Validity and reliability of the Hungarian version of the Pain Self-efficacy Questionnaire among women with endometriosis and chronic pelvic pain

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Validity and reliability of the Hungarian version of the Pain Self-efficacy Questionnaire among women with endometriosis and chronic pelvic pain

https://doi.org/10.21203/rs.3.rs-4060366/v1

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Our study aimed to perform Hungarian cross-cultural adaptation and assess the reliability and validity of the Pain Self-Efficacy Questionnaire (PSEQ) among women with chronic pelvic pain. The current study was conducted in Hungary among women aged 18–50 (34,39 ± 6,68 years). Besides PSEQ, the 36 Item Short-Form Health Survey (SF36), Visual Analog Scale (VAS), and Perceived Stress Scale (PSS) were used. We examined the reliability of the PSEQ-HU by applying internal consistency and test-retest evaluations. For construct validity of the PSEQ-HU we used confirmatory factor analysis (CFA) and for convergent validity Spearman rank correlation analysis was performed to assess the correlations between PSEQ-HU and SF-36, PCS, PSS and NRS. For discriminant validity two groups were created based on the NRS (0–4, 5–10). The results were analyzed via IBM SPSS version 28.0 software with a significance level of p < 0.05. 262 women took part in the study. Cronbach’s α was 0.966, the intraclass correlation coefficient values showed adequate reliability (ICC = 0.939. 95% CI 0.884–0.968) for the PSEQ-HU. Spearman correlation analysis showed significant correlations between pain-related self-efficacy and health-related quality of life, perceived stress levels and pain catastrophizing. We concluded that PSEQ is a reliable and valid measurement among Hungarian women endometriosis-related pelvic pain.

ClinicalTrials.gov registration: https://register.clinicaltrials.gov/prs/app/action/LoginUser?ts=1&cx=-jg9qo4

Unique protocol ID: 9534-PTE2023 NCT05863663

Health sciences/Diseases

Health sciences/Health care

Health sciences/Medical research

Health sciences/Signs and symptoms

Chronic pain is a prevalent and multifactorial problem that has a significant impact on both individuals and society worldwide. Chronic pain affects a significant amount of the population and represents a serious socioeconomic burden ¹.

Chronic pelvic pain is a common chronic pain syndrome that affects a significant number of women, especially those suffering from endometriosis. The global prevalence of Chronic Pelvic Pain (CPP) varies from 5–43% for women and 2–17% for men ². Chronic pelvic pain involves unique areas of life such as the ability to sit, sexual life and has a significant effect on work productivity.

Endometriosis is a chronic, progressive, inflammatory gynecological disease that affects more than 70 million women worldwide. In the United States 11% of women and approximately every 10th woman worldwide and in Hungary suffer from endometriosis ³⁴. Additionally, it occurs among 40–50% of women with pelvic pain, 20% of women with infertility, 50% and 70% of women suffering from dysmenorrhea and dyspareunia ^{5 6}. Pelvic pain, lower quality of life, and high levels of fatigue are highly prevalent among women with endometriosis, and according to the literature, up to 50% of them may experience depression and anxiety ⁷. Pelvic pain associated with endometriosis is one of the main reasons for the decline in health-related quality of life of women concerned. It also reduces the quality of sleep and the level of physical activity as well as increases the level of perceived stress and influences body image ⁸. Psychological factors play an essential role in coping with chronic pain, and self-efficacy ⁹ has been identified as an important resilience factor to manage pain moreover it has a significant effect on functioning and coping with chronic pain ¹⁰. Self-efficacy has been proven to be an even more important determinant of disability than pain intensity, fear of movement, pain duration, or anxiety ^{11 12}. A lower self-efficacy level is identified with higher pain intensity ¹³ while a higher self-efficacy level is associated with greater physical functioning and physical activity participation ¹⁴.

Pain-related self-efficacy has been confirmed to be negatively associated with stress and pain catastrophization among patients suffering from chronic pain ¹⁴.

There are several other measurement tools for evaluating self-efficacy as the Arthritis Self-Efficacy Scale ¹⁵, the Rheumatoid arthritis Self-Efficacy Scale ¹⁶, the Chronic Pain self-Efficacy Scale ¹⁷, but among these the Pain Self-Efficacy Questionnaire ¹⁸ is an extensively researched and reliable tool for evaluating pain-related self-efficacy in subjects with chronic pain (cancer, musculoskeletal chronic pain). According to a 2019 Delphi Study, the Pain Self-Efficacy Questionnaire (PSEQ) is an extensively researched and reliable tool for evaluating pain-related self-efficacy in subjects with chronic pain ¹⁹.

The original version of PSEQ was developed and validated in English ¹⁸ (Nicholas 2007) and has been tested in samples with chronic pain.

Excellent reliability and validity have been demonstrated in different languages such as Japanese ¹⁴, Dutch ²⁰, Hebrew ²¹, Yoruba ²¹, Italian ²², Arabic ²³ Catalan ²⁴, Persian ²⁵, Canadian-French ²⁶ (Dubé et al., 2022), and Brazilian ²⁷. As PSEQ is still not available in the Hungarian language, the translation and cultural adaptation of PSEQ is required by the growing number of studies concerning the behavioral and psychological aspects of chronic pain in Hungary.

The aims of the present study were to translate the PSEQ into Hungarian language through a process of cross-cultural adaptation and to test its measurement properties on a Hungarian sample of patients presenting with chronic pelvic pain and endometriosis.

The current study is a cross-sectional online survey, distributed via social media using endometriosis support groups in Hungary between 2023. January and 2023. April.

The sample size to assess internal consistency and construct validity was determined according to the COSMIN guideline, which recommends that the sample size be 10 times larger than the number of items ^{28 29}.

Voluntarily participating women suffering from endometriosis and chronic pelvic pain ³⁰ aged between 18–50, and living in Hungary were recruited for the study. Pregnant women, women not diagnosed with endometriosis, or women under 18 and above 50 were excluded from the study. We asked 39 participants to fill in the questionnaire 2 weeks after the initial testing according to the COSMIN guideline and other relevant studies ^{31 32} (COSMIN checklist is in the Supplementary data file 1).

Original Pain Self-efficacy Questionnaire

The self-administered PSEQ is a specific questionnaire developed to assess pain-related self-efficacy covering the previous 4 week period in people with chronic pain, aimed to evaluate how confident the participants are in everyday activities despite the pain. The questionnaire includes 10 questions using a 7-point Likert scale. The score is calculated by summing up the responses, the maximum score is 60 showing excellent pain-related self-efficacy. The original English version of the questionnaire showed excellent internal consistency (Cronbach α: 0.92) and test-retest reliability ¹⁸.

Pain Catastrophizing Scale

PCS ³³ is a validated, self-assessment questionnaire, consisting of 13 statements containing different thoughts and feelings one may experience when enduring pain. The items are divided into the categories of rumination (items 8–11) (Cronbach α: 0.792), magnification (items 6,7 és 13) (Cronbach α: 0.785) and helplessness (items 1–5 and 12) (Cronbach α: 0.883), with each item scored on a 5-point scale. The overall score has a range of 0–52. Higher scores indicate a higher level of pain catastrophizing. The Hungarian version of PCS ³⁴, has demonstrated good internal consistency.

36 Item Short-Form Health Survey

The questionnaire ³⁵ consisting of 8 domains: physical functioning, bodily pain, role limitations due to physical health problems, role limitations due to personal or emotional problems, emotional well-being, social functioning, energy/fatigue, and general health perceptions. Higher scores indicate higher health-related quality of life. The scores were transformed to a 0-100 scale. During the cross-cultural adaptation of the SF-36 the Hungarian version of 36 Item Short-Form Health Survey ³⁶ showed excellent internal consistency, Cronbach 0.93.

Perceived Stress Scale- 10

PSS-10 ³⁷ is a self-administered questionnaire developed to assess stress levels and “the degree to which individuals appraise situations in their lives as stressful”. The scale includes 10 questions, consisting of 5 answer options related to frequency, varying from 0–4. Higher scores indicate higher stress levels, 40 is the highest possible score. The Hungarian version of PSS-10 ³⁸ had good internal consistency (Cronbach α: 0.85).

Numeric Pain Rating Scale

The scale ³⁸ is a widely used and valid instrument in the literature, aimed to assess the subjective level of pain on a scale of 0–10, where 0 is no pain at all and 10 is the maximum possible pain. In the current study, the participants were asked to rate their average and maximum pain levels in the last 4 weeks and their actual pain intensity.

Ethical considerations

The study was conducted anonymously and all participants were asked for a written consent after receiving detailed information. Ethical approval for the study was obtained by the Institutional Review Board of the Faculty of Medicine, University of Pécs, in 2023 (no.: 9534-PTE 2023; Clinical trial number: NCT05863663) following the 2008 Helsinki Declaration.

Validation process

Translation and cultural adaptation process

The translation and cross-cultural adaptation were completed through a multistage process ³⁹. Receiving the consent from the original investigator of the PSEQ to the translation, cross-cultural adaptation, and validation into the Hungarian language, the linguistic validation was carried out according to the relevant guidelines.

In phase one of the study, the PSEQ was forward-translated from English to Hungarian by two independent translators. The first translator was aware of the concept of the questionnaire and as a physiotherapist had a clinical background, while the second translator was not informed about the questionnaire, and as an English teacher did not have a clinical perspective. Then a synthesis between translations was made to confirm the equivalence with the original version.

The back translation of the PSEQ into the original English language was performed by an independent physiotherapist with high-level English proficiency.

We had an committee composed of a medical doctor, an English teacher, a physiotherapist, and a patient suffering from endometriosis, which created the pre-final version of the questionnaire.

The pre-final version was piloted to 15 Hungarian women suffering from endometriosis and they were asked to report back on the readability, cultural relevance and comprehensiveness of the translated version. Only minor changes were suggested so the final Hungarian version of the self-administered PSEQ-HU was accepted.

Following the creation of the final version of the questionnaire, we evaluated the following psychometric properties of the PSEQ-HU: content validity, structural validity, internal consistency, test-retest reliability, convergent validity, and discriminative validity.

Statistical analysis

Reliability

Internal consistency assesses the degree to which items within an instrument are interconnected, indicating their strength of association (homogeneity). Cronbach’s α was used to verify internal consistency and values between 0.70 and 0.95 are considered adequate ⁴⁰. Test-retest reliability was examined with an intraclass correlation coefficient (ICC). ICC values of 0.75–1.00 were interpreted as excellent ⁴¹.

Validity

Content validity was explored by score distributions and floor/ceiling effects, the latter are considered to be present if more than 15% of the sample achieves the lowest (floor) or highest (ceiling) possible score.

Our study aimed to confirm the structural validity of the instrument using confirmatory factor analysis CFA) and reliability statistics such as CFI, TLI, RMSEA, and 90% CI. A ratio of < 3 between the chi-square test and degrees of freedom, CFI and TLI of 0.90 or more, and RMSEA values of 0.08 or less indicated a good model fit. We calculated factor loadings for each item and identified loadings below 0.5 for potential item reduction ⁴².

Convergent validity of the PSEQ was explored using Spearman’s rank correlation analysis between the total score of the PSEQ and the NRS and SF-36, PCS ²² PSS Correlation was classified as moderate (0.3 < r > 0.69) or strong (r > 0.7) ⁴³.

For the examination of discriminant validity, based on the average scores of NRS over the past 4 weeks, we created 2 groups (0–4, no or mild pain 5–10 moderate and severe). Mann-Whitney U-test tested discriminative validity to examine the differences in PSEQ scores between patients having mild or moderate/severe pain⁴⁴.

Descriptive statistics were applied to establish sample characteristics, central tendency estimates, and the variability of the data set. These data were presented as means, standard deviations (SD) or percentages (%).

Data analysis was performed using IBM SPSS 28.0 software and IBM SPSS AMOS 29.0 (SPSS Inc., Chicago, IL) version. The level of significance was set at p < 0,05.

Initially, 277 participants were recruited and then 15 were excluded therefore 262 adult women suffering from endometriosis (mean age 34.39 ± 6.68) participated in the study (Fig. 1). A subgroup of 39 participants was asked to fill out the survey twice, 14 days after the initial testing sample-be írni inkább. The sample’s profile and sociodemographic characteristics are shown in Table 1.

Table 1

Sample characteristics
Variable	Final sample n = 262 (n;%)
1. Marital status
living alone	34 (13.1%)
living with partner	94 (36.2%)
married	127 (48.8%)
divorced	5 (1.9%)
2. Educational level
elementary school	4 (1.5%)
secondary school	106 (40.6%)
higher education	151 (57.9%)
3. Work category
sedentary	154 (59.7%)
light physical	56 (21.7%)
heavy physical	7 (2.7%)
standing	27 (10.5%)
unemployed	14 (5.4%)
4. Residence
city	112 (42.9%)
village	43 (16.5%)
administrational center	41 (15.7%)
capital	65 (24.9%)
7. Pelvic pain duration (years)	9.23 ± 7.7

The internal consistency of the PSEQ- HU was excellent with Cronbach’s α = 0.966 (Table 3). Test-retest reliability of the PSEQ-HU in a sample of 39 women yielded excellent results (ICC = 0.939. 95% CI 0.884–0.968).

Table 2

The descriptive results of the instruments
Outcomes		Mean (SD)
Pain self-efficacy (PSEQ- HU)		36.18 ± 17.04
Current pain intensity. NRS		4.09 ± 3.02
Perceived stress level - PSS		30.92 ± 8.72
Pain catastrophizing - PCS		27.46 ± 14.24
Health-related quality of life - SF-36	Physical functioning	73.38 ± 23.59
	Role limitations due to physical health	43.87 ± 41.61
	Role limitations due to emotional problems	50.83 ± 44.39
	Energy/fatigue	45.06 ± 14.03
	Emotional wellbeing	46.16 ± 14.45
	Social functioning	62.26 ± 32.35
	Pain	46.33 ± 28.11
	General health	44.93 ± 23.74

Table 3

Internal consistency of the PSEQ-HU
Item	Mean (SD)		Corrected item-total correlation	Cronbach’s α when deleted
PSEQ-HU 1	3.60	1.81	0.823	0.964
PSEQ-HU 2	4.11	1.78	0.864	0.962
PSEQ 3	3.76	1.97	0.854	0.962
PSEQ 4	3.87	1.80	0.861	0.962
PSEQ 5	4.01	1.85	0.869	0.962
PSEQ 6	3.57	1.93	0.890	0.961
PSEQ 7	2.73	2.26	0.700	0.969
PSEQ8	3.56	2.01	0.871	0.962
PSEQ9	3.52	2.03	0.892	0.961
PSEQ10	3.44	1.97	0.876	0.962
PSEQ-HU Cronbach’s α = 0.966

Floor and ceiling effects were insignificant, 0.7% and 8.9% of the participants scored the lowest and highest possible scores respectively. Table 2 shows the values of the mean and standard deviation of the different questionnaires.

The CFA supported the one-factor structure of the PSEQ-HU questionnaire in the sample we used. (RMSEA = 0.070; TLI (Tucker Lewis) = 0.981; CFI = 0.987; χ²=70.597; df = 31; p < 0.001; χ²/df = 2.277). All items converged meaningfully onto the scale as predicted with significant standardized factor loadings (all p’s < 0.01) ranging from 0.71 to 0.91. Modification indices suggested that the errors between different items presented on Fig. 2.

Table 4 presents the correlations between PSEQ – HU and other measurment tools. We have found weak to moderate correlations between SF-36 subscales and the PSEQ-HU total score and negative significant moderate correlations between PCS. PSS and PSEQ-HU total scores.

Table 4

*Convergent validity of the PSEQ-HU and the other measurement tools (n = 262).*
Questionnaire	Correlation with total score of PSEQ HU (r. p) (n = 262)
SF-36	Correlation with total score of PSEQ HU (r. p) (n = 262)
Physical functioning	0.539**
Role Functioning Physical	0.552**
Social Functioning	0.560**
Bodily pain	0.626**
Role functioning emotional	0.427**
Emotional Well-Being	0.221**
Energy/Vitality	0.520**
General Health perception	0.427**
PSS	-0.404**
PCS	-0.544**
level of significance =p < 0.001

During the examination of discriminant validity, we applied the Mann-Whitney U test, and the test results indicated a significant difference in the mean scores of the PSEQ-HU between the two groups formed based on the current NRS (p < 0.001). The „no or mild pain” group (45.35 ± 15.19) and the „moderate or severe pain” group (30.41 ± 15.58) showed significant (p < 0.001) differences regarding the PSEQ-HU mean value scores.

Our study aimed to translate and cross-culturally adapt the PSEQ into the Hungarian language and examine its reliability and validity on a sample of women suffering from endometriosis-related chronic pelvic pain. PSEQ itself was used in other studies examining chronic pelvic pain ⁴⁵. We examined the psychometric properties of the Hungarian version of PSEQ-HU.

Our sample was patients suffering from endometriosis and chronic pelvic pain. According to a 2021 study, PSEQ has been proven to be a reliable, valid and responsive tool, and further studies are required to determine responsiveness in populations with other chronic pain disorders. Dubé’s study examined the psychometric properties of the PSEQ among patients with chronic muscoloskeletal pain.⁴⁶.

The mean score of the PSEQ in our study was 36.18 ± 17.04 while the mean score of the original PSEQ was 25.8 ± 12.4 points in a sample of patients with CLBP. Our study was similar to the values in the Persian 36.7 ± 14.3, or Italian study 36.12 ± 12.90. The NRS value of the Hungarian sample (current pain 4.09 ± 3.02) were also similar to the Italian validation study (current pain intensity 4.58 ± 2.0).

Similar to other studies, in the current study CFA supported the one-factor structure of the PSEQ. With each item was deleted. Cronbach’s α remained stabil. No significant ceiling and floor effects were found similar to other studies as Italian ²² version.

The PSEQ-HU showed good psychometric properties with good indications of reliability and validity. The PSEQ-HU showed excellent internal consistency (Cronbach’s α = 0.966), in congruence with the Hebrew (Cronbach’s α = 0.97) version, Italian ²² (Cronbach’s α = 0.94), Persian²⁵ (Cronbach’s α: 0.92), Dutch ²⁰ (Cronbach’s α: 0.92) and the original validation ²⁷ (Cronbach’s α: 0.92) studies showed. The PSEQ-HU had excellent test-retest reliability.

The PSEQ-HU demonstrated high test-retest reliability (ICC = 0.939. 95% CI 0.884–0.968) congruent with the other validation studies of the PSEQ. We used 2 weeks between initial test and retest suggested by the relevant literature ^{31 32}.

Convergent validity was confirmed in our study. The study showed that PSEQ-HU is significantly and negatively associated with measures of pain catastrophizing, higher stress and pain levels ⁴⁷. The correlation between the PSEQ-HU and the PCS was moderate (r=-0.544), similar to the Japanese (r=-0.49), and Italian: (r=-0.418) validational studies. Correlations with NRS: current study (r=-0.479), Italian: (r=-0.399).

Our findings that higher Health-related Quality of life is associated with higher self-efficacy is consistent with the results of the other cross-cultural adaptations and validations. Among SF-36 domains we have found a significant moderate positive correlation between physical functioning (r = 0.539) correspondence with similar moderate correlations in other studies Dutch: (r = 0.315), Amharic (r = 0.38) and Persian (r = 0.31). Bodily pain had the strongest correlation with PSEQ-HU in the current study (r = 0.626) in other studies it is a moderate association: Amharic (r = 0.51), Japanese (r = 0.45). We have also found significant moderate correlations between PSEQ-HU and general health domain of the SF-36 (r = 0.427), Amharic (r = 0.40), Persian (r = 0.52), Japanese: (r = 0.31). Vitality was also significantly correlated with PSEQ-HU in our study (r = 0.520), similar to Persian (r = 0.51) and Japanese (r = 0.46) results. Regarding social functioning in our study we have found moderate correlations (r = 0.560), similar tot he Dutch: (r = 0.489), Persian (r = 0.43) and Japanese (r = 0.43) validations. A moderate correlation has been found between PSEQ-HU and the role limitations due to physical health domain of SF-36 (r = 0.552), in accordance with the Amharic (r = 0.32), Persian (r = 0.33), and Japanese (r = 0.41) validation studies of the PSEQ. Role limitations due to mental health showed a moderate significant correlation in our study (r = 0.42), and Japanese (r = 0.41), Persian (r = 0.34) studies showed similar moderate correlations. Only mental health and emotional wellbeing domain showed a weak correlation in the current study (r = 0.221), while in other studies moderate correlations were found (Amharic (r = 0.36), Persian (r = 0.42), Japanese (r = 0.40) ^{14 25 20}.

The results of the current study indicated a significant difference in the mean scores of the PSEQ-HU between the two groups ⁴⁹ (Breivik et al.. 2008) formed based on the NRS values of the participants (p < 0.001).

Although the current article has several strengths, our study has some limitations. First, all patients were recruited from 3 thematic social media groups, the sample was not representative. The number of participants were 262, which is an average number. Also this is the first time this measurement tool has been validated on chronic pelvic pain and endometriosis population.

The current study indicates that the PSEQ-HU is a valid and reliable instrument for evaluating pain related self-efficacy of individuals with chronic pelvic pain. The translation and cultural adaptation of the PSEQ-HU could contribute to further studies of chronic pain, pain-related self-efficacy and the factors influencing pain-related self-efficacy.

The PSEQ-HU may be a useful tool to help determining the effect of different treatment methods on chronic pain and pain-related self-efficacy. Additionally it can be suitable for developing patient-centered care in the Hungarian population with pelvic pain and endometriosis as pain-related self-efficacy is an important predictor of overall health beliefs.

Conflict of interest

Authors have no conflict of interest to declare in the current study.

Funding:

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Author Contribution

ZSKSZ wrote the main manuscript text, AM helped in preparing statistical analysis, MH helped in writing the main manuscript text and preparing the figures, PÁ prepared the tables. All authors reviewed the manuscript.

Data availability:

All data generated or analyzed during this study are included in this published article. The data presented in this study are available on request from the corresponding author. The data is not publicly available due to privacy concerns.

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No competing interests reported.

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Validity and reliability of the Hungarian version of the Pain Self-efficacy Questionnaire among women with endometriosis and chronic pelvic pain

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Abstract

Figures

Introduction

Methods

Original Pain Self-efficacy Questionnaire

Pain Catastrophizing Scale

36 Item Short-Form Health Survey

Perceived Stress Scale- 10

Numeric Pain Rating Scale

Ethical considerations

Validation process

Translation and cultural adaptation process

Statistical analysis

Reliability

Validity

Results

Discussion

Conclusion

Declarations

Conflict of interest

Funding:

Author Contribution

Data availability:

References

Additional Declarations

Supplementary Files

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