1. Cultural differences in self-care self- efficacy in patients with chronic illnesses Elise L. Lev, Ed.D., RN Rutgers University, College of Nursing, Newark, NJ USA.

2. College of Nursing Co-Authors and Affiliations Semiha Akin, PhD, BSc, RN. & Zehra Durna, PhD, BSc, RN 1 Lucille S. Eller, PhD, RN 2 Huijuan Qian, MA, RN 3 Changrong Yuan, PhD 4 Miklos Zrinyi, PhD, RN 5 1. Bahcesesehir University, Besiktas, Istanbul,Turkey. 2. Rutgers Univerisity, Newark, NJ, USA 3. Shanghai JiaoTong University, Shanghai, China 4. Shanghai Second Military Medical University, Shanghai, China. 5. Nyiregyhaza, University of Debrecen, Hungary.

3. College of Nursing Background Health care professionals seek to increase quality of life (QOL) in survivors of chronic illnesses. Self-care self-efficacy influences QOL as efficacy expectations exert a causal influence on behavior. Culture in this study refers to values that are learned, shared, and transmitted from one generation to the next in a specific group. Previous researchers reported decreased self-efficacy in Chinese population vs. Western cultures. Establishing psychometric equivalence across languages is necessary to study self-efficacy across cultures.

4. College of Nursing Processes effecting self-care Social learning theory used to explain health related behavior (Bandura, 1997). People’s functioning is facilitated by a personal sense of control. People who believe they can take action to solve a problem are more inclined to so do. People from different cultures view self-care differently (Garcia, 2006). Culturally-competent decision-making involves encouraging patients’ participation while respecting cultural factors and respect for individual’s preferences (Dy & Purnell, 2012).

5. College of Nursing Aims To compare how people in various cultures perceive their ability to care for their health during treatment for chronic illnesses. To use Strategies Used by People to Promote Health (SUPPH) to assess patients’ confidence in carrying out self-care strategies. To assess self-care self-efficacy of patients with chronic illnesses in various cultures using Strategies Used by People to Promote Health (SUPPH) in multi- countries cross-sectional survey studies. To compare how people in various cultures perceive their ability to care for their health during treatment for chronic illnesses.

6. College of Nursing SUPPH Measures patients’ confidence in performing self-care strategies. Each item rated on a 5-point scale from 1=very little confidence to 5=quite a lot of confidence. Subscales: Positive Attitude; Decision-Making; and Stress Reduction. Reliability and validity evidence given in each of the studies.

7. College of Nursing Methodology Participants were diagnosed with either cancer or ESRD. Participants completed the SUPPH in their native language in –China (n=764); –Hungary (n=68); –Turkey (n=141); –US three studies (n=33; n=185; n=129).

8. College of Nursing Procedures Researchers in each setting received institutional review board or ethical approval. Subjects were recruited during regularly scheduled visits to the health care setting. Patients in each setting gave informed consent for their participation. After completing questionnaires, participants returned them to the researcher. Translations on the SUPPH (when needed) included forward translation, backward translation and cultural adaptations that were congruent with the theoretical construct of self-efficacy.

9. College of Nursing Measurements of SUPPH in various populations RegionDxNAlpha Pos Att Alpha St Red Alpha Mk Dec Alpha Total ChinaCancer764F: 0.95 M: 0.94 F: 0.92 M: 0.92 F: 0.83 M: 0.84 HungaryESRD 680.84 TurkeyBreast Cancer 141 F: 0.93 F: 0.85 F: 0.670.92 US (1)Prostate Cancer 33 US (2)PCa185 M: 0.91 M: 0.87 M: 0.71 US (3)PCa129 M: 0.94 M: 0.88 M: 0.77

10. College of Nursing Evidence of validity of SUPPH Content validity index (CVI) of Turkish version of SUPPH is 91%. Significant positive correlations with QOL Significant negative correlations –depression, –anxiety, –symptoms.

11. College of Nursing Confirmatory factor analysis (CFA) Testing the congruence of the item pattern across groups can be performed by CFA. Multi-lingual equivalence was supported by confirmatory factor analysis in several studies.

12. College of Nursing Means of SUPPH in different populations Country of study Total SUPPH Stress Reduction Making Decisions Positive Attitude ChinaF: 84.98 M: 83.23 F: 48.94 M: 47.33 F: 9.17 M: 9.27 F: 26.87 M: 26.63 Hungary 86.3 Turkey 99.64 32.19 9.84 57.61 US (1) 118.79 38.18 12.84 67.75 US (2) 105.83 31.92 12.21 61.69 US (3) 95.19 23.35 9.96 57.50

13. College of Nursing Findings & Discussion The pattern of correlations with other psychological variables is congruent with self-efficacy theory. Some researchers reported that respondents had difficulty answering questions on the decision-making scale. Individual decision-making may not be relevant in cultures with strong reliance on authority figures. Decision-making in ESRD patients may be lower than in patients with cancer because there are fewer choices. Low mean levels of participants’ perceived self- efficacy in non-Western cultures could indicate less individualism than in Western cultures.

14. College of Nursing Recommendations Focus groups in different cultures may yield information regarding respondents’ interpretation of stress reduction, decision-making, and positive attitude. Health care strategies need to be based on knowledge of cultural effects and adapted to individual’s situation—including their culture. Cultural competence of health providers is necessary to influence patients’ self-care behaviors.

15. College of Nursing Implications for nursing Using specific assessments to identify gaps in QOL outcomes is critical to early detection of psychological distress. Nurses can deliver targeted interventions that can impact patients’ psychological problems, increase self- care self-efficacy and improve QOL.

16. College of Nursing Conclusions Activities for promoting self-care require an understanding that culture is a powerful determinant of health behaviors. Western concepts of self-care can be taught to people in cultures that do not share that value. Efficacy enhancing interventions enhance patients’ QOL and decrease patients’ symptoms. Efficacy enhancing interventions may assist people to have a more positive attitude, reduce stress, and make decisions regarding their health.

17. College of Nursing References Akin, S, Can, G, Durna, Z et al. (2008). The quality of life and self- efficacy of Turkish breast cancer patients undergoing chemotherapy. European Journal of Oncology Nursing. 12, 443-456. Bandura, A. (1997). Self-efficacy: the exercise of control. New York: WH Freeman & Co. Dy, SM. & Purnell, TS. (2012). Key concepts relevant to quality of complex and shared decision-making in health care: A literature review. Social Science and Medicine. 74, 582-7. Garcia, A. (2006). Is health promotion relevant across cultures and socioeconomic spectrum? Family & Community Health. 29(1), 20S- 27S. Lev, E. (1996). A measure of self-care self-efficacy. Research in Nursing and Health. 19, 421-9. Lev, EL, Eller, LS, Gejerman, G et al. (2009). Quality of life of men treated for localized prostate cancer. Supportive Care in Cancer. 17(5), 509-517. Quian, H & Yuan, C. (2012). Factors associated with self-care self- efficacy among gastric and colorectal cancer patients. Cancer Nursing. 35(3), E22-31.

18. College of Nursing Acknowledgement and thanks To the researchers in each study; To the participants in each study; To the funding agencies supporting the various studies; To this audience for your attention.