How Perceived Severity and Mistrust Add to the Cost of Care: Through the Lens of Health Belief Model

I had come across the Health Belief Model¹ while reading a paper a few years ago, but the true reality of how the model plays out in real-world settings became clearer to me much later, during my field visit to Ludhiana as part of a time and motion study. While shadowing the field staff during a patient interaction, I observed that trust is at the heart of any health intervention. Trust affects how patient receives advice on severity of disease and how he approaches care. This ultimately shapes how healthcare interactions pan out and how much time, money, and effort are spent even before the start of actual care.

A middle-aged woman from a colony in Ludhiana had been diagnosed with TB, and we were following up with her on the use of a monitoring technology. The patient was guarded from the start and kept saying, “We can manage on our own, don’t worry.” The field staff wanted to educate her about tuberculosis, its treatment and the use of adherence technology, but she was uncomfortable with the interaction and kept brushing our concerns off.

The recognition that she registered our presence as interference and not an intervention dawned on me when, despite her obvious ill-health, she said, “It’s just some cough and fever. What’s the big deal? I can tackle this myself.” On the surface, it was just an attempt to end the conversation quickly, but it was clear that she did not fully know the potential seriousness of untreated tuberculosis. Evidence suggests that delayed care seeking among TB patients thwarts its effective management.²

Through the lens of the Health Belief Model, her response modelled low perceived severity, where she thought TB was easily manageable and not as dreadful as we were making it sound. This reminded me of the cases of lower perceived severity of COVID-19 among people despite the scale of the pandemic and its consequences.¹

As I turned to fetch my diary, I noticed her daughter standing next to a pillar in the veranda close by. She held the phone steady, filming us. What looked like a disproportionate reaction to a harmless conversation, was probably their way of feeling safe during the interaction by keeping a record and making sure nothing was misunderstood later. It was a heartbreaking yet human response, most likely stemming from their past experiences with the health systems. This mistrust becomes a barrier to healthcare. However, this isn’t uncommon among people who have seen the struggles of navigating the overstretched Indian health systems. Having dealt with overcrowded health facilities for years, the patients often feel unheard and unsupported. They learn that questions and conversations may not necessarily lead to help.

Mistrust can also result in delayed care seeking, which, in turn, is one of the several reasons for catastrophic cost¹ for the patients and their families. Even before the start of the actual treatment, patients and their families tend to spend extra on multiple consultations with different providers, drugs, diagnostics and travel. A study shows that delaying treatment increases out-of-pocket expenses, with each week of delay linked to a borderline significant rise in costs incurred {with adjusted odds ratio-OR=1.01 (1.00,1.03), p<0.08}.³

A patient’s resistance to care means more than just a health seeking behaviour; it can become an operational and financial constraint. If a patient does not feel safe with an intervention, every step takes longer, slowing decision-making and increasing the delay in treatment. This, in turn, amounts to extra costs. Thus, trust, low perceived severity, and safety emerge as the hidden variables that decide whether a workflow moves forward or stalls and how cost-effective care feels to a recipient.

*The views expressed in this article are solely the personal opinions and reflections of the author(s) and do not necessarily reflect the objectives of the study they are part of.

References:

1. Alyafei, A., & Easton-Carr, R. (2024, May 19). The Health Belief Model of Behavior Change. Stat Pearls. https://www.statpearls.com/point-of-care/161679  

2. Makgopa, S., & Madiba, S. (2021). Tuberculosis Knowledge and Delayed Health Care Seeking Among New Diagnosed Tuberculosis Patients in Primary Health Facilities in an Urban District, South Africa. Health Services Insights, 14, 117863292110540. https://doi.org/10.1177/11786329211054035   

3. Chatterjee, S., Das, P., Stallworthy, G., Bhambure, G., Munje, R., & Vassall, A. (2024). Catastrophic costs for tuberculosis patients in India: Impact of methodological choices. PLOS global public health, 4(4), e0003078. 10.1371/journal.pgph.0003078