4 Changing Behavior Using the Health

Belief Model and Protection

Motivation Theory
Sheina Orbell, Hina Zahid, and Caroline J. Henderson

Practical Summary

The health belief model and protection motivation theory are long-established models of
behavior change. They underpin many health communications, such as warnings on cigarette
packets, and are often the basis of commercial advertisements. According to these models,
behavior change follows from inducing a person to perceive threat if they do not act and
simultaneously providing information about an effective behavior they can easily enact in order
to address that threat (coping appraisal). Threat can be manipulated by increasing a sense of
vulnerability to a serious outcome. Coping appraisal involves providing information that
behavior will be effective in reducing threat and by illustrating that behavior, showing that it is
easy and not unpleasant to enact. If behavior change interventions manipulate threat appraisal
alone, they may backfire, because they create anxiety without a solution, and, in this case,
people will cope by discounting or denying the evidence or engage in wishful thinking.
4.1 Introduction Over time, cancer, cardiovascular disease, and
stroke became major sources of early mortality
(e.g., CDC, 2013). These changes set the scene
During the twentieth century, developed
for development of scientific interest in
countries witnessed a significant shift in major
understanding how best to promote behavior
causes of mortality from those predominantly
that would maximize the effectiveness of new
related to bacterial and viral infection, which
public health preventive measures such as
were exacerbated by living conditions such as
screening and modify behaviors such as
overcrowding and poor sanitation, to mortality
smoking, alcohol use, poor diet, and insufficient
that was attributable to what is now commonly
physical activity that are major causes of ill
referred to as
health.
“lifestyle”-related. Several factors contributed
Psychological science also underwent a
to this shift, including improvements in living
major paradigm shift toward the middle of
conditions; the development and introduction of
the twentieth century. During the early
new medical technologies such as screening for
decades of the twentieth century,
tuberculosis and vaccination programs for
psychology was dominated by behaviorism
diseases such as polio; and economic
and the view that people learn
development associated with declining working
stimulusresponse associations so that their
hours, jobs that were less physically
actions are controlled by external factors,
demanding, and greater disposable income.

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 47 SHEINA ORBELL, HINA ZAHID, AND CAROLINE J. HENDERSON

specifically contingent rewards or empirical evidence is evaluated, and the

punishments (Hull, 1943; Skinner, 1938). (enduring) use and efficacy of the models in
However, behaviorism was soon replaced informing intervention to modify behavior
is considered.
https://doi.org/10.1017/97811086773180.004 4.2 Overview of Theory and Evidence
by a view that people acquire mental
representations of their world and
expectations concerning the outcomes of 4.2.1 The Health Belief Model
their action. This shift from external to The health belief model is illustrated in Figure
internal cognitive control of behavior led to 4.1. The model focused on two aspects of
the development of a class of models people’s cognitive representations of health
referred to as expectancy value theories. behavior. Two key beliefs, perceived
The health belief model (Becker, Haefner,
susceptibility to illness and expected severity or
Kasl et al., 1977; Hochbaum, 1958;
impact of illness, comprise the mental
Rosenstock, 1966, 1974) and protection
representation of illness itself. Perceived
motivation theory (Rogers, 1975, 1983) are
benefits of action and perceived barriers/costs
two ofthe earliestsocial cognitiveaccounts
to action comprised the mental representation
ofpersonal behavior that were developed
of action. The model also proposed that cues to
primarily in the context of understanding
action serve to trigger behavior when
and changing health behavior. They
appropriate beliefs are held. Cues to action
established enduring theoretical principles
might include such things as a reminder letter
for behavior change that persist in some
or text message, a new symptom, or a television
more recent theoretical developments (see,
advertisement. An individual’s general health
e.g., Chapters 2, 7, and 10, this volume). In
motivation was also included in later versions
the following sections, the components and
of the model (e.g., Becker, Haefner, & Maiman,
structure of the health belief model and
1977). These six constructs together comprised
protection motivation theory are outlined,
the health belief model. No formal propositions

Perceived susceptibility
Perceived severity
Socio-demographic Health motivation
Action
variables Perceived costs or
barriers
Perceived benefits

Cues to
Action
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Figure 4.1 Schematic representation of the health belief model

 Changing Behavior Using the Health Belief Model and Protection Motivation Theory
regarding the operationalization of constructs,
nor combinatorial rules, were proposed.
Typically, the constructs are viewed and
operationalized as separate independent
variables that additively predict behavior.
These features of the model may be viewed as
weaknesses in the status of the model
(Harrison, Mullen, & Green, 1992) but may
also be seen as strengths in the context of a
developing understanding of beliefs associated
with a wide range of different behaviors with
implications for health. For example, the
severity of a condition or illness might be
conceptualized in relation to a range of
expectancies regarding a wide range of
potentially relevant outcomes such as
disfigurement, change in personal or sexual
relations, inability to work, loss of income or
loss of the ability to engage in desired leisure
activities, and
soon,aswellasearlydeath,andperceivedbenefits
might correspondingly be related to potential
prevention of these outcomes. Relatedly,
barriers will be behavior-specific. For example,
barriers to a behavior that requires appointment
keeping may include such things as time or
distance or means of transport, whereas
unpleasantness or lack of skill may be more
relevant in another context such as making
complex dietary changes. The generic
conceptualization of health beliefs permits
researchers to undertake effective pilot work in
order to identify context-appropriate beliefs
about illness and barriers to action to measure
and to target in behavior change intervention.
A further important feature of the health
belief model concerns the relationship of health
beliefs to socioeconomic status and other
demographic indices such as gender, ethnicity,
and age. Figure
4.1showsthesevariablesontheleft-handportionof
themodel.Earlyaccountsofthehealthbeliefmodel
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48
were grounded in the need to explain and
intervene to achieve improved health equality in
society via uptake of preventive health services
or modifications of personal behavior with
implications for health (Rosenstock, 1974).
Sociodemographic variables are not considered
modifiable variables by psychologists, but it
was hypothesized that identification of
modifiable health beliefs that
distinguishbetweenindividualsevenofthesameba
ckground would inform evidence-based health
education to achieve greater health equality
(e.g., Orbell, Crombie, & Johnstone, 1996).
Currently, morbidity, mortality, and virtually all
health behaviors are persistently associated with
socioeconomic status, even in contexts where
health care interventions such as screening are
publicly financed and free at point of delivery
(e.g., Orbell et al., 2017). The health belief
model proposes that health beliefs mediate the
relationship of sociodemographic variables to
health action. For example, social experience
engendered by social structural position might
shape beliefs and subsequent
behavior(e.g.,doperceivedcosts/barriersloomlarg
erfor those with limited economic resources, or
less daily experience of job discretion?) (Orbell
et al., 1996; Salloway, Pletcher, & Collins,
1978). From a theoretical point of view, an
important moderator hypothesis can also be
derived from the model;
modificationofhealthbeliefswillmoderate(attenu
ate) the relationship of sociodemographic
variables to behavior, thereby narrowing
sociodemographic inequality.
 49 SHEINA ORBELL, HINA ZAHID, AND CAROLINE J. HENDERSON

4.2.2 Protection Motivation Theory result in negative experiences, aka

“perceived barriers”), and self-efficacy
Protection motivation theory is represented
(beliefs in one’s competence and confidence
in Figure 4.2. The theory formalizes the
to perform the recommended action;
idea that protection motivation, that is,
Bandura, 1977) (see
motivation to take action to promote health
alsoChapters3and7,thisvolume).Threatappr
and prevent illness, or some other potential
aisal is proposed to enhance motivation to
threat, is derived from threat appraisal
act, in circumstances where response
combined with coping appraisal. Coping
efficacy is high, response costs are low, and
appraisal is viewed as the mental
self-efficacy is high.
representation of the “recommended”
Protection motivation theory also makes
behavioral response to threat.
theoretical predictions regarding the
Unlikethehealth belief model,the mental
possibility that an individual may not
representations of threat and coping
respond to threat by taking appropriate
appraisal are not proposed as direct
protective action to address it but, instead,
determinants of action but as direct
attempt to manage and reduce feelings of
determinantsofprotectionmotivation,usually

Cope with Threat

(e.g., Avoidance
Threat Appraisal Denial, Fatalism,
Perceived susceptibility Wishful thinking,
Perceived severity Hopelessness)
Fear

Coping Appraisal Protection Threat

Perceived response- motivation protective
efficacy (Intention to act behavior
Perceived response-cost to manage threat)
Perceived self-efficacy

Figure 4.2 Schematic representation of protection motivation theory

operationalized as intention. Intention, in threat. These alternate responses are often
turn, is a proximal determinant of action. referred to as “maladaptive coping
Threat appraisal comprises responses” (Rippetoe & Rogers, 1987),
perceivedsusceptibilityto, and perceived illustrated in Figure 4.2 by the box labeled
severityof,anoutcomeifactionisnottaken.Co “Cope with threat.” Where threat appraisal
ping appraisal comprises response efficacy is high, but response efficacy and self-
(beliefs that efficacy are low and response costs high,
therecommendedresponsewillbeeffectiveinr rather than embark on the goal of avoiding
educing threat, aka “perceived benefits”), threat, an individual may employ a range of
response costs (expectancies that strategies directed at discounting evidence
performing the recommended response will or denying threat or avoiding thinking about

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 Changing Behavior Using the Health Belief Model and Protection Motivation Theory 50

threat in order to minimize unpleasant

emotions.
4.2.3 Empirical Evidence
Unsurprisingly, given their longevity and
continued use, the health belief model and
protection motivation theory have been subject
to multiple research syntheses and meta-
analyses. Janz and Becker’s (1984) review of
forty-six studies employing the health belief
model using a votecount procedure provided
strong support for the model components:
susceptibility (81 percent significant tests of
association), severity (65 percent), benefits (78
percent), and barriers (89 percent). Harrison,
Mullen, and Green (1992) and Carpenter (2010)
provided full meta-analyses that were capable
of not only establishing if relations were
significant but also estimating the size and
variability in the effects. Two metaanalytic
syntheses of protection motivation theory
(Floyd, Prentice-Dunn, & Rogers, 2000; Milne,
Sheeran, & Orbell, 2000) estimated the size and
variability of effects among the theory
constructs. These meta-analyses have tended to
focus on health behaviors but the models have
also been employed in occupational and
marketing contexts (see Sidebars 4.1 and 4.2).
Previous summaries of evidence have tended
to
relyontestsofassociationderivedfromprospective
designs, wherein beliefs and behavior are
measured

Sidebar 4.1 Protection motivation in an occupational setting

Safety is a major concern in many workplace settings and occupational injury contributes
substantially to absence from work. Lower back pain is a widespread occupational hazard
facing health care workers. Patient handling is often unpredictable, the human load bulky and
unstable, and often lifting is required in awkward and unplanned situations – factors that
contribute to manual handling risks
notfoundinotheroccupationalsettings.Inaddition,protectivebehaviorviatheuseof a hoist
requires the cooperation of coworkers. Rickett, Orbell, and Sheeran (2006)
investigatedtheroleofthreatandcopingappraisalspecifiedbyprotectionmotivation theory in

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 51 SHEINA ORBELL, HINA ZAHID, AND CAROLINE J. HENDERSON

explaining consistent hoist usage by health care workers. They developed scales to assess
threat appraisal via perceived susceptibility to back problems (the
likelihoodofacquiringbackproblemsasaconsequenceofmovingpatients),perceived severity (the
extent to which back problems would interfere with career and social roles), and fear of back
problems. Coping appraisal comprised response efficacy (the
extenttowhichusingahoistwouldreducethechancesofacquiringorworseningback problems),
response costs of using the hoist (such as the extent to which hoist use was perceived as time-
consuming or would make the health care worker difficult to work with), response costs of
not using the hoist (such as annoying my boss or colleagues), and self-efficacy (control over,
competency, and ease of hoist use). Findings showed that threat appraisal variables were
unrelated to the intention to use a hoist, and actual hoist use, during the following six weeks,
whereas coping appraisal variables were important predictors, including self-efficacy (r =
0.43), response costs (r = −0.41), response benefits (r = 0.23), and social costs of not using a
hoist (r = 0.35). The study pointed to the importance of workplace culture in ensuring safety
equipment was available and staff competent in its use and to the promotion of shared
beliefs regarding the appropriateness and normative expectation of hoist use.

Sidebar 4.2 Protection motivation in advertising to promote purchasing behavior

Adverts that aim to create new markets or increase product sales often combine elements
that seek to enhance threat, followed by a “recommended response” to buy and usea
product, consistent with protection motivation theory. These adverts typically exploit social
anxieties. This form of advertising is common in relation to dental hygiene products such as
mouthwash, home germ-cleansing products, and products related to home or family
security such as life insurance. For example, the manufacturers of a mouthwash (Listerine TM)
created an advert that self-evidently changed behavior by creating a remarkable new
multimillion-dollar market for a previously unknown product in the 1950s. 1 One of these
adverts showed an

attractiveyoungwomanwhowas“atrisk”(susceptibility)offailingtoattractaman and being left

lonely and without companionship (undesired consequence: severity) because of her bad
breath. The advert went on to introduce a coping response (bottle of mouthwash) that
was portrayed as effective (in curing halitosis and attracting men: response efficacy) and
easy to use (illustrated by images of placing the bottle conveniently by the sink and a
demonstration of its use: self-efficacy).
Modern advertising often follows a similar format by first arousing or making salient the
threat that might arise from neglecting funeral insurance, or allowing children to come
into contact with unclean surfaces, or failing to get the boiler serviced, followed by
product information that emphasizes elements of coping
appraisaldesignedtoenhanceperceptionsthattheproductiseasytoobtainanduse and highly
effective in reducing threat. The purpose of adverts is to create novel behavior and

1 See “Listerine Mouthwash to the Rescue – 1950s,” Online video clip. www.youtube.com/watch? v=_39gkDAbMaI.

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 Changing Behavior Using the Health Belief Model and Protection Motivation Theory 52

increase sales so they often employ effective behavior change techniques such as
modeling to illustrate the perceived ease of use and efficacy of
theproduct.Greateruseofthesecopingappraisaltechniquesininterventionsmight enhance
behavior change in many domains.
at different points in time and measurement of consequence of new experience and knowledge.
beliefs precedes measurement of behavior. Prospective studies, in which the measurement
Many early tests employed what of beliefs precedes the measurement of
epidemiologists might call “case-control behavior, are likely to provide more reliable
studies,” or retrospective designs, in which estimates of the relative importance of beliefs in
people enacting a particular behavior are promoting motivation and behavior change.
compared with those not enacting a previous
behavior. Such approaches may have value in
epidemiology through identifying the location
of an outbreak of disease by answering key
questions (e.g., “Have people with salmonella
poisoning been in a recent location more than
people who do not have salmonella
poisoning?”). However, when applied to the
measurement of beliefs, that is, comparing the
current beliefs of people who have or have not
performed a behavior in the past, they are
fraught with theoretical and empirical
limitation. For example, a person who has
undergone screening for cancer and received a
normal result, or who always uses a condom
during sexual intercourse, may perceive low
personal susceptibility to illness, even if
perceived susceptibility to illness was originally
a motivating force for action (Weinstein &
Nicolich, 1993).
The effect of perceived susceptibility on
behavior might also be attenuated if an
individual responds to threat by engaging in a
threat management coping response such as
denial of risk or fatalism. In such cases, a
measure of perceived susceptibility might
reflect the outcome of this cognitive process.
Relatedly, a person who has performed a given
behavior repeatedly and found it straightforward
and easy will probably perceive few barriers
and high self-efficacy, based on that experience.
Second, beliefs may change over time, as a

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 53 SHEINA ORBELL, HINA ZAHID, AND CAROLINE J. HENDERSON

A summary of evidence derived from
prospective studies of the health belief model
and protection motivation theory is provided in
Table 4.1. Taken together, the table shows that
all variables specified by the health belief model
and protection motivation theory show small
consistent relationships in the theoretically
predicted direction with future behavior. Given
that barriers may be equated to response costs
Table 4.1 Summary of prospective relations between constructs specified by the health belief model and
protection motivation theory and behavior
1995; Hodgkins & Orbell, 1998). For example,
Ben-Ahron and colleagues observed that low-
perceived severity and self-efficacy predicted
avoidance coping and lowresponse efficacy and
self-efficacy predicted religious faith coping in
relation to binge drinking. Abraham and
colleagues showed that low response and self-
efficacy were associated with wishful thinking
in relation to condom use to prevent
Meta-analysis

Construct Harrison et al. (1992) Carpenter (2010) Milne et al. (2000)

Susceptibility 0.19 0.05 0.12

Severity 0.13 0.15 0.07
Benefits 0.10 0.27

Barriers −0.16 −0.30

Response Efficacy 0.09

Response Costs −0.25

Self-Efficacy 0.22

Protection Motivation 0.44

(Intention)
Note. Coefficients are bias-corrected averaged correlation coefficients.
and benefits to response efficacy, itmay also
beinferred that thesevariables appear to be more
strongly associated with future behavior than
threat appraisal variables. Selfefficacy also
emerged as an important variable not included
in the health belief model. The authors of all
meta-analytic synthesis do, however, note that
there is large unexplained heterogeneity in
effects across studies. In addition, the
metaanalyses did not include consideration
ofmaladaptive responses to threat predicted by
protection motivation theory. A few studies
have examined these predictions (e.g., Abraham
et al., 1994; BenAhron, White, & Phillips,
HIVinfection. Hodgkins and Orbell observed
that high response costs predicted avoidance of
breast self-examination. These studies provide
evidence consistent with the theoretical
prediction that, in the absence of high coping
appraisal, perceived threat may prompt
maladaptive coping responses.
These reviews of evidence are derived only
from studies conducted in the health behavior
domain. However, protection motivation theory,
in particular, has also guided research in
occupational settings (e.g., Melamed et al.,
1996; Rickett, Orbell, & Sheeran, 2006) (see
Sidebar 4.1) and more recently in relation to

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 Changing Behavior Using the Health Belief Model and Protection Motivation Theory
cybersecurity (e.g., Ashley et al., 2016; Hanus
& Wu, 2016). The meta-analyses provide
valuable estimates of the size of the relationship
between cognitive representations (beliefs) and
behavior. However, it should be borne in mind
that these syntheses provide summaries of the
strength of the relation between single variables
and the behavior in question. They do not
provide an assessment of the extent to which the
individual
variables,incombination,explainvarianceinfutur
e behavior. Future research may consider
combining meta-analysis with techniques to test
the combined effects of the theory variables in
predicting behavior (e.g., Cheung & Hong,
2017; Hagger et al., 2017). Researchers should
also note the possibility of ceiling effects, a
class of response invariance that occurs when
all participants in a study endorse a belief to an
almost identical extent (e.g., the belief that
cancer is a serious disease).
Invariance will render a variable statistically
incapable of explaining variance in behavior,
underlining the importance of considering the
wording of relevant items carefully.
4.3 How Have the Theories Been
Used to Change Behavior?
The health belief model and protection
motivation theory have both been tested in
interventions to change behavior. However,
health belief model interventions have more
often been employed in public health or clinical
contexts, whereas protection motivation theory
has been subject to more laboratory
experimental tests (Milne, Orbell, & Sheeran,
2002). Interventions should aim to modify
constructs specified by the theory. Typically,
health belief model and protection motivation
theory interventions take the form of written
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54
communications(leafletsorbooklets)
(e.g.,Strecher et al., 1994), video presentations,
or verbal communications viatelephone(e.g.,
Anderson etal., 2011), or in person (e.g., Tola et
al., 2016). Modern approaches might also
involve text or e-communications (see Chapter
29, this volume). Some interventions employ
health professionals and intensive education
programs lasting over several sessions. For
example, Tolaet al.(2016) report ahealth belief
model intervention in Ethiopia to improve
adherence to treatment in patients with
tuberculosis. The intervention involved seven
sessions of health education delivered by health
professionals that included psychological
distress counseling to facilitate the processing
of information and material to address
perceived susceptibility and response efficacy,
methods to overcome barriers to adherence and
to enhance self-efficacy. The intervention
resulted in a substantial increase in adherence
that
wassupportedbyachangeintargetedhealthbeliefs.
Interventions designed to demonstrate that a
change in beliefs results in a change in behavior
should follow baseline assessment of beliefs
specified by the theory, followed by
reassessment of the beliefs to determine if the
manipulation has been successful in changing
beliefs (see Chapters 19 and 22, this volume).
Final assessment of behavior at an appropriate
point in time to observe behavior change should
follow. Good practice to test theory would also
establish that the changes in beliefs engendered
by the education mediate the impact of the
intervention on behavior change.
Recommended elements of an intervention to
change beliefs are presented in Appendix 4.1
(supplemental materials).
 55 SHEINA ORBELL, HINA ZAHID, AND CAROLINE J. HENDERSON
4.4 Evidence Base for the Use of the
Theories in Changing Behavior
4.4.1 Evaluation of Behavior Change
Interventions Based on the
Health Belief Model and
Protection Motivation Theory
The first reported intervention based on the
health belief model was published in 1970
(Haefner & Kirscht, 1970). The study
concerned check-up visits to the doctor with an
impressive eight-month follow-up. Just one
systematic review of interventions employing
the health belief model has been published to
date (Jones et al., 2013) and there is, to date, no
review of interventions based on protection
motivation theory, although Milne et al. (2002)
reviewed the impact of experimental
manipulations on changing cognitive
representations. Jones and colleagues reviewed
eighteen studies, including sixteen randomized
controlled trials, in contexts such as alcoholism,
sleep apnea, asthma, and diabetes. The authors
concluded that 77 percent of interventions
applying the health belief model resulted in
significant changes in behavior but noted that
few studies provided evaluation of the
mediation hypothesis discussed in section 4.2.1.
While there is considerable support for the
idea that behavior change interventions based
on the health belief model and protection
motivation theory are capable of changing
behavior, it is perhaps timely, given that
severity, benefits, and barriers are threat-
specific, to consider reviews of studies that
address behavior change in particular contexts
in those contexts alone rather than attempt to
aggregate them across contexts. As noted in
Section 4.2.1, the measurement (and appropriate
manipulation) of relevant constructs will always
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be behavior- and context-specific. The
assumption that “off-the-shelf” measures, or
pre-validated measures similar to those
available for constructs such as anxiety or
depression, represent superior measures is very
unhelpful in the context of establishing the
specific cognitive change brought about by an
intervention targeting specific social cognition
variables (see Chapter 19, this volume). For
example, Jones et al. (2013) note the use of a
wide range of intervention evaluation measures
that are validated but irrelevant to establishing
the veridicality of manipulation of health belief
model variables. Further limitations of the
extant evidence base relate to inadequate
transparency and reporting of intervention
content in research reports and articles,
practices that stymie evaluationand
replicationefforts (see also Chapter 23, this
volume), and inadequate follow-up, in terms of
both time lag and the objective measurement of
behavioral outcomes.
4.4.2 Theoretical and Empirical
Relationship to Fear Appeals
Perceived “threat” is a fundamental variable in
both the health belief model and protection
motivation theory and in both theories
comprises perceptions of susceptibility to an
adverse outcome and perceived severity of that
outcome. Both accounts are premised on the
idea that motivation follows from awareness
that there is a threat to be addressed (see also
Chapter 5, this volume). Response to threat is a
function of beliefs about the likelihood of a
response being effective, and beliefs that the
response is easy to perform, and will not result
in unpleasant consequences that undermine the
positive consequences or benefits. Thus threat
arousal might be seen as fundamental to
interventions to promote behavior change. A
 Changing Behavior Using the Health Belief Model and Protection Motivation Theory
useful summary term for this idea is “fear
appeal.” This section considers current evidence
regarding the importance of “appealing to fear.”
The history of fear appeals is a long one and
the importance of threat in fear appeals is a
contentious and much debated issue. In recent
years, several meta-analyses have tackled the
question of when appealing to fear may or may
not effect behavior change (Kok et al., 2018;
Peters, Ruiter, & Kok, 2013; Tannenbaum et al.,
2015; Witte &
Allen, 2000). Peters and colleagues conducted a
review of studies that had manipulated both
threat (via perceived susceptibility or severity
or a combination thereof) and efficacy (via
response or self-efficacy or a combination
thereof). Their review adopted very stringent
inclusion criteria, requiring that threat and
coping efficacy be manipulated in a 2 × 2
experimental design (low vs. high or present vs.
absent), and assessed a “real” behavioral
outcome (e.g., studies where behavior involved
requesting more information were excluded).
Surprisingly, given that no date restrictions
were applied to their search criteria, just six
studies were eligible for inclusion. They
encompassed a range of behaviors such as
taking roundworm medication, earthquake
preparation, tetanus vaccination, truancy, and
condom use.
The key hypothesis was that there would be a
significant interaction between threat and
efficacy manipulations, and this was supported
in the analysis. Effect sizes (Cohen’s d) from an
analysis of simple effects of the manipulations
are presented in Appendix 4.2 (supplemental
materials). Threat manipulations significantly
increased behavioronly when efficacy was
high.Infact, the effect of manipulating threat in
combination with low efficacy was negative,
suggesting that this combination of intervention
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56
components might undermine attempts to
change behavior. The effect of manipulating
efficacy under conditions of low threat was
nonsignificant, whereas the effect of
manipulating efficacy under conditions of high
threat was highly significant and large (d =
0.71). This analysis provides important
clarification of behavior change processes not
available either from meta-analyses of bivariate
relations between constructs in prospective
studies or from existing reviews of behavior
change interventions employing protection
motivation theory and the health belief model.
Although the analysis is based on the small
number of rigorous tests available, findings
indicate that behavior change interventions
should not target threat appraisals unless either
the population is already high in self-efficacy
and response efficacy (low barriers, high
benefits) or the intervention also includes
elements that will substantially increase
response and self-efficacy. For example, if an
intervention seeks to address accessibility to a
service by providing the service in the worksite
without loss of income, manipulating threat
perceptions may be adequate. More often,
however, personal self-efficacy needs to be
addressed. Findings are consistent with recent
meta-analyses with admittedly less stringent
inclusion criteria that also propose that
interventions that promote threat are unlikely to
be effective in isolation. For example, in a
meta-analysis of interventions to promote
condom use to protect against sexually
transmitted disease, there was minimal evidence
that threat-inducing arguments were effective
(Albarracín et al., 2005). Related to these
findings, Sheeran et al. (2014) suggest that
interventions that increased perceptions of
susceptibility have larger effects on behavior
 57 SHEINA ORBELL, HINA ZAHID, AND CAROLINE J. HENDERSON
change if they also increase response efficacy
and selfefficacy (d = 0.52).
Behaviorchangestudiesneedtoemployeffectiv
e methods to target these constructs and
demonstrate,
inpilotworkwithsimilarpopulations,thattheinterv
ention has powerful effects on these constructs
prior to implementation (see Appendix 4.2).
Further work is also warranted that employs 2
(threat manipulation/intervention) × 2
(selfefficacy/response efficacy manipulation), or
even 2 (severity manipulation) × 2
(susceptibility manipulation) × 2 (response
efficacy manipulation) × 2 (self-efficacy
manipulation), designs with sufficiently large
samples to examine the effects of manipulations
of severity, susceptibility, response efficacy, and
self-efficacy independently on behavior and
their interactive effects. Protection motivation
theory provides a theoretical rationale for
people making “threat control” or emotion
control responses to health communications (see
Figure 4.2). Peters and colleagues’ (2013)
observation that threat combined with low
efficacy had a negative effect on behavior is
consistent with the prediction from protection
motivation theory that people will engage in
denial, refutation of evidence,
oremotionmanagementresponseswhentherecom
mended coping response is difficult or
psychologically costly (Rippetoe & Rogers,
1987). Behavior change interventions that
manipulate threat alone are not indicated by
current evidence and may do more harm than
good. Whereas health communications such as
graphic threat images on cigarette packets tend
to neglect the importance of
selfefficacyofrecommendedactiononbehaviorcha
nge (interested readers might like to consider
recent debate of this issue: Borland, 2018;
Brewer, Hall, & Noar, 2018; Kok et al., 2018;
Malouff, 2018;
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at https://www.cambridge.org/core/terms. https://doi.org/10.1017/9781108677318.004
Niederdeppe & Kemp, 2018; Peters &
ShootsReinhard, 2018; Peters et al., 2018;
Roberto, Mongeau, & Liu, 2018; White &
Albarracín, 2018), those communications
focused primarily on behavior change (that
leads to economic gains by
sellingproducts)tendtoemploythreatasameansto
introduce clear visual and narrative
representations of response efficacy, and self-
efficacy, including behavioral modeling (see
Sidebar 4.2). However, it should also be noted
that a good deal of behavior change in health
contexts concerns changing existing behavioral
habits that require specific skills and techniques
(see Chapter 13, this volume).
4.4.3 Relationship of Beliefs to
Sociodemographic Variables
The health belief model (Figure 4.1) proposed
that beliefs mediate the effects of social
structural variables such as socioeconomic
status, income, and education and demographic
variables such as gender, age, and ethnicity on
behavior. Relatively few studies have formally
examined this mediation hypothesis (e.g.,
Orbell et al., 1996). More recently, Orbell et al.
(2017) provided a unique evaluation of the
ability of health beliefs to mediate the effects of
both socioeconomic status and ethnicity on
objectively observed colorectal screening
behavior. Findings provided strong support for
the role of perceived costs (barriers) and self-
efficacy as mediator variables. As noted in
Section 4.2.1, the identification of modifiable
cognitive representations not only permits
intervention to change behavior but such
intervention should also moderate (attenuate)
the relationship of sociodemographic variables
on future behavior where such prior
relationships between sociodemographic
 Changing Behavior Using the Health Belief Model and Protection Motivation Theory
variables and behavior have been established
(see also Chapter 27, this volume).
This hypothesis remains largely untested.
Some recent research does suggest one
possible route by which manipulation of
perceived benefits (response efficacy) and
perceived barriers (response costs) might
modify sociodemographic variability.
Manipulations in which the benefits of action
are framed as more immediate and the costs
more distal have been shown to increase
motivation for preventive health behavior across
multiple domains (Orbell, Perugini, & Rakow,
2004; Orbell & Hagger, 2006; Orbell &
Kyriakai, 2008; see also Whitaker et al., 2011).
A recent study showed that these manipulations
modified the motivation of people with
Pakistani ethnicity to take up screening (Zahid,
2019). People of Pakistani ethnicity may share a
form of predeterministic fatalism that results in
low perceived efficacy to modify the long-term
life course. Manipulating response efficacy as
an immediate benefit served to promote
motivation for screening. Further research is
required that investigates the moderation
hypothesis.
4.5 Conclusions
The health belief model and protection
motivation theory provided an important
delineation of key variables in motivating
behavior change, particularly in the context of
health threat, and were two of the earliest
expectancy value models of behavior change.
Variables specified by the models predict
behavior prospectively and many interventions
guided by these models show effects on
behavior change. Use of the models to change
behavior should ensure adequate consideration
of coping efficacy, publication of content of
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at https://www.cambridge.org/core/terms. https://doi.org/10.1017/9781108677318.004
58
manipulations, evidence that the manipulations
impact on coping efficacy, and long-term
follow-up of behavior.
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