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Self-efficacy as a mediator between physical and psychological factors in the disease management of patients with occupational respiratory diseases: a structural equation model

Katrin Mueller, Christina Niermann, Nicola Kotschy-Lang, Petra Wagner


Objectives: Sustaining physical capacity and reducing psychological symptoms are important, person-centered aims in the disease management of patients with occupational lung diseases. Self-efficacy is an individual resource that appears crucial in disease management. The objective of this study is to explore the association between the severity of disease, psychological risk, self-efficacy and physical capacity.

Methods: In a cross-sectional study, 197 patients (age: M = 69.9 years) with occupational lung diseases were included at the beginning of inpatient rehabilitation. The parameters were objectively (FEV1%pred, FVC%pred) and subjectively measured severity of disease (mMRC), psychological risk (HADS-D, CRQ Emotion), self-efficacy (CSES-D) and physical capacity (6MWD).

Results: Illness-specific self-efficacy is significantly correlated with FEV1%pred, FVC%pred, perceived dyspnoea, depression, anxiety and physical capacity. Structural equation models revealed a negative effect of psychological risk on physical capacity mediated by self-efficacy with a good model fit.

Conclusions: The results emphasize the relevance of patients’ self-efficacy in the disease management of occupational lung diseases. Self-efficacy directly affects physical capacity and mediates the effect of psychological health on physical capacity. Psychological risk factors such as depressive symptoms are negatively related to self-efficacy in managing lung disease in difficult situations. However, self-efficacy is a psychological resource which is positively related to physical capacity. Therefore, our results suggest that promoting self-efficacy during rehabilitation could improve disease management in patients with occupational lung diseases.


Cognitive behavioural therapy, disease management, interpersonal psychotherapy, occupational respiratory diseases, person-centered healthcare, physical capacity, psychological risk, self-efficacy, severity of diseases, structural equation model

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Global Initiative for Chronic Obstructive Lung Disease (GOLD) (2015). Global Strategy for the diagnosis, management, and prevention of COPD (Updated, 2015). Available at: (last accessed 15. April 2015)

Mathers, C.D. & Loncar, D. (2006). Projections of global mortality and burden of disease from 2002 to 2030. PLOS Medicine 3, e442.

Deutsche Gesetzliche Unfallversicherung (DGUV) (Hrsg.) (2014). DGUV-Statistiken für die Praxis 2013. Aktuelle Zahlen und Zeitreihen aus der Deutschen Gesetzlichen Unfallversicherung. Paderborn: Bonifatius GmbH. Druck-Buch-Verlag.

Li, L.S.K., Caughey, G.E. & Johnston, K.N. (2014). The association between co-morbidities and physical performance in people with chronic obstructive pulmonary disease: A systematic review. Chronic Respiratory Disease 11 (1) 3-13.

Panagioti, M., Scott, C., Blakemore, A. & Coventry, P.A. (2014). Overview of the prevalence, impact, and management of depression and anxiety in chronic obstructive pulmonary disease. International Journal of Obstructive Pulmonary Disease 9, 1289-1306.

Yohannes, A.M., Willgoss, T.G., Baldwin, R.C. & Connolly, M.J. (2010). Depression and anxiety in chronic heart failure and chronic obstructive pulmonary disease: prevalence, relevance, clinical implications and management principles. International Journal of Geriatric Psychiatry 25, 1209-1221.

Kraus, T., Baur, X., Teschler, H. et al. (2011). Empfehlung für die Begutachtung asbestbedingter Berufskrankheiten - Falkensteiner Empfehlung. Deutsche Gesetzliche Unfallversicherung (DGUV) (ed.). Berlin, Meckenheim: DCM Druckcenter Meckenheim. Available at: (last accessed 08. September 2015)

Cramm, J.M. & Nieboer, A.P. (2012). Self-management abilities, physical health and depressive symptoms among patients with cardiovascular diseases, chronic obstructive pulmonary disease, and diabetes. Patient Education and Counseling 8, 411-415.

Lee, H., Yoon, J.Y., Jung, H., Kim, S., Yoo, Y., Ahn, J.J. & Park, H.K. (2015). The effect of nurse-led problem-solving therapy in coping, self-efficacy and depressive symptoms for patients with chronic obstructive pulmonary disease: a randomized controlled trial. Age and Ageing 44 (3) 397-403.

Reddel, H.K., Jenkins, C.R. & Partridge, M.R. (2014). Self-management support and other alternatives to reduce the burden of asthma and chronic obstructive pulmonary disease. International Journal of Tuberculosis and Lung Disease 18 (2) 1396-1406.

Johnson-Warrington, V., Harrison, S., Mitchell, K., Steiner, M., Morgan, M. & Singh, S. (2014). Exercise capacity and physical activity in patients with COPD and healthy subjects classified as Medical Research Council dyspnea scale grade 2. Journal of Cardiopulmonary Rehabilitation and Prevention 34 (2) 150-154.

Enfield, K., Gammon, S., Floyd, J., Falt, C., Patrie, J., Platts-Mills, T.A., Truwit, J.D. & Shim, M. (2010). Six-Minute walk distance in patients with severe end-stage COPD. Journal of Cardiopulmonary Rehabilitation and Prevention 30 (3) 195-202.

Maters, G.A., de Voogd, J-N., Sanderman, R. & Wempe, J.B. (2014). Predictors of all-cause mortality with stable COPD: medical co-morbid conditions or high depressive symptoms. COPD 11 (4) 468-474.

Tödt, K., Skargren, E., Jakobsson, P., Theander, K. & Unosson, M. (2015). Factors associated with low physical activity in patients with chronic obstructive pulmonary disease: a cross-sectional study. Scandinavian Journal of Caring Sciences 29 (4) 697-707.

Altenburg, W.A., Bossenbroek, L., de Greef, M.H., Kerstjens, H.A., ten Hacken, N.H. & Wempe, J.B. (2013). Functional and psychological variables both affect daily physical activity in COPD: a structural equations model. Respiratory Medicine 107 (11) 1740-1747.

Miravitlles, M., Molina, J., Quintano, J.A., Campuzano, A., Pérez, J., Roncero, C. (2014). Factors associated with depression and severe depression in patients with COPD. Respiratory Medicine 108 (11) 1615-1625.

Pumar, M.I., Gray, C.R., Walsh, J.R., Yang, I.A., Rolls, T.A. & Ward, D.L. (2014). Anxiety and depression - Important psychological comorbidities of COPD. Journal of Thoracic Diseases 6 (11) 1615-1613.

Doyle, T., Palmer, S., Johnson, J., Babyak, M.A., Smith, P., Mabe, S., Welty-Wolf, K., Martinu, T. & Blumenthal, J.A. (2013). Association of anxiety and depression with pulmonary-specific symptoms in chronic obstructive pulmonary disease. International Journal of Psychiatry in Medicine 45 (2) 189-202.

Giardino, N.D., Curtis, J.L., Andrei, A.C., Fan, V.S., Benditt, J.O., Lyubkin, M., Naunheim, K., Criner, G., Make, B., Wise, R.A., Murray, S.K., Fishman, A.P., Sciurba, F.C., Liberzon, I., Martinez, F.J. & NETT Research Group. (2010). Anxiety is associated with diminished exercise performance and quality of life in severe emphysema: a cross-sectional study. Respiratory Research 11, 29.

Di Marco, F., Terraneo, S., Roggi, M.A., Repossi, A.C., Pellegrino, G.M., Veronelli, A., Santus, P., Pontiroli, A.E. & Centanni, S. (2014). Physical activity impairment in depressed COPD subjects. Respiratory Care 59 (5) 726-734.

Zöckler, N., Rief, W, Kühl, K. & Kenn, K. (2012). COPD-specific anxiety and depressive symptoms in COPD patients. Pneumologie 66 (5) 290-296.

Blumenthal, J.A., Emery, C.F. & Smith, P.J. (2014). The effects of a telehealth coping skills intervention on outcomes in chronic obstructive pulmonary disease: primary results from the INSPIRE-II study. Psychosomatic Medicine 76 (8) 581-592.

Stenzel, N.M., Vaske, I., Kühl, K., Kenn, K. & Rief, W. (2015). Prediction of end-of-life fears in COPD - hoping for the best but preparing for the worst. Psychology & Health 30 (9) 1017-1034.

Wigal, J.K., Creer, T.L. & Kotses, H. (1991). The COPD Self-Efficacy Scale. Chest 99 (5) 1193-1196.

Garrod, R., Marshall, J. & Jones, F. (2008). Self efficacy measurement and goal attainment after pulmonary rehabilitation. International Journal of Chronic Obstructive Pulmonary Disease 3 (4) 791-796.

Inal-Ince, D., Savci, S., Coplu, L. & Arikan, H. (2005). Factors determining self-efficacy in chronic obstructive pulmonary disease. Saudi Medical Journal 26 (4) 542-547.

Lee, H., Lim, Y., Kim, S., Parl, H.K., Ahn, J.J., Kim, Y. & Lee B.C. (2014). Predictors of low levels of self-efficacy among patients with chronic obstructive pulmonary disease in South Korea. Nursing and Health Sciences 16 (1) 78-83.

Simpson, E. & Jones, M.C. (2013). An exploration of self-efficacy and self-management in COPD patients. British Journal of Nursing 22 (19) 1105-1109.

Jackson, B.E., Coultas, D.B., Ashmore, J., Russo, R., Peoples, J., Uhm, M., Singh, K.P. & Bae, S. (2014). Domain-specific self-efficacy is associated with measures of functional capacity and quality of life among patients with moderate to severe chronic obstructive pulmonary disease, Annals of the American Thoracic Society 11 (3) 310-315.

Hartman, J.E., Boezen, H.M., de Greef, M.H. & ten Hacken, N.H.T. (2013). Physical and psychological factors associated with physical activity in patients with chronic obstructive pulmonary disease. Archives of Physical Medicine and Rehabilitation 94, 2396-2402.

Bentsen, S., Rokne, B., Wentzel-Larsen, T., Henriksen, A. & Wahl, A. (2010). The Norwegian version of the chronic obstructive pulmonary disease self-efficacy scale (CSES): a validation and reliability study. Scandinavian Journal of Caring Science 24 (3) 600-609.

Müller, K., Kotschy-Lang, N. & Wagner, P. (2013). Physical performance capability and psychic comorbidity in patients with occupational respiratory diseases in in-patient rehabilitation. Occupational, Social & Environmental Medicine 48, 748-753.

Müller, K., Kotschy-Lang, N. & Wagner, P. (2013). Prevalence and correlations of depression, anxiety and physical activity with occupational respiratory diseases. In: Unifying sport science, 18th annual Congress of the European College of sport science (ed. N. Balagué et al), pp. 446. Barcelona: Open Print.

Baur, X., Preisser, A., Voshaar, T. et al. (2012). Empfehlung für die Begutachtung der Berufskrankheiten der Nummern 1315 (ohne Alveolitis), 4301 und 4302 der Anlage zur Berufskrankheiten-Verordnung – Reichenhaller Empfehlung. Deutsche Gesetzliche Unfallversicherung (DGUV) (Hrsg). Berlin, Meckenheim: DCM Druckcenter Meckenheim. Available at: (last accessed 8 September 2015)

Baur, X., Kraus, T., Voshaar, T. et al. (2011). Empfehlung für die Begutachtung von Quarzstaublungenerkrankungen (Silikosen) – Bochumer Empfehlung. Deutsche Gesetzliche Unfallversicherung (DGUV) (Hrsg). Berlin, Meckenheim, DCM Druckcenter Meckenheim. Available at: (last accessed 8 September 2015)

Deutsche Gesellschaft für Psychologie. Ethische Richtlinien der Deutschen Gesellschaft für Psychologie e.V. und des Berufsverbandes Deutscher Psychologinnen und Psychologen e.V. Available at: = 96422 (last accessed 8 September 2015)

Laszio, G. (2006). Standardisation of lung function testing: helpful guidance from the ATS/ERS Task Force. Thorax 61 (9) 744-746.

Miller, M.R., Hankinson, J., Brusasco, V., Burgos, F., Casaburi, R., Coates, A., Crapo, R., Enright, P., van der Grinten, C.P., Gustafsson, P., Jensen, R., Johnson, D.C., MacIntyre, N., McKay, R., Navaias, D., Pederson, O.F., Pellegrino, R., Viegi, G., Wanger, J. & ATS/ERS Task Force. (2005). Standardisation of spirometry. European Respiratory Journal 26, 319-338.

Wanger, J., Clausen, J.L., Coates, A., Pedersen, O.F., Brusasco, V., Burgos, F., Casaburi, R., Crapo, R., Enright, P., van der Grinten, C.P., Gustafsson, P., Hankinson, J., Jensen, R., Johnson, D., Macintyre, N., McKay, R., Miller, M.R., Navajas, D., Pellegrino, R. & Viegi, G. (2005) Standardisation of the measurement of lung volumes. European Respiratory Journal 26, 511-522.

Vogelmeier, C., Buhl, R., Criøe, C., Gillissen, A., Kardos, P., Köhler, D., Magnussen, H. & Morr, H. (2007). Guidelines for the diagnosis and therapy of COPD issued by Deutsche Atemwegsliga and Deutsche Gesellschaft für Pneumologie und Beatmungsmedizin. Pneumologie 61, e1-e40.

Fletcher, C.M., Elmes, P.C., Fairbairn, M.B. & Wood, C. (1959). The significance of respiratory symptoms and the diagnosis of chronic bronchitis in a working population. British Medical Journal 29, 257-266.

Zwerink, M., Brusse-Keizer, M., van der Valk, P.D., Zielhuis, G.A., Monninkhof, E.M., van der Palen, J., Frith, P.A. & Effing, T. (2014). Self management for patients with chronic obstructive pulmonary disease. Cochrane Database Systematic Reviews 3. CD002990.

Bestall, C., Paul, E.A., Garrod, R., Garnham, R., Jones, P.W. & Wedzicha, J.A. (1999). Usefulness of the Medical Research Council (MRC) dyspnoea scale as a measure of disability in patients with chronic obstructive pulmonary disease. Thorax 54, 581-586.

ATS Statement. (2002). Guidelines for the Six-Minute Walk Test. American Journal of Respiratory and Critical Care Medicine 166 (1) 111-117.

Büsching, G., Hilfiker, R., Mangold, F., Messmer, G., van Oort, E., Schädler, M., Schenker, M., Wettstein, M. & van Wittenberge, P. (2009). Assessments in der Rehabilitation. Band 3. Kardiologie und Pneumologie. Bern: Hans Huber Verlag.

Müller, K., Einhorn, N., Kotschy-Lang, N. & Wagner, P. (2014). Validierung einer deutschen Version der COPD Self-Efficacy Scale. Pneumologie 68 (S01) P36.

Kaşakçi, M.K. (2011). Using self-efficacy theory to educate a patient with chronic obstructive pulmonary disease: A case study 1-year follow-up. International Journal of Nursing Practice 17, 1-8.

Guyatt, G.H., Berman, L.B., Townsend, M., Pugsley, S.O. & Chambers, L.W. (1987). A measure of quality of life for clinical trials in chronic lung disease. Thorax 42, 773-778.

Puhan, M.A., Behnke, M., Frey, M., Grueter, T., Brandli, O., Lichtenschopf, A., Guyatt, G.H. & Schunemann, H.J. (2004). Self-administration and interviewer-administration of the German Chronic Respiratory Questionnaire: instrument development and assessment of validity and reliability in two randomised studies. Health and Quality of Life Outcomes 2, 1.

Hermann-Lingen, C., Buss, U. & Snaith, R.P. (1995). Hospital Anxiety and Depression Scale - deutsche Version (HADS-D). Bern: Verlag Hans Huber.

Little, R.J.A. (1988). A test of missing completely at random for multivariate data with missing values. Journal of the American Statistical Association 83 (404) 1198-1202.

Curran, P.J., West, S.G. & Finch, J.F. (1996). The robustness of test statistics to nonnormality and specification error in confirmatory factor analysis. Psychological Methods 1 (1) 16.

Cohen, J. (1988): Statistical Power Analysis for the Behavioral Sciences, (2nd edn.). Hillsdale: Lawrence Erlbaum Associates.

Schermelleh-Engel, K., Moosbrugger, H. & Müller, H. (2003). Evaluating the fit of structural equation models: Tests of significance and descriptive goodness-of-fit measures. Methods of Psychological Research Online 8 (2) 23-74.

Hayes, A.F. (2009). Beyond Baron and Kenny: Statistical mediation analysis in the new millennium. Communication Monographs 76 (4) 408-420.

Enright, P.L. & Sherrill, D.L. (1998). Reference equations for the six-minute walk in healthy adults. American Journal of Respiratory Critical Care Medicine 158, 1384-1387.

Yildiz, T., Eşsizoğlu, A., Onal, S., Ateş, G., Akyildiz, L., Yaşan, A., Özmen, C.A. & Cimrin, A.H. (2011). Quality of life, depression and anxiety in young male patients with silicosis due to denim sandblasting. Tuberkuloz ve toraks 59 (2) 120-125.

Von Leupoldt, A., Taube, K., Lehmann, K., Fritzsche, A. & Magnussen, H. (2011). The impact of anxiety and depression on outcomes of pulmonary rehabilitation in patients with COPD. Chest 10, 1-26.

Cafarella, P.A., Effing, T.W., Usman, Z-A. & Frith, P. (2012). Treatments for anxiety and depression with chronic obstructive pulmonary disease: A literature review. Respirology 17, 627-638.

Bonsaksen, T., Lerdal, A. & Fagermoen, M.S. (2012). Factors associated with self-efficacy in persons with chronic illness. Scandinavian Journal of Psychology 53, 333-339.

Karvala, K., Uitti, J., Luukkonen, R. & Nordman, H. (2013). Quality of life of patients with asthma related to damp and moldy work environments. Scandinavian Journal of Work, Environment & Health 39 (1) 96-105.

Giuli, C., Papa, R., Mocchegiani, E. & Marcellini, F. (2012). Predictors of participation in physical activity for community-dwelling elderly Italians. Archives of Gerontology and Geriatrics 54 (1) 50-54.

Reichert, C.L., Diogo, C.L., Vieira, J.L. & Dalacorte, R.R. (2011). Physical activity and depressive symptoms in community-dwelling elders from southern Brazil. Revista Brasileira de Psiquiatria 33 (2) 165-170.

Dietrich, A. (2006). Transient hypofrontality as a mechanism for the psychological effects of exercise. Psychiatry Research 145 (1) 79-83.

Sonstroem, R.J. & Morgan, W.P. (1989). Exercise and self-esteem: rationale and model. Medicine and Science in Sports and Exercise 21 (3) 329-337.

Lavoie, K.L., Joseph, M. & Bacon, S.L. (2009). Psychological distress and occupational asthma. Current Opinion in Allergy and Clinical Immunology 9 (2) 103-109.

Hill, K., Geist, R., Goldstein, R.S. & Lacasse, Y. (2008). Anxiety and depression in end-stage COPD. European Respiratory Journal 31 (3) 667-677.

Papaioannou, A.I., Bartziokas, K., Tsikrika, S. Karakontaki, F., Kastanakis, E., Banya, W., Haniotou, A., Papiris, S., Loukides, S., Polychronopoulos, Y. & Kostikas, K. (2013). The impact of depressive symptoms on recovery and outcome of hospitalised COPD exacerbations. European Respiratory Journal 41 (4) 815-823.

Xu, W., Collet, J.P., Shapiro, S., Lin, Y., Yang, T., Platt, R.W., Wang, C. & Bourbeau, J. (2008). Independent effect of depression and anxiety on chronic obstructive pulmonary disease exacerbations and hospitalizations. American Journal of Respiratory Critical Care 178 (9) 913-920.

Liu, L., Wen, F., Xu, X. & Wang, L. (2015). Effective resources for improving mental health among Chinese underground coal miners : Perceived organizational support and psychological capital. Rehabilitation Nursing 57, 58-68.

Marino, P., Sirey, J.A., Raue, P.J. & Alexopoulos, G.S. (2008). Impact of social support and self-efficacy on functioning in depressed older adults with chronic obstructive pulmonary disease. International Journal of COPD 3 (4) 713-718.

Coventry, P.A., Bower, P., Keyworth, C., Kenning, C., Knopp, J., Garrett, C., Hind, D., Malpass, A. & Dickens, C. (2013). The effect of complex interventions on depression and anxiety in chronic obstructive pulmonary disease: systematic review and meta-analysis. PLoS One 8 (4) e60532.

Bratas, O., Espnes, G.A., Rannestad, T. & Walstad, R. (2012). Relapse of health related quality of life and psychological health in patients with chronic obstructive pulmonary disease 6 months after rehabilitation. Scandinavian Journal of Caring Sciences 26, 219-227.

Ochmann, U., Kotschy- Lang, N., Raab, W., Kellberger, J., Nowak, D. & Jörres, R. (2012). Long-Term Efficacy of Pulmonary Rehabilitation in Patients with Occupational Respiratory Diseases. Respiration 84 (5) 396-405.

Waschki, B., Kirsten, A., Holz, O., Müller, K.-C., Meyer, T., Watz, H.& Magnussen, H. (2011). Physical activity is the strongest predictor of all-cause mortality in patients with COPD. Chest 140 (2) 331-342

Bourbeau, J. (2010). Making pulmonary rehabilitation a success in COPD. Swiss Medical Weekly 140, E1-E8.

Hartman, J.E., ten Hacken, N.H.T., Boezen, H.M. & de Greef, M.H.G. (2013). Self-efficacy for physical activity and insight into its benefits are modifiable factors associated with physical activity in people with COPD: a mixed-methods study. Journal of Physiotherapy 59 (2) 117-124.

Nguyen, H.Q., Donesky, D, Reinke, L.F., Wolpin, S., Chyall, L., Benditt, J.O., Paul, S.M. & Carrieri-Kohlmann, V. (2013). Internet-based dyspnea self-management support for patients with chronic obstructive pulmonary disease. Journal of Pain and Symptom Management 46 (1) 43-55.

Nguyen, H.Q., Donesky-Cuenco, D., Wolpin S., Reinke, L.F., Benditt, J.O., Paul, S.M. & Carrieri-Kohlman, V. (2008). Randomized controlled trial of an internet-based versus face-to-face dyspnea self-management program for patients with chronic obstructive pulmonary disease: pilot study. Journal for Medical Internet Research 10, e9.

Hogg, L., Grant, A., Garrod, R. & Fiddler, H. (2012). People with COPD perceive ongoing, structured and socially supportive exercise opportunities to be important for maintaining an active lifestyle following pulmonary rehabilitation: a qualitative study. Journal of Physiotherapy 58, 189-195.



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