Self-Management and Self-Efficacy in Stroke Survivors: Validation of The Italian Version of The Stroke Self-Efficacy Questionnaire

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Self-management and self-efﬁcacy in stroke survivors: Validation of the

Italian version of the Stroke Self-Efﬁcacy Questionnaire
Article in European journal of physical and rehabilitation medicine · December 2016

DOI: 10.23736/S1973-9087.16.04451-8
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© 2016 EDIZIONI MINERVA MEDICA European Journal of Physical and Rehabilitation Medicine 2018 February;54(1):68-74
Online version at http://www.minervamedica.it DOI: 10.23736/S1973-9087.16.04451-8
ORIGINAL ARTICLE
Self-management and self-efficacy in stroke survivors:

validation of the Italian version of the
Stroke Self-Efficacy Questionnaire
Laura DALLOLIO 1 *, Rossella MESSINA 1, Simona CALUGI 1, Stefania FUGAZZARO 2,
Roberta BARDELLI 2, Paola RUCCI 1, Maria P. FANTINI 1, Enrica CAVALLI 3,
Mariangela TARICCO 3 on behalf of Look After Yourself Project
1Sectionof Hygiene and Biostatistics, Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum, University of
Bologna, Bologna, Italy; 2IRCCS Arcispedale Santa Maria Nuova, Reggio Emilia, Italy; 3University Hospital Policlinico Sant’Orsola
Malpighi, Bologna, Italy
*Corresponding author: Laura Dallolio, Section of Hygiene and Biostatistics, Department of Biomedical and Neuromotor Sciences, University of Bologna,
Via San Giacomo 12, Bologna, Italy. E-mail: laura.dallolio@unibo.it
ABSTRACT
BACKGROUND: Self-efficacy is an important mediator of the adaptation process after stroke. However, few studies have attempted to measure
self-efficacy in a stroke population. The most recently developed scale is the Stroke Self-Efficacy Questionnaire that measures self-efficacy rat-
ings in specific domains of functioning relevant for a stroke survivor.
AIM: The aim of this study was to validate the Italian version of Stroke Self-efficacy Questionnaire in stroke survivors.
DESIGN: Cross-sectional study.
SETTING: Three Physical Medicine and Rehabilitation Units located in public hospitals.
POPULATION: 149 adult patients recruited after their first stroke.
METHODS: Patients were assessed using the Self-efficacy in stroke survivors questionnaire, the Modified Barthel Index, the Geriatric Depres-
sion Scale and the Short Form Health Survey.
RESULTS: Patients (38.3% female, mean age 69.3 years) completed the Self-efficacy in stroke survivors questionnaire with the help of an
interviewer. Using confirmatory factor analysis two factors were identified (activity and self-management). The factor score ‘activity’ was sig-
nificantly associated with the Modified Barthel Index and with the physical component of the Short Form Health Survey, but uncorrelated with
the mental component of the Short Form Health Survey and with the Geriatric Depression Scale, supporting the convergent/discriminant validity
of the instrument. The ‘self-management’ factor was weakly associated with the Modified Barthel Index, the physical and mental components
of the Short Form Health Survey and uncorrelated with the Geriatric Depression Scale, suggesting that it measures a different construct. When
we categorized patients according to their walking status, we found that the walking group had significantly higher scores on the activity factor
than the non-walking group, while no significant differences were found concerning the self-management factor.
CONCLUSIONS: The findings supported the validity of the Italian version of the Stroke Self-efficacy questionnaire . It measures two dimen-
sions of self-efficacy, activity and self-management, strongly related to independence and recovery after stroke and therefore it represents a
useful tool to assess self-efficacy.
CLINICAL REHABILITATION IMPACT: The Italian version of the Stroke Self-efficacy questionnaire is a valid and reliable measure of self-
efficacy. Clinicians can use this instrument to target rehabilitation interventions according to patients’ individual confidence in their functional
and self-management capacity and in order to set realistic goals.
(Cite this article as: Dallolio L, Messina R, Calugi S, Fugazzaro S, Bardelli R, Rucci P, et al.; Look After Yourself Project. Self-management and
self-efficacy in stroke survivors: validation of the Italian version of the Stroke Self-Efficacy Questionnaire. Eur J Phys Rehabil Med 2018;54:68-74.
DOI: 10.23736/S1973-9087.16.04451-8)
Key words: Stroke - Validation studies as topic - Self care - Self efficacy - Surveys and questionnaires.
S
or other proprietary information of the Publisher.
troke is the second leading cause of death and the of stroke, but progress after stroke, as with any other
first cause of long-term neurological disability chronic disease, is complex.
worldwide.1 Several rehabilitative interventions have Stroke survivors often experience depressive symp-
proven their effectiveness in acute and postacute phases toms, functional impairment and reduction in mobil-
68 European Journal of Physical and Rehabilitation Medicine February 2018

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SELF-MANAGEMENT AND SELF-EFFICACY IN STROKE SURVIVORS DALLOLIO
ity.2 The process of adjustment to stroke includes both Following the authors’ indications SSEQ has been de-
biomedical and psychosocial adaptation processes, in veloped in order to identify “those individuals that re-
which the physical, psychosocial and emotional aspects quire more targeted support from practitioners in order
of the adaptation are obviously interlinked.3, 4 Recent to build self-confidence with an associated beneficial
studies highlighted that patients often feel unprepared reduction of mood disorders and life dissatisfaction in
to deal with long-term disabilities, especially at the end the longer term”.21 The SSEQ, in its original version,
of the rehabilitation program. demonstrated good internal consistency and criterion
Stroke survivors often have their own personal bench- validity.21 Moreover, a principal component analysis
marks for recovery, which may include aspects related provided evidence that the instrument is unidimension-
to both physical and psychosocial outcomes.5 Neverthe- al. This finding has been recently disconfirmed by Riazi
less, rehabilitation is frequently oriented to functional et al.23 who, using Rasch analysis, identified two dis-
improvement, and, despite a move towards more per- tinct constructs: self-management self-efficacy and ac-
son-centred goal setting, often professionals decide the tivity self-efficacy. Therefore, there is a need to clarify
content and direction of rehabilitation.6, 7 whether the scale has a uni- or bidimensional structure.
One psychological construct, which has recently been The primary aim of this study was to validate the Ital-
found to predict both quality of life and disablement post- ian version of the SSEQ, and to assess its psychometric
stroke, is self-efficacy.8 The concept of self-efficacy orig- properties in stroke survivors. The secondary aim is to
inates from “Social Learning Theory” and is defined as examine how self-efficacy is associated with patients’
“the belief in one’s capabilities to organise and execute walking status.
the courses of action required to produce given attain-
ments”.9 Moreover, self-efficacy has been found to pre- Materials and methods
dict mood, quality of life and functional independence
for patients with other chronic conditions.10-12 Participants
A growing literature investigating self-management The study sample included consecutive adult patients
in stroke survivors indicated that self-management recruited after their first stroke at the Physical Medicine
programmes are associated with several outcomes, in- and Rehabilitation Unit of St. Orsola Malpighi Hospital,
cluding quality of life, depression, activities of daily Bologna (Italy), Physical Medicine and Rehabilitation
living (ADL) and physical functioning and a reduced Unit of IRCCS Arcispedale Santa Maria Nuova, Reggio
incidence of falls.13-16 For these reasons, there is an Emilia (Italy) and Rehabilitation Medicine Unit of St.
increasing interest in supporting stroke survivors and Agostino-Estense Baggiovara New Hospital, Modena
their caregivers in self-managing the long-term conse- (Italy) from to October 2014 to March 2016.
quences of stroke. Self-efficacy influences the initiation Inclusion criteria were 1) age >18; 2) a confirmed
of behavior change,9 so it is considered the main out- first-ever diagnosis of stroke according to the World
come measure of many stroke self-management pro- Health Organization’ definition;24 3) having a caregiver
grammes.17, 18 as reference person, sent to mild communication dis-
Coping and self-efficacy have been proposed as im- ability (Communication Disability Scale <3); 4) pa-
portant determinants of the adaptation process in indi- tient’s willingness to sign the informed consent form.
viduals after stroke.19, 20 Few studies have attempted to Exclusion criteria were previous stroke episodes, se-
measure self-efficacy in a stroke population. The most vere cognitive impairment (Mini-Mental State Exami-
recently developed scale is the Stroke Self-Efficacy nation MMSE<15/30, Communication Disability Scale
Questionnaire (SSEQ) 21 that measures self-efficacy ≥3), life threatening diseases (i.e. severe heart failure,
ratings in specific domains of functioning relevant to a respiratory insufficiency, advanced cancer, sepsis).
person. Items include common self-management tasks
in stroke suggested by the guidelines by Lorig et al.22 Procedures

The SSEQ is a 13-item self-report scale designed to as-
sess the confidence levels of stroke individuals in rela- Participants were recruited for a non-randomized
tion to functional performance and self-management. 21 controlled trial aimed to evaluate the efficacy of a stan-
Vol. 54 - No. 1 European Journal of Physical and Rehabilitation Medicine 69

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DALLOLIO SELF-MANAGEMENT AND SELF-EFFICACY IN STROKE SURVIVORS
dardized therapeutic education patient (TPE) program using words like “emotional distress” and “suffering”.
for stroke survivors. The present study is focused on Moreover, item 6 was modified to make it appropriate
baseline assessments including the SSEQ, the Modified for patients with hemiplegia (“use your hands for eat-
Barthel Index (MBI), the Geriatric Depression Scale ing your food” instead of “use both your hands”). The
(GDS) and the Short Form Health Survey (SF-12). The time of administration of SSEQ ranged from 10 to 20
Ethics Committee of the Hospital Trust Sant’Orsola minutes.
Malpighi of Bologna (registration number: 29/2014/O/ To test the convergent/discriminant validity of SSEQ,
Sper), the Ethics Committee of the Hospital Trust Santa the following instruments were administered: ��
the Modi-
Maria Nuova of Reggio Emilia (registration number: fied Barthel Index (MBI) 25 was used to assess the abil-
2014/0008420) and the Provincial Ethics Committee ity to perform activities of daily living. It is the modified
of Modena approved the study (registration number: form of the original Barthel Index 26 with 10 items that
44/2014). All eligible patients provided a written in- explore functional and motor abilities. The total score
formed consent after receiving an explanation of study ranges from 0 to 100. Scores from 0 to 20 indicate total
procedures and aims and after having an opportunity to dependence, 21-60 severe dependence, 61-90 moderate
ask questions. dependence, 91-99 slight dependence and 100 total in-
dependence.
Measures The SF-12 27 is a validated and widely used health-re-
lated quality of life measure. It consists of 12 items that
The SSEQ is a 13-item self-report scale measuring are aggregated into two summary measures of physical
self-efficacy after stroke in specific domains of func- health (PCS) and mental health (MCS), expressed as T-
tioning. The purpose of the SSEQ is to measure the scores (mean=50, SD=10), where higher scores denote
strength of confidence that stroke survivors have about a better health-related quality of life.
regaining activities lost after their stroke. Each item is The Geriatric Depression Scale (GDS) 28 was used to
rated on a 0-3 scale, where 0 indicates absolutely no measure the presence and severity of depression. Scores
confidence and 3 complete confidence about accom- of 0 to 5 indicate the absence of depression, 6 to 8 in-
plishing the task. dicate mild depression, and ≥9 indicate moderate to se-
The Italian version was translated from the original vere depression.
English version 21 and back-translated to English by a To examine the criterion validity of SSEQ, patients
bilingual person of English mother tongue. were categorized according to their walking status. Sub-
In order to improve the comprehensibility, items were jects currently able to walk with or without assistance
discussed by the investigators’ team and a final version were those scoring>0 on BMI Mobility item and non-
was agreed. The final Italian version of the SSEQ was walking were those not able to walk in any capacity
then administered to a pilot sample of 30 stroke sur- (BMI Mobility item score =0).
vivors in a real-world setting in order to evaluate the
face validity of items. Results of the supervised pilot Sample size
administration of the instrument indicated that patients
had difficulties rating items 7 (��
dress and undress your- Sample size was determined to perform a Confirma-
self even when you feel tired), 8 (prepare a meal you tory Factor Analysis (CFA), for which at least a ten-to-
would like for yourself) ��
and 11 (��
cope with the frustra- one ratio between patients and items is recommended.29
tion of not being able to do some things because of your
stroke). Regarding item 7, it was therefore decided to Statistical analysis
instruct patients to answer whether they could dress or
undress in some way, using strategies if needed. Re- The convergent/discriminant validity of SSEQ versus
garding meal preparation (item 8), if patients were not the MBI, the SF-12 and the GDS was tested by using
used to cook in daily life, they were asked to answer by Pearson’s correlation coefficient. The criterion validity
imagining to do it. The term ‘frustration’ included in the was examined by comparing the mean SSEQ Score of
item 11 that someone did not understandwas clarified patients who were currently able to walk and with that

©
Table I.—Demographic, clinical characteristics and scales meas- of non-walking patients using the independent-samples
uring functional status, health-related quality of life and depres-
sion of study participants (N.=149). t-test. Four patients had missing data on Modified Bar-
thel Index, the SF-12 and or Geriatric Depression Scale
Characteristics N. (%) or mean±SD
and were excluded from these analyses.
Gender
Males 92 (61.7%)
Confirmatory Factor Analysis (CFA) was performed
Female 57 (38.3%) to compare the goodness of fit of the the two-factor so-
Age (years) 69.3±12.7 lution identified by Riazi et al. 2014 in 118 stroke survi-
Living alone 31 (20.8%)
Type of stroke
vors with that of the one-factor solution proposed in the
hemorrhagic 27 (18.1%) original version by Jones et al.21
ischemic 122 (81.9%) In this analysis items were used as categorical vari-
Days post stroke 16.6±12.7
Cumulative Illness Rating Scale
ables and factors were estimated using a robust weight-
Severity Index 1.5±0.3 ed least squares estimator.
Comorbidity Index 2.0±1.9 Model fit was evaluated using the Comparative Fit
MMSE 24.6±4.9
Barthel Index Modified* 36.8±20.9
Index (CFI), Tucker-Lewis Index (TLI) and the root
SF-12† Mean Square Error of Approximation (RMSEA).
PCS 34.7±8.6 TLI and CFI values >0.90 reflect acceptable fit and
MCS 44.0±12.9 values >0.95 imply very good fit. RMSEA values <0.05
Geriatric Depression Scale‡ 7.0±2.0
indicate close model fit; values up to 0.08 suggest a rea-
MMSE: Mini-Mental State Examination; SF12: Short Form health survey; PCS:
Physical Component Score; MCS: Mental Component Score. sonable error of approximation in the population, and
*1 missing value; †1 missing value; ‡2 missing values.
values >0.10 indicate poor fit.
1: into bed 2: exit bed 3: walk few steps inside 4: move around inside 5: walk outside
6: eat food 7: dress 8: prepare meal
9: make progress 10: own exercise 11: cope 12: do things 13: get faster
Figure 1.—Frequency distribution of responses to the 13 SSEQ item. Items are rated 0 to 3, with 0 indicating not at all confident, 1 some confidence,
2 moderate confidence, 3 very confident. Legend to the items from left to right: item 1: into bed; item 2: exit bed; item 3: walk few steps inside; item
4: move around inside; item 5: walk outside; item 6: eat food; item 7: dress; item 8: prepare meal; item 9: make progress; item 10: own exercise;
item 11: cope; item 12: do things; item 13: get faster. Grey: items measuring activity (1-8); dark gray: items measuring self-management (9-13).

©
were males and 20.8% were living alone before stroke.

Other clinical characteristics are reported in Table I.
The frequency of response to the 13 items is provided
in Figure 1.
Items 1-5 and 8 were skewed to the right, and the
modal answer was “not at all confident”, indicating that
a large percentage of patients did not feel confident in
walking around, going to bed, prepare meals. On the
contrary, items 6, 9-13 were skewed to the left, sug-
gesting that patients felt confident in improving, eat-
ing using their hands, following the exercise program
and overcome frustration of not being able to do some
things because of the illness.
A confirmatory factor analysis was carried out to
identify the latent structure of the SSEQ items. Results
indicate that the two-factor model proved to have a bet-
ter fit compared to the one-factor model (CFI=0.934,
TLI=0.918, RMSEA=0.195 vs. CFI= 0.991, TLI=0.989,
RMSEA=0.073).
The results of CFA are depicted in Figure 2, in which
factor loadings are listed on along the arrows connect-
ing items to factors.
Items 3, 4, 5 had the highest loadings on factor 1,
and item 6, measuring the ability to eat independently,
had the lowest loading. This first factor was named
“activity”.
Items 9 and 10 had the highest loading on factor 2,
Figure 2.—Structure of the SSEQ resulting from CFA. The two factors
identifies are activity and self-management. Numbers above two-sided
arrows denote correlations. Numbers above directed arrows indicate Activity
item loadings. Loadings range from 0 to 1. The higher the loadings the 2 factor score
stronger the association of the item with the factor. Self-
management
1 factor score
The fit indices were assessed collectively, so that a

single index that fell just outside the acceptable range 0
was not necessarily considered to reflect poor model fit,

provided that the other statistics indicated good model fit. -1
The significance level was set at P<0.05. IBM SPSS

Statistics (version 20, Chicago, USA) and Mplus Ver- -2
sion 7 (http://www.statmodel.com) were used for the

analyses. -3
-4
Results
Not walking Walking

One hundred forty-nine patients completed the Walking status
SSEQ. Participants had a mean age of 69.3 (SD=12.7) Figure 3.—Boxplot of the SSEQ factor scores by walking status. Walk-
years, were on average 16.6 days poststroke, 61.7% ing patients have significantly higher scores on activity factor.

©
that was named self-management. Notably, the two fac- Moreover, the mental component of quality of life
tors were correlated to each other (r=0.45, P<0.001). and geriatric depression were unrelated with SSEQ
The SSEQ ‘activity’ factor score was significantly “activity” factor, confirming that this factor measures a
associated with MBI (r=0.46, P<0.001) and with the conceptually different construct.23
physical component of the SF-12 (r=0.25, P=0.002), but The main strength of this study is that it was carried
it was uncorrelated with the mental component of the out in a large sample of stroke survivors. Clinicians
SF-12 (r=0.09, P=0.262) and with the GDS (r=-0.10, can use SSEQ to target rehabilitation interventions for
P=0.234). The SSEQ ‘self-management’ factor score stroke survivors according to patients’ individual con-
was weakly associated with MBI (r=0.21, P=0.009), the fidence in functional activity and self-management and
physical component of the SF-12 (r=0.21, P=0.012), the using it to set realistic goals. Moreover, SSEQ may also
mental component of the SF-12 (r=0.18, P=0.033) and assist clinicians in the identification of patients at risk
uncorrelated with the GDS (r=-0.08, P=0.364). of difficulty coping with stroke consequences and the
Moreover, walking patients had significantly higher transition phases (e.g. from hospital to home).
mean scores on SSEQ activity factor than non-walking The SSEQ can also be used as a primary outcome
patients (t=5.4, P<0.001), while no significant differ- measure in stroke patient education programs or to
ences were found concerning the SSEQ self-manage- monitor response to specific physical rehabilitation in-
ment factor (t=1.5, P=0.124) (Figure 3). terventions.
Limitations of the study

Discussion
Our results should be interpreted keeping in mind
The aim of this study was to validate the Italian ver- some limitations.
sion of the SSEQ, and to analyze the factor structure First, our sample includes patients who were assessed
of the questionnaire. Our results, based on stroke survi- from few days to few weeks post-stroke and this large
vors recruited in a real-world setting, indicate an excel- time frame may affect the participants’ judgment about
lent fit of the two-factor model and are consistent with their capacity and confidence in performing specific ac-
those of Riazi et al.23 The two SSEQ factors measure tivities of daily living. Furthermore, we did not attempt
two dimensions of self-efficacy, activity and self-man- to verify whether the SSEQ was able to distinguish stroke
agement, strongly related to independence and recov- survivors during the rehabilitation phase from patients
ery after stroke. These two dimensions are conceptually who had already completed the rehabilitation process.
different. In fact, as argued by Bandura,30 self-efficacy Our results cannot be generalized to patients with at least
in functional activity in not necessarily linked to self- one previous stroke and/or severe cognitive impairment.
efficacy in self-management. This seems reasonable
as stroke survivors may have different levels of self- Conclusions
efficacy in performing activities of daily living as they
would in self-managing illness. These two aspects are Our results suggest that the Italian version of the
conceptually distinct, thus someone with high self-ef- SSEQ is a valid and reliable tool for assessing self-ef-
ficacy in performing daily activities may not have high ficacy in stroke survivors. The instrument can be used
self-efficacy in the self-management of illness. to identify strengths to be leveraged in targeting per-
Moreover, our SSEQ factor “activity” showed a good sonalized interventions. Future perspectives include the
convergent validity with the Modified Barthel score and conduction of prospective studies assessing how self-
with the physical component of the quality of life, con- efficacy varies as a result of specific educational or mo-
firming previous results.21 Notably, mean SSEQ activity tivational interventions.
scores of walking patients were higher than those of non-
walking patients. This is in line with the previous study

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Contributors.—The Look After Yourself Project includes the following investigators: Mariangela Taricco, Enrica Cavalli, University Hospital Policlinico
Sant’Orsola Malpighi, Bologna, Italy; Claudio Tedeschi, Stefania Fugazzaro, Bardelli Roberta, Monia Allisen Accogli, Alessandra Altavilla, Gennaro Maisto,
Monica Denti, Giovanni Gallo, Mirco Piccinini, IRCCS Arcispedale Santa Maria Nuova, Reggio Emilia, Italy; Stefano Cavazza, Azienda USL di Modena,
Nuovo Ospedale Civile S. Agostino – Estense Baggiovara, Modena, Italy; Donatella Pagliacci, Azienda USL 6 Livorno, Italy; Maria Pia Fantini, Paola Rucci,
Laura Dallolio, Simona Calugi, Rossella Messina, Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum – University of Bologna,
Italy.
Funding.—This paper was developed with a grant from the “Progetto-Regione Università”, Emilia-Romagna Region (Italy), ‘Research for Clinical Gover-
nance’ 2013, for the project: “Patient Therapeutic Education (PTE) in the rehabilitation process of stroke patients: improving self-management and fostering
transition from hospital to community”. The Emilia-Romagna Region had no role in the definition of the study design; in the collection, analysis and inter-
pretation of data; in the writing of the report; and in the decision to submit the article for publication.
Conflicts of interest.—The authors certify that there is no conflict of interest with any financial organization regarding the material discussed in the manuscript.
Article first published online: December 19, 2016. - Manuscript accepted: December 5, 2016. - Manuscript revised: November 28, 2016. - Manuscript re-
ceived: August 5, 2016.
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Self-Management and Self-Efficacy in Stroke Survivors: Validation of The Italian Version of The Stroke Self-Efficacy Questionnaire

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Self-management and self-efﬁcacy in stroke survivors: Validation of the

Article in European journal of physical and rehabilitation medicine · December 2016

Rossella Messina Simona Calugi

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Stefania Fugazzaro Roberta Bardelli

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Self-management and self-efficacy in stroke survivors:

68 European Journal of Physical and Rehabilitation Medicine February 2018

in stroke suggested by the guidelines by Lorig et al.22 Procedures

Vol. 54 - No. 1 European Journal of Physical and Rehabilitation Medicine 69

70 European Journal of Physical and Rehabilitation Medicine February 2018

6: eat food 7: dress 8: prepare meal

Vol. 54 - No. 1 European Journal of Physical and Rehabilitation Medicine 71

were males and 20.8% were living alone before stroke.

The fit indices were assessed collectively, so that a

was not necessarily considered to reflect poor model fit,

The significance level was set at P<0.05. IBM SPSS

sion 7 (http://www.statmodel.com) were used for the

Not walking Walking

72 European Journal of Physical and Rehabilitation Medicine February 2018

Limitations of the study

walking patients. This is in line with the previous study

Vol. 54 - No. 1 European Journal of Physical and Rehabilitation Medicine 73

74 European Journal of Physical and Rehabilitation Medicine February 2018

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