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- PATIENTS AND METHODS
There is a growing body of empirical evidence demonstrating that a person's perceived self-efficacy positively affects his or her physical health and emotional wellbeing. For example, patients with arthritis have been found to experience less pain and functional disability, as well as better emotional wellbeing, if they perceive high self-efficacy for coping with the negative consequences of the disease (1–6).
The construct of perceived self-efficacy was introduced by Bandura, who described in his social-cognitive theory how cognitive and social factors contribute to health and disease (7–9). Self-efficacy refers to the belief in one's capabilities to mobilize the motivation, cognitive resources, and courses of action required to produce given levels of attainment and is considered to be influenced by information from 4 principal sources.
Of these 4 sources of self-efficacy, mastery experience may be the most powerful influence. Personal successes (i.e., experiences of overcoming obstacles through perseverant effort) create a robust belief in one's personal efficacy. For example, an arthritis patient who starts exercising at an easily mastered intensity and frequency may become more and more confident of being able to improve functional disabilities through regular exercise.
Second, vicarious experience provided by social models conveys knowledge and effective skills/strategies for managing environmental demands. An arthritis patient observing other patients successfully exercising may realize that he or she also possesses the capabilities to master comparable activities for improving functional disabilities.
Third, social persuasion encourages positive appraisals of capabilities to master given tasks and achieve goals. An arthritis patient may receive corrective and reinforcing feedback and in that way acquires confidence in his or her ability to perform physical exercises necessary for improving functional disabilities.
Finally, interpretations of somatic and emotional states provide information about one's self-efficacy. While exercising, an arthritis patient may interpret pain as a sign of personal or physical inefficacy. Another patient, in contrast, may know that pain does not commonly mean worsening disease and may therefore not misinterpret the information with respect to his or her efficacy belief.
It has been proposed that self-efficacy mediates health through 2 processes (7, 8). First, the belief that one is able to successfully cope with stressors should activate biologic systems that promote health and healing processes (7, 8), and self-efficacy affects people's perception of, interpretation of, and ways of coping with pain experiences (10). Second, perception of high self-efficacy increases the likelihood of consideration, adoption, and maintenance of health-promoting behaviors.
Increasing evidence shows that people with arthritis who perceive high self-efficacy have better physical health and emotional wellbeing (i.e., fewer depressive symptoms). It has been found, for example, that arthritis patients with high self-efficacy for coping with pain or disability report less pain, disability, and depressive symptoms (1, 3–5, 11–13). Health-promoting effects of self-efficacy have also been observed in longitudinal studies of patients with arthritis (1–3, 6, 14, 15). In addition, a number of studies of arthritis patients have shown that increases in self-efficacy are associated with short- and long-term improvements in health (3, 14, 16–19). Furthermore, recent research with arthritis patients has demonstrated enhancement of self-efficacy through self-management programs and cognitive-behavioral and other psychological interventions (2, 3, 14, 16–29).
The above-mentioned intervention studies involved programs in which self-efficacy–enhancing strategies were specifically incorporated (i.e., mastery experience, role modeling, persuasion, reinterpretation of physical states). In the present study, in contrast, we investigated changes in self-efficacy from a routine multidisciplinary inpatient rehabilitation program that offers exercise therapy, occupational therapy, and patient education but does not explicitly target self-efficacy as one of its components. Considering the sources of self-efficacy described above, we hypothesized that a routine program that does not specifically target self-efficacy would nevertheless lead to increased self-efficacy because it indirectly provides various self-efficacy–enhancing experiences. During exercise therapy, patients may learn to perform and monitor their exercises for improving functional ability and to interpret accompanying physical states (e.g., pain). In occupational therapy in which joint-protection strategies and the use of assistive devices (e.g., canes) are taught, patients may learn how to compensate for limitations. Furthermore, patients receive health knowledge and information about health-promoting behaviors during patient education as part of a routine program.
Routine rehabilitation programs should therefore indirectly provide relevant learning experiences through direct experience, feedback and encouragement, and the opportunity for patients to observe other patients. We thus propose that routine programs that do not specifically target self-efficacy nevertheless lead to enhanced self-efficacy and, consequently, improved health outcomes. Building on research that demonstrates the benefits of self-efficacy in patients with mild or moderate arthritis, we examined benefits in patients who underwent hip joint replacement (i.e., whose arthritis was in an advanced stage). Although joint replacement provides marked pain relief and functional improvement in most arthritis patients (30–32), patients must apply continued self-management behaviors and coping strategies to improve their health outcomes (33). As suggested in previous studies (34, 35), self-efficacy plays a role in rehabilitation after hip joint replacement by contributing to improved health outcomes. Therefore, we investigated whether a routine multidisciplinary inpatient rehabilitation program after hip joint replacement can increase patients' physical health, emotional wellbeing, and self-efficacy, and whether higher and/or increased levels of self-efficacy result in better health outcomes across the course of the treatment and after discharge.
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- PATIENTS AND METHODS
The present longitudinal study examined whether a routine multidisciplinary inpatient rehabilitation program that was not specifically targeted to enhance self-efficacy can nevertheless increase self-efficacy, and whether self-efficacy promotes better health in patients who participated in the rehabilitation program after hip joint replacement. On the basis of reported theories and empirical findings, we hypothesized that the program contains elements of self-efficacy–enhancing strategies. In addition, we postulated that the more highly patients perceived their self-efficacy at admission and the larger the experienced increase in self-efficacy throughout the program, the more health outcomes would improve from admission to 6-month followup. The presented findings support these hypotheses.
We found that patients' physical health and emotional wellbeing improved throughout the period of inpatient rehabilitation. Patients reported lower levels of disability, pain, and depressive symptoms at discharge than at admission. Decreases in disability continued during the first 6 months after discharge, while pain levels remained stable and depressive symptomatology increased after discharge. Despite this increase, we note that the level of depressive symptomatology was on average still lower 6 months after discharge than at admission. This pattern of results is in accordance with previous research demonstrating greater and faster improvements after joint replacement with respect to pain, while functional improvements seemed to take place within a protracted recuperation period of 3–6 months postsurgery (30–32, 43). Depressive symptomatology, in contrast, increased from 1 month to 6 months postsurgery after a decrease during the first month postsurgery (43). To explain these different recovery trajectories, one may have to consider that depressive symptomatology can be a function of experiences across different areas of life. In this regard, it may be that the positive surgery-related experiences play a less and less important role the longer the time passed since the surgery.
Our findings also show that patients' self-efficacy increased throughout the inpatient rehabilitation period. This supports the assumption that self-efficacy can be enhanced through a routine multidisciplinary inpatient rehabilitation program that comprises exercise therapy, occupational therapy, and patient education. Such routine programs may provide experiences and information about task demands and capabilities for mastering certain tasks and achieving goals, and thereby indirectly strengthen patients' self-efficacy.
On the basis of previous research on arthritis patients, we had predicted that individual differences in self-efficacy at admission and in its increase across the inpatient rehabilitation period would predict physical and emotional health changes. The reported results strongly support this hypothesis by demonstrating that higher self-efficacy at admission and larger increases in self-efficacy throughout the program result in larger decreases in disability, pain, and depressive symptoms from admission to discharge, over and above patients' baseline health status. Thus, these findings provide evidence in support of a central assumption of social-cognitive theory, i.e., that confidence in one's capabilities to mobilize the motivation, cognitive resources, and courses of action required to produce given levels of attainment facilitates the adoption of behaviors that promote the attainment of desired outcomes (8).
Taken together, the results suggest that patients acquired skills and resources that facilitated their adjustment to the hip joint replacement and its consequences. This finding thus supports the following conclusions: 1) The higher the level of perceived self-efficacy for disability, the more effort patients may invest in exercise therapy. If this is the case, then they may acquire more muscle strength, stability of joints, range of motion, and aerobic fitness, which are assumed to reduce pain and disability (44). 2) Patients who perceive high self-efficacy to cope with pain may have lower pain levels because they use more adaptive pain-coping strategies, as demonstrated in previous studies (6, 11, 14, 45, 46). 3) The belief in one's ability to cope with disability and pain can have positive consequences regarding emotional wellbeing (e.g., depressive symptomatology) (3, 4, 11, 14, 16, 34, 47). However, these interpretations are speculative, and more research is needed to directly test the postulated mediating processes.
Moreover, our results showed that both self-efficacy measures for disability contributed to health changes after inpatient rehabilitation following hip joint replacement. Both the level of self-efficacy for disability at admission and its increases accounted for differences in changes in disability, and admission levels of self-efficacy for disability accounted for differences in changes in depressive symptomatology from discharge to 6-month followup. This is consistent with findings from self-efficacy research suggesting that when patients experience high and/or increased self-efficacy, they experience substantial and prolonged health benefits (1, 15, 48), better long-term health outcomes (18), and reduced utilization of health care services in the future (49). Thus, benefits of self-efficacy seem to be sustained, and self-efficacy–enhancing interventions (whether direct or indirect) provided early in the rehabilitation process may promote positive long-term health.
Given the predictive value of (enhanced) self-efficacy for health improvements, more efforts should be made to improve self-efficacy in the context of hip joint replacement surgery and the subsequent rehabilitation process. Our results underscore the fact that a routine multidisciplinary inpatient rehabilitation program provides opportunities to enhance self-efficacy. It does not seem necessary to implement an intervention specifically designed to increase self-efficacy. In rehabilitation settings, simple techniques such as guiding mastery experiences in the context of exercise therapy, facilitating vicarious experiences, providing specific feedback, and/or providing support in interpretation of somatic states can simply be implemented by therapists. Furthermore, implementation of similar techniques early in the treatment process may promote self-efficacy even before admission to a rehabilitation facility.
Although the results of this study supported our hypotheses and general expectations, some limitations should be addressed in future research. First, participants remaining in the study through the followup period were older and less affected by their pain and emotional condition at discharge than patients who dropped out. Second, our study did not examine the variables that may explain the health-promoting effects of self-efficacy. Future research may assess possible mediating variables such as investment of effort in exercise therapy or adaptive pain-coping strategies. Finally, although our findings confirmed the self-efficacy–enhancing effects of a routine rehabilitation program, it is unclear which program components or experiences (indirectly) enhanced self-efficacy. Future research is needed to study directly the self-efficacy–enhancing factors in routine rehabilitation programs, based on the 4 described sources of self-efficacy. In light of the apparent health-promoting effects of high and/or enhanced self-efficacy, understanding the contributing factors would be most relevant to improving routine care early in the rehabilitation process after hip joint replacement.