Psychometric properties of the Fear-Avoidance Beliefs Questionnaire and Tampa Scale of Kinesiophobia in patients with neck pain

OBJECTIVE: To examine selected psychometric properties of these instruments in a cohort of patients with mechanical neck pain. DESIGN: Cohort design of 78 subjects completing self-report measures of pain, disability, and the Fear-Avoidance Beliefs Questionnaire Work (FABQW) and Physical Activity (FABQPA) subscales, as well as the Tampa Scale of Kinesiophobia (TSK) at baseline and a 2-day follow-up. Intraclass correlation coefficients were used to calculate test-retest reliability, and Cronbach's alpha was used to calculate internal consistency. Concurrent validity was analyzed between the FABQPA, FABQW, TSK, pain, and disability using Pearson correlation coefficients and hierarchical linear regression modeling. RESULTS: The FABQPA and FABQW subscales exhibited substantial test-retest reliability, whereas the TSK exhibited moderate reliability. Internal consistency was high for all measures. The FABQW subscale was the only measure that significantly contributed to the regression model for both pain and disability in this group of patients with neck pain. CONCLUSIONS: Whereas the reliability and internal consistency of all measures ranged between moderate and substantial, the results of this study suggest weaker relationships between measures of fear and avoidance beliefs and pain/disability among patients with mechanical neck pain than has been reported among patients with low-back pain.     

Fear of movement and (re)injury in chronic musculoskeletal pain: Evidence for an invariant two-factor model of the Tampa Scale for Kinesiophobia across pain diagnoses and Dutch, Swedish, and Canadian samples

The aims of the current study were twofold. First, the factor structure, reliability (i.e., internal consistency), and validity (i.e., concurrent criterion validity) of the Tampa Scale for Kinesiophobia (TSK), a measure of fear of movement and (re)injury, were investigated in a Dutch sample of patients with work-related upper extremity disorders (study 1). More specifically, examination of the factor structure involved a test of three competitive models: the one-factor model of all 17 TSK items, a one-factor model of the TSK (Woby SR, Roach NK, Urmston M, Watson P. Psychometric properties of the TSK-11: a shortened version of the Tampa Scale for Kinesiophobia. Pain 2005;117:137-44.), and a two-factor model of the TSK-11. Second, invariance of the aforementioned TSK models was examined in patients with chronic musculoskeletal pain conditions (i.e., work-related upper extremity disorders, chronic low back pain, fibromyalgia, osteoarthritis) from The Netherlands, Sweden, and Canada was assessed (study 2). Results from study 1 showed that the two-factor model of the TSK-11 consisting of 'somatic focus' (TSK-SF) and 'activity avoidance' (TSK-AA) had the best fit. The TSK factors showed reasonable internal consistency, and were modestly but significantly related to disability, supporting the concurrent criterion validity of the TSK scales. Results from study 2 showed that the two-factor model of the TSK-11 was invariant across pain diagnoses and Dutch, Swedish, and Canadian samples. Altogether, we consider the TSK-11 and its two subscales a psychometrically sound instrument of fear of movement and (re)injury and recommend to use this measure in future research as well as in clinical settings.     

Confirmatory factor analysis of the Tampa Scale for Kinesiophobia: invariant two-factor model across low back pain patients and fibromyalgia patients

OBJECTIVES: (1) To investigate the factor structure of the Tampa Scale for Kinesiophobia (TSK) in a Dutch-speaking sample of chronic low back pain (CLBP) patients using confirmatory factor analysis, (2) to examine whether the internal structure of the TSK extends to another group of fibromyalgia (FM) patients, and (3) to investigate the stability of the factor structure in both patient groups using multi-sample analysis. PATIENTS AND METHODS: TSK-data from 8 studies collected in Dutch and Flemish chronic pain patients were pooled. For 188 CLBP patients and 89 FM patients, complete data were available. Confirmatory factor analyses were performed to assess 4 models of kinesiophobia, and to examine which factor model provided the best fit. Furthermore, a multi-sample analysis was performed to investigate the stability of the factor structure in both patient groups. RESULTS: For both CLBP and FM patients, the 2-factor model containing the factors "activity avoidance" and "pathologic somatic focus" was superior as compared with the 4-factor model containing the factors "harm," "fear of (re)injury." "importance of exercise," and "avoidance of activity". Moreover, the 2-factor model was found to be invariant across CLBP and FM patients, indicating that this model is robust in both pain samples. DISCUSSION: As the 2-factor structure provided the best fit of the data in both patient samples, we recommend to use this version of the TSK and its 2 subscales in both clinical practice and research. Based on the content of the items, the subscales were labeled "Harm" and "Fear-avoidance."     

Validation study of the Chinese version of the Brief Fatigue Inventory (BFI-C)

A cross-sectional study was conducted among 249 Chinese cancer patients with multiple diagnoses to validate a Chinese version of the Brief Fatigue Inventory (BFI-C). Cronbach's coefficient alpha was 0.92 for fatigue severity items and 0.90 for fatigue interference items. Construct validity was explored by principal factor analysis and suggested a two-factor solution: fatigue severity and fatigue interference. Internal consistency reliability was excellent. Convergent validity was examined by correlating the BFI-C with 2 subscales and 2 component scores of the MOS 36-Item Short-Form Health Survey (coefficients ranged between -0.44 and -0.71, P<0.001). Known-group validity was examined by comparing fatigue severity in patients having different scores on the Eastern Cooperative Oncology Group Performance Status Scale. Approximately 60% of patients experienced moderate to severe fatigue (4 or greater on the 0-10 scale of the BFI-C "fatigue worst" item). The BFI-C is a valid, reliable instrument to measure the severity and impact of cancer-related fatigue among Chinese patients.     

The Psychological Inflexibility in Pain Scale (PIPS) – Statistical properties and model fit of an instrument to assess change processes in pain related disability

Recent developments within CBT have emphasized acceptance rather than control of pain and distress in treatments aimed at improving functioning and life quality, but there is still a lack of reliable and valid instruments to assess relevant processes in such interventions. The Psychological Inflexibility in Pain Scale (PIPS) was developed to assess target variables in exposure and acceptance oriented treatments. A preliminary validation study resulted in a two‐factor solution with subscales for avoidance and cognitive fusion related to pain, showing satisfactory psychometric properties. This study sought to evaluate the instrument with 611 participants with whiplash associated disorders. Exploratory and confirmatory factor analyses supported a two‐factor solution with 12 items which showed an acceptable model fit, adequate internal consistencies, and strong relations with criteria variables (e.g. disability and life satisfaction). The construct validity of the instrument was supported by high correlations with subscales from the Chronic Pain Acceptance Questionnaire (CPAQ) and the Tampa Scale of Kinesiophobia (TSK). Notably, hierarchical regression analyses illustrated that PIPS explained more variance than TSK in pain, disability, life satisfaction and depression. Furthermore, PIPS was found to mediate the relationship between e.g. pain and disability, suggesting the usefulness of PIPS as a process measure in treatments of people with chronic pain. Thus, it is argued that this 12‐item version of PIPS may be used to explore the importance of psychological in/flexibility in chronic pain and to analyse processes of change in exposure based interventions, as well as for clinicians in tailoring interventions for patients with chronic debilitating pain.     

Body Awareness Rating Questionnaire: Measurement properties

The purpose of present study was to investigate important measurement properties of the Body Awareness Rating Questionnaire (BARQ) subscales: Function; Mood; Feelings; and Awareness. Samples of 50 patients with prolonged musculoskeletal pain and psychosomatic disorders, and 50 gender and age-matched healthy persons participated in the study. Relative (ICC 2,1) and absolute reliability (S_w) were calculated. Construct validity was examined by testing hypothesis using Pearson (r) or Spearman rank (r_s) correlation. Discriminate ability was examined using a receiver operating characteristic (ROC) curve, the area under the curve (aROC) being the measure of discriminative validity. All patients reported more or less improvement after treatment, using the Patient Global Impression of Change (PGIC) as an external indicator of important change. Responsiveness to important change was therefore examined by one-way repeated measures analysis of variance (ANOVA), relating change scores of BARQ subscales to the PGIC categories. Relative and absolute reliability values were within recommended limits for all four subscales. Construct and discriminate validity was indicated for Function, Feelings and Awareness, but not for Mood. Responsiveness was indicated for the subscales Function and Awareness, but not for Feelings and Mood. Further research is needed to complement the subscales of BARQ, found with appropriate measurement properties.     

Validation of the brief pain inventory in patients six months after cardiac surgery

The Brief Pain Inventory (BPI) is a questionnaire developed to assess the severity of pain and the impact of pain on daily function. The purpose of the current study was to evaluate the psychometric properties of the BPI for use in patients undergoing cardiac surgery. Between September 2004 and September 2005, 534 patients completed the BPI before surgery and 462 responded six months after surgery. The BPI was validated with respect to construct validity, internal consistency, criterion validity, and responsiveness. To evaluate the criterion validity, the BPI was validated against the bodily pain (BP) scale of the Medical Outcomes Study Short-Form Health Survey (SF-36). The factor analysis resulted in two distinct factors, supporting the validity of the two-factor structure of the original BPI, with high loadings on pain severity and pain interference. Results indicated acceptable internal consistency, with Cronbach's alpha coefficients between 0.84 and 0.94. The association between the BPI and the SF-36 BP dimension supported the criterion validity, with correlation coefficients between 0.47 and 0.65. The pain severity scale and the pain interference scale declined from baseline to follow-up. These results supported the responsiveness of the BPI. The study confirmed that the BPI shows good psychometric properties of reliability, validity, and responsiveness, enabling it to be used to measure pain in patients after cardiac surgery. Validating pain measures for use in this population is an important part of establishing a foundation for future studies on chronic pain after cardiac surgery.     

Body Awareness Rating Questionnaire: Measurement properties

The purpose of present study was to investigate important measurement properties of the Body Awareness Rating Questionnaire (BARQ) subscales: Function; Mood; Feelings; and Awareness. Samples of 50 patients with prolonged musculoskeletal pain and psychosomatic disorders, and 50 gender and age-matched healthy persons participated in the study. Relative (ICC 2,1) and absolute reliability (S(w)) were calculated. Construct validity was examined by testing hypothesis using Pearson (r) or Spearman rank (r(s)) correlation. Discriminate ability was examined using a receiver operating characteristic (ROC) curve, the area under the curve (aROC) being the measure of discriminative validity. All patients reported more or less improvement after treatment, using the Patient Global Impression of Change (PGIC) as an external indicator of important change. Responsiveness to important change was therefore examined by one-way repeated measures analysis of variance (ANOVA), relating change scores of BARQ subscales to the PGIC categories. Relative and absolute reliability values were within recommended limits for all four subscales. Construct and discriminate validity was indicated for Function, Feelings and Awareness, but not for Mood. Responsiveness was indicated for the subscales Function and Awareness, but not for Feelings and Mood. Further research is needed to complement the subscales of BARQ, found with appropriate measurement properties.     

Cognitive assessment of musculoskeletal pain with a newly validated Greek version of the Fear-Avoidance Beliefs Questionnaire (FABQ).

Fear of pain and avoidance are psychological factors of primary importance when assessing chronic musculoskeletal pain, which are often measured with the Fear-Avoidance Beliefs Questionnaire (FABQ). Both two- and three-subscale versions have been described. The aims of this study were: to assess the cognitive traits of musculoskeletal pain patients using a newly validated Greek version of the FABQ, and to further examine the construct validity and responsiveness of the measure. Factor analysis yielded three factors that accounted for 65% of the total variance. Physical activity explained 12.3% of the variance and was identical to the original version, unlike the work subscale which split into two: the FABQ work1 related to "work as cause" (15.2% of the variance) and the FABQ work2 related to "work as prognosis" (37.5% of the variance). Internal consistency was good (0.72-0.90). Test-retest reliability was satisfactory and close to the original version both for individual items and the subscales. Responsiveness of the 3-factor model was satisfactorily assessed as the ability to detect: (A) change in general - (paired t test, effect size); (B) clinically important change (paired t test, standardised effect size), and (C) real change in the concept being measured (ROC analysis). Construct validity of the FABQ was shown through the interaction with anxiety and depression, pain control and responsibility, psychological distress and pain intensity, and criterion-related validity through the association with another fear-avoidance measure (TSK). New aspects of responsiveness and construct validity were demonstrated for the FABQ, using a three-subscale validated Greek version.     

The Tampa Scale for Kinesiophobia for Temporomandibular Disorders (TSK-TMD)

For musculoskeletal disorders like low back pain and fibromyalgia, evidence is growing for fear of movement to play an important role in the development of chronic pain. In temporomandibular disorder (TMD) patients, however, this construct has not received any attention yet. Therefore, in this paper, (1) a generally used instrument to measure fear of movement, the Dutch version of the Tampa Scale for Kinesiophobia (TSK), was adapted for its use in TMD patients (and translated for equivalence to English), (2) the psychometric properties of the Dutch version of the TSK-TMD were assessed, and (3) the association of various symptoms of TMD (i.e., pain, joint sounds, and limited jaw movements) with fear of movement was evaluated. In a sample of TMD patients (N = 301), confirmatory factor analysis indicated that a two-factor model based on 12 items provides the best fit of the TSK-TMD, with activity avoidance and somatic focus as its subscales. This two-factor solution of the Dutch TSK-TMD has generally good reliability and convergent validity. Multiple regression analysis showed that TMD functional problems (i.e., temporomandibular joint sounds or a stuck/locked feeling) were more strongly associated with fear of movement than with pain. This finding leads to new perspectives regarding the interplay between musculoskeletal complaints, cognition, and avoidance behavior. The results provide a basis for use of the 12-item version for routine assessment of fear of movement in TMD patients, and for future clinical studies, for example, to the role of fear of movement in TMD-treatment success.     

Fear of movement/(re)injury in chronic pain: a psychometric assessment of the original English version of the Tampa scale for kinesiophobia (TSK)

The Tampa scale for kinesiophobia (TSK) was developed to measure fear of movement/(re)injury in chronic pain patients. Although studies of the Dutch adaptation of the TSK have identified fear of movement/(re)injury as an important predictor of chronic pain, pain-related avoidance behaviour, and disability, surprisingly little data on the psychometric properties of the original English version of the TSK are available. The present study examined the reliability, construct validity and factor structure of the TSK in a sample of chronic pain patients (n=200) presenting for an interdisciplinary functional restoration program. Consistent with prior evaluations of the Dutch version of the TSK, the present findings indicate that the English TSK possesses a high degree of internal consistency and is positively associated with related measures of fear-avoidance beliefs, pain catastrophizing, pain-related disability and general negative affect. The TSK was not related to individual differences in physical performance testing as assessed using standardised treadmill and lifting tasks. Confirmatory factor analyses suggest that the TSK is best characterized by a three-factor trait method model that includes all 17 of the original scale items and takes into account the distinction between positively and negatively keyed items. The results of the present study provide important details regarding the psychometric properties of the original English version of the TSK and suggest that it may be unnecessary to remove the negatively keyed items in an attempt to improve scale validity.     

The psychometric properties of the Brief Symptom Inventory depression and anxiety subscales in patients with heart failure and with or without renal dysfunction

More than 5 million Americans have heart failure (HF); approximately one third have concomitant renal dysfunction. Anxiety and depressive symptoms are the most common psychological responses of these individuals and may influences outcomes; thus a reliable valid instrument to measure these is needed. This article reports a psychometric evaluation of the Brief Symptom Inventory (BSI) depression and anxiety subscales in patients with HF and with or without renal dysfunction, as these scales are commonly used in this population for research studies. This rigorous psychometric analysis used existing data from 590 patients with HF with an average ejection fraction of 35% ± 15% and average age of 63 ± 13 years. Patients were categorized as normal renal function (n = 495) or renal dysfunction (n = 95), and groups were compared and analyzed separately. Cronbach's alpha for the BSI subscales was .82 for those with normal renal function and .88 for those with renal dysfunction. Factor analysis determined that the subscales evaluated one dimension, psychological distress, in both groups. Construct validity was examined using hypothesis testing, and construct validity was supported in patients with HF and with normal renal function by significant associations of the BSI subscales with another measure of depression and a measure of perceived control. Construct validity in patients with HF and renal dysfunction was not strongly supported. Only the BSI depression subscale predicted poorer outcomes in patients with HF and with normal renal function; neither subscale was associated with event-free survival at 12 months in those with renal dysfunction. The BSI anxiety and depression subscales provide reliable and valid data in patients HF and normal renal function. Although reliability is excellent, construct validity was weak in those patients with HF and with concomitant renal dysfunction, which may reduce the validity of those data.     

The pain vigilance and awareness questionnaire (PVAQ): further psychometric evaluation in fibromyalgia and other chronic pain syndromes

In chronic pain patients, preoccupation with or attention to pain is associated with pain-related fear and perceived pain severity. The current study investigated psychometric properties of the pain vigilance and awareness questionnaire (PVAQ). An exploratory factor analysis on Dutch fibromyalgia patients indicated that a two-factor solution was most suitable. The first factor could be referred to as attention to pain and the second factor was interpreted as attention to changes in pain. A confirmatory factor analysis, testing three different factor structures in two independent samples (Dutch fibromyalgia patients and American pain patients with various diagnoses) showed that the goodness-of-fit indicators for all models were satisfactory. The existence of the previously reported intrusion subscale of the PVAQ as a unique construct within the PVAQ was discussed. This subscale should be further extended by non-reverse-keyed items. With regard to the convergent validity, the PVAQ was highly correlated with related constructs such as the pain catastrophizing scale (PCS), pain anxiety symptoms scale (PASS), and Tampa scale of kinesiophobia (TSK). The attention to pain subscale was significantly stronger associated with these pain-related measures than the attention to changes in pain subscale, indicating that attention to changes in pain is a distinctive construct. The uniqueness of the attention to changes in pain subscale was also supported by an exploratory factor analysis on all items of the PVAQ, PCS, PASS, and TSK which showed that all items from that scale loaded on one separate factor. Overall, the PVAQ showed good internal consistency. Implications for future research and treatment interventions are discussed.     

The Italian version of the Sickness Impact Profile-Roland Scale for chronic pain: cross-cultural adaptation,reliability, validity and sensitivity to change

Purpose.?As no adapted form of the 23-item Sickness Impact Profile (SIP)-Roland Scale for patients with chronic pain has ever been validated in the Italian population, the aim of this study was to translate, culturally adapt and validate an Italian version.

Methods.?The development of the Italian version involved translation and back-translation, a final review by an expert committee and the testing of the pre-final version to establish its correspondence with the original. The psychometric testing included testing reliability by internal consistency (Cronbach's α) and test-retest repeatability (intraclass coefficient correlation; ICC), construct validity by comparison with an 11-point pain intensity numerical rating scale (NRS; Pearson's correlation) and the Short Form Health Survey (SF-36; Pearson's correlation) and sensitivity to change by calculating the minimum detectable change (MDC).

Results.?It took 3 months to obtain a shared version of the scale, which was administered to 243 subjects and proved to be satisfactorily acceptable. It had a high degree of internal consistency (α == 0.860) and test-retest reliability (ICC == 0.972). Construct validity testing revealed a moderate correlation with the NRS (r == 0.418), close correlations with the SF-36 physical subscales and moderate-poor correlations with the mental and social subscales; the MDC was 2.33.

Conclusions.?The SIP-Roland scale was successfully translated into Italian, showing satisfactory psychometric properties. The measure can be recommended for use in research and clinical practice to improve the assessment of physical dysfunction in subjects with chronic pain.     

Reliability, validity and responsiveness of the fear-avoidance beliefs questionnaire: methodological aspects of the Norwegian version.

OBJECTIVE: To evaluate reliability, validity and responsiveness of the Fear-Avoidance Beliefs Questionnaire (FABQ) for use in Norwegian patients with low back pain. DESIGN: A prospective cohort study with 2 groups. PATIENTS: The questionnaire was tested in 123 patients with acute low back pain and 50 patients with chronic low back pain. METHODS: A translation and cross-cultural adaptation was performed. Test-retest reliability was assessed in 28 patients with chronic low back pain. Responsiveness was assessed in acute low back pain. RESULTS: Two factors for the FABQ were confirmed; fear-avoidance beliefs about work (FABQ-Work) and physical activity (FABQ-PA), accounting for 60% and 54% of the total variance in acute and chronic low back pain, respectively. For FABQ-Work and FABQ-PA internal consistency was 0.90 and 0.79, intra-class correlation coefficients 0.82 and 0.66, minimal detectable changes 12 and 9 points, and coefficients of variation were 16% and 23%. The FABQ correlated weakly to moderately with pain, disability, distress, and clinical variables. Standardized response means were low for FABQ-Work (0.32) and moderate (0.56) for FABQ-PA. Both FABQ subscales showed initially floor and/or ceiling effects. CONCLUSION: The Norwegian FABQ version had acceptable factor structure, internal consistency, test-retest reliability and construct validity. The responsiveness of the FABQ-Work was low, and for the FABQ-PA moderate, in the acute sample.     

Psychometric testing of the social support survey on a Taiwanese sample

BACKGROUND: The Medical Outcomes Study Social Support Survey (MOS-SS) is a multidimensional, self-administered instrument used to assess various functional dimensions of social support. Less is known regarding its value for a Chinese population. OBJECTIVE: The aim of this study was to assess the psychometric properties of the MOS-SS on an adult sample in Taiwan. METHODS: A total of 265 adult family caregivers of patients with cancer from four different hospitals in the north, middle, and south regions of Taiwan completed the MOS-SS. RESULTS: In the original five-factor model, unsatisfactory item discriminant validity was found in almost half of the items; the item-own subscale correlation was lower than the item-other subscale correlation. A two-factor model accounting for 68.98% of the variance was found using exploratory factor analysis. The first factor (emotional support) accounted for 62.28% of the total variance, whereas the second factor (tangible support) accounted for 6.7%; the interfactor correlation was .71. The two-factor model seemed to have satisfactory reliability and validity and better discrimination between different subscales than did the original five-factor model. DISCUSSION: Good reliability and validity were demonstrated in the MOS-SS when applied to an adult sample in Taiwan. A two-factor model, instead of a five-factor model as found in the Western countries, was found for this sample. Confirmation of the two-factor model and exploration of the two-factor model in related concepts are suggested for future studies.     

Cancer patients' barriers to pain management and psychometric properties of the Norwegian version of the Barriers Questionnaire II

The Barriers Questionnaire II (BQ-II) was developed to assess barriers to effective pain management. The purpose of this study was to evaluate the psychometric properties of the BQ-II in a sample of Norwegian cancer patients. The BQ-II was translated into Norwegian and pilot tested with eight oncology outpatients. Then, a convenience sample of 321 cancer patients from two different sites was recruited to maximize the number of questionnaires available for the psychometric analyses. Patients were included if they: were >18 years of age; had a diagnosis of cancer; and self-reported pain and/or use of analgesics. Construct validity of the Norwegian version of the BQ II (NBQ-II) was evaluated using an exploratory factor analysis. A seven-factor solution was found that was more consistent with the original version of the BQ. Construct validity of the NBQ-II was demonstrated through positive correlations between most of the subscale and total scores on the NBQ-II and pain intensity and pain interference scores. Finally, Cronbach's α coefficients of ≥0.7 for six of the seven subscales and 0.89 for the total scale demonstrated acceptable levels of internal consistency. In conclusion, the NBQ-II demonstrated adequate psychometric properties. However, further revision and testing of the questionnaire should be performed to confirm the factor structure that was identified in this study.     

Development of a self-report screening instrument for assessing potential opioid medication misuse in chronic pain patients

This study constituted the first step in the psychometric development of a self-report screening instrument for risk of opioid medication misuse among chronic pain patients. A 26-item instrument, the Pain Medication Questionnaire (PMQ), was constructed based on suspected behavioral correlates of opioid medication misuse, which heretofore have received limited empirical investigation. The PMQ was administered to 184 patients at an interdisciplinary pain treatment center. Reliability coefficients for the PMQ were found to be of moderate but acceptable strength. Construct and concurrent validity were examined through correlation of PMQ scores to measures of substance abuse, physical and psychological functioning, and physicians' risk assessments. To explore high and low cutoff points for misuse risk, subgroups were formed according to the upper and lower thirds of PMQ scores and compared on validity measures. Higher PMQ scores were associated with history of substance abuse, higher levels of psychosocial distress, and poorer functioning. Future psychometric analyses will consider predictive validity and examine shortened versions of the instrument.     

The Health Self-Determinism Index for Children

A convenience sample of 501 children 7 to 13 years old completed the newly developed Health Self-Determinism Index for Children (HSDI-C), a measure of intrinsic motivation in health behavior. Construct validity was supported through the factorial isolation of four theory-consistent subscales, and the correlation of the total HSDI-C (r = .36, p less than or equal to .009) with a general measure of intrinsic motivation. Alpha coefficients in three separate trials ranged between .79 and .88 for the total scale, and .78 to .88, .87 to .92, .78 to .86, and .63 to .77 on the respective subscales. Test-retest reliability for the total scale was .83 at 2 weeks and .48 at 1 year. A nominated population of 21 third- through seventh-grade children known to practice positive health promotion behaviors had an HSDI-C mean score of 106.5 versus 76.5 in the general sample of children.