected.                                                                           
• Perceived benefits: how the effectiveness of various available actions to reduce the risk of illness are perceived. One example is wearing face masks during a respiratory pandemic.                                                
• Perceived barriers: obstacles to performing a recommended health action that may stop one from doing what is recommended. Examples include the availability, perceived social implications, or discomfort associated with wearing a respirator during a respiratory infectious disease outbreak.                                                    
• Self-efficacy: an individual's belief in their capacity to perform a specific behavior or task effectively. It is also related to the likelihood of a person engaging in a desired behavior. Self-efficacy was initially incorporated into the perceived barriers construct of the model by Janz and Becker, but many psychologists later identified it as an essential and independent cognitive construct.[7][8] For example, a patient with a chronic illness who adheres to their healthcare provider's medication regimen demonstrates self-efficacy. They believe in remembering to take their medications, following dosage instructions, and managing adverse effects effectively.                                                                                                                     
• Cues to action: whether from one's surroundings or subjective experiences. Specific cues can influence the actions one chooses to take.[9] While less explored, cues to action are the stimuli that initiate the decision-making process to embrace a recommended health intervention. These cues can be either internal or external, from noticing symptoms of an illness to being exposed to a health campaign.[10]

The HBM, a practical and widely used framework to illustrate the key cognitive constructs of health-related behavior change, is often cited in the context of tobacco cessation in smoking cessation clinics as follows:

• Perceived susceptibility is when tobacco users contemplate the fact that there are diseases or undesirable outcomes resulting from using tobacco.                                                                                                                          
• At the same time, the perceived severity is based on the known fact of the relationship between cardiovascular and pulmonary diseases, death, and tobacco use.                                                                                           
• In contrast, the perceived benefits are the expected advantages following tobacco cessation, such as cardiovascular event risk reduction or chronic lung disease.                                                                                           
• The commonly encountered barriers are peer influence, considering tobacco as an enjoyable behavior to relieve stress, and being addicted to it.                                                                                                              
• Self-efficacy is the ability to adhere to the cessation plan, such as taking the medication regularly and adopting healthcare workers' behavioral advice.                                                                                               
• The cues to action might be a close friend who recently suffered an acute myocardial infarction after lifelong nicotine use.[11][12]

Screening for breast cancer using mammography has also been frequently analyzed using this model, as follows:

• Perceived susceptibility is a 56-year-old woman considering her lifetime risk of developing breast cancer due to her age and risk factors.                                                                                                                                                                                     
• Perceived severity focuses on the publicly understood morbidity and mortality caused by breast cancer.                                                                                                                                                                
• The perceived benefit of screening using mammography is the ability to detect breast cancer at an earlier and more treatable stage while considering the risks of false positives and negatives.                                             
• Perceived barriers may be the reluctance to undergo the screening because of difficulty scheduling, discomfort, and anxiety related to possible abnormal findings.                                                                                                
• Self-efficacy is confidence in obtaining the procedure and following up in the case of abnormal findings. This may be reinforced by health education about the process, offering insights into what to expect and how to arrange the procedure.                                                                                                                                                               
• The cues to action may include family encouragement, health reminders from a physician or insurance company, media influence, or the successful experience of a friend who underwent a similar scenario.[9]

Implementation

The HBM has been adapted to fit diverse medical and cultural contexts influencing public health through health promotion and preventive community-based programs.

One example of a practical application of the model is its use in reducing the risk of diabetes. For instance, a high perception of diabetes risk among adult females who were newly diagnosed with prediabetes was compared with those with normal fasting blood glucose levels. However, there was no association between a prediabetes diagnosis and implementation of healthy lifestyle behavior compared with those without prediabetes. This identified an opportunity to apply evidence-based approaches to motivate health behaviors to reduce the risk of disease progression in this population.[13]

In a 2024 systematic review, Alani Abdallah et al found that individuals' beliefs about their susceptibility, perceived benefits, and sense of self-efficacy are strongly linked to their adoption and use of preventative measures for common treatable diseases, such as cervical cancer.[14] Anokye et al came to a similar conclusion while examining patients undergoing screening cardiovascular interventions. They found that these interventions encouraged individual confidence when engaging in beneficial health-related behaviors.[15]

A systematic review in 2020 by Ritchie et al found inconsistencies in the effectiveness of the HBM in encouraging the adoption of healthier choices. They discovered that although the models explained observed findings in screening behavior, they often failed to report effectiveness.[16] Masoumeh et al determined that a cervical screening education program based on the HBM effectively improved Iranian women's participation in cervical cancer screening.[17] The HBM has been used to examine and improve compliance with beneficial oral health interventions, medication adherence in adults with chronic disease who take multiple drugs, and intentions to get the COVID-19 vaccine with inconsistent results.[18][19][20]

The effectiveness of the HBM in changing behavior was also questioned by Xiao et al following the assessment of the impact of theory on human papillomavirus vaccination promotion.[21] Tremblay and his colleagues concluded in a 2024 published systematic review that the diagnosis of sexually transmitted diseases would impact the subsequent protective behaviors among younger adults.[22]

The HBM extends beyond health promotion and has been used to evaluate intervention effectiveness using pre- and post-intervention methods. For instance, Jones et al used this model to assess a stroke prevention program for atrial fibrillation patients. They aimed to boost patients' perception of stroke severity and susceptibility by enhancing their knowledge about the link between atrial fibrillation and stroke. The study found an increase in aspirin use from 23% to 33% and an improved understanding of anticoagulant therapy risks.[23]

Furthermore, the HBM has been applied to various health behaviors and conditions, including adopting a healthy lifestyle, alcohol use, obesity, weight management, regular physical exercise, and dietary intake.[24][25][26] It also exhibited effectiveness in safety-related behaviors such as seatbelt use, preparedness for infectious disasters, and dental health.[27][28][29] Moreover, the model demonstrated effects regarding chronic diseases such as HIV, prostate cancer, and type 2 diabetes mellitus.[30][31][32]

Limitations

As with any model attempting to understand and influence a process as complex as human behavior, the HBM has several limitations. One of the most notable limitations is the lack of an individual's belief in his capacity, which was addressed earlier by many psychologists but amended by Janz and Becker in the 1980s by adding self-efficacy to the model. 

The model fundamentally focuses on cognitive constructs such as perceived susceptibility, severity, benefits, and barriers. Thus, it may not capture the emotional and social aspects that affect health behaviors.[7]

Some have criticized the model for not adequately addressing the impact of social and cultural factors on health beliefs and behaviors.[33] The model also assumes that individuals make rational decisions based on weighing the advantages and disadvantages of health actions even though emotions, habits, and other external pressures can complicate decisions.[34]

The HBM has also been criticized for its static nature, which does not account for changes in beliefs, attitudes, and behaviors over time or in response to interventions. Furthermore, it can, at times, overemphasize individual responsibility for health, neglecting broader environmental and structural factors that influence health behaviors.[8][35]

Although the model was amended to include self-efficacy in the 1980s, some reviews suggested that the HBM has a low predictive value (20% to 40%) in explaining health behaviors compared to other models or theories.[36][5]

Future Directions

The HBM continues to be a constructive framework for understanding and promoting health behaviors. Incorporating social determinants of health into the model may give a deeper understanding of changing human behavior, particularly by recognizing the role of social, economic, environmental, and other factors in health beliefs. This can be achieved by tailoring interventions based on cultural beliefs to enhance their relevance and effectiveness.[37]

Using recent technology to deliver customized health messages might effectively enhance health promotion and prevention and make the model more applicable to current lifestyle practices.[38]

Furthermore, focusing on the key constructs of the HBM may benefit health promotion. Advancing interventions to enhance awareness and understanding of health risks and their potential severity might enhance perceived susceptibility and severity.[7] Khodaveisi et al. addressed practical, financial, and logistical barriers to adopting healthy behaviors in the hopes of reducing overall perceived barriers.[39] While Bandura et al postulated that empowering individuals with the confidence and skills to act and maintain healthy behaviors would promote self-efficacy.[40]

While created in the 1950s, the HBM remains a relevant and valuable foundational framework for understanding and promoting behavior change in preventative medicine. By recognizing the significance of individual perceptions, beliefs, and cues to action, the current model enables healthcare professionals to tailor interventions effectively to address specific health concerns and motivate individuals to adopt healthier behaviors. Through the application of strategies aimed at enhancing perceived susceptibility, severity, benefits, and barriers, alongside the reinforcement of cues to action, the HBM empowers individuals to take proactive steps toward safeguarding their health and well-being. As society continues to face ongoing health challenges, the continued utilization and refinement of this model hold promise for promoting positive health outcomes and fostering a culture of prevention and wellness.