INTRODUCTION:
Self-efficacy, i.e., the confidence in one's capacity to perform a behavior, is crucial to the development of inflammatory bowel disease (IBD) self-management skills. We aimed to measure IBD self-efficacy and the relationship between self-efficacy and the patient-reported impact of IBD on daily life.
METHODS:
We surveyed patients with IBD from a single academic center using the IBD Self-Efficacy Scale (IBD-SES) and patient-reported outcome (PRO) measures. The IBD-SES assesses 4 IBD domains: patients' confidence in managing stress and emotions, symptoms and disease, medical care, and remission. IBD PROs evaluate daily life impact, coping strategies, emotional impact, and systemic symptoms. We examined the association between IBD-SES domains with the lowest scores and IBD daily life impact.
RESULTS:
A total of 160 patients completed the survey. Domain scores on the IBD-SES were lowest for managing stress and emotions (mean 6.76, SD 1.86) and symptoms and disease (mean 6.71, SD 2.12) on a 1–10 scale. Controlling for age, sex, IBD type, disease activity, moderate-to-severe disease, depression and anxiety, a higher confidence in managing stress and emotions (β −0.12, 95% confidence interval −0.20 to −0.05, P = 0.001), and managing symptoms and disease (β −0.28, 95% confidence interval −0.35 to −0.20, P < 0.001) were each associated with lower IBD daily life impact.
DISCUSSION:
Patients with IBD report low confidence in managing stress and emotion and managing symptoms and disease. Higher self-efficacy in these domains was associated with lower IBD daily life impact. Self-management tools that promote self-efficacy in managing these domains have the potential to reduce IBD's daily life impact.
KEYWORDS: Crohn's disease, ulcerative colitis, self-management, behavioral intervention
INTRODUCTION
The goals of inflammatory bowel disease (IBD) treatment are to limit inflammation, control symptoms, improve quality of life, and prevent disability (1). However, despite the availability of effective medications, many patients exhibit suboptimal disease control, preventable IBD complications, and disability (2–6). IBD is predominantly managed by gastroenterologists whose time constraints and limited contact with patients between face-to-face visits hinder proactive management, making effective self-care vitally important (7). Patients with IBD need to master a variety of daily tasks to keep their illness under control, minimize its impact on their physical health, and cope with comorbid or resulting psychological symptoms (8). IBD self-management skills include recognizing and managing symptoms, taking medication as prescribed, coping with stress, collaborating effectively with healthcare providers, engaging in treatment and diagnostic choices, and navigating health insurance and the healthcare system (9–14). Because IBD management is complex and the disease course is unpredictable, patients are often unable to consistently perform these self-management tasks (15–17).
Self-efficacy is defined as the belief in one's capacity to perform a behavior or action including initiating a behavior, mastering it, and sustaining that behavior in the context of setbacks (18). High self-efficacy has been linked to successful self-management and improved health outcomes for patients with chronic conditions such as diabetes, heart failure, and chronic obstructive pulmonary disease (19–21). Self-efficacy is modifiable and can be successfully improved using cognitive behavioral and motivational interviewing techniques (22,23). Furthermore, studies suggest that successful IBD self-management interventions may be most effective when they support self-efficacy (Figure 1) (24). However, the relationship between self-efficacy and clinical outcomes in IBD is not clear. To address this knowledge gap and better understand potential targets for effective self-management interventions, we aimed to study self-efficacy among patients with IBD and examine the relationship between self-efficacy and the impact of IBD on patients' daily lives.
Figure 1.
Conceptual model depicting relationship between self-management interventions, self-efficacy, and disease outcomes. IBD, inflammatory bowel disease.
METHODS
Study sample and participant recruitment
Patients were identified from a single tertiary referral center using International Classification of Diseases, Tenth Revision diagnostic codes for Crohn's disease or ulcerative colitis. A random sample of 631 patients who carried a diagnosis of IBD, were English speaking, and had the mental capacity to consent were eligible for participation and received an invitation to complete a survey through email. We followed a modified Dillman approach (25). Two reminder messages outlining the purpose and nature of the study were sent at 2-week intervals and included a link to electronically complete the survey or opt-out of participation. The survey was administered using the REDCap platform. Eligible patients who did not complete the survey or opt out were contacted by telephone. Patients received the initial phone call and up to 2 reminder phone calls outlining the nature and purpose of the study. Interested patients were given the opportunity to complete the survey electronically or by telephone.
Surveys
IBD-SES.
IBD Self-Efficacy Scale (IBD-SES) is a 29-item questionnaire assessing patients' confidence to manage 4 IBD-related domains on a scale ranging from 1 (not at all) to 10 (totally). These domains are (i) managing stress and emotions, (ii) managing medical care, (iii) managing symptoms and disease, and (iv) maintaining remission. Total IBD-SES scores range from 29 to 290, with higher scores representing higher self-efficacy. The IBD-SES was developed by Keefer et al in 2011 with high internal reliability (26). It was externally validated with high reliability (Cronbach's α = 0.97), and the 4-factor structure was supported on confirmatory factor analysis (27). The scale can be considered as a total value or by each of its 4 domains.
CD-PRO and UC-PRO measures.
The Crohn's Disease Patient-Reported Outcome (CD-PRO) and Ulcerative Colitis Patient-Reported Outcome (UC-PRO) instruments were developed by Higgins et al to assess the signs, symptoms, and impact of IBD using several distinct domains, including bowel signs and symptoms, abdominal symptoms, systemic symptoms, required coping strategies, daily life impact, and emotional impact. The daily life impact, systemic symptoms, required coping strategies, and emotional impact domains contain identical survey items for both Crohn's disease and ulcerative colitis (28,29).
Statistical analysis
Baseline characteristics.
We described continuous and categorical variables using mean values (SD) and counts (percentages), respectively. We examined the association between patient characteristics (including demographics, medical history, IBD characteristics, and psychosocial factors) and self-efficacy using unpaired Student t tests.
IBD-SES factor analyses.
Given our focus on self-efficacy and using the IBD-SES as our main independent variable(s), we examined the extent to which the original Keefer et al 4-factor structure fit the data. We determined internal reliability by calculating Cronbach's α and its factor structure using confirmatory factor analysis. It was unclear whether the confirmatory factor analysis was influenced by sample power or by baseline differences in the sample populations; however, goodness-of-fit measures indicated poor fit. Therefore, we conducted a sensitivity analysis using exploratory factor analysis to determine whether an alternative factor structure better fit patients' response. In their analysis of the IBD-SES, Graff et al described the potential for a 3-factor model by embedding measure of “managing remission” into the 3 other domains. Here, we report findings of the original Keefer et al 4-factor model, as well as the exploratory factor analysis–derived 4-factor and 3-factor models as a sensitivity analysis.
Outcome measures.
Our primary outcome of interest was the daily life impact of IBD, calculated using the daily life impact module from either the CD-PRO or UC-PRO as appropriate. The IBD daily life impact score includes 9 questions related to how IBD affected one's daily life in the past 7 days, each scored on a 0–4 scale (from “not at all” to “a great deal”). Outcomes were reported as a continuous variable with higher scores demonstrating a higher burden of IBD on daily life. Secondary outcomes of interest included systemic symptoms, required coping strategies, and emotional impact calculated using the relevant modules. Higher scores in each of these modules also indicate a higher burden of IBD in each respective domain. Pearson's correlations were calculated for each of the PRO domains and IBD-SES subscales to determine whether these measures were significantly related.
In separate multivariable linear regressions and controlling a priori for age, sex, IBD type, clinical disease activity, moderate-to-severe disease, history of depression, and history of anxiety, we examined the relationship between each of 4 IBD-SES subscales and patient-reported outcomes. All covariates including IBD type, medications, and comorbidities were based on patient-reported survey responses. Clinical disease activity was defined based on current use of systemic corticosteroids. Moderate-to-severe disease was defined based on the current or previous use of immune-targeted IBD therapies (i.e., biologics, immunomodulators, or small molecules). A P value less than 0.05 was considered statistically significant.
Exploratory analyses.
In a sensitivity analysis, we added an interaction term to the original multivariable logistic regression to examine whether disease activity moderated the association between IBD-SES and IBD daily life impact. We also conducted a subgroup analysis to examine the association between IBD-SES and IBD daily life impact in patients with clinically inactive disease defined by the absence of current steroid use. All statistical analysis was performed using STATA/IC version 14.2 (StataCorp, College Station, TX). This study was approved by the institutional review board (HUM#00194000).
RESULTS
Study population
Participants were drawn from a sample of 631 patients with IBD followed at a single center. The analytic cohort of 160 respondents was 54.1% female, 92.6% white, with 51.3% age 50 years or older. Regarding their IBD, 58.1% had Crohn's disease, 36.9% had ulcerative colitis, 1.9% had indeterminate colitis, and 3.1% did not know their IBD subtype. Roughly three-quarters of all patients had moderate-to-severe disease and had been or were currently being prescribed immune-targeted therapy (75.6%), and 10% had clinically active disease and were using systemic steroids at the time the survey was completed (Table 1). One-quarter (24.4%) of patients reported a comorbid diagnosis of depression, whereas 36.9% reported comorbid anxiety. Clinically active disease and comorbid depression and anxiety were associated with lower IBD-SES scores (Table 1). Baseline characteristics from this sample were similar to the population of patients with IBD seen at our single center (see Supplementary Table 1, Supplementary Digital Content 1, http://links.lww.com/CTG/A924).
Table 1.
Association between patient characteristics and IBD self-efficacy
| Patient characteristics | Sample totals, n (%) | Mean IBD-SES (SD) | P |
| Total sample | 160 | 218.0 (39.6) | — |
| Age (yr) | 0.212 | ||
| 18–29 | 29 (18.4) | 224.0 (35.7) | |
| 30–49 | 47 (29.8) | 216.9 (36.7) | |
| 50–69 | 63 (39.9) | 210.4 (44.4) | |
| 70 and older | 19 (12.0) | 235.8 (32.1) | |
| Sex | 0.334 | ||
| Female | 86 (54.1) | 215.1 (40.0) | |
| Male | 72 (45.3) | 221.2 (39.1) | |
| Unspecified | 1 (0.6) | — | |
| Education | 0.257 | ||
| No bachelor's degree | 61 (38.1) | 212.4 (42.6) | |
| Bachelor's degree | 99 (61.9) | 221.4 (37.4) | |
| Location of residence | 0.109 | ||
| Urban | 28 (17.6) | 216.9 (36.9) | |
| Suburban | 101 (63.5) | 219.0 (37.3) | |
| Rural | 30 (18.9) | 216.8 (49.8) | |
| Missing | 1 (0.6) | 183.0 (0.0) | |
| Race | 0.674 | ||
| White | 148 (92.6) | 219.4 (39.9) | |
| Black | 6 (3.7) | 195.3 (36.4) | |
| Other | 6 (3.7) | 206.5 (29.2) | |
| Type of IBD | 0.543 | ||
| Ulcerative colitis | 59 (36.9) | 225.8 (37.4) | |
| Crohn's disease | 93 (58.1) | 213.0 (41.0) | |
| Indeterminate colitis | 3 (1.9) | 242.7 (19.5) | |
| Unknown | 5 (3.1) | 203.6 (30.8) | |
| Clinically active diseasea | 16 (10.0) | 197.1 (58.6) | 0.025c |
| Clinically inactive disease | 144 (90.0) | 220.3 (36.4) | |
| Moderate-to-severe diseaseb | 121 (75.6) | 213.8 (37.9) | 0.018 |
| Mild disease | 39 (24.4) | 230.9 (42.3) | |
| 5-ASA | 44 (27.5) | 228.0 (35.2) | 0.048c |
| No 5-ASA | 116 (72.5) | 214.2 (40.6) | |
| Immunomodulator | 41 (25.6) | 214.7 (31.6) | 0.541 |
| No immunomodulator | 119 (74.4) | 219.1 (42.0) | |
| Biologic | 83 (51.9) | 214.6 (38.6) | 0.268 |
| No biologic | 77 (48.1) | 221.6 (40.5) | |
| Tofacitinib | 4 (2.5) | 231.3 (27.3) | 0.499 |
| No tofacitinib | 156 (97.5) | 217.6 (39.8) | |
| Comorbid depression | 39 (24.4) | 194.7 (39.2) | <0.001c |
| No depression | 121 (75.6) | 225.5 (36.8) | |
| Comorbid anxiety | 59 (36.9) | 203.9 (40.2) | 0.001c |
| No anxiety | 101 (63.1) | 226.2 (37.0) | |
| Comorbid rheumatoid arthritis | 18 (11.3) | 196.3 (56.9) | 0.013c |
| No rheumatoid arthritis | 142 (88.7) | 220.7 (36.2) |
5-ASA, 5-aminosalicylic acid; IBD, inflammatory bowel disease; IBD-SES, IBD Self-Efficacy Scale.
Active disease defined by current use of corticosteroids.
Moderate-to-severe disease defined by current or past use of immune-targeted therapies.
P < 0.05.
IBD-SES factor analysis
The original 4-factor model proposed in the Keefer et al study was not completely supported in this sample. Confirmatory factor analysis was performed by loading all items onto the original proposed IBD-SES subscales (Q1–9 managing stress and emotions, Q10–17 managing medical care, Q18–24 managing symptoms and disease, and Q25–29 managing remission) (see Supplementary Table 2, Supplementary Digital Content 1, http://links.lww.com/CTG/A924). Path loadings from individual items to the subscale factors were significant, with good effect sizes (R2 = 0.11–0.81). However, goodness-of-fit measures (comparative fit index = 0.748; Tucker-Lewis index = 0.724; and standardized root mean-square residual = 0.092) and root mean-square error of approximation (0.134; 90% confidence interval [CI] 0.127–0.141) did not indicate a well-fitted model.
Exploratory factor analyses to identify alternative factor structures for our sample resulted in a 4-factor model with high internal reliability (Cronbach's α = 0.95) and the following domains: managing stress and emotions, managing symptoms and disease, managing physician-patient communication, and managing medications (Table 2). A 3-factor model incorporating managing remission into the 3 other domains had high internal reliability (Cronbach's α = 0.95). The 3 identified factors were similar to those in the exploratory factor analysis model, i.e., managing stress and emotion, managing symptoms and disease, and managing medical care (Table 3).
Table 2.
Psychometrics of 4-factor exploratory factor analysis model
| IBD-SES | No. of items | Eigenvector | Proportion | Cronbach's α | Mean score (SD) |
| Factor 1: Managing stress and emotions | 12 | 12.26 | 0.56 | 0.95 | 6.88 (1.80) |
| Q1 Keep from getting stressed | |||||
| Q2 Do something to reduce stress | |||||
| Q3 Keep from getting discouraged | |||||
| Q4 Do something to reduce discouragement | |||||
| Q5 Keep from feeling sad | |||||
| Q6 Do something to reduce sadness | |||||
| Q7 Keep sadness/anxiety from interfering | |||||
| Q8 Do something to reduce interference of sadness/anxiety | |||||
| Q9 Get emotional support | |||||
| Q27 Engage in self-care (exercise, diet, and rest) | |||||
| Q28 Engage in stress management program | |||||
| Q29 Maintain your sense of well-being | |||||
| Factor 2: Managing symptoms and disease | 9 | 3.3 | 0.15 | 0.94 | 6.91 (2.00) |
| Q18 Reduce symptoms | |||||
| Q19 Keep sleep problems from interfering | |||||
| Q20 Keep discomfort/pain from interfering | |||||
| Q21 Keep diarrhea/urgency from interfering | |||||
| Q22 Keep symptoms from interfering | |||||
| Q23 Decrease fatigue | |||||
| Q24 Keep fatigue from interfering | |||||
| Q25 Manage your disease | |||||
| Q26 Keep disease in remission | |||||
| Factor 3: Patient-physician communication | 5 | 2.19 | 0.1 | 0.89 | 9.04 (1.22) |
| Q13 Work with providers on treatment plan | |||||
| Q14 Ask doctor about illness | |||||
| Q15 Discuss problems with medication | |||||
| Q16 Workout differences with doctors | |||||
| Q17 Ask doctor about medications | |||||
| Factor 4: Managing medications | 3 | 1.57 | 0.07 | 0.86 | 9.35 (1.14) |
| Q10 Follow medication prescription | |||||
| Q11 Take medication at instructed times | |||||
| Q12 Take medication as directed to prevent flare-up |
IBD-SES, Inflammatory Bowel Disease Self-Efficacy Scale.
Table 3.
Psychometrics of 3-factor exploratory factor analysis model
| IBD-SES | No. of items | Eigenvector | Proportion | Cronbach's α | Mean score (SD) |
| Factor 1: Managing stress and emotions | 12 | 12.26 | 0.56 | 0.95 | 6.88 (1.80) |
| Q1 Keep from getting stressed | |||||
| Q2 Do something to reduce stress | |||||
| Q3 Keep from getting discouraged | |||||
| Q4 Do something to reduce discouragement | |||||
| Q5 Keep from feeling sad | |||||
| Q6 Do something to reduce sadness | |||||
| Q7 Keep sadness/anxiety from interfering | |||||
| Q8 Do something to reduce interference of sadness/anxiety | |||||
| Q9 Get emotional support | |||||
| Q27 Engage in self-care (exercise, diet, and rest) | |||||
| Q28 Engage in stress management program | |||||
| Q29 Maintain your sense of well-being | |||||
| Factor 2: Managing symptoms and disease | 10 | 3.3 | 0.15 | 0.93 | 7.15 (1.84) |
| Q12 Take medication as directed to prevent flare-up | |||||
| Q18 Reduce symptoms | |||||
| Q19 Keep sleep problems from interfering | |||||
| Q20 Keep discomfort/pain from interfering | |||||
| Q21 Keep diarrhea/urgency from interfering | |||||
| Q22 Keep symptoms from interfering | |||||
| Q23 Decrease fatigue | |||||
| Q24 Keep fatigue from interfering | |||||
| Q25 Manage your disease | |||||
| Q26 Keep disease in remission | |||||
| Factor 3: Patient-physician communication | 7 | 2.19 | 0.1 | 0.85 | 9.13 (1.04) |
| Q10 Follow medication prescription | |||||
| Q11 Take medication at instructed times | |||||
| Q13 Work with providers on treatment plan | |||||
| Q14 Ask doctor about illness | |||||
| Q15 Discuss problems with medication | |||||
| Q16 Workout differences with doctors | |||||
| Q17 Ask doctor about medications |
IBD-SES, Inflammatory Bowel Disease Self-Efficacy Scale.
IBD self-efficacy scores
The overall mean IBD-SES score was 218.0 (SD 39.6), on a scale ranging from 29 to 290, with higher scores representing higher self-efficacy. Using the subscale components from the original study, patients scored lowest on their confidence in managing stress and emotions (mean 6.76, SD 1.86) and managing symptoms and disease (mean 6.71, SD 2.12) compared with managing medical care (mean 9.16, SD 0.99) and managing remission (mean 7.43, SD 1.76). When considering the alternative subscale components in the 4-factor exploratory factor analysis model, patients similarly scored lowest on their confidence in managing stress and emotions (mean 6.88, SD 1.80) and managing symptoms and disease (mean 6.91, SD 2.00) compared with managing patient-physician communications (mean 9.04, SD 1.22) and managing medications (mean 9.35, SD 1.22) (Table 2). Similarly, in the 3-factor exploratory factor analysis model, patients scored lowest in managing stress and emotions (mean 6.88, SD 1.80) and managing symptoms and disease (mean 7.15, SD 1.84) compared with managing patient-physician communications (mean 9.13, SD 1.04) (Table 3).
IBD symptom burden
The mean IBD daily impact score was 6.6 (SD 8.4; range 0–36 [9 questions ranging from 0 to 4]) where higher scores indicate a higher burden of IBD. Mean scores for other outcomes included systemic symptoms (mean 4.4 [SD 3.7]), required coping strategies (mean 1.7 [SD 2.3]), and emotional impact (mean 6.9 [SD 6.4]). There was moderate negative correlation between each of these patient-reported outcome domains and IBD-SES scores (see Supplementary Table 3, Supplementary Digital Content 1, http://links.lww.com/CTG/A924).
In a multivariable linear regression, adjusting for age, sex, IBD type, clinically active disease, moderate-to-severe disease, depression, and anxiety, a higher IBD self-efficacy score was associated with lower IBD daily life impact (β −0.09, 95% CI −0.12 to −0.06, P < 0.001) (Table 4). A higher IBD self-efficacy score was also associated with fewer systemic symptoms (β −0.04, 95% CI −0.05 to −0.03, P < 0.001), a need for fewer required daily coping strategies (β −0.02, 95% CI −0.03 to −0.01, P < 0.001), and a lower emotional impact (β −0.10, 95% CI −0.12 to −0.08, P < 0.001).
Table 4.
Adjusted relationship between total IBD-SES score and daily life impact of IBD
| Patient characteristic | β | 95% CI | P |
| IBD-SES score | −0.09 | −0.12 to −0.061 | <0.001a |
| Age (yr) | |||
| 18–30 | — | — | — |
| 31–49 | 1.63 | −1.45 to 4.72 | 0.296 |
| 50–69 | 2.06 | −0.92 to 5.05 | 0.174 |
| 70 or older | −0.15 | −4.10 to 3.79 | 0.939 |
| Female sex | 1.68 | 0.37 to 3.72 | 0.108 |
| IBD type | |||
| Crohn's disease | — | — | — |
| Ulcerative colitis | 2.91 | 0.52 to 4.29 | 0.017a |
| Indeterminate colitis | −2.89 | −12.17 to 6.39 | 0.539 |
| Unknown | −2.42 | −8.43 to 3.60 | 0.429 |
| Clinically active disease | 5.03 | 1.62 to 8.43 | 0.004a |
| Moderate-to-severe disease | 0.77 | −1.97 to 3.51 | 0.581 |
| Depression | 1.71 | −1.07 to 4.49 | 0.227 |
| Anxiety | −2.59 | −4.92 to −0.28 | 0.029a |
CI, confidence interval; IBD, inflammatory bowel disease; IBD-SES, IBD Self-Efficacy Scale.
Statistical significant to P < 0.05 or smaller.
In multivariable regression models with the original IBD-SES subscales and adjusting for age, sex, IBD type, clinically active disease, and moderate-to-severe disease, higher confidence in managing stress and emotions (β −0.12, 95% CI −0.20 to −0.05, P = 0.001) and higher confidence in managing symptoms and disease (β −0.28, 95% CI −0.35 to −0.20, P < 0.001) were each separately associated with a lower daily life impact of IBD. Similarly, a higher confidence in managing stress and emotions and a higher confidence in managing symptoms and disease were also both associated with fewer systemic symptoms, fewer required coping strategies, and a lower emotional impact of IBD (Table 5). In sensitivity analyses using the alternative 4-factor and 3-factor exploratory factor analysis IBD-SES models, these associations between self-efficacy subscales and the impact of IBD persisted (Table 5). In an exploratory analysis, when further adjusting our original model with the addition of an interaction term for disease activity and IBD-SES, clinically active disease did not significantly moderate the relationship between IBD-SES and daily life impact (β −0.059, 95% CI −0.12 to −0.004, P = 0.066). However, in a subgroup analysis of patients with clinically inactive disease, the association between IBD-SES and IBD daily life impact remained significant (β −0.081, 95% CI −0.11 to −0.05, P < 0.001).
Table 5.
Relationship between IBD-SES subscales and patient-reported outcomes
| Symptom domain | Original Keefer et al model | 4-factor EFA model | 3-factor EFA model | ||||||
| β | 95% CI | P | β | 95% CI | P | β | 95% CI | P | |
| Daily life impact | |||||||||
| Self-efficacy for managing stress and emotion | −0.12 | −0.20 to −0.05 | 0.001 | −0.11 | −0.16 to −0.05 | <0.001 | −0.11 | −0.16 to −0.05 | <0.001 |
| Self-efficacy for managing symptoms and disease | −0.28 | −0.35 to −0.20 | <0.001 | −0.25 | −0.31 to −0.19 | <0.001 | −0.24 | −0.30 to −0.18 | <0.001 |
| Systemic symptoms | |||||||||
| Self-efficacy for managing stress and emotion | −0.06 | −0.090 to −0.03 | <0.001 | −0.05 | −0.08 to −0.03 | <0.001 | −0.05 | −0.08 to −0.03 | <0.001 |
| Self-efficacy for managing symptoms and disease | −0.12 | −0.15 to −0.09 | <0.001 | −0.10 | −0.12 to −0.07 | <0.001 | −0.09 | −0.12 to −0.07 | <0.001 |
| Required coping strategies | |||||||||
| Self-efficacy for managing stress and emotion | −0.02 | −0.04 to −0.002 | 0.030 | −0.02 | −0.04 to −0.01 | 0.007 | −0.02 | −0.04 to −0.01 | 0.007 |
| Self-efficacy for managing symptoms and disease | −0.07 | −0.09 to −0.05 | <0.001 | −0.06 | −0.08 to −0.05 | <0.001 | −0.06 | −0.08 to −0.04 | <0.001 |
| Emotional impact | |||||||||
| Self-efficacy managing stress and emotion | −0.21 | −0.26 to −0.16 | <0.001 | −0.17 | −0.21 to −0.13 | <0.001 | −0.17 | −0.21 to −0.13 | <0.001 |
| Self-efficacy for managing symptoms and disease | −0.23 | −0.29 to −0.16 | <0.001 | −0.19 | −0.24 to −0.14 | <0.001 | −0.18 | −0.23 to −0.13 | <0.001 |
CI, confidence interval; EFA, exploratory factor analysis; IBD, inflammatory bowel disease; IBD-SES, IBD Self-Efficacy Scale.
Adjusted for age, sex, IBD, type, disease activity, moderate-to-severe disease, depression, and anxiety.
DISCUSSION
Self-management is defined as the health behaviors and actions that patients engage in to care for a chronic condition, whereas self-efficacy refers to the belief in one's capacity to perform those behaviors and actions (15,18). Although studies suggest that IBD self-management interventions may be most effective when they support self-efficacy, the relationship between self-efficacy and IBD-related health outcomes is not well understood. To address this knowledge gap and better understand potential targets for effective self-management interventions, we aimed to examine the relationship between self-efficacy and the impact of IBD on patients' daily lives.
We found that patients with IBD report low self-efficacy in managing stress and emotions and in managing symptoms and disease, relative to other IBD self-management domains (i.e., managing medical care or maintaining remission). Higher IBD self-efficacy is associated with lower IBD daily life impact, systemic symptoms, use of daily coping strategies, and emotional impact. These findings may be explained by Bandura's Theory of Self-Efficacy, which states that a person is more likely to engage in an activity or behavior for which they are confident in their ability to succeed (18). In this case, patients with higher self-efficacy are more likely to successfully manage their IBD, leading to less impact of IBD on their daily life. Furthermore, the association between self-efficacy and IBD daily life impact remained significant on subgroup analysis of patients with clinically inactive disease, suggesting that self-efficacy may be an important modifiable factor not only for patients with clinically active IBD.
Social cognitive theory (SCT) is a predominant framework for developing effective self-management interventions in targeted populations with chronic illness (30). SCT emphasizes the cognitive, behavioral, and environmental factors that interact to influence human behavior and aims to promote behavioral change by improving knowledge, self-efficacy, and problem-solving skills through strategies such as self-monitoring, goal setting, and skill building (30–32). Indeed, SCT-based interventions, such as Stanford's Chronic Disease Self-Management Program, that are designed to improve self-efficacy through cognitive behavioral therapy, problem-solving skills training, and peer support (Figure 1), have been shown to improve self-management and disease outcomes for many chronic conditions, including asthma, arthritis, weight loss, and diabetes (18,30,31,33–36). Our findings, which demonstrate a relationship between self-efficacy and IBD daily life impact, also suggest that targeting self-efficacy may be a promising strategy for supporting IBD self-management and improving IBD outcomes.
Existing self-management interventions for IBD have not shown consistent improvement in symptom burden or quality of life (35–38). Many of these interventions focus on patient education and symptom monitoring, often engaging patient by using telemedicine tools (35–38). However, this one-size-fits-all approach to self-management has not been shown to consistently improve outcomes (35,36). Our results suggest that a targeted approach focused on improving specific self-efficacy domains may improve overall symptom burden and quality of life.
For example, our study respondents reported low self-efficacy for managing stress and emotion, suggesting self-efficacy in this domain may be a potential target for self-management interventions. Robust research has shown that mental health and symptom burden are strongly correlated with quality of life in IBD (39–41). A recent meta-analysis demonstrated that up to one-third of patients with IBD struggled with anxiety and one-quarter had symptoms of depression, with a higher prevalence in those with clinically active disease (39). In addition, cognitive-behavioral therapy and mindfulness interventions have been shown to improve quality of life and decrease psychological distress in this population (40). These data, combined with our results, suggest that focusing on mental health through targeted interventions, such as cognitive-behavioral therapy programs, that develop self-efficacy for managing stress and emotions has potential to improve the overall quality of life for patients with IBD.
In addition to managing stress and emotion, our survey respondents reported low self-efficacy for managing symptoms and disease, suggesting another potential target for a self-management intervention. Clinically active disease and high symptom burden have been associated with overall lower quality of life in patients with IBD (41). Self-management Using Couples' Coping EnhancEment in Diseases is one example of a self-management program focused on improving self-efficacy for managing heart failure symptoms. Self-management Using Couples' Coping EnhancEment in Diseases was designed to facilitate skill building and allow patients to manage their heart failure, related negative emotions, and build a fulfilling life with heart failure (42). Similarly, developing an intervention for patients with IBD that supports self-efficacy for managing their symptoms and disease, e.g., with peer support or problem-solving skills training, could support IBD self-management and reduce the impact of IBD.
As part of our survey study, we assessed the original factor structure of the IBD-SES instrument developed by Keefer et al with our IBD patient sample (26). Although a previous confirmatory factor analysis by Graff et al supported the original 4-factor model with a Canadian IBD cohort, our confirmatory factor analysis did not support this 4-factor model (27). Furthermore, Graff et al proposed that self-efficacy for coping with IBD in remission may be similar to self-efficacy for coping with IBD during clinically active disease, and that moving items from the maintaining remission subscale to other subscales may improve the overall model fit. Both our alternative 4- and 3-factor models demonstrated high internal reliability and support the idea proposed by Graff et al that self-efficacy and coping behaviors in IBD may be similar both during remission and active disease periods (27). However, the more descriptive nature of the 4-factor model, as well as the findings from Graff et al and Keefer et al supporting the 4-factor structure, suggests that the 4-factor model may be superior to the proposed 3-factor model (26,27). Ultimately, further work needs to be performed to deploy screening tools such as the IBD-SES into clinical practice as a step toward identifying patients with low self-efficacy who could benefit from self-efficacy targeted self-management interventions.
Our study findings should be considered in context of its inherent limitations. As with all survey studies, there is the potential for selection bias. Therefore, our findings may not be generalizable to all patients, particularly those who were not likely to complete the survey; however, study responders are likely representative of the cohort for which the IBD-SES was originally developed. Second, our analysis was limited to a single-center cohort compromised of mostly white (92.6%) participants. Although black patients reported lower IBD-SES scores than white patients, our study sample was not powered to detect statistically significant racial differences in IBD-SES. With research indicating racial differences in patient beliefs, preferences, and self-management, there is a critical need for examining IBD self-efficacy in more diverse populations (43). Therefore, understanding racial and ethnic differences in self-efficacy will be an important aspect of future efforts to improve self-management and health outcomes for all patients. Finally, our analytic findings do not demonstrate a causal relationship between self-efficacy and patient outcomes. Although we accounted for potential confounders, it is possible we incompletely controlled for certain unmeasured variables. For example, no formal validated or consensus definitions of mild, moderate, or severe IBD currently exist. Our definition of moderate-to-severe disease is based on previous and current medication use, which is specific but not sensitive for moderate-to-severe IBD. Although causal inferences cannot be drawn, our findings support future prospective interventional studies, where the indirect and direct effects of self-efficacy on IBD outcomes can be better elucidated.
In conclusion, these analyses indicate that higher self-efficacy is associated with a lower impact of IBD on patients. This is particularly true for self-management behaviors such as managing stress and emotions and managing symptoms and disease—2 domains with which patients with IBD report the lowest self-efficacy. According to Bandura's theory, self-efficacy is a modifiable factor influenced by previous mastery experiences through which they develop beliefs about expected outcomes and particular skills; vicarious experience by watching others succeed or fail; social persuasion manifesting as direct encouragement from a desirable individual; and emotional arousal in response to a task (18). Guided by theory, future interventions should target one or more of these elements through activities such as goal setting, symptom monitoring, positive feedback, and social support to increase self-efficacy for patients with IBD to ultimately support patients in self-management and reduce the impact of IBD on patients' daily life.
CONFLICTS OF INTEREST
Guarantor of the article: Shirley Cohen-Mekelburg, MD, MS.
Specific author contributions: S.K., J.M., J.P., K.R., and S.C.-M.: conceptualization. J.S. and S.C.-M.: data curation and writing—original draft. J.S., K.R., and S.C.-M.: formal analysis. J.S., P.H., and S.C.-M.: supervision. All authors: investigation, methodology, critical revisions, and final approval.
Financial support: This research was supported by Clinical and Translational Science Award UL1TR002240 through the Michigan Institute for Clinical and Health Research from the National Institutes of Health. SCM is supported by KL2TR002241 through the Michigan Institute for Clinical and Health Research from the National Institutes of Health. P.D.R.H. is supported by R01 DK125687, R01 DK118154, R01 DK109032, and T32 DK062708 through the National Institutes of Health. J.P. and S.K. are Research Career Scientists from the US Department of Veterans Affairs. J.L.M. is support by NIAAA K23 023666. J.L.S. is supported by T32DK062708-20.
Potential competing interests: None to report.
Study Highlights.
WHAT IS KNOWN
✓ For people with chronic illnesses, self-efficacy, i.e., one's confidence to perform a behavior, is important to performing self-management tasks, such as taking medication as prescribed or engaging in treatment and diagnostic choices.
✓ The role of self-efficacy in inflammatory bowel disease (IBD) is not well understood.
WHAT IS NEW HERE
✓ Patients with IBD report low confidence in managing stress and disease-related symptoms.
✓ Higher self-efficacy is associated with lower impact of IBD on daily life.
Supplementary Material
Footnotes
SUPPLEMENTARY MATERIAL accompanies this paper at http://links.lww.com/CTG/A924.
Contributor Information
Jessica L. Sheehan, Email: jesheeha@med.umich.edu.
LaVana Greene-Higgs, Email: lvgreene@med.umich.edu.
Linnea Swanson, Email: linneasw@med.umich.edu.
Peter D.R. Higgins, Email: phiggins@med.umich.edu.
Sarah L. Krein, Email: sarah.krein@va.gov.
Akbar K. Waljee, Email: awaljee@med.umich.edu.
Sameer D. Saini, Email: sdsaini@med.umich.edu.
Jeffrey A. Berinstein, Email: jberinst@med.umich.edu.
Jessica L. Mellinger, Email: jmelling@med.umich.edu.
John D. Piette, Email: jpiette@umich.edu.
Ken Resnicow, Email: kresnic@umich.edu.
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