Pain Beliefs And Perceptions Inventory Research Articles

Pain Catastrophizing, Beliefs and Perception, and Their Association With Profiling Characteristics in Athletes.

Variables associated with pain catastrophizing and beliefs in athletes presenting with musculoskeletal pain and/or sports-related injuries are largely unexplored. We aimed to evaluate which anthropometric, sociodemographic, sporting, injury history, and care-seeking characteristics were associated with the Pain Catastrophizing Scale (PCS) and Pain Beliefs and Perceptions Inventory (PBAPI) scores in athletes. This study followed a cross-sectional design. Three hundred and twelve athletes (40% females) from different sports and levels completed a questionnaire including demographic information, details regarding sports practice, injury history, health care use, PCS, and PBAPI. Univariable associations between PCS and PBAPI scores and each variable were assessed using linear regression. Variables with univariable associations where P < .05 were entered into multivariable regression models. The final multivariable model including gender, recurrent and persistent pain, a history of a severe atraumatic injury, and a history of more than 5 atraumatic injuries explained 14.9% of the variance in PBAPI scores. Performing a team sport and a history of more than 5 atraumatic injuries explained 5.1% of the variance in PCS scores. Gender, sporting, and injury history characteristics explained only a small portion of the variance in PCS and PBAPI scores, whereas having received healthcare support and the number of appointments did not. Most of the variance was left unexplained.

Classification of pain intensity with the pain beliefs and perceptions inventory (PBPI) and the pain catastrophizing scales (PCS)

PurposeThe pain beliefs and perceptions inventory (PBPI) and the pain catastrophizing scales (PCS) characterize beliefs or distress dimensions of the pain experience. It is relatively unknown, however, to what degree the PBPI and the PCS are well suited to classifying pain intensity.MethodsThis study applied a receiver operating characteristic (ROC) approach to these instruments against the criterion of a visual analogue scale (VAS) of pain intensity with fibromyalgia and chronic back pain patients (n = 419).ResultsThe largest areas under the curve (AUC) were moderate and limited to the constancy subscale (71%) and total score (70%) of the PBPI and to the helplessness subscale (75%) and total score (72%) of the PCS. The best cut-off scores for the PBPI and PCS were better off at detecting true negatives than true positives, with larger specificity than sensitivity values.ConclusionWhereas, the PBPI and PCS are certainly useful instruments to evaluate diverse pain experiences, they may be inappropriate to classify intensity. The PCS performs marginally better than the PBPI for classifying pain intensity.

Correlation among family cohesion, cancer pain sensation and belief-perception of patients with primary liver cancer

Objective To observe the family cohesion, cancer pain sensation and belief-perception of patients with primary liver cancer and to analyze the correlations among them. Methods From December 2014 to December 2017, we selected 129 inpatients with primary liver cancer of the First Bethune Hospital of Jilin University as subjects by convenience sampling. The family cohesion, cancer pain sensation and belief-perception of patients were evaluated with the family adaptability and cohesion evaluation scale, second edition (FACESⅡ) , Pain Intensity Numerical Rating Scale (PINRS) and Pain Beliefs and Perceptions Inventory (PBPI) . Besides, Pearson correlation analysis was used to analyze the correlations among them. Results The scores of family cohesion and pain sensation of patients with primary liver cancer were (56.00±5.12) and (5.53±1.18) respectively. In pain belief and perception, the highest score was (1.35±0.05) in the dimension of feeling pain is very mysterious . Pearson correlation analysis showed that primary liver cancer patients' family cohesion had negative correlations with cancer pain as well as the items of pain belief and perception (r=-0.426, -0.523, -0.434, -0.451, -0.420; P<0.05) . Conclusions The family cohesion of primary liver cancer patients is in a low level affecting the cancer pain sensation and belief-perception of patients, which suggests nurses attach importance to patients' family cohesion, encourage family members to pay attention to patients and increase communication so as to improve treatment effects of patients. Key words: Carcinoma, hepatocellular; Family cohesion; Cancer pain sensation; Belief-perception

Psychometric properties revised reinforcement sensitivity theory (r-RST) scale in chronic pain patients.

ObjectiveThe aim of present study was to evaluate the psychometric properties of the Reinforcement Sensitivity Questionnaire (RSQ) in patients with chronic pain.MethodsFor this purpose, 312 (first study) and 70 (second study) patients with chronic pain were selected, and the Reinforcement Sensitivity Theory Personality Questionnaire (RST-PQ) and Pain Beliefs and Perceptions Inventory (PBPI) were distributed among them for their response. The reliability of the questionnaire was evaluated by Cronbach’s alpha, retest, and split-half coefficient; then, the criterion validity with other questionnaires was evaluated to determine the psychometric properties of the RSQ. The factor structure was assessed via confirmatory factor analysis.ResultsThe results of the factor analysis indicated that the RSQ has five factors, and checking the validity by using Cronbach’s alpha, retest, and split-half coefficient reflected the stability of the scale; the criterion validity of the RSQ with other questionnaires showed desirable discriminant and convergent validity.ConclusionOverall, the findings indicated that the RSQ has good psychometric properties in chronic pain samples, and the tool can be used in studies of chronic pain. It seems that the RSQ is a good predictor for pain in patients with chronic pain.

Relationship between pain severity, emotion and beliefs

Objective To analyze the relationship between pain sensation, emotion and recognition in three dimensions. Methods By using questionnaires which contained general information questionnaire, Cancer Pain Questionnaire, Self-reporting Inventory (SCL-90), Pain Beliefs and Perceptions Inventory (PBPI) to investigate pain sensation, emotion and recognition of 46 patients with cancer pain. Results There were 13(28.3%) cases sufferd from mild pain,17 (37.0%) cases were moderate pain, 16 (34.8%)cases were severe pain.As to the result of SCL-90,patients showed obvious symptom in somatization, depression, anxiety and hostility.They holded deep belief of that pain was very mysterious.There was a significant correlation between pain severity and depression(rs=0.377), anxiety (rs=0.388) on the condition that confidence level was 0.01; there was also a significant correlation between pain degree and interpersonal sensitivity(rs=0.308), hostility(rs=0.320) on the condition that confidence level was 0.05.As to pain beliefs, pain degree had a significant correlation with it in the dimension of pain as mystery (rs=0.529) and pain was persistent(rs=0.680) on the condition that confidence level was 0.01. Conclusions The survey shows a positive correlation between pain severity, emotion of pain(such as anxiety,depression,hostility and interpersonal sensitivity) and beliefs about pain as mystery or permanent. Key words: Neoplasms; Pain; Emotions; Cognition; Antineoplastic protocols

Portuguese Version of the Pain Beliefs and Perceptions Inventory: A Multicenter Validation Study.

We aimed to perform the translation, cultural adaptation, and validation of the Pain Beliefs and Perceptions Inventory (PBPI) for the European Portuguese language and chronic pain population. This is a longitudinal multicenter validation study. A Portuguese version of the PBPI (PBPI-P) was created through a process of translation, back translation, and expert panel evaluation. The PBPI-P was administered to a total of 122 patients from 13 chronic pain clinics in Portugal, at baseline and after 7days. Internal consistency and test-retest reliability were assessed by Cronbach's alpha (α) and intraclass correlation coefficient (ICC). Construct (convergent and discriminant) validity was assessed based on a set of previously developed theoretical hypotheses about interrelations between the PBPI-P and other measures. Exploratory and confirmatory factor analyses were performed to test the theoretical structure of the PBPI-P. The internal consistency and test-retest reliability coefficients for each respective subscale were α=0.620 and ICC=0.801 for mystery; α=0.744 and ICC=0.841 for permanence; α=0.778 and ICC=0.791 for constancy; and α=0.764 and ICC=0.881 for self-blame. Exploratory and confirmatory factor analysis revealed a four-factor structure (performance, constancy, self-blame, and mystery) that explained 63% of the variance. The construct validity of the PBPI-P was shown to be adequate, with more than 90% of the previously defined hypotheses regarding interrelations with other measures confirmed. The PBPI-P has been shown to be adequate and to have excellent reliability, internal consistency, and validity. It may contribute to a better pain assessment and is suitable for research and clinical use.

Cross-Cultural Adaptation and Validation of the Russian Version of the Pain Beliefs and Perceptions Inventory (R-PBPI) in Patients with Chronic Pain

The Pain Beliefs and Perceptions Inventory (PBPI) is one of the most applicable measures for assessing beliefs among pain patients. To date, this instrument has not been tested for its applicability and validity in Belarusian populations. To translate the English language version of the PBPI into Russian (R-PBPI) and to evaluate its reliability, validity, and factor structure. A total of 238 Belarusian patients with heterogeneous chronic pain were recruited from a neurologic outpatient clinic of a public hospital in Minsk. In addition to the pain beliefs, some the other factors such as pain catastrophizing, depression, disability, pain intensity and demographic characteristics were examined. Exploratory factor analyses, using the principal components analysis, revealed a four-factor structure for R-PBPI. Results also showed that R-PBPI has adequate internal consistency (Cronbach’s αs: 0.73–0.85). The four R-PBPI scales showed significant positive correlations with DASS-d, PCS, pain intensity, and disability. Results of hierarchical multiple regression analyses showed the R-PBPI scales predicted concurrent depression (F (4, 221) = 3.75, p < 0.000), pain intensity (F (4, 218) = 6.01, p < 0.000), and pain disability (F (4, 215) = 4.41, p < 0.000) scores. These findings support the factorial validity of the scales of the R-PBPI as well as its reliability and construct validity. Our study support the use of the R-PBPI for clinical or research purposes identifying or evaluating pain beliefs.

Pain Beliefs and Perceptions Inventory: A Cross‐Sectional Study in Chronic and Episodic Migraine

This study aims to compare differences in pain beliefs according to headache type, chronic vs episodic migraine, in a large cohort of patients, using the Pain Beliefs and Perceptions Inventory (PBPI), and to identify possible predictive factors of the same pain beliefs. All patients referring for the first time at our center in 2011 were screened using PBPI and the Hamilton Anxiety and Depression Scale (a total of 1032 patients). PBPI is a 4-subscale questionnaire that explores a patient's personal beliefs on their subjective experience of pain. Headache patients also completed the Headache Impact Test (HIT-6) and a 30-day headache diary. For all participants, age, gender, duration of pain were collected. The sample was narrowed down to 899 as we experienced a nonresponse rate of 12.8%. For the purpose of this study, 2 groups were identified: chronic and episodic migraine, consisting of 116 and 126 patients, respectively, which were compared using Student's t-test; correlation analyses were conducted to investigate the relationship between variables before running a model selection based on Akaike's Information Criterion to identify possible predictive factors of different pain beliefs. Patients below 18 years of age and those diagnosed with other painful conditions were excluded from the analysis. Beliefs from chronic and episodic migraine patients were very similar, with only a difference in beliefs related to constancy of pain (Mean value ± SD 0.5 ± 1.1 vs -0.6 ± 1.1, P<.001). Predictive factors were depression and HIT-6 scores for all PBPI subscales apart from Self-Blame, which showed a stronger relation to anxiety scores. Number of days with headache per month was correlated to higher constancy values. Diagnosis was a predictive factor for any particular belief. This is the first study, to our knowledge, that addresses differences and predictive factors in pain beliefs according to headache diagnosis. A deeper knowledge of beliefs pattern in patients could lead to better-tailored psychological management.

The Italian version of the Pain Beliefs and Perceptions Inventory: cross-cultural adaptation, factor analysis, reliability and validity

To create an Italian version of the Pain Beliefs and Perceptions Inventory (PBAPI-I) and evaluate its psychometric properties. The PBAPI was culturally adapted in accordance with international standards. The psychometric testing included factor analysis, investigating reliability by internal consistency (Cronbach's alpha) and test/retest stability (intraclass correlation coefficient, ICC), and exploring construct validity by comparing the PBAPI-I with a pain numerical rating scale (NRS), the Roland Morris Disability Questionnaire (RMDQ), the Pain Catastrophizing Scale (PCS), the Tampa Scale of Kinesiophobia (TSK), the Hospital Anxiety and Depression Score (HADS) and the Chronic Pain Coping Inventory (Pearson's correlation). One hundred and sixty-seven subjects with chronic low back pain (83% compliance) completed the tool. Factor analysis revealed a three-factor (Time, Mystery and Self-Blame), 16-item solution (explained variance: 80%). The questionnaire was internally consistent (α=0.91-0.96), and its stability was good (ICCs=0.73-0.82). As expected, the construct validity estimates indicated that the Time and Mystery subscales moderately correlated with the NRS (r=0.33-0.54), RMDQ (r=0.34-0.47), PCS (r=0.37-0.49) and TSK (r=0.30-0.43), whereas the correlations between the Self-Blame subscale and the same measures were poorer. The correlations with the HADS were moderate and poor (anxiety: r=0.37-0.05; depression: r=0.39-0.07). Maladaptive coping strategies were more related to pain beliefs than adaptive strategies. The PBAPI-I has good psychometric properties that replicate those of other versions.

Internal consistency and construct validity of the Revised Illness Perception Questionnaire adapted for work disability following a musculoskeletal disorder

Purpose: To assess internal consistency and construct validity of the French version of the Revised Illness Perception Questionnaire adapted for Work Disability (IPQR-WD). Method: A cross sectional study was conducted in rehabilitation centers and private clinics in the Montreal region of Canada, involving 43 men and women, French speaking, absent from work between 3 months and a year due to musculoskeletal disorders. The 9 dimension IPQR-WD and the following eight-related instruments for construct validity were administered: Tampa Scale for Kinesiophobia (TSK), Pain Catastrophizing Scale (PCS), Psychological Distress Index (PDI-14), Pain Disability Index (PDI), Self-Efficacy for Return to Work Scale (SERWS), Pain Beliefs and Perceptions Inventory (PBPI), Implicit Models of Illness Questionnaire (IMIQ) and a Visual Analog Scale for pain intensity (VAS). Results: Calculations of Cronbach’s α (from 0.58 to 0.87) revealed satisfactory internal consistency of the IPQR-WD dimensions. Multiple regression analyses were performed with each IPQR-WD dimension and significant independent variables. Final models explained a good proportion of the variance (adjusted r2 = 0.33–0.70) for each dimension, except for the Cyclical timeline dimension for which associations became non-significant after adjusting for gender, age and length of sick leave. The SERWS and the VAS were not significantly associated to any of the IPQR-WD dimensions. Conclusions: Moderate to strong correlations were found with six-related instruments which support the multidimensional nature of the IPQR-WD and its unique contribution as one simple questionnaire that can assess representations related to work disability.Implications for RehabilitationCertain unhelpful beliefs related to the worker’s own understanding (i.e. representation) of his/her current health condition may lead to behaviours that are poorly adapted to reducing the work disability following a musculoskeletal disorder.The Revised Illness Perception Questionnaire adapted for Work Disability (IPQR-WD) is the only questionnaire available in French that can specifically assess the worker’s representation following a musculoskeletal disorder.The use of this questionnaire will facilitate a systematic evaluation of the worker’s representation according to a biopsychosocial approach, which may contribute to a clinical practice based on the latest scientific evidences available in the work disability field.

Assessing Attitudes Toward and Beliefs About Pain Among Chinese Patients with Chronic Pain: Validity and Reliability of the Chinese Version of the Pain Beliefs and Perceptions Inventory (ChPBPI)

Research consistently has evidenced the reliability and validity of the Pain Beliefs and Perceptions Inventory (PBPI). The instrument, however, has not been tested for its applicability and validity in non-Western populations. To translate the English language version of the PBPI into Chinese (ChPBPI) and to evaluate its reliability, validity, and factor structure. A total of 208 Chinese patients with mixed origin chronic pain were recruited from an orthopedic specialist outpatient clinic associated with a public hospital in Hong Kong. In addition to the ChPBPI, patients were administered the Chronic Pain Grade (CPG) questionnaire, the Pain Catastrophizing Scale (PCS), the Center for Epidemiological Studies-Depression Scale (CES-D), and questions assessing sociodemographic characteristics. Using the original factor structure of the PBPI as a model, confirmatory factor analyses revealed that all four ChPBPI scales demonstrated good data-model fit (CFI≥0.92) and adequate internal consistency (Cronbach's αs: 0.60-0.76). The four ChPBPI scales showed significant positive correlations with CES-D, PCS, pain intensity, and disability. Results of hierarchical multiple regression analyses showed that the ChPBPI scales predicted concurrent depression (F(4, 187)=6.01, P<0.001), pain intensity (F(4, 186)=4.61, P<0.01), and pain disability (F(4, 190)=3.54, P<0.05) scores. These findings support the factorial validity of the scales of the ChPBPI, and its reliability and construct validity. Now clinically relevant beliefs about pain can be assessed among Chinese patients with chronic pain.

Health-related quality of life and pain beliefs among people suffering from chronic pain

Chronic pain, when not effectively treated and relieved, may have a harmful effect on all aspects of health-related quality of life (HRQL). Furthermore, pain beliefs are considered an important mediating psychological factor in chronic pain. The present study focused on HRQL as measured by the Medical Outcomes Survey-Short Form (SF-36) and addressed possible relationships between pain beliefs as measured by the Pain Beliefs and Perceptions Inventory (PBAPI). The possible impact of background variables such as age, gender, social support, pain intensity, pain duration, and analgesics on HRQL were controlled for in the analyses. The study sample consisted of 81 people who were recruited from a multidisciplinary pain management program. Data were collected as the first part of a routine pretreatment evaluation. The chronic-pain patients reported lower scores on all dimensions of HRQL compared to normal controls and other patient groups. No significant association was found between pain beliefs and the physical health dimension of HRQL whereas gender, pain duration, and pain intensity were significant predictors of that dimension. In addition, one of the dimensions of pain beliefs (i.e., mystery) was found to be predictive of the mental health dimension of HRQL. Social support made an additional contribution to the explained variance in mental health. The implications of these results for assessing HRQL and pain beliefs in chronic pain are discussed.

Validation of the Pain Beliefs and Perceptions Inventory

OBJECTIVE: To examine the test‐retest reliability, construct validity and factor structure of the Pain Beliefs and Perceptions Inventory (PBPI).DESIGN: A sample of 195 individuals attending a chronic pain clinic completed the PBPI along with a preclinic assessment battery. A subset of this sample completed the assessment package two to four weeks and four to six months later in order to examine the test‐retest reliability of the PBPI.RESULTS: Confirmatory factor analysis revealed a four‐factor solution: pain constancy, self‐blame, mystery and understanding of chronicity. Internal consistency estimates ranged from 0.63 to 0.75. Pain constancy and understanding of chronicity had good test‐retest reliability, while test‐retest reliability of the remaining subscales was not adequate. These results differ from those reported in the initial development of the PBPI. Construct validity was determined through examination of correlations between the PBPI and the Beck Depression Inventory, the McGill Pain Questionnaire, the Multidimensional Pain Inventory and a self‐blame questionnaire.CONCLUSIONS: The results of this investigation are consistent with the findings of recent investigations that revealed a four‐factor solution to the PBPI. However, the subscales of this instrument were not found to be uniformly stable over time. These results suggest that further examination and refinement of item content for two of the subscales are required before the instrument is suitable for clinical use.

The pain beliefs and perceptions inventory: a British replication

The factorial structure, reliability, and validity of the Pain Beliefs and Perceptions Inventory (PBPI) was investigated in a sample of 84 pain patients drawn from a pain clinic in the United Kingdom. The recovered factorial structure replicated that of a previous study. The 4 derived subscales, Mysteriousness, Self-Blame, Pain Constancy and Pain Permanence, had excellent reliability (internal consistency); Chronbach's alpha was greater than 0.80. However, the construct validity of the PBPI, assessed by examining the association between the subscales and the Coping Strategies Questionnaire (CSQ), was not supported. The results are discussed with particular reference to the interpretative issues concerning 2 of the subscales and their relation to the concept of the ‘time line’ component of illness representation.

Pain beliefs: assessment and utility

When pain becomes persistent, patients may abandon previously held cultural or personal beliefs about pain to form new pain beliefs that are more consistent with their persistent pain experience. The Pain Beliefs and Perceptions Inventory (PBPI) is an instrument to assess these new beliefs. This paper presents 4 studies examining the utility of the PBPI. Two studies are factor analytic and support recent literature identifying 4 belief factors associated with this instrument. The third and fourth studies used a new scoring method for the PBPI creating 4 scales: Mystery, Self-blame, Pain Permanence, and Pain Constancy. These scales were then correlated with important pain indices such as measures of pain quality, psychological states (i.e., depression and anxiety), personality traits, physical functioning, and coping strategies. Each belief appears to have a unique association with the pain indices thus supporting the rescoring of this instrument with 4 scales. Belief in pain constancy is associated with greater pain self-report, permanence is associated with anxiety, mystery is associated with greatest overall distress, and self-blame is associated with depressive symptoms. An appendix is included that provides clinical norms for the use of the PBPI and a revised scoring key.

Relationship of cognitive constructs to adjustment in rheumatoid arthritis patients

The present study investigated the interrelationship of several commonly used arthritis-related cognitive measures and their relationship to physical disability, pain, depression, and anxiety in rheumatoid arthritis (RA)_patients. Subjects were 103 RA patients recruited from an outpatient rheumatology clinic. Each subject completed the Cognitive Errors Questionnaire (CEQ), the Arthritis Self-Efficacy Scale, the Coping Strategies Questionnaire (CSQ), the Pain Beliefs and Perceptions Inventory (PBAPI), and the Arthritis Impact Measurement Scale (AIMS). Correlational analysis indicated that the cognitive measures were highly interrelated. Factor analysis of the summary scores from these cognitive measures suggested two separate factors, labeled a distorted cognition factor and an efficacy expectations factor. Regression analyses revealed that after controlling for age, gender, and physician disease severity rating, each factor separately was significantly related to all measures of adjustment. However, in a regression model including both factors, the efficacy expectations factor was more strongly related to all adjustment measures. Patients scoring higher on the efficacy expectations factor had lower levels of physical disability, pain, depression, and anxiety. Taken together, these findings physical disability, pain, depression, and anxiety. Given the strength of this relationship, further investigation detailing the relative importance and interrelationships of cognitive constructs and their association with other clinical variables will be a useful next step in assisting RA patients with a chronic and painful disease.

The measurement of attitudes towards and beliefs about pain

This study compared the psychometric properties of two scales designed to measure attitudes towards and beliefs about pain. The Survey of Pain Attitudes (Revised) SOPA(R) (Jensen and Karoly 1987) and the Pain Beliefs and Perceptions Inventory (PBPI) (Williams and Thorn 1989) were examined in terms of internal consistency, discriminant validity, factor structure, construct validity and sensitivity to age and gender effects. Results provided strong support for the SOPA(R) as a useful measurement tool for use with patients with chronic low back pain. Further work is suggested for the PBPI, as the reported factor structure was not replicated. Discussion centred around the possible reasons for this finding, with issues such as the possible orientation of different treatment facilities, the possible differences in attitudes between patients with different types of pain, and the possible influence of length of years in pain or the receipt of workers compensation payments being considered.

Pain beliefs and the use of cognitive-behavioral coping strategies

Patients' beliefs about chronic pain, such as how long it will last and whether it is a mysterious experience, have been shown to be related to compliance with treatment programs. The present study examined whether these pain beliefs relate to a specific component of pain management, namely the frequency of use and the perceived effectiveness of cognitive and behavioral coping strategies. One hundred twenty chronic pain patients were administered the Pain Beliefs and Perceptions inventory (PBAPI) and the Coping Strategies questionnaire (CSQ). A cluster analysis of 2 pain beliefs (that pain is enduring and that pain is mysterious) was conducted revealing 3 distinct subgroups of patients based upon these 2 beliefs. Multivariate analysis of variance was used to detect whether the use of cognitive-behavioral pain coping strategies differed in patients in the 3 pain beliefs subgroups. The results indicated that patients belonging to the group characterized by the belief that pain was enduring and mysterious were less likely to use cognitive coping strategies (e.g., reinterpretation of pain sensation), more likely to catastrophize, and less likely to rate their coping strategies as effective in controlling and decreasing pain than patients believing their pain to be understandable and of short duration. The implications of these results for understanding the patient's choice of and compliance with treatment and coping efforts is discussed.

An empirical assessment of pain beliefs

Pain beliefs represent patients' own conceptualizations of what pain is and what pain means for them. Such beliefs may be discordant with current scientific understanding and may serve to adversely affect compliance with modern methods of chronic pain treatment. This study attempts to assess several of the core dimensions around which pain beliefs develop and examines the relationship between pain beliefs and behavioral manifestations of the pain experience. An empirically and factorially derived product of this study, the Pain Beliefs and Perceptions Inventory (PBAPI) assess 3 dimensions of pain beliefs: 1. (1) self-blame, 2. (2) perception of pain as mysterious, and 3. (3) beliefs about the duration of pain. These core pain beliefs were found to be predictive of subjective pain intensity, multidisciplinary chronic pain treatment compliance, poor self-esteem, somatization and psychological distress, and associated with attributions about health locus of control.