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British Journal of Health Psychology (2013), 18, 237–243

© 2013 The British Psychological Society
www.wileyonlinelibrary.com

Editorial
The role of self-efficacy in changing health-related
behaviour: Cause, effect or spurious association?

Self-efficacy is a core construct in health psychology as well as in other areas of psychology.

It has been defined as ‘Beliefs about whether one can produce certain actions’ (Bandura,
1997, p29). It is proposed to motivate behaviour by directing people towards choosing
challenging tasks and by energizing persistence in those tasks in the face of barriers and
setbacks. However, whilst it has been proposed to play a causal role in changing health-
related behaviour (Bandura, 1977), the evidence for this may not be as compelling as is
widely believed. This is of critical importance, as only if self-efficacy is a genuine cause of
behaviour is it sensible to intervene to change it to bring about behaviour change.
To illustrate issues surrounding the causal role of self-efficacy in changing health-
related behaviour in general, the focus here will be on whether self-efficacy is a cause of
changes in levels of physical activity performed by adults. To do this, the nature of
causation will be briefly considered, some theoretical issues relating to self-efficacy as a
cause will be outlined, and the empirical evidence relating to self-efficacy as a cause of
physical activity will be evaluated.

Nature of Causation
Part of the reason for the neglect of causality is undoubtedly that the issue of causality is a
thorny one: there is no simple checklist of criteria that, once satisfied, can indicate that a
relationship is a causal one (Rothman, Greenland, Poole & Lash, 2008). However, criteria
such as those proposed by Bradford-Hill (1965) can be useful in flagging up the kinds of
issues one should consider and for identifying where there are gaps in the evidence base.
The criteria that may be particularly illuminating in the current context are those relating
to strength of relationship, consistency of relationship (across populations, behaviours
and studies), temporality (Is change in self-efficacy prior to change in behaviour?) and
dose–response relationship (i.e., the extent to which increases in self-efficacy are
associated with corresponding increases in behaviour).
It is useful in this context to make a distinction between necessary, sufficient and
component causes (Rothman et al., 2008). If self-efficacy is a necessary cause of change in
physical activity, then changes in physical activity will occur only when self-efficacy
increases. If self-efficacy is a sufficient cause, then changes in self-efficacy will always
produce changes in physical activity, although it may be that factors other than self-
efficacy also produce changes in physical activity. It has been argued that most identified
causes of disease are neither necessary nor sufficient to cause disease (Rothman et al.,
2008). Instead, they are component causes, sometimes termed contributory causes. The
DOI:10.1111/bjhp.12038
238 Editorial

criteria to indicate causation for component causes are much less stringent than those that
needed to be satisfied to indicate necessary or sufficient causes. For self-efficacy to be a
component cause, bringing about changes in self-efficacy should bring about subsequent
changes in physical activity, at least for some people, and does not rule out the possibility
that there are people who increase their physical activity without first increasing their self-
efficacy.

Theoretical Issues Relating to Cause

In line with the idea of a component cause, it is important to be clear that social cognitive
theory does not propose that self-efficacy will cause changes in behaviour in all
circumstances. Specifically, social cognitive theory states that the effects of self-efficacy
on behaviour will be moderated by outcome expectancies, that is, beliefs that a particular
behaviour will lead to a particular outcome. Further, that outcome must be a valued goal
for self-efficacy to play a role in motivating behaviour. For example, a person may believe
they are capable of performing their recommended 150 min per week of moderate or
vigorous physical activity, but unless they expect that behaviour would contribute to
achieving a personal goal such as weight loss, fitness, well-being or transport, they will not
deliberately attempt to engage in this behaviour.
A further theoretical issue relating to causation is that self-efficacy is proposed to be
both a cause and an effect of performing a behaviour. Specifically, mastery experience,
that is, successful performance of the behaviour, is held to be a key determinant of self-
efficacy. Consequently, there is a need for careful attention to temporal aspects of
attempts to test this theory. Where an intervention is run over several sessions, and change
in self-efficacy is recorded from beginning to end of the intervention, then observed
change in self-efficacy may be a consequence of behaviour change, and reporting an
association between such a change in self-efficacy and post-intervention behaviour does
not provide useful information about the direction of causation. Care is needed.
A third theoretical issue is that interventions that increase skill, such as planning how
to increase physical activity (see Gollwitzer & Sheeran, 2006) may lead to increases in self-
efficacy and behaviour, but this may be due to increased skill resulting in changes to both.
In short, the causal mechanism may be actual efficacy, not self-efficacy. However, an
evaluation would show an increase in self-efficacy and behaviour, and such an increase
may satisfy tests of mediation. However, this result would be spurious, as the change
in self-efficacy and behaviour is caused by an uncontrolled confounding variable. One
should in this instance want to increase skill, as this is the actual causal agent, and not
self-efficacy.

Evidence of Self-Efficacy as a Cause of Physical Activity

Given these many caveats, there are examples of empirical studies that do appear at first
blush to present a compelling cause for self-efficacy causing behaviour, including one we
conducted (e.g., Darker, French, Eves & Sniehotta, 2010). In this waiting list control trial,
130 participants were randomized to receive a brief (10–15 min) intervention to promote
walking, or to a control task. The intervention consisted of a single session that aimed to
promote self-efficacy and planning behaviours of various kinds (for details see French,
Darker, Eves & Sniehotta, in press). In both experimental conditions, measures of self-
efficacy and self-reported planning, amongst others, were taken both before and
 Editorial 239

immediately after the intervention or control task. Walking was objectively measured in
the week following the intervention using pedometers. Large changes in self-efficacy and
behaviour were found in the intervention group, relative to controls.
This study provides several grounds for optimism regarding the causal role of self-
efficacy, as it satisfied many of the criteria proposed by Bradford-Hill (1965). First, it was an
experimental study that induced changes in self-efficacy in the intervention but not the
control group, and the change in self-efficacy was observed before the participants had
any chance to increase their walking (‘temporality’). Therefore, this rules out the
possibility that behaviour change was responsible for the increase in self-efficacy. The
change in self-efficacy and behaviour was large, and the strength of association between
these variables was strong. Further analyses indicated that self-efficacy was the mediator
of the effect of the intervention (‘strength of relationship’). By contrast, other constructs
that were changed by the intervention, namely attitudes and self-reported planning, did
not satisfy the same tests of mediation. It is noteworthy that the mediation analyses
essentially showed that those people who showed the largest change in self-efficacy were
the ones who showed the largest increase in walking, as assessed objectively: there was
evidence of a ‘dose–response relationship’. Finally, effects were replicated (‘consistency
of relationship’) when delivered in a different city by a different individual (French,
Stevenson & Michie, 2012).
By contrast, it is clearly possible that the increases in self-efficacy and behaviour
were brought about by a third factor, which was either not measured or not measured
adequately. In the latter category, planning was assessed using the self-report measure
that has become a standard measure (Sniehotta, Schwarzer, Scholz & Sch} uz, 2005).
Despite its widespread use, it is open to question whether planning can be assessed
adequately by self-report. Similarly, the intervention may have had a positive effect on
mood, which was not measured, and it may be this construct that was responsible for
changes in both self-efficacy and behaviour. It has also been argued that many measures
of self-efficacy are contaminated by assessments of outcome expectancies (Williams,
2010). For example, items that assess self-efficacy in line with Bandura’s (1997)
recommendations may ask people whether they are confident that they can be more
physically active when they have work commitments or there is inclement weather, or
even when they lack motivation. Use of such measures may therefore result in
incorrect attributions of causation to the self-efficacy construct of any genuinely causal
effect of outcome expectancies.
Further, all experimental studies, even replicated ones, have limited generalizability,
so to firmly establish ‘consistency of relationship’, it is useful to examine systematic
reviews of the relationship between self-efficacy and physical activity.
There has been a wealth of research assessing the role of self-efficacy in predicting and
changing physical activity in adults, and there is strong evidence that self-efficacy and
physical activity are consistently associated (Bauman et al., 2012). Moreover, a review of
intervention studies has shown that changes in self-efficacy following interventions are
associated with changes in physical activity (Ashford, Edmunds & French, 2010; Williams
& French, 2011). For each study, effect size estimates for change in self-efficacy, and
where available, physical activity, were calculated. The intervention descriptions were
coded using the CALO-RE taxonomy (Michie et al., 2011), a list of 40 behaviour change
techniques, thereby allowing characterization of the intervention contents. The review
examined whether effect sizes for changes in self-efficacy and physical activity were
associated with the presence or absence of each behaviour change technique in the
intervention. For example, those studies that included the technique of ‘action planning’
240 Editorial

produced significantly greater changes in self-efficacy (mean d = 0.49) than those that did
not include this technique (mean d = 0.11).
However, for present purposes, it is more noteworthy that there was a strong
association between changes in self-efficacy and change in physical activity (Spearman’s
r = 0.71, n = 20, p < .001). That is, those studies that produced larger changes in self-
efficacy also produced larger changes in physical activity. Those that were ineffective at
changing one also tended to be ineffective at changing the other.
Such a strong association is suggestive of a causal relationship, although the direction
of causality is not clear. Thus, given that mastery experience is theorized to lead to
increased self-efficacy, one would expect that any successful increase in physical activity
would lead to a commensurate increase in self-efficacy. Stronger tests of causality come
from tests of mediation.
There are at least three reviews of the extent to which self-efficacy mediates the effects
of interventions on adult physical activity (Baranowski, Anderson & Carmack, 1998;
Lewis, Marcus, Pate & Dunn, 2002; Rhodes & Pfaeffli, 2010). The two earlier reviews
lamented the lack of testing of mediation in such trials. The most recent review found
more evidence of such tests, but concluded that ‘self-efficacy has considerably limited
support for its role as a mediator of PA changes due to interventions at present’ (Rhodes &
Pfaeffli, 2010, p6).
This conclusion was based upon 22 intervention studies of at least moderate quality, of
which 19 assessed self-efficacy. Of these 19 studies, 10 showed an effect on physical
activity, and of these, seven showed an effect on self-efficacy. Four assessed the
association between change in self-efficacy and physical activity and three found
significant associations to be present. Of the 10 interventions that showed an effect on
physical activity, five examined whether the effects were mediated by self-efficacy and
one supported mediation.
It is also useful when considering the causal status of self-efficacy to compare the
results of intervention studies in this review that showed no effects on physical activity
with those of studies that did produce effects on physical activity. Of the nine studies that
showed no effect of the intervention on physical activity, only two showed an effect on
self-efficacy. This proportion is considerably lower than the seven studies that showed an
effect on self-efficacy, out of the 10 which showed an effect on physical activity. Thus,
there was at least an association between interventions changing self-efficacy and
changing physical activity (v2 = 4.34, df = 1, N = 19, p = 0.037), even if the tests of
mediation did not provide firm grounds for optimism about self-efficacy as a possible
cause.
There is also a growing movement to question the usefulness of mediation analyses
using the method described by Baron and Kenny (1986) in establishing evidence of
causation (Cerin & MacKinnon, 2009; Zhao, Lynch & Chen, 2010). Not least amongst the
drawbacks of the Baron and Kenny (1986) method is that it provides a very conservative
tests of mediation, as the method relies on several null hypothesis significance tests,
which all have to be satisfied for mediation to be judged to be present. Such analyses are
also limited in any event by a general lack of consideration of the temporal aspects of
mediation in favour of statistical aspects and relatedly by a lack of consideration of
whether changing behaviour mediates effects on self-efficacy. Perhaps most tellingly,
estimation of the relationship between the mediating variable (self-efficacy) and the
dependent variable (behaviour) is essentially observational, even in experimental studies,
so it cannot provide compelling proof of causation, in line with other observational data
(see Sutton, 2002). Aside from such generic criticisms of methods for establishing
 Editorial 241

mediation, it is notable that only one of these studies included in the Rhodes and Pfaeffli
(2010) review constituted a ‘high’-quality test of mediation, with the rest being only
‘moderate’ quality.
Taken as a whole, the results of the Rhodes and Pfaeffli (2010) review provide only one
study indicating self-efficacy was a mediator of changes in physical activity, which does
not provide much support for the idea of self-efficacy as a cause. However, there are
several caveats to this conclusion. First that the searches in this review were performed in
2008 and therefore missed more recent literature such as the Darker et al. (2010) study.
Second, that tests of mediation are not always conducted, their results are often
conservative, and they cannot in any event completely resolve issues of causality. The
association across studies between change in self-efficacy and change in behaviour in the
Rhodes and Pfaeffli (2010) review, and a strong association in the Williams and French
(2011) review suggest that relationships between self-efficacy and physical activity are
causal, but direction of causality is unresolved. Third, the test of mediations were (with
one exception) not of high quality.
Given limitations in this literature, the safest conclusion currently is that there is an
absence of compelling evidence for whether self-efficacy is a cause of physical activity or
whether the consistent association is due to self-efficacy being an effect. Despite a wealth
of research in this area, there is still a dearth of studies that have attempted to seriously
tackle the issue of whether self-efficacy is a cause of changes in physical activity. A large
body of intervention research has targeted multiple constructs in an attempt to develop
useable interventions to address the major health challenge of physical inactivity.
However, whilst this is a worthy aim, analytic studies focussing on more core theoretical
issues surrounding causality should not be neglected, given that understanding causal
relationships is key to developing truly evidence-based interventions (Sutton, 2004), and
the current evidence base is still weak. So whilst the question of the causal status of self-
efficacy appears to be reasonably tractable, it has not yet been resolved. The final section
proposes how future research could do better in this regard.

Future Research Required

First, more randomized analytic experiments are needed, as this allows the strongest
inference possible about causality (Weinstein, 2007). In particular, interventions
delivered in single sessions allow the clearest attribution of causality: where physical
activity behaviours cannot be performed during sessions, any change in self-efficacy
over the course of that session cannot be attributed to mastery experience. These
interventions should have the single target of self-efficacy or be factorial to examine
the interaction between interventions targeting two single targets, such as self-
efficacy and planning. Such factorial designs may provide the clearest information
about the specific effects of intervention techniques used, upon both self-efficacy
and behaviour.
Second, measures of other plausible mediating variables including planning and other
skills should be taken in such studies, to examine the possibility that self-efficacy and
behaviour are caused by a third construct.
Third, care should be taken that measures of self-efficacy are as pure as possible and not
contaminated by outcome expectancies. The use of ‘think aloud’ studies (e.g., French,
Cooke, McLean, Williams & Sutton, 2007) to assess what sources of information people
draw upon in answering self-efficacy items may help in this regard.
242 Editorial

Fourth, such studies should be adequately powered for mediation analyses, either by
using intervention techniques shown to produce large effects on self-efficacy (see Ashford
et al., 2010) or by having sufficiently large sample sizes.
Fifth, other factors such as goals and outcome expectancies are theorized to moderate
the impact of self-efficacy on behaviour and hence may moderate the effects of
self-efficacy on behaviour to zero in some populations. Future reviews might consider
the relationship between self-efficacy and behaviour in conjunction with the effects
of outcome expectancies.
As a final point, it should be acknowledged that this discussion is limited to the causal
role of self-efficacy in the initiation of physical activity. The issue of whether self-efficacy
has a causal role in maintaining change in behaviour is another, possibly more important,
question for research to answer.

Acknowledgement
This article is based upon a presentation given to a Medical Research Council (MRC) Population
Health Sciences Research Network–funded workshop held at the MRC Lifecourse Epide-
miology Unit, University of Southampton, on 24th October 2012. It was shaped by encouraging
and helpful feedback by Marie Johnston, who does necessarily agree with the views expressed
here.

David P. French (Manchester Centre for Health Psychology, School of Psychological

Sciences, University of Manchester, Manchester, UK)

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