Prevention and Health Promotion: Research, Social Action, Practice And Training: Volume 7, Issue 1 1

Prevention and Health Promotion: Research, Social Action, Practice and Training is a publication of the Prevention Section of
the Society for Counseling Psychology. The publication is dedicated to the dissemination of information on prevention theory,
research, practice and training in counseling psychology, stimulating prevention scholarship, promoting collaboration between
counseling psychologists engaged in prevention, and encourages student scholars. The publication focuses on prevention in specific
domains (e.g., college campuses) employing specific modalities (e.g., group work), and reports summaries of epidemiological and
preventive intervention research. All submissions to the publication undergo blind review by an editorial board jury, and those
selected for publication are distributed nationally through electronic and hard copies.

Editor
Julie M. Koch, Oklahoma State University

Editorial Board Chair

Sally M. Hage, Springfield College

Members of the Editorial Board

Aimee Arikian, The Emily Program
Kimberly Burdine, Texas Tech University
Stephanie Chapman, Baylor College of Medicine
Robert Conyne, University of Cincinnati
Simon Chung, Toronto, Canada
Michael Gale, University at Albany
Arthur Horne, University of Georgia
LeRoy Reese, Morehouse School of Medicine
Chandra Story, Oklahoma State University
Ellen Vaughan, Indiana University

Editorial Assistants
Fae Frederick, Oklahoma State University
Brenda Martin-Tousignant, Springfield College

Submission Guidelines
The Prevention Section of the Society of Counseling Psychology publishes Prevention and Health Promotion: Research, Social
Action, Practice and Training. This is a blind peer-reviewed publication presenting scholarly work in the field of prevention that is
distributed nationally. Contributions can focus on prevention theory, research, practice or training, or a combination of these topics.
We welcome student submissions. As a publication of the Prevention Section of Division 17, presentations and awards sponsored by
the section will be highlighted in these issues. We will also publish condensed reviews of research or theoretical work pertaining to the
field of prevention. All submissions need to clearly articulate the prevention nature of the work. Submissions to this publication need
to conform to APA style. All submissions must be electronically submitted. Please send your documents prepared for blind review
with a cover letter including all identifying information for our records. Submissions should be emailed to Julie Koch, Managing
Editor, at julie.koch@okstate.edu.

Prevention and Health Promotion: Research, Social Action, Practice And Training: Volume 8, Issue 1 2
 PREVENTION AND HEALTH PROMOTION
RESEARCH, SOCIAL ACTION, PRACTICE AND TRAINING
From Science to Practice: Race-Related Trauma, Maternal Well-Being and Emotional Distress
Among African American Women During Pregnancy and Postpartum
Lekeisha A. Sumner, Norma Scarborough, Vivian L. Tamkin 4

Symptoms of Polycystic Ovary Syndrome: Self-Esteem, Distress, and Quality of Life in College
Women
Signe S. Simon, Merle A. Keitel, Molly Brawer, Melda S. Uzun 14

A Structural Equation Model Examining Multiple Mediation Pathways between Age, Gender,
Social Support, Exercise Self-Efficacy, and Physical Activity
Kelly A. Cotter, Nicole G. Lancaster 28

The Relationship between Paperwork and Quality of Mental Health Care

Christopher T. Copeland, Bela Geczy, Thomas W. Westerling III 43

Prevention and Health Promotion: Research, Social Action, Practice And Training: Volume 8, Issue 1 3
 RESEARCH, SOCIAL ACTION, PRACTICE AND TRAINING

From Science to Practice: Race-Related Trauma, Maternal Well-Being and

Emotional Distress Among African American Women During Pregnancy and
Postpartum
Lekeisha Sumner Norma Scarborough
Alliant International University Vivian Tamkin
University of California Los Angeles Alliant International University

Correspondence concerning this article should be addressed to Lekeisha A. Sumner Ph.D., ABPP, Alliant International
University, Los Angeles CA. E-mail: LSumner@alliant.edu

Abstract
Maternal and child health is a public health concern.
Given the influence of psychological and social factors in
pregnancy outcomes, psychotherapists have much to offer in
improving the health outcomes of these populations. Despite
this capacity, there remains a paucity of clinically based
discussions that have considered psychosocial and cultural
constructs in addressing maternal health in psychotherapeutic
settings, especially among African American women who
suffer higher rates of adverse pregnancy outcomes relative to
women of other ethnic and racial groups. As the healthcare
model continues to place greater emphasis on preventive
health, it is imperative that mental health professionals
develop increased familiarity with the contributions of
psychosocial factors and ethnic-specific stressors in maternal
health in this population and consider these factors when
conceptualizing and addressing concerns within the
therapeutic context. As such, this article aims to advance
knowledge of maternal mental health among African
Americans to mental health professionals by providing a brief
overview of the psychosocial factors and race-related trauma
most associated with maternal well-being and emotional
distress among within a socio-historical context. Clinical
implications and culturally-congruent recommendations are
discussed.
Introduction
Maternal and child health are public health concerns
that affect the current health of our nation, as well as that of
future generations (Healthy People 2020, n.d ; World Health
Organization [WHO], 2008). Indeed, improving maternal and
child health and well being in the United States is a high
priority issue among Healthy People 2020 Leading Health
Indicators (Healthy People 2020, n.d.). In accordance with the
goals of Healthy People 2020, strategies aimed at improving
maternal and child health must consider not only physical
indicators of maternal health, but also social determinants of
health and well-being. These determinants are key
components in health promotion and disparities, particularly
among African American women of reproductive ages
(Healthy People 2020, n.d.).
The associations between maternal mental and
physical health are well documented. Accumulating evidence
has indicated the influence of maternal health on a range of
domains, including parenting styles, neurodevelopment of the
fetus, psychiatric risk of offspring, and maternal emotional
distress (Dunkel Schetter, 2009; Sumner, Valentine et al.,
2011; WHO, 2008). Maternal health, which is characterized as
health surrounding pregnancy and post-partum periods (WHO,
2008) as it relates to improving the health and quality of life of
women, has been largely examined within the maternal and

Prevention and Health Promotion: Research, Social Action, Practice And Training: Volume 8, Issue 1 4
child health literature through the contextual lens of its
significance on child health. However, we assert that while
this focus is significant (and even crucial for improving
health), maternal health warrants clinical attention even
beyond the scope of infant and child health. In accordance
with conceptual models of well-being and maternal health that
consider the role of social determinants, including racial,
ethnic and gender discrimination and associated chronic
stressors in explaining health disparities, treatment
interventions aimed at improving health must appreciate the
larger social contexts that have shaped health (Dominguez,
2010; Dominguez, Dunkel Schetter, Mancuso, Rini, & Hobel,
2005; Krieger, Rowley, Herman, Avery, & Phillips, 1993).
The emotional, hormonal and physical fluctuations
experienced during pregnancy and postpartum can continue to
impact a womans emotional well-being and distress long after
giving birth (Dunkel Schetter, 2009).
There is a robust association between psychological
factors and pregnancy outcomes (Dunkel Schetter, 2009). For
example, psychological distress has contributed to such
occurrences as miscarriage, bleeding during pregnancy, higher
rates of Caesarean-section delivery, and preterm delivery, as
well as prolonged labor (Meintjes, Field, Sanders, van
Heyningen, & Honikman, 2010). Symptoms of emotional
distress during pregnancy have also predicted postpartum
symptoms of distress (Sumner, Wong, Dunkel Schetter,
Myers, & Rodriguez, 2011). As a result, there is an urgent and
pressing need for the prevention and better management of
mental distress during pregnancy and the post-partum periods,
especially among groups who are at heightened risk for
adverse pregnancy outcomes (Allan, Carrick-Sen, & Martin,
2013). Given the substantial role of psychological factors in
influencing maternal health during such an exciting and
sometimes stressful time, psychotherapists are well equipped
to help improve these important outcomes.
The factors contributing to maternal health and well-
being are multi-faceted, complex, and beyond the scope of the
present discussion, as is an extensive review of the
mechanisms underlying these associations (for excellent
Prevention and Health Promotion: Research, Social Action, Practice And Training: Volume 8, Issue 1
discussions in these areas, see Dunkel Schetter, 2009;
Mathews & MacDorman, 2013). Nonetheless, as some authors
have noted, there is no health without mental health. An
insistence by health institutions and providers to separate the
two domains in treatment undermines alleviating disability,
morbidity, and well-being (Prince et al., 2007). While levels of
emotional distress during pregnancy and postpartum periods
that meet diagnostic criteria (e.g., Major Depressive Disorder,
Postpartum Depression) have received moderate clinical
attention, far less research oriented towards psychotherapists
has been published on distress symptoms below the cut-off
threshold. In this article, we seek to familiarize
psychotherapists with some of the major psychosocial
constructs contributing to maternal health and well being, with
an emphasis on chronic stress among African Americans
within the context of historical and current societal inequities.
We begin with a brief overview of adverse pregnancy
outcomes, followed by a discussion on maternal mental health
and psychosocial factors in pregnancy and postpartum
associated with maternal distress and well-being, and the
influence of ethnic discrimination and race-related trauma on
social experiences. We conclude by discussing cultural
considerations and clinical implications for psychotherapeutic
interventions.
Adverse Pregnancy Outcomes Among African American
Women
For African American women in the United States,
pregnancy is a particularly vulnerable period, putting them at
heightened risk for adverse outcomes relative to women from
other racial and ethnic groups (Hamilton, Martin, Osterman, &
Curtin, 2014). Gross racial disparities in maternal mortality
persist, with African Americans carrying a disproportionate
share of the burden even after controlling for differences in
socioeconomic status (Walker & Chesnut, 2010). In 2012,
approximately 16.5% of African American women in the
United States had a preterm birth (delivery before 37 weeks of
complete gestation; [PTB]), relative to the national average of
11.5% (Hamilton et al., 2014). In addition, relative to other
ethnic and racial groups, African American births represent
5
the highest percentage of low birth weight babies (14%) and
rates of infant mortality (13.5%) (Mathews & MacDormand,
2013). Moreover, while the preterm-related infant mortality
rate was 1.8 for Caucasians, it was 6.0 for African Americans
in 2007 (Culhane & Goldenberg, 2011). These findings
underscore the continuing need for greater clinical attention to
this population.
An extensive review of the empirical literature
reveals that psychosocial stress has contributed to the
pathogenesis of pregnancy outcomes and maternal health
among African American women (Giscomb & Lobel, 2005).
Throughout the lifespan, African Americans experience
extraordinarily high levels of chronic stress, which contributes
to health outcomes, including pregnancy (Dominguez et al.,
2005). One particularly compelling explanation for the
striking disparities in birth outcomes found among African
American women is the weathering hypothesis, which posits
that ethnic discrimination (e.g., social, economic, and political
exclusion) across the lifespan, rather than socioeconomic
status, is the primary contributor to the striking disparities
found in birth outcomes (Geronimus, 1997). According to this
hypothesis, cumulative stressful experiences (including
racism) across the lifespan result in a weathering, or
prematurely aging, reproductive system. This hypothesis helps
to explain why college-educated African American women
have demonstrated increased numbers of low-birth weights
relative to Caucasian women of similar socioeconomic and
educational backgrounds (Schoendorf, Hogue, Kleinman, &
Rowley, 1992).
Explanations for the high rates of adverse pregnancy
outcomes among African American women have also focused
on health behaviors and socioeconomic status; increased levels
of psychological stress among African American women;
variations in neuroendocrine, vascular and immunological
processes resulting from stress; and vulnerability to
experiencing stressful events (Giscomb & Lobel, 2005). As
previously mentioned, numerous studies have also
substantiated the unique role of interpersonal exposure to
ethnic discrimination in contributing to adverse outcomes
Prevention and Health Promotion: Research, Social Action, Practice And Training: Volume 8, Issue 1
among African Americans (Collins, David, Handler, Wall, &
Andes, 2004; Dominguez, Dunkel-Schetter, Glynn, Hobel &
Sandman, 2008; Harper, Dugan, Espeland, Martinez-Borges,
& Mcquellon, 2007). Thus, to adequately develop
interventions to ameliorate risk for adverse outcomes among
African Americans, psychosocial factors and ethnic-specific
factors contributing to chronic stress must be considered.
Psychosocial Factors in Maternal Health
Socio-demographic and psychosocial characteristics
during the prenatal period predict maternal health status
during pregnancy and the post-birth periods (Sumner et al.,
2011). Psychological processes influence maternal mental
health and pregnancy outcomes through several pathways,
including health behaviors and biological processes (Dunkel
Schetter, 2009; Zuckerman, Amaro, Bauchner, & Cabral,
1998). Not surprisingly, low-income women and ethnic
minority women, who are more likely to have poor pregnancy
outcomes than women of higher incomes, are vulnerable to
chronic prenatal stress.
Many investigators are attempting to better identify
and understand the specific biological pathways by which
psychological factors contribute to disparities in birth
outcomes. A recent study by Catov, Flint, Lee, Roberts, &
Abatemarco (2014) sought to determine if lower levels of
optimism and higher levels of anxiety among African
American women contributed to greater inflammation, as
determined by the inflammatory markers of C-reactive protein
(CRP) and interluetin-6 (IL 6). Such markers are evident
within human reproduction processes, such as ovulation,
menstruation, and the onset of labor (Jabbour, Sales, Catalano,
& Norman, 2009), and CRP and IL 6 have both been
associated with increased risk of preterm birth (Catov et al.,
2014). In a sample of 435 women (African American, N =
119; Caucasian, N = 315) at 20 weeks gestation, levels of
anxiety and optimism and C-reactive protein (CRP) were
assessed among all participants with interluetin-6 (IL 6)
assessed only among African Americans. Results revealed that
relative to Caucasian women, African American women
reported higher levels of anxiety (> 75 th percentile) with no
6
differences in low levels of optimism observed between the
groups. African American women with high levels of anxiety
or low levels of optimism had lower concentrations of pro-
inflammatory markers at mid-gestation when compared to
participants without those characteristics (Catov et al., 2014).
An unexpected finding, according to the authors, was that
lower concentrations of CRP were found among African
American women with high levels of anxiety. These findings
are consistent with prior findings implicating the association
of physiological sequelae of chronic anxiety in pregnancy with
poorer outcomes. Interestingly, there is increasing evidence
that anxiety specific to pregnancy may be an even greater
predictor of preterm birth than general anxiety (Dunkel
Schetter, 2009). Pregnancy-specific anxiety, which focuses on
anxiety specific to fears and concerns about pregnancy, has
also been associated with maternal health outcomes even after
controlling for non-pregnant specific anxiety (Rini, Dunkel
Schetter, Wadhwa, & Sandman, as cited in Dunkel Schetter,
2009). These findings suggest that even women who do not
meet diagnostic criteria for a psychiatric diagnosis should be
screened for symptoms of anxiety, fears and apprehensions
about pregnancy and subsequent life adjustments.
Often symptoms of anxiety co-occur with depressive
symptoms during pregnancy (Littleton, Breitkopf, &
Berenson, 2007). Depressive symptoms during the prenatal
periods have been associated with adverse birth outcomes,
including premature births and low birth weights (Davalos,
Yadon, & Tregellas, 2012). Although approximately 20% of
women experience depressive symptoms during pregnancy
(Gaynes et al., 2005), the rate is 42% among low-income
African American women (Dailey & Humphreys, 2011). In
addition to smoking, a history of depression, and a history of
trauma, women with elevated levels of anxiety and those
without the support of the babys father appear to be at
heightened risk (Garfield et al., 2014). Despite the consensus
on the contributions of affective states on maternal health and
pregnancy outcomes and the importance of assessing for
mental disorders before, during, and after pregnancy, it should
be noted that much of the recent research on maternal health
Prevention and Health Promotion: Research, Social Action, Practice And Training: Volume 8, Issue 1
has assessed for symptomatology and not diagnosable
psychological disorders (Dunkel Schetter, 2009).
Social Adversity, Race-Related Trauma & Maternal
Health
Across all social strata, the social experiences of
African American women have rendered them susceptible to
greater vulnerability and exposure to traumatic events (e.g.,
racism, poverty). The impact of psychosocial stress related to
such exposures on pregnancy has yet to be fully examined;
however, as previously mentioned, there is general consensus
on the role of chronic and traumatic stressors. What is known
is that the historical trauma of African Americans during and
after American slavery continues to shape their lived
experiences across multiple spheres (e.g., institutional,
interpersonal, etc.) (Moore & Madison-Colmore, 2005). While
some African Americans are making progress into the middle
class, too often the specters of unemployment and under-
employment have raised barriers to opportunities leading to
the possibility of real wealth in the form of property and
investment holdings. Since women are more likely to live in
poverty (Smith, 2013), they are also more likely to experience
lack of adequate housing and health care. The persistent
targeting of marginalized communities of color by some
institutions using aggressive and deceptive practices to
advance their own financial gain further complicates the path
to economic stability. For example, the Justice Departments
second largest fair lending settlement was the product of an
investigation into systematic and discriminatory lending
practices of mortgage corporations, which targeted African
American and Latino communities for subprime loans with
higher interest rates than those received by similarly qualified
white borrowers (U.S. Department of Justice, 2012, para. 7).
It is quite likely that the chronic stress experienced by African
Americans is at least in part, fueled by chronic financial strain.
Financial strain may be fueled by difficulties in
employment and disruptions in the family system resulting
from inequities in the criminal justice system. During the
nations recent economic recession, African Americans had
higher unemployment rates and greater difficulty in securing
7
employment, relative to other ethic and racial groups (U.S.
Congress Joint Economic Committee, 2013). Within the legal
and criminal justice systems, glaring ethnic and racial
disparities in prosecutions, convictions, and sentencing in the
legal system have also been noted, with African American
men being prosecuted and convicted at much higher rates and
receiving significantly more severe sentencing than their white
counterparts, for the same crimes (Kansal, 2005). Disparities
in the application of the law, housing and employment
discrimination, and corporate financial exploitation have
helped to create even greater disruptions in the family system,
such as availability for partner support during pregnancy and
opportunities for economic growth from dual income
households. Interestingly, the presence of a partner along with
supportive involvement before, during, and after pregnancy
has been found to predict not only maternal distress but also
infant distress (Stapleton et al., 2012)
These data indicate that African Americans
experiences with racial inequality are not only a concern of the
past, but remain a salient factor shaping this populations
present day health. Vestiges of systemic inequities constructed
during slavery, many current challenges are multi-level,
occurring across institutions (e.g., legal, health, educational,
economic) and contributing to alarmingly high levels of stress
throughout the African American lifespan. Stressors arising
from chronic economic and relational strain, as well as
continued social marginalization, continue to affect well-being
and emotional distress (Giscomb & Lobel, 2005).
Societal and political movements have enormously
impacted the shaping of attitudes about the sexual and
reproductive health and health choices of African American
women, as well as low-income women. This has been
achieved largely through medical control and limited
treatment options, as evidenced through the eugenics
movement, elective hysterectomies and sterilization without
consent as well as targeted marketing of birth control
(Roberts, 1997). It is likely that historical and recent attitudes
toward reproduction among African Americans are
represented in some of the current barriers to accessing health
Prevention and Health Promotion: Research, Social Action, Practice And Training: Volume 8, Issue 1
care during prenatal phases, as attitudes of distrust toward
health professionals may be found among some African
American women (Washington, 2006). Studies have
suggested that European Americans are likely to hold
particularly negative views about African Americans
(Schuman, Steeh, Bobo, & Krysan, 1997). It is not a stretch to
suggest that these attitudes are reflected in the delivery of
health care. McDermott and Samson (2005) point out that
because whiteness is viewed as normative in the United States
and is the racial and ethnic reference point for the countrys
other groups, African Americans are constantly reminded of
their minority status. The frequency and severity of the
exposure of African Americans to racist traumatic events
throughout the lifespan undoubtedly contribute to feelings of
anxiety.
Clinical Approaches to Improving Maternal Mental and
Behavioral Health
African Americans generally do not seek out
psychotherapy when faced with life stressors (Moore &
Madison-Colmore, 2005). African American women who may
believe the stereotype of the strong Black woman may find
it even more difficult to reach out (Cowdery, Scarborough,
Lewis, & Sheshadri, 2009). Racial discrimination, appropriate
cultural mistrust, and perceived oppressive experiences with
health care professionals can compound the challenge of
seeking out psychological help when faced with multiple
stressors. In addition to the pervasive strong Black woman
stereotype, erroneous perceptions about pregnant African
American women include: (a) African American women
irresponsibly bring children, for whom they are unable to
provide, into the world; (b) African American mothers are
unmarried, poor, and universally on welfare; and (c) African
American women have poor eating habits that will negatively
affect their children (Sawyer, 1999).
In order to create an engaging environment,
therapists who are unfamiliar with African American culture
must understand the stereotypes and historical trauma created
by racism (Jackson, 2003). First, clinicians must become
aware that psychotherapy models are socially constructed
8
based on a Euro-normative perspective. Those models often
do not allow for the experiences of racism that many African
Americans live with and non-African Americans have
difficulty hearing or understanding. Secondly, some therapists
may frequently dismiss narratives of racial discrimination as
expressions of paranoia, choosing to believe that modern
American culture is different today, and that we are all living
in a post-racial society. Conversely, therapists may believe
that the client discussing experiences of race-related trauma is
attempting to abdicate personal accountability. Therapists can
also spend time trying to talk their clients out of their feelings.
These microaggressions, or unintentional, subtle put-downs
expressed in a variety of ways (Sue, Capodilupo, Nadal, &
Torino, 2009) can lead to African American clients not feeling
heard or understood, and consequently not returning for
additional sessions. The non-African American therapist may
be left feeling that African American clients are difficult to
work with and are resistant to change. A pregnant African
American pregnant woman who wants to talk about how her
physician automatically assumed that she was poor and
unmarried should not be labeled as resistant or paranoid;
further, the therapists verbal and/or nonverbal responses
could deepen the clients sense that she should remain silent
around those who are different and that therapy is a waste of
time. Microaggressions such as these, commonly committed
by mental health professionals, perpetuate cultural
insensitivity.
When working with pregnant women from the
African American community, there are several
recommendations a mental health practitioner provider will
want to keep in mind. First, it is critical that therapists not only
acknowledge the continued existence of racism, but they must
also understand the deep impact of race-related stress. This
can only be accomplished if non-African American therapists
examine their own worldviews for prejudices and biases
toward African Americans in particular. This means being
mindful of microaggressive beliefs and values that conflict
with African American culture and worldviews. An ongoing
and authentic examination of the self is imperative when
Prevention and Health Promotion: Research, Social Action, Practice And Training: Volume 8, Issue 1
working with different cultures and ethnicities; supervision
and/or consultation is strongly suggested for mental health
professionals who find themselves struggling with honest self-
evaluation and rooted introspection.
Another recommendation is to listen attentively to the
narratives of African American women and recognize their
needs as well as their strengths. Despite the challenges faced
by pregnant African American women, there are numerous
cultural strengths that clinicians are encouraged to incorporate
in treatment when clients are slow to identify individual
resources, including high levels of resilience, spiritual or
religious practices, strong kinship bonds, and cultural identity
and a sense of community (Boyd-Franklin, 2003). African
American women who are empowered to acknowledge and
accept that they deserve attention and care may experience
reduced stress related to caretaking of others and previous
neglect of self-care. The clinicians ability to address these
needs from a non-pathologizing, non-judgmental stance is
essential to making a difference in the lives of both the
African American woman and her infant. Providers are urged
to assess for multiple traumatic experiences across the
lifecycle, and particularly to include the experience of being
silenced in the face of racial trauma. Clinical professionals
who fail to invite their pregnant African American clients to
speak openly in a supportive environment ultimately fail these
women.
There is a growing call from scientists and agencies,
such as the Division of Reproductive Health at the Centers for
Disease Control and Prevention, for studies that
comprehensively document, assess, and examine the
influences of factors unique to the African American
community to better understand the experience of pregnancy
among this population. Trauma exposure throughout the
lifespan, as well as chronic and ethnic-specific stress among
African American women in relation to birth outcomes should
be studied more extensively. More specifically, future research
may benefit from assessing ethnic-discrimination across
several domains (e.g. institutional, healthcare, interpersonal),
symptoms of affective distress, and partner support. Similarly,
9
the importance of examining culture-specific factors that may
moderate or mediate health outcomes is increasingly
recognized as central to identifying health risks and
understanding health disparities (Healthy People 2020, n.d.).
These factors should be explored in greater depth to facilitate
an increased understanding of their roles in buffering stress
and psychological distress during pregnancy, as well as
identifying methods of allocating resources that amplify
cultural strengths.
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 RESEARCH, SOCIAL ACTION, PRACTICE AND TRAINING

Symptoms of Polycystic Ovary Syndrome: Self-Esteem, Distress, and

Quality of Life in College Women
Signe S. Simon
Merle A. Keitel
Molly Brawer
Melda S. Uzun
Fordham University

Signe S. Simon, Merle A. Keitel, Molly Brawer, and Melda S. Uzun, Department of Psychological and Educational Services, Fordham
University. Correspondence concerning this article should be addressed to Signe Simon, Department of Psychological and Educational
Services, Fordham University, New York, NY 10458. Email: ssimon8@fordham.edu

Abstract lower quality of life than college women without a PCOS

Polycystic ovary syndrome, or PCOS, is a common
female endocrine disorder estimated to affect between 4% and
8% of women. Some researchers estimate that PCOS affects
up to 12% of women, yet it remains an under-recognized and
under-diagnosed condition. The symptoms of PCOS may
negatively impact appearance, body image, and self-esteem.
This study sought to explore whether having a PCOS
diagnosis or PCOS symptoms is related to psychosocial
functioning in female college students. If so, the results can be
used to raise the awareness in professionals on college
campuses so that steps can be taken to prevent or reduce the
negative impact of the disorder and its related symptoms. The
sample consisted of 165 full-time college students between the
ages of 18 and 24 (M = 20.37, SD = 1.83) in the United
States. Approximately one third of participants had a formal
PCOS diagnosis, however many participants without a formal
diagnosis had PCOS symptoms (103 of 165 participants had
severe or moderate symptoms and 56 had mild or no
symptoms).. Participants completed an anonymous online
survey assessing their self-esteem, distress, quality of life, and
PCOS symptoms. Results indicated that women with a PCOS
diagnosis exhibited significantly higher levels of distress and
diagnosis and that regardless of diagnostic status, women in
college who report more PCOS symptoms tend to have lower
levels of psychological wellbeing. To tackle this problem,
college counseling centers and student health centers can work
together to address mental health symptoms in women with
PCOS or PCOS symptoms before they escalate.
Introduction
Polycystic ovary syndrome, or PCOS, is a common
female endocrine disorder. The condition is characterized by
irregular or missed menstrual periods, excessive facial and
body hair (hirsutism), skin issues such as oily skin, acne, or
dark, patchy skin, and in some cases, small cysts that develop
on the ovaries (American College of Obstetricians and
Gynecologists [ACOG], 2011). In addition, up to 80% of
women affected by PCOS are obese, and PCOS is a leading
cause of female infertility (ACOG, 2011). PCOS is caused by
factors including insulin resistance and increased levels of
hormones called androgens, which can prevent ovulation and
lead to hirsutism and acne (ACOG, 2011). There is also
evidence for a genetic component to the condition. (Kahsar-
Miller, Nixon, Boots, Go, & Azziz, 2001; Wood et al., 2004)
Diagnosis and Prevalence

Prevention and Health Promotion: Research, Social Action, Practice And Training: Volume 8, Issue 1 14
 The prevalence of PCOS is traditionally estimated to
be between 4% and 8% (Azziz et al., 2004; Knochenhauer et
al., 1998) and may be up to 12% depending on the criteria
used for diagnosis (March et al., 2010). Diagnosis is
logistically difficult due to the need for blood tests or
ultrasounds to confirm the disorder (March et al., 2010).
Moreover, diagnosis is not straightforward given the
heterogeneous and variable nature of the symptoms as well as
the lack of a uniform definition of the syndrome's presentation
(Ehrmann, 2005). According to the Androgen Excess Society,
PCOS is present in women who exhibit clinical or biochemical
signs of excess androgen secretion along with irregular or
infrequent ovulation and/or ovarian cysts, with the exclusion
of other disorders (Azziz et al., 2006). As new diagnostic
criteria are instituted, the number of PCOS diagnoses is
expected to rise. In a study conducted by March et al. (2010),
an alarming 68-69% of women testing positive were
previously undiagnosed. It is likely that many cases of PCOS
remain undiagnosed (Christensen et al., 2013,
Sivayoganathan, Maruthini, Glanville, & Balen, 2011), and
the actual prevalence of the syndrome may be significantly
higher than current estimates.
PCOS is a condition that can be diagnosed once
menstruation begins. However, diagnosis can be delayed
because acne and irregular menstruation are commonplace in
teens (The Amsterdam ESHRE/ASRM-Sponsored 3rd PCOS
Consensus Workshop Group, 2012). Many women, therefore,
are diagnosed in their 20's. Incidence of the syndrome does
not differ in Black and White women (Azziz et al., 2004;
Knochenhauer et al., 1998), however, obesity and metabolic
symptoms do appear to differ along racial and ethnic lines
(The Amsterdam ESHRE/ASRM-Sponsored 3rd PCOS
Consensus Workshop Group, 2012). For example, Lo et al.
(2006) demonstrated that in 11,035 women diagnosed with
PCOS, Black and Hispanic patients were more likely than
White patients to be obese, and Asian patients were the least
likely to be obese. In addition, diabetes was more prevalent in
Asian and Hispanic patients, Blacks were more prone to
hypertension, and Hispanics were less likely to be
Prevention and Health Promotion: Research, Social Action, Practice And Training: Volume 8, Issue 1
hypertensive. Thus the manifestation of PCOS differs across
racial/ethnic groups, and different treatment options may be
indicated depending on the ethnic origins of the patient and
their symptom presentation.
Treatment
There is no known cure for PCOS and therefore
treatment is symptom management (U.S. Department of
Health and Human Services [HHS], 2010). Since the
manifestation of PCOS varies, treatment options are selected
that target different symptoms (Sheehan, 2004). PCOS
treatment may also depend on a womans age and
expectations. For example, college students might be less
likely to be concerned about infertility and more likely to be
coping with weight issues, irregular menstrual cycles,
diabetes, acne, hair loss, and hirsutism. Women may be
prescribed birth control pills, Metformin (a diabetes drug) or
Spironolactone and Finasteride to manage symptoms (HHS,
2010). Some women who experience unwanted hair growth
may opt for laser treatments, which have been proven
effective (Clayton, Lipton, Elford, Rustin, & Sherr, 2005).
Women with PCOS are also encouraged to manage their
weight through healthy eating and exercise (HHS, 2010).
PCOS can trigger low self-esteem, anxiety, and
depression (Deeks, Gibson-Helm, Paul, & Teede, 2011). It is
possible that symptom management itself may increase stress
for women as they navigate treatment options and cope with
the pressure to maintain a certain weight. For example, certain
treatments such as laser hair removal may not be easily
accessed by college students living on campus. Kitzinger and
Willmott (2002) found that women with PCOS felt
stigmatized and defeminized when medical professionals
described PCOS as a male hormone disease.
Relationship to Mental Health
Because there is no clearly defined diagnostic criteria
for PCOS, it may be difficult for women to understand or
accept their diagnosis. Physical symptoms associated with
PCOS can affect self-esteem and body image (Deeks et al.,
2011). Because females are often diagnosed during emerging
adulthood, a time characterized by identity formation and
15
potential body image concerns (Syed & Seiffge-Krenke,
2013), college women may be particularly sensitive to factors
that negatively impact appearance. Many studies have shown
that women with PCOS tend to evaluate their bodies more
negatively than women without PCOS, in particular women
with higher BMI scores tend to show higher rates of
depression (Himelein & Thatcher 2006; Kerchner, Lester,
Stuart, & Dokras, 2009). Excess facial and body hair and
weight gain can contribute to increased body dissatisfaction
and decreased self-esteem in young women (Pastore, Patrie,
Morris, Dalal, & Bray, 2011).
Ekback, Wijma, and Benzein (2009) interviewed ten
women with PCOS who had unwanted facial and body hair.
All of these women had poor opinions of their bodies, had low
self-esteem, and reported feeling masculine and abnormal. global self-esteem, especially for those who place a high value
They felt the need to hide their bodies while in public places,
which for some women led to social anxiety and loneliness.
Research has shown that anxiety disorders are common in
individuals with endocrine disorders (Annagr et al., 2013).
Although the factors causing anxiety are not completely
understood, the shame associated with body image and feeling
different from ones peers may contribute (Keegan, Liao, &
Boyle, 2003).
Jones, Hall, Lashen, Balen, and Ledger (2011)
interviewed adolescent girls suffering from PCOS and found
that the majority reported weight gain and unwanted body hair
as the two factors contributing most to decreased quality of
life. The adolescents also tended not to understand their
diagnosis and this lack of information about the syndrome
added to confusion and distress (Jones et al., 2011).
In young women with PCOS, distress is often related
to hirsutism and weight gain while in older women it is related
to worries about infertility (Moran, Gibson-Helm, Teede, &
Deeks, 2010). Laggari and Colleagues (2009) found that most
adolescents with PCOS suffer from state anxiety due to issues
regarding their sexual and feminine identity, and relationships
with romantic partners. Overall, the literature indicates that
PCOS may affect self-esteem, body image, and overall quality
of life regardless of age, but that the issues within those
Prevention and Health Promotion: Research, Social Action, Practice And Training: Volume 8, Issue 1
domains that are most relevant (e.g., infertility) may differ
depending on a womans age. This highlights a need for
increased awareness of the unique needs of young women
with PCOS.
Body Image and Self-Esteem
Global self-esteem is our evaluation of our worth
(Rosenberg, 1989) and is a central feature of emotional
wellbeing (Leary & Baumeister, 2000). Self-esteem can act as
a protective factor against psychological and behavioral
problems (Donnellan, Trzesniewski, Robins, Moffitt, & Caspi,
200; Haney & Durlak, 1998) whereas low self-esteem is
associated with stress (Hubbs, Doyle, Bowden, & Doyle,
2012) and depression (Sowislo & Orth, 2012).
Studies show that body image is highly related to
on appearance (Mendelson, Mendelson, & Andrews, 2000).
Lowery et al. (2005) found that among first year female
college students, self-esteem and body dissatisfaction were
significantly related. Participants who felt in control of their
appearance experienced comparatively higher self-esteem.
Dormitory living may pose significant challenges to self-
esteem if students compare themselves to others, and make
negative appearance-related self-evaluations (Danis & Harter,
1996 as cited in Harter, 2012, p. 152).
As previously noted, PCOS symptoms including
weight gain, unwanted facial and body hair, and loss of hair
from the head, can negatively affect body-esteem and global
self-esteem (Himelein & Thatcher, 2006; Morgan, Scholtz,
Lacey, & Conway, 2008). Living in a new environment and
meeting the social and academic demands of college, while
struggling with appearance concerns, could lead to higher
stress and depression.
Studies of Other Endocrine Conditions
Studies of the psychological impact of other
endocrine disorders with similar symptom presentation have
used varying approaches and frameworks to explore mental
health consequences. Gulseren et al. (2006) examined the
impact of thyroid dysfunction on patient quality of life,
depression, and anxiety, specifically exploring the differences
16
in these variables among subgroups of patients with varying
types and severities of thyroid dysfunction as well as assessing
changes in these psychological variables over the course of
treatment. Fornaro et al. (2010) assessed more broadly for
comorbid Axis-I disorders among women with new endocrine
diagnoses, examining the prevalence of psychological
conditions such as major depressive disorder, generalized
anxiety disorder, and panic disorder both at baseline and at 12-
week follow-up. Repeated findings of the psychosocial
sequelae of endocrine conditions have led to Sonino and
Fava's (2012) proposal that recovery be defined not only by
the achievement of hormonal normalization, but also by the
stabilization of psychological functioning. This highlights the
importance of including psychological treatment as part of
comprehensive medical care of patients with endocrine
conditions.
Statement of the Problem
It is hypothesized that female college students with a
PCOS diagnosis will have lower levels of self-esteem, higher
levels of distress, and poorer quality of life compared to those
without a diagnosis. Furthermore, it is predicted that females
endorsing more PCOS symptoms will differ from participants
that report few symptoms with respect to self-esteem, distress,
and quality of life (QOL), regardless of whether or not they
carry a PCOS diagnosis. This study examines whether a PCOS
diagnosis or PCOS symptoms is associated with distress, self-
esteem and quality of life in college women. The results can
raise awareness in college professionals who are in a position
to prevent or reduce the negative psychological impact of the
disorder and related symptoms.
Method
Participants
Participants were recruited from various colleges via
online postings and emails delivered through PCOS-related
listservs, message boards, online discussion groups, and
organization websites, and participants clicked a link to the
anonymous online survey. An email describing the study was
also sent to local colleges and universities in the New York
City area and then delivered to the female college students on
Prevention and Health Promotion: Research, Social Action, Practice And Training: Volume 8, Issue 1
campus. Additionally, a flyer describing the study and
including the survey link was provided to student health
centers and counseling centers at local colleges in the New
York City area. Participants diagnosed with PCOS were also
recruited through the qualitative portion of a larger mixed
methods study conducted by other members of the research
team exploring the experience of college women who have
been diagnosed with PCOS. Participation in this study was
voluntary, but participants were provided the option to enter
into a raffle for a chance to win a $100 Amazon gift card.
The sample consisted of 165 full-time college
students, between the ages of 18 and 24 (M = 20.37, SD =
1.83), in the United States. Of these participants, 50 reported a
formal PCOS diagnosis, 103 had severe or moderate PCOS
symptoms, and 56 participants had mild to no symptoms. The
PCOS group and control group were comparable in their
racial/ethnic composition, except for a lack of Hispanic
participants with PCOS. There was an even spread of
participants from each college year and a normal distribution
of socioeconomic backgrounds.
Instruments
Demographic questionnaire. Demographic
questions assessed gender, age, race/ethnicity, socio-economic
status, number of years in college, overall GPA, medical
conditions, mental health diagnoses, and medications. The
demographic questions for participants with PCOS included a
question about the age of diagnosis and how the individual
sought information about the disorder.
Rosenberg Self-Esteem Scale. The Rosenberg Self-
Esteem Scale (Rosenberg, 1989) is a 10-item measure
assessing global self-esteem. Participants respond on a 4-point
Likert scale progressing from strongly agree to strongly
disagree. When used with college students, the scale was
found to have strong reliability at = 0.85 0.88 (Martn-
Albo, Nez, Navarro, & Grijalvo, 2007). Internal consistency
of the scale for this study was found to be very strong ( =
0.90).
Kessler Psychological Distress Scale. The Kessler
Psychological Distress Scale (K10; Kessler et al., 2002) is a
17
questionnaire consisting of ten items that primarily assess
depression and anxiety. A question such as In the past 30
days about how often did you feel hopeless? is used to assess
the depression domain and a question such as In the past 30
days did you feel so restless that you could not sit still? is
used to assess the anxiety domain. Individual responses are
provided on a 5-point Likert scale ranging from 1 (none of the
time) to 5 (all of the time). The highest possible score of 50
signifies the most severe level of distress, the middle scores
between 16-30 signify medium levels of distress, and the
lowest score of 10 signifies little to no distress (Andrews &
Slade, 2001; Fassaert et al., 2009).
Overall, validity and reliability of the K10 scale has
been established (Baggaley et al., 2007; Browne, Wells, Scott,
& McGee, 2010; Furukawa, Kessler, Slade, & Andrews,
2003). Baggaley and colleagues confirmed high internal
consistency for the K10 scale with a= 0.87 . Reliability for this
study was found to be very strong ( = 0.90).
World Health Organization (WHO) Quality of
Life BREF. The WHOQOL-BREF is a 26-item measure
assessing quality of life within four domains: physical health,
psychological, social relationships, and environment
(WHOQoL Group, 1998). Participants are asked to respond on
a 5-point Likert scale ranging from very dissatisfied to very
satisfied. The instrument has been found to have good overall
reliability ( = 0.70), as well as strong discriminant and
construct validity (Skevington, Lotfy, & O'Connell, 2004). In
this study the reliability for individual domains including
physical ( = 0.79), psychological ( = 0.82), social ( =
0.70), and environmental ( = 0.79) was adequate. The two
general quality of life questions ( = 0.64) did not meet
reliability requirements and these questions were not included
in the analysis.
PCOS symptoms. Eleven additional questions
assessing the severity of PCOS specific symptoms (e.g., acne,
fatigue, weight gain) were created by the primary researcher.
Participants respond on a 4-point Likert scale ranging from,
not at all to very much. The first ten questions address
physical symptoms and the final question addresses worry
Prevention and Health Promotion: Research, Social Action, Practice And Training: Volume 8, Issue 1
about future health. Scale totals range from 11-44 including
the final question and 10-40 when only including the physical
questions.
Procedure
College females (N = 212) were evaluated on the
basis of their PCOS status, PCOS symptoms, self-esteem,
distress, and quality of life. After reading through the email
announcement, online posting, or flyer announcement,
individuals who determined they were eligible to participate
were asked to access an electronic version of the survey
through a website address. The online survey was completely
anonymous and at no point were participants asked to provide
identifying information.
The data were initially screened for missing data and
eligibility. Data for participants that did not respond to any of
the items past the demographic questionnaire were excluded,
as were participants whose age was outside of the specified
range (18-24). Measures were then assessed to ensure
reliability. Missing responses were dealt with by inputting the
mean response of a participant within a particular measure to
account for the missing value.
Data analysis was completed using SPSS. First,
independent-samples t-tests were conducted to compare self-
esteem, distress, and quality of life in individuals formally
diagnosed with PCOS and those without the diagnosis.
Correlational analysis was used to assess the relationship
between PCOS symptomatology and the psychological
variables. Frequencies were calculated for PCOS symptoms.
Next, the participants were divided into three groups based on
their level of PCOS related physical symptoms (group 1 = 10-
15, group 2 = 16-20, and group 3 = 21+). Finally, a one-way
ANOVA was conducted to determine how the three groups
differed across self-esteem, distress, and quality of life. Post-
hoc comparisons were conducted using Tukeys test for
significant findings to determine where differences occurred
between the three groups.
Results
Descriptive statistics are reported in Table 1. Initially,
212 individuals responded to the survey, however the data
18
from 47 participants were removed (41 who did not continue
after they completed the demographic questionnaire as well as
6 who were not in the specified age range). Table 2 reports the
results of independent-samples t-tests conducted to examine
potential differences in self-esteem, distress, and quality of life
for college students with and without PCOS. Participants with
a PCOS diagnosis had significantly higher distress scores and
lower quality of life subscale scores. No significant
differences in self-esteem scores were found for the PCOS
group (M = 18, SD = 5.81) and no-diagnosis group (M =
19.66, SD = 5.62) yet the effect size was moderate at d = .27.
These results indicate that women in college with a PCOS
diagnosis exhibit significantly higher levels of distress and
lower quality of life than college women without a PCOS
diagnosis.
Correlations, as reported in Table 3, were computed
between PCOS symptomatology and self-esteem, distress, and
quality of life. The results show that all correlations were
moderate to strong, and were all statistically significant. The
strongest correlations were found between PCOS symptoms
and distress r(159) = .55, p < .01, and PCOS symptoms and
psychological quality of life r(159) = -.58, p < .01. In general,
the results suggest that women in college who report more
symptoms tend to have lower levels of psychological
wellbeing.
As predicted, participants with a PCOS diagnosis
were more likely to endorse PCOS symptoms. In particular,
they endorsed severe symptoms of fatigue (32.7%), unwanted
hair (47.99%), irregular menstruation (51%), and
obesity/overweight (61.2%), as compared to 14.7% of
participants without a PCOS diagnosis that reported severe
fatigue, 2.7% that reported severe symptoms of unwanted hair,
5.5% reporting a very high degree of irregular menstruation,
and 10% that reported severe symptoms of
obesity/overweight. Most individuals scoring 21 or above,
representing the most symptomatic participants (n = 46), were
diagnosed with PCOS (n = 32). However, 14 were not
diagnosed with PCOS, representing 12.72% of all the
participants without a PCOS diagnosis. While these women
Prevention and Health Promotion: Research, Social Action, Practice And Training: Volume 8, Issue 1
might have been diagnosed with PCOS, it is possible that they
do have the disorder. It is also possible that their symptoms
were occurring for other reasons that have a significant
negative relationship with psychological wellbeing.
Table 4 reports the results of an analysis of variance
(ANOVA) on the three symptom groups (low, medium, and
high), which yielded significant differences across all
psychological measures including self-esteem, distress, and
quality of life (p < 0.01 level). Post hoc Tukey tests showed
that the three groups differed significantly across all the
measures of psychological wellbeing. Notably, the standard
deviations for group 3 were relatively high, indicating greater
variability between participants with greater symptoms. These
results suggest that the greater the severity of PCOS-related
symptoms, the lower the psychological wellbeing of college
women. Notably, the distress levels and quality of life in
groups 1 and 2 were not significantly different, but were
significantly different from group 3 suggesting that upon
reaching a certain threshold, distress intensifies and quality of
life decreases. Furthermore, a significant difference was found
between group 1 and 2 on social quality of life but not
between groups 2 and 3, suggesting that social quality of life
is impacted at a lower level of PCOS-related symptoms.
Within the WHOQOL-BREF (WHOQoL Group,
1998) item 22 addressed social support (How satisfied are
you with the support you get from your friends?).
Participants with a formal PCOS diagnosis (M =3.14, SD
=1.06) were significantly less satisfied with the support they
received compared to those without a diagnosis (M= 3.80,
SD= 1.04), t(-3.66), p < .01, d = .62. Additionally, while there
was no significant difference between participants with mild
to moderate symptoms (groups 1 and 2), there was
significantly lower satisfaction with social support for
participants with moderate symptoms (group 2) and those with
severe symptoms (group 3).
Additional information was collected from
participants diagnosed with PCOS, specifically whether or not
they had ever utilized mental health services and where they
had found information about PCOS. The majority of PCOS
19
participants (80.5%, n = 33) had never received treatment
from a mental health provider. Females with PCOS in this
sample used a number of sources for information about PCOS.
The most popular source of information was the internet,
utilized by 80.5% (n = 33) of participants with PCOS followed
by health care providers, with 51% (n = 21) of PCOS subjects
citing their gynecologist as a source of information, 46% (n =
19) identifying their primary care provider as a source of
information, and 41.5% (n = 17) listing their endocrinologist
as an information source. Only one participant cited student
health services as a source of information about PCOS, which
could speak to a lack of available information at student health
services, or alternatively a hesitation on the part of students to
seek information on campus.
Discussion
This research sought to explore the psychological
impact of PCOS on women in college. Given that many
women with PCOS are undiagnosed, this study looked at both
the impact of having a diagnosis of PCOS and separately, the
impact of having the symptoms of PCOS. As was predicted,
the findings suggest that having a PCOS diagnosis and the
associated symptoms is associated with reduced psychological
wellbeing in college women. Previous research on the mental
health impact of having a PCOS diagnosis supports these
findings (Coffey, Bano, & Mason, 2006; Deeks et al., 2011).
Women with a PCOS diagnosis were more worried
about their future health than women without a PCOS
diagnosis with over half of participants with PCOS endorsing
very much compared to less than ten percent of participants
without PCOS, indicating that having the diagnosis could be a
risk factor for elevated levels of anxiety. The majority of
women with PCOS in this sample indicated seeking
information about their diagnosis from the internet which can
be inaccurate and present extreme cases that likely elicit
excess worry and fear. One example of this is that there is a
slightly higher cancer risk for women with PCOS (Dumesic &
Lobo, 2013). This fact is referenced as a risk factor online but
not necessarily with statistical data to put it in context. As
noted earlier, in addition to anxiety about the future,
Prevention and Health Promotion: Research, Social Action, Practice And Training: Volume 8, Issue 1
individuals with endocrine disorders report higher levels of
anxiety. College student services could be an invaluable
support for women who are worried about their symptoms and
future health.
Women with a PCOS diagnosis endorsed higher
levels of distress and lower quality of life across physical,
psychological, social, and environmental domains. Notably,
having a PCOS diagnosis was not related to self-esteem.
Those women with greater symptoms of PCOS, however,
tended to have reduced self-esteem. This suggests that there
might be protective factors that guard against reduced self-
esteem in women with a PCOS diagnosis up to a certain
physical symptom threshold at which point the protective
factors are no longer able to guard against reductions in self-
esteem.
This study also sought to explore whether having
symptoms, regardless of having a diagnosis of PCOS, was
related to poorer psychological wellbeing. Findings suggest
that as symptoms increase, psychological wellbeing is
significantly reduced with regard to self-esteem, distress, and
quality of life. There was a small group of women (n = 14)
without a PCOS diagnosis who endorsed elevated levels of
PCOS symptoms. Although these women do not carry a PCOS
diagnosis they are at risk for reduced psychological wellbeing
due to their symptoms and in some cases, may have
undiagnosed PCOS. If these women are identified early and
receive support from their college, through counseling and
medical services, they might have a more positive college
experience and an increased ability to cope with their
symptoms in the future.
Having symptoms of PCOS, even without the formal
diagnosis, is associated with lower psychological wellbeing
that can affect significant life domains such as academics
(Kessler, Foster, Saunders, & Stang, 1995) and relationships
(Kessler, Walters, & Forthofer, 2004, as cited in Hunt &
Eisenberg, 2010). Fatigue, which was endorsed to a far greater
extent in women with a PCOS diagnosis, has the potential to
decrease cognitive functioning (Palmer, 2013), potentially also
impacting academic work. Given that women with symptoms
20
of PCOS or a diagnosis of PCOS are at greater risk for lower
self-esteem, increased distress, and lower quality of life,
identifying these women early in their college experience
would be helpful.
College counseling centers and student health centers
can work together to address mental health symptoms in
women with PCOS or PCOS symptoms before they escalate.
The first step is for college counselors to understand the
physical and psychological symptoms associated with PCOS.
Many counselors have never heard of PCOS despite the fact
that it is a common endocrine disorder. Even when it is
indicated on intake forms, counselors may not recognize the
significance.
Intake forms at college counseling centers can inquire
about general health concerns. If clinicians at college
counseling centers get trained to recognize the symptoms of
PCOS, general health questions can alert the clinician to
PCOS-related symptoms that may be affecting mental health.
Questions such as, do you have any physical symptoms you
are concerned about? or asking students to rate their level of
fatigue and body image concerns could help to uncover areas
that may be impacting mental health. Student health centers
that recognize a pattern of symptoms associated with PCOS,
could make it a policy to inquire about mental health concerns
and subsequently refer these students to counseling if
indicated. In addition, colleges should have educational
materials about PCOS available for students in waiting rooms
and on the counseling centers website to help draw attention
to PCOS and guide people to healthcare and counseling
resources. Such resources could include fact sheets published
by the American College of Obstetricians and Gynecologists
(2011) and the Office of Women's Health of the U.S.
Department of Health and Human Services (2010), both of
which address frequently asked questions about PCOS.
College students may also benefit from PCOS-specific online
resources such as message boards and discussion forums,
including but not limited to: www.soulcysters.net, the
Polycystic Ovarian Syndrome Association webpage,
www.pcosupport.org, PCOS Challenge support group forum
Prevention and Health Promotion: Research, Social Action, Practice And Training: Volume 8, Issue 1
webpage, www.pcoschallenge.com, as well as various
Facebook support groups such as PCOS Diva and PCOS,
containing over 10,000 members who subscribe to the pages.
There are some study limitations that should be
addressed. While the overall sample size was adequate, there
was an unequal split between the participant group with a
PCOS diagnosis and those without, limiting the
generalizability of results. Furthermore, results were based on
self-report data from anonymous participants responding to an
online survey, which could potentially limit the validity of
results. Finally, this study used a limited set of constructs
including self-esteem, distress, and quality of life to assess
psychological wellbeing.
Future research could focus on the impact of PCOS
on other psychological variables including anxiety and
depression. Results from the social support question on the
WHOQOL-BREF indicate that college women with fewer
PCOS symptoms were more satisfied with the support they
receive from friends. Therefore, future research could explore
factors that protect against the negative psychological impact
of PCOS and its related symptoms, such as peer social
support, as well as the efficacy of interventions to address
these psychological symptoms in patients with PCOS.
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Table 2

Table 3

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Table 4

Prevention and Health Promotion: Research, Social Action, Practice And Training: Volume 8, Issue 1 27
 RESEARCH, SOCIAL ACTION, PRACTICE AND TRAINING

A Structural Equation Model Examining Multiple Mediation

Pathways between Social Support, Exercise Self-Efficacy, and
Physical Activity
Kelly A. Cotter Nicole G. Lancaster
California State University Stanislaus University of Nevada, Reno

This research was partially supported by the Sacramento State University 2009-2010 Research and Creative Activity Award Program
Summer Fellowship Grant. The study was conducted at Sacramento State. Correspondence concerning this article should be addressed
to Kelly A. Cotter, California State University Stanislaus, 612 East Magnolia, Stockton, CA 95202. Email: kcotter@csustan.edu

Abstract intervention for many diagnoses, such as heart disease,

Physical activity is an important health behavior for
preventing age-related disabilities and as a point of
intervention for many diagnoses, such as heart disease,
diabetes, and depression. Understanding psychosocial
influences on physical activity is imperative in order to
increase rates of this significant health behavior. Participants
in this study were 370 adults ages 18 to 97 (M = 45.21, SD =
26.94), who completed surveys of general perceived social
support and strain, social support for exercise, exercise self-
efficacy, and physical activity. A structural equation model
revealed multiple mediation pathways, such that higher
general support and strain predicted higher exercise support,
which predicted higher exercise self-efficacy, which predicted
more frequent physical activity. Results demonstrate that
social influence may work through self-efficacy beliefs to
impact behavior. Therefore, in order to increase physical
activity participation, health care providers may need to enlist
the aid of patients friends and family members by
encouraging them to adopt a supportive approach toward
patients and clients.
Introduction
Physical activity is an important health behavior for
preventing age-related disabilities and as a point of
diabetes, and depression (Centers for Disease Control and
Prevention [CDC], 2005; Stanton & Happell, 2013). Because
of the importance of physical activity to public health, social
and psychological factors from multiple theoretical
orientations were examined for their potential to facilitate
physical activity in the present study. Implications for clinical
practice in prevention and health promotion based on the
current findings are provided.
Perceived social support and strain
Perceived social support is the belief that one is cared
for and understood by his or her social network (e.g.,
experiences affirmation from a social partner for engaging in
healthy behaviors) (Walen & Lachman, 2000). On the other
hand, received social support refers to a recipients
retrospective account of actual support transactions (e.g.,
attended by a friend to an exercise class) (Scholz, Kliegel,
Luszczynska, & Knoll, 2012). Perceived social support is an
important psychological resource that is theorized to promote
health via two distinct, but potentially simultaneous pathways:
via (a) direct effects on health outcomes and/or (b) indirect
effects from buffering the negative health effects of perceived
stress (Cohen, 2004). Consistent with the theory of social
support, there is strong evidence that perceived social support

Prevention and Health Promotion: Research, Social Action, Practice And Training: Volume 8, Issue 1 28
both improves health and well-being (Cohen, 2004; Yarcheski,
Mahon, Yarcheski, & Cannella, 2004), and that it attenuates
the negative impact of physiological and psychological
distress on health (Cohen, 2004). In addition to its associations
with improved health both directly and indirectly via stress
buffering, perceived support is also theorized to improve
health indirectly through encouraging engagement in health
promoting behaviors (Cohen, 2004). Consistent with the
theory, perceived social support shares a positive relationship
with physical activity across the adult lifespan, such that
adults who perceive greater support from their social partners
also report more frequent physical activity (Cohen, 2004;
Cotter & Lachman, 2010).
Given the health implications of social support, it is
important to consider demographic differences in the
perception of support available from ones social network. In a
national study of married and cohabitating couples, older
adults reported more social support from their families than
did middle-aged and younger adults (Walen & Lachman,
2000). Further, women report more close social ties in their
support network then men report (Antonucci, Akiyama, &
Lansford, 1998). However, strong social ties may benefit men
more than women, with the marital relationship particularly
more beneficial to men (Westmaas, Wild, & Ferrence, 2002).
Theories examining the influence of social support on
health initially ignored the negative aspects of social relations,
like criticism, hostility, and conflict (Rook, 1984). This social
negativity, or social strain, typically affects health and well-
being negatively, such that those who report more social strain
also report worse physical (Davis & Swan, 1999) and mental
health (Antonucci et al., 1998). In fact, the negative effects of
strain may even be more potent than the positive effects of
support on health and well-being (Newsom, Rook, Nishishiba,
Sorkin, & Mahan, 2005).
Similar to perceptions of support, demographic
differences also exist in perceptions of social strain. Studies
demonstrate that younger and middle-aged adults report more
social strain from families than do older adults, and that
women are more negatively impacted by the strain (reporting
Prevention and Health Promotion: Research, Social Action, Practice And Training: Volume 8, Issue 1
more negative mood and health problems) than men (Walen &
Lachman, 2000). Additionally, social strain from friends has
an inverse relationship with life satisfaction and positive mood
for younger adults and unmarried older women (Walen &
Lachman, 2000).
When considering their associations with health
outcomes, perceived support and perceived strain tend to work
in opposition, and thus higher perceived social strain should
theoretically be associated with less frequent physical activity.
However, perceptions of social strain have not been widely
examined for their relationships to health behaviors. In the few
studies that have examined perceived social strain and
physical activity, researchers have found that more frequent
negative social interactions were associated with more
frequent physical activity in both Japanese (Krause,
Goldenhar, & Liang, 1993) and American samples (Cotter &
Lachman, 2010). To explain these counter-intuitive findings,
Cotter and Lachman argued that the higher rate of physical
activity associated with greater perceived social strain may be
a reaction to a social partners attempt to influence health
behavior through exercise-specific social control/social
support, described below.
Social support for exercise
Social support for exercise (exercise support) is a
specific type of support, whereby a social partner provides
support specifically for engaging in exercise behavior
(McAuley, Elavsky, Jerome, Konopack, & Marquez, 2005).
This type of domain-specific support operates as an extension
of general perceived social support, such that relations
perceived as being generally supportive and positive are also
more likely to provide domain-specific support. An important
distinction, however, is that exercise support has typically
been operationalized as a specific form of received support
(McAuley et al., 2005), not perceived support. Similarly to
general perceived social support, exercise support is also
associated with more frequent physical activity (Warner,
Ziegelmann, Schz, Wurm, & Schwarzer, 2011; Yarcheski et
al., 2004).
29
 While exercise support is likely to be received in the
context of a supportive relationship, Cotter and Lachman
(2010) assert that supportive messages may stem from both
supportive and straining social relationships. For example,
encouraging a friend to engage in physical activity may be
interpreted as an expression of love and caring (support) or as
an expression of hostility and criticism (strain). The link
between perceived strain and exercise support has not been
examined in previous research, but provides an opportunity to
more completely understand how social partners impact the
health and health behaviors of friends and family members.
Exercise self-efficacy
In addition to influencing behavior directly through
supportive and straining interactions, social partners can also
influence behavior indirectly through self-efficacy, which is
an individuals belief in his or her ability to succeed in a
particular situation (Bandura, 1997). Exercise self-efficacy is
one of the best psychological predictors of physical activity
(Jerome & McAuley, 2013; Rovniak, Anderson, Winett, &
Stephens, 2002). However, exercise self-efficacy often shares
an inverse relationship with age, such that older adults tend to
report lower levels of exercise self-efficacy than younger
adults report (Leenders, Silver, White, Buckworth, &
Sherman, 2002; Warner et al., 2011). Therefore, given that
individuals with higher exercise self-efficacy are consistently
more active than their counterparts with lower exercise self-
efficacy (Warner et al., 2011), developing exercise self-
efficacy is a vital component to increasing physical activity
levels across the lifespan.
When describing his theory of self-efficacy, Bandura
(1997) proposed four potential pathways for the development
of self-efficacy: mastery experiences, modeling, persuasion,
and affective states. Of these pathways, persuasion and
modeling rely on a social network. In fact, Banduras
persuasion pathway is analogous to the concept of behavior-
related social support (exercise support in this case) and
therefore may explain the positive relationship between
perceived social support (both general and exercise-specific)
and exercise self-efficacy. Consistent with Banduras theory,
Prevention and Health Promotion: Research, Social Action, Practice And Training: Volume 8, Issue 1
both general perceived and exercise-specific social support
have been shown to work through exercise self-efficacy to
influence physical activity, such that higher support predicts
higher exercise self-efficacy, which predicts greater physical
activity participation (McAuley et al., 2005; Rovniak et al.,
2002; Warner et al., 2011).
Expanding further, individuals who perceive higher
levels of social support may receive more positive health-
related social support messages, thus boosting their exercise
self-efficacy and, in turn, their physical activity participation.
For example, someone who feels that her or his friends
generally care about her or him may interpret encouragement
to exercise as a demonstration of love, thereby boosting her or
his confidence in her or his ability to exercise. In addition,
individuals who perceive higher levels of social strain may
also receive more positive health-related social support
messages. For instance, someone else may interpret
encouragement to exercise as a criticism and may be irritated
by such interaction, yet still engage in exercise behavior.
Thus, higher support and strain may both correlate with more
exercise support.
Based on previous research, higher general perceived
support should predict higher exercise support, which should
predict higher exercise self-efficacy, and thus increased
physical activity levels. The association of perceived strain to
outcomes is less clear because of the dearth of research on this
variable. However, this is an important hole in the literature
with implications for clinical practice. We argue that higher
general perceived strain may also predict higher exercise
support. However, perceptions of strain may undermine
exercise self-efficacy beliefs (Cotter & Sherman, 2008), and
thus reduce physical activity participation. Clearly, testing for
multiple mediation pathways between variables is imperative
for understanding the process by why social relations affect
physical activity behavior, and thus for informing therapeutic
intervention. We address this important omission in the
present study.
The present study
30
 The present study examined the interrelationships of
age, gender, perceived social support, perceived social strain,
exercise support, exercise self-efficacy, and physical activity
using structural equation modeling. Based on previous
empirical research and theories of social support (Thoits,
2011), social strain (Brooks & Dunkel Schetter, 2011), and
self-efficacy (Bandura, 1997), we predicted that younger age,
male gender, higher perceived support, higher perceived
strain, higher exercise support, and higher exercise self-
efficacy would be directly related to more frequent physical
activity. As shown in Figure 1, we also predicted that support
and strain would be associated with physical activity indirectly
through higher exercise support. Finally, we hypothesized that
younger age, higher perceived support, and higher exercise
support would be associated with higher exercise self-efficacy,
which would be associated with more frequent physical
activity.
Method
Procedure
Data for the present study were simultaneously
collected from two different sources: undergraduate
Psychology majors at a Northern California university and
community-dwelling older adults who were recruited through
flyers and presentations at local senior centers. Upon
volunteering, participants were guided through an informed
consent procedure. Next, participants completed the survey. A
research assistant was available to answer questions as the
participants completed the survey. Finally, participants were
debriefed and given information about psychological and
fitness resources. Undergraduates received course research
credit for their participation, and older adults were entered into
a raffle for one of fifteen $25 gift cards. The protocol received
institutional approval for the ethical treatment of participants.
Participants
Participants were 370 community-dwelling, English-
speaking adults ages 18 to 97 (M = 45.21, SD = 26.94), who
volunteered to participate in a paper-and-pencil survey. The
sample recruited through the university ranged between 18
and 52 years old (N = 203, M = 22.02, SD = 4.46, 72%
Prevention and Health Promotion: Research, Social Action, Practice And Training: Volume 8, Issue 1
female), while the sample recruited through senior centers
ranged between 46 and 97 years old (N = 165, M = 73.74, SD
= 10.75, 64% female). Information regarding the demographic
characteristics of race/ethnicity, marital status, education, and
income was also collected (see Table 1) and each of these
variables was dichotomized for analyses.
For the race/ethnicity variable, White participants
comprised one group (51.1%) and all other ethnicity groups
were combined to create the non-White group (48.9%).
Marital status was re-coded with one category of participants
who were currently married (17%) and the second category
with participants who were separated, divorced, widowed, or
never married (83%). Education was dichotomized with one
group of participants who had earned up to a high school
diploma or GED (22.9%) and the other group who attended
some college or higher education (77.1%). Finally, annual
household income was dichotomized at the median, such that
participants earning $20,000 or less comprised one group
(50%) and participants earning $20,001 or more comprised the
other group (50%).
The undergraduate sample reflects an accurate
representation of the age and ethnicity of the undergraduate
population of the university at the time of data collection
(Voluntary System of Accountability Program College
Portrait, 2012). However, women are over-represented.
Women, African Americans, and people of multi-ethnic
heritage are over-represented in the older adult sample
compared to the American population (Howden & Meyer,
2011; Transgenerational Design Matters, 2009). Furthermore,
it should be presumed that the older adults sampled for the
present study represent a relatively healthy and active segment
of the older adult population. While participants were not
asked specific questions regarding health conditions or pain,
all were healthy enough to either attend classes at a university
or to attend functions and activities at a community center.
Measures
Perceived support and strain. Responses to four
questions reflecting each of the following were collected
31
(Walen & Lachman, 2000): perceived social support (e.g.,
How much do your friends really care about you?) and
perceived social strain (e.g., How often does your family
criticize you?) from the family and friends, with higher
scores reflecting more support (M = 3.38, SD = .64, = .82
from family; M = 3.39, SD = .66, = .88 from friends) or
strain (M = 2.09, SD = .77, = .81 from family; M = 1.70, SD
= .64, = .80 from friends). The range of scores in the present
sample reflects the possible range (1 = Not at all to 4 = A lot)
and published reliability ( range from .79 to .91; Walen &
Lachman, 2000). Subscales for each social partner (i.e.,
family, friends) were included in the analyses as observed
indicators of the latent constructs of support and strain.
Social support for exercise. Social support for
exercise was measured with items adapted by Cotter (Cotter,
2012) from Sallis and colleagues (Sallis, Grossman, Pinski,
Patterson, & Nader, 1987) measuring exercise support from
family (13 items) and friends (13 items; e.g., How much do
your friends encourage you to exercise?). Responses to items
were averaged, with higher scores reflecting more exercise
support (M = 2.24, SD = 1.08, = .96 from family, M = 2.30,
SD = 1.05, = .95 from friends). The range of scores in the
present sample reflects the possible range (1 = Never to 5 =
Very Often) and published reliability ( range from .77 to
.97). Subscales for each social partner (i.e., family, friends)
were included in the analyses as observed indicators of the
latent construct of exercise support.
Exercise self-efficacy. Exercise self-efficacy was
measured with 11 items adapted from McAuley (McAuley,
1992); for example, How sure are you that you will be able to
continue exercising when you do not enjoy it? Only one
scale measured exercise self-efficacy. Thus, two item parcels
were created by randomly assigning five items to Parcel A
(items 3, 6, 9, 10, and 11) and six items to Parcel B (items 1,
2, 4, 5, 7, and 8). Each parcel was included in the analyses as
an observed indicator of the latest construct. Responses to
items were averaged, with higher scores reflecting more
exercise self-efficacy (M = 6.19, SD = 2.12, = .78 for Parcel
A, M = 5.70, SD = 2.36, = .87 for Parcel B). The range of
Prevention and Health Promotion: Research, Social Action, Practice And Training: Volume 8, Issue 1
scores in the present sample reflects the possible range (0 =
Not At All Confident to 10 = Very Confident).
Physical activity. Physical activity was measured
with nine items assessing participants frequency of vigorous
and moderate physical activity on a six-point scale ranging
from 0 (Never) to 5 (Several times a week). Vigorous activity
was defined for participants as activity that: causes your heart
to beat so rapidly that you can feel it in your chest and you
perform the activity long enough to work up a good sweat and
are breathing heavily (e.g., competitive sports like running,
vigorous swimming, or high intensity aerobics; digging in the
garden, or lifting heavy objects). Moderate activity was
defined for participants as activity that: is not physically
exhausting, but it causes your heart rate to increase slightly
and you typically work up a sweat (e.g., leisurely sports like
light tennis, slow or light swimming, low impact aerobics, or
golfing without a power cart; brisk walking, mowing the lawn
with a walking lawnmower). Participants scores reflected the
possible range in the present sample.
In accordance with Cotter and Lachman (2010), the
setting in which the participant was most active (work, home,
or leisure) comprised the participants vigorous and moderate
scores. In other words, the highest moderate score of the
three settings was used as the indicator of frequency of
moderate physical activity, and the highest vigorous score of
the three settings was used as the indicator of frequency of
vigorous physical activity. In this manner, if the participant
performed regular activity in the home but not at work or for
leisure, the respondent was still classified as regularly active.
Moderate (M = 3.73, SD = 1.63) and vigorous (M = 3.10, SD =
1.88) activity were included in the analyses as observed
indicators of the latent construct of physical activity.
Analyses
To examine the relative contributions and
interrelations of perceived social support, perceived social
strain, exercise support, exercise strain, and exercise self-
efficacy to physical activity frequency, variables were
examined in structural equation models using AMOS 20
software. Because multiple indexes of fit are preferable when
32
explaining how well data fit structural equation models
(Byrne, 2010), the comparative-fit index (CFI), the parsimony
ratio (PRATIO), and the root mean square error of
approximation (RMSEA) along with its 90% confidence
interval and an index of its closeness of fit (PCLOSE) are
reported.
The CFI reflects the degree to which an independent
model matches the observed data, with values greater than .95
indicating an acceptable fit and values greater than or equal to
.97 indicating a good fit (Schermelleh-Engel, Moosbrugger&
Mller, 2003). The PRATIO provides a measure of model
parsimony, with values expected in the 50s (Bryne, 2010). The
RMSEA is an index of fit that takes the error of approximation
of the population into account. A value less than .05 reflects a
good fit, a value less than .08 reflects a reasonable fit, and a
value greater than .10 indicates a poor fit (Browne & Cudeck,
1993; MacCallum, Browne, & Sugawara, 1996). In addition to
reporting the RMSEA, Byrne argues for reporting the
PCLOSE, which tests whether the RMSEA fits the population.
P-values for the PCLOSE should be greater than .05 (Jreskog
& Srbom, 1996).
To control for the effects of chance when conducting
multiple significance tests simultaneously, the False Discovery
Rate method was adopted (Benjamini & Hochberg, 1995) for
determining a path coefficients statistical significance. In
accordance with others who have applied this method to
structural equation modeling (Lackner, Jaccard, & Blanchard,
2004), a family of tests was defined as the path coefficients
leading from the exogenous variables to a given endogenous
variable.
Results
Before examining SEMs, analyses were conducted on
all variables to ensure normality of the distribution and
reliability of measures. Next, confirmatory factor analyses
(CFAs) were conducted on all latent constructs. Model
statistics for each CFA are presented in Table 2.
Zero-order correlations between all variables were
calculated and examined next (see Table 3). Based on patterns
of correlations, age and sex were the only demographic
Prevention and Health Promotion: Research, Social Action, Practice And Training: Volume 8, Issue 1
characteristics included in SEMs. Next, the hypothesized
model was examined (see Figure 1). This model yielded an
adequate fit to the data, 2(40) = 138.55, p < .001, CFI = .91,
PRATIO = .51, RMSEA = .08 [CI(90) .07 - .10], PCLOSE <
.001. To improve model fit, non-significant pathways were
trimmed and two error terms were allowed to correlate (the
error term associated with perceived family support was
allowed to correlate with the error term associated with
perceived family strain and the error term associated with
perceived friend support was allowed to correlate with the
error term associated with perceived friend strain; Byrne,
2010). The final model, shown in Figure 2, yielded a good fit
to the data, 2(45) = 92.52, p < .001, CFI = .96, PRATIO =
.58, RMSEA = .05 [CI(90) .04 - .07], PCLOSE = .34.
The standardized path coefficients for the final model
are presented in Figure 2, and show that age, sex, perceived
support, perceived strain, exercise support, and exercise self-
efficacy explained 36% of the variance in physical activity
frequency. Both younger age ( = -.53) and higher exercise
self-efficacy ( = .38) directly predicted more frequent
physical activity. Exercise self-efficacy also mediated the
relationships of age and exercise support to physical activity,
such that older age ( = .19) and higher exercise support ( =
.33) were directly associated with higher exercise self-
efficacy, explaining 13% of the variance in exercise self-
efficacy, and higher exercise self-efficacy was associated with
more frequent physical activity in turn. Finally, exercise
support mediated the relationships of perceived support and
perceived strain to exercise self-efficacy, such that higher
perceived support ( = .51) and higher perceived strain ( =
.32) were both associated with higher exercise support,
explaining 36% of the variance in exercise support, which was
associated with higher exercise self-efficacy in turn. Higher
perceived support ( = .06) and higher perceived strain ( =
.04) were associated with more frequent physical activity
indirectly through exercise support, and higher support ( =
.17) and higher strain ( = .11) were also indirectly associated
with higher exercise self-efficacy through exercise support.
33
 Because these data are cross-sectional, causal
direction of effects cannot be determined. In order to yield
more confidence in the present findings, an alternative model
was examined, whereby exercise support predicted both
perceived support and strain. In this way, the reverse
direction of the proposed effect was tested. In this alternative
model, available upon request by the first author, the
mediation pathway between exercise support, exercise self-
efficacy, and physical activity was preserved, 2(23) = 46.70, p
= .002, CFI = .97, PRATIO = .51, RMSEA = .05 [CI(90) .03 -
.08], PCLOSE = .39. Exercise support significantly predicted
perceived support in this alternative model ( = .57).
However, exercise support did not predict perceived strain,
and neither perceived support nor perceived strain predicted
other variables.
Discussion
Results revealed that younger age and higher exercise
self-efficacy directly predicted more frequent physical
activity. Exercise self-efficacy also mediated the relationships
of age and exercise support to physical activity, such that older
age and higher exercise support were directly associated with
higher exercise self-efficacy, and higher exercise self-efficacy
was associated with more frequent physical activity in turn.
Finally, social support for exercise mediated the relationships
of general perceived support and general perceived strain to
exercise self-efficacy, such that higher support and higher
strain were both associated with higher exercise support,
which was associated with higher exercise self-efficacy.
Age
Despite the research demonstrating that regular
physical activity can help mitigate a multitude of health
problems for older adults (CDC, 2005), we found an inverse
relationship between age and physical activity in the present
investigation. This pattern of older adults adopting more
sedentary lifestyles than younger adults is consistent with
previous research (CDC, 2005) and has been at least partly
attributed to changes in exercise self-efficacy: Prior studies
have shown that older adults tend to report lower exercise self-
efficacy than younger adults report (Leenders et al, 2002;
Prevention and Health Promotion: Research, Social Action, Practice And Training: Volume 8, Issue 1
Warner et al., 2011), which may account for some of the age
difference in physical activity levels (Rovniak et al., 2002).
However, in contrast to these reports, the current investigation
revealed a positive relationship between age and exercise self-
efficacy. The present finding that older age is associated with
higher exercise self-efficacy may be explained in part by the
present sample of older adults, who were generally well
educated and active. In fact, many attended the sampled
community centers for the purpose of engaging in a physical
activity program, and thus were likely to be confident in their
ability to exercise regularly. Therefore, the present results may
only generalize to community-dwelling older adults with an
interest in and commitment to physical activity.
Exercise self-efficacy
As mentioned above, exercise self-efficacy has been
reported to be one of the strongest predictors of physical
activity across the life span (Rovniak et al., 2002). In support
of these findings, we found a positive relationship between
exercise self-efficacy and physical activity in the present
samples of both younger and older adults. Corroborating the
recommendations of others (Rovniak et al., 2002), we suggest
that exercise self-efficacy is an important target of
intervention toward the goal of enhancing physical activity
behavior (Kangas et al., 2014; McGowan et al., 2012),
particularly for older adults who are not currently active
(McAuley et al., 2011). Social cognitive theory (Bandura,
1997) includes four pathways for enhancing self-efficacy,
including direct mastery experiences (e.g., successful exercise
experiences) and positive affective states (e.g., positive
evaluations of exercise and limited perceptions of stress
regarding exercise behavior). Two pathways, direct modeling
and persuasion, rely upon the social network. Modeling
involves enhancing self-confidence by mimicking social
models similar to the self, while persuasion includes socially
supportive messages, described below.
Social support for exercise
Bandura (1997) theorized that social partners can
convince targets that they have the ability to engage in specific
behaviors. Thus, direct persuasion and modeling serve as
34
social forces that can enhance self-efficacy. Indeed, our
research revealed a positive relationship between exercise
support and exercise self-efficacy, where higher exercise
support worked through higher exercise self-efficacy to
predict more frequent physical activity. These results support
Banduras arguments that domain-specific support can
increase behavior-specific self-efficacy as well as literature
demonstrating that exercise support influences health behavior
indirectly through exercise self-efficacy (McAuley et al.,
2005; Rovniak et al., 2002). For adults seeking health services,
care providers can provide this encouragement and affirmation
toward increased physical activity as well, potentially boosting
self-efficacy for exercise (Tse, Vong, & Tang, 2013).
Perceived support and strain
Extrapolating beyond domain-specific received social
support to a general perception of relationships as supportive
or straining, past studies demonstrate that social support has a
positive relationship with physical activity across the lifespan
both directly (Warner et al., 2011) and indirectly through
bolstering exercise self-efficacy (Bandura, 1997). In line with
these previous studies, the current study revealed similar but
more complicated indirect relationships between support, self-
efficacy, and physical activity. Specifically, we found that
higher perceived social support from friends and family was
associated with higher exercise support, which was associated
with higher exercise self-efficacy, which was associated with
more frequent physical activity.
These patterns are partially consistent with the
domain-specific effects hypothesis of social relationships,
which states that positive relationship characteristics (e.g.,
social support) elicit positive outcomes (e.g., adopting a
positive health behavior), while negative relationship
characteristics (e.g., social strain) elicit negative outcomes
(e.g., negative affect) (Newsom et al., 2005; Okun, Huff,
August, & Rook, 2007). In partial support of this hypothesis,
higher general social support was associated with higher
exercise support in the present study. Applied to clinical
settings, care providers can encourage patients to reflect on the
supportive aspects of their social environment. Furthermore,
Prevention and Health Promotion: Research, Social Action, Practice And Training: Volume 8, Issue 1
providers can train patients friends and family members to
provide emotional and tangible support, imposing upon them
the importance of offering support and remaining available to
patients if needed (Aschbrenner et al., 2013). Group or family
modalities may be particularly effective toward enhancing
patients perceptions of social support (Gallagher et al., 2013).
The present study also provided an opportunity to
examine the influence of perceived social strain on physical
activity. Consistent with results from Cotter and Lachman
(2010) and Krause et al. (1993), the present findings revealed
a positive association between social strain from friends and
family and physical activity frequency; however, the
relationship was mediated by support for exercise. Consistent
with expectations but perhaps counter-intuitive to many, the
present results revealed that higher perceived social strain
from friends and family was associated with higher exercise
support. Higher exercise support, in turn, predicted higher
exercise self-efficacy, which was associated with more
frequent physical activity.
This result is consistent with Cotter and Lachmans
(2010) assertion that engagement in physical activity may be a
reaction to a social partners attempt to influence health
behavior through health-related social support/social control.
These supportive messages may stem from both supportive
and straining social relationships. For example, a friend may
encourage a target to engage in physical activity. This
interaction may be interpreted as an expression of love and
caring if experienced in the context of a supportive
relationship, or as an expression of hostility and criticism if
experienced in the context of a strained relationship.
Thus, the present results provide evidence for cross-
domain effects of social relations (Okun et al., 2007). The
cross-domain effect hypothesis states that positive relationship
characteristics can elicit negative outcomes, and that negative
relationship characteristics can elicit positive outcomes. For
example, in a sample of college students engaged in
heterosexual dating relationships, Okun et al. (2007) found
that health-related social influences created the dual effects of
having a beneficial impact on health behavior change, while
35
simultaneously eliciting negative emotions. While affect was
not measured in the present study, it is possible that the
present participants received supportive messages that elicited
both negative feelings and behavior change, similar to the
experiences of Okun and colleagues participants. We do not
suggest that care providers encourage the provision of or the
perception of social strain because of its direct negative
influence on health and negative affect (Brooks & Dunkel
Schetter, 2011). Instead, we encourage care providers to
suggest that patients reframe messages they receive from
friends and family as supportive rather than straining. This
mechanism may preserve the pathway from perceived support
to exercise support, thus still possibly boosting self-efficacy
and physical activity.
Limitations and future directions
There are a few limitations of the present study that
must be considered when contextualizing the results. First,
because the current study focused on family and friend
relationships it did not account for other important
partnerships, such as an intimate partners or spouses. Previous
research examining the intimate partner relationship has
revealed mixed findings on the effectiveness of social support
as a health promotion strategy (Stephens et al., 2009). In the
future, including multiple relationship types in one study
would allow for comparisons across relationship type and
would potentially highlight the most efficacious avenues for
intervention.
Moreover, personality and relationship quality may
also affect a social support targets perceptions of and
interpretations of social support messages, as well as his or her
reactions to these messages (Tucker, Elliott, & Klein, 2006).
Thus, future investigations on this topic should include these
and other relevant psychosocial factors. Additionally, while
the participants in the present study were ethnically diverse,
they were also disproportionately female, educated, and in
good health. Furthermore, the current sample included only
younger adults and older adults, and did not include a segment
of midlife individuals, thereby lessening the generalizability of
the findings. Finally, the use of cross-sectional data only
Prevention and Health Promotion: Research, Social Action, Practice And Training: Volume 8, Issue 1
allows for descriptive associations but does not provide causal
evidence. To address these limitations, future investigations
should rely on longitudinal and experimental design and
include more diverse samples of participants.
Implications
Health-related social support and self-efficacy are
potentially easy, inexpensive, and effective targets for
behavioral intervention for adults. Based on the current
results, future intervention work may be effective at eliciting
greater physical activity by adopting a social approach. For
example, exercise can be promoted with a team focus
among friends and family members in order to bolster exercise
support and exercise self-efficacy. As older adults are at
particular risk of sedentary behavior (CDC, 2005), they are a
sound target for these types of intervention programs.
References
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Prevention and Health Promotion: Research, Social Action, Practice And Training: Volume 8, Issue 1 39
Table 1

Prevention and Health Promotion: Research, Social Action, Practice And Training: Volume 7, Issue 1 40
 Table 2

Table 3

Prevention and Health Promotion: Research, Social Action, Practice And Training: Volume 7, Issue 1 41
Figure 1. Hypothesized conceptual model.

Figure 2. Structural equation model examining physical activity frequency.

Note: Standardized path coefficients are presented.

Prevention and Health Promotion: Research, Social Action, Practice And Training: Volume 8, Issue 1 42
 RESEARCH, SOCIAL ACTION, PRACTICE AND TRAINING

The Relationship between Paperwork and Quality of Mental

Health Care
Christopher T. Copeland
Bela Geczy
Thomas W. Westerling III
Oklahoma City Veterans Affairs Medical Center Psychology Service

Thomas W. Westerling III is now at Cambridge Health Alliance, Department of Psychiatry, Harvard Medical
School, Cambridge, MA 02139. Correspondence concerning this article should be addressed to Christopher
Copeland, Psychology Service, Veterans Affairs Medical Center, Oklahoma City, Oklahoma 73104. E-mail:
christopher.copeland@va.gov

Abstract
Although several survey studies demonstrate the
negative impact of a rising burden of paperwork on mental
health care treatment providers (McDaniel, Spieglman, &
Beattie, 2006; Robinson, Murrells, & Smith, 2005; Rupert &
Baird, 2004; Rupert & Morgan, 2005; Stubbe & Thomas,
2002), little is known about actual paperwork increases. We
aimed to test providers subjective notions that paperwork has
increased by comparing medical progress note word counts for
April 2002 and April 2012 at a Veterans Affairs (VA)
psychiatric inpatient unit. Furthermore, because we wanted to
examine whether or not paperwork predicted quality of care,
we entered the number of words written per patient per day by
clinical staff into a regression equation with the number of
times patients were re-admitted within the year for April 2002
or April 2012 as the criterion variable. Results support our
hypotheses that paperwork has risen substantially and does not
predict quality of care. We provide an analysis of causal
influences on the paperwork burden and offer suggestions for
future investigations.
Introduction
Over the past twenty years, several survey studies
suggest a nationwide rise in the paperwork burden for mental
health care professionals. From mental healthcare nursing staff
(Robinson, Murrells, & Smith, 2005), psychiatrists (Stubbe &
Thomas, 2002), and psychologists (Bowers & Knapp, 1993), a
growing consensus has emerged: treatment providers across
the broad spectrum of mental healthcare perceive paperwork as
one of their greatest challenges (Rupert & Morgan, 2005) and
attribute it to their emotional exhaustion and burnout
(McDaniel, Spieglman, & Beattie, 2006; Rupert & Morgan,
2005). Mental healthcare professionals often believe that
administrative paperwork is time consuming, redundant,
unnecessary for clinical care decision-making (Carise, Love,
Zur, McLellan, & Kemp, 2009), and takes face time away from
patients (Cypres, Landsberg, & Spellmann, 1997).
Paperwork demands, for which some programs have
reported relegating full-time clinical staff (McLellan, Carise, &
Kleber, 2003), take clinicians time away from other
administrative responsibilities (e.g., supervision and staff
meetings) and face-to-face interactions with patients while

Prevention and Health Promotion: Research, Social Action, Practice And Training: Volume 7, Issue 1 43
exhausting the clinicians energy (Kirschner & Lachicotte,
2001). Agency psychologists in particular reported spending
more time on administrative tasks and paperwork than solo or
group practitioners (Rupert & Baird, 2004). While time spent
performing administrative and paperwork tasks are related to
greater emotional exhaustion and a lower sense of personal
accomplishment (Rupert & Morgan, 2005), time spent
conducting therapy is positively related to perceptions of
personal accomplishment among psychologists (Rupert &
Morgan, 2005). The negative attitudes among clinicians
regarding paperwork also may be a significant contributing
factor to poor patient care in inpatient settings. To quote
Gaston (1980):
Signs and symptoms of a demotivating organizational
climate are easy to spot. The individual finds that
unwanted actions or decisions affecting his [or her]
institutional life are imposed on him [or her]
externally, and he [or she] has no genuine chance to
consider, influence, or appeal them. He [or she] then
feels vulnerable, helpless, discounted, disregarded,
distrusted, depreciated, or coerced. Conversely, he [or
she] perceives those who impose the unwanted
actions or decisions as attacking, discounting,
disregardful, distrusting, or coercive (409).
Excessive paperwork requirements can also impair
the therapeutic alliance between providers and consumers.
Effective treatment for mental healthcare consumers requires a
strong therapeutic alliance that is characterized by trust,
empathy, and mutual respect (Ruiz-Cordell & Safran 2007;
Wampold, 2012; Weinberger & Rasco, 2007). Clinicians who
are distracted by worries over completing voluminous
documentation may inadvertently convey the impression that
their clients are unimportant compared to more pressing
concerns (Burnett-Zeigler, Zivin, Ilgen, & Bohnert, 2011).
Such disruptive meta-communication may not only impair the
therapeutic alliance and the clients progress but may even
result in treatment failure.
Prevention and Health Promotion: Research, Social Action, Practice And Training: Volume 8, Issue 1
Despite survey data on provider perception of
paperwork, relatively little administrative performance data has
been collected and published to verify the actual extent to
which paperwork has increased. Whether or not the paperwork
burden may be attributed to the development of managed care
in the United States (Carise et al., 2009), to the overall
healthcare governance framework (Jamrozik, 2004), or to a
principals tendency to disregard a subordinates cost (Strausz,
2006), the purpose of the present study is to investigate the
actual rise of paperwork and its effect on quality of care. While
several other variablessuch as administrative meetings or
numerical data keepingare relevant for understanding the
impact of growing administrative tasks, the amount of
paperwork growth over the past ten years was selected for its
salience with mental health care providers and its growing
relevance to the literature on mental health care. Based on
survey data indicating staff perception of paperwork increases,
we hypothesized that paperwork has grown significantly over
the past ten years. Furthermore, we hypothesized that the
increase in paperwork would be unrelated to recidivism as a
quality of care measure. We chose recidivism based on its
utility as indicated by previous researchers and administrators,
because of its ease of access, and because it has been found to
be related to important survey indicators of patient satisfaction
(Druss, Rosenheck, & Stolar, 1999).
Method
Sample and Procedure
We calculated the number of words per patient, per
day (WPD) that clinical staff employed at a psychiatric
inpatient unit wrote for psychiatric inpatients in April 2002 (n
= 81) and April 2012 (n = 88). We copied and pasted
electronic text from each note into a word processor that
recorded word counts, and we protected patient confidentiality
by erasing all data from the word processor file. Note text was
accessed through the Department of Veterans Affairs
Computerized Patient Record System (CPRS) software. We
did not count words in lab reports or medication lists, and we
did not count words in progress notes authored by staff from
other units in the medical center. We operationalized
44
recidivism as the number of times a patient, who was admitted
in April 2002 or April 2012, was re-admitted within the year.
We obtained re-admission counts by totaling admission notes
for each patient authored by staff on the psychiatry inpatient
unit subsequent to patient admission in April 2002 or April
2012. Only the investigators had access to this data. The
procedure described herein was approved by the institutional
review board (IRB) of the medical school with which our
inpatient unit is affiliated and by the VAs local Office of
Research and Development (R & D).
In order to test our hypothesis that paperwork has
increased over time and that this increase did not predict an
increase in quality of care, we tested the mean difference
between April 2002 WPD and April 2012 WPD and entered
WPD into a regression equation with re-admissions as the
criterion variable.
Results
WPD in April 2012 (M = 3176.75, SD = 1116.01) was
significantly greater, t(113.11) = 18.23, p < .001, than WPD in
April 2002 (M = 836.58, SD = 421.56), representing a
278.65% increase in paperwork over time. Readmissions were
not significantly different, t(105.44) = -1.70, p = .092, between
April 2012 (M = 1.11, SD = 2.48) and April 2002 (M = .64, SD
=.78). WPD and readmissions were not significantly related (r
= -.053, p = .248). In a regression equation with WPD as the
predictor variable and readmissions as the criterion variable,
the model was not significant, F(1, 167) = .47, p = .496, as
WPD did not predict readmissions, = -.053, t = -0.68, p =
.496.
Discussion
Results support the hypotheses that paperwork
substantially increased from April 2002 to April 2012 and that
paperwork variables would not predict the number of times
that patients were readmitted within the year. These findings
are consistent with a number of survey studies demonstrating
widespread perceptions of an increasing paperwork burden for
mental health care staff. The increase in the number of words
written per patient represents a troubling statistic in itself, but it
is especially alarming that this increase, which has been shown
Prevention and Health Promotion: Research, Social Action, Practice And Training: Volume 8, Issue 1
to exact costs to staff morale and face-time with patients,
should demonstrate no predictive relationship on such an
important quality of care indicator as recidivism. While several
studies have demonstrated the negative impact of increasing
paperwork on staff satisfaction, our findings speak to the
negligible benefits that this increase has for quality of mental
health care.
Although the research literature has clearly
demonstrated the deleterious impact of excessive
documentation requirements on the morale of clinicians
(Kirschner & Lachicotte, 2001; McDaniel, Spieglman, &
Beattie, 2006; Rupert & Morgan, 2005), complaints in this
regard are rarely, if ever, subjected to empirical
disconfirmation. To our knowledge, our study is the first to (a)
quantitatively measure paperwork change over time, (b)
demonstrate a statistically and clinically significant increase,
and (c) demonstrate its impact, or lack thereof, on a quality of
care performance indicator. Although representativeness for
quality of care is limited by use of one performance measure,
we argue that our resultshowever limitedare more
substantial than evidence published by regulatory and
administrative bodies that enforce paperwork requirements. To
our knowledge, there are no studies that demonstrate a causal
or influential relationship between paperwork requirements
and positive consumer outcomes.
Oversight Entities
Multiple reasons can be hypothesized as contributing
to the increasing documentation requirements for clinical staff.
One potential source is the various administrative oversight
entities that dictate policies and procedures. In the Veterans
Health Administration these include the Congress of the
United States, the VA Central Office (VACO), the Veterans
Integrated Service Network (VISN) headquarters, hospital
administrative policies, various service policies (nursing,
psychiatry, etc.), state laws pertaining to the treatment of the
mentally ill, and various oversight agencies such as the Joint
Commission on Accreditation of Hospital Organizations
(JCAHO), the Commission on Accreditation of Rehabilitation
Facilities (CARF), and the Office of the Inspector General
45
(OIG). Each of these entities has the authority to require
documentation from the clinical staff, but none has the
authority to limit the workload imposed by other entities. If the
documentation capacity of the clinical staff, measured in terms
of number of words written per consumer per day, is
conceptualized as a limited resource, then it logically follows
that, with constantly increasing documentation, a point will be
reached where providers will be unable to complete their
clinical responsibilities. Consequences are likely to include
increased staff stress, decreased consumer contact, decreased
consumer satisfaction, increased job dissatisfaction, impaired
clinical decision making, and provider burnout. Ironically, the
quantity of the documentation may lead oversight entities to
the mistaken conclusion that all is well with the staff and the
quality of the services they provide (Vrouva & Dennington,
2012). Future studies could address the impact of bureaucratic
entities as causal influences on administrative paperwork
demands.
Standardized Care
There are, of course, multiple other factors that could
contribute to increased paperwork aside from oversight
entities. Local conditions such as staff inefficiency in
documentation, staff turnover, changes in staffing levels,
changes in admission rates or length of stay, or increases in the
provision of services could all increase documentation.
Another factor that may be less obvious is an increase in work
standardization. Large health care agencies, such as the VHA,
are constantly striving to provide uniformly excellent health
care. Standardization of all aspects of health care, including
documentation, is an important component of this process.
Veterans seeking care should receive the same excellent level
of care regardless of program type or geographic location.
However, many standardization processes are driven by a
response to a problem that is viewed as a systemic threat. For
example, in 2009 there was an incident on a VA psychiatric
inpatient unit where a patient eloped through an unlocked
window. In response, the VACO sent a national directive
stating that henceforth staff must document, prior to each
admission, that the windows in the room to which the new
Prevention and Health Promotion: Research, Social Action, Practice And Training: Volume 8, Issue 1
patient is assigned have been checked. Our psychiatric
inpatient unit is on the 8th floor; the windows are imbedded in
the wall and cannot be opened. Nevertheless, our staff
document in each chart: Windows are checked. If window is
found unsecured, the key is obtained from the 8N medication
room and window is secured before patient allowed entry into
room.
While the amount of effort required to insert the above
phrase is relatively small, when it is multiplied by an average
of 978 admissions per year, as well as considering the other
minute additions to documentation that are added each year,
the resulting paperwork becomes significant. Even if a
clinician is not responsible for authoring paperwork, clinicians
who read this paperwork must scroll through distracting, vast
volumes of data that is only relevant to oversight entities.
A factor closely related to standardization is the
increasing shift from paper to electronic record keeping.
Electronic charts have multiple advantages over paper
(Hillestad, et al., 2005). However, their easy accessibility and
utility also contribute to the documentation load. With
electronic records it is relatively easy to create a new template
in response to a new requirement. Once a template becomes a
standard part of the record, it is very difficult to remove, even
if its purpose is irrelevant. Users of the record usually do not
have the authority to terminate it, and oversight entities who
initiate documentation rarely rescind requirements.
Limitations and Conclusions
Our study has a number of limitations. Its
generalizability is limited to inpatient psychiatric units in the
VA system, and is based on one sample in a limited geographic
location. With respect to our research design, the
representations of time and quality of care as constructs are
especially prone to validity threats. Regarding our
representation of time, we only measured one out of twelve
months for two different years. It may rather be the case that
April 2002 and April 2012 do not adequately depict changes
over the past ten years. Regarding our representation of quality
of care, readmission rate represents one variable among many
potential indicators. Although readmission rate is popular
46
because of its availability and quantitative nature, it is not
sensitive to more subjective indicators of quality such as
patient satisfaction. Furthermore, a reasonable argument could
be made that increased readmission represents an increase in
care quality since patients who readmit themselves may do so
because they are better connected to their local health care
system. Due to these limitations, our conclusions are tentative
and may not generalize to all or even most other VA medical
centers across the United States. Despite these limitations,
however, we were able to provide a first step to empirically
supporting the view among many clinicians that there has been
a significant paperwork increase in the past ten years and that
this increase has not been consistent with an increase in quality
of health care. We suggest that future investigations address
our limitations by including sampling cases across more time
points, more locations, and more quality of care indicators.
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