J Behav Med (2016) 39:935946

DOI 10.1007/s10865-016-9782-2

The Common-Sense Model of Self-Regulation (CSM): a dynamic

framework for understanding illness self-management
Howard Leventhal1 L. Alison Phillips2 Edith Burns3

Received: May 9, 2016 / Accepted: August 2, 2016 / Published online: August 11, 2016
 Springer Science+Business Media New York 2016

Abstract The Common-Sense Model of Self-Regulation Keywords Common-Sense Model of Self-Regulation

(the Common-Sense Model, CSM) is a widely used Illness representations
Treatment representations

theoretical framework that explicates the processes by Illness perceptions
which patients become aware of a health threat, navigate
affective responses to the threat, formulate perceptions of
The Common-Sense Model of Self-Regulation (CSM)
the threat and potential treatment actions, create action
provides a conceptual framework for examining the per-
plans for addressing the threat, and integrate continuous
ceptual, behavioral and cognitive processes involved in
feedback on action plan efficacy and threat-progression. A
individuals self-management of ongoing and future health
description of key aspects of the CSMs historyover
threats. The CSM describes a dynamic, multi-level process
50 years of research and theoretical developmentmakes
that generates individuals representations of threats to
clear the models dynamic underpinnings, characteristics,
health, procedures for management, and a system for cre-
and assumptions. The current article provides this historical
ating action-plans and implementing action. The process is
narrative and uses that narrative to highlight dynamic
often initiated by somatic sensations and deviations from
aspects of the model that are often not evaluated or utilized
normal function (e.g., symptoms, falls), as well as by
in contemporary CSM-based research. We provide sug-
observation and discussions of illness in others (including
gestions for research advances that can more fully utilize
medical diagnoses), and on occasion from mass media and
these dynamic aspects of the CSM and have the potential to
other environmental cues. These stimuli activate proto-
further advance the CSMs contribution to medical practice
types, or memory structures of the individuals normal
and patients self-management of illness.
functioning self, past experiences of illnesses, and treat-
ments and lifestyle activities; and they generate mental
representations of illness threats (i.e., beliefs regarding
illness identity, cause, control, consequences, and dura-
& L. Alison Phillips tion/timeline beliefs), possible treatments, and action plans.
alisonp@iastate.edu This article reviews the development of the CSM over
Howard Leventhal several decades, illustrating how its contemporary con-
hleventhal@ifh.rutgers.edu ceptual structure derived from specific lines of empirical
Edith Burns study. It covers both the most widely used concepts of the
eaburns@mcw.edu CSM as well as those that are less often utilized but equally
1
important for understanding and promoting successful self-
Institute for Health and Department of Psychology, Rutgers
management of chronic illnessincluding a discussion of
University, 112 Paterson St, New Brunswick, NJ 08901, USA
2
methods that could be used to better evaluate and translate
Department of Psychology, Iowa State University, Ames, the CSM for patient care. The article is in four sections: (1)
IA 50011, USA
3
Principles Underlying the Common-Sense Model; (2)
Division of Geriatrics, Medical College of Wisconsin, Development of the CSM: Identification of CSM Processes
Milwaukee, WI 53295, USA

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and Concepts; (3) Moving from Behavioral Initiation to
Continued, Controlled Self-Management of Illness; and (4)
The Future of Common-Sense Modeling.
Principles underlying the Common-Sense Model
(CSM)
Beyond prediction: focus on the processes
and mechanisms of self-management
The Common-Sense Model (CSM) provides a framework
for describing and understanding the processes involved in
the initiation and maintenance of behaviors for managing
illness threats. The model was designed to describe
dynamic interactions among the variables controlling
health behaviors in response to future or current health
threats. As the CSM addresses factors underlying behavior,
it provides a framework for predicting adherence to treat-
ments and lifestyle changes for managing health threats.
The CSM is relevant for understanding adherence, there-
fore, to a variety of self-reported and objectively observed
health outcomes, and for creating media and clinician
messages to affect these factors. The CSM is also struc-
tured to describe transitions in behavior, that is, from non-
adherence to adherence and from adherence to non-ad-
herence, though few investigators have addressed the
details of transitional processes. Many empirical studies
testing hypotheses predicting adherence and health out-
comes, have used self-report inventories to assess these
variables (e.g. IPQ-R; Moss-Morris et al., 2002) at single or
multiple time points (see Hagger & Orbell, 2003).
Although predictive analyses are valuable for identifying
moderators of adherence and outcomes and provide insight
into mediational factors and pathways to outcomes, these
approaches do not evaluate the complex interactions
among specific variables in moving toward these outcomes
(e.g., the dynamics of the processes underlying action and
the transitions in these factors over time).
An example of the dynamics that the CSM asks us to
model would be to describe the mechanisms that underlie
well known predictors of self-management, such as self-
efficacy (Bandura, 1982). The CSM asks us to examine,
What were the specific rules that highly self-efficacious
people learned when solving a problem and what did they
do when planning and implementing a specific action to
prevent or treat an illness?; How do highly self-effica-
cious people insure consistent management?; and What
factors prevent non-self- efficacious people from imple-
menting and sustaining specific health actions? This
example also illustrates the complementarity of Social
learning concepts and those of the CSM, one assisting in
identifying successful performers, the other asking ques-
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tions about how they succeed. In summary, although
identifying factors that predict behavior and health out-
comes (e.g., self-efficacy and variables in the Illness Per-
ception Questionnaire) identifies for whom specific
behaviors and health outcomes occur in specific contexts,
the CSM asks us to address the dynamic mechanisms
underlying these predictive relationships. Having both
types of data allows us to identify specific targets for
intervention at the individual, family or community level,
and to generate the conditions for addressing the processes
underlying action, a necessary step for improving health
behaviors and health indicators.
Multi-level concepts
Theoretical concepts in the CSM differ from those in many
other models of health behavior, such as the Health Belief
Model and Theory of Planned Behavior, in that concepts in
the CSM are multi-level. In other models, constructs such as
perceived personal vulnerability and illness severity are
abstract ideas, referenced by self-reports. The CSM instead
focuses on the perceptual and behavioral referents of abstract
concepts and their interactions. For example, the perceived
severity of a condition is more than the overall judgment as to
how bad it is; it involves immediate and projected con-
sequences (e.g., pain disrupting thought and action; potential
impact on the ability to handle critical current and future life
tasks), and its projected time-line and controllability.
Prototypes and representations
Differentiation of prototypes and representations
As the CSM is a dynamic, process-oriented model, it also
distinguishes between prototypes (memory structures) and
representations (the mental models activated at specific
instances in time). The distinction is necessary as the
stimuli activating a representation may match features of
more than one prototype, creating a representation that is
ambiguous. An individuals history of somatic sensations
and physical and cognitive functioning, is embedded in
prototypesof the self (structure and function when heal-
thy and when ill), and in prototypes of illnesses and
treatments. For example, past experiences of the common
cold builds a prototype of the somatic sensations, func-
tional impairments, and required treatments for the com-
mon cold, so that when one gets a new sore throat or stuffy
nose, the common-cold-prototype activates the illness
representation for the common cold. The history for the
self is unique as it is built upon the innate neuro-biological
representation of the normal body and its functions,
which is validated and updated by daily life. By contrast,
experiences of many illnesses and treatments are formed
J Behav Med (2016) 39:935946
episodically, though some acquired chronic conditions
come to pervade daily life. Disabilities, if congenital, early-
onset, or long-term may be part of the normal self-pro-
totype, whereas new or short-term and changing disabilities
(e.g., temporary work injury; cyclical disability, such as
carpal tunnel syndrome) may activate representation for-
mation and treatment action plans. How these various
prototypes interact, i.e., complement and compete in
influencing decision making to promote health and func-
tion, needs exploration. In addition to individuals own
experiences with illness and treatment, prototypes for both
are enriched by observation, social comparison and com-
munications from family, friends, and mass media.
Activation of representations
Deviations from the usual, normative self (e.g., onset of lated biological processes. In other words, the experiential
symptoms or disruption of function), are likely the most
common stimuli that interact with illness prototypes and
activate the representation of a specific threat to health at a
given moment. For example, if one experiences an abrupt
onset of severe chest pain, the properties of the experience
(e.g., its location, time for onset and duration, disruption of
activity), in interaction with ones prototypes of illnesses
and perceived vulnerabilities of self, can create the repre-
sentation of a heart attack, or of severe food poisoning (see
Bunde & Martin, 2006).
Parameters of prototypes and representations
Prototypes and representations of a current/future health
threat can have attributes in five areas. Both can have an (1)
identity, a label or name and perceptions of associated
symptoms/conditions (e.g., cancer, heart disease, flu). Both
have perceived (2) time-line, or perceived and measured
rates of onset, duration and decline; (3) consequences, or
experienced and anticipated physical, cognitive and social
disruption; 4) causes (e.g., environmental toxins as causes
of cancer; stress as a cause of heart attacks); and 5) control
(e.g., self- versus medical provider). The same five sets of
variables define treatment representations, both self-se-
lected and medically prescribed. Thus, the identity of a
treatment involves its name and experiences when used.
The time-lines for expected, experienced benefits are crit-
ical for adherence; a medication that takes longer to act
than expected can be perceived as ineffective, and those
that have unwanted consequences (e.g., symptoms causing
emotional distress), can be problematic for adherence. It is
also clear that common-sense perceptions of the effec-
tiveness for control can affect choice of treatment (e.g.,
surgery may be perceived as better than radiation). Com-
mon-sense perceptions of cause can also impact perceived
effectiveness of a treatment (e.g., the burning sensation of
937
alcohol when applied to a wound may be convincing evi-
dence that it kills germs).
It is important to repeat that inputs for both prototypes and
representations are perceived or processed schematically (e.g.,
pain is felt; cuts and bruises are felt and seen) and labelled, that
is, conceptualized (e.g., as heart attack or stomach upset; that
alcohol kills germs when it burns). Experiences, somatic events
and functional changes, are the concrete referents for concepts
(e.g., the bleeding red area is the cut or abrasion, the lump is the
cancer, the chest pain the heart attack). Effective self-man-
agement of an experienced condition can be undermined when
its representation and associated representation of treatment are
at variance with the biology of the underlying condition. The
criteria used to evaluate treatment (e.g., removal of specific
symptoms) may not be valid indicators of effective control of
the underlying condition. The symptoms may be due to unre-
features of the representation (i.e., its schematic structure) may
or may not be congruent with its propositional (i.e., label)
structure, and neither may be valid representations of an
underlying biomedical threat.
Development of the CSM: identification of CSM
processes and concepts
Neither the principles nor the concepts and processes
defining the CSM came into being at a single, defined
moment. The CSM had different names at different times
and investigators may not recognize that earlier versions
were precursors to later ones. This is particularly true of the
early studies that examined the role of concrete-perception
processes in health behavior, establishing the basic prin-
ciple of multi-level concepts. These studies, which are
described in this section, identified the components of the
CSM and determined that the components of the CSM
interact to generate actions to manage current and prevent
future health threats, leading to its fuller development by
identifying general illness prototypes and representations
(e.g. acute vs. chronic) as well as specific prototypes and
representations (e.g., flu; heart attack). They also suggested
the need for studies examining how communication from
care-givers, including medical providers, and creating
action plans can improve adherence and health outcomes.
Importance of concrete-perceptual processes;
the multi-level nature of CSM concepts
Everyday experiences as antecedents to action: early
evidence
A longitudinal study conducted during the 1957 Asian Flu
epidemic was designed to identify predictors of taking flu
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shots. It was one of the first studies to examine the relative
importance of beliefs and everyday experience as ante-
cedents to action. Interviews, based on the Health Belief
Model, were designed to assess participants beliefs in their
personal vulnerability to flu and beliefs about its severity.
The goal was to predict two different outcomestaking an
inoculation and talking to a health professional. The Health
Belief Model was modified however, in an important way;
the interview assessed whether participants concrete
experiences (e.g., symptoms and/or observations of flu in
family members) were critical for action (Rosenstock et al.,
1960). The data showed that beliefs in vulnerability to flu
and its severity were related to the presence of illness in the
family and/or the experience of symptoms (Leventhal
et al., 1960). Beliefs in vulnerability to flu and its severity
were dependent upon exposure to illness, but so too was
action. For example, over half of the respondents reported
calling a physician when someone was ill; nearly half
consulted a pharmacist. Beliefs and action were dependent
upon experienceaction more so.
Preparing patients for stressful procedures in clinic:
sensory information and action plans
Collaborators from medicine and nursing played a critical
role in initiating a second set of studies examining the
effects of preparing patients about to undergo potentially
noxious clinical procedures, and similar studies conducted
in laboratory settings with university studentss. The results
expanded upon earlier Asian Flu Study findings in three
ways: (1) they reinforced the role of concrete experience
(i.e., somatic sensations) as a critical driver of behavior; (2)
they validated the importance of action plans or coping
procedures as separate, critical antecedents to action; and
(3) they clarified conditions in which representations and
coping were inter-dependent versus independent.
In a clinical study assessing observed distress and heart
rate for patients undergoing endoscopy (Johnson et al.,
1973), patients randomized to a prepared arm were normalize what was happening. Further studies revealed
given detailed descriptions of what they would experience
when swallowing a fiber optic endoscopic tube (e.g., gag-
ging and feeling as though they had overeaten when the
stomach was inflated). In addition, half of the prepared
patients also received an action plan describing how to
respond to facilitate swallowing during the insertion (e.g.,
make swallowing motions). Patients randomized to the
control condition were given an equal quantity of infor-
mation, but it focused on the environment (e.g., a detailed
description of the room in which the procedure was to take
place) but no details about what they would experience.
The results were clear; heart rates were stable for the
patients who were prepared and accelerated for those in the
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control condition; each type of information, sensory
preparation and coping action, had independent effects. An
unexpected feature of the data was the time to introduce the
endoscope into the stomach; those who were prepared took
twice as long a time to swallow the endoscope than did
patients in the control condition (43 vs. 28 s). Tube swal-
lowing by prepared patients was under their control, and
like most new, volitional actions was slower than an
automatic action or one controlled by a practitioner.
Unfortunately, we did not question patients regarding their
recall of the preparation; several, however, remarked at the
post procedure interview that they did not recall being told
anything the night before, reinforcing the idea that action
plans can be activated automatically.
A laboratory study with student participants confirmed
the importance of preparing the perceptual system by
establishing expectations for somatic sensations: partici-
pants were exposed to a cold pressor test (a hand immersed
in ice water at 32 degrees F) and reported on the strength of
sensations and their emotional distress; skin temperatures
were also recorded (Leventhal et al., 1979). Participants
randomized to the prepared arm were given detailed
descriptions of the sensations they would experience (e.g.,
extreme cold followed by pins and needles) and the
changes they would see in skin color. These participants
reported less stress over time and their skin temperature
rebounded while their hands were still immersed. Partici-
pants randomized to the unprepared arm reported higher
levels of stress and their hand temperatures remained low
until their hands were withdrawn minutes later.
The findings of these early studies have been replicated
in numerous studies ranging from preparing children for
the noise, vibration, and flying powder during the removal
of a cast to a number of other laboratory and clinical
studies (e.g., Johnson & Leventhal, 1974). In each of these
studies, the preparatory information, the abstract words
(i.e., propositional input) referred to, and matched later
experience, allowing the individuals to make sense of and
moderating factors, however. For example, those high in
behavioral (self) control were more likely to show benefit
and lower levels of distress during clinical procedures
(Kanfer & Seider, 1973; Staub et al., 1971). These studies
reinforced two conclusions: few if any preparatory proce-
dures would work equally well for everyone, and prepa-
ration focused on sensory experience per se may fail to
prepare for and match participants embellishment of the
eventthat is, their automatic emotional reactions to
painful stimuli (Thompson, 1981). The moderating findings
make clear that much is to be learned regarding individu-
als automatic versus deliberative responses during stress-
ful laboratory and clinical experiences, and how their
J Behav Med (2016) 39:935946
responses would enhance and/or undermine the benefits of
preparation (see Rutter, 2013, for contemporary review of
resilience in clinical procedures).
Identifying the parameters of specific prototypes
and representations
Studies examining predictors of preventive and self-treat-
ment responses in everyday life examined responses to a
variety of conditions ranging from acute maladies leading
to care seeking, and chronic conditions such as cardio-
vascular disease, diabetes, and asthma. Examining
responses to acute as well as a range of chronic conditions
is particularly relevant to the current research landscape, in
which many if not the majority of chronically ill elderly
patients are managing multiple chronic conditions after
years of experiencing acute illnesses (Wolff et al., 2002).
There are numerous opportunities therefore, for misrepre-
senting and mismanaging chronic conditions as though
they are acute (e.g., treating heart failure as a heart attack).
Confusion and mismanagement of chronic illness are
products of the processes involved in the activation of ill-
ness representations, a process that often begins with
experiencing a deviation from the prototype or norm of the
self. The deviation matches one or more illness prototypes
that, in turn, generate both targets for action (e.g., pain or
dysfunction in need of treatment) and treatment prototypes
that match (i.e., has properties that are coherent with) the
perceived illness (e.g., gastric distress triggers a prototypes
for antacids). If the initial treatment fails to ameliorate the
targets in an anticipated time frame, or the pain increases in
severity, the changing representation will activate a second
tier of treatment options (e.g., severe and uncontrollable
deviations may lead to seeking professional care). Most
everyday experiences are consistent with the pattern for
acute, self-manageable conditions. The sequence of reac-
tions to perceiving an acute health threat was discovered in
a series of studies that validated the acute model, and then
demonstrated how this model acts as the default model
that guides expectations or targets for self-management
that are invalid for chronic conditions.
Acute model: response to short-term health threats
There is an abundance of evidence that deviations from the
normal self, that is, symptoms and other physical and
cognitive dysfunctions, motivate care seeking (Stoller
et al., 1994). Whether a deviation leads to care seeking
depends, however, on its properties in one or more of the
five areas of its representation, discussed above (e.g., per-
ceived severity and cause, quick onset or long duration,
lack of response to self-treatment, degree of disruption
caused). The impact of these variables on seeking medical
939
care was documented in a year-long study comparing
individuals who sought medical care with matched controls
who had not. The care-seekers (n = 111) were interviewed
at a clinic visit, and their responses were compared to the
responses of control, non-care seekers (n = 111); the non-
seekers were matched to the care seekers on gender, age,
and family size. All care seekers reported symptoms, in
comparison to only 33 of the matched controls; symptoms
were clearly an antecedent to care seeking (Cameron et al.,
1993). Further comparisons of the 111 care seekers to the
33 symptomatic, non-care seeking controls, showed dif-
ferences in the time-lines (care seekers symptoms had
been present for approximately 10 days, controls less than
6) and identity (care seekers were more likely than the 33
symptomatic control participants to label their symptoms;
68 % of care seekers vs. 46 % of controls). The 33 control
patients also regarded their symptoms as less disruptive
(1.39 vs. 3.27 out of 5) and were far less likely to be
advised to seek care after communicating to someone (9 vs.
50 % for the care seekers). There is little reason to doubt
that symptom onset is critical for care seeking when onset
is amplified by duration and social input. The parameters of
a general acute illness model (symptoms vanish in a brief
time, and not disruptive of daily life) underlies the
Cameron et al. data (1993). These parameters define many
patients expectations and influence care seeking across
multiple acute and chronic conditions.
Chronic model: potentially life-long health threats
As many chronic conditions are completely or partially
asymptomatic, treatment adherence and life style changes
for management require a different framework for goal
setting in comparison to the short term management con-
sistent with the acute model. The acute model leads
patients to expect symptoms and a short time-line, which
are inconsistent with the asymptomatic progression and
life-long framework of chronic health threats such as
hypertension, asthma, congestive heart failure and diabetes.
These are four of the five most prevalent conditions (de-
pression the 5th) that drive health care spending in the
United States (Halvorson, 2007). The discrepancies
between the acute representation and the demands of a
biologically chronic condition seem to be the major culprits
for deficits in self-management (i.e., treatment non-adher-
ence). Patients will not take drugs unless they perceive a
need to do so, particularly when asymptomatic (DiMatteo
et al., 2002; Haynes et al., 2008).
Hypertension Our early study of patients with hyperten-
sion, an asymptomatic condition, examined the content and
operation of the representation of the disorder among 165
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patients (Meyer et al., 1985). Fifty patients had been in care
for hypertension for many years and virtually all (80 %)
agreed with the statement that, People cant tell whether
their blood pressure is up. However, they reported that I
can tell when my own blood pressure is up (92 %). This
percentage of long-term treated patients was higher than
the percentage of those newly diagnosed (73 % of 65) and
of those patients attending these same clinics who were not
hypertensive (48 % of 50) that endorsed an acute model of
hypertension. The continually treated patients reported a
commonsense array of blood pressure symptoms (e.g.,
headache; dizziness; warm face) and the 70 % of these
patients, who adhered to treatment, believed the treatment
moderated their blood pressure symptoms, which is a
medically inaccurate belief. Inaccurate though they may
be, the treatment and illness targets perceived by the
patients were coherent; they made sense and encouraged
adherence. Adherence was also related to better blood
pressure control. It is interesting to consider why coherence
(i.e., a match between perceived markers of illness and
treatment actions) generated adherence in this instance, but
does not in asthma.
Asthma The Acute model is also at work for many
patients with asthmaa condition for which the underlying
inflammatory process is largely asymptomatic, punctuated
by highly symptomatic attacks. Asthma is therefore a
condition that mimics acute disorders but has an underlying
chronic framework. Like their hypertensive counterparts,
92 % of 198 patients with asthma believed that they would
always have asthma (definitely, probably, or possibly), but
53 % believed that they had it only when symptomatic
that they did not have asthma when they were not experi-
encing symptoms (Halm et al., 2006). In short, the disease
is there for a lifetime, but not all of the time. Patients
holding to an acute model (i.e., having asthma only when
symptomatic) are less likely to use a peak flow meter or to
make and keep routine visits for asthma (see Kaptein et al.,
2008). Actionusing medication when asymptomaticis
not coherent with the acute framework that anchors the
representation of illness threats!
Myocardial infarction (MI) and heart failure The widely
held common-sense prototype for heart attacks, or
myocardial infarction (MI), includes chest and/or shoulder
pain and profuse sweating. The symptoms are recognized
as cardiac-related by both laypersons and practitioners.
While these classic symptoms are the most common, a
significant number of individuals with MI will present with
atypical symptoms (Grosmaitre et al., 2013). If pain is
perceived to be in the upper abdomen rather than chest, it
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can be interpreted as gastric distress and not a heart
problem. Bunde and Martin (2006) have shown that such
common-sense views of symptoms affect the behavior of
individuals experiencing an MI; those who delay least in
getting to hospital have a prior cardiac history, report
experiencing chest pain, profuse sweating, and shoulder
pain. Care-seeking is delayed if pain is perceived as gastric,
and for individuals reporting fatigue and sleep distur-
bances. Common-sense misidentification of symptoms also
occurs for patients with heart failure. Breathlessness,
chronic fatigue and swollen feet are signs of heart failure
for a physician, but likely interpreted as signs of aging by
an elderly person with heart failure; after all, ones heart
is not in ones feet. Patients articulate these mispercep-
tions: When you hear about having heart problems
youre supposed to feel maybe a pain in your left arm,
maybe a pain in your chest, or pressureIt would have
been clearer to me if I had chest pain and then I would have
said, okay, Ill call and say Im having chest pain.
(Horowitz et al., 2004). Patients fail to act when the
somatic pattern fails to map onto the prototype pattern of
symptoms for heart disease. If it is nothing more than the
usual acute event (e.g., a stomach ache, fatigue), even a
dramatic event will fail to elicit care seeking. As one
patient with heart failure said, I guess that I could have
gone to the doctor after I had that collapse on the hallway
floor. It might have been a good idea.
Failure to respond or delay in responding is common,
therefore, across an array of chronic conditions, and in each
case the default, acute model, sets the stage for treatment
choices, action plans, and outcome expectations that are
coherent with the acute model. The parameters of the acute
model generate expectations of common-sense simplicity;
illnesses are symptomatic, time limited, controllable,
caused by everyday known events, with limited conse-
quences. For hypertension, the expectations focus on
somatic cues generated by the patients common sense
perception (e.g. headache, fatigue) but which are usually
unrelated to the condition. For asthma, rescue inhalers are
coherent with and used to manage the acute onset of
attacks; chronic inflammation with its less distinctive cues
is untreated. The somatic and functional changes of heart
failure are misattributed and serious episodes of failure are
unattended to till far too late in time. Action requires
coherence between illness and treatment representations
and experiences.
Treatments: prototypes and representations
Many representations and their behavioral outputs are
highly automatic and elicited without thought (Henderson
et al., 2007). The consistent association of specific treat-
ments with specific conditions, often observed when a
J Behav Med (2016) 39:935946
home remedy has been used for the same symptomatic
event over repeated occasions, is evidence for the forma-
tion of coherent packages and automatic, habitual respon-
ses that may be relatively thoughtless. An individual may
engage in intensive, conscious deliberation if a deviation is
extremely ambiguous, encourages social communication,
or is highly threatening. A treatment can be misinterpreted
as controlling a health threat when it is effective in con-
trolling symptoms that are misperceived as related to but
are actually unrelated to an underlying medical condition.
For example, avoiding stressful situations may reduce
stress symptoms that are perceived incorrectly, as indica-
tors of hypertension (Meyer et al., 1985). The relationship
of social factors to the formation of prototypes of diseases
and specific treatment procedures is an area open for study.
Beliefs about medications is one of the few treatment-
representations that have been studied systematically. Horne
and colleagues (2013) developed scales to assess patients
beliefs about medications (Horne et al., 1999). Two are
specific to the medications patients are using (regarding the
necessity of the medication for ones health; and regarding
concerns about the medication, such as side effects), and one
regards general concerns about medications, including doc-
tors over-prescribing and patients over-use of medications.
A meta-analysis of 94 publications showed that the Specific
Necessity Beliefs measure was positively and consistently
related to adherence, and Specific Concerns scores were
consistently and negatively related to adherence. The con-
sistent and moderate size of the relationship of these scales to
reported adherence is evidence of the importance of treatment
representations for adherence and supports the value of
addressing both treatment and illness prototypes in clinical
settings. Designing and testing communications to increase
adherence in randomized clinical trials will require addressing
both illness and treatment representations and their coherence
(i.e., whether the treatment meets common sense criteria with
regard to prior experiences and/or expectations).
Communicating action plans and planning for self-
management
An Action Plan defines a specific response (e.g., take your
anti-hypertension medications), a place for performing the
response (e.g., in the morning with your orange juice, tea or
coffee), and a set of expectations as to the outcome of the
response. The response package is linked to a particular
condition and/or set of symptoms. In other words, an action
plan can be activated in response to the abstract features of
a condition: hypertension (identity) can lead to a stroke
(consequences) and needs to be controlled by medication
(control). The plan can also be activated by the schematic
or experiential level of the condition: noticeable heart beats
and headaches (symptom/Identity) indicate risk of stroke
941
(abstract identity) and medication reduces symptoms
(schematic/perceived consequence), thereby avoiding a
stroke (abstract concepts of consequences and control).
Multiple examples of the communication process exist in
experimental and clinical settings. Understanding the
planning process (i.e., how individuals generate plans) is
critical for developing clinical trials to increase the initia-
tion and maintenance of treatment and translate these
processes for clinical use.
Fear arousing messages and action plans
Action plans were introduced into the CSM framework in
the 1960s, in a series of experimental studies examining the
persuasive effects of fear arousing messages (Leventhal,
1970). These studies examined the relationship of action to
antecedent factors, such as attitudes and intentions
expressed after exposure to a fear message (e.g., regarding
the consequences of having tetanus). In perhaps the most
important of these studies, participants were exposed either
to a high or a low threat message describing the conse-
quences of tetanus, with half of the participants exposed to
each message receiving a detailed plan for implementing
action (Leventhal et al., 1965). Taking an inoculation
required exposure both to one of the two threat messages,
weak or strong, and an action plan; neither threat messages
nor an action plan led to action when presented alone.
Although the strong threat message aroused more negative
emotional responses, more favorable attitudes and stronger
intentions to be inoculated, the proportion of respondents
seeking inoculation was virtually identical for both strong
and milder threat messages when either was accompanied
by a concrete, action plan. Two components of the action
plan were presumed critical: the participants, university
students living in campus housing, were provided a map of
the campus highlighting the location of the health clinic,
and given examples of class changes that led past the
clinic. The students were next instructed to review their
own class changes in order to identify similar transitions
past the clinic. They were given clear examples of the
required response and asked to identify a highly available
cue (class change passing the clinic) to initiate responding.
It is worth noting that getting a tetanus inoculation occur-
red in both the days and weeks following exposure to the
messages, well after the fear and positive attitudes had
evaporated (Leventhal, 1970). As the level of fear was
irrelevant, it appeared that the representation of the threat,
not the momentary affective component, was critical for
action when combined with the plan (Leventhal, 1970;
Tannenbaum et al., 2015). As the plans were provided in
large part by the investigators, the data raised a second
question; How do people generate action plans on their
own?
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A key difference between the tetanus inoculation study
and the findings of the endoscopy study described earlier is
worth noting. Each of the independent variables in the
endoscopy study (sensory information and coping instruc-
tions) had independent effects in the absence of the other.
By comparison, in the tetanus study, each produced an
effect only when combined with the other. The difference
reflects the contexts: the endoscopic examination itself
activated the representation of the context, the sensations
of tube insertion were present and activated coping; sen-
sory information and coping instructions had independent
effects. In the fear communication study, the representation
of the threat and the plan for coping were in the partici-
pants mind, not in the clinical context. As a conse-
quence, the representation of a threat and action plan were
interdependent.
Clarifying illness and treatment prototypes and initiating
action-planning
Can clinicians encourage and improve effective self-man-
agement of chronic conditions by clarifying the nature and
treatment of the presenting problem; that is, by clarifying
illness and treatment representations and action-plans?
Although descriptive studies may lack the elegance of the
randomized trial, they can provide important clues
respecting the content of clinical communications and
patients perceptions of a clinicians style that do or do not
encourage treatment adherence. Phillips and colleagues
(Phillips et al., 2012) initiated a longitudinal study exam-
ining these factors by asking clinic patients a day after a
clinic visit to complete a questionnaire that assessed the
psychosocial (My doctor understood my feelings about
this problem), and/or the common-sense nature of the
visit (The doctor told me how to monitor my problem to
see if the treatment is working). When patients were
called a month later and asked about their treatment
adherence, the problems resolution, and subsequent visits
to the emergency room (ER), those who gave the visit high
scores on the common-sense items were more adherent,
had better problem resolution, and were less likely to go to
the ER. In contrast, patients who praised their practitioners
psychosocial skills were more likely a month later to report
high levels of satisfaction with the visit, but satisfaction
was unrelated to adherence and negatively related to
problem resolution. Further, all 18 visits to the ER were
associated with higher scores on the psychosocial items.
The study illustrates the importance of going beyond
general instruction for treatment; practitioners who spelled
out the details of when and how to do a treatment, and what
to expect during and after doing it, were effective com-
municators. How one defines a problem sets the stage for
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J Behav Med (2016) 39:935946
action and evaluation of treatment efficacy (Omer et al.,
2013).
Clarifying self-prototypes in clinical settings
Can communications delivered in clinical settings help
patients re-define the self-prototype and improve treatment
outcomes? How patients perceive and label themselves has
observable effects on measures taken in clinical practice.
For example, patients may be labelled as hypertensive
when their blood pressure is elevated during a clinic visit,
though they may be normotensive with ambulatory moni-
toring in their everyday environments. Defining the self as
hypertensive based only on the office measures, illustrates
what practitioners call white coat hypertension (Spruill
et al., 2007).
The effects of self-perceptions and labels (such as those
seen with hypertensive patients) are visible in a range of
settings, including that for new mothers immediately post-
partum. Howell and colleagues conducted two randomized
clinical trials to reduce reporting of depressive symptoms
post-partum (Howell et al., 2012, 2014). In the first trial, a
total of 495 African-American and Hispanic patients, all
new mothers, were randomized into treatment and control
(enhanced usual care) conditions and interviewed at
3 weeks, and 3 and 6 months following delivery of the
newborn. The primary question was whether an interven-
tion clarifying expectations regarding the postpartum self
would reduce negative experiences and reporting of
depressive symptoms. The intervention used simple
graphical representations to describe the typical state of a
new mothers body postpartum (thus bypassing possible
deficits in literacy and numeracy) and provided simple
instructions and clear expectations for self-care. The
intervention was successful in altering how new mothers
saw themselves post-partum and reduced depressive
symptoms by roughly 40 % at all three time points.
The second trial, conducted with Anglo and Asian
mothers, identified a critical necessity in designing a clin-
ical trial, which is ongoing assessment of the targeted
outcome, independent of the trial itself. In the case of this
second trial, there was no ongoing assessment of the base
rate of postpartum depressive symptoms. As the CSM is
Bayesian (i.e., study results are interpreted in light of prior,
sample-specific probabilities), it asks investigators to
secure a valid estimate of the population parameter targeted
in the trial; that is, to measure the percent of new mothers
meeting or exceeding criteria for depressive symptoms in
the months and days before initiating a trial and during the
trial itself. Had this measure been in place, it would have
pre-empted the subsequent, second trial, as the percentage
of Caucasian and Asian mothers reporting depressive
J Behav Med (2016) 39:935946
symptoms above tonic baseline, was far too low a target for
the intervention (only 6 % of the mothers in the control
group exceeded criterion for depressive symptoms). The
intervention failed, as there was essentially nothing on
which to intervene. The 6 % frequency was 20 % lower
than expected based on prior longitudinal studies con-
ducted in the same hospital with similar participants.
It is important to repeat that the post-partum trial was
based on the assumption that postpartum expectations are
based on a normative, pre-pregnancy prototype of the self.
As norms are averages of ongoing life experiences, they are
historically remote in time and likely to represent a more
robust and functional self than the immediate, pre-pregnant
self. The expectations generated by these prototypes are
likely, therefore, to set unrealistic targets for self-evalua-
tions of recovery. This is true for many conditions, such as
rehabilitation following sports injury (Podlog et al., 2014).
Though prototypes can and do change, it is likely that
prototypes of illnesses and treatments are typically far
more malleable than the prototype of the self, since they
are based on sporadic, less-frequent experiences. There-
fore, issues that arise due to problematic illness prototypes
(e.g., expectations of a chronic illness fitting an acute
model) may be more easily changed than issues that arise
due to problematic self-prototypes (e.g., the prototype of
self as fully functional, which is difficult to budge when a
new self-image is needed, as in the postpartum period or
after severe limitation of functioning, e.g., from stroke).
Moving from behavioral initiation to continued,
controlled self-management of illness
Telling patients when, where and how to respondgiving
them an action planis effective in providing strategies for
action, but it is not the same as assisting them with acquiring
the skills for planning on their own, or for building automatic
management routines. In addition, though many patients
know how to initiate action, such as filling a prescription and
taking a prescribed medication, many fail to generalize their
initial performance into lifelong habits. CSM researchers have
begun to examine the settings patients have discovered for
habitual performance and to describe the ways in which they
went about trying and rejecting different tactics for habit
formation. A lesson that is already quite clear is that the habit
concept encompasses a variety of factors; there are different
habitual routines and different procedures for their formation
(Brooks et al., 2015).
Routinized adherence
How do consistent, automatic behaviors emerge from ini-
tial performance for patients with chronic conditions?
943
Phillips et al. (2013) found that patients with hypertension
who had been prescribed a medication for multiple years
were most adherent when they reported having a habit or
routine for taking their medication; if medication use was
associated with consistently experienced, environmental
cues, taking medication was habitual and the patient was
highly adherent (not just to the day, but to a specific time of
day). Factors such as treatment-related beliefs, presence or
absence of barriers to adherence, and experiences that the
treatment worked as expected were not the essential
ingredients. Bolman et al. (2011) found that patients habit
strength for taking their prophylactic asthma medication
predicted adherence, but also found that patients medica-
tion-beliefs explained variance in adherence.
The importance of routines for long term, i.e., habitual,
adherence was revealed again in a recent study of 306 low
income patients with asthma; 68 % were African American
and Hispanic, and all were over 60 years of age (Brooks
et al., 2015). The proportion of adherent patients in the
sample was low; only 38.6 % of the 306 participants
reported strict adherence to daily medication. A small sub-
set of participants, 16 % of the sample, who combined
medication use with existent habit patterns were 3.7 times
more likely to be highly adherent than patients who did not
integrate taking medication with existent, daily, routines.
An example of such a routine was . putting the inhaler
in the bathroom and using it when I get up in the morning;
67 % of patients using this strategy were highly adherent.
Although initiating and converting adherence into sys-
tematic habit is more common among educated, financially
well off patients, any patient using these strategies is highly
adherent regardless of their position on moderating factors.
The strategies work! The question is, how did they plan and
incorporate these strategies into their daily routines?
Creating routines: patients with diabetes
Patients who are expert at self-management of one or
more chronic conditions can provide insight not only to the
strategies used for long term adherence, but to the strate-
gies they used to discover and create automatic manage-
ment routines. Unlike many qualitative studies that recruit
patients struggling with adherence, Tanenbaum and col-
leagues (2015) recruited patients with diabetes who had
achieved excellent control. The participants read a series of
scenarios describing patients having problems adhering to
diabetes medication and/or life styles, and after each sce-
nario, they were asked what they would recommend to the
patient in trouble, and how they handled similar problems
in their own lives. These expert patients described an
array of strategies for generating routines that combined
monitoring daily behavioral patterns and identifying those
patterns that provided slots, or locations/times for
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introducing and sustaining new behaviors for effective self- Next critical research steps involve uncovering the
management. Participants strongly agreed that one needed concepts and processes involved in the development of
to recognize the threat (e.g., diabetes can be life threaten- coherent illness and treatment representations and self-
ing), but to then put it aside. One needs to focus on action management habits and habit-sets (e.g., using self-moni-
and find start points; You just cannot be a bystander in toring of blood glucose to determine appropriate action
this disease; You change your food in the super market, from known set of efficacious actions). We need to identify
not when you sit down to eat! They urged adopting a and assess the variables and dynamic process involved in
gradual approach to change, take one day at a time, and the initial transitions from discovering symptoms and
allowing the body time to adjust (e.g., to a new exercise labeling oneself as ill, to the intermediate term for seeking
routine). They emphasized the need to experiment and care and initiating treatment, to the transition from initia-
monitor blood glucose levels to detect safe and risky foods: tion to habitual performance of behaviors that is locked
tested a lot at first. Trying to test out my food. When into daily behavioral patterns. In the language that might be
confused, they sought and recommended seeking assis- used by a psychologically trained member of one of our
tance (e.g., called nurse to discuss readings). Finally, focus groups: My asthma is under control because my
they created consistent habitual sequences and transitioned inhaler prevents attacks, and because I keep it in the
from new and novel sequences to routine performance bathroom. When I get up in the morning I always go to the
(e.g., testing became second nature, like tying my shoes; bathroom and its there! So I use it. In short, the system is
an AM routine: wash face, brush teeth, test blood). fully integrated and representations are coherent; the pro-
The responses by these participants suggest that con- totypes for treatment are those for the illness, the action
sistent management is the outcome of planning processes plan assures habitual performance. The development and
and making use of identifiable strategies for organizing and integration of life style changes may be more complex. For
creating routines. The strategies included identifying start example, encouraging patients with heart failure to begin
points for initiating behavior change (e.g., change food in walking routines requires more planning (e.g., at which
the super-market, not when eating), trying and monitoring places, when) and effort than taking medication. Beyond
the performance and outcomes of specific actions to see if planning, assisting patients with heart failure requires
they met expectations, and making use of professional and integration of the concept that heart failure symptoms
lay resources. By monitoring, testing and continually represent the risk of the illness and the response of a
updating the baseline levels of symptoms and behaviors, system in need of strengthening. It also requires developing
the system becomes coherent and automatic. The organi- a metric for observing and convincing oneself of
zational process is initiated and sustained by the implicit improvement.
awareness that one is managing a life-long threat that is Understanding and predicting behavior change in the
potentially disabling and lethal. short- and long-term requires more than infrequently asses-
sed, static measures of illness and treatment representations
and experimenter- or practitioner-provided action plans.
The future of common-sense modelling Survey measures of the CSM could be captured longitudi-
nally, but at an intensive frequency, for evaluating intra-
The development of the CSM reflects an ongoing interplay individual variation/change in CSM constructs (Dunton &
between data and theoretical concepts. Representing the Atienza, 2009). Beyond survey measures, for example,
mechanisms and processes underlying self-management of ecological momentary event sampling and technology could
anticipated and current health threats requires a substantial be used to better capture CSM constructs in context, at
degree of complexity; this complexity ranges from ele- important transitions and between transitions for individuals,
ments active at specific moments in time (e.g., represen- from before or directly after diagnosis to longer-term control
tations of self, illness, treatments, action plans), to their of a condition, or from treatment initiation to maintenance
histories or prototypes, and to strategies for action, (Heron & Smith, 2010; Riley et al., 2011). Examining tran-
changing action, and maintenance. Additional complexity sitional dynamics may require advanced techniques includ-
arises from the multi-level nature of the conceptsthat is, ing computer simulations describing how different factors or
the concrete, perceptual, and behavioral referents for the inputs (e.g., symptoms, clinicians diagnosis, experiences
abstract concepts or labels. Conceptual frameworks post adherence) alter subsequent factors, such as perceived
focused on verbalized concepts or beliefs (e.g., the HBM), causes, control, and consequencesproviding a picture of
are wedded to designs and analyses that test hypotheses the ongoing, updating process that leads to new, measurable
using belief scales with abstract statements rather than outcomes.
descriptions of what I see and do. Many studies using Experimental designs can also advance CSM theory and
the CSM share this approach to design and analysis. use. Others have begun to use implicit methods for

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experimentally evaluating nonconscious influences on
prototype activation (e.g., Henderson et al., 2007). This
research could evaluate if and how these implicit associa-
tions change with experience of chronic illness, among
other dynamic CSM aspects. Although action planning can
be studied descriptively, it naturally lends itself to inter-
ventions in which participants are presented with sugges-
tions for monitoring ones environment and behavioral
patterns, and targets and time-lines for observing treatment
outcomes. Howell et al. (2012) is an example; by activating
an alternative view of the postpartum self, a view that is
understandable but not necessarily in a new mothers
memory bank, the intervention altered new mothers views
of their current status and reduced reported experience of
depressive symptoms. Reluctance of investigators to shift
to experiments may reflect a pattern common to the history
of science: complex causal models may be less good at
predicting outcomes than are descriptive approaches; it is
easier to predict sunrise and sunset from a table of past
history than from a dynamic model of the solar system.
Lastly, interventions can be designed to give patients the
experiential feedback, the concrete experiences, required to
understand the abstract concepts of their chronic conditions
and to better self-manage. For example, Levine et al.
(2016) recently tested an intervention that taught patients
with diabetes to use blood-glucose meters to monitor the
effect of their behaviors (dietary, activity, medication) on
their blood sugar; intervention participants had significant
improvements in their HbA1c. In sum, the CSM explicates
processes from perceptions through action, to appraisal of
outcomes, and to routinization and re-evaluation of
behavior as the body changesand needs methods that
allow these processes to be studied and translated for
patient care.
Compliance with ethical standards
Conflict of interest Howard Leventhal, L. Alison Phillips and Edith
Burns declare that they do not have any conflict of interest.
Human and animal rights and Informed consent This article does
not contain any studies with human participants or animals performed
by any of the authors.
References
Bandura, A. (1982). Self-efficacy mechanism in human agency.
American Psychologist, 37, 122147.
Bolman, C., Arwert, T. G., & Vollink, T. (2011). Adherence to
prophylactic asthma medication: Habit strength and cognitions.
Heart and Lung, 40, 6375.
Brooks, T. L., Leventhal, H., Wolf, M. S., OConor, R., Morillo, J.,
Martynenko, M., et al. (2015). Strategies used by older adults
with asthma for adherence to inhaled corticosteroids. Journal of
General Internal Medicine. doi:10.1007/s11606-014-2940-8
945
Bunde, J., & Martin, R. (2006). Depression and prehospital delay in
the context of myocardial infarction. Psychosomatic Medicine,
68, 5157.
Cameron, L., Leventhal, E. A., & Leventhal, H. (1993). Seeking
medical care in response to symptoms and life stress. Psycho-
somatic Medicine, 57, 3747.
DiMatteo, R., Giordani, P. J., Lepper, H. S., & Croghan, T. W.
(2002). Patient adherence and medical treatment outcomes: A
meta-analysis. Medical Care, 40, 794811.
Dunton, G. F., & Atienza, A. A. (2009). The need for time-intensive
information in healthful eating and physical activity research: A
timely topic. JADA, 109, 3035. doi:10.1016/j.jada.2008.10.019
Grosmaitre, P., Le Vavasseur, O., Yachouh, E., Courtial, Y., Jacob,
X., Meyran, S., et al. (2013). Significance of atypical symptoms
for the diagnosis and management of myocardial infarction in
elderly patients admitted to emergency departments. Archives of
Cardiovascular Diseases, 106, 586592.
Hagger, M. S., & Orbell, S. (2003). A meta-analytic review of the
Common-Sense Model of Illness Representations. Psychology &
Health, 18, 141184. doi:10.1080/088704403100081321
Halm, E. A., Mora, P., & Leventhal, H. (2006). No symptoms, no
asthma: The acute episodic disease belief is associated with poor
self-management among inner city adults with persistent asthma.
Chest, 129, 573580.
Halvorson, G. (2007). Health care reform now! San Francisco, CA:
Jossey-Bass Publishing.
Haynes, R. B., Ackloo, E., Sahota, N., McDonald, H. P., & Yao, X.
(2008). Interventions for enhancing medication adherence.
Cochrane Database of Systematic Reviews. doi:10.1002/
14651858.CD000011.pub3
Henderson, C., Hagger, M., & Orbell, S. (2007). Does priming a
specific illness schema result in an attentional information-
processing bias for specific illnesses? Health Psychology, 26,
165173.
Heron, K. E., & Smyth, J. M. (2010). Ecological momentary
interventions: Incorporating mobile technology into psychoso-
cial and health behavior treatments. British Journal of Health
Psychology, 15, 139.
Horne, R., Chapman, S. C. E., Parham, R., Freemantle, N., Forbes, A.,
et al. (2013). Understanding patients adherence-related beliefs
about medicines prescribed for long-term conditions: A meta-
analytic review of the necessity-concerns framework. PLoS One,
8, e80633.
Horne, R., Weinman, J., & Hankins, M. (1999). The Beliefs about
Medicines Questionnaire: The development and evaluation of a
new method for assessing the cognitive representation of
medication. Psychology & Health, 14, 124.
Horowitz, C. R., Rein, S. B., & Leventhal, H. (2004). A story of
maladies, misconceptions and mishaps: Effective management
of heart failure. Social Science and Medicine, 58, 631643.
Howell, E. A., Balbierz, A., Wang, J., Parides, M., Zlotnick, C., &
Leventhal, H. (2012). Reducing postpartum depressive symp-
toms among Black and Latina mothers: A randomized controlled
trial. Obstetrics and Gynecology, 119, 942949. doi:10.1097/
AOG.0b013e318250ba48
Howell, E. A., Bodnar-Deren, S., Balbierz, A., Loudon, H., Mora, P.
A., Zlotnick, C., et al. (2014). An intervention to reduce
postpartum depressive symptoms: A randomized controlled trial.
Archives of Womens Mental Health, 17, 5763.
Johnson, J. E., & Leventhal, H. (1974). Effects of accurate
expectations and behavioral instructions on reactions during a
noxious medical examination. Journal of Personality and Social
Psychology, 29, 710718.
Johnson, J. F., Morrissey, J. F., & Leventhal, H. (1973). Psychological
preparation for an endoscopic examination. Gastrointestinal
Endoscopy, 19, 180182.
123
946
Kanfer, F., & Seider, M. L. (1973). Self-control: Factors enhancing
tolerance of noxious stimuli. Journal of Personality and Social
Psychology, 25, 381.
Kaptein, A. A., Hughes, B. M., Scharloo, M., Fischer, J. J., Snoel, L.,
Weinman, J., et al. (2008). Illness perceptions about asthma are
determinants of outcome. Journal of Asthma, 45, 459464.
doi:10.1080/02770900802040043
Leventhal, H. (1970). Findings and theory in the study of fear
communication. Advances in Experimental and Social Psychol-
ogy, 5, 119186.
Leventhal, H., Brown, D., Shacham, S., & Engquist, G. (1979).
Effects of preparatory information about sensations, threat of
pain, and attention on cold pressor distress. Journal of Person-
ality and Social Psychology, 37, 688714.
Leventhal, H., Hochbaum, G. M., & Rosenstock, I. M. (1960).
Epidemic impact of the general population. In The impact of
Asian influenza on community life: A study of five cities. United
States Department of Health, Pub. No. 706, Washington, DC.
Leventhal, H., Singer, R., & Jones, S. (1965). Effects of fear and
specificity of recommendation upon attitudes and behavior.
Journal of Personality and Social Psychology, 2, 2029.
Levine, J. C., Burns, E., Whittle, J., Fleming, R., Knudson, P., Flax,
S., et al. (2016). Randomize trial of technology-assisted self-
monitoring of blood glucose by low-income seniors: Improved
glycemic control in Type 2 diabetes mellitus. Journal of
Behavioral Medicine. doi:10.1007/s10865-016-9763-5
Meyer, D., Leventhal, H., & Gutmann, M. (1985). Common-sense
models of illness: The example of hypertension. Health
Psychology, 4, 115135.
Moss-Morris, R., Weinman, J., Petrie, K. J., Horne, R., Cameron, L.
D., & Buick, D. (2002). The Revised Illness Perception
Questionnaire (IPQ-R). Psychology & Health, 17, 116.
Omer, Z. B., Hwang, E. S., Esserman, L. J., Howe, R., & Ozanne, E.
M. (2013). Impact of ductal carcinoma in situ terminology on
patient treatment preferences. JAMA Internal Medicine, 173,
18301831.
Phillips, L. A., Leventhal, H., & Leventhal, E. A. (2012). Physicians
communication of the Common-Sense Self-Regulation Model
results in greater reported adherence than physicians use of
interpersonal-skills. British Journal of Health Psychology, 17,
244257.
Phillips, L. A., Leventhal, H., & Leventhal, E. A. (2013). Assessing
theoretical predictors of long-term medication adherence:
123
J Behav Med (2016) 39:935946
Patients treatment-related beliefs, experiential feedback, and
habit development. Psychology and Health, 28, 11351151.
doi:10.1080/08870446.2013.793798
Podlog, L., Heil, J., & Schulte, S. (2014). Psychosocial factors in
sports injury: Rehabilitation and return to play. Physical
Medicine and Rehabilitation Clinics of North America, 25,
915930.
Riley, W., Rivera, D., Atienza, A., Nilsen, W., Allison, S., &
Mermelstein, R. (2011). Health behavior models in the age of
mobile interventions: Are our theories up to the task? TBM, 1,
5371.
Rosenstock, I. M., Hochbaum, G. M., & Leventhal, H. (1960). The
impact of Asian influenza on community life: A study in five
cities. (DHEW Publication No. 766). Washington, DC.
Rutter, M. (2013). Annual research review: Resilienceclinical
implications. The Journal of Child Psychology and Psychiatry,
54, 474487. doi:10.1111/j.1469-7610.2012.02615.x
Spruill, T. M., Pickering, T. G., Schwartz, J. E., Mostofsky, E.,
Ogedegbe, G., Clemow, L., et al. (2007). The impact of
perceived hypertension status on anxiety and the white coat
effect. Annals of Behavioral Medicine, 34, 19.
Staub, E., Tursky, B., & Schwartz, G. E. (1971). Self-control and
predictability: Their effects on reactions to aversive stimulation.
Journal of Personality and Social Psychology, 18, 157162.
Stoller, E. P., Pollow, R., & Forster, L. E. (1994). Older peoples
recommendations for treating symptoms: Repertoires of lay
knowledge about disease. Medical Care, 32, 847862.
Tanenbaum, M. L., Leventhal, H., Breland, J. Y., Yu, J., Walker, E.
A., & Gonzalez, J. S. (2015). Successful self-management
among non-insulin-treated adults with Type 2 diabetes: A self-
regulation perspective. Diabetes Medicine, 32, 15041512.
doi:10.1111/dme.12745.
Tannenbaum, M. B., Hepler, J., Zimmerman, R., Saul, L., & Jacobs,
S. (2015). Appealing to fear: A meta-analysis of fear appeal
effectiveness and theories. Psychological Bulletin, 141(6),
11781204.
Thompson, S. C. (1981). Will it hurt less if I can control it? A
complex answer to a simple question. Psychological Bulletin, 90,
89101.
Wolff, J. L., Starfield, B., & Anderson, G. (2002). Prevalence,
expenditures, and complications of multiple chronic conditions
in the elderly. Archives of Internal Medicine, 162, 22692276.