Premature Ovarian Failure (POF) is cessation of ovarian functions before the age of 40 years with consequent cessation of menstruation. The objective of study was therefore to evaluate the emotional reaction and self-efficacy of women with POF. Forty-two women confirmed to have Premature Ovarian Failure seen at the outpatient clinic of Maternity Hospital fulfilled the study criteria, were enrolled into the study. Another group of 42 healthy women formed the control group. The instrument of data collection included three types of questionnaires to assess the depth of emotional reaction to the diagnosis of POF including the subjects’ biodata, modified Health Orientation Scale (HOS) and Stanford Chronic Disease Self-Efficacy Scale. The women with POF presented at the clinic with infertility ( P < 0.01), amenorrhea ( P < 0.01) and hot flashes ( P < 0.05). The diagnosis of ovarian insufficiency was a traumatic life event similar to bereavement (grieving of no obvious loss to others), with high level of anxiety, depression, fear of divorce, lower life satisfaction and impaired self-esteem. Fertility was generally of profound concern to all of them, because fertility was a societal landmark of womanhood and youth. The Stanford Chronic Self Efficacy scores were generally low (below 7) in coping with emotion reaction to loss of fertility, loss of menstruation, loss of self-esteem and other significant emotional reactions. The present study has demonstrated that Premature Ovarian Failure is associated with severe emotional distress and impaired ability to cope with them especially low self-esteem. A multidisciplinary management team is advocated for POF.
Premature ovarian failure (POF) (also known as hyper gonadotropic hypogonadism), premature ovarian failure, and premature menopause) involves the cessation of normal ovarian function before age 40 [
Learning of the diagnosis of ovarian insufficiency is a traumatic life event similar to bereavement, with high level of depression, lower life satisfaction and impaired self-esteem. Loss of fertility potential was usually of profound concern [
The diagnosis of POF is associated with high level of depression, lower life satisfaction and impaired self- esteem. Fertility is generally of profound concern to most women with POF, because fertility is a societal landmark of womanhood and youth. Groff et al. [
Self-efficacy according to Bandura [
To evaluate the emotional reaction of women with Premature Ovarian Failure/Primary Ovarian Insufficiency in Kuwait.
The primary hypotheses to be tested were: 1) Compared to healthy controls, women with POF will report prior menstrual irregularity, less successful marital union, infertility and 2) More emotional affective reactions, lower levels of self-esteem, and 3) Low levels of perceived social support and self-esteem score levels.
The study was approved by the Maternity Hospital, Kuwait, Institutional Review Board.
We recruited women with spontaneous 46, XX Premature Ovarian Failure that were seen at the General Outpatient and Infertility clinics of Maternity Hospital, Kuwait. The eligibility criteria included:
1. Women with previously known ovarian function and were previously menstruating
2. Women previously healthy and active
3. Women with cessation of menstruation for at least 4 - 6 months
4. Hormone profile revealed high FSH (≥40 IU/L), high LH (≥28 IU/L and low estradiol (≤100 pmol/L) and Anti-Mullerian Hormone (≤4.8 mg/L).
1) Exclusion criteria
Women with Premature Ovarian Failure/primary ovarian insufficiency as a result of surgery, radiation, chemotherapy, or known karyotype abnormalities were not included.
2) Controls
1. They were between the ages of 18 and 39 years,
2. Healthy, free of chronic disease, not pregnant,
3. Regularly menstruating (cycles between 22 and 35 days).
3) Ethical considerations
The Institutional Review Board of the Maternity Hospital, Kuwait approved the study. Verbal informed consent was obtained from all participants.
4) Clinical Evaluation
Prior menstrual irregularity and amenorrhea of at least 4 - 6 months (as detailed in Questionnaire 1) associated with two serum FSH levels in the menopausal range (FSH ≥40 IU/L were required for diagnosis of Premature Ovarian Failure 1.
5) Interviews
All interviews were conducted between September 2010 and August 2015 when the patients attended the clinic for consultation either on referral from the polyclinic or direct referral by colleagues, after establishing eligibility for this study. This was certainly based on the informant’s willingness to participate in the study and her ability to converse in English or Arabic languages. In a few cases, translators were sought for when the patient spoke any other language. Although the setting was in the combined infertility clinic, the women were interviewed without their husbands before seeing the medical team. The interviews in languages other than English language were taped, transcribed and translated into English. Patients who were eligible were given three questionnaires.
Questionnaire No. 1: This include the biodata of each women with POF in five sections:
(A) General Data, (B) Lifestyle, (C) OB-GYN History, (D) Past Medical History, and (E) Comprehensive Physical Examination. The age, marital and educational status and occupation including that of the husband, and smoking (cigarette and sheesha) and alcohol consumption habits were documented. The obstetric and gynecological history included pubertal developmental milestones especially age at menarche and other sexual characteristics and menstrual history including cyclicity and any abnormality especially oligomenorrhea and amenorrhea with hot flushes and night sweats and parity and mode of delivery and outcome and infertility were collated. Any medical and surgical disorder or intervention were documented. Physical examination included blood pressure, body mass index (BMI) and full system evaluation.
Questionnaire No. 2: This questionnaire was designed internally in the infertility unit but mainly derived from the Health Orientation Scale (HOS) (Snell et al. 1991). This is a short, reliable, and easily used instrument to determine the intensity of the participant bodily fatigue. Higher scores indicate a higher intensity of affective emotional reaction.
The scale we used consists of 15 questions aimed at obtaining subjective information regarding emotional reactions. The affective reactions to POF included fear of childlessness, anxiety, depression, worry about possibility of divorce and loneliness especially if they remain single or divorced. Other emotional concerns evaluated with this scale include grief, poor concentration, labile moods, aggression, irritability and fatigue.
We used the scale derived from the Health Orientation Scale (HOS) to assess the psychological reaction of women to a diagnosis of Premature Ovarian Failure (POF).
Instructions to participants/respondents
The items listed below refer to people’s reaction to the diagnosis of premature Ovarian Failure. Please read each item carefully and decide to what extent it is characteristic of you. Give each item a rating of how much it applies to you by using the following scale:
1) = Not at all characteristic of me.
2) = Slightly characteristic of me.
3) =Somewhat characteristic of me.
4) = Moderately characteristic of me.
5) =Very characteristic of me. (see Appendix 1)
Questionnaire 3. Stanford Chronic Disease Self-Efficacy Scale was used to assess how the women with premature ovarian failure coped with Emotional reactions. These scales were developed and tested for the Chronic Disease Self-Management study. The 6-item scale contains items taken from several self-efficiency scales developed for the Chronic Disease Self-Management study [
For example (see Appendix 2)
We analyzed fully completed questionnaires only. We tested comparisons with the Wilcoxon Rank Sum, proportions by Chi Square, and correlations with the Spearman Rank Order. We report results as mean (SD) or median (range). The correlation among variables in each set of emotional reaction to POF was calculated using the Spearman and Pearson lineal correlation coefficients, respectively (significant correlation was considered at significance level < 0.05).
As shown in
The POF study group was significantly associated with spinsterhood and divorce (P < 0.05). Similarly, more women with POF had only primary education (P < 0.05). The main reasons for the clinic consultation included
Variables | POF N = 42 (%) | Healthy Women N = 42 (%) | P value | |
---|---|---|---|---|
1. | Age (years) 20 - 29 30 - 39 | 19 (45.2) 23 (54.8) | 18 (42.9) 24(57.1) | NS NS |
2 | Marital Status Single Married Divorced | 13 (30.9) 19 (45.2) 10 (23.8) | 4 (9.5) 35 (83.3) 3 (7.1) | 0.05 0.05 0.05 |
3 | Education Primary Secondary University | 8 (19.1) 26 (61.9) 8 (19.1) | 3 (7.1) 22 (52.4 ) 17 (40.5) | 0.05 0.9 0.05 |
4 | Parity 0 1 - 3 | 26 (61.9) 16 (38.1) | 6 (14.3) 36 (64.3) | 0.01 0.05 |
5 | Presenting Symptoms Oligomenorrhea Infertility Primary Secondary Hot Flashes Night Sweats | 34 (81.0) 31 (73.8) 15 (37.5) 16 (38.1) 30 (71.4) 23 (54.8) | 6 (14.3) 9 (21.4) 3 (7.1) 6 (14.3) 3 (7.1) 4 (9.5) | 0.01 0.05 0.05 0.05 0.01 0.05 |
presenting symptoms included oligomenorrhoea (81%), infertility (74%), uncomfortable hot flashes (71%) and night sweats (55%) and dyspareunia like women at natural menopause. The diagnosis was discussed with them after the results of their hormone profile. All the women admitted that all these conditions gave them tremendous distress.
The items on the anxiety subscale refer to anxious feelings associated with the status of one’s health. More directly, these items were designed to emphasize the patient’s feelings of tension, discomfort and anxiety about their physical health and consequences of premature ovarian failure. People who endorse these items are those who experience chronic anxiety as a result of thinking about their physical health and consequences of premature ovarian failure. Fear of childlessness or loss of fertility and associated anxiety alternating with depression were more common in women with premature ovarian failure compared to control (P < 0.01).
Although depression set in later, it was quite significant, with the concern of possibility of the husband asking for divorce and marrying a younger and healthy wife (P < 0.05). Fear of loneliness, grief and poor concentration were also common. About 43% of the women felt guilty and regretted not getting married earlier when they were having regular menstrual periods. About a third of the women had labile mood. One of the graduates with POF described it as having bipolar nature. Another woman threatened to kill herself and the husband if the latter tried to marry another woman. During the study period, there were three single women who became engaged but had no intention of divulging the nature of their fertility potential to their fiances.
Using the Spearman’s coefficient, loss of fertility, anxiety, depression, concerns and fear of divorce and poor concentration were all expressed significantly high levels and ultimately lead to loss of self-esteem.
Majority of the patients in this study identified the following ten major reactions when they were diagnosed with POI: anxiety, depression, anger, fear of divorce, loss of self-esteem, loss of femininity and youth, loss of ability to have children, fear of disease, loss of social contacts, problem of communication with physician and family.
Thematic analysis of emotional reaction was done providing relevant themes for the adaptation of the Stanford Chronic Disease Self-Efficacy Scale [
Variables | POF Women Number = 42 | Healthy Women Number = 42 | P value |
---|---|---|---|
Fear of Childlessness | 31 (73.8) | 5 (11.9) | 0.01 |
Anxiety | 31 (73.8) | 7 (16.7) | 0.01 |
Depression | 28 (66.7) | 8 (19.1) | 0.05 |
Worry of Divorce | 28 (66.7) | 4 (9.5) | 0.05 |
Loneliness | 24 (57.1) | 8 (19.1) | 0.05 |
Grief | 18 (42.9) | 7 (16.7) | |
Poor Concentration | 18 (42.9) | 6 (14.3) | 0.05 |
Guilt | 18 (42.9) | 4 (9.5) | 0.05 |
Regret | 15 (35.7) | 2 (4.8) | 0.05 |
Labile Moods | 14 (33.3) | 2 (4.8) | 0.05 |
Aggression | 12 (28.6) | 3 (7.1) | 0.05 |
Irritability | 12 (28.6) | 4 (9.5) | NS |
Fatigue | 8 (19.1) | 3 (7.1) | NS |
1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | |
---|---|---|---|---|---|---|---|---|---|---|
1 | 0.864 | |||||||||
2 | 0.654 | 0.782 | ||||||||
3 | 0.722 | 0.544 | 0.434 | |||||||
4 | 0.824 | 0.648 | 0.564 | 0.446 | ||||||
5 | 0.242 | 0.123 | 0.112 | 0.084 | 0.224 | |||||
6 | 0.446 | 0.432 | 0.242 | 0.118 | 0.246 | 0.224 | ||||
7 | 0.126 | 0.065 | 0.212 | 0.216 | 0.128 | 0.084 | 0.242 | |||
8 | 0.548 | 0.128 | 0.126 | 0.234 | 0.098 | 0.324 | 0.222 | 0.118 | ||
9 | 0.476 | 0.562 | 0.128 | 0.234 | 0.224 | 0.442 | 0.466 | 0.322 | 0.234 | |
10 | 0.642 | 0.484 | 0.568 | 0.436 | 0.464 | 0.542 | 0.442 | 0.543 | 0.646 | 0.454 |
1 = Fear of Childlessness. 2 = Anxiety. 3 = Depression. 4 = Worry of divorce. 5=Loneliness. 6 = Grief. 7 = Poor concentration. 8 = Guilt. 9 = Regret. 10 = Aggression. *Spearman’s coefficient ≥ 0.300 P < 0.05.
Variable | No of Subjects | No of Items | Scale range | Mean | Standard deviation | Internal Const. reliability | Retest Reliability |
---|---|---|---|---|---|---|---|
Anxiety | 42 | 3 | 1 - 10 | 8.72 | 1.40 | 0.64 | 0.72 |
Depression | 42 | 6 | 1 - 10 | 5.28 | 2.12 | 0.74 | 0.78 |
Anger | 42 | 4 | 1 - 10 | 4.64 | 2.20 | 0.72 | 0.68 |
Fear of Divorce | 42 | 2 | 1 - 10 | 7.24 | 1.80 | 0.78 | 0.80 |
Loss of self esteem | 42 | 2 | 1 - 10 | 6.44 | 2.24 | 0.72 | 0.68 |
Loss of Social contacts | 42 | 3 | 1 - 10 | 4.32 | 1.60 | 0.74 | 0.78 |
Loss of Menstruation | 42 | 5 | 1 - 10 | 6.22 | 1.28 | 0.78 | 0.76 |
Loss of fertility | 42 | 3 | 1 - 10 | 6.48 | 2.48 | 0.82 | 0.84 |
Communication with Physician | 42 | 3 | 1 - 10 | 7.48 | 2.82 | 0.72 | 0.72 |
Obtain help from close relatives | 42 | 2 | 1 - 10 | 6.22 | 2.62 | 0.72 | 0.82 |
fear of divorce, Self esteem, and obtaining help subscale measure the extent to which people derive a sense of esteem from their affective reaction, and the extent to which they feel confident about their diagnosis of premature ovarian failure. More specifically, these items are concerned with how positive individuals feel about their physical wellness. People who endorse these items are those who feel good about the health status of their bodies; they feel positive esteem about their health and they have an air of confidence that their health is robust and durable.
Apart from anxiety, all the coping scores were low at about 7 and below, thus showing they were unable to cope with loss of self-esteem, loss of fertility, menstruation and other associated disorders, such as ability to seek help from close relative and with ability to communicate with their physician are issues in which they have coping impairment
The present study has demonstrated that emotional reaction to the diagnosis of POF is common in Kuwait. Majority of the patients in the present study identified the following ten major reactions when they were diagnosed with POI: anxiety, depression, anger, fear of divorce, loss of self-esteem, loss of femininity and youth, loss of ability to have children, fear of disease, loss of social contacts, problem of communication with physician and family. These reactions are similar to those reported by Mann et al. [
The present study did not evaluate strategies of intervention to ameliorate the emotional reaction to POF. An integrated approach to the management of POF as advocated by the National Institute of Health on POF [
The patient should be counselled about self-care and validation of her feelings and confirm self-worth and reduce low self-esteem [
Rafique and research team [
1. A major limitation of this study is the small sample size. In future it will be commendable to study a large number of women with premature ovarian failure through a multicenter study design.
2. There was no intervention in the present study. Evaluation of the role of spirituality through the inclusion of Islam and Christianity will be of clinical interest.
Premature Ovarian Failure is associated with severe emotional reactions and pose significant psychological difficulty for a sizeable proportion of those who have the condition, with impaired ability to cope with their low self-esteem. Management should involve a multi-disciplinary and holistic approach in which the provision of psychological care should be an integral part of clinical management. Affected women need an effective support system to help them come to terms with their diagnosis.
The authors declare no conflict of interest in the present study.
F. E.Omu,A. A. M.El Biaa,A. A.Ghafour,I. T.Gadalla,A. E.Omu, (2016) Emotional Impacts of Premature Ovarian Failure in Kuwait. Health,08,262-278. doi: 10.4236/health.2016.83028
Scale 2.
HEALTH ORIENTATION SCALE (HOS)
INSTRUCTIONS: The items listed below refer to people’s health. Please read each item carefully and decide to what extent it is characteristic of you. Give each item a rating of how much it applies to you by using the following scale:
A = Not at all characteristic of me.
B = Slightly characteristic of me.
C = Somewhat characteristic of me.
D = Moderately characteristic of me.
E = Very characteristic of me.
NOTE:
Remember to respond to all items, even if you are not completely sure.
Your answers will be kept in the strictest confidence.
Also, please be honest in responding to these statements.
1. I am very aware of how healthy my body feels.
2. I sometimes wonder what others think of my physical health.
3. I feel anxious when I think about my health.
4. I feel confident about the status of my health.
5. I do things that keep me from becoming physically unhealthy.
6. I’m very motivated to be physically healthy.
7. I feel like my physical health is something that I myself am in charge of.
8. The status of my physical health is determined mostly by chance happenings.
9. I expect that my health will be excellent in the future.
10. I am in good physical health.
11. I notice immediately when my body doesn’t feel healthy.
12. I’m very concerned with how others evaluate my physical health.
13. I’m worried about how healthy my body is.
14. I rarely become discouraged about my health.
15. I am motivated to keep myself from becoming physically unhealthy.
16. I’m strongly motivated to devote time and effort to my physical health.
17. My health is something that I alone am responsible for.
18. The status of my physical health is controlled by accidental happenings.
19. I believe that the future status of my physical health will be positive.
20. My body is in good physical shape.
21. I’m sensitive to internal bodily cues about my health.
22. I’m very aware of what others think of my physical health.
23. Thinking about my health leaves me with an uneasy feeling.
24. I am pleased with how well and healthy I feel.
25. I try to avoid engaging in behaviors that undermine my physical health.
26. I have a strong desire to keep myself physically healthy.
27. The status of my physical health is determined largely by what I do (and don’t do).
28. Being in good physical health is just a matter of luck.
29. I do not expect to suffer health problems in the future.
30. I am a well-exercised person.
31. I know immediately when I’m not feeling in great health.
32. I’m concerned about how my physical health appears to others.
33. I usually worry about whether I am in good health.
34. I have positive feeling about my health.
35. I really want to prevent myself from getting out of shape.
36. It’s really important to me that I keep myself in proper physical health.
37. What happens to my physical health is my own doing.
38. Being in excellent physical shape has little or nothing to do with luck.
39. I will probably experience a number of health problems in the future.
40. My body needs a lot of work in be in excellent physical shape.
41. I’m very aware of changes in my physical health.
42. I’m concerned about what other people think of my physical health.
43. I feel nervous when I think about the status of my physical health.
44. I feel that I have handled my health very well.
45. I am really motivated to avoid being in terrible physical shape.
46. I strive to keep myself in tip-top physical shape.
47. Being in good physical health is a matter of my own ability and effort.
48. I don’t believe that chance or luck play any role in the status of my physical health.
49. I anticipate that my physical health will deteriorate in the future.
50. My physical health is in need of attention.
Copyright-1996
Scoring Instructions for the Health Orientation Scale (HOS)
The Health Orientation Scale (HOS) consists of10 health-oriented subscales, each containing five items.
The labels, descriptions, and items for each of these subscales are listed below:
1. Personal Health Consciousness: The items on the Personal Health Consciousness (PHC) subscale refer to an awareness of one’s health. These items were designed to measure people’s tendency to think about and to reflect about their health. People who endorse these items are those who think about that status of their physical health, and who in general are reflective about the nature of the health and wellness of their body.
1. I am very aware of how healthy my body feels.
11. I notice immediately when my body doesn’t feel healthy.
21. I’m sensitive to internal bodily cues about my health.
31. I know immediately when I’m not feeling in great health.
41. I’m very aware of changes in my physical health.
2. Health Image Concern: The items on the Health Image Concern (HIC) subscale refer to an awareness of other people’s reactions to one’s health. More specifically, these items were designed to measure people’s public concern about the image which their health (or lack thereof) projects to others. People who endorse these items are those who are concerned about the appearance of their health to others, the impression their health makes on others, and how healthy and well others consider them to be.
2. I sometimes wonder what others think of my physical health.
12. I’m very concerned with how others evaluate my physical health.
22. I’m very aware of what others think of my physical health.
32. I’m concerned about how my physical health appears to others.
42. I’m concerned about what other people think of my physical health.
3. Health Anxiety: The items on the Health Anxiety (HA) subscale refer to anxious feelings associated with the status of one’s health. More specifically, these items were designed to tap people’s feelings of tension, discomfort and anxiety about their physical health. People who endorse these items are those who experience chronic anxiety as a result of thinking about their physical health.
3. I feel anxious when I think about my health.
13. I’m worried about how healthy my body is.
23. Thinking about my health leaves me with an uneasy feeling.
33. I usually worry about whether I am in good health.
43. I feel nervous when I think about the status of my physical health.
4. Health-Esteem and Confidence: The items on the Health-Esteem and Confidence (HEC) subscale were designed to measure the extent to which people derive a sense of esteem from the physical status of their body, and the extent to which they feel confident about their physical health. More specifically, these items are concerned with how positive individuals feel about their physical wellness. People who endorse these items are those who feel good about the health status of their bodies; they feel positive esteem about their health and they have an air of confidence that their health is robust and durable.
4. I feel confident about the status of my health.
14. I rarely become discouraged about my health. (R)
24. I am pleased with how well and healthy I feel.
34. I have positive feeling about my health.
44. I feel that I have handled my health very well.
5. Motivation to Avoid Unhealthiness: The items on the Motivation to Avoid Unhealthiness (MAU) subscale refer to motivational tendency to avoid being or becoming unhealthy. More specifically, these items were designed to measure people’s motivational tendency to avoid poor physical health. People who endorse these items are those who are concerned about becoming unhealthy; they are motivated to avoid behaviors and activities which undermine their physical health.
5. I do things that keep me from becoming physically unhealthy.
15. I am motivated to keep myself from becoming physically unhealthy.
25. I try to avoid engaging in behaviors that undermine my physical health.
35. I really want to prevent myself from getting out of shape.
45. I am really motivated to avoid being in terrible physical shape.
6. Motivation for Healthiness: The items on the Motivation for Healthiness (MFH) subscale refer to the motivation to pursue positive physical health. More specifically, these items were designed to measure people’s motivation to keep in excellent physical health. People who endorse these items are those who are motivated to attend to the physical health of their body, to engage in activities which promote their physical health, and to strive to maintain the wellness and integrity of their physical health.
I’m very motivated to be physically healthy.
I’m strongly motivated to devote time and effort to my physical health.
26. I have a strong desire to keep myself physically healthy.
36. It’s really important to me that I keep myself in proper physical health.
46. I strive to keep myself in tip-top physical shape.
7. Health Internal Control: The items on the Internal Health Control (IHC) subscale refer to people’s belief that their health status is determined by their own personal control. More specifically, these items were designed to measure people’s expectation that they themselves can exert an influence on their health. People who endorse these items are those who believe that they can determine whether their physical health is positive or negative.
7. I feel like my physical health is something that I myself am in charge of.
17. My health is something that I alone am responsible for.
27. The status of my physical health is determined largely by what I do (and don’t do).
37. What happens to my physical health is my own doing.
Being in good physical health is a matter of my own ability and effort.
8. Health External Control: The items on the External Health Control (EHC) subscale refer to people’s belief that their health status is determined by experiences and influences outside of their personal control. More specifically, these items were designed to measure people’s expectation that their health status is largely determined by forces which they themselves can neither anticipate nor influence. People who endorse these items are those who believe that their health is not controlled by themselves rather that their physical health is under the influence of factors external to themselves.
8. The status of my physical health is determined mostly by chance happenings.
18. The status of my physical health is controlled by accidental happenings.
28. Being in good physical health is just a matter of luck.
38. Being in excellent physical shape has little or nothing to do with luck. (R)
48. I don’t believe that chance or luck play any role in the status of my physical health. (R)
9. Health Expectations: The items on the Health Expectations (HE) subscale refer to an expectation that one will continue to experience positive physical health in the future. More specifically, these items were designed to measure people’s belief that their health will continue to be excellent and robust. People who endorse these items anticipate that their future physical health will continue to be good.
9. I expect that my health will be excellent in the future.
19. I believe that the future status of my physical health will be positive.
29. I do not expect to suffer health problems in the future.
39. I will probably experience a number of health problems in the future. (R)
49. I anticipate that my physical health will deteriorate in the future. (R)
10. Health Status: The items on the Health Status (HS) subscale concerns people’s assessment of the physical status of their body. More specifically, these items were designed to measure the extent to which people assess their body as being in excellent and robust health. People who endorse these items believe that they are in excellent physical health.
10. I am in good physical health.
20. My body is in good physical shape.
30. I am a well-exercised person.
40. My body needs a lot of work in be in excellent physical shape. (R)
50. My physical health is in need of attention. (R)
The Development and Validation of the Health Orientation Scale:
A Measure of Personality Tendencies Associated with Health
ABSTRACT
In recent years a number of investigators have begun to examine the impact of people’s personality tendencies on their physical health. The present investigation sought to further explore this issue through the development and validation of an objective self-report instrument designed to measure multiple aspects of people’s health-related personality tendencies. Reliability analyses provided evidence of internal consistency for the subscales on the Health Orientation Scale (HOS). Other results indicated that both gender and age jointly influenced people’s responses to the Health Orientation Scale. A final set of results revealed that the personality variables measured by the Health Orientation Scale were predictive of women’s and men’s compliance with actual health-promoting behaviors. The discussion focuses on the potential uses of the Health Orientation Scale in both research and applied settings.
Discussion
The purpose of the present investigation was to construct and validate an objective self-report measure of several health-related personality features: private health consciousness, defined as the tendency to be highly aware of and to think about one’s physical health-fitness; health image concern, defined as the tendency to be highly aware of the external, observable impression that one’s physical health makes on others; health anxiety, defined as the tendency to be anxious and nervous about one’s physical health-fitness; health esteem-confidence, defined as a generalized tendency to positively evaluate and to feel confident about one’s physical health; motivation to avoid unhealthiness, defined as the motivation and desire to avoid being in a state of unhealthiness; motivation for healthiness, defined as the motivational tendency and desire to keep oneself in great physical health; internal health control, defined as the tendency to believe that one’s physical health and fitness is a direct function of one’s own behaviors and actions; external health control, defined as the tendency to believe that one’s health status is determined by uncontrollable factors factors external to oneself; health expectations, defined as the tendency to expect that one’s health will be excellent and positive in the future; and health status, defined as the tendency to regard oneself as being currently well-exercised and in good physical shape. The measurement of these health-related personality tendencies was accomplished through the development of the Health Orientation Scale (HOS).
Reliability analyses confirmed that all ten subscales on the Health Orientation Scale possessed clearly acceptable levels of internal reliability. Additional findings indicated that men reported more internal health control than did women, and that they also tended to report higher scores on the health esteem-confidence and health status subscales than women. This indicates that the men in the present study believed they had more personal control of their physical health-fitness than did the women. In addition, the men in the present study tended to derive a greater sense of esteem from their physical health than did the women, and they tended to report being in better physical health. Several age related finding were also reported in this investigation. Older individuals expressed less concern than did younger and middle-age individuals about the public impression which their physical health creates. In addition, older individuals reported less anxiety about their physical health and less motivation for healthiness than did both younger and middle-age people. These findings corroborate earlier evidence reported by Bausell (1986) that there is a need for health promotion activities among older persons. Age was also found to interact with gender in predicting people’s scores on the Health Orientation Scale (HOS). Middle-age males and older females expressed the strongest belief that their physical health was predominantly influenced by factors external to their own personal control.
Future research is needed, however, to clearly understand the nature of this finding. Middle-age males, for example, may be spending so much time and effort at career development that it interferes with the promotion of their physical health―and thus they develop an external locus of control orientation toward their physical health. In addition, older males may have already established themselves in their careers or else they may have already retired from their jobs, with the result that excessive career dedication no longer fosters an external orientation toward the control of their physical health. Certainly these are interesting ideas that need to be investigated in future work that focuses on both working men and women. Two other age related findings were found among the men and women examined in the present research. Among males, those who were younger reported the greatest motivation for healthiness and the greatest motivation to avoid unhealthiness. These young males may have reported this health motivation because of an interest in attracting members of the other gender through a healthy physical appearance. Whatever the true explanation, this finding underscores the need for greater health promotion among middle-age and older males, both of whom seemed to be the least interested in the maintenance of their physical health. Interestingly, middle-age women also reported a high level of motivation for healthiness and a high level of motivation to avoid unhealthiness, suggesting that younger and older women are especially in need of information about their physical health. Perhaps middle-age women are more knowledgeable about behaviors that contribute to physical health and thus they are more motivated to take care of themselves. Alternatively, it could be that as women approach middle-age they become more concerned about their physical appearance and the physiological implications of the aging process itself, which in turn could lead to greater motivation for healthiness and greater motivation to avoid unhealthiness. While these explanations seem possible, still future research is needed to more closely examine their plausibility.
The present investigation also provided evidence for the validity for the subscales on the Health Orientation Scale. Both men and women who reported higher scores on the motivation for healthiness and the motivation to avoid unhealthiness subscales were found to engage in a wide variety of dietary and life-style behaviors that contribute to good physical health and fitness. Further evidence for the validity of the Health Orientation Scale was indicated by the findings that internal health control was positively associated and that external health control was negatively associated with compliance to a number of health-seeking behaviors. These findings are consistent with those found for the Multidimensional Health Locus of Control Scales (Wallston, Wallston, & DeVellis, 1978). People who believe that they themselves are the primary determinants of their health status are more likely to take control of their life in a way that contributes to the avoidance of health risks and to the promotion of health sustaining behaviors. For example, in the present investigation both men and women who had an internal health control orientation reported that they watched their weight and exercised in a routine fashion. These findings provide clear evidence that the study of the psychological tendencies assessed by the Health Orientation Scale can add to our understanding of the determinants of healthy behaviors.
Permission is granted to individuals to use the Health Orientation Scale (HOS) for research purposes. Permission granted by William E. Snell, Jr. on February 18, 1997.
Chronic Disease Self-Efficacy Scales
We would like to know how confident you are in doing certain activities. For each of the following questions, please choose the number that corresponds to your confidence that you can do the tasks regularly at the present time.
Scales/Items (using the same format as above):
Self-Efficacy to Perform Self-Management Behaviors
Exercise Regularly Scale
1. How confident are you that you can do gentle exercises for muscle strength and flexibility three to four times per week (range of motion, using weights, etc.)?
2. How confident are you that you can do aerobic exercise such as walking, swimming, or bicycling three to four times each week?
3. How confident are you that you can exercise without making symptoms worse?
Get Information About Disease Item
1. How confident are you that you can get information about your disease from community resources?
Obtain Help from Community, Family, Friends Scale
1. How confident are you that you can get family and friends to help you with the things you need (such as household chores like shopping, cooking, or transport)?
2. How confident are you that you can get emotional support from friends and family (such as listening or talking over your problems)?
3. How confident are you that you can get emotional support from resources other than friends or family, if needed?
4. How confident are you that you can get help with your daily tasks (such as housecleaning, yard work, meals, or personal hygiene) from resources other than friends or family, if needed?
Communicate With Physician Scale
1. How confident are you that you can ask your doctor things about your illness that concerns you?
2. How confident are you that you can discuss openly with your doctor any personal problems that may be related to your illness?
3. How confident are you that you can get work out differences with your doctor when they arise?
General Self-Efficacy
Manage Disease in General Scale
1. Having an illness often means doing different tasks and activities to manage your condition. How confident are you that you can do all the things necessary to manage your condition on a regular basis?
2. How confident are you that you can judge when the changes in your illness mean you should visit a doctor?
3. How confident are you that you can do the different tasks and activities needed to manage your health condition so as to reduce your need to see a doctor?
4. How confident are you that you can reduce the emotional distress caused by your health condition so that it does not affect your everyday life?
5. How confident are you that you can do things other than just taking medication to reduce how much your illness affects your everyday life?
Self-Efficacy to Achieve Outcomes
Do Chores Scale
1. How confident are you that you can complete your household chores, such as vacuuming and yard work, despite your health problems?
2. How confident are you that you can get your errands done despite your health problems?
3. How confident are you that you can get your shopping done despite your health problems?
Social/Recreational Activities Scale
1. How confident are you that you can continue to do your hobbies and recreation?
2. How confident are you that you can continue to do the things you like to do with friends and family (such as social visits and recreation)?
Manage Symptoms Scale
1. How confident are you that you can reduce your physical discomfort or pain?
2. How confident are you that you can keep the fatigue caused by your disease from interfering with the things you want to do?
3. How confident are you that you can keep the physical discomfort or pain of your disease from interfering with the things you want to do?
4. How confident are you that you can keep any other symptoms or health problems you have from interfering with the things you want to do?
5. How confident are you that you can control any symptoms or health problems you have so that they don’t interfere with the things you want to do?
a) Manage Shortness of Breath Item
1. How confident are you that you can keep your shortness of breath from interfering with what you want to do?
Control/Manage Depression Scale
1. How confident are you that you can keep from getting discouraged when nothing you do seems to make any difference?
2. How confident are you that you can keep from feeling sad or down in the dumps?
3. How confident are you that you can keep yourself from feeling lonely?
4. How confident are you that you can do something to make yourself feel better when you are feeling lonely?
5. How confident are you that you can do something to make yourself feel better when you are feeling discouraged?
6. How confident are you that you can do something to make yourself feel better when you feel sad or down in the dumps?
Scoring
The score for each item is the number circled. If two consecutive numbers are circled, code the lower number (less self-efficacy). If the numbers are not consecutive, do not score the item. The score for each scale is the mean of the items. For scales of 1 - 2 items, do not score the scale if any item is missing; for scales with 3-4 items, do not score the scale if more than 1 item is missing; for scales with 5 - 6 items, do not score the scale if more than 2 items are missing. Higher number indicates higher self-efficacy.
Characteristics
Source of Psychometric Data
Stanford Chronic Disease Self-Management Study. Psychometrics reported in: Lorig, K., Stewart, A., Ritter, P., González, V., Laurent, D. and Lynch, J. (1996) Outcome Measures for Health Education and other Health Care Interventions. Sage Publications, Thousand Oaks, 24-25, 41-45.
Comments
These scales were developed and tested for the Chronic Disease Self-Management study. We use a shorter, 6-item scale now, as it is much less burdensome for subjects.
References