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Continence Coach: Revitalizing the Health Belief Model in Support of Shared Decision-Making
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. Researchers found that 79% of participants who used online forums to motivate each other stuck with the 16-week walking program aimed at effective prevention of fractures stemming from the onset of osteoporosis. Among women in the study who used a version of the site without the social components, only 66% completed the program. Both groups saw equal physical progress. In essence, at the University of Michigan, the HBM is being applied to change health behaviors using online tools to mitigate the downside — in this situation, a high drop-out rate — of so many behavioral strategies.
Another missing component in so many settings is the call to action in the form of dialogue between patient and provider, where the latter serves as a health educator, not just practitioner. The provider must expand his/her role beyond technician to include the role of teacher, beyond administrator to include the responsibility as mentor, and beyond player to include the game plan as coach. Specifically in continence care, this may involve initiating a weight-reduction discussion by noting that just 10% loss of body weight in the obese can cut the symptoms of stress urinary incontinence in half as an incentive to lose excess weight as a first line, behavioral strategy. As health educators, we cannot shy away from conversations that otherwise feel awkward or that rely heavily on the motivation of the patient to succeed.
There is nothing evil or untoward about marketers crafting messages in media campaigns and product advertising to build awareness of a condition or set of symptoms; the problem is their one-solution remedy. Unless health educators balance the information, guidance, and perspective, Americans will remain over- and in some instances unnecessarily medicated and never take responsibility for their health beyond filling prescriptions. Let’s reverse that trend.
Dr. Muller is the Executive Director, National Association For Continence (NAFC). The NAFC is a national, private, nonprofit organization dedicated to improving the quality of life of people with incontinence. The NAFC’s purpose is to be the leading source for public education and advocacy about the causes, prevention, diagnosis, treatments, and management alternatives for incontinence. This article was not subject to the Ostomy Wound Managment peer-review process.
1. Rosenstock IM. Why people use health services. Milbank Memorial Fund Quarterly. 1996;44(3):94–127.
2. Ogden J. Health Psychology. A Textbook, 4th Ed. New York, NY: McGraw-Hill;2007.
3. Available at: http://en.wikipedia.org/wiki/File:Healthbeliefmodel.png. Accessed May 4, 2012.
4. Schwitzer G. Disease-mongering of Menopause and Premature Ejaculation. Available at: www.healthnewsreview.org/2009/12/disease-mongering-of-menopause-and-of-premature-ejaculation/. Accessed May 4, 2012.
5. Kolata G. The nation: health of nations; if you’ve got a pulse, you’re sick, The New York Times, May 21, 2006. Available at: http://query.nytimes.com/gst/fullpage.html?res=9A03EEDA133EF932A15756C0A9609C8B63&pagewanted=all. Accessed May 4, 2012.
6. Schwitzer G. Overactive Marketing of Drugs for Overactive Bladder. Available at: www.healthnewsreview.org/2010/02/overactive-marketing-of-drugs-for-overactive-bladder/. Accessed May 4, 2012.
7. Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol, Series A, biological sciences and medical sciences, 2001;56(3):M146–M156.
8. Abate M, Di Iorio A, Di Renzo D, Paganelli R, Saggini R, Abate G. Frailty in the elderly: the physical dimension. Eur Medicophys. 2007;43(3):407–415.
9. Richardson CR, Buis LR, Janney AW, Goodrich DE, Sen A, Hess ML, et al. An online community improves adherence in an internet-mediated walking program. Part 1: results of a randomized controlled trial. J Med Internet Res. 2010;12(4):e71.
