Exercise, Self-Perceptions and Mood during Pregnancy

Khaliah Petersson

BPHE, Dip Phys. Ed

Supervisor; Professor J. Robert Grove

This thesis is presented as one of the requirements for the degree of

Master of Science at

The University of Western Australia

School of Sport Science, Exercise and Health

2008

ii

Acknowledgements There are a number of people I would like to thank in making this thesis a reality. First and foremost, I would like to extend my deepest gratitude to my mentor and supervisor, Professor Bob Grove, who has provided me with this golden opportunity to experience this research journey. His patience, tolerance and dedication are beyond words. With his vast knowledge and especially his enthusiasm, he not only provided me with a deeper understanding of exercise and health psychology, but also to fully appreciate the research profession. I now fully understand the concept of “selling a product”. I would also like to express my sincere thanks to the ladies who took part in this study. The exchange of stories and experiences was welcoming and inspirational. It opened my eyes to pregnancy in a whole different light. I am also grateful to Professor John Newnham and the receptionists at King Edward Memorial Hospital antenatal clinics for their help and words of encouragement during data collection. Warmest thanks to all my friends; the list is endless, for your prayers, help and support throughout the past year. Especially to my dear friend Veronica, who’s endless bursts of energy and laughter, deserves special thanks. You have been there for me through thick and thin, throughout this long process, I am sincerely grateful for your constant support and most importantly your friendship. To my family; for all your love and support. A very special warm thanks to my ‘adopted’ Swedish mum, Ebba, for her positive words of wisdom and most importantly for believing in me. I am deeply grateful for your constant encouragement in my pursuing this dream. Finally, I dedicate this thesis to my husband Johnny - without his constant support and encouragement and unwavering belief in me, this trip would not have been possible. And to my beautiful daughter, Sarah, who’s constant kisses and laughter and imitations of me while working on the thesis, distracts me from my work and just makes things a lot more bearable when the going gets tough.

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Abstract

The general purpose of this research was to investigate physical activity levels as a correlate of selected aspects of psychological health among pregnant women. Specifically, the aims of the study were (1) to provide a cross-sectional description of changes in physical self-concept, mood, and perceived stress during pregnancy; (2) to evaluate physical activity patterns of pregnant women over time during pregnancy; and (3) to determine if there is a difference between physical activity and physical self-concept, mood, perceived stress and/or burnout symptoms during pregnancy. Participants were pregnant women from various antenatal clinics at King Edward Memorial Hospital. The women completed a questionnaire package containing questions on physical activity levels and measures of physical self-concept, social physique anxiety, perceived stress, mood and burnout symptoms. A series of ANOVAs was used to provide a descriptive profile of how these psychological variables change during the course of pregnancy. Significant time-related differences were found for the perceived health subscale of the PSDQ and the tension subscale for the BRUMS. Findings also suggested a significant association between physical activity, and physical self-perceptions, most importantly self-esteem. Higher levels of physical activity were also found to be closely related to positive mood states, lower levels of perceived stress and fewer burnout symptoms. No significant association was found between physical activity and social physique anxiety. Key words: Physical self-perceptions, perceived stress, social physique anxiety, mood states, burnout syndrome, physical activity, exercise, pregnant women

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Table of Contents

Page

Acknowledgements ii Abstract iii Table of Contents iv List of Tables vi List of Figures vii Chapter 1 Introduction 1 1 Overview 1 1.1 Purpose of the research 4 1.2 Significance of the study 4 1.3 Definition of terms 5 1.4 Hypotheses 6

Chapter 2 Literature Review 7 2.1 The extent of the problem 7 2.2 Benefits of physical activity during pregnancy 8 2.3 Physical self-concept 11 2.4 Physical activity/exercise and mental health 15

2.4.1 Physical self-concept and physical

activity/exercise 15 2.4.2 Social physique anxiety and physical

activity/exercise 17

2.4.3 Perceived stress and physical activity/exercise 18

2.4.4 Mood and physical activity/exercise 20

2.4.5 Burnout and physical activity/stress 22

Chapter 3 Method 24 3.1 Participants 24 3.2 Instruments and Measures 25 3.2.1 Physical activity 25

3.2.2 Physical self-concept 26

3.2.3 Mood 27

3.2.4 Stress 27

3.2.5 Burnout 27

3.3 Procedure 29 3.4 Analysis of data 29

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Chapter 4 Results 30 4.1 Descriptive statistics and reliability 30 4.2 Analyses related to pregnancy weeks 31

4.3 Analyses related to physical activity 35 4.3.1 Physical activity and perceived stress 35 4.3.2 Physical activity and physical self-concept

and physique anxiety 36 4.3.3 Physical activity and mood states 40

4.3.4 Physical activity and burnout symptoms 41 Chapter 5 Discussion 43 5.1 Analyses related to pregnancy weeks 44 5.2 Analyses related to physical activity 47 5.2.1 Physical self-concept findings 47

5.2.2 Social physique anxiety findings 49

5.2.3 Mood state findings 49

5.2.4 Perceived stress findings 50

5.2.5 Burnout symptom findings 51

5.3 Summary and Implications 51 5.4 Limitation and Delimitations 52 5.5 Conclusions 53 5.6 Future directions 54

References 55

Appendices 66

Appendix A Research Information Sheet Appendix B Informed Consent Form

Appendix C Research Questionnaire

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List of Tables

Page

Chapter 3 Methods Table 3.1 Modified version of the Maslach Burnout Inventory –

General Survey 28

Chapter 4 Results Table 4.1 Descriptive Statistics – Demographics 30

Table 4.2 Descriptive Statistics – Psychological Measures and Internal Consistency 32

Table 4.3 Descriptive Statistics – Physical Activity Measures 33

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List of Figures

Chapter 2 Literature Review Figure 2.1 Diagrammatic representation of the hierarchical structure

of self-concept 12

Figure 2.2 Diagrammatic representation of the Conceptual Framework for the Physical Self-Perception Profile 13

Figure 2.3 Diagrammatic representation of the PSDQ 14

Chapter 4 Results Figure 4.1a PSDQ Perceived Health according to pregnancy weeks 34 Figure 4.2a Tension (BRUMS) according to pregnancy weeks 34 Figure 4.3a Physical Activity and Perceived Stress 35 Figure 4.4a Physical Activity and Perceived Coordination (PSDQ) 37 Figure 4.4b Physical Activity and Perceived “Physically Active” (PSDQ) 37 Figure 4.4c Physical Activity and Perceived Endurance (PSDQ) 38 Figure 4.4d Physical Activity and Perceived Health (PSDQ) 38 Figure 4.4e Physical Activity and Perceived Strength (PSDQ) 39 Figure 4.4f Physical Activity and General Self-Esteem (PSDQ) 39 Figure 4.5a Physical Activity and Vigor (BRUMS) 40 Figure 4.5b Physical Activity and Total Negative Mood (BRUMS) 41 Figure 4.6a Physical Activity and Personal Efficacy (MB!-GS) 42 Figure 4.6b Physical Activity and Total Burnout (MBI-GS) 42

Chapter 5 Discussion Figure 5.1a Diagrammatic representation of relationships investigated 43

1

CHAPTER 1 Introduction

1 Overview

Pregnancy and childbirth are major life events for the expectant mother as well as

her family members. Therefore, the way in which these events are managed can

have long-lasting effects on both maternal and child health as well as the “social

health” of the family unit. Currently there are 20.1 births per 1000 of the world

population (U.S. Census Bureau, 2007). In Australia alone, there were 259, 800

registered births in 2005, an increase of 2.2% from 2004 (Australian Bureau of

Statistics, 2006). The latest figures show that birth rates have increased to 265, 900

per year, the highest on record (Australian Bureau of Statistics, 2007). This trend of

rising birth rates increases the likelihood of an associated increase in the cost of

birth-related hospital care.

Along with the increasing healthcare expenditure associated with pregnancy, there

are also a number of social and psychological consequences. The pregnancy and

childbirth process initiates numerous physical and psychological challenges, as well

as placing great physiological demands on the woman’s body. The physical

challenges are widespread with multiple body systems involved. Because of these

physical changes, it has been argued that pregnancy stresses the body more than

any other physiological event in a healthy woman’s life (Sternfeld, 1997). Thus, an

investigation of cost-effective strategies for improving both physical and mental

health during pregnancy is useful and important. Improving the health status of

individuals in the society is a step towards producing significant effects on the

overall health of the nation and subsequently reducing its healthcare expenditure.

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Exercise could be a cost-effective strategy for optimizing physical and mental health

during pregnancy. The potential benefits of regular physical activity and exercise in

terms of physical and psychological health have been well-documented in various

populations. Regular physical activity promotes physical health such as reducing

obesity, preventing bone loss associated with aging and increasing oxygen

consumption. It also leads to decreases in the risk of mortality associated with

cardiovascular disease, diabetes mellitus and cancer as well as decreasing all-cause

mortality (Sundquist, Qvist, Sundquist, & Johansson, 2004). In a narrative review of

the literature on physical inactivity and its role in the development of chronic

diseases such as cardiovascular disease, diabetes, cancer, hypertension, obesity,

osteoporosis, and depression, sufficient evidence was found to confirm that regular

physical activity is effective in the primary and secondary prevention of the above-

mentioned chronic diseases (Warburton, Nicol, & Bredin, 2006). Improvements in

various mental processes (e.g., reaction time, intellectual and memory capabilities)

have also been documented as a result of both acute exercise and chronic exercise

programs (Etnier et al., 1997).

Exercise has also been shown to lead to improvements in psychological health.

These changes include more positive self-concept (Fox, Boutcher, Faulkner, &

Biddle, 2000; Fox & Corbin, 1989; Sonstroem, Speliotis, & Fava, 1992); a greater

sense of well-being (Alfermann & Stoll, 2000); reductions in anxiety, tension,

confusion, fatigue, anger and depression (Allison, Dywer, & Makin, 1999; Biddle,

1995; Feldman, Barnett, Shrier, Rossignol, & Abenheim, 2003); and improvements

in quality of life and mood (Steptoe & Cox, 1988). Exercise has also been proven to

be effective in treating mild to moderate depression and anxiety (Dunn, Trivedi, &

O'Neill, 2001).

Mood enhancement has been associated particularly with aerobic exercise (Plante

& Rodin, 1990). Consistent with this are findings on measures taken after exercise

which have documented improvements in mood states such as anxiety, tension,

confusion, and vigour (Berger & Owens, 1988; Steptoe & Cox, 1988). The magnitude

of these mood changes seems to depend on a variety of factors such as fitness

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status, type and intensity of exercise, and/or the time lag between exercise and

assessment of mood (Boutcher & Landers, 1988). Nonetheless, experimental

studies have documented positive mood effects from exercise interventions ranging

in length from 6 weeks to 12 months (Blumenthal, Williams, Needels, & Wallace,

1982). Moreover, comprehensive reviews have consistently documented exercise-

related reductions in the stress-related emotions of anxiety and depression (North,

McCullagh, & Tran, 1990).

Similar benefits are evident with respect to depression, and the effects appear to be

greatest for more severely depressed individuals (McDonald & Hodgdon, 1991;

North, McCullagh, & Tran, 1990). For this reason, exercise is viewed as a useful tool

in the treatment of clinical depression (Blumenthal, Brosse, Lett, & Sheets, 2002).

Studies of stress reactivity and perceived stress have also found beneficial effects

from exercise (Aldana, Sutton, Jacobson, & Quirk, 1996). Interestingly, women

appear to be especially receptive to the use of exercise as a stress reduction

strategy (Rodgers & Gauvin, 1998).

Studies have also shown that exercise is potentially beneficial to pregnant women

(Brown, 2002; Poudevigne & O'Connor, 2005). Pregnancy is thus an ideal time to

promote healthier lifestyles as the expectant mother is likely to be more receptive

to information that can bring potential benefits to both herself and her child.

Against this backdrop, exercise is a potentially beneficial coping resource for

pregnant women in order to meet the challenges that accompany the physical and

psychological stress placed upon them during this period. Unfortunately, very little

attention has been given to the psychological correlates of exercise during

pregnancy, especially in relation to its beneficial effects on physical self-concept,

mood states, burnout and perceived stress. The limited number of studies that have

been conducted in this area suffer from a variety of methodological inadequacies.

For example, studies of the relationship between exercise and self-perception

during pregnancy have relied almost exclusively on global self-concept measures

and, as a result, have produced inconsistent findings (Koniak-Griffin, 1994; Wallace,

Boyer, Dan, & Holm, 1986). There is a definite need for a more precise focus on the

4

physical self and its specific dimensions when conducting research in this area.

Most current conceptualisations of self-concept are not unidimensional. Instead,

they are multidimensional in nature and hierarchical in organisation, with self-

perceptions in specific domains subsumed by progressively more global dimensions

(Marsh & Shavelson, 1985). Similarly, studies of the potential benefits of exercise

on mood states and perceived stress during pregnancy have either examined acute

responses to isolated sessions of laboratory exercise (Williams et al., 1988), or they

have examined a limited range of mood state measures (Dragonas, Petrogiannis, &

Adam, 1997; Zorn, 1988). An investigation of the relationships among habitual

exercise activity, multiple mood states, and stress perceptions would be more

informative as well as more ecologically valid.

1.1 Purpose of the research

This study had three primary objectives: (1) to provide a cross-sectional description

of changes in physical self-concept, mood, burnout and perceived stress over time

during pregnancy; (2) to evaluate physical activity patterns of pregnant women over

time during pregnancy; and (3) to determine if there is a difference between

physical activity and physical self-concept, mood, burnout level and/or perceived

stress during pregnancy.

1.2 Significance of the study

The proposed investigation will aid in: (1) the establishment of a firm empirical

basis for planning and implementing physical activity interventions from within the

clinic setting both during and after pregnancy; and (2) the development of protocols

that could subsequently be used to examine the relationship between physical

activity and mental health among women after childbirth.

5

1.3 Definition of terms

Physical Self-Concept

Physical self-concept is an important aspect of the more general self-concept. It is

based on the perception people have of themselves in terms of both appearance

and physical abilities. Researchers have acknowledged it as being an important

contributor to feelings of global self-worth and self-esteem (Fox & Corbin, 1989;

Marsh, Richards, Johnson, Roche, & Tremayne, 1994; Sonstroem & Morgan, 1989).

Physical self-concept was operationalised in this study using the Physical Self-

Description Questionnaire (PSDQ; Marsh et al., 1994). The PSDQ consists of two

broad constructs (global self-esteem and global physical self-concept) as well as

nine specific sub-domain constructs.

Social Physique Anxiety

Social Physique Anxiety is the degree to which a person becomes anxious due to

concerns that their physique may be negatively evaluated by others (Hart, Leary, &

Rejeski, 1989). This construct was operationalised in this study via the 7-item Social

Physique Anxiety Scale (Motl & Conroy, 2000).

Mood

Mood is the global set of affective states we experience on a day-to-day basis (Fox,

Boutcher, Faulkner, & Biddle, 2000). Mood states were assessed in this study using

the Brunel Mood Scale (BRUMS; Terry, Lane, Lane, & Keohane, 1999), which

provides scores for tension, depression, anger, vigour, fatigue and mental

confusion. The BRUMS is based on the Profile of Mood States (McNair, Lorr, &

Droppleman, 1992).

Perceived Stress

Perceived stress is the degree to which circumstances in life are perceived as

difficult, challenging and/or problematic. Perceived stress was operationalised using

the Perceived Stress Scale (PSS; Cohen, Kamarck, & Mermelstein, 1983).

6

Burnout

Burnout is defined as a psychological syndrome consisting of emotional exhaustion,

depersonalization, and feelings of reduced personal accomplishment (Maslach &

Jackson, 1981). The Maslach Burnout Inventory-General Survey was used to assess

burnout symptoms in this study.

Physical Activity/Exercise

Physical activity is defined as any bodily movement produced by skeletal muscles

that result in energy expenditure. Exercise is a specific type of physical activity that

is planned, structured and repetitive and focuses on the improvement or

maintenance of physical fitness (Caspersen, Powell, & Christenson, 1985). Within

this study, both forms of activity were assessed using a modified version of the

International Physical Activity Questionnaire (Craig et al., 2003; IPAQ, 2002). More

specifically, the frequency and duration of vigorous activity, moderate activity, and

walking were combined to create a composite measure of minutes of physical

activity per week.

1.4 Hypotheses

1. pregnant women who participate in more physical activity will have

a better physical self-concept, more positive mood states, and a

lower level of perceived stress than those who participate in less

physical activity;

2. physical self-concept in women will become less positive as

pregnancy progresses due to changes in the body;

3. social physique anxiety will increase towards the end of the

pregnancy as body changes become more obvious;

4. burnout symptoms will be negatively related to regular physical

activity levels.

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CHAPTER 2 Literature Review

2.1 The Extent of the Problem The transition to parenthood involves a series of emotional, physical and

psychological challenges to the pregnant woman. Not only does she need to cope

with the physiological changes to her body, the pregnant woman has to prepare

herself both mentally and physically for one of the biggest and most significant

challenges in her life. Pregnancy is also a period where health and well-being have

important implications to both mother and child.

A noteworthy psychological challenge encountered during pregnancy is the need to

maintain a positive perception of the physical self despite the numerous changes to

the body. Additional challenges that pregnant women need to face may involve the

need to cope with imminent role changes as well as potential changes in lifestyle,

relationships, job routines and financial status. Expectant mothers are also prone to

experience approach/avoidance conflicts about childbirth, worry about the health

of their child, and experience heightened emotionality (Osofsky et al., 1985).

Changes in specific emotional states that have been shown to accompany

pregnancy include increases in anxiety, confusion, and depression as well as

decreases in vigour and friendliness (Kaplan, 1986; Steiner, 1998; Williams, Reilly,

Campbell, & Sutherst, 1988). Negative mood states are strongly linked to perceived

stress which, in turn, is associated with a variety of negative outcomes for the

mother and child (Lederman, 1996). Extensive research have also identified stress,

anxiety, depression and low self-esteem as contributors to adverse fetal and adult

outcomes likewise postnatal depression (Beck, 1996; Beck, 2001; Lobel, Hamilton, &

Cannella, 2008; Milgrom et al., 2008).

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Given the observed frequency and potentially harmful consequences of body

concerns, negative mood states, and perceived stress during pregnancy, it is of

utmost importance that the mother-to-be prepares herself adequately for this

significant life event through developing resources for managing these

psychological challenges (Glover, 1997; Steiner, 1998). Physical activity/exercise

offers much promise in this regard for several reasons.

2.2 Benefits of physical activity during pregnancy

According to the American College of Obstetricians and Gynaecologists’

recommendation and guidelines on exercise during pregnancy, pregnant women

can engage in 30 minutes of moderate to vigorous physical activity on most days, if

not all days of the week provided that the pregnancy is free of medical or obstetric

complications (Artal & O'Toole, 2003). However, certain activities such as contact

sports (e.g., rugby, soccer) and recreational activities with increased risks of falling

(e.g., gymnastics, skiing) and scuba diving should be avoided because of the

increase in injury potential in such sports.

Involvement in physical activity may assist in the development of resources against

the physical and psychological challenges facing pregnant women. Over the years,

extensive research has been conducted regarding the potential benefits and the

safety concerns of physical activity for both mother and child (Artal & O'Toole,

2003), and evidence provided by these studies indicates that exercise is indeed safe

for the mother and fetus, with both short and long term benefits.

Firstly, exercise can play a role in alleviating many frequent physical discomforts

women experience as a result of anatomical changes in the body during pregnancy.

The most significant change is the expanding uterus which can lead to a shift in the

centre of gravity and progressive lumbar lordosis, subsequently resulting in lower

back pain which is a common physical discomfort experienced by pregnant women.

Some other common physical discomforts experienced by pregnant women include

sacroiliac joint pain, carpal tunnel syndrome, de Quervain's stenosing tenosynovitis,

pelvic pain and leg cramps (Ireland & Ott, 2000; Koniak-Griffin, 1994). Reductions

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in other pregnancy-related discomforts such as nausea, fatigue, and muscle cramps

may also be associated with exercise and physical fitness (Koniak-Griffin, 1994;

Sternfeld, 1997; Wallace et al., 1986).

Evidence along these lines was obtained by Smith and Michel (2006) in a study of

the effects of aquatic exercises on discomforts of pregnancy. They concluded that

aquatic exercise during pregnancy decreased maternal discomfort and enhanced

physical functioning. Similarly, Sternfeld and colleagues (1995) found that exercising

participants in their study reported less pregnancy-related discomfort than a non-

exercising group .

Physical discomforts in pregnancy can limit daily activities, thus indirectly

encouraging a more sedentary lifestyle. A sedentary lifestyle will then, in turn, lead

to unnecessary weight gain which can subsequently be detrimental to both mother

and child. Potential pregnancy-related risks associated with overweight and obesity

include preterm premature rupture of membranes and early induced preterm

deliveries (Juhl et al., 2008; Nohr et al., 2007), as well as pregnancy-related diseases

such as gestational diabetes and preeclampsia (e.g., Catov, Ness, Kip, & Olsen,

2007; Dempsey, Butler, & Williams, 2005). The benefits of exercise for reducing

such conditions were seen in a study by Avery and Walker (2001) which found that

blood glucose levels in women with gestational diabetes declined significantly

following exercise of low-to-moderate intensity. DeMaio and Magann’s (in press)

evidence-based review on exercise in pregnancy also indicated an association

between exercise and decreased risk of preeclampsia. Active and fit women are also

less likely to experience premature rupture of the membranes as delivery

approaches, and they report less pain during labour than less fit women (Magann,

Evans, & Newnham, 1996).

Furthermore, there is evidence that exercise may assist in reducing both maternal

and foetal weight gain and subcutaneous fat deposition (Clapp, 1996; Clapp & Little,

1995). Specifically, Clapp and Little (1995) compared 44 women who continued

their preconception exercise regime during pregnancy with those who voluntarily

stopped the pre-pregnancy exercise regime or reduced it below baseline levels in

10

very early pregnancy. Body mass and skinfold measurement were taken before and

during pregnancy. It was found that exercise performance was unrelated to changes

in weight or skinfold measures in the first and second trimesters. However, less

weight gain and a smaller increase in skinfolds was found for the exercising group

when compared to the sedentary group during the third trimester.

Secondly, it is possible that the prepartum and postpartum effects of negative self-

perceptions and emotional states are mediated by reductions in health-related

behaviour (Adler & Matthews, 1994). Because exercise is inherently a health-

enhancing activity, it can stimulate other positive lifestyle choices and decrease the

incidence of unhealthy behaviour. Smith and Michel (2006) evaluated the effects of

aquatic exercise in promoting healthy behaviours in a sample of 40 participants

who were allowed to self-select between the non-exercise group or the aquatic

exercise intervention group. The intervention group participated in an aquatic

exercise program 3 times per week for 6 weeks and each session lasted 60 minutes.

Pender’s Health Promotion Lifestyle Profile was administered to evaluate health

promoting behaviours. The profile consisted of 52 items with higher total scores

indicating more participation in health-promoting activities. Pre-test results

indicated no significant differences between groups, but post-test comparison of

groups revealed that women who participated in the aquatic exercise program

reported increased participation in health-promoting behaviours.

Finally, along with the numerous physical benefits of exercise shown by studies,

physical activity during pregnancy has also been shown to have significant effects

on psychological measures reflecting mental health and emotional well-being

(Sternfeld, 1997). However, the benefits of continued participation in physical

activity during pregnancy on psychological health have not been as widely

researched. A common weakness in the existing literature on psychological

correlates of exercise during pregnancy is the tendency to focus on mood during

and after pregnancy (e.g., Polman, Kaiseler, & Borkoles, 2007; Poudevigne &

O'Connor, 2005; Williams, Reilly, Campbell, & Sutherst, 1988).

11

Although exercise has been repeatedly shown to be associated with positive self-

esteem in the general population, very little attention has been given to these

relationships during pregnancy. Therefore, psychological constructs such as physical

self-concept, social physique anxiety, and self-esteem warrant further investigation.

Indeed, the limited number of studies that have been conducted in this area suffer

from a variety of methodological inadequacies, such as a tendency to rely almost

exclusively on global (rather than multidimensional) self-concept measures. As a

result, these studies have produced inconsistent findings (Koniak-Griffin, 1994;

Wallace, Boyer, Dan, & Holm, 1986).

2.3 Physical self-concept

Physical self-concept is an important aspect of the more general self-concept. It is

the perception people have of their physical self, in terms of both appearance and

physical abilities. Physical self-concept has been acknowledged by researchers as

being an important contributor to feelings of global self-worth and self-esteem (Fox

& Corbin, 1989; Marsh et al., 1994; Sonstroem & Morgan, 1989). Although

qualitatively distinct, these two concepts are inter-related, with the physical self-

concept helping to shape our more general self-concept and indirectly affecting

self-esteem. Self-esteem is how positive or negative a person feels about

themselves overall, and it has been widely accepted as a general indicator of

emotional stability and well-being (Fox & Corbin, 1989). According to Richardson

(1990), the maintenance of a strong physical self-concept despite disconcerting

body experiences is an important component of normal, healthy pregnancies.

Self-concept was initially viewed as a unidimensional construct and was assessed

through questionnaires that required responses to different life scenarios such as

physical activity, fitness and health. However, due to the complexity of self-

perceptions, a more multidimensional approach was needed to acknowledge the

fact that a total individual is made up of multiple selves that contribute to overall

self-regard (Fox & Corbin, 1989; Harter, 1982; Marsh et al., 1994).

12

Self-concept and self-esteem are thus viewed as inter-related, higher order

components of self-perception. Self-concept, in turn, is viewed as multidimensional

in nature and hierarchical in organisation, with self-perceptions in specific domains

subsumed by progressively more global dimensions (Marsh & Shavelson, 1985). The

multidimensionality of these self-concept models means that each of the self-

concept sub-components will have different effects on the more general self-

evaluations perceived as important by the individual as shown in Figure 2.1.

Currently, perceptions of the physical self are widely accepted as a key dimension

within this hierarchical structure (Marsh et al., 1994).

Fig. 2.1 Diagrammatic representation of the hierarchical structure of self-concept

(based on Fox, 2000)

Global Self-Concept

Emotional self-concept

Physical self-concept

Social self-concept

Academic self-concept

Perceived physical ability

Perceived physical appearance

Global Self-Esteem

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As a result of research on the physical self-concept, several multidimensional

measures have been developed and validated. These measures include (1) the

Physical Self-Perception Profile (PSPP; Fox & Corbin, 1989), (2) the Physical Self-

Concept Scale (PSC; Richards, 1988) and (3) the Physical Self-Description

Questionnaire (Marsh et al., 1994). The frameworks behind all of these measures

are hierarchical in nature but they differ in terms of the specific physical

perceptions addressed.

The 30-item Physical Self-Perception Profile (PSPP) was developed by Fox and

Corbin (1989) in an effort to measure self-concept dimensions specific to the

physical domain. The relationship between the physical domain and global self-

esteem is highlighted in the model behind this measurement tool. More

specifically, the PSPP model has global self-esteem at the apex and general physical

self-worth located beneath it. The specific physical sub-domains of sport

competence, body attractiveness, physical strength and physical condition are seen

as contributing to perceptions of general physical self-worth. The diagrammatic

representation of this structure is shown in Figure 2.2.

Fig. 2.2 Diagrammatic representation of the Conceptual Framework for the

Physical Self-Perception Profile

Global Self-Esteem

General Physical

Self-Worth

Sports Competence

Physical Condition

Body Awareness

Physical Strength

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The Physical Self-Concept Scale (PSC) was developed by Richards (1988) in an effort

to create a measurement tool appropriate for males and females over the age of

12. It contained 35 true-false items measuring perceptions of Body Build,

Appearance, Health, Physical Competence, Strength, Action Orientation, and

Overall Satisfaction with the physical self. The instrument appeared to possess good

psychometric properties with internal consistency measures of over .80 for all

subscales across both gender and age, but its development and evaluation has only

been described in one unpublished conference paper (Marsh et al., 1994).

The Physical Self-Description Questionnaire (PSDQ) was developed by Marsh and

colleagues according to the hierarchical structure proposed by Shavelson, Hubner

and Stanton (1976). The preliminary version of the PSDQ (Marsh & Redmayne,

1994) assessed six physical self-concept dimensions and was aimed at upper-level

primary school students and high school students. This version was later revised by

Marsh et al. (1994), and the current PSDQ instrument measures global self-esteem

as well as 10 specific physical self-concept dimensions: Strength, Flexibility, Physical

Activity, Coordination, Sport Competence, Health, Body Fat, Appearance,

Endurance/Fitness and General Physical Self-Concept. The conceptual model

guiding this instrument is shown in Figure 2.3.

Fig. 2.3 Diagrammatic representation of the PSDQ (based on Marsh & Redmayne, 1994)

General

Self-Concept

Global Physical Self-Concept

Appearance Body

Fat Health Coordination Flexibility Strength Endurance Sports

Competence

Physical

Activity

General

Self-Esteem

15

2.4 Physical activity/exercise and mental health

An area of research that has been widely examined within the normal population is

the relationship between physical activity and various psychological constructs

which contribute positively to overall mental health. The same relationship can also

be extended to the pregnant population as seen in the burgeoning body of

literature which indicates that exercise has beneficial effects on self-perceptions

and psychological states that are potentially problematic for pregnant women.

The relationships of each construct examined in this study are discussed in greater

detail.

2.4.1 Physical self-concept and physical activity/exercise Exercise is believed to have direct effects on physical self-concept and indirect

effects on the global self-concept (Sonstroem & Morgan, 1989). Sonstroem (1984)

reviewed 16 studies on the relationship of exercise to general self-concept and

concluded that a positive relationship did indeed exist. Consistent with this

conclusion, more recent studies have also confirmed this relationship (Alfermann &

Stoll, 2000; Fox, Boutcher, Faulkner, & Biddle, 2000; Fox & Corbin, 1989; Shaw,

Ebbeck, & Snow, 2000; Sonstroem, Speliotis, & Fava, 1992; Van Vorst, Buckworth, &

Mattern, 2002). For example, Alfermann and Stoll (2000) examined the effect of a

6-month walking intervention on previously sedentary but healthy, middle-aged

adults. When the exercise intervention was completed, it was found that the

participants in the study showed improvements in physical self-concept when

compared to wait-list controls.

The relationship between physical self-concept and muscular strength was

examined in a study which involved college students enrolled in a weight training

class (Van Vorst et al., 2002). Each participant was allowed to develop and

implement their own training program and train at their own pace. Strength

assessments were done at week one and week nine of the program after

completion of the PSDQ. Findings from the study revealed a positive relationship

between physical strength changes and physical self-concept in the early stages of

16

exercise. It was also found that regardless of participants’ exercise history, a

positive impact was made on self-esteem.

The positive effects of exercise on physical self-concept and self-esteem may be

particularly relevant for women, because some research suggests that they have

less positive physical self-perceptions than males. For example, in a study that

examined the effect of gender on physical self-concept, it was found that males

scored higher than females on all PSDQ subscales except for body attractiveness

(Asci, 2002). Small but significant differences in global self-esteem favouring males

were also found in a study by King and colleagues (Kling, Hyde, Showers, & Buswell,

1999).

Two studies looked at the effect of exercise on body composition changes and

physical self-concept. Findings indicated a significant, positive relationship between

selected physical parameters and overall physical self-concept (Shaw, Ebbeck, &

Snow, 2000; Van Vorst, Buckworth, & Mattern, 2002). Specifically, improvements in

physical self-concept were predicted by improvements in lower body strength and

decreases in leg fat but not overall body composition. In another study exploring

body-related experiences and their relationship to measures such as self-esteem,

Kamysheva, Skouteris, Wertheim, Paxton, and Milgrom (2008) found that low self-

esteem was associated with body dissatisfaction (feeling fatter and less attractive).

Other studies have obtained findings that support the mediating role of improved

physical self-efficacies and perceived physical competence in producing these

effects (Sonstroem, Speliotis, & Fava, 1992). Moreover, recent evidence suggests

that positive physical self-concept may also have a direct, beneficial effect on life

adjustment. Specifically, Sonstroem and Potts (1996) found that various

components of physical self-competence were related to positive affect, negative

affect, depression and health complaints, and that these relationships were

independent of the effects of global self-esteem and social desirability.

17

In general, a positive association is also seen between physical activity and

psychological health during pregnancy (Goodwin, Astbury, & McMeeken, 2000;

Kirkby & Birmingham, 1996; Poudevigne & O'Connor, 2006; Wallace, Boyer, Dan, &

Holm, 1986). In particular, there is considerable evidence that exercise positively

improves physical self-concept (Marquez-Sterling, Perry, Kaplan, Halberstein, &

Signorile, 2000) and also reduces negative mood states as well as perceived stress.

Goodwin et al. (2000) compared the body image and psychological well-being

between exercisers and non-exercisers during pregnancy. Sixty-five women were

recruited for this study and were divided into groups according to their recreational

exercise participations levels. Psychological health was assessed using the General

Health Questionnaire (GHQ-28) which was completed at 30 weeks gestation.

Findings from the study indicated that there was a significant difference in favour of

the exercisers for overall psychological well-being and anxiety at late pregnancy.

Similarly, Da Costa, Rippen, Dritsa and Ring (2003) conducted a longitudinal study to

determine the relationship between psychological well-being and self-reported

leisure time physical activity in each trimester of the pregnancy. The measures used

to assess their hypotheses included three structured interviews and questionnaires

on depression, pregnancy-specific stressors, state-trait anxiety (stress) and minor

daily stress. It was found that pregnant women who reported being physically

active had fewer symptoms of depression and anxiety than those who were less

physically active. Specifically, there was an association between physical activity

and enhanced psychological well-being in the first and second trimesters.

2.4.2 Social Physique Anxiety and Physical Activity/Exercise

Social physique anxiety (SPA) is the degree to which a person becomes anxious

because of concerns that their physique may be negatively evaluated by others

(Hart et al., 1989). Hart and colleagues introduced this concept to address a gap in

research on the negative effect of people’s perceptions of their physique on their

more general self-perceptions and self-esteem. It was argued that these physique-

related perceptions could either impede or motivate involvement in physical

activity due to dissatisfaction with appearance.

18

The self-presentational literature suggests that women are more concerned about

their body than men (e.g., Frederick & Morrison, 1996; McAuley, Bane, & Mihalko,

1995) . They are worried about how positively they are presenting themselves to

others as it may have social implications. They then become socially anxious if they

feel that they are unable to make a positive impression on others (Hart et al., 1989).

Social physique anxiety is thus a specific form of this more general social anxiety

where the source of concern is others’ evaluation of one’s physique. These

concerns may subsequently have an impact on exercise behaviour. If an individual

either perceives her body as negative or that other’s are evaluating her body, this

may prevent her from taking part in health-promoting activities such as exercise

where the body might be on display.

As with self-esteem, gender differences are also associated with social physique

anxiety. In a study by Hausenblaus and Fallon (2001), it was found that low

physique anxiety and high body satisfaction were reported by the male participants

with greater exercise behaviour whereas females, especially those who had higher

body mass index scores had higher levels of physique anxiety and lower levels of

body satisfaction. Other researchers have also found that females score

consistently higher in levels of physique anxiety than males (Frederick & Morrison,

1996; McAuley, Bane, & Mihalko, 1995). In addition, several studies have found

lower levels of physique anxiety in people who exercise regularly when compared

with those who do not (Frederick & Morrison, 1996; Hausenblas & Fallon, 2001;

McAuley, Bane, & Mihalko, 1995; Williams & Cash, 2001). This relationship appears

to hold irrespective of the type of exercise engaged in. Lower levels of physique

anxiety have also been found in people with lower levels of body fat (Hart et al.,

1989).

2.4.3 Perceived stress and physical activity/exercise

Stress occurs daily around us and can be caused by different sources. However if

not handled properly it, can lead to adverse effects on the individual. As defined by

Cox (1985) stress arises when our perceived capabilities and perceived situational

19

demands are imbalanced. As a result, we worry, begin doubting and become more

anxious as we believe that we are not able to cope with the demands placed on us.

Perceived stress is the degree to which circumstances in life are interpreted as

difficult, challenging and/or problematic. Cohen et al. (1983) argue that “perceived

stress” provides an objective way of measuring stress and offers advantages over

other measures. Firstly, it allows an estimate of the disease risk associated with the

occurrence of easily identifiable events. Secondly, it is a simple and non-invasive

measurement procedure. Perceived stress is therefore the measurement of

experienced level of stress as a function of objective stressful events.

The role of exercise in the alleviation of perceived stress has been examined widely

as one of the psychological outcomes of exercise. King, Taylor and William (1993)

evaluated the effect of different formats and intensities of exercise training on

psychological outcomes in a group of older adults. Participants were randomly

assigned to four groups; (1) higher intensity, group-based exercise training, (2)

higher intensity, home-based exercise training, (3) lower intensity, home-based

exercise training, and (4) assessment-only control. Findings indicated reductions in

perceived stress and anxiety in the exercising groups as compared to the control

group. Similarly, a significant association between regular exercise and lower levels

of depression, anger, and stress was seen in a cross-sectional study in which 3403

participants in the Finnish cardiovascular risk factor survey reported on their

exercise habits and perceived health and fitness (Hassemen, Koivula, & Uutela,

2000). Ng and Jeffery (2003) examined associations between perceived stress and

fat intake, exercise, alcohol consumption, and smoking behaviours. The cross-

sectional analyses between stress and health behaviours indicated an association

between high stress and less frequent exercise in their sample of working men and

women.

Stress arises from a variety of interpersonal and life change processes during

pregnancy. In addition, there is sufficient evidence to suggest that stress can lead

directly or indirectly to negative birth outcomes such as premature delivery and low

20

birth weight (Wadhwa, Sandman, Porto, Dunkel-Schetter, & Garite, 1993). It has

also been suggested that pregnancy stress can negatively impact upon the

emotional, behavioural and cognitive development of fetus and child (Clapp, 2000).

Studies have shown the effectiveness of exercise in reducing this potentially

harmful psychological state. Lox and Treasure (2000) examined 44 pregnant women

who participated in a water aerobics exercise program twice a week for a total of 6

weeks. Each exercise session lasted approximately 45 minutes. An association was

found between exercise participation and psychological distress with exercisers

reporting less stress and fatigue as well as greater feelings of well-being. Upon

assessing the same states after each bout of exercise during the program, the same

positive results were reported.

2.4.4 Mood and physical activity/exercise

Mood has been defined as the global set of affective states we experience on a day-

to-day basis (Fox et al., 2000). In the assessment of mood, the Profile of Mood

States (POMS; McNair, Lorr, & Droppleman, 1992) has been widely used in exercise

and health settings. Besides mood assessment, the POMS can also be used in the

identification of mechanisms involved in mood alteration.

In general, research findings support a relationship between exercise involvement

and mood improvements (Berger & Motl, 2000). This relationship has been

documented in both normal populations (e.g., Berger & Owens, 1988; Hoffman &

Hoffman, 2008; Johansson, 2008) and in clinical populations (e.g., McDonald &

Hodgdon, 1991; North, McCullagh, & Tran, 1990). In fact, exercise is considered to

be effective in treating mild and moderate depression and anxiety (Dunn, Trivedi, &

O'Neill, 2001) and is therefore a useful tool in the treatment of patients with clinical

depression (Blumenthal, Brosse, Lett, & Sheets, 2002). Specifically, Lane and

Lovejoy (2001) examined the extent to which pre-exercise depressed mood

moderated the influence of exercise on changes in other mood dimensions. Pre-

exercise depression scores were taken and participants were then stratified into

21

either a depressed mood group or a non-depressed mood group. Following the

exercise intervention, the POMS was administered. Results indicated improvements

in mood scores, with the depressed mood group showing significantly greater

reductions in anger, confusion, fatigue, and tension, and greater increases in vigor.

Their findings thus indicated that the mood enhancing effects of exercise were

greater among individuals with depressed mood symptoms before exercise. Similar

conclusions have been drawn in reviews of the exercise/mood literature (McDonald

& Hodgdon, 1991; North, McCullagh, & Tran, 1990).

Although there is some debate in the literature, the positive association between

exercise and mood does not appear to depend on aerobic fitness effects (Lane &

Lovejoy, 2001; Plante & Rodin, 1990; Steptoe & Cox, 1988). In a review of 25

studies, Berger and Motl (2000) found that many of the changes in mood were

associated with acute bouts of moderate intensity aerobic exercise and physical

activity. However, it was also found that mood changes still occurred despite the

lack of fitness and training benefits from moderate intensity exercise (Berger &

Owens, 1988). Similarly, Johansson (2008) examined fifty-nine Qigong exercisers

who were randomized into two groups. Pre- and post mood measurements were

taken and results indicated that participants in the Qigong group had significant

reductions in scores on the POMS subscales of depression, anger and fatigue as

compared to the control group.

Mood improvements were also seen in a study by Polman and colleagues (2007). In

this study, women in their second and third trimesters undertaking a single bout of

aquatic or studio-based exercise were compared to women in a parent craft class.

Both types of exercise resulted in an increase in overall positive mood and vigour.

All three groups also reported decreases in tension, anger, fatigue and confusion

after taking part in the activity.

22

2.4.5 Burnout and physical activity/exercise The concept of burnout was introduced to explain the psychological syndrome of

emotional exhaustion, depersonalization and reduced personal accomplishment

often seen amongst individuals working in the human services industry (Maslach &

Jackson, 1981). The interaction of these three psychological processes was believed

to contribute to work-related problems, absenteeism, personal distress, and health

complications.

Extensions of the burnout model beyond the human services profession led to the

development of the MBI-GS (Schaufeli et al., 1996) for the assessment of the

related processes in other occupations. Further extensions of the model have

suggested that burnout is also applicable outside of the occupational context in

connection with activities that are structured, coercive in nature, directed towards

specific goals, and from a psychological perspective, are similar to work (Schaufeli &

Taris, 2005). As a result, burnout symptoms have been assessed across a wide range

of occupations, activities and cultures (e.g., Greenglass, Burke, & Fiksenbaum, 2001;

Leiter & Schaufeli, 1996; Pretorius, 1994; Schaufeli, Martinez, Marques Pinto,

Salanova, & Bakker, 2002).

In a study that examined the relationship between burnout, job strain and

depressive symptoms, it was found that high job strain was associated with a

greater incidence of burnout, depressive symptoms, and depressive disorders than

low job strain (Ahola et al., 2006). The authors concluded that depression was

related to burnout symptoms in the work context. In addition, the types of work

demands were also associated with burnout and depression. In another study of

120 restaurant managers, researchers examined the relationship between

optimism, stress, life satisfaction and job burnout (Hayes & Weathington, 2007).

Findings indicated that stress and job burnout were significantly related and

suggested that health problems could occur if no interventions were employed.

23

Pregnancy and the transition of to motherhood are potentially one of the most

challenging and stressful times in a woman’s life. The expectant mother not only

has to learn to cope with the changes in her body but also faces the reality of being

a parent and its associated demands. As a result, many women find this transition

stressful, and without proper social support, may have difficulty coping with the

situation. Thus it is likely that pregnant women will experience many of the same

symptoms of burnout that have been identified in work-related contexts. If so,

these symptoms could be detrimental to both the mother and child. Examination

of burnout symptoms has not, to the best of our knowledge, been extended to the

pregnant population. However, the potential relevance of this construct during

pregnancy is highlighted by studies which have shown an association between

stress, depression and burnout symptoms (Ahola et al., 2006; Hayes &

Weathington, 2007). Pregnant women, as mentioned throughout this literature

review, are subjected to many physical and psychological changes which can lead to

health problems. Monitoring burnout symptoms among pregnant women may

provide a convenient means of evaluating overall mental health during this time.

24

CHAPTER 3 Method

3.1 Participants

Three hundred and twenty pregnant women were approached at the various

antenatal clinics at King Edward Memorial Hospital, whilst waiting for their

appointment. Two hundred and seventy-seven patients who agreed to participate

in the study were then recruited.

Participation was voluntary. Each participant was informed of the purpose of the

study, and that their responses would remain anonymous and confidential. In

addition, they were informed of their right to withdraw from the study at any time.

After informed consent was obtained, the questionnaire was then distributed and

completed either before or after the scheduled appointment. Women who were

unable to complete the questionnaires were allowed to complete them at home

and return them to the researchers by post, of which nineteen women failed to do

so. Another 23 women returned the questionnaires but were excluded for the

following reasons: multiple births, taking anti-depressants, wheelchair-bound, or

known by the clinic staff to be heavy users of drugs/alcohol.

The final sample consisted of 235 pregnant women aged between 17 and 41 years

(Mean = 29.51; SD = 5.84). Height and weight ranged from 145cm to 186cm (Mean

= 165.7; SD = 7.83). The participants were predominantly from Australia (94.5%),

with a few from the United Kingdom (0.9%) and other parts of the world (11.1%).

The majority were married (n=146) whilst the rest indicated that they were not

married (n=88). Current living arrangements were as follows: 36.2% lived with

partner only, 51.9% lived with partner and one or more children, 4.3% lived with

other adults who were neither their partner nor children, 5.5% lived only with their

25

children and 2.1% lived alone. Descriptive statistics for participant demographics

are presented in Table 4.1 in the Results section.

3.2 Instruments and Measures

3.2.1 Physical Activity

Physical activity was assessed using a modified version of the International Physical

Activity Questionnaire (IPAQ; Craig et al., 2003). The IPAQ was designed to assess

physical activity levels of individuals aged 18 to 65 years irrespective of nationality.

It has been used by the World Health Organization and the European Union

National Physical Activity Surveillance System for monitoring physical activity levels

(Bassett, 2003). There are currently eight versions of the IPAQ. A 9-item modified

version of the short, self-administered (last 7-days) IPAQ was used for this study.

Research indicates that this version of the IPAQ has good criterion-related validity

(pooled ρ = .33, 95% CI = .26 - .39), concurrent validity (ρ = .67) and a test-retest

correlation coefficient of .75 (Craig et al., 2003). A copy of this modified version is

attached in Appendix A.

This modified questionnaire required respondents to recall the frequency, average

intensity and average duration of vigorous activities, moderate activities and

walking during the past seven days. For an activity to be counted, it needed to have

been undertaken for at least 10 minutes at a time.

The frequency of each type of the exercise was indicated by circling a number on an

8-point scale ranging from (0) “only rarely” to (8) “every day”. For duration

estimates, participants responded to eight choices ranging from “0-10 minutes”,

“11-15 minutes”, “16-20 minutes”, “21-25 minutes”, “26-30 minutes”, “31-45

minutes”, “46-60 minutes” and “more than 60 minutes”. A slightly modified version

of the Borg (1982) Rating of Perceived Exertion was used to estimate the intensity

of the physical activity. The intensity scale ranged from (7) “extremely light”

through (9) “very light”, (11) “light”, (12) “somewhat light, (13) “somewhat hard”,

(15) “hard” and (17) “very hard” to (19) “extremely hard”.

26

3.2.2 Physical Self-Concept

Physical self-concept was assessed using a modified version of the Physical Self-

Description Questionnaire (PSDQ). The original instrument was developed by Marsh

and colleagues (1994) and contains 70 items that measure nine specific dimensions

of physical self-concept (strength, body fat, activity, endurance/fitness, sport

competence, coordination, health, appearance and flexibility) and two general self-

concept dimensions (global physical self-concept and global self-esteem).

Statements such as “I am attractive for my age”, or “I have a lot of power in my

body” are rated on a 6-point scale from 1 (false) to 6 (true). Participants are then

required to choose one of the six possible answers to indicate the extent to which

the statements are characteristic of them.

In this study, the sport competence subscale was removed and replaced with the

Social Physique Anxiety Scale (SPAS) due to the latter’s relevance to the sample

being studied. Social Physique Anxiety was deemed more relevant as it is one of the

instruments used for self-presentational studies, and thus a complement to this

study’s physical self-concept investigation. Hart et al. (1989) developed this scale to

measure the perceived negative evaluation of one’s physique by others. The 7-item

unidimensional version of the questionnaire was used in this study. This version was

incorporated as a subscale of the PSDQ measure, and statements such as “I feel

nervous about my physique/figure in the presence of others” were answered on the

6-point scale ranging from 1 (false) to 6 (true). Internal consistency for the physique

anxiety subscale is .921.

Research by Marsh (1996) and Marsh and colleagues (1994) has provided strong

evidence for factorial invariance (TLI = .923 - .948), internal consistency (ranging

from .82 to .96) and test-rest reliability (.70 - .89) for the original instrument.

Criterion-related validity has also been established for the original scale via

significant correlations with body composition measures, self-reports of activity

levels and field tests of physical performance (Marsh, 1996). The modified

instrument used in this study was also found to possess good psychometric

27

properties with Cronbach’s alphas ranging from .837 to .953 across the various

subscales.

3.2.3 Mood

Mood states were measured using the Brunel Mood Scale (BRUMS; Terry et al.,

1999). The BRUMS is derived from the Profile of Mood States (McNair, Lorr, &

Droppleman, 1992). It contains 24 items with subscales for the mood states of

tension, depression, anger, vigour, fatigue and confusion. Four adjectives

pertaining to each of these mood states are rated on a 5-point scale ranging from

“not at all” to “extremely” according to the respondent’s state-of-mind at the time

of administration. The BRUMS subscales possess strong internal consistency of .75

to .86 among young athletes and .79 to .85 among school children. The 6-factor

structure has been confirmed within samples of young athletes, school children,

adult athletes and adult students (Terry, Lane, & Fogarty, 2003; Terry et al., 1999).

3.2.4 Stress

Stress was measured using the Perceived Stress Scale (PSS). The PSS was developed

by Cohen et al. (1983) to measure the degree to which circumstances in life are

perceived as stressful. There are three versions of the PSS: the 4-item, the 10-item

and 14-item versions of the scale. For all versions, respondents indicate how often

they have experienced various stress-related cognitions and emotions recently

using a 5-point scale ranging from “never” to “very often”. The 10-item version was

used in this study because it appears to offer the best balance between economy of

assessment and psychometric strength (Cohen & Williamson, 1988). This version

has been shown to have an internal consistency of .78, and scores correlate

significantly with self-reports of negative life-events, illness symptoms and drug use

(Cohen & Williamson, 1988).

3.2.5 Burnout

Burnout symptoms were measured using the modified Maslach Burnout Inventory-

General Survey. The original inventory, Maslach Burnout Inventory (Maslach &

28

Jackson, 1981) was developed to assess the burnout syndrome amongst human

services workers. The inventory has been shown to have an internal consistency of

.59 to .89 (frequency) and .57 to .86 (intensity) for subscales of Emotional

Exhaustion, Personal Accomplishment and Depersonalization and Involvement.

Test-retest reliability reported coefficients being significant beyond .001.

Convergent reliability has also reported for this scale.

Due to the limitations of the original inventory, the MBI-GS (Schaufeli et al., 1996)

was developed for use with people outside the human services profession. This

version has been shown to have good internal consistency and external validity

(Taris, Schreurs, & Schaufeli, 1999). For use in this study, we modified the wording

of the MBI-GS instrument to suit the population being investigated. The MBI-GS

items were either reworded or had parts of the sentence removed. More

specifically, all references relating to “work” were either removed or replaced with

references relating to “society”, “life” or “responsibilities. The modified version of

the MBI-GS instrument is shown in Table 3.1.

Table 3.1 Modified MBI-GS

(1) I feel emotionally drained.

(2) I feel used-up at the end of the day.

(3) I feel tired when I get up at the end of the day.

(4) My daily routine is really a strain for me.

(5) I can effectively solve the problems that arise in my life.

(6) I feel burned out from my responsibilities.

(7) I feel I am making an effective contribution to society.

(8) I have become less interested in lots of things lately.

(9) I have become less enthusiastic about my responsibilities.

(10) In my opinion, I am good at what I do.

(11) I feel exhilarated when I accomplish something.

(12) I have accomplished many worthwhile things recently.

(13) I just want to get on with things and not be bothered.

(14) I have become more cynical about whether I am making a contribution to society.

(15) I doubt the significance of my role in society.

(16) I feel confident that I am effective at getting things done.

29

The changes to wording did not affect the internal consistencies of the subscales

which ranged from .747 to .880 in this study.

3.3 Procedure

Prior to data collection, approval from King Edward Memorial Hospital Ethics

Committee was obtained. Pregnant women were then approached whilst they were

waiting for appointments at the various antenatal clinics at the hospital. The

purpose of the study was explained to the participants and a written consent

document was signed if they indicated their interest in taking part in the study.

After consent was obtained, participants completed the questionnaires assessing

exercise behaviour, physical self-concept, mood, burnout and perceived stress. The

questionnaire was completed at the hospital whilst waiting for a clinic appointment.

The questionnaire took an average of 20 minutes to complete. Those unable to

complete the questionnaire before or after their appointment were allowed to

complete them at home and return them to the researchers using a reply-paid

envelope.

3.4 Analysis of data

Analyses were completed using the Statistical Package for the Social Sciences (SPSS)

for Windows version 15.0. Analysis of variance procedures were used to compare

the self-concept measures (11 subscales), mood state measures (7 subscales),

burnout measures (3 subscales) and perceived stress measure (1 scale) across

groups defined on the basis of pregnancy weeks and physical activity levels.

30

CHAPTER 4

Results

Questionnaires were received from 258 women. Preliminary data screening

identified 23 participants who were removed from the data set prior to data

analysis. These individuals were removed due to the following reasons: multiple-

birth pregnancy, taking anti-depressant medication, wheelchair-bound, and known

to be using drugs/alcohol. The final sample therefore consisted of 235 women at

various stages of single-birth pregnancy.

4.1 Descriptive Statistics and Reliability

Table 4.1 summarizes the demographic statistics of the sample. On average, the

women in the sample were 30 years old and in their 30th week of pregnancy at the

time of the study. Their yearly household income was approximately $68, 000

(AUD) and they had given birth once in the past. The most recent prior birth was a

little over two years before.

Table 4.1 Demographics

Attribute N Mean SD Median Skew Kurtosis

Age 235 29.51 5.84 30 -.05 -.88

Height(cm) 220 165.73 7.83 167 -.13 -.05

Pre-pregnancy weight 231 72.69 21.84 67.50 1.11 .84

Yearly household income 226 67966 29568 70000 -.09 -1.19

Weeks pregnant 235 29.71 7.48 30 -.68 -.09

Previous births 235 - - 1.00 .74 -.40

Months since last birth 234 27.56 36.97 19 2.18 5.59

31

Internal consistency estimates (Cronbach’s alphas) were computed for the PSS, the

11 subscales of the modified PSDQ, the 4 subscales of the BRUMS, and the 3

subscales of the modified MBI-GS. The findings are summarised in Table 4.2, along

with summary information on the key measures. This summary information

includes the number of respondents, the means and standard deviations,

minimums, maximums, and indices for skewness and kurtosis. Examination of the

reliability indices revealed good to very good internal consistency for all measures

(Cronbach alpha’s ranging from .69 to .95). The skewness and kurtosis indices

indicated that all measures were essentially normally distributed.

The descriptive statistics for physical activity involvement are presented in Table

4.3. Frequency and duration of vigorous exercise were positively skewed and

exhibited positive kurtosis. This showed that very few pregnant women in the study

engaged in both shorter and less frequent vigorous exercise sessions per week. Self-

reports of moderate exercise and walking were essentially normally distributed.

Total minutes of exercise per week exhibited a tendency toward positive skew and

positive kurtosis, but the departures from normality were minor.

4.2 Analyses Related to Pregnancy Weeks

In order to examine physical activity patterns of pregnant women as a function of

time during pregnancy, the participants were divided into three groups based on

weeks. Early pregnancy (n = 72) was defined as being between 5 and 26 weeks

pregnant. Mid-pregnancy (n = 87) was defined as being between 27 and 34 weeks

pregnant. Late pregnancy (n = 76) was defined as being between 35 and 41 weeks

pregnant. An analysis of variance was then conducted to compare minutes of

physical activity undertaken per week across these three groups. No significant

group differences were found with respect to minutes of exercise per week, [all

Fs(2, 231 ) <1 .15, all ps > .33].

32

Table 4.2: Descriptive Statistics and Internal Consistency

Attribute N Mean Per Item

SD Median Range Skew Kurtosis Alpha

PSS 225 1.44 .80 1.50 3.80 .33 -.37 .69

Physical Self-Perceptions Questionnaire

General self-esteem 231 5.02 4.91 5.38 4.50 -1.3 1.63 .91

Global self-concept 231 4.13 1.24 4.17 5.00 -.51 -.24 .92

Appearance 231 4.38 0.91 4.50 4.33 -.68 .47 .84

Body Fat 231 3.99 1.63 4.20 5.00 -.33 -1.19 .95

Coordination 231 4.15 0.97 4.17 5.00 -.45 .03 .86

Strength 231 3.99 1.10 4.17 4.83 -.48 -.29 .88

Endurance 231 2.68 1.18 2.67 5.00 .44 -.45 .91

Health 231 4.46 1.03 4.75 4.63 -.89 .41 .87

Flexibility 231 3.95 1.17 4.00 5.00 -.37 -.26 .91

Physical Activity 231 3.07 1.23 3.17 5.00 .25 -.50 .87

Social Physique Anxiety 231 2.23 1.43 3.00 5.00 .28 -.94 .92

BRUMS

Anger 225 1.08 .90 1.00 4.00 1.01 .73 .87

Confusion 225 1.10 .89 1.00 4.00 .77 -.01 .85

Depression 225 .85 .95 0.50 4.00 1.36 1.35 .91

Fatigue 225 2.43 .95 2.50 3.75 -.08 -.76 .89

Tension 225 1.19 .99 1.00 4.00 .28 .95 .90

Vigour 225 1.82 .78 1.75 3.50 .25 -.64 .80

MBI-GS

Emotional exhaustion 225 2.46 .98 2.4 4.00 .62 -.13 .88

Cynicism 225 2.34 .72 2.2 3.60 .28 -.15 .75

Personal Efficacy 225 1.94 .87 1.67 4.00 .86 -.02 .83

33

Table 4.3: Descriptive Statistics for Physical Activity Measures

PA Activity N Mean SD Median Skew Kurtosis

Min/Wk Vigorous 234 19.85 57.39 0 4.89 29.65

Moderate 234 54.50 95.14 13.0 2.68 7.55

Walking 234 130.78 119.11 92.0 1.27 1.04

TOTAL (Min/wk)

234

205.13

193.85

150.50

1.80

4.35

Vigorous Frequency 234 .68 1.46 0 2.76 7.94

Duration 234 11.34 12.43 5.0 2.62 7.38

Intensity 234 9.28 2.66 7.0 .70 -.51

Moderate Frequency 234 1.83 2.26 1.0 1.17 .22

Duration 234 17.77 17.52 13.0 1.54 1.48

Intensity 234 10.07 2.52 11.0 .04 -.82

Walking Frequency 234 4.51 2.41 4.0 -.32 -1.31

Duration 234 26.00 17.18 23.0 1.01 .22

Intensity 234 11.06 1.84 11.0 -.61 1.54

A similar analysis of variance procedure was used for all other measures of interest.

No significant group differences were found for the PSS, F(2,222) = 1.27, p = .28,

the SPAS, F(2,228) = .51, p =.60 , or the MBI-GS subscales, [all Fs(2,222) <1.27, all ps

>.28]. However, a significant group difference was found across the different stages

of pregnancy for the perceived health subscale of the PSDQ, F(2,228) = 6.01, p =

.003 (Fig 4.1a). There was also a significant difference found for the tension

subscale of the BRUMS, F(2, 223) = 3.32, p = .038 (Fig 4.2a). It is interesting to note

that the late phase of pregnancy was characterised by the highest scores for

perceived health but also the highest scores for tension.

34

Tukey HSD

Group

Subset

1 2

Early Preg 4.1337

Mid Preg 4.5431

Late Preg 4.6901

Note: Values are significantly different if they do not appear in the same subset

Fig 4.1a PSDQ Perceived Health According to Pregnancy Weeks

Fig 4.2a Tension (BRUMS) According to Pregnancy Weeks

Tukey HSD

Group

Subset

1 2

Early Preg 1.0199

Mid Preg 1.1295 1.1295

Late Preg 1.4223

Note: Values are significantly different if they do not appear in the same subset.

35

4.3 Analyses Related to Physical Activity

In order to examine the hypotheses that pregnant women who participated in

regular exercise would have positive self-perceptions, more positive mood states

and lower levels of perceived stress than those who did not participate in regular

exercise, participants were divided according to their levels of physical activity.

Three groups were created based on minutes of exercise per week. Low physical

activity (n = 79) was defined as exercising between 0 and 90 minutes per week.

Moderate physical activity (n =79) was defined as exercising between 91 and 235

minutes per week. High physical activity (n =76) was defined as exercising between

236 and 1106 minutes per week. Group differences were assessed using ANOVAs,

and results indicated significant group differences for specific subscales within each

cluster of measures.

4.3.1 Physical Activity and Perceived Stress

A trend for group differences was observed for perceived stress, F(2,221) = 2.50, p =

.084 (Fig 4.3a). Women with higher levels of physical activity had a tendency to

report less perceived stress than those with lower levels of physical activity.

Tukey HSD

Group

Subset

1 2

Low PA 1.5915

Mod PA 1.3857

High PA 1.3117

Fig 4.3a Physical Activity and Perceived Stress

36

4.3.2 Physical Activity, Physical Self-Concept and Physique

Anxiety

Significant group differences were found between physical activity levels and the

PSDQ subscales of coordination, F(2,227) = 3.85, p = .023 (Fig 4.4a); physically

active, F(2,227) = 45.44, p< .001 (Fig 4.4b); endurance, F(2, 227) = 9.87, p < .001 (Fig

4.4c); health, F(2,227) = 3.52, p = .031 (Fig 4.4d); strength, F(2,227) = 5.08, p = .007

(Fig 4.4e) and self-esteem, F(2,227) = 3.47, p = .034 (Fig 4.4f). Post hoc analysis

using Tukey’s HSD criterion indicated a significant difference in means between the

Low PA group (M = 3.94) and the High PA group (M = 4.37) for the PSDQ perceived

coordination subscale, d = 0.43.

Similarly, for the PSDQ “physically active” subscale, a significant means difference

was found between Low PA group (M = 2.33) and both Mod PA group (M = 3.01)

and High PA group (M = 3.94), d = .55 and d = 1.31 respectively. A significant

difference in means was also found between Low PA group (M = 2.33) and High PA

group (M = 3.94), d = .75. Post hoc analysis for the PSDQ endurance subscale

revealed a significant difference in means between Low PA group (M = 2.28) and

High PA group (M = 3.09), d = .68.

For the PSDQ health subscale, a significant difference in means was found between

Low PA group (M = 4.23) and High PA group (M = 4.64), d = .40. A significant

difference in means was also found for the PSDQ strength subscale between the

Low PA group (M = 3.68) and Mod PA group (M = 4.10), d = .40; and between Low

PA group (M = 3.68) and High PA group (M = 4.21), d = .47.

Finally, those who reported higher physical activity levels (M = 5.16) had

significantly higher mean scores for the PSDQ subscale of general self-esteem than

those who reported low levels of physical activity (M = 4.82), d = .41. No group

differences were found for Social Physique Anxiety, F(2,227) = .107, p = .899.

37

Fig 4.4a Physical Activity and Perceived Coordination (PSDQ)

Fig 4.4b Physical Activity and Perceived “Physically Active” (PSDQ)

Tukey HSD

Group

Subset

1 2

Low PA 3.9427

Mod PA 4.1677 4.1677

High PA 4.3705

Note: Values are significantly different if they do not appear in the same subset.

Tukey HSD

Group

Subset

1 2 3

Low PA 2.3338

Mod PA 3.0141

High PA 3.9401

Note: Values are significantly different if they do not appear in the same subset.

38

Fig 4.4c Physical Activity and Perceived Endurance (PSDQ)

Fig 4.4d Physical Activity and Perceived Health (PSDQ)

Tukey HSD

Group

Subset

1 2

Low PA 2.2801

Mod PA 2.6891 2.6891

High PA 3.0973

Note: Values are significantly different if they do not appear in the same subset.

Tukey HSD

Group

Subset

1 2

Low PA 4.2255

Mod PA 4.5501 4.5501

High PA 4.6383

Note. Values are significantly different if they do not appear in the same subset.

39

Fig 4.4e Physical Activity and Perceived Strength (PSDQ)

Fig 4.4f Physical Activity and General Self-Esteem (PSDQ)

Tukey HSD

Group

Subset

1 2

Low PA 3.6814

Mod PA 4.1038

High PA 4.2050

Note. Values are significantly different if they do not appear in the same subset.

Tukey HSD

Group

Subset

1 2

Low PA 4.8161

Mod PA 5.0974 5.0974

High PA 5.1612

Note. Values are significantly different if they do not appear in the same subset.

40

4.3.3 Physical Activity and Mood States

A significant difference was found between physical activity levels and the vigor

subscale of the BRUMS, F(2,221) = 16.89, p < .001 (Fig 4.5a). Post hoc analysis using

Tukey procedures indicate that those who reported low physical activity (M = 1.48)

scored significantly lower in the BRUMS vigor subscale than those in the Mod PA

group and High PA group (M = 2.14), d = .55 and d = .89 respectively. The results

indicated that those who reported higher levels of physical activity had more

positive mood profiles on this measure. A strong trend toward group differences

was also observed for total negative mood, F(2,221) = 2.98, p = 0.053 (Fig 4.5b). This

showed that there was a slight tendency towards positive mood as levels of physical

activity increases. However these differences must be treated with caution as post

hoc analyses does not reveal any significant difference between means.

Fig 4.5a Physical Activity and Vigor (BRUMS)

Tukey HSD

Group

Subset

1 2

Low PA 1.4572

Mod PA 1.8799

High PA 2.1444

Note. Values are significantly different if they do not appear in the same subset.

41

Fig 4.5b Physical Activity and Total Negative Mood (BRUMS)

4.3.4 Physical Activity and Burnout Symptoms

A significant difference was found between physical activity levels and the MSI-GS

subscale of personal efficacy, F(2,221) = 5.48, p = .005 (Fig 4.6a). Post hoc analysis

revealed that those who reported higher physical activity levels (M = 1.67) scored

lower on the personal efficacy subscale of the MBI-GS than those who reported

moderate (M = 2.00) and low physical activity levels (M = 2.12), d = .52 and d = .38

respectively. Significant group differences were also found for the total score on the

MBI-GS, F(2,221) = 3.68, p = .027 (Fig 4.6b). Tukey’s post hoc analysis showed that

the Low PA group (M = 7.19) differed significantly in mean scores with those from

the Mod PA (M = 6.74), d = .44. There was also a significant difference in means

between Mod PA group (M = 6.74) and High PA groups (M = 6.26), d = .23.

Tukey HSD

Group

Subset

1 2

High PA .7126

Mod PA .7343

Low PA .9567

42

Fig 4.6a Physical Activity and Personal Efficacy (MBI-GS)

Fig 4.6b Physical Activity and Total Burnout (MBI-GS)

Tukey HSD

Group

Subset

1 2

High PA 1.6690

Mod PA 2.0000

Low PA 2.1202

Note. Values are significantly different if they do not appear in the same subset. Lower scores on this measure reflect better efficacy perceptions.

Tukey HSD

Group

Subset

1 2

High PA 6.2597

Mod PA 6.7409 6.7409

Low PA 7.1876

Note. Values are significantly different if they do not appear in the same subset. Lower scores reflect fewer overall burnout symptoms.

43

CHAPTER 5

Discussion

This study sought to determine the differences between physical activity and

selected aspects of psychological health among pregnant women, namely physical

self-concept, mood, perceived stress and burnout. This was done through a cross-

sectional analysis of responses from pregnant women (at various stages of their

pregnancy) who were attending antenatal clinics at King Edward Memorial Hospital.

An evaluation of physical activity patterns as a function of time in the pregnancy

was also undertaken. The variables involved in this study are represented in Fig. 5.1.

Figure 5.1 Conceptual model of the variables investigated

The results will be discussed in two parts: (1) physical activity in relation to time in

pregnancy and (2) physical activity in relation to amount of exercise undertaken.

The findings will also be examined in line with the hypotheses presented for the

study.

PHYSICAL ACTIVITY Frequency

Duration

Intensity

PERCEIVED STRESS

BURNOUT SYMPTOMS

SELF-PERCEPTIONS Physical Self-Concept

Social Physique Anxiety

Global Self-Esteem

MOOD STATES

44

5.1 Analyses related to pregnancy weeks

In order to evaluate physical activity patterns as a function of time into the

pregnancy, the participants were divided into three groups according to weeks: (1)

5-26 weeks, (2) 27-34 weeks, and (3) 35-41 weeks. These cut-points were used

instead of the classic trimester breakdown so that roughly equal numbers of

women represented each time-point. All of our participants were recruited at the

antenatal clinics and the majority did not normally make contact with the midwives

at the clinic until the end of their first trimester when an ultrasound scan was due.

A few participants whose pregnancies were less than the 12th week were recruited

as they were at the clinics to attend medical appointments, but the numbers were

quite small. As a result, our time-based comparisons emphasized the mid-to-late

pregnancy period rather than a broader time spectrum.

Our findings indicated no significant differences between groups in terms of

number of minutes spent on physical activities. Upon closer examination of

Significant time-related differences were also not apparent for perceived stress,

social physique anxiety or burnout symptoms in the present study. These results

suggest that the exercise levels reported by the pregnant women in our sample

were similar despite the difference in their weeks of pregnancy. Our findings are in

contrast to those of prior studies where physical activity patterns have been

observed to change during pregnancy. Rousham, Clarke, and Gross (2006) assessed

levels of physical activity during pregnancy using accelerometers and interviews.

Data were collected at 12, 16, 25, 34 and 38 weeks gestation. It was found that both

methods indicated a significant decline in physical activity levels as the pregnancy

progressed. Similar findings were obtained in a study using retrospective postal

questionnaires (Mottola & Campbell, 2003). However, consistent with our findings,

a study by Stein, Rivera, and Pivarnik (2003) found no significant change in physical

activity amongst 28 habitually active and 28 habitually sedentary pregnant women.

Physical activity was assessed as energy expenditure using heart rate telemetry,

45

accelerometers and physical activity recall. These women’s energy expenditure was

calculated at 2 time points during pregnancy (20 weeks and 32 weeks) and at 12

weeks postpartum. Results indicated that unadjusted energy expenditure did not

differ across periods of pregnancy when using the heart rate telemetry or the

Caltrac motion sensor (accelerometer). It is noteworthy that the pre-partum “time

window” in the Stein et al. (2003) study was similar to the time window used in this

study, and similar results were obtained.

In contrast to our hypothesis, no significant differences were found in social

physique anxiety across the groups formed on the basis of pregnancy weeks. These

findings are interesting because they suggest that these women were not overly

concerned about others’ evaluation of their bodies and were, in general, rather

satisfied with their bodies even towards the end of their pregnancies where bodily

changes are more evident. In contemporary Western society, there is a major focus

on a person’s body, with body shape and weight playing an important role in their

self-perceptions (Tiggemann, 2003). It is therefore not surprising if people regularly

evaluate their bodies in relation to societal ideals. During pregnancy, where body

changes are pronounced, it is possible that additional body image concerns might

be triggered (Duncombe, Wertheim, Skouteris, Paxton, & Kelly, 2008) . Since the

social physique anxiety construct has not been widely examined during pregnancy,

the related constructs of body image and body dissatisfaction have been addressed.

Body image is an individual’s perception of their current appearance, while body

dissatisfaction is a facet of body image related to the degree of dissatisfaction with

particular aspects of the body (Thomas, Heinberg, Altabe, & Tantleff-Dunn, 1999).

Our findings are in contrast with prior research which generally suggests that body

satisfaction declines as the pregnancy progresses (Goodwin, Astbury, & McMeeken,

2000). For example, Goodwin, Astbury, and McMeeken (2000) conducted a

longitudinal study that compared 2 groups of pregnant women (recreational

exercisers and non-exercisers) in terms of their body image and body satisfaction at

17 and 30 gestational weeks. Results suggested a small positive change in body

image from early pregnancy to late pregnancy. Similarly, Boscaglia, Skouteris and

46

Wertheim (2003) reported no changes in body image satisfaction in both high and

low exercising pregnant women. Specifically, their results indicated no significant

difference from 15-22 weeks gestation to 23-30 weeks gestation. Some researchers

have suggested this absence of body image change may be due to the fact that

pregnant women are able to accept their body changes as they see them as

temporary stage and specific to childbearing (Richardson, 1990). It has also been

argued that an absence of body image changes may result from a relaxation in

societal pressure to conform to certain body shape ideals (Davies & Wardle, 1994).

Similarly in another study, it was found that body image was relatively stable across

pregnancy and that the women able to make cognitive adaptations to their rapidly

changing body (Duncombe, Wertheim, Skouteris, Paxton, & Kelly, 2008).

No significant time-related differences were found for perceived stress. Stress can

have a negative effect on the pregnant woman and thus can be detrimental to the

health of both mother and fetus. Moreover, stress is often augmented during

pregnancy because additional stressors that are not usually present in a

nonpregnant state may also be experienced (Parker & Smith, 2003). Very few

studies on stress during pregnancy have looked at changes in stress levels over time

during pregnancy. Instead the focus has been on the overall incidence of stress

during pregnancy and its relationship to birth outcomes. Specifically, premature

birth and low birth weight are related to psychological stress (e.g., Dole et al., 2003;

Wadhwa, Sandman, Porto, Dunkel-Schetter, & Garite, 1993). The development and

use of techniques for managing stress are therefore potentially beneficial for

pregnant women.

Significant time-related differences were found for the perceived health subscale of

the PSDQ and the tension subscale of the BRUMS. More specifically, the late phase

of pregnancy was characterized by the highest scores on both perceived health and

tension. This interesting finding suggests that the women in late pregnancy

perceived themselves to be in good health even though they were feeling rather

tense in anticipation of the baby’s arrival. Poudevigne and O’Connor (2005) made a

comparison of three physical activity measures and also examined the mood

47

correlates of physical activity changes during pregnancy. A sample of 12 pregnant

women and 12 non-pregnant women were used and mood changes were examined

using the Profile of Mood States at different time points during the pregnancy.

Results on the tension subscale of the POMS showed tension scores increasing from

weeks 16 to 24 and decreasing from weeks 28 to 32. However, tension scores

increased again towards the end of the pregnancy at week 36. These findings are

consistent with those obtained in this study where the late phase of pregnancy

(weeks 35-41) produced the highest score on the tension subscale of the BRUMS.

5.2 Analyses related to Physical Activity

In order to examine the effects of physical activity on physical self-concept, mood,

perceived stress and burnout, participants were divided into three groups: (1) Low

PA, (2) Moderate PA, and (3) High PA. Overall the findings indicated that pregnant

women who participated in regular exercise had more positive self-perceptions,

more positive mood states, lower levels of perceived stress, and fewer burnout

symptoms than those who reported lower levels of exercise. The specific findings

are discussed in greater detail below.

5.2.1 Physical self-concept findings

The hypothesis that physical self-concept would be more positive with higher levels

of exercise was strongly supported by our findings. Specifically, group differences

indicated that increased levels of participation in physical activity were related to

higher levels of perceived coordination, perceptions of being physically active,

perceived endurance, perceived strength, perceived health, and global self-esteem.

Pregnant women who were involved in physical activity generally perceived

themselves as physically active people who were well-coordinated, fit, strong, and

in good overall health. These positive physical self-perceptions are potentially

important because, as Duncombe, Wertheim, Skouteris, Paxton, and Kelly (2008)

48

have shown, women with fewer body concerns during pregnancy are likely to

experience fewer depressive symptoms, diet less, and smoke less. The positive

impact of exercise on these physical self-concept dimensions is also noteworthy

because of the association between physical self-concept and global self-esteem.

Hierarchical self-concept models typically assume that positive impressions of the

physical self will have spin-off benefits for global self-esteem (e.g., Marsh et al.,

1994; Sonstroem & Morgan, 1989). This theoretical assumption was supported in

this study, with higher levels of exercise being associated not only with positive

physical self-perceptions but also higher levels of self-esteem.

A number of studies have focused on the relationship between physical activity and

self-esteem in the general population, but this relationship has not been adequately

investigated during pregnancy. When it has been examined, the findings have been

ambiguous. One of the earliest studies into this relationship was conducted by

Wallace, Boyer, Dan, and Holm (1986) who compared global self-esteem scores for

sedentary pregnant women with those of women participating in a pre-natal

aerobic exercise programme. Self-esteem scores in the exercise group were found

to be significantly higher than those in the sedentary control group. The effects of

exercise on self-esteem was also studied by Koniak-Griffin (1994). Pregnant women

in that study were assigned to two groups (exercise group and control group), with

self-esteem measured at pre-test and post-test using the Coopersmith’s Self-

Esteem Inventory. Results indicated improvements in self-esteem for both groups,

although the change in mean score for the control group was not significant. In a

similar study, Goodwin, Astbury, & McMeeken (2000) assessed self-esteem

between pregnant non-exercisers and pregnant exercisers. The Body Cathexis Scale

was used to measure physical self-concept at approximately 17 weeks gestation

and 30 weeks gestation. Data relating to the prepregnancy period was collected

retrospectively. Results indicated no significant differences between groups at each

time interval. Thereafter, the non-exercise group had less positive physical self-

esteem over time as compared to the exercise group.

49

These very limited numbers of studies have tried to show the relationship between

physical activity and self-esteem. However, they suffer from methodological

inadequacies with only two out of three studies using global self-esteem as the

main focus. This is where the present study makes a unique contribution to the

literature. To the best of our knowledge, no prior studies have simultaneously

investigated physical activity, multidimensional physical self-concept and self-

esteem during pregnancy. However, numerous studies have noted the positive

effects of exercise on self-perceptions in the general population, and the findings of

this study suggest the same benefits occur for pregnant women.

5.2.2 Social physique anxiety findings Our findings did not indicate any significant differences between physique anxiety

and levels of physical activity during pregnancy. There could be several explanations

for this finding. Firstly, it has been argued that pregnancy is viewed as a temporary

stage in one’s life (Richardson, 1990), and concerns about negative physique

evaluation may therefore be temporarily dismissed. Women become more relaxed

about their bodies during pregnancy and are less shy about displaying them to

others because weight and/or size concerns are reduced during the transitional

childbearing period especially towards the middle and late stages of pregnancy

(Davies & Wardle, 1994; Richardson, 1990; Skouteris, Carr, Wertheim, Paxton, &

Duncombe, 2005). In effect, a socially desirable and uncontrollable attribution is

readily available at this time for any perceived physique “problems”, so it is likely

that evaluation apprehension will be reduced (Clark & Wells, 1995; Taylor & Wald,

2003).

5.2.3 Mood state findings The hypothesis that mood state would improve with higher levels of exercise was

partially supported by our findings. More specifically, a significant difference was

found between physical activity levels and the vigor subscale of the BRUMS

questionnaire. An examination of the mean scores on the vigor subscale revealed

50

that women with high physical activity levels responded more positively than those

with lower levels of physical activity. In other words, pregnant women who were

exercising more reported that they felt more energetic than those who were

exercising less. In addition, a strong trend was also observed for total negative

mood as indicated in Fig. 4.5b. This trend must however be treated with caution as

post hoc analyses revealed no significant difference in mean scores. These findings

are consistent with a large body of research showing mood state benefits from

exercise involvement (Berger & Motl, 2000; McDonald & Hodgdon, 1991), as well

research specifically addressing the issues of energy and fatigue (Puetz, O'Connor, &

Dishman, 2006). They are also in line with findings from research on pregnant

women in which exercise has been associated with positive mood states (Kirkby &

Birmingham, 1996; Lox & Treasure, 2000; Polman, Kaiseler, & Borkoles, 2007).

Specifically, Polman and colleagues (2007) noted an increase in overall positive

mood and vigor following a bout of aqua or studio exercise among women in their

2nd or 3rd trimester of pregnancy. Given that fatigue is frequently reported during

pregnancy (Chou, Lin, Cooney, Walker, & Riggs, 2003; Puetz, O'Connor, & Dishman,

2006), the findings of the present study suggest that regular exercise might

counteract some of those feelings of tiredness.

5.2.4 Perceived stress findings A trend for group differences was observed for the relationship between perceived

stress and levels of physical activity. Research on the harmful effects of prenatal

stress and anxiety for pregnant women and their unborn child suggests that

exercise might be beneficial at this time. Despite the small differences in mean

scores in terms of perceived stress from a practical perspective, our findings thus

somewhat help reinforce the potential of exercise in reducing perceived maternal

stress. Consistent with the findings of this study, Lox and Treasure (2000) found

lower levels of stress among pregnant women who participated in prenatal aquatics

exercise classes twice a week for six weeks. More specifically, it was found that

psychological stress was reduced not only at the end of the program but also

immediately after each of the exercise sessions. However, despite the extensive

51

literature on the relationship between exercise and stress in the general population,

there has been very little research undertaken within the pregnant population. This

area therefore offers much scope for future research.

5.2.5 Burnout symptom findings A significant difference was found between physical activity levels and the burnout

subscale of personal efficacy. There were also significant group differences found

for the total burnout score. To the best of our knowledge, no studies have been

conducted to investigate the burnout syndrome in pregnant women. On the one

hand, this lack of research is understandable because the burnout construct is most

often addressed in connection with work-related stress. On the other hand, there is

evidence that burnout symptoms correlate positively with anxiety as well as

depression and also correlate negatively with self-esteem (Golembiewski &

Aldinger, 1994; Shirom, 2003; Turnipseed, 1998) Our finding that women who had

lower levels of physical activity also reported more burnout symptoms than those

with higher levels of physical activity therefore suggests that exercise may assist

with the maintenance of positive mental health during pregnancy.

5.3 Summary and Implications

Pregnant women are faced with a number of physical and psychological challenges

prior to the birth of their child. The antenatal period is characterized by rapid

physical and emotional changes that interact with one another and potentially

create stress for both the mother and the baby. The available literature offers

evidence of the detrimental effects of poor mental states on both the mother and

child not only during pregnancy but also postpartum. This study examined exercise

as a correlate of various psychological states during pregnancy. Findings revealed a

positive association between exercise and several markers of mental health such as

mood, perceived stress, physical self-perceptions and self-esteem. It is also worth

noting that these positive effects were evident even though the average level of

activity was not excessive. The women in this study reported an average of 20

minutes of vigorous exercise per week, slightly less than 60 minutes of moderate-

intensity exercise and just over 2 hours of walking per week. These levels of

52

exercise should be achievable by most pregnant women, and it is desirable for them

to be advised accordingly. Incorporating such education into standard antenatal

care protocols would seem to be a convenient and cost effective method of doing

so.

5.4 Limitations and Delimitations

This study had several limitations which must be acknowledged. Firstly, this study is

cross-sectional in nature. While it is able to capture a large number of participants

and the assessment of risk factors and outcomes at one time point, it is not does

allow for any causal inferences to be made.

Secondly, this study was restricted to volunteer participants recruited from

antenatal clinics at one metropolitan hospital in Perth. Thus, the sample may not be

representative of the broader population of pregnant women, and findings cannot

be generalised to the broader population.

Thirdly, the participants’ prior physical activity/exercise levels and medical

background were not systematically controlled. The study also required participants

to recall what their physical activities were for the past seven days. It is therefore

based on a self-report method which could be biased and prone to inaccuracy as

the participants had to rely on their memories to recall physical activities for a week

prior to answering the questionnaire. Despite the potential for inaccuracy, this

method has been widely used and is the most practical way of obtaining

information when surveying large numbers of participants.

Another limitation of this study was the length of the questionnaire. Most

participants took an average of 20 minutes to complete the questionnaire. Although

most participants welcomed the questionnaire as a relief from the boredom of

waiting for their appointments, a briefer questionnaire would have facilitated data

collection in some instances. For example, a shorter questionnaire might have

elicited a more accurate response from the participants, especially when they were

interrupted while completing the questionnaire to go to their appointments.

53

Finally, the mental health measures examined in this study were restricted to self-

concept, perceived stress, physique anxiety and selected mood states. Other

psychological states which might be influenced by pregnancy were not examined.

Participants were also surveyed before childbirth. No conclusions are therefore

warranted with regard to postpartum psychological states.

5.5 Conclusions

This aims of this study were to: (1) provide a cross-sectional description of changes

in physical self-concept, mood, burnout and perceived stress over time during

pregnancy; (2) evaluate physical activity patterns of pregnant women over time

during pregnancy; and (3) determine if there is a difference between physical

activity and physical self-concept, mood, burnout level and/or perceived stress

during pregnancy.

Several conclusions can be drawn from our findings which may have implications

for future research. More specifically, pregnancy is a time when healthy lifestyle

changes can be encouraged as pregnant women are inclined to make healthy

choices for both themselves and their child. At the same time, the transition to

parenthood has been described as a highly stressful life event involving widespread

bodily and emotional changes that can cause detrimental effects to both mother

and child. It is therefore important that the expectant mother is educated on these

stressors and is made aware of the availability of resources that can be easily

accessed by them to reduce stress.

Physical activity is one such resource and, according to the American College of

Obstetricians and Gynecologists’ recommendations and guidelines, pregnant

women can engage in regular moderate-intensity exercise at least 3 times a week if

there are no medical or complications associated with the pregnancy (Artal &

O'Toole, 2003). A noteworthy finding in this study was a positive association

between exercise and self-esteem. Self-esteem is accepted as a key indicator to

emotional stability and life adjustment (Fox, 2000), and it therefore reflects a

person’s overall mental well-being. According to Fox (2000), self-esteem has close

54

relationships with choice and persistence in achievement and health behaviours.

Findings in this study also reinforce the relationship between physical activity and

other mental health correlates such as mood and stress. Improved levels of mental

health have further implications on the health of the child, which are the future

generation. An interesting finding to note is also that of the similarity between

women in both the moderate and high physical activity groups. From this, it can be

inferred that there might be a certain “cut-off” level of physical activity during

pregnancy that produces positive psychological effects. This knowledge and along

with the findings of this study thus have important implications to health

practitioners in terms of planning intervention programs for this population.

5.6 Future Directions

The importance of physical activity / exercise has been emphasized strongly for all

population types. The findings in this study has not only reiterated this importance

but has also offered new insights within the pregnant population. Future research

involving a longitudinal study of the variables involved in this study would allow for

causal inferences to be made on the direction of associations between physical

activity levels and psychological health. Specifically, the prospective longitudinal

study could aid in the investigation on the use of physical activity levels in early

pregnancy as a tool for the prediction of psychological health such as physical self-

concept and/or self-esteem in later pregnancy.

55

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APPENDICES

Appendix A Research Information Sheet Appendix B Informed Consent Form Appendix C Research Questionnaire

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