Self-efficacy in management of osteoarthritis

Rheum Dis Clin N Am 29 (2003) 747 – 768

Self-efficacy in management of osteoarthritis John P. Allegrante, PhDa,b,c,*, Ray Marks, EdDa,c a

Department of Health and Behavior Studies, Teachers College, Columbia University, 525 West 120th Street, Box 114, New York, NY 10027, USA b Mailman School of Public Health, Columbia University, 722 West 168th Street, New York, NY 10032 – 2603, USA c Research Division, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA

Self-efficacy is a psychologic construct defining a person’s confidence in performing a particular behavior and in overcoming barriers to that behavior. It is a significant predictor of psychologic well-being, adherence to prescribed treatments, and pain coping mechanisms in patients who have arthritis. Enhanced self-efficacy might also preserve function and prolong physical well-being in people who have chronic arthritis. This article reviews the theory of self-efficacy, describes applications of self-efficacy in the management of osteoarthritis (OA), and presents approaches to enhancing patients’ self-efficacy in the clinical management of OA and prevention of OA-related disability. In addition, it contains a discussion of a hypothetical model to explain how self-efficacy might influence OA disability.

The theory of self-efficacy Historical background Self-efficacy, a term describing an individual’s belief in his or her ability to successfully perform a future task or specific behavior, was initially proposed as a powerful mediator of behavior by the eminent Stanford psychologist Albert Bandura [1]. Derived from social cognitive theory, which assumes that personal characteristics affect behavior, the concept of self-efficacy involves three interrelated domains: (1) having tacit task knowledge and related skills, (2) having an explicit sense of confidence in one’s ability to mobilize the motivation and cognitive resources required to perform a specific task or skill, and (3) having

* Corresponding author. Department of Health and Behavior Studies, Teachers College, Columbia University, 525 West 120th Street, Box 114, New York, NY 10027. E-mail address: [email protected] (J.P. Allegrante). 0889-857X/03/$ – see front matter D 2003 Elsevier Inc. All rights reserved. doi:10.1016/S0889-857X(03)00060-7

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confidence in one’s ability to successfully execute a specific task, behavior, or skill in a given context. These three elements and the value placed on the anticipated outcome by the individual are viewed by Bandura [1– 3] as potent mediators of an individual’s willingness to perform a given task. Self-efficacy beliefs can also mediate levels of motivation, moods and attitudes, and the capacity and willingness to elicit health-promoting behaviors [4,5] despite the presence of disability. Self-efficacy beliefs have also been found to predict how much effort a person will expend on a task in the face of obstacles and adverse experiences [1,4]. Self-efficacy and osteoarthritis With respect to an association between self-efficacy levels and chronically painful and potentially disabling OA [6], despite intact knowledge of how to perform a task the performance ability of people who have OA might be reduced by pain. The presence of fear, stress, and anxiety in the face of diminished physical ability might affect function similarly. In addition, poor pain coping skills and mood fluctuations congruent with a perceived reduction in functional ability [7] can impair function, as can fatigue [8] and a perception of helplessness [9]. Moreover, the patient’s confidence in his or her ability to perform routine activities of daily living might be further eroded if OA demands the use of novel movement strategies or adaptive devices. The psychologic impact of this cycle of events might reinforce debilitating behaviors and result in physical inactivity and diminished social, economic, and psychologic rewards. This deleterious situation might further debase self-judgments, confidence levels, and generalized self-efficacy [10] regardless of the severity of the disease [11]. Notably, self-efficacy for exercise might diminish considerably, adversely affecting health status, regardless of the individual’s belief in the benefits of exercise [12]. The failure to believe in one’s ability to cope with pain and to overcome barriers to exercise despite persistent pain might hence be an overlooked, albeit extremely important, factor contributing to avoidance behaviors in patients who have OA. These avoidance behaviors might further diminish the patient’s ability to function physically, hastening damage to affected and unaffected joints (Fig. 1). That is, the extent of the disability experienced by people who have OA might be influenced negatively and substantially by diminished confidence in their functional ability. This might be the case even if the joints in question have good mobility. Relevance of self-efficacy in the context of osteoarthritis management Understanding the degree to which perceptions of self-efficacy can influence the physical, social, and economic capacities of people who have OA is particularly relevant in an aging population, members of which might be susceptible to the detrimental effects of commonly prescribed drugs. Other patients might have

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Fig. 1. Model of OA disability depicting pathologic and nonpathologic interactions including selfefficacy effects.

limited monetary and physical means at their disposal for seeking medical attention, including physical or occupational therapy. Even individuals who are affluent and can afford medical and therapeutic assistance on a regular basis might suffer unduly from the effects of aging on mobility and independence and from the chronicity and unpredictability of OA. In these cases the patient’s overall condition and quality of life (and that of family members) might depend to a large degree upon the patient’s ability to perceive the situation from an optimal perspective (ie, one that enables the patient to carry out skills or perform desired behaviors that build self-confidence and facilitate coping and control [13] in the face of a potentially debilitating medical condition [14]). The general well-being and overall health status of people who have OA might depend on their belief in their ability to undertake self-management activities prescribed by the physician successfully to help maintain physical and mental wellbeing. In the case of obese individuals who have OA, such activities will often include weight reduction and dietary change. Research indicates that low selfefficacy might mediate poor health outcomes, especially pain and poor mental health status [15].

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Enhancing self-efficacy Fortunately, self-efficacy beliefs, which might affect patients’ ability to adjust to and successfully manage the pain and disability of OA are amenable to intervention [16]. Enhancement of self-efficacy might foster the adoption and maintenance of favorable health behaviors and the ability to discontinue unfavorable behaviors [1,17,18]. The ability to engage in specific behaviors in specific situations regardless of where and when these might occur can likewise depend on the magnitude of perceived self-efficacy for performing a particular task such as using public transportation.

Review aims and summary tables Some individuals who have OA might be confident in their ability to perform their daily tasks without any need for direct intervention; however, many people diagnosed with OA are likely to be less than confident in their ability to adapt successfully to various aspects of daily life. This review specifically focuses on interventions to enhance perceptions of self-efficacy as they might apply to successful adaptation to the various manifestations of OA (Box 1) [19]. In addition, a vast array of medical and nonmedical factors might influence OA morbidity (Box 2). Management strategies that are commonly recommended to offset these physiologic, physical, or psychosocial determinants of OA include those shown in Box 3. Tasks and behaviors that people who have OA might need to learn to self-manage their condition include those listed in Box 4.

Box 1. Manifestations of osteoarthritis in which perceptions of self-efficacy might enhance adaptation to the consequences of the disease Pain in one or more joints, muscle, soft tissue, or bone Stiffness of one or more joints Joint swelling and inflammation Decreased range of motion in one or more joints Deformity or instability in one or more joints Depression or anxiety Diminished muscle strength and endurance Difficulty performing tasks of daily living Limitations in social activity, work, and recreational activity Impaired balance or joint sensory perception Chronic comorbid conditions such as heart disease, diabetes, cancer, and respiratory conditions that might further limit the ability of the patient to function physically and confidently [20]

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Box 2. Medical and nonmedical factors that can influence the morbidity of osteoarthritis Persistent pain resulting in avoidance behaviors Poor psychologic adjustment caused by fear or anxiety Lack of confidence in one’s prevailing abilities Poor pain coping skills Low self-esteem and self-worth Limited knowledge about the disease Mood fluctuations Stress and fatigue Muscle weakness Reduced aerobic capacity Limited flexibility of joints and muscles Obesity or malnourishment A feeling of helplessness Affective distress in general Poor physician communication skills Sleep disturbance Marital status and stability Poor adherence to long-term treatment regimens Deficient social support Age, race, ethnicity, socioeconomic status, educational level, occupational status, and gender Self-efficacy for function and managing arthritis pain Outcome expectations

Box 3. Management strategies commonly recommended for patients who have osteoarthritis Range of motion, strengthening, and aerobic exercises Weight loss or weight normalization Joint protection and energy conservation strategies Use of assistive devices or aids Medication regimens Surgery Home and workplace modifications Patient education to improve knowledge and self-management skills and to strengthen self-efficacy and outcome expectations

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Box 4. Information required by people who have osteoarthritis to effectively self-manage their disease How to use medications correctly How to carry out behaviors designed to improve symptoms or slow disease progression How to interpret and report symptoms accurately How to adjust to their condition socially and economically How to cope with the emotional consequences of their disease How to participate in decisions concerning prescribed treatments How to communicate effectively with physicians and other caregivers How to modify their work, recreational, and home environments effectively How to manage their condition postoperatively, if and when required

Application of self-efficacy theory in the management of osteoarthritis Background One of the earliest indications that self-efficacy might be an important mediator of arthritis-related outcomes was provided by the success of the Arthritis SelfManagement Program (ASMP)—a program not originally set within the theoretical framework of social cognitive theory, but one in which participants exhibited significant early and sustained clinical improvement. This improvement seemed to be linked closely to changes in self-efficacy scores for pain and other arthritis symptoms such as self-efficacy for managing fatigue [21,22]. The heightened selfefficacy scores appeared to be associated with improvement in (1) the ability to manage pain, (2) a decrease in depression, and (3) an increase in exercise, relaxation, and self-management behaviors [23,24]. Moreover, participation in the ASMP program reduced the use of medical services while reducing health care costs by $189 per OA patient [25]. It also produced improvements in the participant’s perception of control, general activity status, their ability to adjust to their situation, and their health status [26]. These results were generally consistent with those of a number of studies of persons who had various forms of arthritis of varying severity who participated in similar self-management programs [27 – 31]. Results of correlational studies Among people who have painful, disabling knee OA, competency beliefs related to the management of arthritis symptoms were shown to account for 15% of the performance variance, especially in the presence of lower extremity weakness [32,33]. Gaines et al [34] similarly observed that self-efficacy scores accounted for 7% to 21% of self-reported functional ability in subjects who had knee OA.

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Results of several correlational studies have likewise stressed the importance of self-efficacy beliefs in mediating key arthritis-related outcomes such as suffering, feelings of helplessness [35], and overt pain behaviors such as limping, facial grimaces, and guarded movements [36]. These effects are apparent even after controlling for disease activity and demographic variables, suggesting that arthritis pain behaviors are mediated to a considerable degree by self-efficacy perceptions, not only by disease severity (Table 1). OA patients’ pain self-efficacy, feelings of mastery [33], and general selfefficacy perceptions about their functional ability [14,37] can also affect their psychologic well-being and their ability to feel sufficiently empowered to carry out basic self-care activities. In the context of OA self-management, higher pain selfefficacy beliefs predict less use of avoidance behaviors [38] and the ability of patients who have knee OA to get down to the floor, to stand, and to ascend and descend a flight of stairs [39]. Strong self-efficacy beliefs can attenuate functional declines in the face of diminished physical capacity [14]. They might also influence self-reported ratings

Table 1 Studies demonstrating positive relationships between self-efficacy levels and key outcomes in management of osteoarthritis Study

Sample

Results

Buescher et al [36]

72 RA cases

Taal et al [31]

86 RA cases

Venohr [37]

202 Older adults

Beckham [63]

65 RA cases

Gecht et al [12]

81 Arthritis cases

Keefe et al [59]

130 Knee OA cases

Arnstein et al [11]

126 Chronic pain cases

Brus et al [41]

65 RA cases

Lefebvre et al [7]

128 RA cases

Asgari & Nicholas [38]

145 Chronic pain cases

Patient pain behaviors were related to self-efficacy, not solely to disease activity. Self-efficacy was related to subjective experience of health status. Pain and general self-efficacy partially explained with arthritis and were important influences in maintaining psychologic well-being. Patient self-efficacy expectations including control over arthritis-related symptoms predicted caregiver burden and optimism; caregiver pessimism was related to patient’s physical status. Self-efficacy for exercise was associated with participation in and adherence to exercise. Adaptive pain coping was related to enhanced self-efficacy. Lack of belief in one’s own ability to manage, cope, and function despite persistent pain predicts the extent to which individuals who have chronic pain become disabled or depressed. Self-efficacy and adherence to medication were related. Self-efficacy ratings were significantly related to daily ratings of pain, mood, coping, and coping efficacy. Higher pain self-efficacy beliefs predicted reduced avoidance behaviors over time.

Abbreviation: RA, rheumatoid arthritis.

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of (1) the severity of knee pain during stair climbing and lifting/carrying tasks, (2) task difficulty, and (3) the perceived ability to perform tasks, even after controlling for physical function [33]. Perceptions of self-efficacy have been found to mediate the outcomes of physical activity programs designed to improve the functional status of people who have knee OA [40] and to predict exercise adherence in the elderly [20]. Adherence by individuals who have OA to health recommendations that might have a strong bearing on their disease status might be related to their expectations about their ability to cope with their circumstances and health condition [41,42]. Having high self-efficacy for coping, for exerting control over stressors, and for mobilizing the social network effectively have been shown to mitigate the fatigue associated with inflammatory arthritis [8]. Arnstein et al [11] found that a diminished sense of self-efficacy contributed to disability and depression in people who had chronic pain, and they advocated inclusion of measures to enhance selfefficacy beliefs in treatment regimens for chronic pain. This latter approach seems valid even though a number of recent studies have shown that participation in an intervention program (eg, group education) is better than standard treatment for improving self-efficacy outcomes for people who have OA [16,27,43]. As indicated by Braden et al [29] and Lorig and Gonzalez [44], specific self-efficacy –enhancing strategies impact more significantly upon an individual’s sense of confidence and thereby improve the health status of people who have arthritis to a greater degree than programs that do not contain such strategies. Specific self-efficacy – related studies In accordance with the results of Braden et al [29], Lorig and Holman [22] and Lorig and Gonzalez [44], Allegrante et al [45] reported favorable results in a comprehensive hospital-based patient education program based on self-efficacy theory. This program specifically tried to promote functional capacity among patients who had disabling knee OA by enhancing their self-efficacy for walking. A randomized, controlled trial to evaluate the ability of this intervention to improve function of people who had knee OA [46] showed that the intervention resulted in significant and clinically meaningful improvement in the patient’s functional status without an increase in pain. As part of this study, 47 patients who had moderate to severe knee OA participated in an 8-week walking education program conducted for approximately 90 minutes three times per week for groups of 10 to 15 patients. A control group of 45 patients who had knee OA was included for comparison purposes. Each session included direct instruction by a trained interventionist or a guest speaker on a topic of special interest, provision of social support, light physical activity, and walking. Participants also received a manual describing exercises to be learned, a videotape and audiocassette about walking, and a diary in which they were asked to record their physical activity levels during the study. To enhance self-efficacy and task mastery, participants were exposed to the

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four primary strategies recommended by Bandura [2,3] for increasing behavioral competence: 1. 2. 3. 4.

Facilitation of task performance or skills mastery Exposure to direct or vicarious walking experiences Social and verbal encouragement and persuasion Assistance in dealing with emotions believed to impede adherence to recommendations about walking

The program was organized into four successive phases that incorporated selected methods of fostering the desired behaviors derived from behavioral psychology precepts. The first phase involved promoting, shaping, and guiding the adoption of the walking practices using a variety of reinforcement strategies. The second phase involved having the patients provide evidence of their commitment to walking. The third phase promoted the maintenance of walking under a variety of conditions. The final phase attempted to help the patients recognize high-risk situations for relapse. In comparison with the control group, the interventions to enhance selfefficacy resulted in clinically meaningful improvement in walking distance and positive effects in the participants’ perceptions of their physical abilities. Scores for their ability to manage arthritis-related symptoms other than pain (eg, fatigue) were also significantly improved. Despite these favorable short-term results, a 1-year follow-up study [47] showed that interventions to promote self-efficacy in patients who have disabling knee OA might need to include periodic booster sessions if the initial positive effects are to be sustained. In addition, an emphasis on enhancing the patient’s belief in the benefits of exercise might improve exercise adherence in people who have moderate to severe disease limitations [12]. Enhancing exercise self-efficacy, which is similarly associated with participation in exercise activities [12], might be important in sustaining initial program benefits [48]. Further opportunities for participants to meet and share concerns with other similar patients in a nonthreatening and socially supportive environment might be required to prolong the benefits [26]. Because self-efficacy beliefs are likely to have a profound effect on the ability of older adults who have knee pain—especially those who have lower extremity muscle weakness—to maintain a viable level of function [32], these suggestions are highly pertinent to management of people who have knee OA. More recently, the self-efficacy theory was applied by Allegrante et al [49] in a hospital setting to foster competence and self-confidence in regaining function among older people who had sustained hip fractures. The intervention used written materials, mutual aid and peer support, telephone interviews, and a motivational videotape. The study showed that hip fracture patients who received this multiplecomponent intervention performed more ably in their physical roles 6 months after the fracture than those who did not. It is possible that the greater improvements in physical ability reported by the patients in the experimental arm of this study occurred because the group was better

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at dealing with their fear of falling. It is also possible that they were more able to adapt to their new health situation and to carry out their exercise prescriptions more effectively and consistently because they felt more empowered. These factors could have helped them undertake self-care practices more ably. It also might have helped them overcome the challenging task demands of recovery and cope more successfully with pain, fatigue, depression, and weakness. In a similar group education program for people who had rheumatoid arthritis (RA), Taal et al [42] helped participants adjust to their exercise, rest, and medication regimens and to their varying levels of disease activity by helping them make correct decisions about adjustments in their treatment regimen and fostering ‘‘self-management’’ behaviors. Based on Bandura’s social learning theory [1– 3] and the ASMP developed by Lorig and Holman [22], the goal of this program was to strengthen the individuals’ perceived self-efficacy, outcome expectations, and self-management behaviors and, ultimately, to improve their health status. Results of a prospective trial established significant positive effects of the training intervention on functional ability, joint tenderness, adherence to relaxation and physical exercise regimens, self-management behaviors, outcome expectations, and overall self-efficacy for function and knowledge. Positive results of the intervention with respect to the practice of exercise, self-efficacy for function, and knowledge were still evident 14 months after implementation. Hammond et al [50] similarly applied the self-efficacy theory as a framework for evaluating the outcome of an educational –behavioral joint protection program for people who had RA that might be helpful if adapted for people who have OA. The strategies used to maximize adherence to joint protection principles were similar to those advocated by Jensen et al [51] and included goal setting, contracting, modeling, homework programs, physical practice, improving recall, and mental practice. Although no significant changes were noted in pain, functional disability, grip strength, self-efficacy, or helplessness, the use of joint protection strategies was increased significantly at 12 and 24 weeks, suggesting that the specific cognitive behavioral methods used in this study were effective in facilitating adoption of this specific health behavior; however, the investigator’s focus on disability and on passive interventions rather than exercise might have failed to optimally reinforce those self-efficacy perceptions needed to effect positive health outcomes among people who have arthritis [40]. In addition, the ability to enhance physical well-being among people who have OA might be increased by combining principles of self-management, adult learning, case management, and self-efficacy enhancement in an interdisciplinary program that integrates group and individualized treatment [4,52]. This method might require a collaborative intervention effort rather than one directed solely by the patient’s physician. The findings of Alderson [52] stress the value of this approach. People who had arthritis who participated in a program aimed at promoting independent self-management that incorporated concepts of self-efficacy enhancement theory showed increases in self-efficacy immediately after the program that were sustained for up to 6 months. Disability and pain also decreased over the follow-up period.

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Conflicting findings Substantial support for the introduction of strategies to enhance self-efficacy into regimens for individuals who have OA is available in correlational studies examining relevant outcomes (Table 1), even though some studies provide conflicting results: For example, Newman [53] found self-efficacy for function was not affected after an arthritis self-help course. Although Schiaffino et al [54] noted that self-efficacy beliefs were associated with better function and greater use of problem solving among arthritis patients who had more severe pain, greater selfefficacy correlated with greater depression. French [55], who demonstrated favorable changes in psychologic disability and depression among women who had OA after a self-management program that included self-efficacy theory, found no significant improvement in pain. More recently, Stephenson et al [56] found that while older African Americans showed improvement in physical function after completing an arthritis self-help course, self-efficacy measures for exercise and cognitive symptom management were not influenced by the intervention. Similarly, Barlow [57] found no evidence that self-efficacy mediated outcomes in patients who had ankylosing spondylitis. It is important to consider these findings in light of recent evidence that arthritis self-efficacy and self-reported functional performance in patients who have knee OA can vary with gender [58]. Furthermore, results of reports that have examined self-efficacy among people who have RA or other forms of arthritis might not apply to people who have OA. Self-efficacy outcomes might also fluctuate depending upon the readiness of the patient to adopt new behaviors. For example, patients who have already adopted a behavioral change might be more confident than those who have not even contemplated such a change. The interventionist and his ability to communicate effectively with the patient and the nature of the intervention approach employed might also help explain inconsistent findings in the literature [59,60], as might intra- and interindividual variation in self-efficacy perceptions. For example, the Arthritis Self-Efficacy Scale [61] contains five items covering aspects of pain, nine items related to function, and six items related to control. While individuals might be confident that they can perform one or more of these items and score highly, they might be unconfident about other items.

Approaches to enhancing self-efficacy Recommended strategies To promote self-efficacy for a given behavior and general confidence in one’s performance ability, Bandura [2,3] and Strecher [5] have suggested that clinicians try several strategies: 1. Try to identify and reinforce the patient’s past and present successes or accomplishments. 2. Direct the patient to observe successful behaviors of others.

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3. Provide positive feedback for the patient’s efforts or encourage people in the patient’s social network to do so. 4. To help the patient adopt new health behaviors, clinicians can try to ensure that their patients do not interpret incorrectly how they are feeling. For example, if a patient felt anxious about undertaking a new behavior such using an assistive device, the clinician might explain that this feeling is reasonable given what the patient is being asked to undertake and is likely to abate when the requisite skill is acquired. In the study mentioned previously, Kovar et al [46] attempted to maximize the self-efficacy of OA subjects for walking, pain, and management of other symptoms by incorporating the above four elements into their intervention design. To do this successfully they divided their intervention into four successive phases: 1. 2. 3. 4.

Try to promote the adoption of walking. Have patients document their commitment to walking. Try to promote maintenance of the walking activities. Try to prevent problems leading to walking nonadherence.

The primary goal of the program was to enhance self-confidence levels through a variety of learning activities including lectures, discussions, brainstorming, demonstrations, goal-setting, modeling, and mutual aid and support. Secondary goals were to provide participants with information about the benefits of regular physical activity, salient role models, skills training, and peer support using a team approach. For example, the group meetings involved discussions, demonstrations, an exercise component, and a social component. Patients worked together with their leader and with each other to achieve their goals. Hammond et al [50], who attempted to enhance adherence to a joint protection program for people who had arthritis, similarly included goal setting, contracting, modeling, homework programs, and methods to enhance recall. As supported by principles of motor learning, these joint protection strategies were performed incrementally. The learning process involved a composite of verbal, visual, and kinesthetic instructions supported by extrinsic feedback about performance achievements. Subjects also used mental imagery techniques and practiced in pairs or threes to improve their speed of skill acquisition. Finally, to promote patients’ ability to transfer the learning and self-efficacy expectations attained under supervision in the investigator’s laboratory to their home environment, self-management and self-monitoring strategies were used. In accordance with the importance of encouragement and persuasion in enhancing self-efficacy beliefs, support for the desired changes was enhanced throughout by inviting patient’s partners or significant others to attend the classes. The partners or significant others were asked by the investigator to help promote the patient’s use of the recommended novel practices at home and to assist the patient with any required modifications.

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Other strategies for promoting self-efficacy Other strategies that might directly enhance OA self-efficacy include [27,42,61]        

The ASMP or other similar patient education programs directed at improving knowledge Reducing pain through cognitive techniques such as distraction and guided imagery Promoting relaxation and exercise Improving sleep hygiene and use of medications Providing instruction in joint protection strategies and energy conservation Optimizing nutrition and eating strategies Providing directives for managing anxiety and depression Improving communication behaviors and problem-solving skills

In addition, education self-management programs combined with provision of pain coping skills and social –emotional support to strengthen self-efficacy expectations [42] might increase self-efficacy and improve the physical and psychologic status of individuals who have arthritis [62]. Educating spouses, significant family members, and caregivers might also impact favorably upon patients’ expectations about their ability to control arthritis-related symptoms such as pain and functional limitation [62,63]. Recent evidence suggests that self-efficacy for exercise, which is an extremely important intervention for promoting health in people who have OA, might be specifically increased by encouraging participation in a regular goal-directed exercise program rather than in one in which patients exercise only if they feel relatively pain-free [48]. In addition to cognitive – behavioral and other education interventions, goal-directed exercise programs might enhance arthritis self-efficacy with respect to mood, fatigue, physical capacity, pain, disability, and function [10,14,16,48]. Building and maintaining a sound patient – therapist relationship that permits mutual inquiry, information giving, and the negotiation of goals that are important to the patient might also increase self-efficacy. This relationship requires that the therapist be knowledgeable and empathetic. Problem-solving techniques to identify barriers to achieving these goals and reaching solutions for overcoming the barriers should be fostered (Box 5) [51]. To promote long-term gains and adherence to treatment recommendations, Jensen et al [51] have advocated an interactive multilevel process of mutual inquiry, problem solving, negotiation between the therapist and client, and the provision of ‘‘motivational hooks.’’ Several techniques might facilitate the success of an efficacy-enhancing experience, such as breaking down a goal into achievable steps starting with the easiest task or the one that is most likely to be accomplished successfully; providing mastery aids to ensure success; and practice, including role-playing and homework [65]. Previous positive or deleterious experiences with

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Box 5. Outcome variables related to expectations of self-efficacy in patients who have osteoarthritis Whether or not successful coping strategies will be initiated The time and effort expended on a task in the face of obstacles Whether or not a given behavior will be sustained The extent to which individuals become disabled The degree of hope experienced versus despair The degree to which persons with OA can regain a sense of control over their lives [64] The degree to which the doctor–patient relationship can be maximized [28] Outlook of the caregiver, which predicts physical outcomes [63]

the health behavior in question should be addressed. In particular, the health care provider should address any lack of confidence the patient might have in carrying out the recommended behavior as a result of negative past experiences. A discussion should ensue about how to construct a plan that will permit the patient to overcome any perceived barriers to change [58].

Discussion and summary Self-efficacy is a psychologic construct denoting a person’s confidence in being able to carry out activities. The previous discussion examines whether or not selfefficacy beliefs play an important role in mediating functional outcomes in OA. Further, it examines whether or not the application of self-efficacy theory to the treatment of OA might result in improvements in patients’ perception about their ability to cope with pain and their general confidence in functioning physically given the chronic and progressive course of OA. The discussion also examines the relationship between levels of perceived self-efficacy and adherence with exercise and medication regimens [41,48], and whether or not levels of perceived selfefficacy predict arthritis-related outcome variables such as fatigue, pain, and wellbeing. The application of strategies to enhance self-efficacy is also discussed. Taken as a whole, these data strongly suggest that regardless of the number of joints or the joint sites affected by OA, the role that self-efficacy perceptions might play in mediating disease outcomes should not be ignored in efforts to improve selfmanagement. Evidence is mounting that carefully graded multiple-component strategies aimed at enhancing arthritis self-efficacy are more beneficial than basic educational strategies alone for improving health status among people who have arthritis [29,34]. Fostering self-efficacy might significantly strengthen the beneficial effects of interventions designed to improve the well-being of patients who have OA, and

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these improvements are likely to be as great as those obtained with analgesics/ NSAIDs. Lorig et al [25] found that conventional treatment was not as effective as the ASMP in reducing pain among OA patients over a 4-year period and that physician visits for arthritis by those who had attended the ASMP were reduced by 39% while they increased by 6% in those who had not attended. Furthermore, while disability in the two groups was comparable over time, OA patients who had participated in ASMP generally experienced slower deterioration of function. Similarly, Barlow et al [28] reported that participation in ASMP not only decreased pain but decreased the number of visits to general practitioners, rheumatologists and other health professionals significantly and improved communication with physicians. Although levels of function remained stable over time, it could be argued that functional status does not improve as a consequence of the self-efficacy effects of the ASMP [53] because OA is frequently progressive. Stabilization or slowing of the loss of function could be regarded as a positive result. Moreover, sustained efforts to promote self-efficacy rather than short-term efforts might produce functional benefits that are longerlasting than those presently reported in the literature. In addition, Kovar et al [46] found that participation in their self-efficacy –based intervention not only resulted in a decrease in pain but in a decreased level of intake of analgesics and NSAIDs among subjects who had knee OA. Although generic education programs can help people who have OA function more ably [24,29,44,66], specific programs that incorporate attempts to apply selfefficacy theory are likely to prove more successful in mediating health outcomes in OA patients. As outlined in Fig. 1, these programs might have a strong bearing on the patient’s ability and willingness to perform activities of daily living as independently and effectively as possible. Patients who exhibit higher self-efficacy scores for OA pain control can be expected to have significantly higher pain thresholds than those who have lower self-efficacy scores [7]. Patients who have high self-efficacy might have a better life quality and fewer problems with mobility and suffering, and they are more likely to adopt and maintain favorable health behaviors than patients who have low self-efficacy. In addition, carefully designed and implemented interventions to enhance selfefficacy are likely to yield significant early and sustained treatment benefits for people who have OA [21]. They might reduce the use of, and dependence upon, health care services [25] and reduce caregiver burden and caregiver pessimism, which is strongly related to patient physical status [63]. Improvement in selfefficacy might also positively affect mental health status [64]. Clinicians who foster strong self-efficacy beliefs among their OA patients can facilitate adherence to arthritis self-management and treatment recommendations, fostering favorable health outcomes (Box 6). In addition, implementation of strategies tailored to the individual’s specific self-efficacy profile, socioeconomic status, education level, learning style, personal situation, needs, goals, and disease status is likely to reduce barriers to implementation of essential OA self-management activities significantly. These strategies might also enhance self-esteem, cooperation, decision-making ability, independence, and well-being. This approach

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Box 6. Measures to enhance self-efficacy of people who have osteoarthritis The use of a variety of learning strategies including lectures, discussions, brainstorming, demonstrations, goal setting, contracting, modeling, mental practice, homework, recallenhancing methods, and mutual aid and support The involvement of significant others such spouses/family members and significant others/health care providers The graduated promotion of the ability to self-manage fear, stress, pain, depression, and anxiety; to exercise and protect joints; and related self-monitoring strategies The application of encouragement, persuasion, and direct or indirect support for the desired changes The promotion of decision-making skills, the necessary knowledge, skills, and problem-solving ability, practice, and roleplaying regarding how to deal with disease-related issues The use of multicomponent strategies such as pamphlets, lectures, and videotaped instructions The integration of individual and group intervention approaches

Fig. 2. Hypothetical model of possible intermediate, primary, and secondary outcomes of using selfefficacy – enhancing strategies in the conservative management of OA.

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might ultimately reduce demands on an overburdened health care system, having far-reaching economic and social implications (Fig. 2). In light of these possibilities, what can physicians, patient educators, and other health care professionals involved in the care of patients who have OA do to apply knowledge about the potentially valuable role of self-efficacy in reducing OA-related morbidity and disability? Most importantly, they can acknowledge the importance of the patient’s self-perceptions about the disease in mediating disease outcomes. This action can be facilitated by assessing patients’ physical and cognitive status carefully, including their self-efficacy perceptions about pain and function and by advocating the incorporation of appropriate strategies to enhance self-efficacy into current standard health promotion or patient treatment recommendations. This goal might require referral to other allied health professionals who are trained to assess self-efficacy or to design and deliver appropriate confidence-enhancing interventions. Clinicians can also be instrumental in supporting patient education programs designed to address self-efficacy. Many local chapters of the Arthritis Foundation offer organizing self-management programs based on self-efficacy theory and can help make appropriate referrals on behalf of the patient to these programs. Similarly, physical therapy organizations or organizations of behavioral medicine and health education are likely to be knowledgeable resources, and they have personnel who can help direct the patient to programs designed to enhance selfefficacy. In addition, clinicians can learn to administer and interpret the Arthritis Self-Efficacy Scale [61]. The Arthritis Self-efficacy Scale consists of three subscales: measuring selfefficacy for pain, physical function, and coping with other symptoms such as fatigue. Each item is scored separately and the mean of the subscale items is reported. The scale ranges from 10 to 100, and acceptable reliability and validity have been reported [61]. Patients answer each question by responding to a separate scale. The scale as applied by Kovar et al [46] for assessing self-efficacy of people who have OA included the following two subscales.

Self-efficacy pain scale Instructions In the following questions we would like to know how your arthritis pain affects you. For each of the following questions, please indicate the number that corresponds to your certainty that you can now perform the following tasks (a scale from 10 to 100, where 10 is very uncertain, 50– 60 is moderately uncertain, and 100 is very certain). 1. How certain are you that you can decrease your pain quite a bit? 2. How certain are you that you can continue most of your daily activities? 3. How certain are you that you can keep arthritis pain from interfering with your sleep?

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4. How certain are you that you can make a small-to-moderate reduction in your arthritis pain by using methods other than taking extra medication? 5. How certain are you that you can make a large reduction in your arthritis pain by using methods other than taking extra medication. Self-efficacy ‘‘other’’ symptoms subscale Instructions In the following questions we would like to know how you feel about your ability to control your arthritis. For each of the following questions, please indiacte the number that corresponds to the certainty that you can now perform the following activities or tasks. 1. How certain are you that you can control your fatigue? 2. How certain are you that you can regulate your activity so as to be active without aggravating your arthritis? 3. How certain are you that you can do something to help yourself feel better if you are feeling blue? 4. As compared with other people with arthritis like yours how certain are you that you can manage arthritis pain during your daily activities? 5. How certain are you that you can manage your arthritis symptoms so that you can do the things you enjoy doing? 6. How certain are you that you can deal with the frustration of arthritis? The third subscale asks some questions that might be more related to RA than to OA and might require modifications depending on which joints are affected by OA. Self-efficacy function scale Instructions We would like to know how confident you are in performing certain activities. For each of the following questions, please indicate the number, which corresponds to your certainty you can perform the tasks as of now, without assistive devices or help from another person. Please consider what you can do routinely, not what would require a single extraordinary effort. As of now, how certain are you that you can 1. 2. 3. 4. 5. 6. 7.

Walk 100 ft on flat ground in 20 seconds? Walk 10 steps downstairs in 7 seconds? Get out of an armless chair quickly, without using your hands for support? Button and unbutton three medium sized buttons in a row in 12 seconds? Cut two bite-size pieces of meat with a knife and fork in 8 seconds? Turn an outdoor faucet all the way on and all the way off? Scratch your upper back with both your left and right hands?

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8. Get in and out of the passenger side of a car without any assistance from another person and without physical aids? 9. Put on a long-sleeve front-opening shirt or blouse (without buttoning) in 8 seconds? By ascertaining the self-efficacy responses to some or all of the above questions, physicians can potentially ascertain a better profile of their patient’s self-efficacy beliefs and more clearly discern which intervention recommendations should be stressed. Based on these data, physicians can enlist the help of the patient’s family, close friends, or caregivers to support one or more of their suggestions. If indicated, physicians can also refer their OA patients to appropriate self-help groups or exercise programs such as the 20-week Arthritis Foundation aquatic exercise program so that the patients can see other patients coping successfully with their OA. They can also possibly derive positive reinforcement and social support from such groups. Physicians can also refer patients for other forms of therapy that might enhance self-efficacy indirectly such as cognitive – behavioral treatment, encouraging patients to join walking programs, or recommending other activities or skills development that they think will bolster the patient’s confidence and the likelihood that the patient will adopt the physician’s recommendations. Finally, because no single method of enhancing self-efficacy has been shown to be superior to another and each might have its place, the role of the clinician is to identify patients’ needs and select intervention approaches that are most likely to achieve the desired results for that individual. This process can be facilitated by having the physician or patient educator evaluate patients’ physical and psychologic statuses carefully (eg, their level of anxiety, mood state, and their responses to the aforementioned self-efficacy questionnaire about their current functional abilities). The process might also require an understanding of patients’ preferred learning styles and a discussion of the options available.

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