Why your patient might not be following your advice: The Health Belief Model

In my last two posts, I've been sharing some introductory ideas about Health Behavior Theory (HBT).  I'd like to take things a step further today and delve a little more deeply into some specific concepts.

Let's explore one of the most well-studied health behavior theories - the Health Belief Model (HBM).

The HBM states that our health choices are a direct consequence of our perceived susceptibility to a disease, our perceived severity of a disease, and the perceived barriers that keep us from adopting better habits.

Perceived susceptibility, perceived severity, and perceived barriers are three of the main constructs from the HBM.  The word "perceived" is very important; these assumptions are based on individual perceptions and deductions based on a combination of environment, experiences, and personality.

"Perceived susceptibility" refers to how at risk we think we are to a particular disease.  In my master's thesis,* I studied the literature on adherence to high blood pressure medications.  Turns out that people who think they're not at risk to have high blood pressure (even if they really do have it) don't take their meds.

"Perceived severity" refers to how bad we think having a particular disease is.  Turns out that people who know they have high blood pressure but don't think it's a particularly dangerous condition (they don't know, for example, that high blood pressure can lead to heart attacks, strokes, or kidney failure) don't take their meds.

"Perceived barriers" almost always boils down to one of three obstacles: not having enough money, not having enough time, or not having enough social support.  If people can't afford their high blood pressure medication, they're not going to take it.  If they don't think they have the time to exercise, they won't.  If the foods we tell them to eat are different from the food their friends and family eat, they probably won't eat them.

Identifying which of these constructs is at play when a patient isn't following our advice is key to improving adherence with our recommendations. Doctors and health professionals can help patients change their perceptions, and thereby change their attitudes about treatment - but only if we've taken the time to identify what is making it hard for our patients to follow our advice.

We can do this by being careful listeners and asking thoughtful questions.
   "What kind of person do you think gets high blood pressure?" (perceived susceptibility)
   "What kinds of problems can result from high blood pressure?" (perceived severity)
   "What has made it hard for you to take your medicine?" (perceived barriers)
These  questions can uncover if an HBM construct is at play. Only after identifying and validating** our patients' beliefs and attitudes can we gently correct incorrect assumptions, supply additional knowledge, and/or problem-solve with our patients.

"Because I said so" doesn't work with patients, but exploring their beliefs and attitudes about disease and treatment can go a long way toward helping them to improve their health.

* Here's a summary of my master's thesis that was published in 2009 if you're interested: http://www.ncbi.nlm.nih.gov/pubmed?term=2009%5Bpdat%5D+AND+A+proposed+new+model+of+hypertensive+treatment+behavior+in+African+Americans.&TransSchema=title&cmd=detailssearch. 
(I focused on African Americans since I was primarily serving an African-American neighborhood  in my prior job.  I did a subsequent unpublished literature review that showed the same concepts basically hold for most white patients.)

** As the residents I teach are probably tired of hearing me say, "validating" does not equal "agreeing."  We can acknowledge to our patients that we can see how their belief makes sense to them without necessarily agreeing with the accuracy of that belief.  Patients who feel that their beliefs are unvalidated are unlikely to accept our alternative belief.

Why don't our patients do what we tell them?

This question was what drove me to graduate school for a Master's in Public Health a few years ago.  I was finishing up my Family Medicine residency at, arguably, one of the top residency programs in the nation.  I had been well trained in both medical science and doctor-patient relationship skills.  Yet my patients still consistently did not adhere to my advice.

I was not disappointed in my MPH studies.  It turns out that most people (with the exception of the cognitively challenged) are rational actors.  They make decisions that seem rational to them, based on their personalities, environments, and social pressures.  One person may not agree with another's decision, and yet both will arrive at his/her own decision based on some rational process.  This tenet is the basis of Health Behavior Theory (HBT).

Here's one scenario:

3 year child sees her parents drinking soda pop at dinner every night.  She gets juice to drink several times a day.  When her parents give her a taste of their soda pop, she immediately realizes that this stuff is much tastier than water or milk.  This same child has a TV set in her bedroom, so she sees advertisements for juice and soda pop frequently.  She lives in a disadvantaged neighborhood where there are no grocery stores, just corner markets.  Soda pop is cheap, and WIC covers juice, so there's always some of both at home.  Her parents, who like drinking soda pop and have no reason to believe it could hurt their health, begin acquiescing to the child's frequent requests for soda pop.

Before long, this 3 year old is now 14.  Her high school cafeteria stocks Starbucks Frappucino, which makes her feel very grown-up when she drinks it.  The school vending machines can't sell soda anymore, but there's lots of juice and flavored waters still to choose from - not to mention that she usually picks up a 20 oz bottle of Mountain Dew or Pepsi on the way to school to help her wake up, since school starts much earlier than her teenage circadian rhythm prefers.  Milk and plain water are anathema to her.

She grows into a young adult, who presents to your family practice office.  She tells you that her dad was just diagnosed with diabetes, so you screen her and find that she has pre-diabetes.  When you talk to her about switching her beverages to water or zero-calorie sodas, she looks at you like you're from outer space.

This hypothetical patient learned, from a very young age, that sugared beverages taste good.*  Her experiences provided her with the perceived norm that everyone drinks soda pop and juice multiple times a day.  I now have fifteen minutes during this appointment with her to overcome twenty years of belief and experience that have led to her sugared beverage consumption behavior.

Sounds difficult, right?

Just telling her that sugared beverages are bad for her, and if she doesn't do anything she'll end up with diabetes, won't work most of the time.  What can work, interestingly enough, is asking her (non-judgmentally) about her specific beliefs about soda pop.  What has she seen, what has she heard, why does she like them, etc.  Then, it's possible to gently explore these beliefs together. I've found that patients are usually much more interested in hearing doctors' advice if they feel they've been heard and respected first.

In my next post, I'll talk a little about some of the more specific constructs, or ways of thinking about health attitudes and beliefs, in HBT.  Identifying which one is at play with your patient may just help you both achieve a better outcome.

* And they do taste good.  The manufacturers of these beverages know exactly what they're doing.  Soda pop is very inexpensive to produce, so it can be sold for a huge profit margin while still keeping prices affordable.  High profit margin, tasty product = big bucks for these companies.  Sugared beverages are so ubiquitous and socially acceptable that it's hard for me to imagine how anyone is able to resist them.

Our health isn't all up to us

I inherited motion sickness from my father's side of the family.  I can't sit in the back seat of a car for more than 10 minutes without becoming sick.  I take meclizine before every plane flight.

I inherited asthma from my mother's side of the family.  Exposure to perfume, 90+ degree temps with 90+% humidity, or even a good laugh will all prompt me to cough.

These two maladies of mine have one thing in common - multiple people over the years have informed me that they're "all in my head."  Among the advice I've received:  

       "You just need to distract yourself."

       "It's all stress.  You need to relax."

       "Yoga. Yoga will realign your energies."

       "You're taking too much medication.  Your body is reliant on it."

Upon hearing these statements, I rapidly cycle through the following emotions: Hurt. Indignation.  Disappointment.  Anger.  None of those emotions provide a good starting point for hearing this advice, which I have to admit is probably well-intended.

But, if I am honest with myself, I can't pretend that I am not guilty of thinking some of the same things about my patients.  I get frustrated that my overweight patients continue to choose unhealthy foods and avoid exercise.  I bite my tongue when my patient with liver damage continues to drink alcohol.  Maybe blaming others makes us feel better about ourselves, and it might even make us feel that we're invulnerable to the disease under discussion; we're making the "right" choices, after all, and that somehow makes us superior to the afflicted person.*  I am certainly guilty of those same thought processes.

When I catch myself thinking this way, I try to override these thoughts with the knowledge I gained through my studies in Health Behavior Theory (HBT).  The basic tenet of HBT is that each individual believes that the health choices he/she makes are rational and reasonable.  These choices are usually based on 1) the priorities their environment imposes on them and 2) their beliefs about health.  For example, if a person grows up in a poor neighborhood where most people are overweight and with limited access to healthy food, this person will likely deduce that being overweight and eating fast food everyday are normative conditions.**

HBT teaches that blaming others for their health problems helps no one.  Whether it's motion sickness, asthma, mental illness, fibromyalgia, obesity, diabetes...most 21st century health conditions are due to some combination of genetics, environment, and personal choice.  Health is a combination of personal responsibility along with the luck of the genetics and environment we're born into.

Maybe if we could spend less time on blame and more time on supporting each other - and creating healthier environments - our good intentions might result in more than just hurt feelings.

* I can't take credit for these ideas - that belongs to Susan Sontag and her ground-breaking book Illness as Metaphor. If you are interested in learning how and why humans assign emotional value to various diseases, this short book is a worthy read.

** This is a terribly oversimplified description of HBT.  I'll discuss this topic further in a future post, but if you'd like to read more in the meantime, check out: http://www.gchd.us/ReportsAndData/ClioModelPlanningProcess/PDF/HealthBehaviorTheoryfromGenCoHlthDpt%20ClioBook.pdf and  http://www.unc.edu/~ntbrewer/pubs/2008,%20brewer%20&%20rimer.pdf.

Hitting the "reset" button

When I asked a colleague to cover my patient in-box for my vacation last week, she said, "Of course.  Hitting the reset button is very beneficial."

I've never thought of vacation in those terms.  According to researchers, the blissful effects of a vacation wear off within days to weeks. (1)  I've always considered vacation as little more than a brief blip of respite among a mostly hectic, busy life.

I've been thinking about her comment a lot during this past week off, though.  Perhaps I've been thinking about vacation incorrectly.  What if vacation could be more than just a time to escape?

What if vacation could help to reset us back to that best, brightest version of ourselves?

Like most others in medicine, I don't mind working hard.  It's the price I pay to have the incredible privilege of caring for other human beings.  Most days, I truly enjoy what I do.

But the constant stream of responsibility and worry and stress adds up.  By the time my husband and I left last week, I was struggling to find the energy to truly give it my all at work.  The enthusiastic, committed teacher and doctor in me was worn out.

So, last week, I made a conscious effort to reset.  I lived in the moment and let all of those pressures go.  I ate and slept and toured.  I basked in the temporary release.

And, unlike prior last-Sunday-nights-of-the-vacation, I am ready to return.  Oh, I know, there'll be a big pile of mail and journals and patient issues to sort through waiting on my desk.  The usual busy-ness of the day will be compounded by catching up on e-mail and office events.

But, this time, I'm ready.  I have the mental and physical energy to put the best version of myself out there.  Vacation doesn't have to be just a break; it can be a chance for a fresh, new start.

I hit the reset button, and it feels good.

(1) http://www.dailymail.co.uk/travel/article-2021473/The-health-effects-holidays-wear-just-weeks--breaks-say-experts.html, http://www.npr.org/templates/story/story.php?storyId=111887591