Health and Social Development, Faculty of (Okanagan)
Nursing, School of (Okanagan)
DSpace
UBCO
Roe, Melissa
Master of Science in Nursing - MSN
University of British Columbia
Background: Multiple sclerosis (MS) is a debilitating chronic neurological disease affecting 2.8 million people worldwide. Mobility impairment is one of the most common and disruptive symptoms of MS. Research has shown a disconnect between actual level of mobility impairment and peopleâs perceptions of how impaired their mobility is. There is a need to understand psychological factors relating to how people with MS perceive their level of mobility impairment, as these psychological factors may be more modifiable by intervention than other disease factors. Purpose: To examine the psychological correlates of symptom control self-efficacy and somatic cognitive errors and whether they are associated with perceived walking impairment in people with MS. Methods: This study involved a secondary analysis of anonymous survey data from a larger primary study. 105 participants were eligible for this inclusion in the analysis. Participants responded to an online survey with demographic information, disease characteristics and psychological and physical variables. Three specific measures from the primary study were included in this study: MS symptom control self-efficacy (MS symptom-control self-efficacy scale (MSSE)); somatic cognitive errors (somatic subscale of the Cognitive Errors Questionnaire (CEQ)); and perceived walking impairment (12-item MS Walking Scale (MSWS-12). Descriptive statistics were used to summarize sample demographics. Correlational analyses were conducted to examine the study hypotheses and relationships between study variables. Results: Somatic cognitive errors were significantly and positively correlated with perceived walking impairment (r = .336, p < .001). Symptom control self-efficacy was significantly and negatively correlated with perceived walking impairment (r = -.363, p < .001). In the multiple regression, the addition of somatic cognitive errors was found to be significantly and positively associated with perceived walking impairment (B = .272, p < .001) beyond the covariates (including symptom control self-efficacy). Conclusion: Somatic cognitive errors account for a significant proportion of perceived walking impairment in people with MS beyond the more well understood concept of self-efficacy. This highlights important considerations for future research to understand possible causal relationships between these concepts and exploration of intervention-based therapies to support people with MS in managing their disease and improving their quality of life.
AN EXAMINATION OF THE ASSOCIATION OF SYMPTOM-CONTROL SELF-EFFICACY AND SOMATIC COGNITIVE ERRORS WITH PERCEPTIONS OF WALKING IMPAIRMENT IN PEOPLE WITH MULTIPLE SCLEROSIS: A QUANTITATIVE STUDY by Melissa Roe BSN, University of British Columbia Okanagan, 2012 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING in THE COLLEGE OF GRADUATE STUDIES (Nursing) THE UNIVERSITY OF BRITISH COLUMBIA (Okanagan) April 2024 © Melissa Roe, 2024 ii The following individuals certify that they have read, and recommend to the College of Graduate Studies for acceptance, a thesis entitled: An Examination of the Association of Symptom-Control Self-Efficacy and Somatic Cognitive Errors with Perceptions of Walking Impairment in People with Multiple Sclerosis: A Quantiative Study submitted by Melissa Roe in partial fulfillment of the requirements of the degree of Master of Science in Nursing. Dr. Kathy L. Rush, School of Nursing Supervisor Dr. Sean R. Locke, School of Kinesiology, Brock University Co-Supervisor Dr. Lise Olsen, School of Nursing Supervisory Committee Member Dr. Laura Struik, School of Nursing Supervisory Committee Member Dr. Maya Libben, School of Psychology External Examiner iii Abstract Background: Multiple sclerosis (MS) is a debilitating chronic neurological disease affecting 2.8 million people worldwide. Mobility impairment is one of the most common and disruptive symptoms of MS. Research has shown a disconnect between actual level of mobility impairment and peopleâs perceptions of how impaired their mobility is. There is a need to understand psychological factors relating to how people with MS perceive their level of mobility impairment, as these psychological factors may be more modifiable by intervention than other disease factors. Purpose: To examine the psychological correlates of symptom control self-efficacy and somatic cognitive errors and whether they are associated with perceived walking impairment in people with MS. Methods: This study involved a secondary analysis of anonymous survey data from a larger primary study. 105 participants were eligible for this inclusion in the analysis. Participants responded to an online survey with demographic information, disease characteristics and psychological and physical variables. Three specific measures from the primary study were included in this study: MS symptom control self-efficacy (MS symptom-control self-efficacy scale (MSSE)); somatic cognitive errors (somatic subscale of the Cognitive Errors Questionnaire (CEQ)); and perceived walking impairment (12-item MS Walking Scale (MSWS-12). Descriptive statistics were used to summarize sample demographics. Correlational analyses were conducted to examine the study hypotheses and relationships between study variables. Results: Somatic cognitive errors were significantly and positively correlated with perceived walking impairment (r = .336, p < .001). Symptom control self-efficacy was significantly and negatively correlated with perceived walking impairment (r = -.363, p < .001). In the multiple iv regression, the addition of somatic cognitive errors was found to be significantly and positively associated with perceived walking impairment (B = .272, p < .001) beyond the covariates (including symptom control self-efficacy). Conclusion: Somatic cognitive errors account for a significant proportion of perceived walking impairment in people with MS beyond the more well understood concept of self-efficacy. This highlights important considerations for future research to understand possible causal relationships between these concepts and exploration of intervention-based therapies to support people with MS in managing their disease and improving their quality of life. v Lay Summary Multiple sclerosis (MS) affects many people worldwide, with people in Canada impacted at a higher rate. MS can cause mobility troubles which make it hard to perform basic daily functions and have an enjoyable life. Physical activity can help people with MS manage their disease and enjoy life. Physical activity can be difficult for people with MS, but it might be possible to change peopleâs inaccurate beliefs or thinking patterns about their mobility challenges (e.g., we may think we are more impaired than we are). This study explored whether beliefs in oneâs abilities (called self-efficacy), negative beliefs about physical experiences (called somatic cognitive errors) or other factors (such as gender or age) relate to how one views their walking impairment. The aim of this study was to better understand these concepts that may help people with MS correct thinking patterns if they view their mobility as worse than it actually is. vi Preface This thesis was completed as a requirement for the degree of Master of Science in Nursing. This thesis is the original, unpublished work of the author, Melissa Roe. The University of Brock research ethics board provided study approval (REB# 20-102). As the present study involved a secondary analysis of anonymous survey data, and the original study was approved by another institution, the University of British Columbia, Okanagan, Behavioural Research Ethics Board (BREB) did not require an ethics submission. All components of this thesis were completed in consultation with supervisor Dr. Kathy Rush, co-supervisor Dr. Sean Locke and committee members Dr. Lise Olsen and Dr. Laura Struik. vii Table of Contents Abstract ....................................................................................................................................................... iii Lay Summary .............................................................................................................................................. v Preface ......................................................................................................................................................... vi Table of Contents ...................................................................................................................................... vii List of Tables .............................................................................................................................................. ix Acknowledgements ..................................................................................................................................... x Chapter 1: Introduction ............................................................................................................................. 1 1.1 Background ............................................................................................................................... 1 1.2 Purpose and Objective ............................................................................................................... 5 1.3 Overview of Thesis ................................................................................................................... 6 Chapter 2: Review of Literature ................................................................................................................ 7 2.1 Multiple Sclerosis ...................................................................................................................... 7 2.2 Mobility Impairment in MS ...................................................................................................... 8 2.3 Self-Efficacy .............................................................................................................................. 9 2.4 Cognitive Errors ...................................................................................................................... 11 2.4.1 Somatic Cognitive Errors .................................................................................................. 12 2.5 Rapid Literature Review ......................................................................................................... 14 2.5.1 Search Methods ................................................................................................................. 14 2.5.2 Rapid Review Findings ..................................................................................................... 15 Chapter 3: Research Methods ................................................................................................................. 17 3.1 Primary Study .......................................................................................................................... 17 3.2 Secondary Study Design ......................................................................................................... 18 3.2.1 Ethics ................................................................................................................................ 19 3.2.2 Sample Recruitment and Sample Size .............................................................................. 19 viii 3.2.3 Data Collection Procedures............................................................................................... 20 3.3 Study Measures ....................................................................................................................... 20 3.4 Data Analysis .......................................................................................................................... 23 Chapter 4: Study Results .......................................................................................................................... 24 4.1 Demographics .......................................................................................................................... 25 4.2 Descriptive Statistics and Correlations .................................................................................... 25 4.2.1 Hypothesis One ................................................................................................................. 26 4.2.2 Hypothesis Two ................................................................................................................ 27 4.2.3 Hypothesis Three .............................................................................................................. 27 Chapter 5: Discussion ............................................................................................................................... 32 5.1 Discussion of Findings ............................................................................................................ 32 5.1.1 Hypothesis One ................................................................................................................. 32 5.1.2 Hypothesis Two ................................................................................................................ 33 5.1.3 Hypothesis Three .............................................................................................................. 34 5.1.4 Examining Associations with Demographic Variables .................................................... 35 5.2 Theoretical Implications .......................................................................................................... 37 5.3 Implications for Practice ........................................................................................................ 39 5.4 Study Limitations .................................................................................................................... 41 5.5 Future Research Directions ..................................................................................................... 42 5.6 Conclusion ............................................................................................................................... 44 References .................................................................................................................................................. 45 Appendices ................................................................................................................................................. 60 Appendix A: Literature Review Data Extraction Table ..................................................................... 60 Appendix B: Participant Information and Consent Form................................................................... 68 Appendix C: Online Study Recruitment Post .................................................................................... 71 ix List of Tables Table 1: Demographic Information ...................................................................................................29 Table 2: Variable Means and Correlations ........................................................................................30 Table 3: Results from Regressions Examining Predictors of Perceived Walking Impairment..........31 x Acknowledgements At times, this thesis truly felt like an insurmountable challenge (thanks, in part, to a global pandemic, a major home flood and a variety of other crazy life events) but thanks to the unwavering support of my supervisory team (Dr. Kathy Rush, Dr. Sean Locke and Dr. Donna Kurtz) over the past five yearsâ¦ here we are! I will never have the proper words to adequately thank these three for sticking by me, encouraging me, and pulling me over this finish line. I also want to extend my sincerest gratitude to my committee and defense members, Dr. Lise Olsen, Dr. Laura Struik and Dr. Maya Libben, for their thoughtful review and invaluable contributions to my work. 1 Chapter 1: Introduction 1.1 Background Multiple Sclerosis (MS) is a chronic, debilitating neurological disease that affects approximately 2.8 million people (35.9 per 100,000) worldwide (Walton et al., 2020). Canada has one of the highest MS prevalence rates in the world, with over 90,000 Canadians, or one in every four hundred people, affected: significantly higher than the one in every three thousand people living with MS worldwide (MS International Foundation, 2020). MS is the most common unpredictable, unpleasant, chronic neurological disease affecting young and middle-aged adults and it affects at least twice as many women as men (MS International Foundation, 2020; Poppe et al., 2008). MS occurs most often in adults aged twenty to sixty years of age and the average age of diagnosis is 32 (MS International Foundation, 2020). Individuals with MS have a similar life expectancy to that of the general population, meaning those with MS may experience a prolonged period of suffering from their disease and the accompanying symptoms and many live with the disease for many decades (Hartung, 2011). MS severity, symptomology and disease progression vary greatly among individuals and in addition to profound social, physiological and emotional consequences, MS can cause great uncertainty regarding the future (Dennison et al., 2010; Foley et al., 1987). Given there is no cure for MS, individuals are required to live with, and manage their disease and progressively deteriorating symptoms (Roman & Menning, 2017). A variety of genetic, environmental, cardiovascular, and behavioural factors have been implicated in the prevention and management of MS (Olsson et al., 2017). Researchers and clinicians can look to these factors to try to understand the potential causes of MS and itsâ progression. They can also look to these factors as potential targets for intervention. While factors like genetics and environment are either not modifiable or not easily modifiable, it is 2 well-established there are modifiable behaviours that can be improved through lifestyle modification (Wadden et al., 2007). Lifestyle behavior modifications have been shown to improve mobility, enhance disease management and improve the overall quality of life for people with MS (Fascewski et al., 2018; Motl & McAuley, 2009). One of the most common, visible and disruptive symptoms of MS is mobility impairment, which can have significant effects on multiple facets of daily living including independence and ability to perform routine activities of daily living (ADLs). Lifestyle behaviours, specifically exercise and physical activity, have repeatedly demonstrated benefit(s) for people with MS for facilitating both symptom management and psychological well-being (Motl & Gosney, 2008). Unfortunately, it is well documented that MS is associated with a dramatic decrease in physical activity behaviour (Motl & Gosney, 2008). A 2005 meta-analysis found that people with MS were significantly moderately less active than a comparison group of people with either no chronic illness or another non-MS chronic condition (Motl et al., 2005). Thus, a challenging inverse relationship exists between MS symptoms and physical activity, given that those with increased symptoms are less likely to engage in physical activity, while engagement in physical activity contributes to symptom reduction and improved QOL (Motl et al., 2006). There is a growing need to understand client-specific factors that may predict or impact peopleâs physical activity, mobility and, more specifically, their walking impairment as this is one of the most prominent and debilitating symptoms for people with MS (Motl & Gosney, 2008). Perceptions about mobility are important psychological factors that contribute to adjustment and thriving for those living with MS (Motl et al., 2009). Given the growing acceptance of physical activity self-management interventions, it is important to understand 3 psychological factors leading to health behaviours important for MS adjustment. Psychological factors often better predict individual differences in disease adjustment than physical factors and, unlike physical or environmental factors, have the potential for modification through intentional psychological interventions (Dennison et al., 2009). Determining psychological predictors of mobility impairment perceptions can help provide future targets for intervention. Being active and mobile is not easy and people with MS are less physically active than the general population, with fewer than 20% of people with MS meeting guidelines for health-promoting levels of physical activity (Hartung, 2011; Riemann-Lorenz et al., 2021). Individuals will often provide some description of the challenges they have encountered in trying to be active and mobile, termed a perceived barrier (Glasgow, 2008). Perceived barriers are a personâs estimation of the level of challenge of psychological, social, physical, or environmental obstacles to a behaviour (Glasgow, 2008). Perceived barriers are subjective perceptions that are mentally constructed and therefore may or may not align with the âobjectiveâ levels of challenge associated with the obstacles. For example, a lack of time is one of the most commonly reported barriers to physical activity (Cerin et al., 2010). However, believing there is not enough time to exercise and be active may be misaligned with reality, particularly given recent statistics suggesting the average adult has over 5 hours of daily free time (Sturm & Cohen, 2019). The subjective nature of perceptions suggests that they are subject to misinterpretation, exaggeration, and bias (Kahneman, 2011). Past research has reported a disconnect between the perceived level of mobility impairment and actual impairment among individuals with MS. For example, across five time points over a two and a half year period the correlations between perceived walking impairment and patient-determined disability status (a metric of ability to ambulate) were moderate found by 4 Motl et al. (2015), suggesting there were discrepancies between the perceptions and actual function of patients with MS. It could be that individualsâ perceptions of their level of mobility may have the potential to be inaccurate and subject to exaggeration and bias. Inaccurate or exaggerated perceptions of MS symptoms may help in understanding how individuals perceive their symptoms and level of mobility. Beckâs (1976) cognitive errors model provides a framework for understanding biased perceptions. Cognitive errors, commonly referred to in the literature as cognitive distortions, are a type of disordered illness perception. They involve the collection of thinking errors in which individuals display a lack of logic or bias when interpreting situations (Moss-Morris & Petrie, 1997). The positive beliefs and thoughts people have about their health, including those which resemble personal agency and efficacy, have been shown to manifest health-promoting activities, while beliefs that are demoralizing or passive do not (Shnek et al., 1997). Cognitive errors are one under-researched factor that may be associated with and help in understanding individualsâ perceptions of their level of walking impairment. As a relatively new and understudied factor impacting behaviour, cognitive errors may be influenced by more established factors, such as past behavior or self-efficacy. Self-efficacy is one established factor that might aid in our understanding of how individuals manage their symptoms and are able to be mobile. Self-efficacy is an individualâs perception of the extent to which they have confidence in their capabilities to manage a potential situation (Bandura, 1977). Individual differences in self-efficacy have been shown to positively impact the physical and psychological health of people with MS (Riazi et al., 2004; Stuifbergen et al., 2000). Based on Banduraâs (1986) Social Cognitive Theory, self-efficacy should also be a strong predictor of behavioural outcomes like mobility. A systematic review and meta-analysis by Casey et al. (2017) found a moderate positive association between physical activity and both objective and 5 subjective self-efficacy. As MS is progressive, with no cure, supporting people to manage and live with their symptoms is of paramount importance. An individualâs self-efficacy for interpreting and managing their symptoms is referred to as symptom-control self-efficacy and may be a critical factor in understanding mobility perceptions for individuals with MS. The limited, but convincing, body of research highlights the importance of understanding modifiable psychological factors in people with MS. The available literature demonstrates that an individualâs self-efficacy is related to physical activity and mobility for people with multiple sclerosis. While Locke and Brawley (2016) found an association between perceived cognitive errors and physical activity and exercise, the role of cognitive errors in physical activity and mobility for people with multiple sclerosis has been less well defined. Cognitive errors about physical activity have been associated with attentional biases (Locke & Brawley, 2018). Those who had high cognitive errors almost solely focused on the negatives/challenges of being active compared to those with low cognitive errors. Cognitive errors could help us understand mobility perceptions, but the association between somatic cognitive errors and perceived mobility has not yet been studied for people with MS. This gap in knowledge development is addressed in this study. 1.2 Purpose and Objective The current study represents a secondary analysis of a larger survey study to examine psychological predictors of physical activity and mobility for people with MS. The purpose of the current study was to examine the psychological correlates of individualâs perceptions of mobility impairment. Specifically, the present study examined whether symptom-control self-efficacy and somatic cognitive errors are associated with perceived walking impairment in people with MS. The current study proposed the following hypotheses: 6 1. It was hypothesized that somatic cognitive errors will be positively correlated with perceptions of walking impairment. 2. It was hypothesized that symptom-control self-efficacy will be negatively correlated with perceptions of walking impairment. 3. It was hypothesized that somatic cognitive errors will be positively associated with and account for a significant proportion of variance in perceptions of walking impairment beyond the contribution of symptom-control self-efficacy and demographic covariates. It was predicted that individuals with MS who displayed higher levels of somatic cognitive errors would have increased perceptions of walking impairment. Those who reported lower scores for symptom control self-efficacy would have increased perceptions of walking impairment. Finally, in line with findings in the exercise literature (Locke & Brawley, 2016), it was expected that both somatic cognitive errors and symptom-control self-efficacy would be associated with perceived walking impairment. Demonstrating an association between cognitive errors and perceived mobility beyond the contribution of symptom control self-efficacy has the potential to enhance understanding of the contribution of multiple psychological factors in perceptions of mobility impairment among individuals with chronic diseases, such as MS. 1.3 Overview of Thesis The remainder of this thesis will be laid out as follows: Chapter two will present a review of current literature and theoretical models. Chapter three will provide a description of the quantitative research study design and methods. Chapter four will present the research findings and results. Chapter five will discuss the research findings; recommendations and implications of the findings; and a conclusion. 7 Chapter 2: Review of the Literature This chapter provides an overview of the key concepts and supporting theoretical frameworks examined in this thesis. It also includes a rapid review exploring the impact of self-efficacy and somatic cognitive errors on walking impairment in people with MS. 2.1 Multiple Sclerosis MS is a chronic autoimmune disease that affects the entire central nervous system including the brain, spinal cord and optic nerve (MS Canada, 2023). MS has an unknown etiology with evidence suggesting a mixture of environmental and genetic factors may contribute to the onset of the disease (Poppe et al., 2008). MS causes demyelination of the central nervous system, which delays or prevents proper transmission of nerve impulses leading to a variety of disabling symptoms including abnormal gait (walking), numbness, pain, limb spasticity, stiffness or spasms (including sphincter spasms), memory/cognitive problems and fatigue (Poppe et al., 2008, Shnek et al., 1995, Shnek et al., 1997). MS severity, symptomology and disease progression vary greatly between individuals. Considered an episodic disability, the severity and duration of illness can vary and may be followed by periods of wellness for some while the disease is progressive for others (MS Canada, 2020). Approximately 85% of MS patients present with a relapsing-remitting course, characterized by periods of neurological deficit followed by periods of partial or complete symptom recovery (Roman & Menning, 2017). The remaining minority of patients present with primary progressive MS and have continuous disability progression with no remission and rare relapses (Lublin et al., 2014). Current treatment recommendations for MS fall into three categories: providing symptomatic therapies, treating symptom exacerbations and disease-modifying therapies (DMT) 8 aimed at slowing disease progression. Additionally, as the number of available DMTs continues to grow substantially, the abundance of treatment options makes treatment selection more complex (Roman & Menning, 2017). There are some âhigher-efficacyâ pharmacological treatment options available; however, these are often employed only as second- or third-line options in patients who have a more aggressive MS course due to severe safety concerns and unpleasant drug side effects (Dennison et al., 2010; Roman & Menning, 2017). Additionally, there are nondrug treatment modalities available for individuals with MS; however, it is difficult to assess the efficacy of many of these complementary treatment options due to the variability in MS disease progression and the power of the placebo effect. Non-drug therapies include cannabinoid administration with a goal to control pain and spasticity, reflexology for paresthesia control, magnetic therapy with a goal to reduce fatigue and gingko balboa supplements for fatigue control (Roman & Menning, 2017). 2.2 Mobility Impairment in MS Mobility impairment in MS can be progressive, resulting in ever-worsening disability and increasing loss of independence (van Asch, 2011). Prevalence studies have shown that up to 75% of individuals with MS experience mobility problems and a United Kingdom focus group of people with mild to moderate MS identified mobility, gait and balance as key physical issues experienced (Hobart et al., 2003). A variety of MS symptoms contribute to mobility challenges including weakness in the legs, fatigue, overall difficulty walking, lack of balance/coordination, slowed movement, numbness in the legs and dropping/dragging of feet (van Asch, 2011). A 2011 study by van Asch found that nearly one in two (45%) patients reported experiencing mobility issues within the first month of their disease diagnosis and found that women (51%) were more likely to be affected within the first month than men (37%). Within just one year of 9 diagnosis, 58% of participants reported mobility problems, 67% within two years and 84% within five years. An astonishing 93% of individuals reported mobility problems within 10 years of MS diagnosis with the majority of patients (76%) considering mobility a significant issue in their life related to their diagnosis. When offered the opportunity to choose from a list of words to describe their feelings about their mobility challenges, the most selected words were âlimitedâ, âfrustratedâ, âpowerlessâ, âchallengedâ and âacceptingâ (van Asch, 2011). Regardless of degree of impairment or time since diagnosis, people with MS ranked maintaining mobility as one of the highest priorities for them, of higher importance than twelve other bodily functions (including visual function, pain control, cognition and bowel and bladder control) with ambulation reported to have a greater impact on quality of life than pain, dexterity or cognition (van Asch, 2011). Impaired mobility for individuals with MS results in decreased work-related productivity contributing to the significant economic burden of the disease, with the highest associated cost being the loss of productivity due to work absence or early retirement (Hartung, 2011; van Asch, 2011). Impaired mobility in persons with MS also places a significant, often long-term, burden on caregivers, including professional but also unpaid or informal caregivers, resulting in emotional, economic, physical and psychosocial caregiver burdens (van Asch, 2011). Prevention of comorbidities benefits not only the individual but also contributes to a decreased overall burden on the healthcare system. Additionally, physical activity participation can help maintain mobility, which will help ensure individuals with MS are able to participate in their ADLs and move around their community more freely. 10 2.3 Self-Efficacy Self-efficacy is the key psychological concept within the agency aspect of Banduraâs (1986) Social Cognitive Theory (SCT). Self-efficacy refers to an individualâs level of confidence in their ability to enact behaviours or self-management strategies related to their specific condition or situation, or their perceived ability to manage potential situations. SCT is a behavioural theory that outlines core behavioural determinants and their mechanism(s) of action that help us understand how a person acquires and maintains behaviours. At itsâ core, SCT suggests that our thoughts, behaviours, and the environment each impact one another. As such, establishing which psychological variables predict behaviour represents an important precursor to interventions. SCT helps us understand individualsâ perceptions about their ability to effectively translate knowledge into practice in a way that will promote self-management of their health (Anderson et al., 2007; Bandura, 2004; Jang & Yoo, 2012). As SCT focuses not only on initiating behaviour changes but also on how these changes can be maintained, it is a very useful theory for helping improve self-management behaviours of patients with chronic diseases (Jang & Yoo, 2012). Self-efficacy reflects an individualâs perception of their capability instead of their actual capability (Schwartz et al., 1996). Self-efficacy has an effect directly on health behaviour but also indirectly influences health behaviour by its influence on other determinants including goals, outcome expectations, impediments to health-promoting behaviour and perception of sociostructural facilitators (Bandura, 2004). Perceived self-efficacy directly shapes the expected outcomes of oneâs efforts and those with stronger self-efficacy set higher goals for themselves, allowing them to view challenges as surmountable to achieve more favorable outcomes. Those with higher self-efficacy are more likely to push forward despite difficulties that arise (Bandura, 11 2004). Perceived self-efficacy plays a critical role in self-management activities and in both implementing and maintaining health behaviour changes, leading to improved health outcomes (Jang & Yoo, 2012). There are a variety of factors that influence an individualâs self-efficacy. These include an individualâs vicarious experience, verbal persuasion, performance accomplishment/capacity and interpretation of both affective and physiological states (Bandura, 1997). For those with MS, symptoms may represent both the affective and physiological states within which they interpret their experience(s) and are one source of direct influence on their self-efficacy for disease management. An individualâs specific self-efficacy for interpreting and managing their symptoms is referred to as symptom-control self-efficacy. Symptom self-management has been identified as one of the most urgent areas of concern for the provision of quality health care (Committee on Identifying Areas for Quality Improvement, 2003). Symptom-control self-efficacy in people with MS is often overlooked as other factors contributing to overall self-efficacy are frequently prioritized in research. There is a lack of research examining symptoms or symptom control as a correlate of mobility in people with MS, despite the understanding that symptom management and control are important for the promotion of physical activity (which is prescribed to help manage symptoms) (Motl et al., 2006). 2.4 Cognitive Errors Cognitive factors, including beliefs that people hold about their illness(es) and how they interpret their symptoms, are increasingly recognized as critical components contributing to the understanding of chronic diseases and their impact(s) can appear both at disease onset and throughout ongoing disease management and maintenance (Moss-Morris & Petrie, 1997). Cognitive errors, which may also be referred to as cognitive distortions, represent a form of 12 disordered illness perception and refer to a collection of thinking errors where individuals display a lack of logic in interpreting various situations (Moss-Morris & Petrie, 1997). Beck (1976) provides a model which outlines the most common types of cognitive errors: catastrophizing, overgeneralization, personalization and selective abstraction. Catastrophizing is a misinterpretation or anticipation that the outcome of an event will be disastrous, while overgeneralization represents the assumption that the outcome of a single event will apply to the outcome of all future similar events. Personalization is interpreting negative events to reflect personal responsibility or meaning and seeing oneself as responsible for the negative outcomes. Selective abstraction involves attending to only the negative aspects of the experience (Beck, 1976; Shnek et al., 1995). Cognitive errors cause an individualâs perceptions to be extreme, unrealistic or negatively distorted (Pössel, 2011). Cognitive errors were initially conceptualized in people with depression with Beck (1976) initially suggesting that cognitive errors/distortions were perpetuating or exacerbating depression. Since then, other research has found that cognitive errors also occur in other populations, including Moss-Morris & Petrie (1997) who confirmed that cognitive errors in patients with chronic fatigue syndrome were not just a feature of depression. While the prevalence rate of depression in people with MS (31.7%) is higher than that of the general population (20.5%), it is possible that cognitive errors may occur in people with MS regardless of whether or not they are depressed (Feinstein et al., 2014). 2.4.1 Somatic Cognitive Errors Moss-Morris and Petrie (1997) were able to empirically differentiate cognitive errors into two categories: general errors of thinking and errors of thinking specific to somatic experience. Somatic cognitive errors are specific cognitive errors that correlate with a focus on the self and the experience of somatic symptoms. An example of a cognitively errored somatic belief would 13 be an individual catastrophizing feeling tired after swimming as a belief that âPretty soon, I wonât be able to swim at allâ (Moss-Morris & Petrie, 1997). While the experience of somatic symptoms itself does not necessarily lead to errored thinking, individuals who are overly focused on their symptoms and themselves appear more prone to misinterpret their somatic experiences and display cognitively errored thinking (Moss-Morris & Petrie, 1997). The measures of cognitive errors specifically related to somatic experience were validated across 3 of the cognitive error domains (Moss-Morris & Petrie, 1997). While their instrument validation focused on the conditions of chronic fatigue syndrome (CFS) and chronic pain, they highlighted the need for further research regarding cognitively errored thinking among other chronic condition groups and the need to further clarify the specific role of somatic cognitive errors in characterizing peopleâs experiences of their chronic conditions. To help address this gap, the present study explores the specific role of somatic cognitively errored thinking among individuals with MS. Positive thoughts and beliefs people hold regarding their health and well-being, including those which resemble personal agency and efficacy, have been shown to manifest health-promoting activities while beliefs that are demoralizing or passive do not manifest heatlh-promoting behaviour (Shnek et al., 1997). Further, when an individual feels or believes they are in control of their illness, they are more likely to be self-efficacious to carry out self-management techniques for their own well-being (Lenker et al., 1984). Dennison et al. (2010) suggested that addressing peopleâs dysfunctional assumptions about themselves might be key for distress moderation in MS. Now that the key concepts have been defined, findings from a rapid literature review are presented to highlight the narrow scope of research that has investigated the proposed independent variables: symptom control self-efficacy and somatic cognitive errors, in the context of MS and walking impairment. 14 2.5 Rapid Literature Review 2.5.1 Search Methods A rapid review of the literature was conducted to better understand the breadth of research examining these concepts in MS. This search was conducted in consultation with a university librarian using keywords and related medical subject heading (MeSH) terms. Database searches of Medline and CINAHL were conducted using search terms (multiple sclerosis OR MS) AND (walking impairment OR gait impairment OR physical activity) AND either (somatic cognitive errors (catastrophizing, correlates of adjustment, thinking errors, dysfunctional thinking, dysfunctional errors, overgeneralization) OR (self-efficacy OR symptom-control self-efficacy). To be included in the literature review, articles were required to [1] be published in English, [2] include an abstract, [3] be published in a peer-reviewed journal, and [4] have full-text availability through the University of British Columbia library server. Due to the limited volume of research on the specific topic area, no date range exclusions were applied. The initial database searches provided 325 articles for initial review. Articles were screened for duplicates and 80 duplicates were removed, leaving 245 articles for preliminary abstract review. Titles and abstracts of the remaining articles were compared to the inclusion/exclusion criteria, search term/key concept criteria and relevance to the present research question by a single reviewer and 31 articles were selected for full-text review. 22 of these articles were removed following full-text review due to irrelevance to the current research, leaving nine articles for inclusion in the literature review. The process of selecting articles for inclusion in this review was conducted following the preferred reporting systems for systematic reviews and meta-analyses (PRISMA) guidelines (Moher, 2009). 15 2.5.2 Rapid Review Findings A total of nine articles met all inclusion criteria and were included in the review which follows. Of these nine, five studied self-efficacy and its relationship with physical activity in people with MS, while four explored the impact of somatic cognitive errors on individualsâ experiences of their illness/symptoms or self-efficacy. Three of these studies were in the MS population, with a fourth looking at patients with chronic fatigue syndrome (CFS) also included as chronic fatigue is a common symptom of MS (Wilski & Tasiemski, 2016). A summary of key relevant results will now be provided. A data extraction table outlining participant characteristics, sample sizes, study designs and diverse key variables/measures used is included as Appendix A. Self-Efficacy Of the nine articles included in this literature review, five studied self-efficacy in persons with MS and explored the relationship(s) between an individualâs self-efficacy and their levels of physical activity. Five of the included studies showed that self-efficacy was significantly and positively associated with physical activity and was also a significant predictor of MS patientsâ acceptance of their illness and adaptation to their symptoms (Casey et al., 2018; Dymecka et al., 2021; Fasczewski et al., 2018; Motl & McAuley, 2009; Riemann-Lorenz et al., 2021). A prospective study found those who were more physically active reported higher levels of self-efficacy for managing MS at baseline and changes in physical activity were directly associated with changes in self-efficacy for managing MS at six-month follow-up (Motl & McAuley, 2009). Individuals who were not regularly active had lower self-efficacy levels than those who were currently active or had been active long-term and those who believed they had the ability to be active were found to be more active (Fasczewski et al., 2018; Riemann-Lorenz et al., 2021). 16 Somatic Cognitive Errors Four studies included in the literature review explored the impact of somatic cognitive errors on individualsâ experiences of their illness/symptoms or self-efficacy: three of the studies looked specifically at individuals with MS, while a fourth was in a population of people with CFS. People with MS who were less physically active showed more negative perspectives on their illness than those who were active (Riemann-Lorenz et al., 2021). Patientâs cognitive interpretations of their symptoms (e.g., tending to attribute a wide range of their symptoms to MS; feelings of being embarrassed about MS symptoms, etc.) were significantly associated with fatigue. Participants who catastrophized about the consequences of experiencing symptoms, believed their symptoms to be a sign of actual physical damage or felt embarrassed about their symptoms were more likely to be fatigued and experience non-medical disabilities (for e.g., limits to employability; isolation from family and friends). Participants who responded to their symptoms by engaging in excessive rest or avoiding activity, and those who pushed themselves too hard and then crashed (all-or-nothing behaviour), were also more disabled and fatigued (Skerrett & Moss-Morris, 2006). Wilski and Tomczak (2016) found that participants who had realistic or underestimated perceptions of the overall impact of their MS presented with significantly higher levels of self-efficacy than those who overestimated the impact of their MS. Additionally, they reported that those who overestimated the impact of their MS generally tended to assess each aspect of their lives as worse (lower self-esteem, impaired body perception, etc.) compared to those who realistically or underestimated impact. Patients with CFS showed an interpretive bias for somatic information, which was hypothesized as a contributing factor to maintaining the disorder by heightening individualâs experience of physical symptoms and maintaining negative illness schemas (Moss-Morris & Petrie, 2003). When performing an 17 ambiguous cues task, patients with CFS made significantly more somatic interpretations than controls; this bias was significantly associated with the extent to which people reported symptoms (Moss-Morris & Petrie, 2003). Conclusion In summary, the association between self-efficacy and physical activity/mobility outcomes is more well-established. There is less literature examining somatic cognitive errors and most of the available evidence is in other populations (such as patients with CFS). Given the state of the evidence, this study will examine whether somatic cognitive errors are associated with perceptions of walking impairment in people with MS, beyond the contribution of symptom-control self-efficacy. Chapter 3: Research Methods This chapter will provide a brief overview of the primary research study and a more detailed overview of the current secondary study, including a review of the study design, recruitment/sampling, data collection including the specific study measures (for the secondary study), data analysis and ethics. 3.1 Primary Study This thesis research examines the secondary research questions of a larger survey study conducted in Fall 2021 that sought to understand psychosocial factors that predict physical activity for people with MS. While there is evidence suggesting physical activity supports MS symptom management (Motl et al., 2009), low rates of physical activity participation are observed (Kim et al., 2019). Exercise-related cognitive errors (ECEs) are a new concept applied to our understanding of exercise self-regulation for people with MS. ECEs are a bias that might 18 hinder the ability to translate self-efficacy into physical activity engagement (Locke & Brawley, 2016). The primary hypothesis of the primary study was that exercise-related cognitive errors (ECEs) would be negatively associated with moderate to vigorous physical activity levels for individuals with MS, beyond the contribution of symptom-control self-efficacy. It was also hypothesized that the interaction between ECEs and self-efficacy would be significantly associated with physical activity. The main study sample and methods were identical to those reported below in this thesis. There was a significant interaction between ECEs and self-efficacy in predicting physical activity. The interaction showed that self-efficacy predicted physical activity when ECEs were high, but not when they were moderate or low. However, Beckâs (1976) cognitive error model suggests that cognitive errors are domain specific, such as specific to exercise or disease related. The purpose of the primary paper was to explore whether ECEs predicted physical activity. A secondary research question intended to be examined, but not included, in the primary study was to examine the role of somatic (disease-related) cognitive errors in predicting physical activity along with other outcomes resulting from physical activity engagement. The current thesis examined whether somatic cognitive errors, as a disease-related cognitive error factor, predicted perceptions about mobility as an important outcome related to physical activity engagement. 3.2 Secondary Study Design For this secondary study, three specific measures from the larger survey study were utilized: perceived walking impairment; MS symptom-control self-efficacy; and somatic cognitive errors. The study used a cross-sectional online survey design and used an existing database that included the variables that were the focus of this study. 19 3.2.1 Ethics The study was approved by the University of Brock Research Ethics Board (REB# 20-102). As the present study involved a secondary analysis of anonymous survey data, and the original study was approved by another institution, the University of British Columbia, Okanagan, Behavioural Research Ethics Board (BREB) did not require an ethics submission. All participants provided informed consent online for participating in the study prior to completing the online questionnaire. The participant information and consent form is attached as Appendix B. 3.2.2 Sample Recruitment and Sample Size Adults with MS were recruited using two methods. The first was via Qualtrics; a panel aggregator that partners with more than 20 online panel providers to survey participants across Canada and the United States. Qualtrics ensures quality responses using the following automated checks: duplicate prevention (i.e., ensuring participants complete the survey once), bot detection, GeoIP restriction (i.e., ensuring survey respondents are coming from the country specified), and speeding (e.g., quick survey completions flagged). Secondly, a research assistant posted recruitment advertisements in a variety of online locations (e.g., MS-specific Facebook groups, Kijiji volunteers, MS Society website; see Appendix C). Inclusion criteria required being 18 years of age or older, able to read English and having a Patient-Determined Disease Steps (PDDS) score below seven. The PDDS is a patient-reported outcome of disability in MS on a scale ranging from zero to eight, with increasing scores reflecting greater degrees of disability (Learmonth et al., 2013). Those who were wheelchair-bound (PDDS=7) or bedridden (PDDS=8) were excluded from the study as the main study outcomes examined physical activity and mobility-related cognitions for those who were ambulatory. 20 Sample size calculation. A projected minimum sample size of 109 was calculated for the current secondary study using Gpower version 3.1.9.7 based on two tails, p<.05, power of 0.8, 3 predictors, and a small-to-medium effect (f2 = .09). This was calculated based on previous findings examining the association between catastrophizing cognitive error and physical fatigue when holding disability status constant (Skerrett & Moss-Morris, 2006). 3.2.3 Data Collection Procedures After viewing the study recruitment advertisement, participants could click a link that directed them to the online study using Qualtrics. Qualtrics uses ReCAPTCHA to screen out potential bots seeking to complete the study. Participants first completed eligibility questions. Those who were eligible were directed to the consent form to complete, while those who were not eligible were thanked for their time. Those who provided informed consent completed an online survey that took approximately 15 minutes to complete. The survey asked participants about their recent physical activity and their perceptions about their mobility, demographic descriptors, and potential psychological predictors of physical activity and mobility (e.g., somatic cognitive errors, symptom self-efficacy). Participants who completed the survey were entered into a draw to win one of two $50 gift cards for participation. 3.3 Study Measures Perceived Disability. Perceived disability status was used to determine participant eligibility in this study. Participants self-reported their perceived physical disability using the Patient-Determined Disease Scale (PDDS). The PDDS is a validated scale that assesses an individualâs perceived level of physical ability (Learmonth et al., 2013). This measure instructs the participant to identify their level of physical ability from 0 (Normal â or No limitations to physical ability) to 8 (Bedridden). Participants were included in the study if they self-reported 21 being at a level 6 or below on the PDDS scale (i.e., they are able to be mobile, at minimum, with bi-lateral support for up to 25 feet). The PDDS scale has been concurrently validated and is highly correlated with the Expanded Disability Status Scale - the practitioner-administered version to assess disability status (Learmonth et al., 2013). Perceived Walking Impairment was measured using the 12-item MS Walking Scale (MSWS-12) (Hobart et al., 2003). This scale asked participants to rate the extent to which MS has impacted their ability to be ambulatory. Items are rated on a Likert scale from 1 (not at all) to 5 (extremely). Some examples from the scale include inquiring whether MS has limited an individualâs ability to run or made it necessary to use support when walking outdoors in the past two weeks. Goldman et al. (2017) demonstrated the predictive validity of the MSWS-12 in predicting loss of functional independence for people with MS. Internal reliability for the present study was Cronbachâs alpha = .972. In line with how the scale has been validated, the overall item summative score was used in this study. MS Symptom Control Self-Efficacy. Study participants responded to the 9-item âcontrolâ subscale of the MS self-efficacy scale which assesses self-efficacy specific for controlling MS-related symptoms (Schwartz et al., 1996). This scale asks participants to rate their confidence in managing their MS-related symptoms on a scale from 0 (very uncertain) to 100 (very certain). An example item from this scale is: âAs of now, how certain are you that you can manage your MS symptoms so that you can do the things you enjoy doing?â. This scale has been validated for use in the MS population. It showed convergent validity with measures of a secondary functional self-efficacy subscale from the larger MS Self-Efficacy Scale (MSSE) (Schwartz et al., 1996). Internal reliability for the present study was Cronbachâs alpha = .953. In 22 line with the standard practice when using self-efficacy scales, and how this scale has been previously validated, the overall item mean was used in this study. Somatic Cognitive Errors were measured using the somatic subscale of the Cognitive Errors Questionnaire (CEQ) (Moss-Morris & Petrie, 1997). This is a 9-item subscale depicting cognitively errored somatic reactions to everyday situations in the form of vignettes, with responses rated on a 5-point scale from 1 (almost exactly like I would think) to 5 (not at all like I would think). Scores for somatic cognitive errors were reverse coded so that higher scores reflect higher levels of somatic cognitive errors. Questions on the scale are grouped into three categories: overgeneralization, selective abstraction and catastrophizing. An example vignette item is âRecently your job has been so demanding that you have worked straight through your lunch hour. As a result, you have been feeling increasingly fatigued and have had difficulties concentrating. Driving home from work, you think, âIf I donât get some time to relax during the day, I am going to have a total collapse and be unable to workââ. Previous research has accumulated evidence for construct validity for this measure in other chronic disease populations including chronic fatigue syndrome, chronic pain and depression and this measure has demonstrated predictive utility for examining the relationship between cognitive distortions and disability in a variety of illnesses (Moss-Morris & Petrie, 1997). Internal reliability for the present study was Cronbachâs alpha = .922. In line with how this scale has been used in other populations, the overall mean of the nine somatic items was used in this study. Demographics. Participants were asked to self-report the following demographic questions: age, gender, marital status, employment status, education level, Ethnicity, and length of time since MS diagnosis (years). 23 3.4 Data Analysis Data analyses were conducted using SPSS (version 28). Descriptive statistics (e.g., mean, standard deviation, frequencies) were used to summarize the demographics of the sample. Correlational analyses were conducted to examine the three hypotheses and the relationships between the study variables. A stepwise hierarchical multiple regression was used to examine study hypothesis three. Stepwise hierarchical multiple regression allows the researcher to enter sets of independent variables at different times (Field, 2018). Hierarchical multiple regression is often used in theory-based research to allow for the test of independent variables in a sequential order before other variables are added (Field, 2018). Weinstein (2007) has argued that researchers should control for established predictors, like past behaviour or self-efficacy (Motl et al., 2006), when examining new behavioural predictors. This type of regression allows researchers to examine the predictive contribution of new variables (i.e., somatic cognitive errors) before adding variables that have established relationships with the dependent variable (i.e., self-efficacy; Bandura, 1986). In step one of the regression, perceived disability, age, gender, and length of time since MS diagnosis (years) were entered as covariates since they are potentially important disease- and demographic-related factors that may impact the relationship between variables (Hobart et al., 2003). While there were multiple response options for self-reported gender, only those who identified as women and men participated in the study. For this reason, gender was dummy-coded for the regression analysis, with men coded as 0 and women coded as 1 (Field, 2018). When interpreting this dummy-coded variable, positive correlations of the dummy-coded 24 variable suggested women had higher scores on the variables while negative correlations suggested men had higher scores on the variables. In step two of the regression, somatic cognitive errors were entered. In step three, MS symptom-control self-efficacy was entered into the regression. According to Cohenâs (1988) effect size conventions for correlations are r â 0.10 represents a small effect, r â 0.30 is a moderate effect and r â 0.50 is a large effect. Multivariate statistical assumptions were tested and managed prior to the main analyses in line with Field (2018) and Tabachnick and Fidell (2007). The assumption of normality was assessed using Skewness and Kurtosis statistics. The assumption was met if values did not exceed 2. The assumption of influential multivariate outliers was assessed using the Mahalanobis distance. The assumption was met if observed values did not exceed the Chi-square critical value. The absence of influential multivariate outliers was determined if observed scores on the DIFFIT statistic did not exceed 2 or Cookâs distance of 1. The assumption of multicollinearity was assessed through the VIF and tolerance statistics. The assumption was met if observed VIF values did not exceed the critical value of 10 and tolerance values exceeded .01. Finally, the assumption of independence of errors was assessed using the Durbin- Watson statistic. The assumption was met if observed values fell below the critical value of 2, suggesting uncorrelated residuals. Only cases with complete data were used in the analysis. Thus, listwise deletions were made for cases with missing data per SPSS default. Chapter 4: Study Results This chapter will present the results of the study which examined psychological predictors of physical activity in people with MS, specifically whether symptom-control self-efficacy and/or somatic cognitive errors predict or relate to outcomes of perceived walking impairment in people with MS. First, study demographic findings will be discussed followed by 25 a brief review of study variable descriptives and correlations. Finally, results and findings for each of the three specific study hypotheses will be presented. All demographic information and statistical analyses will also be presented in table format at the end of the chapter. 4.1 Demographics A total of 210 participants accessed the online survey but only 105 were eligible for inclusion in the current study. The remaining 105 individuals were deemed ineligible due to incomplete responses to screening questions (n = 37), not having an MS diagnosis (n = 27), having PDDS scores greater than 6 (n = 25), being under the age of 18 (n=11), or being removed because of their ReCAPTCHA score (bot detection) (n = 5). The majority of participants identified as women (n = 69; 65.7%) who are white (n = 88). Table 1 outlines all sociodemographic information. There were 6.2% item-level data missing across all variables in the current study. The missing data were substituted with the scale mean. 4.2 Descriptive Statistics and Correlations PDDS score is typically measured on a scale from 0 (normal) to 8 (bedridden); however, participants with scores of 7 or 8 were excluded from the present study so the included scale was measured from 0-6. The study cohort reported a mean PDDS of 3.48 (SD = 1.97) representing moderate levels of disability/gait disability. Participants reported a low to moderate level of symptom-control self-efficacy (M = 57.04, SD = 23.43) on a scale ranging from 0 to 100. Participants reported near the middle of the somatic cognitive error scale (M = 2.73, SD = 1.08) on a scale ranging from 1 to 5 suggesting a moderate level of bias with higher scores reflecting greater bias. Participants, on average, reported a sum of 33.95 (SD = 14.36) on a scale from 12 to 26 60 for perceived walking impairment, suggesting moderate to quite a lot of perceived impairment. PDDS was significantly positively correlated with perceived walking impairment (r = .628; p = < .001). This represents a large effect size correlation. PDDS was also significantly negatively correlated with self-efficacy (r= -.370; p = < .001). This represents a moderate effect size correlation. PDDS was not correlated with somatic cognitive errors. Participant age was significantly negatively correlated with somatic cognitive errors (r = -.253, p = .009), a small effect size correlation, but showed no correlation with self-efficacy or perceived walking impairment. Gender was significantly negatively correlated with perceived walking impairment (r = -.271; p = .005) showing men/those who did not report gender had higher perceived walking impairment than women. This represents a small effect size correlation. Gender showed no correlation with self-efficacy or somatic cognitive errors. Years diagnosed with MS showed a significant negative correlation with somatic cognitive errors (r = -.379; p = < .001), showing a moderate effect size correlation, but showed no correlation with perceived walking impairment or self-efficacy. Somatic cognitive errors and self-efficacy were significantly negatively correlated (r = -.245; p = .012). See Table 2 for descriptive statistics and correlations between study variables. 4.2.1 Hypothesis 1: It was hypothesized that somatic cognitive errors would be positively correlated with perceptions of walking impairment. In support of hypothesis 1, somatic cognitive errors were significantly and positively correlated with perceived walking impairment (r = .336, p < .001). This represents a moderate 27 effect size correlation. As participantsâ level of somatic cognitive errors increased, their perceived level of walking impairment also increased. 4.2.2 Hypothesis 2: It was hypothesized that symptom-control self-efficacy would be negatively correlated with perceptions of walking impairment. In support of hypothesis 2, symptom control self-efficacy was significantly and negatively correlated with perceived walking impairment (r = -.363, p < .001). This represents a moderate effect size correlation. As participantsâ level of symptom control self-efficacy increased, their perceived level of walking impairment decreased. 4.2.3 Hypothesis 3: It was hypothesized that somatic cognitive errors would positively predict and account for a significant proportion of variance in walking impairment beyond the contribution of perceived disability and symptom-control self-efficacy. Prior to conducting the regression analysis, statistical assumptions for multiple regression were checked to ensure there were no violations (Cohen et al., 2003; Field, 2009). Data were normally distributed as evidenced by the skewness (all variables less than .41) and kurtosis (all variables less than 1.13) statistics which did not exceed two for any of the variables in our multiple regression. Furthermore, there were no univariate outliers as evidenced by the absence of standardization values exceeding +/- 3.29 SD of the mean and values of the Mahalinobis statistic were under the critical value (Χ2 = 16.37, df = 3). There were no influential outliers as evidenced by the DIFFIT statistic (values less than 2) and Cookâs distance (values less that 1). The assumption of independence of errors was considered met, as the residuals exhibited a value of 1.76. The final tested assumption was multicollinearity which were satisfied (observed 28 tolerance values greater than .86 and observed VIF values less than 1.23). Based on these statistics, no assumptions were violated, and we proceeded with the regression analysis. As only two response options for gender were self reported by participants, it was dummy coded (where man = 0 and woman = 1) and used as a covariate in the analysis. Findings from the regression analysis are summarized in Table 3. In step 1 of the multiple regression where covariates were entered, only the PDDS and gender were significantly associated with perceived walking impairment (PDDS: B = .652, p < .001; gender: B = .176, p < .05). In step 2, the addition of somatic cognitive errors was found to be significantly and positively associated with perceived walking impairment (B = .272, p < .001) beyond the covariates. The strength of this association was moderate in size. As somatic cognitive scores increased so did perceptions of walking impairment. The contribution of somatic cognitive errors significantly improved the model and accounted for an additional 6.2% of the variance. In step 3, the addition of the symptom-control self-efficacy did not significantly improve the model beyond the covariate of somatic cognitive errors and was not significantly associated with perceived walking impairment (B = -.114, p = .143). In this final step, the PDDS, gender, and somatic cognitive errors were all significant and accounted for 54.4% of the variance in perceived walking impairment, which represented a large effect size. 29 Table 1. Demographic information. Demographic variable (n = 105) Age M (SD) 41.88 (15.59) Years diagnosed with MS M (SD) 18.61 (11.36) Gender Woman Man Did not report Trans: Man to Woman Trans: Woman to Man Two-Spirited Inter-sexed Other: Please describe _____ 69 (65.7%) 23 (21.9%) 13 (12.4%) 0 0 0 0 0 Marital Status Married Single Widowed/divorced Other Did not report 58 (55%) 16 (15.2%) 16 (15.2%) 2 (1.9%) 13 (12.4) Employment Status Retired Currently working Not working/unable to work Did not report 38 (36.2%) 34 (32.4%) 20(19%) 13 (12.4%) Education College Diploma 33 (31.4%) University Degree or higher High school diploma Some high school 26 (24.8%) 32 (30.5%) 1 (1%) Did not report 13 (12.4%) Ethnicity N Caucasian/white 88 Asian 3 Black 3 Latinx 3 Other 3 30 Table 2. Variable means and correlations. Variables Mean (SD) PDDS Score Perceived walking impairment MSSE SCE PDDS Score 3.48 (1.97) Perceived walking impairment 33.95 (14.36)1 .628*** MSSE 57.04 (23.43) -.370*** -.363*** SCEs 2.73 (1.08) .043 .336*** -.245* Age 41.97 (15.41) .187 -.056 -.030 -.253** Gender .66 (.477) -.101 -.271** -.107 -.058 Years diagnosed with MS 18.42 (10.19) .174 -.077 .054 -.379*** Note: *p < .05; **p < .01; ***p < .001; 1Sum score of perceived walking impairment reported; Abbreviations: PDDS = patient determined disease steps; SCEs = Somatic cognitive errors; MSSE = Multiple sclerosis symptom control self-efficacy; Gender was dummy coded with men = 0 and women = 1; positive correlations with gender indicate women have higher values than men whereas negative correlations with gender indicate men have higher values than women. 31 Table 3. Results from regressions examining predictors of perceived walking impairment. Variable β Model statistics DV: Perceived walking impairment F(4,100) = 17.53, p < .001, r2 = .472 Step 1: PDDS .652*** Years diagnosed with MS -.113 Age -.114 Gender -.176* Step 2: F(5,99) = 15.84, p < .001, r2 = .534 PDDS .616*** Years diagnosed with MS -.018 Age -.078 Gender -.183* Somatic cognitive errors .272*** Step 3: F(6,98) = 13.45, p < .001, r2 = .544 PDDS .572*** Years diagnosed with MS -.009 Age -.81 Gender -.202** Somatic cognitive errors .247** Symptom control self-efficacy -.114 Note: *p < .05; **p < .01; ***p < .001. Abbreviations: DV = dependent variable; PDDS = Patient Determined Disease Steps; Gender was dummy coded with men = 0 and women = 1; positive correlations with gender indicate women have higher values than men whereas negative correlations with gender indicate men have higher values than women 32 Chapter 5: Discussion The purpose of this thesis study was to examine concurrent psychological predictors of perceived walking impairment for people with MS. Specifically, I examined whether symptom-control self-efficacy and/or somatic cognitive errors were associated with perceived walking impairment. The study involved an analysis of data collected as part of a larger MS study that sought to understand a range of psychological factors that may predict physical activity or related behaviours for people with MS. While physical activity was the primary outcome of the larger study, perceptions about walking impairment were also collected as an important secondary outcome measure that may contribute to the promotion of an active lifestyle for people with MS. This discussion chapter will provide an interpretation of the findings to determine whether symptom-control self-efficacy and/or somatic cognitive errors are associated with perceptions of walking impairment. Additionally, a brief discussion on the relationship of demographic covariates in the analyses will also be provided. The findings will be compared to existing literature, with new and supportive findings from this study being highlighted, and limitations of the current study being outlined. This discussion chapter will then discuss both the theoretical and practical implications of the current findings, inclusive of future research recommendations. 5.1 Discussion of Findings 5.1.1 Relationship between somatic cognitive errors and perceived walking impairment (hypothesis 1) While other studies have investigated the role of cognitive distortions of somatic experiences in both fatigue and social impairment in MS, as well as chronic/persistent pain, 33 depression and chronic fatigue among non-MS patients, to the best of my knowledge, this is the first study that has specifically examined the association between somatic cognitive errors and a behaviour-related variable (specifically walking impairment) in people with MS (Moss-Morris & Petrie, 2001; Moss-Morris, 2005; Skerrett & Moss-Morris, 2006). The first study hypothesis was that somatic cognitive errors would be positively correlated with individualsâ perceptions of their walking impairment. This hypothesis was supported, showing that as participantsâ level of somatic cognitive errors increased, impaired perceptions of their walking abilities also increased. This is a novel finding in the field of research surrounding people with MS. Additionally, this finding may suggest that in people with MS, perceptions of their walking impairment may not be completely accurate. Individuals who exaggerate their level of impairment from their disease generally tend to assess each aspect of their lives as worse and these impaired perceptions may cause individuals to become less likely to engage in health promoting behaviours, such as physical activity (Wilski & Tomczak, 2017). 5.1.2 Relationship between symptom-control self-efficacy and perceived walking impairment (hypothesis 2) Our study found, in support of hypothesis two, that symptom-control self-efficacy was significantly and negatively correlated with perceived walking impairment. As participantsâ level of symptom-control self-efficacy increased, their perceived level of walking impairment decreased indicating that those with more self-efficacy had lower levels of perceived impairment related to walking. This finding supports the finding of Sikes et al. (2019) who reported a strong negative correlation between self-efficacy and perceived walking impairment accounting for 45% of variance in perceived walking impairment for young adults (β = -.67) and 48% of 34 variance in older adults (β = -.69) with MS. Uszynski et al. (2018) also found that self-efficacy was significantly associated with perceived walking impairment (β = .297). The strength of association and proportion of variance in these studies were similar to that of the current study. More broadly, this finding also aligns with suggestions that self-efficacy is an important behavioural predictor in people with MS. For example, Motl et al. (2009) found that those with higher symptom-control self-efficacy were more likely to engage in physical activity programs and Riemann-Lorenz et al. (2020) reported recovery self-efficacy (oneâs beliefs about their ability to resume an action after a lapse) as a predictor of adherence to physical activity (Luszczynska et al., 2007). 5.1.3 Examining predictors of perceived walking impairment (hypothesis 3) Another novel contribution of this research comes from the analysis of hypothesis three which predicted that somatic cognitive errors would be positively associated with, and account for, a significant proportion of variance in walking impairment beyond the contribution of perceived disability, symptom-control self-efficacy and other covariates. In this analysis, the addition of somatic cognitive errors was found to be significantly and positively associated with perceived walking impairment beyond the covariates. Of note, while symptom-control self-efficacy was correlated with perceptions of walking impairment on itsâ own, in the regression analysis self-efficacy was not significantly correlated beyond the covariates (including somatic cognitive errors). This finding was contrary to previous literature exploring self-efficacy in people with chronic disease, which has shown that self-efficacy is a consistent predictor of physical activity for individuals with MS (Casey et al., 2018; Fasczewski et al., 2018). One possible explanation for this important finding is that beliefs and perceptions that are negatively 35 valenced tend to be more similarly related to each other, than are negative perceptions with positive perceptions. In other words, somatic cognitive errors (a negative perception) may be more likely linked to perceived walking impairment (a negative perception) than self-efficacy (positive perception). This relationship has been demonstrated in literature exploring self-compassion, which found the uncompassionate components of self-compassion (e.g., self-judgments) accounted for a larger percentage of explained variance in negative psychopathological symptoms than scores on compassionate characteristics (e.g., self-kindness; Muris et al., 2018). Put simply, negative psychological phenomena may tend to stick together. In the present study, individualâs negative perceptions, measured as somatic cognitive errors, were more significantly associated with perceptions of walking impairment than their positive self-efficacy beliefs were. 5.1.4 Examining associations with demographic variables Years since diagnosis and age were both significantly negatively correlated with somatic cognitive errors, with years since diagnosis being more strongly correlated than age. It could be that as people age, they develop better self-management skills through experience (Takahashi et al., 2004). Those who had been diagnosed with MS for longer showed less exaggeration in their symptoms and perceived barriers. This may be because those who are early in their diagnosis may still be adjusting to it, with the potential for overall greater psychological distress compared to those who have been living with MS for longer durations. Both these relationships could possibly be due to people having more experience living with their disease, learning from their real experience (and therefore being less able to exaggerate potential outcomes) and/or becoming more adjusted and/or stabilized in their MS treatment(s) and management (Clark & Bennett, 36 2013). Studies have shown that people faced with chronic physical illness report personal growth over time arising from their illness and many even find benefit from their chronic disease (Danoff-Burg & Revenson, 2005). Benefits identified over time include deepened interpersonal relationships, an enhanced sense of spirituality or life purpose and a satisfaction from educating others on how to live with the same chronic illness (Danoff-Burg & Revenson, 2005). Others reported learning to accept help from others was something that had to develop over time following their diagnosis (Danoff-Burg & Revenson, 2005). Overall, research has shown that individuals can build self-management skills as they learn to live with their chronic conditions. Gender was found to be negatively correlated with perceived walking impairment, with men perceiving greater impairment than women. There was no significant association found between gender and actual impairment (measured with the PDDS). This finding could suggest that while gender was not associated with different levels of walking impairment, men in the sample perceived themselves as having greater impairment than women did. These observed differences between men and women could be related to their varied socialization experiences related to masculine and feminine roles and identities (Racine et al., 2012). This finding, however, differs from previous research by Solaro et al. (2015). The perceived walking impairment scale (MSWS-12) has been previously validated with a norming sample showing no significant differences between mensâ and womensâ reported perceptions of walking impairment (Solaro et al., 2015). While the men in our sample reported similar walking impairment scores as Solaro et al.âs participants, our sample deviates from this norming sample as the women in our sample reported much lower levels of perceived impairment. This lower reporting by women may explain why men in our sample appeared to report more perceived walking impairment when, in fact, they reported similar levels to participants in Solaro et al.âs findings. 37 5.2 Theoretical Implications The findings of hypothesis one and three support Beckâs (1976) model of cognitive errors which suggests that cognitive errors can perpetuate negative states or thoughts and should be associated with other cognitive and behavioural variables. While Beckâs (1976) cognitive error model was originally conceptualized to explain the development and maintenance of depression (including its role in leading people to not engage in health-promoting behaviours), there may be a similar impact of other somatic cognitive errors on why people are not engaging in these behaviours. Somatic cognitive errors are specific cognitive errors that focus on a personâs physical experience, and it can be theorized that these errors would bias peopleâs specific perceptions of how impaired their walking is and/or their overall walking ability. It may be that perceptions of walking impairment are, in part, governed by somatic cognitive errors or related thought processes or patterns of thinking. Research regarding thoughts and beliefs people have about their health has shown that demoralizing or negative thoughts do not support the manifestation of health-promoting behaviours (Shnek et al., 1997). If an individual thinks they are not able to walk as well as they are able to, they may be less likely to engage in the physical activity based on this biased, inaccurate perception (Motl et al., 2015). Other research, including a study by Locke & Brawley (2018), found that exercise-related cognitive errors (ECE) were associated with lower physical activity levels in people with MS and has clearly identified the role cognitive errors play in peopleâs engagement in physical activity. In their study of patients with depression, William and Garland (2002) found these thoughts may not actually be errored or wrong, but could be true or accurate, but still unhelpful. Following this discovery, they proceeded to use the term âextreme and unhelpful thoughtsâ, which may better lend itself to the complex nature of peopleâs thinking 38 patterns. Although depression was not the focus of the current study it is possible that patients with MS accurately perceived their inability to enage in mobility/walking because of symptom flare-ups, making activity inappropriate, during this time. There remains ongoing debate in the literature regarding the appropriateness of the term âcognitive errorâ and whether these ways of thinking are, in fact, errored, or if there are more appropriate terms that could be utilized to describe these unhelpful patterns of thinking. The findings of hypothesis two in the present study support Banduraâs (1986) Social Cognitive Theory, as participants with increased symptom-control self-efficacy had less impaired perceptions of their walking impairment, reaffirming self-efficacy as an important theoretical antecedent of behaviour. What is most interesting in the current findings is the discovery in hypothesis three that self-efficacy did not account for a significant proportion of variance in walking impairment beyond the contribution of perceived somatic cognitive errors. A possible theoretical explanation for this is that the Social Cognitive Theory (Bandura, 1986) does not include a construct that explicitly accounts for biased or inaccurate perceptions, even though Bandura (1997) has suggested that an individualâs beliefs are not always accurate. In fact, there is convincing evidence that peopleâs interpretations and decision-making are often biased (Tversky et al., 1990). Despite this knowledge, much research to date has been designed in a manner that assumes self-efficacy is bias-free. The findings of the present study support a need for additional theoretical research to understand the role of biases in how individuals view their self-efficacy experiences (including of chronic illness). People who display somatic cognitively errored thinking may evaluate their self-efficacy through the lens of this errored thinking. For example, an individual may think âthe last time I watched the children on the playground I was so exhausted I couldnât return to work laterâ (somatic cognitive error) and may evaluate their 39 overall self-efficacy through this cognitively errored thought. If the negative feelings associated with the somatic experience are then internalized, the individual may interpret this as having lower personal confidence (i.e., self-efficacy) for performing this activity in the future. 5.3 Implications for Practice While the present study is cross-sectional in nature, and cannot confirm causality, if the findings were confirmed by future experimental research, there may be significant implications for healthcare practice and those working in health promotion, chronic disease self-management or other relevant areas. Self-efficacy and other psychological factors may be taught in some entry-level healthcare programs; however, they are likely not well understood by healthcare providers. For example, many traditional methods by which patients receive information from healthcare providers include verbal or written communication during an in-person or virtual visit and while these passive approaches to education may facilitate some increase in understanding, they may not actually contribute to a person developing self-efficacy or making meaningful behaviour change (Farley, 2019). Given the importance of building self-efficacy, it may be appropriate to provide consistent education on psychological variables, with a focus on the role that perceptions like cognitive errors or self-efficacy may play in chronic disease self-management. Promoting physical activity is important for people with MS (Motl & Gosney, 2008). Healthcare providers, and others who work in areas of health promotion and chronic disease self-management must have a strong focus on how to support patients to remain physically active. Understanding factors that contribute to how people view their physical walking impairment remains of utmost importance, given their direct connection to a personâs quality of life (Motl et al., 2006). Within Beckâs (1976) model of cognitive errors, cognitive reframing is an evidence-40 based strategy used to target and reduce the impact of cognitive errors. Cognitive reframing is a strategy designed to help people challenge the accuracy of their thoughts. It aims to help people identify their core thoughts and any biases that contribute to inaccuracies in their thinking (Leahy, 2017). Cognitive reframing has been shown in exercise literature to be effective at modifying biased barrier perceptions, reducing peopleâs struggles with exercise and helping people to increase their physical activity (Locke et al., 2019). As cognitive reframing techniques do not require a lot of extensive training, general health practitioners who work with people with MS could be taught how to perform cognitive reframing to promote mobility and physical activity in this population. Reframing can be taught to practitioners who do not have a background in psychology or counselling (Locke et al., 2019). The present study highlights a need to consider the potential impact of somatic cognitive errors on people with MSâ perceptions of their walking impairment when designing care plans and care interventions. This is especially true for nurses when seeking to provide a holistic, client-centred approach to care planning. A significant contribution of the present findings is highlighting that a personâs perception of their walking impairment is not the same as their actual level of impairment; peopleâs perceptions can be inaccurate. Sometimes, it is more difficult to change peopleâs actual behaviour than it is to change their perceptions (Wadden et al., 2007). If perceptions are more directly related to why people are less mobile (versus actual impairment), this may have important implications for interdisciplinary teams working with patients as perceptions may be more easily targeted to adapt (Dennison et al., 2009). Healthcare providers can consider questioning, more intentionally, what might be happening with an individual patient when interventions targeting their actual walking ability may be unsuccessful (e.g., âThis person has the physical ability to walk; we have been working on this with interventions, so what else is 41 going on here?â). Additionally, the current findings highlight the importance of considering demographic moderators (for example, gender) when exploring a personâs perceptions and designing care plans and interventions. 5.4 Study Limitations There are several limitations to the present study that warrant consideration. The study employed a cross-sectional research design which limits the findings to a single point in time, preventing the ability to interpret findings as causal. While our independent variables did show significant correlation to our dependent variables, the causal direction (i.e., does one cause the other?) of these relationships cannot be determined by the present study. Additionally, changes over time cannot be measured in a cross-sectional study (Cook et al., 2002). Another limitation of this study was the recruitment method of online, convenience sampling. Online recruitment has several limitations, including the potential to create a sampling bias by excluding individuals who do not have access to, or do not frequently access, the internet. Additionally, studies that recruit participants online are susceptible to data quality issues (e.g., fraudulent responses) (Pozzar et al., 2020). As the study was advertised about physical activity, the method of convenience sampling may introduce a potential source of bias by attracting participants who are more physically active or have an existing interest in physical activity, thus potentially limiting the generalizability of the findings to the broader population of people with MS. Further, the limited demographic composition, with a high prevalence of white, middle-aged women participants warrants caution in generalizing the findings to the broader population. Additionally, while the Qualtrics panel aggregator ensured that only participants located in Canada or the United States be included in the data collection, participants were not asked specifically to report 42 which country they live in, or what type of region (e.g., rural, urban) so this limits generalizability of the findings across different demographic regions. Particular covariates of interest that were not collected in the current study, which may have introduced limitations, are comorbid diagnosis of depression and whether those with a relapsing-remitting MS diagnosis were currently experiencing a symptom flare up. As cognitive errors were initially conceptualized in people with depression, it is possible that those with MS who are also depressed may be experiencing these due to their depression. Distinguishing between those who were in an active MS flare up (and therefore may be accurate, and not errored, in their current perception that they were more impaired) and those who were not in a flare up, may have helped better clarify whether the âcognitive errorsâ were actual errors in thinking, or in true alignment with someone in the midst of a symptom flare up. There were other potential covariates that could have been included in the study; however, these were intentionally excluded in the present study to increase the overall statistical power of the research findings. 5.5 Future Research Directions As the present study was not intervention based, there is a need for further research before specific practice implications can be appropriately purported. Further research examining the role of cognitive biases in predicting exaggerated mobility perceptions is warranted. This is especially true given the body of convincing evidence which highlights the importance of engagement in physical activity by people with MS both for symptom management and overall psychosocial well-being (Motl & Gosney, 2008). More broadly, there is a lack of intervention research on cognitively errored thinking and its impact on behaviour-related variables (e.g., walking impairment) for people with MS, and future research in this area is warranted. Building on insights from the current study, it would be prudent to conduct experimental studies in an 43 attempt to define the temporal stability of the relationship between the variables. If results are confirmed, and causality can be established, further intervention-based research investigating modifiable cognitive factors (perhaps alongside fluctuations in disease symptoms/progression over time) may also provide valuable insight into potential strategies for correcting or mitigating cognitive errors in people with MS. There is also an opportunity for future research to focus on the appropriateness of measures used to assess cognitive errors, or unhelpful thinking styles, across populations. The cognitive errors questionnaire utilized lengthy vignettes that may not be relevant or resonate with all individuals. Future research could explore other formats that may be more appropriate measures for assessing these complex thinking patterns. For example, a tool that provided broad examples that could be tailored to an individualâs personal experience may be beneficial. Evidence clearly supports the significant impact of mobility impairment for individuals with MS and the benefits of physical activity for people with MS. From this perspective, the current findings suggest there is a significant need to understand somatic cognitive errors (which may be modifiable by intervention) more fully, including their impact on perceptions of walking impairment (and engagement with physical activity, more broadly) in a meaningful way (Motl & Gosney, 2008; Motl et al., 2006). Following more confirmatory studies, future experimental research should focus on intervention-based studies exploring the role of behavioural modification interventions in preventing or correcting cognitively errored thinking in people with MS, to promote mobility. For example, a possible intervention-based future study could explore the use of cognitive reframing in reducing the impact of somatic cognitive errors on perceptions of mobility impairment in people with MS. Future research should explore whether walking and physical activity engagement in people with MS reflects truly errored thinking, or whether it 44 reflects accurate, but potentially unhelpful, thinking (for e.g., comparing unhelpful or errored thinking when someone is in a disease flare-up with when they are in a remission). Future research should also explore whether there are better or more acceptable terms that can be used to more clearly and meaningfully delineate the difference between errors in thinking and unhelpful thinking styles. Future research addressing perceptions of mobility impairment in people with MS should include knowledge users (e.g., people with living experience of MS) in all stages of the research, from designing the questions/scales until research dissemination. Research can have more impact when knowledge users/partners are integrated throughout the research process (Canadian Institutes of Health Research, 2024). 5.6 Conclusion The main purpose of this study was to examine psychological correlates, specifically self-efficacy and somatic cognitive errors, and their association with perceptions of walking impairment in people with MS. The findings of this research help to highlight the important role of a personâs self-efficacy and somatic cognitively errored beliefs on their perceptions of their walking impairment. Those with higher self-efficacy displayed lower levels of perceived walking impairment, while those with higher scores for somatic cognitive errors displayed higher levels of impaired mobility perception. 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International Journal of MS Care, 15(2). 90-97. https://doi.org/10.7224/1537-2073.2012-032 60 Appendix A Literature Review Data Extraction Table Citation N M age % women Study Design Research Design Outcome variable(s)/measure(s) Main findings Casey et al., 2018 59 42 84.6 Cross-sectional Quantitative Physical activity was measured through the SenseWear Armband (SWA) Self-efficacy (Exercise Self-Efficacy Scale (EXSE) (McAuley, 1993)) Walking endurance/ Impact of walking (12-Item MS Walking Scale (Hobart et al., 2003)) Self-efficacy was significantly associated with physical activity and explained 9.1% of physical activity behaviour in the sample The relationship between self-efficacy and physical activity was stronger when the presence of anxiety was lower No other variable statistically moderated the relationship between self-efficacy and physical activity MS symptoms including depression and walking limitations were significantly associated with self-efficacy Dymecka et al., 2021 137 46.5 53.28 Cross-sectional correlational study Self-efficacy Self-efficacy was a significant predictor of the psychological aspect of quality of 61 Citation N M age % women Study Design Research Design Outcome variable(s)/measure(s) Main findings Multivariate regression analysis (Liverpool Self-efficacy Scale (LSES) (Airlie et al., 2001)) Physical impact/ disability of MS (Multiple Sclerosis Impact Scale (MSIS-29) (Hobart et al., 2001); Expanded Disability Status Scale (EDSS), (Kurtzke, 2015)) life and showed a strong correlation with both dimension of Health-related quality of life (HRQoL) Self-efficacy was a significant predictor of MS patientsâ functioning Statistically significant positive correlation between HRQoL and degree of motor impairment Fasczewski et al., 2018 15 (highly active with MS) 40.3 73.3 Mixed methods with a focus on qualitative interviews Self-Determination Theory Online survey followed by semi structured telephone interviews with Self Determination Scale (SDS) (Sheldon & Deci, 1996) Quality of Life Survey (Gill et al., 2011) Satisfaction with Life Scale (Diener et al., 1985) Consistent with self-determination theory: participants described feelings of accomplishment and competent in physical activity and daily life, sense of independence and autonomy (when remained physically active) Main theme identified: enhanced satisfaction with life and overall positive outlook (when remained physically active) 62 Citation N M age % women Study Design Research Design Outcome variable(s)/measure(s) Main findings open-ended questions (n = 8) Godwin Leisure Time Physical Activity Scale (Godin & Shephard, 1985) Physical activity level was highly correlated with self-efficacy for PA participation (r = 0.728, p < 0.01) â individuals who believed they had the ability to be active were more likely to be active PA also highly correlated with SE for ability to live a normal life (r = 0.734, p < 0.01) All participants reported experiencing benefits of PA related to controlling MS symptoms and improving QOL Moss-Morris & Petrie, 2003 49 (With CFS: n = 25; healthy 46.96 87.75 25 individuals with CFS were compared to 24 healthy matched controls completing a modified Stroop task and an ambiguous Modified Stroop task Ambiguous cues task Chronic fatigue symptom (CFS) patients showed an interpretive bias for somatic information which may contribute to maintaining the disorder by heightening their experience of physical symptoms 63 Citation N M age % women Study Design Research Design Outcome variable(s)/measure(s) Main findings control: n = 24) cues task to investigate information processing biases in CFS patients and maintaining their negative illness schemas. On ambiguous cues task, CSF patients made significantly more somatic interpretations than controls; this bias was significantly associated with the extent they reported symptoms. Motl & McAuley, 2009 292 48 83.9 Prospective study Participants wore an accelerometer for 7 days and completed a battery of questionnaires at baseline, on day 8 and 6 months later at follow up Godin Leisure-Time Exercise Questionnaire (Godin & Shepherd, 1985) ActiGraph single-axis accelerometer Leeds Multiple Sclerosis Quality of Life Scale (LMSQOP) (Ford et al., 2001) Satisfication with Life Scale (SWLS) (Diener et al., 1985) Change in physical activity was associated with a small residual change in QOL over time. At baseline: Those who were more physically active reported higher levels of self-efficacy for managing MS. Those who reported higher levels of self-efficacy for controlling MS reported higher levels of QOL. At follow-up: 64 Citation N M age % women Study Design Research Design Outcome variable(s)/measure(s) Main findings MSSE (Schwartz et al., 1996) Change in physical activity was associated with residual changes in self-efficacy for managing MS. Changes in self-efficacy for controlling MS was associated with a residual change in QOL. Riemann-Lorenz et al., 2020 1027 44.5 76 Mixed methods Qualitative semi-structure interviews with MS exercise experts; thematic analysis informing questionnaire development Quantitative questionnaire for PwMS Descriptive analysis HRQoL (SF12 Physcial and Mental Health Summary Scales (Ware et al., 1995)); Hamburg Quality of Life Questionnaire in Myltiple Sclerosis (HAQUAMS) (Gold et al., 2001)) Physical Activity (Godin Leisure-Time Exercise Questionnaire (GLTEQ) (Godin et al., 1985) Those who are less active had more negative perspectives on their illness than those who are active. Those who are not regularly active had lower self-efficacy levels than those who are currently or long-term active 65 Citation N M age % women Study Design Research Design Outcome variable(s)/measure(s) Main findings Beliefs about capabilities: Action, maintenance, and recovery self-efficacy; The Brief Illness Perception Questionnaire Skerrett & Moss-Morris, 2006 149 44.5 85 Cross-sectional questionnaires Cognitive and Behavioural Responses to Symptoms Questionnaire (Moss-Morris et al., 2003): â¢ Contains 6 measures- the first measures somatic attributes Patientsâ cognitive interpretations of their symptoms (e.g. tendency to attribute a wide range of symptoms to MS; feelings of embarrassment re: symptoms) were significantly associated with fatigue and social adjustment Almost all cognitive variables showed significant positive associations with physical and mental fatigue and social impairment. â¢ Somatic function was unrelated to mental fatigue but did show small significant associations to physical fatigue and social adjustment 66 Citation N M age % women Study Design Research Design Outcome variable(s)/measure(s) Main findings Treatment approaches that challenge unhelpful cognitive interpretations and behavioural responses to symptoms may be important in improving the overall management of fatigue in MS Wilski & Tasiemski, 2016 257 47.9 66.9 Cross-sectional study Hierarchical multivariate regression analysis Self-efficacy (General Self-Efficacy Scale (GSES) (Schwarzer & Jerusalem, 1995)) HRQoL (MSIS-29 (Hobart et al., 2001)) Self-efficacy was a significant correlate of HRQoL General self-efficacy was a significant predictor of psychological HRQoL domain General self-efficacy was the only correlate of both HRQoL dimensions Wilski & Tomczak, 2016 264 49.3 65.1 Cross-sectional survey of PwMS compared with physician assessment of health status Self-efficacy (University of Washington Self-Efficacy Scale (UW-SES, Multiple Sclerosis Version, 2016)) Participants with realistic or underestimated impact of their MS presented with significantly higher self-efficacy levels than those who overestimated the impact of their MS (when compared with physician objective assessment measure) 67 Citation N M age % women Study Design Research Design Outcome variable(s)/measure(s) Main findings Linear regression analysis Physical functional ability (MSIS-29 Physical Scale, 2004) Patients who overestimated the impact of their disease generally tended to assess each aspect of their lives as worse (lower self-esteem, body perception, etc.) 68 Appendix B Participant Information and Consent Form Examining the relationship between physical activity and illness-related perceptions for people with Multiple Sclerosis (MS) Principal Investigator: Dr. Sean Locke Ph.D., Assistant Professor, Department of Kinesiology, Brock University, slocke@brocku.ca INVITATION Your participation in this study is voluntary and you are being invited to take part in this research study to examine the relationship between exercise participation and illness-related perceptions for people with Multiple Sclerosis. BACKGROUND & STUDY PURPOSE Exercise is related to improved quality for life in persons with MS. Despite this, low rates of participation in physical activity are still observed in people with MS. The purpose of this study is to examine if exercise and illness-related perceptions are related to the exercise habits of people with MS. WHO CAN PARTICIPATE IN THIS STUDY? Adults aged 18 years or older who have been diagnosed with Multiple Sclerosis and are classified as 6 or lower on the Patient-Determined Disease Steps scale are eligible to participate (i.e. individuals who do not use a wheelchair as their main form of mobility). WHAT DOES THE STUDY INVOLVE? You will be asked to complete an online questionnaire about your perceptions of your health status and motivations to exercise. The total time commitment is approximately 15 minutes. WHAT ARE THE POSSIBLE HARMS AND BENEFITS OF PARTICIPATING? It is possible that some may experience discomfort due to the nature of some of the questions being asked. If you have concerns related to these issues, please consult with your physician. Information about the Canadian Mental Health Association (CMHA) can be found at the following website: https://cmha.ca/. Information about the National Institute of Mental Health can be found at the following website: https://www.nimh.nih.gov/index.shtml. Participants may be more motivated to exercise after being asked to reflect on their exercise thoughts and participation. You will be compensated the amount you agreed upon before you entered into the survey. WHAT HAPPENS IF I DECIDE TO WITHDRAW MY CONSENT TO PARTICIPATE? 69 Your participation in this study is entirely voluntary and you may refuse to participate or withdraw from the study at any time without any explanation. If you choose to withdraw, you can close out of the browser. If you have partially completed the survey your data will be retained, unless you go back and delete your responses. Your compensation for partial completion will be in accordance to your agreed upon terms. You are also free not to answer any of the questions that you feel uncomfortable with. Your data is anonymous and once you submit your responses you will be unable to remove it. WILL MY TAKING PART IN THIS STUDY BE KEPT CONFIDENTIAL? Your confidentiality will be respected. We will not collect any personal information and your responses will be anonymous. All data collected from these questionnaires will be stored on an encrypted server and password protected computers and will be accessible only to the research team. All records will be retained for a minimum of 5 years after publication. Any information you provide will be treated with confidentiality. Access to the data will be restricted to the principal investigator and research assistants. However, please note that some journals now require us to provide anonymized data to other researchers for verification purposes only. If required, we will upload our data with no identifying information onto an open access repository for this purpose only. WHO DO I CONTACT IF I HAVE QUESTIONS ABOUT THE STUDY DURING MY PARTICIPATION? If you have any questions or desire further information with respect to this study, you may contact Dr. Sean Locke via email at slocke@brocku.ca or via telephone at +1 (905) 6885550 x4958). PUBLICATION OF RESULTS Results of this study may be published in professional journals and presented at conferences. The results will involve group findings only. A summary of results will be available in Winter 2021 (either by mail in hard copy or electronically by email). Would you like to receive a copy of the studyâs main results when the study has been completed? Yes/No â Yes, Iâd like to be informed about future research opportunities. If you said yes to either of the above questions, please enter in your email address. [EMAIL BOX WILL BE INSERTED HERE] ___________________ WHO DO I CONTACT IF I HAVE ANY QUESTIONS OR CONCERNS ABOUT MY RIGHTS AS A SUBJECT? If you have any questions about this study or require further information, please contact the principal investigator using the contact information provided above. This study has been reviewed and received ethics clearance through the Office of Research Ethics at Brock 70 University (File # 20-102). If you have any comments or concerns about your rights as a research participant, please contact the Office of Research Ethics at (905) 688-5550 Ext. 3035, reb@brocku.ca. If youâd like to be informed of future research opportunities, please check the box below and provide your email address. WOULD YOU LIKE TO KEEP A COPY OF THE CONSENT FORM? If you would like a copy of this consent form for your records, you may print a copy of this page from your web browser. PARTICIPANT CONSENT Your participation in this study is entirely voluntary. Your survey responses are anonymous. Once you click submit and complete the study, we will be unable to remove your data. If you would like to participate, please click on the ânext pageâ button to begin. This will indicate that you have read and understood the above information and have consented to participate in this study. If you do not wish to participate, please exit this website. Thank you in advance for your participation. 71 Appendix C Online Study Recruitment Post Study Ad title alternatives: Note: within Kijiji or craigslist, itâs difficult to determine which titles will be most receptive to prospective participants. We have included 3 different versions to try to most effectively attract prospective participants. 1. Join our short study looking at exercise and illness-related perceptions for persons with multiple sclerosis. 2. Do exercise and illness-related perceptions affect the fitness habits of people with Multiple Sclerosis (MS)? Complete our short survey 3. Do you have Multiple Sclerosis (MS)? Join our study on the possible connections between illness and exercise-related perceptions Online ad Body: What is the Purpose of the Study? The purpose of the study is to understand whether exercise and illness-related perceptions are related to physical activity engagement for individuals with Multiple Sclerosis. Are you eligible? Adults age of 18 years or older who have been diagnosed with Multiple Sclerosis and are classified as 6 or lower on the Patient-Determined Disease Steps scale are eligible to participate (i.e. individuals who do not use a wheelchair as their main form of mobility). Whatâs involved: 1. Find our survey 15-minute online survey and consent form by clicking here. 2. Benefits of participating: Youâll be entered to win a $50 Amazon giftcards for participating! Primary Investigator: Dr. Sean Locke Ph.D., Assistant Professor, Department of Kinesiology, Brock University, slocke@brocku.ca Study title: Examining the relationship between physical activity and illness-related perceptions for people with Multiple Sclerosis (MS) This study has been reviewed and received ethics clearance though the REB (file # 20-102) on all recruitment materials. Remember: Comments and likes on this post are public and your anonymity for participating in the study may be compromised is you choose to comment on or like this post.
Thesis/Dissertation
eng
Nursing
Vancouver : University of British Columbia Library
Attribution-NonCommercial-NoDerivatives 4.0 International
Graduate
Rush, Kathy L.
Locke, Sean
An examination of the association of symptom-control self-efficacy and somatic cognitive errors with perceptions of walking impairment in people with multiple sclerosis : a quantitative study
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