Rheumatology

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Rheumatology 2001; 40: 387-392
© 2001 British Society for Rheumatology

Self-efficacy and health status in rheumatoid arthritis: a two-year longitudinal observational study

M. Brekke, P. Hjortdahl¹ and T. K. Kvien

Oslo City Department of Rheumatology, Diakonhjemmet Hospital, Oslo and
¹ University of Oslo, Institute of General Practice and Community Medicine, Oslo, Norway

	Abstract

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Objective. To investigate the relationship between baseline level of self-efficacy for pain and other symptoms and changes in measures for similar dimensions of health status over a period of 2 yr in patients with rheumatoid arthritis (RA).

Methods. Data collected from patients with RA enrolled in a county-based disease register in Oslo, Norway were analysed: 815 patients were examined by mail questionnaire in 1994 and again in 1996. Relationships of the baseline level of self-efficacy and demographic variables with 2-yr changes in health status measures were examined by bivariate and multiple regression analysis. The following health status measures were included: pain and fatigue on a visual analogue scale; the patient's global assessment of disease activity; the symptom and affect scales of the Arthritis Impact Measurement Scales (AIMS2); and the bodily pain, mental health, general health and vitality scales of the Short Form-36 (SF-36).

Results. For all health status measures, there was a significant correlation between the change over a 2-yr span and baseline self-efficacy, even after adjustment for demographic variables and for the baseline level of the health status measure. Favourable changes were associated with high self-efficacy scores.

Conclusions. In patients with RA, the baseline levels of self-efficacy for pain and other symptoms seem to influence 2-yr changes in health status measures regarding these aspects.

KEY WORDS: Rheumatoid arthritis, Self-efficacy, Health status, Health service research, Longitudinal study.

	Introduction

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Rheumatoid arthritis (RA) is a well-defined disease, the diagnosis of which can be established by universally accepted classification criteria [1]. It is chronic and potentially disabling and has pervasive adverse effects on the physical, mental and social well-being of affected individuals. The disease is a challenge in terms of medical therapy, and often requires social support and social insurance. Its course may be influenced by several factors, including the use of disease-modifying drugs [2] and circumstances that are not controlled by doctors. Social deprivation [3, 4], formal education [5], helplessness [5] and social support [6] have all been shown to have an influence, and some authors have suggested, on the basis of cross-sectional studies, that the patient's level of self-efficacy may also be important [6, 7].

The theory of self-efficacy was developed within the framework of social-cognitive theory by Bandura [8]. Perceived self-efficacy is defined as ‘people's judgement of their capabilities to organise and execute courses of action required to attain designated types of performance. It is concerned not with the skill one has, but with the judgement of what one can do with whatever skill one possesses’ [8]. This judgement, whether accurate or faulty, is based on four major sources of information: mastery experiences, modelling, social persuasion and psychological state [9]. Lorig et al. [10] proposed and tested the hypothesis that, for patients with RA, there is an association between perceived self-efficacy and health status related to the disease.

In an earlier study, which included data from a clinical examination and a questionnaire, we compared patients with RA living in an affluent area in Oslo with patients living in a less affluent area [4]. We found no significant difference regarding joint counts, blood test results and number of joint replacements between the two groups. However, significant differences were observed for various health status measures, as patients in the less affluent area reported poorer health status. Patients in this area also had significantly lower scores for self-efficacy, and we raised the question of whether the level of self-efficacy might have acted as the mediator that brought about the differences we observed in health status [4]. The present study was an attempt to further explore this topic. We wanted to investigate whether the baseline level of self-efficacy for pain and other symptoms was correlated with changes in health status measures regarding these dimensions. We were able to study this over a 2-yr span in a large number of patients with RA, recruited from a county-based patient register.

	Materials and methods

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The Oslo Rheumatoid Arthritis register
The basis for this study was the permanent Oslo Rheumatoid Arthritis register [11], which is organized by the Oslo City Department of Rheumatology. Inclusion criteria are a diagnosis of RA [1] and a residential address in Oslo. Patients with juvenile arthritis, i.e. disease onset before the age of 16 yr, are excluded. Inclusion of patients started in 1991, and a variety of procedures were performed in order to identify all patients with RA living in Oslo. The register is updated continually, and now includes about 1600 living patients. The completeness of the register is estimated to be 85% [11, 12].

Data collection
The data used in this study were collected in two phases. Data on self-reported health status and on self-efficacy were collected from the patients in the RA register by a postal survey in April 1994. This was done by well-known and validated measures of health status (see below), which were included in a 30-page questionnaire. The questionnaire also included items about some demographic variables. In 1994 the Oslo Rheumatoid Arthritis register comprised information on 1542 patients, of whom 1024 (66.4%) answered the questionnaire.

In April 1996 a slightly less comprehensive questionnaire (including fewer questions about demographic variables and none about self-efficacy) was mailed to the 1620 patients in the register, of whom 1153 (71.2%) responded. Among the respondents were 815 patients who had also answered the questionnaire in 1994. The data from these 815 patients were analysed in this study.

Measures of self-efficacy and health status
The Arthritis Self-Efficacy Scale (ASES) is a valid and reliable instrument developed to measure self-efficacy in patients with rheumatic diseases [10]. The questionnaire, designed by Lorig et al. [10], contains five items concerning coping with pain, nine items concerning function and six items concerning other symptoms related to RA. Each item presents a statement with which the patient may agree or disagree. The scores are expressed as values between 10 and 100, a score of 10 representing the lowest possible self-efficacy level. In our study we chose not to include the nine questions regarding function. We considered 30 pages as the maximum feasible size for the questionnaire, and therefore had to omit some instruments and questions, among them the self-efficacy function scale. We thus expressed self-efficacy as two scores: one for pain and one for other symptoms (fatigue, depression etc.).

The questionnaires included several instruments examining self-reported health status. Pain and fatigue were measured on a 100-mm visual analogue scale (VAS; 0=best score). The patient's global assessment of disease activity was measured on a five-point categorical scale (0=best score), and the Arthritis Impact Measurement Scales (AIMS2) and the Short Form-36 (SF-36) were also used. Since 1980, the AIMS has become the standard for disease-specific measures of disability and health-related quality of life in relation to rheumatic diseases [13]. It has later been revised, extended and improved, and now comprises 78 items [14]. Health status may be expressed by five subscales [physical, symptom (=pain), role, social interaction, affect], with scores in the range 0–10 (0=best score).

The SF-36 is a 36-item generic measure of health status, and provides information on eight aspects of health status (physical functioning, physical role, mental health, emotional role, bodily pain, social functioning, general health and vitality) [15]. It has been used in a variety of conditions and has been adapted to and validated in various populations, including that of Norway, according to internationally accepted guidelines [16]. Values for the SF-36 are between 0 and 100 (0=poorest score).

We chose to include a generic as well as a disease-specific health status measure, as the two types of measure provide complementary information [16]. In this study we exclusively analysed data from the subscales giving information on pain and other symptoms: the symptom and affect scales of the AIMS2 and the scales for mental health, bodily pain, general health and vitality of the SF-36.

Data analysis
Statistical analysis was carried out with the Statistical Package for the Social Sciences (SPSS for Windows, version 8.0). Pearson's correlation coefficient was used to examine the bivariate relationships between baseline self-efficacy and baseline health status measures. Partial correlation coefficients were used to investigate the relationships between baseline self-efficacy and health status measures after 2 yr, adjusted for the baseline level of the health status measure. Correlation coefficients below 0.30 were considered weak, coefficients of 0.30–0.70 moderate to substantial, and coefficients of 0.70 or above were considered high.

Multiple linear regression analysis was used to examine the relationships between the baseline self-efficacy level and the health status measures after 2 yr, adjusted for both demographic variables and for the baseline score of the health status measure. The criterion of statistical significance chosen was P<0.05. Bonferroni adjustment was carried out to exclude chance significance (i.e. the P values were multiplied by the number of analyses made).

	Results

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The sample of respondents to both questionnaires (n=815) constituted the study population. This represents 53% of the patients enrolled in the register in 1994. Mean age was 61.4 (S.D. 14.6) yr and mean disease duration was 12.8 (11.0) yr; 79% of the respondents were female, 58% were living with a spouse, and the mean duration of education was 11.4 (3.4) yr.

Table 1 shows the mean values for the health status measures in 1994 and 1996 and the change in each measure. Pain and fatigue measured on a VAS and the patient's global assessment of disease activity changed in the direction of improved health status. The AIMS2 scores for symptom and affect were unchanged, as were the SF-36 scores for bodily pain, general health and vitality. The SF-36 mental health score worsened between 1994 and 1996. However, despite minor changes in health status at the group level, there were frequent changes in both directions at the individual level, as indicated by the large standard deviations (Table 1).

View this table: [in this window] [in a new window]   TABLE 1. Self-efficacy scores at baseline and health status measures, with changes from 1994 to 1996 (n=815)

 
As shown in Table 2, there were moderate to substantial correlation between self-efficacy scores and the scores on all health status measures in 1994 (all P values <0.001, r=0.32–0.53). Low self-efficacy level was correlated with poor health status.

View this table: [in this window] [in a new window]   TABLE 2. Correlation between self-efficacy and health status measures at baseline (n=815)

 
Table 3 shows the partial correlations between baseline self-efficacy and the scores for each health status measure after 2 yr, adjusted for the baseline level of the health status measure. High self-efficacy scores were correlated with favourable changes in all health status measures. The correlations were significant but weak (P0.001, r=0.12–0.22) with one exception: the correlation between self-efficacy pain and the change in the AIMS2 affect subscale was not significant (r=-0.007, P=0.05).

View this table: [in this window] [in a new window]   TABLE 3. Partial correlations between baseline self-efficacy and scores for health status measures after 2 yr, controlling for baseline health status scores (n=815)

 
Table 4 shows the multivariate analysis of the relationships between the levels of each health status measure after 2 yr, the baseline score of the measure, demographic variables and the baseline level of self-efficacy pain (unstandardized ß, P value, total R²). A poor baseline score for a health status measure was the single factor that most strongly correlated with an unfavourable outcome after 2 yr. Age, gender, educational level and disease duration were not significantly correlated to outcome, with the exception of female gender to change in pain level. The baseline level of self-efficacy pain showed a significant correlation, even after Bonferroni adjustment, to favourable changes in all three pain measures (VAS, AIMS2 and SF-36), and to other measures (except the two measures related to mental health).

View this table: [in this window] [in a new window]   TABLE 4. Multiple regression analysis of relationships between health status measures after 2 yr (dependent variables), baseline health status scores, demographic variables and self-efficacy for pain (independent variables) (n=815)

 
In Table 5 the score for self-efficacy other symptoms replaces self-efficacy pain in the multivariate analyses, as the two self-efficacy scores were substantially correlated (r=0.7). The baseline level of self-efficacy for other symptoms showed a significant independent correlation with the scores for all health status measures in 1996 after Bonferroni adjustment (except with the symptom scale of AIMS2).

View this table: [in this window] [in a new window]   TABLE 5. Multiple regression analyses of relationships between health status measures after 2 yr (dependent variables), baseline health status scores, demographic variables and self-efficacy for other symptoms (independent variables) (n=815)

 

	Discussion

Top Abstract Introduction Materials and methods Results Discussion References

 
Our study showed a significant correlation between patients' baseline level of self-efficacy for pain and other symptoms and the change in health status measures regarding pain and other symptoms related to RA over a 2-yr period. High baseline self-efficacy scores were correlated with favourable changes, and this correlation persisted after adjustment for demographic factors and for the baseline level of the health status measures.

The major strengths of this study were the longitudinal design and the large patient sample. Eight hundred and fifteen patients with RA were followed over 2 yr. Database searches have revealed only one longitudinal study on similar issues. Scharloo et al. [17] examined 71 patients with RA on two occasions 1 yr apart. They found that coping strategies and illness perceptions contributed to health outcome, measured as the number of visits to the out-patient clinic and the number of hospital admissions. Other studies have been either cross-sectional or aimed at improving the level of self-efficacy [6, 7, 18–31]. The use of several measures of health status, generic as well as disease-specific, was also a strength in our study, as this allowed us to demonstrate consistent findings within the same dimension across different instruments.

The study had some limitations. One was that we omitted the self-efficacy function scale, and thus could not study the possible correlation of this score with health status measures of physical functioning. Another limitation was that we did not include self-efficacy in the 1996 questionnaire. If we had done so, we would have been able to study changes in self-efficacy scores over the 2-yr period and their possible correlation with changes in the health status measures.

The interpretation of our results has to take into account the large number of patients, which indicates that the strength of an association needs to be considered as well as the significance level. It appeared that the correlation between self-efficacy scores and baseline health status measures was moderate to substantial (Table 2), and that the correlation between self-efficacy and changes in health status measures over 2 yr were significant but weak (Table 3). This correlation remained significant after adjusting for the baseline level of the health status measure and for demographic variables, and after Bonferroni adjustment (Tables 4 and 5). We chose to show unstandardized B values in the tables in order to show directly how much a certain difference in self-efficacy score will influence the score for the various health status measures. For example, for each unit increase in baseline self-efficacy for pain (10–100), the 1996 score for SF-36 bodily pain (0–100) increased by 0.14 and the AIMS2 symptom score (0–10) declined by 0.01 (Table 4). For each unit increase in the baseline score for self-efficacy symptom (10–100), the 1996 VAS score for fatigue (0–100) declined by 0.22 and the SF-36 vitality score (0–100) increased by 0.20 (Table 5). Correlations of this magnitude, though considered weak in statistical terms, must be regarded as clinically interesting.

It is widely recognized that the psychological and sociological characteristics of patients influence the outcome of chronic diseases, including RA. However, the mechanisms and relative contributions of the different aspects are poorly understood, despite the availability of several measures of psychological distress. The development of the ASES [10] has proved useful for the reliable investigation of some of these connections. Several authors have studied the effect of self-efficacy on certain aspects of RA, almost exclusively in cross-sectional studies [4, 6, 18, 19, 21–24]. Taal et al. [6] found that the higher the level of self-efficacy, the better the patients judged their health status, independently of disease activity. Self-efficacy has been found to correlate with the level of fatigue [18] and with daily pain and mood [19], and to be one of the factors that determines patients' demand for informal and professional care [17, 22]. The level of self-efficacy is a determinant of how well arthritis patients comply with treatment programmes [6], including taking medication regularly [21] and carrying out prescribed physical exercises [23]. The coping strategy of patients has been shown to influence the use of analgesic medication [24].

Our study offers additional empirical evidence of the importance of recognizing an individual's level of self-efficacy when health-care for a chronic disease is being provided. However, self-efficacy is not a static trait: it can be altered. Several clinical trials of educational interventions for patients with rheumatic disease have been published in recent years [7, 20, 25–30, 32–34]. Self-management programmes, the most common kind of intervention, focus on the use of information, problem-solving and coping skills for the management of symptoms.

Evaluation after 3–15 months has shown that these self-efficacy programmes have a beneficial effect [7, 20, 25–30, 32, 33]. Some of the trials showed an additional effect on other outcome measures: reduction in the use of health care services [27], greater use of physical exercises [28], increased adherence to joint protection [26], reduced anxiety, depression, fatigue and pain [7, 20, 25], and reduced morning stiffness [28]. Lorig et al. [34] found sustained health benefits of the Arthritis Self-Management Program 4 yr after participation. They also found a 40% reduction in visits to physicians, and estimated 4-yr savings of US$ 648 per patient [34]. Kruger et al. [32] found that self-help courses for patients with RA may result in savings of ten times the cost of the course.

RA is a disease that affects different aspects of life: physical, mental, social and occupational. Treatment correspondingly requires a comprehensive approach, including pharmacotherapy, surgery, physical therapy and ergonomic measures. Several studies have shown relationships between psychological factors, such as self-efficacy, and the severity and course of the disease. We found that patients' baseline self-efficacy level was correlated with the change in health status measures over 2 yr. Thus, our study supports the idea that systematic education aimed at improving self-efficacy should be an integral part of a total management programme for patients with RA.

	Acknowledgments

 
This study was funded by the Norwegian Research Council, The Lions Clubs International, MD 104, Norway, The Norwegian Rheumatism Association, The Norwegian Women Public Health Association, Trygve Gythfeldt and Wife's Legacy and Marie and Else Mustad's Legacy. We thank Kirsten Mossin for keeping the Oslo Rheumatoid Arthritis Register updated and Dr Liv Marit Smedstad and Professor Odd Aalen for help with the statistical analysis.

	Notes

 
Correspondence to: M. Brekke, Norwegian Resource Centre for Rheumatological Rehabilitation, Oslo City Department of Rheumatology, Diakonhjemmet Hospital, Box 23, Vindern, N-0319 Oslo, Norway.

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Submitted 8 November 1999; revised version accepted 17 October 2000.
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