Annals of Behavioral Medicine

, Volume 23, Issue 2, pp 125–132

Injectable medication for the treatment of multiple sclerosis: The influence of self-efficacy expectations and infection anxiety on adherence and ability to self-inject

  • David C. Mohr
  • Arne C. Boudewyn
  • William Likosky
  • Ellen Levine
  • Donald E. Goodkin


The management of many chronic illnesses involves medications that must be injected on a frequent basis. With fewer support resources available, patients are increasingly being obliged to manage injectable medications themselves. Interferon beta-1a (IFNβ-1a), recommended for the treatment of multiple sclerosis (MS), must be injected intramuscularly on a weekly basis. Patients are generally advised and taught to self-inject, if possible. This longitudinal study examined cognitive and affective contributions to the ability to self-inject and adherence to IFNβ-1a over 6 months following initiation of medication. Participants were 101 patients with a relapsing form of MS. Injection self-efficacy expectations, injection anxiety, adherence expectations, method of injection administration, and 6-month adherence to IFNβ-1a were fitted to a path analytic model Pretreatment injection self-efficacy expectations were significantly related to 6-month adherence. This relation was mediated by the patient's ability to self-inject. Patients’experienced level of injection anxiety was related to adherence but not to method of injection.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. (1).
    Anderson DW, Ellenberg JH, Leventhal CM, et al.: Revised estimate of the prevalence of multiple sclerosis in the United States.Annals of Neurology. 1992,31:333–336.PubMedCrossRefGoogle Scholar
  2. (2).
    Goodkin DE: The natural history of multiple sclerosis. In Rudick RA, Goodkin DE (eds), Treatment of Multiple Sclerosis: Trial Design, Results and Future Perspectives. New York: Springer-Verlag, 1992, 7–46.Google Scholar
  3. (3).
    Mohr DC, Dick LP: Multiple sclerosis. In Camic PM, Knight S (eds). Clinical Handbook of Health Psychology: A Practical Guide to Effective Interventions. Seattle: Hogrefe & Huber, 1998, 313–348.Google Scholar
  4. (4).
    Jacobs LD, Cookfair DL, Rudick RA, et al.: Intramuscular interferon beta-1a for disease progression in relapsing multiple sclerosis.Annals of Neurology. 1996,39:285–294.PubMedCrossRefGoogle Scholar
  5. (5).
    The IFNB Multiple Sclerosis Study Group: Interferon beta-1b is effective in relapsing-remitting multiple sclerosis. 1. Clinical results of a multicenter, randomized, double-blind, placebo-controlled trial.Neurology. 1993,43:655–661.Google Scholar
  6. (6).
    Johnson KP, Brooks BR, Cohen JA, et al.: Copolymer 1 reduces reiapse rate and improves disability in relapsing-remitting multiple sclerosis: Results of a phase III multicenter, double-blind, placebo-controlled trial.Neurology. 1995,45:1268–1276.PubMedGoogle Scholar
  7. (7).
    American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th Ed.). Washington, DC: American Psychiatric Association, 1994.Google Scholar
  8. (8).
    Bienvenu OJ, Eaton WW: The epidemiology of blood-injection-injury phobia.Psychological Medicine. 1998,28:1129–1136.PubMedCrossRefGoogle Scholar
  9. (9).
    Agras S, Sylvester D, Oliveau D: The epidemiology of common fears and phobia.Comprehensive Psychiatry. 1969,10:151–156.PubMedCrossRefGoogle Scholar
  10. (10).
    Cartwright PS, McLaughlin FJ, Martinez AM, et al.: Teenagers’ perceptions of barriers to prenatal care.Southern Medical Journal. 1993,86:737–741.PubMedCrossRefGoogle Scholar
  11. (11).
    Costello CG: Fears and phobias in women: A community study.Journal of Abnormal Psychology. 1982,4:280–286.CrossRefGoogle Scholar
  12. (12).
    Hamilton JG: Needle phobia: A neglected diagnosis.Journal of Family Practice. 1995,41:169–175.PubMedGoogle Scholar
  13. (13).
    Glasgow RE, McCaul KD, Schafer LC: Barriers to regimen adherence among persons with insulin-dependent diabetes.Journal of Behavioral Medicine. 1986,9:65–77.PubMedCrossRefGoogle Scholar
  14. (14).
    Johnson SB: Compliance and control in insulin-dependent diabetes: Does behavior really make a difference? In Scheiderman N, McCabe P, Baum A (eds), Perspectives in Behavioral Medicine: Stress and Disease Processes. Hillsdale, NJ: Lawrence Erlbaum Associates, Inc., 1992, 275–297.Google Scholar
  15. (15).
    Bandura A: Self-efficacy in human agency.American Psychologist. 1982,37:122–147.CrossRefGoogle Scholar
  16. (16).
    Strecher VJ, DeVellis BE, Becker MH, Rosenstock IM: The role of self-efficacy in achieving health behavior change.Health Education Quarterly. 1986,13:73–91.PubMedGoogle Scholar
  17. (17).
    Ferguson JM, Taylor CB, Wermuth B: A rapid behavioral treatment for needle phobics.The Journal of Nervous and Mental Disease. 1978,166:294–298.PubMedCrossRefGoogle Scholar
  18. (18).
    Pfohl DC: A multiple sclerosis (MS) center injection training program.Axone. 1997,19:29–33.PubMedGoogle Scholar
  19. (19).
    Mohr DC, Likosky W, Boudewyn AC, et al.: Side effect profile and compliance in the treatment of multiple sclerosis with interferon beta-1a.Multiple Sclerosis. 1998,4:487–489.PubMedGoogle Scholar
  20. (20).
    Neilley LK, Goodin DS, Goodkin DE, Hauser SL: Side effect profile of interferon beta-1b in MS: Results of an open label trial.Neurology. 1996,46:552–554.PubMedGoogle Scholar
  21. (21).
    Poser CM, Paty DW, Scheinberg L, et al.: New diagnostic criteria for multiple sclerosis.Annals of Neurology 1983,13:227–231.PubMedCrossRefGoogle Scholar
  22. (22).
    Beatty WW, Paul RH, Wilbanks SL, et al.: Identifying multiple sclerosis patients with mild or global cognitive impairment using the Screening Examination for Cognitive Impairment (SEFCI).Neurology. 1995,45:718–723.PubMedGoogle Scholar
  23. (23).
    Benton AL, Hamsher KdS:Multilingual Aphasia Examination. Iowa City, Iowa: AJA Associates, 1989.Google Scholar
  24. (24).
    Debanne SM, Patterson MB, Dick R, et al.: Validation of a telephone cognitive assessment battery.Journal of the American Geriatrics Society. 1997,45:1352–1359.PubMedGoogle Scholar
  25. (25).
    Desmond DW, Tatemichi TK, Hanzawa L: The telephone interview for cognitive status (TICS): Reliability and validity in a stroke sample.International Journal of Geriatric Psychiatry. 1994,9:803–807.CrossRefGoogle Scholar
  26. (26).
    Welsh KA, Breitner JCS, Magruder-Habib KM: Detection of dementia in elderly using telephone screening of cognitive status.Neuropsychiatry, Neuropsychology, and Behavioral Neurology. 1993,6:103–110.Google Scholar
  27. (27).
    Chang W, Chan C, Slaughter SE, Cartwright D. Evaluating the FONE FIM: Part II. Concurrent validity and influencing factors.Journal of Outcome Measurement. 1997,1:259–285.PubMedGoogle Scholar
  28. (28).
    Potts MK, Daniels M, Burnam MA, Wells KB. A structured interview version of the Hamilton Depression Rating Scale: Evidence of reliability and versatility of administration.Journal of Psychiatric Research. 1991,24:335–350.CrossRefGoogle Scholar
  29. (29).
    Sharrack B, Hughes RAC: The Guy's Neurological Disability Scale (GNDS): A new disability measure for multiple sclerosis.Multiple Sclerosis. 1999,5:223–233.PubMedGoogle Scholar
  30. (30).
    Mohr DC, Goodkin DE, Likosky W, et al.: Therapeutic expectations of patients with multiple sclerosis upon initiating interferon beta-1b: Relationship to adherence to treatment.Multiple Sclerosis. 1996,2:222–226.PubMedGoogle Scholar
  31. (31).
    Schwartz CE, Coulthard-Morris L, Zeng Q, Retzlaff P: Measuring self-efficacy in people with multiple sclerosis: A validation study.Archives of Physical Medicine and Rehabilitation. 1996,77:394–398.PubMedCrossRefGoogle Scholar
  32. (32).
    StatSoft, Inc.: Statistica (1998 Ed., Ver. 6.0). Tulsa, OK: StatSoft, Inc., 1998.Google Scholar
  33. (33).
    Carmines EG, McIver JP: Analyzing models with unobserved variables: Analysis of covariance structures. In Bohrnstedt GW, Borgatta EF (eds).Social Measurement: Current Issues. Beverly Hills, CA: Sage, 1981, 63–115.Google Scholar
  34. (34).
    Tabachnick BG, Fidell LS:Using Multivariate Statistics (3rd Ed.). New York: HarperCollins, 1996.Google Scholar
  35. (35).
    Baron RM, Kenny DA: The moderator-mediator variable distinction in social psychological research: Conceptual, strategic, and statistical considerations.Journal of Personality and Social Psychology. 1986,51:1173–1182.PubMedCrossRefGoogle Scholar
  36. (36).
    Ellinwood EH, Hamilton JG: Case report of a needle phobia.The Journal of Family Practice. 1991,32:420–422.PubMedGoogle Scholar
  37. (37).
    Fazio AF: Implosive therapy in the treatment of a phobic disorder.Psychotherapy: Theory. Research and Practice. 1970,7:228–232.CrossRefGoogle Scholar
  38. (38).
    Trijsburg RW, Jelicic M, van den Broek WW, et al.: Exposure and participant modelling in a case of injection phobia.Psychotherapy and Psychosomatics. 1996,65:57–61.PubMedCrossRefGoogle Scholar
  39. (39).
    Jacobsen JB: Treating a man with needle phobia who requires daily injections of medication.Hospital and Community Psychiatry. 1991,42:877–878.PubMedGoogle Scholar

Copyright information

© The Society of Behavioral Medicine 2001

Authors and Affiliations

  • David C. Mohr
    • 1
  • Arne C. Boudewyn
    • 1
  • William Likosky
    • 3
  • Ellen Levine
    • 4
  • Donald E. Goodkin
    • 1
  1. 1.University of CaliforniaSan FranciscoUSA
  2. 2.Department of PsychiatryVAMCSan Francisco
  3. 3.Kaiser Permanente Medical Care Group of Northern CaliforniaUSA
  4. 4.California Pacific Medical CenterUSA

Personalised recommendations