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The quality of human health is heavily inﬂuenced by lifestyle habits. By exercising control over several health habits people can live longer healthier and slow the process of aging. Exercise, reduce dietary fat, refrain from smoking, keep blood pressure down, and develop eﬀective ways of coping with stressors. If the huge health beneﬁts of these few lifestyle habits were put into a pill it would be declared a spectacular breakthrough in the ﬁeld of medicine. The recent years have witnessed a major change in the conception of human health and illness from a disease model to a health model. It is just as meaningful to speak of levels of vitality as of degrees of impairment. The health model, therefore, focuses on health promotion as well as disease prevention. Perceived self-eﬃcacy plays a key role in the self-management of habits that enhance health and those that impair it.
1. Perceived Self-Eﬃcacy
Perceived self-eﬃcacy is concerned with people’s beliefs in their capabilities to exercise control over their own functioning and over environmental events. Such beliefs inﬂuence what courses of action people choose to pursue, the goals they set for themselves and their commitment to them, how much eﬀort they put forth in given endeavors, how long they persevere in the face of obstacles and failure experiences, their resilience to adversity, whether their thought patterns are self-hindering or self-aiding, how much stress and depression they experience in coping with taxing environmental demands, and the level of accomplishments they realize (Bandura 1997, Schwarzer 1992).
In social cognitive theory, perceived self-eﬃcacy operates in concert with other determinants in regulating lifestyle habits. They include the positive and negative outcomes people expect their actions to produce. These outcome expectations may take the form of aversive and pleasurable physical eﬀects, approving and disapproving social reactions, or self-evaluative consequences expressed as self-satisfaction and self-censure. Personal goals, rooted in a value system, provide further self-incentives and guides for health habits. The perceived sociostructural facilitators and impediments operate as another set of determinants of health habits.
Self-eﬃcacy is a key determinant in the causal structure because it aﬀects health behavior both directly, and by its inﬂuence on these other determinants. The stronger the perceived eﬃcacy, the higher the goal challenges people set for themselves, the more they expect their eﬀorts to produce desired outcomes, and the more they view obstacles and impediments to personal change as surmountable.
There are two major ways which a sense of personal eﬃcacy aﬀects human health. At the more basic level, such beliefs activate biological systems that mediate health and disease. The second level is concerned with the exercise of direct control over habits that aﬀect health and the rate of biological aging.
2. Impact Of Eﬃcacy Beliefs On Biological Systems
Stress is an important contributor to many physical dysfunctions (O’Leary 1990). Perceived controllability appears to be the key organizing principle in explaining the biological eﬀects of stress. Exposure to stressors with the ability to exercise some control over them has no adverse physical eﬀects. But exposure to the same stressors without the ability to control them impairs immune function (Herbert and Cohen 1993b, Maier et al. 1985). Epidemiological and correlational studies indicate that lack of behavioral or perceived control over stressors increases susceptibility to bacterial and viral infections, contributes to the development of physical disorders and accelerates the rate of progression of disease (Schneiderman et al. 1992).
In social cognitive theory, stress reactions arise from perceived ineﬃcacy to exercise control over aversive threats and taxing environmental demands (Bandura 1986). If people believe they can deal eﬀectively with potential stressors, they are not perturbed by them. But, if they believe they cannot control aversive events, they distress themselves and impair their level of functioning. Perceived ineﬃcacy to manage stressors activates autonomic, catecholamine and opioid systems that modulate the immune system in ways that can increase susceptibility to illness (Bandura 1997, O’Leary 1990).
The immunosuppressive eﬀects of stressors is not the whole story, however. People are repeatedly bombarded with taxing demands and stressors in their daily lives. If stressors only impaired immune function people would be highly vulnerable to infective agents that would leave them chronically bedridden with illnesses or quickly do them in. Most human stress is activated while competencies are being developed and expanded. Stress aroused while gaining a sense of mastery over aversive events strengthens components of the immune system (Wiedenfeld et al. 1990). The more rapid the growth of perceived coping eﬃcacy, the greater the boost of the immune system. Immunoenhancement during development of coping capabilities vital to eﬀective adaptation has evolutionary survival value.
The ﬁeld of health functioning has been heavily preoccupied with the physiologically debilitating eﬀects of stressors. Self-eﬃcacy theory also acknowledges the physiologically strengthening eﬀects of mastery over stressors. As Dienstbier (1989) has shown, a growing number of studies is providing empirical support for physiological toughening by successful coping.
Depression is another aﬀective pathway through which perceived coping eﬃcacy can aﬀect health functioning. It has been shown to reduce immune function, and to heighten susceptibility to disease (Herbert and Cohen 1993a). The more severe the depression, the greater the reduction in immunity. Perceived self-eﬃcacy to exercise control over things one values highly produces bouts of depression (Bandura 1997).
Social support reduces vulnerability to stress, depression, and physical illness. But social support is not a self-forming entity waiting around to buﬀer harried people against stressors. People have to go out and ﬁnd, create, and maintain supportive relationships for themselves. This requires a robust sense of social eﬃcacy. Perceived social ineﬃcacy contributes to depression both directly, and by curtailing development of social supports (Holahan and Holahan 1987). Social support, in turn, enhances perceived self-eﬃcacy. Mediational analyses show that social support alleviates depression and fosters health-promoting behavior only to the extent that it boosts personal eﬃcacy.
3. Self-Eﬃcacy In Promoting Healthful Lifestyles
Lifestyle habits can enhance or impair health. This enables people to exert some behavioral control over their vitality and quality of health. Eﬃcacy beliefs aﬀect every phase of personal change: whether people even consider changing their health habits; whether they enlist the motivation and perseverance needed to succeed should they choose to do so; and how well they maintain the habit changes they have achieved (Bandura 1997).
3.1 Initiation Of Change
People’s beliefs that they can motivate themselves and regulate their own behavior play a crucial role in whether they even consider changing detrimental health habits. They see little point in even trying if they believe they do not have what it takes to succeed. If they make an attempt, they give up easily in the absence of quick results or setbacks. Among those who change detrimental health habits on their own, the successful ones have stronger perceived self-eﬃcacy at the outset than nonchangers and subsequent relapsers.
Eﬀorts to get people to adopt healthful practices rely heavily on persuasive communications in health education campaigns. Health communications foster adoption of healthful practices mainly by raising beliefs in personal eﬃcacy, rather than by transmitting information on how habits aﬀect health, by arousing fear of disease, or by increasing perception of one’s personal vulnerability or risk (Meyerowitz and Chaiken 1987). To help people reduce health-impairing habits requires a change in emphasis, from trying to scare people into health, to enable them with the skills and self-beliefs needed to exercise control over their health habits. In community-wide health campaigns, people’s pre-existing beliefs that they can exercise control over their health habits, and the eﬃcacy beliefs enhanced by the campaign, both contribute to health-promoting habits (Maibach et al. 1991).
3.2 Adoption Of Change
Eﬀective self-regulation of health behavior is not achieved through an act of will. It requires development of self-regulatory skills. To build people’s sense of eﬃcacy, they must develop skills on how to inﬂuence their own motivation and behavior. In such programs, they learn how to monitor their health behavior and the social and cognitive conditions under which they engage in it; set attainable subgoals to motivate and guide their eﬀorts; draw from an array of coping strategies rather than rely on a single technique; enlist self-motivating incentives and social supports to sustain the eﬀort needed to succeed; and apply multiple self-inﬂuence consistently and persistently (Bandura 1997, Perri 1985). Once equipped with skills and belief in their self-regulatory capabilities, people are better able to adopt behaviors that promote health, and to eliminate those that impair it. A large body of evidence reveals that the self-eﬃcacy belief system operates as a common mechanism through which psychosocial treatments aﬀect diﬀerent types of health outcomes (Bandura 1997, Holden 1991).
3.3 Maintenance Of Change
It is one thing to get people to adopt beneﬁcial health habits. It is another thing to get them to adhere to them. Maintenance of habit change relies heavily on self-regulatory capabilities and the functional value of the behavior. Development of self-regulatory capabilities requires instilling a resilient sense of eﬃcacy as well as imparting skills. Experiences in exercising control over troublesome situations serve as eﬃcacy builders. Eﬃcacy aﬃrmation trials are an important aspect of self-management because, if people are not fully convinced of their personal eﬃcacy, they rapidly abandon the skills they have been taught when they fail to get quick results or suﬀer reverses. Like any other activity, self-management of health habits includes improvement, setbacks, plateaus, and recoveries. Studies of refractory detrimental habits show that a low sense of eﬃcacy increases vulnerability to relapse (Bandura 1997, Marlatt et al. 1995). To strengthen resilience, people need to develop coping strategies not only to manage common precipitants of breakdown, but to reinstate control after setbacks. This involves training in how to manage failure.
4. Self-Management Health Systems
Healthcare expenditures are soaring at a rapid rate. With people living longer and the need for healthcare services rising with age, societies are confronted with major challenges on how to keep people healthy throughout their lifespan, otherwise they will be swamped with burgeoning health costs. Health systems generally focus heavily on the supply side with the aim of reducing, rationing, and curtailing access to health to contain health costs. The social cognitive approach works on the demand side by helping people to stay healthy through good self-management of health habits. This requires intensifying health promotion eﬀorts and restructuring health delivery systems to make them more productive.
Eﬃcacy-based models have been devised combining knowledge of self-regulation of health habits with computer-assisted implementation that provides eﬀective health-promoting services in ways that are individualized, intensive and highly convenient (DeBusk et al. 1994). In this type of self-management system, people monitor their health habits. They set short-term goals for themselves and receive periodic feedback of progress towards their goals along with guides on how to manage troublesome situations.
Eﬃcacy ratings identify areas in which self-regulatory skills must be developed and strengthened if beneﬁcial changes are to be achieved and maintained. The productivity of the system is vastly expanded by combining self-regulatory principles with the power of computer-assisted implementation. A single implementer, assisted with a computerized coordinating and mailing system, provides intensive individualized training in self-management for large numbers of people simultaneously. The self-management system reduces health risk factors, improves health status, and enhances the quality of life in cost-eﬀective ways (Bandura 1997).
The self-management system is well received by participants because it is individually tailored to their needs, provides continuing personalized guidance and informative feedback that enables them to exercise considerable control over their own change; is a home-based program that does not require any special facilities, equipment, or attendance at group meetings that usually have high dropout rates; serves large numbers of people simultaneously under the guidance of a single implementer; is not constrained by time and place; and provides valuable health-promotion services at low cost. By combining the high individualization of the clinical approach with the large-scale applicability of the public health approach, the self-management system includes the features that ensure high social utility. Linking the interactive aspects of the self-management model to the Internet can vastly expand its availability for preventive and promotive guidance.
Chronic disease has become the dominant form of illness and the major cause of disability. The treatment of chronic disease must focus on self-management of physical conditions over time rather than on cure. This requires, among other things, pain amelioration, enhancement and maintenance of functioning with growing physical disability and development of self-regulative compensatory skills. Holman and Lorig (1992) have devised a prototypical model for the self-management of diﬀerent types of chronic diseases. Patients are taught cognitive and behavioral pain control techniques; proximal goal setting combined with self incentives as motivators to increase levels of activity; problem solving and self-diagnostic skills; and the ability to locate community resources and to manage medication programs. How healthcare systems deal with clients can alter their eﬃcacy in ways that support or undermine their restorative eﬀorts. Clients are, therefore, taught how to take greater initiative for their healthcare in dealings with health personnel. These skills are developed through modeling of self-management skills, guided mastery practice, and enabling feedback.
The self-management program retards the biological progression of the disease, raises perceived self-regulatory eﬃcacy, reduces pain and distress, fosters better cognitive symptom management, lessens the impairment of role functions, improves the quality of life, and decreases the use of medical services. Both the perceived self-eﬃcacy at the outset, and the eﬃcacy beliefs instilled by the self-management program predict later health status and functioning (Holman and Lorig 1992).
5. Childhood Health Promotion Models
Many of the lifelong habits that jeopardize health are formed during childhood and adolescence. For example, unless youngsters take up the smoking habit as teenagers they rarely become smokers in adulthood. It is easier to prevent detrimental health habits than to try to change them after they have become deeply entrenched as part of a lifestyle. The biopsychosocial model provides a valuable public health tool for societal eﬀorts to promote the health of its youth.
Health habits are rooted in familial practices. But, schools have a vital role to play in promoting the health of a nation. This is the only place where all children can be easily reached so it provides a natural setting for promoting healthful habits and building self-management skills.
Eﬀective health promotion models include several major components. The ﬁrst component is informational. It informs people of the health risks and beneﬁts of diﬀerent lifestyle habits. The second component develops the social and self-regulative skills for translating informed concerns into eﬀective preventive action. As noted earlier, this includes self-monitoring of health practices, goal setting, and enlistment of self-incentives for personal change. The third component builds a resilient sense of self-regulatory eﬃcacy to support the exercise of control in the face of diﬃculties that inevitably arise. Personal change occurs within a network of social inﬂuences. Depending on their nature, social inﬂuences can aid, retard, or undermine eﬀorts at personal change. The ﬁnal component, therefore, enlists and creates social supports for desired changes in health habits.
Educational eﬀorts to promote the health of youth usually produce weak results. They are heavy on didactics but meager on personal enablement. They provide factual information about health, but do little to equip children with the skills and self-beliefs that enable them to manage the emotional, and social pressures to adopt detrimental health habits. Managing health habits involves managing emotional states and diverse social pressures for unhealthy behavior not just targeting a speciﬁc health behavior for change.
Health promotion programs that encompass the essential elements of the self-regulatory model prevent or reduce injurious health habits. Health knowledge can be conveyed readily, but changes in values, attitudes, and health habits require greater eﬀort. The more behavioral mastery experiences provided in the form of role enactments, the greater the beneﬁcial changes (Bruvold 1993). The more intensive the program and the better the implementation, the stronger the impact (Connell et al. 1985). Comprehensive approaches that integrate guided mastery health programs with family and community eﬀorts are more successful in promoting health and preventing adoption of detrimental health habits, than are programs in which the schools try to do it alone (Perry et al. 1992).
6. Eﬃcacy Beliefs In Prognostic Judgment And Health Outcomes
Much of the work in the health ﬁeld is concerned with diagnosing maladies, forecasting the likely course of diﬀerent physical disorders and prescribing appropriate remedies. Medical prognostic judgments involve probabilistic inferences from knowledge of varying quality and inclusiveness about the multiple factors governing the course of a given disorder. One important issue regarding medical prognosis concerns the scope of determinants included in a prognostic model. Because psychosocial factors account for some of the variability in the course of health functioning, inclusion of self-eﬃcacy determinants in prognostic models enhances their predictive power (Bandura 2000).
Recovery from medical conditions is partly governed by social factors. Recovery from a heart attack provides one example. About half the patients who experience heart attacks have uncomplicated ones. Their heart heals rapidly, and they are physically capable of resuming an active life. But the psycho- logical and physical recovery is slow for those patients who believe they have an impaired heart. The recovery task is to convince patients that they have a suﬃciently robust heart to resume productive lives. Spouses’ judgments of patients’ physical and cardiac capabilities can aid or retard the recovery process. Programs that raise and strengthen spouses’ and patients’ beliefs in their cardiac capabilities enhance recovery of cardiovascular capacity (Taylor et al. 1985). The couple’s joint belief in the patients’ cardiac eﬃcacy is the best predictor of improvement in cardiac functioning. Those who believe that their partners have a robust heart are more likely to encourage them to resume an active life than those who believe their partner’s heart is impaired and vulnerable to further damage. Pursuit of an active life strengthens the cardiovascular system.
Prognostic judgments are not simply inert forecasts of a natural course of a disease. Prognostic expectations can aﬀect patients’ beliefs in their physical eﬃcacy. Therefore, diagnosticians not only foretell, but may partly inﬂuence the course of recovery from disease. Prognostic expectations are conveyed to patients by attitude, word, and the type and level of care provided them. People are more likely to be treated in enabling ways under positive than under negative expectations. Diﬀerential care that promotes in patients diﬀerent levels of personal eﬃcacy and skill in managing health-related behavior can exert stronger impact on the trajectories of health functioning than simply conveying prognostic information. Prognostic judgments have a self-conﬁrming potential. Expectations can alter patients’ sense of eﬃcacy and behavior in ways that conﬁrm the original expectations. The self-eﬃcacy mechanism operates as one important mediator of self-conﬁrming eﬀects.
7. Socially Oriented Approaches To Health
The quality of health of a nation is a social matter not just a personal one. It requires changing the practices of social systems that impair health rather than just changing the habits of individuals. Vast sums of money are spent annually in advertising and marketing products and promoting lifestyles detrimental to health. With regard to injurious environmental conditions, some industrial and agricultural practices inject carcinogens and harmful pollutants into the air we breathe, the food we eat, and the water we drink, all of which take a heavy toll on health. Vigorous economic and political battles are fought over environmental health and where to set the limits of acceptable risk.
We do not lack sound policy prescriptions in the ﬁeld of health. What is lacking is the collective eﬃcacy to realize them. People’s beliefs in their collective eﬃcacy to accomplish social change by perseverant group action play a key role in the policy and public health approach to health promotion and disease prevention (Bandura 1997, Wallack et al. 1993). Such social eﬀorts take a variety of forms. They raise public awareness of health hazards, educate and inﬂuence policymakers, devise eﬀective strategies for improving health conditions, and mobilize public support to enact policy initiatives.
While concerted eﬀorts are made to change sociostructural practices, people need to improve their current life circumstances over which they command some control. Psychosocial models that work best in improving health and preventing disease promote community self-help through collective enablement (McAlister et al. 1991). Given that health is heavily inﬂuenced by behavioral, environmental, and economic factors, health promotion requires greater emphasis on the development and enlistment of collective eﬃcacy for socially oriented initiatives.
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