Mr. Markman is Head of Mental Health Nursing, Shoenbrun Academic Nursing School, Tel Aviv University, Tel Aviv, and Deputy Head Nurse, Beer Yaakov-Ness Ziona Mental Health Center, Ness Ziona, Dr. Balik is Director, Shoenbrun Academic Nursing School, Tel Aviv University, Tel Aviv, Dr. Braunstein-Bercovitz is Senior Lecturer, School of Behavioral Sciences, Tel Aviv Academic College, Tel Aviv, and Dr. Ehrenfeld is Head and Associate Professor, Department of Nursing, Tel Aviv University, Tel Aviv, Israel.
The authors have no financial or proprietary interest in the materials presented herein.
Address correspondence to Uri Markman, MA, RN, Head of Mental Health Nursing, Shoenbrun Academic Nursing School, Tel Aviv University, Tel Aviv, Israel; e-mail: firstname.lastname@example.org.
Students’ test anxiety appears when they know their performance is under examination or assessment and constitutes a reaction to that stress (Powell, 2004; Tubiana, 2001). Test anxiety is a common phenomenon and reaches its peak in higher levels of education. It can be present not only during the test itself but also throughout the preparatory period as well. A test performance impaired by test anxiety causes deep frustration and despair, and hinders students’ ability to continue with their studies. Test anxiety and other anxiety disorders belong to the spectrum of mental disorders that affect both the quality of life of the individual and the level of functioning in various areas.
Students, who begin their studies on their own initiative, seek to succeed and can naturally feel tension, stress, and anxiety before a test or any other situation that checks their level of performance. Reasonable intensity of anxiety influences and improves the process of examination preparation and performance. However, a high level of anxiety disrupts examination preparation and decreases performance (Zeidner, 1998). On the other hand, test anxiety may be related to a student’s lack of study and organizational skills. Nevertheless, in both cases, personal and professional development can be hindered (Brewer, 2002; Ya’ari, 1998).
Many forms of therapy for this anxiety are now available, ranging from one-off counseling sessions, relaxation exercises, and cognitive-behavioral therapies to psychiatric intervention for the most serious cases. The success rate is high (Sharif & Armitage, 2004; Tubiana, 2001; Ya’ari, 1998), and up to 95% of clients show significant improvement.
Programs for treating test anxiety in Israel are conducted as workshops by institutions of higher learning. However, program operators report that participation is poor. Schaefer, Matthess, Pfitzer, and Kohle (2007) found that no more than 6% of the respondents in their study were willing to enroll in a therapeutic program.
People do not decide to accept or refuse treatment in a vacuum. Individuals need to overcome myriad social, cultural, and personal obstacles before bringing themselves to seek help, particularly because these treatments tend to be associated with some kind of stigma. The decision of whether to seek treatment is based on how well students know the subject matter, their personality, their view of the pros (benefits) and cons (costs) (Ajzen, 2001; Ajzen & Fishbein, 1980), and their health beliefs. Health beliefs, which can be one of the major obstacles to seeking treatment, are subjective views of the world of health and sickness, and consist of affective, cognitive, and behavioral elements (Trandis, 1971), which are inherited from a variety of sources at an early age and are fostered and become ingrained throughout an individual’s life. These behavioral elements are patterns of thinking and knowing, which exert a strong influence on our behavior and attitudes.
As such, these health beliefs have been identified as comprising a key factor in determining the willingness of individuals to seek and adhere with medical care in general, and mental health care in particular. They also partially determine the type of care people will seek. A change in health beliefs can alter attitudes to and adherence with treatment. A better understanding of the factors that shape health beliefs paves the way to taking the appropriate steps to modify these behaviors to improve treatment adherence (Adams & Scott, 2000; Balush-Kleinman et al., 2002; Budd, Hughes, & Smith, 1996).
This study was designed to investigate to what extent the Health Belief Model (Becker, 1974; Rosenstock, 1974; Rosenstock, Strecher, & Becker, 1988) can serve to explain the willingness or reluctance to seek treatment for anxiety associated with taking tests. The rationale behind this model is that the individual’s decision of whether to act or to avoid any action is affected by the subjective value and remuneration provided by that action (Becker, 1974). The model determines the probability of an individual’s choosing to act on a recommended health activity based on his or her perception of personal vulnerability and the extent of threat posed by a given condition (Becker, 1974; Rosenstock, 1974). This Health Belief Model also aims to explain an individual’s adherence with the treatment regimen and the subsequent behavioral changes. The model is based on five components:
- Extent to which the illness is believed to be threatening (i.e., the perception of potential damage and the gravity of the current situation, such as anxiety at the prospect of failing examinations).
- Perceived benefit of change to the sufferer (e.g., passing examinations).
- Motivation and desire to be healthy.
- Obstacles to treatment (e.g., accessibility and associated stigma).
- Perceived effectiveness of available treatments.
In the context of mental health, a number of studies have shown that health beliefs can be a significant factor in affecting the level of adherence. Patients who perceive their state of health to be poor and their risk of falling ill to be high tend to trust that the treatment is effective and put more effort into getting well. The result is that their adherence to treatment will also be higher. Adherence is one of the more important factors of treatment success and remains one of the leading challenges to health care providers (Simpson et al., 2006). Adherence is an active, responsible, and flexible process that focuses on a patient and the alliance between the patient and the caregiver (Balush-Kleinman et al., 2002; Osterberg & Blaschke, 2005).
Willingness and consent to participate in all treatment programs constitute a necessary condition to the achievement of full success of the procedure. Therefore, we assume that the components of the Health Belief Model will predict nursing students’ willingness to seek treatment for anxiety related to taking tests. To evaluate this assumption, students’ health beliefs and their willingness and consent to seek treatment were assessed. Willingness was investigated indirectly by identifying students’ attitudes about seeking treatment in general and directly by students’ willingness or refusal to join a treatment group.
The study hypothesis was that nursing students’ attitudes to seeking treatment for test anxiety would be influenced by the five elements of health belief. Students’ health beliefs and their willingness to apply for treatment were measured. The latter was assessed directly by inviting students to enroll in a treatment program and indirectly by evaluating students’ attitudes toward applying for treatment.
Sample and Research Process
Sampling was completed in two stages.
Stage One. Having received permission from the ethics committee of a university in central Israel and its affiliations, we asked a sample of nursing students at these institutions to complete a questionnaire on test anxiety. This was completed during the examination period when the issue was most relevant.
The research questionnaires were not part of any examinations at any stage, and the participants did not have any type of teacher-student relationships during the research. Students were invited to volunteer, and no reward of any kind was offered. At this stage, of the 246 students who completed the questionnaire, 87 (35.3%) scored > 86, placing them in the top quartile of the score for test anxiety (range = 86 to 112, mean = 92.9, SD = 6.07).
Stage Two. The 87 students who scored high on test anxiety in stage one were divided according to gender, 69 (79%) women and 18 (21%) men. Their ages ranged from 21 to 33 (mean age = 24 ± 2.47). These students were told that the aim of the study was to investigate attitudes and reactions to test anxiety and its treatment, and that they were now invited to participate in stage two because they had scored above the mean on test anxiety. Students were assured that their data would be applied solely for the purposes of this research. They were asked to complete two additional questionnaires: the first questionnaire assessed health beliefs and the second assessed attitudes of seeking treatment for test anxiety and the willingness to adhere with the treatment.
Test Anxiety (Stage One Sample). We used a questionnaire developed by Bandes and Friedman (1997), who reported Cronbach’s alpha coefficient was 0.91. The instrument consisted of 23 statements describing the thoughts and behaviors of adolescents and young adults in Israel with respect to tests and examinations. The instrument is designed to investigate three areas:
- Fear of social condemnation, including statements such as “I fear that if I fail a test, the teachers will look down on me.”
- Disorderly functioning and thinking, with a specimen statement of “I find it hard to organize my thoughts in a test.”
- Excitement and tension, with a specimen statement of “Tests frighten me a lot.”
Respondents were asked to rate how far each statement applied to them on a 6-point Likert scale (1 = not at all and 6 = very much). Total scores ranged from 23 to 138. Cronbach’s alpha coefficient for the instrument on this study was 0.87.
Health Beliefs (Stage Two Sample). The Tabak, Shiaabana, and Shasha (2006) instrument was adapted for this study. It consisted of 28 closed items and was constructed to investigate the five components of the selected Health Belief Model. Section one assessed how high respondents rated their risk of experiencing test anxiety (e.g., “The probability that I will experience test anxiety is higher than for most people.”). Section two assessed to what extent respondents thought test anxiety would spoil their chances of academic success (e.g., “Everyone who has test anxiety fails their tests.”). Section three assessed the perceived effectiveness of treatment for test anxiety (e.g., “The treatment for test anxiety reduces the severity of the problem.”). Section four assessed respondents’ perception of the obstacles to seeking treatment for test anxiety (e.g., “The treatment for test anxiety is long, expensive, and complex.”). Section five assessed motivation for success in taking tests (e.g., “Getting good test results is important to me”).
Respondents were asked to rate all of the statements on a 6-point Likert scale (1 = totally disagree and 6 = totally agree). Cronbach’s alpha coefficient for each section of the instrument and Health Belief Model was as follows: probability of suffering test anxiety, 0.88; the extent to which test anxiety would damage chances of academic success, 0.76; the perceived effectiveness of treatment for test anxiety, 0.89; the perception of obstacles to seeking treatment for test anxiety, 0.90; and the motivation for success in taking tests, 0.89.
Attitudes of Seeking Treatment for Test Anxiety (Stage Two Sample). The Fischer and Turner (1970) instrument was adapted for the needs of this study. The questionnaire addressed two components of attitudes toward seeking professional psychological care: acknowledging the need for professional help (e.g., “If I suffered from test anxiety, I would be sure that psychological treatment would help.” [Cronbach’s alpha coefficient = 0.83]) and confidence in mental health professionals (e.g., “I don’t think that talking to a psychologist about my test anxiety would do any good.” [Cronbach’s alpha coefficient = 0.86]).
Respondents were asked to rate all of the statements on a 6-point Likert scale (1 = totally disagree and 6 = totally agree). Their final score, representing their attitude toward seeking professional help for their test anxiety, was the mean of their 14 scores. The higher the score, the more positive their attitude. The questionnaire concluded with two additional questions for examining the same issue in a more direct manner. The first question asked respondents if they were interested in enrolling in a test anxiety therapy program (yes or no). Those who replied no to that question were asked to explain why they declined the treatment.
The final overall scores for each section of the Health Belief Model were as follows (all scores had a possible high of 6): probability of suffering test anxiety, 3.29 (SD = 0.93); extent to which test anxiety would spoil the chances of academic success, 3.26 (SD = 0.81); perceived effectiveness of treatment for test anxiety, 3.25 (SD = 0.91); perception of obstacles to seeking treatment for test anxiety, 3.25 (SD = 1.2); and motivation for test success, 3.39 (SD = 1.06). The final score on attitudes toward seeking treatment for test anxiety was 3.24 (SD = 0.67). Only 13 (15%) of the 87 respondents expressed a willingness to enroll in a test anxiety therapy program.
The relationship between health beliefs about test anxiety and the willingness to seek professional help were analyzed using Pearson correlation coefficients and linear regression. Attitudes toward seeking professional help were positively correlated to the perceived effectiveness of treatment for test anxiety (r = 0.659, p < 0.01), motivation for test success (r = 0.617, p < 0.01), probability of suffering test anxiety (r = 0.417, p < 0.01), and amount of damage test anxiety would cause (r = 0.349, p < 0.01). These attitudes were negatively correlated to the perception of obstacles to seeking treatment for test anxiety (r = −0.717, p < 0.01). In other words, the more numerous and serious the obstacles were perceived, the more negative was the respondent’s attitude toward seeking professional care.
Multiple linear regression was used to measure the contribution of each of the five components of the Health Belief Model in predicting attitudes to seeking professional help (F[5, 82] = 48.266, p < 0.001). The five components taken together accounted for 74.9% of the variation in attitudes toward seeking professional help. Notably, only two of the components, perceived effectiveness of treatment and perceived obstacles to seeking treatment, in combination explained 72.8% of the total (Table 1).
Table 1: Five Components of the Health Belief Model as Predictors of Attitudes Toward Seeking Professional Help for Test Anxiety (Multiple Linear Regression)
Only 13 (15%) of the 87 respondents expressed their willingness to enroll in a test anxiety therapy program. The reasons for refusal given by the remaining 74 respondents are shown in the Figure. The two major reasons for not enrolling were the location and timing of the meetings and a feeling of unease. For the former, respondents’ comments included “I want to enroll in principle but it is a long way to travel,” and “I work in the evenings.” For the latter, the comments included “Group therapy frightens me,” and “I do not want others to know my problems.”
Figure. Reasons for not Enrolling in Therapy Program (percentage Frequencies).
Logistic regression (enter and stepwise methods) was used to check whether “attitudes toward seeking professional help” functioned as a mediating variable between health beliefs and adherence with treatment for test anxiety. This was confirmed. Two components, the perceived effectiveness of treatment and the perceived obstacles to seeking treatment, directly impacted on adherence (Table 2). Gender and age did not influence attitudes toward seeking treatment for test anxiety.
Table 2: Relationship Between Health Beliefs, Attitudes Toward Seeking Professional Help, and Adherence with Test Anxiety Treatment (Logistic Regression)
The results of this study demonstrated significant correlations between the five components of our Health Belief Model and the participants’ attitudes toward seeking professional help with test anxiety. It should be noted, however, that two of the five components (perceived effectiveness of treatment and perceived obstacles to seeking treatment) in combination accounted for 72.8% of the total and that the “perceived obstacles” alone accounted for 51.4%. Adams and Scott (2000) reported the perceived obstacles and the perceived harm that test anxiety could cause explained 43% of the variations in adherence. As such, a common factor for both their study and our study is the large part played by perceived physical and mental obstacles in deterring individuals from seeking professional help. This finding is reinforced by a second finding of our study, the reasons our respondents gave for refusing to join a therapy program. Indeed, just the physical reasons alone (cost, place, and time) accounted for 57% of the reasons given. Thus, more than half of the reasons given for avoiding participation in the test anxiety treatment program were related to accessibility problems and not to the attitudes and health beliefs toward treatment of test anxiety.
It is important to recognize the real factors that keep students out of a treatment program. One way to determine this is to reduce the physical obstacles to a minimum and note any change in program enrollment rate. Toward that end, we recommended that treatment accessibility be improved by opening counseling units within the confines of the institution, developing academic counseling services that directly address the problem of test anxiety, and decreasing students’ costs for treatment.
Approximately 23% of the respondents who refused to join a therapy program did not cite physical obstacles but rather feelings of unease with the prospect of receiving professional therapy for their test anxiety. The feelings that were cited reflect the usual objections to joining any mental health program. The stigma of mental health therapy discourages many individuals from seeking professional care and reduces adherence significantly (Lowry, 1998; Sheikh & Furnham, 2000). Test anxiety, however, is so ubiquitous and the range of available therapies is so wide that it should not be difficult to mitigate the stigma attached to seeking assistance in this setting.
The issue of the perceived benefit of therapy also needs to be addressed. Perceived benefits are decisive in an individual’s choice of whether to seek care. In the current study, a low perception of benefits accounted for 21.4% of nonadherence (the second strongest predictor after perceived obstacles), and 23% of those who refused the offer to join a therapy program did so because of a lack of confidence in the program itself. These two factors are clearly intertwined: the solution lies in making the high level of effectiveness, the high rates of success of test anxiety therapies, and the practical benefits to clients more widely known to the general public (Herrman, 2001; Tubiana, 2001). Both students and staff should be made aware that test anxiety is common and part of the general academic milieu, and that it can be successfully overcome by validated approaches.
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Five Components of the Health Belief Model as Predictors of Attitudes Toward Seeking Professional Help for Test Anxiety (Multiple Linear Regression)
|Perceived obstacles to seeking treatment||–4.377||–0.561||0.000*||–8.583||0.514|
|Perceived effectiveness of treatment||3.192||0.312||0.001*||3.356||0.728|
|Motivation for test success||1.263||0.143||0.05||1.946||0.739|
|Perceived harm from test anxiety||0.236||0.021||0.818||0.231||0.744|
|Perceived probability of suffering test anxiety||1.267||0.124||0.206||1.276||0.749|
Relationship Between Health Beliefs, Attitudes Toward Seeking Professional Help, and Adherence with Test Anxiety Treatment (Logistic Regression)
|Health Belief Model Components||B||R||p|
|Preliminary model for treatment adherence without attitude toward seeking professional help for test anxiety|
| Perceived effectiveness of treatment||0.2400||0.1565||0.0504**|
| Perceived damage from test anxiety||–0.2514||0.0000||0.1997|
| Motivation for test success||0.0134||0.0000||0.9203|
| Perceived probability of suffering test anxiety||0.2056||0.0628||0.1303|
| Perceived obstacles to seeking treatment||–0.1509||–0.2095||0.0223*|
|Final model for treatment adherence without attitude toward seeking professional help for test anxiety|
| Perceived effectiveness of treatment||0.2793||0.3548||0.0008*|
| Perceived obstacles to seeking treatment||–0.1475||–0.2416||0.0122*|
|Preliminary model for treatment adherence with attitude toward seeking professional help for test anxiety|
| Perceived effectiveness of treatment||0.2374||0.1140||0.0856**|
| Perceived harm from test anxiety||–0.2625||0.0000||0.2264|
| Motivation for test success||–0.0640||0.0000||0.6928|
| Perceived probability of suffering test anxiety||0.1111||0.0000||0.4533|
| Perceived obstacles to seeking treatment||–0.0183||0.0000||0.8432|
| Attitude toward seeking professional help for test anxiety||0.1996||0.1094||0.0838**|
|Final model for treatment adherence with attitude toward seeking professional help for test anxiety|
| Perceived effectiveness of treatment||0.1811||0.1358||0.0671**|
| Attitude toward seeking professional help for test anxiety||0.2011||0.2970||0.0036*|