Exploring self-efficacy as a predictor of disease management

Reliability and validity of the Turkish adaptation of medication adherence self-efficacy scale in hypertensive patients

BACKGROUND

Despite a lot of study related to medication adherence in hypertension, a major problem in research is the measurement of adherence.

AIM

To evaluate the reliability and validity of the Turkish version of the Medication Adherence Self-Efficacy Scale (MASES) among hypertensive patients in an outpatient setting in Turkey.

METHODS

One hundred-forty adult patients, who are receiving medication for hypertension in the last one year, were included to study sample. MASES was translated using a back-translation technique, which includes the use of a panel of experts and interpreters to translate the items from the source language to the target language and then back-translate them to the source language. Psychometric evaluations of MASES-Turkish form were used construct validity; item analysis, principal component analysis and known group validity and internal consistency reliability (Chronbach's alpha)

RESULTS

Reliability coefficient of the Turkish adaptation of MASES was found 0.92, and item-total correlations ranged between 0.26 and 0.72. It was found that factor structure of the MASES-Turkish consisted with original instrument. Patients with uncontrolled hypertension had lower self-efficacy scores compared to those with normal blood pressure.

How important are individual counselling, expectancy beliefs and autonomy for the maintenance of exercise after cardiac rehabilitation?

Aims: We examined whether autonomy supportive and self-efficacy enhancing individual lifestyle counselling was associated with improved maintenance of exercise and physical capacity compared with group based counselling. We also tested whether self-efficacy beliefs and autonomous motivation was associated with improved maintenance of exercise over time. Methods: Randomised controlled trial and longitudinal study of predictor variables. One hundred and seventy six (38 female) patients mainly with coronary heart disease were randomized to either have standard group based rehabilitation or to additionally receive the intervention. Patients were recruited from a 4-week cardiac rehabilitation programme with two years follow-up at Krokeide Centre in Bergen, Norway. Results: We found no statistically significant between-group differences. The groups showed an overall improvement of their self-evaluated physical capacity during the two years of the study, corresponding 7% change of score (p<0.001). The composite exercise score improved 6% during follow-up (p<0.001). Intensity of exercise activities improved 17% from inclusion to 24 months' follow-up (p<0.001). Self-efficacy for increased exercise, general expectancy and autonomous motivation were significant predictors of increased exercise and physical capacity. Controlled motivation hampered physical capacity improvement. Conclusions: Among this self-selected and motivated group of rehabilitation patients we found no additional effect of adding individual counselling to group-based interventions. Based on longitudinal documentation this cardiac rehabilitation programme improves long-term maintenance of exercise and physical capacity and this maintenance is related to autonomous motivation, general expectancy and self-efficacy.

Psychosocial predictors of lifestyle management in adults with epilepsy

The purposes of the work described in this article were to (1) describe a model of predictive relationships among psychosocial variables and lifestyle management, and (2) test the model among people with epilepsy. The variables selected for the model were based on social cognitive theory and the results of previous studies examining psychosocial predictors of self-management among people with chronic physical health conditions. Variables included in the model were self-efficacy, outcome expectancies, depressive symptoms, and social support. Participants for the study were recruited from epilepsy treatment facilities in Boston, MA, and Atlanta, GA, USA. Half of the participants were female, 81% were white, and their mean age was 43.1 years. As predicted by social cognitive theory, self-efficacy was related to lifestyle management and explained 23% of its variation. Depressive symptoms were related to both self-efficacy and social support. Social support was related to self-efficacy. These findings suggest that lifestyle management is influenced by a number of relationships between psychosocial variables, particularly by self-efficacy.

Qualitative analysis of a mutual goal-setting intervention in participants with heart failure

OBJECTIVE

The purpose of this study was to identify factors influencing self-management in patients with heart failure. Themes were determined by examining the review of the Goal Attainment Follow-up Guide and anecdotal records made by nurse interventionists during their implementation of mutual goal setting for the study of participants with heart failure.

METHODS

Anecdotal records from a study using a mutual goal-setting intervention with participants with heart failure were reviewed and analyzed using qualitative methods to determine emerging themes.

RESULTS

The anecdotal records of 27 patients were reviewed. Four themes emerged from this analysis: (1) competing priorities, (2) self-efficacy related to heart failure self-management, (3) activity level, and (4) psychosocial adaptation.

CONCLUSION

Goals set by participants reflected their life experiences and exemplified challenges with heart failure self-management. Some themes reflected the complexity of their lives, whereas other themes demonstrated levels of knowledge and motivation. Mutual goal setting was helpful in understanding the perspective of the participants and their receptivity to the process of adopting health-promoting behaviors.

The role of self-efficacy in vascular risk factor management: a randomized controlled trial

OBJECTIVE

Given the large number of patients at high risk of vascular events, new strategies are needed to reduce vascular risk. We investigated whether self-efficacy promotion could change self-efficacy levels in patients with vascular diseases and whether baseline self-efficacy and changes in self-efficacy were related to changes in vascular risk factors.

METHODS

One hundred fifty-three recently referred patients with symptomatic vascular diseases (cerebrovascular, abdominal, or peripheral arterial) participated in a randomized trial investigating the effect of nursing care, as compared with usual care, on vascular risk factors. Nursing care consisted of self-efficacy promotion and medical treatment of vascular risk factors. Self-efficacy and vascular risk factors (smoking, BMI, waist, blood pressure, lipid, and glucose levels) were measured at baseline and after 1 year.

RESULTS

While total self-efficacy did not change over the 1-year intervention period in either treatment group, self-efficacy in choosing healthy food (mean +0.4+/-1.4, p-value 0.01) and in doing extra exercise (mean +0.3+/-1.3, p-value 0.03) increased in the intervention group. No relation was seen between baseline total self-efficacy or change in composite self-efficacy and change in vascular risk factors.

CONCLUSION

The nursing intervention did not influence total self-efficacy but did improve self-efficacy in choosing healthy food and doing extra exercise. Change in composite self-efficacy was not related to change in vascular risk factors in patients at high risk of developing (new) cardiovascular diseases.

PRACTICE IMPLICATIONS

Influencing self-efficacy in choosing healthy food and doing extra exercise could be incorporated in vascular risk reduction programs in addition to medical treatment of vascular risk factors.

Self-efficacy and self-management behaviors in patients with chronic kidney disease

Although past research has examined self-management among patients with end-stage renal disease (ESRD), little is known about self-management in patients with chronic kidney disease (CKD). In this cross-sectional survey (no intervention), 174 patients with CKD (serum creatinine > or =1.7 mg/dL) completed self-reported measures of self-efficacy, physical and mental functioning, and self-management. The purpose of the study was to explore the association between patients' perceived self-efficacy and their self-management behaviors. Five types of self-management behaviors were measured: communication with caregivers, partnership in care, self-care, self-advocacy, and medication adherence. Controlling for other relevant variables including age, education, diabetic status, hypertension, serum creatinine, physical functioning, and mental health functioning, higher perceived self-efficacy scores were associated with increased communication, partnership, self-care, and medication-adherence behaviors. In this study, patients' perceived self-efficacy was a more consistent correlate of self-management behavior than were demographic or health characteristics. Because self-management has been associated with positive patient outcomes, fostering self-management by supporting patient self-efficacy may have long-term benefits.

Effects of self-efficacy, self-care behaviours on depressive symptom of Taiwanese kidney transplant recipients

AIMS

The aim of this study was to examine the effect of self-efficacy on depression and to consider the mediating effect of self-care behaviour.

BACKGROUND

Depression is a problem for kidney transplant recipients and can compromise their quality of life. From other studies on chronic illnesses, self-efficacy and self-care behaviour have been considered to be potential determinants for depressive symptoms. However, none of these previous studies have investigated the relationships among these variables in kidney transplantation recipients.

DESIGN

A cross-sectional survey employing correlation design and purposive sampling was used.

METHODS

One hundred and seventy-seven persons who had received a kidney transplant participated. A self-administrated questionnaire and a medical record audit were used to collect data. The data were analysed using correlation and hierarchical linear regression methods.

RESULTS

The average score of depressive symptoms was 8.61 SD 7.64. Among the participants in the study, 32.8% had scores of depressive symptoms higher than 11 (indicating mild to severe symptoms of depression). Self-efficacy and self-care behaviour had direct negative effects on depressive symptoms. Self-care behaviour had partial mediating effect on the relationship between self-efficacy and depression. Total variance explained was 23%.

CONCLUSION

Depressive symptoms are still a problem that need to be addressed among kidney transplantation patients. Patients who have higher self-efficacy and higher self-care behaviour will have lower depressive symptoms. Our results support that self-efficacy is the significant predictor of depressive symptoms.

RELEVANCE TO CLINICAL PRACTICE

Self-efficacy is a powerful and modifiable determinant of depressive symptoms. We should design interventions that focus not only on the skill aspects of self-care behaviour but also on those that have a strong connection with self-efficacy. We could incorporate the self-efficacy-enhanced strategies as proposed by social cognitive theory into the kidney transplantation care programme.

Heart disease management by women: does intervention format matter?

A randomized controlled trial of two formats of a program (Women Take PRIDE) to enhance management of heart disease by patients was conducted. Older women (N = 575) were randomly assigned to a group or self-directed format or to a control group. Data regarding symptoms, functional health status, and weight were collected at baseline and at 4, 12, and 18 months. The formats produced different outcomes. At 18 months, the self-directed format was better than the control in reducing the number (p < or = .02), frequency (p < or = .03), and bothersomeness (p < or = .02) of cardiac symptoms. The self-directed format was also better than the group format in reducing symptom frequency of all types (p < or = .04). The group format improved ambulation at 12 months (p < or = .04) and weight loss at 18 months (p < or = .03), and group participants were more likely to complete the program ( p < or = .05). The availability of different learning formats could enhance management of cardiovascular disease by patients.

Self-efficacy mediates the relationship between depressive symptoms and medication adherence among hypertensive African Americans

Many studies have documented the negative effects of depression on adherence to recommended treatment; however, little is known about the mechanism underlying this relationship. Using the Kenny and Baron analytic framework of mediation, the authors assessed whether self-efficacy mediated the relationship between depression and medication adherence in 167 hypertensive African Americans followed in a primary care practice. Depressive symptoms are associated with poor medication adherence (beta=.013, p=.036) and low self-efficacy (beta=-.008, p=.023). Self-efficacy is negatively associated with medication adherence at follow-up (beta=-.612, p<.001). The relationship between depressive symptoms and medication adherence becomes nonsignificant when controlling for self-efficacy (beta=.010, p=.087). Implications for further examination into the mediating role of self-efficacy and the deleterious effect of depression on medication adherence are discussed.

A 6-item brief measure for assessing perceived control of asthma in culturally diverse patients

BACKGROUND

A concise yet accurate measurement tool is needed for use in research and practice in asthma self-management perceptions across culturally diverse patient populations.

OBJECTIVES

To evaluate the psychometric properties of the 11-item Perceived Control of Asthma Questionnaire (PCAQ) and to derive a brief, psychometrically sound, and culturally sensitive measure using item response theory.

METHODS

The PCAQ was administered as one of a battery of measures to 375 adults with asthma as part of an ongoing larger project studying asthma disparities. Analyses of differential item functioning (DIF) were conducted to detect the effects of sex, race/ethnicity, and health literacy on psychometric properties.

RESULTS

Forty-eight percent of the sample was non-Hispanic white and 44% was African American. The mean +/- SD age was 43.7 +/- 13.7 years. The derived 6-item version, with 5 DIF items not scored, correlated highly with its full version (r = 0.903; P < .001).

CONCLUSIONS

The 6-item PCAQ short form has the potential to maintain scale integrity while reducing administration time and lessening survey fatigue in studies using multiple questionnaires. DIF analyses also enabled us to understand the unique aspects of perceived asthma control in demographic groups most affected by asthma.

Evaluation of expectations and knowledge in bariatric surgery patients

BACKGROUND

Preoperative psychosocial evaluations of bariatric surgery candidates primarily focus on screening for psychiatric co-morbidities. However, the role of weight loss expectations and knowledge about surgery can also influence patients' postoperative behavior. The purpose of this study was to investigate preoperative patient knowledge and expectations about postoperative weight loss.

METHODS

Data on the knowledge and expectations were extracted from a database of psychosocial evaluations of 334 bariatric surgery candidates. Expectations were measured by patient report of the expected pounds to be lost. Knowledge was operationalized using the University of Virginia Bariatric Knowledge Scale, a 22-item multiple choice scale, that assesses knowledge about medical, nutritional, and psychosocial components related to bariatric surgery. The data were analyzed using frequencies, descriptive statistics, and analysis of variance.

RESULTS

The data on weight loss expectations from 217 preoperative patients indicated that, compared with the average weight loss data presented in published reports, 65% of patients overestimated the degree of weight loss and only 25% of patients maintained accurate expectations of weight loss. Knowledge data on the nutritional, medical, and behavioral components of the surgery were available for 96 patients. The items frequently answered incorrectly included expected weight loss and the utility of surgery in increasing the ability to make changes in diet and exercise. The mean body mass index differences were observed to determine the accuracy of weight loss expectations

CONCLUSION

The results of our study have shown that a significant number of bariatric surgery patients present with misconceptions about weight loss. The preoperative psychosocial evaluation can be used as an intervention to use psychoeducation, cognitive restructuring, and behavioral interventions to improve patients' knowledge and expectations.

Effects of a diabetes self-management program on glycemic control, coronary heart disease risk, and quality of life among Thai patients with type 2 diabetes

Uncontrolled diabetes is a major health problem in Thailand. The objective of this study was to determine the effects of a diabetes self-management program on glycemic control, coronary heart disease (CHD) risk, and quality of life in 147 diabetic patients (aged 56.8 +/- 10.2 years). Type 2 diabetic patients who met the research criteria were randomized into two groups for a period of 6 months: the experimental group received the diabetes self-management program and the control group received the usual nursing care. The findings indicated that the experimental group demonstrated a significant decrease in the hemoglobin A(1c) level and CHD risk, with an increase in quality of life (QOL) compared to the control group. The diabetes self-management program was effective for improving metabolic control and the QOL for individuals with diabetes. Further studies should be replicated using larger groups over a longer time frame.

Self-efficacy and its association with use of diet-related behavioral strategies and reported dietary intake

The construct of self-efficacy has been widely used in studies of dietary behavior change and is accepted as a helpful process indicator. This study examined associations between self-efficacy and use of specific diet-related behavioral strategies and reported dietary intake over time. Data are from two community surveys of rural adults conducted 1 year apart (n=354). Results indicate that changes in self-efficacy are positively associated with changes in strategy use but not dietary intake. Strategies may be thought of as leading to a particular level of dietary intake but are not the only influence on intake. Findings therefore confirm hypothesized associations between these components of the behavior change process. By attending to and measuring these specific links in the process, researchers and practitioners can better determine where behavioral interventions are succeeding and where they are breaking down.

Work factors related to psychological and health-related distress among employees with chronic illnesses

OBJECTIVE

This study examined specific psychosocial factors associated with psychological and health-related distress amongst employees reporting different chronic illnesses.

METHODS

The sample consisted of 1029 employees managing either musculoskeletal pain (n=324), arthritis and rheumatism (n=192), asthma (n=174), depression and anxiety (n=152), heart disease (n=96) or diabetes (n=91). Information on psychological distress, work limitations, illness management, disclosure, absence, presenteeism, support and demographic factors were obtained through self-administered questionnaires.

RESULTS

Both low psychological well-being and high health-related distress were associated with an increase in work limitations (beta=0.20, SE=.03; and beta=0.19, SE=.01, respectively), poorer management of illness symptoms at work (beta=-0.17, SE=.12; and beta=-0.13, SE=.02), high presentieesm (beta=0.19, SE=.25; and beta=0.14, SE=.05) and low workplace support (beta=-0.05, SE=.22; and beta=-0.12, SE=.05). Health-related distress was additionally associated with disclosure of illness at work (beta=0.18, SE=.08) and long-term sickness absence (beta=0.10, SE=.06).

CONCLUSIONS

To enable individuals to effectively manage both their illness and their work without serious repercussions, it is important for both healthcare professionals and employers alike, to improve the well-being of workers with chronic illness by supporting and facilitating their efforts to over-come health-related limitations at work.

Self-efficacy and health status in patients with coronary heart disease: findings from the heart and soul study

OBJECTIVE

To examine the relationship between cardiac self-efficacy and health status, including symptom burden, physical limitation, quality of life, and overall health among outpatients with stable coronary heart disease (CHD). We hypothesized that lower self-efficacy would predict worse health status, independent of CHD severity and depression.

METHODS

We performed a cross-sectional study of 1024 outpatients with CHD, who were recruited between 2000 and 2002 for the Heart and Soul Study. We administered a validated measure of cardiac self-efficacy, assessed cardiac function using exercise treadmill testing with stress echocardiography, and measured depressive symptoms using the Patient Health Questionnaire. Health status outcomes (symptom burden, physical limitation, and quality of life) were assessed using the Seattle Angina Questionnaire, and overall health was measured as fair or poor (versus good, very good, or excellent).

RESULTS

After adjustment for CHD severity and depressive symptoms, each standard deviation (4.5-point) decrease in self-efficacy score was independently associated with greater symptom burden (adjusted odds ratio (OR) = 2.1, p = .001), greater physical limitation (OR = 1.8, p < .0001), worse quality of life (OR = 1.6, p < .0001), and worse overall health (OR = 1.9, p < .0001). Depressive symptoms and poor treadmill exercise capacity were also associated with poor health status, but left ventricular ejection fraction and ischemia were not.

CONCLUSIONS

Among patients with CHD, low cardiac self-efficacy is associated with poor health status, independent of CHD severity and depressive symptoms. Further study should examine if self-efficacy constitutes a useful target for cardiovascular disease management interventions.

Self-efficacy and overprotection are related to quality of life, psychological well-being and self-management in cardiac patients

This repeated-measures study explores how self-efficacy and overprotection relate to psychological well-being, health-related quality of life and self-management. Eighty-two cardiac patients, suffering from congestive heart failure (CHF) or myocardial infarction (MI), completed questionnaires at T1 and three months later. Perceived overprotection is associated with concurrent levels of anxiety and depression, and lowered quality of life. Self-efficacy is related to psychological well-being in both patient groups, but only associated with quality of life in CHF patients. In addition, self-efficacy predicts MI patients' self-management behaviours in the medium term. Findings have implications for cardiac rehabilitation, where attention may usefully be focused on enhancing self-efficacy and dealing with issues of support and overprotection by the partner.

Effect of personal and cultural beliefs on medication adherence in the elderly

Approximately 50% of patients across all age groups with varied types of medical conditions do not adhere to their prescribed medication regimens. Medication nonadherence is common in older adults who are often prescribed medications for age-related chronic disorders. The purpose of this paper is to investigate the effect of personal and cultural beliefs on older adults' medication adherence through a review of research studies published in journals across different disciplines. A systematic literature search using ten databases found 14 articles meeting the inclusion criteria. Belief-laden variables including self-efficacy (i.e. the belief that one can perform a specific behaviour under differing conditions), medication efficacy, confidence in the physician's knowledge, perceptions about natural products and home remedies, beliefs of control (over one's health), and illness perceptions were found to be significantly related to medication adherence among older adults. However, several measurement, design and sampling problems were identified in this review. The majority of the studies in the review evaluated older adults' medication adherence by self-report and used cross-sectional designs and convenience samples. Future studies should utilise prospective longitudinal designs and a more objective measure of medication adherence, such as electronic event monitoring, when examining factors related to older adults' medication adherence. Future research should also evaluate belief-related variables in larger and more ethnically diverse samples of older adults. Implications for assessment and intervention are evident from this literature review of the effect of personal and cultural beliefs on medication adherence in older adults.

Dealing with self-management of chronic illness at work: predictors for self-disclosure

This paper explores the role of self-management of chronic illness at work, as a predictor for self-disclosure. The study reports findings from a survey sent to all staff at a UK university, of which 610 employees reported managing a chronic illness: arthritis, musculoskeletal pain, diabetes, asthma, migraine, heart disease, irritable bowel syndrome and depression. The study found that discrete self-management factors predicted different levels of disclosure: partial self-disclosure (employees informing line managers about the presence of a chronic illness) and full self-disclosure (employees informing line managers how that chronic illness affected them at work). For partial disclosure, a greater reported experience of chronic illness by employees was positively associated with self-disclosure. For full-disclosure, employees were more likely to report disclosure to line managers if they had already disclosed to colleagues, and if they perceived receiving support from their line managers in relation to their chronic illness as important. Except for academics who were least likely to disclose, occupational groups did not emerge as significant predictors for either partial or full disclosure. Except for diabetes, chronic illness itself was not a significant predictor or barrier to self-disclosure. Our findings suggest that chronically ill employees adopt a disclosure strategy specifically related to different self-management needs of chronic illness at work.

American nurses' work autonomy on patient care and unit operations

Work autonomy is an essential aspect of nurses' professional lives. The aim of this research was to study American nurses' work autonomy and, in particular, autonomy over patient care and unit operations decisions. Data were collected electronically during July of 2004. A total of 300 American nurses were recruited from two clinical listserves in which nurses communicate electronically as a group. Nurses were more autonomous about decisions relating to patient care than unit operations, and their total work autonomy was moderate. Correlations and stepwise regression analyses revealed that nurses' experience, education, and time commitments influenced their work autonomy. Findings suggest that nurses' work autonomy should be enhanced to reach its full potential and that nurse administrators should promote their nurses' work autonomy.

A review and synthesis of research evidence for self-efficacy-enhancing interventions for reducing chronic disability: implications for health education practice (part I)

Disability and poor quality of life attributable to chronic diseases such as arthritis, diabetes, and heart disease constitute challenging public health problems for American society. In the absence of any effective cure for these conditions, the secondary prevention of complications and improving quality of life and functional capacity through better disease self-management becomes critical and are key objectives of Healthy People 2010. The organizing focus of such disease self-management should be on improving coping, communication, and control by enhancing self-efficacy. Part I of this two-part article describes the common clinical features of chronic diseases and the diverse disease management strategies used for alleviating pain and preventing disability associated with these and reviews the role of self-efficacy as a theoretical framework for successful self-management interventions. Part II identifies and synthesizes the key research evidence for educational interventions designed to enhance individual self-efficacy perceptions and presents implications for practice in patient education.

Care satisfaction, hope, and life functioning among adults with bipolar disorder: data from the first 1000 participants in the Systematic Treatment Enhancement Program

OBJECTIVE

The Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) is designed to evaluate the longitudinal outcome of patients with bipolar disorder. The STEP-BD disease-management model is built on evidence-based practices and a collaborative care approach designed to maximize specific and nonspecific treatment mechanisms. This prospective study examined the longitudinal relationships between patients' satisfaction with care, levels of hope, and life functioning in the first 1000 patients to enter STEP-BD.

METHODS

The study used scores from the Care Satisfaction Questionnaire, Beck Hopelessness Scale, Range of Impaired Functioning Tool, Young Mania Rating Scale, and Montgomery-Asberg Depression Rating Scale at 5 time points during a 1-year interval. Analyses tested mediational pathways between care satisfaction, hope, and life functioning, depression, and mania using mixed-effects (random and fixed) regression models.

RESULTS

Increases in care satisfaction were associated with decreased hopelessness (P < .01) but not related to symptoms of depression or mania. Similarly, decreased hopelessness was associated with better life functioning (P < .01) but not related to symptoms of depression or mania. Depression was independently associated with poorer life functioning (P < .0001).

CONCLUSIONS

This study provided support for the hypothesized mediational pathway between care satisfaction, hopelessness, and life functioning. Findings suggest that providing care that maximizes patient hope may be important. By so doing, patients might overcome the learned helplessness/hopelessness that often accompanies a cyclical illness and build a realistic illness-management strategy.

Medication non-adherence among older adults: a review of strategies and interventions for improvement

Medication non-adherence among older adults is a prevalent and costly problem; approximately one half have problems following their prescribed medication regimen, and more than 10% of hospital admissions are the result of medication non-adherence. In this literature review, medication non-adherence is defined and described among adults age 50 and older. Factors associated with medication non-adherence are presented, interventions to improve medication non-adherence are discussed, and methods for assessing medication non-adherence are reviewed. In addition, nursing assessment and intervention to improve medication non-adherence are described.

Empowerment of patients with end-stage renal disease--a randomized controlled trial

The purpose of the study is to investigate the effectiveness of an empowerment program on empowerment level, self-care self-efficacy and depression in patients with end-stage renal disease. The study was a randomized controlled trial; qualified patients in two dialysis centers of major hospitals in southern Taiwan were randomly assigned into an empowerment group (n=25) and a control group (n=25). The empowerment program included identification of problem areas for self-management; exploration of emotions associated with these problems; development of a set of goals and strategies to overcome these problems to achieve these goals; creation and implementation of behavioral change plans; and stress management. The outcomes measured were the Empowerment Scale, the Strategies Used by People to Promote Health and the Beck Depression Inventory. Data were collected at baseline and 6 weeks following intervention. Primary statistical analysis was by means of t-test and analysis of covariance. The results indicated that scores of the empowerment (t(48)=6.54, p<0.001), self-care self-efficacy (F(1,47)=10.82, p=0.002) and depression (t(48)=2.49, p=0.03) in the empowerment group have a significantly greater improvement than the control group.

Changes in self-efficacy and health status over 5 years: a longitudinal observational study of 306 patients with rheumatoid arthritis

OBJECTIVE

To investigate changes in self-efficacy and health status over 5 years in patients with rheumatoid arthritis (RA), the relationships between these changes, and the influence of baseline values on subsequent changes.

METHODS

306 adult patients with RA, born in 1926 or later, were examined by questionnaire in 1994 and again in 1999. We analyzed data regarding pain (visual analogue scale [VAS], Arthritis Impact Measurement Scale [AIMS2] symptom scale, Short Form-36 [SF-36] pain scale), fatigue (VAS, SF-36 vitality scale), mental distress (AIMS2 affect scale, SF-36 mental health scale) and self-efficacy (Arthritis Self-Efficacy Scales for pain and for other symptoms).

RESULTS

On group level, all health status measures were numerically somewhat improved, and self-efficacy slightly reduced. Changes in self-efficacy and in corresponding health status measures were significantly correlated. For patients with above average educational level self-efficacy for pain at baseline was positively correlated to improvement in pain measures. Good mental health at baseline was correlated to improvement in self-efficacy for other symptoms, but only for patients with below average educational level.

CONCLUSION

Baseline self-efficacy seems to influence future level of perceived pain and baseline mental health status seems to influence future self-efficacy. These associations seem to be affected by level of education.

Can a disease self-management program reduce health care costs? The case of older women with heart disease

BACKGROUND

There is increasing interest in the potential for chronic disease self-management interventions to provide health benefits while reducing health care costs.

OBJECTIVES

To assess the impact of a heart disease management program on use of hospital services; to estimate associated hospital cost savings; and to compare potential cost savings with the cost of delivering the program.

RESEARCH DESIGN

Randomized, controlled study design. Data were collected from hospital billing records during a 36 month period. Multivariate models were used to compare health care use with cost between treatment and control groups. Estimated differences were then compared with the program costs to determine cost-effectiveness.

SUBJECTS

Participants were recruited from 6 hospital sites. Screening criteria included: female, 60 years or older, diagnosed cardiac disease, and seen by a physician approximately every 6 months. The study included 233 women in the intervention group and 219 in the control group. The "Women Take PRIDE" program utilizes a self-regulation process for addressing a problematic area of the heart regimen recommended by each woman's physician. It is tailored to the unique needs of older women.

MEASURES

Hospital admissions, in-patient days, emergency department visits.

RESULTS

Program participants experienced 46% fewer in-patient days (P <0.05) and 49% lower in-patient costs (P <0.10) than women in the control group. No significant differences in emergency department utilization were found. Hospital cost savings exceeded program costs by a ratio of nearly 5-to-1.

CONCLUSIONS

A heart disease self-management program can reduce health care utilization and potentially yield monetary benefits to a health plan.

Epilepsy self-management: a comparison of self-efficacy and outcome expectancy for medication adherence and lifestyle behaviors among people with epilepsy

The purpose of this study was to describe self-efficacy beliefs and outcome expectancies toward medication, seizure, and lifestyle management behaviors among 108 adults with epilepsy. Participants responded to an adapted version of the Epilepsy Self-Efficacy and Epilepsy Outcome Expectancy scales. Modifiable behavioral risk factors such as confidence for following medication dosing schedule, planning for medication refills, coping with adverse effects of medication, getting sufficient sleep, avoiding alcohol, and obtaining social support were identified. A larger proportion of persons reported higher self-efficacy for medication management behaviors than for healthful lifestyle behaviors. Findings from this study extend previous research on chronic disease that showed that individuals may be adherent with medication therapy, but not with healthful lifestyle behaviors necessary for the prevention and treatment of chronic disease. Individuals with low self-efficacy would benefit from interventions that increase efficacy beliefs to enhance their ability to adopt and maintain good self-management practices.

Concepts in health promotion. Perceived self-efficacy and barriers in older adults

Many older adults have reached later life in apparent good health while others' lack of self-care activities has greatly accelerated the process of aging. In this article, self-efficacy and perceived barriers are explored as significant concepts that influence the self-care activities of elderly individuals. A conceptual model is presented depicting perceived self-efficacy and barriers as determinants of self-care activities. This conceptual model differs from earlier health promotion models because it is specific for older adults. Based on empirical studies, this conceptual model demonstrates that the variables of perceived self-efficacy and barriers have a profound effect on an older adult's participation in self-care activities. Testing of this model is needed to provide a knowledge base for designing health promotion strategies, maximizing cost containment strategies, and contributing to Healthy People 2010 objectives of increasing quality of life for all older adults.

The influence of social support on chronic illness self-management: a review and directions for research

A review of the empirical literature examining the relationship between social support and chronic illness self-management identified 29 articles, of which 22 were quantitative and 7 were qualitative. The majority of research in this area concerns diabetes self-management, with a few studies examining asthma, heart disease, and epilepsy management. Taken together, these studies provide evidence for a modest positive relationship between social support and chronic illness self-management, especially for diabetes. Dietary behavior appears to be particularly susceptible to social influences. In addition, social network members have potentially important negative influences on self-management There is a need to elucidate the underlying mechanisms by which support influences self-management and to examine whether this relationship varies by illness, type of support, and behavior. There is also a need to understand how the social environment may influence self-management in ways other than the provision of social support

Leading the Way in Exercise and Diet (Project LEAD): intervening to improve function among older breast and prostate cancer survivors

The U.S. population is aging, bringing with it an increased prevalence of chronic disease and concomitant declines in physical function. The risk of developing cancer increases significantly with age, and functional decline is much more likely once a cancer diagnosis is rendered. Thus, functional status in later life is a key concern, one that is heightened among elders who have been diagnosed with cancer. To date, however, there have been few trials that have exclusively addressed issues related to cancer survivorship among older cancer patients, and to our knowledge, none has focused on preserving or enhancing physical functioning. This paper describes the study design and methodological considerations of a randomized controlled trial to determine if a personally tailored workbook and telephone counseling program can positively affect physical activity and dietary behaviors and ultimately the physical functioning of up to 420 older men and women newly diagnosed with breast or prostate cancer. This trial is unique because the cancer diagnosis is used not only as a marker of risk for functional decline, but also as a "teachable moment" - an opportune time when elders may be more receptive to making beneficial lifestyle changes. Undoubtedly, as cure rates for cancer increase and intersect with ever-growing numbers of elderly, there will be numerous opportunities to provide and test interventions within this vulnerable population and to target functional status as a primary outcome. In reporting our methods, we hope to give others "a leg up," so that they can hurdle with greater ease the barriers we experienced, and thus advance the field more rapidly.

The role of choice in health education intervention trials: a review and case study

Although the randomized, controlled trial (RCT) is considered the gold standard in research for determining the efficacy of health education interventions, such trials may be vulnerable to "preference effects"; that is, differential outcomes depending on whether an individual is randomized to his or her preferred treatment. In this study, we review theoretical and empirical literature regarding designs that account for such effects in medical research, and consider the appropriateness of these designs to health education research. To illustrate the application of a preference design to health education research, we present analyses using process data from a mixed RCT/preference trial comparing two formats (Group or Self-Directed) of the "Women take PRIDE" heart disease management program. Results indicate that being able to choose one's program format did not significantly affect the decision to participate in the study. However, women who chose the Group format were over 4 times as likely to attend at least one class and were twice as likely to attend a greater number of classes than those who were randomized to the Group format. Several predictors of format preference were also identified, with important implications for targeting disease-management education to this population.

Health-related interactions and the self in marriage

This study investigated the association between self processes and married partners' (N = 59 couples) perspectives of their health-related social interactions. Findings revealed that wives' self processes were associated with their social behavior from the perspective of each partner. The wives' self processes differentially predicted wives' and husbands' perspectives of their interactions, however. These findings demonstrate that wives' future expectations for the health of their husband, as well as for their role in maintaining his future health, motivate their current social behavior to promote the positive health lifestyle behaviors of their husband.

Effect on hip fractures of increased use of hip protectors in nursing homes: cluster randomised controlled trial

OBJECTIVE

To assess the effects of an intervention programme designed to increase use of hip protectors in elderly people in nursing homes.

DESIGN

Cluster randomised controlled trial with 18 months of follow up.

SETTING

Nursing homes in Hamburg (25 clusters in intervention group; 24 in control group).

PARTICIPANTS

Residents with a high risk of falling (459 in intervention group; 483 in control group).

INTERVENTION

Single education session for nursing staff, who then educated residents; provision of three hip protectors per resident in intervention group. Usual care optimised by brief information to nursing staff about hip protectors and provision of two hip protectors per cluster for demonstration purposes.

MAIN OUTCOME MEASURE

Incidence of hip fractures.

RESULTS

Mean follow up was 15 months for the intervention group and 14 months for the control group. In total 167 residents in the intervention group and 207 in the control group died or moved away. There were 21 hip fractures in 21 (4.6%) residents in the intervention group and 42 hip fractures in 39 (8.1%) residents in the control group (relative risk 0.57, absolute risk difference -3.5%, 95% confidence interval -7.3% to 0.3%, P=0.072). After adjustment for the cluster randomisation the proportions of fallers who used a hip protector were 68% and 15% respectively (mean difference 53%, 38% to 67%, P=0.0001). There were 39 other fractures in the intervention group and 38 in the control group.

CONCLUSION

The introduction of a structured education programme and the provision of free hip protectors in nursing homes increases the use of protectors and may reduce the number of hip fractures.

Program development for promoting adherence during and after exercise therapy for urinary incontinence

This paper presents the development process of a health education program to promote adherence to a pelvic floor muscle exercise (PFME) therapy for women with urinary incontinence (UI). The development process started with a needs assessment phase in which the health problem, health-related quality of life, and behavioral and environmental determinants were assessed. Guided by the intervention mapping (IM) approach, program objectives were formulated and, on the basis of both empirical and theoretical data, intervention methods for influencing determinants of adherence to PFME therapy were chosen and translated into practical strategies. This information was assimilated to a transparent description of the program design. The theoretical rationale of the program was based on the transtheoretical model, the self-regulation theory and principles of targeted communication and sex-specific health care.

The relative importance of physician communication, participatory decision making, and patient understanding in diabetes self-management

OBJECTIVE

Patients' self-management practices have substantial consequences on morbidity and mortality in diabetes. While the quality of patient-physician relations has been associated with improved health outcomes and functional status, little is known about the impact of different patient-physician interaction styles on patients' diabetes self-management. This study assessed the influence of patients' evaluation of their physicians' participatory decision-making style, rating of physician communication, and reported understanding of diabetes self-care on their self-reported diabetes management.

DESIGN

We surveyed 2,000 patients receiving diabetes care across 25 Veterans' Affairs facilities. We measured patients' evaluation of provider participatory decision making with a 4-item scale (Provider Participatory Decision-making Style [PDMstyle]; alpha = 0.96), rating of providers' communication with a 5-item scale (Provider Communication [PCOM]; alpha = 0.93), understanding of diabetes self-care with an 8-item scale (alpha = 0.90), and patients' completion of diabetes self-care activities (self-management) in 5 domains (alpha = 0.68). Using multivariable linear regression, we examined self-management with the independent associations of PDMstyle, PCOM, and Understanding.

RESULTS

Sixty-six percent of the sample completed the surveys (N = 1,314). Higher ratings in PDMstyle and PCOM were each associated with higher self-management assessments (P < .01 in all models). When modeled together, PCOM remained a significant independent predictor of self-management (standardized beta: 0.18; P < .001), but PDMstyle became nonsignificant. Adding Understanding to the model diminished the unique effect of PCOM in predicting self-management (standardized beta: 0.10; P =.004). Understanding was strongly and independently associated with self-management (standardized beta: 0.25; P < .001).

CONCLUSION

For these patients, ratings of providers' communication effectiveness were more important than a participatory decision-making style in predicting diabetes self-management. Reported understanding of self-care behaviors was highly predictive of and attenuated the effect of both PDMstyle and PCOM on self-management, raising the possibility that both provider styles enhance self-management through increased patient understanding or self-confidence.

Intentions to use an automated external defibrillator during a cardiac emergency among a group of seniors trained in its operation

OBJECTIVE

By decreasing the time to defibrillation, automated external defibrillators (AEDs) provide an opportunity for lay people to improve survival in out-of-hospital sudden cardiac arrest. We examined how beliefs, expectations, and actual performance are related to intentions to use an AED during a future heart emergency among a group of seniors.

DESIGN AND OUTCOME MEASURES

One hundred fifty-nine seniors who had been previously trained in the operation of an AED were tested on their AED skills and asked about their perceptions regarding their AED skills; their expectations that an AED would save the life of a cardiac arrest victim; and their intentions to use an AED during a future cardiac event.

RESULTS

Logistic regression analyses showed that greater self-perceived ability to use an AED better actual performance on skills assessment but not expectations regarding the efficacy of AED treatment were independently associated with positive intentions to use an AED in a future heart emergency.

CONCLUSIONS

The likelihood that an elderly lay bystander will actually use an AED during a cardiac event may be closely tied to perceptions of his or her ability to operate an AED.

Self-efficacy as a predictor of adult adjustment to sickle cell disease: one-year outcomes

OBJECTIVE

The present study prospectively investigated the role of self-efficacy in predicting disease symptomatology and health services utilization for adult patients with sickle cell disease.

METHODS

These data are derived from a 12-month prospective cohort study of African American adults with sickle cell disease. Disease-specific perceptions of coping self-efficacy and indices of disease severity, health care utilization, and psychosocial adjustment were assessed by use of standardized questionnaires administered by trained clinicians.

RESULTS

Perceptions of self-efficacy for coping with sickle cell disease were moderately stable across the 12-month study period. At baseline (N = 147), significant inverse relationships, measured with Pearson correlations, were noted between self-efficacy and the following variables: physical symptoms, psychological symptoms, pain severity, and number of physician visits over the preceding 12 months (p <.01). Similar relationships with self-efficacy were noted at the 1-year follow-up (N = 104) period for measures of physical symptoms, psychological symptoms, and pain severity (p <.01). In multiple-regression models, baseline self-efficacy scores predicted changes over the 1-year study period in physical and psychological sickle cell disease symptomatology. Moreover, changes in self-efficacy from baseline to 1-year follow-up were significantly and independently related to changes in physical symptoms, psychological symptoms, and pain ratings from baseline to 1-year follow-up.

CONCLUSIONS

Self-efficacy beliefs among African American adults with sickle cell disease are inversely related to reported disease symptomatology, and these relationships persist across time. Future investigations should examine the mechanisms through which relationships between self-efficacy and adjustment to sickle cell disease are effected, as well as the feasibility and effectiveness of enhancing self-efficacy beliefs as a means of improving adjustment to sickle cell disease.

Self-regulation training enhances dietary self-efficacy and dietary fiber consumption

OBJECTIVE

To evaluate the effectiveness of incorporating two self-regulation strategies (goal setting and self-monitoring) into a nutrition education class to enhance dietary fiber self-efficacy and foster a positive change in dietary fiber consumption.

DESIGN

College students in an introductory nutrition class (n = 113) were randomly assigned to one of four treatment conditions: goal setting, self-monitoring, goal setting and self-monitoring, and no goal setting and no self-monitoring. Twenty-six college students from an introductory health class served as the control group.

STATISTICAL ANALYSES

The main and interaction effects of goal setting and self-monitoring on postintervention variables were analyzed using analysis of covariance with baseline intake levels as the covariate. Analysis of variance was used to examine differences in the mean changes between the groups. Path analysis was conducted to analyze the causal linkage among the pretest and intervening variables to predict postintervention knowledge, self-efficacy, and fiber consumption.

RESULTS

Goal setting had a significant main effect on dietary fiber self-efficacy and on dietary fiber consumption Subjects who set goals scored 15% higher on the dietary fiber self-efficacy scale and consumed 91% more fiber than subjects who did not set goals. Self-monitoring had no significant main effect on either dietary fiber self-efficacy or dietary fiber consumption. There was no significant interaction between goal setting and self-monitoring. Changes in dietary fiber scores differed between the groups. Increases in dietary fiber for the goal setting and self-monitoring group were significantly higher than the goal-setting, self-monitoring, no goal setting and no self-monitoring, and control groups. In addition, the goal setting only group had significantly greater increases in fiber intake than the self-monitoring, no goal setting and no self-monitoring, and control groups. Changes in self-efficacy scores were significantly different between the groups. The goal setting and goal setting and self-monitoring groups had significantly higher self-efficacy scores than the control group. Path analysis revealed that both goal setting and self-monitoring affected dietary fiber consumption through knowledge and dietary fiber self-efficacy, goal setting had a strong direct effect on fiber consumption, and postintervention knowledge affected fiber consumption only through self-efficacy.

APPLICATIONS/CONCLUSIONS

Our findings suggest that dietary change requires active self-regulation of food intake. Combining goal setting and self-monitoring significantly enhances dietary behavior change. This strategy can easily be incorporated into nutrition education or counseling programs to enhance dietary behavior change.

Activities of the APN to enhance unpartnered elders self-efficacy after myocardial infarction

Unpartnered elders recovering from a myocardial infarction find themselves with limited support to contend with their physical and emotional recovery. The advanced practice nurse (APN) can play an instrumental role in improving the health outcomes of these elders. Detailed description of the activities of the APN that affect patient outcomes in current randomized clinical trials have been inadequate in published reports. Therefore, the purpose of this article is to describe the activities of an APN in a nurse-coached intervention study for unpartnered elders post-myocardial infarction. Thematic analysis from the subject logs and narratives from the APN identified the four themes of patient education, validation/feedback, encouragement/support, and problem solving as the unique activities of the APN. These activities enhanced the recovery of these vulnerable unpartnered elders after a myocardial infarction.

Internal locus of control and social support associated with some dietary changes by elderly participants in a diet intervention trial

OBJECTIVE

Measure relationships of locus of control and social support to diet changes in an intervention trial.

DESIGN

Participants in the Polyp Prevention Trial (PPT) completed Multidimensional Health Locus of Control (MHLC) and Norbeck Social Support Questionnaires (NSSQ) and modified Block food frequency questionnaires. Data were collected at baseline and 1 year later.

SUBJECTS/SETTING

A convenience sample of PPT intervention (N = 68) and control (n = 43) participants at 1 clinical center participated in this ancillary study.

MAIN OUTCOME MEASURES

Mean daily dietary intakes after 1 year were compared with baseline values. Intervention participants' scores for MHLC internal locus of control and NSSQ total functional network were correlated with diet changes.

STATISTICAL ANALYSES PERFORMED

Group percentages were compared using the Fisher exact test; means were compared by t test.

RESULTS

Groups were comparable in demographics, baseline diet, and scores for internal locus of control and total functional network. Intervention group participants made greater diet changes than control participants in intake of fat (-27 g vs -8 g), fat as a percentage of kilocalories (-8% vs -2%), fiber as grams per 1,000 kcal (7 g vs 0.3 g), and daily fruit/vegetable servings (2.0 vs 0.2). Pearson correlations of diet changes with internal locus of control scores (all P > .05) were fat grams, r = 0.031; fat as percentage of kilocalories, r = 0.023; fiber grams per 1,000 kcal; r = 0.230; and fruit/vegetable servings, r = 0.186. Correlations with total functional network scores were: fat grams, r = 0.022 (P > .05); fat as percentage of kilocalories, r = -0.108 (P > .05); fiber grams per 1,000 kcal, r = 0.276, P < .05; and daily fruit/vegetable servings, r = 0.326, P < .05.

APPLICATIONS/CONCLUSIONS

Intensive and skillful dietary intervention can succeed whether or not clients bring strong internal locus of control or social support to the diet change program.

Changes in functional health status of older women with heart disease: evaluation of a program based on self-regulation

OBJECTIVES

This study involving 570 women aged 60 years or older with heart disease, assessed the effects of a disease management program on physical functioning, symptom experience, and psychosocial status.

METHODS

Women were randomly assigned to control or program groups. Six to eight women met weekly with a health educator and peer leader over 4 weeks to learn self-regulation skills with physical activity as the focus. Evaluative data were collected through telephone interviews, physical assessments, and medical records at baseline and 4 and 12 months post baseline.

RESULTS

At 12 months, compared with controls, program women were less symptomatic (p < .01), scored better on the physical dimension of the Sickness Impact Profile (SIP; p < 0.05), had improved ambulation as measured by the 6-minute walk (p < 0.01), and lost more body weight (p < .001). No differences related to psychosocial factors as measured by the SIP were noted.

CONCLUSION

A self-regulation-based program that was provided to older women with heart disease and that focused on physical activity and disease management problems salient to them, improved their physical functioning and symptom experience. Psychosocial benefit was not evident and may be a result of measurement error or due to insufficient program time spent on psychosocial aspects of functioning.