Multidimensional Health Locus of Control: Comments on the Construct and its Measurement

Development of fidelity of delivery and enactment measures for interventions in communication disorders

OBJECTIVES

This study was part of a process evaluation for a single-blind, randomized controlled pilot study comparing Better Conversations with Primary Progressive Aphasia (BCPPA), an approach to communication partner training, with no speech and language therapy treatment. It was necessary to explore fidelity of delivery (delivery of intervention components) and intervention enactment (participants' use of intervention skills in the form of conversation behaviours comprising facilitators, that enhance the conversational flow, and barriers, that impeded the flow of conversation). This study aimed to: (1) Outline an adapted methodological process that uses video observation, to measure both fidelity of delivery and enactment. (2) Measure the extent to which the BCPPA pilot study was delivered as planned, and enacted.

DESIGN

Observational methods were used alongside statistical analysis to explore the fidelity of intervention and enactment using video recordings obtained from the BCPPA pilot study.

METHODS

A 5-step methodology, was developed to measure fidelity of delivery and enactment for the BCPPA study using video-recorded data. To identify delivery of intervention components, a random sample of eight video recorded and transcribed BCPPA intervention sessions was coded. To examine the enactment of conversation behaviours, 108 transcribed 10 -min-video recorded conversations were coded from 18 participants across the control and intervention group.

RESULTS

Checklists and guidelines for measurement of fidelity of treatment delivery and coding spreadsheets and guidelines for measurement of enactment are presented. Local collaborators demonstrated 87.2% fidelity to the BCPPA protocol. Participants in the BCPPA treatment group increased their use of facilitator behaviours enacted in conversation from a mean of 13.5 pre-intervention to 14.2 post-intervention, whilst control group facilitators decreased from a mean of 15.5 to 14.4, over the same timescale.

CONCLUSIONS

This study proposes a novel and robust methods, using video recorded intervention sessions and conversation samples, to measure both fidelity of intervention delivery and enactment. The learnings from this intervention are transferable to other communication interventions.

Illness intrusiveness, health locus of control, and anxiety symptoms among veterans with congestive heart failure

Disease severity, illness intrusiveness, and health locus of control (HLC) each contribute to psychosocial wellbeing in patients with congestive heart failure (CHF). To better understand the relationships between these variables regarding anxiety symptoms, we analyzed data from 116 adult male veterans with comorbid CHF and anxiety. Results suggested that illness intrusiveness significantly mediated the relation of CHF severity to anxiety symptom severity, and that the illness intrusiveness domains of physical well-being/diet, work/finances, and other aspects of life (religious/spirituality, community/civic, self-improvement/expression) were also significant mediators of that relationship. The relation of illness intrusiveness to anxiety was not moderated by internal HLC. Findings highlight the importance of assessing and treating various aspects of illness intrusiveness to manage anxiety symptoms in CHF patients.

Results from a randomised controlled pilot study of the Better Conversations with Primary Progressive Aphasia (BCPPA) communication partner training program for people with PPA and their communication partners

BACKGROUND

There has been a growing focus on functional communication interventions for primary progressive aphasia (PPA). These interventions aim to support individuals to participate in life situations. One such intervention, communication partner training (CPT) aims to change conversation behaviours in both the person with PPA and their communication partner (CP). CPT has a growing evidence base in stroke aphasia; however, these programmes are not designed to meet the needs of people with progressive communication difficulties. To address this, the authors developed a CPT program entitled Better Conversations with PPA (BCPPA) and undertook a pilot trial to establish for a future full trial; predicted recruitment rates, acceptability, an assessment of treatment fidelity and an appropriate primary outcome measure.

METHODOLOGY

This was a single-blind, randomised controlled pilot study comparing BCPPA to no treatment, delivered across 11 National Health Service Trusts in the UK. A random sample of eight recordings of local collaborators delivering the intervention were analysed to examine fidelity. Participants completed feedback forms reporting on acceptability. Pre- and post-intervention measures targeted conversation behaviours, communication goals and quality of life.

RESULTS

Eighteen people with PPA and their CPs (9 randomised to BCPPA, 9 randomised to no treatment) completed the study. Participants in the intervention group rated BCPPA positively. Treatment fidelity was 87.2%. Twenty-nine of 30 intervention goals were achieved or over-achieved and 16 of 30 coded conversation behaviours demonstrated change in the intended direction. The Aphasia Impact Questionnaire was identified as the preferred outcome measure.

CONCLUSION

The first randomised controlled UK pilot study of a CPT program for people with PPA and their families demonstrates BCPPA is a promising intervention. The intervention was acceptable, treatment fidelity high and an appropriate measure identified. Results of this study indicate a future RCT of BCPPA is feasible.

TRIAL REGISTRATION

Registered 28/02/2018 ISRCTN10148247 .

Psychometric properties of the risk, pain, and injury questionnaire in Chinese collegiate athletes and its relationship with locus of control

PURPOSE

This study aimed to adapt the Risk, Pain, and Injury Questionnaire (RPIQ) to Chinese collegiate athletes and examine its reliability and validity.

METHODS

Six hundred thirty collegiate athletes aged 17 to 24 years agreed to complete the RPIQ, the Chinese version of the SIAS and an LOC scale. Exploratory factor analysis (EFA, n = 300) and confirmatory factor analysis (CFA, n = 330) were conducted to explore its structure, and convergent and construct validity were investigated by examining the relationships between various factors of the RPIQ, LOC, SIAS and injury risk.

RESULTS

The results of EFA show the Chinese version of the RPIQ contained 12 items and was divided into three factors: tough, pressed and rational choice. CFA confirmed its factorial structure (CMIN/DF = 2.61, CFI = 0.93, TLI = 0.91, RMSEA = 0.07). The reliability of the scale was satisfactory (Cronbach's alpha = 0.75). Significant associations between the RPIQ factors and LOC and SIAS were found, suggesting the construct validity of the scale was acceptable. Additionally, significant gender differences were found in the RPIQ factors and athletes who participated in individual sports scored higher on tough and rational choice factors than those who participated in team sports.

CONCLUSIONS

The Chinese version of the RPIQ has sufficient psychometric properties and can be used as a reliable and effective tool for measuring attitudes of the risk, pain and injury of collegiate athletes.

Adherence to and Persistence with Adalimumab Therapy among Swedish Patients with Crohn’s Disease

Objectives: (1) to determine the adherence and persistence rates of adalimumab therapy among Swedish patients with Crohn’s disease (CD), and (2) to compare self-administration devices to predict the medication adherence and persistence. Methods: We conducted a retrospective analysis of the Swedish National Board of Health and Welfare database during a unique time period, when both the pen and the syringe were available. The pen was proposed to indicate a larger extent of internal control, according to health locus of control. Medication adherence was defined as a medication possession ratio (MPR) ≥ 0.8. A patient was considered nonpersistent if the time between any two dispensing records, minus the days of supply dispensed exceeded 180 days. The predictors of adherence were evaluated using a logistic regression, and the predictors of persistence were evaluated using a Cox proportional hazards model. Results: Among the 1083 patients studied, 89% were adherent and 77% were persistent. The patients using the pen and the patients treated in gastroenterology centers were more likely to be adherent and less likely to be nonpersistent. Conclusions: The adherence rate to adalimumab therapy was 89% and the one-year persistence rate was 70%. The pen and treatment in a gastroenterology center had a positive impact on the adherence and persistence among Swedish patients with CD.

Feeling Capable in an Ubuntu Way: Kenyan Comprehensions of Control Beliefs Compared with the German Perspective

In Western personnel psychology, control beliefs are a valued predictor for work-related outcomes. Yet, little is known about the culture-specific functioning of control in East Africa. Kenya, as an Ubuntu culture, is examined regarding control beliefs and contrasted with a German sample considered to represent an individualistic or Western culture. Responses to N=143 quantitative personality tests were attended with qualitative interviews on control beliefs (self-concept of ability, internality, powerful others, and chance). Content validity and factor structure of control beliefs were analyzed, followed by a Procrustean target rotation. Linear regression analyses were conducted to assess the predictability of job performance, achievement motivation, and well-being. Item comprehension, as well as factor structure of the four control aspects, differ between the two samples. In particular, the ‘powerful others’ control aspect diverges the most between the cultures. Linear regression analyses showed comparable, but not fully congruent predictability. Results indicate that an uncritical transfer of the control beliefs measure from one culture to another is inappropriate. Results fit in the picture of African Ubuntu philosophy, emphasizing social-relational aspects shaping control beliefs. More emic-etic based research is demanded concerning intra- and intercultural variability of control beliefs to depict a transcultural applicable and invariant model.

Health locus of control in a pandemic situation: cross-cultural differences between European and Asian respondents

Background

The present cross-cultural study examined the health locus of control construct during the COVID-19 pandemic. The scien-tific purpose of the study was to determine whether, during the pandemic situation, cultural and sex differences influence the health locus of control construct and change the internal health locus of control (IHLC), powerful others health locus of control (PHLC), and chance health locus of control (CHLC).

Participants and procedure

A total of 2617 recipients aged 18-70 years from Asia (China, India, and Indonesia), and Europe (Bulgaria, Germany, and Hungary) completed a questionnaire about their health. The participants completed an online version of the Multidimen-sional Health Locus of Control Scale – Form A.

Results

The survey shows that in a pandemic life-threatening situation, most individuals strive to rely on IHLC and/or PHLC, and fewer of them tend to rely on CHLC. However, there are differences (p < .001) between the two cultural samples: the rep-resentatives of Asian collectivistic culture are more dominated by PHLC, compared to the representatives of the European individualistic culture. When the comparison is between individuals from different cultures, sex differentiation affects the health locus of control, and as a result, significant differences in relation to IHLC, PHLC, and CHLC levels (р < .05) appear.

Conclusions

In conclusion, the study indicates that cultural differences influence both the IHLC and PHLC levels, and that Asian partici-pants are dominated by PHLC more than European respondents. Asian females are more likely to seek support from pow-erful others (PHLC) compared to European women, who perceive themselves as more independent. Asian male partici-pants are prepared to rely on powerful others (doctors or medical institutions), while European male respondents are prone to rely on themselves mainly (IHLC). The results show that sex differences do not significantly affect the health locus of control within the same cultural group.

Health locus of control in a pandemic situation: cross-cultural differences between European and Asian respondents

BACKGROUND

The present cross-cultural study examined the health locus of control construct during the COVID-19 pandemic. The scientific purpose of the study was to determine whether, during the pandemic situation, cultural and sex differences influence the health locus of control construct and change the internal health locus of control (IHLC), powerful others health locus of control (PHLC), and chance health locus of control (CHLC).

PARTICIPANTS AND PROCEDURE

A total of 2617 recipients aged 18-70 years from Asia (China, India, and Indonesia), and Europe (Bulgaria, Germany, and Hungary) completed a questionnaire about their health. The participants completed an online version of the Multidimensional Health Locus of Control Scale - Form A.

RESULTS

The survey shows that in a pandemic life-threatening situation, most individuals strive to rely on IHLC and/or PHLC, and fewer of them tend to rely on CHLC. However, there are differences (p < .001) between the two cultural samples: the representatives of Asian collectivistic culture are more dominated by PHLC, compared to the representatives of the European individualistic culture. When the comparison is between individuals from different cultures, sex differentiation affects the health locus of control, and as a result, significant differences in relation to IHLC, PHLC, and CHLC levels (p < .05) appear.

CONCLUSIONS

In conclusion, the study indicates that cultural differences influence both the IHLC and PHLC levels, and that Asian participants are dominated by PHLC more than European respondents. Asian females are more likely to seek support from powerful others (PHLC) compared to European women, who perceive themselves as more independent. Asian male participants are prepared to rely on powerful others (doctors or medical institutions), while European male respondents are prone to rely on themselves mainly (IHLC). The results show that sex differences do not significantly affect the health locus of control within the same cultural group.

Facing the pandemic lockdown questionnaire - FPLQ: A brief tool to assess individual differences in front of pandemic experience

This paper presents the development and the initial validation of a self-report questionnaire (the Facing the Pandemic Lockdown Questionnaire - FPLQ) focused on the way in which people faced the impact of the lockdown related to the Coronavirus Disease 19. 504 adults (81.55% females; M age = 32.71 years, SD = 11.19) took part to the study. Exploratory and confirmatory factor analyses revealed a 15-item 4-factor structure, invariant for gender and age: two dimensions related to maladaptive processes (i.e., "Perception of low social connectedness and lack of routines" and "Health worry") and two dimensions related to adaptive processes (i.e., "Positive re-thinking" and "Perception of online social connectedness"). Further, we investigated the associations between these dimensions and measures pertaining cognitive (i.e., internal and external health locus of control), emotional (i.e., positive and negative affect), and relational (i.e., attitude and behaviors toward civic engagement) processes, also testing the moderating role of gender and age. Finally, the potential usefulness of this new tool for both extant and future psychological research was highlighted.

Demographics, health literacy and health locus of control beliefs of Australian women who take complementary medicine products during pregnancy and breastfeeding: A cross-sectional, online, national survey

Background

Pregnant and breastfeeding women's use of complementary medicine products (CMPs) is common, and possibly associated with autonomous health care behaviours. However, the health literacy levels and health locus of control (HLOC) beliefs of women who use CMPs in pregnancy and lactation have not been previously assessed in a large Australian sample.

Aim

The aim of this study is to determine the health literacy levels and HLOC beliefs of women who use CMPs in pregnancy and lactation and determine the types of CMPs used.

Methods

A cross‐sectional, national, online survey of Australian pregnant or breastfeeding women aged 18 years and older, and currently using CMPs was conducted.

Results

A total of 810 completed surveys (354 pregnant and 456 breastfeeding women) were analysed. Most had adequate functional health literacy levels (93.3%). Health care practitioners (HCPs) HLOC mean scores were the highest for the sample, followed by Internal HLOC beliefs mean scores. Almost all (n = 809) took at least one dietary supplement, the most popular being pregnancy and breastfeeding multivitamins, iron supplements and probiotics. Use was generally in line with clinical recommendations, except for low rates of iodine supplementation. Herbal medicine use was lower for the total sample (57.3%, n = 464), but significantly higher (p < .0001) for the breastfeeding cohort, with consumers taking one to four herbal medicines each. The most popular herbs were raspberry leaf, ginger, peppermint and chamomile (pregnant respondents) and chamomile, ginger and fenugreek (breastfeeding respondents).

Conclusions

Respondents were health literate, with high scores for Internal and HCP HLOC scales, suggesting that they are likely to demonstrate self‐efficacy, positive health behaviours and work well in partnership with HCPs. HCPs can facilitate discussions with pregnant and breastfeeding women using CMPs, while considering women's health literacy levels, health beliefs and goals.

Seeking control during uncontrollable times: Control abilities and religiosity predict stress during COVID-19

The COVID-19 pandemic has created an urgent need to understand the protective factors that can buffer individuals against psychological distress. We employed a latent-variable approach to examine how control-related factors such as religiosity, self-control, cognitive control, and health locus of control can act as resilience resources during stressful periods. We found that cognitive control emerged as a protective factor against COVID-19-related stress, whereas religiosity predicted a heightened level of stress. These results provide novel insights into control factors that can safeguard individuals' psychological well-being during crises such as a pandemic.

Science Interest, Utility, Self-Efficacy, Identity, and Science Achievement Among High School Students: An Application of SEM Tree

The current study explored the associations between non–cognitive science-related variables, i.e., science interest, utility, self-efficacy, science identity, and science achievement in a serial mediation model. The study also further explored the potential heterogeneity in the model parameters using one of the data-mining techniques, which is the structural equation model (SEM) Tree. Data on 14,815 high school students were obtained from a large-scale database High School Longitudinal Study of 2009 (HSLS:09). The results highlighted science interest and science utility positively influencing science achievement through a sequential pathway of mediators, including science self-efficacy and science identity. The strength of direct effects considerably varied across students, resulting in classifying them into four subgroups. For instance, among females with a low SES subgroup, developing substantial science interest would result in better science self-efficacy and science identity that flourish science achievement. These valuable findings provide fruitful tailored recommendations, elevating the science achievement in the subgroups (146 words).

Psychological Variables Associated with HPV Vaccination Intent in Romanian Academic Settings

The aim of this study was to evaluate (1) the female medical students’ knowledge about HPV infection; (2) the associations between the HPV vaccination intent and coping strategies, health locus of control (HLOC), and sense of coherence; and (3) the specific differences between preclinical and clinical students in terms of the vaccination intent. Participants included 1243 female medicine students (mean age = 21.526, SD = 2.007), who completed The Multidimensional Health Locus of Control (MHLC)—Form A, the Brief COPE Scale, the Sense of Coherence Scale (SOC-13), and two questionnaires measuring the knowledge about the HPV infection and the HPV vaccination intent. Results show a good knowledge about HPV, which progressively increased during the study cycles. Still, the main contributors to vaccination intent are represented by coping strategies and health locus of control. Refusal of vaccination is associated to behavioral disengagement and the use of religion, precontemplation and contemplation to denial, and preparation to planning, positive reframing, and the powerful others component of HLOC. Sense of coherence did not predict vaccination intent. In clinical years, active coping outweighs HLOC in making the decision to get vaccinated. These results could be helpful in designing personalized strategies for addressing vaccine hesitancy in academic communities.

Stress, locus of control, hope and depression as determinants of quality of life of pregnant women: Croatian Islands' Birth Cohort Study (CRIBS)

The aims were to investigate determinants of the quality of life (QoL) of pregnant women. Total of 302 healthy women 18 to 28 weeks of gestation participated in prospective study. WHOQOL-bref, Multidimensional Health Locus of Control scales, Edinburgh Postnatal Depression Scale, and the perceived stress appraisals were administered. Various patterns of predictors for four domains of QoL were identified, for psychological (42% variance explained), social relationship (29%), environmental (29%) and physical health (25%). Depression and hope, together with the extent to which one's health is influenced by powerful other or chance should be targeted in health promotion strategies during pregnancy.

Visual Design Cues Impacting Food Choice: A Review and Future Research Agenda

This review aims to tackle the challenge of understanding how visual design cues can affect behavioural outcomes in a food context. The review answers two key questions: (1) What are the effects of the most important visual design cues on behavioural outcomes and how can they be explained? (2) What are the research gaps in this area? We start from a comprehensive taxonomy of visual design cues delineating the most important visual design cues. Next, we evaluate the extant research based on a structured, narrative literature review on visual design cues in the food domain. We differentiate between object processed and spatially processed visual design cues in food choice contexts and show how they affect behavioural outcomes through a range of psychological processes (attention, affective-, cognitive- and motivational reactions, food perceptions and attitudes). We end with recommendations which take into account the current food store context, the state-of-art in measuring psychological processes and behavioural outcomes and the specific food-, person- and context-related moderators. This review offers guidance for research to untangle the complexity of the effect of visual design cues in a food choice context.

Psychometric evaluation of the Multidimensional Health Locus of Control scales in English- and Spanish-speaking Hispanic Americans

The English and Spanish versions of the Multidimensional Health Locus of Control scales have not been psychometrically evaluated for use with Hispanic Americans. Hispanic American adults (N = 436) completed the English (n = 210) or Spanish (n = 226) Multidimensional Health Locus of Control scales. A multiple-group confirmatory factor analysis did not support equivalent four-factor structures for Spanish- and English-speaking Hispanic Americans. Follow-up exploratory factor analyses of the 24 items supported an 18-item, four-factor structure for English-speaking Hispanic Americans and a 22-item, three-factor structure for Spanish-speaking Hispanic Americans. These results suggest caution when using the Multidimensional Health Locus of Control scales with Hispanic Americans.

Disproportionate positive feedback facilitates sense of agency and performance for a reaching movement task with a virtual hand

This study investigated the generalized effects of positive feedback (PF) versus negative feedback (NF) during training on performance and sense of agency for a reach-to-touch task with a virtual hand. Virtual reality (VR) is increasingly employed for rehabilitation after neuromuscular traumas such as stroke and spinal cord injury. However, VR methods still need to be optimized for greater effectiveness and engagement to increase rates of clinical retention. In this study, we observed that training with disproportionate PF subsequently produced greater reaching performance (minimizing path length) and greater agency (perception of control) than with disproportionate NF. During PF training, there was also progressive increase in agency, but conversely a decrease in performance. Thus, the increase in performance after training may not be due to positively bolstered learning, but rather priming higher confidence reflected in greater agency. Agency was positively measured as compression in perceived time-intervals between the action of touch to a sound consequence, as standard with intentional binding paradigms. Positive feedback desirably increased agency (~180 msec) and reduced path length (1.8 cm) compared to negative feedback, which itself showed insignificant, or neutral, effects. Future investigations into optimizing virtual reality paradigms for neuromotor rehabilitation should consider agency as a driving factor for performance. These studies may serve to optimize how feedback is better presented with performance results for complex motor learning. Investigators should also ponder how personal characteristics, both cognitive and physical, may further affect sensitivity to feedback and the rate of neuromotor rehabilitation.

Multiple mediation effects of health locus of control and hope on the relationship between stroke patients’ social support and self-management

Objective

This study aimed to identify the mediation effects of health locus of control (HLC) and hope between stroke patients’ social support and self-management.

Methods

A cross-sectional study was conducted. A total of 300 Chinese stroke patients were recruited by convenient sampling from the acupuncture department of two Chinese Traditional Medical Hospitals in Tianjin Province from June to September 2018. The self-report questionnaires include Social Support Assessment Scale, Herth Hope Index, Mental Health Locus of Control Scale, Stroke Self-management Behavior Scale, and personal information questionnaires. All the survey data were entered in Excel and analyzed using the SPSS 24.0 program. Mediation was tested with Bootstrapping in AMOS 23.0 program.

Results

The result showed that internal health locus of control (IHLC), chance health locus of control (CHLC) and hope were the mediators between social support and self-management. The direct, indirect, and total effects of social support on self-management behavior were 0.306 P < 0.01), 0.109 (P < 0.01), and 0.415 (P < 0.01), respectively.

Conclusions

Social support can directly influence self-management, and it can also indirectly influence self-management through IHLC, CHLC, and hope.

Playing with fire. Understanding how experiencing a fire in an immersive virtual environment affects prevention behavior

A potentially effective way to influence people's fire prevention behavior is letting them experience a fire in an immersive virtual environment (IVE). We analyze the effects of experiencing a fire in an IVE (versus an information sheet) on psychological determinants of behavior-knowledge, vulnerability, severity, self-efficacy, and locus of control-based mainly on arguments from Protection Motivation Theory and the Health Belief Model. Crucial in our setup is that we also relate these determinants to actual prevention behavior. Results show that IVE has the hypothesized effects on vulnerability, severity, and self-efficacy, and an unexpected negative effect on knowledge. Only knowledge and vulnerability showed subsequent indirect effects on actual prevention behavior. There remains a direct positive effect of IVE on prevention behavior that cannot be explained by any of the determinants. Our results contradict the implicit assumption that an induced change in these psychological determinants by IVE, necessarily implies a change in behavior. A recommendation for research on the effects of IVE's is, whenever possible, to study the actual target behavior as well.

Environmental Exposures Such as Smoking and Low Vitamin D Are Predictive of Poor Outcome in Cutaneous Melanoma rather than Other Deprivation Measures

A lack of basic resources within a society (deprivation) is associated with increased cancer mortality, and this relationship has been described for melanoma. We have previously reported the association of smoking and low vitamin D levels with melanoma death. In this study, we further explored the associations of these with melanoma in addition to deprivation and socio-economic stressors. In this analysis of 2,183 population-ascertained primary cutaneous melanoma patients, clinical, demographic, and socio-economic variables were assessed as predictors of tumor thickness, melanoma death and overall death. Using the Townsend deprivation score, the most deprived group did not have thicker tumors compared to the least deprived. Of the World Health Organization 25x25 risk factors for premature death, smoking and body mass index (BMI) were independently associated with thicker tumors. Low vitamin D was also independently associated with thicker tumors. No socio-economic stressors were independent predictors of thickness. Smoking was confirmed as a key predictor of melanoma death and overall death, as were low vitamin D levels, independent of other measures of deprivation. Neither BMI nor the Townsend deprivation score were predictive in either survival analysis. We report evidence for the role of smoking, vitamin D, and BMI in melanoma progression independent of a postcode-derived measure of deprivation.

Relationships Among Self-perception of Aging, Physical Functioning, and Self-efficacy in Late Life

Objectives

The purpose of the current study was to examine the longitudinal relationship between 2 central concepts in the study of subjective well-being in old age-self-perception of aging (SPA) and physical functioning, and to assess the mediating role of self-efficacy beliefs in this relationship.

Methods

Interviews were conducted in the home with 1,216 randomly selected persons aged 75+ years (T1) and repeated with 892 of them 2 years later (T2). We collected data on SPA, physical functioning, self-efficacy, self-rated health, and demographics. Using SEM techniques, we examined cross-lagged autoregressive relationships between SPA and physical functioning and between SPA and self-efficacy, and the mediating effect of self-efficacy.

Results

Findings indicated that it was SPA that affected physical functioning and self-efficacy and not vice versa, while controlling for age, gender, education, economic status and self-rated health. Evaluation of a mediation model showed that self-efficacy fully mediated the longitudinal relationship between SPA-T1 and physical functioning -T2.

Discussion

Our results indicated a psychological pathway by which SPA affected physical functioning through self-efficacy. SPA also affected self-efficacy, which in turn probably motivated people to use effective coping patterns for maintaining their physical functioning.

Under-the-Mango-Tree: a theatre-based male EMTCT engagement intervention in post-conflict northern Uganda

Male involvement in human immunodeficiency virus (HIV) care cascades is identified as a critical prerequisite for the successful elimination of mother-to-child transfer of HIV. Scant evidence exists on efficacious culturally appropriate and male-inclusive elimination of mother-to-child transfer interventions. This reflection-in-action paper highlights field notes and observations of the development of Under-the- Mango-Tree, a theatre-based male-inclusive intervention pilot tested in northern Uganda. The intervention included: (a) traditional drama, dances and songs and (b) expert testimonies and group dialogue. Observations in this pilot showed that a theatre-based intervention was suitable for social persuasion; role modelling and moderating mastery of experience through effectively combining simple songs, dances and drama; testimonies of successful adherence by expert clients; and through reflective group discussions. These observations have implications for male-inclusive elimination of mother-to-child transfer intervention development.

Evaluating the Validity of the Risk Perception Survey for Developing Diabetes Scale in a Safety-Net Clinic Population of English and Spanish Speakers

PURPOSE

The purpose of this study is to examine the factor structure of the Risk Perception Survey for Developing Diabetes (RPS-DD) and test for factorial invariance by language (English, Spanish) and gender (males, females) in a clinically engaged, racially diverse, low-education population.

METHODS

Adult patients seen in a safety-net health system (N = 641) answered an interviewer-administered survey via telephone in their preferred language (English: 42%, Spanish: 58%). Three constructs in the RPS-DD were assessed-personal control (2 items for internal control and 2 for external control), optimistic bias (2 items), and worry (2 items). Single and multigroup confirmatory factor analyses (CFAs) were performed using maximum-likelihood estimation to determine the factor structure and test for invariance.

RESULTS

Contrary to previous psychometric analyses in white, educated populations, CFAs supported a 4-factor measurement model with internal and external control items loading onto separate factors. The 4-factor structure was equivalent between males and females. However, the structure varied by language, with the worry subscale items loading more strongly for English than Spanish speakers.

CONCLUSIONS

The RPS-DD can be used to investigate group differences across gender and language and to help understand if interventions have differential effects for subgroups at high risk for diabetes. Given the increasing prevalence of diabetes among Spanish speakers, researchers should continue to examine the psychometric properties of the RPS-DD, particularly the worry subscale, to improve its validity and clinical utility.

Agents of change among people living with HIV and their social networks: stepped-wedge randomised controlled trial of the NAMWEZA intervention in Dar es Salaam, Tanzania

INTRODUCTION

NAMWEZA is a novel intervention that focuses on preventing HIV and promoting sexual and reproductive health and rights by addressing underlying factors related to vulnerability of acquiring HIV, such as depression, intimate partner violence (IPV) and stigma. The goal of the study was to evaluate the effect of the NAMWEZA intervention on risk behaviour as well as factors potentially contributing to this vulnerability for people living with HIV and their network members.

METHODS

A stepped-wedge randomised controlled trial was conducted from November 2010 to January 2014 among people living with HIV and their network members in Dar es Salaam, Tanzania. 458 people living with HIV were randomised within age/sex-specific strata to participate in the NAMWEZA intervention at three points in time. In addition, 602 members of their social networks completed the baseline interview. Intention-to-treat analysis was performed, including primary outcomes of uptake of HIV services, self-efficacy, self-esteem, HIV risk behaviour and IPV.

RESULTS

For people living with HIV, a number of outcomes improved with the NAMWEZA intervention, including higher self-efficacy and related factors, as well as lower levels of depression and stigma. IPV reduced by 40% among women. Although reductions in HIV risk behaviour were not observed, an increase in access to HIV treatment was reported for network members (72% vs 94%, p=0.002).

CONCLUSION

These results demonstrate the complexity of behavioural interventions in reducing the vulnerability of acquiring HIV, since it is possible to observe a broad range of different outcomes. This study indicates the importance of formally evaluating interventions so that policymakers can build on evidence-based approaches to advance the effectiveness of HIV prevention interventions.

TRIAL REGISTRATION NUMBER

NCT01693458.

Relationship of Health Locus of Control with Breast Cancer Screening Belief of Iranian Women

Promoting breast cancer screening (BCS) behavior of women can lead to a reduction in mortality. The health locus of control affects cancer screening behavior of women; however, there is not sufficient evidence regaring this issue in Iran. The overall goal of our study is to determine the relationship of the health locus of control with the breast cancer screening belief of Iranian Women. This is a cross-sectional study carried out on 325 women in Tehran. The Multidimensional Health Locus of Control (MHLC), Breast Cancer Screening Belief Questionnaire (BCSBQ), and Demographic questionnaire were used for collecting data. Statistical analyze was performed by the SPSS version 17 software. The Pearson correlation and regression model were used for data analyze. In this study, 325 women, age 18 to 75 years, participated in this study. The mean±SD of BCSBQ and MHLC score was 40.72±10.41 and 67.78±17.67 respectively. The regression analysis showed that for the one-unit increase in the Internal Health Locus of Control (IHLC), Powerful others Health Locus of Control (PHLC), and Chance Health Locus of Control (CHLC) score (dimensions of Health Locus of Control), the total BCSBQ scores increased 0.54, 0.31, and 0.57 respectively. For each unit increase in age and education, the knowledge and perceptions of the BC score increased 0.05 and 0.23 units respectively. For the one-unit increase in the IHLC, PHLC, age, and education dimensions, the attitudes towards the general health check-up score increased 0.17, 0.1, 0.05, and 0.188 respectively. The current study provided new insights about the BCSB of Iranian women with MHLC. In the study, all the dimensions of the health locus of control were useful in predicting the breast cancer screening belief of the participants.

The data on health locus of control and its relationship with quality of life in HIV-positive patients

Locus of control is a concept defined based on social learning theory, and focuses on individuals' beliefs regarding factors that influence their health status. Health Locus of Control (HLC) and its relationship with Quality of Life (QOL) in HIV positive patients in local population were studied. This was a cross-sectional study on 80 HIV-positive patients. Multidimensional Health Locus of Control (MHLC) Scale and Medical Outcome Study Short-Form Health Survey (MOS-SF-36) used to measure patients' HLC and QOL, respectively. Internal, external, and chance HLC mean ± SD scores were 30.31±3.87, 24.17±5.03, and 32.01±4.49, respectively. Positive correlation was found between internal HLC scores and both physical (p <0.001, r = 0.53) and mental quality of life (p <0.001, r = 0.48). Multiple regression analysis showed that internal HLC was the only significant predictor of quality of life. HIV-positive patients who believe their health is mostly influenced by individual's actions and behaviors (internal HLC) showed a higher quality of life. These findings suggest that modifying health locus of control beliefs, hypothetically could influence patients' quality of life.

Psychometric Properties of the God Locus of Health Control Scale in Churchgoing Latinas

This study evaluated the psychometric properties of the Spanish version of the God Locus of Health Control scale, a measure of the extent to which an individual believes God has control over one's health, among a sample of churchgoing Latinas (N = 398). Confirmatory factor analysis showed support for a one-factor structure and internal consistency reliability, as measured by Cronbach's coefficient alpha, was good. Evidence for convergent validity was demonstrated by significant correlations in the expected magnitudes and directions with two measures of perceived religious involvement in health. These results suggest that the God Locus of Health Control scale can be used to examine the extent to which God is perceived to control an individual's health among Latinas.

Effects of Different Types of Virtual Reality Display on Presence and Learning in a Safety Training Scenario

The increasing availability of head-mounted displays (HMDs) for home use motivates the study of the possible effects that adopting this new hardware might have on users. Moreover, while the impact of display type has been studied for different kinds of tasks, it has been scarcely explored in procedural training. Our study considered three different types of displays used by participants for training in aviation safety procedures with a serious game. The three displays were respectively representative of: (i) desktop VR (a standard desktop monitor), (ii) many setups for immersive VR used in the literature (an HMD with narrow field of view and a 3-DOF tracker), and (iii) new setups for immersive home VR (an HMD with wide field of view and 6-DOF tracker). We assessed effects on knowledge gain, and different self-reported measures (self-efficacy, engagement, presence). Unlike previous studies of display type that measured effects only immediately after the VR experience, we considered also a longer time span (2 weeks). Results indicated that the display type played a significant role in engagement and presence. The training benefits (increased knowledge and self-efficacy) were instead obtained, and maintained at two weeks, regardless of the display used. The paper discusses the implications of these results.

Health locus of control: Its relationship with medication adherence and medication wastage

BACKGROUND

Non-adherence is a significant factor contributing to medication wastage. Whilst there is some evidence on the influence of patients' health locus of control in relation to adherence, there has been little inquiry into its relationship with mediation wastage.

OBJECTIVES

To determine the relationship between medication adherence and health locus of control as well as medication wastage and health locus of control in patients with chronic conditions.

METHODS

Outpatients having a diagnosis of asthma, cardiovascular conditions, or diabetes participated in a cross-sectional study employing a self-administered questionnaire. The questionnaire determined presence of unused medication (wastage), adherence using 'Tool for Adherence Behaviour Screening' (TABS), and health locus of control using 'Multidimensional Health Locus of Control' (MHLC) scale Form C. Logistic regression was performed to ascertain the effects of MHLC and demographics in relation to adherence and wastage. MHLC beliefs were divided into 8 types of health locus of control. One-Way ANOVA was used to assess differences between conditions and belief types. P-values ≤ .05 were considered significant.

RESULTS

There were 330 patients recruited (58% male; age, mean±(SD): 61 ± 15 years; 110 asthma, 110 cardiovascular, 110 diabetes). In terms of health locus of control, females had higher 'doctors' beliefs (p = .054) and significantly lower 'other people' beliefs (p = < .0005). Lower 'chance' beliefs (p = .016) were associated with adherence. Lower 'doctors' beliefs and higher 'other people' beliefs were significantly associated with wastage (p = < .0005). There was a significant difference in adherence (p = < .0005) and in wastage (p = .002) between the eight types of health control. 'Yea-sayers' had the least presence of unused medication, followed by 'pure internal' believers. 'Pure powerful others external' had the highest presence of unused medication.

CONCLUSIONS

Healthcare professionals should take into account patients' health locus of control beliefs whilst conducting an intervention with patients; this can impact positively medication adherence and minimisation of medication wastage.

Anxiety, locus of control and sociodemographic factors associated with adherence to an annual clinical skin monitoring: a cross-sectional survey among 1000 high-risk French patients involved in a pilot-targeted screening programme for melanoma

OBJECTIVE

The aim of the study was to assess whether adherence to annual clinical skin monitoring is dependent on patient sociodemographic characteristics or personality traits.

DESIGN

The study was a questionnaire survey.

SETTING AND PARTICIPANTS

Data were collected between February and April 2013 in a sample of 1000 patients at high risk of melanoma who participated in a pilot-targeted screening programme in western France.

OUTCOME MEASURES

Sociodemographic data, overall anxiety level (State-Trait Anxiety Inventory questionnaire), locus of control (Multidimensional Health Locus of Control scale) and levels of anxiety specifically associated with screening and melanoma were collected. Actual participation in the skin monitoring examination was reported by 78 general practitioner investigators.

STATISTICAL ANALYSIS

Statistical analysis was performed using R statistical software. Factors associated with non-adherence were identified by multivariate analysis.

RESULTS

Our analysis included 687 responses (526 adherent patients and 161 non-adherent patients). Non-adherence was higher in younger patients and in men (OR=0.63 (0.41-0.99)). Viewing health status as dependent on external persons (OR=0.90, 95% CI 0.83 to 0.97) or determined by chance (OR=0.89, 95% CI 0.80 to 0.98) and overall anxiety (OR=0.98, 95% CI 0.97 to 0.99) were also factors associated with non-adherence. In contrast, there was no link between anxiety specifically associated with the screening performed or melanoma and patient adherence to monitoring. Adherence was higher in married patients (OR=1.68 95% CI 1.08 to 2.60).

CONCLUSIONS

The results of this study suggest that sociodemographic and psychological characteristics should be considered when including patients at elevated risk of melanoma in a targeted screening programme.

TRIAL REGISTRATION NUMBER

NCT01610531; Post-results.

The health locus of control concept: Factorial structure, psychometric properties and form equivalence of the Multidimensional Health Locus of Control scales

Contradictory evidence exists on the Multidimensional Health Locus of Control scale’s factor structure and the psychometric equivalence between Form A and Form B. University students (N = 359) completed the Multidimensional Health Locus of Control and General Self-Efficacy scales. The three-factor model had better fit and parsimony in both Forms. ‘Internal’ scale negatively correlated with ‘chance’ but positively with ‘others’. The two external scales positively correlated. The scales’ reliability was satisfactory, but the two Forms were not psychometrically equivalent. Convergent validity was confirmed. The evidence suggests a three-factor structure and psychometric non-equivalence of the two Forms. Researchers should make an informed choice on which Form to use.

Self concepts, health locus of control and cognitive functioning associated with health-promoting lifestyles in schizophrenia

PURPOSE

The study aimed to investigate the relationship among self concepts, health locus of control, cognitive functioning and health-promoting lifestyles in patients diagnosed with schizophrenia. We examined health-promoting lifestyles through self-efficacy, self-esteem, health locus of control and neurocognitive factors.

METHOD

Fifty-six people with schizophrenia were enrolled in the study group. All subjects participated in the self-esteem (Rosenberg Self-Esteem Scale), self-efficacy (General Self-Efficacy Scale), health locus of control (The Multidimensional Health Locus of Control Scales), health-promoting lifestyles (Health Promotion Life-style Profile-II) and a series of neurocognitive measures.

FINDINGS

Stepwise regression analysis revealed that self-efficacy, internal health locus of control and attentional set-shifting accounted for 42% of the variance in total health-promoting lifestyles scores. Self-efficacy, self-esteem, internal and powerful others health locus of control and attentional set-shifting were significant predictors for domains of health-promoting lifestyles, respectively.

CONCLUSION

Study findings can help mental health professionals maintain and improve health-promoting behaviors through a better understanding of self-esteem, self-efficacy, health locus of control and neurocognitive functioning among people with schizophrenia.

Follow-up over 20 months confirms gains of online behavioural training in frequent episodic migraine

Aim This study examined the change over 20 months in 178 participants with frequent episodic migraine under adequate treatment as usual, who had completed online behavioural training (oBT) in migraine self-management either directly (group 1, n = 120) or after 10 months of watchful waiting (group 2, n = 58). Methods Participants completed questionnaires and an online headache diary and migraine monitor following the International Classification of Headache Disorders at T0 (baseline), T1 (post-training), T2 (6-month follow-up; extended baseline in group 2), T3 (post-training, group 2 only) and T4 (group 1: 16-month follow-up; group 2: 6-month follow-up). Statistical analyses were conducted on the observed data without imputation of missing observations. Results Both groups were highly comparable. The data over time revealed benefits in response to oBT, with significant between-group differences in the change achieved in the training episodes T2-T0 (group 1) and T4-T2 (group 2). Improved attack frequency ( M = -23%) was higher in participants with more (i.e. 4-6) attacks per month at baseline, and the effects of oBT were durable over 16 months of follow-up. Conclusions oBT is beneficial in frequent episodic migraine, which deserves special efforts in care. Self-management variants such as oBT reach patients easily and supplement these efforts with durable results.

The Validity of the Multidimensional Health Locus of Control Scales

This introductory article addresses the question,‘Are the Multidimensional Health Locus of Control (MHLC) scales valid?’ The initial evidence for the validity of the family of MHLC scales is reviewed, followed by a discussion of the empirical evidence for the hypothesis linking MHLC scale scores to measures of health behavior. There is ample evidence in the literature that the MHLC scales validly assess health locus of control beliefs. Nevertheless, caution should be used when making generalizations regarding the validity of the MHLC scales to new theoretical or situational contexts. The theoretical relationships between these beliefs and other constructs are complex, making it necessary to thoughtfully consider the valid application of the MHLC scales in each new study.

Psychometric properties of Multidimensional Health Locus of Control - A and General Self-Efficacy Scale in civil servants: ELSA-Brasil Musculoskeletal Study (ELSA-Brasil MSK)

Background

Health-related control and self-efficacy beliefs can be assessed in the general population using Multidimensional Health Locus of Control-A subscales (MHLC-A) and the General Self-Efficacy Scale (GSES), respectively.

Objective

To test construct validity, internal consistency, reliability (test-retest) and ceiling and floor effects of Portuguese-Brazil versions of MHLC-A and GSES.

Method

Civil servants (N=2901) enrolled in a large Brazilian cohort were included. A new version of the GSES was produced (GSES-Brazil). Procedures for cross-cultural adaptation and testing of psychometric properties followed well-accepted international guidelines.

Results

Confirmatory factor analyses yielded the following indices: MHLC-A (tridimensional model): χ²[df]=223.45[132], p-value <0.01; CFI=0.87; TLI=0.85; RMSEA=0.07 (0.07-0.08); WRMR=3.00. GSES-Brazil (unidimensional model): χ²[df]=788.60[35], p-value <0.01; CFI=0.95; TLI=0.94; RMSEA=0.09 (0.08-0.09); WRMR=2.50. Cronbach’s alpha coefficients and Intraclass Correlation Coefficients (ICC_2,1) ranged from 0.57 (0.54-0.59) and 0.57 (0.47-0.65) for MHLC-A internality to 0.80 (0.79-0.81) and 0.71 (0.66-0.77) for GSES-Brazil, respectively. There was no evidence of ceiling and floor effects. Convergent validity analyses provided further support for construct validity of both scales.

Conclusion

These findings support the use of the newly developed version of GSES-Brazil for the assessment of general self-efficacy of adult Brazilians. Internal consistency was lower than ideal for MHLC-A, indicating these subscales may need further refinements to provide a more psychometrically sound measure of control beliefs.

Modified social learning theory re-examined: correlates of self-management behaviors of persons with Type 2 diabetes

Modified social learning theory (MSLT) applied to health predicts that health behavior is a multiplicative function of health value and perceptions of control over health. The self-management behaviors of persons with Type 2 diabetes mellitus, internal diabetes locus of control (IDLC), diabetes self-efficacy (DSE), and health value (HV) were assessed with an index of diabetes self-care activities in 107 patients receiving insulin. Multiple regression analysis showed DSE as the only MSLT construct that correlated with the index of diabetes self-care behaviors (β = .21, p < .05). While the predicted three-way interaction of IDLC × DSE × HV was significant (∆R² = 4.5 %, p < .05) in the final step of the hierarchical model, the pattern of the findings only partially supported MSLT. Instead of finding that patients who were simultaneously high on all three predictors scored highest on the behavioral index, we found that patients who were low on all three constructs reported the least amount of diabetes self-care behavior. Implications for further modification of MSLT and its applications to clinical practice are discussed.

Relationships among depression during pregnancy, social support and health locus of control among Iranian pregnant women

BACKGROUND

Prenatal depression is a significant predictor of postpartum depression and is detrimental to fetal development.

AIM

To examine whether depression during pregnancy is associated with social support and health locus of control (HLC).

METHOD

Data were collected from a sample of 208 Iranian pregnant women using a demographic questionnaire, the Edinburgh Postnatal Depression Scale, the multidimensional HLC Scale and the social support appraisals.

RESULTS

Depression was experienced by 37% of participants. Overall, women reported higher level of family support (6.88 ± 1.15) than other supports (6.87 ± 1.29). Protective supports from other resources (6.87 ± 1.29) were higher than those from friends (5.94 ± 1.5). Internal, powerful others and chance beliefs had the highest mean scores. Social support and chance HLC significantly influenced the proposed mediator (depressive mood) in the linear regression model. Bivariate analysis showed significant associations between social support (friend, family and others) and depressive mood. Internal HLC had a significant association with social support and powerful others HLC. However, Pearson correlation coefficient was not significant between depressive mood and all dimensions of HLC.

CONCLUSION

Clinicians could assess social support and chance HLC to identify and treat women at risk of prenatal depression. By providing support during pregnancy, depression levels in women and its effects on the fetus may be decreased, which could prevent postpartum depression.

Confirmatory factor analysis and invariance testing between Blacks and Whites of the Multidimensional Health Locus of Control scale

The factor structure of the Multidimensional Health Locus of Control scale remains in question. Additionally, research on health belief differences between Black and White respondents suggests that the Multidimensional Health Locus of Control scale may not be invariant. We reviewed the literature regarding the latent variable structure of the Multidimensional Health Locus of Control scale, used confirmatory factor analysis to confirm the three-factor structure of the Multidimensional Health Locus of Control, and analyzed between-group differences in the Multidimensional Health Locus of Control structure and means across Black and White respondents. Our results indicate differences in means and structure, indicating more research is needed to inform decisions regarding whether and how to deploy the Multidimensional Health Locus of Control appropriately.

A Qualitative Study into Egyptian Patients' Satisfaction with Physiotherapy Management of Low Back Pain

BACKGROUND AND PURPOSE

There is strong evidence suggesting that patient satisfaction may improve therapy outcomes independent of the treatment given. Thus the aim of this study is to explore Egyptian patients' expectations and satisfaction with physical therapy management of low back pain.

METHODS

A qualitative study design involving two focus groups and 10 semi-structured interviews; all discussions were audio recorded, transcribed verbatim and analysed using a Framework analysis approach.

RESULTS

The five final themes were about outcome of the treatment episode, the therapist characteristics, their ability to provide patient education, the service provision and involvement in the decision-making process.

CONCLUSION

The therapeutic encounter between patients and therapists in an episode of back care is complex and reflects the multidimensional nature of patient satisfaction. Participants had several criteria according to which they evaluated the quality of care and were able to determine when these criteria were met or not during physiotherapy. Copyright © 2015 John Wiley & Sons, Ltd.

Health locus of control in Indonesian women with breast cancer: a comparison with healthy women

The aims of this study were to assess whether Indonesian women with breast cancer havea higher external health locus of control (HLC) than healthy women, and to explore the association between HLC and symptoms of anxiety and depression. In this study, 120 consecutive women with breast cancer were recruited at the outpatient surgical oncology clinic at the Hasan Sadikin Hospital in Bandung. One hundred and twenty two healthy women were recruited from the Bandung area as controls. A standard demographic form, Form C of the Multidimensional Health Locus of Control, as well as the Hospital Anxiety and Depression Scale and patients' medical records were used. Data were analyzed using descriptive statistics, t-test, Pearson's correlation, MANOVA and multiple linear regressions. Women with breast cancer had higher scores on all external HLC subscales, i.e. chance, doctor, powerful others and God, and lower internal HLC compared to healthy women. High God LHC scores were associated with a high level of anxiety (β=0.21, p<0.05), whereas none of the HLC subscales were associated with depression. Our results suggest that women with breast cancer tend to have high external HLC, while healthy women tend to have high internal HLC. A strong belief in an external source of control, i.e. God, might be negatively associated with patient emotional adjustment. Further research is needed to give an insight into the direction of this association.

Predictors of health behavior change after an integrative medicine inpatient program

BACKGROUND

Health behavior change can improve physical and psychosocial outcomes in internal medicine patients.Purpose This study aims to identify predictors for health behavior change after an integrative medicine inpatient program.

METHOD

German internal medicine patients' (N =2,486; 80 %female; 53.9±14.3 years) practice frequency for aerobic exercise(e.g., walking, running, cycling, swimming), meditative movement therapies (e.g., yoga, tai ji, qigong), and relaxation techniques(e.g., progressive relaxation, mindfulness meditation,breathing exercises, guided imagery) was assessed at admission to a 14-day integrative medicine inpatient program, and 3, 6, and 12 months after discharge. Health behavior change was regressed to exercise self-efficacy, stage of change, and health locus of control (internal, external-social, external-fatalistic).

RESULTS

Short-term increases in practice frequency were found for aerobic exercise: short- and long-term increases for meditative movement therapies and relaxation techniques (all p <0.01). After controlling for sociodemographic characteristics,clinical characteristics, and health status, exercise self-efficacy or interactions of exercise self-efficacy with stage of change predicted increased practice frequency of aerobic exercise at 6 months; of meditative movement therapies at 3 and 6 months; and of relaxation techniques at 3, 6, and 12 months (all p <0.05). Health locus of control predicted increased practice frequency of aerobic exercise at 3 months and of relaxation techniques at 3, 6, and 12 months (all p <0.05).

CONCLUSION

Health behavior change after an integrative medicine inpatient program was predicted by self-efficacy,stage of change, and health locus of control.Considering these aspects might improve adherence to health-promoting behavior after lifestyle modification programs.