CHAPTER 2

Health Beliefs,
Health Behaviors &
Seeking Healthcare
1
 Adopting Health-Related Behaviors

■ Although health is highly valued, people do not always

behave in ways that promote their health

Approaches related to health beliefs:

■ Attribution Theory
■ Health Locus-of-Control
■ Unrealistic Optimism

2
Attribution Theory (Kelley, 1971)
■ Since its original formulation, attribution theory has been developed
extensively
■ internal versus external (e.g. my failure to get a job is due to my
poor performance in the interview versus the interviewer’s
prejudice);
■ stable versus unstable (e.g. the cause of my failure to get a job
will always be around versus was specific to that one event);
■ global versus specific (e.g. the cause of my failure to get the job
influences other areas of my life versus only influenced this specific
job interview);
■ controllable versus uncontrollable (e.g. the cause of my failure to
get a job was controllable by me versus was uncontrollable by me).
■ Bradley (1985)--> attributions of diabetes patients
■ external attribution→insulin pump & doctor responsibility

3
Health Locus-of-Control
■ Perceptions that one ’s health is under personal control also
determine health habits.
■ The degree to which people perceive themselves to be in
control of their health, perceive powerful others to be in
control of their health, or regard chance as the major
determinant of their health.
■ Is health locus of control a state or a trait? (Am I
always internal?)
■ Is it possible to be both external and internal?
■ Is going to the doctor for help external (the doctor is a
powerful other who can make me well) or internal (I
am determining my health status by searching out
appropriate intervention)?

4
Unrealistic Optimism
■ False perceptions about risks of getting a health problem
■ Weinstein (1984) - list of health problems
◻ compared to people of your age and sex, what are the
chances of having those health problems?
◻ majority of the participants → less likely to have those
problems
■ Predictors of unrealistic optimism:
◻ lack of personal experience with the problem;
◻ the belief that the problem is preventable by individual
action;
◻ the belief that if the problem has not yet appeared, it will
not appear in the future;
◻ the belief that the problem is infrequent.

5
 Adopting Health-Related Behaviors

■ Although health is highly valued, people do not always

behave in ways that promote their health

■ There are several theories attempting to predict and to

make sense of health-related behaviors

■ Useful theories
◻ Generate research
◻ Organize and explain observations
◻ Guide the practitioner in predicting behavior

6
 I. Theories of Health-Protective Behaviors

■ Health Belief Model

■ Protection Motivation Theory
■ Theory of Reasoned Action
■ Theory of Planned Behavior
■ Transtheoretical Model

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Health Belief Model (Becker & Rosenstock, 1970s
and 1980s)
■ Beliefs contribute to health-seeking behavior
■ 4 Beliefs that should combine to predict health-
related behavior:
◻ Perceived SUSCEPTIBILITY to disease/disability
◻ Perceived SEVERITY disease/disability
◻ Perceived BENEFITS of health enhancing behaviors
◻ Perceived BARRIERS to health enhancing behaviors
e.g. financial cost
◻ Cues to action
■Research findings
◻ Does not predict health related behavior as well as models that
include additional variables such as, perceived health, optimism,
perceived personal control, poverty, ethnic background
8
Health Belief Model (Becker & Rosenstock, 1970s
and 1980s)

9
•If HBM is useful, then the use of interventions that
change beliefs should be an effective way to influence
health-protective behaviors

•Champion (1994) used HBM to teach women with no

family hx of breast cancer about the benefits of
mammography.
• Unfortunately, other factors were better at predicting the use of
mammography (ethnicity, access to regular health care,
physician recommendation)
• Criticism to HBM:
• Lack of emotional factors
• Assuming rational decision-making

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Protection Motivation Theory (Rogers, 1975, 1985)
■Threat appraisals: severity, susceptibility, fear
■ Coping appraisals: response effectiveness, self-efficacy
■ Rippetoe & Rogers (1987)- breast cancer self-examination
→response effectiveness, severity, self-efficacy

11
 Theory of Reasoned Action (Ajzen &
Fishbein, 1980; Fishbein & Ajzen, 1975)
This theory assumes:

1. that people are reasonable & make systematic use of

information when deciding how to behave;

2. that they consider the implications of their actions before

their decision to engage/disengage in a particular
behavior;

3. that behavior is directed toward a goal or outcome & that

people freely choose those actions that move them
towards that goal.
12
■ What determines behavior is the INTENTION to act
◻ Intentions are shaped by two factors:
1. Personal evaluation of the behavior (one’s attitude toward the
behavior)
■ Attitudes are shaped by beliefs that the behavior will lead to
positively or negatively valued outcomes
2. One’s perception of the social pressure to perform/not to perform the
action (one’s subjective norm)
■ Subjective norms are shaped by perception of the evaluation that
a person places on the behavior & the motivation to comply with
the norms set by that person
• The theory of reasoned action considers the relative
weight of personal attitudes measured against subjective
norms
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 Determinants of Behavior
Personal evaluation of behavior

attitude toward behavior

Relative Importance of Intention to

attitude Behavior
Act/Not Act
and subjective norm

Subjective norm

Perception of social pressure to

perform/not perform 14
 Usefulness of Theory of Reasoned Action

•Research has shown this theory to be useful in

predicting certain health-related behaviors:

• Mammograms
• Condoms
• Breast self-examination
• Attendance at health-information classes

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 Comparison of 2 Theories

■ Although HBM & Theory of Reasoned Action have not

been directly compared, research suggests that the theory
of reasoned action is at least as adequate as HBM in
explaining & predicting health-seeking behavior.
◻ HBM→ people are rational
◻ Theory of Reasoned Action → subjective norms
■ What is the key factor in Theory of Reasoned
Action?
◻ Intention to perform a behavior

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 Theory of Planned Behavior
■ Ajzen extended the theory of reasoned action to include the concept of
perceived behavioral control

■ PBC is the key difference between Theory of Reasoned Action and

Theory of Planned Behavior

■ What motivates people to act is their perceived behavioral control

◻ PBC is how much control people have over their behavior

◻ The more resources and opportunities people believe they have,
the stronger are their beliefs that they can control their behavior

17
■3 factors that predict intentions to perform a
behavior:

◻ People’s attitude toward the behavior

◻ Their subjective norm
◻ Their perceived behavioral control

■ All 3 components interact to shape people’s

intentions to behave

■ People who believe they can easily perform a

behavior are more likely to intend to perform it.

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Theory of Planned Behavior

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Research using this model have found that
theory of planned behavior predicts

■Intentions of young people

◻ to purchase and use the illicit drug ecstasy (Orbell,
Blair, Sherlock, & Conner, 2001),
◻ to smoke marijuana (Sayeed, Fishbein, Hornik,
Cappella, & Ahern, 2005),
◻ to binge-drink alcohol (Johnston & White, 2003)

20
 Transtheoretical Model - Prochaska

■Developed by Prochaska

■Stage theory that predicts changes in health-

seeking behavior.

■Assumes that we progress through 5 stages in

making behavioral changes

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1. Precontemplation:
◻ No intent to change
◻ Do not believe have problem

2. Contemplation:
◻ Aware of problem
◻ CONSIDER changing behavior w/in next 6
months
◻ No REAL EFFORT to change
◻ Fixin’ to get ready

22
3. Preparation:
◻ Thoughts initiated into action
◻ e.g. Smoking less

4. Action:
◻ Behavior modified

5. Maintenance:
◻ Sustain changes
◻ Resist temptations to relapse

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 Transtheoretical Model

Maintenance Stage 5 Changes are sustained & temptation

to relapse is resisted

Action Stage 4 Overt changes in behavior are made

Preparation Stage 3 Thoughts & action. Specific plans

about change are made

Awareness of the problem & thoughts

Contemplation Stage 2 about changing behavior in next 6
months, but no effort made to change

Precontemplation Stage 1 No intention of changing behavior.

May fail to see they have a
problem 24
 Transtheoretical Model
■Prochaska argued that individuals move between
stages in a spiral fashion rather than linearly.

■Several relapses that recycle people into previous stage ,

from which they progress through the stages

■Relapses are to be expected & serve as learning

experiences.

■Don’t expect yourself to go through each step

successively – relapses are ok – recover from
them and go on!
25
 Transtheoretical Model

■ People in each stage need different types of assistance

in making changes!!!

◻ Precontemplation Stage - Don’t want to change (do nothing) OR

Assistance will unlikely cause change because no problem is
acknowledged

◻ Preparation Stage - don’t need convincing to change their

behavior but specific advice on how to change

◻ Maintenance Stage - need help/info to preserve their changes

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Research Findings

■Prochaska found that the transtheoretical model

applied to 12 different problem behaviors including
◻ smoking cessation
◻ weight control
◻ safe sex
◻ mammography screening.

■Levy (1997) found in a study an application for

the model with bulimic women

27
Critique of Health-Related Theories

■Models are still needed to better differentiate b/w

people who will & will not seek medical attention in a
variety of health-related situations.

■Fleury (1992) found weaknesses in each of the

models, specifically inconsistent results when predicting
behavior around heart disease

■None of the models explain all of the complexities of

health-related behavior, but the concept of intention and
optimistic bias have supporting research

28
Why Are Theories Less Than Adequate?
1. Health-seeking behavior is determined by factors other
than an individual’s beliefs/perceptions
• Poverty, public policy, ethnic background, legislation, lack of
medical and health info., institutional factors, and community
factors

2. Theories rely on consistent & accurate instruments

which do not yet exist

3. Models may have some value for predicting health-

seeking behaviors for one disease/disorder but not
others

4. Models posit some type of obstacle/barrier to seeking

health care & an unlimited number of barriers are
possible. 29
 II. Seeking Medical Attention
■How do you know WHEN to seek medical
attention?

■How do you know WHEN to go to doctor?

■How do you know whether you are ill or not?

■A complex problem compounded by personal,

social, and economic factors!

30
 Disease and Illness
■ They are used interchangeably

◻ Disease:
■Process of physical damage within the body
■Can exist even in the absence of a label or diagnosis
■Identifiable via medical tests

◻ Illness
■EXPERIENCE of being sick and
■Having been diagnosed as being sick
■SUBJECTIVE feelings of discomfort and distress

31
 Disease and Illness

■ Can be ILL, but not have disease

◻ feel very bad, but have no identifiable disease

■ Can have DISEASE, but not be ill

◻ e.g. people w/ undiagnosed hypertension, HIV infection, or
cancer all have a disease, but they may appear quite healthy
and be completely unaware of their disease

■ They often overlap

◻ When a person feels ill and has also been officially diagnosed

32
 Dealing with Symptoms Occurs in 2 Stages:

1. Illness Behavior
◻ the activities undertaken by people who experience symptoms but
have not yet received a diagnosis.
◻ Occurs before diagnosis
◻ Goal = oriented toward determining one’s state of health and
discovering suitable remedies

2. Sick Role Behavior

◻ Behavior AFTER diagnosis – either from a health-care provider or
a self-diagnosis
◻ Goal = oriented toward getting well

■ A diagnosis, then, is the event that separates the illness behavior

from sick role behavior!
33
 1. Illness Behavior
■ Takes place before diagnosis and is directed
toward determining health status in the
presence of symptoms
■ Conditions that shape people’s response to
symptoms:
1. Personal factors
2. Gender
3. Age
4. Socioeconomic and ethnic factors
5. Characteristics of the symptoms
6. Conceptualization of disease
34
1. Personal Factors

1. People’s way of viewing their own body

■ Many women see vaginitis (inflammation of vagina) as a
sexually transmitted disease due to sexual infidelity

2. Their level of stress

■ People who experience great deal of stress are more likely to
seek health care than those under less stress, even w/ equal
symptoms

3. Their personality traits

■ People high in neuroticism (people w/ strong emotional
reactions) had high self-reports of illness whether or not
objective evidence confirmed their reports
35
 2. Gender

■ Women are more likely than men to use health care

■ However, men seem to be more predisposed than women
to attribute minor symptoms to major problems
■ Women are more sensitive to internal body signals, and
thus, they report more symptoms than men
■ When asked about their symptoms, men tend to report
only life-threatening situations, e.g. heart disease,
36
2. Gender (cont.)

■ Females – gender role allows women to seek many sorts

of assistance than are acceptable for males
■Greatest risks – physical inactivity, unemployment,
stress
■ Males – gender role is to act strong and deny pain and
discomfort unless their disease is life-threatening →
failure to seek healthcare
■Greatest risks – alcohol use, job hazards
■Worse chronic health than women

37
 3. Age
■ Young and middle-aged adults show greatest
reluctance to see health professional
■ Older people are more likely than any other age group
to seek health care
■ Compared w/ younger and middle-age patients, older
people are more likely to
1. Attribute their symptoms to age
2. Experience more severe and lengthy symptoms
3. Attribute their symptoms to some other disorder
4. Have had previous experience w/ cardiac problems
■ Children are usually more inclined to go to the doctor
than adolescents, particularly adolescent males
38
 4. Socioeconomic and Ethnic Factors
■ Higher SES folks experience fewer symptoms & report higher levels of
health than lower SES folks.

■ However, when higher SES folks are sick, they are more likely to seek
health care.

■ Poor people are overrepresented among the hospitalized indicating that

they are much more likely than middle- and upper income people to become
seriously ill.

■ The poor also have less access to medical care, have to travel longer to
reach health care facilities, and must wait longer once they arrive at those
facilities.

■ Lower SES folk tend to wait longer before seeking care, making treatment
more difficult & expensive

■ European Americans are more likely than people in other ethnic groups to
visit a physician
39
5. Symptom Characteristics

■ Several symptom characteristics influence people’s

decision to seek help.

■ Mechanic (1978) listed 4 characteristics of the

symptoms that determine one’s response to disease:

1. Visibility of the symptom

2. Perceived severity of the symptom
3. Extent to which symptom interferes with a person’s life
4. Frequency & persistence of symptoms

40
5. Symptom Characteristics (cont.)

1. Visibility of the Symptoms:

■ How apparent is the symptom to the individual and to

others?

■ Klohn & Rogers (1991) showed the importance of

visibility of symptoms.
◻ Young women who received education about the disfiguring
aspects of osteoporosis were more likely to intend to adopt
precautions than those who were not so educated.

41
5. Symptom Characteristics (cont.)

2. Perceived Severity of Symptom

■Symptoms seen as severe would be more likely

◻ to prompt action,
◻ produce greater concern
◻ cause stronger belief that treatment was urgently
needed.

42
5. Symptom Characteristics (cont.)

3. Extent of Symptoms Interference with Life

■ the more the person is incapacitated the more

likely he/she is to seek medical care.

43
5. Symptom Characteristics (cont.)

4. Frequency & Persistence of Symptoms

■Conditions that are severe & continuous are

seen as requiring care by people, whereas
intermittent symptoms generate less illness
behavior (Suchman, 1965)

44
6. Conceptualization of Disease

■ Most people are largely ignorant of how their body

works and how disease develops.
■ May attribute illness to supernatural forces
◻ More prevalent among ethnic minorities
■ Often people gain information on a disease and
integrate it into their preexisting knowledge rather
than updating their knowledge.
■ This frequently leads to distortions & incomplete
conceptualizations

45
6. Conceptualization of Disease (cont.)

■ Leventhal & colleagues studied five components

in the conceptualization of disease:

1. Identity of the disease

2. Time line (course of disease & treatment)
3. Cause of the disease
4. Consequences of the disease
5. Controllability of the disease

46
6. Conceptualization of Disease (cont.)

1. Identity of the Disease

■Very important to illness behavior.
■The presence of symptoms is not sufficient to motivate
health-seeking behavior, however the labeling that occurs
with the symptoms may be critical in a person’s decision to
seek or not seek medical care.
■A label carries with it a prediction about the time course
of the disease
■Alleviate symptom anxieties

47
6. Conceptualization of Disease (cont.)

[Link] Line
■When people receive a diagnosis, they think about
the time course
■People’s understanding of the time involved in a
disease is not necessarily accurate.
■ People with chronic diseases often conceptualize
them as acute (Meyer et al., 1985).

48
6. Conceptualization of Disease (cont.)

3. Cause of the Disease

■ Important for illness behavior

■ Attribution of causality is often faulty
■ People are less likely to seek professional help for
conditions they consider as having emotional or spiritual
causes
■ Most people feel less anxious when they can attribute
some cause to their symptoms
49
6. Conceptualization of Disease (cont.)
4. Consequences of a Disease

■An incorrect understanding of the consequences of a

disease can have a profound effect on illness behavior.
■Some people overestimate or underestimate the mortality
rates of certain diseases
■Cancer is often viewed as a death sentence, resulting in
the neglect of health care since the situation is perceived to
be hopeless.
50
6. Conceptualization of Disease (cont.)

5. Controllability of the disease

■ People’s belief that they can control the course of their

illness by controlling the disease

■ People who believe that they can control their own

disease process (e.g. through diet or exercise) are less
likely than others to seek health care

51
 Dealing with Symptoms Occurs in 2 Stages:

1. Illness Behavior
◻ the activities undertaken by people who experience symptoms but
have not yet received a diagnosis.
◻ Occurs before diagnosis
◻ Goal = oriented toward determining one’s state of health and
discovering suitable remedies

2. Sick Role Behavior

◻ Behavior AFTER diagnosis – either from a health-care provider or
a self-diagnosis
◻ Goal = oriented toward getting well

■ A diagnosis, then, is the event that separates the illness behavior

from sick role behavior!
52
 2. The Sick Role

■ Activities engaged in by people who believe

themselves ill (Kasl & Cobb, 1966)

◻ Occurs AFTER diagnosis

◻ Purpose is getting well

53
 2. The Sick Role (cont.)

■ After people become convinced that they are ill, they

adopt the sick role, which allows them both privileges
and responsibilities (Segall, 1997) :
◻ Privileges
■ (1) Right to make decisions concerning health-related issues
■ (2) Right to be exempt from normal activities
■ (3) Right to become dependent on others for assistance
◻ Responsibilities
■ (1) Maintain health & get well
■ (2) Perform routine health care management
■ (3) Use range of health care services

54
Receiving Health Care

55
 Hospital Patient Role
■Part of the role of being a patient frequently
requires the patient to conform to the rules of the
health care institution & comply to medical advice.

■Unfortunately, in some traditional hospitals,

patients become nonpersons.

56
 Hospital Patient Role
■ Non-person treatment - Identified by the DISEASE not the person
◻ “The breast cancer” in Room 123
◻ Comments and questions may be overlooked
◻ Ignorance of patients’ emotional needs
◻ Doctors and nurses do not perceive pain the way the patient does
■ Lack of Information
◻ Comes from hospital routine rather than from an attempt to keep
information from patients
◻ Patients should be fully informed. However, it is not unusual for a
patient in a hospital to not have information about their condition.
◻ More open communication occurs in doctor’s office than in
hospital
◻ Can often cause stress and add to the patient’s anxiety.

57
 Hospital Patient Role (cont.)

■ Loss of Control
◻ is the major complaint of patients
◻ Patients are expected to conform submissively to
the rules of hospital and the orders of their doctor –
relinquishing much control over their lives
◻ Patients exposed to uncontrollable, unpleasant
situation experience more discomfort than if the
situation was under their control (Glass & Singer,
1972).

58
Restoration Small Types of Control to Patients

■ Allowing patients some choice of foods

■ Provide TV remote controls to give patients the

power to select a program to watch (or not watch)

59
 Preparing Patients for Stressful Medical Procedures

■Simply being in a hospital can be stressful.

■Some experience additional stress due to complicated

medical procedures.

■Psychologists & other health care workers have

developed support programs & specific trainings to help
patients to get prepared for medical procedures and to
cope with the associated stress.

60
 Coping Techniques

■Usually include at least three approaches:

1. Receiving accurate information
2. Relaxation training
3. Modeling

■Patients can reduce the distress of stressful medical

procedures with any one or a combination of these
activities

61
[Link] Accurate Information

■Patients receive information about the procedures they

will undergo.

■Sometimes information about the sensations that will

be experienced is given.

■Research suggests that sensory information is

generally more valuable (Kendall & Watson, 1981).

62
[Link] Training

■Effects of relaxation are significant & positive for

relatively minor medical procedures.

■For more serious procedures, although relaxation

training is helpful, the results are less dramatic.
e.g. breathing, progressive muscle relaxation

Let’s watch!: [Link]

v=ClqPtWzozXs

63
3. Modeling
■Modeling, or learning by watching others performing,
is an effective technique for coping with unpleasant
surgical procedures.

■Often used with children prior to surgery.

■Melamed (1984) showed that the best models appear

anxious at first (maybe even fearful), but eventually
successfully cope with the stress.

■Videotapes – need time between viewing and the

procedure for optimal effect
64
An example video to prepare
children for surgeries

[Link]
v=DU2Uz_pliuk

65
 “Good” vs. “Bad” Patients
■ “GOOD” patients ■ “BAD” patients
◻ Conform to nonperson role ◻ Ask questions
◻ Do not ask questions ◻ Demand answers
◻ Cooperate with requests ◻ Behave like consumers who
◻ Don’t make trouble for the have rights
staff ◻ “Make trouble”
■ Consequences ■ Consequences
◻ Learned helplessness – ◻ Attempt to restore control
Seligman ◻ Angry reaction to nonperson
◻ Passive treatment - reactance
◻ May withhold important ◻ May not comply with
information treatments – compromise
◻ Depression their health

66