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Health belief model

The Health Belief Model (HBM) is a psychological framework developed in the 1950s by social psychologists at the U.S. Public Health Service, including Irwin M. Rosenstock, Godfrey M. Hochbaum, S. Stephen Kegeles, and Howard Leventhal, to explain and predict why individuals engage in preventive health behaviors, such as disease screening or vaccination, particularly when uptake was low for available interventions.^[1]^[2] The model emphasizes that health actions occur when individuals perceive a personal health threat as significant and believe that the recommended action will effectively reduce that threat without excessive barriers.^[1]^[3] At its core, the HBM comprises six key constructs that influence behavior: perceived susceptibility (one's belief about the risk of contracting a health condition), perceived severity (the seriousness of the condition and its consequences), perceived benefits (the effectiveness of the recommended action in reducing the threat), perceived barriers (the potential negative aspects or obstacles to taking action, such as cost or discomfort), cues to action (triggers that prompt behavior, like media campaigns or symptoms), and self-efficacy (confidence in one's ability to successfully perform the action), which was added later in the 1980s.^[1] These elements assume rational decision-making based on cognitive evaluations, where the likelihood of action increases when benefits outweigh barriers and susceptibility/severity are seen as high.^[3] The model has been foundational in health behavior research, originally applied to tuberculosis screening and smallpox vaccination efforts.^[1] The HBM has been widely used in health education and public health interventions to promote behaviors addressing chronic diseases, infectious outbreaks, and lifestyle risks, such as smoking cessation, mammography adherence, and COVID-19 preventive measures, though it has limitations including its focus on individual cognition over social, emotional, or environmental factors, and modest predictive power (typically 20–40% variance in behavior).^[1]^[3] Over decades, it has evolved through integrations with other theories, remaining influential due to its simplicity and applicability in tailoring messages to target populations.^[1]

Historical Development

Origins

The Health Belief Model (HBM) emerged in the early 1950s through the collaborative efforts of social psychologists Godfrey Hochbaum, Stephen Kegeles, Irwin Rosenstock, and Howard Leventhal, who were affiliated with the Behavioral Sciences Unit of the U.S. Public Health Service.^[1] This development occurred amid growing public health initiatives aimed at disease prevention following World War II, when infectious diseases like tuberculosis remained significant threats despite available interventions.^[4] The model's inception was driven by the need to explain low participation rates in free preventive health programs, particularly tuberculosis screening via chest X-rays and other immunization programs, which were promoted nationwide but often underutilized.^[1] Researchers observed that even when services were accessible and cost-free, many individuals declined to engage, prompting an investigation into the psychological and perceptual factors influencing such decisions.^[5] This focus addressed a critical gap in understanding voluntary health behaviors in asymptomatic populations during an era of expanding public health campaigns.^[6] The HBM drew key theoretical influences from value-expectancy theories, which posit that behavior arises from the anticipated value of outcomes weighted by the expectation of achieving them, and Kurt Lewin's field theory, emphasizing how individuals perceive their environment as a field of forces shaping action.^[7] These foundations were adapted to public health contexts to predict engagement in preventive actions based on personal beliefs about health threats and benefits.^[8] The model's first formal articulation appeared in Hochbaum's 1958 socio-psychological study on public participation in tuberculosis screening programs, which outlined core beliefs influencing uptake of early detection services.^[5] This work laid the groundwork for subsequent elaborations by Rosenstock and others, establishing the HBM as a foundational framework for health behavior research.^[1]

Evolution and Modifications

In the 1960s and 1970s, Irwin M. Rosenstock refined the Health Belief Model to address gaps in its original emphasis on perceived threat and benefits, incorporating cues to action and modifying variables as key components.^[1] Cues to action, added during this period, represent external or internal triggers—such as media campaigns or personal symptoms—that prompt individuals to translate readiness into actual health behaviors.^[1] Modifying variables, including demographic factors, knowledge levels, and socioeconomic status, were introduced to account for how these elements influence perceptions and decision-making processes within the model.^[1] A significant modification occurred in 1988 when Rosenstock, along with Victor J. Strecher and Marshall H. Becker, integrated self-efficacy as an independent construct, drawing directly from Albert Bandura's social cognitive theory.^[9] This addition aimed to explain not only the initiation but also the sustained performance of health actions, recognizing that individuals' confidence in their ability to execute recommended behaviors is crucial for long-term adherence.^[9] During the 1970s and 1980s, the model's applications shifted from a narrow focus on individual psychology to wider health promotion initiatives, paralleling the field's evolution toward community-oriented strategies as outlined in the 1986 Ottawa Charter for Health Promotion, which stressed enabling environments and policy support for behavioral change. In the 2020s, the Health Belief Model has undergone minor tweaks rather than major revisions, primarily through integrations with digital health tools; for instance, combining it with technology acceptance frameworks to enhance predictions of e-health adoption and personalized interventions. These adaptations maintain the model's core structure while addressing contemporary contexts like mobile apps and telehealth, without overhauling its foundational elements.

Theoretical Constructs

Perceived Susceptibility

Perceived susceptibility refers to an individual's subjective assessment of their personal vulnerability or risk of experiencing a health problem or negative health outcome, such as contracting a specific disease.^[1] This construct emphasizes the person's belief about the likelihood of the threat affecting them personally, rather than objective epidemiological probabilities.^[8] Within the Health Belief Model, perceived susceptibility forms one component of the broader "perceived threat" dimension, alongside perceived severity, motivating individuals to engage in protective health behaviors only if they believe the risk is personally relevant.^[8] Low levels of perceived susceptibility often result in inaction, as individuals may dismiss the need for preventive measures if they do not see themselves as at risk.^[1] This perception can be influenced by demographic factors, such as age or ethnicity, which modify how threats are evaluated.^[8] Perceived susceptibility interacts briefly with perceived severity to shape the overall sense of threat in the model.^[8] Measurement of perceived susceptibility typically involves self-report surveys using Likert scales to gauge beliefs about personal risk.^[8] For instance, respondents might rate agreement with statements like "My chances of getting breast cancer are high" on a 5-point scale ranging from "strongly disagree" to "strongly agree."^[8] Such scales allow for quantitative assessment of subjective vulnerability, often adapted to specific health contexts.^[1]

Perceived Severity

Perceived severity refers to an individual's subjective assessment of the seriousness of a health condition and its potential consequences, encompassing medical outcomes such as pain or death, as well as emotional aspects like fear and social repercussions including impacts on family or career.^[10]^[1] This construct, originally articulated in the Health Belief Model (HBM), emphasizes how personal evaluations of harm influence motivation beyond mere factual risks.^[3] In the HBM, perceived severity combines with perceived susceptibility to form an overall sense of threat, which heightens the urgency for preventive action when the acknowledged threat is significant.^[10]^[3] High perceived severity amplifies behavioral motivation by underscoring the stakes involved, though it interacts with evaluations of benefits and barriers to determine net action likelihood.^[1] This dynamic was foundational in early HBM formulations aimed at explaining participation in screening programs.^[11] Factors shaping perceived severity include objective medical information, such as mortality rates or disease progression data, alongside personal values that highlight losses like reduced family time due to illness.^[10]^[12] Individual differences in interpreting these elements, influenced by cultural or experiential contexts, lead to varied severity appraisals across populations.^[1] For instance, individuals who view cancer as severely disruptive—potentially causing financial insecurity or career setbacks—may be more inclined to pursue early screening behaviors like mammography.^[10] Similarly, heightened perceptions of COVID-19's severe outcomes, informed by morbidity statistics, have driven compliance with preventive measures in affected communities.^[1]

Perceived Benefits

Perceived benefits, a core construct of the Health Belief Model, refer to an individual's subjective assessment of the effectiveness of a recommended health action in reducing the risk or severity of a health threat.^[13] This belief focuses on the expected positive outcomes, such as improved health or avoidance of illness, rather than objective probabilities.^[1] In the model, perceived benefits serve as a key motivator for initiating health behaviors, as individuals weigh these anticipated gains against potential drawbacks to decide on action.^[8] Originating from early applications in preventive screening, this construct helps explain why people engage in actions like diagnostic tests when they believe such steps will effectively mitigate threats.^[13] For instance, in Godfrey Hochbaum's 1950s tuberculosis studies, individuals who perceived high benefits from early chest X-ray detection—such as preventing disease progression—were significantly more likely to participate, with 82% compliance among those holding strong beliefs in susceptibility and benefits compared to 21% without.^[13] Measurement of perceived benefits typically involves validated self-report scales using Likert-type items to capture beliefs about action efficacy.^[14] The Champion Health Belief Model Scales, widely used for breast cancer screening, include items like "Having a mammogram would decrease my chances of dying from breast cancer" and "Having a mammogram would help find breast lumps early," rated from strongly disagree to strongly agree, with reported reliability coefficients around 0.75.^[14] Similar approaches appear in scales for other behaviors, such as colorectal cancer screening, where items assess beliefs like "Finding colorectal cancer early will save your life."^[14] Representative examples illustrate its application: the perception that wearing face masks effectively reduces respiratory infection risk during pandemics promotes adherence, while beliefs in the benefits of tobacco cessation for lowering cardiovascular events drive quitting attempts.^[1] In dental health, Kegeles' studies showed that individuals perceiving strong benefits from preventive visits—such as avoiding pain and tooth loss—were more likely to follow through, highlighting the construct's influence on routine care.^[13]

Perceived Barriers

Perceived barriers in the Health Belief Model (HBM) refer to an individual's assessment of the potential negative consequences or obstacles associated with adopting a recommended health action, including factors such as cost, inconvenience, pain, or social stigma.^[15]^[8]^[1] These barriers represent the anticipated challenges that could deter behavior change, forming a core construct originally developed by social psychologists Godfrey Hochbaum, Irwin Rosenstock, and Stephen Kegeles in the 1950s at the U.S. Public Health Service.^[8] In the HBM, perceived barriers play a critical inhibitory role by subtracting from the perceived benefits of a health action, contributing to a net evaluation that determines the likelihood of inaction.^[1]^[8] High levels of perceived barriers can override even strong perceptions of susceptibility and severity, effectively blocking the motivation to act despite recognized health threats.^[15] This dynamic underscores how barriers influence decision-making, as individuals weigh potential downsides against advantages to assess overall feasibility.^[1] Perceived barriers can be categorized into tangible and intangible types. Tangible barriers involve concrete obstacles, such as financial costs (e.g., the expense of a gym membership) or logistical issues like time constraints that hinder adherence to a diet plan.^[15]^[8] Intangible barriers, by contrast, encompass psychological or social hurdles, including fear of pain (e.g., discomfort from needles during vaccination) or embarrassment associated with procedures like mammography screening.^[15]^[1] These distinctions highlight how both measurable and subjective factors can impede health behaviors, as evidenced in early HBM applications to compliance studies.^[15]

Cues to Action

In the Health Belief Model (HBM), cues to action refer to the triggers or stimuli that prompt individuals to initiate health-related behaviors when they already perceive a health threat and believe the benefits of action outweigh the barriers.^[2] These cues serve as catalysts, providing the necessary impetus to translate motivation into actual behavior, as readiness alone may not suffice without such instigators.^[1] Without cues to action, even favorable perceptions of susceptibility, severity, benefits, and barriers can fail to result in change.^[2] Cues to action are categorized into internal and external types. Internal cues arise from personal experiences, such as recognizing bodily symptoms or subjective sensations that signal a health issue.^[1] External cues originate from the environment, including interpersonal influences like advice from healthcare providers or encouragement from family, as well as broader societal factors like public service announcements.^[2] The intensity required for a cue to be effective varies depending on the level of perceived threat; higher threat perceptions lower the threshold for action.^[2] Examples of external cues include mass media campaigns highlighting disease outbreaks, reminder postcards from physicians, or newspaper articles on preventive measures, which have been shown to increase vaccination uptake during events like flu seasons.^[16] Internal cues might involve the onset of symptoms prompting a visit to a doctor, as observed in studies of SARS-like illnesses where symptomatic individuals were more likely to engage in protective behaviors such as handwashing.^[16] These cues can interact with modifying variables, such as prior knowledge, to amplify their impact on decision-making.^[1]

Self-Efficacy

Self-efficacy in the Health Belief Model (HBM) refers to an individual's confidence in their ability to successfully execute a recommended health behavior and overcome associated barriers, a concept borrowed from Albert Bandura's social cognitive theory.^[12] This construct emphasizes task-specific beliefs about personal capability, distinguishing it from general self-confidence by focusing on perceived competence in the face of challenges like stress or environmental obstacles.^[1] Self-efficacy was formally incorporated into the HBM in 1984 to address limitations in the model's original formulation, enhancing its explanatory power for not only the initiation but also the maintenance of health behaviors over time.^[12] In the model, high self-efficacy strengthens the intention to act by reinforcing the balance between perceived benefits and barriers, thereby supporting sustained adherence to preventive or therapeutic actions.^[17] For instance, it predicts persistence in behaviors such as smoking cessation, where individuals with stronger self-efficacy are more likely to resist relapse despite temptations.^[12] Self-efficacy is typically measured using self-report scales that assess confidence levels on a continuum, often through Likert-type items tailored to specific health tasks, such as "How confident are you that you can quit smoking even when under stress?"^[17] These instruments evaluate perceived ability across varying levels of difficulty, providing a nuanced gauge of motivational strength.^[7] In practical applications, high self-efficacy has been linked to improved outcomes in chronic disease management, exemplified by its role in promoting consistent blood sugar monitoring among individuals with diabetes, where stronger beliefs in personal capability correlate with better self-care adherence.^[18]

Modifying Variables

In the Health Belief Model (HBM), modifying variables refer to external factors such as demographics, knowledge, personality traits, and sociocultural influences that indirectly shape an individual's perceptions of health threats and actions.^[3] These variables do not directly predict health behaviors but instead moderate the interpretation of core HBM constructs, including perceived susceptibility, severity, benefits, and barriers, by providing contextual influences on motivation and decision-making.^[12] Demographic factors, such as age, gender, ethnicity, and socioeconomic status, play a key role in altering these perceptions; for instance, older adults may perceive higher severity of chronic conditions due to accumulated life experiences, while lower socioeconomic status can amplify barriers through limited access to resources.^[12] Knowledge levels, often tied to education, similarly modify perceptions by enhancing awareness; higher education has been shown to increase perceived susceptibility to conditions like breast cancer through greater understanding of risk factors, as evidenced in studies on preventive screening behaviors.^[12] Personality traits, including locus of control, further influence how individuals weigh benefits against barriers, with an internal locus promoting stronger beliefs in personal efficacy to mitigate health risks.^[12] Sociocultural factors, such as cultural beliefs and social norms, interact with the model by reshaping barrier perceptions; for example, in mental health contexts, cultural stigma surrounding treatment-seeking can heighten perceived barriers, deterring individuals from pursuing care despite recognized threats.^[19] These interactions underscore the model's recognition that modifying variables must be considered to tailor interventions effectively, as they can either reinforce or undermine the motivational impact of health beliefs.^[20]

Empirical Support

Key Studies and Findings

The Health Belief Model (HBM) originated from early research in the 1950s and 1960s aimed at understanding compliance with preventive health screenings, particularly chest X-ray programs for tuberculosis detection. Godfrey Hochbaum's seminal 1958 study examined over 1,200 adults across three U.S. cities and found that individuals who perceived themselves as personally susceptible to tuberculosis were significantly more likely to obtain free X-rays, with perceived vulnerability serving as the strongest predictor of participation among asymptomatic individuals. Irwin Rosenstock built on this work in the 1960s, conducting field studies that demonstrated how perceived threat—combining susceptibility and severity—was a key predictor of screening compliance, highlighting the model's utility in explaining why many eligible individuals ignored available preventive measures despite low barriers like free access. These foundational investigations established the HBM's core premise that personal threat appraisal drives health-protective actions in the absence of symptoms.^[11] In the 1970s, the HBM was extended to chronic disease screening, notably hypertension detection programs. Donald Haefner and James Kirscht's 1970 experimental study involved 166 participants and tested interventions to modify health beliefs; results showed that exposure to educational films enhancing perceptions of susceptibility to conditions like hypertension and benefits of early detection increased reports of medical checkups to 57% in the experimental group compared to 39% in controls, with belief changes directly correlating to behavioral uptake. This work illustrated the model's potential for intervention design, as targeted education on threat and benefits led to measurable improvements in preventive behavior. Similarly, 1990s research applied the HBM to emerging infectious disease threats like HIV/AIDS, focusing on behaviors such as condom use. A 1992 prospective study by John E. McCluskey on 195 sexually active adolescents revealed that higher perceived susceptibility to HIV and lower perceived barriers to condom use predicted consistent safer sex practices over six months, accounting for variance in risk reduction behaviors among this high-risk group.^[21]^[22] The HBM has also demonstrated predictive power in cancer screening uptake, such as mammography. Victoria Champion's 1984 study on 278 women used HBM constructs to assess breast self-examination frequency, finding that perceived benefits and low barriers explained 28% of the variance in regular performance, with susceptibility beliefs showing moderate correlations (r ≈ 0.30) to adherence. Extending to mammography, Champion's subsequent applications confirmed similar patterns, where HBM variables like susceptibility correlated with screening compliance at r = 0.25-0.40 across diverse samples, underscoring the model's relevance for promoting early detection in women's health. Overall, these key studies affirm the HBM's ability to predict variance in preventive behaviors through threat and outcome evaluations, providing a robust framework for health promotion.^[23]^[12]

Meta-Analyses and Efficacy

A seminal review by Janz and Becker in 1984 synthesized findings from 46 studies on the Health Belief Model (HBM), revealing that its core constructs—particularly perceived benefits, barriers, and susceptibility—were significant predictors of health behaviors in approximately 75% of the analyses, with perceived severity showing weaker associations.^[24] This quantitative synthesis highlighted the model's utility in explaining preventive actions, though it emphasized variability across study designs. Subsequent meta-analyses built on this foundation; for instance, Harrison, Mullen, and Green (1992) examined 16 studies involving adults and reported mean effect sizes (Pearson's r) ranging from 0.08 for perceived severity to 0.30 for perceived barriers, indicating small to moderate associations with behaviors such as screening and vaccination compliance.^[25] More recent quantitative reviews confirm the HBM's modest explanatory power. Carpenter's 2010 meta-analysis of 18 longitudinal studies (N=2,702) found that perceived benefits (r=0.21), barriers (r=-0.23), and self-efficacy (r=0.22) were the strongest predictors of subsequent health behaviors, while susceptibility (r=0.10) and severity (r=0.07) showed smaller effects, corresponding to moderate Cohen's d values around 0.30 for key constructs in preventive contexts. Overall, these meta-analyses demonstrate the HBM's strongest efficacy in predicting screening and vaccination behaviors, where constructs can account for up to 25-50% of variance in some aggregated findings, compared to weaker performance (typically under 15% variance) for sustained lifestyle changes like diet or exercise adherence.^[26] Bibliometric analyses underscore the model's enduring impact and evolving applications. A 2024 study analyzing over 5,900 publications from 1974 to 2023 reported more than 5,000 citations for foundational HBM works alone, with sustained publication growth peaking at 671 articles in 2022 and increasing integration into digital health interventions such as mHealth apps for behavior promotion.^[27] Despite this, evidence gaps persist, including a scarcity of longitudinal studies that track long-term behavior maintenance beyond initial predictions, limiting insights into the model's durability over time.

Applications

Public Health Campaigns

The Health Belief Model (HBM) guides the development of public health campaigns by structuring messages around individuals' perceptions of health threats and the efficacy of recommended actions, enabling broad-scale efforts to foster preventive behaviors. Campaigns leveraging HBM tailor communications to enhance perceived susceptibility and severity of diseases, highlight benefits of compliance, address barriers, incorporate cues to action such as media reminders, and build self-efficacy through practical demonstrations. This approach has been applied in diverse global initiatives to promote population-level adherence to health guidelines.^[28] In anti-smoking campaigns, HBM principles have informed efforts to emphasize the perceived severity of tobacco-related illnesses (e.g., heart disease and cancer) and the benefits of quitting (e.g., reduced risk and improved quality of life). Messages are designed to counter barriers like addiction through community education and cues such as public service announcements, resulting in heightened awareness and increased participation in cessation programs among adults.^[28] Design strategies in vaccination drives, such as the U.S. Centers for Disease Control and Prevention's (CDC) seasonal influenza vaccination campaign, have drawn on HBM to tailor messages that amplify perceived susceptibility to severe outcomes (e.g., hospitalization) and cues to action like targeted ads and community outreach, while minimizing barriers through accessible clinic information. These efforts aimed to boost vaccination rates by reinforcing self-efficacy in accessing shots.^[29] During the 2014-2016 Ebola outbreak in West Africa, theoretical applications of the HBM to behavior change by organizations including the World Health Organization have highlighted perceived susceptibility to community transmission and the severity of the virus's high mortality (approximately 55% case-fatality rate), promoting benefits of practices like handwashing and safe burials while addressing cultural barriers through trusted local leaders as cues to action.^[30] At a global scale, HBM has underpinned World Health Organization (WHO) programs for tuberculosis (TB) control, originally developed in the 1950s to explain TB screening uptake by stressing perceived susceptibility to exposure and the benefits of early detection via X-rays. Ongoing WHO initiatives, such as the End TB Strategy, align with HBM by using media cues and community mobilizers to overcome barriers like stigma, resulting in expanded screening and treatment adherence in high-burden countries.^[31]

Clinical and Individual Interventions

The Health Belief Model (HBM) has been widely applied in clinical settings to guide individualized interventions that target patients' perceptions of health threats, benefits, barriers, and self-efficacy, facilitating personalized behavior change plans in one-on-one therapeutic contexts. In primary care and specialized clinics, clinicians use HBM constructs to assess and address individual factors influencing health behaviors, such as adherence to treatment regimens or lifestyle modifications. These interventions often involve tailored counseling sessions that enhance patients' motivation by emphasizing perceived benefits while mitigating barriers, leading to improved health outcomes in chronic disease management.^[1] In diabetes self-management programs, HBM-based interventions focus on evaluating perceived barriers and self-efficacy to promote behaviors like blood glucose monitoring, diet adherence, and physical activity. For instance, a quasi-experimental study involving 70 patients with type 2 diabetes implemented four educational sessions centered on HBM constructs, resulting in a significant increase in self-care behavior scores from a mean of 31.44 to 49.20 (p < 0.001), alongside improvements in perceived susceptibility (from 14.94 to 22.46, p < 0.001), benefits (from 10.33 to 28.29, p = 0.032), and self-efficacy (from 28.36 to 36.31, p = 0.012). Similar programs in clinical settings have demonstrated sustained enhancements in self-care practices by addressing individual barriers, such as fear of complications or low confidence in managing the condition.^[32] Patient counseling strategies informed by the HBM aim to boost perceptions of benefits through targeted discussions and educational tools, particularly in weight loss clinics where clinicians help patients weigh the advantages of behavior change against personal barriers. In one such intervention targeting overweight Malaysian adults, a bilingual video-based program emphasized the emotional, physical, and social benefits of weight control, leading to significant gains in self-efficacy for dieting (mean score from 3.76 to 3.96, p = 0.003) and exercise (from 3.63 to 4.12, p < 0.001), as well as increased behavioral intentions for weight management. These approaches, often integrated into routine clinic visits, foster intrinsic motivation similar to techniques like motivational interviewing, enabling patients to develop actionable plans for sustained weight reduction.^[33]^[34] Outcomes from HBM-guided interventions in HIV care have shown notable improvements in medication adherence, particularly among younger patients where perceived benefits and self-efficacy play key roles. A 2007 study of 185 HIV-positive adults found that higher perceived treatment utility increased the odds of good adherence by 1.176 times per unit (95% CI: 1.06, 1.31), while greater self-efficacy raised odds by 1.330 times per unit (95% CI: 1.06, 1.67), with overall poor adherence at 68% among those under 50 years. These 2000s-era findings underscore how clinical interventions targeting HBM components can enhance uptake and persistence with antiretroviral therapy, reducing viral loads and improving long-term health.^[35]^[36] HBM-based questionnaires serve as practical tools in primary care to identify individual readiness for behavior change and inform customized plans. A validated 47-item instrument for prediabetic patients assesses constructs like perceived susceptibility, severity, benefits, barriers, self-efficacy, and cues to action, demonstrating high reliability (Cronbach’s alpha = 0.821) and content validity (CVI: 0.77–1.00), making it suitable for routine screening and intervention design in diabetes management. Such tools enable clinicians to quantify patients' beliefs and track progress, ensuring interventions are responsive to personal health perceptions.^[37]^[32]

Limitations and Criticisms

Theoretical Shortcomings

The Health Belief Model (HBM) has been critiqued for its foundational assumptions that prioritize individual cognition over broader contextual influences, leading to conceptual gaps in explaining health behaviors. Developed in the mid-20th century within a Western psychological framework, the model posits that personal perceptions of threat, benefits, barriers, and cues drive preventive actions, yet this individualistic orientation overlooks the role of social norms, environmental constraints, and interpersonal dynamics in shaping decisions.^[38] These theoretical shortcomings limit the model's explanatory power, particularly in diverse or complex behavioral scenarios.^[39] A primary limitation is the HBM's individualistic bias, which overemphasizes personal beliefs and attitudes while ignoring social norms and environmental factors. For instance, the model assumes health actions stem primarily from an individual's assessment of susceptibility and severity, but it fails to incorporate how community expectations or structural barriers, such as access to resources, influence behavior.^[38] This focus on isolated cognition neglects power relationships and social influences, rendering the model less applicable to behaviors embedded in relational or societal contexts.^[1] Critics argue that such oversight stems from the model's origins in U.S.-based public health research, where individual agency is presumed dominant.^[40] The model's static nature further compounds these issues by assuming rational, deliberate decision-making without accounting for habitual patterns, emotional responses, or evolving beliefs over time. HBM constructs like perceived benefits and barriers are treated as fixed predictors with additive effects, lacking defined interactions or mechanisms for change, which hinders its ability to model dynamic processes like habit formation or affective influences on motivation.^[41] This rigidity presumes a linear, cognitive pathway to action, disregarding how emotions or ingrained routines may override rational threat appraisals in everyday health choices. Another conceptual gap lies in the incomplete threat model, where perceived threat—combining susceptibility and severity—is deemed sufficient to prompt action, yet interpersonal influences and competing priorities are inadequately addressed. Research indicates that threat perception alone often correlates weakly with behavior, potentially leading to defensive avoidance rather than engagement, as it does not integrate social support or relational factors that mediate responses to health risks. The model's emphasis on a singular threat ignores multifaceted scenarios, such as behaviors involving multiple people or alternative risks, thus underestimating the need for broader motivational elements.^[40] Finally, the HBM exhibits cultural limitations, being inherently Western-centric and less effective in collectivist societies where group norms and interdependence prevail over individual perceptions. Originating from individualistic cultural contexts, the model struggles to predict behaviors in settings like Asia or Latin America, where social obligations and communal values significantly shape health decisions beyond personal threat assessments.^[42] For example, in collectivist environments, self-efficacy may be subordinated to family or community expectations, a dynamic the HBM does not formally incorporate, reducing its cross-cultural validity.^[43] Adaptations have been proposed for non-Western applications, but the core framework's bias toward autonomy limits its universal applicability.^[44]

Empirical and Practical Challenges

The measurement of constructs within the Health Belief Model (HBM) primarily depends on subjective self-report questionnaires, which are vulnerable to biases such as social desirability—where participants overreport positive beliefs to align with perceived social norms—and recall inaccuracies, potentially distorting the assessment of perceived susceptibility, severity, benefits, and barriers. ^[45] These issues are particularly pronounced in health behavior research, where self-reports often inflate adherence to recommended actions, leading to overestimation of the model's explanatory strength. ^[46] In diverse populations, HBM instruments may exhibit challenges in reliability due to linguistic, contextual, or interpretive differences, thus limiting the model's cross-cultural validity. ^[47] The HBM demonstrates limited predictive power, typically accounting for only 20-40% of the variance in preventive health behaviors, with substantially lower explanatory capacity for complex, multifaceted behaviors such as addiction or chronic disease management influenced by habitual, environmental, or addictive factors. ^[48] Seminal meta-analyses, including reviews of over 40 studies, confirm this modest utility, where core constructs like perceived barriers show the strongest associations (significance ratios >80%), yet overall effect sizes remain small (e.g., r ≈ 0.13-0.21), explaining minimal behavioral variance even in controlled settings. ^[12] ^[49] For instance, in applications to substance use prevention, the model lacks consistent predictive strength due to its narrow focus on cognitive beliefs, overlooking entrenched psychological dependencies. ^[50] Implementing the HBM in practical interventions faces significant hurdles, particularly with the cues to action construct, which is challenging to manipulate in real-time settings because it depends on unpredictable external triggers like media exposure or interpersonal prompts that cannot be standardized or controlled across participants. ^[1] Empirical reviews highlight that cues to action receive the least research attention and support, with low significance ratios (around 50%) in predictive studies, complicating their integration into scalable public health programs where consistent activation is essential for behavioral change. ^[12] Equity concerns arise from the HBM's individualistic orientation, which inadequately addresses access disparities and structural barriers, resulting in uneven intervention outcomes that disadvantage low-income, racial/ethnic minority, or underserved groups facing systemic obstacles like limited healthcare resources. ^[51] This oversight can exacerbate health inequities, as the model prioritizes personal perceptions over social determinants such as economic constraints or discrimination, leading to interventions that assume equal opportunity for action across populations. ^[52]

Extensions and Comparisons

Integrations with Other Models

The Health Belief Model (HBM) is frequently integrated with the Theory of Planned Behavior (TPB) to augment its emphasis on perceived threats and benefits with TPB's components of subjective norms, attitudes, and perceived behavioral control, thereby providing a more comprehensive framework for predicting health behaviors influenced by social and volitional factors.^[53] This hybrid model has been applied in various contexts, enhancing predictions by incorporating normative pressures.^[54] Similarly, HBM constructs are combined with the Transtheoretical Model (TTM) of stages of change, sequencing elements like perceived susceptibility and barriers across TTM's precontemplation, contemplation, preparation, action, and maintenance stages to tailor interventions to an individual's readiness for behavior change.^[55] Research demonstrates that HBM factors vary systematically by stage; for instance, perceived benefits and self-efficacy are stronger predictors in later stages like action and maintenance, facilitating stage-matched strategies for behavior adoption.^[55] In chronic disease management, integrated HBM-TTM frameworks have been applied in studies to promote exercise adoption by addressing readiness alongside threat perceptions. These combinations yield benefits like improved explanatory power.^[54]

Recent Adaptations

In recent years, the Health Belief Model (HBM) has been adapted to incorporate digital health technologies, particularly mobile health (mHealth) applications that track and enhance self-efficacy in managing health behaviors. A 2020 conceptual framework integrated HBM with technological self-efficacy, adding constructs such as perceived technological benefits and barriers to explain how users' beliefs about digital tools influence adoption for self-tracking and behavior change in sustainable smart health initiatives.^[56] This adaptation emphasizes self-efficacy as a dynamic element monitored through apps, enabling real-time feedback to bolster users' confidence in overcoming health challenges. For instance, in mental health contexts during the 2020s, mHealth apps have leveraged HBM to personalize interventions, where perceived susceptibility to mental health issues is assessed via user inputs, and self-efficacy is built through gamified tracking features that reduce barriers like stigma or access limitations.^[57] The COVID-19 pandemic prompted significant updates to HBM for addressing misinformation and utilizing social media as cues to action, particularly in studies from 2020 to 2023. Researchers analyzed health department tweets across countries like the United States, South Korea, and the United Kingdom, finding that HBM-guided messaging emphasizing cues—such as reminders for masking or vaccination—significantly increased engagement metrics like retweets and likes, adapting the model to counter misinformation by framing perceived benefits against false narratives.^[58] These adaptations extended HBM's cues construct to digital platforms, where social media algorithms amplify timely prompts to mitigate barriers like doubt in vaccine efficacy, as seen in content analyses of vaccine-related posts that linked misinformation exposure to altered perceived severity. By 2023, such modifications proved effective in promoting preventive behaviors, with HBM predicting compliance even amid rampant online falsehoods about COVID-19 transmission.^[59] To enhance inclusivity, recent HBM adaptations have incorporated equity factors for underserved groups, focusing on structural barriers in vaccine hesitancy among racial and ethnic minorities. A 2023 study applied HBM to survey racial minorities, revealing that lower trust in public health guidelines—mediated by perceived severity and benefits—exacerbated hesitancy, yet these groups often took more actions when equity-focused cues addressed historical mistrust.^[60] Building on this, 2024 research on rural, medically underserved populations used HBM to identify cultural and access-related barriers, adapting the model to include socioeconomic modifiers that tailor interventions for minorities, such as community-based cues to improve perceived benefits of vaccination.^[61] These enhancements prioritize equity by integrating social determinants into core HBM constructs, ensuring the model accounts for disparities in perceived susceptibility among marginalized communities. Emerging trends in HBM adaptations involve AI-driven personalization for assessing and addressing barriers, particularly in predictive health tools. A 2022 experimental study integrated HBM into AI chatbots, demonstrating that personalized responses—tailored to users' perceived benefits, self-efficacy, and barriers—increased intention to use health services when combined with source expertise, effectively customizing barrier evaluations through natural language processing.^[62] By 2024, AI models leveraging HBM predicted vaccine hesitancy among healthcare providers by analyzing open-text responses for constructs like perceived barriers, enabling targeted interventions that adapt the model to individual risk profiles and reduce generalized assumptions.^[63] These AI enhancements represent a shift toward dynamic, data-informed applications of HBM, focusing on scalable personalization to overcome traditional limitations in barrier assessment.

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Health Belief Model (HBM). During the early 1950s a variety of health screening (e.g., tuberculosis and pap smear) and preventive care services (e.g. ...
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The health belief model - Cambridge Handbook of Psychology ...
Rosenstock (1974) attributed the first health belief model (HBM) research to ... Journal of Health and Social Behaviour, 20, 397–406.Google Scholar.
[6]
Godfrey H. Hochbaum (1916–1999): From Social Psychology ... - NIH
He is most noted for the development of and research surrounding the Health Belief Model (HBM), one of the most widely used models for understanding health ...
[7]
The Health Belief Model - Rural Health Promotion and Disease ...
Mar 7, 2025 · Key elements of the Health Belief Model focus on individual beliefs about health conditions, which predict individual health-related behaviors.<|control11|><|separator|>
[8]
Health Behavior and Health Education | Part Two, Chapter Three
The Health Belief Model (HBM) was developed in the 1950's by social psychologists Hochbaum, Rosenstock and others, who were working in the U.S. Public Health ...
[9]
Social Learning Theory and the Health Belief Model - Sage Journals
Strecher VJ, DeVellis BM, Becker MH, Rosenstock IM: The role of self-efficacy in achieving health behavior change, Health Education Quarterly, 13; 73-92, 1986.
[10]
The health belief model predicts vaccination intentions against ...
Perceived susceptibility. It consists of two levels: high (+1) and low (−1). The perceived personal risk of getting infected with the COVID‐19 virus ...
[11]
Perceived Severity | Division of Cancer Control and Population ...
Health Belief Model. The Health Belief Model (HBM) (Hochbaum, 1958) was developed to understand the uptake of prevention and early detection behaviours, such as ...Missing: formal | Show results with:formal
[12]
[PDF] PUBLIC PARTICIPATION IN MEDICAL SCREENING PROGRAMS A ...
In the absence of noticeable symptoms, accepting the possibility of having contracted tuberculosis depends upon an additional belief: that the absence of such ...Missing: Model | Show results with:Model
[13]
The Health Belief Model: A Decade Later - Sage Journals
While both were important overall, "perceived sus ceptibility" was a stronger contributor to understanding PHB than SRB, while the reverse was true for " ...
[14]
Why People Use Health Services - ROSENSTOCK - 2005
Nov 18, 2005 · He tapped beliefs in susceptibility to tuberculosis and beliefs in the benefits of early detection. Perceived susceptibility to tuberculosis ...<|control11|><|separator|>
[15]
Perceived Benefits | Division of Cancer Control and Population ...
The construct of perceived benefits is defined as beliefs about the positive outcomes associated with a behavior in response to a real or perceived threat.General Description... · Similar Constructs · Measurement and... · Conclusion
[16]
Perceived Barriers to Self-Management and Preventive Behaviors
Barriers are a central part of many theories of health behavior. The health belief model (HBM) was one of the earliest to prominently feature perceived barriers ...
[17]
https://cancercontrol.cancer.gov/sites/default/files/2020-06/self-efficacy.pdf
[18]
[PDF] Self-Efficacy and Health Behavior Theories
Self-efficacy beliefs are cognitions that determine whether health behavior change will be initiated, how much effort will be expended, and how long it will be ...
[19]
The Association Between Health Belief Model Components and Self ...
Self-efficacy, or the belief in one's ability to perform diabetes management tasks successfully, was the most robust predictor of self-care behaviors. These ...
[20]
Pathways from health beliefs to treatment utilization for severe ...
Oct 7, 2020 · Perceived barriers were assessed by perceived mental health treatment stigma and by failure to perceive the significant threat of severe ...
[21]
The impact of health information and cultural factors on immigrant ...
The health belief model (HBM) has been a widely utilized framework in immigrant behavioral health research for predicting improvements in health-related ...
[22]
Motivational and behavioral effects of modifying health beliefs
Motivational and behavioral effects of modifying health beliefs. ... 1970 Jun;85(6):478-84. Authors. D P Haefner, J P Kirscht. PMID: 4987767; PMCID ...Missing: hypertension Model
[23]
AIDS, Adolescents, and Sexual Risk Taking: A Test of the Health ...
This study investigated the validity of the Health Belief Model when applied to adolescents' responses to the threat of AIDS. A sample of 195 sexually ...
[24]
Use of the health belief model in determining frequency of breast ...
The purpose of this research was to identify the relationships of attitudes about breast self-examination and breast cancer to the frequency of breast ...Missing: mammography | Show results with:mammography
[25]
The Health Belief Model: a decade later - PubMed
This article presents a critical review of 29 HBM-related investigations published during the period of 1974-1984, tabulates the findings from 17 studies ...
[26]
A meta-analysis of studies of the Health Belief Model with adults
We conducted a meta-analysis of the relationships between four HBM dimensions (Susceptibility, Severity, Benefits and Costs) and health behavior on 16 studies.Missing: 2015 | Show results with:2015
[27]
The Health Belief Model as an Explanatory Framework in ...
The Health Belief Model (HBM) posits that messages will achieve optimal behavior change if they successfully target perceived barriers, benefits, self-efficacy, ...
[28]
Behavior Change Theories and Models Within Health Belief Model ...
Jun 25, 2024 · This study aims to provide a comprehensive bibliometric analysis of the HBM research landscape to reveal its evolving trends and impact.
[29]
[PDF] Theory at a Glance: Application to Health Promotion and Health ...
The Health Belief Model (HBM) addresses the individual's perceptions of the threat posed by a health problem (susceptibility, severity), the benefits of ...<|control11|><|separator|>
[30]
The Health Belief Model as an Explanatory ... - CDC Stacks
The Health Belief Model (HBM) posits that messages will achieve optimal behavior change if they successfully target perceived barriers, benefits, self-efficacy, ...
[31]
New targets for behaviour change in Ebola outbreaks
Beside the original health belief model, other health theories have been developed to provide a foundation for behaviour change; some include the social ...Background On Ebola · More Psychosocial Response... · Importance Of Theory For...
[32]
Health Belief Model - an overview | ScienceDirect Topics
The health belief model is a psychological model that attempts to explain and predict health behaviors by focusing on the attitudes and beliefs of individuals.
[33]
Effect of educational intervention based on the Health Belief Model ...
The HBM Model about type 2 diabetes patients' self-care problems has been considered in the variety of studies (17, 20–21).
[34]
Health Belief Model: Self-care among diabetes patients. | DMSO
May 13, 2021 · This study aimed at assessing the use of the health belief model to describe self-care practices among patients with diabetes.
[35]
Assessing the effectiveness of health belief model-based ... - Nature
Oct 28, 2024 · The Health Belief Model (HBM) is a health-specific social cognition model that predicts the reasons for change or maintain specific behaviour ...
[36]
Health Belief Model Offers Opportunities for Designing Weight ...
The Health Belief Model (HBM) is a conceptual framework that identifies perceptions reflecting the extent to which people are willing to adopt health-protective ...Missing: counseling boost loss
[37]
Age-Associated Predictors of Medication Adherence in HIV-Positive ...
These data support components of the health beliefs model in predicting medication adherence among younger HIV-positive individuals. However, risk of adherence ...
[38]
Factors Influencing Medication Adherence Beliefs and Self-Efficacy ...
(2000). The relationship of disease severity, health beliefs and medication adherence among HIV patients. AIDS Care, 12, 387-398. Google Scholar. Gordillo, V ...Missing: studies | Show results with:studies
[39]
Validity and reliability of the health belief model questionnaire for ...
Feb 28, 2025 · The HBM questionnaire was found to be valid and reliable for assessing behavior about dietary patterns and physical activity in prediabetic.
[40]
https://doi.org/10.1080/10410236.2010.521906
[41]
https://doi.org/10.1177/109019818401100101
[42]
https://doi.org/10.3389/fpsyg.2021.627575
[43]
https://doi.org/10.1037/0033-295X.98.2.224
[44]
https://doi.org/10.1093/pubmed/fdy057
[45]
https://pmc.ncbi.nlm.nih.gov/articles/PMC5639921/
[46]
https://www.sciencedirect.com/science/article/pii/S235282731830346X
[47]
Lies, Damned Lies, and Survey Self-Reports? Identity as a Cause of ...
Nov 18, 2016 · We offer an alternative explanation rooted in identity theory that focuses on measurement directiveness as a cause of bias.
[48]
Biases in self-reported height and weight measurements and their ...
Self-reported anthropometrics are often used as proxies for measured anthropometrics, but research has shown that heights and weights are often misreported.
[49]
Psychometric validation of a culturally adapted health belief model ...
This study aimed to validate a culturally adapted Health Belief Model (HBM) questionnaire for assessing breast cancer screening beliefs among Chinese women ...
[50]
The Health Belief Model of Behavior Change | Point of Care
May 19, 2024 · The main contributors to the development of the model were Irwin M. Rosenstock, Godfrey M. Hochbaum, S. Stephen Kegels, and Howard Leventhal.Missing: origins Kegeles<|control11|><|separator|>
[51]
A meta-analysis of the effectiveness of health belief model variables ...
The Health Belief Model (HBM; Rosenstock, 1966) was constructed to explain which beliefs should be targeted in communication campaigns to cause positive health ...Missing: variance | Show results with:variance
[52]
Health belief model: Need for more utilization in alcohol and drug ...
Aug 9, 2025 · They concluded that the model lacked consistent predictive power mainly because it focuses on a limited number of factors. Cultural factors ...
[53]
Using the health belief model to assess racial/ethnic disparities in ...
This analysis presents a better understanding of how HBM factors may influence health disparities in the cancer center's catchment area.
[54]
Advancing Racial Equity in U.S. Health Care - Commonwealth Fund
Apr 18, 2024 · This report evaluates disparities in health and health care across racial and ethnic groups, both within states and between U.S. states.
[55]
An integration of the Health Belief Model and the Theory of Planned ...
Mar 9, 2021 · This instrument may help health care providers understand beliefs in physical activity and facilitate targeted interventions among (pre)frail older adults.
[56]
Transtheoretical Model (Stages of Change) and Health Belief Model
The transtheoretical model and the health belief model are valuable for understanding hearing health behaviors and can be applied when developing interventions ...
[57]
[PDF] Association of Health Belief Model Constructs with Stages of ...
The efficacy of physical activity in the prevention of osteoporosis has been proven based on the transtheoretical model. ... constructs across the stages of ...<|control11|><|separator|>
[58]
The effects of a transtheoretical model-based exercise stage ...
Aug 8, 2025 · Conclusion The transtheoretical model-based ESMI had significantly positive effects on the exercise behavior of sedentary CHD patients. Practice ...
[59]
An integration of the Health Belief Model and the Theory of Planned ...
... integration of the Health Belief Model and the Theory of Planned Behavior ... explanatory power increases by 3.6% when DN is taken into account. Model 3 ...
[60]
The health belief model and theory of planned behavior applied to ...
Nov 30, 2020 · The Health Belief Model (HBM) and the Theory of Planned Behavior (TPB) are used to explain screening behavior.Missing: integration | Show results with:integration
[61]
https://pmc.ncbi.nlm.nih.gov/articles/PMC12300449/
[62]
Integrating Technology Acceptance and Health Belief Models for ...
Nov 23, 2023 · This study explores the link between health belief model (HBM) and technology acceptance model (TAM) factors.Missing: TTM | Show results with:TTM
[63]
https://www.mdpi.com/2076-328X/14/3/217
[64]
Prevalence of Health Misinformation on Social Media—Challenges ...
Aug 19, 2024 · Associations between COVID-19 misinformation exposure and belief with COVID-19 knowledge and preventive behaviors: cross-sectional online study.
[65]
https://doi.org/10.1371/journal.pgph.0003871
[66]
Exploring Vaccine Hesitancy, Structural Barriers, and Trust in ... - NIH
The purpose of this study is to understand vaccine hesitancy among racially and ethnically diverse and medically underserved rural populations, to assess ...
[67]
https://doi.org/10.1177/20552076221129718