Journal of Behavioral Medicine

, Volume 38, Issue 4, pp 673–688 | Cite as

Theory of planned behavior and adherence in chronic illness: a meta-analysis

  • Antonia Rich
  • Kim Brandes
  • Barbara Mullan
  • Martin S. Hagger


Social-cognitive models such as the theory of planned behavior have demonstrated efficacy in predicting behavior, but few studies have examined the theory as a predictor of treatment adherence in chronic illness. We tested the efficacy of the theory for predicting adherence to treatment in chronic illness across multiple studies. A database search identified 27 studies, meeting inclusion criteria. Averaged intercorrelations among theory variables were computed corrected for sampling error using random-effects meta-analysis. Path-analysis using the meta-analytically derived correlations was used to test theory hypotheses and effects of moderators. The theory explained 33 and 9 % of the variance in intention and adherence behavior respectively. Theoretically consistent patterns of effects among the attitude, subjective norm, perceived behavioral control, intention and behavior constructs were found with small-to-medium effect sizes. Effect sizes were invariant across behavior and measurement type. Although results support theory predictions, effect sizes were small, particularly for the intention-behavior relationship.


Adherence Compliance Meta-analysis Chronic illness Theory of planned behavior 



We would like to thank Selena Russo for her assistance with data extraction and analysis, Jemma Todd for her assistance with R Studio and the authors who sent additional data.

Conflict of interest

Antonia Rich, Kim Brandes, Barbara Mullan, Martin S. Hagger declare that they have no conflict of interest to disclose

Human and Animal Rights and Informed Consent

No animal or human studies were carried out by the authors for this article.

Supplementary material

10865_2015_9644_MOESM1_ESM.docx (47 kb)
Supplementary material 1 (DOCX 46 kb)


  1. Ajzen, I. (1985). From intentions to actions: A theory of planned behavior. In J. Kuhl & J. Beckman (Eds.), Action-control: From cognition to behavior (pp. 11–39). Heidelberg: Springer.Google Scholar
  2. Ajzen, I. (1991). The theory of planned behavior. Organizational Behavior and Human Decision Processes, 50, 179–211.Google Scholar
  3. Ajzen, I. (2014). The theory of planned behaviour is alive and well, and not ready to retire: A commentary on Sniehotta, Presseau, and Araújo-Soares. Health Psychology Review. doi: 10.1080/17437199.2014.883474 Google Scholar
  4. Ajzen, I., & Fishbein, M. (1980). Understanding attitudes and predicting social behaviour. Englewood Cliffs, NJ: Prentice-Hall.Google Scholar
  5. Albarracin, D., et al. (2001). Theories of reasoned action and planned behavior as models of condom use: A meta-analysis. Psychological Bulletin, 127, 142–161.PubMedGoogle Scholar
  6. Alwan, A. (2011). Global status report on noncommunicable diseases 2010. Geneva: World Health Organization.Google Scholar
  7. Armitage, C. J. (2014). Time to retire the theory of planned behaviour? A commentary on Sniehotta, Presseau and Araújo-Soares. Health Psychology Review. doi: 10.1080/17437199.2014.892148 PubMedGoogle Scholar
  8. Armitage, C. J., & Conner, M. (2001). Efficacy of the theory of planned behaviour: A meta-analytic review. British Journal of Social Psychology, 40, 471–499.PubMedGoogle Scholar
  9. Bagozzi, R. P. (1981). An examination of the validity of two models of attitude. Multivariate Behavioral Research, 16, 323–359.Google Scholar
  10. Bagozzi, R. P., et al. (1992). Development and test of a theory of technological learning and usage. Human Relations, 45, 659–686.Google Scholar
  11. Brandes, K., & Mullan, B. (2014). Can the common-sense model predict adherence in chronically ill patients? A meta-analysis. Health Psychology Review, 8, 129–153.PubMedGoogle Scholar
  12. Campbell, N. C., et al. (2007). Designing and evaluating complex interventions to improve health care. British Medical Journal, 334, 455–459.PubMedCentralPubMedGoogle Scholar
  13. Carr, J. Z., et al. (2003). Climate perceptions matter: A meta-analytic path analysis relating molar climate, cognitive and affective states, and individual level work outcomes. Journal of Applied Psychology, 88, 605–619.PubMedGoogle Scholar
  14. Cohen, J. (1992). A power primer. Psychological Bulletin, 112, 155.PubMedGoogle Scholar
  15. Conner, M. (2014). Extending not retiring the theory of planned behaviour: A commentary on Sniehotta, Presseau and Araújo-Soares. Health Psychology Review. doi: 10.1080/17437199.2014.899060 Google Scholar
  16. Conner, M., & Sparks, P. (2005). Theory of planned behaviour and health behaviour. In M. Conner & P. Norman (Eds.), Predicting health behaviour (pp. 170–222). Maidenhead: Open University Press.Google Scholar
  17. Cooke, R., & French, D. P. (2008). How well do the theory of reasoned action and theory of planned behaviour predict intentions and attendance at screening programmes? A meta-analysis. Psychology and Health, 23, 745–765.PubMedGoogle Scholar
  18. Costa, V., et al. (2012). Partner support, social-cognitive variables and their role in adherence to self-monitoring of blood glucose in type 2 diabetes. European Diabetes Nursing, 9, 81–86.Google Scholar
  19. Courneya, K. S., et al. (2008). Predictors of supervised exercise adherence during breast cancer chemotherapy. Medicine and Science in Sports and Exercise, 40, 1180–1187.PubMedGoogle Scholar
  20. de Bruin, M., et al. (2012). Self-regulatory processes mediate the intention-behavior relation for adherence and exercise behaviors. Health Psychology, 31, 695–703.PubMedGoogle Scholar
  21. Dickersin, K. (1990). The existence of publication bias and risk factors for its occurrence. JAMA, 263, 1385–1389.PubMedGoogle Scholar
  22. Didarloo, A. R., et al. (2012). Prediction of self-management behavior among iranian women with type 2 diabetes: Application of the theory of reasoned action along with self-efficacy (ETRA). Iranian Red Crescent Medical Journal, 14, 86–95.PubMedCentralPubMedGoogle Scholar
  23. DiMatteo, M. R. (2004). Variations in patients’ adherence to medical recommendations: A quantitative review of 50 years of research. Medical Care, 42, 200–209.PubMedGoogle Scholar
  24. DiMatteo, M. R., et al. (2007). Health beliefs, disease severity, and patient adherence: A meta-analysis. Medical Care, 45, 521–528.PubMedGoogle Scholar
  25. DiMatteo, M. R., et al. (2012). Improving patient adherence: A three-factor model to guide practice. Health Psychology Review, 6, 74–91.Google Scholar
  26. Duval, S., & Tweedie, R. (2000). Trim and fill: A simple funnel plot based method of testing and adjusting for publication bias in meta-analysis. Biometrics, 56, 455–463.PubMedGoogle Scholar
  27. Easterbrook, P. J., et al. (1991). Publication bias in clinical research. The Lancet, 337, 867–872.Google Scholar
  28. Fan, X., et al. (1999). Effects of sample size, estimation methods, and model specification on structural equation modeling fit indexes. Structural Equation Modeling: A Multidisciplinary Journal, 61, 56–83.Google Scholar
  29. Ferguson, C. J., & Heene, M. (2012). A vast graveyard of undead theories publication bias and psychological science’s aversion to the null. Perspectives on Psychological Science, 7, 555–561.Google Scholar
  30. Fishbein, M., & Ajzen, I. (1975). Belief, attitude, intention and behavior: An introduction to theory and research. Reading, MA: Addison-Wesley.Google Scholar
  31. Fishbein, M., & Ajzen, I. (2010). Predicting and changing behavior: The reasoned action approach. New York: Psychology Press (Taylor & Francis).Google Scholar
  32. Gatt, S., & Sammut, R. (2008). An exploratory study of predictors of self-care behaviour in persons with type 2 diabetes. International Journal of Nursing Studies, 45, 1525–1533.PubMedGoogle Scholar
  33. Godin, G., & Kok, G. (1996). The theory of planned behavior: A review of its applications to health-related behaviors. American Journal of Health Promotion, 11, 87–98.PubMedGoogle Scholar
  34. Gollwitzer, P. M., & Sheeran, P. (2006). Implementation intentions and goal achievement: A meta-analysis of effects and processes. Advances in Experimental Social Psychology, 38, 69–119.Google Scholar
  35. Grenard, J. L., et al. (2011). Depression and medication adherence in the treatment of chronic diseases in the United States: A meta-analysis. Journal of General Internal Medicine, 26, 1175–1182.PubMedCentralPubMedGoogle Scholar
  36. Hagger, M. S., & Chatzisarantis, N. L. (2009). Integrating the theory of planned behaviour and self-determination theory in health behaviour: A meta-analysis. British Journal of Health Psychology, 14, 275–302.PubMedGoogle Scholar
  37. Hagger, M. S., & Chatzisarantis, N. L. (2014a). An integrated behavior change model for physical activity. Exercise and Sport Sciences Reviews, 42, 62–69.PubMedGoogle Scholar
  38. Hagger, M. S., & Chatzisarantis, N. L. D. (2014b). It is premature to regard the ego-depletion effect as ‘Too Incredible’. Frontiers in Psychology, 5, 1–2.Google Scholar
  39. Hagger, M. S., & Chatzisarantis, N. L. D. (2015). The trans-contextual model of autonomous motivation in education: Conceptual and empirical issues and meta-analysis. Review of Educational Research. doi: 10.3102/0034654315585005 Google Scholar
  40. Hagger, M. S., & Luszczynska, A. (2014). Implementation intention and action planning interventions in health contexts: State of the research and proposals for the way forward. Applied Psychology: Health and Well-Being, 6, 1–47.Google Scholar
  41. Hagger, M. S., et al. (2002). A meta-analytic review of the theories of reasoned action and planned behavior in physical activity: Predictive validity and the contribution of additional variables. Journal of Sport & Exercise Psychology, 24, 3–32.Google Scholar
  42. Hall, P. A. (2014). Re-establishing momentum in theory development: a commentary on Sniehotta, Presseau and Araújo-Soares. Health Psychology Review. doi: 10.1080/17437199.2014.896080 Google Scholar
  43. Hall, P. A., & Fong, G. T. (2010). Temporal self-regulation theory: Looking forward. Health Psychology Review, 4, 83–92.Google Scholar
  44. Hardeman, W., et al. (2002). Application of the theory of planned behaviour in behaviour change interventions: A systematic review. Psychology and Health, 17, 123–158.Google Scholar
  45. Haskard-Zolnierek, K. B., & DiMatteo, M. R. (2009). Physician communication and patient adherence to treatment: A meta-analysis. Medical Care, 47, 826–834.PubMedCentralGoogle Scholar
  46. Hausenblas, H. A., et al. (1997). Application of the theories of reasoned action and planned behavior to exercise behavior: A meta-analysis. Journal of Sport & Exercise Psychology, 19, 36–51.Google Scholar
  47. Haynes, R. B., et al. (2008). Interventions for enhancing medication adherence. Cochrane Database Syst Rev, 2, CD000011.PubMedGoogle Scholar
  48. Hebert, E. A., et al. (2010). Attrition and adherence in the online treatment of chronic insomnia. Behavioral Sleep Medicine, 8, 141–150.PubMedGoogle Scholar
  49. Higgins, E. T., et al. (2003). Transfer of value from fit. Journal of Personality and Social Psychology, 84, 1140–1153.PubMedGoogle Scholar
  50. Hooghe, M., et al. (2010). Why can’t a student be more like an average person? Sampling and attrition effects in social science field and laboratory experiments. Annals of the American Academy of Political and Social Science, 628, 85–96.Google Scholar
  51. Horne, R., & Weinman, J. (1999). Patients’ beliefs about prescribed medicines and their role in adherence to treatment in chronic physical illness. Journal of Psychosomatic Research, 47, 555–567.PubMedGoogle Scholar
  52. Horne, R., et al. (2005). Concordance, adherence and compliance in medicine taking. London: NCCSDO.Google Scholar
  53. Horne, R., et al. (2013). Understanding patients’ adherence-related beliefs about medicines prescribed for long-term conditions: A meta-analytic review of the necessity-concerns framework. PLoS ONE, 8, e80633.PubMedCentralPubMedGoogle Scholar
  54. Hu, L. T., & Bentler, P. M. (1999). Cutoff criteria for fit indexes in covariance structure analysis: Conventional criteria versus new alternatives. Structural Equation Modeling: A Multidisciplinary Journal, 6, 1–55.Google Scholar
  55. Jackson, C., et al. (2014). Applying COM-B to medication adherence. The European Health Psychologist, 16, 7–17.Google Scholar
  56. Jones, C. J., et al. (2013). Evaluating the effectiveness of health belief model interventions in improving adherence: A systematic review. Health Psychology Review, 8, 1–17.Google Scholar
  57. Kardas, P., et al. (2013). Determinants of patient adherence: A review of systematic reviews. Frontiers in Pharmacology, 4, 91.PubMedCentralPubMedGoogle Scholar
  58. Kohler, J. C., & Baghdadi-Sabeti, G. (2011). The world medicines situation 2011. Geneva: World Health Organization.Google Scholar
  59. Langebeek, N., et al. (2014). Predictors and correlates of adherence to combination antiretroviral therapy (ART) for chronic HIV infection: A meta-analysis. BMC Medicine, 12, 142.PubMedCentralPubMedGoogle Scholar
  60. Leventhal, H., et al. (1980). The common sense representation of illness danger. Contributions to Medical Psychology, 2, 7–30.Google Scholar
  61. Loghman-Adham, M. (2003). Medication noncompliance in patients with chronic disease: Issues in dialysis and renal transplantation. American Journal of Managed Care, 9, 155–173.PubMedGoogle Scholar
  62. Manning, M. (2009). The effects of subjective norms on behaviour in the theory of planned behaviour: A meta-analysis. British Journal of Social Psychology, 48, 649–705.PubMedGoogle Scholar
  63. McEachan, R. R. C., et al. (2011). Prospective prediction of health-related behaviours with the theory of planned behaviour: A meta-analysis. Health Psychology Review, 5, 97–144.Google Scholar
  64. McHorney, C. A. (2008). The adherence estimator: A brief, proximal screener for patient propensity to adhere to prescription medications for chronic disease. Current Medical Research and Opinion, 25, 215–238.Google Scholar
  65. McLachlan, S., et al. (2011). The development of a scale measuring integrated regulation in exercise. Br J Health Psychol, 16, 722–743.PubMedGoogle Scholar
  66. Michie, S., et al. (2011). The behaviour change wheel: A new method for characterising and designing behaviour change interventions. Implementation Science, 6, 42.PubMedCentralPubMedGoogle Scholar
  67. Miller, P., et al. (1992). Fishbein’s Model of Reasoned Action and compliance behavior of hypertensive patients. Nursing Research, 41, 104–106.PubMedGoogle Scholar
  68. Moher, D., et al. (2009). Preferred Reporting Items for Systematic reviews and Meta-analyses: The PRISMA statement. Annals of Internal Medicine, 151, 264–269.PubMedGoogle Scholar
  69. Morisky, D. E., et al. (1986). Concurrent and predictive validity of a self-reported measure of medication adherence. Medical Care, 24, 67–74.PubMedGoogle Scholar
  70. Mullan, B., et al. (2011). The role of executive function in bridging the intention-behaviour gap for binge-drinking in university students. Addictive Behaviors, 36, 1023–1026.PubMedGoogle Scholar
  71. Nieuwlaat, R., et al. (2014). Interventions for enhancing medication adherence. Cochrane Database of Systematic Reviews, 11, CD000011.Google Scholar
  72. Ockene, I. S., et al. (2002). Task Force #4—adherence issues and behavior changes: Achieving a long-term solution. Journal of the American College of Cardiology, 40, 630–640.PubMedGoogle Scholar
  73. Ogden, J. (2014). Time to retire the theory of planned behaviour? One of us will have to go! A commentary on Sniehotta, Presseau and Araújo-Soares. Health Psychology Review. doi: 10.1080/17437199.2014.898679 PubMedGoogle Scholar
  74. Osterberg, L., & Blaschke, T. (2005). Adherence to medication. New England Journal of Medicine, 353, 487–497.PubMedGoogle Scholar
  75. Peters, G.-J. Y., et al. (2013). Everything should be as simple as possible, but no simpler: Towards a protocol for accumulating evidence regarding the active content of health behaviour change interventions. Health Psychology Review, 9, 1–14.PubMedCentralPubMedGoogle Scholar
  76. Peters, J. L., et al. (2007). Performance of the trim and fill method in the presence of publication bias and between-study heterogeneity. Statistics in Medicine, 26, 4544–4562.PubMedGoogle Scholar
  77. Rhodes, R. E. (2014). Will the new theories (and theoreticians!) please stand up? A commentary on Sniehotta, Presseau and Araújo-Soares. Health Psychology Review. doi: 10.1080/17437199.2014.882739 Google Scholar
  78. Ried, L. D., & Christensen, D. B. (1988). A psychosocial perspective in the explanation of patients’ drug-taking behavior. Social Science and Medicine, 27, 277–285.PubMedGoogle Scholar
  79. Rosenstock, I. (1974). The health belief model and preventive health behaviour. Education Monographs, 2, 354–386.Google Scholar
  80. Sabaté, E. (2003). Adherence to long-term therapies: Evidence for action. Geneva: World Health Organization.Google Scholar
  81. Sainsbury, K., & Mullan, B. (2011). Measuring beliefs about gluten free diet adherence in adult coeliac disease using the theory of planned behaviour. Appetite, 56, 476–483.PubMedGoogle Scholar
  82. Sainsbury, K., et al. (2013). Gluten free diet adherence in coeliac disease. The role of psychological symptoms in bridging the intention–behaviour gap. Appetite, 61, 52–58.PubMedGoogle Scholar
  83. Schulze, R., & Wittmann, W. W. (2003). A meta-analysis of the theory of reasoned action and the theory of planned behavior: The principle of compatibility and multidimensionality of beliefs as moderators. In R. Schulze, H. Holling, & D. Böhning (Eds.), Meta-analysis: New Developments and Applications in Medical and Social Sciences (pp. 219–250). Seattle, WA: Hogrefe & Huber.Google Scholar
  84. Schwarzer, R. (2008). Modeling health behavior change: How to predict and modify the adoption and maintenance of health behaviors. Applied Psychology, 57, 1–29.Google Scholar
  85. Sheeran, P. (2002). Intention-behavior relations: A conceptual and empirical review. European Review of Social Psychology, 12, 1–36.Google Scholar
  86. Sheeran, P., & Orbell, S. (1998). Do intentions predict condom use? Meta-analysis and examination of six moderator variables. British Journal of Social Psychology, 37, 231–250.PubMedGoogle Scholar
  87. Sheeran, P., & Taylor, S. (1999). Predicting intentions to use condoms: A meta-analysis and comparison of the theories of reasoned action and planned behavior. Journal of Applied Social Psychology, 29, 1624–1675.Google Scholar
  88. Sheeran, P., et al. (2013). Nonconscious processes and health. Health Psychology, 32, 460–473.PubMedGoogle Scholar
  89. Shet, A., et al. (2014). Effect of mobile telephone reminders on treatment outcome in HIV: Evidence from a randomised controlled trial in India. BMJ, 349, g5978.PubMedCentralPubMedGoogle Scholar
  90. Sniehotta, F. (2009a). An experimental test of the theory of planned behavior. Applied Psychology: Health and Well-Being, 1, 257–270.Google Scholar
  91. Sniehotta, F. F. (2009b). Towards a theory of intentional behaviour change: Plans, planning, and self-regulation. British Journal of Health Psychology, 14, 261–273.PubMedGoogle Scholar
  92. Sniehotta, F., et al. (2015). On the development, evaluation and evolution of health behaviour theory. Health Psychology Review. doi: 10.1080/17437199.2015.1022902 Google Scholar
  93. Sniehotta, F. F., et al. (2005). Bridging the intention–behaviour gap: Planning, self-efficacy, and action control in the adoption and maintenance of physical exercise. Psychology and Health, 20, 143–160.Google Scholar
  94. Sniehotta, F. F., et al. (2014). Time to retire the theory of planned behaviour. Health Psychology Review, 8, 1–7.PubMedGoogle Scholar
  95. Sterne, J. A., et al. (2011). Recommendations for examining and interpreting funnel plot asymmetry in meta-analyses of randomised controlled trials. British Medical Journal, 343, 302–307.Google Scholar
  96. Syrjala, A. M. H., et al. (2002). The theory of reasoned action in describing tooth brushing, dental caries and diabetes adherence among diabetic patients. Journal of Clinical Periodontology, 29, 427–432.PubMedGoogle Scholar
  97. Terrin, N., et al. (2005). In an empirical evaluation of the funnel plot, researchers could not visually identify publication bias. Journal of Clinical Epidemiology, 58, 894–901.PubMedGoogle Scholar
  98. Todd, J., et al. (2014). Reasoned versus reactive prediction of behaviour: A meta-analysis of the prototype willingness model. Health Psychology Review. doi: 10.1080/17437199.2014.922895 Google Scholar
  99. Topa, G., & Moriano, J. A. (2010). Theory of planned behavior and smoking: Meta-analysis and SEM model. Substance Abuse and Rehabilitation, 1, 23–33.PubMedCentralPubMedGoogle Scholar
  100. Trafimow, D. (2014). On retiring the TRA/TPB without retiring the lessons learned: A commentary on Sniehotta, Presseau and Araújo-Soares. Health Psychology Review. doi: 10.1080/17437199.2014.884932 Google Scholar
  101. Trafimow, D., et al. (2002). Evidence that perceived behavioural control is a multidimensional construct: Perceived control and perceived difficulty. British Journal of Social Psychology, 41, 101–121.PubMedGoogle Scholar
  102. Viechtbauer, W. (2010). Conducting meta-analyses in R with the metafor package. Journal of Statistical Software, 36, 1–48.Google Scholar
  103. Vissman, A. T., et al. (2013). Correlates of HAART adherence among immigrant Latinos in the Southeastern United States. AIDS Care, 25, 356–363.PubMedGoogle Scholar
  104. Viswesvaran, C., & Ones, D. S. (1995). Theory testing: Combining psychometric meta-analysis and structural equations modeling. Personnel Psychology, 48, 865–885.Google Scholar
  105. Wallace, L., et al. (2014). Planning for, implementing and assessing the impact of health promotion and behaviour change interventions: A way forward for health psychologists. Health Psychology Review, 8, 8–33.PubMedGoogle Scholar
  106. Webb, T. L., & Sheeran, P. (2006). Does changing behavioral intentions engender behavior change? A meta-analysis of the experimental evidence. Psychological Bulletin, 132, 249–268.PubMedGoogle Scholar
  107. West, R., & Brown, J. (2013). Theory of addiction. Chichester: Wiley.Google Scholar

Copyright information

© Springer Science+Business Media New York 2015

Authors and Affiliations

  • Antonia Rich
    • 1
    • 2
  • Kim Brandes
    • 1
    • 3
  • Barbara Mullan
    • 4
  • Martin S. Hagger
    • 4
  1. 1.Atlantis HealthcareNorth RydeAustralia
  2. 2.Graduate School of HealthUniversity of Technology SydneySydneyAustralia
  3. 3.Amsterdam School of Communication ResearchUniversity of AmsterdamAmsterdamThe Netherlands
  4. 4.Health Psychology and Behavioral Medicine Research Group, School of Psychology and Speech Pathology, Faculty of Health SciencesCurtin UniversityPerthAustralia

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