Emotional Impacts of Premature Ovarian Failure in Kuwait

of the Study 1. A major limitation of this study is the small sample size. In future it will be commendable to study a large number of women with premature ovarian failure through a multicenter study design. 2. There was no intervention in the present study. Evaluation of the role of spirituality through the inclusion of Islam and Christianity will be of clinical interest. 5. Conclusion Premature Ovarian Failure is associated with severe emotional reactions and pose significant psychological difficulty for a sizeable proportion of those who have the condition, with impaired ability to cope with their low self-esteem. Management should involve a multi-disciplinary and holistic approach in which the provision of psychological care should be an integral part of clinical management. Affected women need an effective support system to help them come to terms with their diagnosis. Conflict of Interest The authors declare no conflict of interest in the present study. Appendix 1 Scale 2. HEALTH ORIENTATION SCALE (HOS) INSTRUCTIONS: The items listed below refer to people’s health. Please read each item carefully and decide to what extent it is characteristic of you. Give each item a rating of how much it applies to you by using the following scale: A = Not at all characteristic of me. B = Slightly characteristic of me. C = Somewhat characteristic of me. D = Moderately characteristic of me. E = Very characteristic of me. NOTE: Remember to respond to all items, even if you are not completely sure. Your answers will be kept in the strictest confidence. Also, please be honest in responding to these statements. 1. I am very aware of how healthy my body feels. 2. I sometimes wonder what others think of my physical health. 3. I feel anxious when I think about my health. 4. I feel confident about the status of my health. 5. I do things that keep me from becoming physically unhealthy. 6. I’m very motivated to be physically healthy. 7. I feel like my physical health is something that I myself am in charge of. 8. The status of my physical health is determined mostly by chance happenings. 9. I expect that my health will be excellent in the future. 10. I am in good physical health. 11. I notice immediately when my body doesn’t feel healthy. 12. I’m very concerned with how others evaluate my physical health. 13. I’m worried about how healthy my body is. 14. I rarely become discouraged about my health. 15. I am motivated to keep myself from becoming physically unhealthy. 16. I’m strongly motivated to devote time and effort to my physical health. 17. My health is something that I alone am responsible for. 18. The status of my physical health is controlled by accidental happenings. 19. I believe that the future status of my physical health will be positive. 20. My body is in good physical shape. 21. I’m sensitive to internal bodily cues about my health. 22. I’m very aware of what others think of my physical health. 23. Thinking about my health leaves me with an uneasy feeling. 24. I am pleased with how well and healthy I feel. 25. I try to avoid engaging in behaviors that undermine my physical health. 26. I have a strong desire to keep myself physically healthy. 27. The status of my physical health is determined largely by what I do (and don’t do). 28. Being in good physical health is just a matter of luck. 29. I do not expect to suffer health problems in the future. 30. I am a well-exercised person. 31. I know immediately when I’m not feeling in great health. 32. I’m concerned about how my physical health appears to others. 33. I usually worry about whether I am in good health. 34. I have positive feeling about my health. 35. I really want to prevent myself from getting out of shape. 36. It’s really important to me that I keep myself in proper physical health. 37. What happens to my physical health is my own doing. 38. Being in excellent physical shape has little or nothing to do with luck. 39. I will probably experience a number of health problems in the future. 40. My body needs a lot of work in be in excellent physical shape. 41. I’m very aware of changes in my physical health. 42. I’m concerned about what other people think of my physical health. 43. I feel nervous when I think about the status of my physical health. 44. I feel that I have handled my health very well. 45. I am really motivated to avoid being in terrible physical shape. 46. I strive to keep myself in tip-top physical shape. 47. Being in good physical health is a matter of my own ability and effort. 48. I don’t believe that chance or luck play any role in the status of my physical health. 49. I anticipate that my physical health will deteriorate in the future. 50. My physical health is in need of attention. Copyright-1996 Scoring Instructions for the Health Orientation Scale (HOS) The Health Orientation Scale (HOS) consists of10 health-oriented subscales, each containing five items. The labels, descriptions, and items for each of these subscales are listed below: 1. Personal Health Consciousness: The items on the Personal Health Consciousness (PHC) subscale refer to an awareness of one’s health. These items were designed to measure people’s tendency to think about and to reflect about their health. People who endorse these items are those who think about that status of their physical health, and who in general are reflective about the nature of the health and wellness of their body. 1. I am very aware of how healthy my body feels. 11. I notice immediately when my body doesn’t feel healthy. 21. I’m sensitive to internal bodily cues about my health. 31. I know immediately when I’m not feeling in great health. 41. I’m very aware of changes in my physical health. 2. Health Image Concern: The items on the Health Image Concern (HIC) subscale refer to an awareness of other people’s reactions to one’s health. More specifically, these items were designed to measure people’s public concern about the image which their health (or lack thereof) projects to others. People who endorse these items are those who are concerned about the appearance of their health to others, the impression their health makes on others, and how healthy and well others consider them to be. 2. I sometimes wonder what others think of my physical health. 12. I’m very concerned with how others evaluate my physical health. 22. I’m very aware of what others think of my physical health. 32. I’m concerned about how my physical health appears to others. 42. I’m concerned about what other people think of my physical health. 3. Health Anxiety: The items on the Health Anxiety (HA) subscale refer to anxious feelings associated with the status of one’s health. More specifically, these items were designed to tap people’s feelings of tension, discomfort and anxiety about their physical health. People who endorse these items are those who experience chronic anxiety as a result of thinking about their physical health. 3. I feel anxious when I think about my health. 13. I’m worried about how healthy my body is. 23. Thinking about my health leaves me with an uneasy feeling. 33. I usually worry about whether I am in good health. 43. I feel nervous when I think about the status of my physical health. 4. Health-Esteem and Confidence: The items on the Health-Esteem and Confidence (HEC) subscale were designed to measure the extent to which people derive a sense of esteem from the physical status of their body, and the extent to which they feel confident about their physical health. More specifically, these items are concerned with how positive individuals feel about their physical wellness. People who endorse these items are those who feel good about the health status of their bodies; they feel positive esteem about their health and they have an air of confidence that their health is robust and durable. 4. I feel confident about the status of my health. 14. I rarely become discouraged about my health. (R) 24. I am pleased with how well and healthy I feel. 34. I have positive feeling about my health. 44. I feel that I have handled my health very well. 5. Motivation to Avoid Unhealthiness: The items on the Motivation to Avoid Unhealthiness (MAU) subscale refer to motivational tendency to avoid being or becoming unhealthy. More specifically, these items were designed to measure people’s motivational tendency to avoid poor physical health. People who endorse these items are those who are concerned about becoming unhealthy; they are motivated to avoid behaviors and activities which undermine their physical health. 5. I do things that keep me from becoming physically unhealthy. 15. I am motivated to keep myself from becoming physically unhealthy. 25. I try to avoid engaging in behaviors that undermine my physical health. 35. I really want to prevent myself from getting out of shape. 45. I am really motivated to avoid being in terrible physical shape. 6. Motivation for Healthiness: The items on the Motivation for Healthiness (MFH) subscale refer to the motivation to pursue positive physical health. More specifically, these items were designed to measure people’s motivation to keep in excellent physical health. People who endorse these items are those who are motivated to attend to the physical health of their body, to engage in activities which promote their physical health, and to strive to maintain the wellness and integrity of their physical health. I’m very motivated to be physically healthy. I’m strongly motivated to devote time and effort to my physical health. 26. I have a strong desire to keep myself physically healthy. 36. It’s really important to me that I keep myself in proper physical health. 46. I strive to keep myself in tip-top physical shape. 7. Health Internal Control: The items on the Internal Health Control (IHC) subscale refer to people’s belief that their health status is determined by their own personal control. More specifically, these items were designed to measure people’s expectation that they themselves can exert an influence on their health. People who endorse these items are those who believe that they can determine whether their physical health is positive or negative. 7. I feel like my physical health is something that I myself am in charge of. 17. My health is something that I alone am responsible for. 27. The status of my physical health is determined largely by what I do (and don’t do). 37. What happens to my physical health is my own doing. Being in good physical health is a matter of my own ability and effort. 8. Health External Control: The items on the External Health Control (EHC) subscale refer to people’s belief that their health status is determined by experiences and influences outside of their personal control. More specifically, these items were designed to measure people’s expectation that their health status is largely determined by forces which they themselves can neither anticipate nor influence. People who endorse these items are those who believe that their health is not controlled by themselves rather that their physical health is under the influence of factors external to themselves. 8. The status of my physical health is determined mostly by chance happenings. 18. The status of my physical health is controlled by accidental happenings. 28. Being in good physical health is just a matter of luck. 38. Being in excellent physical shape has little or nothing to do with luck. (R) 48. I don’t believe that chance or luck play any role in the status of my physical health. (R) 9. Health Expectations: The items on the Health Expectations (HE) subscale refer to an expectation that one will continue to experience positive physical health in the future. More specifically, these items were designed to measure people’s belief that their health will continue to be excellent and robust. People who endorse these items anticipate that their future physical health will continue to be good. 9. I expect that my health will be excellent in the future. 19. I believe that the future status of my physical health will be positive. 29. I do not expect to suffer health problems in the future. 39. I will probably experience a number of health problems in the future. (R) 49. I anticipate that my physical health will deteriorate in the future. (R) 10. Health Status: The items on the Health Status (HS) subscale concerns people’s assessment of the physical status of their body. More specifically, these items were designed to measure the extent to which people assess their body as being in excellent and robust health. People who endorse these items believe that they are in excellent physical health. 10. I am in good physical health. 20. My body is in good physical shape. 30. I am a well-exercised person. 40. My body needs a lot of work in be in excellent physical shape. (R) 50. My physical health is in need of attention. (R) The Development and Validation of the Health Orientation Scale: A Measure of Personality Tendencies Associated with Health

In recent years a number of investigators have begun to examine the impact of people’s personality tendencies on their physical health. The present investigation sought to further explore this issue through the development and validation of an objective self-report instrument designed to measure multiple aspects of people’s health-related personality tendencies. Reliability analyses provided evidence of internal consistency for the subscales on the Health Orientation Scale (HOS). Other results indicated that both gender and age jointly influenced people’s responses to the Health Orientation Scale. A final set of results revealed that the personality variables measured by the Health Orientation Scale were predictive of women’s and men’s compliance with actual health-promoting behaviors. The discussion focuses on the potential uses of the Health Orientation Scale in both research and applied settings.

The purpose of the present investigation was to construct and validate an objective self-report measure of several health-related personality features: private health consciousness, defined as the tendency to be highly aware of and to think about one’s physical health-fitness; health image concern, defined as the tendency to be highly aware of the external, observable impression that one’s physical health makes on others; health anxiety, defined as the tendency to be anxious and nervous about one’s physical health-fitness; health esteem-confidence, defined as a generalized tendency to positively evaluate and to feel confident about one’s physical health; motivation to avoid unhealthiness, defined as the motivation and desire to avoid being in a state of unhealthiness; motivation for healthiness, defined as the motivational tendency and desire to keep oneself in great physical health; internal health control, defined as the tendency to believe that one’s physical health and fitness is a direct function of one’s own behaviors and actions; external health control, defined as the tendency to believe that one’s health status is determined by uncontrollable factors factors external to oneself; health expectations, defined as the tendency to expect that one’s health will be excellent and positive in the future; and health status, defined as the tendency to regard oneself as being currently well-exercised and in good physical shape. The measurement of these health-related personality tendencies was accomplished through the development of the Health Orientation Scale (HOS). Reliability analyses confirmed that all ten subscales on the Health Orientation Scale possessed clearly acceptable levels of internal reliability. Additional findings indicated that men reported more internal health control than did women, and that they also tended to report higher scores on the health esteem-confidence and health status subscales than women. This indicates that the men in the present study believed they had more personal control of their physical health-fitness than did the women. In addition, the men in the present study tended to derive a greater sense of esteem from their physical health than did the women, and they tended to report being in better physical health. Several age related finding were also reported in this investigation. Older individuals expressed less concern than did younger and middle-age individuals about the public impression which their physical health creates. In addition, older individuals reported less anxiety about their physical health and less motivation for healthiness than did both younger and middle-age people. These findings corroborate earlier evidence reported by Bausell (1986) that there is a need for health promotion activities among older persons. Age was also found to interact with gender in predicting people’s scores on the Health Orientation Scale (HOS). Middle-age males and older females expressed the strongest belief that their physical health was predominantly influenced by factors external to their own personal control. Future research is needed, however, to clearly understand the nature of this finding. Middle-age males, for example, may be spending so much time and effort at career development that it interferes with the promotion of their physical health―and thus they develop an external locus of control orientation toward their physical health. In addition, older males may have already established themselves in their careers or else they may have already retired from their jobs, with the result that excessive career dedication no longer fosters an external orientation toward the control of their physical health. Certainly these are interesting ideas that need to be investigated in future work that focuses on both working men and women. Two other age related findings were found among the men and women examined in the present research. Among males, those who were younger reported the greatest motivation for healthiness and the greatest motivation to avoid unhealthiness. These young males may have reported this health motivation because of an interest in attracting members of the other gender through a healthy physical appearance. Whatever the true explanation, this finding underscores the need for greater health promotion among middle-age and older males, both of whom seemed to be the least interested in the maintenance of their physical health. Interestingly, middle-age women also reported a high level of motivation for healthiness and a high level of motivation to avoid unhealthiness, suggesting that younger and older women are especially in need of information about their physical health. Perhaps middle-age women are more knowledgeable about behaviors that contribute to physical health and thus they are more motivated to take care of themselves. Alternatively, it could be that as women approach middle-age they become more concerned about their physical appearance and the physiological implications of the aging process itself, which in turn could lead to greater motivation for healthiness and greater motivation to avoid unhealthiness. While these explanations seem possible, still future research is needed to more closely examine their plausibility. The present investigation also provided evidence for the validity for the subscales on the Health Orientation Scale. Both men and women who reported higher scores on the motivation for healthiness and the motivation to avoid unhealthiness subscales were found to engage in a wide variety of dietary and life-style behaviors that contribute to good physical health and fitness. Further evidence for the validity of the Health Orientation Scale was indicated by the findings that internal health control was positively associated and that external health control was negatively associated with compliance to a number of health-seeking behaviors. These findings are consistent with those found for the Multidimensional Health Locus of Control Scales (Wallston, Wallston, & DeVellis, 1978). People who believe that they themselves are the primary determinants of their health status are more likely to take control of their life in a way that contributes to the avoidance of health risks and to the promotion of health sustaining behaviors. For example, in the present investigation both men and women who had an internal health control orientation reported that they watched their weight and exercised in a routine fashion. These findings provide clear evidence that the study of the psychological tendencies assessed by the Health Orientation Scale can add to our understanding of the determinants of healthy behaviors. Permission is granted to individuals to use the Health Orientation Scale (HOS) for research purposes. Permission granted by William E. Snell, Jr. on February 18, 1997. Appendix 2 Chronic Disease Self-Efficacy Scales We would like to know how confident you are in doing certain activities. For each of the following questions, please choose the number that corresponds to your confidence that you can do the tasks regularly at the present time. Scales/Items (using the same format as above): Self-Efficacy to Perform Self-Management Behaviors Exercise Regularly Scale 1. How confident are you that you can do gentle exercises for muscle strength and flexibility three to four times per week (range of motion, using weights, etc.)? 2. How confident are you that you can do aerobic exercise such as walking, swimming, or bicycling three to four times each week? 3. How confident are you that you can exercise without making symptoms worse? Get Information About Disease Item 1. How confident are you that you can get information about your disease from community resources? Obtain Help from Community, Family, Friends Scale 1. How confident are you that you can get family and friends to help you with the things you need (such as household chores like shopping, cooking, or transport)? 2. How confident are you that you can get emotional support from friends and family (such as listening or talking over your problems)? 3. How confident are you that you can get emotional support from resources other than friends or family, if needed? 4. How confident are you that you can get help with your daily tasks (such as housecleaning, yard work, meals, or personal hygiene) from resources other than friends or family, if needed? Communicate With Physician Scale 1. How confident are you that you can ask your doctor things about your illness that concerns you? 2. How confident are you that you can discuss openly with your doctor any personal problems that may be related to your illness? 3. How confident are you that you can get work out differences with your doctor when they arise? General Self-Efficacy Manage Disease in General Scale 1. Having an illness often means doing different tasks and activities to manage your condition. How confident are you that you can do all the things necessary to manage your condition on a regular basis? 2. How confident are you that you can judge when the changes in your illness mean you should visit a doctor? 3. How confident are you that you can do the different tasks and activities needed to manage your health condition so as to reduce your need to see a doctor? 4. How confident are you that you can reduce the emotional distress caused by your health condition so that it does not affect your everyday life? 5. How confident are you that you can do things other than just taking medication to reduce how much your illness affects your everyday life? Self-Efficacy to Achieve Outcomes Do Chores Scale 1. How confident are you that you can complete your household chores, such as vacuuming and yard work, despite your health problems? 2. How confident are you that you can get your errands done despite your health problems? 3. How confident are you that you can get your shopping done despite your health problems? Social/Recreational Activities Scale 1. How confident are you that you can continue to do your hobbies and recreation? 2. How confident are you that you can continue to do the things you like to do with friends and family (such as social visits and recreation)? Manage Symptoms Scale 1. How confident are you that you can reduce your physical discomfort or pain? 2. How confident are you that you can keep the fatigue caused by your disease from interfering with the things you want to do? 3. How confident are you that you can keep the physical discomfort or pain of your disease from interfering with the things you want to do? 4. How confident are you that you can keep any other symptoms or health problems you have from interfering with the things you want to do? 5. How confident are you that you can control any symptoms or health problems you have so that they don’t interfere with the things you want to do? a) Manage Shortness of Breath Item 1. How confident are you that you can keep your shortness of breath from interfering with what you want to do? Control/Manage Depression Scale 1. How confident are you that you can keep from getting discouraged when nothing you do seems to make any difference? 2. How confident are you that you can keep from feeling sad or down in the dumps? 3. How confident are you that you can keep yourself from feeling lonely? 4. How confident are you that you can do something to make yourself feel better when you are feeling lonely? 5. How confident are you that you can do something to make yourself feel better when you are feeling discouraged? 6. How confident are you that you can do something to make yourself feel better when you feel sad or down in the dumps? Scoring The score for each item is the number circled. If two consecutive numbers are circled, code the lower number (less self-efficacy). If the numbers are not consecutive, do not score the item. The score for each scale is the mean of the items. For scales of 1 - 2 items, do not score the scale if any item is missing; for scales with 3-4 items, do not score the scale if more than 1 item is missing; for scales with 5 - 6 items, do not score the scale if more than 2 items are missing. Higher number indicates higher self-efficacy. Characteristics Source of Psychometric Data Stanford Chronic Disease Self-Management Study. Psychometrics reported in: Lorig, K., Stewart, A., Ritter, P., González, V., Laurent, D. and Lynch, J. (1996) Outcome Measures for Health Education and other Health Care Interventions. Sage Publications, Thousand Oaks, 24-25, 41-45. Comments These scales were developed and tested for the Chronic Disease Self-Management study. We use a shorter, 6-item scale now, as it is much less burdensome for subjects.

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