health belief model nursing essay

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Health Belief Model, Essay Example

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Researchers have always tried to establish the causes and remedy for diseases but there are researchers who chose to come up with something different. This is the health belief model that was designed as a tool for helping health officials study health behavior. The model is based on the assumption that the personal beliefs people have affect their health behaviors. Many people concerned with heath education have adopted this model and this is because it can simply be adapted to suit a health practice. Rosenstock, Strecher and Becker (1994) claim that the last three decades have seen wide use of the health belief model in health related behavior.   The health belief model was a 1950s development of several Public Health Service officials; Hochbaum, Rosenstock, Leventhal and Kegels.

The model was initially created with an aim of analyzing how people tended to use public health services provided by the U. S Public Health Service. This was prompted by tuberculosis service use which according to Hachbaum (1958) were proving to be unsuccessful. The model was adopted for the United States Public Health Service prevention programs. It contained four elements or perceptions which the researchers identified as important components that can help one understand health behavior. These perceptions have so far been increased and according to Rosenstock, Strecher and Becker (1994), they are perceived threat (perceived susceptibility and perceived severity), perceived benefits, perceived barriers, cues to action, other variables and self-efficacy. Gatewood et al. (2008) think that the purpose of the health belief model was to explain people’s lack of action in preventing asymptomatic disease. Thus, the health belief model was geared towards health related behavior which Glanz and Maddock (2002) think that the advancements in medicine as well as improvement in sanitation have increased its necessity.

Perceived Threat

Mackey (2002) asserts that the identification of health risks inherent in a community by its members is a determinant of their health. The threat perception people attach to a health condition in terms of how serious it is and their chances of being affected by it is what constitutes the perceived threat construct. For a health condition, people hold certain beliefs about how and what may happen if they contract it. One person may perceive a health concern as being severe while it may be less severe to another. There are many things that people use to determine the seriousness of a condition and when people know they are more at risk of losing something and would therefore be prompted to take action for their lives. Some people may decide to take action because they are aware of what it might cost them if they were to get sick. When it comes to susceptibility, someone may tend to think that because he/she is of a certain age, then the disease cannot affect him/her. Someone may also have the perception that because they are healthy, they cannot be affected and this is also a belief that affects use of new behaviors.

Perceived Benefits

This refers to the usefulness a behavior will have in helping the individuals reduce their susceptibility and severity of a health condition. When people are introduced to a new behavior that may help to keep them safe, their adoption of the behavior will depend on the benefits they perceive. Hence, people will make use of health services when they know the kind of benefits they can get from them. People will usually assess a disease and the possible outcomes against what they may get from the recommended behavior and when the benefits outweigh the consequences, they are more likely to change behavior. For a health official, there is the need to make people aware of all the benefits associated with a new action.

Perceived Barriers

People also tend to look at the barriers that may prevent them from adopting the new recommended behavior. When someone analyzes his/her condition and determines that there are no perceived barriers, then change of behavior easily occurs. Perceived barriers may include financial constraints in which case a person may lack the money needed for a new behavior. When people are advised to do something, they will have perceptions of things that may prevent them and for a health official, your duty is to help in identifying and getting rid of them.  A new action may come with effects people may not want and this also creates a barrier. Reducing barriers is the best way to get people doing using a new action. Glanz and Maddock (2002) assert that barriers are used in decision making where people consider the advantages and disadvantages of an action.

Cues to Action

Cues to action is a like something that reminds people of the new behavior they need to adopt or something that motivates them towards it. These can be used as a way of making people more aware of the need at the same time letting them know how to go about it. Cues to action strategies can do well in influencing the kind of behavior change required from people. Here, various media can be used and these include posters, radio, TV where you can remind people of the kind of danger they are facing if they will not take up a recommended action. Safety instructions on many products that can easily affect health are a good example of cues to action as it reminds people of what they should be doing or avoiding.

Other Variables

Other variables include characteristics that may be unique to an individual but are also influential in forming perceptions. These include such things as education level which may place one in a position to know everything about a condition as compared to one who knows less. Similarly, cultural and demographic differences may also bring about the difference in perception in which case someone they may have different views about a behavior. The belief that people who live in certain areas are susceptible to some kind of diseases may make other people not to take a disease seriously.  People experiences, especially ones related to a disease will also result in their different perceptions since someone may consider it serious while the other may take it lightly.

Self-Efficacy

Bandura (1977) introduces self-efficacy as one’s own belief to do something. With self-efficacy, people have to believe that they can take the required action so to succeed otherwise, a barrier is created. When people have the fear of not being able to do the new action correctly, it hinders them from getting the intended benefits. Thus, you can only evoke behavior change in your subjects if you make them confident enough to believe they can perform. Rosenstock, Stretcher and Becker (1998) insist that the focus of the health belief model should also be on the individual’s confidence. This is because it was found to have an influence on the kind of choices people make regarding recommended actions. Self-efficacy can be improved through a variety of strategies but it works well of you take time to show people what they ought to be doing to prevent them from shying away.

Implications for Health Behaviors

Many health researchers have applied the health belief model in several studies to determine how people behave towards diseases and practices and these can  portray well the implication of the model to health behavior. Glanz and Maddock (2002) say that there are many factors that might affect health behaviors apart from policies and regulations. Breast-self examination is one of them and for this; early detection is always the best. However not many of the women are keen on conducting breast self examinations and in their study, Norman and Brian (n. d) found that breast self examination performance was affected by several independent predictors which included intention, perceived benefits and self-efficacy.

Hanson and Benedict (2006) use the model in their study to establish food handling behaviors among the older adults. Thus, health belief model is also applicable in nutrition where it can be used to find out how safe people are handling their food. One of the things Hanson and Benedict’s study established is that sanitation was prompted by the perceived severity people had of foodborne illnesses. This is just one of the things that people will use to take action, for instance, when they see on posters or other media of how an illness may affect them, they may have that perception of its severity and would therefore conform to cleanliness.

Radius and Joffe (1988) sought to focus their use of the model on young mothers or adolescents and their perception of breastfeeding.  This is because they may be presented with barriers arising from their own beliefs about activity. These are also benefits and together with the barriers help to influence the young mothers’ decision on whether to breastfeed or not. Radius and Joffe found that many of the adolescent mothers perceived fewer barriers to breastfeeding which shows that many of them found the method to be better than bottle feeding. Many times, people tend to have the wrong information about something which creates the perceived barriers.

While the health belief model can be used on women regarding changing behavior on breast self examination, it can also be used to study the perceptions men have on prostate cancer.  Kleier (2004) conducted such a study on Jamaican and Haitian men where she also sought to find out how much they knew about the illness. In comparing the two Kleier found that Jamaican men seemed to have more information as compared to Haitian men. The study also established that there are other variables affecting perceptions which include language and culture with regard to the subjects of the study. Here, many of the Haitian men have language problems which not made it difficult for them to acquire the relevant knowledge about the disease.

Health belief model does not just have an effect on patient behavior but the staff also has perceptions that can be studied. This is the focus of Agarwal, Sypher and Dutta’s (2009) study where they chose to find the effect of selected constructs of the model on staff behavior. The researchers used knowledge, perceived effectiveness and cues to action and found, among other things, that greater knowledge contributed to a low perception of benefits but did not affect barriers or behaviors. Gatewood et al. (2008) seek to find out how perceived barriers and self-efficacy affect the attendance of a community health program, specifically for cardiovascular risk reduction. They established that participants who had not been exposed to the program tended to have more perceived barriers as compared to those who know about the program.

Roden (2004) used of the model for the promotion of health practices among young families. The researcher used perceived behavioral control and behavioral intention for the study where the model could be modified to suit the selected group. It was established that the two were suited for the modified model. Cerkoney and Hart (1980) used the model to explain behavior of people with diabetes mellitus with regard to how well they complied with their treatment. It was found that there are procedures that they seemed to take seriously with which many of them were complaint while there are those they seemed to ignore.

The use of cues to action is a common practice in health field when there is a need to sensitive people on an issue. Marifran (1999) examines the role HIV test counselors can play in persuading people to play safe sex. The study found that such cues to action improved the condition and many people tended to play safe. Winfield and Whaley (2002) chose to use the model to study the use of condoms where they focused on African American college students. The study found out that condom use was determined by perceived barriers and gender.

Behavior change

Recognition and labeling of one’s behavior

Behavior change is best effected when an individual is able to recognize that he/she exhibits bad behavior which needs to be changed. Here, one would need to know what kind of behavior is questionable and to realize that one can easily be affected by such behavior. In their study Marcus et. al (1992) established that people could adopt more to exercising by understanding the stages of exercise behavior and self-efficacy through the necessary information.

Making a commitment to change behavior

The second step is to make a decision to reduce or do away with the behavior that has been identified as bad. Here, one may have to look at both the advantages and disadvantages as well as how the change may affect you. Since behavior change is to help reduce the risks involved, you may also want to analyze what kind of response you may get once you become the person of desirable qualities. Just like in the health relief model, self-efficacy involves a person determining whether he/she is able to take that action that would lead to behavior change. With this, it may be worthwhile for an individual to consider what will be needed in order to make the process successful. This is in terms of being able to perform the activities chosen and the willingness to keep on trying in case of failure.

Taking action the third action

The third action to behavior change is to take action and this is where an individual may have to consider things such as level of self esteem and communication abilities. This stage may occur in three phases but are not a must and may be skipped. In phases, an individual would be required to seek information first that would be useful to the situation. This is the stage that one needs to have good communication skills as well so you can explain to people that you have changed and the reasons. The individual is exposed to a number of choices with regard to whether formal or informal help is required. There may also be need to have certain resources to help in the adoption of a desired behavior which is also identified at this stage of behavior change model.

Stages of Change

Stages of Change Theory identify some stages which are to be considered during the behavior change cycle. This model is useful in a number of instances where behavior change is necessary and Kern (2008) says that behavior change with this model is a series of steps where individuals will go through different stages before successful change can be realized. Usually, someone will move to the next stage when he/she has established that it is appropriate to proceed and this is only after completing the previous stage.

The developers of this theory advance the four stages which are pre-contemplation, contemplation, action and maintenance and there is also a fifth stage which is the preparation for action.  Prochaska, DiClemente and Norcross (1992) provide a description for each of the stages involved in the cycle. Each of the stages involve an individual doing a different activity, from the initial stages where the person is still considering whether to decide to change or not to the end when he/she either maintains the new behavior or relapses.

Pre contemplation

This is the initial stage which Kern (2008) says that people here are not serious and may not even be interested in getting help. This is where they are still trying to come to terms with the bad side of their behavior and it may take some time to convince them that they ought to get rid of their current behavior. In this stage, the individual needs to be given a lot of information which will help in understanding their bad habits. There is also need to let the people know what environmental effect their behavior is causing.

Contemplation

At this stage, people have started to take more interest and can therefore accept that they have a behavior problem. This may be prompted by several factors which include experiencing someone suffering as a result of the behavior but this generally involves a self evaluation. Zimmerman, Olsen and Bosworth (2000) say that this is a stage where a patient examines benefits and costs involved and may be helped by incorporating other models such as health belief model.

Preparation for Action

This is where the decision has already been made regarding behavior change and the individual is making plans to take necessary action. When the person understands and can see how serious their bad habits are, he/she would start finding the help needed. This may involve the person finding as much information as possible about the situation and the possible solutions that could be of help.

The action stage is where the person has already selected a course of action such as a behavior change and is not practicing it. This may not be very easy since it may involve a complete change of behavior and since one may have been used to the bad habits very much, there are chances of relapsing. Kern (2008) says that this is people may take different amount of times at this stage but may last up to 6 months.

Maintenance

At the maintenance stage, the person is trying not to relapse and move back to the old habits. When you are in the action stage, it only takes a while before you enter into the maintenance stage provided you are consistent. Those who are able to prevent relapse tend to benefit more from the benefits that change in behavior was meant to bring. The amount of time here is indefinite and will depend on how well a person is able to adapt to new behavior without chances of going back.

Studies that used the Health Belief Model

Attia, A. K., Rahman, D. A., & Kamel, L. I. (1997). Effect of an educational film on the Health

Belief Model and breast self-examination practice. Eastern Mediterranean Health Journal .   Volume 3, Issue 3, 1997, Page 435-443.Page 435-443

Cerkoney, K. A., & Hart, L.K. (1980). The relationship between the health belief model and compliance of persons with diabetes mellitus. Diabetes Care, September 1980 vol. 3 no. 5 594-598 doi: 10.2337/diacare.3.5.594.

Gatewood, Jadah Sataje &  George Munroe. (2008). Perceived barriers to community-basedhealth promotion program  participation. American Journal of Health Behavior , May-June, 2008. Retrieved 13 th March, 2010 from <http://findarticles.com/p/articles/mi_7414/is_3_32/ai_n32056841/>

Hanson, J. A. & Benedict, J. A.  (2002). Use of the health belief model to examine older adults’food-handling behaviors. Journal of Nutrition Education and Behavior. Volume 34, Supplement 1, March-April 2002, Pages S25-S30. Retrieved 14 th March, 2010 from http://dx.doi.org/10.1016/S1499-4046%2806%2960308-4

Kleier, J, A. (2004). Using the health belief model to reveal the perceptions of Jamaican and

Haitian men regarding prostate cancer. Journal of Multicultural Nursing & Health , Fall 2004. Retrieved 29 th March, 2010 from http://findarticles.com/p/articles/mi_qa3919/is_200410/ai_n9459581/

Mackey, J. A. (2002). Using a health belief model in teaching preventive health care principles to Israeli RNs. A paper for presentation at the CITA Conference University of Massachusetts Lowell November 7, 8, 9, 2002 .

Norman, P., & Brian, K. (n. d) . Health belief model and breast self-examination: An application of the health belief model to the prediction of breast self-examination in a national sample of women with a family history of breast cancer. Institute of Medical Genetics

University of Wales College of Medicine, UK. Radius, S.M., & Joffe, A. (1988). Understanding adolescent mothers’ feelings about breast-feeding : A study of perceived benefits and barriers. Journal of Adolescent Health Care Volume 9, Issue 2, March 1988, Pages 156-160. doi:10.1016/0197-0070(88)90063-0

Roden J. (2004). Validating the revised Health Belief Model for young families: implications for nurses’ health promotion practice. Nurs Health Sci . 2004 Dec; 6(4):247-59.

Winfield, E. B., & Whaley, A. L. (2002). A comprehensive test of the health belief model in the prediction of condom use among African American college students. Journal of Black Psychology , Vol. 28, No. 4, 330-346

Agarwal, V., Sypher, H. E. and Dutta, M. J. (2009). Health belief model in healthcare settings: knowledge, perceived effectiveness, and cues to action on staff behaviors.  Paper presented at the annual meeting of the International Communication Association, Marriott, Chicago, IL Online <PDF>. Retrieved 19 th March 2010 from http://www.allacademic.com/meta/p300001_index.html

Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioral change. Psychological Review , 84, 191-215.

Gatewood, J.  G. et al. (2008). Perceived barriers to community-based health promotion program participation. American Journal of Health Behavior , Retrieved  29 th March, 2010 from <http://findarticles.com/p/articles/mi_7414/is_3_32/ai_n32056841/>

Glanz, K., & Maddock, J. (2002). Behavior, Health-Related. Encyclopedia of Public Health. Retrieved 29 th March, 2010 from< http://www.encyclopedia.com/topic/Health_behavior.aspx>

Hanson, J. A. & Benedict, J. A.  (2002). Use of the health belief model to examine older adults’ food-handling behaviors. Journal of Nutrition Education and Behavior. Volume 34, Supplement 1, March-April 2002, Pages S25-S30. Retrieved 14 th March 2010 from http://dx.doi.org/10.1016/S1499-4046%2806%2960308-4

Hochbaum, G. M. (1958). Public Participation in medical screening programs: A socio-psychological study. ( Public Health Service Publication No. 572 ). Washington, DC: Government Printing Office.

Kern, M. F. (2008). Stages of change model. AddctionInfo.org . retrieved 29 th March 2010 from <http://www.addictioninfo.org/articles/11/1/Stages-of-Change-Model/Page1.html>

Kleier, J, A. (2004). Using the health belief model to reveal the perceptions of Jamaican and Haitian men regarding prostate cancer. Journal of Multicultural Nursing & Health , Fall 2004. Retrieved 29 th March, 2010 from http://findarticles.com/p/articles/mi_qa3919/is_200410/ai_n9459581/

Mackey, J. A. (2002). Using a health belief model in teaching preventive health care principles to Israeli RNs. A paper for presentation at the CITA Conference University of Massachusetts Lowell November 7, 8, 9, 2002

Marcus, B. H et al. (1992) Self-efficacy and the stages of exercise behavior change. To insert individual citation into a bibliography in a word-processor, select your preferred citation style below and drag-and-drop it into the document.   Res Q Exerc  Sport , Vol. 63, No. 1. (March 1992), pp. 60-66.

Marifran, M. (1999). Toward a reconceptualization of communication cues to action in the health belief model: HIV test counseling. Communication Monographs , 1479-5787, Volume 66, Issue 3, 1999, Pages 240 – 265

Norman, P., & Brian, K. (n. d) . Health belief model and breast self-examination: An application  of the health belief model to the prediction of breast self-examination in a national sample of women with a family history of breast cancer . Institute of Medical Genetics University of Wales College of Medicine, UK.

Prochaska, J.O., DiClemente, C.C. and Norcross, J.C. (1992). In search of how people change – applications to addictive behaviors. American Psychologist , 47(9), 1102-1114.

Radius, S.M., & Joffe, A. (1988). Understanding adolescent mothers’ feelings about breast- feeding : A study of perceived benefits and barriers. Journal of Adolescent Health Care Volume 9, Issue 2, March 1988, Pages 156-160. Retrieved 20 th March, 2010 fromhttp://dx.doi.org/10.1016/0197-0070%2888%2990063-0

Rosenstock I., Strecher, V., & Becker, M. (1994). The health belief model and HIV risk behavior change. In R.J. DiClemente, and J.L. Peterson (Eds.), Preventing AIDS: theories and methods of behavioral interventions New York: Plenum Press; pp. 5-24.

Rosenstock, I.M., Strecher, V.J., & Becker, H.M. (1988). Social learning theory and the health belief model. Health Education Quarterly , 15, 175-183.

Zimmerman, G. L., Olsen, C. G., & Bosworth , M. F.(2000). A ‘Stages of Change’ approach to helping patients change behavior. American Family Physician (12), p.4.

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Nursing theories

Open access articles on nursing theories and models.

Health Belief Model (HBM)

Introduction.

The Health Belief Model (HBM) is one of the first theories of health behavior.

It was developed in the 1950s by a group of U.S. Public Health Service social psychologists who wanted to explain why so few people were participating in programs to prevent and detect disease.

HBM is a good model for addressing problem behaviors that evoke health concerns (e.g., high-risk sexual behavior and the possibility of contracting HIV) (Croyle RT, 2005)

The health belief model proposes that a person's health-related behavior depends on the person's perception of four critical areas:

the severity of a potential illness,

the person's susceptibility to that illness,

the benefits of taking a preventive action, and

the barriers to taking that action.

HBM is a popular model applied in nursing, especially in issues focusing on patient compliance and preventive health care practices.

The model postulates that health-seeking behaviour is influenced by a person’s perception of a threat posed by a health problem and the value associated with actions aimed at reducing the threat.

HBM addresses the relationship between a person’s beliefs and behaviors. It provides a way to understanding and predicting how clients will behave in relation to their health and how they will comply with health care therapies.

THE MAJOR CONCEPTS AND DEFINITIONS OF THE HEALTH PROMOTION MODEL

There are six major concepts in HBM:

1.       Perceived Susceptibility

2.       Perceived severity

3.       Perceived benefits

4.       Perceived costs

5.       Motivation

6.       Enabling or modifying factors

Perceived Susceptibility: refers to a person’s perception that a health problem is personally relevant or that a diagnosis of illness is accurate.

Perceived severity:   even when one recognizes personal susceptibility, action will not occur unless the individual perceives the severity to be high enough to have serious organic or social complications.

Perceived benefits : refers to the patient’s belief that a given treatment will cure the illness or help to prevent it.

Perceived Costs: refers to the complexity, duration, and accessibility and accessibility of the treatment .

Motivation: includes the desire to comply with a treatment and the belief that people should do what.

Modifying factors: include personality variables, patient satisfaction, and socio-demographic factors.  

Criticisms of HBM

Is health behaviour that rational?

Its emphasis on the individual (HBM ignores social and economic factors)

·The absence of a role for emotional factors such as fear and denial.

Alternative factors may predict health behaviour, such as outcome expectancy (whether the person feels they will be healthier as a result of their behaviour) and self-efficacy (the person’s belief in their ability to carry out preventative behaviour) (Seydel et al. 1990; Schwarzer 1992.

Marriner TA, Raile AM. Nursing theorists and their work. 5th ed. Sakraida T.Nola J. Pender. The Health Promotion Model. St Louis: Mosby; 2005

Polit DF, Beck CT. Nursing research:Principles and methods. 7th ed. Philadelphia: Lippincott Williams & Wilkins; 2007

Black JM, Hawks JH, Keene AM. Medical surgical nursing. 6th ed. Philadelphia: Elsevier Mosby; 2006.

Potter PA, Perry AG. Fundamentals of nursing. 6th ed. St.Louis: Elsevier Mosby; 2006.

Rosenstoch I. Historical origin of Health Belief model. Health Educ Monogr 2:334, 1974.

• Croyle RT. Theory at a Glance: Application to Health Promotion and Health Behavior (Second Edition). U.S. Department of Health and Human Services, National Institutes of Health, 2005.

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Encyclopedia of Behavioral Medicine pp 999–1000 Cite as

Health Beliefs/Health Belief Model

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Rosenstock’s Health Belief Model (HBM) is a theoretical model concerned with health decision-making. The model attempts to explain the conditions under which a person will engage in individual health behaviors such as preventative screenings or seeking treatment for a health condition (Rosenstock 1966 ).

Description

Under the HBM, a person’s likelihood for health behavior is assumed to be related to four main variables. First, action is more likely if the person perceives himself to be susceptible to or at risk for the condition. For example, if Lucy has a history of breast cancer in her family, she may see herself as more susceptible to developing breast cancer, and thus, be more likely to get a mammogram each year. Second, the likelihood for action depends on the perceived seriousness of the condition. Seriousness may be judged based on the amount of emotional arousal produced by thinking about the condition as well as the anticipated physical, social, and psychological...

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References and Readings

Davidhizar, R. (1983). Critique of the health-belief model. Journal of Advanced Nursing, 8 , 467–472.

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Janz, N. K., & Becker, M. H. (1984). The health belief model: A decade later. Health Education Quarterly, 11 , 1–47.

Kirscht, J. P. (1988). The health belief model and predictions of health actions. In D. S. Gochman (Ed.), Health behavior: Emerging research perspectives (pp. 27–41). New York: Springer.

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Rosenstock, I. M. (1966). Why people use health services. Milbank Memorial Fund Quarterly, 44 , 94–127.

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Rosenstock, I. M. (1974). Historical origins of the health belief model. Health Education Monographs, 2 , 328–335.

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Luger, T.M. (2020). Health Beliefs/Health Belief Model. In: Gellman, M.D. (eds) Encyclopedia of Behavioral Medicine. Springer, Cham. https://doi.org/10.1007/978-3-030-39903-0_1227

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Nursing: Becker’s Health Belief Model

Introduction, 1st basic concept of nursing metaparadigm: person, 2nd basic concept of nursing metaparadigm: health, 3rd basic concept of nursing metaparadigm: environment, 4th basic concept of nursing metaparadigm: nursing, theoretical assumptions of becker’s health belief theory.

The middle of the XX century has faced a significant uprising in sociological studies of healthcare initiatives. Anuar et al. (2020) state that “HBM was developed in the 1950s to explain the drop in public involvement in health screening and prevention programs” (p. 207). Although Becker was not the first scientist to create the Health Belief Model, he still contributed greatly to the development of the theory and its implementation into healthcare practices. According to Becker (1974), the adoption of healthy behavior by a person depends on two sets of assessments: the threat their health problem poses and the pros and cons of leading a healthy life. There are also many variables that might influence these assessments, such as the perceived susceptibility to a concrete illness, how severe they think their condition is, demographic and sociopsychological specifics, and others. Becker used the theory to develop a more comprehensive approach to how nurses should encourage patients to adopt healthier behavior.

The first basic nursing metaparadigm refers to the needs of individuals and how healthcare workers have to apply personalized care to each and every patient. The Health Belief Model integrates very well with this approach, as it emphasizes that there are many variables that influence one’s behavior and motivation, and they need to be recognized by the nurse. Only by determining the specific conditions that affect the patient, such as their age, sex, race, presence of other diseases, cultural belonging, assumptions about their current health problem, and how they evaluate potential outcomes, can the nurse design an appropriate care plan.

Within this metaparadigm, it becomes important for the nurse to be aware of multiple aspects of care and how to administer it. Each patient needs to be properly assessed before the treatment begins, and the process should be repeated throughout the whole duration of it. With the Health Belief Model, nurses can use the existing framework to evaluate patient’s condition – both physical and psychological – and incorporate this knowledge into everyday care.

It is always important to be aware of how the world around the individual affects their health state to be able to provide comprehensive treatment. Making the immediate environment of the patient as calm and stress-free as possible is another task nurses should engage in. However, healthcare workers also need to be provided with suitable working conditions that do not force them to get overworked and burnout.

Meaningful relationships provide individuals with positive emotions, a sense of fulfillment, and relatability. Thus, the fourth basic concept of nursing metaparadigm postulates that nurses should establish connections with their patients to ensure that all their needs – physical, psychosocial, emotional, and spiritual – are met. By expressing empathy and compassion towards the patients, nurses can assess their health-related beliefs more comprehensively and correctly, as a higher level of trust can be reached.

Becker’s Health Belief Model postulates that a person’s motivation to change their health behavior is influenced by many factors that can be arranged into the aforementioned three groups. Green et al. (2020) explain that “HBM is incorporated into interventions to increase knowledge of health challenges, enhance perceptions of personal risk, encourage actions to reduce or eliminate the risk, and build a sense of self-efficacy to undertake the needed changes” (p. 1). By understanding how a concrete individual develops their assumptions about their health problems, what specific variables and knowledge influence their decisions, and how they can be motivated, a framework for changing health behavior can be developed. Moreover, by knowing how a person evaluates their health-related risks and what barriers they perceive as most significant on their path towards a healthier lifestyle, healthcare sociologists can design more effective health promotion campaigns.

The Health Belief Model is a reliable framework for assessing a person’s health behavior and its predispositions. Nurses can use HBM as a tool for designing more individualized and thus more effective treatment plans. HBM incorporates well into basic nursing meta paradigms, as it emphasizes interpersonal connections, a humane approach, and comprehensive care.

Anuar, H., Shah, S. A., bin Abdul Gafor, A. H., & Mahmood, M. I. (2020). Usage of Health Belief Model (HBM) in Health Behavior: A Systematic Review. Malaysian Journal of Medicine and Health Sciences, 16(supp11), 201–209.

Becker, M. H. (1974). The health belief model and sick role behavior . Health Education Monographs, 2(4), 409–419. Web.

Green, E. C., Murphy, E. M., & Gryboski, K. (2020). The health belief model. In K. Sweeny et al. (Eds.), The Wiley Encyclopedia of Health Psychology, 211–214.

McKellar, K., & Sillence, E. (2020). Teenagers, sexual health information and the Digital age. Academic Press.

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Revisiting the Health Belief Model: Nurses applying it to young families and their health promotion needs

2004, Nursing and Health Sciences

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Background: Health education, using new approaches in the nursing area, is of great importance. The current study aimed to evaluate the effects of a health belief model-based education on maternal abilities to caring for children with Avoidant Restrictive Food Intake Disorder (ARFID). Methods: This was a quasi-experimental non-randomized controlled trial with pre-test, posttest and a control group design. In total, 30 families with children with ARFID in Malang regency, Indonesia were divided into experimental and control groups. The experimental group was trained based on the Health Belief Model (HBM); however, the control group received an education based on the routine nursing process model. The necessary data were collected by a researcher-made questionnaire constructed based on HBM constructs. The obtained data were analyzed in SPSS. Descriptive statistics, homogeneity test, and Paired-Samples t-test were used to outline the relationship between the dependent and independent variables. Results: HBM effectively improved maternal abilities to manage eating disorders (P=0.009), promoting behaviors (P=0.000), and paternal involvement (P=0.000). Conclusion: HBM-Based education is recommended to be used in the provision of training in the mothers of children with ARFID.

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SUMMARY To increase the understanding of difficulties in promoting healthy habits to parents, we explore barriers in health-care provision. The aim of this study is to describe nurses' perceived barriers when discussing with parents regarding healthy food habits, physical activity and their child's body weight. A mixed method approach was chosen. Nurses (n ¼ 76) working at 29 different Child Health Care Centers' in an area in west Sweden were included in the study. Three focus group interviews were conducted and 17 nurses were selected according to maximum variation. Data were categorized and qualitative content analysis was the chosen analysis method. In the second method, data were obtained from a questionnaire distributed to all 76 nurses. The latent content was formulated into a theme: even with encouragement and support, the nurses perceive barriers of both an external and internal nature. The results identified four main barriers: experienced barriers in the workplace—internal and external; the nurse's own fear and uncertainty; perceived obstacles in nurse– parent interactions and modern society impedes parents' ability to promote healthy habits. The nurses' perceived barriers were confirmed by the results from 62 of the nurses who completed the questionnaire. Despite education and professional support , the health professionals perceived both external and internal barriers in promoting healthy habits to parents when implementing a new method of health promotion in primary care. Further qualitative studies are needed to gain deeper understanding of the perceived barriers when promoting healthy habits to parents.

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• Clin Interv Aging

Models and theories of health behavior and clinical interventions in aging: a contemporary, integrative approach

W jack rejeski.

1 Department of Health & Exercise Science, Wake Forest University, Winston-Salem, NC, 27109, USA

Jason Fanning

Background: Historically, influential models and theories of health behavior employed in aging research view human behavior as determined by conscious processes that involve intentional motives and beliefs. We examine the evolution, strengths, and weaknesses of this approach; then offer a contemporary definition of the mind, provide support for it, and discuss the implications it has for the design of behavioral interventions in research on aging.

Methods: A narrative review was conducted.

Results: Traditionally, models and theories used to either predict or change health behaviors in aging have not viewed the mind as encompassing embodied and relational processes nor have they given adequate attention to multi-level, in-the-moment determinants of health behavior.

Discussion: Future theory and research in aging would benefit from a broader integrative model of health behavior. The effects of adverse life experience and changes in biological systems with aging and chronic disease on health behavior warrant increased attention.

Introduction

The health care of older adults is complex requiring varying degrees of commitment on the part of patients to follow prescribed regimens of treatment. These regimens include behaviors such as dietary intake, physical activity, prescription drug use, taking preventive health screenings, and adherence to behavior protocols for physical rehabilitation. As a field, Behavioral Medicine has come to recognize that health behaviors are determined by multiple levels of influence. 1 For example, significant others and interactions with health care providers play a powerful role in shaping the beliefs of older adults. Similarly, what older adults would “like to do” and what they are “able to do” in the realm of health behavior is often determined, in part, by environmental and policy decisions such as access to facilities and reimbursement from Medicare. Of critical importance is that, while theories often conceptualize health behaviors as intentional and under conscious control, this is often not true as is evident in the biological and environmental determinants of addictive behaviors. 2

We open this review by touching on several models and theories of health behavior and/or health behavior change, capturing evolving thought on the topic. Our goal is to demonstrate how models/theories of health behavior have evolved across time and gaps that exist. We then present a contemporary definition for the concept of mind and review support for an integrative model based on this perspective. We believe this model will help to advance intervention development in aging research and foster an interdisciplinary science of health behavior and health behavior change.

A progression in models/theories of health behavior and behavior change

Behavioral scientists have devoted considerable effort to the development and evaluation of models and theories designed to understand and/or influence health behavior. As theory has advanced, scientists have adopted increasing specificity in the conceptual definition and measurement of constructs while becoming more interested in behavior change over understanding why individuals engage in particular health behaviors. Additionally, there has been increased interest in affect as well as the physiological and environmental input to health behavior and health behavior change. To illustrate the evolution of extant models/theories and the current state-of-the-art, we discuss the health belief model, the Social Cognitive Theory, the relapse prevention model, self-determination theory, research on affect and a biological model of desire, along with the socio-ecological model.

Health belief model (HBM)

The HBM first appeared in the 1950s as a guide to research on tuberculosis screening. 3 , 4 It distilled concepts from an established body of psychological and behavioral research and set the stage for the theories that followed. HBM is an expectancy-value model. As an example, people take medication to control their cholesterol because they value avoiding cardiovascular disease. Core constructs include perceived threat of a given disease state, which is the product of perceived susceptibility to the disease and perceived disease severity. The model also emphasizes decisional balance: the relative weight of perceived benefits as compared to perceived barriers to engaging in a behavior. As shown in Figure 1 , health behavior results from the combined effect of perceived threat and decisional balance over anticipated outcomes. 4 The HBM acknowledges the input on health behavior from other factors such as psychosocial variables and environmental cues, but it conceptualizes these effects as acting through either perceived threat or decisional balance . Of note, HBM practitioners have long recognized the limited scope of the model. For instance, as Janz and Becker noted: 4 “It is clear that other forces influence health actions as well; for example…some behaviors (eg, cigarette smoking; tooth-brushing) have a strong habitual component obviating any ongoing psychosocial decision-making process”.

The health belief model.

Note: Adapted from Janz NK, Becker MH. The health belief model - a decade later.  Health Ed Quart . 1984;11(1):1–47. Copyright 1984, with permission from SAGE Publications. 4

Social cognitive theory (SCT)

As a second approach to models/theories of health behavior, we focus on Bandura’s SCT. 5 As with HBM, SCT conceptualizes individuals as rational actors. While there is continued emphasis on the concept of expectancy-value, a chief advancement of SCT is its focus on personal agency and the importance of context as a determinant of health behavior. Moreover, while SCT has been useful in understanding why people perform a specific health behavior, it has also had a major effect on interventions for behavior change.

Self-efficacy, or one’s perceived ability to bring about a specific course of action in a particular context, is the core construct in SCT. Efficacy beliefs are dynamic, affecting and being affected by several downstream constructs highlighted in SCT (see Figure 2 ). These include outcome expectations and barriers/facilitators of behavior that arise from both social relations and cultural forces. Individuals with higher self-efficacy for a behavior are likely to have higher expectations for associated outcomes. They also perceive greater support from the social and physical environment and engage in more favorable self-regulatory behaviors than those with low self-efficacy. Success with the behavior fuels self-efficacy, especially when success occurs in the face of challenge. In addition, encouragement from others and observing relatable peers or those less skilled having success with a given behavior also enhances self-efficacy. Finally, one’s physiological state has an immediate influence on self-efficacy. For example, Bandura calls forth the image of preparing for a public speaking event. As anxiety mounts in preparing to deliver a talk, some individuals become hypersensitive to physical symptoms such as rising heart rate, increasingly sweaty palms, and a queasy stomach. The result is that they experience a sharp, in-the-moment decline in their speech-related self-efficacy.

Social cognitive theory.

Note: Aadapted from Bandura A. Health promotion by social cognitive means.  Health Educ Behav.  2004;31(2):143–164, copyrught 2004 by permission of SAGE Publications. 6

In part, the appeal of SCT arises from its specificity. 7 Other contemporary theories, such as the theory of planned behavior, prioritize parsimony and do not address behavior change. 8 , 9 SCT also offers interventionists clear targets for improving efficacy beliefs, supporting self-regulation, minimizing external barriers, and bolstering positive outcome expectancies. Moreover, it explicitly models the interplay between underlying transient biological states, one’s sense of agency, and the influence of proximal socio-structural pressure. Unfortunately, these key considerations are typically lost in implementation, with the focus constrained to individual-level perceptions and the influence of proximal social connections. 7

Relapse prevention (RP)

The third model of health behavior that we chose for inclusion is RP for addictive behavior. 10 RP is a model targeted specifically to behavior change. As an outgrowth of SCT, the intent behind RP was to describe the process of relapse for addictive behavior, emphasizing the importance of early intervention. They conceptualized relapse as an expected and transitional process; a key aim is to avoid or to learn how to cope with high-risk situations.

RP identified two categories of factors that contribute to a risk for relapse: immediate determinants and covert antecedents. Akin to Bandura’s recognition that transient, in-the-moment physiological states can exert substantial influence on self-efficacy, RP proposes that high-risk situations serve a similar function. They are immediate (in-the-moment) determinants of addictive behavior. These range from social and physical environments, to internal states such as depression or negative affect. Another immediate determinant, coping, captures how an individual responds to a high-risk situation. Outcome expectancies are a third determinant, in that individuals who expect short-term benefits such as reduced anxiety from the behavior are more likely to relapse. The fourth immediate determinant is the abstinence violation effect, which refers to the feeling of guilt or lack of control accompanying a single lapse.

Covert antecedents of relapse are a partial determinant of whether an individual successfully negotiates immediate determinants. Here, lifestyle factors, including both positive and pleasurable activities alongside one’s responsibilities contribute to or alleviate stress, which in turn is related to the likelihood of a relapse. More recent iterations of the model 11 specify both trait-like—tonic — influences on relapse, which are thought to dictate initial susceptibility to a relapse, and more dynamic and transient influences—phasic. Phasic influences include momentary mood states, urges and cravings, and in-the-moment changes in self-efficacy or outcome expectations. These phasic influences represent the most proximal determinants of a relapse.

Although not explicitly stated in RP, an interesting feature is the awareness that conscious goals related to recovery often succumb to the physiological symptoms of withdrawal, negative affective states, and the emotional tipping point created by the abstinence violation effect. Thus, it is not surprising to find that recent research on mindfulness-based treatment techniques specific to RP (MBRP) have been successful in countering the influence of negative affective states on the likelihood of relapse, and enhancing individuals’ abilities to cope with distress. 12 , 13

Self-determination theory (SDT)

We believe it is important to briefly discuss Deci and Ryan’s SDT 14 because it unites concepts from SCT (eg, goal setting; mastery), RP (eg, one’s inner state affects motivated behavior), the motivational role of affect in behavior by way of enjoyment, and the importance of strong social ties. SDT posits that humans are driven by three core needs: the need to experience competence, meaningful social connection (ie, relatedness), and autonomy (ie, a sense of control over one’s behaviors). The core needs outlined in SDT are positioned to be innately valued, and as with other theories, Deci and Ryan underscore the importance of aligning the content of one’s goals with an individual’s core needs. 14 For instance, an exercise goal formed for the explicit purpose of looking better to one’s peers, an extrinsic personal goal, will lose salience more rapidly than an intrinsic exercise goal emanating from the value of human connection and formed for the purpose of being able to engage with one’s grandchildren or to foster a relationship with friends. 15

Moreover, the ways in which these goal-driven behaviors are regulated are given importance in SDT. An intrinsically motivated behavior is one that brings about feelings of interest, enjoyment, or satisfaction, and it is theorized that this produces self-motivated, or self-determined behavior that is likely to last. When the behavior is motivated by factors aside from the merits of the behavior itself, it is said to be externally regulated. These more “controlling” forms of motivation are expected to sometimes regulate short-term behavior, but have a low likelihood of facilitating behavioral maintenance. 15

There are several important conclusions to be drawn from research on SDT and health behavior. As with research on incentives and affective valence described below, SDT highlights the importance of maximizing behaviors that produce positive bodily states such as enjoyment. It also provides a useful framework for considering appropriate incentives. Namely, by emphasizing incentives that are intrinsic as opposed to extrinsic. Lastly, it underscores the value of leveraging the group as a tool of behavior change; a notion we will highlight in the final section of this manuscript.

Incentives/affect

Although the motivational significance of incentives and affective valence that people associate with particular outcomes of a health behavior are evident in the concept of expectancy-value, within contemporary theoretical frameworks it is frequently assumed that people value their health and the focus of most research has been on self-efficacy, outcomes expectation, and behavioral intention. 7 Researchers traditionally assumed that increases in self-efficacy are valued because they increase a sense of personal agency. 5 , 16 One exception is research on RP in which researchers clearly appreciate the role of physiological withdrawal on relapse and the fact that addictive substances are often valued as a means of coping with life stress. 11

There has been a surge of interest in the affective determinants of health behavior, including work on both reflective and reflexive affect. 17 Reflective affect is cognitive based and referred to as “subjective liking”, whereas reflexive affect has been characterized as “core liking”, the pure, abrupt, visceral experience that is a function of contextual stimuli and associations. 18 Reflexive affect can be an in-the-moment experience or anticipatory in nature. Rhodes and Gray 19 recently note that most research on affect and health behavior has focused on reflective as opposed to reflexive affect. Although not conducted on older adults, reviews of the exercise literature have shown that reflexive affect may be more important in predicting future exercise behavior than reflective affect or social cognitive variables. 20

Given the growing interest in reflexive affect 17 and the importance of incentives to health behavior, there are important lessons to be learned from work in the biology of addiction. In the “Biology of Desire”, Lewis 2 describes the neuroscience of how substances and behaviors of desire become habitual through activity in the reward network. The central axis for desire begins in the ventral tegmental area (VTA) of the midbrain. Activation of this region of interest provides the fuel for desire—dopamine! Other key areas of the brain involved in impulsive behavior—the initiation of an addictive behavior—include the ventral and dorsal striatum, amygdala, hippocampus, and prefrontal cortex (PFC). In the early stages of desire for a substance or behavior, both nonconscious and conscious processing are involved. The amygdala acquires and maintains emotional sensations and communicates with the hippocampus, a structure that stores explicit memories of experience. The ventral striatum is responsible for feelings of attraction, desire, and craving. It is the main driver for impulsivity, getting its fuel from the VTA. The PFC creates conscious, context-specific interpretations of highly motivating situations and is key to executive function, planning, bringing memories into consciousness, sorting and comparing memories, and making decisions.

Once a person has been repeatedly exposed to a desired substance or behavior, involvement of the PFC in the reward network weakens to the point where conscious processing is no longer involved—the dorsal lateral region of the striatum has led to addiction, a compulsive act. The substance or behavior is now a habit: stimuli lead to a response (S-R) in the absence of conscious thought. We believe this model describing the biology of desire is important for several reasons. First, desire—or the incentive value of a behavior—is applicable to both functional and dysfunctional health behaviors. Second, as this model illustrates, intervention development would benefit from integrating concepts from neuroscience into the study of health behavior change. Third, as we will see later, there may be important neural phenotypes that could assist in tailoring treatment. Fourth, we believe this model is applicable to understanding incentives or desire more generally; habits vary in their strength! If we hope to promote health behaviors among older adults, there is little question that we need to discover the motivational levers that operate for different people in varied contexts. Fifth, we believe a focus on desire has wide application to the design of behavioral interventions and should give pause to health scientists implementing aversive interventions such as highly popular high-intensity physical activity training regimens.

Socio-ecological models

Finally, it is important to note the growing popularity of ecological models of health behavior. Drawn from a biological sciences view of ecology, which is interested in capturing the interplay between an organism and its environment, socio-ecological models identify multiple levels of influence, typically ranging from individual factors such as one’s biological state to broader community, geopolitical, and policy influences. 21 – 23

A key assumption of these models is that researchers can study individuals at various levels of influence, including the individual, community, state, or national level. However, effective health behavior change likely needs to consider the individual as affected by these various levels of influence. For instance, the likelihood an individual sets a goal to eat better, engage in exercise, commute in an active manner, or reduce sitting will be influenced by their built (eg, are there bike paths and healthy food options?) and social (eg, do social norms support healthy behavior?) environments. Similarly, the extent to which the environment is low-stress and perceived as safe may help or hinder an individuals’ ability to adhere to behavioral goals. 24 , 25 They also recognize that environments and those existing within them are in a constant state of flux; thus, interventions should be flexible and adaptable. 23 Clearly, social-ecological approaches to behavior change require considerable resources and time relative to individual-level interventions; however, they also underscore the important role that social and physical environments have on health behaviors, a point we will come back to later.

Across the models/theories reviewed, there is general acceptance for the concept of expectancy-value. That is, people engage in health behaviors because of the belief that the behavior will yield outcomes of value. It is interesting to note that, with the emergence of SCT, the focus has been on self-efficacy even though it is one of the several core constructs alongside incentives and outcome expectations. Although the role of affect and physiological states on health behavior is apparent in SCT, the theory posits that self-efficacy mediates these effects. In addition, it is surprising that researchers have paid so little attention to the incentives underlying health behaviors, how incentives and goals benefit from being linked to core needs central to SCT, and how the affect associated with the incentive value of health behavior may be tempered by the sacrifices that older adults are often required to make when changing their behavior.

Of note is the fact that, as models and theories of health behavior have evolved, there has been an increasing conceptual focus on behavior change. In fact, RP identified the importance of phasic determinants of behavioral maintenance, emphasizing the role of reflexive affect. Peoples’ psychological and physiological states can change over relatively brief periods and cause dramatic shifts in behavioral intentions. Finally, as far back as 1984, Janz and Becker recognized that conscious, decision-based models such as HBM could not explain all health behaviors, specifically noting the habitual drive underlying behaviors such as cigarette smoking. Supported by recent trends in neuropsychology, future research in intervention development must consider the role played by nonconscious processes and, in particular, how to modify these processes.

The concept of mind: theory development and scientific inquiry

We believe there is merit in stepping back for a moment to reconsider the concept of “mind” in greater depth. The reason for this reflection is that how theoreticians/researchers think about the mind heavily influences what they believe to be the primary drivers of behavior. Traditionally separated from the body, behavioral science has conventionally viewed the mind as a faculty of being human that enables people to have an awareness of the world and of their experience; it is responsible for consciousness and gives humans the capacity to think and to feel. The role of the mind or lack thereof in theory development is perhaps most evident the classic work of B.F. Skinner. Skinner proposed that the mind was irrelevant to understanding human behavior; rather, he argued that people behave in response to operant conditioning to reinforcement and/or punishment; promoting the concept of environmental engineering as a means for shaping behavior. Even in contemporary thinking, concepts such as “nudging”, 26 popular in behavioral economics, have shown that some desired health behaviors can be achieved through positive incentives or indirect influence; reemphasizing the point that in some instances the mind, when defined by traditional criteria of awareness, thinking, and feeling, is irrelevant to human behavior. Alternatively, the cognitive revolution that followed Behaviorism and continues to be favored by many theoreticians, places an emphasis on conscious, cognitive processes as determinants of health behavior. 7

As we consider why older adults do or do not behave optimally within the context of medical research or health care, we will continue to reinforce the notion that the health behavior of older adults requires considering multiple levels of influence, some of which obviate the need for conscious decision-making. We will also emphasize that human behavior is not always rational, and that implicit memories and biased processing of information are more common than currently recognized. Most important, we believe that a more complete understanding of why older adults behave as they do within the context of medical research and health care would emerge from a broader, alternative view of the mind. Specifically, we adopt the position that the mind should be conceptualized as a process rather than as an outcome such as a thought or feeling, noting that this process is responsible for regulating energy and information flow, and that this process is both embodied and relational.

The Mind as a Process and Implications for Health Behavior

Paraphrasing Siegel, 27 the human mind is a process that regulates the flow of energy and information between the body, brain, and relationships—thus, it is both embodied and relational (see Figure 3 ). As we will soon demonstrate, defining the mind as a process is consistent with Hebb’s 28 concept of associative learning: neurons that fire together wire together. What begins as energy through activation of neurons eventually becomes information that then defines learning and the formation of memories. Furthermore, as Siegel pointed out, the flow of energy and information occurs not only in the brain, but in conjunction with the body and relationships as well. Conceptualizing the mind as embodied is critically important to understanding health behavior for two reasons. First, it positions various biological inputs that may be either stable or unstable as important determinants of subjective experience and behavior. And second, Glass and McAtee 29 argue that features of the social, built and natural environment become embodied and act as “risk-regulators” that effect health behavior via various biological pathways. In other words, toxic environments adversely affect biological regulatory systems. These systems then become “internal risk regulators” that can have powerful effects on health behavior.

The mind as a process.

Note: Reprinted from Lucas AR, Klepin HD, Porges SW, Rejeski WJ. Mindfulness-based movement: a polyvagal perspective. Integrative Cancer Therapies. 2018;17(1):5–15. 30

This complex, co-dependency between molecules, the mind, and the environment has also been supported by McEwen 31 and is obvious in the area of drug addiction where toxic microenvironments influence exposure to drugs 32 that then lead to molecular and cellular adaptations in the body that result in drug abuse. 33 Drug abuse also leads to other behaviors that can compromise health such as exposure to violence and a rapid drop off in self-care.

When Siegel noted that the mind is relational, he emphasized that the human brain is engaged in a constant flow of energy and information with other people. In fact, as we have just described, micro-social environments serve as a “risk regulator” of drug use. The powerful role of social relationships on health behavior is not surprising. We all enter this world dependent on others for our survival; as one leading neuroscientist puts it, our brains are wired to connect with others. 34 It is important to note that Siegel’s focus on the relational mind emphasized the effect that attachment through close interpersonal relations in childhood has on behavior and well-being. We agree that early interpersonal attachment experience plays an important role in health behavior not only in infancy but also across the lifespan. However, as we note above and consistent with Glass and McAtee, 29 we would argue that the relational mind encompasses powerful influences from social, built, and natural environments that range from the micro to macro levels of analysis.

Figure 4 provides a conceptual model of health behavior that describes the interrelationships between the relational mind (box to the left) and the biological regulatory systems that embody relational experiences (the box to the right). Embodiment occurs when relational experiences alter biological regulatory systems (BRS) through their effects on genetic and biological substrates of these systems. Note the distinction between the body and brain in depicting the BRS. Activity within the BRS at the level of the body directly influences neural networks and neural networks affect functioning of the BRS at the level of the body. Neural networks in the brain give rise to both conscious and nonconscious levels of processing. Of particular importance to models/theories of behavior change is that, for the most part, they operate at the level of conscious processing and ignore the fact that neural networks below the level of consciousness are critically important to health behavior and health behavior change. We also want to emphasize that BRS of the body can effect behavior through both conscious and nonconscious processing. Because our relational experience alters biological regulatory structures of the body and brain, these experiences also affect health behavior through these same pathways. This is readily apparent in how social and physical environmental factors support obesogenic behavior, including physical inactivity. 35

An embodied and relational model of health behavior.

The embodied mind

In addition to addiction, there is a large body of literature supporting the notion that biological regulatory systems influence health behavior either through their effects on conscious subjective experience or via nonconscious processes. An example of such nonconscious effects that comes to mind is the phenomenon termed “sickness behavior”, a cluster of behaviors including decreased movement and increased time spent sleeping, lack of appetite, and the propensity for social isolation. Specifically, what we now know is that the release of interleukin-1 from the immune system stimulates the vagus nerve and, independent of the specific illness, has effects on the central nervous system that fuel this cluster of behavior. 36 Perhaps an even more glaring reminder of the embodied mind is depression. Tiermeier, 37 underscoring the public health significance of this disease in late life, concluded that over 50% of those with severe depression have disturbed glucocorticoid feedback mechanisms. Depression is also common with increasing comorbid conditions associated with aging, a phenomenon that appears to be related to inflammation and cell-mediated immune activation. 38 Not surprisingly, researchers have investigated the adverse effects that depression has on expectations and motives to engage in desired health behavior. For example, it is well known that depression is related to obesity 39 and sedentary behavior. 40 Additionally, there is evidence that digestive health plays a role in affect and emotion 41 and that gut bacteria can motivate people to pursue the consumption of specific macronutrients. 42 Data suggest that inflammation is a correlate of inactivity. 43 – 45 Moreover, body fat is associated with increased inflammation, whereas intentional weight loss in older adults lowers body fat and reduces inflammation. 46

Equally important is an awareness and appreciation of the fact that dynamic changes in biological regulatory systems and their substrates across relatively brief periods can profoundly influence functional brain networks and subjective states. For example, in a study of obese older adults, we found that craving for favorite foods dramatically increased over a period of 3 hrs when restricted to consume water only versus ingesting a meal replacement. 47 Even more interesting was the fact that following this brief fasting period, functional imaging of the resting state brains in the water only condition looked similar to what you would see in other addictive behaviors, brain states that differed dramatically from resting states taken following consumption of a meal replacement.

We do not want to create the impression that we are encouraging investigators to treat subjective experience as subordinate to objective biological influence in the study of health behavior. In this regard, we want to make two points. First, we believe that biological regulatory systems play a particularly potent role in certain health behaviors. This point has been made for addiction. 33 Yet, even in the case of addiction, it is clear that the precise embodiment of micro-social environments is not a given. "Medical researchers are correct that the brain changes with addiction. Nevertheless, the way it changes has to do with learning and development—not disease. Addiction can therefore be seen as a developmental cascade, often foreshadowed by difficulties in childhood” (page xiii). 2

Second, there is evidence that the role of biology in health behavior likely interacts with a person’s subjective sense of agency. For example, in a prospective study, we tracked 480 older men and women who had knee pain on most days of the week to examine how lower leg strength and baseline self-efficacy influence decline in stair climbing performance across 30 months. 48 What we observed was that older adults with low strength (estimated at the 25th percentile) and low self-efficacy (estimated at the 25th percentile) experienced a 4.15-s decrease in their stair climb performance that was statistically inferior in performance to any other subgroup. The other subgroups (high strength and low self-efficacy; low strength and high self-efficacy or high strength and low self-efficacy) lost about 1.30 s in their stair climb time and were not distinguishable from one another. In short, having high self-efficacy for the stair climb task buffered the effects that low strength was expected to have on decline in task performance.

Indeed, self-efficacy nicely illustrates the interplay between bodily states and the brain. The extent to which one’s self-efficacy beliefs are under the influence of fluctuations in biology differs depending on an individual’s experience in the behavior at hand. For a novice, efficacy beliefs are volatile and likely to change in response to shifting biological and psychosocial states, for example, momentary increases in muscle soreness and fatigue. Conversely, those with experience tend to display stability in their beliefs regarding their capability, and these beliefs are likely to persist despite momentary setbacks. 49

Whereas dynamic biological systems can influence the motivation to approach or desire specific substances or outcomes, equally important is how the body influences the motivation to avoid behavior. In fact, Porges 50 has argued that a major evolutional attribute of the human nervous system is the nonconscious motive to identify threat and thus to avoid harm to oneself. In fact, this probably explains why, when threatened even modestly as is true with many health events, people have a hard time thinking about anything but escaping the threat. Within the nervous system, the ventral root of the vagus nerve serves this function and one can estimate activity of this pathway linking body to brain via a biomarker known as respiratory sinus arrhythmia (RSA). 50 As a person is threatened and the threat exceeds resources, RSA decreases and there is a concomitant increase in sympathetic nervous system activity. A major consequence of a decrease in RSA is that the brain becomes less reflective and acts automatically as a means of neutralizing the threat—favoring neural pathways that result in a rapid response. This distinction between the capacities for slow, reflective cognitive processing of input versus a fast, automatic mode is a core principle of dual-processing models of social cognition. 51 , 52 Both low tonic levels of RSA (resting) and high phasic levels in response to withdrawal from stress are relevant to behavior change because they can promote behavioral and affective responses that can be inconsistent with consciously stated goals: “I know that I should stop eating snack food, but it helps me to get through the strain in my marriage.” Potential consequences of a dysfunctional vagal brake in aging might include outcomes such as a decrease in life space, social isolation, a lack of openness to adopting preventive health behaviors, increased likelihood of relapse, excessive sedentary behavior, dropping out of treatment, and the exacerbation of pain.

We want to end this section by pointing out that biological regulatory systems are likely to be useful in understanding individual differences in response to behavioral interventions. For example, Hendershot and colleagues 11 reviewed the growing literature of genetic influences on treatment response and relapse. They concluded that genetic polymorphisms moderate treatment effects for a variety of addictive behaviors including smoking, alcohol, and drug abuse through a range of metabolic and neurotransmitter pathways. Recently, research from our lab 53 used baseline dynamic brain networks from functional magnetic resonance imaging (fMRI) to identify older, obese, adults most likely to succeed in a behavioral weight loss intervention. We combined machine learning and functional brain networks to produce multivariate prediction models using baseline data to predict success with weight loss (a median split on percent weight lost) following 18 months of treatment. Older adults above the median lost on average 13.96% of the body weight, whereas it was 2.87% for those below the median. The prediction accuracy of our model was 95% as compared to static and random models that were either at or below 50%. Principal component analysis of the data suggested that effective self-regulation involved both nonconscious and conscious processes. 53

The relational mind: attachment

Having established the concept of the mind as an embodied process, we next examine why it is also important to consider the interpersonal, relational nature of the mind as an integral topic of theoretical inquiry into health behavior and aging. As infants come into the world, they directly connect with sources of energy and information flow communicated by significant others through physical proximity, nonverbal cues, and vocal tones. Cozolino 54 argues that just as neural synapses enable the flow of energy and information between neurons, people also exchange the flow of energy and information with others via social synapses. Shaw and colleagues, using a large national database, 55 found that a lack of emotional support from parents early in life was prospectively related to increased depression and chronic health conditions that persisted across the lifespan. Moreover, Mate 56 in a Canadian bestseller argued persuasively that early emotional disturbances steer people toward addiction. He is not alone in this promoting this thesis, and it would appear relevant to a range of health behavior including drugs, alcohol, smoking and even dietary choices. 57

Polyvagal theory provides a strong theoretical rationale for the fact that it is the ventral vagus nerve and its network of connectivity with other cranial nerves in the brainstem that serves as the main neural enabler of social connection in infancy and throughout the lifespan. Positive attachment, via this embodied network of connection with others, results in feelings of safety and security. Logically, polyvagal theory 50 posits that safety established through social connection is the primary need state of humans (note the overlap with core needs within SDT) and that failure to satisfy this need results in a variety of psychiatric complications. In fact, there is a substantial body of literature linking developmental dysfunction in RSA to psychopathology. 58 What we do not know at this point is whether developmental deficiencies in RSA lead to excessive health care utilization and accelerated rates of disability as people age.

The relational mind: micro- and macro-social/physical environments.

Because human relations extend well beyond primary caregivers, as discussed and depicted in Figure 4 , health behavior is profoundly affected by micro- and macro-relational effects. The effects are often due to “…constraints that limit choice and the role of normative structures that shape the social values attached to activities, identities and choices. It also engages themes of inequality and power in society” (pp. 79–80). 1 While one might typically conceive of these influences as exclusively social in nature, through experience, people become part of a relational fabric of existence with their physical and economic environments. For example, it is well known that physical features of neighborhoods, such as walkability 59 and safety 60 play a role in the physical activity behavior and social interactions of older populations.

Without question, a powerful social influence on health behavior of older adults, beyond early attachment, involves family members’ role in scheduling screening visits, managing medications, and noticing changes in function that warrant medical attention. 61 While these effects are generally favorable, family members can also have a negative impact on the health of older family members by being overprotective, and through various means restrict their life space and activity levels. These adverse consequences reflect the powerful role that ageism has on the health behavior of older adults. 62

Interestingly, there is evidence that as the complexity and size of social networks decline with aging, the effect of social forces on health behavior also decreases. 63 Perhaps this is one area where careful application of technology could be useful. Specifically, facilitating regular face-to-face communication (eg, via video telephony) with peers and with health care providers may be especially powerful on the well-being of individuals who are socially isolated. However, it is important that the use of technology is carefully considered, as increasing perceived isolation can be an adverse side-effect as well. For instance, the widespread use of automation in digital health interventions should be balanced with the cost and time burden of personal contacts, as automated programs may reduce meaningful face-to-face interactions with health care providers. In fact, there is emerging evidence that younger individuals who are the highest users of social media sites, which often maximize brief and effortless contacts instead of more effortful face-to-face communication, perceive greater isolation. 64 Still, with a careful approach to the design of digital health tools, robust social contacts can be extended to individuals who are at present socially and geographically isolated.

Also deserving attention is the topic of multiple exposures to toxic micro- and macro-relational environments. Lynch and colleagues 65 reported in the New England Journal of Medicine on how cumulative economic hardship affects the functional health of older adults. They defined economic hardship as an income <200% of the poverty level in 1965, 1974, and/or 1985. They found a strong-graded association between the number of times individuals were classified experiencing economic hardship (0, 1, 2, or 3) and the risk ratios for poor physical, cognitive, and psychological health. Others have reported a dose–response relationship between both the number and duration of toxic relational environments and disease risk. 66 , 67 Glass and McAtee 29 concluded that late life appears to be a period of increasing vulnerability to the cumulative effects of disadvantaged social and economic environments.

As aging research on health behavior advances, we want to emphasize our belief that researchers should pay more attention to micro-relational effects on health behavior, specifically, a focus on physician–patient interactions and the value of small group interactions on the health behavior of older adults. We base this position on the knowledge that attachment behavior is a lifespan need with peaks at both ends of the age spectrum. As espoused by polyvagal theory, 50 self-determination theory, 16 and advances in neuroscience, 34 we are wired for and need close human relationships. Epstein 68 has called upon medicine to rebuild a health care system that prioritizes attentive listening and compassion, a shift that would benefit the health of physicians and provide meaningful, close interpersonal experiences for patients. Illness, disease and the loss of function that occur with aging are major sources of threat to personal safety. In the midst of these threats, a powerful antidote can be active listening and compassion in the care of older adults.

Likewise, we believe there is opportunity in leveraging the social power of small group interactions between older adults. As an example, we have been promoting group-mediated behavioral interventions as a means of delivering movement-based and weight loss programs to older adults for close to 20 years. 69 – 72 Run in small groups of 8–15 participants, they use the group as an agent of change, that is, as a vehicle to promote self-regulatory skills, to enhance a sense of agency, and to increase commitment to change. Consistent with Epstein, 68 group leaders are taught to model and promote active listening and compassion among group members. Moreover, the group is used as a means of bringing awareness to what Neff 73 terms “community humanity”, that is, an appreciation for the fact that you are never alone in the struggle to make change or to deal with behavior change in the face of adversity.

In closing this section, one point we want to emphasize is that as one moves from micro- to macro-relational effects, level of personal control decreases. For example, there is no doubt that social programs and health policies influence the health behavior of older adults; however, the average individual has no control over how these programs or policies operate. Clearly, however, as we have observed with federal laws related to smoking, macro-level influences on health behavior warrant serious attention due to their potential effect on population health.

Summary and conclusions

There are several areas identified in this review that are important to aging research on health behavior. First, health behavior is highly influenced by dynamic in-the-moment processes that may originate in the environment, the body, and the brain 11 , 74 suggesting that the concept of awareness should be key to theories of behavior change. Awareness is a multidimensional concept, including in-the-mome n t awareness of (a) the target behavior, (b) the processes that lead to the behavior, and (c) action plans to interrupt these in-the-moment processes. To this end, we believe that emerging digital health tools, such as in-the-moment self-reports enabled via ecological momentary assessment and connected monitoring devices (eg, activity monitors, location sensors) offer tremendous resources for enhancing awareness of behaviors and factors that enhance or impede health behavior change. However, as with the application of technology for reducing social isolation, we would emphasize that digital health tools should be used in a manner that enhances awareness of one’s behavior without fostering negative psychosocial states that act against an individual’s ability to self-regulate. For instance, we would caution against delivering content on a social media platform alongside unregulated content that increases stress and results in ruminative thought processes. Clearly, additional research is needed in the area of aging and the role of technology in health behavior change.

Additionally, the dynamic nature of health behavior casts doubt on the ability to adequately assess constructs using static study designs in which measures are taken at baseline, usually at a single time point during the day, and then again at one or two follow-up visits across the span of several weeks, months, or years. As we have shown, subjective states related to the regulation of health behavior can change in a matter of hours as a result of fluctuations in physiologic state. 47 This lack of attention to within-person variability compromises the goal of social science to understand mechanisms of health behavior change. This seems particularly important to the study of older adults given the variability created by aging biological systems, chronic health conditions, and the prevalence of physical symptoms such as pain and fatigue. This also holds implications for the design of health promotion interventions, which typically reply on a small number of weekly contacts between participants and their group members. This leaves individuals alone in their effort to overcome these powerful transient behavioral influences. Here again, mHealth tools may provide a bridge to social connection and to in-the-moment interventions during particularly challenging times.

Second, most theories of health behavior focus on conscious psychological processes, yet it is apparent that health behavior is highly influenced by nonconscious processes. 74 Indeed, health behavior is often under the control of stimuli from the environment and signals within the body—automatic responses resulting from brain networks that have been shaped through experience dependent learning across the lifespan. 75 Additionally, the digital age and advanced marketing strategies have accelerated the degree to which human behavior is subject to and controlled by environmental influence. With the nonconscious flow of energy and information empowered by fixated attention to internet-connected devices, powerful developmental experience, and rumination over multiple threats to the self, future theories and interventions on health behavior require expansion beyond conscious-derived constructs. In fact, one promising topic of influence in this area has been research on the role of implementation intentions in priming adaptive responses to contexts that normally short-circuit attempts to change behavior. 74

Third, it is clear that the relational nature of the human brain to the environment and to other people is central to health behaviors and attempts to change these behaviors. This was apparent in our discussion of the role that nonconscious processes play in health behavior. As noted previously, early life adversity created by impoverished social environments create “…constraints that limit choice and the role of normative structures that shape the social values attached to activities, identities and choices” (pp. 79–80). 1 While this adversity may stem from poverty and limited resources, the lack of trust and connection to others caused by developmental trauma constitutes an underappreciated influence on health behavior. As noted by Duffy and colleagues, 75 the negative impact of living in impoverished social environments and the existence of early attachment-related trauma on health behaviors are likely due to resultant dysfunction in brain networks that are critical to effective self-regulation as people age. The challenge these barriers create for behavior change are monumental and largely nonconscious.

Finally, in an attempt to understand and change health behavior, recent research suggests that greater attention should be devoted to the incentive value of health behaviors and affective processes that occur prior to, during and following the enactment of these behaviors. 17 How can we design behavioral interventions to optimize affective processes that facilitate the adoption and maintenance of positive health behaviors among older adults? As reviewed in this paper, answers to this question likely require intervention development targeting multiple levels of influence. It also requires paying close attention to the psychophysical state of older adults. Life transitions such as the onset or exacerbation of chronic disease, the death of a spouse, and coping with the biology of aging can drain the incentive value from either adopting new health behaviors or maintaining good health practices in the midst of emotional discord.

Acknowledgments

This paper was prepared for the keynote presentation at an NIA sponsored workshop for the Research Centers Collaborative Network (RCCN, December 2018) entitled “Achieving and Sustaining Behavior Change to Benefit Older Adults”. Partial support for this paper was provided through NIH/NIA funding: R56 AG051624.

The authors declare that there are no conflicts of interest in this work.

Health Belief Model

Health Belief Model is a unique model that gives an insight and prediction of health behaviors. This has been achieved through monitoring one’s beliefs and attitudes at different intervals of time. This belief model has some constructs that are used to determine one’s attitude and behavior. Perceived susceptibility is a construct that gives one’s opinion when it comes to the chances he/she has of getting a predetermined condition. The second construct is perceived severity which revolves around the opinion one has about how severe a condition is. In addition to that, perceived severity also outlines one’s opinions regarding the consequences associated with a particular condition. The third construct is perceived benefits. This construct talks about a different belief that one has when it comes to the efficacy of an action to be taken with the aim of minimizing risk and consequences that come with that particular action. Perceived barriers is another construct that is instrumental in the model. It revolves around an individual’s thoughts about both psychological and tangible barriers against a cause of action. Cues to action are the last construct that tends to outline various events or people that could be used to explain a particular cause of action diligently. All these constructs are interdependent because they all involve behavioral matters in an individual.

Perceived susceptibility gives a clear outline of the populations that are at risk, and the risk levels associated with the condition. Populations that are at risk, in this case, are those that are in a dynamic environment where there is little or no enforcement of the law (Greene, 2013). In this case, it is important to note that the risk levels vary from one individual to another since it is largely dependent on emotions.

When it comes to perceived barriers, one can able to identify the obstacles that are a hindrance to a successful anger management plan. In this case, one identifies the barriers that inhibit the process of anger management (Corcoran, 2007). The second step is followed by reducing the identified barriers through assistance, incentives, and reassurance.

1. Becker, M. (2012). The Health belief model and personal health behavior. San Francisco: Society for Public Health Education.

2. Corcoran, N. (2007). Communicating health. Los Angeles: SAGE.

3. Greene, I. (2013). Anger management skills for adults. San Diego, Calif.: P.S.I. Publishers.

4. Hershey, J. (2009). Formalization of the health belief model (2nd Ed.). Philadelphia: National Health Care Management Center, University of Pennsylvania.

5. Krueger, L. (2009). Anger management. Detroit: Greenhaven Press.

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