Journal of Behavioral Medicine

, Volume 39, Issue 6, pp 1076–1091 | Cite as

Self-management of chronic illness: the role of ‘habit’ versus reflective factors in exercise and medication adherence

  • L. Alison Phillips
  • Joshua Cohen
  • Edith Burns
  • Jessica Abrams
  • Steffi Renninger


Non-adherence to health behaviors required for chronic illness self-management is pervasive. Advancing health-behavior theory to include behavioral initiation and maintenance factors, including reflective (e.g., belief- and feedback-based) and automatic (e.g., habit-based) mechanisms of adherence to different treatment-related behaviors could improve non-adherence prediction and intervention efforts. To test behavioral initiation and maintenance factors from an extended common sense self-regulation theoretical framework for predicting medication adherence and physical activity among patients with Type 2 diabetes. Patients (n = 133) in an in-person (n = 80) or online (n = 53) version of the study reported treatment-related (1) barriers, (2) beliefs and experiential feedback (reflective mechanisms of treatment-initiation and short-term repetition), and (3) habit strength (automatic mechanism of treatment-maintenance) for taking medication and engaging in regular physical activity at baseline. Behaviors were assessed via self-reports (n = 133) and objectively (electronic monitoring pill bottles, accelerometers; n = 80) in the subsequent month. Treatment-specific barriers and habit strength predicted self-reported and objective adherence for both behaviors. Beliefs were inconsistently related to behavior, even when habits were “weak”. Experiential feedback from behavior was not related to adherence. Among patients with Type 2 diabetes diagnosis, medication and physical activity adherence were better predicted by their degree of automatic behavioral repetition than their beliefs/experiences with the treatment-actions. Habit strength should be an intervention target for chronic illness self-management; assessing it in practice settings may effectively detect non-adherence to existing treatment-regimens. However, future research and further refining of CS-SRM theory regarding the processes required for such habit development are needed.


Commonsense self-regulation Adherence Exercise Habit Type 2 diabetes 



This work was funded by a Research Starter Grant in Adherence Improvement from the PhRMA Foundation.

Compliance with ethical standards

Conflict of interest

L. Alison Phillips, Joshua Cohen, Edith Burns, Jessica Abrams and Steffi Renninger declare that they have no conflict of interest.

Human and animal rights and Informed consent

All procedures followed were in accordance with ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000. Informed consent was obtained from all patients for being included in the study.


  1. Aarts, H., Paulussen, T., & Schaalma, H. (1997). Physical exercise habit: On the conceptualization and formation of habitual health behaviours. Health Education Research, 12, 363–374. doi: 10.1093/her/12.3.363 CrossRefPubMedGoogle Scholar
  2. Ajzen, I. (1991). The theory of planned behavior. Organizational Behavior and Human Decision Processes, 50, 179–211. doi: 10.1016/0749-5978(91)90020-T CrossRefGoogle Scholar
  3. Andersen, F., Engstad, T. A., Straume, B., Viitanen, M., Halvorsen, D. S., Hykkerud, S., & Sjøbrend, K. (2010). Recruitment methods in Alzheimer’s disease research: General practice versus population based screening by mail. BMC Medical Research Methodology, 10, 35. doi: 10.1186/1471-2288-10-35 CrossRefPubMedPubMedCentralGoogle Scholar
  4. Bandura, A. (2001). Social cognitive theory: An agentic perspective. Annual Review of Psychology, 52, 1–26. doi: 10.1146/annurev.psych.52.1.1 CrossRefPubMedGoogle Scholar
  5. Bolman, C., Arwert, T. G., & Völlink, T. (2011). Adherence to prophylactic asthma medication: Habit strength and cognitions. Heart & Lung: The Journal of Acute and Critical Care, 40, 63–75. doi: 10.1016/j.hrtlng.2010.02.003 CrossRefPubMedGoogle Scholar
  6. Brooks, T. L., Leventhal, H., Wolf, M. S., O'Conor, R., Morillo, J., Martynenko, M., Wisnivesky, J. P., & Federman, A. D. (2014). Strategies used by older adults with asthma for adherence to inhaled corticosteroids. Journal of General Internal Medicine, 29, 1506–1512. doi: 10.1007/s11606-014-2940-8 CrossRefPubMedPubMedCentralGoogle Scholar
  7. Cooper, V., Horne, R., Gellaitry, G., Vrijens, B., Lange, A. C., Fisher, M., & White, D. (2010). The impact of once-nightly versus twice-daily dosing and baseline beliefs about HAART on adherence to efavirenz-based HAART over 48 weeks: The NOCTE study. JAIDS, 53, 369–377. doi: 10.1097/QAI.0b013e3181ccb762 PubMedGoogle Scholar
  8. Creer, T. L., & Holroyd, K. A. (1997). Self-management. In A. Baum (Ed.), Cambridge handbook of psychology, health, and medicine (pp. 255–258). New York: Cambridge University Press.Google Scholar
  9. Danner, U. N., Aarts, H., & de Vries, N. K. (2008). Habit vs. intention in the prediction of future behavior: The role of frequency, context stability, and mental accessibility of past behavior. British Journal of Social Psychology, 47, 245–265. doi: 10.1348/014466607X230876 CrossRefPubMedGoogle Scholar
  10. DiMatteo, R., Giordani, P. J., Lepper, H. S., & Croghan, T. W. (2002). Patient adherence and medical treatment outcomes: A meta-analysis. Medical Care, 40, 794–811.CrossRefPubMedGoogle Scholar
  11. Elwood, W. (2015). Self, others, and chronic conditions: An opportunity to understand the sociobehavioral underpinnings of the healthiest-possible life with self-management [web post].
  12. Faul, F., Erdfelder, E., Buchner, A., & Lang, A. G. (2009). Statistical power analyses using G*Power 3.1: Tests for correlation and regression analyses. Behavioral Research Methods, 41, 1149–1160. doi: 10.3758/BRM.41.4.1149 CrossRefGoogle Scholar
  13. Fleig, L., Pomp, S., Schwarzer, R., & Lippke, S. (2013). Promoting exercise maintenance: How interventions with booster sessions improve long-term rehabilitation outcomes. Rehabilitation Psychology, 58, 323–333. doi: 10.1037/a0033885 CrossRefPubMedGoogle Scholar
  14. García-Pérez, L. E., Álvarez, M., Dilla, T., Gil-Guillén, V., & Orozco-Beltrán, D. (2013). Adherence to therapies in patients with type 2 diabetes. Diabetes Therapy, 4, 175–194. doi: 10.1007/s13300-013-0034-y CrossRefPubMedPubMedCentralGoogle Scholar
  15. Gardner, B. (2014). A review and analysis of the use of ‘habit’ in understanding, predicting and influencing health-related behaviour. Health Psychology Review,. doi: 10.1080/17437199.2013.876238 PubMedPubMedCentralGoogle Scholar
  16. Gardner, B., Abraham, C., Lally, P., & de Bruijn, G. (2012). Towards parsimony in habit measurement: Testing the convergent and predictive validity of an automaticity subscale of the Self-Report Habit Index. International Journal of Behavioral Nutrition and Physical Activity, 9, 102. doi: 10.1186/1479-5868-9-102 CrossRefPubMedPubMedCentralGoogle Scholar
  17. Glasgow, R. E., Hampson, S. E., Strycker, L. A., & Ruggiero, L. (1997). Personal-model beliefs and social-environmental barriers related to diabetes self-management. Diabetes Care, 20, 556–561. doi: 10.2337/diacare.20.4.556 CrossRefPubMedGoogle Scholar
  18. Hagger, M. S., Rebar, A. L., Mullan, B., Lipp, O. V., & Chatzisarantis, N. L. D. (2014). The subjective experience of habit captured by self-report indexes may lead to inaccuracies in the measurement of habitual action. Health Psychology Review. doi: 10.1080/17437199.2014.959728
  19. Horne, R. (2004). The medication adherence report scale. Brighton: University of Brighton.Google Scholar
  20. Horne, R., Chapman, S. C. E., Parham, R., Freemantle, N., Forbes, A., & Cooper, V. (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. doi: 10.1371/journal.pone.0080633 CrossRefPubMedPubMedCentralGoogle Scholar
  21. Horne, R., & Weinman, J. (2002). Self-regulation and self-management in asthma: Exploring the role of illness perceptions and treatment beliefs in explaining non-adherence to preventer medication. Psychology and Health, 17, 17–32. doi: 10.1080/08870440290001502 CrossRefGoogle Scholar
  22. 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 and Health, 14, 1–24. doi: 10.1080/08870449908407311 CrossRefGoogle Scholar
  23. Jarvis, C. B., Mackenzie, S. B., & Podsakoff, P. M. (2003). A critical review of construct indicators and measurement model misspecification in marketing and consumer research. Journal of Consumer Research, 30, 199–218. doi: 10.1086/376806 CrossRefGoogle Scholar
  24. Knowler, W. C., Barrett-Connor, E., Fowler, S. E., Hamman, R. F., Lachlin, J. M., Walker, E. A., & Nathan, D. M. (2002). Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. New England Journal of Medicine, 346, 393–403. doi: 10.1056/NEJMoa012512 CrossRefPubMedGoogle Scholar
  25. Kravitz, R. L., & Melnikow, J. (2004). Medical adherence research: Time for a change in direction? Medical Care, 42, 197–199.
  26. Leventhal, H., Brissette, I., & Leventhal, E. A. (2003). The common-sense model of self-regulation of health and illness. In L. D. Cameron & H. Leventhal (Eds.), The self-regulation of health and illness behaviour (pp. 42–65). London: Routledge.Google Scholar
  27. Leventhal, H., Weinman, J., Leventhal, E. A., & Phillips, L. A. (2008). Health psychology: The search for pathways between behavior and health. Annual Review of Psychology, 59, 477–505. doi: 10.1146/annurev.psych.59.103006.093643 CrossRefPubMedGoogle Scholar
  28. Mann, D. M., Ponieman, D., Leventhal, H., & Halm, E. A. (2009). Predictors of adherence to diabetes medications: The role of disease and medication beliefs. Journal of Behavioral Medicine, 32, 278–284. doi: 10.1007/s10865-009-9202-y CrossRefPubMedGoogle Scholar
  29. McAndrew, L. M., Musumeci-Szabó, T. J., Mora, P. A., Vileikyte, L., Burns, E., Halm, E. A., et al. (2008). Using the common sense model to design interventions for the prevention and management of chronic illness threats: From description to process. British Journal of Health Psychology, 13, 195–204. doi: 10.1348/135910708X295604 CrossRefPubMedGoogle Scholar
  30. McDonald, H. P., Garg, A. X., & Haynes, R. B. (2002). Interventions to enhance patient adherence to medication prescriptions. JAMA, 288, 2868–2879. doi: 10.1001/jama.288.22.2868 CrossRefPubMedGoogle Scholar
  31. Meng, X. L., Rosenthal, R., & Rubin, D. B. (1992). Comparing correlated correlation coefficients. Psychological Bulletin, 111, 172–175. doi: 10.1037/0033-2909.111.1.172 CrossRefGoogle Scholar
  32. Meyer, D., Leventhal, H., & Gutmann, M. (1985). Common-sense models of illness: The example of hypertension. Health Psychology, 4, 115–135. doi: 10.1037//0278-6133.4.2.115 CrossRefPubMedGoogle Scholar
  33. Mora, P., & McAndrew, L. (2013). Common-sense model of self-regulation. In M. D. Gellman & J. R. Turner (Eds.), Encyclopedia of behavioral medicine (pp. 460–467). New York: Springer. doi: 10.1007/978-1-4419-1005-9_1220 CrossRefGoogle Scholar
  34. Moss-Morris, R., Weinman, J., Petrie, K., Horne, R., Cameron, L., & Buick, D. (2002). The revised illness perception questionnaire (IPQ-R). Psychology and Health, 17, 1–16. doi: 10.1080/08870440290001494 CrossRefGoogle Scholar
  35. Nagelkerk, J., Reick, K., & Meengs, L. (2006). Perceived barriers and effective strategies to diabetes self-management. Journal of Advanced Nursing, 54, 151–158. doi: 10.1111/j.1365-2648.2006.03799.x CrossRefPubMedGoogle Scholar
  36. Norris, S. L., Engelgau, M. M., & Narayan, K. M. V. (2001). Effectiveness of self-management training in type 2 diabetes: A systematic review of randomized controlled trails. Diabetes Care, 24, 561–587. doi: 10.2337/diacare.24.3.561 CrossRefPubMedGoogle Scholar
  37. Orbell, S., & Verplanken, B. (2010). The automatic component of habit in health behavior: Habit as cue-contingent automaticity. Health Psychology, 29, 374–383. doi: 10.1037/a0019596 CrossRefPubMedGoogle Scholar
  38. Petrie, K. J., Jago, L. A., & Devcich, D. A. (2007). The role of illness perceptions in patients with medical conditions. Current Opinion in Psychiatry, 20, 163–167. doi: 10.1097/YCO.0b013e328014a871 CrossRefPubMedGoogle Scholar
  39. 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, 244–257. doi: 10.1111/j.2044-8287.2011.02035.x CrossRefPubMedGoogle Scholar
  40. Phillips, L. A., Leventhal, H., & Leventhal, E. A. (2013). Assessing theoretical predictors of long-term medication adherence: Patients’ treatment-related beliefs, experiential feedback, and habit development. Psychology and Health, 28, 1135–1151. doi: 10.1080/08870446.2013.793798 CrossRefGoogle Scholar
  41. Rhodes, R. E., & De Bruijn, G. J. (2010). Automatic and motivational correlates of physical activity: Does intensity moderate the relationship? Behavioral Medicine, 36, 44–52. doi: 10.1080/08964281003774901 CrossRefPubMedGoogle Scholar
  42. Rosenstock, I. M., Strecher, V. J., & Becker, M. H. (1988). Social learning theory and the health belief model. Health Education Quarterly, 15, 175–183. doi: 10.1177/109019818801500203 CrossRefPubMedGoogle Scholar
  43. Rothman, A. J. (2000). Toward a theory-based analysis of behavioral maintenance. Health Psychology, 19, S64–S69. doi: 10.1037/0278-6133.19.Suppl1.64 CrossRefGoogle Scholar
  44. Rothman, A. J. (2004). “Is there nothing more practical than a good theory?”: Why innovations and advances in health behavior change will arise if interventions are used to test and refine theory. International Journal of Behavioral Nutrition and Physical Activity, 1, 1–7. doi: 10.1186/1479-5868-1-11 CrossRefGoogle Scholar
  45. Rothman, A. J., Sheeran, P., & Wood, W. (2009). Reflective and automatic processes in the initiation and maintenance of dietary change. Annals of Behavioral Medicine, 38, 4–17. doi: 10.1007/s12160-009-9118-3 CrossRefGoogle Scholar
  46. Ryan, R. M., & Deci, E. L. (2000). Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. American Psychologist, 55, 68–78. doi: 10.1037/0003-066X.55.1.68 CrossRefPubMedGoogle Scholar
  47. Scott, S., Walter, F., Webster, A., Sutton, S., & Emery, J. D. (2012). The model of pathways to treatment: Conceptualization and integration with existing theory. British Journal of Health Psychology, 18, 45–65. doi: 10.1111/j.2044-8287.2012.02077.x CrossRefPubMedGoogle Scholar
  48. Sechrist, K. R., Walker, S. N., & Pender, N. J. (1987). Development and psychometric evaluation of the exercise benefits/barriers scale. Research in Nursing & Health, 10, 357–365. doi: 10.1002/nur.4770100603 CrossRefGoogle Scholar
  49. Siegel, K., Schrimshaw, E. W., & Dean, L. (1999). Symptom interpretation and medication adherence among late middle-age and older HIV-infected adults. Journal of Health Psychology, 4, 247–257. doi: 10.1177/135910539900400217 CrossRefPubMedGoogle Scholar
  50. Svarstad, B. L., Chewning, B. A., Sleath, B. L., & Claesson, C. (1999). The brief medication questionnaire: A tool for screening patient adherence and barriers to adherence. Patient Education and Counseling, 37, 113–124. doi: 10.1016/S0738-3991(98)00107-4 CrossRefPubMedGoogle Scholar
  51. Tanenbaum, M. L., Leventhal, H., Breland, J. Y., Walker, E. A., & Gonzalez, J. S. (2015). Successful self-management among non-insulin-treated adults with type 2 diabetes: A self-regulation perspective. Diabetic Medicine, 32, 1504–1512. doi: 10.1111/dme.12745 CrossRefPubMedPubMedCentralGoogle Scholar
  52. van Dulmen, S., Sluijs, E., van Dijk, L., de Ridder, D., Heerdink, R., & Bensing, J. (2007). Patient adherence to medical treatment: A review of reviews. BMC Health Services Research, 7, 55. doi: 10.1186/1472-6963-7-55 CrossRefPubMedPubMedCentralGoogle Scholar
  53. Verplanken, B., & Orbell, S. (2003). Reflections on past behavior: A self-report index of habit strength. Journal of Applied Social Psychology, 33, 1313–1330. doi: 10.1111/j.1559-1816.2003.tb01951.x CrossRefGoogle Scholar
  54. Wiedemann, A. U., Gardner, B., Knoll, N., & Burkert, S. (2014). Intrinsic rewards, fruit and vegetable consumption, and habit strength: A three-wave study testing the associative–cybernetic model. Applied Psychology: Health and Well-Being, 6, 119–134. doi: 10.1111/aphw.12020 Google Scholar
  55. Williams, G. C., McGregor, H. A., Zeldman, A., Freedman, Z. R., & Deci, E. L. (2004). Testing a self-determination theory process model for promoting glycemic control through diabetes self-management. Health Psychology, 23, 58–66. doi: 10.1037/0278-6133.23.1.58 CrossRefPubMedGoogle Scholar
  56. Wood, W., & Neal, D. T. (2007). A new look at habits and the habit-goal interface. Psychological Review, 114, 843–863. doi: 10.1037/0033-295X.114.4.843 CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2016

Authors and Affiliations

  • L. Alison Phillips
    • 1
  • Joshua Cohen
    • 2
  • Edith Burns
    • 3
  • Jessica Abrams
    • 4
  • Steffi Renninger
    • 4
  1. 1.Department of PsychologyIowa State UniversityAmesUSA
  2. 2.Division of Endocrinology, Medical Faculty AssociatesThe George Washington UniversityWashingtonUSA
  3. 3.Division of Geriatrics and Gerontology, Department of MedicineMedical College of WisconsinMilwaukeeUSA
  4. 4.Department of PsychologyThe George Washington UniversityWashingtonUSA

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