Adolescence is a period of growth and development bridging childhood and adulthood. The physical and emotional changes in this period influence behaviors that affect health (Yannakoulia, Karayiannis, Terzidou, Kokkevi, & Sidossis, 2004) in that adolescence is a time of risk taking and experimentation (Dowdell & Santucci, 2003). It is also a critical period, because lifestyle patterns for health behaviors are frequently tested and/or acquired during adolescence (Dowdell & Santucci; Yannakoulia et al.).

Researchers have shown that adolescents experiment with cigarette smoking and substance abuse, are not very physically active often become obese, and many have insufficient sexual knowledge (Alikasifoglu et al., 2002; Çimen & Savaşer, 2003; Geçkil & Yıldız, 2006; Ege, Akın, & Altuntuğ, 2008). Smoking rates have been found to vary from 13% to 35% among Turkish high school students (Alikasifoglu et al., 2002; Geçkil & Yıldız, 2006; Kara, Hatun, Aydoğan, Babaoğlu, & Gökalp, 2003). International researchers have also shown that adolescents behave in ways that pose risks for their continuing good health in such areas as substance abuse, violence, sexuality, nutrition, and physical activity (Dowda, Ainsworth, Addy, Saunders, & Riner, 2001; Michael & Ben-Zur, 2007; Ruangkanchanasetr, Plitponkarnpim, Hetrakul, & Kongsakon, 2005; Yannakoulia et al., 2004). Health risk behaviors of adolescents have been found to be associated with age, grade, perceived health status, and perceived school performance (De Bruijn, Kremers, van Mechelen, & Brug, 2005; Ruangkanchanasetr et al., 2005; Yorulmaz, Aktürk, Dağdeviren & Dalkiliç, 2002).

Self-esteem is considered to be one of the variables with the greatest potential for inhibitory or promotional influence on health behaviors (De Bruijn et al., 2005; Yarcheski, Mahon, & Yarcheski, 1997). Torres, Fernández, and Maceira (1995) found significant positive correlations between general health behaviors and self-esteem in both 12 to 13 and 16 to 17 year olds. Källestål, Dahlgren, and Stenlund (2006) found a relationship between self-esteem and tooth-brushing behavior during adolescence. Yorulmaz et al. (2002) described how self-esteem is an important factor that affects the behaviors of adolescents.

Mortality and morbidity during childhood and adolescence can result from health risk behaviors. The objective in this study was to examine the relationship between the health risk behaviors and self-esteem levels of adolescents in Adıyaman, Turkey.

Method

Participants

This descriptive study was conducted during April and May 2006 in Adıyaman, which is located in southeastern Turkey. The sample size was calculated by using the formula [n = Nt²σ²/d² (N–1) + t²σ²] (Sümbüloğlu & Sümbüloğlu, 2002). N = the total population of high school students in Adıyaman and this was 14,307, t = 1.96 for 95% of students the confidence level, σ = 8 standard deviation of previous study (Çimen & Savaşer, 2003) and d = 0.5 the deviation from ± mean. The sample was composed of 1,361 adolescents (655 girls and 706 boys), aged from 14 to 19 years. Participants were randomly selected from 9th to 11th grade students attending five high schools.

Legal Ethical Consent

Ethical permission for the study was obtained prior to collecting data, by contacting and receiving approval from the education directorships of the province and district involved.

Procedure

The data were collected by the authors using the Health Risk Behaviors Scale (HRBS; Çimen & Savaşer, 2003), the Rosenberg Self-Esteem Scale (SES; Rosenberg, 1965), and a questionnaire that included nine questions concerning independent variables of age, gender, school, perceived school performance, and perceived health status.

Health Risk Behaviors

Çimen and Savaşer (2003) developed the Health Risk Behaviors Scale for adolescents aged between 15 and 18, and the scale has been determined to be valid and reliable. The HRBS consists of five subscales: psychosocial − 10 items (such as approaches to problem solving, communication skills, and relationships with peers or family), nutrition − 11 items (such as having breakfast regularly, number of meals consume per day, and consumption of vegetables, fruits, or meats), physical activity − 4 items (such as walking, cycling, and taking part in team sports), hygiene − 5 items (such as bathing, washing hands, and brushing teeth), and substance abuse − 5 items (such as smoking, episodic drinking, and addictive drug use). These 35 items are rated on a 5-point scale (1 = never, 5 = always) summed to form a total scale and converted to a percentage. A higher score indicates a greater health risk. Çimen and Savaşer found that the Cronbach’s alpha for this scale was .86. The Cronbach’s alpha for the sample in this study was .69.

Self-Esteem

Self-esteem was measured using the Turkish version (Çuhadaroğlu, 1985; Uyanık Balat & Akman, 2004) of the Rosenberg Self-Esteem Scale (Rosenberg, 1965). Cronbach’s alpha coefficient for this scale was found to be between .77 and .88 (Rosenberg; Uyanık Balat & Akman), and it was .77 for the sample in this study. A 4-point scale (strongly disagree to strongly agree) was used for the 10 items and the range of scores possible is from 1 to 40. High scores indicate high self-esteem.

Statistical Analysis

Health risk behaviors and self-esteem were chosen as the dependent variables, and gender, age, school performance, and perceived health status as the independent variables of this study. Independent samples t test was used for analysis of the relationships. One-way analysis of variance (ANOVA) was used to analyze the association between dependent and other variables. The relationship between health risk behaviors and self-esteem was analyzed using the Pearson correlation test. Self-esteem was dichotomized into a measure of low (below median) self-esteem as performed by Nelson and Gordon-Larsen (2006). A level of p < .05 was considered statistically significant.

Results

Demographic characteristics of the adolescents are shown in Table 1. The mean HRBS total score for the group from a possible 100 was 43.0 (SD = 6.7). The highest scores were on the physical activity subscale. In other words, the most risk behaviors of the adolescents occurred in the area of physical activity. According to the results nutrition, psychosocial, hygiene, and substance abuse were other areas of risk. The mean of the SES scores from a possible score of 40 was 29.0 (SD = 4.4).

Males’ total HRBS scores were higher than females’ scores. Males had more risk behaviors than did females in psychosocial, hygiene, and substance abuse subscales than females. Females took more risks than males did in the areas of nutrition and physical activity. No statistical difference was found between the SES scores of males and females (see Table 2).

Scores gained on the HRBS for adolescents aged between 17 and 19 years were higher than the scores of adolescents aged between 14 and 16 years. The SES scores for both groups were not statically different (see Table 3).

An inverse correlation between health risk behaviors and perceived health status was found. Adolescents’ total HRBS scores decreased as perceived health status improved. However, there was a correlation between perceived health status and SES scores of adolescents.

There was also a significant correlation between health risk behaviors and school performance. Adolescents whose school performance was poor had the highest total HRBS scores. As school performance improved, SES scores also increased.

Adolescents with lower self-esteem had more health risk behaviors. Their total HRBS scores and scores for all subscales were higher than were those for adolescents with medium or high self-esteem (Table 4). There was also a significant inverse correlation between adolescents’ total HRBS scores and their SES scores (r = -.30, p < .001).

Discussion

Health Risk Behaviors and Related Factors

The most prevalent health risk behavior in adolescents was lack of physical activity. In this study we found that the females were less physically active than males. These findings support those of previous studies (Çimen & Savaşer, 2003; Nelson & Gordon-Larsen, 2006; Yannakoulia et al., 2004; Young et al., 2007). These data provide evidence of the adolescents not being involved in physical activity to any great extent, particularly females. It is obvious that involvement in organized activity during high school would be beneficial. It is necessary to create various physical activity opportunities for all adolescents, especially for females.

Secondly, risk behaviors of adolescents were common in the nutrition area in our study. The literature also indicates that eating food that is not nutritious (junk food) is a problem for all adolescents (Neumark-Sztainer, Paxton, Hannan, Haines, & Story, 2006; Özmen, Çetinkaya, Ergin, Şen, & Erbay, 2007; Phongsavan et al., 2005). We found that females experienced more risk behaviors in nutrition than did males. Some other researchers have gained similar results (Neumark-Sztainer et al., 2006; Özmen et al., 2007; Phongsavan et al., 2005; Yannakoulia et al., 2004).

Another problem prevalent among adolescents was risky psychosocial behaviors, followed by hygiene and substance abuse problems. We found that males in this study showed more health risk behaviors than females did in psychosocial, hygiene, and substance abuse areas. Similarly, in many studies it has been reported that males were at greater risk for substance abuse, hygiene, and psychosocial behaviors (Çimen & Savaşer, 2003; Erci, 1999; Kara et al., 2003; Källestål et al., 2006; Ruangkanchanasetr et al., 2005). We found that the adolescents in this study who were performing well at school had fewer health risk behaviors than did poor school performers. This finding is consistent with the literature (Källestål et al., 2006; Ruangkanchanasetr et al., 2005; Yorulmaz et al., 2002). As we expected the adolescents who perceived their health status as excellent had fewer health risk behaviors. These findings are consistent with previous studies in which relationships between healthy behaviors and school performance or perceived health were found (Çimen & Savaşer, 2003; Källestål et al., 2006; Ruangkanchanasetr et al., 2005; Yarcheski et al., 1997; Yorulma, et al., 2002).

Self-Esteem and Related Factors

No relationship was found in this study between self-esteem and age. This result is similar to that of Yarcheski and Mahon (1989). We also found no significant difference between the SES scores of males and females and this finding is supported by the findings of some other researchers (e.g., Uyanık Balat & Akman, 2004; Yarcheski et al., 1997).

The Association Between Health Risk Behaviors and Self-Esteem

We found an important relationship between self-esteem and health risk behaviors of the adolescents in this study. Those whose self esteem was lower got higher scores for behaviors that were a risk to their health and there was a significant inverse correlation between total HRBS scores and SES scores. Various researchers have also previously found that there was a significant relationship between health behaviors and self-esteem of adolescents (Källestål et al., 2006; Neumark-Sztainer et al., 2006; Ruangkanchanasetr et al., 2005; Yarcheski et al., 1997). It is important to strengthen the self-esteem of adolescents to reduce their risk health behaviors.

The greatest risk of behaviors that would be injurious to good health to these adolescents was related to physical activity and nutrition, along with health risk behaviors associated with gender, poor self-esteem, poor school performance, and older age. In the light of these findings we believe that developing social, educational, and sports programs to improve health behaviors in the areas of physical activity and nutrition would be advantageous, especially for females. For males, the focus should be on decreasing risk behaviors related to psychosocial, hygiene, and substance abuse. The knowledge obtained from the present study may be useful for health professionals and teachers developing health promotion programs for adolescents.

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Appreciation is due to reviewers including

Mehmet Top

Hacettepe University

Ankara

Turkey

Email

[email protected]

Belgin Akin

Selcuk University

Konya

[email protected]">[email protected]

Emine Geçkil, School of Health, Adiyaman University, Adiyaman 02040, Turkey. Phone: +90 416 223-3003; Fax: +90 416 223-3005; Email: [email protected]