Analyse and Critique the Health Belief Model as a Food Choice Model.
The Health Belief Model (HBM) is a psychological model that attempts to explain and predict health behaviors including food choice behaviour.
The Health Belief Model regarding food choice, is based on the understanding that a person will make healthy food choice, if that person:
- Feels that a negative health condition due to wrong food habits/ choices could be avoided.
- Has a positive expectation that by making healthy food choices he/she will avoid bad health.
- Believes that he/ she can successfully and comfortably make healthy food choices.
Thus health belief model is based on four constructs of perceived threats and net benefits; and these constructs are perceived susceptibility, perceived severity, perceived benefits and perceived barriers. An added construct called cues to action would stimulate the overt food choice behaviour. Another addition is self-efficacy or the persons’ believe in one-s own ability to perform a task.
Perceived susceptibility is the belief that one can get a bad health or disease or illness. If a person is able to understand that there is a possibility of getting a disease or bad health due to poor nutrition or bad eating habits; he will be more conscious regarding his diet and will try to improve his/her eating habits.
Perceived severity is the belief about, how severe a disease or condition could be. If a person believes that the bad health due to poor diet is a minor issue or the disease will not be a severe one, he may not be very cautious with his diet. But if the person believes that the disease could be severe one, he will be very cautious with the diet and eating habits.
“Perceived benefits” is one’s belief about possible benefits of making a healthy food choice. There are positive incentives also. If a person believes that a good diet will improve his health and will have a positive impact on his life and will make him more successful or happy; he will be more particular to take a healthy diet.
“Perceived barriers” is one’s belief about the possible barriers or difficulties in making healthy food choices. If there are barriers due to which he could not take healthy diet, they need to be addressed. Here the domain of health belief model may go outside the individual behaviour as the barriers could be contextual or structural. For a simple example, he may not afford the healthy diet.
“Cues to action” are reminders that provide information or promote awareness regarding making healthy food choices. The campaigns play an important role to generate health cues. Print ads on metros, trains, other transport; could remind the commuters daily that they have to take a healthy diet.
“Self-efficacy” involves providing guidance or training in successfully making healthy food choices. A person needs to believe in himself that he can change his behaviour and could adopt more healthy lifestyles including healthy diet. There is a need to generate self-confidence and self-efficacy in the individual and motivate him to take healthy diet.
Source – Glanz et.al. 2008
Analysis of Health-Belief Model
A meta-analysis of 18 studies (2,702 subjects) was done to determine the effectiveness of health belief model in predicting behaviour. Perceived benefits and perceived barriers were found to be strongest predictors of a healthy behaviour. The relationship was strong for prevention of a disease outcomes but the relationship was weak for adherence to a treatment outcomes. Perceived susceptibility and perceived severity were found to be weak predictors. Also the effect of HBM variables on predicted health behaviours got weakened when measured over an increased length of time. Thus the meta-analysis did not recommend the HBM model based on its weaknesses.
Although there is a component of perceived barriers; the Health Belief Model (HBM) largely focus only on behavioural determinants of food choice and thus the interventions also focus only on individual level factors. The barriers as described by Health Belief Model are individual-centric which says that these barriers are perceived by an individual and the individual should alter his perception while the barriers remain then and there unaltered. Thus Health Belief Model totally focuses on altering the individual behaviour making him responsible for his poor diet. But the individuals do not exist in isolation and form societies as a part of their socio-cultural environments which plays a very important role in their food choice behaviour. Socio-cultural environment determines what is socially acceptable to eat and is socially prevalent in various societies. Physical environment defines availability and accessibility of various food items, including financial accessibility. Lot of studies have been done on environmental determinants of food choice and are well grounded in theoretical frameworks.
Educational interventions and programmes also influence food choice behaviour. The educational interventions must address environmental factors along with individual level factors in determining food choice. Educational interventions are also based on theoretical frameworks that determine food choice behaviour.
Other determinants or models of food-choice
Legislative policies such as soda taxes; nutrition guidelines for schools, educational institutions and public procurement systems; restrictions on food marketing targeting children; regulations on vending machines; licensing fast food establishments; mandatory calorie labelling; also influence food choice behaviour of consumers to a great extent. One such example is NewYork city’s 2006 regulation of mandatory calorie labelling on menu items by all restaurants; and the research have shown that customers made lower calorie choices after implementation of this legislation.
Environmental factors also influence lifestyles such as eating out of home. This include taking food and beverages from vending machines, consuming ‘ready-to-eat’ meals, eating at restaurants, work-sites or on-the-go. It has been found that eating out of home was associated with unhealthy food choices which were high in energy and low in micronutrients particularly Vit.C, Calcium and Iron. Thus lifestyle is an important determinant of food choice behaviour which is further influenced by larger macro-level determinants such as socio-economic status and working environments.
Food choice is also influenced by social networks or the company with whom we eat. Relationships such as spouse, friends and siblings; plays a very important role in our eating behaviours or food choices we make. Research has found that newly formed couples tend to eat more of fruits and vegetables and less of fat-foods. Peer groups tend to consume more of snacks and alcohol. Thus social environment including company while eating influence food choice behaviour to a large extent.
People spend most of their time at workplace and the meals served at work-site canteens also play an important role in determining food choice behaviour of individuals. Increasing the availability of healthy food at workplace helps individuals in making healthy food choices.
There are diverse contextual aspects when individuals make food choices such as combining food with drink, physical condition of the individual, physical settings, social settings, state of mind while making food choice, consecutive activities, time of food, recurrence of meals etc. All these contextual level determinants influence the food choice behaviour of individuals.
Sobal and colleagues have come up with some eating maps based on places, time and people involved while making food choices. For example, if the person is alone at work, he may quickly finish with a sandwich and continue his work. If a person is at home with family, he may eat home-cooked fresh food. If a person is eating out at restaurant with his friends, he may choose some fast-food with drinks. If the person is eating out with family he may choose some healthy meals for his family which may not be as good as home-cooked meal. If a person is in a car with someone, he may choose some snacks like chips.
Food choices are also made throughout the process of food acquisition, preparing the food, serving the food, eating the food, cleaning up, and disposal. For example the person who picks up raw material, fruits and vegetables for cooking-up food choose the items at the first place, then the person who cooks up the food also choose ingredients for cooking, the person who serve the food also make choices about how to serve different food items which have an influence over consumers’ eating behaviour, the person who clean-up after eating also gives feedback about which food item gets wasted most of the time and thus to regulate its quantity of preparation and serving. Thus whole process right from acquisition to clean-up influence the food-choice behaviour of individuals.
Jastran et. al. in 2009 theorised that the regularity occurs in eating behaviour determined by eating situations. Eating routines thus formed are embedded in daily schedules related to family, work and recreational activities. People make food choices as a part of different eating routines depending on varying daily schedules of life. For example during early hours of work-days a person may regularly take a diet-cola or a coffee. During late-hours of work-days a person may eat left-over dinner or order a pizza on a regular basis. During Sundays a person may regularly eat breakfast with spouse. Thus daily schedules have an influence over food choice of individuals.
Blake et. al. in 2008 gave some mental maps individuals use during eating situations resulting in a sequential behaviour that guide food choices in relation to different contexts. For example, a cook may ask the kids of a family regarding what to cook. In another situation, wife may pick-up fresh fruits and vegetables from market. The family may decide a night before what to cook in the morning. Thus these mental maps as a contextual behaviour may decide food choice.
The life-course perspective tells that food choices change over the person’s life-course and it depends on what stage of life he or she is. The children may prefer ice-creams, biscuits and candies. The young adults may prefer drinks, pizzas, and fast-food. The elderly people may prefer some home-cooked, low-calorie, easily digestible food. This life-course trajectory is further influenced by micro and macro level determinants such as family, friends, community, workplace, school, cultural and social environment, economic growth, and government policies.
Food choice is also influenced by the seasons of the year and what is available during specific seasons. For example individuals may prefer easily digestible food during hot summers and may prefer water-melons, coconut-water, mangoes and fruits with high water content. During winters people prefer dry-fruits, spinach, sweets with ghee and dishes cooked in oil.
Religious health belief may also decide the food choice of individuals. For example certain religions like “Jainism” may advocate strict vegetarianism. Cow is worshiped in “Hindu” religion and thus beef is not eaten by Hindus. On the other hand goat is sacrificed by Muslims on Eid and its meat is served.
The appeal of food to the five senses also determines food choice. How the food smells, how it looks and how it tastes determine the food choice of individuals. Also the different societies have different sensory perceptions about food. Some societies prefer blend food. Some other societies prefer spicy food. Some societies prefer sweetness in their food.
At the most important structural level, the prices of healthy food diet and affordability as determined by socio-economic status of individuals play a very important role in determining what people buy and eat.[18-19] The evidence shows that prices of food items is the strongest predictor of food choice among low-income populations.[18-19] Thus an already inequitable society creates even more socio-economic disparities related to food and health if the government is unable to control the prices of food items, fruits and vegetables.
The reverse is also true. The unhealthy food items such as sugar-sweetened beverages, aerated drinks, tobacco and alcohol need to be taxed more such as to increase their prices and thus discourage their use. Thus government policies including taxation on various food items play a very important role in determining the food choices its citizens make.
For healthy food items such as fruits and vegetables; the government should ensure a price ceiling policy so that the healthy food items remain available to the poor sections of society.[22-23] The governments must ensure a food subsidy or public procurement system to decrease inequities in healthy food consumption.
The individuals in a country have a ‘right to food’ and it is the responsibility of state to respect and protect this right. The financial ability of individuals to procure healthy food is generally ignored by governments and thus there is a need to address social and policy circumstances that leads to poverty and thus inability to make healthy food choices. The solutions to address the food choice issues should be directed at structural level determinants rather than blaming the individuals themselves for their unhealthy choices and thus directing all the energies towards altering the behaviour of the individuals.
Thus there are lot of contextual and structural level variables that affect food choice behaviour among individuals as described in other food-choice models. Some factors have been emphasised by one model and some other factors have been emphasised by some other models. In reality all these factors play their role simultaneously and thus confound each other. So it becomes difficult to precisely measure how much role a particular factor plays while modifying food-choice behaviour among individuals.
After studying all the food choice models; an attempt has been made to formulate a self-created holistic and comprehensive food choice model which has been described as follows.
The development of a self-created model
Thus after discussing many of the determinants of food choice, I hereby arrive at the following multi-level ecological model of food choice.
Figure 2 – Self-developed multi-level ecological food choice model.
At the centre of model is the food choice behaviour of an individual and the behavioural processes working at the individual level as determined by the health belief model. Individual perceptions regarding susceptibility and severity of diseases or ill health influence the food choices at the individual level. Other perceptions like perceived benefits and barriers to a healthy food choice also work at the level of an individual. The next level is the contextual level where food choices are made by an individual in context of social relationships, religion, lifestyle, life-course and other contextual level determinants. The outermost circle include structural level determinants such as food policies, legislations related to food, food prices, socio-economic disparities and social inequities; determine the food choice behaviour of populations. Thus this model is a holistic model which takes into account behavioural as well as social and structural determinants of food choice.
The individual level determinants as described by Health Belief model affect the individual behaviour directly. At the centre of the model is always an individual who is making food-choices. He perceives some benefits, some susceptibility to diseases, the severity of diseases, the barriers and his own self-efficacy. Then in the outer circle are the contextual level determinants which determine his various perceptions. Throughout his life he has learnt many perceptions from his social relationships; he may be eating out in a particular company; he may follow a particular religion and lifestyle. Throughout his day, he may be in different situations that put him in a certain probability of making certain food-choices. In the outer-most circle are structural level determinants that alter even the behaviour of populations or masses and also alter the contextual level determinants. The governments may formulate certain legislations such as a ban on tobacco consumption by state or a ban on sale of tobacco products. The governments may increase taxes on certain food products such as sweetened beverages and tobacco products. The government may not be able to regulate food prices or the inflation is high in economy. There may be extreme poverty in the society and majority of its population may not be able to buy fresh fruits and vegetables. The society may be rich but may not have distributive justice or equity in resource allocation. The government may not have public distribution system or food security. There may not be enough production due to poor climatic conditions such as drought or heavy rains or floods. The food may be getting rotten in warehouses and there may not be the provision of minimum support price by the government. Thus there are macro issues which can alter the individual behaviour in a sweep and the individual may be helpless. Thus various macro level, meso level and micro level determinants of food choice have been discussed in this model. In this way this model turns out to be a more comprehensive and holistic, multi-level, ecological model.
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