O R I G I NA L A R T I C L E
Factors Related to Performance of Health Practices Among Asian Adolescents in the United States Cynthia G. Ayres1*, PhD, RN, Robert Atkins1, PhD, RN, Ganga Mahat2, EdD, RN 1
Assistant Professor, Rutgers College of Nursing, Rutgers, The State University of New Jersey, Newark, USA 2 Clinical Associate Professor, Rutgers College of Nursing, Rutgers, The State University of New Jersey, Newark, USA
Purpose This study examined factors related to positive health practices (PHP) among Asian adolescents. More specifically, it tested theoretical relationships postulated between PHP and social support, optimism, self-esteem, loneliness, and acculturation in this population. Method A correlational research design was used and a convenience sample of 151 Asian adolescents was obtained. Participants completed a demographic sheet and six study instruments. Results Significant positive relationships were found between reported performance of PHP and social support, optimism, self-esteem, and acculturation. A significant inverse relationship was found between loneliness and PHP. Conclusions Study findings extend existing knowledge and contribute to a more comprehensive knowledge base regarding health practices among Asian adolescents. Having this knowledge base provides practitioners with a better understanding of the factors related to health practices in Asian adolescents and assists them in developing culturally sensitive interventions aimed at promoting PHP in this population. [Asian Nursing Research 2010;4(2):64–74] Key Words
adolescent, health behavior, health promotion, minority health
INTRODUCTION Many health promoting behaviors such as diet and exercise emerge during the stage of adolescence, a critical developmental period in regards to health and illness. However, it is also during this period when important health risk behaviors such as smoking and
alcohol use, poor eating habits and physical inactivity, and unsafe sexual practices begin to develop (Chassin, Presson, Rose, & Sherman, 1996; Chen & Kandel, 1995; Cohen, Brownell, & Felix, 1990; Holden & Nitz, 1995; Katchadourian, 1990; Williams, Holmbeck, & Greenley, 2002). It is between the ages of 18 and 21, also referred to as late adolescence,
*Correspondence to: Cynthia G. Ayres, PhD, RN, Assistant Professor, Rutgers, The State University of New Jersey, Rutgers College of Nursing, 180 University Avenue, Newark, New Jersey 07102, USA. E-mail: [email protected] Received: April 1, 2010
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Revised: May 11, 2010
Accepted: May 27, 2010
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that individuals have the autonomy to engage in behaviors that lead to health risks or to develop a healthy lifestyle (Millstein, Nightingale, Peterson, Mortimer, & Hamburg, 1993). By targeting the behaviors in areas as smoking, alcohol use, nutrition, physical activity, and sexual behavior during adolescence, the risks of the major sources of mortality and morbidity during adolescence, and later in life, can be significantly reduced (US Department of Health and Human Services, 2001). Asian Americans are one of the fastest growing population groups in the United States, increasing at a rate faster than the general population between 1990 and 2000 (Barnes & Bennett, 2002). Like many racial/ethnic populations, Asian Americans are disproportionately affected by many health disparities. Cancer and cardiovascular disease, for example, are the two leading causes of death for Asian Americans in the US. Additionally, cancer is the leading cause of death in Asian women in the US, due to the fact that Asian American women have the lowest cancer screenings rates and are usually diagnosed at a later stage compared to other racial and ethnic groups. Mental health problems in the Asian American community are disturbingly high, yet its services are inadequate. Asian American adolescent girls reportedly have the highest rates of depressive symptoms compared to girls of other ethnicities. Additionally, Asian American youth in grades 7 through 12 have the highest increase in smoking rates of any racial and ethnic group (Asian American Health Initiative, n.d.). However, unlike many other racial/ethnic groups, there is a lack of studies that have examined factors which may contribute to the performance of general positive health practices (PHPs) in Asian adolescents. Therefore, research that increases our knowledge of Asian adolescents’ health promoting behaviors, including those factors related to PHPs, has the potential to reduce the risks of disease in this age group, improve their health and longevity, and help to eliminate the health disparities among this ethnic/racial group. Therefore, the purpose of this study is to examine factors that may be related to the performance of PHPs in Asian adolescents. More specifically, this study tested theoretical relationships postulated in Asian Nursing Research ❖ June 2010 ❖ Vol 4 ❖ No 2
the literature between the dependent variable, PHPs, and the independent variables of (a) social support, (b) optimism, (c) self-esteem, (d) loneliness, and (e) acculturation.
Conceptual framework Positive health practices and social support Positive health practices are defined as a composite of exercise, nutrition, relaxation, avoidance of substance use, and the promotion of health (Brown, Muhlenkamp, Fox, & Osborn, 1983). Social support is defined as consisting of six categories of relational provisions: attachment, social integration, opportunity for nurturance, reassurance of worth, a sense of reliance, and obtaining guidance and information in stressful situations (Weiss, 1974). Social support can influence the performance of specific health behaviors, such as seat belt use, exercise and nutrition, medical checkups, dental care, immunizations, and miscellaneous screening exams by providing information about PHPs and by establishing norms that encourage healthy behaviors (S. Cohen, 1988; Langlie, 1977). Empirical research have supported the relationship between social support and PHPs in adolescent populations (Ayres, 2008; Mahat & Scoloveno, 2001; Mahat, Scoloveno, & Whalen, 2002; Mahon, Yarcheski, & Yarcheski, 2004; Yarcheski, Mahon, & Yarcheski, 2003). These findings add credence to the work of classic theorists (S. Cohen; Langlie) suggesting a relationship between the two variables. Therefore, it is postulated that there is a positive relationship between PHPs and social support in Asian adolescents. Positive health practices and optimism Optimism has been theorized to contribute to the performance of PHPs. According to Scheier and Carver (1992), optimism, or the belief that good things will happen throughout one’s lifetime, is postulated to affect individuals’ actions, including their health behaviors. Optimists are more likely to follow treatment regimens and change behaviors that might compromise their health, and to engage in behaviors that help them to adapt to situations. Since PHPs are considered to be adaptive, optimists have more 65
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of a tendency to perform them (Scheier & Carver). Research findings support a low positive relationship between optimism and the performance of PHPs in adolescents (Ayres, 2008; Yarcheski, Mahon, & Yarcheski, 2004). On the basis of theory and previous research, it is hypothesized that there is a positive relationship between optimism and PHPs in Asian adolescents. Positive health practices and self-esteem Self-esteem is defined as the individual’s assessment of self-worth (Rosenberg, 1965). It has been posited that self-esteem or one’s sense of self-worth influences one’s health behaviors (Bandura, 1968). There is existing empirical support for a positive relationship between self-esteem and the performance of PHPs in adolescents (Yarcheski, Mahon, & Yarcheski, 2003). Self-esteem is therefore hypothesized to be positively related to PHPs in Asian adolescents. Positive health practices and loneliness Loneliness is defined as the felt lack of meaningful relationships (Sisenwein, 1964). An unfulfilled desire to have friends, an understanding of the gap between actual and desired social status, and a lack of affective bonding may contribute to feelings of loneliness. According to the classic works of Peplau and Perlman (1982), loneliness occurs when relationships do not meet social needs, fail to fulfill personal desires, or decrease social rewards. Additionally, loneliness apparently has paradoxical motivational properties in that loneliness might arouse motivation for interpersonal contact but diminish motivation for nonsocial activities. When motivation is diminished, lonely people are apathetic and aimless and do not have the energy to complete tasks successfully, which clearly could influence the carrying out of PHPs. There is empirical support for this proposed inverse relationship in adolescents (Ayres, 2008; Mahon et al., 2004). Loneliness is hypothesized to be inversely related to PHPs in Asian adolescents. Positive health practices and acculturation Acculturation is defined as the process that can occur when two or more cultures interact (Suinn, Ahuna, & 66
Khoo, 1992). Berry (1980) describes acculturation as the process by which one group asserts its influence over another and what happens is likely to be difficult, reactive, and conflictual, affecting one’s physical as well as psychological functioning. Several possible outcomes of this process can occur, including assimilation, whereby a host culture absorbs the immigrant culture, or multiculturalism, whereby both cultures exists side-by-side. Exposure to another culture can lead an individual to (a) resist changes in his/her values and behavioral competencies, (b) adopt the host culture’s values and behavioral skills and styles as a replacement for his/her parent culture’s values/ behaviors, (c) acquire host culture values/behaviors while retaining parent culture values/behaviors with situational reliance, that is, determining which values/ behaviors are in effect at different times (Suinn et al.). There is empirical support for the proposed relationship between acculturation and PHPs (AfableMunsuz & Brindis, 2006; Bond, Jones, Cason, Campbell & Hall, 2002; Lee, 2007). Acculturation is postulated to be positively related to PHPs in Asian adolescents. Based on the theoretical relationships postulated in the literature, it was hypothesized that there would be (a) a significant positive relationship between PHPs and social support, (b) a significant positive relationship between PHP and optimism, (c) a significant positive relationship between PHP and selfesteem, (d) a positive health practice between PHP and acculturation, and (e) a negative relationship between PH and loneliness.
METHODS Design Using a correlational research design, this study examined the abovementioned hypotheses constructed from theory and research. Sample A non-probability, convenience sample consisted of Asian late adolescents, between the ages of 18 and 21 years who attended a series of Asian student meetings Asian Nursing Research ❖ June 2010 ❖ Vol 4 ❖ No 2
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held at an urban university. In determining the appropriate sample size, a small to medium effect was chosen based on the previously reported theoretical and empirical literature with respect to the relationships investigated in the present study. Using an alpha of .05 and power of the significance test set at level .80 (β = .20), a small to medium effect size of R2 = .10 was anticipated. Therefore, using power calculation recommended by J. Cohen (1988), a sample of at least 129 subjects was necessary to keep risks of statistical errors to standard levels for calculating multiple regression with six predictor variables (Polit, 2010). The final sample size (n = 151) provided the requirements for performing this regression analysis.
Data collection Following approval of the university’s institutional review board and approval of the delegation planning committee of the Asian student meetings, individuals who met the delimitations of the study were approached by the principal investigator between meetings to discuss the purpose of the study and potential participation. A packet of six questionnaires, a demographic form, and a one-page description of the research project were provided to eligible individuals who identified interest in participating in this study. Completed survey questionnaires provided to the researchers on one of the two days of data collection indicated subjects’ consent and voluntary participation in the study (n = 174). Delimitations of the study included individuals who self-identify as an Asian; individuals between the ages of 18 and 21, with the ability to speak and write English, and attendance at the Asian student meetings on at least one of the two days of data collection. Data from 23 students were subsequently eliminated due to response biases, such as extreme responses across negatively worded items and incomplete items on the questionnaires. The final sample was 151 Asian adolescents between the ages of 18 and 21. Instruments Positive health practices The Personal Lifestyle Questionnaire (PLQ) is a 24item self-administered instrument used to measure Asian Nursing Research ❖ June 2010 ❖ Vol 4 ❖ No 2
the positive health practices of individuals (Brown et al., 1983). The PLQ is a 4-point summated rating scale with a total range of possible scores from 22 to 88; higher scores reflect the practice of more positive health behaviors. This instrument consists of six subscales: exercise, less substance use, nutrition, relaxation, safety, and general health promotion. Since one health promotion item on the PLQ was relevant only to females, “Do a monthly self-breast exam” (females only) the following item was added for males: “Do a monthly testicular self-exam (males only).” Each subject responded to a total of 22 items on the PLQ. Numerous studies have been performed using this instrument within the past decade, demonstrating validity (Mahon, Yarcheski, & Yarcheski, 2002) and appropriate coefficient alphas as a measure of reliability (Yarcheski, Mahon, & Yarcheski, 1997; Mahon et al.). In addition, the findings of those studies have been consistent with the theoretical literature, supporting theoretical propositions (Ayres, 2008). For example, Yarcheski et al. and Mahon et al. reported coefficient alphas ranging from .72 to .80 for the PLQ when used with adolescents. In the present sample, the coefficient alpha was .73. Social support The Personal Resource Questionnaire (PRQ85-Part 2) is a 25-item instrument developed by Brandt and Weinert (1981) that measures relational provisions in Weiss’s (1974) definition of social support, with subscales representing intimacy, social integration, nurturance, worth, and assistance. This selfadministered instrument has a 7-point Likert-type scale, with possible scores ranging from 25 to 175; higher scores indicate higher perceived social support. Numerous studies have been performed using this instrument within the past decade, demonstrating validity (Weinert, 1987) and appropriate coefficient alphas as a measure of reliability (Ayres, 2008; Mahat & Scoloveno, 2001; Mahat et al., 2002; Mahon et al., 2004; Yarcheski, Mahon, & Yarcheski, 2001). In addition, the findings of those studies have been consistent with the theoretical literature, supporting theoretical propositions. Researchers (Mahat & Scoloveno; Mahat et al., 2002; Mahon et al., 2004; 67
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Yarcheski et al.) reported coefficient alphas ranging from .76 to .92 for the PRQ85-Part 2 in samples of adolescents. In the present sample, the coefficient alpha was .92. Optimism The Life Orientation Test (LOT) is a 12-item (including 4 filler items) self-report instrument that assesses dispositional optimism, defined as generalized outcome expectancies conceptualized by Scheier and Carver (1987). The five-response format has a range of scores from 0 to 32; higher scores indicate higher levels of optimism. Numerous studies have been performed using this instrument within the past decade, demonstrating validity (Terrill, Friedman, Gottschalk, & Haaga, 2002) and appropriate coefficient alphas as a measure of reliability (Goodman, Knight, & DuRant, 1997; Mahon & Yarcheski, 2002). In addition, the findings of those studies have been consistent with the theoretical literature, supporting theoretical propositions (Ayres, 2008). For example, Goodman et al. (1997) and Mahon and Yarcheski reported coefficient alphas ranging from .58 to .78 in samples of adolescents. In the present sample, the coefficient alpha was .79. Self-esteem The Rosenberg Self-Esteem Scale is a 10-item selfreport instrument that assesses self-esteem, defined as the individual’s assessment of self-worth conceptualized by Rosenberg (1965). This 4-point summated rating scale has a range of scores from 0 to 30; higher scores indicate higher self-esteem. Numerous studies have been performed using this instrument within the past decade, demonstrating validity (Rosenberg, 1965) and appropriate coefficient alphas as a measure of reliability (Yarcheski et al., 2003; Mahon & Yarcheski, 1992). In addition, the findings of those studies have been consistent with the theoretical literature, supporting theoretical propositions (Yarcheski et al.; Mahon & Yarcheski). For example, Mahon and Yarcheski and Yarcheski et al. reported coefficient alphas ranging from .76 to .86 in samples of adolescents. In the present sample, the coefficient alpha was .85. 68
Loneliness The Revised UCLA Loneliness Scale is a 20-item summated rating scale that measures the subjective experience of loneliness (Russell, Peplau, & Cutrona, 1980). Possible scores can range from 20 to 80; higher scores indicate higher levels of loneliness. Numerous studies have been performed using this instrument within the past decade, demonstrating appropriate validity (Russell et al, 1980) and coefficient alphas as a measure of reliability (Mahon, Yarcheski, & Yarcheski, 2001; Mahon et al., 2004). In addition, the findings of those studies have been consistent with the theoretical literature, supporting theoretical propositions. Ayres (2008), Brage-Hudson, Eleck, and Campbell-Grossman (2000), Mahon et al. (2001), and Mahon et al. (2004), reported coefficient alphas ranging from .84 to .90 in adolescents. In the present sample, the coefficient alpha was .92. Acculturation The Suinn-Lew Asian Self Identity Acculturation (SL-ASIA) is a 21-item summated rating scale that measures the acculturation, the process that can occur when two or more cultures interact together as conceptualized by Suinn et al. (1992). A final acculturation score is calculated by summing across the answers for all 21 items and then dividing the total value by 21. Possible scores for each item can range from 1.00 to 5.00; higher scores indicate higher levels of acculturation. Numerous studies have been performed using this instrument within the past decade, demonstrating appropriate validity (Suinn et al.) and coefficient alphas as a measure of reliability (Suinn et al.; Suinn, Khoo, & Ahuna, 1995). In the present sample, the coefficient alpha was .86.
Data analysis The data collected for this study were analyzed using the SPSS statistical package, version 16.0 (SPSS Inc., Chicago, IL, USA). Pearson r correlations were obtained to test the hypothesized relationships between the dependent variable, positive health practices, and each of the independent variables of social support, optimism, self esteem, loneliness, and acculturation. Additionally, descriptive statistics for sample Asian Nursing Research ❖ June 2010 ❖ Vol 4 ❖ No 2
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and survey instruments were obtained. Multiple regression analyses were also performed to determine the predictor values of the independent variables of social support, optimism, self-esteem, loneliness, and acculturation on the dependent variable, PHPs.
RESULTS Study participants consisted of 67 (44.4%) males and 84 (55.6%) females aged 18–21 years. Approximately 52.3% were Chinese, 15.2% were Korean, 11.9% were Filipino, 9.3% were Vietnamese, 7.9% were Japanese; the remaining 3.0% Taiwanese. The majority of participants (59.6%) reported they were born in the US, while about 40.4% reported they were born in another country. However, 85.3% of participants grew up in the US, while 14.7% did not. Approximately 10% of study participants currently have a medical condition that requires them to limit or restrict normal activity. A total of 31% of all study participants are currently participating in organized sports, while 69% indicated they do not currently participate in organized sports. Descriptive statistics for the study variables, social support, positive health practices, optimism, self-esteem, loneliness, and acculturation, are presented in Table 1. Pearson correlations were used to test the hypothesized relationships (see Table 2). Significant positive relationships were found between reported performance of positive health
practices and social support (r = .438, p < .01), between positive health practices and optimism (r = .399, p < .01), between positive health practices and self-esteem (r = .269, p < .01). A significant inverse relationship between positive health practices and loneliness was also found (r = −.254, p < .01). Lastly, there was a positive significant relationship between positive health practices and acculturation (r = .229, p < .01).
Additional findings The independent variables of social support, acculturation, self-esteem, and loneliness were examined as predictors to the dependent variable, positive health practices, through multiple regression analyses. The overall model was found to be statistically significant F (6, 150) = 9.549, p < .001. Approximately 25.5% of the variability of positive health
Table 1 Descriptive Statistics of Study Variables (N = 151) Study variables Positive health practices Social support Optimism Self-esteem Loneliness Acculturation
Score range
M
SD
41–72
57.25
6.738
90–174 9–30 8–29 20–57 1–4
138.02 20.1 19.50 38.62 2.44
17.284 4.12 4.071 8.927 0.561
Table 2 Correlation Matrix Among Study Variables (N = 151) Variables Positive health practices Social support Acculturation Optimism Self-esteem Loneliness
Positive health practice
Social support
–
.438** –
Acculturation .229** .093 –
Optimism .399** .590** .141 –
Self-esteem
Loneliness
.269** .433** .036 .582** –
–.254** –.678** .004 –.494** –.536** –
**p < .01, one-tailed.
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Table 3 Summary of Enter Multiple Regression Analysis for Variables Predicting Positive Health Practices in Asian Adolescents (N = 151) Variable Social support Acculturation Optimism Self-esteem Loneliness
B
SE B
β
0.133 1.924 0.174 0.105 0.075
.041 .862 .109 .154 .078
.342** .160* .157 .063 .099
*p < .05, one-tailed; **p < .01, one-tailed. Adjusted R2 = .255.
practices is accounted for by the variables in the model even after taking into account the number of predictor variables in the model. Regression analyses indicated that effect of social support (B = 0.133, p = .002) was found to be positively significant, indicating that the greater the social support, the greater number of PHP performed. The effect of acculturation (B = 1.924, p = .027) was found to also be positively significant. The positive coefficient indicates that the greater the level of acculturation, the greater number of PHP performed. Optimism (B = 0.174, p = .114), self-esteem (B = 0.105, p = .497), and loneliness (B = 0.075, p = .339) were not significant predictors of performance of PHPs among Asian adolescents (see Table 3). In addition, the respondents’ demographic variables were examined in relation to positive health practices. T-tests showed only a significant difference in positive health practices (t = − 3.002, p = .003) between respondents who do not participate in organized sports and those who do participate in organized sports; those who participate had practiced more positive health practices.
DISCUSSION The findings of this study demonstrated a positive and moderate relationship between social support and PHP in a sample of Asian adolescents. This finding (r = .438) is consistent with previous research 70
that examined the relationship between social support and PHP in adolescents (Ayres, 2008; Mahat & Scoloveno, 2001; Mahat et al., 2002; Mahon et al., 2004; Yarcheski et al., 2003). Thus, this finding extends the theory regarding the relationship between social support and PHP to a population of Asian adolescents, aged 18–21. Asian adolescents’ social support may have influenced their performance of positive health practices, such as seat belt use, getting adequate sleep, exercise and nutrition, by providing information about positive health practices and by establishing norms that encourage healthy behaviors, as suggested by Langlie (1977) and S. Cohen (1988). The moderately strong positive relationship (r = .399) between optimism and positive health practices found in this study is higher than in previous research (Ayres, 2008; McNicholas, 2001) examining this relationship. These findings extend the existing knowledge of the relationship between optimism and positive health practices to a sample of Asian adolescents. Asian adolescents who are more optimistic about life may have been more likely to engage in behaviors that help them to adapt to situations, such as wearing seat belts, getting adequate sleep, along with other positive health behaviors. As suggested by Scheier and Carver (1992), optimists have a greater tendency to perform positive health practices since they are considered to be adaptive. Therefore, the subjective, generalized expectation of positive experiences and outcomes throughout one’s life may increase the extent to which Asian adolescents incorporate positive health behaviors into their lifestyle. The findings of this study demonstrated a positive and moderate relationship between self-esteem and positive health practices in a sample of Asian adolescents. This finding (r = .269), although somewhat lower, is nonetheless consistent with previous research that examined the relationship between self-esteem and PHP in adolescents (Yarcheski & Mahon, 1989; Yarcheski et al., 2003). Asian adolescents’ assessment of one’s self may have influenced their behaviors to engage in positive health practices, as posited by Bandura (1968). In addition, the findings of this study demonstrated a low inverse Asian Nursing Research ❖ June 2010 ❖ Vol 4 ❖ No 2
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relationship between loneliness and positive health practices in a sample of Asian adolescents. This finding (r = −.254), however, is lower than previous research that examined the relationships between loneliness and positive health practices in adolescents (Yarcheski & Mahon; Yarcheski et al.). Lonely Asian adolescents may have diminished motivation, making them apathetic and/or aimless. They may not have the energy to complete tasks successfully, which clearly could influence the carrying out of positive health practices, as postulated by Peplau and Perlman (1982). Thus, these findings extend the theory regarding the relationships between positive health practices and self esteem and loneliness to a population of Asian adolescents. Hypothesis testing demonstrated a significant positive correlation between acculturation and positive health practices (r = .229). This positive correlation was comparable to the findings from previous studies that examined this relationship in adults (Afable-Munsuz & Brindis, 2006; Bond et al., 2002; Sohn & Harada, 2005). For the Asian adolescents in this study, the mean acculturation score was 2.44, which according to Suinn et al. (1992) would indicate somewhat “bicultural”, and would be reflected in a SL-ASIA score of three. Asian adolescents may have been capable of assuming the best of both worlds, without denial to either. Asian adolescents in this study may not have experienced difficult, reactive, or conflictual situations which tend to occur with the exposure to another culture, affecting one’s physical as well as psychological functioning. Therefore, these findings add additional empirical support to this positive relationship between positive health practices and acculturation, extending theory to a population of Asian adolescents. There was a significant difference in positive health practices between those who reported having participated in sports and those who do not. It may be that information-sharing about health care practice occurs among individuals within the same sport. Individuals with this social network of organized sports may internalize conventional beliefs about health promotion. In addition, organized sports facilitate healthy behaviors such as exercising, Asian Nursing Research ❖ June 2010 ❖ Vol 4 ❖ No 2
drinking plenty of fluids, and getting adequate rest (Ayres, 2010). This study’s findings should be taken with caution given several limitations. First, study participants were recruited from those individuals attending Asian student meetings. These student meetings were hosted by an organization that wants to strengthen the East Coast Asian student community, and to bring students to new heights of awareness, activism, and pride in the Asian community. By the nature and philosophy behind these meetings, Asian adolescents in attendance were more likely to be engaged in their community and be proactive about basic issues that may affect them and their community. With that being said, study participants may have been more likely to engage in behaviors that positively affect them, including positive health practices, than the general population of Asian adolescents. Therefore, the generalizability of the study findings is therefore limited. In addition, reliance on self-report for the measurement of both dependent and independent variables raises concern about the validity of conclusions based on participants’ possible lack of candor. The Asian adolescents may have distorted their behaviors or their self-disclosures of their behaviors in an effort to present themselves in the best possible light. Although study participants’ responses were anonymous, the physical act of handing completed surveys to another person may have biased their responses to present themselves in a better light, consciously or subconsciously.
CONCLUSION The findings of this study contribute to a body of knowledge related to positive health practices in a population which has not been closely examined. It provides a better understanding of the factors related to the positive health practices in Asian adolescents, having practice, education, and research implications. In the present study, social support, optimism, selfesteem, loneliness, and acculturation contributed to positive health practices in Asian adolescents. Knowledge of these relationships can help nurses in clinical 71
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practice to better understand the mechanism through which positive health practices are influenced in this population. This is essential, given that many behaviors associated with adult morbidity and mortality are initiated during the adolescent years. It is important for adolescents to have knowledge of and engage in positive health practices; these health practices need to become incorporated into their lifestyles. Nurses working with Asian adolescent populations can identify and develop cultural and age-specific interventions to promote and maintain healthy behaviors, taking into consideration the roles certain variables play in influencing positive health practices. Such variables include those examined in this study, including the adolescents’ social support, outlook on life, self assessment of oneself, feelings of loneliness, and level of acculturation. Nurses in practice can assess the variables that play a role in promoting healthy behaviors by using valid instruments that have demonstrated reliability in Asian adolescents, such as the PRQ-85 Part 2 and LOT for assessing the Asian adolescents’ social support and outlook on life. Practitioners’ knowledge of these factors as they relate to the Asian adolescent has the potential to not only promote health and reduce the risk of disease, but help to minimize health disparities among this ethnic/racial group. Furthermore, findings of this study provide implications for nursing education. The theoretical propositions tested in this study emerged from the literature. Students need to be cognizant of the importance of reviewing the theoretical and empirical literature and be taught to conduct reviews to develop and test theory which will provide a better understanding of phenomena. The study findings elucidated the relationships between the phenomena of interest, positive health practices, and related variables of social support, optimism, self-esteem, loneliness, and acculturation. Both undergraduate nursing students and graduate nursing students should apply this new knowledge gained through scientific inquiry in their clinical practice and/or research endeavors in an effort to improve nursing practice. Findings of this study also present research implications. Given the limitations of the study, replication 72
studies with other Asian study participants are vital to provide generalizability to the Asian adolescent population. Attention in the design of these replication studies should include eliminating bias, especially those identified as limitations to this study. Future studies should also test these relationships in samples of different racial/ethnic groups with special attention placed on generational status and their effect on positive health practices. In addition, interventions based on the theoretical and empirical propositions supported in this study, should be developed and tested in Asian adolescents to determine their effect on positive health practices. Interventions that would, for example, facilitate an increase in the quality or quantity of their social support or decrease their feelings of loneliness, should be considered.
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Mahat, G., & Scoloveno, M. (2001). Factors influencing health practices of Nepalese adolescent girls. Journal of Pediatric Health Care, 15, 251–255. Mahat, G., Scoloveno, M. A., & Whalen, C. (2002). Positive health practices of urban minority adolescents. Journal of School Nursing, 18, 244–260. Mahon, N. E., & Yarcheski, A. (1992). Alternate explanations of loneliness in adolescents: A replication and extension study. Nursing Research, 41, 151–156. Mahon, N. E., & Yarcheski, A. (2002). Alternative theories of happiness in early adolescents. Clinical Nursing Research, 11, 306–323. Mahon, N. E., Yarcheski, A., & Yarcheski, T. J. (2001). Mental health variables and positive health practices in early adolescents. Psychological Reports, 88, 1023–1030. Mahon, N. E., Yarcheski, A., & Yarcheski, T. J. (2002). Psychometric evaluation of the Personal Lifestyle Questionnaire for adolescents. Research in Nursing and Health, 25, 68–75. Mahon, N. E., Yarcheski, A., & Yarcheski, T. J. (2004). Social support and positive health practices in early adolescents: A test of mediating variables. Clinical Nursing Research, 13, 216–236. McNicholas, S. L. (2001). An investigation of the mediators of the relationship between social support and positive health practices in middle–aged adults. (Doctoral Dissertation, Rutgers, The State University of New Jersey, 2001). Dissertation Abstracts International, 62, 1322. Millstein, S. G., Nightingale, E. D., Peterson, A. C., Mortimer, A. M., & Hamburg, D. A. (1993). Promoting the healthy development of adolescents. Journal of the American Medical Association, 269, 1413–1415. Peplau, L. A., & Perlman, D. (1982). Perspectives on loneliness. In L. A. Peplau & D. Perlman (Eds.), Loneliness: A sourcebook of current theory, research and therapy (pp. 1–19). New York: John Wiley. Polit, D. F. (2010). Statistics and data analysis for nursing research (2nd ed). New Jersey: Pearson Education. Rosenberg, M. (1965). Society and the adolescent self-image. Princeton, NJ: Princeton University. Russell, D., Peplau, L. A., & Cutrona, C. (1980). The Revised UCLA Loneliness Scale: Concurrent and discriminant validity evidence. Journal of Personality and Social Psychology, 39, 472–480. Scheier, M. F., & Carver, C. S. (1987). Dispositional optimism and physical well–being: The influence of generalized outcome expectancies on health. Journal of Personality, 55, 169–210.
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Asian Nursing Research ❖ June 2010 ❖ Vol 4 ❖ No 2
Factors Related to Performance of Health Practices Among Asian Adolescents in the United States Cynthia G. Ayres1*, PhD, RN, Robert Atkins1, PhD, RN, Ganga Mahat2, EdD, RN 1
Assistant Professor, Rutgers College of Nursing, Rutgers, The State University of New Jersey, Newark, USA 2 Clinical Associate Professor, Rutgers College of Nursing, Rutgers, The State University of New Jersey, Newark, USA
Purpose This study examined factors related to positive health practices (PHP) among Asian adolescents. More specifically, it tested theoretical relationships postulated between PHP and social support, optimism, self-esteem, loneliness, and acculturation in this population. Method A correlational research design was used and a convenience sample of 151 Asian adolescents was obtained. Participants completed a demographic sheet and six study instruments. Results Significant positive relationships were found between reported performance of PHP and social support, optimism, self-esteem, and acculturation. A significant inverse relationship was found between loneliness and PHP. Conclusions Study findings extend existing knowledge and contribute to a more comprehensive knowledge base regarding health practices among Asian adolescents. Having this knowledge base provides practitioners with a better understanding of the factors related to health practices in Asian adolescents and assists them in developing culturally sensitive interventions aimed at promoting PHP in this population. [Asian Nursing Research 2010;4(2):64–74] Key Words
adolescent, health behavior, health promotion, minority health
INTRODUCTION Many health promoting behaviors such as diet and exercise emerge during the stage of adolescence, a critical developmental period in regards to health and illness. However, it is also during this period when important health risk behaviors such as smoking and
alcohol use, poor eating habits and physical inactivity, and unsafe sexual practices begin to develop (Chassin, Presson, Rose, & Sherman, 1996; Chen & Kandel, 1995; Cohen, Brownell, & Felix, 1990; Holden & Nitz, 1995; Katchadourian, 1990; Williams, Holmbeck, & Greenley, 2002). It is between the ages of 18 and 21, also referred to as late adolescence,
*Correspondence to: Cynthia G. Ayres, PhD, RN, Assistant Professor, Rutgers, The State University of New Jersey, Rutgers College of Nursing, 180 University Avenue, Newark, New Jersey 07102, USA. E-mail: [email protected] Received: April 1, 2010
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Revised: May 11, 2010
Accepted: May 27, 2010
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that individuals have the autonomy to engage in behaviors that lead to health risks or to develop a healthy lifestyle (Millstein, Nightingale, Peterson, Mortimer, & Hamburg, 1993). By targeting the behaviors in areas as smoking, alcohol use, nutrition, physical activity, and sexual behavior during adolescence, the risks of the major sources of mortality and morbidity during adolescence, and later in life, can be significantly reduced (US Department of Health and Human Services, 2001). Asian Americans are one of the fastest growing population groups in the United States, increasing at a rate faster than the general population between 1990 and 2000 (Barnes & Bennett, 2002). Like many racial/ethnic populations, Asian Americans are disproportionately affected by many health disparities. Cancer and cardiovascular disease, for example, are the two leading causes of death for Asian Americans in the US. Additionally, cancer is the leading cause of death in Asian women in the US, due to the fact that Asian American women have the lowest cancer screenings rates and are usually diagnosed at a later stage compared to other racial and ethnic groups. Mental health problems in the Asian American community are disturbingly high, yet its services are inadequate. Asian American adolescent girls reportedly have the highest rates of depressive symptoms compared to girls of other ethnicities. Additionally, Asian American youth in grades 7 through 12 have the highest increase in smoking rates of any racial and ethnic group (Asian American Health Initiative, n.d.). However, unlike many other racial/ethnic groups, there is a lack of studies that have examined factors which may contribute to the performance of general positive health practices (PHPs) in Asian adolescents. Therefore, research that increases our knowledge of Asian adolescents’ health promoting behaviors, including those factors related to PHPs, has the potential to reduce the risks of disease in this age group, improve their health and longevity, and help to eliminate the health disparities among this ethnic/racial group. Therefore, the purpose of this study is to examine factors that may be related to the performance of PHPs in Asian adolescents. More specifically, this study tested theoretical relationships postulated in Asian Nursing Research ❖ June 2010 ❖ Vol 4 ❖ No 2
the literature between the dependent variable, PHPs, and the independent variables of (a) social support, (b) optimism, (c) self-esteem, (d) loneliness, and (e) acculturation.
Conceptual framework Positive health practices and social support Positive health practices are defined as a composite of exercise, nutrition, relaxation, avoidance of substance use, and the promotion of health (Brown, Muhlenkamp, Fox, & Osborn, 1983). Social support is defined as consisting of six categories of relational provisions: attachment, social integration, opportunity for nurturance, reassurance of worth, a sense of reliance, and obtaining guidance and information in stressful situations (Weiss, 1974). Social support can influence the performance of specific health behaviors, such as seat belt use, exercise and nutrition, medical checkups, dental care, immunizations, and miscellaneous screening exams by providing information about PHPs and by establishing norms that encourage healthy behaviors (S. Cohen, 1988; Langlie, 1977). Empirical research have supported the relationship between social support and PHPs in adolescent populations (Ayres, 2008; Mahat & Scoloveno, 2001; Mahat, Scoloveno, & Whalen, 2002; Mahon, Yarcheski, & Yarcheski, 2004; Yarcheski, Mahon, & Yarcheski, 2003). These findings add credence to the work of classic theorists (S. Cohen; Langlie) suggesting a relationship between the two variables. Therefore, it is postulated that there is a positive relationship between PHPs and social support in Asian adolescents. Positive health practices and optimism Optimism has been theorized to contribute to the performance of PHPs. According to Scheier and Carver (1992), optimism, or the belief that good things will happen throughout one’s lifetime, is postulated to affect individuals’ actions, including their health behaviors. Optimists are more likely to follow treatment regimens and change behaviors that might compromise their health, and to engage in behaviors that help them to adapt to situations. Since PHPs are considered to be adaptive, optimists have more 65
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of a tendency to perform them (Scheier & Carver). Research findings support a low positive relationship between optimism and the performance of PHPs in adolescents (Ayres, 2008; Yarcheski, Mahon, & Yarcheski, 2004). On the basis of theory and previous research, it is hypothesized that there is a positive relationship between optimism and PHPs in Asian adolescents. Positive health practices and self-esteem Self-esteem is defined as the individual’s assessment of self-worth (Rosenberg, 1965). It has been posited that self-esteem or one’s sense of self-worth influences one’s health behaviors (Bandura, 1968). There is existing empirical support for a positive relationship between self-esteem and the performance of PHPs in adolescents (Yarcheski, Mahon, & Yarcheski, 2003). Self-esteem is therefore hypothesized to be positively related to PHPs in Asian adolescents. Positive health practices and loneliness Loneliness is defined as the felt lack of meaningful relationships (Sisenwein, 1964). An unfulfilled desire to have friends, an understanding of the gap between actual and desired social status, and a lack of affective bonding may contribute to feelings of loneliness. According to the classic works of Peplau and Perlman (1982), loneliness occurs when relationships do not meet social needs, fail to fulfill personal desires, or decrease social rewards. Additionally, loneliness apparently has paradoxical motivational properties in that loneliness might arouse motivation for interpersonal contact but diminish motivation for nonsocial activities. When motivation is diminished, lonely people are apathetic and aimless and do not have the energy to complete tasks successfully, which clearly could influence the carrying out of PHPs. There is empirical support for this proposed inverse relationship in adolescents (Ayres, 2008; Mahon et al., 2004). Loneliness is hypothesized to be inversely related to PHPs in Asian adolescents. Positive health practices and acculturation Acculturation is defined as the process that can occur when two or more cultures interact (Suinn, Ahuna, & 66
Khoo, 1992). Berry (1980) describes acculturation as the process by which one group asserts its influence over another and what happens is likely to be difficult, reactive, and conflictual, affecting one’s physical as well as psychological functioning. Several possible outcomes of this process can occur, including assimilation, whereby a host culture absorbs the immigrant culture, or multiculturalism, whereby both cultures exists side-by-side. Exposure to another culture can lead an individual to (a) resist changes in his/her values and behavioral competencies, (b) adopt the host culture’s values and behavioral skills and styles as a replacement for his/her parent culture’s values/ behaviors, (c) acquire host culture values/behaviors while retaining parent culture values/behaviors with situational reliance, that is, determining which values/ behaviors are in effect at different times (Suinn et al.). There is empirical support for the proposed relationship between acculturation and PHPs (AfableMunsuz & Brindis, 2006; Bond, Jones, Cason, Campbell & Hall, 2002; Lee, 2007). Acculturation is postulated to be positively related to PHPs in Asian adolescents. Based on the theoretical relationships postulated in the literature, it was hypothesized that there would be (a) a significant positive relationship between PHPs and social support, (b) a significant positive relationship between PHP and optimism, (c) a significant positive relationship between PHP and selfesteem, (d) a positive health practice between PHP and acculturation, and (e) a negative relationship between PH and loneliness.
METHODS Design Using a correlational research design, this study examined the abovementioned hypotheses constructed from theory and research. Sample A non-probability, convenience sample consisted of Asian late adolescents, between the ages of 18 and 21 years who attended a series of Asian student meetings Asian Nursing Research ❖ June 2010 ❖ Vol 4 ❖ No 2
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held at an urban university. In determining the appropriate sample size, a small to medium effect was chosen based on the previously reported theoretical and empirical literature with respect to the relationships investigated in the present study. Using an alpha of .05 and power of the significance test set at level .80 (β = .20), a small to medium effect size of R2 = .10 was anticipated. Therefore, using power calculation recommended by J. Cohen (1988), a sample of at least 129 subjects was necessary to keep risks of statistical errors to standard levels for calculating multiple regression with six predictor variables (Polit, 2010). The final sample size (n = 151) provided the requirements for performing this regression analysis.
Data collection Following approval of the university’s institutional review board and approval of the delegation planning committee of the Asian student meetings, individuals who met the delimitations of the study were approached by the principal investigator between meetings to discuss the purpose of the study and potential participation. A packet of six questionnaires, a demographic form, and a one-page description of the research project were provided to eligible individuals who identified interest in participating in this study. Completed survey questionnaires provided to the researchers on one of the two days of data collection indicated subjects’ consent and voluntary participation in the study (n = 174). Delimitations of the study included individuals who self-identify as an Asian; individuals between the ages of 18 and 21, with the ability to speak and write English, and attendance at the Asian student meetings on at least one of the two days of data collection. Data from 23 students were subsequently eliminated due to response biases, such as extreme responses across negatively worded items and incomplete items on the questionnaires. The final sample was 151 Asian adolescents between the ages of 18 and 21. Instruments Positive health practices The Personal Lifestyle Questionnaire (PLQ) is a 24item self-administered instrument used to measure Asian Nursing Research ❖ June 2010 ❖ Vol 4 ❖ No 2
the positive health practices of individuals (Brown et al., 1983). The PLQ is a 4-point summated rating scale with a total range of possible scores from 22 to 88; higher scores reflect the practice of more positive health behaviors. This instrument consists of six subscales: exercise, less substance use, nutrition, relaxation, safety, and general health promotion. Since one health promotion item on the PLQ was relevant only to females, “Do a monthly self-breast exam” (females only) the following item was added for males: “Do a monthly testicular self-exam (males only).” Each subject responded to a total of 22 items on the PLQ. Numerous studies have been performed using this instrument within the past decade, demonstrating validity (Mahon, Yarcheski, & Yarcheski, 2002) and appropriate coefficient alphas as a measure of reliability (Yarcheski, Mahon, & Yarcheski, 1997; Mahon et al.). In addition, the findings of those studies have been consistent with the theoretical literature, supporting theoretical propositions (Ayres, 2008). For example, Yarcheski et al. and Mahon et al. reported coefficient alphas ranging from .72 to .80 for the PLQ when used with adolescents. In the present sample, the coefficient alpha was .73. Social support The Personal Resource Questionnaire (PRQ85-Part 2) is a 25-item instrument developed by Brandt and Weinert (1981) that measures relational provisions in Weiss’s (1974) definition of social support, with subscales representing intimacy, social integration, nurturance, worth, and assistance. This selfadministered instrument has a 7-point Likert-type scale, with possible scores ranging from 25 to 175; higher scores indicate higher perceived social support. Numerous studies have been performed using this instrument within the past decade, demonstrating validity (Weinert, 1987) and appropriate coefficient alphas as a measure of reliability (Ayres, 2008; Mahat & Scoloveno, 2001; Mahat et al., 2002; Mahon et al., 2004; Yarcheski, Mahon, & Yarcheski, 2001). In addition, the findings of those studies have been consistent with the theoretical literature, supporting theoretical propositions. Researchers (Mahat & Scoloveno; Mahat et al., 2002; Mahon et al., 2004; 67
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Yarcheski et al.) reported coefficient alphas ranging from .76 to .92 for the PRQ85-Part 2 in samples of adolescents. In the present sample, the coefficient alpha was .92. Optimism The Life Orientation Test (LOT) is a 12-item (including 4 filler items) self-report instrument that assesses dispositional optimism, defined as generalized outcome expectancies conceptualized by Scheier and Carver (1987). The five-response format has a range of scores from 0 to 32; higher scores indicate higher levels of optimism. Numerous studies have been performed using this instrument within the past decade, demonstrating validity (Terrill, Friedman, Gottschalk, & Haaga, 2002) and appropriate coefficient alphas as a measure of reliability (Goodman, Knight, & DuRant, 1997; Mahon & Yarcheski, 2002). In addition, the findings of those studies have been consistent with the theoretical literature, supporting theoretical propositions (Ayres, 2008). For example, Goodman et al. (1997) and Mahon and Yarcheski reported coefficient alphas ranging from .58 to .78 in samples of adolescents. In the present sample, the coefficient alpha was .79. Self-esteem The Rosenberg Self-Esteem Scale is a 10-item selfreport instrument that assesses self-esteem, defined as the individual’s assessment of self-worth conceptualized by Rosenberg (1965). This 4-point summated rating scale has a range of scores from 0 to 30; higher scores indicate higher self-esteem. Numerous studies have been performed using this instrument within the past decade, demonstrating validity (Rosenberg, 1965) and appropriate coefficient alphas as a measure of reliability (Yarcheski et al., 2003; Mahon & Yarcheski, 1992). In addition, the findings of those studies have been consistent with the theoretical literature, supporting theoretical propositions (Yarcheski et al.; Mahon & Yarcheski). For example, Mahon and Yarcheski and Yarcheski et al. reported coefficient alphas ranging from .76 to .86 in samples of adolescents. In the present sample, the coefficient alpha was .85. 68
Loneliness The Revised UCLA Loneliness Scale is a 20-item summated rating scale that measures the subjective experience of loneliness (Russell, Peplau, & Cutrona, 1980). Possible scores can range from 20 to 80; higher scores indicate higher levels of loneliness. Numerous studies have been performed using this instrument within the past decade, demonstrating appropriate validity (Russell et al, 1980) and coefficient alphas as a measure of reliability (Mahon, Yarcheski, & Yarcheski, 2001; Mahon et al., 2004). In addition, the findings of those studies have been consistent with the theoretical literature, supporting theoretical propositions. Ayres (2008), Brage-Hudson, Eleck, and Campbell-Grossman (2000), Mahon et al. (2001), and Mahon et al. (2004), reported coefficient alphas ranging from .84 to .90 in adolescents. In the present sample, the coefficient alpha was .92. Acculturation The Suinn-Lew Asian Self Identity Acculturation (SL-ASIA) is a 21-item summated rating scale that measures the acculturation, the process that can occur when two or more cultures interact together as conceptualized by Suinn et al. (1992). A final acculturation score is calculated by summing across the answers for all 21 items and then dividing the total value by 21. Possible scores for each item can range from 1.00 to 5.00; higher scores indicate higher levels of acculturation. Numerous studies have been performed using this instrument within the past decade, demonstrating appropriate validity (Suinn et al.) and coefficient alphas as a measure of reliability (Suinn et al.; Suinn, Khoo, & Ahuna, 1995). In the present sample, the coefficient alpha was .86.
Data analysis The data collected for this study were analyzed using the SPSS statistical package, version 16.0 (SPSS Inc., Chicago, IL, USA). Pearson r correlations were obtained to test the hypothesized relationships between the dependent variable, positive health practices, and each of the independent variables of social support, optimism, self esteem, loneliness, and acculturation. Additionally, descriptive statistics for sample Asian Nursing Research ❖ June 2010 ❖ Vol 4 ❖ No 2
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and survey instruments were obtained. Multiple regression analyses were also performed to determine the predictor values of the independent variables of social support, optimism, self-esteem, loneliness, and acculturation on the dependent variable, PHPs.
RESULTS Study participants consisted of 67 (44.4%) males and 84 (55.6%) females aged 18–21 years. Approximately 52.3% were Chinese, 15.2% were Korean, 11.9% were Filipino, 9.3% were Vietnamese, 7.9% were Japanese; the remaining 3.0% Taiwanese. The majority of participants (59.6%) reported they were born in the US, while about 40.4% reported they were born in another country. However, 85.3% of participants grew up in the US, while 14.7% did not. Approximately 10% of study participants currently have a medical condition that requires them to limit or restrict normal activity. A total of 31% of all study participants are currently participating in organized sports, while 69% indicated they do not currently participate in organized sports. Descriptive statistics for the study variables, social support, positive health practices, optimism, self-esteem, loneliness, and acculturation, are presented in Table 1. Pearson correlations were used to test the hypothesized relationships (see Table 2). Significant positive relationships were found between reported performance of positive health
practices and social support (r = .438, p < .01), between positive health practices and optimism (r = .399, p < .01), between positive health practices and self-esteem (r = .269, p < .01). A significant inverse relationship between positive health practices and loneliness was also found (r = −.254, p < .01). Lastly, there was a positive significant relationship between positive health practices and acculturation (r = .229, p < .01).
Additional findings The independent variables of social support, acculturation, self-esteem, and loneliness were examined as predictors to the dependent variable, positive health practices, through multiple regression analyses. The overall model was found to be statistically significant F (6, 150) = 9.549, p < .001. Approximately 25.5% of the variability of positive health
Table 1 Descriptive Statistics of Study Variables (N = 151) Study variables Positive health practices Social support Optimism Self-esteem Loneliness Acculturation
Score range
M
SD
41–72
57.25
6.738
90–174 9–30 8–29 20–57 1–4
138.02 20.1 19.50 38.62 2.44
17.284 4.12 4.071 8.927 0.561
Table 2 Correlation Matrix Among Study Variables (N = 151) Variables Positive health practices Social support Acculturation Optimism Self-esteem Loneliness
Positive health practice
Social support
–
.438** –
Acculturation .229** .093 –
Optimism .399** .590** .141 –
Self-esteem
Loneliness
.269** .433** .036 .582** –
–.254** –.678** .004 –.494** –.536** –
**p < .01, one-tailed.
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Table 3 Summary of Enter Multiple Regression Analysis for Variables Predicting Positive Health Practices in Asian Adolescents (N = 151) Variable Social support Acculturation Optimism Self-esteem Loneliness
B
SE B
β
0.133 1.924 0.174 0.105 0.075
.041 .862 .109 .154 .078
.342** .160* .157 .063 .099
*p < .05, one-tailed; **p < .01, one-tailed. Adjusted R2 = .255.
practices is accounted for by the variables in the model even after taking into account the number of predictor variables in the model. Regression analyses indicated that effect of social support (B = 0.133, p = .002) was found to be positively significant, indicating that the greater the social support, the greater number of PHP performed. The effect of acculturation (B = 1.924, p = .027) was found to also be positively significant. The positive coefficient indicates that the greater the level of acculturation, the greater number of PHP performed. Optimism (B = 0.174, p = .114), self-esteem (B = 0.105, p = .497), and loneliness (B = 0.075, p = .339) were not significant predictors of performance of PHPs among Asian adolescents (see Table 3). In addition, the respondents’ demographic variables were examined in relation to positive health practices. T-tests showed only a significant difference in positive health practices (t = − 3.002, p = .003) between respondents who do not participate in organized sports and those who do participate in organized sports; those who participate had practiced more positive health practices.
DISCUSSION The findings of this study demonstrated a positive and moderate relationship between social support and PHP in a sample of Asian adolescents. This finding (r = .438) is consistent with previous research 70
that examined the relationship between social support and PHP in adolescents (Ayres, 2008; Mahat & Scoloveno, 2001; Mahat et al., 2002; Mahon et al., 2004; Yarcheski et al., 2003). Thus, this finding extends the theory regarding the relationship between social support and PHP to a population of Asian adolescents, aged 18–21. Asian adolescents’ social support may have influenced their performance of positive health practices, such as seat belt use, getting adequate sleep, exercise and nutrition, by providing information about positive health practices and by establishing norms that encourage healthy behaviors, as suggested by Langlie (1977) and S. Cohen (1988). The moderately strong positive relationship (r = .399) between optimism and positive health practices found in this study is higher than in previous research (Ayres, 2008; McNicholas, 2001) examining this relationship. These findings extend the existing knowledge of the relationship between optimism and positive health practices to a sample of Asian adolescents. Asian adolescents who are more optimistic about life may have been more likely to engage in behaviors that help them to adapt to situations, such as wearing seat belts, getting adequate sleep, along with other positive health behaviors. As suggested by Scheier and Carver (1992), optimists have a greater tendency to perform positive health practices since they are considered to be adaptive. Therefore, the subjective, generalized expectation of positive experiences and outcomes throughout one’s life may increase the extent to which Asian adolescents incorporate positive health behaviors into their lifestyle. The findings of this study demonstrated a positive and moderate relationship between self-esteem and positive health practices in a sample of Asian adolescents. This finding (r = .269), although somewhat lower, is nonetheless consistent with previous research that examined the relationship between self-esteem and PHP in adolescents (Yarcheski & Mahon, 1989; Yarcheski et al., 2003). Asian adolescents’ assessment of one’s self may have influenced their behaviors to engage in positive health practices, as posited by Bandura (1968). In addition, the findings of this study demonstrated a low inverse Asian Nursing Research ❖ June 2010 ❖ Vol 4 ❖ No 2
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relationship between loneliness and positive health practices in a sample of Asian adolescents. This finding (r = −.254), however, is lower than previous research that examined the relationships between loneliness and positive health practices in adolescents (Yarcheski & Mahon; Yarcheski et al.). Lonely Asian adolescents may have diminished motivation, making them apathetic and/or aimless. They may not have the energy to complete tasks successfully, which clearly could influence the carrying out of positive health practices, as postulated by Peplau and Perlman (1982). Thus, these findings extend the theory regarding the relationships between positive health practices and self esteem and loneliness to a population of Asian adolescents. Hypothesis testing demonstrated a significant positive correlation between acculturation and positive health practices (r = .229). This positive correlation was comparable to the findings from previous studies that examined this relationship in adults (Afable-Munsuz & Brindis, 2006; Bond et al., 2002; Sohn & Harada, 2005). For the Asian adolescents in this study, the mean acculturation score was 2.44, which according to Suinn et al. (1992) would indicate somewhat “bicultural”, and would be reflected in a SL-ASIA score of three. Asian adolescents may have been capable of assuming the best of both worlds, without denial to either. Asian adolescents in this study may not have experienced difficult, reactive, or conflictual situations which tend to occur with the exposure to another culture, affecting one’s physical as well as psychological functioning. Therefore, these findings add additional empirical support to this positive relationship between positive health practices and acculturation, extending theory to a population of Asian adolescents. There was a significant difference in positive health practices between those who reported having participated in sports and those who do not. It may be that information-sharing about health care practice occurs among individuals within the same sport. Individuals with this social network of organized sports may internalize conventional beliefs about health promotion. In addition, organized sports facilitate healthy behaviors such as exercising, Asian Nursing Research ❖ June 2010 ❖ Vol 4 ❖ No 2
drinking plenty of fluids, and getting adequate rest (Ayres, 2010). This study’s findings should be taken with caution given several limitations. First, study participants were recruited from those individuals attending Asian student meetings. These student meetings were hosted by an organization that wants to strengthen the East Coast Asian student community, and to bring students to new heights of awareness, activism, and pride in the Asian community. By the nature and philosophy behind these meetings, Asian adolescents in attendance were more likely to be engaged in their community and be proactive about basic issues that may affect them and their community. With that being said, study participants may have been more likely to engage in behaviors that positively affect them, including positive health practices, than the general population of Asian adolescents. Therefore, the generalizability of the study findings is therefore limited. In addition, reliance on self-report for the measurement of both dependent and independent variables raises concern about the validity of conclusions based on participants’ possible lack of candor. The Asian adolescents may have distorted their behaviors or their self-disclosures of their behaviors in an effort to present themselves in the best possible light. Although study participants’ responses were anonymous, the physical act of handing completed surveys to another person may have biased their responses to present themselves in a better light, consciously or subconsciously.
CONCLUSION The findings of this study contribute to a body of knowledge related to positive health practices in a population which has not been closely examined. It provides a better understanding of the factors related to the positive health practices in Asian adolescents, having practice, education, and research implications. In the present study, social support, optimism, selfesteem, loneliness, and acculturation contributed to positive health practices in Asian adolescents. Knowledge of these relationships can help nurses in clinical 71
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practice to better understand the mechanism through which positive health practices are influenced in this population. This is essential, given that many behaviors associated with adult morbidity and mortality are initiated during the adolescent years. It is important for adolescents to have knowledge of and engage in positive health practices; these health practices need to become incorporated into their lifestyles. Nurses working with Asian adolescent populations can identify and develop cultural and age-specific interventions to promote and maintain healthy behaviors, taking into consideration the roles certain variables play in influencing positive health practices. Such variables include those examined in this study, including the adolescents’ social support, outlook on life, self assessment of oneself, feelings of loneliness, and level of acculturation. Nurses in practice can assess the variables that play a role in promoting healthy behaviors by using valid instruments that have demonstrated reliability in Asian adolescents, such as the PRQ-85 Part 2 and LOT for assessing the Asian adolescents’ social support and outlook on life. Practitioners’ knowledge of these factors as they relate to the Asian adolescent has the potential to not only promote health and reduce the risk of disease, but help to minimize health disparities among this ethnic/racial group. Furthermore, findings of this study provide implications for nursing education. The theoretical propositions tested in this study emerged from the literature. Students need to be cognizant of the importance of reviewing the theoretical and empirical literature and be taught to conduct reviews to develop and test theory which will provide a better understanding of phenomena. The study findings elucidated the relationships between the phenomena of interest, positive health practices, and related variables of social support, optimism, self-esteem, loneliness, and acculturation. Both undergraduate nursing students and graduate nursing students should apply this new knowledge gained through scientific inquiry in their clinical practice and/or research endeavors in an effort to improve nursing practice. Findings of this study also present research implications. Given the limitations of the study, replication 72
studies with other Asian study participants are vital to provide generalizability to the Asian adolescent population. Attention in the design of these replication studies should include eliminating bias, especially those identified as limitations to this study. Future studies should also test these relationships in samples of different racial/ethnic groups with special attention placed on generational status and their effect on positive health practices. In addition, interventions based on the theoretical and empirical propositions supported in this study, should be developed and tested in Asian adolescents to determine their effect on positive health practices. Interventions that would, for example, facilitate an increase in the quality or quantity of their social support or decrease their feelings of loneliness, should be considered.
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