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A study of the relationships between "the role of coping strategies and coping efficiency" and "the locus of control" in experiencing mammography pain.


"Breast cancer" is one of the most vital health problems of the world. Among diseases, cancer is the second cause of death (after cardiac diseases). More than 200 types of cancer have been known so far, among which Breast Cancer is the most prevalent one [6]. Mammography is the radiography of breasts to find out any changes in those females without any breast cancer symptoms. It was one of the first medical equipment to study breast changes and is nowadays one of the most accurate methods to find out breast cancer in initial stages. Mammography is recommended to all females above 40 and is significantly capable of decreasing the risks of death caused by this cancer [14,5,42,45].

Kashikar, et al. [24] tried to explain mammography pain through psychological explanations. They studied the role of "coping strategies" and understanding "coping efficacy" in mammography pain by means of a 125-sample of 50 year of age and above. Results of their statistical analysis showed that those who describe their abilities in decreasing the pain using coping strategies as "weak", generally experience more intense pains than those who describe their abilities to decrease routine pains as "higher".

Previous researches have shown that the methods or strategies one applies to cope with stressful situations play a basic role in mental and physical health; therefore, "coping strategies" are conscious methods one applies when facing stressful situations" [10]. Coping strategies can be assessed in terms of hidden and visible behaviors. Visible coping strategies (behavioral) include resting, medicine taking, relaxation, etc. while hidden strategies (cognitive) include diverting the attention from pain, self-assurance in decreasing pain, searching for information related to pain, and problem-solving. It seems that coping strategies applied to both changing the perception of pain intensity and changing the ability to control or tolerate pain and continuing routines [46].

Based on previous researches, different coping strategies among people is the result of social and psychological factors which are mediating stressing factors on an individual. In this case, researchers have remarkably considered the factor of "Locus Control" [12,29,39,13,30,35,41].

Concept of locus of control is a personality trait at first introduced by Rotter [41] in line with the theory of social learning. He defines the locus of control as one's general expectation of the results of an event existing either in or out of her control or personal perception. On one hand, those with personality characteristic of external locus of control perceive events away from their control and ascribe the event results to chance, luck or under the control of other powerful individuals or even considering the events as not predictable due to many complexities. On the other hand, those involved with internal locus of control believe that the events depend on their relatively permanent behaviors and characteristics; some, too, believe that they can influence the results through their rewards, abilities, skills and characteristics.

Lazarus and Folkman reason that since those with internal locus of control believe they can control the results of the events, they most likely apply active coping strategies in comparison to those with external locus of control [28]. In this line, Carver et al. delineated a positive relationship between active coping and internal locus of control [9]. Blanchard-Fields and Iron, found a positive relationship between avoidant coping (i.e. coping based on avoidance) and the external locus of control [7].

Other studies showed that those with internal locus of control can cope or adapt the stressful events better than those with external locus of control [4]. Some studies state that, in adapting and coping with stress and diseases, an internal locus of control is a better predictor compared to the external one [31,21].

Asghari [2] concluded that active coping strategies (i.e. trying to do something during the pain, ignoring the pain, or diverting attention from the pain and dealing with special activities) have adaptive results while passive coping strategies (depending or relying on others for help to control the pain, limiting the activities, and applying disaster-making coping strategies) are related to pain intensity. Special beliefs may lead to maladaptive coping strategies, the increase in suffering [1], avoidant pain behaviors [2], and pain intensity [46].

The present research aims to study the relationship between "the role of coping strategies and coping efficiency" and "locus of control" in experiencing mammography pain.


Rotter's locus of control scale (internal-external):

This questionnaire is prepared in order to assess peoples' expectations about the locus of control, and includes 29 items each with two choices (A-B). The individuals were asked to choose one of the two in each item. It is clear that such selection is based on the person's profound and vivid reliance.

Rotter designed 23 of the items specially to clarify peoples' expectations about locus of control while the other 6 items (1, 8, 14, 19, 24, and 28) are neutral and make the calculated structure and dimension ambiguous for the testee (i.e. they draw away the testee from the main point and goal of the test).

Scoring the testee is done by summing up the number of crosses she has put in front of the questions. The score is obtained just by summing up those 23 articles and the total score of each testee shows her degree of control. The average was 8.48 and the mean was 8.

In these 23 items of scoring, "A" questions score 1 and "B" questions score 0. Since the total score of an individual shows the type and degree of her locus of control, those with score 9 or above have "external" and those with scores below 9 have "internal" locus of control.

-- Visual analogue scale: it is a direct line of 100mm long, on either ends of which written the terms "no pain" and "most possible intense pain". The testee was asked to put a point on the line to show her pain intensity during mammography. Different studies verified Psychometric properties (validity, reliability, and sensitivity against therapeutic effects) of this scale [47,21,38]. This scale is applied in mammography studies in which numbers equal to or less than 2mm are reported as "no pain", more than 2mm up to 40mm as "mild pain", between 40-70mm as "medium pain", and more than 70mm as "intense pain" [27,24]. On this scale, the testee's score is variable from 0 to 100 [2].

-- Numerical rating scale: it is a direct line on either end of which is written the numbers 0 and 10by which the line is divided into 11 equal parts. "No pain" is written under the 0 and "most-possible intense pain" under 10.The testee was asked to specify her pain intensity by choosing a number within this range. Validity, reliability and sensitivity of this scale are verified against therapeutic effects [23]. Kornguth, [27] Kashikar-zuck et al., [24] applied this scale to mammography and reported numbers less than 1 as "no pain", between 1-4 as "mild pain", between 4-7 as "medium pain" and those more than 7 as "intense pain". In the present study, these 11 parts were used and the testee's score was variable from 0 to 10 [2].

-- Pain rating scale: all female individuals who participated in the study were asked to report the pain rate they had experienced during mammography by means of this scale which has been applied in various mammography studies [25] It includes 6 descriptors of which the testee ought to choose one that she clearly experienced during mammography. The descriptors include: "very comfortable", "comfortable", "a bit suffered", "suffered but tolerable", "suffered and intolerable" and "painful and intolerable". This scale is not capable of presenting accurate assessment of the pain due to a combination of the two groups of descriptors (pain and suffering) in one form and also asking the testee to choose only one choice. However, it was decided to use this scale in order to compare the results of this study with those of previous ones.

-- Situation coping strategies: post to mammography, all females rated the frequency of strategies they used for coping with the mammography pain and their perception about the coping efficiency by means of the questionnaire of situation coping strategies. This questionnaire is adopted from the Iranian version of "questionnaire of coping strategies" and is adjusted to apply to the present study [2]. The "questionnaire of coping strategies" [40] was made to assess the frequency of strategies people apply for coping with pain. This questionnaire assesses the 6 cognitive coping strategies (diverting attention, pain reinterpretation, self-talking, pain ignoring, disaster making, and pray/hope) and one behavioral coping strategy (behavioral activity increase) by means of 42 statements. Each coping strategy includes 6 statements and on a7-degree scale (0-6),the testee has to specify up to what extent she uses that strategy against pain. This questionnaire also asked the testees to specify that up to what extent they were capable of decreasing or tolerating their pain by the strategies they applied against the pain. The "intra-class correlation coefficient" of the 7 subscales in this questionnaire was reported between 0.71 and 0.85 [40]. The "concurrent validity" and "intra-class correlation coefficient" of this questionnaire in a research including 154 Iranian patients suffering from chronic pain was verified [1]. In the present study, the intra-class correlation coefficient of the 7 subscales in the questionnaire was variable between 0.71 and 0.83 and since the least acceptable intra-class correlation coefficient is 0.70 [34], the Iranian version of the "questionnaire of coping strategies" has an acceptable intra-class correlation coefficient. Providing a questionnaire to assess the frequency of mammography coping strategies, two changes were made in the questionnaire of coping strategies [1], namely: 1-behavioral coping strategy (activities like walking, going to another place, joining others and doing something) were omitted from the questionnaire since applying such items is not possible during mammography. 2-Restatement of the method of expression or the test situations adjusted e.g. "not paying attention to pain" instead of "I divert my attention while feeling pain". Then, the questionnaire was applied in a sample of 50 females referring to mammography in a preliminary study. The results of this preliminary study showed the possibility of such a questionnaire. Therefore, the questionnaire of situation coping strategies assesses 6 cognitive strategies against mammography pain through 36 items; by means of a 7 degree scale (0-6) the testees specified that up to what extent they use each one of the strategies to cope with mammography pain. Also, at the end of the questionnaire, the testee's perception about the coping efficiency in decreasing pain as well as the rate of the controlling felt on the pain due to applied strategies were assessed [1].

-- Tending to do another mammography: after finishing the mammography, all the testees were asked wether they had a tendency to do the next mammography or not.


Characteristics of the testees:

Most of those participated in the study were married, Persian, housewife, with the average age of 47.43 (sd = 8.86). About 58% of the participants reported their education level diploma or higher. 35% of them did mammography at least once previously, and a significant percentage of them (46.9%) mentioned doing the mammography by a physician's recommendation.

* Psychometric characteristics of coping strategies questionnaire. Table 1 summarizes intra-class correlation coefficient of 6 studied coping strategies. Obtained Cronbach's Alpha coefficients are variable between 67% and 86% and thus can be considered acceptable [34].

Table 3 delineates the frequency and percentage of the type of locus of control for the studied sample. As shown here, most of the testees had external locus of control (120 individuals or 80%). Moreover, there were 30 individuals (20%) among all the testees who had internal locus of control.

Note: testees who got 9 or more in scoring have internal locus of control and those with scores less than that have external locus of control.

As shown in the above Table, the average of using the subscales were as follows:

"Self-talking" 16.13 (SD = 11.77), "hope" 16.05 (SD = 9.07), "ignoring pain" 12.56 (SD = 10.24), "attention diverting" 7.71 (SD = 8.85), "pain reinterpretation" 7.49 (SD = 8.57) and "disaster making" 4.49 (SD = 5.86).

Average of pain control scale is 4.22 (SD = 1.78), of pain reduction scale is 3.78 (SD = 1.94) and of locus of control (internal-external) is 10.57 (SD = 2.691).

Obtained statistical indicators in the above Table were calculated by Coping Strategies Questionnaire (CSQ) for the first 8 scales and by Rotter's questionnaire of locus of control for the last one.

As shown in the above table, those who had external locus of control reported more pain intensity in VAS which means there was a significant relationship just between the type of locus of control and VAS (in alpha level = 0.05). However, there was not any significant relationship between the type of locus of control, NRS, and the coping strategies subscales.

Of course, it is noteworthy that since VAS is a relative measuring scale, it clarifies the difference between internal and external locus of control during mammography pain. Therefore, the more accurate the applied scales in measuring pain are, the more significant the relationships become.

As shown in the above table, the correlation coefficient between the assessed pain intensity by VAS and the locus of control in level p = 0.03 was significant. Positive direction of the correlation (r = 0.19) delineated that the higher one's score is in locus of control scale, the more pain she experiences. Since higher scores in locus of control scale shows external locus of control, it can be concluded that there is a positive and significant relationship between pain intensity and external locus of control.

As shown in the calculations, the above table delineated that those who apply "disaster making" and "self-talking" coping strategies more, tend to report more pain of mammography. There was not a significant relationship between other subscales i.e. "attention diverting", "pain ignoring", "hope", "pain reinterpretation", and "pain intensity during mammography".

As shown in the above table, there is significant difference between 5 classified groups of participants' feelings during mammography ("very comfortable", "comfortable", "a bit suffered", "suffered but tolerable", "suffered and intolerable" and "painful and intolerable") in the three variables "self-talking", "pain intensity assessed by NRS" and "pain intensity assessed by VAS". Regarding the variable "self-talking", Scheffe test results show that the second group (comfortable) was significantly different from the fifth group (suffered but tolerable) which, by itself, connotes that the members of the fifth group would use self-talking mechanisms more significantly than the second group.

About the NRS variable, Scheffe test results showed that the members of the first group (very comfortable), the second group (comfortable), and the third group (a bit suffered)reported less pain than the fifth group (suffered but tolerable) and the forth group (suffered but tolerable).

About the VAS variable, Scheffe test results delineated that the members of the first group (very comfortable) felt less pain than the third group (a bit suffered); also members of the first and the second groups felt less pain than the fifth group; moreover, the members of the first, the second, and the third groups felt less pain than the forth one.


The present study was conducted in order to specify the differences between individuals of internal and external locus of control from the viewpoint of coping strategies during mammography pain. The results delineated that those individuals with more external control used more maladaptive coping strategies during mammography pain and reported more pain; the results were in line with those of the Hahn [19], Anderson [3], Carver, Scheier and weintraub [9], Blanchard--Fields, and Irion [7]. These researchers have mainly found out that individuals with internal locus of control have high usage of active coping strategies than those with external locus of control.

Results of multivariable regression analysis showed that using more of the two coping strategies "attention diverting" and "pain ignoring" and also using less of "disaster making" and "self-talking" can lead to a decrease in pain (i.e. a milder pain) during mammography; these findings were in line with those of the previous studies [27,24,2,42].

Based on the findings by this study, applying the two coping strategies "attention diverting" and "pain ignoring" during mammography can lead to milder pain and it showed that these two strategies were adaptive in facing such experimental pains like mammography. In another study including a sample of Iranian women, the adaptive role of the coping strategy "pain ignoring" was verified [2].

Moreover, the adaptive role of the mentioned strategy in previous studies include Rheumatoid patients confirmed [37,20]. The results of the present study also showed that more usage of the coping strategy of "self-talking" during mammography can lead to feeling of more pain; similar results also repeated in several other studies (mammography pain, Asghri and Nicholas [2]; electromyography pain, Buckelew and et al., [8]; chronic pain; Gustafsson and et al., [18]; Rosenstiel and Keef; [40] proved the non-adaptive role of "self-talking" while facing the pain. In addition to what mentioned earlier, the present study showed that applying "disaster making" strategy during mammography pain can lead to more intense pain. On the other hand, those females dependant on "disaster making" strategy during mammography reported more intense pain. In line with the results obtained from the patients of chronic pain [26,16,43] and also the studies conducted by healthy individuals in test pain studies [44], the results of the present study delineated that "disaster making" is a maladaptive coping strategy and its applying is a risky factor to adapt to chronic and acute pains [44].

* The results of the present study include vital clinical applications. If it is possible to plan educational interferences and to ask the individuals to use "attention diverting" (thinking of enjoyable issues, counting some numbers, saying something in mind, not thinking of the pain, ignoring the pain, and "concentrating on and continuing the test") strategies more during mammography and to avoid applying strategies like "self-talking" (e.g. assuming the pain as a challenge) and "disaster making" (e.g. assuming the pain horrible, frightening, worrying, feeling of defeat and intolerance), then it can be expected that they may end mammography with less pain. Some of the primary research evidences support this interfering plan [2].

* Applied cognitive-behavioral interferences in many studies could reduce the pain intensity [25] and these programs may help potentially reduce the pain in women intending to do mammography.

* As conclusion, pain is a common and usual phenomenon among individuals doing mammography. This study showed that applying some of the coping strategies while facing mammography pain could explain some part of the mammography pain. Consequently, it is possible to help reduce such pain through planning and applying appropriate interfering-cognitive methods.


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(1) Masume Azizi and (2) Zahra Bisadi

(1) University of Zabol

(2) MSc Graduated at Allameh Tabataba'i University

Masume Azizi and Zahra Bisadi; A study of the relationships between "the role of coping strategies and coping efficiency" and "the locus of control" in experiencing mammography pain

Corresponding Author

Masume Azizi, University of Zabol
Table 1: Intraclass correlation coefficient of 6 coping strategies.

Indicators/              Statements   Alpha         N
Strategy                 No.          Coefficient

Self-talking             6            86%           150
Attention-diverting      6            82%           150
Pain reinterpretation    6            80%           150
Pain Ignoring            6            79%           150
Hope                     6            73%           150
Disaster-making          6            67%           150

Table 2: Cronbach's alpha coefficient for
locus of control.

Indicators/   Questions   N     Cronbach's
Strategy      No.               alpha

Locus of      23          150   37%

The above Table delineated that "locus of
control" with Cronbach's alpha coefficient
of 37% has weak Cronbach's alpha coefficient.

Table 3: Frequency and percentage of
type of locus of control.

Indicators/   Frequency   Percentage
Locus of

Internal      30          20
External      120         80
Total         150         100

Table 4: Statistical indicators for 6 coping strategies
subscales and 3 scales of pain control, pain reduction,
and locus of control.

Indicator/                    Average   Standard
Scale                                   deviation

Self-talking (CSQ)            16.13     11.77
Hope (CSQ)                    16.05     9.07
Pain-ignoring (CSQ)           12.65     10.24
Attention-diverting (CSQ)     7.71      8.85
Pain reinterpretation (CSQ)   7.49      8.57
Disaster-making (CSQ)         4.49      5.86
Pain control (CSQ)            4.22      1.78
Pain reduction (CSQ)          3.78      1.94
Locus of control (Rotter)     10.57     2.69

Table 5: Comparing pain intensity and coping strategies in
experiencing mammography pain with the locus of control (a = 0.05).

Indicators/             External       Internal       t amount
Variable                control M,SD   control M,SD

Pain intensity NRS      3/94(2/67)     3/53(2/64)     -0/76
Pain intensity VAS      3/98(2/69)     2/75(2/38)     -2/16 *
Disaster-making         4/5(5/76)      4/4(6/35)      -0/09
Attention-diverting     8(8/82)        6/53(9/01)     -0/81
Pain-ignoring           12/14(9/81)    14/66(11/76)   1/21
Hope                    16/18(8/69)    15/50(10/58)   0/37
Pain reinterpretation   7/21(8/30)     8/60(9/61)     0/79
Self-talking            16/28(11/38)   15/5(13/38)    -0/33

Indicators/             Significancy

Pain intensity NRS      0.449
Pain intensity VAS      0/03 *
Disaster-making         0/92
Attention-diverting     0/419
Pain-ignoring           0/228
Hope                    0/713
Pain reinterpretation   0/431
Self-talking            0/749

* Significant relationship

Table 6: Correlation between pain intensity
of VAS, NRS and locus of control.

Indicator/    NRS        VAS

Locus of      0.11       0.19
  control     P = 0.18   P = 0.03 *

* Significant relationship

Table 7: Ccorrelation between pain intensity (by VAS & NRS) and 6
coping mechanism subscales.

Pain intensity/         NRS                  VAS

Disaster-making         0/25 (P = 0/002) *   0/22 (P = 0/003) *
Attention-diverting     0/08 (p = 0/34)      0/04 (P = 0/61)
Pain-ignoring           0/03 (P = 0/75)      -0/02 (P = 0/83)
Hope                    0/13 (P = 0/13)      0/09 (P = 0/28)
Pain reinterpretation   0/06 (p = 0/49)      0/02 (p = 0/83)
Self-talking            0/28 (P = 0/001) *   0/24 (p = 0/005) *

* Significant relationship

Table 8: One-way variance analysis (a = 0.05).

Variables                Average     Average     Average     Average
                        and SD of   and SD of   and SD of   and SD of
                        1st group   2nd group   3rd group   4th group

Locus of control          10/77       10/37       10/86       11/62
                         (2/88)      (2/10)      (2/93)      (3/02)
Disaster-making           3/83        2/25        4/90        5/75
                         (5/45)      (4/83)      (5/31)      (5/80)
                          6/88        5/75        8/11        11/62
Attention-diverting      (8/26)      (7/78)      (8/02)      (9/33)
Pain-ignoring             12/88       12/25       10/79       11/37
                         (9/49)      (10/61)     (9/20)      (9/53)
Hope                      14/38       14/53       14/77        17
                         (8/76)      (8/75)      (8/61)      (5/75)
Pain reinterpretation     5/91        5/65        7/46        6/37
                         (7/57)      (7/88)      (8/42)      (7/36)
Self-talking              14/94       11/87       14/59       16/75
                         (11/11)     (11/69)     (11/52)     (8/84)
painNRS                   1/44        2/87        2/30        6/62
                         (2/03)      (2/07)      (2/16)      (2/26)
painVAS                   1/40        2/71        3/49        6/92
                         (1/78)      (2/08)      (2/31)      (2/12)

Variables               Average and   [F.sub.prob]   [F.sub.Ratio]
                         SD of 5th

Locus of control           10/14          0/54           0/78
Disaster-making            5/42           0/15           1/72
                           8/19           0/49           0/86
Attention-diverting       (10/38)
Pain-ignoring              14/65          0/49           0/85
Hope                       18/44          0/22           1/46
Pain reinterpretation      9/72           0/25           1/36
Self-talking               20/51         % 1 *           3/08
painNRS                    5/42         0/001 *          16/64
painVAS                    4/89         0/001 *          12/07

* Significant relationship
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Title Annotation:Original Article
Author:Azizi, Masume; Bisadi, Zahra
Publication:Advances in Environmental Biology
Article Type:Report
Geographic Code:7IRAN
Date:Apr 1, 2012
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