Health Belief Model Use

The Health Belief Model’s 6 constructs - Perceived Susceptibility, Perceived Severity, Perceived Benefits, and Perceived Barriers, as well as Cues to Action, and Self-Efficacy, were used differently in the studies and expressed through different statements. A total of 119 different statements were used across all the studies, as shown in Table 2.

Table 2. Number of statements used by authors for all the Health Belief Model constructs

Three studies used the HBM as a framework to measure knowledge, risk perception, attitude, and practices with regard to heatwaves. ^{Reference Wang, Zhang and Li45–Reference Wong, Alias and Aghamohammadi47} Arsad et al. used the HBM as a guiding principle to develop and validate a questionnaire on knowledge, risk perception, attitudes, and practices regarding heatwaves in Malaysia. Wang et al. used 4 different constructs of the HBM (Perceived Susceptibility, Perceived Severity, Perceived Benefits, and Cues to Actions) to develop a questionnaire for assessing the health-related adaptive behaviors and perception towards climate change among students. ^{Reference Wang, Zhang and Li45} Furthermore, the study investigated specific climate change-related phenomena such as extreme heat exposure, extreme cold exposure, and rainstorm exposure. Wong et al. used the HBM as a framework aiming to measure people’s knowledge, attitudes, prevention practices, and health impact of temperature rise associated with the Urban Heat Island. ^{Reference Wong, Alias and Aghamohammadi47}

Three studies used the HBM to predict the adoption of healthy behaviors during heatwaves. ^{Reference Akompab, Bi and Williams38,Reference Richard, Kosatsky and Renouf41,Reference Rauf, Bakhsh and Abbas44} Akompab et al. used the HBM as a framework to study cognitive determinants that play a key role in an individual’s perception and adaptive behaviors regarding heatwaves. ^{Reference Akompab, Bi and Williams38} Rauf et al. used the HBM as a theoretical framework to assess heatwaves related perception of Faisalabad’s residents in both urban and peri-urban settings, ^{Reference Rauf, Bakhsh and Abbas44} while Richard et al. used the HBM to test the predictive performance in taking preventive action for older adults with chronic health conditions such as Chronic Heart Failure (CHF) and Chronic Obstructive Pulmonary Disease (COPD). ^{Reference Richard, Kosatsky and Renouf41}

Likewise, 4 studies used the HBM along with other models and theories in measuring adaptation behaviors toward heatwaves. ^{Reference Valois, Talbot and Bouchard42,Reference Semenza, Ploubidis and George43,Reference Beckmann, Hiete and Schneider48,Reference Grothmann, Leitner and Glas49} Beckman et al. used the HBM model to measure heatwave risk perception among private household owners. Grothmann et al. used the HBM constructs along with other theories such as Protection Motivation Theory (PMT) and Norm-Activation Theory (NAT), to develop targeted communication formats to change behaviors. The study emphasized the use of these theories for designing communication interventions that are relevant to the behavioral change. ^{Reference Grothmann, Leitner and Glas49} Semenza et al. applied the HBM to measure respondents’ motivation to involve in voluntary mitigation and adaptation actions based on their beliefs and attitudes. ^{Reference Semenza, Ploubidis and George43} Valois et al. used the HBM along with the Theory of Planned Behavior (TPB) to predict and explain elderly people’s self-reported Heat Adaptation Behavior (HAB). They evaluated whether using two HBM constructs in addition to TPB variables increased the predictive performance of the model in predicting the adoption of HAB.

The analysis of the fidelity of original studies to the HBM revealed that all studies except 2 were either guided by or grounded in the principles of the HBM. ^{Reference Valois, Talbot and Bouchard42,Reference Beckmann, Hiete and Schneider48} Two studies implemented the HBM in its complete and original form. ^{Reference Semenza, Ploubidis and George43,Reference Wong, Alias and Aghamohammadi47} Six studies ^{Reference Akompab, Bi and Williams38,Reference Richard, Kosatsky and Renouf41–Reference Rauf, Bakhsh and Abbas44,Reference Wong, Alias and Aghamohammadi47} integrated the HBM across all phases of their research, including problem formulation, objective establishment, and methodology, as well as data interpretation, and more. Lastly, apart from a single study, ^{Reference Beckmann, Hiete and Schneider48} the HBM model played a pivotal role in shaping the findings of the reviewed articles. Supplementary Table (Level of fidelity to the theory of the included articles) provides an overview of the level of fidelity to the theory of the articles included in this review.

HBM Constructs

The aim of this section is to show how the HBM’s 6 constructs were utilized and what types of statements were selected. The sub-themes identified within each construct are presented visually in Figure 2.

Figure 2. Sub-categorization of Health Belief Model constructs based on the reviewed articles.

Perceived susceptibility

Two studies referred to perceived vulnerability as a synonym for perceived susceptibility. ^{Reference Inal, Altintas and Dogan32,Reference Rauf, Bakhsh and Abbas44} In this context, 2 main thematic areas have been identified, namely “health and well-being,” and “location and environment” (Figure 2). “Health and well-being” items were largely focused on health complications arising due to extreme heat such as dehydration, respiratory disease, and sunburn (e.g., “Due to my state of health, if I do not protect myself from the heat, I am more likely to suffer from respiratory difficulties during a heatwave”). ^{Reference Richard, Kosatsky and Renouf41} “Location and environment” items refer to the susceptibility of someone’s living and/ or working environment and location (e.g., “Meteorologists speak of ‘hot days,’ these are days with temperatures of more than 30 degrees Celsius. To what extent do you think that climate change will lead to an increase in the number of hot days in the region in which you work?”). ^{Reference Grothmann, Leitner and Glas49}

Perceived severity

Based on the statements used, 3 main thematic areas were identified within the perceived severity construct, namely “physical health,” “mental health,” and “lifestyle disruption and health services utilization” (Figure 2). “Physical health” encompassed the risk of physical injuries, respiratory difficulties, dehydration, and skin cancer, as well as long-term health complications, and personal loss (e.g., “Dehydration due to heatwaves may lead me to long-term health damages”) ^{Reference Rauf, Bakhsh and Abbas44} . “Mental health” included the possible consequences of heatwaves on people’s mental health (e.g., “Some people say that they feel negative impacts on their mental health during periods of high heat and high humidity. If this happens to you next summer, would you say that the negative consequences for your mental health will be very severe?”). ^{Reference Valois, Talbot and Bouchard42} “Lifestyle disruption and health services utilization” incorporated statements on disruption in life and lifestyle as a result of heatwaves (e.g., “Do you believe that climate change can endanger your life/ lifestyle?”). ^{Reference Semenza, Ploubidis and George43}

Perceived benefits

Statements on Perceived benefits were further sub-categorized into 3 key areas, namely “hygiene and sanitation measures,” “lifestyle and behavioral measures,” and “care for others” (Figure 2). “Hygiene and sanitation measures” highlighted benefits such as safe water, better sleep, stable health, and personal preparedness to reduce negative health consequences (e.g., “Staying at home allows me to keep my health stable during a heatwave”). ^{Reference Richard, Kosatsky and Renouf41} “Lifestyle and behavioral measures” reported the benefits of adopting new habits, use of protective measures, and staying cool in an air-conditioning environment, etc. (e.g., “Staying in an air-conditioned environment will reduce the chance of me suffering from dehydration”). ^{Reference Akompab, Bi and Williams38} “Care for others” encompasses measures that benefit friends, family members, and loved ones (e.g., “Is there already something you currently do to prevent negative effects of heat on the people you care for? If so, what?”). ^{Reference Grothmann, Leitner and Glas49}

Perceived barriers

The different statements used in retrieved studies were categorized into 4 key domains, namely “economic barriers,” “health barriers,” “security barriers,” and “general barriers” (Figure 2). “Economic barriers” included high costs associated with the use of available resources such as buying an air conditioner (AC) or paying electric bills (e.g., “During a heatwave, it is too expensive to buy or run an AC”). ^{Reference Akompab, Bi and Williams38} “Health barriers” included actions such as drinking less water due to personal health or a perception of ACs as bad for personal health (e.g., “My health condition will not allow me to drink more water”). ^{Reference Rauf, Bakhsh and Abbas44} “Security barriers” included household-related obstacles in implementing protective actions, and hesitance to leave doors open at night due to safety issues (e.g., “Due to security issues, I will not open my doors at night even during a heatwave”). ^{Reference Akompab, Bi and Williams38} “General barriers” included a lack of understanding by older populations of available resources such as AC, or the disturbance caused by the noise generated by AC (e.g., “During a heatwave, it is difficult to adjust the temperature/ air-conditioner”). ^{Reference Richard, Kosatsky and Renouf41}

Cues to action

The different statements used to measure cues to action construct of the HBM were classified into 2 main domains: “internal cues” and “external cues” (Figure 2). “Internal cues” include the experience of heatwaves and personal motivations (e.g., “As a result of my personal experience of heatwaves, I would keep safe during such a heatwave”). ^{Reference Akompab, Bi and Williams38} “External cues” included warnings received from others, and the acquisition of early warning information to avoid the negative impacts of extreme heat (e.g., “I will adapt to heatwaves if I would have been warned by a family member/friend about their severity”). ^{Reference Rauf, Bakhsh and Abbas44}

Self-efficacy

Only 2 studies in the retrieved articles used self-efficacy in their analysis through the use of 2 different statements (e.g., Do you think that you have the ability and power to protect yourself from dangerous events from climate change?”). ^{Reference Semenza, Ploubidis and George43} Both studies focused on how people can bring change in their lifestyles i.e., the “ability to change” (Figure 2).

Strengths and Limitations

The present review had some limitations which should be considered. The search was restricted to published scientific articles, thus excluding any relevant insights from grey literature. Additionally, the focus of the review was narrowed to the use of the HBM in the context of heatwaves, as expanding the search to encompass all 6 constructs of the HBM separately would have gone beyond the scope of this rapid review, potentially warranting a separate dedicated literature review. Likewise, the scarcity of articles using the HBM resulted in a small number of articles selected for a thorough analysis. Despite these limitations, the review offers a glimpse into the current use of HBM in this context that can be useful to guide future research. Additionally, the review highlights a growing trend in the use of the HBM in recent years, indicating a growing interest in the model.