Marshall H. Becker

Social Learning Theory and the Health Belief Model

The Health Belief Model, social learning theory (recently relabelled social cognitive theory), self-efficacy, and locus of control have all been applied with varying success to problems of explaining, predicting, and influencing behavior. Yet, there is con ceptual confusion among researchers and practitioners about the interrelationships of these theories and variables. This article attempts to show how these explanatory fac tors may be related, and in so doing, posits a revised explanatory model which incor porates self-efficacy into the Health Belief Model. Specifically, self-efficacy is pro posed as a separate independent variable along with the traditional health belief var iables of perceived susceptibility, severity, benefits, and barriers. Incentive to behave (health motivation) is also a component of the model. Locus of control is not included explicitly because it is believed to be incorporated within other elements of the model. It is predicted that the new formulation will more fully account for health-related behavior than did earlier formulations, and will suggest more effective behavioral interventions than have hitherto been available to health educators.

SOCIOBEHAVIORAL DETERMINANTS OF COMPLIANCE WITH HEALTH AND MEDICAL CARE RECOMMENDATIONS

Over the past two decades, hundreds of articles, editorials, and commentaries have been published describing the considerable disruptive effects on quality of care of individual noncompliance with health and medical advice. While much research has been directed at determining factors responsible for poor compliance, past studies have tended to focus upon easily measured characteristics of the patient, regimen, or illness which, unfortunately, are usually neither predictive nor alterable. This paper systematically reviews the literature on patient acceptance of recommended health behaviors, attempting to find social-psychological and related variables which have proven to be consistent predictors of compliance. The review suggests that certain health beliefs (especially personal estimates of vulnerability to, and seriousness of, the disease, and faith in the efficacy of care), health-related motivations, perceptions of psychological and other costs of the recommended action, various aspects of the doctor-patient relationship, and social influence arc the most productive dimensions for present intervention and further exploration. Building upon an earlier formulation, an hypothesized model is presented which combines these elements for explaining and predicting compliance behavior. Further research should, with standardized questionnaires and analysts techniques, employ prospective, experimental designs for a variety of population groups, settings, and regimens, to evaluate the ability of practical attempts to modify the model variables and thus enhance compliance.

The Role of Self-Efficacy in Achieving Health Behavior Change

The concept of self-efficacy is receiving increasing recognition as a predictor of health behavior change and maintenance. The purpose of this article is to facilitate a clearer understanding of both the concept and its relevance for health education research and practice. Self-efficacy is first defined and distinguished from other related concepts. Next, studies of the self-efficacy concept as it relates to health practices are examined. This review focuses on cigarette smoking, weight control, contraception, alcohol abuse and exercise behaviors. The studies reviewed suggest strong relationships between self-efficacy and health behavior change and maintenance. Experimental manipulations of self-efficacy suggest that efficacy can be enhanced and that this enhancement is related to subsequent health behavior change. The findings from these studies also suggest methods for modifying health practices. These methods diverge from many of the current, traditional methods for changing health practices. Recommendations for incorporating the enhancement of self-efficacy into health behavior change programs are made in light of the reviewed findings.

The Health Belief Model and Sick Role Behavior

Most research directed a t understanding ”activity undertaken by those who consider themselves ill, for the purpose of getting well” has yielded an unsystematic multiplicity of findings which are often either not predictive of such patient compliance,’” or are mutually contradictory.7.8 These difficulties arise, in part, from past dependence on a “medical” model of patient behavior, which stresses such easily identified and quantified dimensions as characteristics of the patient (e.g., demographic and social),6~B~lO the regimen (e.g., type, complexity, discomfort, duration),ll-l3 and the illness (e.g., medically-defined seriousness, duration, disability).7,14J5

Understanding and Improving Patient Compliance

The problem of patient compliance, as well as the ability of the physician to understand, detect, and improve compliance are described in relation to a new model of health decisions and patient behavior. The health decision model combines decision analysis, behavioral decision theory, and health beliefs. This model provides a framework for modifying general health beliefs; treatment recommendations; experience with therapeutic regimens and health care providers; patient knowledge and social interaction patterns. Physicians, guided by certain ethical restraints, are in a unique position of responsibility and opportunity to actively encourage patient compliance with treatment.

AIDS and behavioral change to reduce risk: a review.

Published reports describing behavioral changes in response to the threat of AIDS (acquired immunodeficiency syndrome) are reviewed. These studies demonstrate rapid, profound, but expectably incomplete alterations in the behavior of both homosexual/bisexual males and intravenous drug users. This is true in the highest risk metropolitan areas such as New York City and in areas with lower AIDS incidence. Risk reduction is occurring more frequently through the modification of sexual or drug-use behavior than through its elimination. In contrast to aggregate data, longitudinal descriptions of individual behavior demonstrate considerable instability or recidivism. Behavioral change in the potentially vulnerable heterosexual adolescent and young adult populations is less common, as is risk reduction among urban minorities. Reports of AIDS-related knowledge and attitudes generally parallel the pattern of behavioral changes. Nonetheless, few studies investigate the relationship of knowledge and attitudes to risk reduction. Future studies should provide much-needed information about the determinants as well as the magnitude of behavioral changes required to reduce the further spread of AIDS.

The Health Belief Model and HIV Risk Behavior Change

The Health Belief Model (HBM) was initially developed in the 1950s by a group of social psychologists in the U.S. Public Health Service in an effort to explain the widespread failure of people to participate in programs to prevent or to detect disease (Hochbaum, 1958; Rosenstock, 1960, 1966, 1974). Later, the model was extended to apply to people’s responses to symptoms (Kirscht, 1974) and to their behavior in response to diagnosed illness, particularly compliance with medical regimens (Becker, 1974). Over three decades, the model has been one of the most widely used psychosocial approaches to explaining health-related behavior.

The Health Belief Model: Origins and Correlates in Psychological Theory*

The Health Belief Model relates psychological theories of decision making (which attempt to explain action in a choice situation) to an individual’s decision about alternative health behaviors. Rosenstock 1 has attributed the origins of that tradition of behavior motivation theory underlying the Health Belief Model to Lewinian 2 theory of goal setting in the level-of-aspiration situation (a special case of the latter’s general field theory). Lewin and associates hypothesized that behavior depends mainly upon two variables: (1) the value placed by an individual on a particular outcome and (2) the individual’s estimate of the likelihood that a given action will result in that outcome.

Selected Psychosocial Models and Correlates of Individual Health-Related Behaviors

RELATIVELY LOW LEVELS of public participation in screening, immunization, and other preventive health programs have been extensively documented,21 50 55, 91 as have the generally poor rates of individual compliance with prescribed medical therapies.42, 52, 81, 86 Over the past two decades, hundreds of research reports and review articles have been published reflecting the desire to both discover and better under-

Self-Management of Chronic Disease by Older Adults A Review and Questions for Research

This article summarizes the literature describing the at-home management of and psychosocial coping with five chronic diseases (heart disease, asthma, chronic obstructive pulmonary disease, arthritis, and diabetes) by the general population of adults. It also reviews the literature describing self-management of these chronic diseases by older adults. Conclusions drawn subsequent to the review are (a) that there are strong commonalities in the essential nature of tasks that exist across disease entities, (b) that the context for self-management of disease by the ill elderly is likely to differ somewhat from the context for other age groups. Questions for future research are posed.