Ill/ll,/II///I////l//I/I///I/IfW/llllllllll L This is to certify that the thesis entitled THE RELATIONSHIP BETWEEN HEALTH BELIEFS AND PHYSICAL FITNESS IN ADOLESCENTS presented by NANCY L . TUP l CA has been accepted towards fulfillment of the requirements for Master degree in Nursnng WI, 4.3 ’ I or professor Date May 1: 1396 0-7639 MS U is an Affirmative Action/Equal Opportunity Institution PLACE fl RETURN BOXto romovo thlo chookouttrom your rooord. TO AVOID FINES rotum on or botoro duo duo. DATE DUE DATE DUE DATE DUE MSU loAn Amrmulvo ActloNEquol Opportunity Inofltwon WWI THE RELATIONSHIP BETWEEN HEALTH BELIEFS AND PHYSICAL FITNESS IN ADOLESCENTS BY Nancy Lee Tupica A THESIS Submitted to Michigan State University in partial fulfillment of the requirements for the degree of MASTER OF SCIENCE IN NURSING College of Nursing 1996 ABSTRACT THE RELATIONSHIP BETWEEN HEALTH BELIEFS AND PHYSICAL FITNESS IN ADOLESCENTS BY Nancy Lee Tupica Childhood and adolescent obesity and lack of physical fitness is a growing concern for families. The purpose of this study was to determine the relationship between health beliefs and physical fitness in adolescents. Using the 12 health-related subscales of the Adolescent Health Concerns Inventory (AHCI) and the Chrysler-AAU physical fitness test to measure concepts, it was hypothesized that eighth grade adolescents who have more positive health beliefs would also have high physical fitness achievement ratings. A sample of 84 eighth grade students from a rural Michigan school participated in the study. Correlations using Pearson's r found there is no relationship between the health beliefs and physical fitness of adolescents. Copyright by NANCY LEE TUPICA 1996 ACKNOWLEDGMENTS In appreciation of Linda Spence, RN, Ph.D.as thesis chairperson, and Cynthia Gibbons, RN, Ph.D.and Carla Barnes, Ph.D., ACSW as committee members. Without their support and encouragement, this thesis would not have been possible. I would also like to recognize my best friend and spouse, Rich Tupica,our children, Sarah, Angelia, Rachael, Richard, Melissa, and Bryant and my parents, Henry and Shirley Kubin. Without their love, support, understanding, encouragement and never ending belief in me, the realization of my personal and professional goals would not be possible. iv TABLE OF CONTENTS LIST OF TABLES... ............. . .......................... vii LIST OF FIGURES ................................................ viii CHAPTER 1 THE PROBLEM .................................................... 1 Introduction .............................................. 1 Physical activity and obesity .............................. 2 Study Purpose .............................................. 4 CHAPTER 2 LITERATURE REVIEW .......................................... 4 Physical Fitness ........................................ ...4 Influences on Physical Fitness .......................... ...7 Health Beliefs .......................................... ..10 Influences on Health Beliefs .............................. 13 Limitations of the Current Literature ..................... 17 CHAPTER 3 THEORETICAL FRAMEWORK ..................................... 18 The Children’s Health Belief Model ...................... ..18 Significance to Nursing ................................... 26 CHAPTER 4 METHODS..... ............................................. .28 Research Design ........................................... 28 Definition of Terms ....................................... 29 Sample .................................................... 29 Instrumentation ......................................... ..30 Procedure for Data Collection ............................. 33 Scoring and Data Summary Procedures. ...................... 35 Procedure for the Protection of Human Subjects ......... ...37 CHAPTER 5 RESEARCH FINDINGS ......................................... 38 Sample and Background Information ......................... 38 Interpretation of Findings ................................ 43 Limitations of the Study............ ...................... 46 Implications for Future Research .......................... 48 Implications for Advanced Practice Nursing ................ 49 .APPENDIX.A UCRIHS Letters ............................................ 54 REFERENCES ................................................ 65 vi Table Table Table Table LIST OF TABLES Characteristics of Study Participants ........... 40 Endurance Run times and frequencies ............. 42 Mean's and Standard Deviations for AHCI Subscale ........................................ 42 Pearson’s r for AHCI Subscales .................. 43 vii LIST OF FIGURES Figure 1. The Children's Health Belief Model ............. 19 Figure 2. The Adolescent Health Belief Model ............. 21 viii The Problem Intreductign What is the relationship between physical fitness and health beliefs in adolescents? Concern over inactivity and the rising incidence of childhood and adolescent obesity is making health care providers and educators take a closer look at adolescent behaviors related to lack of physical fitness. Adolescents are of particular concern because adolescence is the period in life where many health behaviors and attitudes toward health develop and become a permanent part of a person’s life. Caught up in change and experimentation, young people develop behaviors that become permanent in their lives (U.S. Department of Health and Human Services, 1990). The developed patterns and attitudes related to diet, physical activity, safety and other health behaviors may persist from childhood and adolescence to adulthood. Healthy People 2000 reports that life time diet and exercise patterns may be established in childhood (U.S. Department of Health and Human Services, Public Health Services, 1990). The problem is adolescents are not learning the importance of healthy exercise and eating patterns early in life. Michigan Department of Public Health surveys (1990) report 2 that 55% of adults have no regular exercise pattern. If healthy diet and exercise patterns are taught at an early age, than healthy lifestyle habits will likely continue into adulthood. E] . 1 E I' 'I I H d Evidence suggests that activities leading to physical fitness are directly related to the problem of adolescent obesity in the United States. According to a 1992 University of Michigan study, more than one-third of all Michigan school children and adolescents are overweight (Foren, 1995). Many studies strongly link inactivity and poor nutritional habits to the problem (U.S. Department of Health & Human Services, 1992). A study conducted by Search Institute addressed the problem of adolescent sedentary lifestyle (Benson, 1993). The results revealed that 81% of eighth grade children watch television for an average of two or more hours on a daily basis. The study compared this with only 6% that do homework for two or more hours daily. Concerned educators are trying to reach Michigan children early in order to stop a longtime tide of poor fitness in adults, traditionally ranked among the worst-fit in the country (Foren, 1995). It is clear that adolescents need to be encouraged to use their time away from the classroom more 3 productively. Daily physical activity and/or exercise should be encouraged to promote a higher level of wellness. Exercise habits established in childhood and adolescence may help maintain a physically active lifestyle throughout adulthood. Although much has been studied regarding adolescent self esteem related to physical fitness, there are virtually no studies in the literature comparing adolescent health beliefs as they relate to physical fitness. Promotion of physical fitness to control weight is encouraged through both moderate and vigorous physical activity on a regular basis. Motivation is a barrier to exercise for some people. Also, locus of control has shown some promise in predicting and explaining specific health-related behavior such as physical activity (Shillinger, 1983). Locus of control refers to individuals’ beliefs about whether a contingency relationship exists between their behavior(actions)and their reinforcements(outcomes). Individuals who tend to expect reinforcements to come from their own behavior have an internal locus of control while individuals who expect reinforcement or outcomes to relate to forces outside themselves have an external locus of control. Some people have an external locus of control while others have an 4 internal locus of control. When individuals think that control for their health lies within their grasp as it does with an internal locus of control, they are able to take responsibility to bring about desired outcomes Zindler, Wernet, & Weiss, 1987). An important factor in assuming this individual responsibility for their health is whether the person believes that they can actually affect their health outcomes by their health attitudes and behavior. We The purpose of this study was to answer the question: Is there a relationship between health beliefs and physical fitness in eighth grade adolescents? Literature Review E] . J E'! Physical fitness is the state of physiologic well being that is achieved through a combination of balanced diet, regular physical exercise, and other practices that promote good health such as not smoking and wearing a seat belt (The American Heritage College Dictionary,1993). Healthy physical fitness behavior during adolescence is important to learn while attending school. Learning healthy behaviors is important because as students leave the school setting, they lose physical and social supports and incur time constraints 5 that can result in decreased levels of physical activity (U.S. Department of Health and Human Services, Public Health Services, 1990). If the importance of daily regular physical activity is not part of adolescent behavior, the result could be an overall decrease in physical fitness in childhood and adolescence as well as adulthood. Attitudes about diet and physical activity may persist from adolescence into adulthood (U.S. Department of Health and Human Services,1990). Glenmark, Hedberg,& Jansson (1994) studied physical activity in adolescence as it relates to the prediction of physical activity in adulthood. The researchers followed 62 men and 43 women who completed questionnaires about physical activity during their leisure time at age 16 and again at age 27. They found that aerobic potential, running performance, strength performance, and physical activity while in physical education class during adolescence explained 82% of physical activity in adult women and 47% for the men. The attitude toward exercise over the years changed to more positive for the women and less positive for the men. Results of this study are interesting and reflect on the status of physical activity over a time span. They also open up ideas for more research concerning body image in females in both adolescence and 6 adulthood. The results of a 1994 study conducted by Douthitt indicated that females exercise more for perceived romantic appeal while males exercise for perceived athletic ability. The perceived need for females to increase attractiveness increases with age while the perceived need for male athletic ability decreases with age. In females, a more negative body image independent of actual body mass was the only motive related to self-reported frequency of exercise (Ashford, Biddle, & Goudas, 1993; Cash, Novy, & Grant, 1994). In other words, the more negative the body image of the women in this study, the more motivated they were to exercise. Results of the Ashford, Biddle, & Goudas (1993) study indicated that older subjects are more motivated by socio- psychological well-being than younger subjects. These results may be linked to the specific motivation factors. Motivation of older subjects may be attributed to confirmed health problems such as hypertension and heart disease that would improve with exercise. Perhaps younger subjects with fewer medical problems than their elders lack motivation because they perceive fewer benefits. There is no indication in the current literature that young people exercise for the sake of good health. Therefore, the need 7 for education regarding the benefits of physical exercise, besides athletic ability and physical appearance is clearly needed in order to promote positive health behaviors for the sake of good health. I E] h . 1 E'! BargnLL§_inflnengg. Research on the subject of physical fitness strongly links parents as major influences on adolescent's physical fitness. Health values taught in the home may be a large part of the adolescent's development of physical fitness. It is believed that families are important influences on the development of health habits. One study concluded that family is an extremely significant influence on physical activity (Sallis, Patterson, Buono, Atkins,& Nader,l988). Data in this study support the interpretation that physical activity habits are moderately aggregated within families. For instance, children of sedentary parents are likely to also be sedentary. On the other hand, children of physically active parents are likely to be physically active. It is possible that children learn to value and enjoy physical activity merely by observing parents participate and talk about physical activity. Parents who are physically active have a stronger influence on encouraging physical activity in their children. The best investment parents can make in the physical fitness of their adolescents is to be active in their adolescent's learning about health. Parents should insist schools provide high quality physical education programs that result in physical fitness in their adolescents (Updyke & Willett,1989). They can also encourage physical activity and be positive role models by engaging in and encouraging physical fitness behaviors in the home. ' ' fl n . Results from a study exploring school influences on children's behavior suggest that there is a strong probability of a causal relationship between school process and children's achievements (Rutter, 1980). School processes in this study were defined as various school features found to be important in relation to outcome in classes. These features included degree of academic emphasis, styles of classroom management, pattern of rewards and punishments, and pupils' opportunities for responsibility and participation. Results of this study suggest that school programs can heavily influence student's outcome beliefs and behavior related to health and wellness. While it is not argued that schools are the most important influence on children's progress, it is suggested that ' schools constitute one major area of influence. 9 Although little research has been reported on the relationship between fitness and self esteem in adolescents, one study found 60% of a group of physical education teachers considered the enhancement of self esteem to be the primary benefit of physical fitness development (Updyke & Willett, 1989). Unfortunately, only 34% regarded the prevention of disease as the primary outcome. These results suggest that teachers may need some education on the health benefits of physical fitness development and maintenance. Updyke & Willett (1989) found that it makes no difference whether the teacher is male or female, or whether the teacher exercises with the students. Of all the variables affecting fitness in schools including classroom, time of day, attitude and motivation, Updyke & Willett stated personal characteristics of physical education teachers is the most important. Two important characteristics are motivation and interest in physical fitness. The fact that many teachers spent a lot of time recording and sending in their work on students' test results for the Chrysler-AAU physical fitness program shows that they are clearly interested in physical fitness. Motivation, on the other hand, may be somewhat low. Only 46% of these physical~ fitness teachers listed fitness improvement as their primary 10 objective. Teachers control the classroom curriculum, therefore, they are in the position to provide their students with the necessary motivation and information for the achievement of physical fitness. The development of the desired understanding, attitudes and behaviors toward physical fitness can only be achieved through a consistent, well-conceived educational program under the direction of dedicated and qualified teachers. W Health beliefs can be defined as positive or negative evaluations, emotional feelings, and pro or con tendencies with respect to health (Tinsley, 1992). .Adolescents develop health attitudes, or beliefs, during the early years of life. Early and sustained exposure to a variety of environmental influences affects the development of these health beliefs. Health beliefs also include values concerning health and illness, attitudes toward health services, and knowledge about disease (Strain, 1991). Anderson and Newman (1973) argue that health and illness behavior ultimately may be influenced by what an individual thinks about health. Individuals who place greater value on health, potentially have different utilization of services than those who attach less value. 11 One assumption is that individuals who are more skeptical of medicine are less inclined to use medical services than those who are not. Tinsley (1992) concluded that the development of children's health concepts evolves in a systematic and predictable sequence and that individual differences exist in children's understanding of health. These differences are related to the developmental stage of the child. Piaget, a cognitive developmental theorist, studied changes in children's attitudes and ideas over time (Bibace & Walsh, 1980). For instance, children’s understanding of health related concepts including the causes of illness, health knowledge and other related issues, can be characterized as demonstrative of Piaget’s cognitive- structural tradition. Other studies have also utilized Piagetian concepts. These studies suggest that children in the preoperational stage of cognition have ideas about health and illness that are characterized by confusion in cause and effect, superstition, and lack of differentiation (Bibace & Walsh, 1980; Perrin & Gerrity, 1981). Children’s principles of health and illness begin to resemble those of adults by the concrete operational stage of cognition which extends from school age to early adolescence. Children in 12 the concrete operational stage believe that all illness is caused by germs and that wellness depends upon adherence to specific rules. In the formal operational period of cognition, which typically occurs in adolescence or early adulthood, more sophisticated concepts of health and illness are understood. In the formal operational stage, adolescents understand the concept of infection and preventive health behavior. The role of adolescent’s health beliefs in the development of their health related behaviors is an important relationship. A.moderate relationship among health knowledge, health beliefs, and avoidance of risk behaviors was identified (Radius, Dillman, Becker, Rosenstock, & Harvath, 1980). Only about one-half of the participants in this sample reported worrying about health at all and about one-third reported personal accountability for their health. The results of this study were inconclusive because of the wide age range, from age 6 years to age 17 years, of the participants. In a 55 year study starting with subjects in their adolescent years and extending well into their adult years, it was found that negative health behaviors that result in obesity and lack of physical fitness in adolescence predict a broad range of 13 negative health effects (Must, Jacques, Dallal, Bajema, & Dietz, 1992; Himes and Dietz, 1994). These negative health effects included increased serum cholesterol and lipoprotein subfraction concentrations and increased blood pressure readings. Evidence from longitudinal studies indicates that lack of physical fitness and increases in measures such as blood pressure, cholesterol and lipoproteins, may predict later elevated health risks and increased adult mortality. Other studies have found few relationships among perceived susceptibility, severity, and the effectiveness of action related to health behaviors (Kegles & Lund, 1982; Weisenberg, Kegles, & Lund, 1980). It is unclear whether there are actually few relationships between adolescent's health attitudes and behavior in these studies or as the authors suggest, the lack of relationship may be due to the defined outcome behavior being too specific. Perhaps the study results would be more pertinent if outcome behaviors were defined as a group of health related behaviors rather than one specific behavior. WW Barent;§_influenge. Specific demographic variables have been used to describe and predict the impact of families on child beliefs about health (Tinsley, 1992). 14 Social class has been cited most frequently as an important variable. However, social class merely describes families and children who vary in health attitudes, behavior, actual health, or family dynamics and influences. Social class is not an indicator of family health nor does it explain why families differ in their values or influences on health beliefs. A.study exploring the differences of health beliefs using several different models of health found no differences between social classes in the population (VanDalen, Williams, & Gudex, 1994). These subgroups were selected from a representative sample of the general population and included 196 people aged 18 years and over. Results of this study concluded that health was seen as multidimensional irrespective of whether respondents addressed health in self or health in others, or good or poor health. Parents and/or guardians are an important and vital influence on the health beliefs of adolescents. Health attitudes and health beliefs are related. Also, parents' own health attitudes are a somewhat direct influence on their children's preventive health behavior. Children usually function by copying their parent's behavior rather than by verbal parental direction (Dielman, Leech, Becker, 15 Rosenstock, Horvath, & Radius, 1982). Results of one study concluded that method of child rearing and health attitudes and behavior of children may be related. Pratt (1978) found that a developmental pattern of child rearing was associated with better health care practices by children than a disciplinary pattern of child rearing. The developmental approach to child rearing focuses parental perception on the child's ability to care for him/herself. Disciplinary methods of child rearing focus on parental expectation of the child's unquestioning obedience to the parents' expectations. The hypothesis of the Pratt study was that children whose parents encouraged autonomy and responsibility, supplied reasons and information, and rewarded good behavior to a greater extent than those who punished misbehavior. They also would have better health practices than children whose parents made little attempt to develop informed, independent performance by the child, and who emphasized punishment to enforce behavior standards. It was found that granting of autonomy fosters a child’s competence and active coping behavior related to health. On the other hand, control inhibits the development of these capacities and produces a superficial and rigid conformity to adult standards that fails to enable 16 the child to successful performance the routines of caring for his own body. The results of this study are confusing. It would seem that a balanced method of child rearing geared toward a child's cognitive stage of development and involving reasons and information for behavior along with reinforcement for both positive and negative behavior would be desired. SghQQlL§_influgngg. Teachers and health programs have demonstrated a significant influence on adolescent's health beliefs, apart from the family (Harlin, 1989; Rutter, 1980; Walter, 1989). Evaluative studies of the outcomes of school health education programs have shown they are very effective in increasing health knowledge, and somewhat effective in improving health attitudes. Effective school programs foster the development of positive health beliefs and, as a result, health behavior in children. They demonstrate what positive and negative health behaviors are and the consequences as well as the benefits of these behaviors (Sarafino, 1979). Also, school health programs are often where interventions designed to modify health attitudes and behaviors are initiated. School based health education can help students avoid developing negative health beliefs that may lead to negative health behaviors. School programs can 17 also help students to acquire health protective attitudes and behaviors that become established or habitual aspects of their beliefs and lifestyles. 1' 'l I' E H I 1.! I Current research on the subject of health beliefs related to physical fitness in adolescence is limited. The concept of physical fitness has been linked with obesity and self esteem, but not health beliefs. Also, there are few studies that specifically address the health beliefs of adolescents. The results of one study using the health belief model suggested that participation of adolescents in a school-based preventive dental program did not follow predictions of the Health Belief Model (Weisenberg, Kegles & Lund, 1980). The study found that health beliefs are difficult to change and are often unrelated to behavior, suggesting that health beliefs and behavior might be parallel developments in the individual rather than a cause and effect relationship. Studies have been conducted to determine health behaviors of children (Anderson & Neuman,1973; Kegles & Lund,1982; Pratt, 1978; Radius, et al.,1980; Sarafino, 1979; Weisenberg, Kegeles & Lund, 1980), but some only focus on reports of parental beliefs rather than the children's own 18 values and beliefs (Dielman et al.;1982 Pratt,1978). These studies focus on what parents believe their children believe and not the child's individual opinion. There are also studies that use participants from a broad age range and try to generalize their results to a specific population or group of children (Radius, et al. 1980). The intent of the proposed study is to consider specific health beliefs of adolescents to determine if these beliefs are related to their physical fitness. Theoretical Framework T ' n’ H l h E 1i f M l The Children's Health Belief Model (CHBM) was designed to increase understanding of how children acquire health beliefs, and to identify personal and environmental factors that predispose children to expect treatment for common health problems. The model, specific to children, was developed in order to study and explain expected medication use for five common health problems (Bush & Iannotti, 1990). The results of Bush & Iannotti’s work indicate that the CHBM is a promising model for studying the development of children’s health beliefs and expectations. The CHBM is depicted in Figure 1. It takes into account (1)modifying factors, (2)readiness factors, and (3)behavior l9 hi’kililying mm”. Hardiness l'aclor L'omilivd/Ul‘ttlivc litullh Locus ul'Coulwl Scll’lislouu [\rblivulions I luillli Risk'l'aking Md melulge __> lIIans Comm us IV‘Lxl Autonomy DEBLMEIUQ Ufllbllllg {"99 F M) Visits . 61:8 lIIiiess I‘iummcy H l’uocworl Illness 'lln‘mt 33X l’eiu'ivul Vulnerability I’el‘cci veil chu it y Czu'ctuku's l’ucciml lluiclils oI' * Mulivulim I‘UI‘ U'i'd Nblicims * I’u cci vorl (liild 's :"IICIS .llu'cul . _ I’uoeiwtllVLxl Dulclil Iucuvul mud“ of I’uccivul NoMstl Bcnclil IVL‘UIUIIKS * lixpouul Child's Med Use Figure l. The Children’s Health Belief Model. SES, Socioeconomic status; med, medicine; MD, physician(Bush &Iannotti,1990). Behavior Factors lisuxtul Mud Use IVLXI Use J 20 factors. The CHBM with the variables and concepts of the current study included is shown in Figure 2. One aspect of the adolescent’s health attitudes is perceived vulnerability to health problems. This vulnerability is an assessment of the extent to which adolescents perceive the likelihood of experiencing health problems (Tinsley, 1992). Perceived vulnerability increases between the ages of eight and thirteen and decreases during the adolescent years and adulthood (Gochman, 1982). A child's perceived health vulnerability is related to self- concept and self esteem, however, there has been no attempt to relate these issues to health behavior (Tinsley, 1992). Health motivation is a concept that is instrumental in predicting health behavior (Becker, 1974). In this sense, health motivation is defined as a generalized state of intent that results in behaviors to maintain or improve health. Health beliefs are the thoughts and attitudes a person has concerning his/her own health. With this definition, health motivation and health beliefs are similar. Health beliefs are combined with health motivation to result in health related behaviors. Measures to maintain 21 h/kidil'ying Rwdiness Factor Behavior Factors (7 . 'li e/AIT ‘l' "l % (’fil‘lh‘ BeliZI‘slw >| l lcallli Bdmvior l I l t ll_"- y {_ | Musical I'ilncss ' + Enabling .De._n__mn_p.w.Lli9 / Age ' V A'loliialions Sex Liniluumulal Figure 2. Adolescent health beliefs related to physical ' fitness. Adapted from Bush and Iannotti(1990) . 22 physical fitness, such as proper diet and exercise, could be described as health motivation behaviors. Two factors that influence the strength of a person's intention to perform a specific behavior are attitude toward the behavior and the influence of the social or subjective norm on the behavior. In other words, whether a person performs a specific behavior depends on personal attitude toward the behavior and norms put on that behavior by the person and society. If a person’s belief is strongly against a specific behavior, he or she will not perform it. On the other hand, if the person believes that performing the behavior is the norm in their society or the way they were raised they are likely to perform it. This suggests that behavioral change ultimately is the result of changes in beliefs, and that people will perform behavior if they think they should perform it (Blair, 1993; Salazar, 1991). Therefore, it can be hypothesized that adolescents with positive health beliefs will perform health behaviors that result in physical fitness. The adolescents will perform positive or negative health behaviors secondary to their individual health beliefs, because they think they should. 23 Modifying factors Modifying factors include data that is demographic, cognitive/affective, enabling and/or environmental that influences an individual's conceptualization of health. Demographic data are included as a variable in the CHBM. These variables are defined in Bush and Iannotti's model as modifying factors relating to the fact that results may vary depending on the age and the sex of the population to be studied. Cognitive/affective factors of the CHBM are those factors that affect the child's understanding about illness- related processes. These cognitive/affective factors are strongly influenced by teachers and parents. The health beliefs of the adolescents were the cognitive/affective factor for this study. Enabling factors are those factors that supply the opportunity for the behavior factors. Environmental factors are those things outside the person in the environment that may affect the child’s perception about illness-process. These can include things like other’s motivations for the child and child’s perceived threat or benefit to taking action. In the current study, modifying factors included the demographic data of age and sex. There was the probability that results would vary depending on the age and the sex of 24 the study participant. Modifying factors could include cognitive/affective factors such as health beliefs and knowledge of health, but for this study only health beliefs were eXplored. The concept of health beliefs was described earlier as positive or negative evaluations, emotional feelings, and pro or con tendencies with respect to health (Tinsley, 1992). For the purpose of this study, health beliefs included the adolescents’ beliefs about health, their understanding of how illness is prevented, and how optimum health is achieved. Modifying factors are strongly influenced by teachers, parents, and environmental issues. Environmental factors include teachers desired behavior for the adolescent, parents desired behavior for the adolescent, the adolescent’s perceived threat of illness, perceived benefit of positive health beliefs, and perceived benefit of positive health behaviors. Enabling factors, such as the frequency of illness are also included as modifying factors. For example, a child with a chronic illness such as diabetes mellitus will likely have health beliefs that differ from those of a healthy child. Motivations are concerns of illness resulting from health related behavior that the adolescent may have. If an adolescent is not concerned that an illness from health behavior will occur, the motivation 25 to do something to stop illness from happening is low. However, if the adolescent is concerned about illness or adverse effects of behavior, motivation for behavior leading to good health will increase. Perceived illness threat includes perceived vulnerability to illness and perceived severity of illness. Perceived vulnerability refers to a person’s view of experiencing a potentially harmful condition. Perceived severity is concerned with how threatening the condition is to the person. For example, if an adolescent engages in behavior that is dangerous to his health, he/she may continue the behavior if it is not perceived as a harmful health threat. Perceived benefit, in the CHBM, focuses on the effectiveness of specific behavior in reducing the threat of the condition. In the present study, perceived benefit of the action was the degree to which the adolescent perceives a certain behavior or action will benefit him or her. The specific behavior that was examined in the present study was exercise as it relates to physical fitness. A barrier relates to the negative aspect of the anticipated behavior. Barriers to running one mile, as in the present study, included time of day, motivation, present health, and other 26 individual perceptual beliefs such as relationship with the physical education teachers or other students. Physical limitations related to running such as illness, obesity or physical handicap may have also been limitations to running. Behavior factors Behavior factors, the third concept in the CHBM, are those health related behaviors that result in the desired outcome. Health behaviors are defined as overt behavior patterns, actions, and habits that relate to health maintenance and wellness, to health restoration, and to health improvement (Gochman, 1982). Behavior factors for this study included health behaviors that result in physical fitness. 5' 'E' ! 'n Results of a study examining adolescent physical fitness, specifically related to the relationship to adolescents' health beliefs, will help guide advanced practice nurses in primary care to promote health and prevent disease. The advanced practice nurse can educate adolescents about positive health attitudes that lead to positive health behaviors and an increase in their personal physical fitness. This can best be accomplished through the work of an advanced practice nurse in cooperation with the 27 adolescent’s school and family as well as with the adolescent. Nurse practitioners could use the results of this study to understand how adolescents perceive health concerns and if their perceived health concerns relate to health behavior that results in physical fitness. This is important because what adolescents perceive as important to them is important for nurse practitioners to plan their care regarding health promotion and the prevention of disease. Understanding of adolescents’ health beliefs and behaviors related to physical fitness will help identify positive health behaviors related to physical fitness outcome. If more is known about the relationship between health beliefs and physical fitness then health promoting physical fitness programs can be developed and incorporated in the schools. Also, practical public health programs for control in the community can be developed. The health promotion challenge is to develop public health interventions that reach children and adolescents and enhance the adoption and maintenance of healthy lifestyles (Curry, Kristal & Bowen, 1992). Social service professionals, health educators, primary health care providers, community groups, and families can all make a 28 difference in the health of adolescents. Methods W A nonexperimental, correlational design was used to examine the relationship between health beliefs and physical fitness in eighth grade adolescents enrolled at a rural midwestern middle school. This design made it possible to examine whether adolescents who have positive health beliefs are also more physically fit than those adolescents who do not have positive health beliefs. One reason for selecting a nonexperimental design was that to study the relationship between health beliefs and physical fitness requires no intervention. The relationship of the two concepts must be studied before initiating an intervention. Inducing an intervention would have risked manipulating responses and created uncertainty about the outcome. The major disadvantage of nonexperimental research is, compared with experimental and quasi-experimental research, it is weak in its ability to reveal causal relationships (Polit & Hungler, 1995). The difficulty of interpreting correlational findings stems in large part from the fact that behaviors, states, attitudes, and characteristics are interrelated in complex ways. On a 29 positive note, correlational research is often an efficient and effective means of collecting a large amount of data about a problem area, such as health beliefs and physical fitness. Prior to obtaining the results of the present study, it was not known whether health beliefs and physical fitness in adolescence were correlated. D E' 'I' E! Health beliefs and physical fitness as they relate to adolescents are the variables that were examined in this study. Physical fitness was defined as the state or condition of being physically fit as determined by a one mile timed score on the Endurance Run portion of the Chrysler FUnd-AAU Physical Fitness Program test. Health belief was defined as health motivating behavior to maintain or improve health as measured by the Adolescent Health C6ncerns Inventory (Weiler & Sliepcevich, 1993). For clarification purposes and because the term can be defined in a variety of different ways, adolescent in this study was defined as children who are in the eighth grade. Sammie- The target population included all eighth grade students in a rural midwestern middle school. The school is located in a rural area with a pOpulation of 6,107. The 30 main industry is farming. The city is also the host of a 960-bed men’s State Correctional Facility where many people from the city are employed. The study population included an accessible population of all eighth grade students. Sample selection procedure was nonrandom and nonprobability for the sample (Brink & Wood, 1994). Nonprobability sampling is less likely than probability sampling to produce accurate and representative samples (Polit & Hungler, 1995). Eligibility criteria for inclusion in the study meant the student was enrolled in the eighth grade at the identified middle school and was present in school on the days the testing took place. The type and size of the sample were chosen with the possibility of attrition in mind. In this study, attrition may have occurred due to either parental or student withdrawal from the study and/or absenteeism on the days the study was conducted. The sample frame was 129 students. Instmmentarinn There are several components measured in the overall Chrysler Fund-AAU physical fitness test. These components include five required events and seven optional events. Required events include the endurance run (one mile); bent- knee situps; sit and reach; pullups; and flexed-arm hang. 31 Optional events include the Hoosier endurance shuttle run; long jump; isometric pushup; pushups; phantom chair; shuttle run; and sprint. Scores of the events are added together and a total score determines the fitness classification of the student as outstanding, attainment, or participant. For the measurement of physical fitness, each test component is independent of the others. Therefore, it was not possible to construct a meaningful single index of physical fitness using results from the entire test. It was more informational to study trends by examination of scores on one measure of physical fitness (Updyke, 1994). For purposes of this study, the measurement of the Endurance Run was used to measure level of physical fitness. The fitness scores for 8th graders were available and an expert in the field suggested that not all of the test, but one aspect of the test should be used to measure physical fitness. The Endurance Run was selected to measure physical fitness because the expert recommended it for this study (W. Updyke, personal communication, September 26, 1995). Reasoning is that the Endurance Run is a measure of circulorespiratory endurance after prior training. This training prerequisite consists of at least three practice sessions per week for a six week training period. The Endurance Run is a one mile 32 measured course to be covered as rapidly as possible and although participants are not disqualified for walking, they are encouraged to run. The AHCI is a pencil and paper tool containing 150 health-related items grouped into twelve topical subscales. There are pre and post test questions that relate to demographic variables and specific questions regarding perception of importance of health and health related classes. On the health concerns part of the questionnaire, participants answer each item under three categories. These categories are “a personal concern for myself,” “a concern among my best friends,” and “a concern among other teenagers.” Although only the category of “a personal concern for myself” was used for this study, participants filled out all three categories of the AHCI as they perceived them. Subscales include: substance use and abuse; diseases and disorders; the environment; consumer health; human sexuality; personal health; personal safety; nutrition; social health; relationships; emotional health; and the future. The substance use and abuse category includes 14 items; diseases and disorders include 17 items; the environment 11 items; consumer health 7 items; human sexuality 12 items; personal health 13 items; personal 33 safety 12 items; nutrition 9 items; social health 16 items; relationships 14 items; emotional health 17 items; and the future 8 items. Reliability estimates for the twelve subscales as measured by Cronbach’s alpha ranged from .76 to .92 (Weiler & Sliepcevich, 1993). A panel of experts was used to assess content validity. Construct validity was assessed using principle components’ factor analysis. This tool was specifically selected because of its applicability to adolescents. It specifically addresses issues that are common among adolescents, their friends, or other teenagers they know and is written for the adolescents’ level of understanding and cognitive development. Questionnaires are less time consuming than interviews but the responses are limited to answers to predetermined questions. An opportunity to collect verbal data to clarify the meaning of questions was not available. An advantage of written questionnaires is that subjects can remain anonymous (Brink & Wood, 1994). BMW Physical fitness was measured using scores earned by students during a one mile endurance run. The measure used to obtain scores was from the Chrysler—Fund-AAU Physical Fitness program’s criteria for the endurance run. The 34 purpose of the Chrysler-Fund-AAU Physical Fitness program is to enhance the “fitness literacy” of young Americans (Updyke, 1994). Fitness literacy consists of two components, knowledge and experience. Knowledge is knowing what physical fitness is, its benefits, its limitations, how it is acquired, how it is maintained, and its relationship to disease prevention, mental health, physical and mental efficiency and productivity. Experience is the personal experience of having acquired an enhanced state of physical fitness. The goal of the program is to empower young people to take greater responsibility for their own well-being.The score is in number of minutes and seconds it takes to complete the one mile course. Individual scores of all the current 8th grade students were gathered in May of 1995 by physical education teachers who were properly trained to administer the Chrysler Fund-AAU physical fitness test. Health beliefs were measured using the Adolescent Health Concerns Inventory (AHCI). This tool enabled the researcher to learn the concerns adolescents have about their health. The terms “health concerns” and “health beliefs” are comparable in their conceptual definitions. Both terms address the concerns adolescents believe about their health. 35 For the present study, data concerning the health beliefs of the adolescent participants was collected during home room time at the onset of the school day at the chosen middle school. Questionnaires were distributed and completed during the regular class time. Participants were informed of the purpose of the study, that participation was voluntary, and that they had the right to not participate in or withdraw from any part of or all of the study without penalty. In the presence of the homeroom teacher, the researcher distributed questionnaires in each home room. Attached to the questionnaires was the physical fitness testing scores attached to a sheet of paper with the adolescents’ name on it. These two items were attached to the Adolescents Health Concerns Inventory. When participants returned their completed questionnaires, they were instructed to tear off the identification sheet leaving the results of the physical fitness testing attached to the Adolescents Health Concerns Inventory without compromising anonymity. WW It was hypothesized that a high score on the “personal concern for myself” portion of the Adolescent Health Concerns inventory would be related to a high level of 36 performance on the Endurance run. Data analysis for the study was done with descriptive and correlational statistical procedures using inferential statistics. This included frequency distributions for the participants including age and sex. Frequency measures were also used for race and living arrangements, ie. single-parent or two parent households, and the participants perception of their health status as poor, fair, good, or excellent. Descriptive statistics were used to measure frequency distributions on the Endurance Run. Physical fitness was measured in number of seconds it took to finish the one mile Endurance Run. Health beliefs are divided into 12 subscales, as described earlier in the Adolescent Health Concerns Inventory. The descriptive data, based on a 150-point maximum score is usually measured by the number of concerns checked by the participant in the “a personal concern for myself,” “a concern among my best friends,” and/or a “concern among teenagers”. Because only perception of health beliefs as they relate to individual physical fitness was to be examined for the present study, only the boxes checked in the “a personal concern for myself” category were used for data analysis. The score for each of the twelve 37 subscales was determined as well as the percent of items checked within the scale. The scores of each of the twelve subscales marked on the participants’ AHCI were correlated with the participants’ scores on the Endurance Run. After all scoring was computed, the relationship of subject’s health beliefs and physical fitness was computed using Pearson’s correlation coefficient. E I E I] ! I' E H 51 . ! The proposal was submitted for approval to the University Committee on Research Involving Human Subjects (UCRIHS) at Michigan State University. Several strategies were utilized to protect the rights of subjects who agreed to participate in the study. Prior to the research study being conducted, the following conditions were met; (1)approval from the Human Subjects Review Committee at Michigan State University; (2)parenta1/guardian permission; (3)student consent; and (4)permission from the school principal and homeroom teachers. By way of a detailed newsletter, participants were informed of the purpose of the study, that participation was voluntary and what information would be gathered. The newsletter also informed parents/guardians and participants that students had the right to not 38 participate in or withdraw from any part or all of the study without penalty. This letter was distributed to all eighth grade students during the week of testing. Anonymity of the adolescents and their families was maintained at all times. Data was organized by subject codes to maintain confidentiality. Research Findings B k n nf rm i There were 129 eighth grade students enrolled in the middle school on the day of the study. The researcher was available for questions by going from room to room. Sixteen of the 129 students were unable to complete the questionnaire. Of these, 13 were absent, one lacked permission to participate, one did not return their questionnaire, and one was in the principal’s office being reprimanded for behavior. The Adolescent Health Concerns Inventory was administered to 104 students, including one who did not turn it back in, who were in school on March 22, 1996 in five homerooms during the beginning part of the school day. Homeroom teachers read instructions to the study participants prior to handing out the questionnaires. Of the 103 questionnaires turned in, 19 were not usable because they lacked Endurance Run physical fitness data. 39 Some of these students were absent the days of the fitness testing, while others lacked only the Endurance Run data. A total of 84 (n=84) questionnaires, complete with fitness scores attached were returned for analysis. Completion of the questionnaire was accomplished within 20 minutes. Results of demographic data using frequency procedures are reported in Table 1. Age of participants at the time the AHCI was administered was 13 years (21.4%), 14 years (66.7%), and 15 years (10.7%). One participant (1.2%) did not report an age but did report being in the 8th grade. There were more male participants (56%) than female (42.8%) or unreported sex( 1.2%) participants. Race/Ethnicity was predominately white (86.9%), while Native Americans(3.6%), those who reported other (7.1%), and those who did not report race(2.4%)were represented in minority. The majority of the participants reside with both parents (67.9%). Others reported living with their mother (23.8%) or father (4.7%) most of the time. One participant lived in foster care and two did not answer the question. Most of the eighth graders (64.3%) reported good health, while others reported excellent (21.4%), or fair (13.1%) health. One participant (1.2%) did not answer the question. 40 Table 1. Characteristics of Study Participants Character- Value Frequency istic (n=84) %Percentage Age 13 years 18 21.4 14 years 56 66.7 15 years 9 10.7 Not reported 1 1.2 Sex Female 36 42.8 Male 47 56 Not reported 1 1.2 Race/Ethnic White 73 86.9 Native 3 3.6 American Other 6 7.1 Not reported 2 2.4 Living Both parents 57 67.9 Arrangement Mostly 20 23.8 mother Mostly 4 4.7 father Foster 1 1.2 parents Not reported 2 2.4 Perception Fair 11 13.1 of Health Good 54 64.3 Excellent 18 21.4 Not reported 1 1.2 41 Frequency distributions were run on the Endurance Run portion of the Chrysler-AAU physical fitness test. Participants Endurance Run scores were then equally divided into four time intervals for ease of interpretation of a large amount of data. Run scores were converted from seconds to minutes and seconds for ease of understanding the timed one mile run score. Recorded scores ranged from 5:31 to 18:06. Category one ranges from 5:36-8:21(n=18), category two ranges from 8:22-10:25(n=39), category three(n=13)range is 10:26-13:00, category four(n=14)range is 13:01-18:06. These results show that the majority of runners(n=39)were in the second time category. Table 2 summarizes Endurance Run score frequencies and timed run score intervals in seconds and minutes. Means and standard deviation’s on all twelve subscales of the AHCI and are shown in Table 3. Pearson’s r was calculated for physical fitness and each of the twelve topical subscales of the AHCI using the total sample of subjects(n=84) and reported in Table 4. Results were consumer health (r=.0197), diseases and disorders (r=.0098), emotional health( r=.0548), the environment (r=.0284), the future (r=.0696), human sexuality (r=.0458), nutrition‘ (r=.0236), personal health (r=.1002),relationships(r=.0714), 42 Table 2. Endurance Run times and frequencies Run Time (seconds) # of minutes and Frequency (n=84) seconds 322-469 5:36-8:21 18 470-615 8:22-10:25 39 616—756 10:26-13:00 13 757-1060 13:01-18:06 14 Table 3. Means and Standard Deviations for AHCI _ 1 subscales Health Concern # of Mean Standard Deviation items Consumer Health 7 2.9286 2.5116 The Future 8 6.2024 2.8190 The Environment 11 5.2143 4.2485 Human Sexuality 12 3.1548. 3.6979 Personal Safety 12 4.9524 3.6764 Nutrition 9 4.0595 3.1407 Social Health 16 5.4881 5.4805 Emotional Health 17 6.7143 3.7741 Personal Health 13 5.5952 3.7741 Relationships 14 7.9167 4.6935 Substance Use & 14 3.6905 4.5283 Abuse Diseases & 17 4.7738 4.8105 Disorders 43 Table 4. Pearson’s r for AHCI Subscales -—__—____._____—_____=____ __n Health Concern Pearson’s r Consumer Health .0197 Diseases & Disorders .0098 Emotional Health .0548 The Environment .0284 The Future .0696 Human Sexuality .0458 Nutrition .0236 Personal Health .1002 Relationships .0714 Personal Safety .0704 Social Health .0083 Substance Use & Abuse .0180 personal safety (r=.0704), social health (r=.0083), and substance use and abuse (r=.0180). None of the correlations were significant. I l l l . E E' 1. It is not the intention of this study to imply that adolescents with high times on the Endurance Run are not physically fit or that these individuals do not have positive health beliefs. The hypothesis for this study was that adolescents with a lower time on the Endurance Run 44 portion of the Chrysler-AAU physical fitness test would report more positive health beliefs on the AHCI then those adolescents who had longer endurance run times. Results of this study indicate that there is no relationship between health beliefs and physical fitness in adolescents. The literature suggests that learning healthy fitness attitudes may lead to healthy attitudes about fitness as adults (U.S. Department of Health and Human Services, 1990). Results of this study indicate there is a strong need for more health attitude teaching to adolescents by parents, educators and health care providers. Since most of the participants (64.3%) rated their health as good or excellent (21.4%) and there is no indication in the literature that people exercise for the sake of good health (Ashford et.al, 1993), some of this attitude may come from the adolescent’s attitude about their own current health status. This attitude could contribute to lack of motivation to practice healthy behaviors because the adolescents perceive their health as good or excellent, even though they do not necessarily practice healthy behaviors. Lack of positive health beliefs can also possibly be attributed to the adolescent’s cognitive stage of development. Many young adolescents may be in Piaget’s concrete operational period 45 of development and believe that wellness depends upon adherence to specific rules (Bibace & Walsh, 1980). Yet, some do not understand the more abstract concepts of health promotion and preventive health behavior. When used in the Children’s Health Belief Model (CHEM), it is proposed that demographic variables such as age and sex affect health beliefs and that health beliefs lead to specific health behaviors which result in physical fitness. The evidence from this study does not support a relationship between health beliefs and physical fitness. The CHBM was a good model for this study. Even though there was no correlation between health beliefs and physical fitness in this study, the results were related to the participant’s perception of their health concerns and indicate the need for more intense teaching on the part of parents, educators, and health care providers. Based on low correlations in all of the subscales of the AHCI and participant’s perception of their current health as good or excellent, there could be a low perceived benefit of action for health related behaviors whether physical fitness scores are high or low. Research by Search Institute (1995) indicates that adolescents’ biggest barrier to program participation is that nothing interests them and they did 46 not know that programs exist. It is possible that these factors may also be true in the current study. Perhaps middle school students did not know programs existed because interest was not obtained prior to initiating programs. Educators and health care providers can make a difference by finding ways to initiate interest in learning about and practicing positive health beliefs and behaviors in adolescents. Although results of this study are beneficial for the teaching strategies of parents, educators, and health care providers, there are some limitations to the findings. Different participants may interpret the items of the AHCI differently depending on their age, sex, race/ethnicity, or reading ability. Some participants may not be able to read at an eighth grade level. Most of the participants were white (86.9%) therefore, minority groups are under represented in this study. Although participant’s physical limitation data was not recorded by the teachers who administered the Chrysler-AAU Physical Fitness Test, there may have been participants who had temporary or permanent physical limitations to running on the days of testing.‘ .Also, the sample of 84 subjects who completed both 47 the AHCI and the Chrysler Fund AAU physical fitness testing was limited. Some participants did not have scores for the Endurance Run due to illness or refusal to participate. Also, some participants did not answer all of the questions from the AHCI. Some questions were left blank and some participants wrote in things like, “it’s none of your business”, or “don’t have health class”. Individual perceptions of what health is may vary depending on demographic factors. Another limitation of the study was that physical fitness data was collected ten months prior to filling out the AHCI. Because they were older and their bodies were more mature, participants may have scored higher on the physical fitness portion of the test if repeated in 1996. Participants may have had difficulty interpreting the word “concern” on the AHCI. Individuals may practice a behavior they are not concerned about or may be concerned about behavior they do not practice. Answers may vary depending on interpretation of the word “concern”. For instance, if an adolescent smokes they may not check the box if they are not concerned about practicing the behavior. Also, perceptions of health may differ depending on other 48 extraneous variables such as mood, room temperature and time of day. WW Results of this study indicate a need for more research examining the health beliefs of children and adolescents. The AHCI is rated at the eighth grade reading level and perhaps the use of older subjects or a tool designed for younger subjects should be used for instruments for future research. More descriptive research about adolescent health beliefs is needed. It may also be beneficial to determine if adolescents themselves perceive a relationship between their health beliefs and physical fitness. Future research on the subject of adolescent health beliefs may want to examine the relationship between health beliefs and obesity and compare results with the implications of this study. To enhance this study, the relationship between obesity and physical fitness should be examined to determine if obesity and physical fitness are correlated. To determine if the homogeneity of the study population significantly affected the results of this study, the entire study should be replicated and repeated using different populations including participants from rural as well as. urban area schools. It also would be interesting to repeat 49 the present study on the same population on a different day of the week or time of the year. Weather may affect mood as evidenced by people who become depressed only in the winter months and get “Spring fever” in the Spring season of the year. Researchers may want to try different instruments or a combination of instruments for measuring physical fitness and health beliefs. Physical fitness is a difficult concept to measure so it may be beneficial to measure it using a combination of instruments rather than a single one. The Children’s Health Belief Model is specific to children and adolescents. It takes readiness factors into consideration and is useful and specific to the study of adolescent’s health beliefs. The use of the CHBM would be beneficial in future studies. Adolescent wellness, the promotion of health and the prevention of disease in primary care can be enhanced by Advanced Practice Nurses (APNs) when using the results of the present study. Findings suggest there is no relationship between health beliefs and physical fitness in adolescents. This suggestion is important for the realization that adolescents may not be as concerned abOut their wellness as they should be. Results of this study 50 suggest educators and APN’s as health care practitioners need to improve teaching of health related issues and tie health behavior to outcomes that are relevant to adolescents. Since some adolescents may not yet understand the concept of health promotion and preventive health behavior, other ways of capturing their interests adolescents need to be explored. Studies show that girls exercise more for perceived romantic appeal and males exercise for perceived athletic ability (Ashford, Biddle & Goudas, 1993; Douthitt, 1994). Perhaps Advanced Practice Nurses should develop health programs for families and schools that appeal to adolescents in other ways than strictly for the sake of health. Stressing exercise and healthy habits for the sake of enhancing body shapes and beauty for girls and strength, as well as athletic ability for boys, may be a way to capture and keep the interest of adolescents. Caution should be taken to separate physical fitness and weight. With the high incidence of eating disorders among this age group, it would be important to stress the beauty of physical fitness and that being physically fit does not mean being thin. It should be pointed out that physically fit people weigh more because muscle weighs more than fat. 51 Toned muscles are much more attractive than bony appearances. APN consultants are educated to teach these concepts and collaborating with one would be beneficial to utilize in school based health programs. Eventually, this information may even help to improve the incidence of eating disorders among adolescents. This information could also be used by APN’s for the promotion of adolescent wellness in primary care settings. Adolescents visit primary care settings for reasons like sports physicals as well as illness or disease. APN’s also have the opportunity to be involved with performing sports physicals for teams within the school setting. These opportunities are prime times for teaching wellness. When the adolescent is hoping to be in the best possible condition to perform a sport, they may be more apt to listen to and perform healthy behaviors that lead to physical fitness. Those that are not involved in sports may come to the primary care setting for yearly check ups or illness related visits and APN’s should use every opportunity to promote healthy lifestyles. Inquiring and teaching about diet, exercise and other health behaviors should be a part of every routine visit with adolescents because the APN may get few opportunities to carry out this important function. 52 Finally, the study of health beliefs may promote the desire for physical fitness in adolescents. The more educated they are about the importance of positive health behaviors, the more apt adolescents are to perform them. APN’s as role models are educated to teach health promotion and disease prevention behaviors that lead to an optimum state of wellness. Perhaps adolescents who are well and practice healthy behaviors leading to physical fitness will lead to physically fit adults that promote wellness in their family members. Eventually, there may be more individuals and families who see health as a rule and not an option. APPENDIX A 53 APPENDIX A PERMISSION LETTER TO PARENTS/GUARDIANS Nancy Tupica 216 Giddings Place St. Louis, MI 48880 (517)681-2930 March 18, 1996 Dear Parent or Guardian: I am a graduate student from the College of Nursing at Michigan State University and I am conducting a study of the relationship between health beliefs and level of physical fitness in adolescents. This study will be important to determine if adolescents with more positive health beliefs are more physically fit than those who do not have positive beliefs. The results can be used to develop health and fitness programs in the schools. I have obtained consent from the school principal to conduct the study and would like your permission for your adolescent to participate in the study. One aspect of the study, level of physical fitness, has already been measured. Last year the physical education teachers at the school administered a test called the Chrysler Fund-AAU Physical Fitness Test. I am requesting 54 Appendix.A your permission to use part of your child’s fitness results for my study. The second part of the study, health beliefs, involves your adolescent filling out a questionnaire entitled the Adolescent’s Health Concern Inventory and asks questions including demographic (age, grade,-race, height and weight), and questions concerning the adolescents’ beliefs about their health. The questionnaire will be completed during school hours in your adolescent’s home room with myself, their home room teacher and/or a designee present. Please note that, although there are no individual risks or benefits to participating in this study, you are completely free to withdraw your consent at any time. Your child’s participation is completely voluntary and he/she can withdraw from any or all of the study at any time without penalty. If you do not wish your adolescent to be included in the study or have any questions concerning the study please notify Mr. John Raab at 681-5155 or myself at 681— 2930. You may also contact Linda Spence, my thesis chairperson, at Michigan State University (517)353-8684. Also note that all information gathered in this study will 55 be completely confidential. Thank you for your consideration in this matter. Sincerely, Nancy Tupica, RN, BSN Graduate student College of Nursing Michigan State University 56 APPENDIX.A LETTER TO MIDDLE SCHOOL PRINCIPAL Nancy L. Tupica 216 Giddings Place St. Louis, MI 48880 October 15, 1995 John Raab, Principal T.S. Nurnberger Middle School 312 North Union St. Louis, MI 48880 Dear Mr. Raab: As you are aware, I am a registered nurse working on my Master’s degree at Michigan State University to become a Family Nurse Practitioner. .Adolescent obesity and the implications the problem poses on society and the future is of great concern. .According to a 1992 University of Michigan study, more than one-third of all Michigan school children are overweight. Many studies link poor nutritional habits to the problem. With the rising concern over the incidence of childhood obesity, I wou address the question: What is the relationship between level of physical fitness and health beliefs in adolescents? The target population includes all 57 students age 12-14 enrolled at T.S Nurnberger Middle School. I would like the sample to include all students at the middle school age 12-14 that have formal parental consent to be included in the study.To measure level of physical fitness, I will use the data gathered by your physical education teachers in May, 1995 using the Chrysler Fund AAU Physical Fitness test. To measure health beliefs, I will use a questionnaire called the Adolescent’s Health Concern Inventory. No students will be involved in the testing unless parental or guardian permission is obtained prior to the day of testing. I hope to administer the questionnaire in late February or early March. Thank you for your consideration in this matter. I am requesting your permission to conduct my study at T.S. Nurnberger Middle School as explained above. I will look forward to your response and will be happy to answer any questions you may have concerning the study. Sincerely, Nancy L. Tupica, RN, BSN Graduate Student Michigan State University 58 APPENDIX A LETTER TO DR. WEILER FOR AHCI USE PERMISSION 216 Giddings Place St. Louis, MI 48880 517-681-2930 October 14, 1995 Robert M. Weiler College of Health and Human Performance Department of Health Science Education University of Florida Gainsville, Florida Dear Dr. Weiler, Thank you for considering me to use the Adolescent’s Health Concern’s Inventory for my Master’s thesis at Michigan State University. I am a student in the College of Nursing, working toward my Master’s degree to become a Family Nurse Practitioner. Of particular interest to me and my future practice is the health and wellness of our adolescent population. Adolescent obesity and the implications the problem poses on society and the future is of great concern. My study will answer the question: What is the relationship between level of physical fitness and health beliefs in preadolescents? 59 The target population includes all students age 12-14 enrolled at T.S. Nurnberger Middle School in St. Louis, Michigan. St. Louis is in a rural area. The population is 6,107 and the main industry is farming. Level of physical fitness will be measured using the Chrysler Fund-AAU Physical fitness program, which was administered to the students in May of 1995. Theoretical basis of the study will be based on Pender’s Health Belief Model. I will look forward to receiving your reply and any other materials or suggestionss you may have for my study. Sincerely, Nancy L. Tupica, RN, BSN Graduate Student Michigan State University 60 .APPENDIX A INSTRUCTIONS FOR STUDENTS FOR USE OF AHCI March 22, 1996 Dear Advisors: Thank you very much for agreeing to assist me on this important project. I really appreciate it. Please pass out the questionnaires to the students with their names on them. Some will not have fitness scores attached and some will. Please instruct the students to tear off the piece of paper with their name on it prior to turning in the completed questionnaire. This will keep the information anonymous. Also, please read the following paragraph to the students after passing out the questionnaires. However, please be aware that information will be completely anonymous (we won’t know who answered what on the questionnaire). Also, results of this information will help educators and health care professionals to develop health and fitness programs for students like yourself all over Michigan. The study is based at Michigan State University and Nancy Tupica, a graduate student from Michigan State, is the chief 61 investigator. You may see her coming in and out of the room while you fill out the questionnaire. There are instructions for completing the qustionnaire at the beginning of each section. The questions ask you if each issue is a “personal concern for myself,” “a concern among my best friends,” and/or “a concern among other teenagers.” some items may affect you and some may not. You may feel some items are a concern among teenagers outside of St.Louis. This will take you about 20 minutes to complete. The questionnaire is not graded and whether you complete it or not is completely voluntary. You may mark more than one box or no boxes if you wish. When you turn in the questionnaire, please remove the piece of paper with your name on it, but leave the physical fitness results attached.If you were not here last year for the fitness testing,there will not be any scores attached to your questionnaire. Nancy will be roaming through all the rooms if you have any questions. You may begin. 62 APPENDIX A UNIVERSITY March 15, 1996 TO: Nancy Tupica 216 Giddings Place St. Louis, MI 48880 RE: IRBN: 96-112 ‘ TITLE: ‘ THE RELATIONSHIP BETWEEN HEALTH BELIEFS AND PHYSICAL FITNESS IN ADOLESCENTS REVISION REQUESTED: N/A CATEGORY: _2-n,I APPROVAL DATE: 03/15/96 The University Committee on Research Involving Human Subjects'IUCRIHS) review of this project is complete._ I am pleased to adVISe that the rights and welfare of the human subjects appear to be adequately protected and methods to obtain informed consent are appropriate. Therefore, the UCRIHS approved this prOJect and any reVISions listed above. RENEWAL: UCRIHS approval is valid for one calendar year, beginning with the approval date shown above. Investigators planning to continue a project beyond one year must use the green renewal form (enclosed with t e original agproval letter or when a project is renewed) to seek u date certification. There is a max1mum of four such expedite renewals possible. Investigators wishing to continue a project beyond that time need to subm1t it again or complete rev1ew. REVISIONS: UCRIHS must review any changes in procedures involving human subjects, rior to initiation of tie change. If this is done at the time o renewal, please use the green renewal form. To revise an approved protocol at any other time during the year, send your written request to the CRIHS Chair, requesting revised approval and referencing the project's IRB # and title. Include in your request a description of the change and any revised instruments, consent forms or advertisements that are applicable. PROBLEMS/ - CHANGES: Should either of the followin arise during the course of the work, investigators must noti UCRIHS promptly: (1) roblems (unexpected Side effects, comp aints, etc.) involving uman subjects or (2) changes in the research environment or new information indicating greater risk to the human sub'ects than existed when the protocol was previously reviewed an approved. If we can be of any future help, please do not hesitate to contact us at (517)355-2180 or FAX (517)432-1171. , Li~ avid E. Wright, Ph. UCRIHS Chair Sincerel DEW : bed cc: Linda Spence 63 APPENDIX A John Raab 312 N. Union St. Louis, MI 48880 November 7, 1995 Nancy L. Tupica 216 Giddings Place St. Louis, MI 48880 Dear Ms. Tupica, It has come to my attention that you would like to do a research project on adolescent obesity. We certainly would be willing to participate in any way with your study. My concern is parent permission. You have answered that question in your letter. I give you permission to conduct your study here at TSN Middle School. Sincerely, John F. Raab Principal 64 .2. UNIVERSITY OF FLORIDA College of Health and Human Performance Department of Health Science Education 30 March 1995 Nancy L. Tupica 216 Giddings Place St. Louis, Ml 48880 Dear Nancy Tupica, According to your request I have enclosed a copy the Adolescent Health Concerns Inventory (AHCI). You have my permission to use the instrument contingent upon the following conditions: (1) that you do not modify any portion of the instrument, please note the AHCI is copyrighted; (2) that you use the instrument in accordance with the guidelines for research involving human subjects established by your directing institution; (3) that you send me a copy of any paper or publication engendered from your research. I regret any inconvenience these conditions maycause, but they are necessary to safeguard the integrity of the instrument and protect the rights and well-being of potential participants. If you have any questions or if I can be of further assistance, please do not fail to let me know. ° Sincerely, «MN MW Robert M. Weiler, PhD, MPH Assistant Professor LI ST OF REFERENCES REFERENCES Anderson, R. & Newman, J. (1973). Societal and individual health determinants of medical care utilization in the United States. Ihe_Milhan£_Menoria1 EundQuarterlxiél 95-124- Ashford, B., Biddle, S., & Goudas, M. (1993). Participation in community sports centres: motives and predictors of enjoyment. l9ELflfll_Qi_§29£L§_§§i£Q£§L_Ll(3)r 249-256. Becker, M.(1974). The Health Belief Model and personal health behavior. Hea1th_Education_Moaogra2hsi_2(4l. 336- 353. Benson, P.(1993). Ihe_;rgubled_igurn§y. .A portrait of 6th-12th grade youth. Minneapolis: Search Institute. Bibace, R.,& Walsh, M.(1980). 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Fitness programs to shape up kids. Curriculum tries to instill at an early age the benefits of lifelong fitness activities over competitive sports. AEELArbor_HeEsE pp. A15. Glenmark, B.,Hedberg, G., & Jansson E.(1994). Prediction of physical activity level in adulthood by physical characteristics, physical performance and physical activity in adolescence: an 11- year follow—up study. Euroaean_Journa1_of_Asalied_£hxsiologxl_§_I6). 530- 538. Gochman, D. (1982). Labels, systems and motives: Some perspectives for future research and programs. Health Education_Quarterlxl_2. 167- 174. Harlan, W. (1989). A perspective on school- -based cardiovascular research. Health_fiducation_Quarterlxi_1§(2). 152-168. Himes, J. & Dietz, W. (1994). Guidelines for overweight in adolescent preventive services: recommendations from an expert committee. American_figurnal cf_cliaica1_flursingl___. 307- 316. Kegles, S. & Lund, As (1982). 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Adolescent perspectives on health and illness. Adolescencei_1§. 375-384. Rutter, M. (1980). School influences on Children' s behavior and development: The 1979 Kenneth Blackfan lecture, Children' 3 hospital medical center, Boston. PedietrieeL §§(2), 208- 220. Salazar, M. (1991). Comparison of four behavioral theories; A literature review. AAQflN_QeereelL_;2(3), 128— 135. Sallis, J., Patterson, T., Buono, M., Atkins, C. & Nader, P. (1988). Aggregation of physical activity habits in Mexican-American and Anglo families. lengeel_efi Behavioral_nedicinel_ll(1). 31-41. Sarafino, E. (1979). Health_p§xcholos¥= Bi9nexchosocial_interactiens. New York. Search Institute (1995). Seugee, A geerterly w l r r i l r r h n fi in hi1 r n n yenthL_1Q(2); Minneopolis:Search Institute. Shillinger, F. (1983). Locus of control: Implications for Clinical Nursing Practice. lmege: The Journal efi Nursing_§cholarshipl_2§(2). 58- 63. 68 Strain, L. (1991). Use of health services in later life: The influence of health beliefs. qureal_cf Gerontologxz_i§(3l, 143-150. Ihe_American_Heritase_sollege_nictionar1 (3rd d.).(1993). Boston, MA: Houghton Mifflin Company. Tinsley, B.(1992). Multiple influences on the acquisition and socialization of children's health attitudes and behavior: An integrative review. thld_DeyelcpmenLL_§§, 1043-1067. Updyke. W.(1994).AAHLphxsical_fitness_prosram.122A: 2§_Le§tigg_packet. Available from: AAU physical fitness program. Poplars building. Bloomington IN. Updyke. W. & Willett. M. (1989). thsical.fitness trends in American yccth, 1989-1989. .A study conducted by the Chrysler-AAU physical fitness program. 1989 Press conference. Washington, D.C. Available from the Chrysler Fund-AAU physical fitness program. Bloomington, Indiana. U.S. Department of Health and Human Services. National children and youth fitness study II. leu;aal_cf_£hy§ical ' n R i n D n 58(50), 50-96. U.S. Department of Health and Human Services. Public Health Services (1990). Health 1 Eecple 2000 Nacicaal r m ' n Di P v n n 'v . Washington D.C: DHHS Publication. VanDalen, H. & Williams, A. (1994). Lay people' 5 evaluations of health: Are there variations between different subgroups? Qouraal_of_Eaideniologx_§onnuaitx Healthi_i2(3), 248- 253. Walter, H. (1989). Primary prevention of chronic disease among children: The school- based “know your body” intervention trials. Health.2ducation_2uarterlxi_1§(2). 202- 213. Weiler, R. & Sliepcevich, E.(1993). Development of the adolescent health concerns inventory. Healch_§cccacicn Quarterlxl_22(4). 569-83. 69 Weisenberg, M., Kegeles, S., & Lund,.A. (1980). Children' 5 health beliefs and acceptance of a dental Preventative activity. Qonrnal_of_nealth_aad_fiocial Behaxiori_21(3). 59-74. Zindler- -Wernet, P. & Weiss, S. (1987). Health locus of control and preventive health behavior. Wea;ern_ficcraal_cf Nursing_flesearchz_2(2). 160- 179. HICH IGRN STATE UNIV. 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