Susan ayers cambridge handbook of psychology he

C. Abraham and P. Sheeran
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Using the HBM to change health behaviour
Accurate prediction is an indicator of veridical explanation. As
Sutton (1998, p. 1317) observed, ‘models that do not enable us to
predict behaviour are unlikely to be useful as explanatory models’
Consequently, considerable effort has been invested in testing the
predictive utility of the HBM. However, the model was originally
conceived of as a tool to improve health education and so shape
health behaviour and it has inspired researchers interested in behaviour
change interventions for decades (e.g. Haefner & Kirscht,
1970). We have noted limitations in the predictive utility of the
HBM and these findings suggest concomitant limitations in the
effectiveness of behaviour-change interventions that target HBMspecified
beliefs. Nonetheless, HBM constructs are correlated with
a range of health-related behaviours and changing these beliefs may
prompt behaviour change (whether or not this involves simultaneous
changes in cognitions not specified by the HBM – e.g. intention
and self-efficacy). (See ‘Health promotion’).
Abraham and Sheeran (2005) report a review of evaluations of
HBM-based, behaviour-change interventions and highlight 17
such evaluations. Some of these were derived directly from the
HBM (e.g. Carmel et al., 1996) whereas others drew upon HBM
and other social cognition models in order to target a broader
range of cognitions (e.g. Strecher et al., 1994). Some took the form
of educational presentations to groups in classes or workshops (e.g.
Abood et al., 2003) and/or involved the distribution of leaflets or
booklets (e.g. Carmel et al., 1996) whereas others were delivered at
an individual level (referred to variously as ‘educational’ or ‘counseling’
interventions), and often involved assessment of the recipient’s
current beliefs before new information and persuasive arguments
were presented (e.g. Champion, 1994, Jones et al., 1998). Such interventions
are tailored to the individual’s cognitions. Computergenerated,
individually tailored letters have also been used
(Strecher et al., 1994). All of the interventions relied on information
provision and verbal persuasion as means to change HBM-specified
beliefs. Thirteen of the 17 evaluations found evidence of behaviour
change. This is encouraging but, because these evaluations were
not selected on the basis of methodological rigour, conclusions
regarding effectiveness need be examined on a study-by-study basis.
Jones et al. (1988) provide a good illustration of an evaluation of
an HBM-based behaviour change intervention. These researchers
report a randomized controlled trial (RCT) of an intervention
designed to persuade patients using hospital emergency services
to make and keep follow-up appointments with their own doctor.
The sample comprised 842 patients with 11 presenting problems
(chest pain, hypertension, asthma, otitis media, diabetes, urinary
tract infection, headache, urethritis [men], vaginitis [women], low
back pain and rash) which did not require hospitalization. An intervention
for individual patients was developed. This involved assessment
of patients’ HBM-specified beliefs and delivery of protocolbased,
condition-specific educational messages to target beliefs
that were not accepted by recipients. The intervention was designed
to increase the patients’ perceived susceptibility to illness complications,
perceived seriousness of the complications, and benefits of a
follow-up referral appointment in terms of avoiding further complications.
It was delivered by a research nurse during required nursing
care. Four intervention conditions were tested: (i) a routine care,
control group, (ii) the individual, nurse-delivered hospital
intervention, (iii) the hospital intervention combined with a
follow-up telephone call (iv) a follow up telephone call without the
hospital intervention. Only 33% of the control group patients scheduled
a follow-up appointment whereas 76% of the hospital intervention
group, 85% of the telephone intervention group and 85% of the
combined intervention did so. Twenty four percent of the control
group kept a follow-up appointment compared to 59% in the
hospital intervention group, 59% in the telephone intervention
group and 68% in the combination group. Thus, the combination
intervention worked most effectively. Jones et al. did not conduct
a cost-effectiveness analysis, but noted that the telephone intervention
alone might be the most effective practical intervention
when costs such as staff training and staff time are taken into
account.
Abraham and Sheeran (2005) identified a number of shortcomings
in HBM intervention evaluations. Evaluation designs have been limited
due to the lack of appropriate control groups, lack of randomization
to conditions, samples that do not support generalization,
and short-term follow-ups. Moreover, the HBM, like other social
cognition models, specifies targets for cognition change but does
not describe processes responsible for belief change. It is possible
to combine models like the HBM with cognition change theories
such as cognitive dissonance theory (Festinger, 1957; see Stone
et al., 1994, for an empirical example) in order to design interventions
with theory-based targets and theory-based intervention
techniques. However, this approach is not typical of HBM-based
interventions. Consequently, the selection of intervention techniques
(as opposed to cognition targets) is often not, or not explicitly,
theory-based. In addition, interventions usually comprise a variety
of techniques making it unclear which particular technique (or
combinations of techniques) are crucial to effectiveness. Finally,
in order to establish whether an intervention generates behaviour
change because it alters target beliefs, it is necessary both to measure
cognitions and behaviour pre- and post-intervention and to
conduct mediation analysis (Baron & Kenny, 1986). However, mediation
analysis is rarely reported in HBM-inspired intervention evaluations.
Consequently, even when HBM-inspired interventions are
effective in changing behaviour, it is unclear whether such effects
are due to changes in HBM-specified beliefs. In summary, although
the HBM has inspired the development of effective behaviour
change interventions, the lack of programmatic experimental work
means that we are unable to identify a series of belief-changing
techniques and, in most cases, unable to say whether effective
HBM-inspired interventions work because they change HBMspecified
beliefs.
Conclusions
The HBM has provided a useful theoretical framework for investigators
of the cognitive determinants of a wide range of behaviours
for more than 30 years. The model’s common-sense constructs are
easy for non-psychologists to assimilate and are easy to operationalize
in self-report questionnaires. The HBM has focused researchers’
and health care professionals’ attention on modifiable psychological
prerequisites of behaviour and provided a basis for practical interventions
across a range of behaviours. Research to date has, however,
predominantly employed cross-sectional correlational designs