Theory supporting effective intervention

(There is a need to) ‘…increase an individual’s confidence and belief to take control over their life’. (Department of Health 2002, p. 25: Expert Patient Programme)

Supporting effective self-management can be a complex process for the patient and their family. The person living with a chronic condition needs to have confidence in their ability to exercise self-management. Self-efficacy is an important and related concept which is similar to but distinct from that of confidence. It may be regarded as a key motivational force which health professionals need to support. Self-efficacy is defined as: ‘an individual’s belief in their capacity to successfully execute a health related behaviour’ (Bandura, 1977, 1989). It reflects a positive perception or belief set. The concept is based on Albert Bandura’s Social Learning Theory (Bandura, 1977, 1997) which indicates that people learn by observing the behaviour of others within a social context. Furthermore, they are more likely to engage in certain behaviours when they believe they are capable of carrying them out successfully; i.e. when they have high self-efficacy. Belief in one’s efficacy to exercise control is viewed by Bandura as a common pathway through which psychosocial influences affect health functioning. Self-efficacy reflects a degree of mastery or control achieved through the development of behavioural or cognitive skills, social skills, life knowledge and skills, all of which are directly relevant to managing a chronic skin condition.

So much of chronic illness management is about behavioural adaptation to ensure that lifestyle is adapted to enduring illness, with people managing their illness in the context of their daily lives. Its application has been seen in work with a wide range of groups living with long-term conditions, including those with diabetes mellitus (Shortridge-Baggett and van der Bijl, 1996; Shui, 2006) and end-stage renal disease (Tsay, 2003).

Self-efficacy is directly relevant to a person’s agency; this refers to their capacity to make choices and to bring about actions and influences arising from these choices, which are a key facet of such adaptation. However, it is important to note that learning may or may not result in behavioural change. For example, a person may be taught to apply their topical treatments; however, they may not have the confidence to apply them or, say, the skill to effectively apply a wrapping bandage. It is fundamental for a change of behaviour for the person, or indeed the carer, to have sufficient degree of self-belief by the person in their capacity to act, as well as knowledge, skill and indeed motivation. Enhancing a person’s capacity to make choices is fundamental to helping them adapt to and effectively self-manage with a chronic illness; as such, this is a fundamental area of facilitative competence that requires development. Self-efficacy is a significant quality for those living with chronic skin conditions because it has been demonstrated to be important to a health-promoting lifestyle (Gillis, 1993). Self-efficacy is recognised as a key basis for effective self-care ability for those with chronic conditions. Principles of self- efficacy have been used to develop self- management skills; extensive testing revealed relief of debility and chronic pain in arthritis (Holman and Lorig, 1992). Perceived self-efficacy has been identified as a predictor of functional disability regardless of the level of pain or disease duration (Schiaffino and Revenson, 1992).

Social learning can be an important route to health promotion since people learn through vicarious experience (Bandura, 2004). Health professionals need to take account of this when working with patients to plan their care. Nurses can use self-efficacy–orientated education to support patient (and family) empowerment and achieve health improvement. The focus for support using the self-efficacy concept may be on the patient, carer or the parent (de Montigny and Lacharite, 2005). Parental selfefficacy is very relevant to the care of the child with conditions such as eczema, since effective management is highly dependent on the parent’s effective engagement in the treatment plan. Work has been undertaken to examine parental self-efficacy in other related contexts, such as childhood asthma self-management (Hanson, 1998; Grus et al., 2001).

There is a distinction between the concepts of self-efficacy and locus of control, which requires consideration when planning patient education. Self-efficacy reflects beliefs in control over action (such as the belief in your ability to manage your child’s eczema symptoms), whereas the locus of control conveys beliefs in control over outcomes (such as the parent’s ability to improve their child’s eczema symptoms). These are distinct but interrelated ideas.