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1

European Journal of Pain xxx (2008) xxx–xxx

www.EuropeanJournalPain.com

2 The contribution of self-efficacy and depression to disability and work

3 status in chronic pain patients: A comparison between Australian

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4 and Brazilian samples

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5 Jamir Sardá Jr. a,b,*, Michael K. Nicholas b, Ali Asghari b,c, Cibele A.M. Pimenta d
6 a
CAPES – MEC,1 Department of Psychology, Univali, Brazil
7 b
Pain Management and Research Centre – RNSH, University of Sydney, AV. Campeche 1157, bloco C-1 apto 403,
8 Campeche, Florianopolis, SC. Cep 88063-300, Australia

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9 c
Department of Psychology, University of Shahed, Tehran, Iran
10 d
Nursing School, University of São Paulo, São Paulo, Brazil
11 Received 13 June 2007; received in revised form 28 February 2008; accepted 11 March 2008
12 ED
13 Abstract

14 There is evidence that cognitions (beliefs) and mood contribute to physical disability and work status in people with chronic pain.
15 However, most of the current evidence comes from North America and Europe. This study examined the contribution of demo-
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16 graphic, pain and psychosocial factors to disability and work status in chronic pain patients in two matched samples from quite
17 different countries (Australia and Brazil). Data were collected from 311 chronic pain patients in each country.
18 The results suggest that although demographic and pain variables (especially pain levels) contribute to disability, self-efficacy
19 beliefs made a significant contribution to disability in both samples. Age and educational level also contributed to unemployment
20 in both samples. But there were some differences, with self-efficacy and physical disability contributing to work status only in the
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21 Brazilian sample. In contrast, depression was the only psychological risk factor for unemployment in the Australian sample.
22 Catastrophising and pain acceptance did not contribute to disability or unemployment in either sample. These findings confirm
23 key aspects of biopsychosocial models of pain in two culturally and linguistically different chronic pain samples from different coun-
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24 tries. They suggest that different chronic pain populations may share more similarities than differences.
25 Ó 2008 Published by Elsevier Ltd on behalf of European Federation of Chapters of the International Association for the Study of
26 Pain.

27 Keywords: Disability; Work status; Cognition; Depression; Cross cultural

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28

29 1. Introduction enced, the person’s responses to it, and the impact of 32

pain on their daily activities (Linton, 2000; Pincus 33
30 It has been recognised that a number of psychological et al., 2002; Turk and Okifuji, 2002). 34
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31 factors may influence the degree to which pain is experi-
1
Research conducted as part of a Ph.D. degree, supported by
CAPES-MEC scholarship.
*
Corresponding author. Address: Pain Management and Research
Centre – RNSH, University of Sydney, AV. Campeche 1157, bloco C-1
apto 403, Campeche, Florianopolis, SC. Cep 88063-300, Australia.
Tel.: +55 48 38798335.
E-mail address: jamirsarda@hotmail.com (J. Sardá Jr.).
Among affective factors associated with chronic pain, 35
depression is the most extensively researched (Keefe 36
et al., 2004). It seems that depression may mediate the 37
perception of noxious stimuli and responses to chronic 38
pain, which in turn may increase pain-related disability 39
and maladjustment (Worz, 2003). Response to pain Q1 40
treatments can also be restricted by the presence of 41
depression (Cherkin et al., 1996). 42

1090-3801/$34.00 Ó 2008 Published by Elsevier Ltd on behalf of European Federation of Chapters of the International Association for the Study of
Pain.
doi:10.1016/j.ejpain.2008.03.008

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43 Besides depression, a number of cognitive factors ple of 311 Australian chronic pain patients, matched for 95
44 appear to contribute to the levels of distress and disabil- age and gender, were selected from a database at the 96
45 ity in people with chronic pain (Keefe et al., 2004; Turk Pain Management and Research Centre – RNSH (Syd- 97
46 and Okifuji, 2002). These factors include self-efficacy, ney, Australia). The participants represent a conve- 98
47 catastrophising and acceptance. nience sample, selected on specific criteria. 99
48 Turk and Okifuji (2002) has argued that people with
49 chronic pain who believe they can reduce their degree of 2.1.1. Inclusion criteria 100
50 suffering are more likely to use their resources or skills 101
51 and to persevere in their efforts to cope with their pain.  Having pain lasting more than 3 months, and willing 102
52 On the other hand, low self-efficacy or a sense of pessi- to join in the study. 103

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53 mism about managing pain or functioning despite pain,  Age over 18 years. 104
54 may result in a person to make little effort towards  Literate in Portuguese or English. 105

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55 implementing possible coping strategies. In turn, this  P4 years of formal education. 106
56 may promote further dysphoria and helplessness.  No cancer pain. 107
57 In the context of chronic pain, self-efficacy has been  No major psychiatric disorder (i.e., psychoses or 108
58 defined as the degree of confidence a person has in dementia). 109
59 his/her capacity to function despite pain (Nicholas, 110

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60 2007). In chronic pain populations self-efficacy beliefs
61 have been found to be related to levels of functioning 2.2. Measures 111
62 (Altmaier et al., 1993; Geisser et al., 2003), physical dis-
63 ability (Arnstein, 2000; Nicholas and Asghari, 2006), With the Brazilian sample Portuguese translations of 112
64 depression (Anderson et al., 1995; Nicholas and Asgha- the original English-language versions of the self-report 113
65 ri, 2006; Rahman et al., 2005), avoidance behaviour scales were employed. Each scale had been translated 114
66 (Asghari and Nicholas , 2001) and occupational status
ED according to standard criteria (Guillemin et al., 1993) 115
67 (Adams and Williams, 2003; Rahman et al., 2005). and these have been reported elsewhere (Sardá, 2007). 116
68 Catastrophising and acceptance can also contribute The psychometric properties of the questionnaires for 117
69 to poor adjustment to chronic pain. For example, Sulli- the Brazilian sample are reported briefly on the mea- 118
70 Q2 van et al. (2005) showed that catastrophic beliefs about sures section. The psychometric properties of these mea- 119
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71 pain have more impact on disability than pain severity sures on the Australian sample are adequate and have 120
72 in patients with neuropathic pain. McCracken and been reported elsewhere (e.g., Nicholas, 2007). 121
73 Q3 Eccleston (2005) showed that higher acceptance of pain
74 is predictive of reduced pain-related disability, distress 2.2.1. Demographic and clinical data 122
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75 and use of health services in chronic pain patients. Data were collected on the participants’ age, gender, 123
76 Despite the growing strength of evidence on the con- level of education, working status, pain site, pain inten- 124
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77 tribution of psychological factors to the impact of sity and pain duration. 125
78 chronic pain on people’s lives, it is striking that the evi-
79 dence comes predominantly from developed countries in 2.2.2. The Roland and Morris Disability Questionnaire 126
80 Europe and North America. It is not clear if these fac- The Roland and Morris Disability Questionnaire – 127
81 tors play similar roles for chronic pain sufferers from less RMDQ (Roland and Morris, 1983) was initially devel- 128
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82 developed countries and from other cultures. oped to measure self-rated physical disability in back 129
83 The aim of this study was to contrast the contribution pain patients. The RMDQ has 24 items, each item is 130
84 of socio-demographic and pain variables, depression scored 0 or 1, score may range from 0 (no disability) 131
85 and cognitions (self-efficacy, catastrophising and accep- to 24 (severe disability). 132
86 tance) to disability and work status in chronic pain An alternative version (in English and Portuguese) of 133
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87 patients from two countries with different cultures, lan- the RMDQ, modified by replacing the word ‘back’ with 134
88 guages and degrees of economic development – Austra- ‘pain’, was employed in this study (Asghari and Nicho- 135
89 lia and Brazil. las , 2001). In this study, the Cronbach alpha is 0.90 136
(Sardá, 2007). 137

90 2. Materials and methods 2.2.3. The Pain Self-efficacy Questionnaire – PSEQ 138
The Pain Self-efficacy Questionnaire (Nicholas, 2007) 139
91 2.1. Participants is based on Bandura’s self-efficacy theory, and assesses a 140
person’s confidence in his/her ability to function despite 141
92 Data were collected from 311 patients attending nine pain. 142
93 pain clinics in Southern and Southeastern Brazil (from The PSEQ has 10 items rated on a 0–6 Likert scale. 143
94 March to June 2005). For comparison, data from a sam- Higher scores reflect stronger self-efficacy beliefs. The 144

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145 PSEQ has been used in a number of countries and its the project in more detail (in Portuguese), answered 194
146 psychometric properties have been reported as adequate any questions they may have had and administered 195
147 (Asghari and Nicholas , 2001; Gibson and Strong, 1996; the battery of self-report measures. All participants 196
148 Nicholas, 2007). The Cronbach alpha in the present completed an informed consent form to confirm their 197
149 study for the PSEQ is 0.90. voluntary participation in the study. Additional rele- 198
vant demographic and medical data were then copied 199
from the patients’ clinic files. 200
150 2.2.4. The depression anxiety stress scale – DASS
The Australian pain clinic sample was derived from a 201
151 The depression scale of the DASS was employed as it
database of patients’ initial assessment measures at the 202
152 contains no somatic items. The depression scale has 14
Pain Management and Research Centre (PMRC), Royal 203
153 items, ranging from 0 to 3, with higher scores meaning

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North Shore Hospital, Sydney (Nicholas et al., 2007). Q4 204
154 more depressed.
All those used in this study had given their consent for 205
155 The DASS has sound psychometric properties and

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their data to be used anonymously in the research pro- 206
156 high to moderate correlation with the BDI (Lovibond
ject and this was supported by the Area Health’s Human 207
157 and Lovibond, 1995; Taylor et al., 2005). Good internal
Research and Ethics Committee). The participants were 208
158 consistency for the depression scale has been reported
patients seen at the centre between March 2005 and June 209
159 (0.96) (Taylor et al., 2005) and 0.91 (Lovibond and
2006. The Australian sample was matched with the Bra- 210
160 Lovibond, 1995), as well as construct validity (Lovibond

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zilian sample for age and gender. 211
161 and Lovibond, 1995; Taylor et al., 2005). The Brazilian
162 validation of the Depression scale has also shown ade-
163 quate reliability (Cronbach alpha = 0.96) and construct 2.4. Statistical analyses 212
164 validity (Sardá et al., 2007).
A number of statistical analyses were conducted to 213
examine the relationships between variables and to com- 214
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165 2.2.5. Pain response self-statements scale (PRSS)
pare the samples. These analyses included t-tests, chi- 215
166 catastrophising scale
square tests (v2), correlations (Pearson r), multivariate 216
167 Catastrophising was assessed by the PRSS (Flor
hierarchical and logistic regression. All the analyses 217
168 et al., 1993). The catastrophising scale contains nine
were conducted using SPSS 14.0. 218
169 items. The score can range from 0 to 5; higher scores
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When comparing the two samples on some mea- 219

170 indicate more frequent catastrophising when experienc-
sures, whenever a t was used the equality of variances 220
171 ing pain. The PRSS has good psychometric properties
between groups was examined using Levene’s test. 221
172 and is sensitive to change after treatment (Flor et al.,
Chi-square tests (v2) were also used to compare the 222
173 1993). The psychometric properties of this measure have
two samples. 223
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174 been examined by the first author in a Brazilian sample.

Due to the large number of correlations (28), and the 224
175 Results in this study show adequate reliability (Cron-
increase chance of type I error, a Bonferroni adjustment 225
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176 bach’s a = 0.89).

was applied (p = 0.05/28 = 0.001) to examine the corre- 226
lations. Only variables that attained this p value were 227
177 2.2.6. Chronic pain acceptance questionnaire (CPAQ) entered in the equations. 228
178 The CPAQ (McCracken et al., 2004) has 20 items A Bonferroni correction was also applied for the hier- 229
179 yielding two subscales (i.e., activity engagement and archical regression analysis (stepwise method). To exam- 230
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180 pain willingness). Both scores can be combined to yield ine predictors of disability, pain and demographic 231
181 a total pain acceptance score (range 0–120), with higher variables were entered in the first step, after controlling 232
182 scores indicating greater acceptance. In this study, only for these variables the psychological variables were 233
183 the total score is reported. entered. 234
184 A number of studies have reported adequate reliabil- A multivariate logistic regression modelling was used 235
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185 ity and validity for the CPAQ (McCracken, 1999; McC- to identify variables contributing to unemployment. 236
186 racken et al., 2004). At the present study, the Cronbach Reduced parsimonious models were produced by a pro- 237
187 alpha for this study is 0.78. cess of backwards elimination. At each stage, the effect 238
of dropping out an independent variable was assessed 239
188 2.3. Study design and procedure using the likelihood ratio test at a significant level 240
(p = 0.05). Odds ratios, beta coefficients and confidence 241
189 A cross-sectional study design was used, with intervals were inspected at each stage to check for possi- 242
190 patients attending the Brazilian pain clinics being ble confounding or effect modification and the goodness 243
191 invited to participate in the study by their physician of fit of the model. Some variables that did not attain a 244
192 when they attended their clinic. If they agreed they significant level were kept in the model due to their con- 245
193 were asked to see the researcher (JS) who explained tribution to the best fit of the model. 246

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247 3. Results Regarding educational level, the two samples had a 267
significant difference on distribution (v2 = 111.26, 268
248 The distribution of the data collected from both sam- p = 0.001). In the Brazilian sample there were more par- 269
249 ples was inspected to check for skewed distributions, ticipants with up to 8 years of education and tertiary 270
250 multicollinearity and singularity. Data were confirmed level, whilst in the Australian sample there were more 271
251 as normally distributed, correlations between variables participants with secondary education. 272
252 were <0.90 and there were no redundant variables, The samples also differed regarding their pain inten- 273
253 therefore no statistical transformations were necessary. sity (t = 2.67, df = 592, p = 0.008). Although this differ- 274
ence is statistically significant it is not clinically 275
254 3.1. Demographic and clinical characteristics of the significant. 276

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255 samples The samples also did not differ in relation to pain site 277
and pain duration (v2 = 22.54, df = 10, p = 0.13, and 278

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256 In Table 1, data describing the Brazilian and Austra- v2 = 12.13, df = 10, p = 0.06, respectively). 279
257 lian samples are presented. Level of education was associated with higher scores 280
258 Both samples had similar mean scores on disability on disability in both samples (Brazilian sample 281
259 (t = 1.27, df = 619, p = 0.20) and acceptance v2=17.27, df = 1, p = 0.001, Australian sample 282
260 (t = 0.66, df = 611, p = 0.50), but the Brazilian sample v2 = 4.40, df = 1, p = 0.003). Pain site was only associ- 283

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261 had higher mean scores on self-efficacy (t = 6.50, ated with higher scores on disability in the Brazilian 284
262 df = 613, p = 0.001) and depression (t = 3.84, sample (v2 = 17.27, df = 1, p = 0.003). 285
263 df = 611, p = 0.001) than the Australian sample, and Intercorrelations between the study variables in both 286
264 lower mean scores on catastrophising (t = 2.70, samples are presented in Tables 2 and 3. 287
265 df = 612, p = 0.007). Whether these differences are clin- In the Brazilian sample significant, but low to moder- 288
266 ically significant will be discussed later. ate correlations were found between most variables. 289
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Table 1
Characteristics of the Australian and Brazilian sample
Demographic and clinical characteristics Australian sample no. (%) Brazilian sample no. (%)
Age mean (years) 49.2 (SD = 14.8) 48.9 (SD = 14.0)
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Gender
Male 83 (26.7) 81 (26.0)
Female 228 (73.3) 230 (74.0)
Marital status
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Single 74 (23.7) 55 (17.7)

Married 188 (60.5) 200 (64.3)
Separated, divorced or widowed 49 (15.8) 56 (18.0)
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Educational level
Less than year 10 in Australia 4–8 years in Brazil 77 (25.7) 101 (32.5)
Year 10–12 or technical studies in Australia 9–11 years (and/or technical) in Brazil 146 (45.0) 89 (28.6)
Higher level of education (i.e., university) 88 (29.3) 121 (38.9)
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Employment status
Working 183 (58.8) 179 (58.9)
Unemployed due to pain 128 (41.2) 125 (41.1)
Pain duration (mode was 3–5 years) 72 (24.2) 87 (28.0)
Pain intensity (mean) 5.8 (SD:2.0) 6.2 (SD: 2.4)* Q7
Major pain sites
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Head, face, neck 27 (8.7) 36 (11.6)

Cervical, shoulders and upper limbs 44 (14.1) 48 (15.5)
Upper back or spine 31 (10.0) 16 (5.1)
Lower back and lower limbs 46 (14.8) 30 (9.6)
Two or more major sites 107 (34.4) 140 (45.0)
Other 56 (18.0) 41 (13.2)
Mean scores and standard deviation
Roland and Morris Disability Questionnaire 11.66 (6.62) 12.03 (6.21)
Pain self-efficacy beliefs 27.57 (13.65) 34.84 (14.08)*
DASS – Depression Scale 11.73 (10.44) 14.03 (12.02)*
Chronic Pain Acceptance Questionnaire 59.65 (17.56) 60.20 (18.11)
Catastrophising Scale 2.73 (1.50) 2.38 (1.38)*
Expected t is 1.96 at a significant level of 0.05

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Table 2
Pearson correlations among demographic, clinical and psychological measures (Brazilian sample)
Age Pain duration Pain intensity Disability Depression Self-efficacy Catastrophising Acceptance
Age –
Pain duration 0.01 –
Pain intensity 0.08 0.01 –
Disability 0.06 0.08 0.30* –
Depression 0.13 0.18* 0.25* 0.34* –
Self-efficacy 0.06 0.07 0.25* 0.58* 0.38* –
Catastrophising 0.16* 0.22* 0.28* 0.34* 0.59* 0.39* –
Acceptance 0.17 0.13 0.12 0.40* 0.44* 0.64* 0.47* –

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*
Significant correlations at P 6 0.001 after a Bonferroni adjustment.

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Table 3
Pearson correlations among demographic, clinical and psychological measures (Australian sample)
Age Pain duration Pain intensity Disability Depression Self-efficacy Catastrophising Acceptance
Age –
Pain duration 0.14 –

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Pain intensity 0.04 0.02 –
Disability 0.03 0.06 0.40* –
Depression 0.12 0.02 0.14 0.38* –
Self-efficacy 0.20* 0.09 0.26* 0.53* 0.52* –
Catastrophising 0.20* 0.03 0.19* 0.31* 0.45* 0.43* –
Acceptance 0.04 0.06 0.21* 0.23* 0.49* 0.54* 0.39* –
*
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Significant correlations at P = 0.001 after a Bonferroni adjustment.

290 Most importantly, correlations between all the psycho- ables (cognitions and depression), only educational level 303
291 logical measures and disability were higher than between and pain site obtained significant p levels. Among the 304
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292 disability and pain variables (e.g., pain intensity). second block of variables which accounted for an addi- 305
293 In the Australian sample, the correlations between tional 27% of variance in disability, only self-efficacy 306
294 most variables were broadly similar to those found in contributed significantly to disability (beta = 0.47, 307
295 the Brazilian sample. However, age also correlated pos- p < 0.001). 308
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296 itively with self-efficacy, but pain duration was not sig- As shown in Table 5, in the Australian sample the 309
297 nificantly correlated with any other variable assessed. pain and demographic block accounted for 17% of the 310
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variance in physical disability. But when taking into 311

298 3.2. Predictors of physical disability account the second block of variables (cognitions and 312
depression), only pain intensity obtained significant 313
299 As shown in Table 4, in the Brazilian sample the pain p levels. Among the second block of variables which 314
300 and demographic block accounted for 19% of the vari- accounted for an additional 21% of variance in disabil- 315
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301 ance in physical disability (measured by the RMDQ). ity, only self-efficacy contributed significantly to disabil- 316
302 But when taking into account the second block of vari- ity (beta = 0.41, p < 0.001). 317
Table 4
Results of hierarchical regression analyses predicting physical disability from pain variables, level of education, cognitive variables and depression
(Brazilian sample)
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Step and predictors Total R2 F df R2 Change F Change Betaa t

Criterion variable: disability
Step 1 0.19 23.13 304 0.19 23.13
Pain intensity 0.09 2.1
Pain site .19 4.4*
Level of education .21 4.7*
Step 2 0.46 37.71 300 0.27 36.25
Depression 0.03 0.6
Acceptance 0.01 0.09
Catastrophising 0.09 1.7
Self-efficacy 0.47 8.1*
a
Standardised regression coefficient: P 6 0.005 *p 6 0.001.

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Table 5
Results of hierarchical regression analyses predicting physical disability from pain variables, level of education, cognitive variables and depression
(Australian sample)
Step and predictors Total R2 F df R2 Change F Change Betaa t
Criterion variable: disability
Step 1 0.17 17.41 256 0.17 17.41
Pain intensity 0.27 5.2*
Pain site 0.04 0.87
Level of education 0.09 1.8
Step 2 0.38 22.37 252 0.21 21.84
Depression 0.16 2.6

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Acceptance 0.13 2.2
Catastrophising 0.05 0.80

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Self-efficacy 0.41 6.3*
a
Standardised regression coefficient: P 6 0.005, p 6 0.001.

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318 3.3. Predictors of work status All the disability and psychological measures were 337
coded in the same direction using upper quartile score 338
319 Since work status is likely to be affected by age, only as a cut off point (i.e., for disability, depression and cat- 339
320 participants aged more than 18 years and less than 65 astrophising scores lower than the third quartile were 340
321 years were selected for the analysis. Thus, the number coded 0 and the upper quartile scores were coded 1). 341
322 of subjects for the Brazilian sample was 222, mean age However, when higher scores on the measure was a posi- 342
323 for this group was 45 and it was used as the cut off point
ED tive outcome it was coded 0 and lower scores were coded 343
324 for the re-coded age variable. The numbers of available 1 (i.e., self-efficacy and acceptance). This meant that all 344
325 subjects for the Australian sample was 207, mean age 44 these variables were coded in the same direction. 345
326 was used as the cut off point for this sample. Summaries of these multivariate logistic regression 346
327 Participants having pain in a single site were coded 0, analyses used to examine variables associated with 347
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328 while those with pain in two or more sites were coded 1. unemployment in both samples are presented in Table 6. 348
329 Pain duration was coded 0 for participants with pain for In the Brazilian sample, among the variables entered 349
330 up to 5 years, and 1 for participants who were in pain in the analysis only age, level of education, disability 350
331 for 6 years or more. Pain intensity cut off point was and self-efficacy were associated with unemployment. 351
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332 set at 5. In this model those participants with less than 11 years 352
333 Education was also coded as a dummy variable. Par- of education had nearly 3.5 times more chance of being 353
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334 ticipants with less than 12 years of education or equiva- unemployed than those with higher education. Those 354
335 lent levels were coded as 1, while subjects with technical participants with high scores on physical disability 355
336 education or tertiary were coded as 0. (top quartile score group) had nearly three times more 356
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Table 6
Multivariate logistic regression analysis of the associations between clinical, demographic and psychological variables and work status (adjusted odds
ratio, p values and confidence intervals) for the Australian and Brazilian sample
Variable Adjusted odds ratio* 95% CI P level
Pain site (two or more) Australian sample 2.35 1.24–4.47 0.009
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Age (P45 years) Brazilian sample 0.39 0.20–0.74 0.004

Age (P44 years) Australian sample 0.38 0.20–0.70 0.002
Educational level (611 years) Brazilian sample 3.49 1.81–6.74 0.001
Educational level (612 years) Australian sample 1.94 1.06–3.56 0.03
Physical disability (score P17) Brazilian sample 2.75 1.27–5.97 0.01
Physical disability (score P16)a Australian sample 1.81 0.85–3.87 0.12
Self-efficacy – PSEQ(score 625) Brazilian sample 2.52 1.06–6.00 0.04
Acceptance – CPAQ(score 651)b Brazilian sample 1.92 0.86–4.30 0.11
Depression – DASS (score P16) Australian sample 2.53 1.24–5.17 0.01
Catastrophising (score P3.3)a Australian sample 0.53 0.25–1.12 0.09
Pain intensity, pain duration, gender, self-efficacy and acceptance were also included in the regression in the Australian sample.
a
Variable retained for improved model fit.
b
Variable retained for improved model fit.
*
Pain intensity, pain site, pain duration, gender, depression and catastrophising were also included in the regression in the Brazilian sample.

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357 chance of being unemployed than those with lower ian sample, self-efficacy beliefs and disability level also 410
358 scores. The same trend occurred with self-efficacy. Fur- made significant contributions to work status, while in 411
359 thermore, those aged over 45 years had nearly 40% more the Australian sample it was depression and number 412
360 chance of being unemployed than those in the younger of pain sites that also contributed to work status. In 413
361 group. contrast, neither acceptance of pain nor catastrophising 414
362 In contrast to the Brazilian findings, in the Australian made significant contributions to disability or work sta- 415
363 sample the results indicate that participants with pain in tus in either sample. 416
364 two or more sites had 2.35 times the chance of being The finding that pain intensity contributed to disabil- 417
365 unemployed than those with pain in only one site. Par- ity in the Australian sample is consistent with previous 418
366 ticipants aged over 44 years had 40% more likelihood findings elsewhere (e.g., Marhold et al., 2002). Why this 419

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367 of being unemployed than younger participants. Having relationship was not found in the Brazilian sample is 420
368 lower educational level (up to 12 years of education) unclear. Nevertheless, the finding with the Brazilian 421

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369 also seemed to increase the likelihood of being unem- sample that having multiple pain sites was related to 422
370 ployed (odds ratio = 1.94). Participants with high higher disability was consistent with previous findings 423
371 depression scores (P16) appear to have nearly 2.5 times in other countries (Natvig et al., 2001). Similarly, the 424
372 more chance of being unemployed than those with lower finding that educational level was related to pain-related 425
373 scores. disability in the Brazilian sample was also consistent 426

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with previous research in other countries (Von Korff 427
et al., 1990). It is unclear why that finding was not rep- 428
374 4. Discussion licated in the Australian sample as education level was 429
found to be associated with unemployment in the same 430
375 The primary aim of this study was to compare sample. This finding may suggest that factors other than 431
376 chronic pain patients from two countries (Brazil and disability can influence unemployment (e.g., Marhold 432
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377 Australia) with different languages, cultures and degrees et al., 2002). Even so, it is notable that education level 433
378 of economic development. The secondary aim of the has been found to be predictive of pain-related disability 434
379 study was to replicate previous findings from research in an Australian community-based population (i.e., non- 435
380 in North America and Europe concerning the contribu- clinical chronic pain sample) study (Blyth et al., 2001). Q5 436
381 tion of cognitions (i.e., self-efficacy, acceptance and cat- The finding that educational level made almost twice 437
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382 astrophising) and depression to physical disability and the contribution to unemployment in the Brazilian sam- 438
383 work status in chronic pain patients. ple (OR:3.49) as in the Australian sample (OR:1.94) was 439
384 Despite differences in some psychological measures, also interesting. Others have also found that age and 440
385 the samples were broadly similar on many dimensions educational level are common risk factors for unemploy- 441
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386 (e.g., mean age, work status). Interestingly, there was a ment, independent of chronic pain (Lampreia, 1995). 442
387 higher proportion of tertiary educated participants in Among chronic pain patient samples others have also 443
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388 the Brazilian sample than the Australian sample (38.9 found this relationship between employment, age and 444
389 vs 29.3%, respectively), but this may have been related education level (Tan et al., 1997; Vowles et al., 2004; 445
390 to the higher proportion of participants recruited from Watson et al., 2004). In the present study, the finding 446
391 private clinics in Brazil than the Australian clinic sample that education level was more strongly related to unem- 447
392 which had a mixture of private and public participants. ployment in the Brazilian sample, relative to the Austra- 448
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393 Mean scores on measures of depression, self-efficacy, lian sample, may reflect the source of the samples and 449
394 and catastrophising were significantly different between health system differences between the two countries. In 450
395 the samples. Even so, in both groups these mean scores Australia, access to university hospital outpatient ser- 451
396 were in the middle range (i.e., varying from the 40th to vices is free and private health insurance is not required, 452
397 60th percentiles) when compared with Australian nor- whereas in Brazil accessing the better facilities is more 453
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398 mative pain clinic data on the same measures (Nicholas dependent on private health insurance. In the present 454
399 et al., 2008). study a higher proportion (about 55%) of the Brazilian 455
400 Hierarchical regression analyses revealed that in both sample had private health insurance (versus about 30% 456
401 samples pain variables (number of pain sites in the Bra- in the Australian sample), which, in turn, is likely to 457
402 zilian sample and pain intensity in the Australian sam- be related to income and, ultimately, completed educa- 458
403 ple) and psychological variables (particularly, self- tion level. 459
404 efficacy) made significant contributions to disability. In Among psychological variables, the findings from 460
405 the Brazilian sample only, educational level also contrib- both samples confirm the role of self-efficacy beliefs in 461
406 uted significantly to disability level. pain-related disability (Arnstein, 2000; Keefe et al., 462
407 Logistic regression analyses revealed that in both 2004; Nicholas and Asghari, 2006; Turk and Okifuji, 463
408 samples, education level and age made a significant con- 2002). Why acceptance of pain, depression and catastro- 464
409 tribution to work status (unemployment). In the Brazil- phizing were not significantly related to disability in 465

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466 either sample is unclear as other studies have found such tional design of the study also means that causal 522
467 relationships (McCracken, 2007; Sullivan et al., 1998). relationships between the studied variables and their 523
468 On the other hand, these findings are consistent with directions cannot be confirmed. Thus, findings based 524
469 other studies that indicate catastrophising is more on cross-sectional data should be supported by further 525
470 strongly related to depression than disability in chronic replication and, preferably, prospective studies. Another 526
471 pain patients (Edwards et al., 2005; Nicholas, 2007). limitation concerns the samples employed. It is possible 527
472 Altogether, these findings suggest that regardless of lan- that some of the differences and similarities found 528
473 guage, social or cultural differences between chronic between samples were due to how each sample was 529
474 pain patients in different countries, those who have assembled and health system contingencies. However, 530
475 low confidence in their ability to function while in pain this was not an epidemiological survey but rather a sam- 531

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476 are more likely to be disabled by their pain. ple of people attending pain clinics for help with their 532
477 The finding that psychological variables were differ- pain. Accordingly, neither sample was intended to be 533

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478 entially related to unemployment in the two samples representative of the general population of chronic pain 534
479 also merits comment. Somewhat surprisingly, high patients in both countries. Furthermore, many factors 535
480 depression scores were associated with unemployment that could influence return to work (e.g., work environ- 536
481 in the Australian sample, but not the Brazilian sample. ment factors) were not investigated and this limits the 537
482 On the other hand, self-efficacy beliefs and physical dis- generalisability of our findings (Franche et al., 2005). 538

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483 ability contributed to unemployment only in the Brazil- Despite its limitations, this study has a number of 539
484 ian sample. The finding that disability and self-efficacy strengths. These include the validity and reliability of 540
485 were not predictive of unemployment in the Australian the measures have been tested in both samples; the sam- 541
486 sample is contrary to expectations and, as noted earlier, ple size was large; and the samples were matched on 542
487 it suggests that other factors are playing more of a role some key variables. It is also the first study, to our 543
488 Q6 in this domain in this sample (e.g., Gauthier et al., 2006). knowledge that compares Brazilian and Australian 544
489 One factor could be heightened depression. There is evi-
ED chronic pain patients, and one of only a few studies that 545
490 dence from elsewhere that depression can inhibit compares such patients between countries (ten Klooster 546
491 response to treatment in chronic pain patients (Cherkin et al., 2006). 547
492 et al., 1996; Marhold et al., 2002; Sullivan et al., 2006).
493 Even so, in the present study the Brazilian sample was
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494 significantly more depressed than the Australian sample.

495 Why the Brazilians appeared less affected by depression Acknowledgement 548
496 than the Australians in relation to employment is puz-
497 zling. It is possible this reflects a social contingency dif- The authors thank Dr. Fiona Blyth for her valuable 549
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498 ference between the two countries, where in Brazil there comments on an earlier draft of this manuscript. 550
499 might be a greater demand (possibly for financial rea-
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500 sons) to work regardless of emotional state (Edwards

501 et al., 2005). Unfortunately, this is purely conjecture as References 551
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