pessimistic attributional style and

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Author info: Correspondence should be sent to: Dr. Kymberley K. Bennett,Department of Psychology, Cherry Hall, Room 302, University of Missouri Kansas City, Kansas City, MO, 64110. Email: [email protected].

North American Journal of Psychology, 2012, Vol. 14, No. 2, 293-306.

NAJP

Pessimistic Attributional Style and CardiacSymptom Experiences:

Self-Efficacy as a Mediator

Kymberley K. Bennett, Alisha D. Adams, & Jillian M. RicksUniversity of Missouri Kansas City

This study tested the hypothesis that self-efficacy mediates therelationship between pessimistic attributional style and experiences ofcardiac symptoms among a sample of cardiac rehabilitation (CR)patients. Questionnaire data were collected from 100 patients at thebeginning of CR (Time 1), at the end of CR, 12 weeks later (Time 2), andsix months after CR completion (Time 3). Results of path models showed

that Time 1 generality scores (the sum of stability and globality ratings)were negatively associated with Time 2 diet self-efficacy, but were un-related to Time 2 exercise self-efficacy. In turn, both forms of self-efficacy were negatively associated with Time 3 cardiac symptomexperiences. Findings suggest that self-efficacy should be studied as amediator of the relationship between pessimistic attributional style andpoor health, and they echo other research demonstrating the importanceof self-efficacy in CR patients recovery. Theoretically, our resultssupport a focus on the effects of generality scores (the sum of stable andglobal dimensions) on health, rather than the internal dimension.Clinically, our results suggest that CR providers should screen fortendencies to see the causes of negative events as long-lasting andpervasive, and assess patients for self-efficacy in domains relevant to CR.

Cardiovascular disease (CVD) is the leading cause of death in theUnited States (Roger et al., 2011). It is estimated that one American diesfrom CVD every 39 seconds, and that 33.6% of deaths in 2007 wereattributable to CVD. Currently, the American Heart Associationestimates that one in three Americans has at least one form of CVD.These prevalence data underscore the importance of secondaryprevention programs, like cardiac rehabilitation (CR), for CVD patients.CR programs have been shown to markedly affect health outcomes,including reducing rates of all-cause mortality, cardiac-related mortality,and myocardial infarction, and improving functional status, quality of lifeappraisals, and modifiable risk factors such as cholesterol levels andblood pressure (Clark, Hartling, Vandermeer, & McAlister, 2005; Tayloret al., 2004). Over the past two decades, pessimistic attributional stylehas emerged as a psychosocial correlate of poor health, including CVD.


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Bennett, Adams, & Ricks ATTRIBUTIONAL STYLE 295

people adopting a pessimistic attributional style may have difficultyestablishing friendships, and therefore lack the protective effects of socialsupport on health. Third, it has been suggested that people with apessimistic attributional style become behaviorally passive on account ofthe perceived independence between their actions and outcomes.Consequently, they may see no benefit in engaging in health-promotingbehaviors (Lin & Peterson, 1990). Fourth, symptoms of depression mayserve as a mechanism linking pessimistic attributional style to poorhealth. Although research shows that pessimistic attributional style is arisk factor for depression (Sweeney, Anderson, & Bailey, 1986), resultsare mixed when testing depression as a mediator. Support for a mediatingrole of depressive symptoms was reported for college students (Bennett& Elliott, 2002; Buchanan, Gardenswartz, & Seligman, 1999), but not forolder adults (Kamen-Siegel et al., 1991) or adolescents with diabetes(Kuttner et al., 1990).

Therefore, additional research is needed to examine the specificmechanisms linking pessimistic attributional style to poor health,especially among CVD patients. One psychosocial candidate formediation is self-efficacy, or a patients confidence in his/her ability toperform a behavior, which, when performed, should result in a desirableoutcome (Bandura, 1977). When applied to the health domain, self-efficacy refers to ones confidence to enact health behaviors whichshould positively impact health status. For CR patients, research hasdemonstrated self-efficacy to be related to gains in cardiopulmonaryfitness (Cheng & Boey, 2002) and psychosocial adjustment (Burns &Evon, 2007), and to compliance with CR (Maddison & Prapavessis,2004). In addition, low self-efficacy among heart disease patients was

associated with a greater likelihood of hospitalization for heart failureand all-cause mortality across four years of follow-up. Results showedthese associations were explained by poor cardiovascular functioning(e.g., left ventricular ejection fraction) at baseline for patients low in self-efficacy (Sarkar, Ali, & Whooley, 2009), suggesting that assessments ofself-efficacy may be important when implementing plans for recovery forCR patients.

No research of which we are aware has tested self-efficacy as amediator of the link between pessimistic attributional style and poorhealth. It is possible that feelings of hopelessness and helplessnessexperienced by people with a pessimistic attributional style may manifestas feelings of low self-efficacy. The reformulated learned helplessnessmodel suggests that adopting a pessimistic attributional style results in a

perceived independence between ones actions and outcomes (Abramson,Seligman, & Teasdale, 1978). If true, these feelings may translate to lowconfidence levels to enact healthy behaviors. Within the CR domain,


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296 NORTH AMERICAN JOURNAL OF PSYCHOLOGY

feeling that ones actions do not impact ones outcomes may negativelyaffect self-efficacy to enact the changes prescribed by CR staff (e.g.,establishment of an exercise routine). In turn, research has alreadydemonstrated the effects of low self-efficacy on CR-related endpoints(e.g., Sarkar et al., 2009). Thus, the current study was undertaken to testthe hypothesis that self-efficacy serves as a mediator of the relationshipbetween pessimistic attributional style and poor health, hereoperationalized as the experience of cardiac symptoms, among CRpatients.

METHOD

Participants

Data were collected from 100 patients (69.0% male) participating inPhase II CR programs. These programs are comprised of monitoredexercise classes and lifestyle change classes focusing on stressmanagement, pharmacology, and proper diet. This sample representsparticipants from a larger study who completed questionnaires at all threetimes.1 At Time 1, ages ranged from 38 to 85 years, with an average ageof 63.7 years (SD = 9.8). A vast majority of the sample reported theirethnic background to be European American (94.0%), with 4.0% AfricanAmerican, 1.0% Asian, 1.0% Native American, and one person failing toprovide his/her ethnic background. Although most participants weremarried or living with a partner (77.0%), 10.0% were widowed, 9.0%reported being divorced, 3.0% were single and had never married, and1.0% was separated from his/her spouse. Most participants hadcompleted high school or attended a college or trade school (42.4%),whereas 13.1% held a 2-year college degree, 22.2% held a 4-year collegedegree, and 22.2% completed a graduate degree. A majority of

participants reported not working outside the home (64.0%) and theaverage household income range for the previous year was between$60,000 and $69,999.

Participants diagnoses varied widely. The most common diagnosis,for which 23.0% were referred to CR, was the placement of a stent. Theother most common diagnoses were MI with the placement of a stent(14.0%), CABG (5.0%), and MI alone (4.0%). Participants werestratified by risk for disease progression on the basis of AmericanAssociation of Cardiovascular and Pulmonary Rehabilitation guidelines(2004). Risk stratification assignments of low, moderate, or high weremade by CR staff and based on participants diagnoses, prior cardiacevents if appropriate, and current risk factors (e.g., smoking, concurrentailments, diet). Risk stratification assignments were used by CR staff to

customize participants target energy expenditures during exercisesessions, but were not explicitly shared with participants. Within thissample, 51.2% were stratified as low in risk for disease progression,


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whereas 45.0% and 3.8% were assigned moderate and high riskstratifications, respectively. Finally, participants attended an average of17.8 exercise sessions (SD = 7.4) during their 12-week cardiacrehabilitation programs.

Measures

A self-administered questionnaire comprised of several standardizedmeasures previously used with cardiac populations was utilized in thestudy. Questionnaires were completed at the beginning of CR (Time 1),at the completion of CR (Time 2), and six months after completion of CR(Time 3).

Pessimistic attributional style. At Time 1, pessimistic attributionalstyle was assessed with the Attributional Style Questionnaire-Revised(ASQ-R; Dykema, Bergbower, Doctora, & Peterson, 1996). The ASQ-Rpresents participants with six hypothetical, negative situations (e.g., youhave trouble sleeping, you cant get done all the tasks that others expectof you). Participants are asked to write the main cause for each event,followed by ratings of each cause on internal, stable, and globaldimensions. Ratings are made on 7-point scales (e.g., will never affectyou again to will always affect you). According to the reformulatedlearned helplessness model (Abramson, Seligman, &Teasdale, 1978),each dimension of pessimistic attributional style is hypothesized to resultin unique intrapersonal consequences: internality with loss of self-esteem, stability with long-lasting feelings of hopelessness, and globalitywith pervasive feelings of helplessness. More recently, researchers havefocused on the stable and global dimensions to create a generality score,as internality has produced mixed results with outcomes (e.g., Bennett &

Elliott, 2005; Hommel, Wagner, Chaney, & Mullins, 2001). Moreover,Janoff-Bulman (1992) distinguishes between different types of internalattributions (i.e., behavioral ones that are controllable versuscharacterological ones that are uncontrollable), and her theory hasreceived support (e.g., Friedman et al., 2007). Therefore, as done inprevious research, we computed a generality score that includesresponses to the stable and global questions (e.g., Fresco, Heimberg,Abramowitz, & Bertram, 2006; Lo, Yo, & Hollon, 2010). Highergenerality scores reflect stronger beliefs that negative events are due tolong-lasting and pervasive causes.

Diet self-efficacy. Self-efficacy about dietary improvements at Time2 was measured via the Cardiac Diet Self-Efficacy Inventory (CDSEI;Hickey, Own, & Froman, 1992). The CDSEI is a 16-item scale designed

to assess cardiac patients confidence in making a variety of dietarychanges (e.g., staying on a healthy diet when busy or in a rush, knowinghow to cook healthy meals). Responses to items are made on a 5-point


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scale (very little confidence to quite a lot of confidence) and summed,with higher scores indicating more diet self-efficacy.Exercise self-efficacy. Self-efficacy about enacting an exercise

routine at Time 2 was measured via the Cardiac Exercise Self-EfficacyInventory(CESEI; Hickey, Own, & Froman, 1992). The CESEI is a 16-item scale designed to assess cardiac patients confidence inimplementing and maintaining an active exercise program (e.g.,exercising for at least 20 minutes three times each week, exercising athome). Responses to items are made on a 5-point scale (very littleconfidenceto quite a lot of confidence) and summed, with higher scoresreflecting more exercise self-efficacy.

Experience of cardiac symptoms. Patients experiences of cardiac-related symptoms at Time 1 and Time 3 were assessed with threequestions adapted from Rose (1962). Participants were asked how manytimes during the preceding two weeks they suffered from three commoncardiovascular disease-related symptoms: (a) pain in chest, (b) pressureor heaviness in chest, and (c) shortness of breath. Responses were madeon a 1 (never) to 5 (more than 15 times) scale and summed, with highscores indicating more frequent experience of symptoms.

Procedure

Participants were recruited through two Phase II CR programs in aMidwestern state. These programs typically run for 12 weeks, offeringexercise sessions three times per week (i.e., for a total of 36 sessionspossible), with the total number of sessions often being determined by apatients insurance company. Patients with more severe diagnoses (e.g.,coronary artery bypass graft [CABG]) are often approved for more

sessions than patients with less severe conditions (e.g., MI). The timebetween patients transitions from hospitalization (i.e., Phase I) to PhaseII varies by the severity of the cardiac event, with entry into Phase IIwhen exercise does not pose a risk.

Participant recruitment occurred in two phases. First, CR staffmembers summarized the studys objectives and procedures duringintroductory, intake interviews with new Phase II patients. If patientsprovided preliminary written consent, their contact information wasforwarded to our research team. The second phase of recruitmentoccurred when our research team members called interested patients.During phone calls, more detailed information about the study wasprovided to patients, and if they expressed interest, a study packet with aconsent form, Time 1 questionnaire, and postage-paid return envelope

was mailed to them. If a patient consented to being in the study, he/shewas asked to sign the consent form and return it, along with thecompleted questionnaire, in the enclosed envelope. Signing the consent


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form also provided our research team permission to access patientsmedical records from their CR programs. Time 2 questionnaires weremailed to participants 12 weeks later, at the end of their respective PhaseII programs. Time 3 questionnaires were mailed to participants sixmonths after completion of CR (i.e., nine months following entrance intoCR).

RESULTS

Descriptive statistics for, and correlations among, all study variablesare presented in Table 1, along with coefficient alphas.2 Table 1 showsthat Time 1 generality scores were positively related to cardiac symptomexperiences at Times 1 and 3, and negatively associated with diet self-efficacy at Time 2. Internality, however, was unrelated to cardiacsymptoms and both forms of self-efficacy. There was moderate stabilityin cardiac symptom experiences between Times 1 and 3, and appraisalsof diet and exercise self-efficacy at Time 2 were moderately correlated.Both forms of Time 2 self-efficacy were negatively associated withcardiac symptom experiences at Time 3.

TABLE 1 Descriptive Statistics and Correlations among Study Variables1 2 3 4 5 6

1. INT, T1 (.51) .41* .18 .00 .02 .012. GEN, T1 (.80) .27* -.25* -.06 .22*3. SYM, T1 (.71) -.21* -.09 .61*4. DSE, T2 (.95) .60* -.44*5. ESE, T2 (.90) -.29*6. SYM, T3 (.82)

Mean 27.47 50.74 5.22 57.58 61.62 4.50SD 6.21 12.33 2.40 13.18 13.20 2.20

Note. INT, T1 = Internality at Time 1; GEN, T1 = Generality Score at Time 1; SYM, T1 =Cardiac Symptoms at Time 1; DSE, T2 = Diet Self-Efficacy at Time 2; ESE, T2 = ExerciseSelf-Efficacy at Time 2; SYM, T3 = Cardiac Symptoms at Time 3. Coefficient alphas areprovided along the diagonal. Probabilities are expressed only to thep< .05 level.*p< .05.

The studys hypothesis that self-efficacy serves as a mediator of therelationship between pessimistic attributional stylehere operationalizedas generality scoresand cardiac symptom experiences was tested withpath analysis, using AMOS 19.0. Figure 1 shows results of the modeltesting diet self-efficacy as the mediator, controlling for baseline cardiacsymptom experiences. Results showed Time 1 generality scores were

negatively related to Time 2 diet self-efficacy, which, in turn, wasnegatively associated with Time 3 cardiac symptom experiences.


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Bivariate analyses showed that baseline generality was significantlyassociated with Time 3 cardiac symptoms, but in the path model, this

FIGURE 1 Path Model Testing Time 2 Diet Self-efficacy as a Mediatorof the Relationship between Time 1 Generality Scores and Time 3Cardiac Symptom Experiences. Model controls for Time 1 CardiacSymptoms. *p< .05, ***p< .001. 2(1) = 2.30,p= .13, NFI = .97, IFI= .98, CFI = .98, and RMSEA = .02.

association was non-significant. Our model indicated that the total effectof Time 1 generality scores on Time 3 cardiac symptom experiences was.083, with an indirect effect via diet self-efficacy of .08. Thus,approximately 96% of the total effect of baseline generality scores on

cardiac symptoms at Time 3 operated indirectly through diet self-efficacy. The Sobel (1982) test to examine the significance of themediated effect yielded a z= 2.04, p< .05. This model, controlling forbaseline symptoms, explained 42.2% of the variance in Time 3 cardiacsymptom experiences. Findings support the hypothesis that diet self-efficacy mediates the association between pessimistic attributional styleand cardiac symptom experiences.

Figure 2 shows results of the model testing exercise self-efficacy asthe mediator, controlling for baseline cardiac symptom experiences.Results showed Time 1 generality scores were unrelated to Time 2exercise self-efficacy, but that exercise self-efficacy was significantlyassociated with Time 3 cardiac symptom experiences. Although we didnot find mediation, the model explained 39.3% of the variance in Time 3cardiac symptom experiences. Thus, findings do not support thehypothesis that exercise self-efficacy serves as a mediator of therelationship between pessimistic attributional style and cardiac symptomexperiences.


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FIGURE 2 Path Model Testing Time 2 Exercise Self-efficacy as aMediator of the Relationship between Time 1 Generality Scores andTime 3 Cardiac Symptom Experiences. Model Controls for Time 1Cardiac Symptoms. **p < .01. 2(1) = .59,p= .44, NFI = .99, IFI = .99,CFI = .99, and RMSEA = .001.

DISCUSSION

The purpose of this study was to test self-efficacy as a mediator of therelationship between pessimistic attributional style and poor health in aCR sample. Results supported diet self-efficacy as a mediator, but notexercise self-efficacy. Our findings suggest that the tendency to seenegative events as stemming from stable and global causes is associatedwith low confidence in making CR-prescribed dietary changes, but notassociated with confidence in making exercise changes. These resultsimply that the exercise education and instruction provided to patientsduring CR may be powerful enough to override this maladaptive

cognitive tendency in certain domains. Where the deleterious effects ofpessimistic attributional style may manifest are with confidence levelssurrounding dietary changes. Although CR programs are multi-disciplinary in nature (Balady et al., 2007), the exercise aspects of theprograms may be most salient to patients. The one-on-one exerciseinstruction and feedback provided by CR staff may instill confidence inpatients to maintain healthy exercise habits, but the instruction in dietarychanges may not be intensive enough to overcome the cognitive tendencyto presume independence between actions and outcomes, a hallmark ofpessimistic attributional style.

The interpretation that CR interventions have their most powerfuleffects on exercise-related beliefs (as compared to diet-related beliefs) issupported by the fact that levels of exercise self-efficacy (M= 59.20) and

diet self-efficacy (M = 58.08) prior to CR did not significantly differfrom each other (t [90] = .71, n.s.) in our sample, and by the Time 2means shown in Table 1. Specifically, a paired-samples t-test showed


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that the two self-efficacy means differed significantly from one another (t[91] = 3.77, p< .001), with exercise self-efficacy higher than diet self-efficacy at the end of CR. Thus, our findings suggest that pessimisticattributional style operates through low confidence to make dietarychanges to affect participants experiences of cardiac-related symptomssix months later. Our results also support other research documenting theimportance of self-efficacy among CR patients (Burns & Evon, 2007;Cheng & Boey, 2002; Maddison & Prapavessis, 2004). Regardless ofattributional style, diet and exercise self-efficacy at the end of CR werenegatively related to the experience of cardiac symptoms six monthslater.

Theoretically, our findings support others who have downplayed theimportance of the internal dimension of attributional style, in favor of anexamination of the effects of generality scores (derived as a sum ofratings to the stable and global dimensions; Fresco et al., 2006; Lo et al.,2010). Mixed results have been reported for the effect of internality onhealth outcomes (e.g., Bennett & Elliott, 2005; Hommel et al., 2001), butnot for the effects of the stable and global dimensions. In fact, the stabledimension has been associated with poor CVD-related outcomes acrossmultiple studies (e.g., Bennett & Elliott, 2005; Buchanan, 1995; Grewenet al., 2000). Table 1 shows that Time 1 internality scores were unrelatedto Times 1 and 3 cardiac symptom experiences, as well as to Time 2 dietand exercise self-efficacy. As it is written, it is impossible to knowwhether the self-blame captured by the internal dimension on the ASQ-Ris perceived to be changeable (as with behavioral self-blame) orunchangeable (as with characterological self-blame). The distinctionbetween malleable and non-malleable self-blame is an important one

(Janoff-Bulman, 1992), and may shed light on the reasons for the mixedeffects of internality on health outcomes.

Two main implications for practice follow from our results. First, CRproviders should identify people who assign stable and global causes tonegative events. Although we did not examine the relationship betweengenerality scores and distress (e.g., symptoms of depression and anxiety),it is likely that the effect of perceived independence between actions andoutcomes goes beyond self-efficacy to other cognitive and affectiveconstructs, which, in turn, negatively affect health outcomes. Althoughattributional style is assumed to be a stable trait, research suggests that itcan be altered through intervention (Peters, Constans, & Matthews, 2011;Proudfoot, Corr, Guest, & Dunn, 2009). Our data suggest that alteringpessimistic tendencies would benefit health indirectly through its impact

on self-efficacy. Second, CR providers should assess patients self-efficacy given its strong relationship with health outcomes (e.g., Sarkar etal., 2009). Identifying patients low in self-efficacy is likely to provide


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important information for CR program planning. For example,identifying patients low in diet self-efficacy, as opposed to low inexercise self-efficacy, may provide CR staff with information aboutwhere intervention efforts should be targeted. In this case, a patient couldbe referred to a nutritionist for additional nutrition counseling to addresslow diet self-efficacy. Furthermore, promoting confidence in patients,regardless of their baseline levels, should promote the enactment ofhealth-promoting behaviors.

Although this is the first study of which we are aware to examineself-efficacy as a mediator of the link between pessimistic attributionalstyle and cardiac symptom experiences, there are limitations worthnoting. First, these data were collected from an ethnically homogenousand relatively affluent sample of CVD patients participating in a CRprogram. Evidence suggests that referral rates to CR are low(approximately 56%; Brown et al., 2009), and that rates of participationin CR among eligible patients are even lower (approximately 19%; Suayaet al., 2007). Therefore, in order to increase generalizability, futureresearch should recruit a more heterogeneous sample of CVD patients.Second, all data in this study were collected via self-report, and thusshare common method variance. In addition, self-report data are open tothe hazards of social desirability and other response biases. Negativeaffect also is likely to play a role in symptom reporting. To the extentthat pessimistic attributional style contains a component of negativeaffect, it is possible that pessimistic individuals report/experience moreCVD-related symptoms than their optimistic counterparts. Therefore,future research would benefit from clinical assessments of health status,as well as from cross-informant ratings. Third, although we followed

patients over six months following CR, this is a relatively short period ina patients recovery process. A longer span between data collectionperiods in future studies would allow for the examination of theseprocesses over a more meaningful period.

In conclusion, beliefs at the beginning of CR that the causes ofnegative events are long-lasting and pervasive (i.e., stable and global)were negatively associated with diet self-efficacy at the end of CR. Inturn, diet self-efficacy was negatively related to cardiac symptomappraisals six months later. Although diet self-efficacy mediated theassociation between generality scores and cardiac symptoms, exerciseself-efficacy was not a mediator. Results showed that both forms of self-efficacy at the end of CR negatively predicted cardiac symptoms sixmonths later, supporting prior research. Our results imply that CR

providers should screen for both pessimistic attributional style and self-efficacy, as interventions to change these constructs may prove fruitful inthe recovery process.


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FOOTNOTES1We tested for possible differences between this sample and the larger study fromwhich it was drawn (n = 155), using t-tests and chi-squares on Time 1demographic and study variables. Results showed that the groups differedsignificantly in age and education: participants in this sample who completed allthree questionnaires were significantly older (M= 63.7) and more educated (M=5.0) than their counterparts who did not complete all three questionnaires (Ms =59.7 and 4.5, respectively). These differences warrant some caution ingeneralizing findings to all patients in the larger study.2For normality purposes, Time 1 and Time 3 cardiac symptom experiences weresubjected to log transformations.


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