Because I said so: Why that doesn’t work with patients

Let’s explore one of the most well-studied health behavior theories – the health belief model (HBM).

The HBM states that our health choices are a direct consequence of our perceived susceptibility to a disease, our perceived severity of a disease, and the perceived barriers that keep us from adopting better habits.

Perceived susceptibility, perceived severity, and perceived barriers are three of the main constructs from the HBM.  The word “perceived” is very important; these assumptions are based on individual perceptions and deductions based on a combination of environment, experiences, and personality.

“Perceived susceptibility” refers to how at risk we think we are to a particular disease.  In my master’s thesis, I studied the literature on adherence to high blood pressure medications.  Turns out that people who think they’re not at risk to have high blood pressure (even if they really do have it) don’t take their meds.

“Perceived severity” refers to how bad we think having a particular disease is.  Turns out that people who know they have high blood pressure but don’t think it’s a particularly dangerous condition (they don’t know, for example, that high blood pressure can lead to heart attacks, strokes, or kidney failure) don’t take their meds.

“Perceived barriers” almost always boils down to one of three obstacles: not having enough money, not having enough time, or not having enough social support.  If people can’t afford their high blood pressure medication, they’re not going to take it.  If they don’t think they have the time to exercise, they won’t.  If the foods we tell them to eat are different from the food their friends and family eat, they probably won’t eat them.

Identifying which of these constructs is at play when a patient isn’t following our advice is key to improving adherence with our recommendations. Doctors and health professionals can help patients change their perceptions, and thereby change their attitudes about treatment – but only if we’ve taken the time to identify what is making it hard for our patients to follow our advice.

We can do this by being careful listeners and asking thoughtful questions.

“What kind of person do you think gets high blood pressure?” (perceived susceptibility)

“What kinds of problems can result from high blood pressure?” (perceived severity)

“What has made it hard for you to take your medicine?” (perceived barriers)

These  questions can uncover if an HBM construct is at play. Only after identifying and validating our patients’ beliefs and attitudes can we gently correct incorrect assumptions, supply additional knowledge, and/or problem-solve with our patients.

“Because I said so” doesn’t work with patients, but exploring their beliefs and attitudes about disease and treatment can go a long way toward helping them to improve their health.

Jennifer Middleton is a family physician who blogs at The Singing Pen of Doctor Jen.

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  • Steve Wilkins


    Your post is right on the money in terms of advice. You missed one key step in the Health Belief Model – the last one. There has to be a “call to action” in order to get the patient to do what you want them to do (theoretically anyway). I actually did my Master Thesis at Michigan School of Public Health on the HBM. Marshall Becker, one of the major contributors to the model along with Rosenstock, was ne of my professors.

    Steve Wilkins, MPH

    • Jennifer Middleton

      You are absolutely correct. I confess to simplifying things to keep the post from running too long, but perhaps I need to write a follow-up post on this important construct. Thanks very much for commenting!

  • Maggie Beaumont

    As a patient, I appreciate this analysis. You’re exactly right about most of this. I would add another barrier, one that (in my personal experience) has often been softpedaled or even ignored by doctors and other healthcare professionals: side effects.

    If the medication you prescribed makes me sleepy when I need to be awake, or wakeful when I’m trying to sleep … if it gives me heartburn … if it clouds my mind or saps my creativity when I’m trying to finish a project … then I won’t take it.

    Not to mention that if I’m depressed about my marriage and you prescribe an antidepressant that ruins my sex life …

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