In healthcare, we have long understood the importance of patient activation in chronic disease self-management. Activation refers to an individual’s sense of empowerment to take control of his or her health. It consists of knowledge, skills, attitudes and confidence about managing one’s health and/or chronic conditions.1 Hibbard et al. succinctly summarize the review of activation literature by stating that: ”… patients who are able to: (1) self-manage symptoms/problems; (2) engage in activities that maintain functioning and reduce health declines; (3) be involved in treatment and diagnostic choices; (4) collaborate with providers; (5) select providers and provider organizations based on performance or quality; and (6) navigate the health care system, are likely to have better health outcomes.”1 There are health coaching studies that show that clinicians can be trained to address and improve activation levels of their patients through motivational interviewing-based health coaching interventions.2-4
Barriers to Patient Activation
What are barriers to patients being able to take charge of their health and successfully manage their health? There are psychosocial factors such as depression, stress, lack of resources, etc. There are still traditional views held by both clinicians and patients that encourage patients to be a passive recipient of care. And there are constructs such as self-efficacy and personal agency that also play a significant role.
In healthcare, self-efficacy refers to an individual’s confidence in one’s ability to manage a chronic condition or change a health habit. Self-efficacy can exert a powerful influence on how successful we are in achieving important health or life goals. In fact, Lorig et al.5 found that self-efficacy levels may predict clinical outcomes better than actual health behaviors. In another review, the researchers determined that self-efficacy explained more than 50% of the variability in behavior change.6
As one example of low self-efficacy, many patients realize that quitting smoking is important to their health, but, based on their previous attempts, lack the confidence that they can quit. This lack of confidence blocks their feeling of empowerment and may keep them from even trying to quit again unless this sense of low self-efficacy improves.
Conversely, having a sufficient sense of self-efficacy in changing a lifestyle habit predicts success; the resulting success raises self-efficacy, in turn increasing the odds of attempting and completing the next step/task.7 One’s self-efficacy is also a significant determinant of one’s “personal agency”.8
Personal agency is defined as the understanding of oneself as an agent who is capable of having an influence over one’s own motives, behavior, and possibilities.8 Agency is akin to constructs such as self-efficacy, locus of control, autonomy, implicit beliefs, and self-esteem but the closest concept to agency is one’s belief in free will. In other words, I believe that I have choice and am not overly bound or restricted by external factors (e.g., God’s will, predestination, etc.) or internal factors (e.g., genes, lack of control over urges/needs, etc.).9
In the context of behavior change science, it is the belief that what I do matters and has an influence on my health – if I walk daily, I can help my blood pressure go down. An example of a patient with low self-agency is a woman with diabetes who does not take her prescribed medications or check blood sugars regularly because she does not believe doing so will make a difference or avoid the set course of her disease.
Addressing Self-efficacy and Personal Agency in the Healthcare Setting
It is quite common to encounter patients/clients in various healthcare settings with low self-efficacy and/or personal agency. In a follow-up study to our clinical trial,10 we compared/contrasted perspectives and beliefs between employees with chronic conditions who had declined to join a free health management program (non-adopters) with those who had joined the program (full adopters).11 We collected both quantitative (survey) and qualitative (focus group and interview) data, and found that the non-adopters had lower levels of self-efficacy and personal agency. It is important to note that there was no difference between the two groups about their belief in the importance of health to one’s quality of life. In addition, the full adopters freely discussed and focused their attention on motivating factors to make healthy lifestyle choices, whereas the non-adopters were more overwhelmed by/focused on perceived barriers and challenges to chronic disease self-management.
Understanding the constructs of self-efficacy and personal agency, and incorporating strategies that address them in engagement and coaching activities can increase our chances in activating patients towards better chronic disease self-management. There are several evidence-based interventions that can target personal agency or self-efficacy-related beliefs, such as cognitive-behavioral therapy (CBT) and motivational interviewing (MI).2,12 CBT is mostly used by behavioral health therapists; however, MI has been successfully adapted for use by clinicians in the healthcare setting.13, 14
MI-Based Health Coaching Addresses Self-Efficacy and Personal Agency
In a previous blog article, we made the case for the efficacy of MI and the many benefits of integrating into your healthcare setting. Being able to use this approach to address a patient’s self-efficacy or personal agency to help activate proficient MI practitioner will naturally do this, it can be helpful to include this specific application to health coaches during initial MI training as well as during subsequent advanced and skill-building activities.
In traditional patient education encounters, when it becomes apparent that a patient has not been following the treatment plan, there is a tendency for the clinician to repeat instructions and/or focus on conveying the importance of the lifestyle change or treatment plan. In the MI approach, instead of automatically assuming that the sticking point is lack of knowledge or lack of belief in importance, the health coach is trained to use one of multiple strategies to assist in identifying individuals who have low self-efficacy or personal agency. Once the health coach is aware that a patient is low in one or both constructs, there are also multiple MI strategies to help the individual improve in their belief that their efforts will make a difference and that they can be successful when they decide to undertake these actions. See Table 1 below for an overview of some of these MI strategies.
It is common for patients to appear as if they are in precontemplation phase for adopting a new lifestyle or following a treatment plan; instead, they may lack the confidence or belief that their efforts will make a difference. By identifying what the sticking point is for the patient and using MI strategies to address low self-efficacy or personal agency when warranted, we can encourage individuals to believe in themselves and empower them to begin to take charge of their health.
1 Hibbard JH, Stockard J, Mahoney ER, et al. Development of the Patient Activation Measure (PAM): Conceptualizing and Measuring Activation in Patients and Consumers. Health Serv Res 2004;39(4p1):1005-1026.
2 Linden A, Butterworth SW, Prochaska JO. Motivational interviewing-based health coaching as a chronic care intervention. J Eval Clin Prac 2010;16(1):166-174.
3 Linden A, Butterworth SW. A Comprehensive Hospital-Based Intervention to Reduce Readmissions for Chronically Ill Patients: A Randomized Controlled Trial. Am J Man Care 2014;20(10):783-792.
4 Skolasky RL, Maggard AM, Li D, et al. Health Behavior Change Counseling in Surgery for Degenerative Lumbar Spinal Stenosis. Part I: Improvement in Rehabilitation Engagement and Functional Outcomes. Arch Phys Med Rehab 2015;96(7):1200-1207.
5 Lorig KR, Hurwicz ML, Sobel D, et al. A national dissemination of an evidence-based self-management program: a process evaluation study. Pat Educ Couns 2005;59(1):69-79.
6 AbuSabha R, Achterberg C. Review of self-efficacy and locus of control for nutrition- and health-related behavior. J Am Diet Assoc 1997;97(10):1122-32.
7 Bandura A. Self-Efficacy Mechanism in Human Agency. Am Psychol 1982;37(2): 122-147.
8 Bandura A. Social cognitive: an agentic perspective. Annu Rev Psychol 2001;52:1-26.
9 Feldman G. Making sense of agency: Belief in free will as a unique and important construct. Soc Personal Psychol Compass 2017;11(1):e12293. doi: 10.1111/spc3.12293.
10 Prochaska, J.O., Butterworth, S., Redding, C.A., et al. (2008). Initial Efficacy of MI, TTM Tailoring and HRI’s with Multiple Behaviors for Employee Health Promotion. Prev Med, 46, 226-31.
11 Butterworth SW, Prochaska JO, Redding CA. Evaluation of Project META (Motivating Employees Towards Action). Research Presentation to 2010 Art & Science of Health Promotion Conference, Hilton Head, SC; March 2010.
12 Goldin PR, Ziv M, Jazaieri H, Werner K, et al.Cognitive reappraisal self-efficacy mediates the effects of individual cognitive-behavioral therapy for social anxiety disorder. J Consult Clin Psych 2012;80(6):1034-1040.
13 Butterworth SW, Linden A, McClay W. Health Coaching as an Intervention in Health Management Programs. Dis Manage Health Outc 2007;15(5):299-307.
14 VanBuskirk KA, Wetherell JL. Motivational Interviewing Used in Primary Care: A Systematic Review and Meta-analysis. J Behav Med 2014;37(4):768-80.