LIFESTYLE BEHAVIORS OF ADOLESCENTS: RELATIONSHIP OF SELF-EFFICACY, OPTIMISM, UNREALISTIC OPTIMISM AND SELECTED DEMOGRAPHIC VARIABLES TO THE LIFESTYLE BEHAVIORS by Mary Margaret Proudfoot B.N., Memorial University of Newfoundland, 1973 THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE in COMMUNITY HEALTH SCIENCE THE UNIVERSITY OF NORTHERN BRITISH COLUMBIA April 2004 © Mary Margaret Proudfoot, 2004 1^1 Library and Archives Canada Bibliothèque et Archives Canada Published Heritage Branch Direction du Patrimoine de l'édition 395 W ellington Street Ottawa ON K 1A 0N 4 Canada 395, rue W ellington Ottawa ON K 1A 0N 4 Canada Your file Votre référence ISBN: 0-494-04652-X Our file Notre référence ISBN: 0-494-04652-X NOTICE: The author has granted a non­ exclusive license allowing Library and Archives Canada to reproduce, publish, archive, preserve, conserve, communicate to the public by telecommunication or on the Internet, loan, distribute and sell theses worldwide, for commercial or non­ commercial purposes, in microform, paper, electronic and/or any other formats. AVIS: L'auteur a accordé une licence non exclusive permettant à la Bibliothèque et Archives Canada de reproduire, publier, archiver, sauvegarder, conserver, transmettre au public par télécommunication ou par l'Internet, prêter, distribuer et vendre des thèses partout dans le monde, à des fins commerciales ou autres, sur support microforme, papier, électronique et/ou autres formats. The author retains copyright ownership and moral rights in this thesis. Neither the thesis nor substantial extracts from it may be printed or otherwise reproduced without the author's permission. L'auteur conserve la propriété du droit d'auteur et des droits moraux qui protège cette thèse. Ni la thèse ni des extraits substantiels de celle-ci ne doivent être imprimés ou autrement reproduits sans son autorisation. In compliance with the Canadian Privacy Act some supporting forms may have been removed from this thesis. Conformément à la loi canadienne sur la protection de la vie privée, quelques formulaires secondaires ont été enlevés de cette thèse. While these forms may be included in the document page count, their removal does not represent any loss of content from the thesis. Bien que ces formulaires aient inclus dans la pagination, il n'y aura aucun contenu manquant. Canada 11 , ABSTRACT The purposes of this investigation were to examine (1) the lifestyle behaviors of adolescents in northern B.C.; (2) differences in lifestyle behaviors based on demographic variables; and (3) the relationship o f demographic and psychosocial variables to a health-promoting lifestyle. A cluster sample of 595 male and female adolescents attending school and a convenience sample of 34 male and female adolescents either attending alternate school or not in school completed questionnaires that measured demographics, lifestyle, general selfefficacy, optimism and unrealistic optimism. Analyses indicated that nutrition, physical participation, social support, stress management, general health practices awareness and safety had a significant relation to gender. Physical participation and general health practices awareness had a significant relation to living arrangements. Physical participation had a significant relation to school location. General health practices awareness and safety had a significant relation to ethno-cultural groups, and physical participation and safety had a significant relation to risk status. Nutrition, physical participation, general health practices awareness and safety were significantly negatively correlated to age. Nutrition, physical participation, social support, stress management, identity awareness, general health practices awareness and safety were significantly positively correlated to grade average. Physical participation, social support, stress management, identity awareness and safety were s i^ fic a n tly positively correlated to parent education. Hierarchical regression analyses indicated that demographic and psychosocial variables made a statistically significant contribution to predicting a health-promoting lifestyle. These findings are discussed in relation to efforts to enhance health-promoting behaviors in adolescents. Ill TABLE OF CONTENTS Abstract ii Table o f Contents iii List of Tables v Acknowledgements vii Chapter One - Introduction Self-efficacy Optimism Unrealistic optimism Demographics 1 4 15 18 22 Chapter Two - Methods Participants Ethics Materials Procedures 28 28 30 31 33 Chapter Three - Results Demographic Information Chi-square Testing o f the Categorical Variables Correlation Coefficients o f the Continuous Variables Regression Analyses of the Predictor Variables 36 36 42 51 52 Chapter Four - Discussion The Role o f Self-efficacy The Role o f Optimism The Role o f Unrealistic Optimism The Role o f Demographic Variables Strengths o f the Study Limitations o f the Study Implications for Nursing Practice Implications for Nursing Education Implications for Public Policy Implications for Future Research 67 73 74 75 76 78 78 79 82 83 84 References 86 Appendices Appendix A: Adolescent Demographic Questionnaire 99 IV Appendix B: Adolescent Lifestyle Questionnaire 102 Appendix C: Self-Efficacy Scale 105 Appendix D; Life Orientation Test 107 Appendix E: Unrealistic Optimism Measure 109 Appendix F : Information and Parent Consent Letter 111 Appendix G: Information and Participant Consent Letter 113 LIST OF TABLES Table 1 Range o f Ages for Adolescents 37 Table 2 Ethno-Cultural Origin of Adolescents 38 Table 3 Grade Average of Adolescents 39 Table 4 Living Arrangements of Adolescents 40 Table 5 Education Level of Parents 41 Table 6 Occupations o f Parents 42 Table 7 Cross tabulation of Nutrition by Categorical Predictor Variables 44 Table 8 Cross tabulation of Physical Participation by Categorical Predictor Variables 45 Table 9 Cross tabulation of Social Support by Categorical Predictor Variables 46 Table 10 Cross tabulation of Stress Management by Categorical Predictor Variables 47 Table 11 Cross tabulation of Identity Awareness by Categorical Predictor Variables 48 Table 12 Cross tabulation of General Health Practices Awareness by Categorical Predictor Variables 49 Table 13 Cross tabulation of Safety by Predictor Variables 50 Table 14 Correlations Between Age, Grade Average, Parent Education, Parent Job and the Adolescent Lifestyle Questionnaire Subscales 52 Table 15 Summary of Hierarchical Regression Analysis for Variables Predicting a Healthy Nutrition Level Among Adolescents (N = 629) 54 Table 16 Summary of Hierarchical Regression Analysis for Variables Predicting a Healthy Physical Participation Level Among Adolescents (N - 629) 56 VI Table 17 Summary o f Hierarchical Regression Analysis for Variables Predicting a Healthy Social Support Level Among Adolescents (N = 629) 58 Table 18 Summary of Hierarchical Regression Analysis for Variables Predicting a Healthy Stress Management Level Among Adolescents (N = 629) 60 Table 19 Summary o f Hierarchical Regression Analysis for Variables Predicting a Healthy Identity Awareness Level Among Adolescents (N = 629) 62 Table 20 Summary o f Hierarchical Regression Analysis for Variables Predicting a Healthy General Health Practices Awareness Level Among Adolescents (N = 629) 64 Table 21 Summary o f Hierarchical Regression Analysis for Variables Predicting a Healthy Safety Level Among Adolescents (N = 629) 66 vu ACKNOWLEDGEMENTS I would like to express my sincere appreciation to my thesis supervisor, Ken Prkachin, for his guidance, support, time, understanding and his great ability to teach. I would also like to thank my committee members, Peter MacMillan and Dennis Procter for their insightful comments, constructive feedback and attention to detail. This study could not have been possible without the participation of the adolescents and the assistance o f the administrators, the teachers and the support staff of School Districts #57 and #91, as well as, the youth and staff of YAP. I extend my deepest appreciation to my husband, Reid, and my daughters. Shannon, Kathryn and Laura Beth. Your love, encouragement and endless support were always there throughout the course work and thesis. Finally, a special thank you to my mother and sisters for their unwavering confidence in me, their prayers, and for instilling a love of learning. Also, thank you to my friend, Carolyn, for her support from the beginning. CHAPTER ONE: INTRODUCTION The concept o f a healthy lifestyle has emerged as a major issue in the nursing and health literature. A review o f the literature for major causes of morbidity and mortality indicates that lifestyle factors are major contributors to many of today’s leading health problems and this is particularly true for adolescents (Gillis, 1997). Health habits and lifestyles, established in adolescence, are likely to continue throughout life (lessor, 1984; Maggs, Schulenberg, & Hurrelmann, 1997; Millstein, Nightingale, Petersen, Mortimer, & Hamburg, 1993) and have long-term consequences for individual health and well-being and for society in general (lessor, Turbin, & Costa, 1998). Many health problems of adulthood, such as smoking, exercise, and unhealthy eating habits, have their origin in behaviors developed in adolescence (Chassin, Presson, Rose, & Sherman, 1996; Chen & Kandel, 1995; Cohen, Brownell, & Felix, 1990; lessor, 1984). The early formation of healthy behavioral practices, such as healthy eating and regular exercise, contributes to the delay or prevention of major causes o f morbidity and mortality in adulthood such as heart disease, diabetes and cancer (Haskell, 1984; Sallis, 1993). Although many adolescents move through the transition to adulthood with minimum difficulty, others develop health-compromising behaviors that place them at risk for motor vehicle accidents, unplanned pregnancies, sexually transmitted diseases, alcohol and drug abuse, obesity, eating disorders and an increasing sedentary lifestyle that affect their long­ term health. Issues of emotional health such as stress, low self esteem, negative body image, loneliness, depression and suicide have also been identified as significant concerns (Dietz, 1998; Hanvey & Gallant, 1994; Heaven, 1996; Millstein, Peterson, & Nightingale, 1993; World Health Organization [WHO], 1998a). Adolescence is a critical period of development for the adoption of behaviors that are important to health (lessor, 1984; Maggs et al., 1997). As such, it is an ideal time to promote healthy behaviors so that good health outcomes are achieved. Research on the lifestyle behaviors o f adolescents with respect to health-promoting behaviors is limited. There is even less research on the lifestyle behaviors of adolescents living in the north and in particular with respect to examining the role of demographic and psychosocial variables in predicting a healthy lifestyle among adolescents. The purpose of this research is to examine the lifestyle behaviors o f adolescents living in the north, to determine the relationship of demographic and psychosocial variables to a healthy lifestyle, and finally, to determine which of these variables best predicts a healthy lifestyle in adolescents. A descriptive correlational design is employed in this study, with chi-square tests and Pearson’s product-moment correlation coeffieients used to measure the relationships between the seven subscales of the Adolescent Lifestyle Questionnaire (Gillis, 1997) and the predictor variables. A hierarchical regression analysis is carried out to identify the contribution of the predictor variables to a healthy level of the subscales o f the Adolescent Lifestyle Questionnaire. The most significant factors influencing the health of adolescents are “found in their environments, and in the choices and opportunities for health-enhancing or healthcompromising behaviors that these contexts provide” (Call, Riedel, Hein, McLoyd, Petersen, & Kipke, 2002, p.69), Adolescents appear to experience one of the healthiest periods of life as they have survived childhood diseases and most do not show evidence of chronic health conditions or experience declining health associated with older adulthood (Call et al., 2002; Spear & Kulbok, 2001). This perception of adolescents’ health, however, is based on a narrow view o f morbidity and mortality, and does not take into account the cumulative impact of adolescents’ behaviors that can lead to health problems manifested later in life. It also does not take into account the positive behaviors that adolescents develop that improve their chances for long-term well-being (Call et al., 2002). Adolescence is a time for first experiences, increasing independence and exploring new identities. During this formative stage o f development, adolescents make decisions and develop habits with lifelong implications for their health. Adolescence is a time of increased developmental risk, however, it is also a period for developing health-promoting behaviors. Adolescents are developmentally very receptive to information about themselves and their bodies. They are also striving to become more autonomous in their decision-making. Adolescents value information relevant to their health and desire to achieve and maintain lifestyles that are more healthful than their parents (Boehm et al., 1993). These characteristics can be used to enable adolescents to make positive choices in their lives and to foster their taking responsibility for their own health. Research on adolescent lifestyle has been much less extensive than that on adult lifestyle (Gillis, 1994). One o f the reasons given for this by Gillis (1997) is that there is a lack o f empirical measurement instruments appropriate for adolescents. Many o f the instruments that have been developed to test adolescent health behaviors or lifestyle are limited to focusing on risk reduction rather than healthy lifestyle patterns and address single health behaviors rather than a pattern of behavior. A health-promoting lifestyle has been defined as “ a multidimensional pattern of self-initiated actions and perceptions that serve to maintain or enhance the level o f wellness, self-actualization, and fulfillment of the individual” (Walker, Sechrist, & Pender, 1987, p. 77). The World Health Organization [WHO] (1998b) refers to lifestyle as a way of living based on identifiable patterns of behavior that are determined by an interplay between an individual’s personal characteristics, social interactions, and socio-economic and environmental living conditions. An area o f debate in the healthy lifestyle literature is whether measurement of a healthy lifestyle should include the distinct categories of preventive, protective and healthpromoting behaviors, or should deal only with health-promoting behaviors that increase one’s level o f well-being. Although there are differences in the conceptualization of the term “healthy lifestyle”, a consistent meaning of a tendency directed towards sustaining or enhancing well-being is evident generally. One instrument that has been used to measure adolescent lifestyle is the Adolescent Lifestyle Questionnaire (ALQ), (Gillis, 1997). The instrument was developed and tested to enable investigation of lifestyle patterns in adolescents that include health promotive and protective behaviors. Gillis (1997) proposed that an integrated view o f healthy lifestyle includes health-promoting and health-protecting behaviors because an integrated approach increases the scope of interventions and offers an opportunity for a holistic approach rather than a fragmented approach to adolescent health promotion. The testing of this tool also demonstrated that the health behaviors assessed were correlated, thus suggesting that adolescents’ involvement in these diverse health behaviors reflected an overall orientation toward well-being. Self-efficacv Self-efficacy, a construct of Bandura’s social cognitive theory, refers to beliefs people have in their capability to successfully execute a given behavior (Bandura, 1977). According to Bandura (1997a), self-efficacy regulates human functioning in the following four ways: 1) cognitively, in that people with high self-efficacy are more likely to have high aspirations, set difficult challenges and commit themselves to meeting those challenges; 2) motivationally, in that people with high self-efficacy beliefs will set goals for themselves, expend effort and persevere to achieve these goals and are resilient in the face of setbacks; 3) emotionally, in that self-efficacy lowers stress, increases one’s ability to manage threats and increases coping abilities; and 4) reduces depression through the development of satisfying social relationships which in turn leads to social efficacy and support. Efficacy expectations are learned from four major sources: performance accomplishments attained through personal experiences; vicarious experiences which include learning that occurs through observation of events and/or other people; social persuasion in that if people are persuaded to believe in themselves, they will exert more effort and increase their chances of success; and physiological states which act as cues in that people rely on their physical and emotional states to judge their capabilities. One’s physiological reactions to a situation, such as fatigue and pain, are not mistakenly interpreted as a sign of physical inefficacy. Bandura (1986) and Hofstetter, Sallis, and Hovell (1990) proposed that self-efficacy judgments are specific to behaviors and the situations in which they occur. People are not self-efficacious in general; rather their sense of efficacy is tied to particular behaviors and the situational context in which they occur. However, Sherer and Maddux (1982) and Long and Haney (1988) view self-efficacy as a general concept based on a broader sense of peoples’ ability to perform a range o f actions in a variety of situations well. According to this more general view, self-efficacy is learned early in life and changes little during adulthood. Bandura (1997b) asserts that efficacy expectations reflect a person’s perceived, rather than actual capabilities, and that it is these perceptions and not one’s true abilities that often influence behavior. According to Bandura (1986) individuals with greater perceptions about their own abilities are more likely to initiate challenging behaviors compared to those whose self-efficacy is low. Bandura differentiated between expectancies of self-efficacy, and expectations o f outcome - one’s belief that a specific behavior will produce a desired outcome - and characterized expectancies of self-efficacy as a stronger predictor of behavior than outcome expectancies. People with greater self-efficacy attribute failures to external factors and construe failures as momentary setbacks to overcome, whereas people with lower self-efficacy attribute negative outcomes to their own inability to carry out the task (Maibach & Murphy, 1995). The research on self-efficacy and health behaviors has been primarily focused on adults. The research on adolescent self-efficacy and health behaviors has focused on the influence o f self-efficacy on risk behaviors and treatment adherence in chronic disease management. Recently, self-efficacy is assuming an increasingly important role in health promotion practice, disease prevention and research (Catania, Kegeles, & Coates, 1990; Holloway & Watson, 2002; Maddux & Rogers, 1983). The concept of self-efficacy is recognized as a predictor of health behavior change and maintenance (Hofstetter et al., 1990; Strecher, DeVellis, Becker, & Rosenstock, 1986). In their review of the research examining the concept of self-efficacy and how it relates to health practices, Strecher et al. (1986) grouped their findings into five healthrelated behaviors-cigarette smoking, weight control, contraceptive behavior, alcohol abuse and exercise. Most o f the participants in the 26 studies they reviewed were adults, although there were adolescents in five studies. For all five of the areas studied in the review, selfefficacy was a consistent predictor of initiating and maintaining health behavior change. The role of self-efficacy in health behavior change has been documented in a variety o f health domains; drug use (Hays & Ellickson, 1990), sexual activity (Jemmott, Jemmott, Spears, 7 Hewitt, & Cruz-Collins, 1992; Kasen, Vaughan, & Walter, 1992), smoking (Fagen et al., 2003; Holm, Kremers, & de Vries, 2003; Lawrance & Rubinson, 1986; Tucker, Ellickson, & Klein, 2002) and weight loss and diet (Hertog, Finnegan, Rooney, Viswanath, & Potter, 1993). The relationship between self-efficacy and health behaviors in adolescence is of interest because o f the changes in physical, hormonal, social and emotional development during this period (Ozer & Bandura, 1990). A literature review on adolescents with respect to self-efficacy and health behaviors includes the areas of diet, exercise, AIDS prevention behaviors, contraceptive behavior, smoking and interpersonal stress management. This research will be discussed in each specific area that follows. All of these behaviors are included in the Adolescent Lifestyle Questionnaire (Gillis, 1997) to measure lifestyle practices in adolescents. Nutrition. Dietary patterns developed during childhood and adolescence may contribute to obesity and eating disorders and may increase the risk for chronic diseases later in life such as heart disease, cancer and diabetes. Reducing dietary fat and sodium and increasing dietary fiber and fruits and vegetables are important for cardiovascular risk reduction (Kumanyika et al., 2000). Adolescents have limited ability to influence food choices at home and spend much o f their time in settings that do not encourage healthy food consumption such as school, fast food restaurants, and shopping malls. Only three studies were found that examined the relationship of self-efficacy and diet in youth. Heatey and Thombs (1997) in their testing of fmit-vegetable consumption self-efficacy in youth, found that varied eaters showed higher levels of self-efficacy and were more likely to be girls. Hertog et al. (1993) concluded from their survey that included teenagers, that self-efficacy was predictive o f healthy eating intentions and behavior. Gracey, Stanley, Burke, Corti, and 8 Beilin (1996) found that self-efficacy was positively related to healthy eating and nutrition knowledge and having influence over food at home. Exercise. Regular physical activity is important for cardiovascular fitness and to avoid overweight and obesity. Sedentary lifestyle is considered to be a major contributing factor to escalating adolescent obesity. Not only does exercise reduce the risk of heart disease and obesity, it also has been shown to reduce the rates of risk behaviors such as smoking, marijuana use and poor dietary habits (Pate, Heath, Dowda, & Trost, 1996). Pate et al., in their examination of the associations between physical activity and other health behaviours, found that a low level of exercise activity is associated with lower fruit and vegetable consumption and greater television watching. The amount o f time that adolescents spend in physical activity has decreased significantly over the past decades (Heath, Pratt, Warren, & Kann, 1994). This decline in physical activity in adolescence increases with age among students in grades 9 through 12 (Heath et al., 1994; Nigg, 2001) and is more prominent in female adolescents (Sallis, 1993; Sallis, Alcaraz, McKenzie, & Hovell, 1999). Self-efficacy has been found to be a determinant o f physical activity among youth (Garcia et al., 1995; Pender, Bar-Or, Wilk, & Mitchell, 2002; Sallis, Prochaska, & Taylor, 2000). In their research on self-efficacy and perceived exertion o f girls, 8 to 17 years of age, during exercise, Pender et al. found that less efficacious girls reported higher perceived exertion during exercise, and that this perception of greater effort during exercise had a deleterious effect on exercise self-efficacy. This finding supports Bandura’s self-efficacy theory. Pender et al. also found that there was a significant increase in girls’ self-efficacy from pre to post exercise indicating that hy providing mastery experiences with positive feedback, self-efficacy for physical activity, which promotes a healthier lifestyle, is inereased. The most frequently eited sources of selfefficacy for physical activity and sport, as reported by Chase (1998), were significant others’ praise and encouragement, followed by successful personal performance. Interventions directed at increasing exercise self-efficacy and enhancing positive responses during physical activity could be used to prevent the decrease in physical activity that occurs as adolescents age. Social support. Soeial support from parents and friends has been found to play a significant role in the health o f adolescents. Social support may enhance well-being through preventing isolation and feeling a valued part of a network. Heraldo Gaead (2002) in his research found that an increase in soeial support predicted an inerease in health-promoting behaviors. Garcia et al. (1995) reported that in contrast to pre-adolescents, adolescents identified less social support for exercise and fewer exereise role models. St. Lawrence, Brasfield, Jefferson, Allyene, and Shirley (1994) in their study of social support as a factor in African-American adolescents’ sexual risk behavior, found that adolescents with less social support were less knowledgeable about AIDS, held more negative attitudes towards condoms, and were lower in self-efficacy than adolescents with higher levels of social support. McFarlane, Bellissimo, and Norman (1995) in their study on the role of family and peers in social self-efficacy found that social self-efficacy and social support from family and peers were negatively associated with depression and thus acted as a protective factor. Ayres. (2003) reported that middle-aged adolescents, between 15 and 17 years, who had an inadequate social support system, found that it interfered with their performance of healthy behaviors. 10 Stress management. The majority of the studies reported in the literature on the relationship o f self-efficacy and stress management is on adults managing chronic diseases or related to employment. A relative lack o f empirical research was found on this topic for the adolescent population. One study that did examine the relationship between social selfefficacy and interpersonal stress in adolescence (Matsushima and Shiomi, 2003) found that social self-efficacy is negatively correlated with the interpersonal stress and positively correlated with interpersonal stress coping. Matsushima and Shiomi also found that even if the adolescents have high interpersonal stress coping skill, if they do not have self-efficacy, they seem to experience high stress. They concluded that adolescents cope well with stress hy enhancing social self-efficacy and that they may also show high self-efficacy hy learning stress coping skill. Boardway, Delamater, Tomakowsky and Gutai (1993) in their study evaluating the effects o f stress management training for adolescents with diabetes found that diabetes-specific stress decreased significantly for patients over the course of the intervention and follow-up, however, self-efficacy about diabetes was unchanged. The areas covered in the Adolescent Lifestyle Questionnaire with respect to safety were related to avoidance o f tobacco, drugs and alcohol, protection against sexually transmitted diseases, AIDS and pregnancy, automobile safety and seat belt use. A review of the literature on self-efficacy and its relation to these areas follows. Contraception. The relationship between contraceptive knowledge and contraceptive behavior has been studied extensively in an effort to address ineffective patterns of contraceptive use among adolescents. Earlier studies on the impact of contraceptive education on behavior found that although contraceptive knowledge was increased with education, the effect on sexual behavior and contraceptive usage was inconsistent and 11 inconclusive (Marsiglio & Mott, 1986; Whitley & Schofield, 1985/86). Later studies, however, found that some educational programs have had an impact on adolescents’ contraceptive and sexual behavior (Eisen, Zellman, & McAlister, 1990; Howard & McCabe, 1990). Providing information to adolescents on contraception does not mean that they will become more effective users of contraceptives or alter their sexual behavior. Effective use of contraception involves engaging in a set of skills that include communication between partners, dealing with partner demands and acquisition and use of specific contraceptive methods. Heinrich (1993) in his study of a sample of white females between the ages of seventeen and twenty-five foimd that contraceptive self-efficacy was highly correlated with contraceptive use and that contraceptive self-efficacy was the most important predictor of contraceptive use and behavior change. Lack of barriers to contraception, knowledge and length of time o f sexual activity were also important factors. While most demographic variables and future orientation in education and career plans were not significantly associated with effective contraceptive use, Heinrich found that variables measuring sexual experience and personal attitudes about birth control were more significantly associated with effective use. Levinson (1986) in her earlier study of the relationship between self-efficacy and teenage girls’ contraceptive behavior found that although there was no relationship between reproductive and contraceptive knowledge and contraceptive behavior, girls with a high contraceptive self-efficacy think that they should and can be responsible for their sexual activity and act accordingly to achieve contraceptive protection. In later research, Levinson, Wan and Beamer (1998) in their effort to establish generalizability of the contraceptive selfefficacy scale found that contraceptive self-efficacy was significantly predictive of 12 contraceptive behavior for all four of their samples. In their comparative study of male and female contraceptive practices among adolescents aged 18-20, Van Den Bossche and Rubinson (1997) found that both genders need to develop communication skills regarding contraceptive issues and that contraceptive self-efficacy was significantly different for males and females in that males need to develop the ability to talk about using contraceptives and avoid intercourse without contraception, whereas females need to learn how to assume responsibility and to beeome more efficaeious in securing contraceptives. Longmore, Manning, Giordano, and Rudolph (2003) in their investigation of whether demographic characteristics influence contraceptive self-efficacy among male and female adolescents and whether contraceptive self-efficacy increases the likelihood of contraceptive use found that female adolescents, who are older and whose mothers approve of contraceptive use, report higher contraceptive self-efficacy. HIV/AIDS/STD prevention. As patterns of health behaviors and risk taking are often established in adolescence, this period is a critical time for the development of sexually transmitted diseases, including AIDS preventive behaviors. Behaviors that place adolescents at greater risk o f exposure to sexually transmitted diseases include early initiation of sexual intercourse, greater number o f partners and high-risk partners, increased frequency of intercourse and the infrequent use of barrier contraceptives (Aral, 1994). Consistent condom use has been strongly promoted by health care professionals as an effective means to prevent. human immunodeficiency virus (HIV) transmission (Padian, Shiboski, Glass, & Vittinghoff, 1997). Basen-Engquist and Parcel (1992) in their study of a sample of grade 9 students found that self-efficacy was significantly related to sexual intentions and condom use but not to the number o f sexual partners. Kasen et al. (1992) in a sample of grade 10 students found 13 that a degree o f uncertainty existed in this sample for all areas of self-efficacy surveyed refusing intercourse in a variety of circumstances, questioning sexual partners about past risky behaviors, and correct and consistent condom use. Goh, Primavera, and Bartalini (1996) in their study of AIDS related behaviors in a sample of students in grades 10 through 12 found that the group was fairly knowledgeable about AIDS and demonstrated a sense of self-efficacy for AIDS prevention. Intention to abstain from sex was negatively related to sexual experience and intention to use condoms was positively related to actual use of condoms. Goh et al. suggest that their finding demonstrates that intentions and actual behaviors regarding AIDS prevention tend to co-occur. Their research found that students with lower self-efficacy were twice as unlikely to be able to refuse sexual intercourse and were five times less likely to have used condoms consistently. Dilorio, Dudley, Soet, Watkins, and Maibach (2000), in their study of self-efficacy condom use behaviors among college students between the ages of 18 and 25, supported the findings of earlier studies of O’Leary, Goodhart, Jemmott, and Boccher-Lattimore (1992) and Wulfert and Wan (1993) in that self-efficacious participants expressed confidence in using condoms and were more likely to do so. Jemmott et al. (1992) in their investigation of an AIDS prevention intervention provided to inner city black adolescent females based on three separate interventions found that those participants who received the social cognitive condition based on increasing their self-efficacy subsequently expressed firmer intentions to use condoms than the participants in the information alone and the general health-promotion interventions. Substance abuse prevention. Although substantial research has been conducted on adolescents and risk factors including substance abuse, very few studies have examined the moderating role of protective factors. In addition, this limited research has been primarily 14 conducted on adolescents already in treatment programs for substance abuse. One study by Hays and Ellickson (1990) examined the nature of resistance self-efficacy to different drugs and social situations as well, as its relationship to perceived pressure to use drugs in a sample o f high school adolescents. The researchers found that both self-efficacy and perceived pressure to use drugs appear to be generalizable across the substances of alcohol, cigarettes and marijuana. The adolescents reported lower self-efficacy when they experience pressure to conform particularly in social drinking environments and the pressure was greatest for alcohol use. The results o f this study suggest that when providing prevention programs to adolescents that include self-efficacy skills, it can be expected that by increasing selfefficacy resistance skills for one or more commonly used drugs that the skills will generalize to other drugs. Hersch (1997) in her study of risk and protective factors for substance use behaviors among sixth and tenth graders found that resistance self-efficacy and negative parental attitudes predicted decreased substance use among the participants in students in both grades. Smoking resistance and cessation. Cigarette smoking typically begins in adolescence and is a significant risk factor for a number of chronic diseases including heart disease, emphysema and stroke (Bachman & Wallace, 1991). Adolescents who initiate smoking are most likely to develop lifelong addiction (WHO, 1998a). Fagen et al. (2003) in their examination o f self-efficacy to avoid smoking in adolescents found that daily smokers were less confident in their ability to avoid smoking than those who smoked less frequently, and as nicotine dependence increased, self-efficacy beliefs decreased. In addition, they found that as friends' encouragement to quit increased, self-efficacy beliefs also increased. Martinelli (1996) in her research on factors that influence avoidance of tobacco smoke among 15 adolescents reported that general self-efficacy was a significant factor. Tucker et al. (2002) from their study o f smoking cessation during the transition from adolescence to yoimg adulthood found that higher smoking resistance self-efficacy correlated with higher success with quitting and concluded that because there were few significant sex differences in the predictors o f smoking, smoking cessation programs did not need to be adapted to the special needs of male and female smokers. Optimism Optimism is defined as the tendency to believe that things will go well and that one will generally experience good versus bad outcomes in life (Scheier & Carver, 1985). Scheier and Carver propose that optimism is a stable personality characteristic and that optimists have general positive expectations that are not limited to a particular behavioral domain or setting. Optimists, when experiencing misfortune or setbacks believe that the setbacks are not their fault and that with enough perseverance, the circumstances will be overcome. Scheier and Carver (1992) and Seligman (1990) in their research report a positive relationship between optimism and better health outcomes and longevity. Possible explanations for this relationship as offered by Peterson and Bossio (1991) are that optimists are better at avoiding dangerous situations or engaging in risk behaviors and they continue to strive for better outcomes in spite of setbacks. Several studies, (Friedman et al., 1992; Scheier et al., 1989) offered an alternative explanation for the differences in health outcomes between optimists and pessimists in that optimists may use more adaptive health habits and may view positive health behaviors as more beneficial so will engage in them more often. Optimism has been shown in the research to be an important predictor, of well-being (Scheier et al., 1989). Cassidy (2000) in his longitudinal study with adolescents over a four- 16 year period found that optimism is predictive of both psychological well-being and self-rated health. Mulkana and Hailey (2001) in their research on the relationship between general health behaviors and optimism measured optimism and participation in general healthenhancing behaviors rather than behaviors in a particular health context among healthy individuals. They found not only a positive association between optimism and the use of general health behaviors but also with each of the six health-promoting behaviors they examined. These health-promoting behaviors included health responsibility, physical activity, nutrition, spiritual growth, interpersonal relationships and stress management. The implication o f these findings is significant in determining health-promoting strategies in that different strategies may be used to attain better outcomes. Mulkana and Hailey suggested that individuals who are optimistic might benefit more from health education, while individuals who are less optimistic may benefit more from behavior modification to assist them in making better health habits. Most studies on optimism have used adult participants, however, there is a growing body o f knowledge regarding optimism in adolescents (Brissette, Scheier, & Carver, 2002; Carvajal, Gamer, & Evans, 1998; Puskar, Sereika, Lamb, Tusaie-Mumford, & McGuinness, 1999; Tusaie-Mumford, 2001). The Life Orientation Test (LOT), the instrument developed by Scheier and Carver (1985) and used to measure optimism was tested on a predominantly white undergraduate college population. Goodman, Knight, and DuRant (1997) in their study to examine the scale’s validity and reliability in an ethnically diverse sample of adolescents attending an urban medical clinic found good internal consistency and test-retest reliability which supported the use of the tool with the adolescent population. This research on adolescents has included optimism and depression - less optimistic adolescents use more 17 problem avoidance and withdrawal (Chang, 1996). Optimism is positively correlated with active coping (Scheier, Carver, & Bridges, 1994), and optimism may be reduced by anxiety (Dewberry & Richardson, 1990). Optimism was also found to be positively correlated with general interest in school, peer relationships and academic studies at all grade levels (Koizumi, 1995). Adolescence is a period when coping styles are developed in response to the increased pressure to adapt and within the context o f peer pressure to explore new and often risky behaviors (lessor, 1984). Puskar et al. (1999) in their investigation of gender differences and the relationship o f optimism with depression, coping, anger and life events among rural adolescents, found that rural adolescents were less optimistic compared to established norms o f college students. They also found more optimistic adolescents had lower levels o f depression, had less anger, and used the more preferred problem-focused strategies but could adapt to emotion-focused strategies when problem-focused strategies were not a possibility. Brissette et al. (2002) in their research on the role of optimism in social network development, coping and psychological adjustment in first year college students found that optimists report more well-being, social support from friends and better adjustment to stressful life events through active coping and planning rather than denial and disengagement. Whether coping differences between optimists and pessimists underlie the effects of optimism on psychological and physical well-being was demonstrated as well in the research by Aspinwall and Taylor (1992) who found that optimists were more likely than pessimists to engage in active coping and that this active coping, rather than the avoidance coping demonstrated by pessimists, was a significant predictor of later coping. Psychosocial distress has been reported to contribute to adolescent injuries, homicide and suicide, which 18 are leading causes o f adolescent deaths. Tusaie-Mumford (2001) in a study of psychosocial resilience in rural adolescents found that optimism and perceived family support were most predictive o f psychosocial resilience. The literature found on the relationship of optimism and HIV antibody testing and HIV prevention has yielded equivocal findings. Goodman, Chesney, and Tipton (1995) in their study examining the extent to which optimism, knowledge, attitudes and beliefs predict the use of HIV testing services in a group of at-risk female adolescents reported that adolescent girls with higher optimism are less likely to use health promotional educational and screening services. Goodman et al. reported that among adolescent females, higher optimism is not necessarily associated with HIV protective behaviors and may serve as a barrier to HIV prevention. Their findings suggest that females with higher optimism engage in “optimistic denial” and may engage in high-risk behaviors and believe testing is unnecessary for them because they feel they will experience positive outcomes in life. Carvajal et al. (1998) in their research on sexually active inner-city minority adolescents found that optimism is a protective factor in relation to intentions to avoid engaging in unsafe sex. They foimd that the adolescents who were more optimistic had higher levels of condom use self-efficacy and negative expectancies toward unsafe sex. Unrealistic optimism Unrealistic optimism or optimistic bias has been well studied in the research of Weinstein (1980; 1984; 1989). Weinstein defines unrealistic optimism as the tendency of individuals to believe they are more likely than the average person or comparable person in terms of age, gender and educational background, to experience positive outcomes and less likely than the average person or comparable person to experience negative outcomes. 19 According to Weinstein (1980) unrealistic optimism results from both positive and negative events when two conditions are satisfied. Firstly, the event is perceived to be controllable and secondly, people have some degree o f commitment or emotional investment in the outcome. Klein and Helwig-Larsen (2002) in their meta-analytic review of the literature on the relationship between perceived control and unrealistic optimism found a strong association between the two constructs and this relationship was moderated by sample characteristies such as nationality, student status and risk status. Unrealistic optimism exists for males and females across all ages and educational levels (Weinstein, 1987). Van der Pligt, Otten, Richard, and van der Velde (1993) in their overview of the literature on unrealistic optimism offer six possible causes for unrealistic optimism: (1) perceived control (in that optimism is greater when people judge risks to be under their control); (2) egocentric bias (in that people generally have more knowledge about their own protective behaviors than those of others, and they are less aware of the protective behaviors o f others); (3) personal experience; (4) stereotypical judgements (in that people infer that risk applies to others because the image people have of those that are high risk does not fit their self-perception); (5) self-esteem maintenance (in that people generally believe their own actions are better than others); and (6) coping strategies (in that denial offers protection and helps one to adapt to threatening events). Kulik and Mahler (1987) in their study o f healthy and acutely ill college students found that healthy students show an equal level o f unrealistic optimism for health and nonhealth problems whereas ill students show less unrealistic optimism for future health problems even though the health problems were unrelated to their current illness. 20 Past experience o f a negative event results in increased perceptions of its probability and decreased optimism, whereas lack of experience with an event promotes optimism (Greening & Chandler, 1997; Weinstein, 1989). Burger and Palmer (1992) in their research on changes in unrealistic optimism following a stressful event found that unrealistic optimism among a sample that experienced an earthquake, though completely eliminated in the few days following the event, had returned three months later. Possible explanations for this given by Burger and Palmer are the need to reduce anxiety, the need to regain control and a reduction in perceived vulnerability because of engagement in risk-prevention actions. The research on adolescents’ perception of risks, including health risks, varies with respect to adolescents’ understanding and estimation o f risk. Quadrel, Fischoff, and Davis (1993) suggested that adolescents do not understand the risks they are taking. Morrison (1985) indicated that adolescents lack understanding of the consequences o f risk-taking and others (Chapin, 2001; Eiser, Riser and Lang, 1989) concluded that adolescents are very cognizant o f the risks. A widely held view is that adolescents are egocentric and underestimate or ignore the risks. Researchers offer unrealistic optimism as one explanation as to why adolescents take risks (Cohn, Macfarlane, Yanez, & Imai, 1995; Weinstein, 1987). Adolescents’ view o f themselves as facing less risk than others reflects invulnerability (Quadrel et al., 1993). A number of studies have looked at the influence of unrealistic optimism and risk taking comparing adolescents with other age groups. Todesco and Hillman (1999) found that adolescents perceive themselves as less likely to encounter harm when they compare themselves to peers and parents but more likely than children. Quadrel et al. found that adolescents did not perceive themselves to be less likely than their parents to encounter misfortune. Schinnerer (2001) found that both adolescents and adults saw 21 themselves as facing less risk than others, however, unrealistic optimism was more pronounced for adolescents. Cohn et al. studied adolescents’ feelings of invulnerability toward the leading causes o f adolescent morbidity and mortality, whether feelings of invulnerability are greatest among adolescents who report engaging in health-threatening behaviors and whether adolescents regard their own behaviors as safe. Cohn et al. found that adolescents do not regard their behaviors as extremely risky or unsafe, and that those at greatest risk were least likely to exaggerate their own invulnerability. They also found that compared to their parents, adolescents minimized the harm associated with experimental and occasional involvement in health-threatening behaviors yet they were less optimistic about avoiding injury and illness. Arnett (2000) in looking at unrealistic optimism in adolescent and adult smokers found that optimistic bias was stronger for both adolescent and adult smokers than for nonsmokers. Like Cohn et al., Arnett also found it was higher for adolescents than adults. In Arnett’s study 29 % o f the adolescents believed that they would never die from smoking and 60 % of the adolescents believed that the long-term risks of smoking did not apply to them, since they would be able to quit at anytime. From these findings, Arnett proposed that smoking prevention programs for adolescents should focus on the risk of addiction rather than on the long-term consequences of smoking. Chapin (2001) in his study of optimistic bias among urban minority at-risk adolescents found that the adolescents in his study believed they were less likely than others to contract HIV/AIDS later in life and that no relationship was found between optimistic bias and grade level, academic achievement and attitudes toward safer-sex messages, which is consistent with Weinstein’s (1987) findings. 22 Demographics Studies in the literature examining the relationship of the demographic variables of gender, age, location, ethnicity and culture, educational level and socio-economic status to adolescent lifestyle were reviewed. The literature reveals that although demographic influences on health behaviors are believed to be strong, empirical findings are mixed and rest largely on single factor, adult-focused studies. Most of what is known about demographics and health behaviors has been based on pairwise comparisons, i.e., one demographic variable and one health behavior (Terre, Ghiselli, Taloney and DeSouza, 1992). There is a caution with this type o f comparison because as there may be some overlap of demographic variables, an exclusive reliance on pairwise comparisons may be misleading. This literature review will summarize the research on the relationship found between demographics and single health behaviors, as well as to participation in a healthy lifestyle the focus of this research. Gender. Although much of the research related to gender differences and health has been on health status and risk behaviors, several studies have reported differential gender patterns o f health behaviors. Adolescent males consistently reported higher levels of physical activity in spite o f the increasing awareness of the importance of physical exercise to female health in terms of osteoporosis and weight regulation (Cohen et al., 1990; Fardy et al., 1994; Federal/Provincial/Territorial Advisory Committee on Population Health, 2000; Kidder, Stein, Fraser, & Chance, 2000; Terre et al., 1992). The incidence of smoking is declining for adolescent males, and is increasing among adolescent females (Cohen et al., 1990; Federal/Provincial/Territorial Advisory Committee on Population Health, 2000). Females report healthier food habits (Cohen et al.). Kidder et al. (2000) reported that female 23 adolescents were unhappier about how they looked and were more likely to diet than their male peers. Gender differences with respect to use of seat belts is less clear. It was found by Health Canada (1999a) and Kidder et al. that girls use seat belts more frequently than boys at all grade levels while Schichor, Beck, Bernstein, and Crabtree (1991), and Tinsley, Holtgrave, Reise, Erdley, and Cupp (1995) found no gender differences in seat belt usage among adolescents. Adolescent females report practicing regular dental hygiene more frequently than males (Health Canada, 1999a; Tinsley et al., 1995). Age. The influence o f age on health behaviors appears to depend on the specific behavior studied. As adolescents get older, there is a progression in health compromising behaviors. This pattern is observed particularly in relation to alcohol, substance use, and the use o f tobacco products (Nutbeam, Aar, and Catford, 1989). Perry, Griffin, and Murray (1985) found that both selection of nutritive food and exercise rates decrease between ages 9 and 16. This concurred with the research of Sallis (2000) who found that the steepest decline in physical activity occurs between 13 and 18 years of age. Consumption of fast foods increases with age (Cohen et al., 1990). Seat belt use and bicycle helmet use decline as adolescents grow older (Health Canada, 1999b; Kidder et al., 2000). Location. The researcher’s review of the literature found there was little research comparing urban and rural adolescents with respect to health-promoting behaviors. The research that has been done has focused on risk behaviors among adolescents either from rural areas or among urban minorities (Felton, 1998; Kristjansdottir & Vilhjalmsson, 2001; Muscari, Phillips, & Bears, 1997; Puskar et al., 1999). Muscari et al. reported that although rural adolescents experience many of the same health issues as urban adolescents, they also face unique health-promotion challenges including access to health promotion services and 24 trained personnel, lack o f social opportunities, and a value system which emphasizes keeping personal issues within the family. Puskar et al. reported that the main health concerns o f the rural adolescents in their study were tiredness, headaches, weight problems, depression, and confusion about the future. Alcohol and tobacco use were the most frequent risk behaviors reported. Felton, in a study o f health promoting behaviors in rural adolescent women, reported that self-image was the most important predictor of health-promoting behavior. Kristjansdottir and Vilhjalmsson found that rural students were more sedentary and less involved in strenuous exercise during their leisure time. Ethnicity and culture. The literature on ethnicity and culture is controversial and the inclusion of these variables in adolescent health surveys raises methodological and social issues (Aspinall, 1997; Bhopal, 1997). For example, there are inconsistent definitions of race, ethnicity and culture as well as, misinterpretation of these words (Michaud, Blum, & Slap, 2001). Currently little is known about how adolescents from ethnically diverse backgrounds perceive their health (Rew, 1997). There is also a lack of information available regarding the cultural impacts on health outcomes (Health Canada, 1999a). Because some ethnic groups may have lower incomes, questions arise in the research literature as to whether differences in adolescents’ health behaviors are the result of ethno-cultural differences or in fact be reflective of socio-economic differences (Blum et al., 2000). Adolescents o f some cultural groups face additional risks because of marginalization, stigmatization and lack o f culturally appropriate health care. Most of the research found in the literature on adolescent health behaviors with respect to ethno-eultural characteristics is centered on health-compromising behaviors. Cigarette and alcohol use was reported to be highest among Caucasian adolescents; Black adolescents were more likely to have had 25 earlier onset o f sexual intercourse and more likely to engage in violence (Blum et al., 2000; Bachman et al., 1991). Chapman and Mullis (2000) found that African-American adolescents reported using coping strategies more frequently than Caucasian adolescents, and Health Canada (1999a) reported that Aboriginal youth have higher injury-related mortality rates, drowning rates and suicide rates. Grade average. Very few studies were found in the literature on the relationship between grade average and adolescent health behaviors. There is a positive relationship reported between grade performance and the health-promoting lifestyles of adolescents (Nutbeam et al., 1989; lessor et al, 1998). Pate et al., (1996) reported that little or no involvement in physical activity was associated with perception of low academic performance. Bailey and Hubbard (1990) in their research found that academic difficulties and low commitment to school are predictive of higher levels of risk behaviors. Socio-economic status (SES). Research indicates that socio-economic inequalities have profound effects on health status and health behavior (Anderson & Armstead, 1995; Link & Phelan, 1995). Higher morbidity and mortality rates have been reported among persons with lower education, income and occupations (Adler, Boyce, Chesney, Folkman, & Syme, 1993; Marmot, Ryff, Bumpass, Shipley, & Marks, 1997). However, the relationship, between socio-economic status and adolescent health status is not clearly defined (Dutton, 1985). In addition, the standard health indicators of mortality and chronic disease are only one aspect o f how health varies in the adolescent population. Wellness indicators are not generally included in health status indicators. Inconsistent or minor differences have been found in self-rated health, chronic disease and measures of general well-being among adolescents by parents’ socio-economic status (Glendinning, Love, Hendry, & Shucksmith, 26 1992; West, 1997). Huurre, Aro, and Rahkonen (2003) in their research found that male and female adolescents from manual class origin had lower self-esteem and females had more distress symptoms. With respect to health behaviors, both genders form manual class families smoked more frequently, reported less physical activity and the proportion of overweight individuals was higher for females in this group. Frequent use of alcohol was reported more frequently by both genders in the non-manual class. No significant class differences were found for either gender for depression, health status or chronic diseases. Conversely, Goodman (1999) in her study of the role of SES on adolescents’ health found that the associations between socio-economic status and self-rated health, depression and obesity were robust. This is significant since both diseases in adolescence are predictive of adult disease. Studies have shown that parental occupation information obtained from adolescents is relatively reliable (Ensminger et al., 2000; Lien, Friestad, & Klepp, 2001; West, Macintyre, Annandale, & Hunt, 1990). For the purposes of this research, SES was determined by combining parents’ occupation, using a national coding system, with parental education. Whether poverty is defined by income, occupation, social class or education, there is a link between those factors and adolescent health and development (Health Canada, 1999a; Kidder et al., 2000). Children from families living in poverty are more likely to experience adverse health effects and experience low academic achievement. They are also less likely to engage. in organized recreational activities that promote self-esteem and physical health (Kidder et al., 2000). Whether the link between SES and adolescent health is direct or intervening remains debatable in the research. 27 There is increasing evidence in the literature that lifestyle factors are major contributors to many o f today’s leading health problems (Gillis, 1997; Pender, Barkauskas, Hayman, Rice, & Anderson, 1992). Many of these health habits and lifestyles are established in adolescence and continue throughout adult life (lessor, 1984; Maggs, Schulenberg, & Hurrelmann, 1997; Millstein, Nightingale, Petersen, Mortimer, & Hamburg, 1993). Self-efficacy has been identified in the research as a predictor of a health-promoting lifestyle. Studies have shown a positive relationship between optimism and better health outcomes and optimism to be an important predictor of well-being. Researchers offer unrealistic optimism as one explanation as to why adolescents take health risks. The influence of demographic characteristics as modifying factors on health-promoting behaviors warrants investigation as they may serve in understanding differences in health behaviors among the adolescent population. Despite an increase in the number of studies done on adolescent lifestyle in recent years, there remains a limited understanding of the factors that influence adolescents’ participation in health-promoting behaviors, as well as limited understanding of the psychosocial variables associated with adolescent engagement in health-promoting behaviors. This is particularly true for adolescents living in the north. This research addressed the lifestyle behaviours of adolescents living in northern British Columbia, as well as, explored the relationship o f self-efficacy, optimism, unrealistic optimism and selected demographic variables to engagement in a health-promoting lifestyle. 28 CHAPTER TWO: METHODS A descriptive correlational design, followed by a series of hierarchical regressions, was used to (1) examine the lifestyle behaviors of adolescents living in the Northern Interior health region of British Columbia; (2) to determine the relationship of the demographic variables of gender, age, location, living arrangements, ethno-cultural group, grade average, risk status, and the educational and socio-economic characteristics of the adolescents’ parents to the lifestyle behaviours of adolescents; and (3) to determine the relationship of selfefficacy, optimism and unrealistic optimism to the practice of a healthy lifestyle among adolescents in this health region. Participants Six hundred and twenty-nine adolescents between the ages o f 13 and 19 years living in the Northern Interior health region participated in this study. Criteria for inclusion in the study were (a) the ability to read and understand English, (b) attendance at a regular education program, or those qualifying as clients of the Youth Around Prince Resource Center (YAP) in Prince George, (c) participant agreement, and (d) parental consent, where appropriate. A cluster sample o f participants was selected from grades eight to twelve in high schools in Prince George and surrounding rural communities. In cluster sampling, the participants are identified from a naturally occurring group unit such as a school district, and then randomly selected from these units for the research. A convenience sample of adolescents was selected from the Youth Around Prince Resource Center (YAP) in Prince George. A convenience sample is one based on selecting participants who are accessible or available. The participants from YAP provided the perspective of at-risk youth. Youth 29 Around Prince Resource Center is a Ministry of Children and Families Development service that also incorporates community services and the services of other Ministries in providing multidisciplinary, integrated support services that are youth-centered. One of the goals of YAP is to prepare youth for independent living through the provision of education, life skills, counselling, employment preparation and peer support programs. The youth who access YAP are considered at-risk because of unstable personal relationships or home situations, a history of neglect or abuse, drug and alcohol use, and/or not being integrated in the regular school system. As such, these adolescents require more than one core service. Adolescents receiving services from the child welfare system are more likely to have emotional, behavioral and learning problems that affect their physical, psychological and emotional health (Kidder et al., 2000). The consent parameters of school district administration, the willingness of adolescents to participate, as well as parental consent, where required, influenced the selection of the participating communities throughout the region. A sample size o f 500 adolescents was arbitrarily estimated to be required to take into account the need to over sample because of failure to return questionnaires and unusable questionnaires. In addition, a sufficient number of participants was required from the different subgroups selected so that any differences in lifestyle practices related to gender, school district, school location, living arrangements, ethno-cultural groups, risk status, age, grade average and the socio-economic level and educational level of the parents could be identified. O f the 629 adolescents who participated in the study, 595 attended secondary school and the 34 at-risk youth from YAP either attended alternate education classes or did not attend school. The gender of the adolescents was roughly evenly divided with 317 (50.4 %) being female and 308 (49.0 %) being male. Four (0.6 %) of the participants did not 30 identify their gender. O f the two school districts within the Northern Interior health region, 416 (66.1 %) o f the participants were from School District #57 and 213 (33.9 %) were from School District #91. Three hundred and seventeen (50.4 %) of the participants were from urban Prince George and 312 (49.6 %) of the participants were from four surrounding rural communities. Of the initial 638 returned questionnaires, 629 were usable (99.0 %). Seven (1.0 %) were not usable because o f missing data or evidence that the respondents had not taken the questionnaire seriously. Two (0.31 %) of the respondents did not qualify because of their age. Ethics The Ethics Committee o f the University o f Northern British Columbia and B.C. School Districts #57 and #91 approved the study. Approval was also received from Youth Around Prince Resource Center. Participants attending school, as well as their parents, were asked to sign a consent form that fully described the nature o f the study and their role in it (Appendices F and G). Participants at Youth Around Prince Resource Center were asked to sign the consent form before participating. However, because of their more independent living arrangements, parental consent was not required. Participants were informed that their participation was voluntary, that they could withdraw at any time and that the information collected was anonymous as no identifying information was collected. Data were secured in locked files. Participants were informed that a copy of the research findings would be kept at the school district office, at requesting schools and at Youth Around Prince Resource Center. If participants wished to receive an individual copy of the results of the study, they were informed that they could request a copy from the researcher. 31 Materials Participants were given one package of questionnaires with the instrument names removed. This was done so that the participants would not be influenced in their answers by the use of such terms as unrealistic optimism questionnaire and self-efficacy scale, for example. Demographic Data: The instrument that was used to collect the socio-demographic data on the participants and their parents was the investigator developed Adolescent Demographic Questionnaire (Appendix A). This tool collected information on age, gender, ethno-cultural background, school location, grade level, grade average, living arrangements, and socio­ economic factors. Adolescent lifestyle. Information on the lifestyle practices of the participants was obtained via the Adolescent Lifestyle Questionnaire (Appendix B), developed and tested by Gillis (Gillis, 1997). The Adolescent Lifestyle Questionnaire (ALQ) is a 43-item instrument consisting o f seven subscales: nutrition, physical participation, social support, stress management, identity awareness, general health practices awareness, and safety. These subscales are considered dimensions of a healthy lifestyle in adolescence. The ALQ uses a 5-point Likert type scale with responses ranging from 1 “never” to 5 “almost always”. This instrument was used because it enabled the researcher to investigate lifestyle patterns in adolescents. The preliminary testing of the instrument showed evidence of validity and reliability among rural, middle class adolescents (Gillis, 1997). The dimensional structure is based on the outcomes of factor analytic studies utilizing populations similar to that examined in the present study. The word “usually” was eliminated in this research from questions 20, 35, 37, 38, and 41 so as to decrease confusion in the ratings of the adolescents. 32 Self-efficacy. Self-efficacy, defined as a person’s belief that one can successfully perform the behavior in question (Sherer et al., 1982), was measured by using the General SelfEfficacy Subscale of Sherer et al. (1982), (Appendix C). The General Self-Efficacy Subscale employs a five point Likert type scale with response choices ranging fi'om 1 “disagree strongly’’ to 5 “agree strongly’’. Some items are reversed scored. The General Self-Efficacy Scale was selected because it has established reliability and construct and criterion validity; it has been used with different age groups including adolescents; and it is the most frequently used measure o f self-efficacy in relation to health-promoting behaviors (Gillis, 1993b). This measure is not tied to specific situations or behaviors. The General Self-Efficacy subscale does not include the 6 items of the Social Self-Efficacy Subscale or the 7 filler items. Optimism. Optimism, the tendency to believe that one will generally experience good versus bad outcomes in life (Scheier & Carver, 1985), was measured by the Life Orientation Test (LOT), (Scheier & Carver, 1985), (Appendix D). The LOT consists of eight items plus four filler items that were inserted to disguise the underlying purpose o f the test. Respondents are asked to indicate their answers using a scale ranging from 4 “strongly agree” to 0 “strongly disagree”. In order to keep the rating of the scales consistent for the participants, the researcher reversed the scoring o f the items in this scale. Adequate internal consistency, reliability and validity have been demonstrated for this scale (Scheier and Carver, 1985). Unrealistic optimism or optimistic bias. Optimistic bias, the belief that other people, but not oneself, are more likely to develop a disease, have an accident, or experience other negative events (Weinstein, 1987) was measured by the shortened version of the Unrealistic Optimism Measure (UOM, Weinstein, 1987), (Appendix E). The shortened version of the UOM was used because in past research these 11 items have found a range of optimistic biases in 33 assessing peoples’ health-related risks (Weinstein, 1987). In addition, pilot testing of both measures by Davidson and Prkachin (1997) found higher internal consistency for the 11 items than for the 42-item scale. Procedures A preliminary overview of the research proposal was presented to the Director of Curriculum and Instruction for School District #57, the Superintendent of School District #91 and the Program Coordinator of Youth Around Prince Resource Center to determine their willingness to participate in the research and to elicit their input on how best to conduct this research within the schools and agency. Preliminary approval to conduct the research within the schools was given dependent on the approval of the Ethics Committee at the University o f Northern British Columbia, approval of the School Districts’ Ethics Committee, the school board, and the principals of the participating schools. Preliminary approval to conduct the research at Youth Around Prince Resource Center was given based on the approval o f the Ethics Committee at the University of Northern British Columbia. After approval was received from the Ethics Committee of the University o f Northern British Columbia, a copy of the research proposal was provided to both School Districts and the Program Coordinator o f Youth Around Prince Resource Center. Permission was granted to conduct the research in School District #57 based on the consent of each principal and the signed consents o f the participating students and their parent. Permission was granted by School District #91 based on the consent of the participating students and the passive consent of their parents. Passive consent of parents was obtained by the School District sending a notice home to the parents informing them of the research and advising them to contact the school if they did not wish their adolescent to be involved in the research. A letter was sent 34 by each School District to their respective principals informing them that the researcher would be contacting them for permission to conduct the research in their school. Youth Around Prince Resource Center granted permission based on the adolescents’ willingness to participate. Personal or phone interviews were arranged with the principals of seven of the eight secondary schools in School District #57. O f the seven schools contacted, the research was carried out in six. Phone interviews were arranged with the principals of two of the four secondary schools in School District #91. Both o f these schools participated in the research. The reasons for the four secondary schools not participating were either because consents were not returned or attempts to arrange for the discussion of how the research would be carried out were not successful during the time period. For the secondary schools in Prince George, the researcher either met with the individual teachers who had students participating in the research or with the teacher assigned to coordinate the research for that school. The purpose of the meeting was to explain the research, review the instructions for the participants, and to arrange for the distribution and return o f the consents and questionnaires. For the rural schools, this process was carried out by telephone with the school principal and in some schools with the classroom teacher. The students who participated in the research in four o f the secondary schools were registered in the Career and Personal Planning (CAPP) class during the semester the questionnaires were to be completed. In the remaining four secondary schools, a class representing each grade from eight to twelve was selected based on a particular class block. For Youth Around Prince Resource Center, the program coordinator organized the distribution o f the questionnaires after the instructions for completion were reviewed. 35 Following receipt o f the consent forms, where required, participants attending school completed the set o f questionnaires during a class block. Participants attending Youth Around Prince Resource Center completed the set of questionnaires during a conveniently arranged time. The adolescents completed the instruments independently during the period of December 2001 to January 2002. The completed packages were returned to the teacher or for those not attending school, to the coordinator at the site, who forwarded them to the researcher. The data from the questionnaires were entered into an Excel spreadsheet and subsequently transferred to a Statistical Package for the Social Sciences (SPSS) data file (SPSS 7.5,1996) for analysis. Descriptive and inferential statistics were used to interpret the data. Frequency distributions were used to tabulate the demographic data o f the participants and their parents. Chi-square tests were used to measure the relationship between the subscales o f the Adolescent Lifestyle Questionnaire and the various categorical predictor variables. Pearson’s product-moment correlation coefficients were calculated between the seven subscales of the Adolescent Lifestyle Questionnaire and the identified continuous predictor variables. Finally, a hierarchical regression analysis was used to identify the relative contribution of the predictor variables to a healthy level of the seven subscales of the Adolescent Lifestyle Questionnaire. 36 CHAPTER THREE: RESULTS After the initial cleaning and verification procedure, the data from the questionnaires were analyzed. First, the sample of adolescents and their parents is described. Then the nonparametric testing o f the seven subscales of the Adolescent Lifestyle Questionnaire using the chi-square for the categorical variables of gender, school district, school location, ethno­ cultural groups, living arrangements and risk status is presented. Next, the Pearson’s product-moment correlation coefficients calculated between the identified continuous predictor variables o f age, grade average, parent education and parent job and the criterion measures of the seven subscales o f the Adolescent Lifestyle Questionnaire are presented. Finally, the hierarchical regression analyses performed to examine how large a contribution the significant demographic variables, as well as the variables of optimism, unrealistic optimism and self-efficacy played in predicting a health-promoting lifestyle are presented. Demographic Information Age. The adolescents ranged in age from 13 to 19 years with a mean age of 15.3, standard deviation of 1.43. O f the twenty-six 18 and 19-year-old participants, 14 (53.8 %) were attending YAP, 6 (23.1 %) were attending high schools in Prince George, and 6 (23.1 %) were attending high schools in the rural communities of School District #91. 37 Table 1 Range o f Ages for Adolescents Years Number Percent 13 95 15.1 14 88 14.0 15 140 22.3 16 179 28.5 17 101 16.1 18 19 3.0 19 7 1.1 Ethno-cultural group. O f the participants, 433 (68.8 %) were Caucasian, 55 (8.7 %) were Aboriginal and 39 (6.2 %) were of mixed ethno-cultural origins. The remaining 67 (10.7 %) participants who responded to this item identified themselves as South Asian, Chinese, Arab/West Asian, Latin American, Korean, Black, Philippine, Southeast Asian, Japanese or other. Ethno-cultural origin was not identified by 35 (5.6 %) of the sample. 38 Table 2 Ethno-Cultural Origin o f Adolescents Ethno-cultural origin Frequency Percent Caucasian 433 68.8 Aboriginal 55 8.7 Chinese 5 0.8 South Asian 27 4.3 Black 1 0.2 Arab/West Asian 4 0.6 Philippine 1 0.2 Southeast Asian 1 0.2 Latin American 3 0.5 Japanese 1 0.2 Korean 2 0.3 Multiple 39 6.2 All Others 22 3.5 No response 35 5.6 Grade. Over half, (51.9 %) of the adolescents were in grades 10 and 11. The 3 (0.5 %) who were not attending school were at-risk adolescents attending the Youth Around Prince program in Prince George. The remaining adolescents were evenly distributed among grades eight, 110 (17.5 %); nine, 96 (15.3 %); and twelve, 93 (14.8 %). 39 Grade average. An A or B grade average was reported by 367 (58.3 %) of the participants. An average o f C- or less was reported by 41 (6.5 %) participants. Two hundred and nineteen (34.8 %) of the adolescents reported a grade average o f C to C+. Table 3 Grade Average o f Adolescents Grade average Frequency Percent A 118 18.8 B 249 39.6 C+ 136 21.6 c 83 13.2 c- 35 5.6 .5 large; .3 ^ < .5 medium; .1 ^ < .3 small Regression Analvsis of the Predictor Variables to the Seven Subscales of the ALQ Hierarchical regression analyses were performed to model relationships among the demographic variables, self-efficacy, optimism, and unrealistic optimism and each of the seven subscales o f the Adolescent Lifestyle Questionnaire. In step one o f the hierarchical regression, the nominal variables of gender, school district, school location, living arrangements, etlmo-cultural groups and risk status, that had statistically significant chisquare values with respect to the seven subscales, were entered into the equation as predictor variables. In step two, the continuous variables of age, grade average, parent education and parent job, that had a statistically significant correlation with respect to the seven subscales. 53 were entered into the equation as predictor variables. In step three, the scores on the selfefficacy, optimism, and unrealistic optimism scales were entered into the equation. This model of analysis was repeated for each o f the seven subscales of nutrition, physical participation, social support, stress management, identity awareness, general health practices awareness, and safety. Results are shown in Tables 15-21. Cohen’s classification (1992) for the significance o f the correlations/^ was used which gives the effect size indexes, small, medium and large at .02, .15, and .35 respectively. Nutrition. The percentage of variance in a healthy nutrition level explained in step one by gender was 5.0 %. The regression analysis of model 1 was significant, F (1,628) - 32.976,/? < .001. The addition of age and grade average to the equation in model 2 added an additional 9.0 % to the variance that was accounted for, which was significant, F (3,628) = 35.285, p < .001. The percentage of variance due to the addition of the variables o f self-efficacy, optimism, and unrealistic optimism in model 3, was 10.0 %, which was significant, F (6,628) = 32.450,/? < .001. The variables of gender, grade average, self-efficacy and optimism entered in step 3 made a statistically significant contribution to a healthy nutrition level at the p < .001 level. The variables of age and umealistic optimism were statistically significant at the p < .01 level. In step 3, the direction of the relationship was positive for female gender, grade average and self-efficacy. The direction of the relationship was negative for age, optimism and unrealistic optimism. The effect size of the correlation according to Cohen’s classification (1992) was calculated to be medium =.31). 54 Table 15 Summary o f Hierarchical Regression Analysis fo r Variables Predicting a Healthy Nutrition Level Among Adolescents (N = 629) B SEB P J6 9 .064 .224*** Gender .293 .062 .178*** Age -.063 .022 -.110** Grade average .192 .027 .271*** Gender J55 .060 .215*** Age -.066 .021 -.115** Grade average .142 .027 .199*** Self-efficacy .310 .054 .217*** Optimism -.337 .062 -.193*** Unrealistic optimism -.104 .030 -.127** Variable Step 1 Gender Step 2 Step 3 . ..... ... ....... ; (/75<.001). *p<. 05; **p<. 01; 001. ......... 55 Physical participation. The percentage of variance accounted for in model 1 by the variables o f gender, living arrangement, school location and risk status was 8.0 %. The regression analysis of model 1 was significant, F (4, 628) = 13.695, < .001. The addition of age, grade average and parent education in model 2 accounted for an additional 20.0 % of the variance which was significant, F (7, 628) = 33.688, p < .001. The addition o f the variables self-efficacy, optimism, and unrealistic optimism in model 3 accounted for an additional 7.0 % of the variance, which was significant, F (10, 628) = 32.216,/? < .001. The variables of gender, age, grade average, self-efficacy and optimism entered at step 3 made a statistically significant contribution to a healthy level of physical participation at the /? < .001 level. Parent education and unrealistic optimism were significant at/? < .01 level. School location, living arrangements and risk status were not statistically significant. In step 3 the direction o f the relationship was positive for grade average, parent education and selfefficacy. The direction o f the relationship was negative for the variables of gender, age, optimism and unrealistic optimism. The effect size of the correlation was calculated to be large - .52). 56 Table 16 Summary o f Hierarchical Regression Analysis fo r Variables Predicting a Healthy Physical Participation Level Among Adolescents (N = 629) B Variable SE E P Step 1 Gender -.448 487 -.200*** School location .180 489 .081* Living arrangement -.149 .074 -.084* Risk status -.472 321 -.095* Gender -.566 .079 -.252*** School location .122 .081 .055 Living arrangement -.025 .067 -.014 Risk status -.039 .193 -.008 Age -.212 429 -.271*** Grade average ^68 .035 .276*** Parent education .114 .030 .135*** Gender -.495 .076 -.220*** School location .130 .077 458 Living arrangement -.036 .064 -.020 Risk status -.087 .185 -.018 Age -jT 9 428 _ 279*** Grade average .202 435 .208*** Parent education 497 429 .117** Self-efficacy .406 469 .209*** Optimism -306 .079 -.129*** Unrealistic optimism -.117 438 -.105** Step 2 Step 3 iNUlC. IV — .UOi iU l OLCp 1 , £iiv (ps < .001). *p < .05; **p < .01; ***p < .001. ‘ AT... .195 for Step 2 {ps<■ .001); AR ..for Step 3 57 Social support. The percentage of variance in a healthy social support level explained in model 1 by gender was 10.0 %. The regression analysis of model 1 was significant, F (1,628) = 66.811,/? < .001. The addition o f grade average and parent education to the equation in model 2 explained an additional 5.0 % of the variance which was significant F (3,628) = 34.091,/? < .001. The percentage of variance due to the variables o f self-efficacy, optimism, and unrealistic optimism added in model 3 was 13.0 % which was significant F (6,628) - 37.549,/? < .001. The variables of gender and self-efficacy entered at step 3 made a statistically significant contribution to a healthy social support level at the /? < .001 level. The variables o f grade average, optimism and unrealistic optimism were significant at the p < .05 level. In step 3, the direction of the relationship was positive for gender, grade average, and self-efficacy. The direction o f the relationship was negative for optimism and unrealistic optimism. The effect size of the correlation was calculated to be large (f^ = .36). 58 Table 17 Summary o f Hierarchical Regression Analysis fo r Variables Predicting a Healthy Social Support Level Among Adolescents (N = 629) B SE E P .424 .052 .310*** Gender .376 .052 .275*** Grade average .107 .023 .183*** Parent education .042 .019 .082* Gender .419 .048 .307*** Grade average .052 .022 .088* Parent education .029 .018 .057 Self-efficacy .398 .044 .330*** Optimism -.175 .050 -.121* Unrealistic optimism -.064 .024 -.095* Variable Step 1 Gender Step 2 Step 3 Note. - .096 for Step 1; AR^ - .044 for Step 2 (ps < .001); AR^ for Step 3 = .125 {ps < .001). *p < .05; **p < .01; ***p < .001. 59 Stress management. The percentage of variance in a healthy stress management level explained in step 1 by gender was 4.0 %. The regression analysis of model 1 was significant, F (1,628) = 27.011, p < .001. The addition of grade average and parent education to the equation in model 2 explained an additional 6.0 % of the variance which was significant, F (3.628) = 23.522, /? < .001. The percentage of variance due to the variables of self-efficacy, optimism, and unrealistic optimism added in model 3 was 9.0 % which was significant, F (6.628) = 24.272,/? < .001. The variables of gender, grade average, self-efficacy and optimism entered at step 3 made a statistically significant contribution to a healthy stress management level. Parent education and umealistic optimism were not significant. In step 3, the direction of the relationship was positive for gender, grade average, and self-efficacy. The direction o f the relationship was negative for optimism. The effect size of the correlation was calculated to be medium {f^ = .23). 60 Table 18 Summary o f Hierarchical Regression Analysis fo r Variables Predicting a Healthy Stress Management Level Among Adolescents (N = 629) B SEE P .345 .066 .203*** Gender .271 .065 .160*** Grade average .170 .029 .232*** Parent education .036 .025 .056 Gender .320 .063 .189*** Grade average .120 .028 .164*** Parent education .022 .024 .035 Self-efficacy .364 .057 .248*** Optimism -.320 .066 -178*** Unrealistic optimism -.060 .032 -.072 Variable Step 1 Gender Step 2 Step 3 ... ............Z77:"n... ......... ............7 (ps < .001). *p < .05; **p < .01; ***p < .001. ... 61 Identity awareness. The percentage of variance in a healthy identity awareness level explained in model 1 by grade average and parent education was 9.0 %. The regression analysis o f model 1 was significant, F (2,628) = 32.473,/? < .001. The percentage of variance due to the addition o f self-efficacy, optimism, and unrealistic optimism in model 2 was 28.0 % which was significant F (5,628) = 73.166, p < .001. The variables of grade average, self-efficacy, optimism and unrealistic optimism entered at step 2 made a statistically significant contribution to a healthy identity awareness level. Parent education was not statistically significant. In step 2 the direction of the relationship was positive for grade average and self-efficacy. The direction of the relationship was negative for optimism and unrealistic optimism. The effect size of the correlation was calculated to be large .59). 62 Table 19 Summary o f Hierarchical Regression Analysis fo r Variables Predicting a Healthy Identity Awareness Level Among Adolescents (N = 629) Variable B Grade average Parent education SEE P .153 .022 .271*** .049 .019 .100* Grade average .086 .019 .152*** Parent education .032 .016 .065 Self-efficacy .491 .039 .433*** Optimism -.339 .045 -.244*** Unrealistic optimism -.129 .021 -.199*** Step 1 Step 2 .................................. — Note. = .094 for Step 1; AR = .276 for Step 2{ps< .001). *p < .05; **p < .01; ***p < .001. 63 General health practices awareness. The percentage of variance in a healthy general health practices awareness level explained in model 1 by gender, ethno-cultural group and living arrangement was 10.0 %. The regression analysis of model 1 was significant, F (3,628) = 22.295, p < .001.The addition of age and grade average to the equation in model 2 explained an additional 5.0 % of the variance which was significant, F (5,628) = 22.154, p < .001. The percentage of variance due to the variables of self-efficacy, optimism, and unrealistic optimism added in model 3 was 7.0 % which was significant F (8,628) = 21.588, p < .001. The variables o f gender, ethno-cultural group, grade average, self-efficacy and optimism entered at step 3 made a statistically significant contribution to a healthy general health practices awareness level at the /? < .001 level. The variables of living arrangement and age made a statistically significant contribution at the p < .05 level. Unrealistic optimism was not statistically significant. In step 3, the direction of the relationship was positive for gender, living arrangements, ethnicity, grade average and self-efficacy. The direction of the relationship was negative for age and optimism. The effect size of the correlation was calculated to be medium (f^ - .28). 64 Table 20 Summary o f Hierarchical Regression Analysis fo r Variables Predicting a Healthy General Health Practices Awareness Level Among Adolescents (N = 629) Variable SEE B (3 Step 1 Gender .475 .069 .264*** Living arrangement .091 .054 .064 Ethno-cultural group .164 .045 .138*** Gender .412 .068 229*** Living arrangement .165 .054 .116* Ethno-cultural group .166 .044 140*** Age -.067 .024 -.106* Grade average .152 .030 196*** Gender .466 .066 .248*** Living arrangement .155 .052 .109* Ethno-cultural group .155 .042 .130*** Age -.075 .024 -.119* Grade average .107 .030 .138*** Self-efficacy .335 .060 .215*** Optimism -.350 .069 -.184*** Unrealistic optimism .079 .033 .009 Step 2 Step 3 ..^............... {ps < .001). *p < .05; **p < .01; * * * p < .001. 65 Safety. The percentage of variance in a healthy level of safety behaviors explained in model 1 by gender, ethno-cultural group and risk status was 10.0 %. The regression analysis of model 1 was significant, F (3 , 628) = 21.806,/? < .001. The addition of age, grade average and parent education to the equation in model 2 explained an additional 14.0 % of the variance which was significant, F (6,628) = 30.967,/? < .001. The addition of self-efficacy, optimism and unrealistic optimism to the equation in model 3 explained an additional 5.0 % o f the variance which was significant F (9,628) - 27.311,/? < .001. The variables of gender, risk status, grade average, and unrealistic optimism made a statistically significant contribution at the/? < .001 level. Self-efficacy made a statistically significant contribution at the /? < .01 level and optimism made statistically significant contribution at the p < .05 level. Ethno-cultural group, age and parent education were not statistically significant. In step 3, the direction o f the relationship was positive for gender, grade average, and selfefficacy. The direction o f the relationship was negative for risk status, optimism and unrealistic optimism. The effect size of the correlation was calculated to be large (f^ = .39). 66 Table 21 Summary o f Hierarchical Regression Analysis fo r Variables Predicting a Healthy Safety Level Among Adolescents (N = 629) Variable B SE E P Step 1 Gender .402 .061 .252*** Ethno-cultural group .072 .040 .007 Risk status -.671 .134 -.191*** Gender .293 .057 .184*** Ethno-cultural group .017 .037 .016 Risk status -.474 .130 -.135*** Age -.023 .021 -.041 Grade average .245 .026 .357*** Parent education .026 .022 .044 Gender .349 .056 .218*** Ethno-cultural group .059 .036 .006 Risk status -.500 .126 -.142*** Age -.022 .021 -.039 Grade average .211 .026 .306*** Parent education .019 .021 .033 Self-efficacy .162 .051 .117** Optimism -.116 .058 -.069* Unrealistic optimism -.144 .028 -.183*** Step 2 Step 3 . ips < .001). *p < .05; **p < .01; ***p < .001. 67 CHAPTER FOUR: DISCUSSION This study examined the lifestyle behaviors of adolescents living in the Northern Interior health region o f British Columbia to determine whether there were differences in lifestyle behaviors based on gender, age, location, ethno-cultural factors, education level, grade average, living arrangements, risk status and the socio-economic characteristics of their parents and to determine which of these variables, in addition to the variables of selfefficacy, optimism and unrealistic optimism, best predicted the practice of a healthpromoting lifestyle. I will begin this discussion with a summary o f the main findings of this study; then relate these current findings to that found in the literature; and finally I will consider the implications o f the findings for nursing practice, education, public policy and future research. An examination o f the relationship between the seven subscales of the Adolescent Lifestyle Questionnaire (Gillis, 1997) and the nominal variables showed that, with the exception o f identity awareness, the other six subscales had a significant relation with gender. Being female was associated with reporting healthy nutrition, and higher levels of social support, stress management, general health practices awareness and safety. Being male was associated with more healthy physical participation. All of the relationships between the six subscales and gender were significant at the p <001 level. These findings are consistent with that found in the research with respect to nutrition (Cohen et al., 1990) and with respect to physical participation (Terre et al., 1992). Living arrangements had a significant relationship with physical participation and general health practices awareness. These relationships were significant at thep < .05 level. Adolescents who lived with two parents reported healthy physical participation more 68 frequently than those adolescents living in single-parent families or in other living arrangements. Possible explanations for this could be related to the type of physical activities that adolescents are engaged in. Adolescents, today, are moving to more structured exercise activities in the form o f teams or clubs and moving away from casual exercise with friends such as riding bikes or playing street hockey (Health Canada, 1999b). Adolescents who are living on their own, in single-parent families or with others may not have the financial resources to afford registration and equipment costs. Also, parental levels of physical activity and their belief in the value of being active have a strong influence on their children’s activity level (Health Canada, 1999a). Single parents who are working would have less time to engage in recreational physical activity and thus would not role model this for their children. Adolescents who lived on their own or in households with people other than single or two parents reported healthy general health practices awareness more frequently than those living with parents. Although the literature reports that adolescents who are strongly connected with one or both parents are less likely to engage in risk behaviors such as early and unprotected sex, smoking and alcohol and drug use (Kidder et al., 2000), the current research found no statistically significant differences in these areas among adolescents living with parents, on their own or with others. School location (urban versus rural) had a statistically significant relationship with physical participation at p < .001. In this study, adolescents from rural communities reported engaging in healthy physical participation more frequently than adolescents from the urban community of Prince George. This finding was different from that of Kristjansdottir and Vilhjalmsson (2001) who reported that rural students were more sedentary and less involved in strenuous exercise during their leisure time. 69 Ethno-cultural group was significantly related to general health practices awareness ip <001) and safety ip < .05). Adolescents who identified themselves as having an ethno­ cultural origin other than Caucasian and Aboriginal reported better general health practices awareness and safety more frequently. Risk status was related significantly to physical participation (p < .001) and safety ip < .01). Adolescents who attended regular school reported healthy physical participation and healthy safety more frequently than those adolescents who attended the Youth Around Prince program. There were no significant differences between adolescents living within the boundaries o f School District #57 and those living within the boundaries o f School District #91. Of the continuous variables, age was negatively correlated with nutrition, physical participation and general health practices awareness. Younger adolescents reported healthy levels of these health behaviors more frequently than older adolescents. Grade average was positively correlated with all of the lifestyle subscales. Those students who did better in school more frequently reported healthy nutrition, physical participation, social support, stress management, identity awareness, general health practices awareness, and safety. There was a statistically significant correlation between parent education and the subscales of physical participation, social support, stress management, identity awareness and safety. Adolescents o f parents who had higher levels of education reported healthy levels of these subscales more frequently than those adolescents of parents with lower education levels. There were no statistically significant correlations between parent job and any of the lifestyle subscales. All of the significant correlations between age and grade average and the seven subscales of the Adolescent Lifestyle Questionnaire had either a medium or small effect size. 70 All o f the correlations between parejit education and the seven subscales had a small effect size. Modeling adolescent lifestyle, hierarchical regression analyses of the predictors of the seven subscales o f the Adolescent Lifestyle Questionnaire showed strong relationships between specific predictor variables and the various subscales of a health-promoting lifestyle. Female adolescents who had a higher grade average and higher self-efficacy showed higher degrees of healthy nutrition while adolescents who were older and had higher levels o f optimism and unrealistic optimism showed lower healthy nutrition. Taken together, these variables contributed to explaining 9.0 % (p < .001) of the variance in healthy nutrition scores. Better grade average, greater self-efficacy scores and higher parental education levels predicted more healthy levels o f physical participation. Being female, older and having higher levels of optimism and unrealistic optimism predicted less healthy physical participation. Together, these variables contributed to explaining 7.0 % {p < .001) of the variance in healthy physical participation scores. Being female, having a better grade average and a higher self-efficacy score predicted more healthy levels o f social support while higher levels of optimism and unrealistic optimism predicted less healthy levels of social support. These variables contributed to explaining 13.0 % {p < .001) o f the variance in healthy social support scores. With respect to stress management, being female, having a better grade average and a higher self-efficacy score predicted more healthy stress management scores while higher optimism score was a negative predictor of healthy stress management. Together they 71 contributed to explaining 9.0 % {p < .001) of the variance in healthy stress management scores. Having a better grade average and higher self-efficacy were positive predictors of healthy identity awareness. Higher levels of optimism and unrealistic optimism were negative predictors o f healthy identity awareness. These variables contributed to explaining 28.0 Vo(p< .001) o f the variance in healthy identity awareness scores. Being female, living alone or with people other than parents, being from an ethno­ cultural group other than Caucasian or Aboriginal, having a better grade average and higher level o f self-efficacy were positive predictors of healthy general health practices awareness while being an older adolescent and having a higher level of optimism were negative predictors. Together they contributed to explaining 7.0 % ( p < .001) o f the variance in healthy general health practices awareness scores. Being female, having a better grade average and greater self-efficacy were positive predictors o f healthy safety practices. Belonging to the at-risk group, and having a higher level o f optimism and unrealistic optimism were negative predictors. Taken together, these variables contributed to 5.0 % ( p < .001) of the variance in healthy safety scores. Each of the variables o f risk status, living arrangements, ethno-cultural group and parent education were predictive of only one subscale of the ALQ. In the case of risk status it was safety. Adolescents who were defined as at-risk in this study, namely those who attended YAP, had less healthy safety behaviors, while attendence at regular school was predictive o f healthy safety behaviors. For living arrangements, it was general health practices awareness in that being an adolescent who lived on his/her own or with other than one or both parents was predictive of having healthy general health practices awareness. For 72 ethno-cultural group, it was general health praetices awareness in that being of an ethno­ cultural group other than Caucasian or Aboriginal was predictive of healthy general health practices awareness. For parent education, it was physical participation in that being an adolescent of parents who had a higher level of education was predictive of healthy physical participation. Caution must be exercised in interpreting the significant relationship finding between risk status and the safety subscale, as there was minimum representation of the atrisk group, only 5.3 % o f the sample in this study. This caution should also be exercised in interpreting the relationship between living arrangements and the general health practices awareness subscale as the representation of subjects living in households with other than both or single parents was only 8.8 %. The likelihood o f misinterpretation is high given the disproportionate representation o f these participants. Age was predictive o f four subscales of the ALQ - nutrition, physical participation, general healthy practices awareness and safety. Unrealistic optimism was predictive of five of the subscales o f the ALQ -nutrition, physical participation, social support, identity awareness and safety. Optimism was predictive of six of the subscales of the ALQ nutrition, physical participation, social support, stress management, identity awareness and general health practices awareness. Both grade average and self-efficacy were predictive of all seven of the subscales of the ALQ. The effect size of the product-moment correlations, using Cohen’s classification (1992), between the continuous variables and the subscales of the ALQ were either small or medium. The effect size of the correlations, between the predictor variables and each of the seven subscales of the ALQ were either medium or large. As no research was found that examined the specific relationships of the specific variables o f this study to adolescent lifestyle or the subscales of the Adolescent Lifestyle 73 Questionnaire, the results o f this research will be compared to related research in the literature. The Role o f Self-Efficacy Self-efficacy has been found to be a significant predictor of health-promoting behaviors (Gillis, 1993a; Levinson, 1986) and health behavior change and maintenance (Hofstetter et al., 1990; Strecher et al., 1986). In the current study, self-efficacy was a significant predictor o f a healthy level of all the seven subscales of the Adolescent Lifestyle Questionnaire. This is contrary to what Maibach and Murphy (1995) proposed. Maibach and Murphy stated, “measures o f generalized self-efficacy have little explanatory and predictive value” (p 40). The results, however, are consistent with the research of Gillis (1993b) who found that self-efficacy, as measured by the general self-efficacy scale, was a significant predictor of an overall health-promoting lifestyle as well as a significant predictor o f the subscales o f nutrition, exercise and interpersonal support. The results of the present study support previous findings that self-efficacy is predictive o f healthy eating behavior (Gillis, 1993b; Gracey et al., 1996; Heatey & Thombs, 1997; Hertog et al., 1993); physical activity (Garcia et al., 1995; Gillis, 1993b; Pender et al., 2002; Sallis et al., 2000); social support (Gillis, 1993b; Heraldo Gacad, 2002) stress management (Boardway et al., 1993; Matsushima & Shiomi, 2003); safety with respect to contraception (Heinrich, 1993; Levinson et al., 1998) HIV/AIDS/STD prevention through condom use (Baele, Dusseldorp, & Maes, 2001; Basen-Engquist & Parcel, 1992) to substance abuse prevention (Hersch, 1997); and to smoking resistance and cessation (Martinelli, 1996). 74 The implication of these findings is that providing health education, in itself, to adolescents on a health-promoting lifestyle is not sufficient. Health education research has established that providing information rarely is sufficient to initiate or maintain health behaviors (Curtis, 1992; Hatcher & Scarpa, 2002). Efforts should also include promoting self-efficacy, which has been shown to not only have a direct impact on behavior but also to mediate the transition o f knowledge into behavior. Health promoting interventions based upon the self-efficacy concept would allow the consideration of personal, social and environmental variables that influence adolescents in their everyday life (Holloway & Watson, 2002). One way of incorporating self-efficacy development into health-promoting interventions is through the social learning theory techniques of modeling and skill training. By having adolescents observe their peers role model health-promoting behaviors, by involving them in role plays or having them watch videos of the health behavior to be promoted, self-efficacy can be fostered. In skill development the desired health-promoting behavior would be broken down into the tasks needed for successful completion and positive reinforcement given for each step attained. The Role of Optimism Optimism is defined by Scheier and Carver (1985) as the tendency to believe that one will experience positive outcomes in life. The research shows optimism to be an important predictor o f well-being (Cassidy, 2000; Scheier et al., 1989). Research on optimism with adolescents has generally found it to be positively correlated with self-rated health (Cassidy, 2000); general health-promoting behaviors (Mulkana & Hailey, 2001); coping (Aspinwall & Taylor, 1992; Scheier et al., 1994); general interest in school and peer relationships (Koizumi, 1995); less depression and anger (Puskar et al., 1999); and psychosocial resilience 75 (Tusaie-Mumford, 2001). Only one study in the literature on adolescents (Goodman et al., 1995) found that optimism was not associated with behaviors that are health protective and this was in respect to HIV prevention. The findings o f the present study indicated that optimism was predictive of all seven subscales o f the Adolescent Lifestyle Questionnaire including nutrition, physical participation, social support, stress management, identity awareness, general health practices awareness and safety. However, the relationship for all seven was negative. This was an unexpected finding and was not the general finding in the research. A possible explanation for this is presented in the following section on unrealistic optimism. The Role o f Unrealistic Optimism Unrealistic optimism is the tendency of individuals to believe they are more likely than the average person or comparable person in terms of age, gender and educational background, to experience positive outcomes and less likely than the average person or comparable person to experience negative outcomes (Weinstein, 1980). A review of the literature on unrealistic optimism in adolescents found only research that was related to risk behaviors and not health-promoting behaviors of adolescents. The findings of the present study indicated that unrealistic optimism was predictive of five of the subscales of the Adolescent Lifestyle Questionnaire including nutrition, physical participation, social support, identity awareness and safety. However, the relationship was negative. Unrealistic optimism was not predictive o f stress management and general health practices awareness behaviors. The findings o f this research concurred with the literature with respect to unrealistic optimism being negatively correlated with healthy behaviors. 76 One could infer from the findings in the present research that in this adolescent sample, optimism had the same effect as unrealistic optimism. One explanation for this result could be related to what Goodman et al. (1995) refer to as optimistic denial in that people who expect positive outcomes in life may not feel the need to engage in healthpromoting behaviors. This would coincide with the research of Davidson and Prkachin (1997) who found that there was an interrelation between the constructs of optimism and unrealistic optimism that suggested that as positive expectancies increase so do predictions of decreased future health risks. Davidson and Prkachin posited that those who believe that they will experience good outcomes in life and are less likely than their peers to experience future health problems will be less likely to engage in health-promoting behaviors. The implication o f this finding may have an impact on what health-promoting strategies are used in promoting a health-promoting lifestyle as Davidson and Prkachin (1997) and Mulkana and Hailey (2001) have indicated from their studies. Different strategies may need to be used (e.g. health education versus behavior modification) to attain better outcomes depending on the individual’s outcome expectancy (Mulkana & Hailey) or the individual’s perception of health threat (Davidson & Prkachin). The Role of Demographic Variables The results o f this study provided support for the relationship of several of the demographic variables to the subscales of the Adolescent Lifestyle Questionnaire. With respect to gender, being female had a significant positive relationship in predicting healthy nutrition, social support, stress management, general health practices awareness and safety while being male had a positive relationship to physical participation. This concurs with the literature, which indicates that adolescent males consistently reported higher levels of 77 physical activity (Cohen et al., 1990; Kidder et al., 2000;Terre et al., 1992) and the research on gender and nutrition which indicates that even though female adolescents are more likely to diet (Kidder et al., 2000) they reported healthier food habits (Cohen et al., 1990). The research of Barnett (1989) on adolescents and health-promoting lifestyles also found that there was a significant difference in the health-promoting behaviors of middle adolescent males compared to females, with females reporting more health-promoting behaviors than males. In the present study, age had a significant negative relationship to healthy nutrition, physical participation and general health practices awareness. This concurs with the literature, which indicates that as adolescents age their selection o f nutritious foods and exercise rates decrease (Perry et al, 1985). Safety practices, with respect to the use of seat belts and helmets, also were found to decline with age (Health Canada, 1999b). The results contrast, however, with the results of Barnett (1989) and Gillis (1993b) who did not find a relationship between age and a health-promoting lifestyle. Gillis (1993b) reported that this unusual finding may have been the result of the homogeneous nature of her study sample. Grade average was predictive of all seven of the subscales in that doing well in school predicted healthier behaviors with respect to these seven subscales. This finding was consistent with the findings of Nutbeam et al. (1989) and lessor et al. (1998). Living arrangements was predictive of healthy general health practice awareness in a positive direction. Adolescents living in all circumstances, other than living with one or two parents, had healthier general health practice awareness levels. This was an unexpected finding. One possible explanation for this is that the adolescents in this study who live on their own, in group homes/foster homes or with friends or other relatives may report health 78 concerns and ask questions about their health more comfortably and readily with friends, teachers or coaches. Without parents, friends or other significant adults would be their primary resource. Risk status was predictive o f safety in a negative direction. Adolescents attending regular school reported healthy safety practices more frequently than those adolescents attending the Youth Around Prince program. This finding was interesting in that safety was the only area where there was a difference between the at-risk adolescents attending Youth Around Prince and all other adolescents in the sample in predicting the lifestyle variables. In summary, efforts to enhance health-promoting behaviors in adolescents should focus on self-efficacy, and on the effects of optimism and unrealistic optimism. Among the demographic variables, the influence of grade average, gender and age need to be taken into consideration. Strengths of the Studv One o f the strengths o f this research is that the sample consisted o f a large selection o f adolescents from urban and rural communities and across dimensions such as gender, age, risk status, various living arrangements, grade performance, socio-economic groups, and ethno-cultural influences. Another strength is that the sample is largely one of normal teenagers as opposed to a sample of adolescents seeking treatment in a clinic or institutiontype setting. This is important since from a theoretical perspective, adolescents seeking treatment can be expected to differ significantly from those not seeking treatment. Limitations o f the Studv There are several limitations that must be borne in mind in reflecting on this study. First, it is based on self-report measures completed by adolescents in a school setting. The 79 focus on self-report data may have opened the research to consistency biases. In particular, the findings would be strengthened by more objective behavioral measures such as observation o f the behaviors, or validation by significant others. Social desirability bias in the responses may have been a factor, even though efforts were made to emphasize that there were no right or wrong answers and that study participants could be most helpful by reporting what they thought as honestly and accurately as possible. Second, volunteers, rather than randomly selected individuals, participated in the study. This may have resulted in a sample with an overall higher degree of motivation and less overall variability in motivation to engage in healthy behaviors. Third, the descriptive correlational design of the research precludes causal inferences about the relationship between the variables studied and lifestyle behaviors. The findings, however, with respect to the relationships among the variables, can help nurses better understand the influences o f health-promoting behaviors in the adolescent population and assist in the development o f nursing interventions, education programs and health policy related to adolescent health promotion. Implications for Nursing Practice Findings from the present study may have significant implications for nursing practice and health promotion in general. In order for nurses to promote a health-promoting lifestyle in adolescents, it is important for them to have an understanding of the variables that influence adolescents’ decisions to engage in health-promoting behaviors. An understanding of the role that demographic variables, self-efficacy, optimism and unrealistic optimism play in influencing the choices that adolescents make may provide the foundation for the development of initiatives that promote health-promoting lifestyles in adolescents. 80 Nurses need to continue raising awareness about health-promoting lifestyles, as adolescents need an adequate knowledge base if they are to engage in healthy behaviors. However, knowledge alone is not sufficient. The findings of this research provide evidence that it is important for nurses to focus on enhancing self-efficacy when engaged in health promotion initiatives with adolescents. This is important because self-efficacy has been shown to not only have a direct impact on behavior, but also mediates the transition of knowledge into behavior (Rimal, 2000). Ways for nurses to enhance adolescents’ selfefficacy are through the four principal sources of self-efficacy as identified by Bandura (1977). They are verbal persuasion, performance accomplishment, vicarious performance and understanding o f physiological reactions to a situation. Nurses working with adolescents in the school environment and in the community have the opportunity during health education sessions to enhance adolescents’ self-efficacy by persuading them that healthpromoting behaviors are within their control. This can be undertaken by role modeling health-enhancing behaviors; by highlighting the adolescents’ past accomplishments; by role playing; and by making them aware of the affective benefits of health-promoting choices. To take a practical example o f this, public health nurses provide AIDS prevention education to adolescents as part o f their school health role. Kasen et al. (1992) in their research on selfefficacy for AIDS preventive behaviors among tenth grade students, found a degree of uncertainty existed for self-efficacy among adolescents with respect to refusing sex under a variety of circumstances, for questioning partners about past high-risk activity, for accessing and using condoms correctly and consistently and after drinking or using marijuana. Public health nurses could include in their AIDS prevention program, communication and negotiation skills, as well as skills related to accessing and purchasing condoms. Videos of 81 adolescents modeling effective management of these situations, role-playing opportunities that apply the necessary practice o f these skills, and instructive feedback, can provide adolescents with the tools to empower them to enhance self-efficacy and exercise personal control in health risk situations. This study suggests that it would be useful for nurses to be aware of the impact that optimism and unrealistic optimism have in modifying the choices that adolescents make with respect to their health behavior choices. Although there is research that shows that optimism in adolescents is positively correlated with general health-promoting behaviors, this study found it to be negatively correlated. If adolescents believe that they will have good outcomes in life and thus do not need to engage in health-promoting behaivors, public health nurses could assist adolescents in appraising their optimism level, provide them with information on the impact o f optimism on the initiation and maintenance of health-promoting behaviors and design their health program strategy based on the results. This study found that adolescents with higher levels of unrealistic optimism were less likely to have healthy nutrition, physical participation, social support, identity awareness and safety. If adolescents believe they are less likely than others to encounter negative consequences of health-risk behaviors then providing information alone on the risks will not be pertinent to them. Public health nurses should include information on unrealistic optimism in their encounters with adolescents, emphasizing the impact this can have on their receptiveness to health education, and in turn, on their health choices. Having an understanding o f the influence that demographic variables have on adolescents’ decision to engage in a health-promoting lifestyle would be most useful for nurses in planning health-promotion programs with this age group. In particular, knowing 82 the impact that gender, age, location, grade average, ethno-cultural background, living arrangements and risk status have on the adolescents’ choices with respect to healthy nutrition, physical participation, social support, stress management, identity awareness, general health practices awareness and safety will enable nurses to plan interventions that are appropriate in meeting the developmental and cultural needs of this group. Implications for Nursing Education It is important for educators to promote an understanding of the developmental stages of adolescence and the importance of adolescence in relation to the onset of health behaviors that will have an impact in adult years. Given that most chronic diseases are rooted in lifestyle behaviors, which are initiated in adolescence, enhancing knowledge among students o f the health promotion and protective factors that can prevent or mediate health-risk behaviors is important. Educators should promote an understanding o f self-efficacy, optimism, unrealistic optimism, and the demographic variables that impact on the adolescent’s lifestyle. Incorporating knowledge about the developmental stages o f adolescence, the impact of demographic variables as well as theory on self-efficacy, optimism, and unrealistic optimism into the planning of health-promoting interventions aimed at this age group will increase the effectiveness o f the interventions, and in turn, may increase the likelihood of enhancing health-promoting choices in this population. As adolescents and professionals differ in their prioritization of adolescent health concerns, with adolescents focusing on physical appearances and relationships and professionals focusing on interventions to reduce health risks, an approach to healthpromotion must incorporate both viewpoints. Incorporating topics of interest to adolescents 83 in health-promoting interventions will result in more receptive learners. A heart health program for example, could emphasize the potential for weight control and social interaction through exercise classes and team sports, as well as address risk factors for heart disease. Implications for Public Policv The importance o f healthy adolescent development to good health in adulthood is well documented. Adolescents are more likely to have positive health outcomes as adults if they adopt and maintain health-promoting behaviors during adolescence. It is vital that the health system be one that is sensitive to adolescents and responds not only to providing treatment services but to health-promotion programs as well. Health promotion and prevention strategies that enable adolescents to make informed decisions about their health, that assist them in choosing health-promoting behaviors and in reducing health-risk behaviors, will enhance their health and well-being in the short term as well as in the future. Involving adolescents in the development and implementation of adolescent health policies that incorporate gender and ethno-cultural perspectives is imperative. The findings o f this research indicate that it is important to work with the education sector to enhance the school health curriculum and school programs that promote healthy nutrition, physical participation, stress management, identity awareness, safety and general health practices awareness as well as the importance of the role of social support in achieving a health-promoting lifestyle. Developing health-promoting policies at the community and regional level that are adolescent focused, that span agencies and Ministries, that recognize the contribution o f adolescents, as well as support parents in their role, will have a significant influence on adolescent lifelong health outcomes 84 Implications for Future Research The findings o f this research offer a beginning understanding of the variables that have an impact on a health-promoting lifestyle of adolescents living in a northern region. Future research should use hierarchical regression analysis for each of the significant variables to determine the percent of the variance attributed to each variable. These results will assist in developing a health-promotion model and programs for adolescents that will be effective in enhancing a health-promoting lifestyle in adolescents. Future studies should include a more heterogeneous group with respect to various ethno-cultural groups so that the results can be generalized. Including more at risk adolescents, whether in alternate school or out o f school, and from more than one community, would allow for greater generalization of the findings. It will also identify whether there are differences in lifestyle behaviors of the adolescent-at-risk population depending on whether they come form urban or rural communities. The results o f this current research show that adolescents who do well in school are more likely to engage in health-promoting behaviors. School performance has been identified as a significant source of stress for adolescents. Adolescents who are not successful in school are at much higher risk for school dropout and for engaging in healthrisk behaviors such as interpersonal violence and alcohol and drug use. (Rew & Homer, 2003). Future research should look at how best to promote a health-promoting lifestyle among adolescents in this group. 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Health Psychology, 12(5), 346-353. 99 Appendix A Adolescent Demographic Questionnaire 100 Section A: Please Oil in the blank or circle the most appropriate answer for each question. 1. Age: years old. I am 2. Gender: Male Female 3. Ethno-cultural characteristics: (Statistics Canada designations) A. Caucasian H. B. C. D. Aboriginal Chinese South Asian (includes India, Pakistan, Punjab, Sri Lanka) Black (includes Africa, Haiti, Jamaica, Somalia) Arab and West Asian (includes Armenia, Egypt, Iran, Lebanon, Morocco) Philippines I. J. K. E. F. G. Southeast Asian (includes Cambodia, Indonesia, Laos, Vietnam) Latin American Japanese Korean M. Persons belonging to more than one of the above All others G. H. I. J. K. L. Lakewood Jr. Secondary Mackenzie Secondary McBride Secondary Prince George Secondary Valemount Secondary Other E. F. G. Eleven Twelve I do not attend school. Last grade attended was L. 4.1f attending school, the name o f my school is: A. Blackburn Jr. Secondary B. College Heights Secondary C. D P Todd Secondary D. Duchess Park Secondary E. John Mclnnes Jr. Secondary F. Kelly Road Secondary 5. My current grade in school is: A. Seven or less B. Eight C. Nine D. Ten 101 6. My overall letter grade average in my last year o f school was: I. A 2. B 3. C+ 4. 5. 6. C CLower than C- 7 .1 currently live with: A. B. C. D. E. Both parents My mother My mother and step-father My father My father and step-mother F. Other relatives G. Friends H. On my own I. Group home/foster home J. Other 8.What is your father’s job? Please write down exactly what he does (for example, teacher, car mechanic, logger, homemaker, dentist, banker). If you do not know please do not write anything. 9. What is you mother’s job? Please write down exactly what she does (for example, medical doctor, homemaker, secretary, nurse, taxi driver, store clerk). If you do not know please do not write anything. 10. What is the highest level o f education completed by your father? A. B. C. Grade 7 or less Partial high school High school certificate D. E. F. Some university education Trade or non-university diploma University degree 10. What is the highest level of education completed by your mother? A. B. C. Grade 7 or less Partial high school High school certificate II.In what community do you live? D. E. F. Some university education Trade or non-university diploma University degree 102 Appendix B Adolescent Lifestyle Questionnaire 103 Section B: Welcome to a survey about you! There are no right or wrong answers! Please circle the answer that is honest for you. No one else will ever know how you answered. 1 = NEVER 1. 2 = RARELY 3 = SOMETIMES 4 = OFTEN In an average week, I exercise 3-4 times such as running, taking long walks, dancing, playing ball, swiimning. 5 = ALMOST ALWAYS 2 3 4 5 2. I discuss problems & concerns with people close to me. 2 3 4 5 3. I like who I am. 2 3 4 5 4. When riding in an automobile, I wear a seatbelt. 2 3 4 5 5. I participate in a regular program o f sports/exercise at school. 2 3 4 5 6. I enjoy spending time with my friends. 2 3 4 5 7. I avoid doing drugs. 2 3 4 5 8. I read labels on packaged foods I eat. 2 3 4 5 9. I express my concerns. 2 3 4 5 10. I know my strengths and weaknesses. 2 3 4 5 11. I refuse to get into a car if the driver is drinking or taking drugs. 2 3 4 5 12. I exercise vigorously for 20-30 minutes at least 3 times per week. 2 3 4 5 13. I have good friendships with girls and guys my age. 2 3 4 5 14. If I had a problem, I have people I could tum to. 2 3 4 5 15. I am happy and content. 2 3 4 5 16. I look forward to the future. 2 3 4 5 17. I avoid use o f tobacco in cigarette & chewable forms. 2 3 4 5 18. I report any unusual changes in my body to others such as a nurse, my parents, friends, or physician. 2 3 4 5 19. I play sports at least 3 times per week. 2 3 4 5 20. I follow a healthy diet. 2 3 4 5 104 1 = NEVER 2 = RARELY 3 = SOMETIMES 4 = OFTEN 5 = ALMOST ALWAYS 21. I try notto eat too many foods high in fats. 2 4 22. I try notto eat too many foods high in salt. 2 4 23. I try notto eat too many foods high in sugar. 2 4 2 4 24. If I needed help, I have someone to tum to such as my family, friends, teachers, coaches. 1 25. I can express my feelings to other, such as my family or friends. 2 3 4 5 26. I can exercise (walk, jog, play sports) to control my stress. 2 3 4 5 27. I talk to my friends about my stress. 2 3 4 5 28. I set goals for myself in life. 2 3 4 5 29. I examine my beliefs and values in life. 2 3 4 5 30. I avoid drinking alcohol. 2 3 4 5 31. I talk to the health teacher/nurse about ways to improve my health. 2 3 4 5 32. I read pamphlets, teen magazines about health topics of interest. 2 3 4 5 33. I discuss health concerns with others such as friends, family, coaches, health nurse, teachers. 2 3 4 5 34. I often choose salads, fruits & vegetables for snacks. 2 3 4 5 35. I limit my intake o f “junk food” for snacks. 2 3 4 5 36. I believe my life has a purpose. 2 3 4 5 37. I use helpful strategies to help me deal with stress. 2 3 4 5 38. I make informed choices about sexual relationships. 2 3 4 5 39. I use prayer or spiritual beliefs to help me deal with stress. 2 3 4 5 40. If I was going to be sexually active, I would use protection against pregnancy or sexually transmitted diseases, such as AIDS. 2 3 4 5 41. I choose foods without additives. 2 3 4 5 42. I try to do my best each day. 2 3 4 5 43. I am confident about my beliefs and values in life. 2 3 4 5 105 Appendix C Self-Efficacy Scale 106 Section C: This questionnaire is a series of statements about your personal attitudes and traits. Read each statement and decide to what extent it describes you. There are no right or wrong answers. You will probably agree with some o f the statements and disagree with others. Please indicate your own personal feelings about each statem ent below by putting a circle around the answer th at best describes your attitude or feeling. Please be very truthful and describe yourself as you really are, not as you would like to be. 1. 4. DISAGREE STRONGLY AGREE MODERATELY 2. 5. DISAGREE MODERATELY AGREE STRONGLY 3. NEITHER AGREE/DISAGREE t 1 •a 1. When I make plans, I am certain I can make them work. 2 3 4 5 2. One of my problems is that I can’t get down to work when I should. 2 3 4 5 3. If I can’t do a job the first time, I keep trying until I can. 2 3 4 5 4. When I set important goals for myself I rarely achieve them. 2 3 4 5 5. I give up on things before completing them. 2 3 4 5 6. I avoid facing difficulties. 2 3 4 5 7. If something looks too complicated, I will not even bother to try it. 2 3 4 5 8. When I have something unpleasant to do, I stick to it until I finish it. 2 3 4 5 9. When I decide to do something, I go right to work on it. 2 3 4 5 10. When trying to learn something new, I soon give up iff am not initially successful. 2 3 4 5 11. When unexpected problems occur, I don’t handle them well. 2 3 4 5 12. I avoid trying to learn new things when they look too difficult for me. 2 3 4 5 13. Failure just makes me try harder. 2 3 4 5 14. I feel insecure about my ability to do things. 2 3 4 5 15. I am a self-reliant person. 2 3 4 5 16. I give up easily. 2 3 4 5 17. I do not seem capable of dealing with most problems that come up in my life. 2 3 4 5 107 Appendix D The Life Orientation Test 108 Section D: Please indicate the extent to which you agree with each of these items by using the guide below. There are no correct or incorrect answers so be accurate and honest with your responses. Circle the number for each item that is the best answer for you. 0 3 STRONGLY DISAGREE AGREE 1 4 DISAGREE STRONGLY AGREE 2 NEUTRAL 1. It’s easy for me to relax. 0 2 3 4 2. If something can go wrong for me, it will. 0 2 3 4 3. I always look on the bright side o f things. 0 2 3 4 4. I’m always optimistic about my future. 0 2 3 4 5. I enjoy my friends a lot. 0 2 3 4 6. It’s important for me to keep busy. 0 2 3 4 7. I hardly ever expect things to go my way. 0 2 3 4 8. Things never work out the way I want them to. 0 2 3 4 9. I don’t get upset too easily. 0 2 3 4 10. I’m a believer in the idea that “every cloud has a silver lining.” 0 2 3 4 11. In uncertain times, I usually expect the best. 0 2 3 4 12. I rarely count on good things happening to me. 0 2 3 4 109 Appendix E Unrealistic Optimism Measure 110 Section E; Compared to other teenagers in Prince George of the same age and sex as you, what do you think are the chances that the following events will happen to you? Please circle the number that best describes you answer. Remember you are identifying the likelihood of these events happening to you compared to other teenagers. 1. 2. 3. 4. NO CHANCE A LOT LESS CHANCE A LITTLE LESS CHANCE AVERAGE CHANCE 5. A LITTLE HIGHER CHANCE 6. A LOT HIGHER CHANCE 7. CERTAIN THAT IT WILL HAPPEN 1. Getting mugged 1 2 3 4 5 6 7 2. Being injured in an automobile accident 1 2 3 4 5 6 7 3. Having decayed teeth 1 2 3 4 5 6 7 4. Having high blood pressure 1 2 3 4 5 6 7 5. Getting diabetes 1 2 3 4 5 6 7 6. Getting lung cancer 1 2 3 4 5 6 7 7. Developing another cancer 1 2 3 4 5 6 7 8. Getting an ulcer 1 2 3 4 5 6 7 9. Having a heart attack 1 2 3 4 5 6 7 10. Having a drinking problem 1 2 3 4 5 6 7 11. Attempting suicide 1 2 3 4 5 6 7 Ill Appendix F Information and Parent Consent Letter 112 Information and Parent Consent Letter I am a Public Health Nursing Assistant Administrator at the Northern Interior Health Unit and a student in the Community Health Science Master’s degree program at the University of Northern British Columbia. As part of my degree, I am undertaking a research project that will identify the lifestyle practices of adolescents living in the Northern Interior Health region and the relationship o f self-efficacy (personal mastery) optimism and unrealistic optimism to a healthy lifestyle. Identifying the lifestyle practices of adolescents in our region is important so that adolescents can be assisted in making choices that have long-term positive health effects. Adolescents enrolled in grades 8 through 12 in the school districts in our region, as well as, adolescents in this age group not attending school will be invited to participate in the study. Your child will be asked to complete a package of questionnaires that will take approximately forty minutes. This will take place in one of your child’s classes if he/she attends school. Participation in the study is voluntary and your child can withdraw at any time. Your child may benefit fi-om participating in the study by becoming aware o f his/her lifestyle practices. There is no risk involved in your child’s participation and your child’s grades will not be affected by participating in the study. Demographic information collected will consist primarily of your and your child’s education level, ethnicity and occupation. Confidentiality and anonymity are maintained, as names will not be used on the questionnaires thus, preventing linking information to any one family. Only the researcher and my supervisor will have access to the responses o f the adolescents. All the data collected will be destroyed after completion o f the study. A copy of the research findings will be available at the school district office as well as the participating schools and agencies. If you have any questions about this research or wish to obtain an individual copy of the final results, please contact me, Mary Margaret Proudfoot, at . You may also contact my supervisor. Dr. Peter MacMillan, at the University o f Northern British Columbia at . Any complaints about this project should be directed to the Office of Research, UNBC, at Thank you, in advance for agreeing to have your child participate in this research on adolescent lifestyle. Knowing what the lifestyle health practices are of adolescents enables us to promote healthy choices among adolescents and thus contributes to the health of our community in general. Your signature below indicates that you have agreed to have your child participate in the study described and that you have an adequate understanding of what this means. Please return this signed consent to you child’s school. Name (print)________________________________ Date_________________________ Signature: ________________________________ 113 Appendix G Information and Participant Consent Letter 114 Information and Participant Consent Letter I am a Public Health Nursing Assistant Administrator at the Northern Interior Health Unit and a student in the Community Health Science Master’s degree program at the University of Northern British Columbia. As part of my degree, I am undertaking a research project that will identify the lifestyle practices of adolescents living in the Northern Interior Health region and the relationship o f self-efficacy (personal mastery) optimism and unrealistic optimism to a healthy lifestyle. Identifying the lifestyle practices of adolescents in our region is important so that adolescents can be assisted in making choices that have long-term positive health effects. Your involvement will include filling out a number o f questionnaires and will take approximately forty minutes. This will take place in one of your classes if you attend school. Participation in the study is voluntary and you can withdraw at any time. You may benefit from participating in the study by becoming aware of your lifestyle practices. There is no risk involved in your participation and your grades will not be affected by participating in the study. Demographic information collected will consist primarily of your and your parent’s education level, ethnicity and occupation. Confidentiality and anonymity are maintained, as names will not be used on the questionnaires thus, preventing linking information to any one family. Only the researcher and my supervisor will have access to the responses of the adolescents. All the data collected will be destroyed after completion o f the study. A copy o f the research findings will be available at the school district office as well as at the participating schools and agencies. If you have any questions about this research or wish to obtain an individual copy of the final results, please contact me, Mary Margaret Proudfoot, at You may also contact my supervisor. Dr. Peter MacMillan, at the University o f Northern British Columbia at ,. Any complaints about this project should be directed to the Office of Research, UNBC, at ' Thank you, in advance for agreeing to participate in this research on adolescent lifestyle. Knowing what the lifestyle health practices are of adolescents enables us to promote healthy choices among adolescents and thus contributes to the health of our community in general. Your signature below indicates that you have agreed to participate in the study described and that you have an adequate understanding of what this means. Please return this signed consent to your teacher. Name (print)________________________________ Date: _______________________ Signature: _________________________________