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Self-referent thought has become an issue that pervades psychological research in many domains. In 1977, the famous psychologist Albert Bandura at Stanford University introduced the concept of perceived self-efficacy in the context of cognitive behaviour modification. It has been found that a strong sense of personal efficacy is related to better health, higher achievement, and more social integration. This concept has been applied to such diverse areas as school achievement, emotional disorders, mental and physical health, career choice, and sociopolitical change. It has become a key variable in clinical, educational, social, developmental, health, and personality psychology. The present chapter refers to its influence on the adoption, initiation, and maintenance of health behaviours. It represents the key construct in Social Cognitive Theory (Bandura, 1977, 1986, 1991, 1992).
Behavioural change is facilitated by a personal sense of control. If people believe that they can take action to solve a problem instrumentally, they become more inclined to do so and feel more committed to this decision. While outcome expectancies refer to the perception of the possible consequences of one's action, perceived self-efficacy pertains to personal action control or agency (Bandura, 1992; Maddux, 1991, 1993; Wallston, 1994). A person who believes in being able to cause an event can conduct a more active and self-determined life course. This "can do"-cognition mirrors a sense of control over one's environment. It reflects the belief of being able to master challenging demands by means of adaptive action. It can also be regarded as an optimistic view of one's capacity to deal with stress.
Self-efficacy makes a difference in how people feel, think and act. In terms of feeling, a low sense of self-efficacy is associated with depression, anxiety, and helplessness. Such individuals also have low self-esteem and harbour pessimistic thoughts about their accomplishments and personal development. In terms of thinking, a strong sense of competence facilitates cognitive processes and academic performance. Self-efficacy levels can enhance or impede the motivation to act. Individuals with high self-efficacy choose to perform more challenging tasks. They set themselves higher goals and stick to them (Locke & Latham, 1990). Actions are preshaped in thought, and people anticipate either optimistic or pessimistic scenarios in line with their level of self-efficacy. Once an action has been taken, high self-efficacious persons invest more effort and persist longer than those with low self-efficacy. When setbacks occur, the former recover more quickly and maintain the commitment to their goals. Self-efficacy also allows people to select challenging settings, explore their environments, or create new situations. A sense of competence can be acquired by mastery experience, vicarious experience, verbal persuasion, or physiological feedback (Bandura, 1977). Self-efficacy, however, is not the same as positive illusions or unrealistic optimism, since it is based on experience and does not lead to unreasonable risk taking. Instead, it leads to venturesome behaviour that is within reach of one's capabilities.
2.0 Description of the Model
According to Social Cognitive Theory, human motivation and action are extensively regulated by forethought. This anticipatory control mechanism involves three types of expectancies: (a) situation-outcome expectancies, in which consequences are cued by environmental events without personal action, (b) action-outcome expectancies, in which outcomes flow from personal action, and (c) perceived self-efficacy, which is concerned with people's beliefs in their capabilities to perform a specific action required to attain a desired outcome.
Situation-outcome expectancies represent the belief that the world changes without one's own personal engagement. Risks are perceived, and persons may feel more or less vulnerable towards critical events that they anticipate. Individuals may sit and wait for things to happen, but illusions about the future may help one cope with threat. When, for example, people anticipate a disease they may distort its likelihood of occurrence. This can be seen as a defensive optimism. Defenses can be made in terms of social comparison bias, e.g., "I am less vulnerable than others to illness." On the other hand, action-outcome expectancies and self-efficacy expectancies include the option to change the world and to cope instrumentally with health threats by taking preventive action. These action beliefs and personal resource beliefs reflect a functional optimism. Empirically, the distinction of the latter two is hard to confirm because the second does not operate without the first. In making judgments about health-related goals, people usually unite personal agency with means. Perceived self-efficacy implicitly includes some degree of outcome expectancies because individuals believe they can produce the responses necessary for desired outcomes.
Adopting health-promoting behaviours and refraining from health-impairing behaviours is difficult. Most people have a hard time making the decision to change and, later on, maintaining the adopted changes when they face temptations. The likelihood that people will adopt a valued health behaviour (such as physical exercise) or change a detrimental habit (such as quitting smoking) may therefore depend on three sets of cognitions: (a) the expectancy that one is at risk ("My risk of getting cancer from smoking is above average"), (b) the expectancy that behavioural change would reduce the threat ("If I quit smoking, I will reduce my risk"), and (c) the expectancy that one is sufficiently capable of adopting a positive behaviour or refraining from a risky habit ("I am capable of quitting smoking permanently"). In order to initiate and maintain health behaviours, it is not sufficient to perceive an action-outcome contingency. One must also believe that one has the capability to perform the required behaviour. A large body of research has examined the role of optimistic self-beliefs as a predictor of behaviour change in the health domain (for an overview see Bandura, 1992; Maddux, 1993; O'Leary, 1992; Schwarzer, 1992). Behavioural change goals exert their effect through optimistic self-beliefs. These beliefs slightly overestimate perceived coping capabilities rather than simply reflect the existing ones.
Both outcome expectancies and efficacy beliefs play influential roles in adopting health behaviours, eliminating detrimental habits, and maintaining change. In adopting a desired behaviour, individuals first form an intention and then attempt to execute the action. Outcome expectancies are important determinants in the formation of intentions, but are less so in action control. Self-efficacy, on the other hand, seems to be crucial in both stages of the self-regulation of health behaviour. Positive outcome expectancies encourage the decision to change one's behaviour. Thereafter, outcome expectancies may be dispensable because a new problem arises, namely the actual performance of the behaviour and its maintenance. At this stage, perceived self-efficacy continues to operate as a controlling influence.
Perceived self-efficacy represents the belief that one can change risky health behaviours by personal action, e.g., by employing one's skills to resist temptation. Behaviour change is seen as dependent on one's perceived capability to cope with stress and boredom and to mobilize one's resources and courses of action required to meet the situational demands. Efficacy beliefs affect the intention to change risk behaviour, the amount of effort expended to attain this goal, and the persistence to continue striving in spite of barriers and setbacks that may undermine motivation. Perceived self-efficacy has become a widely applied theoretical construct in models of addiction and relapse (e.g., Donovan & Marlatt, 1988; Marlatt, Baer & Quigley, 1994; Marlatt & Gordon, 1985). This view suggests that success in coping with high-risk situations depends partly on people's beliefs that they operate as active agents of their own actions and that they possess the necessary skills to reinstate control should a slip occur. The common denominator of relapse prevention theory and the model to be described later on refers to the assumption of distinct stages and the claim that specific self-efficacy operates at these stages.
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