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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
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
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
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

936 J Behav Med (2016) 39:935946

and Concepts; (3) Moving from Behavioral Initiation to tions about how they succeed. In summary, although
Continued, Controlled Self-Management of Illness; and (4) identifying factors that predict behavior and health out-
The Future of Common-Sense Modeling. 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,
Principles underlying the Common-Sense Model the CSM asks us to address the dynamic mechanisms
(CSM) underlying these predictive relationships. Having both
types of data allows us to identify specific targets for
Beyond prediction: focus on the processes intervention at the individual, family or community level,
and mechanisms of self-management and to generate the conditions for addressing the processes
underlying action, a necessary step for improving health
The Common-Sense Model (CSM) provides a framework behaviors and health indicators.
for describing and understanding the processes involved in
the initiation and maintenance of behaviors for managing Multi-level concepts
illness threats. The model was designed to describe
dynamic interactions among the variables controlling Theoretical concepts in the CSM differ from those in many
health behaviors in response to future or current health other models of health behavior, such as the Health Belief
threats. As the CSM addresses factors underlying behavior, Model and Theory of Planned Behavior, in that concepts in
it provides a framework for predicting adherence to treat- the CSM are multi-level. In other models, constructs such as
ments and lifestyle changes for managing health threats. perceived personal vulnerability and illness severity are
The CSM is relevant for understanding adherence, there- abstract ideas, referenced by self-reports. The CSM instead
fore, to a variety of self-reported and objectively observed focuses on the perceptual and behavioral referents of abstract
health outcomes, and for creating media and clinician concepts and their interactions. For example, the perceived
messages to affect these factors. The CSM is also struc- severity of a condition is more than the overall judgment as to
tured to describe transitions in behavior, that is, from non- how bad it is; it involves immediate and projected con-
adherence to adherence and from adherence to non-ad- sequences (e.g., pain disrupting thought and action; potential
herence, though few investigators have addressed the impact on the ability to handle critical current and future life
details of transitional processes. Many empirical studies tasks), and its projected time-line and controllability.
testing hypotheses predicting adherence and health out-
comes, have used self-report inventories to assess these Prototypes and representations
variables (e.g. IPQ-R; Moss-Morris et al., 2002) at single or
multiple time points (see Hagger & Orbell, 2003). Differentiation of prototypes and representations
Although predictive analyses are valuable for identifying
moderators of adherence and outcomes and provide insight As the CSM is a dynamic, process-oriented model, it also
into mediational factors and pathways to outcomes, these distinguishes between prototypes (memory structures) and
approaches do not evaluate the complex interactions representations (the mental models activated at specific
among specific variables in moving toward these outcomes instances in time). The distinction is necessary as the
(e.g., the dynamics of the processes underlying action and stimuli activating a representation may match features of
the transitions in these factors over time). more than one prototype, creating a representation that is
An example of the dynamics that the CSM asks us to ambiguous. An individuals history of somatic sensations
model would be to describe the mechanisms that underlie and physical and cognitive functioning, is embedded in
well known predictors of self-management, such as self- prototypesof the self (structure and function when heal-
efficacy (Bandura, 1982). The CSM asks us to examine, thy and when ill), and in prototypes of illnesses and
What were the specific rules that highly self-efficacious treatments. For example, past experiences of the common
people learned when solving a problem and what did they cold builds a prototype of the somatic sensations, func-
do when planning and implementing a specific action to tional impairments, and required treatments for the com-
prevent or treat an illness?; How do highly self-effica- mon cold, so that when one gets a new sore throat or stuffy
cious people insure consistent management?; and What nose, the common-cold-prototype activates the illness
factors prevent non-self- efficacious people from imple- representation for the common cold. The history for the
menting and sustaining specific health actions? This self is unique as it is built upon the innate neuro-biological
example also illustrates the complementarity of Social representation of the normal body and its functions,
learning concepts and those of the CSM, one assisting in which is validated and updated by daily life. By contrast,
identifying successful performers, the other asking ques- experiences of many illnesses and treatments are formed

J Behav Med (2016) 39:935946 937

episodically, though some acquired chronic conditions alcohol when applied to a wound may be convincing evi-
come to pervade daily life. Disabilities, if congenital, early- dence that it kills germs).
onset, or long-term may be part of the normal self-pro- It is important to repeat that inputs for both prototypes and
totype, whereas new or short-term and changing disabilities representations are perceived or processed schematically (e.g.,
(e.g., temporary work injury; cyclical disability, such as pain is felt; cuts and bruises are felt and seen) and labelled, that
carpal tunnel syndrome) may activate representation for- is, conceptualized (e.g., as heart attack or stomach upset; that
mation and treatment action plans. How these various alcohol kills germs when it burns). Experiences, somatic events
prototypes interact, i.e., complement and compete in and functional changes, are the concrete referents for concepts
influencing decision making to promote health and func- (e.g., the bleeding red area is the cut or abrasion, the lump is the
tion, needs exploration. In addition to individuals own cancer, the chest pain the heart attack). Effective self-man-
experiences with illness and treatment, prototypes for both agement of an experienced condition can be undermined when
are enriched by observation, social comparison and com- its representation and associated representation of treatment are
munications from family, friends, and mass media. at variance with the biology of the underlying condition. The
criteria used to evaluate treatment (e.g., removal of specific
Activation of representations symptoms) may not be valid indicators of effective control of
the underlying condition. The symptoms may be due to unre-
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 features of the representation (i.e., its schematic structure) may
common stimuli that interact with illness prototypes and or may not be congruent with its propositional (i.e., label)
activate the representation of a specific threat to health at a structure, and neither may be valid representations of an
given moment. For example, if one experiences an abrupt underlying biomedical threat.
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 Development of the CSM: identification of CSM
and perceived vulnerabilities of self, can create the repre- processes and concepts
sentation of a heart attack, or of severe food poisoning (see
Bunde & Martin, 2006). Neither the principles nor the concepts and processes
defining the CSM came into being at a single, defined
Parameters of prototypes and representations moment. The CSM had different names at different times
and investigators may not recognize that earlier versions
Prototypes and representations of a current/future health were precursors to later ones. This is particularly true of the
threat can have attributes in five areas. Both can have an (1) early studies that examined the role of concrete-perception
identity, a label or name and perceptions of associated processes in health behavior, establishing the basic prin-
symptoms/conditions (e.g., cancer, heart disease, flu). Both ciple of multi-level concepts. These studies, which are
have perceived (2) time-line, or perceived and measured described in this section, identified the components of the
rates of onset, duration and decline; (3) consequences, or CSM and determined that the components of the CSM
experienced and anticipated physical, cognitive and social interact to generate actions to manage current and prevent
disruption; 4) causes (e.g., environmental toxins as causes future health threats, leading to its fuller development by
of cancer; stress as a cause of heart attacks); and 5) control identifying general illness prototypes and representations
(e.g., self- versus medical provider). The same five sets of (e.g. acute vs. chronic) as well as specific prototypes and
variables define treatment representations, both self-se- representations (e.g., flu; heart attack). They also suggested
lected and medically prescribed. Thus, the identity of a the need for studies examining how communication from
treatment involves its name and experiences when used. care-givers, including medical providers, and creating
The time-lines for expected, experienced benefits are crit- action plans can improve adherence and health outcomes.
ical for adherence; a medication that takes longer to act
than expected can be perceived as ineffective, and those Importance of concrete-perceptual processes;
that have unwanted consequences (e.g., symptoms causing the multi-level nature of CSM concepts
emotional distress), can be problematic for adherence. It is
also clear that common-sense perceptions of the effec- Everyday experiences as antecedents to action: early
tiveness for control can affect choice of treatment (e.g., evidence
surgery may be perceived as better than radiation). Com-
mon-sense perceptions of cause can also impact perceived A longitudinal study conducted during the 1957 Asian Flu
effectiveness of a treatment (e.g., the burning sensation of 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 control condition; each type of information, sensory
importance of beliefs and everyday experience as ante- preparation and coping action, had independent effects. An
cedents to action. Interviews, based on the Health Belief unexpected feature of the data was the time to introduce the
Model, were designed to assess participants beliefs in their endoscope into the stomach; those who were prepared took
personal vulnerability to flu and beliefs about its severity. twice as long a time to swallow the endoscope than did
The goal was to predict two different outcomestaking an patients in the control condition (43 vs. 28 s). Tube swal-
inoculation and talking to a health professional. The Health lowing by prepared patients was under their control, and
Belief Model was modified however, in an important way; like most new, volitional actions was slower than an
the interview assessed whether participants concrete automatic action or one controlled by a practitioner.
experiences (e.g., symptoms and/or observations of flu in Unfortunately, we did not question patients regarding their
family members) were critical for action (Rosenstock et al., recall of the preparation; several, however, remarked at the
1960). The data showed that beliefs in vulnerability to flu post procedure interview that they did not recall being told
and its severity were related to the presence of illness in the anything the night before, reinforcing the idea that action
family and/or the experience of symptoms (Leventhal plans can be activated automatically.
et al., 1960). Beliefs in vulnerability to flu and its severity A laboratory study with student participants confirmed
were dependent upon exposure to illness, but so too was the importance of preparing the perceptual system by
action. For example, over half of the respondents reported establishing expectations for somatic sensations: partici-
calling a physician when someone was ill; nearly half pants were exposed to a cold pressor test (a hand immersed
consulted a pharmacist. Beliefs and action were dependent in ice water at 32 degrees F) and reported on the strength of
upon experienceaction more so. sensations and their emotional distress; skin temperatures
were also recorded (Leventhal et al., 1979). Participants
Preparing patients for stressful procedures in clinic: randomized to the prepared arm were given detailed
sensory information and action plans descriptions of the sensations they would experience (e.g.,
extreme cold followed by pins and needles) and the
Collaborators from medicine and nursing played a critical changes they would see in skin color. These participants
role in initiating a second set of studies examining the reported less stress over time and their skin temperature
effects of preparing patients about to undergo potentially rebounded while their hands were still immersed. Partici-
noxious clinical procedures, and similar studies conducted pants randomized to the unprepared arm reported higher
in laboratory settings with university studentss. The results levels of stress and their hand temperatures remained low
expanded upon earlier Asian Flu Study findings in three until their hands were withdrawn minutes later.
ways: (1) they reinforced the role of concrete experience The findings of these early studies have been replicated
(i.e., somatic sensations) as a critical driver of behavior; (2) in numerous studies ranging from preparing children for
they validated the importance of action plans or coping the noise, vibration, and flying powder during the removal
procedures as separate, critical antecedents to action; and of a cast to a number of other laboratory and clinical
(3) they clarified conditions in which representations and studies (e.g., Johnson & Leventhal, 1974). In each of these
coping were inter-dependent versus independent. studies, the preparatory information, the abstract words
In a clinical study assessing observed distress and heart (i.e., propositional input) referred to, and matched later
rate for patients undergoing endoscopy (Johnson et al., experience, allowing the individuals to make sense of and
1973), patients randomized to a prepared arm were normalize what was happening. Further studies revealed
given detailed descriptions of what they would experience moderating factors, however. For example, those high in
when swallowing a fiber optic endoscopic tube (e.g., gag- behavioral (self) control were more likely to show benefit
ging and feeling as though they had overeaten when the and lower levels of distress during clinical procedures
stomach was inflated). In addition, half of the prepared (Kanfer & Seider, 1973; Staub et al., 1971). These studies
patients also received an action plan describing how to reinforced two conclusions: few if any preparatory proce-
respond to facilitate swallowing during the insertion (e.g., dures would work equally well for everyone, and prepa-
make swallowing motions). Patients randomized to the ration focused on sensory experience per se may fail to
control condition were given an equal quantity of infor- prepare for and match participants embellishment of the
mation, but it focused on the environment (e.g., a detailed eventthat is, their automatic emotional reactions to
description of the room in which the procedure was to take painful stimuli (Thompson, 1981). The moderating findings
place) but no details about what they would experience. make clear that much is to be learned regarding individu-
The results were clear; heart rates were stable for the als automatic versus deliberative responses during stress-
patients who were prepared and accelerated for those in the ful laboratory and clinical experiences, and how their

J Behav Med (2016) 39:935946 939

responses would enhance and/or undermine the benefits of care was documented in a year-long study comparing
preparation (see Rutter, 2013, for contemporary review of individuals who sought medical care with matched controls
resilience in clinical procedures). who had not. The care-seekers (n = 111) were interviewed
at a clinic visit, and their responses were compared to the
Identifying the parameters of specific prototypes responses of control, non-care seekers (n = 111); the non-
and representations seekers were matched to the care seekers on gender, age,
and family size. All care seekers reported symptoms, in
Studies examining predictors of preventive and self-treat- comparison to only 33 of the matched controls; symptoms
ment responses in everyday life examined responses to a were clearly an antecedent to care seeking (Cameron et al.,
variety of conditions ranging from acute maladies leading 1993). Further comparisons of the 111 care seekers to the
to care seeking, and chronic conditions such as cardio- 33 symptomatic, non-care seeking controls, showed dif-
vascular disease, diabetes, and asthma. Examining ferences in the time-lines (care seekers symptoms had
responses to acute as well as a range of chronic conditions been present for approximately 10 days, controls less than
is particularly relevant to the current research landscape, in 6) and identity (care seekers were more likely than the 33
which many if not the majority of chronically ill elderly symptomatic control participants to label their symptoms;
patients are managing multiple chronic conditions after 68 % of care seekers vs. 46 % of controls). The 33 control
years of experiencing acute illnesses (Wolff et al., 2002). patients also regarded their symptoms as less disruptive
There are numerous opportunities therefore, for misrepre- (1.39 vs. 3.27 out of 5) and were far less likely to be
senting and mismanaging chronic conditions as though advised to seek care after communicating to someone (9 vs.
they are acute (e.g., treating heart failure as a heart attack). 50 % for the care seekers). There is little reason to doubt
Confusion and mismanagement of chronic illness are that symptom onset is critical for care seeking when onset
products of the processes involved in the activation of ill- is amplified by duration and social input. The parameters of
ness representations, a process that often begins with a general acute illness model (symptoms vanish in a brief
experiencing a deviation from the prototype or norm of the time, and not disruptive of daily life) underlies the
self. The deviation matches one or more illness prototypes Cameron et al. data (1993). These parameters define many
that, in turn, generate both targets for action (e.g., pain or patients expectations and influence care seeking across
dysfunction in need of treatment) and treatment prototypes multiple acute and chronic conditions.
that match (i.e., has properties that are coherent with) the
perceived illness (e.g., gastric distress triggers a prototypes Chronic model: potentially life-long health threats
for antacids). If the initial treatment fails to ameliorate the
targets in an anticipated time frame, or the pain increases in As many chronic conditions are completely or partially
severity, the changing representation will activate a second asymptomatic, treatment adherence and life style changes
tier of treatment options (e.g., severe and uncontrollable for management require a different framework for goal
deviations may lead to seeking professional care). Most setting in comparison to the short term management con-
everyday experiences are consistent with the pattern for sistent with the acute model. The acute model leads
acute, self-manageable conditions. The sequence of reac- patients to expect symptoms and a short time-line, which
tions to perceiving an acute health threat was discovered in are inconsistent with the asymptomatic progression and
a series of studies that validated the acute model, and then life-long framework of chronic health threats such as
demonstrated how this model acts as the default model hypertension, asthma, congestive heart failure and diabetes.
that guides expectations or targets for self-management These are four of the five most prevalent conditions (de-
that are invalid for chronic conditions. pression the 5th) that drive health care spending in the
United States (Halvorson, 2007). The discrepancies
Acute model: response to short-term health threats between the acute representation and the demands of a
biologically chronic condition seem to be the major culprits
There is an abundance of evidence that deviations from the for deficits in self-management (i.e., treatment non-adher-
normal self, that is, symptoms and other physical and ence). Patients will not take drugs unless they perceive a
cognitive dysfunctions, motivate care seeking (Stoller need to do so, particularly when asymptomatic (DiMatteo
et al., 1994). Whether a deviation leads to care seeking et al., 2002; Haynes et al., 2008).
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, Hypertension Our early study of patients with hyperten-
lack of response to self-treatment, degree of disruption sion, an asymptomatic condition, examined the content and
caused). The impact of these variables on seeking medical operation of the representation of the disorder among 165

940 J Behav Med (2016) 39:935946

patients (Meyer et al., 1985). Fifty patients had been in care can be interpreted as gastric distress and not a heart
for hypertension for many years and virtually all (80 %) problem. Bunde and Martin (2006) have shown that such
agreed with the statement that, People cant tell whether common-sense views of symptoms affect the behavior of
their blood pressure is up. However, they reported that I individuals experiencing an MI; those who delay least in
can tell when my own blood pressure is up (92 %). This getting to hospital have a prior cardiac history, report
percentage of long-term treated patients was higher than experiencing chest pain, profuse sweating, and shoulder
the percentage of those newly diagnosed (73 % of 65) and pain. Care-seeking is delayed if pain is perceived as gastric,
of those patients attending these same clinics who were not and for individuals reporting fatigue and sleep distur-
hypertensive (48 % of 50) that endorsed an acute model of bances. Common-sense misidentification of symptoms also
hypertension. The continually treated patients reported a occurs for patients with heart failure. Breathlessness,
commonsense array of blood pressure symptoms (e.g., chronic fatigue and swollen feet are signs of heart failure
headache; dizziness; warm face) and the 70 % of these for a physician, but likely interpreted as signs of aging by
patients, who adhered to treatment, believed the treatment an elderly person with heart failure; after all, ones heart
moderated their blood pressure symptoms, which is a is not in ones feet. Patients articulate these mispercep-
medically inaccurate belief. Inaccurate though they may tions: When you hear about having heart problems
be, the treatment and illness targets perceived by the youre supposed to feel maybe a pain in your left arm,
patients were coherent; they made sense and encouraged maybe a pain in your chest, or pressureIt would have
adherence. Adherence was also related to better blood been clearer to me if I had chest pain and then I would have
pressure control. It is interesting to consider why coherence said, okay, Ill call and say Im having chest pain.
(i.e., a match between perceived markers of illness and (Horowitz et al., 2004). Patients fail to act when the
treatment actions) generated adherence in this instance, but somatic pattern fails to map onto the prototype pattern of
does not in asthma. 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
Asthma The Acute model is also at work for many patient with heart failure said, I guess that I could have
patients with asthmaa condition for which the underlying gone to the doctor after I had that collapse on the hallway
inflammatory process is largely asymptomatic, punctuated floor. It might have been a good idea.
by highly symptomatic attacks. Asthma is therefore a Failure to respond or delay in responding is common,
condition that mimics acute disorders but has an underlying therefore, across an array of chronic conditions, and in each
chronic framework. Like their hypertensive counterparts, case the default, acute model, sets the stage for treatment
92 % of 198 patients with asthma believed that they would choices, action plans, and outcome expectations that are
always have asthma (definitely, probably, or possibly), but coherent with the acute model. The parameters of the acute
53 % believed that they had it only when symptomatic model generate expectations of common-sense simplicity;
that they did not have asthma when they were not experi- illnesses are symptomatic, time limited, controllable,
encing symptoms (Halm et al., 2006). In short, the disease caused by everyday known events, with limited conse-
is there for a lifetime, but not all of the time. Patients quences. For hypertension, the expectations focus on
holding to an acute model (i.e., having asthma only when somatic cues generated by the patients common sense
symptomatic) are less likely to use a peak flow meter or to perception (e.g. headache, fatigue) but which are usually
make and keep routine visits for asthma (see Kaptein et al., unrelated to the condition. For asthma, rescue inhalers are
2008). Actionusing medication when asymptomaticis coherent with and used to manage the acute onset of
not coherent with the acute framework that anchors the attacks; chronic inflammation with its less distinctive cues
representation of illness threats! 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
Myocardial infarction (MI) and heart failure The widely coherence between illness and treatment representations
held common-sense prototype for heart attacks, or and experiences.
myocardial infarction (MI), includes chest and/or shoulder
pain and profuse sweating. The symptoms are recognized Treatments: prototypes and representations
as cardiac-related by both laypersons and practitioners.
While these classic symptoms are the most common, a Many representations and their behavioral outputs are
significant number of individuals with MI will present with highly automatic and elicited without thought (Henderson
atypical symptoms (Grosmaitre et al., 2013). If pain is et al., 2007). The consistent association of specific treat-
perceived to be in the upper abdomen rather than chest, it ments with specific conditions, often observed when a

J Behav Med (2016) 39:935946 941

home remedy has been used for the same symptomatic (abstract identity) and medication reduces symptoms
event over repeated occasions, is evidence for the forma- (schematic/perceived consequence), thereby avoiding a
tion of coherent packages and automatic, habitual respon- stroke (abstract concepts of consequences and control).
ses that may be relatively thoughtless. An individual may Multiple examples of the communication process exist in
engage in intensive, conscious deliberation if a deviation is experimental and clinical settings. Understanding the
extremely ambiguous, encourages social communication, planning process (i.e., how individuals generate plans) is
or is highly threatening. A treatment can be misinterpreted critical for developing clinical trials to increase the initia-
as controlling a health threat when it is effective in con- tion and maintenance of treatment and translate these
trolling symptoms that are misperceived as related to but processes for clinical use.
are actually unrelated to an underlying medical condition.
For example, avoiding stressful situations may reduce Fear arousing messages and action plans
stress symptoms that are perceived incorrectly, as indica-
tors of hypertension (Meyer et al., 1985). The relationship Action plans were introduced into the CSM framework in
of social factors to the formation of prototypes of diseases the 1960s, in a series of experimental studies examining the
and specific treatment procedures is an area open for study. persuasive effects of fear arousing messages (Leventhal,
Beliefs about medications is one of the few treatment- 1970). These studies examined the relationship of action to
representations that have been studied systematically. Horne antecedent factors, such as attitudes and intentions
and colleagues (2013) developed scales to assess patients expressed after exposure to a fear message (e.g., regarding
beliefs about medications (Horne et al., 1999). Two are the consequences of having tetanus). In perhaps the most
specific to the medications patients are using (regarding the important of these studies, participants were exposed either
necessity of the medication for ones health; and regarding to a high or a low threat message describing the conse-
concerns about the medication, such as side effects), and one quences of tetanus, with half of the participants exposed to
regards general concerns about medications, including doc- each message receiving a detailed plan for implementing
tors over-prescribing and patients over-use of medications. action (Leventhal et al., 1965). Taking an inoculation
A meta-analysis of 94 publications showed that the Specific required exposure both to one of the two threat messages,
Necessity Beliefs measure was positively and consistently weak or strong, and an action plan; neither threat messages
related to adherence, and Specific Concerns scores were nor an action plan led to action when presented alone.
consistently and negatively related to adherence. The con- Although the strong threat message aroused more negative
sistent and moderate size of the relationship of these scales to emotional responses, more favorable attitudes and stronger
reported adherence is evidence of the importance of treatment intentions to be inoculated, the proportion of respondents
representations for adherence and supports the value of seeking inoculation was virtually identical for both strong
addressing both treatment and illness prototypes in clinical and milder threat messages when either was accompanied
settings. Designing and testing communications to increase by a concrete, action plan. Two components of the action
adherence in randomized clinical trials will require addressing plan were presumed critical: the participants, university
both illness and treatment representations and their coherence students living in campus housing, were provided a map of
(i.e., whether the treatment meets common sense criteria with the campus highlighting the location of the health clinic,
regard to prior experiences and/or expectations). and given examples of class changes that led past the
clinic. The students were next instructed to review their
Communicating action plans and planning for self- own class changes in order to identify similar transitions
management past the clinic. They were given clear examples of the
required response and asked to identify a highly available
An Action Plan defines a specific response (e.g., take your cue (class change passing the clinic) to initiate responding.
anti-hypertension medications), a place for performing the It is worth noting that getting a tetanus inoculation occur-
response (e.g., in the morning with your orange juice, tea or red in both the days and weeks following exposure to the
coffee), and a set of expectations as to the outcome of the messages, well after the fear and positive attitudes had
response. The response package is linked to a particular evaporated (Leventhal, 1970). As the level of fear was
condition and/or set of symptoms. In other words, an action irrelevant, it appeared that the representation of the threat,
plan can be activated in response to the abstract features of not the momentary affective component, was critical for
a condition: hypertension (identity) can lead to a stroke action when combined with the plan (Leventhal, 1970;
(consequences) and needs to be controlled by medication Tannenbaum et al., 2015). As the plans were provided in
(control). The plan can also be activated by the schematic large part by the investigators, the data raised a second
or experiential level of the condition: noticeable heart beats question; How do people generate action plans on their
and headaches (symptom/Identity) indicate risk of stroke own?

942 J Behav Med (2016) 39:935946

A key difference between the tetanus inoculation study action and evaluation of treatment efficacy (Omer et al.,
and the findings of the endoscopy study described earlier is 2013).
worth noting. Each of the independent variables in the
endoscopy study (sensory information and coping instruc- Clarifying self-prototypes in clinical settings
tions) had independent effects in the absence of the other.
By comparison, in the tetanus study, each produced an Can communications delivered in clinical settings help
effect only when combined with the other. The difference patients re-define the self-prototype and improve treatment
reflects the contexts: the endoscopic examination itself outcomes? How patients perceive and label themselves has
activated the representation of the context, the sensations observable effects on measures taken in clinical practice.
of tube insertion were present and activated coping; sen- For example, patients may be labelled as hypertensive
sory information and coping instructions had independent when their blood pressure is elevated during a clinic visit,
effects. In the fear communication study, the representation though they may be normotensive with ambulatory moni-
of the threat and the plan for coping were in the partici- toring in their everyday environments. Defining the self as
pants mind, not in the clinical context. As a conse- hypertensive based only on the office measures, illustrates
quence, the representation of a threat and action plan were what practitioners call white coat hypertension (Spruill
interdependent. et al., 2007).
The effects of self-perceptions and labels (such as those
Clarifying illness and treatment prototypes and initiating seen with hypertensive patients) are visible in a range of
action-planning settings, including that for new mothers immediately post-
partum. Howell and colleagues conducted two randomized
Can clinicians encourage and improve effective self-man- clinical trials to reduce reporting of depressive symptoms
agement of chronic conditions by clarifying the nature and post-partum (Howell et al., 2012, 2014). In the first trial, a
treatment of the presenting problem; that is, by clarifying total of 495 African-American and Hispanic patients, all
illness and treatment representations and action-plans? new mothers, were randomized into treatment and control
Although descriptive studies may lack the elegance of the (enhanced usual care) conditions and interviewed at
randomized trial, they can provide important clues 3 weeks, and 3 and 6 months following delivery of the
respecting the content of clinical communications and newborn. The primary question was whether an interven-
patients perceptions of a clinicians style that do or do not tion clarifying expectations regarding the postpartum self
encourage treatment adherence. Phillips and colleagues would reduce negative experiences and reporting of
(Phillips et al., 2012) initiated a longitudinal study exam- depressive symptoms. The intervention used simple
ining these factors by asking clinic patients a day after a graphical representations to describe the typical state of a
clinic visit to complete a questionnaire that assessed the new mothers body postpartum (thus bypassing possible
psychosocial (My doctor understood my feelings about deficits in literacy and numeracy) and provided simple
this problem), and/or the common-sense nature of the instructions and clear expectations for self-care. The
visit (The doctor told me how to monitor my problem to intervention was successful in altering how new mothers
see if the treatment is working). When patients were saw themselves post-partum and reduced depressive
called a month later and asked about their treatment symptoms by roughly 40 % at all three time points.
adherence, the problems resolution, and subsequent visits The second trial, conducted with Anglo and Asian
to the emergency room (ER), those who gave the visit high mothers, identified a critical necessity in designing a clin-
scores on the common-sense items were more adherent, ical trial, which is ongoing assessment of the targeted
had better problem resolution, and were less likely to go to outcome, independent of the trial itself. In the case of this
the ER. In contrast, patients who praised their practitioners second trial, there was no ongoing assessment of the base
psychosocial skills were more likely a month later to report rate of postpartum depressive symptoms. As the CSM is
high levels of satisfaction with the visit, but satisfaction Bayesian (i.e., study results are interpreted in light of prior,
was unrelated to adherence and negatively related to sample-specific probabilities), it asks investigators to
problem resolution. Further, all 18 visits to the ER were secure a valid estimate of the population parameter targeted
associated with higher scores on the psychosocial items. in the trial; that is, to measure the percent of new mothers
The study illustrates the importance of going beyond meeting or exceeding criteria for depressive symptoms in
general instruction for treatment; practitioners who spelled the months and days before initiating a trial and during the
out the details of when and how to do a treatment, and what trial itself. Had this measure been in place, it would have
to expect during and after doing it, were effective com- pre-empted the subsequent, second trial, as the percentage
municators. How one defines a problem sets the stage for of Caucasian and Asian mothers reporting depressive

J Behav Med (2016) 39:935946 943

symptoms above tonic baseline, was far too low a target for Phillips et al. (2013) found that patients with hypertension
the intervention (only 6 % of the mothers in the control who had been prescribed a medication for multiple years
group exceeded criterion for depressive symptoms). The were most adherent when they reported having a habit or
intervention failed, as there was essentially nothing on routine for taking their medication; if medication use was
which to intervene. The 6 % frequency was 20 % lower associated with consistently experienced, environmental
than expected based on prior longitudinal studies con- cues, taking medication was habitual and the patient was
ducted in the same hospital with similar participants. highly adherent (not just to the day, but to a specific time of
It is important to repeat that the post-partum trial was day). Factors such as treatment-related beliefs, presence or
based on the assumption that postpartum expectations are absence of barriers to adherence, and experiences that the
based on a normative, pre-pregnancy prototype of the self. treatment worked as expected were not the essential
As norms are averages of ongoing life experiences, they are ingredients. Bolman et al. (2011) found that patients habit
historically remote in time and likely to represent a more strength for taking their prophylactic asthma medication
robust and functional self than the immediate, pre-pregnant predicted adherence, but also found that patients medica-
self. The expectations generated by these prototypes are tion-beliefs explained variance in adherence.
likely, therefore, to set unrealistic targets for self-evalua- The importance of routines for long term, i.e., habitual,
tions of recovery. This is true for many conditions, such as adherence was revealed again in a recent study of 306 low
rehabilitation following sports injury (Podlog et al., 2014). income patients with asthma; 68 % were African American
Though prototypes can and do change, it is likely that and Hispanic, and all were over 60 years of age (Brooks
prototypes of illnesses and treatments are typically far et al., 2015). The proportion of adherent patients in the
more malleable than the prototype of the self, since they sample was low; only 38.6 % of the 306 participants
are based on sporadic, less-frequent experiences. There- reported strict adherence to daily medication. A small sub-
fore, issues that arise due to problematic illness prototypes set of participants, 16 % of the sample, who combined
(e.g., expectations of a chronic illness fitting an acute medication use with existent habit patterns were 3.7 times
model) may be more easily changed than issues that arise more likely to be highly adherent than patients who did not
due to problematic self-prototypes (e.g., the prototype of integrate taking medication with existent, daily, routines.
self as fully functional, which is difficult to budge when a An example of such a routine was . putting the inhaler
new self-image is needed, as in the postpartum period or in the bathroom and using it when I get up in the morning;
after severe limitation of functioning, e.g., from stroke). 67 % of patients using this strategy were highly adherent.
Although initiating and converting adherence into sys-
tematic habit is more common among educated, financially
Moving from behavioral initiation to continued, well off patients, any patient using these strategies is highly
controlled self-management of illness adherent regardless of their position on moderating factors.
The strategies work! The question is, how did they plan and
Telling patients when, where and how to respondgiving incorporate these strategies into their daily routines?
them an action planis effective in providing strategies for
action, but it is not the same as assisting them with acquiring Creating routines: patients with diabetes
the skills for planning on their own, or for building automatic
management routines. In addition, though many patients Patients who are expert at self-management of one or
know how to initiate action, such as filling a prescription and more chronic conditions can provide insight not only to the
taking a prescribed medication, many fail to generalize their strategies used for long term adherence, but to the strate-
initial performance into lifelong habits. CSM researchers have gies they used to discover and create automatic manage-
begun to examine the settings patients have discovered for ment routines. Unlike many qualitative studies that recruit
habitual performance and to describe the ways in which they patients struggling with adherence, Tanenbaum and col-
went about trying and rejecting different tactics for habit leagues (2015) recruited patients with diabetes who had
formation. A lesson that is already quite clear is that the habit achieved excellent control. The participants read a series of
concept encompasses a variety of factors; there are different scenarios describing patients having problems adhering to
habitual routines and different procedures for their formation diabetes medication and/or life styles, and after each sce-
(Brooks et al., 2015). nario, they were asked what they would recommend to the
patient in trouble, and how they handled similar problems
Routinized adherence in their own lives. These expert patients described an
array of strategies for generating routines that combined
How do consistent, automatic behaviors emerge from ini- monitoring daily behavioral patterns and identifying those
tial performance for patients with chronic conditions? patterns that provided slots, or locations/times for

944 J Behav Med (2016) 39:935946

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

J Behav Med (2016) 39:935946 945

experimentally evaluating nonconscious influences on Bunde, J., & Martin, R. (2006). Depression and prehospital delay in
prototype activation (e.g., Henderson et al., 2007). This the context of myocardial infarction. Psychosomatic Medicine,
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tions change with experience of chronic illness, among medical care in response to symptoms and life stress. Psycho-
other dynamic CSM aspects. Although action planning can somatic Medicine, 57, 3747.
be studied descriptively, it naturally lends itself to inter- DiMatteo, R., Giordani, P. J., Lepper, H. S., & Croghan, T. W.
(2002). Patient adherence and medical treatment outcomes: A
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patterns, and targets and time-lines for observing treatment information in healthful eating and physical activity research: A
outcomes. Howell et al. (2012) is an example; by activating timely topic. JADA, 109, 3035. doi:10.1016/j.jada.2008.10.019
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memory bank, the intervention altered new mothers views elderly patients admitted to emergency departments. Archives of
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Hagger, M. S., & Orbell, S. (2003). A meta-analytic review of the
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to experiments may reflect a pattern common to the history Health, 18, 141184. doi:10.1080/088704403100081321
of science: complex causal models may be less good at Halm, E. A., Mora, P., & Leventhal, H. (2006). No symptoms, no
predicting outcomes than are descriptive approaches; it is asthma: The acute episodic disease belief is associated with poor
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with diabetes to use blood-glucose meters to monitor the specific illness schema result in an attentional information-
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their blood sugar; intervention participants had significant Heron, K. E., & Smyth, J. M. (2010). Ecological momentary
improvements in their HbA1c. In sum, the CSM explicates interventions: Incorporating mobile technology into psychoso-
processes from perceptions through action, to appraisal of cial and health behavior treatments. British Journal of Health
Psychology, 15, 139.
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Medicines Questionnaire: The development and evaluation of a
new method for assessing the cognitive representation of
Conflict of interest Howard Leventhal, L. Alison Phillips and Edith
medication. Psychology & Health, 14, 124.
Burns declare that they do not have any conflict of interest.
Horowitz, C. R., Rein, S. B., & Leventhal, H. (2004). A story of
maladies, misconceptions and mishaps: Effective management
Human and animal rights and Informed consent This article does
of heart failure. Social Science and Medicine, 58, 631643.
not contain any studies with human participants or animals performed
Howell, E. A., Balbierz, A., Wang, J., Parides, M., Zlotnick, C., &
by any of the authors.
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/
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