Bandura s Social Cognitive Theory

1. Bandura’s Social Cognitive Theory Wipa Iamsumang

2. Objective To analyze Bandura’s Social Cognitive Theory To apply Bandura’s Social Cognitive Theory in Nursing Practice To discuss the appropriateness of SCT to improve adherence to prescribed treatment by Self-Management.

3. Contents Theory analysis origin, meaning, logical adequacy, usefulness, generalizability, parsimony, and testability Bandura’s SCT to improve adherence to prescribed treatment by Self-Management

4. Theory analysis

5. Origins: The purpose and reason for its development To explain “how do people's experiences, environments, and behaviors affect, and how they learn?” Stemmed from the Social Learning Theory (SLT). Combining behavioral and cognitive philosophies to form observational leaning. The human personality as an interaction between the environment and person’s psychological processes. Humans are able to control their behavior by self-regulation (self-observation, judgment, self response) Determining the origins of a theory involves examining the purpose and reason for its development as well as existing evidence for support of its claims. Albert Bandura developed the Social Cognitive Theory (SCT) in an effort to explain “how do people's experiences, environments, and behaviors affect, and how they learn?” The SCT describes learning in terms of the interrelationship between behavior, environmental factors, and personal factors. It also provides the theoretical framework for interactive learning used to develop both constructivism and cooperative Learning. The SCT can be considered deductive in origin because it was developed from another theory. The SCT stemmed from the Social Learning Theory (SLT). The SCT has its origins in the discipline of psychology, with its early foundation being laid by behavioral and social psychologists. In 1941, the original SLT by Miller and Dollard incorporated the principles of learning: reinforcement, punishment, extinction, and imitation of models. The SLT expanded on the reciprocal relationship between environment and behavior, while incorporating the beginnings of an internal mediating variable into the model. From Miller and Dollard’s work came a flood of different versions of the SLT (Woodward, 1982). The SLT proposed by Miller and Dollard was a theory of learning, however, that failed to take into account the creation of novel responses or the processes of delayed and non-reinforced imitations (Pajares, 2002). In 1963, Bandura and Walters wrote Social Learning and Personality Development, broadening the frontiers of social learning theory with the now familiar principles of observational learning and vicarious reinforcement. By the 1970s, however, Bandura was becoming aware that a key element was missing not only from the prevalent learning theories of the day but from his own social learning theory. In 1977, with the publication of "Self-efficacy: Toward a Unifying Theory of Behavioral Change," he identified the important piece of that missing element—self-beliefs (Stone, 1999).Determining the origins of a theory involves examining the purpose and reason for its development as well as existing evidence for support of its claims. Albert Bandura developed the Social Cognitive Theory (SCT) in an effort to explain “how do people's experiences, environments, and behaviors affect, and how they learn?” The SCT describes learning in terms of the interrelationship between behavior, environmental factors, and personal factors. It also provides the theoretical framework for interactive learning used to develop both constructivism and cooperative Learning. The SCT can be considered deductive in origin because it was developed from another theory. The SCT stemmed from the Social Learning Theory (SLT). The SCT has its origins in the discipline of psychology, with its early foundation being laid by behavioral and social psychologists. In 1941, the original SLT by Miller and Dollard incorporated the principles of learning: reinforcement, punishment, extinction, and imitation of models. The SLT expanded on the reciprocal relationship between environment and behavior, while incorporating the beginnings of an internal mediating variable into the model. From Miller and Dollard’s work came a flood of different versions of the SLT (Woodward, 1982). The SLT proposed by Miller and Dollard was a theory of learning, however, that failed to take into account the creation of novel responses or the processes of delayed and non-reinforced imitations (Pajares, 2002). In 1963, Bandura and Walters wrote Social Learning and Personality Development, broadening the frontiers of social learning theory with the now familiar principles of observational learning and vicarious reinforcement. By the 1970s, however, Bandura was becoming aware that a key element was missing not only from the prevalent learning theories of the day but from his own social learning theory. In 1977, with the publication of "Self-efficacy: Toward a Unifying Theory of Behavioral Change," he identified the important piece of that missing element—self-beliefs (Stone, 1999).

6. The SCT SLT explain human behavior in terms of continuous reciprocal interaction between cognitive, behavioral, an environmental influences. In 1986, Bandura discusses that behavior occurs within a triadic reciprocally (reciprocal interactions among behaviors, environmental variables, and personal ) Bandura has led the efforts on cognitive SLT development. Bandura’s SLT places a heavy focus on cognitive concepts. His theory focuses on how children and adults operate cognitively on their social experiences and how these cognitions then influence behavior and development (A Bandura, 1986). His theory was the first to incorporate the notion of modeling, or vicarious learning, as a form of social learning. In addition, Bandura also introduced several other important concepts, including reciprocal determinism, self-efficacy, and the idea that there can be a significant temporal variation in time lapse between cause and effect. In 1986, Bandura renamed his SLT, Social Cognitive Theory (SCT), as better description of what he had been advocating since the 1960’s (Bandura, 1986). Bandura has led the efforts on cognitive SLT development. Bandura’s SLT places a heavy focus on cognitive concepts. His theory focuses on how children and adults operate cognitively on their social experiences and how these cognitions then influence behavior and development (A Bandura, 1986). His theory was the first to incorporate the notion of modeling, or vicarious learning, as a form of social learning. In addition, Bandura also introduced several other important concepts, including reciprocal determinism, self-efficacy, and the idea that there can be a significant temporal variation in time lapse between cause and effect. In 1986, Bandura renamed his SLT, Social Cognitive Theory (SCT), as better description of what he had been advocating since the 1960’s (Bandura, 1986).

7. General Principles of SCT People can learn by observing the behaviors of others and the outcomes of those behaviors. Learning can occur without a change in behavior. The consequences of behavior & Cognition play a role in learning.

8. The processes of the SCT (Observational learning) Attention Must pay attention to the features of the modeled behavior. Retention Behavior stored in the form of mental images/ verbal descriptions Recalling Reproduction Converts symbolic representations into appropriate actions Motivation

9. Motivation Incentives act as reinforcers Behavior modification Behavior Modeling used in training programs Self-efficacy/self-regulatory behaviors To imitate a behavior, the person must have some motivating factor behind it, such as incentives that a person envisions or values. Incentives : negative reinforcers discourage the continuation of the modeled activity. Behavior modification :Ex. Bobo Doll experiment – Bandura showed a video to children in which an adult beat up on a doll, called it names.(Adult praised for actions, adult punished for behavior, no consequences for the behavior, and result boys more often imitated positive modeling)To imitate a behavior, the person must have some motivating factor behind it, such as incentives that a person envisions or values. Incentives : negative reinforcers discourage the continuation of the modeled activity. Behavior modification :Ex. Bobo Doll experiment – Bandura showed a video to children in which an adult beat up on a doll, called it names.(Adult praised for actions, adult punished for behavior, no consequences for the behavior, and result boys more often imitated positive modeling)

10. Motivation (cont.) Self-efficacy/self-regulatory behaviors (Schunk, 2004) Beliefs concerning one’s capabilities to organize & implement actions necessary to learn/perform behaviors at designated levels. A learner learns while they work on tasks (positive feedback). The learner’ s behaviors alter the environment. (Trainers/teachers emphasize only points not understand)

11. Bandura’s SCT A heavy focus on cognitive concepts. How children and adults operate cognitively on their social experiences and how these cognitions then influence behavior and development . The first to incorporate the notion of modeling & vicarious learning, as a form of social learning. Introducing reciprocal determinism self-efficacy In 1986, Bandura renamed his SLT, Social Cognitive Theory (SCT),

12. Origins: Existing evidence for support of its claims Bandura’s theoretical writings supported by his reports of empirical research. Experimental analogues of socialization situations (particularly modeling) Demonstrations of procedures for achieving therapeutic changes, such as training in self-efficacy. Bandura’s theoretical writings have continued to be supported by his reports of empirical research. The research has been of two sorts: (a) experimental analogues of socialization situations (particularly modeling), and (b) demonstrations of procedures for achieving therapeutic changes, such as vicarious desensitization and training in self-efficacy. The experimental analogues of socialization were well accepted at the time of their appearances as clever simulations of complex social situations and relationships that enabled developmental psychologists to make major progress in their studies of processes involved in socialization. Thus, they opened up new models of investigation that freed researchers from reliance on interviews with their attendant limitations and enabled them to make causal inferences from data rather than having to guess at the direction of effect (Grusec, 1992). For example, in 1963, Bandura and his colleagues were able to take the complex and often opaque concepts of three theories of identification, including social power, status envy, and secondary reinforcement, and test them in a manageable way through manipulations of the characteristics and behavior of models to whom young children were exposed. A series of studies in which children viewed aggressive models showed with starting clarity how such exposure could lead to increase in the children’s own aggression ( Bandura, 1999). In 1963, Bandura and McDonald questioned the basic tenets of cognitive developmental theorizing concerning moral development by showing that, through a training procedure involving social reinforcement and modeling, the moral judgments of young children could be modified (Bandura, 1999). Moreover, in 1973, they demonstrated how knowledge could exist in the absence of performance, and that children could be fully cognizant of the nature and consequences of a given behavior without ever having engaged it (Bandura, 1999). Bandura and Schunk demonstrated how the enhancement of perceived self-efficacy could improve children’s cognitive skill development and their intrinsic interest in academic subjects (Bandura & Schunk, 1981).Bandura’s theoretical writings have continued to be supported by his reports of empirical research. The research has been of two sorts: (a) experimental analogues of socialization situations (particularly modeling), and (b) demonstrations of procedures for achieving therapeutic changes, such as vicarious desensitization and training in self-efficacy. The experimental analogues of socialization were well accepted at the time of their appearances as clever simulations of complex social situations and relationships that enabled developmental psychologists to make major progress in their studies of processes involved in socialization. Thus, they opened up new models of investigation that freed researchers from reliance on interviews with their attendant limitations and enabled them to make causal inferences from data rather than having to guess at the direction of effect (Grusec, 1992). For example, in 1963, Bandura and his colleagues were able to take the complex and often opaque concepts of three theories of identification, including social power, status envy, and secondary reinforcement, and test them in a manageable way through manipulations of the characteristics and behavior of models to whom young children were exposed. A series of studies in which children viewed aggressive models showed with starting clarity how such exposure could lead to increase in the children’s own aggression ( Bandura, 1999). In 1963, Bandura and McDonald questioned the basic tenets of cognitive developmental theorizing concerning moral development by showing that, through a training procedure involving social reinforcement and modeling, the moral judgments of young children could be modified (Bandura, 1999). Moreover, in 1973, they demonstrated how knowledge could exist in the absence of performance, and that children could be fully cognizant of the nature and consequences of a given behavior without ever having engaged it (Bandura, 1999). Bandura and Schunk demonstrated how the enhancement of perceived self-efficacy could improve children’s cognitive skill development and their intrinsic interest in academic subjects (Bandura & Schunk, 1981).

13. Example In 1963, Bandura and his colleagues Identifying & test social power, status envy, and secondary reinforcement in a manageable way through manipulations of the characteristics and behavior of models A series of studies in which children viewed aggressive models showed with starting clarity how such exposure could lead to increase in the children’s own aggression (Bandura, 1999)

14. Example (cont.) Demonstrating how knowledge could exist in the absence of performance, & children could be fully cognizant of the nature and consequences of a given behavior without ever having engaged it (Bandura, 1999). Demonstrating how the enhancement of perceived self-efficacy could improve children’s cognitive skill development & their intrinsic interest in academic subjects (Bandura & Schunk, 1981).

15. Meaning The major concepts presented by Bandura (1986,1999) in his SCT Environment situation behavioral capability outcome expectations outcome expectancies self-control observational learning Reinforcements self-efficacy emotional coping responses reciprocal determinism self-regulation Although abstract, these concepts are all theoretically and operational defined. Examining the meaning of a theory includes identifying the basic ideas or concepts of the theory, defining those concepts, and examining the relationships between the concepts, which usually are expressed as statements. The major concepts presented by Bandura (1977,1986,1989,1999) in his SCT are as follows: (a) environment, (b) situation , (c) behavioral capability, (d) outcome expectations, (e) outcome expectancies , (f) self-control, (g) observational learning, (h) reinforcements, (i) self-efficacy, (j) emotional coping responses, (k) reciprocal determinism, and (l) self-regulation. Although abstract, these concepts are all theoretically and operational defined. Examining the meaning of a theory includes identifying the basic ideas or concepts of the theory, defining those concepts, and examining the relationships between the concepts, which usually are expressed as statements. The major concepts presented by Bandura (1977,1986,1989,1999) in his SCT are as follows: (a) environment, (b) situation , (c) behavioral capability, (d) outcome expectations, (e) outcome expectancies , (f) self-control, (g) observational learning, (h) reinforcements, (i) self-efficacy, (j) emotional coping responses, (k) reciprocal determinism, and (l) self-regulation. Although abstract, these concepts are all theoretically and operational defined.

16. Example Reciprocal Determinism Behavior changes result from interaction between person and environment; change is bidirectional Involve the individual and relevant others; work to change the environment, if warranted. Behavioral Capability Knowledge and skills to influence behavior  Provide information and training about action. Expectations Beliefs about likely results of action Incorporate information about likely results of action in advice. Self-Efficacy Confidence in ability to take action and persist in action Point out strengths; use persuasion & encouragement; approach behavior change in small steps. Observational Learning Beliefs based on observing others Point out others' experience, physical changes; identify role models to emulate. Reinforcement Responses to a person's behavior that increase or decrease the chances of recurrence Provide incentives, rewards, praise; encourage self-reward; decrease possibility of negative responses that deter positive changes.

17. Basic assumptions of SCT Learn from observing others (Demonstration) Learning is an internal process that may or may not result in a behavior change (Not immediate). Behavior is goal-directed (Help set goals). Behavior becomes self-regulated (Encourage high standards). Reinforcement and punishment have indirect effects on learning and behavior (Be sure consequences send correct message). Moreover, on the SCT built, five underlying assumptions are identified: a) learn from observing others (demonstration), b) learning is an internal process that may or may not result in a behavior change (not immediate), c) behavior is goal-directed (help set goals), d) behavior becomes self-regulated (encourage high standards), e) reinforcement and punishment have indirect effects on learning and behavior (be sure consequences send correct message). Theses underlying assumptions are important to interpretation and when considering the usefulness of the SCT.Moreover, on the SCT built, five underlying assumptions are identified: a) learn from observing others (demonstration), b) learning is an internal process that may or may not result in a behavior change (not immediate), c) behavior is goal-directed (help set goals), d) behavior becomes self-regulated (encourage high standards), e) reinforcement and punishment have indirect effects on learning and behavior (be sure consequences send correct message). Theses underlying assumptions are important to interpretation and when considering the usefulness of the SCT.

18. The statements of the SCT The highest level of observational learning is achieved by first organizing and rehearsing the modeled behavior symbolically and then enacting it overtly. Coding modeled behavior into words, labels or images results in better retention than simply observing. Individuals are more likely to adopt a modeled behavior if it results in outcomes they value. if it is similar to the observer if it has admired status the behavior has functional value. 1. The highest level of observational learning is achieved by first organizing and rehearsing the modeled behavior symbolically and then enacting it overtly. Coding modeled behavior into words, labels or images results in better retention than simply observing. 2. Individuals are more likely to adopt a modeled behavior if it results in outcomes they value. 3. Individuals are more likely to adopt a modeled behavior if the model is similar to the observer and has admired status and the behavior has functional value. 1. The highest level of observational learning is achieved by first organizing and rehearsing the modeled behavior symbolically and then enacting it overtly. Coding modeled behavior into words, labels or images results in better retention than simply observing. 2. Individuals are more likely to adopt a modeled behavior if it results in outcomes they value. 3. Individuals are more likely to adopt a modeled behavior if the model is similar to the observer and has admired status and the behavior has functional value.

19. Three strategies for increasing self-efficacy  (Pajares,2002) Setting small, incremental goals Behavioral contracting Monitoring and reinforcement Because self-efficacy is considered so important in SLT, it is worth looking at ways to increase self-efficacy. The advantages of greater self-efficacy include higher motivation in the face of obstacles and better chances of persisting over time outside a situation of formal supervision. Three strategies for increasing self-efficacy are consistent with other aspects of SLT, too: 1. Setting small, incremental goals: When someone achieves a small goal, like exercising for 10 minutes each day, her self-efficacy increases. Thus, the next goal (longer periods each day, 5 days in a row) seems achievable, and her persistence is greater. 2. Behavioral contracting: By using a formalized process to establish goals and specify rewards (reinforcement), a patient trying to adhere to a self-care regimen can receive feedback about performance, praise, and a tangible, motivating reward. 3. Monitoring and reinforcement: Feedback from self-monitoring or recordkeeping can reduce anxiety about one's ability to achieve a behavior change, thus increasing self-efficacy.Because self-efficacy is considered so important in SLT, it is worth looking at ways to increase self-efficacy. The advantages of greater self-efficacy include higher motivation in the face of obstacles and better chances of persisting over time outside a situation of formal supervision. Three strategies for increasing self-efficacy are consistent with other aspects of SLT, too: 1. Setting small, incremental goals: When someone achieves a small goal, like exercising for 10 minutes each day, her self-efficacy increases. Thus, the next goal (longer periods each day, 5 days in a row) seems achievable, and her persistence is greater. 2. Behavioral contracting: By using a formalized process to establish goals and specify rewards (reinforcement), a patient trying to adhere to a self-care regimen can receive feedback about performance, praise, and a tangible, motivating reward. 3. Monitoring and reinforcement: Feedback from self-monitoring or recordkeeping can reduce anxiety about one's ability to achieve a behavior change, thus increasing self-efficacy.

20. Logical Adequacy Some of the major concepts of the SCT can predict some behaviors in different situations. For example: Self-efficacy is used as an important predictor for a wide range of health behaviors such as smoking, weight control, nutrition, use of alcohol, and AIDS-prevention (van der Bijl et al., 1999). Self-efficacy for independent exercise was the significant predictor of exercise in cardiac patients over 6 months (Carlson et al., 2001). Logical adequacies refers to whether the concepts involved are precise and clear enough for the relations among them to be expressed abstractly and whether the model’s logic is correct in moving from statements to predictions and conclusions. Some of the major concepts of the SCT can predict some behaviors in different situations. For example, self-efficacy is the best predictor for health status outcomes (Lorig et al., 2001a). Maibach and Murphy in 1995 (as cited in van der Bijl, van Poelgeest-Eeltink, & Shortridge-Baggett, 1999) stressed that self-efficacy is used as an important predictor for a wide range of health behaviors such as smoking, weight control, nutrition, use of alcohol, and AIDS-prevention (van der Bijl et al., 1999). Once more, self-efficacy for independent exercise was the significant predictor of exercise in cardiac patients over 6 months (Carlson et al., 2001). Therefore, the SCT makes sense as it is built on several sound philosophical and scientific traditions.Logical adequacies refers to whether the concepts involved are precise and clear enough for the relations among them to be expressed abstractly and whether the model’s logic is correct in moving from statements to predictions and conclusions. Some of the major concepts of the SCT can predict some behaviors in different situations. For example, self-efficacy is the best predictor for health status outcomes (Lorig et al., 2001a). Maibach and Murphy in 1995 (as cited in van der Bijl, van Poelgeest-Eeltink, & Shortridge-Baggett, 1999) stressed that self-efficacy is used as an important predictor for a wide range of health behaviors such as smoking, weight control, nutrition, use of alcohol, and AIDS-prevention (van der Bijl et al., 1999). Once more, self-efficacy for independent exercise was the significant predictor of exercise in cardiac patients over 6 months (Carlson et al., 2001). Therefore, the SCT makes sense as it is built on several sound philosophical and scientific traditions.

21. Usefulness In general, researchers have established that self-efficacy, behavior changes and outcomes are highly correlated self-efficacy is an excellent predictor of behavior, especially in psychology and education (Graham & Weiner, 1996). Understanding of aggression & psychological disorders, particularly in the context of behavior modification (Bandura, 1969). The theoretical foundation for the technique of behavior modeling (training programs). The most common examples of social learning situations are television commercials. The usefulness of a theory refers to its practicality in explaining the phenomenon under study. The SCT has generated research in areas as diverse as medicine, athletics, media studies, business, social and political change, psychology, psychiatry, and education. In psychology, the SCT has been the focus of studies on clinical problems such as phobias, depression, social skills, assertiveness, smoking behavior, and moral development. Moreover, this theory has been especially prominent in studies of educational constructs such as academic achievement, attributions of success and failure, goal setting, social comparisons, memory, problem solving, career development, and teaching and teacher education (Pajares, 2002). In general, researchers have established that self-efficacy and behavior changes and outcomes are highly correlated and that self-efficacy is an excellent predictor of behavior, especially in psychology and education (Graham & Weiner, 1996). The SCT has been applied extensively to the understanding of aggression (Bandura, 1973) and psychological disorders, particularly in the context of behavior modification (Bandura, 1969). It is also the theoretical foundation for the technique of behavior modeling which is widely used in training programs. In recent years, Bandura has focused his work on the concept of self-efficacy in a variety of context. The most common (and pervasive) examples of social learning situations are television commercials (Bandura, 1986). In public health, the SCT has been used to study a wide range of health problems, from medical therapy compliance, to alcohol abuse, to immunizations. In terms of health education practice, the most widely used and accepted theoretical constructs are those born out of the SCT (Bandura, 2005; Macdonald, 2000). The SCT is recognized ‘feeder’ theory for health education and health promotion practice (Macdonald, 2000). The usefulness of a theory refers to its practicality in explaining the phenomenon under study. The SCT has generated research in areas as diverse as medicine, athletics, media studies, business, social and political change, psychology, psychiatry, and education. In psychology, the SCT has been the focus of studies on clinical problems such as phobias, depression, social skills, assertiveness, smoking behavior, and moral development. Moreover, this theory has been especially prominent in studies of educational constructs such as academic achievement, attributions of success and failure, goal setting, social comparisons, memory, problem solving, career development, and teaching and teacher education (Pajares, 2002). In general, researchers have established that self-efficacy and behavior changes and outcomes are highly correlated and that self-efficacy is an excellent predictor of behavior, especially in psychology and education (Graham & Weiner, 1996). The SCT has been applied extensively to the understanding of aggression (Bandura, 1973) and psychological disorders, particularly in the context of behavior modification (Bandura, 1969). It is also the theoretical foundation for the technique of behavior modeling which is widely used in training programs. In recent years, Bandura has focused his work on the concept of self-efficacy in a variety of context. The most common (and pervasive) examples of social learning situations are television commercials (Bandura, 1986). In public health, the SCT has been used to study a wide range of health problems, from medical therapy compliance, to alcohol abuse, to immunizations. In terms of health education practice, the most widely used and accepted theoretical constructs are those born out of the SCT (Bandura, 2005; Macdonald, 2000). The SCT is recognized ‘feeder’ theory for health education and health promotion practice (Macdonald, 2000).

22. Usefulness (cont.) In psychology, the SCT has been the focus of studies on clinical problems such as phobias, depression, social skills, assertiveness, smoking behavior, and moral development. In studies of educational constructs; academic achievement, attributions of success and failure, goal setting, social comparisons, memory, problem solving, career development, and teaching and teacher education (Pajares, 2002).

23. Usefulness in Health In public health, the SCT has been used to study a wide range of health problems, from medical therapy compliance, to alcohol abuse, to immunizations. In health education practice, the most widely used and accepted theoretical constructs are those born out of the SCT (Bandura, 2005; Macdonald, 2000). The SCT is recognized ‘feeder’ theory for health education and health promotion practice (Macdonald, 2000). The SCT is relevant to health for three reasons (Bandura, 2005). Dealing with cognitive, emotional and behavior aspects for understanding behavioral change. Providing ways for new behavioral research in health education. Ideas for other theoretical areas such as psychology are welcome to provide new insights and understanding. The SCT draws heavily from health psychology as a means to explain health behaviors. It focuses on the social context of health-related behavioral change and its associated cognitive processes (Whitehead, 2001). Bandura (1986) most notably applied them to the field of health, particularly in highlighting the concept of self-efficacy and its relationship with health-related behavioral change (Whitehead, 2001). The SCT is relevant to health communication for three reasons. First, the theory deals with cognitive, emotional aspects and aspects of behavior for understanding behavioral change. Second, the concepts of the SCT provide ways for new behavioral research in health education. Finally, ideas for other theoretical areas such as psychology are welcome to provide new insights and understanding (Bandura, 2005). Most of the models of health behavior are concerned only with predicting health habits, but they do not tell health care providers how to change health behavior. The SCT offers both predictors and principles on how to inform, enable, guide, and motivate people to adapt habits promoting health and reducing those that impair it (Bandura, 2004). The social cognitive behavioral models are valuable tools that nurses can incorporate routinely into existing frameworks of practice. It make the adoption of health-related behavioral change in clients easier and more realistic (Whitehead, 2001). For example, Rogers and colleagues explored the SCT for promoting exercise among breast cancer patients. They found that the SCT appears to be a useful framework for future study of exercise among beast cancer patients during treatment and its constructs should be considered when designing such studies (Rogers et al., 2004). The SCT draws heavily from health psychology as a means to explain health behaviors. It focuses on the social context of health-related behavioral change and its associated cognitive processes (Whitehead, 2001). Bandura (1986) most notably applied them to the field of health, particularly in highlighting the concept of self-efficacy and its relationship with health-related behavioral change (Whitehead, 2001). The SCT is relevant to health communication for three reasons. First, the theory deals with cognitive, emotional aspects and aspects of behavior for understanding behavioral change. Second, the concepts of the SCT provide ways for new behavioral research in health education. Finally, ideas for other theoretical areas such as psychology are welcome to provide new insights and understanding (Bandura, 2005). Most of the models of health behavior are concerned only with predicting health habits, but they do not tell health care providers how to change health behavior. The SCT offers both predictors and principles on how to inform, enable, guide, and motivate people to adapt habits promoting health and reducing those that impair it (Bandura, 2004). The social cognitive behavioral models are valuable tools that nurses can incorporate routinely into existing frameworks of practice. It make the adoption of health-related behavioral change in clients easier and more realistic (Whitehead, 2001). For example, Rogers and colleagues explored the SCT for promoting exercise among breast cancer patients. They found that the SCT appears to be a useful framework for future study of exercise among beast cancer patients during treatment and its constructs should be considered when designing such studies (Rogers et al., 2004).

24. Usefulness (cont.) The SCT offers both predictors & principles on how to inform, enable, guide, and motivate people to adapt habits promoting health and reducing those that impair it (Bandura, 2004). The SCT models are valuable tools for nurses to make the adoption of health-related behavioral change in clients easier & more realistic (Whitehead, 2001). Ex: Rogers and colleagues explored the SCT for promoting exercise among breast cancer patients. They found that the SCT appears to be a useful framework for future study of exercise among beast cancer patients during treatment and its constructs should be considered when designing such studies (Rogers et al., 2004)

25. Generlizability SCT has relatively wide boundaries in many areas. The wider the focus of this theory, and the more broadly it can be applied, the more generalizable it is. Defining a theory’s generalizability centers on assessing its applicability to other situations or phenomena. The SCT has relatively wide boundaries in many areas. The wider the focus of this theory, and the more broadly it can be applied, the more generalizable it is.Defining a theory’s generalizability centers on assessing its applicability to other situations or phenomena. The SCT has relatively wide boundaries in many areas. The wider the focus of this theory, and the more broadly it can be applied, the more generalizable it is.

26. Parsimony Reciprocal determinism in a triadic reciprocality is very succinct to make people understand the entire theory. Considering each concept, we are confused. The relational statements of the SCT are complex because there are many concepts related to each other. Some of concepts are redundant, especially self concepts. The SCT has many concepts but most of studies which applied this theory focused on only one or two concepts especially self-efficacy. Parsimony refers to how succinct, yet complete, the model is in describing its component and structure. The concept of reciprocal determinism explaining the relationships among three main factors of the SCT in a triadic reciprocality is very succinct to make people understand the entire theory. However, when considering each concept, we are confused. The relational statements of the SCT are complex because there are many concepts related to each other. Some of concepts are redundant, especially self concepts. Moreover, the SCT has many concepts but most of studies which applied this theory focused on only one or two concepts especially self-efficacy.Parsimony refers to how succinct, yet complete, the model is in describing its component and structure. The concept of reciprocal determinism explaining the relationships among three main factors of the SCT in a triadic reciprocality is very succinct to make people understand the entire theory. However, when considering each concept, we are confused. The relational statements of the SCT are complex because there are many concepts related to each other. Some of concepts are redundant, especially self concepts. Moreover, the SCT has many concepts but most of studies which applied this theory focused on only one or two concepts especially self-efficacy.

27. Testability Empirical evidences from many studies generated by repeated testing not only serves to support the SCT’s usefulness and gerneralizability, but also demonstrates that the hypotheses examined made good sense. The asset of testability has been reliably documented for this theory. The testability of a theory has to do with the capacity of the theory to generate hypotheses that can be supported or refuted by empirical investigation. Reliable statistical measurement of all concepts demonstrates model testability. Moreover, empirical evidences from many studies generated by repeated testing not only serves to support the SCT’s usefulness and gerneralizability, but also demonstrates that the hypotheses examined made good sense. The asset of testability has been reliably documented for this theory. For example, Walker and colleagues tested a theoretical model where self-efficacy is hypothesized to influence people’s behavioral intentions directly and indirectly through effects on outcome expectancy in 115 college students. They found that path analysis indicated that efficacy had both a direct impact on intention and an indirect impact through its effects on outcome expectancy. The more efficacious people were, the more positive the outcomes they associated with jogging and the surer they were they would jog (Walker et al., nd). The testability of a theory has to do with the capacity of the theory to generate hypotheses that can be supported or refuted by empirical investigation. Reliable statistical measurement of all concepts demonstrates model testability. Moreover, empirical evidences from many studies generated by repeated testing not only serves to support the SCT’s usefulness and gerneralizability, but also demonstrates that the hypotheses examined made good sense. The asset of testability has been reliably documented for this theory. For example, Walker and colleagues tested a theoretical model where self-efficacy is hypothesized to influence people’s behavioral intentions directly and indirectly through effects on outcome expectancy in 115 college students. They found that path analysis indicated that efficacy had both a direct impact on intention and an indirect impact through its effects on outcome expectancy. The more efficacious people were, the more positive the outcomes they associated with jogging and the surer they were they would jog (Walker et al., nd).

28. For example Walker & colleagues tested a theoretical model where self-efficacy is hypothesized to influence people’s behavioral intentions directly and indirectly through effects on outcome expectancy in 115 college students. They found that path analysis indicated that efficacy had both a direct impact on intention and an indirect impact through its effects on outcome expectancy. The more efficacious people were, the more positive the outcomes they associated with jogging and the surer they were they would jog (Walker et al., nd).

29. Apply the SCT in the Nursing Care “Adherence to prescribed treatment improved with Self-Management based on enhanced Self-efficacy”

30. Problem Failure to take prescribed medicine is a massive world-wide problem. EX: In the US, hypertension affects 43-50 million adults. About 50% of those who have been diagnosed are treated, and only 51% of those treated adhere to the prescribed treatment (Graves, 2000; Munger, 2000). Data for depression reveal non-adherence of between 30% and 60 % to antidepressant therapies (Demyttenaere & Haddad, 2000). Poor or non- adherence attenuates optimum clinical benefit. EX: low adherence has been identified as the primary cause of unsatisfactory blood pressure control (Waeber et al., 2000). In the US, only 30% of those treated achieved the expected blood pressure (Graves, 2000). Adherence positively impact on the health status of patients with chronic illness, higher rates of adherence confer economic, including direct savings generated by less use of sophisticated and expensive health services caused by disease exacerbation, crisis or relapses of patients. Indirect savings may be attributable to enhancement to or preservation of quality of life and patient’s social and vocational roles (Rassool, 2004). Failure to take prescribed medicine is a massive world-wide problem. A rigorous review has found that in developed countries adherence among patients suffering chronic diseases only 50%, and it is even lower in developing countries (Rassool, 2004) Failure to take prescribed medicine is a massive world-wide problem. A rigorous review has found that in developed countries adherence among patients suffering chronic diseases only 50%, and it is even lower in developing countries (Rassool, 2004)

31. Solve the Problem Interventions to improve adherence fall into three main types, including educational, cognitive/behavioral, and self regulatory skill training (Fielding & Duffy, 1999). Chronic disease self-management education programs have demonstrated their impact on health behaviors, health status, and healthcare utilization. Positive effects of self-management training on knowledge, frequency and accuracy of self-monitoring of blood glucose, self-reported dietary habits, and glycemic control were demonstrated in these studies with short follow-up (< 6 months). (Norris et al., 2001), Interventions to improve adherence fall into three main types, including educational, cognitive/behavioral, and self regulatory skill training (Fielding & Duffy, 1999). During the past decade, chronic disease self-management education programs have demonstrated their impact on health behaviors, health status, and healthcare utilization (Dongbo et al., 2003; Glasgow et al., 1997; Lorig et al., 1985; Lorig et al., 2001a; Lorig et al., 2003; Norris et al., 2001). A systemic review of randomized controlled trials (Norris et al., 2001), for a total of 72 studies described in 84 articles , found that positive effects of self-management training on knowledge, frequency and accuracy of self-monitoring of blood glucose, self-reported dietary habits, and glycemic control were demonstrated in these studies with short follow-up (< 6 months). Moreover, Maes and Karoly (2005) report the growing shift from the medical management model centered on prescriptive regimens and compliance with them, to a collaborative self-management model (Bandura, 2005). Interventions to improve adherence fall into three main types, including educational, cognitive/behavioral, and self regulatory skill training (Fielding & Duffy, 1999). During the past decade, chronic disease self-management education programs have demonstrated their impact on health behaviors, health status, and healthcare utilization (Dongbo et al., 2003; Glasgow et al., 1997; Lorig et al., 1985; Lorig et al., 2001a; Lorig et al., 2003; Norris et al., 2001). A systemic review of randomized controlled trials (Norris et al., 2001), for a total of 72 studies described in 84 articles , found that positive effects of self-management training on knowledge, frequency and accuracy of self-monitoring of blood glucose, self-reported dietary habits, and glycemic control were demonstrated in these studies with short follow-up (< 6 months). Moreover, Maes and Karoly (2005) report the growing shift from the medical management model centered on prescriptive regimens and compliance with them, to a collaborative self-management model (Bandura, 2005).

32. Despite the growing recognition that chronic disease self-management is one of the most vital heath care issues of the century, success in the management of chronic diseases is limited (Keysor et al., 2001; Wagner et al., 1996). Increasing self-efficacy, along with providing medical care and education, can empower patients to take control in the management of their chronic disease (Farrell et al., 2004; Lorig et al., 2001b).

33. A Self-management based on Self-efficacy A chronic disease self-management program, based on the self-efficacy enhancing strategies of skills mastery, modeling, reinterpretation of symptoms, and social persuasion.

34. Ex: Self-Management based on Self-efficacy The program was evaluated for nearly 1,000 subjects with heart disease, lung disease, stroke or arthritis. Outcomes of the 6-month randomized trial and the 2-year longitudinal follow-up evaluation demonstrated that participants had significant increases in health behaviors and health status as well as reduced healthcare use (Lorig et al., 2001a). Likewise, a chronic disease self-management program, based on Bandura’s self-efficacy theory in an under-served, poor, rural population, significantly improved self-efficacy, self-efficacy health, and self-management behaviors (Farrell et al., 2004). The SCT approach, rooted in a model of health promotion, focuses on health problems. The SCT promotes effective self-management of health habits that keep people healthy through their life span (Bandura, 2005). Self-management requires the exercise of motivational and self-regulatory skills (Bandura, 2005). Self-management for improving adherence to prescribed treatment in chronic illness based on Bandura’s SCT include self-monitoring of health-related behavior and the social and cognitive conditions under which one engages in it, adoption of goals to guide one’s efforts and strategies for realizing them, and self-reactive influences that include enlistment of self-motivating incentives and social support to sustain healthful practices. An important component of Bandura’s SCT of behavior is the concept of self-efficacy, including efficacy expectations and outcome expectation. Healthcare professional in therapeutic exercise setting can increase self-efficacy by developing interventions to enhance efficacy expectations. Efficacy expectations are derived from four sources, including performance mastery, vicarious experience, verbal persuasion, and physiological states (Bandura, 1986). More recently, a chronic disease self-management program, based on self-efficacy concept emphasizing the efficacy-enhancing strategies of skills mastery, modeling, reinterpretation of symptoms, and social persuasion (Bandura, 1997), was evaluated for nearly 1,000 subjects with heart disease, lung disease, stroke or arthritis (Lorig et al., 1999). Outcomes of the 6-month randomized trial and the 2-year longitudinal follow-up evaluation demonstrated that participants had significant increases in health behaviors and health status as well as reduced healthcare use (Lorig et al., 2001a; Lorig et al., 1999). Likewise, a chronic disease self-management program, based on Bandura’s self-efficacy concept in an under-served, poor, rural population, significantly improved self-efficacy, self-efficacy health, and self-management behaviors (Farrell et al., 2004). Self-efficacy has become an issue that pervades psychological research in many domains. It has been found that a strong sense of personal efficacy is related to better health, higher achievement, and more social integration (Bandura, 2004). Self-efficacy and outcome expectations influence health behavior and health status outcomes. Specifically, they work very well in behavior changes, such as adherence to exercise, smoking cession, and diet modifications (Resnick et al., 2000). Self-efficacy expectations are related to adherence to medications for diseases such as rheumatoid arthritis, explaining 58 % of medication behavior (Brus et al., 1999). Increasing self-efficacy, along with providing medical care and education, can empower patients to take control in the management of their chronic disease (Farrell et al., 2004; Lorig et al., 2001b). Therefore, the author beliefs that self-efficacy based on Bandura’s SCT in context of self-management can improve the adherence to long-term therapies in the elderly with type 2 diabetes The SCT approach, rooted in a model of health promotion, focuses on health problems. The SCT promotes effective self-management of health habits that keep people healthy through their life span (Bandura, 2005). Self-management requires the exercise of motivational and self-regulatory skills (Bandura, 2005). Self-management for improving adherence to prescribed treatment in chronic illness based on Bandura’s SCT include self-monitoring of health-related behavior and the social and cognitive conditions under which one engages in it, adoption of goals to guide one’s efforts and strategies for realizing them, and self-reactive influences that include enlistment of self-motivating incentives and social support to sustain healthful practices. An important component of Bandura’s SCT of behavior is the concept of self-efficacy, including efficacy expectations and outcome expectation. Healthcare professional in therapeutic exercise setting can increase self-efficacy by developing interventions to enhance efficacy expectations. Efficacy expectations are derived from four sources, including performance mastery, vicarious experience, verbal persuasion, and physiological states (Bandura, 1986). More recently, a chronic disease self-management program, based on self-efficacy concept emphasizing the efficacy-enhancing strategies of skills mastery, modeling, reinterpretation of symptoms, and social persuasion (Bandura, 1997), was evaluated for nearly 1,000 subjects with heart disease, lung disease, stroke or arthritis (Lorig et al., 1999). Outcomes of the 6-month randomized trial and the 2-year longitudinal follow-up evaluation demonstrated that participants had significant increases in health behaviors and health status as well as reduced healthcare use (Lorig et al., 2001a; Lorig et al., 1999). Likewise, a chronic disease self-management program, based on Bandura’s self-efficacy concept in an under-served, poor, rural population, significantly improved self-efficacy, self-efficacy health, and self-management behaviors (Farrell et al., 2004). Self-efficacy has become an issue that pervades psychological research in many domains. It has been found that a strong sense of personal efficacy is related to better health, higher achievement, and more social integration (Bandura, 2004). Self-efficacy and outcome expectations influence health behavior and health status outcomes. Specifically, they work very well in behavior changes, such as adherence to exercise, smoking cession, and diet modifications (Resnick et al., 2000). Self-efficacy expectations are related to adherence to medications for diseases such as rheumatoid arthritis, explaining 58 % of medication behavior (Brus et al., 1999). Increasing self-efficacy, along with providing medical care and education, can empower patients to take control in the management of their chronic disease (Farrell et al., 2004; Lorig et al., 2001b). Therefore, the author beliefs that self-efficacy based on Bandura’s SCT in context of self-management can improve the adherence to long-term therapies in the elderly with type 2 diabetes

36. Conclusion Theory analysis provides a systemic method for examining a theory’s potential for nursing knowledge deployment. In clinical practice, knowledge of the soundness of any theory enables healthcare providers to choose appropriate interventions with some expectation of their efficacy. For research, theory analysis can reveal gaps or inconsistencies, thereby spurring further hypothesis testing and theory refinement.

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38. Reference (cont.) Lorig, K. R., Sobel, D. S., Ritter, P., Laurent, D., & Hobbs, M. (2001b). Effects of a self-management program on patients with chronic disease. Effective Clinical Practic, 4(6), 256-262. Munger, M. A. (2000). Critical overview of antihypertensive therapies: What is preventing us from getting there? American Journal of Managed Care, 6, S211-S221. Norris, S. L., Engelgau, M. M., & Narayan, K. M. V. (2001). Effectiveness of self-management training in type 2 diabetes. Diabetes Care, 24(3), 561-587. Rassool, G. H. (2004). Current issues and forthcoming events. Journal of Advanced Nursing, 45(4), 447-449. Schunk, D. H. (2004). Learning theories: An educational perspective (4 ed.). Upper Saddle River, New Jersey: Pearson Merrill Prentice-Hall. Waeber, B., Burnier, M., & Brunner, H. R. (2000). How to improve adherence with prescribed treatment in hypertensive patients? Journal of Cardiovascular Pharmacology, 35 Suppl, S23-S26. Wagner, E., Austin, B., & Von Korff, M. (1996). Improving outcomes in chronic illness. Managed Care Quaterly, 4(2), 12-25.

39. Thanks for your attention