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A Critical Review of Effects of COPD Self-Management Education on Self-Efficacy
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Title: A Critical Review of Effects of COPD Self-Management Education on Self-Efficacy
Physical Description: Journal Article
Creator: Stellefson, Michael
Tennant, Bethany
Chaney, J. Don
Publisher: Hindawi Publishing Corporation
Publication Date: January 26, 2012
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Abstract: Chronic obstructive pulmonary disease (COPD) causes progressive airflow limitation which results in prolonged episodes of coughing and shortness of breath. COPD self-management education (COPDSME) programs attempt to enhance patient self-efficacy for managing symptoms. The purpose of this paper was to conduct a critical literature review that identified peer-reviewed articles assessing the effects of COPDSME on self-efficacy outcomes. Seven articles were located after an exhaustive search. Most studies ( 𝑛 = 6 ) reported statistically significant improvements in self-efficacy following intervention. Almost all of the studies tested interventions that drew upon at least 2 recommended sources of efficacy information. Two studies specifically noted increased self-efficacy for controlling physical exertion following COPDSME. Within the reviewed studies, the content within each educational treatment varied widely and showed a lack of standardization, and the types of instruments used to assess self-efficacy varied. This paper highlights the need for more controlled trials that investigate potential between-subjects effects of different types of COPDSME programs on self-efficacy outcomes. Incorporating practice models for patient-centered primary care in COPD requires the use of tailored efficacy building strategies for specific self-management behaviors.
Acquisition: Collected for University of Florida's Institutional Repository by the UFIR Self-Submittal tool. Submitted by Michael Stellefson.
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Resource Identifier: doi - 10.5402/2012/152047
System ID: IR00001284:00001

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InternationalScholarlyResearchNetwork ISRNPublicHealth Volume2012,ArticleID152047, 10 pages doi:10.5402/2012/152047ReviewArticle ACriticalReviewofEffectsofCOPDSelf-Management EducationonSelf-EfcacyMichaelStellefson,BethanyTennant,andJ.DonChaneyDepartmentofHealthEducationandBehavior,UniversityofFlorida,P.O.Box118210,Gainesville,FL32611,USA CorrespondenceshouldbeaddressedtoMichaelStellefson, mstellefson@u.edu Received4January2012;Accepted26January2012 AcademicEditors:P.BendtsenandK.M.Rospenda Copyright2012MichaelStellefsonetal.ThisisanopenaccessarticledistributedundertheCreativeCommonsAttribution License,whichpermitsunrestricteduse,distribution,andrepro ductioninanymedium,providedtheoriginalworkisproperly cited. Chronicobstructivepulmonarydisease(COPD)causesprogressiveairowlimitationwhichresultsinprolongedepisodesof coughingandshortnessofbreath.COPDself-managementeducation(COPDSME)programsattempttoenhancepatientselfe cacyformanagingsymptoms.Thepurposeofthispaperwastoconductacriticalliteraturereviewthatidentiedpeer-reviewed articlesassessingthee ectsofCOPDSMEonself-e cacyoutcomes.Sevenarticleswerelocatedafteranexhaustivesearch.Most studies( n=6)reportedstatisticallysignicantimprovementsinself-e cacyfollowingintervention.Almostallofthestudies testedinterventionsthatdrewuponatleast2recommendedsourcesofe cacyinformation.Twostudiesspecicallynoted increasedself-e cacyforcontrollingphysicalexertionfollowingCOPDSME.Withinthereviewedstudies,thecontentwithin eacheducationaltreatmentvariedwidelyandshowedalackofstandardization,andthetypesofinstrumentsusedtoassessselfe cacyvaried.Thispaperhighlightstheneedformorecontrolledtrialsthatinvestigatepotentialbetween-subjectse ectsof di erenttypesofCOPDSMEprogramsonself-e cacyoutcomes.Incorporatingpractice modelsforpatient-centeredprimary careinCOPDrequirestheuseoftailorede cacybuildingstrategiesforspecicself-managementbehaviors.1.IntroductionChronicobstructivepulmonarydisease(COPD)isapreventableandtreatabledisease,characterizedbyprogressive airowlimitationthatisnotfullyreversibleandisassociated withanabnormalinammatoryresponseofthelungto noxiousparticlesand/orgases[ 1 ].Airwayobstructionresultsinprolongedepisodesofcoughinganddyspnea(i.e., shortnessofbreath),exacerbationswhichcancausefear leadingtoavoidanceofregularactivity,causingadditional deconditioningthatcanaggravatedyspneaevenfurther [ 2 ].COPDisnowthethirdleadingcauseofdeathin theUnitedStates[ 3 ].Accordingly, HealthyPeople2020 objectivesaimtoreducetheproportionofadultswhose activitiesarelimitedduetochroniclungandbreathingproblems,reduceCOPD-relatedhospitalizationratesandreduce COPD-relatedhospitalemergencydepartmentvisitrates[ 4 ]. Becausepulmonaryrehabilitationprogramsaredeliveredinanoutpatientand/orhospitalfacility,various estimatessuggestonly114%ofpatientswithCOPDare referredtotheseformalprograms[ 5 ].Duetothelimited accessandutilization,itissuggestedthat"pulmonary rehabilitation ... notstandasanisolated,albeitmultidimensionalintervention.Itshouldbepartofanintegrated careprocessandincludeself-managementsupport ... aiming toachieveashiftfrommanagementbythehealthcare provider,tomanagementbythepatientsthemselves"[ 6 page462].COPDself-managementreferstoengagingin activitiesthatpromoteadequateinhalationtechnique,build physiologicreservesandpreventadversehealthoutcomes, monitoringrespiratoryandemotionalstatusandmaking appropriatemanagementdecisionsonthebasisofthisselfmonitoring,andmanagingthedeleteriouse ectsofillness withprescribedcopingskills[ 7 ].Whilepatientsclaimtobe wellinformedaboutcopingwithCOPD,actualknowledgeof COPDself-managementislimited[ 8 ].Forexample,only1 / 4 ofpatientswithCOPDhaveeverbeentoldhowtoprevent adyspneaexacerbation[ 9 ].Ithasbeensuggestedthatthis lackofawarenessisrelatedtothegeneralabsenceofinformationavailableforCOPDpatientsregardingsocialand

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2 ISRNPublicHealth behavioraldimensionsofself-management[ 10 ].Hernandez andcolleagues[ 9 ]notethat"clearly,betterpatienteducation regardingthepreventionandmanagementof[dyspnea] exacerbationsisrequired"(page1011).Todate,psychosocial interventionsaimedatimprovingCOPDself-management haveillustratedalackofconsensusregardingwhatparticular skilldevelopmentactivitiesshouldbeincludedinmost COPDself-managementeducation(COPDSME)programs [ 10 11 ]. COPDSMEprogramscanenhance self-e cacy ,afundamentalintermediaryobjectiveforreducinghealthcare utilizationduetoCOPDexacerbations[ 6 ].E ngandcolleaguessuggestthat,"core-elementsofbehaviourchange (e.g.,enhancing self-e cacy (emphasisadded)expectations orsocialsupport)shouldbeimplementedintheselfmanagementeducationalprogrammes"(page12).Individualswithsimilarlevelsofphysicalimpairmentfrom COPDmayachievedi erentlevelsoffunctionaloutcomes basedontheirlevelofself-e cacy.Enhancedself-e cacy isfundamentaltopromotinge ectiveself-managementand enablingbehaviorchangeinthelongterm[ 12 ],andis aquantiablemediatorbetweendiseaseandunnecessary activityrestriction[ 13 ].Numerousstudiesofpatientswith COPD[ 13 19 ]havesuggestedtherelationshipbetween objectivelungfunctionandHRQoLismediatedbyselfe cacy.Self-e cacyforcopingwithCOPDhasbeento showntoa ectself-reportedHRQoLmoresothanmeasuresofobjectivelungfunction[ 15 17 ].Highself-e cacy predictsreducedpsychosocialimpactofdisease,improved physicalactivitylevels,andincreasedHRQoL[ 20 ].Conversely,lowself-e cacyhasbeenshowntopredictpoor self-managementofCOPD[ 21 ].Whilegreaterself-e cacy isassociatedwithe ectiveCOPDself-management,littleis knownaboutwhatparticularsourcesofe cacyinformation inuenceCOPDself-e cacy.Becausewedonotyetknow whetherCOPDeducation(withoutformalself-management training)issu cienttoimproveself-e cacy[ 22 ],itis importanttoinvestigatetheimpactvariousCOPDSME programshavehadonself-e cacyoutcomes.Thepurpose ofthisstudywastoconductasystematicliteraturereview thatidentiedarticleswhichassessede ectsofCOPDSME onCOPDself-e cacy. 1.1.Self-E cacyTheory. Self-e cacyreferstoone'scondenceintheirabilitytocontrol,organize,andexecutea courseofactionrequiredforperformingspecictasksthat willleadtocertainoutcomes[ 23 ].Beliefinone'se cacy toexhibitbehavioralcontrolisacommonpathwaythrough whichpsychosocialinuencesa ecttheadoptionandmaintenanceofhealthbehaviorchange[ 24 ].Workinginconcert withtheassumptionsofhumancapabilityandexpectancy [ 25 ],allcognitiveandbehaviorchangeinitiatesthroughan individual'sperceivedself-e cacy[ 23 ].Expectationsabout self-e cacyarebasedonfoursourcesofinformation:(a) performancemasteryexperience,(b)vicariousexperienceor modeling,(c)emotionalorphysiologicalarousal,and(d) verbalpersuasion[ 23 ]. Performancemastery(i.e.,informationderivedfrom masteryofdi culttasks)isbelievedtobethemostreliable sourceforself-e cacyexpectations.Itinvolvesgettingpeopleactivelyinvolvedinbehaviorchange,byadvocating thedevelopmentandadoptionofaspecicactionplan forachievingaspecicgoal[ 26 ].Informationgathered followingthemasteryofatasko erspeopleassurancethat theinformationisindeedreliable[ 23 ].Socialmodeling, orvicariouslyexperiencinganactivitythroughobserving orimitatingarolemodel,isanotherimportantsourceof e cacyinformation.Rolemodelswhoareperceivedas similartothelearnerhavethegreatestimpactwhendeliveringe cacyinformation,becausemodelidenticationis strengthenedbyobservingsimilarattributesportrayedby models[ 27 ].Itispreferabletoillustratemodelsovercoming anyobstaclesassociatedwithbehavioraladaptations,as thisportrayalhasbeenshowntoproducemorepositive inuencesonself-e cacy[ 25 28 ].Self-e cacyinformation isalsoacquiredthroughsomaticindicators,suchasphysical anda ectivestates,whichcana ectintentionstocarry outhealthbehaviors[ 23 ].Physiologicalandemotional arousalandfeedbackcansubstantiallyinuenceself-e cacy. Forexample,positivebiofeedbackaboutexercisecapacity canpositivelyinuencepersonale cacybeliefsandoutcomeexpectanciesregardingphysicalactivitylimitations; whilehighphysiologicalarousal(e.g.,dyspnea,pain,and weakness)candiminishself-e cacybeliefsbyimpairing physicalactivityperformance.Analsourceofself-e cacy informationisgatheredthroughverbalpersuasion.This informationisprovidedthroughverballyconvincingan individualoftheirownabilitytoachievetheirgoals.Verbal persuasioncanbetheprimarymotivatorforactionor leveragedthroughadvicewhichendorsessustainede ort [ 29 ].Thepersuadermustberespected,knowledgeable,and provideinformationinamannerconducivetoenhancingpersonale cacy.2.MaterialsandMethods2.1.SearchProcedures. Thispaperadoptedthefollowing denitionofCOPDSME:plannedlearningexperiences aimedathelpingpatientsactivelyutilizeasupportsystem toacquirepersonalknowledgeandcarryoutskillsrelatedtoCOPDself-management,increaseself-condencein appropriatediseaseself-managementdecisionmaking,and facilitateactiontocorrectlyself-managediseasecomplications[ 30 31 ].Theexperimentalunitsofanalysisforinclusionwerepeer-reviewedjournalarticlesevaluatinge ects ofCOPDSMEprogramactivitiesonCOPDself-e cacy. TheeducationalelementsincludedwithineachCOPDSME programwererecordedinanattempttomakeassociations betweenprogramactivitiesandself-e cacyoutcomes.Only thee ectsoftreatmentconditionsthatmetthecriteriafor COPDSMEwereconsidered. 2.2.DataSources. Inordertogenerateasampleofempirical studies,anexhaustivesearchofelectronicdatabaseswas conducted.Thesearcheddatabasesincluded:EBSCO,ERIC, PsychINFO,MEDLINE,EMBASE,MasterFILEPremier, AcademicSearchComplete,CINAHLPluswithFullText,

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ISRNPublicHealth 3 AppliedSocialSciencesIndexandAbstracts,Cambridge, andCSA.Bandurainitiallydescribedself-e cacyin1977; therefore,allmanuscriptswerepublishedfrom1977until December2010(timeofsearch).Thekeytermswere enteredinvariouscombinationswithmultipleBooleanoperators,andincluded: COPD,chronicobstructivepulmonary disease,chronicairowobstruction,obstructivelungdisease,emphysema,chronicbronchitis,self-management,selfmanagementeducation,self-care,self-e cacy,mastery,and literaturereview .Followingthedatabasesearch,theinvestigatorsconductedhandsearches(i.e.,manualmethodof searchingandscanningprintjournalsforresearcharticles) ofreferencelistswithineacharticle. 2.3.InclusionCriteria. Withinthesystematicliterature search,thefollowinginclusioncriteriawereapplied: (1)anyrandomizedcross-sectional,case-control,orlongitudinalstudyassessingthee ectsofatleastone COPDSMEprogramactivity; (2)measurementofself-e cacyusingsurveyinstrumentsduringand/orfollowingCOPDSMEprogram participation; (3)maleand/orfemalepatientswithCOPDabovethe ageof40whoparticipatedinCOPDSMEprogram activitiesasdenedabove; (4)patientsdescribedasbeingclinicallydiagnosedwith COPD(e.g.,FEV1/FVC < 0.7). 2.4.ExclusionCriteria. Withinthesystematicliterature search,thefollowingexclusioncriteriawereapplied: (1)studiesthatassessedself-e cacyasanoutcome amongCOPDpatients,withnoCOPSMEactivities includedanddescribed; (2)educationalinterventionstargetedforpatientswith multiplecomorbiditiesoutsideofCOPD. 2.5.DataExtraction. Theinvestigatorsindependently assessedthetitlesandabstractsofallidentiedcitations. Eachofthereviewersrecordedeachcitationasbeing "acceptable"or"unacceptable"basedonsetforthinclusion andexclusioncriteria.Theratingsofeachinvestigator werethenrecordedandcompared.Foreachmanuscript inquestion,thefulltextofthepaperwasevaluatedand adenitiveagreementwasmadeastotheinclusionor exclusionofeacharticleinquestionbasedonconsensus agreement.Whenconsensuscouldnotbemet,anadditional colleaguewasconsultedtocontributeanextraexpert opinion.Basedonthisselectionprocedure,naldecisions weremaderegardingwhichstudiestoincludeandexclude fromthesystematicreview. 2.6.MeasurementofCOPDSelf-E cacy. Variousscales wereusedinthereviewedstudiestoassessself-e cacy amongpatients.The34-itemCOPDSelf-E cacyScale (CSES)specicallyassessesself-e cacyinindividualswith COPD.Thismeasurehasdemonstratedgoodtest-retest reliability( r=0 77),excellentinternalconsistency( =0.95),andave-factorstructure(negativea ect,intense emotionalarousal,physicalexertion,weather/environments, andbehavioralriskfactors).TheSelf-E cacyforManagingShortnessofBreathscale(SEMSOB)isasingle-item instrumentthatmeasurespatients'overallcondencein keepingshortnessofbreathincheckduringactivitiesof dailyliving.TheSEMSOBhasdemonstratedadequatetestretestreliability( r=0 77)andconstructvalidity[ 32 ]. TheSelf-E cacyforWalkingQuestionnaire(SE-W)has demonstratedevidenceofconstructvalidity,withhigher scoresreectingmorecondencewhenwalking[ 33 ]. Additionally,theself-e cacydimensionoftheSelfManagementAbilityScale(SMAS)hasalsobeenused[ 34 ]. ThissubscaleoftheSMASconsistsofveitemseachof whichareratedona6-pointscale,withahighertotalscore indicatinggreaterself-e cacy.Reliabilitymeasureswerenot reportedfordatacollectedusingtheSE-WandSMAS. Finally,theSelf-E cacyforManagingChronicDisease-6 (SEMCD-6)itemscalewasused.TheSEMCD-6[ 35 ]isa six-itemscalethatmeasuresself-e cacytomanagechronic disease.Scoresonthisscalearecomputedasthemeanofthe sixitems,eachmeasuredonLikertscalesrangingfrom1(not atallcondent)to10(totallycondent).Reliabilitymeasures fortheSEMCD-6havebeenhigh( =0.91)[ 35 ]andtestretestreliabilityhavebeenreportedasstatisticallysignicant ( r=0 87)[ 32 ].3.ResultsAllarticlesgatheredthroughtheinitialsearchandscreen process( n=305)wereevaluatedforinclusioninthesample pool.Twohundredtwenty(220)recordswereexcludedafter thescreenoftitlesandabstracts.Theprimaryreasonforthe initialexclusionincludedlackofself-e cacymeasurements duringorfollowingexposuretoCOPDSMEinterventions. Inadditiontothe85papersthatremainedaftertheinitial exclusion,11otherarticleswereidentiedasmeetingcriteria forafulltextassessmentbyhandsearcheswhichoccurred followingascanofthereferencesectionsofeachdatabaseidentiedarticletoenhancethebreadthoftheexamination. Overall,96paperswereincludedinthisfulltextassessment, ofwhich89wereexcludedforavarietyofreasonslisted anddescribedin Figure1 .Seven( n=7)articleswere leftdescribingempiricalstudiesassessingCOPDself-e cacy amongpatientsparticipatinginCOPDSMEinterventions. FourstudieswerecarriedoutintheUnitedStates,onein HongKong,oneinTurkey,andoneincentralNetherlands. Table1 describesthedesigncharacteristicsofallreviewed studies.Studycharacteristicsdescribedhereinclude:assessmentinstrumentsusedineachstudy,thereliabilityofdata collectedusingsurveyinstruments(describedabove),and thedataanalysesusedtodeterminestudyresults.Resultsof thesevenreviewedstudiesarediscussedbelowaccordingto surveyinstrumentthatwasusedtoassessCOPDself-e cacy. 3.1.DataSynthesis. Thissystematicreviewdemonstrated thatmoststudies(85.7%)showedstatisticallysignicant

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4 ISRNPublicHealth Title and abstract screening Initial exclusion Full text assessment    Secondary exclusion        Included journal articles From database ( n=85) From hand search ( n=11) Secondary sources of information ( n=9) Conceptual or theoretical ( n=6) No explicit measurement of self-e cacy ( n=25) Opinion/editorial piece ( n=5) Sampled patients not su ering from COPD primarily ( n=17) Self-e cacy measures in studies on pulmonary rehabilitation ( n=15) No COPDSME component within intervention ( n=22) n=305 n=220 n=96 n=89 n=7 Figure 1:Flowdiagramofsystematicliteraturesearchprocess. Table 1:Characteristicsofreviewedstudies. AuthorSamplesize( n )DesignInstrumentInstrumentreliabilityPrimarydataanalysis Davisetal.[ 36 ]102RCTSE-W;SEMSOB Notreportedforstudy data Two-wayrepeated measuresANOVA Donesky-Cuencoetal., [ 37 ] 103 SecondaryData AnalysisofRCT SE-W;SEMSOB Notreportedforstudy data Two-wayrepeated measuresANOVA KaraandAsti[ 38 ]60RCT AdaptedCSES (Turkish) =0.94(total);0.89, 0.80,0.73,0.75;0.64 (subscales) Repeatedmeasures ANOVA Lemmensetal.[ 39 ]189Quasi-experimentalSMAS Notreportedforstudy data Pairedsample t -tests Schereretal.[ 40 ]59 Two-group, pretest-posttest CSES Notreportedforstudy data Paired t -tests Stellefsonatal.[ 41 ]41 Multiplegroup, pretest-posttest SEMCD-6; SOLQ-Coping SEMCD-6( =. 97); Multivariateanalysisof covariance (MANCOVA) Wongetal.[ 42 ]60RCT AdaptedCSES (Chinese) Test-retest( r=0 88)Mann-Whitney U -tests RCT:RandomizedControlTrial;SE-WALK:Self-E cacyforWalkingQuestionnaire;SEMSOB:Self-E cacyforManagingShortnessofBreath;SMAS: Self-ManagementAbilityScale;SEMCD-6:Self-E cacyforManagingChronicDisease,6-itemscale;SOLQ-Coping:SeattleObstructiveLungDisease Questionnaire-Coping;CSES:COPDSelf-E cacyScale.improvementsinCOPDself-e cacyfollowingself-managementeducation. Table2 providesasynopsisofthemain ndingsgeneratedfromeachreviewedstudy.Specically, twostudies[ 40 42 ]notedincreasedcondencespecically withregardtocontrollingphysicalexertionexperienced duringactivitiesofdailyliving(e.g.,climbingstairstoofast, gettinguptooquickly,rushingtoaccomplishhousehold chores,etc.).Theonlystudywhichfailedtoshowanynotable changesinself-e cacyfollowingCOPDSMEintervention wasaquasi-experimental(noncontrolled)study[ 39 ].Even still,thisstudyshowednodeleteriouse ectonself-e cacy overthe12-monthstudytimeperiod.Inallofthereviewed studies,self-e cacywasassessedoveraperiodnolonger than12monthsafterintervention. 3.2.EducationalInterventions. Themodesofeducation varied,withtwostudiesimplementingstrictlydidactic educationinagroupsetting,twostudiesusingacombinationofdidacticandindividualizededucation,twostudies usinginteractivemeetingswithindividualpatients,and

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ISRNPublicHealth 5Table 2:Mainndingsfromeachreviewedstudy. Author(citation)Mainndings Davisetal.[ 36 ] (i)Participantswhocompletedaneducationprogramwithaprescribedwalkingregimen exhibitedgreaterself-e cacyforwalking. (ii)Noimprovementinself-e cacyformanagingshortnessofbreathwasfoundafter treatmentwhenmeasuringtheconstructusingtheCOPDSelf-E cacyScale(CSES); however,astatisticallysignicante ectwasfoundwhenmeasuringself-e cacyusingthe Self-E cacyforManagingShortnessofBreath(SEMSOB). (iii)Participantsexposedtoaneducationprogramwithaprescribedwalkingregimen revealedimprovementsinself-e cacywithoutparticipationinstructuredexercise regimens. Donesky-Cuencoetal.[ 37 ] (i)Statisticallysignicantimprovementsinself-e cacyforwalkingfoundat4and12 months,butnotpresentat8months. (ii)Self-e cacyformanagingshortnessofbreathimprovedat4and8months,butthe signicante ectdisappearedat12months. KaraandAsti[ 38 ] (i)Within-groupimprovementsinself-e cacyshowntovaryslightlybetweenthe experimentalandcontrolgroup,withtheself-e cacyenhancemente ectdiminishing overtimeforthecontrolgroupbutlastingfortheexperimentalgroupexposedtothe structurededucation. Lemmensetal.[ 39 ] (i)Groupexposedtoeducationshowednostatisticallysignicantchangeinself-e cacy overa12-monthperiod,withmeanscoresonself-e cacyremainingstablethroughout thestudy. Schereretal.[ 40 ] (i)Statisticallysignicantimprovementintotalself-e cacyfrombaselinetoonemonth followingimplementationoftheeducationalintervention. (ii)Statisticallysignicantimprovementinself-e cacyforcontrollingphysicalexertion frombaselinetosixmonthsfollowingintervention. (iii)Nostatisticallysignicantdi erencesintotalself-e cacyfoundat6-month followup. Stellefsonetal.[ 41 ] (i)Participantsreceivingapamphletreportedhigherself-managementself-e cacythan thosereceivingaDVDandespeciallygreaterthanthatthosereceivingbotheducational treatments(DVD+pamphlet)concomitantly. Wongetal.[ 42 ] (i)Participantsintelephoneeducationinterventionshowedstatisticallysignicant improvementtotalself-e cacy,yetrevealednocorrespondingsignicante ectsonany subscales,exceptforphysicalexertion. onestudyprovidingindividualizededucationalmaterialsto patients. Table3 describestheeducationaldeliverystrategy, theeducationalcontentincludedwithineachintervention, andtheextent(e.g.,durationofsessionplusintervention timeperiod)oftheinstructionalinteractionwithpatients. Thecontentincludedwithineachinterventionwasvariable; yet,themostoftenincludedself-managementtopicswere properbreathingtechniques( n=5),physicalactivity( n=3),nutrition( n=4),andsmokingcessation( n=1). Inaddition,themethodsusedwithineachintervention toincreaseself-e cacyarereportedin Table4 .Allofthe studiesexceptone[ 39 ]describedinterventionactivities thatdrewuponatleast2recommendedsourcesofe cacy information.Thelengthoftimeforeachinterventionalso rangedwidely,withinterventionsoccurringanywherefrom lessthanonemonthtoupto12months(M=4.68months, SD=5.06months). 3.3.InterventionResponseMeasuredbyCSES. Schereret al.(1998)[ 40 ]conductedastudyofCOPDpatientsto determinethee ectsoftwointerventionstrategiesonselfe cacyexpectationsformanagingbreathingdi culty.A nonexperimental,twogrouppreposttestdesign( n=59) wasutilizedtocompareaprogramthato eredonlyselfmanagementeducationwithapulmonaryrehabilitation programthatcombinededucationandexercisetraining. Participants'self-e cacywasmeasuredatbaseline,one monthandthensixmonthsfollowingintervention.Paired t -testanalysesrevealedthatparticipantsintheeducationonlyprogramshowedasignicantimprovementintotal CSESscoresfrombaselinetoonemonthfollow-up(mean di erence=0.33; P=. 05).Theanalysiscomparing baselinescoreswiththosemeasuredsixmonthsfollowing interventionshowedimprovementinself-e cacyonlyin thedomainofphysicalexertion(paired t -test=Š2.11; P=. 047);however,nosignicantdi erencesintotalCSESscore werefoundwhencomparingpretestscoreswith1-month (meandi erence=0.18; P=. 15)and6-monthfollowup (nomeandi erencereported; P=. 265).Itshouldbe notedthatmultiplepaired t -testsincreasedtheprobabilityof experimentwiseerrorbytestinganexcessnumberofpairwise hypotheses[ 43 ].Forthisparticularresearchdesign,itwould havebeenadvisabletoconductrepeatedmeasuresanalysis ofvariance(ANOVA)tolimitthenumberofhypotheses

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6 ISRNPublicHealthTable 3:COPDSMEdeliverymode,content,anddurationofinstruction. ReviewedstudyDeliverymodeContentLengthofeducation Davisetal.[ 36 ] Dyspneaself-management education(DME)+individualized walkingplan Walking,purselippedbreathing, diaphragmaticbreathing,measure breathlessnessandheartrate 8weeks Donesky-Cuencoet al.[ 37 ] (secondarydata analysisfromDaviset al.[ 36 ]) Dyspneaself-management education(DME)+individualized walkingplan Walking,measurebreathlessness andheartrate 12months KaraandAsti[ 38 ]Groupeducation Breathingtechniques,coughing techniques,relaxation,medication, diet,exercise 4weeksof3-4sessions perweekforabout 3540mineachsession Lemmensetal.[ 39 ] Practicenursemeetingswith patients Smokingbehavior,medication usage,nutrition,andphysical activity Atleast15minute meetingsovera 12-monthperiod Schereretal.[ 40 ] Classesconductedbyaclinical nursespecialist PathophysiologyofCOPD, nutrition,self-careinstruction, purselippedbreathing, diaphragmaticbreathing 1hour,3timesaweek for12weeks Stellefsonetal.[ 41 ] DVDORPamphletORDVD+ Pamphlet COPDknowledge,actionsteps followingadiagnosis,seeking medicalattention,breathing techniqueswhenstationaryand moving,infectiondetection, nutrition30minDVDor4-page pamphletreviewed individuallyover2 months Wongetal.[ 42 ] Telephonecounselingbyrespiratory nurse Patientdependentbutincluding energysavingandbreathing techniques,medication management,relaxationtechniques Twocallsovera20-day period Table 4:Sourcesofe cacyinformationusedinthereviewstudies. Reviewedstudy Performancemastery experience Vicarious experience/modeling Emotionalor physiologicalarousal Verbal persuasion Davisetal.[ 36 ] Donesky-Cuencoetal.[ 37 ] KaraandAsti[ 38 ] Lemmensetal.[ 39 ] Schereretal.[ 40 ] Stellefsonetal.[ 41 ] Wongetal.[ 42 ] beingtestedanddecreasingtheprobabilityofaTypeI error. KaraandAsti[ 38 ]conductedanexperimentalstudyto assessthee ectofcoordinatededucationonself-e cacy expectationsinpatientswithCOPD.Sixtypatientsatan outpatientclinicwererandomlyassignedtoanexperimental groupreceivingfourweeksofstructurededucationwhile thecontrolgroupwasonlyo erededucationaladviceatan initialmeeting.Participants'self-e cacywasmeasuredat baseline,1-month(immediatelyfollowingtheprogram),and at2-monthusinganadaptedversionoftheTurkishCSES. Toassessthedi erenceinself-e cacy,twoseparaterepeated measuresanalysesofvariance(ANOVAs)wereconducted assessingself-e cacyinboththecontrolandexperimental groups.Forthecontrolgroup,therewasasignicant improvementbetweenbaselineand1-month(meandi erence=Š0.31; P=. 001),andbetweenbaselineand2-month followup(meandi erence=Š0.21; P=. 002);however, therewasnosignicantimprovementbetween1-monthand 2-monthfollowupacrossanyofthe5dimensionsofselfe cacyasmeasuredbytheCSES(meandi erence=Š0.10; P=. 074;totalscores).Forparticipantsintheexperimental group,however,therewasasignicantimprovementin totalCSESscoresonall3measurementoccasions(mean di erence=Š.21toŠ1.15; P<. 001).Moreover,withingroupimprovementsinself-e cacywasshowntovary slightlybetweentheexperimentalandcontrolgroup,with theself-e cacyenhancemente ectdiminishingovertime

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ISRNPublicHealth 7 forthecontrolgroupbutlastingfortheexperimentalgroup exposedtothestructurededucation. Wongetal.[ 42 ]examinedthee ectsofanurse-initiatedtelephonefollow-upinterventiononself-e cacy amongCOPDpatients.Oneoftheaimsofthisrandomized controlledtrialsoughttodeterminewhetheranurse-led telephonefollow-upprogramcouldincreasetheself-e cacy ofpatientsmanagingdyspnea.SixtypatientswithCOPD wererecruitedfromahospitalinHongKongandwere randomlyassignedtoaninterventiongroupthatreceived anindividualizededucationalandtelephonesupportfollowupprogram( n=30)oracontrolgroupreceivingusual care( n=30).Bothgroupscompletedapreandposttest thatincludedanadaptedChineseversionoftheCSES. DataanalysisusingtheMann-Whitney U -testdetermined groupdi erencesinthesubscalesandtotalscoresonthe ChineseCSES.Findingsindicatedstatisticallysignicant improvementonthetotalscoresoftheadaptedChinese CSESamong,withnocorrespondingsignicante ects foundonanyofthesubscales,exceptforimprovementin physicalexertion( P=. 001). Davisetal.[ 36 ]publishedarandomizedclinicaltrial undertakentodeterminethee ectofthreetypesofinterventionsonself-e cacytomanagedyspneainCOPD patients.One-hundredandtwoparticipantsreceivedone ofthreeself-managementinterventionsdesignedtoenhance theprimarysourcesofself-e cacyinformation.Oneofthe threeinterventionsconsistedofadyspneaself-management educationprogramthatlasted3hoursandwascoupledwith anindividualizedhome-walkingprescription.Arepeated measuredANOVAwasusedtoassessthee ectoftreatment (threeinterventions)andtime(2months)oneachoffour dependentvariablesatpreandposttest.Foramultiple group,pretest-posttestdesignwithrandomassignment (testingmultipledependentvariables),itissuggestedthata multivariateanalysisofcovariance(MANCOVA)onposttest scoresbeconducted,withpretestscoresusedasthecovariate(s)[ 37 44 ].Nevertheless,participantswhocompleted theeducationprogramandreceivedtheprescribedwalking regimenexhibitedgreaterself-e cacyforwalking( P< 0005).Thissignicanttreatmente ectmirroredsignicant e ectsfoundinthetwootherpulmonaryrehabilitation conditions.However,noimprovementindisease-specic self-e cacywasfoundaftertreatment. 3.4.InterventionResponseMeasuredbyOtherScales. Daviset al.[ 36 ]showedastatisticallysignicante ectwhenmeasuringself-e cacyusingtheSEMSOB( P<. 0005)at2months followingintervention.Todeterminewhetherimprovements inself-e cacypersistedafter2months,Donesky-Cuenco andcolleagues[ 37 ]extendedtheworkofDavisetal.[ 36 ] byconductingasecondarydataanalysisbyfollowingup onpatientsparticipatingintheformerstudy.Univariate repeatedmeasuresanalysisofvariance(ANOVA)wasused toassessthee ectoftreatmentontwodependentvariables (SE-WandSEMSOB)atthreepointsmeasurementoccasions (4,8,and12months).Whilethechoiceofdataanalysis techniquecouldhavebeenmultivariate(e.g.,MANOVA)to considerthetwodistincttypesofself-e cacyunderstudy [ 44 45 ],therewerestatisticallysignicantimprovementsin SE-Wfoundat4and12months,yetwasnotapparentat8 months.Interestingly,self-e cacyformanagingdyspnea,as measuredbytheSEMSOBimprovedat4and8monthsbut disappearedat12months. Lemmensetal.[ 39 ]conductedaquasi-experimental, one-groupprepostteststudythatevaluatedthee ectofa patienteducationinterventiondesignedtoincreasepatients' understandingofCOPDself-managementstrategies.Participantsinthisstudyweretaughtself-managementstrategies andgiveninformationbookletsduringmultiple15-minute contactsovera12-monthperiod(numberofcontactsper patientnotspecied).Self-e cacywasmeasuredamong189 patientsusingtheself-e cacydimensionoftheSMAS[ 34 ]. Comparisonsbetweenbaselineand12-monthself-e cacy outcomesweredoneusingapaired t -testanalysis.Results showednostatisticallysignicantchangeinself-e cacy overthe12-monthperiod( P=. 865),withmeanscores remainingalmostpreciselystablethroughouttheduration oftheintervention[pretest:4.24(0.74);posttest:4.23 (0.78)]. Stellefsonetal.[ 41 ]conductedamultiple-group,pretestpostteststudytotestthee ectsofthreeeducationaltreatments(DVDversusPamphletversusDVD+Pamphlet) onmultiplehealth-relatedoutcomes,includingself-e cacy. Self-e cacywasmeasuredusingtheSEMCD-6[ 35 ].Nontrendorthogonalplannedcontrasts(pairwiseandcomplex) weretestedcomparingthee ectivenessofviewingand reviewingaDVD(group1)andpamphlet(group2)exclusivelyversusdistributingbothinterventionsconcurrently (group3).Amultivariateanalysisofcovariancedetermined thee ectofinstructionalstrategyonSEMCD-6scores, withpretestSEMCD-6scoresadjustingforinitialdi erences amongtreatmentgroupsontheoutcomemeasures.At posttest,contrastanalysesrevealedthatwhencomparingthe DVDtothePamphletgroupandtheDVD+Pamphletgroup totheDVDandPamphletgroupconsideredtogether,there werestatisticallysignicantdi erencesonSEMCD-6scores ( P=. 001and P<. 001,resp.).Interestingly,participants receivingaPamphletreportedhigherself-managementselfe cacy(adjustedmeancentroid=7.15)thanthosereceiving aDVD(adjustedmeancentroid=5.10)andespecially greaterthanthatthosereceivingbotheducationaltreatments concomitantly(adjustedmeancentroid=3.35).4.Discussion4.1.MainFindings. Thissystematicreviewdemonstrated thatmoststudies( n=6or85.7%)showedstatistically signicantimprovementsinCOPDself-e cacyfollowing self-managementeducation.Specically,twostudies[ 40 42 ] notedincreasedcondenceforcontrollingphysicalexertion experiencedduringactivitiesofdailyliving(e.g.,climbing stairstoofast,gettinguptooquickly,rushingtoaccomplish householdchores,etc.).Therewasalimitedfollow-up postinterventiontoexaminetheseoutcomeslongitudinally. Severalreviewedstudiescollecteddataatvarioustime pointspostinterventioninanattempttodeterminelasting e ectsofCOPDSMEinterventionsonself-e cacyover

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8 ISRNPublicHealth time[ 36 38 ].Findingsfromthesestudieswereinconsistent. Themodesofeducationusedineachinterventionvaried withunstandardizedcontentcoveredindi erentstudies. However,thetopicsincludedineachintervention,while variable,diddrawuponthefoursourcesofself-e cacy explicatedbyBandura. 4.2.ImplicationsforBuildingCOPDSelf-E cacy. Thissystematicreviewdoesnotprovideclearevidenceregarding whatparticulareducationalelementsareimportantto improveself-e cacy;however,twostudiesspecicallynoted increasedself-e cacyforcontrollingphysicalexertionexperiencedduringADLs.Theredoexistguidelines(albeit vague)notingimportantself-managementtopicstoinclude withinCOPDSMEprograms[ 46 47 ].Thesetopicsinclude informationonmedicationuse,propernutrition,operation ofinhalationdevices,andperformanceofrehabilitative breathingtechniques.However,littletheoreticalguidance existsrelatedtowhichsourcesofself-e cacyinformation areimportantforcreatingself-condenceforthesetypesof self-managementskillsandbehaviors.Forexample,coordinatedlearningexperiencesinformedbyprinciplesofselfregulation(i.e.,self-monitoring,goalsetting,feedback,selfreward,self-instruction,andenlistmentofsocialsupport),a coretenetofsocialcognitivetheory[ 23 ],maybeespecially appropriateforCOPDSMEinterventions. Thispaperfurtherhighlightstheneedformorerandomizedcontrolledtrialsthatinvestigatebetween-subjects e ectsofdi erent,sociocognitive,andbehavioraltheorybasedCOPDSMEprogramswithlong-termfollowup.In ordertodeterminetheimpactanddoseofCOPSMEneeded tosupportCOPDself-e cacy,guidedself-management interventionsthatincludespeciedamountsofperformance mastery,socialmodeling,e cacyinformation,andverbal persuasionarewarranted.Onceaclearideaofe cacy enhancingeducationalapproachesisbetterunderstood,it willbeimportanttodeterminehowofteninstructional strategiesneedtobedeliveredtoprocureandstrengthen e cacybeliefsandstandardizepatient-centeredoutcomes. Thenatureoftheeducationalexperiencesprovidedto patientswasvariable,makingreplicationofbest-practice COPDSMEinterventionsanambiguoustask.Patientsmay respondbettertoconsistenteducationalexperiencesover timeratherthansporadic(perhapsconicting)piecesof informationprovidedatperiodicpatientvisits,whichmay causecontradictionand/orconfusion.Onestudyoutside thescopeofthepresentpaperfoundthatusingaudiovisualbasedtechnologiesovertimeo eredastabilizinge ect fortheclinicalprogressionofCOPDandalsopositively impactedHRQoL[ 48 ].Itisimportantthatpatientsare taught toself-managetheirdisease,ratherthan told to learn tolivewithit (emphasisadded)[ 11 ].Theinstructional deliveryprotocolforeducationisimportanttodeneifwe expecttosustainself-e cacybeliefsoverthelongterm. 4.3.MethodologicalLimitations. Withinasubstantialproportionofreviewedstudies(42.9%),therewasquestionable dataanalysistechniquesused.Becauseofthis,questions remainastothevalidityandreliabilityofndingsgenerated fromthesestudies.Morethanhalfofthereviewedstudies (57.1%)failedtoreportreliabilitymeasuresfortheirdata. TwoadaptedversionsoftheCSESwereconvertedintodi erentlanguages[ 38 42 ],whichmayhaveattenuatedtheability ofitemstoassessintendedlatentconstructs(despiteback translatione ortsaimedtopreventthisfromhappening).As well,twoofthereviewedstudies[ 36 37 ]assessedself-e cacy usingasingle-itemsurvey.Thisisproblematic,because individualitemshaveconsiderablerandommeasurement error,usuallycannotdiscriminateamongdegreesofan attribute,andlackscopewhenmeasuringacomplextheoreticalconstruct[ 49 ].Finally,mostofthestudiesincluded inthispaperrecruitedrelativelysmallsamples(n=41 to189),thuslimitingtheexternalorecologicalvalidity ofstudyndings.Nonetheless,almostallstudies(6of7) usedrandomselectiontoassignparticipantstoeducational interventions.Inaddition,thereviewedstudieslacklongtermfollowup.Theaveragelengthofthereviewedstudies waslessthanvemonthsandnoneofthestudiesassessed self-e cacyoveraperiodlongerthan12months. 4.4.RecommendationsforFutureResearchandPractice. More researchisneededtodeterminewhetherthedevelopmentof COPDSMEprogramsenhancesCOPDself-e cacyamong patients.Fromndingsofthispaper,itisdi cultto determinehowmuchofthevarianceinself-e cacycanbe attributabletovariousCOPDSMEprograms.Limitationsin thedesignofthereviewedstudiescallintoquestionthemain ndingsofthestudiesandlimittheconclusionsthatcanbe madebasedontheresults.Sourcesofe cacyinformation werefoundtobepresentbutvariableinthecurrentpaper (e.g.,somelackedvicariousexperiences),illustratingthe lackofconsensusorstandardizationinCOPDSMEcontent [ 50 ].Linkingspeciceducationalinterventionstoselfe cacyoutcomesassociatedwithspecicself-management skills/behaviorsisanimportantavenueforfutureresearch. E ortstowardscustomizedCOPDSMEstrategieshavebeen exploredintheliterature[ 48 51 ]andmoreshouldbe donetoexploretheimpactofvaryingsourcesofselfe cacyinformationone cacyoutcomes.Aswell,the depthandbreadthoffutureinterventionsinCOPDSME shouldbeinformedbydesirableande ectiveinstructional considerations(e.g.,time,location,delivery,content,etc.).5.ConclusionsWhiletransmittinggenerichealthknowledgeisfairlyeasy intheInformationAge,changingself-e cacyandthevalue patientsplaceintertiarypreventionofchronicdiseasecan takeconsiderableplanningande ort.Takingstepstowards thisdi cultendisbecomingincreasinglyessentialfor managingdebilitatingchronicdiseases.Afteranexhaustive literaturesearch,thispaperdemonstratesthatonlyalimitednumberofstudieshaveexaminedthee ectsofselfmanagementeducationonCOPDself-e cacy.Theliterature inCOPDmanagementliteraturesupportsthegeneralized hypothesissuggestedbyBandura[ 23 ],whostatesthat, "functionallimitationmaybegovernedmorebybeliefsof capabilitythanbydegreeofactualphysicalimpairment"

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ISRNPublicHealth 9 (page300).COPDself-e cacyhasrevealeditselfasan importantpredecessortohealthe ectsamongpatients; thus,itshouldbemeasured,reported,andcomparedwithin controlledstudiesexaminingthee ectsofCOPDSME duringthediseasemanagementprocess.References[1]K.F.Rabe,S.Hurd,A.Anzuetoetal.,"Globalstrategyforthe diagnosis,management,andpreventionofchronicobstructivepulmonarydisease:GOLDexecutivesummary," American JournalofRespiratoryandCriticalCareMedicine ,vol.176,no. 6,pp.532555,2007. [2]J.Z.Reardon,S.C.Lareau,andR.ZuWallack,"Functional statusandqualityoflifeinchronicobstructivepulmonary disease," AmericanJournalofMedicine ,vol.119,supplement 1,no.10,pp.S32S37,2006. 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