When new diseases emerge, the typical reaction is panic, fear, and uncertainty. The Health Belief Model (HBM) is a major cognitive framework used by public health institutions to predict people’s likelihood of engaging or not engaging in health behaviors. Zombie narratives such as The Last of Us, The Walking Dead, Train to Busan, and Rec demonstrate the flaws in using Rosenstock’s (1966) Health Belief Model (HBM) as a foundation for public health policy.

The HBM, a cognitive theory meant to explain and predict why people choose or choose not to engage in health behaviors, lists four main factors that influence a person's likelihood of engaging in health behaviors: susceptibility (a person’s perceived likelihood of contracting the disease), severity (the level of danger or damage a person perceives an illness to cause), barriers (perceived obstacles to engaging in a health behavior), and benefits (perceived rewards to engaging in the behavior). The model also includes "cues to action," overt indicators that prompt a person to engage in a health behavior.

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Analyzing Zombie narratives exposes three main flaws with using the HBM as a guide to determine public health policy when novel diseases emerge. First, times of crisis cause social upheaval that leads to social roles and groups changing, adding a layer of unpredictability and lessening civil authority. Second, the lack of knowledge about the new disease makes creates difficulty in combatting the disease's spread and leaves people unable to make informed assumptions about susceptibility and severity. Finally, while a few actions can be taken to prevent the spread of disease, no action can cure the disease, which is contrary to the model’s assumption that people have options.

When a crisis occurs, tensions rise both between individuals and among the groups to which they belong. Scarcity of resources—whether real or perceived—creates a zero-sum mindset in which people view others’ gains as their losses¹. This zero-sum mindset is not typically true in public health scenarios, as medical providers are typically prepared to deal with infection surges such as with the flu season; however, when outbreaks do occur, a shift occurs where resources can be overwhelmed and spread too thin, forcing those with access to make choices about who will receive them². The HBM does not account for this shift from individualized disease prevention to competition over resources. In zombie narratives, while the disease itself plays a central role in the plot, conflict between individuals and groups often takes the focus. In The Walking Dead, when the group of survivors led by Rick Grimes encounters the community led by The Governor, the conflict between Rick’s group and The Governor’s enforcement of rules takes precedent over any thoughts of infection prevention.

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Similar to the conflict in The Walking Dead, the conflict in The Last of Us, between FEDRA (the new civil authority) and the Fireflies (a rebel group), often overshadows the larger issue of fungus-sprouting zombies roaming the land. In Kansas City, rebels overthrow the government, which has the capability to combat the spread of disease, in favor of the rebel's having control over resources and influence over the population³. During the COVID-19 pandemic, intense political polarization turned violent when a group of right-wing extremists invaded the Capitol building on January 6. During that period of panic and turmoil, as guards attempted to suppress the group, few were concerned about social distancing or proper wearing of masks. Here, both zombie media and real-world events reflect how “the model is predicated on the premise that ‘health’ is a highly valued concern or goal...and also that ‘cues to action’ are widely prevalent; where these conditions are not satisfied, the model is not likely to be useful”⁴. In crisis situations, conflict often overtakes health as a priority, making the HBM a poor predictor of health behavior under these conditions.

In addition to the shifting roles of private citizens and groups, the role of government also shifts during a crisis. The United States relies on several federal organizations to manage public health and safety: the Centers for Disease Control and Prevention (CDC), Federal Emergency Management Agency (FEMA), and the Department of Homeland Security (DHS). Public order is essential to any plan to combat disease, especially concerning the strict measures taken in zombie apocalypse scenarios and during the COVID-19 pandemic. The HBM assumes cues to action are prevalent⁵ and have some authority backing them, but in crisis, authority shifts. Extreme situations, especially those which the government appears to be mishandling, call into question “assumptions about the role of the government and the place of the governed”.⁶ Authoritarian-leaning measures such as quarantine depend on societal compliance⁷ , which the HBM is not equipped to address. In Rec, several figures of authority, including both civic and medical figures, convene in an apartment building to address an incident which turns out to be a zombie-like infection. The police attempt to exert control over the tenants and news crew present in the building, but the infection ultimately runs rampant due to a lack of compliance and inability to provide cues to action ⁸ . When everyone is scattered and doing side quests, there is no way for health protocols to be delivered and thus factored into decisions.

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Alongside a lack of clear social roles and authority, the lack of knowledge about novel diseases contributes to the failure of the HBM. While organizations such as the CDC and World Health Organization (WHO) have generalized plans and vast resources available to both healthcare workers and private citizens, those aren’t always effective in managing novel diseases⁹.Though these plans may be helpful in reminding people to engage in basic hygiene and safety precautions, they do not slow or prevent the spread. Added to the inefficacy of the plans and resources, pinning down a disease is nearly impossible, as the disease reservoir must be at least partially known for authorities to recommend action against it¹⁰ . When no or little knowledge on the disease exists, it is nearly impossible to construct ideas of susceptibility and severity and, subsequently, to act upon them. In The Last of Us, the cordyceps infection was originally spread, allegedly, by grain products containing spores¹¹. Joel and his family narrowly avoid consuming these and avoid being infected; however, that was luck or happenstance, and not a conscious choice resulting from perceived susceptibility.

In Train to Busan, the infection enters a train from a single person who is travelling from Seoul to Busan, spreading rapidly and violently across the passengers¹². While passengers near the woman may have chosen to sit farther away to avoid a perceived illness, all the passengers could not make a choice based on metrics of susceptibility to a zombie disease whether to use public transport or not. In Rec, the infection initially presents in a dog with rabies-like symptoms, as well as in the dog’s owner as bronchitis-like symptoms. No research or information is available to the building's residents to determine that they are, in fact, now susceptible to the disease. When people are unable to gauge their susceptibility to and the severity of a disease, the HBM cannot be enacted to predict behavior. Furthermore, in meta-analyses of the HBM’s efficacy of predicting health behaviors, retrospective studies showed larger effect sizes than prospective studies¹³. The model is suited for explaining previous health behavior choices, not for predicting future choices with a lack of key information, as in the case of novel disease outbreaks.

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A lack of knowledge coupled with a lack of resources in novel disease scenarios leads to limited preventative options and no curative options. In The Walking Dead amputation of a bitten limb serves as a sort-of cure, yet amputation still falls under the category of prevention, merely stopping the infection from spreading rather than reversing it. Nearly every zombie apocalypse narrative has the same simple option for disease prevention: don’t get bitten, which is easier said than done. The trope of characters being bitten by zombies while struggling to fend off the undead has been so overused the trope risks becomning a cliche of dramatic reveals. To avoid being bitten by a zombie, one must not only be aware of the zombies' presence, which is unlikely during initial stages of disease spread, but also be able to avoid their jaws and/or neutralize them. With the demands of avoiding being bitten and obtaining weapons for defense combines with the need to scavenge for necessities, an impossible demand is placed upon survivors, leading to unpredictable choices. During the COVID-19 lockdown, the world was not scrounging abandoned stores for canned beans, but there was a choice that many had to face regarding their ability to survive concerning their employment. Those who were deemed essential healthcare workers had to decide between following general lockdown orders and following employers’ orders. For example, workers who are socially and often contractually expected to tend to sick patients,¹⁴ were forced to work extreme hours with a lack of support regarding supplies and personnel. While they may not have been avoiding the rotting jaws of a shambling corpse, they were avoiding the jaws of unemployment, poverty, and potential lawsuits over negligence¹⁵. Outside of healthcare, other workers deemed essential were expected to show up and work, regardless of guidelines and personal risk. For these workers, taking preventative actions included staying home from work, which is not an option for those who live paycheck to paycheck. The ability to consider and possibly take preventative actions requires a “political economy that permits people to stay at home without starving”¹⁶. In an unprecedented crisis, this political econopmy takes time to establish, if it is ever established at all.

Even if there is an available preventative of a disease, people may not consider that prevention as an option. Zombie narratives often present ethical dilemmas around killing infected humans. In The Walking Dead, Herschel keeps several zombies in a barn, including his zombie-wife, and refuses to kill them, as killing them is against his beliefs, and his hope for a cure. Rick and the other survivors are enraged by this, as the presence of the zombies on the farm poses a major risk of infection should any of the zombies escape. On the opposite end of the individual-group needs spectrum, in Train to Busan, the main character, Seok-Woo, throws himself off the train to ensure he does not infect his daughter and the only other survivor who have barricade themselves in the conductor car for the final leg of the ride. Both characters, Herschel and Seok-Woo, make decisions about illness spread which impact others, and Herschel’s is perceived as selfish while Seok-Woo’s is undoubtably selfless. These decisions reflect the real-world variance in how people prioritize their values versus public health guidelines and preventative measures available. Choices to get vaccinated, wear masks, stay home, or participate in contact tracing efforts (or do the opposites of these) are based on individual perceptions of how these actions align with their ethical code. Zombie outbreaks, like all diseases, are charged with implications, and often those in the scenarios are hesitant to take actions that would prevent disease spread.

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The HBM falls short of predicting behavior and thus providing a guide for public health institutions during the emergence of new diseases. HBM assumes a state of stable social roles and hierarchies, a level of knowledge about the disease, and a basic ability and willingness to prioritize health. HBM also makes assumptions about how the individual acts within the environment, discounting how objective reality may influence behavior over individual perceptions¹⁷. HBM also relies on an idea of “readiness” to prompt behavior, but that readiness does not exist, p[erhaps, cannot exist, when novel diseases such as the COVID-19 virus or a zombie plague emerge¹⁸ . The HBM has usefulness in explaining behaviors that have already occurred, and possibly in making predictions and plans for established diseases, but not for planning in novel or constantly evolving disease outbreaks. Instead of attempting to predict the unpredictable, public health institutions should focus on establishing trust, preparing officials at all levels of government to respond to crisis, and ensuring all individuals are able to follow any guidelines released in case of an outbreak.

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Endnotes

1. ^{[Return to Article]} Van Bavel, Jay J. et al. “Using Social and Behavioral Science to Support COVID-19 Pandemic Response.” Nature Human Behavior, vol. 4, 2020, p. 465.
2. ^{[Return to Article]} Ibid.
3. ^{[Return to Article]} Mazin, Craig and Neil Druckmann, creators. The Last of Us. The Mighty Mint, Word Games, PlayStation Productions, Naughty Dog, and Sony Pictures, 2023.: Season 1, Episode 4
4. ^{[Return to Article]} Janz, Nancy K. and Becker, Marshall H. “The Health Belief Model: A Decade Later.” Health Education Quarterly, vol. 11, no. 1, 1984, p. 44. Sage Journals.
5. ^{[Return to Article]} Ibid.
6. ^{[Return to Article]} Murphy, Patrick D. “Lessons from the Zombie Apocalypse in Global Popular Culture: An Environmental Discourse Approach to the Walking Dead.” Environmental Communication, vol. 12, no. 1, 2018, p. 46. Taylor & Francis Online.
7. ^{[Return to Article]} Greer, Scott L. et al. “The Comparative Politics of COVID-19: The Need to Understand Government Responses.” Global Public Health, vol. 15, no. 9, 2020, pp. 1414. Taylor & Francis Online.
8. ^{[Return to Article]} Rec. Directed by Jaume Balagueró and Paco Plaza, Casteleo, 2007.
9. ^{[Return to Article]} Thompson, Amy L. and Thompson, Antonio S., editors. …But If a Zombie Apocalypse Did Occur: Essays on Medical, Military, Governmental, Ethical, Economic and Other Implications. McFarland & Company Inc., 2015.: 48.
10. ^{[Return to Article]} Ibid, 49.
11. ^{[Return to Article]} The Last of Us, Season 1, Episodes 1-2.
12. ^{[Return to Article]} Train to Busan. Directed by Yeon Sang-ho, Next Entertainment World and RedPeter Film, 2016.
13. ^{[Return to Article]} Carpenter, Christopher J. “A Meta-Analysis of the Effectiveness of Health Belief Model Variables in Predicting Behavior.” Health Communication, vol. 25, no. 8, 2010, p. 663. Taylor & Francis Online.
14. ^{[Return to Article]} Thompson & Thompson, 108.
15. ^{[Return to Article]} Ibid.
16. ^{[Return to Article]} Greer et al., 1414.
17. ^{[Return to Article]} Davidhizar, Ruth. “Critique of the Health-Belief Model.” Journal of Advanced Nursing, vol. 8, no. 6, 1983, p. 467. Wiley Online Library.
18. ^{[Return to Article]} Davidhizar, 471.