Impact of the health risk appraisal process on health behaviors and beliefs of college freshmen


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Impact of the health risk appraisal process on health behaviors and beliefs of college freshmen
Physical Description:
ix, 204 leaves : ill. ; 28 cm.
Stiles, Claire Ann
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Subjects / Keywords:
Health behavior   ( lcsh )
Health attitudes   ( lcsh )
College freshmen -- Health and hygiene   ( lcsh )
Counselor Education thesis Ph. D
Dissertations, Academic -- Counselor Education -- UF
bibliography   ( marcgt )
non-fiction   ( marcgt )


Thesis (Ph. D.)--University of Florida, 1987.
Bibliography: leaves 181-202.
Statement of Responsibility:
by Claire Ann Stiles.
General Note:
General Note:

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University of Florida
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All applicable rights reserved by the source institution and holding location.
Resource Identifier:
aleph - 000968168
oclc - 17374197
notis - AEU3378
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Full Text







Copyright 1987


Claire Ann Stiles

To Pearl and Charles Schmidt,

my beloved parents,

whose love, faith, and humanitarian ideals have been

a constant source of strength and inspiration for me


The support of many beautiful people has made the

completion of this dissertation possibi

Without their

help and encouragement, it could not have been done.

extend my

sincere gratitude to Dr

. Peggy Fong-Beyette

for her expert guidance and special efforts to meet with me

whenever I could travel to Gainesville and, most of all, for

the time and assistance she so generously gave to me.

Without her friendship and support, I would have lost my


I also want to express my thanks to my other committee


, Dr

. Jim Pitt

and Dr

. Owen Holyoak, who provided


suggestions, critical comments, and their own

unique perspectives which enhanced my work on thi


To my Gainesville friends and colleagues Shari Miller,

Jean Boardman, Janet Renuart, Marj and Bruce Cuthbert, Linda

Thornton, and Larry Gage, I extend my special thanks for

keeping my spirits up during the hard times and sharing the

agony and ecstacy of this experience with me.


are also due to the Eckerd College students who

participated in thi

research and to th

resident advisors,

$ cl-.. ,, I r 1 ri- n ,n cA c m i n i c n w \n

l_* UIr A 1\ IA .A I "^ t



I would

especially like to thank administrators,

Lloyd Chapin, Mark Smith, Kathy Watson, and Molly Ransbury;

faculty members, Peg Malchon, Sarah Dean,

McDowell, Nancy Carter

Tom West, Barry

, and Howard Carter; staff members,

Eleanor Pugh and Myrtle Coursin; and students, Kathy

Gallagher, Clint Ferrara, Kim Leeper, Steve Pisano, Dawn

Smith, and Joni Smith for an abundance of


distance and

support throughout the year.

Finally, I cannot fail to thank the network of friends

in St. Petersburg, Florida, whose love, encouragement, and

patience have kept me going through the past five years.

Lastly, words are inadequate to expre

very exceptional people

graduate school experience

my gratitude to two

who have stood by me throughout this

and offered constant support and


My very special thank

are extended to my mother

Pearl Schmidt, and to my friend, Ruth Petti

for their

extraordinary contributions to my work.







. . . . . Viii


Statement of the Problem
Purpose of the Study .
Research Hypotheses .

Importance of the S
Definition of Terms


S. 4 .

Organization of the Study .


Health Behavior and Health Belief
Health Behavior .

Health Belief

Health Behavior Change
Health Risk Appraisal .
Reliability and Validity
Use of Health Risk Appraisal

to Motivat


Health Behavior and Belief

of College
Alcohol and
Cigarette S


Substance Use
making. .

Weight Control .
Sexual Activity. . .
Motor Vehicle and Other Accident

Health Behavior Change
on College Campuses



* 85


4 4 4 4 4 4 4 4 4 4

. - -. Qr;



Health Group One (Health Risk Appraisal
Health Group Two (Health Information). .
Health Group Three (Control) .
struments: Dependent Variables .
Health Behaviors . . .









ptibil ity
acy .

. . . . . .


U1SCUSSlOn . .
Health Behavior. .
Perceived Susceptibility
Perceived Efficacy .
Self-efficacy. . .
Limitations. . .
Conclusions. .
Recommendations. . .



S S S S 5 4 S S S S S S S S S






* S S S
. S
* .
* .






Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the


for the Degree of Doctor of Philosophy



Claire Ann Stiles

August 1987

Chairperson: Margaret L. Fong-Beyette
Major Department: Counselor Education

The purpose of this study was to determine the impact

of the Health Risk Appraisal process on health behaviors and

health belief

health risk level

of college freshmen at average and high

Based in Health Belief Model research,

an underlying assumption of thi

investigation was that

behavior change resulting from the intervention was


to a change in one or more of three beliefs:

(a) perceived susceptibility, (b) perceived efficacy, and

(c) perceived self-efficacy.

A randomized, pretest-posttest control/comparison group

design was used in this study.

The Martin Index of Health

Behavior and three ind


on a Health Belief Questionnaire

were administered to 101 voluntary subjects who were divided

by risk level into two groups and randomly


signed to one

of three treatment conditions:

(a) Health Risk Appraisal


x 2(risk level) factorial analysis of

covariance was employed to analyze the adjusted posttest

means for each of the four dependent variable

Significant differences (p

susceptibility and perceived

< .05) in both perceived

If-efficacy were found among

the thr


The Health Risk Appraisal process group

scored lower in perceived susceptibility and the control

group scored lower in perceived self-efficacy than either of

the other two groups, respectively. Higher risk subjects

reported fewer health behaviors and weaker self-efficacy

beliefs than average risk subject

intercorrelations between variabi


revealed moderate

negative correlations between health behavior and perceived

susceptibility and positive correlations between health

behavior and perceived


Conclusions were that the Health Risk Appraisal process

lowers perceived susceptibility and raises perceived self-

efficacy but has no direct effect on health behaviors of

college freshmen.

Since outcomes further suggest that self-

efficacy may be the key variable in th

actual performance

of health behavior

it was speculated that u

of health

risk appraisal emphasizing participant

abilities to

perform recommended health behaviors to gain immediate and
ef,1tiir nr <1rre wniirl inrran2c adnntinn nf ha lth hahavinrc


Since the early 1900s, chronic disease has gradually

replaced infectious disease as the leading cause of

premature death in America.

Heart disease, cancer, and

cerebrovascular disease claim the greatest number of lives

today, and estimates are that 75% of all deaths are due to

degenerative diseases (Califano, 1979)

In addition to the

increase in mortality caused by chroni


since 1950

deaths due to motor vehicle accidents have also increased

substantially for those under th

age of 40 (P

. R. Harris,

1981), and, within the past five years, Acquired Immune

Deficiency Syndrome (AIDS), an incurabi


infectious disease

proportion, has caused the death of over 15,000


in th

United States (Koop, 1986).

supported by epidemiological, biomedical, and

behavioral research, the 1979 Surgeon General'


stated that a reduction in th


premature death rates and

further improvement in health status would be achieved only

through the promotion of health and prevention of disease

efforts, not through treatment (Califano, 1979)


life-threatening, sexually transmitted disease.

With the

leading causes of death in our country strongly linked to

individual health behavior

, the development of more

effective techniques for motivating changes in lifestyle


essential to lower health risk

and the rising costs

of health care (Matarazzo, 1984).

Although disease or death is not caused by any single

factor (Milsum, 1980a), the contributions of smoking to the

development of lung cancer; of


saturated fat,

cholesterol consumption, and Type A behavior patterns to

heart disease; and of


ive alcohol use and non-use of

seat belts to traffic

fatalities are well documented (Reed,


been a

In a 1



substantial way chronic disease has also

iated with poor

leep patterns, low physical

activity level



high in sodium and sugar and low in

, overweight, and high level

(Mechanic & Cleary, 1980).

etiologic factors in

In fact,

of psychological stress

trong if not major

of the 10 leading cau

of death

among Americans today are related to lifestyle and

individual behaviors (Matarazzo, 1984). Moreover, high risk

sexual practi


and intravenous drug use have been

correlated with death

caused by the AIDS virus (Koop,



mortality patterns of Americans reflect the impact of


As Knowl

(1977) so succinctly stated "over 99

percent of us are born healthy and made sick as a result of

personal misbehavior and environmental conditions" (p. 58).

Earlier public

Public Health

admonitions to change health behavior

service, 1964), the urgency of the


linking behavior to mortality in th



General's Report, and

subsequent governmental publications

have prompted some peopi

who might b


"innovators" and "early adopters" of change to adopt

suggested health behavior

and abandon destructive habits

(Green, Kreuter, Deeds, & Partridge, 1980).

Over the past

15 years mortality from all causes has declined because of

changes in smoking, diet, and exercise pattern

treatment for hypertension (P

. R. Harris, 1981; Oberman,


Estimates are that 30 million American


successfully quit smoking (Schachter

1982) and that this

type of change is attributable to stronger governmental and

professional endorsement of prevention programs and


Apparently, where enough resources are

allocated to raise the level of consciousness about risks to

health, some people

will voluntarily modify their health

c Lk t U


disappointing in our adolescent and young adult


As a result of health-compromising behavior,

such as alcohol and drug abuse and not wearing a seatbelt

while driving, premature death and disability rates are high

among this relatively healthy adolescent population.


decreasing in the general population, smoking "appears to be

on the increa

among some adolescents [primarily females],

alcohol [and drug] abuse has been called an epidemic,

teenage pregnancy rates are on the increa

disproportionate percentage of our youth

, and a


unfit" (Kreuter, Christenson, & Davis, 1983, p. 28).

According to data from the National Center for Health

Statistics (U.S. Public Health Service, 1982), youth aged 15

to 24 years old had a higher death rate in 1977 than they

did in 1960.

Major causes of death were attributed to

accidents (primarily auto accidents), violence, and suicide.

Not only i

current health status jeopardized by

health-compromising behavior

but "there is good evidence

that many of th

causes of death at age 40 ar

the result of

behaviors that were established during the adolescent and

young adult years" (Feeney & Leonardo, 1984. p.270).

In a

landmark study, Belloc and Breslow (1972) found that among


000 adults surveyed in California

seven individual




followed, the better the physical health status experienced.

Over a five-and-a-half year period data also revealed a

clear relationship of lifestyle to mortality; the proportion

of men and women in each age group who died was relatively

smaller for those following mor

practices, i.

of the

seven to eight hours of

seven health

leep, regular

meals, daily breakfast, frequent exercise, moderate alcohol

consumption, no smoking, and maintenance of appropriate body

weight (Breslow & Enstrom, 1980).

Responsible for their own health habits for perhaps

first time, the approximately 12.4 million youth enrolled in

institutions of higher education and post-secondary

technical school

(Department of Education, 1984) are

particularly at risk for developing unhealthy patterns of


The uniqueness

of th

college setting and the

developmental tasks of late adolescence create a challenge

for even the most conscientious and health-minded students.

College students are dealing with the major tasks of

competence, autonomy, identity, interpersonal relationships,

and intimacy (Chickering, 1969).

parated from home and

family for the first time, many students are faced with

pressures to experiment sexually and with mood-altering

subItances achiPev acadPmicallvy commit themsel



compensation for unresolved problems and ineffective coping

can easily result in poor eating habits, lack of adequate

sleep, alcohol/drug abuse, relationship conflicts,


ion, and suicide for a growing number of these young

adults (Falk, 1975).

Though "college students are at risk of failing to

develop adequate solutions to the challenges of independent

living and the increased responsibilities of adulthood"


, 1984, p.509), these young adult year

are also an

ideal time for remolding of patterns.


universities are natural settings in which to influence

current and future health practices of a large segment of

our population.

A unique opportunity, therefore, exists to

affect the future well-being and lifespan of these young

people by helping them to appreciate the importance of

health, to accept individual responsibility for their

behaviors, to develop the knowledge and

kills necessary for

health attainment and maintenance, and to moderate self-

imposed risks (Stuehler & O'Dell, 1979).

Although promoting healthier behaviors among college

students would have positive impact on immediate and long

term health status, the obstaci

rhanna 0 ar nimorn nlc

uch health behavior

Frnm tfh nutcaf t health hphavinr rhannp


Gestalt, individually unique and created over many years

(Milsum, 1980b).

Green et al. (1980) have proposed that

health behaviors are more difficult to change when they are

long established habits and intimately connected to an

individual's lifestyle

and culture; smoking, alcohol use,

and sedentary lifestyles are but a few of our socially

acceptable behavior

which meet the

riteria of difficulty

for change

Initially effortful and lacking in immediate

gratification, the adoption of health behaviors may also

conflict with values of higher priority such as academic

achievement, economic


ial approval, and meeting the


of significant oth


(Mechanic & Cleary,


In a culture where the economy depends upon high

production and consumption, even in the area of medical

care, where instant gratification is expected, and

unrestricted individual freedom at any cost is considered a

right, these value conflicts are inevitable

Furthermore, the link between behavior and di




is not

directly observable

because symptoms of developing chronic

sease are often not diagnosed until several decades after

health-compromising habits begin.

Reasons for change are

therefore not immediately compelling.

The maior obstacle

to behavior change encountered on


peer and environmental press


to engage in unhealthy


rates a real

challenge for health promoters and

educators (Bloom, 1981)


peer norms and expectations

frequently interfere with health behaviors and the taking of

responsibility for one's health status (Cafferata, 1980),

research has shown that young people are unrealistically

optimistic about susceptibility to health problems and that

this optimistic bias undermines interest in risk reduction

(Urberg & Robbins, 1984

Weinstein, 1982

, 1984).

A dilemma

for health prof



on most college campuses is,

therefore, how to motivat

the retention or adoption of

health behaviors despite lack of a felt need and peer

support to the contrary

Over the years college and university campuses have

been the focus of many different health behavior change


For many years health education classes were

the main vehicle for promotion of health-protective

behaviors on college campuses.

By increasing pertinent

health knowledge through structured academic

classes, health

professionals sought to change attitudes, values, and

behaviors of students (Zapka & Love, 1985)


positive associations between health knowledge and action

were reported for those students who took the el



factor in changing health behavior" (Green et al., 1980,

p. 72).

During the 1970s and early 1980

there was widespread

development of extra-curricular health education programs,

such as workshops, seminars, clubs, and self-help groups for

weight-management, smoking cessation, exercise, etc., to

motivate individual behavior change, and, more recently,

wellness and health promotion programs which attempted to

affect not only individual behavior change but institutional

norms and policies

well (Hettler


Again, only

those students with prior interest in health were attracted

to these non-credit program

which frequently conflicted

with other commitments and interests (Zapka & Love, 1985).

A particularly promising health behavior change

strategy, health risk appraisal, has been used in many

health education and promotion programs to motivate the

adoption of health behavior among college students since the

mid-1970s (Hettler

, 1980)

Arising from the prospective

medicine philosophy of Robbins and Hall (1970), health risk

appraisal was originally developed as an instrument for

physicians to use in counseling patients to "promote a

healthy life by preventing death and disability due to

reducible risk" (Milsum, 1980b, p. 125).

Combining a


vulnerability to illness or disability, increasing

awareness of

self-responsibility for health status, and

recommending behavioral

changes to minimi

risks to health.

By using the instrument a person

known risk factors

may be compared with his or her peers in the general

population and an appraised age or risk score over the next

10 years projected.

The appraised age, i.e., age ranking of

an individual based on risk factors, and an achievabi


i.e., age ranking altered by change in lifestyle, are

generally given with recommendations for adaptation of

behaviors conducive to health

A wellness score, i.e., the

total achievabi

death rate divided by the total appraisal

death rate multiplied by 100 points, can also be


"an alternative means of communicating the overall level of

a participant's reducible risk" (Lasco, Moriarty, & Nelson,

1985, p. 64).

Separate risk factor levels for each of the


on (a) U.

top 12 causes of death are also provided.

. mortality data by age, race, and gender



relative risk data from epidemiological studi


data, e.g., amount of smoking and drinking by



(Lasco, 1984), calculations are made concerning

probabilities of death occurring in the next 10 years and

rprliirinn nf ric nnccihl

hv mnHifiratinn nf cncr-ifir

II .



questionnaire has the potential to change health behavior by

first modifying the beliefs which precede or accompany the

initiation of that behavior

According to the original

Health Belief Model, adoption of recommended health


likely when people perceive themselves as

susceptible to illness or accident and the condition as

serious, believe in the efficacy of the behavior to reduce

the threat to health, and


minimal difficulty in

undertaking the action.

In addition, an internal or

external "cue" to take action and a general health

motivation or concern for health are assumed to be necessary

for the initiation of health behavior change.


factors which modify or enable th


beliefs and the

readiness to take action are included in the Health Belief


Information from a health risk appraisal, therefore,

has the potential to heighten perceived susceptibility by

personalizing health risks, to enhance the belief in the

benefits of taking action by showing the lowering of risk

with suggested behavior change, and to decrease barriers to

action by providing resource and referral information to

ist with change.

Additionally, health risk appraisal

information may act as a "cue" or trigger for actual

initiation of previously considered changes.

review of the most current literature.

In a recent survey,

alcohol abuse, smoking, drug abuse, intimate relationships,

and weight control were among the top 12 most serious

problems reported by university students (Henggeler

& Cooper, 1980).

, Sallis,

With an increase in substance use and

sexual activity among this population, the need for health

education and promotion, with an empha

on reduction of

health risks through behavior change, has intensified over

the past decade.

Lester and Leach (1983) reported significant increases

in alcohol use, marijuana use, and sexual activity among

college undergraduates, particularly women. Wi

increase in the drinking age to 21 in most stat


th the recent

, college

are also predicting an increase in alcohol use and

related problems

students drink in uncontrolled settings

or turn to other drugs (Ingall


Even alcohol-

related fatalitie

among 18

- 20 year old individual

not shown a

consistent decrease in states raising th

minimum legal drinking age ("Higher Drinking Age," 1985).

The use of cocaine on college campuses has also


substantially from 2.5% in 1970 to 44% trying

cocaine at least once in 1984 (Greene, 1985)

According to

most health officials, cocaine is more addictive than heroin


In addition to the prevalence of substance use,

researchers have estimated that as many as 1 in 10 college

students suffers from chlamydia, the most prevalent sexually

transmitted disease in the United States (T. J. Meyer,


Less monogamous but more sexually active than the

adult population, college students are at high risk for this

disease and its accompanying symptoms and long-term

complications, including

although the number of c

terility for women.



of AIDS among college

undergraduates is small, this population is at risk for

exposure to the AIDS virus, for the development of Aids

Related Compl

(ARC) or AIDS, and for premature death due

to the invasion of "opportunistic disease

pneumonia, tuberculosis

" such as

ancer, within 5 to 10 years

after graduation (Biemiller, 1987a)

Finally, 1 out of every 20 students

, primarily female

is estimated to be at risk for developing an eating disorder

which commonly begins in the freshmen year when pressures to

achieve and adjust to college life can be overwhelming

(Greene, 1986).

The real extent of this disorder, which has

been linked to weight control and inadequate coping with

stress, is currently unknown, but the effects upon health

status have been well documented.

Foundation survey of 5000 undergraduates at 310

colleges and

universities, 99.4% of the participants responded that good

health was a goal considered very important or fairly

important to them.

In fact, among the 10 goals listed, good

health received the highest percentage of responses for an

important goal to be achieved (Jacobson, 1986).

Despite evidence

of increased need and interest among

undergraduates (Koplik & DeVito, 1986), many of them are

unwilling to attend health promotion programs or register

for health education cl


because of competing demands

and interests, e.g., required course work, studying,

employment, and social activities (McClaran & Sarris, 1985).

Time demands for students prevent many of them from

participating in structured health promotion activities.

Moreover, interest in reducing health risks and achieving

good health status i

often undermined by unrealistic

optimism about susceptibility to illness or accidents

(Weinstein, 1984).

Although the use of health risk appraisal in college

health programs

a motivator of behavior seems justified,

has been well received by the college-age student, and


to be gaining in popularity (Cottrell & St. Pierre,

1983: Petosa. Hvner

. & Melbv. 1986)

. exDerimental research


young adults is not yet persuasive (Kirscht, 1983; Moody &

Moriarty, 1983; Wagner

, Beery, Schoenback, & Graham, 1982).

Researchers investigating the use of health risk

appraisal with college students have reported inconsistent


Wilson, Wingender, Redican, and Hettler (1980)

found no significant differences in health behaviors between

27 undergraduates receiving Risk of Death feedback from the


Assessment Questionnai

and a control group of 62

who did not receive results

freshmen, Nagelberg (1981)

Similarly, in a total sample

tated that there were no

significant differences in health attitudes, values, locus

of control, and enrollment in voluntary intervention

programs among a no-feedback control group, a mail feedback

group, and a peer heath education group after administration

of the Database Acquisition for Student Health


More recently, Chan and Davis (1985) reported a

significant difference in smoking behavior between two

groups of 300 freshmen, one which received a health risk

appraisal with interpretation of results and one which did


At the end of the school year students in the feedback

group were more likely to quit smoking, reduce th

cigarettes, or to not begin smoking.

number of

Authors of two


appraised age or health behaviors between health risk

appraisal and non-health risk appraisal feedback groups


Health risk appraisal research with non-college

populations has been even more supportive of modest

appraised age and behavior changes with health risk

appraisal use (Bartlett, Pegues,

LaDou, Sherwood, & Hughes, 1979


Lauzon, 197

, & Crump, 1983;




a review of this research reveal


variations and inconsistency in research design with most

studies weakened or confounded by

(a) lack of a strong

theoretical model guiding th


b) emphasis on

behavior change as the only dependent variabi


regard for prebehavioral factors, (c) lack of a control

group, (d) use of volunteer subjects, (e) small sample


(f) use of the appraised age from a health risk appraisal as

the dependent variable, and (g) the combining of health risk

appraisal use with other intensive change strategies, e.g.,

individual or small group health counseling sessions, health

education classes, and fitness programs.

The timing of the evaluation has also affected the

results of such studies.

Whether health risk appraisal has

short-term or long-term effects on health behaviors has not


Health risk appraisal was intended to be used

primarily as the first phase in facilitating health behavior

change (Hyner & Melby, 1985).

If it can be shown that

initial behavior change is motivated by health risk

appraisal, then more comprehensive follow-up strategies to


ist participants in the maintenance of that change can be




exploring the effects of health risk

appraisal on health behavior chang

to 12 months after the intervention.

have measured change 3

Considering that th

short-term effects of many health behavior change strategies

and the subsequent relapse of individual

into previous

modes of behavior are well-documented in this field

(Chesney, 1984; Marlatt & Gordon, 1980), any initial

behavior change resulting from health risk appraisal may not

have been maintained over this extended length of time.

the other hand, after long periods of time, causal inference

is not possible

, and assumptions made about the effect of

any strategy on behavior may be highly inaccurate.

timing of an evaluation of treatment outcome

crucial to

results of a study and "must distinguish among the

initial induction of therapeutic change, its generalization

to the natural environment, and its maintenance over time"

of the evaluation is al


Following an

intervention in two recent studies, the immediate increases

in posttest scores measuring perceived susceptibility,

perceived severity, and perceived barriers decayed over a

one-month period of time (Kolbe, 1979;


ero, Kok, & Pruyn,

Since the initial adoption or activation of belief

are addressed in the Health Belief Model, researcher

examining changes in dimensions of the Health Belief Model

after a health risk appraisal intervention have generally

measured change occurring within a month or less of the

intervention to allow enough time for th


of the

beliefs but not time for a diminishment in effect (Cioffi,

1980; Faust, Graves, & Vilnius, 1981).

Any longer term

follow-up would also be measuring the maintenance of beliefs

rather than the initial change or adoption of beliefs.

more immediate belief change can also be used

intervention effectiveness in the

evidence of

hort-term because the

activation of existing health beliefs or changing of beliefs

makes health behavior more likely in the future (Kirscht,


Currently, impact evaluation, i.e., the evaluation of

the immediate effects of a intervention, is the most

practical and necessary method of assessing a health belief


improvements in such programs" (Green et al., 1980, p.136).

By assessing the short-term impact of health risk appraisal

on either health beliefs or behaviors, researcher

data which clarify the next best


tep in a logical sequence

of strategies necessary to


t individual

in initiating,

adhering to, and, eventually, maintaining health behaviors

over the long term.


Innovative and effective short-term

are needed as well as techniques to prevent

relapse (Brownell, 1982)

To plan and implement a program

without determining the immediate impact of health risk

appraisal on health beliefs and/or behaviors may result in

duplication of efforts and a waste of time and resources.

Finally, the characteristics of subjects at different

health risk levels, the interaction of initial risk level

with a health risk appraisal itself, and the subsequent

effect on behavior and belief change has rarely been

directly addressed.

One notable exception was the study by

Cioffi (1980) who reported that low risk individual


appraised age was mor

than two year


than their

chronological age had low anxiety about health, a high

health value, and perception of

health status.

If as above average in

Nevertheless, no changes in health beliefs

were found to be related to the health risk level.


risk appraisal, the present study was designed to determine

whether the Health Risk Appraisal process had any immediate

effect on either the adoption or retention of health

beliefs, i.e., perceived susceptibility to disease or

accident, perceived efficacy of preventive behaviors, and

perceived self-efficacy to perform suggested health

behaviors, and/or the adoption or retention of health


The extent to which risk level of the students

influenced adoption or retention of health beliefs and

behaviors was also explored, i.e., whether the Health Risk

Appraisal process had a differential effect upon the health


and behaviors of high and average risk students.

Research Hypoth


In this study the effects of involvement in a Health

Risk Appraisal process on the health beliefs and behaviors

of high and average health risk college freshmen were


The following hypotheses were tested at the .05

level of significance.

There is no significant difference in adjusted

scores on a health behavior ind



freshmen involved in the

Health Risk Apprai

sal pr


in a health

information session, or in neither


years and can gain a minimal number of years of life

expectancy under th

health risk appraisal system of risk

age calculation, they may be 1



to health risk

appraisal than adults over th

age of 40 (Cottrell & St.

Pierre, 1983; Nagelberg, 1981

afer, 1982).

Dunton and

Rasmussen (1977) also concluded that the amount of positive

behavior change was directly related to the amount of

initial risk identified by a health risk appraisal.

However, despite the assumed relationship between risk level

and subsequent change and the alleged limitations of using

health risk appraisal with healthy young adult


been done to actually


the eff

ects of risk level on

cognitive and behavioral outcomes of health risk appraisal.

As a relatively new strategy for health behavior and

belief change, the immediate impact of health risk appraisal

had not been adequately evaluated, particularly for the

college student population

In addition, it was unknown

whether the impact of health risk appraisal varied on the

basis on the student


evel of risk

Finally, it

was unclear whether health risk appraisal acted to motivate

retention of current health behaviors or beliefs and/or

adoption of additional health behaviors.

Purpose of the


__~~ _



between high and average health risk level

college freshmen.

There is no significant interaction effect of risk

level and treatment on the adjusted scores on a

health behavior index of college freshmen.

There is no significant difference in adjusted

scores on the health beliefs index measuring

perceived susceptibility to illness or accidents


college freshmen involved in the

Health Risk Appraisal process, in a health

information session, or in neither.

There is no significant difference in adjusted

scores on the health beliefs index measuring

perceived susceptibility to illness or accidents

after treatment between high and average health

risk levels of college freshmen.

There is no significant interaction effect of risk

level and treatment on the adjusted scores on the

health beliefs index measuring perceived

susceptibility to illness or accidents of college


There is no significant difference in adjusted

scores on the health beliefs index measuring


Appraisal process, in a health information

session, or in neither.

There is no significant difference in adjusted

scores on the health beliefs index measuring

perceived efficacy of preventive action after

treatment between high and average health risk

levels of college freshmen.

There is no significant interaction effect of risk

level and treatment on the adjusted scores on the

health beliefs index measuring perceived efficacy

of preventive action of college freshmen.

There is no significant difference in adjusted

scores on the health beliefs index measuring

perceived self-efficacy to perform a health

behavior among college freshmen involved in the

Health Risk Appraisal process, in a health


session, or in neither

There is no significant difference in adjusted

scores on th

perceived se

health beliefs index measuring

If-efficacy to perform a health

behavior after treatment between high and average

health risk levels of college freshmen.

There is no significant interaction effect of risk


self-efficacy to perform a health behavior of

college freshmen.

Importance of the Study

The impact of health risk appraisal on college students

is further

larified in this

Belief Model (Becker

, 1974),

tudy based on the Health

self-efficacy theory (Bandura,

1977b), and communication/persuasion theory (Beck & Frankel,


In addition, a contribution is made to the growing

body of literature addressing the effect of this strategy on

health beliefs and behaviors.

investigation ha

Additionally, this

important implications for the development

and delivery of health risk reduction programs in higher

education and for the professional in health counseling.

According to cognitive model

change, prebehavioral change

of health behavior

in knowledge, attitude

values, and perceptions may be predisposing factors to

actual behavior change (Green et al., 1980)


concerning health, particularly beliefs identified as

perceptions of susceptibility to disease or disability,

response or outcome efficacy, and barriers to action,

particularly pers-onal or self-efficacy

be related to and predictiv

have been shown to

of health behavior (Bandura,

1977a; Beck & Frankel, 1981

Janz & Becker




in addition to determining the effect of health risk

appraisal on health behaviors, the impact of health risk

appraisal on health beliefs is also determined.

Despite a continuing need for the development and

evaluation of risk reduction programs, particularly for

places where large populations can be reached over time and

the benefit-to-cost ratios are favorabi



limited resources and budget cuts in higher education make a

reduction in student health and counseling services likely

(Shropshire, Van Ginkle, & Goodale, 1985).

If cost

containment efforts in higher education are not to result in

the virtual

elimination of college health promotion

programs, the most efficient yet least offensive ways of

motivating the retention or adoption of health behaviors by

college students must be identified.

A primary prevention strategy, health risk appraisal,

selectively applied, may be a cost effective method to

reduce the current and future health risks for a large

number of students.

Computerized assessments are typically

"inexpensive, noninvasive, personalized health assessment

tools" (Petosa, Hyner, & Melby, 1986, p. 52) and can be used

with large groups where general risk reduction is the

objective (Neutens & Pursley, 1985)

By determining the


beliefs among college freshmen of different risk levels i


For whom and in what way health risk appraisal is

most effectively utilized is also


Therefore, the

future investment of time and energy in health risk

reduction programming for this young adult population can be

guided more efficiently by the results of this study.

In an era of limited resources and increased demands

for accountability, empirical evaluation of health risk

reduction strategies becomes essential to justify their use.

Although the efficacy of health risk appraisal ha

preliminary support


an approach to stimulate behavior

change (Weiss, 1984), the lack of well-controlled research

designs and a plethora of contradictory results from studies

done on college campuses necessitates continued investment

of time and energy in the development and evaluation of this

risk reduction strategy (Fielding, 1982; Wagner

Schoenbach, & Graham

, Beery,

, 1982).

By further testing th

effectiveness of a widely

adopted health promotion



tudy also

contributes to knowledge utilized by health counseling


whose primary role is to identify health risks

and plan intervention strategies before the onset of illness

or disability (Childe

& Guyton, 1985).

Health counselors


By basing their use of facilitation strategies on

well-designed research, health counselors can have a greater

impact on the health status of their clients.

Results of

this research facilitates increased awareness of the

appropriate applications and potential effects of health

risk appraisal on clients' adoption or retention of health

behaviors and health beliefs.

Definition of Terms

To further one's understanding of the research

hypotheses and methodology used in thi

terms ar

study, the following


College freshmen are students, with 12 semester hours

or 1


of college level work credited toward graduation

requirements, entering a four-year private, protestant

college in the autumn term of 1986.

Health risk appraisal is a general method using a

standardized questionnaire and health status feedback

describing an individual's chances of dying or acquiring

specific disease

usually within a 10-year period of time

(Fielding, 1982).

Health Risk Appraisal process refers to the

administration of the Centers for Disease Control (CDC),

Atlanta, Georgia, Health Risk Appraisal questionnaire,


results, response to questions, advocacy of and


for adoption or retention of health

behaviors, and dissemination of resource and referral

information to assist with voluntary behavior changes (see

Appendix B).

Health information session refers to a group


incorporating advocacy of and recommendations for adoption

or retention of health behaviors and dissemination of

resource and referral information to assist with voluntary

behavior changes.

This session duplicates the Health Risk

Appraisal pr


with the exclusion of the return and

interpretation of the computerized feedback form from the

Health Risk Appraisal questionnaire.

Health risk level is the classification of an

individual as high, average, or low health risk based on the

value obtained by substracting the health risk appraisal

appraised age from the individual's actual age.

Low health risk is a lower than average risk for

disease or accidents within the next 10 years.

In this

study an individual whose appraised age was more than two

years less than his or her actual age is at low health risk.

Average health risk is an average risk for disease and

accidents within the next 10 years.

In thi

study an


High health risk is a greater than average risk for


or accidents in the next 10 years.

In this study an

individual whose appraised age was two or more years greater

than his or her actual age i

Health behavior i

at high health risk.

any behavior performed by a person

to protect, promote, or maintain hi

or her health as

measured by a health behavior questionnaire (




Health beliefs are beliefs identified in the Health

Belief Model concerning susceptibility to disease or

accident, the efficacy of recommended action, and barriers

to suggested action, particularly self-efficacy, as

measured by a health belief questionnaire (see Appendix C).

Organization of the


The remainder of this study is organized into four


The second chapter is a review of literature and

includes discussion of (a) health behavior and belief

theory, (b) strategies of health behavior change, (c) health

risk appraisal as a health behavior and belief change

strategy, (d) health behavior and beliefs of college

students, and (e) health behavior change strategies in

higher education.


Chapter III contains the research

chapter IV incorporates the results of the


In this chapter literature related to the current study

is reviewed in five topical areas:

(a) the nature of health

behavior and the relationship between health behavior and

health beliefs, (b) current approaches to changing health

behavior, (c) health risk appraisal a


a health belief and

change strategy, (d) health behavior and beliefs of


students, and (e)


employed to change


student health behavior

Health Behavior and Health Beliefs

Health Behavior

Although behavior related to health has been described

in elaborate terms, any behavior undertaken to promote

health and to reduce risks to health is simply a health

behavior (Taylor, 1986)

The classic term, preventive

health behavior, has referred primarily to medically

approved and recommended behavior "undertaken by a person

believing himself to be healthy

preventing disease or detecting

(Kasl & Cobb, 1966, p.

, for the purpose of

it in an asymptomatic stage"

The newer phrase, health


protect, promote, or maintain his or her health, whether or

not such behavior is objectively effective toward that end"

(p. 18).

This latter definition included a wide range of

activities believed to promote health, some of which were

not necessarily sanctioned by health care professional

supported by scientific research.

Recently researchers have suggested that "disease

prevention behavior," i.e., behaviors that require the

assistance of a health professional, and "health promotion

behavior, i.e.

contact such as exerci

different entities" (Yoder, Jone

, behaviors not requiring professional

and eating nutritiously, are "two

& Jones, 1985, p. 30) and

that practicing disease prevention does not nece

correlate with practicing health promotion.



established health behaviors, performed automatically

without conscious awareness and partially independent of

reinforcement, have been further delineated as "health

habits" which ar

maintained primarily through practice and

repetition (Hunt, Matarazzo, W


& Gentry, 1979).

Thus health behavior may be multidimensional rather

than unidimensional and the performan

of one type of

behavior may be independent of other health behaviors.
RP~sarrh anrpomnf t n tfh nA nlro an1 ovftont nf tho

Two independent



of health behaviors,


risk behaviors," e.g., driving and pedestrian behavior

personal hygiene, and smoking, and "indirect risk

behaviors," e.g., medical checkups, screening exams,

immunizations, nutrition, and exercise, were found in a

survey of 617 adult

in Illinois by Langlie (1979).

A study

based on 84

interviews of adults in Ohio (Harris & Guten,

1979) revealed that health protective behavior clustered

into five groups:

(a) health practices such as

leep, diet,

weight control, and exerci

(b) safety practices

preventive health care, e.g., medical checkups; (d)

environmental hazard avoidance; and (e) harmful substance


Conversely, in a study of 330 adults, Mechanic

(1979) stated that the 10 dimensions of health behaviors

assessed were only modestly intercorrelated.


combined eight of the dimensions into a single index of

degree of positive health behavior for each subject and drew

the conclusion from an additional analysis that positive

behavior for an adult is part of a comprehensive lifestyle

reflecting the ability to anticipate health problems,

mobilize to meet them, and cope actively (Mechanic & Cleary,


This cnn rnt nf a hrnaH health nrinntatinn nr lifoctvla

1979; Epstein, 1979; Matarazzo, 1984).

Agreement on the

underlying elements of this orientation has not been


Much of the problem in determining the association

among health behaviors ha

been a function of measurement.

Epstein (1979) demonstrated that when measures of a behavior

were averaged over a greater number of events,


coefficients for such behaviors increased to high level

Most researchers have assessed health behaviors on only one

or two occasions and therefore have obtained low


Other problems a


lated with


ing health

behavior are related to the method of attaining data which

has primarily been through


In particular, the

need for social approval has been

strongly a


iated with

general measures of preventive health behavior

In a


measuring this relationship within sample

of the British

public and students at the University of Toronto, Canada (N

= 637), 21 of the 60 correlations between a measure of

health behaviors and the scores on a social desirability

scale were significant, j<.05 (Kristiansen & Harding, 1984).



sment procedures for

socially sensitive health


such as smnkina or alcnhnl uip hav

invnl vpd



The inconsistency of health behavior over time has also

been noted (Mechanic 1979)

With the exception of firmly

established health habits (Hunt et al., 1979), change in

internal and external factors influencing the individual'

behavior has resulted in the modification of the health


This has been most apparent in

studies of

consciously made and highly desired health behavior change

where maintenance rates have been low (Brownell, 1982;

Lichtenstein, 1982; Marlatt & Gordon, 1980; Martin &

Dubbert, 1982)

The fact that health behavior is a highly complex

phenomenon and a function of multiple factors has been

supported by the information from health behavior surveys.

The next step of identifying the factors which influence

health behavior has been of central concern to those in the

health-related professions attempting to assist peopi

the modification of such behavior.

The significance of education, age, income, and

involvement in a social network in predicting health

behavior was revealed in an analysis of a 1979 national

survey of health practices (Gottlieb & Green, 1984).

this study, income, education, and social support were

Dositivelv related and ano was nPnativPIv rPlatPd tn hPalth


For mal

the direct effect of age on health

practices was not significant

The social network elements

of church attendance and marriage were also positively

related to a reduction of alcohol and tobacco u

for both

men and women. Marriage was, however, negatively associated

with exercise in men. Mechanic and Cleary (1980) have also

reported that female gender is positively related to health

behavior and that alcohol use, risk-taking, and a low level

of preventive medical checkups were more common among adult

males than adult femal

An examination of the data on ag

and health behavior

indicated that while


children and adults take

moderately good care of their health, adolescent

and young

adults compromise their health behavior in an attempt to

achieve independent


confirm a personal identity, cope with

rebel against conventional norms, or achieve an

alliance with their peers (Green, 1981).

In the 1980s, a

pattern of heavy alcohol and illicit drug use, cigarette

smoking, and precocious

ual activity h

emerged among

adolescents that is the antith

Equally prevalent for males and femal

is of health behavior

, this problem

behavior may constitute a syndrome or interrelated cluster

of behaviors (Jessor



. Th

occurrence of thi

1 __ w --



increase among adolescents moving from 7th to 12th grades

(Jessor, 1984).

Considering the numerous potential determinants of

health behavior among different age, gender, socioeconomic

status, marital status, and educational level groups,

it is

not surprising that county



have been developed

to explain health behavior

Currently no comprehensive

single model has been widely accepted or consistently

applied in research to meet the criterion of being a

paradigm in this field (Parcel, 1983)

In an attempt to develop a unified framework for

explaining health behavior, Cummings, Becker, and Maile

(1980) asked the model builders to partition a set of 109


from 14 different models into 12


factors emerged:

Using a small

(a) ac

- 14 groups based

est space analysis,. six common

ibility to health service

including cost and availability; (b) attitudes toward

benefits and quality of health care; (c) threat of illness

and beliefs about susceptibility and



(d) social network characteristic

about disease

(e) knowledge

and (f) demographic characteristic



have suggested that the models are not independent

2,l h A "h t + k a i h P t- i f i t t n n i 1 ni-, ^mn^ i,'i 4, n ^1 ^ m ^" n4

Health Beliefs

In the most widely applied approach to th

of health behavior,

1. e.,


the Health Belief Model

(Rosenstock & Kirscht, 1979), health behavior i

consequence of prebehavioral beliefs.

has been applied extensively to the e

based action,

Although this model

explanationn of medically

it has also been applied to the investigation

of other health behavior

e.g., contraceptive behavior

ester & Macrina, 1985), exercise (Slenker

, Price, Roberts,

& Jurs, 1984), and breast



am (Calnan & Moss, 1984).

ince its inception in 1966, the Health Belief Model ha

continued to evolve and currently has a number of variables

in common with many other models, particularly social

learning theory and fear appeal

communication theory.

According to the original Health Belief Model

senstock, 1974),

the likelihood of an individual adopting

a health behavior is a function of four

specific beliefs:

(a) perceived susceptibility to threat of illness or harm,

(b) perceived seriousness of the threat, (c) per


benefits of preventive action, and (d) perceived barriers to


More recent modifications of the model have also

incorporated "cues" to action which bring a health decision

intn rnn'rin 1

awarpnpce a nncifivu h.mlth mntiu.ftinn an



Although many researchers have suggested further


of the model, e.g.

locus of control (Wallston &

Wallston, 1978), health value (Lau, Hartman, & Ware, 1986),

and social support (Langlie, 1977), the original principal

remain the focu

of most research.

Related to psychological theories of decision-making

under conditions of uncertainty, the revised Health Belief

Model is an expectancy-theory approach which views action as

related to a subjective desire

severity and an estimation of benefit

incentive value of any health action i

to lower susceptibility and

minus costs; the

therefore its

ability to lower perceived susceptibility and severity

(Maiman & Becker, 1974)

Thus health behavior becomes more

likely when both the perception of threat or ill health and

the perceived value of the behavior are increased as the

perceived obstacle

to action are reduced (Kirscht, 1974).

Behavior change strategies based on this model tend

primarily to emphasize increasing an individual'


of personal risk, enhancing the belief that change will

ult in the expected outcome of reduced risk, and reducing

the perception of barriers by increasing opportunities for

action, personal health skill

and the individual's

perceived caoabilitv to take aoorooriate action.


for the Health Belief Model from both prospective and

retrospective research and have confirmed the strength of

the Health Belief Model to provide a conceptual basis for

health behavior and its modification.

Research over the


0 year

in the area of health beliefs has continued to

support a high correlation between both perceived

susceptibility to illne

and perceived benefits of taking

action and adopting health behaviors (Shortell, 1984).

However, beliefs concerning perceived barriers and perceived

susceptibility have proven to be the most powerful of the

Health Belief Model dimensions (Janz & Becker, 1984).

In a recent study of exercise behavior, Slenker, Price,

Roberts, and Jur

(1984) reported that 61% of the variance

between the sample

of 124 jogger

and 96 nonexercisers was

accounted for through an analysis

based on eight predictor


of the Health Belief Model

The top three items

on the questionnaire with the high

t correlation to the

criterion variable of jogging vs. nonexercising wer

measurements of barriers.

The authors concluded that the

major factor separating joggers from nonexercisers was

perceived barriers.


in a sample

of 111 college students,

secondary schnnl tPacrhPr and lirpncpd nrartiral nlur~cC thh

effectiveness correspond


pectively to the concepts

perceived costs or barriers and perceived benefit

Health Belief Model.

of the

The fact that students and teachers

were more concerned with effectiveness while nurses were

more concerned with effort also suggested that perhaps

different dimensions of the Health Belief Model were

relevant for different populations in explaining health


The Health Belief Model provides an

explanation for the

impact of the health risk appraisal process on health


By increasing the perceived susceptibility to

disease or accident, i.e., health risk age and probabilities

of death within the next 10 years and the perceived benefits

of health behavior, i.e., increased lifespan and avoidance

of illness, and, at the same time, by decreasing the

barriers to action, i.e., ignorance of effective health

action and the availability of resources, and lack of


confidence, the health risk appraisal process may directly

affect the beliefs which precede health behavior.

Health Behavior Change

"Inconsistencies, unanswered questions, and rapid

development" (Davidson & Davidson, 1980, p. xvi) depict the

icrrPnt 'tata nf thP art nf r cparrh and nrarti

I -

in hpa1th


individual, group, and community level and have included

both passive and active approaches (Williams, 1982).

In the public health domain the passive

approach ha

been successful in reducing potential harm to health with

pasteurization of milk and treatment of water serving as two

good exampi

Even mor

recently federal standards for new

cars manufactured since 1968 resulted in a decrease of an

estimated 9,000 deaths per year of drivers and passengers

(Robertson, 1981)


, the enactment of laws requiring

behavior change has not been

successful as environmental

modification, particularly with behaviors which are not

publically observable.

It has been estimated that only

about 1 in 2,000 individuals driving under the influence of

alcohol are actually arrested for the offense (Robertson,




archers have

continued to

how that

environmental conditions contribute

substantially to chronic

disease and accident rates, most solutions also involve

individual behavior change,


, active strategic

contrast to the passive approach, active strategic


implementation by individuals and have been useful only when

people are influenced through education, mass media


leqal sanctions, and behavior modification


they have been the main targets of intervention and have

spawned a new approach to medical care that is both

behavioral and preventive (Matarazzo, 1984).

The concept of

risk was basically derived from epidemiological

investigation in which incidence rates of a disea

or cause

of death were related to a given factor suspected of

affecting health (Milsum, 1984).

Reducing the risk factors

became a national commitment when the federal government

established 15 health goals which, if attained, were

intended to produce

better health for Americans by 1990

. Harri


Goals under the area of health

promotion included reduction of risk through change in the

targeted behaviors of smoking, alcohol and drug misu

nutrition, physical fitness and exerci

and control of

stress and violent behavior

The difficulty with these and similar behaviors has

been that individual

must be personally motivated to adopt

and maintain health practices over a lifetime if health

risks are to be minimized.

In addition, health behavior,


it threatens the welfare of another, i


behavior and thus change cannot be imposed but must be

motivated through education and persuasion (Green et al



has been behavior change, Green et al. (1980) have suggested

that the

expectation of immediate change in health practices

for the majority of participants has been unrealistic and

nai ve.

One explanation posited for this lack of change has

been related to the nature of the health behavior change


According to Brown (1976), health behavior change

occurs progre

ively and by



She has

proposed that the five

tages organic

n a hierarchical

fashion are (a) awareness of risk to health, (b) acceptance

of information concerning the health risk,

of this information into the

behavior change

(c) integration

self-image, (d) effort toward

, and (e) achievement of behavior change.

This concept of stages in the adoption of a behavior has

grown out of the research in communication, education, and

public health.

Green et al. (1980) have extended the notion of stages

in behavior change in the PRECEDE,


, Predisposing,

, and Enabling Causes in Educational Diagnosis

and Evaluation, model of health education programming

accordance with thi

followed by th

behavior, and th

approach, an initial motivation to act,

deployment of resources to enable the

reaction to the behavior by others act


With the inception of the Health Belief Model this

concept of belief change preceding behavior change has been

widely supported


, the process

of building toward

the threshold of actual initiation of change as explained by

the PRECEDE and

similar model

has not yet been fully

larified (Milsum 1980b).

The concept of

tages and

evidence that the effectiveness of a health behavior change

strategy i

enhanced when a variety of methods are used have

led theorists to suggest that the optimal strategies to

change behavior are dependent not only upon the specific

haracterisitics of the health behavior itself, but also

upon which predisposing belief

and knowledge, enabling

resources and skills, and reinforcing factors,

feedback and social support, are lacking (Green & Lewis,


Only through a thorough assessment of the health

problem and related behavior could the focus of the most

effective intervention be identified.

Another conceptual basis for health behavior change is

found in the persuasive communication research regarding

fear appeal

(Beck & Frankel, 1981)

Although varied

results and marked inconsistency have characterized the

history of research in threatening health communications

Kirtrht 1QR31 ovidpnro

Yitc that holiaf in ridc a nr itc




increased attitude and behavior change occurs under

conditions of

trong threat information.

Exposing 80 adults to on

of four versions of a 13-



communication about periodontal disease,

Beck and Lund (1981) investigated the relationship between

high fear arousal and performing th

prevent the disease.

recommended behavior to

The four messages varied in

seriousness and susceptibility information and, across all

versions, recommended effective oral hygiene procedures to

reduce the health threat. T

the greatest amount of fear,

'he high threat message generated

intention to comply, and actual

compliance with the procedures

in addition, th


found that perceived

self-efficacy in performing the

behavior was the best predictor of the actual behavior.

Although fear may act to focus attention on risks,

earchers have generally confirmed that fear arousal alone

is insufficient for immediate and long term changes (Beck &

Lund, 1981; Leventhal, 1970

Smith, 1982).

Basing their

research on protection motivation theory, Rogers and Mewborn

(1976) demonstrated that for

making, driving

and venereal


increments in the outcome efficacy variable and the

noxiousness variable increased the intentions of 176 college


- *II -I u 11 *|- -

tn drnnt tho rarnmmmnrdI nrartiroc

h nwi\ar




apparently strengthened the intentions to adopt recommended

behaviors whereas lack of control had th

opposite effect.

In a more recent study, Sutton and Eiser (1984)

examined the effects of viewing a highly threatening video

tape on smoking and health risks with a sample

in London.

of 61 adults

Intention to stop smoking was significantly

correlated with high fear arousal and high reported

confidence in the ability to stop smoking.


Three months

self-reported behavior was directly affected by


In integrating existing theoretical approaches in the

fear appeal literature, Beck and Frankel (1981) have

theorized that beliefs concerning personal success in

controlling the threat, i.e., perceived threat control,

appear to be prime factors in determining whether or not

subsequent behavior will be initiated.

It was suggested

that the motivational effect of a health threat

communication depends primarily on two of the recipient'


response efficacy or the perceived ability of the

recommended actions to control the threat (called perceived

benefit of action in the Health Belief Model) and personal

efficacy or perceived ability of a person to perform

recommended actions suc

- .-

fully (called perceived barriers


studies (Beck & Lund, 1981; Rogers, Deckner, & Mewborn,


Another more familiar term for personal efficacy, self-

efficacy, has been associated with social learning theory

(Bandura, 1977b).

Social learning theory supports the view

that behavior is significantly influenced by three

regulatory systems:

antecedent events, consequent events,

and mediational cognitive process

A recent refinement of

social learning theory has focused on the significance of

self-efficacy or personal control in the generalization of

coping behavior (Bandura & Adams, 1977).

The conviction

that one can successfully perform a behavior to produce a

specific outcome ha

been shown to influence the execution

and persistence of behavior and the generalization of the

behavior to other

situations (Wilson, 1980)

In th

original study with adult snake phobics, Bandura (1977a)

extinguished anxiety reactions through desensitization, yet

subjects emerged with varying degrees of



The actual post-treatment performance of

subjects corresponded closely to level of self-efficacy

which was an accurate predictor of performance on 85% of all


In other studi

investigators have shown that the

evel of self-efficacy is


ianificantlv related tn smnkinn


Most behavior change strategic

can be classified as

(a) attitude-change or communication approaches and (b)

behavioral-change or skills training approaches

many are a

combination of the two

Attitude change



primarily been applied in primary prevention effort

encourage the maintenance of health behavior and th

avoidance of risk factors while behavioral-change methods

have been more frequently applied in secondary prevention

efforts to change frequent and complex behaviors (Taylor,


In recent years mass media campaigns have been

advocated as a way to communicate health-related information

and to change health attitudes and behaviors on a large-

scale basi

in the community

An increasing number of


have been made to influence general health, safety,

making, alcohol and drug use, family planning, and medical

heckup behavior via the electronic and print media

(Alcalay, 1983; Flay, DiTecco, &

hlegel, 1980).


"public communication campaigns to induce people to adopt

more healthful lifestyle

(McGuire, 1984, p. 303)

have had only modest success"

, the Stanford Three Community

Project (Meyer, Nash, McAlister, Maccoby, & Farquhar, 1980)

and the North Karplia nrnnram in Finland rl P cc

T 1nmil hfn


One of the largest preventive medicine research efforts

in the United States, the Stanford Three Community study was

a mass media campaign initiated in 1972 to reduce the risks

associated with heart disease in three California


In the first phase residents of two small

communities similar in size and socioeconomic status were

exposed to a three-year massive media campaign to modify

smoking, fat consumption, and exerci

behavior; to increase

knowledge of risk factors; and to alter various physiologic

indicators of risk. Receiving no information, the third

community acted as a control. In addition to the

information received through the electronic and print media,

in one of the experimental communities people at high risk

for heart disease received intensive face-to-face

instruction in behavioral

self-control techniques.

For both

of the experimental communities, a 20% reduction in a total

risk index

i.e., changes in blood pressure, obesity,


esterol level, consumption of fat

and smoking resulted

from the interventions.

The media plus face-to-face

intervention group also maintained a significantly greater

reduction in smoking behavior

In general, it was

discovered that the media alone successfully reduced risk to

a 14 e +ka +lli 44nn l ir NakF i4nnr.

Ph r < /

kn~l-/ avi+ *-


the effectiveness of this study, Kasi (1980) noted that

assessment of the stage of readiness of the target

population for various lifestyle changes and a determination

of the preferred strategy was needed to increase the power

of th

mass media intervention.

A five-year mass media campaign directed at North

Karelia, Finland, a rural community of 180,000 having a very

high incidence of heart di


, also

ulted in a

reduction in the level


of risk factors (Puska et al

A 17% decrease in cardiovascular disease risk for

and an 11.5% decrease for female


A 10-

year followup evaluation showed an even further reduction in

risk level (Puska, 1984).

In contrast to these promising results, television

campaigns promoting the use of seat belts have resulted in

no significant changes in level

of use (Robertson, 1978).


in evaluating th

effectiveness of a series of

public television shows on alcohol u

(1977) found that few peopi

Dickman and Keil

watched the series, and of

those who did, only 40% reported an increased awareness of

alcohol as a personal problem.

A decision to seek treatment

or recommend treatment for another also did not result.

Althnuinh inrnnrllusivp cvi

1I r |

nf mn~a cft i nd a n

have been combined (Maccoby & Alexander, 1980)

How much

change in knowledge, belief, and behavior has been

facilitated by exposure


to a mass media campaign has not yet

clearly determined.

Within the school

setting attempts to influence health

behavior have been through formal instruction in a health

education course.



ion and audiovisual aids

have been used to convey factual information to

adolescents while

children and

peer-group discussions have been held to

encourage peer support for health behavior


computer software has been introduced as a motivational




games, and programmed

instruction mad


increasingly available in health education

(Gold & Duncan, 1980).

school health education classes

impact on the health knowledge, attitude

have had a limited

kills, and

behaviors of children and adolescent


(1977) noted

that health education programs in




abysmal and that the effectiveness of th



reducing overall risk-taking behavior among youth had not

been properly


In a review of several health


studies, Pigg (1983) found that American children

ani' vnunn a2rHln taA nart

1 a r n A r4 FII t k 1 51 k1 6^ 4-

lacked appropriate

self-care education programs.

As a

result of these poorly financed and delivered health

education programs, high school graduates have frequently

exited the formal educational system without adequate health

knowledge or the


and motivation necessary to adopt

health behaviors.

A notable exception has been a skills training approach

to inoculate young adolescents against the peer pressure

which encourage

smoking behavior

Referred to as the

Houston project, Evans, Rozelle, and Mittlemark (1978)

developed a preventive approach by focusing on training

adolescents to be more aware of and to cope actively with

pressures to smoke from peers, adult models, and the media.

Rates of smoking were significantly reduced

n the

experimental school

using this approach.

Botvin, Eng, and

Williams (1980) further refined thi

concept in the life


curriculum for adolescents to build a positive


image, assertiveness and decision-making skill

and coping

strategies to deal with peer pressure to smoke.

Where the focus of health educators and public health


has been on risk reduction in large

populations within the school and community, the focus of

Pffnrt fnr rlinirianc

nhvcirianc anrl h ah2ninr= 1 crian-i e'l-e


described extensively in the literature (Stachnik,

Stoffelmayr, & Hoppe, 1983)

C An emphasis

on individuals,

the assessment of overt target behavior, the antecedents and

consequences of the behavior, and, for cognitive

proponents, accompanying thoughts, belief


and images, has

characterized the behavioral approach to health behavior

modification (Chesney, 1984).

Some specific technique


included reinforcement of desired behavior, contingency

shaping, modeling, stimulus control,

contracting, skill

training, and monitoring of targeted behavior


self-management techniques,




evaluation, self-reinforcement, and


control, have

also received increased attention and have been recommended

as a way to prevent relapse of behavior to pretreatment


, particularly with smoking cessation, exercise, and

weight control behavior (Kanfer, 1980).

For the management of difficult health problems, such

as obesity, smoking, and alcohol use which involve the

acquisition of new behavior and the elimination of undesired

behavior, behavior modification methods have been the most



long-term adherence rates for most

interventions have tended to be low (Kaplan, 1984).

In a

rPviPw nf thp litfrntirQ nn tho opffrtfimnnocc nf cmnLinn


Martin and Dubbert (1982) made the same observations about

behavior related to obesity and exercise respectively.

A major intervention study based primarily upon

behavioral modification strategic

es, the Multiple Risk Factor

Intervention Trial Research Group (1982) involved 1

age 35 to 57 in the upper 10% of the population by

risk factor for heart disease.

During a 5-year study, 6000

of the patients were randomly assigned to a special

intervention program where informational and group


trategies to reduce smoking, change dietary

habits, and increase exercise were used to supplement

traditional treatment for hypertension.

compared at regular interval

These men were

for 7 years to a control group

which only received usual care for risk reduction from

personal physicians.

In comparison to predicted rat

results indicated that for both group

risk factors declined

but to a greater degree for the experimental group.

Although the rate of mortality due to coronary heart disease

between the two groups was not statistically significant,

confounding variable

such as unfavorable reactions to a

hypertension drug and unexpected risk factor reduction among

the control group, were cited


explanations for

- 1 a C A 4 C EC a a n a a j

time consumption of such

major issue concerning maintena

to be addressed and resolved.

trategies have surfaced.

of change has only begun

Whereas communication and

behavioral change strategies have overlapped considerably

and have been applied in many

tors to reduce risks to

health status (Faber, 1980), controversy continue

to exist

about the most effective methods for change and the most

appropriate level of intervention (Creswell, 1985; Kasi,



toffelmayr, & Hoppe, 1983).

Health Risk Appraisal

Health risk appraisal i

basically the computation and

persuasive communication of personal health risks and has

been used with increasing frequency in medical practi


governmental agencies, business and industry, and

educational institutions.

By October 1982,

The Center


Control in Atlanta had disseminated their Health

Risk Appraisal software to 194 agencies and found that the



had been u

(Hargraves, 1

sed most often at the worksite and in

983). In the same year a review of 217

health risk appraisal program

indicated that half were

conducted in the workplace followed by programs located in

public health departments, colleges and universities, and

mPdic alr

rp nrn ani tinn i 7 (W nnar

R rr-l i/ Crknnha 9.


and (c) the efficacy of health behavior to

reduce risk, health risk appraisal ha

individual and group level to motivat

been applied at the

the retention or

adoption of health behavior (Hyner & Melby, 1985)

analysis of family history, personal

self-reported behavior

From an

characteristics, and

health risk appraisal printout

represents a communication about life expectancy which

varies in degree of threat for each individual.

appraisal, however

Health risk

is more than a computer printout; it is

a pr


which ha

a minimum of three components:

intake questionnaire, a risk estimation procedure, and a

written or printed output known as an individual risk


Goetz & McTyre, 1981)

supplementary tool for us

Originally developed as a

by physician

in the practice of

prospective medicine, health risk appraisal was meant to b

combined with an interpretive-educational counseling


where recommendations for risk reduction and assistance with

behavioral change were provided (Hall & Sheedy, 1980).


(1984) has reported that health risk appraisal has

been most effective in motivating behavior change when used

in combination with one or more of the following: (a)

individual or group counseling, (b) education program
nh k t i j V rrn^ ^I AvnA 4rC 4 'n I A^ a Jk -n 4n a / a \

' a


Health hazard or risk appraisal was first tested in

1959 with 25 medical students at Templ

University under the

direction of John Hanlon, M.D., and based on Harvey Geller's

system of probability of death tabi

derived from national

mortality statistics (J. H. Hall & Zwemer, 1979).

From the

use of tables, forms, and instructions to make health risk

estimates ba

sed on th

publication How to Practice

Prospective Medicine by Robbin

and Hall (1970), the health

risk appraisal system has evolved into mass processing of

standardized questionnaires via mainframe

computers and then

into microcomputer-interactive programs (Ellis & Raines,


Within the past 15 years many versions of health risk

appraisal questionnaires hav

been developed.

In an

inventory of 29 representative instruments made by the

National Health Information Clearinghouse in 1980, Fielding

(1982) found great diversity in price, length, scoring,

scope, and population applicability among th

Health risk appraisal


instruments vary in the

extensiveness of the data collected from the participant and

the intended age of use

At one extreme are those

instruments used in clinical settings which include complete

m o i r a hi ctn r hinrl a c kah + kt


continuum are appraisal

that focus only on lifestyle

avoid medical assessments (Wellness check, 1982).

most health risk appraisal


such as the Centers for Disease

Control 1984 version have been developed for adult

populations (Lasco, Moriarty, & Nelson, 1985), a number were

created for adol


ents and college students (Hettler, 1980;

Moody & Moriarty, 1983).

Reliability and Validity

Despite their widespread u

, concerns have been voiced

regarding the accuracy and predictive ability of the

instruments used to




surrounded many of the risk indicators to di


and the

level at which these precursors become hazardous.

Scientific evidence of the risk of dietary c

sodium intake, overweight, and lack of exerc


has remained

in dispute (Hyner & Melby, 1985; Kaplan, 1984; Wagner,

Beery, Schoenbach, & Graham, 1982). Accuracy of the

derivation and method of combining risk factors has been

questioned as well (Goetz, Duff

Schoenbach, Wagner, & Karon, 191

, & Bernstein, 1980;

33). Petosa, Hyner and Melby

(1986) have

suggested that the

combined effect of multiple

risk factors i

synergistic and that, in using an additive

ADDroaChK multinlp rick fa.rntc mai h i nnAriacfimfaMl Tn


Most health risk appraisal instruments are based

on actuarial tabi

from national averages of white, middle-

lass populations; socioeconomic status,

educational level,

geographic region, and ethnic background have not generally

been included (Imrey & Williams, 1977).

average mortality tabi


used to predict future chances of

dying are by nec


ity out of date when projecting

probability of death 10 years into th


These 10-

year projections are also inadequate

35 and over 65.

for participants under

Chronic diseases do not usually appear

until after age 40 and,


the .risk appraisal


of youth ar

likely to show negligible risk to

health of current health-compromising behaviors.


since death i

quite likely for many within 10

years of age 65, th

printout for the aging individual may

be unnecessarily alarming (Brothers, 1981; Safer

, 1982).

The reliability of health risk appraisal instruments

over time was challenged by



clinical trial of 203 adult

recent studies.


In a


Krushat, and Newman (1980) found that only 15% had no

logical inconsistency between the response

on a b



and follow-up health hazard appraisal questionnaire

approximately 85 days after th

e baseline.

Resoonses mnst


(1977) had discovered that of 21 subjects completing a

baseline and follow-up risk appraisal questionnaire 6 months



reported on the average more than one and

a half

changes which the authors concluded probably did not



in reports of past chronic diseases, the

death of parents, and height were but a few of the


ponses found on the second administration of

the appraisal.

Although the apparent lack of reliability of the risk

appraisal questionnaires has

caused som

researchers to



skepticism regarding the use of these instruments

& Pursley, 1985), others have questioned the data

and methodology upon which the estimates wer


McTyre, 1981) and the level of accuracy needed for effective

use of health risk appraisal

Elias and Dunton (1981) have

argued that, although lack of reliability exists in health

risk appraisals instruments, for most age groups reliability

ponses had a small

effect on risk age accuracy.


ption was for the younger participant where

ven a small

unreliability effect in alcohol consumption and mileage

would have a large impact on appraisal age

issues have b


become more of a problem when the health risk

aoorai sal auestionnairP ha

heP n i1cod a c tIho dnonArint



behavior change should interpret results cautiously (Petosa,

Hyner, & Melby, 1986).

Research on the technical characteristics of the health

risk appraisal instruments has been in its infancy (Doerr &

Hutchins, 1981)

Validity and reliability studies have not

kept pace with the proliferation of instrument

which vary

widely in the data and assumption upon which they are


Only recently have researchers addressed the need

to improve the quality of the health risk appraisal

instrument and the data upon which it is based (D. Moriarty,

personal communication, April 23, 1987).

Use of Health Risk Appraisal to Motivate Change

Controlled research studies assessing the efficacy of

health risk appraisal to motivate change are presently only

embryonic in design and have yielded conflicting result

Initial studies with adult populations have been descriptive

in nature or, if experimental, lacked controlled designs.

Although positive attitudinal and behavioral responses to

health risk appraisal are generally reported in these


they lack an adequate basis from which to draw

empirical conclusions.

Included among these early research efforts was the use
nC k .I, r4 e I + In 4 W n ^ +i.^ ^ -


family practice patients in a clinical setting (Bartlett,

Pegues, Shaffer, & Crump, 1983).

In all of these studies

subjects reported either the intention to make recommended

changes or actual health behavior change within 3 to 12

months of

exposure to health risk appraisal.

However, high

experimental mortality and the unreliability of the

behavioral change measure

make it difficult to draw

accurate inferences from these results.

More controlled

clinical studies from which mor

accurate conclusion

can be

made about the effectiveness of health risk appraisal in

motivating adults to change health behavior have been

limited in number

From these some positive trends can be


In a

tudy by Johns (1976), 144 volunteer patients at a

multispecialty medical clinic in Utah completed the

Interhealth Health Risk Appraisal Questionnaire and were

assigned to either an interpretive health


sion with a

physician, an interpretive

or to a control group. Ni


on with a health educator,

nety of the original sample


then retested with the same questionnaire four month


Despite a lack of statistical significance, Johns contended

that in comparison to th

control group who had received no

feedback from their health risk annraical


in tho




a relatively healthy, predominantly Mormon population; and

the length of the follow-up period may have contributed to

the lack of

statistical significance in this investigation

Lauzon (1977) evaluated whether exposure to the Health

Hazard Appraisal/Evalu*vi

stimulated risk-reduction

behavior among

93 federal


in Ontario, Canada.

initial volunteer sample of 346

illness or disability between the ag

randomly assigned to one of the thr

subjects without

of 30 and



5 years was


(b) interpretation only of appraisal results, and

interpretation of appraisal and health counseling by a unit


After 1

weeks, the appraisal and supplementary

questionnaires were readministered.

Although in both

experimental groups th

appraised ag

was reduced,

the risk

appraisal stimulated

significant positive changes only in

alcohol habits, weight, exercise

behavior, breast


and diastolic blood pressure

Minimal or no change was

reported for smoking, seat belt use, systoli

pressure, rectal exams, and Pap smears. Add



health hazard appraisal with counseling was associated with

superior results as

compared to health hazard appraisal

alone regarding alcohol habits, breast

self-exam, and

anoraised aaP.

subjects, among mal

between the ages of 30 and 40 years,

and among femal

between 41 and 55 years.

The health

hazard appraisal was more

effective in motivating change in

male exercise habits among high risk mal

and in seatbelt

usage of females aged 41

- 55 year

Although this research

was a more highly controlled trial than previous studies,

the fact that health hazard appraisal



est and posttest measures again makes th

were used as


ect considering the lack of strong reliability data for

the health hazard appraisal instruments.

Also using a follow-up d

approximately 700 employee

esign with a group of

n California, Rodnick (1982)

found similar positive results using health hazard appraisal

with an hour interpretation


on which included

plantations of extensive lab test

the one-year follow-up, 292 individual

and physical exams.

volunteered for a


A significant reduction in risk age,

i.e. from

.6 years younger than their true age to 2.37 years younger

.001) resulted for men in particular

0 to 24 year

Young men aged

reduced their risk age by 6.5 years

.08), the largest reduction in any age group by gender

Citing the

riticisms of the unreliability of the health

ha7l ar annraical inctrnmonic DA ni! (1009 \ n nFacnA


consistent from the first testing to the second testing


However, no control group,


participants, and a multiple component intervention make it

impossible to interpret these results accurately.

Health risk appraisal studies that have been conducted

with college student populations also contain methodological

problems in health risk appraisal research.

It has been

established that a health education course alone can


behavior and attitude changes.

McClaran and Sarris

(1985) examined the effect

of a 6-week health and lifestyle

course on the health behaviors, attitudes, and knowledge of

85 undergraduate students during the 1982-82 academic year.

For this

self-selected group, 74% of which wer


comparison of pretest and posttest data revealed significant

positive changes in eating behavior, alcohol use, exercise,

and driving behavior

In addition significant changes were

reported for the attitude that one could prevent illness.

A major dilemma in many of the studies has been the

lack of objective assessment instruments and the difficulty

of separating out the effect

of health risk appraisal from

those of an intensive health education course.

In early

studies of health risk appraisal, investigators reported on

r*h caan e *i kis 1A t n .- 4. n ..* -_| in A -* 1 4 La 4 I.

+* k a f* +1 HI /i a rt *(


motivated them to take action (Bensley, 1980; Fenger & Byrd,


Another typical example

is the research by Cottrell and

St. Pierre (1983) who investigated the effect of health risk

appraisal on behavior

change as measured by a questionnaire

developed and validated specifically for their

Participants included 234 undergraduates

health education


enrolled in seven

tions at Pennsylvania State University

in the

spring of 1981

Three sections served as th

experimental group,


health risk appraisal plus health

course; two sections served as the health

lifestyle course only group; and two sections acted as a


During the first and last cl

all students were administered th


of an 11-week semester,


Only students in the health risk appraisal

plus course group completed a Medical Datamation Health Risk

Appraisal qu


In the fifth class, print-out

were returned to students, explained in great detail, and

utilized in conjunction with discussion of each health risk

factor in subsequent cla


Throughout the semester both

experimental groups received instruction in the relationship

rC 1 n fl n r 1 +. l1 -- 4 i. C un. .aa L 1 L L Lt-



two experimental groups; however, there were no significant


between the health risk appraisal plu

course and lifestyle

itself was an intensive

course alone groups.

exploration of lifestyle


the cour

and risks,

virtually duplicating the information supplied by the health

risk appraisal questionnaire,

it was not surprising that the

health behaviors of the two experimental groups were not

significantly different.

A more effective comparison would

have been to


the differences in health behaviors of


exposed to the health risk appraisal procedure

alone with those exposed to a course.

In previous

studies, Fultz (1977), M. B. Hall (1979),

and Chenoweth (1981) had also reported similar changes in

attitude, knowledge, or health behavior for interventions

combining health education classes with health risk


Again whether exposure to health risk appraisal

by itself would have resulted in the

ame changes as

exposure to health risk appraisal within the context of the

health education course cannot be determined from these


In the few studied


ing the effect of health risk

appraisal alone on college student health behaviors,

researchers havP rPnnrtpd nn

innifirant differ anre in


i.e., smoking (Chan & Davis, 1985).

Clearly the problems

associated with research designs with the college student

population and the limited number of controlled

studies have

made it difficult to a


the utility of health risk

appraisal in altering health behaviors.

Recently interest ha

risk appraisal on health belief

developed in the effect of health

Using the Health Belief

Model, Cioffi (1980) studied the issue of what makes health

risk appraisal work by evaluating the effect

of the health

risk appraisal message or printout on the health beliefs of

97 Blue Cross employees in Georgia.

in accordance with recommended

research, Cioffi measured th

Creating an instrument

standards for health belief

effects of health risk

appraisal feedback within a 30-minute interpretive


and feedback via printed material alone on beliefs about

susceptibility to disea


of preventive health

behaviors, and general health motivation one month after the

health risk appraisal feedback.

feedback prior to post-testing.

A control group received no

In addition, Cioffi

examined the association between belief change and (a)


of risk for a specific di


and (b) discrepancy of

information received with pre-existing perceptions of

e ,lenln44 K 4144.

1* f *

I~ %* t I II *I I I IVII l5r rrn I*~n 1 i I f~I* IA r Ifl Lrn l y n nn.9 .

L .^ I f r t B t tJ^ <

were significant differences

ociated with discrepancy of

susceptibility views and susceptibility belief



Despite the lack of


effect on

beliefs, the author intimated that the possibility of a

subsequent effect on behavior should not be

1imi nated.

Although health beliefs have been shown to be predictive of

health behavior

, the failure to change health beliefs does


the p

iblity of a change in behavior

(Becker, 1974)

One additional finding of interest from

this study was that the construct "motivation to control"

measured by the Health Locus of Control

Wallston, Kaplan, & Maid


1976), best delineated the high

and low risk groups.

Building upon the previous research, Faust, Graves, and

Vilnius (1981) studied the effects of three different health

hazard appraisal

on perceived susceptibility to disease,

perceived efficacy of action to prevent heart attacks, and

knowledge of risk factors.

Eleven Blue Cross and Blue

Shield offices in Michigan were allocated to three groups.

Out of the 247 eligible employees, 18

volunteered to

participate in this study and an additional 75 employees

were used as control

snrciallv dlpinnpd fnr thi

A Health and Attitude Survey

nrni0rtf Iwa arminictrrlA n all


Centers for Disease Control version.

One week after receipt

of the report, participants were retested to as


the more

immediate impact of the risk appraisal on beliefs

perceived susceptibility to disease nor perceived



of action to prevent heart attacks was significantly changed

one week after exposure to printed feedback from either of

three health risk appraisal

The one exception was an

increased belief in the benefits of exercise, weight

control, and medical checkups to prevent heart attack.

Although Faust et al.

questioned th

(1981) and Cioffi (1980) have

impact of health risk appraisal on two

specific health beliefs, more research studies with

different populations, timing of measurement, and

interpretive protocol ar

necessary before it can be stated

with any degree of certainty that health risk appraisal does

or does not change belief

The effectiveness of health risk appraisal needs to be



sed, particularly in relation to more immediate

belief and behavior changes. More e

needed to evaluate the impact of thi

empirical eviden

strategy on different

age groups and in various settings (Milsum, 1980b)

goal of the current

tudy was to further explore the

ralatinrnchin ho t waan l" a 1 + reL' 5 ^iel ,


Health Behavior and Beliefs of College Students

In the contemporary Western life cycle, the year

between 17 and


have been regarded as a transitional

Levinson (1978) has designated this period as the

"early adult transition" in which individuals leave

childhood behind and form an adult lif


college years have been conceptual

zed a

a mini-life cycle

in which certain psychosocial task

confront students as

they progr


through their four-year college experience

(Blimling & Miltenberger, 1984; Medalie, 1981)



previously described these developmental

tasks which

hare many principal

developing autonomy, id

and purpose (Chickering



in common,

interpersonal relationships,

Knefelkamp, 1981; Prince,

Miller, & Winston, 1977).

As college students explore

different identity options, confront constant change

decision points, and develop new relationships,


interests, rapid shifts in behavior can be expected.

Astin (1977) ha

Is, and


pointed out, health behavior has been no


It ha

been shown in recent surveys that health

enhancing behaviors not only decrease

college experience but that freshmen

1 I S a a a *

e during the four-year

students are entering

r rn nL nl a l.1 I r v j n a n I S -. -


^ ^ 1

for many college students.

Over thi

time period, Astin

(1977) noted that drinking of alcohol


increased from 27% to

making increased by 10%, and taking vitamins declined

by 9% in the

ohorts that were freshmen in 1969.


than average increases in drinking, smoking, gambling,

staying up all night, and oversleeping were found among men,

Roman Catholics, and student

well-educated families, livi

who were highly able, from

ng in a dormitory, members of a

sorority or fraternity, or attending a larger institution.

Smaller increases occurred among women, older students, and

religious students.

Finally, while

increases in

making were particularly great among younger students,

blacks, dormitory residents, fraternity and



, and drinkers, drinking was more likely to increase

among men, Catholics, younger students, and smokers.

In more current research an increase in pre-college

alcohol and marijuana use

, sexual activity, and femal

smoking behavior has been reported (P

. R. Harris, 1981

Lester & Leach, 1983)


in a survey of 1,203


in grades 4 to 11 in two


from the north

central United States, unhealthy food

particularly among mal

out-of-s~hnnl aPrnhi


es, and a low participation rates in
artivitv wcro ronnrtnrl (oDnrr



Schalit, 1985), national norms for all freshmen in the fall

of 1985 indicated that 9.1% had smoked cigarettes (11.3%


, 6.6% mal

es), 66.5% had drunk beer, and 74.3% had

stayed up all night during the past year

approximately 50% rated them


Lives above average in

emotional and physical health.

A lifestyle of increased health compromising behaviors

among adolescents and entry-level student

coupled with the

rapid change in a hedonistic direction of health behaviors

during the college year

the health


can result in a situation wherein

tatus of college students is increasingly

ese health-compromising behaviors and the

high level of emotional distr


reported by today's

freshmen (Koplik & DeVito, 1986) have created the potential

for serious health problems in the near and distant future.

In addition to this long-term risk of chronic disease,

health-compromising behaviors among college student


been correlated with more immediate health-related


Furthermore, college student health behaviors

may be intercorrelated, and unlik

adult health behavior,

constitute a syndrome or lifestyle not unlike that

identified by Jessor (1984) with younger adolescents.

Tavlnr and Mrlillin (1OQfN faiin,4 nuii, ln a

th It nam eans



cigarette smoking, coffee consumption, and work correlated

positively, and adequate

negatively (p

leep and

exercise correlated

.05) with perceived illness.


cigarette smoking, alcohol use, coffee consumption, sexual

activity, and overweight correlated positively, and exerci

correlated negatively with use of medical services.

a factor analysis procedure, three lifestyle



identified, i.e., stressful, hedonic, and studious; health-

compromising behaviors were more highly correlated with the

stressful and hedonic lifestyle


In student surveys at different institutions

similarities in health behaviors, interests, and expressed

needs among college students have been revealed.

Stanford University an analysis of perceived health behavior

and interests indicated that weight and eating problems,


substance use, nonexercise, and emotional distress

were important areas of concern (Chervin & Martinez, 1984).

Health behavior issues of concern at the University of

Maryland included exercise, stress, contraception,

nutrition, and weight control (Downey, 1984).


habits, weight control


smoking, and alcohol use

were the five major health risks identified in an analysis
of a health rick annraic~1 nivun -n 000 frochmnn at tfh

sexual activity are among the major health risks for the


age population.

Moreover, the risks of death or

disability associated with motor vehicle and other accidents

are well documented for the 15

- 24 year

age range

(National Center for Health Statisti


Alcohol and Substance Use

An increase in alcohol and substance use of



been cited in the literature (Blane & Hewitt,

1977; Nicholi, 1983, 1984a, 1984b, 1985).

In a

tudy in

Canada, high



also indicated a


increase in the use of alcohol and drugs from 1981 to 1983

(Altorf, 1985).

Although it has been difficult to measure

the extent of use with any accuracy, especially with illegal


, Nicholi (1985) has asserted that, based in a review

of literature, a vast majority of the college student

population have experimented with alcohol and recreational



on yearly

urveys at the University of

Massachusetts have indicated that approximately 80% of the

students drink at least once a month (Duston, Kraft, &

Laworskt, 1981).

In an anonymous survey of over 900 students at the

University of Illinois in 198

CC 0^ C-

In f L f i i fnr I r

Valois (1986) observed that

Ild e a A 1 .1 i r I, 1 i, ^ b A 4 1 ., t. 4- L



while 2.4% used nicotine and 3.4% used caffeine monthly.

Alcohol, marijuana, nicotine, and caffeine were clearly the

most frequently used drugs in thi

representative sample.

In a New England college during the 1976-1977 academic

year, a stratified sample of 195 student

representative of

college population was interviewed about alcohol u

(Hashway, Hesse

in their reason

, Nutile, & Taylor, 1980).

for drinking,

Students differed

in their classification of

drinking types,

in their location for drinking, and in their


for not drinking

. The researchers determined that

the major reasons for drinking were to relieve academic

tension and social tension.

The two typ

of drinkers

identified wer


intimate and group drinkers.

in which students drank included dormitory,

athletic events, concerts, and on-campus grounds for group

drinkers; in apartments, homes of friends, or with parents

for intimate drinker

for the formal drinker

and in bars, taverns, and restaurants

reason for not drinking was a

general dislike for the effect of alcohol.

college students are learning to u

alcohol to



rather than a health promoting alternative,

the long-term

consequences may be a lack of effective coping

c ill

i n adult l if

J I I I t UJ L L. I l

and nrpat r rick fnr namain^ra va=Fh

particularly vulnerable to the health risks associated with

the use of illegal substances,

e.g., marijuana and cocaine,

and the illegal use of sedatives and tranquilizers.

Research on the adverse biological and psychological

effects of marijuana and estimate


1 million students

have used the substance and several million

smoke it daily,

also have implications for the present and future health

status of thi

age group (Nicholi, 1983).

In reviewing past

research, Nicholi (1983) mad

the following observation

the long- and short-term effect

of marijuana use on



Moderate doses of the drug have been found to

impair reading ability; the capacity to acquire, store, and

recall information; and communication


In addition,

motor coordination, particularly driving



and judgment have also been impaired.

Although long-term effects remain unclear

impairment of

lung function, reproductive functions in both mal


, birth defects, and mental disorder have also been

linked to regular usage.

An increase in cocaine, sedative, and tranquilizer use


college students has also been documented (Nicholi,

1984a, 1984b).

Within the

ollege-age group the reported

USe Of cocainP hat inrrPcrard frnm annrnvim=talx 0U million in


Adverse biological and psychological effects have

also been associated with these drugs which are a large part

of the college scene.

Belief in the harmlessne

of the

substances, peer

action, and a desire to feel better are

among the

strongest reason

for their prevalence among

college students (Cafferata, 1980; Nicholi, 1984a).

Cigarette Smoking

Smoking cigarettes has been another health-

compromising behavior, especially for college women.

In an


sment of smoking behavior among 7,016 student

in 34

New England colleges, 32% of the mal

and 44% of th


reported smoking


(Wechsler & Gottlieb,


In addition,

making for both



significantly related to per

ived health status; heavier

smokers reported the poorest health statu

Page and Gold (1983) have speculated that smoking


between mal

and femal

may be a function of


gender differences.

In a study of


at Southern Illinois University at Carbondale,

ignifi cant

gender differences on b

iefs were found.


were more

likely than mal

to believe that smoking left a bad odor on


hplnPrld r

increased their dependency on

nntrnl thair wolnhf

cigarettes, and

M2l 1 ac warn mnra 14 tlal ^, 4


more willing than mal


to comply with the wishes of their

important others, and doctors.

In another study investigating the effect of beliefs of

college women on smoking, Gottlieb (1983) reported that in a


of 953 college women from four colleges in the Boston

area, 86.1% had begun smoking before entering college

were primarily motivated to smoke because

making helped

them to manage stress associated with school work,

situation, and jobs.

pregnancy, an


Furthermore, over half stated that

asy way to quit, and definite proof of their

personal vulnerability to lung cancer would definitely

motivate them to quit.

Former smokers indicated that they

quit smoking primarily for health reasons, dislike of

of control of their lives, and social eff

smokers were also most

likely to believe that



making wa

serious health risk than current smokers


Results of this

support the Health Belief Model in that

susceptibility to a threatening consequence was a factor in

motivating college women to quit smoking.

In addition to smoking

cigarettes in an attempt to

control weight and deal with e



college femal

may also be vulnerable to abusing food for the same reasons.

I II 1-

hfrnp nf thmir nwn oftinn hahitc fiA wtfh

2rralC rn

Weight Control

Estimates have been made that between 5% and 25% of all

college-age women engage in th

binging-purging cycle known

as bulimia (Blimling & Miltenberger, 1984).

reliable statistics are lacking,


experts such as Elizabeth

S. Ohirich, Medical Director of the University of Wisconsin

Eating Disorders Program in Madison have asserted that the

prevalence of both bulimia and anorexia nervosa has been

increasing on college

campuses (Greene, 1986).

Used as a

tension relea

and weight control method for young women,

bulimia-type behavior has serious long-term health


separate yet related bulimic-like syndrome,


bulimia," has also been observed on college campuses and may

more prevalent than clinically diagnosed

ating disorders

(Cesari, 1986)

Although "fad bulimia" involves

intense and more public eating behavior,

it i


a serious

concern because

ome students participating in frequent

binge-purge behaviors are candidates for a life-threatneing

clinical bulimic disorder in th


Although all forms of substance use create potential

health problem

for college students, perception of the

cikIne lfa L j IL..m q a e a4 - L -l- _

Cdrinilc rc riE nF- -ht^^^/

mental-health problems reported as most serious for this

random and representative sample were alcohol abuse,

smoking, and drug abuse; coping with stress and weight

control ranked 7th and 11th respectively (Henggeler, Sallis,

& Cooper, 1980).

professionals on


In contrast, rankings by 30 mental health

ampus differed considerably from those of

From their viewpoint career choices, academic

difficulties, and coping with


were the top three

problems, and substance use and weight control problems were

ranked much lower

This discrepancy in perspective may

account for inappropriate and ineffective programming and

service provision in many college campuses.

A direct

assessment of student health behaviors and expressed needs

has led to more relevant health promotional efforts in a

number of college communities (Hettler, 1980).

Health risks associated with

exual activity have also

been perceived as less critical by health professional


by students (Henggeler, Sallis, & Cooper

, 1980).


transmitted diseases and unplanned pregnancy

to the physical and mental health

increased by th


are two risks

tatus of college students

frequency and variety of sexual contact


PYIIal Activity



Estimates have b

een that 10% of students are

infected with chlamydia and that a significantly higher

incidence of herpes has been found among college student

than for the general population (T

. J. Meyer, 1985; NIAID

Study Group, 1980).

In a study of 416 minority students at an undergraduate

college in New York City, analysis of a questionnaire


sing health beliefs and venereal disease preventive

behaviors showed that, of those responding to thi


(N=358), 70% had never received asymptomatic checkups for

venereal disease

and 13.7% went every 3

4% went for checkup

- 6 month

every 9

for checkup


(Simon & Das,


A direct relationship between perceived

susceptibiltiy to venereal disease and perceived benefits of

taking active and frequent asymptomatic checkups was noted.



who perceived barriers as minimal also were

more likely to seek preventive medical care.

Of the entire

sample, only two-thirds believed that they were at risk if

they or their partner douched after intercour

or were



one-quarter wer

concerned about pain,

embarrassment, and confidentiality when seeking a venereal

disease checkup.


- 40 % of the sampi


a a. I 1 1 1 I I a

indicated which personal beliefs hampered the adoption of

health behaviors related to their sexual activity.

Despite widespread publicity about the seriousness of

the AIDS epidemic and th

need to modify sexual behavior to

control the spread of thi

infectious d



students have also continued to believe that they are immune

to thi

threat (Biemiller, 1987a)

In a survey of 13,000

students at Stanford University, 74% reported that they did

not discu

sexually tranmitted diseases (STD's) with

partners before engaging in sexual

intercourse, and 25% of

the students did not know what "safe sex" practices wer

(Hirschorn, 1987). Furthe

Austin, 50% of the student

rmore, at the University of Texas,

surveyed revealed that AIDS had

no effect on their sexual behavior.

Although students are increasingly aware of the dangers

of AIDS and other STD's, peer pressure to be sexual coupled

with th


of alcohol and drugs has continued to promote

sexual promiscuity among many college-age students. I

addition, the fear of breach of confidentiality and of

mislabeling as homosexual have prevented students from

eking protection or from

hanging their sexual behavior

(Biemiller, 1987b).

Rpl isMf

r nn r rn inn ciicrontih i hl r f n nn~n^>t n A + L


of 171 femal

students seeking care at a family

planning clinic at the University of Illinois, 50.5%

employed effective use of

ontracepti v

49.4% employed

ineffective u

and were either inconsistent in their use

.4%), relied upon unreliable method

(28.6%), or failed

to use any method (16.7%).

None of the women in the


were attempting to get pregnant at the time.

The variabi

most predictive of adequate contraceptive behavior were

perceived benefits and barriers and perceived susceptibility.

Inadequate users were mor

embarrassed to obtain birth

control, believed that it interfered more with enjoyment,

and perceived it as more of an inconvenience


than adequate

Adequate users believed that benefits out-weighed

the costs.

The seriousness

of this inadequate use of


an be

clearly seen when national estimates

of pregnancy rat

on college campuses are considered.

Pregnancy rates have been conservatively estimated at

between 6% and 10%, an increase from 5

- 6% in the early

1970s, and the number of women who terminate the


has been approximately 90% (Dorman, 1981).

Ineffective contraceptive use was found to be th


reason for nrpnnanrv_

nnrea Anin in c11nnnrt mnf h


UL 1a s

In a more recent


ment at the University of

Arizona, Price,

hawn, and LaViola (1985) found that out of

515 students who returned th

questionnaire, 79% were

sexually active and 20% used no birth control. Although

pregnancy may not constitute a risk to physical health,

emotionally and socially it poses a threat to many young

women and the

similar threat

choice to terminate a pregnancy also poses

Although free from the direct health risks associated

with unplanned pregnancy, young males are mor


than female college students to the risks of death or

disability caused by motor vehicle and other accidents

(Matarazzo, 1984).

Motor Vehicle and Other Accidents

Motor vehicle and non-motor vehicle accidents also

threaten th

health of



Among the major

threats to life and health, accidents ar

of morbidity and mortality for individual

age, and the highest rat

the greatest cause

under 45 years of

of fatal accidents occur in the

late teenage to young adulthood years (National Center for

Health Statisti

, 1981).

In th

4 years age range,

have a 372% higher rate of fatal injuries than femal

in that aae arouo (National Center for Health Statisti

t.. -3


populations places them at higher than average risk (Rivara,


The extent to which students drove automobile


under the influence of either alcohol or marijuana was

revealed in a recent study by Valois (1986).

Driving while

drinking alcohol was reported by 15.8% on a weekly-daily

basis, 19.9% on a monthly basis, and 28.1% less than 10

times per year

Using marijuana and driving was reported by

6.3% on a weekly-daily basis, 9

% on a monthly basis, and

18.6% 1


than 10 tim

per year

Twice as many mal



admitted to driving while using either alcohol or

a. Significant associations between regular use of

these substances and moving traffic violations and accidents

were also discovered.

Beck (1981) explored this association between alcohol

use and driving in a survey of

college students enrolled

in various health education


and consisting of a high

percentage of seniors, 39.7%, and behavioral-social

majors, 40.3%.


Both drinking-driving intentions and actual

behavior were significantly related to the beliefs that one

could effectively avoid getting caught by the police and

avoid causing an accident while


under the influence

RPrk rnnrlrldrld that fho o,'rrnoni, c hb liaF h*i


related to the prevalence of drinking and driving in this


Accidents other than motor vehicle accidents are also a

leading cau

of death for the college-age population and

multiple life chang


hort period

of time have been

associated with vulnerability to accident and injury.

From a

tudy of 241 college-age mal

at a southern

university, Furney (1983) presented evidence that an

increase in life change events was associated with increased

accident rates.

Numbers of accidents of varying level

severity were assessed over a 12-week period and the

accident rate of those scoring in the upper and lower 27% on

a life change events questionnaire

were compared.

significantly higher rate of accidents was associated with

high scores on the College Schedule of Recent Experience.

Although no one theory of accident causation exists,

generally the inability to respond appropriately to

hazardous situations has been

linked to the incidence of


The use of substan

and high


have been known to increa

an individual '


to accidents (Rivera, 1984).

In reviewing th

literature on the health behavior and


of college students_

it has harnmP Pvident thAt wi

recreational drug use has increased, as well as the number

of traffic accidents associated with this substance use

percentage of college students, particularly women, who are

smoking and abusing food has grown in the past five years;

and the increase in

sexual activity without a subsequent


n the use of

contraception has led to higher rates


ually transmitted disease and unwanted pregnancy.

It ha

become apparent that a reduction of health risks

is necessary to prevent

hort- and long-term premature


of functional ability and of life among



Efforts to change health beliefs and increase

health behaviors in this population have ranged from


instruction in health education to campus-wide

health promotion programs.

Health Behavior Change Strategies on College Campuses

From their inception in 1818 at Harvard College, health

education class

have traditionally been the primary

strategy for influencing th

health belief

and behaviors of

college students.


since it


acceptance in the 19th century, over time health education

has lost credibility and support in higher education.

From a

urvey of schools which offer health education

rnlir:P< l(ittlecnn and (a1nn QRA1 f inndrl tihat nnlv 1I

that enrollment in these courses has been voluntary and that

"only 10.7% of the universities in the United States require

general health education of all its students for graduation"

(Kittleson & Ragon, 1984, p. 92) has limited the impact of

health education on college campuses.


the limited number of college students

receiving formal health instruction, health educators have

increasingly applied behavioral techniques in their classes

in an attempt to more effectively motivate the adoption of

health behaviors

Behavioral assessment, behavioral

contracting, and the designing and implementation of

individual behavior change projects have been incorporated

with varying degrees of

(McClaran, & Sarris, 1985



in health education courses

, 1986; Petosa, 1984).

Increasingly, health promotion and education programs
have been sponsored by student health services on a campus-

wide basis.

Since most college health services are prepaid

plans where costs are spread over the entire student body,

it has become feasible to offer a broad scope of organized

health education programs (Zapka & Love, 1985).

A survey of

158 American College Health Association Member institutions

revealed that the most extensively sponsored programs
included (a) contraception and wpinht rPdirrtinn ((4 i{ h\

sexuality (39.9%) (Chervin & Sloane, 1985).

The type and

extent of programming has varied greatly among institutions

with the large four-year universities generally offering

more programs.

A major trend in health promotion in higher education

has been the establishment of institutional

commitment to

organized and coordinated programming involving the

collaborative efforts of academic departments, student

health and mental health services, and the

student life

division (Zapka & Love, 1985)

In the past

0 years a

philosophy of student development has emerged wherein


are viewed more as whol


needing emotional,

social, psychomotor, and

spiritual growth as well as

intellectual development (Opatz, 1985).

institutions have

A number of

established programs focusing on total

development and optimal well-being.

A key element to these

programs has been student participation in planning and


Along with administration and clinical

advisement, student health council

and intern and practicum

students from various academic departments have provided

direction and leadership to these comprehensive health

promotion programs (Chandler, 1979).

Tn c CIivnv nf w1al na

C ,n A 1a. a a 4 A- -





were student health center staff and 44% were faculty

related positions.

For a majority of the respondents, the

student health center was the organizational home of the


Although the campus health center has been

perceived as the most obvious and appropriate location for

the health promotion efforts, particularly in a small

college campu

(Parker, 1985), campus-wide programs

including all facets of the community such as the one at the

University of Wisconsin, Stevens Point, have been advocated

(Hettler, 1980).

Using a model by Allen (1981) which emphasizes

environmental modification and cultural support for

successful health behavior change, William Hettler

launched the first comprehensive wellnes

, M.D.,

program on a

university campus in 1972

In implementing thi


Hettler and the Student Life Division of the university

mobilized the student affairs and residence hall staff, food


taff, health center personnel, counseling



interested faculty, students, and administrators to

establish a supportive


environment for attitude and behavior

The guiding philosophy of this lifestyle

improvement model wa

pursuit of high-level wellness in

iY dimancinn

{ I infallatf fial

(k\ amn* alnn