Introduction
Persistent or chronic pain among adolescents is recognized as a global growing health problem. Headache, abdominal pain and back pain are most commonly reported, but these frequently coexist with persistent pain at multiple locations [
1,
2]. Pain in adolescence is often complex, may have no clear cause and can include cycles of flares [
3]. Chronic pain is defined as persistent or recurrent pain lasting more than 3 months [
4]. Internationally comparable data indicate that persistent pain is highly prevalent among adolescents [
5]. Research indicates that the prevalence of persistent pain among adolescents in Western countries ranges from 20 to 35%, is clearly higher in girls than in boys and increases with age [
6‐
11]. The national annual Young-data surveys have revealed an increase in psychosocial complaints among Norwegian adolescents attending high schools, herein about half of the adolescents have concerns like “everything feels like a struggle” [
12]. Further, Norwegian adolescents have reported that the feeling of stress and struggle may be a contributing factor to their pain experience [
13]. However, persistent pain in a school-based (non-clinical) population of adolescents usually has an unconfirmed aetiology with no underlying pathological condition or apparent single explanation [
14]. Thus, further insight into the complexity of pain associations in adolescence is needed.
Persistent pain in adolescence has several consequences. Short-term consequences may include absence from school and social activities, resulting in periods of isolation from peers and role loss, which may explain why adolescents with pain tend to have fewer friends compared with healthy adolescents [
3,
15,
16]. In addition, pain that begins in adolescence may have long-term consequences if the adolescents enter adulthood suffering persistent pain, which carries risks of psychosocial and socio-economic distress [
17,
18] Other long-term consequences include higher levels of perceived stress, sleep disturbance, reduced physical activity and overall reduced health-related quality of life (HRQOL), which all negatively affect different aspects of the adolescent’s everyday life [
19,
20].
HRQOL is a multidimensional concept that includes physical, psychological, social and spiritual aspects of life [
21]. The concept of HRQOL is often used when assessing how pain can influence the daily life of adolescents, because pain impacts all aspects of life [
22,
23]. Several studies that examined the association between pain and HRQOL among adolescents showed that persistent pain is associated with reduced HRQOL [
10,
20,
22‐
25]. There are several questionnaires that measure HRQOL, of which KIDSCREEN-52 has been shown to have the best structural validity [
26]. However, there is limited research investigating HRQOL and pain in a school-based population of adolescents using the 10 sub-scales of the KIDSCREEN-52 questionnaire [
27]. A Norwegian study showed that pain in children and adolescents was associated with lower HRQOL demonstrated by reduced scores for all 10 sub-scales of the KIDSCREEN-52 questionnaire, but had the greatest effect on the HRQOL sub-scales of self-perception, psychological well-being, mood, relationship with parents and school environment [
27]. Further research on pain and HRQOL in a school-based sample of adolescents is needed to explore whether this association can be explained by underlying mechanisms or is related purely to the pain itself.
Self-efficacy, defined by Albert Bandura as “one’s beliefs in one’s capability to organize and execute the courses of action required to achieve given results”, is well-known to affect a person’s cognition [
28,
29]. In adults, general self-efficacy (GSE) has been shown to positively impact QOL by reducing stress and, thereby, increasing QOL [
30,
31]. In young adolescents, a higher degree of self-efficacy has been shown to be related to higher HRQOL scores [
32], and has been associated with several positive health outcomes for adolescents with chronic pain, including higher self-esteem and acceptance, and lower disability and somatic symptoms [
33,
34]. In a sample of adolescents with chronic headache, higher self-efficacy was associated with improved school performance and lower disability [
35].
Previous research evidence has shown that self-efficacy acts as an underlying mechanism by mediating the relationship between pain-related fear and school-related disability in adolescents with chronic headache [
36]. In adults with chronic pain, self-efficacy was found to be a mediator of the relationship between pain intensity, disability and depression [
37]. Bandura has proposed that self-efficacy might act as a mediator between stressful experiences and outcomes such as well-being [
38]. However, no study has investigated whether self-efficacy acts as a possible mediator of the relationship between pain and HRQOL in a school-based sample of adolescents.
Thus, the purpose of this study was to describe the pain experience (intensity, frequency, duration and location), HRQOL and GSE in a sample from a school-based population of adolescents with persistent pain, and to assess possible associations between pain intensity, GSE and HRQOL. We hypothesized that pain intensity is negatively associated with HRQOL, and that self-efficacy plays a role as a mediator.
Discussion
This study described the pain experience (intensity, frequency, duration and location) of adolescents with persistent pain, assessed the association between pain intensity, GSE and HRQOL, and tested self-efficacy as a possible mediator of pain. Our findings demonstrated that the participants were affected by the intensity, duration, frequency and locations of their experienced pain. Pain intensity was associated with impairments in the scores for several sub-scales of HRQOL and GSE. Further, GSE was a significant mediator between pain intensity and the HRQOL sub-scales of physical well-being, psychological well-being, mood, self-perception, autonomy and school environment. Up to 67% of the reduction in these respective HRQOL sub-scales was explained by the mediating variable (indirect effect).
Considering that the study sample was recruited from a school-based setting, and that headaches were the most commonly reported pain (88.5%), the overall presence of pain could be categorized as severe, with a mean pain intensity score of 5.4 (VAS) [
52]. However, epidemiological studies have reported similar mean pain intensity scores ranging from 4.5 to 5.6 [
2,
8]. Our data also revealed several gender differences: girls reported higher scores for pain intensity (VAS 5.7) compared with boys (VAS 4.2). Although all participants experienced persistent multi-site pain, girls reported pain in a greater number of body regions. These findings are consistent with the literature showing that headache is the most commonly reported type of pain, and that girls in late adolescence seem to experience more intense and frequent pain of longer duration than that experienced by boys, and more often have pain in multiple sites [
7,
9,
11,
27]. Because pain is known to impact HRQOL, our findings predictably identified a gender difference in HRQOL sub-scale scores, with generally higher scores for boys than for girls. Higher HRQOL in adolescence in boys compared with girls is consistent with previous reports [
53‐
56]. Data from 12 European countries (
n = 21,590) showed no gender difference in HRQOL of young children; however, with increasing age, HRQOL in girls declined significantly compared with that in boys [
56]. However, given that our study population was considered homogenous with respect to age, we were not able to perform any statistical inference concerning age.
Our findings revealed that pain intensity was negatively associated with all sub-scales of HRQOL and GSE, and that the participants generally reported low scores for HRQOL. However, in our regression analyses of pain intensity (independent) and sub-scales of HRQOL (dependent), the non-standardized estimates of B explained the difference in HRQOL in our study with that reported in an earlier published study, which used 10 sub-scales of KIDSCREEN-52 in a school-based population of children and adolescents (
n = 1099) [
27]. In this earlier school survey, the most impaired sub-scales of HRQOL for adolescents with persistent pain were psychological well-being, mood, self-perception, autonomy and school environment; this was generally consistent with our findings. However, unlike the earlier study, we did not identify any significant relationship between pain intensity and the HRQOL sub-scale autonomy, while our data showed a significant relationship between pain intensity and the scores for the HRQOL sub-scales of physical well-being and social support. These findings may relate to those of previous studies, which showed that persistent pain may result in periods of isolation from peers and, thus, absence from school, everyday physical activities and other social activities [
3,
15]. Adolescents have reported that one of the most important things for their quality of life is to be social together with friends [
57], and children and adolescents with persistent pain are commonly reported to have reduced social functioning and reduced physical activity levels [
9,
58‐
60].
We hypothesized that self-efficacy would play a role as a possible mediator between pain and HRQOL. Interestingly, self-efficacy, a well-known approach to evaluating effects on a person’s cognition, did not only mediate the relationship between pain intensity and scores for HRQOL sub-scales connected with the adolescent’s perception of themselves, such as psychological well-being, mood and self-perception, but we showed that a reduction in self-efficacy also appeared to play a role in other HRQOL sub-scales, such as school environment. These findings are consistent with previous research that has shown that higher scores for self-efficacy in adolescents with chronic pain were associated with improved school functioning and lower school-related disability [
35,
36]. Further, earlier studies showed that higher self-efficacy positively influences academic achievement and the likelihood of remaining in school [
61]. Moreover, the highest indirect effect was found for the HRQOL sub-scale physical well-being, which is an important finding given that a reduction in physical well-being in adolescence is an indication of an impaired physical activity level, which is considered as a key component of a healthy lifestyle, herein self-efficacy is identified as a determinant for physical activity [
62,
63]. A systemic review with meta-analyses by Ashford and colleagues discussed numerous ways to change self-efficacy, and reported that interventions, including feedback on past performance, feedback on performance compared with others and vicarious experience (role model), produced the highest levels of self-efficacy [
64]. Bandura [
65,
66] defined the concept of self-efficacy as a self-regulatory mechanism by which it is possible to change as a result of being motivated by others or through goal-setting and education. Thus, enhancing self-efficacy seems to be an important intervention strategy when aiming to improve HRQOL in adolescents with persistent pain.
Strengths and limitations
All data analysed were cross-sectional, so no causal relationships could be identified. We could not test statistically the possible effect of gender due to the limited sample size and the homogeneity of the sample (a great majority were girls). Moreover, we were not able to control for other possible confounders as medication use. Hence, larger samples are recommended in future studies. The mediation model seeks to identify underlying mechanisms between observed associations but is of exploratory nature. Thus, this current meditation model is based on our assumptions and understanding of this research area, e.g. we can only assume causality and direction of the direct and indirect effect. Our findings are exploratory and should be verified and replicated in future and large studies and may only be generalized to a school-based population of adolescents with persistent and weekly pain. The effects may be over-estimated due to the shared source of variance. However, we consider that our findings shed new light on the underlying mechanisms of the association between pain and HRQOL in a sample from a school-based population of adolescents. We do not have any data regarding the 34 individuals who initially enrolled but were lost after registration; thus, the recruited adolescents might be those who were most interested because they had more severe pain. Hence, the findings may not be generalizable to the general population. A strength of the study is that we used well-validated questionnaires; however, the instrument for self-reported pain measures (LPQ) had a 3-month recall period for pain location, which might be a long period for adolescents to remember and may have reduced the validity of the data. In contrast, KIDSCREEN-52 used a 1-week recall period, which has been shown to be advantageous [
16,
67].
Clinical implications
Our findings provide new insight by showing that the association between pain intensity and HRQOL in a school-based sample of adolescents with persistent pain was explained by the mediating variable self-efficacy. Thus, this study extends previous assumptions and empirical research and shows that in future interventions for pain management, promoting self-efficacy could be beneficial for HRQOL. Given that research evidence has identified numerous ways to change self-efficacy [
64‐
66], these findings may contribute to the design of more effective pain-management interventions that promote HRQOL in adolescents with persistent pain. Finally, regarding the adolescents’ school environment, teachers and health care nurses should be aware of targeting self-efficacy as a strategy to increase HRQOL.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.