Introduction: What is self-efficacy and how might it relate to cardiovascular health?
Self-efficacy refers to the confidence in one's ability to behave in such a way as to produce a desirable outcome (Bandura, 1977). Self-efficacy makes a difference in how people feel, think, and act. In terms of feeling, a low sense of self-efficacy for a particular situation is positively related to depression and anxiety. High self-efficacy for a specific situation allows one to deal better with uncertainty, distress, and conflict. In terms of thinking, the strong sense of competence resulting from high self-efficacy facilitates enhanced cognitive processes and academic performance. Finally, in terms of action, self-related cognitions are a major ingredient of the motivation process. Self-efficacy levels can enhance or impede motivation. People with high self-efficacy in a particular domain of human functioning choose to perform more challenging tasks. They set higher goals and stick to them. Actions are preshaped in thought, and people anticipate either optimistic or pessimistic expected outcomes of a specific task in line with their level of self-efficacy. Once an action has been taken, high self-efficacious persons invest more effort and persist longer than those low in self-efficacy to accomplish a specific task. When setbacks occur, those with high self-efficacy recover more quickly and maintain commitment to their goals (Schwarzer, 1992). Self-efficacy levels for specific cardiovascular health-related behaviors may be an important determinant of future cardiovascular health. Dietary self-efficacy, physical activity self-efficacy, and cessation of smoking self-efficacy are among the examples that will be discussed where self-efficacy for specific health-related behaviors likely plays a large role in future cardiovascular risk factor profiles. The following sections will review the evidence supporting links between self-efficacy of specific cardiovascular health-related behaviors and specific well-established cardiovascular risk factors.
Assessing the multiple dimensions of self-efficacy
Bandura (1986) argued that self-efficacy expectations consist of three dimensions: magnitude, generality, and strength. Each of these dimensions implies different measurement procedures. Magnitude refers to the ordering of tasks by difficulty level. Generality concerns the extent to which efficacy expectations about a specific situation can be generalized to other situations. Finally, strength refers to a judgment of how certain one is of being able to succeed at a particular task (Mudde et al., 1995).
There is no standard measurement for self-efficacy. Self-efficacy, unlike dimensions of personality, must be considered in terms of a specific situation (Gerin et al., 1995). Therefore, different measures are used to assess self-efficacy for each particular health-related behavior studied. In addition, a different measure is often used to assess each of the three dimensions of self-efficacy for a particular health-related behavior.
Self-efficacy and Smoking Cessation
Cigarette smoking has been identified as a risk factor for cardiovascular disease. Furthermore, studies indicate that patients with coronary artery disease who stop smoking have a lower mortality from all causes of death and a less frequent occurrence of myocardial infarction in particular than those who continue to smoke (Vlieststra et al., 1986). Self-efficacy in the area of smoking cession has been thoroughly studied. Thus, this is an excellent first example of how self-efficacy has been shown to predict behavioral change for an important cardiovascular risk factor. i.e., smoking. "Several studies have emphasized the predictive value of self-efficacy for behavior change among smoking cessation treatment participants (for review see: Strecher et al., 1986; Crey et al., 1989). The consensus of these studies is as follows: pre-treatment self-efficacy was generally not predictive of smoking status after treatment. However, post-treatment self-efficacy of subjects who were abstinent after treatment was significantly higher than self-efficacy of those who were not successful. Post-treatment self-efficacy expectations were significant predictors for short-term maintenance of smoking cession (3-6 months after treatment) (Pederson et al., 1991; Haaga, 1989; Coelho, 1984; McIntyre et al., 1983). This relationship held true even when post-treatment smoking status was controlled for and only subjects, who were abstinent after the treatment were included (Haaga and Stewart, 1992; Bear and Lichtenstein, 1988; Diclemente, 1981). For self-quitters the predictive power of self-efficacy may be even stronger. Gritz et al., 1992 found that self-efficacy predicted long-term abstinence (12-18 months) from smoking as a result of self-initiated quit attempts in agroup of female smokers (Mudde et al., 1995).
A recent prospective study by Mudde et al., 1995 provides further insight by comparing different measures of self-efficacy for smoking cessation in regards to which is the strongest predictor for smoking cessation. Each measure represented different combinations of the three dimensions of self-efficacy. The perceived difficulty scale used (PDS- Strecher et al.,1985) represented magnitude and generality. The perceived ability scale (PAS- Coletti et al., 1985) and a 1-item perceived ability measure (PAM- Mudde et al., 1995) both incorporated generality and strength in different degrees. Their results confirmed that perceived self-efficacy for smoking cessation predicts short and long-term smoking cessation. Results also suggested that the PDS may predict short-term cessation, while the PAS may be a predictor of long-term abstinence. By means of factor analyses, various subscales were found in both of these scales. The negative/affective subscale of the PDS and the negative/moodstates subscale of the PAS appeared to be the most important elements of these two scales. However, it was the PAM measure that showed the greatest predictive power for post-follow-up abstinence from smoking. Since all three measures included the dimension generality, a conclusion might be that magnitude is the dimension of greatest importance for the prediction of short-term cessation success, while strength may be the dimension that best determines long-term abstinence. Please see Mudde et al., 1995 for further details or for a discussion of the external validity of the study.
"In summary, the predictive ability and consistency of self-efficacy evaluations for smoking behavior have been impressive. Few constructs in the social sciences can boast such a record. In almost every case, efficacy evaluations, particularly abstinence efficacy evaluations, have been the most significant, or among the only significant, predictors of smoking cessation treatment outcome that emerged from studies that included a wide range of other predictors (DiClemente, 1986; DiClemente et al., 1995).
Self-efficacy and Weight Loss
Being overweight is a significant risk factor for the development of hypertension and coronary heart disease (see the link for a review of obesity and cardiovascular health by clicking on "overweight" among the listed risk factors our web page: www.workhealth.org). Weight control self-efficacy to perform behaviors that lead to weight loss has been examined in a number of ways. In fact, the assessment of self-efficacy varies greatly from study to study and is more diverse than in smoking cessation self-efficacy research. Due to the great variety in assessment of the construct of weight control self-efficacy, it should be noted that it is difficult to summarize the findings and make generalizable conclusions. The closest thing to a standard assessment in the field of weight control self-efficacy is Glynn and Ruderman's (1986) Eating Self-Efficacy scale (ESES) (DiClemente et al., 1995).
There is a large amount of evidence suggesting that weight control self-efficacy plays an important role in weight loss. Chambliss and Murray (1979) have found cross-sectional evidence that a self-efficacy enhancing treatment group had greater weight loss than a comparison group. However, this effect was only apparent for those with an internal locus of control. Much stronger evidence comes from numerous prospective studies investigating the predictive powers of weight control self-efficacy on weight control. "Efficacy to resist the urge to overeat increases during the course of treatment (Glynn & Ruderman, 1986; Forster & Jeffrey, 1986). Expectations that seem more like outcome expectancies than efficacy expectancies (i.e., subjects' confidence in reaching their goal weight, confidence in losing a certain amount of weight, or confidence in their ability to lose weight and maintain that loss) have been able to predict dropout from a weight control program (Mitchell & Stuart, 1984), as well as weight loss (Weinberger et al., 1984), and the maintenance of that weight loss (Blair et al., 1989). Most studies that use efficacy to resist the urge to eat or refrain from overeating have found these efficacy evaluations to be predictive of weight loss during the active phase of treatment (Glynn & Ruderman, 1986; Forster & Jeffrey, 1986). In addition, posttreatment efficacy evaluations have been related positively to maintenance of weight loss (Patsis & Hart, 1991; Rodin et al., 1988; DiClemente et al., 1995).
"Despite all the difficulties and differences in the assessment of self-efficacy related to eating behavior in weight control, the role that self-efficacy appears to play is quite similar to that in smoking cessation, where the assessments have been a bit more uniform. Efficacy evaluations appear to be useful and unique predictors of weight loss. Few constructs predict weight loss and maintenance of that loss in as consistent a fashion as self-efficacy focused on overeating behaviors (DiClemente et al., 1995).
Self-Efficacy and Low-Fat Diet
"There is substantial evidence that reducing saturated fat in the diet decreases the risk of coronary heart disease (CHD) in populations (Kromhout and Lezenne-Coulander, 1984; Kushi et al., 1985; Keys et al., 1986). Efforts to alter dietary habits through various programs have met with limited effectiveness (Advisory Board - IHHC, 1992). One reason for the limited success is the failure to fully understand the cognitive mediators of dietary change (Plotnikoff and Higginbotham, 1995) .One recent study by Plotnikoff and Higginbotham (1995) found significant positive association between self-efficacy for following a low-fat diet (dietary self-efficacy) and outcome measures related to low-fat diet. Future research is needed focusing specifically on dietary self-efficacy to determine whether substantial saturated fat reductions can be obtained by treatment programs developed to increase dietary self-efficacy.
Self-efficacy and Recovery from Heart Attack
Ewart and colleagues have studied the relationship between physical activity self-efficacy and recovery from heart attack. According to Ewart, 1992, "large numbers of heart attack survivors experience unnecessary distress and put themselves at significant medical risk due to excessive fear of physical activity." Self-efficacy theory has improved their ability to identify and alleviate these inappropriate fears. Research reviewed by Ewart(1992) suggests that self-efficacy appraisals influence patient involvement in exercise regimens and mediate beneficial effects of exercise participation." Furthermore, evidence is reviewed that self-efficacy predicts physical over-exertion and has called for the development of scales of self-efficacy to identify individuals who may be at risk of dangerous overexertion due to unrealistically optimistic appraisals of their physical capabilities (Ewart, 1992).
Self-efficacy and Physical Activity
Of course, physical activity is not only important to recovery from heart attack. Physical activity appears to decrease the risk of coronary artery disease. The United States Center for Disease Control reviewed existing observational studies and found a significant and graded relationship between physical activity and the risk of coronary artery disease (Powell et al., 1987; Littman, 1993). Exercise is widely recommended for health promotion and primary-risk reduction in people who have not developed symptoms of cardiovascular illness, and who are not inhibited by the anxieties patients experience after a heart attack (Ewart, 1995). However, relatively few people engage in regular exercise for a period of time to secure the benefits of moderate exercise to physical health (Dubbert, 1992). "The attrition rate for both clinical and community-based exercise programs can be as high as 50% within the first 3 to 6 months of participation (Brawley & Rogers, 1993; Dishman, 1988). Social-cognitive variables, including self-efficacy, seem to play a major role in this attrition." Research suggests that self-efficacy expectancy, outcome expectancy, and outcome value are important in the initiation and maintenance of a variety of exercise programs (Brawley & Rogers, 1993; Brawley & Horne, 1988; Desharnais et al., 1986; Dzewaltowski et al., 1990; Garcia & King, 1991; McAuley, 1991, 1994; McAuley & Courneya, 1993; McAuley & Jacobson, 1991; Poag-Ducharme & Brawley, 1991a, 1991b; Rogers & Brawley, 1991a, 1991b). The relative influence of self-efficacy and outcome expectancy on exercise behavior has been shown to differ at different stages of exercise experience (Marcus et al., 1992; McAuley, 1991; McAuley & Jacobson, 1991; McAuley & Rowney, 1990; Poag-DuCharme & Brawley, 1993). Although initial experience with exercise may base their decision to try it largely upon their beliefs of the value of the benefits of exercise, this initial experience with exercise strongly influences self-efficacy (Ewart et al., 1983) which become the primary determinant of persistence (Maddux et al., 1995). Recently, studies have attempted to learn more about what types of self-efficacy best predict exercise behavior over time. Self-efficacy for the exercise components, self-efficacy for scheduling, and self-efficacy for overcoming barriers have been studied by Poag-DuCharme and Brawley (1993). The types of self-efficacy that predicted exercise intentions varied at different points in their 12-week community-based exercise program. This study and others (Poag-Charme, 1993; McAuley, 1992, 1993) suggest the need for further study concerning changes in the relationship between self-efficacy and exercise over time (Maddux et al., 1995).
Self-efficacy as a Component of Active Coping to Stress, and Resulting Enhanced Cardiovascular Reactivity
Stress, specifically model of job stress called "job strain," has been shown in over a dozen epidemiological studies over the last decade to be a significant risk factor for CHD (Schnall et al., 1994; See our review of job strain). The concept of active coping is one model in which we think about the stress-illness relationship (Gerin et al., 1996). Active coping to stress enhances cardiovascular reactivity, elevating blood pressure and heart rate (Gerin et al., 1996). However, it is unclear which aspect of the process actually produces the elevations. A recent study by Gerin et al., 1996 has "concluded that self-efficacy for a particular task may be an integral part of the active coping process, indirectly affecting the blood pressure response by acting on the effort involved in the coping response." Subjects engaged in a video game shape-matching task, who were preevaluated to have a high self-efficacy for this task, had greater blood pressure cardiovascular reactivity than subjects engaged in the same task who were preevaluated to have a low efficacy for this task.
Social determinants of Self-efficacy
There has been remarkably little research on the determinants of self-efficacy, particularly social class and job stress. Such factors might shape personality development in childhood. For example, certain parental behavior patterns (i.e., overly strict, critical and demanding of conformity) are more common in low SES households, and may be viewed as a reflection of the parents' occupational and other life experiences, which are characterized by low control and insecurity (see Sennett &Cobb, 1973, The Hidden Injuries of Class; Rubin, 1976, Worlds of Pain: Life in the Working Class Family). Similarly, an adult's experience, which might include stressful, low control jobs, may shape their personality development (Kohn and Schooler, 1982). The active motivated persistent personality style described in the beginning of this review as resulting from "self-efficacy" is quite similar to the hypothesized effects of active (high demand-high latitude) jobs on personality and coping in Karasek's model (Karasek, 1979; 1981; Landsbergis et al., 1992). In the Cornell worksite blood pressure study, a three year increase in job decision latitude among men was associated with quitting smoking (Landsbergis et al., 1998). It is not known whether increased self-efficacy was a mediator in this causal pathway. Thus, research on the social determinants of personality measures believed to be associated with illness outcomes needs to be a major priority in future research.
Smoking cessation, a CVD risk factor, has been the most common cardiovascular health-related behavior that self-efficacy has been linked to. "The predictive ability and consistency of self-efficacy evaluations for smoking behavior have been impressive. Few constructs in the social sciences can boast such a record. In almost every case, efficacy evaluations, particularly abstinence efficacy evaluations, have been the most significant, or among the only significant, predictors of smoking cessation treatment outcome that emerged from studies that included a wide range of other predictors." (DiClemente, 1986; DiClemente et al., 1995).
Numerous studies have also investigated the relationship self-efficacy has on weight control, since obesity is a well-established CVD risk factor. Despite all the difficulties and differences in the assessment of self-efficacy related to eating behavior in weight control, the role that self-efficacy appears to play is quite similar to that in smoking cessation, where the assessments have been a bit more uniform. Efficacy evaluations appear to be useful and unique predictors of weight loss. Few constructs predict weight loss and maintenance of that loss in as consistent a fashion as self-efficacy focused on overeating behaviors." (DiClemente et al., 1995).
Self-efficacy has been shown to play a role in influencing other CVD risk factors, such as high-fat diet, physical inactivity, and high blood pressure (via active coping to stress). In regards to high-fat diet, future research is needed focusing specifically on dietary self-efficacy to determine whether substantial saturated fat reductions can be obtained by treatment programs developed to increase dietary self-efficacy.
Concerning physical inactivity, research suggests that self-efficacy expectancy, outcome expectancy, and outcome value are important in the initiation and maintenance of a variety of exercise programs. Self-efficacy for physical activity may become particularly important for those recovering from a heart attack. However, the links between self-efficacy and these CVD health-related behaviors have not been as thoroughly studied as for smoking cessation and weight control. Finally, concerning high blood pressure, it appears that self-efficacy for confronting mentally and physically vigorous psychosocial environmental stressors may be a component of active coping. Active coping to stress enhances cardiovascular reactivity, elevating blood pressure and heart rate (Gerin et al., 1996). High blood pressure is of course a major CVD risk factor. As for high-fat diet and physical activity, the link between self-efficacy and high blood pressure through active coping to stress has not been studied thoroughly enough. More research is needed investigating the role that self-efficacy plays in active coping, work-stress models (i.e., job strain, effort-reward and John Henryism), and as a possible risk factor for hypertension.
Further research is definitely needed to better understand how much self-efficacy influences each of these CVD health-related behaviors, and the mechanism of that change by further narrowing in on what tasks self-efficacy is particularly important for in affecting behavioral change. Lastly, very little is known about the determinants of self-efficacy. Research on the social determinants of personality measures believed to be associated with illness outcomes needs to be a major priority in future research.
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