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Abstract

Background:

According to clinical practice guidelines for polycystic ovary syndrome, first-line treatment includes performing 150 min of moderate-to-vigorous physical activity on most days of the week plus at least 2 days of resistance training. However, <40% of women with polycystic ovary syndrome engage in regular physical activity, and about 60% are sedentary. Research evidence supports theory-informed physical activity interventions to improve motivation for physical activity. This study examined the fit of a behavioral change theory for women with polycystic ovary syndrome.

Objectives:

The purposes of this qualitative study were to analyze physical activity barriers through the lens of self-determination theory and identify motivational strategies that may promote initiation and maintenance of physical activity among women with polycystic ovary syndrome.

Design:

The study involved a qualitative, descriptive design using theory-driven thematic analysis.

Methods:

After emailing a demographic questionnaire and Personal Health Questionnaire-8 to screen for depressive symptoms, participants (n = 7) met three times via Zoom during the summer of 2021. Meetings were audio-recorded, transcribed, and analyzed.

Results:

Participants were aged 33.9 (±8.1) years, premenopausal, mostly White (71%), educated (100% with at least some college), employed full-time (86%), and married (86%) with a mean depressive symptoms score of 6.4 (±3.4) indicating mild depression. Strategies such as a buddy system, physician support, technology, and behavioral change techniques are necessary to meet the psychological needs of autonomy, competence, and relatedness among women with polycystic ovary syndrome to help increase exercise motivation.

Conclusion:

Findings supported the use of self-determination theory by emphasizing that the social context of polycystic ovary syndrome can undermine physical activity behavior. Thus, physical activity interventions should consider the social context, peer support system, and mental health status of women with polycystic ovary syndrome, and include tailored programs and motivational strategies to help meet the psychological needs of autonomy, competence, and relatedness.

Keywords

polycystic ovary syndrome PCOS psychological theory motivation physical activity depression qualitative research

Introduction

Polycystic ovary syndrome (PCOS), the most common endocrinopathy among women,¹ affects about 20 million women in the United States across all races and ethnicities.² PCOS is a complex, heterogenous collection of symptoms involving hormonal dysregulation.¹ Diagnosis of PCOS occurs when two of three of the following conditions are present: menstrual irregularities, clinical or biochemical signs of hyperandrogenism, and/or polycystic ovarian morphology.³ PCOS is associated with central adiposity, insulin resistance, dyslipidemia, and depressive symptoms, placing the women at risk for cardiometabolic diseases, reproductive cancers,⁴ and psychological morbidity.⁵ Women with PCOS are three to eight times more likely to have depressive symptoms⁶ and seven times more likely to attempt suicide⁷ than women without PCOS.

Physical activity (PA) has been well-established as a therapy for managing PCOS symptoms and reducing the risk of comorbidities.³ PA is defined as any bodily movement produced by skeletal muscles requiring energy expenditure.⁸ PA includes exercise, both aerobic and resistance, which is planned, structured bodily movement with a fitness goal.⁸ As such, the Endocrine Society Clinical Practice PCOS Guidelines recommend that women with PCOS follow the PA guideline of 150 min/week of moderate-to-vigorous aerobic activity to prevent or delay the onset of comorbidities, as well as improve cardiorespiratory fitness, body mass index, and quality-of-life.^3,8 Resistance exercise is recommended on at least 2 days/week,³ as it has been shown to increase metabolic capacity via increased lean mass, reduce insulin resistance, and increase bone mineral density,^9,10 while reducing depressive symptoms among those with and without clinical depression, and more in women with PCOS than in women without PCOS.^3,9
–15 However, <40% of women with PCOS engage in regular PA, and about 60% are sedentary.^16,17

PCOS-specific PA barriers have been reported as stigma-related stress due to appearance (e.g. hirsutism, obesity), symptom burden (e.g. depressive symptoms, fatigue), and lack of understanding of the condition by society in general, time, and confidence.^18,19 These barriers impede motivation to exercise, especially in group-based and public settings, necessitating a search for effective and meaningful strategies to improve motivation. Research evidence supports interventions underpinned by theory and inclusive of psychological support.²⁰ Motivation determines the initiation and maintenance of PA, as motivation drives all aspects of intention, activation, and persistence of goal-directed behavior.²¹ Interventions informed by self-determination theory (SDT) have growing evidence of improving motivation by identifying supports that help meet psychological needs.²² When psychological needs are met, people attain more intrinsic motivation to exercise, which may lead to behavioral engagement.^22
–25 Thus, the purposes of this qualitative descriptive study were to explore PA barriers through the lens of SDT and identify motivational strategies that may promote the initiation and maintenance of PA among women with PCOS.

Theoretical framework

The science of health behavior change has increasingly emphasized theory-based approaches to intervention, as theories help identify underlying mechanisms of action and proximal targets of intervention (i.e. mediators and moderators).^21,22 SDT, as introduced by Ryan and Deci, is a metatheory for the study of human motivation, personality development, and well-being.²³ The underlying assumption of SDT is that humans not only are naturally inspired and agentic, but also require social supports or strategies to develop and maintain natural potential and well-being. SDT intersects personality and social context to predict the likelihood of adopting and maintaining a behavior, such as PA, by predominantly focusing on a taxonomy of motivations and three innate psychological needs.

SDT was chosen as the lens for structuring the study, given its focus on motivation within unique social contexts. SDT explains that social norms may suppress an individual’s innate psychological needs of autonomy (freedom to choose a behavior), competence (ability to perform and master a behavior), and relatedness (sense of belonginess).²³ Unmet needs suppress natural self-governing and create a shift in motivation away from self-determined behavior to more externally motivated behavior. Furthermore, based on SDT, individuals with decreased motivation require multiple strategies to improve need satisfaction. Thus, the extent to which people meet these psychological needs dictates their position on the continuum of motivation. Researchers that have employed an SDT perspective found that self-determination and motivational orientation, along with self-efficacy, offered an appropriate framework to further understand PA behavior among those with chronic health conditions²⁰ (see Figure 1).

Figure 1.

The process of self-determination theory as adapted from Ryan and Deci²³ by Wee.²⁶

Materials and methods

Design and ethics approval

A qualitative descriptive study was conducted from May 2021 to December 2021. The study was conducted in accordance with the principles stated in the Declaration of Helsinki and 45 CFR 46.104(d)(2) and 45 CFR 46.111(a)(7). The University of South Carolina (USC) Institutional Review Board (IRB) approved the study (Pro00105265, December 7, 2020). As approved by the USC IRB, verbal consent was obtained from participants prior to each virtual meeting. The interviewer was supported by NIH Ruth L. Kirschstein Predoctoral Individual National Research Service Award (1F31 NR019206-01A1).

Study setting and sample

A focus group was formed of women with PCOS (n = 7) to analyze exercise barriers through the lens of SDT and identify motivational strategies that may promote initiation and maintenance of PA among women with PCOS from the perspective of women with PCOS. Our recruitment goal was for 6–10 individuals to keep the group size manageable and its participants comfortable sharing their expertise while also achieving diversity of opinion. Participants were recruited using the snowball method and social media, which allowed for a wider geographic reach and more diversity among a small group of participants. The researchers had no previous relationships with the participants. Due to the COVID-19 pandemic, the study was conducted virtually and used secure email to distribute and collect surveys.

Inclusion/exclusion criteria

Eligibility criteria were premenopausal women with a confirmed diagnosis of PCOS by a healthcare provider, an age of 18–42 years, and internet access for virtual meetings. Potential participants were required to submit via secured email confirmation of a PCOS diagnosis by a healthcare provider to be considered for the study. The age range was chosen based on a systematic review and meta-analysis that defined the start of the menopausal transition for women with PCOS at or greater than the age 45 years.²⁷

Measures

Demographics

The demographic questionnaire included age, race, geographic location, educational attainment, employment and insurance status, marital status, number of children, height, weight, and comorbidities (see Supplemental Appendix A).

Depressive symptoms

The Personal Health Questionnaire-8 (PHQ-8) is one of several tools used to assess depressive symptoms among women with PCOS in previous studies, and it has been recommended for symptom monitoring among patients with medical (versus psychiatric) diagnoses.²⁸ As such, the PHQ-8 was used to assess the presence and severity of depressive symptoms experienced within the past 2 weeks. The PHQ-8 consists of eight items with a four-point rating ranging from 0 (not at all) to 3 (nearly every day). As a screening instrument, PHQ-8 scores suggest potential levels depression based on the number of depressive symptoms: 5–9 mild, 10–19 moderate, and ⩾20 major.²⁹ Construct validity was reported at 0.75 and internal reliability was reported at 0.81.²⁹

Virtual meetings

The focus group met three times for ~1 h/meeting. The virtual meetings took place during the summer months spaced apart by ~3 weeks. The researcher (P.J.W.) introduced the purpose of the focus group. Meetings were structured by using an SDT-informed interview guide (see Supplemental Appendix B) created by the first author (P.J.W.), a doctoral-prepared female nurse researcher with experience working with and recruiting women with PCOS, and the second author (R.M.D.), a female qualitative methodologist and nurse practitioner familiar with PCOS medical management. Interview guides were specifically developed to address knowledge, facilitators, and barriers of PA,^19,30 SDT psychological needs,²³ and strategies to increase motivation. Meetings were conducted by P.J.W. and audio-recorded via Zoom, a cloud-based videoconferencing service. Zoom offers the ability to communicate in real-time with participants in different geographic locations via computer or mobile device. This platform was chosen because it has several privacy features including user authentication, secure recording and storage, and real-time meeting encryption. Field notes were made during the focus group meetings. The recordings were transcribed and then compared to the audio to ensure that they accurately represented the participants’ discussion. Each participant received a $20 e-gift card per meeting for their time and expertise.

Data analysis

Using theory-driven thematic analysis,³¹ the data were organized and categorized based on predetermined themes drawn from SDT. Two researchers (P.J.W. and R.M.D.) independently coded the responses using deductive reasoning according to the three SDT psychological needs. Subsequently, an iterative categorization process was followed to organize data according to theoretical constructs. The two researchers discussed data saturation and unanimously agreed that data saturation had been reached after the three focus group meetings. Rigor was strengthened through the reflexivity of the researchers via reflexive journaling and regular meetings to discuss personal experiences and knowledge of both PCOS and PA in relation to the statements of the focus group participants. Rigor was further enhanced by following COREQ guidelines³² (see Supplementary File).

Results

Participants (n = 7) represented three U.S. states (South Carolina, Georgia, and Texas) and four different counties in South Carolina, both rural and suburban. Participants were 33.9 (±8.1) years of age, mostly White (71%), married (86%), and employed full-time (86%). The participants’ mean depressive symptom score was 6.4 (±3.4), indicating “mild depression.” Participants’ characteristics are listed in Table 1.

Table 1.

Descriptive statistics of characteristics of the focus group participants (n = 7).

Characteristic	Mean ± SD or frequency, % (n) or range
Age	33.9 ± 8.1
Race
African
American/Black	14% (1)
Hispanic	14% (1)
White	71% (5)
Educational attainment
Some college	43% (3)
Bachelors	43% (3)
Masters	14% (1)
Employment status
Part-time	14% (1)
Full-time	86% (6)
Medical insurance	100% (7)
Marital status
Single	14% (1)
Married/partnership	86% (6)
# Children	0.0–4.0
# Comorbid conditions	0.0–4.0
Body mass index (kg/m²)	33.2 ± 6.3
18.5–24.9	14% (1)
25–29.9	29% (2)
⩾30	57% (4)
PHQ-8 score	6.4 ± 3.4
⩽4^a	29% (2)
5–9^b	29% (2)
10–19^c	43% (3)
⩾20^d	0% (0)

PHQ-8: Personal Health Questionnaire-8.

Minimal depressive symptoms.

Mild depressive symptoms.

Moderate depressive symptoms.

Severe depressive symptoms.

Five participants (71%) self-reported at least one comorbid condition. See Table 2 for all self-reported comorbidities.

Table 2.

Comorbidities self-reported by five participants.

Comorbidity	Frequency, n (%)
Attention deficit/hyperactivity disorder	2 (40%)
Depression	3 (60%)
Diabetes	2 (40%)
Hidradenitis suppurativa	1 (20%)
Hirsutism	4 (80%)
Hypertension	2 (40%)
Insulin resistance	1 (20%)
Vitamin D deficiency	1 (20%)

The PHQ-8 scores of the three participants who reported depression as a comorbidity corresponded.

All focus group participants acknowledged the multiple health benefits of exercise. However, all reported being insufficiently active, that is, they did not regularly accumulate 150 min of moderate intensity PA most days of the week. All focus group participants reported using extrinsic motivation to make decisions about PA behavior. For example, one participant was motivated by incentives such as discounts on facility memberships and another participant was motivated by her physician’s guidance to lose weight. No participant represented amotivation nor fully self-determined intrinsic motivation. When asked to rank the SDT psychological needs in general, focus group participants unanimously agreed that relatedness was most important, with mixed responses about whether competence or autonomy would follow.

Themes were deductively categorized by the three psychological needs of SDT. A fourth theme, motivational strategies, comprised focus group participants’ suggestions for improving exercise motivation. Quotes illuminating the themes are italicized and presented as stated by the focus group participants and are minimally edited for clarity (e.g. removal of dysfluencies). Participants’ initial and age follow each quote.

Autonomy: And it was something else that hindered me

Autonomy is the volitional choice and control of one’s behavior. Internal and external factors impact autonomy by creating shifts in perception of priorities. The women filled multiple roles (e.g. spouse, mother, daughter, employee, student, patient), resulting in daily competing time demands. As a result, the women felt a loss of control in their ability to schedule time for PA: My barrier is time.

Life just got in the way. (M, 41)

Other barriers, children, family, school, blah, blah, blah, blah get in the way. (C, 37)

My biggest struggle is making the time and making that a priority over other things. (S, 29)

As women who struggle with PCOS, some women expressed being robbed of choice due to comorbid conditions, such as hidradenitis suppurativa (inflamed and infected sweat glands; n = 1) and depression (n = 3).

Other factors that go with PCOS impede physical activity. Hidradenitis suppurativa is one of those factors. So the sweat glands may become clogged, they break out into boils and they have to be surgically removed. So the more you sweat, the more there’s pain. (M, 42)

It (PCOS) was affecting me mentally . . . so like depression and just like . . . hopelessness. Um, so, you know, I never exercised. (J, 23)

Hyperandrogenism is a feature of PCOS with physical sequelae such as obesity, hirsutism, and acne. Several women expressed feeling “unattractive” and having poor self-image, which led to avoidance of PA in public places.

You hate your body and you feel fat all the time. (T, 24)

Autonomous choices were also limited by facility location and costs.

And the next closest one (gym) is 30 minutes away. (C, 37)

And so there’s also the monetary component to it as well. (M, 42)

Competence: (Lack of weight loss) crushed my spirit. And, ever since then, I haven’t tried to do anything

Competence involves the sense of mastery and self-efficacy of one’s behavior and the need to feel effective when performing that behavior. A person will more likely accomplish a task or meet a goal when feeling capable of successfully performing the related activities, or when the task results in the expected outcome.

[Exercise] gave me a sense of accomplishment. (J, 23)

It’s (the body) working correctly and everything’s going great and you’re powerful, I think that’s the most rewarding thing about it. (S, 29)

When one feels ineffective, incompetent, or unable to accomplish a task or goal, the effort may seem meaningless.¹³

So I will not do a group because I have no rhythm. I can’t do anything like that. (M, 41)

It’s depressing when you don’t see your results, you don’t want to try anymore. (C, 41)

Focus group participants cited weight loss as the most salient reason to both start and stop a PA. Weight loss was prioritized based on body dissatisfaction and physician advice.

I want to lose weight. I don’t like my body. (C, 41)

The doctor says, “Well just lose weight, a lot of your symptoms will be fixed.” Wouldn’t it be nice to know how? (M, 42)

Relatedness: We are in it together

Relatedness is the interpersonal dimension, reflecting the extent to which a person feels connected to and accepted by others and has caring relationships.³²

I can’t do it on my own. (S, 29)

just like family in general or anyone who will just go on that journey with you (M, 41)

Focus group participants explicitly stated the need for social contact(s) who can relate to or understand PCOS and its physical and mental consequences.

just someone who understands what you’re going through and who is someone who is also knowledgeable about PCOS. (C, 41)

Participants discussed that groups, even groups with all women, were intimidating because they felt less feminine and less of a woman compared to others.

They don’t have it (PCOS) so they don’t get it. I compare myself to them and feel less of a woman. I’m big, have all this hair, can’t have a baby. (S, 29)

Motivational Strategies: I’ve, like everybody, tried all kinds of different things and I’ve liked some and I’ve not liked some

Focus group participants listed potential motivational strategies to promote and sustain PA as a healthy lifestyle behavior. For example, one participant stated that coaching (the support) increased her competence, which in turn enabled autonomy to make exercise choices that accommodated limited time and space. Each motivational support caters to one or more psychological needs. For example, the motivational support of people affects the need for relatedness; a service support affects the need for competence; the motivational support of technology mostly affects the need for autonomy, whereas the motivational support of behavioral change strategies affects all three needs. The motivational strategies presented by the focus group are listed in order of importance to the participants and with stated advantages and disadvantages of each in relation to general and PCOS-specific PA barriers (Table 3).

Table 3.

Motivation support types, strategies, advantages, and disadvantages grouped by psychological need as discussed by the focus group (n = 7).

Motivational support	Strategy	Advantages	Disadvantages	Exemplar quote
Relatedness
People	“Accountability buddy”	Personal connection, fun	Availability	“. . .someone to guide you through, to say don’t give up, don’t sit on that couch.” (C, 37)
	Coach	Personal connection, performance-based feedback, progression, tailored programs	Personality mismatch, cookie cutter programs, little PCOS knowledge	“A coach keeps me accountable.” (T, 24)
	Community support group	Empathy, knowledge, ideas	Difficult to find	“. . .I’m learning new things about PCOS from other people across the world who have found things that work for them . . . .” (C, 41)
	Family	Promotes health for all, fun	Not interested, different schedules	“And if you get the family into it, I mean, of course our kids, it’s fun and they see us and it’s a family activity . . . .” (M, 41)
Competence
Services	Group training	Fun competition	Lost in crowd, not tailored to ability, self-conscious, self-efficacy	“. . . no, I do not have the self-confidence to be able to do a (aerobics) group like that.” (M, 41)
	Personal training	Personal connection, tailored program	Cost, little PCOS knowledge	“. . .finding trainers who understand and will be your companion during it, be a teammate with you while you’re going through your journey . . . .” (T, 24)
	Physician guidance and support	Trust	Sole focus on weight loss	“So, I will definitely go to the doctor first.” (M, 42)
Autonomy
Technology	• Digital products• Applications• Videos• Podcasts• Websites	Convenient leveled educational	Easy to ignore, cost, eventual boredom, technology upgrades	“I started using (an app). . . for free. And I found a coach which is like a counselor too and another group of people who we bounce ideas off each other and support each other.” (S, 29)
	• Wearables• Pedometer• Watches	Competition with self and others can be more holistically health-focused	“Obsession with numbers,” promote “guilt”	“. . . athletic watches, whether you’re trying to fill a ring or keep track of the amount of steps you’re taking, can really be a useful tool.” (S, 29)
Relatedness, competence, and autonomy
Behavioral change strategies	Goal setting	Provides reason, provides focus, measurable	Setting wrong goal, unrealistic expectations	“I think it can be very hard to keep striving for the extra goals and to keep setting goals.” (T, 24)
	Incentives	Fun	Short-lived	“So, at some point, I’d probably be like, ‘Okay, I don’t care anymore’.” (C, 37)
	Motivational pictures	Inspirational	Unrealistic	“. . .because when you look at magazines, they’re going to show you the skinny models, not what real people look like . . . .”
	Environmental change	Flexible, tailor to comorbid conditions	Weather, access	“. . . I can hike down here in the fall and wintertime and not be as miserable sweaty . . . .” (M, 42)

PCOS: Polycystic ovary syndrome.

Discussion

Women with PCOS encounter general and PCOS-specific exercise barriers. According to SDT, the cultural context of PCOS necessitates meaningful motivational strategies to help meet psychological needs of autonomy, competence, and relatedness. In turn, as needs are met, motivation to engage in PA becomes more intrinsic. The purposes of this qualitative study were to analyze PA barriers through the lens of SDT, a motivation theory, and identify motivational strategies that may promote PA initiation and maintenance from the perspective of women with PCOS. The discussion is organized by the three innate SDT psychological needs and then motivational strategies that may promote need satisfaction and increase PA motivation.

Autonomy

Focus group participants expressed that volitional choice to be physically active followed other priorities, such as family demands. The focus group participants detailed many competing time commitments. Although this is probably true for many people, the women with PCOS desired strategies to best incorporate PA given both life demands (e.g. family) and PCOS-specific needs (e.g. grooming rituals, physical comorbidities). The concept of little to no discretionary time to participate in activities that build social and human capital is referred to as time poverty.³³ Time poverty encourages unhealthy behaviors, (e.g. buying fast food) which creates a cyclic pattern of defeat or learned helplessness.³³ Time poverty is not necessarily a mismatch between responsibilities and available hours, but a mental outlook on the value of those hours.³³ A creative way to “fund time” is changing perspective about the value of time, such as giving time a financial equivalent and then budgeting time and money together.³³

Focus group participants described responsibilities beyond the traditional definition of paid employment, such as childrearing, caregiving for aging parents, and other family obligations. Women in developed and developing nations spend, respectively, an average of 2 and 3.4 times more hours per day than men on unpaid work shouldering the heaviest burden of cooking, cleaning, and caring for children and the elderly.³⁴ This inequitable gender-based allocation of unpaid domestic work, representing “double-duty” for women who enter the workforce, often limits discretionary time for women and promotes self-neglect.³⁵ While this finding is not unique to women with PCOS, other researchers reported that women with PCOS more strongly adhere to cultural female gender roles to reclaim a feminine identity.³⁶

The systemic oppression of women via gender inequality is accompanied by restrictive gender norms dictating societal female expectations, including the gender-specific ideals permeated about a woman’s presentation and gender performativity.³⁷ The focus group participants frequently mentioned hirsutism and obesity as PCOS aspects causing stigma-related stress. Pfister and Romer found similar results when they interviewed Danish women with PCOS, all who perceived their bodies as different from femininity norms.³⁸ Negative self-evaluation of bodyweight and shape can lead to low self-esteem, depressive symptoms, and social phobia.³⁹ More and Phillips also found that body dissatisfaction led to less autonomous regulation among women, which led to less frequent PA.⁴⁰ Lastly, several of the participants in the current study reported lack of autonomy due to physical and mental features imposed by PCOS (e.g. obesity, hidradenitis suppurativa, depressive symptoms). Some conditions could be circumvented by choosing alternative forms of PA. For example, the participant with hidradenitis suppurativa chose swimming versus traditional cardiovascular exercise such as walking to avoid hot environments and thus an aggravating factor of excessive perspiration. Recent meta-analyses indicate that PA can significantly improve psychological well-being among people with depressive symptoms.⁸ However, focus group participants stated that depression caused lack of energy and drive to be physically active. Screening for depressive symptoms and providing resources may be an essential first step before prescribing PA as therapeutic management. Longitudinal studies assessing PA and subjective well-being have shown that greater well-being predicts maintained or increased activity over time,⁴¹ and that changes in leisure-time exercise predict changes in happiness.⁴²

Competence

Focus group participants relayed clinical encounters and public health messaging that issued absent or confusing directives for weight loss. Clinical guidance for weight loss often excludes accurate and more detailed information about the role of exercise for weight loss as PA alone will not produce quick weight loss.⁴³ PA enhances the ability to lose weight over time but mostly confers metabolic benefits.⁴⁴ Accurate and specific guidance about realistic goal expectations increases knowledge and builds self-efficacy.

In addition to accurate and detailed information, individuals must experience success with a behavior to build confidence in their actions.⁴⁵ Positive behavioral experiences build self-efficacy, which in turn facilitates perceived competence for the behavior.⁴⁵ Goal reframing is one strategy to establish other expected and more immediate health outcomes such as improved endurance, increased strength, and improved sleep. Recognizing more immediate health outcomes as goals and subsequently meeting those goals increases the likelihood for sustained behavior change.⁴⁵ Positive and informative feedback also increases perceived competence.⁴⁶

Focus group participants reported physicians as a trusted source of information and competent care. However, physicians cite barriers to exercise counseling such as lack of clinical time, limited education about PA dosing, and the absence of a PA counseling protocol.⁴⁷

Relatedness

Several studies (correlational, longitudinal, experimental) revealed a strong positive correlation between sense of belongingness and life satisfaction and wellness.⁴⁸ The focus group participants agreed. Focus group participants emphasized the need to be understood in the context of PCOS, which is consistent with previous literature about women with PCOS.⁴⁹ Being socially connected is influential on psychological and emotional well-being and has a significant and positive influence on physical well-being and overall longevity.⁵⁰ As social beings, people strive for social connection to feel accepted and supported and avoid isolation and loneliness. This sentiment was consistent with a series of experiments designed to examine types of social connection, in which people were motivated to perform a task based on “being understood” or “mere belonging.” Being understood was independent of casual acquaintance versus longstanding relationships with family or friends or one individual versus many people.⁵¹ Thus, strategies to enable relatedness for women with PCOS could include online peer support, a buddy system, or social support groups.

Focus group participants ranked relatedness as the most important category when discussing motivational strategies to be more physically active. In a cross-sectional study of women with PCOS about PA perceptions, respondents reported a choice not to be physically active due to feelings of rejection, stigma, and isolation from a general lack of understanding from others about PCOS and its impact.¹⁹ In a similar study to ours, Dalgas et al. found that unmet needs of relatedness led to feelings of isolation and frustration that prohibited PA, especially in group settings.⁵² As the focus group participants discussed, relatedness is enhanced when there is understanding of PCOS specifically followed by consistent support from the source providing true understanding.

The SDT literature emphasizes conducting a needs analysis to prioritize the psychological needs when designing tailored interventions for most populations.⁵³ However, when considering the differential effects of the three psychological needs among women in general, relatedness contributed strongly to autonomy and competence while autonomy and competence did not impact relatedness. As such, behavioral interventions should consider prioritizing relatedness needs to affect all other needs and promote intervention efficacy among women with PCOS.,

Interrelatedness of the psychological needs

The three innate psychological needs of autonomy, competence, and relatedness are also interrelated, as they each reinforce the other and work synergistically to contribute to overall well-being and promote more intrinsic motivation.²²

Autonomy and competence

Autonomy facilitates competence. As individuals choose behaviors that align with priorities and interests, they will invest time and effort in those activities or behaviors, leading to the development of competence. Conversely competence can enhance autonomy. As competence for a behavior increases, individuals are more likely to choose that behavior.

Autonomy and relatedness

Autonomy also involves the freedom to choose when and how to engage in social interactions. Voluntary social interactions are more likely to yield more authentic and meaningful connections with others. Perceived social support, especially types such as emotional and appraisal,⁵⁴ can reinforce autonomous choice.

Competence and relatedness

Findings from information management research indicate that competence leads to knowledge sharing,⁵⁵ which can create a sense of contribution to and connection with those receiving informational support.⁵⁶ In turn, relatedness involves a social environment in which individuals can receive feedback, guidance, and support to fuel their competence and create reciprocal giving and mutual reciprocity.⁵⁷

Motivational strategies

Motivational strategies may serve to help meet one or more psychological needs. For example, a personal trainer (the support) may provide empathetic listening and feedback to meet both relatedness and competence needs. Whereas, a technological device, such as a smartwatch, may promote and individual to engage in PA through daily activity recording and self-competition, thus meeting the need of autonomy. Behavioral change strategies, such as proper goal setting, meet all three psychosocial needs, as a woman with PCOS must first choose a behavior (autonomy) which she feels confident to perform (competence) and then find one or more people or norms, or benchmarks for which to “compete” or compare (relatedness). The importance of relatedness for engaging in PA superseded autonomy and competence for this sample of women with PCOS. Focus group participants explicitly stated that they sought encouragement from strategies such as tips and success stories about PA and were more motivated by the support of people who had experiential or factual PCOS knowledge.

Self-awareness is critical while traversing the dynamic life course.⁵⁸ Behavioral self-regulation is the capacity to assess cognitive, affective, and/or behavioral responses to daily life in the context of a larger goal and adapt accordingly.⁵⁹ Thus, motivational strategies may need to change or coexist to match life’s demands. For example, a woman with PCOS may benefit from a coach to enable competence and a technological device to promote accountability. The capacity to self-regulate and appropriately choose alternative motivational strategies are teachable skills. These skills could be taught by healthcare professionals, such as nurses or other ancillary staff.

Implications for PA interventions and healthcare

The findings of this qualitative study highlight implications for PA interventions for women with PCOS. SDT can be a suitable theory to underpin PA interventions to increase motivation for PA by recognizing the context of PCOS and including strategies to meet the women’s psychological needs of autonomy, competence, and relatedness. Developers of PA interventions, specifically within the health realm, could consider the comprehensive guides to SDT techniques complied by Teixeira et al.⁴⁶ For example, to meet the need for autonomy, women with PCOS can be provided choice of activity and given responsibility to schedule the activity. Strategies to meet the need for competence could include goal setting, positive and process-focused feedback, and extrinsic rewards. The need for relatedness could include individual and/or group-level social support from peers with PCOS or healthcare professionals knowledgeable about PCOS. Such social support systems can provide women with PCOS understanding from others while avoiding stigma-related stress due to appearance.

Healthcare professionals, as a trusted source of information, have a role in promoting PA to women with PCOS. They are in a unique position to recognize and reinforce healthy behaviors and the additional health-related outcomes from PA. Available resources, such as the “Exercise is Medicine,” an initiative launched by the American College of Sports Medicine in 2007, are available to healthcare providers. These resources include PA counseling scripts and PA protocols, thus enabling healthcare providers to prescribe PA as part of a treatment plan.⁶⁰ One resource of the “Exercise is Medicine” initiative is the “PA level as a vital sign” strategy and form (https://www.exerciseismedicine.org/).⁶⁰ Assessing PA as a vital sign at clinic visits could increase the value of PA among clinicians, encourage counseling about positive PA outcome expectations, and confirm the patients’ knowledge and efforts.

Interventions that meet the needs for autonomy, competence, and relatedness in PA for women with PCOS can lead to more autonomous motivation to be physically active. PA, performed regularly over time, will promote health outcomes by helping to manage PCOS symptoms and mitigating the risk of cardiometabolic health conditions.

Limitations

A limitation of this study was the small sample size of volunteer participants, which limits generalizability. Our recruitment goal was for 6–10 individuals to keep the group size manageable and the participants comfortable sharing their expertise while also achieving diversity of opinion. Additionally, the homogeneity the participants’ sociodemographic characteristics limits generalizability to the entire population of premenopausal women with PCOS. However, the statistics for demographics, PA, and body mass index matched those found in other U.S. studies of premenopausal women with PCOS, except for depressive symptomology. The participants, as a group, were categorized as having mild depressive symptomology compared to moderate in another U.S. PCOS study.⁶¹ Thus, the volunteer participants for this focus group may have been more motivated to meet and discuss PA and therefore may not be representative of the PCOS population. While the PHQ-8 scores were better than those in other U.S. studies involving women with PCOS, it is possible that the COVID-19 pandemic affected the responses to the depressive symptom screening tool. None of the focus group participants were teenagers or women of peri-postmenopausal age or residing in other countries, further limiting generalizability to all women with PCOS. Some focus group participants (n = 3) were recruited from other PCOS studies, which can introduce bias, as these participants may be more interested in research. None of the participants reported meeting the guidelines for PA; however, they may have been more interested in PA as compared to the population of U.S. women with PCOS. A limitation was the lack of a validated tool to measure PA status among the participants. Due to COVID-19, meetings were held virtually. This was a strength as women from different geographic locations participated. However, one meeting was interrupted with technical challenges of a dropped call and pauses due to poor connectivity. Overall, the virtual platform was convenient and cost-effective, while providing an easier and more secure way to record and transcribe sessions. The data were collected in three virtual meetings, possibly limiting its depth. The interview guide was not pilot tested. The researchers analyzed each transcript immediately after meetings to check for data saturation. Only two researchers iteratively read all transcripts and worked to identify codes and sub-themes. However, a third researcher was available for any variance, and all authors reviewed the themes and supporting evidence.

Conclusion

PCOS is a chronic health condition requiring life-long management, and PA is a first-line treatment strategy. Enacting PA requires motivation. The purposes of this qualitative study were to analyze PA barriers through the lens of SDT, a motivation theory, and identify strategies that may promote PA initiation and maintenance among women with PCOS.

Findings from this study underscored that the cultural context of PCOS can undermine PA behavior. Motivational strategies can help meet the women’s psychological needs of autonomy, competence, and relatedness and promote PA adoption and maintenance. Assessments of cultural context and depressive symptoms, followed by skill-building (e.g. choosing alternative PA types and environmental settings), could precede a PA intervention to circumvent PA barriers. Lastly, focus group participants strongly emphasized the need to be understood by those who support their efforts to adopt and maintain PA. All focus group participants agreed that social support from one or more people with factual or experiential PCOS knowledge would enable motivation. Such motivational strategies could include a peer coach, a community support group, or an invested healthcare team to provide accountability and encouragement.

Supplemental Material

sj-docx-1-whe-10.1177_17455057251357061 – Supplemental material for Self-determined strategies for physical activity motivation among women with polycystic ovary syndrome

Supplemental material, sj-docx-1-whe-10.1177_17455057251357061 for Self-determined strategies for physical activity motivation among women with polycystic ovary syndrome by Pamela J. Wright, Cynthia Corbett, Bernardine M. Pinto, Michael D. Wirth and Robin M. Dawson in Women’s Health

Supplemental Material

sj-docx-2-whe-10.1177_17455057251357061 – Supplemental material for Self-determined strategies for physical activity motivation among women with polycystic ovary syndrome

Supplemental material, sj-docx-2-whe-10.1177_17455057251357061 for Self-determined strategies for physical activity motivation among women with polycystic ovary syndrome by Pamela J. Wright, Cynthia Corbett, Bernardine M. Pinto, Michael D. Wirth and Robin M. Dawson in Women’s Health

Supplemental Material

sj-docx-3-whe-10.1177_17455057251357061 – Supplemental material for Self-determined strategies for physical activity motivation among women with polycystic ovary syndrome

Supplemental material, sj-docx-3-whe-10.1177_17455057251357061 for Self-determined strategies for physical activity motivation among women with polycystic ovary syndrome by Pamela J. Wright, Cynthia Corbett, Bernardine M. Pinto, Michael D. Wirth and Robin M. Dawson in Women’s Health

Footnotes

Acknowledgements

The authors sincerely thank the participants of the focus group that volunteered time and expertise throughout the process of this research study. The authors would like to acknowledge the support of the NIH National Institute of Nursing Research for the Ruth L. Kirschstein Predoctoral Fellowship (1F31 NR019206-01A1) and the Advancing Chronic Care Outcomes through Research and Innovation (ACORN) Center.

Ethical considerations

The study was conducted in accordance with the principles stated in the Declaration of Helsinki and 45 CFR 46.104(d)(2) and 45 CFR 46.111(a)(7). The University of South Carolina Institutional Review Board approved this virtual study (Pro00105265, December 7, 2020).

Consent to participate

All focus group participants provided verbal consent prior to meetings, as this was a virtual study that presented no anticipated harm beyond normal daily experiences.

Author contributions

Pamela J. Wright: Conceptualization; Data curation; Formal analysis; Funding acquisition; Investigation; Methodology; Writing – original draft; Writing – review & editing.

Cynthia Corbett: Conceptualization; Formal analysis; Funding acquisition; Supervision; Writing – review & editing.

Bernardine M. Pinto: Writing – review & editing.

Michael D. Wirth: Writing – review & editing.

Robin M. Dawson: Conceptualization; Formal analysis; Methodology; Writing – review & editing.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the National Institutes of Health under funding from Grant 1F31 NR019206-01A1 (Ruth L. Kirschstein Predoctoral Fellowship).

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data availability statement

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

Supplemental material

Supplemental material for this article is available online.

References

Azziz

Epidemiology and pathogenesis of the polycystic ovary syndrome in adults. Up-to-date, http://www.uptodate.com/contents/epidemiology-and-pathogenesis-of-the-polycystic-ovary-syndrome/ (2019, accessed 17 December 2024).

Engmann

Jin

Sun

, et al Racial and ethnic differences in the polycystic ovary syndrome (PCOS) metabolic phenotype. Am J Obstet Gynecol 2017; 216(5): 493.e1–493.e13.

Teede

Tay

Laven

JJE

, et al Recommendations from the 2023 international evidenced-based guideline for the assessment and management of polycystic ovary syndrome. J Clin Endocrinol Metab 2023; 108(10): 2447–2469.

Meier

RK.

Polycystic ovary syndrome. Nurs Clin North Am 2019; 53(3): 407–420.

Cooney

Dokras

Depression and anxiety in polycystic ovary syndrome: etiology and treatment. Curr Psychiatry Rep 2019; 19(11): 83.

Gnawali

Patel

Cuello-Ramirez

, et al Why are women with polycystic ovary syndrome at increased risk of depression? Exploring the etiological maze. Cureus 2021; 13(2): e13489.

Mansson

Holte

Landin-Wihelmsen

, et al Women with polycystic ovary syndrome are often depressed and anxious: a case–control study. Psychoneuroendocrinology 2008; 33(8): 1132–1138.

King

Power

Buchner

, et al Physical Activity Guidelines Advisory Committee, https://www.com/PhysicalActivityGuidelinesAdvisoryCommittee|health.gov (2018, accessed 17 December 2024).

Stepto

Patten

Tassone

, et al Exercise recommendations for women with polycystic ovary syndrome: is the evidence enough?. Sports Med 2019; 49: 1143–1157.

10.

Patten

Boyle

Moholdt

, et al Exercise interventions in polycystic ovary syndrome: a systematic review and meta-analysis. Front Physiol 2020; 11(606): 1–17.

11.

Steel

Fisher

Skivington

, et al A higher effort-based paradigm in physical activity and exercise for public health: making the case for a greater emphasis on resistance training. BMC Pub Health 2017; 17(300): 300–308.

12.

Pericleious

Stephanides

Can resistance training improve the symptoms of polycystic ovary syndrome?. BMJ Open Sport Exerc Med 2018; 4(1): e000372.

13.

Kogure

Miranda-Furtado

Silva

, et al Resistance exercise impacts lean muscle mass in women with polycystic ovary syndrome. Med Sci Sports Exerc 2015; 48(4): 589–598.

14.

Almenning

Reiber-Mohn

Lundgren

, et al Effects of intensity interval training and strength training on metabolic, cardiovascular and hormonal outcomes in women with polycystic ovary syndrome: a pilot study. PLoS One 2015; 10(9): e0138793.

15.

Vizza

Smith

Swaraj

, et al The feasibility of progressive resistance training in women with polycystic ovary syndrome: a pilot randomized controlled trial. BMC Sports Sci Med Rehabil 2016; 8(14): 1–12.

16.

, et al Prevalence of sufficient physical activity among general adult population and sub-populations with chronic conditions or disability in the USA. Eur J Public Health 2023; 33(5): 891–896.

17.

Butt

Saleem

Zakar

, et al Comparison of physical activity levels and dietary habits between women with polycystic ovarian syndrome and healthy controls of reproductive age: a case–control study. BMC Womens Health 2024; 24(1): 21.

18.

Thomson

Buckley

Brinkworth

GD.

Perceived exercise barriers are reduced and benefits are improved with lifestyle modification in overweight and obese women with polycystic ovary syndrome: a randomized controlled trial. BMC Womens Health 2016; 16: 14–22.

19.

Wright

Corbet

Pinto

, et al The impact of exercise perceptions and depressive symptoms on PCOS-specific health-related quality-of-life. Womens Health 2021; 17: 1–10.

20.

Woodward

Klonizakis

Broom

, et al A qualitative analysis of factors influencing physical activity behavior in women with PCOS: key learning for physical activity interventions and beyond. Health Educ Res 2024; 40(1): cyae040.

21.

Kwasnicka

Dombrowski

White

, et al Theoretical explanations for maintenance of behavior change: a systematic review of behavior theories. Health Psychol Rev 2016; 10(3): 277–296.

22.

Ntoumanis

JYY

Prestwich

, et al A meta-analysis of self-determination theory-informed intervention studies in the health domain: effects on health behavior, physical, and psychological health. Health Psychol Rev 2021; 15(2): 214–244.

23.

Ryan

Deci

EL.

Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. Am Psychol 2000; 55(1): 68–78.

24.

Sheeran

Wright

Avishai

, et al Does increasing autonomous motivation or perceived competence lead to health behavior change? A meta-analysis. Health Psychol 2021; 40(10): 706–716.

25.

Kang

Lee

Kwon

Basic psychological needs, exercise intention and sport commitment as predictors of recreational sport participants’ exercise adherence. Psychol Health 2019; 35(8): 916–932.

26.

Wee

Kevin Wee’s blog of curiosity, https://kevinwee.com/2020/10/self-determination-theory/ (2020, accessed 17 December 2024).

27.

Millan-de-Meer

Luque-Ramirez

Nattero-Chavez

, et al PCOS during the menopausal transition and after menopause: a systematic review and meta-analysis. Hum Reprod Update 2023; 29(6): 741–772.

28.

Amtmann

Kim

Chung

, et al Comparing CESD-10, PHQ-9, and PROMIS depression instruments in individuals with multiple sclerosis. Rehabil Psychol 2014; 59(2): 220–229.

29.

Kroenke

Strine

Spitzer

, et al The PHQ-8 as a measure of current depression in the general population. J Affect Disord 2009; 114(1–3): 163–173.

30.

Blackshaw

LCD

Chhour

Stepto

, et al Barriers and facilitators to the implementation of evidence-based lifestyle management in polycystic ovarian syndrome: a narrative review. Med Sci 2019; 7(7): 76.

31.

Fife

Gossner

JD.

Deductive qualitative analysis: evaluating, expanding, and refining theory. Int J Qual Methods 2024; 23: 1–12.

32.

Tong

Sainsbury

Craig

Consolidated Criteria for Reporting Qualitative Research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care 2007; 19(6): 349–357.

33.

Whillans

Time smart: how to reclaim your time & live a happier life. Harvard Business Review Press, 2020.

34.

Division of the United Nations. Moving forward on gender statistics. The world’s women 2015, un.org, https://unstats.un.org/unsd/gender/dataWW2015.html (2015 accessed 17 December 2024).

35.

Ranji

Rosenzweig

Gomez

, et al Overview: 2017 Kaiser Women’s Health Survey, KFF (2017, accessed 17 December 2024).

36.

Kitzinger

Willmott

“Thief of womanhood”: women’s experience of polycystic ovary syndrome. Soc Sci Med 2002; 54(3): 349–361.

37.

Butler

Performative acts and gender constitution: an essay in phenomenology and feminist theory. Theatre J 1988; 40(4): 419–433.

38.

Pfister

Romer

“It’s not very feminine to have a mustache”: experiences of Danish women with polycystic ovary syndrome. Health Care Women Int 2017; 38(2): 167–186.

39.

Weinberger

Kersting

Riedel-Heller

, et al Body dissatisfaction in individuals with obesity compared to normal-weight individuals: a systematic review and meta-analysis. Obes Facts 2016; 9(6): 424–441.

40.

Phillips

LA.

The influence of body dissatisfaction on cardiovascular and strength-based physical activity by gender: a self-determination theory approach. Psychol Health 2019; 34(12): 1437–1450.

41.

Kim

Kubzansky

Soo

, et al Maintaining healthy behavior: a prospective study of psychological well-being and physical activity. Ann Behav Med 2017; 51(3): 337–347.

42.

Wang

Orpana

Morrison

, et al Long-term association between leisure-time physical activity and changes in happiness: analysis of the Prospective National Population Health Survey. Am J Epidemiol 2012; 176(12): 1095–1100.

43.

Haskell

Lee

I-M

Pate

, et al Physical activity and public health: updated recommendation for adults from the American College of Sports Medicine and the American Heart Association. Circulation 2007; 116(9): 1081–1093.

44.

Fuzeki

Engeroff

Banzer

Health benefits of light physical activity: a systematic review of accelerometer data of the National Health and Nutrition Examination Survey (NHANES). Sports Med 2017; 47(9): 1769–1793.

45.

Schunk

DiBenedetto

MK.

Motivation and social cognitive theory. Contemp Educ Psychol 2020; 60:101832.

46.

Teixeira

Silva

Duda

, et al A classification of motivation and behavior change techniques used in self-determination theory-based interventions in health care. Motiv Sci 2020; 6(4): 438–455.

47.

Gagliardi

Abdallah

Faulkner

, et al Factors contributing to the effectiveness of physical activity counselling in primary care: a realist systematic review. Patient Educ Couns 2015; 98(4): 412–419.

48.

Lambert

Stillman

Hicks

, et al To belong is to matter: sense of belonging enhances meaning in life. Pers Soc Psychol Bull 2013; 39(11): 1418–1427.

49.

Wright

Corbett

Dawson

RM.

Social construction of the biopsychosocial and medical experiences of women with PCOS. J Adv Nurs 2020; 76(7): 1728–1736.

50.

Shor

Roelfs

Yogev

The strength of family ties: a meta-analysis and meta-regression of self-reported social support and mortality. Soc Netw 2013; 35(4): 626–638.

51.

Walton

Cohen

Cwir

, et al Mere belonging: the power of social connections. J Pers Soc Psychol 2012; 102(3): 513–532.

52.

Dalgas

Elmose-Osterlund

Viskum

, et al Exploring basic psychological needs within and across domains of physical activity. Int J Qual Stud Health Well-being 2024; 19: 1–19.

53.

Slemp

Lee

Mossman

LH.

Interventions to support autonomy, competence, and relatedness needs in organizations: a systematic review with recommendations for research and practice. J Occup Organ Psychol 2021; 94(2): 427–457.

54.

Zhao

Liu

, et al Exploring the relationship between perceived social support and college students’ autonomous fitness behavior: chain mediating effect test. Front Psychol 2023; 13: 1–13.

55.

Llopis

Foss

NJ.

Understanding the climate-knowledge sharing relation: the moderating roles of intrinsic motivation and job autonomy. Eur Manag J 2016; 34(2): 135–144.

56.

Curry

Rowland

Van Lissa

, et al Happy to help? A systematic review and meta-analysis of the effects of performing acts of kindness on the well-being of the actor. J Exp Soc Psychol 2018; 76: 320–329.

57.

Haslam

Cruwys

Haslam

SA.

Social connectedness and health. In: Pachana

(ed.) Encyclopedia of geropsychology. Springer, 2015, pp.1–10.

58.

Ryff

Singer

BH.

Know thyself and become what you are: a Eudaimonic approach to psychological well-being. J Happiness Stud 2008; 9(1): 13–39.

59.

Weidner

Sieverding

Chesney

The role of self-regulation in health and illness. Psychol Health Med 2016; 21(2): 135–137.

60.

Lobelo

Stoutenberg

Hutber

The exercise is medicine global health initiative: a 2014 update. Br J Sports Med 2014; 48(22): 1627–1633.

61.

Wright

Tavakoli

Corbett

CF.

PCOS health-related quality-of-life and depressive symptoms across the lifespan: a comparative study. J Women Aging 2024; 36(1): 45–60.

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