S c h o l a r l y P a p e r H e a l t h a n d R e s p o n s i b i l i t y S e l f - e f f ic a c y , s e l f - c a r e a n d S e l f - r e s p o n s ib il it y A B S T R A C T : Self-care and self-efficacy have been discussed in the medical, psychological and sociological literature (B andura, 1977b; Barofsky, 1978; Hickey, 1988; M ahler and Kulik, 1990; Mahler, 1991). H ow ever neither o f these two concepts accurately describe the beha­ viour required o f a p a tien t with a chronic disease to ensure the best outcom e o f m edical treatment. The concept o f self-responsibility seem s to be more appropriate. This article presents the definitions o f self-efficacy, self-care and self-responsibility. A n argum ent w hy self-responsibility is o f im portance in patients who have undergone bypass surgery w ill be presented. Coronary artery disease is a chronic disease, f o r which CABG is indicated only in special cases. The surgical intervention is costly and the operative outcome w ill not be successful i f the pa tien t does not com ply with lifestyle and risk fa c to r modification. In a clim ate where health costs are under scrutiny and attempts are being made to m ake the available fu n d in g accessible to a greater percentage o f the population, there is a m oral responsibility f o r patients who have undergone expensive interventions to accept the responsibility f o r their rehabilitation to ensure the optim al outcome o f these interventions. K EYW O RD S: SELF-EFFICIENCY, SELF-CARE, SELF-RESPONSIBILITY, CORONARY A R T E R Y BYPASS SURGERY, REHABILITATIO N EALES CJ, PhD; STEWART AV, MSc (Medicine)’; 1 Department of Physiotherapy, University of the Witwatersrand The concepts o f self-care and self- efficacy have been docum ented and discussed in the m edical, psychological and sociological literature (B andura, 1977b; Barofsky, 1978; Hickey, 1988; M ahler and Kulik, 1990; M ahler, 1991). H ow ever it is the perception o f the authors that neither o f these two con­ cepts accurately describe the behaviour required o f a patient w ith a chronic disease to ensure the best outcom e of medical treatm ent. The concept o f self­ responsibility seems to be m ore appro­ priate. T he three concepts self-efficacy, self-care and self-responsibility, as well their definitions will be discussed in the follow ing article. An argum ent why self­ responsibility is o f importance in patients who have undergone bypass surgery will be presented. THE CONCEPT OF SELF-EFFICACY Self-efficacy has been defined as “the CO RR E SP O N D E N C E TO: C J Eales D epartm ent o f Physiotherapy W its M edical School 7 York Rd, Parktow n 2193 Tel: (0 1 1 )4 8 8 -3 4 5 0 Fax: (0 1 1 )4 8 8 -3 2 1 0 Em ail: 159eales@ chiron.wits.ac.za conviction that one can successfully execute the behaviour required to pro­ duce the outcom es” (Bandura, 1977a). This m eans that patients have to believe that they can do w hat is required of them, to ensure that the outcom e o f the m edical treatm ent is successful. Self- efficacy is regarded by som e as the m ost im portant prerequisite for behavioural change, because it affects how m uch effort the patient will invest in a given task (E w art et al, 1983). Successful repetition o f sim ple tasks will enhance a person’s perform ance expectancy and therefore his/her sense o f self-efficacy. By sim plifying each step o f the required health b e h a v io u r and allo w in g the patient to practise each step in isolation the result will be that the patient builds a sense o f self-efficacy about perform ­ ing each step (G lanz et al, 1997). As the patient gains confidence in accom plish­ ing each step, the steps can be put together so that a sense o f self-efficacy for accom plishing the entire task will prevail. One o f the im portant goals of health education is to bring the perfor­ m ance o f health behaviour under the control o f the patient (G lanz et al, 1997). Self-efficacy has an im portant role in self-control because it will affect the extent to which patients will m ake an effort to change their behaviour patterns. Definitions of self-efficacy B andura (1977b) defined self-efficacy as “the conviction that one can success­ fully execute the behav iour required to produce the outcom es” . Self-efficacy is the m ost im p o rtan t p re req u isite for behavioural change (Ew art et al, 1983) and a lack o f self-efficacy prevents patients from taking a recom m ended health action (G lanz et al, 1997). THE CONCEPT OF SELF-CARE. In the 1970’s the concept o f self-care caused a controversial discussion amongst A m erican health care w orkers (DeFriese et al, 1994). T hese health care workers regarded this as a counter m edical m es­ sage that advocated a stronger and m ore central role for patients in clinical deci- sion-m aking. H ealth care workers felt that they w ere reduced to secondary status by the concept o f self-care and that, as such, they w ould be in a subm is­ sive and inferior role to the patient. Investigators in the field o f self-care envisaged self-care as a form o f lay education to im prove personal health functioning that could em pow er and protect the individual from “the som e­ tim es negative consequences o f profes­ sio n alizatio n and m e d ic a liz a tio n ” o f health in our m odern society (Barofsky, 1978; B utler et al, 1979). 20 SA J o u r n a l o f P h y s io th e ra p y 2001 V o l 57 No 1 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) mailto:159eales@chiron.wits.ac.za Som e researchers defined self-care in a way that included the active partici­ pation o f the patient in a collaborative partnership w ith the health care worker. Such a health interaction w ould subse­ quently relieve the health care w orker o f the total responsibility for health care decisions that affected p atients’ lives (Stoller et al, 1993). Towards the end o f the 1980’s the c o n ce p t o f self-care w as form ally accep ted in the literatu re and w ithin the practice o f m edicine (Hickey, 1988; Dean, 1986). A ccording to D eFriese et al (1994) findings from m any studies o f self-care educational program m es sh o w ed that p a tien ts w ere b eing instructed on certain skills that were low risk and easily taught to the lay public, that w ould enhance health. H aug et al (1991) describes self-care as a response behaviour to a perceived sym ptom w ithout the involvem ent o f physicians. It has been suggested that the decision not to accept medical care in certain situations could also be classi­ fied as self-care (Stoller et al, 1993). In contrast to the two above statem ents, the W H O describes self-care as an inter­ action b etw e en the p atien t and the p h y sician im plyin g that the p atien t w ould take positive action for his/her ow n health (D eFriese et al, 1994). T he follow ing is a sum m ary o f the significant points o f the W H O ’s defini­ tion (W HO , 1983): 1. It states that self-care is intentional, with the aim o f m aking a positive contribution to health through certain actio n s that w ill p re v en t disease, lim it illness and restore health. It also im plies that the individual will m ake a positive effort to im prove the exist­ ing state o f health w hich may be a chronic condition. 2. To im plem ent these strategies the individual would have to have tech­ nical k n o w led g e and skills. T his m eans the know ledge o f the required health behaviour and the know ledge to im plem ent these and in this way effect changes in lifestyle. 3. T his definition im plies participative collaboration betw een the individual seeking medical assistance and the health-care worker, with the purpose o f enhancing diagnosis and therapy as well as the m aintenance o f optimum levels o f health. The definition given by the W HO im plies that the patient will act in a responsible m anner and for their defi­ nition the term “s e lf-re sp o n sib ility ” could be considered m ore appropriate than “self-care” . B ecause o f the free interpretation o f self-care in the litera­ ture, it is not considered an appropriate term to describe the required action o f patients to ensure the optim al outcom e o f a m edical intervention. The definition of self-care The definition o f self-care as suggested from the lite ra tu re is then that the patient will act in a responsible m anner with regard to the m aintenance o f opti­ mal health and that the patient will take positive action. THE CONCEPT OF SELF-RESPONSIBILITY In the O xford D ictionary (1992) respon­ sibility is defined as being m orally accountable for actions. Therefore self­ responsibility means that an individual can be held m orally accountable for his/her or her actions regarding the self. This can be in a physical sense, a psychological (attitudinal) sense or an educational sense. “M oral” is described in the O xford D iction ary (1992) as “being concerned with the accepted rules and standards o f hum an behaviour (of rights and duties)” . Self-responsibility im plies the moral duty o f the patient to successfully execute the required health behaviour for im proved health. I f a patient makes a decision not to have any treatm ent w hen treatm ent that has been know n to have value is avail­ able, and this behaviour is identified as a part o f the definition o f self-care (Dean, 1986; Stoller et al, 1993), then self-care cannot possibly have the sam e m eaning as self-responsibility. H aug et al (1991) defined self-care as a response beha­ viour to a perceived sym ptom without the involvem ent o f physicians. Such a definition w ould imply that there is a difference between self-care and self­ responsibility. Self-responsibility implies know ing the correct action to take and also taking the correct action. Self-efficacy is the sub ject’s appraisal o f his/her ability to cope w ith a specific situation. It is the p atient’s perception o f h is/h e r control over the disease (Cunningham et al, 1991). Self-efficacy m ay be an aspect o f self-responsibility b u t self-responsibility is m ore than the b elief in the ability to control a situation, it im plies a responsibility for control o f the situation. Definition of self-responsibility Self-responsibility is the necessary action for an optim al health outcom e and can be defined as the moral duty o f the patient to successfully execu te the required health behaviour for im proved health. Responsibility for health The issue o f w ho is responsible for the health or illness o f an individual is one w hich has not yet produced an answer but has elicited m any opinions (W allston and W allston, 1982). As stated before, m any patients and indeed m ost physi­ cians regard doctors as the ones who are prim arily responsible. A m edical problem is after all for the doctor to rec­ tify. There are how ever people who believe that the ultim ate responsibility for health lies with the individual and if it does not, it should. G inzberg as far back as 1977, stated that im provem ent in any health care system would not be e ffectiv e unless the citizen b ecam e responsible for his/her own well-being. M ost people are not concerned about their health until they lose it. In many cases preventing disease m eans that the individual m ust give up certain habits, o f w hich sm oking is a good exam ple, or do things w hich require an effort such as exercising regularly. T he freedom of the individual to m ake h is/h er own decisions regarding his/her health puts trem en d o u s p re ssu re on go v ern m en t resources for health care. This results in an increase in taxes so that “one m a n ’s freedom in health is another m an ’s shackle in taxes and insurance prem ium s” (K now les, 1977). Eventually this becom es a national and not an individual responsibility. K now les 1977 argues that the “right” to health should be replaced by a moral obligation to preserve o n e ’s health. T he individual then w ould have the “right” to: SA J o u r n a l o f P h y s io th e ra p y 2001 V o l 57 No 1 21 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) • B etter and m ore inform ation • A ccessible services o f good quality • M inim al financial barriers to these services M ore doctors and m ore expensive hospitals will not im prove health. Indi­ viduals w ho are w illing to take respon­ sibility for them selves and follow rea­ sonable rules for healthy living can possibly extend their productive working life by avoiding disease and disability. If this is the case for the healthy indi­ vidual, then the individual w ho has had costly intervention because o f disease processes should be responsible enough to follow the prescribed lifestyle changes to m aintain his health. If a hum an person is “a life lived according to a plan” then it seems logical that the person should take responsibi­ lity for that plan especially when chronic disease interferes w ith lifestyle. This sense o f self-responsibility in chronic disease is probably the best predictor of reduction o f disability and handicap (O ldridge, 1986). It is im portant to bear in m ind that persons w ith chronic disease are often m ore reliant on fam ily m em bers and health professionals for care (W allston and Wallston, 1982). In order to success­ fully becom e responsible the patient and the fam ily members should be considered m em bers o f the medical team and be provided w ith inform ation about the disease, the treatm ent o f the disease and the rehabilitation process. In conclusion it can be said that self­ responsibility is the successful execution o f the required behaviour. M ost outcomes flow from actio n s (B and ura, 1986). Being proactive means recognising the responsibility to m ake things happen. A proactive patient will be responsible for his own life. Relevance of the concept of self-responsibility in patients who have undergone CABG surgery In 1986, Neil O ldridge reflected on the g oals o f card iac re h a b ilita tio n and su g g ested that c ard iac reh ab ilitatio n should not only focus on issues such as im proved quality o f life but also on the issue o f the acceptance o f self-responsi­ bility for rehabilitation. He also drew a ttention to the com m o nly accep ted definition o f cardiac rehabilitation that reinforced the concept that the surviving cardiac patient should be “restored to, and m aintained at” optim al clinical, psy­ chological, vocational and social status. This definition im plied that the health­ care w orker w ould do this for the patient. T he d efinition o f the W orld H ealth Organisation (1964) on the other hand su g g ested th at p atien ts take som e responsibility for their rehabilitation so that they can regain as normal as possi­ ble a place in the com m unity and lead an active, productive life. To be consis­ tent w ith the W HO concept o f rehabili­ tation patients should be encouraged to b ecom e in creasin g ly self-resp o n sib le for their own active and productive life (Pashkow et al, 1988). This means that they essentially have to becom e respon­ sible for im proving their own quality o f life (Oldridge, 1986). Important concepts from the literature on health behaviour that may influence self­ responsibility The im portance o f behavioural and psy­ chological factors in the cause and treat­ m ent o f disease is becom ing clear. In addition there is a grow ing feeling that patients should becom e m ore involved with their own care (M ahler, 1991). Two m ethods by w hich patients can becom e involved in their ow n treatm ent w ere identified by Krantz et al, in 1980. Patients may seek “inform ation involve­ m ent” by learning everything about the condition such as the diagnosis, progno­ sis, treatm ent plan and m edication. The second w ay in w hich p a tien ts m ay desire involvem ent is by “behavioural involvem ent” and this is m anifested by getting involved in self treatm ent w hen­ ever possible, requesting specific m edi­ cations and delaying seeking treatm ent by a health care worker. Inform ation-seeking copers are gener­ ally believed to be m ore distressed than patients w ho seek behavioural involve­ ment, especially when there has not been adequate preparation o f the patient prior to the medical treatm ent. In contrast, patients who seek behavioural involve­ m ent before surgery have been shown to start w alking (am bulate) sooner after the operation and are also discharged sooner (M ahler and Kulik, 1990). The bulk o f the research investigating information involvem ent and behavioural involvem ent is in the acute care setting. The only study exam ining these two patterns in a chronic setting that could be identified in the literature was one by M ahler and Kulik (1991). They stated that as chronic diseases place greater responsibility on patients, it is m ost desirable that these patients becom e involved in their own treatm ent. They studied 83 male patients adm itted for non-em ergency CA BG surgery using the H ealth O pinion Survey (HOS). The HOS was adm inistered to patients pre- operatively, and at one m onth, four m onths and 13 m onths postoperatively. The significant results from this study were that patients with high behavioural involvem ent had less am bulation dys­ function at one month postoperatively (p=0.006); few er social interaction p ro ­ blem s at four m onths postoperatively (p=0.01); and had consulted a doctor significantly less often in connection with “heart problem s” at 13 m onths (p=0.02). T hey c o n c lu d e d th at p atien ts w ho desired behavioural involvem ent with their treatm ent w ere “m otivated by a basic desire to exert som e control over the situation” w hereas patients who have a desire for inform ation involvem ent reflected a “desire to reduce uncertainty and arousal rather than control disease per se” (M ahler, 1991). At this stage one should probably also consider the theory that the focus o f attention influences health care out­ com es. Focusing attention on objective, concrete aspects o f an experience will be m ore beneficial than focusing on the em otional or affective aspects especially in term s o f long-term outcom e (Suls and Fletcher, 1985). In a study by King et al (1992) two groups o f patients w ere identified who thought that the surgery was worth it. One group believed it was w orth it b ecau se they ex p e rie n c e d im p ro v ed function and the other because it saved them from death or m yocardial infarc­ tion. In these two groups, patients who reported im proved functional capacity had more positive scores on life satisfac­ tion and mood states. Those who believed they w ere saved from death or a more serious illness scored the same on life 22 SA J o u r n a l o f P h y s io th e ra p y 2001 V o l 57 No 1 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) satisfactio n and m ood states as the patients who reported no benefit from the surgery. The follow ing questions com e to mind: • Are self-responsible patients more focused on objective and concrete aspects o f m edical care? • W h at is the relatio n sh ip betw een focus o f attention and involvem ent preferences? In conclusion one can therefore say that self-responsibility is the successful execution o f the required health beha­ viour to bring about improved health. The concept includes aspects o f self-care and self-efficacy but extends beyond both concepts. It im plies that the indi­ vidual is m orally accountable for his/her actions regarding his/her health. T he p a tie n t’s accep tan ce o f self- responsibility for his/her medical care will im pact on the social behaviour o f the patient and will have an effect on all who com e in contact with the patient. For this reason the spouse should be included when doing a survey on self­ responsibility. If the patient accepts the responsi­ bility for his/her health care when suf­ fering from a chronic disease, then the focus o f the health care team should be on the patient playing the most active role and the health care w orker becom ­ ing m ore passive but always rem aining supportive. BEHAVIOUR AND BEHAVIOUR CHANGE In 1996 M cG innis stated that certain behaviours that lead to a decline in the w ell-being o f individuals, com m unities and populations, although m ost disturb­ ing, were fundam ental to civilisation (M cG innis, 1997). He goes on to say that poor individual behavioural choices have been docum ented as the source o f perhaps h alf o f all prem ature deaths that occur (M cG innis, 1997). The evidence is overw helm ing that C A D is not a consequence o f old age but is a chronic lifestyle disease. It is also evident that the tem po o f the atheros­ clerotic process can be changed even in the presence o f significant disease if attention is given to risk factor m anage­ m ent (Sm ith, 1997). In order to success­ fully rehabilitate patients with coronary a th ero sclero tic heart disease, certain b eh av io u rs th at are detrim en tal to health, have to be changed. This requires know ledge, skills and the active parti­ cip atio n o f the in dividual involved. W hat makes this process difficult is that patients are generally resistant towards attending special program m es w hich assist in changing unhealthy lifestyle behaviours. W hat m akes it even more difficult is that behavioural intervention does not result in im m ediate gratifica­ tion; change com es slowly and som e­ tim es it seems that very little is being achieved (National Centre for H ealth Statistics, 1987). Preventative and health prom oting behaviours aim at achieving the m ainte­ nance o f good cardiac health, a reduction in the likelihood o f developing CAD, and favourably intervening in the rate of progression o f the existing CAD. The problem o f regim en adherence is well docum ented in the medical lite­ rature and it has not changed m uch in the past twenty years. Up to 80% o f patients will not follow the prescribed treatm en t pro g ram m e su fficien tly to attain therapeutic benefit (Dunbar-Jacob et al, 1995). This problem extends over different age groups, diagnoses, socio­ econom ic strata as well as different treatm ent regim es. All patients may be at risk for non-adherence to the thera­ peutic regim en prescribed and the prac­ titioner needs to advise patients in a way that will support adherence. D eB u sk (1996) states that m any physicians are not com fortable with risk factors m odification based on b eh a­ vioural principles. He feels that they lack the com petency required for suc­ cessful risk factor m odification and also because the results o f risk factor m odi­ fication can not be as easily observed as the results o f an acute intervention. W hen m aking these statem ents he rein­ forces the statem ent by M um ford et al (1982) that “T he elaborate services pro ­ vided in the surgical recovery room or the coronary care unit leave little to chance. They contrast m arkedly with the m inim al atten tio n sy stem atically provided to educate patient and fam ily fo r recuperation follo w ing ho sp itali­ sation. In an action-oriented society, reports o f m odest interventions may com m and less attention than reports o f the m odest effects o f more flam boyant interventions” . A review o f the literature on CA BG surgery, risk factor m odification, quality o f life and self-respo nsibility w ould thus not be com plete w ithout a b rief com m entary on aspects o f behaviour m odifications. A ccording to O ckene and O ckene (1992) there are four im portant theories to consider when hoping to achieve behavioural change in patients with CAD. These four theories are: The C o n su m er In fo rm atio n P ro cessin g Theory, Social Cognitive Theory, The H ealth B elief M odel, and the Stages o f Change Model. The follow ing is a sum m ary o f these theories as explained by O ckene and O ckene (1992) with the addition o f one more model, The Theory o f R easoned A ction, regarded by Glanz et al (1997) as important. THE CONSUMER INFORMATION PROCESSING THEORY This theory explains the factors that influence the processing o f know ledge and the effect o f know ledge on health behaviour. In order to make rational d ecisio n s, kno w led g e is essen tial. K now ledge also has an im portant influ­ ence on hum an behaviour. A lthough know ledge is very im portant, it alone is not sufficient to ensure health-enhanc­ ing behaviours (Rudd and Glanz, 1990). To illustrate this point, Schucker et al (1987) rep orted that alth o u g h m any adults believe that cholesterol reduction would have a favourable effect on CAD, they continue to eat high fat diets. There are a num ber o f essential conditions nec­ essary for a patient to make use o f avail­ able inform ation. These are: the infor­ m ation m ust be available; the patient m ust want the inform ation and believe it; the patient m ust have the tim e, the energy and ability to com prehend this inform ation; and it m ust not be confus­ ing. O nce the patient has the necessary info rm atio n they m ay still lack the m otivation, the skills, the support or the resources to act on the inform ation. The factors that will enable them to do so are explained by the social learning theory and the health belief model. SA J o u r n a l o f P h y s io th e ra p y 2001 V o l 57 No 1 23 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) THE SOCIAL LEARNING THEORY (SOCIAL COGNITIVE THEORY) This theory em phasises that as m ost behaviours are learned, they can also be unlearned or changed (Perry et al, 1990). It states that a person is able to self- m anage behaviour and that active partic­ ipation is needed in learning and the application o f behaviour-changing skills. H ealth is constantly interacting w ith - and being influenced by - m any different determ inants. No single factor is suffi­ cient to totally influ ence behaviour. T hese m ultip le d e term in a n ts are: personal characteristics o f the patient (co g n itiv e factors, p erso n a lity and dem ographic factors); environm ental influences (social, cultural and econom ic factors); o th er associated behaviours e.g. a patient trying to stop sm oking and taking alcohol instead. Physiological and/or pharm acological factors such as drug addiction or other addictive pat­ terns such as sm oking, over-eating and alcohol abuse m ay also be associated factors (Bandura, 1977b). C ognitive factors include knowledge, thou g h ts, a ttitu d es and skills. T he social learning theory states that when a ttach in g th oughts o r feelin g s to certain behaviours, these behaviours can becom e habits. Therefore thoughts or feelin g s can trig g e r b eh av io u ral resp o n se s. To illu strate this point, c o n sid er in d iv id u als w ho e a t w hen becom ing anxious because they have experienced in the past that eating allays anxiety. Eventually the urge to eat may appear so rapidly that they no longer realise that there is an association with anxiety (O ckene and Ockene, 1992). T hese patients need to be helped so they can identify triggers and reinforcem ents o f behaviour. N ot only do they need to identify them but m ust learn how to control them and find reinforcem ents for appropriate preventative behaviours. THE HEALTH BELIEF MODEL A cco rd in g to R o sen sto ck (1990) an appreciation o f the know ledge and the attitude o f a patient will facilitate the understanding o f the p a tien t’s m otiva­ tion and the likelihood that the patient will adhere to a specific health behaviour change. This m odel em phasises that beliefs held by an individual form the basis o f that p erson’s decisions regard­ ing health care. In the health belief model several factors are suggested that may influence the likelihood that a patient will com ply with preventative action. Patients are m ore likely to take action if they believe that they are personally vulnerable to a given condition such as CAD. They will also take action if they believe that there will be serious conse­ quences if they do not take action. They will take action if they believe that by doing so they will decrease their risk and that the cost o f the action will be outw eighed by the benefits (Rosenstock, 1990). These concepts help to explain why individuals w ho have had a m yocardial infarct are more likely to stop sm oking or chang e th e ir eatin g hab its than patients w ho still have no sym ptom s o f any illness. By providing a patient w ith inform ation on the atherosclerotic pro cess and exp lain in g the personal relevance to him, a health behaviour change m ay be induced if the patient understands the personal risk involved. THE STAGES OF CHANGE MODEL This model em phasises that behaviour ch an g e is an ex te n d e d p ro cess and occurs in stages. U sing sm oking as an exam ple: it can often take a patient five to ten years to successfully break the habit o f sm oking and there may be a num ber o f attem pts before the patient finally succeeds (Prochaska and DiClem ente, 1983).The stages o f beha­ viour change include precontem plation, contem plation, preparation, action and m aintenance o f the altered behaviour. M aintenance o f the altered behaviour is usually regarded as successful if the patient can m aintain the altered health behaviour for a period o f at least six m onths. T hese stages are cyclical rather than linear and so if a patient relapses into his/her old behaviour it is com m on to cycle back to the precontem plation or contem plation phases. This model is im portant because the health w o rk er’s intervention and encour­ agem ent in the various stages m ay spur the patient on to taking action. It is also im portant that health workers realise that this is a process so that they do not alien­ ate the em barrassed relapser. The sm oker who has m anaged to quit sm oking for three m onths and then resum es the habit should not be regarded as a failure but rather as som eone w ho is learning and does not find the process easy. THE THEORY OF REASONED ACTION From the above behavioural m odels it is clear that in order for a patient to m odify their health behaviour they have to have the know ledge to do so but know ledge alone is not enough and does not guarantee behaviour m odification. T he T h eo ry o f R easo n ed A ction is concerned with the relations between beliefs, attitudes, intentions and beha­ viour (G lanz et al, 1997). A ccording to this theory the m ost im portant deter­ m inant o f beh av io u r is the p e rso n ’s behavioural intention. T he behavioural intention is determ ined by the p erson’s a ttitu d e and his su b jectiv e norm . A ttitude is determ ined by an indivi­ d u a l’s beliefs about the outcom e o f perform ing a certain behaviour and the im portance they attach to that outcom e. The subjective norm o f a patient is determ ined by his/her norm ative beliefs (w hether people he regards as im portant w ould approve or disapprove o f the behaviour) and m otivation to com ply (w hether he is m otivated to com ply with the w ishes o f those referents). B ehavioural beliefs and norm ative beliefs are linked to behavioural inten­ tion w hich in turn w ould lead to a sp e cific b e h a v io u r (M ontano et al, 1997). This m ay be the reason why patients respond favourably to recom ­ m endations m ade by their physicians. SUMMARY From this literature review one can conclude that CA D is a chronic disease, for w hich C A B G is indicated only in special cases. T he operative outcom e will not be successful if the patient does not com ply with lifestyle and risk factor m odification. The surgical intervention is costly and in a clim ate w here health costs are under scrutiny and attem pts are being made to m ake the available fund­ ing accessible to a greater percentage o f the pop u latio n , there is a m oral resp o n sib ility fo r patien ts w ho have undergone expensive interventions to accept the responsibility for their reha­ 24 SA J o u r n a l o f P h y s io th e ra p y 2001 V o l 57 No 1 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) bilitation to ensure the optim al outcom e o f these interventions. It is obvious that the barriers to the assum ption o f self-resp o n sib ility for o n e ’s ow n health are lack o f knowledge, lack o f sufficient interest in what is preventable, and a culture which progres­ sively erodes the idea o f individual responsibility while stressing individual rights. Patients have to overcom e these barriers and becom e self-responsible in order to experience an im proved quality o f life (K now les, 1977). The hypothesis can thus be made that for patients with chronic diseases to be considered success­ fully rehabilitated, they should accept responsibility for their own rehabilitation REFERENCES B andura A 1977 (a) Self-efficacy: tow ard a unifying theory o f behavioural change. Psych R ev 84:191-215. B andura A. 1977 (b) Social L earning Theory. E n g lew o o d C liffs, N J:Prentice-H all. B a n d u ra A 1986 S ocial fo u n d a tio n s o f th ought and action. A social cognitive theory. P rentice-H all Inc., E nglew ood C liffs, New Jersey, pp 390-453. B a ro fsk y I 1978 C o m p lia n c e , a d h e re n c e and the th erap eu tic alliance: Steps in the d e v e lo p m en t o f self-care. Social S cience and M ed ic in e 12:369-376. B u tle r R N , G ertm an JS , O b e rla n d e r DL, S c h in d ler L. 1979. Self-care, self-help and the elderly. International Journal o f A geing and H um an D ev elo p m e n t 10: 95-119. C un n in g h am A J, L ockw ood G A, C unningham JA 1991 A relationship betw een perceived self-efficacy a n d quality o f life in can cer patients. P a tient Education and C ounseling 17:71-78 D ean K. 1986. L ay care in illness. Social S cience and M edicine 22: 275-284. D eB u sk R F 1996 M ultifit: A new approach to risk facto r m odification. C ardiology C linics 14:143-157 D e F rie s e G H , K o nrad T R , W o o m e rt A, N o rb u m JE K , B ernard S. 1994 S elf-care and q uality o f life in old age. In: A beles RP, G ift H C , Ory M G (eds) A geing and quality o f life.pp 99-117. D u nbar-Jacob J, B urke LE, Puczynski S 1995 C linical assessm ent and m anagem ent o f adher­ ence to m edical regim ens. In: N icassio PM , Sm ith T W (eds) M anaging chronic illness: a biophysical perspective. American Psychological A ssociation, 750 First S treet N E, W ashington DC pp 313-349 E w a rt C K, T aylor C B, R esse L B, D eB usk R F I 983 E ffe c ts o f ea rly p o s t m y o ca rd ia l infarction exercise testing on self-perception and su b sequent physical activity. A m erican Journal o f C ardiology 51: 1 0 7 6 - 1080 G lanz K, L ew is FM , R im er B K eds. Health behavior and health education: theory, research and p ractice 1997 Jo sse y-B a ss P ublishers, San Francisco. G inzberg E 1977 T he sacred cow s o f health m anpow er. M an and M edicine 2: 235 - 242 H aug M R , Tryban H, S onoda K, Sykle M. 1988. Self-care: Japan and the U.S. com pared. Social S cience and M edicine 33:1011-1022. H ickey T. 1988 S elf-care behaviour o f older adults. Family and C om m unity Health 11:23-32. K ing KB, P o rter L A , N orsen LH , R eis HT 1992 Patient perception o f life after coronary artery surgery: Was it w orth it? R esearch in N ursing and H ealth 15:327-334 K now les J H 1977 R esponsibility for health. S cience 198: 4322 (editorial) K rantz DS, B aum A, W idem an M W 1980 A ssessm ent o f preferences for self-treatment and inform ation in health care. Journal o f P ersona­ lity and Social Psychology 39: pp 977-990 M ahler H IM , K ulik JA . 1990 Preferences for health care involvem ent, perceived control and surgical recovery: A prospective study. Soc. Sci. M ed 31:743-751. M ahler H IM . 1991 H ealth care involvem ent p references and social-em otional recovery o f m ale coro n ary -artery -by p ass patients. H ealth Psychology; 10:399-408. M cG innis M J Forew ord pp X V-XVI. In: G lanz, L ew is F M , R im er B K (eds) 1997 Health behaviour and heal education: theory, research and practice. Jossey-B ass Publishers, San Francisco M ontano D E, K asprzyk D, Taplin S H The theory o f reasoned action and the theory o f planned behaviour pp85 - 112. In: Glanz, Lewis F M , R im er B K (eds) 1997 H ealth behaviour and heal education: theory, research and p ra c­ tice. Jossey-B ass P ublishers, San Francisco M um ford E , S chlesinger H J, G lass G V 1982 T he effects o f psychological intervention on recovery from surgery and heart attacks: An analysis o f the literature. A m erican Journal o f Public H ealth 72: 1 4 1 -1 5 1 N ational C enter for H ealth S tatistics, N ational Heart, L ung and B lood C o llab o rativ e L ipid G roup. Trends in serum cholesterol levels am ong US adults aged 20 to 74 years: data fro m th e n a tio n a l H e a lth an d N u tritio n E xam ination Surveys, 1960 to 1980. JA M A 1 9 8 7 ;2 5 7 :9 3 7 -9 4 2 . O ckene IS, O ckene JK 1992 P revention o f C oronary A rtery D isease. L ittle, Brow n and Com pany. B oston. 103 - 122; 173 - 199. O ldridge N B 1986 C ardiac R ehabilitation, S e lf-re s p o n s ib ility , a n d Q u a lity o f L ife . Jo urnal o f C a rd io p u lm o n ary R ehabilitation 6: 153 - 156 O xford D ictionary 1992 Pashkow F, P ashkow P, S chafer M . 1988 Successful C ardiac R ehabilitation. AB H irsch- feld P ress Inc. U SA . pp 253 - 287. Perry C L, B aranow ski T, Parcel G S How in d iv id u a ls, e n v iro n m e n ts, a n d h ea lth behaviour interact: Social L earning T herapy p 16 f - 186. In: G lanz K, L ew is F M , R im er B K (eds) 1990 H ealth B eh av io u r and health E d u c a tio n , Jo s s e y -B a s s P u b lish e rs, San Francisco P rochaska J, D iC lem ente C. 1983 S tages and Processes o f self-change o f sm oking: tow ard an integrative m odel o f change. J C ounseling and C linical Psych 51: R osenstock IM . 1990 T h e health b elief m odel an d p erso n al h e a lth b e h a v io u r th ro u g h ex pectancies. In: G lanz K, L ew is FM , R im er BK (eds). H ealth behaviour and health e d u ­ cation: theory, resea rc h and p ractice. San Francisco: Jossey-B ass Publishers. R udd J, G lan z K. 1990 H ow individuals use inform ation for health action: co n su m er inform ation processing. In: G lanz K, L ew is FM , R im er BK (eds). H ealth behaviour and health education: theory, research and p ra c ­ tice. San F rancisco: Jossey-B ass Publishers. S c h u ck er B, B ailey K, H eim bach JT. 1987 C h ange in public perspective on cholesterol and heart disease: results from tw o national surveys. JA M A 258: 3521-3526. Sm ith S C 1997 T he ch a llen g e o f risk red u c­ tion th erap y for c a rd io v a s c u la r d ise ase. A m erican Fam ily Physician 55: 491 - 500 S toller EP, F o rsy er L E, Portugal S. 1993. Self- care responses to sym ptom s by o ld er persons: a health diary study o f illness behaviour. M edical C are 3 1 :24-42. Suls J, F letcher B 1985 T he relative efficacy o f avoidant and non av o id an t coping strategies: A m e ta -a n a ly sis. H e a lth P sy c h o lo g y 4: 249-288 W allston KA, W allston B S: W ho Is R espon­ sible for Your H ealth? The co n stru ct o f H ealth L ocus o f Control pp65 - 67. In: S anders G S, Suls J (edsO 1982 Social Psycholgoy o f health and Illness. L aw rence E rlbaum A ssociates, H illsdale, N ew Jersey W orld H ealth O rganization 1964 R eh ab ili­ tation o f patients w ith cardiovascular diseases: rep o rt o f a W H O E x p ert C om m ittee. G eneva W orld H ealth O rg a n iz a tio n . 1983. H ealth e d u c a tio n in s e lf-c a re : p o ss ib ilitie s and lim itations. R ep ort o f a scientific consultation. G eneva: N ovem ber, 21-25. SA J o u r n a l o f P h y s io th e ra p y 2001 V o l 57 No 1 25 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )