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Virginia Commonwealth University. Forty patients scheduled for dental extraction surgery were given either specific or general preparatory information, and this ...
Copyright 1983 by the American Psychological Association, Inc.

Journal of Personality and Social Psychology 1983, Vol. 44, No. 6, 1284-1296

Anxiety, Information, Interpersonal Impacts, and Adjustment to a Stressful Health Care Situation Stephen M. Auerbach and Michael F. Martelli Virginia Commonwealth University

Louis G. Mercuri

Department of Oral and Maxillofacial Surgery Virginia Commonwealth University Forty patients scheduled for dental extraction surgery were given either specific or general preparatory information, and this information was presented in either a personalized or relatively impersonal fashion using nonverbal cues. Changes in state anxiety over the course of the experiment were accounted for by individual differences in the Dental Anxiety Scale. The most important determinant of adjustment during surgery was the congruence between specificity of information received and individual differences in preference for information as measured by the Information subscale of the Krantz Health Opinion Survey (KHOS; Krantz, Baum, & Wideman, 1980). Findings with the KHOS and the Dental Anxiety Scale are examples of the growing importance of situation-specific personalitytrait measures. The finding that high levels of presurgery anxiety are associated with poor adjustment is discussed in terms of Janis's (1958) model. Patients' perceptions of information-giver hostility and dominance were also significantly (inversely) related to adjustment; the differential impact of informational versus interpersonal variables is discussed in terms of moderating characteristics of health carfe settings.

Health psychology, the application of the principles of the behavioral sciences to health care, is a rapidly growing field. Recently, special emphasis has been given to the study of the medical procedure as an interpersonal process between health care provider and patient. The nature of the interaction, the patient's understanding of the illness, and his or her degree of information about and participation in the process are all variables of great interest (DiMatteo, 1979; Korsch & Negrete, 1972; Krantz, Baum, & Wideman, 1980). Although there has been no dearth of generally accepted assumptions concerning the effects of variables such as participation and information (e.g., the assumption that This article is based on a thesis by the second author supervised by the first author, entitled "Effects of Specificity and Mode of Presentation of Stress-Relevant Information on Adjustment During Dental Extraction Surgery," submitted in partial fulfillment of the requirements for the MS degree at Virginia Commonwealth University. Requests for reprints should be sent to Stephen M. Auerbach, Department of Psychology, Virginia Commonwealth University, Richmond, Virginia 23284.

more information is always superior to less), when put to empirical test these assumptions sometimes prove unwarranted. Mclntosh (1974), in a review of the literature on communication of information to cancer patients, concluded that existing research was inadequate to answer such questions as how, when, and how much to tell patients. Surgery in particular, probably because it represents a discrete event that allows for the collection of prestress data and the implementation of programmed intervention procedures, has been the focus of a great deal of research. Current findings indicate that there is much individual variation in response to information and participation among surgical patients, and thus a growing trend is the evaluation of individual differences in an attempt to match the most effective interventions (aimed at facilitating such variables as adjustment, recovery, cooperation, and satisfaction with care) with particular types of individuals (Auerbach & Kilmann, 1977). The present investigation is a "semianalogue" study conducted with

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ANXIETY, INFORMATION, INTERPERSONAL IMPACTS, AND ADJUSTMENT

patients undergoing dental extraction surgery. It is an analogue in the sense that the independent variables (specificity of preparatory information and degree of personalization or engagement of the patient in information delivery) are systematically varied, and the information is delivered by an individual not normally present in the setting. It is assumed that the levels of the independent variables are representative of the range of actual variation in specificity and style of information delivery present in clinical settings, where information is delivered by members of the health care team (or perhaps fellow patients or family members). The dependent variables (patient anxiety level and patient adjustment during surgery) are of immediate practical concern in the clinical setting. Anxiety and adjustment are evaluated as a function of the independent variables in conjunction with a situation-specific patient, individual-difference measure (Krantz Health Opinion Survey, KHOS; Krantz et al., 1980) and with a global measure of expectation for control (Locus of Control Scale; Rotter, 1966). Anxiety Surgery is a stressor that consistently elicits elevated levels of transitory anxiety in those confronting it, and degree of anxiety elevation and its subsequent postoperative decline may be predicted by situation-specific trait anxiety measures administered as early as 3 weeks prior to surgery (Auerbach, Kendall, Cuttler, & Levitt, 1976; Martinez-Urrutia, 1975). Janis (1958), in one of the first studies that views the medical patient as an active information processor whose adaptation is dependent on the generation of appropriate coping statements, found that surgical patients with moderate preoperative anxiety levels adjusted better than did those with lowor high-preoperative anxiety. He interpreted his findings in terms of the construct "work of worrying," reasoning that patients with moderate anticipatory anxiety levels develop higher stress tolerance based on realistic appraisal of the situation and engagement in appropriate planning and rehearsal. Subsequent studies that attempted to validate Janis's findings have produced mixed results (cf. Auerbach, 1980), and many researchers

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have proceeded on the assumption that presurgical anxiety always impedes adjustment and have focused on its minimization (e.g., Aiken & Henrichs, 1971; Field, 1974). The present study reevaluates Janis's anxiety-adjustment relationship, and reassesses the effectiveness of a situation-specific trait anxiety measure (Dental Anxiety Scale; Corah, 1969) to account for differences in presurgical elevations and postoperative decrements in state anxiety. Information Specificity From another standpoint, Janis's (1958) investigation was a precursor of studies employing cognitive-behavioral interventions designed to alter appraisal of impending health-related stressors (Johnson & Leventhal, 1974; Kendall etal., 1979; Langer, Janis, & Wolfer, 1975). Many of these approaches are based on the assumption, validated in laboratory research (Johnson, 1973; Leventhal, Brown, Shacham, & Engquist, 1979), that preparatory information and accurate expectations produce cognitive control that diminishes the deleterious effects of impending stressors. Other research, however, suggests that providing control does not always produce beneficial effects and that in actual clinical situations some individuals fare best when given treatments congruent with their expectations for control (Auerbach et al., 1976) and typical manner of dealing with stress (Andrew, 1970; Cohen & Lazarus, 1973; De Long, 1971; Shipley, Butt, Horwitz, & Farbry, 1978). Given these latter findings, the KHOS was designed specifically to evaluate individual differences in preference for information from health care personnel and behavioral involvement in self-care, with the intention that it might eventually serve as a means of matching patients a priori with particular practitioners or treatment approaches. In the context of the broader question of the utility of matching patients' preference for information and situational treatments, the present study attempts to provide construct validational data for the Information subscale of the KHOS. Mode of Information Delivery One focus of the present study is thus to evaluate the role of what is communicated

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to patients undergoing a stressful health-related procedure. Another component of this study deals with how the message is delivered. In most previous experimental studies involving information transmission to patients, information has been conveyed mechanically, and when personally delivered it has been presented in a standardized fashion designed to minimize "extraneous" nonverbal cues. These studies provide valuable practical analogues to the patient-education programs currently being developed by many hospitals, which use film and other audiovisual devices to help prepare patients and inform them of impending medical procedures. However, they do not evaluate variables relevant to the subtle interpersonal aspects of the relationship between patient and health care provider. Empirically, Geersten, Gray, and Ward (1973) found that arthritis patients who described their physicians as "personal" followed medical regimens better than did those who described their physicians as "businesslike." Davis (1968a, 1968b) and Cobb (1954) found that rejection of medical treatment was associated with physician hostility and failure to communicate sympathy and support, and DiMatteo, Prince, and Taranta (in press) found that patients' perception of the caring, concern, warmth, and positive feelings of their physician is a significant determinant of the decision to keep future appointments and continue the relationship. Regarding communication on nonverbal channels, Friedman (1979) argues that unfamiliar scientific terminology and medical jargon, the unfamiliar hospital environment, and the presence of imposing machinery all leave patients especially observant and sensitive to nonverbal cues emitted by health care practitioners. Several recent "naturalistic" studies have linked physician nonverbal expressiveness and sensitivity to patient satisfaction (DiMatteo, 1979; Korsch & Negrete, 1972), but although post hoc correlational data attesting to the importance of nonverbal messages is available, there have been no experimental studies that systematically manipulate the nonverbal message in a health care setting. In the present study, the nonverbal communication dimension (i.e., personal and friendly vs. impersonal, cursory, and businesslike) is varied while presenting patients

either general or specific preparatory information. The way in which patients are interpersonally impacted by the communications is assessed via a self-report measure designed specifically for this purpose (Impact Message Inventory, IMP, Kiesler et al., 1976; Perkins, Kiesler, Anchin, Chirico, & Kyle, 1979). In summary, the present study evaluates the impact of three sets of variables that have been empirically or conceptually associated with patient adjustment and/or satisfaction in stressful health care settings: (a) patient anxiety level just prior to the onset of the stressor, (b) specificity of information about the impending stressor as a main effect and in conjunction with an individual-difference measure of preference for such information, and (c) personalization of information delivery, and independent of this, the perceived interpersonal impact of the information-giver and primary health care provider on the patient. Method Subjects Forty subjects of predominantly tow socio-economic status (60% female, 60% black) were drawn from patients 18 years or older, scheduled for dental extraction surgery at a university-affiliated outpatient oral surgery clinic. Only patients whose reading level was sufficient to respond to the self-report scales were selected. A standard screening procedure was employed that required prospective subjects to read aloud the first paragraph of the consent form for participation in the study. Aside from screening for literacy, selection wa& on a random basis. Four subjects declined to participate.

Measures Dental Anxiety Scale. Corah's (1969) Dental Anxiety Scale is a four-item self-report scale that assesses the degree to which individuals anticipate experiencing anxiety in dental situations. State-Trait Anxiety Inventory (STAI). The A-State Scale of Spielberger, Gorsuch, and Lushene's (1970) STAI consists of 20 self-report items and measures current level of transitory anxiety. Because of time constraints, a short-form version of the scale was used at all testing periods. This version consists of the four items from the full scale with the highest item-remainder correlation coefficients and has been employed for similar reasons in previous studies (Auerbach et al., 1976; O'Neil, Spielberger, & Hansen, 1969). The four items include: I feel pleasant, I feel regretful, I find myself worrying about something, and I am calm. Internal/External Locus of Control Scale, Rotter's (1966) I-E Scale consists of 29 items, including 4 fillers.

ANXIETY, INFORMATION, INTERPERSONAL IMPACTS, AND ADJUSTMENT Locus of control orientation refers to a generalized expectancy for control over one's life."Internals" are characterized as perceiving themselves as having personal control over the reinforcement they obtain,1 whereas "externals" perceive their reinforcement as being determined by factors outside of their personal control, Krantz Health Opinion Survey, The KHOS (Krantz et al., 1980) is a measure of individual differences in receptiveness to information and self-care in treatment situations. It consists of (a) a behavioral involvement scale that is concerned with attitudes toward self-care and with taking an active role in medical care and (b) an information scale that evaluates desire to ask questions and to be informed of and involved in medical decisions. Impact Message Inventory (IMI). The IMI (Kiesler et al., 1976; Perkins et al., 1979) is a 90-item self-report inventory designed to assess the momentary emotional, cognitive, and behavioral covert engagements of one person by another during ongoing face-to-face transactions in counseling, psychotherapy, and other dyads. It produces measures of 15 interpersonal-style subscales: Dominant, Competitive, Hostile, Mistrustful, Detached, Inhibited, Submissive, Succorant, Abasive, Deferent, Agreeable, Nurturant, Affiliative, Sociable, and Exhibitionistic. Rating of Patient Behavior Form. A rating form assessing patient behavior on a 4-point scale (1 = not at all, 4 = very much so) in four areas was used: the extent to which the patient (a) responded to the prospect of anesthesia with apprehension or fear, (b) exhibited signs of anxiety or tenseness during the entire surgical procedure, (c) was overtly uncooperative, and (d) responded to painful stimuli with verbal admissions of pain. This scale was previously used by Auerbach et al. (1976) for evaluating adjustment during dental extraction surgery. Reliability data is presented in the Results section.

Stimulus Material: The InformationPresentation Scripts The text of the scripts for general and specific information were modeled on the videotapes used by Auerbach et al. (1976) for dental surgery patients and edited and modified slightly by an oral surgeon for use in the present study. The specific information script described the procedures the dentist would engage in, the physical sensations the patient could expect, and the postoperative instructions he or she would receive. The general information script presented marginally relevant information that described the Medical College of Virginia— Virginia Commonwealth University (MCV—VCU) Dental School, check-in procedures at the clinic, and a listing of the dentists' equipment. The following information was given to each subject; each presentation took approximately 5 minutes. Specific Information Surgical removal of the tooth is a common procedure. Many patients who are about to have this surgery know little about it or what to expect afterwards. A tooth may have to be removed for several reasons, but most frequently it is because it can no longer perform

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the function for which it was designed. A tooth can lose its function in several ways. A neglected tooth may become grossly infected and badly decayed. The cavity process destroys and undermines healthy tooth tissue, thus weakening the tooth and causing it to fracture. If the cavity process is not arrested in time, the infection may involve the pulp or nerve of the tooth. The infection may then spread to the roots of the tooth or an abscess results. Patients are often not familiar with the clinical procedures and do not know exactly what to expect. Consequently, they may become upset or frightened by routine procedures. I cannot tell you exactly what will happen since your surgeon will evaluate your medical history 1and current health status and then describe what he believes is the best procedure for you, rather than just following a set routine. However, I can give you an idea of what happens to the average person who has his tooth removed and what he can do to improve his recovery. As you already know, prior to the removal of a tooth, a diagnosis with X fays is performed. In most cases, a thorough scouting X ray is performed. Upon your arrival at the clinic, your medical history will be reviewed, your blood pressure will be taken and your diagnosis reviewed. Before removal of any teeth, an anesthetic will be administered. This anesthetic will numb the tooth or teeth and the surrounding tissues, thus removing all pain sensation from the immediate area. After the anesthetic has taken effect, the surgical procedure will begin. The first procedure is the removal of the attachment of the tooth to the gum tissue with a tissue blade. Next the tooth is moved in the socket with a straight instrument. This helps loosen the tooth. Forceps will then be placed on the tooth and a front-to-back or side-to-side rocking motion will be initiated by the surgeon. This motion further helps loosen the tooth and will continue until the tooth is removed. During this procedure, you may feel considerable pressure on your tooth tissues, but you should not feel pain. If you do feel pain, more anesthetic will be given. In some cases, either a bone scraping or rotary instrument will be used to help remove bone surrounding the tooth. This procedure produces very little trauma and enables the surgeon to quickly remove the tooth. Following the extraction, you will be given detailed postoperative instructions. You will be told to bite on a sterile gauze pad for one (1) hour to help a blood clot form. You will be given a prescription for a pain killing drug should you have any discomfort after the extraction. It is also advisable that you place ice on your face after the extraction site to minimize any swelling that might occur. You will be advised to avoid any hot or hard foods for the remainder of the day and not to rinse or spit out of your mouth for twenty four (24) hours. After twenty-four (24) hours you will be advised to rinse your mouth with warm salty water four (4) times a day. These instructions will be given to you on a sheet of paper following the extraction. If your extractions requires sutures, it will be necessary for you to return to the clinic in seven (7) days for their removal. You may experience some discomfort and tenderness for a few days. This will diminish as time goes on. However, if it does not, do not hesitate

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to call the clinic and ask for an examination. We hope this information will be helpful to you and will answer some of the questions you have had. If you have additional questions, please feel free to ask your surgeon. General Information Patients who come to the A.D. Williams Outpatient Oral Surgery Clinic at MCV Hospital arrive for the first time with many questions about the clinic itself or about its procedures. Often patients forget to mention these questions to the doctor who treats them. It is for this reason we wish to take this time to talk with you. We hope to provide you with some knowledge of our facilities and acquaint you with a few of the clinic's procedures so you may be more comfortable during your visit. The A.D. Williams Outpatient Clinic serves the people of Richmond and the Commonwealth of Virginia. Last year over 8,000 patient visits involved the Oral Surgery Clinic. The A.D. Williams Outpatient Clinic provides care for the young as well as elderly in all of its clinics from pediatrics to medicine and surgery. The clinic facilities and staff are provided for by the tax money of the people of the Commonwealth of Virginia as well as the fees which are charged for patient visits. The fee that you pay for your visit and surgery are decided based on a financial code assigned to you as the result of the information you have provided at your initial interview adjacent to the wailing room area and cashier's window. The quality of any clinic depends not only on the availability of all the needed facilities but also on the excellence of its staff. The A.D. Williams Outpatient Clinic maintains an esteemed full-time as well as parttime faculty that are involved as consultants to other hospitals, participants in scientific meetings and other educational functions and active also in their respective communities. A full-time housestaff of doctors round out the staff, offering the highest quality of care to patients. Now that I have given you a brief review of the numerous activities here at the A.D. Williams Outpatient Clinic, I would like to continue with information of more immediate interest to you. As you already are aware, your first appointment at the Oral Surgery Clinic was for a preliminary examination and diagnosis as well as X Rays. You were then scheduled to have the indicated teeth removed at this visit. For removal of teeth, the patient arrives for his/her appointment at the A.D. Williams Outpatient Oral Surgery Clinic. The patient must then check in with the receptionist and have their clinic appointment and procedure validated at the cashier's window. At the time of surgery, the patient is called from the waiting area to the clinic and directed to the operating room where the procedure will be performed. The operatory contains a completely mobile dental chair and a high intensity lamp which.provides good visibility for the surgeon as well as any other interested party. Another very important part of the operatory is the bracket table. This is a freely moveable, completely adjustable unit which will hold all the necessary instruments for the various procedures. There are specially designed sinks with foot pedal controls available at strategic locations around the

clinic available to the surgeon in the scrubbing up procedure. He uses special sterilizing soap to kill any bacteria that may be present on his hands. Following the surgery, the patient is given postoperative instructions relating to the particular case. The patient is then discharged and given a return appointment as indicated. We hope this information will answer some of the questions you may have had. If you have any additional ones, please feel free to ask your surgeon. Half of the patients in each condition (general, specific) were presented information in a warm, personal fashion and the other half were presented information in a relatively cold, impersonal fashion using nonverbal cues. These cues were emitted in standardized fashion with regard to time of occurrence during each presentation and were operationalized as noted below: Impersonal

Personal 0

Smiles Eye contact

* or more

20% or less 0

Yes—nods Voice tone

variable, enthusiastic

monotonous, flat

Body orientation

direct, open

angled, closed

Body lean

forward — 2

0

Hand movements

5—emphasizing content

5—interruptive, rubbing of eyes

Thus there were four information-presentation scripts for each of four experimental groups: general information/personal presentation, general information/impersonal presentation, specific information/personal presentation, and specific information/impersonal presentation.

Procedure All procedures were carried out on the same day. Upon arrival at the cashier's window, the patient was referred to the Outpatient Oral Surgery Clinic. At the clinic office, the patient was directed to the experimenter who introduced himself as a dental researcher. He asked to speak with the patient in a small recovery room adjacent to the surgical operating area. The introduction was conducted in a neutral, matter-of-fact manner, as was the explanation of the research project, so that the experimenter would not present himself as either personal or impersonal. When the experimenter met the patient, he introduced himself in the following way: "Hi, my name is Mr. and I'm a dental researcher here at the dental school. We're presently conducting a study and I would appreciate it if you would be. willing to talk with me about it. We can go to a room around the hall and talk for a minute." If any questions were asked, the experimenter offered to answer them in the recovery room. The experimenter then led the patient to the recovery

ANXIETY, INFORMATION, INTERPERSONAL IMPACTS, AND ADJUSTMENT room, which had two seats. The recovery room was small and equipped with two hospital-type beds covered with blankets used for sitting. The experimenter explained that the dental school was interested in collecting some information about how people respond to dental surgery in the hope that this information could be used to benefit future patients by making them more comfortable during dental surgery. The patient was informed that participation was not required and would not affect dental treatment in any way. Patients who agreed to participate and whose reading ability was determined to be adequate were given the Dental Anxiety Scale, the KHOS, the STAI A-State Scale and the Rotter Locus of Control Scale. Once the patient completed the forms the experimenter said, "Now I would like to give you some information, after which I want you to fill out two more forms." The experimenter then delivered one of the four information-presentation scripts (i.e., general/personal, general/impersonal, specific/personal, or specific/impersonal) in an ABCDDCBA sequence by subjects. Any questions by the patients were referred to the dental surgeon. Following information delivery, the patient was asked to respond (a) to the STAI A-State Scale, as a measure of current anxiety level following the information presentation, and (b) to the IMI as a measure of the interpersonal impact the information deliverer (experimenter) had on the patient. Upon completion, the patient was taken directly to a clinic nurse, who directed the patient to the dental surgeon. Following surgery, an observing resident and the performing surgeon rated the patients' adjustment during surgery using the 4-item Rating of Patient Behavior Form. All raters were blind to the type of information and the manner of presentation. Finally, the patient was asked, while in the recovery room, to again fill out the STAI A-State Scale (to assess postsurgery anxiety level) and the IMI oif the dental surgeon (as a measure of the interpersonal impact the,surgeon had on the patient).

Results Correlational data evaluating the interrelationships among the main subject variables (health opinion, locus of control, and dental anxiety) are presented in Table 1. It may be noted that the individual KHOS subscales are Table 1 Intercorrelations Among Subject Variables

HT HI HB IE

HI

HB

IE

DA

.73*

.63* -.07

-.04 -.29 .27

.21 .18 .10 .10

Note. HT = health opinion—total; HI = health opinion—information; HB = health opinion—behavioral involvement; IE = locus of control; DA = dental anxiety. *p 5.0, p < .01). Among and Adjustment low dental-anxiety patients, there was no difIn order to evaluate the impact of speciference among periods (all ^s < 1). Similar analyses using locus of control and the KHOS ficity of information (general, specific) and scales as subject variables produced no sig- manner of presentation of information (pernificant effects other than the main effect for sonal, impersonal) on adjustment for patients who differed in preference for information periods. As noted above, adjustment was evaluated (high, low), a three-way ANOVA was convia ratings made by. the dental surgeon and ducted on mean adjustment ratings. Subjects an attending resident. Independent reliability were split into high and low preferences for estimates were obtained on each item. The information groups based on approximate interrater reliability coefficient for Item 1 was median split of KHOS-Information subscale .92, for Item 2, .89, for Item 3, .95, and for scores. Scores for subjects in the low group Item 4, .58. Because a less than acceptable (n - 18) ranged from 0 to 3; scores for subreliability coefficient was obtained for the last jects in the high group (n = 22) ranged from item, it was discarded from the scale, and the 4 to 7. The only significant effects were (a) total adjustment score was computed as the a main effect for information, JF(1, 32) = sum of the mean ratings on Items 1 through 5.58, p < .03, resulting from the fact that 3. The interrater reliability for the total three- subjects receiving specific information aditem scale was .92. Higher scores represent justed better than did subjects receiving genpoofer adjustment. In order to test for the eral information, and (b) an interaction bepredicted curvilinear relationship between tween specificity of information and preferpresurgical (postinformation delivery) state ence for information, F(l, 32)= 11.78, anxiety and adjustment, an ANOVA using ad- p < .002. This interaction is depicted in justment as the dependent variable and Pe- Figure 2. It may be noted that subjects with riod 2 state anxiety as the classification vari- a high preference for information showed able was conducted. Using the most even sub- much better adjustment when they received classification, subjects with scores ranging specific versus general information; subjects from 4 to 6 on state anxiety were placed in low in preference for information adjusted the low-anxiety group (« =? 14), subjects with slightly better than when they received genscores ranging from 7 to 9 were placed in the eral as compared to specific information. A moderate-anxiety group (« = 14), and sub- Scheffe test revealed that the only significant jects with scores ranging from 10 to 16 were mean difference occurred for the former placed in the high-anxiety group (n = 12). comparison, ^ = 4.07, p < .01. It was noted above, that the Information The following mean adjustment scores were obtained for each group: high anxiety, M = subscale and the total KHOS scale were 6.38, moderate anxiety, M = 4.46, and low strongly correlated (.73). Therefore the same anxiety, M = 4.36. The difference in the analysis using an approximate median (6.5) means was significant, F(l, 37) = 5.54, split on the full KHOS scale also produced p < .01, and indicates that patients who re- an Information Specificity X KHOS inter-

ANXIETY, INFORMATION, INTERPERSONAL IMPACTS, AND ADJUSTMENT

action, F(l, 32) = 11.47. The same analysis using an approximate median (2.5) split on the Behavioral Involvement subscale, on the Locus of Control Scale (mdn = 9.5), and on the Dental Anxiety Scale (mdn = 10.5) produced no Subject Variable X Information Specificity interactions, Fs(l, 32) = 2,91,