The role of self-efficacy in the self-care of patients with chronic conditions

Background. The management of chronic conditions requires that patients perform specific self-care behaviors and obtain the contribution of their families (e.g., for taking medications as prescribed and eating a healthy diet). Self-care is associated with better outcomes in chronic conditions (e.g., improved quality of life and mortality). However, patients often struggle to perform self-care. Self-efficacy, defined as the confidence to perform a certain behavior despite barriers, can improve patient self-care behaviors and the contribution of their family caregivers. However, so far, we still do not know whether patient self-efficacy can influence the relationship between family support and self-care in populations with multiple chronic conditions (MCC). Self-efficacy represents an easily targetable construct; the use of psychoeducational interventions such as motivational interviewing (MI) can improve intermediate outcomes (e.g., quality of life and self-care). However, little is known whether this intervention can also improve distal outcomes (i.e., mortality and health services use) as a result of self-care behavior change.

Objective. The objective of this research program was to (i) describe the mechanism by which family support influences self-care in people with multiple chronic conditions, with particular focus on patient self-efficacy; (ii) develop an instrument to measure caregiver self-efficacy in contributing to patient self-care (CSE-CSC scale) in MCC, and (iii) investigate the influence of a MI intervention that targets self-efficacy, in improving health service use and mortality in a chronic disease population (i.e., heart failure) as a result of sustained behavior change.

Methods. In the first cross-sectional study we analyzed data from the SODALITY study, which enrolled a sample of 541 older adults affected by MCC (mean age = 76.6 ± 7.3 years, 55.6% females) from seven Italian regions. Data were analyzed by descriptive statistics and a series of structural equation models. In the second cross-sectional study, we enrolled 358 caregivers (mean age = 54.6 ± 15.1 years, 71.5% females) of patients from the SODALITY study. Data were analyzed with descriptive statistics, exploratory and confirmatory factor analysis, and reliability analysis. In the third study we analyzed longitudinal data from the MOTIVATE-HF trial. Patients and caregivers were randomized to Arm 1 (MI for patients), Arm 2 (MI for patients and caregivers) or Arm 3 (control group). months. We enrolled 510 patients (median age 74 years, 58% male) and caregivers (median age 55 years, 75% female) and we collected data at baseline and at 3, 6, 9 and 12 months. Above and beyond descriptive statistics, we performed a longitudinal generalized linear mixed model and unadjusted Cox proportional-hazards regression model.

Results. In the first study depression and self-efficacy were significant mediators of the relationship between family support and self-care; however, in men, depression was not a significant mediator. In the second study, the dimensionality analysis of the CSE-CSC confirmed 2 factors within the scale. Construct validity testing showed significant correlations between the scores of the CSE-CSC scale and the scores of the Caregiver Contributions to Self-Care of Chronic Illness Inventory scales. Reliability coefficients were also satisfactory. In the third study, we found that at 12 months, 16.1%, 17% and 11.2% of patients used health-care services at least once in Arms 1, 2 and 3, respectively, without significant differences. At 3 months, 1.9%, 0.6% and 5.1% of patients died in Arms 1, 2 and 3, respectively. Mortality was lower in Arm 2 vs Arm 3 at 3 months (p=0.04), but no difference was found at subsequent follow-ups.

Conclusion. This doctoral dissertation offers new knowledge on the self-efficacy construct in patients and caregivers in the context of MCC. The finding that self-efficacy is reaffirmed as essential in the dynamics of family and self-care in MCC allows us to target this construct more effectively in clinical environments. We also provided investigators with a new instrument to measure self-efficacy of the caregivers; this tool has adequate psychometric properties and is ready for use both in clinical practice and research. Finally, we provided evidence on the effectiveness of motivational interviewing on mortality in heart failure patients. Health care professionals will have stronger evidence to rely on, to incorporate MI into their interactions with patients. These results contribute to advancing the science of family nursing in HF self-care.