Health value

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Health Value, Perceived Social Support, and Health Self-Efficacy as Factors in a

Health-Promoting Lifestyle

Article  in  Journal of American College Health · July 2007

DOI: 10.3200/JACH.56.1.69-74 · Source: PubMed

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Health Value, Perceived Social Support, and Health Self- Efficacy as Factors in a Health-Promoting Lifestyle Erin S. Jackson PhD a , Carolyn M. Tucker PhD a & Keith C. Herman PhD b a The Psychology Department, The University of Florida, Gainesville b Department of Child and Adolescent Psychiatry, Johns Hopkins University, Baltimore, MD Published online: 07 Aug 2010.

To cite this article: Erin S. Jackson PhD , Carolyn M. Tucker PhD & Keith C. Herman PhD (2007) Health Value, Perceived Social Support, and Health Self-Efficacy as Factors in a Health-Promoting Lifestyle, Journal of American College Health, 56:1, 69-74, DOI: 10.3200/ JACH.56.1.69-74

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Health Value, Perceived Social Support, and Health Self-Efficacy as Factors

in a Health-Promoting Lifestyle

Erin S. Jackson, PhD; Carolyn M. Tucker, PhD; Keith C. Herman, PhD

Abstract. During their college years, students may adopt health- promoting lifestyles that bring about long-term benefits. Objec- tive and Participants: The purpose of this study was to explore the roles of health value, family/friend social support, and health self-efficacy in the health-promoting lifestyles of a diverse sample of 162 college students. Methods: Participants completed an Assessment Battery consisting of the following instruments: (1) a demographic questionnaire, (2) the Multi-Dimensional Support, (3) the Value on Health Scale, (4) the Self-Rated Abilities for Health Practices, (5) the Health-Promoting Lifestyle Profile II, and (6) the Marlowe-Crowne Social Desirability Scale. Results: Correlational analyses indicated that health value, perceived fami- ly/friend social support, and health self-efficacy were significantly associated with engagement in a health-promoting lifestyle. An analysis of covariance (ANCOVA) revealed that health value and health self-efficacy significantly predicted the level of engagement in a health-promoting lifestyle. Perceived family/friend social support was not significant in the model. As age increased, level of perceived family/friend social support decreased. Conclusion: Present findings suggest that health interventions programs focus on assessing and increasing health self-efficacy and health value of these youth. College health professionals can design and evaluate the effectiveness of such health-promoting interventions.

Keywords: health-promoting lifestyle, health self-efficacy, health value, social support

any college students are living away from home for the first time and are challenged with the responsibility of their personal health.1 They are

also challenged with greater autonomy, new demands, and stressors associated with a different structure to daily life.2 The behaviors that college students develop in the process of meet-

ing these challenges may become parts of their lifestyle into adulthood. These behaviors can promote health or increase the frequency of risk behaviors that lead to poor health.3 The promotion and maintenance of health-promoting lifestyles for college students are critical to prevent the development of chronic diseases.4 In addition, health-promoting behaviors make it more likely that students will be successful in school, by reducing absenteeism and fostering positive mental health.4 Research aimed at identifying the health-promoting needs of college students may assist in the adoption of healthy lifestyle behaviors throughout their life spans.

To improve the health of college students, it is imperative to reduce the frequency, delay the onset, and aim for the prevention of health-risk behaviors. Therefore, an impor- tant goal of researchers investigating college student health must be to identify factors that influence health-promoting behaviors, such as exercising frequently, eating healthy foods, and getting sufficient rest.

Pender5 proposed the Health Promotion Model to explain the multidimensional pattern of a health-promoting life- style and to guide future research. According to this model, performing health-promoting behaviors can be achieved through the direct and indirect effects of a combination of individual cognitive-perceptual factors, modifying factors, and cues to action.6 Cognitive-perceptual factors are moti- vational mechanisms that directly influence the maintenance of health-promoting behaviors. These factors may include definitions of health, health value, perceived health status, perceived control, perceived self-efficacy, perceived benefits, and perceived barriers. We used 2 key cognitive-percep- tual terms: health value and self-efficacy. Health value is an enduring belief that a specific health-promoting behavior is preferred to an alternative behavior. Self-efficacy is the belief that one can successfully engage in an expected health behav- ior. Modifying factors are variables that impact the decision-

Drs Jackson and Tucker are with the Psychology Department at the University of Florida, Gainesville. Dr Herman is with Johns Hopkins University’s Department of Child and Adolescent Psychiatry, Baltimore, MD.

Copyright © 2007 Heldref Publications

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making process by influencing individual perceptions. These variables involve demographic factors (eg, age, gender, race, ethnicity, education, and income), biologic characteristics (eg, body weight, height, and body fat), interpersonal influ- ences (eg, social support), situational factors (eg, access to alternatives), and behavioral factors (eg, past experiences). A key modifying factor term used in this article is perceived social support, which is a perceived sense of social belong- ing or social connection influenced by the preferred versus desired frequency of social interaction and level of intimacy in those interactions. This modifying factor can serve as a cue to action. Cues to action are variables that may move the individual from the decision-making phase to the action phase. These cues may be personal awareness, advice from others, the impact of mass media, and social and political movements.

Pender’s Health Promotion Model5 can be viewed as an extension and elaboration of the more familiar Health Belief Model.4 Pender’s model is more comprehensive because it delineates multiple cognitive-perceptual variables and modifying variables that lead to health decisions and behaviors. For instance, one of the primary criticisms of the Health Belief Model has been its failure to account for self- efficacy and social support,4 2 central variables in Pender’s Model. Pender’s Model has been successfully applied to understanding the health-promoting lifestyles of several populations, such as older women,7 blue collar workers,8 ambulatory cancer patients,9 adolescent girls,10 and college students.11

Although the health behaviors of college students have been frequently studied,12–17 few studies have used Pender’s Health Promotion Model to guide such research.18 Pender’s Model may be particularly applicable to college students because of its emphasis on modifiable self variables, health value, and self-efficacy. Recent studies have supported its applicability to adolescents and diverse samples.19,20 We based our study on Pender’s Model and designed it to explore the factors associated with the health-promoting lifestyles of college students. Health value and perceived health self- efficacy were the cognitive-perceptual factors from Pender’s Model that we examined as motivational tools that may directly influence the adoption and upholding of positive health behavior. We examined social support as a modifying factor that may affect the decision-making process involved with engagement in positive health behavior. Aspects of social support, such as advice from others, serve as cues to action that may guide the college students from the deci- sion-making stage to the action phase of engaging in health promoting behaviors. In sum, we explored the roles of health value, self-efficacy, and social support in the engagement in health-promoting behaviors of college students.

METHODS Participants

Following Institutional Review Board approval, the first author recruited students from 2 introductory psychology classes at a large university located in the southeastern part of

the United States. We selected these classes because students from a wide range of majors and of varying backgrounds typi- cally enroll in these courses and because they provided easy access to a large pool of students. We distributed question- naires to 180 interested students and collected them during subsequent classes. We informed participants that participation was voluntary and anonymous. The response rate was 90%.

The sample included 162 participants; 49 were men and 113 were women. The median age of the participants was 20 years (standard deviation [SD] = 0.85). The ethnic backgrounds of the students comprised 3% Latino/Hispanic black, 7% Asian American/Pacific Islander, 8% Latino/His- panic white, 11% African American/black, 68% Caucasian/ white American, and 4% other. Table 1 shows additional descriptive data obtained from these participants.

TABLE 1. Descriptive Statistics for Research Participants

Demographic variable n %

Age (y) 18 6 3.7 19 38 23.5 20 43 26.5 21 35 21.6 22 22 13.6 23 and older 18 11.0 Gender Female 113 69.8 Male 49 30.2 Race/ethnicity African American/black 17 10.5 Asian American/Pacific Islander 11 6.8 Caucasian/white American 110 67.9 Latino/Hispanic black 4 2.5 Latino/Hispanic white 13 8.0 Other 7 4.3 Class Freshman 1 .6 Sophomore 30 18.5 Junior 73 45.1 Senior 56 34.6 Post-baccalaureate 2 1.2 Family income Less than $20,000 8 4.9 $20,001–$40,000 21 13.0 $40,001–$60,000 39 24.1 $60,001–$80,000 26 16.0 $80,001–$100,000 22 13.6 More than $100,001 40 24.7 Primary caregiver in home Mother/mother figure 82 50.6 Father/father figure 54 33.3 Other relative 3 1.9 Other 11 6.8 Adults mostly present in home Mother/mother figure 32 19.8 Father/father figure 2 1.2 Mother and father 124 76.5 Other 4 2.5

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Instruments We used an Assessment Battery consisting of the follow-

ing instruments: (1) a demographic questionnaire to obtain information including age, gender, race, current academic level, and family income; (2) the Multi-Dimensional Sup- port Scale21 to assess the frequency/availability and ade- quacy of perceived social support from family and friends (previously reported internal reliability coefficient alphas for the scale range from .81 to .9021); (3) the Value on Health Scale22 to assess the value placed on or the importance of different aspects of health, including fitness or good physical state, energy or vigor, endurance or stamina, maintaining an appropriate weight, and opposition to disease (the Value on Health Scale has good internal consistency [α = .77])22; (4) the Self-Rated Abilities for Health Practices Scale23 to assess health self-efficacy regarding exercise, well-being, nutrition, and general health practices (the internal consistency of the Self-Rated Abilities for Health Practices Scale is .92)23; (5) the Health-Promoting Lifestyle Profile II (HPL II)24,25 to measure the degree of engagement in a health-promoting lifestyle along 6 dimensions: spiritual growth, health respon- sibility, physical activity, nutrition, interpersonal relations, and stress management (the Cronbach alpha for the total scale is .94 and ranges from .79 to .87 for subscales24); and (6) the Marlowe-Crowne Social Desirability Scale, short form (M-C SDS [20],26 to measure the amount of variance in the data caused by the participant’s desire to present self in a socially desirable manner. (Reliability coefficients for the 20-item instrument range from .78 to .83.26) Researchers in prior studies with college students used all the scales that we used.

Procedure We recruited participants from 2 introductory psychol-

ogy classes. Extra course credit was provided for each study participant. We informed students that their participation was voluntary and anonymous and that at any time they could withdraw from the study or refuse to answer any question. We told students that the purpose of the study was to inves- tigate the relationships between beliefs and health behaviors. We asked those students interested in participating to demon- strate their interest by collecting a packet after class.

We distributed an Informed Consent Form and an Assess- ment Battery in an envelope to students who approached the investigator for a packet. We instructed participants to complete the assessments in the packets at home and return them at 1 of the following 2 class meetings, which were held 2 days and 4 days after the initial distribution of Assessment Batteries. We also informed participants of the contents of the packet. We then gave participants instruc- tions for completing the contents of the package. First, we instructed participants to read and sign the Informed Consent Form. Second, we told them to complete the Assessment Battery, which included the 5 assessments described above that totaled 113 items. Third, we instructed participants to complete the Demographic Questionnaire. To ensure confidentiality, we told participants to place the

completed Assessment Battery and Demographic Ques- tionnaire, which were stapled together, into the provided envelope and to seal the envelope. We told participants to drop the Informed Consent Form in a box that was separate from the box in which the envelopes with their completed questionnaires were collected to guarantee that their ques- tionnaire responses were kept confidential.

Upon submission of the completed Assessment Battery, we gave each participant a Debriefing Form to read and sign that was kept separate from the completed packets. The Debriefing Form outlined the nature and purpose of the study. We asked participants to return the signed Debriefing Form to the Principal Investigator immediately after read- ing it over carefully and having any questions addressed.

Finally, to obtain extra course credit, participants signed a roster upon submission of their signed Debriefing Form. We gave this roster directly to the class instructors or their teaching assistants to insure each student received extra credit for research participation.

RESULTS Preliminary Analysis

We performed preliminary Pearson product-moment cor- relation analyses to examine the relationship between social desirability and the other studied variables. The analyses revealed that social desirability significantly correlated with health-promoting lifestyle (r = .28, n = 144, p < .01), per- ceived family/friend social support (r = .17, n = 153, p < .05), and health self-efficacy (r = .17, n = 153, p < .05). Therefore, we used social desirability as a covariate in the analyses used to test the proposed hypotheses and research question.

Results Regarding the Hypotheses and Research Question

Correlation analyses revealed significant positive rela- tions between the health-promoting lifestyle variable and levels of health value (r = .51, n = 141, p < .01), perceived family/friend social support (r = .35, n = 141, p < .01), and health self-efficacy (r = .61, n = 141, p < .01). Table 2 pres- ents the correlational matrix from these analyses.

We conducted an analysis of covariance (ANCOVA) to determine the unique contribution of 3 independent vari- ables—health value, perceived family/friend social support, and health self-efficacy—in predicting health-promoting lifestyle when controlling for social desirability. The over- all model was significant, F(4,132) = 36.35, r2

adj = .51, p

< .01, and accounted for 51% of the variance in level of engagement in a health-promoting lifestyle. Significant main effects included health self-efficacy, t(1) = 7.03, p < .001, and health value, t(1) = 5.18, p < .001 (see Table 3).

We also performed a multivariate ANCOVA (MAN- COVA) to determine whether there was a significant dif- ference in the level of value of health, level of perceived family/friend social support, level of health self-efficacy, or level of engagement in a health-promoting lifestyle in association with gender, age, family income, or ethnicity

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(see Table 4). The dependent variables in the MANCOVA were health value, perceived family/friend social support, health self-efficacy, and health-promoting lifestyle. The independent variables included gender, age, family income, and ethnicity. We once again entered social desirability as a covariate. The multivariate tests revealed that race, Wilks’s lambda (Λ) = .675, F(20, 398) = 2.512, p < .05, and age, Λ = .924, F(4,120) = 2.468, p < .05, had statistically sig- nificant main effects. Univariate results indicated that race was significantly associated with level of engagement in a health-promoting lifestyle, F(5, 123)= 4.22, p < .01; how- ever, follow-up tests to determine the nature of these asso- ciations revealed no significant racial differences in level of engagement in health-promoting lifestyle. Univariate tests also revealed that age was significantly associated with level of perceived family/friend social support, F(1, 123) = 6.46, p < .05. Inspection of relationship direction indicated

that as participants’ age increased, level of perceived fam- ily/friend social support tended to decrease.

COMMENT Our research affirmed the importance of health value and

health self-efficacy as variables in health-promoting life- styles among college students. Intervention programs that empower students to make positive health decisions and to engage in health-promoting behaviors may counter the influences to engage in health risk behaviors such as sub- stance abuse that are common in college environments.3,4

Health value and health self-efficacy significantly con- tributed to participants’ engagement in a health-promoting lifestyle. Participants who placed a higher value on health and on health self-efficacy tended to also have a greater involvement in a health-promoting lifestyle. This find- ing lends support for Pender’s Health Promotion Model

TABLE 2. Intercorrelations of Major Investigated Variables

Variable 1 2 3 4

1. Health value — 2. Family/friend social support .23 — 3. Health self-efficacy .29 .34 — 4. Health-promoting lifestyle .51 .35 .61 —

Note. All variables are significant at p < .01. N = 141.

TABLE 3. Analyses Predicting Health-Promoting Lifestyle, Controlling for Social Desirability

Variable B SE t p

Health value 2.32 .33 5.18 .00*

Perceived social support .52 .35 1.49 .14 Health self-efficacy .60 .09 7.03 .00*

Note. F(4,132) = 36.35, r2 adj

= .51, p < .01. *p < .01.

TABLE 4. Analyses of Significant Variables in Multivariate Analyses

Significant relationship B t p

Race and health-promoting lifestyle*

African American –13.72 –1.13 .26 Asian American –17.66 –1.39 .17 Caucasian 3.58 .32 .75 Latino/Hispanic black –11.97 –.81 .42 Latino/Hispanic white –8.89 –.71 .48 Age and family/friend social support† –.46 –2.54 .01

*F(5, 123) = 4.22, p < .01. †F(1, 123) = 6.46, p < .05.

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because it is consistent with the Pender’s tenet that engage- ment in health behavior is a function of the value attached to the outcome of good health and of personal beliefs, such as self-efficacy. However, family/friend social support was not a significant predictor of engagement in a health-promoting lifestyle. This unexpected finding suggests that, for this col- lege student sample, personal variables, such as health value and health self-efficacy, are stronger influences on engage- ment in a health-promoting lifestyle than are the external influence of general family/friend social support. Because college students typically spend more time away from home and their families, family support may be less influential in their engagement in health-promoting lifestyles. Indepen- dent exploration of family versus friend social support may provide clarity regarding the role of external social support in the health-promoting activities of college students.

Implications for College Student Personnel

Health professionals working on college campuses can facilitate the adoption and maintenance of health-promot- ing lifestyles among college students.13 By providing out- reach education on health issues, the self-efficacy beliefs of college students may be increased. As students are informed and instructed on how to perform certain posi- tive health behaviors, confidence in their ability to perform those actions may also be enhanced. Planners of outreach education programs can address breast self-examining, constructing healthy meal plans, balancing salt and sugar intake, proper exercise techniques, stress management, and relaxation. Administrators can also address these self-care practices at campus health fairs or in health classes.

Health professionals can also develop and implement programs aimed at increasing the health value of college students. Furthermore, they can offer seminars address- ing self-management strategies for engaging in health behaviors that decrease the likelihood of cancer, diabetes, hypertension, obesity, arthritis, substance addiction, and unplanned pregnancy. By explicitly describing the link between current health behavior and long-term health qual- ity of life, students’ value of health may be enhanced. At the same time, college students may desire healthier lifestyles and, therefore, increase levels of engagement in health-pro- moting behaviors. In addition, changing perceived social norms about health behaviors is an established way to alter health value valences.4 For instance, most students who engage in harmful behaviors, such as smoking or excessive alcohol use, significantly overestimate the percentage of their peers that engage in the same behaviors. Measuring social norms on campus and then advertising them can significantly alter student health value beliefs.

College and university administrators must aid college students in the adoption and maintenance of health-promot- ing lifestyles. By creating campuses in which students feel empowered to make healthy choices, college students can adopt healthy lifestyles as they enter the workforce. Health researchers, health educators, and mental health providers can facilitate this empowerment.

Our findings that 2 self variables, health self-efficacy and health value, were significant predictors of engagement in a health-promoting lifestyle among college students provides support for health-promoting interventions that empower college students to make positive health decisions. College health professionals possess the necessary skills to promote this empowerment of college students through teaching self-management strategies and using cognitive interven- tions designed for the adoption and maintenance of health- promoting lifestyles.

Implications for Future Research

Our study has several implications for advancing research. First, researchers should explore the health- promoting lifestyles of college students of different eth- nic backgrounds. Different ethnic populations must be researched independently to better grasp the motivating factors for each population. Possible contributing vari- ables include family value of health, family and close friend support for positive health behavior, family health practices, locus of control, and perceived barriers to health-promoting lifestyles.

Second, future studies are needed in which researchers further examine the role of health value in the health- promoting lifestyles of college students. It would also be beneficial to conduct this research with larger samples that include a representative number of male college students.

Third, researchers also should investigate the roles of family support and friend support separately as external social support influences on health-promoting lifestyles among college students. Because college students have limited interaction with their families during the college years, the support of friends may have been what accounted for the weak association between family/friend support and engagement in a health-promoting lifestyle in the present study.

Fourth, future research in which investigators explore the role of health self-efficacy in health-promoting lifestyles is clearly indicated. Such research would benefit from the inclusion of a general self-efficacy measure so that the relative influence of general self-efficacy and health self- efficacy can be assessed within the same study.

Limitations

Although our findings generally supported the hypotheses, some limitations must be considered when interpreting the results. The first major limitation of this study concerns the small sample size; 162 students participated in the study, and 68% were Caucasian Americans. Furthermore, the sample was predominantly female (70%). Because the sample was drawn from 2 classes on a single university, it is not known how well the findings generalize to students in other schools in other parts of the country or even to students at the same school. Additional research is needed to augment the present findings.

A second limitation of the study is the use of a cross- sectional design. This design does not allow for the infer-

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ence of causality. Therefore, research using longitudinal data may assist in determining a specific relationship between the investigated factors and engagement in a health-promoting lifestyle among college students.

Conclusion

Colleges and universities are environments where health professionals can establish intervention programs to pro- mote the adoption and maintenance of healthy lifestyles among college students. These programs are particularly meaningful, given that college students are challenged with the responsibility for their personal health.1 New life experiences in college may lead college students to engage in unhealthy behaviors, such as unprotected sex, substance abuse, or smoking. Research in which investigators aim to identify factors that contribute to health-promoting life- styles among college students can provide information that would aid in establishing effective health-promotion pro- grams on college campuses.

NOTE For comments and further information, address corre-

spondence to Dr Keith C. Herman, Johns Hopkins Univer- sity, 600 N. Wolfe St., CMSC 394, Baltimore, MD 21287 (e-mail: [email protected]).

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