Abstract
We have read with great interest the article by Liacos et al. [1], who investigated the predictive validity, minimal important difference (MID) and responsiveness of the Pulmonary Rehabilitation Adapted Index of Self-Efficacy (PRAISE). In addition to the interesting findings concerning the predictive validity of PRAISE, the authors raised questions regarding its usefulness due to low responsiveness and poor MID measurement properties. The authors’ explanations included moderately high PRAISE scores at baseline and lack of responsiveness of PRAISE to Pulmonary Rehabilitation (PR).
Although we understand the authors’ arguments focusing on the limitations of the instrument, we would like to add another insight based on the Social Cognitive Theory (SCT), self-efficacy [2, 3, 4] and PR protocol limitations. PR delivered in Liacos et al.’s [1] study was not intentionally developed to tackle self-efficacy enhancement; therefore, it is reasonable to assume a non-effect in self-efficacy beliefs, making it difficult to promote behavioural changes [5]. Patients received the PR core components (aerobic/resistance exercise training and self-management education) [6]. However, if PR continues to be delivered according to a standardised framework [7], physical and no emotional/behavioural gains will be obtained.
From a behavioural change perspective, the intervention/treatment has to be outcome-related, unlike the aforementioned study [1]. SCT is a triadic reciprocal causation framework and, instead of the overt behaviour, mutual interactions between enhancing self-efficacy and the environment should be considered [2, 4]. Moreover, a “one-size-fits-all” approach does not seem to work for every patient. The approaches might need to include the varying self-efficacy profiles of the population, since personal inputs and background contextual affordances are strongly related to the patients’ learning experiences. Providing a positive learning experience through a supportive environment is likely to increase self-efficacy [2, 5, 8], and baseline self-efficacy assessment should be used to consider the person´s needs and adapt PR.
Ultimately, a broader view of SCT in the PR context is necessary. Important constructs of SCT, such as outcomes expectations, are not explored. The assumed causal link between PR and self-efficacy can be mediated by the patients’ beliefs about the expected consequences of their actions. Also, outcomes expectations can strongly provide motivation during the goal-striving process and influence how patients intentionality embrace the behavioural change process. Rather than considering the PRAISE tool as non-responsive to PR, we believe that there is an urgent need to approach PR in a different manner. Health professionals should design programs aiming to support autonomy by promoting pro-environmental behaviours for self-efficacy/motivational changes, intentionally designed according to the patients’ baseline characteristics.
Ethical approval: Not applicable.Conflicts of interest: None declared.
Acknowledgement
Ms Karloh received a research grant from the Research Productivity Program (Estácio University Centre, São José, Santa Catarina, Brazil).
Citation
Lack of responsiveness of the PRAISE tool to pulmonary rehabilitation: instrument or protocol limitation?