A comparative study of self-efficacy in men and women with multiple sclerosis.
Multiple sclerosis (MS) is almost always more common in women than men. The sex ratio for MS is 2 females per 1 male, irrespective of ethnicity. In children with MS, the sex ratio is 3 females per 1 male. MS diagnosed after the age of 50 years commonly affects men and tends to have a primary progressive course (Compston & Wekerle, 2006). Overall, 85% of individuals have an initial course of MS as relapsing-remitting (RRMS) and 15% have progressive forms of MS (Confavreaux & Compston, 2006). Other than the gender differences in MS susceptibility and course of the disease, comparison of men's and women's responses to living with MS is scarce in the literature.
One important aspect of living successfully with a chronic condition such as MS is perceived self-efficacy. Bandura (1986) defines self-efficacy as an individual's judgment of his or her ability to organize and implement a course of action necessary to accomplish a task. According to Bandura (1997), beliefs about one's capabilities and aspirations are influenced by one's family, the educational system, mass media, and culture at large. As a result, gender differences exist in self-efficacy. For example, men may have higher perceived computer efficacy and mathematical efficacy when compared to women. Occupational choices will differ between men and women, with women who have low self-efficacy avoiding careers in scientific and technical fields. Self-efficacy is context-specific and varies in different aspects of life (Bandura, 1997). In the context of MS, self-efficacy has been found to be a significant predictor of adherence to an injectable, disease-modifying drug for MS. Patients with higher self-efficacy were more likely to adhere to use of this drug (Fraser, Hadjimichael, & Vollmer, 2001, 2003; Fraser, Morgante, Hadjimichael, & Vollmer, 2004).
Some individuals with disabling chronic illnesses lead active and productive lives, while others with minimal disability restrict their activities and feel despair (Bandura, 1997). A high sense of efficacy in managing a chronic illness fosters beneficial coping strategies and lessens functional disability.
It is unclear whether there is a difference in level of self-efficacy between men and women with MS or between patients with RRMS and progressive forms of MS. The latter question is of concern because progressive forms of MS generally lead to greater disability. Therefore, the purpose of this study was to examine if there was a difference in the level of self-efficacy between men and women with RRMS and progressive MS.
The research questions for this study were as follows:
1. Is there a difference in self-efficacy between men and women with MS?
2. Is there a difference in self-efficacy between men with RRMS and men with progressive forms of MS?
3. Is there a difference in self-efficacy between women with RRMS and women with progressive forms of MS?
A quantitative, descriptive, comparative design was used. Approval for the study was obtained from Monmouth University's Institutional Review Board (IRB).
The Multiple Sclerosis Self-Efficacy Scale (MSSE; Schwartz, Coulthard-Marris, Zeng, & Retzlaff, 1996) contains 18 items for individuals to rate on a scale of 10 to 100--where 10 is very uncertain and 100 is very certain--how certain they are that they will be able to perform specific behaviors. There are 2 subscales containing 9 items each. One subscale measures belief in the patient's ability to control his or her MS, and the other subscale measures belief in the patient's ability to function with MS. Each subscale can range in score from 90 to 900, with higher scores representing higher self-efficacy. The instrument has been demonstrated to have excellent reliability in patients with RRMS and progressive forms of MS. The control subscale reliability has been reported in various studies as .90, .94, .94, and .96 (Schwartz et al., 1996; Fraser et al., 2001; Fraser et al., 2003; Fraser et al., 2004, respectively). The function subscale reliability has been reported as .86, .90, .90, and .93 (Schwartz et al., 1996; Fraser et al., 2001; Fraser et al., 2003; Fraser et al., 2004, respectively). Demographic data were collected to describe the study participants. The demographic questionnaire asked the following: type of MS, gender, age, ethnicity, education, time since diagnosis of MS, and disease modifying drugs taken.
Data Collection Procedure
Potential participants were notified of the study through a mailing to an MS patient database, by postings on appropriate Web sites, and invitations to contact the researchers by e-mail. Individuals with RRMS and progressive forms of MS who contacted the researchers and were at least 18 years of age were sent information via e-mail about participating in the study. These volunteers were advised of the potential risks related to study participation. These risks included fatigue, eye strain, difficulty in reading the questions, and difficulty in responding to the e-mail questionnaire. The potential participants were provided with the e-mail address and telephone number of the principal investigator (PI) and were invited to contact her if they had any questions, concerns, or difficulties regarding their study participation.
Patients interested in completing the questionnaire responded by providing their preferred e-mail address. The study questionnaire was embedded in an e-mail and also attached as a Word document. Participants could complete the questionnaire in a reply e-mail or print out the Word document and fax or mail the completed questionnaire to the PI. The approximate time needed to complete the questionnaire was about 10 minutes. Consent was implied by participants completing the questionnaire and returning it to the PI. At any time the participant could contact the PI and withdraw his or her consent and the data would be excluded from the analysis.
The convenience sample included 556 individuals with RRMS and progressive forms of MS who completed the MSSE and a demographic questionnaire. There were 124 men (73 RRMS and 51 progressive MS) and 432 women (348 RRMS and 84 progressive MS).
Among the men, those with RRMS had a mean age of 47 years, with a range from 26 to 59 years. The men with progressive MS had a mean age of 53 years, with a range from 31 to 66 years. Those with RRMS were significantly younger than those with progressive MS (t = -3.5, p = .001). Men with RRMS had had MS for a mean of 8.3 years, with a range from 2 months to 24 years. Those with progressive MS had had the disease for a mean of 14.4 years, with a range from 1.3 to 27 years. Men with RRMS had a significantly shorter length of time since the diagnosis of MS (t = -3.7, p = .000).
The ethnicity of the 124 male participants was 96.8% Caucasian, 1.6% African American, 0.8% Hispanic, and 0.8% Native American. The men who participated were well-educated and relatively affluent, with 75% having a college degree (associate 21%, baccalaureate 24%, and master's or doctorate 30%) and 53% having a household income of at least $60,000. Disease-modifying drugs for MS were taken by 91% of the men with RRMS (69% interferon beta-1a [intramuscularly (IM)], 6% interferon beta-1b, 12% glatiramer acetate, and 4% interferon beta-1a [subcutaneously (SQ)]) and by 49% of those with progressive forms of MS (41% interferon beta1a [IM], 8% interferon beta-1b).
Among the women, those with RRMS had a mean age of 43 years, with a range from 21 to 62 years. Those with progressive MS had a mean age of 51 years with a range from 31 to 61 years. The women with RRMS were significantly younger than those with progressive MS (t = -6.8, p = .000). Women with RRMS had had MS for a mean of 7.4 years, with a range from 1 month to 32 years. The women with progressive MS had had MS for a mean of 13.3 years, with a range from 1 month to 35 years. Women with RRMS had a significantly shorter length of time since the diagnosis of MS (t = -5.8, p = .000).
The ethnicity of the 432 female participants was 91.8% Caucasian, 2.5% African American, 0.2% Asian Indian, 3.2% Hispanic, 0.5% Native American, 0.2% Semitic/Arab, and 1.6% other. The women who participated were well-educated and relatively affluent, with 71% having a college degree (associate 19%, baccalaureate 28%, and master's or doctorate 24%) and 55% having a household income of at least $60,000. Disease-modifying drugs for MS were taken by 88% of the women with RRMS (59% interferon beta-1a [IM], 10% interferon beta-1b, 15% glatiramer acetate and 4% interferon beta-1a [SQ]) and by 51% of those with progressive forms of MS (32% interferon beta-1a [IM], 5% interferon beta-1b, 8% glatiramer acetate, and 6% interferon beta-1a [SQ]).
Statistical Program for Social Sciences (SPSS) version 11.5 was used to analyze the data. Descriptive statistics were used for the demographic data. The independent t test was used to check for differences in self-efficacy between men and women with MS and to answer the research questions.
Women had significantly higher scores on the MSSE function subscale (M= 734) when compared to men (M=667; t=3.4, p=.001). Women also had a higher score on the MSSE control subscale (M = 595) when compared to men (M = 566), although the difference was not significant (t = 1.5, p = .14).
When men (73 RRMS and 51 progressive MS) were compared by type of MS, the men with RRMS had significantly higher scores on the MSSE control subscale (M = 593) than men with progressive forms of MS (M = 523; t = 2.01, p = .05). Similarly, men with RRMS had significantly higher scores on the MSSE function subscale (M = 759) than those with progressive forms of MS (M = 539; t = 6.2, p = .000).
When women (348 RRMS and 84 progressive MS) were compared by type of MS, the women with RRMS had significantly higher scores on the MSSE control subscale (M = 619) than those with progressive forms of MS (M = 492; t = 5.4, p = .000). Similarly, women with RRMS had significantly higher scores on the MSSE function subscale (M = 777) than those with progressive forms of MS (M=555; t=11.2, p=.000).
This study found gender differences in self-efficacy in people living with MS. Bandura (1997) states there are gender differences in self-efficacy, and this was supported by the findings of this study. When women were compared to men, women had a significantly greater belief in their ability to function with MS. They also had a greater belief in their ability to control their MS, although the difference was not significant.
Women's greater belief in their ability to control the MS and function with it may be influenced by their sense of connectedness with others. Bandura (1997) states that social support enhances a person's level of self-efficacy. Another perspective is presented by Surrey (1991), who states that the basic elements of the core of self in women include an interest in and attention to others, which influence emotional connection and the ability to empathize. The self develops in the context of relationships, with "relationships" meaning an experience of emotional and cognitive intersubjectivity. This perspective emphasizes that women have a greater sense of connectedness and perceive more support when compared to men.
This study also found significant differences in self-efficacy between those with RRMS and those with progressive forms of MS. When men were compared by type of MS, the men with RRMS had significantly greater belief in their ability to control and function with MS than men with progressive forms of MS. The same result held when women were compared by type of MS.
The difference in self-efficacy between patients with RRMS and progressive forms of MS may be related to the increasing disability and psychosocial changes over time. Bandura (1997) states that in chronic illness, "fluctuations in the disease activity convey the impression that the condition is neither predictable nor personally controllable" (p. 300).
According to Wallin, Wilken, Turner, Williams, and Kane (2006), MS is associated with multiple losses that may include losses in social roles, sense of control, vocational status, and participation activities. Social changes may occur in personal relationships and social networks as a result of MS. Losses may include the loss of professional colleagues, decreased contact with social groups, and the loss of social independence. Patients with greater disability tend to perceive less overall support. Likewise, patients with a longer duration of the illness tend to perceive less affection and affirmative support than those with a shorter duration of MS.
The cognitive impairment of those who have lived with MS longer may result in the individuals being less likely to work outside the home, more likely to need assistance with activities of daily living, and more likely to have limited social support (Wallin et al., 2006). In addition, greater mobility impairments are associated with progressive forms of MS. Finlayson and van Denend (2003), state that altered mobility may result in psychosocial changes, such as emotional loss, changes in self-image and self-esteem, and decreased opportunities to socialize, leading to isolation of those with greater mobility impairments. In their qualitative study of the experience of loss of mobility, Finlayson and van Denend found that throughout the course of MS, participants experienced numerous losses related to their mobility at both a personal and community level.
Limitations of the Study
This sample was limited to individuals with access to a computer and who use e-mail. The accuracy of completing an instrument via e-mail was also a limitation in this investigation. Although patients' participation was invited through diverse approaches, the majority of those who chose to participate tended to be well-educated Caucasians.
Men and women with MS could benefit from strategies to enhance self-efficacy, especially those with progressive forms of MS. In chronic illness, one's sense of self-efficacy can be enhanced through modeling of self-management skills, guided mastery experiences, and informative feedback (Bandura, 1997).
Because men tend to rely more on behavioral strategies, while women rely more on cognitive control (McCarthy & Newcomb, 1992), men may benefit more from guided mastery experiences. Holman and Lorig (1992) suggest that in self-management of chronic illness, guided mastery experiences should involve learning and practicing appropriate behaviors. The investigators suggest that desired behaviors be broken into small, graded tasks that can be accomplished in a relatively short time. After part of the task is accomplished, another portion can be added until the entire task is achieved. For example, a patient may want to start a walking program. The first phase would be to walk one block four times a week. Gradually blocks would be added to the walking distance. The patient's ultimate goal might be to walk a mile four times a week.
Bandura (1997) states that there are gender differences in efficacy beliefs in ability to juggle multiple roles, with some men doubting their ability to competently combine the demands of work and other roles. Guided mastery experiences for men could include a plan to gradually increase their role in self-care in managing their MS. For example, this could include mastery of self-injection of a medication to reduce the number and severity of flare-ups, followed by mastery of behaviors for regular exercises to stretch and strengthen muscles.
Strauser (1995) provides guidance on how to apply principles of self-efficacy to improve outcomes through the use of performance accomplishments, vicarious experiences, and verbal persuasion. He suggests thoroughly assessing the patient to identify specific areas to target to enhance self-efficacy. In patients who are disabled, activities of daily living are often areas to address. The use of assistive devices and physical reconditioning can enhance self-efficacy through performance accomplishment. To draw upon vicarious experience, a role-model patient--one who is living successfully with disability--can be identified. The interaction
between the role model and the patient with low self-efficacy can provide the latter with experiences of hope and increased confidence to perform target tasks and cope effectively with challenges. Support groups can also be recommended to enhance self-efficacy. Patients who see others successfully managing a disability may have a greater belief in their ability to manage their own. Group activities that provide support and education are another means to enhance self-efficacy through vicarious experience. Verbal persuasion can be used to encourage individuals and to provide reinforcement for successful accomplishments. Patients who are convinced that they have the ability to master a specific task are more likely to sustain greater effort to achieve the task. Some patients may seem unmotivated to participate in managing their disabilities; for example, they may miss appointments. Strauser (1995) suggests that such patients should not immediately be identified as "unmotivated," but rather they should be considered as possibly having low self-efficacy.
Healthcare professionals should consider the use of Bandura's model to guide interventions. According to Bandura (1997), strategies to enhance self-efficacy include assisting individuals to have realistic expectations, instilling self-confidence, providing positive feedback and praise, mobilizing social support, and providing skills for self-management of MS.
One recommendation for future research is to replicate this study in a sample with more representative levels of education. For example, recruitment of potential participants through local chapters of the National MS Society might result in a more heterogeneous sample. In addition, study questionnaires administered in a traditional way may be more appropriate and appealing for potential participants who do not have a college education or are unable to use a computer.
This study found gender differences in self-efficacy in patients with MS. When women with MS were compared to men with MS, the women were found to have a greater belief in their ability to control and function with MS. This study also found patients with RRMS had greater self-efficacy than patients with progressive forms of MS.
Healthcare professionals should become familiar with Bandura's (1997) construct of self-efficacy and strive to enhance self-efficacy in individuals living with MS. Strategies should be used to enhance self-efficacy, especially in men with RRMS and in both men and women with progressive forms of MS.
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Strauser, D. R. (1995). Applications of self-efficacy theory in rehabilitation counseling. Journal of Rehabilitation, 6(1), 7-11.
Surrey, J. L. (1991). The self-in-relation: A theory of women's development. In J. V. Jordan, A. G. Kaplan, J. B. Miller, I. P. Stiver, & J. L. Surrey (Eds.), Women's growth in connection (pp. 51-66). New York: The Guilford Press.
Wallin, M. T., Wilken, J. A., Turner, A. P., Williams, R. M., & Kane, R. (2006). Depression and multiple sclerosis: Review of a lethal combination. Journal of Rehabilitation Research and Development, 43(1), 45-62.
Questions or comments about this article may be directed to Cira Fraser, PhD APRN BC MSCN, at firstname.lastname@example.org or email@example.com. She is an associate professor and graduate faculty member at the Marjorie K. Unterberg School of Nursing and Health Studies at Monmouth University, West Long Branch, NJ.
Sue Polito, MSN APN-C, is a specialist professor at the Marjorie K. Unterberg School of Nursing and Health Studies at Monmouth University, West Long Branch, NJ.
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|Author:||Fraser, Cira; Polito, Sue|
|Publication:||Journal of Neuroscience Nursing|
|Article Type:||Clinical report|
|Date:||Apr 1, 2007|
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