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Developing a New Model for Cross-Cultural Research: Synthesizing the Health Belief Model and the Theory of Reasoned Action
This article discusses the development of a new model representing the synthesis of two models that are often used to study health behaviors: the Health Belief Model and the Theory of Reasoned Action. The new model was developed as the theoretic framework for an investigation of the factors affecting participation by Mexican migrant workers in tuberculosis screening. Development of the synthesized model evolved from the concern that models used to investigate health-seeking behaviors of mainstream Anglo groups in the United States might not be appropriate for studying migrant workers or persons from other cultural backgrounds. Key words: crosscultural research, Health Belief model, health care behaviors, model development, Theory of Reasoned Action

Jane E. Poss, DNSc, ANP, C Associate Professor and Director Family Nurse Practitioner Program University of Texas at El Paso El Paso, Texas

HIS ARTICLE discusses the development of a new model representing the synthesis of two models that are often used to study health behaviors: the Health Belief Model (HBM) and the Theory of Reasoned Action (TRA). The new model was developed as the theoretic framework for an investigation of the factors affecting participation by Mexican migrant farm workers in tuberculosis screening, a research topic that had not been previously examined. Development of the synthesized model resulted from the concern that models used to investigate health-seeking behaviors of mainstream Anglo groups in the United States might not be appropriate for studying

This study was partially funded by grants from the Gamma Kappa chapter of Sigma Theta Tau International and the Mark Diamond Research Fund, State University of New York at Buffalo. The author thanks the following faculty of the School of Nursing, State University of New York at Buffalo: Mecca Cranley, PhD, Dean, for her help in the original synthesis of these models and for her invaluable assistance with an earlier version of this manuscript; and Mary Ann Jezewski, PhD, Brenda Haughey, PhD, and Yow-Wu Bill Wu, PhD, for their help with the model development. Adv Nurs Sci 2001;23(4):115 2001 Aspen Publishers, Inc.

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migrant workers. The synthesized model was developed to allow for a more culturally specic approach while providing previously tested concepts useful for the analysis of screening behaviors. In this article, the models are discussed individually, a critique of each is provided, and the synthesized model is presented. Relevant studies based on each of the models and the combined model are reviewed.

HEALTH BELIEF MODEL The HBM was developed in the 1950s in an attempt to explain the failure of people to participate in preventive health behaviors such as screening and immunization programs.1,2 The origins of the HBM are in psychosocial theory, particularly the work of Lewin,3 which is based on a phenomenologic orientation to positive and negative inuences in the individuals subjective world as they affect behavior. The HBM, a value expectancy model, proposes that, in general, behavior depends on how much an individual values a particular goal and on his or her judgment that a particular action will achieve that goal. If the goal is to avoid a health problem, the individual must feel personally vulnerable (perceived susceptibility) to a problem judged to be potentially serious (perceived severity), and he or she must estimate that specic action will be benecial in reducing the health threat (perceived benet) and will not involve overcoming obstacles (perceived barriers). A nal variable completes the original HBM: the presence of an internal or external stimulus, or cue to action, that triggers the individuals health behavior. An internal cue may include symptoms of illness,

whereas external cues include media campaigns about health promotion or interpersonal interactions, such as learning that a friend has been affected by a health problem. A diagram of the HBM is presented in Fig 1. More recently, the concept of self-efcacy has been added to some versions of the HBM. Rosenstock4 suggests that self-efcacy was not explicitly incorporated into early versions of the HBM because the focus was on circumscribed preventive actions, such as receiving an immunization or accepting a screening test. He proposes that self-efcacy is more useful in understanding behaviors, such as those related to chronic illness care, that occur over a period of time and require lifelong changes in behaviors. Because the behavior of interest in the migrant worker

Fig 1. Health Belief Model. Source: Reprinted with permission from MH Becker and LA Maiman, Sociobehavioral Determinants of Compliance with Health and Medical Care Recommendations, Medical Care, Vol 13, pp 1024, 1975, Lippincott Williams & Wilkins.

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study was a circumscribed action, namely participation in a screening test, the concept of self-efcacy was not felt to add explanatory power and thus was not included in the model. Although the HBM has been used extensively in studies of health behaviors, critics of the model have pointed out a variety of limitations. There has been a lack of uniformity in testing the model, especially in the way variables are operationalized.5,6 Tools used to measure HBM components have not been rened or standardized. In addition, the model does not apply numeric coefcients to the concepts of susceptibility, severity, benets, and barriers, nor does it delineate the specific nature of the relationships among the variables.4 Most studies, however, have treated the model as additive and have tested only direct relationships between the variables and the health-related behavior of interest. Another problem with the HBM is a lack of consistency in the use and testing of the model. That is, not all variables have been included in all studies. For example, identifying and measuring the concept of cues to action has been problematic. Cues can be diverse in nature, may occur in a eeting manner, and the subject may or may not consciously remember events that trigger action. In retrospective studies, the nature and importance of cues is more difcult to evaluate because subjects are questioned about behaviors performed in the past. For these and other reasons, the variable cues has not been included in many studies based on the HBM.7,8 Other investigators have added variables to the HBM that were not included in the original model, for example, self-efcacy.4,9 When the model is analyzed over time, there-

fore, it is apparent that different versions of the model are being compared. These issues relate more to how investigators design studies than to problems with the model itself. Because the HBM is a psychosocial model, it accounts for only as much of the variance in health behaviors as can be explained by attitudes and beliefs that are obvious to and consciously evaluated by individuals. 10 Other factors related to the individual, such as demographic variables, personality factors, social support, or previous health experiences, may play a role in inuencing behavior, but they are not an explicit part of this model. Instead, they are thought to inuence the major variables in the model. In addition, concepts reective of the larger social structure, such as institutional or public policy, poverty, and social isolation that may affect access to health care, are not included in the HBM. This criticism, however, could be directed at most psychosocial models. Another criticism of the HBM is that it does not account for normative or cultural factors that may be important in explaining health-seeking behavior. Although Rosenstock2 states that a persons beliefs about risk-reducing behaviors are undoubtedly inuenced by the norms and pressures of his or her social groups, a normative concept is not explicitly included in the HBM. Rubel and Garro11 have questioned whether the HBM can explain behavior in a variety of cultural settings because it lacks a culturally specic concept. This was considered to be a signicant concern in designing a study involving non-Anglo subjects. A possible solution to the problem of cultural relevance is discussed below. In spite of criticisms, the HBM has been used successfully for over 30 years to under-

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stand health behaviors in a variety of circumstances. As Kirscht wrote in his analysis of the HBM, it is complex and variable in its history, yet surprisingly robust and useful.12(p38) The model is useful in explaining health behaviors, it is generalizable to a variety of settings, it is parsimonious, and because it is a middle-range theory, it can generate hypotheses for testing. Specically, it has been demonstrated to be a good predictor of participation in screening programs, the dependent variable of interest in the study of Mexican farm workers. Instead of abandoning the HBM in the face of criticisms, adapting it by including a second, more culturally based model, may be a better approach.

THEORY OF REASONED ACTION The TRA, a general theory of human behavior, was introduced by Fishbein and was further developed and tested by Fishbein and Ajzen.13 The TRA attempts to explain the relationship among beliefs, attitudes, intentions, and behavior, and it is based on the assumption that human beings are rational and apply information available to them in a systematic manner to weigh the costs and benets of a particular action.14 The goal of the TRA is to be able to predict and understand directly observable behaviors that are primarily under the control of the individual.15 A model of the TRA is depicted in Fig 2.

Fig 2. Theory of Reasoned Action. Understanding Attitudes and Predicting Social Behavior by Ajzen/Fishbein, 1980. Reprinted by permission of Prentice-Hall, Inc, Upper Saddle River, New Jersey.

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According to the TRA, intention to act in a certain way is the immediate determinate of behavior. If there is an opportunity to act, then intention will result in behavior. If intention is measured accurately, and if there is correspondence between the measure of intention and the measure of behavior, then intention will provide the best predictor of behavior. Measuring intention as close as possible in time to the behavioral observation helps to maximize accurate prediction. Intention is a function of two factors: (1) the persons attitude toward performing the behavior and (2) a general subjective norm concerning the performance of the behavior. The theory provides for assignment of relative weights to these two determinants of intention in order to explain behavior. Attitude toward a concept is a persons general feeling of favorableness or unfavorableness for the concept.14 An attitude is seen as a persons overall evaluation that performing the behavior under study is good or bad. Ajzen and Fishbein14 suggest measuring attitude using standard scaling procedures such as the semantic differential in order to locate respondents on a bipolar evaluative dimension. It is important that the measure of attitude toward the behavior corresponds with the outcome behavior of interest. The subjective norm is the persons perception of social pressures to act, or whether most important referents believe he or she should or should not perform the behavior in question. The actors perception is measured, not the actual beliefs of the important others. According to the TRA, intention to perform a certain behavior depends on what the person thinks important others want him or her to do.

In the TRA, attitude and subjective norm are each assigned a weight reecting their relative importance in determining intention; this weight may change depending on the behavior and the person performing it. The theory can be summarized in the following formula:
B I f [w1 Ab w2 SN]

where B is the behavior, I is the intention to perform the behavior, Ab is the attitude toward performing that behavior, SN is the subject norm concerning the behavior, and w1 and w2 are the weights of the attitudinal and normative components, respectively.15 If appropriate measures of these components are used, then they should predict intention. The ability of attitude and subjective norm to predict behavior depends on the strength of the relationship between intention and behavior. A persons attitude toward a behavior is in turn determined by his or her beliefs about that behavior. According to the TRA, only salient beliefs, that is, beliefs that are uppermost in the persons mind, are determinants of attitude. The term salient behavioral beliefs is applied to the beliefs that underlie a persons attitude toward a behavior. Attitude is determined by (1) an individuals belief that a given outcome will occur if he or she performs the behavior and

The ability of attitude and subjective norm to predict behavior depends on the strength of the relationship between intention and behavior.

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(2) the individuals evaluation of the outcome of performing the behavior. This relationship between attitude and salient behavioral beliefs can be summarized by the formula
Ab bi ei

where Ab is the persons attitude toward performing the behavior, b is the belief that performance of behavior will lead to a given outcome (i), and e is the persons evaluation of outcome i.15 Ajzen and Fishbein14 suggest measuring each of the potential consequences of a behavior on a seven-point bipolar scale and the likelihood of each outcome on a Likerttype scale. Attitude is then predicted by multiplying the subjects evaluation of the consequence of each behavior by the strength of belief that performing the behavior will lead to that consequence, and summing the products. Obtaining a set of beliefs that are salient in a given population can be accomplished by asking representatives of that population to list the advantages and disadvantages of performing the behavior being studied. The subjective norm is in turn determined by a persons normative beliefs about what particular salient individuals want him or her to do. Whereas the subjective norm is the perception of what a generalized important other wants the subject to do, the normative belief involves the perceived desires of specic referents around the subject. A listing of important others can be obtained by using a free-response format to ask representatives of the population to list referents who would inuence their performance of the specic behavior under study. Study subjects are then asked to rank on a seven-point scale their belief

that each referent wants them to perform the behavior in question. In addition to understanding a persons beliefs about the perceived wishes of relevant referents, the persons motivation to comply with each of the referents must be measured. This can be accomplished using a Likert-type scale. The subjective norm can be predicted by using an index produced by multiplying normative beliefs by the corresponding motivations to comply, and summing the products. The subjective norm is related to normative beliefs as expressed in the following formula:
SN bj mj

where SN is the subjective norm, b is a normative belief that referent j thinks the subject should perform, and m is the motivation to comply with referent j.15 Like the HBM, the TRA does not include other variables such as demographic characteristics and personality traits. These are considered to be potentially important but are not incorporated into the core of the theory. Instead, they are termed external variables that may inuence a persons beliefs but affect behavior only via the major variables that are included in the TRA. When applying the TRA to a study of human behavior, it is important that behavior be defined and measured accurately. Behaviors can be studied as single actions or as behavioral categories. A single act refers to a very specic behavior that has been clearly dened, whereas a behavioral category includes several single acts. For example, the behavioral category dieting can be broken down into specic observable single acts such as eating fewer calories, changing types of food consumed, exercising more, or taking diet pills.14

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Measurement of the single action or the behavioral category depends on the accuracy of the denition. It is also important to specify certain other behavioral elements, including the target at which the behavior is aimed, the context in which the behavior occurs, and the time frame within which the behavior takes place. There must be a correspondence among these elements in the way intention and behavior are measured; that is, the target, context, and timing of intention must be equivalent to the target, context, and timing of the behavior. One of the principal criticisms of the TRA is that it focuses on explaining intentions rather than behavior, whereas the goal of most health care researchers is to understand behavior.6 In addition, the methodology of the TRA can be time consuming for studying complex behaviors because measures of each component of the behavior in question must be created. Research based on the TRA also takes time because of the need to conduct elicitation research about salient behavioral and normative beliefs in the population under study as the basis for instrument development. As a result, many studies omit this procedure.16 However, it is this very methodology that is also the strength of the model because it can add a culturally based perspective on behavior.

SELECTED RESEARCH LITERATURE BASED ON THE HEALTH BELIEF MODEL Both the HBM and the TRA have been used as models in studies of health behavior. Over the past 30 years, the HBM has been applied not only to screening behaviors but also to preventive health behav-

iors in general, as well as to illness behaviors and compliance with medical regimens.10,12,17,18 According to Leventhal and colleagues,19 the HBM is the cognitive model that most frequently is the basis for studies of health behavior and compliance. As a result, there are many studies based on this model. In this section, reviews are presented of selected studies that examined preventive health behaviors, that is, those actions that are undertaken by a person in an asymptomatic state, such as participation in screening or vaccination programs. According to Janz and Becker,10 investigations based on the HBM provide substantial support that the variables in the model contribute to explaining and predicting the health-related behaviors of diverse populations. These authors reviewed both prospective and retrospective studies of health behavior based on the HBM that were conducted between 1974 and 1984, and they found consistent support for the ability of the HBM to predict a variety of behaviors, including participation in screening programs. A review of the literature reveals two investigations of tuberculosis screening using the HBM as the theoretic model. An early study of tuberculosis prevention behaviors by Hochbaum,20 one of the developers of the HBM, found that individuals who believed they personally could contract tuberculosis were more likely to have a screening chest X-ray than persons who did not hold these beliefs. Hochbaums study, however, was not a test of the full HBM because it omitted the concepts of perceived severity, perceived benets, and cues to action. In a second study, Wurtele and colleagues21 prospectively studied compliance of participants in a tuberculosis detection

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drive. These investigators included all of the original HBM variables except cues to action. Interestingly, the authors added behavioral intention as an independent variable to determine if it increased the predictive ability of the HBM. They used stepwise discriminant analysis to analyze the data and found that intention alone accounted for 71.3% of the variance in behavior. In the late 1970s, a number of studies based on the HBM were conducted relative to inuenza vaccination behavior. In a retrospective study, researchers examined the ability of HBM variables to explain participation of older patients in an inuenza vaccination program.22 Signicant correlations between receipt of vaccination and all of the HBM variables were found; furthermore, patients who received a postcard cue were twice as likely to be vaccinated as those who did not. Another group of researchers studied inuenza vaccination prospectively in a telephone survey of adults.23 These investigators included, in addition to the HBM variables, behavioral intention, social inuences, and physicians recommendation (although they did not classify this as a cue to action). The variables behavioral intention and social inuences are concepts from the TRA. Zero-order correlations were statistically signicant between each of the four main HBM variables and vaccination behavior, but the highest correlations were found for intention (r .581, P .01) and physicians recommendation (r .343, P .01). Stepwise multiple regression analysis revealed that a model without the HBM variables was able to explain 40% of the variance in behavior, but path analysis showed that most of the inuence of the

HBM variables on behavior was mediated through their effect on behavioral intention. Using a version of the HBM that included the variable of general health motivation, Rundall and Wheeler24 studied vaccination behavior of senior citizens. Logit analysis revealed that this model accounted for 34% of the variance in vaccination behavior. Perceived susceptibility and barriers were signicantly related to the odds of receiving the immunization (P .01). Bodenheimer 25 applied the HBM to a and colleagues study of health care workers acceptance of the hepatitis B vaccination. The authors added other variables to the HBM, including locus of control and knowledge of hepatitis B, and they studied both intention to receive the vaccination and actual vaccination. Stepwise multiple regression revealed that the variables benets, susceptibility, and severity explained 20% of the variance in vaccine acceptance. There was a strong correlation between intention to be vaccinated and actual vaccination (r .6; 95% CI .498, .686). Of those who intended to receive the vaccination, 61% eventually received it, whereas only 4% of those who did not were ever vaccinated. Several studies have analyzed the relationship between HBM variables and participation in screening for breast cancer. Champion26 applied the HBM to a retrospective study of breast self-examination frequency. Her version of the HBM omitted the concept of cues to action and included the concept of health motivation. Stepwise multiple regression revealed that 26% of the variance in breast self-examination was accounted for by all the HBM variables tested together, with barriers accounting for 23% of the variance.

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In a retrospective study of health beliefs and compliance with mammography screening, Aiken et al27 tested the original HBM concepts plus a variable termed physician recommendation for screening. Hierarchical logistic regression analysis revealed that physician recommendation and having a regular place for medical care accounted for 24% of the variance in the dependent variable of compliance. Norman28 used the HBM plus two variablesintention and general health value to examine the predictors of attendance at screening examinations. Logistic regression analysis revealed that the HBM variables accounted for 56% of the variance in intention to attend, with benets and barriers emerging as significant independent predictors. Norman concluded that, in this study, the HBM variables were better predictors of intention than of actual behavior. This review of studies framed within the HBM provides evidence that a number of researchers have included intention, a concept that is part of the TRA, as a variable in their models.21,23,25,28 These and other studies have shown that intention is a good predictor of behavior, and that, in some cases, the effects of HBM variables on behavior are mediated through intention.29

SELECTED RESEARCH LITERATURE BASED ON THE THEORY OF REASONED ACTION The TRA has been used to study a variety of health-related behaviors, but an extensive literature review failed to uncover any studies in which the TRA was used as a framework to study participation in tuber-

culosis screening. Several studies have used the TRA to study behavior related to AIDS-preventive behaviors. Jemmott and Jemmott30 used the TRA to study condom use among Black female university students. The investigators did not conduct prior elicitation research to identify salient behavioral beliefs and normative referents as the basis for developing the items in their questionnaire. In addition to the standard TRA variables, the authors added the variable of AIDS knowledge. Multiple regression analysis revealed that 62% of the variance in intention was predicted by attitudes and subjective norms. In this study, however, the authors tested the relationship between intention to use condoms in the future with behavior that occurred in the past, which is not consistent with the prospective nature of the TRA, which posits that intention predicts future behavior. Boyd and Wandersman31 studied condom use by college undergraduates. Their research was based on both the TRA and a version of the Triandis theory of attitudebehavior relations. The Triandis theory has a core of concepts similar to the TRA, but it employs several additional concepts, including susceptibility, fear, self-efficacy, and habit. Results of the analysis using the TRA variables revealed that 38% of the variation in intention to use a condom was explained by the behavioral and normative beliefs concepts, whereas 34% was explained by the intervening variables of general attitude and general subjective norm. The Triandis model, on the other hand, explained 47% of the variance in intention and 53% of the variance in behavior. After testing several different models, the authors concluded that the best model for predicting

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behavior included all of the TRA variables plus susceptibility, fear of AIDS, and personal normative beliefs. The rst two variables, susceptibility and fear, which are essentially the same as two of the HBM concepts, significantly increased the explanatory power of intention to predict condom use. Adler et al32 used the TRA as the conceptual basis for a prospective study of four contraceptive methods in adolescents. Multiple regression analysis was used to examine the relationship between general attitude and social norm and intention to use contraception. The authors concluded that attitudes and social norms contribute significantly to adolescent decision making about contraception, and that intention was related signicantly to future behavior, even when measured 1 year previously. Lierman and colleagues33 studied the ability of the TRA to predict breast selfexamination; however, this study was retrospective, relating intention to perform breast self-examination during the coming year with breast self-examination performance over the past 6 months. Pearson correlation coefficients between the major components of the TRA and breast selfexamination were significant, with the strongest correlation between intention and actual breast self-examination. Multiple regression analysis revealed that behavioral and normative beliefs accounted for 32% of the variance in intention and 39% of the variance in actual behavior. Like the HBM, the TRA has been used as the framework for studying vaccination behavior. Montano34 used the TRA in a study of patients at high risk for developing severe inuenza complications and found that attitude and social norm accounted for 62%

of the variance in intention and 31% of the variance in behavior. The TRA allows for a culturally based study because of the methodologic approaches recommended. A group of researchers used the TRA as the framework for a comparative study of smoking behaviors and attitudes in Latinos, many of whom had low educational levels, and non-Latino Whites.35 The authors of this study specically chose the TRA because its concepts enhance the ability to conduct cross-cultural investigations. The model clearly distinguished between the two groups and showed signicant differences in their behavioral and normative beliefs. The researchers found, for example, that familyrelated reasons for quitting smoking were more important for Hispanic than for nonHispanic White smokers. These studies reveal that the TRA variables can account for a signicant proportion of the variance in intention and behavior, but that, as a rule, they are better predictors of intention. One study included variables from the HBM, which increased the explanatory power of the TRA. In addition, the study of Latino smokers demonstrated the effectiveness of the TRA in addressing health-related behaviors across cultural groups.35

These studies reveal that the TRA variables can account for a signicant proportion of the variance in intention and behavior, but that, as a rule, they are better predictors of intention.

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RESEARCH BASED ON THE COMBINED HEALTH BELIEF MODEL AND THEORY OF REASONED ACTION As we have seen, several studies based on either the HBM or the TRA incorporated variables from one model into the other. Examples include adding the concept of intention to the HBM and using concepts such as perceived susceptibility in the TRA. One group of investigators formally combined the two models as the basis for research investigation. VanLandingham et al36 applied the combined HBM and TRA to a retrospective study of condom use among Thai men visiting commercial sex workers. Logistic regression analysis applied to test the effect on the variables from the combined model on condom use classied 70% of subjects into the correct condom-usage category. In operationalizing the variables from the two models, these researchers combined the concepts of perceived severity, perceived barriers, and perceived benets from the HBM with the concept of beliefs and evaluations about behavioral outcomes from the TRA. As can be seen from previous discussion of HBM and TRA concepts in this manuscript, the concept of perceived severity from the HBM is not equivalent to the concept of beliefs and evaluations about behavioral outcomes from the TRA and should remain a separate concept. The researchers did not include the concept of cues to action among the HBM variables, and they used a version of the HBM that included the concept of self-efcacy. Because the study was retrospective, the investigators omitted the concept of intention from the TRA and used actual behavior as the de-

pendent variable. Further, the authors did not operationalize the concept of beliefs and evaluations about behavioral outcomes according to the guidelines set forth by Ajzen and Fishbein.14 Thus, there are a number of shortcomings in the way in which the models were combined for this study. Other studies have used variables from the HBM and TRA but did not combine them formally into a new model. Instead, only variables of interest for the study were selected. Examples include a study of the sociopsychologic correlates of smoking cessation among African-American women,37 an analysis of the effect of health beliefs and social inuences on home safety practices of inner-city mothers with young children,38 and an investigation of knowledge and beliefs about sexually transmitted diseases in Morocco.39

COMBINING THE HEALTH BELIEF MODEL AND THE THEORY OF REASONED ACTION The HBM, the TRA, and a model combining the two have been used successfully to study participation in screening programs as well as the health behaviors and beliefs of culturally distinct groups. The HBM and TRA have common characteristics. Both are based on a value-expectancy theory of behavior; that is, behavior depends on the value an individual places on a particular outcome as well as the individuals calculation of the probability that a given action will result in that outcome. Both models posit that beliefs about behavioral consequences should predict behavior. The TRA includes a normative component and incorporates a methodology aimed

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at eliciting the basic concerns and beliefs of a group under investigation. In designing the study of Mexican migrant workers, it was noted that one of the basic cultural values attributed to Hispanics is collectivism, evidenced by high levels of personal interdependence, conformity, and readiness to be inuenced by others.40 Based on these values, it was anticipated that the concept of normative beliefs would be an important contributor to the explanation of intention and behavior. One advantage of including the TRA in the synthesized framework for the study of Mexican migrant workers is that normative inuences or peer group norms are likely to be important in explaining farm workers participation in tuberculosis screening. The emphasis on norms also adds a culturally based perspective on behavior, and using this concept may help to overcome the failure of the HBM to include culturally relevant concepts. In addition, the methodology suggested by the TRA, that is, basing the research instrument on a preceding exploratory study of subjects behavioral and normative beliefs, also adds cultural relevance to the model. Although adding concepts from the TRA to the HBM makes the resulting model somewhat less parsimonious, the normative concept and the requirement for a prior elicitation study enhance the explanatory power and cultural t of the model. If the two models are integrated to form a new model, several concepts can be combined to improve parsimony. A model depicting the combined HBM and TRA is presented in Fig 3. The concepts of perceived barriers and perceived benefits from the HBM are equivalent to the concept of beliefs and evaluations about behavioral outcomes

Fig 3. Combined Health Belief Model and Theory of Reasoned Action.

from the TRA. The HBM concepts of perceived barriers and perceived benets refer to the participants perception of the positive and negative aspects or outcomes of the behavior in question, in this case tuberculosis screening behavior. The TRA concept of beliefs and evaluations about behavioral outcomes refers to the beliefs about the outcomes of the behavior in question and the participants positive or negative evaluation of these outcomes. In developing a research instrument based on the combined model, operationalization of the concept of behavioral beliefs and evaluations should be accomplished following the guidelines from the TRA because these are so well delineated. Although the concept of intention is not part of the HBM, this concept was retained in the combined model for several reasons. First, the literature review reveals that in studies where this concept was included in

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the HBM, it served as a good predictor of behavior.21,23,25,28 Second, intention is an integral part of the TRA, which was developed to explain this concept. The TRA specically proposes that, if conditions are right, intention will lead to behavior. The combined HBM and TRA model was applied to a quantitative study of the factors affecting Mexican migrant farm workers participation in a tuberculosis screening program. As recommended by Ajzen and Fishbein,14 an instrument was developed for this study based on a prior qualitative elicitation study of migrant workers explanatory models of tuberculosis. The results of the qualitative study and the procedures for instrument development are detailed elsewhere.41,42 In the quantitative study of migrant workers, the combined HBM and TRA model was tested in two different ways.43 In one version of the combined model, the dependent variable was intention, and in the other, behavior was the dependent variable. When behavior was treated as the dependent variable, intention was included as one of the independent variables in order to analyze its contribution to explaining behavior. Logistic regression analysis of the interview data from 206 subjects eligible to take part in the tuberculosis screening program revealed that a more parsimonious model than the full combined HBM and TRA model predicted each of the dependent variables, intention and behavior.
REFERENCES
1. Rosenstock IM. What research in motivation suggests for public health. Am J Public Health. 1960;50:295301. 2. Rosenstock IM. Why people use health services. Milbank Memorial Fund Q. 1966;44(part 2):94124.

In this study, intention to take part in tuberculosis screening was best explained by a model containing four variables: subjective norm, attitude, susceptibility, and cues to action (operationalized as attendance at an educational program). The best model for predicting behavior (actual participation in screening) required only two variables: intention and susceptibility. In both cases, variables derived from both the HBM and the TRA were necessary to predict the dependent variable. The population in the United States is becoming increasingly racially and ethnically diverse, and by the year 2050, persons representing ethnic and racial minority groups will comprise nearly half of all Americans.44 Nurse researchers must have appropriate theoretic models to conduct investigations in populations representing an array of cultural backgrounds. The synthesized HBM and TRA presented in this article is an attempt to develop a model that will be useful across cultures. The strengths of this model include the proven past performance of the component models, the inclusion of the culturally based concepts from the TRA, and the fact that instrument development is based on a preceding exploratory study of subjects behavioral and normative beliefs. Further application of the model in different populations will allow researchers to test its ability to help nurses understand the health-seeking behaviors of clients from a variety of cultural backgrounds.

3. Lewin K. A Dynamic Theory of Personality. New York: McGraw-Hill; 1935. 4. Rosenstock IM. The Health Belief Model: Explaining health behavior through expectancies. In: Glanz K,

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COLLEGE OF NURSING
ASSOCIATE PROFESSOR OR PROFESSOR DIRECTOR OF GRADUATE STUDIES & SR. RESEARCHER
The University of South Florida College of Nursing is seeking applicants for two faculty, tenureearning Senior Nurse Scientists, to be appointed to the rank of Associate or Full Professor. Director of Graduate Studies (position #2022) and Sr. Researcher (position #2202). Requirements for both positions are an earned doctoral degree in Nursing or related field, a masters degree in Nursing and eligibility to practice nursing in Florida. Significant scholarly achievement, a proven track record of securing external funding for research and demonstrated teaching excellence are expected. Appointment above the rank of Associate Professor is commensurate with credentials and experience. Salary is negotiable. The College of Nursing is one of three colleges in the Health Sciences Center at the University of South Florida and offers a baccalaureate, masters and a Ph.D. program. The College is part of the 2nd largest university in the Southeast with more than 35,000 students and one of three Research 1 Universities in the Florida State University System. The campus is a national leader in health sciences research with over $150 million in grants and contracts in FY 1999. The opportunity for collaboration in interdisciplinary research, teaching and clinical practice is a strength of this institution. The College offers NLN and CCNE accredited baccalaureate and masters programs. The PhD program in Nursing supports three Research Interest Groups: Children, Families and Communities, Quality of Life and Rehabilitation and Occupational Health. The College of Nursing offers a comprehensive benefits package along with a New Faculty Package that includes: research start-up funds, joint appointments with our collaborative institutions, full travel reimbursement for presentations, moving expenses, state-of-the-art computing facilities and opportunities for faculty practice through the faculty practice plan. Please visit our web site @ www.hsc.usf.edu/nursing for more details on the College of Nursing. These positions are open until filled. To apply, please submit a letter of intent and curriculum vitae to: Patricia A. Burns, RN, PhD, FAAN, Dean College of Nursing University of South Florida 12901 Bruce B. Downs Blvd., MDC 22 Tampa, FL 33612-4766
USF is an Equal Opportunity/Affirmative Action/Equal Access Institution. For disability accommodations contact Mary Geary at (813) 974-9163 at least five working days in advance. According to Florida law, applications and meetings regarding them are open to the Public.

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