Health Psychology - Theses

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    Stress, coping and quality of life in patients with cancer
    (University of Hyderabad, 2013-07-01) Vijaya Prasad, Barre ; Padmaja, G
    Cancer is a demon which threatens the life of many both by its presence and likelihood of arrival in the present day world marked by stressful living. The main objectives of the proposed research were, to explore the level of stress, coping strategies, and quality of life of patients with cancer and to find out the relationship between the stress, coping strategies, quality of life, ECOGPS and the age of the patients with cancer pre- and post-medical intervention (Part A); to develop psychological intervention package based on Part A results; and to test the effectiveness of the developed package on a new sample of patients with cancer by measuring the same variables as in Part A, pre- and post-medical and psychological intervention (Part C). The study is a quasi-experimental design conducted in three parts. During the Part A, 105 patients and in Part C 30 patients with cancer between the ages of 28 - 65 years were included in the study with equal distribution of subjects from three types of cancer viz. lung, breast and head-neck-cancer in both Part A and Part C. The tools used were Questionnaire on Stress in Cancer Patients- Revised Version (QSC-R23) to measure stress level, Brief COPE for coping, European Organization for the Treatment and Research of Cancer Quality of Life Questionnaire-QLQ-C30, version 3.0 to assess the quality of life, during pre- and post- Medical Intervention Assessment (pre- and post-MIA) in Part A. A psychological intervention package was developed during Part B with psychoeducation, relaxation, and Cognitive Behaviour Therapy modules which were applied along with medical intervention in Part C. The impact of psychoeducation was measured using Cancer Information Scale, impact of relaxation by using Visual Analogue Scale and impact of cognitive behaviour therapy was measured by using Triple Column Technique pre- and post-MPIA inCancer is a demon which threatens the life of many both by its presence and likelihood of arrival in the present day world marked by stressful living. The main objectives of the proposed research were, to explore the level of stress, coping strategies, and quality of life of patients with cancer and to find out the relationship between the stress, coping strategies, quality of life, ECOGPS and the age of the patients with cancer pre- and post-medical intervention (Part A); to develop psychological intervention package based on Part A results; and to test the effectiveness of the developed package on a new sample of patients with cancer by measuring the same variables as in Part A, pre- and post-medical and psychological intervention (Part C). The study is a quasi-experimental design conducted in three parts. During the Part A, 105 patients and in Part C 30 patients with cancer between the ages of 28 - 65 years were included in the study with equal distribution of subjects from three types of cancer viz. lung, breast and head-neck-cancer in both Part A and Part C. The tools used were Questionnaire on Stress in Cancer Patients- Revised Version (QSC-R23) to measure stress level, Brief COPE for coping, European Organization for the Treatment and Research of Cancer Quality of Life Questionnaire-QLQ-C30, version 3.0 to assess the quality of life, during pre- and post- Medical Intervention Assessment (pre- and post-MIA) in Part A. A psychological intervention package was developed during Part B with psychoeducation, relaxation, and Cognitive Behaviour Therapy modules which were applied along with medical intervention in Part C. The impact of psychoeducation was measured using Cancer Information Scale, impact of relaxation by using Visual Analogue Scale and impact of cognitive behaviour therapy was measured by using Triple Column Technique pre- and post-MPIA inPart C. Again the tools to measure stress, coping and quality of life were used pre- and post- Medical and Psychological Intervention Assessment (pre- and post- MPIA). Statistical procedures used were descriptive statistics, paired and independent t test, Pearson r, Wilcoxon signed rank test (to measure the effect of relaxation) and ANCOVA (to find out whether treatment response of the patients varies according to the variation in intervention) with help of SPSS 16.0. The results indicated that the impact of medical and psychological intervention was clearly found on following parameters. There were differences in levels of stress, coping strategies and General Health Status/Quality of life (GHS/QoL) in functional and symptom scales during Part C i.e. pre- and post-medical and psychological intervention assessment. Whereas, no differences were found in GHS/QoL during Part A i.e. pre- and post-medical intervention assessment. Findings of part C indicated a change in myths and misconceptions, minimal changes in negative automatic thoughts and it was seen that the impact of relaxation was felt by the patients. These significantly seemed to have helped to significantly show the difference viz. reduce stress, fostering coping strategies and enhancing their quality of life when used alongside medical intervention. The psychological intervention when combined with medical intervention showed better results. This signifies the effectiveness of psychological intervention for the patients with LC, BC and HNC. Findings of the present study indicated that there is a wide scope/ importance of psychological intervention alongside medical intervention in the field of psychooncology. Limitations of the study and implications are also discussed
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    Health communication between doctors and patients \b impact on patient adherence and disease prognosis
    (University of Hyderabad, 2013-08-01) Sunayana Swain ; Meena Hariharan
    Health Communication is the crucial link that keeps the health care system running and delivering effective service. Doctor-patient communication is one form of health communication which has a direct impact on treatment and prognosis, particularly in Non-Communicable Diseases (NCDs) like Hypertension, Diabetes, Arthritis, etc. The present study investigates into the impact of Quality of Communication between doctors and patients diagnosed with primary hypertension on their adherence to treatment and prognosis of the disease. The objective is to determine if doctor-patient communication has an effect on the treatment adherence and prognosis of the patients with primary hypertension and the impact of adherence on prognosis. For this a mixed approach of correlational design, between-subjects and Simple Mixed factorial design was adopted. A sample of 30 doctors and 300 hypertensive patients forming 30 nests, each with one doctor and 10 patients was studied. Quality of communication was measured with a unique method using similarity index that took into account the transaction between the doctor and the patient as a whole. Adherence was measured through self report while prognosis was measured by pre and post Blood Pressure readings as well as doctors‟ ratings. Results revealed that quality of communication plays a significant role in adherence to treatment and prognosis. Results also revealed that adherence plays an important role in deciding the prognosis. Further, the impact of quality of communication on prognosis suggested a definite pathway through adherence. The implications discussed included the need for scientific approach to study the quality of doctor-patient communication, and the analysis of cost- effectiveness of training the doctors in effective communication to address the disease burden of Hypertension.
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    Psychosocial care in intensive care units : impact on trauma and wellbeing
    (University of Hyderabad, 2013-08-01) Venkata Usha, Chivukula ; Meena Hariharan
    Intensive Care Units (ICUs) are isolated areas of hospitals meant for providing focused care to patients critically ill or convalescing from surgery. Patients here need close monitoring and intervention. Such isolation, while necessary to protect the patients from infection and complications may create distress and trauma. This can be minimized with biopsychosocial approach in ICU treatment. The present study investigates the impact of Psychosocial Care on ICU Trauma and Wellbeing of patients convalescing in ICU after Coronary Artery Bypass Graft. The study involved a combination of a correlation design and a between subject design with unrelated samples. A multistage sampling method was used. The sample consisted of hospitals and 250 post-operative CABG patients. The study measured the ICU Quality, Psychosocial Care received by the patients, their Trauma and Hospital Wellbeing. The results indicated that Psychosocial Care was a major predictor of ICU Trauma and Hospital Wellbeing. The results revealed significant differences among hospitals in Quality of ICU and Psychosocial Care. The findings indicated that patients treated in High ICU Quality, received higher Psychosocial Care experienced lower levels of ICU Trauma and higher Wellbeing, than patients treated in a Low ICU Quality. The study suggests a biopsychosocial approach in treatment and care of ICU patients. The implications and limitations of the study are disc
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    Resilience and adversity among institutionalised children : contributions towards health
    (University of Hyderabad, 2015-01-30) Swati Agarwal ; Sushma, B
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    Impact of Psychological intervention on adherence and prognosis in patients undergoing coronary artery bypass grafting
    (University of Hyderabad, 2016-03-01) Thomas, Marlyn ; Meena Hariharan
    Coronary Artery Bypass Grafting (CABG) is an invasive surgical procedure for patients with Coronary Artery Disease. Given the intensity of pain, dependency and medical protocols during the period of CABG, patients tend to experience psychological distress which may lower their adherence and prognosis after surgery. This research study examined the impact of psychosocial intervention, facilitated in conjunction with standard hospital treatment, on adherence and prognosis in patients undergoing CABG. Using a pretest-posttest non-equivalent control groups design, three groups of patients were compared. The first group received the Programme for Affective and Cognitive Education (PACE) intervention, the second was given the Relaxation intervention, and the third formed the Control group with standard hospital treatment only. The participants were assessed using Hospital Anxiety and Depression Scale, Multidimensional Scale of Perceived Social Support, Locus of Control checklist for CABG, Adherence Scale for Cardiac Patients, and Biopsychosocial Prognosis Scale for CABG. A sample of 300 participants was sequentially assigned to the three groups (100 in each) in the order of PACE, Relaxation, and Control. The interventions were administered twice to the participants. They were also given the intervention CD or DVD, to be used for reinforcement after discharge. A day before CABG, the pre-surgery assessment was carried out to measure psychological distress, perceived social support and health locus of control. Following this on the same day, the PACE and Relaxation groups received their respective intervention. CABG was performed the next day as per schedule. A day before discharge from hospital (pre- discharge phase), the PACE and Relaxation groups received the second part of their respective intervention. All participants were followed up for six weeks afterdischarge. Psychological distress was assessed during participants’ first and second medical reviews, while adherence and prognosis were measured at the second medical review. A sub-sample of 100 participants was followed up five months after discharge as part of the assessment of prognosis. Semi-structured interviews were individually conducted with a sub-sample of 15 participants to gain deeper insight into their feelings, experiences, and opinions. Results showed that the PACE group had the highest adherence and prognosis as well as the highest reduction in psychological distress from pre-surgery to second review assessments. The Control group had the lowest adherence and prognosis as well as the lowest reduction in psychological distress from pre-surgery to second review assessments. Further, the study attempted to trace the pathway between interventions, adherence and prognosis. By means of pathway modelling using multiple linear regression analyses, adherence was found to be independently and positively predicted by the PACE intervention, the Relaxation intervention and perceived social support, and negatively predicted by psychological distress at second review. The PACE intervention was the only positive independent predictor of prognosis, while psychological distress before surgery, psychological distress at second review and female gender were negative independent predictors. Thematic analysis of qualitative data indicated three themes in participants’ experiences: relief through psychosocial intervention, differential impact of psychosocial interventions, and finding solace in interaction and assessment. The results consistently indicated that psychosocial intervention, namely PACE, was effective in optimising adherence and prognosis after CABG, primarily by reducing psychological distress prior to surgery and during convalescence. The indispensability of integrating psychosocial care into CABG alongside biomedical treatment is the key conclusion. Implications, strengths, and limitations of the study are also discussed
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    Flourishing and its major indicators in school-going Indian adolescents
    (University of Hyderabad, 2016-05-01) Durgesh Nandinee ; Rana, Suvashisa
    Research on adolescence—the second decade of life—has focused predominantly on adolescent’s negative characteristics, which is not enough to understand the underlying complexities. Therefore, this study emphasizes on adolescent’s flourishing—a positive dimension of mental health continuum—which is a relatively new construct. The main objectives of the study are to assess the level of flourishing in school-going Indian adolescents across two types of school and gender, and to identify its major indicators. The study has explored the occurrence of natural groups among these adolescents using cluster analysis in terms of their flourishing and measured variation between these natural groups on the indicators of flourishing. The study has also attempted to explore the adolescents’ lived experiences to understand the dynamics of their flourishing. On the basis of the review of literature, hypotheses have been formulated to address all the objectives except the last one as it has been addressed by the qualitative research method. The study is based on sequential mixed method design. In the first phase, under the framework of quantitative research design, the study has adopted a prospective, more than one independent variable, factorial design developed under the ex post facto approach. As there are two factors, a 2 (School) x 2 (Gender) factorial design has been adopted. In the second phase, under the framework of qualitative research design, the study is based on Interpretative Phenomenological Analysis for understanding the process and identifying the dynamics of flourishing in school-going Indian adolescents. The sample comprises of 400 school-going Indian adolescents, who are in their late adolescence phase and selected by multistage sampling. After obtaining the ethical approval of the Institutional Ethics Committee of the University, five measures, such as Mental Health Continuum-Short Form, Modified Differential Emotional Scale, Personal Growth Initiative Scale, Sources of Adolescent’s Happiness Scale, and Big Five Inventory-10 have been administered in smallgroups. In addition to this, individual in-depth interview sessions have been conducted on five flourishing and five languishing participants. The obtained quantitative data have been analysed by means of Mean, SD, 95% Confidence Interval, 2 X 2 Between-subjects ANOVA, Pearson’s r, hierarchical regression analysis, k-means cluster analysis, t-test, and Cohen’s d. In addition to these, exploratory factor analysis, confirmatory factor analysis, and Cronbach’s alpha have been used to develop Sources of Adolescent’s Happiness Scale. The qualitative data have been analysed by means of data driven thematic analysis. The findings of the study have revealed that the Indian adolescents do not vary in terms of their level of flourishing across school and gender. It is observed that 6.2% participants are flourishing, 83.8% are moderately mentally healthy, and 10% are languishing. The study, however, has identified seven major indicators of adolescent’s flourishing. Cluster analysis has revealed two natural groups (high flourishing and low flourishing) and these two groups have been found to be significantly different from each other in terms of the indicators of flourishing. In addition to this, the study has contributed a specific instrument—SAHAS—to measure the sources of adolescent’s happiness. The findings have also unfolded eight facilitating factors and seven barriers in the form of a functional model of the dynamics of adolescent’s flourishing, which would help in developing intervention programme for fostering flourishing during adolescence, theory generation, and theory verification. Limitations and future direction are discussed along with the implications in terms of assessment and evaluation, intervention, and theory generation and verification
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    Adherence and quality of life of patients II Diabets : Role of psychosocial Factors
    (University of Hyderabad, 2016-06-01) Angiel, Padiri Ruth ; Meera Padhy
    Diabetes is a daily personal challenge for those suffering from the condition, along with being a major public health burden for India. Treatment and management for diabetes is complex, demanding, and a lifelong continuous process which can be overwhelming for the patients and strains their quality of life. Adherence is a major factor in managing diabetes to achieve optimal glycemic control and delay or reduce the risk of any diabetes- related complications. The present study aimed to assess the difference in the level of social support, knowledge, self-efficacy, adherence, and quality of life among three groups of Type II diabetes patients categorized on the basis of duration of illness. It was also aimed to understand the role of social support, knowledge, and self-efficacy in adherence and quality of life of Type II diabetes patients. In phase I of the study, the pilot study was conducted to develop two new psychological instruments such as Diabetes Symptoms Checklist and Diabetes Knowledge Test for Indian Population and also to check the feasibility of the study. In phase II, the main study was conducted. In the main study, a correlational design was used to understand the relationship among the variables and the role of predictor variables on the criterion. Using purposive sampling method, 235 Type II diabetes patients both men and women, whose age range was from 25-75 years were included in this study. To assess the difference in the level of the variables under study, the sample was categorized into three groups based on the duration of illness, such as group I (one month to one year), group II (above one year to five years), and group III (above five years to 20 years). The instruments used to measure the variables under study were Clinical History Proforma, Diabetes Symptoms Checklist, The Diabetes Knowledge Test for Indian Population (DKT-I), Interpersonal SupportEvaluation List (ISEL), Stanford Self-efficacy Scale for Diabetes, Diabetes Adherence Scale (DAS), and Diabetes-39 Quality of Life Questionnaire. These instruments were administered in two sessions to the patients. Results showed that the three groups differed significantly, on few of the variables namely knowledge of diabetes, self-efficacy, adherence and quality of life. After ascertaining that there exists a relationship between the variables, subsequent analyses were conducted to assess the role of the predictor variables in the criterion variables. It was found that the only significant positive and independent predictor contributing to overall adherence was self-efficacy. And the significant independent predictors contributing to overall quality of life were overall diabetes knowledge, self-efficacy and adherence. A pathway was depicted to illustrate the influence of the identified predictor variables on the criterion variables, and it was noticed that self-efficacy played a major role in both adherence and quality of life of Type II diabetes patients. The implications, strengths and limitations of the study are also discussed.
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    Major determinants of adherence among persons with primary hypertensio
    (UNIVERSITY OF HYDERABAD, 2017-10-07) Vincent, Kallavarapu ; Suvashisa Rana
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    Form and frequency of congnitive intervention : Impact on adherence and management of primary hypertension
    (University of Hyderabad, 2018-07) Asher Andrew ; Meena Hariharan
    The exponential rise in the prevalence of hypertension and the resultant surge in cardiac emergencies highlight the urgent need for management of primary hypertension. Hypertension, being a chronic illness mandates high clinical adherence for effective management resulting in good prognosis. Optimizing adherence behaviour is possible through Cognitive Intervention. The purpose of Cognitive Intervention is to enhance knowledge and form a cognitive base about the seriousness of the disease and significance of its management. This in turn is expected to create a conviction and affect state that culminates in enhancing adherence behaviour. The research study examined the differential impact of the Cognitive Intervention modules varying in form and frequency on adherence and management of primary hypertension. Using a pretest-posttest control group quasi experimental design, five groups of patients were compared. Group 1 called ‗Direct Interaction Single Exposure Group‘ (DIS) received Cognitive Intervention through Direct Interaction (DI) mode, where a qualified doctor through a session exposed them to the functional knowledge on primary hypertension. Group 2 called as ‗Direct Interaction Double Exposure (DID)‘ received the same DI form of Cognitive Intervention twice with a gap of 15 days. Group 3 is referred to as ‗Audio Visual Single Exposure Group‘ (AVS) which received the Cognitive Intervention through Audio-visual recorded form (AV) without the physical presence of the doctor while group 4, referred to as ‗Audio Visual Double Exposure Group‘ (AVD) was given the same AV form twice with a gap of 15 days between them. All these four intervention groups were compared with group 5, called as Control Group (C) that was given mere standard medical care. A sample of 450 participants was sequentially assigned to the five groups in the order of DIS, DID, AVS, AVD and Control. The participants were assessed before and after intervention usingHypertension Knowledge Test, Hypertension Compliance Scale, Hospital Anxiety and Depression Scale, Multidimensional Scale of Perceived Social Support and Hypertension Self Efficacy Scale. To assess hypertension management, Blood pressure readings were recorded thrice before and thrice after the intervention with a gap of one week between the recordings. In a three month follow up the groups were compared on adherence and management before and after the intervention. ANCOVA results showed that cognitive intervention was successful in impacting the adherence and management of hypertension. Particularly the Direct interaction form when repeated had the highest impact on the adherence and management. The audio visual form when repeated proved counterproductive on management of hypertension. In addition, the Cognitive Intervention through direct interaction when repeated reduced the levels of depression compared to the control group. Cognitive Intervention also enhanced the levels of perceived social support land Hypertension specific self-efficacy. Further the study attempted to trace the pathway between the intervention and the management of hypertension. By means of pathway modeling using multiple regression analyses, pathways evolved for both the direct interaction modules (DIS and DID). The knowledge enhancements by the exposure to these modules enhanced self-efficacy. This in turn enhanced hypertension management through enhanced clinical adherence. Thus indispensability of integrating Cognitive Intervention into the hypertension care alongside standard medical treatment is the key conclusion. Implications, strengths and limitations of the study are also discussed.
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    Effect of cancer patients' activity level and psychosocial factors on caregivers' quality of life
    (University of Hyderabad, 2018-08-01) Vanlalhruaii, C ; Padmaja, G
    Cancer as a disease affects the lives of millions across the globe. It is now clear that the cause of cancer is not due to one single event or factors but is multifactorial. In India, breast cancer is the most common cancer among women and is also the leading cause of death. Among men in India, lip, oral cavity cancer is the most common cancer. Head and neck cancer accounted for 30% of all cancers among males. The outcome of a cancer diagnosis can be atrocious. For patients diagnosed with breast cancer (BC) and head and neck cancer (HNC), the physical disfigurement as a result of the cancer treatment can be enormous. It can have a negative impact on the patients' psychological, physical, and social functioning. Cancer patients require assistance and caregiving at some point during their illness trajectory. The persons who assumes the role of caregiving are often family members who are underprepared for the task they need to carry out as caregivers. Hence, these family caregivers as a result of the physical and emotional assistance that they provide to their loved ones often experience negative psychological states (distress, depression, anxiety, and somatization). The upheavals may result in poor quality of life. During the cancer illness trajectory, interpersonal relationship which is open and supportive between patients and their caregivers plays an important role in reducing the negative psychological states and thus resulting in a good quality of life. The present study has the following objectives: 1) To assess the level of psychological states and perception of the interpersonal relationship among cancer patients (BC & HNC) and their family caregivers and assess the quality of life of family caregivers 2) To find out the differences in the levels of psychological states, interpersonal relationship, and quality of life among caregivers, categorized on the basis of patients’ activity levels 3) To find out the agreement or disagreement in perception of the interpersonal relationshipbetween cancer patients (BC & HNC) and their family caregivers 4) To find out indicators of family caregivers’ quality of life 5) To categorize family caregivers of cancer patients (BC & HNC) based on their levels of quality of life and to examine the differences in indicators of their quality of life. The study used between-groups design and included 248 pairs of cancer patients (breast cancer and head and neck cancer) and their family caregivers. Eastern Cooperative Oncology Group Performance Status was administered to the patients. Cancer-Specific Interpersonal Relationship- Form A and Form B and The Four-dimensional Symptoms Questionnaire were administered to both patients and their caregivers. Caregivers' quality of life was assessed using Caregivers Quality of Life- Cancer. Data were analysed using IBM SPSS and MATLAB programming. The results of the present study showed that patients had a higher mean score in psychological states such as distress, depression, anxiety, somatization than their caregivers. However, patients perceived a higher overall interpersonal relationship between them and their caregivers. The result of one-way ANOVA showed significant differences in distress and mutual communication among the three groups of caregivers based on the patients' activity level. The result of feature analysis showed disagreement between patients and their caregivers in their perception of their interpersonal relationship. The result of the hierarchical regression analysis showed that demographic details, specific dimensions of psychological states, and the interpersonal relationship were the predictors of caregivers' quality of life. Based on their quality of life caregivers were categorized into three groups and significant differences were found on dimensions of interpersonal relationship and psychological states. The present study proposed a SMILE model to address the psychological needs, improvement in interpersonalrelationship and thus enhance the quality of life of both patients and their caregivers.Limitations of the study and future directions were also discussed in the study
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    Role of self-efficacy outcome expectancy perceived health competence in coping and self-management of diabetes patients
    (University of Hyderabad, 2019-04-01) Lalnuntluangi, R ; Meera Padhy
    Diabetes is a chronic disease associated with high rates of morbidity and mortality, as well as increased health care costs that require multitude of daily self-management decisions and self-care activities. Management of diabetes encompasses maintaining normal blood glucose level and thus prevent the likelihood of long term complications. This includes self management activities like oral medications, insulin injections, blood glucose monitoring, following prescribed diet and exercise regime. Patients understand that these self-management activities are essential elements for improvement of their health status as a result of which they use different coping strategies to deal with these activities. In addition to coping, different psychological factors such as self-efficacy, outcome expectancy and perceived health competence also have significant influence on self-management of illness. Taking all the above factors into consideration the study used a mixed methods sequential explanatory design to assess the following objectives: (i) to examine the difference in the level of self-efficacy, outcome expectancy, perceived health competence among three groups of Type II diabetes patients categorized on the basis of duration of disease (ii) to examine the relationship between self-efficacy, outcome expectancy, perceived health competence, coping and self-management of illness of type 2 diabetes patients (iii) to understand the role of self-efficacy, outcome expectancy, perceived health competence in coping of illness of Type 2 diabetes patients (iv) to understand the role of self-efficacy, outcome expectancy, perceived health competence and coping in self-management of illness of Type 2 diabetes patients (v) to explore the lived experiences of Type 2 diabetes patients regarding their coping strategies to diabetes. The study included two phases: in phase I, a total of 295 (147 men and 148 women) patients age range from 30-73 years from the state of Mizoram participated and completed the measures namely, Multidimensional Diabetes Questionnaire, Perceived Health Competence, Diabetes Coping Measure and Diabetes Self-management Questionnaire. Inphase II, Interpretative Phenomenological Analysis was employed to explore the coping strategies of 11 patients with type 2 diabetes (34-67 years) who were randomly selected from phase I. The data collected in phase 1 were analyzed using descriptive (frequencies and percentages) and inferential statistics (ANOVA, Pearson Correlation and Hierarchical Multiple Regression). The results of the study showed that the three groups categorized on the basis of duration of disease differed in the level of self-efficacy, coping and self-management. After ascertaining that the significant relationships between the variables under study, subsequent analyses were conducted to assess the role of predictor variables on criterion variables. Self-efficacy, outcome expectancy, perceived health competence and demographic variables explained significant proportion of variance in overall diabetes coping. In addition to the above predictors, coping was added, which explained significant proportion of variance in overall diabetes self-management. Using thematic analysis, results of phase 2 identified five (5) coping strategies along with eight (8) themes and sixteen (16) sub-themes. The identified coping strategies were - planful problem solving, seeking social support, shifting burden to supernatural power, distancing and escape -avoidance. The limitations and implications of the study are also discussed.