Zamani-Alavijeh et al.

BMC Medical Education (2019) 19:16

https://doi.org/10.1186/s12909-018-1448-z

RESEARCH ARTICLE Open Access

Sources of Health care providers’ Self-

efficacy to deliver Health Education: a
qualitative study
Fereshteh Zamani-Alavijeh1, Marzieh Araban2, Tayebeh Fasihi Harandy3, Fatemeh Bastami1*
and Mohammad Almasian4

Abstract
Background: The self-efficacy of educators plays a crucial role in their professional competence and subsequent
provision of care. The present study aims to explain the main sources contributing to the development of self-
efficacy beliefs among healthcare providers in delivering health education.
Methods: This qualitative study was conducted from 2015 to 2016 in various settings of Isfahan such as hospitals,
doctor’s offices, and healthcare centers. Twenty three health educators with an average of 10-year work experience in
healthcare participated in the study. Data were collected using semi-structured in-depth individual interviews and were
analyzed through conventional content analysis. Prolonged engagement with the participants, maximum variation in
the participants’ characteristics, sampling, and member check were among the factors enriching the research.
Results: The six main categories extracted during data analysis included: 1) Quantity and quality of their experience; 2)
Encountering unexpected events; 3) Client trust; 4) Self-concept; 5) Professional knowledge and skill; 6) Vicarious
experiences.
Conclusions: The study results show two new findings, including “encountering unexpected events” and “client trust”,
affecting professional self-efficacy beliefs among healthcare providers in the delivery of health education. The other
main findings were extremely similar to Bandura’s theory. These results can be used as a basis in planning and
implementing health development educational models for human resources.
Keywords: Self-efficacy, Iranian health educators, Qualitative study

Background [3–5]. In addition, access to complete information about

Through designing learning experiences, health education their own health, disease, and even treatment [2, 6] can be
helps to increase the knowledge or influence the attitudes classified as one of the most important rights of clients.
of individuals and communities in order to improve their Therefore, depriving them of such education and training
health [1]. It encourages them to perform appropriate be- is unethical [7, 8].
haviors and helps them to overcome diseases and maintain As some of the most important elements of health
good health [2]. Studies indicate that health education is promotion, health care providers, particularly nurses and
an important factor in enhancing client satisfaction, inde- family health experts, can play a significant role in health
pendence, and participation in healthcare programs and education owing to their greater access to individuals and
promoting healthy behaviors, leading to helpful outcomes families and the considerable time they spend with them to
such as improved quality of life and better mental status take care of them. As a result, they have numerous oppor-
by reducing diseases complications and decreasing anxiety tunities to educate them [9, 10]. However, in most cases,
they do not properly utilize the methods and principles of
* Correspondence: [email protected]
health education [2, 10, 11], and some studies even demon-
1
Department of Health Education and Promotion, School of Health, Isfahan strate that their weak performance leads to acquisition of
University of Medical Sciences, Isfahan, Iran incorrect information and beliefs by the clients [12, 13].
Full list of author information is available at the end of the article

© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Zamani-Alavijeh et al. BMC Medical Education (2019) 19:16 Page 2 of 9

The results of previous studies have shown that excessive contributing to the development of self-efficacy beliefs
workload and insufficient force, inadequate qualifications of among healthcare providers in delivering health education.
health educators, failure to integrate patient education into
the rehabilitation process, lack of job satisfaction, regarding Methods
education as unimportant, education by non-professionals, Research design
ignoring patients’ rights in education, inappropriate com- This qualitative study, which was conducted using con-
munication skills, physician-oriented atmosphere, conflict ventional content analysis methods, considers the reality
and lack of coherence in education, lack of motivation, lack based on the context, and investigates various structures
of a rewarding system in the organization, and poor super- of the phenomenon under study [31, 33].
vision and control, problems in planning the time and
space for the program, nurses’ belief in not considering Participants and research context
patient education as their duties, insufficient facilities in This qualitative study was conducted on 23 health
hospitals and lack of enough time are the most important educators from 2015 to 2016 in various settings of Isfahan’s
causes of insufficiency of client education [14–18]. This hospitals, doctor’s offices and healthcare centers. The
behavior of healthcare providers, insufficient health educa- participants included 3 nurses, 6 individuals with M.Sc. de-
tion, may be partly attributed to the above factors. How- grees in health education, 11 public health workers, 2 social
ever, other influential factors such as self-efficacy probably pathologists (i.e. individuals offering counseling services to
contribute this behavior. Based on the literature review, it clients in centers for behavioral disorders.), and 1 individual
can be mentioned that self-efficacy, as an adaptable factor, with a Ph.D. degree in health education and promotion (19
can be the strongest predictor of many behaviors. For this women and 4 men in total) who on average had 10-year
reason, we have addressed it in this article [19–23]. work experience in healthcare. At the beginning of each
Some studies have indicated that educators’ self-efficacy interview, the willingness and ability of the participant to
(i.e. their perception of their abilities) plays an important transfer experiences were examined. Purposive sampling
role in the performance of their educational and training was used: Those who had at least 3 years of health educa-
duties [24, 25]. In other words, individuals’ anticipations tion practice were included in the study. Health education
and expectations depend on their judgments about their services that offered care to the general public were
ability to perform a particular behavior in a specific selected as the study settings.
situation. Therefore, individuals with higher self-efficacy
tend to visualize positive outcomes [19, 26, 27]. However, Ethical considerations
researchers have primarily investigated this factor in clients, The Ethics Committee of Isfahan University of Medical Sci-
and few researchers have examined health educators’ ences approved the study (No.IR.MUI.REC.1395.1.O95).
self-efficacy. The results show that if educators believe in The necessary explanations were presented to the partici-
their own ability to communicate, work with media, and pants concerning the significance, objectives, methodology,
hold educational programs, their performance will be more the consent process, and the maintenance of confidentiality
successful and satisfactory [28–30]. Further studies are at all stages of the study. In addition, the participants were
needed to identify this type of self-efficacy and the factors informed about the characteristics of the study team and
contributing to its formation. An extensive study of the how the results were achieved. The decision on determin-
literature and previous studies in Iran has demonstrated ing the time and place of the interviews was made with the
that this issue has not been adequately studied in its real participants’ consent. In a qualitative study, obtaining in-
context via the real experiences of healthcare providers formed consent from the participants for their voluntary
without presuppositions. As a result, adequate knowledge participation in the study is a process; thus, in the
has not been obtained regarding the factors affecting whole period of data collection, this issue should be
healthcare providers’ self-efficacy in performing health edu- considered and checked. In the current study, the
cation. Therefore, the question leading to the present study participants’ consent was continuously verified.
is that which factors contribute to formation of self-efficacy Although the initial consent forms were obtained at the
among healthcare providers in offering health education. beginning of the interviews, the participants’ were
Since self-efficacy is a complex issue and is associated with asked about their consent and convenience to partici-
different social and psychological factors, the most appro- pate in the study during the study. The participants
priate approach to a better understanding of the concept were also assured that they could freely leave the study
seems to be qualitative methods [31]. It is necessary to con- at any stage.
duct qualitative studies to explain and describe the essence
of the notions and concepts and their interrelationships in Data collection and analysis
the natural setting of the occurrence of the phenomena Data collection was conducted using semi-structured,
[32]. Therefore, this paper aims to explain the main sources in-depth individual interviews. The participants were
Zamani-Alavijeh et al. BMC Medical Education (2019) 19:16 Page 3 of 9

interested in precisely and clearly explaining and Results

expressing their experiences to the researcher; the data Based on the obtained results, the main sources of
were collected by recording the participants’ voices, but re- self-efficacy beliefs in health educators could be divided
cording interviews seemed to raise concerns in the partici- into 6 categories, including: 1) Quantity and quality of
pants and most participants seemed to be unwilling to talk their experience; 2) Encountering unexpected events
while their interviews were being recorded. In this regard, causing self-efficacy reduction; 3) Vicarious experiences;
they were assured of the confidentiality of their data, and 4) Self-concept; 5) Self-efficacy as a reciprocally interact-
the researchers pledged to delete the recordings after tran- ing influence on the client’s perception of trust; 6) Pro-
scribing the interviews. This issue facilitated communica- fessional knowledge and skill as a factor enhancing
tion with health educators and gained their trust, resulting self-efficacy.
in obtaining enriched data and experiencing a more effi-
cient data collection process. Open-ended and general Quantity and quality of their experience
questions were initially employed in the interviews. The Quantity of experience: Lack of experience leading to low
participants were requested to freely talk about their expe- Self-efficacy
riences as health educators. The interviews began with a The study results showed that inexperienced educators
general question concerning barriers and facilitators to initially had low self-efficacy regarding the holding of edu-
health education. Afterward, the interviews were con- cational sessions. A participant told the researcher about
tinued by asking exploratory questions like “Please ex- his first experience with educating others as follows:
plain how you held that session?” The time of each
interview varied from 20 to 60 min, depending on the “Because this was my first work experience, I was
participants’ views, and the interview situation and anxious and worried all night long, as I might not
process. The researcher continued the interviews up to have been able to organize the session well, speak well,
the point where no new data could be obtained. After or be unable to answer some questions.”
conducting and recording each interview, it was fully
transcribed verbatim. Data analysis was concurrently : “… When I started the educational session, I felt I
conducted with data collection using the qualitative was hot and even flushed, and everyone knew I was inex-
method of conventional content analysis in three perienced, (Public health worker, 6 years of work
phases: preparation, organization and reporting. experience).”
All interviews were analyzed. In preparing the interviews,
a complete interview, which could be regarded as a mean- Quality of experience
ingful unit, was chosen as the most suitable analysis unit.
Each interview was reviewed several times to achieve data Individual impression of the quality of the educational
immersion. To organize the data, open-coding was utilized. effort (previous success as a factor contributing to self-
Then, the coded data were recorded in coding sheets for efficacy) The findings of the study showed that if the
further reference, and grouping was carried out after educational programs were successfully performed, and
several interviews. By repeating the mentioned process for relevant successful and satisfactory experiences were ob-
each new interview, some topics were added until the final tained, self-efficacy would increase. This increase in
pattern emerged. Merging and comparing groups reduced self-efficacy occurred not only in future programs, but
the number of categories. Sub-categories were formed also in the same session. As one of the participants said:
based on similar characteristics, and the category names “This experience helped me understand that I have the
showed their contents [34]. ability to educate others. Because before the educational
session, I did not have that much belief in my own
ability…But at the end of the session, my self-confidence
Rigor increased, and I understood that if an educational pro-
Spending sufficient time to communicate and collect data gram was delegated to me, I would be able to deal with
and prolonged engagement helped to achieve in-depth it.” (Public health worker, 5 years of work experience).
data collection and build trust and rapport with the partic-
ipants. Maximum-variation sampling was employed based Receiving feedback A participant expressed his experi-
on the health educators’ age, gender, job, number of years ence of oral feedback received from the clients as fol-
of work experience and place of residence. To insure that lows: “When addicts who quit see me, they express their
the analysis reflected the participants’ experiences accur- gratitude by saying that whatever we have achieved was
ately, member check was carried out with several partici- due to you. This helps me believe in my ability to offer
pants, and a number of changes were applied to the data education and counseling to these people.” (Social path-
based on this procedure [35]. ologist, 11 years of work experience).
Zamani-Alavijeh et al. BMC Medical Education (2019) 19:16 Page 4 of 9

A participant who worked in substance abuse treat- educator’s place of residence. A female health educator said
ment centers described his/her experience of observing “Men show more pride and you need to pay more attention
changes in the target group: “I have educated and to the tone of the word so that they don’t feel affronted .....
advised drug addicts for four years now. I am proud of How you communicate is important to them. Particularly
myself because I can perform my duty well. Because I see illiterate or poorly educated men do not want to learn from
previously-referred individuals who are now healthy and female health educators.” She said “Older men interact bet-
drug-free as a result of training and counseling.” (Social ter and ask for training but young men are rebellious and
pathologist, 9 years of work experience). ridicule everything ... If the nurse is unable to control the
Another factor affecting the enhancement of self-efficacy situation, she cannot provide effective education .... We
among health educators is official feedback: often send male nurses to male patients because they are
more accepted by male patients” (Health education super-
“When your boss gives you a low evaluation score, this visor, 15 years of work experience).
does not affect your salary, and only your morale
suffers, and you think that you do not want to educate
Encountering unfamiliar clients
people any longer.” (Public health worker, 10 years of
Inadequate knowledge of the clients, and their character-
work experience).
istics can reduce educators’ self-efficacy. One of the par-
ticipants said about holding a session in a public hall,
“Each month, I recommend 10 health educators who
“[Because I didn’t know them] it took me a while to feel
are active and work well for a pay raise, because I
normal again. While the audiovisual equipment operator
have noticed that this is really effective and helps
was preparing, the slides for display, with a quick evalu-
them believe in their own capabilities.” (The city
ation, I learned about the class personality types and the
health education planner, 10 years of work
educational levels of the audience. And I was able to
experience).
hold the educational session based on this and I grad-
ually felt normal again.” (Public health worker, 7 years
work experience).
Self-efficacy reduction when encountering unexpected
events
Unexpectedly large number of clients Vicarious experiences
Based on the experiences of educators, sometimes they Spending time with other colleagues in the health and
faced unexpected events such as a large number of clients, treatment system with the same health education context
which reduced their self-efficacy in conducting the health can positively affect health educators’ self-efficacy, and
education program. For example, a participant who was when individuals possess limited previous experience, they
invited to hold an educational session at the cultural cen- are more sensitive to this issue. A participant who was the
ter of the municipality said: “In the morning, when I went health educator of a province explained his/her vicarious
to conduct the educational program, I thought the audi- experience in relation to other colleagues working in the
ence consisted of 20-30 individuals. However, 150 individ- field of health education: “Once in the spring, my colleague
uals were present. Because of stress, I became confused. I and I went to visit an agricultural field. There were 7 or 8
had not thought there would be so many attendants. I felt women farmers there. After greetings, my colleague taught
I couldn’t handle it. At first, I was nervous….”)Public them contraception methods for one hour. He taught them
health worker, 4 years of work experience). so well that the next day some of them referred to the
health center for the TL operation. As a result of this ex-
Clients with an unexpected gender composition perience, I understood that I could be an effective educator
Additionally, if it is unexpected by the educator, the too…” (The head of the health education affairs of the city,
clients’ gender can affect the educator’s self-efficacy. “... 11 years of work experience).
especially half of those present were men (I didn’t expect A participant described the experience of his M.Sc.
men to participate). It took me a moment to reclaim my studies regarding the effect of vicarious experience on
self-confidence. I was sure that I could work with the self-efficacy, “For example, when I go somewhere for giving
women, but not men … I became anxious ….” (Public a lecture, while I am waiting for the earlier speaker to fin-
health worker, 4 years of work experience). This partici- ish his/her speech, I get anxious especially in cases where
pant added, “Men asked me more questions and also the speaker is not successful, or on the contrary, when he/
acknowledged and praised me more.” she has an excellent lecture. Also, I may think that my
There is no common view in this regard, and the experi- topic is not as interesting as his/her topic, and, I become
ence is different for educators with different backgrounds, nervous whether I can give a good lecture or not.” (Public
such as work experience and the culture of the health health worker, 14 years of work experience).
Zamani-Alavijeh et al. BMC Medical Education (2019) 19:16 Page 5 of 9

Educators’ Self-concept as a source of Self-efficacy beliefs the disease.” (Public health worker, 4 years of work
Participants’ feelings, emotions, ideas, mentality, and experience).
images play an important role in understanding their Not only can earning the trust of the clients increase
abilities in health education. A participant explained that health educators’ self-efficacy, but also their self-efficacy
“I behave in a manner that children admire me, and can help to earn the clients’ trust and confidence. A par-
admit that I am an authority or a role model to be ticipant said, “We should be able to communicate, not only
followed on this issue. Because I feel that they are search- with words, but also with the type of eye contact we make,
ing for a role model at this age.” (School Health Nurse, so that we can earn their trust, and educate and offer them
Bachelor of Nursing, 3 years of work experience). counseling.” (Midwife, 13 years of work experience).
Another participant said that “I am relaxed in contact One of the participants described his/her experience
with others. I have good interpersonal skills. I am popular in earning the trust of the clients and its effects on his/
among children, so I can influence and educate them and her self-efficacy thus: “Sometimes, when I am invited to
give them advice.” (School Health Nurse, Bachelor of educate healthcare personnel, if they do not trust me and
Nursing, 10 years of work experience). if I feel that I can’t teach acceptable issues, I become ner-
The results of this study indicate that considering your- vous and anxious. First, I try to earn their trust…For ex-
self creative is an enhancing factor for self-efficacy. For ex- ample, there were clients in my class that I felt that did
ample, a participant said: “My instructional creativity has not feel any need for what I taught. They thought my
resulted in having an educational program with an effect- speech was not relevant to them, so they did not trust me
iveness of 70% and has led to client satisfaction.” (Nursing adequately. I conducted a research study in this regard,
health education manager, 13 years of work experience). and for the next session, I started my educational session
Another one expressed her self-concept beliefs by the by presenting a review study in my chosen field which
following statement: “The clients admire me more. Because was conducted by one of the prominent people in their
they expect a midwife to be tall and have wide shoulders, field. Thus they understood that some people who out-
they assume me more suitable for this job. Since I am mar- shone in their field used these methods, and in this way,
ried, I can educate sex and midwifery issues better. People their trust and confidence increased, and I succeeded.”
do not accept my colleague who is single and has a small (Ph.D. in health education and promotion, Faculty mem-
body well.” (Midwife, 10 years of work experience). ber, 14 years of work experience).
One of the participants described his/her self-concept:
“I don’t talk much about a healthy lifestyle (nutrition Professional knowledge and skill as a factor enhancing
and exercise) because I feel I am not a good role model (I Self-efficacy
am overweight). I think this belief about myself can lead Professional knowledge and skill are one of the factors en-
to anxiety and feelings of helplessness in every educator.” hancing educators’ self-efficacy. A participant said, “I am
(Ph.D. in health education and promotion, Faculty mem- familiar with the PEN-3 model and its use, I can success-
ber, 14 years of work experience). fully educate women about the pap-smear test.” (Midwife,
health educator, 5 years of work experience). Another par-
Self-efficacy as reciprocally interacting influence on the ticipant said, “I am familiar with the practical skills for
client’s perception of trust health education. For instance, I can describe the self-care
The self-efficacy of the educator is largely affected by cli- program very tangibly. For example, if you want to go
ents’ trust and assurance such that if he/she believes that walking, when do you have the time, and how do you like
the clients trust him/her, his/her self-efficacy will in- to do it.” (Nurse, 12 years of work experience).
crease. A participant who worked in a doctor’s office A participant suggests that lack of knowledge about
stated that: “Here, trust is very important, and the client up-to-date information is a factor reducing professional
should trust the educator, especially in our field, that is, self-efficacy: “...In that session, the clients talked about is-
midwifery and sexual issues. If the clients don’t have con- sues that made me feel that they were more up-to-date
fidence in us, we can’t…When the trust and confidence is than me. That is because they were constantly in contact
formed, the counseling could be offered well.” (Midwife, with their doctors, and the things that I knew were fossil-
13 years of work experience). ized in the books, and that is why I could not educate
Another participant who had held an educational ses- them well.” (Public health worker, 13 years of work
sion for the caregivers of Alzheimer’s patients’ said, “I experience).
started to speak. I tried to earn their trust by telling them A participant pointed out that, “For example, I go to a
that I have the same problem and I take care of my school to teach children a fertility health program. The
mother who has the same problem. I was aware of the first thing I need to know is needs assessment to learn
details of the disease clinically and in terms of the what necessities they have, at what level their awareness
awareness and attitudes of the family members regarding is on this specific topic, what needs they have in mind, so
Zamani-Alavijeh et al. BMC Medical Education (2019) 19:16 Page 6 of 9

that I can conduct a good educational program …” (mid- play an important role in increasing self-efficacy. Accord-
wife, 13 years of work experience). ing to Bandura’s theory and the results obtained by the
Another one described the effect of professional know- present study and other studies [19, 40], it can be inferred
ledge and skill like this: “If at the time of the educational that social encouragement is another way of increasing
program you are constantly worried that you have not self-efficacy. People might obtain an incorrect under-
mastered what you are teaching, then you will be stressed standing of their own competence by incorrectly evalu-
and will feel that you can’t control the class.” (Master of ating their own knowledge, abilities, and skills. The
Science in Nursing, 10 years of work experience). results of the present study indicate that feedback from
clients and officials plays a crucial role in reemphasiz-
ing the abilities of health educators and their own com-
Discussion petence interpretation. This finding is similar to that of
The present study aimed to explain the factors contrib- the study by Usher [39]. This review study reports
uting to the formation of health educational self-efficacy social and oral encouragements as the third source of
among health care providers. The results indicated exist- self-efficacy according to Bandura. In this regard,
ence of a new classification with 6 categories of factors students not skilled in self-evaluation depend on the
affecting health educational self-efficacy. Based on the feedback and others’ evaluative judgments about their
participants’ statements, self-efficacy means the educa- own educational performance. These supportive
tor’s faith in his/her own abilities to hold educational messages boost students’ efforts and self-confidence to
programs and sessions, which were considered an attempt to succeed. Similar to previous studies [41, 42],
important factor in their success and in performing their the present study showed that receiving supportive
duties. In one study conducted by Haghbaghery and feedback from the environment enhanced individuals’
Salsali [36], the participants also emphasized the key role self-efficacy.
of self-efficacy in creating professional feelings and using The second factor affecting self-efficacy was “encounter-
its power. Factors affecting self-efficacy as extracted by ing unexpected events”. This factor was not reported in
this study are largely consistent with the sources previous studies and was not directly in line with the
proposed by Bandura [19, 37, 38], but there were some sources proposed by Bandura [19, 26, 27]. In the present
differences. In the following, each of these factors is study, facing events such as clients’ unexpected gender
compared to the sources proposed by Bandura and the composition, unexpectedly large number of clients, and un-
results obtained from other studies. familiarity with them, particularly among inexperienced
The first factor presented in this study was “the quantity educators, reduced their self-efficacy due to the partici-
and quality of their experience”. In previous studies [19, pants’ stress and nervousness in encountering the
37, 38], only the “previous experience factor” is men- above-mentioned situations. In this respect, an equivalent
tioned. However, the present study redefined and ex- for the concept “the ability to encounter unexpected
plained the educators’ experiences in both quantitative events” can be found in previous studies as “resiliency”.
and qualitative dimensions, such that being inexperienced However, given that resiliency is defined as skills, charac-
was assumed as the quantitative dimension, and personal teristics, and abilities enabling individuals to adapt to diffi-
interpretation and impression regarding the quality of pre- culties and challenges [43], it has some differences with
vious experiences of educating others were also assumed the concept extracted in the present study, i.e. “encounter-
as a qualitative dimension (referring to prior individual ing unexpected events”. The latter concept refers to an en-
successes), which were both presented as the factors vironmental factor affecting the individual, that is, events
affecting self-efficacy. These two concepts are in line with that are unpredictable and affect the educators’
the first source of self-efficacy proposed by Bandura. self-efficacy. Resiliency is an internal characteristic in indi-
Based on Bandura’s theory, successful experience in the viduals. Another difference is that “unexpected events”
performance of some behaviors can enhance self-efficacy, affect self-efficacy, while resiliency is affected by such
while experiencing a failure will lead to weakened events. The results of the present study showed that unex-
self-efficacy [19, 37, 38]. Furthermore, the result of a pected events influenced individuals’ self-efficacy in con-
review study by Usher indicated that the most important ducting the educational program. However, self-efficacy
sources of self-efficacy beliefs in school students were itself can enhance resiliency and the ability to encounter
mastery experiences [39]. However, these studies do not unexpected events [44]. Certainly, studies have indicated
report anything about “lack of previous experience” as a that individuals with lower resiliency are more likely to
factor affecting self-efficacy. suffer from anxiety. Despite threats and unfavorable envir-
Additionally, the present study showed that, in addition onmental conditions, resilient individuals can successfully
to individual perceptions of failure and success, other peo- adapt themselves to circumstances [44, 45]. Therefore, it
ple’s perceptions, especially those of officials and clients, can be inferred that resilient individuals’ self-efficacy
Zamani-Alavijeh et al. BMC Medical Education (2019) 19:16 Page 7 of 9

decreases less seriously in encountering with unexpected would have?” Self-concept can predict future behaviors.
events. Self-concept is able to form behavioral motivations and
According to Bandura, emotional and physiologic direct them toward specific behaviors [47]. The results of
states such as anxiety, stress and tiredness are sources this study showed that participants who believed in their
conveying self-efficacy beliefs to individuals [19, 40]. The feelings, could educate others, based on earning the cli-
perception of individuals regarding physiologic and emo- ents’ trust. In one study conducted by Aghabarary into
tional responses to a specific behavior is another source nurses and patients’ views on barriers to communication,
of self-efficacy, since these perceptions may affect their it is reported that the confidence and trust of the patient
judgments about their abilities. Similar to a previous in the practical and scientific capability of the healthcare
study conducted on medical students in the United staff are the most important factors in this regard [48].
Stated [46], the present study showed that negative emo- In the present study, the participants stated that if
tions like anxiety could affect self-efficacy beliefs. Al- healthcare personnel did not have “professional skills and
though physiologic and emotional responses did not knowledge”, they would become anxious; this feeling
emerge in the present research as a separate category, negatively affects their self-efficacy. According to the study
the results of this study showed that these physiologic by Haghbaghery and Salsali, self-efficacy originates from
responses could reduce the educators’ self-efficacy as a personal characteristics, but the level of knowledge and
result of factors such as lack of experience of the educa- work-related social relationships affects individuals’ pro-
tor, encountering unexpected events, inadequate profes- fessional self-efficacy. In this study, the participants men-
sional knowledge and skills, inability to earn the trust of tion factors such as the use of inappropriate methods of
the clients, negative effect of the educator’s self-concept, education, casting doubt on the scientific and technical
and effect of vicarious experiences. Therefore, it can be competence of the healthcare personnel, thereby affecting
mentioned that healthcare providers considering an edu- their self-efficacy [36]. In the present study, the partici-
cational situation a stressful event are less able to con- pants mentioned lack of up-to-date information as one of
trol that situation, thereby resulting in lower perceived the factors reducing self-efficacy. Studies suggest that the
self-efficacy for health education practice. majority of the healthcare personnel feel they do not have
The forth factor affecting self-efficacy in this study was the self-confidence regarding the skills required for edu-
“vicarious experiences”, which is consistent with the cating others. However, clients’ educational needs can mo-
fourth source of self-efficacy according to Bandura [19, tivate them [14, 49, 50].
37, 38]. This result is similar to the finding obtained in
Usher. It indicated that in addition to interpreting the Conclusion
results of their actions, individuals build their Some factors associated with self-efficacy as extracted by
self-efficacy beliefs through vicarious experiences by ob- the present study are largely in line with the sources
serving others [39]. Students would evaluate their cap- proposed by Bandura but in a more extensive sense.
abilities in many academic duties, in which they had no Some new categories such as “encountering unexpected
experience, by comparing the performances of others. If events” and “clients’ trust”, which affected the healthcare
the majority of the classmates obtain lower marks, the providers’ professional self-efficacy beliefs in health edu-
self-efficacy of the student rises, and vice versa [39]. In cation practice, emerged from the study. According to
the present study, health educators create vicarious the results of our study, it seems that it is necessary to
health education experiences with their colleagues in develop educational programs based on the extracted
similar situations, particularly, when they have limited factors to increase health educators’ self-efficacy.
previous experience, they are more sensitive to this
issue. As mentioned in the findings section, one of the Strengths and weaknesses
educators said that as a result of having vicarious experi- One of the strengths of the study was participation of
ences, he/she came to believe that he/she would be able people from diverse backgrounds in the study, for ex-
to educate others effectively. Additionally, when individ- ample from both health and treatment fields. In
uals compare their own situation with others, if they feel addition, the emergence of the concept of sexuality as af-
they are at a lower level, they feel stressed, and these fecting the self-efficacy of health educators in the Iranian
emotional signs of stress reduce their self-efficacy. culture was among the strengths of the present study.
Health educators’ “self-concept” is the fifth factor af- Furthermore, the results of this research can be used to
fecting their perception of self-efficacy in successful edu- provide more precise instruments to measure these fac-
cational sessions. For example, if this self-image is not tors or design empowerment interventions.
positive, it can lead to anxiety and reduce his/her In the present study, although the nature and quiddity
self-efficacy. The question is “How can self-concept help of the self-efficacy sources were clearly explained and
the health educator, and what benefits its understanding comparisons and contrasts with Bandura’s sources were
Zamani-Alavijeh et al. BMC Medical Education (2019) 19:16 Page 8 of 9

made, no findings were offered about how these sources Received: 8 August 2017 Accepted: 28 December 2018
were affected, particularly in cases where this leads to re-
duced self-efficacy in health education. Moreover, no
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