Self-efficacy and health promotion behaviors of older adults in Iran
Main Article Content
Increasing healthy behaviors is the major challenge facing health professionals and populations globally. Our purpose in this study was to ascertain if a relationship exists between self-efficacy and health promotion behaviors in a sample of older Iranian adults. The organizing framework for the study was Pender’s (1996) revised Health Promotion Model. The study participants were 102 community-dwelling old people residing in Yazd district. The results supported Pender’s Health Promotion Model in which self-efficacy accounted for 58% of variance in health promotion behaviors. Health promotion behaviors were found to be correlated with level of education. Additionally, there were associations between self-efficacy and gender, marital status, and level of education. It was concluded that interventions aimed at improving self-efficacy may improve health promotion behaviors of older adults.
Health promotion is receiving ever-increasing attention regarding the prominent role it plays in health care. The high costs in health care have necessitated a shift in the emphasis of care to the prevention of disease, rather than strictly the treatment of disease (Adams, Bowden, Humphrey, & McAdams, 2000). Historically, the relationship between health promotion and disease prevention has been the focus of study by nurses and other health professionals. However, since the late 1980s, when public attention focused more readily on health promotion, the demand has risen for information to explain the factors that motivate people to seek their health potential (Pender, 1996; Pender, Murdaugh, & Parsons, 2002).
Studies over the last two decades have shown that old people practice a variety of health promotion activities in varying degrees (Pender, 1996; Potts, Hurwicz, Goldstein, & Berkanovic, 1992; Riffle, Yoho, & Sams, 1989; Strawbridge, Camacho, Cohen, & Kaplan, 1993). Health promotion activities benefit old people by preventing or controlling health problems, decreasing disabilities, lowering health care costs, and enhancing a sense of well-being (Frenn, 1996; Kaufman, 1996; Strawbridge et al., 1993). The identification of variables that influence old people to practice health promotion activities should facilitate the planning and provision of interventions to achieve these goals. There is a growing consensus that self-efficacy is among the most important and modifiable predictors of health promotion behaviors (Acton, 2002; Becker, Stuifbergen, Ingalsbe, & Sands, 1989; Bottorff, Johnson, Ranter, & Hayduk, 1996; Duffy, 1997; Shong, Shong, & Yeom, 2002). Research concerning the relationship between self-efficacy and health promotion behaviors using Pender’s theoretical framework is limited. Most recent researchers have focused on self-efficacy and specific health promotion behaviors such as exercise, but there is also evidence that self-efficacy influences other aspects of health promotion behaviors. Gillis (1993) reviewed the research literature from 1983 to 1991 and concentrated on the determinants of a health-promoting lifestyle. Self-efficacy, social support, perceived benefits, self-concepts, perceived barriers, and health definitions were found to be the strongest predictors of health-promoting behaviors. Self- efficacy was found to be the strongest predictor of a health-promoting lifestyle for Hispanics, African Americans, and Caucasians in a study by Weitzel and Waller (1990). Adults with disabilities were more likely to engage in a health- promoting lifestyle if perceived self-efficacy was present (Stuifbergen & Becker, 1994). Grembowski et al. (1993) found that older adults with high self-efficacy had a lower health risk in all behaviors, and better health. The results in Clark and Nothwehr’s (1999) study showed that exercise self-efficacy scores were greater among persons with a current exercise habit, no pain or fear of shortness of breath with exercise, and good self-rated health. Resnick, Palmer, Jenkins, and Spellbring (2000) examined the effect of age, sex, and mental and physical health on self-efficacy and the effect of all these variables on exercise behavior. The results in their study supported all hypotheses. Shin, Jang, and Pender (2001) found that exercise self-efficacy was significantly correlated with gender, education, regular exercise, and frequency of exercise. The findings of Wu and Pender (2005) suggest that gender, social support, modeling, self-efficacy, and perceived benefits and barriers to performing physical activity directly and indirectly influence the behavior of physical activity in Taiwanese adolescents. The effects of self-efficacy and social support on the mental health of 65 members of a mutual-aid organization in Hong Kong were examined by Cheung and Sun (2000). Results in that study showed that residualized self-efficacy was a strong predictor of the mental-health variables and effects of functional and structural social support were mainly mediated by self-efficacy.
Our purpose in this study was to ascertain if a relationship exists between self- efficacy and health promotion behaviors of older adults in Iran as a developing country. In addition, a review of the literature showed that there is not a history of reliable research concerning health promotion behaviors and self-efficacy in Iran.
The following research questions guided the study:
Is there a relationship between self-efficacy and health promotion behaviors of older adults?
Is there a relationship between self-efficacy and spiritual growth, health responsibility, nutrition, physical activity, stress management, and inter- personal relations
of older adults?
Is there a relationship between demographic variables of age, gender, marital status, and education level and self-efficacy and health promotion behaviors of older adults?
Method
Organizing Framework
The organizing framework for the study was Pender’s Health Promotion Model (HPM; 1996). The HPM was developed to provide a framework for predicting health promotion behaviors. The model seeks to explain individual characteristics and experiences as well as how behavior-specific cognition and affect influence these behavioral outcomes (Pender et al., 2002).
As a central concept of Bandura’s social-learning theory (Bandura, 1986), self- efficacy refers to individuals’ assessment of their effectiveness or competency to perform a specific behavior successfully. It is concerned not with the skill one has but with judgments of what one can do with whatever skills one possesses. Judgment of personal efficacy is distinguished from outcome expectations. Perceived self-efficacy is a judgment of one’s abilities to accomplish a certain level of performance, whereas an outcome expectation is a judgment of the likely consequences (e.g., benefits, costs) such behavior will produce. Perceptions of skill and competence in a particular domain motivate individuals to engage in those behaviors in which they excel. Feeling efficacious and skilled in one’s performance is likely to encourage one to engage in the target behavior more frequently than is feeling inept and unskilled. Pender et al. (2002) reported that of the HPM studies reviewed, 86% provided support for the importance of self- efficacy as a determinant of health-promoting behavior.
Design
We used an ex-post facto correlational design. A power analysis was performed to determine a sufficient sample size in order to reduce the possibility of a type II error. The minimum acceptable power for a correlational study is 0.80 (Burns & Grove, 1997). We set the alpha at .05, so the present study required a sample size of 100 study participants to have a power level of .80 (Marascuilo & Serlin, 1988).
For the study, health promotion behaviors were defined as a measurement of a positive state that an older person pursues in regard to spiritual growth, health responsibility, nutrition, physical activity, stress management, and interpersonal relations as measured using the Health-Promoting Lifestyle Profile II (Walker, Sechrist, & Pender 1995). Self-efficacy refers to individuals’ assessment of their effectiveness or competency to perform the health promotion behaviors successfully. It was measured using a modified version of the Self-rated Abilities for Health Practices Scale (SRAFHPS; Becker, Stuifbergen, Oh, & Hall, 1993). Older adults were defined as individuals aged 65 years and above. The study participants were obtained by cluster sampling from 20 urban health care centers in the city of Yazd in central Iran of older adults who were living in their own homes. Participation in the study was voluntary.
Instruments
The survey instruments consisted of a demographic data form, HPLP II, and SRAFHPS. The demographic data form was used to gather information about the study participant’s age, sex, educational level, and marital status.
The HPLP II is a 52-item, summated behavior rating scale that uses a 4-point response format (1 = never, 2 = sometimes, 3 = often, 4 = routinely). It consists of six subscales, which are intended to measure major components of a healthy lifestyle: health responsibility (nine items), physical activity (eight items), nutrition (nine items), interpersonal relations (nine items), spiritual growth (nine items) and stress management (eight items). The mean can be derived for each subscale separately, or a mean can be obtained on the total instrument as a measure of overall health-promoting behaviors. Walker et al. (1995) reported Cronbach’s alphas for the English version of the scale as follows: health responsibility (0.86), physical activity (0.85), nutrition (0.80), interpersonal relations (0.87), spiritual growth (0.86), stress management (0.79), and total HPLP II (0.94). The 52-item instrument was translated into Persian. An expert Iranian panel assessed the content validity of the Persian version. The scale was found to be culturally relevant and reliable in a pilot study. In this study, the alpha coefficient for the total HPLP II scale was 0.88, and the subscales ranged from 0.60 to 0.74.
Perceived self-efficacy for health promotion behaviors was measured with a modified version of SRAFHPS, which is used to measure beliefs about one’s abilities to perform health-promoting practices in the areas of nutrition, physical activity, and/or exercise, psychological well-being, and responsibility for health practices. Respondents rate how well they are able to perform each practice, not whether they actually engage in the activity. The 5-point scale ranges from 0 (not at all) to 4 (completely). Ratings for the 28 items are summed to yield a total score (range = 0-112). Internal consistency for the total scale was found to be 0.92. The two-week test- retest reliability was 0.70 (Becker et al., 1993). The 28-item instrument was translated into Persian. Two items were deleted because of cultural irrelevancy. The 5-point scale was changed to a 3-point scale ranging from 1 (not at all) to 3 (completely). All the changes were made based on experts’ suggestions, and the developers of the scale were informed as well. Content validity of the Persian version was assessed by an expert Iranian panel. An alpha coefficient of 0.91 was obtained in the present study. Approvals for the use of the SRAFHPS and HPLP II were obtained prior to use.
Procedures
After approval by the Committee for the Protection of Human Subjects at the Shahid Sadooghi University of Medical Sciences and Health Services in Yazd, two urban health care centers, from 20 were selected with a simple random sampling as selected clusters. In the second stage of sampling, from a starting point of each geographic region of selected urban health care centers, all the eligible old people, 65 years and older, who volunteered to participate in the study were included until the required total number of 102 participants (51 individuals in each region) was reached. Data were collected using a one-time face-to-face private interview. SPSS was used for the purpose of data analysis, which included descriptive statistics, correlations, t tests, and analyses of variance (ANOVAs).
Results
Demographic Analysis
Descriptive statistics were used to analyze the demographic data. The participants were 102 older adults, ranging in age from 65 to 99 years, with a mean age of 71 (SD = 6.27). The demographic data indicated that 66.7% were female; all were Muslim; 67.6% were illiterate, 20.6% had reading and writing ability, 6.9% had primary school education, and 5% had higher than primary school education; and that 54.9% were living with their spouses.
Research Questions
The ranges, means, and standard deviations for self-efficacy and health promotion behaviors variables are shown in Table 1.
Table 1. Ranges, Means, and Standard Deviations for the Self-Efficacy Scale and Overall Health-Promoting Lifestyle Profile II and Subscales
The Pearson product moment correlation coefficient (Pearson r) was used to describe the magnitude and direction of the bivariate associations between SRAFHPS scores and the overall HPLP II and its subscales. There was a statistically significant relationship between self-efficacy and the health promotion behaviors of older adults and also a statistically significant relationship between self-efficacy and all subscales of HPLP II at the 0.01 level. Results are summarized in Table 2.
Table 2. Pearson Correlation Coefficients of Health Promotion Behaviors and Subscales with Self-Efficacy
Moreover, self-efficacy, using the SRAFHPS score was the statistically significant predictor of health promotion behaviors of older adults and accounted for 58% of variance in health promotion behaviors.
t tests and one-way ANOVAs were used to examine the nature of the relationship between self-efficacy and health promotion behaviors of older adults and demographic variables of age, gender, marital status, and level of education. Regarding health promotion behaviors, level of education was the only statistically significant factor. Gender, marital status, and level of education were found to be statistically significant factors in relation to self-efficacy. Results are summarized in Table 3.
Table 3. Means and Standard Deviations for Health Promotion Behaviors and Self-Efficacy of Older Adults by Demographic Variables
Regarding SRAFHPS and level of education a Tukey’s HSD post hoc analysis showed that the significant difference of self-efficacy is related to illiterate participants and those with primary school and higher level of education (p = .007).
Discussion
Self-efficacy was found to be a strong predictor of whether or not an individual engaged in health promotion. These findings are supported in the research literature. Several researchers have identified the positive relationship of self-efficacy and health behaviors (Gillis, 1993; Grembowski et al., 1993).
Pender’s perspective that self-efficacy is directly related to health promotion behaviors was affirmed by this research. In the revised HPM (Pender, 1996), self-efficacy is viewed as a behavioral cognition which increases the likelihood of commitment to a plan of action and therefore, to a health-promoting behavior and actual performance of the behavior. Based on the findings in this study, self-efficacy corroborates one of the basic beliefs proposed by the model.
Education level was one of the factors that showed a statistically significant relationship to health promotion behaviors. The factor of educational preparation was addressed in the research by some other studies with similar results (Adams et al., 2000; Riffle et al., 1989; Shong et al., 2002). Moreover, male old people, old people who were living with their spouses, and old people with a higher level of education reported a higher level of self-efficacy. Some other researchers have reported a higher level of self-efficacy among male subjects (Clark & Nothwehr, 1999; Grembowski et al., 1993; Resnick et al., 2000; Shin et al., 2001), adults who were living with their spouses (Shin et al., 2001), and people with a higher level of education (Shin et al., 2001; Shong et al., 2002).
Conclusion
Our results in this study showed that a relationship existed between self- efficacy and health-promoting behaviors of older adults. The assumption was that by determining if such a relationship exists, further investigation into the elements that enhance self-efficacy could be used as predictors of health promoting behaviors.
There are three additional conclusions that can be drawn from the findings. First, each of the major components of a healthy lifestyle (health responsibility, spiritual growth, nutrition, physical activity, interpersonal relations, and stress management) correlated with self-efficacy. Secondly, self-efficacy and health- promoting behaviors are in relation with level of education. Thirdly, the level of engaging in health-promoting behaviors is low among the old people in the study community.
As a result of the study, it is clear that self-efficacy has a strong relationship with health-promoting behaviors of older adults. Based on this correlation, two implications for health promotion practice are identified: a) Perceived self-efficacy for individuals should be assessed and evaluated with the initial health history; b) Self-efficacy interventions should be included in the overall health promotion plan and complement an individual’s ability to achieve total wellness.
Moreover, evaluation of self-efficacy interventions using qualitative and quantitative research methodologies should be used to validate strategies that health professionals use to promote wellness for their clients.
References
Acton, G. J. (2002). Health-promoting self care in family caregivers. Western Journal of Nursing Research, 24, 73-89.
Adams, M., Bowden, A., Humphrey, D., & McAdams, L. (2000). Social support and health-promotion lifestyle of rural women. Online Journal of Rural Nursing and Health Care, 1 [online only publication].
Bandura, A. (1986). Social function of thought and action: A social cognitive theory. Englewood Cliffs, NJ: Prentice-Hall.
Becker, H., Stuifbergen, A., Ingalsbe, K., & Sands, D. (1989). Health promoting attitudes and behaviors among persons with disabilities. International Journal of Rehabilitation Research, 12, 235-250.
Becker, H., Stuifbergen, A., Oh, H., & Hall, S. (1993). Self-rated abilities for health practices scale: A health self-efficacy measure. Health Values, 17, 42-50.
Bottorff, J. L., Johnson, J. L., Ranter, P. A., & Hayduk, L. A. (1996). The effect of cognitive perceptual factors on health promotion behavior maintenance. Nursing Research, 41, 30-36.
Burns, N., & Grove, S. (1997). The practice of nursing research: Contact, critique and utilization (3rd ed.). Philadelphia, PA: Saunders.
Cheung, S. K., & Sun, Y. K. (2000). Effects of self-efficacy conditions of mutual-aid organization members. Social Behavior and Personality: An international journal, 28, 413-422.
Clark, D. O., & Nothwehr, F. (1999). Exercise self-efficacy and its correlates among socioeconom- ically disadvantaged older adults. Health Education and Behavior, 26, 535-546.
Duffy, M. E. (1997). Determinants of reported health promotion behavior in employed Mexican American women. Health Care Women International, 18, 149-63.
Frenn, M. (1996). Older adults’ experience of health promotion: A theory for nursing practice. Public Health Nursing, 13, 65-71.
Gillis, A. (1993). Determinants of a health-promoting lifestyle: An integrative review. Journal of Advanced Nursing, 18, 345-353.
Grembowski, D., Patrick, D., Diehr, P., Durham, M., Beresford, S. H., Kay, E., & Hecht, J. (1993). Self-efficacy and health behavior among older adults. Journal of Health and Social Behavior, 34, 89-104.
Kaufman, J. E. (1996). Personal definitions of health among elderly people: A link to effective health promotion. Family & Community Health, 19, 58-68.
Marascuilo, L. A., & Serlin, R. C. (1988). Statistical methods for the social and behavioral sciences. New York: Freeman & Company.
Pender, N. (1996). Health promotion in nursing practice (3rd ed.). Stamford, CT: Appleton & Lange.
Pender, N. J., Murdaugh, C. L., & Parsons, M. A. (2002). Health-promotion in nursing practice (4th ed.). Englewood Cliffs, NJ: Prentice-Hall.
Potts, M. K., Hurwicz, M. L., Goldstein, M. S., & Berkanovic, E. (1992). Social support, health-promotive beliefs, and preventive health behaviors among the elderly. Journal of Applied Gerontology, 11, 425-441.
Resnick, B., Palmer, M. H., Jenkins, L. S., & Spellbring, A. M. (2000). Path analysis of efficacy expectations and exercise behavior in older adults. Journal of Advanced Nursing, 31, 1309-1315.
Riffle, K., Yoho, J., & Sams, J. (1989). Health-promoting behaviors, perceived self-efficacy, and self-reported health of Appalachian elderly. Public Health Nursing, 6, 204-211.
Shin, Y. H., Jang, H. J., & Pender, N. J. (2001). Psychometric evaluation of the exercise self-efficacy scale among Korean adults with chronic disease. Research in Nursing and Health, 24, 68-75.
Shong, K. Y., Shong, S., & Yeom, H. A. (2002). Health-promoting behaviors of elderly Koreans in the United States. Public Health Nursing, 19, 294-300.
Strawbridge, W. J., Camacho, T. C., Cohen, R. D., & Kaplan, G. A. (1993). Gender differences in factors associated with change in physical functioning in old age: A 6 year longitudinal study. Gerontologist, 33, 603-609.
Stuifbergen, A. K., & Becker, H. A. (1994). Predictors of health-promoting lifestyle in persons with disabilities. Research in Nursing and Health, 17, 3-13.
Walker, S. N., Sechrist, K. R., & Pender, N. J. (1995). Health-Promoting lifestyle Profile II. University of Nebraska Medical Center, College of Nursing. Omaha, Nebraska. USA.
Weitzel, M., & Waller, P. (1990). Predictive factors for health-promotive behaviors in White, Hispanic, and Black blue-collar workers. Family and Community Health, 13, 23-34.
Wu, T. Y., & Pender, N. J. (2005). A panel study of physical activity in Taiwanese youth. Family and Community Health, 28, 113-124.
Acton, G. J. (2002). Health-promoting self care in family caregivers. Western Journal of Nursing Research, 24, 73-89.
Adams, M., Bowden, A., Humphrey, D., & McAdams, L. (2000). Social support and health-promotion lifestyle of rural women. Online Journal of Rural Nursing and Health Care, 1 [online only publication].
Bandura, A. (1986). Social function of thought and action: A social cognitive theory. Englewood Cliffs, NJ: Prentice-Hall.
Becker, H., Stuifbergen, A., Ingalsbe, K., & Sands, D. (1989). Health promoting attitudes and behaviors among persons with disabilities. International Journal of Rehabilitation Research, 12, 235-250.
Becker, H., Stuifbergen, A., Oh, H., & Hall, S. (1993). Self-rated abilities for health practices scale: A health self-efficacy measure. Health Values, 17, 42-50.
Bottorff, J. L., Johnson, J. L., Ranter, P. A., & Hayduk, L. A. (1996). The effect of cognitive perceptual factors on health promotion behavior maintenance. Nursing Research, 41, 30-36.
Burns, N., & Grove, S. (1997). The practice of nursing research: Contact, critique and utilization (3rd ed.). Philadelphia, PA: Saunders.
Cheung, S. K., & Sun, Y. K. (2000). Effects of self-efficacy conditions of mutual-aid organization members. Social Behavior and Personality: An international journal, 28, 413-422.
Clark, D. O., & Nothwehr, F. (1999). Exercise self-efficacy and its correlates among socioeconom- ically disadvantaged older adults. Health Education and Behavior, 26, 535-546.
Duffy, M. E. (1997). Determinants of reported health promotion behavior in employed Mexican American women. Health Care Women International, 18, 149-63.
Frenn, M. (1996). Older adults’ experience of health promotion: A theory for nursing practice. Public Health Nursing, 13, 65-71.
Gillis, A. (1993). Determinants of a health-promoting lifestyle: An integrative review. Journal of Advanced Nursing, 18, 345-353.
Grembowski, D., Patrick, D., Diehr, P., Durham, M., Beresford, S. H., Kay, E., & Hecht, J. (1993). Self-efficacy and health behavior among older adults. Journal of Health and Social Behavior, 34, 89-104.
Kaufman, J. E. (1996). Personal definitions of health among elderly people: A link to effective health promotion. Family & Community Health, 19, 58-68.
Marascuilo, L. A., & Serlin, R. C. (1988). Statistical methods for the social and behavioral sciences. New York: Freeman & Company.
Pender, N. (1996). Health promotion in nursing practice (3rd ed.). Stamford, CT: Appleton & Lange.
Pender, N. J., Murdaugh, C. L., & Parsons, M. A. (2002). Health-promotion in nursing practice (4th ed.). Englewood Cliffs, NJ: Prentice-Hall.
Potts, M. K., Hurwicz, M. L., Goldstein, M. S., & Berkanovic, E. (1992). Social support, health-promotive beliefs, and preventive health behaviors among the elderly. Journal of Applied Gerontology, 11, 425-441.
Resnick, B., Palmer, M. H., Jenkins, L. S., & Spellbring, A. M. (2000). Path analysis of efficacy expectations and exercise behavior in older adults. Journal of Advanced Nursing, 31, 1309-1315.
Riffle, K., Yoho, J., & Sams, J. (1989). Health-promoting behaviors, perceived self-efficacy, and self-reported health of Appalachian elderly. Public Health Nursing, 6, 204-211.
Shin, Y. H., Jang, H. J., & Pender, N. J. (2001). Psychometric evaluation of the exercise self-efficacy scale among Korean adults with chronic disease. Research in Nursing and Health, 24, 68-75.
Shong, K. Y., Shong, S., & Yeom, H. A. (2002). Health-promoting behaviors of elderly Koreans in the United States. Public Health Nursing, 19, 294-300.
Strawbridge, W. J., Camacho, T. C., Cohen, R. D., & Kaplan, G. A. (1993). Gender differences in factors associated with change in physical functioning in old age: A 6 year longitudinal study. Gerontologist, 33, 603-609.
Stuifbergen, A. K., & Becker, H. A. (1994). Predictors of health-promoting lifestyle in persons with disabilities. Research in Nursing and Health, 17, 3-13.
Walker, S. N., Sechrist, K. R., & Pender, N. J. (1995). Health-Promoting lifestyle Profile II. University of Nebraska Medical Center, College of Nursing. Omaha, Nebraska. USA.
Weitzel, M., & Waller, P. (1990). Predictive factors for health-promotive behaviors in White, Hispanic, and Black blue-collar workers. Family and Community Health, 13, 23-34.
Wu, T. Y., & Pender, N. J. (2005). A panel study of physical activity in Taiwanese youth. Family and Community Health, 28, 113-124.
Table 1. Ranges, Means, and Standard Deviations for the Self-Efficacy Scale and Overall Health-Promoting Lifestyle Profile II and Subscales
Table 2. Pearson Correlation Coefficients of Health Promotion Behaviors and Subscales with Self-Efficacy
Table 3. Means and Standard Deviations for Health Promotion Behaviors and Self-Efficacy of Older Adults by Demographic Variables
Appreciation is due anonymous reviewers.
Mohammad ali Morowatisharifabad, Health Education Department, Tarbiat Modares University, Tehran, Iran. Email: [email protected]