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date: 21 July 2017

Message-Induced Self-Efficacy and Its Role in Health Behavior Change

Summary and Keywords

Self-efficacy is the personal belief in one’s ability to meet a goal or perform a specific task. Although it can be applied to any type of human endeavor, the construct of self-efficacy is thought to be central to changing behaviors to improve health outcomes. For this reason, message designers have been attempting to understand how messages detract from or enhance self-efficacy. Persuasive messages have and can be used to enhance perceived self-efficacy related to health and risk behavior. Self-efficacy-strengthening messages and interventions in health promotion can be assessed in general or specfically in regards to fear appeals. Other aspects of self-efficacy interventions include collective efficacy and professional self-efficacy.

Keywords: behavior change, collective efficacy, fear appeals, health message design, message frames, social cognitive theory

Introduction

Self-efficacy is an individual’s belief in his or her ability to overcome challenging circumstances to achieve a desired outcome. A wide body of research has supported its influence in motivation, self-regulation, and achievement in various domains such as education, career development, and health behavior (Schunk & Pajares, 2009). Self-efficacy is a particularly crucial construct for facilitating health behavior change because it is inward-focused and self-reflective, references future behaviors, and is a major cognition directly proximal to the behavior under consideration (Bandura, 1997; Luszczynska & Schwarzer, 2005). Although self-efficacy is typically considered to be malleable and domain-specific, some researchers have argued for a general self-efficacy construct that represents overarching optimistic assessments of one’s adaptive capabilities (Schwarzer & Jerusalem, 1995). Bandura (1997) identified four sources for enhancing self-efficacy: (a) actual experiences of personal achievement or mastery, (b) vicarious experiences achieved through observing another individual, (c) persuasive messages or symbolic experience, and (d) physiological or emotional arousal. The goal of this article is to present an overview of how persuasive messages have and can be used to enhance perceived self-efficacy related to health and risk behavior. This review will consider self-efficacy-strengthening messages and interventions in health promotion in general, then with regard to fear appeals specifically. Finally, other applications of self-efficacy interventions are summarized.

Message-Based Self-Efficacy in Health Promotion Interventions

A good conceptual review of self-efficacy as a predictor of health behavior can be found in Strecher, McEvoy DeVellis, Becker, and Rosenstock (1986). According to their review of 21 studies prior to 1986, the predominant health behaviors that have been positively impacted by self-efficacy are weight control, contraception, cigarette smoking, alcohol abuse, and exercise behaviors. Thirty years later, these behaviors are still the most heavily represented in the self-efficacy literature, potentially because they are health behaviors that are difficult to change, whereas less difficult behaviors may be less dependent upon individual belief of one’s capabilities. However, despite the wide acceptance of self-efficacy as a target of theory-based interventions targeting health behaviors (Schwarzer & Fuchs, 1995), findings remain inconsistent regarding how self-efficacy can be strengthened and leveraged to promote health behavior (Latimer, Brawley, & Bassett, 2010).

One example of a health behavior intervention that was successful in targeting self-efficacy for health behavior change is provided by Luszczynska, Tryburcy, and Schwarzer (2007). These researchers tested three message conditions to see which would increase fruit and vegetable consumption most. The self-efficacy group received information on the importance of self-efficacy, ways to increase self-efficacy, and personalized feedback comparing the individual’s self-efficacy score against those of the entire group. The self-efficacy plus action plans group also received this message, but also was asked to reflect upon a time they were successful in choosing a healthy food item over a less healthy food item and then received positive feedback regarding that circumstance. They then had to construct an action plan for how they would increase their fruit and vegetable consumption. The third group (control group) simply received a message that stressed the importance of good nutrition. Surprisingly, both intervention groups were equally successful in increasing fruit and vegetable consumption six months later (compared to the control group). The results of this study underline the primacy of self-efficacy enhancement messages in behavior change interventions, regardless of additional components such as an action plan. According to Strecher et al. (1986), self-efficacy can be enhanced by breaking up aspects of the desired behavior into easily manageable steps, where a person can easily master one step before moving unto the next, toward the goal of achieving the overall target behavior. Strecher et al. added that the first steps should be designed to be easier than subsequent steps, which may allow a person to more easily address any failures or lapses.

The study by Luszczynska et al. (2007) also shows how feedback can be incorporated into successful self-efficacy interventions—a strategy that has been employed by other researchers. For example, Priebe and Spink (2014) increased exercise performance by incorporating a feedback component. After hearing a message that 80% of their peers could hold a plank position longer than their first attempt, more participants increased their planking time than those who were not given such a message (Priebe & Spink, 2014). More recent studies by Gell and Wadsworth (2015) and Pedersen, Grønhøj, and Thøgersen (2016) have also demonstrated how interventions offering feedback on people’s past performance or on other people’s performances are effective in increasing perceived self-efficacy.

On the other hand, evidence from an Australian study in 2002 showed a decrease in self-efficacy among women who reported higher exposure to a Pap test campaign designed to rebuke barriers related to cancer screening (Fernbach, 2002). However, in this study, self-efficacy was measured with only one item, causing the author to suggest that more sophisticated measurement might help untangle the true relationship between message exposure, self-efficacy, and intention to engage in cervical screening tests. Thus, one lesson from contradictory findings in the literature is that measurement of the self-efficacy construct should be considered carefully prior to implementation. Effective measures of self-efficacy should be tailored specifically to the targeted health behavior/s and should adequately reflect the multidimensionality of that behavior (Egbert & Reed, 2016).

As seen in the Priebe and Spink (2014) study, manipulating information about social norms is one way that researchers have been able to increase task-related self-efficacy related to a health behavior. Changing people’s self-efficacy looks to be just as important as baseline self-efficacy, according to Maibach, Flora, and Nass (1991). As part of the Stanford Five Cities Project, participants were exposed to an intervention that included efforts to establish behavior change goals, model health behavior changes, and develop skills needed to meet these goals (which included weight loss, smoking cessation, and exercise). Their results showed that 14–16 months after baseline measurements, increases in self-efficacy predicted behavior change over and above self-efficacy at baseline. The most interesting finding of their study, however, showed that baseline self-efficacy was highly and negatively correlated to change in self-efficacy, suggesting that those participants who were low in self-efficacy showed a much higher increase in self-efficacy throughout the course of the intervention, compared to those participants who began the intervention with high baseline self-efficacy. In that same project, additional data showed that after four years of exposure to the intervention, participants whose self-efficacy increased had higher correlations between their dietary knowledge and behavior than those whose self-efficacy decreased over the four years (Rimal, 2000). These results reinforce the notion that self-efficacy, knowledge, and behavior are reciprocally related, as Bandura (1997) first theorized.

Another intervention that demonstrated how those low in self-efficacy might benefit more from self-efficacy interventions came from a demonstration project developed by the New York State Department of Health. Adolescents’ perceived self-efficacy was significantly greater after engaging the computer role-playing game that taught players how to turn down risky sex or ask a partner to use a condom. Players whose self-efficacy was lower at baseline had greater increases in self-efficacy after approximately 60 minutes of game play (Thomas, Cahill, & Santilli, 1997). In this study, players with high self-efficacy at baseline showed a slight decrease in self-efficacy after playing the game. Thomas et al. suggested that overconfident youth felt less confident in their ability to negotiate safer sex after seeing the required behaviors acted out in the role-playing game. However, these trends were much smaller than the positive increases in self-efficacy attained in the group that showed lower self-efficacy at baseline.

Self-efficacy interventions have been developed into successful communication strategies for target audiences of all ages. Dattilo, Martire, Gottschall, and Weybright (2014) were concerned that senior citizens rarely engage in moderate physical activity due to fear of falling. Therefore, they conducted a study designed to increase senior citizens’ self-efficacy in their ability to become more physically active, which resulted in increased walking self-efficacy and actual walking. The eight-week intervention program included both educational and exercise/experiential components to increase self-efficacy and enjoyment of walking (respectively) among older adults.

Gell and Wadsworth (2015) also evaluated the effects of text message intervention on the physical activity levels of a group of full-time career women. The women in the intervention group received weekly motivational and informational text messages designed to encourage them to perform physical activity. The text messages contained information about the daily recommended amount of physical activity, specific recommendations on how to meet the daily physical activity guideline, and self-regulation strategies in the form of goal setting, reinforcement, relapse prevention, etc. Gell and Wadsworth (2015) found a significant decrease in physical activity levels for members of the control group during the winter months when compared to the intervention group. Members of the intervention group also maintained self-efficacy to engage in physical activity in bad weather compared to the control group, which recorded a decrease in physical activity. Additionally, overall self-efficacy during the duration of the study was maintained for the intervention group as compared to the control group, which experienced a significant decrease in self-efficacy.

Finally, a similar study utilizing text messaging as a feedback intervention tool for changing healthy eating behavior in young people involved the random assignment of adolescents, from 5th to 9th grade, in one of three groups: a control group, a text messaging group, and a text messaging and nutrition education group (Pedersen, Grønhøj, & Thøgersen, 2016). Youngsters in the intervention group reported their daily consumption of fruit and vegetables, and received feedback on their performance via text messages. Pedersen et al. found that participants who sent more than 50% of the possible text messages significantly increased their consumption of fruit and vegetables—indicating the role that high engagement with the message and self-efficacy play. However, participants who sent between 10% and 50% of the possible text messages had a significant decrease in self-efficacy, which the researchers attributed to the participants perceiving the text messages as reminders of their inability to complete a task, likely leading to low self-efficacy—helplessness and a lack of confidence in their ability to succeed.

Fear Appeals that Integrate a Self-Efficacy Component

Although the concept of self-efficacy can be incorporated into health behavior messages invoking any emotional response, it has been used most frequently in designing fear-based messages. The generally accepted viewpoint is that fear appeal messages are most effective when they include concrete information for behavior change, and when message recipients possess high self-efficacy to adopt and maintain the desired behavioral change (Pischke et al., 2013). This strategy is a major premise of the Extended Parallel Process Model (EPPM; Witte, 1992). In this model, perceived threat is a result of perceived susceptibility (the belief that the threat is likely to affect someone personally) and perceived severity (the belief that the threat is serious and harmful). Although perceived threat is necessary for an effective fear appeal, it is not sufficient. Effective fear appeals must also include an efficacy component that includes both response efficacy (the belief that the suggested behavior will stave off the threat) and self-efficacy (the belief that the individual will be able to enact the behavior). If the efficacy component is not present, the impending perceived threat will put the individual into fear control, which may cause the person to avoid the behavior or engage in some maladaptive response. Instead, a message that contains both the threat and efficacy components (especially if those efficacy components contain clear instructions or action steps) will result in danger control or adaptive health behaviors.

The EPPM has been tested in a wide variety of context, including cardiovascular disease (McKay, Berkowitz, Blumberg, & Goldberg, 2004), hand washing (Botta, Dunker, Fenson-Hood, Maltarich, & McDonald, 2008), meningitis (Gore & Bracken, 2005), and AIDS prevention behaviors (Witte, 1994). Like many of these studies, health message designers found success by following the theoretical tenets of the EPPM, incorporating both risk and efficacy components. For example, guided by the EPPM, Stephenson and Witte (1998) investigated the effectiveness of fear appeal messages in promoting skin protective behaviors. The messages that they used in the study included statements that conveyed the seriousness of sun exposure to the skin, as well as recommendations for protection against sunburns. They found that fear appeals were effective in promoting skin protective behaviors, especially when high threat messages were accompanied by strong efficacy messages, further supporting EPPM.

In addition to considerations of threat, health message designers also must decide how to balance health information with content related to self-efficacy. An important precursor to behavior change, health knowledge may create stressful situations for individuals if they feel they are unable to follow through (Rimal, 2000). Some researchers argue that self-efficacy mediates the relationship between health knowledge and behavior (e.g., Rimal, 2000), in that increasing self-efficacy will strengthen the correlation between health knowledge and behavior. Pischke et al. (2013) examined risk perceptions of tobacco use among teachers in India. They looked at how risk perceptions, self-efficacy, and adopting a planned approach to quit smoking can be promoted using different message formats. Some of the tobacco-use cessation messages specifically focused on self-efficacy and the willpower and skills needed for quitting. These researchers found that the teachers’ preference was for tobacco-cessation health information and depictions of teachers displaying willpower when confronted with tobacco-use triggers, including healthy substitutes and alternative behaviors. For example, if stress is a reason for tobacco use, the self-efficacy health message should include an alternative behavior for overcoming stress, such as taking a walk or yoga.

Researchers conducting a study of the effects of sun protection health promotion messages found that participants who received self-efficacy messages reported greater message acceptance than those who received the threat-only message (Good & Abraham, 2011). Confidence building in the ability to perform certain tasks through statements that increase self- and response-efficacy can be effective in health behavior change. For example, Good and Abraham’s (2011) campaign for sun protection included messages, such as “you can carry a small bottle, sachet, or pouch of sunscreen so you can’t forget” and “sunscreen can block up to 96% of UV radiation” (p. 806)—messages that enhance or reinforce people’s belief in their ability to perform the recommended tasks. Similarly, Egbert and Parrott (2001) found that, by observing their peers follow through on prescribed cancer detection practices, rural farm women had more confidence in their own ability to do the same.

To create messages to motivate low-income, African American women to access low- or no-cost mammograms through the CDC’s National Breast and Cervical Cancer Early Detection Program, Hall and Johnson-Turbes (2015) conducted focus groups among the target population. They first determined the perceived susceptibility and threat of developing breast cancer among African American women. This information was used to develop the audience profile by assessing cultural and environmental information, and identifying their preferred message, channel, and source (print media, health departments, churches, survivors, etc.). Lastly, Hall and Johnson-Turbes (2015) designed persuasive messages that indicated that African American women are susceptible to breast cancer, but by obtaining regular mammograms, they could reduce the incidence of cancer mortality. Their messages included the threat of breast cancer, but also empowered the women to seek out mammograms, which are easily accessible to them. The messages did not focus a lot on the threat of breast cancer, but more on the power that women have in taking action to do something about it. The message design helped to increase their self-efficacy levels. Examples of the messages included: “You can’t put a price on life,” “Strength comes from within.” “A mammogram is something we can’t do without.”

Just as people differ in terms of what they find threatening to their health, they also differ in terms of how they can be empowered through self-efficacy. It is crucial that campaign designers consider how culture impacts individuals’ perceptions of both threat and self-efficacy (Dutta-Bergman, 2005). A good example of successfully developing culturally sensitive fear appeals can be found in a study conducted by DeMarco, Kendricks, Dolmo, Looby, and Rinne (2009). They focused on inner-city Boston women of mixed ethnicity living in transitional housing who were at high risk for HIV. Following their participation in a four-week intervention program, the women reported an increase in the use of safe sex behaviors, including more frequent condom use (DeMarco et al., 2009). DeMarco et al.’s (2009) intervention incorporated a documentary-style film that featured four African American women who talk about how HIV impacted their lives and those of their families. According to DeMarco et al., most of the study participants were positively impacted by the film, and saw the need to protect themselves by using condoms because they could identify with the women and messages portrayed in the film.

Similarly, a culturally tailored media campaign focused on self-efficacy to promote physical activity among Canadians (Craig et al., 2015). The media campaign featured messages from Canadians that outlined the steps that they took to incorporate physical activity into their lifestyles, such as walking their dog or taking the stairs. The researchers assessed saliency, engagement, and campaign-specific self-efficacy (if they could relate to the person in the ad, if the ad helped them consider ways that they could be more active, and if the ad made them think that if the person featured in the ad could be more active, they could too; Craig et al., 2015).

Persuasive fear appeal messages, therefore, can be made more effective by incorporating self-efficacy components delivered by appealing representatives of the target population. This argument makes sense, according to Bandura (1997), as one of the sources from which efficacy is learned is through observation of events or other people. Strecher et al. (1986) stated that, by observing a model master a situation that was feared or considered to be difficult, individuals enhanced their self-efficacy for similar situations, especially where the model has similar characteristics to them, such as age, sex, etc.

Shadel, Fryer, and Tharp-Taylor (2009) found that anti-smoking public service announcements (PSAs) can be more effective in increasing smoking resistance when they feature actors whom adolescents perceive to be appealing. Participants’ smoking resistance self-efficacy was measured following exposure to each PSA by asking if the PSA had given them confidence to resist smoking if a friend offered a cigarette. Shadel et al.’s (2009) study revealed that attractive sources are critical to designing persuasive messages and can impact young people’s self-efficacy in regard to a health issue. Another way to enhance self-efficacy among young people is by using channels that they can relate to. An interesting study designed to increase self-efficacy in HIV/AIDS preventive behavior among high-risk adolescents incorporated the use of a computer game, which featured several negotiating tasks that gamers were required to perform, such as negotiating condom use or turning down sex (Thomas et al. 1997). Thomas et al. (1997) reported that participants had increased self-efficacy scores, especially for those who had low self-efficacy levels before the intervention.

Message Frames and Message-Induced Self-Efficacy

Self-efficacy in health message design often involves message framing and manipulation of the self-efficacy construct (Werrij, Ruiter, Van’t Riet, & De Vries, 2010). However, not all messages that influence public health are the result of planned message development by health-promotion agencies and researchers. The public is also highly influenced by health messages found in news media. However, the news media, unlike health promotion organizations, are more directly impacted by the need to compete with other media outlets for advertising dollars and public attention. Thus, news media differ from public health organizations in how they frame health issues, including how self-efficacy is represented.

In the United States, health-related news articles tend to lack information that builds self-efficacy, such as modeling a beneficial health behavior or providing information about health-enhancing behaviors. In an analysis of cancer stories found in 44 U.S. newspapers in 2003, 6.5% included efficacy messages about prevention, and 8% included efficacy messages related to cancer screening (Moriarty & Stryker, 2008). Most of the stories that did contain efficacy messages were about cancers that are more preventable, such as breast, cervix, prostate, and skin. A similar study, published in 2012, collected news stories during the first five months of the H1N1 outbreak in 2009 (Goodall, Sabo, Cline, & Egbert, 2012). The researchers found that only about half of these stories included self-efficacy messages about how individuals and organizations could protect themselves, with most stories referencing fear-inducing messages that overemphasized death. Thus, media messages are increasing the public’s perceived fear but providing too little information about how to be proactive in averting the health threat.

Outside of the U.S., a qualitative study by Sandell, Sebar, and Harris (2013) compared H1N1 messages in Australian and Swedish newspapers. These researchers found that, whereas Australian news stories framed the pandemic in terms of inadequacies of the government, other public service organizations, and physicians, Swedish newspapers emphasized the public’s responsibility to take precaution using specific actions outlined in the stories. These differences in media messages may have been one reason why free immunizations increased 60% in Sweden, compared to only 18% in Australia.

Recently, scholars have begun isolate the effects of message frames on self-efficacy, finding that positively framed messages (as opposed to negatively framed messages) are more likely to increase self-efficacy and behavioral intentions in the short term (two weeks), and positive exercise behavior in the long-term (nine weeks; Latimer et al., 2008). A more recent meta-analysis has supported the general superiority of gain-framed messages over loss-framed messages for prevention behaviors (Gallagher & Updegraff, 2012). These findings support the theoretical basis of the construct; Bandura argued that positively framed messages that enhance self-efficacy are better than loss or fear-based appeals, and that message designers should “shift the emphasis, from trying to scare people into health behavior, to empowering them with the tools and self-beliefs for exercising personal control over their health habits” (Bandura, 2001, p. 289). More specifically, he advocated the combination of vicarious modeling and guided mastery, whereby “newly acquired skills are first tried under conditions likely to produce good results, and are then extended to more unpredictable and difficult circumstances” (Bandura, 2001, p. 289).

Additional Applications of Self-Efficacy

Aside from the traditional task- and context-specific conceptualizations of self-efficacy, several other trends in self-efficacy research may be relevant to researchers and health message designers. One notable trend is conceptualizing self-efficacy as a perception of the ability of one’s in-group to accomplish a task or new behavior, instead of the traditional focus on the choices of the individual. Defined by Bandura (1997) as “a group’s shared belief in its conjoint capabilities to organize and execute the courses of action required to produce given levels of attainments’’ (p. 477), collective efficacy may be a more appropriate concept when studying non-Western populations such as Asian or Eastern European samples (Klassen, 2004). However, although non-Western samples often rate their self-efficacy lower than Western samples, self-efficacy scores are still highly predictive of performance. Collective efficacy has been a useful concept for what Bandura (2004, p. 159) termed “socially oriented approaches to health.” These approaches emphasize how groups of individuals feel enabled to change the “social, political, and environmental conditions that affect health” (p. 159).

Collective efficacy is also utilized in academic and professional contexts where behavior is conceptualized as the product of a group instead of an individual. Collective efficacy is related to group goal attainment, specifically to both teacher self-efficacy and student achievement (Goddard, Hoy, & Hoy, 2004). Teacher self-efficacy refers to one’s perceived ability to help students learn (Schunk & Pajares, 2009). The self-efficacy and collective efficacy literature as related to educational performance is quite well-developed and may be of interest to health communication researchers who study the process by which self-efficacy cognitively impacts goal attainment.

Finally, professional self-efficacy is another related construct that has implications for health promotion and health communication campaign designers. Gains in individual self-efficacy beliefs can cross over to professional domains, creating enhanced performance in multiple areas (Parrott, Wilson, Buttram, Jones, & Steiner, 1999). Therefore, health interventions that utilize health professionals, peer educators, or anyone in a “teaching” role should give special consideration to increasing the self-efficacy of the individuals charged with modeling the behavior or delivering the message. Increases in professional self-efficacy may have the added benefit of reducing professional stress and burnout (Rabinowitz, Kushnir, & Ribak, 1996).

Further Reading

Bandura, A. (1997). Self-efficacy: The exercise of control. New York: Freeman.Find this resource:

Bandura, A. (2004). Health promotion by social cognitive means. Health Education & Behavior, 31, 143–164.Find this resource:

Luszczynska, A., & Schwarzer, R. (2005). The role of self-efficacy in health regulation. In W. Greve, K. Rothermund, & D. Wentura (Eds.), The adaptive self: Personal continuity and intentional self-development (pp. 137–152). Cambridge, MA: Hogrefe & Huber Publishers.Find this resource:

O’Leary, A. (1985). Self-efficacy and health. Behavioral Research Therapy, 23, 437–451.Find this resource:

Rimal, R. N. (2000). Closing the knowledge-behavior gap in health promotion: The mediating role of self-efficacy. Health Communication, 12, 219–237.Find this resource:

Strecher, V. J., McEvoy DeVellis, B., Becker, M. H., & Rosenstock, I. M. (1986). The role of self-efficacy in achieving health behavior change. Health Education Quarterly, 13, 73–91.Find this resource:

Werrij, M. Q., Ruiter, R. A., Van’t Riet, J., & De Vries, H. (2010). Self-efficacy as a potential moderator of the effects of framed health messages. Journal of Health Psychology, 16, 199–207.Find this resource:

Witte, K. (1992). Putting the fear back into fear appeals: The extended parallel process model. Communication Monographs, 59, 329–349.Find this resource:

Witte, Kim. (1994). Fear control and danger control: A test of the extended parallel process model (EPPM). Communications Monographs, 61, 113–134.Find this resource:

Witte, K., & Allen, M. (2000). A meta-analysis of fear appeals: Implications for effective public health campaigns. Health Education & Behavior, 27, 591–615.Find this resource:

References

Bandura, A. (1997). Self-efficacy: The exercise of control. New York: Freeman.Find this resource:

Bandura, A. (2001). Social cognitive theory of mass communication. Media Psychology, 3, 265–299.Find this resource:

Bandura, A. (2004). Health promotion by social cognitive means. Health Education & Behavior, 31, 143–164.Find this resource:

Botta, R. A., Dunker, K., Fenson-Hood, K., Maltarich, S., & McDonald, L. (2008). Using a relevant threat, EPPM and interpersonal communication to change hand-washing behaviours on campus. Journal of Communication in Healthcare, 1, 373–381.Find this resource:

Craig, C. L., Bauman, A., Latimer-Cheung, A., Rhodes, R. E., Faulkner, G., Berry, T. R., et al. (2015). An evaluation of the My ParticipACTION campaign to increase self-efficacy for being more physically active. Journal of Health Communication, 20, 995–1003.Find this resource:

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