Factors Affecting Health-promoting Behaviors in Nursing Students of ...

Journal of Public Health, May-August 2010 Vol. 40 No. 2Factors Affecting Health-promoting Behaviorsin Nursing Students of the Faculty of Nursing,Srinakharinwirot University, ThailandYuwadee Wittayapun* Viroj Tanasirirug**Benjamaporn Butsripoom*** Chatchai Ekpanyaskul****ABSTRACTThis research was a cross-sectional study aimed to a) examine the relationships between studylevel, monthly income, perceived benefits of action, perceived barriers to action, perceivedself-efficacy, and health-promoting behaviors, and b) explore factors affecting health-promoting behaviorsof nursing students. An accidental sampling was used to sample 323 nursing students in the secondsemester of the Academic Year 2009 of the Faculty of Nursing, Srinakharinwirot University, Thailand.Data collection was employed on September 2009 using a self-administered scale developed by researchersand guided by Pender’s health promotion model. Descriptive statistics (i.e., percentage, mean andstandard deviation) and analytic statistics (i.e., One-way ANOVA, Pearson’s product moment correlationcoefficients, and Stepwise multiple regression analysis) were utilized to analyze data.The finding revealed that most of participants were first year nursing students (30.0%) andreceived a monthly income of 3,000-6,000 baht (87.3%). The sample practiced health-promotingbehaviors at a moderate level. The participants with differences of study level had different healthpromotingbehaviors (p < 0.01). The perceived self-efficacy and perceived benefits held statisticallysignificant positive relationships with health-promoting behaviors (p-value < 0.001); whereas perceivedbarriers had a negative relationship (p-value < 0.001). The statistically significant predictor of healthpromotingbehaviors was perceived self-efficacy, accounting for 79.0% of the variance in healthpromotingbehaviors of nursing students (p-value < 0.001).The findings suggest that interventions are needed to enhance practicing health promotingbehaviors. Tailored interventions should emphasize increasing perceived self-efficacy and perceivedbenefits as well as decreasing perceived barriers particularly in the first and third year nursing students.Key words: health-promoting behaviors, nursing students, perceived self-efficacyJ Public Health 2010; 40(2): 215-225.Correspondence: Lecturer Dr. Yuwadee Wittayapun. Department of Community Health Nursing, Faculty of Nursing,Srinakharinwirot University, 63 Moo 7 Rangsit-Nakhon Nayok Road, Ongkharak District, Nakhon NayokProvince 26120 Thailand* Department of Community Health Nursing, Faculty of Nursing, Srinakharinwirot University** Department of Social Medicine, Suratthani Hospital*** Department of Nursing, Faculty of Medicine Ramathibodi Hospital, Mahidol University**** Faculty of Medicine, Srinakharinwirot University

216 «“√ “√ “∏“√≥ ÿ¢»“ µ√åIntroductionThe new paradigm of health indicatesthat health is the responsibility of all individualsand societies, since the determinants of health donot depend soley on medical and public healthservices but on several factors, including personaland environmental factors. Accordingly, the newpublic health approach increasingly emphasizeshealth promotion that places importance onbuilding public health policy, creating supportiveenvironments, strengthening community action,reorienting health services, and developingpersonal skills, including giving individuals’opportunity to learn skills of self-care and livingwith health-promoting behaviors. 1-3Pender and colleagues 4 indicatedthat health-promoting behaviors are a part of dailyactivities of life that impact individual happiness,values, and well-being. Health-promotingbehaviors comprise six components includinghealth responsibility, physical activity, nutrition,interpersonal relations, spiritual growth, and stressmanagement. Increasing evidence indicates thatif individuals can practice properly and routinely,it would result in better health and life style. 4According to Pender’s health promotion model,current health personnel give more attentionassessing individual characteristics andexperiences (e.g., personal factors), behaviorspecificcognitions and affects (e.g., perceivedbenefits of health-promoting behaviors, perceivedbarriers to practicing health-promoting behaviors,and perceived self-efficacy), and behavioraloutcome (e.g., health-promoting behaviors andphysical activities). In light of that, they candevelop plan, implement, or evaluate healthpromotion programs to be conducted or alreadycarried out in tangible ways. 4-8Nursing students of the Faculty ofNursing, Srinakharinwirot Univertisy, who willbecome health care professionals when theygraduate, not only have responsibilities withthe potential to influence the conditionsaffecting the health of others, but they also havean opportunity to be role models of good practicein relation to health promotion. 9 Accordingly,protecting health and promoting the well-beingof nursing students is determined as one keyelement of health-promoting universities/faculties. Hence, this study aimed to examine therelationships between personal factors, perceivedbenefits of action, perceived barriers to action andperceived self-efficacy in practicing healthpromotingbehaviors, and health-promotingbehaviors in nursing students attending the Facultyof Nursing, Srinakharinwirot University. Also, thedeterminants of health-promoting behaviors wereexplored. The profile from this study would serveas baseline data to further develop health promotionprograms in accordance with health promotionneeds of nursing students. In addition, it wouldbenefit the Faculty of Nursing, SrinakharinwirotUniversity to reach the goal of being a healthyfaculty. Furthermore, the findings resulting fromthis study would be supporting evidence of thetheoretical constructs of Pender’s health promotionmodel.MethodologyThis study design employed a crosssectionalsurvey. The population of this studytotaled 373 nursing students attending the secondsemester of Academic Year 2009 of the Facultyof Nursing, Srinakharinwirot University, NakhonNayok Province, Thailand. An accidental sampleincluded 367 nursing students, who were availableand willing to participate in this study. The researchinstruments used were developed by theresearchers, guided by Pender’s health promotionmodel 4 , Health-Promoting Lifestyle Profile

ªï∑’Ë 40 ©∫—∫∑’Ë 2 ª√–®”‡¥◊Õπ情¿“§¡- ‘ßÀ“§¡ 2553 217II 10-11 , and literature review 5 , and designed as aself-administered scale including five subscales:Personal Factors Subscale (PFS)included structured questions of study level andstudent monthly income. Perceived Benefits ofAction Subscale (PBAS), Perceived Barriers toAction Subscale (PbAS), and Perceived SelfefficacySubscale (PSS) were designed to measureindividual perceptions about benefits, barriersand self-efficacy in practicing health-promotingbehaviors. Health-Promoting Behaviors Subscale(HPBS) measured the practice of health-promotingbehaviors. Each of these (PBAS, PbAS, PSS andHPBS) was composed of a set of 35 items thatassessed six dimensions of a healthy lifestyle:health responsibility (seven items), physicalactivity (four items), nutrition (seven items),interpersonal relations (seven items), spiritualgrowth (six items), and stress management(four items) in parallel. All four subscales werefour-point self-reporting rating scales. The positivestatements were questioned for PBAS, PSS, andHPBS. The statements about existing obstacleswere worded for PbAS. The response options ofthe PBAS and PbAS were strongly agree,moderately agree, moderately disagree, anddisagree; the PSS were high confidence, moderateconfidence, low confidence, and no confidence;and the HPBS were yes or truly met, high partiallymet, low partially met, and no or poorly met. Thescore of response options of each subscale rangedfrom 4 to 1. The content validity of the PBAS,PbAS, PSS, and HPBS was assessed by threeexperts, including two professional experts (twolecturers working in Srinakharinwirot University)and a lay expert (a nurse working in the hospital).Cronbach’s alpha reliability coefficients of thePBAS, PbAS, PSS, and HPBS were 0.93, 0.97,0.93, and 0.92, respectively.This study was reviewed and approvedbased on the Declaration of Helsinki by theInstitutional Review Board of SrinakharinwirotUniversity. The documentary proof of ethicalclearance, number 33/2552, was granted on April23, 2009. All subjects received an oral explanationregarding this research by the principal researcherin their classroom. Nursing students could refuseor withdraw from the study at any time. Codenumbers were assigned to ensure confidentiality.Data collection was carried out in thesubjects’ classroom on September 2009 duringthe second semester of the Academic Year 2009.A total of 367 subjects; who were available andwilling to participate in the study, were asked tocomplete a self-administered scale anonymously.Descriptive statistics including frequency,percentage, standard deviation, skewness andkurtosis was performed to examine the accuracyof data entry, assess basic assumptions, and presentgeneral information about the sample and studiedvariables. As such, the 367 returned questionnaireswere analyzed. Cases extremely out of the normand considered not representative of the samplewere deleted. 12 A total of 323 useablequestionnaires were analyzed and assumptions ofmultivariate analysis were tested.According to the PBAS, PbAS, PSS andHPBS subscale, the rating score of 4, 3, 2, and1 were given to item responses. Obtained scoresof items of each subscale (overall) and eachdimension were summed and divided by the totalnumber of items to compute the mean. The meanwas categorized into four levels: 1.00-1.49 = lowestlevel, 1.50-2.49 = low level, 2.50-3.49 = moderatelevel and 3.50-4.00 = high level. 13The differences of health-promotingbehaviors among different groups of nursingstudents classified by study level were analyzedby One-way ANOVA and Least-SignificantDifference (LSD) test. Pearson’s moment product

218 «“√ “√ “∏“√≥ ÿ¢»“ µ√åcoefficients were carried out to assess therelationships between independent variables andhealth-promoting behaviors. Stepwise multipleregression analysis was used to explore thepredictors of health-promoting behaviors.ResultPersonal factorsThe results showed that most subjects(30.0%) were first year nursing students. The meanscore of monthly income was 4,461.61 baht withthe lowest income 1,000 and the highest income9,000 baht. The majority of subjects (87.3%)received income of 3,000 to 6,000 baht monthly.Perceived benefits, perceived barriers,perceived self-efficacy, and health-promotingbehaviorsThe results revealed that the participantshad overall perceived benefits of action at a highlevel (mean 3.59, SD 0.26) and overall perceivedbarriers to action at a low level (mean 1.50,SD 0.24); whereas overall perceived self-efficacyand practicing health-promoting behaviors wereat moderate levels (mean 3.29, SD 0.31; mean3.22, SD 0.33, respectively). Considering eachdimension of each subscale, subjects had perceivedbenefits for all six dimensions at a high level(mean 3.55 to 3.63); perceived barriers to actionat the lowest level in aspects of interpersonalrelations (mean 1.25, SD 0.26) and spiritual growth(mean 1.32, SD 0.32); and perceived self-efficacyof all aspects at a moderate level (mean 3.04-3.58). For health-promoting behaviors, participantspracticed at a high level only in the dimensionof interpersonal relations. Physical activity wasthe lowest practice (mean 2.94, SD 0.61) followedby nutrition (mean 3.01, SD 0.50) and stressmanagement (mean 3.08, SD 0.48) (Table 1).Table 1Mean and standard deviation (SD) of variablesStudied Perceived Perceived Perceived Health Promotingvariables Benefits of Action Barriers to Action Self-efficacy BehaviorsDimensions Mean SD level Mean SD level Mean SD level Mean SD levelHealth 3.63 0.30 high 1.54 0.30 low 3.29 0.36 moderate 3.20 0.35 moderateresponsibilityPhysical activity 3.56 0.41 high 1.56 0.45 low 3.08 0.59 moderate 2.94 0.61 moderateNutrition 3.56 0.35 high 1.79 0.46 low 3.04 0.47 moderate 3.01 0.50 moderateInterpersonal 3.59 0.33 high 1.25 0.26 lowest 3.58 0.39 moderate 3.60 0.41 highrelationsSpiritual growth 3.61 0.33 high 1.32 0.32 lowest 3.46 0.42 moderate 3.34 0.44 moderateStress 3.55 0.37 high 1.57 0.38 low 3.14 0.48 moderate 3.08 0.48 moderatemanagementOverall 3.59 0.26 high 1.50 0.24 low 3.29 0.31 moderate 3.22 0.33 moderate

ªï∑’Ë 40 ©∫—∫∑’Ë 2 ª√–®”‡¥◊Õπ情¿“§¡- ‘ßÀ“§¡ 2553 219Differences of health-promoting behaviorsamong groups of nursing students classified bystudy levelPracticing health-promoting behaviorsamong first, second, third, and fourth Year studentsor study level groups were statistically significantlydifferent (F = 4.10, p < 0.01). The post-hoc LSDtest for multiple comparisons showed a meandifference of two pairs. The fourth year studentshad significantly higher mean scores of healthpromotingbehaviors than third year (meandifference = 6.51, p < 0.01) and first year students(mean difference = 4.43, p < 0.05) (Table 2).Table 2Differences of health promoting behaviors among groups classified by study level,results from One-way ANOVA analysisSource of variance Sum of df Mean F p-valuesquaressquareGrade or study levelBetween groups 1609.26 3 536.42 4.10 0.007Within groups 41654.84 319 130.57Total 43264.10 322Relationships between independent variablesand health-promoting behaviorsPearson’s correlation coefficientsshowed perceived self-efficacy and perceivedbenefits of action held statistically significantpositive relationships with health-promotingbehaviors (r = 0.889, p < 0.001; r = 0.380, p < 0.001,respectively); whereas perceived barriers held anegative relationship (r = -0.368, p < 0.001). Theperceived self-efficacy had the highest correlationwith health-promoting behaviors followed byperceived benefits of action and perceived barriersto action (Table 3).Table 3Pearson’s correlation coefficients between independent variables and healthpromoting behaviorsIndependent Variables r p-valueMonthly income 0.060 0.294Perceived benefits of action 0.380

220 «“√ “√ “∏“√≥ ÿ¢»“ µ√åFactors affecting health-promoting behaviorsIn multiple regression analysis, a dummyvariable for a variable of study level was created(first year student = 0, second year student = 1,third year student = 2, and fourth year student= 3). Among the five independent variables, theresults of stepwise multiple regression analysisshowed that perceived self-efficacy was the onlypredictor of practicing health-promoting behaviorsof nursing students. With the constant of 4.827,perceived self-efficacy could account for 79.0percent of the variance of health-promotingbehaviors of nursing students with a standard errorof 5.317 (R 2 = 0.790, F = 1209.19, p < 0.001)(Table 4).DiscussionThe findings provided some importantimplications in developing health promotionprograms for nursing students at the Faculty ofNursing, Srinakharinwirot University, though thestudy was limited to generalization due to anaccidental sample.Differences of health-promoting behaviors bypersonal factorsThe findings showed that fourth yearstudents had significantly higher mean scores ofhealth-promoting behaviors than third and firstyear students. This may have resulted fromincreasing individual maturity. Also, fourth yearstudents were enrolled in the course, “CommunityHealth Nursing Practicum” during the time ofdata collection; whereas third year students hadpassed the course, “Health Promotion and IllnessPrevention” in the previous year and first yearstudents did not study any health promotionsubject. The findings suggested that studyexperience regarding health and health promotionaffected the performance of health-promotingbehaviors. In addition, the nursing discipline itselfhas high opportunities for studying, learning, andengaging in health promotion activities. However,participants practiced health-promoting behaviorsat a moderate level. The problem areas werephysical activity, nutrition and stress management.This evidence indicated that the beginning of healthpromotion interventions were desirable for firstand third year nursing students. Also, furtheranalysis or research should investigate the specificproblems related to these groups. Anotherchallenge was determining whether the differencesof health-promoting behaviors between nursingstudents and other students or other populationsexist or not. The importance of study level wasconfirmed by a prior study reporting that as ageincreased, academic staff had higher scores ofhealth-promoting behaviors. 14 However, the otherhas revealed that individuals with differences instudy level or age did not have different healthpromotingbehaviors. 15 The conflicting findingssuggest that nurses have to thoroughly assess healthpromotion needs of their population to determinewhich age or study level groups are high risktarget groups to be dealt with first, second, third,and so on.Income was not found to have astatistically significant relationship with healthpromotingbehaviors. This may be because nursingstudents normally do not have to worry aboutearning money or receiving payment forperforming health-promoting behaviors. In otherwords, monthly income was not an important factoramong the subjects. Though some students hadto earn by themselves or receive financialassistance, the majority of the total income camefrom their parents. The findings were incongruence with previous Thai study revealingthat individuals having different incomes had nosignificant difference in health-promoting

ªï∑’Ë 40 ©∫—∫∑’Ë 2 ª√–®”‡¥◊Õπ情¿“§¡- ‘ßÀ“§¡ 2553 221behaviors. 16 However, the results were contraryto the findings of Kruttanart S 15 who found thatpublic health personnel working in KingChulalongkorn Memorial Hospital with a monthlyincome of 4,001 to 6,000 baht practiced healthpromotingbehaviors more frequently than thosehaving monthly incomes more than 6,000 baht.Relationships between behavior-specificcognitions and affects and health-promotingbehaviorsThe findings showed perceived benefitsof action and perceived self-efficacy heldsignificantly positive relationships with healthpromotingbehaviors. The results suggested thatnursing students with increasing scores ofperceived benefits and perceived self-efficacy hada higher level of practicing health-promotingbehaviors. This evidence supported the conceptthat individual plans to take on certain behaviorsby thinking about the benefits to be obtained andtheir ability to perform. 4 Similar findings werereported in previous study. 17 The perceivedbarriers to action had a negative relationship withhealth-promoting behaviors. The results suggestedthat nursing students with decreasing scores ofperceived barriers had a higher level of practicinghealth-promoting behaviors. The results wereconsistent with previous study. 18The findings in this study were logicalas the subjects were nursing students mostly livingin university dormitories. The university campuslife offers great opportunities to realize benefits,eliminate barriers, and feel confident in practicinghealth-promoting behaviors. For example, subjectshad a university hospital to feel safe and take careof their health, gymnasiums and running trails forphysical activities, many food establishments tomake healthy choices in eating, and friends livingtogether to enhance interpersonal relations. Theyhad opportunities to live and study on campushelping them develop spiritual growth, and studentactivities and associations for relaxation andenhanced interpersonal relations. However,subjects perceived benefits at a high level, andperceived barriers at a low level, so they shouldpractice health-promoting behaviors at a high level,but they just practiced at a moderate level. Thiswas because they perceived self-efficacy at amoderate level. It was earlier noted that perceivedself-efficacy had the highest correlation withhealth-promoting behaviors followed by perceivedbenefits of action and perceived barriers to action.The predictors of dependent variablesThe findings showed perceived selfefficacycould account for 79.0 percent of thevariance of health-promoting behaviors of nursingstudents. The results indicated that perceived selfefficacywas the most important determinant ofpracticing health-promoting behaviors of nursingstudents. The findings confirm the Pender’ssummary of empirical support for constructs inthe health promotion model that the perceivedself-efficacy was the best predictor influencinghealth behaviors. Since perceived self-efficacy isthe judgment of an individual’s capability toaccomplish a certain level of behaviors,consequently, they can execute the givenperformance. 4 The findings were supported byseveral studies. 18-20 For example, Nilrach P et al 19found that perceived self-efficacy, perceivedbarriers and situational influences could accountfor 45.2 percent of the variance in healthpromotingbehaviors among female professionalnurses in Songkhla Province (p < 0.05). PanautaiN et al 17 showed that 62.1 percent of the variancein health-promoting behaviors among the elderlywith chronic illnesses could be explained by theperceived benefits, perceived barriers, social

222 «“√ “√ “∏“√≥ ÿ¢»“ µ√åsupport and perceived self-efficacy (p < 0.001). Inaddition, Srof BJ and Velsor-Friedrich B 20 statedthat all four of Bandura’s sources of self-efficacyexist in Pender’s health promotion model,including prior related behavior as masteryexperience, interpersonal influence as vicariousexperience and social persuasion, and activityrelated affect as affective cues. The suggestionwas made that the researcher should emphasizeinterpersonal influences, particularly withteenagers who may be vulnerable to negativeenvironmental influences.As a predictive study, the findingscontributed additional supporting evidence toPender’s health promotion model (HPM) and gavemore understanding regarding the aspects on whichhealth promotion intervention can be tailored tonursing students of the Faculty of Nursing,Srinakharinwirot University as well as which targetgroup should be the first priority. The findingshave implications for nursing practice, education,and research. As nursing student are expected topractice health-promoting behaviors at high levels,this study showed that nursing students onlypracticed health-promoting behaviors at moderatelevels, especially for physical activity, nutrition,and stress management. Hence, nurse practitionersand educators can take part in dealing withperceived self-efficacy (the best predictor) andperceived benefits as well as perceived barriers(the associated factors) in order to enhancepracticing health-promoting behaviors of nursingstudents particularly for first and third year nursingstudents. For example, preferred exercises,nutrition programs, and stress coping techniquesshould be offered to nursing students. In addition,nurses have to assess health promotion needs inthe population under their responsibility in orderto identify high risk groups, encourage specificoutcome determination, and tailor specific healthpromotion activities. Moreover, other aspects orfactors of health promotion needs should beexplored by different methods, designs, settings,populations or other factors. The emphasis shouldbe given to prior related behavior, activity relatedaffect, interpersonal, and situational influences,considered the four sources of self-efficacy, thebest predictor. Furthermore, according to theOttawa Charter, further interventions and researchshould go beyond the scope of individuals towardpolicy, community, environment and health careservices. A good example would be bringing theconcept of healthy faculties or universities to trackthe development of health promotion to nursingstudents and their assets.AcknowledgementThis research was funded by the 2009Faculty Income, Faculty of Nursing, SrinakharinwirotUniversity (Contract No. 158/2009).The researchers would like to express their sinceregratitude to Associate Professor SasithornWannapong, Dean of the Faculty of Nursing,Srinakharinwirot University, for her support inconducting research.References1. World Health Organization, Health andWelfare Canada, Canadian Public HealthAssociation. Ottawa charter for healthpromotion. In an international conferenceon health promotion: The move towards anew public health, November 17-21, 1986,Ottawa, Ontario, Canada. Available athttp://www.phac-aspc.gc.ca/ph-sp/phdd/pdf/charter.pdf, accessed Oct 14,2009.

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