self-efficacy and self-management behaviors in patients with chronic kidney disease

WILDCARD

Self-Efficacy and Self-Management Behaviorsin Patients With Chronic Kidney DiseaseRoberta Braun Curtin, Brian A. J. Walters, Dorian Schatell,Philip Pennell, Meg Wise, and Kristi Klicko

Although past research has examined self-management among patients with end-stage renal disease

(ESRD), little is known about self-management in patients with chronic kidney disease (CKD). In this

cross-sectional survey (no intervention), 174 patients with CKD (serum creatinine $1.7 mg/dL) com-

pleted self-reported measures of self-efficacy, physical and mental functioning, and self-management.

The purpose of the study was to explore the association between patients’ perceived self-efficacy and

their self-management behaviors. Five types of self-management behaviors were measured: commu-

nication with caregivers, partnership in care, self-care, self-advocacy, and medication adherence. Con-

trolling for other relevant variables including age, education, diabetic status, hypertension, serum

creatinine, physical functioning, and mental health functioning, higher perceived self-efficacy scores

were associated with increased communication, partnership, self-care, and medication-adherence be-

haviors. In this study, patients’ perceived self-efficacy was a more consistent correlate of self-manage-

ment behavior than were demographic or health characteristics. Because self-management has been

associated with positive patient outcomes, fostering self-management by supporting patient self-effi-

cacy may have long-term benefits.

Q 2008 by the National Kidney Foundation, Inc.

Index Words: Self-management; Self-efficacy; Self-care; Self-advocacy; Medication adherence; Chronic

kidney disease

As the number of chronically ill individualscontinues to grow, it becomes increas-

ingly difficult for the existing health care sys-tem to adequately address their many anddiverse needs. By definition, chronic diseaserequires ‘‘chronic’’ care, and thus for feasibil-ity, logistical, and financial reasons, manyhave come to believe that a substantial propor-tion of such care must be carried out by pa-tients themselves.1,2 However, practicality isonly one of the arguments in favor of self-man-agement; even more compelling is the fact thatpatient self-management is associated witha range of positive patient outcomes.3,4

End-stage renal disease (ESRD) is a chronicdisease that requires a great deal of self-man-agement. Past research provides insights intohow ESRD patients treated with peritonealdialysis and hemodialysis (HD) carry outself-management activities in day-to-day liv-ing. Based on dialysis patients own accounts,5 interdependent dimensions of self-manage-ment of health care have been identified: (1)communication, (2) partnership in care, (3)self-care activities, (4) self-advocacy, and (5)medication and/or treatment adherence.5,6

The first of these dimensions, communica-tion, is essential because disease self-manage-ment is neither safe nor feasible unless

Advances in Chronic Kidney Disease, V

patients provide their clinicians with informa-tion about their symptoms, ask questions thatpromote independent problem solving, andreceive relevant information and guidancefrom their clinicians in return.2,7,8

Partnership in care is also crucial to self-management. It is interdependent with thecommunication dimension of self-manage-ment because true partnership with the healthcare team is only possible when patientsare able to effectively communicate withthem.6,8,9 Successful partnership includes be-haviors related to patients’ pursuit of im-proved communication with clinicians aswell as independent and proactive informa-tion seeking from sources other than theclinicians, such as articles, books, or healthwebsites.

From Medical Education Institute Inc., Madison, WI; Uni-

versity of Miami, Miami, FL; and Center for Health Systems Re-search and Analysis, University of Wisconsin, Madison, WI.

Supported by an unrestricted educational grant by Amgen

Inc. for the Life Options Rehabilitation Program.

Address correspondence to Kristi Klicko, CHES, MedicalEducation Institute, 414 D’Onofrio Drive, Suite 200, Madison,

WI 53719. E-mail: [email protected]

� 2008 by the National Kidney Foundation, Inc.1548-5595/08/1502-0016$34.00/0

doi:10.1053/j.ackd.2008.01.006

ol 15, No 2 (April), 2008: pp 191-205 191

mailto:[email protected]

Curtin et al192

Self-care is the ‘‘action’’ dimension of self-management and is based on the premisethat the best outcomes of health care resultwhen patients are actively involved in theirown care.10 Self-care entails performing someaspects of physical care and also includessuch behaviors as tracking treatment progress,monitoring symptoms and side effects, andpursuing positive wellness-related behaviorssuch as a healthy diet and regular exercise.

Self-advocacy in self-management repre-sents patients’ willingness to act positively intheir own self-interest, to make decisions forthemselves, to negotiate with health care pro-fessionals, and to exercise control over theirown care and treatment.11,12 Examples ofself-advocacy behaviors include seeking sec-ond opinions, changing doctors, offering sug-gestions regarding care and treatment, andusing treatments other than or in addition towhat is suggested by the physician.5,13

The final component of self-management ismedication/treatment adherence. In mostcases, medications constitute a critical part ofcare, and clinicians must rely on patients totake medications as prescribed. The interde-pendence of the various dimensions of self-management becomes clear in the context ofthe adherence component. That is, if commu-nication is effective and a working partnershipis present, there should be, in turn, a greaterlikelihood of adherence.7,14

There is growing evidence in the literaturethat self-management activities can contributeto a range of positive health outcomes.3,4,15,16

Recent qualitative research has linked ESRDpatients’ self-management behaviors to theiroverall functioning and well-being.5,6 Func-tioning and well-being, in turn, independentlypredict morbidity and mortality in this popu-lation.17-20 The value and effectiveness of self-management has been verified in other patientpopulations as well.21 Self-management sup-port is associated with improved outcomessuch as glycemic control and improved A1Clevels in diabetic patients22 and with reduc-tions in nighttime symptoms, hospitalizations,and emergency room visits among patientswith asthma.23 Moreover, the Institute ofMedicine’s inclusion of the topic of patientself-management in their 2003 report bearstestimony to the fact that patient self-manage-

ment plays a key role in today’s health carelandscape.24

Although research is ongoing regardingself-management behaviors among patientswith ESRD, little is known about self-manage-ment among patients with chronic kidneydisease (CKD). Because patients with earlyand largely asymptomatic CKD may nothave yet been identified as individuals inneed of much specific treatment, educationalintervention, or self-management of theirhealth, this population is not easily amenableto study. However, because CKD is a chronicdisease that requires self-management in itsown right and because its effective manage-ment has the potential to delay the onset ofESRD, questions arise regarding what typesof self-management such patients might prac-tice and what factors might be associated withtheir self-management behaviors. Variablesconsidered as likely correlates of self-manage-ment behavior in other patient populationsinclude demographic characteristics such asage, sex, race, and education and health-relatedcharacteristics such as mental health function-ing and physical functioning.25

Perceived self-efficacy is a proven correlateof self-management in other diagnoses andbears further investigation in the CKD popu-lation. In general, perceived self-efficacy hasbeen conceptualized as the degree to whichpatients have confidence in their ability to dowhat needs to be done in order to achievethe outcomes they are seeking.26,27 Past re-search has shown a relationship betweenself-efficacy and self-management.25 More-over, increased self-efficacy has been shownto be associated with positive changes inhealth care behaviors as well as in health sta-tus.15,16 There is evidence that increased self-efficacy is associated with improved controlof interdialytic weight gain among HD pa-tients28 and decreased hospitalizations, de-creased amputations, and improved qualityof life in diabetic dialysis patients.4,29 Basedon past research and in light of these consider-ations, the primary goals of this study were to(1) observe the types of self-management be-haviors performed by the 174 CKD patientssurveyed and (2) to describe the associationbetween CKD patients’ perceived self-efficacyand the 5 categories of self-management

Self-Efficacy and Self-Management Behaviors in CKD Patients 193

behavior described in past research, control-ling for relevant demographic and health-re-lated factors. It was hypothesized that CKDpatients’ perceived self-efficacy would be pos-itively associated with the 5 categories of self-management behavior discussed earlier.

Methods

Sample

This study was conducted through collabora-tion between the Life Options RehabilitationProgram, the Division of Nephrology and Hy-pertension at the University of Miami, and theMedical College of Virginia, Chronic KidneyDisease Clinic. The Life Options Rehabilita-tion Program was founded in 1993 to investi-gate methods for improving rehabilitation(broadly defined as optimal functioning andwell-being) among kidney patients.30 Afterprivate institutional review board approvalwas obtained, the 2 treatment locations thathad access to CKD patients with elevated se-rum creatinine levels who had not yet begunkidney replacement therapy began recruit-ment. A small monetary honorarium sug-gested for use in their patient programs wasoffered to the recruitment sites. To be eligible,patients were required to have a serum creat-inine level of at least 1.5 mg/dL; be at least18 years old; able to understand, read, andwrite in English; able to provide informedconsent; and physically able to independentlycomplete a written survey. Patients wereasked to participate as they appeared at thetreatment center for care. Every patient meet-ing the study criteria was invited to partici-pate. A small monetary honorarium was alsooffered to patients who completed and re-turned the survey materials. Of the 130 eligi-ble patients at the larger recruitment site, 6patients refused participation, reporting thatthey were too ill, lacked the time or interest,or had privacy concerns despite assurancesof confidentiality. After providing informedconsent and agreeing to participate, another23 patients at this site failed to return their sur-veys. A total of 101 patients from this site ulti-mately completed and returned surveys. Atthe second recruitment site, 85 patients wereasked and only 2 patients refused; one citing

medical privacy issues and the other citinglack of time and interest. However, 10 otherpatients who initially agreed to participatedid not return completed surveys. Betweenthe 2 sites then, 215 patients were asked to par-ticipate and 41 refused or did not return sur-veys, resulting in a sample of 174 patientswith CKD and an overall response rate of 81%.

Measures

The survey items devised to measure self-management in this study were based onfindings from an earlier qualitative study ofself-management among a small sample ofHD patients13 and a follow-up quantitativestudy of self-management among 372 HD pa-tients.31 These past studies suggested a rangeof discreet self-management behaviors aswell as 5 broad categories of behaviors, whichhave been previously described.

To measure the categories of self-manage-ment targeted, 44 items were devised. Theseitems were pretested with a convenience sam-ple of 10 patients in a CKD clinic. Pretest feed-back from these patients suggested that theitems were well understood, the length of thesurvey was not problematic, the items werenot ‘‘uncomfortable,’’ and the topic of self-man-agement was adequately covered. Based on thepretest, no significant changes were made tothe survey items before use in the larger study.The self-management items included in the fi-nal version of the survey are listed in Table 1.

Of major interest in this investigation wasthe concept of perceived self-efficacy. To mea-sure perceived self-efficacy in this study, thePerceived Efficacy in Patient-Physician Inter-action Questionnaire (PEPPI) was used.32 Inprevious research, the 5-item PEPPI shortform has shown excellent reliability as wellas good discriminant and convergent valid-ity.32,33 In addition to the PEPPI short form, 7additional de novo self-efficacy items wereadded to the survey. Because perceived self-efficacy can be conceived as patients’ beliefin their own ability to perform the behaviorsnecessary to achieve desired health outcomes,these additional items were designed tospecifically query respondents’ confidenceregarding their capacity to execute keyself-management behaviors.6 The PEPPI short-form items and the additional self-efficacy

Curtin et al194

Table 1. Self-Management Items

Self-Management Indices and Items

During the past 6 months, how often have you kept track of:

Blood glucose (sugar) levels

Appointments with your doctor

Blood pressure

Thoughts and feelings about your health

Laboratory results related to how your kidneys are working

Symptoms of heath condition

Side effects of treatments

How often (past 6 months) have your symptoms influenced you to:

Rearrange your daily schedule

Increase or decrease your physical activities*

Adjust your food intake or food choices*

How often (past 6 months) have you done the following health-related activities:

Arranged your schedule to have more time to rest or sleep*

Chosen healthier foods to eat

Allowed time in your day for an enjoyable activity

Taken time to unwind and feel better

Exercised or stretched for 20 minutes or more

Avoided talking with those with negative attitudes re: kidney disease/treatment

Taken medications as prescribed by your doctor

How often (past 6 months) have you talked with your doctor re:

A treatment or medication that might be useful for you

A medication that was not working the way you thought it should be

An adjustment you made on your own with your medication

How often (past 6 months) did you look for info re: kidney problems/treatments by:

Talking with your friends or family

Talking with your pharmacist

Talking with your doctor

Asking your doctor for more information

Asking for copies of laboratory values

Asking about something you read re: disease/health/medication/treatment

Reading books/magazines/websites re: disease/health/medication/treatment

Attending an educational class

Searching for a way to treat a problem, symptom, or side effect

Going to another doctor for a second opinion

Writing questions down before seeing the doctor

During the past 6 months how often have you asked your doctor:

To explain the medical terms in words you could understand

For a change in your treatment

How often (past 6 months) have you spoken to your doctor because you:

Thought the doctor was doing something wrong

Believed you were given the wrong treatment

Wanted to get better care

Have you ever:

Reported concerns to a higher authority

Changed doctors because things were not done as you thought they should be

Contacted state or federal representatives re: health care provision or coverage*

In the past 6 months, how often have you:

Taken medication in different ways than it was prescribed*

Not taken a prescribed medication*

Used others’ prescriptions without the knowledge of your doctor/care providers*

Taken herbs, nonprescribed vitamins, or other natural remedies

Used additional treatments other than what your doctor prescribed

(Continued )


Table 1. Self-Management Items (Continued )

Perceived Self-Efficacy Measures

Perceived Efficacy in Patient-Physician Interactions: Short Form (PEPPI)

How confident are you in your ability to:

Know what questions to ask a doctor

Get a doctor to answer all of your questions

Make the most of your visit with a doctor

Get a doctor to take your chief concerns seriously

Get a doctor to do something about your chief health concerns

Perceived Self-Efficacy Items


Make decisions about what is best for your health

Search for ways to treat a symptom or side effect

Make decisions about your treatment

Learn what kidneys do

Learn about kidney treatments

Manage your kidney treatments

Adjust your activities to improve you health

*Excluded from further analysis.

questions included in the survey are alsolisted in Table 1.

Patients’ functioning and well-being weremeasured using the Medical Outcomes Study36-Item Short Form Health Survey question-naire, which measures 8 health and functioningdomains and includes 2 summary scales: thePhysical Component Summary (PCS) Scaleand the Mental Component Summary (MCS)Scale.34 PCS and MCS scales are standardizedto have a mean of 50 and a standard deviationof 10 in the normal US population. Low scoresgenerally indicate considerable limitation inthe ability to perform activities of daily living.PCS and MCS scales have now been used witha range of patient populations, includingESRD patients on dialysis, and consistent scoreshave been reported.17,18,35 In addition to thesemeasures, basic demographic and clinicaland/or health-related data, including selectedlaboratory values, were collected for all partici-pating patients.

Analyses

Statistical analyses were conducted by usingthe Statistical Package for the Social Sciences(SPSS Inc, Chicago, IL) version 10.0, 1999. Asa first step, self-management questionnaireitems were grouped according to the 5hypothesized self-management behaviorcategories: communication with caregivers,partnership in care, self-care activities, self-advocacy, and medication adherence. In the

4 multi-item categories (communication withcaregivers, partnership in care, self-care activ-ities, and self-advocacy), item to total correla-tions were used to estimate the degree towhich the grouped ‘‘sets’’ of items measureda single domain. Items within each categorythat caused that category’s overall alpha reli-ability (Cronbach a) to decrease appreciablywere deleted from the category. Seven of the44 original items were accordingly droppedfrom further analyses. The items dropped areindicated in Table 1. Thirty-seven items wereretained to measure the 5 categories of self-management behaviors as follows: communi-cation with caregivers (8 items), partnershipin care (7 items), self-care activities (11 items),self-advocacy (10 items), and medication ad-herence (1 item). The specific items that wereincluded in each category of self-managementbehaviors are shown in Table 2.

In a similar analysis, the 5 items of thePEPPI short form and the 7 de novo self-effi-cacy items were combined into a single index.Item to total correlations indicated that the 12items measured a single dimension; all 12items were retained in this self-efficacy indexfor further analysis. Cronbach a was used toestimate the reliability of the 4 multi-item cat-egories of self-management behaviors and ofthe self-efficacy index.36,37

In the next step of analysis, summary anddescriptive statistics, including frequencies,means, and standard deviations, were obtained

Curtin et al196

Table 2. Self-Management Behavior Indices: Items and Alpha Reliabilities

a

Communication index

1. Kept track of thoughts and feelings .77

2. Talked to doctor about potential treatments or medications

3. Talked to doctor about medications that were ‘‘not working’’

4. Talked to doctor about adjustments you made to medications

5. Talked to pharmacist to obtain information

6. Talked to doctor to get information

7. Talked to doctor for additional information

8. Asked doctor to explain medical terms

Partnership in care .84

1. Looked for information by talking with family and friends

2. Asked for copies of laboratory value results

3. Asked questions about something re: disease that you read

4. Read books, Internet, magazines for information re: health disease

medications or treatment

5. Attended a class to obtain information

6. Searched for a way to treat a problem, symptom, or side effect

7. Wrote questions down before seeing the doctor

Self-efficacy .92


1. Know what questions to ask a doctor PEPPI items 1–5

2. Get a doctor to answer all of your questions

3. Make the most of your visit with the doctor

4. Get a doctor to take your chief health concerns seriously

5. Get a doctor to do something about your chief health concern

6. Make decision about what is best for your health

7. Search for ways to treat a symptom or side effect

8. Learn what kidneys do

9. Learn about kidney treatments De Novo items 7–12

10. Manage your kidney problems

11. Adjust your activities to improve your health

12. Adjust your food intake to improve your health

Self-care index .77

1. Kept track of glucose

2. Kept tract of appointments

3. Kept track of blood pressure

4. Kept track of laboratory results

5. Kept track of symptoms

6. Kept track of side effects

7. Arranged your schedule to allow time for rest/sleep

8. Chose healthier food to eat

9. Allow time for enjoyable activity in a day

10. Took time out to unwind and feel better

11. Exercised or stretched for 20 minutes or more

Self-advocacy index .70

1. Avoided talking to people with negative attitudes

2. Sought second opinion

3. Asked doctor for change in treatment

4. Spoke up because you thought doctor was doing something wrong

5. Spoke up because you thought you were receiving wrong treatment

6. Spoke up because you wanted better care

7. Reported concerns to higher authority

8. Changed doctors to get better care

9. Took herbs, nonprescription vitamins, or natural remedies

10. Used additional treatments besides what doctor suggested

Adherence

1. How often in the past 6 months have you taken your medications as

prescribed by your doctor?

Abbreviation: PEPPI, Perceived Efficacy in Patient-Physician Interaction Questionnaire.


Table 3. Patient Demographic and Health Characteristics (N ¼ 174) Compared With US Renal Data System

Study Sample (N ¼ 174) US Incident ESRD*,†

Age in years, mean (SD) 50.89 (13.57) 62.7 (NA)

Male 42.0% 53.8%

White 12.1% 64.4%

Black 64.4% 28.7%

.High school education 37.3% —

Diabetes 46.6% 44.6%

Hypertension 92.0% 78.4%

Serum creatinine, mean (SD) 4.57 (2.31) 7.3

Hematocrit, mean (SD) 33.5 (6.93) 29.7 (NA)

MCS, mean (SD) 43.9 (10.97) 50.0 (10.3)†

PCS, mean (SD) 35.16 (1.21) 37.3 (11.6) †

Abbreviations: SD, standard deviation; NA, not applicable; MCS, Mental Component Summary; PCS, Physical Com-ponent Summary.*From U.S. Renal Data System 2003.38

†From Perlman et al, 2005.39

for the patient demographic variables, clinicalvariables, MCS, PCS, the adherence item, theself-efficacy index, and the self-managementbehavior indices. Next, Pearson correlationcoefficients were used to assess the relation-ships among the demographic and clinical vari-ables, the PCS and MCS scores, the single-itemcompliance measure, the self-efficacy index,and the 4 self-management behavior indices.Finally, multiple regression was used to explorethe significant relationships between the PCSand MCS scores and self-efficacy index andthe 5 self-management behavior indices,controlling for relevant patient characteristicsincluding age, education, diabetes, hyperten-sion, and serum creatinine.

Results

Patient Demographic and ClinicalCharacteristics

As shown in Table 3, the mean age of the 174patients with CKD participating in this studywas 50.9 years, 42.0% of participants weremale, 12.1% were white, 64.4% were black,and 37.3% reported more than high school ed-ucation. Furthermore, 46.6% reported diabe-tes, 92% reported hypertension, participants’mean hematocrit was 33.5% (66.93), andmean serum creatinine was 4.57 mg/dL(62.31). The sample of patients enlisted forthis study differed from the United States Re-nal Data System reported national populationof incident ESRD patients (who, theoretically,should be most comparable) in that participat-

ing patients were markedly younger than inci-dent ESRD patients, a higher percentage ofblack patients participated in the study thanare present in the incident population ofESRD patients, and fewer whites participatedthan are present in the incident sample ofESRD patients.38 Furthermore, more hyper-tension was reported by the study participantsthan is present among the national populationof incident ESRD patients. The mean PCSscore for respondents was 35.2 6 11.22 andthe mean MCS score was 43.9 6 10.97 com-pared with 37.7 6 1.6 and 40.6 6 2.0 in a simi-lar CKD population in a recent study.40

Self-Report Measures

Items included in each index used in the studyand the internal reliability score for the 4 self-management behavior indices and self-efficacy index are shown in Table 2. Reliabilitycoefficients (alpha) ranged from .70 to .84 forthe self-management behavior indices and.92 for the 12 self-efficacy items. In general, re-liability coefficients greater than or equal to .70are considered more than adequate.36

Table 4 indicates the numbers of items perindex, the mean index scores, the mean scoreper item, and the range of index scores (possi-ble and actual). Items in the self-managementbehavior indices were coded as follows: 1 ¼never, 2 ¼ a few times, 3 ¼ a lot of the time,and 4 ¼ all the time. The self-efficacy indexitems were coded according to a 1 through 5Likert Scale where which 1 ¼ not at all confi-dent and 5 ¼ very confident.

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Table 4. Self-Management and Self-Efficacy Indices: Summary

Indices Items

Index Mean

Score (SD) Item Mean Score Possible Range Actual Range

Communication* 8 18.83 (4.89) 2.35 8–32 8–31

Partnership* 7 13.46 (4.88) 1.92 7–28 7–28

Self-care* 11 30.07 (5.89) 2.73 11–44 13–43

Self-advocacy* 10 14.57 (4.22) 1.45 10–40 10–36

Adherence* 1 3.64 (.805) 3.64 1–4 1–4

Self-efficacy† 12 48.66 (10.79) 4.05 12–60 12–60

*Items coded as 1 ¼ never, 2 ¼ a few times, 3 ¼ a lot of the time, and 4 ¼ all the time.†Items coded as 1 ¼ not at all confident to 5 ¼ very confident.

Self-Management Behaviors andPerceived Self-Efficacy

Among the self-management behaviors, theglobal medication adherence item had thehighest item mean score (3.64), indicatingthat most participants reported taking theirmedications as prescribed most of the time.Self-care was the category of behavior re-ported as most frequently performed with anitem mean of 2.73. Least often performedwere self-advocacy behaviors (1.45) followedby partnership behaviors (1.92). Also shownin Table 4 are the mean index score and rangeof possible and actual scores for the self-effi-cacy index. As can be seen, patients reportedhigh levels of self-efficacy; the mean itemscore was 4.05 on a 1 though 5 scale.

Self-Management and Self-Efficacy:Correlations With Patients’ Demographicand Clinical Characteristics

The correlations among the self-managementbehavior indices, the self-efficacy measure,

and patients’ demographic and clinical char-acteristics are shown in Table 5. Significantcorrelations were noted between the commu-nication behavior index and the health-relatedcharacteristics of diabetic status, serum creati-nine level, MCS, PCS, and self-reported self-efficacy. The partnership behavior index wassignificantly correlated with only 2 of the in-dependent variables (i.e., patient educationand self-reported self-efficacy), whereas theself-care behavior index was correlated withthe following patient characteristics: age andeducation, the health characteristics diabeticstatus, hypertension, and serum creatininelevel, and PCS and self-reported self-efficacy.Self-advocacy behavior was significantly asso-ciated with only MCS, whereas the adherenceitem was associated with the health-relatedcharacteristics of diabetic status, hypertension,serum creatinine, PCS, and self-reported self-efficacy. Because patient age, education, dia-betic status, hypertension, serum creatininelevel, MCS, PCS, and perceived self-efficacy

Table 5. Correlations: Self-Management Behaviors Indices, Relevant Demographics, Health Characteristics,

and Self-Efficacy Index

Communication Partnership Self-Care Self-Advocacy Adherence

r (P) r (P) r (P) r (P) r (P)

Age — — .156 (.035) — —

Sex — — — — —

Race — — — — —

Education — .158 (.021) .165 (.027) — —

Diabetes .158 (.021) — .222 (.004) — .137 (.036)

Htn — — .209 (.007) — .159 (.019)

Scr 2.138 (.038) — 2.165 (.028) — 2.202 (.004)

Hct — — — — —

MCS 2.171 (.016) — — 2.253 (.001) —

PCS 2.133 (.048) — 2.253 (.002) — 2.239 (.001)

Self-efficacy .292 (.000) .295 (.000) .274 (.001) — .201 (.007)

Abbreviations: Htn, hypertension; Scr, serum creatinine; Hct, hematocrit; MCS, Mental Component Summary; PCS, Phys-ical Component Summary.


were each significantly associated with 1 ormore of the self-management behavior indices,they were retained for further analysis.

Self-Efficacy: Associations With Self-Management Behaviors Controlling forPatients’ Demographic and ClinicalCharacteristics

The results of the regression of self-efficacy oneach of the self-management behavior scales,controlling for the demographic and health-related variables that were retained for furtheranalysis, are shown in Tables 6 through 10. Asseen in Table 6, diabetic status and self-effi-cacy were positively associated with commu-nication behavior (P ¼ .037 and P ¼ .000),whereas MCS was negatively associated withit (P ¼ .027). In Table 7, education and self-ef-ficacy were positively associated with thepartnership in care behavior index (P ¼ .036and P ¼ .000). Table 8 shows PCS to be nega-tively associated with self-care behavior (P ¼.038) and self-efficacy to be positively associ-ated with it (P ¼ .013). On the other hand, asseen in Table 9, self-efficacy was not associatedwith the self-advocacy index; only 1 health-related variable, MCS, was negatively associ-ated with this behavior index (P ¼ .001).Finally, in Table 10, serum creatinine leveland PCS were both negatively associatedwith adherence (P ¼ .025 and P ¼ .007), andself-efficacy was positively associated with

Table 6. Multiple Linear Regression: Relevant

Demographic and Health Characteristics and Self-

Efficacy on Communication Behavior Index

Characteristics b SE P

Age 2.025 .028 —

Education 2.801 .256 —

Diabetes 1.530 .729 .037

Htn 21.098 1.491 —

Scr 2.237 .154 —

MCS 2.076 .034 .027

PCS 2.030 .034 —

Self-efficacy .132 .036 .000

R2 ¼ .15 P ¼ .001

NOTE. The b coefficient is the unstandardized regres-sion coefficient. It represents the amount that thedependent variable (communication behavior index)changes as each independent variable increases 1 unitand the other independent variables are held constant.Abbreviations: SE, standard error; Htn, hypertension;Scr, serum creatinine; MCS, Mental Component Sum-mary; PCS, Physical Component Summary.

the adherence item (P ¼ .071). Figure 1 graph-ically depicts the associations between selfperceived self-efficacy and 4 of the 5 self-man-agement behavior categories.

Discussion

There are 2 findings of particular note in thisstudy. The first is that patients with CKD re-ported different levels of engagement in thevarious categories of self-management behav-ior examined. The second is that perceived



Efficacy on Partnership in Care Behavior Index


Age 2.011 .028 —

Education .546 .258 .036

Diabetes .186 .732 —

Htn 22.856 1.499 —

Scr 2.076 .155 —

MCS 2.053 .034 —

PCS 2.036 .034 —


R2 ¼ .13 P ¼ .003

NOTE. The b coefficient is the unstandardized regres-sion coefficient. It represents the amount that the de-pendent variable (partnership in care behavior index)changes as each independent variable increases 1unit and the other independent variables are held con-stant.Abbreviations: SE, standard error; Htn, hypertension;Scr, serum creatinine; MCS, Mental Component Sum-mary; PCS, Physical Component Summary.



Efficacy on the Self-Care Behavior Index


Age .0167 .030 —

Education .489 .276 —

Diabetes 1.435 .784 —

Htn 1.709 1.605 —

Scr 2.230 .166 —

MCS 2.0418 .037 —

PCS 2.0760 .036 .038


R2 ¼ .17 P ¼ .000

NOTE. The b coefficient is the unstandardized regres-sion coefficient. It represents the amount that the de-pendent variable (self-care behavior index) changesas each independent variable increases 1 unit and theother independent variables are held constant.Abbreviations: SE, standard error; Htn, hypertension;Scr, serum creatinine; MCS, Mental Component Sum-mary; PCS, Physical Component Summary.

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self-efficacy was positively associated with 4of the 5 categories of self-management behav-ior, controlling for patient age, education, dia-betic status, hypertension, serum creatininelevel, PCS, and MCS.

The self-management behavior reportedmost frequently was medication adherence.In response to the global adherence item,most patients reported that they took theirmedications as prescribed ‘‘almost all of thetime.’’ Although pill-count measures and elec-



Efficacy on Self-Advocacy on the Self-Advocacy

Behavior Index


Age 2.032 .025 —


Diabetes 1.238 .649 —

Htn 2.891 1.328 —

Scr 2.108 .137 —

MCS 2.103 .030 .001

PCS .012 .030 —

Self-efficacy .032 .032 —

R2 ¼ .10 P ¼ .023

NOTE. The b coefficient is the unstandardized regres-sion coefficient. It represents the amount that the de-pendent variable (self-care behavior index) changesas each independent variable increases 1 unit and theother independent variables are held constant.Abbreviations: SE, standard error; Htn, hypertension;Scr, serum creatinine; MCS, Mental Component Sum-mary; PCS, Physical Component Summary.



Efficacy on Adherence Behavior Measure


Age 2.004 .005 —


Diabetes .122 .123 —

Htn .348 .251 —

Scr 2.058 .026 .025

MCS .004 .006 —

PCS 2.016 .006 .007


R2 ¼ .14 P ¼ .001

NOTE. The b coefficient is the unstandardized regres-sion coefficient. It represents the amount that the de-pendent variable (adherence behavior index) changesas each independent variable increases 1 unit and theother independent variables are held constant.Abbreviations: SE, standard error; Htn, hypertension;Scr, serum creatinine; MCS, Mental Component Sum-mary; PCS, Physical Component Summary.

tronic tracking measures of medication adher-ence would likely challenge these patients’reports, in fact, this finding is consistent withpast adherence research. Research that relieson patient report of medication adherencesuggests that patients routinely overestimatetheir own medication adherence, ‘‘forgetting’’that they failed to take certain doses.41 Addi-tionally, many medications prescribed forCKD patients have no obvious effects nor arethe negative effects of not taking the medica-tions readily apparent to patients. Past re-search has shown that the best predictors ofadherence with prescribed regimen are subjec-tive perception of the conditions’ severity andperceived consequences of nonadherence.42

However, despite the fact that the study pa-tients’ adherence to their medication regimensis probably somewhat less than their estima-tions, their report of a high degree of adher-ence might indicate a willingness andintention to adhere to the regimens and, inturn, suggest a positive intention to self-man-age their disease and its treatment.

Self-care was another category of self-man-agement behavior frequently carried out byparticipants. This category addressed pa-tients’ performance of behaviors such ashealthy eating and exercise as well as theirself-monitoring of ongoing health status. Al-though some of the items included, such astracking doctors’ appointments, are routineactivities of daily living, others such as track-ing laboratory results, blood pressure, andsymptoms are somewhat beyond what theaverage patient might be apt to do. It is partic-ularly interesting that patients even at these

Perceived self-efficacy

Medication adherence(ß=.011, p=.071)

Self-care activities(ß=.096, p=.013)

Partnership behaviors(ß=.130, p=.000)

Communication behaviors(ß=.132, p=.000)

Figure 1. The positive associations between per-ceived self-efficacy and self-management behav-ior categories (controlling for age, education,diabetes, hypertension, serum creatinine, MCS,and PCS). MCS, Mental Component Summary;PCS, Physical Component Summary.


earlier stages of kidney disease are motivatedto perform such self-care activities. However,past research has shown that patients areable and often do evaluate the advantagesand disadvantages of adopting a wide varietyof health care activities.43 Furthermore, otherresearch has shown that CKD patients ex-posed to educational programming were ableto maintain higher serum albumin levels.44

Similarly, CKD patients experiencing an edu-cational intervention were able to postponetheir need for dialysis for 4 to 6 months.45,46

Taken together, these findings not only af-firm that some CKD patients are engagingin appropriate self-care behaviors but sug-gest that despite the difficulties involved inidentifying and reaching early CKD patients,efforts to educate them to self-managementbehaviors of the self-care category mightreap health benefits for them. Moreover, es-tablishing a habit of self-care early in thecourse of progressive kidney disease mightalso have the potential to extend the positivebenefits of educational interventions acrossthe lifetime and disease course of the patient.

Partnership in care, which in the context ofthis study entails actively seeking informationfrom sources outside of caregivers and ac-commodating symptoms and health-relatedschedules, was a category of self-managementbehaviors that was less frequently performed.This finding (i.e., that study participants lessfrequently engaged in active health seeking)is in contrast to a recent study of CKD patientsthat found that 43.5% of CKD patients hadused the Internet (either independently orwith help) to obtain health information.47

The need for independent and active informa-tion acquisition by patients is based on the as-sumption that passive and static informationsources fail to address patients’ particular con-cerns and fail to help them integrate their ill-ness and its treatments into their individuallifestyles.48 Without such integration, self-care and also adherence will likely be nega-tively affected. As was the case regardingadherence among this population of patients,an explanation for the fact that the partnershipactivities included in this category of self-management were less commonly practicedmight be that patients do not yet perceivea need for some of the specific behaviors at

this relatively early point in their diseasecourse.41,49 Additionally, some of the behav-iors included, such as reading books or search-ing the Internet for information about thedisease and its treatment, would seem torequire a degree of independent thinking,self-motivation, and even health-relatedknowledge and/or ‘‘sophistication’’ for whichpatients may require specific training and en-couragement.2,50 It is clear that many patientswill never be interested in or capable of a highlevel of partnership as it is conceptualizedhere. However, some level of active participa-tion might be possible for all with the right en-couragement and support. It is unlikely thatsuch education, support, and encouragementhave been provided for these patients at thispoint in their disease course. Past researchhas shown that self-management can betaught and supported and that patient educa-tion can improve physical health.15,16,45 Thatthis important category of self-managementbehaviors was less frequently reported by pa-tients in this study underscores the idea thatfocused educational and motivational pro-grams geared to teaching self-managementstrategies and behaviors might be beneficialfor individuals with CKD.

The self-advocacy category of self-manage-ment that included such behaviors as seekinga second opinion, asking the doctor fora change in treatment, or changing doctorswas the least performed category of self-man-agement behaviors. Past research has sug-gested that successful self-managers aremotivated to act positively in their own bestinterests, to make their own assessments anddecisions, to negotiate with health care profes-sionals, and to have control over many aspectsof their own care and treatment.11,12 Further-more, past research with hemodialysispatients has identified this type of active self-advocacy as a strategy for self-management.13

However, this style of self-management isapparently less frequently carried out bypatients with CKD. Previous research has ver-ified that although confrontational copingstyles are often preferred by patients on dialy-sis, predialysis patients engage in this styleless frequently.51 This may be because ESRDpatients treated with HD are a great dealsicker and have a great deal more interaction

Curtin et al202

with and dependency on the health care sys-tem. These conditions may put them at riskfor greater numbers of patient-perceived‘‘problems’’ with their health care provision.Recent qualitative research has identifiedavoidance behaviors such as changing doctorsor avoiding medical care and advocacy behav-iors such as getting a second opinion, speak-ing up for oneself, or becoming a policyadvocate as patient responses to perceivedpreventable problems with their health careprovision.52 Such problems included primar-ily administrative and communication prob-lems but ranged from excessive waiting timefor appointments to actual misdiagnoses.CKD patients may not yet have ‘‘tested’’ thehealth care system or their specific healthcare providers and so may at this point feelno need to adopt the kinds of proactive behav-iors included in the self-advocacy category ofself-management.

Physical and mental health functioning areimportant concepts in the self-managementconstruct. In this analysis, PCS and MCS wereregarded as independent variables, broad mea-sures of health status that have been shown inpast research to be sensitive to changes in pa-tients’ well-being that may not have yet beenreflected in laboratory values and/or clinicalobservations.53 The significant relationshipsthat were present between these measures offunctional status and the 5 self-managementcategories were negative in every case (i.e., asPCS scores decreased, self-care and adherencebehaviors increased, and, as MCS scores de-creased, communication and self-advocacy be-haviors increased). The findings regarding PCSand the self-management behaviors might beinterpreted from a common sense perspective.As discussed, nonadherence is more likelywhen the need for the medication regimen isnot obvious to patients.41,42 However, as phys-ical functioning (PCS) becomes increasinglycompromised, the need for adherence to medi-cation regimens is obviated and patients thusreport more consistent adherence. Similarly,as PCS decreases, the need for self-care behav-iors of the types included in the self-care cate-gory of self-management become increasinglynecessary. Past research has found that percep-tions of illness and vulnerability to conse-quences were also significantly related to

measures of therapeutic self-care.54 In thisstudy as well then, it is likely the case that pa-tients reported more self-care behavior in directresponse to this increasing need.

The findings with regard to mental healthfunctioning might be similarly explained. Asmental health functioning (MCS) decreasesor because of declining mental health func-tioning, patients may find some aspects oftheir care somewhat less satisfying and/ormore ‘‘problematic.’’ As discussed earlier,such feelings might lead to more communica-tion behaviors, including the initiation of sub-stantive conversational exchanges with keycaregivers and increased self-advocacy behav-ior such as changing doctors, seeking a secondopinion, or speaking up on their own be-half.13,51 The cross-sectional nature of thesedata prevents the explicit specification ofcausal direction. It might be the case that in-creased communication of certain types andself-advocacy behaviors cause mental healthfunctioning to decrease. This is an interestingquestion in itself, but its answer lies beyondthe scope of the present observational study.

It was hypothesized at the outset that CKDpatients’ perceived self-efficacy would bepositively associated with 5 categories ofself-management behavior: communicationwith caregivers, partnership in care, self-care,self-advocacy, and medication adherence.The results supported the proposed hypothe-ses in all but 1 instance. Perceived self-efficacywas positively associated with 4 of the 5 cate-gories of self-management examined, control-ling for relevant patient demographic andclinical characteristics; it was not associatedwith the self-advocacy category, the categoryleast practiced by and relevant to patientswith CKD. In this study then, as has beenthe case in past research, patients’ perceivedself-efficacy was a more consistent correlateof self-management behavior than were eitherdemographic or health characteristics.

That there is a relationship between self-efficacy and self-management and, in turn,between self-management and positive heathoutcomes in various populations of chroni-cally ill individuals has been well establishedin recent research.1,55 What has been lesswell known to date has to do with self-man-agement in general among individuals with


CKD and specifically with what types of self-management seem to be most significantlyassociated with CKD patients’ perceivedself-efficacy. In this study of CKD patients,self-efficacy was positively associated withcommunication behaviors, conceived as initi-ating substantive conversational exchangeswith key caregivers, and partnership behav-iors operationalized largely as active informa-tion seeking from sources other than primarycaregivers with moderate effect sizes. Self-effi-cacy was also associated in this study withself-care activities and medication adherencewith smaller but statistically significant effectsizes. These findings are consistent with re-search among other populations in whichself-efficacy has been shown to affect commu-nication,55 self-care activities,56 and medica-tion adherence.56 Scant research regardingthe association between self-efficacy and part-nership in care (operationalized as health-related information seeking) is available. Onerecent study suggested an association be-tween cancer patients’ low information-seek-ing self-efficacy and difficulty interactingwith physicians.57 Another study found self-efficacy to be a moderator of general informa-tion-seeking effectiveness; however, this studywas conducted in an industrial rather thana health care context.58 Clearly, the relation-ship between self-efficacy and partnership incare behaviors including information seekingis a topic that warrants further considerationin future research.

There are some limitations to this study thatmust be kept in mind when interpreting thesefindings. As mentioned, the cross-sectionalstudy design means that causality cannot beunequivocally determined. Additionally, thesmall sample size limits statistical power todetect association; however, the a priori–hy-pothesized relationship between perceivedself-efficacy and self-management behaviorspersisted in multivariate analysis. Further-more, although efforts to obtain a randomsample were made, the complexity involvedin identifying and reaching patients withCKD made it difficult to obtain a large andtruly random sample of individuals withCKD. Finally, the demographic distributionin the sample derived is somewhat differentfrom the national incident population of

ESRD patients, a population that wouldseem to be the most closely comparable tothe study sample, in that the study patientswere somewhat younger than the incidentpopulation of ESRD patients, a higher percent-age of black patients participated than arepresent in the incident population of ESRD pa-tients, and more hypertension was reportedby study participants than is present amongthe national population of incident ESRD pa-tients.37 These differences were not surprisingbecause the population of patients served in 1of the 2 recruitment sites was generally youn-ger and predominately black.

Given the chronic nature of kidney diseaseand the realities of the health care system,there is no doubt that over time CKD patientswill be required to self-manage many aspectsof their own care. The ability to measure var-ious types of self-management behaviorsamong individuals with CKD is an importantfirst step toward understanding the scopeand nature of their current involvement intheir own care and treatment. Once such anassessment is accomplished, the logical nextstep might be to conceive and design inter-ventions to improve self-management perfor-mance in selected categories. Self-efficacy hasbeen shown to mediate self-management,and it has been definitively shown that self-efficacy can be enhanced through programsthat include elements of training, support,encouragement, positive personal experi-ences, and modeling.1 Fostering self-manage-ment by supporting patient self-efficacy mayhave long-term benefits for individuals withCKD.

Acknowledgment

The authors wish to express their gratitude to Gam-bro Healthcare and Ann Compton of the Universityof Virginia. Without their help and support, thisstudy would not have been possible.

References

1. Marks R, Allegrante JP, Lorig K: A review and synthe-

sis of research evidence for self-efficacy-enhancinginterventions for reducing chronic disability: Implica-tions for health education practice (part I). HealthPromot Pract 6:37-43, 2005

Curtin et al204

2. Bodenheimer T, Lorig K, Holman H, et al: Patient self-

management of chronic disease in primary care.JAMA 288:2469-2475, 2002

3. Lorig KR, Sobel DS, Stewart AL, et al: Evidence suggest-

ing that a chronic disease self-management programcan improve health status while reducing hospitaliza-tion: A randomized trial. Med Care 37:5-14, 1999

4. Meers C, Singer MA, Toffelmire EB, et al: Self-deliv-

ery of hemodialysis care: a therapy in itself. Am J Kid-ney Dis 27:844-847, 1996

5. Curtin RB, Johnson HK, Schatell D: The peritoneal

dialysis experience: insights from long-term patients.Nephrol Nurs J 31:615-624, 2004

6. Curtin RB, Mapes D, Schatell D, et al: Self-manage-

ment in patients with end-stage renal disease: explor-ing domains and dimensions. Nephrol Nurs J 32:389-395, 2005

7. McDonald VM, Gibson PG: Asthma self-management

education. Chron Respir Dis 3:29-37, 20068. Epstein RM, Alper BS, Quill TE: Communicating evi-

dence for participatory decision making. JAMA 291:2359-2366, 2004

9. Clark NM: Management of chronic disease by pa-

tients. Annu Rev Public Health 24:289-313, 200310. Brennan P, Safran C: Report of conference track 3: pa-

tient empowerment. Int J Med Inform 69:301-304,2003

11. Berman RL, Iris MA: Approaches to self-care in late

life. Qual Health Res 8:224-236, 199812. Walsh-Burke K, Marcusen C: Self-advocacy training

for cancer survivors. The Cancer Survival Toolbox.Cancer Pract 7:297-301, 1999

13. Curtin RB, Mapes DL: Health care management strat-

egies of long-term dialysis survivors. Nephrol Nurs J28:385-394, 2001

14. Zrinyi M, Juhasz M, Balla J, et al: Dietary self-efficacy:

Determinant of compliance behaviours and biochem-ical outcomes in haemodialysis patients. Nephrol DialTransplant 18:1869-1873, 2003

15. Lorig K, Holman H: Self-management education: His-

tory, definition, outcomes, and mechanisms. AnnBehav Med 26:1-7, 2003

16. Lorig K, Gonzalez V, Ritter P: Community-based

Spanish language arthritis education program: A ran-domized trial. Med Care 37:957-963, 1999

17. Diaz-Buxo JA, Lowrie EG, Lew NL, et al: Quality-of-

life evaluation using Short Form 36: Comparison inhemodialysis and peritoneal dialysis patients. Am JKidney Dis 35:293-300, 2000

18. Kalantar-Zadeh K, Kopple JD, Block G, et al: Associ-

ation among SF36 quality of life measures and nutri-tion, hospitalization, and mortality in hemodialysis.J Am Soc Nephrol 12:2797-2806, 2001

19. Curtin RB, Mapes D, Petillo M, et al: Long-term dial-

ysis survivors: A transformational experience. QualHealth Res 12:609-624, 2002

20. Lev EL, Owen SV: A prospective study of adjustment

to hemodialysis. J Am Nephrol Nurs Assoc 25:495-504, 1998

21. Coleman MT, Newton KS: Supporting self-manage-

ment in patients with chronic illness. Am Fam Physi-cian 72:1503-1510, 2005

22. Anderson RM, Funnell MM, Butler PM, et al: Patient

empowerment. Results of a randomized controlledtrial. Diabetes Care 18:943-949, 1995

23. Gibson PG, Powell H, Coughlan J, et al: Self-manage-

ment education and regular practitioner review foradults with asthma. Cochrane Database Syst Rev 4:CD001117, 2003

24. Institute of Medicine: Formulating new rules to redesign

and improve care, in Crossing the Quality Chasm: ANew Health System for the 21st Century. Washington,DC, National Academy Press, 2001, pp 61-88

25. Yarcheski A, Mahon NE, Yarcheski TJ, et al: A meta-

analysis of predictors of positive health practices.J Nurs Scholarsh 36:102-108, 2004

26. Bandura A: Self-efficacy: The Exercise of Control.

New York, NY, Freeman, 199727. Bandura A: Social Foundations of Thought and Ac-

tion: A Social Cognitive Theory. Englewood Cliffs,NJ, Prentice-Hall, 1986

28. Tsay SL: Self-efficacy training for patients with end-

stage renal disease. J Adv Nurs 43:370-375, 200329. McMurray SD, Johnson G, Davis S, et al: Diabetes ed-

ucation and care management significantly improvepatient outcomes in the dialysis unit. Am J KidneyDis 40:566-575, 2002

30. Oberley E, Sadler J, Alt PS: Renal rehabilitation: obsta-

cles, progress, and prospects for the future. Am J Kid-ney Dis 35:S141-S147, 2000

31. Curtin RB, Sitter DC, Schatell D, et al: Self-manage-

ment, knowledge, and functioning and well-beingof patients on hemodialysis. Nephrol Nurs J 31:378-387, 2004

32. Maly RC, Frank JC, Marshall GN, et al: Perceived

efficacy in patient-physician interactions (PEPPI):Validation of an instrument in older persons. J AmGeriatr Soc 46:889-894, 1998

33. Maly RC, Leake B, Frank JC, et al: Implementation of

consultative geriatric recommendations: The role ofpatient-primary care physician concordance. J AmGeriatr Soc 50:1372-1380, 2004

34. Ware JE, Kosinski M, Keller SD: SF-36 Physical and

Mental Health Summary Scales: A User’s Manual(ed 2). Boston, MA, The Health Institute, NewEngland Medical Center, 1994

35. DeOreo PB: Hemodialysis patient-assessed functional

health status predicts continued survival, hospitaliza-tion, and dialysis-attendance compliance. Am J Kid-ney Dis 30:204-212, 1997

36. DeVellis RF: Scale Development: Theory and Applica-

tions (vol 26). Newbury Park, CA, Sage Publications,Inc, 2003

37. Cronbach LJ: Coefficient Alpha and the Internal

Structure of Tests. Psychometrika 16:297-334, 195138. U.S. Renal Data System, USRDS 2003 Annual Data

Report: Atlas of end-stage renal disease in the UnitedStates. Bethesda, MD, National Institutes of Health,National Institute of Diabetes and Digestive and Kid-ney Diseases, 2003

39. Perlman RL, Finkelstein FO, Liu L, et al: Quality of

life in chronic kidney disease (CKD): a cross-sectionalanalysis in the Renal Research Institute–CKD study.Am J Kidney Dis 45:658-666, 2005


40. Walters BA, Hays RD, Spritzer KL, et al: Health-re-lated quality of life, depressive symptoms, anemia,and malnutrition at hemodialysis initiation. Am JKidney Dis 40:1185-1194, 2002

41. Curtin RB, Svarstad BL, Keller T: Hemodialysis pa-tients’ noncompliance with oral medications. ANNAJ 26:307-316, 1999

42. Owens N, Larrat E, Fretwell M: Improving compli-ance in the older patient: The role of comprehensivefunctional assessment, in Cramer J, Spilker B (eds.):Patient Compliance in Medical Practice and ClinicalTrials. New York, NY, Raven Press, 1991, pp 107-119

43. Feste C, Anderson RM: Empowerment: From philos-ophy to practice. Patient Educ Couns 26:139-144, 1995

44. Slowik MM: Early education of patients with chronicrenal insufficiency: The healthy start program. Neph-rol Nurs J 28:643-646, 2001

45. Devins GM, Mendelssohn DC, Barre PE, et al: Pre-di-alysis psychoeducational intervention and copingstyles influence time to dialysis in chronic kidney dis-ease. Am J Kidney Dis 42:693-703, 2003

46. Binik YM, Devins GM, Barre PE, et al: Live and learn:patient education delays the need to initiate renal re-placement therapy in end-stage renal disease. J NervMent Dis 181:371-376, 1993

47. Schatell D, Wise M, Klicko K, et al: In-center hemodi-alysis patients’ use of the Internet in the UnitedStates: A national survey. Am J Kidney Dis 48:285-291, 2006

48. Deutsch T, Gergely T: An intelligent partner systemfor improving chronic illness care. Inform Prim Care11:13-19, 2003

49. Thomas-Hawkins C, Zasworsky D: Self-management

of chronic kidney disease. Am J Nurs 105:40-48, 200550. Hill-Briggs F: Problem solving in diabetes self-man-

agement: A model of chronic illness self-managementbehavior. Ann Behav Med 25:182-193, 2003

51. Klang B, Bjorvell H, Cronqvist A: Patients with

chronic renal failure and their ability to cope. ScandJ Caring Sci 10:89-95, 1996

52. Elder NC, Jacobson CJ, Zink T, et al: How experienc-

ing preventable medical problems changed patients’interactions with primary health care. Ann FamMed 3:537-544, 2005

53. Lowrie EG, Curtin RB, LePain N, et al: Medical Out-

comes Study Short Form-36: A consistent and power-ful predictor of morbidity and mortality in dialysispatients. Am J Kidney Dis 41:1286-1292, 2003

54. Connelly CE: An empirical study of a model of self-care

in chronic illness. Clin Nurse Spec 7:247-253, 199355. Lorig K, Sobel DS, Ritter PL, et al: Effect of a self-man-

agement program on patients with chronic disease.Eff Clin Pract 4:256-262, 2001

56. Clark NM, Dodge JA: Exploring self-efficacy as a pre-

dictor of disease management. Health Educ Behav 26:72-89, 1999

57. Collie K, Wong P, Tilston J, et al: Self-Efficacy, coping,

and difficulties interacting with healthcare profes-sionals among women with breast cancer living inrural communities. Psychooncology 14:901-912, 2005

58. Brown SP, Ganesan S, Challagalla G: Self-efficacy as

a moderator of information-seeking behavior. J ApplPsychol 86:1043-1051, 2001

self-efficacy and self-management behaviors in patients with chronic kidney disease

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