A narrative review of the evaluation and selection of instruments which assess self-efficacy amongst patients with essential hypertension

Abstract

Hypertension is a chronic disease that is mostly managed by the patients themselves inbetween consultation with their physicians. Self-efficacy, which is an individual’s belief in their capabilities to produce given attainments, is a desirable quality to enable the person to take charge of their health and any long-term illness. Assessment of self-efficacy is thus pivotal in developing a holistic patient-centric care plan to optimize their disease control. For hypertension, self-efficacy is associated with better self-care and outcomes of the disease.

This literature review aims to identify self-efficacy assessment instruments, evaluate their origin, quality and development, compare their strengths and limitations, and applicability in specific target population.

Searches performed using PubMed, Scopus and The Cochrane Library eventually yielded 34 relevant articles and 12 instruments. All instruments were validated in specific populations. Two instruments were specific to hypertension, two instruments measured multiple domains of self-management, while medication adherence was the most common single domain assessed. To select an appropriate instrument, one should take into consideration the clinical context and study design. An algorithm is proposed to facilitate the selection of instrument that is best suited for the specific purpose.

Keywords

Hypertension self-care self-efficacy

Background

Globally, 26.4% of the adult population in 2000 had hypertension and 29.2% (28.8–29.7%) are estimated to be hypertensive by 2025.¹ As the prevalence of hypertension rises with age, the burden of managing this chronic disease is likely to increase further with an aging population, adding more strain to the healthcare system. There is an urgent need to review the existing care delivery model to address its deficiency and enhance its capacity to cater to the growing population of hypertensive patients without compromising their safety and the quality of care they receive.

As a life-long disease, self-care is a key tenet in hypertension management.² Beyond episodic consultation with primary care professionals, patients have to manage their condition every day of their lives. Self-care for hypertension includes taking medication as prescribed, monitoring blood pressure response to therapy and adopting healthier lifestyles such as a low calorie diet and regular exercise.³ The ability to consistently perform these self-care measures varies between individuals, and such behavior is influenced by their culture and beliefs.⁴

Self-efficacy is an individual’s belief in their capabilities to produce given attainments.⁵ It is associated with higher self-care capacity in chronic disease management.⁶ Patients with stronger self-efficacy beliefs are more likely to initiate and maintain recommended health behavior.⁶ Potentially, these patients require less frequent follow-up appointments and fewer medications.

Measurements of these multi-faceted self-care activities as an aggregated indicator for self-efficacy can be challenging. Literature suggests that self-efficacy can be measured using instruments such as questionnaires. An example is the Hypertension Self-care Profile (HBP-SCP), which was developed and validated in an African-American population and was also validated in a Korean-American population.⁷ This paper aims to identify such instruments, evaluate their origin, quality and development, and compare their strengths and limitations.

Materials and methods

Searches were performed using PubMed, Scopus and The Cochrane Library. These three databases provided coverage of all the high-quality, peer-reviewed literature available in the fields of medicine, nursing and healthcare systems. Disease, patient and assessment-related terms were used and combined using Boolean logic commands. Searches of related English-based publications were conducted between May and July 2014 and were limited to articles published between 1998 and 2014. Terms relating to disease, patient and assessment were used in the searches, together with Boolean logic commands: (“Hypertension”) AND (“Self-efficacy”) AND (“Tool” OR “Measure” OR “Instrument” OR “Questionnaire”). “Hypertension” and “Self-efficacy” are medical subject headings. The term “Tool” was expanded to include all of its synonyms.

Searches in PubMed yielded 42 articles while searches in Scopus yielded an additional 43 articles. A total of 18 additional articles were also obtained from the Cochrane Library. Two additional articles were sieved from the reference lists of these articles. Overall, a combined total of 105 studies were identified. In order to be included in this review, the manuscripts were required to be: (a) assessing instruments related to self-efficacy for management of chronic diseases; and (b) come from a manuscript that was published in English. Groups of two to three reviewers independently assessed whether the primary studies met each criterion. The groups met and deliberated to finalize the selection of the articles through consensus. Studies that did not meet one or more of the inclusion criteria were excluded.

In total, 71 studies were excluded as their abstracts did not include any use of an instrument for assessing self-efficacy in patients with hypertension. The full texts of the remaining 32 studies were reviewed. The investigators further reviewed the reference lists from these articles to identify two more relevant studies.

A final total of 34 articles were selected for inclusion in this review. The process of article selection is featured in Figure 1.

Figure 1.

Flow chart showing the process of selecting the relevant studies for the narrative review.

Key information from each selected article was retrieved and summarized into a table, such as the specific self-efficacy assessment instrument, its morphology, origin and characteristics, and the target population in which the instrument was validated. The instruments were also evaluated for their strengths based on the following criteria: whether or not they assess both self-efficacy and self-management; their specificity to hypertension; whether they assess a single domain or multiple domains; whether they are validated in Asian populations; their validity; and their reliability, which includes test–retest stability and internal consistency, as assessed by Cronbach’s alpha index.

Results

From the final 34 articles, 11 instruments that assessed self-efficacy were identified (Tables 1 –3). Some instruments were not discussed due to the following reasons: the instrument was unavailable, or was a translated or adapted version of a validated instrument.

Table 1.

Origin and development of the self-efficacy assessment instruments.

Instrument	No. of items	Validation population	Sample size	Validity	Reliability
General Self-Efficacy Scale (GSE)^a,8	10	23 countries	^d	Criterion validity	Internal consistency – Cronbach’s alpha ranges from 0.76 to 0.90
Perceived health competence^a,9	8	American, age 17–65, 39% female	1106	Construct validity	Internal consistency – Cronbach’s alpha ranges from 0.82 to 0.90; test–retest reliability – ranges from 1 week to 30 months
Medication Adherence Self-Efficacy Scale^a,10	26	African American, age 20–83, 58% female	178	Criterion validity	Internal consistency – Cronbach’s alpha at 0.95; test–retest reliability – several days
Self-Efficacy for Appropriate Medication Use Scale^c,11	13	African American (predominantly), age 63.8±10.4, 55.7% female, 78.6% retired or disabled, 54.8% higher literacy skills	436	Content validity and criterion validity	Internal consistency – Cronbach’s alpha at 0.89; test–retest reliability – 3 months
Long Term Medication Behavior Self-Efficacy Scale^b,12	33	American, Belgium, Netherlands, age >18, 29% female; transplant, hyperlipidemia, and AIDS/HIV patients	1021	Content validity, little evidence for criterion validity	Internal consistency – Cronbach’s alpha not available; currently research ongoing
Weight Efficacy Life-Style Questionnaire^a,13	20	American, mean age 42, 73% female, patients of an outpatient weight-management service at The Miriam Hospital, Rhode Island	220	External validity	Internal consistency – Cronbach’s alpha ranges from 0.70 to 0.90
Self-Efficacy for Eating Behaviors Scale^a,14	61	American (predominantly Caucasian), mean age 21.3, 75% female, 45% employed	171	Construct validity and criterion validity (concurrent validity only)	Internal consistency – Cronbach’s alpha ranges from 0.85 to 0.93; test–retest reliability
Self-Efficacy for Exercise Behaviors Scale^a,14	12	American (predominantly Caucasian), mean age 21.3, 75% female, 45% employed	171	Construct validity and criterion validity (concurrent validity only)	Internal consistency – Cronbach’s alpha ranges from 0.83 to 0.85; test–retest reliability
Abstinence Self-Efficacy Temptation to Smoke^a,15	17	American, age 17–73, 66% female, majority with some college education	421	Internal validity	Internal consistency – Cronbach’s alpha ranges from 0.800 to 0.946; test–retest reliability – 1 month
Hypertension Self-Care Profile^b,7	60	African American (predominantly), age 30–95, 76.1% female, 61.5% ≤ High School education	213	Concurrent validity and construct validity	Internal consistency – Cronbach’s alpha ranges from 0.83 to 0.93
Chronic Disease Self-Efficacy Scale^a,16	33	American	1130	Construct validity	Internal consistency – Cronbach’s alpha ranges from 0.77 to 0.92; test–retest reliability – 10 days

Self-administered.

Interviewer-administered.

Both self-administered and interviewer-administered.

More details of the individual validation studies can be found on the author’s website.

Table 2.

Strengths and weakness of the self-efficacy assessment instruments.

Instrument	Strengths	Weaknesses
General Self-Efficacy Scale	• Validated in 25 different countries¹⁷	• Does not measure perceived values and self-management • Assesses only one domain: general self-efficacy • Test–retest stability not measured
Perceived health competence	• Validated in UK primary care setting⁹	• Does not measure perceived values and self-management • Assesses only one domain: general self-efficacy
Medication Adherence Self-Efficacy Scale	• Validated in predominantly Caucasian American population¹⁸	• Does not measure perceived values and self-management • Assesses only one domain: medication adherence
Self-Efficacy for Appropriate Medication Use Scale	• Initially validated in patients with coronary heart disease and other chronic diseases such as hypertension, hypercholesterolemia and diabetes	• Does not measure perceived values and self-management • Assesses only one domain: medication adherence
Long Term Medication Behavior Self-Efficacy Scale	• Validated in American population¹⁹	• Does not assess actual self-management; only self-efficacy and beliefs. • Assesses only one domain: medication adherence
Weight Efficacy Life-Style Questionnaire	• Validated in other populations – African-American women²⁰, adolescents²¹ and predominantly male population²² • Also validated for other diseases – Attention Deficit/Hyperactivity Disorder²³ and osteoarthritis²⁴ • Predictive validity for weight loss has been supported in multiple studies²⁵	• Does not measure perceived values and self-management • Assesses only one domain: diet • Test–retest stability not measured
Self-Efficacy for Eating Behaviors Scale	• Validated in Korean Americans (Korean and English language)²⁶ and predominantly white rural women population²⁷	• Does not measure perceived values and self-management • Assesses only one domain: diet
Self-Efficacy for Exercise Behaviors Scale	• Validated in young African-American women²⁸ and older African-American and white women²⁹	• Does not measure perceived values and self-management • Assesses only one domain: exercise
Abstinence Self-Efficacy Temptation to Smoke	• Validated in Korean Americans³⁰ and in a largely African-American population³¹	• Does not measure perceived values and self-management • Assesses only one domain: smoking
Hypertension Self-Care Profile	• Validated in Korean Americans³² • Assessed multiple domains of self-efficacy • Measured perceived values and self-management	• Test–retest stability not measured
Chronic Disease Self-Efficacy Scale	• Validated in Korean³³ and Chinese³⁴ populations • Assessed multiple domains	• Does not measure perceived values and self-management

Table 3.

Domains covered by the individual self-efficacy assessment instruments.

Instrument	Specific to hypertension	General self-efficacy	Medication adherence	Diet	Exercise	Smoking	Stress	Others	Access
General Self-Efficacy Scale		✓(10 items)							Open access
Perceived health competence		✓(8 items)							Open access
Medication Adherence Self-Efficacy Scale			✓(26 items)						Approval required
Self-Efficacy for Appropriate Medication Use Scale			✓(13 items)						Approval required
Long Term Medication Behavior Self-Efficacy Scale			✓(33 items)						Approval required
Weight Efficacy Life-Style Questionnaire				✓(20 items)					Approval required
Self-Efficacy for Eating Behaviors Scale				✓(61 items)					Open access
Self-Efficacy for Exercise Behaviors Scale					✓(12 items)				Open access
Abstinence Self-Efficacy Temptation to Smoke						✓(17 items)			Open access
Hypertension Self-Care Profile	✓		✓(6 items)	✓(33 items)	✓(6 items)	✓(3 items)	✓(6 items)	✓(6 items)	Approval required
Chronic Disease Self-Efficacy Scale		✓			✓(3 items)	✓(30 items)			Open access

Discussion

Domains of self-efficacy

The key domains of self-efficacy in hypertension self-management include personal beliefs of the condition and its treatment, propensity for medication adherence and lifestyle modifications. The majority of instruments focus on the assessment of the patients’ confidence levels in certain behavior or performing self-management measures. Generally, the higher the score obtained, the higher the level of self-efficacy.

Besides the confidence component, the HBP-SCP tool also asks patients “How often do you” and “How important is it to you” in carrying out certain self-care activities. It also includes items reporting on direct self-care measures such as home blood pressure monitoring and regular physician review. Instruments of this genre not only allude to patients’ beliefs and personal values but also assess their actions, enhancing their potential as a tool to be used to stratify patients of varying self-management capacities.

Need to validate instruments in specific populations

All of the instruments in this review have been validated and described in the literature. Many of these were validated in the African-American population. They constitute a substantial proportion of patients with suboptimal blood pressure control in North America, which may reflect on their specific self-efficacy capacity.³⁵ Self-efficacy appears to be influenced by indigenous and sociocultural factors, which vary between populations and ethnic groups. The selection of an instrument to assess self-efficacy will have to consider such influences, as reflected in the sites of validation and content of the questionnaire. This is especially pertinent in a multi-ethnic Asian community like Singapore.

Relevance and applications of self-efficacy measurement in current healthcare context

In countries with graying population such as those in Singapore, the incidence and the burden of chronic diseases on its healthcare system inevitably increases. The management of chronic disease requires a multidisciplinary approach for which good outcome is closely linked to self-care.^4,6 Four studies have shown that self-care interventions can achieve greater health outcomes for chronic diseases.^4,36 This is because patients who are able to take care of themselves are likely to identify their problems, make their own decisions, take appropriate actions and alter their behavior if they encounter changes in circumstances or their disease status.⁴ Those with stronger self-efficacy beliefs are more likely to initiate and maintain recommended health behavior.⁴ Such patients may thus require less frequent follow-up appointments, fewer medications and lower the chronic disease burden on the healthcare system, but this potential benefit requires evaluation with further research.

A systematic approach towards selecting a suitable tool to measure self-efficacy

As a benefit from this review, we propose a systematic approach towards selecting a self-efficacy assessment instrument. Primarily, it should be based on the validity and reliability of the instrument and secondly, the given clinical scenario. An algorithm (Figure 2) is suggested to assist physicians, healthcare professionals and health service researchers to select the most appropriate instrument for their target usage.

Figure 2.

A proposed algorithm to select suitable instruments to assess self-efficacy in hypertension.

The majority of the instruments featured in this review underwent the three major validation processes – namely, content, construct and criterion validity. For reliability, assessment, internal consistency and test–retest stability are used for evaluation.³⁶ An instrument which is both valid and reliable will be ideal and will be high on the selection list. They can be easily retrieved and referenced in the tables provided in this review.

The clinical scenario for the use of such instruments can differ, depending on the patient profile and the healthcare professional user. A patient with multiple co-morbidities, for example, will require a tool with questions that cover chronic disease in general and those which are specific to each condition. An example is the Chronic Disease Self-efficacy Scale, which can be adapted for various chronic diseases, thus it may be more suitable for patients with multiple co-morbidities.³⁷

Specific groups of healthcare professionals will have a tendency to select the instrument which is relevant to their respective job scope. For a pharmacist whose expertise lies in pharmacotherapy, an instrument which focuses on medication adherence will likely be picked for their utility. Hence, they may favor a questionnaire such as the Medication Adherence Self-Efficacy Scale.¹⁰

Strength

This narrative review attempts to assemble and evaluate the instruments used to measure self-efficacy in hypertensive patients. An algorithm is incorporated in this review as a logical and systematic approach in the selection of these instruments, which are matched both to their purpose and the healthcare professional groups of users.

Limitations

This narrative review examined only self-efficacy assessment instruments featured in publications in the period between 1993 and 2014. Self-efficacy instruments for other chronic conditions and in non-English literature were not included. Due to limited resources, the relevant literature is retrieved only in selected but major medical databases such as PubMed, Scopus and the Cochrane Library.

Conclusion

This narrative review has examined self-efficacy assessment instruments which have been developed in the past two decades. It highlights the strength and limitations of each instrument and proposes an algorithm to select an appropriate instrument based on purpose and user groups. By selecting and using the most appropriate instrument, healthcare professionals can potentially use it to stratify their patients with hypertension or other chronic diseases, and re-design their healthcare services to cater to patients of different levels of self-efficacy.

Footnotes

Acknowledgements

The authors are grateful to Patricia Kin, Caris Tan and Eileen Koh of the Department of Research in SingHealth Polyclinics for their assistance and support during the project execution and finalizing of the manuscript.

Authors’ contribution

TNC conceptualized the study design. AL, LYH, MT, SB, SW, KZO and JY searched and reviewed the online articles. AL wrote the first draft and all other authors gave critical revision of the draft and approved the final manuscript for submission to journal.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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