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The Associations between the Health-Promoting Behaviors of Low Income Patients/Caregivers and Those of Their Chronically...

Permanent Link: http://ufdc.ufl.edu/UFE0023683/00001

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Title: The Associations between the Health-Promoting Behaviors of Low Income Patients/Caregivers and Those of Their Chronically Ill Adolescents
Physical Description: 1 online resource (92 p.)
Language: english
Creator: Mack, Christopher
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2008

Subjects

Subjects / Keywords: Psychology -- Dissertations, Academic -- UF
Genre: Counseling Psychology thesis, Ph.D.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: The purpose of this study was to empirically examine whether primary parents'/caregivers' engagement in specific health-promoting behaviors that help constitute a healthy lifestyle (e.g., exercising consistently, eating a healthy diet, and health responsibility behaviors) will influence engagement in these health promoting behaviors and a health promoting lifestyle among their chronically ill adolescents. This study used the concept of modeling as described by Social Learning Theory (Bandura, 1986) as a framework for examining parental influences of engagement in both a health-promoting lifestyle (HPL) and individual health-promoting behaviors among chronically ill, low-income Black and non-Hispanic White adolescents (N=79). The individual health promoting behaviors investigated are exercising consistently, eating a healthy diet, and health responsibility behaviors. Results from a Pearson Correlation indicated that the participating adolescents? levels of engagement in the investigated specific health promoting behaviors (e.g., exercising consistently, eating a healthy diet, and health responsibility behaviors) were indeed associated with their primary parents?/caregivers' engagement in these specific health promoting behaviors. Additionally, multiple regression analyses revealed that primary parents'/caregivers' levels of engagement in consistent exercise and display of health responsibility behaviors were significant influences of one or more their adolescents? level(s) of engagement in the investigated specific health-promoting behaviors. Finally, a multiple regression analysis revealed that primary parents'/caregivers' level of display of health responsibility behaviors was the only significant influence of their adolescents? level of engagement in a health promoting lifestyle. Findings from this study suggest that the concept of modeling as described in social learning theory should be used to inform future research that aims to (a) better understand engagement in health promoting behaviors among low-income racially/ethnically diverse adolescents with a chronic illness, and (b) guide the development of culturally sensitive family-based interventions to increase levels of engagement in the investigated specific health-promoting behaviors among such adolescents.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility: by Christopher Mack.
Thesis: Thesis (Ph.D.)--University of Florida, 2008.
Local: Adviser: Tucker, Carolyn M.
Electronic Access: RESTRICTED TO UF STUDENTS, STAFF, FACULTY, AND ON-CAMPUS USE UNTIL 2010-12-31

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2008
System ID: UFE0023683:00001

Permanent Link: http://ufdc.ufl.edu/UFE0023683/00001

Material Information

Title: The Associations between the Health-Promoting Behaviors of Low Income Patients/Caregivers and Those of Their Chronically Ill Adolescents
Physical Description: 1 online resource (92 p.)
Language: english
Creator: Mack, Christopher
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2008

Subjects

Subjects / Keywords: Psychology -- Dissertations, Academic -- UF
Genre: Counseling Psychology thesis, Ph.D.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: The purpose of this study was to empirically examine whether primary parents'/caregivers' engagement in specific health-promoting behaviors that help constitute a healthy lifestyle (e.g., exercising consistently, eating a healthy diet, and health responsibility behaviors) will influence engagement in these health promoting behaviors and a health promoting lifestyle among their chronically ill adolescents. This study used the concept of modeling as described by Social Learning Theory (Bandura, 1986) as a framework for examining parental influences of engagement in both a health-promoting lifestyle (HPL) and individual health-promoting behaviors among chronically ill, low-income Black and non-Hispanic White adolescents (N=79). The individual health promoting behaviors investigated are exercising consistently, eating a healthy diet, and health responsibility behaviors. Results from a Pearson Correlation indicated that the participating adolescents? levels of engagement in the investigated specific health promoting behaviors (e.g., exercising consistently, eating a healthy diet, and health responsibility behaviors) were indeed associated with their primary parents?/caregivers' engagement in these specific health promoting behaviors. Additionally, multiple regression analyses revealed that primary parents'/caregivers' levels of engagement in consistent exercise and display of health responsibility behaviors were significant influences of one or more their adolescents? level(s) of engagement in the investigated specific health-promoting behaviors. Finally, a multiple regression analysis revealed that primary parents'/caregivers' level of display of health responsibility behaviors was the only significant influence of their adolescents? level of engagement in a health promoting lifestyle. Findings from this study suggest that the concept of modeling as described in social learning theory should be used to inform future research that aims to (a) better understand engagement in health promoting behaviors among low-income racially/ethnically diverse adolescents with a chronic illness, and (b) guide the development of culturally sensitive family-based interventions to increase levels of engagement in the investigated specific health-promoting behaviors among such adolescents.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility: by Christopher Mack.
Thesis: Thesis (Ph.D.)--University of Florida, 2008.
Local: Adviser: Tucker, Carolyn M.
Electronic Access: RESTRICTED TO UF STUDENTS, STAFF, FACULTY, AND ON-CAMPUS USE UNTIL 2010-12-31

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2008
System ID: UFE0023683:00001


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1 THE ASSOCIATIONS BETWEEN THE HE ALTH PROMOTING BEHAVIORS OF LOW INCOME PARENTS/CAREGIVERS AND THOSE OF THEIR CHRONICALLY ILL ADOLESCENTS By CHRISTOPHER ERIC MACK A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLOR IDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 2008

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2 2008 Christopher Eric Mack

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3 This work is dedicated to the fond loving memo ries of three significant women in my life: Mrs. Ophelia Pen Pen Cooke (1939-2006); Ms. Annie Mae Grandma Stinson (1912-2007); and Ms. Bernadine Bert Barbee (1948-2008) Thank you for loving me and treating me as your own. You will never be forgotten. To my dearly departed friend Dari us D Hubbard (1975-2002) I say: This world has not been the same since youve been gone. You taught me that today is what matters not tomorrow and not yesterday, but today. Thanks for all the memories. To my father Dale Ellison Wilson (1954-1991) You will always be a part of me.

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4 ACKNOWLEDGMENTS First and forem ost, I must thank the one pe rson without whom none of this would have been possible, my advisor, Dr. Carolyn M. Tucker. From the first day I met her seven years ago, she has been a teacher, mentor, and true friend to me. I thank her for all of her guidance, support, and inspiration. I will forever be indebted to her for her kindness, and I hope that my career will be an example of all the lessons she has taught and role modeled. Ralph Waldo Emerson stated it best What lies behind us and what lies before us are tiny matters compared to what lies within us. She has encouraged me to think in new ways, pushing me to see beyond how things are to what they could be. Somehow, she knew just when I needed an extra dose of encouragement or that last lit tle push. I am appreciative beyond words for her mentorship. I also thank my committee, Dr Scott Miller, Dr. Mary F ukuyama, Dr. Max Parker, and Dr. Carlos Hernandez for their support, encouragement, and willingness to meet short deadlines. Additionally, I thank my fellow in terns and post docs, for lending me their ear and opening their hearts to me. Finally, I thank the members of the Senior Staff at the University of Florida Counseling Center, Dr. Dave Su chman, Dr. Rafael Harris, and Dr. Wayne Griffin, for their invaluable support and encouragement. I feel compelled to express my gratitude to the kind and generous people from the University of Floridas Office of Graduate Minority Programs for their patience, flexibility, encouragement, understanding, and concern. Specifi cally, I thank Mr. Earl Wade and Ms. Sarah Traylor; they are truly the best. I also thank the members of the Children s Health Self-Empowerment Team and the Family Health Self Empowerment Team (especi ally Ms. Lily Kaye, Ms. Marie Bragg, and Dr. Frederic Desmond) for your continued support and direction throughout this dissertation process.

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5 I would also like to acknowledge those members of the communities in the following states who believed that this doctoral venture was possible: Gainesville, Florida; Ann Arbor and Detroit, Michigan; New Orleans, Louisiana; and Roanoke Virginia. Finally, I wi sh to extend special thanks to all my family and friends whose pa tience, support, and encouragement made this dissertation possible. Finally, I want to acknowledge my fianc and best friend, Dr. Rene S. Campbell. She has been an incredible source of strength for me. I thank her for every sleepless night she endured, every (often one-sided) stats c onversation she tolerated, every frustrated rant she reframed, and for just being there through all the chaos that comes with being a doctoral student. Her love and support has been unconditional. I am bl essed to have her in my life.

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6 TABLE OF CONTENTS page ACKNOWLEDGMENTS ............................................................................................................... 4LIST OF TABLES ...........................................................................................................................8ABSTRACT ...................................................................................................................... ...............9 CHAP TER 1 INTRODUCTION .................................................................................................................. 11Prevalence of Adolescent Chronic Illness .............................................................................. 11Need for Health Promotion .....................................................................................................12Investigated Health Promoting Behaviors that Constitute a Health Promoting Lifestyle ...... 13Exercising Consistently ................................................................................................... 13Eating a Healthy Diet ......................................................................................................14Health Responsibility Behaviors .....................................................................................15Consequences of Not Engaging in a Health Promoting Lifestyle .......................................... 16Physical Health Consequences ........................................................................................16Psychological Consequences ...........................................................................................16Economic Consequences ................................................................................................. 17Parent/Caregiver Modeling a H ealth Promoting Lifestyle .....................................................18Purpose of the Present Study .................................................................................................. 21Hypotheses .................................................................................................................... ..........212 REVIEW OF THE LITERATURE ........................................................................................22Prevalence of Adolescent Chronic Illness .............................................................................. 22Prevalence of Adolescent Ch ronic Illness among Low Inco me Minority Adolescents ......... 23Need for Health Promotion .....................................................................................................24Investigated Health Promoting Behaviors that Constitute a Health Promoting Lifestyle ...... 24Exercising Consistently ................................................................................................... 25Parent/Caregiver Influence on Exercising Consistently ..................................................26Eating a Healthy Diet ......................................................................................................26Parent/Caregiver Influence on Eating a Healthy Diet ..................................................... 27Health Responsibility ......................................................................................................28Parent/Caregiver Influence on Health Responsibility .....................................................29Consequences of Failure of Adolescents to Engage in a Health Promoting Lifestyle ...........30Physical Health Consequences ........................................................................................30Psychological Consequences ...........................................................................................31Economic Consequences ................................................................................................. 32Parent/Caregiver Modeling a H ealth Promoting Lifestyle .....................................................333 METHODOLOGY ................................................................................................................. 37

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7 Participants .................................................................................................................. ...........37Overview of Measures ............................................................................................................38Measures to Obtain Demographic Information ...................................................................... 40Procedure ..................................................................................................................... ...........404 RESULTS ....................................................................................................................... ........43Descriptive Data for the Major Variables ............................................................................... 43Hypothesis 1 .................................................................................................................. .........43Hypothesis 2 .................................................................................................................. .........44Hypothesis 3 .................................................................................................................. .........465 DISCUSSION .................................................................................................................... .....53Summary and Interpretation of Results ..................................................................................53Limitations of this Study ..................................................................................................... ...60Clinical Implications of the Results and Future Research Directions .................................... 62Implications for Counseling Psychologists ............................................................................ 63Conclusion .................................................................................................................... ..........64APPENDIX A PARTICIPANT INVITATION LETTER .............................................................................. 65B ADULT DEMOGRAPHIC QUESTI ONNAIRE ................................................................... 68C YOUTH DEMOGRAPHIC QUESTI ONNAIRE ................................................................... 70D THE HEALTH PROMOTING LIFESTYLES PROFILE-II .................................................75LIST OF REFERENCES ...............................................................................................................79BIOGRAPHICAL SKETCH .........................................................................................................92

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8 LIST OF TABLES Table page 3-1 Demographic variables ......................................................................................................424-1 Descriptive Data for the Majo r Variables for All Participants .......................................... 474-2 Correlations for the Major Variab les for All Participants (N=79) .....................................484-3 Multiple Regression with Primary Parents/Caregivers Health Promoting Lifestyle Variables as Predictors of Adolescents E ngagement in Exercising Consistently (AEC) ........................................................................................................................... ..........494-4 Multiple Regression with Primary Parents/Caregivers Health Promoting Lifestyle Variables as Predictors of Adolescents Engagement in Eating a Healthy Diet (AHD) ........................................................................................................................... .........504-5 Multiple Regression with Primary Parents/Caregivers Health Promoting Lifestyle Variables as Predictors of Adolescents Engagement in Health Responsibility Behaviors (A-HRB) ...........................................................................................................514-6 Multiple Regression with Primary Parents/Caregivers Health Promoting Lifestyle Variables as Predictors of Adolescents E ngagement in a Health Promoting Lifestyle (A-HPL) .............................................................................................................................52

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9 Abstract of Dissertation Pres ented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy THE ASSOCIATIONS BETWEEN THE HE ALTH PROMOTING BEHAVIORS OF LOW INCOME PARENTS/CAREGIVERS AND THOSE OF THEIR CHRONICALLY ILL ADOLESCENTS By Christopher Eric Mack December 2008 Chair: Carolyn M. Tucker Major: Psychology The purpose of this study was to empirically examine whether primary parents/caregivers engagement in specific he alth-promoting behaviors that help constitute a healthy lifestyle (e.g., exercising consistently, eating a healthy diet, and hea lth responsibility behaviors) will influence engagement in these health promoting behaviors and a health promoting lifestyle among their ch ronically ill ad olescents. This study used the concept of modeling as described by Social Learning Theory (Bandura, 1986) as a framework for examining pa rental influences of engagement in both a health-promoting lifestyle (HPL) and individual health-promoting behaviors among chronically ill, low-income Black and non-Hispanic White adolescents (N=79). The individual health promoting behaviors investigated are exercising consistently, eating a healthy diet, and health responsibility behaviors. Results from a Pearson Correlation indicated that the participating adolescents levels of engagement in the investigated specific health promoting behaviors (e.g., exercising consistently, eating a healthy diet, and health responsibility behaviors) were indeed associated with their primary parents/caregivers engagement in these specific health promoting behaviors.

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10 Additionally, multiple regression analyses revealed that primary parents/caregivers levels of engagement in consistent exercise and display of health responsibility behaviors were significant influences of one or more their adolescents level( s) of engagement in the investigated specific health-promoting behaviors. Finally, a multiple regression analysis revealed that primary parents/caregivers level of display of health responsibility behaviors was the only significant influence of their adolescents level of e ngagement in a health promoting lifestyle. Findings from this study suggest that the c oncept of modeling as described in social learning theory should be used to inform futu re research that aims to (a) better understand engagement in health promoting behaviors among low-income racia lly/ethnically diverse adolescents with a chronic illnes s, and (b) guide the development of culturally sensitive familybased interventions to increase levels of engagement in the investigated specific healthpromoting behaviors am ong such adolescents.

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11 CHAPTER 1 INTRODUCTION Prevalence of Adolescent Chronic Illness Chronic Illnesses in the United States has re ached epidem ic proportions, with the number of chronically ill adolescents and adults increasing dramatically during the past four decades (Centers for Disease Control [CDC], 2008; Unite d States Department of Health and Human Services [USDHHS], 2001). A chronic illness is defined as any condition (e.g., diabetes, cancer, cardio vascular disease, asthma, and obesity) cau sed by a lack of engagement in the specific behaviors that constitute a health promoting lifestyle (e.g., exercising consistently, eating a healthy diet, and health responsibil ity behaviorsi.e., r eading nutrition labels) and that interferes in the daily life of an adoles cent for longer than three months in a year (Perrin & Gerrity, 1984; Pless &Pinkerton, 1975). According to the National Health and Nutrition Examination Survey [NHANES III], an estimated 4.7 mill ion children and adolescents (6 to 17 years old) in the United States are chronically ill (Institute of H ealth [IOH], 2004; Kopl an, Liverman, & Vivica, 2005; Troiano & Flegal, 1998). Although overall rates of chronic health conditions among children are alarmingly high, they are higher still in ethnic minority and low-in come communities in the United States [U. S.]. Furthermore, although health problems has increas ed among all adolescents regardless of age, sex, and race, it disproportionately affects certain minority youth populations Flegal et al. (2005) found that Black adolescents and Hispanic adoles cents ages 12-19 are twice as likely to be chronically ill than non-Hispanic White adol escents (CDC, 2004; Gordon-Larsen, Adair, & Popkin, 2003; Strauss & Pollack, 2001). Importantl y, data has shown health problems during adolescence to be a key predictor of co-mor bid illnesses in adulthood (Deckelbaum & Williams, 2001; USDHHS, 2007).

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12 The epidemic of increased incidence of adolescent chronic health problems subsequent health consequences has gained national attention. The U. S. report, Healthy People 2010, identified decreasing the rates of chronic illnes ses among adolescents as a national health care priority. This report called for the developm ent of effective interv entions for reducing body weight and caloric intake, incr easing activity, and improving health responsibility behaviors (which emphasizes being informed about and doing the necessary work e.g., reading nutrition labels when shopping) among all adolescents, especially low-income minorities (USDHHS, 2000). Need for Health Promotion According to the U.S. Interagency Comm itt ee on Nutritional Monitoring (1989), harmful lifestyle behaviors associated wi th many chronic diseases are likel y to have their origins between the ages of 12-17. It was further reported that pe ople who engage in health promoting behaviors (such as reducing fat and caloric intake, increas ing physical activities, and displaying health responsibility behaviors) decrease their risk for chronic diseases ; these people can expect to live healthier and longer lives (CDC, 2006; Institute of Medicine [IOM], 2004). It is especially important for low-income minority adolescents who suffer from one or more chronic illnesses to engage in the specifi c health promoting behaviors that constitute a health promoting lifestyle, as failure to do so can intensify their health problems and possibly result in life-threatening cons equences (Suris, Michaud, & Vine r, 2004). Clearly, there is an urgent need for research that has implications for fostering health promoting behaviors and ultimately a health promoting lifestyle am ong adolescents, particularly those who are ethnic/racial minorities, are members of low-income families, and/or are living with one or more chronic illnesses.

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13 Investigated Health Promoting Behaviors that Constitute a Health Promoting L ifestyle Researchers have defined health promoting lif estyle as engagement in self-initiated behaviors that contribu te to the maintenance of or enha nce an individuals wellness and fulfillment (Walker, Sechrist, & Pender, 1987). These behaviors that comprise a health promoting lifestyle include exercising consistentl y, eating a healthy diet, a nd a display of health responsibility behaviors (Walker et al., 1987). Exercising Consistently A review of the health prom oti on literature shows that a fail ure to exercise consistently has been linked to co-morbid diseases among chronically ill adolescents (Gittelsohn, & Kumar, 2007). Furthermore, authors have reported that en gagement in the health promoting behavior of exercising consistently has a beneficial effect on a variety of chronic il lnesses including obesity and cardiovascular disease among adolescents (Lee et. al, 2007). The implication of such research findings is that among racial/ethnic minorities and families of low socioeconomic status, leading a healthy lifesty le and engaging in specific health promoting behaviors that comprise this lifestyle may help to decrease th e chronic illnesses that disproportionately impact the health and health-rela ted quality of life of these individuals/groups. Promoting a healthy lifestyle and specific he alth promoting behaviors among low-income minority adolescents with at least one chronic illness and their parents/caregivers may be particularly indicated. The American Academy of Pediatrics [AAP] (2006) reported that 26% of all children and adolescents in the United States engage in a sedentary lifestyle, spending more than four hours a day watching television. Speci fically, in a report released by the Kaiser Foundation (2004), chronically ill lo w-income Black and Hispanic children and adolescents aged 8-18 spend significantly more time watching tele vision and playing video games than their White counterparts. Several rese arch studies reported a positiv e association between the times

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14 spent viewing television and increased failure of engagement in a health promoting lifestyle chronically ill among adolescents (Lowry et al., 2002; Sherwood et al., 2004). Sedentary activities, specifically television viewing, have replaced time chronically ill adolescents spend engaging in the specific health promoting behavior of consistent exercise. Eating a Healthy Diet Eating a healthy diet is essential for good health, norm al growth, and development of children and adolescents (USDA, 200 5). A healthy diet includes fr uits, vegetables, whole grains, and fat-free or low-fat milk and milk products. It also consists of lean meats, poultry, fish, and nuts as well as low saturated fats. However, adherence to a healthy diet is low among the majority of the U.S. adolescent population (U SDHHS, 2000). According to the United States Department of Agriculture [USD A], approximately 68% to 75% of U.S. adolescents exceed the current dietary recommendations for intake of total or saturated fats primarily from grain mixtures (pizza & pasta) and sugary beverages. Additionally, while adolescents of all ethnicities eat more fat and sodium rich foods than fru its, vegetables, and whole grains (Simons-Morton, Baranowski, Parcel, OHare, & Matteson, 2002), low income chronically ill Black and Hispanic adolescents eat significantly mo re pork, lunch meat, high fat foods, and fewer vegetables than their White counterparts (CDC, 2005, Frank et al., 2004; Hedley et. al, 2004). Such socioeconomic and race/ethnicity related eating patte rn differences put minority youth at risk for increased chronic health problems. Co-morbid health problems such as cardiovascular disease, Type 2 diabetes, and hypertension are rapidly increasing among minor ity adolescents in low-income families (USDHHS, 2004). The implication of such realiti es is that among chronically ill low-income minority adolescents, engaging in a health promoting lifestyle and in the specific behaviors that

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15 comprise this lifestyle may help to decrease the health disparities in the U. S. that negatively impact the health and health-related qua lity of life of th ese individuals. Health Responsibility Behaviors Adolescence m arks the beginning of many behavior s, attitudes, and habits that contribute to the increased risk of declining health among adolescents. A growing body of literature indicates that chronically ill adolescents are as likely, or more likely, to engage in risky behaviors than their healthy p eers (Suris & Parera, 2005). For example, some adolescents experiment with alcohol and drugs, engage in un protected sexual encounters, smoke, engage in a sedentary life style (i.e., do not participate in moderate or vigorous physical activity at recommended levels), and engage in poor di etary practices (Garn, 1979; Lowry, Wechsler, Galuska, Fulton, & Kann, 2002). Such behaviors evidence a lack of heal th responsibility and thus are inconsistent with a health promoting lif estyle. Adolescents who are failing to engage in a health promoting lifestyle by having a limited di splay of health responsibility behaviors tend to weigh more and have higher blood pressure, both of which can lead to (a) a deterioration in their chronic health condition and (b) an increased risk of premat ure mortality (Lifshay et al., 2003). According to a report released by the Institute of Medicine (2004), improving the overall health of low-income chronically ill minority adolescents must be the focus of national efforts to reduce both the health (physical and psychological) and economic costs of adolescent health problems. Specifically, there is a need for st udies that emphasize the promotion of healthy lifestyles by increasing engagement in health responsibility behaviors among adolescents in order to reduce their risk for cardiovascular re lated illnesses and asso ciated health problems (AHRQ, 2008; IOM, 2004; USDHHS, 2000).

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16 Consequences of Not Engaging in a Health Promoting Lifestyle Failur e to engage in the specific behaviors that constitute a health promoting lifestyle (e.g., exercising consistently, eati ng a healthy diet, and health responsibility behaviors) among low income chronically ill minority adolescents is increasingly being recognized as a global epidemic (Tremblay & Willms, 2000; World Health Organization, 2002). This failure to engage in a health promoting lifestyle among chronically ill adolescents represents a serious public health concern given its associ ated physical, psychological, and economic consequences to society (Dietz, 1998; Janssen et al., 2005). Physical Health Consequences Health cons equences associated with failure to engage in heath promoting behaviors are similar among children, adolescents, and the ad ult population. Chronically ill adolescents who do not engage in health promoting be haviors are at risk for serious co-morbid health problems that once occurred almost exclusively among adults such as: (a) cardiovascular diseases such as high blood pressure, (b) obesity, (c) high cholesterol, and (d) Type 2 diabetes (CDC, 2007). These health problems, can lead to serious adult medical conditions like heart dis ease, heart failure, and stroke (IOM, 2004). Absence of physical activity, combined w ith poor eating habits, and a limited display of health responsibility behaviors among chronically i ll low-income minority adolescents contributes to more than 50,000 preventable deaths a year in the U.S. (CDC, 2006). Poor behavioral choices have b een cited as the source of approxi mately one-half of all premature deaths in the U.S. (CDC, 2006; McGinnis, 1993; USDHHS, 2000). Psychological Consequences Consequences of adolescents failure to enga ge in a health prom o ting lifestyle are not limited to physical ailments; many of these cons equences are psychological in nature. Studies have shown that children express negative attitudes toward their chronically ill peers as early as

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17 kindergarten (Moran, 1999, Shuman & La Greca, 1999). Further, it was reported that there is a clear association between chroni c illnesses and low self-esteem, especially among adolescents (Miauton, Narring, & Michaud, 2003; Reilly et al., 2003.). Adolescents who engage in a health compromising lifestyle have reportedly experien ced less psychosocial well-being and lower selfesteem than peers who engage in a health prom oting lifestyle (Mellin, Neumark-Sztainer, Story, Ireland, & Resnick, 2002; Miaut on, Narring, & Michaud, 2003). In a study cited by the CDC (Stunkard et al 1986), failure to engage in a health promoting lifestyle was linked to behavioral a nd learning problems, social discrimination, and a negative self-image during adolescence that ofte n persists into adulthood (Mellbin & Vuille, 1989). Further, it was reported that chronically ill adolescents experience lowered self-esteem, increased levels of sadness, loneliness and nervousness, and have an increased likelihood to engage in high-risk behaviors such as smoki ng and drinking alcohol (CDC, 2000; Eberstadt, 2003; Strauss, 2000). While this engagement in hi gh-risk behaviors (i.e., smoking or drinking) can be harmful to any adolescent, those adolescen ts with one or more chronic illness increase their chances for more serious health consequen ces when they engage in those same high-risk behaviors (Suris, Michaud, & Viner, 2004). Economic Consequences As the prevalence of health com promising beha viors have increased in the U. S., so have related health care costs. Failure to engage in a health promoting lifesty le and the occurrence of chronic illnesses (e.g., obesity, diabet es, cardiovascular disease) that is often associated with this failure both often lead to hea lth problems and have a significant economic impact on the U.S. health care system (USDHHS, 2001) Although the majority of th ese health care costs are generated by adults, there has been a dramatic increase in health care costs due to health problems among adolescents. Increas ed physician visits, medications, and hospital stays, as well

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18 as restricted activity and premature death among chronically ill adolescen ts have all accounted for the medical expenditures attr ibutable to health compromising behaviors. These expenses have been estimated at $70 billion and approximate ly half of these co sts associated with chronically ill low-income minority adolescents were paid by Medicaid (Finkelstei n, Fiebelkorn, and Wang, 2003; USDHHS, 2001; Wang & Dietz, 2002). Parent/Caregiver Modeling a Health Promoting Lifestyle Fam ily provides the adolescents major social learning environment. Parents/caregivers serve both as a source of authority and a role m odel for their chronically ill adolescents (Golan, Weizman, & Fainaru, 1998; Golan, 2006). Indeed, pa rents/caregivers have a major influence on their adolescents health promoting behavior s (Krasnegor, Grave, & Kretchmer, 1988). For example, they influence their adolescents de velopment of health re sponsibility behaviors by modeling eating behaviors, encouraging and providing healthy food preferences, promoting reading of food labels, and engagi ng in consistent exercise. Healthy People 2010 (USDHHS, 2000) reports fa ilure to engage in a health promoting lifestyle is a major contributor to preventable causes of death. Adopti ng a healthy lifestyle by improving dietary habits, increasing physical ac tivity and increasing health responsibility behaviors have been identified as modifiable vari ables that influence the health status of all adolescents, especially ones who suffer from one or more chronic illn ess (AAP, 2003; Barlow & Dietz, 1998; Hayman et al., 2004). Several theories and models have been developed to attempt to explain levels of engagement in a health promoting lifestyle among ad olescents including: (a) the Health Belief Model, (b) th e Theory of Reasoned Action, and (c) the Social Learning Theory (Montgomery, 2002). The Health Belief Model and the Theory of Reasoned Action were developed as a means to explain and predict preventiv e health behavior. The Health Belief Model postulates that

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19 engagement in a health promoting lifestyle is influenced by a chronically ill adolescents perception of a threat posed by a co-morbid health condition and the value a ssociated with health promoting behaviors aimed at reducing the threat (Ajzen & Fishbein, 19 80). According to the Theory of Reasoned Action, chronically ill adol escents engagement in health promoting behaviors is based on their attit ude toward engaging in a health promoting lifestyle and their perception of social pressures fr om significant others to engage or not to engage in health promoting behaviors (Ajzen and Fishbein, 1980; Chehab, Pfeffer, Vargas, Chen, & Irigoyen, 2007). Although the Health Belief Model and the Theo ry of Reasoned Action have been utilized in previous research to examine the predictors of engagement in health promoting behaviors among adolescents they have been criticized. Both the Health Belief Model and the Theory of Reasoned Action have been found to be inade quate in their ability to generalize across racial/ethnic, socio-economic, and cultural li nes because of their limitations in addressing parent/caregiver influences of poor health and family environmental barriers to the adoption of health promoting behaviors among chronically ill minority adolescents (Elder et al, 1998; Ogden, 2003). Given the criticism of the Health Beli ef Model and the Theory of Reasoned Action, engagement in health promoting behaviors among chronically ill low-income adolescents may be better understood by utilizing a theory that r ecognizes the effects of parent/caregiver determinants. It is important when investigating the heal th behaviors of chronically ill low-income minority adolescents that it be guided by theoretic al perspectives that consider the adolescents social context. Families have been identified as ideal environments for the promotion of a healthy lifestyle by the engagement in health promoting behaviors. The Social Learning Theory

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20 (SLT) (Bandura, 1977) has been used extensively to understand health behaviors in adolescents and their families. SLT focuses on the learning th at occurs within a so cial context (i.e., parents/caregivers). According to SLT, mode ling influences learning primarily through its informative functions. Observers retain a sym bolic representation of the modeled behavior, which then serves as a blueprint for the beha vior. Individuals learn through observing others' behavior. If individuals observe positive, desired outcomes in the observed behavior, they are more likely to model, imitate, and adopt th e behavior themselves (Bandura 1977; Bandura 1986). Research has shown that SLT can be successfully used to implement interventions that targeted adolescents. For example, it has been shown that such interventions have enabled adolescents to minimize their health compromising behaviors and convert them into the modeled health promoting behaviors (Budd & Volpe, 2006). Although there are many personal factors th at influence behavior, Bandura (1986 & 1997) identified modeling as the most salient wh en altering the health promoting behaviors of adolescents. Despite these aforementioned fact s, few studies have attempted to determine parent/caregiver influence on the levels of engagement in specific health promoting behaviors or levels of engagement in a health promoting li festyle among chronically ill low income minority adolescents. Yet, knowledge of these influences will enable the development of interventions to increase health promoting behavi ors during adolescence, behaviors that may delay or prevent the major causes of premature disease and mortalit y (e.g., diabetes, cardiovascular disease, cancer) in adulthood (Jessor, Turbin, & Costa, 1998) Such knowledge in relation to minority adolescents and associated interventions has th e potential of helping to reduce the health disparities that plague the U.S.

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21 Purpose of the Present Study The purpose of this study was to empirical ly exam ine whether parent/caregivers engagement in specific health-promoting behavior s that help constitute a healthy lifestyle (e.g., exercising consistently, eating a healthy diet, and health re sponsibility behaviors) and engagement in a health promoting lifestyle will influence these health promoting behaviors and health promoting lifestyle among their adolescents. Hypotheses The specific hypotheses for this study are as follows: Hypothesis (1): Levels of prim ary parents /caregivers engagement in specific healthpromoting behaviors (e.g., exercising consistently, eating a healthy diet, and health responsibility behaviors) that help constitute a health promoting lifestyle will have significant positive associations with the levels of their adolescents engagement in these sp ecific health promoting behaviors. Hypothesis (2): Levels of primary parents/caregivers engagement in a health promoting lifestyle will influence their adolescents engage ment in the specific health-promoting behaviors (e.g., exercising consistently, eating a healthy diet, and health respons ibility behaviors) that help constitute a health promoting lifestyle. Hypothesis (3): Levels of primary parents/caregivers engagement in a health-promoting lifestyle will influence their adolescents engagement in a health promoting lifestyle.

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22 CHAPTER 2 REVIEW OF THE LITERATURE This literature review is organized into f our sections. In the f irst section, literature regarding prevalence of adolescent chronic illness is discussed. The second section provides health promotion literature addressing the health promoting behaviors that constitute a health promoting lifestyle. Next, a review of the liter ature that addresses the consequences (physical, psychological, and economic) of failure to engage in a health promoting lifestyle is presented. Finally, research findings regard ing parent/caregiver influences of adolescent engagement the health promoting behaviors that constitute a health promoting lifestyle is discussed. Prevalence of Adolescent Chronic Illness The Surgeon Generals Call to Action repor ted that the health consequences (e.g., obesity, card iovascular disease, a nd Type 2 diabetes) of failure to engage in a health promoting lifestyle among chronically ill adolescents in the United States has reached epidemic proportions (Centers for Disease Control [CDC], 2008; U.S. Department of Health and Human Services [USDHHS], 2001). A chronic illness is defined as any condition (e.g., diabetes, cancer, cardio vascular disease, asthma, and a dolescent obesity) caused by a lack of engageme nt in the specific behaviors that constitute a health promoting lifestyle (e.g., exercising consistently, eating a healthy diet, and health responsib ility behaviors) and that interferes in the daily life of an adolescent for longer than three months in a year (Perrin & Gerrity, 1984; Pless &Pinkerton, 1975). According to the National Health and Nutr ition Examination Survey (NHANES) data, the prevalence of chronic illnesses caused by not engaging in the specific health promoting behaviors that constitute a healthy lifestyle (e .g., exercising consistently, eating a healthy diet, and health responsibility behavi ors) has doubled for children a nd has tripled for adolescents between 1999 and 2000 (Ogden, Flegal, Carroll, & Johnson, 2002). Obesity, cardiovascular

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23 disease, and Type 2 diabetes affects an esti mated 15% of all adoles cents (aged 12-19), making them the most prevalent preventable chronic illn esses in the United States (Centers for Disease Control [CDC], 2004; National Center fo r Health Statisti cs [NCHS] 2002). Prevalence of Adolescent Chronic Illness among Low Income Minority Adolescents Chronic health problems among adolescents w ho fail to engage in the specific health promoting behaviors that constitute a healthy lif estyle exist in many segments of the population and are particularly common among low-income minority groups (USDHHS, 2001). In the past thirty years, the percentage of adolescents with chronic heal th conditions including obesity, cardiovascular disease, and Type 2 diabetes has more than tripled (NCHS, 2002). This increase is seen in both sexes and in children of all ag es, with low-income Blac k children and adolescents and Hispanic children and adolescents dispr oportionately affected (Dietz, 2004). In both racial/ethnic groups, prevalence of chronic health problems increas ed by more than 10% between 1988 to 1994 and 1999 to 2000, compared with an incr ease of less than 5% in White children (Odgen et al., 2002). According to the National Longitudinal Survey of Youth (NLSY), the rate of chronic health problems among Blacks and Hispanics has increased 47% to 73%. This increase in chronic health conditions among Blacks and Hisp anics was reported to be faster among these two ethnic groups than among the White popula tion (Strauss, 2002). The prevalence of poor health among adolescents due to limited engageme nt in the specific hea lth promoting behaviors of exercising consistently, eati ng a healthy diet and, a display of health re sponsibility behaviors are highest among Black females, followed by Hispanics of both sexes and White males (Gordon-Larsen, Adair, and Popkin 2003). Specifical ly among adolescent males, Blacks are 1.13 times more likely and Hispanics are 1.73 times more likely to be suffering from health problems due to a failure to engage in a health promoting lifestyle as compared to their White counterparts

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24 (Ogden et al., 2006). Among female adolescents, Blacks are 1.46 times more likely and Hispanics are 1.56 times more likely to be afflic ted with health problems due to a lack of engagement in a healthy lifestyle as compared to their White counterpa rts (Ogden et al., 2006). Researchers from a program entitled Child and Adolescent Trial for Cardiovascular Health (CATCH) reported that being a low income Black adolescent was a strong predictor of having chronic health problems due to a failure to engage in a hea lth promoting lifestyle by age 11 (Crawford, Story, Wang, R itchie, & Sabry, 2001). Need for Health Promotion It is especially im portant for low-income minority adolescents who are diagnosed with one or more chronic illnesses to engage in a he alth promoting lifestyle. It has been shown that not engaging in the specific behaviors that constitute a healthy lifestyle (e.g., exercising consistently, eating a healthy diet and health responsibility beha viors) can exacerbate a current chronic illness and have possi ble fatal consequences (JAM A, 2003; Gortmaker, Walker, Weitzman, & Sobol, 1990; Suris, Michaud, & Viner, 2004). Clearly, there is an urgent need for research that has implications for fostering he alth promoting behaviors and a health promoting lifestyle among adolescents, partic ularly those who are ethnic/racial minorities, are members of low-income families, and/or are living w ith one or more chronic illnesses. Investigated Health Promoting Behaviors that Constitute a Health Promoting L ifestyle Researchers have defined health promoting lifestyle as a pattern of self-initiated behaviors that contribu te to the maintenance of or enha nce an individuals wellness and fulfillment (Walker, Sechrist, & Pender, 1987). Thes e health promoting behaviors that comprise a health-promoting lifestyle include exercising co nsistently, eating a healthy diet, and a display of health responsibility behaviors (Walker, et al., 1987).

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25 Exercising Consistently According to a report released by the CDC (2003) engagem ent in exercising consistently among chronically ill adolescents will not only help to prevent additional health problems, it will also help to promote health maintenance. Th is CDC report (2003) indicated that exercising consistently among chronically i ll adolescents helps control weight, build lean muscle, and reduce fat build-up. Exercising also (a) helps to maintain healthy bones, muscles, and joints, (b) helps to reduce blood pressure in adolescents with hypertension, and reduces feelings of depression (CDC, 2003). However, although ma ny chronically ill adolescents know that engaging in health promoting behaviors such as exercising consistently ai ds in overall health management, many still do not engage in these behaviors (Croll, Neumark-Sztainer, & Story, 2001; Sallis et al., 2000). Exercising consistently is a component of energy expenditure that may be a strong predictor of poor health among adolescents (IOM, 2005). Unfortunately, there has also been a recent change in the types and amounts of activi ties adolescents are engaged in. Adolescents are spending more time on health risk activities in cluding sedentary activities, such as watching television, and less time engaged in health promo ting activities including physical activities, such as walking, running, or exercisi ng. Research suggests that th e average adolescent spends between 3-4 hours/day watching te levision (Mokdad et al., 2000; Tucker & Friedman, 1989) and only 8-10 minutes/day engaged in consiste nt exercise (Janz et al., 1992). Chronically ill low-income minority adolescent s are more likely to be sedentary than their White counterparts (Taylor, Baranowsk i, &Young, 1998). For example, one study reported a higher percentage of chronically ill low income Black and Hispanic yout h than chronically ill low income non-Hispanic White children watche d four or more hours of television per day (Anderson, Crespo & Bartless, 1998). According to a report released by Ni elsen Media Research

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26 (2000), Black households watch more television than typical White households and are more likely to view an increased number of advertisements for fast-food restaurants and unhealthy foods (i.e., sweets and soda) (Tirodkar & Jain, 2003). Lastly, a study conducted on high school stude nts found that 14% of students watched at least five hours of television per day (Lowr y, Wechsler, Galuska, Fulton, & Kann, 2002). The authors of this study reported that 52 % of Hispanic high school students admitted watching more than two hours of television a day. This hi gh rate of television viewing can be understood since children are exposed to television as early as their firs t year and have seen an estimated 360,000 commercials before graduating from hi gh school (Certain & Kann, 2002). Researchers have found that television viewing promotes the consumption of food, while watching and exposes adolescents to unhealthy food ads and messages (Dietz & Gortmaker, 1985; Schmitz et al., 2002). Parent/Caregiver Influence on Exercising Consistently Sallis et al. (2000) reported fi nding th at parental support and engagement in exercising consistently was frequently and positively corre lated with their chroni cally ill adolescents engagement in physical activities The authors reported many ways in which parents/caregivers can help to increase their chronically ill adolescen ts level of engagement in health promoting behaviors. One of these ways is by encouraging and accompanying their chronically ill adolescent in a range of physical activities (i.e., walki ng or taking stairs inst ead of an elevator) that may promote a healthy lifestyle (IOM, 2004). Eating a Healthy Diet A failure to engage in the health promoting be havior of eating a healt hy diet is one of the m ajor causes of co-morbidity of chronic illnesses including diabet es, cardio vascular disease, and obesity among adolescents. A growing body of evidence has demonstrated that following a

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27 healthy diet that complies with United States Department of Agricultures [USDA] Dietary Guidelines may reduce the risk of chronic illnesses (CDC, 2004; USDA, 2005); unfortunately, many chronically ill adolescents st ill do not engage in this specific health promoting behavior. Research has also shown differences in le vel of engagement in a healthy diet among racial/ethnic groups. For example, chronically ill low-income Black and Hispanic adolescents consume more daily fast food and eat larger portion sizes of high-calori e nutrient-poor foods than their White counterparts (Bowman, Gortma ker, Ebbeling, Pereira & Ludwig, 2004; Hill and Peters 1998). Parent/Caregiver Influence on Eating a Healthy Diet Parents play an im portant role in the growt h, development, and socialization of children (Darling and Steinberg 1993). Pare nts can influence their children through the use of modeling and creating a home environment that endorses health promoting behaviors. Parents who consume fruits and vegetables, for example, have adolescents who do the same. Similarly, parents who display their master y of portion control can positivel y influence their children to engage in portion control (Cullen et al., 2001; Nicklas et al., 2001; Fisher et al., 2002). The family is a major influence on a chroni cally ill adolescents' eating behavior. A growing body of research suggests the importance of parent caregiver behavior on food choices of their chronically i ll adolescent (Story, Neumark-Sztainer & French, 2002; Birch & Davison, 2001). Although adolescents may consume fewe r meals with their family than do young children, research suggests that adolescents st ill consume 65% of their total energy intakes at home (Guthrie, Lin & Frazao, 2002). Parent/caregiver modeled be havior regarding food conveys their attitudes, preferences, and values around eating behaviors and f ood preferences (Booth, Sallis, Ritenbaugh, Hill, Birch, et. al 2001; Nickla s, Baranowski, Baranowski, Cullen, Rittenberg et al, 2001). According to research pres ented by Birch & Davison (2001) low income

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28 parents/caregivers mediate their chronically ill adolescents' hea lthy eating behaviors by being the provider of food and modeling heal thy attitudes, prefer ences, and values that affect their chronically ill adolescents lifetime eating habits. Despite the importance of healthy eating duri ng adolescence, studies have consistently shown that adolescents as a group have poor eati ng habits and that thes e habits do not meet current dietary recommendati ons (Munoz, Krebs-Smith, Ballard -Barbash, & Cleveland, 1997; Morton & Guthrie, 1998; Story, Neumark-Sztainer, 2002). Nutrition-related concerns include unhealthy dieting, high intake of fast foods and other foods high in fat, low intake of fruits, vegetables, fiber, and dairy foods, and erratic eating behaviors, such as skipping meals (Morton & Guthrie 1998; Munoz, Krebs-Smith, Ballard-Bar bash, & Cleveland, 1997; Neumark-Sztainer, Story, Resnick, Blum 1998). Recent national data show that only 1% of adolescent males and females meet national recommendations for a ll the Food Guide Pyramid groups, and 18% of girls and 7% of the boys did not meet any of the recommendations (Story, Neumark-Sztainer & French, 2002). Adolescence offers a unique opportunity to positively influence the adoption of healthy eating that could be sustained throughout life. Specific health promoting behaviors acquired during this period are likely to influence long-term health beha viors engagement for healthier lifestyle (Croll, Neumark-Sztainer, & Story, 2001; Gittelsohn, & Kumar, 2007; IOM, 2005). Health Responsibility Adolescence marks the beginning of many attitu des and habits that contribute to the decline of their health. A failure to engage in health responsibility behaviors among chronically ill adolescents (as evidenced by experimentati on with alcohol and drugs, unprotected sexual encounters, smoking, a sedentary lif estyle, and poor dietary practi ces) increases th e potential for additional health problems (Garn, 1979; Lowry, Wechsler, Galuska, Fulton, & Kann, 2002).

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29 In contrast, adolescence is also a critical time for the develo pment of health responsibility behaviors related to a healthy lifestyle. As demonstrated in a study by Kelder, Perry, Klepp, & Lytle (1994), health responsibil ity behaviors (e.g., eating a bala nced diet, reading food labels, limiting sweets and sodas, exercising, preparing healthy meals) learned during adolescence are carried over into adulthood. Health promotion literature reveal that a limited displa y of engagement in health responsibility behaviors among chronically ill adolescents have been linked to the development co-morbid conditions including the following: co ronary heart disease, cancer, diabetes, hypertension, and obesity (Gittelsohn, & Kuma r, 2007; Lee, 2007). On the other hand, it has been reported that engagement in the specific h ealth promoting behavior of health responsibility has been associated with increased psychological and mental well-being, reduced cardio vascular risk, and proper weight maintenance (CDC, 200 3; Gordon-Larsen, et al ., 2002; IOM, 2005; Lee, 2007). According to Gordon-Larsen, et al. (2005), the implication of such research findings is that among low-income chronically ill adolescen ts, leading a healthy lif estyle and displaying health responsibility behaviors may help to decr ease the health disparities in the U. S. that negatively impacts the health and health-relate d quality of life of these individuals. Parent/Caregiver Influence on Health Responsibility Fa mily members provide adolescents major social learning environment. The family environment can be supportive of healthy beha viors or provide unhea lthy opportunities that increase the risk for a variety of adverse health conditions and consequences. Parents/caregivers have a significant influence on thei r chronically ill adolescent as he r or his first model of health responsibility behaviors. Parents who overeat, have sedentary lifes tyles, do not read food labels, eat excessively fast, or ignore their internal satiety clues provid e a poor example for their family (Golan & Weizman, 2001). When parents adopt a healthier lifestyle, in addition to positively

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30 affecting their lives, this lifestyle may help the level of engagement in health promoting behaviors in their chroni cally ill adolescents. Parents/caregivers can influence their chronically ill adolescents attitudes and behaviors that contribute to a healthy lifestyle by modeling health resp onsibility behaviors such as encouraging and providing healthy food prefer ences, promoting reading food labels, and engaging in consistent exercise (Birch & Fisher, 1998). Imitation is a vital aspect of learning, and the process of adopting a health ier lifestyle can be enhanced by the presence of proper social models (Golan & Weizman, 2001). Consequences of Failure of Adolescents to En gage in a Health Promoting Lifestyle Adolescent failure to engage in a health pr omoting lifestyle has been associated with immediate and long-term physical and psycholog ical health and future healthcare costs (USDHHS, 2001). Epidemiological studies have shown that h ealth consequences due to behaviors during adolescence are correlated with chronic health problems (e.g., obesity, cancer, diabetes, hypertension, and cardiovascular dise ase) in adults (Hill & Trowbridge, 1998). Adolescents who fail to engage in the health promoting behaviors that constitute a healthy lifestyle currently pose a major public h ealth threat in the United States. Physical Health Consequences Failure to engage in a health prom oting lifes tyle is associated w ith significant health problems and is an important early risk factor for both adolescent morbid ity and early mortality. Many co-morbid health problems have been associated with this failure to engage in the specific health promoting behaviors that constitute a health promoting lifestyle, including obesity, diabetes, cardiovascular disease, hypertens ion, and cancer (Goodman & Whitaker, 2002). Between one-third and one-half of chronically ill adults first develop health problems due to a

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31 lack of engagement in a health promoting lifestyle during childhood or adolescence (Price, 2002; Steinbeck, 2001). Common physical co-morbid consequences asso ciated with child a nd adolescent failure to engage in the specific hea lth promoting behaviors that constitute a healthy lifestyle (e.g., exercising consistently, eating a h ealthy diet, and health responsi bility behaviors) include the following: cardiovascular risk factors, early maturation, sleep apnea, abnormal insulin and cholesterol concentrations, and orthopedic comp lications (Dietz, 1998). The rapid growth in the prevalence of chronically ill adolescents who do not engage in a healthy lifestyle has likely contributed to the high prevalence of co-morbid chronic health problems in this group. Support for this view are the findings that 60% of chronically-ill 5to 10-year-old children already have one associated cardiovascular dise ase risk factor such as elevat ed blood pressure, and more than 20% of these children have two or more cardiovascular disease risk factors. It is also noteworthy that the incidence of Type 2 diabetes, which until recently was thought to be an almost exclusively adult-onset disease, has dramati cally increased among youth (Copeland, Becker, Gottschalk, & Hale, 2005; Diet z & Gortmaker, 2001). In fact, it has been reported that low income minority adolescents no w account for as much as 50% of new cases of Type 2 diabetes (Fagot-Campagna et al., 2000; Gittelsohn & Kumar, 2007). Psychological Consequences In addition to the physical risk factors for chr onic illn ess, the consequences of a failure to engage in a health promoting li festyle also is associated with psychological morbidities including depression, difficulty with peer relationships, poor self-esteem, and social isolation (Ebbeling, 2002; Katz et al., 2005). Adolescents with chronic illnesses have become the targets of teasing and bullying, negative stereotyping, and social marginalization (IOM, 200 4). Thus, adolescents who are physically ill face an increased risk of social, emotional, and academic problems lasting

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32 well into adulthood (IOM, 2004; Katz et al., 200 5). Specifically, result s from one study reported young men who were chronically ill as adolescents were found to be less likely to be married (Gortmaker et al, 1993). Further, it was repor ted that chronically ill adolescent females completed fewer years of education, experience hi gher poverty rates, and ha ve decreased rates of marriage (Karger & Basel, 2001). Adolescents who do not engage in a health prom oting lifestyle are at risk for a number of psychosocial consequences which can begin early in life. Empiri cal research shows that many chronically ill adolescents are rejected by th eir peers and experience discrimination and rejections as adults (LeBow, 1984). Lastly, in a study by Crocke r, Major, and Steele (1998) it was found that chronically-ill adolescents have a devalued personal identity. According to these authors, adolescents who were chronically-ill are aware of their peers negative views about their illness, which in turn, is personalized a nd results in lowered self-esteem. Economic Consequences The health care cos ts directly associated with a failure to engage in a health promoting lifestyle were estimated to be $70 billion in 1995; the direct costs asso ciated with physical inactivity alone were estimated to be $24 bill ion, or 2.4% of U.S. health care expenditures (Colditz, 1999; Grundy, et al., 1999). Further, it was reported that medical costs associated with health problems due to a failure to engage in the specific health pr omoting behaviors that constitute a healthy lifestyle increased fr om $70 billion in 1995 to $78.5 billion in 1998 (Finkelstein, Fiebelkorn, & Wang, 2003). The U. S. is already affected by the costs associated with the increased prevalence of adolescents who fail to engage in a healthy lifestyle. For example, from 1997 through 1999, hospital costs for adolescents with chr onic health problems averaged $127 million a year (CDC, 2003).

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33 Failure to engage in a health promoting lifes tyle among adolescents is of concern in part because when this failure begins at an early age, it increases the demand for costly health services over their lifespan. A decrease in he alth promoting behaviors has increased the need and subsequent cost of treatment for and risk of early disability and de ath from heart disease, kidney disease and, diabetes am ong chronically ill low income adolescents (Young-Hyman et al., 2001). The overall direct and indirect costs of childhood diabetes in 2002 were nearly $132 billion (CDC, 2003). The increasing prevalence of health problems in children and adolescents due to failure to engage in a healthy lifestyle may also lead to increased hospital stay s (CDC 2003; Wang et.al, 2002). The majority of these health care costs are generated mainly by low-income minority adults with chronic illnesses. However, there ha s been a dramatic increase in health problems among chronically ill low-income minority adolescents. Approximate ly half of these costs were for low-income and minority adolescents and their families. These cost were paid for by Medicaid to cover medications and hospital stays (Finkelstein, Fi ebelkorn, and Wang, 2003; USDHHS, 2001; Wang & Dietz, 2002). Parent/Caregiver Modeling a Health Promoting Lifestyle Parenting strategies aim ed at preventing adolescent health problems should include encouraging the engagement of health promoting behaviors that are consistent with a healthpromoting lifestyle. These behaviors include ex ercising consistently, ea ting a healthy diet, and health responsibility behavior s (Walker, et al., 1987; Ebbeli ng et al. 2002; International Association for the Study of Obesity, 2004; Ja mes & Gill, 2004; Muller et al. 2004). Most preventative strategies that examine th e level of engagement in health promoting behaviors among low-income chroni cally ill adolescents and their parents/care givers are theory driven (St. Jeor, Perumean-Chaney, Sigman-Gra nt, Williams, & Foreyt, 2002). Several theories

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34 and models have been developed to attempt to explain levels of e ngagement in a health promoting lifestyle among adolescents including: (a) the Health Belief Model, (b) the Theory of Reasoned Action, and (c) the Social L earning Theory (Montgomery, 2002). The Health Belief Model and the Theory of Reasoned Action were developed as a means to explain and predict preventive health behavi or. The Health Belief Model posits the likelihood that a chronically ill adolescent will engage in health promoting behaviors to prevent co-morbid illnesses depends on the adolescents perception that: (a) they are vulnerable to worsened conditions, (b) engaging in health promoting behaviors effectively prevents co-morbid conditions, and (d) the benefits of reducing the th reat of co-morbid conditi ons exceed the costs of engaging in health promoting behaviors (Cheha b, Pfeffer, Vargas, Chen, & Irigoyen, 2007). According to the Theory of Reasoned Action, adol escents intend to behave in ways that allow them to obtain favorable outcomes and meet the expectations of others (Ajzen & Fishbein, 1980). Specifically, the Theory of Reasoned Action posits that engagement in a health promoting lifestyle among chronically ill adolescent s increases afte r they: (a) have developed an intention (i.e., the subjective probability of pe rforming a behavior), which requires adopting a positive attitude toward the behavior, (b) accept engagement in health promoting behaviors as a norm, and (c) believe they have the ability to engage in health promoting behaviors (Ajzen & Fishbein, 1980). Although the Health Belief Model and the Theo ry of Reasoned Action have been utilized in previous research to examine the predictors of engagement in health promoting behaviors among adolescents they have been criticized. Bo th the Health Belief Model and the Theory of Reasoned Action have been found to be inadequate to be inadequate in thei r ability to generalize across racial/ethnic, socio-economic, and cultural lin es because of their limitations in addressing

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35 parent/caregiver influences of poor health and family environmental barriers to the adoption of health promoting behaviors among chronically ill minority adolescents (Elder et al, 1998; Ogden, 2003). Given the criticism of the Health Beli ef Model and the Theory of Reasoned Action, engagement in health promoting behaviors among chronically ill low-income adolescents may be better understood by utilizing a theory that r ecognizes the effects of parent/caregiver determinants. Social Learning Theory (SLT) is a theoretical framework commonly used to explain how people learn behavior (IOM, 2005). Accordi ng to Bandura (1977) people learn through observing others' behavior. If people observe positive, desired outcomes from observed behavior, they are more likely to model, imitate, and adopt the behavior themselves (Bandura, 1977; Bandura, 1986; Glanz & Rimer, 1997). The concept of modeling, as described by SLT, is particularly applicable to this study. Speci fically, if adolescents observe that their parents/caregivers have more energy, look and feel better from making health responsibility choices, exercising, and eating healt hy, they see a positive consequen ce of this behavior and thus are more likely to engage in these behaviors. According to SLT (Bandura, 1977), imitation is an essential aspect of learning and the process of adopting a new behavior (e.g., engaging in specific health promoting behaviors) can be enhanced by the presence of proper social models (i.e., parents/caregivers). The concept of modeling as described by th e SLT has been widely used to examine parent/caregiver influence on th e level of engagement in speci fic health promoting behaviors (e.g., exercising consistently, eati ng a healthy diet, and health responsibility behaviors) among middle-income elementary school children from grades 3 to 5 (Corwin, Sargent, Rheaume, & Saunders, 1999; Cullen, Baranowski, & Olvera, 2000; Cullen et al., 2002; Kratt, Reynolds, &

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36 Shewchuk, 2000; Neumark-Sztainer, Wall, Perry & Story, 2003; Resnicow et al., 1997; Reynolds et al., 2000). More recentl y, studies have begun to use th e concept of modeling to the study parent/caregiver influence on the level of engagement in specific health promoting behaviors among chronically ill mi nority adolescents (Granner et al., 2004; Lytle et al., 2003; Neumark-Sztainer et al., 2003; Reinaerts, Nooijer, Candel, Vries, 2007). Results of such studies have shown racial and economic differences in levels of engagement in specific health promoting behaviors. For example, Molaison et al. (2005) indicated fr om their study that lowincome Black adolescents with at least one chronic illness were more likely to engage in specific health promoting behaviors (e.g., exercising cons istently, eating a hea lthy diet, and health responsibility behaviors) if a pare nt/caregiver provided proof that engagement in these behaviors are related to improved health. The authors of this study also reported that levels of engagement in specific health promoting behaviors among these chronically ill adolescents are heavily influenced both positively and negatively by thei r parents' engagement in health promoting behaviors (Bandura, 1977; Mola ison et al. (2005).

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37 CHAPTER 3 METHODOLOGY Participants The participants in this study we re recruited as part of a larg er study created to test an intervention program designed to increase health promoti ng lifestyles/behaviors among adolescents who have chronic health problems, li ve in families with low incomes, and receive health care through Childrens Medi cal Services [CMS] in North Cent ral, Florida. CMS is a state healthcare assistance program for any severely or chronically ill adolescent in Florida whose family meets low-income eligibility requirements and/or whose healthcare costs place a financial burden on the adolescents family. A total of 145 eligible adolescents and their primary parents/caregivers agreed to participate in the present study. From thos e 145 adolescent/child-par ent/caregiver pair participants, 94 pairs returned their assessments ( 65 % return rate) to the principal investigator. Of those who did not return their assessments, 10 indicated that they changed their mind about participating in this study and the remaining 41 e ither could not be contacted or did not return our follow-up telephone calls to solicit their study participation. It is not known whether those who participated in this study ar e a representative sample of a ll eligible CMS patients because the CMS data management system was not capable of identifying demographic distributions (e.g., ethnicity, race, gender) among their patient population. Of those 94 adolescent/child-parent/caregiver pair participants who returned their Assessment Battery (AB), only 79 of these pairs totally and correctly completed the ABs and thus provided usable data for the present study. Therefore, the final participant sample for the present study consisted of this 79 adolescent/child-parent/caregiver pairs. Specifically, this sample consisted of 32 Black adolescents ( 23 females and 9 males) and their primary

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38 parents/caregivers (32 females) and 47 White ad olescents (27 females and 20 males) and their primary parents/caregivers (47 fe males). The adolescent participants ranged in age from 12 to 17 years old, with a mean age of 13.3 for the Black adolescents ( SD = 1.5) and 13.8 for the White adolescents (SD = 1.3). The participating primary pare nts/caregivers, who were all female, ranged in age from 30 to 67 (M=43), and their median annual family income range was $10,000 to $20,000. Eighty-two percent of these primary parents/caregivers reported annual family incomes below $30,000, indicating that the research participants constituted a low-income skewed sample. Seventy percent of these primary parents/caregivers report ed their highest level of education obtained as completion or less th an completion of high school. The demographic characteristics of the participants in this st udy are presented in more detail in Table 3-1. The criteria for inclusion in the larger study a nd thus in the present study were as follows: (a) is between the ages of 12 and 17 years old; (b) has attended CMS at least once in the year prior to the start of this research; (c) identifies as Black not of Hispanic origin or White not of Hispanic origin (d) has had a diagnosis of a chronic medical illness (e.g., asthma, diabetes, hypertension) for at least one year prior to the pl anned research, (e) self-re ports as being able to communicate effectively verbally or in writing in her or his native language, and (f) gives written assent or consent to be a research participant. Th e criteria for exclusion from this study were as follows: (a) children younger than age 12 and adolescents older than age 18 or, (b) identifies her or his race/ethnicity as bei ng other than Black or White. Overview of Measures Each participating adolescent and her/his prim ary parent/caregiver com pleted an AB that included a measure of health pr omoting lifestyles and behavior s and a demographic information form. Below is a brief description of the two measures that constitute each AB.

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39 The Health Promoting Lifestyles Profile-II (H PLP-II; Walker, Sechrist, & Pender, 1987). The HPLP-II is a 52-item self-report inventory that measures the degree to which participants engage in a health-promoting lifestyle. The HPLP -II consists of six subscales that assess levels of the following specific aspects of a health promoting lifestyle (e.g., six health-promoting behaviors): (a) exercising cons istently, (b) eating a healthy di et, (c) health responsibility behaviors, (d) engaging in stre ss management practices, (e) s eeking to reach ones fullest potential, and (f) the ability to form close interpersonal relationships. Only the first three subscales were used in the present study as they assess objective modifiable behaviors that have been identified as (a) potentially playing a substantial role in the development and management of chronic illnesses among low-income minority a dolescents and b) modifiable under whatever conditions that exist in peoples lives. HPLP-II items are rated on a 4-point Likert s cale with polar responses labeled never and routinely. Higher scores on the HPLP are indicative of a more health promoting lifestyle. Sample items on the HPLP-II are as follows: Do you exercise vigorously for 20 or more minutes at least 3 times a week? (exercising consistently); D o you eat 6-11 servings of bread, cereal, rice, and/or pasta each day? (eating a healthy diet) and Do you choose a diet low in fat, saturated fat, and cholesterol? (health re sponsibility behavior). The reli ability (Cronbach alpha) of the overall HPLP-II has been reported to be .79 (Walke r et al., 1987). For adolescent participants in the present study, Cronbachs alphas for the full HPLP-II scale and the three sub-scales used were .95 (full scale); .85 (exerc ising consistently); .80 (eating a healthy diet); and .86 (health responsibility behaviors). For the primary parent /caregiver participants Cronbachs alphas were .85 (full scale); .75 (exercising consistently); .73 (eating a healthy diet); and .70 (health responsibility behaviors).

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40 Measures to Obtain Demographic Information A Demographic Data Form (DDF). The DDF was constructed by the researchers to obtain demographic information on the participati ng primary parents/caregivers. Specifically, the following demographic information was obtained on the DDF completed by the participating primary parents/caregivers: ethni c/racial group, education, gender, age, and family income range. An Adolescent Demographic Data Form (ADDF). The ADDF was constructed by the researchers to obtain information including the participants race/ethnic ity, gender, age, and diagnosed chronic illness (or illne sses). Adolescent participants we re asked to obtain any needed help in completing the ADDF (i.e., help from their primary parent(s)/caregiver(s)). Procedure Staff at a local north central Flo rida Child rens Medical Services (CMS) Program mailed research participation invitation materials to the parents/caregivers of 14 5 arbitrarily selected Black adolescent patients and non-Hispanic White adolescent patients (ages 12 17) in this program. These materials included a cover letter describing the study, an informed consent form, an assent form, a DDF, an ADDF, and a postage-p aid, pre-addressed business reply envelope to return a signed informed consent form and assent form and completed DDF and ADDF to the researchers. The cover letter provided informa tion on the following topics: (a) purpose of the study (to determine the factors that influence leve l of engagement in health promoting lifestyles and behaviors of adolescents), (b) participants responsibilities (approximat ely 2 hours of time to complete a set of questionnaires), (c) actions taken to ensure participants confidentiality (inclusion of the instruction on questionnaires completed by particip ants to not write their names on these questionnaires, and informing participants that their individual questionnaire responses would not be shared with their health care provide rs and staff nor with anyone else in the public), (d) questionnaire completion timeframe (3 week s), and (e) participation compensation (a $20

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41 check mailed to the participating primary pare nt/caregiver within 3 weeks of receiving completed questionnaires from the primary parent/caregiver and their adolescent). All of the primary parents/car egivers and their adolescents who were mailed research participation invitation materials agreed to pa rticipate in this study, provided signed informed consent and assent forms verifying this agreem ent, and completed DDFs and ADDFs. Each of these primary parents/caregivers se lf-identified as the parent/careg iver of an adolescent who was participating in the earlier identified CMS Program It is not known whether those who agreed to participate in this study are a representative sample of all eligible CMS patients. This information is not known because the participant da ta management system for this participating CMS was not capable of identifying demographic distributions (e.g., ethnic/racial group distribution, gender distribu tion, etc.) for the adolescents and pare nts/caregivers that it serves. Each of the 145 primary parents/caregivers and their adolescents who returned signed informed consent and assent forms and a completed DDF and ADDF were mailed the Assessment Battery (AB) for this study and a postage-paid, return-add ressed envelope for returning the completed AB to the researchers. Reminder telephone calls were made by trained undergraduate researchers to the participants who had not returned a completed AB by the end of the 3-week deadline for returning this document. To allow for completed ABs to be mailed following the reminder phone calls, the data co llection period was ex tended two weeks beyond the original 3-week deadline for receiving completed ABs. At the end of this extended two-week data collection period, th e researchers had received comple ted ABs from 94 of the 145 primary parents/caregivers and their ad olescents who had been invited via letters to be research participants (65 % return rate). The entir e duration of this study was four months.

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42 Table 3-1 Demographic variables Demographic variables N Mean SD % Adolescent gender male 30 38 female 49 62 Adolescent race Black 32 41 White 47 59 Adolescent gender/race Black male 9 11 Black female 23 29 White male 20 27 White female 27 33 Adolescent age Black 32 13.3 1.5 (12-17) White 47 13.8 1.3 Parent race Black 32 41 White 47 59 Parent age 43 1.6 (30-67) Parent marital status divorced 21 27 married 26 33 single/live-in 9 11 single 20 25 widow 3 4 Parent education middle school 5 6 high school 25 32 some college 35 44 college 14 18 Parent employment full time 30 38 part time 15 19 does not work 34 43

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43 CHAPTER 4 RESULTS This section presents the results from th e analyses to test each of the hypotheses that were set forth in this study. First, desc riptive data for the ma jor variables of this study are presented. Second, the results of th e Pearson Correlation analysis to test hypothesis (1) are reported. Fina lly, the results of the multiple regressions to test hypotheses (2) and (3 ) are presented. Descriptive Data for the Major Variables The descriptive data for the m ajor variab les in the present study (e.g., exercising consistently, eating a healthy diet, and health responsibility behavior s) are presented in Table 4-1. Hypothesis 1 Hypothesis 1 states that le vels of prim ary parents/caregivers engagement in specific health-promoting behaviors (e.g., exercising consistently, eating a healthy diet, and health responsibility behaviors) that help constitute a health promoting lifestyle will have significant positive associations with the levels of their adolescents engagement in these specific health promoting behaviors. To test hypothesis 1, Pearson correlation co efficients were computed to determine whether a relationship exists between the levels of primary parents/caregivers engagement in specific health promoting be haviors (e.g., exercising consistently, eating a healthy diet, and health responsibility be haviors) and their ad olescents level of engagement in these specific health promoting behaviors, respectively. A p-value equal

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44 to or less than .05 was required for statistical significance. Table 4-2 shows the results of these analyses. Results revealed that adolescents engage ment in exercising consistently had a significant but low positive association w ith their primary parents/caregivers engagement in exercising consistently, r = .29, p < .01. Results also revealed that adolescents engagement in eating a hea lthy diet had a significant but low positive association with their primary parents/ caregivers engagement in (a) exercising consistently, r = .24, p < .05, and (b) health responsibility behaviors, r = .30, p < .01. Finally, results revealed adoles cents engagement in health responsibility behaviors had a significant but low positive association w ith their primary parents/caregivers engagement in (a) exercising consistently, r =.25, p < .05; (b) eating a healthy diet, r =.32, p < .01; and (c) health re sponsibility behaviors, r = .38, p < .01. Hypothesis 2 Hypothesis 2 states that leve ls of prim ary parents/caregivers engagement in a health promoting lifestyle will influence thei r adolescents engagement in the specific health promoting behaviors (e.g., exercising cons istently, eating a hea lthy diet, and health responsibility behaviors) that help constitute a health promoting lifestyle. To test hypothesis 2, three multiple regression analyses were performed. In the first multiple regression, the predictor variable s were primary parents/caregivers engagement in exercising consistently, eati ng a healthy diet, and health responsibility behaviors and the criterion variable was adolescents engagement in exercising consistently. Results indicated that primary pa rents/caregivers engagement in exercising consistently was the only statistically significan t influence of adolescents engagement in

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45 exercising consistently, F (3, 75) = 2.83, p < .05 (adjusted R2 = .07, p < .05). This finding implies that increases in adolescent engagement in the specific health promoting behavior of exercising consistently may be signifi cantly influenced by an increase in primary parent/caregiver engagement the specific health promoting behavior of exercising consistently. The results of this first regres sion analysis to test hypothesis 2 are presented in Table 4-3. In the second multiple regression, the predictor variables were primary parents/caregivers engagement in exercising consistently, eati ng a healthy diet, and health responsibility behaviors, and the criterion variable wa s adolescents engagement in eating a healthy diet. Results revealed that primary parents/caregivers engagement in health responsibility behavior s was the only one of the inve stigated predictor variables that had a statistically significant influence on adolescents engagement in a healthy diet, F (3, 75) = 3.85, p < .05 (adjusted R2 = .10, p < .05). This finding implies that increases in adolescents engagement in the specific he alth promoting behavior of eating a healthy diet may be significantly influenced by an increase in primary parents/caregivers engagement in health responsibility behaviors. The results of this regression analysis are presented in Table 4-4. In the third multiple regression, the predictor variables were primary parents/caregivers engagement in exercising consistently, eati ng a healthy diet, and health responsibility behavior s and the criterion variable was adolescents engagement in health responsibility behaviors. Results in dicated that primary parents/caregivers engagement in health responsibility behaviors was the only one of the investigated predictor variables that had a statistically significant influence on adolescents health

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46 responsibility behaviors, F (3, 75) = 5.50, p < .05 (adjusted R2 = .15, p < .05). This finding implies that increases in adolescent en gagement in health responsibility behaviors may be significantly influenced by an incr ease in primary parents/caregivers engagement the specific health promoting be havior of health res ponsibility behaviors. The results of this regression analysis are presented in Table 4-5. Hypothesis 3 Hypothesis 3 stated that leve ls of prim ary parents/caregivers engagement in a health promoting lifestyle will influence th eir adolescents engagement in a health promoting lifestyle. To test this hypothesis, the predictor vari ables were primary parents/caregivers engagement in exercising consistently, eati ng a healthy diet and, health responsibility behaviors, and the criterion vari able was adolescents engage ment in a health promoting lifestyle. Results indicated that primary pa rents/caregivers engagement in health responsibility behaviors was the only one of th e investigated predictor variables that had a statistically significant influence on th eir adolescents engagement in a health promoting lifestyle, F (3, 75) = 5.54, p < .05 (adjusted R2 = .15, p < .05). This finding implies that increases in adolescents engage ment in a health promoting lifestyle may be significantly influenced by an in crease in primary parents/car egivers engagement in the specific health promoting behavior of health responsibility behaviors. The results of this regression analysis are pr esented in Table 4-6.

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47 Table 4-1 Descriptive Data for the Major Variables for All Participants Variables n M SD Min Max Norm M A-EC 79 2.2 .57 1.0 3.5 2.9 a A-HD 79 2.3 .49 1.3 3.6 2.8 a A-HRB 79 2.1 .57 1.0 3.8 2.5 a PC-EC 79 1.9 .61 1.0 3.5 2.2 b PC-HD 79 2.4 .51 1.3 3.7 2.5 b PC-HRB 79 2.3 .57 1.1 3.7 2.7 b Note : A-EC= Adolescent exercise consistently; A-HD= adolescent eating a healthy diet; A-HRB= Adolescent health res ponsibility behaviors; PC-EC= Primary parent/caregiver exercise consistently; PC-HD= Primary pare nt/caregiver eating a healthy diet; PC-HRB= Primary parent/caregiver heal th responsibility behaviors; a Callaghan, 2006; b Monteith & Ford-Gilboe, 2002

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48 Table 4-2 Correlations for the Major Variables for All Participants (N=79) Variable 1 2 3 4 5 6 1. A-EC 1 2. A-HD .57 1 3. A-HRB .38 .45 1 4. PC-EC .29** .24* .25* 1 5. PC-HD .12 .19 .32** .46 1 6. PC-HRB .21 .30** .38** .41 .48 1 Note : ** indicates a significant correlation at the 0.01 level (2-tailed); indicates a significant correlation at the 0.05 level (2 -tailed); A-EC= Adolescent exercise consistently; A-HD= adolescent eating a h ealthy diet; A-HRB= Adolescent health responsibility behaviors; PC-EC= Primary pa rent/caregiver exerci se consistently; PCHD= Primary parent/caregiver eating a healt hy diet; PC-HRB= Primar y parent/caregiver health responsibility behaviors

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49 Table 4-3 Multiple Regression with Primary Parents/Caregivers Health Promoting Lifestyle Variables as Predictors of Adolescents Engagement in Exercising Consistently (A-EC) R2 F df B Model 0.07 2.83* 3, 75 PC-EC .24* PC-HD -.14 PC-HRB .20 Note: PC-EC= Primary parent/caregiver exercise consistently; PC-HD= Primary parent/caregiver eating a healthy diet; PC -HRB= Primary parent/caregiver health responsibility behaviors = p < .05

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50 Table 4-4 Multiple Regression with Primary Parents/Caregivers Health Promoting Lifestyle Variables as Predictors of Adolescents Engagement in Eating a Healthy Diet (A-HD) R2 F df B Model 0.10 3.85* 3, 75 PC-EC .19 PC-HD -.04 PC-HRB .26* Note: PC-EC= Primary parent/caregiver exercise consistently; PC-HD= Primary parent/caregiver eating a healthy diet; PC -HRB= Primary parent/caregiver health responsibility behaviors = p < .05

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51 Table 4-5 Multiple Regression with Primary Parents/Caregivers Health Promoting Lifestyle Variables as Predictors of Adolescents Engagement in Health Responsibility Behaviors (A-HRB) R2 F df B Model 0.15 5.50* 3, 75 PC-EC .09 PC-HD .11 PC-HR .31* Note: PC-EC= Primary parent/caregiver exercise consistently; PC-HD= Primary parent/caregiver eating a healthy diet; PC -HRB= Primary parent/caregiver health responsibility behaviors = p < .05

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52 Table 4-6 Multiple Regression with Primary Parents/Caregivers Health Promoting Lifestyle Variables as Predictors of Adolescents Engagement in a Health Promoting Lifestyle (A-HPL) R2 F df B Model 0.15 5.54* 3, 75 PC-EC .18 PC-HD .02 PC-HR .30* Note: PC-EC= Primary parent/caregiver exercise consistently; PC-HD= Primary parent/caregiver eating a healthy diet; PC -HRB= Primary parent/caregiver health responsibility behaviors = p < .05

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53 CHAPTER 5 DISCUSSION The purpose of this chapter is to (1) summ arize a nd interpret the results of this study, (2) identify the limitations of this study, (3) discuss the c linical implications of the results from this study and offer directions for future research, and (4) discuss the implications of the present st udy for counseling psychologists. This study empirically examined the rela tionship between low-income Black and Non-Hispanic White primary parents/careg ivers engagement in specific healthpromoting behaviors that help constitute a health promoting lifes tyle (e.g., exercising consistently, eating a healthy diet, and h ealth responsibility behaviors) and their chronically ill adolescents engagement in thes e specific health prom oting behaviors. It also examined the relationship between lo w-income Black and Non-Hispanic White primary parents/caregivers engagement in a health promoting lifestyle and their chronically ill adolescents engagement in a health promoting lifestyle. Summary and Interpretation of Results Hypothesis 1 posited that there would be a significant relationship between the levels of prim ary parents/caregivers engage ment in specific health-promoting behaviors (e.g., exercising consistently, ea ting a healthy diet, and health responsibility behaviors) that help constitute a health promoting lifestyle and the levels of their adolescents engagement in these specific health promoting behaviors. Results from this study lend support for Hypothesis 1. Results from Pearson Correlations revealed significant correlat ions between adolescents engagement in consistent exercise and their primary pare nts/caregivers engagement in exercising

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54 consistently. This finding is consistent w ith the conclusion of Epstein (2001) that parents/caregivers have a significant influence on the physical activity and eating behaviors of children and adolescents with ch ronic illnesses. In fact, according to Golan, Weizman, Apter, & Fainaru (1998) the paren t/caregiver is the primary mediator of change (i.e., increasing engagement in health promoting behaviors) among their adolescents. Further, results also revealed a signi ficant correlation be tween adolescents engagement in eating a healthy diet and their primary parents/caregivers engagement in (a) exercising consistently and (b) health responsibility behaviors. These results are consistent with findings of Van der Horst and colleagues (2007) that parents/caregivers levels of engagement in eating a healthy di et and health responsi bility behaviors are positively associated with their chronically ill adolescents engagement in eating a healthy diet. Additionally, in the results of a five year (1999-2004) longitudinal study of economically and racially diverse adolescents dietary behaviors, Arcan and colleagues (2007) reported that parents/ca regivers engagement in health responsibility behaviors and consumption of healthy foods (i.e., fruits and vegetables) were positively associated with their adolescents engagement in health responsibility behaviors and consumption of healthy foods. Finally, results in the present study re lated to hypothesis 1 revealed that adolescents health responsibility behaviors had a significant positive association with their primary parents/caregivers engagement in all of the specific investigated healthpromoting behaviors (e.g., exercising consis tently, eating a healthy diet, and health responsibility behaviors) that help constitute a health promoting lifestyle. This finding is

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55 consistent with that of Fitzgibbon, Stolle y, & Kirschenbaum (1995) who reported the finding that low-income parents/caregivers engagement in health responsibility behaviors (i.e., reading labels ) was associated with their chronically ill adolescents engagement in specific health-promoting be haviors (e.g., exercising consistently, eating a healthy diet, and health respons ibility behaviors) a nd weight loss. Such associations have been explained as due in part to primar y parents/caregivers being positive health promotion role models and contributing to healthy home environments such as by purchasing and cooking healthy foods (Epstein et al., 1990; Epstein et al., 1994; Dietz, 2001). Hypothesis 2 posited that leve ls of primary parents/caregivers engagement in a health promoting lifestyle will influence thei r adolescents engagement in the specific health promoting behaviors (e.g., exercising cons istently, eating a hea lthy diet, and health responsibility behaviors) that help constitute a health promoting lifestyle. Results from this study lend support for Hypothesis 2. Specif ically, it was found that primary parents/caregivers engageme nt in exercising consistently significantly influenced their adolescents engagement in exercising consistently, whereas these primary parents/caregivers engagement in eat ing a healthy diet and health responsibility behaviors did not significantly influence their adolescents engagement in exercising consistently. These findings are consistent with two reviews of low income chronically ill adolescents engagement in physical activit y, which reported that parental engagement, parental support of, and opportunities to exer cise are significantly associated with increases in these adolescents engagement in the specific health promoting behavior of

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56 exercising consistently (Sallis, Prochaska et al 2000; van der Horst, Chin A. Paw et al. 2007). Further, the small amount of variance in adolescents engagement in consistent exercise accounted for by primary parents/c aregivers behaviors suggest that other variables influence engagement in consiste nt exercise among the adolescents in the present study. According to two adolescent health promotion studies, pe er influences play a role in the engagement in exercising cons istently among the adolescents similar to those in the present study (Mackey & LaGreca, 2006; Stice, 2002). Given the amount of time adolescents spend outside the home, it is not surprising that peers play such a powerful role in the engagement of health promoting behaviors (i.e., exercising consistently) (Csikszentmihalyi & Larson, 1984). Future research is needed to further explore additional variables that may play a role in the investigated health promoting behavior of exercising consistently in adolescents similar to those in the present study. Results from an examination of Hypot hesis 2 also revealed that primary parents/caregivers engagement in health responsibility beha viors significantly influenced their adolescents engagement in eating a healthy diet, whereas these primary parents/caregivers engagement in exercisi ng consistently and eati ng a healthy diet did not significantly influence th eir adolescents engagement in eating a healthy diet. These findings are consistent with a study that reported a significant positive association between low income parents/caregivers he alth responsible choices and the level of engagement in healthy behaviors (i.e., eati ng a healthy diet) among their chronically ill adolescents (Davison et al., 2003).

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57 Additionally, the small amount of variance in adolescents enga gement in eating a healthy diet accounted for by primary parents/c aregivers behaviors suggest that it is likely that other factors influence engage ment in eating a healthy diet among the adolescents in the present study. Existing re search suggest that there are multiple influences that contribute to eating hab its and quality of lif e among chronically ill adolescents including physical and social environmental factors (Mokdad et al., 2005). Specifically, findings from Story, Neumark-Sztainer, & French (2002) reported low income chronically ill adolescents eating be haviors are influenced by (a) interpersonal (i.e., peers), (b) medical (i.e., adherence to a prescribed diet), (c) environmental (i.e., schools), and (d) societal (i.e., media) f actors (Story, Neumark-Sztainer, & French (2002). Factors influencing eat ing behaviors of chronically ill adolescents need to be better understood to develop effective interventions to improve eating behaviors among adolescents similar to th ese in the present study. It was also found from the test of Hypothe sis 2 that primary parents/caregivers who engage in health responsibility behavior s significantly influenced their adolescents engagement in health responsibility behaviors, whereas these primary parents/caregivers engagement in eating a healthy diet and exerci sing consistently did not significantly influence their adolescents engagement in health responsibility behaviors. These findings are consistent with the results from in a report released by the US Department of Health and Human Se rvices (2000) which concluded that among chronically ill low income adolescents, pare nt/caregiver encouragement and modeling of health responsibility behaviors (a) promotes normal growth and development, and (b) is positively associated with engagement in hea lth responsibility beha viors. It was also

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58 stated in this report that health responsibi lity behaviors acquired during adolescence are likely to influence long-term health promoting behaviors. Furthermore, the small amount of variance in adolescents enga gement in health responsibility behaviors accounted for by primar y parents/caregivers behaviors suggest that other variables play a significant role in the level of engagement in health responsibility behaviors among the adolescents in the present study. Clearly, parents/caregivers are not the only influen ces of engagement in the health promoting behavior of health responsibility among ch ronically ill adolescents (Beal, Ausiello, & Perrin, 2001). An additional influence to consider is the significance of adult authority figures with whom adolescents have regular c ontact, for example: (a) health teachers, (b) school nurses, (c) sports coaches, and (d ) physicians who may have emphasized the importance of engaging health responsibi lity behaviors (Williams, Holmbeck & Greenley, 2002). Hypothesis 3 posited that leve ls of primary parents/caregivers engagement in a health promoting lifestyle will influence th eir adolescents engagement in a health promoting lifestyle. Results from this st udy lend support for Hypothe sis 3. Specifically, it was found that primary parents/caregivers engagement in health responsibility behaviors significantly influen ced their adolescents engagement in a health promoting lifestyle, whereas these primary parents/caregivers engageme nt in eating a healthy diet and exercising consistently did not influence their adolescents engagement in a health promoting lifestyle. This finding is consistent with the results from a report released by the Institute of Medicine IOM (2005) which states that low income parents/caregivers can

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59 have a profound influence on their chronically ill adolescents engagement in a healthy lifestyle by promoting certain values and attitudes and by serving as role models. According to the IOM, the parent/caregiver is an essential mediator of change for adolescents. Parents/caregive rs can promote a healthy lifestyle by engaging in health responsibility behaviors and by (a) providi ng healthy food and beve rage choices, (b) carefully considering nutrie nt quality and the number of calories per gram of food prepared for ones family and, (c) educating adolescents about making health responsible decisions regarding types of food and beverages to eat and dri nk, how often and how much to eat, d) limiting television viewing time to less than two hours per day, and e) serving as positive role models for children regarding engagement in specific healthpromoting behaviors that help constitu te a healthy lifesty le (IOM, 2005). Further, the small amount of variance in adolescents engagement in a healthy lifestyle accounted for by primary parents/c aregivers behaviors suggest that other variables play a significant role in the leve l of engagement in a healthy lifestyle among the adolescents in the pres ent study. Parry-Langdon & Robert s (2005) reported that in addition to the influence of parent/caregiver engagement in a healthy lifestyle, other variables likely play a role in the level of engagement in a healthy lifestyle among adolescents similar to those in the present study. Specifical ly, these researchers reported these other variables to be as follows: (a) friends, (b) schools (c) neighborhoods, (d) doctors, (e) Internet, and (f) the media. Sin ce adolescents typically spend more time away from home and their families, parent/ caregiver behaviors may be among the less influential factors in their adolescents' enga gement in a healthy lif estyle (Parry-Langdon & Roberts, 2005).

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60 Together, the findings in this study are cons istent with the concept of modeling as described by the SLT (Bandura, 1977). SLT implies that the pro cess of adopting the specific health promoting behaviors that cons titute a healthy lifestyle (e.g., exercising consistently, eating a healthy diet, and h ealth responsibility behaviors) among lowincome minority adolescents with at l east one chronic illness can be enhanced by modeling their primary parents/caregivers engagement in these behaviors (Golan & Weizman, 2006). These findings suggest that using the concept of modeling as described by the SLT may be useful in understanding pare nt/caregiver influence on the levels of engagement in each of the investigated health promoting behaviors examined in the present study. Limitations of this Study The findings in this study m ust be consid ered preliminary given the limitations of this study. These limitations in clude that the samples of parent/caregiver and adolescent pairs were small and thus may have limited the power to find some significant relationships between the predic tor and criterion variables inve stigated in this study. This low number of participants was due to lim itations including (a) the fact that many participants failed to provide required complete data (i.e., a complete demographic data) and/or (b) the fact that some participants completed the self-report measures incorrectly (i.e., did not answer all questions on a measur e or gave two answers for one question). Although the study had a small sample size, sign ificant associations and influences were detected between parent/caregiver engageme nt in specific health promoting behaviors and engagement in such behaviors by their adolescents.

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61 Another limitation that wa s encountered during this study was the absence of male primary parent/caregiver participants. Th is is likely due to th e high number of single female headed households among low income mi nority families. It is not known whether the primary parents/caregivers who agreed to participate in this st udy are a representative sample of all eligible Children Medi cal Services [CMS] patients primary parents/caregivers. This information is not known because the participant data management system for this participa ting CMS was not capable of identifying demographic distributions (e.g., ethnic/racial group distribution, gende r distribution, etc.) for the parents/caregivers that it serves. Yet another limitation with regard to the sample in this study is that all participants are members of low-income families from North Central Florida, which limits external validity of its results and the ability to generalize these results to the larger population of Am erican families, or even of low-income families of the ethnic groups represented in this study. An additional limitation of the present study is the use of self-report measures to assess engagement in health promoting beha viors by the participat ing adolescents and primary parents/caregivers. As in any study utilizing self-report m easures there is an inherent risk that participants are not truthful and thus results will not be valid or reliable (Johnson, 2005). The use of self-report meas ures to assess the variable s of interest without the inclusion of a social desirability measure (i .e., the Marlow Crown Social Desirability Inventory) was also a limitati on of this study. Indeed, partic ipants may have been giving socially desirable rather than honest respons es on the selfreport measures. Without a

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62 measure of social desirability, any influence of this variable could not be controlled for in the analyses performed. Clinical Implications of the Resu lts and Future Research Directions The descriptive data presented in Table 4-1 suggest that the prim ary parent/caregiver and adolescent participants in this study had limited engagement in the investigated specific health promoting behavi ors that constitute a healthy lifestyle, as evidenced by low HPLP-II mean scores. This was particularly apparent in the primary parents/caregivers and adolescents m ean levels of engagement in exercising consistently (1.9 and 2.2, respectively). Gi ven the considerable physical, psychological, and social demands involved in caring for a chronically ill adoles cent and living with a chronic illness, it should come as no surprise that lower ra ther than higher levels of engagement in the specific behaviors that constitute a healthy lifestyle (i.e., exercising consistently) have been shown to be preval ent in such families (Holmbeck et al., 2002; Power et al., 2003). Future research addressing chronically il l adolescents engagement in health promoting behaviors should include a focus of environmental barriers that may make it especially difficult for low income minority families to engage in a healthy lifestyle. These barriers include, but are not limited to the following barriers: (a) the close proximity of fast-food restaurants to low income neighborhoods (b) the lack of availability and the high cost of healthy foods and beverages (e.g., high-fiber breads, lowfat milk, and fresh fruits and green vegetables ) in low income areas, (c) the presence of perceived threats (e.g., litter, graffiti, youth gangs, heavy traffic, drug activity), and (d)

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63 fewer physical activity settings (e.g., parks, walking paths, and play grounds) in low income communities. In the present study, the parent/caregiver behaviors (e.g., exercising consistently, eating a healthy diet, and health responsibility behaviors) t ogether significantly accounted for 7%, 10%, 15%, and 15% of the variance in their adolescents levels of engagement in exercising consistently, eating a healthy diet, health responsibility behaviors, and a healthy lifestyle, respectivel y. The small amount of variance in adolescents engagement in health promoting behaviors accounted for by primary parents/caregivers behaviors could be due to stronger influences of p eers and environmental conditions. For example, the behaviors of peers (i.e., engagement in a health promoting lif estyle) and schools (e.g., athletic programs, physical activity classes a nd health classes, avai lability of healthy foods) likely significant influence adolescen ts engagement in a health promoting lifestyle (Jacobson, 2003). The challenges of future research in addressing the health promoting lifestyles of low income minority adolescents with a chronic illness are (a) to raise the awareness of the importance of e ngaging in the specif ic health promoting behaviors that constitute a healthy lifestyle, a nd (b) to conduct culturally sensitive familybased research examining parent/caregiver in fluence on their adolescents engagement in a health promoting lifestyle. Implications for Counseling Psychologists Counseling psychologists can use their knowle dge of social learning theories and multicultural research an d theories to conduct similar research to the present study for the purpose of understanding health promotion among low-income minorities. The commitment of counseling psychologists to social justice and health promotion also

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64 renders them to be ideal for implementing su ch health promotion research. Furthermore, the multicultural counseling training of couns eling psychologists prepares them for developing and implementing family intervention s that may be implicated from research such as that in the present study. Conclusion Overall, the results of the present study suggest that pr im ary parents/caregivers self-reported engagement in sp ecific health-promoting behaviors that help constitute a healthy lifestyle (e.g., exercising consiste ntly, eating a health y diet, and health responsibility behaviors) are a ssociated with their adolescent s engagement in these same self-reported health-related behaviors. If the results in this study are replicated in future similar studies, with larger samples, s upport will be provided for developing family interventions to positively impact the hea lth promoting behaviors of adolescents who have one or more chronic illnesses, especia lly those from low-income minority families. The low self-reported levels of engagement in health promoting behaviors by the adolescents with one or more chronic illne sses who participated in the present study and by their primary parents/caregivers have a sign ificant implication. Sp ecifically, these low levels of engagement in health promoting behaviors indicate that ad olescents and primary parents/caregivers similar to those in th e present study could possibly benefit from interventions designed to provide health info rmation and skills to promote and increase engagement in the specific health promoting behaviors that constitute a healthy lifestyle (e.g., exercising consistently, ea ting a healthy diet, and health responsibility behaviors).

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65 APPENDIX A PARTICIPANT INVITATION LETTER Date: Dear Paren t/Caregiver: Childrens Medical Services is supporting a new health impr ovement research project in which children and parents are being invited to participate. Dr. Carolyn M. Tucker, who works at the University of Florida, is leadi ng the project. Because our records show that one of your children has attended Childrens Medical Services within the past 3 months, we are inviting both you and your child to take part in the project. One of the major reasons for this project is to teach childr en who have health problems (are overweight, have diabetesalso called sugar, and/ or have high blood pressure) how to live healthier lives. Another r eason for this project is to find out what you think your healthcare providers (doctors, nu rses, clinic staff, etc.) and Nurse Care Coordinators can do to make you feel more comfortable, feel mo re respected by them, and also feel more trusting of them. This information may help healthcare professionals give healthcare that is more satisfactory to you and your family. Please carefully read the Adult Informed Consent Form and the Adolescent Informed Consent that wa s included in this mailing. Also have your child read the Adolescent Assent Form. These forms explai n the project and what you and your child will be asked to do, if you choose to participat e. Basically, if you and your child agree to participate, both of you will complete some questionnaires during the next 12 months. Some parents and children will also be asked to attend three health improvement workshops. If you decide to participate in the project, you will be paid for completing the questionnaires and/or for attending the workshops The amount of pay is explained in the Informed Consent Forms. A parent or primary caregiver must participat e with each child. Also, only one parent (or primary caregiver) and one child from each fa mily can take part in the project. If you do not wish to participat e, do not return the forms sent along with this letter. If you do not participate, the heal thcare your child receives at Childrens Medical Services will not change in any way In fact, the doctors, nurses, and office staff at Childrens Medical Services and at the clinics will not know if you and your child do or do not take part in this project. If you and your child would like to part icipate, you should do the following : 1. Read the Adult Informed Consent Form and the Adolescent Informed Consent Form. 2. Print your full name on the first page of the Adult Informed Consent Form and the Adolescent Informed Consent Form (item number 1).

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66 3. Sign BOTH of the Adult Informed Consent Forms and BOTH of the Adolescent Informed Consent Forms. 4. Complete the Payment Release Form (the last page of the Adult Informed Consent Form) and sign your name at the bottom of the page. 5. Keep one of the Adult Informed Cons ent Forms and one of the Adolescent Informed Consent Forms for your records and information. 6. Complete the Adult Information Questionnaire. 7. Put the Adult Information Questionnaire, ONE copy of the signed Adult Informed Consent Form (please do not tear off the Payment Release Form), and ONE copy of the signed Adolescent Informed Consent Form in one of the pre-stamped, pre-addressed envelopes. 8. Put this envelope in the mail. Now, 1. Have your child read and sign his/her name on BOTH of the Adolescent Assent Forms. 2. Have your child complete the Youth Information Questionnaire. 3. Your child should keep one of the Adolescent Assent Forms for her or his records and information. 4. Have your child put the Youth Information Questionnaire and ONE copy of the signed Adolescent Assent Form in the second pre-stamped, pre-addressed return envelope. Put this envelope in the mail. NOTE : Please do not put your forms and your childs forms in the same envelope. Also, if you want to pa rticipate please make sure that you return these materials within 2 weeks. Within two months of sending us these mate rials, we will send your first packet of questionnaires (if you and your chil d are selected to take part in the project). If you move before you receive this first packet, or at any time during the project, please call the researchers at (352) 392-0601, Ext. 260 to give them your new address. During the whole project, we will make sure that your confidentiali ty is protected as much as possible. Also, no one at Children s Medical Services w ill see what you or your child writes on any of the questionnaires. If you have any questions about taking part in this research project, or would like the materials we have sent you in English, call the Principal Inve stigator of the research, Dr. Carolyn M. Tucker, at (352) 392-0601, Ext. 260. Thank you for your time. We hope you will thin k about participating in this project.

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67 Sincerely, Arlan Rosenbloom, M.D. Gainesville/Ocala Medical Director, Childrens Medical Services

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68 APPENDIX B ADULT DEMOGRAPHIC QUESTIONNAIRE Directions : Please give all of your answers by comp letely filling in the circle beside your answer. It s hould look like this: Remember, your answers to all questions in this packet will be kept completely private What is your sex? O Female O Male How do you describe yourself? O African-American/Black-American (not of Hispanic origin) O Caucasian/White/European-Ame rican (not of Hispanic origin) O Hispanic/Latino O Multi-Racial (Please describe:_____________________________) What is your current relationship status? O Divorced or separated O Married, living with partner O Married, not living with partner O Single, living with partner O Single, living without partner O Widow/Widower What is your employment status? O Work Full Time (30-40 hrs) O Work Part Time (10-30 hrs) O Do not work What is the highest level of education that you have completed ? O Elementary School O Middle/Junior High School O High School O Some College/Technical School O College O Professional/Graduate School What is your annual household income level? O Below $10,000 O $10,000 to $19,999 O $20,000 to $29,999 O $30,000 to $39,999 O $40,000 or above

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69 How many children currently live with you in your home? O none O five O one O six O two O seven O three O seven O four O other:_______ How many adults currently live with you in your home? O none O five O one O six O two O seven O three O seven O four O other:_______ When we mail you things would yo u like them to be written in: O English O Spanish Which county do you live in? O Alachua O Hernando O Bradford O Levy O Columbia O Marion O Dixie O Putnam O Gilchrist O Other (Please specify: ________________________) Please write your answers to the follo wing questions in the blanks provided: In the last year, how many times have you visi ted the medical clinic you usually attend: _______ How many years have you lived in this community: __________ Your age: __________ PLEASE RETURN BOTH PAGE S OF THIS QUESTIONNAIRE Thank you for helping us with this research!

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70 APPENDIX C YOUTH DEMOGRAPHIC QUESTIONNAIRE Directions : Please give all of your answers by comple tely filling in the circle beside your answer. It should look like this : Remember, your answers to all questions in this packet will be kept completely private. Are you female or male? O Female O Male How old are you? O 12 O 15 O 13 O 16 O 14 O 17 How do you describe yourself? O African-American/Black-American (not of Hispanic origin) O Caucasian/White/European-American (not of Hispanic origin) O Hispanic/Latino O Multi-Racial (please describe:____________________________) What grade are you in? O 5th O 10th O 6th O 11th O 7th O 12th O 8th O I do not go to school O 9th How many hours per week do you usually take pa rt in sports and athletics at school or in your community (such as soccer, football, cheerl eading, swimming, running, walking, or weightlifting) ?

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71 O None O 1-5 hours each week O 6-10 hours each week O 11 or more hours each week How many hours each week do you usually take part in activities at school or in your community that are not sports (such as music groups, clubs, scouts, church, volunteering, chores) ? O None O 1-5 hours per week O 6-10 hours per week O 11 or more hours per week How many hours each week do you usually work at a paid job? O None O 1-10 hours O 11-20 hours O 21-30 hours O 31-40 hours Do you have any children of your own? O No O Yes (How many?:_______) When we mail you things would yo u like them to be written in: O English O Spanish Have you felt any of these things? (Fill in all that you have felt.) O blurry vision O shortness of breath O dizzy O thirsty a lot of the time O headaches O tired a lot of the time O none Which of the following, if any, has your doctor or someone else at your doctors office asked you to do to treat your high blood p ressure, diabetes (sugar), or weight? (Fill in all that you have been told to do.)

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72 O take medication O change the kinds of things you eat O exercise O lose weight O other: _________ _____________________________________ _____________ Do you think your doctor or someone else at you r doctors office has taught you about high blood pressure, diabetes (sugar), and/or obesity? (Fill in one answer only. ) O Agree a lot O Agree a little O Not Sure O Disagree a little O Disagree a lot Do you have (Fill in all that you have) : O high blood pressure O diabetes (sugar ) O obesity (very overweight) O none Does any other member of your immediate family (par ent, brother, sister) have any of the following problems? (You can fill in more than one bubble.) O high blood pressure O diabetes (sugar) O very overweight O none In school, which of these gr ades do you mostly make? O A O B O C O D O F What is your Grade Point Average (GPA)? _________

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73 In the past year, what grade have you most ly made in English/Language Arts/Reading ? O A O B O C O D O F In the past year, what grade have you mostly made in Math ? O A O B O C O D O F In the past year, what grade have you mostly made in So cial Studies/History ? O A O B O C O D O F In the past year, what grade h ave you mostly made in Science ? O A O B O C O D O F

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74 The following information will only be used to check your school grades and will be kept completely private To protect your privacy, the CHSE researchers will separate this page from all of the above information. What school do you go to ? ____________________ _____________________ What county do you live in? _______________ _______________ What is your birth da te? ______ ______________ What is your Social Security Number? ______ ______________ _________ What is your Florida Student ID Number ( located on any of your report cards )? ____________________ _____________ PLEASE RETURN ALL PAGES OF THIS QUESTIONNAIRE Thank you for helping us with this research!

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75 APPENDIX D THE HEALTH PROMOTING LIFESTYLES PROFILE-II How often do you: NeverSometimes Often Routinely (Very Often) 1. Discuss your problems and concerns with people close to you? 2. Choose a diet low in fat, saturated fat, and cholesterol? 3. Report any unusual signs or symptoms to a physician or other health professional? 4. Follow a planned exercise program? 5. Get enough sleep? 6. Feel you are growing and changing in positive ways? 7. Praise other people easily for their achievements? 8. Limit the use of sugars and food containing sugar (sweets)? 9. Praise yourself, think positively about yourself, or feel good about yourself when you limit the use of sugars and food containing sugar (sweets)? 10. Read or watch TV programs about improving health? 11. Exercise vigorously for 20 or more minutes at least three times a week (such as brisk walking, bicycling, aerobic dancing, using a stair climber?) 12. Take some time for relaxation each day? 13. Believe that your life has purpose? Directions: We want to know about your way of life and personal habits. Please answer each question as honestly as you can, and try not to skip any ques tion. Show how often you do each behavior by filling in one circle for each question. Your answer should look like this:

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76 14. Maintain meaningful and fulfilling relationships with others? How often do you: NeverSometimes Often Routinely (Very Often) 15. Eat 6-11 servings of bread, cereal, rice, and pasta each day? 16. Question health professionals in order to understand their directions? 17. Take part in light to mo derate physical activity (such as sustained walking 30-40 minutes five or more times a week)? 18. Accept those things in your life that you cannot change? 19. Look forward to the future? 20. Spend time with close friends? 21. Eat 2-4 servings of fruit a day? 22. Praise yourself, think positively about yourself, or feel good about yourself when you eat 2-4 servings of fruit a day? 23. Get a second opinion when you question your health care providers advice? 24. Take part in leisuretime (recreational) physical activities (such as swim ming, dancing, bicycling)? 25. Concentrate on pleasant thoughts at bedtime? 26. Feel content and at peace with yourself? 27. Find it easy to show concern, love, and warmth to others? 28. Eat 3-5 servings of vegetables each day? 29. Praise yourself, think positively about yourself, or feel good about yourself when you at 3-5 servings of vegetables each day?

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77 How often do you: NeverSometimes Often Routinely (Very Often) 30. Discuss your health co ncerns with health professionals? 31. Do stretching exercises at least 3 times per week? 32. Use specific methods to control your stress? 33. Work toward long-term goals in your life? 34. Touch and get touched by people you care about? 35. Eat 2-3 servings of milk, yogurt, or cheese each day? 36. Praise yourself, think positively about yourself, or feel good about yourself when you eat 2-3 servings of milk, yogurt, or cheese each day? 37. Inspect your body at least monthly for physical changes/danger signs? 38. Get exercise during usual daily activities (such as walking during lunch, usi ng stairs instead of elevators, parking car away from destination and walking)? 39. Praise yourself, think positively about yourself, or feel good about yourself when you get exercise during usual daily activities? 40. Balance time between work and play? 41. Find each day interesting and challenging? 42. Find ways to meet your needs for intimacy? 43. Eat only 2-3 servings fr om the meat, poultry, fish, dried beans, eggs, and nuts group each day? 44. Ask for information from health professionals about how to take good care of yourself?

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78 How often do you: NeverSometimesOften Routinely (Very Often) 45. Check your pulse rate when exercising? 46. Practice relaxation or meditation for 15-20 minutes daily? 47. Think about what is important in your life? 48. Get support from a network of caring people? 49. Read labels to iden tify nutrients, fats, and sodium content in packaged food? 50. Attend educational programs on personal health care? 51. Reach your target heart rate when exercising? 52. Pace yourself to pr event tiredness? 53. Feel connected with some force greater than you? 54. Settle conflicts with others through discussion and compromise? 55. Eat breakfast? 56. Seek guidance or counseling when necessary? 57. Expose yourself to new experiences and challenges? 58. Praise yourself, think positively about yourself, or feel good about yourself?

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79 LIST OF REFERENCES Am erican Academy of Pediatrics (AAP). (2002) Clinical practice gui deline: diagnosis and management of childhood obstr uctive sleep apnea syndrome. Pediatrics, 109, 704 American Academy of Pediatrics (AAP). (2006) Active healthy living: prevention of childhood obesity through increa sed physical activity. Pediatrics 117:1834-1842. Agency for Healthcare Research and Quality (AHRQ). (2008). HCUP Databases. Healthcare cost and utilization project (HCUP). Retrieved on March 23, 2008 from www.hcupus.ahrq.gov/nisoverview.jsp. American Obesity Association (AOA). Retrieved December 4, 2006, from www.obesity.org. Arcan, C., Neumark-Sztainer, D., Hannan, P., va n den Berg, P., Story, M., & Larson ,N. (2007). Parental eating behaviors, home food environment and adolescent intakes of fruits, vegetables and dairy foods: Longitu dinal findings from Project EAT. Public Health Nutrition 10, 1257-1265. Bandura, A. (1977). Social learning theory. Englewood Cliffs, NJ: Prentice-Hall. Bandura, A. (1982). Self-efficacy mechanism in human agency. American Psychologist, 37, 122-215. Bandura, A. (1986). Social foundations of thought and ac tion: A Social cognitive theory. Englewood Cliffs, NJ: Prentice-Hall. Bandura, A. (1997). Self-efficacy: The exercise of control New York: Freeman. Bandura, A. (2001). Social cognitive theory: An agentive perspective. Annual Review of Psychology, 52, 1-26. Barlow, S.E., & Dietz, W.H. (1998). Obesity evaluation and treatment: Expert committee recommendations. Pediatrics 102, e29. Berry, D., Sheehan, R., Heschel, R., Knafl, K ., Melkus, G., & Grey, M. (2004). Family-based interventions for chil dhood obesity: A review. Journal of Family Nursing 10(4), 429 449. Birch, L., & O Fisher, J. ( 1998). Development of eating behaviors among children and adolescents. Pediatrics, 101, 539-541. Birch, L.L., & Davison,K.K. (2001). Family en vironmental factors infl uencing the developing behavioral controls of f ood intake and childhood overweight. Pediatric Clinician North America 48, 893-907.

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80 Booth, S., Sallis, J., Ritenbaugh, C., Hill, J., Bi rch, L., Frank, L., et al. (2001). Environmental and societal factors affect food choice and physical activit y: Rationale, influences, and leverage points. Nutrition Reviews 59(3, Part 2), 21-39. Bowman, S. A., Gortmaker, S. L., Ebbeling, C. B., Pereira, M. A., & Ludwig, D. S. (2004). Effects of fast-food consumption on energy in take and diet quality among children in a national household survey. Pediatrics 113(1), 112-118. Budd, G., Volpe, B. (2006). School-based obesity prevention: Research, recommendations, and challenges. Journal of School Health, 76(1), 485-495. Callaghan, D. (2006). Basic conditio ning factors' influences on adolescents' healthy behaviors, self-efficacy, and self care. Issues in Comprehensive Pediatric Nursing. 29. 191-204. Centers for Disease Control a nd Prevention (CDC). (2000). Phys ical Activity and Youth, CDC Kidsmedia web page, http:// www.cdc.gov/kidsmedia/background.htm CDC. (2003b). Resource guide for nutrition and physical activity interventions to prevent obesity and other chronic diseases Retrieved February 27, 2008, from http://www.cdc.gov/nccdphp/dnpa/obesityprevention.htm. CDC. (2003). New state data show obesity and diabetes still on the rise. Retrieved November 2, 2007 from http://www.cdc.gov/od/oc/media/pressrel/r 021231.htm CDC. ( 2003c). U.S. obesity trends 1985 to 2002 Retrieved February 27, 200, from http://www.cdc.gov/nccdphp/dnpa/obesity/trend/m aps/index.htm. CDC. (2004). Participation in high sc hool physical educationUnited States, 1991, Morbidity and Mortality Weekly Report 53: 844. CDC. (2004). Using the BMI-for-age growth charts. Retrieved March 22, 2008, from http://www.cdc.gov/nccdphp/dnpa/growthchart s/training/m odules/module1/text/page1a. tm CDC. (2005). Healthy People 2010 Retrieved October 27, 2007 from http://www.healthypeople.gov/. CDC. (2005d). Physical activity for everyone: Recommendations: Are there special recommendations for young people? Retrieved February 5, 2008, from http://www.cdc.gov/nccdphp/dnpa/p hysical/recommendations/young.htm CDC. (2005e). Make a difference at your school! CD C resources can help you implement strategies to prevent obesity among children and adolescents. Retrieved January 5, 2008 from http://www.cdc.gov/HealthyYouth/ke ystrategies/obesity_catalog.pdf.

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81 CDC. (2006). Overweight and obesity: health consequences. Retrieved September 12, 2008 from http://www.cdc.gov/nccdphp/dnpa/obesity/consequences.htm. CDC. (2007). Overweight and obesity Retrieved December 12, 2007 from http://www.cdc.gov/nccdphp/dnpa/obesity/defining.htm CDC. (2008). U.S. Obesity Trends 1985. Retrieved April 26, 2008 from http://www.cdc.gov/nccdphp/dnpa/obesity/trend/m aps/. C.L. Ogden, M.D. Carroll, L.R. Curtin, M.A. McDowell, C.J. Tabak & K.M. Flegal. (2006). Prevalence of overweight and obesi ty in the United States, 1999. Journal of the American Medical Association, 295, pp. 1549. Crocker, J., Major, B., & Steele, C. (1998). Soci al stigma. In D. Gilbert, S. T. Fiske, & G. Lindzey (Eds.), Handbook of social psychology (4th ed., pp. 504-553). Boston: McGraw Hill. Coates, T.J., Killen, J.D., & Slinkard, L.A. (1982). Parent participation in a treatment program for overweight adolescents International Journal of Eating Disorders 1, 37-45. Colditz, G., (1999). Economic cost s of obesity and inactivity. Medicine & Science in Sports & Exercise 31, pp. S663S667. Corwin, S. J., Sargent, R. J., Rheaume, C. E., & Saunders, R. P. ( 1999). Dietary behaviors among fourth graders: A social cognitive theory study approach. American Journal of Health Behavior, 23, 182-197. Crawford, P., Story, M., Wang, M., Ritchie, L., Sabry, Z. (2001). Ethnic issues in the epidemiology of child obesity. Pediatric Clinics of North America 48(4), 855-878. Croll, J. K., Neumark-Sztainer, D., & Story, M. (2001). Healthy eating: What does it mean to adolescents? Journal of Nutrition Education 33(4), 193-198. Cullen, K., W., Baranowski, T., Rittenberry, L. & Olvera, N. (2000). Socio-environmental influences on childrens diets: Results fr om focus groups with African Euro and Hispanic children and their parents. Health Education Research 15, 581-590. Cullen, K., Baranowski, T., Rittenberry, L., Cosart, C., Owens, E., Hebert, D., & de Moor, C. (2000). Socio-environmental influences on children's fruit, juice and vegetable consumption as reported by parents: Reliability and validity of measures. Public Health Nutrition 3, 345-356. Cullen, K.W., Baranowski, T., Owens, E., DeMoor C., Rittenberry, L., Olvera, N., & Resnicow, K. (2002). Ethnic differences in soci al environmental correlates of diet. Health Education Research 17, 7-18.

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82 Cullen, K. W., Baranowski, T., Owens, E., Mars h, T., Rittenberry, L., & de Moor, C. (2003). Availability, accessibility, and preferences fo r fruit, 100% fruit juice, and vegetables influence children's dietary behavior. Health Education & Behavior 30, 615-626. Davison, K. K., Cutting T. M., & Birch, L. L. (2003). Parents activity-related parenting practices predict girls physical activity. Medicine and Science in Sports and Exercise 35, 1589-95. Deckelbaum, R.J., & Williams, C.L. (2001). Childhood obesity: the health issue. Obesity Resources. 9, 239SS. Dietz, W. (1998). Health consequences of obesity in youth: childhood predic tors of adult disease. Pediatrics 101, 518-525. Dietz, W. H. (2004). Overweight in childhood and adolescence. The New England Journal of Medicine, 350, 855-857. Ebbeling, C.B., Pawlak, D.B., Ludwig, S.L. (2002). Childhood obesity: Public-health crisis, common sense cure. The Lancet, 30, 473-482. Eberstadt, M. (2003). The Child-Fat Problem. Policy Review, 117, Hoover Institute, Stanford University http://www.policyreview.org/FEB03/eberstadt.html Epstein, L. H., Wing, R. R., Koeske, R., & Valoski, A. (1987). Long-term effects of family based treatment of childhood obesity. Journal of Consulting and Clinical Psychology 55(1), 91-95. Epstein, L.H., Valoski, A., Wing, R.R., & Mc Curley, J. (1990). Ten-year follow-up of behavioral, family-based treatment for obese children. Journal of the American Medical Association 264, 2519-2523. Epstein, L.H., Valoski, A., Wing, R. R., & McCurley, J. (1994). Ten-year outcomes of behavioral family-based treatment for childhood obesity. Health Psychology, 13, 373 383. Dietz, W.H. & Gortmaker, S.L. (2001). Preven ting obesity in child ren and adolescents. Annual Review of Public Health 22, 337. Fagot-Campagna, A., Pettitt ,D.J., Engelgau, M.M., Burrows ,N.R., Geiss, L.S., Valdez, R., Beckles, G.L., Saaddine, J., Gregg, E. W., Williamson, D.F., & Narayan, K.M. (2000). Type 2 diabetes among North American ch ildren and adolescents: an epidemiologic review and a public health perspective. Pediatrics, 136: 664-672. Falkner, N.H., Neumark-Sztainer, D., Story, M ., Jeffery, R.W., Beuhring, T. & Resnnick, M.D. (2001). Social, educational, and psychological correlates of weigh st atus in adolescents. Obesity Research, 9, 32 42.

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92 BIOGRAPHICAL SKETCH Christopher Mack received his Bachelor of Arts (B.A.) in psychology and Master of Social W ork (M.S.W.) from the University of Michigan and began to work with abused and abandoned children in Ann Arbor, Michigan. Cu rrently, Christopher Mack is attending the University of Florida pursuing his PhD in counseling psychology. His research interests include investigating the health risk and violent behaviors as well as academic achievement amongst low-income at-risk minority youth and their families.