10

The Contribution of Beliefs

to Treatment Engagement
Vivian Auyeung, Lyndsay D. Hughes,
and John A. Weinman

Key Points
• Patients’ beliefs and expectations about their health problem and recommended
treatment influence the extent to which they engage with their treatment.
• A wide range of psychological models have been applied to explain the very
large variation which has been found in treatment engagement.
• At best, these models only provide a partial explanation of the variation in
engagement either between or within individuals but those focusing on
patients’ beliefs about prescribed treatment appear to be the most useful or
consistent.
• Recently a more generic behavior change approach, the COM‐B, has been
applied to understanding treatment engagement and this includes a wider
range of factors, such as capability and opportunity, to provide a more compre-
hensive explanatory framework.

Theoretical models provide a way to integrate a set of beliefs known to explain variation
in patient behavior thereby identifying possible targets to promote treatment engage-
ment. Whilst acknowledging that treatment engagement is complex  –  encompassing
aspects related to the patient, clinician, treatment, and the wider healthcare
­environment – this chapter will outline and critique various theoretical models that have
been used to explain and predict patient health behaviors, with a particular emphasis on
adherence to prescribed treatment. We start with models that focus on patients’ beliefs
about health behaviors, namely, the Health Belief Model (HBM) and the Theory of
Planned Behavior (TPB). We then turn to a model that focuses on patients’ beliefs
about illness and the treatment prescribed: the Extended Self‐regulatory Model. The
final section introduces the COM‐B framework, a new approach that recognizes the
wide variety of factors, in addition to beliefs, that can influence behavior.

The Wiley Handbook of Healthcare Treatment Engagement: Theory, Research, and Clinical Practice,
First Edition. Edited by Andrew Hadler, Stephen Sutton, and Lars Osterberg.
© 2020 John Wiley & Sons Ltd. Published 2020 by John Wiley & Sons Ltd.
 The Contribution of Beliefs to Treatment Engagement 189

The Importance of Using Beliefs to Predict

Health‐related Behavior
Epidemiological studies in the mid-twentieth century identified that certain behaviors
such as smoking, alcohol consumption, exercise, and diet were related to mortality
(e.g. Belloc 1973). Recognition that influences beyond the hitherto observed health
inequalities associated with gender, socioeconomic status, and other demographic
factors led to the development of models of health behavior to understand how and
why people engaged in health preserving and health damaging behaviors. Importantly,
health behaviors are potentially modifiable through intervention, and the develop-
ment of these models coincided with public health initiatives designed to improve
health outcomes. The resulting models were therefore developed and tested in rela-
tion to preventive treatments such as health screening and annual check‐up attend-
ance. These models have at their core the concept of expected utility, first proposed by
Ward Edwards in 1954. This is an assumption that people will make a rational and
conscious decision based on the expected costs and benefits of performing the behav-
ior. Understanding this decision‐making process would be the first step for research-
ers and policymakers to support people in engaging in health protective behaviors.
This approach recognizes that the transmission of knowledge alone is not sufficient
to promote health behaviors in patients. Ley’s Cognitive Model of Compliance
(1982) is a case in point. It argues that failure to adhere with treatment is due to the
patient’s inability to understand and recall the health‐related information provided
and low satisfaction with their medical care. Though Ley acknowledges the influence
of the transmission of information from the patient to the clinician, there is little
acknowledgment of the role of a patient’s existing health beliefs. Instead, the model
is focused on explaining what can disrupt the transmission of information from the
clinician to the patient; the failure to adhere is then due to a failure in communication.
Without dismissing the impact of health literacy (e.g. Zhang et al. 2014), the cogni-
tive models that follow all recognize the patient as active decision‐makers holding
beliefs about themselves, others, and recommended health behaviors, including
beliefs about their illness and the treatment prescribed.

The Health Belief Model (HBM)

The HBM was proposed by Rosenstock (1966) and is one of the earliest and there-
fore most influential health models. It initially relied heavily on the concept of
expected utility, assuming that the perceived cost of performing a health behavior
would be directly weighed against the perceived benefit. However, the model was
extended and refined over time with the addition of demographic and psychosocial
effects such as social influences and personality traits (Becker 1974). The HBM was
developed against a background of public health reform and as such focused mainly
on preventive health behaviors and treatments initially, although it has been used
extensively in relation to ongoing treatment adherence.
The HBM focuses on two aspects of health and health behavior; threat perception
and behavioral evaluation, both of which are further broken down into two compo-
nents (Figure 10.1). Threat perception concerns an individual’s perceived susceptibility
to a health outcome, considered alongside the anticipated severity. Perceived
190 Vivian Auyeung, Lyndsay D. Hughes, and John A. Weinman

THREAT PERCEPTION

Perceived susceptibility

Demographic
variables Perceived severity

Health motivation Behavior

Psychological
characteristics
(e.g.
personality,
peer pressure Perceived benefits
Cues to
etc.)
action

Perceived barriers

BEHAVIOURAL EVALUATION

Figure 10.1  The Health Belief Model (HBM).

susceptibility refers to the possibility or probability the individual believes they have of
becoming ill with a new or recurrent illness. The reference against which this probabil-
ity is measured can be either other people who are considered to be similar in terms of
age, health status, geographical location, etc. or it can be self‐referent in terms of previ-
ous illness experience. Perceived susceptibility can be negatively influenced by “unreal-
istic optimism” (Weinstein 1980) whereby people underestimate their personal
susceptibility to negative outcomes. Anticipated severity refers to the perceived health
consequences associated with the behavior. For example, when considering whether to
take up an influenza vaccination, an individual may consider how likely they are to
become ill with ’flu compared to other people like them, and how bad the illness is
likely to be. Generally, perceptions that an individual is highly susceptible to illness and
that the severity would be high would result in engagement with the associated health
behavior. In relation to treatment engagement for long‐term conditions, an individual
is likely to weigh the perceived susceptibility and severity to their own past experiences
of their illness and decide accordingly on whether to engage with their prescribed
treatment. Those who have experienced many severe periods of active disease would be
more likely to engage in their treatment program.
The second part of the model refers to behavioral evaluation and includes the per-
ceived benefits of undertaking a behavior which is weighed against the perceived costs/
barriers. The benefits could be immediate or longer term, concrete, such as alleviation
of symptoms, or more abstract, such as preventing future illness. The costs/barriers
refer to practical costs such as time, expense, availability of a treatment; psychological
barriers including embarrassment or threat to current lifestyle; or physical costs such
as pain and medication side effects. In our influenza example, an individual may weigh
the benefit of increased protection against ’flu infection with the expected costs in
terms of time, effort, money, and potential side effects of the vaccination. As the
model shows, this is processed in parallel with the threat perceptions of susceptibility
 The Contribution of Beliefs to Treatment Engagement 191

and severity, with the costs and benefits of receiving the vaccination being considered
in conjunction with the belief of one’s own susceptibility and likely severity if develop-
ing ’flu. Similarly, an individual prescribed ongoing medication for a long‐term condi-
tion may weigh the benefits of improved disease management with the resource costs
and potential side effects of taking the medication. It is important to note that the
four concepts described above are defined as the individuals’ personal perception of
the outcome, and are not standard across individuals, leading to differing outcomes.
Later versions of the model added a health motivation component (Becker et al.
1977) in an attempt to explain willingness to engage in behaviors in order to protect
health and prevent illness. An important addition to the model is that of cues to action
which trigger the behavior in question. These could be internal such as experiencing
symptoms, or external including social influences, health education programs or
explicit reminders to perform a behavior. Mattson (1999) proposes that cues are caus-
ally prior to beliefs, with a cue to action stimulating beliefs and the decision‐making
process. However, this is the least well‐researched part of the model, giving rise to
uncertainty in the direction of effect (Zimmerman and Vernberg 1994).
Evidence for the HBM is mainly concerned with preventive behaviors, with a meta‐
analysis conducted by Harrison et al. (1992) finding that all four major constructs cor-
related somewhat weakly with various health behaviors, although the largest effects have
been consistently found for the benefits and cost/barriers constructs (Carpenter 2010).
However, the overall explanatory power of the model is weak and could be reduced
further if studies allowed for covariance between the four variables. Perceived severity is
a particularly weak correlate of health behavior (and it may be that severity needs to
exceed a threshold before it has an effect) and, once the threshold has been met, antici-
pated susceptibility may have more of an effect on motivation (Sheeran and Abraham
1996). Moving from explaining behavior to changing it, a recent systematic review of
health interventions based on the HBM found promising results in that 14 of the 18
studies reviewed reported significant improvements in treatment adherence (Jones et al.
2014). However, of the 18 studies reviewed, only 6 measured all constructs of the
HBM and the success of the interventions does not appear to be related to these con-
structs. This calls the utility of the HBM for intervention development into question.
The HBM started the journey of considering people’s beliefs about their health and
health‐related behaviors, but the model has a number of limitations. Important fac-
tors such as mood are not included, and there is a lack of acknowledgment of the
importance of non‐volitional behaviors such as addictions and habits. There is also a
limited role for social influences, culture, and attitude on behavior, beyond the inclu-
sion of motivation. These omissions, along with the poor predictive ability of the
model have led to the recommendation that the simple four‐construct HBM as pre-
sented is no longer used, but that potential moderators or mediators should be con-
sidered to improve the explanatory power of the HBM (Carpenter 2010).

The Theory of Planned Behavior

The TPB proposed by Ajzen (1988) is an extension of Fishbein and Ajzen’s

(1975) Theory of Reasoned Action (TRA). The TRA was based on the assump-
tion that behavior is under volitional control and that a person will perform a
behavior if they form an intention to do so. Intention is central to both the TRA
192 Vivian Auyeung, Lyndsay D. Hughes, and John A. Weinman

Background factors (e.g. demographics, culture, knowledge)

Behavioral Normative Control

beliefs beliefs beliefs

Attitude
Perceived
toward Subjective
behavioral
the norm
control
behavior

Intention

Behavior

Figure 10.2  The Theory of Planned Behavior (TPB). Source: adapted from Ajzen (1991, 182).

and TPB, with Ajzen (1991) proposing that an intention to perform a behavior is
the single most predictive factor of actual performance. Extension to the TPB was
necessitated as the TRA ignores the level of volitional control an individual has
over the behavior.
Figure 10.2 shows that the TPB aims to predict intention, which in turn predicts
behavior. There are three important predictors of intention according to this theory:

1 Attitudes refer to the overall evaluation of a behavior which is informed by the

accessible beliefs about the behavior and the perceived consequences.
2 Subjective norm refers to the subjective assessment by the individual that “impor-
tant others” think that they should (or should not) perform the behavior.
3 Perceived behavioral control is influenced by the individual’s belief that they
have access to the necessary skills and resources to perform the behavior
successfully.

Perceived behavioral control is an important addition to the TPB and is based on

Bandura’s (1977) concept of self‐efficacy. Confidence in performing a behavior is
related to self‐esteem and past experience. Successful completion of a behavior can
improve self‐efficacy beliefs, encouraging further engagement with that behavior.
However, the predictive power of perceived behavioral control is in part due to the
actual level of control that an individual has over the behavior. Interventions that
improve both perceived and actual control over the behavior, specifically modeling of
other people’s successful behaviors and mastery of behavior through graded exposure
would increase the likelihood of a behavior being carried out. This is conceptualized
in the model by the arrow that runs directly from perceived behavioral control to the
 The Contribution of Beliefs to Treatment Engagement 193

behavior, indicating that aside from the strength of the intention to perform the
behavior, actual control over the behavior also influences successful completion.
The TPB is one of the first theories to conceptualize behavior within a social envi-
ronment with subjective norm representing an important acknowledgment of the
impact of other people on behavior. There are two groups of social influences; the first
is other similar people and the perception of whether they are performing the behav-
ior (or not). For example, patients may be more willing to take their medication if
they believe that others with the same illness are also taking their medication. Further,
“important others” exert influence, including family, friends, and health professionals,
and the subjective assessment by the individual of whether these important others
think they should perform the behavior (or not). However, subjective norm must be
evaluated with respect to the motivation the individual has to comply with the wishes
of the important others. If an individual is not motivated to please health professionals
who wish them to engage in the prescribed behavior, the relative importance of that
perception is minimized.
As seen in Figure 10.2, the theory acknowledges that the three factors are corre-
lated and that the relative importance of attitudes, subjective norm, and perceived
behavioral control may differ across populations and behaviors. A large meta‐analysis
by Armitage and Conner (2001) found average correlations of 0.5 between attitudes
and intention to perform a behavior as well as between subjective norm and intention.
However, it is important to note that the relative influence of each of the components
differed between behaviors demonstrating that personal beliefs can have a stronger
effect than the influence of others on some behaviors, and vice versa. Although Ajzen
(2005) proposes that actual behavior can be predicted with considerable accuracy
from intention and control beliefs, the literature suggests a substantial intention‐
behavior gap whereby high intentions to perform a behavior are not translated into
actual behavior (Sniehotta et al. 2005). This is more pronounced for some behaviors,
specifically safe sex and drug abstinence, than others, such as physical activity
(McEachan et al. 2011).
A plethora of studies over the past three decades have investigated the explana-
tory and predictive power of the TPB in a range of health behaviors with numer-
ous health interventions which have been designed utilizing various aspects of the
model. A systematic review by Hardeman and colleagues (2002) found that
approximately half of interventions targeting smoking cessation, physical activity,
exercise, drink driving, sugar consumption, and testicular self‐­ examination
resulted in positive changes in intention and around one third changed behavior.
Despite this, the body of evidence for behaviors under volitional control is modest
overall and behaviors which require particular skills, knowledge, or resources such
as engaging in a complicated treatment regimen will not be well predicted by the
TPB. The exclusion of emotion and unconscious processes such as habits also
limits the explanatory power of the model. There is a lack of strong evidence that
the TPB can predict and explain non‐preventive behaviors such as ongoing medi-
cation adherence, partly due to the static nature of the theory which does not
sufficiently explain how new experiences and knowledge change attitudes and per-
ceived behavioral control over the same behavior, over time. For these reasons,
recent debate has suggested that the TPB has outlived its utility in explaining
health behaviors and should be retired in favor of more comprehensive models
(Sniehotta et al. 2014).
194 Vivian Auyeung, Lyndsay D. Hughes, and John A. Weinman

The Self‐regulatory Approach

While social cognition models were developed for explaining a wide range of behav-
iors, including those involved in managing health and illness, some psychologists have
argued for the development of models that have a more exclusive focus on under-
standing the ways in which people make sense of and cope with the demands of the
illness, for which their treatment has been prescribed.
The self‐regulatory approach proposes that, as health threats and illnesses pose a
challenge to the self‐system and to an individual’s key goals, people actively attempt
to make sense of these threats in order to minimize their impact. While Carver and
Scheier (2001) have provided a generic model of self‐regulation, the most widely used
model which has been used in clinical health psychology is the Common‐sense Model
of Self‐regulation (CS‐SRM) developed by Leventhal and colleagues (1997). This
provides a framework for explaining how the individual attempts to adjust to a health
threat by developing both cognitive and emotional representations, which then acti-
vate behavioral responses (e.g. deciding to seek medical help, adhering to medical
advice, etc.).
The main components of the CS‐SRM are shown in Figure 10.3 and it is character-
ized by a number of key features. It proposes three broad stages of processing, namely
representation, coping, and appraisal, within a dynamic parallel processing system.
The individual’s initial representations of a health problem (e.g. “my stomach ache is

EXTENDED MODEL

Identity Necessity for

Consequences treatment
Timeline
Control/cure Concerns about
Causes treatment

Illness
Coping Appraisal
representation

Illness threat

Emotion Coping Appraisal

Figure 10.3  The extended Common‐sense Model of Self‐regulation including treatment

perceptions. Source: adapted from Leventhal et al. (2003).
 The Contribution of Beliefs to Treatment Engagement 195

a temporary problem brought on by something specific such as over‐eating”) give rise

to specific coping procedures (e.g. not eating, taking antacids) which are appraised for
their effectiveness. If the appraisal process indicates that the mode of coping is not
working, then another coping procedure may be selected or the individual may change
their perception of the nature of the problem (e.g. “this stomach pain has lasted for
the whole day and has not responded to indigestion medication – it must be some-
thing more serious”) and their response to it (e.g. deciding to seek medical help).
At the core of this approach is the individual’s own understanding or representation
of their problem, and this consists of a number of related beliefs about the nature of
the problem (Leventhal et al. 1997). Thus, on experiencing a new symptom or an
illness, the individual will typically provide a label or description and will link this with
other symptoms that they are experiencing. These aspects constitute their perceived
identity of the problem, and this is typically linked with a causal explanation, as well
as expectations about how long the problem will last (time‐line), its likely effects (con-
sequences), and the extent to which it is amenable to cure or control by the individual
and others, such as healthcare staff. These representations will influence how the
individual responds to the initial symptoms and to the results of any subsequent inves-
tigation, as well as their evaluation of the appropriateness and efficacy of recom-
mended treatment or advice. The CS‐SRM is very much a dynamic model since it
proposes that individuals evaluate the effectiveness of their chosen coping strategy
and then determine whether to continue or to change strategy, or even change their
representation of the problem (see Figure 10.3).
There have been a large number of cross‐sectional and longitudinal observational
studies that have used the CS‐SRM to demonstrate clear associations between illness
perceptions and a wide number of patient outcomes (see meta‐analysis by Hagger and
Orbell 2003). This field of research has benefited from the application of standardized
measures of illness perceptions, which have been widely translated and used with a
very wide range of patient and carer groups (Weinman et al. 1996; Moss‐Morris et al.
2002; Broadbent et al. 2006; Broadbent et al. 2015). In addition there have been a
number of intervention studies which have shown that illness perceptions are amena-
ble to change and that this can lead to positive patient outcomes, including behavior
change, improved mood, and improved quality of life. For example Petrie et al. (2002)
conducted a brief intervention with post‐myocardial infarction patients, which focused
on eliciting and challenging dysfunctional illness beliefs in order to develop personal-
ized action plans. Patients in the intervention group reported they were better pre-
pared for leaving hospital and returned to work quicker than those in the control
group.
From a CS‐SRM perspective, the decision as to whether to engage with a treatment
will depend very much on the way in which the individual perceives their health condi-
tion. All of the five components of illness perception can influence the decision to fol-
low treatment. For example, with the identity component of illness perception, it has
been shown that hypertensive patients, who believed that they could judge when their
blood pressure was high by the presence of symptoms such as stress or headache, have
been found to only take their medication when these symptoms were experienced
(Meyer et al. 1985). From a CS‐SRM perspective, the level of treatment adherence
may be indicative of a strategic coping response, which is entirely consistent with the
patient’s perception of their problem. Thus, patients with asthma who perceive their
condition as cyclical in nature are less likely to adhere to their daily preventer ­medication
196 Vivian Auyeung, Lyndsay D. Hughes, and John A. Weinman

than those patients who perceive their asthma as a more permanent condition and
hence in need of continuous treatment (Horne and Weinman 2002; Halm et al. 2006).
Illness perceptions have also been shown to explain levels of engagement with psycho-
logical therapies, such as cognitive behavioral therapy (CBT). For example, Freeman
and colleagues (2013) found that the level of adherence to CBT in patients with early
psychosis was related to their beliefs about the cause, timeline, and control of their
condition in a way that significantly influenced the efficacy of the treatment.
Despite these encouraging findings, a number of studies have failed to reveal con-
sistent links between illness perceptions and treatment adherence (see Brandes and
Mullan 2014; Aujla et al. 2016), and recently the SRM has been extended to include
a focus on treatment beliefs to provide greater explanatory power. In addition to
acknowledging the role of patients’ beliefs about their illness, much current adher-
ence research has shown that patients hold views about their treatment and that these
seem to play a critical role in influencing levels of intentional non‐adherence (Horne
et al. 2013). This research has revealed two broad factors describing people’s beliefs
about their prescribed medicines: their perceived necessity for maintaining health and
their concerns based on worries about possible dependence or harmful long‐term
effects. Patients with stronger concerns based on beliefs about the potential for long‐
term effects and dependence reported lower adherence rates, whilst those with
stronger beliefs in the necessity of their medication reported greater adherence to
medication regimen (Horne and Weinman 1999). In an extensive systematic review
and meta‐analysis, Horne et al. (2013) showed that both necessity and concern beliefs
have good explanatory power across a very wide range of illnesses. However, in some
conditions (e.g. cancer, schizophrenia) the necessity beliefs seemed to exert a stronger
influence on adherence whereas in others (e.g. hypertension, bipolar disorder, pain)
the decision to adhere appears to be more strongly influenced by patients’ concerns
and negative beliefs about their treatment. Horne has proposed that treatment beliefs
will combine and interact with illness beliefs, and that Leventhals’s basic SRM could
be augmented into an extended SRM, which incorporates both illness and treatment
beliefs (see Figure 10.3).
As yet there are relatively few treatment adherence interventions based on the
extended CS‐SRM but there are some studies, which have revealed its promise. Using
Horne and Weinman’s (2002) findings on the explanatory role of both illness and
treatment in adherence to preventer inhaler use in asthma, Petrie et al. (2012) devel-
oped a mobile phone‐based intervention for challenging these beliefs. Using a large
bank of brief messages which were designed to challenge both illness (e.g. “your
asthma is present even when you don’t have symptoms”) and treatment beliefs (e.g.
“your asthma inhaler is safe to use every day”), they were able to improve adherence
rates from around 50% to 70% in the intervention group. The important finding from
this study was that this improvement in adherence was maintained for six months after
the SMS messages ceased, indicating that this was due to durable changes in illness
and treatment beliefs.
Another study that focused on changing necessity and concern beliefs to improve
medication adherence was carried out by O’Carroll et al. (2013) with patients one year
after ischemic stroke. The intervention consisted of two sessions involving (i) eliciting
and modifying negative medication beliefs and (ii) an implementation intention for
medication taking, and led to a significant uplift in adherence at three months. Adding
a goal‐setting (implementation intention) component to a treatment‐belief‐based
 The Contribution of Beliefs to Treatment Engagement 197

intervention provides a good example of what Horne (2001) has described as a percep-
tions and practicalities approach to improving treatment adherence.
Although the CS‐SRM lacks the apparent precision of the simpler and more closely
defined social cognition models, such as the TPB, it has many positive attributes as a
framework for understanding patients’ response to illness and engagement with treat-
ment. Although representations and coping are linked in a logical way, both can and
do change over time as the result of appraisal processes. For example, with an effective
treatment, a patient may become symptom free which, in turn, could make them
believe that they no longer have their condition and hence can stop taking treatment.
The model also incorporates emotional processing, and a patient’s emotional repre-
sentations can also influence motivation to adhere to treatment. For example, as the
result of accessing the internet for medical information, patients may stop or reduce
their medication after reading about possible risks or the negative experiences of other
patients on the same treatment.

The COM‐B Model

The theoretical models presented thus far have focused on patients’ beliefs as the key
drivers to explain patient adherence to their medicines or to other health‐related rec-
ommendations. However, it is now known that there are many other factors that can
have significant effects on health behaviors so a more comprehensive approach is
needed. The COM‐B model (Michie et  al. 2011a) proposes that people need the
capability, [C] opportunity [O], and motivation [M] to perform a particular behavior
(Figure 10.4). It was developed with reference to existing theories of behavior not
just models focused on people’s beliefs. It has been applied to understand behavior in
a number of health contexts such as smoking and obesity (Michie et al. 2011a), dental
hygiene (Asimakopoulou and Newton 2015), improving the adoption of hearing aid
use (Barker et al. 2016), and the provision of health assessments by doctors for school
children (Alexander et al. 2014), as well as treatment adherence (Jackson et al. 2014).
Capability is the psychological and physical ability to engage in the behavior. When
applied to treatment adherence, psychological ability can include the patient’s capac-
ity to understand, to remember, and to plan their treatment (Jackson et al. 2014). For
example, a deficit in prospective memory function means that the patient’s ability to

Capability

Motivation Behavior

Opportunity

Figure 10.4  The COM‐B framework. Source: adapted from Michie et al. (2011b).
198 Vivian Auyeung, Lyndsay D. Hughes, and John A. Weinman

remember to do something in the future, i.e. to take their medicines, can be impaired.
Physical ability refers to the level of physical skill required to actually use medicines or
devices, such as an asthma inhaler or insulin pen needles.
Opportunity covers both the physical and social factors that are external to the indi-
vidual that make the behavior possible or prompt it. Physical factors include the qual-
ity of healthcare communication and also the physical characteristics of the prescribed
treatment, such as the regimen complexity and also the taste and smell of the medi-
cine itself. Moving beyond this clinical focus, physical factors also include family and
friends, i.e. significant others who can encourage medicine taking and, equally, dis-
courage it; this is analogous to the construct of subjective norm as identified in the
TPB. Social factors refers to the wider social context which may include religious
beliefs and cultural beliefs held by the patient (Jackson et al. 2014).
Motivation includes the want or need to perform the behavior more than any other
competing behaviors at that moment; this is driven by both reflective and automatic
brain processes. Reflective or deliberate processes refer to the patient’s beliefs about
medicines and the condition for which the treatment has been prescribed (Jackson
et al. 2014). For example, a patient’s beliefs about the negative impact of side effects,
both anticipated and experienced, or the perceived seriousness of their condition – as
identified earlier in the Self‐Regulatory Model developed by Leventhal and colleagues.
Automatic processes include innate dispositions and impulses arising from associative
learning. This may be a purposefully constructed learning experience. For example, a
patient may establish a routine whereby their medicine taking becomes associated
with a daily behavior such as eating breakfast. When this routine is disrupted, the cue
to action may be missed so the medicines are not taken. Or if the patient associates
setting their alarm clock in the evening with taking their tablets, this routine may be
disrupted if the patient is on holiday.
In addition, the COM‐B is a dynamic model so that not only do the three compo-
nents interact, after the performance of a behavior this can feed back into the person’s
motivation to perform the behavior again and also influence capability and opportu-
nity drivers, both positively if the behavior is successfully performed or negatively if
the patient was unable to perform the behavior. The complex treatment regimen
might be beyond the planning capabilities of a patient, so it may negatively influence
the decision of whether or not to continue taking the treatment over time; especially
if the patient fears disclosure about a health condition which is incorrectly perceived
to have a detrimental effect on their ability to do their job. In this example, there is an
interaction between psychological capability, reflective motivation, and social oppor-
tunity factors.
It is important to note that Jackson et al. (2014) have highlighted that factors may
not necessarily map onto one single subcomponent of the COM‐B model. They iden-
tified four such factors: depression, substance abuse, marital status, and forgetting.
For example, depression might negatively influence engagement to treatment by dis-
torting beliefs about illness and treatment or self‐efficacy (reflective motivation),
impacting mood (automatic motivation), impairing cognitive function (psychological
capability), and withdrawal from any social support (physical opportunity).
The COM‐B model and the associated Behaviour Change Wheel approach (Michie
et al. 2014) is said to allow intervention developers a systematic way to identify the
factors that influence the target behavior. Once this behavioral analysis has been con-
ducted, the corresponding intervention that is most likely to be effective can be
 The Contribution of Beliefs to Treatment Engagement 199

deployed. A corresponding taxonomy of Behaviour Change Techniques (BCT)

(Michie et al. 2013) has also been proposed to assist with the design, evaluation, and
replication of any behavioral interventions. This method of systematically matching
determinants of behavior to interventions via a theoretical framework is argued to
facilitate comparisons between adherence interventions (e.g. Allemann et al. 2016),
and the BCT taxonomy is increasingly being used to describe adherence intervention
designs (e.g. Joost et al. 2014).
The COM‐B model was created to overcome the problem of overlap and confusion
among the plethora of models and frameworks to explain behavior. However, its com-
prehensiveness has also been criticized as one of its key weaknesses: Ogden (2016)
argues that given its constructs are so broad and all‐encompassing it cannot ever be
falsified as a theory. Furthermore, such a rigid and systematic approach risks restrict-
ing the discipline and simply produces technicians that can apply techniques, rather
than promoting innovation (Ogden 2016). Evidence for the utility of the COM‐B
model to guide development of behavior‐change interventions continues to amass
but within the context of individual clinical consultations with patients, the COM‐B
model reminds us that beliefs alone cannot account for variability in patient
behavior.

Summary

Early educational models of patient behavior depicted patients as passive recipi-

ents. In contrast, models such as the HBM and TPB considered individuals to be
active decision‐makers, arguing that individuals make rational decisions about
whether or not to engage in a particular health behavior based on their beliefs.
These models of behavior were mostly concerned with understanding and predict-
ing preventive health behaviors. Such approaches have been criticized for neglect-
ing the role of emotions and unconscious processes – as demonstrated by instances
of habitual behavior. Furthermore, they fail to take into account the dynamic
nature of chronic disease and the ongoing or repetitive nature of certain health
behaviors by depicting the decision‐making process as a one‐off event. The self‐
regulatory approach addresses this particular weakness, explicitly recognizing the
impact of appraisal on future behavior through modifying existing beliefs about
illness and treatment; it also acknowledges the influence, both positive and nega-
tive, of emotions on patient behavior. As the prevalence of chronic illness rises in
an aging society, we need to consider dynamic models that recognize the chang-
ing perspectives of patients living with long‐term treatments. Recently, a more
comprehensive approach has been adopted by researchers and behavior‐change
intervention developers. The Behaviour Change Wheel, incorporating the COM‐B
Model, formally acknowledges the wide variety of factors that can influence
patient behavior: the patient’s physical and psychological capability, aspects of the
social and physical environment, on top of the beliefs and other associations that
patients hold about their illness and treatment. The implication for clinicians and
researchers is clear: patients bring with them their own understanding, their own
sets of beliefs and motivations. These must be considered for successful treatment
engagement alongside the recognition that beliefs alone cannot predict health
behavior.
200 Vivian Auyeung, Lyndsay D. Hughes, and John A. Weinman

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