Perceive to Believe: The Health Belief Model and Obesity in Newfoundland and Labrador

Obesity is associated with many increased health risks including some types of cancers, diabetes, heart disease and increased severity of COVID-19 infection (Wharton et al, 2020). Newfoundland and Labrador has the highest obesity rate in Canada. In 2018 40.2% of the population fit the criteria for obesity according to stats Canada. Newfoundland and Labrador has many obesogenic characteristics, it has an infrastructure that is not very conducive to physical activity, easy access to non-nutritive high caloric foods, a high sedentary rate and a low socioeconomic status (Kirk et al, 2009). Multi-level health models, like the Health Belief Model (HBM) can be used to explain and guide management of this disease. The complex interplay between an individual, their social and geographical environment and their perception of the same can create the conditions for a problem like obesity to take hold of a population.

The HBM is a psycho-social approach to explaining health related behaviour. It was first developed in an attempt to address behaviour associated with modifiable risk factors. The HBM addresses the foundations of a person's beliefs that shape their behaviour. Beliefs by definition are changeable and can be influenced by socialization (Conner & Norman, 2015). According to the HBM a behaviour can be changed if five criteria are met: an individual must perceive themselves to be at risk, that risk must be believed to be severe, they must believe there are benefits to behaviour change and that barriers are surmountable, they must feel that they have the power to make the change and they must experience a cue to action (Champion and Skinner, 2008). Those beliefs and perceptions that form the constructs of the HBM are derived from the social determinants of health (SDH) as illustrated by the figure one.

Figure 1. Health Belief Model

https://plos.figshare.com/articles/figure/Health_belief_model_components_and_linkages_/6005795/1

Overweight individuals often underestimate their own weight and therefore their risk and severity of their condition (Visscher et. al. 2017). An individual's perception is a product of their lived experience within their family, their community and the society within which they are socialized. Gender, race, education and income have all been associated with a person's own underassessment of body weight (Gregory et al, 2008). It has been shown that the media can improve the awareness of obesity and increased adiposity in the general public (Gregory et al, 2008). Improved awareness of overweight and obesity statistics is an important step to an individual acknowledging the severity of a condition and so deciding to change their behaviour. An individual's underassessment of their excess weight has been associated with disagreement about the health consequences that accompany that excess weight, many obese people are aware that an increased body mass index (BMI) can lead to cardiovascular disease and type II diabetes but are unaware of its association with liver disease and cancers (Visscher et al, 2017). Overweight individuals may not think of living with the repercussions of congestive heart disease or the complications of diabetes when they consider that these diseases are possible outcomes. It has been recommended with severity of a disease in mind that education by media and public health emphasize the health risks around obesity (Gregory et al, 2008).

The HBM assumes that people will change their behaviour if they believe that the change is beneficial for them (Vazini & Barati, 2014). Messaging about improved mobility and increased longevity with weight-loss, about quality active time with families advertised in the media or disseminated through public health campaigns would address this construct. Some benefits may be more incentivizing, Newfoundland's government offered a benefit in its 2021 budget to address obesity that included a tax credit for families involved in sport and recreational activities that in combination with a tax on sugary drinks are examples of policies on a provincial level employed to make healthy decisions more attractive (https://www.gov.nl.ca/budget/2021/what-you-need-to-know/promoting-a-healthier-newfoundland-and-labrador/). This added financial incentive is intended to help people choose a course of behaviour that will lead them on a path of weight-loss.

Perceived barriers on an individual level may prevent action due to an individuals belief that the costs are too great too attempt change. This may be something like the price of healthy food or beliefs that certain treatments are ineffective or too physically demanding. Family dynamics may come into play, families contribute greatly to the behaviour pattern of children from activity level to eating habits (Kirk et al, 2009). People often rely on support from their family when entering a weight loss journey. A barrier that has been written about frequently is the healthcare workers approach to addressing weight loss. Often times overweight or obese people are aware of the risk and the severity of the condition but healthcare workers are not supportive. The solution overweight individuals are given is to exercise more and eat less which does not address all the route causes of obesity. Visscher et al. (2017) emphasizes the importance of health care workers approaching obesity as a team and not leaving it to the individual to solve. Health care workers should be aware of the treatments available to people struggling with their weight so that the client does not face the same advice that has failed every time they have an interaction with a health care worker (https://www.cbc.ca/player/play/1964895811702). Interactions from health professionals should never be seen as a barrier to a healthy change.

The cue to action is an important piece of the HBM, this is the particular stimulus a person needs to change an unhealthy behaviour. These cues can be internal or external. Internal cues may include individual symptoms a person is experiencing like shortness of breath decreased mobility (LaMorte, 2019). External cues highlight the importance of the many levels of influence in a person's environment for example a family member's illness, a fitness campaign or a newspaper article about obesity rates and their cost to the health care system. Movements with in the community such as fitness challenges in a work place or mall walking events in a seniors home may encourage some to make a change. Information from local media, information from health care providers and even governmental policies can have an impact on health promotion behaviour. Working with this model to effect change health departments can make information on what obesity is, how prevalent it is in society and how it can be managed.

Self efficacy was the latest concept to be added to this model and some believe it is the strongest predictor for behaviour change (Orji & Mandryk, 2021). It has been shown that individuals with an internal locus of control are more successful in weight loss attempts and can better adhere to exercise regimes (Neymotin et al., 2014). The social-determinants of health can contribute to an individuals sense of self-efficacy, one study found that children who felt safe in their neighbourhood and had supportive parents had a greater sense of self efficacy (McCoy & Bowen, 2014). The Newfoundland and Labrador chronic disease action plan emphasizes self management of chronic conditions like obesity, referencing the importance of a person to feel confident in their ability to contribute to their health. The plan highlights the teaching of relevant skills to individuals citing that those who learn to manage their own conditions have had less hospital stays and tend to slow the progress of their disease.

The HBM outwardly sees focused on the individual level as it depends on the perceptions and beliefs of the individual to effect change. The perceptions of the individual however are a product of their environment and cannot be separated from the determinants of health. This model demonstrates that it is important to include the social environment, media and policy makers when promoting health. The information gathered from these modalities are a tool an individual can use to empower themselves to change their behaviour to a healthier pattern. If educators know their audience they can propagate appropriate, accessible information to shape beliefs that will encourage a healthier population.

https://www.statista.com/statistics/936787/obesity-among-canadians-by-province/

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