Outline of Health Belief Model and Protection Motivation Theory and their Application to Screening Behaviour.Introduction
The aim of this essay is to describe health belief model (HBM) and protection motivation theory (PMT), their application to screening behaviour, prediction they offer and some of the research done in the area. Furthermore, personal understanding, criticism, models’ comparison and possible additions will be discussed. In the end, decision will be made on which model offers the best understanding and prediction of screening behaviour.
Both competing models will be defined later, however, there is a need for brief definition of screening now. Screening behaviour can be defined from various sources. According to NHS website screening is a public health service generally aimed at certain population. Its purpose it to reduce risk of disease and this is usually done by asking questions and carrying out tests (Screening: a definition, 2009). The multiattribute utility model defines screening as “a behaviour employed by health care consumers to maximise health gains” (Yarbrough & Braden, 2001, p. 678). On the other hand the cognitive transactional model of stress and coping defines screening as “a way to cope with anxiety associated with being at risk” (Yarbrough & Braden, 2001, p. 678). It is important to understand that screening is a process not a status. It requires stages of contemplation and action in order to be accomplished (Yarbrough & Braden, 2001 ). It can involve attending screening examination performed by health professional at a clinic, or it can be a self-screening behaviour performed in privacy. Self-screening involves systematic examination of one’s body in order to detect abnormalities or illness (McCaskill, 2006). All definitions of screening or screening behaviour have been accepted for the purpose of this essay and first psychological model to be described is health belief model followed by protection motivation theory.
Health Belief Model and Screening
Since 1950s many researchers (for example Hochbaum, Zola, Rosenstock, Suchman) concentrated on developing theoretical models which would explain health related behaviours (Becker, Maiman, Kirscht, Haefner, & Drachman, 1977). Most of the attention was directed at health belief model which was consolidated with a paper written by Becker et al. published in 1977 (Conner & Norman, 2005). Since then this model has been widely researched and used in exploring and predicting 3 main areas of health related behaviour: sick role behaviours, clinic use and preventive health behaviours (Conner & Norman, 2005). Model’s basic components were derived from Lewin’s work of value-expectancy in which decision is predicted from the value of outcome and the expectation that action will result in this outcome (Becker et al., 1977). Original model had three major elements: threat perception comprising of perceived severity (how serious the illness is) and susceptibility (how likely is one to get the illness); perceived benefits of health behaviour; and perceived barriers/cost of health behaviour (Becker et al., 1977). Existence of internal (for example symptoms) or external (for example advice) cues to action and various demographic and sociopsychological variables was also identified. However no causal relationships were described, which made it harder for the model to be well understood and applied (Becker et al., 1977). Further research has enriched and partly operationalised HBM into its current form which is best described by 1.
The model’s generic presumption is that if a person thinks that illness can be prevented, and also has a positive expectation that by taking action this condition can be avoided and, furthermore, if the person believes that he or she can successfully perform this action and benefits outweigh the cost of new behaviour, then this person is likely to perform health protecting behaviour (McCaskill, 2006). In case of this essay the performed behaviour is health screening.
HBM has a long research history and broad applicability and it is the most widely used framework for understanding and predicting health behaviours (McCaskill, 2006). However, it can be argued that there is a need for a situational or environmental factor to be included as individual component of HBM. Reason behind this is that sometimes screening behaviour relates to sexual organs or other sensitive areas (for example rectum) and requires attendance at clinic. In these circumstances characteristics like health professional’s gender, sensitivity and professionalism as well as privacy and comfort of environment are often situational and out of patient’s control. As a result of these, situational factors can become important influence in regards to attendance and individual’s confidence and satisfaction (DeHart, 2008).
Past experience and self-efficacy particularly are not well captured in HBM. Past behaviour is important source of information because people generally think about their future behaviour according to how they behaved in the past (Umeh, 2004). However, it could be argued that past behaviour and its effects on individual could be part of psychological factors. The same could apply for self-efficacy which is important in coping behaviour (Bandura, 1977) and which is missing as independent variable as well. The lack of definition of psychological factor allows it to be as flexible as one wishes, which might be practical in real life, but can pose serious problems for research.
Although major components are captured well in HBM, criticism could be aimed at its internal relationships. Health motivation has the potential to influence threat perception (perceived susceptibility and severity), behavioural evaluation (perceived benefits and barriers) and cues to action. It could be argued that health motivation is imbedded in individual’s self-preservation instinct. Health motivation could sensitise individual to recognise cues in environment or body and, therefore, in a way start up and influence the process of threat perception and behavioural evaluation. On the other hand, outcome of behavioural evaluation (whether perceived barriers outweigh perceived benefits or vice versa) could influence the strength of the health motivation. In turn the threat perception process (whether we feel at risk or not) could again influence the strength of the health motivation. The lack of operationalisation of the HBM has already been identified in the literature as the weakness of this model (Conner & Norman, 2005).
Chang, Hung, Chou, & Ling (2007) conducted study in which they looked on taking up X-ray as screening behaviour for tuberculosis (TB) among indigenous nursing students in Taiwan, as this country still has high rates of TB incidence and mortality predominantly in rural areas. At the moment, annual chest X-ray screening is compulsory in Taiwan for everyone over 12 years of age in order to facilitate treatment and prevent cross-infection. This screening has not been entirely effective in upland and rural area largely due to logistic reasons. In order to promote screening, Taiwanese government is providing financial incentives to health professionals to motivate them to return to their hometown and serve their community but the description of these incentives is lacking. It can be presumed that Chang at al. (2007) meant good salary and other personal financial rewards. This could be a good idea and motivating factor, however, it might be difficult to enjoy this financial incentives in rural areas with limited access to facilities where money can be spent or which would enable health professionals to carry on with lifestyle they adopted in more developed towns. Explanation would be welcomed from authors of the research on how effective are these financial incentives in promoting return to hometown and thus more accessible health care and TB education in rural areas. This has not been discussed and it might provide some explanations of why are people at indigenous areas at much higher risk. The interesting point here is that if health care professional returns to his or her own community where he or she is well-known and respected then he or she can also become a model and, therefore, influence screening behaviour in this way as well. Health professional can in a way become a cue to action. Chang at al. (2007) randomly selected 1000 students and had 865 self-report questionnaires returned. Sample, sampling, measures and procedure were well described in the research report and provide support for its results. Important finding is that the average score on knowledge questionnaire (infection, treatment, symptoms and prevention of TB) was 61%. Considering that participants taking part in the study were nursing students this is a poor result, suggesting that the knowledge of TB in generic population might be even worse. This finding is yet more significant when one considers that knowledge was associated with perceived benefits and barriers to preventing TB in Chang at al. (2007) research report. Chang at al. (2007) identified this weakness and suggested and recommended health education programmes targeted specifically on TB. This can be considered a strong advantage of their study as it provides practical implementation that can improve health screening and prevention targeted at TB. Overall, Chang at al. (2007) findings indicates that indigenous nursing students who scored higher on perceived severity and susceptibility and had lower perception of barriers showed a higher intention to take up X-ray screening in line with HBM’s presumption. The most significant benefit motivating preventive behaviour was early detection enabling early treatment. Disadvantage of their research report is that it only used self-reported measure of intention and not actual behaviour. Therefore, results apply only to the intention of taking up screening rather than the screening behaviour itself. In Chang at al. (2007) research, it has been pointed out that lack of accessibility of screening facilities presents a significant barrier to act (but not to intention to act). This provides evidence that barriers have a valid place in HBM and also support their importance when trying to predict and influence health screening behaviour. In conclusion, results of Chang at al. (2007) study provide support for ability of HBM to predict screening behaviour.
Chang at al. (2007) research described importance of the knowledge on promoting screening behaviour. On the other hand, a good example where knowledge can become a barrier to some extent are findings reported by McCaskill (2006) which suggest that fear of death and physical disment as a result of discovering breast cancer can lead to denial and hinder cancer screening behaviour. Therefore, it is accurate to assume that knowledge as a mediating factor is dependant on various aspects, for example, type of illness and its consequences and how is the information passed on. Consequently, it is necessary to consider carefully how this knowledge is used in intervention. Protection motivation theory offers possible explanation for these finding but this will be discussed later in the conclusion.
Psychological and demographic variables were not well captured in most of the studies researched for the purpose of this essay which might be due to their high individuality. Nevertheless, their possible influences were considered to some extent in most of the research examined. A good example of study concentrating primarily on psychological factors is research about breast health screening behaviour amongst lesbians published by DeHart in 2008. In her study she found that psychological variables (sexual orientation) did to a certain degree hindered communication with health care professional, care received and frequency of attending breast screening service. It can be argued that this could lead to increased risk of diagnosing breast cancer later and to increased seriousness of the illness. However, DeHart’s (2008) research report has got numerous limitations (for example small sample, self-report measures which were not statistically evaluated) and, therefore, further research would be needed in order to generalise findings. Another research that considers psychological factors which are important in application of HBM is the study concentrating on personality through five-factor model by Vollrath, Knoch, & Cassano published in 1999. These authors identified that neuroticism is related to tendency to worry about one’s health and inflate perception of disease symptoms. On the other hand, consciousness had negative effect on perceived susceptibility.
In conclusion, health belief model is able to explain and predict health screening behaviour although it has its weaknesses.
Protection Motivation Theory and Screening
PMT was developed by Rogers in order to understand the impact of fear appeals (Conner & Norman, 2005; Milne, Sheeran, & Orbell, 2000). Fear appeal is a form of communication about a danger which also suggests ways how to avoid or reduce this threat (Milne et al., 2000). Since then research has concentrated in two main areas: where PMT has been used to develop persuasive communication and as a tool to predict health behaviour (Conner & Norman, 2005). One of the core assumptions of this model is that if information causes fear then individual will be motivated to reduce this unpleasant emotion (Conner & Norman, 2005). One could argue that as outlined in operational conditioning, fear reduction can evoke positive emotion of relief which will become reward for the action and, therefore, reinforce the behaviour in the future. However, for this assumption to work it is crucial that information does contain advice and this advice must have a potential to reduce fear. If this is not the case then maladaptive behaviour in form of denial or avoidance can be used as a way for reducing fear (Conner & Norman, 2005). Rogers’s PMT model was based on work of team of researchers lead by Hovland (Conner & Norman, 2005). It was suggested that fear appeal has 3 main variables and Rogers has assigned to these corresponding cognitive process: severity of the noxious event (perception of severity); probability that this event will happen if new behaviour is not created or old one changed (perception of vulnerability); and efficacy of the response to reduce or eliminate the event (perception of response self-efficacy) (Conner & Norman, 2005; Milne et al., 2000). These perceptions then influence protection motivation which can be defined as intention to follow the behavioural advice (Conner & Norman, 2005) or as an intention to perform protective behaviour (Milne et al., 2000; Helmes, 2002). Difference between these two definitions will be reasoned later. Criticism of this early model of PMT would relate to the picture it draws here about an individual just being a puppet and if one pulls the right string individual will move the way one wants him or her to move and follow the advice. Further research seemed to have recognised this weakness and other variables were added, for example past experience, self-efficacy or personality (Conner & Norman, 2005). It was proposed by Rogers (as cited in Conner & Norman, 2005) that within PMT model there are two independent appraisal processes evoked by internal (within body) or external information: threat appraisal and coping appraisal. PMT is best summarised by 2. which will be closely described below (Conner & Norman, 2005).
Threat appraisal concentrates on threat and factors that can influence the maladaptive response (for example denial, wishful thinking or hopelessness). Such factors are severity of the threat and vulnerability to the threat which generally seem to inhibit maladaptive response (Conner & Norman, 2005; Milne et al., 2000) and motivate people to act in health protecting way. It was encouraging to see that literature (Conner & Norman, 2005) has recognised existence of rewards which can keep the maladaptive behaviour going, for example pleasure that maladaptive behaviour can bring (intrinsic) and social approval/expectation for this behaviour (extrinsic) which were not accounted for in original Hovland’s model (Conner & Norman, 2005). The balance between coping and maladaptive response here depends on which fear is bigger, the fear of getting sick or fear of loosing rewards of immediate situation which usually is providing some benefits (bringing pleasure or peer’s acceptance). According to Orbell, Perugini, & Rakow (2004), there are personal differences which influence whether individual concentrates on more immediate needs or future implications and this needs to be accounted for when intervention is designed. These differences further stress the importance of individual or group tailored interventions. Orbell et al. (2004) found that person with low orientation on future is more likely to undergo screening when positive outcomes are immediate and negative consequences are seen as more long term. Vice versa, person with high orientation on future is more likely to attend screening when long term consequences of the screening are positive and immediate outcomes are negative. This is a very important finding that can make advice more effective because the content of communication affects the decision made.
Coping appraisal concentrates on coping response (for example following behavioural advice) and factors that influence it. Such factors are the belief in effectiveness of coping response (response efficacy) and belief that one is able to execute this behaviour (self-efficacy). However, response cost or barriers might inhibit coping behaviour (Conner & Norman, 2005). Protection motivation will emerge if individual facing threat of illness perceives severity and vulnerability to an illness in a degree which outweigh rewards of maladaptive behaviour and, furthermore, his or her perception of response efficacy and self-efficacy outweigh cost and barriers associated with adaptive behaviour (Conner & Norman, 2005).
It would be wise to come back to the definition of protection motivation now. If it is defined as an intention to perform a recommended behaviour/advice (Conner & Norman, 2005) then this definition would have to be considered too narrow. It would be more effective to expand the understanding of health motivation to any form of health protecting behaviour as defined by Milne et al. (2000). Following example will demonstrate why. A person at high risk of heart attack is advised by doctor to increase appropriate exercise (advice) in order to reduce the risk (fear appeal). However, environmental limitations (for example work or family related responsibilities) might be too big of a barrier for the person to follow advice and, therefore, initiate protection motivation defined as following recommendations. The fear and threat of falling sick does not disappear though and person decides to avoid stressful situations because he or she notices that the heartache usually appears then. This behaviour has not been part of the advice but it still is health protective and brought on by fear of heart attack so the model’s core idea is preserved, it is only the definition of protection motivation which doesn’t fit. Therefore, definition of protection motivation as a health protecting behaviour (Milne et al., 2000; Helmes, 2002) is more appropriate.
Milne et al. (2000) have conducted a meta-analytic review of PMT. They evaluated 27 studies (15 correlation designs, 8 experimental manipulations and 3 comparing health education versus no education, description of 1 study design is missing) with total sample of 7694 participants. Seven of these evaluated studies concentrated on screening behaviour (for example breast examination, testicular examination, hepatitis screening, dental screening/preventive visits). Results of Milne et al. (2000) review showed that both threat and coping appraisals were significantly associated with intention, and intention was found to be significantly associated with subsequent behaviour. Furthermore, this association was stronger for coping appraisal than threat appraisal. Self-efficacy was the most strongly associated variable with intention and behaviour. Self-efficacy and response efficacy were also negatively correlated with maladaptive behaviour which inhibits protection motivation. In conclusion, this analytic review offers support for PMT model and its applicability to health behaviour, including screening behaviour.
Slightly contradictory is study published by Azzarello and Jacobsen (2007) investigating factors influencing participation in cutaneous screening amongst individuals with family history of melanoma. This research had a good sample (N=96) and sampling description. Procedure, measures and analyses were also described in detail, however, it is not very clear how was the health professional recommendation delivered and lack of this crucial information brings the quality of this study down. On the other hand, the advantage of Azzarello and Jacobsen (2007) research is that authors actually looked into behaviour not just into an intention to act. Perceived vulnerability and severity of the illness have promoted attendance for skin screening examination but only in univariate analysis and these results disappeared in multivariate analysis. Self-efficacy and response efficacy have failed to show any significant results. Some of the background variables, specifically education and number of risk factors, seemed to have promoted skin screening examination in research completed by Azzarello and Jacobsen (2007). Recommendation by health care professional also seemed to have increased the attendance to screening. Clearly, this research provides limited support for PMT model. Although Azzarello and Jacobsen (2007) openly discussed limitations, they do not offer any explanation to why self-efficacy and response efficacy have failed to show significant results. These findings are contradictory to results reported by Milne at al. (2000) and by Umeh (2004) in which self-efficacy was identified to have the strongest association to intention and behaviour when compared to other variables. This contradiction requires further investigations.
In conclusion, presented research supports applicability of PMT to understanding of screening behaviour and how this can be influenced.
Both models (health belief model and protection motivation theory) have been successful in predicting screening behaviour. They both have their similarities and differences, advantages and disadvantages and, moreover, they have a potential to complement each other.
Both models are very similar in their main constructs/variables. They both consider vulnerability of individual, severity of possible illness as well as barriers and benefits. However, there are some advantages of health belief model to protection motivation theory. Personal and demographic variables are acknowledged much clearer in HBM and more neutral cues to action are also recognised which do not necessary have to pose a threat (for example modelling/following behaviour of hero that is seen as attractive). Another important factor is that HBM allows for health motivation to stand on its own and be relatively independent and equal variable within the model. This allows individual to act in health protecting way even when there is no evident threat (for example cervix screening is mandatory every 3 years, there is a possibility that some women go because they are told to do so by their doctor rather than because they think that they are susceptible to the illness). As discussed before the disadvantage of HBM is the lack of operationalisation of its variables.
The advantages of PMT are recognition of self-efficacy and, more importantly, possibility of maladaptive response, why does this happen and how it can be changed. Another important advantage is the fact that PMT specifies clearly what does the information need to contain (threat and advice how to avoid this danger) in order to be effective. This is where it is apparent why findings reported in article by McCaskill (2006), stating that fear of disment as a result of diagnosing breast cancer can hinder breast self-examination, could have emerged. The right information was most likely not provided. This demonstrates how both theories could complement each other. The flexibility of HBM in having more neutral cues to action, relatively independent health motivation and clear recognition of psychological and demographic variables combined with PMT’s acknowledgment of self-efficacy, response efficacy, maladaptive response and also clear advice on how to frame information could help to overcome some of the disadvantages of individual models (HBM and PMT).
In the end, however, the decision has to be made on which of these models have the capacity to predict and influence screening behaviour the best. It is not an easy choice as it would be interesting to see the combination of both being tested. However protection motivation theory appears to be more concrete and specific framework. The reasons for these are various. Firstly, even though one might wish for people to act in a health protecting way without a clear danger, it probably does not happen very often. Secondly, PMT acknowledges maladaptive behaviour, and existence of rewards that keep this behaviour going and it also offers solutions in form of appropriate communication. Last but not least, it clearly establishes self-efficacy and past behaviour as important factor. In conclusion for research and intervention purposes protection motivation model is more suitable for predicting and influencing screening behaviour.
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