The High School Journal, Volume 92, Number 1, October-November. 2008 ... High School Students in Turkey .... Holroyd, 2003; Behling & Law 2000) as it gives.
Health-enhancing Behaviors among High School Students in Turkey Didem M. Siyez The High School Journal, Volume 92, Number 1, October-November 2008, pp. 46-55 (Article) Published by The University of North Carolina Press DOI: 10.1353/hsj.0.0012
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Health-enhancing Behaviors among High School Students in Turkey Dr. Digdem M. SIYEZ Dokuz Eylul University
Problem Statement: A body of research has documented the positive consequences of health-enhancing behaviors. Studies in western countries showed that participation in health enhancing behaviors declines in the period of adolescence. The aim of the study was to examine the involvement in healthenhancing behaviors among adolescents in Izmir, Turkey. In this study interrelations among the health-enhancing behaviors and whether the adolescents’ healthy behaviors differed significantly in their gender were also investigated Method: A total of 1237 adolescents (666 girls, 571 boys) randomly selected from high schools in Izmir were surveyed. The Health-Enhancing Behavior Index (HEBI) was used to identify the healthy behaviors. Results: Turkish adolescents showed a low prevalence of healthy diet, exercise, and a high prevalence of sedentary behaviors. In addition, the findings revealed that adolescents’ health-enhancing behaviors were statistically correlated with each other’s, and involvement in health-enhancing behaviors differed by gender. Conclusions: These results may be useful in developing targeted health education programs in Turkey. Introduction Adolescence is traditionally viewed as a time of ‘’excellent health’’ with low levels of morbidity and chronic diseases (Erginöz et al., 2004; Friestad & Klepp, 2006). At the same time, adolescence is a period of great creativity and energy, of new experiences, ideas and skills (WHO, 1993) and these significant and rapid physical, psychological and social changes associated with adolescence may have deleterious effects on the health of adolescents (Erginöz et al., 2004).
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On the other hand, it must be recognized that adolescents can make major contributions to their own health and well-being through the adoption of particular health-enhancing behaviors (e.g., exercise, healthy diet) and the avoid-
Health-enhancing Behaviors ance of negative health-threatening behaviors, such as smoking. (Millstein, Petersen & Nightingale, 1993). Health-enhancing behaviors can be defined as being when an individual undertakes on his/her own behalf to maintain health, prevent illness, and promote well-being (Lasky & Eichelberger, 1985; Perry & Jessor, 1985). The health-enhancing behaviors include adequate hours of sleep, paying attention to healthy diet, regular physical exercise, low sedentary behaviors, dental care and safety behaviors such as using seat-belt and contraceptive methods (Fortenberry, Costa, Jessor & Donovan, 1997). A body of research has documented the positive consequences of health-enhancing behaviors. For example, sports participation has been associated with fewer mental health and general health problems and higher levels of selfesteem and self-concept (Calfas & Taylor, 1994; Steiner, McQuivey, Pavelski, Pitts & Kraemer, 2000). An analysis of the national data from the Youth Risk Behavior Survey has found that sports participants were less likely to report suicidal behaviors, the female sports participants were less likely to have had sexual intercourse, and the male sports participants were less likely to report carrying a weapon (Pate, Trost, Levin & Dowda, 2000). Mental health aspects, such as keeping up good morale, relaxing, and maintaining good relationships with others, are also mentioned (Kalnins, Jutras, Normandeau & Morin, 1998). Also, health-enhancing behavior is a protective factor against problematic behaviors (Jessor, 1991). It must be recognized that research about adolescents’ health issues has shown a focus on the long-term consequences of specific diseases. (Centers for Disease Control and Prevention, 1997; Beech, Rice, Myers, Johnson & Nicklas, 1999; Young-ho, 2001). For example, inadequate fruit and vegetable consumption has been linked to certain types of cancer and other diseases such as obesity and hypertension (WHO, 1993; Young-ho, 2001). And it has been estimated that at least 35% of the cancer deaths may be attributable to unhealthy diets (Bas¸ & K1z1ltan, 2007). It is well known that “Healthy students make better learners, and better learners make healthy communities” (Pateman, 2003/2004).
Although adolescence as a key period for lifestyle establishment is receiving renewed interest (Friestad & Klepp, 2006), research suggests that a considerable proportion of adolescents did not engage in health-enhancing behaviors (Centers for Disease Control and Prevention, 1997). For example, using longitudinal data, Murphy, et al. (2001) found that 43% of the sample reported having unprotected sex at last intercourse. One study of middle school and high school students in South Korea showed that a large number of youths spend the bulk of their leisure time on sedentary activities (Cho, 2004). A study in Australian secondary school students demonstrated that consumption of unhealthy/non-core foods was high among the students with 46% of them having fast food meals at least twice a week, 51% eating snack foods four or more times per week, and 44% having high-energy drinks four or more times per week (Scully, Dixon, White, & Beckman, 2007). Although data related to the adolescents’ health-enhancing behaviors in Turkey are limited, available Turkish studies (Demirezen & ¸ Cosansu, 2005; Siyez, 2005; Savc1, Öztürk, Ar1kan, Inal-Ince, & Tokgözoglu, 2006) have demonstrated that most of the students did not have healthy behaviors. For example, ¸ Demirezen & Cosansu (2005) reported that in a sample of 638 adolescents from secondary schools in Istanbul, Turkey, 98.8% of the sample were found to be at risk for dietary pattern. Another study looked at the pattern of physical activity among 1097 university students and reported only 18% of the university students were sufficiently active (Savc1 et al., 2006). The aim of this study, then, was to examine the involvement in health-enhancing behaviors among Turkish adolescents. Also interrelations among these behaviors and whether the adolescents’ health-enhancing behaviors significantly differed by gender were examined in this study. The current study has been conducted to answer the following research questions: 1. What proportion of adolescents is involved in undertaking health-enhancing behaviors? 2. Are sub-domains of the stated health-enhancing behaviors correlated with each other? 47
The High School Journal – October/November 2008 3. Does involvement in health-enhancing behaviors differ by gender and grade among the adolescents studied? Methods Sample The study was quantitative, with data gathered through the use of the self-reported survey instruments that examined health-enhancing behaviors of the adolescents. The study sample comprised 1,237 randomly-selected, 9th-11th grade students attending fifteen randomlyselected high schools in Izmir (population: 3.7 million in 2007) which is the third biggest province of Turkey. There are currently 412 high schools (general, Anatolian, science, vocational, etc.) operating in Izmir. In total, 158,319 students are enrolled in these schools in 2007. In the group of students responding, 51% (n=80.737) are girls and 49% (n=77.582) are boys (Ministry of Education in Izmir, 2008). The sample consisted of 1,237 Turkish adolescents. There were 666 girls (53.8%) and 571 boys (46.2%). In this group, 39.8% (n=492) was comprised of 9th grade students; 32.3% (n=399) was comprised of 10th grade students; and the remainder, 28% (n=346) was comprised of 11th grade students. Most of the adolescents’ parents (84.9%) lived together. 34.1% of fathers and 41.1% of mothers of the subjects have graduated from primary school. Instruments The Health-Enhancing Behavior Index (HEBI) included in the Adolescent Health and Development Questionnaire (AHDQ) was used in this study (Jessor, Costa, Turbin, 2004). HEBI was computed by totaling seven subscales, including low sedentary behavior, regular physical activity, dental care, adequate sleep, healthy diet, contraceptive use and seat belt use. Higher scores denote higher levels of health-enhancing behaviors. The assessed socio-demographics are gender, grade, mother’s and father’s education, and parental status selfassessment. Turkish version of the HEBI: The Turkish version of the HEBI (Siyez, 2006) was developed by using the back-translation method. The backtranslation is commonly used and regarded as a standard method for translating research instru48
ments from one language to another. This method has been recommended by many scholars (Hyrkas, Appelquist-Schmidlechner, & Paunonen-Ilmonen, 2003; Chang, Chau, & Holroyd, 2003; Behling & Law 2000) as it gives an investigator control over the original instrument and its translation. Back translation was maintained through the procedure described by Brislin’s (1970) classic back-translation model. First, the original version was translated into Turkish, and then cross-translation was performed by two independent translators. After re-translation of the original items into English, the scale was completely identical to the original version. The Turkish version of HEBI was found to have adequate features of validity and reliability for adolescents. According to the explanatory factor analysis, seven factors explained 65.7% of total variance. Moreover, the Confirmatory Factor Analysis has showed that values X2/df: 4.73, RMSEA: 0.06, GFI: 0.80, AGFI: 0.77, CFI: 0.70, NNFI: 0.67. Accordingly, the results indicate that the convergent validity for each construct is adequate (McDonald & Moon-Ho, 2002). The Cronbach alpha reliability of the Turkish form of HEBI ranged from 40 to 82. Procedure The study was conducted after approval was obtained from the Ministry of Education in Izmir. After receiving permission, students were informed of the main goal of the research, the anonymity, and the voluntary participation. All of the students accepted to participate in study. The questionnaires were self-administered under close supervision by the researcher. The students filled out questionnaires during the class period. The questionnaires took approximately 30-40 minutes to complete. Analysis of Data Frequency distribution, Pearson Correlation Analysis and t-test were applied to the data regarding the sample. Data analysis benefited from the use of the SPSS 11.0 packet program. In the following analysis, the criterion of p
