Libyan International Medical University

Faculty of Business Administration

Postgraduate Studies
SAHA PROJECT (MSc) Programme in Healthcare Management

COGNITION MODELS
DR: SOUADA ELHDERE
Intended learning outcomes
By the end of this session you will be able to:

1. Describe the cognition models

a. The Health Belief Model
b. The Protection Motivation Theory
Introduction
Cognition models examine the predictors and precursors to health
behaviours. They are derived from subjective expected utility (SEU)
theory (Edwards 1954), which suggested that behaviours result from
a rational weighing-up of the potential costs and benefits of that
behaviour.
Cognition models describe behaviour as a result of rational
information processing and emphasize individual cognitions, not the
social context of those cognitions. This section examines the health
belief model and the protection motivation theory.
The Health Belief Model (HBM)
The health belief model (HBM) was developed initially by Rosenstock
(1966) and further by Becker and colleagues throughout the 1970s
and 1980s in order to predict preventive health behaviours and also
the behavioural response to treatment in acutely and chronically ill
patients. However, over recent years, the health belief model has
been used to predict a wide variety of health-related behaviours.
Components of the HBM
The HBM predicts that behaviour is a result of a set of core beliefs,
which have been redefined over the years. The original core beliefs are
the individual’s perception of:

 Susceptibility to illness (e.g. ‘my chances of getting lung cancer are

high’)

 The severity of the illness (e.g. ‘lung cancer is a serious illness’)

 The costs involved in carrying out the behaviour (e.g. ‘stopping
smoking will make me irritable’)
 The benefits involved in carrying out the behaviour (e.g. ‘stopping
smoking will save me money’)

 Cues to action, which may be internal (e.g. the symptom of

breathlessness), or external (e.g. information in the form of health
education leaflets).
Figure 1: HBM
The HBM suggests that these core beliefs should be used to predict
the likelihood that a behaviour will occur. In response to criticisms
the HBM has been revised originally to add the construct ‘health
motivation’ to reflect an individual’s readiness to be concerned
about health matters (e.g. ‘I am concerned that smoking might
damage my health’).
More recently, Becker and Rosenstock (1987) have also suggested
that perceived control (e.g. ‘I am confident that I can stop smoking’)
should be added to the model.
Support for the HBM
Several studies support the predictions of the HBM. Research
indicates that dietary compliance, safe sex, having vaccinations,
making regular dental visits and taking part in regular exercise
programmes are related to the individual’s perception of
susceptibility to the related health problem, to their belief that the
problem is severe and their perception that the benefits of
preventive action outweigh the costs .
Testing the theory
Testing a theory: Improving diet quality using HBM model

Title: Improving diet quality among adolescents, using health belief model in a
collaborative learning context: a randomized field trial study

Background: There is a great emphasis on improving healthy nutrition behavior

during childhood and adolescence through effective education as a key strategy
to maintain and improve health in this critical period of life. This study used the
Health Belief Model (HBM) as a theoretical framework to understand how
students’ knowledge and perceptions of susceptibility, severity, benefits,
barriers, indications of action and SE affect their dietary behavior. 
Aims: This study aimed to assess the impact of educational intervention, based
on health belief model (HBM) and collaborative learning techniques on diet
quality in adolescents.

Methodology

Subjects: A total of 311 Iranian students aged 13–15 years old were recruited
from secondary schools, they were randomly allocated into two groups ,an
intervention and a control group.

Design: A random control trial

Tools:

 Nutritional assessment
 Dietary intakes of the previous month were assessed using a validated, 168-
item food frequency questionnaire.
 Revised children’s diet quality index (RCDQI), which was used to assess
nutrition status of the adolescents,
HBM questionnaire: Knowledge- Perceived benefits and barriers- Self-efficacy-
Perceived severity- Perceived susceptibility- Cues to action
Instructional techniques: The interventions performed in this study were based on
the HBM model and the collaborative learning techniques. The educational contents
were determined based on the latest version of the Dietary Guidelines for Americans.

Results:

All HBM’s constructs and knowledge had significantly improved in the experimental
group and mean differences were increased after the intervention. Diet quality
improved in the experimental group (P < 0.001), which was significantly different
from the comparison group (P = 0.001).
Conclusion:

The findings support the integration of appropriate models/theories into the

context of collaborative learning methods to target large number of behavioral
determinants, and ultimately increase the effectiveness of the educational
interventions amongst adolescents.
Criticisms of the HBM
There are several criticisms of the HBM, however, including its focus on the
conscious processing of information (for example, is tooth-brushing really
determined by weighing up the pros and cons?); its emphasis on the
individual (for example, what role does the social and economic
environment play?); the absence of the role for past behavior and habit; and
the absence of a role for emotional factors such as fear and denial. But the
HBM has been a useful approach for carrying out research and designing
interventions.
The protection motivation theory:
PMT
The original PMT claimed that health-related behaviours are a product
of four components:
1. Severity (e.g. ‘Bowel cancer is a serious illness’).
2. Susceptibility (e.g. ‘My chances of getting bowel cancer are high’).
3. Response effectiveness (e.g. ‘Changing my diet would improve my
health’).
4. Self-efficacy (e.g. ‘I am confident that I can change my diet’).
These components predict behavioural intentions (e.g. ‘I intend to
change my behaviour’), which are related to behaviour.

Rogers (1985) has also suggested a role for a fifth component, fear
(e.g. an emotional response), in response to education or
information.
The PMT describes severity, susceptibility and fear as relating to
threat appraisal (i.e. appraising to outside threat) and response
effectiveness and self-efficacy as relating to coping appraisal (i.e.
appraising the individual themselves).

According to the PMT, there are two types of sources of information

environmental (e.g. verbal persuasion, observational learning) and
intrapersonal (e.g. prior experience).
This information influences the five components of the PMT (self-
efficacy, response effectiveness, severity, susceptibility, fear), which
then elicit either an ‘adaptive’ coping response (i.e. behavioural
intention) or a ‘maladaptive’ coping response (e.g. avoidance,
denial).
Figure 2
Using the PMT
If applied to dietary change, the PMT would make the following
predictions:

information about the role of a high fat diet in coronary heart

disease would increase fear, increase the individual’s perception of
how serious coronary heart disease was (perceived severity), and
increase their belief that they were likely to have a heart attack
(perceived susceptibility/susceptibility).
If the individual also felt confident that they could change their diet
(self-efficacy) and that this change would have beneficial
consequences (response effectiveness), they would report high
intentions to change their behaviour (behavioural intentions). This
would be seen as an adaptive coping response to the information.
Criticisms of the PMT
The PMT has been less widely criticized than the HBM; however,
many of the criticisms of the HBM also relate to the PMT. For
example, the PMT assumes that individuals are conscious
information processors; it does not account for habitual behaviours,
nor does it include a role for social and environmental factors.
The Example of Eating Behavior
Eating behavior is a health behavior which is clearly linked to health
and illness. For example, poor diet is associated with a range of health
conditions including obesity, diabetes, coronary heart disease (CHD),
cancer, joint problems, hypertension, and stroke. Eating behavior has
been studied using the two key theoretical approaches which can also
be applied to all other health behaviors. These are as follows:
A cognitive approach to eating behavior focuses on an individual’s
cognitions and has explored the extent to which cognitions predict
and explain behavior.
Some research using a cognitive approach to eating behavior has
focused on predicting the intentions to consume specific foods such
as the intentions to eat whole grains, skimmed milk, organic
vegetables, and whole grain bread. Much research suggests that
behavioral intentions are not particularly good predictors of
behavior.
Studies have also used the TPB to explore the cognitive predictors of
actual behavior and have explored behaviors such as table salt use,
healthy eating, low-fat milk consumption, and the intake of fruit and
vegetables. The belief which seems to be most predictive of diet is
perceived behavioral control indicating that the more control
someone feels that they have over eating well, the more likely it is
that they are able to actually eat well
In Summary
Behavior is central to health and illness and is clearly linked to the
beliefs we hold. Psychology has identified a number of beliefs to
predict behavior and then pulled these together into models which
can be used for research and to design behavior change
interventions . In conclusion psychological theory can help explain
why we behave in the way that we do?
For Discussion
Consider one of your regular health-related behaviors (e.g. smoking,
what you eat for breakfast, how much you sleep, getting check-ups).
Discuss how your health beliefs relate to this behavior.