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Epilepsy & Behavior 9 (2006) 158–163

Behavioral, social, and affective factors associated with self-efficacyfor self-management among people with epilepsy

Colleen DiIorio a,*, Patricia Osborne Shafer b, Richard Letz a, Thomas R. Henry c,Donald L. Schomer b,d, Katherine Yeager a, for the Project EASE Study Group

a Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, Atlanta, GA 30322, USAb Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA 02215, USAc Department of Neurology, School of Medicine Emory University, Atlanta, GA 30322, USA

d Harvard Medical School, Boston, MA 02215, USA

Received 26 July 2005; revised 2 May 2006; accepted 3 May 2006

Abstract

The purpose of the study described in this article was to evaluate the extent to which selected behavioral, social, and affective factorscontribute to self-reported epilepsy self-efficacy. Participants completed three assessments 3 months apart, with only those completingboth the first and second assessments included in this analysis. Self-efficacy scores at the second assessment were regressed on the behav-ioral, social, and affective characteristics ascertained at the first assessment. The analysis revealed that self-management, depressive symp-toms, and seizure severity explain the most variance in self-efficacy; patient satisfaction and stigma are less important predictors; andsocial support and regimen-specific support are not significant predictors. The results provide direction for identifying people withlow levels of self-efficacy and highlighting areas that might help enhance self-efficacy in persons with epilepsy.� 2006 Published by Elsevier Inc.

Keywords: Self-efficacy; Epilepsy; Adults; Depression; Stigma

1. Introduction

Much research has been directed toward the study ofhealth behaviors and factors associated with successfulbehavior change and maintenance. One factor that hasreceived considerable attention is that of self-efficacy,which Bandura [1] defines as ‘‘beliefs in one’s capabilitiesto organize and execute the courses of action required toproduce given attainments.’’ The construct is a central con-cept within social cognitive theory, which suggests thatpeople who have high levels of self-efficacy are more likelyto perform a given behavior [1]. Moreover, they are morelikely to persevere to overcome barriers and to work longerat mastering the behavior before giving up. Studies of peo-ple with chronic health problems such as epilepsy, diabetes,

1525-5050/$ - see front matter � 2006 Published by Elsevier Inc.

doi:10.1016/j.yebeh.2006.05.001

* Corresponding author. Fax: +1 404 712 8872.E-mail address: cdiiori@sph.emory.edu (C. DiIorio).

arthritis, and asthma repeatedly demonstrate the value ofthis construct. The findings of several studies indicate thatpeople with high levels of self-efficacy are more successfulat managing self-care tasks such as taking medications,avoiding triggers for symptoms, and monitoring health sta-tus [2–6].

Although much is known about the association betweenself-efficacy and self-management, less is known about fac-tors that foster the development of self-efficacy itself. Sev-eral investigators have explored sources of self-efficacyrelated to career choice [7,8]; however, only a few haveexamined factors associated with self-efficacy related tohealth behaviors. Cousins and Tan [9] evaluated cognitiveand contextual elements that contribute to self-efficacyfor walking blocks and climbing stairs. The self-referentbeliefs they evaluated included those about exercise, socialsupport, and risks and benefits of exercise, and the contex-tual characteristics included age, education, and health.

C. DiIorio et al. / Epilepsy & Behavior 9 (2006) 158–163 159

The results indicated that both cognitive and contextualvariables were important in fostering self-efficacy.McAuley et al. studied, social, affective and behavioralinfluences of exercise self-efficacy among older adults [10].They found that exercise self-efficacy of older men andwomen participants was associated with more frequentexercise, a perception that the exercise group was moresupportive and feeling good after exercising.

The findings of previous studies of self-management inepilepsy indicate that self-efficacy is a primary determinantof general epilepsy self-management and medication man-agement [3,11]. Moreover, people who have high levels ofsocial support are more likely to express a strong sense ofself-efficacy [3]. In the present study, we sought to expandthe previous research by exploring behavioral, social, andaffective factors associated with self-efficacy for self-man-agement in persons with epilepsy. Variables selected forevaluation were based on social cognitive theory and areview of the self-efficacy literature. The variables selectedwere previous performance of self-management behaviors,social support, regimen-specific support, satisfaction withcommunication with physician, depressive symptoms, andstigma. Previous self-management behavior was selectedbecause Bandura [1] notes that people who have successful-ly mastered a behavior are likely to have a strong sense ofefficacy related to that behavior. Repeated success increasesor sustains confidence, whereas continued failure leads todefeat and a weak sense of efficacy. Based on previousresearch, it was expected that individuals who perceivemore support from various sources would exhibit higherlevels of self-efficacy. Because affective states can influenceperformance, we included a measure of depressive symp-toms and a measure of stigma to explore how these vari-ables would affect one’s self-efficacy for self-managementof epilepsy.

Data for this study were taken from a larger study onepilepsy self-management. This study was a longitudinalstudy that included three interviews over a 6-month period.Thus, we were able to use data from the predictor variablesthat were measured 3 months before self-efficacy. Thisapproach strengthened our model that sought to determinewhich of the predictor variables fostered the developmentof self-efficacy. If self-efficacy is an important concept inpromoting self-management behavior, then it is importantto understand the factors needed to improve or sustain self-efficacy.

2. Methods

This study was part of a larger research project designed to exploreself-management among people with epilepsy. The National Institute ofNursing Research funded the research, and the institutional review boardsat the researchers’ institutions and clinical sites approved the research pri-or to the initiation of the study. The research was conducted at three clin-ical sites: two in Atlanta, GA, and one in Boston, MA, USA. Two sites,one in each city, were epilepsy centers, and the second site in Atlantawas a neurology clinic. The recruitment process began with the health careprovider, who gave people visiting for a regularly scheduled appointment

a brief description of the project. Those who were interested were referredto a study nurse, who gave patients a more detailed description of theresearch and determined eligibility for the study. The eligibility criteriawere: (1) diagnosis of epilepsy for at least 1 year, (2) currently receivinga treatment for seizures, (3) between 18 and 75 years of age, (4) able toread and understand English, (5) mentally competent as judged by a healthcare provider, and (6) willing to participate. Exclusion criteria were (1)presence of a rapidly progressing neurological or medical disorder, (2) his-tory of psychiatric syndromes that could limit participation, (3) seizuresthat were exclusively nonepileptic and not being treated with antiepilepticdrugs (AEDs), (4) history of sensitivity to photic or pattern stimulation,(5) history of significant substance abuse within the past year, and (6) par-ticipation in a study of porcine cell transplantation being conducted at oneof the clinics. Patients with a history of sensitivity to photic or patternstimulation on electroencephalography were able to participate if theyhad not had a seizure associated with computer use in the previous year.The physician made the decision to allow people with a history of photicsensitivity to participate.

All people who volunteered to participate signed an informed consentform. Participants completed a baseline assessment and two additionalassessments 3 months apart. They received $25 for each completed assess-ment. Participants in Atlanta received an additional small stipend to covertravel and parking expenses. The participants completed the assessmentsusing audio computer-assisted interviewing technology (ACASI). Thenurse interviewer asked the participant the first set of items and enteredthe responses into the computer. The nurse used this opportunity toinstruct the participant on the use of the pen-based computer and the dif-ferent types of questions included in the assessment. When the participantfelt comfortable, she or he completed the remainder of the assessmentalone. The nurse interviewer was available to answer questions.

2.1. Instruments

The Epilepsy Self-Efficacy Scale was used to measure self-efficacy orconfidence in ability to complete self-management tasks associated withepilepsy [12]. This instrument is a summated rating scale composed of33 items, and each item is rated on an 11-point rating scale, ranging from0 (‘‘I cannot do at all’’) to 10 (‘‘sure I can do’’). Higher total scores corre-spond to higher levels of confidence in ability to manage epilepsy. Reliabil-ity and validity had been assessed with an earlier 25-item instrument [13].a coefficients ranged from 0.91 to 94 [3,11,13,14]. The reliability coefficientfor responses from participants in this study was 0.89.

The Epilepsy Self-Management Scale was used to assess the frequencyof use of epilepsy self-management practices. The instrument is a 38-itemsummated rating scale with each item rated on a 5-point scale rangingfrom 1 (‘‘never’’) to 5 (‘‘always’’). Higher total scores correspond to morefrequent use of epilepsy self-management practices. An earlier 26-item ver-sion of the scale had been assessed for reliability and validity [11,13].a coefficients ranged from 0.81 to 0.86, and the scale was associated withtheoretically relevant constructs. In preparation for the research project,12 items that measure lifestyle issues and safety measures were added,yielding the 38-item version. The reliability coefficient for responses fromparticipants in this study was 0.78.

The Personal Resource Questionnaire 85 Part 2 (PRQ85-2) [15] wasused to measure social support. Each of the 25 items is rated on a 7-pointscale, ranging from 1 (‘‘strongly disagree’’) to 7 (‘‘strongly agree’’). Totalscores are calculated by summing individual responses, and higher scorescorrespond to higher levels of social support. Reliability and validity ofthe scale have been reported [16,17]. Cronbach’s a values computed forprevious samples of people with epilepsy were 0.88 and 0.90 [11,13,18].The a coefficient for the responses of the present sample of participantswas 0.91.

The Epilepsy Regimen Specific Support Scale was used to measure per-ceived support available to assist one with the tasks related to epilepsy.Each of the nine items is rated on a 5-point scale ranging from 1 (‘‘never’’)to 5 ‘‘(always’’). Total scores are calculated by summing individualresponses, and higher scores are associated with more regimen specific

Table 1Descriptive statistics for demographic and seizure variables

Variable Stratum Frequency Percentage

Age group 20 34 12.530 70 25.740 79 29.050 67 24.660 22 8.1

Gender Female 130 47.8Male 142 52.2

Race Caucasian 223 82.0Non-caucasian 49 18.0

Education Postgraduate 35 12.9College graduate 85 31.3Some college or trade 91 33.5High school graduate 56 20.6< High school 5 1.8

Income 6$10,000 41 15.4>$10,000–$30,000 67 25.2>$30,000–$50,000 61 22.9>$50,000–$70,000 44 16.5>$70,000 53 19.9

Marital status Married/partner 138 50.7Never married 80 29.4Separated/divorced/widowed 54 19.9

Employmentstatus

Work for pay 134 49.3Do not work for pay 138 50.7

Living situation Alone 57 21.0With immediate family 176 64.7Other 39 14.3

Table 2Descriptive statistics for seizure variables

Variable Stratum Frequency Percentage

Age at first seizure <50 254 93.4P50 18 6.6

Seizure in past year Yes 201 73.9No 71 26.1

Seizure type Partial 104 38.2General 115 42.3Other 8 2.9Unknown 45 16.5

Seizure control inpast year

Not applicable 73 26.8Very good control 37 13.6Fairly good control 72 26.5Little control 45 16.5No control 45 16.5

Activities restrictedin past year

All of them 60 22.1A lot of them 117 43.0A few of them 80 29.4None of them 15 5.5

Seizure severityin past year

No seizures 71 26.1Very mild 41 15.1Mild 85 31.3Severe 64 23.5Very severe 11 4.0

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support. Cronbach’s a for a sample of people with epilepsy previously test-ed was 0.84 [3,11]. The a coefficient for the responses of the present sampleof participants was 0.89.

The Patient Satisfaction Questionnaire-III (PSQ) [19] was used to mea-sure satisfaction with care. The PSQ consists of 50 items divided into sixsubscales: Interpersonal Manner, Communication, Technical Compe-tence, Time Spent with Doctor, Financial Aspects, Access to Care, anda summary index of General Satisfaction. Items are rated on a 5-pointscale from 1 (‘‘strongly disagree’’) to 5 (‘‘strongly agree’’). Reliabilityand validity have been assessed [19]. The communication subscale of thePSQ was used in the present study, and the a coefficient for responsesobserved in the present study was 0.74.

The Center for Epidemiologic Studies Depression Scale (CES-D) wasused to measure current depressive symptoms [20]. The 20 items are eachrated on a 4-point scale from 0 (‘‘rarely occurs’’) to 3 (‘‘occurs most or allof the time’’). The items are summed, yielding total scores, with higherscores corresponding to more depressive symptoms. The scale has beenassessed for reliability and validity [20]. Cronbach’s a for the responsesfrom the present sample was 0.92.

The Epilepsy Stigma Scale was used to measure stigma. This scale,which assesses the degree to which a person believes that epilepsy is per-ceived as negative and interferes with relationships with others, is a mod-ified version of the Parent Stigma Scale [21]. The 10 items are each ratedon a 7-point scale from 1 (‘‘strongly disagree’’) to 7 (‘‘strongly agree’’).Item responses are summed to yield a total score, with higher scores cor-responding to a greater perception of stigma. The scale has been assessedfor content validity and internal consistency reliability (a = 0.80), and con-struct validity [22]. The a coefficient for the responses of the participants inthe current study was 0.91.

Information was also collected on personal characteristics such as age,gender, and marital status and on characteristics of epilepsy including timesince diagnosis and severity of seizures.

2.2. Data analysis

Descriptive statistics, including skewness and kurtosis, were calculatedand examined for all variables using SPSS Version 10. Univariate generallinear models were fitted with total self-efficacy at the 3-month follow-upvisit as the dependent variable. A series of models were fitted with nonpre-dictive variables (P > 0.15) not retained in subsequent models. First, onlythe demographic variables were included in the model. Then, seizure vari-ables were added, and finally, behavioral, social and affective summaryvariables were added. Demographic variables were entered into the modelsas categorical variables. The categories for the demographic variables arelisted in the first column of Table 1. The categories for the seizure variablesare listed in the first column of Table 2. The dichotomous variable ‘‘seizurein the past year’’ was collinear with other seizure variables, so it was notemployed as a predictor variable. The ordinal seizure variables ‘‘seizurecontrol in the past year’’ and ‘‘seizure severity in the past year’’ were high-ly correlated (r = 0.68), so only the latter was employed as a predictor var-iable. The behavioral, social, and affective predictor variables from thebaseline examination were used. These variables exhibited generally linearunivariate relationships with self-efficacy, so they were entered as contin-uous variables in the models.

3. Results

3.1. Sample

Of 320 participants enrolled in the study, 3 participantswere excluded because of incomplete assessments or with-drawal after baseline. Of the 317 participants completingthe baseline examination, 272 (86%) returned for the3-month follow-up examination and completed the Epilep-sy Self-Efficacy Scale. The analyses reported included these

272 participants: 125 from Boston and 147 from Atlanta.Descriptive statistics are summarized for demographicvariables in Table 1 and for seizure variables in Table 2.The participants ranged in age from 19 to 74, with a meanof 43.7 (SD = 11.3). About 52% of the participants were

Table 3Descriptive statistics for behavioral, social, and affective variables

Variable Mean SD a Skewness Kurtosis

Self-efficacy 7.91 1.29 0.89 �0.60 0.48Self-management 3.78 .38 0.78 �0.33 �0.07Social support (PRQ) 5.52 .92 0.91 �0.64 �1.02Regimen-specific support 2.94 1.05 0.89 0.08 0.16Patient satisfaction

with communication4.07 0.75 0.74 �0.71 �0.94

Depression (CES-D) 1.79 0.59 0.92 0.97 0.07Stigma 3.69 1.56 0.91 �0.08 0.05

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male, 82% were white, and 51% were currently married orliving with a partner (Table 1). Participants were well-edu-cated, with most reporting attendance at a trade school orcollege, and almost 13% with graduate degrees. Althoughslightly more than half were not employed, close to 60%reported a household income of $30,000 per year or more.The average length of time living with seizures was 20 years(SD = 14.1), with the average age at first diagnosis of 22years. Most participants (74%) reported at least one seizurewithin the past year, and 42% of these reported some formof generalized seizure. One-third of participants reportedlittle or no control of their seizures, and 22% reportedrestriction of all activities. More than one-quarter of par-ticipants rated their seizure severity in the past year assevere or very severe.

Descriptive statistics, including Cronbach’s a, for self-ef-ficacy and the behavioral, social, and affective predictorvariables are listed in Table 3. Self-efficacy, social support,and patient satisfaction were somewhat skewed to the left,with evidence of a slight ceiling effect. Depressive symp-toms were skewed to the right. Almost 40% of participantshad CES-D scores P16, a standard cutoff for elevateddepressive symptoms.

3.2. Model testing

The initial model containing eight demographic vari-ables (age group, race, gender, educational level, incomegroup, marital status, living situation, and employment sta-tus) accounted for 7% of the total variance in self-efficacyscores at the second assessment. Of these variables, only

Table 4Results of analysis of the final modela

Source Type III sum of squares df

Corrected model 116.347Intercept 58.509Seizure severity 18.083Self-management 17.153Patient satisfaction with

communication with physician4.404

CES-D 23.554Stigma 3.817Error 273.459 26Total 17,334.575 27Corrected total 389.806 26

a R2 = 0.298(adjusted R2 = 0.277).

current employment status was significantly (P = 0.013)related to self-efficacy score. Employment status and fourseizure variables (age >50 at first seizure, seizure type,activity restriction in the past year, and seizure severity inthe past year) were entered into the second model. This sec-ond model accounted for 16% of the variance in self-effica-cy, with seizure type, activity restriction, and seizureseverity being potentially important predictors (i.e.,P < 0.15). The third model included these three seizurevariables and six variables (self-management, social sup-port, regimen-specific support, patient satisfaction, depres-sive symptoms, stigma). This model accounted for 32% ofthe total variance in self-efficacy, with seizure severity,self-management, patient satisfaction, depressive symp-toms, and stigma being potentially significant predictors.These five variables were retained in a ‘‘final’’ model sum-marized in Table 4, which accounted for 30% of the vari-ance in self-efficacy. Self-management, depressivesymptoms, and seizure severity explained the most variancein self-efficacy, as indicated in the last column of Table 4.Patient satisfaction and stigma were less importantpredictors.

4. Discussion

The purpose of this analysis was to identify the sourcesof self-efficacy information that contribute to fosteringconfidence among persons with epilepsy. Based on socialcognitive theory and a review of the self-efficacy literature,we expected that previous self-management experiences,social support, communication with the physician, depres-sive symptoms, and perceived stigma measured at onepoint in time would predict self-efficacy for epilepsyself-management behavior measured 3 months later. Theresults of the study partially support our expectations.Self-management behavior measured at baseline was astrong predictor of self-efficacy measured 3 months later,a finding consistent with self-efficacy theory. Bandura [1]states that performance of a behavior is the most powerfulsource of efficacy information because it is derived directlyfrom mastery experiences. By performing behaviors, peopledevelop and refine skills that are important in the

Mean square F P value Partial g2

8 14.543 13.881 0.000 0.2981 58.509 55.844 0.000 0.1764 4.521 4.315 0.002 0.0621 17.153 16.371 0.000 0.0591 4.404 4.204 0.041 0.016

1 23.554 22.481 0.000 0.0791 3.817 3.643 0.057 0.0141 1.04809

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continued enactment of the behavior. Our results suggestthat successful execution of strategies to control seizuresand their consequences increases a person’s confidence inability to manage epilepsy in the future. The link betweenpast performance and self-efficacy has been substantiatedin other studies on sports, exercise, and career developmentself-efficacy [7,9,10,23,24]. McAuley et al., for example,found that frequency of physical activity was a significantpredictor of exercise self-efficacy among older adults [10].The present study extends these findings to include self-management behaviors for chronic illnesses.

Our results demonstrate that participants who weremore satisfied with their physicians also expressed higherlevels of self-efficacy. This finding suggests that physiciansplay an important role in enhancing a patient’s confidencein managing his or her epilepsy. Bandura [1] maintains thatthe credibility and expertise of the person providing theencouragement are important in changing attitudes. Thus,it is not surprising that physicians, who are recognized ascredible authorities on epilepsy, would have such an impacton the participants’ attitudes toward self-managementbehaviors.

Interestingly, neither social support nor regimen-specificsupport was related to self-efficacy. This finding is in con-trast to those of other studies assessing the role of socialsupport as a source of self-efficacy [10,25]. One reason forthe lack of association in our study may be the global nat-ure of the items on the social support scale (PRQ85). Theseitems did not address epilepsy self-management directly. Incontrast, the Epilepsy Regimen Specific Support Scale didinclude items about epilepsy management. However, thelack of association suggests that providing instrumentalsupport such as reminders about medication or transporta-tion is not necessarily important in fostering confidence inmanaging epilepsy. These findings contrast with a previousstudy that reported a strong correlation between social sup-port and self-efficacy among people with epilepsy [3]. Thus,before concluding that family and friends do not play animportant role in efficacy development, future researchshould reexamine this relationship. In addition, the Epilep-sy Regimen Specific Support Scale could be refined toinclude items that assess encouragement and verbal sup-port. The items on the current scale assess only being avail-able to help an individual as needed. Although beingavailable is useful, building confidence is more stronglycorrelated with verbal persuasion and encouragement [1].

Depressive symptoms demonstrated the strongestrelationship with self-efficacy. Depression is not specific toself-management behavior, yet both often co-occur with epi-lepsy. Approximately 30% of individuals with epilepsy com-plain of depressive symptoms [26]. Our findings areconsistent with other studies that demonstrate that affectiveaspects of behaviors often influence confidence in ability tomaintain the behaviors [9,10]. It would seem that peoplefeeling hopeless or sad would find it difficult to manage theirepilepsy. Nurses and physicians seeking to foster self-efficacyshould consider the role of depressive symptoms.

According to Bandura [1], self-efficacy is enhanced whenothers like oneself overcome obstacles and succeed, butdiminished when they fail. People with potentially stigma-tizing conditions such as epilepsy live among healthy peo-ple, and through encounters with ‘‘normals,’’ they learnthat they are different and may internalize the negativebeliefs that some people hold about them [27]. The inverserelationship found between perceived stigma and self-effi-cacy in this study suggests that those who harbor negativethoughts about epilepsy also feel less confident in their abil-ity to manage epilepsy. This finding not only adds to ourunderstanding of self-efficacy for people with epilepsy; italso points out the negative consequences of stigma. Thisfinding would suggest that those who perceive high levelsof stigma feel less efficacious in managing epilepsy, which,in turn, could lead to ineffective management, the conse-quences of which might be more seizures and less indepen-dence. It is well-known that affective states associated withperformance (i.e., test anxiety) influence self-efficacy andperformance of the behavior [1]. The results of this studysuggest that more enduring feelings such as those associat-ed with depression and stigma can also affect one’s level ofconfidence in performing behaviors.

4.1. Implications

The results of this study suggest that behavioral, social,and affective factors foster self-efficacy for self-manage-ment among people with epilepsy. Health care providersseeking to increase a person’s ability to manage her orhis epilepsy should consider their own role in providingadvice and direction for self-management. Creating anenvironment in which patients feel free to discuss issuesrelated to living with epilepsy and providing supportivestatements acknowledging a person’s ability to manageare important in developing a sense of confidence. In coun-seling patients, nurses and physicians often focus on previ-ous attempts at self-management, including takingmedications as prescribed, creating a safe environment,and monitoring seizures. The results of this study suggestthat providers should also consider the role of social andemotional aspects of epilepsy that might interfere with fullydeveloping confidence in dealing with daily epilepsy man-agement issues.

4.2. Limitations

The study assessed the sources of self-efficacy for epilep-sy self-management. Data for this study were obtainedfrom a larger study on epilepsy self-management. Thus,to conduct this assessment, we were limited to the variablesincluded in the study and the data already collected. Ban-dura [1] provides a model of self-efficacy development inwhich he proposes four principal sources of self-efficacy:previous performance of the behavior, vicarious experienc-es, verbal persuasion, and physiological or affective states.People who have successfully mastered a behavior are

C. DiIorio et al. / Epilepsy & Behavior 9 (2006) 158–163 163

likely to have a strong sense of efficacy related to thatbehavior. Repeated success increases or sustains confi-dence, whereas continued failure leads to defeat and a weaksense of efficacy. Observing the performance of others alsoinfluences self-efficacy assessment. Noting the successfulperformance of people similar to oneself can enhanceself-efficacy, whereas the unsuccessful performance of oth-ers can weaken it. In the context of one’s personal beliefthat he or she possesses the skills necessary to be successful,verbal persuasion by significant others can bolster self-effi-cacy. Finally, feedback from physiological and affectiveprocesses related to behavioral performance provide infor-mation about one’s capabilities and can increase or hinderone’s performance. Because data in the present study hadalready been collected in the larger study, we were unableto test the entire model. However, based on the results ofthis study, it seems likely that these sources of self-efficacymight apply to epilepsy self-management. Further researchshould include specific measures of verbal persuasion andaffective states associated with self-management to fullytest the model. Understanding the best approaches toenhancing self-efficacy can provide avenues for interven-tions that can be delivered by health care professionals.

Acknowledgments

This research was supported by Grant R01-NR04770from the National Institute of Nursing Research and inpart by Grant M01-RR01032 from the National Insti-tutes of Health to the Beth Israel Deaconess MedicalCenter—GCRC. We acknowledge the following membersof the Project EASE Study Group: Emory University,

Atlanta, GA: Charles M. Epstein, M.D., Page Pennell,M.D., Sandra Helmers, M.D., Sandra Clements, M.S.,R.N.; Beth Israel Deaconess Medical Center, Boston,

MA: Francis W. Drislane, M.D., Steven C. Schachter,M.D., K.B. Krishnamurthy, M.D., Bernard Chang,M.D., Diane Sundstrom, R.N., BSN, Karyn Geary,R.N., N.P. We would like to acknowledge our friend,colleague, and coauthor, Richard Letz. He was instru-mental in the implementation of Project EASE and ofthe writing of this manuscript. Unfortunately, Rickpassed away on April 11, 2006 while the manuscriptwas under revision. Without his contributions, this man-uscript would not have been possible.

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