There is evidence that the psychological attribute of perceived self-efficacy plays a role in mediating health outcomes for persons with chronic arthritis who take the Arthritis Self-Management Course. An instrument to measure perceived self-efficacy was developed through consultation with patients and physicians and through study of 4 groups of patients. Tests of construct and concurrent validity and of reliability showed that the instrument met appropriate standards. Health outcomes and self-efficacy scores improved during the Arthritis Self-Management Course, and the improvements were correlated.We describe the development and testing of an instrument to measure patients' perceived self-efficacy (SE) to cope with the consequences of chronic arthritis. The need for such an instrument arose in the course of studying the effects of the Arthritis SelfManagement Course (ASMC). When evaluated in randomized studies, subjects who took the ASMC were found to have less pain and to be more active than controls (1). These results persisted, albeit attenuated, for 20 months after the course, without reinforcement. However, when the data were examined for anticipated associations between changes in behavior (ex- ercise, relaxation, and walking) and changes in health status (pain, disability, and depression), the expected associations were weak or were absent (2).These unexpected findings precipitated an interview with the participants and evaluation of their experiences in the course. Fifty-four participants were asked why they found the course helpful or not helpful. For half the people interviewed, pain and/or disability had decreased; for the other half, pain and/or disability had not changed or had increased. The former group attributed their benefits to an increased sense of influence over the consequences of arthritis; the latter group believed that they could do little to improve their situation (3).The findings from these interviews indicated that a sense of one's personal ability to affect the consequences of disease was strong in some subjects and relatively weak in others, and interacted with the course to create the health outcomes. This sense of ability to effect change (akin to confidence) is similar to the psychological concept of perceived SE (43). In a preliminary study using early instruments to measure perceived SE to cope with the consequences of arthritis, we found statistically significant correlations between perceived SE and health status (ref. 6 and unpublished observations). We therefore sought to develop a reliable and valid instrument for measuring perceived SE.Perceived SE, as postulated by Bandura (4), is one's belief that one can perform a specific behavior or task in the future. It refers to personal judgments of performance capabilities in a given domain of activity.Although it is related to other psychological concepts, such as locus of control, learned helplessness, and self-esteem, it differs in that it is behavior-specific.

Evaluation of the Arthritis Self-ManagementCourse revealed significant positive changes in the practice of behaviors that were taught and in health outcomes. However, utilizing a variety of statistical techniques, we were able to demonstrate only weak associations between changes in behavior and changes in health status. This suggests the need to examine the mechanisms by which health education affects heaMh status.As do other persons who have chronic and disabling illnesses, the person who has arthritis plays a potentially significant role in the management of his or her health care. This role includes using techniques for maintaining mobility and strength, engaging in practices that reduce pain, and balancing the beneficial and adverse effects of medication. If the patient's role is to emerge fully, it is necessary that he or she gain new understanding about chronic illness and skills for coping with the effects. The purpose of the Arthritis Self-Management Course (ASMC) was to assist patients in attaining such understanding and skills.The underlying assumptions of those who developed the ASMC hold that enhanced knowledge and adoption of specific self-management behaviors will lead to improved functional outcomes. The ASMC, as originally tested in a randomized trial of 190 people with arthritis, was successful: Knowledge about arthritis was increased, taught behaviors were adopted, and pain was diminished by approximately 20%. No significant improvement in the average degree of disability was observed, but there was no deterioration. The effects persisted without reinforcement, albeit with some decay, for as long as 20 months, which was the longest time interval studied (1). We describe here the results of an inquiry into mechanisms of the effects of the ASMC. The first part of the report presents ASMC outcomes for 707 people, including the original 190 participants in the initial study. The second part describes the associations between participants' adoption of taught behaviors and improved health outcomes. The data reveal only weak correlations between the two.The weak associations of behavior change with health outcomes, which run counter to the usual perception of a direct progression from health education intervention to specified behavior change to improved health outcome, raise potentially important questions concerning the sources of benefit from health education. PATIENTS AND METHODSPublic service announcements in newspapers, on radio, and on television in the San Francisco Bay area were used to recruit 854 persons with arthritis. A physician's consent form confirming the patient's diagnosis was part of the application process.Upon completion of the application, all subjects were classified by the site at which they chose to take

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