Health belief model

Last updated

The health belief model (HBM) is a social psychological health behavior change model developed to explain and predict health-related behaviors, particularly in regard to the uptake of health services. [1] [2] The HBM was developed in the 1950s by social psychologists at the U.S. Public Health Service [2] [3] and remains one of the best known and most widely used theories in health behavior research. [4] [5] The HBM suggests that people's beliefs about health problems, perceived benefits of action and barriers to action, and self-efficacy explain engagement (or lack of engagement) in health-promoting behavior. [2] [3] A stimulus, or cue to action, must also be present in order to trigger the health-promoting behavior. [2] [3]

Contents

The health belief model Xin Jian Xiang Mu .jpg
The health belief model

History

One of the first theories of health behavior, [5] the HBM was developed in the 1950s by social psychologists Irwin M. Rosenstock, Godfrey M. Hochbaum, S. Stephen Kegeles, and Howard Leventhal at the U.S. Public Health Service. [4] [6] At that time, researchers and health practitioners were worried because few people were getting screened for tuberculosis(TB), even if mobile X-ray cars went to neighborhoods. [7] The HBM has been applied to predict a wide variety of health-related behaviors such as being screened for the early detection of asymptomatic diseases [2] and receiving immunizations. [2] More recently, the model has been applied to understand patients' responses to symptoms of disease, [2] compliance with medical regimens, [2] lifestyle behaviors (e.g., sexual risk behaviors), [6] and behaviors related to chronic illnesses, [2] which may require long-term behavior maintenance in addition to initial behavior change. [2] Amendments to the model were made as late as 1988 to incorporate emerging evidence within the field of psychology about the role of self-efficacy in decision-making and behavior. [5] [6]

Theoretical constructs

The HBM theoretical constructs originate from theories in Cognitive Psychology. [7] In early twentieth century, cognitive theorists believed that reinforcements operated by affecting expectations rather than by affecting behavior straightly. [8] Mental processes are severe constitutes of cognitive theories that are seen as expectancy-value models, because they propose that behavior is a function of the degree to which people value a result and their evaluation of the expectation, that a certain action will lead that result. [9] [10] In terms of the health-related behaviors, the value is avoiding sickness. The expectation is that a certain health action could prevent the condition for which people consider they might be at risk. [7]

The following constructs of the HBM are proposed to vary between individuals and predict engagement in health-related behaviors. [2]

Perceived susceptibility

Perceived susceptibility refers to subjective assessment of risk of developing a health problem. [2] [3] [6] The HBM predicts that individuals who perceive that they are susceptible to a particular health problem will engage in behaviors to reduce their risk of developing the health problem. [3] Individuals with low perceived susceptibility may deny that they are at risk for contracting a particular illness. [3] Others may acknowledge the possibility that they could develop the illness, but believe it is unlikely. [3] Individuals who believe they are at low risk of developing an illness are more likely to engage in unhealthy, or risky, behaviors. Individuals who perceive a high risk that they will be personally affected by a particular health problem are more likely to engage in behaviors to decrease their risk of developing the condition.

The combination of perceived severity and perceived susceptibility is referred to as perceived threat. [6] Perceived severity and perceived susceptibility to a given health condition depend on knowledge about the condition. [3] The HBM predicts that higher perceived threat leads to a higher likelihood of engagement in health-promoting behaviors.

Perceived severity

Perceived severity refers to the subjective assessment of the severity of a health problem and its potential consequences. [2] [6] The HBM proposes that individuals who perceive a given health problem as serious are more likely to engage in behaviors to prevent the health problem from occurring (or reduce its severity). Perceived seriousness encompasses beliefs about the disease itself (e.g., whether it is life-threatening or may cause disability or pain) as well as broader impacts of the disease on functioning in work and social roles. [2] [3] [6] For instance, an individual may perceive that influenza is not medically serious, but if he or she perceives that there would be serious financial consequences as a result of being absent from work for several days, then he or she may perceive influenza to be a particularly serious condition.

Perceived benefits

Health-related behaviors are also influenced by the perceived benefits of taking action. [6] Perceived benefits refer to an individual's assessment of the value or efficacy of engaging in a health-promoting behavior to decrease risk of disease. [2] If an individual believes that a particular action will reduce susceptibility to a health problem or decrease its seriousness, then he or she is likely to engage in that behavior regardless of objective facts regarding the effectiveness of the action. [3] For example, individuals who believe that wearing sunscreen prevents skin cancer are more likely to wear sunscreen than individuals who believe that wearing sunscreen will not prevent the occurrence of skin cancer.

Perceived barriers

Health-related behaviors are also a function of perceived barriers to taking action. [6] Perceived barriers refer to an individual's assessment of the obstacles to behavior change. [2] Even if an individual perceives a health condition as threatening and believes that a particular action will effectively reduce the threat, barriers may prevent engagement in the health-promoting behavior. In other words, the perceived benefits must outweigh the perceived barriers in order for behavior change to occur. [2] [6] Perceived barriers to taking action include the perceived inconvenience, expense, danger (e.g., side effects of a medical procedure) and discomfort (e.g., pain, emotional upset) involved in engaging in the behavior. [3] For instance, lack of access to affordable health care and the perception that a flu vaccine shot will cause significant pain may act as barriers to receiving the flu vaccine. In a study about the breast and cervical cancer screening among Hispanic women, perceived barriers, like fear of cancer, embarrassment, fatalistic views of cancer and language, was proved to impede screening. [11]

Modifying variables

Individual characteristics, including demographic, psychosocial, and structural variables, can affect perceptions (i.e., perceived seriousness, susceptibility, benefits, and barriers) of health-related behaviors. [3] Demographic variables include age, sex, race, ethnicity, and education, among others. [3] [6] Psychosocial variables include personality, social class, and peer and reference group pressure, among others. [3] Structural variables include knowledge about a given disease and prior contact with the disease, among other factors. [3] The HBM suggests that modifying variables affect health-related behaviors indirectly by affecting perceived seriousness, susceptibility, benefits, and barriers. [3] [6]

Cues to action

The HBM posits that a cue, or trigger, is necessary for prompting engagement in health-promoting behaviors. [2] [3] [4] Cues to action can be internal or external. [2] [4] Physiological cues (e.g., pain, symptoms) are an example of internal cues to action. [2] [6] External cues include events or information from close others, [2] the media, [4] or health care providers [2] promoting engagement in health-related behaviors. Examples of cues to action include a reminder postcard from a dentist, the illness of a friend or family member, and product health warning labels. The intensity of cues needed to prompt action varies between individuals by perceived susceptibility, seriousness, benefits, and barriers. [3] For example, individuals who believe they are at high risk for a serious illness and who have an established relationship with a primary care doctor may be easily persuaded to get screened for the illness after seeing a public service announcement, whereas individuals who believe they are at low risk for the same illness and also do not have reliable access to health care may require more intense external cues in order to get screened.

Self-efficacy

Self-efficacy was added to the four components of the HBM (i.e., perceived susceptibility, severity, benefits, and barriers) in 1988. [6] [12] Self-efficacy refers to an individual's perception of his or her competence to successfully perform a behavior. [6] Self-efficacy was added to the HBM in an attempt to better explain individual differences in health behaviors. [12] The model was originally developed in order to explain engagement in one-time health-related behaviors such as being screened for cancer or receiving an immunization. [3] [12] Eventually, the HBM was applied to more substantial, long-term behavior change such as diet modification, exercise, and smoking. [12] Developers of the model recognized that confidence in one's ability to effect change in outcomes (i.e., self-efficacy) was a key component of health behavior change. [6] [12] For example, Schmiege et al. found that when dealing with calcium consumption and weight-bearing exercises, self-efficacy was a more powerful predictors than beliefs about future negative health outcomes. [13]

Rosenstock et al. argued that self-efficacy could be added to the other HBM constructs without elaboration of the model's theoretical structure. [12] However, this was considered short-sighted because related studies indicated that key HBM constructs have indirect effects on behavior as a result of their effect on perceived control and intention, which might be regarded as more proximal factors of action. [14]

Empirical support

The HBM has gained substantial empirical support since its development in the 1950s. [2] [4] It remains one of the most widely used and well-tested models for explaining and predicting health-related behavior. [4] A 1984 review of 18 prospective and 28 retrospective studies suggests that the evidence for each component of the HBMl is strong. [2] The review reports that empirical support for the HBM is particularly notable given the diverse populations, health conditions, and health-related behaviors examined and the various study designs and assessment strategies used to evaluate the model. [2] A more recent meta-analysis found strong support for perceived benefits and perceived barriers predicting health-related behaviors, but weak evidence for the predictive power of perceived seriousness and perceived susceptibility. [4] The authors of the meta-analysis suggest that examination of potential moderated and mediated relationships between components of the model is warranted. [4]

Several studies have provided empirical support from the chronic illness perspective. Becker et al. used the model to predict and explain a mother’s adherence to a diet prescribed for their obese children. [15] Cerkoney et al. interviewed insulin-treated diabetic individuals after diabetic classes at a community hospital. It empirically tested the HBM's association with the compliance levels of persons chronically ill with diabetes mellitus. [16]

Applications

The HBM has been used to develop effective interventions to change health-related behaviors by targeting various aspects of the model's key constructs. [4] [12] Interventions based on the HBM may aim to increase perceived susceptibility to and perceived seriousness of a health condition by providing education about prevalence and incidence of disease, individualized estimates of risk, and information about the consequences of disease (e.g., medical, financial, and social consequences). [6] Interventions may also aim to alter the cost-benefit analysis of engaging in a health-promoting behavior (i.e., increasing perceived benefits and decreasing perceived barriers) by providing information about the efficacy of various behaviors to reduce risk of disease, identifying common perceived barriers, providing incentives to engage in health-promoting behaviors, and engaging social support or other resources to encourage health-promoting behaviors. [6] Furthermore, interventions based on the HBM may provide cues to action to remind and encourage individuals to engage in health-promoting behaviors. [6] Interventions may also aim to boost self-efficacy by providing training in specific health-promoting behaviors, [6] [12] particularly for complex lifestyle changes (e.g., changing diet or physical activity, adhering to a complicated medication regimen). [12] Interventions can be aimed at the individual level (i.e., working one-on-one with individuals to increase engagement in health-related behaviors) or the societal level (e.g., through legislation, changes to the physical environment). [17]

Limitations

The HBM attempts to predict health-related behaviors by accounting for individual differences in beliefs and attitudes. [2] However, it does not account for other factors that influence health behaviors. [2] For instance, habitual health-related behaviors (e.g., smoking, seatbelt buckling) may become relatively independent of conscious health-related decision making processes. [2] Additionally, individuals engage in some health-related behaviors for reasons unrelated to health (e.g., exercising for aesthetic reasons). [2] Environmental factors outside an individual's control may prevent engagement in desired behaviors. [2] For example, an individual living in a dangerous neighborhood may be unable to go for a jog outdoors due to safety concerns. Furthermore, the HBM does not consider the impact of emotions on health-related behavior. [6] Evidence suggests that fear may be a key factor in predicting health-related behavior. [6]

Alternative factors may predict health behavior, such as outcome expectancy [18] (i.e., whether the person feels they will be healthier as a result of their behavior) and self-efficacy [19] (i.e., the person’s belief in their ability to carry out preventive behavior).

The theoretical constructs that constitute the HBM are broadly defined. [4] Furthermore, the HBM does not specify how constructs of the model interact with one another. [4] [6] Therefore, different operationalizations of the theoretical constructs may not be strictly comparable across studies. [6] [20]

Research assessing the contribution of cues to action in predicting health-related behaviors is limited. [2] [3] [4] [6] Cues to action are often difficult to assess, limiting research in this area. [3] [6] For instance, individuals may not accurately report cues that prompted behavior change. [3] Cues such as a public service announcement on television or on a billboard may be fleeting and individuals may not be aware of their significance in prompting them to engage in a health-related behavior. [3] [6] Interpersonal influences are also particularly difficult to measure as cues. [3]

Scholars extend the HBM by adding four more variables (self-identity, perceived importance, consideration of future consequences and concern for appearance as possible determinants of healthy behavior). They prove that consideration of future consequences, self-identity, concern for appearance, perceived importance, self-efficacy, perceived susceptibility are significant determinants of healthy eating behavior that can be manipulated by healthy eating intervention design. [21]

Related Research Articles

Behavior or behaviour is the actions and mannerisms made by individuals, organisms, systems or artificial entities in conjunction with themselves or their environment, which includes the other systems or organisms around as well as the (inanimate) physical environment. It is the computed response of the system or organism to various stimuli or inputs, whether internal or external, conscious or subconscious, overt or covert, and voluntary or involuntary.

Behavior change, in context of public health, refers to efforts put in place to change people's personal habits and attitudes, to prevent disease. Behavior change in public health is also known as social and behavior change communication (SBCC). More and more, efforts focus on prevention of disease to save healthcare care costs. This is particularly important in low and middle income countries, such as Ghana, where health interventions have come under increased scrutiny because of the cost.

Theory of planned behavior in psychology, a theory that links ones beliefs and behavior

In psychology, the theory of planned behaviour is a theory that links one's beliefs and behaviour.

Transtheoretical model integrative theory of therapy that assesses an individuals readiness to act on a new healthier behavior, and provides strategies, or processes of change to guide the individua

The transtheoretical model of behavior change is an integrative theory of therapy that assesses an individual's readiness to act on a new healthier behavior, and provides strategies, or processes of change to guide the individual. The model is composed of constructs such as: stages of change, processes of change, levels of change, self-efficacy, and decisional balance.

Self-efficacy is, according to psychologist Albert Bandura who originally proposed the concept, a personal judgment of "how well one can execute courses of action required to deal with prospective situations".

Self-care necessary human regulatory function which is under individual control, deliberate and self-initiated

In health care, self-care is any necessary human regulatory function which is under individual control, deliberate and self-initiated.

Social cognitive theory (SCT), used in psychology, education, and communication, holds that portions of an individual's knowledge acquisition can be directly related to observing others within the context of social interactions, experiences, and outside media influences. This theory was advanced by Albert Bandura as an extension of his social learning theory. The theory states that when people observe a model performing a behavior and the consequences of that behavior, they remember the sequence of events and use this information to guide subsequent behaviors. Observing a model can also prompt the viewer to engage in behavior they already learned. In other words, people do not learn new behaviors solely by trying them and either succeeding or failing, but rather, the survival of humanity is dependent upon the replication of the actions of others. Depending on whether people are rewarded or punished for their behavior and the outcome of the behavior, the observer may choose to replicate behavior modeled. Media provides models for a vast array of people in many different environmental settings.

Behavioural change theories are attempts to explain why behaviours change. These theories cite environmental, personal, and behavioural characteristics as the major factors in behavioural determination. In recent years, there has been increased interest in the application of these theories in the areas of health, education, criminology, energy and international development with the hope that understanding behavioural change will improve the services offered in these areas. Some scholars have recently introduced a distinction between models of behavior and theories of change. Whereas models of behavior are more diagnostic and geared towards understanding the psychological factors that explain or predict a specific behavior, theories of change are more process-oriented and generally aimed at changing a given behavior. Thus, from this perspective, understanding and changing behavior are two separate but complementary lines of scientific investigation.

Fear appeal is a term used in psychology, sociology and marketing. It generally describes a strategy for motivating people to take a particular action, endorse a particular policy, or buy a particular product, by arousing fear. A well-known example in television advertising was a commercial employing the musical jingle: "Never pick up a stranger, pick up Prestone anti-freeze." This was accompanied by images of shadowy strangers (hitchhikers) who would presumably do one harm if picked up. The commercial's main appeal was not to the positive features of Prestone anti-freeze, but to the fear of what a "strange" brand might do.

Economic epidemiology is a field at the intersection of epidemiology and economics. Its premise is to incorporate incentives for healthy behavior and their attendant behavioral responses into an epidemiological context to better understand how diseases are transmitted. This framework should help improve policy responses to epidemic diseases by giving policymakers and health-care providers clear tools for thinking about how certain actions can influence the spread of disease transmission.

The extended parallel process model (EPPM) is a framework developed by Kim Witte which attempts to predict how individuals will react when confronted with fear inducing stimuli. It was first published in Communication Monographs, Volume 59, December 1992; Witte subsequently published an initial test of the model in a later article published in Communication Monographs Volume 61, June 1994.

In psychology, the I-change model or the Integrated Model, for explaining motivational and behavioral change, derives from the Attitude – Social Influence – Self-Efficacy Model, integrates ideas of Ajzen's Theory of Planned Behavior, Bandura's Social Cognitive Theory, Prochaska's Transtheoretical Model, the Health Belief Model, and Goal setting theories. Previous versions of this model have been used to explain a variety of types of health behavior.

Health action process approach Theory of health behavior change

The health action process approach (HAPA) is a psychological theory of health behavior change, developed by Ralf Schwarzer, Professor of Psychology at the Free University of Berlin, Germany.

Protection motivation theory is a theory that was originally created to help clarify fear appeals. The protection motivation theory proposes that people protect themselves based on four factors: the perceived severity of a threatening event, the perceived probability of the occurrence, or vulnerability, the efficacy of the recommended preventive behavior, and the perceived self efficacy. Protection motivation stems from both the threat appraisal and the coping appraisal. The threat appraisal assesses the severity of the situation and examines how serious the situation is. The coping appraisal is how one responds to the situation. The coping appraisal consists of both efficacy and self-efficacy. Efficacy is the individual's expectancy that carrying out recommendations can remove the threat. Self-efficacy is the belief in one's ability to execute the recommended courses of action successfully. PMT is one model that explains why people engage in unhealthy practices and offers suggestions for changing those behaviors. It is educational and motivational. Primary prevention: taking measures to combat the risk of developing a health problem.. Secondary prevention: taking steps to prevent a condition from becoming worse..

Audience segmentation is a process of dividing people into homogeneous subgroups based upon defined criterion such as product usage, demographics, psychographics, communication behaviors and media use. Audience segmentation is used in commercial marketing so advertisers can design and tailor products and services that satisfy the targeted groups. In social marketing, audiences are segmented into subgroups and assumed to have similar interests, needs and behavioral patterns and this assumption allows social marketers to design relevant health or social messages that influence the people to adopt recommended behaviors. Audience segmentation is widely accepted as a fundamental strategy in communication campaigns to influence health and social change. Audience segmentation makes campaign efforts more effective when messages are tailored to the distinct subgroups and more efficient when the target audience is selected based on their susceptibility and receptivity.

The PRECEDE–PROCEED model is a cost–benefit evaluation framework proposed in 1974 by Lawrence W. Green that can help health program planners, policy makers and other evaluators, analyze situations and design health programs efficiently. It provides a comprehensive structure for assessing health and quality of life needs, and for designing, implementing and evaluating health promotion and other public health programs to meet those needs. One purpose and guiding principle of the PRECEDE–PROCEED model is to direct initial attention to outcomes, rather than inputs. It guides planners through a process that starts with desired outcomes and then works backwards in the causal chain to identify a mix of strategies for achieving those objectives. A fundamental assumption of the model is the active participation of its intended audience — that is, that the participants ("consumers") will take an active part in defining their own problems, establishing their goals and developing their solutions.

A behavior change method, or behavior change technique, is a theory-based method for changing one or several psychological determinants of behavior such as a person's attitude or self-efficacy. Such behavior change methods are used in behavior change interventions. Although of course attempts to influence people's attitude and other psychological determinants were much older, especially the definition developed in the late nineties yielded useful insights, in particular four important benefits:

  1. It developed a generic, abstract vocabulary that facilitated discussion of the active ingredients of an intervention
  2. It emphasized the distinction between behavior change methods and practical applications of these methods
  3. It included the concept of 'parameters for effectiveness', important conditions for effectiveness often neglected
  4. It drew attention to the fact that behavior change methods are influence specific determinants.

The reasoned-action approach (RAA) is an integrative framework for the prediction of human social behavior. The reasoned-action approach states that attitudes towards the behavior, perceived norms, and perceived behavioral control determine people's intentions, while people's intentions predict their behaviors.

Bullying is abusive social interaction between peers can include aggression, harassment, and violence. Bullying is typically repetitive and enacted by those who are in a position of power over the victim. A growing body of research illustrates a significant relationship between bullying and emotional intelligence.

Nola J. Pender is a nursing theorist, author, and academic. She is a professor emerita of nursing at the University of Michigan. She created the Health Promotion Model. She has been designated a Living Legend of the American Academy of Nursing.

References

  1. Siddiqui, Taranum Ruba; Ghazal, Saima; Bibi, Safia; Ahmed, Waquaruddin; Sajjad, Shaimuna Fareeha (2016-11-10). "Use of the Health Belief Model for the Assessment of Public Knowledge and Household Preventive Practices in Karachi, Pakistan, a Dengue-Endemic City". PLOS Neglected Tropical Diseases. 10 (11): e0005129. doi:10.1371/journal.pntd.0005129. ISSN   1935-2735. PMC   5104346 . PMID   27832074.
  2. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Janz, Nancy K.; Marshall H. Becker (1984). "The Health Belief Model: A Decade Later". Health Education & Behavior. 11 (1): 1–47. doi:10.1177/109019818401100101. hdl: 2027.42/66877 . PMID   6392204.
  3. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Rosenstock, Irwin (1974). "Historical Origins of the Health Belief Model". Health Education & Behavior. 2 (4): 328–335. doi:10.1177/109019817400200403.
  4. 1 2 3 4 5 6 7 8 9 10 11 12 13 Carpenter, Christopher J. (2010). "A meta-analysis of the effectiveness of health belief model variables in predicting behavior". Health Communication. 25 (8): 661–669. doi:10.1080/10410236.2010.521906. PMID   21153982.
  5. 1 2 3 Glanz, Karen; Bishop, Donald B. (2010). "The role of behavioral science theory in development and implementation of public health interventions". Annual Review of Public Health. 31: 399–418. doi:10.1146/annurev.publhealth.012809.103604. PMID   20070207.
  6. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 Glanz, Karen; Barbara K. Rimer; K. Viswanath (2008). Health behavior and health education: theory, research, and practice (PDF) (4th ed.). San Francisco, CA: Jossey-Bass. pp. 45–51. ISBN   978-0787996147.
  7. 1 2 3 Glanz, Karen (July 2015). Health behavior: theory, research, and practice. Rimer, Barbara K., Viswanath, K. (Kasisomayajula) (Fifth ed.). San Francisco, CA. ISBN   9781118629055. OCLC   904400161.
  8. Lewin, K. (1951). The nature of field theory. In M. H. Marx (Ed.), Psychological theory: Contemporary readings. New York: Macmillan.
  9. Köhler, Wolfgang, 1887-1967, author. (1999). The mentality of apes. ISBN   9780415209793. OCLC   1078926886.CS1 maint: multiple names: authors list (link)
  10. Lewin, K., Dembo, T., Festinger, L., & Sears, P. S. (1944). Level of aspiration. In J. Hunt (Ed.), Personality and the behavior disorders  (pp. 333–378). Somerset, NJ: Ronald Press.
  11. Austin, Latoya T et al. “Breast and Cervical Cancer Screening in Hispanic Women: a Literature Review Using the Health Belief Model.” Women’s Health Issues 12.3 (2002): 122–128. Web.
  12. 1 2 3 4 5 6 7 8 9 Rosenstock, Irwin M.; Strecher, Victor J.; Becker, Marshall H. (1988). "Social learning theory and the health belief model". Health Education & Behavior. 15 (2): 175–183. doi:10.1177/109019818801500203. hdl: 2027.42/67783 . PMID   3378902.
  13. Schmiege, S.J., Aiken, L.S., Sander, J.L. and Gerend, M.A. (2007) Osteoporosis prevention among young women: psychological models of calcium consumption and weight bearing exercise, Health Psychology, 26, 577–87.
  14. Abraham, Charles, and Sheeran, Paschal. “The Health Belief Model.” Cambridge Handbook of Psychology, Health and Medicine. Cambridge University Press, 2001. 97–102. Web.
  15. Becker, Marshall et al. “The Health Belief Model and Prediction of Dietary Compliance: A Field Experiment.” Journal of Health and Social Behavior 18.4 (1977): 348–366. Web.
  16. Cerkoney, K A, Hart, L K, and Cerkoney, K A. “The Relationship Between the Health Belief Model and Compliance of Persons with Diabetes Mellitus.” Diabetes care 3.5 (1980): 594–598. Web.
  17. Stretcher, Victor J.; Irwin M. Rosenstock (1997). "The health belief model" . In Andrew Baum (ed.). Cambridge handbook of psychology, health and medicine. Cambridge, UK: Cambridge University Press. pp.  113–117. ISBN   978-0521430739.
  18. Schwarzer, Ralf (April 2001). "Social-Cognitive Factors in Changing Health-Related Behaviors". Current Directions in Psychological Science. 10 (2): 47–51. doi:10.1111/1467-8721.00112.
  19. Seyde, Erwin; Taal, Erik; Wiegman, Oene (1990). "Risk-appraisal, outcome and self-efficacy expectancies: Cognitive factors in preventive behaviour related to cancer". Psychology & Health. 4 (2): 99–109. doi:10.1080/08870449008408144.
  20. Maiman, Lois A.; Marshall H. Becker; John P. Kirscht; Don P. Haefner; Robert H. Drachman (1977). "Scales for Measuring Health Belief Model Dimensions: A Test of Predictive Value, Internal Consistency, and Relationships Among Beliefs". Health Education & Behavior. 5 (3): 215–230. doi:10.1177/109019817700500303.
  21. Orji, Rita, Vassileva, Julita, and Mandryk, Regan. “Towards an Effective Health Interventions Design: An Extension of the Health Belief Model.” Online journal of public health informatics 4.3 (2012): n. pag. Web.