Attitude to Health

Abstract

Attitude to Health is a type of attitude: the favorable or unfavorable evaluations a person holds about illness, treatment, risk, and their own health behavior. This article sets out the expectancy-value models that dominate the field, the Health Belief Model and the Theory of Planned Behavior, the control beliefs measured by self-efficacy and the Multidimensional Health Locus of Control scales, the illness representations of the Common-Sense Model, and the stubborn intention-behavior gap that separates a favorable attitude from the act it is supposed to predict. A worked example computes a behavioral intention from its components, and three interactive demonstrations follow.

Keywords: attitude to health, health belief model, theory of planned behavior, intention-behavior gap

A person's health is shaped less by what they know than by what they believe and feel about it. Two patients given the identical diagnosis and the identical advice will often act in opposite ways, one adhering to a regimen and the other quietly abandoning it, and the difference is rarely a difference in information. It lies in their attitudes: how threatening the condition seems, whether the recommended action is judged worth its cost, whether they feel able to carry it out, and whom they hold responsible for the outcome. Attitude to health is the study of those evaluations, and of the models that specify which of them predict what people actually do.

This article is organized around that predictive ambition. It sets out the expectancy-value models that formalized health attitudes as weighted beliefs, the control and self-efficacy beliefs that decide whether an intention is even attempted, the illness representations through which people make sense of a symptom, and the gap that remains between the best-measured attitude and the behavior it forecasts. The organizing fact throughout is that a health attitude is a structured, measurable composite, not a single global feeling, and that its structure is what gives it whatever predictive power it has.

What Attitude to Health Is

An attitude to health is a favorable or unfavorable evaluation of an object relevant to health, whether that object is a disease, a treatment, a risk, a provider, or one's own capacity to act. Like any attitude, it is not a single global feeling but a composite with cognitive, affective, and behavioral components, and the central project of the field has been to decompose it into parts that can be measured separately and recombined to predict behavior. The reason the decomposition matters is practical: a global “positive attitude to vaccination” predicts little, whereas the specific beliefs that a disease is dangerous, that the vaccine is effective, and that getting it is easy each predict a distinct piece of the decision.

The models differ in which beliefs they privilege, but they share a common ancestor in the expectancy-value principle: that an attitude toward an action is the sum of the person's beliefs about its likely outcomes, each weighted by how good or bad that outcome is judged to be. From that root grow the two dominant frameworks, the Health Belief Model and the Theory of Planned Behavior, together with the control-belief and illness-representation traditions that correct and extend them. What unites them as a field is a single question: given that a person evaluates a health action in a particular way, what will they do, and why so often does the doing fall short of the evaluation?

Types of Attitude to Health

In the Medical Subject Headings vocabulary, Attitude to Health is a descriptor beneath the broader heading Attitude, and it has three narrower descriptors of its own. These are its children in the MeSH tree, and they illustrate how a general evaluative disposition specializes into distinct, separately studied objects: what people know and do about health, how they misuse services, and whether they follow treatment.

The categories are an indexing classification, not a theory. They are the branches the National Library of Medicine uses to file the literature, so they are organized for retrieval rather than carved at the joints of any one psychological model, and they are not mutually exclusive: a single study of medication-taking may be indexed under treatment adherence and under health knowledge at once. They are best read as orthogonal facets of the same construct rather than a partition of it.

Of the three, Health Services Misuse has no article on this site yet; the other two are treated in their own right at the links above.

The Expectancy-Value Models: HBM and TPB

The oldest formal account of health attitudes is the Health Belief Model (HBM), developed to explain why people failed to take up free preventive services. It proposes that a preventive action is taken when four beliefs align: a perceived susceptibility to the condition, a perceived severity of its consequences, a belief in the benefits of the action, and a low perception of its barriers, with cues to action triggering the decision (Rosenstock, 1974). The model's logic is a cost-benefit calculation over threat and response: one acts when the threat feels real and the remedy feels worth its cost. A decade of research let Nancy Janz and Marshall Becker quantify which components mattered most, and their review found perceived barriers the single strongest predictor across studies, with susceptibility and benefits close behind, severity consistently weakest (Janz & Becker, 1984).

The Theory of Planned Behavior (TPB) gave the expectancy-value principle its most general and most tested form. Icek Ajzen's theory holds that behavior follows from a behavioral intention, which is itself assembled from three components: the attitude toward the behavior (its expected value), the subjective norm (perceived social pressure), and the perceived behavioral control (the felt ease or difficulty of acting), the last of which also influences behavior directly (Ajzen, 1991). Each component is in turn an expectancy-value sum: the attitude, for instance, is the total of the person's beliefs about the behavior's outcomes, each multiplied by their evaluation of that outcome. This structure is what lets the TPB turn a diffuse feeling into a weighted equation, and it is the equation the first demonstration makes manipulable.

Rate each of the three components from 1 (maximally unfavorable) to 7 (maximally favorable). The intention is their weighted sum, with attitude and control given the larger share: I = 0.40 × A + 0.20 × SN + 0.40 × PBC. Watch which component moves the intention most.

The presets reproduce the article’s Worked Example: Maria (A = 6, SN = 5, PBC = 6) reaches 5.80, Jordan (A = 6, SN = 5, PBC = 2) only 4.20. Their attitudes and norms are identical; the whole 1.60 difference comes from perceived control, the point the Theory of Planned Behavior makes against a pure attitude account.

Control Beliefs and Self-Efficacy

The addition of perceived behavioral control to the TPB was an acknowledgment of a parallel tradition holding that beliefs about control, not just about value, govern health behavior. The most influential is Albert Bandura's self-efficacy, the belief in one's own capacity to execute the action required. Bandura argued that this belief is a distinct and powerful determinant of whether a behavior is attempted and sustained, separate from the incentive to act: a person may value quitting smoking highly and still not try if they doubt they can succeed (Bandura, 1977). Perceived behavioral control is in practice close kin to self-efficacy, and the two traditions converged on the same claim, that an attitude without a sense of agency rarely becomes behavior.

A second control construct is health locus of control, the generalized expectancy about what determines one's health. Kenneth Wallston and colleagues operationalized it as three separable dimensions with their Multidimensional Health Locus of Control (MHLC) scales: internality (health as a consequence of one's own behavior), powerful others (health as controlled by doctors and family), and chance (health as a matter of luck or fate) (Wallston et al., 1978). Because the three are measured independently, a person has a profile rather than a single score, and the profile predicts behavior better than any one dimension alone. A related dispositional belief is optimism, the generalized expectation that outcomes will be good; Charles Carver and colleagues showed that dispositional optimism predicts better physical-health outcomes and more adaptive coping, operating as a stable attitudinal resource rather than a situation-specific belief (Carver et al., 2010). The second demonstration builds an MHLC profile and shows how it is classified.

The Multidimensional Health Locus of Control scales measure three beliefs independently, each from 6 to 30, so a person has a profile rather than a single score. Set each subscale and see which named orientation the profile falls into. The navy line marks the scale midpoint of 18.

Because the three axes are independent, the same high internality means something different in a person who also trusts powerful others than in one who also believes in chance. That is why Wallston and colleagues read the profile, not a single number, and why the profile predicts behavior better than any one dimension alone.

Illness Representations: The Common-Sense Model

The expectancy-value and control models treat the health threat as given and ask how the person evaluates acting on it. Howard Leventhal's Common-Sense Model of self-regulation (CSM) turns the question around: it asks how the person represents the threat in the first place, on the premise that people act not on the clinical facts of an illness but on their own lay model of it. The CSM identifies five dimensions along which a patient builds an illness representation: its identity (the label and symptoms), cause, timeline (acute, chronic, or cyclical), consequences, and controllability or cure (Leventhal et al., 2016). These representations have an emotional track running in parallel with the cognitive one, and together they drive the coping procedures a patient adopts and then appraises.

The model's empirical standing rests on showing that these representations predict outcomes. Martin Hagger and Sheina Orbell's meta-analysis synthesized the illness-representation literature and confirmed a coherent structure to the five dimensions and their reliable relationships with coping and with outcomes such as adherence and recovery, establishing the CSM as more than a descriptive scheme (Hagger & Orbell, 2003). The practical force of the model is that two patients with the same disease but different timelines in mind, one believing a condition acute and self-limiting, the other chronic and progressive, will adopt entirely different behaviors, and the only way to change the behavior is to address the representation. This reframes a health attitude as an organized model of a threat rather than a simple valence toward an action.

From Attitude to Behavior

Every model so far predicts behavior from an attitude or an intention, and the field's most consequential finding is how far short that prediction falls. Paschal Sheeran and Thomas Webb, reviewing the evidence, put a figure on the intention-behavior gap: intentions account for only about a quarter of the variance in behavior, and a large fraction of people who form a genuine intention to act on their health nonetheless fail to carry it out (Sheeran & Webb, 2016). The gap is not noise. It is structured, concentrated among the “inclined abstainers” who intend but do not act, and it is the central obstacle any attitude-based intervention must overcome.

Two responses follow. The first questions whether changing attitudes changes behavior at all. A meta-analysis by Sheeran and colleagues provided the strongest test, synthesizing experiments that actually manipulated attitudes, norms, and self-efficacy and tracking the downstream effect on behavior; it found that a medium-to-large change in these antecedents produced only a small-to-medium change in behavior, confirming that attitude change is necessary but far from sufficient (Sheeran et al., 2016). The second response specifies when behavior does follow intention. James Prochaska and Carlo DiClemente's Transtheoretical Model recast change as movement through stages, from precontemplation and contemplation through preparation, action, and maintenance, implying that an intention matters only at the stage where the person is ready to act on it (Prochaska & DiClemente, 1983). A complementary line identifies the self-regulatory act that narrows the gap directly: Peter Gollwitzer's implementation intentions, simple if-then plans that bind a specified situational cue to a goal-directed response in the form “if situation X arises, I will perform response Y,” which hand control of the behavior to the anticipated cue and produce reliably larger effects on enactment than forming a goal intention alone (Gollwitzer, 1999). The upshot, as Mark Conner and Paul Norman argue in surveying the field's open problems, is that health psychology has shifted its question from predicting behavior to changing it, and from measuring attitudes to bridging the gap between intention and action (Conner & Norman, 2017). The final demonstration makes the gap visible.

Set the mean intention strength of a 100-person cohort. Those with an intention split into people who act and the “inclined abstainers” who intend but do not. Even at the strongest intention a large gap remains, because intention translates into behavior only partly.

A didactic illustration of the gap’s structure, not a fitted epidemiological model. The review puts the gap at intentions explaining only about a quarter of the variance in behavior, concentrated among inclined abstainers; the self-regulatory support toggle shows why interventions now target the translation step rather than the intention alone.

Worked Example: Computing a Behavioral Intention

Consider two people deciding whether to exercise regularly, each rated on the three components of the Theory of Planned Behavior. Every component is measured on a 1-to-7 scale, where 1 is maximally unfavorable and 7 maximally favorable: attitude (A, how good the person judges exercising to be), subjective norm (SN, how much they feel others expect it), and perceived behavioral control (PBC, how easy they feel it is to do). The theory predicts a behavioral intention as a weighted combination of the three. Using illustrative weights that sum to one, giving attitude and control the larger share that meta-analyses typically find, the intention is `I = 0.40 × A + 0.20 × SN + 0.40 × PBC` (Ajzen, 1991).

- Maria holds a positive attitude, feels moderate social pressure, and feels fully able: A = 6, SN = 5, PBC = 6. - Jordan holds the identical attitude and feels the identical social pressure, but feels unable to fit exercise in: A = 6, SN = 5, PBC = 2.

Maria's intention is `0.40 × 6 + 0.20 × 5 + 0.40 × 6 = 2.40 + 1.00 + 2.40 = 5.80`; Jordan's is `0.40 × 6 + 0.20 × 5 + 0.40 × 2 = 2.40 + 1.00 + 0.80 = 4.20`. The two differ by exactly `0.40 × (6 − 2) = 1.60`, the whole of it attributable to perceived control, even though their attitudes and norms are identical. This is the point the Theory of Planned Behavior makes against a pure attitude account: a favorable evaluation that is not backed by a sense of control yields a weaker intention (Ajzen, 1991). And the intention is only the forecast. Because the intention-behavior gap is large, even Maria's strong 5.80 translates into action with substantial slippage, and whether it does depends on the control and self-regulatory factors the forecast does not contain (Sheeran & Webb, 2016).

Discussion

The study of attitude to health is the story of progressively decomposing a global evaluation into parts that predict behavior, and then discovering how much of behavior those parts still fail to predict. The Health Belief Model supplied the first decomposition into threat and response beliefs (Rosenstock, 1974; Janz & Becker, 1984); the Theory of Planned Behavior generalized it into a weighted equation over attitude, norm, and control (Ajzen, 1991); the control and illness-representation traditions added the beliefs about agency and the lay models of the threat that the expectancy-value equation omitted (Bandura, 1977; Wallston et al., 1978; Leventhal et al., 2016). Each refinement improved prediction, and each left a residue.

That residue is the intention-behavior gap, and it is what distinguishes the mature field from its origins. Where the early models assumed that getting the attitude right would get the behavior right, the evidence is that even a well-measured, successfully changed attitude moves behavior only modestly (Sheeran et al., 2016; Sheeran & Webb, 2016). The field's response has been to stop treating attitude change as the end of the task and to treat it as the first half, pairing it with the self-regulatory and structural supports, implementation plans, staged readiness, eased access, that carry an intention into action (Prochaska & DiClemente, 1983; Conner & Norman, 2017). An attitude to health is a genuine cause of behavior, but a partial and often weak one, and knowing exactly how weak is the field's hardest-won result.

Cognitive Implications

Attitude to health is a sustained case study in the relationship between an attitude and the behavior it is supposed to produce, and the lessons generalize well beyond health. The expectancy-value models are, cognitively, a claim that an evaluation is computed, not felt whole: the attitude toward an action is a sum over beliefs about outcomes weighted by their values, which makes a health attitude a worked arithmetic of expectancies rather than a unitary affect (Ajzen, 1991). That the components predict better than the global attitude is evidence for the decomposition, and against treating an attitude as a single stored number.

The deeper implication is the asymmetry between evaluation and action. The intention-behavior gap shows that even a correctly measured, deliberately changed evaluation translates into behavior only partly, which locates the bottleneck not in attitude formation but in the self-regulatory machinery that must enact an intention against habit, competing goals, and failures of control (Sheeran et al., 2016). The illness-representation tradition adds that people reason from a constructed model of a threat rather than from its facts, so the cognition that drives health behavior is a lay theory with its own structure, assembled to make a symptom sensible rather than to be accurate (Leventhal et al., 2016). For cognitive psychology the field is a reminder that measuring a belief well is necessary but never sufficient to predict what a person will do with it.

Current Directions

The field's center of gravity has moved from predicting health behavior to changing it, and that shift is reorganizing the research. The most direct expression is the turn to intervention taxonomy. Charles Abraham and Susan Michie built a standardized taxonomy of behavior change techniques, giving the field a shared vocabulary of the active ingredients, such as goal-setting, self-monitoring, and prompting implementation plans, so that an intervention can be specified, replicated, and its components tested rather than described loosely (Abraham & Michie, 2008). The taxonomy is a response to the intention-behavior gap: if attitude change alone moves behavior only modestly, the leverage lies in naming and testing the techniques that carry an intention into action.

A second direction is the rigorous test of whether the models' causal claims hold under experimental manipulation rather than correlation. Sheeran and colleagues' meta-analysis of experiments that actually changed attitudes, norms, and self-efficacy is the template, and the agenda it sets is to identify which antecedents, when moved, actually move behavior, and by how much (Sheeran et al., 2016). Conner and Norman, surveying the open problems, frame the live questions as integrating the dual-process and reflective accounts of health behavior, incorporating habit and automaticity alongside deliberate intention, and designing interventions that bridge rather than merely predict the gap (Conner & Norman, 2017). The attitudes remain central, but they are increasingly studied as one input to a self-regulating system rather than as the whole story.

Common Misconceptions

A positive attitude to health predicts healthy behavior.

Only weakly. A global positive attitude predicts little; it is the specific component beliefs, and above all the intention and the sense of control, that carry what predictive power there is, and even they leave a large intention-behavior gap (Ajzen, 1991; Sheeran & Webb, 2016).

People fail to act on health advice because they lack information.

Usually not. The models locate the failure in beliefs about threat, benefit, and control and in the enactment of an intention, not in a knowledge deficit, which is why information-only interventions so often fail to change behavior (Janz & Becker, 1984; Sheeran et al., 2016).

A health attitude is a single feeling a person either has or lacks.

No. Every major model treats it as a structured composite, of susceptibility, severity, benefits, barriers, norms, and control, each measured separately, because the components predict behavior where the global attitude does not (Rosenstock, 1974; Ajzen, 1991).

Patients respond to the medical facts of their illness.

They respond to their representation of it. The Common-Sense Model shows people act on a lay model of the threat, its identity, timeline, consequences, and controllability, so two patients with the same diagnosis but different representations behave differently (Leventhal et al., 2016; Hagger & Orbell, 2003).

Glossary

Attitude.

A favorable or unfavorable evaluation of an object, action, or idea, with cognitive, affective, and behavioral components; a health attitude is its application to illness, treatment, and risk.

Behavior change technique.

A specified active ingredient of an intervention, such as goal-setting or self-monitoring, drawn from a standardized taxonomy so interventions can be replicated and tested.

Behavioral intention.

A person's readiness to perform a behavior, assembled in the Theory of Planned Behavior from attitude, subjective norm, and perceived behavioral control; the proximal predictor of action.

Common-Sense Model.

Leventhal's account of self-regulation in which behavior follows from a patient's lay representation of an illness along five dimensions, paired with an emotional track.

Cues to action.

In the Health Belief Model, the triggers, a symptom, a reminder, another's illness, that convert a favorable belief configuration into action.

Dispositional optimism.

The generalized expectation that future outcomes will be good; a stable attitudinal resource associated with better physical-health outcomes and more adaptive coping.

Expectancy-value model.

The principle that an attitude toward an action equals the sum of beliefs about its outcomes, each weighted by the value placed on that outcome; the common root of the HBM and TPB.

Health Belief Model.

The classic account holding that preventive action depends on perceived susceptibility, severity, benefits, and barriers, with cues to action triggering the decision.

Health Knowledge, Attitudes, Practice.

A narrower MeSH descriptor and survey tradition relating what a population knows, believes, and does about a health topic.

Illness representation.

A patient's organized lay model of a health threat along the dimensions of identity, cause, timeline, consequences, and controllability; the object the Common-Sense Model places at the center of behavior.

Implementation intention.

Gollwitzer's if-then plan linking a specified situational cue to a goal-directed response; a self-regulatory strategy that narrows the intention-behavior gap by delegating action to the anticipated cue.

Intention-behavior gap.

The systematic shortfall by which behavioral intentions predict only a fraction of behavior, concentrated among those who intend but do not act.

Multidimensional Health Locus of Control.

Wallston and colleagues' three-dimensional measure of the generalized expectancy that health is controlled by internality, powerful others, or chance.

Perceived behavioral control.

In the Theory of Planned Behavior, the felt ease or difficulty of performing a behavior; it shapes intention and also predicts behavior directly.

Perceived susceptibility.

In the Health Belief Model, a person's belief about their own likelihood of contracting a condition; a component of perceived threat.

Self-efficacy.

Bandura's belief in one's own capacity to execute a required action; a determinant of whether a behavior is attempted and sustained, distinct from the incentive to act.

Subjective norm.

In the Theory of Planned Behavior, the perceived social pressure to perform or not perform a behavior.

Theory of Planned Behavior.

Ajzen's model predicting behavior from an intention built out of attitude, subjective norm, and perceived behavioral control.

Transtheoretical Model.

Prochaska and DiClemente's stages-of-change account, in which behavior change proceeds through precontemplation, contemplation, preparation, action, and maintenance.

Treatment Adherence and Compliance.

A narrower MeSH descriptor covering the extent to which a person's behavior follows agreed clinical recommendations; the behavioral endpoint most health attitudes are studied to predict.

Key Researchers

Icek Ajzen

(University of Massachusetts Amherst). Social psychologist who formulated the Theory of Planned Behavior, the dominant expectancy-value account of how a health attitude, together with subjective norm and perceived behavioral control, assembles into the intention that predicts behavior. Wikipedia · Wikidata · Google Scholar · Faculty

Charles S. Carver

(University of Miami). Personality and health psychologist who developed dispositional-optimism theory and the Life Orientation Test, establishing a generalized positive expectancy as a stable attitude that predicts physical-health outcomes and coping. Memorial

Howard Leventhal

(Rutgers University). Health psychologist who originated the Common-Sense Model of self-regulation, recasting a health attitude as the lay cognitive and emotional representation a person builds of a health threat. Faculty

Ralf Schwarzer

(Freie Universität Berlin). Health psychologist who developed the Health Action Process Approach, which separates the motivational formation of a health intention from the volitional work of enacting it, addressing the intention-behavior gap directly. ORCID · Wikipedia · Wikidata · Google Scholar

Paschal Sheeran

(University of North Carolina at Chapel Hill). Social-health psychologist whose meta-analyses quantified the intention-behavior gap and tested whether experimentally changing attitudes, norms, and self-efficacy actually moves health behavior. Google Scholar · Faculty

Kenneth A. Wallston

(Vanderbilt University). Co-developer of the Multidimensional Health Locus of Control scales, which operationalized health-related control beliefs as a measurable, three-dimensional attitude profile. Faculty

Frequently Asked Questions

What is an attitude to health?

It is a favorable or unfavorable evaluation of something relevant to health, such as a disease, a treatment, a risk, or one's own ability to act. The field treats it not as a single feeling but as a structured composite of beliefs that can be measured separately and combined to predict behavior (Ajzen, 1991).

What is the Health Belief Model?

It is the classic account holding that a person takes a preventive action when they believe they are susceptible to a condition, that it is severe, that the action is beneficial, and that its barriers are low, with cues to action triggering the decision. A review found perceived barriers the strongest of its components (Rosenstock, 1974; Janz & Becker, 1984).

What is the Theory of Planned Behavior?

It predicts behavior from an intention assembled out of three parts: the attitude toward the behavior, the subjective norm, and the perceived behavioral control. Perceived control also predicts behavior directly, not only through intention (Ajzen, 1991).

Why do self-efficacy and locus of control matter so much?

Because a favorable attitude rarely becomes behavior without a sense of agency. Self-efficacy is the belief that one can perform the action, and health locus of control is the generalized expectancy about what determines one's health; both predict whether an intention is ever attempted (Bandura, 1977; Wallston et al., 1978).

What is the Common-Sense Model?

It is Leventhal's account in which people act not on the clinical facts of an illness but on their own lay representation of it, built along five dimensions: identity, cause, timeline, consequences, and controllability. A meta-analysis confirmed these representations predict coping and outcomes (Leventhal et al., 2016; Hagger & Orbell, 2003).

What is the intention-behavior gap?

It is the finding that intentions predict only about a quarter of the variance in behavior, so many people who genuinely intend a healthy action never carry it out. The gap is concentrated among those who intend but do not act, and it is the main obstacle for any attitude-based intervention (Sheeran & Webb, 2016).

Does changing a health attitude actually change behavior?

Only partly. A meta-analysis of experiments that manipulated attitudes, norms, and self-efficacy found that a medium-to-large change in these antecedents produced only a small-to-medium change in behavior, confirming that attitude change is necessary but far from sufficient (Sheeran et al., 2016).

How do researchers try to close the gap?

By pairing attitude change with the self-regulatory and structural supports that carry an intention into action, specified as standardized behavior change techniques such as goal-setting, self-monitoring, and implementation plans, and by matching the technique to the person's stage of readiness (Prochaska & DiClemente, 1983; Abraham & Michie, 2008).

References