The effects of life events on the performance of health-promoting behaviors of young and middle aged men.

The health-promoting behaviors (HPB) of men ages 20 to 50 years old (n = 61) were studied in relationship to the number and quality of life change events (LCE) they had experienced. The sample was divided into young men, age 20 to 34 (n = 29) and middle age men (n = 32) to determine if there were any age-related differences in the performance of HPB and the experience of LCE. This study utilized the Health Promotion Model as well as the Life-Span Developmental theory, as theoretical frameworks to guide this research. The Health-Promoting Lifestyle Profile (HPLP) was used to gather data on HPB. The Life Experiences Survey was used to gather data on LCE. Data on HPB and LCE were analyzed using a series of independent t-tests to determine if there were any differences between group means on the measures of HPB and life experiences. Though the younger group scored slightly higher on measures of HPB, there were no significant differences between groups. The older groups scored higher on measures of LCE, but again there were no significant differences. Pearson Product Moment correlations and Spearman's rho were calculated for selected variables. The result of these analyses suggest a positive, significant correlation between HPB and church support (p<.001) and positive, significant correlations between number of years married and positive life events (p =.025). Analysis of individual items on the HPLP allowed the researcher to identify several specific HPB with low levels of performance by this sample of men. This finding has strong implications for Nursing;, by allowing nurses and other health care providers to identify specific behaviors that can be targeted for intervention with male patients.

THE EFFECTS OF LIFE EVENTS ON THE PERFORMANCE OF HEALTH-PROMOTING BEHAVIORS OF YOUNG AND MIDDLE AGED MEN by Eric C. Johnson A thesis submitted to the faculty of The University of Utah in partial fulfillment of the requirements for the degree of Master of Science College of Nursing University of Utah June 1995 Copyright © Eric C. Johnson 1995 All Rights Reserved THE UNIVERSITY OF UTAH GRADUATE SCHOOL SUPERVISORY COMMITTEE APPROVAL of a thesis submitted by Eric C. Johnson This thesis has been read by each member of the following supervisory committee and by majority vote has been found to be satisfactory. ... ~~~ ~anne Tarmina Wrig1::)rt G THE UNIVERSITY OF UTAH GRADUATE SCHOOL FINAL READING APPROVAL To the Graduate Council of the University of Utah: I have read the thesis of ~ric c. Johnson in its final form and have found that (1) its format, citations and bibliographic style are consistent and acceptable; (2) its illustrative materials including figures, tables and charts are in place; and (3) the final manuscript is satisfactory to the supervisory committee and is ready for submission to The Graduate School. Date J Karin T. Kirchho f Chair, Supervisory Committee /1 APpr;iiv£ ed,~ e MajOr, Department '-~--:- •. / / ~ ~ Approved for the Graduate Council Ann W. Hart Dean of The Graduate School ABSTRACT The health-promoting behaviors (HPB) of men ages 20 to 50 years old (n=61) were studied in relationship to the number and quality of life change events (LCE) they had experienced. The sample was divided into young men, age 20 to 34 (n=29) and middle age men (n=32) to determine if there were any age-related differences in the performance of HPB and the experience of LCE. This study utilized the Health Promotion Model as well as the Life-Span Developmental theory, as theoretical frameworks to guide this research. The Health-Promoting Lifestyle Profile (HPLP) was used to gather data on HPB. The Life Experiences Survey was used to gather data on LCE. Data on HPB and LCE were analyzed using a series of independent t-tests to determine if there were any differences between group means on the measures of HPB and life experiences. Though the younger group scored slightly higher on measures of HPB, there were no significant differences between groups. The older groups scored higher on measures of LCE, but again there were no significant differences. Pearson Product Moment correlations and Spearman's rho were calculated for selected variables. The result of these analyses suggest a positive, significant correlations between HPB and church support (~<.OOl) and positive, significant correlations between number of years married and positive life events (~=.025). Analysis of individual items on the HPLP allowed the researcher to identify several specific HPB with low levels of performance by this sample of men. This finding has strong implications for nursing, by allowing nurses and other health care providers to identify specific behaviors that can be targeted for intervention with male patients. v TABLE OF CONTENTS ABSTRACT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i v LIST OF TABLES........ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. vi ACKNOWLEDGMENTS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. vi i Chapter I . INTRODUCTION. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 1 II. LITERATURE REVIEW................................ 3 Midlife Period and Transitions ................. 3 Life Change Events and Stress .................. 5 LCE as a Positive Influence on HPB ............. 7 Theoretical Frameworks ......................... 8 Implications for Nursing.................... . .. 13 Research Questions ............................. 14 Operational Definitions ........................ 15 I I I . METHOD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 16 Study Design ................................... 16 Sample. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 16 Instruments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 1 7 Data Analysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 22 IV . RESULTS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 25 Age Differences and HPB ........................ 25 LCE and the Relation to HPB .................... 27 Age and LES.................................... 28 Selected Health-Promoting Behaviors ............ 29 Demographics and Measures of Variability ....... 29 V . DISCUSS ION. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 31 Limitations .................................... 31 Examination of Selected Health Behaviors ....... 32 Appendix A. HEALTH-PROMOTING LIFESTYLE PROFILE ............. 35 REFERENCES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 38 vii LIST OF TABLES Table 1. Demographic Characteristics of the Study Sample ...... 18 2. Internal Consistency of the HPLP and its Subscales ... 20 3. Correlations Between Selected Variables .............. 24 4. Independent t-tests Between Groups on Selected Variabl es ............................................ 26 ACKNOWLEDGMENTS I would like to thank my wife Kaye for her love, support, and patience throughout the preparation of this manuscript. I would also like to express my appreciation to my committee chair, Karin Kirchhoff, for her time, patience, professionalism, and all her help. Thank you to Scott Wright for his assistance and support. A special thank you to Suzie Tarmina for her support and concern. CHAPTER 1 INTRODUCTION There is a popular perception that men undergo some change at mid-life. The media has often used the term "Male Menopause" to describe this period of transition (Forman, 1993; Skolnick, 1992; Thomson, 1992). Described are men in their late thirties and early forties with flagging libidos, seeking the company of a younger women; the successful executive quitting his career and moving to the country in order to get back to nature. New sports cars, new adventures, divorces, extra-marital affairs and generally negative and irrational behaviors are often attributed to "Male Menopause" (Fabris, Bianchi, & Fasalo, 1981; Mastrogiacomo, Feghali, Foresta & Ruzza, 1982; McKinlay, 1989; Nieschlag, 1979). Midlife is indisputably an era of significant and often intense change for many men (and women) (Chiriboga, 1984; Tamir, 1982; Wrightman, 1988). The average man, by midlife, is exposed to and experiences many life events, some quite stressful and some quite rewarding. All create some sort of impact on the future behavior and lifestyle of the individual (Fiske & Chiriboga, 1990; Levinson, 1978, 1986; Sherman, 1987; Smolak, 1993; Tamir, 1982). The focus of this study was to determine if normative and non-normative life events, over'a period of time, have an effect on the performance of health promoting-behaviors for middle age men. It was expected that the passage of time alone would guarantee that older men would experience more life events than their younger counterparts. This study compared a group of 20-34 year old men to a group of 35-50 year old men in an attempt to determine differences in the number of life events experienced and if life events have an effect on the performance of health-promoting behaviors. The assumption in this study was that the greater the cumulative life experiences, both positive and negative, the healthier the lifestyle, and that age will be a significant variable in both factors. This is an area of research that has yet to be fully explored. Much of the literature on life events and their effect on behavior concerns the negative effects of stress on the health of the individual (Hultsch & Plemons, 1979; Stein, Keller, & Scheifer, 1988). Very little has been written or studied concerning the possibility that life events, stressful or not, may, over time, exert a positive influence on the health behaviors of individuals. 2 CHAPTER 2 LITERATURE REVIEW The literature was reviewed using CD-ROM Silver­Platter technology and expanded by using references of selected studies and articles. Data bases searched included MEDLINE, 1981 to present; CINHAL, 1983 to present; PSYCHLIT, 1973 to present and SOCIOLIT, 1974 to present. Three searches were conducted, the first using the terms "Male Menopause," "male climacteric," Ifmid-life crisis, If and Ifandropause," to provide a background on the midlife period. The second search of MEDLINE and CINHAL utilized the terms "life change event," "health-promoting behavior,lI and "life stress," to review research related to this study. The third search employed combinations of the terms used in the two initial searches. This was done to narrow the search parameters and see if any specific research had been conducted comparing health behavior and life events. This third search revealed related research, but none similar to this study. Midlife Period and Transitions The initial search of the literature of midlife suggests that the period of a man's life from age 30 to 50 is indeed an era of transition and change (Fiske & Chiriboga, 1990; Kat senbaum , 1993; Levinson, 1978, 1986; Sherman, 1978). Various explanations of the nature of this period of life have found their way into the popular and scientific literature since the 19th century (Featherstone & Hepworth, 1985). Current research and thought seek to explain this middle period of a man's life from both physiological and psychosocial perspectives. The medical community has long sought a physiological explanation for the changes associated with the middle period of a man's life. There has been an attempt to compare "male menopause" with a woman's menopausal period. Research in this area has centered on seeking a hormonal cause such as a decrease in testosterone, comparable to a woman's the drop in estrogen during menopause. Early research suggested a hormonal etiology to men's midlife changes (Bauer, 1940, 1944; Werner, 1939). More recent studies have not supported a physiologic basis for midlife change in men (Bartsch & Voight, 1984; Fabris, et al., 1982; Gray, Jackson, & Mckinlay, 1991; Mastrogiacomo, et al., 1982; McKinlay, 1989; Nieschlag, 1972; Vermeulen & Deslypere, 1985). Historically, psychosocial theories have indicated the period from age 30 to 50, for both sexes, is a period of intense transition and change. Various theorists have defined midlife differently, but all definitions fall 4 between the ages of 30 to 50 (Fiske & Chiriboga, 1990; Levinson, 1978; Sherman, 1987; Smolak, 1993; Tamir, 1982; Wrightman, 1988). Carl Jung (1934) specifically pinpointed the age of 40 as the time of midlife transition. In summary these theorists believe that midlife is a pivotal and critical period in a person's life that affects personal development during the remainder of the life span. Life span developmental theorists also view midlife as important and theorize that the events an individual experiences are shaped, in part, by the individual and contribute to the future development and behavior of the individual. In a general sense, life change events (LCE) are necessary for continued growth and development of the individual (Blank, 1993; Featherman, 1983; Kastenbaum, 1993; Lerner, 1983; Lerner & Ryff, 1978). Life Change Events and Stress It would be difficult to dispute that the events individuals experiences have an impact on their lives. An individual's interpretation and perception of various life events will, in part, determine the impact of any specific event on future thought and behavior (Chiriboga, 1984). All LCE place some stress on the individual. The level of that stress and its perception as either positive or negative will moderate the individual's response 5 (Wrightman, 1988). Smolak (1993) describes life change events either as normative or non-normative. Normative events are, for most people, expected occurrences. Examples of these are marriage, birth of children, death of an elderly parent, and new career. Non-normative LCE are the unexpected events in a person's life. These include loss of a child, serious accident, unexpected promotion or increase in income. It should be noted that, whether normative or non-normative, positive or negative, all LCE require some form of adaptive behavior (Smolak, 1993). Chiriboga (1984) divides LCE into three levels: the micro, meso, and macro. Micro events are the day to day hassles of living. They can be positive or negative and may include running out of toothpaste, receiving flowers, being late for work, etc. The meso level of LCE is very similar to the normative and non-normative events described earlier. These are events that typically mark the transition periods of life and have the most impact on the individual. Meso level events are the pivotal events in a person's life that demand some form of personal adaptation and/or behavioral change (Chiriboga, 1984; Smolak, 1993). Macro level life change events are those more global in nature and have an effect on society as a whole. The Depression, the World Wars, the collapse of the Soviet 6 empire have impacted large segments of the world population on a very global level, as well as individuals on a very personal level. As an example, the change in women's roles over the past 20 years has had a major social impact with wide ranging effects on society. This type of macro level event can also influence the behaviors of individuals even when they are not directly involved in the event. LCE are often viewed as stressors and often classified as negative. They are seen as having only short-term (less than 1 year) impact on the individual (Duer, Swenk, & Coyne, 1988; Ferketich & Mercer, 1989; Rahe, 1988; Williams, Zyzanski, & Wright, 1992). Few studies have focused on the cumulative effects of LCE over longer periods of time. None involved people in their middle years. No studies were found directly examining the possible existence of positive effects of LCE. LCE as Positive Influence on HPB Several studies were examined that support the premise that LCE can be cues to initiate behavioral change. When confronted with serious medical diagnoses, (a negative LCE) , studies have indicated that people will increase the number and extent of health promoting behaviors (HPB) (Cleary, Van-Devanter, Rogers, Singer, Shipton-Levy, Stielen, Stuart, Avorn, & Pindyck, 1991; 7 Currie, Amos, & Hunt, 1991; Stromberg, Pender, Walker, & Sechrist, 1990). Marriage, a significant LCE, has a positive impact on HPB, especially among men (Urr~erson, 1992) . Several studies support the premise that LCE may have a positive influence on HPB. They indicate that increasing age positively correlates with the performance of HPB (Bechtal & Franklin, 1993; Heck & Pinch, 1990; Nakagawa, Ishitake, Iwamoto, Suenaga, Mori, Matoba, Takaki, & Hara, 1993; Walker, Volkan, Sechrist, & Pender, 1988). If the assumption that increasing age exposes an individual to more LCE is accepted, then there may be support for a further assumption that exposure to LCE is a determinant of health-promoting behavior. A review of nursing research into the demographic characteristics of indiyiduals exhibiting HPB or healthy lifestyles also indicates older adults have more HPB and a generally healthier lifestyle (Redland & Stuifbergen, 1993; Stromberg, et aI, 1990). In their review of the literature, Redland and Stuifbergen (1993) agree that there is little available research on what influences individuals to change their HPB. Theoretical Frameworks The theoretical frameworks selected for use in this study are Pender's Health Promotion Model (HPM) (Pender, 8 1987) and Life Span Developmental Theory (LSDT) (Baltes, 1979; Featherman, 1983). These two theoretical frameworks provided basic support for the central questions of this study. Health Promotion Model. Pender's (1987) HPM is complementary to and an expansion of the Health Belief Model (HBM). The HBM was developed in the 1950s to explain the existence of health preventative or protective behaviors (Pender, 1987). Pender's HPM (1987) was developed to provide a more holistic approach for examining the health of individuals, groups and communities. The HPM describes behaviors directed towards "increasing the level of well-being and self-actualization of a given individual or group" (Pender, 1987, p. 57). Pender (1987) defines HPB as those activities that have become integral parts of an individual's life. Examples of HPM include management of stress, good eating habits, exercise, and development of social support systems (Pender, 1987; Walker et aI, 1988). An example of a HPB is a young man exercising simply because it makes him feel better. In contrast to the HPM, the older HBM focuses on risk avoidance behaviors aimed at decreasing the likelihood of becoming ill. These avoidance behaviors are described as health protective. An example might be a 45 year old man beginning to exercise after an acquaintance the same age 9 10 suffers a heart attack. Though some HPB may initially begin as health protective behaviors (with avoidance of illness as the original motivating force), they can evolve to HPB. The HPM identifies three areas that act as determinants of HPB. The first are cognitive-perceptual factors that influence the acquisition and maintenance of HPB and are considered the primary motivational factors for HPB. The factors have been identified as "(1) importance of health, (2) perceived control of health, (3) perceived self-efficacy, (4) definition of health, (5) perceived health status, (6) perceived benefits of HPB, and (7) perceived barriers to HPB" (Pender, 1987, p. 60). The second group of determinants of HPB are five modifying factors or characteristics. These also have direct influence on the performance of HPB. They are demographic characteristics, biological characteristics, interpersonal influences, situational or environmental factors, and behavioral factors (Pender, 1987). Cues to action are the third area of influence on HPB. Cues to action are the triggering events for the initiation of HPB. These cues can arise from either internal or external sources (Pender, 1987). This study utilized this portion of the HPM as a basis for the creation of its research questions. The proposed theory is that life change events will act as cues to action for 11 the acquisition and maintenance of HPM. This model has shown itself to be a useful determinant in health behavior research. Several studies have been conducted using the HPM and its supportive instrument, the Health-Promoting Lifestyle Profile (HPLP; Walker, Sechrist, & Pender, 1985) and found it to be an appropriate framework for examining HPB (Johnson, Ratner, Bottorff, & Hayduk, 1993; Lusk & Kelemen, 1993; Pender, Walker, Sechrist, & Stromberg, 1990; Stromberg, et aI, 1990; Walker, Volkan, Sechrist, & Pender, 1988; Weitzel, 1989). In addition, the abstracts of several doctoral dissertations were reviewed and the authors indicated that use of the HPM and the HPLP had efficacy for their research (Bagwell, 1988; Barnett, 1989; Buenting, 1990; Fehir, 1988; Hudak, 1988; Simmons, 1990; Vines, 1991). A critique of Pender's theory (Johnson, 1994) found it to be a useful theoretical framework for nursing research and suitable for the population in this study. Life-Span Developmental Theory. The LSDT began to take form in the late 1960s and early 1970s as an attempt to provide an explanation for continuing personal development into adulthood and to explain the apparent existence of the midlife crisis or transition (Featherman, 1983). Featherman (1983) summarized the basic tenets of LSDT. The first and most central premise is that developmental change continues to occur throughout the 14 A portion of this study sought to identify the number of LeE occurring from ages 20 to 50. Secondly, it sought to determine if there is any relationship between the occurrence of LeE and the perceived or real impact of LeE and the performance of HPB. This information may be of use to nurses and other health care providers in identifying individuals with needs for external support in their performance of HPB. This study also enabled the researcher to identify some specific health behaviors that may assist health care providers in targeting interventions in their male patient population. Research Questions 1. Is there an increase in HPB, as measured by the HPLP, from young adulthood (20-34 years old) to middle age (35-50 years old), as indicated by higher scores on the HPLP? 2. Is there a correlation between the number of LeE experienced and the performance of HPB? 3. Is there any difference between positively perceived LeE and negatively perceived LeE on the performance of HPB? 4. Will the older group will have experienced a greater number of LeE than those in the younger group? 5. Will the 35-50 year old group score more LeE as positive or negative? 12 life span, without regard to age. The second assumption is that developmental changes are modified and influenced by biological, social, psychological, physical and historical events (Featherman, 1983). These factors are very similar to Pender's modifying factors, as previously discussed. The third premise, which has been supported by recent longitudinal research (Fiske & Chiriboga, 1990), is that the determinants of change (including LCE) have cumulative and interactive influences on the behavior and personality of individuals throughout their life span (Featherman, 1983). In other words LCE may have significant short- and long-term impact on a person's behavior. A fourth concept, having parallels in Pender's (1987) cognitive-perceptual factors, is that individuals are agents of their own development. Further, the multiple factors affecting development are modified by the motivation and response of the individual (Featherman, 1983) . The fifth assumption of LSDT is that each generation or birth cohort has their development affected by the larger geopolitical/historical events of their lives (Featherman, 1983). This is consistent with the concept of macro stressors as proposed by Chiriboga (1984). The final belief, which has strong implications for nursing, is that intervention efforts at any age can be effective in altering the behavior of individuals (Featherman, 1983). This suggests an inherent plasticity or flexibility to the human personality and spirit enabling growth and change throughout the life-span (Lerner, 1983, 1984). Implications for Nursing 13 As previously stated, there is little or no available research on the performance of HPB by middle age men and factors associated with HPB. If there is a correlation between the experience of LCE and the performance of HPB and if specific events or behaviors can be identified, then they can be used by nurses and other health care providers, in a variety of settings, as cues for intervention. The nurse or other health care provider would then be able to aid the individual in the acquisition and maintenance of HPB. This thought is supported by Pender's (1987) HPM in that LCE may act as cues to action and that the nurse may have a role as a part of the individual's social support. A study by Rosenstock (1988) indicates that support by health care providers can have a positive therapeutic impact on change to a healthier lifestyle. Social support (as viewed in the HPM) has been positively correlated with the performance of HPB (Ahijevych & Bernhard, 1994; Lusk & Kelemen, 1993). Operational Definitions The following terminology will be used throughout this thesis. Young Adulthood, ages 20-34. Middle Age, ages 35-50. Life Change Event, positive or negative events with a perceived or real impact on the individual, that have the potential to alter behavior. Health-Promoting Behavior, those behaviors identified as items on the Health-Promoting Lifestyle Profile (Appendix A) . 15 CHAPTER 3 METHODS Study Design A cross-sectional study design was utilized to answer the proposed research questions. This particular design was chosen because of its economy, practicality, and appropriateness to this type of research (Baltes, Reese, & Nesselroade, 1977). This design has provided preliminary data that may be useful in guiding future research efforts in this area. Approval for this study was obtained from the Institutional Review Board of the University of Utah Health Sciences Center. Sample A sample of convenience was used in this study. The sample consisted of two groups of adult males, ages 20-34 (n=29) and 40-50 (n=32), with a mean age of 35.6 years old, median and mode of 35 years. Male members of selected church congregations in metropolitan Salt Lake City were contacted through the church pastor or other church members. They were asked to fill out a demographic profile, the Life Experiences Survey (LES), and the HPLP. They were also provided with a cover letter that explained 17 the purpose of this study, guaranteed confidentiality, and gave notice of infor.med consent by return of the survey to the researcher. Surveys were handed out at the conclusion of Sunday church services and returned by the respondents to a designated contact person at the church or to the researcher by mail. There were 120 surveys distributed with a return of 66. Four contained no demographic data and were not used for data analysis. The response rate (51%) was calculated as 65 minus 4 for returned and usable surveys, divided by 120. The individuals in this study were predominantly white (92%) and married (75%). Their education ranged from eighth grade to doctorally prepared with 98% being high school graduates and 66% college graduates. Income ranges were $10,000 to greater than $50,000 per year with the mean being $30,000 to $40,000 per year and the majority (38%) greater than $50,000 per year. The majority of respondents (66%) listed their occupation as professional (Table 1). Instruments Health Promoting Lifestyle Profile. Data on health promoting-behavior were collected using the Health­Promoting Lifestyle Profile developed by Walker, Sechrist, health-oriented behaviors. The HPLP is a series of 48 18 Table 1 Demographic Characteristics of Study Sample (n=61) Characteristic N %* Age Group 1 (20-34) 29 48 Age Group 2 (35-50) 32 52 Marital Status Married 46 75 Single 9 15 Divorced 5 8 Widowed 1 2 Race/Ethnicity White 56 92 Hispanic 1 2 Native American 1 2 Asian 2 3 Other (not specified) 1 2 Education Level 8th-12th Grade 1 2 H.S. Graduate 1 2 Some College 19 31 College Graduate 17 28 Some Postgrad. 10 16 Masters Degree 5 8 Doctorate 8 13 Occupation Professional 40 66 Clerical 3 5 Skilled 14 23 Missing 4 7 Income Less than $10,000 4 7 $10,000-$20,000 11 18 $20,000-$30,000 8 13 $30,000-$40,000 10 16 $40,000-$50,000 5 8 Greater than $50,000 23 38 Religion Episcopal 12 20 Catholic 14 23 Presbyterian 12 20 Lutheran 23 38 Religious Support Very Little Support 18 30 Little Support 10 16 Some Support 8 13 Great Support 16 26 Very Great Support 9 15 *May not total 100% due to rounding error. statements describing HPB and the frequency of performanceand Pender (1987). This instrument measures the number of HPB. Respondents are asked to indicate if they engage in these behaviors: never, sometimes, often, or routinely. The responses were then scored one to four, summed and averaged to give a total score. Scores for the six subscales were also calculated in a similar manner. 19 The HPLP was developed based on Pender's HPM. The original instrument was tested on 952 volunteer subjects from two large midwestern cities, ages 18-88 (m=39.2),the majority were from the middle class, all were literate. The original instrument, of 107 items, was reduced to its current 48 after item analysis was run to eliminate items that decreased internal consistency. The final instrument consists of six subscales, with high internal consistency, alpha coefficients ranged from .702 to .904, with an alpha coefficient of .922 for the total instrument (Pender, et al., 1987). The reliability of the HPLP for this study was determined by obtaining alpha coefficients for all subscales and the total instrument. The alpha coefficient for the total instrument was .936 and the subscales ranged from .910 to .684 (Table 2). These scores were consistent with Pender's original measures of reliability and in most cases higher. These scores indicate the HPLP has a high Table 2. Internal Consistency of the Health-Promoting Lifestyle Profile and its Subscales Subs cales Number of Items Alpha Self-Actualization 13 .910 Health Responsibility 10 .867 Exercise 5 .783 Nutrition 6 .806 Interpersonal Support 7 .851 Stress 7 .684 HPLP Total 48 .936 level of internal consistency. Secondly, the alpha coefficients for the subscales indicate modest to high levels of internal consistency. 20 Pender, et al. (1987) conducted test-retest measures with a sample of 63 adults over a 2-week interval. Pearson's ~ scores ranged from .808 to .905 for the subscales and .926 for the entire instrument, indicating a high level of stability. The authors of this instrument appear satisfied that the HPLP has "sufficient reliability and validity for use by researchers ll (Walker, Sechrist, & Pender, 1987, p. 80). Other research (as previously cited on HPM) has also found the HPLP to be a more than adequate instrument as a measure of health-promoting lifestyles. 21 Life Experiences Survey. Life change events data were collected using the Life Experiences Survey (LES) developed by Sarason, Johnson, and Siegel (1978). The LES is a 57 item self-report instrument based on the Schedule of Recent Life Experiences (SRE; Holmes & Rahe, 1967). The LES differs from the SRE in that it has been adjusted to include sex-specific experiences and to measure the positive or negative impact of experiences, as perceived by the individual. Study participants were asked to indicate, on the LES, if a particular life event had occurred and to rate its impact on their life. The impact ratings were from negative 3 to positive 3, indicating extremely negat~ve impact to extremely positive impact. A score of 0 was rated as no impact. Three separate scores were calculated on the LES: negative score (sum of all negative responses), a positive score (sum of all positive responses), and a total score (sum of positive and negative scores) . The LES has shown moderate test-retest reliability in three studies, ~=.63, .64, and .82. Reliability coefficients on the positive scores were less than those of the total and negative scores. The negative score coefficients were in a range similar to the total score. The authors reported no threats to validity and state the LES is a moderately reliable instrument suitable for studies "aimed at identifying moderator variables" (Sarason, Johnson, & Siegal, p.942, 1978). 22 The LES was shown to have a high level of internal consistency for this study with an alpha coefficient of .823. Nunnally (1978) has stated that reliability of .80 is suitable for basic research. No other studies utilizing this instrument were found during the literature search. Additional data. Demographic data were gathered on study participants. Items included, age, marital status, race, years married, income, occupation, number of children, hobbies, and education. Additionally a Likert­type item was included asking respondents to indicate the amount of support they may have received from their church during stressful life events. This was scored from 1 to 5, with a score of 5 indicating very great support. An open-ended question asking respondents to describe any events that may have had an impact on their health was also included as a part of the demographics survey. Data Analysis Data were analyzed utilizing SPSS-PC+ statistical package version 4.0. Frequencies were calculated for all variables and descriptive statistics were also obtained for all variables. 23 Pearson's Product Moment Correlations between demographic variables and the HPLP and its subscales, the LES (total, positive and negative scores), church support and age group were analyzed to determine if there were any significant relationships among variables. The existence of significant correlations (~ < .01 or .001) was used to determine additional pairings of variables for further analysis (Table 3). A series of t-tests were performed to see if differences in scores on the HPLP and its six subscales, total LES, positive LES, negative LES, and church support existed between the two groups. Group one consisted of young adult males, 20-34 years of age (n=29) and group two middle age adult males, 35-50 years of age (n=32). Because of the unequal numbers in groups, F-tests were done to determine homogeneity of variance. Examination of the individual item scores from the HPLP revealed several specific health behaviors with overall low scores for the entire sample. A series of independent t-tests were performed on the selected variables to see if any differences between groups existed. 24 Table 3. Correlations Between Selected Variables Variables HPLP Church Support LES positive .47** .41* Total Positive Life Events .44** .49** HPLP - - - - - .48** ** 12 < .001, *12 < .01 n=61 CHAPTER 4 RESULTS Means and standard deviations for the HPLP and its six subscales, LES (total, positive, and negative scores), a total number of events score and the Likert type measure of church support were computed for both age groups and the entire sample. The results of the data analysis were specifically targeted at answering the research questions. The outcomes of the data analysis as it relates to each question will be discussed in detail below. Age Differences and HPB An independent t-test was run to determine if there was any significant difference between the groups in their HPLP scores. The mean score for the HPLP for the entire sample was 2.52 with a range of 1.56 to 3.42. The mean HPLP score for group one (ages 20-34) was 2.57 compared to the mean for group two (ages 35-50) of 2.48 (Table 4). The results of this analysis appear to indicate that there was no increase in HPB from young adulthood to middle age within this sample. Independent t-tests were also calculated on the six subscales of the HPLP (Table 4). No significant Table 4. Independent t-tests Between Groups on Selected Variables M M Variable Group 1a SD Group 2b SD HPLP 2.57 .43 2.48 .40 . 84 HPLP Subscales: Self- Actualization 3.19 .48 3.00 .58 1.34 Health Respon. 2.01 .67 2.02 .55 -.07 Exercise 2.35 . 66 2.17 .76 1.01 Nutrition 2.58 .77 2.62 .68 - .21 Interpersonal Support 3.09 .63 2.89 .61 1.24 Stress Management 2.36 .48 2.35 .48 .09 Church Support 2.83 1.51 2.78 1.48 . 12 LES 36.72 14.55 39.78 15.34 - .80 LES positive 20.66 10.58 23.38 12.91 -.90 LES Negative 16.07 12.06 16.41 12.74 .11 Total Life Events 19.83 6.35 20.50 7.26 -.39 a 11=29 b 11=32 26 sig. N.S . N.S. N.S. N.S . N.S. N.S. N.S. N.S . N.S. N.S. N.S. N.S. 27 differences were found between the calculated means forthe two groups. It should be noted that the younger group scored higher on every subscale measure except health responsibility and nutrition. The subscale measuring self-actualization had scores of 3.19 for the younger group and 3.00 for the older group. This difference in scores though not statistically significant (~=.187) is somewhat surprising. There would be some expectation that as men grow older they would be more self-fulfilled and content. This may also be a partial explanation for the "midlife crisis." LCE and the Relation to HPB In examining the possible effects of the number of LCE on the performance of HPB, Pearson's Product Moment Correlations were calculated for the HPLP and its six subscales against the total number of LCE, the total number of negative events, and the total number of positive events. No significant correlations, positive or negative, were found as a result of this analysis. The results of a two-way ANOVA comparing the effects of age and the LES score on HPLP scores also failed to show any significant interactions. The results of this data analysis lead the researcher to conclude, for this sample, that LCE appear to have a neutral effect on HPB. 28 Age and LES Further data analysis was performed to support the assumption that increasing age guarantees the experience of a greater number of life events and to see if the older group in this study experienced more life events than their younger counterparts. The LES scores, the sum of positively and negatively scored events, for the entire sample ranged from 10 to 82 with a mean of 38.33. Mean score for the younger group was 36.72 compared to a mean of 39.78 for the older group. The mean total number of events score for the entire sample was 20.18 events, ranging from 5 to 43 events. There was only a small and nonsignificant difference between the two groups; group one, 19.83 events, group two 20.50 events. Independent t­tests were computed for the age groups and their LES scores and total number of events scores. This revealed no significant difference between the two groups on either measure. The two groups were then compared on the positive and negative LES scores, and their positive and negative number of events scores. Independent t-tests on all of these variables also revealed no significant differences between groups on these variables (Table 4). 29 Selected Health-Promoting Behaviors Independent t-tests performed on selected items from the HPLP to reveal any differences in responses by members of the two age groups. These items were chosen on the basis of high (>3.00) mean scores or low «2.20) mean scores for all respondents. The analysis of these data revealed no significant differences between the two groups, except on the item "Have my cholesterol level checked and know the result" (HPLP, Walker, Sechrist, & Pender, 1985). The mean score for the younger group was 1.62 compared to the mean score of 2.13 for the older group. This resulted in a h-value significant at the .02 level. Demographics and HPLP As was discussed previously, this study sample tended towards homogeneity. In an attempt to explain the variance of response to the HPLP, LES, total number of life events, total number positive life events, and total number negative life events, nonparametric correlations were obtained with selected demographic variables. The demographic variables were chosen on the basis of apparent heterogeneity. They were years of marriage, income and church support. Regression analysis was run plotting HPLP with years of marriage, church support and education. Spearman's rho correlation for years of marriage and education was not significant and explained less than 2% of variance. 30 The relationship of church support to the HPLP scores was in the moderate range with a Spearman's rho correlation of .439 (~=.0004). This explained 19% of the variance. Regression analysis was also run plotting years of marriage against total numbers of positive life events, LES positive score, and HPLP score. The relationship between years of marriage and the HPLP score was non­significant and explained les than 1% of the variance. In contrast years of marriage and positive life events as measured by positive LES and total number of positive events showed moderate to low correlations. The Spearman's rho correlation between years of marriage and the positive LES score was .302, significant at the .025 level. This explained 9% of the variance. A strong correlation between years of marriage and the total number of positive life events was noted with a Spearman's rho correlation of .422, significant at the .001 level with an explanation of variance of 18%. An examination of other demographic variables to the measures of HPLP and its six subscales, LES, total, positive, and negative scores revealed no significant correlations. Explanation of variance was less than 2%. CHAPTER 5 DISCUSSION Limitations This study has several limitations that may have afffected the results. The small sample size probably contributed most to the lack of differences in group means across the measured variables. Secondly, there may not have been enough difference in age between the two groups, leading to a lack of variability. A third factor is the sample's lack of demographic heterogeneity. This lack of heterogeneity may have negated any effects of age difference. The use of volunteer subjects is always open to self­selection bias and could have been partially responsible for lack of differences between groups in the obtained results. Additional research utilizing a larger sample with larger differences in age between groups may provide researchers with more usable results. As with any study random selection of subjects would certainly strengthen the overall study and provide a more representative sample. The results of this study are not generalizable to all groups, but should be representative of 20 to 50 year- 32 old white males who attend church. The sample utilized in this study was quite homogeneous. Studies involving men from more diverse ethnic backgrounds, different socio­economic groups, varied occupations, and more single, divorced and widowed men could have a significant impact on the final results. Similar studies comparing men and women on the same measures may yield some useful data. Examination of Selected Health Behaviors An examination of individual items within the HPLP reveals several areas of health behavior that have strong implications for nursing. An item by item analysis uncovered several items with low mean scores and low scores for a majority of the respondents on those items. The item on the HPLP with the lowest mean score was item number seven, "Have my cholesterol level checked and know the results" (Walker, Sechrist, & Pender, 1985). The mean for all respondents was 1.89, with 84% (n=51) responding either never or sometimes. This is an obvious area of patient education that nurses and other health care providers can target. A second item with a low mean score (2.37), was number 43 "Observe my body at least once a month for physical changes/danger signs" (HPLP, Walker, Sechrist, & Pender, 1985). The responses never and sometimes were given by 56% of the sample. This highlights the need for 33 nurses and others to continue to educate their patients on testicular self-exam, skin examination, and the need for age appropriate physical exams and tests. Only 38% of the respondents answered, "often or routinely" to the item, "plan or select meals to include the basic four food groups each day" (Walker, et al., 1985). Similarly only 23% responded "often or routinely" to an item about discussing their health with a health care provider. The most telling statistic was the response to item 42, "Seek information from health professionals about how to take good care of myself" (Walker, et al., 1985). The mean for this item was 1.92, with 80% (n=49) indicating never or sometimes. This result suggests that health care professionals are either unavailable to their patients or unapproachable. The fact that this study population of middle class, well-educated men does not seek advice from their health care providers has strong implications for nursing and points to a need for further research to determine possible reasons for patients not seeking health advice. If nurses and other health care providers are to serve the needs of their patients, they must be able to target those specific areas of health promotion, not being performed by their patients. Further research into 34 health-promoting behaviors and the factors affecting their acquisition and maintenance can provide nurses and others with the data needed to help their patients towards healthier lifestyles. Pender (1987) has suggested that the acquisition and maintenance of health-promoting behaviors are dependent on a variety of internal and external factors. Nurses and other health care providers can provide their patient with cues to action for the acquisition of HPB and can provide important support for the maintenance of health-promoting behaviors. APPENDIX A HEALTH-PROMOTING LIFESTYLE PROFILE 36 Ufestyle Profile DIREcnONS: This questionnaire contains statements regarding your present way of life or personal habits. Please respond to each item as accurately as possible, and try not to skip any item. Indicate the regularity with which you engage in each behavior by circling: N for never S for sometimes. o for often 1. Eat Breakfast. 2. Report any unusual signs or symptoms to a physician. 3. Uke myself. 4. Perform stretching exercises at least 3 times per week 5. Choose foods without preservatives or other additives. 6. Take some time for relaxation each day. 7. Have my cholesterol level checked and know the result. 8. Am enthusiastic and optimistic about life. 8. Feel I am growing and changing personally in positive directions 10. DiscLtss personal prob~ems and concems with persons close to me. 11. Am aware of the sources of stress ira my life. 12. Feel happy and content. 13. Exercise vigorously for 20-30 minutes at least 3 times per week. 14. Eat 3 regular meals a day. 15. Read articies or books about promoting health. 16. Am aware of my personal strengths and weaknesses. 17. Work toward long-term goals in my life. 18. Praise other people easily for their accomplishments. 19. Read labels to identify the nutrients in packaged food. 20. Question my physician or seek a second opinion when I do not agree with recommendations. 21. Look forward to the future. 22. Participate in supervised exercise programs or activities. N N N N N N N N N N N N N N N N N N N N N N R for routinely s s s s s s s s s s s s s s s s s s s s s o o o o o o o o o o o o o o o o o o o o o o Reprinted by permission of Walker, S., Sechrist, K., and Pender, N. (1985). Health-Promoting Lifestyle Profile. R R R R R R R R R R R R R R R R R R R R R R 37 ewn ~ :e w 0::: i= z z ~ w w i= :i t: ::. :wz 0en 0 00: :: 23. Am aware of what is important to me in life. N S 0 R 24. Enjoy touching and being touched by people close to me. N S 0 R 25. Maintain meaningful and fulfilling Interpersonal relationships. N S 0 R 26. Include roughagelfiber (whole grains, raw fruits, raw vegetables) in my N S 0 R diet. 27. Practice relaxation or meditation for 15-20 minutes daily. N S 0 R 28. Discuss my health care concerns with qualified professionals. N S 0 R 29. Respect my own accomplishments. N S 0 R 30. Check my pulse rate when exercising. N S 0 R 31. Spend time with close friends. N S 0 R 32. ~Have my blood pressure checked and know what it is. N S 0 R 33. Attend educational programs on Improving the environment in which N S· 0 R we live. 34. Find each day Interesting and challenging. N S 0 R 35. Plan or select meals to include the -basic four'" food groups each day. N S 0 R 36. Consciously relax muscles before sleep. N S 0 R 37. Find my living envlronrhent pleasant and satisfying. N S 0 R 38. Engage in recreational physical activities (such as walking, swimming, N S 0 R soccer, bicycling). 39. Find it easy to express concem, love and warmth to others. N S 0 R 40. COncentrate on pleasant thoughts at bedtime. N S 0 R 41. Find constructive ways ~o express my feelings. N S 0 R 42. Seek information from health professionals about how to take good N S 0 R care of myself. 43. Observe my body at least monthly for physical changes/danger signs. N S 0 R 44. Am realistiC about the goals that I set. N S 0 R 45. Use specific methods to control my stress. N S 0 R 46. Attend educational programs on personal health care. N S 0 R 47. Touch and am touched by people I care about. N S 0 R 48. Believe that my life has purpose. N S 0 R REFERENCES Ahijevych, K. & Bernhard, L. (1994). Health-promoting behaviors of African American women. Nursing Research, 43(2), 86-89. 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