Continence Coach: Revitalizing the Health Belief Model in Support of Shared Decision-Making
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The Health Belief Model (HBM) is one of the first and certainly the most enduring of theories aimed at explaining health behavior change by means of social cognition. Developed nearly a half-century ago by Irwin W. Rosenstock of the US Public Health Service, the theory initially was applied to predict behavioral response to treatment of acutely or chronically ill patients.1 Although it has been expanded by others to predict more general health behaviors, its core concept remains the same: how an individual perceives a personal health threat, combined with his perception of the effectiveness of a treatment or intervention, will predict the likelihood such an action will be pursued.2 The theory is presented graphically in Figure 1.3
In an age of managed care ruled by cost containment, it is easy for some policymakers to abandon the fundamental tenets of the HBM. There is no better time than now to revitalize this model to help jumpstart shared decision-making between provider and patient. How else can a physician or nurse elicit a dedicated, lasting commitment from the patient to his/her own wellness? Why have we allowed our healthcare delivery system to engender multiple generations of patients who passively accept an ever-lowered threshold for what we call disease — including menopause and premature ejaculation — as yet another reason for one more pill or injection?4 Should we blame industry for disease-mongering, its not-so-sublime messages as cues to seek a diagnosis related to another prescription or procedure and an easy fix?5 Even marketers of prescription drugs for overactive bladder have been criticized for the over-medicalization of symptoms when advertising messages have emphasized how much quality of life is threatened by such a condition if left untreated.6
What is missing here? Quite simply, patient engagement — ie, taking responsibility for behavioral strategies in combination with drug therapy or even surgery. In the case of overactive bladder and urge incontinence, the patient first needs to be motivated to understand the problem and how bladder retraining and pelvic floor muscle strengthening can make a difference and to appreciate the fact that despite the ease of taking a pill to address symptoms, you might be able to alleviate, if not eliminate, symptoms by exercising (ie, modifying behavior).
Patients also need to witness progress to stay motivated. Because we lose 2% of our body’s muscle mass every year of our lives after age 25, pelvic exercises need to become routine, if not a lifelong commitment, like any other type of exercise. In fact, physiologists note that the entire musculoskeletal system of muscle, neuromuscular responsiveness, endocrine function, and vasocapillary access among tendons, joints, ligaments, and bones depends on regular and lifelong exercise to maintain integrity.7 The slow atrophy of muscle tissue that medical professionals sometimes describe as sarcopenia (from the Greek meaning flesh loss) is currently thought to be the result of cumulative loss of musculoskeletal strength and mass associated with chronic absence of exercise of sufficient intensity or volume.8 That’s right — another disease! But “feeling the burn” may reduce feeling the urge. The clinician can be the motivator.
I am impressed by the work being undertaken by the Family Medicine Department at the University of Michigan Medical School, where studies8 have shown that adding community features to online health programs for older adults can be a powerful tool for reducing attrition in physical exercise programs.