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Measuring Pain Self-efficacy
Clare L. Miles, PhD,* Tamar Pincus, MSc, MPhil, PhD,* Dawn Carnes, BSc (Hons), PhD,
w
Stephanie J.C. Taylor, MBBS, MD, FFPH, MRCGP,
w
and Martin Underwood, MD, FRCGP
z
Background: It is likely that people with chronic pain who have low
self-efficacy have a worse prognosis. A standard, high-quality
measure of self-efficacy in such populations would improve
evidence, by allowing meaningful comparisons amongst subgroups
and between treatments, and by facilitating pooling across studies
in systematic reviews.
Objectives: To identify self-administered pain-related self-efficacy
measures used in people with chronic pain and to evaluate the
clinimetric evidence of the most commonly used scales system-
atically.
Methods: We searched 2 databases to identify self-efficacy
questionnaires. We evaluated questionnaires identified against
previously developed criteria for clinimetric assessment.
Results: We identified 13 relevant measurements assessing self-
efficacy, and clinimetrically assessed 5 of these. These question-
naires were the Arthritis Self-Efficacy Scale, the Chronic Disease
Self-Efficacy Scale, the Pain Self-Efficacy Questionnaire, the
Chronic Pain Self-Efficacy Scale, and the Self-Efficacy Scale. None
of the questionnaires showed satisfactory results for all properties.
All scales were easily scored and dimensionality was assessed in 2 of
6 of the scales. Internal consistency was acceptable for all
questionnaires. There was positive evidence for construct validity
in 4 of 6 of the questionnaires. None of the studies used the most
up-to-date method of test-retest reliability or responsiveness.
Information on interpretability of the scores was minimal in all
questionnaires.
Discussion: Further research should focus on assessing responsive-
ness and interpretability of these questionnaires. Researchers
should select questionnaires that are most appropriate for their
study aims and population and contribute to further validation of
these scales. Future research should measure outcome expectancy
alongside self-efficacy to best predict future behavior.
Key Words: self-efficacy, questionnaire, psychometric, chronic pain
(Clin J Pain 2011;00:000–000)
Chronic pain is a common and costly health problem.
The biopsychosocial model of back pain has improved
our understanding of the disorder. Several psychological
factors, including self-efficacy have affected prognosis; it
may also moderate response to treatment.
1
Self-efficacy
(SE) is a concept describing a set of beliefs about oneself,
specifically about one’s ability to perform certain behaviors
within a particular environment.
2
SE is not only related to
specific behaviors but also to the beliefs that people have
about how they can cope in adverse situations.
3
SE in
people suffering from pain include beliefs about one’s
ability to control the pain and the negative emotions
associated with it, to maintain everyday life activities
including work, to communicate their needs to health
carers, and implement advice about their pain. There is
some evidence that higher SE about managing pain is
associated with more positive treatment outcomes,
4
higher
return to work rates,
5
better adherence,
6
more effective
control of pain and effect,
7
and better prognosis.
8
It has
also been proposed that SE beliefs mediate the relationship
between pain and pain-related disability in different chronic
pain samples.
9
Test-retest data has shown that SE is a psychological
state that is changeable and therefore modifiable in the
context of treatment.
10
Social learning theory suggests that
interventions designed to enhance SE of carrying out
specific behaviors will be associated with improved health-
related outcomes in those areas affected by those specific
behaviors.
11
A systematic review of lay-led self-manage-
ment interventions for people with chronic conditions
found that SE can be modified, and that improvements in
SE can lead to improved quality of life outcomes for
patients.
12
Another systematic review (Miles et al, 2010; in
preparation) looking at SE as both a predictor and
mediator of health-related outcomes after self-management
programs found that more positive outcomes were asso-
ciated with higher baseline SE or with changes in SE as a
result of the self-managment intervention (for outcomes
including health distress, role-function, pain, disability, and
physical function). Standardizing the measurement of SE
would benefit research, providing the standard measure
comprehensively, and has been shown to be of high
clinimetric standards.
SE has been measured through self-report question-
naires. Questionnaire choice is usually determined by
factors such as time constraints of the questionnaire battery
in a study and the population studied, alongside clinimetric
merits of the particular scale. Earlier expert consensus
studies have made recommendations of measures to
improve the quality and completeness of measurement in
prospective cohort studies in populations with low back
pain and chronic pain.
13,14
These recommendations did not,
however, include SE. There is, therefore, a gap in the
literature recommending a measure of SE suitable for
chronic pain populations. We are not aware of a systematic
review of pain-related SE measures for pain populations
followed by clinimetric assessment.
Copyright r2011 by Lippincott Williams & Wilkins
Received for publication July 28, 2010; accepted November 8, 2010.
From the *Department of Psychology, Royal Holloway University of
London; wCentre for Health Sciences, Barts and the London School
of Medicine and Dentistry, London; and zClinical Trials Unit,
Warwick Medical School, Coventry, UK.
Supported by the National Institute for Health Research, UK, under
its Programme Grants for Applied Research (Grant #: RP-PG-
0707-10189). The views expressed in this publication are those of
the author(s) and not necessarily those of the NHS, the NIHR, or
the Department of Health.
Reprints: Tamar Pincus, MSc, MPhil, PhD, Royal Holloway,
University of London, Egham Hill, Egham, Surrey TW20 0EX,
UK (e-mail: t.pincus@rhul.ac.uk).
REVIEW ARTICLE
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Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
The aim of this study was to review pain-related SE
measures that have been used in pain populations (focusing
on populations with pain arising from chronic disease or
musculoskeletal disorders) systematically and to assess
them clinimetrically.
MATERIALS AND METHODS
Stage 1: First Search
We searched Medline and PsycInfo (1950 to Septem-
ber 2010). We used both keywords and Medical Subject
Heading terms. Limits of human studies and English
language were applied. We used the following search terms:
self-efficacy combined with scale, inventory, instrument,
measure, outcome, questionnaire, outcome assessment, and
psychometrics and this combined with (chronic disease,
pain, musculoskeletal diseases, low back pain, fibromyalgia,
neck pain, shoulder pain, osteoarthritis, chronic, persistent,
long term, wide spread, recurrent, nonspecific, ongoing, or
musculoskeletal).
Inclusion Criteria
We included studies if they were published in a peer-
reviewed journal and were used with adults with pain as
either a result of chronic disease or musculoskeletal
disorders and the item content explicitly included pain-
related SE.
Stage 2: Second Search
We selected pain-related SE measures for further
clinimetric-focused searching on the basis of the following
criteria: (1) The tool was used in at least 1 study in a pain
population (chronic disease or musculoskeletal disorder);
(2) The tool was presented in English and the measures that
fulfilled these criteria from the first search were selected for
focus in a second search; and (3) The content of the
questionnaire items explicitly included the term “pain.” The
second search attempted to identify clinimetric evaluation
of these SE measures and used the names of these
questionnaires. Search terms used were: Arthritis self-
efficacy, Chronic Disease self-efficacy, Stanford self-effi-
cacy, Pain self-efficacy, PSEQ, Chronic Pain Self-efficacy
Scale, CPSS, Self-Efficacy Scale, SES, Movement and Pain-
Prediction Scale, or MAPPS combined with Test Relia-
bility, exp Psychometrics, exp Test Validity, exp Test
Interpretation, validity, reliability, development, consis-
tency, responsiveness, interpretability, psychometrics, and
clinimetrics. The reference lists of the identified psycho-
metric studies were scanned to obtain further psychometric
studies.
Stage 3: Clinimetric Assessment
We carried out clinimetric assessment on the pain-
related SE questionnaires selected at stage 2. We assessed
these studies using the clinimetric criteria adopted from
earlier research
15,16
and included information regarding the
following: time to administer, ease of scoring, readability
and comprehension, content validity, internal consistency,
criterion validity, construct validity, reproducibility (agree-
ment and reliability), responsiveness, interpretability, and
floor/ceiling effects. Table 3 presents the scoring criteria and
definitions.
RESULTS
The first electronic search identified 1520 articles—180
of these were screened for inclusion in this review. Table 1
presents the questionnaires that were obtained from the
first broad search. There were 13 pain-related SE ques-
tionnaires identified in the search (Table 1). On closer
inspection, we excluded 8 measures as they were either not
pain-related SE measures, leaving 6 pain-related SE
measures. These were: (1) The Arthritis Self-Efficacy Scale
(ASES)
10
and its 2 variants (shorter versions); (2) The
Chronic Disease Self-Efficacy Scale (CDSES)
44
and its 1
variant (shorter version); (3) The Pain Self-Efficacy Ques-
tionnaire (PSEQ)
27
; (4) The Chronic Pain Self-efficacy Scale
(CPSS)
17
; (5) The Self-Efficacy Scale (SES)
33
; and (6) The
Movement and Pain Prediction Scale.
The second search identified a further 80 references for
the ASES, CDSES, PSEQ, CPSS, and SES. In the end, 35
references included clinimetric evaluation and 85 references
that used the main questionnaires. There were no studies
that included clinimetric evaluation of the Movement and
Pain Prediction Scale.
49
Figure 1 presents a detailed search
process.
Descriptives of the Questionnaires
There are 3 versions of the ASES (short and long
versions, ASES-20,
10
ASES-11,
10
and ASES-8
10
) two
CDSES (short and long versions, CDSES-33 and CDSES-
6
44,45
), the PSEQ,
27
the CPSS,
17
and the SES (Altmaier
et al, 1993). Descriptives regarding the domains measured,
numbers of scales and items, time to administer, burden of
scoring, and target populations are presented in Table 2.
All questionnaires were scored easily as defined by Bot
et al.
15
Time to administer was generally under 10 minutes.
Where times were not available for 4 questionnaires (ASES-
20, CPSS, CDSES-30, and SES), it is estimated at 10 to 15
minutes for the ASES-20, CPSS, and SES and 15 to 20
minutes for the CDSES-30. It is also important to note that
the CPSS is an adaptation of the original version of the
ASES. The items of the ASES were adapted for use with a
general chronic pain population and are very similar in item
content. The CPSS has 2 additional items and different
behaviors are used to the ASES.
Readability and Comprehensibility
Readability and comprehensibility were assessed in 3
questionnaires (PSEQ, ASES-11, and CPSS). No informa-
tion on either readability or comprehension was provided
for the other questionnaires.
Content Validity
Ratings regarding the content validity and other
clinimetric domains are presented in Table 3. The majority
of the questionnaires rated positively for content validity.
There was not enough information provided for assessment
in the CDSES-6 and the SES.
Internal Consistency
Factor analysis and Principal Components Analysis
showed presence of factors for the ASES-20 (3 factors),
ASES-11 (2 factors), PSEQ (1 factor), and CPSS (3 factors).
Internal consistency was studied in all of the questionnaires
and Cronbach aranged from 0.76 to 0.98 and is given a
Miles et al Clin J Pain Volume 00, Number 00, ’’ 2011
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Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
positive rating if more than 0.70.
56
Item Reduction was
carried out only for ASES-20 and SES. Confirmatory
Factor Analysis was only carried out for the ASES-20.
Criterion Validity
As there is no “gold standard” of SE measure against
which the evaluated questionnaires could be compared,
however, this quality was assessed where other SE measures
were used as a comparator. None of the questionnaires
scored positively on criterion validity. The correlations
were less than 0.70 for the ASES-20 and ASES-11. The
method was doubtful or there was no justification given for
using the comparator SE measure with the CDSES-33.
There was not enough information provided for assessing
criterion validity on the ASES-8, CDSES-6, PSEQ, CPSS,
and SES.
Construct Validity
Construct validity was showed for all measures, except
the CDSES-6 and the SES, through correlations of the SE
measures with various outcomes. Hypotheses were given
regarding expected relationships, although not always direc-
tional. Outcomes were depression, psychological well-being,
reported pain and fatigue, positive effect, pain-related
disability, and pain-coping strategies (among the ASES
scales). PSEQ scores were correlated with depression, anxiety,
unhelpful coping strategies, pain ratings, somatic focusing,
TABLE 1. Summary of Pain-related Self-efficacy Measures and Clinimetric Evaluation
Measure
No. References
That Used These
Measures
Reason for
Exclusion
Studies That Featured Clinimetric
Evaluation (for Measures That Met the
Inclusion Criteria)
Chronic Pain Self-Efficacy Scale
(Anderson et al
17
)
19 Included Anderson et al
17
; Arnstein
9
; King et al
18
;
King et al,
19
; Woby et al
20,21
; Woby
et al
22
; Schachter et al
23
; Wells-Federman
et al
24
;Heetal
25
;
Martı
´n-Arago
´netal
26
Pain Self-Efficacy Questionnaire
(Nicholas et al
27
)
14 Included Nicholas and Nicholas
28
; Asghari et al
29
;
Sarda et al
30
; Lim et al
31
; Sharp and
Nicholas
32
; Altmaier et al
33
; Williams
et al
34
; Coughlan et al
35
; Gibson and
Strong
36
; Cohen et al
37
; Adams and
Williams
38
Arthritis Self-Efficacy Scale
(Lorig et al
10
) and variants (CDSES)
47 Included O’Leary et al
4
; Lorig et al
10
; Burckhardt
et al
39
; Levin et al
40
; McKay et al
41
;
Barlow et al
42
; Turner et al
43
;
Lorig et al
44
; Lorig et al
45
; Lomi and
Nordholm
46
; Lomi et al
47
; Mueller et al
48
The Self-Efficacy Scale (Altmaier et al
33
) 4 Included Altmaier et al
33
The Movement and Pain Prediction Scale
(MAPPS, Council
49
)
2 (1 review) Included
Exercise Self-Efficacy (Marcus et al
50
) 2 Main content was
not about self-
efficacy in relation
to pain
Pain-Related Self-Efficacy (Mueller et al
48
) 1 In German
Self-Efficacy Scale (SES, Kaivanto et al
51
2 (1 review) Pain is not
mentioned
Self-Efficacy Health Cantril Ladder
(Martin and Panicucci
52
)
1 Main content was
not about self-
efficacy in relation
to pain
Measured using 3 self-report items
assessing respondents’ perceived ability
to manage their pain, to deal with
physical limitations, and to continue
daily activities despite their illness. These
items are similar to those used by Lorig
in studies of RA patients (O’Leary et al
4
)
1 Incomplete
Self-Efficacy Gauge (Gage et al
53
) 1 Pain is not
mentioned
Liste des Cognitions de la Douleur
(List of Cognitions of Pain)
(Vlaeyen et al).
54
Some questions on SE.
Dutch questionnaire
1 In Dutch
20-item Exercise Beliefs Scale
(Gecht et al
55
)
1 Main content was
not about self-
efficacy in relation
to pain
CDSES indicates Chronic Disease Self-Efficacy Scale; RA, rheumatoid arthritis.
Clin J Pain Volume 00, Number 00, ’’ 2011 Measuring Pain Self-efficacy
r2011 Lippincott Williams & Wilkins www.clinicalpain.com |3
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
and perceived capacity work-related tasks. CPSS scores were
associated with mood, depression, feelings of hopelessness,
pain severity, pain interference, and pain control.
Reproducibility
Agreement
To calculate the agreement of a questionnaire, the
minimal important change (MIC) and the smallest detect-
able change should be provided by the researchers
constructing the questionnaire. This information was not
provided for all questionnaires reviewed here and therefore
agreement could not be calculated.
Reliability
Test-retest reliability was assessed for 4 of the 8
questionnaires (ASES-20, CDSES-33, PSEQ, and CPSS).
Time intervals between test administrations were between 3
days and 16.3 weeks. Test-retest correlations ranged from
0.68 to 0.88 across the 4 questionnaires. Pearson product
correlations were used to assess test-retest reliability for the
ASES-20, CDSES-33, and PSEQ; however the intraclass
correlation coefficient is thought to be the most adequate
test of retest-reliability
57
and was carried out for the CPSS
only.
Responsiveness
The responsiveness of 5 of the questionnaires (ASES-
20, CDSES-33, PSEQ, CPSS, and SES) was evaluated in 8
studies. Hypotheses were given from all studies (except
Burckhardt et al
39
) regarding a specific change in SE in
association with the intervention (note that a change was
explored in study by Nicholas et al,
27
but was not
predicted). No data on responsiveness were found for the
other 3 questionnaires (ASES-11, ASES-8, and CDSES-6).
Recent recommendations suggest that an adequate way to
analyze responsiveness is through receiver operating
characteristic curve analysis or by relating the smallest
detectable change to the MIC.
16
No study used these
Stage 1: 1520 references identified in
the initial search
Exclusions: n=1276 based on an
ENDNOTE search to identify only
papers with the term ‘self-efficacy’ in
the title or abstract.
Stage 1: 244 references. Title and
abstracts assessed.
Exclusions: 38 dissertations, 3 books, 2
reviews; 21 did not fit the inclusion
criteria of chronic pain populations,
including musculoskeletal conditions.
Stage 1: 180 references. From these 6
pain-related self-efficacy measures
were found.
Stage 2:
80 references were identified from the second search focusing
on clinimetric evaluation of the 6 self-efficacy questionnaires.
Stage 2: 34/80 references included clinimetric evaluation of 5
out of 6 of the self-efficacy questionnaires (one questionnaire
dropped from further assessment due to no studies retrieved
including clinimetric evaluation.
Stage 3:
Clinimetric assessment of the final five pain-related self-efficacy
questionnaire
FIGURE 1. Search process.
Miles et al Clin J Pain Volume 00, Number 00, ’’ 2011
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TABLE 2. Description of the Self-efficacy Questionnaires
Questionnaire
Target
Population Domains No. Scales No. Items
No. Response
Options
Range of
Scores
Time to
Administer
(min)
Ease of
Scoring
Study Population
(s) Used in
Clinimetric Studies
ASES-20
10
Arthritis
patients
SE for pain, SE function,
SE other symptoms
3 20 10 20-200 ? Easy Arthritis, chronic
low back pain,
and fibro-
myalgia
4,10,39–41
ASES-11
(short
version)
10
Arthritis
patients
SE for pain, self-efficacy other
symptoms
2 11 10 Self-efficacy
pain: 5-50 Self-
efficacy other:
6-60
<10 Easy Arthritis patients
42
ASES-8 (short
version)
10
Arthritis
patients
SE pain, self-efficacy other
symptoms
2 8 10 8-80 <10 Easy Chronic pain
43
CDSES-33
44
Chronic
disease
patients
Exercise regularly; getting
information about disease;
help from community, family
and friends; communication
with physician; managing
disease in general;
achievement of outcomes;
managing symptoms;
shortness of breath;
controlling depression
10 s33 10 33-330 ? Easy Chronic disease
44
CDSES-6
45
Chronic
disease
Symptom control, role function,
emotional functioning, and
communicating with
physicians
Questions
taken from 3
scales of
CDSES-33
6 10 6-60 <10 Easy Chronic disease
45
PSEQ
27
Chronic
pain
Measures the strength and
generality of a patient’s beliefs
about how confident they are
that they can do each of the
10 activities or tasks at
present despite the pain they
experience
1 10 7 0-60 10 Easy Chronic pain,
chronic low back
pain, chronic
upper limb pain,
and neck-arm
pain
27,28,33–38
CPSS
17
Chronic
pain
3 domains: Coping SE;
Functional SE; and Pain SE
3 22 10 30-300 ? Easy Chronic pain,
chronic low back
pain, and
fibromyal-
gia
9,17,19–22,24
SES
33
Chronic
pain
Patient’s confidence in their
ability to perform activities of
daily living, despite their pain
0 20 11 0-200 ? Easy Chronic low back
pain
33
? indicates time taken to complete not reported; ASES, Arthritis Self-Efficacy Scale; CDSES, Chronic Disease Self-Efficacy Scale; CPSS, Chronic Pain Self-Efficacy Scale; PSEQ, Pain Self-Efficacy Questionnaire;
SES, Self-Efficacy Scale.
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TABLE 3. Summary of the Clinimetric Assessment of the Pain-related Self-efficacy Questionnaires
Reproducibility
Time to
Administer
Ease of
Scoring
Readability and
Comprehension
Content
Validity
Internal
Consistency
Construct
Validity
Criterion
Validity Agreement Reliability
Responsive-
ness
Floor or
Ceiling Effect
Interpret-
ability
ASES-20
10
?+ ? ++O? ? O ?
ASES-11
10
+++++O?O O O
ASES-8
10
++ ? + ? +O O ? ? + O
CDSES-33
44
?+ ? +++? O? O + ?
CDSES-6
45
++ ? ? ? OOOOO O O
PSEQ
27
++++++OO?? O ?
CPSS
17
?++++O O+ ? O O
SES
33
?+ ? ?OOOO ? O O
Scoring key:
Time to administer (Bot et al)
+ Questionnaire could be administered within 10 min
? No information given on administration times
Ease of scoring (Bot et al
15
)
+ Easy—simple summing of items
Visual analog scale use or a formula used
? No information on scoring
Readability and comprehension (Bot et al
15
)
+ When patients tested the questionnaire in a pilot study
? No information on either readability or comprehension
Content validity (The extent to which the domain of interest is represented by the questionnaire items—Terwee et al
16
)
+ The aims, the target population, and domains of measurement are clearly described. Investigators and patients were involved in the item selection
? There was not enough information for adequate assessment
The assessment was not adequate
Internal consistency [The extent to which items in a (sub)scale are intercorrelated, thus measuring the same construct—Terwee et al
16
]
+ Dimensionality assessed on adequate sample size (7* # items and >100), Cronbach afor each dimension (between 0.70 and 0.95)
? No dimensionality assessment or Cronbach areported
Inadequate Cronbach aor sample size
Criterion validity
Criterion validity [The extent to which scores on the questionnaire of interest correlate with a gold standard (other self-efficacy measures) —Terwee et al
16
]
+ Correlation Z0.70 with gold standard tool. Justification given for this instrument as a gold standard
? No justification given, method is doubtful
Correlation r0.70 with gold standard tool
O no information given
Construct validity (The extent to which scores on a particular questionnaire relate to other measures in a manner that is consistent with theoretically derived hypotheses concerning the
concepts that are being measured—Terwee et al
16
)
+ Specific hypotheses given, 75% of hypotheses confirmed
? No specific hypotheses given
<75% hypotheses confirmed
O no information given
Reproducibility
Agreement [The extent to which the scores on repeated measures are close to each other (absolute measurement error)—-Terwee et al
16
]
+ MIC <SDC or MIC outside the LOA or justification that agreement is acceptable
O no information given
Reliability [The extent to which patients can be distinguished from each other, despite measurement errors (relative measurement error) —Terwee et al
16
]
+ ICC/kZ0.70
? Doubtful method
O No information given
Miles et al Clin J Pain Volume 00, Number 00, ’’ 2011
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Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
techniques to analyze responsiveness and therefore, there
were no positive ratings given for this measure.
Floor/Ceiling Effects
Floor and ceiling effects were evaluated for the ASES-
8 and CDSES-33 by calculating the proportions of the
sample that had the lowest and highest possible scores.
Both questionnaires were free from floor effects, although
minimal ceiling effects was reported for the CDSES-33.
Such information was missing for the ASES-20, ASES-11,
CDSES-6, PSEQ, CPSS, and SES.
Interpretability
None of the questionnaires scored positively for
providing adequate interpretability data. Although baseline
and post-means were given for 4 questionnaires (ASES-20,
CDSES-33, PSEQ, and CPSS) and scores of a relevant
subgroup was described for the PSEQ, minimal clinically
important differences (MCID) were not reported for any of
the SE measures and there was no interpretability data
available for the other 4 questionnaires (ASES-11, ASES-8,
CDSES-6, or SES).
Versions in Other Languages
The PSEQ has been translated into Persian, Portu-
guese, and Chinese
29–31
; the ASES has Swedish, Spanish,
and German versions
46–48,58
; the CPSS has Spanish and
Chinese versions
25,26
; and the SES has a Swedish version.
59
DISCUSSION
To our knowledge, this study was the first to system-
atically search pain-related SE questionnaires and carry out
clinimetric assessment of them. This review did not intend to
provide recommendation of the “best” tool to use in research
but rather to provide information to researchers about the
range of pain-related SE questionnaires and their clinimetric
qualities to aid selection.
We identified 13 pain-related SE questionnaires and
clinimetrically assessed 5 (8, including variants) of these
questionnaires (ASES, CDSES, PSEQ, CPSS, and SES).
These questionnaires were identified as being used in those
with pain as a result of chronic disease or musculoskeletal
disorders. Three questionnaires (CDSES, CPSS, and
PSEQ) are more suitable for chronic pain populations in
general. For the development of these questionnaires, the
CDSES used a heterogeneous pain group, whereas for the
PSEQ and CPSS, the populations were predominantly
those with musculoskeletal disorders. The ASES was
designed specifically for patients with arthritis and the
SES was developed in a low back pain population. The
populations in which the questionnaires were validated in
should be considered when selecting measures for use in
other populations. Furthermore, this review is limited to
these populations and should not be generalized to other
pain populations.
Future research should aim to explore the meaning of
different score ranges within each questionnaire. This
would improve understanding by relating scores to clinical
status. None of the studies provided MCIDs. The MCID is
“the smallest (absolute) difference in score which patients
perceive as beneficial and which would mandate, in the
absence of troublesome side-effects and excessive cost, a
change in the patient’s management” (http://www.jrheum.
com/subscribers/07/03/463.html).
60
There have been
developments in the assessment of MCID,
61
which now
Responsiveness (The ability of a questionnaire to detect clinically important changes over time—Terwee et al
16
)
+ SDC or SDC <MIC or MIC outside the LOA or RR >1.96 or AUC>0.70; sample size Z50
? Doubtful method
O No information given
Floor/ceiling effects (The number of respondents who achieved the lowest or highest possible score—Terwee et al
16
)
+ <15% of the respondents achieved the highest or lowest possible scores
O No information found on interpretation.
Interpretability (The degree to which one can assign qualitative meaning to quantitative scores—Terwee et al
16
)
+ Mean and SD scores presented of at least 4 relevant subgroups of patients. MIC provided
? Doubtful design
O No information given
indicates negative rating; ?, indeterminate rating; +, positive rating; 0, no information available; ASES, Arthritis Self-Efficacy Scale; AUC, area under receiver operating characteristic; CDSES, Chronic Disease
Self-Efficacy Scale; CPSS, Chronic Pain Self-efficacy Scale; ICC, intraclass correlation; LOA, limits of agreement; MIC, minimal important change; PSEQ, Pain Self-Efficacy Questionnaire; RR, relative risk; SES, Self-
Efficacy Scale; SDC, smallest detectable change.
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split the analysis into a minimal important difference and
MIC, however, none of the questionnaires in this study
measured either. For some of the questionnaires, there was
some information that could assist with interpretation of
the scores, such as presentation of means and SDs of
patient scores before and after treatment, however,
information regarding relevant subgroups was provided
for the PSEQ only.
Overall, there was disappointment that these are not
better validated but inadequate validation is common
across a range of domains that are measured through
self-report questionnaires. On the basis of the review of
these questionnaires, we make recommendations for future
researchers carrying out validation of questionnaires of SE:
(1) factor structures of questionnaires should be explored
and confirmed; (2) when testing construct validity, specify
directional hypotheses; (3) provide descriptive statistics for
distribution of scores for adequate evaluation of floor/
ceiling effects; (4) test-retest data and interrater reliability
data using adequate statistical procedures need to be
carried out; and (5) information regarding the interpret-
ability of scores should be provided or other information
such as scores of relevant subgroups and means and SDs to
aid comparability and responsiveness.
The research team for this review decided upon aspects
thought to be important in SE in pain populations. These
are outlined in the introduction as beliefs about one’s
ability to control the pain and the negative emotions
associated with it; to maintain everyday life activities
including work; to communicate their needs to health
carers; and implement advice about their pain. The ASES
and CPSS address most of these aspects of SE, but do not
include items that cover communication with their health
carers. The CDSES covers all aspects of these SE criteria,
whereas the PSEQ only addresses confidence to maintain
everyday lives. The SES focuses purely on activities of daily
living and items do not address any of the above.
Additional research is needed before final decisions about
the important aspects of SE can be made. Patient-centered
research should address the issue of what should be
included in a truly comprehensive evaluation of pain-
related SE.
SE is not only related to specific behaviors but also to
the beliefs that people have about how they can cope
in adverse situations.
3
For a questionnaire to measure, SE
it is important that both components are covered in the
questionnaire items. All the questionnaires we assessed
featured items that ask about patients’ coping and about
their beliefs in relation to their own behaviors. However, it
could be argued that this is not situation-specific enough.
For example, “I can enjoy things, despite my pain,” may be
too general a question, and may not tap beliefs about
specific behaviors that have been affected by pain. Negative
beliefs about a small range of very specific behaviors may
be incredibly detrimental to patients’ coping and adjust-
ment, but maybe obscured if items ask only general
questions. Clearly, it is difficult to measure SE using such
a general tool when SE is sensitive to specific behaviors.
One idea is to use a more patient-centered instrument in
which individuals indicate the specific behaviors associated
with their own personal SE, beliefs, behaviors, and goals
that also measures obstacles to effective coping, for
example, Measure Yourself Medical Outcome Profile
(MYMOP).
62
MYMOP aims to measure the outcomes
that the patient considers the most important. On the first
occasion, the questionnaire is completed within the
consultation, or with some confidential help. The patient
chooses 1 or 2 symptoms that they are seeking help with,
and that they consider to be the most important. The
MYMOP has been shown to be practical, reliable, and
sensitive to change.
62
This method can be applied to any
measurement construct and is directly applicable to the
patient, leading to high response and completion rates.
There are several individualized measures available that
could be used, 1 example of which is the MYMOP.
However, to our knowledge, there is no investigation of the
use of the MYMOP to measure SE. Furthermore, the
MYMOP cannot be completed as a purely self-adminis-
tered tool, as it requires initial guidance and therefore, is
not suitable for studies using only postal questionnaires.
The method does, however, place high reliance on patient
self-awareness of their problem areas and problematic in
economic evaluations because of the individualized nature
of the data.
Limitations
Despite our efforts to carry out a systematic and
comprehensive search, it is possible that we missed important
target articles. Our search was limited to Medline and
PsycInfo, and although there is evidence that Medline is
superior to other databases in its discriminating power and
comprehensiveness,
63
a wider search may have yielded further
publications. We note, however, that we have reviewed the
most commonly used instruments, and have been able to
retrieve information on most aspects of their clinimetric
properties. Another limitation is our focus on the label “self-
efficacy” alone: There are no doubt many overlapping
concepts, such as patient enabling, locus of control, etc.
However, generating all the overlapping terms and searching
for them would yield an unmanageable amount of data. In
addition, it is not clear how much shared and unique variance
each concept has with SE, such a conceptual analysis was
beyond the scope of this study.
In summary, on the basis of the published information
at this point in time, we were able to identify 5 good
candidates for use in measurement of SE in pain popula-
tions. All 5 measures follow social learning theory in terms
of measuring SE for coping in adverse situations, although
it can be argued that some items in all the reviewed
questionnaires are not situation-specific. Further research-
ers need to be aware that the clinimetric limitations are
variable across questionnaires. Researchers are encouraged
to continue the development of these questionnaires in
reference to interpretability and responsiveness of the
scales, particularly in the shorter versions of the ASES
and the CDSES. Where the existing measures are not
appropriate, we acknowledge that a more patient-centered
approach, such as MYMOP could be used. Furthermore,
outcome expectations need to be measured alongside SE to
best predict future behavior.
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