Enhancing self-efficacy has become an essential feature of many arthritis management interventions because of its robust relationships with health behaviors and health status. Empirical studies document that self-efficacy predicts health behaviors such as physical activity, eating behaviors, and pain coping strategies (1). In rheumatoid arthritis and osteoarthritis, self-efficacy has also been correlated with measures of health status such as daily pain and mood ratings (2), pain, stiffness, function, and physical and mental well-being (3); it has also been correlated with changes in pain, function, and depression (4). Adherence with medications and other health recommendations has also been associated with self-efficacy (5, 6). In addition to evidence that self-efficacy is associated with health behaviors, current and future health status, and adherence to health recommendations, the fact that self-efficacy can change through efficacy-enhancing interventions makes it a rich target of arthritis interventions (1).
Self-efficacy, defined in Bandura's seminal 1977 article as “the conviction that one can successfully execute the behavior required to produce the outcomes” (7), was hypothesized to influence whether a behavior was initiated and sustained despite obstacles or adverse experiences, and to influence the level of effort invested in the behavior. Bandura's definition of self-efficacy evolved slightly over time; in his 1997 publication, Bandura defined self-efficacy as “belief in one's capability to organize and execute the courses of action required to produce given attainments” (8). Bandura has consistently described self-efficacy as domain specific and distinct from other constructs in social learning theory such as outcome expectations, defined as a person's estimate that a given behavior will lead to certain outcomes (7). Self-efficacy beliefs are also conceptualized as distinct from actual ability to perform a task (e.g., can I ride a bicycle), actual task performance (e.g., do I ride a bicycle), or intention to perform task (e.g., do I intend to ride a bicycle) (8, 9). These different types of beliefs are clearly distinguished in Gecht et al's survey of exercise beliefs and habits among people with arthritis (10). In that survey, respondents were asked about their self-efficacy expectations regarding exercise (“If I want to exercise, I know I can do it”), and their outcome expectations regarding exercise (“regular exercise will probably make my arthritis worse in the future”); they were also asked to report their actual behavior (how often they did specific exercises in the past 2 weeks). Self-efficacy theory hypothesizes that both efficacy expectations and outcome expectations influence whether or not an individual will initiate and sustain a specific behavior (7). Gecht et al found that positive outcome expectations and self-efficacy for exercise were associated with participation in exercise (10). Conversely, self-efficacy theory predicts that if a patient believes that they can exercise (self-efficacy expectation) but also believes that exercise will be harmful for their arthritis (outcome expectation), the patient would be less likely to exercise than if they expected positive outcomes from exercise (7). Social learning theory suggests that it is important for clinicians and others hoping to help a person adopt health behaviors to understand both whether the person believes they can perform the behavior, and whether they believe that behavior will lead to positive outcomes.
Outcome expectations have received very little attention in arthritis-related research, but self-efficacy has been measured extensively (11). This review focuses on self-efficacy measures in the domain of arthritis management, and measures frequently used in arthritis management intervention studies (i.e., Arthritis Self-Efficacy Scales , Rheumatoid Arthritis Self-Efficacy Scale ). One nonarthritis specific measure, the Chronic Diseases Self-Efficacy Scale (14), is included because it is frequently used in evaluation of self-management education programs. The review also includes a child-focused measure, the Children's Arthritis Self-Efficacy Scale (15), and a companion scale focused on parents' self-efficacy to manage arthritis-specific parenting tasks, the Parent's Arthritis Self-Efficacy Scale (16).
There are a number of related domain-specific measures, such as exercise self-efficacy scales (17, 18), self-efficacy for managing anterior cruciate ligament injuries (19), and chronic pain self-efficacy scales (20–22), that are not reviewed here. However, all are included in a 2006 review by van Hartingsveld et al that covers a wide number of measures of patient expectations, including self-efficacy, across a wide range of musculoskeletal conditions (23).
Also not included in this review are scales which include the term self-efficacy in their titles, but do not measure domain- or behavior-specific efficacy beliefs such as the Generalized Self-Efficacy Scale (24, 25) and the Self-Efficacy Scale (26). These general scales measure global beliefs in self-efficacy without specifying activities or conditions (e.g., “I can handle whatever comes my way,” or “I can always manage to solve difficult problems”) and are designed to assess a unidimensional global perception or static trait (25) rather than changeable domain- or behavior-specific beliefs. As such, these general scales appear more closely related to measures of perceived coping competence or mastery (27) rather than the domain-specific construct of self-efficacy as delineated by Bandura (7).
One area in the conceptualization and operationalization of self-efficacy that remains unclear in the literature is the delineation between efficacy expectations and outcome expectations, and this ambiguity is reflected in self-efficacy measures. In his more recent writings, Bandura has focused on self-efficacy as a person's belief in their “capability to produce given attainments” (8, 18) rather than to execute the behavior required to produce outcomes (7); although in distinguishing self-efficacy from locus of control, Bandura described perceived self-efficacy as “beliefs about whether one can produce certain actions” while describing locus of control as “beliefs about whether actions affect outcomes” (8). Bandura cautioned against confusing performance, an accomplishment specified by descriptive markers (e.g., the academic grades of A, B, C, D, and F), with outcome, defined as something that flows from performance (specifically positive or negative physical, social, or self-evaluative effects) (8). This delineation between performance (attainment) and the physical, social, or self-evaluative effects (outcomes) that follow from that attainment is reasonably clear when considering academic grades (can I perform to the level of an A) but less clear when examining symptom relief, such as relief of pain (28). Some arthritis-related self-efficacy measures, such as the Arthritis Self-Efficacy Scales (12), consider symptom relief part of the efficacy belief (as a descriptive marker of the accomplishment), while others, such as the Rheumatoid Arthritis Self-Efficacy Scale (13), which focuses more on the execution of behaviors, consider symptom relief an outcome expectation (and not part of the efficacy belief). These distinctions are highlighted in the following review of measures.