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Self-efficacy in management of OA

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 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 inter-
related 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: allegrante@tc.columbia.edu (J.P. Allegrante).

0889-857X/03/$ – see front matter D 2003 Elsevier Inc. All rights reserved.
doi:10.1016/S0889-857X(03)00060-7
748 J.P. Allegrante, R. Marks / Rheum Dis Clin N Am 29 (2003) 747–768

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-judg-
ments, 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
 J.P. Allegrante, R. Marks / Rheum Dis Clin N Am 29 (2003) 747–768 749

Fig. 1. Model of OA disability depicting pathologic and nonpathologic interactions including self-
efficacy 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 well-
being. In the case of obese individuals who have OA, such activities will often
include weight reduction and dietary change. Research indicates that low self-
efficacy might mediate poor health outcomes, especially pain and poor mental
health status [15].
750 J.P. Allegrante, R. Marks / Rheum Dis Clin N Am 29 (2003) 747–768

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]
 J.P. Allegrante, R. Marks / Rheum Dis Clin N Am 29 (2003) 747–768 751

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-manage-
ment skills and to strengthen self-efficacy and outcome
expectations
752 J.P. Allegrante, R. Marks / Rheum Dis Clin N Am 29 (2003) 747–768

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 Self-
Management Program (ASMP)—a program not originally set within the theoreti-
cal 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 self-
efficacy 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, relaxa-
tion, 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 partici-
pant’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 re-
lated 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.
 J.P. Allegrante, R. Marks / Rheum Dis Clin N Am 29 (2003) 747–768 753

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 self-
efficacy 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 self-
efficacy 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 Patient pain behaviors were related to self-efficacy,
not solely to disease activity.
Taal et al [31] 86 RA cases Self-efficacy was related to subjective experience
of health status.
Venohr [37] 202 Older adults Pain and general self-efficacy partially explained
with arthritis and were important influences in
maintaining psychologic well-being.
Beckham [63] 65 RA cases Patient self-efficacy expectations including control
over arthritis-related symptoms predicted caregiver
burden and optimism; caregiver pessimism was
related to patient’s physical status.
Gecht et al [12] 81 Arthritis cases Self-efficacy for exercise was associated with
participation in and adherence to exercise.
Keefe et al [59] 130 Knee OA cases Adaptive pain coping was related to enhanced
self-efficacy.
Arnstein et al [11] 126 Chronic pain cases 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.
Brus et al [41] 65 RA cases Self-efficacy and adherence to medication
were related.
Lefebvre et al [7] 128 RA cases Self-efficacy ratings were significantly related to
daily ratings of pain, mood, coping, and
coping efficacy.
Asgari & 145 Chronic pain cases Higher pain self-efficacy beliefs predicted reduced
Nicholas [38] avoidance behaviors over time.
Abbreviation: RA, rheumatoid arthritis.
754 J.P. Allegrante, R. Marks / Rheum Dis Clin N Am 29 (2003) 747–768

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 ad-
herence 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 self-
efficacy 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 signifi-
cantly 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 approxi-
mately 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
 J.P. Allegrante, R. Marks / Rheum Dis Clin N Am 29 (2003) 747–768 755

four primary strategies recommended by Bandura [2,3] for increasing behav-

ioral competence:

1. Facilitation of task performance or skills mastery

2. Exposure to direct or vicarious walking experiences
3. Social and verbal encouragement and persuasion
4. 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 self-
efficacy 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 nonthreat-
ening 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 multiple-
component 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
756 J.P. Allegrante, R. Marks / Rheum Dis Clin N Am 29 (2003) 747–768

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-effi-
cacy 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.
 J.P. Allegrante, R. Marks / Rheum Dis Clin N Am 29 (2003) 747–768 757

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 self-
efficacy 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. Simi-
larly, 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.
758 J.P. Allegrante, R. Marks / Rheum Dis Clin N Am 29 (2003) 747–768

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. Try to promote the adoption of walking.

2. Have patients document their commitment to walking.
3. Try to promote maintenance of the walking activities.
4. 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.
 J.P. Allegrante, R. Marks / Rheum Dis Clin N Am 29 (2003) 747–768 759

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 im-

proving 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 expec-
tations [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 iden-
tify 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
760 J.P. Allegrante, R. Marks / Rheum Dis Clin N Am 29 (2003) 747–768

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 self-
efficacy 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 self-
efficacy predict arthritis-related outcome variables such as fatigue, pain, and well-
being. 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 self-
management. 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
 J.P. Allegrante, R. Marks / Rheum Dis Clin N Am 29 (2003) 747–768 761

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 longer-
lasting 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 self-
efficacy 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 self-
efficacy 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 self-
efficacy 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-manage-
ment activities significantly. These strategies might also enhance self-esteem, co-
operation, decision-making ability, independence, and well-being. This approach
762 J.P. Allegrante, R. Marks / Rheum Dis Clin N Am 29 (2003) 747–768

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, recall-
enhancing 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 in-
direct support for the desired changes
The promotion of decision-making skills, the necessary knowl-
edge, skills, and problem-solving ability, practice, and role-
playing 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 self-
efficacy – enhancing strategies in the conservative management of OA.
 J.P. Allegrante, R. Marks / Rheum Dis Clin N Am 29 (2003) 747–768 763

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 profes-
sionals 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 self-
efficacy. 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 self-
efficacy 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?
764 J.P. Allegrante, R. Marks / Rheum Dis Clin N Am 29 (2003) 747–768

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 corre-
sponds 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. Walk 100 ft on flat ground in 20 seconds?

2. Walk 10 steps downstairs in 7 seconds?
3. Get out of an armless chair quickly, without using your hands for support?
4. Button and unbutton three medium sized buttons in a row in 12 seconds?
5. Cut two bite-size pieces of meat with a knife and fork in 8 seconds?
6. Turn an outdoor faucet all the way on and all the way off?
7. Scratch your upper back with both your left and right hands?
 J.P. Allegrante, R. Marks / Rheum Dis Clin N Am 29 (2003) 747–768 765

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, encour-
aging 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 psycho-
logic 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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