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Family Practice Vol. 4, No.

Oxford University Press 1987 Printed in Great Britain

Construction and Validation of a

Questionnaire to Measure the Health
Beliefs of General Practice Patients

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Cockburn J, Fahey P and Sanson-Fisher R W. Construction and validation of a questionnaire to measure
the health beliefs of general practice patients. Family Practice 1987; 4: 108116.
The health belief model has been widely used as a conceptual framework for understanding and
explaining compliance behaviour. A weakness characterizing work in the area has been lack of standard-
ization of measurement of the components of the health belief model. This paper describes the develop-
ment and validation of a questionnaire to measure these components. The questionnaire was designed
for use with general practice patients who have a wide range of different illnesses, therefore the nature of
the patients' illness is not mentioned in the content of the items. Principal components analysis was used
to determine the dimensions underlying patients' beliefs. Principal components analysis and application
of Cronbach's alpha statistic identified four reliable sub-scales of the questionnaire. The sub-scales
measured patient's beliefs about: the threat caused by illness, the efficacy of traditional medical care, the
way illness is dealt with and the barriers to taking medications.

The health belief model, a theoretical framework cal harm and interference with social roles
for explaining and understanding individuals' (perceived severity).
responses to health related matters, has been the 2. The individual's beliefs in the efficacy or the
focus pf considerable attention in health value of the recommended action in reducing
research. The model was originally developed to the threat (perceived benefits).
explain and predict patients' participation in pre- 3. The individual's estimates of the physical, psy-
ventive health activities such as immunization chological, financial or other costs involved in
and attendance at screenings.1-2 It has since been the proposed action (perceived barriers).'-2
used to explain compliance with prescribed medi-
cations, dietary and other types of medical As research investigating the ability of the
advice.M model to explain health related behaviours has
The original health belief model'-2 argued that progressed, the original model has been refor-
an individual's decision about undertaking a mulated and expanded to incorporate new find-
recommended health action was a function of the ings. In its early form, the model focused on
individual's beliefs on three subjective specific disease-avoidance interactions, but an
dimensions: increasing body of evidence suggested that a per-
son's general motivation towards health related
1. The threat posed by an index condition. This matters influenced compliant behaviour.10"12 The
dimension comprises the individual's percep- category of 'general health concerns' was added
tion of the likelihood of the occurrence or in an effort to describe an individual's degree of
recurrence of the condition (perceived sus- interest in, and concern about, health practices
ceptibility) and its potential for causing physi- and preventive activities. Similarly, the original
model focused exclusively on beliefs about one
index condition. General categories of vul-
nerability to disease and worry about illnesses
Disciplinc of Behavioural Science in Relation to Medicine. Faculty of
Medicine. The University of Newcastle. NSW 2308. Australia. Corre-
were added to the model to tap broader non-
spondence to Professor R. W. Sanson-Fisher. specific perceptions of health threat. Other cate-
gories which have been added have included the sharing of operational and conceptual defi-
'feeling of control over health matters', and 'faith nitions, so thatfindingscould be compared across
in doctors and medical care'. l0 In addition, demo- studies. They also pointed to the need for more
graphic, structural and enabling factors, which sensitive measures of dimensions of the health
had been found to be predictive in other com- belief model, using interval or ratio scales. Such
pliance research, were included as mediating scales enable individuals to be placed on a con-
variables in the revised model.1013 tinuum according to the strength of belief, rather
The adequacy of a theory for explaining than to be classified into one of only two groups
behaviour can be judged onfivecriteria proposed according to whether the belief is held or not.
by Gergen.l4 These are that a theory should have: Continuous scores allow noteworthy differences
heuristic value for a discipline or field of study; between individuals to be assessed.
parsimony of statement; operationally defined Green25 summarized the situation by describ-
terms; predictive capability; and a strong data ing the health belief model as 'the most docu-

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base. mented set of health beliefs, but nonetheless
Fisher15 has pointed out that the health belief without standardization, or tests of reliability or
model fits most, but not all, of the above criteria. validity'.
Its heuristic value for health research is shown by Though several studies since the remarks of
the plethora of studies which have used the con- Green have reported the reliability of the scales
ceptual framework.91M4 It is beyond doubt that used,18-24-26 there have been few attempts at
the model has had a major influence on the think- assessing the validity of these scales. This is an
ing of those studying non-compliance. The model obvious and major problem. Though items which
is parsimonious, with only a limited number of appear in current scales are usually chosen with
major variables which together provide a simple some theoretical basis and therefore have face
statement concerning health-related behaviours. validity, there is little evidence that the scales
A major weakness of the health belief model, have construct validity. Factor analysis is a poten-
however, is uncovered when the third criterion is tially useful tool for examining this dimension of
considered. Despite its widespread use, the con- validity as it determines which groups of items
structs of the health belief model are oper- cluster to form scales in the questionnaire.27 If the
ationalized in different ways by various factor-based groupings correspond to the a priori
investigators attempting to measure the same theoretical grouping of items then empirical sup-
beliefs. The final two criteria are related to these port is given for the construct validity of the
changing operational definitions. The data base questionnaire.
supporting the model has expanded considerably Factor analysis has been used to develop
since its formulation. The predictive capability instruments based on the health belief model to
has been tested, and support for the predictive measure the beliefs of women regarding breast
capability of the model has been found in some self-examination,23 the health beliefs of dia-
instances.9 However, research is often plagued betics17 and the more general health beliefs of a
by methodological problems in the measurement community sample.28 All of these questionnaires
of the model. have demonstrable construct validity and analy-
As early as 1974, Rosenstock2 pointed out that sis has confirmed that distinct dimensions of
no two studies had used identical questionnaires beliefs exist in people's perceptions of health
to determine the presence of absence of each related matters. However, the specificity of the
belief. This raised the possibility that the con- content of items in the questionnaires of Given
cepts being measured may also have varied from and colleagues17 and Champion and colleagues23
study to study. Rosenstock recommended that limit their applicability to the groups for which
standardized methods of asking questions and they were designed. The questionnaire of Jette
the reliability of measures be examined, so that and colleagues28 is more general in its appli-
the utility of the model could be examined with- cation, but has as yet only been tested on a
out the confounding influence of different, and 'healthy' population; 78% of the sample in Jette's
perhaps inaccurate, measurement procedures. study considered themselves to be in excellent
Becker and Maiman10 reiterated the points of health at the time the questionnaire was admin-
Rosenstock stressing that consensus was needed istered. It is possible that people's beliefs about
on ways to standardize measurement, including health may be different when they are faced with
actual illness. For example, Jette's group28 found (3) structured interviews with groups of medical
that beliefs about severity of potential illnesses students, general practice patients and col-
were distinct from perceptions about suscep- leagues to determine the appropriate content and
tibility. This is contrary to the traditional group- wording of items within specific areas. In these
ing of the dimensions under the concept of 'threat interviews people were asked to describe how
posed by illness' in the theoretical literature. they dealt with illness, their attitudes to medica-
A standardized questionnaire which can be tions and to traditional medical care.
used to examine the health beliefs of different Thirty-five items were derived by these means.
patient groups is important, so that comparisons These were edited to exclude repetitions and
between studies can be made without the con- ambiguities, resulting in 22 items being included
founding factor of different measurements and in the pilot form. The number of items in each
operationally defined terms. The aim of the pres- hypothesized dimension were: general health
ent study was to develop and field test a question- threats, 3 items; general health concern, 2 items;

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naire of individuals' health beliefs which would specific threat level factors, 6 items; control over
meet standard psychometric criteria, and have an illness, 4 items; medical motivation, 3 items; and
application for primary care patients. barriers to medication, 4 items.
Items were structured in the form of a com-
METHOD plete statement, for example 'Doctors know best
Study Setting and Design for you when you are ill.' A seven-point Likert29
The data were collected as part of a large-scale response scale, ranging from strongly agree to
direct observational study (the primary care strongly disagree, was used for all items. The
study) which was examining the processes of uniformity of response format works on the pre-
general practice and relating these processes to a mise that once respondents become familiar with
number of outcomes. The primary care study was the response choices, statements can be read and
conducted in the surgeries of randomly selected responses indicated quickly. Differing item
general practitioners from Newcastle, Australia response formats increase the time and effort
and data were collected over an 18-month period needed to understand and complete question-
from November 1982 to April 1984. naires.30 A seven-point scale was used as it allows
The patient sample was recruited in the waiting more information about the varying strengths of
rooms of the general practice surgeries. Patients a patient's beliefs to be obtained and yields more
were eligible for inclusion if they were aged 18 reliable data than response choices with fewer
years or more, were literate in English and were alternatives.31
not too ill or in too much pain to complete ques- Items from each content area were randomly
tionnaires. After consultation with their doctor, distributed throughout the questionnaire and
consenting patients were given a questionnaire patients marked responses directly on to the
package, which included the health belief ques- questionnaire.
tionnaire. Instructions were given to patients to The pilot form of the questionnaire was tested
take the questionnaire home to complete, and to on a sample of 115 patients from three general
return it using a reply-paid envelope. A reminder practitioners who were participating in the
letter was sent to patients on the day after the primary care study. Analyses for the pilot study
consultation, and if the questionnaire had not were confined to calculations of means and stan-
been returned within one week of distribution, a dard deviations, the sample size being too small
reminder phone call was made. for factor analysis.32 The examination focused
particularly on comparability of item score distri-
Instrument Development butions. Roughly symmetrical response distri-
The revised expanded version of the health belief butions with a mean of 4 and a standard deviation
model1013 was used as the conceptual framework near 2.6 are desirable characteristics for items to
for the construction of the questionnaire. be combined in summated rating scales.33 Careful
The initial pool of items to reflect these dimen- note was also made of items which were fre-
sions came from three sources: (1) review of the quently missedan indication that the items
theoretical literature pertaining to health beliefs; were either not relevant to general practice
(2) revision of past scales, with particular atten- patients or that the wording of items caused prob-
tion to items shown to be valid and reliable and lems with interpretation.
The format of thefinalform of the health belief adequate indication of internal consistency for a
questionnaire was identical to that described for questionnaire in the early stages of construction.
the pilot form. The reading ease of the question-
naire was calculated using the Flesch formula.34 Validity. Empirical evidence for the construct
The score of 91 indicates that the questionnaire validity of the health belief questionnaire was
could be understood by 90% of the general popu- provided by the results of the principal com-
lation (those with an IQ of 81+). ponents analysis. These results were compared
with the a priori theoretical grouping of items,
the rationale being that if the factor-based scales
Field Test of Questionnaire were in accordance with hypothesized groupings,
The data for the main study were obtained from then confirmatory evidence would be given for
patients of the remaining 53 general practitioners the theoretical constructs being measured.41
who were participating in the primary care study.
Procedures for gaining consent and distribution The discriminant validity of the derived health

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of the questionnaire were similar to those belief scales, and support for the independence
described previously. of different beliefs was provided by 'reliability of
The analysis of the health belief questionnaire difference' scores.42 These scores determine the
took place in four stages: factor analysis, index amount of overlap shared by all possible pairs of
score derivation, reliability analysis and validity scales within an instrument. The reliability of
analysis. difference between two scales is based on the
reliability of each scale and the correlation
Factor analysis. The principal components between them. The higher the reliability of
method was used to extract factors from a matrix difference score the more likely it is that separate
of correlations among pairs of the 22 health belief dimensions are being measured. A standard of
items. The analysis was done using the statistical 0.50 and greater has been used in previous
package BMDP, programme P4M. (University research as an indication that distinct dimensions
of California, 1982.) The initial unrotated com- are being assessed.42"44
ponent was evaluated against four criteria to
determine how many factors should be retained RESULTS AND DISCUSSION
for rotation. The criteria used were the Scree Patient Sample
test,35 the 5% guideline,36 consideration of eigen- In all 821 questionnaires were distributed, of
values27 and use of trial rotations.27 Factors were which 621 were returned, a return rate of 75%.
rotated so as to maximize 'simple structure', a Of those returned, 509 had every question
criteria proposed by Thurstone37 as a means of answered. As the principal components analysis
providing a parsimonious description of the programme works only on complete data sets
observed relationships. Varimax orthogonal these 509 respondents were the sample for the
rotation, which does not allow correlations current study. Sixty per cent of the sample were
among the factors, was used. Items with loadings male, 40% were female. The mean age of the
of 0.40 or above within factors were grouped sample was 41 years. Eight per cent of the sample
together in an index. had received no secondary schooling, 75% had
completed lower secondary school, and 17% had
Index score derivation. A score for each patient full secondary education; 7% of the sample also
for each of the derived factor-based scales was had tertiary qualifications. In order to determine
computed by adding up the scores on items with the representativeness of the sample, and there-
significant loadings on the factor.29 Scoring of fore the generalizability of obtained results, the
negatively worded items was reversed prior to demographic characteristics of respondents in
scale computation, so that a low score repre- the sample have been compared with those of
sented a strongly held belief about the particular patients who were given a questionnaire and
health related matter being examined. failed to return it. No significant differences were
Reliability. The internal consistency of items con- found on any of the comparisons made.
tributing to each factor-based scale was estimated
using Cronbach's alpha.38 In keeping with the Principal Components Analysis
recommendations of Helmstadter39 and Principal components anaylsis identified seven
Nunally, a coefficient of 0.50 was considered factors with eigenvalues greater than 1. These
seven factors accounted for 18%, 9%, 7%, 7%, factors were rotated. These six factors accounted
5%, 5%, and 4% respectively of the total vari- for 53% of the total variance, a proportion which
ance. Therefore, using the 5% guideline, six has been deemed acceptable in previous
factors would be appropriate for rotation. Scree research.44 These six factors were rotated to
test results, however, suggested that four impor- simple orthogonal structure. The rotated
tant factors were defined by items in the ques- orthogonal factor loadings for items are shown in
tionnaire. Thus, depending on the criterion used, Table 1. Communality estimates are shown in the
between four and seven factors are deemed suit- far right hand column.
able for rotation. Trial rotations of four, five, six The first factor contained items which related
and seven factors were compared. The clearest to perceived severity of the current condition, the
information about the dimensionality of the perceived severity of illness in general, and per-
health belief questionnaire was given when six ceived susceptibility to illnesses in general. These

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TABLE 1 Correlations between health belief items and rotated principal components

Rotated component Commun-

_ uslitv
No. Item I II III IV V VI h

17. My current condition will lead to serious

long-term health problems. 0.73 -0.04 0 0.08 0.09 -0.10 0.55
19. My current condition is causing me a lot
of worry and concern. 0.72 0.20 -0.06 -0.05 -0.18 -0.04 0.59
11. The illnesses I get worry me a great deal. 0.72 0.10 -0.04 -0.05 -0.15 0.08 0.56
20. Whenever I get sick it seems to be
serious. 0.67 0.03 0.01 -0.17 0 0.17 0.50
8. My current condition will interfere a
great deal with my normal activities. 0.60 0.06 -0.03 0.02 0.26 -0.14 0.45
4. I will become very sick as a result of my
current condition. 0.59 -0.08 0 0.01 0.47 -0.15 0.60
16. I get sick more easily than other people
my age. 0.58 -0.02 0.01 -0.19 0.08 0.28 0.46
7. I am concerned about the possibility of
becoming seriously ill. 0.57 0.25 -0.01 0.05 0.10 0 0.40
6. I worry that taking tablets may cause
problems. 0.07 0.75 -0.12 -0.10 -0.11 0.11 0.62
14. The trouble with tablets is that you can
get too dependent on them. 0.04 0.75 -0.03 0.13 0.15 -0.13 0.61
22. Often the side-effects from tablets are
worse than the illness. 0.16 0.66 -0.12 0.06 0.14 0.07 0.50
1. Doctors know best for you when you are
ill. 0.10 -0.10 0.80 0.08 0.06 0.08 0.68
3 When I follow my doctor's advice I
usually feel better. -0.08 -0.01 0.80 0.12 -0.01 0.03 0.66
21. I trust my own feelings about my health
rather than a doctor's advice. 0.09 0.18 -0.60 0.11 0.16 0.18 0.48
13. When I get sick, I just keep going as
usual. 0.07 0.03 0.05 0.76 0.02 0.02 0.59
12. I do not let illness interfere with my life. -0.19 -0.07 0.02 0.66 0.09 -0.02 0.49
18. When I think I am going to be sick I fight
it. 0.10 0.11 0.03 0.62 -0.16 0.04 0.43
10. Often remembering to take tablets is
more trouble than its worth. 0.08 0.18 -0.13 0 0.64 0.10 0.48
9. Looking after my health is one of my
major concerns. 0.32 0.17 0.10 0.11 -0.58 -0.02 0.49
15. It's likely that my current condition will
happen again. 0.18 -0.11 0.09 0.02 0.47 -0.02 0.28
2. Good health is largely a matter of good
luck. 0.20 -0.05 -0.06 0.10 0.14 0.77 0.66
5. Compared to other illnesses, my
condition is not serious. -0.40 0.21 0.03 -0.05 -0.15 0.56 0.55
items were originally hypothesized to fall into the were from the 'general health concern' and 'per-
specific threat level and general health threat ceived severity' of the presenting condition
content areas. This finding is contrary to that of domains.
Jette and colleagues.28 Whereas their work sug-
gested that condition-specific threat level factors Reliability
were distinct from general threat level factors, Cronbach's alpha coefficients for the six factor-
the results from the present study do not support based scales are shown in Table 2. These ranged
this distinction. Patients in this study saw all ill- from 0.14 for items loading on the sixth factor to
nesses, including the specific condition for which 0.82 for the first factor-based scale. The low
advice was being sought, in the same way. This reliabilities of the fifth and sixth scales were a
discrepancy may be due to the different samples further indication that these derived scales were
used. In the present study, the beliefs of patients more a reflection of factor analytic techniques
concerning a real illness episode were explored. than an indication of patients' perceptions. These

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Jette and colleagues asked healthy subjects about scales were therefore not considered to be valid
hypothesized situations. It seems that when reflectors of underlying health beliefs. The alpha
people are genuinely ill, the threat caused by all of 0.49 for the 'belief about illness' scale was just
illnesses, potential or real, are perceived in the below that recommended by Helmstader39 and
same way. This first factor has therefore been Nunually,40 but it was decided to retain the scale,
labelled 'perceived threat to health caused by as the questionnaire was in the early stages of
illness'. development. However, if this scale were to be
Items which related to beliefs about medica- used in future research, further examination of
tion made up the second factor, labelled 'per- its reliability should be obtained. The reliability
ceived barriers to taking medication'. These of all the other scales in the present research
questions were all concerned with general atti- appears adequate.
tudes to taking tablets.
Items loading significantly on the third factor Construct Validity
'medical motivation', were concerned with trust Factor analysis provided empirical evidence for
in doctors and traditional medical care. the validity of health belief constructs which were
Items of the fourth factor reflected people's measured in this study. With few exceptions,
beliefs about the way they deal with illness. This items hypothesized a priori to be measuring the
factor has been labelled 'perceived control over same underlying construct were found to be
illness'. A patient who would endorse the beliefs statistically related. All items from the medical
measured by this subscale would be one with a motivation grouping factored together, as did
stoic approach when faced with ill-health. items measuring the 'control over illness' dimen-
The fifth factor extracted contained three sion. Three of the four items which were hypoth-
items, one of which was originally hypothesized esized to be measuring the 'barriers to taking
to fall into 'barriers to taking medication' dimen- medication' dimension also factored together.
sion, one from the 'general health threat' domain Support was therefore given for the construct
and the other which related to the 'general health validity of these scales. The first factor to
concern' domain. The content of these items emerge'threat caused by illness'was a com-
showed little in common. Therefore no label was posite of specific severity, general severity and
attached to this factor. This also holds true for general susceptibility. Theory has suggested that
factor 6. The two items with significant loadings 'perceived severity' and 'perceived suseptibility'
be grouped together under 'threat of illness'.1013
TABLE 2 Cronbach's alpha for factor-based scales The appropriateness of this grouping was con-
firmed by factor analysis and support given for
Scale Label Alpha the contention that the 'threat' elements of the
health belief model be considered together
1 Illness threat 0.82 conceptually.
2 Barriers 0.63
3 Medical motivation 0.56 The data also susbstantiated the independence
4 Control over illness 0.49 of the four perceptual dimensions measured in
5 0.27 this questionnaire. Examination of the reliability
6 0.14
of difference scores between pairs of subscales
TABLE 3 Correlations (shown above the diagonal), Cron- included a separate, distinct factor for 'specific
bach's alpha (shown in bold) and reliability of difference vulnerability' may have emerged in the general
scores (shown below the diagonal) of health belief subscales
practice sample. This finding will need to be
'Threat' 'Barriers' 'Medical' 'Control' explored as refinement of the scale continues.
'Threat' 0.82 0.21 -0.08 -0.11 Descriptive Statistics of Health Belief Subscales
'Barriers' 0.65 0.62 -0.25 0.05 A score was obtained from each patient on each
'Medical' 0.72 0.68 0.58 0.08
'Control' 0.69 0.53 0.5O 0.49 of the four retained subscales by the method of
summated ratings.29 In order to facilitate visual
comparisons, the ranges of the summated ratings
showed that all six pair-wise comparisons met the have been standardized to lie between 0 (indicat-
minimum standard for subscale distinctness ing the belief is strongly held) and 100 (indicating
(Table 3). The data suggested that clear and dif- the least belief strength). The distributions of the

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ferent belief dimensions exist, helping to sub- standardized scores are shown in Figure 1.
stantiate the model as presently formulated. From Figure 1 it can be seen that the scores on
The item measuring resusceptibility for the the 'perceived threat caused by illness' subscale
presenting condition, however, did not factor as were skewed towards the lower end of belief
expected with the other threat level items. Only strength. The general practice patients in this
one such item was included, as it was thought that study tended to believe that any illness, including
it would be conceptually linked with other threat the one for which they were seeing a doctor, was
level factors, such as perceived severity. Perhaps not a major threat to them. Figure 1 also shows
if more items in this specific area had been that people's beliefs measured by the 'perceived

20 40 60 80 100 20 40 60 80 100
a) Threat posed by illness b) Barriers

20 40 60 80 100 20 tO 60 80 100
c) Medical Motivation d) Control over illness
FIGURE 1 Distribution of standardized scores on subscales of the health belief
barriers to taking medications' subscale were between different studies examining the efficacy
fairly evenly distributed. The distribution of of the health belief model for explaining health
scores on the third subscale 'Medical motivia- related behaviours.
tion', is skewed towards the end of the scale
which indicated a more strongly held belief. This
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