**3. Key theoretical underpinning: Self-efficacy**

As discussed, the majority of contemporary SMT programs foster an individualized approach, with a strong emphasis on coaching by a health care professional or peer leader [50]. A common goal of SMT intervention developers is to maintain a focus on wellness in the foreground and improve overall HRQL. In so doing, three key objectives of self-management coaching are to prepare people to do the following a) take better care of their health through physical activity, relaxation and stress reduction, and effective use of available treatments, b) maintain optimal social and occupational role functioning, and c) manage challenging emotional responses to chronic illness [51].

To facilitate effective coaching and desired health outcomes, most successful SMT interven‐ tions are developed on the basis of well-established psychological models of behavior change [50]. Such models delineate the instrumental processes inherent in successful role modeling, self-management skills acquisition, realistic goal setting, problem solving, and identification and management of obstacles to health-related improvements [50].

A well-integrated model in SMT research and practice is Bandura's Self-Efficacy Theory [52-54]. Renowned sociologist Albert Bandura [53] defined the concept of self-efficacy as "The exercise of human agency through people's beliefs in their capabilities to produce desired effects by their actions" (p iv). Bandura argued that fundamental to human nature is the need for control, or causative capacity in everyday situations. Human enactments of control are thought to be played out in the form of agency, or one's intentional actions. People's beliefs about their self-efficacy drive their personal senses of agency [52-54]. Therefore, chronic disease self-management is not simply a question of knowing what to do; the process requires incremental increases in one's perceived capacity to organize and integrate cognitive, social and behavioural skills to meet a variety of aims in managing illness from day to day [52-54].

context of patient priorities and preferences, b) *self-reflection:* sharing of feelings to provide opportunities for discussion about the personal meaning of chronic illness and difficult emotional responses, c) *mini-lectures and supplemental reading/workbooks*: providing opportuni‐ ties for brief information sharing about relevant educational content in accessible language and formats, d) *brainstorming and problem solving*: facilitating discussion of the potential benefits of various self-management strategies such as safe exercise, sound nutrition, energy conser‐ vation and pacing, identifying and reframing negative self-talk, etc., e) *regular action plan‐ ning:* learning the process of setting incremental positive behaviour change, and f) *selfmonitoring, accountability, and feedback:* reporting back to peers or counsellors about individual

Self-management training programs have been delivered in a variety of formats including individual counseling, small group sessions, or individual and group-based approaches in combination. Programs that engage either health care professional facilitators or lay peer leaders have been shown to be effective, as have programs that use these delivery methods in combination [46,48,49]. Regardless of format, most established SMT interventions offer a range of self-management techniques for participant rehearsal and uptake over the course of several days or weeks [44-49]; typical settings for program delivery include clinical outpatient settings

As discussed, the majority of contemporary SMT programs foster an individualized approach, with a strong emphasis on coaching by a health care professional or peer leader [50]. A common goal of SMT intervention developers is to maintain a focus on wellness in the foreground and improve overall HRQL. In so doing, three key objectives of self-management coaching are to prepare people to do the following a) take better care of their health through physical activity, relaxation and stress reduction, and effective use of available treatments, b) maintain optimal social and occupational role functioning, and c) manage challenging emotional responses to

To facilitate effective coaching and desired health outcomes, most successful SMT interven‐ tions are developed on the basis of well-established psychological models of behavior change [50]. Such models delineate the instrumental processes inherent in successful role modeling, self-management skills acquisition, realistic goal setting, problem solving, and identification

A well-integrated model in SMT research and practice is Bandura's Self-Efficacy Theory [52-54]. Renowned sociologist Albert Bandura [53] defined the concept of self-efficacy as "The exercise of human agency through people's beliefs in their capabilities to produce desired effects by their actions" (p iv). Bandura argued that fundamental to human nature is the need for control, or causative capacity in everyday situations. Human enactments of control are thought to be played out in the form of agency, or one's intentional actions. People's beliefs about their self-efficacy drive their personal senses of agency [52-54]. Therefore, chronic

progress and obtaining constructive feedback.

**3. Key theoretical underpinning: Self-efficacy**

and management of obstacles to health-related improvements [50].

and community centres.

222 Current Trends in Atherogenesis

chronic illness [51].

Under the direction of Kate Lorig, the Stanford Patient Education Research Centre has been a world leader in the application of self-efficacy theory to chronic disease SMT research and implementation [55]. Lorig et al.s' seminal work, the Arthritis Self-Management Program (ASMP)—developed in 1978 and funded by the National Institutes of Health—has been widely disseminated through national arthritis societies on three continents [56-61]. Multiple process evaluations and randomized-controlled trials (RCTs) of the ASMP [56-61], and its prevalent, generic adaptation, the Chronic Disease Self-Management Program (CDSMP) [62-71] (devel‐ oped in 1996), have shown that participation in a standardized SMT program results in significantly improved levels of self-efficacy for those with chronic pain and other chronic diseases. In the ASMP evaluations, improved self-efficacy was found consistently to mediate sustained significant changes in HRQL, knowledge, pain, depression and disability. Reduc‐ tions in health care costs up to 4 years post intervention, without formal reinforcement of program content, have also been found [60,61]. Similarly, self-efficacy enhancement in the CDSMP trials has repeatedly demonstrated significant improvements in exercise, cognitive symptom management, communication with physicians, self-reported general health, health distress, fatigue, disability, and role and social functioning. Participants have also spent significantly fewer days in hospital; sustained outcome improvements have been demonstrat‐ ed up to three years post-intervention [62-71].

Both the ASMP [56-61] and CDSMP [62-71] employ a standardized 6-week, community-based format, Sessions are delivered in 2-hour sessions weekly for small groups of approximately 12 to 15 patients. As preeminent models of SMT, the ASMP and CDMSP programs have consis‐ tently supported [72] the following major precepts of Self-Efficacy Theory—summarized by Lorig et al. [73], (p. 5-6)—as principal drivers of effective chronic disease self-management:

