569536
research-article2015
TCNXXX10.1177/1043659615569536Journal of Transcultural NursingPolat et al.
Education Department
Factors Affecting Health-Promoting Behaviors in Nursing Students at a University in Turkey
Journal of Transcultural Nursing 2016, Vol. 27(4) 413–419 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1043659615569536 tcn.sagepub.com
Ülkü Polat, PhD1, Şükrü Özen, MS1, Burcu Bayrak Kahraman, PhD1, and Hatice Bostanoğlu, PhD1
Abstract This descriptive study was carried out to determine factors affecting health-promoting behaviors in nursing students. The sample consisted of 245 students. A questionnaire about factors affecting lifestyle behavior and the Health Promotion Lifestyle Profile Scale-II were used to collect data from 245 nursing students during the spring semester of the 2012-2013 academic year. A significant difference was found between students with and without diagnosed health problems in terms of their mean scores on the Health Promotion Lifestyle Profile Scale-II subscales of health responsibility, spiritual growth, and interpersonal relations, as well as their total mean scores (p < .05). The exercise, nutrition, spiritual growth, and stress management subscale scores of those students regularly going for health checks were determined to be significantly higher than those of the students who did not obtain regular health checks. Students’ healthy lifestyle behaviors were generally found to be at the medium level. This study provides evidence of the need for interventions to help nurses in Turkey. Keywords nursing, lifestyle, health promotion
Introduction A health-promoting lifestyle includes far more than preventing disease and is characterized by behaviors that are complementary parts of the healthy lifestyles of individuals. These behaviors include activities such as assuming responsibility for personal health, participating in physical activities, and acquiring good nutritional habits (Bayramova & Karadakovan, 2004; Çelik et al., 2009; Yılmazel, Çetinkaya, & Naçar, 2013). The World Health Organization (WHO; 2010) reports that noncommunicable diseases are caused, to a large extent, by four behavioral risk factors that are pervasive aspects of economic transition, rapid urbanization, and 21st-century lifestyles: tobacco use, unhealthy diet, insufficient physical activity, and the harmful use of alcohol (WHO, 2010). Consequently, one of the aims of health promotion is to enable people to improve their health by changing their behavior (Yılmazel et al., 2013). A healthy society requires a healthy population. Thus, it is very important to assist individuals to develop and adopt behaviors that will protect, sustain, and improve their own health and well-being, as well as to help them make correct decisions about their health. For nurses, these behaviors are generally acquired in university years when receiving professional education. This reveals the need to determine the health behaviors of students who are going to study in health
service fields as well as the factors that influence these behaviors (Çelik et al., 2009; Yılmazel et al., 2013). Nurses constitute the largest group among medical professionals. The individual lifestyle behaviors of nursing students influence the manner in which they perceive their role as health promoters (Alpar, Senturan, Karabacak, & Sabuncu, 2008). In order for nurses to be able to inform and guide individuals regarding healthy behavior, it is necessary for them to be able to demonstrate healthy behavior and be role models (Alpar et al., 2008; Mooney, Timmins, Byrne, & Corroon, 2011). This is because nurses have important roles in both determining the prevalence of adverse behaviors that may have an impact on health in society and promoting healthy lifestyles. In order for nursing students to be competent nurses in the future, they first must have healthy lifestyle behaviors (Tambağ, 2011). Even though health promotion was emphasized substantially in the “Health for All Objectives” (WHO, 1998), deficiencies can be observed in the practice of basing nursing 1
Gazi University, Ankara, Turkey
Corresponding Author: Ülkü Polat, PhD, Faculty of Health Sciences, Nursing Department, Gazi University, Ankara 06500, Turkey. Email: [email protected]
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education on the protection and promotion of health (Ayaz, Tezcan, & Akıncı, 2005; WHO, 1998). However, in the nursing profession today, the inclusion of programs that focus on the individual and are based on the protection and promotion of health is required (Kocaakman, Aksoy, & Eker, 2010). At present, health promotion behaviors are coming into prominence, and awareness of them is increasing in nursing students who will assume a primary role in health services. Nursing students, who will become health care professionals when they graduate, not only have responsibilities with the potential to influence the conditions affecting the health of others but they also have an opportunity to be role models of good practice in relation with health promotion. Accordingly, the determination of healthy lifestyle behaviors of nursing students can contribute to the evaluation of the current status and identification of needs in this area. The aim of the study was to determine health promotion behaviors in nursing students.
Method
and it was revised in 1996 (Walker & Hill-Polerecky, 1996). Its validity and reliability were confirmed by Bahar, Beşer, Gördes, Ersin, and Kıssal (2008) in Turkey. The permission to use this scale was obtained from Bahar et al. (2008). The scale measures the health promotion behaviors associated with a healthy individual’s lifestyle. It consists of a total of 52 items along six subscales. The subscales are spiritual growth, health responsibility, exercise, nutrition, interpersonal relations, and stress management. The overall score of the scale provides the healthy lifestyle behavior score. All items on the scale are positive. Scoring is in a 4-point Likert-type scale format. Items are answered as 1 = never, 2 = sometimes, 3 = often, or 4 = regularly. The lowest possible score for the entire scale is 52, and the highest possible score is 208. The Cronbach’s alpha reliability coefficient of the scale is .94. The Cronbach’s alpha coefficients of the subscales vary between .79 and .87. The Cronbach’s alpha reliability coefficient for our study was determined to be .93, and for the subscales, it varied between .66 and .81.
Statistical Evaluation
Design and Participant Recruitment This descriptive study was conducted for the purpose of determining the healthy lifestyle behaviors of students at Gazi University, Faculty of Health Sciences, and the Department of Nursing. A total of 408 students were enrolled for the spring semester of 2012-2013. Of the 408 students, 245 agreed to take part in this study and were present at the time of data collection. Nursing students who were willing to participate were given a questionnaire form and Health Promotion Lifestyle Profile Scale-II (HPLP-II) to complete in the classrooms. The questionnaire form and HPLP-II scale were fulfilled by students. Researchers explained to the students incomprehensible or misunderstood questions in these instruments. The instruments took 10 to 15 minutes to complete and were collected after class.
SPSS for Windows 15.0 was used to analyze the data. Number and percentile calculations were used to evaluate the sociodemographic characteristics. Mean, student’s t test, the Mann–Whitney U test, one-way analysis of variance, and the Kruskal–Wallis test were all used to compare sociodemographic characteristics with the mean HPLP-II scores of nursing students. The nonparametric Mann–Whitney U test was used to compare the difference in means on the HPLP-II between two groups. For comparisons of parametric values between two groups, we used a student t test. The nonparametric Kruskall–Wallis test was used to compare the difference in means on the HPLP-II among three or more groups. For comparisons of parametric values among three or more groups, we used an analysis of variance.
Ethical Considerations
Instruments Questionnaire. This consisted of 15 questions designed to facilitate the collection of demographic data and descriptive characteristics; for example, height, weight, age, gender, education, and information about lifestyle factors such as smoking, exercise, and long-term health conditions. The questionnaire was based on the related literature and the writers’ clinical and academic experiences. A small pilot study was conducted with 10 students to ensure that the questions were understandable. As there was no negative feedback from students, the content of the questionnaire was not changed. Health Promotion Lifestyle Profile Scale-II. The HPLP-II was developed by Walker, Sechris, and Pender (1987) for the purpose of determining the healthy lifestyle behaviors of students,
In order to be able to conduct the study, written approval was obtained from the faculty administration, and ethics board approval was received from the Gazi University Social Research Ethics Board. Finally, verbal consent was obtained, and an informed consent form was given to all participants, which included statements that participation in the study was voluntary.
Results The mean age of students was 20.91 ± 2.156 years and 90.2% were females. About 27.8% of students were in the first year, 29.4% were in the second year, 13.9% were in the third year, and 29% were in the fourth year. A majority of students, 98.8%, were high school graduates, 83.3% had a nuclear family structure, 75.5% stated that they spent a large
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Polat et al. Table 1. Health Promotion Lifestyle Profile Scale-II Mean Scores of Students According to Their Sociodemographic Characteristics. N Age 18-21 166 22+ 79 t p Gender Male 24 Female 221 Mann–Whitney U test p Grade First year 68 Second year 72 Third year 34 Fourth year 71 F p Education High school graduate 242 Medical vocational 3 Mann–Whitney U test P
Health responsibility
Exercise
Nutrition
Spiritual growth
Interpersonal relations
Stress management
Total score
67.8 32.2
20.79 ± 4.12 22.51 ± 4.41 −2.987 .003*
16.62 ± 4.12 17.92 ± 5.13 −2.120 .035*
20.66 ± 3.44 21.83 ± 4.30 −2.280 .023*
26.98 ± 4.18 28.27 ± 4.13 −2.265 .024*
25.92 ± 4.21 26.64 ± 4.20 −1.257 .210
20.40 ± 3.46 21.26 ± 3.41 −1.829 .069
131.40 ± 17.71 138.46 ± 20.96 −2.746 .006*
9.8 90.2
21.04 ± 4.99 21.38 ± 4.21 2387.500 .421
20.00 ± 5.03 16.72 ± 4.34 1589.500 .001*
20.75 ± 4.57 21.07 ± 3.69 2463.500 .566
25.79 ± 5.05 27.57 ± 4.07 2088.500 .087
23.79 ± 5.15 26.41 ± 4.03 1683.500 .003*
20.79 ± 3.58 20.66 ± 3.45 2573.500 .811
132.16 ± 24.35 133.84 ± 18.46 2491.500 .626
27.8 29.4 13.9 29.0
20.48 ± 4.16 20.65 ± 3.87 21.85 ± 4.14 22.64 ± 4.59 4.020 .008*
16.54 ± 3.83 16.56 ± 4.27 17.50 ± 4.41 17.78 ± 5.28 1.311 .271
20.44 ± 3.41 20.40 ± 3.23 22.29 ± 3.76 21.67 ± 4.39 3.264 .022*
27.26 ± 4.25 26.55 ± 4.35 27.38 ± 3.93 28.40 ± 3.99 2.394 .069
25.89 ± 43.1 25.48 ± 4.50 26.50 ± 3.58 26.91 ± 4.05 1.543 .204
20.80 ± 2.91 19.73 ± 3.52 20.67 ± 3.84 21.52 ± 3.52 3.298 .021*
131.44 ± 17.10 129.40 ± 18.01 136.20 ± 18.08 138.95 ± 21.20 3.646 .013*
98.8 1.2
21.35 ± 4.26 21.00 ± 7.00 302.500 .619
17.04 ± 4.52 17.33 ± 4.16 347.500 .899
21.05 ± 3.79 20.33 ± 2.51 321.000 .730
27.40 ± 4.15 27.66 ± 8.50 298.000 .593
26.16 ± 4.20 25.00 ± 6.24 352.500 .931
20.71 ± 3.46 18.33 ± 3.21 213.000 .217
133.73 ± 19.95 129.66 ± 24.17 334.500 .815
%
*p < .05.
proportion of their lives in their home province, and 44.1% stated that they lived with their families. A total of 55.5% of students stayed in a dormitory, 91.4% had social insurance security, and 73.5% had medium-economic status (see Table 1, Table 2). A total of 26.1% of students had a diagnosed health problem (see Table 2). These problems include iron-deficiency anemia (3 persons), familial Mediterranean fever anemia (2 persons), diabetes mellitus (2 persons), asthma (2 persons), migraine (2 persons), epilepsy (2 persons), depression (2 persons), gastritis (2 persons), mitral insufficiency (2 persons), scoliosis (3 persons), goiter (3 persons), myopia (3 persons), and other diseases (36 persons; polycystic ovarian syndrome, ulcers, lumbar disc herniation, chronic pharyngitis, hypophyseal adenoma, etc.). The chronic diseases in the first-degree relatives of students (mother, father, siblings) encountered most frequently are diabetes mellitus, hypertension, asthma, coronary artery disease, rheumatoid arthritis, chronic obstructive pulmonary disease, and cancer. When the body mass indices, based on what the students said in the questionnaire form, were evaluated after data collection, it was determined that 14.7% were overweight and 3.3% were obese. The percentage of those who smoked at least one cigarette per day was 4.1%, 4.5% stated that they used alcohol at least once a week, and 65.3% stated that they did not exercise regularly (Table 2). The mean total HPLP-II score of nursing students was 133.68 ± 19.07. The mean scores for HPLP-II subscales were, respectively, health responsibility 21.35 ± 4.29, exercise 17.04 ± 4.50, nutrition 21.04 ± 3.77, spiritual growth 27.40 ± 4.20, interpersonal
relations 26.15 ± 4.21, and stress management 20.68 ± 3.46 (see Table 3). The mean total HPLP-II scores and the mean scores on health responsibility, spiritual growth, and interpersonal relations subscales determined a significant difference between the scores of students with diagnosed long-term health problems and those of other students without such problems (p < .05; see Table 2). The mean health responsibility (22.51 ± 4.41), exercise (17.92 ± 5.13), nutrition (21.83 ± 4.30), and spiritual growth (28.27 ± 4.13) subscale scores of students aged 22 years and older were determined to be significantly higher than the mean scores of the 18- to 20-year age group (respectively, 20.79 ± 4.12, 16.62 ± 4.12, 20.66 ± 3.44, and 26.98 ± 4.18; p < .05). While the mean exercise score of male students (20.00 ± 5.03) was determined to be significantly higher than that of female students (16.72 ± 4.34), the mean spiritual growth (27.57 ± 4.07) and interpersonal relations (26.41 ± 4.03) scores of female students were determined to be significantly higher than those of male students (respectively, 25.79 ± 5.05 and 23.79 ± 5.15; p < .05). The mean total score and the mean stress management score of students in the fourth year were determined to be significantly higher than those of students in the other years (p < .05; see Table 1). The mean exercise score (17.38 ± 4.61) of students with a nuclear family was higher than that of students with fragmented (15.23 ± 2.89) and extended-type (15.39 ± 3.80) families; the difference between mean scores was determined to be significant (p < .05; see Table 2). The mean nutrition (22.29 ± 3.76) score of students in the third year was higher
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Table 2. Health Promotion Lifestyle Profile Scale-II Mean Scores of Students According to Their Economic, Family, and Health Status. N Family structure Nuclear family 204 Extended family 28 Fragmented family 13 Kruskal–Wallis test p Economic status Low 20 Medium 180 High 45 Kruskal–Wallis test p Place of residence Village 35 Town 25 City 185 Kruskal–Wallis test p Living arrangement At home with family 48 At home with friends 55 At home with relatives 6 At the dormitory 136 Kruskal–Wallis test p Diagnosed health problem Yes 64 No 181 Mann–Whitney U test p Going to regular health checks Yes 39 No 206 Mann–Whitney U test p
Health responsibility
Exercise
Nutrition
Spiritual growth
Interpersonal relations
Stress management
Total score
83.3 11.4 5.3
21.40 ± 4.39 20.78 ± 3.85 21.69 ± 3.72 0.134 .935
17.38 ± 4.61 15.39 ± 3.80 15.23 ± 2.89 7.252 .027*
21.27 ± 3.83 19.89 ± 3.30 19.92 ± 3.25 3.527 .171
27.44 ± 4.29 26.92 ± 3.95 27.76 ± 3.29 0.313 .855
26.25 ± 4.36 25.28 ± 3.72 26.46 ± 2.50 1.258 .533
20.78 ± 3.56 19.82 ± 2.95 20.92 ± 2.75 1.808 .405
134.55 ± 19.72 128.10 ± 15.91 132.00 ± 12.50 2.361 .307
8.2 73.5 18.4
20.95 ± 4.85 21.25 ± 4.20 21.91 ± 4.43 1.285 .526
16.35 ± 4.68 17.13 ± 4.49 16.97 ± 4.55 1.274 .529
20.55 ± 4.21 21.02 ± 3.75 21.33 ± 3.72 0.428 .807
26.20 ± 4.62 27.30 ± 4.16 28.35 ± 4.09 3.732 .155
24.30 ± 4.15 26.07 ± 4.23 27.28 ± 3.91 7.225 .027*
19.90 ± 4.15 20.66 ± 3.39 21.08 ± 3.44 2.192 .334
128.25 ± 22.40 133.46 ± 18.82 136.95 ± 18.27 4.414 .110
14.3 10.2 75.5
21.34 ± 4.050 21.36 ± 5.02 21.35 ± 4.25 .016 .992
17.14 ± 4.06 17.44 ± 4.60 16.97 ± 4.59 0.121 .941
20.71 ± 3.11 21.56 ± 4.95 21.03 ± 3.72 0.329 .848
27.71 ± 3.45 26.64 ± 4.87 27.44 ± 4.24 0.831 .660
25.94 ± 3.65 25.32 ± 4.81 26.30 ± 4.24 1.471 .479
20.54 ± 2.67 20.84 ± 4.02 20.68 ± 3.53 0.254 .881
133.40 ± 14.43 133.16 ± 23.02 133.80 ± 19.35 0.506 .776
19.6 22.4 2.4 55.5
21.16 ± 4.55 21.32 ± 4.05 20.33 ± 4.03 21.47 ± 4.33 0.535 .911
16.54 ± 4.69 17.20 ± 4.95 16.33 ± 4.03 17.19 ± 4.30 0.765 .858
21.33 ± 3.49 20.74 ± 4.10 20.50 ± 4.96 21.08 ± 3.71 1.285 .733
27.89 ± 3.93 26.85 ± 4.73 24.33 ± 5.92 27.58 ± 3.95 2.796 .424
26.45 ± 4.79 25.85 ± 4.22 25.50 ± 5.16 26.19 ± 3.99 0.934 .817
20.95 ± 3.23 20.18 ± 3.25 22.00 ± 3.52 20.72 ± 3.62 2.340 .505
134.35 ± 18.96 132.16 ± 19.25 129.00 ± 21.70 134.26 ± 19.07 0.687 .876
26.1 73.9
22.37 ± 4.09 20.98 ± 4.31 4537.000 .010*
17.78 ± 4.71 16.78 ± 4.41 5073.000 .139
21.53 ± 3.61 20.87 ± 3.82 5204.000 .226
28.93 ± 3.77 26.86 ± 4.22 4212.000 .001*
27.04 ± 3.67 25.83 ± 4.36 4711.000 .026*
21.48 ± 3.63 20.39 ± 3.36 4936.500 .078
139.15 ± 17.94 131.74 ± 19.12 4441.000 .006*
15.9 84.1
23.46 ± 4.03 20.95 ± 4.22 2622.000 .001*
19.02 ± 4.78 16.66 ± 4.36 2804.500 .003*
22.28 ± 3.31 20.81 ± 3.81 2986.500 .011*
29.15 ± 3.19 27.07 ± 4.29 2931.500 .007*
27.17 ± 3.37 25.96 ± 4.34 3391.000 .121
21.84 ± 3.08 20.46 ± 3.49 3090.000 .022*
142.94 ± 14.92 131.92 ± 19.29 2526.500 .000*
%
*p < .05.
Table 3. Mean Total Health Promotion Lifestyle Profile Scale-II and Dimension Scores. Health Promotion Lifestyle Profile Scale-II dimensions Health responsibility Exercise Nutrition Spiritual growth Interpersonal relations Stress management Total
X ± SD
Minimum
Maximum
21.35 ± 4.29 17.04 ± 4.50 21.04 ± 3.77 27.40 ± 4.20 26.15 ± 4.21 20.68 ± 3.46 133.68 ± 19.07
10.00 8.00 11.00 12.00 14.00 11.00 83.00
35.00 32.00 34.00 36.00 36.00 30.00 200
than the mean scores of students in other years (20.44 ± 3.41, 20.40 ± 3.23, 21.67 ± 4.39); the difference between mean scores was determined to be statistically significant (p < .05; see Table 1). It was determined that the mean interpersonal
relations score of students with a high-economic status (27.28 ± 3.91) was significantly higher than those students with medium- (26.07 ± 4.23) and low-economic (24.30 ± 4.15) statuses (p < .05). Furthermore, the total mean score (142.94 ± 14.92), health responsibility (23.46 ± 4.03), exercise (19.02 ± 4.78), nutrition (22.28 ± 3.31), spiritual growth (29.15 ± 3.19), and stress management (21.84 ± 3.08) subscale scores of students regularly going for health checks were determined to be significantly higher than the scores of those who did not go (respectively, 132.12 ± 19.42, 21.01 ± 4.23, 16.73 ± 4.39, 20.81 ± 3.85, 27.08 ± 4.31, and 20.47 ± 3.52; p < .05; see Table 2).
Discussion Given the increasing emphasis placed on health promotion, nurses have important roles to play as health educators and
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Polat et al. as role models. This study shows that some are better placed than others in terms of demonstrating healthy lifestyle behaviors. Positive health behaviors are associated with higher HPLP-II scores; the highest possible score is 208. In this study, the mean score was 133.68 ± 19.97. It can be seen that the healthy lifestyle behaviors of students included within this study are at a medium level. This result is similar to those obtained from other studies conducted in Turkey (Ayaz et al., 2005; Çelik et al., 2009; Kocaakman et al., 2010; Yılmazel et al., 2013). Similarly, Wittayapun, Tanasirirug, Butsripoom, and Ekpanyaskul (2010) indicated that nursing students in Thailand practiced health-promoting behaviors at a moderate level. The reason for this is considered to be the positive effect of the nursing education process on the students’ health behaviors. In studies conducted by Alpar et al. (2008) and Gözüm and Tezel (2000), it was reported that, in Turkey, the healthy lifestyle behaviors of nursing students after nursing education were better than they had been before; nursing education has a positive impact on healthy lifestyle behaviors (Ayaz et al., 2005; Gözüm & Tezel, 2000; Mooney et al., 2011). In our study, mean HPLP-II scores for spiritual growth were higher, and those for exercise were lower than other subscales. Al-Khawaldeh (2014) reported similar results after surveying university students in Jordan. In Iran, RezaeiAdaryani Morteza and Rezaei-Adaryani Mina (2012) noted that medical nursing and allied health students had low scores for exercise. In Turkey, Yılmazel et al. (2013) and İlhan, Batmaz, and Akhan (2010) reported that nursing students’ exercise scores were lower than in any other subscale. In Thailand, Wittayapun et al. (2010) found that exercise scores were lower among nursing students; nutrition and stress management were also low. Physical activity was the lowest practice followed by nutrition and stress management among health-promoting lifestyle behaviors of nursing students. Exercise and proper nutrition protect individuals from deadly chronic diseases and from problems that may develop as a result of these diseases. They are key elements in reducing the harmful effects of chronic diseases such as heart disease, stroke, cancer, and diabetes. Unhealthy behaviors create burdens for individuals, their families, and the health economy as they increase health care costs (Abu-Moghli, Khalaf, & Barghoti, 2010). The effects of regular exercise have been suggested in many studies (Clement, Jankowski, Bouchard, Perreault, & Lepagei, 2002; Kamwendo, Faresjo, Gustavsson, & Jansson, 2000; Pawloski & Davidson, 2003). It has many positive effects on weight control, cardiovascular diseases, some cancers, obesity prevention, mental health, self-esteem, and body image. However, in our study, only 34.7% of students engaged in regular exercise; their mean exercise scores were low. This may be due to lack of appropriate facilities. In studies conducted in the United States, Canada, Sweden, and England, it was reported that a majority of nursing students did not
engage in regular exercise and had tendencies toward low activity (Callaghan, 1999; Clement et al., 2002; Kamwendo et al., 2000; Pawloski & Davidson, 2003). While students’ scores on the health responsibility, nutritional habits, spiritual growth, and stress-management subscales of the HPLP-II did not differ significantly by gender, males scored better than females on the physical exercise subscale. This result is consistent with previous studies, which have shown that male students are more active than female students are (Al-Kandari, Vidal, & Thomas, 2008; Al-Khawaldeh, 2014; Lee & Loke, 2005). However, female students scored better than male students did in spiritual growth. Several other studies support these results (Bothmer & Fridlund, 2005; Can et al., 2008; Johnson, 2005). In Quattrin, Zanini, Zamolo, and Brusaferro’s (2010) study, 87.2% of nursing students stated that they were satisfied with their health condition, 70.5% stated that they had a normal body mass index, 62% stated that they smoked, and 75.2% stated that they drank alcohol at least once in their life. The investigators reported that, even though nursing students perceived their health to be good, they had low physical activity levels and demonstrated unhealthy behaviors such as smoking and drinking alcohol. In our study, the number of students smoking and drinking alcohol was low, and the majority had a normal body mass index. A survey at a regional college for health care professions in 2008 and 2013 showed that being overweight, physical inactivity, smoking, and alcohol consumption were quite common among nursing students (Lehmann, von Lindeman, Klewer, & Kugler, 2014). Approximately 40% of the surveyed 259 female nursing students were smokers, 40% were alcohol consumers, and 20% were overweight or obese (Lehmann et al., 2014). Furthermore, our study determined that the mean total and mean health responsibility, exercise, nutrition, and self-actualization scores of students aged 22 years and older were significantly high. These findings are similar to those of other studies. In Turkey, Kocaakman et al. (2010) reported that the mean self-actualization, health responsibility, and interpersonal support scores of students in the 22 to 25 years age group were higher than those of students in the 17 to 21 years age group. Other studies of university students in Turkey have shown that, as age increases, so do HPLP-II scores in their mean HPLP-II health responsibility, exercise, and nutrition subscale scores (Yıldırım, 2005; Zaybak & Fadıloğlu, 2004). In our study, the health responsibility, nutrition, and stress management scores of students in the fourth year were determined to be significantly high. However, Alpar et al. (2008) found that health behavior changes over time from the beginning of professional education until graduation. Ayaz et al. (2005) reported similar findings and that health responsibility scores increased significantly throughout nursing education. Karadeniz, Yanıkkerem Uçum, Dedeli, and Karaağaç (2008) noted high health responsibility scores among fourth-year students. Cihangiroğlu and Deveci (2011) also determined
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that health responsibility and interpersonal support scores increased as age increased; the health responsibility mean scores of third- and fourth-year students were significantly higher than the mean scores of first- and second-year students. In addition, the nutrition habit scores of nonsmokers were higher compared with those of smokers. It has been reported that persons with a low-socioeconomic status, constituting a considerable proportion of society, are as disadvantaged with respect to health means, as they are in all areas. Thus, this group is at risk for developing chronic diseases that may have an adverse impact on life quality (Ayaz et al., 2005). The fact that positive social and economic factors have a positive impact on the healthrelated behaviors of individuals has also been verified by studies (Cihangiroğlu & Deveci, 2011). Most of the students in our study had social insurance, and it was determined that the mean interpersonal relations scores of students with a high-economic status were significantly higher compared with those of students of medium-and low-economic status. Ulla Díez and Pérez-Fortis (2010) argued that economic status influenced interpersonal relations. İlhan et al. (2010) identified a relationship between economic status and several HPLP-II subscales. Higher scores for spiritual growth, exercise, and interpersonal relations were related to higher economic status and vice versa. In our study, a significant difference was found between the mean total and mean health responsibility, spiritual growth, and interpersonal relations subscale scores of students with and without a diagnosed long-term health problem. Ayaz et al. (2005) reported that the health responsibility scores of students with long-term health problems needing monitoring and treatment were higher than those who did not have such problems.
Conclusion In conclusion, our study found that a proportion of nursing students are at risk for chronic diseases, and that their mean total HPLP-II score is at a medium level. The findings suggest that interventions are needed to enhance practicing health-promoting behaviors. It is important to take into consideration influential factors in the promotion of healthy lifestyle behaviors, such as the formation of training programs for nursing students and the distribution of these training programs over all years of education. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
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Tambağ, H. (2011). Hatay sağlık yüksekokulu öğrencilerinin sağlıklı yaşam biçimi davranışları ve etkileyen faktörler [Hatay health school students’ healthy lifestyle behaviors and influencing factors]. Sağlık Bilimleri Fakültesi Hemşirelik Dergisi, 18, 47-58. Ulla Díez, S. M., & Pérez-Fortis, A. (2010). Socio-demographic predictors of health behaviors in Mexican college students. Health Promotion International, 25, 85-93. Yıldırım, N. (2005). Üniversite Örencilerinin Bazı SosyoDemografik Özelliklerinin Sağlıklı Yaşam Biçimi Davranışlarına Etkisi [Influence of sociodemographic characteristics of university students on healthy lifestyle behaviors]. Cumhuriyet Üniversitesi Sağlık Bilimleri Enstitüsü Hemşirelik Programı Yüksek Lisans Tezi, Sivas. Yılmazel, G., Çetinkaya, F., & Naçar, M. (2013). Hemşirelik Öğrencilerinde Sağlığı Geliştirme Davranışları [Health promotion behavior of nursing school students]. TAF Preventive Medicine Bulletin, 12, 261-270. Walker, S. N., & Hill-Polerecky, D. M. (1996). Psychometric evaluation of the Health Promoting Lifestyle Profile II. Unpublished manuscript, University of Nebraska Medical Center, Omaha, Nebraska. Walker, S. N., Sechris, K. R., & Pender, N. J. (1987). The HealthPromoting Lifestyle Profile: Development and psychometric characteristics. Nursing Research, 36, 76-80. Wittayapun, Y., Tanasirirug, V., Butsripoom, B., & Ekpanyaskul, C. (2010). Factors affecting health-promoting behaviors in nursing students of the faculty of nursing, Srinakharinwirot University, Thailand. Journal of Public Health, 40, 215-225. World Health Organization. (1998). Health 21: An introduction to the health for all policy framework for the WHO European Region. Copenhagen, Denmark: Regional Office for Europe. World Health Organization. (2010). Global status report on noncommunicable diseases 2010. Retrieved from http://www.who. int/nmh/publications/ncd_report_full_en.pdf Zaybak, A., & Fadıloğlu, Ç. (2004). Üniversite örencilerinin sağlığı geliştirme davranışları ve bu davranışları etkileyen etmenlerin belirlenmesi [Determining the health promotion behaviors of university students and the factors affecting these behaviors]. Ege Üniversitesi Hemşirelik Yüksek Okulu Dergisi, 20, 77-95.
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research-article2015
TCNXXX10.1177/1043659615569536Journal of Transcultural NursingPolat et al.
Education Department
Factors Affecting Health-Promoting Behaviors in Nursing Students at a University in Turkey
Journal of Transcultural Nursing 2016, Vol. 27(4) 413–419 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1043659615569536 tcn.sagepub.com
Ülkü Polat, PhD1, Şükrü Özen, MS1, Burcu Bayrak Kahraman, PhD1, and Hatice Bostanoğlu, PhD1
Abstract This descriptive study was carried out to determine factors affecting health-promoting behaviors in nursing students. The sample consisted of 245 students. A questionnaire about factors affecting lifestyle behavior and the Health Promotion Lifestyle Profile Scale-II were used to collect data from 245 nursing students during the spring semester of the 2012-2013 academic year. A significant difference was found between students with and without diagnosed health problems in terms of their mean scores on the Health Promotion Lifestyle Profile Scale-II subscales of health responsibility, spiritual growth, and interpersonal relations, as well as their total mean scores (p < .05). The exercise, nutrition, spiritual growth, and stress management subscale scores of those students regularly going for health checks were determined to be significantly higher than those of the students who did not obtain regular health checks. Students’ healthy lifestyle behaviors were generally found to be at the medium level. This study provides evidence of the need for interventions to help nurses in Turkey. Keywords nursing, lifestyle, health promotion
Introduction A health-promoting lifestyle includes far more than preventing disease and is characterized by behaviors that are complementary parts of the healthy lifestyles of individuals. These behaviors include activities such as assuming responsibility for personal health, participating in physical activities, and acquiring good nutritional habits (Bayramova & Karadakovan, 2004; Çelik et al., 2009; Yılmazel, Çetinkaya, & Naçar, 2013). The World Health Organization (WHO; 2010) reports that noncommunicable diseases are caused, to a large extent, by four behavioral risk factors that are pervasive aspects of economic transition, rapid urbanization, and 21st-century lifestyles: tobacco use, unhealthy diet, insufficient physical activity, and the harmful use of alcohol (WHO, 2010). Consequently, one of the aims of health promotion is to enable people to improve their health by changing their behavior (Yılmazel et al., 2013). A healthy society requires a healthy population. Thus, it is very important to assist individuals to develop and adopt behaviors that will protect, sustain, and improve their own health and well-being, as well as to help them make correct decisions about their health. For nurses, these behaviors are generally acquired in university years when receiving professional education. This reveals the need to determine the health behaviors of students who are going to study in health
service fields as well as the factors that influence these behaviors (Çelik et al., 2009; Yılmazel et al., 2013). Nurses constitute the largest group among medical professionals. The individual lifestyle behaviors of nursing students influence the manner in which they perceive their role as health promoters (Alpar, Senturan, Karabacak, & Sabuncu, 2008). In order for nurses to be able to inform and guide individuals regarding healthy behavior, it is necessary for them to be able to demonstrate healthy behavior and be role models (Alpar et al., 2008; Mooney, Timmins, Byrne, & Corroon, 2011). This is because nurses have important roles in both determining the prevalence of adverse behaviors that may have an impact on health in society and promoting healthy lifestyles. In order for nursing students to be competent nurses in the future, they first must have healthy lifestyle behaviors (Tambağ, 2011). Even though health promotion was emphasized substantially in the “Health for All Objectives” (WHO, 1998), deficiencies can be observed in the practice of basing nursing 1
Gazi University, Ankara, Turkey
Corresponding Author: Ülkü Polat, PhD, Faculty of Health Sciences, Nursing Department, Gazi University, Ankara 06500, Turkey. Email: [email protected]
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education on the protection and promotion of health (Ayaz, Tezcan, & Akıncı, 2005; WHO, 1998). However, in the nursing profession today, the inclusion of programs that focus on the individual and are based on the protection and promotion of health is required (Kocaakman, Aksoy, & Eker, 2010). At present, health promotion behaviors are coming into prominence, and awareness of them is increasing in nursing students who will assume a primary role in health services. Nursing students, who will become health care professionals when they graduate, not only have responsibilities with the potential to influence the conditions affecting the health of others but they also have an opportunity to be role models of good practice in relation with health promotion. Accordingly, the determination of healthy lifestyle behaviors of nursing students can contribute to the evaluation of the current status and identification of needs in this area. The aim of the study was to determine health promotion behaviors in nursing students.
Method
and it was revised in 1996 (Walker & Hill-Polerecky, 1996). Its validity and reliability were confirmed by Bahar, Beşer, Gördes, Ersin, and Kıssal (2008) in Turkey. The permission to use this scale was obtained from Bahar et al. (2008). The scale measures the health promotion behaviors associated with a healthy individual’s lifestyle. It consists of a total of 52 items along six subscales. The subscales are spiritual growth, health responsibility, exercise, nutrition, interpersonal relations, and stress management. The overall score of the scale provides the healthy lifestyle behavior score. All items on the scale are positive. Scoring is in a 4-point Likert-type scale format. Items are answered as 1 = never, 2 = sometimes, 3 = often, or 4 = regularly. The lowest possible score for the entire scale is 52, and the highest possible score is 208. The Cronbach’s alpha reliability coefficient of the scale is .94. The Cronbach’s alpha coefficients of the subscales vary between .79 and .87. The Cronbach’s alpha reliability coefficient for our study was determined to be .93, and for the subscales, it varied between .66 and .81.
Statistical Evaluation
Design and Participant Recruitment This descriptive study was conducted for the purpose of determining the healthy lifestyle behaviors of students at Gazi University, Faculty of Health Sciences, and the Department of Nursing. A total of 408 students were enrolled for the spring semester of 2012-2013. Of the 408 students, 245 agreed to take part in this study and were present at the time of data collection. Nursing students who were willing to participate were given a questionnaire form and Health Promotion Lifestyle Profile Scale-II (HPLP-II) to complete in the classrooms. The questionnaire form and HPLP-II scale were fulfilled by students. Researchers explained to the students incomprehensible or misunderstood questions in these instruments. The instruments took 10 to 15 minutes to complete and were collected after class.
SPSS for Windows 15.0 was used to analyze the data. Number and percentile calculations were used to evaluate the sociodemographic characteristics. Mean, student’s t test, the Mann–Whitney U test, one-way analysis of variance, and the Kruskal–Wallis test were all used to compare sociodemographic characteristics with the mean HPLP-II scores of nursing students. The nonparametric Mann–Whitney U test was used to compare the difference in means on the HPLP-II between two groups. For comparisons of parametric values between two groups, we used a student t test. The nonparametric Kruskall–Wallis test was used to compare the difference in means on the HPLP-II among three or more groups. For comparisons of parametric values among three or more groups, we used an analysis of variance.
Ethical Considerations
Instruments Questionnaire. This consisted of 15 questions designed to facilitate the collection of demographic data and descriptive characteristics; for example, height, weight, age, gender, education, and information about lifestyle factors such as smoking, exercise, and long-term health conditions. The questionnaire was based on the related literature and the writers’ clinical and academic experiences. A small pilot study was conducted with 10 students to ensure that the questions were understandable. As there was no negative feedback from students, the content of the questionnaire was not changed. Health Promotion Lifestyle Profile Scale-II. The HPLP-II was developed by Walker, Sechris, and Pender (1987) for the purpose of determining the healthy lifestyle behaviors of students,
In order to be able to conduct the study, written approval was obtained from the faculty administration, and ethics board approval was received from the Gazi University Social Research Ethics Board. Finally, verbal consent was obtained, and an informed consent form was given to all participants, which included statements that participation in the study was voluntary.
Results The mean age of students was 20.91 ± 2.156 years and 90.2% were females. About 27.8% of students were in the first year, 29.4% were in the second year, 13.9% were in the third year, and 29% were in the fourth year. A majority of students, 98.8%, were high school graduates, 83.3% had a nuclear family structure, 75.5% stated that they spent a large
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Polat et al. Table 1. Health Promotion Lifestyle Profile Scale-II Mean Scores of Students According to Their Sociodemographic Characteristics. N Age 18-21 166 22+ 79 t p Gender Male 24 Female 221 Mann–Whitney U test p Grade First year 68 Second year 72 Third year 34 Fourth year 71 F p Education High school graduate 242 Medical vocational 3 Mann–Whitney U test P
Health responsibility
Exercise
Nutrition
Spiritual growth
Interpersonal relations
Stress management
Total score
67.8 32.2
20.79 ± 4.12 22.51 ± 4.41 −2.987 .003*
16.62 ± 4.12 17.92 ± 5.13 −2.120 .035*
20.66 ± 3.44 21.83 ± 4.30 −2.280 .023*
26.98 ± 4.18 28.27 ± 4.13 −2.265 .024*
25.92 ± 4.21 26.64 ± 4.20 −1.257 .210
20.40 ± 3.46 21.26 ± 3.41 −1.829 .069
131.40 ± 17.71 138.46 ± 20.96 −2.746 .006*
9.8 90.2
21.04 ± 4.99 21.38 ± 4.21 2387.500 .421
20.00 ± 5.03 16.72 ± 4.34 1589.500 .001*
20.75 ± 4.57 21.07 ± 3.69 2463.500 .566
25.79 ± 5.05 27.57 ± 4.07 2088.500 .087
23.79 ± 5.15 26.41 ± 4.03 1683.500 .003*
20.79 ± 3.58 20.66 ± 3.45 2573.500 .811
132.16 ± 24.35 133.84 ± 18.46 2491.500 .626
27.8 29.4 13.9 29.0
20.48 ± 4.16 20.65 ± 3.87 21.85 ± 4.14 22.64 ± 4.59 4.020 .008*
16.54 ± 3.83 16.56 ± 4.27 17.50 ± 4.41 17.78 ± 5.28 1.311 .271
20.44 ± 3.41 20.40 ± 3.23 22.29 ± 3.76 21.67 ± 4.39 3.264 .022*
27.26 ± 4.25 26.55 ± 4.35 27.38 ± 3.93 28.40 ± 3.99 2.394 .069
25.89 ± 43.1 25.48 ± 4.50 26.50 ± 3.58 26.91 ± 4.05 1.543 .204
20.80 ± 2.91 19.73 ± 3.52 20.67 ± 3.84 21.52 ± 3.52 3.298 .021*
131.44 ± 17.10 129.40 ± 18.01 136.20 ± 18.08 138.95 ± 21.20 3.646 .013*
98.8 1.2
21.35 ± 4.26 21.00 ± 7.00 302.500 .619
17.04 ± 4.52 17.33 ± 4.16 347.500 .899
21.05 ± 3.79 20.33 ± 2.51 321.000 .730
27.40 ± 4.15 27.66 ± 8.50 298.000 .593
26.16 ± 4.20 25.00 ± 6.24 352.500 .931
20.71 ± 3.46 18.33 ± 3.21 213.000 .217
133.73 ± 19.95 129.66 ± 24.17 334.500 .815
%
*p < .05.
proportion of their lives in their home province, and 44.1% stated that they lived with their families. A total of 55.5% of students stayed in a dormitory, 91.4% had social insurance security, and 73.5% had medium-economic status (see Table 1, Table 2). A total of 26.1% of students had a diagnosed health problem (see Table 2). These problems include iron-deficiency anemia (3 persons), familial Mediterranean fever anemia (2 persons), diabetes mellitus (2 persons), asthma (2 persons), migraine (2 persons), epilepsy (2 persons), depression (2 persons), gastritis (2 persons), mitral insufficiency (2 persons), scoliosis (3 persons), goiter (3 persons), myopia (3 persons), and other diseases (36 persons; polycystic ovarian syndrome, ulcers, lumbar disc herniation, chronic pharyngitis, hypophyseal adenoma, etc.). The chronic diseases in the first-degree relatives of students (mother, father, siblings) encountered most frequently are diabetes mellitus, hypertension, asthma, coronary artery disease, rheumatoid arthritis, chronic obstructive pulmonary disease, and cancer. When the body mass indices, based on what the students said in the questionnaire form, were evaluated after data collection, it was determined that 14.7% were overweight and 3.3% were obese. The percentage of those who smoked at least one cigarette per day was 4.1%, 4.5% stated that they used alcohol at least once a week, and 65.3% stated that they did not exercise regularly (Table 2). The mean total HPLP-II score of nursing students was 133.68 ± 19.07. The mean scores for HPLP-II subscales were, respectively, health responsibility 21.35 ± 4.29, exercise 17.04 ± 4.50, nutrition 21.04 ± 3.77, spiritual growth 27.40 ± 4.20, interpersonal
relations 26.15 ± 4.21, and stress management 20.68 ± 3.46 (see Table 3). The mean total HPLP-II scores and the mean scores on health responsibility, spiritual growth, and interpersonal relations subscales determined a significant difference between the scores of students with diagnosed long-term health problems and those of other students without such problems (p < .05; see Table 2). The mean health responsibility (22.51 ± 4.41), exercise (17.92 ± 5.13), nutrition (21.83 ± 4.30), and spiritual growth (28.27 ± 4.13) subscale scores of students aged 22 years and older were determined to be significantly higher than the mean scores of the 18- to 20-year age group (respectively, 20.79 ± 4.12, 16.62 ± 4.12, 20.66 ± 3.44, and 26.98 ± 4.18; p < .05). While the mean exercise score of male students (20.00 ± 5.03) was determined to be significantly higher than that of female students (16.72 ± 4.34), the mean spiritual growth (27.57 ± 4.07) and interpersonal relations (26.41 ± 4.03) scores of female students were determined to be significantly higher than those of male students (respectively, 25.79 ± 5.05 and 23.79 ± 5.15; p < .05). The mean total score and the mean stress management score of students in the fourth year were determined to be significantly higher than those of students in the other years (p < .05; see Table 1). The mean exercise score (17.38 ± 4.61) of students with a nuclear family was higher than that of students with fragmented (15.23 ± 2.89) and extended-type (15.39 ± 3.80) families; the difference between mean scores was determined to be significant (p < .05; see Table 2). The mean nutrition (22.29 ± 3.76) score of students in the third year was higher
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Table 2. Health Promotion Lifestyle Profile Scale-II Mean Scores of Students According to Their Economic, Family, and Health Status. N Family structure Nuclear family 204 Extended family 28 Fragmented family 13 Kruskal–Wallis test p Economic status Low 20 Medium 180 High 45 Kruskal–Wallis test p Place of residence Village 35 Town 25 City 185 Kruskal–Wallis test p Living arrangement At home with family 48 At home with friends 55 At home with relatives 6 At the dormitory 136 Kruskal–Wallis test p Diagnosed health problem Yes 64 No 181 Mann–Whitney U test p Going to regular health checks Yes 39 No 206 Mann–Whitney U test p
Health responsibility
Exercise
Nutrition
Spiritual growth
Interpersonal relations
Stress management
Total score
83.3 11.4 5.3
21.40 ± 4.39 20.78 ± 3.85 21.69 ± 3.72 0.134 .935
17.38 ± 4.61 15.39 ± 3.80 15.23 ± 2.89 7.252 .027*
21.27 ± 3.83 19.89 ± 3.30 19.92 ± 3.25 3.527 .171
27.44 ± 4.29 26.92 ± 3.95 27.76 ± 3.29 0.313 .855
26.25 ± 4.36 25.28 ± 3.72 26.46 ± 2.50 1.258 .533
20.78 ± 3.56 19.82 ± 2.95 20.92 ± 2.75 1.808 .405
134.55 ± 19.72 128.10 ± 15.91 132.00 ± 12.50 2.361 .307
8.2 73.5 18.4
20.95 ± 4.85 21.25 ± 4.20 21.91 ± 4.43 1.285 .526
16.35 ± 4.68 17.13 ± 4.49 16.97 ± 4.55 1.274 .529
20.55 ± 4.21 21.02 ± 3.75 21.33 ± 3.72 0.428 .807
26.20 ± 4.62 27.30 ± 4.16 28.35 ± 4.09 3.732 .155
24.30 ± 4.15 26.07 ± 4.23 27.28 ± 3.91 7.225 .027*
19.90 ± 4.15 20.66 ± 3.39 21.08 ± 3.44 2.192 .334
128.25 ± 22.40 133.46 ± 18.82 136.95 ± 18.27 4.414 .110
14.3 10.2 75.5
21.34 ± 4.050 21.36 ± 5.02 21.35 ± 4.25 .016 .992
17.14 ± 4.06 17.44 ± 4.60 16.97 ± 4.59 0.121 .941
20.71 ± 3.11 21.56 ± 4.95 21.03 ± 3.72 0.329 .848
27.71 ± 3.45 26.64 ± 4.87 27.44 ± 4.24 0.831 .660
25.94 ± 3.65 25.32 ± 4.81 26.30 ± 4.24 1.471 .479
20.54 ± 2.67 20.84 ± 4.02 20.68 ± 3.53 0.254 .881
133.40 ± 14.43 133.16 ± 23.02 133.80 ± 19.35 0.506 .776
19.6 22.4 2.4 55.5
21.16 ± 4.55 21.32 ± 4.05 20.33 ± 4.03 21.47 ± 4.33 0.535 .911
16.54 ± 4.69 17.20 ± 4.95 16.33 ± 4.03 17.19 ± 4.30 0.765 .858
21.33 ± 3.49 20.74 ± 4.10 20.50 ± 4.96 21.08 ± 3.71 1.285 .733
27.89 ± 3.93 26.85 ± 4.73 24.33 ± 5.92 27.58 ± 3.95 2.796 .424
26.45 ± 4.79 25.85 ± 4.22 25.50 ± 5.16 26.19 ± 3.99 0.934 .817
20.95 ± 3.23 20.18 ± 3.25 22.00 ± 3.52 20.72 ± 3.62 2.340 .505
134.35 ± 18.96 132.16 ± 19.25 129.00 ± 21.70 134.26 ± 19.07 0.687 .876
26.1 73.9
22.37 ± 4.09 20.98 ± 4.31 4537.000 .010*
17.78 ± 4.71 16.78 ± 4.41 5073.000 .139
21.53 ± 3.61 20.87 ± 3.82 5204.000 .226
28.93 ± 3.77 26.86 ± 4.22 4212.000 .001*
27.04 ± 3.67 25.83 ± 4.36 4711.000 .026*
21.48 ± 3.63 20.39 ± 3.36 4936.500 .078
139.15 ± 17.94 131.74 ± 19.12 4441.000 .006*
15.9 84.1
23.46 ± 4.03 20.95 ± 4.22 2622.000 .001*
19.02 ± 4.78 16.66 ± 4.36 2804.500 .003*
22.28 ± 3.31 20.81 ± 3.81 2986.500 .011*
29.15 ± 3.19 27.07 ± 4.29 2931.500 .007*
27.17 ± 3.37 25.96 ± 4.34 3391.000 .121
21.84 ± 3.08 20.46 ± 3.49 3090.000 .022*
142.94 ± 14.92 131.92 ± 19.29 2526.500 .000*
%
*p < .05.
Table 3. Mean Total Health Promotion Lifestyle Profile Scale-II and Dimension Scores. Health Promotion Lifestyle Profile Scale-II dimensions Health responsibility Exercise Nutrition Spiritual growth Interpersonal relations Stress management Total
X ± SD
Minimum
Maximum
21.35 ± 4.29 17.04 ± 4.50 21.04 ± 3.77 27.40 ± 4.20 26.15 ± 4.21 20.68 ± 3.46 133.68 ± 19.07
10.00 8.00 11.00 12.00 14.00 11.00 83.00
35.00 32.00 34.00 36.00 36.00 30.00 200
than the mean scores of students in other years (20.44 ± 3.41, 20.40 ± 3.23, 21.67 ± 4.39); the difference between mean scores was determined to be statistically significant (p < .05; see Table 1). It was determined that the mean interpersonal
relations score of students with a high-economic status (27.28 ± 3.91) was significantly higher than those students with medium- (26.07 ± 4.23) and low-economic (24.30 ± 4.15) statuses (p < .05). Furthermore, the total mean score (142.94 ± 14.92), health responsibility (23.46 ± 4.03), exercise (19.02 ± 4.78), nutrition (22.28 ± 3.31), spiritual growth (29.15 ± 3.19), and stress management (21.84 ± 3.08) subscale scores of students regularly going for health checks were determined to be significantly higher than the scores of those who did not go (respectively, 132.12 ± 19.42, 21.01 ± 4.23, 16.73 ± 4.39, 20.81 ± 3.85, 27.08 ± 4.31, and 20.47 ± 3.52; p < .05; see Table 2).
Discussion Given the increasing emphasis placed on health promotion, nurses have important roles to play as health educators and
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Polat et al. as role models. This study shows that some are better placed than others in terms of demonstrating healthy lifestyle behaviors. Positive health behaviors are associated with higher HPLP-II scores; the highest possible score is 208. In this study, the mean score was 133.68 ± 19.97. It can be seen that the healthy lifestyle behaviors of students included within this study are at a medium level. This result is similar to those obtained from other studies conducted in Turkey (Ayaz et al., 2005; Çelik et al., 2009; Kocaakman et al., 2010; Yılmazel et al., 2013). Similarly, Wittayapun, Tanasirirug, Butsripoom, and Ekpanyaskul (2010) indicated that nursing students in Thailand practiced health-promoting behaviors at a moderate level. The reason for this is considered to be the positive effect of the nursing education process on the students’ health behaviors. In studies conducted by Alpar et al. (2008) and Gözüm and Tezel (2000), it was reported that, in Turkey, the healthy lifestyle behaviors of nursing students after nursing education were better than they had been before; nursing education has a positive impact on healthy lifestyle behaviors (Ayaz et al., 2005; Gözüm & Tezel, 2000; Mooney et al., 2011). In our study, mean HPLP-II scores for spiritual growth were higher, and those for exercise were lower than other subscales. Al-Khawaldeh (2014) reported similar results after surveying university students in Jordan. In Iran, RezaeiAdaryani Morteza and Rezaei-Adaryani Mina (2012) noted that medical nursing and allied health students had low scores for exercise. In Turkey, Yılmazel et al. (2013) and İlhan, Batmaz, and Akhan (2010) reported that nursing students’ exercise scores were lower than in any other subscale. In Thailand, Wittayapun et al. (2010) found that exercise scores were lower among nursing students; nutrition and stress management were also low. Physical activity was the lowest practice followed by nutrition and stress management among health-promoting lifestyle behaviors of nursing students. Exercise and proper nutrition protect individuals from deadly chronic diseases and from problems that may develop as a result of these diseases. They are key elements in reducing the harmful effects of chronic diseases such as heart disease, stroke, cancer, and diabetes. Unhealthy behaviors create burdens for individuals, their families, and the health economy as they increase health care costs (Abu-Moghli, Khalaf, & Barghoti, 2010). The effects of regular exercise have been suggested in many studies (Clement, Jankowski, Bouchard, Perreault, & Lepagei, 2002; Kamwendo, Faresjo, Gustavsson, & Jansson, 2000; Pawloski & Davidson, 2003). It has many positive effects on weight control, cardiovascular diseases, some cancers, obesity prevention, mental health, self-esteem, and body image. However, in our study, only 34.7% of students engaged in regular exercise; their mean exercise scores were low. This may be due to lack of appropriate facilities. In studies conducted in the United States, Canada, Sweden, and England, it was reported that a majority of nursing students did not
engage in regular exercise and had tendencies toward low activity (Callaghan, 1999; Clement et al., 2002; Kamwendo et al., 2000; Pawloski & Davidson, 2003). While students’ scores on the health responsibility, nutritional habits, spiritual growth, and stress-management subscales of the HPLP-II did not differ significantly by gender, males scored better than females on the physical exercise subscale. This result is consistent with previous studies, which have shown that male students are more active than female students are (Al-Kandari, Vidal, & Thomas, 2008; Al-Khawaldeh, 2014; Lee & Loke, 2005). However, female students scored better than male students did in spiritual growth. Several other studies support these results (Bothmer & Fridlund, 2005; Can et al., 2008; Johnson, 2005). In Quattrin, Zanini, Zamolo, and Brusaferro’s (2010) study, 87.2% of nursing students stated that they were satisfied with their health condition, 70.5% stated that they had a normal body mass index, 62% stated that they smoked, and 75.2% stated that they drank alcohol at least once in their life. The investigators reported that, even though nursing students perceived their health to be good, they had low physical activity levels and demonstrated unhealthy behaviors such as smoking and drinking alcohol. In our study, the number of students smoking and drinking alcohol was low, and the majority had a normal body mass index. A survey at a regional college for health care professions in 2008 and 2013 showed that being overweight, physical inactivity, smoking, and alcohol consumption were quite common among nursing students (Lehmann, von Lindeman, Klewer, & Kugler, 2014). Approximately 40% of the surveyed 259 female nursing students were smokers, 40% were alcohol consumers, and 20% were overweight or obese (Lehmann et al., 2014). Furthermore, our study determined that the mean total and mean health responsibility, exercise, nutrition, and self-actualization scores of students aged 22 years and older were significantly high. These findings are similar to those of other studies. In Turkey, Kocaakman et al. (2010) reported that the mean self-actualization, health responsibility, and interpersonal support scores of students in the 22 to 25 years age group were higher than those of students in the 17 to 21 years age group. Other studies of university students in Turkey have shown that, as age increases, so do HPLP-II scores in their mean HPLP-II health responsibility, exercise, and nutrition subscale scores (Yıldırım, 2005; Zaybak & Fadıloğlu, 2004). In our study, the health responsibility, nutrition, and stress management scores of students in the fourth year were determined to be significantly high. However, Alpar et al. (2008) found that health behavior changes over time from the beginning of professional education until graduation. Ayaz et al. (2005) reported similar findings and that health responsibility scores increased significantly throughout nursing education. Karadeniz, Yanıkkerem Uçum, Dedeli, and Karaağaç (2008) noted high health responsibility scores among fourth-year students. Cihangiroğlu and Deveci (2011) also determined
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Journal of Transcultural Nursing 27(4)
that health responsibility and interpersonal support scores increased as age increased; the health responsibility mean scores of third- and fourth-year students were significantly higher than the mean scores of first- and second-year students. In addition, the nutrition habit scores of nonsmokers were higher compared with those of smokers. It has been reported that persons with a low-socioeconomic status, constituting a considerable proportion of society, are as disadvantaged with respect to health means, as they are in all areas. Thus, this group is at risk for developing chronic diseases that may have an adverse impact on life quality (Ayaz et al., 2005). The fact that positive social and economic factors have a positive impact on the healthrelated behaviors of individuals has also been verified by studies (Cihangiroğlu & Deveci, 2011). Most of the students in our study had social insurance, and it was determined that the mean interpersonal relations scores of students with a high-economic status were significantly higher compared with those of students of medium-and low-economic status. Ulla Díez and Pérez-Fortis (2010) argued that economic status influenced interpersonal relations. İlhan et al. (2010) identified a relationship between economic status and several HPLP-II subscales. Higher scores for spiritual growth, exercise, and interpersonal relations were related to higher economic status and vice versa. In our study, a significant difference was found between the mean total and mean health responsibility, spiritual growth, and interpersonal relations subscale scores of students with and without a diagnosed long-term health problem. Ayaz et al. (2005) reported that the health responsibility scores of students with long-term health problems needing monitoring and treatment were higher than those who did not have such problems.
Conclusion In conclusion, our study found that a proportion of nursing students are at risk for chronic diseases, and that their mean total HPLP-II score is at a medium level. The findings suggest that interventions are needed to enhance practicing health-promoting behaviors. It is important to take into consideration influential factors in the promotion of healthy lifestyle behaviors, such as the formation of training programs for nursing students and the distribution of these training programs over all years of education. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
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