Psychology, 2010, 1: 1-8
doi:10.4236/psych.2010.11001 Published Online April 2010 (http://www.SciRP.org/journal/psych)
1
Psychometric Evaluation of the Perceived Stress
Scale in Early Postmenopausal Chinese Women*
Ruby Yu, Suzanne C. Ho
School of Public Health and Primary Care, the Chinese University of Hong Kong, Hong Kong, China.
Received January 22nd, 2010; revised March 18th, 2010; accepted March 19th, 2010.
ABSTRACT
Objective: The objective of this study was to examine the psychometric properties of the Perceived Stress Scale (PSS) in
a population-based sample of early postmenopausal Chinese women in Hong Kong. Methods: 509 postmenopausal
women, 50 to 64 years, recruited from the community through random telephone dialing were interviewed. The inter-
view included the PSS, the Center of the Epidemiological Study of Depression Scale (CES-D), the State Trait Anxiety
Inventory (STAI), the menopausal symptom checklist, and questions on sociodemographic characteristics and health
behaviors. Principle component analysis was used to determine the component structure of the PSS items. The reliabil-
ity related to internal consistency was measured by Cronbach’s alpha coefficient and test-retest by intra-class correla-
tion coefficients. Construct validity was investigated with subgroup comparisons on the basis of sociodemographic
characteristics, and through correlations with the CES-D, the STAI, menopausal symptoms, and health behaviors.
Results: Principle component analysis of the PSS showed that the scale consisted of 2 factors, which explained 52% of
variance. Internal consistency was adequate (Cronbach’s α = 0.81) and the test-retest reliability after an interval of 2
weeks was 0.86. The PSS distinguished well, and in the expected manner, between subgroups on the basis of age, work
status, and marital status, providing evidence of construct validity. The PSS was also correlated with CES-D, STAI,
menopausal symptoms, and health behaviors; hence the construct validity was further supported. Conclusions: The
PSS appears to be a psychometrically sound instrument for measuring psychological perceived stress for Chinese
women in midlife.
Keywords: Perceived Stress Scale, Validity, Reliability, Postmenopausal Women, Chinese
1. Introduction
Symptoms of psychological stress appear to be increased
in midlife women [1] due to life-stage, hormonal, and
metabolic changes [2,3]. A number of studies have pro-
vided evidence that psychological stress is associated
with a broad array of health outcomes, including cardio-
vascular morbidity and mortality [4,5], and respiratory
infection [6]. Recent studies have also demonstrated that
perceived stress is associated with premature death [7]
and adversely affects quality of life [8]. As midlife
women confront many stressors, particularly during the
period soon after menopausal, accurate measurement of
psychological perceived stress is essential for better un-
derstanding of the susceptibility and treatment of psy-
chological distress.
The Perceived Stress Scale (PSS) is one of the most
widely used instruments for measuring psychological
perceived stress. Studies have supported the validity and
reliability of the PSS in a variety of samples [9-11]. The
PSS has also been shown to relate to a number of
physiological responses [12,13]. Nevertheless, the psy-
chometric properties of the PSS have yet to be examined
in early postmenopausal Chinese women. We addressed
this need by examining the factor structure, reliability,
and validity of the PSS in a population-based sample of
early postmenopausal Chinese women in Hong Kong.
2. Methods
2.1 Subjects
The current study was conducted at baseline from 2002 to
2004 as part of a study of subclinical atherosclerosis in
early postmenopausal Chinese women in Hong Kong. A
detailed description of the sample for the study has been
published elsewhere [14]. 518 women aged between 50 to
*This work was supported by Direct Grant (2005.1.073) of the Chinese
University of Hong Kong and Research Funds from the Centre of Re-
search and Promotion of Women’s Health, School of Public Health and
Primary care, the Chinese University of Hong Kong.

Psychometric Evaluation of the Perceived Stress Scale in Early Postmenopausal Chinese Women 2
64 years, and within 10 years since menopause (defined as
12 months since the cessation of the last menses) were
recruited through random telephone dialing based on the
most recent residential telephone directory. At least 6 at-
tempts at different times of the day and week were made
for each number before it was considered a non-contact. If
more than one postmenopausal woman within the house-
hold fell into the targeted age range of 50 to 64 years, the
member with the most recent birthday was selected.
Women with surgical menopause, cardiovascular disease
and severe disease conditions such as cancer and renal
failure were excluded. Eligible subjects were invited for a
face-to-face interview, clinical assessments, and carotid
ultrasound measurements. A response rate of 62.5% was
obtained. Seven women who reported taking psychotropic
medication within the last 3 months from the date of inter-
view, one woman without psychotropic medication data,
and another woman without PSS score were excluded,
thus leaving 509 subjects for analysis. Furthermore, a ran-
dom sub-sample of 25 women were re-interviewed over
the telephone for a reliability test with an intervening
2-week interval. All women gave written, informed con-
sent and the study was approved by the Ethics Committee
of the Chinese University of Hong Kong.
2.2 Measures
Standardized interviews assessed sociodemographic
characteristics, medical history, use of medications, psy-
chological factors, menopausal symptoms, and health
behaviors. In the analyses presented below, we focus on
sociodemographic characteristics, psychological factors,
menopausal symptoms, and health behaviors.
Sociodemographic characteristics
Several questions were administered to elicit informa-
tion about the sociodemographic data including age,
household income, education, work status and occupa-
tion, as well as marital status. Women actively looking
for a job or temporarily not employed because of any
reasons were classified as ‘non-working’. Information
was also gathered about the year since menopause.
Psychological factors
Perceived stress was assessed using the PSS which was
developed by Cohen [15]. This scale is a self-report meas-
ure and the version having used had 10 items [9]. The PSS
measures the degree to which individuals perceived their
daily life as being stressful during the last month with a
5-point Likert scale (0 = never and 4 = very often). Total
scores can range from 0 to 40. Higher scores on the PSS
represent higher levels of perceived stress.
Depression symptoms were assessed using the Center
of the Epidemiological Study of Depression Scale
(CES-D) which was developed by Radloff [16] and was
locally translated and validated by Cheung et al. [17]. The
CES-D is a self-report measure consisting of 20 items,
with response options for each item reflecting varying
degrees of depression symptoms. Respondents were told
that the items constitute a list of ways they may have felt
or behaved during the last week, and they indicated the
frequency of occurrence of each symptom on a 4-point
Likert scale (0 = rarely or none of the time: less than 1 day
and 3 = most or all of the time: 5 to 7 days). Total scores
can range from 0 to 60. Subjects with scores of 16 or more
on the CES-D scale were considered ‘mild depression’.
Anxiety was assessed using the State Trait Anxiety
Inventory—Form Y (STAI) which was developed by
Spielberger et al. [18]. This scale was translated into
Chinese by Tsoi et al. [19] and has been successfully
employed in measuring anxiety in the Chinese population
[20-22]. The STAI comprises of two 20-item self-report
scales for which subjects were asked to indicate the
temporary condition of state anxiety and the more gen-
eral and long-standing quality of trait anxiety on a
4-point Likert scale (1 = not at all and 4 = very much so).
Because half of the items reflect the absence of anxiety,
the scoring of these items were reversed and responses
on all items summed to give a total score ranging from
20 to 80. Scores on the STAI have a direct interpretation:
high scores on their respective scales mean more state or
trait anxiety and low scores mean less.
Menopausal symptoms
Menopausal symptoms were assessed using the
20-item symptom checklist adapted from Avis et al. [23]
and locally translated by Ho et al. [1]. A binary response
was adopted and each woman was asked to respond ‘yes’
or ‘no’ to having had experienced any of the symptom in
the past 2 weeks. The symptom checklists comprised of
five symptom clusters, namely psychological, muscu-
loskeletal and gastrointestinal, non-specific somatic
complaints, respiratory, as well as vasomotor.
Health behaviors
Women were asked to rate their cigarette smoking
habits on a scale of never smoked, once smoked but did
not anymore, or currently smoke if they smoked 1 or
more cigarette per day. Also they were asked about their
alcohol intake habits on a scale of never drinkers, infre-
quent drinkers, or frequent drinkers (at least once per
week). Women were also asked to give information
about the usual level of participation in occupational,
leisure-time physical activity, sport and exercise, and
household activity over the previous 12 months with the
modified and locally translated Baecke questionnaire
[24,25]. Total hours of sleep per day were extracted from
the translated Baecke questionnaire. In addition, women
who reported that she had frequently engaged in a given
sporting activity / exercise were defined as physically
active, and those who infrequently / never engaged were
physically inactive.
2.3 Data Analysis
Continuous variables were reported as mean and standard
deviation. Factor structure was assessed using principle

Psychometric Evaluation of the Perceived Stress Scale in Early Postmenopausal Chinese Women 3
component analysis with varimax rotation. The reliability
related to internal consistency was measured by Cron-
bach’s alpha coefficient (Cronbach’s α) and test-
retest by intra-class correlation coefficients (ICCs). Con-
struct validity was performed through comparisons be-
tween PSS scores across various subgroups on the basis
of sociodemographic characteristics using analyses of
variance (ANOVAs) or t-tests, depending on the number
of categories, through correlations with 2 psychological
measures (CES-D and STAI) tapping similar constructs,
and through correlations with a number of menopausal
symptoms and health behaviors including total hours of
sleep per day, smoking, alcohol intake and physical ac-
tivity. A P < 0.05 was used to denote significant differ-
ence. All analyses were performed with SPSS version
15.0 (SPSS Inc., Chicago, IL, USA).
3. Results
Characteristics of study population
The mean age of the study population was 56 years
and the majority was married (80.7%). About half had
secondary or above level of education and 70.3% were
housewives. 60.7% of the women reported four or more
menopausal symptoms. The prevalence of smoking and
frequent alcohol intake was rather low (less than 4%).
Details of the characteristics of the study population have
been described in a previous paper [14].
Factor structure
The principal component analysis revealed 2 factors
that accounted for 52% of the variance in the items (Ta-
ble 1). The first factor ‘positive perception’, accounting
for 38% of the variance, was made up of 6 positively
worded items. Factor loadings ranged from 0.535 to
0.771, and none of these items loaded onto the second
factor. The second factor ‘negative perception’ accounted
for an additional 15% of variance and was composed of 4
negatively worded items with factor loading ranging
from 0.691 to 0.798.
Reliability
The reliability related to internal consistency (meas-
ured by Cronbach’s α) was 0.81 for the whole PSS, 0.77
for the first factor, and 0.77 for the second factor.
Test-retest reliability (measured by ICCs) after an inter-
val of 2 weeks was 0.86.
Construct validity
Subgroup comparisons
The mean score of the PSS was 11.56, with standard
deviation of 7.16 (Range 0-40) (Table 2). PSS scores
decreased with age (r = –0.173, P < 0.01). Women
within 5 years of menopause were also associated with
higher PSS scores, but the magnitude of this association
was attenuated after adjustment for age (data not
shown). When scores were classified by level of
household income, PSS scores declined as household
income increased. Women with household incomes of
HK $ 10,000 or less reported higher PSS scores than did
those earning $ 10000 - $ 49,999, $ 50,000 - $ 99,999,
and more than $ 100,000. However, none of the com-
parisons between group means were significant (P =
0.536). Women with education beyond tertiary educa-
tion reported more perceived stress than did all those
with less than a tertiary education, but the difference
was not statistically significant (P = 0.367). Women
who were housewives or who were retired had PSS
scores significantly lower than did those in paid em-
ployment (P < 0.01). No significant differences between
the PSS scores for those who were service sector /
manual workers and those who were administrative
professionals were found (P = 0.424). PSS was also
related to marital status. T-test revealed that women
who were married or living with a partner had lower
PSS scores than did those who were never married,
widowed, divorced, or separated (P < 0.05). After ad-
justment for age, the magnitude of this association re-
mained nearly unchanged (P < 0.05) (data not shown).
Relationship between PSS scores and other psycho-
logical measures
Correlations between the PSS, the CES-D, and the
STAI were calculated (Table 3). As expected, both the
latter scales correlated positively with the PSS (r = 0.690,
P < 0.01 and r = 0.693, P < 0.01, for CES-D and STAI,
respectively). When STAI was split into its component
scale, the PSS correlated well with both SAI and TAI (P <
0.01).
Table 1. Rotated factor loadings of PSS items
Item Factor 1 Factor 2
1 0.771 0.154
2 0.535 0.223
3 0.698 0.161
6 0.621 0.172
9 0.686 0.010
10 0.678 0.214
4 0.220 0.712
5 0.293 0.691
7 0.007 0.764
8 0.197 0.798
Eigenvalue 3.774 1.462
Variance accounted
for, % 37.737 14.623

Psychometric Evaluation of the Perceived Stress Scale in Early Postmenopausal Chinese Women 4
Table 2. Mean PSS scores and standard deviations for sociodemographic categories
N PSS score, mean ± SD P-value
Overall 509 11.54 ± 7.15 ---
Age, years
50 - 54 199 13.03 ± 7.78 0.000
55 - 59 225 11.44 ± 6.60
60 - 64 85 8.45 ± 6.02
Years since menopause, years
< 5 261 12.15 ± 7.48 0.049
≥ 5 246 10.91 ± 6.77
Household income
< HK $ 10,000 129 12.09 ± 7.95 0.536
HK $ 10,000 - $ 49,999 157 11.96 ± 6.83
HK $ 50,000 - $ 99,999 169 11.33 ± 6.59
≥HK $ 100,000 45 10.56 ± 7.68
Education
Primary or below 226 11.15 ± 7.50 0.367
Secondary 236 11.74 ± 6.86
Tertiary or above 47 12.66 ± 6.94
Work status
Housewife 356 10.74 ± 6.90 0.000
Employed 151 13.28 ± 7.22
Non-working 2 28.00 ± 9.90
Occupation
Service sector / manual workers 128 13.07 ± 7.12 0.424
Administrative professionals 23 14.48 ± 7.77
Marital status
Single, widow, divorced or separated 98 12.95 ± 7.11 0.033
Married or lived together 411 11.23 ± 7.14
PSS, perceived stress scale
P-values from ANOVAs or T-tests for comparisons of mean values
Relationship between PSS scores and menopausal
symptoms
PSS scores were significantly related to the number of
menopausal symptoms for all of the five symptom
groups (Table 4). PSS scores were associated with more
psychological symptoms (r = 0.406, P < 0.01) and, to a
lesser extent, with more musculoskeletal and gastrointes-
tinal (r = 0.219, P < 0.01), non-specific somatic com-
plaints (r = 0.231, P < 0.01), respiratory (r = 0.180, P <
0.01), and vasomotor symptoms (r = 0.235, P < 0.01) as
well. After adjustment for age, the magnitude of these
associations remained nearly unchanged (data not

Psychometric Evaluation of the Perceived Stress Scale in Early Postmenopausal Chinese Women 5
Table 3. Correlations between PSS scores and other psy-
chological measures
PSS score
Psychological
measures Pearson correlation coefficient P-value
CES-D 0.690 0.000
STAT 0.673 0.000
SAI 0.538 0.000
TAI 0.693 0.000
PSS, perceived stress scale, CES-D, Center of the Epidemiological
Study of Depression Scale, STAI, State Trait Anxiety Inventory, SAI,
State Anxiety Inventory, TAI, Trait Anxiety Inventory
P-values obtained from Pearson correlations
Table 4. Correlations between PSS scores and menopausal
symptoms
PSS score
Menopausal symptom
groups Pearson correlation coefficient P-value
Psychologicala 0.406 0.000
Musculoskeletal and gastro-
intestinalb 0.219 0.000
Non-specific somatic com-
plainsc 0.231 0.000
Respiratoryd 0.180 0.000
Vasomotore 0.235 0.000
All symptomsf 0.412 0.000
PSS, perceived stress scale
aPsychological: difficulty in concentration, nervous tension, rapid
heartbeat, trouble sleeping, feeling blue.
bMusculoskeletal gastrointestinal: diarrhea and/or constipation, aches
or joint stiffness, backaches, upset stomach.
cNon-specific somatic complaints: lack of energy, dizzy spells, head-
aches.
dRespiratory: persistent cough, sore throat, shortness of breath.
eVasomotor: cold sweats, hot flushes, loss of appetite.
fAll symptoms: all of the above, including two symptoms (urinary tract
infection and feeling of pins and needles) not loaded into anyone of the
symptom clusters.
P-values obtained from Pearson correlations
shown).
Relationship between PSS scores and health behaviors
Women who reported that they had 5 hours or less of
sleep per day had PSS scores significantly higher than
those who reported more than 5 hours of sleep per day (P
< 0.01) (Table 5). PSS scores were also significantly
higher amongst physically inactive women when com-
pared with the physically active (P < 0.01). Analyses also
showed decreased PSS scores were associated with in-
creased levels of physical activity by means of total in-
dex assessed by the modified Baecke questionnaire (data
not shown). No relationships of the PSS scores with
smoking or alcohol intake were revealed by the data.
4. Discussion
Overall, the PSS performed reasonably well in this sam-
ple of early postmenopausal Chinese women. The factor
structure of the PSS was consistent with the structure
found in the US population [9]. Items stating positive
attitude were gathered in the ‘positive perception’ factor
and items of negative attitude were in the ‘negative per-
ception’ factor. Cronbach’s α for each factor was high,
indicating that all factors were internally consistent. The
level of stability was sufficient. The PSS was stable over
a period of around 2 weeks.
The PSS scores were able to distinguish between
groups of women in an expected way on the basis of age,
work status, and marital status, providing evidence of its
construct validity. Women who were younger had gener-
ally higher PSS scores. The results are congruent with
those of Cohen and Williamson [9], who reported an
inverse association of PSS scores with age. Compared
with housewives, women with paid employment and
non-working women had higher PSS scores. Ho et al. [26]
also demonstrated that women with paid employment
and non-working women were more likely to report
menopausal symptoms. Perhaps being employed in mid-
life was a source of stress resulting from perceived job
uncertainty, interpersonal conflicts and financial difficul-
ties. Thus, our data are consistent with traditional con-
ceptions of groups who should be experiencing greater
stress because of the demands of their living and working
environments.
Women who were never married, widowed, divorced,
or separated had generally higher PSS scores than those
who were married or living with a partner. Cohen and
Williamson [9] have also noted a significant difference
between mean PSS scores of single or never married,
divorced, or separated and married/living with a partner.
The difference in perceived stress levels may be ex-
plained either by never married women having more dif-
ficulty in identity formation and acceptance of their role
by society or married women whose children are nearly
grown tend to experience more satisfaction and less
stress at midlife.
The PSS was also found to correlate significantly with
other psychological measures (CES-D and STAI) com-
monly used to measure similar psychological constructs,
and thus the construct validity of the PSS was confirmed.
Adequate correlations between the PSS scores and the
number of menopausal symptoms for all of the symptom
groups including psychological, musculoskeletal and
gastrointestinal, non-specific somatic complaints, respi-
ratory, and vasomotor symptoms groups were observed.

Psychometric Evaluation of the Perceived Stress Scale in Early Postmenopausal Chinese Women 6
Table 5. Mean PSS scores and standard de viations for health behavior categories
N PSS score, mean ± SD P-value
Total hours of sleep per day, hours
< 5 35 15.91 ± 7.83 0.001
5 – 6 109 12.03 ± 7.42
6 – 7 171 11.28 ± 6.76
7 – 8 136 10.29 ± 6.84
> 8 58 11.84 ± 7.26
Smoking
Never smokers 492 11.51 ± 7.13 0.571
Former smokers 9 14.00 ± 9.29
Current smokers 8 12.13 ± 6.58
Alcohol intake
Never drinkers 321 11.53 ± 7.12 0.946
Infrequent drinkers 170 11.56 ± 7.36
Frequent drinkers 18 12.11 ± 6.34
Physical activity
Physically inactive 241 13.16 ± 7.38 0.000
Physically active 268 10.12 ± 6.64
PSS, perceived stress scale
P-values from ANOVAs or T-tests for comparisons of mean values
Our results are consistent with that observed in another
study [27] suggesting that perceived stress soon after
menopause may also sensitize women to symptomatic
responses. A possible explanation for this association is
that the effect of stress on catecholamine and estrogen
changes.
A significant inverse association between PSS scores
and total hours of sleep per day was also revealed. Our
result is consistent with findings of a previous study [28]
that perceived stress was a significant predictor of sub-
jective sleep disturbance in middle-aged Chinese women,
but the study was limited by the cross-sectional design,
which could not address causality of associations. Indeed,
the relationship between psychological stress and sleep
loss is bi-directional. Chronic sleep loss may increase the
feelings of stress via the transient or enduring activation
of the neuroendocrine stress systems [29].
Our results are also consistent with another epidemi-
ological study in finding an inverse association between
PSS scores and physical activity [30]. Plausible mecha-
nisms could be that physical activity may enhance
self-esteem, improve mood states, reduce state and trait
anxiety, and resilience to stress [31]. Therefore, in this
study, we had identified a number of menopausal symp-
toms and health behaviors which were associated with
the PSS scores, hence the construct validity of the PSS
was further supported.
This study has several limitations. Our findings were
based on a cross-sectional study, the temporal or cause-
effect relationship was unclear, and thus predictive valid-
ity could not be confirmed. Test-retest reliability was
accessed in 2 different modes of data collection (face-
to-face and telephone interviews), differential response
bias could be introduced. However, the strength of the
study lies in the population-based nature of the sample.
In conclusion, the results of this study suggest that the
PSS is an instrument with adequate psychometric proper-
ties (consistent internal structure, high reliability, and
high construct validity). Therefore, the PSS can be a very
useful tool to detect psychological stress among early
postmenopausal Chinese population. The PSS may also
predict adverse health outcomes when it is used in longi-
tudinal studies. More attention to a long-term temporal
perspective is needed to delineate the predictive validity
of the PSS for health outcomes such as cardiovascular
events in women in midlife.

Psychometric Evaluation of the Perceived Stress Scale in Early Postmenopausal Chinese Women 7
5. Acknowledgment
We wish to thank all subjects for their participation.
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