Interdisciplinaria, 2019, 36, 1, 23-32

Influence of psychosocial factors on self-efficacy

The influence of self-perceived health status, social support and depression on self-efficacy among Brazilian elderly people

La influencia del estado de salud autopercibido, el apoyo social y la depresión en la autoeficacia de ancianos brasileños

Ana Luisa Patrao*, Vicente Paulo Alves** and Tiago Sousa Neiva***

*PhD in Health Psychology. Visiting Professor in Institute of Collective Health, Federal University of Bahia.

E-mail: luisa.patrao@ufba.br

**PhDin Science of Religion. Coordinator of the Post-Graduate Program in Gerontology, Catholic University

of Brasilia. E-mail: tutorvicente@ucb.br

***Master in Gerontology. Doctor of Family and Community Medicine in Department of Health (Secretaria de
Saude) of the Federal District. E-mail: tiagoneiv@gmail.com

Granja do Torto, Brasilia, Distrito Federal (DF), Brasil.

 

 

 

Resumen

El objetivo de este estudio fue identificar los predictores psicosociales de la autoeficacia ge­neral en una muestra de ancianos brasileños. La autoeficacia ha sido reportada como una varia­ble de gran importancia para la salud de las per­sonas mayores. Entre las personas mayores, los niveles más altos de autoeficacia se asocian con menor incapacidad, malestar psicológico, sínto­mas depresivos, buena salud percibida y mayor adaptación al dolor. En este estudio participaron 144 pacientes de la Unidad Básica de Salud en Granja do Torto (Brasilia, Brasil). La muestra era consecutiva. Los datos fueron recogidos a través de un cuestionario que incluyó preguntas sociodemográficas (color, edad, educación, es­tado civil, situación laboral y número de perso­nas de otras generaciones con las que mora) y escalas para las dimensiones psicosociales estu­diadas (estado de salud autopercibido, apoyo social percibido, depresión y autoeficacia ge­neral). La muestra estaba constituida mayorita- riamente por mujeres (58.3%). La edad prome­dio era de 69.3 años (SD= 6.61), con edades que oscilaban entre 60 y 89 años. La mayoría eran blancos y morenos, con menos de 8 años de educación; tenían un compañero estable, vivían con familiares de otra generación y no trabaja­ban (estaban jubilados). El estado de salud auto- percibido, el apoyo social percibido y la depre­sión explicaron el 37.2% de la varianza (AF (3, 140)= 29.20, p= .000). Los participantes que te­nían un nivel más alto de apoyo social percibido (P= .25), un estado de salud autopercibido posi­tivo (P= .30) y niveles más bajos de depresión (P= -.28) tenían niveles más altos de autoefica­cia general. Es muy importante promover ac­ciones comunitarias que ayuden a las personas mayores a disminuir los niveles de depresión y a aumentar los niveles de estado de salud auto- percibido y el apoyo social percibido. Por lo tanto, se contribuirá al aumento de la autoefica- cia en las personas mayores, una variable extre­madamente importante en la salud y el bienestar de esta población específica.

Palabras clave: Autoeficacia; Predictores psico- sociales; Personas mayores.

Abstract

The aim of this study was to identify the psychosocial predictors of general self-efficacy in a sample of Brazilian elderly people. Self-ef­ficacy has been reported as a variable of great importance for elderly people’s health. Among them, higher self-efficacy levels are associated with lower inability, psychological distress, de­pressive symptoms, good perceived health and higher pain adjustment. One hundred and forty- four patients participated in this study. They were all patients of the Health Basic Unit at Granja do Torto (Brasilia, Brazil). The sample is consecutive. The data were collected through a questionnaire that included sociodemographic questions (colour, age, education, marital status, occupational situation and number of people of other generations that you live with) and scales for the studied psychosocial dimensions (self- perceived health status, social support, depres­sion, and general self-efficacy). The sample is mostly (58.3%) constituted by women. The ave­rage age is 69.3 years old (SD= 6.61), with par­ticipants being from 60 to 89 years old. The ma­jority were white and brown people, with less than 8 years of education; they have a stable partner, live with family members of another generation, and do not work (they are retired). Self-perceived health status, social support and depression explained 37.2% of variance (AF(3, 140)= 29.20, p= .000). The participants who had a higher level of perceived social support (P= .25), a positive self-perceived health status (P= .30) and lower levels of depression (P= -.28) had higher levels of general self-efficacy. Future interventions under the scope of health promo­tion in elderly people must consider these de­terminants in order to increase their efficacy. It is very important to promote community actions that help elderly people to decrease depression levels and increase levels of positive self-per­ceived health status and perceived social sup­port. Thus, we will contribute to self-efficacy in­crease in elderly people, an extremely important variable in health and well-being among this specific population.

Keywords: Self-efficacy; Psychosocial Predic­tors; Elderly People.

The self-efficacy concept was introdu­ced by Bandura and it is the belief that it is possible to control our own motivation, thin­king processes, emotional states, and beha­vior patterns (Bandura, 1994; 1997). This construct defines that people tend to avoid the situations that they think surpass their ca­pabilities and to face the ones they think they are capable of managing (Ribeiro, 1995). Thereby, the higher the efficacy per­ception, the more persistent is the effort to­wards a specific behavior (Costa & Leal, 2005). Self-efficacy can be understood as a global and stable belief of being capable of controlling certain environmental challenges (Schwarzer & Jerusalem, 2000). That is, the authors agree that self-efficacy is an indivi­dual belief in one’s own abilities and com­petencies to deal with external demands.

Many studies revealed that self-efficacy is associated with many health issues, na­mely anxiety, neuroticism, depression (Mu- ris, 2002), traumatic injuries recover (Bun- ketorp et al., 2006; Wong, Chan & Chair,

2010)       , response types in patients with can­cer (Luszczynska, Gutierrez-Dona, & Schwarzer, 2005; Luszczynska, Mohamed, & Schwarzer, 2005), glycemic control (Gao et al., 2013), life quality perception (Lus­zczynska, Gutierrez-Dona & Schwarzer, 2005), psychosocial adjustment to chronic disease (Dahlbeck & Lightsey, 2008), oral health care (Souza, Silva & Galvao, 2002), acquisition of many healthy habits (healthy eating, physical exercise practice, smoking interruption and decrease of alcohol con­sumption) (Cardoso, 2006), and adoption of safe sexual behavior (Pallonen, Williams, Timpson, Bowen & Ross, 2008; Rogado & Leal, 2000).

Related specifically to the elderly, many studies point to the same direction: higher self-efficacy levels are associated with lower inability, psychological distress, depressive symptoms, the decrease of basic and instru­mental activities in daily life, good percei­ved health, higher pain adjustment, and more expended effort in required activities, personal adjustment and the capability of confrontation resources mobilization (Ra- belo & Cardoso, 2007). In the gerontologi­cal population, self-efficacy still supports the maintenance of healthy behaviors (ex: physical activity practice, good nutrition) (McAuley et al., 2011; Sant'Anna da Silva & Laurent, 2010), personal perspective of longevity (Sant'Anna da Silva & Laurent,

2010)       , fear of falling (Li et al., 2002), and the practice of group health promoting acti­vities (Kono et al., 2004).

According to Bandura (2004), positive cognitive re-evaluations that focus on one’s own life aspects and that are personally con­trollable can increase the perceived efficacy, which activates many adaptive processes in facing health chronic conditions. This pro­cess is essential in the elderly - their age is when the number of chronic diseases incre­ases and aggravates. The scientific litera­ture has made a strong association between general self-efficacy and other psychosocial factors. Examples of these dimensions are the perceived social support (Bonsaksen, Lerdal, & Fagermoen, 2012; Warner et al.,

2011)      , anxiety (Tahmassian & Moghadam,

2011)      , the disease perception and psycholo­gical suffering (Connolly et al., 2014), and depression (Dilorio et al., 2006; Tahmas­sian & Moghadam, 2011; Qian & Yuan,

2012)       . In this context, the goal of this paper is to identify the psychosocial predictors in general self-efficacy in elderly patients of a Brazilian Health Basic Unit. Psychosocial predictors are related to psychological, so­cial, cognitive, psychopathological and men­tal health factors (among the variables under study) that may have a predictive value in self-efficacy.

Methods

Sample

One hundred and forty-four patients par­ticipated in this study. They were all pa­tients of the Health Basic Unit at Granja do Torto (Brasilia, Brazil), with an average age of 69.3 years (SD= 6.61). The sample is consecutive.

Measures

Socio-demographic characteristics.

Colour. It was asked directly for an open response, and subsequently, categorized into “white”, “pardo” (“browns” or “of mixed color”), “Asian” and “indigenous”.

Age. It was asked directly and for an open response and was subsequently cate­gorized (60-69 years-old, 70-79 years-old, 80-89 years-old).

Education. It was collected through self­report with the question “What is your level of education?” The answer options were: none, 1-3 years, 4-7 years, 8 or more years.It was then categorized in a dichotomous form (less than 8 years of education, 8 years of education or more).

Marital status. It was assessed through the question “What is your marital status?” The answer options were: single, married, divorced, in stable union, separated and wi­dowed. It was then categorized in a dicho­tomous form (with or without a partner).

Occupational situation. It was collected through the questions “Do you work?” and “Are you retired?” It was later categorized in a dichotomous form (active or inactive).

Number of people of other generations that you live with. The question was “Who do you live with?”. It was then dichotomized (1 generation, and 2 or more generations).

Psychosocial variables (possible pre­dictors).

Social Support. It was assessed by 24 items of the translated and adapted version of the original Social Provisions Scale (Cu- trona & Russell, 1987). The items response format was a 4-point Likert scale ranging from “strongly disagree” to “strongly agree”. Some of the items are “if something bad happened to me, I could not count on an­yone’s help” or “I feel responsible for ano­ther person’s well-being”. In this sample, the Cronbach’s alpha of the scale was .81.

Depression. It was assessed by the Cen­ter for Epidemiological Studies Depression

Scale (CES-D) (Randloff, 1977) (Brazilian version by Silveira & Jorge, 1998). This ins­trument has 20 items and the answers are quoted from 0 to 3 (from rarely or never to most of the time or all the time), with 4 items in reverse quotation. Some examples of the items are “I felt scared” and “I felt happy”. The Cronbach’s alpha of the scale was .86.

Self-perceived health status. It was as­sessed by the question ”How do you eva­luate your health condition?” The answer options were “very bad”, “bad”, “reasona­ble”, “good” and “very good”.

Outcome variable.

General Self-Efficacy. It was evaluated through the General Self-Efficacy Scale (Schwarzer & Jerusalem, 1993) from the Brazilian version by Sbicigo, Teixeira, Dias and Dell’Aglio (2012). The scale has 10 items and the answers are quoted from 1 to 4 in a Likert scale (1= strongly disagree and 5= strongly agree). Some of the items are: “I have confidence to do well in unexpected si­tuations” and “I can usually face any adver­sity”. The Cronbach’s alpha of the scale was 0.90.

Procedures

The sample was recruited using the me­dical records on the Basic Health Unit of Granja do Torto (Brasilia, Brazil) according to the following inclusion criteria: (1) being 60 years old or older, and (2) being psycho­logically capable of responding to the inter­view questionnaire. Properly trained inter­viewers (Medicine students from Univer- sidade Católica de Brasilia) administered the questionnaire. The interviews took place at the participants’ houses after being ap­proached on the Basic Health Unit by the responsible doctor and having agreed to par­ticipate in the research. All the participants knew the purpose of the investigation. The data confidentiality as well as the volunteer participation in the research were properly clarified. The patients who agreed to parti­cipate in the research read and signed the free informed consent form. Additionally, the research was authorized by the Ethics Committee of Universidade Católica de Bra­silia and by Granja do Torto’s City Hall.

Analyses

In relation to sample characterization, the data were obtained from descriptive statis­tics, like distribution and frequency analy­ses. First, in order to select which variables should be included in the regression analy­ses, we conducted Spearman’s correlation coefficients between psychosocial variables and self-efficacy. Subsequently, the linear regression analyses were conducted to iden­tify the general self-efficacy predictors. The data were analyzed by using the Statistical Package for the Social Sciences, version 18.0. (SPSS, Inc., Chicago, Illinois, USA).

Results

Participants characteristics

This research sample had a total of 144 elderly patients who were patients at the Health Basic Unit at Granja do Torto (Bra­silia, Brazil). As shown on Table 1, the sam­ple is mostly (58.3%) constituted by wo­men. The average age is 69.3 years old (SD=6.61), with participants being from 60 to 89 years old. The majority were white and brown people, with less than 8 years of edu­cation; they have a stable partner, live with family members of another generation, and do not work (they are retired). These cha­racteristics can be observed on Table 1 with more details, according to gender.

Psychological predictors of general self-efficacy

Table 2 shows the correlations among the psychosocial variables and theself-efficacy. All correlations are significant (p_rang_e= .001 to < .001) and in the expected direction

^(rrange=^{348 to -}.⁴⁰⁸⁾.

Baled on these correlations results, the

psychosocial variables were selected to be included in the regression analysis.

The results of the linear regression analy­ses for psychosocial variables as predictors of self-efficacy are presented in Table 3. These variables (self-perceived health status, social support and depression) explained 37.2% of variance (aF(3, 140)= 29.20, p =.000). The participants who had a higher level of perceived social support (P = .25), a positive self-perceived health status (p = .30) and lower levels of depression (P = -.28) had higher levels of general self-efficacy.

Discussion

This article aimed to identify the psycho­social predictors in general self-efficacy in the Brazilian elderly. The results show that- self-perceived health status, perceived social support and depression are significantly as­sociated with general self-efficacy on the studied sample. The more positive the self- perceived health status, the bigger the levels of perceived social support, and the lower the levels of depression, the higher are the levels of general self-efficacy in elderly pa­tients who were analyzed at the Health Ba­sic Unit. There is no association between so­cio-demographic variables (colour, age, marital status, etc.) and self-efficacy.

Related to the influence of self-perceived health status in general self-efficacy, we did not find studies that could analyze this rela­tion directly, but some of them do that indi­rectly. For example, the study by Connolly et al. (2014) showed that one of the factors more associated with self-efficacy in ill pe­ople who are recovering from severe trau­mas was the disease perception. In other words, a better perception of the real cha­racteristics of the disease are positively as­sociated with higher levels of self-efficacy in those sick people. That means that in some way this disease perception integrates a he­alth status perception. We believe that these results make sense, because whether the self-efficacy is a global and stable belief of being capable of controlling certain envi­ronmental challenges (Schwarzerand Jeru­salem, 2000), it is understandable that this variable is favoured and even potentialized by a better perception of the sickness and he­alth status.

Regarding the association between per­ceived social support and self-efficacy, the results are congruent to the scientific litera­ture. Other studies,for example the one by Bonsaksen, Lerdal and Fagermoen (2012), showed that social support is directly asso­ciated with self-efficacy in adults with chro­nic diseases. The study by Warner et al. (2011) about the relation between self-effi­cacy and the perceived social support in el­derly people found that there is a synergy between these two variables: The ones with a low level of self-efficacy had less proba­bility of being active, even when having high levels of social support. Similarly, the elderly with a low level of perceived social support had a strong probability of being inactive, even with high levels of self-effi­cacy. In other words, the results of this study reveal that these two cognitive dimensions interact, influence each other, and work to­gether in order to promote activeness on el­derly people. These results raise awareness to the need of evaluating this interaction re­garding other health behaviors, having in mind the promotion of integral health in el­derly people.

The evidence of depression as a predictor of self-efficacy has been reported in many studies and in different scopes and samples, namely related to academic performance (Tahmassian & Moghadam, 2011), cancer experiencing (Qian & Yuan, 2012), epilepsy medical conditions (Dilorio et al., 2006), among others. For example, the results of the study by Qian and Yuan (2012) revealed that the patients with cancer who had mild­depression, better physical function and higher social support were those who pre­sented the best level of self-efficacy related to self-care. Depression was the factor which had the most influence in this model, com­pared to self-efficacy predictors. The study by Dilorio et al. (2006) also revealed that the depression symptoms were the main pre­dictors of self-efficacy in people with epi­lepsy. If self-efficacy is related to the indi­vidual belief in their capabilities to perform a specific action and achieve the wanted re­sult (Bandura,1997), it is understood that the elderly who are not depressed are the ones who can better potentialize these be­liefs in their own capabilities.

Limitations

This study has some limitations, namely the possible memory bias related to depres­sion, like when the elderly were asked to re­member events of the last week. We also consider important the development of lon­gitudinal studies in order to better unders­tand the evolution of general self-efficacy in elderly people. Additionally, it would be re­levant to develop similar researches with larger samples. That was not possible in this study because the patients who accepted to participate are all the ones inside the com­munity (Granja do Torto, Brasília, Brazil).

Extending the research to other nearby con­texts would be a good future option. In this case it was not possible due to financial and logistic constraints which the study could not endure. Nevertheless, this is a pioneer study that tries to understand the psychoso­cial predictors of general self-efficacy in the Brazilian elderly population.

Conclusion

Psychosocial factors, such as self-percei­ved health status, perceived social support, and depression are malleable and can be changed by treatment (e.g. depression) or educational and skills-building interventions (e.g. perceived social support). Therefore, it is very important to promote community ac­tions that help elderly people to decrease depression levels and increase levels of po­sitive self-perceived health status and per­ceived social support. Thus, we will contri­bute to self-efficacy increase in elderly people, an extremely important variable in health and well-being among this specific population.

 

Table 1

Characterization of the sample according sociodemographic characteristics and sex (N=144)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Table 2.

Spearman correlation coefficients between psychosocial variables and outcome variable (N=144)

Table 3.

Linear regression results with self-perceived health status, perceived social support and depres­sion as predictors of general self-efficacy (N=144).

References

Bandura, A. (1977). Self-efficacy: towards a unifying theory of behavioral change. Psy­chological Review, 84, 191-215.

Bandura, A. (1997). Self-efficacy: The exercise of control. New York: Freeman.

Bandura, A. (2004). Health promotion by social cognitive means. Health Education & Behavior, 31, 143-164. doi: 10.1177/109019 8104263660

Bonsaksen, T., Lerdal, A., & Fagermoen, M.S. (2012). Factors associated with self-efficacy in persons with chronic illness. Scandinavian Journal of Psychology, 53, 333-339. doi:10.ni1/j.1467-9450.2012.009 59.x

Bunketorp, L., Lindh, M., Carlsson, J., & Stener-Victorin, E. (2006). The effective­ness of a supervised physical training model tailored to the individual needs of patients with whiplash-associated disorders - a ran­domized controlled trial. Clinical Rehabili­tation, 20, 201-217.

Cardoso, C.M. (2006). A influência da auto-efi- cácia na adesao aos comportamentos de saúde [Theinfluenceof self-efficacy on he­alth behavior sad herence]. Uberlândia: Fe­deral University of Uberlândia.

Connolly, F.R., Aitken, L.M., Tower, M., & Macfarlane, B. (2014). Factors associated with self-efficacy for managing recovery in the trauma intensive care population: a pros­pective cohort study. Injury, 45, 272-278. doi:10.1016/j.injury.2013.05.005

Costa, E., & Leal, I. (2005). Dimensoes socio- cognitivas na adesâo das mulheres à contra- cepçâo [Socio-cognitive dimensions of contraception women accession]. Análise Psicológica, 3, 247-260.

Cutrona, C.E., & Russell, D.W.(1987). The pro­visions of social relationships and adapta­tion to stress. Advances in Personal Relationships, 1, 37-67.

Dahlbeck, D.T., & Lightsey, O.R. (2008). Generalized self-efficacy, coping, and self­esteem as predictors of psychological adjus­tment among children with disabilities or chronic illnesses. Children’s Health Care, 37, 293-315. doi:10.1080/02739610802437 509

Dilorio, C., Shafer, P.O., Letz, R., Henry, T.R., Schomer, D.L., & Yeager, K. (2006). Behavioral, social, and affective factors as­sociated with self-efficacy for self-manage­ment among people with epilepsy. Epilepsy & Behavior, 9, 158-163. doi: 10.1016/j. yebeh.2006.05.001

Gao, J., Wang, J., Zheng, P., Haardorfer, R., Kegler, M.C., Zhu, Y., & Fu, H. (2013). Effects of self-care, self-efficacy, social sup­port on glycemic control in adults with type 2 diabetes. BMC Family Practice, 14, 1-6. doi: 10.1186/1471 -2296-14-66

Kono, A., Kai, I., Sakato, C., & Rubenstein, L. Z.(2004). Frequency of going outdoors: A predictor of functional and psychosocial change among ambulatory frail elders living at home. Gerontological Society of America, 59, 275-280. doi:10.1016/j.archger.2006. 10.013

Li, F., Mcauley, E., Fishe, K.J., Harmer, P., Chaumeton, N., Chaumeton, N., & Wilson, N.L. (2002). Self-efficacy as a mediator bet­ween fear of falling and functional ability in the elderly. Journal of Aging and Health, 14, 452-466.

Luszczynska, A., Gutierrez-Dona, B., & Schwarzer, R. (2005). General self-efficacy in various domains of human functioning: evidence from five countries. International Journal of Psychology, 40, 80-89. doi: 10. 1080/00207590444000041

Luszczynska, A., Mohamed, N.E.,            &

Schwarzer, R. (2005). Self-efficacy and so­cial support predict benefit finding 12 months after cancer surgery: the mediating role of coping strategies. Psychology, Health & Medicine, 10, 365-375. doi: 10.1080/ 13548500500093738

McAuley, M., Szabo, A., Gothe, N., & Olson, E.A. (2011). Self-efficacy: implications for physical activity, function, and functional li­mitations in older adults. American Journal of Lifestyle Medicine, 5, 1-15. doi: 10.1177/ 1559827610392704

Muris, P. (2002). Relationships between self­efficacy and symptoms of anxiety disorders and depression in a normal adolescent sam­ple. Personality and Individual Differences, 32, 337-348. doi:10.1016/S0191-8869(01) 00027-7

Pallonen, U.E., Williams, M.L., Timpson, S.C., Bowen, A., & Ross, M.W. (2008). Personal and partner measures in stages of consistent condom use among African-American hete­rosexual crack cocaine smokers. AIDS Care, 20, 205-213. doi: 10.1080/09540120701513 669

Qian, H., & Yuan, C.(2012). Factors associated with self-care self-efficacy among gastric and colorectal cancer patients. Cancer Nursing, 35, 22-33. doi: 10.1097/NCC.0b 013e31822d7537

Rabelo, D.F., & Cardoso, C.M.(2007). Auto- eficacia, doen^as cronicas e incapacidade funcional na velhice [Self-efficacy, cronical diseases and functional disability in the old age]. Psico-USF, 12, 75-81. doi: 10.1590/ S1413-82712007000100009

Radloff, L.S. (1977). The CES-D scale - a self­report depression scale for research in the general population. Applied Psychological Measurement, 1, 385-401.

Ribeiro, J.L.P. (1995). Adapta^ao de umaescala de avalia^ao da auto-eficaciageral [Development and validation of the self­Efficacy scale for wheelchair users]. Avaliagao Psicologica: Formas e Contextos, 3, 163-176.

Rogado, T., & Leal, I. (2000). Auto-eficacia e cren^as em mulheres jovens - o caso espe­cifico do preservativo/camisinha: um estudo comparativo [Self-efficacy and believes in young women - the specific case of the con­dom: a comparative study]. Retrieved from https://www.academia.edu/21249947/Autoe fic%C3 %A1 cia_e_cren%C3 %A7 as_em_mu lheres_jovens_o_caso_espec%C3%ADfico_ do_preservativo_camisinha_um_estudo_co mparativo

Sant'Anna da Silva, M.C., & Laurent, L. (2010). O senso de auto-eficacia na manu- ten^ao de comportamentos promotores de saude em idosos [The sense of self-efficacy in maintaining health promoting behaviors in older adults]. Revista da Escola de Enfermagem da USP, 44, 61-67. doi: 10.1590/S0080-62342010000100009

Sbicigo, J.B., Teixeira, M.A.P., Dias, A.C.G., & Dell'Aglio, D.D. (2012). Psychometric pro­perties of the general perceived self-efficacy scale (EAGP). PSICO, 43, 139-146.

Schwarzer, R., & Scholz, U.(2000, August). Cross-cultural assessment of coping resour­ces: the general perceived self-efficacy scale. Paper presented at the Asian Congress of Health Psychology and Culture, Tokyo, Japan.

Schwarzer, R., & Jerusalem, M. (1993, rev. 2000). General perceived self-efficacy. Retrieved from http://userpage.fuberlin.de/- gesund/skalen/Language_Selection/Turkish/ General_Perceived_SelfEfficac/hauptteil_g eneral_perceived_self-efficac.htm

Silveira, D.X., & Jorge, M.R. (1998). Psychometric properties of the epidemiolo­gic screening scale for depression (CES-D) in clinical and non-clinical populations of adolescents and young adults. Archives of Clinical Psychiatry, 25, 251-261.

Souza, G.G., Silva, A.M., & Galvao, R. (2002). A auto-eficácia como mediadora da melhora em índices clínicos de saúde oral [Self-effi­cacy as a mediator of improvement in oral health clinical índices]. Pesquisa Odontoló­gica Brasileira, 16, 57-62. doi: 10.1590/ S1517-74912002000100010

Tahmassian, K., & Moghadam, N.J. (2011). Relationship between self-efficacy and symptoms of anxiety, depression, worry and social avoidance in a normal sample of stu­dents. Iranian Journal of Psychiatry and Behavioral Sciences, 5, 91-98.

Warner, L.M., Ziegelmann, J.P., Schüz, B., Wurm, S., & Schwarzer, R. (2011). Synergistic effect of social support and self­efficacy on physical exercise in older adults. Journal of Aging and Physical Activity, 19, 249-261.

Wong, E.M., Chan, S.W., & Chair, S.Y.(2010). Effectiveness of an educational intervention on levels of pain, anxiety and self-efficacy for patients with musculoskeletal trauma. Journal of Advanced Nursing, 66, 1120­1131. doi: 10.1111/j. 1365-2648.2010.052.

Received: April 24, 2017 Accepted: March 11, 2019