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I l 4 o 4 . . . I 4 I 4 0 4 ' . D O I ‘ I O D 4 o 4 O 4 4 . . - . 4 .044 _ .440. .- . .. .. .. . . . . .. .. I. . I . _ . . .......-..hw..-I..-- - I 0 . It. I I . . I .« I. - 0 44 - I I I I4 4 . 4 . I - . 4 . 4 . I . . 4 ..4 4 . O .. . I . . . . 0 . . V 4 o I I I 10‘ 4 n .o. . 4 . . . . 4. . ..-. 0 .....fl.44 40.41%” - . . . . .I- .0 . 44.! 0.- l ' t ..IIII' ‘ ll |I'.|ll III. I I .I' It Ill ‘ “'4 an LE_33ARY ma "flu aiate H I University PLACE IN RETURN BOX to remove this checkout from your record. TO AVOID FINES return on or before date due. MAY BE RECALLED with earlier due date if requested. DATE DUE DATE DUE DATE DUE SEP 2 5 2007 ‘09 25 “7 6/01 cJCIRC/DateDuest-p. 1 5 A DESCRIPTIVE STUDY OF THE HEALTH BEHAVIOR OF A COLLEGE POPULATION BY Joann P. Bunce A Research Project Submitted to Michigan State University in partial fulfillment of the requirements for the degree of MASTER OF SCIENCE IN NURSING College of Nursing 1983 To my husband, John, for all his love and encouragement and to my delightful daughter, Jennifer. ACKNOWLEDGEMENTS This research project would not have been completed without the help of many individuals. I would like to thank the members of my committee — Judith Longworth and Brigid Warren - for their patience, enthusiasm and help in completing this project. I would like to thank LeAnn Slicer and Patti Archer for providing the right forms and answering all my questions. I would like to thank Rob Hymes for assisting me with statistics and data analysis. Most of all, I would like to thank Barbara Given for her support and encouragement. Throughout my undergraduate and graduate education, Barbara helped me realize what nursing is and what nursing can be. ABSTRACT A DESCRIPTIVE STUDY OF THE HEALTH BEHAVIOR OF A COLLEGE POPULATION BY Joann P. Bunce A descriptive study was conducted to report the health behavior of a college population. Research questions addressed included exploring the health behavior of a college population in the areas of self- responsibility, physical fitness, nutritional awareness, and stress management. A convenience sample of 268 male and female students was selected from a larger number of students, all of whom completed a health questionnaire. The frequencies and percents demonstrate that students carry out some positive health behaviors including not smoking cigarettes or marijuana, would use birth control, decreasing the intake of caffeine and salt, including fiber in the diet, and being able to cope with stress. TABLE OF CONTENTS CHAPTER I — INTRODUCTION .................. . ..... Purpose ...... ..... ............. ..... ....... Statement of the Problem ......... .......... Definitions ..... . ..................... ..... Assumptions .. ..... . ........... .. ...... ..... Limitations .................... ............ CHAPTER II — CONCEPTUAL FRAMEWORK ....... ..... ... CHAPTER III - REVIEW OF LITERATURE ........ ...... Self-Responsibility ........................ General Health Behaviors ... ....... . ........ Driving Behaviors ........ ..... ........ ..... Self Abuse Behaviors ....... . ....... . ....... Contraceptive Behavior ... .................. Physical Fitness ............ .... ...... ..... Nutritional Awareness . ............ ......... Stress Management . ..... . ........... ........ Integration of Health Behaviors ............ CHAPTER IV — METHODOLOGY AND PROCEDURE .......... Setting and Population ............... ...... The Questionnaire ........ . ........ . ........ Procedure .............. ..... . ....... . ...... Operational Definitions ............. ....... 27 27 33 41 43 45 48 52 61 65 68 68 69 69 72 Page Validity and Reliability .. ..... . ......... . 75 Analysis and Scoring ...................... 77 Research Questions .. ...................... 78 CHAPTER V — DATA PRESENTATION ...... ....... ..... 8l Descriptive Findings of the Population .... 82 Guttman Technique of Scaling for Reliability .............. . ......... ... 85 Presentation of the Findings for Each Area of High Level Wellness ........... 87 Self-Responsibility ................. 87 Physical Fitness .................... 95 Nutritional Awareness ............... 96 Stress Management ................... 100 Correlational Findings ................... 105 CHAPTER VI - NURSING IMPLICATIONS, PROBLEMS AND RECOMMENDATIONS ......OOOOOOOOOOOOOOOOOO 115 Self—Responsibility .... .......... ........ 115 Physical Fitness ..... ...... .... .......... 125 Nutritional Awareness .................... 127 Stress Management .... ............ ... ..... 130 Correlational Findings . ...... .. ....... ... 132 Problems ..... ..... ..................... .. 137 Education Implications ... ......... ....... 145 Page Implications for University Health Care Services ............. ..... ........ 147 Recommendations .......................... 143 APPENDICES ......... ....... . ..... ...... ...... .. 150 Appendix I: Cover Letter ... ......... .... 150 Appendix II: Questionnaire .............. 151 Appendix III: Operational Definitions ... 153 Appendix IV: Division of Questions into Positive (+1) and Negative (0) Health Behavior ....... .......... 155 LIST OF REFERENCES 0............OOOOOOOOOOOOOO. 157 Table Table Table Table Table Table Table Table LIST OF TABLES Page Number and Ages of the Students of the Sample Population ....... . ..... 84 Descriptive Findings in the Area of Self—Responsibility Subscale General Health Behavior ..... 88 Descriptive Findings in the Area of Self-Responsibility Subscale Driving Behavior ............ 90 Descriptive Findings in the Area of Self-Responsibility Subscale Self Abuse Behavior ......... 92 Descriptive Findings in the Area of Self-Responsibility Subscale Birth Control Behavior ...... 94 Descriptive Findings in the Area of Physical Fitness .................. 95 Descriptive Findings in the Area of Nutritional Awareness ............. 97 Descriptive Findings in the Area of Stress Management ... ........ . ..... 101 Table 9. Table 10. Table 11. Table 12. Page The Mean Scores for the 4 Subscales of Self—Responsibility and for the Areas of Physical Fitness, Nutritional Awareness, and Stress Management ....... ........... .. 104 Point Biserial Correlation Coefficients. Calculation Between Sex and 3 Subscales of Self— Responsibility, Nutritional Awareness, and Stress Management ..... . 106 Pearson Correlation Coefficients. Calculation Between Age and 3 Subscales of Self-Responsibility, Nutritional Awareness, and Stress Management .................... 103 Pearson Product-Moment Correlation Coefficients. The Interrelation- ships of the Areas of High Level Wellness ............................. lll Figure 1. LIST OF FIGURES The Nursing Process Model Page 26 CHAPTER I INTRODUCTION According to the Surgeon General in Healthy People (1979) adolescents are relatively healthy if measured by morbidity and mortality indicators and compared to other age groups. However, compared to years past, progress has not been made in reducing the mortality rate for adolescents. "Americans aged 15 to 24 now have a higher death rate than 20 years ago" (Healthy People, 1979, p. 43). Accidents, homicides, and suicides are the major causes of death in this age group. In addition, in this age group, health behaviors are being incorporated into individual lifestyles and "although chronic diseases are not among the major causes of death at this period of life, the lifestyles and behavior patterns shaped during these years may determine later susceptibility to chronic diseases" (Healthy People, 1979, p. 43). There is a need for health prevention and health promotion in this age (15—24 years) group. Primary health prevention includes measures designed to preclude the development of chronic illnesses. Today, many of the primary health prevention measures focus on personal behaviors that increase the risk of chronic diseases. Examples of such high—risk behaviors include: smoking, which contributes to various cancers, cardiovascular disease, chronic obstructive pulmonary disease, and peptic ulcers (Healthy People, Background Papers, 1979 and Botvin and McAllister, 1981); a sedentary lifestyle which contributes to heart disease (Morris, 1980; Paffenbarger, 1975; Blackburn, 1981); diets high in fats which also contribute to cardiovascular disease (Lasser, 1981); and driving habits which contribute to automobile crashes (Accident Facts, 1982). Health promotion includes measures directed toward "...increasing the level of well—being, self-actualization, and fulfillment of a given individual..." (Pender, 1982, p. 65). The focus is on helping healthy persons "...develop lifestyles that can maintain and enhance the state of well-being" (Healthy People, 1979, p. 119). It is appropriate for nursing to be involved in health prevention and health promotion in the adolescent age group. "Nursing aims to assist people in achieving their maximum health potential. Maintenance and promotion of health, prevention of disease, nursing diagnosis, intervention, and rehabilitation encompass the scope of nursing's goals" (Rogers, 1970, p. 86). Nursing is concerned with all people and all areas where there are people (Rogers, 1970). Consequently, when at a large university, nurse run clinics were established in two residence hall complexes, one of the goals identified was to promote high level wellness in the student population. According to Dunn (1977) high level wellness is "an integrated method of functioning which is oriented toward maximizing the potential of which the individual is capable, within the environment where he is functioning" (p. 9). Ardell (1979) describes high level wellness as a lifestyle approach to improving health, reducing risks of disease, and providing a life of greater satisfaction, serenity, and an expanded interest in the future. Promotion of high level wellness is a goal that incorporates health prevention and health promotion. Promotion of high level wellness is also a goal that is congruent with nursing's goal of assisting individuals to achieve their maximum health potential. In order to promote high level wellness a questionnaire was developed and distributed to assess the health behaviors of the college students that the nurse-run clinics served. Assessment is the first step in the nursing process and it "...is an investigative operation that enables nurses to make judgments about the existing health care situation and decisions about what can and should be done" (Orem, 1980, p. 203). By interpreting the results of this questionnaire, the strengths and weaknesses of the students' health behavior can be identified, and appropriate action can be planned and implemented. An initial description of students' health behavior may highlight areas in need of more in depth research or areas in need of immediate nursing intervention. PURPOSE The purpose of this study is to describe the stated health behaviors of a college population. This will be done utilizing four of the five dimensions of high level wellness described by Ardell (1979) that were incorporated into the questionnaire. This is a descriptive study to assess student health behavior, the first step of the nursing process to promote high level wellness in the student population. STATEMENT OF THE PROBLEM In this study, based on Ardell's (1979) model, the following questions are addressed: What are the health behaviors of a college population in the area of self—responsibility? What are the health behaviors of a college population in the area of physical fitness? What are the health behaviors of a college population in the area of nutritional awareness? What are the health behaviors of a college population in the area of stress management? DEFINITIONS Definitions of the concepts are presented to facilitate the understanding of the promotion of high level wellness. High level wellness — a lifestyle approach to improving health and maximizing the potential of which the individual is capable within the environment. A process. (Ardell, 1979). Lifestyle - A unique pattern of behaviors in one's life resulting from what one thinks, feels and does (Vierke, 1980, p. 237). Health behavior - actions taken by an individual to prevent disease and promote health. Health behaviors are incorporated into one's lifestyle. Health - an ideal, dynamic state of perfect integrated functioning in the biological, psychological, social, and spiritual spheres of a human being. An outcome. College population — the study population came from individuals attending a mid—western, Big—10, State university, for the purpose of obtaining a college degree and living in a residence hall. Dimension of self-responsibility — an active sense of accountability for one's own well-being (Ardell, 1979, p. 102). Dimension of nutritional awareness - a sense of wise food selection and sensible diet patterns (Ardell, 1979, p. 125). Dimension of stress management — a sense of knowledge and recognition of stress, stress symptoms, and stress management (Ardell, 1979, p. 145). Dimension of physical fitness - active participation in regular exercise (Ardell, 1979, p. 156). ASSUMPTIONS Assumptions upon which this study was based included: 1. Students' response to the questionnaire were real and honest. 2. Students did not confer with others when responding to the questionnaire. Students were able to identify their own health behaviors among those listed in the questionnaire. Researcher's operationalizing of health behavior is consistent with the meanings by Ardell (1979). Ardell's (1979) model is applicable to a college population. Achievement of high level wellness is a desirable goal and improves the quality of life. LIMITATIONS Limitations associated with this study included: The students who completed the questionnaire may have been different from those who refused to complete the questionnaire. This study examines only those health behaviors considered important by the researchers who developed the questionnaire. The dimension of environmental sensitivity of high level wellness was not examined in this study. The type of sample was a convenience sample. The results of this study can only be generalized to those students living in one residence hall of the university and not ot those students living in other residence halls of off-campus. In the rest of this paper, the investigator describes the conceptual framework, the review of literature, the methodology, the report of the findings and the implications for nursing of the study. CHAPTER II CONCEPTUAL FRAMEWORK According to government statistics the major causes of death in adolescents (age 15—24) are accidents, homicides and suicides. In older adults, those over 44, heart disease, stroke and cancer are the leading causes of death (Healthy People, 1979). Personal behavior or habits can play an important role in preventing death. John Knowles (1977) reports that "A large percentage of deaths (estimates up to 80 per cent) due to cardiovascular disease and cancer are 'premature,' that is, occur in relatively young individuals and are related to the individual's bad habits. Heart disease and strokes are related to dietary factors, cigarette smoking, potentially treatable but undetected hypertension, and lack of exercise. Cancer is related to smoking (oral, buccal, lung, and bladder cancer) and probably to diets rich in fat and refined foodstuffs and low in residue (gastrointestinal and perhaps breast and prostatic cancer) and to the ingestion of food additives and certain drugs, or the 10 inhalation of a wide variety of noxious agents. Certain occupationsl exposures and personal hygienic factors account for a small but important fraction of the total deaths due to cancer. Theoretically, all deaths due to accidents, homicide, and suicide are preventable" (p. 62). Breslow and Belloc (1972) also conclude that following certain health habits with regards to smoking, drinking, diet, sleep, and exercise, can add to an individual's life expectancy. Ardell (1979) emphasizes that following a wellness lifestyle, besides decreasing a person's chances of becoming ill, will enhance an individual's sense of well—being. Pender (1982) supports this point by concluding that "... health promoting behaviors are directed toward 'sustaining' or 'increasing' the level of well-being, self— actualization, and fulfillment of a given individual or group" (p. 65). Ardell (1979) describes a high level wellness as a unique, positive, integrated approach to well—being. He describes five areas of well—being that need attention - self—responsibility, nutritional awareness, 11 physical fitness, stress management, and environmental sensitivty. Self—responsibility is a sense of accountability for one's health. Ardell (1979) stresses that by being responsible for one's health, one would have the desire and energy to sustain activity in the other four dimensions. The health belief model was developed to explain preventive health behavior (Rosenstock, 1974). In this model, perceived benefits, perceived barriers, perceived susceptibility to disease and perceived seriousness of disease are considered important influences on one's health activity and carrying out preventive measures. One's sense of responsibility or accountability may also be influenced by an internal or external locus of health control (Ardell, 1982; Pender, 1982). Self-responsible behavior has preventive and promotive health benefits. Self—care activities such as self breast/self testicle exam, periodic health exams and periodic or annual pap smears can help decrease the mortality of certain cancers through early detection and treatment. The number of car accidents can be decreased by responsible driving habits such as using seat belts 100% of the time, following speed 12 limits, and avoiding drinking and driving (Accident Facts, 1982). Alchol abuse contributes to chronic diseases such as cirrhosis, certain cancers, and heart disease (Lindberg, 1980; Healthy People, Background Papers, 1979). Smoking increases the risk for cardiovascular disease, lung cancer and chronic respiratory diseases. The longer the years of smoking the greater the risk (Botvin and McAlister, 1981; Healthy People, 1979). Not smoking and limited alcohol intake are responsible behaviors in this dimension. Unwanted pregnancy can be decreased and sexual enjoyment increased by responsible birth control use (Ardell, 1982). Ardell (1979) stresses the need for wise food selection in describing the dimension of nutritional awareness. An adequate diet may play a major role in preventing disease and contributing to alertness and energy needed for productive living (Pender, 1982). Activities in this area, that include maintaining ideal body weight, increasing the intake of fiber, and decreasing the intake of salt, fats and food additives, may prevent a number of chronic diseases. An increased intake of fats is linked to elevated serum lipids, a risk for cardiovascular disease (Blackburn, 1983; l3 Lasser, 1981; Stamler, 1979). Salt intake is linked to hypertension which is another risk for cardiovascular disease (Borhani, 1981; Dahl, 1972). Obesity is indirectly linked to heart disease by contributing to hypertension and elevated serum cholesterol (Lasser, 1981). A diet low in fiber may place the individual at risk for cancer of the colon (Burkitt, 1978; Pender, 1982). Food intake should emphasize fresh, whole foods from a variety of sources. Being physically fit will reduce the hazards of inactivity such as fatigue, poor musculature, inflexibility, obesity, and premature aging (Ardell, 1979). Exercise may be a protection against heart disease (Morris et a1, 1980, Paffenbarger et a1, 1978, Siscovick, 1982). Regular exercise may also help reduce stress (Randolpy, 1979; Sutterly, 1979). Other benefits of being physically fit and exercising regularly may be improved self—image, improved psychological well-being, and decreased depression (Fair, 1979; Glasser, 1976; Pender, 1982). In the dimension of physical fitness, Ardell (1979) encourages twenty minutes of exercise at eighty percent maximum heart rate four times a week, in an activity that is non-competitive and enjoyable. This type of exercise 14 is aerobic exercise. Strength building exercises and flexibility exercises are also an important part of physical fitness (Ardell, 1982). Selye (1976) initially researched stress and defined it as "...the non—specific response of the body to any demand..." (p. 1). Inability to adapt to increasing demands or stressors can have negative results. Pelletier (1977) suggests that stress is a factor contributing to cardiovascular disorders, cancer, arthritis, and respiratory diseases. Insomnia may result from too much stress (Diekelmann, 1977). Stress management is important because stress in and of itself is not always harmful but rather the amount of harm depends on how one reacts to it (Selye, 1976). In the stress awareness and management dimension, Ardell (1979) emphasizes "...ways to develop your power to recognize and deal with stress, approaches to consider and techniques to utilize" (p. 21). The fifth dimension of high level wellness is environmental sensitivity. In this area, Ardell (1979) focuses on the need to control one's personal and external environment leading to a sense of purpose, higher self-esteem and self—awareness. Activities in this dimension include better use of natural resources 15 and energy, joining an environmental organization, and minimizing annoyances. High level wellness is an approach to life that integrates principles or activities of healthful living in all five dimensions. Building a wellness lifestyle takes time as particular behaviors are accepted or rejected and incorporated into one's identity, thus high level wellness is unique to each individual. Being independent and in control of one's behavior is the key to well-being now and in the future. College students are at an age where they are becoming independent and forming an identity. Freshmen have not formed an identity compared to seniors (Mussen, 1979). l'Adolescence is a key point in the life cycle for formulating a personal philosophy about the value and meaning of one's wellness" (Bruhn and Cordova, 1978, p. 17). At this age (15—24 years), health habits and practices are being evaluated and incorporated into one's lifestyle. Social pressures or peer expectations may influence the choice of health behaviors. These health behaviors, positive or negative, will probably be carried into adulthood where once established they may be impossible to modify in the later years. There are health problems unique to 16 this age group that can be reduced by improved health behavior. Car accidents, alcohol abuse, suicide, and unwanted pregnancy are examples of these problems (Healthy People, 1979). Consequently, the need for college students to incorporate preventive and promotive health behaviors or to follow a wellness lifestyle becomes critical if the health problems of today and diseases of the future are to be avoided and positive well-being achieved. The nurse may be the health care provider who is ideally suited for helping college students incorporate positive health behavior into their lifestyle and therefore lead to improved health. The aim of nursing is to assist individuals to achieve their maximum health potential and the arena of service includes school (Rogers, 1970). Orem's (1980) model of self—care can be used to describe this process. Within Orem's framework, high level wellness can be explained. Before Orem's model is described, a definition of health is needed. Health is the goal of nursing, self— care, and high level wellness. Orem (1980) discusses health in terms of a state of being whole or sound. "These terms, when used together in regard to health, signify human functional and structural integrity, 17 absence of genetic defects, and progressive integrated development of a human being as an individual unity moving toward higher and higher levels of integration" (Orem, 1980, p. 121). Orem (1980, p. 121) also states that health is "a state of human perfection that includes continuing human development." Ardell (1979) defines health as a dynamic state comprised of three components (physical, emotional, and mental) which is an outcome of a wellness lifestyle. The physical component is freedom from pain and illness. The emotional component is a state of serenity, calm and a zest for living. A state of compassion and purpose describes the mental aspect (Ardell, 1979, p. 74). Based on these definitions, this investigator feels that health is an ideal dynamic state of perfect integrated functioning in the biological, psychological, social, and spiritual spheres of a human being. According to Orem (1980, p. 35) self care "is the practice of activities that individuals initiate and perform on their own behalf in maintaining life, health, and well-being." Self care is based on voluntary actions that individuals are capable of performing. It is also based on thoughtful judgement 18 that leads to appropriate action. Self care has a purpose (Orem, 1980). When individuals are unable to accomplish self care, nursing is needed. "People can benefit from nursing because they are subject to health—related or health-derived limitations that render them incapable of continuous self-care ..." (Orem, 1980, p. 27). The purpose of nursing is to facilitate a person's ability to perform self care, thereby promoting health or speeding recovery from disease. Orem (1980) defines three types of self care. They are universal self care, developmental self care, and health deviation self care. Universal self care requisites are basic human needs and include: 1. The maintenance of a sufficient intake of air. 2. The maintenance of a sufficient intake of water. 3. The maintenance of a sufficient intake of food. 4. The provision of care associated with elimination processes and excrements. 19 5. The maintenance of a balance between activity and rest. 6. The maintenance of a balance between solitude and social interaction. 7. The prevention of hazards to human life, human functioning, and human well-being. 8. The promotion of human functioning and development within social groups in accord with human potential, known human limitations, and the human desire to be normal" (p. 42). Developmental self care requisites are those needs which promote the process of development or prevent negative effects of conditions that affect human development (Orem, 1980). College students are completing the developmental tasks of adolescence and entering adulthood. Although this study does not focus on the success or failure of the completion of these tasks, the investigator recognizes that this process may need to be assessed in order to promote high level wellness. Delayed or unsuccessful completion of developmental tasks may interfere with the person's ability to follow preventive or promotive health behavior. On the other hand, successful completion of 20 the developmental tasks of adolescence may enhance an individual’s learning of wellness behavior. Health deviation self care requisites are needs that arise when a person is ill or injured or requires medical care (Orem, 1980). These self care needs do not apply in this study. Health promotion begins with individuals who are basically healthy and seeks the development of measures that can help these individuals develop lifestyles to maintain and enhance the state of well-being. Finally, Orem (1980) describes three nursing systems that can be utilized in helping individuals meet their self care needs. These systems are based on the ability of the person to engage in self care. The three systems are wholly compensatory system, the partly compensatory system, and the supportive- educative system. The supportive-educative system is appropriate to use in this study. In the supportive—educative system, the client is the primary resource. The client is healthy, able to perform self care, and make decisions but may need education or support to improve his or her health behavior. The nurse role is one of being equal with the client, consultive, supportive and educative. 21 "Health education is a process that informs, motivates, and helps people to adopt and maintain healthful practices and lifestyles..." (Pender, 1982, p. 150). Supporting healthful practices may include physical support, psychological support, or providing an environment that supports development (Orem, 1980). In the supportive—educative system, especially with college students, the nurse needs to assess and capitalize on the existing knowledge, skills, and performance of positive health habits. The promotion of high level wellness fits nicely into the self care model. High level wellness is defined by Dunn (1977, p. 9) as "an integrated method of functioning which is oriented toward maximizing the potential of which the individual is capable, within the environment where he is functioning." Ardell (1979) expands on this concept. High level wellness is a lifestyle—focused approach that incorporates some aspects of five wellness dimensions- self- responsibility, nutritional awareness, stress management, physical fitness, and environmental sensitivity (Ardell, 1979). Activities in the five dimensions of wellness include preventive and promotive health behaviors. One of the principles of high level '1 22 wellness is that the individual is the chairperson of well-being. Self—responsibility is also stressed by Ardell (1979; 1982). This is congruent with Orem's (1980) emphasis on the indiviual performing self care. Accomplishing activities from the five wellness dimensions is similar to meeting some universal self care requisites. Prevention of hazards to human life and promotion of human functioning act as an umbrella encompassing the five wellness dimensions as well as the other universal self care needs. An example would be driving within the speed limit. This is a positive health behavior that fits into the dimension of self responsibility and under the self care requisite of prevention of hazards. Other examples include not smoking, regular exercise, a balanced diet and seven hours of sleep. Based on this explanation, if a person is not following a wellness lifestyle in order to improve health then this person is not meeting their universal self care needs. Consequently, nursing is needed to facilitate these needs. This is the situation that applies to helping college students incorporate positive health behavior into their lifestyle. If these students are not following positive health 23 behaviors then there is a self care deficit. Nursing care is needed. Bruhn and Cordova (1977) report that wellness behavior is learned. Ardel (1979) adds that when an individual initiates high level wellness behaviors support may be needed. The nurse, then, would use the supportive-educative system, according to Orem (1980), to promote positive health behavior. In this system, the "...patient's requirements for assistance relate to decision making, behavior control, and acquiring knowledge and skills" (Orem, 1980, p. 101). This applies to college students who may not be performing a preventive exam, such as self breast/testicle exam because they do not understand the importance of such an exam or lack the skill to perform such an exam. In addition, students who are performing positive health behaviors, such as not smoking or infrequent drinking, may need support for appropriate decision—making and self—control as they try new behaviors or are influenced by peers during their college years. Nursing techniques in this system include combinations of support, guidance, provision of a developmental environment, and consultation (Orem, 1980). 24 Within this system, the nursing process needs to be applied in helping college students incorporate positive health behavior into their lifestyle. Assessment is the first step that is needed to determine the self care needs of the sutdents. What health behaviors do students follow? What are the self care deficits of college students? What are the strengths and weaknesses of the students in following high level wellness? Orem (1980) calls this step diagnosis and prescription. With adequate data, designing and planning appropriate nursing intervention can be accomplished. The final step in the nursing process according to Orem (1980) is producing care to regulate theraputic self care demand. In this step, implementation and evaluation are carried out. The scope of this study is assessment. Data is collected from students by means of a questionnaire that inquires about health behaviors. A description of the health behavior of a college population is needed before planning and implementing appropriate nursing care. This process is summarized in a diagram based on Orem's (1980) self care model and includes the promotion of high level wellness. See Figure I. The nursing process—assess, plan, implement, evaluate, is 25 initiated by the nurse. The need for nurse action or intervention is determined by assessment and planning. If a self—care deficit exists, nursing intervenes to assist the college students to overcome the self care limitations (right side of diagram). If there is not a self-care deficit, nursing can still act to assure continued accomplishment of self care demands (left side of diagram). 26 HEALTH (high level wellness) ACCOMPLISHES ACCOMPLISHES SELF CARE SELF CARE (performing preventive/ r m t' e be ' rs p o 0 iv hav1o ) b T \ STUDENT ACTION OVERCOMES SELF CARE LIMITATIONS (not performing preventive/ promotive behaviors) NURSE ACTION support implementation guidance & evaluation education consultation providing a developmental environment T producing care to regulate self care demand planning designing and planning assessment diagnosis and scope of prescription this study Figure l. The Nursing Process Model - adopted from Orem's Model (1980, p. 98) 27 CHAPTER III REVIEW OF LITERATURE In this chapter, literature relevant to the major areas of study are reviewed. These areas include self- responsibility, physical fitness, nutritional awareness, and stress management. It is beyond the scope of this study to review all of the literature written on these areas. Relevant literature is reviewed to show the risks and benefits of particular health behaviors within each area to demonstrate the need for health prevention and health promotion. A major area for recent research are studies that report on the attitudes and motivations for carrying out certain health actions. Some of these articles are reviewed. Prevalence reports or studies that report the health behavior of college students of‘this age group are reviewed. Finally, the writings of Ardell (1979, 1982) are included since his writings are the basis for the theoretical framework. SELF—RESPONSIBILITY Behavior in relationship to health practices is complex and difficult to predict. There are many varibles that determine whether an action, healthy or unhealthy, will be carried out. Although this study 1‘95' 28 reports what college students are doing and ng£_why they are doing it, a brief review of literature related to the variables studied to predict health action is offered for a beginning understanding of this area. According to Ardell (1979) the means to leading a health enhancing lifestyle is self-responsibility. This is the keystone or basis for all positive action. Self-responsibility is defined by Ardell (1979) as an "...active sense of accountability for your own well— being..."(p.102). He stresses the need for personal accountability to avoid high risk behaviors, the need for a sense of purpose, and being in charge. Motivation to pursue high level wellness comes from a desire for happiness and good health. Ardell (1979) is very upbeat, with a you can do it if you try attitude toward carring out health preventive or health promoting behaviors. In his new book, Ardell (1982) expands on these same themes. Self—responsibility includes being able to understand the limits of medicine and the ability to practice self care and use the medical system effectively. Ardell recognizes the importance of developing an internal locus of control (he doesn't say how to develop it) and that there may be barriers as well as benefits to a wellness 29 lifestyle. Although Ardell (1979, 1982) cites some research, generally his writing is descriptive based on his own beliefs. Ardell (1982) does realize that self—responsibility in following a wellness lifestyle is a difficult and complex process. One model, based on research, that begins to explain the many dimensions of health behavior is the health belief model. In this model, Rosenstock (1974) describes individual perceptions (perceived susceptibility of disease and perceived seriousness of disease), modifying factors (demographic variables, socio—psychological variables, structural variables, cues to action and perceived threat of disease), and likelihood of action (perceived benefits and perceived barriers of action) as predictors of preventive health behavior. Rosenstock (1974) reviews research that support or refute the model. The health belief model has been used a a basis for further research. Pender (1982) modifies the variables in the health belief model that predict preventive health behavior. Under individual perception she adds two variables- importance of health and perceived control. Pender cites several studies that show that concern about protecting health emerge as an important predictor of 3O preventive behavior. Pender also discusses health locus of control and the research that investigates the relationship between internal-external control and physical health and well-being. According to Pender, the importance of health locus of control has been supported by studies in predicting preventive behavior, smoking behavior, weight loss behavior, use of birth control and use of seat belts. Pender (1982) also develops a health promotion model to predict health promoting behavior. In a similar fashion to the health belief model, she describes individual perceptions, modifying factors, and the likelihood of action. Some of the variables she includes under individual perceptions are the importance of health, perceived control, desire for competence, self-awareness, self—esteem, definition of health promoting behaviors. Pender reports studies that demonstrate the relationship of these variables to health promoting behaviors but concludes that further research is needed to determine the extent to which each variable contributes to action. Langlie (1977) studied social networks, health beliefs, and preventive health behavior. Langlie used eleven scales (i.e. driving behavior, smoking, medical 31 check—ups, etc.) to measure preventive health behavior. She found, after studying the inter-correlations among the eleven scales, that preventive behaviors were not independent of one another. Instead, there were two dimensions of preventive health behavior (PHB) which she labeled indirect risk PHB and risk PHB. The independent variables were the social network variables such as neighborhood and family, socioeconomic status, non—kin and kin interaction, conjugal structure, and religious affiliation. Langlie (1977) reports that "...both social-psychological attributes of the individual and characteristics of his social milieu exert a significant impact on indirect risk PHB" (p. 252). Based on her findings, Langlie supports further research into the two dimensions of PHB, direct risk PHB and indirect risk PHB. Mechanic and Cleary (1980), in studying factors associated with positive health behavior concluded that positive health behavior is associated with both psychological well-being and subjective health status (perception of health). Other variables predicting positive health behavior include sex (Women had more positive scores), education (persons with higher levels of education had more positive scores), and 32 conventional behavior orientation (persons more conventional or in harmony with society had more positive scores). Krantz (1980) studied one aspect of self— responsibility-that of patients becoming more active and informed in the health care process. He developed the Krantz Health Opinion Survey made of two subscales, behavioral involvement (B) and information (I). The behavioral involvement scale is concerned with attitudes toward self—care and the information scale is concerned with the desire to ask questions and be involved in medical decisions. In the study, Krantz uses college students who visit the college medical office with minor complaints as subjects. Some of the results reveal that higher I scores were associated with a greater number of questions asked and B scores related significantly to self diagnosis. Requesting specific medications related to the total health Opinion Survey score, showing involvement of both the elements inquisitiveness and behavioral involvement. The importance of the Krantz study is that in college students at least, attitudes toward treatment approaches can be measured and that these attitudes influence health and illness behavior. 33 In summary, the writings of Ardell (1979, 1982) and the research articles reviewed begin to show the complex, multi—faceted nature of self-responsibility in carrying out preventive or promotive health behavior. For nurse researchers, this area presents many questions and research opportunities. For the nurse practitioner, trying to change individual behavior, recognition of the variables influencing action is important and may need assessment. Articles concerning health behavior that require self-responsibility are reviewed in the next sections. These are categarized under four areas - general health behaviors, driving behaviors, self-abuse behaviors, and contraceptive behavior. GENERAL HEALTH BEHAVIOR Preventive Health Examination The need for an annual history, physical exam, and particular screening tests in an asymptomatic adult is being questioned as unnecessary. Morbidity, mortality, available screening tests, available treatments, and costs are considered in making recommendations for preventive health measures. Frame and Carlson (1975) recommend a complete history and physical exam at age 21, including height, weight, blood pressure, and 34 physician breast check for women. This visit also includes smoking history, history of alcohol use, and history of rheumatic fever. Tests obtained include pap smear, cholesterol, VDRL, and PPD. This examination is used for the opportunity to teach self-breast exam, self neck exam, and self testicle exam. Blood pressure and pap smear is obtained one year later and if normal, then checked every two years. Somers (1979) recommends one visit at age 18-19 years for a medical and behavioral history, blood pressure check, height, weight, and for women a breast exam. Procedures that should be done once in the 18-24 year age group include eye screen, urinalysis, PPD skin test, VDRL, serum cholesterol, hemoglobin, and rubella titer in unimmunized women. A pap smear should be done every 2-3 years and a tetanus booster should be given if needed (Somers, 1979). Somers also recommends the need for history and counseling at least once for the problems of smoking, unwanted pregnancy, alcoholism, drug abuse, accidents, obesity, and lack of exercise. Lindberg's (1980) screening flow chart take into account the findings of major studies, so here recommendations are similar to Frame and Carlson (1975) and Somers (1979). Lindberg also recommends teaching *6 35 and counseling in the areas of exercise, nutrition, stress reduction, and use of seat belts. Although the need for a yearly medical check-up is being questioned, the need for a health appraisal, selective screening tests, and counseling is recommended by Frame and Crlson (1975) Somers (1979) and Lindberg (1980) for an individual age 18-24 years, at least once in this age range. In addition, this health visit can be used to teach and encourage health promoting behaviors. Assessment of whether persons in this age group utilize the health care system for this reason needs to be done. Preventive Dental Examination To prevent dental caries, Somers (1979) and Lindberg (1980) recommend a dental examination every one to two years for all adults. According to Cohen (1982) college students are very susceptable to peridontal disease and dental caries. Snyder, Cohen, and Labelle (1982) did a study to examine the dental attitudes that help shape the dental utilization patterns of college students. The independent variables to predict seeking dental care included demographic variables, past dental experience variables, health belief model variables, 36 satisfaction/attitude variables, anxiety and oral health status. Satisfaction with dentists and attitudes towads dentists had the strongest effect in predicting dental-service utilization. In a review of literature by Haefner (1974), health belief model variables such as perceived susceptibility, perceived seriousness, and benefits do not seem to influence preventive dental behavior. Snyder, Cohen, and Labelle (1982), in their study, also agree with these findings. A study by Cohen, Snyder, and Carter (1982) found students to be in generally good oral health. The study by Cohen, Snyder and Carter (1982) and the study by Snyder, Cohen, and Labelle (1982) found that the majority of college students, 67.0% and 65.7% respectively, had visited the dentist within the past year. Further assessment of utilization of dental services by college students needs to be done to determine if this high percentage is consistent, since there is a need for annual dental care. Pap Smear Affecting younger women, invasive cancer of the cervix occurs in 15.6 of 100,000 women. The mortality rate is 5.2 of 100,000 women (Lindberg, 1980). The pap smear is an inexpensive reliable test to screen for 37 cervical cancer. There is disagreement as to how often a pap smear needs to be done. There is agreement in the literature that an initial smear should be obtained by age 20 years or at the onset of sexual activity (Frame and Carlson, 1975; Lindberg, 1980; Somers, 1979). In a study of the reasons for seeking gynecological services by college women, Needle (1976) reports that the primary reason for 33.9% of the women was for a check-up and pap smear. Attitudes of women toward the gynecologic examination was studied by Petravage, Reynolds, Gardner, and Reading (1979). The median age of the women in this study was 28.4 years. They found that women are uncomfortable with pelvic examinations due to physical discomfort. In addition, the study shows that women need and want to be educated about the gynecologic exam and that knowing more would make the women more comfortable during the procedure. Self Breast Examination Breast cancer is the most common malignancy for women and 28% of the time it effects women under 50 years of age (Healthy People Background Papers, 1979). Most breast cancers are found by women themselves. Foster, Lang, Costanza et a1 (1978) report that more 38 frequent performance of breast self—examination was associated with more favorable clinical stage and fewer axillary lymph node metastases. Monthly self examination of the breasts is an important preventive measure. Consequently, there are many studies that research the factors that influence the performance of self-breast examination. Bennett, Lawrence, Fleischmann et a1 (1983) report that women were more likely to practice self breast exam if they were living with their sexual partner, had been shown how to perform breast self examination (BSE) and were confident in their exam technique. They did find that the practice of BSE was not related to the practice of other preventive health activities. In this study, 36% of the respondents report doing self breast exam monthly. Sixty-five percent of the women in this study were age 18—35 years. Trotta (1980) found that only 12% of the subjects had performed BSE monthly in the last six months. Trotta found that women who had been taught by personal interaction tended to practice more frequently. The mean age of the sample in this study was 36 years. Hallel (1982) reports that 42% of the women in her study sample perform BSE monthly. Hallel found that 39 women who practice BSE was correlated with higher levels of health beliefs (perceived benefits and perceived suceptability) and higher self-concept. Stillman (1977) does not come to this conclusion. She found that while a majority of women with high beliefs in perceived benefits and perceived susceptability perform BSE to some degree, 24% with high beliefs in perceived susceptability and 27% with high beliefs in perceived benefits do ngt_practice BSE at all. In this study 62% of the women were age 30-39 years and 39% were found to practice BSE monthly. Schlueter (1980) concludes that knowledge of breast cancer, beliefs about breast cancer and BSE or engaging in regular physical exercises do not affect the practice of BSE. In this study, over half the women were in the range of 20-29 years and from the total sample, 44.1% practice BSE regularly. The articles on BSE begin to show the prevalence of women practicing BSE, from a low of 12% (Trotta, 1980) to a high of 44.1% (Schlueter, 1980). Women in the study samples do include women in the age range (18-24 years) of college women. The reasons for performing or not performing SBE are being explored. Assessment, ongoing research, and intervention need to 40 continue especially if the performance levels for BSE stay low. Self Testicular Examination Although the incidence of testicular cancer is low it does affect young men. "In men between the ages of 29 and 35 it is the most common type of cancer." (American Cancer Society, 1978). Testicular cancer is the number two killer, behind accidents, of men age 20 to 35 years of age (Gault, 1981). The first sign of testicular cancer is enlargement or change in the consistency of the testes. The prognosis improves with early detection and treatment of this cancer. Self palpation of the testicles is an important health action to discover changes early. Research on self testicular exam (STE) such as prevalence or motivation to do, has not been carried out to the extent that research on self breast exam has been done. Conklin, Klint et a1 (1978) interviewed 90 male college students about testicular cancer and STE. They found that none of the subjects knew how to examine their testicles correctly and only one knew what changes to palpate for. Initial research in this area is needed to determine knowledge and performance levels of STE in young men. 41 Craun and Deffenbacher (1981) studied cancer knowledge and examination frequency in college students in relationship to self breast exam, self testicular exam, and getting a pap smear. After a lecture, cancer knowledge significantly increased but performance activities varied. For men, testicular examination frequency increased. For women, self breast exam frequency remained the same. Due to measurement artifact, the number of months since the last pap smear for women increased. In this study, there was a lack of significant correlation between knowledge and behavior. In summary, intervention to improve performance of these and other general health measures needs to be more than just education. Ongoing research can aid the development of intevention strategies. Decreased morbidities and mortality should result from improved performance in getting health check-ups, dental exams, and doing BSE or STE. DRIVING BEHAVIORS The number one cause of death in the 15—24 year age group is car accidents (Healthy People, 1979). In 1981, 17,500 persons aged 15—24 died in motor vehicle accidents (Accident Facts, 1982). Alcohol is indicated 42 in at least half of the fatal accidents. In Michigan, raising the minimum legal drinking age from 18 to 21 years in 1978 resulted in significant reductions in alcohol-related crashes in 1979 for drivers aged 18-20 years of age (Accident Facts, 1982). Another study in Accident Facts (1982) reports that 55% of the 15 to 21 year olds that were in fatal accidents had a blood alcohol content of .10 or higher which is above the legal limit. Excessive speed was a factor in 35 to 40 percent of all vehicular fatalities in 1977. Lack of seat belt use also contributes to serious injuries and fatalities (Healthy People, 1979). Research articles that reported seat belt usage alone were not found in the literature. Seat belt usage was studied as one component of several factors contributing to positie health behavior by Langlie (1977) and Mechanic and Cleary (1980). Langlie (1977) reported that seat belt usage, as a part of appropriate indirect risk, preventive health behavior, is related to the perception of control over one's health status, high benefits and low costs of preventive action, and belonging to a social network characterized by high socio—economic status and frequent interaction between 43 friends and neighbors. Mechanic and Cleary (1980) reported that following positive health behavior, including wearing seat belts, is related to perception of health, psychological well—being, being a woman, being well—educated, and follow conventional behavior. In summary, there is a need to study driving behavior, including seat belt usage, in this age group (15-24 years) and there is a need for health prevention in this age group to reduce the mortality rate. SELF ABUSE BEHAVIORS Smoking Cigarette smoking is linked to many health problems including cardiovascular disease, various cancers, chronic obstructive lung disease, and peptic ulcers (Botvin and McAlister, 1981; Paffenbarger, 1980; Wynder and Hoffman, 1979). The development of a smoking habit in the college age group or an earlier age group is important to prevent since there is a direct relationship between the number of years smoked and the extent of risk for disease (Botvin and McAlister, 1981). Kaufman et al (1983) report that the risk of myocardial infarction increase with the number of cigarettes smoked. Two studies report the prevalence of smoking in 44 college students. Wechsler and Gottlieb (1979) examined the smoking behavior among college students at 34 New England colleges. The final sample included 7,345 students in seven public and twenty—seven private colleges. Wechsler and Gottlieb report that 44% of the women smoke and 32% of the men smoke. Virke and McKillip (1980) in studying a sample of 400 students found only 24% were current smokers. Both studies (Wechsler and Gottlieb, 1979; Vierke and McKillip, 1980) report that smokers rated themselves as significantly less healthy. Drinking and Drug Use Alcohol and drug use are behaviors that increase the risk of accidents, suicides, and homicides. In addition, these behaviors, especially excess alcohol drinking have the potential for leading to chronic disease such as cirrhosis of the liver (Healthy People, 1979; Lasser, 1981). In a study of college students by Wechsler and McFadden (1979), men and women in a frequent-heavy drinking category were more likely to report negative consequences of drinking such as having a car accident, being in trouble with authorities, getting in a fight, forgetting where they were, or doing something they would not do otherwise. 45 Wechsler, McFadden, and Rohman (1980) report the prevalence of drinking and drug use after surveying over 7,000 undergraduates enrolled in 34 colleges in five New England states. More than 95% of both men and women reported current alcohol use although men tend to drink more frequently and in greater quantities than women. Drug use was also reported by 64% of the students, again with drug use more prevalent among men than women. Thirty-nine percent of the students reported smoking marijuana at least once a week. A small number of students, less than 16%, report drug use other than marijuana. The data in this study also suggests that drinking and drug use, other than marijuana smoking, increase over the years in college. Preventive measures such as early case finding or education may be needed if drinking and drug use practices indicate problem drinking or substance dependency (Benforado, 1982; Wechsler et a1, 1980). Adequate assessment and intervention of smoking and drinking behavior is needed since these behaviors have immediate and long-term negative health consequences. CONTRACEPTIVE BEHAVIOR Unwanted pregnancy is risky, mentally and physically, for adolescents and college age students. 46 The morbidity and number of pregnancies for sexual activity without contraception, is higher than the morbidity or pregnancy rate for using 32y method of birth control (Rauh, Burket, Brookman, 1975). Teenage pregnancy is considered an important problem in the 15- 24 year age group by the U.S. government (Healthy People, 1979). Effective birth control is the major means of preventing unwanted pregnancies in sexually active adolescents. There are several studies on the contraceptive use of college students. In assessing, by questionnaire, the sexual experience and behavior of college students, Murphy, Dazzo, Yost, and Parelius (1981) report on contraceptive use. The final sample included 321 female and 235 male undergraduate students at Rutgers University. According to the authors, the contraceptive practices reported by sexually men and women are ineffective. Only 23% of the sexually active single females and their partners always used an effective method such as condom, condom and foam, foam, diaphram, or the pill. This study does not report the use of the intrauterine device. Rindskopf (1981) reviews relevant literature reporting contraceptive use and summarizes, "... the degree of nonuse or unreliable 47 use is high at the time of the first intercourse. Contraceptive use improves some-what with age and experience, and it is used most frequently in the context of affectionate, committed relationships" (p. 114). In a study on male contraceptive responsibility, 109 male students at the University of Melbourne were interviewed (Cole and Allen, 1979). Only thirty-two percent of the sexually active men used an adequate contraceptive method such as condoms, diaphrams, IUDs, oral contraceptives, or sterilization. Two reasons were found for poor contraceptive use - the belief that contraception is a female responsibility and the belief that sexual intercourse should be spontaneous. Awareness of these beliefs in men is important to consider in planning programs to prevent unwanted pregnancy but the limitation of this study is that it takes place in Australia. Further studies are needed at universities to determine if U.S. college men hold similar beliefs and if their contraceptive use is similarly ineffective. In a study at the University of Arkansas, Young (1982) reports that religiousity is an influencing factor both in the sexual behavior and contraceptive 48 use of college females. Young concludes that religious values should be addressed in settings that are concerned with contraceptive use and pregnancy prevention. The use of contraceptives to prevent pregnancy is influenced by many factors and so is an area of research by itself. Assessment of contraceptive use by college students in this study, was done as one part of assessing several health behaviors. In summary, there is a wide range of behaviors included under self-responsibility. The literature reports a variety of health consequences for action or inaction, motivations to carry out certain health activities, and the prevalence of certain health activities in college students. The next section reports on health activities that also require self— responsibility but are separated out by Ardell (1979) to emphasize their importance. These areas include physical fitness, nutritional awareness, and stress management. PHYSICAL FITNESS Ardell (1979) stresses the importance of exercise by claiming that inactivity is linked to hypertension, chronic fatigue, physiological inefficiency, premature 49 aging, poor musculature, inadequate flexibility, and the development of arteriosclerosis and heart disease. Ardell reports the physiological benefits of exercise as decreased heart rate, decreased blood pressure, decreased body fat, and decreased blood cholesterol. The psychological benefits of regular exercise are also described by Ardell, as an increased ability to manage stress, greater self-confidence, improved eating habits, and an improved overall ability to relate to other people. This litany of benefits of exercise and risks of inactivity is stressed by Ardell in order to motivate participation in regular exercise. Physical fitness is an important component in order to achieve high level wellness. Most of the current research on physical fitness focuses on the physiological benefits of exercise especially in relationship to preventing heart disease. Paffenbarger and Hale (1975) studied work activity and coronary heart mortality in 635 longshoremen. The men were aged 35 to 74 years upon entry into the study and followed for twenty-two years, to death, or to age 75 years. The longshore work was computed into categories of high, medium, or low caloric outputs. The age adjusted coronary death rate was lower for the high 50 activity category. Paffenbarger and Hale conclude that repeated bursts of high energy output may have protection against coronary heart disease. In another study, Paffenbarger, Wing, and Hyde (1978), after studying 16,936 Harvard male alumni aged 35—74 years, report that the risk of first heart attack was found to be related inversely to energy expenditure. Men with a physical activity index below 2,000 kilocalories per week were at 64% higher risk than persons with a higher activity index. Morris, Pollard, Everitt, Chave, and Semmence (1980) report that men engaged in vigorous sports and keeping fit had an incidence of coronary heart disease somewhat less than half that of their colleagues who did not exercise. They studied 17,944 middle aged office workers over eight and a half years. Siscovick, Weiss, Hallstrom, Inui, and Peterson (1982) studied physical activity and primary cardiac arrest and conclude that persons who engage in high intensity leisure time activity have a decreased risk of primary cardiac arrest. Taylor (1983) concludes that physical activity is not a primary risk factor for heart disease but that increased activity can change cardiovascular risk factors in a favorable direction 51 through weight loss, decreased blood lipids, and improved blood pressure. Studies that research the relationship between heart disease and activity levels use subjects that are older and most often men. Although research is needed on the cardiovascular benefit of exercise for both men and women and in younger age groups, long term follow- up make this difficult. Assessment of activity levels and short term benefits of regular exercise is needed to strengthen the rationale for exercise in sedentary groups. Koplan, Powell, Sikes, Shirley, and Campbell (1982) report some general, short-term benefits and risks of recreational running. A questionnaire was sent to 1,250 randomly selected men and 1,250 randomly selected women who had registered to run in a 10— kilometer road race. Benefits identified include giving up smoking and losing weight. The major risk reported was musculoskeletal injury. In Positive Addiction, Glasser (1976), describes the mental or psychological benefits derived from running. He had a questionnaire printed in Runner's World asking runners to describe their running habits and their mental state while running. He received 52 almost 700 replies from runners who ran regularly 5-7 days a week for one half to one hour or more. The descriptions of state of mind while running included meditative, a feeling of non self—critical satisfaction, floating, and euphoria. In addition, these runners wrote about their ability to overcome bad habits such as smoking or drinking. Although not a research—based study, this survey begins to report that persons are able to achieve an increasing level of well-being or self-actualization. This may be the most convincing argument to encourage college students to exercise. The activity levels of people need to be assessed and behavior change encouraged since regular exercise has physiological (health preventive) and psychological (health promotive) benefits. This should be done in any age group as well as the college age group. NUTRITIONAL AWARENESS Health enhancement can be achieved through a sensible diet and "wellness dining" (Ardell, 1982, p. 111). Principles to improve nutrition include avoiding food additives (contribute to cancer), avoiding refined sugar (empty calories), avoiding coffee and tea (stimulants) and controlling the intake of salt and 53 saturated fats (implicated in chronic diseases). In addition, other nutritional improvements include eating fresh fruits, vegetables, and natural foods (highest in nutrient value) and including high fiber foods (to speed the passage of wastes through the digestive tract and avoid disease) (Ardell, 1982, 1979). Ardell feels that for optimal performance one needs an optimal diet. Current research is attempting to study the benefits or risks of certain dietary habits. There is much controversy in the area of nutrition and disease. Caffeine There is disagreement as to whether caffeine is harmful. Some researchers have studied the relationship between caffeine and heart disease. Hennekens, Drolette, Jesse, Davies, and Hutchison (1976) studied 649 patients who died or coronary heart disease and the same number of neighborhood controls to obtain information on a number of variables including coffee intake. Their findings suggest that the risk of death from coronary heart disease associated with coffee drinking is small. Rosenberg, Slone, Shapiro, Kaufman, Stolley, and Miettinen (1980) come to a similar conclusion. In this study, 487 patients with first myocardial infarctions were compared with 980 54 controls whose admissions were for acute emergencies. In this sample, there were only women and the age ranged from 30-49 years. For women who drank five cups of coffee a day or more the relative risk for MI was 1.2 compared to nondrinkers of coffee. This is a weak association. Most recently, Dobmeyer, Stine, Leier, Greenberg, and Schaal (1983) studied the arrhythmogenic effects of caffeine in normal volunteers (aged 20-31 years) and in patients with heart disease (aged 17-61 years). They could only conclude that persons prone to arrhythmias should not drink coffee. The data are insufficient to make recommendations to the general public on coffee consumption. Many questions are unresolved and in need of further research. In another study, MacMahon, Yen, Trichopoulos, Warren, and Nardi (1981) found a strong association between coffee consumption and cancer of the pancreas in both sexes even after controlling for cigarette smoking. They emphasize that the association between coffee consumption and cancer of the pancreas needs to be studied further to determine if this association is casual in nature. Fiber 55 Burkitt (1978) reports that epidemiological evidence suggest that a low fiber diet may lead to a number of diseases including diverticulitis, appendicitis, hemorrhoids, varicose veins and cancer of the colon. Lasser (1981) reports that low fiber diets permit an increase in cholesterol absorption and so possibly contribute to the development of heart disease. The benefits of a high fiber diet in preventing disease need to be studied further. Foods high i2 fat Elevated serum cholesterol is considered one of three major risk factors of coronary heart disease (Healthy People, 1979). Carlson and Bottiger (1972) studied the relationship between plasma triglyceride and cholesterol values and the development of ischemic heart disease in a follow-up of 3,168 men They report that the rate of heart disease increases linearly with increasing fasting concentration of plasma triglyceride and plasma cholesterol. Stamler (1978) cites the Pooling Project as one study linking elevated serum cholesterol and elevated coronary heart disease risk. Recent studies have been evaluating the contribution of low density lipoprotein (LDL), very low density lipo— protein (VLDL), and high density lipoprotein (HDL) to 56 heart disease. Elevation of high density lipoprotein may have a cardio-protective effect (Lasser, 1981; Pender, 1982; Stamler, 1978). Stamler (1978) reviewed international and national epidemiological studies and concluded that diet and dietary lipids are important factors influencing serum cholesterol levels. Improved dietary habits, with a decreaed consumption of saturated fats and cholesterol, should contribute to the prevention of premature coronary heart disease. Using this as a hypothesis, recent research is focusing on interventions to reduce risk factors (smoking, high blood pressure, and elevated cholesterol) for coronary heart disease (Fortmann et a1, 1981; Kornitzer et a1, 1980; McAlister et al, 1982; MRFIT Research Group, 1983). The men and women in these studies are generally older, over age 30 years. Some research is being done on younger age groups. Hautvast, Knuiman, West, Brussaard, and Katan (1983) report the serum cholesterol concentrations of 7 and 8 year old boys in 16 countries and found the levels were lower in less developed countries. They also report that controlled trials support that the concentration of serum cholesterol increases under the influence of a 57 more affluent diet. Stamler (1979) provides data on the association between diet and mean serum cholesterol levels of several countries. From youth on, the levels are markedly higher in the western (including the U.S.A.) populations compared to Japan. Using these and other population studies, Stamler links the habitual diet, high in fats, with long term risks of coronary heart disease death and concludes that efforts are needed to improve the lifestyles, including diet, of all_Americans not just high risk individuals. Dietary habits are improving but many questions remain unanswered. At what age should dietary changes begin for optimal benefit? Will a changed diet, with a decrease in intake of fats, prevent heart disease if initiated in the late teens or is this too late? Long term effects of dietary changes may not be known for years. This study does not attempt to answer these unresolved questions, but instead begins to assess the dietary habits of college students to report trends in this age group. Salt/Sodium Hypertension is a major risk factor for heart disease and it increases the risk for strokes (Healthy People, 1979). The Joint National Committee on 58 Detection, Evaluation, and Treatment of High Blood Pressure (1980) and W.H.O./I.S.H. Mild Hypertension Liaison Committee (1982) report that treatment of hypertension, including mild hypertension, with a lowering of blood pressure, reduces morbidity and mortality. With emphasis on reducing high blood pressure, the relationship between dietary salt and hypertension is being examined more closely. Dahl (1972) studied the relationship between dietary salt and hypertension in human and animal experiments. In rats, there is evidence that salt "...induces permanent and fatal hypertension" (p. 242). In man the evidence is not as clearcut and requires further investigation. Swales (1980) also concludes more conclusive evidence is needed before massive efforts are made to reduce the sodium content of foods. Most recently, Trevisan, Cooper, Stamler, Gosch, Allen, Liu, Ostrow, and Stamler (1983) report that "...data supporting a causative relationship between dietary sodium (Na), sodium metabolism, and hypertension come from clinical, animal-experimental, epidemiologic, and anthropologic research" (p. 133). There is only limited evidence from controlled experiments in human nutrition. They feel there are many unanswered 59 questions such as——what is the relationship between dietary sodium and blood pressure for most people, linear, curvilinear, or a threshold one?, are there synergistic effects between sodium reduction and other nutrients?, what is the role of dietary sodium reduction and hypertension over the life span? As with a change to a diet with less fats, what are the long term benefits for decreasing the salt in the diet at an early age or in the late teens. Recommendations are difficult to make and more research is needed. Obesity Chronic obesity is a threat to the health of adults. The death rate among obese adults is 50% greater than normal weight adults. Overweight adults are more likely to have myocardial infarctions or cerebrovascular accidents than normal weight adults (Pender, 1982). Lasser (1981) reports that increasing weight is associated with an increasing incidence of cardiovascular disease. Two of the major risk factors of cardiovascular disease, cholesterol and hypertension, are influenced by weight. Cholesterol, blood pressure, uric acid, and blood glucose all rise 60 as body weight increases. Some studies report that weight loss produces a decrease very low density lipo- protein, a smaller but independent and significant decrease in low density lipoprotein, and an increase in high density lipoprotein, which are all potentially beneficial to reducing coronary risk (Lasser, 1981). Mann (1974) reports that high blood pressure is more common in obese people and that hypertension is a potent risk factor in cardiovascular disease. The cause of this effect, the relationship of obesity to high blood pressure, needs more study. Simis (1983) concludes that the prevention of obesity should begin in the intrauterine stage and be continued through early childhood, adolescence, and adulthood. Obesity and its relation to health and disease will continue to be studied. This study assesses whether college students are within normal weight or not, so that preventive efforts can be initiated if needed. In summary, the relationship between nutrition and the prevention of disease and the promotion of health raise many unanswered questions. This is a broad area with many factors to consider and an area in need of more research. Despite this, the U.S. Dietary goals 61 include reducing the consumption of overall fat, saturated fat, and cholesterol, limiting the intake of sodium, and increasing the consumption of fruits, vegetables, and whole grains (Suitor and Hunter, 1980). This study cannot attempt to answer all the needed questions but it does assess some of the dietary habits of college students. Suggestions to improve diet to a more healthful direction can be made if necessary. STRESS MANAGEMENT Stress was first described by Selye (1976) as "the nonspecific response of the body to any demand" (p. 55). Selye called the entire response the general adaptation syndrome which includes three stages - the alarm reaction, the stage of resistance, and the stage of exhaustion. In the course of his research, Selye reports that there are chemical (neuro, endocrine, and immunological) changes of the body that occur in response to stress. The stress reaction may have good or bad effects depending on the individual response to it. Responding to stress in a positive way enables an individual to adapt to perform activities and face the demands of living. Responding to stress in a negative way can produce health damaging effects. Selye felt that the course of many diseases was influenced by the 62 individual's response to stress. Much of his research was spent showing this to be true. In describing the need for stress management, Ardell (1979) uses the work of Selye and others to describe the negative effects of stress. Stress may be a factor in illnesses such as headaches, ulcers, heart attacks, hypertension, bowel irritations, diabetes, and mental illness. Ardell supports that need to manage stress in order to become more alert, creative, and productive. Pelletier (1977) suggests that stress is a factor contributing to cardiovascular disorders, cancer, arthritis, and respiratory diseases. He describes stress triggers. These include social changes, such as economic instability, developmental changes, such as marriage, job conflicts, and technological innovations. Awareness of stressors is an important part of adaptation and stress reduction. Holmes and Rahe developed a tool to measure the extent of life change as a predictor of becoming ill within the next one to two years (Pender, 1982; Pelletier, 1977). This tool, the Social Readjustment Rating Scale, has been used with college students to measure their levels of stress. Caldwell (1978) used 63 the social readjustment rating scale combined with the problem oriented record to help students identify stressors, gain a new understanding of recent stressors, and improve self care. Marx, Garrity, & Bowers (1975) studied college freshmen to examine the association between stressful episodes or life change events and subsequent illness. A College Schedule of Recent Experience, modified from the Holmes and Rahe scale, was used to measure life change events. They report that there is a significant association between high levels of life change and increased illness within the next sixty days. Garrity, Somes, and Marx (1977) examined the role of personality characteristics of college students as they influenced the life change-health change process. The three personality types were labeled as social conformity, liberal intellectualism, and emotional sensitivity. They found that personality factors play a role in predicting life change and psychophysio— logical strain symptoms. Social conformity is negatively predictive of life change and strain. The more conforming students had less strain. Students with high scores on the intellectualism and sensitivity variables report more life change and strain. 64 Marx, Garrity, Somes (1977) studied college students' ability to cope as a variable influencing the recent life changes and altered health states process. They concluded that coping capacity is an intervening variable between life change and health outcome. These studies show that if the number of life changes or stressful events is going to be measured to predict illness, consideration must be given to other variables effecting this process. This area needs more research. Effective coping or stress management may prevent negative health outcomes. Hill, Smith, and Jasmin (1981) divided two hundred ninety-nine beginning college students into control and experimental groups to study a self-paced learning method to reduce stress. They concluded that predicted illness rates may be decreased through knowledge of personal stress factors and stress management skills. In an exploratory study, Ziemer (1982) questioned sixty—one college students about what behaviors they engaged in when confronted with a stressful event. Behaviors identified included talking with someone, doing something else for distraction, and denial. Although coping strategies are not studied in relationship to illness, this study does show that students are able to recognize their 65 coping strategies. The benefit of coping measures that are effective and stress management techniques need to be studied further. College students are completing the developmental tasks of adolescence and entering adulthood, which may be stressful. Modification of the Holmes and Rahe Social Readjustment Rating Scale to a College Schedule of Recent Experience indicates other potential stressors unique to students. Consequently, the area of stress, illness, and stress management of college students is beginning to receive more attention from researchers. Since stress may lead to illness, the stress levels and stress management abilities of students needs to be assessed. This study attempts to assess if students are adequately dealing with stress. If students are having difficulty in the area of stress and stress management, more research may be needed or intervention may be needed to teach students more effective stress management strategies. INTEGRATION OF HEALTH BEHAVIORS Ardell (1979) emphasizes that integration of the four components is important to achieve high level wellness. Wellness initiatives in one area will reinforce health-enhancing behaviors in other areas. 66 Pursuing all areas of wellness behavior, not only reduces risks of illness but allows one to become full of vitality and become alive clear to the tips of one's fingers. Belloc and Breslow (1972) and Belloc (1973) conclude that good health practices are associated with positive health and decreased mortality. The good health practices include not smoking, sleeping 7-8 hours per night, eating regular meals including breakfast, not snacking between meals, exercising regularly, maintaining desirable weight for height, and limiting the intake of alcohol. The relationship of these activities was cumulative - following all the good practices resulted in better health than if one followed less than seven habits. Taylor and McKillip (1980) studied personal health habits of college students and perceived illness and use of health services. Personal health habits included cigarette consumption, alcohol consumption, coffee consumption, sexual activity, stress, sleep, exercise, work, study, and being overweight. They conclude that personal habits can be shown to have immediate health related consequences. Promotion of 67 positive health activities needs to stress short term as well as long term effects of certain habits. In conclusion, the review of literature shows evidence of benefits and risks of selected health behaviors; periodic health exams, self breast exams, self testicle exams, smoking, drinking alcohol, driving habits, contraceptive behaviors, physical fitness, nutrition habits, and stress management. The health behavior of college students was reported where known. Assessment of the health behavior of college students will add to the knowledge base in the area of health prevention and health promotion. This would give direction for further assessment, research, and intervention. 68 CHAPTER IV METHODOLOGY AND PROCEDURE This is a descriptive study designed to report the health behaviors of a college population. The questions that were asked of the students regarding specific health behavior will be categorized under four broad areas — self-responsibility, nutritional awareness, physical fitness, and stress management. A detailed report of the results of each area will be provided and a description of interrelationships among the areas will be given. Each area or component will be correlated against the age and sex of the students. SETTING AND POPULATION At a large, midwestern, Big-10, State university there are twenty student resident halls. The residence halls are organized into complexes. The majority of the residence halls are co—educational. Students at the university are men and women studying to obtain a degree. In two of the dormitory complexes, nurse run clinics were established. The questionnaire on health behavior was distributed to students living in nine residence halls that were in closest proximity to the nurse run clinics. The returned questionnaires were kept separate by residence hall. For the purpose of 69 this research paper, a sample of convenience was drawn from the returned questionnaires of the students living in one residence hall in one of the dormitory complexes. THE QUESTIONNAIRE The thirty question instrument was developed by two nurse practitioners, who managed the nurse-run health clinics in the residence hall complexes. The nurse practitioners' purposes in collecting this data were: 1. To use as a data base for individual clients. 2. To increase students' awareness of positive health behaviors by asking particular questions. 3. To collect information on the health behaviors of a college population. The primary purpose was not for research. The development of the questionnaire was not a research-based procedure, resulting in problems of validity, reliability, and data analysis. Limitations of the instrument are reviewed in Chapter 6. The complete questionnaire is in Appendex II. PROCEDURE In this section, a description of the procedure used at the time of data collection is given. A 70 description of the procedure used by the investigator is also given. After the questionnaire was developed by the nurse practitioners, and printed, permission was obtained from the Director of Residence Hall Programs and the Manager of Residence Halls to distribute the questionnaire. The nurse practitioners met with the head advisors of the residence halls in a group meeting. At this meeting, the purpose of the questionnaire was described and the process of distribution and collection of the questionnaire was decided. Maintenance of anonymity was stressed. Head advisors then met with resident advisors to explain the purpose of the questionnaire and explain the distribution and collection process. Again, anonymity was stressed. The resident advisors distributed the questionnaire to the students in a group meeting on each floor. The purpose of the questionnaire was described to the students and the options available to the students in completing the questionnaire were outlined: a. student can fill out questionnaire anonymously; b. student can refrain from answering particular questions; c. student can fill in 71 questionnaire completely; d. student does not have to fill out questionnaire. The students then filled out the questionnaire on their own and returned to collection envelopes. Anonymity was stress throughout the process. A cover letter accompanied each questionnaire. See Appendix I. The completed questionnaires in collection envelopes were returned to the nurse practitioners at the nurse-run clinics. Completed questionnaires, kept separate by residence halls, were stored in four boxes at the two nurse—run clinics. Then the four boxes of completed questionnaires were moved from the nurse—run clinics and stored in the investigator's basement. The investigator arbitrarily selected, from one box, a group of questionnaires representing one residence hall for data analysis. The items in the questionnaires were coded and transferred to coding sheets. Each student was given an ID number to maintain anonymity. After coding, the raw data were keypunched into a computer for data analysis. Data analysis is presented in Chapter 5. In summary, the process used to collect data was carried out as described. An effort to maintain 72 confidentiality and ananymity persisted throughout this process. OPERATIONAL DEFINITIONS In this section the four dimensions of high level wellness, self—responsibility, physical fitness, nutritional awareness, and stress management, are operationalized based on the items in the questionnaire. Dimension of self-responsibility — an active sense of ‘accountability for one's own well-being. This dimension is divided into four areas - general health behavior, driving behavior, self abuse behavior, and birth control behavior. The area of general health behavior includes questions about health examinations (See Appendix III-a). The items in this area include: 1. Having a medical exam in the past year 2. Having a dental exam in the past year 3. Having an eye exam in the past 2 years 4. For females, having a pelvic exam and pap smear 5. For females, doing self breast examination 73 6. For males, doing self testicle examination The area of driving behavior includes questions about driving habits (See Appendix III-b). The items in this area include: 18. Driving within the speed limit 19. Using seat belts 20. Avoiding drinking and driving The area of self—abuse behavior includes questions on the use of cigarettes, alcohol, and drugs (See Appendix III-c). The items in this area include: 21. Do you smoke cigarettes 22. How much alcohol do you drink 23. Do you smoke marijuana 24. Do you use other mind-altering drugs The area of birth control behavior includes one question (25) on using a means of contraception if having sex (See Appendix III—d). Dimension of physical fitness — active participation in regular exercise. The dimension of physical fitness is measured by one question (9) concerning how often one exercises (See Appendix Dimension of nutritional awareness — a sense of wise PF I 'll‘. -- t 74 food selection and sensible diet patterns. The dimension of nutritional awareness includes questions on a variety of areas, such as caffeine intake, eating breakfast, number of meals a day, including fiber in the diet, use of salt, and minimizing refined and fatty foods (See Appendix III-f). Items in this area include: 7. Weight appropriate for height 10. Amount of coffee, tea colas one drinks 11. Number of meals eaten per day 12. Do you eat breakfast 13. Do you snack between meals 14. Adding salt to foods 15. Do you minimize refined foods 16. Do you include fiber daily 17. Do you minimize fatty foods Dimension of stress management — a sense of knowledge and recognition of stress, stress symptoms, and stress management. The dimension of stress includes questions on evidence of dealing with stress such as falling asleep easily and amount of sleep, ability to cope with stress, being aware of feelings, and releasing frustrations (See Appendix III—g). Items in this area include: 75 26. Do you fall asleep easily 27. How much sleep do you get 28. Can you cope with a reasonable amount of stress 29. Are you aware of feelings and able to express them satisfactorily to self and others 30. Are you able to release anger and frustration safely The length of the questionnaire was two pages (See Appendix II). A section for the students to identify health concerns was included but not used for the purpose of this research paper. In addition, based on the investigator's judgement, question 8 was eliminated in the operationalization of nutritional awareness. The result was 29 items used for data analysis. VALIDITY AND RELIABILITY Validity refers to the degree which an instrument measures what it is supposed to be measuring (Polit and Hungler, 1978). Three types of validity are used to evaluate an instrument - content, construct, and criterion-related. Content validity is the concern that the items in the questionnaire adequately measure the content area under consideration. Construct 76 validity is the degree to which the particular test or items can be shown to measure the abstract concept under investigation. In criterion-related validity, the emphasis is on showing a relationship between the instrument and some other criterion (Polit and Hungler, 1978). Content validity was considered at the time the questionnaire was developed. Questions were generated based on literature concerning positive health behaviors. Construct validity and criterion-related validity were not considered at the time the questionnaire was developed. Reliability is the degree of consistency of the instrument in measuring the attribute it is supposed to measure. The Guttman anJysis technique was used with this instrument to measure reliability. This technique was used due to the diverse type of responses in the items and because of the small number of items (3 to 8) under each broad component. For the Guttman technique or Guttman scaling, the 29 items in the questionnaire are divided into two portions — pass or carrying out positive health behavior and fail, not behaving in a healthful way. This cutting was done based on the investigator's judgement so that positive health behaviors are assigned a +1 and negative health 77 behaviors are assigned a 0 (See Appendix IV). Then the items or questions within each broad area or dimension are scaled and the statistics calculated. Two coefficients are calculated and utilized to determine reliability. The coefficient of reproducibility measures the extent which a respondent's scale score is a predictor of one's response pattern. This measure should reach .9 or higher to indicate a valid score. The coefficient of scalability measures if the scaled items are unidimensional. Ideally, this coefficient should measure above .6 to indicate a valid scale (Nie, Hull, Jenkins, Steinbrenner, and Bent, 1975). ANALYSIS AND SCORING Measures of frequency and percent will be calculated and reported for each of the 29 items. In the area of self-responsibility four subscales were developed due to the diverse number of questions. Scoring was done as a part of the Guttman scaling process. Each item is given a score of +1 or carrying out positive health behavior or 0, not acting in a healthful way. Measures of central tendency - the mean and standard deviation, will be calculated for three of the broad areas (physical fitness, nutritional awareness, and stress management) and for the four r1 78 subscales of self—responsibility (general health behavior, driving behavior, self—abuse behavior, and birth control behavior). In this way, the mean will fall between 0 and +1, with 0 indicating poor health behavior and +1 indicating positive health behavior. Correlation procedures are used as a method to ' describe the relationship between two measures or two variables. The direction and strength of the relationship is reported utilizing the appropriate I)! numerical index or correlation coefficient. Each component of high level wellness, self-responsibility, physical fitness, nutritional awareness, and stress management, is correlated against the sex of the students using the statistical formula to calculate the point biserial correlation coefficient. Each component is correlated against the age of the students and against the other components of high level wellness using the statistical formula to calculate the Pearson Product-Moment correlation coefficient. RESEARCH QUESTIONS 1. What are the health behaviors of a college population in the area of self—responsibility? a. How do men score in the 4 subscales in the area of self-responsibility? 79 b. How do women score in the 4 subscales in the area of self—responsibility? 2. What are the health behaviors of a college population in the area of physical fitness? a. How do men score in the area of physical fitness? b. How do women score in the area of physical fitness? 3. What are the health behaviors of a college population in the area of nutritional awareness? a. How do men score in the area of nutritional awareness? b. How do women score in the area of nutritional awareness? 4. What are the health behaviors of a college population in the area of stress management? a. How do men score in the area of stress management? b. How do women score in the area of stress management? 5. How does the sex of students relate to general health behavior, driving behavior, self-abuse behavior, nutritional awareness, and stress management? 6. How does age of the students relate to 80 general health behavior, driving behavior, self-abuse behavior, nutritional awareness, and stress management? 7. How do the 4 subscales of self-responsibility — general health behavior, driving behavior, self—abuse behavior, contraceptive behavior and physical fitness, nutritional awareness, and stress management relate to one another? In the final two chapters, the investigator will present the data and the nursing implications. 81 CHAPTER V DATA PRESENTATION In this chapter, the data is presented to describe the health behavior of college students in the areas of self-responsibility, physical fitness, nutritional awareness, and stress management. The findings are presented based on the responses of 268 students. The data are utilized to report the relationships between the four broad areas, the age, and the sex of the students. The findings are presented in the following manner: 1. Descriptive findings of the population 2. Guttman Technique of scaling for reliability 3. Data presentation for research questions a. Descriptive findings of the population in each broad area of health behavior — self-responsibility, physical fitness, nutritional awareness, and stress management. b. The relationship of the scores of each broad area to the sex of the respondents. 82 c. The relationship of the scores of each broad area to the age of the respondents. d. The relationship of the scores of each broad area to each other broad area. 4. Summary of the chapter To test for the reliability of the instrument, the statistical formula for Guttman coefficients of reproducibility and scalability was used. The statistical formulas for point biserial and Pearson Product—Moment correlation were used to correlate the broad components of self-responsibility, physical fitness, nutritional awareness, and stress management with the sex and ages of the population and with the scores of each other broad area. In the area of self— responsibility, four subscales were developed and analyzed using this same process. DESCRIPTIVE FINDINGS OF THE POPULATION The study population consisted of college students, men and women, who lived in nine of the residence halls at a large, Midwestern, Big-10, State university. The students are at the university for the purpose of studying to obtain a degree. One month after the start of fall term, the questionnaires were 83 distributed to the students in the dormitory at a group floor meeting by a resident advisor. The purpose of the questionnaire was described to the students by the resident advisor at this meeting. Students could complete or not complete the written questionnaire. A limitation of the study is that those students who chose not to complete the questionnaire may be different from those students who did fill out the questionnaire. The resident advisor returned the completed questionnaires to a nurse practitioner by residence hall. From the completed questionnaires from the nine residence halls, a convenience sample of the completed questionnaires of 923 residence hall was selected for study and data analysis. This study sample consisted of 268 questionnaires completed by 81 male students (30.2%) and 187 female students (69.8%). The overall response rate was 43%. The response rate for the female students alone was 59.9%. The response rate for male students was much lower, 25.9%. The investigator can only speculate as to the reasons for this large difference — perhaps the male students were less concerned about their health or perhaps they didn't like filling out questionnaires. The students' from age 17 years to age 24 years. ages of the students is presented in Table 1. Age l7 l8 19 20 1 21 22 24 Missing Data Total Table 1 Number and Ages of the Students of the Sample Population (N=268) Number of Students 2 142 78 24 9 1 1 11 268 84 age range in the study sample was The summary of the Percentage .7% 53.0% 29.1% 9.0% 3.4% .4% 4.0% 100.0% The majority of the students (53%) were age 18 years and presumably freshmen. 17 years. Two students (.7%) were age Seventy-eight (29%) of the students were age 19 years, and twenty-four (9%) were age 20 years. Nine students (3%) were 21 years of age and 1 student was age 22 and 1 student was age 24. The study sample is composed of primarily younger students with almost 80% 85 being age 19 or younger. Most of the study sample probably consists of freshmen and sophomore students. GUTTMAN TECHNIQUE OF SCALING FOR RELIABILITY The reliability of the questionnaire was measured by using the Guttman technique of scaling as described in Chapter 4. Using this formula, the coefficient of reproducibility and the coefficient of scalability were computed for three of the four subscales of self- responsibility, and for nutritional awareness, and stress management. Birth control behavior and physical fitness are measured by one question apiece and therefore not scaled. Self Responsibility This area of health behavior is divided into 4 subscales. Reliability coefficients were determined for three subscales - general health behavior, self— abuse behavior, and driving behavior. Birth control behavior was not scaled since it consists of only one question (25). The general health scale consists of six items (1, 2, 3, 4, 5, 6). After removing one item (4 - pelvic exam and pap smear) the coefficient of reproducibility is .857 and the coefficient of scalability is .471. The driving behavior scale consists of three items (l8, 19, 20) and the t (“A coefficient of reproducibility is .922 and the coefficient of scalability is .661. There are four items in the self-abuse scale (21, 22, 23, 24) and the coefficient of reproducibility is .931 and the coefficient of scalability is .507. The driving behavior scale is the most unidimensional and consistent. The coefficient of reproducibility is >.90 and the coefficient of scalability is >.60. The self- abuse scale is also fairly reliable scale since the coefficient of reproducibility is >.90. The self—abuse scale is not as unidimensional as the driving scale since the coefficient of scalability is (.60. The general health scale is the least reliable since both coefficients are below desirable levels. Physical Fitness The area of physical fitness is not scaled since it is only one item or question (9). Nutritional Awareness The area of nutritional awareness consists of eight items (10, ll, 12, l3, 14, 15, l6, l7, 7). Item 7 (weight for height) is not included in the scaling since it is an exact measurement. Even after removing one item (12 - eating breakfast) the coefficients are low indicating the multidimensional nature of this 86 QED 87 scale or the variety in the questions. The coefficient of reproducibility is .849 and the coefficient of scalability is .371. In the area of nutritional awareness, the coefficient of reproducibility does approach the desirable level of .90 but the coefficient of scalability is below .60, so that this scale is not very reliable. Stress Management The area of stress management includes 5 items (26, 27, 28, 29, 30). To improve this scale, one item was removed (26 — falling asleep easily). After computation, the coefficient of reproducibility is .939 and the coefficient of scalability is .633. The stress management scale is the best scale. The high coefficients indicate that this scale meets the test of unidimensionality, cumulativeness, and ability to predict the pattern of responses. PRESENTATION OF THE FINDINGS FOR EACH AREA OF HIGH LEVEL WELLNESS The findings are presented for each broad area of high level wellness for college men and women. Self Responsibility In this section the research question — what are the health behaviors of men and women in the 4 88, subscales in the area of self-responsibility?; how do men score in the 4 subscales of the area of self- responsibility?; and how do women score in the 4 subscales of the area of self—responsibility? are addressed. In the area of self-responsibility the four subscales are general health behavior, driving behavior, self-abuse behavior and birth control behavior. The frequencies and percents are reported for men ! lt-l.‘ and women for the six items of general health behavior, in Table 2. Tafle 2 Descriptive Findings in the Area of Self-Responsibility subscale General Health Behavior (N=268; 81 men and 187 women) hEN WOMflJ Item Variable No. % No. % 1 Medical check-up yes 42 51.9 116 62.0 no 39 48.1 69 36.9 missing data 2 1.1 total 81 100.0 187 100.0 2 Dental exam yes 70 86.4 165 88.2 no 11 13.6 22 11.8 total 81 100.0 187 100.0 Item Variable 3 Ewaexan 4 Pelvic exam & pap smear 5 Self breast exam 6 Self testicle exam High percentages of both men and women get medical check-ups, dental exams and eye exams, percentage of women is slightly greater than men on all three items. Less than half (39%) of the women sampled have had a pelvic exam and pap smear. yes no missing data total yes no missing data total yes no missing data total yes no missing data total 81 17 62 2 81 100.0 21.0 76.5 2.5 100.0 89 WOMEN No. % 136 72.7 48 25.7 3 1.6 187 100.0 73 39.0 112 68.4 2 1.1 187 100.0 49 26.2 128 68.4 10 5.4 187 100.0 although the An even lower - ' ' I'M t.‘ I'W'iin 69’ 90 percent (26.2%) of the female sample report doing breast self examination monthly. Of the men, only 21% check their testicles for unusual lumps. In the area of general health behavior, the mean scores for men is .570 and for women is .638 (see Table 9), indicating the women have slightly higher levels of wellness behavior in this area. The findings in the area of driving behavior are reported in Table 3. Eflfle 3 Descriptive Findings in the Area of Self—Responsibility Subscale Driving Behavior (N=268; 81 men and 187 women) MEN WOMEN Item Variable No. % No. % 18 Drive within usually 54 66.7 160 85.6 speed limit seldom 18 22.2 16 8.5 never 8 9.9 5 2.7 missing data 1 1.2 6 2.2 total 81 100.0 187 100.0 91 MEN WOMEN Item Variable No. % No. % 19 Use seat belt usually 20 24.7 30 16.0 seldom 29 35.8 83 44.5 never 32 39.5 73 39.0 missing data 1 .5 total 81 100.0 187 100.0 20 Avoid drinking always 39 48.1 139 74.3 & driving sometimes 31 38.3 41 22.0 never 8 9.9 l .5 missing data 3 3.7 6 3.2 total 81 100.0 187 100.0 Sixty-six and seven tenths percent of the men and 88.4% of the women usually drive within the speed limit. A high percentage of both men and women seldom or never use seat belts, 75.3% and 83.5% respectively. Women (74.3%) are more likely to avoid drinking and driving than men (48.1%). In the area of driving behavior, the mean score for men is .477 and for women is .592 (see Table 9). Again, the female students have higher wellness behavior than the male students in this area. The findings in the area of self-abuse behavior are reported in Table 4. I mu. "m Table 4 Descriptive Findings in the Area of Self—Responsibility Subscale Self Abuse Behavior (N=268; 81 men and 187 women) MEN Item Variable No. % 21 Smoke cigarettes yes 6 7.4 no 74 91.4 missing data 1 1.2 total 81 100.0 22 Drink alcohol never 15 18.5 1—2 drinks/wk 8 9.9 3—5 drinks/wk 4 4.9 5 drinks/wk 15 18.5 drink-weekends 37 45.7 missing data 2 2.5 total 81 100.0 23 Smoke never 52 64.2 marijuana occ. 25 30.8 freq. 2 2.5 5 joints/day O 0.0 missing data 2 2.5 total 81 100.0 WOMEN No. % 24 12.8 163 87.2 187 100.0 59 31.6 17 9.1 6 3.2 11 5.9 86 45.9 8 4.3 187 100.0 136 72.7 46 24.7 3 1.6 1 .5 1 .5 187 100.0 1" n m- v 93 MEN WOWflJ Item Variable No. % No. % 24 Use other never 74 91.4 185 99.0 drugs occ. 6 7.4 l .5 freq. 0 0 1 .5 am missing data 1 1.2 L total 81 10 Most students do not smoke, with the (91.4%) not smoking greater than the 0.0 187 100.0 percentage of men '1 percentage of women (87.2%) not smoking. Most students report drinking alcohol, with most drinking done on the weekends. A higher percentage of the women (31.6%) report never drinking alcohol compared to 18.5% of the men reporting this. The majority of female (72.7%) students do not smoke students report not using other mind (men 91.4% and women 99.0%). In the behavior, the mean score for men is . the mean score is .873 (see Table 9). male (64.2%) and marijuana and most altering drugs area of self—abuse 817 and for women Students are carrying out positive health behaviors in this area. In the area of birth control behavior, a high percentage of both men and women would use birth control if they were having sex (see Table 5). 94 Tafle 5 Descriptive Findings in the Area of Self Responsibility Subscale Birth Control Behavior (N=268; 81 men and 187 women) MEN WOMEN Item Variable No. % No. % 26 Would use birth yes 68 83.9 173 92.5 control no 11 13.6 5 2.7 missing data 2 2.5 9 4.8 total 81 100.0 187 100.0 In the area of birth students report they This is reflected in for women (see Table In summary, for control behavior, male and female would act in a preventive way. the means .860 for men and .972 9). self—responsibility, students report following some wellness behaviors. The strongest area is that the students report they would use birth control methods if having sex. The weakest area is driving behavior. Self-abuse behavior and general health behavior fall between these two. Generally, the women score slightly better than the men in all areas. 95 Physical Fitness In the area of physical fitness the research questions — what are the health behaviors of a college population in the area of physical fitness?; how do men score in the area of physical fitness?; and how do women score in the area of physical fitness?, are addressed. The numbers and percents are reported for men and women for item 9 in Table 6. Tflfle 6 Descriptive Findings in the Area of Physical Fitness (N=268; 81 men and 187 women) MEN WOMEN Item Variable No. % No. % 9 How often rarely 15 18.5 57 30.5 exercise once/wk 22 27.2 68 36.3 3x/wk 32 39.5 35 18.7 every day 12 14.8 25 13.4 missing data 2 1.1 total 81 100.0 187 100.0 96 The area of physical fitness is measured by one question. Over half the men (54.3%) report exercising three times a week or more. Only 32.1% of the women report exercising this often. Thirty and five tenths percent of the women rarely exercise compared to 18.5% of the men who rarely exercise. In the area of physical fitness, the mean score for men is .543 and for women is .316 (see Table 9). In summary, both male and female students report exercising some, with men exercising more than women. Nutritional Awareness In the area of nutritional awareness the research questions — what are the health behaviors of a college population in the area of nutritional awareness?; how do men score in the area of nutritional awareness?; and how do women score in the area of nutritional awareness?, are addressed. The findings in the area of nutritional awareness are presented in Table 7. T$fle7 97 Descriptive Findings in the Area of Nutritional Awareness Item Variable 10 Coffee, tea colas drink 11 Meals eat/ day 12 Do you eat breakfast none 6/day 5/wk 6/day missing data total 5/day 3/day 2/day irreg. other missing data total always sometimes never missing data total (N=268; 81 men and 187 women) MEN No. % 5 6.2 40 49.4 32 39.5 4 4.9 81 100.0 1 1.2 40 49.4 34 42.1 4 4.9 1 1.2 l 1.2 81 100.0 20 24.7 45 55.6 16 19.7 81 100.0 WOMEN No. % 12 6.4 95 50.8 61 32.6 18 9.7 1 .5 187 100.0 1 .5 59 31.6 96 51.3 24 12.8 2 1.1 5 2.7 187 100.0 35 18.7 104 55.6 47 25.2 1 .5 187 100.0 Item Variable 13 14 15 16 17 Snack between meals Add salt to food Minimize refined foods Include fiber Minimize fatty foods yes no missing data total consistently selectively never total yes no missing data total yes no missing data total yes no missing data total MEN No. % 49 60.5 27 33.3 5 6.2 81 100.0 16 19.8 36 44.4 29 35.8 81 100.0 31 38.3 47 58.0 3 3.7 81 100.0 60 74.1 20 24.7 1 1.2 81 100.0 24 29.6 56 69.2 1 1.2 81 100.0 98 WOMEN No. % 151 80.7 23 12.3 13 7.0 187 100.0 25 13.4 87 46.5 75 40.1 187 100.0 84 44.9 99 52.9 4 2.2 187 100.0 147 78.6 39 20.9 1 .5 187 100.0 94 50.3 90 48.1 3 1.6 187 100.0 99 MEN WOMEN Item Variable No. % No. % 7 Weight within yes 74 91.4 169 90.4 15% of normal no 7 8.6 11 5.9 for height missing data 7 3.7 total 81 100.0 187 100.0 (Calculation based on Table in Suitor and Hunter, 1980, p. 435) Most students, 49.4% of the men and 50.8% of the women report drinking less than six cups of coffee, tea, or colas a day. Almost half the men (49.4%) report eating 3 meals a day, although 75.3% report sometimes or never eating breakfast. Only 31.6% of the female students eat 3 meals a day. Eighty and eight tenths percent of the women report sometimes or never eating breakfast. Most students, especially women snack between meals (60.5% of the men and 80.7% of the women). For the item of adding salt to food, 44.4% of the men and 46.5% of the women report only adding salt to selected items. Thirty-five and eight tenths percent of the male students and 40.1% of the female students in the study sample report never or seldom using salt. Most students, 58% of the men and 52.9% of the women, do not minimize refined foods. A high percentage of both men -\- " o 100 and women, 74.1% and 78.6% respectively, report including fiber in their diets. Most male students (69.2%) do not minimize fatty foods in their diets. About half of the female students (50.3%) report minimizing fatty foods in their diets. A high percentage of both the men and women, 91.4% and 90.4% respectively, are at the appropriate weight for their height. In the area of nutritional awareness, the mean score for men is .573 and the mean score for women is .605 (see Table 9). In summary, there is a wide range of positive health behavior being followed in the area of nutritional awareness such as, not drinking too much caffeine, not using or using salt selectively, and including fiber in the diet. There are areas that the students report carrying out negative health behaviors such as snacking between meals and not minimizing refined or fatty foods. More men eat breakfast and three meals a day than women but overall the female students score slightly better than male students. Most students' weight is appropriate for their height. Stress Management In the area of stress management the research questions - what are the health behaviors of a college 101 population in the area of stress management?; how do men score in the area of stress management?; and how do women score in the area of stress management?, are addressed. The frequencies and percents for men and women in the area of stress management are reported in Table 8. Tdfle 8 Descriptive Findings in the Area of Stress Management (N=268; 81 men and 187 women) MEN WOMEN Item Variable No. % No. % 26 Fall asleep yes 61 75.3 135 72.2 easily no 19 23.5 46 24.6 missing data 1 1.2 6 3.2 total 81 100.0 187 100.0 27 Sleep/night 7 hrs. or more 36 44.5 92 49.2 7 hrs. 44 54.3 92 49.2 missing data 1 1.2 3 1.6 total 81 100.0 187 100.0 28 Cope with yes 76 93.9 179 95.7 stress no 4 4.9 7 3.8 missing data 1 1.2 l .5 total 81 100.0 187 100.0 Item Variable 29 30 Most students, report falling asleep easily. of the men sleep less than 7 hours a night. Aware of feelings express satisfac— yes tory to self no missing data total Satisfactory yes to others no missing data total Able to yes release no frustration missing data total MEN No. % 75 92.6 5 6.2 1 1.2 81 100.0 66 81.5 11 13.6 4 4.9 81 100.0 73 90.1 7 8.7 1 1.2 81 100.0 102 WOMEN No. % 173 92.5 12 6.4 2 1.1 187 100.0 154 82.3 20 10.7 13 7.0 187 100.0 161 86.1 21 11.2 5 2.7 187 100.0 75.3% of the men and 72.2% of the women More than half (54.3%) Almost half (49.2%) of the women sleep less than 7 hours a night. A high percentage of the students, 93.9% of the men and 95.7% of the women, report being able to cope with a reasonable amount of stress. Most students are aware of their feelings and are able to express them in 103 a way satisfactory to themselves — 92.6% of the men and 92.5% of the women. Eighty—one and five tenths percent of the men and 82.3% of the women report being able to express their feelings in a way that is satisfactory to others. Both men and women, 90.1% and 86.1% respectively, are able to release their anger and frustration safely. In the area of stress management, the mean score for men is .820 and for women is .831. In summary, male and female students generally score well in all areas of stress management. In Table 9, the mean and standard deviation are reported for the four subscales of self-responsibility, and the other three areas of high level wellness, physical fitness, nutritional awareness, and stress management. The mean score will fall between 0 and +1, with +1 indicating following a wellness lifestyle and 0 indicating following a worseness lifestyle. 104 Table 9 The Mean Scores* for the 4 subscales of Self—Responsibility and for the Areas of Physical Fitness, Nutritional Awareness, and Stress Management MEN WOMEN St . St . Area Mean Deviation Mean Deviation Self Responsibility General Health Behavior .570 .259 .638 .238 Driving Behavior .477 .310 .592 .251 Self Abuse Behavior .817 .235 .873 .200 Birth Control Behavior .860 ——— .972 -—- Physical Fitness .543 ——- .316 -—— Nutritional Awareness .573 .224 .605 .193 Stress Management .820 .183 .831 .202 *Mean score falls between 0 and +1, with 0 being the least healthful and +1 indicating perfect health behavior. Women score better than men in the four subscales of self-responsibility. The weakest area of self— responsibility for both men and women is driving behavior, with mean scores .477 and .592 respectively. The strongest area is birth control behavior, with the 105 mean score for men .860 and for women .972. In the area of physical fitness, men score better than women. The mean score for men is .543 and the mean score for women is .316. In the area of nutritional awareness, the scores are fair, with women doing slightly better than men. In this area the mean for men is .573 and the mean for women is .605. In the area of stress management both men and women score well with the mean scores .820 and .831 respectively. CORRELATIONAL FINDINGS In this section, the research question - how does sex relate to general health behavior, driving behavior, self—abuse behavior, nutritional awareness, and stress management is addressed. Three areas of self-responsibility — general health behavior, driving behavior, and self—abuse behavior, and the areas of nutritional awareness and stress management were correlated against the sex of the college students using the statistical formula for point biserial correlation. The correlation coefficients are reported in Table 10. 106 Table 10 Point Biserial Correlation Coeffients Calculation Between Sex and 3 subscales of Self—Responsibility, Nutritional Awareness and Stress Management Area Self-Responsibility Correlation Cbefficient General Health Behavior .1275* P < .019 Driving Behavior .1915* P (.001 '9 Self Abuse Behavior .1227* P < .022 Birth Control Behavior Calculation not done Physical Fitness Calculation not done Nutritional Awareness .0728 P ( .118 Stress Management .0252 P < .341 *significantly different from zero P = the probability of this correlation occuring by error or chance is less than the value reported I. a. 107 In analyzing the data, the investigator realized this calculation was not done for the areas of birth control behavior and physical fitness. This oversight is a limitation of the study. There are three areas in which the correlation coefficient is significantly different from zero for men and women. Female students score better than male students in the areas of general health behavior (correlation coefficient .1257), driving behavior (correlation coefficient .1915), and self-abuse behavior (correlation coefficient .1227). There is not a significant correlation between sex and nutritional awareness and stress management. The research question - how does age relate to general health behavior, driving behavior, self-abuse behavior, nutritional awareness, and stress management is addressed next. The statistical formula to calculate a Pearson Product—Moment correlation coefficient was carried out between the ages of the sample population and three subscales of self—responsibility, nutritional awareness, and stress management. The correlation coefficients are reported in Table 11. Table 11 108 Pearson Correlation Coefficients Calculation Between Age and 3 Subscales of Self—Responsibility, Nutriational Awareness and Stress Management Area Self-Responsibility General Health Behavior Driving Behavior Self Abuse Behavior Birth Cbntrol Behavior Physical Fitness Nutritional Awareness Stress Management * significantly different from zero Correlation Coefficient -.1073* P< .043 .1054* P <.046 .0886 P (.078 Calculation not done Calculation not done -.l490* P<.008 .0658 P (.147 P = the prdbability of this correlation occurring by error or chance is less than the value reported 109 In analyzing the data, the researcher realized that this calculation was not done for the areas of birth control behavior and physical fitness. This oversight is a limitation of the study. There are three areas and ages of college students, in which the correlation coefficient is significantly different from zero. Between the area of general health behavior and age the coefficient calculated is —.1073. As college students get older, the scores in general health behavior get smaller, indicating that health behavior worsens with age. Driving behavior improves with age. The correlation coefficient calculated between driving behavior and age is .1054. Between the area of nutritional awareness and age, there is a negative correlation, -.l490. As college students get older their nutritional health habits are less positive in nature. There is not a significant relationship between age and self—abuse behavior and age and stress management. The research question — how do the 4 subscales of self-responsibility — general health behavior, driving behavior, self-abuse behavior, birth control behavior and physical fitness, nutritional awareness, and stress 110 management relate to one another is addressed in this section. A Pearson Product-Moment correlation was calculated between all the areas of high level wellness (4 subscales of self-responsibility, physical fitness, nutritional awareness, and stress management) to show the interrelationships between these areas. Through an oversight, the area of birth control was not correlated with physical fitness. In Table 12, the findings are presented. In several areas the correlation coefficient is significantly different from zero. This indicates that following certain positive health behaviors in one area is somewhat related or can be partially explained by following positive health behavior in another area. The correlation coefficient calculated between- general health behavior and driving behavior is .1055. Students who report following positive health behavior in the area of general health are more likely to have positive driving habits or vice versa. Students who have positive health behavior in the area of general health are also more likely to have positive nutritional habits or vice versa. The correlation coefficient calculated between these two 111 HMon HN mmmwmo: mfloacowlzoamsn OOHHmHdeos nommmHOHmodm Arm HaanHmHdeosmSHUm 0m #30 >Hmmm om EH05 rmUcmm mm3mw wow mm 2» m3 ZCHHHnHosmH wzmnmsmmm H .Nmbm» 123 6008 mdnmmm zmnmamamsw H Amzv *mHQSHmHoman< QHmmmHmsn mwoa NmHo m n nsm UwoomoHHHw< om HSHm oomanmeo: ooocwsto o< mHHOH ow osmnom Hm Hmmm firm: flsm