2011. Vol.2, No.6, 590-597
Copyright © 2011 SciRes. DOI:10.4236/psych.2011.26091
An Examination of Moderators of Perceived Stress and
Jenifer J. Thomas1, Evelinn A. Borrayo2
1Fay W. Whitney School of Nursing, University of Wyoming, Laramie, WY, USA;
2Department of Psychology, University of Colorado-Denver, Denver, CO, USA.
Received May 17th, 2011; revised July 1st, 2011; accepted August 14th, 2011.
The purpose of this study was to examine multiple psychosocial factors (social support, negative affect, coping
skills, and perceived health status) as moderators of perceived stress on illness behavior. College students re-
cruited from undergraduate psychology courses completed measures in an on-line survey. Hierarchical multiple
regression analyses indicated that commonly investigated psychosocial factors such as affectivity, coping, and
social support moderated the relationship between perceived stress and one illness behavior (report of illness
without visits to the doctor). However, other moderator variables less investigated, such as perceived health
status had a significant effect on both illness behaviors (self-reported incidents of illness with and without visits
to the doctor). Our findings highlight the role of behavioral health in primary care and the importance of educat-
ing individuals on the relationship between psychosocial factors and health.
Keywords: Illness Behavior, Psychosocial Factors, Patient Education
The Transactional Model of Stress, proposed by Lazarus and
Folkman (1984), emphasizes the relationship between envi-
ronmental, psychological, and physiological processes; and
research has identified psychosocial factors (processes pertain-
ing to the interaction between social and psychological factors)
that influence the experience of stress. For example, individuals
who perceive high levels of social support feel less stress
(Fleming, Baum, Gisriel, & Gatchel, 1982; Stok, Harvey, &
Reddihough, 2006) and individuals who use approach type
(proactive) coping styles tend to experience fewer psychologi-
cal symptoms of stress (Dolbier, Smith, & Steinhardt, 2007;
Moos & Schaefer, 1993). The impact of stress on illness has
been found to vary based on the presence of certain psychoso-
cial factors as well, including social support, emotional states,
and coping skills (Cohen, Kessler, & Gordon, 1995; Cohen &
Wills, 1985; Moos & Schaefer, 1993). Recent research has
focused on examining the impact of stress on the experience of
specific illnesses or diseases via psychosocial factors (e.g.,
Devins, Bezjak, Mah, Loblaw, & Gotoweic, 2006; Gerber &
Although various studies have investigated the moderating
role of psychosocial factors in the stress-illness relationship, the
effect of these moderators on behaviors associated with illness
remains largely unexamined. Illness behaviors, such as those
examined in the present study, include the activities an indi-
vidual engages in to understand physical symptoms and to seek
care to alleviate them (Herbert & Cohen, 1994). Illness behav-
iors occur even when an objective measure (i.e., physical ex-
amination) has not confirmed the presence or absence of an
organic condition. In other words, illness behavior refers to the
varying ways in which individuals interpret and respond to their
body sensations and internal states, define and interpret symp-
toms, make attributions, and take action through informal and
formal care (Mechanic, 1995; Risor, 2006).
To elaborate upon the definition of illness behavior, Me-
chanic (1978) described these processes at four different levels
of investigation. The first level includes dispositional factors
such as gender. The second level includes psychosocial factors
such as social support (Pilisuk, Boylan, & Acredolo, 1987),
perceived health status (Miilunpalo, Vuori, Oja, Pasanen, &
Urponen, 1997), coping (Soderstrom, Dolbier, Leiferman, &
Steinhardt, 2000), and perceived stress (Miranda, Perez-Stable,
Munoz, Hargreaves, & Henke, 1991). The third level includes
the process of attribution and decision making such as attention
and learning (Pennebaker, 2000) and perceived severity of the
symptoms (Bury, 2005). The fourth level includes the structure
of the health delivery system and the interactions between the
individual and the health care system. Although these levels
contain several important facets of illness behavior, Mechanic
(1978) did not specifically define the interplay among the dif-
ferent levels (Risor, 2006). To further this approach to illness
behavior research, the current study will consider interactions
among the second level (psychosocial factors of social support,
perceived health status, coping, and perceived stress) of inves-
Psychosocial Factors and Illness Behavior
Research has explored a range of psychological and social
factors that influence illness behavior. For example, high per-
ceived stress levels have been found to be related to high num-
bers of medical visits (Miranda et al., 1991; Pilisuk et al., 1987)
and increases in reported symptoms of illness (Mizco, Mizco,
& Johnson, 2006). High levels of social support are associated
with lower medical utilization rates (Pilisuk et al., 1987), and
patients with a negative perception of their heart disease symp-
toms report receiving less social support (Benyamini, Medalion,
& Garfinkel, 2006). It has been found that negative affectivity
is correlated with reported health complaints and upper respi-
ratory infection (Cohen et al., 1995; Watson, Clark, & Tellegen,
1988). The inability to adapt to or cope with difficult life cir-
J. J. THOMAS ET AL. 591
cumstances can intensify the experience of physical symptoms
and poor health outcomes (Connor-Smith & Compas, 2004;
Soderstrom et al., 2000). Subjective perception of poor health
has been found to be a strong predictor of increased physician
visits (Miilunpalo et al., 1997).
Investigative approaches to illness behavior consider the in-
dependent influence of psychosocial factors, but the possibility
of interactions among them is explored less often. Specifically,
social support, affectivity, and coping may moderate the rela-
tionship between stress and illness behavior due to their influ-
ence on the experience of stress. That is, these psychosocial
factors may intensify the relationship. The behaviors associated
with the recognition and interpretation of symptoms, or illness
behaviors, can be affected by individuals’ vulnerability to stress
(Costa & McCrae, 1985). For example, in a sample of indi-
viduals with somatoform disorder it was found that psycho-
logical/stress factors were reported as highly relevant causes of
bodily symptoms (Hiller et al., 2010). The degree of social
support an individual receives is an important factor in the re-
sponse to stress as individuals who perceive high levels of so-
cial support feel less stress (Fleming et al., 1982; Wilks &
Croom, 2008). Negative affectivity is also strongly correlated
with reported stress symptoms (Klainin, 2009; Watson et al.,
1988). In general, individuals who use approach coping styles
tend to adapt better to life stressors and experience fewer psy-
chological symptoms (Dolbier et al., 2007; Moos & Schaefer,
1993). Therefore, psychosocial factors that influence individual
appraisals and perceptions of abilities to cope with stress could
potentially affect the relationship between stress and illness
Individual perceptions of health may also moderate the rela-
tionship between stress and illness behavior, although literature
on such a relationship is limited. Personal views of health and
illness such as attitudes, perceptions, and emotions (including
stress and anxiety) can affect awareness of physical symptoms
and care seeking. For example, physically healthy individuals
with high levels of emotional distress may view themselves as
physically ill (Olfson, Gilbert, Weissman, Blacklow, & Broad-
head, 1995); this perception has also been found to be associ-
ated with increased use of physician services (Miilunpalo et al.,
1997). In addition, negative changes in self-reported health
were found to be frequently associated with stress and tension
in a sample of caregivers (Byers, Beard, & Wicks, 2009). Cog-
nitive-perceptual factors (such as perceived health status and
health self-efficacy) have been found to influence the mainte-
nance of health-promoting behaviors, including seeking health
care services when illness’ symptoms are suspected (Jackson,
Tucker, & Herman, 2007).
Understanding how stress and other factors influence illness
behaviors is important because it could aid in an understanding
of how and under what circumstances individuals evaluate their
health status and consequently use health services. In addition,
such an examination could lead to health education that can
more effectively motivate individuals to seek proper and timely
health care/treatment. The purpose of this study was to examine
multiple psychosocial factors (social support, negative affect,
coping skills, and perceived health status) as moderators of
perceived stress on illness behaviors in a sample of college
students. The two illness behaviors considered were the
self-report of number of visits to a health care provider and
number of instances of illness without visits to a health care
provider. It was hypothesized that less satisfaction with social
support, high negative affectivity, use of more avoidant coping
strategies, and poor perceived health status would intensify the
effect of high perceived stress on high numbers of self-reported
illness behaviors during the past six months.
Sociodemographic information and complete surveys were
obtained from a sample of 303 college students. The respon-
dents were on average 19 years old (range 17-33 years), mostly
female (70% female), single (92% single), and Caucasian (89%
Caucasian/white). Academically, respondents had on average
14 credits, were mostly freshman (51% freshman vs. 19%
sophomore, 17% senior, and 12% junior), and most reported a
cumulative grade point average of 2.6 - 3.0 (26%). The em-
ployment status of respondents was 56% not working and 43%
working. Most respondents lived on campus (52%). With re-
gard to healthcare services, 55% reported utilizing the Univer-
sity Health Services only, 22% reported utilizing both the Uni-
versity Health Services and off campus health services and 21%
reported utilizing off campus health services only.
Approval for this study was obtained from an Institutional
Review Board. Students were recruited from a research pool
and from undergraduate psychology courses at an accredited
university, and self-selected into this study. Participants read
and signed a consent form in-person and the surveys were ad-
ministered on-line through the Student Voice survey package
utilized by the university. They could complete the survey at
any time during the last week of the fall semester. The entire
survey took approximately between 30-60 minutes to complete.
There were three versions of the survey (A, B, and C) with
different ordering of the questionnaires within the survey to
control for order effects.
Illness behavior. Participants reported on both (a) the num-
ber of instances of illness with a visit to a doctor in the past six
months, and (b) the number of instances of illness without a
visit to a doctor in the past six months.
Psychological stress. The Perceived Stress Scale (PSS) was
used to measure levels of perceived stress over the past month
(Cohen, Kamarck, & Mermelstein, 1983). This 14-item meas-
ures levels of perceived stress and the degree to which respon-
dents find their lives unpredictable, uncontrollable, and over-
loading. On a 5-point scale, ranging from never to very often,
respondents were asked to report how often they perceived to
feel stressed. Research has shown that it is a reliable and valid
measure of self-reported stress (Cohen, Tyrrell, & Smith, 1993).
The alpha reliability for this scale in the current sample was
Social support. Social support was measured by the Social
Support Questionnaire Short Form (SSQSR) (Sarason, Sarason,
Shearin, & Pierce, 1987). First, individuals were asked to list
up to nine available others that they feel they can turn to in
times of need (number score). Second, individuals were asked
to rate degree of satisfaction with the perceived support from
these sources on a 6-point Likert scale from “very satisfied” to
“very dissatisfied” (dissatisfaction score) on six items that de-
scribe a variety of situations. The dissatisfaction score was used
in this study due to large variability and outliers in the number
score. The SSQSR has shown to be a reliable and valid measure
J. J. THOMAS ET AL.
of social support (Brown & Schutte, 2006). The alpha reliabil-
ity for this scale in the current sample was 0.80.
Affect. Positive and negative affect was measured using the
Positive affect and Negative affect scales, or PANAS (Watson
et al., 1988). The PANAS estimates the degree of positive or
negative affect and consists of 10 adjectives for Negative affect
and 10 adjectives for Positive affect. Individuals were asked to
rate on a 5-point scale the extent to which they have experi-
enced each mood state. Empirical evidence supports that it is a
reliable and valid measure of positive and negative affect (Bood,
Archer, & Norlander, 2004).The alpha reliability for this scale
in the current sample was 0.85.
Coping. Strategies to cope with stress were measured by the
Brief COPE inventory (Carver, 1997). Individuals were asked
to rate 28 items on a 4-point scale of what they generally do
and feel when experiencing stressful events. The dimensionality
of the 28 items was analyzed using maximum likelihood factor
analysis in order to simplify the use of this scale in the statisti-
cal analysis. The rotated solution yielded two interpretable
factors. Factor 1, or approach coping styles, accounted for
15.9% of the item variance, and factor 2, or avoidant coping
styles, accounted for 13.7% of the item variance. The total rat-
ings on factor 2 became the avoidant coping score. The Brief
COPE inventory has been found to be a reliable and valid
measure of coping strategies (Norlander, Von Schedvin, &
Archer, 2005). The alpha reliability for this scale in the current
sample was 0.79.
Perceived health status and health history. A measure of
perceived health status asked participants to rate their overall
health at the present time as either: excellent, very good, good,
fair, poor, or very poor. The use of this single item has been
shown to be a valid measure of health status (Bowling, 2005).
As part of the questionnaires, participants were asked to pro-
vide a history of past and current medical conditions, medica-
tion use, negative health behaviors (e.g., smoking, alcohol use),
and positive health behaviors (e.g., regular exercise). These
were measured as yes/no dichotomous variables.
The Statistical Package for the Social Sciences (SPSS) was
used for the data analysis. A hierarchical multiple regression
model was used to analyze the collective and separate effects of
perceived stress, negative affect, avoidant coping strategies,
social support dissatisfaction, and perceived health status on
two self-report instances of illness behaviors during the past six
months: number of instances of illness with visits to a doctor
and number of instances of illness without visits to a doctor
For the two dependent measure equations, the covariates (so-
ciodemographic predisposing characteristics that may confound
the relationship between the independent and dependent vari-
ables) of age, living situation, university status, and cumulative
grade point average were entered first. In preliminary analysis,
these variables were highly correlated with independent and
dependent variables. Entered second were the health status
variables (predisposing health related variables that may influ-
ence stress and health outcomes), current medical conditions,
past medical conditions, and current medication use. These
variables were also highly correlated with independent and
dependent variables in preliminary analysis. The main effects
of perceived stress, negative affect, dissatisfaction with social
support, avoidant coping strategies, and perceived health status
were entered third. For the final step, interactions were entered
into the regression equation as the product of two variables.
Separate interaction variables were created based on perceived
stress as the predictor and dissatisfaction with social support,
negative affect, avoidant coping strategies, and perceived health
status as moderators. Only significant interactions were pre-
served in the final analysis.
A power estimate was conducted for each of the dependent
variables (DV) tested with an interaction to determine the ade-
quacy of the explained variance detected with the number of
participants that entered in the analysis for each DV (Cohen,
1988). For the self-reported visits to the doctor DV, at an alpha
level of .05, the sample size of 265 participants yielded a power
of approximately .90 to detect an effect that accounts for 17%
of the variance. For the self-reported instances of illness with-
out a visit to the doctor DV, at an alpha level of .05, the sample
size of 274 participants yielded a power of .90 to detect an ef-
fect that accounts for 28% of the variance. According to this
estimate, the number of participants that entered in the analysis
of each DV allowed for medium (.60) to high (.90) power to
detect effects that accounted for an adequate portion of the
explained variance for each variable.
Instances of illness with a visit to the doctor in the past six
months ranged from 0 to 79 (M = 3.35, median = 1.0, SD =
7.07). The higher mean reflects a skewed distribution, with a
large number of fewer instances of illness behavior. As shown
in Table 1, the presence of current medical conditions was a
significant predictor. All variables entered in the regression
equation accounted for 17% of the variance; F(18, 264) = 2.83,
p = .00. The moderator analysis revealed one significant inter-
action. With excellent, very good, and fair perceived health
status, as perceived stress increases there is minor change in
incidents of self-reported visits to the doctor. However, with
poor perceived health status, as perceived stress increases inci-
dents of self-reported visits to the doctor decreases. Thus, the
hypothesis that poor perceived health status would intensify the
effect of high perceived stress on self-reported visits to the
doctor was not supported. About 20% of the variance was ac-
counted for when the moderators included in the equation; F(19,
264) = 3.22, p = 0.00.
Instances of illness without a visit to the doctor in the past
six months ranged from 0 to 79 (M = 2.96, median = 2.0, SD =
5.97). The higher mean reflects a skewed distribution, with a
large number of fewer instances of illness behavior. As shown
in Table 2, the presence of current medical conditions, major
illnesses in the past, and perceived stress were significant pre-
dictors. This supported the hypothesis that self-reported inci-
dents of illness without visits to the doctor would depend on
high perceived stress. All variables entered in the regression
equation accounted for 18% of the variance; F(18, 273) = 3.18,
p = .00. The moderator analysis revealed four significant inter-
actions. The first interaction revealed that with average and low
levels of social support dissatisfaction, as perceived stress in-
creases incidents of self-reported illness without a doctor visit
increases. With high levels of social support dissatisfaction, as
perceived stress increases incidents of self-reported illness
without a doctor visit decreases. The next interaction shows that
with high and average levels of negative affectivity, as per-
ceived stress increases incidents of self-reported illness without
a doctor visit increases. With low levels of negative affectivity,
increases in perceived stress corresponded with decreases in
J. J. THOMAS ET AL. 593
Hierarchical regression prediction of self-reported instances of illness
with visits to the doctor in the past six months.
Variables B t
Step 1 Age −.04 −.11
Living situation −.04 −.29
University status .12 .20
Grade point average −.01 −1.22
Step 2 Current medical conditions −2.55 −2.41*
Major illnesses in the past −.70 −.73
Current medication use 1.89 1.94
Step 3 PSS (One month) .08 1.00
SSQ (Dissatisfaction) .11 .21
(Negative affectivity) −.03 −.37
(Avoidant coping) −.04 −.35
Perceived health status
(as compared to good)
Excellent 1.60 1.36
Very good .25 .21
Fair −.56 −.40
Poor −18.19 −1.87
Very poor −1.76 −.26
Step 4 PSS * Poor Perceived
Health Status 1.25 2.96**
Note: (N = 265). PSS = Perceived Stress Scale. SSQ = Social Support Question-
naire. PANAS = Positive and Negative Affectivity Scales. B and t are shown from
the last step with all variables entered. R2 = .01 for Step 1; R2 change = .08 for
Step 2; R2 change = .08 for Step 3; R2 change = .03 for Step 4. Total R2 = .20 at
the last step. * p < .05, ** p < .01.
incidents of self-reported illness without a doctor visit. The
third interaction also revealed that with high and average levels
of avoidant coping, as perceived stress increases incidents of
self-reported illness without a doctor visit increases. When low
levels of avoidant coping are reported, as perceived stress in-
creases incidents of self-reported illness without a doctor visit
decreases. The final interaction revealed that with excellent,
very good, and poor perceived health status (as compared to
good), as perceived stress increases incidents of self-reported
illness without a doctor visit increases. With fair perceived
health status, as perceived stress increases incidents of self-
reported illness without a doctor visit decreases. These findings
supported the hypotheses that high negative affectivity, more
avoidant coping strategies, and poor perceived health status
would intensify the effect of high perceived stress on high
self-reported illness without visits to the doctor in the past six
months. However, our findings did not support the hypothesis
that less satisfaction with social support would intensify the
effect of high perceived stress on increased number of self-
reported illnesses without visits to the doctor. When the mod-
erators were included in the equation, 30% of the variance was
accounted for; F(22, 273) = 4.97, p = 0.00.
Hierarchical regression prediction of self-reported instances of illness
without visits to the doctor in t h e past six months.
Variables B t
Step 1 Age .18 .61
Living situation −.00 −.01
University status −.81 −1.69
Grade point average −.01 −.59
Step 2 Current medical conditions −2.53 −3.05**
Major illnesses in the past 1.49 1.20*
Current medication use 1.34 1.76
Step 3 PSS (One month) .14 2.07*
SSQ (Dissatisfaction) −.21 −.47
(Negative affectivity) .01 .07
(Avoidant coping) .00 .98
Perceived health status
(as compared to good)
Excellent −.68 −.74
Very good −.48 −.53
Fair 4.54 1.49
Poor 3.00 1.65
Very poor −8.10 −1.48
Step 4 PSS * SSQ
(Dissatisfaction) −.20 −3.49**
PSS * PANAS
(Negative affectivity) .02 2.78**
PSS * Brief COPE
(Avoidant coping) .04 4.05**
PSS * Fair Perceived
Health Status −.39 −2.69**
Note: (N = 274). PSS = Perceived Stress Scale. SSQ = Social Support Question-
naire. PANAS = Positive and Negative Affectivity Scales. B and t are shown from
the last step with all variables entered. R2 = .02 for Step 1; R2 change = .06 for
Step 2; R2 change = .10 for Step 3; R2 change = .12 for Step 4. Total R2 = .30 at
the last step. * p < .05, ** p < .01.
This study contributes to the limited literature that has ex-
amined the psychosocial factors that moderate the relationship
between perceived stress and illness behavior. While psychoso-
cial factors have previously and consistently been found to have
an effect on the stress-illness relationship, those examined in
this study demonstrate a particular moderating effect on behav-
ior. More specifically, the study findings demonstrate that
commonly investigated psychosocial factors such as affectivity,
coping, and social support moderated the relationship between
perceived stress and one illness behavior (report of illness
without visits to the doctor). However, other moderator vari-
ables less investigated, such as perceived health status had a
significant effect on both illness behaviors (self-reported inci-
J. J. THOMAS ET AL.
dents of illness with and without visits to the doctor). The cur-
rent investigation of multiple moderators and more than one
health outcome measure provides a broader picture of the mod-
erating effect of psychosocial factors on behavior.
The results regarding social support found that participants
with more illness behaviors, and more specifically those who
reported feeling ill without visiting the doctor, were more satis-
fied with social support. These findings were inconsistent with
the hypothesized relationship and with studies that have found
social support satisfaction as a buffer for the effects of stress on
health (Cropley & Steptoe, 2005; Treharne, Lyons, & Tupling,
2001). However, other studies have found no correlation be-
tween stress and social support (Dwyer & Cummings, 2001) or
between positive social support and physical symptoms (Ed-
wards, Hershberger, Russell, & Markert, 2001). Zaleski,
Levey-Thors, and Schiaffino (1998) found that college students
with high family social support reported more physical symp-
toms when faced with stress, possibly due to separation from
the main source of social support. The inconsistency in the
current study could be due to the measurement of social support.
First, it is often unclear what providers of social support do to
encourage or influence health-related behavior, including ill-
ness behavior (Thoits, 2001). In the current study, it is possible
that individuals who were stressed and felt ill had adequate
social support to handle the situation and were then less likely
to go to the doctor. Second, a measure of overall satisfaction
with social support was used and may have been too global to
capture the specific way in which social support was opera-
tional for individuals. It is possible that specific types of social
support (e.g., emotional, instrumental, informational, etc.) may
have been associated to illness behavior in this sample. These
results suggest that the impact of social support on health care
seeking behaviors is more complex than one’s report of satis-
faction/dissatisfaction alone. Perhaps specific types of social
support impact decisions to seek care or not depending on con-
text (i.e., environment and access) and other skills (i.e., coping
skills and resources). Health care providers and health educa-
tors should continue to inquire about and encourage social
support when promoting healthy behaviors and self-care. Al-
though it appears as though detailed inquiry of the type of so-
cial support is important to consider.
Results concerning negative affectivity found that partici-
pants with more illness behavior experienced more negative
emotions. Negative affectivity has been found to be strongly
correlated with reports of perceived stress and health com-
plaints (Watson et al., 1988), as well as with reports of physical
symptoms and illness (Mathis & Lecci, 1999). These results
suggest that because negative affectivity may aggravate the
effects of stress on health it is an important factor to consider
when creating interventions that target stress reduction and
health improvement. For example, Klainin (2009) found a rela-
tionship between negative affectivity, work stress, family stress,
and health outcomes in health care workers and suggests that
interventions should include strategies that promote realistic
and positive thinking. Although, it has been suggested that
negative affect could potentially influence self-report measures
of stress and health (Mathis & Lecci, 1999; Watson & Penne-
baker, 1989) and negative affectivity is often controlled for in
statistical analysis. In the current sample, it is possible that
student recall of past incidents of illness behavior may have
been biased by their current mental state as the data collection
occurred during the week before finals. Among interactions
between individuals and health care providers, recall of symp-
toms and behavior is an important part of communication about
health status. Health care providers should consider that nega-
tive affectivity may impact reporting and should explore this
with the individual. Providers should also consider that pre-
senting an individual with strategies to impact overall negative
affectivity (e.g., realistic thinking) may influence health con-
cerns and behavior.
The results regarding coping were as expected in the current
study. By in large, individuals with more illness behaviors, and
more specifically those who reported feeling ill without visiting
the doctor, implemented more avoidant coping strategies.
Avoidant coping strategies have been found to be associated
with stress, symptoms of illness, and poor health outcomes
(Dyson & Renk, 2006; Pritchard, Wilson, & Yamnitz, 2007).
These results imply that poor coping strategies may impact
self-care and subsequent decisions related to health. Tanaka,
Fukuda, Mizuno, Kuratsune, and Watanabe (2009) found that
stress and avoidant coping styles were related to severe fatigue
in medical students and suggest efforts to develop educational
training programs that reduce stress and help guide individuals
to develop efficient coping styles. Assessment of coping strate-
gies continues to have an important relationship with stress
reduction, but also with overall health.
Levels of perceived health status were found to have differ-
ent influences on the relationship between perceived stress and
each illness behavior (self-reported incidents of illness with and
without visits to the doctor). First, excellent, very good, and fair
perceived health status had minimal influence on the relation-
ship between perceived stress and illness with visits to the doc-
tor. On the other hand, individuals who were highly stressed
and viewed their overall health status as poor were less likely to
indicate that they felt ill and went to the doctor. This result did
not support the expected association between perceived poor
health status and increase in illness behaviors as others have
found (e.g., Miilunpalo et al., 1997). Second, the moderation
effect of perceived health status on perceived stress and inci-
dents of illness without a doctor visit was also unexpected and
complex. Individuals who were highly stressed and viewed
their overall health as excellent, very good, and poor were more
likely to indicate that they felt ill and did not go to the doctor.
On the other hand, those with high stress and a view of fair
health status were less likely to indicate that they felt ill and did
not go to the doctor. These results suggest that the expected
association between perceived health status and health care
seeking behavior is complicated by the inclusion of perceived
stress. Because perceived health status is affecting the per-
ceived stress and illness behavior relationship in a way that has
not been previously observed, this variable needs to be further
investigated. It is possible that the perception of health status
impacts the perception of stress, rather than the other way
Limitations and Future Research
Overall, the psychosocial factors examined in the current
study had an impact on instances of illness without visits to the
doctor and not on instances of illness with visits to the doctor.
Although, conclusions based on this fact should be done with
caution as it is probable that this outcome was measuring the
two factors of symptoms (report of being ill) and behavior (re-
port of decision to visit the doctor or not). The accuracy of
self-report data, particularly of health behaviors, is at times
questionable (Degnan et al., 1992). Among the most common is
that individuals differ with regard to the meaning attributed to
their experiences, such as those related to health center visits
J. J. THOMAS ET AL. 595
(Mathis & Lecci, 1999) and to the labeling and perception of
their symptoms (Herbert & Cohen, 1994). In this study it is not
clear what type of illness (i.e., cold, hangover) is related to the
reported behavior. In addition, other factors that influence ill-
ness-related decisions were not measured (i.e., not seeking
formal care due to over-the-counter medication use, lack of
knowledge of campus health resources). The cross sectional
nature of the data collection limits the extent to which the path
of the relationships can be discerned with certainty. A modera-
tion analysis was used to examine the strength of the relation-
ship between variables but it is possible that some of the vari-
ables were more suitable for mediation. In addition, seeking
other sources of corroborating information (i.e., health center
records, symptom diary) might have provided supporting evi-
dence to test the relationships of interest. The large sample size
allows for adequate statistical power for linear relationships but
such sample size may not have been adequate for moderation
analysis (McClelland & Judd, 1993). Although it is important
to study non-experimental relationships between stress and
illness behavior, it can be difficult to obtain large sample sizes
to detect true relationships.
The results of this study are only appropriate to generalize to
college and university students due to the unique aspects of
college life. The sample was mostly first and second year stu-
dents and the results may not apply to older and more experi-
enced individuals. However, implications for the integration of
mental health into primary care as well as the design of future
interventions might be derived from this study’s findings; spe-
cifically, to consider the impact of stress-related psychosocial
factors on healthcare seeking behavior. In the patient-centered
health home model of primary care, health care is coordinated
amongst an interdisciplinary team and individuals have in-
creased access to mental health care (DeAngelis, 2010). Based
on the results of the current study, it would be important for
individuals to be educated on the influence of avoidant coping
styles and negative affectivity on health as they may intensify
the effect of stress on illness behaviors. For example, when
individuals present with numerous physical symptoms during
medical visits healthcare providers could inquire about stress,
coping skills, and affect. Referrals could then be made to be-
havioral health specialists or counselors for skill instruction
and/or other behavioral interventions. In addition, when indi-
viduals reveal avoidant coping styles and/or negative affectivity
during a medical visit, brief behavioral health interventions (i.e.,
cognitive-behavioral strate- gies such as positive thinking, cog-
nitive restructuring) might help individuals to understand how
these factors affect each other. Such interventions could im-
prove coping and decrease negative affectivity under stressful
circumstances, and therefore positively impact health. The
evaluation of the outcomes of practice that integrate treatment
for mental and physical health will provide further support for
the role of behavioral health in primary care (DeAnglelis, 2010).
Perceived stress and its effects on health are of growing con-
cern for individuals living in fast-paced and socially demanding
societies. Therefore, it is important to provide education on the
role of psychosocial factors and to encourage individuals to use
or modify behaviors in efforts to maintain good health and de-
crease unnecessary and costly illness behaviors (Hudd et al.,
Research should continue to examine the impact of moderat-
ing factors on illness behavior specifically. The current study,
through its research design, provides evidence that the use of
multiple moderators and multiple health outcomes may provide
a more complex picture of the how psychological factors influ-
ence the stress and illness behavior relationship. Future re-
search investigating the impact of psychosocial variables on the
stress and illness behavior relationship should be as specific as
possible on what aspects of the variables are being tested in
order to discern the mechanisms through which their moderat-
ing effect operates. Future studies should also consider other
health-related behavior outcomes (e.g., health information
seeking, the use of home remedies) that may possibly be ex-
plained by the impact of certain psychosocial moderators. In
addition, future research should explore the specific aspects of
perceived health that moderate the relationship between stress
and illness behaviors to clarify the current results. The meas-
urement of illness behavior and health perception continues to
be of importance as it provides information about how indi-
viduals’ health is expressed and how it is affected by their per-
ception and behavior.
Affectivity, coping, and social support moderated the rela-
tionship between perceived stress and one illness behavior (re-
port of illness without visits to the doctor). However, perceived
health status had a significant effect on both illness behaviors
(self-reported incidents of illness with and without visits to the
doctor). Perceived health status is less commonly studied as a
potential moderator of illness behavior and further investigation
is needed. Education on the role of psychosocial factors may
empower individuals to decrease potentially unnecessary and
costly illness behaviors.
The authors would like to thank the undergraduate research
assistants at Colorado State University (CSU) who contributed
to data collection, preparation, and entry. The authors would
also like to express their gratitude to Charles Davidshofer,
Tracy Nelson-Ceschin, and Richard Suinn for serving on the
graduate committee for this project.
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