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  Table of Contents 
Year : 2019  |  Volume : 22  |  Issue : 4  |  Page : 460-468

Relationship between self-efficacy and pain control in Iranian women with advanced knee osteoarthritis

1 Department of Orthopaedics, Shohada Medical Research and Training Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
2 Department of Medical Surgical, Nursing and Midwifery Faculty, Haematology and Oncology Research Centre, Tabriz University of Medical Sciences, Tabriz, Iran
3 Department of Medical Surgical, Nursing and Midwifery Faculty, Tabriz University of Medical Sciences, Tabriz, Iran
4 Department of Anaesthesia/Pain and Palliative Care Unit, Multidisciplinary Oncology Centre, College of Medicine, University of Nigeria, Enugu Campus, Nigeria
5 Department of Statistics and Epidemiology, Faculty of Health, Road Traffic Injury Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
6 Department of Orthopaedics, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran

Date of Acceptance06-Nov-2018
Date of Web Publication11-Apr-2019

Correspondence Address:
Dr. A Ghahramanian
Medical Surgical Department, Nursing and Midwifery Faculty, Haematology and Oncology Research Centre, Tabriz University of Medical Sciences, South Shariati St, Tabriz, East Azerbaijani
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/njcp.njcp_437_17

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Objectives: This study aimed to determine the relationship between pain of osteoarthritis (OA) and body mass index (BMI), age, pain control strategy, self-efficacy for pain control, exercise, and functional activities in a cohort of Iranian women. Subjects and Methods: In total, 150 women with advanced knee OA, candidates for arthroplasty in Tabriz, in the Northwest of Iran were enrolled into the study. A convenience sampling method was used, and data was collected using demographic form, short-form McGill pain questionnaire, pain self-efficacy questionnaire, self-efficacy for exercise, and functional activities scales. Results: The present pain intensity of 74.7% of women was described as excruciating with mean (±SD) score 9.58 (±0.77) in the visual analogue scale. The majority of the women had a low self-efficacy for pain, exercise, and functional activities with means of 31.8, 17.28, and 57.63 respectively. There was a significant inverse relationship between sensory and affective components of pain and self-efficacy for pain control and functional activities (P < 0.001). The sensory and affective components of pain was related to age (P < 0.05), pain control self-efficacy (P < 0.01), and BMI (P < 0.05). A great majority of the women (79.33%) used complementary medicine (CM) for pain management. Those who used CM reported lower pain and higher self-efficacy (P < 0.01). Conclusion: The findings of this study suggest that life style modification and pain management education of women with OA and nurses on non-pharmacological interventions as well as integration of these into nursing care is essential.

Keywords: Complementary medicine, osteoarthritis, pain control, self-efficacy, women

How to cite this article:
Mirmaroofi N, Ghahramanian A, Behshid M, Jabbarzadeh F, Onyeka T C, Asghari-Jafarabadi M, Ganjpour-Sales J. Relationship between self-efficacy and pain control in Iranian women with advanced knee osteoarthritis. Niger J Clin Pract 2019;22:460-8

How to cite this URL:
Mirmaroofi N, Ghahramanian A, Behshid M, Jabbarzadeh F, Onyeka T C, Asghari-Jafarabadi M, Ganjpour-Sales J. Relationship between self-efficacy and pain control in Iranian women with advanced knee osteoarthritis. Niger J Clin Pract [serial online] 2019 [cited 2021 May 17];22:460-8. Available from:

   Introduction Top

Osteoarthritis (OA) is a degenerative joint disease. Pathological changes resulting from OA not only damages the joint cartilage but also destroys all joint structures.[1] Symptomatic knee OA occurs in 10% men and 13% in women aged 60 years or older. The number of people affected with symptomatic OA is likely to increase owing to the aging of the population and the obesity epidemic.[2] This disease is the most common form of the adult joint disease worldwide with limitation of range of motion in 11% of cases reported.[3] The prevalence of OA increases with age,[4] female gender, overweight, and obesity,[2] and it is estimated that by 2020, a 60% increase in the incidence of OA and motor function limitation will occur.[5] It has been shown that women are more severely impacted by knee OA. Differences in knee anatomy, kinematics, previous knee injury, and hormonal influences may play a role.[6]

The knee joint is the most common weight-bearing joint to be involved in OA.[7] The common symptoms of knee OA are pain, stiffness, limited range of motion, joint deformities, and muscle wasting and weakness.[8] The prevalence of knee OA as the causative agent of musculoskeletal pain among people age 65 or older is between 60 and 90%.[9] OA is one of the main reasons for dysfunction, impacting significantly on people's lives in the areas of mobility, independence, and activities of daily living (ADL), and can lead to limitations in recreational, sports, and occupational activities.[10] Knee OA is the most common cause of chronic disability in house-bounded adults.[11] Patients with knee OA suffer from a progressive disability in walking, going up, and down stairs[12] due to pain and stiffness. The aim of treatment and care is to relieve pain, maintain joint mobility, and minimize disability.[13] There may be a perception that women's symptoms are an exaggeration. Some physicians may attribute part of their patients' complaints to being “emotional” or overly dramatic.[14] In addition, women may be more willing to forgo surgery and accept disability and less willing to accept the risks of surgery and any disruption in their care giving responsibilities,[15],[16] and for these reasons, women may suffer more in the disease.

Changes in clinical practice for physicians and nurses can play an important role in early detection and appropriate management of patients' pain.[17] In addition, considering that pain relief is required for fast recovery and achieving the optimal range of motion,[18] it seems that healthcare providers' efforts can improve pain control and patient movement ability simultaneously. Evidence suggests that the improvement of self-efficacy leads to self-care activities, improvement of health, and reduction of the severity of pain and pain-related dysfunctions.[19],[20] The concept of self-efficacy refers to the belief that one can confidently execute a task,[21],[22],[23] the person's belief in his/her ability to organize, and implement the measures required to achieve the treatment aims which in turn can help with the improvement of social and motor functions.[24] In addition, it has been noted that people with higher self-efficacy make more efforts to manage pain.[25] Empowering patients with persistent pain through arthritis self-management education can lead to improvements in pain self-efficacy (PSE) and opioid misuse measures,[26] especially when such education is given alongside standard medical care.[27],[28]

Nurses have the opportunity of spending much time with patients, thus have a unique chance to identify patients problems during their interactions with patients.[29] By identifying factors associated with limited mobility, they can help develop strategies to prevent disability. According to Bandura's cognitive-social theory, individuals' beliefs about their level of performance can predict their function.[30] A relationship has been established between self-efficacy and exercise function in adults and children.[31] It has been reported that self-efficacy positively influences physical activities in patient with knee OA and can lead to improvements in activities such as walking and climbing of stairs.[32] In patients with knee OA, high self-efficacy reduces the amount of patient's complaints of poor physical performance.[33],[34] In one study, patients participating in an educational program with the aim of self-efficacy promotion experienced a decline in physician's visits over a period of 4 years.[35],[36]

Some studies conducted in some countries show the relationship between self-efficacy and unrelieved pain as well as with motor function in patients with knee OA[27],[37],[38] no such study exists in the Iranian women health care context. Therefore, this study aimed todetermine the relationship between pain of OA and BMI, age, pain control strategy, self-efficacy for pain control, exercise, and functional activities in a cohort of Iranian women with advanced OA referred to educational hospitals in Tabriz, Iran.

   Subjects and Methods Top


A cross-sectional study design was used for this study to determine whether pain of OA was significantly associated with BMI, age, pain control strategy, self-efficacy for pain control, exercise, and functional activities in Iranian women with OA.


Participants consisted of 150 women with radiologically confirmed knee OA, who had been being referred to the rheumatology units of educational hospitals in Tabriz, located in the Northwest of Iran and had been selected using a convenient sampling method. The inclusion criteria included (i) female sex, (ii) age ≥18 years (iii) having no hearing disorder and other background diseases that might hinder participation in the study, and (iv) willingness to participate in the study. The exclusion criteria included any history of previous surgeries on the knee and medical disorders that led to the prohibition of physical activity and exercise in the patients. Given the standard deviation of self-efficacy reported by a pilot study, alpha of 0.05, a 95% confidence interval, and 0.05 acceptable errors around the mean, the least number of sample size was determined to be 150 women. The following sampling formula was used to determine the sample size: n = z2 × σ2/d2.

The study was approved by the ethical review board from Tabriz University of Medical Sciences, Tabriz, Iran (Ethical code: TBZMED.1394.526). Permission to enter the research zones was obtained. The women were informed of the study aim and processes. They were assured of the anonymity of their identities and confidentiality of data collection. Of those women who agreed to participate in this study, written informed consent was obtained. The duration of data collection was from November 2015 to February 2016.


Short-form McGill pain questionnaire

The short-form McGill pain questionnaire (SF-MPQ)[39] which is a modification of the long-form,[40] both designed by Melzack in 1987 and 1975, respectively was used to assess the patients' pain. The main component of the SF-MPQ consists of 15 descriptors (11 sensory; 4 affective) that are rated on an intensity scale as 0 = none, 1 = mild, 2 = moderate, or 3 = severe and a score range of between 0 and 45. Three pain scores are derived from the sum of the intensity rank values of the words chosen for sensory, affective, and total descriptors. The SF-MPQ also includes the present pain intensity (PPI) and a visual analogue scale (VAS).[41] It has a Cronbach's coefficient alpha of 0.76.

Pain self-efficacy questionnaire

The PSE questionnaire consists of 10 items with a 6-point Likert scale and a score range of between 1 and 60. It was designed by Nickolas[42] according to the Bandura's theory of self-efficacy,[43] and the Cronbach's coefficient alpha for this questionnaire was 0.93.

Self-efficacy for exercise scale

The self-efficacy for exercise (SEE) scale was developed by Resnick and Jenkins.[44] This questionnaire measured the participants' perceived ability to exercise in various conditions such as bad weather, the feeling of depression, and fatigue. The filling out this questionnaire needed the patients to estimate their self-trust for participation in exercise three times a week and for 20 min. The range of scores was from 0 to 90 with higher scores indicating higher SEE. The reliability of this questionnaire has been confirmed to have an internal consistency (Cronbach's coefficient alpha) of 0.99.

Self-efficacy for functional activities scale

The self-efficacy for functional activities (SEFA) scale initially included 27 items focusing on efficacy expectations related to performance of each ADL (bathing, dressing, transferring, ambulating, and stair climbing) independently, with adaptive equipment and with the help of another person. After initial pilaf testing, the scale was revised to include 9 items that focused on efficacy expectations related to performance of each ADL independently or with the help of another person.[45] The range of its score was from 0 to 90 and the scores of 0 and 10 indicating a lack of ability and having the ability, respectively. The Cronbach's coefficient alpha for this questionnaire was 0.82.

The questionnaires were administered by a research assistant after translation to the official language of Persian and the local language of Azerbaijani Turkish and following validation.

Demographic characteristics

A demographic characteristics' form designed by the authors was used to collect variables such as age, weight and height, BMI, educational level, occupation, marital status, and pain control strategies.

Statistical method

The data were analyzed using the Statistical Package for the Social Sciences (SPSS) software version 16. Descriptive and correlational analyses (means, standard deviations, Pearson correlation coefficient, and linear regression) were used to describe and examine relationships between self-efficacy beliefs and self-reported functional performance and pain. The P value less than 0.05 was considered statistically significant.

   Results Top

Participants' characteristics

The majority of the respondents were housewives (87.3%), married (93.3%), and illiterate (61.3%) with a mean age of 64.96 years. The majority of participants (52.7%) have age 61 to 70 year. In addition, majority (81.3%) had a prior history of unrelated surgery, and 80% were using both orthodox and complementary and alternative therapies as pain control strategies. More information on the demographic characteristics of the respondents is summarized in [Table 1].
Table 1: Women' characteristics (n=150)

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Descriptive data of sensory and affective components of pain, PPI, and VAS: [Table 2] presents the description of the sensory and affective components of the pain experienced by the women. A total of 145 (96.7%) women reported an “aching” sensation that was of severe intensity, whereas 134 women (89.3%) reported the feeling of “sickening” pain that was largely severe in intensity. The total mean of sensory and affective components of pain was 34.76 out of 45. Regarding PPI, majority of the women (74.7%) described their pain as excruciating (mean [SD] = 4.71[.53]), whereas with VAS, the pain score in majority of the patients (72.0%) was 10. In addition, the mean score of pain was 9.58 with a range of 6 to 10 [Table 3].
Table 2: Descriptive data of sensory and affective components of pain

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Table 3: Descriptive data of present pain intensity and visual analogue scale in women with OA

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Descriptive data of pain self-efficacy, self-efficacy for exercise, and self-efficacy for functional activities

The mean of PSE was 31.08 with a range of 0 to 60. In addition, the mean of SEE was 17.28 with a range between 0 and 90. With regard to SEFA, the reported mean was 57.63 with a range between 0 and 90.

Correlation between pain components, present pain intensity, visual analogue scale, pain self-efficacy, self-efficacy for exercise, self-efficacy for functional activities, and independent variables

The sensory and affective components of pain had statistically significant inverse relationships with age (P < 0.05). In addition, there was a statistically significant relationship between pain control strategies with sensory and affective components of pain, VAS, PPI, and SEFA (P < 0.01). The Tukey post hoc test showed that those women who used complementary medicine (CM) for pain control reported less pain and higher SEFA compared with those who used orthodox medications alone and those who used complementary and alternative medicine (CAM) along with modern medicine (P < 0.01). The body mass index (BMI) had a statistically significant direct relationship with sensory and affective components of pain (P < 0.05), whereas there was a statistically significant inverse relationship with self-efficacy for pain control (P < 0.01).

The results of analysis in [Table 4] show a statistically significant direct relationship between the sensory and affective components of pain, VAS, and PPI (P < 0.001). Although a statistically significant inverse relationship was found between the sensory and affective components of pain and self-efficacy for pain control strategies and functional activities (P < 0.01), no statistically significant relationship was seen with SEE (P > 0.05). A statistically significant inverse relationship was found between the VAS and self-efficacy for pain control and functional activities (P < 0.001). However, no such a relationship was found with SEE (P > 0.05). We found a statistically significant inverse relationship between the PPI and SEFA (P< 0.001), but no relationship was reported between self-efficacy for pain control and SEE (P > 0.05).
Table 4: Correlation coefficients between sensory and affective components of pain, PPI, VAS, PSE, SEE, and SEFA

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In the multiple analysis, self-efficacy for pain control as the dependent variable and all other variables as independent variables were entered in stepwise multiple regression. As seen in [Table 5], 13% of the observed variance of the scores of self-efficacy for pain control was explained by the VAS (B = −3.87, 95% of CI = −5.78-1.96, P < 0.001) and BMI (B = −0.42, 95% of CI = −0.77-0.08, P = 0.01). In addition, sensory and affective components of pain (B = −0.24, 95% of CI = −0.53-0.03, P > 0.05) had no statistically significant influence on the model. In other words, one score increases in the VAS, reduced self-efficacy for pain control for 3.87 times. Additionally, one score increase in BMI led to the reduction of self-efficacy for 0.42 times.
Table 5: Regression model showing factors related to pain self-efficacy and self-efficacy for functional activity in women with OA

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With the consideration of the same condition for data analysis mentioned above, SEE as the dependent variable was analyzed using the regression analysis model. However, none of the independent variables had any predictive relationship with SEE. In addition, SEFA was analyzed using the regression analysis model and found that 27% of the observed variance in the scores of SEFA was predicted by the VAS (B = −4.02, 95% of CI = −6.20-1.83, P < 0.001) and sensory and affective components of pain (B = −0.47, 95% of CI = −0.73-0.20, P < 0.001) [Table 5]. In other words, one score increase in the VAS reduced 4.02 times SEFA. In addition, one score increase in sensory and affective components of pain led to the reduction of SEFA of 0.47 times.

   Discussion Top

This study aimed to investigate the relationship between several variables (age, BMI, pain control strategies, and self-efficacy) and pain in women with advanced knee OA. Our participants experienced severe pain in sensory and affective components of pain. The results of other studies are similar to our findings.[46],[47],[48] We theorize from this study that certain lifestyle habits and customs may influence patients' perception of their pain.[49]

Some of these practices include the practice of using squat toilet rather than sitting where the toilet pan or bowl is at floor level, which is synonymous with Muslim practices of the religious ritual of anal cleansing and the strict religious ban of contact with urine and faeces.[50] In addition, the practice of eating and sitting on the floor cross-legged instead of on a sofa or chair,[51] sleeping on the flat rather than bed which is considered a Sunnah, a practice of the faithful of the holy Prophet Mohammed, as well as a low participation of women in exercise activities in the Iranian culture, may also be contributory.

Other factors observed to influence pain in this study was age and BMI. With the mean score for age of subjects in this study at 64.96, and being majority of participants in the age group of 61–70 years. This concurs with other studies that indicate a higher prevalence of knee OA occurs among women older than 50 years, a trait attributed to postmenopausal decline in the hormone, estrogen.[51] Pain and age had a statistically significant inverse relationship together, which was a trend observed in the findings of Rittger et al.[52] in patients with cardiac diseases. The mean BMI of 29.35 obtained in this study seems to indicate that many of the women were overweight. In addition, a statistically significant direct relationship was found in this study between BMI and pain that is consistent with the findings of Stone et al.[53] who reported that the people who are obese are considerably more prone to have daily pain. In contrast, with our result is that of Jabalameli et al. who reported that there was no significant relationship between BMI and VAS for chronic pain.[54] In the Spector study, obesity was the most important factor related to incident OA, and 47% of women with OA were obese.[55] Foy et al.[56] were able to document significant improvements in physical function for overweight subjects with OA who were subjected to an intensive lifestyle intervention, and several other studies[57],[58] involving overweight and obese adults with painful knee OA have demonstrated the ability of physical activity to significantly impact on the pain, physical function, and health-related quality of life in this subset of patients. Hence, educational and lifestyle interventions involving exercise and encourage OA patients to set achievable physical activity goals can be recommended for our subjects with far-reaching and positive consequences for their knee pain.

In this study, the majority of patients used CAM along with orthodox medication to control their pain. The main methods were hot compress composed of bag of salt derived from the Urmia lake, vegetable oils such as olive oil produced in North of Iran, cold therapy, relaxation, and diversion of thoughts. The meta-analysis of randomized controlled trials by Chen et al.[59] indicated a predominant use of Chinese herbs, (chines oral drugs) by patients which were produced in their own region for reducing osteoarthritic pain. It is believed that patients' living location, culture of origin, and life style have some influence on the methods of pain management. In a study in Iran, 42% of people used CM, which were mostly herbs, massage therapy, and relaxation for reliving their pain.[60] Another study showed that the quantity of CAM used was comparable to the use of opioids.[61] According to our results, those women who used CM reported less pain compared with those who used other methods of pain control. These results are in agreement with some studies,[59],[62],[63],[64],[65] whereas another study reported that mind-body intervention had no effect on pain.[66] The findings of the Reid study indicate a correlation between CM users and gender, with reports of a higher rate of use from females than males, and CM users are more likely to seek CM services for a range of chronic conditions[67] such as pain control.[68]

We also found that the method of pain control affected the patients' self-efficacy. Those patients who used CAM had better SEFA. According to Menzies et al., imagination is a suitable strategy for relieving patients' pain.[66] Pain had a statistically significant inverse relationship with self-efficacy, and these findings of ours are supported by other the findings from other studies.[69],[70],[71]

We found that our subjects had a low level of self-efficacy for pain control, exercise, and functional activities. These results are consistent with some other studies.[11],[72] In addition, the finding that study subjects had the worst scores in SEE is similar to findings of Shin et al.[73] and a low mean score for exercise self-efficacy implies that patients will tend toward inactivity with the attendant consequences of overweight and obesity and subsequent worsening of knee pain. The findings of Avazeh et al.[74] in Iran showed that patients were fairly well informed of the positive effects of exercise on the reduction of cardiovascular diseases, but they were not interested in the incorporation of exercise into their daily activities.

In addition, the severity of pain and BMI could predict self-efficacy for pain control in our patients. This finding is also is in line with Pells et al.[75] finding that self-efficacy is important in understanding pain and behavioral adjustment in overweight or obese patients with OA. The severity of pain and perception of pain could predict SEFA that were in line with Shelby et al.[38] finding that showed higher pain catastrophizing contributed to greater pain and disability through lower domain-specific self-efficacy.


Generalization of the results of this study by researchers will be difficult as our women population were derived from Northwest Iran. Hence, these findings may not translate to women of other ethnicities. Despite this, the study results might still be widely applicable as they will help with patient-specific treatment of advanced knee OA in all parts of the world.

Implications for healthcare team and practice

Given the influence of BMI on pain and self-efficacy as illuminated through this study, there is a need to teach women with advanced knee OA to adjust their lifestyle, paying key attention to appropriate nutrition (such as reducing caloric intake), and increasing physical activity. Because older women have more problems with pain control, they need more attention by nurses during the designation of supportive-educational programs. In addition, considering the effect of CAM on self-efficacy and pain, there is a need to inform patients of non-pharmacological methods of pain control through education and also encourage the integration of these methods into women healthcare. Medical and nursing curricula can be revised to integrate complementary and alternative methods of pain control, and CAM can be incorporated in care plans in clinical practice. Further, studies are warranted on the influence of CAM therapies on pain intensity and self- efficacy in similar cohort but different socio-economic, cultural, and religious contexts.

   Conclusion Top

Iranian women with knee OA are known to have poor quality of life[76],[77] because they live in constant pain, have poor SEFA, and exercise and may sometimes look for help through using herbal treatments and other remedies for pain relief depending on local products of their own region, living location, culture, and life style, as revealed by this study. The clinical implementation of educational and lifestyle interventions to encourage these women with chronic knee pain OA are recommended as they may serve as a veritable instrument to increase self-efficacy in those domains and reduce pain.

Financial support and sponsorship

This study was supported by Tabriz University of Medical Sciences. The study was approved by the ethical review board from Tabriz University of Medical Sciences, Tabriz, Iran (Ethical code: TBZMED.1394.526).

Conflicts of interest

There are no conflicts of interest.

Author contributions

AG, MB, and NM prepared study concept and design. AG and MAJ analyzed and interpreted data, drafted the manuscript, and prepared the tools used in the data gathering. NM and JGS had the responsibility of data gathering. AG and TO revised the manuscript, and the whole process was under supervision of AG, MB, and FJ.

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]

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