PHOTO CAPTION: Available in a variety of forms that often easily sync with a smartphone, electronic wearable devices allow people to monitor their own health data. For those with chronic health conditions, this is an important part of self-efficacy.
Electronic wearable devices can help therapists empower patients to reach greater health outcomes.
By Karen Danchalski, DPT
In this modern era of healthcare, patients are playing increasingly active roles in managing their health. They can access their health records, communicate with their health providers, and monitor and report their health status in real time thanks to electronic medical records, patient portals, and electronic wearable devices. It is a reasonable assumption that this heightened level of engagement would increase a patient’s sense of agency in affecting his or her own health outcome.
The aim of this article is to explore self-efficacy theory as it relates to exercise, how electronic wearable devices can enhance self-efficacy, and how physical therapists can best support their patients within a more personalized healthcare system.
Self-efficacy is defined as the belief in one’s ability to carry out a behavior and affect a desired outcome. Patients come to therapy with varying degrees of confidence in their ability to recover from an injury and participate in a rehabilitation program. Physical therapists are adept at recognizing differences in patients’ dispositions and attitudes but may not realize just how strong of a role they can play in boosting a patient’s sense of self-efficacy.
Self-efficacy theory was developed by Albert Bandura, a prominent psychologist and researcher in social cognitive theory. Bandura described four ways in which individuals gain self-efficacy: mastery experience, vicarious experience, social persuasion, and feedback.¹
Let’s take a closer look at these:
Mastery Experience—practice and past performance of an activity with success
Vicarious Experience—watching or learning from others who performed a similar activity with success
Persuasion—help from others to stay on course and meet goals, encouragement
Physiological Feedback—physical and emotional cues during an activity that can facilitate continuation of the activity
Mastery experience refers to having a history of practicing a skill and succeeding. For example, a patient who had a successful knee replacement in the past may have greater confidence in undergoing a second joint replacement. A therapist can help patients recall their previous triumphs to help them through current challenges.
Vicarious experience refers to a patient learning from others who have gone through a comparable situation. A therapist can relay stories about other patients with similar diagnoses, treatments, and achievements. It is beneficial to use examples of typical rather than exceptional patients, as people tend to relate better to others who are like themselves.
Persuasion refers to other people sending encouragement and reassurance. A therapist is a key persuader in a patient’s recovery. Through every step of rehabilitation, the therapist is guiding and educating the patient, helping to set realistic yet challenging goals, and helping patients work through physical and mental barriers. For example, a therapist may need to help a patient break down long-term goals into smaller, more achievable ones, or help a patient change his or her perception of a disability.
Feedback refers to the physiological and emotional cues during an activity that can influence continuation of that activity. The therapist can help a patient discriminate between positive and negative feedback. For example, the therapist can teach a patient who is status post a coronary artery bypass to discern postsurgical chest pain from ischemia. The therapist can teach sedentary patients that it is normal to experience aches and pains when starting up a new exercise routine. It is crucial that the therapist select exercises that challenge the patient but are not too difficult. If a patient leaves a session with a sense of failure, an inability to perform what was asked, or worsened symptoms, self-efficacy can be reduced and compliance with an exercise program may diminish.
The literature supports a strong correlation between self-efficacy and exercise adherence, the pursuit of wellness goals, being more active, and making health behavior changes—especially in the long-term.² Patients with high self-efficacy tend to have clearer intentions, make plans for action, perceive fewer barriers, are more likely to seek out challenging experiences, are less deterred by short-term failures, and have better self-monitoring strategies.
Self-efficacy is also task-specific. For example, someone can feel capable of starting an exercise program but not of maintaining one, or feel competent in only one exercise modality. The physical therapist has several tools to help a patient with self-management, such as keeping an exercise calendar as a cue to action or as a record of compliance.
By improving a patient’s self-efficacy through educational interventions, positive reinforcement, appropriate levels of exercise, and self-management strategies, the therapist can contribute to that patient’s maintenance of healthy behaviors.
Electronic Wearable Technology
A current self-management strategy for improving one’s health is the use of electronic wearable technology to record and track bio-data. Electronic wearable devices (EWDs) refer to devices attached to or inserted into the body which measure heart rate, rhythm and variability, blood pressure, respiratory rate, temperature, biomarkers in sweat, oxygen saturation, calories, and motion such as number of steps, speed, acceleration, changes in body position, distance, elevation, or sleep patterns. Users can also manually enter data such as mood and diet as additional variables. Devices typically link to one’s smartphone for full functionality in order to see graphs, charts, and patterns and to share data with others, if desired.
The market for electronic wearable technology includes fit individuals wanting to track and enhance performance, average people curious about their activity and health patterns, as well as people with chronic illness who are trying to avert medical complications in real time. EWDs can be in the form of watches, arm bands, chest straps, rings, headsets, eyeglasses, belts, clothing, or smartphones. EWDs are now even available as skin patches that attach directly to the skin. This newer platform is more discreet and more accurate in sensing biomarkers in sweat and interstitial fluid. Skin patches are currently being used for the monitoring and treatment of diabetes and cardiovascular disease.
Advancements in material science, miniature biosensors, electronics, and wireless technology have made EWDs more accessible, affordable, and usable.³
EWDs for Therapy
Although devices used for general fitness and those used for medical symptom monitoring are often discussed separately, all devices aim to quantify health and interpret data in a useful and meaningful way. As healthcare becomes more personalized and the burden of health maintenance is placed increasingly on the individual, electronic wearable devices are becoming a common tool for tracking one’s health. Physical therapists will likely come across electronic wearable technology available for a diverse set of patients with varying levels of interest in and aptitude for using devices. Physical therapists who familiarize themselves with EWDs may be better able to relate to and help patients meet their healthcare goals.
Research has shown links between the use of electronic wearable devices, self-efficacy, and activity participation. A 2019 systematic review and meta-analysis on the use of consumer-based wearable trackers and physical activity showed that EWDs can improve physical activity levels particularly in the short-term and have a greater effect when combined with other educational interventions.4 There is a bi-directional relationship between self-efficacy and EWDs in that people with higher self-efficacy lean toward using devices and the use of devices can reinforce self-efficacy.5
Mastery experience is achieved as the device reinforces practicing an activity. Vicarious experience is achieved as users can share their data and accomplishments to the cloud for others to see. An EWD can act as a coach and persuade the user to stay on track with fitness goals by sounding an alarm or giving a verbal reminder when it is time to get up and move. Gamification allows individuals to earn digital medals and social ranking and compete with themselves or others. Social comparison and competition are not universally motivating. Some individuals are not persuaded by this feature, yet others find competition a strong prompt to exercise. Through tracking patterns, setting goals, marking achievements, and potentially sharing data, EWDs can promote self-efficacy and motivate individuals to adhere to a physical activity program.
The ability to self-monitor and self-manage one’s health are critical skills for patients living with chronic illness. Patients with acute injuries tend to rely more on providers for treatment. Patients with chronic illness, on the other hand, must learn to self-monitor variable and fluctuating symptoms and communicate regularly with their providers. High levels of self-efficacy are advantageous for patients who are chronically ill in order to optimize their health and quality of life. Physical therapists can help patients with chronic illness reduce their level of disability, establish realistic expectations and emotional responses to their illness, interpret and manage their symptoms, understand how to manage their medications with their physician, become better problem-solvers, communicate better with professionals, and use community resources where available.6 It is well-known that exercise is an important intervention for people living with chronic illness, and electronic wearable devices can facilitate compliance in an exercise program.
A discussion of self-efficacy and electronic wearable technology falls aptly within the current model of personalized healthcare (PHC). Healthcare has evolved over the decades with regard to types of patients entering the healthcare system and how medical services have been administered.
Early models in the beginning of the 20th century revealed only the very sick seeking help from a sole physician. Throughout the mid-20th century, patients who were less ill entered the mix, as medicine branched out into specialties, diagnostic testing expanded, and services could be provided in places other than hospitals such as rehabilitation centers, nursing homes, and laboratories. By the latter part of the 20th century, patient populations broadened to include well-individuals with pre-conditions looking for screening and preventative services.7
In the 21st century, the number of people utilizing medical services increased further as the volume of people living with chronic illness soared and a growing number of well-individuals were concerned about health maintenance. The escalating cost of healthcare, the rise in demand for services, and advancement in digital technology have shaped the PHC system in use today.
In an effort to reduce healthcare costs, the Health Information Technology for Economic and Clinical Health Act (HITECH-act) of 2009 was designed to promote adoption of electronic medical records across health systems. Payment is currently changing from fee-for-service to fee-for-value, and increased accountability is being placed on the individual to maintain his or her own health.
As consumers face higher deductibles, there is greater incentive to avoid the need for costly medical care. Individuals are proactively tracking and monitoring their own health, sharing their bio-data and medical stories with others, and are seeking alternative services outside of the traditional healthcare system such as using private companies to test their DNA. The physical therapist can play an active role in enhancing a patient’s self-efficacy, in supporting the use of electronic wearable technology and in helping patients achieve greater health outcomes within a personalized healthcare system. RM
Karen Danchalski, DPT, received her bachelor of science in physical therapy from Indiana University in 1998, her transitional doctorate of physical therapy from Widener University in 2006, and became a certified Stott Pilates instructor in 2012. Danchalski currently practices in home healthcare with Northwell and in a private orthopedic clinic with Sparacio Physical Therapy. For more information, contact RehabEditor@medqor.com.
- McAuley E, Szabo A, Gothe N, Olson EA. Self-efficacy: implications for physical activity, function, and functional limitations in older adults. Am J Lifestyle Med. 2011;5(4):10.1177/1559827610392704. doi:10.1177/1559827610392704
- Dishman RK, Motl RW, Sallis JF, et al. Self-management strategies mediate self-efficacy and physical activity. Am J Prev Med. 2005;29(1):10-18. doi:10.1016/j.amepre.2005.03.012
- Guk K, Han G, Lim J, et al. Evolution of wearable devices with real-time disease monitoring for personalized healthcare. Nanomaterials (Basel). 2019;9(6):813. Published 2019 May 29. doi:10.3390/nano9060813
- Brickwood KJ, Watson G, O’Brien J, Williams AD. Consumer-based wearable activity trackers increase physical activity participation: systematic review and meta-analysis. JMIR Mhealth Uhealth. 2019;7(4):e11819. Published 2019 Apr 12. doi:10.2196/11819
- Rieder A, Yeliz EU, Lehrer C, Jung R. Why users comply with wearables; the role of contextual self-efficacy in behavioral change. Int J Hum Comput Interact. 2021;37(3):281-294. doi:10.1080/10447318.2020.1819669
- Holman H, Lorig K. Perceived self-efficacy in self-management of chronic disease. In: Schwarzer Ralf, ed. Self-Efficacy Thought Control of Action. Routledge Taylor & Francis Group; 2016: 305-323
- Garfield SR. The delivery of medical care. Perm J. 2006;10(2):46-56.