Health Belief Model

The Health Belief Model (HBM) is a psychosocial approach to explaining health-related behavior.  Introduced in the 1950’s by psychologists Rosenstock, Hochbaum, Leventhal and Kegeles, it has been one of the most widely used conceptual frameworks over the past 3 decades. 

The model incorporates 4 variables:

• Perceived susceptibility
• Perceived seriousness
• Perceived benefits
• Perceived barriers

Perceived Susceptibility
Individuals will seek preventive care if they believe they are personally at risk.  The perceived susceptibility of a disease refers to the subjective probability that an individual could, in fact, get the disease. 

Perceived Seriousness
The perceived seriousness of a disease may or may not be related to the actual severity of the disease.  People tend to be more motivated to prevent serious diseases than less serious ones.  Susceptibility and seriousness combine to form an overall perceived threat of a disease.

Perceived Benefits
The perceived benefits of a behavior refer to how effective a person thinks the behavior will be.  Taking aspirin for a headache is likely to be perceived as very effective, since it has a rapid and noticeable result.  Obtaining regular fecal occult blood tests to enhance early detection of colorectal cancer, however, usually has no short-term benefit.  It may therefore be perceived as less effective.

Perceived Barriers
Perceived barriers also influence action.  A patient may feel that a treatment or screening takes too much time, requires too much effort, or is too difficult to obtain. 

The highest likelihood of action occurs when the perceived threat of a disease is high and the perceived benefits outweigh the barriers. 

Other Principles
Additional principles of the Health Belief Model include a cue to action such as a health education message or recommendation by a physician.  Self-efficacy, a concept introduced by Bandura (2) and added to the HBM by Rosenstock, et al. (3), refers to confidence in one’s ability to take action.  (See Table 1.)

The HBM also recognizes predisposing, enabling, and reinforcing factors that influence behavior.  Predisposing factors include values, beliefs, attitudes and perceptions of disease.  Enabling factors include availability and accessibility of health resources.  Reinforcing factors include peer support, feedback, and reassurance from the clinician.

Applying the HBM to CRC Screening
Physician recommendation strongly influences whether a patient is screened for colorectal cancer. (4)  The HBM can help you increase the power of that recommendation.  If a patient is not going for regular screening, you can work with that patient to identify the reasons.  You can then tailor strategies (educational materials, counseling, etc.) to eliminate the identified barrier(s) using the framework of the HBM.

Figure 1 illustrates the way in which the HBM may apply to CRC screening.

Addressing Disparities with the HBM
The Health Belief Model provides an appropriate framework for addressing CRC screening in diverse populations. In particular, it can be helpful with patients of low socioeconomic status.  It can also help to overcome racial disparities in screening. 

Low socioeconomic status creates multiple barriers to screening, including poor access to care, lack of resources to cover the cost of screening examinations, and lack of awareness of the risks for colorectal cancer and the modalities used for screening. (41, 42)  In fact, socioeconomic factors such as low educational attainment, lack of health insurance, or lack of access to a usual source of care are associated with underutilization of CRC screening. (1)  Socioeconomic status can also contribute to racial disparities in health care: 24% of African Americans and 23% of Hispanics live below the poverty level compared to 11% of whites, while 18% of African Americans and 35% of Hispanics are medically uninsured compared to 12% of whites. (1)

Cultural affiliations (including medical mistrust and cancer fatalism), religious and spiritual ideologies, and personal perceptions and beliefs affect one’s desire to participate in screening. (41, 42)  Individuals may encounter racial discrimination when seeking health care services.  There may be language barriers that prevent discussion and contribute to higher rates of cancer discovered at later stages.  Lack of confidence and skills to navigate the health care system, negative attitudes toward the tests themselves, fear of the consequences of screening, and inadequate social support have also been suggested as potential barriers. (41, 42)

Most, if not all, of these barriers are modifiable and can be addressed through the use of tailored interventions.  Exploring a patient’s beliefs, fears, expectations, and resources can provide essential information.  With that information, the clinician can work with the patient to overcome barriers that would prevent CRC screening.