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Rheumatology 2001; 40: 1221-1230
© 2001 British Society for Rheumatology

Original Papers

Development and validation of a self-efficacy scale for use in British patients with rheumatoid arthritis (RASE)

S. Hewlett, Z. Cockshott, J. Kirwan, J. Barrett1, J. Stamp2 and I. Haslock2

Rheumatology Unit, University of Bristol Division of Medicine, Bristol Royal Infirmary, Bristol,
1 Department of Experimental Psychology, University of Bristol, Bristol and
2 Rheumatology Unit, South Cleveland Hospital, Middlesborough, UK


   Abstract
Top
 Abstract
Introduction
 Methods
 Results
 Discussion
 Appendix 1
 References
 
Objective. Current arthritis self-efficacy scales have attracted some criticism. Therefore, the aim of this study was to develop and validate a measure of self-efficacy for use in British rheumatoid arthritis patients [Rheumatoid Arthritis Self-efficacy (RASE) scale].

Methods. Phase I: item generation of self-management strategies by rheumatology professionals and patients to create a pilot RASE. Phase II: examination of the internal structure (n=88) using correlation coefficients and principal component analysis (PCA) to create the final RASE. Phase III: reliability in 23 patients. Phase IV: comprehension, construct validity and sensitivity to change in 48 rheumatoid arthritis patients undergoing a self-management programme, using correlation coefficients, PCA and inter-item correlation.

Results. Phase I: of 166 self-management items generated, 100 commonly cited items were selected for the pilot RASE. Phase II: using a correlation matrix and PCA, a 28-item RASE was created. Phase III: good 4-week reliability was seen (r=0.889, P<0.001). Phase IV: the final RASE was shown to be independent of mood, disease status and disability and weakly associated with other self-efficacy scales (r=0.313, P<0.05). The RASE was sensitive to change following an education programme (+5.167, P<0.025), and was associated with behaviour initiation (r=0.35, P<0.01).

Conclusions. Careful construction means that the RASE examines beliefs in potential ability to perform tasks, rather than actual ability, performance or outcome expectancy. It shows good face validity and reliability, plus reasonable construct validity and sensitivity. Further studies are needed to support the validation of this new scale.

KEY WORDS: Rheumatoid arthritis, Self-efficacy, Validation, RASE.


   Introduction
Top
 Abstract
 Introduction
Methods
 Results
 Discussion
 Appendix 1
 References
 
Patient education in rheumatoid arthritis (RA) is now routine practice [1] and can be a route for improving self-management. Self-management, defined as a constant process of behavioural choices and decision-making [2], can be achieved by changing knowledge, skills and attitudes and initiating behaviour change. Initiation of behaviour change is influenced by both outcome expectancy and self-efficacy (SE) [3]. Outcome expectancy is a belief that a certain behaviour will lead to a certain outcome (e.g. pacing one's lifestyle will lead to reduced fatigue) and is based on the patient's knowledge of RA management. However, such behaviours are only likely to be initiated if the patient also believes he/she can perform them, i.e. has high SE. SE is a belief in one's ability to carry out a task, rather than a measure of whether or not one actually can or does perform it [3, 4]. For example, a belief that one could pace one's activity, rather than actually being able to do it or actually doing it. The strength of SE influences how much effort and perseverance people will expend to achieve a goal [3]. High SE for specific behaviours should lead to greater use of those behaviours.

SE for health-related behaviours is known to be associated with current health status, predictive of future health status and may be changed by appropriate interventions. SE is a state of mind which can be improved by performance accomplishments (e.g. breaking items into small tasks for goal setting, such that successful accomplishment reinforces SE), vicarious experience (modelling on the successes of similar others), verbal persuasion (suggestions that one can cope, accompanied by the other methods described here) and teaching about the interpretation of physiological state (e.g. fatigue can be due to disease activity or exercise) [2, 3]. All these are often features of RA self-management programmes.

Enhanced SE for certain behaviours is associated with improved health outcomes in those areas [4]. In addition, a strong belief in one's own potential for managing a chronic, painful, disabling condition, could in its own right, directly reduce stress and depression and therefore improve health status.

SE is behaviour specific and questionnaires have been developed for other areas, e.g. phobias, cystic fibrosis, diet and exercise, and cardiac rehabilitation [3, 5–7], to predict outcome and evaluate interventions. An early instrument for use in RA [8] formed the basis of an arthritis SE scale (Arthritis Self-efficacy Scale, ASES) [4], while a global, rather than task-specific, measure for SE has been developed (General Self-efficacy Scale, GSES) [9].

If the patient is given the knowledge, skills and positive outcome expectancy for a behaviour to deal with RA, then SE is the major determinant of whether or not they initiate and persist in that behaviour [3, 10]. Thus self-management programmes, which are costly in terms of staff time, need to be designed to enhance SE if they are to be maximally effective. A valid measure of SE will allow the identification of the components of self-management programmes that enhance SE well or less well (enabling us to modify programmes) and also identify individual patients who have low SE.

Both the ASES and the GSES have been used in RA [11–14]. However, the only arthritis-specific scale (ASES) [4] was developed in the USA and it is known that different cultures hold different aspects of arthritis important [15]. Other assessment scales developed in the USA have required modification and revalidation prior to their reliable use in the UK [16, 17]. In addition, the ASES has a complex set of 20 visual analogue scales which are unusual in layout compared with standard practice [18] because they include numbers, markers and words, and which some patients find difficult to complete. The phraseology of SE questionnaires is of prime importance if they are to reflect SE. An important reservation about the ASES and several other arthritis SE scales [19] is that the phraseology may suggest measurement of actual ability to perform a task, actual performance of the task or outcome expectancy for the task, rather than SE [4, 20, 21]. If SE is related to the initiation of behaviour change, then any arthritis SE scale should be validated against specific behaviour initiation, as for scales in other diseases [3, 5, 6].

The aim of this study was therefore to develop a measure of SE specifically for RA patients in the UK, using patient-initiated items, including some general and some task-specific items, with varying levels of magnitude of difficulty, and to include validation against behaviour initiation for those tasks.


   Methods
Top
 Abstract
 Introduction
 Methods
Results
 Discussion
 Appendix 1
 References
 
The study was conducted in four phases following approval from local research ethics committees. Phase I: item generation and development of the pilot Rheumatoid Arthritis Self-efficacy (RASE) scale. Phase II: examination of the internal structure and reduction of items to the final RASE format. Phase III: reliability. Phase IV: validation in a fresh group of patients expected to undergo changes in SE.

Phase I (item generation)
As a preliminary step to the generation of patient-initiated items, 19 rheumatology health professionals of all disciplines from a university hospital (centre A, southwest UK) and a district general hospital (centre B, north UK) were individually interviewed. In an open-ended, semi-structured format they were asked to identify common problems for RA patients and self-management strategies to deal with them. The problems were subsequently grouped into broad themes, which arose from inspection of the data. Only the titles of these six problem themes were presented to consecutive patients (n=17) from both centres (disease duration >5 yr). For each of the six problem themes, the patients were asked ‘What sort of things do you do to deal with...........’, in order to generate items of self-management important to them. Only after this were the patients shown a list of the self-management strategies most commonly cited by professionals to deal with the problem themes, and asked to delete any which they felt were not helpful.

The self-management strategies most commonly generated by both professionals and patients, plus some strategies generated by patients alone and some by professionals alone, were combined to create a pilot RASE scale. After examination of the literature [3–7, 9], the stem question for the 100-item pilot RASE was devised to reflect beliefs about potential ability for self-management strategies: ‘Do you believe you could do these things to help you deal with......’. A five-point Likert response scale was used (strongly disagree to strongly agree, 1–5) with high scores indicating high SE.

Phase II (internal structure of the pilot RASE)
One hundred and seven consecutive RA out-patients (disease duration >5 yr) were invited to complete the 100-item pilot RASE, along with measures of pain (10 cm visual analogue score, VAS), disability (Health Assessment Questionnaire, HAQ) [22], mood (Hospital Anxiety and Depression scale, HAD) [23] and general SE (GSES) [9]. Following analysis (see statistics section), the pilot RASE was reduced to a 28-item final RASE with a stem question ‘Do you believe you could do these things to help you with your arthritis? I believe I could..........’ and the same five-point Likert response scale, with high scores indicating high SE. The final score, obtained by summing the 28 answers, ranged from 28 to 140 (Appendix 1).

Phase III (reliability of the final RASE)
Thirty-one consecutive RA patients from centre A (disease duration >5 yr, not undergoing hospital admission or self-management programmes) were invited to complete the RASE scale at entry, 1 and 4 weeks.

Phase IV (completion, construct validity and sensitivity to change)
Sixty-two RA patients participating in routine self-management programmes were invited to complete the RASE before and after their programme (centre A, five group sessions; centre B, between four and five one-to-one sessions, both over approximately 8 weeks). Both programmes aimed to enhance SE by changing knowledge, improving skills, and altering patients’ beliefs about self-management capacity through performance accomplishment, verbal persuasion, interpretation of physiological states and, in the case of centre A, modelling in a group setting. Measures included pain and patient opinion of disease activity (10 cm VAS), disability (HAQ) [22], anxiety and depression (HAD) [23], the five-item helplessness scale (Arthritis Helplessness Index, AHI) [24], the GSES [9] and the ASES [4]. To ascertain behaviour change, the patients were asked, for each RASE question, whether they had used that self-management strategy in the previous month.

Statistics
Descriptive statistics were used for item generation in phase I. In phase II, both inspection of a correlation matrix of all variables (SH, ZC) and principal component analysis (PCA) of the pilot RASE (JB, blind to the correlation data) were used to eliminate duplicate and irrelevant items. The results of both procedures were combined to provide the basis of the final choice of items forming the final RASE scale. In phase III, correlation coefficients were examined to assess reliability. In phase IV, correlation coefficients and PCA were used to explore the construct validity of the final RASE, with inter-item correlation to assess internal consistency further. The ASES and the GSES were used as best comparators for the RASE. Student's t-test (paired) was used to examine sensitivity to change following a self-management programme.


   Results
Top
 Abstract
 Introduction
 Methods
 Results
Discussion
 Appendix 1
 References
 
Phase I (item generation)
Nineteen rheumatology health professionals (eight nurses, four doctors, four physiotherapists, three occupational therapists; centre A=12, centre B=7) were interviewed and no new data emerged after 15 interviews. The professionals generated 110 self-management strategies they believed RA patients could or should use. The data were inspected for broad themes and six problem themes emerged: dealing with symptoms (pain, fatigue, stiffness); functional limitations; social or lifestyle limitations (relationships, leisure, work); disease management strategies (relaxation, sleep, medication, exercise); dealing with emotional distress and general overall approaches to arthritis (e.g. finding a way around problems, seeking advice). Seventeen RA patients (eight of whom had participated in a self-management programme) were interviewed [11 females, mean age 60 yr (range 40–77), disease duration 18.4 yr (range 5–42); centre A=10, centre B=7]. In response to these six problem theme headings, the patients generated 122 self-management strategies, of which 66 were identical to the professionals’ strategies (Table 1Go). Thus, a total of 166 different self-management strategies were generated by the two groups.


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  		TABLE 1. Self-management strategies generated (phase I)

 
The 55 self-management strategies most commonly cited by the professionals (55 items, cited on 227 occasions) were reviewed by the 17 patients who were asked to indicate any they considered unhelpful. Of 935 possible occasions (17 patientsx55 strategies), the patients considered items unhelpful on only 92 occasions (9.8%, Table 2Go). This related to 32 of the 55 strategies (58.2%).


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  		TABLE 2. Patient opinion of the usefulness of the items most commonly cited by professionals (phase I)

 
Using these data and by excluding strategies cited only once by the 36 subjects, the 166 health professional- and patient-generated items were reduced to 100. This pilot RASE thus comprised the six themes listed above, divided into 12 sections on pain (16 items), sleep (11 items), tiredness (10 items), function (10 items), relationships (six items), leisure activities (eight items), work (nine items), emotional distress (11 items), general (six items), relaxation (three items), exercise (five items) and medication (five items). The stem question was as described in the methods section.

Phase II (internal structure of the pilot RASE)
Of 107 invited RA patients, 92 completed the pilot RASE and four data sets were incomplete, leaving 88 evaluable data sets (centre A=64, centre B=24; for demographic data see Table 3Go).


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  		TABLE 3. Demographic data (phases II–IV)

 
The internal structure of the pilot RASE was examined in three ways. First, a correlation matrix of all variables was examined (SH, ZC) looking for potentially irrelevant items (low correlation with other RASE, GSES or ASES items) and potentially duplicated items (high correlation with other RASE, GSES, ASES items, clinical or psychological variables). Using these guidelines, tempered by practical evaluation of remaining items in each RASE section (e.g. reducing multiple approaches to single themes such as pain relief methods), a rationale for selecting 36 of the 100 pilot items was proposed. Second, PCA was performed (JB) blind to the above results. As the number of subjects was less than the number of SE variables plus clinical and psychological variables, PCA was performed on 11 of the 12 RASE sections separately. (The nine-item work section was excluded as insufficient numbers of subjects were employed to allow reliable analysis.) For each of the 11 sections, items loading at >0.5 were selected (n=49). PCA was repeated on these 49 items as a single group, of which 36 loaded at >0.6, yielding 12 factors with little overlap. Factors 1–10 explained 56.6% of the variance in the RASE, with the strongest factors comprising relaxation, exercise, medication, leisure activities and sleep. PCA selected related questions from several RASE sections to form the factors. For example, in factor 2 (exercise), PCA selected one exercise question from each of the pain, tiredness and function sections, plus three questions from the exercise section. By chance, inspection of the correlation matrix and PCA, performed blind to each other, both produced a proposal to reduce the 100 pilot RASE items to 36, of which 13 were common. Third, in order to show the contribution of each item to the factor, and the contribution of each factor to the total RASE score, a further set of analyses was performed, using the correlation between each item and the mean RASE score, multiplied by the standard deviation of that item (a commonly used technique to overcome the problem of low variation in items).

Overall, the three sets of analyses yielded a core set of 24 items which appeared statistically sound and from which 19 were selected for the final RASE using clinical judgement to avoid over-representation of self-management topics. A further nine items with good but slightly less statistical robustness were added, either for face validity (e.g. pain management questions) or because of their relevance to clinical status (e.g. function or fatigue management questions). The final RASE thus comprised 28 items (see Appendix 1). PCA was then performed on these 28 items as supporting evidence rather than validation, as these were the same patients from which the RASE had been developed. Seven factors explaining 70% of the variance in the RASE emerged: SE for relaxation; function and fatigue; emotions; pain; medication; exercise; and leisure activities.

Phase III (reliability of the final RASE)
Twenty-three of 31 invited RA patients completed all data sets at 0, 1 and 4 weeks (for demographic data see Table 3Go). Entry RASE correlated with week 1 RASE at r=0.694 (P<0.001) and with week 4 RASE at r=0.889 (P<0.001).

Phase IV (completion, construct validity and sensitivity to change)
Forty-eight of 62 invited RA patients completed both data sets (centre A=40, centre B=8). There were no statistically significant differences on any variable between the patients who completed the study and the patients who did not.

Completion
No single RASE question was consistently omitted, indicating that the patients understood the questions, and 85% of the patients completed >90% of the questions, with 71% completing 100%. Four per cent of the patients omitted the same whole page of questions, implying that in the large questionnaire battery they turned over two pages at once.

Construct validity
At entry, the RASE correlated with the ASES other subscale (r=0.313, P<0.05), but not with any other ASES subscales or the GSES (Table 4Go). Similarly there was no correlation between the GSES and the ASES. The RASE, like the GSES, was independent of disease activity, disability and mood, while the ASES subscales showed a marked association. Changes in the RASE were associated with changes in the ASES pain and other subscales (r=0.35, r=0.32, P<0.05), but not with changes in the GSES (Table 5Go). There were no associations between changes in the GSES and changes in the ASES. Whilst changes in the ASES were associated with changes in disease status and more strongly with changes in psychological status, changes in the RASE and the GSES were independent of these variables (changes in the RASE correlated only weakly with change in anxiety at r=0.33, P<0.05).


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  		TABLE 4. Correlation between SE scales and other variables at entry (phase IV), n =, n=48

 

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  		TABLE 5. Correlation between change in SE scales and change in other variables (phase IV), n = 48

 
Inter-item correlation showed that 22 of the 28 RASE items correlated significantly with the total RASE score. At an individual question level, some items showed poor or negative inter-item correlation, indicating that SE may not be a unidimensional concept (Table 6GoGo). PCA showed eight factors explaining 75.5% of the variance in the RASE and comprising 25 of the 28 items (Table 7Go). These appeared to represent different SE factors fairly cleanly for relaxation, relationships, function, leisure activities, exercise, sleep, medication and fatigue.


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  		TABLE 6a. Inter-item correlation, RASE (phase IV), n = 48

 

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  		TABLE 6b. Inter-item correlation, RASE (phase IV)

 

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  		TABLE 7. PCA factor analysis of final RASE (phase IV), n = 48

 

Sensitivity to change
The RASE scores improved significantly following the self-management programmes (+5.2, S.D. 15.5, P<0.025) as did SE when measured by the ASES pain and other subscales (Table 8Go). However, SE as measured by the GSES and the ASES function subscale did not change significantly. SE improved in 26 of the 28 individual RASE items following the self-management programme (15 improved significantly). SE for one item remained unchanged and deteriorated in one. The number of self-management behaviours listed in the RASE which were used by the patients increased by 19.3% after education (mean 5.4, S.D. 6.6, P<0.001). This change in behaviour was associated with a change in the RASE (r=0.35, P<0.01, Spearman's rank correlation) and with a change in the GSES (r=0.35, P<0.05), but not with changes in any ASES scale.


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  		TABLE 8. Changes in variables following self-management programme (phase IV), n = 48

 


   Discussion
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
Appendix 1
 References
 
The RASE has been developed to measure task-specific SE in relation to behaviour change, as originally indicated by Bandura [3] and re-iterated by others [10, 19]. It uses culturally relevant items for British RA patients, with self-management items generated and thus valued by both patients and professionals, rather than imposing professionals’ beliefs on self-management strategies. This reflects the fact that patients and professionals do not always agree on the importance of arthritis-related topics [25]. The phraseology has been carefully constructed to reflect beliefs about potential for initiating behaviours rather than actual ability, performance or outcome expectancy for such tasks, which is a common problem in the development of other SE scales [19]. Tasks include emotional and practical coping behaviours which vary in magnitude. Development and validation was carried out in a pragmatic way, involving patients from different parts of the country, using different hospital services and different self-management programmes. Patients who did not attend every session were still included in this study.

The RASE is shown to have good reliability, and appears to have reasonable internal consistency and factor structure. The scale loads on a fairly large number of factors, reflecting its deliberate design of including a variety of self-management topics. Whilst most individual items correlate with the total RASE score, some items do not correlate well with each other. This may reflect the idea that SE is a multidimensional concept. The scale is designed to be task specific rather than to reflect general SE and it is feasible that some patients will have high SE for some tasks (e.g. practising relaxation to deal with worries), but low SE for other tasks (e.g. discussing problems with their family).

Construct validity for the RASE is supported by an association with the ASES other subscale, while change in the RASE is associated with change in other SE scales (Tables 4Go and 5Go). The RASE is also independent of disease status and change in disease status, a pattern also seen in the GSES. In contrast the ASES is associated with disease status. In addition, the RASE is sensitive to change (following education in self-management), while the GSES and the ASES function subscales are not (Table 8Go). This change in the RASE is also associated with behaviour initiation (as was change in the GSES), but none of the changes in the ASES subscales was associated with behaviour initiation. The independence of the RASE from mood and changes in mood (Tables 4Go and 5Go) could be interpreted as reducing the evidence for construct validity of the RASE. But this pattern is the same as that seen with the GSES. Both are different from the ASES, where quite marked association with mood and change in mood are seen. It seems likely that, because of their phraseology, the ASES subscales may be more closely reflecting psychological state or disability than SE [19]. Since the commencement of this study, both the ASES and the GSES have been subject to revalidation for use in the UK and both required amendment, minor for the GSES but major for the ASES [11, 12].

Neither the RASE nor the ASES correlate with the GSES, which may indicate that general SE or a general approach to beliefs about one's abilities is a different concept to beliefs about dealing with specific problems. This suggests that in dealing with a particular illness, a combined disease-specific and task-specific approach, such as the RASE, is more appropriate. The aim of self-management programmes in arthritis is to give patients an armoury of tools to deal with the specific problems of arthritis, while the GSES is shown to measure a unitary global concept of SE [11]. The eight factors shown in the RASE (Table 7Go) shows it has a multidimensional content. This seems reasonable as patients may have varying levels of SE for different aspects of self-management but may not detract from using the RASE as a single score to reflect the patient's overall approach. Further exploration of the internal structure on larger groups of patients may be worthwhile.

Self-management programmes have become routine practice in rheumatology but are expensive to run and, like all other treatment packages, require evidence to support their use. If enhancing SE is the main mechanism by which behaviour change and improved health status can be achieved, then it is important to measure SE in a way which is not accompanied by the ‘noise’ of mood changes. The RASE is one such possible tool that has been carefully constructed and now deserves further investigation. Testing in larger groups of patients is required in order to examine further factor structure, particularly as the large number of variables involved limited the PCA carried out in the more modest number of patients in this study. Further testing may reveal other redundant or irrelevant items, for example the items which did not correlate with the total RASE score or the items not selected in the final PCA. Larger studies of self-management interventions would also permit investigation of the attributes of patients whose SE changes a lot or only modestly and an examination of whether changes in the RASE are ‘dose’ related to the number of sessions attended, which would further support construct validity. Further studies are planned to support the validation of this scale.


   Appendix 1
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Appendix 1
References
 
The Rheumatoid Arthritis Self-efficacy (RASE) questionnaire
We are interested in finding out what things you believe you could do to help you with your arthritis. We want to know what you think you could do, even if you are not actually doing it at the moment. Please tick one column for each question.

Do you believe you could do these things to help you with your arthritis?

1. I believe I could use relaxation techniques to help with pain.
2. I believe I could think about something else to help with pain.
3. I believe I could use my joints carefully (joint protection) to help with pain.
4. I believe I could think positively to help with pain.
5. I believe I could avoid doing things that cause pain.
6. I believe I could wind down and relax before going to bed, to improve my sleep.
7. I believe I could have a hot drink before bed, to improve my sleep.
8. I believe I could use relaxation before bed, to improve my sleep.
9. I believe I could pace myself and take my arthritis into account to help deal with tiredness.
10. I believe I could accept fatigue as part of my arthritis.
11. I believe I could use gadgets to help with mobility, household tasks or personal care.
12. I believe I could ask for help to deal with the difficulties of doing everyday tasks.
13. I believe I could do exercises to deal with the difficulties of doing everyday tasks.
14. I believe I could plan or prioritize my day to deal with difficulties of doing everyday tasks.
15. I believe I could educate my family and friends about my arthritis to help with the strains that arthritis can make on relationships.
16. I believe I could explain to friends and family when I do or do not need help.
17. I believe I could discuss any problems with my partner or family.
18. I believe I could make time for leisure activities, hobbies or socializing.
19. I believe I could save energy for leisure activities, hobbies or socializing.
20. I believe I could focus on the positive when I am feeling down.
21. I believe I could use relaxation to deal with worries.
22. I believe I could allocate time for relaxation.
23. I believe I could use a relaxation tape or instructions to help me relax.
24. I believe I could use regular exercise.
25. I believe I could be aware of my limits in exercise.
26. I believe I could manage my medication, knowing how and when to take it.
27. I believe I could look out for and avoid side-effects of my medication.
28. I believe I could seek help with persistent side-effects.

Likert scoring, strongly disagree to strongly agree, 1–5.


   Acknowledgments
 
The authors would like to thank the patients and professionals from both centres involved in this study, and to acknowledge the support of the Arthritis Research Campaign in funding the project (ARC grant H0547).


   Notes
 
Correspondence to: S. Hewlett, University of Bristol Rheumatology Unit, Bristol Royal Infirmary, Bristol BS2 8HW, UK. Back


   References
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Appendix 1
 References
 

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Submitted 8 August 2000; Accepted 9 May 2001


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