The Health Belief Model (HBM) was initially developed in the 1950s by a group of social psychologists in the U.S. Public Health Service in an effort to explain the widespread failure of people to participate in programs to prevent or to detect disease (Hochbaum, 1958; Rosenstock, 1960, 1966, 1974). Later, the model was extended to apply to people’s responses to symptoms (Kirscht, 1974) and to their behavior in response to diagnosed illness, particularly compliance with medical regimens (Becker, 1974). Over three decades, the model has been one of the most widely used psychosocial approaches to explaining health-related behavior.

This article summarizes the literature describing the at-home management of and psychosocial coping with five chronic diseases (heart disease, asthma, chronic obstructive pulmonary disease, arthritis, and diabetes) by the general population of adults. It also reviews the literature describing self-management of these chronic diseases by older adults. Conclusions drawn subsequent to the review are (a) that there are strong commonalities in the essential nature of tasks that exist across disease entities, (b) that the context for self-management of disease by the ill elderly is likely to differ somewhat from the context for other age groups. Questions for future research are posed.

Women who practice breast-self examination (BSE) occasionally detect breast lumps that are ultimately biopsied and found to be benign. This research examined the impact of a negative breast biopsy on subsequent BSE practice. A total of 655 women comprised three study groups: 83 women who discovered their breast problem by BSE; 179 women whose lump was identified by an individual/procedure in the health care system; and 393 women with no history of breast problems. Telephone interviews determined BSE practice for 6-month intervals prior to, and after, the benign biopsy experience. Among previously-regular practitioners, 21% of the self-discovered group and 16% of those whose lump was discovered in the health care system reduced their BSE practice below the recommended monthly interval following the benign biopsy. In contrast, among initiallynonregular practitioners, 29% of the self-discovered group, and 25% of the health care system group subsequently became regular BSE practitioners. Possible explanations are offered for these opposite shifts in BSE regularity, and some practical suggestions are provided for health care professionals who counsel women following a benign biopsy experience.

Over a period of 6 months, factors related to change in cigarette smoking were investigated in a group of 250 adult outpatients, all of whom smoked at the time of enrollment in the study. Among the variables tested were demographic, social, and situational factors, beliefs about the health effects of smoking and difficulty of quitting, and intentions regarding future smoking. Information was gathered at baseline and the first and sixth months by means of telephone interviews. Relative to smoking at 6 months, intention, education, and professional advice made independent contributions to cessation. The processes of quitting were examined in more detail. Attempting to quit was related to intention, professional advice, level of smoking, and social cues to smoke. Among those who tried to stop, difficulty with urges to smoke, and education affected success versus failure. Earlier success related to less anxiety and tension, and to less difficulty in not smoking when in negative situations. The findings suggest that a complex set of social and cognitive factors affect change in smoking behavior, and that somewhat different factors are operative at different stages.

This study investigated several measures of beliefs about controlling smoking as predictors of cessation and reduction at one and six months after a medically-based control program. Smokers (n = 250 total) attending general medicine clinics at University and Veterans Administration facilities received advice to quit from both physicians and nurses. Beliefs about difficulty resisting urges to smoke in 15 situations, their frequency of occurrence, and general level of difficulty were assessed at baseline. For the University group of patients, significant relationships were found between both general and specific indexes and both cessation and reduction at one month. Although a greater change in smoking was seen at six months, few belief measures remained predictive. At one month, global measures were as useful as specific ones, although difficulty in situations of negative emotion was a consistent and strong predictor. Marked differences between the two sites were found; virtually no measure of difficulty proved predictive for the VA group.

This study examines the influence of parents peers and partners on teenage womens contraceptive-seeking behavior and identifies sources of variation in the amount and direction of influence. Data are based on a survey of 2884 unmarried US women under 20 who were making their 1st visit to a family planning clinic. All family planning clinic sites in 21 of Marylands 23 counties were included in the study. The majority of these young women report active participation in and support for the clinic visit by significant others. However the involvement of parents or peers seems to reflect alternative support strategies: girls who involve parents tend not to involve peers and vice versa. Parental involvement is most likely to be reported by black girls and is least likely among white girls with relatively well-educated mothers. An interpretation of these findings is based on structural and normative differences between American black and white families. The data suggest that a critical factor in determining the particular support strategy to be adopted is perceived parental approval of the adolescent daughters action in seeking a method of contraception. Parental approval for contraception was markedly higher among black than among white parents and was least likely if the young womans mother is white and relatively well-educated. The data imply that contraception has different meanings in different social contexts.

Inadequate adherence to prescribed treatment plans is perhaps the most serious obstacle to achieving success ful therapeutic outcomes, and non compliance by diabetic patients is no exception. This is partly based on pa tients' realization that compliance does not necessarily result in lack of illness. A psychosocial framework for under standing patient compliance is the Health Belief Model, which is based upon the value an individual places on the identified goal and the likelihood that compliance will achieve that goal. This Model has been useful to explain noncompliance, to make an "educa tional diagnosis," and for designing compliance-enhancing interventions.

A controlled evaluation of a minimal-contact smoking cessation intervention was conducted with 213 inpatients and outpatients at a Veterans Administration Medical Center (VAMC). The intervention had three components: Brief consultation from a health practitioner; administration of a selfhelp smoking cessation manual; and provision of an incentive to adhere to recommendations in the manual. Enrollment procedures differed from those of many other smoking-intervention trials in that, instead of enrolling only smokers who were motivated to quit, all patients who smoked and who would normally be considered eligible for a smoking-cessation intervention were included. The evaluation examined acceptability of the program to patients who smoked, overall effectiveness of the intervention, and efficacy of the intervention for specific patient demographic, social status, and health status groups. The program had a high degree of acceptance by patients who smoked, with over 60% agreeing to participate and take home the self-help smokingcessation manual. The program was effective in getting patients to reduce their daily smoking, and marginally effective in influencing smoking cessation, with some patient groups exhibiting higher cessation rates than others. Special problems to be considered when attempting to influence groups of smokers at high levels of psychological stress and with low levels of education and income - factors normally associated with high rates of smoking and failure in traditional smoking-cessation programs - are discussed in light of the results obtained.

An important area of concern in community health is the widespread practice of individuals undertaking courses of treatment in the absence of medical advice or direction. This is especially a problem when it involves the administration of medicines to children. This study examines the extent, determinants, and quality of the independent use by mothers of medications for treating their children's symptoms. Data on mother-initiated medication behavior (MIMB) were obtained from a random sample of 500 mothers of children at two pediatric ambulatory care sites. Six expert pediatric judges rated every reported medication use (N = 3,908) along three dimensions (usefulness, correctness, and harmfulness/helpfulness) and also evaluated the overall appropriateness of each mother's MIMB. Results indicate that: 1) mothers keep available and use for their children a considerable number of different medications; 2) clear relationships exist between mothers' socioeconomic status and the different categories of medications they employ; 3) mothers' perceptions of their children's vulnerability to specific illnesses, and of the efficacy of over-the-counter medications for treating those illnesses, were related to the possession and use of relevant medications; and 4) judges' ratings indicated little enthusiasm for the mothers' therapeutic actions. These findings suggest the need for pediatricians to become aware of the medications their patients may be ingesting as a result of MIMB, and to educate mothers concerning use and misuse of over-the-counter (and other) treatments.

This paper examines the relationships between patients' perceptions of susceptibility to illness, self-efficacy, anxiety, social support and subsequent changes in cigarette-smoking behavior through a prospective study involving 213 patients using a Veterans Administration Medical Center (VAMC). During an inpatient or outpatient visit to the VAMC, veterans received a questionnaire and were then enrolled in a smoking cessation intervention trial wherein some patients received a practitioner-initiated minimal-contact intervention and other patients received usual care. Smoking status was assessed 3 months following hospital discharge. Analyses revealed that patients most likely to have reduced their smoking, whether in the intervention or control group, were those reporting both high perceived susceptibility and high expectations of efficacy. Those least likely to have reduced their smoking were those reporting high susceptibility but low efficacy — what has been characterized as a 'learned helplessness' mode. Expectations of efficacy were inversely associated with general level of anxiety; that is, those reporting high levels of anxiety tended to report lower levels of self-efficacy. This relationship was powerfully buffered by a measure of social support. The results of this study suggest a number of potentially effective counseling strategies for practitioners who are trying to get their-patients to quit smoking.

From the Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, Michigan

Researchers and practitioners have expressed considerable interest in contingency contracting as a promising intervention strategy for enlisting patient cooperation, particularly with regard to long-term treatment regimens. After brief examination of the theoretical background, the authors summarize advantages of contracting, describe elements essential to the development of a contract, and enumerate those ingredients in the contracting process thought to be critical for achieving optimal results. They review relevant research efforts in terms of their designs, methods, target and contracted health-related behaviors, contingencies employed, and initial and follow-up results. On the basis of this review, current issues regarding contingency contracting are raised, and practical considerations for large-scale application are noted along with recommendations for future research.

Adoption of the most effective methods of contraception requires individual decision-making and negotiation with contraceptive providers. In order to take account of both behavioral elements, a two-dimensional framework for understanding contraceptive adoption and continuation by unmarried young is proposed, incorporating a "social-psychological model" of individual decision-making and an "interpersonal model" of factors affecting provider-client interaction. The social-psychological model is based on an earlier value-expectancy theory of behavior motivation as applied to health-related behaviors. The interpersonal model is derived from conflict-bargaining perspectives on professional-client interaction; it is suggested that expectations for this interaction are based on a limited number of internalized "models": the "professional"; the "bureaucratic"; the "commercial"; and the "parental." Insofar as client and professional "models" disagree, communication may break down and client understanding and/or acceptance of provider advice cannot be assured. The components of the social-psychological and interpersonal models are described in detail, and a combined framework is proposed.

This research examined the relative efficacies of three intervention strategies designed to increase compliance to medical regimens in a group of ambulatory hemodialysis patients. The interventions examined included behavioral contracting (with or without the involvement of a family member or friend) and weekly telephone contacts with patients. Compliance was assessed with regard to following dietary restrictions and limiting fluid intake. Data were collected from 116 patients drawn from two outpatient clinics. Within clinics, patients were randomly assigned either to an intervention program or to a control group. The study employed a pretest-posttest control group design. Patients were interviewed before the intervention programs began (T1), after a 6-week intervention period (T2), and 3 months after completion of the intervention period (T3). Results showed that the interventions achieved substantial reductions in patients' serum potassium levels and in weight gains between dialysis treatments between T1 and T2. In general, however, these program effects tapered off to preintervention levels between T2 and T3. The findings thus indicate a need for long-term intervention programs.

Patient noncompliance is a substantial obstacle to the achievement of therapeutic goals. This paper reviews a number of practical interventions with demonstrated efficacy in enhancing patient adherence, including (1) improving patients' levels of information concerning the specifics of their regimens, reinforcing essential points with review, discussion, and written instruction, and emphasizing the importance of the therapeutic plan, (2) taking clinically appropriate steps to reduce the cost, complexity, duration, and amount of behavioral change required by the regimen and increasing the regimen's convenience through "tailoring" and other approaches, (3) obtaining a compliance-oriented history of the patient's prior experiences and present health beliefs and, where necessary, employing strategies to modify those perceptions likely to inhibit compliance, (4) improving levels of patient satisfaction, particularly with the provider-patient relationship, (5) arranging for the continued monitoring of the patient's subsequent compliance to treatment, (6) increasing staff awareness of the magnitude and determinants of the noncompliance phenomenon and attempting to develop an "active influence orientation" in each member of the health care team, (7) using such techniques as patient-provider contracts to involve the patient in therapeutic decisions and in the setting of treatment objectives and creating incentives (through rewards and reinforcements) for achieving these objectives, (8) arranging for as much continuity of provider (and other staff) as possible, (9) establishing methods of supervising the patient, including involvement of the patient's social support network, and (10) involving fully the assistance of all available health care providers, assigning specific roles and responsibilities for activities directed at improving adherence to treatment.