Applied Nursing Research 27 (2014) 67–71

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Applied Nursing Research journal homepage: www.elsevier.com/locate/apnr

Psychosocial variables and self-rated health in young adult obese women
Mary Jane Smith, PhD, RN a,⁎, Laurie Theeke, PhD, FNP-BC a, 1, Stacey Culp, PhD a, 2,
Karen Clark, MD b, 3, Susan Pinto, MSN, RN a, 4 a b

WVU School of Nursing, PO Box 9600, Health Sciences Center South, Morgantown, WV 26506-9600
School of Medicine, Student Health Services, PO Box 9247, Health Sciences Center South, Morgantown, WV 26506-9247

a r t i c l e

i n f o

Article history:
Received 10 October 2013
Revised 4 November 2013
Accepted 4 November 2013
Keywords:
Obesity
Self-rated health
Stress
Loneliness
Self-esteem

a b s t r a c t
Aim: The aim of this study is to describe relationships among self-rated health, stress, sleep quality, loneliness, and self-esteem, in obese young adult women.
Background: Obesity has steadily increased among young adults and is a major predictor of self-rated health.
Methods: A sample of 68 obese (BMI 30 or higher, mean 35), young (18–34 years, mean 22) adult women were recruited from a health center. Survey data were gathered and analyzed using descriptive and bivariate procedures to assess relationships and group differences.
Results: Scores reflected stress, loneliness, poor sleep quality, and poor self-esteem. There were positive correlations among stress, loneliness, and sleep quality and, a high inverse correlation between loneliness and self-esteem. Those who ranked their health as poor differed on stress, loneliness, and self-esteem when compared to those with rankings of good/very good.
Conclusions: Assessing and addressing stress, loneliness, sleep quality and self-esteem could lead to improved health outcomes in obese young women.
© 2014 Elsevier Inc. All rights reserved.

Over the years obesity has steadily increased among adolescents and young adults. Furthermore, 40% of obese children and 70% of obese adolescents will become obese adults (Ogden, Carroll, Kit, &
Flegal, 2012). In this study, it is proposed that stress, sleep quality, loneliness, and self-esteem are holistic indicators associated with selfrated health status for young adult women with a body mass index
(BMI) of 30 and above, which indicates obese status.

1. Self-rated health
Self-rated health is a widely used measure of health and an indicator of personal health. It is determined by asking persons to evaluate their health on a five-point scale of poor, fair, good, very good, and excellent. Jylha (2009) asserts that health belongs in the realm of everyday discourse and the rating of health represents a general understanding of what health is for the person and offers a unique and valuable holistic indicator of health status.
Funding: WVU School of Nursing Research Fund.Dr. Theeke's scholarly work on this project was partially supported by the Robert Wood Johnson Nurse Faculty Scholars
Program.
⁎ Corresponding author. Tel.: +1 304 293 1676 (Office); fax: +1 304 293 6826.
E-mail addresses: mjsmith@hsc.wvu.edu (M.J. Smith), ltheeke@hsc.wvu.edu
(L. Theeke), sculp@hsc.wvu.edu (S. Culp), kclark@hsc.wvu.edu (K. Clark), supinto@hsc.wvu.edu (S. Pinto).
1
Tel.: +1 304 293 1405 (Office); fax: +1 304 293 6826.
2
Tel.: +1 304 293 6409 (Office); fax: +1 304 293 6826.
3
Tel.: +1 304 293 2311 (Office).
4
Tel.: +1 304 293 1393 (Office); fax: +1 304 293 6826.
0897-1897/$ – see front matter © 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.apnr.2013.11.004 Obesity has been associated with self-rated health among individuals over 18 years of age (Prosper, Moczulski, & Qureshi, 2009).
These researchers determined that obesity is a major predictor of selfrated health and demonstrated that obese individuals had threefold greater odds of reduced self-rated health status. In a study of 1894 young adults in which self-rated health was the outcome, obesity was associated with poor self-rated health among young adults (OR 2.69, p = .002). The authors concluded that self-rated health can be viewed as appropriate for assessment of health in young adults
(Kestila, Marrelin, Rahkkonen, Harkamen, & Koskinen, 2009). Bauldry,
Shanahan, Boardman, Miech, and Macmillan (2012) studied age graded patterns of health in 15,701 adolescents transitioning to young adulthood using self-rated health as the outcome variable (Bauldry et al., 2012). Subjects ranged in age from 24 to 33 years and those who were obese had significantly lower measures (b = − 0.455) of selfrated health than normal weight subjects. Furthermore, self-rated health remained stable for normal weight subjects but, for those in the obese group, there was a steady decline in self-rated health over time until age 34. These authors concluded that obesity has a negative effect on self-rated health.
2. Obesity and psychosocial variables
Women who are stressed have an increased risk for obesity (Chen
& Qian, 2012). Their study was based on a national survey of 112,716 adults 18 years and older who answered questions about selfperceived stress and bodyweight. Women who were extremely stressed had a higher prevalence of obesity (OR 1.44) compared

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M.J. Smith et al. / Applied Nursing Research 27 (2014) 67–71

with women who were not stressed. Cortisol levels, perceived stress, and obesity were studied in 78 women ages 24–72 (Farag et al., 2008).
Obese women reported the highest level of stress (p = .07) and a major portion of the cortisol variation was predicted by BMI.
In a study of 496 young adults (mean age 27) sleep duration (less than 6 hours) was a strong and significant predictor of obesity (OR .5, p = .01) (Hasler et al., 2004). In a cross-sectional study of 410 women who were 18–28 years old and short sleepers (less than 6 hours); sleep restriction was associated with a higher BMI. Subjects who slept less than 6 hours were more likely to be overweight and obese (p = .0001)
(Haghighatdoost, Karimi, Esmaillzadeh, & Azadbakht, 2012). Time in bed and obesity were associated among young adults age 18–25 years
(Hart, Larose, Fava, James, & Wing, 2013). They found that less than
6 hours of sleep per night was related to increased BMI (p = .01).
In a survey of 1289 adults, lonely persons had a higher BMI than non-lonely people (Lauder, Mummery, Jones, & Caperchione, 2006). A higher proportion of the lonely group were obese (n = 246; 61.8%) than in the not lonely group (n = 415; 53.8%). In a classic study
(Schumaker, Krejci, & Small, 1985) of 68 obese and 64 non obese persons, the researchers found that obese women (M = 41.9) scored significantly higher (p = .05) on loneliness than non obese women
(M = 33.8). Self-esteem was inversely correlated with body image dissatisfaction (r = .408, p = .001) in a study of 79 obese women
(Matz, Foster, Faith, & Wadden, 2002). In a study of 49 young adults, an inverse relationship between self-esteem and BMI (r = 0.70, p = .05) was found (Singleton, Bienemy, Hutchinson, Dellinger, & Rami, 2011).
The psychosocial variables of perceived stress, sleep quality, loneliness and self-esteem have not been studied as a cluster of variables in a sample of young adult women with a BMI N 30. The purpose of this study was to describe relationships among psychosocial variables and self-rated health status in a sample of obese young adult women. The questions guiding the study were the following:
1. What are the relationships among the variables of perceived stress, sleep quality, loneliness, and self-esteem among obese young adult women?
2. What are the differences in perceived stress, sleep quality, loneliness, and self-esteem for obese young adults who rate health as poor/fair and those who rate health as good/very good?
3. Method

A BMI of 19 to 24 is normal, 25 to 29 is overweight, 30 to 39 is obese, and 40 to 54 is extreme obesity. For this study, participants with
BMI of 30 or above were included. Measures of study variables included self-rated health, perceived stress, sleep quality, loneliness, and self-esteem.
4.2. Self-rated health
Self-rated health was determined by asking persons to evaluate their health on a five-point Likert scale of poor, fair, good, very good, and excellent. Self-rated health is a spontaneous assessment that represents what health is for the person (Bailis, Segall, & Chipperfield,
2003). In this study, the dichotomization of this variable was driven by prior studies of self-rated health. The scores on self-rated health were dichotomized to identify two major groups: those with a rating of poor/fair and those with a rating of good/very good. This approach is consistent with the work of Goodwin et al. (2006) who found differences in diet based on self-rated health group. They described the dietary intake of vegetables and total fat to be higher (p = .01) in adolescents in the poor/fair group when compared to the good/very good group (Goodwin et al., 2006). It was concluded that splitting the measure of self-rated health into two groups offered a clearer understanding of how the groups differed on positive and negative responses regarding self-rated health status.
4.3. Perceived stress
Stress was measured using the perceived stress scale (Cohen &
Williamson, 1991). It is a 10 item tool designed to measure the degree to which an individual perceives life situations as uncontrollable, unpredictable, and overloading. Scores range from 0 to 44 where a higher score indicates greater perceived stress. The scale was determined to be reliable based on Cronbach's alpha coefficients of
.89 in a sample of U.S. college students and convergent validity was supported with a correlation of .87 between the perceived stress scale and a measure of anxiety (Roberti, Harrington, & Storch, 2006).
4.4. Loneliness
Loneliness was measured using the Revised UCLA loneliness scale
(Russell, Peplau, & Cutrona, 1980). Scores range from 20 to 80 and a higher score indicates increased loneliness. The scale has high internal consistency (α = 0.89–0.94) and adequate test–retest reliability
(r = .73). Concurrent validity was confirmed with significant correlations between the Beck Depression Inventory (r = .62), and the
Costello–Comrey Anxiety (r = .32) (Russell et al., 1980).

This study took place in a university student health center in northern West Virginia. Analyses are reported from data that were collected from 68 subjects over a 15 month period. The convenience sample of 68 obese young adult women was recruited using notices placed in the student health center. Inclusion criteria were: students
18 years or older, a BMI of 30 or higher, and attendance for a preventive health care visit at the Student Health Center. Members of the research team employed by the clinic identified potential participants who met the inclusion criteria and offered them the opportunity to participate with a prescribed verbal script.
Data were gathered in a setting where the participants completed pen and paper surveys. Upon completion, the participant gave the packet containing the surveys to a member of the research team who recorded the BMI. Upon completion of the survey, the study participant received a movie ticket. The study was approved by the
West Virginia University Institutional Review Board and was deemed exempt having no more than minimal risk.

Self-esteem was measured using the Rosenberg Self-esteem Scale
(Rosenberg, 1979). He describes adequate reliability and validity of a global measure of self-esteem for both adult men and women. Test retests using the scale over 2 weeks demonstrated correlations of .85 and .88 demonstrating very good reliability. Construct validity was determined by relating the scale to peer group reputation among high school seniors. Those with high self-esteem scores were more likely to obtain high peer-group ratings of peers. The score range on the 10 item scale is 0–30 where higher scores indicate higher self-esteem
(Rosenberg, 1979).

4. Measures

4.6. Sleep quality

4.1. Demographics

Sleep was determined using the Pittsburgh Sleep Quality Index which assesses sleep over a 1 month interval (Buysse, Reynolds,
Monk, Berman, & Kupfer, 1989). It consists of 19 self-rated items. The global score has a range of 0–21 where higher scores indicate poorer

Demographic characteristics gathered were age and BMI. The BMI compares height to weight and provides an indicator of body fatness.

4.5. Self-esteem

M.J. Smith et al. / Applied Nursing Research 27 (2014) 67–71
Table 1
Psychometric properties of major study instruments.
Instrument

Cronbach's alpha Perceived stress scale
(10-item)
Sleep Quality Index
(7-item)
Loneliness scale
(20-item)
Self-esteem scale
(10-item)

M (SD)

.91

69

Table 3
Correlation coefficients for major study variables.
Study
range

Scale range 19.13 (7.53)

4–36

0–44

.70

6.56 (3.70)

1–19

0–21

.92

40.07 (10.66)

24–66

20–80

.94

20.65 (7.03)

3–30

0–30

sleep quality. In a study of sleep quality with in-patients and outpatients in a psychiatric clinic, the global score had an overall reliability coefficient (Cronbach's alpha) of .83 indicating a high degree of reliability (Buysse et al., 1989). Validity was determined by identifying good and poor sleepers in a group of healthy subjects and sleep disturbed subjects. A global sleep score of N 5 offered a sensitive and specific measure of poor sleep quality (Buysse et al., 1989).

Variable

Perceived stress

Sleep quality

Loneliness

Sleep quality
Loneliness
Self-esteem

0.414⁎⁎⁎
0.560⁎⁎⁎
−0.600⁎⁎⁎

0.414⁎⁎⁎
−0.365⁎⁎

−0.688⁎⁎⁎

⁎⁎ p b .01.
⁎⁎⁎ p b .001.

was not statistically significant (t = 1.80, p = .075). The two groups did not differ on mean age (t = 0.78, p = .45). Independent t-tests demonstrated statistically significant mean differences between the two groups on perceived stress (p = .003), loneliness (p b .001), and self-esteem (p b .001). Participants who rated health as poor/fair reported higher mean scores for stress and loneliness and, lower mean scores for self-esteem when compared to those who rated health as good/very good. There was no statistically significant difference between the two groups on sleep quality.
6. Discussion

5. Results
Data analysis was accomplished using SPSS Version 21.0. Initially, the psychometric properties of the study instruments were determined and descriptive analyses were performed to examine sample characteristics. Correlation coefficients were completed to determine relationships among stress, sleep quality, loneliness, and self-esteem.
Secondly, independent t-tests were used to determine differences in stress, sleep quality, loneliness, and self-esteem between the two groups of self-rated health as poor/fair and good/very good.
Table 1 reports the psychometric properties of the study instruments. The reliability coefficients as determined by Cronbach's alpha are .90 or better for stress, loneliness, and self-esteem. The reliability coefficient for the Pittsburgh Sleep Quality Index was .70 demonstrating minimally acceptable reliability.
Table 2 shows sample characteristics. The sample of 68 women ranged in age from 18 to 34 years. The mean age was 22.24 years (SD
3.15). The mean BMI for the group was 35.6 (SD 5.1).
There were significant relationships among the psychosocial variables. The following values were used to guide interpretation of the strength of correlation coefficients: weak association (r = .10 to
.29), moderate association (r = .30 to .49), and a strong association
(r = .5 to 1.0). There was a strong inverse relationship between stress and self-esteem. Higher perceived stress had a strong positive correlation with both increased loneliness and poorer sleep quality.
Loneliness was negatively related to self-esteem and there was a moderately significant negative relationship between sleep quality and self-esteem. Table 3 shows correlation coefficients.
Table 4 shows the t-test results for the differences between two groups based on self-rated health status. No subject rated health as excellent. For this comparison, the sample was divided into two groups: subjects who rated health poor/fair and those who rated health as good/very good. Though the two groups did have different mean BMI values: poor/fair group had mean BMI of 37.3 (SD 6.34) and good/very good group had mean BMI of 34.9 (SD 4.32), this difference

6.1. Relationships among stress, sleep quality, loneliness and self – esteem
This study elucidates new information about the relationships among stress, sleep quality, loneliness, and self-esteem. Knowing that young adults who report higher levels of stress may also be experiencing poorer sleep quality is clinically significant. This finding highlights the importance of assessing for stress in this age group when they express poor sleep quality, and vice versa. Second, the relatively high correlation between perceived stress and loneliness leads to the implication that these psychosocial variables should be assessed concurrently in young adult obese women. Further, the strong inverse correlation between perceived stress and self-esteem could serve as a call for intervention development. These relationships are complex, as evidenced by the additional significant correlations between sleep, loneliness, and self-esteem. It is important for clinicians to understand the interrelationships and to explore the various nuances of each relationship.
These findings are congruent with prior studies that reported that high stress levels were expressed in obese persons (Chen & Qian,
2012). However, new knowledge is gained about how these psychosocial variables may interact with perception of stress in this population. The same is true for the findings of poor sleep quality in obese persons (Hart et al., 2013). Knowing that psychosocial variables may lead to poor sleep quality in this population is important for nurses. Of particular interest is the high correlation between loneliness and stress. Loneliness has been recently linked to obesity in other age samples (Whisman, 2010) but this is the first study to link loneliness to obesity in young adults. The findings on self-esteem in

Table 4
Summary of means, standard deviations, and mean comparisons of major study variables by perceived health status group.
Variable

Variable

Total

Poor/fair health

Good/very good health n
Age
BMI

M (SD)

n

M (SD)

n

M (SD)

68
68

22.2 (3.1)
35.6 (5.1)

20
20

22.7 (3.8)
37.3 (6.3)

48
48

22.0 (2.8)
34.9 (4.3)

Perceived Stress
Sleep Quality
Loneliness
Self-Esteem

Good/very good health n = 48

Significance

M (SD)

Table 2
Total and group sample characteristics.

Poor/fair health n = 20

M (SD)

t

p

23.25
7.55
47.20
15.65

17.42
6.14
37.10
22.73

3.13
1.43
3.92
4.24

.003⁎⁎
.155
b .001⁎⁎⁎ b .001⁎⁎⁎

(6.96)
(3.91)
(11.44)
(6.01)

Note. Equal variances assumed.
⁎⁎ p b .01.
⁎⁎⁎ p b .001.

(7.02)
(3.56)
(8.86)
(6.38)

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M.J. Smith et al. / Applied Nursing Research 27 (2014) 67–71

this sample are consistent with the literature that has previously reported poor self-esteem in obese persons (Singleton et al., 2011).
6.2. Differences in loneliness, self- esteem, and stress
There were statistically significant differences on the variables of loneliness, self-esteem, and stress in this study of 68 obese young adult women grouped by poor/fair or good/very good self-rated health. To establish the clinical significance of these differences, a comparison is made with similar studies found in the literature. The findings in this study are consistent with the scientific literature.
Schumaker et al. (1985) reported a mean loneliness score of 41.9 using the UCLA loneliness scale in a group of 35 obese women ranging in age from 29 to 65 years recruited from shopping centers and two universities in the south. In comparison with this study those who rated health as poor had a mean loneliness score of 47.20 and those who rated health as good had a significantly lower loneliness score of
37.10. Knowing that obese persons who perceive their health as poor may be experiencing loneliness is clinically meaningful to health practitioners caring for young adult women who are obese.
In a study using the Rosenberg self-esteem scale in a sample of 149 women ranging in age from 47 to 67 years, the mean self-esteem score in this group was 26.9 (Chedraui et al., 2010). In comparison, the mean self-esteem scores for women in this study were 15.65 and
22.73 for the poor self-rated health and good self-rated health groups, respectively. The obese young adult women in this study who rated their health as good or very good reported self-esteem scores similar to those of mid-aged women in the previous study. The lower mean self-esteem score for the poor self-rated health group is another indicator of the need for assessment of psychosocial factors in obese young adult women.
In a study of women college students, Roberti et al. (2006) reported mean perceived stress scores of 18.4 in a sample of 285 undergraduates ranging in age from 17 to 60 years (225 were women). In the present study, the mean perceived stress scores were 23.25 for the poor self-rated health group and 17.42 for the good self-rated health groups. The scores for the good self-rated health group were similar to those reported by the college students (Roberti et al., 2006). However, since there was a statistically significant difference between the groups in our study, one could make logical inference that obese young adults report poorer self-rated health.
6.3. Good/very good health status
In this sample of 68 young adult women with a BMI of 30 and above, 48 (70%) rated their health as good or very good. This finding may be the most significant because it reflects health perception from the individual's point of view while experiencing obesity. It is important to note that while the good/very good group had less stress, less loneliness, and better self-esteem than the poor health group, the scores for the good/very good group did not indicate absence of stress, non-lonely status, or very high self-esteem. This suggests that even though the good/very good group reports significant differences in these variables when compared to the poor health group, the experience of added bodyweight may still be contributing to their rankings of stress, loneliness, and self-esteem.
The significant correlations among these variables on the entire sample make it evident that in this group of obese young adults, assessing for self-rated health should include assessment of stress, loneliness, and self-esteem. This specific finding makes it crucial for nurses to understand the interrelationships of these psychosocial variables with self-rated health.
The self-rating of health represents a holistic indicator of human health status in the moment and a rating of good or very good may offer an opportunity to move forward for young adult women who are obese. In-depth assessment of psychosocial variables could provide

knowledge to the clinician so that an accurate comprehensive indicator of readiness for change. Dalton and Gottlieb (2002) studied the concept of readiness to change and found that change was more likely when persons feel better able to manage stress, perceive that they have adequate support, and view their condition in a more positive light.
6.4. Sleep quality
It was expected that sleep quality would be different between the two groups of self-rated health. Carpenter and Andrykowski (1998) reported mean scores on the Sleep Quality Index for subjects who had no sleep problems (3.4 to 4.6) and for those who had sleep problems
(9.8 to 8.4), demonstrating that higher mean sleep quality scores are indicative of sleep problems. The mean sleep scores in this study were
7.55 for the poor/fair health group and 6.14 for the good/very good health group, indicating that more sleep problems were reported by the poor/fair group although the scores did not differ in a statistically significant way. Although not as high as the poor sleep group scores reported by Carpenter and Andrykowski, both of these groups indicated poor sleep quality as evidenced by the higher mean scores on the Sleep Quality Index when compared to the no sleep problem group in Carpenter and Andrykowski's study. This may be partially explained by the difference in samples, knowing that this sample was an all obese sample. The literature supports an association between poor sleep and obesity with lack of sleep being reported as a contributor to fat retention (Nedeltcheva, Kikus, Imperial, Schoeller, &
Penev, 2010).
7. Implications
The first implication for practice is aimed at the levels of perceived stress, sleep quality, loneliness, and self-esteem described in this study. These psychosocial variables, which are all interrelated, could be addressed in practice interventions with the ultimate goal of improving health outcomes in young adult women who are obese.
Given the links between stress, sleep quality, loneliness, and selfesteem, it is possible that interventions aimed at diminishing stress could also impact sleep quality, loneliness, and self-esteem and thereby, the overall experience of obesity. First and foremost, proactive assessment will be instrumental to identifying these factors, particularly in this population that may still rate their health as good.
Once assessed, facilitating or linking the obese person to the appropriate resources for stress reduction could lead to enhance health. Nurses who have demonstrated clinical expertise in specific stress reduction methods with tested efficacy could be a resource to this population. Currently methods may include: story, mindfulness, problem-solving therapy, individual counseling, and group experiences that have been effective in stress reduction. There are limited interventions that have been tested for loneliness but Masi, Chen,
Hawlkey, and Cacioppo (2011) reported in a recent meta-analysis that interventions targeting the maladapted cognitive processes, which are also linked to poor self-esteem, will likely be most effective (Masi et al., 2011).
The second implication for practice is aimed at assessing self-rated health in persons with obesity. Given the group differences on these psychosocial variables, it is clinically important to be aware of each individual's health rating. For persons who rate their health as poor, nurses need to have a heightened awareness that there may be increased risk for psychosocial problems like loneliness or poor selfesteem, both of which are consistently linked to poorer health behaviors and negative physical and psychological health outcomes.
Offering holistic health programs that identify differences in health ratings should lead to tailored health planning to meet individual needs. Further, awareness of good/very good health ratings in obese persons may present a unique challenge for advocating behavior

M.J. Smith et al. / Applied Nursing Research 27 (2014) 67–71

change in the context of limited psychological motivation or readiness for change.
The third implication is aimed at assessing and addressing the sleep pattern of obese young adult women, regardless of self-rated health. Given the poor sleep quality in both groups, interventions to improve sleep are needed. Making sleep quality a focus of a weight reduction program, aiming to improve behavioral and environmental factors related to sleep may lead to better sleep quality, and enhanced motivation to take on a weight reduction program. In one intervention study with 49 obese women, those who participated in a better weight–better sleep group lost weight faster than those in the better weight–behavioral group (Logue et al., 2012).
Three proposed research studies based on the findings of this study are suggested. These include (1) replicating the study with young adult obese men to determine if gender differences exist on these variables; (2) a qualitative study to identify and describe the determinants of health rating in obese young adult women; and (3) a randomized intervention trial targeting self-rated health, perceived stress, loneliness, sleep quality, and self-esteem as outcome variables for obese young adults. This study could be valuable in that it would contribute to understanding how health is viewed in the context of obesity at this particular human developmental age.
8. Conclusions
Health was conceptualized as feelings of fitness and strength in which a healthy body and mind flourish (Von Wright, 1963). This study reports knowledge about the relationships among psychosocial variables with young adult women who are obese. Particularly shedding light on the importance of understanding how stress, sleep, loneliness, and self-esteem may interact with self-rated health status in this specific population. Given the recent declaration by the
American Medical Association clarifying that obesity is a disease, an understanding of how psychosocial variables relate to or contribute to obesity could be paramount to the development of effective interventions. Given the long-term contribution of obesity to negative health problems, implementing effective interventions for this young adult age group could lead to a lifetime of healthier living.
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