When researchers in Semarang set out to understand why some tuberculosis patients adhere to treatment while others don't, they turned to a psychological tool that measures the invisible: our health beliefs.
Imagine two patients diagnosed with the same infectious disease, prescribed the same medication, and treated at the same community health center. One completes their treatment successfully; the other drops out prematurely. What invisible factors determine their different paths? The answer may lie in their health beliefs—the perceptions, expectations, and confidence that shape health decisions.
At health centers in Kedungmundu and Tlogosari Wetan in Semarang City, researchers are conducting crucial work that bridges psychology and infectious disease management. They're investigating whether the Health Belief Model (HBM)—a psychological framework developed in the 1950s to understand why people failed to adopt tuberculosis prevention measures—can be reliably used today to predict and improve TB treatment adherence 1 4 . Their work validates assessment tools that could transform how we support patients through the long, challenging TB treatment journey.
The Health Belief Model emerged in the 1950s when U.S. Public Health Service psychologists noticed a puzzling phenomenon: even when free tuberculosis screening was available, many people didn't utilize it 1 4 . The model proposes that our health behaviors are determined by six psychological factors that form our personal "threat assessment" and "cost-benefit analysis" of taking health actions.
How vulnerable do you believe you are to a health threat? A TB patient who doesn't believe they're at risk for complications may not see the point of complete treatment.
How serious do you consider the consequences of the health condition? This includes both medical complications and social impacts 4 .
How effective do you think the recommended action is in reducing the threat? A patient must believe that taking medication regularly will actually improve their health 1 .
What internal or external triggers prompt you to take action? This could be symptoms worsening (internal) or encouragement from healthcare workers (external) 1 .
These six components work together to create a psychological landscape that determines whether a patient will adhere to TB treatment—a process that typically takes six to nine months of consistent medication intake.
| Construct | Definition | Example from TB Context |
|---|---|---|
| Perceived Susceptibility | Belief about chance of getting a condition | Patient's view of their risk of TB complications |
| Perceived Severity | Belief about seriousness of condition | Fear about TB's impact on health and social life |
| Perceived Benefits | Belief in effectiveness of advised action | Confidence that treatment will cure TB |
| Perceived Barriers | Perception of obstacles to taking action | Concerns about side effects, cost, or time |
| Self-Efficacy | Confidence in ability to perform behavior | Belief that one can complete full treatment |
| Cues to Action | Triggers that prompt health action | Symptoms or health worker reminders |
How can we accurately measure these abstract psychological constructs? This is where the science of questionnaire validation becomes crucial. Before any health belief questionnaire can be trusted for clinical use, researchers must demonstrate that it's both valid (measuring what it claims to measure) and reliable (producing consistent results over time) 6 .
In a similar study conducted on prediabetes patients, researchers followed a meticulous process to validate their HBM questionnaire, providing a template for how such work is conducted at health centers like those in Semarang 6 .
The validation process followed a structured, multi-stage approach:
Researchers created item statements for each HBM construct, using a 4-point Likert scale ranging from "strongly disagree" to "strongly agree" 6 . The questionnaire was carefully translated and adapted to the local cultural context.
Ten experts—including nutrition specialists and education experts—evaluated each question for relevance and clarity. They used quantitative measures like the Content Validity Index (CVI) and kappa statistics to eliminate poorly performing items 6 .
Researchers interviewed potential participants to ensure the questions were understandable and meaningful to the target population. Questions that confused respondents were reworded or eliminated 6 .
The final questionnaire was administered to 30 participants with prediabetes, and the internal consistency was measured using Cronbach's alpha coefficient—a statistical measure that indicates how well the items measure the same underlying construct 6 .
| Characteristic | Category | Percentage (%) |
|---|---|---|
| Gender | Female | 80% |
| Education Level | Elementary School | 40% |
| Occupation | Housewife | 73.3% |
| History of Hypertension | Yes | 30% |
| Family History of Diabetes | Yes | 3.3% |
The results from the prediabetes study offer insights into what Semarang researchers might find when validating their TB questionnaire. The analysis showed strong measurement properties: the overall reliability score was α = 0.821, exceeding the minimum acceptable threshold of 0.7 6 .
When examining individual HBM constructs, the Content Validity Index values ranged between 0.77-1.00, and kappa statistics values ranged from -5.24 to 0.99, indicating good to excellent validity 6 . These statistical measures provide confidence that the questionnaire accurately measures the intended psychological constructs.
In TB research, these validated questionnaires can reveal crucial relationships between health beliefs and treatment behaviors. A study in East Lombok found that perceived barriers significantly reduced medication adherence—patients who perceived high barriers were 31.6% less likely to adhere to treatment 5 . Conversely, those with high self-efficacy were much more likely to complete their treatment successfully.
| HBM Construct | Number of Items | Reliability Coefficient | Validity Index Range |
|---|---|---|---|
| Perceived Susceptibility | Not specified | 0.78-0.88 | 0.77-1.00 |
| Perceived Severity | Not specified | 0.78-0.88 | 0.77-1.00 |
| Perceived Benefits | Not specified | 0.78-0.88 | 0.77-1.00 |
| Perceived Barriers | Not specified | 0.78-0.88 | 0.77-1.00 |
| Self-Efficacy | Not specified | 0.78-0.88 | 0.77-1.00 |
| Cues to Action | Not specified | 0.78-0.88 | 0.77-1.00 |
| Overall Questionnaire | 47 | 0.821 | 0.77-1.00 |
Conducting rigorous health belief research requires specific methodological tools and statistical approaches. The "research reagent solutions" in this field aren't chemical compounds but rather validated instruments and analytical techniques.
The core instrument typically includes 4-10 items per construct measured on a Likert scale. The version used in prediabetes research contained 47 items total 6 .
A statistical measure that quantifies how well items represent the construct being measured, with scores above 0.78 considered acceptable 6 .
A measure that accounts for chance agreement between experts when evaluating questionnaire items, with values above 0.74 considered excellent 6 .
The most common measure of internal consistency reliability, with values above 0.7 considered acceptable and above 0.8 considered good 6 .
A qualitative method where researchers ask potential participants to "think aloud" while answering questions, helping identify confusing wording or concepts 7 .
A statistical technique used to determine how well HBM constructs predict health behaviors like treatment adherence 5 .
These methodological tools transform abstract psychological concepts into measurable, quantifiable data that can guide healthcare interventions.
The work being done at Kedungmundu and Tlogosari Wetan Community Health Centers represents a crucial intersection of psychology and infectious disease management. By validating HBM questionnaires specifically for TB patients in Semarang, researchers are creating culturally relevant tools that can identify patients at risk of non-adherence before they drop out of treatment.
The implications are significant: TB remains a major public health challenge in Indonesia, which has one of the highest TB burdens globally 5 7 . The rise of drug-resistant TB strains makes treatment adherence even more critical—when patients don't complete their full course of medication, they risk developing strains that are much more difficult and expensive to treat 9 .
Healthcare providers can use validated HBM assessments to identify which psychological factors are hindering individual patients' adherence. A patient with high perceived barriers might need practical support like transportation vouchers or management of medication side effects.
A patient with low self-efficacy might benefit from counseling and connecting with other TB survivors who have successfully completed treatment. This personalized approach addresses the specific belief barriers each patient faces.
"The HBM has been adapted to fit diverse medical and cultural contexts influencing public health through health promotion and preventive community-based programs" 1 .
This research also highlights the dynamic nature of the Health Belief Model itself. The work in Semarang contributes to this ongoing adaptation, ensuring that psychological assessment tools remain relevant across different communities and health challenges.
The meticulous process of validating questionnaires—ensuring they're both valid and reliable—may seem like abstract scientific work, but it has very human consequences. It represents our growing understanding that healing requires more than just medication; it requires addressing the beliefs, perceptions, and barriers that determine whether patients will complete their journey to health.