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MEDSURG NursingDecember 2007Vol. 16/No. 6 363

Diane K. Daddario

A Review of the Use of theHealth Belief Model for

Weight Management

Diane K. Daddario, MSN, CNS, RN,BC, CMSRN, was a Graduate Student,CNS Adult Health and Illness program,Bloomsburg University, Bloomsburg,PA, at the time this article was written.She is currently a Staff Nurse,Evangelical Community Hospital,Lewisburg, PA, and a Clinical NursingInstructor, Pennsylvania College ofTechnology, Williamsport, PA.

Research found in the pro-fessional literature on the

Health Belief Model and itsuse in weight management

programs is reviewed. Withinthis model, the primary moti-vation to change is the levelof perceived threat or risk ofa specific condition (obesity),and the primary resource forchange is self-efficacy or con-fidence to make the changeto lose or maintain a healthyweight.

Obesity has become Americas most serious epidemic. After smoking, itis the leading cause of preventable, premature death in the UnitedStates. An estimated 400,000 deaths are attributed to obesity in the UnitedStates each year (Christou et al., 2004). Nurses are involved in manyaspects of care of the overweight or obese patient, either directly in aweight management program (teaching and counseling for conventionalweight management or bariatric surgery) or through providing care to thepatient affected by one or more of the many co-morbidities of obesity.Lifestyle changes are especially relevant when a patients body mass index(BMI) has increased to the point of being overweight (see Table 1).

Behavior change models are important in preventing weight gain andthe subsequent loss of excess weight to help the person meet the goal ofliving a healthier, longer life. The Health Belief Model (HBM) addresses theeffects of beliefs on health and the decision process in making behavioral

changes (see Table 2). Bowden, Greenwood, and Lutz (2005) identified itas one of the most studied theories in health education, used with varyingpopulations, health conditions, and interventions. The model provides acomprehensive framework for understanding psychosocial factors associ-ated with compliance. In this article, a summary of the limited researchfound in a professional literature review of the Health Belief Model asapplied to weight management is offered. To qualify for inclusion, an arti-cle had to be either an analysis or research performed using the HealthBelief Model to maintain a healthy weight or to lose weight for the personalready overweight or obese.

Source: Goldman & Ausiello, 2004.

Table 1.Obesity and BMI Classes

Category BMI

Overweight 25-29.9

Obese Class I 30-34.9

Obese Class II 35-39.9

Extreme Obesity Class III 40 or higher


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364 MEDSURG NursingDecember 2007Vol. 16/No. 6

A Review of BehavioralChange Models in PreventingWeight Gain

Baranowski, Cullen, Nicklas,Thompson, and Baranowski (2003)compared the various behaviorchange models for applicability inpreventing weight gain. Theyfound that behavioral change mayoccur as a result of change in vari-ables that mediate interventions.These mediating variables comefrom theories or models used tounderstand behavior. This reviewof seven different categories ofmodels and theories defined theconcepts and identified the moti-vational mechanisms and re-sources a person needs to change,the processes by which behav-ioral change is likely to occur, andthe procedures necessary to pro-mote change. After analysis wascompleted, authors identified the

most promising model as theTheory of Planned Behavior (TPB)and Social Ecology rather than theHealth Belief Model. They con-cluded that the best step would beto take the most promising con-cepts from each model and inte-grate them for use with specificpopulations.

Authors provided informationregarding the HBM and its relationto weight management. The model

includes perceived susceptibility,perceived severity, perceived ben-efits, perceived barriers, cues toaction, and self-efficacy related toillness. The primary motivation tochange is the level of perceivedthreat or risk of a specific condi-tion, and the primary resource forchange is self-efficacy or confi-dence. The person with a greaterlevel of confidence will more likelyengage in a specific behavior toimprove health. This processoccurs in several steps. Certaincues would stimulate the personsthreat of the disease by influenc-ing perceived seriousness, suscep-tibility, or both. With more power-ful cues, those with more personalrelevance, or the accumulation ofcues, the person is stimulated totake action. This may occur whenthe person watches a televisionprogram about a co-morbidity ofobesity, or an obese family mem-ber or close friend is affected by aco-morbid condition. The personsaction results from perceived ben-efits, perceived barriers that couldbe overcome, costs that could beavoided, and the persons confi-dence in his or her ability to per-form the new behavior. Individualsselect from the alternative behav-iors to minimize the perceivedthreat.

According to the authors, cur-rent research focuses on perform-ing or not performing a specificbehavior; little research has beencompleted related to cues toaction. Internal cues, such as feel-ing better physically or mentallyafter taking an action, were ratedas the most likely to promptaction. The authors found that

people may not rate the impor-tance of a cue to change accurate-ly. They also found a contradictionto the Health Belief Model in thefact that young adults experienc-ing an obesity-related co-morbidi-ty were no more likely to initiateweight loss or increase physicalactivity regardless of the threat.They concluded that this may bedue to a disagreement on how toproject objective disease risk anddiscrepancies in the perception ofdisease risk and the objectiverisks in the health dangers.

In addition, Baranowski andcolleagues (2003) noted that fear-based communications (usingstatements or explanations thatpromote fear to encourage posi-tive changes) have been investi-gated as a means to promotebehavior change by affecting theperceived susceptibility and seri-ousness of an illness. This form ofcommunication effectively influ-enced the persons perception of athreat and the selection of abehavior to reduce the threatbased on the efficacy of a re-sponse (whether the behaviorreduces the threat) and self-effica-cy (whether the person is confi-dent that the behavior can be per-formed).

Perceived Benefits andBarriers Related to PostpartumWeight Loss of Overweight/Obese Postpartum WICParticipants

Lambert, Raidl, Safaii, Conner,Geary, and Ault (2005) attemptedto clarify the perceived benefitsand barriers related to weight lossin a group of overweight/obesepostpartum participants in theWomen, Infants, and Children(WIC) program and identify inter-ventions through the WIC pro-gram to support the participantsweight loss efforts. Concepts fromthe Health Belief Model served as

Table 2.Health Belief Model

Perceived susceptibility A persons perceived risk for contracting anillness or health condition of concern to theresearchers

Perceived severity A persons perception of the personal impact(clinical or social) of contracting the illness

Perceived benefits A persons perception of the good things thatcould happen from undertaking specific behav-iors, especially in regard to reducing the threat ofthe disease

Perceived barriers A persons perception of both the difficulties inperforming the specific behaviors of interest andthe negative things that could happen from per-forming those behaviors, cues to action such asenvironmental events (e.g., learning that a parenthad a heart attack), bodily events (e.g., aches orpains), or stories in the media that trigger percep-tions of susceptibility

Self-efficacy A persons belief or confidence that he or she canperform a specific behavior

Source: Baranowski et al., 2003.


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MEDSURG NursingDecember 2007Vol. 16/No. 6 365

the basis for questions to guidethe focus group that were used asa qualitative research tool to elicitinsights of experiences and atti-tudes of the participants. TheHBM indicates that individualswill change their behavior if theyfirst believe that their health is atrisk and their current behaviorcould lead to detrimental conse-

quences. The individuals mustbelieve that the benefits of makingthe desired behavior changes out-weigh the barriers they may facewhile attempting to make thechanges.

The authors received positive,relevant responses on all six con-cepts of the HBM and concludedthat it was a helpful, appropriateguide for their study. Participantsresponses indicated that partici-pants may not perceive their ownsusceptibility to or severity of riskfrom being overweight/obese tothe extent that it would motivatethem to take action. Because indi-viduals make changes if they be-lieve that their health is at risk andtheir current behavior could haveserious consequences, research-ers recommended emphasizingthe risk and severity of the med-ical conditions and health compli-cations that can occur from beingoverweight/obese.

The Behavior and Psychology

Of Weight ManagementKelly (2004) discussed the

Health Belief Model as a behav-ioral change model that can beused to assess and treat over-weight and obese patients, stress-ing the importance of addressingthe psychological co-morbiditiesthat can affect long-term success.The HBM was offered as a toolthat can be used to determine apatients general health-relatedthoughts concerning personal pre-

vention strategies. The authorapplied the model to the health-related changes occurring when apatient has interest in and con-cern about his or her personalhealth, perceiving both a personalvulnerability to a particular healththreat and potential negative con-sequences if change does notoccur. If the persons healthbeliefs do not support the man-agement of overweight and obesi-

ty, he or she is less likely toachieve and maintain weight loss.Kelly provided examples of ques-tions for the provider to use toassess the components of theHealth Belief Model in the over-weight patient (see Table 3).

Comparing the HBM and theTheory of Planned BehaviorIn Predicting Dieting andFasting Behavior

Nejad, Wertheim, and Green-wood (2005) compared the HealthBelief Model, a modified version ofthe HBM including intention, andthe TPB for their ability to predictdieting and fasting. The studysample consisted of 373 femaleundergraduate psychology stu-dents ages 17-52. They were fromAustralia and their marital statuswas listed, but body mass indexwas not provided. The study com-pared two frequently cited cogni-tive approaches, the HBM and theTPB, in their ability to predict twotypes of weight loss behaviorswhich differed in their severitylevel. The Health Belief Model andthe Theory of Planned Behaviorvariables were constructed ac-cording to previously published

guidelines.The authors of this studyfound that the best prospectivepredictors of dieting using theTPB were the intention to diet andindirect perceived control. The35% variance in dieting was com-parable to earlier prospectiveresearch on a variety of healthbehaviors. The HBM showed a29% variance for dieting and 19%for fasting. The HBM predictors

for dieting and fasting with vari-ances not included in the TPBwere perceived benefits of dietingand self-rated susceptibility. Thissuggested that the best predictorsof behavior to encourage weightloss were the womens view ofdieting as beneficial and theirbelief that they were prone to gainweight. Beliefs that others wouldnot disapprove of weight lossbehaviors were not useful in pre-dicting behaviors in this sample.

Clinical implications for boththe prevention and intervention ofdieting and fasting were found inthis study. For dieting, intentionand benefits appeared to be themost relevant variables becausethey were the strongest predictorsof dieting behavior. Intention wasmost strongly predicted by atti-tude measures, benefits in theHBM, and direct attitude in thetheory of planned behavior, indi-cating that interventions are need-ed that aim to change salientbeliefs or to introduce previouslynonsalient beliefs.

In this study, the authorsfound the theory of planned be-havior and the modified HealthBelief Model, but notthe non-mod-

ified version of the HBM, were ableto predict the variance in intentionto diet, to fast, follow-up dieting,and fasting behavior. Because theywere unable to explain the largepercentage of variance in follow-updieting and fasting, they recom-mended that future models usemodified versions of current mod-els to answer more questions rele-vant to weight loss and obesity.

Source: Kelly, 2004.

Table 3.Applying the Key Components of the Health Belief Model to an

Overweight Patient

Component Ask the Patient

Perceived susceptibility What health risks do you think your weightposes for you?

Perceived seriousness What do you think will happen if you dontlose weight?

Perceived benefits of action How do you think you will benefit by losingthe weight?

Barriers to action What prevents you from losing weight?

Cues to action What will motivate you to lose weight?


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366 MEDSURG NursingDecember 2007Vol. 16/No. 6

Motivational Predictors ofWeight Loss and Weight-LossMaintenance

Williams, Grow, Freedman,Ryan, and Deci (1996) identifiedthe HBM as the motivationalapproach most frequently appliedin health care settings. Relatingrecent formulations of the model(with concepts of locus of controland self-efficacy) to weight loss,the authors suggested that peoplewill be motivated to lose weight ifthey believe that it will decreasetheir likelihood of contracting alife-threatening disease, have aninternal locus of control andexpect that specific behaviors willyield significant loss, and are con-fident that they are able to per-form the requisite behaviors. Theresearchers thoroughly reviewedthe Health Belief Model but stated

preference for the Self-Determina-tion Theory. Related to weightloss, they suggested that lastingbehavior change necessary formaintenance depends not on com-plying with demands for change

but rather on accepting personalownership of the regulation forchange. This process requiresinternalizing values and regulatingrelevant behaviors, integratingthem with a sense of self so theycan become the basis forautonomous regulation. Results ofthe study indicated that patientsautonomous motivation to partici-

pate in a weight-loss program isrelated positively to their stayingin the program and losing weight,then being able to maintain theweight loss.

Nursing ImplicationsOf the five studies reviewed,

only two studies (Kelly, 2004;Lambert et al., 2005) identified theHealth Belief Model as effectiveand appropriate for use in suc-cessful weight management. Thegoal of the staff should be to workwith the patient in a supportivemanner to increase his or her levelof confidence to lose weight. Edu-cation should be provided toensure the patients understand-

ing of the seriousness of obesityand its relation to his or her co-morbidities. As stated by severalof the researchers, it may beappropriate to use the best con-cepts from several models to meetthe patients needs.

References

Baranowski, T., Cullen, K., Nicklas, T.,

Thompson, D., & Baranowski, J. (2003).Are current health behavioral changemodels helpful in guiding prevention ofweight gain efforts? Obesity Research,11(10), 23-42.

Bowden, R., Greenwood, M., & Lutz, R.(2005).Changing lifestyle behavior. RetrievedJuly 10, 2007, from http://faculty.css.edu/tboone2/asep/ChangingLifestyleBehavior.DOC

Christou, N., Sampalis, J., Liberman, M.,Look, D., Auger, S., McLean, A., et al.(2004). Surgery decreases long-termmortality, morbidity, and health careuse in morbidly obese patients. Annalsof Surgery, 240(3), 416-424.

Goldman, L., & Ausiello, D. (Eds.). (2004).

Cecil textbook of medicine. Philadelphia:Saunders.Kelly, K.T. (2004). The behavior and psychol-

ogy of weight management. RetrievedJune 27, 2007, from http://jaapa.com/issues/j20040401/articles/thinkthin.html

Lambert, L., Raidl, M., Safaii, S., Conner, C.,Geary, E., & Ault, S. (2005). Perceivedbenefits and barriers related to postpar-tum weight loss of overweight/obesepostpartum WIC participants. Topics inClinical Nutrition, 20(1), 16-27.

Nejad, L., Wertheim, E., & Greenwood, K.(2005). Comparison of the health beliefmodel and the theory of plannedbehavior in the prediction of dieting and

fasting behavior [Electronic copy]. E-Journal of Applied Psychology, 1, 63-74. Retrieved July 10, 2007, from http://ojs.lib.swin.edu.au/index.php/ejap/article/view/7

Williams, G., Grow, V., Freedman, Z., Ryan,R., & Deci, E. (1996). Motivational pre-dictors of weight loss and weight-lossmaintenance. Journal of Personalityand Social Psychology, 70(1), 115-126.

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