Self-Efficacy and Health Behaviours

Ralf Schwarzer & Reinhard Fuchs

Freie Universität Berlin

To appear in:

Conner, M., & Norman, P. (1995). Predicting Health Behaviour: Research and Practice with Social Cognition Models. Buckingham: Open University Press.

1.0 General Background

Self-referent thought has become an issue that pervades psychological research in many domains. In 1977, the famous psychologist Albert Bandura at Stanford University introduced the concept of perceived self-efficacy in the context of cognitive behaviour modification. It has been found that a strong sense of personal efficacy is related to better health, higher achievement, and more social integration. This concept has been applied to such diverse areas as school achievement, emotional disorders, mental and physical health, career choice, and sociopolitical change. It has become a key variable in clinical, educational, social, developmental, health, and personality psychology. The present chapter refers to its influence on the adoption, initiation, and maintenance of health behaviours. It represents the key construct in Social Cognitive Theory (Bandura, 1977, 1986, 1991, 1992).

Behavioural change is facilitated by a personal sense of control. If people believe that they can take action to solve a problem instrumentally, they become more inclined to do so and feel more committed to this decision. While outcome expectancies refer to the perception of the possible consequences of one's action, perceived self-efficacy pertains to personal action control or agency (Bandura, 1992; Maddux, 1991, 1993; Wallston, 1994). A person who believes in being able to cause an event can conduct a more active and self-determined life course. This "can do"-cognition mirrors a sense of control over one's environment. It reflects the belief of being able to master challenging demands by means of adaptive action. It can also be regarded as an optimistic view of one's capacity to deal with stress.

Self-efficacy makes a difference in how people feel, think and act. In terms of feeling, a low sense of self-efficacy is associated with depression, anxiety, and helplessness. Such individuals also have low self-esteem and harbour pessimistic thoughts about their accomplishments and personal development. In terms of thinking, a strong sense of competence facilitates cognitive processes and academic performance. Self-efficacy levels can enhance or impede the motivation to act. Individuals with high self-efficacy choose to perform more challenging tasks. They set themselves higher goals and stick to them (Locke & Latham, 1990). Actions are preshaped in thought, and people anticipate either optimistic or pessimistic scenarios in line with their level of self-efficacy. Once an action has been taken, high self-efficacious persons invest more effort and persist longer than those with low self-efficacy. When setbacks occur, the former recover more quickly and maintain the commitment to their goals. Self-efficacy also allows people to select challenging settings, explore their environments, or create new situations. A sense of competence can be acquired by mastery experience, vicarious experience, verbal persuasion, or physiological feedback (Bandura, 1977). Self-efficacy, however, is not the same as positive illusions or unrealistic optimism, since it is based on experience and does not lead to unreasonable risk taking. Instead, it leads to venturesome behaviour that is within reach of one's capabilities.

2.0 Description of the Model

According to Social Cognitive Theory, human motivation and action are extensively regulated by forethought. This anticipatory control mechanism involves three types of expectancies: (a) situation-outcome expectancies, in which consequences are cued by environmental events without personal action, (b) action-outcome expectancies, in which outcomes flow from personal action, and (c) perceived self-efficacy, which is concerned with people's beliefs in their capabilities to perform a specific action required to attain a desired outcome.

Situation-outcome expectancies represent the belief that the world changes without one's own personal engagement. Risks are perceived, and persons may feel more or less vulnerable towards critical events that they anticipate. Individuals may sit and wait for things to happen, but illusions about the future may help one cope with threat. When, for example, people anticipate a disease they may distort its likelihood of occurrence. This can be seen as a defensive optimism. Defenses can be made in terms of social comparison bias, e.g., "I am less vulnerable than others to illness." On the other hand, action-outcome expectancies and self-efficacy expectancies include the option to change the world and to cope instrumentally with health threats by taking preventive action. These action beliefs and personal resource beliefs reflect a functional optimism. Empirically, the distinction of the latter two is hard to confirm because the second does not operate without the first. In making judgments about health-related goals, people usually unite personal agency with means. Perceived self-efficacy implicitly includes some degree of outcome expectancies because individuals believe they can produce the responses necessary for desired outcomes.

Adopting health-promoting behaviours and refraining from health-impairing behaviours is difficult. Most people have a hard time making the decision to change and, later on, maintaining the adopted changes when they face temptations. The likelihood that people will adopt a valued health behaviour (such as physical exercise) or change a detrimental habit (such as quitting smoking) may therefore depend on three sets of cognitions: (a) the expectancy that one is at risk ("My risk of getting cancer from smoking is above average"), (b) the expectancy that behavioural change would reduce the threat ("If I quit smoking, I will reduce my risk"), and (c) the expectancy that one is sufficiently capable of adopting a positive behaviour or refraining from a risky habit ("I am capable of quitting smoking permanently"). In order to initiate and maintain health behaviours, it is not sufficient to perceive an action-outcome contingency. One must also believe that one has the capability to perform the required behaviour. A large body of research has examined the role of optimistic self-beliefs as a predictor of behaviour change in the health domain (for an overview see Bandura, 1992; Maddux, 1993; O'Leary, 1992; Schwarzer, 1992). Behavioural change goals exert their effect through optimistic self-beliefs. These beliefs slightly overestimate perceived coping capabilities rather than simply reflect the existing ones.

Both outcome expectancies and efficacy beliefs play influential roles in adopting health behaviours, eliminating detrimental habits, and maintaining change. In adopting a desired behaviour, individuals first form an intention and then attempt to execute the action. Outcome expectancies are important determinants in the formation of intentions, but are less so in action control. Self-efficacy, on the other hand, seems to be crucial in both stages of the self-regulation of health behaviour. Positive outcome expectancies encourage the decision to change one's behaviour. Thereafter, outcome expectancies may be dispensable because a new problem arises, namely the actual performance of the behaviour and its maintenance. At this stage, perceived self-efficacy continues to operate as a controlling influence.

Perceived self-efficacy represents the belief that one can change risky health behaviours by personal action, e.g., by employing one's skills to resist temptation. Behaviour change is seen as dependent on one's perceived capability to cope with stress and boredom and to mobilize one's resources and courses of action required to meet the situational demands. Efficacy beliefs affect the intention to change risk behaviour, the amount of effort expended to attain this goal, and the persistence to continue striving in spite of barriers and setbacks that may undermine motivation. Perceived self-efficacy has become a widely applied theoretical construct in models of addiction and relapse (e.g., Donovan & Marlatt, 1988; Marlatt, Baer & Quigley, 1994; Marlatt & Gordon, 1985). This view suggests that success in coping with high-risk situations depends partly on people's beliefs that they operate as active agents of their own actions and that they possess the necessary skills to reinstate control should a slip occur. The common denominator of relapse prevention theory and the model to be described later on refers to the assumption of distinct stages and the claim that specific self-efficacy operates at these stages.

3.0 Summary of Research

In the following section, the relationship between self-efficacy and specific health behaviours is reviewed. A number of studies on adoption of health practices have measured self-efficacy to assess its potential influences in initiating behaviour change. As people proceed from considering precautions in a general way toward shaping a behavioural intention, contemplating detailed action plans, and actually performing a health behaviour on a regular basis, they begin to crystallize beliefs in their capabilities to initiate change. In an early study, Beck and Lund (1981) exposed dental patients to a persuasive communication designed to alter their beliefs about periodontal disease. Neither perceived disease severity nor outcome expectancy were predictive of adoptive behaviour when perceived self-efficacy was controlled. Perceived self-efficacy emerged as the best predictor of the intention to floss (r = .69) and of the actual behaviour, frequency of flossing (r = .44). Seydel, Taal and Wiegman (1990) report that outcome expectancies as well as perceived self-efficacy are good predictors of intention to engage in behaviours to detect breast cancer (such as breast self-examination) (see also Meyerowitz & Chaiken, 1987; Rippetoe & Rogers, 1987). Perceived self-efficacy was found to predict outcomes of a controlled-drinking programme (Sitharthan & Kavanagh, 1990). Perceived self-efficacy has also proven to be a powerful personal resource in coping with stress (Lazarus & Folkman, 1987). There is also evidence that perceived self-efficacy in coping with stressors affects immune function (Wiedenfeld et al., 1990). Subjects with high efficacy beliefs are better able to control pain than those with low self-efficacy (Altmaier, Russell, Kao, Lehmann & Weinstein, 1993; Litt, 1988; Manning & Wright, 1983). Self-efficacy has been shown to affect blood pressure, heart rate and serum catecholamine levels in coping with challenging or threatening situations (Bandura, Cioffi, Taylor & Brouillard, 1988; Bandura, Reese & Adams, 1982; Bandura, Taylor, Williams, Mefford & Barchas, 1985). Recovery of cardiovascular function in postcoronary patients is similarly enhanced by beliefs in one's physical and cardiac efficacy (C. B. Taylor, Bandura, Ewart, Miller & DeBusk, 1985). Cognitive-behavioural treatment of patients with rheumatoid arthritis enhanced their efficacy beliefs, reduced pain and joint inflammation, and improved psychosocial functioning (O'Leary, Shoor, Lorig & Holman, 1988). Obviously, perceived self-efficacy predicts degree of therapeutic change in a variety of settings (Bandura, 1992).

3.1 Sexual Risk Behaviour

Perceived self-efficacy has been studied with respect to prevention of unprotected sexual behaviour, e.g., the resistance of sexual coercions, and the use of contraceptives to avoid unwanted pregnancies. For example, teenage women with a high rate of unprotected intercourse have been found to use contraceptives more effectively if they believed they could exercise control over their sexual activities (Levinson, 1982). Gilchrist and Schinke (1983) taught teenagers through modeling and role-playing how to deal with pressures and ensure the use of contraceptives. This mode of treatment significantly raised their sense of perceived efficacy and protective skills. Sexual risk-taking behaviour such as not using condoms to protect against sexually transmitted disease has also been studied among homosexual men with multiple partners and intravenous drug users. Beliefs in one's capability to negotiate safer sex practices emerged as the most important predictor of such behaviours (Basen-Engquist, 1992; Basen-Engquist & Parcel, 1992; Kasen, Vaughn & Walter, 1992; McKusick, Coates, Morin, Pollack & Hoff, 1990; O'Leary, Goodhart, Jemmott & Boccher-Lattimore, 1992).

Influencing health behaviours that contribute to the prevention of AIDS has become an urgent issue. Perceived self-efficacy has been shown to play a role in such behaviours. Kok, De Vries, Mudde and Strecher (1991) reported a study from their Dutch laboratory that analyzed the use of condoms and clean needles by drug addicts. Intentions and behaviours were predicted by attitudes, social norms, and especially by efficacy beliefs. Perceived self-efficacy correlated with the intention to use clean needles (.35), reported clean needle use (.46), the intention to use condoms (.74), and reported condom use (.67) (Paulussen, Kok, Knibbe & Kramer, 1989). Bandura (1994) has summarized a large body of research relating perceived self-efficacy to the exercise of control over HIV infection.

Condom use not only requires some technical skills, but interpersonal negotiation as well (Bandura, 1994; Brafford & Beck, 1991; Coates, 1990). Convincing a resistant partner to comply with safer sex practices can call for a high sense of efficacy to exercise control over sexual activities. Programmes were launched to enhance self-efficacy and to build self-protective skills in various segments of the population to prevent the spread of the HIV virus. In particular, studies with homosexual men have focussed on their perceived efficacy to adopt safer sex (Ekstrand & Coates, 1990; McKusick et al., 1990). Jemmott and his associates have conducted a number of interesting intervention studies designed to raise self-regulatory efficacy (Jemmott, Jemmott & Fong, 1992; Jemmott, Jemmott, Spears, Hewitt et al., 1992).

3.2 Physical Exercise

Motivating people to do regular physical exercise depends on several factors, among them optimistic self-beliefs of being able to perform appropriately. Perceived self-efficacy has been found to be a major instigating force in forming intentions to exercise and in maintaining the practice for an extended time (Dzewaltowski, Noble & Shaw, 1990; Feltz & Riessinger, 1990; McAuley, 1992, 1993; Shaw, Dzewaltowski & McElroy, 1992; Weinberg, Grove & Jackson, 1992; Weiss, Wiese & Klint, 1989). Dzewaltowski (1989) has compared the predictiveness of the Theory of Reasoned Action (Fishbein & Ajzen, 1975), and Social Cognitive Theory in the field of exercise motivation. The exercise behaviour of 328 students was recorded for seven weeks and then related to prior measures of different cognitive factors. Behavioural intention was measured by asking the individuals the likelihood that they will perform exercise behaviour. Attitude toward physical exercise, perceived behavioural control, and beliefs about the subjective norm concerning exercise were assessed. The Theory of Reasoned Action fit the data, as indicated by a path analysis. Exercise behaviour correlated with intention (.22), attitude (.18), and behavioural control beliefs (.13). In addition, three social cognitive variables were assessed: (a) strength of self-efficacy to participate in an exercise program when faced with impediments, (b) thirteen expected outcomes multiplied by the evaluation of those outcomes, and finally, (c) self-satisfaction or dissatisfaction with their level of activities and with the multiple outcomes of exercise. Exercise behaviour was correlated with perceived self-efficacy (.34), outcome expectancies (.15), and dissatisfaction (.23), as well as with the interactions of these factors. The higher the three social cognitive constructs were at the onset of the programme, the more days they exercised per week. Persons who were confident that they could adhere to the strenuous exercise programme were dissatisfied with their present level of physical activity and expected positive outcomes, and they exercised more. The variables in the Theory of Reasoned Action did not account for any unique variance in exercise behaviour after the influences of the social cognitive factor was controlled. These findings indicate that Social Cognitive Theory provides powerful explanatory constructs.

The role of efficacy beliefs in initiating and maintaining a regular program of physical exercise has also been studied by Desharnais, Bouillon and Godin (1986), Fuchs (in press), Long and Haney (1988), Sallis et al. (1986), Sallis, Hovell, Hofstetter and Barrington (1992), and Wurtele and Maddux (1987). Endurance in physical performance was found to be dependent on experimentally created efficacy beliefs in a series of experiments on competitive efficacy by Weinberg, Gould and Jackson (1979), Weinberg, Gould, Yukolson and Jackson (1981) and Weinberg, Yukelson and Jackson (1980). In terms of competitive performance, tests of the role of efficacy beliefs in tennis performance revealed that perceived efficacy was related to 12 rated performance criteria (Barling & Abel, 1983).

Patients with rheumatoid arthritis were motivated to engage in regular physical exercise by enhancing their perceived efficacy in a self-management program (Holman & Lorig, 1992). In applying self-efficacy theory to recovery from heart disease, patients who had suffered a myocardial infarction were prescribed a moderate exercise regimen (Ewart, 1992). Ewart found that efficacy beliefs predicted both underexercise and overexertion during programmed exercise. Patients with chronic obstructive pulmonary diseases tend to avoid physical exertion due to experienced discomfort, but rehabilitation programmes insist on compliance with an exercise regimen (Toshima, Kaplan & Ries, 1992). Compliance with medical regimens improved after patients suffering from chronic obstructive pulmonary disease received a cognitive-behavioural treatment designed to raise confidence in their capabilities. Efficacy beliefs predicted moderate exercise (r = .47), whereas perceived control did not (Kaplan, Atkins & Reinsch, 1984).

3.3 Nutrition and Weight Control

Dieting and weight control are health-related behaviours that can also be governed by self-efficacy beliefs (Bernier & Avard, 1986; Chambliss & Murray, 1979; Hofstetter, Sallis & Hovell, 1990; Glynn & Ruderman, 1986; Shannon, Bagby, Wang & Trenkner, 1990; Slater, 1989; Weinberg, Hughes, Critelli, England & Jackson, 1984). Chambliss and Murray (1979) found that overweight individuals were most responsive to behavioural treatment where they had a high sense of efficacy and an internal locus of control. Other studies on weight control have been published by Bagozzi and Warshaw (1990) and Sallis, Pinski, Grossman, Patterson and Nader (1988). It has been found that self-efficacy operates best in concert with general life style changes, including physical exercise and provision of social support. Self-confident clients of intervention programs were less likely to relapse to their previous unhealthy diet.

In sum, perceived self-efficacy has been found to predict intentions and actions in different domains of health functioning. The intention to engage in a certain health behaviour and the actual behaviour itself are positively associated with beliefs in one's personal efficacy. Efficacy beliefs determine appraisal of one's personal resources in stressful encounters and contribute to the forming of behavioural intentions. The stronger people's efficacy beliefs, the higher the goals they set for themselves, and the firmer their commitment to engage in the intended behaviour, even in the face of failures (Locke & Latham, 1990).

3.4 Self-Efficacy Approaches to Addictive Behaviours

Another area in the health field where perceived self-efficacy has been studied extensively is smoking. Quitting the habit requires optimistic self-beliefs which can be instilled in smoking cessation programmes (Baer & Lichtenstein, 1988; Carmody, 1992; Devins & Edwards, 1988; Haaga & Stewart, 1992; Ho, 1992; Karanci, 1992; Kok, Den Boer, DeVries, Gerards, Hospers & Mudde, 1992). Efficacy beliefs to resist temptation to smoke predict reduction in the number of cigarettes smoked (r = -.62), the amount of tobacco per smoke (r = -.43), and the nicotine content (r = -.30) (Godding & Glasgow, 1985). Pretreatment self-efficacy does not predict relapse, but posttreatment self-efficacy does (Kavanagh, Pierce, Lo & Shelley, 1993). Mudde, Kok and Strecher (1989) found that efficacy beliefs increased after treatment, and those who had acquired the highest levels of self-efficacy remained successful quitters as assessed in a one-year period (see also Kok et al., 1991). Various researchers have verified relationships between perceived self-regulatory efficacy and relapse occurrence or time of relapse, with correlations ranging from -.34 to -.69 (Colletti, Supnick & Payne, 1985; Condiotte & Lichtenstein, 1981; DiClemente, Prochaska & Gibertini, 1985; Garcia, Schmitz & Doerfler, 1990; Wilson, Wallston & King, 1990). Hierarchies of tempting situations correspond to hierarchies of self-efficacy: the more a critical situation induces craving, the greater the perceived efficacy needed to prevent relapse (Velicer, DiClemente, Rossi & Prochaska, 1990). In a program of research on smoking prevention with Dutch adolescents, Kok et al. (1992) conducted several studies on the influence of perceived self-efficacy on nonsmoking intentions and behaviours. Cross-sectionally, they could explain 64% of the variance of intentions as well as of behaviour, which was due to the overwhelming predictive power of perceived self-efficacy (r = .66 for intention, r = .71 for reported behaviour) (DeVries, Dijkstra & Kuhlman, 1988). These relationships were replicated longitudinally, although with somewhat less impressive coefficients (DeVries, Dijkstra & Kok, 1989). Also, studies of the onset of smoking in teenagers have shown that perceived self-efficacy mediates peer social influence on smoking (Stacy, Sussman, Dent, Burton & Flay, 1992).

Overcoming addictive behaviours such as substance use, alcohol consumption, and smoking poses a major challenge for those who are dependent on these substances as well as for professional helpers. Smoking, for example, remains the number one public health problem in spite of declining prevalence rates (Shiffman, 1993). Almost one hundred scientific publications per year deal with the issue of smoking cessation. Clinical approaches include multisession, multicomponent counseling or therapy programmes where individuals or small groups receive abstinence and relapse prevention training, often combined with medical treatment. The most promising pharmaceutical aid is the use of a nicotine patch that achieves a transdermal nicotine substitute to help counteract withdrawal symptoms.

On the other end of the treatment continuum lie community interventions, including work site cessation programs. This acknowledges the fact that only one tenth of smokers make use of formal clinical programs. In contrast, most are self-quitters who need only minimal assistance (Cohen et al., 1989; Curry, 1993; Orleans, Kristeller & Gritz, 1993). While relapse rates after professional treatment lie typically between 70% and 90%, those of self-quitters are even higher. Nevertheless, investments in the public health approach are more cost-effective because it reaches a much larger target population and, thus, results in higher overall numbers of persons quitting (Lichtenstein & Glasgow, 1992).

The community-wide minimal treatment programmes benefit from what was learned in clinical settings, although it is not yet clear what the most effective ingredients really are. It seems as if more is better, i.e., treatment packages that consist of many heterogeneous components are superior to theory-based single strategy approaches.

It has also been found that readiness to quit makes a difference. In clinical settings, most clients are self-referred and therefore highly motivated for behavioural change. Public health messages, in contrast, have to be addressed to smokers who are at different stages of motivation (DiClemente et al., 1991). Precontemplators who do not consider quitting at all need a different message than contemplators who struggle with the pros and cons of quitting. Furthermore, those who are ready for action need different kinds of assistance than those who just have quit and face a relapse crisis.

From a social-cognitive viewpoint, the key ingredients of any psychological treatment should be (a) the identification of high-risk situations that stimulate smoking, (b) the development and cultivation of perceived self-efficacy, and (c) the application of adequate coping strategies. This can be described as a competent self-regulation process where individuals monitor their responses to taxing situations, observe similar others facing similar demands, appraise their coping resources, create optimistic self-beliefs, plan a course of action, perform the critical action, and evaluate its outcomes.

Marlatt et al. (1994) propose five categories of self-efficacy that are related to stages of motivation and prevention:

Five Kinds of Self-Efficacy Pertaining to Addictive Behaviours