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1 ASSOCIATIONS AMONG COPING STYLES AND HEALTH PROMOTING LIFESTYLE BEHAVIORS IN A SAMPLE OF CULTURALLY DIVERSE YOUTH By SARAH ELIZABETH MADISON NOLAN A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE UNIVERSITY OF FLORIDA 2010
2 2010 Sarah Elizabeth Madison Nolan
3 To all who encouraged and supported my academic, professional, and personal pursuits that led me to this achievement
4 ACKNOWLEDGEMENTS I am thankful for the guidance and assistance given to me by my committee members, Dr. Carolyn Tucker, Dr Ken Rice, and Dr. Edil Torres River a. I want to especially thank my chairperson and advisor, Dr. Carolyn Tucker, whose guidance, support, and training has helped tremendously throughout the past two years of my doctoral program I am grateful to the entire counseling psychology faculty for facilitating my personal and professional growth over the last two years, while assisting me i n maintaining a sense of humor. I would also like to thank my friend, Dereck Chiu, for inspiring me daily t o continue to pursue my dreams. Lastly, I want to t hank my parents, brother, sister, and close friends for their unending love and support.
5 TABLE OF CONTENTS page ACKNOWLEDGEMENTS ............................................................................................... 4 LIST OF TABLES ............................................................................................................ 7 ABSTRACT ..................................................................................................................... 8 CHAPTER 1 INTRODUCTION .................................................................................................... 10 Impetus for Focusing on Health Promoting Lifestyle Behaviors: The Obesity Epidemic .............................................................................................................. 10 Health Promoting Lifestyle Behaviors ..................................................................... 12 Health Promotion Model ......................................................................................... 15 Coping Styles .......................................................................................................... 16 Present Study ......................................................................................................... 18 2 REVIEW OF THE LITERATURE ............................................................................ 20 Coping Styles .......................................................................................................... 20 Coping and Health Promoting Lifestyle Behaviors .................................................. 22 Impac t of Gender .............................................................................................. 25 Impact of Age Group ........................................................................................ 27 Impact of Race/Ethnicity ................................................................................... 29 3 METHODS .............................................................................................................. 31 Participants ............................................................................................................. 31 Measures ................................................................................................................ 33 Childrens Coping Strategies Checklist Revision 1 ........................................... 33 Active coping. ............................................................................................. 34 Distraction coping. ..................................................................................... 34 Avoidance coping. ...................................................................................... 35 Support seeking coping. ............................................................................ 35 Health Promoting Lifestyles Profile ................................................................... 35 Procedure ............................................................................................................... 36 4 RESULTS ............................................................................................................... 42 Descriptive Data for all Major Variables .................................................................. 42 Reliability of Instruments ......................................................................................... 42 Results of the Preliminary Pearson Correlation Analysis ........................................ 43 Coping Style Variable Associations .................................................................. 44
6 Health Promoting Lifestyle Behavior Variable Associations ............................. 44 Results of the Analyses to Test Hypotheses One and Two .................................... 45 Associations between the ActiveSupport Seeking and Distraction Coping Style Variables and Health Promoting Lifestyle Behavior Variables ...................... 45 Associations between the Avoidance Coping Style Variable and Health Promoting Lifestyle Behavior Variables ......................................................... 45 Results of the Analyses to Address Hypothesis Three ........................................... 46 Results from Assessing Gender Differences in the Associations between Coping Styles and Engagement in Healthy Eating ........................................ 46 Results from Assessing Gender Differences in the Associations between Coping Styles and Engagement in Physical Activity ..................................... 47 Results of the Analyses to Address Research Questions One and Two ................ 48 5 DISCUSSION ......................................................................................................... 53 Summary of the Results .......................................................................................... 53 Hypotheses One and Two ................................................................................ 53 Hypothesis Three ............................................................................................. 55 Research Question One ................................................................................... 57 Research Question Two ................................................................................... 58 Limitations, Strengths, and Fut ure Directions from the Present Study .................... 60 Implications for Counseling Psychologists .............................................................. 62 Conclusions ............................................................................................................ 63 APPENDIX A PARENTAL INFORMED CONSENT FORM ........................................................... 64 B CHILD ASSENT SCRIPT ........................................................................................ 66 C DEMOGRAPHIC DATA QUESTIONNAIRE ............................................................ 67 D CHILDRENS COPING STRATEGIES CHECKLIST R1 ......................................... 69 E HEALTH PROMOTING LIFESTYLE PROFILE: EXERCISING CONSISTENTLY SUBSCALE AND EATING A HEALTHY DIET SUBSCALE .................................... 73 REFERENCES .............................................................................................................. 75 BIOGRAPHICAL SKETCH ............................................................................................ 86
7 LIST OF TABLES Table page 3 1 Demographic characteristics of participants ....................................................... 41 4 1 Means and standard deviations for the variables investigated in the present study for the total sample and by gender and age group .................................... 50 4 2 Pearsons correlation analysis among the variables of interest in the present study for the total sample ................................................................................... 51 4 3 Pearsons correlation analysis among the variables of interest for hypothesis one and hypothesis two ...................................................................................... 51 4 4 Unstandardized beta weights (B), standard error coefficients of beta weights, healthy eating from all investigated predictor variables ...................................... 52 4 5 Unstandardized beta weights (B), standard error coefficients of beta weights physical activity from all investigated predictor variables .................................... 52
8 Abstract of Thesis Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Master of Science ASSOCIATIONS AMONG COPING STYLES AND HEALTH PROMOTING LIFESTYLE BEHAVIORS IN A SAMPLE OF CULTURALLY DIVERSE YOUTH By Sara h Elizabeth Madison Nolan December 2010 Chair: Carolyn M. Tucker Major: Psychology In the present study Penders Health Promotion Model and a four factor theory of coping were used to inform the examination of the associations between coping styles (active coping, distraction coping, avoidance coping, and support seeking coping) and health promoting lifestyle behaviors (engaging in healthy eating and physical activity) among a sample of culturally diverse youth from pre dominately low income families Additionally, whether associations between the investigated coping styles and health promoting lifestyle behaviors differ in association with age group (i.e., children vs. adolescents) and gender was also investigated. Finally, age group and gender dif ferences in coping styles and in health promoting lifestyle behaviors were examined among the participating youth. Specifically, the p articipants in this study consisted of 74 youth (33 children, 37 adolescents, and 4 who did not report age), all of whom wer e between the ages of 9 and 17. Participants were administered an assessment battery that consisted of a Demographic Data Questionnaire, the Childrens Coping Strategies Checklist Revision 1, and the Heal th Promoting Lifestyle Profile. This assessme nt
9 battery was part of the baseline data collection for the larger health promotion intervention study of which the present study is a part. Results provided evidence that among the culturally diverse sample of youth from predominately low income familie s who were participants in this study all four investigated coping styles had significant positive associations with one another, and both investigated health promoting lifestyle behaviors had significant positive associations with one another. The coping styles active coping and support seeking coping were combined into one factor (activesupport seeking coping) based on their highly significant correlation. The active support seeking coping style and distraction coping style each had significant positi ve associat ions with both of the health promoting lifestyle variables (engaging in healthy eating and physical activity) The avoidance coping style was not found to be significantly associated with either of the health promoting lifestyle variables. Taken together, these findings provide support for the first hypothesis and fail to provide support for the second hypothesis. T he associations between coping styles and health promoting lifestyle behaviors did not significantly differ in association with gender This finding failed to provide support for the third hypothesis Additionally, the investigated health promoting lifestyle variables and the coping style variables did not significantly differ by age group or gender. Conclusions, limitations of the study, and implications for research and practice by counseling psychologists are discussed.
10 CHAPTER 1 INTRODUCTION Impetus for Focusing on Health Promoting Lifestyle Behaviors: The Obesity Epidemic The obesity epidemic in the United States has become an important issue because of its economic, medical, sociological, and psychological implications. Furthermore, i n 2000, overweight and obesity were identified as two of the countrys ten leading health indicators because these health problems have been found to be associated with a number of disease conditions, including cardiovascular disease, diabetes, and cancer (U S Department of Health and Human Services, 2000). Among children, b eing overweight is defined as having a body mass index (BMI) at or above the 85th percentile and below the 95th percentile for children of the same age and gender and being obese is defined as having a BMI at or above the 95th percentile for children of the same age and gender (Centers for Disease Control and Prevention [CDC], 2009). It is also noteworthy that more than one third of adults in the U S were classif ied as obese in 2005 2006, and the rate of obesity has consistently risen among adults, with an increase from 15% in the years 1976 1980 to 35% in the years 2005 2006 (National Center for Health Statistics, 2010). This steady rise in the obesity rat e and, subsequently, the associated diseases and disorders, indicates that this epidemic is a growing problem. While problems of overweight and obesity are widespread throughout the entire U S population, there is evidence that children, specifically, ar e becoming increasingly overweight. According to results of the 2007 2008 National Health and Nutrition Examination Survey (NHNES; CDC, 2009) an estimated 17% of children and
11 adolescents between the ages of 2 and 19 in the U S are currently obese. Muc h like the statistics show for adults, the prevalence of overweight children has been increasing over time. In comparing the span of years from 1976 1980 to 2005 2006, children of three age groups showed the following increases in overweight: preschool aged children (ages 2 5), 5% to 11%; school aged children (ages 6 11), 7% to 15%; and adolescents (ages 12 19), 5% to 18% (National Center for Health Statistics, 2010). Given the evidence that children who are overweight or obese tend to also be o verweight or obese when they become adults (Worobey, 2008) it is particularly important to include children in research aimed at preventing obesity in order to address the problem s of overweight and obesity as early as possible. The problems of overweight and obesity in children are particularly prevalent in some children coming from low income families (Balistreri & Van Hook, 2010; Wang, 2001; Wang & Beydoun, 2007), though comparisons across time do suggest that the association between income level and prevalence of overweight or obesity has weakened, particularly from the 1980s to the l ate 1990s (Wang & Zhang, 2007). Additionally, the relationship between socioeconomic status (SES) and rates of overweight and obesity is varied for different groups in terms of gender, age group, and race/ethnicity. One study found that among young boys, those in the high SES group had significantly lower rates of overweight than their lower SES counterparts, but for younger girls, there were no significant differences am ong SES groups. For adolescent boys, there were no significant differences in prevalence of overweight or obesity among SES groups, but for adolescent girls, the low SES group had significantly higher rates of overweight than their me dium and high SES counterparts. Additionally, the
12 relationship between SES and rate of obesity was inverse for nonHispanic Whites, but not for nonHispanic Blacks or Mexican Americans (Wang & Beydoun). Even though t here is a great deal of evidence suggesting that overweight and obesity are problems in youth across many races/ethnicities, certain racial/ethnic minority groups are disproportionately affected by these health problems (Wang & Beydoun, 2007). Specifically, the National Health and Nutrition E xamination Survey (NHANES) for the years 1999 2002 showed that among children aged 6 to 19, 13.6% of nonHispanic Whites were overweight, whereas 20.5% of the nonHispanic Blacks and 22.2% of the Mexican Americans were overweight. Additionally, 28.2% of the nonHispanic Whites were either overweight or at risk of becoming overweight, whereas 35.4 % of the nonHispanic Blacks and 39% of the Mexican Americans were either overweight or at risk of becoming overweight The prevalence of overweight or risk for becoming overweight for nonHispanic Blacks has also been found to be significantly less than for Mexican Americans (Hedley et al., 2004). T he disparity of the problems of overweight and obesity across race/ethnicity gender, and age supports the need f or research with culturally diverse samples that aims to understand the occurrence of these problems and the engagement in behaviors to prevent their occurrence such as health promoting lifestyle behaviors. Health Promoting Lifestyle Behaviors One of the most direct ways to prevent and reverse the obesity epidemic and its related health problems is by engaging in various health promoting lifestyle (HPL) behaviors (de Silva Sanigorski et al., 2010). HPL behaviors are behaviors that directly or indirectly positively impa ct ones health (Pender, 1996). These behaviors include engaging in physical activity, healthy eating, stress management, and health
13 responsibility behaviors. In this paper such behaviors are also called HealthSmart Behaviors ( HSBs ) There is much evidence of links between HealthSmart Behaviors (HSBs) a nd health outcomes among youth. For example, t he HSB engaging in healthy eating has specifically been linked to improved health and obesity reduction among youth (Chaloupka & Johnston, 2007; Bowman, Gortmaker, Ebbeling, Pereira, & Ludwig, 2004; Swinburn, Caterson, Seidell, & James, 2004). There is also evidence that children who live in low income areas may have exposure to certain negative factors and lack of exposure to certain posit ive factors that can influence their engagement in HSBs For example, a significant association has been found between being a lowincome neighborhood and density of unhealthy food establishments (Block, Scribner, & DeSalvo, 2004; Neckerman, et al., 2010). Given this finding an d the evidenced relationship between close proximity to fast food restaurants and increased rates of obesity (Inagami, Cohen, Brown, & Asch, 2009) it is reasonable to conclude that ac cess to unhealthy food options is a factor in the increased rates of overweight and obesity in the population of individuals living in lowincome neighborhoods There is also research i ndicating that low income children have less access to healthy food options (Hosler, Rajulu, Ronsani, & Fredrick 2008; Powell, Chaloupka, & Bao, 2007) and are less likely to consume fruits and vegetables (Dubowitz et al., 2008) than their higher income counterparts. The established positive relationship between increased fruit and vegetable intake and overall heal th (U S Department of Health and
14 Human Services, 2005) indicates that having less access to these foods is a potential contributor to the problem of obesity in this population. P hysical activity has been specifically linked to improved health and obesity reduction among youth (Flynn et al., 2006; Berkey, Rockett, Gillman, & Colditz, 2003; Franzini et al. 2009). Interestingly, t here is evidence suggesting that children from low income families have less access to areas in which they can engage in physical activity than their counterparts from higher income families (Estabrooks, Lee, & Gyurcsik, 2003; Powell, Slater, & Chaloupka, 2004) L ess access to areas in which one can engage in physical activity is a barrier to exercising (Veugelers, Sithole, Zhang, & Muhajarine, 2008). In a focus group study of low income families, participants identified a lack of physical activity as a primary barrier to their prevention of childhood obesity (Correa et al. 2010). Among the reasons given by these participants for their lack of physical activity wer e lack of safety, lack of awareness of activities that already existed, lack of transportation to physical activities and lack of resources (e.g., enough physical education teachers at local schools). These findings suggest that it is particularly important to include youth from low income families in research on factors that influence the engagement of youth in health promoting behaviors. Given the significant relationship between engagement in HealthSmart Behaviors (HSBs) and obesity reduction among children, there is a need for research to gain a better understanding of the variables under the direct control of youth, such as psychological variables, that influence their engagement in t hese behaviors. Consequently, the goal of the present study is to use Penders health promotion model
15 (1996), as well as well established theories of coping behaviors in children and adolescents to examine the relationship between the psychological variable coping styles and engagement in healthy eating and physical activity (i.e., HSBs) among culturally diverse youth ( children and adolescents ) Whether this relationship, if found, differs in associat ion with age group and gender was also examined. Additionally, this st udy examined whether there are differences in coping styles and levels of HSBs (i.e., engagement in healthy eating and physical activity) in association with age group and gender. Health Promotion Model Penders Health Promotion Model (Pender, 1996) has c lear implications for helping and empowering individuals to engage in Health Smart Behaviors (HSBs) In this model, Pender posits that an individuals engagement in HPL behaviors is influenced by her/his personal, behavioral and cognitive characteristics An underlying assumption of this model is that an individual can play an active role in their engagement in a health promoting lifestyle by not only directly influencing the specific HPL behaviors (e.g., engaging in more physical activity or eating more healthy foods), but also by influencing or modifying the personal characteristics and factors (e.g., biological, social, and psychological factors), as well as the cognitive characteristics and factors (e.g., perceived benefits or consequences of actions, perceived barriers to actions, perceived self efficacy, and influences from others) that have been found to be associated with these behaviors (Wu & Pender, 2002). One example of a personal characteristic described above is an individuals coping ability or style which is an individuals response to the stress in their environment (Lazarus, 1993).
16 Stress is a psychological variable that has been found to be significantly associated with engagement in HPL behaviors including among children and adolescent s. For example, i n a study of school aged, culturally diverse children, it was found that children tended to use eating as a strategy for coping with stress. Based on this finding, the researchers who conducted this study concluded that high stress situa tions may lead to unhealthy eating habits (Jenkins, Rew, & Sternglanz, 2005). Similarly, Nguyen Rodriguez, Chou, Unger, and Spruijt Metz (2008) found among a sample of culturally diverse youth that engaging in unhealthy eating is a coping strategy Addit ionally, these researchers found that some individuals learn to use eating as a coping strategy so early in their development that it is already established by adolescence. Stress has also been found to be negatively associated with level of engagement in physical activity among adults (Ensel & Lin, 2004); however, the research investigating this association among children is limited. In a pioneering laboratory study during which children were induced with stress and given the option of being sedentary or being physically active, there was a significant association between stress level and a reduced desire to engage in physical activity (Roemmich, Gurgol, & Epstein, 2003). Given that stress may negatively influence engaging in a health promoting lifestyle among children, it is possible that certain childrens coping styles might be significantly associated with level of engagement in health promoting lifestyle behaviors. The present study examine d this association among a culturally diverse sample of youth. Coping Styles The majority of the research on coping styles has involved adult participants. T he research on the coping styles of children and adolescents has focused on their coping
17 styles in the presence of traumatic and highstress events, such as after natural disasters (Zhang et al., 2010), during treatments for cancer or other diseases (Garralda & Rangle, 2004; Trask et al., 2003), and following parental divorce or other significant family trauma (Sandler, Tein, & West, 1994; Sandler, Tein, Mehta, Wolchik, & Ayers, 2000). As a result, there is not much literature focusing on childrens coping styles for daily or common stressors. Several of the coping style theories that have been used in research with children and adolescents have been found to be too broad in their dimensions of coping styles (Compas, Connor Smith, Saltzm an, Thomsen, & Wadsworth, 2001). Lazarus and Folkman (1984) identified problem focused and emotionfocused coping dimensions to characterize an individuals efforts to either actively do something to reduce a stressor (i.e., problemfocused coping) or to do something to relieve the consequential negative emotions from a stressor (i.e., emotion focused coping). Similarly, the dimensions of primary control (i.e., an individuals efforts to directly regulate an actual stressful event or the negative emotions associated with a stressful event) and secondary control (i.e., an individuals efforts to adapt to a stressful environment in order to reduce the stress) have been identified as two broad dimensions of coping (R udolph, Dennig, & Weisz, 1995). A third set of broad coping dimensions used in research with children and adolescents are engagement coping (i.e., an individuals efforts to address the source of their stress or their negative thoughts or emotions associated with their stress) and disengagement coping (i.e., an individuals efforts to move away from the stressor and its related negative thoughts and feelings ) (Tobin, Holroyd, Reynolds, & Wigal, 1989).
18 Ayers, Sandler, West, and Roosa (1996) set forth a theor etical four factor model of coping among children that has dimensions that are less broad than the above mentioned coping dimensions set forth by other researchers. Ayers et al. proposed the following four coping di mensions: (a) active coping (i.e., using direct problem focused and positive reframing strategies to deal with a stressor), (b) support seeking coping (i.e., seeking problem focused and emotionfocused support in order to deal with a stressor), (c) distrac tion coping (i.e., using distracting actions and the physical release of energy to deal with a stressor), and (d) avoidance coping (i.e., using avoidant action, repression, and wishful thinking strategies to deal with a stressor). Present Study The presen t study is part of a larger health promotion research project investigating the effectiveness of a health promotion intervention program called the Family Health Self Empowerment (FHSE) Program to Modify and Prevent Obesity (called the FHSE Project). The t ested intervention program was anchored in Health Self Empowerment (HSE) Theory which asserts that promoting HSBs requires health motivation, health self efficacy, self praise of HSBs, coping skills /strategies, and most recently health responsibility ( Tuck er, Butler, Loyuk, Desmond, & Surrency, 200 9 ; Tucker, Daly, & Herman, 2010). Th e present study involved only baseline data from the youth participants in the larger health promotion research project The purpose of the present study is to examine the associations between coping styles and engagement in specific HPL behaviors (i.e., engaging in healthy eating and physical activity) among the sample of 917 year old youth in the larger health promotion r esearch project a sample among whom there was an over representation of racial/ethnic minority youth and youth in families with low household incomes.
19 The f irst research hypothes i s investigated in this study stated that t he use of the following coping s tyles w ould have significant positive correlation s with both of the health promoting lifestyle (HPL) behaviors (i.e., engaging in healthy eating and physical activity): active coping, distraction coping, and support seeking coping. The second research hypothesis investigated in this study stated that t he use of avoidance copi ng w o uld have significant negative correlations with both of the HPL behaviors (i.e., engaging in healthy eating and phys ical activity) Finally, the third research hypothesis investigated here stated that t he relationship between each coping style and each HPL behavior w o uld differ by gender. Additionally t w o research questions were examined in this study. The first research question asked if coping styles would differ in association with age group and gender. The second research question asked if levels of the HPL behaviors would differ in association with age group and gender.
20 CHAPTER 2 REVIEW OF THE LITERATURE This chapter will present an overview of the literature on coping styles among children and adolescents and, specifically, on how the identified coping styles are associated with engagement in health promoting lifestyle (HPL) behaviors (also called here He alth Smart Behaviors [HSBs]). Literature on gender and age group differences in these var iables will also be presented. First, a review of the literature on coping styles among youth will be presented. Second, the literature on the relationship between these coping styles and the identified HSBs will be presented. Third, the literature on age group and gender differences in coping styles and HSBs will be discussed. Finally, literature on age group and gender differences in associations between coping s tyles and HSBs will be presented. Coping Styles The coping literature has defined coping in many different ways based on varying theoretical models. Broadly defined, coping is the self regulation process that occurs in response to stress, and can include both involuntary and voluntary behavioral and cognitive efforts to respond to the stressor. The coping strategies that an individual uses may be aimed at directly altering the stressor, the environment, or ones emotional reaction to the stressor (Eisenberg, Fabes, & Guthrie, 1997; Lazarus & Folkman, 1984; Compas et al., 2001). In a review of well founded coping models, Compas et al. highlight the importance of attending to the developmental course of coping, as well as the dim ensions and subtypes of coping. T he way in which individuals use certain coping styles during childhood and adolescence can impact an individuals ability to cope with s tress throughout their lifetime. Thus, it is important to understand which
21 coping styles are positive and adapti ve so that these coping styles can be taught to and reinforced among children and adolescents. The research literature investigating childrens use of coping is sparse. Ayers et al. (1996) tested two well founded coping models that have been used with adults (Lazarus & Folkman, 1984; Billings & Moos, 1981), as well as an untested proposed theory of coping, using data collected from fourththrough sixthgrade children. Using confirmatory factor analyses, these researchers established a four factor m odel of childrens coping style. This model of coping styles includes the following coping styles: active coping, distraction coping, avoidance coping, and support seeking coping. The active coping style involves the use of both problem focused coping strategies (e.g., thinking about how to solve the problem, making efforts to improve the problem, and trying to understand the problem) and positive reframing coping strategies (e.g., thinking about the good things that have happened, thinking optimistically about the future, thinking that one can control what happens, and minimizing the problem). The coping literature indicates that children who are judged to be more effective at using active coping strategies or who use these strategies more often have more fav orable behavioral and emotional adjustment s than children who do not use active coping strategies as effectively or as often (Faith, Leone, Ayers, Heo, & Pietrobelli, 2002; Zimmer Gembeck & Locke, 2007). Additionally, use of active coping strategies by ch ildren has been found to increase their coping efficacy over time (Sandler, Tein, Mehta, Wolchik, & Ayers, 2000). The distraction coping style involves use of strategies involving the physical release of emotions (e.g., physically working off feelings wit h exercise) and strategies
22 involving distracting actions (e.g., avoid ing thinking about a problem situation by using a distraction). Research investigating the effectiveness of distraction coping among children and adolescents indicates that this type of coping is adaptive and is associated with a decrease in symptoms of anxiety, depression, and aggressive behavior (Hampel & Petermann, 2005; Langrock, Compas, Keller, Merchant, & Copeland, 2002). The avoidance coping style involves use of avoidant action st rategies (e.g., staying away from a problem), repression strategies (e.g., pushing the problem out of ones mind), and wishful thinking strategies (e.g., imagining that the problem does not exist). The coping literature indicates that the use of avoidance coping strategies in youth (i.e., children and adolescents) is associated with an overall negative psychological adjustment, feelings of helplessness, and an increase in behavioral and emotional problems (Liu, Tein, & Zhao, 2004; SeiffgeKrenke, 2000; deB oo & Spiering, 2010; Compas, Connor Smith, & Jaser, 2004). The support seeking coping style involves seeking support for action strategies (e.g., seeking advice or information to solve a problem) and support for feeling focused strategies (e.g., talking about ones feelings with another person). Research indicates that this style of coping is associated with positive health outcomes and increased well being (Visconti & TroopGordon, 2010; Broderick & Korteland, 2002; Kochenderfer Ladd & Skinner, 2002; Fields & Prinz, 1997; de Boo & Wicherts, 2009). Additionally, support seeking has been found to be an effective coping mechanism when faced with stress or other problems (Seiffge Krenke, Aunola, & Nurmi, 2009). Coping and Health Promoting Lifestyle Behaviors Given that individuals often experience disturbances in their eating and physical activity when they do not cope well with stress and other such emotions (Jenkins et al.
23 2005; Birkeland, Torsheim, & Wold, 2009; Eisenberg et al., 1997) an outcome of inadequate coping with these emotions over time can and often does lead to overweight/obesity (MartynNemeth, Penckofer, Gulanick, Velsor Friedrich, & Bryant, 2009). Thus, having an effective coping style that promotes effective management of stress and other emotions may also be associated with engagement in HPL behaviors. Unfortunately, there is a paucity of research investigating the specific relationships between coping styles and engagement in health promoting lifestyle behaviors among children and adolescents. In a study involving children with asthma, Mitchell and Murdock (2002) found that higher levels of both active coping and avoidance coping strategies among these youth were significantly related to their increased participation in developmentally appropriate activities (i.e., developmentally appropriate physical, social, and family household activities) and to their increased engagement in asthma management behaviors (i.e., treatment compliance and medical management). Researchers investigating the relationship between weight criticism during physical activity and engagement in and enjoyment of physical activity among middle school students also looked at the use of active and avoidance coping styles as moderators of this relationship (Faith et al. 2002). Results indicated that not only was the use of problem focused coping (i.e., a dimension of active coping) an effective moderator of this relationship, but that the use of avoidance coping was a moderator for the relationship between weight criticism during physical activity and enjoyment of physical activity. The latter finding regarding avoidance coping is surprising given the aforementioned literature indicating that avoidance coping is associated with increased emotional and behavioral problems
24 among children. The findings regarding active coping, however, have been supported by research indicating that active coping can have positive health benefits (i.e., increased engagement in healthy eating and physical activity ) among children who are coping with stressful events (Manne, Bakeman, Jacobson, & Reed, 1993). Research investigating the relationship between coping styles and unhealthy eating patterns among children and adolescents has also been reported. In one such study of individuals aged 6 to 17, researchers investigated the relationship between various psychosocial characteristics and level of risk for engaging in disturbed eating patterns (Steinhaus en, Gavez, & Metzke, 2005). Results indicated that there was a signif icant negative association between active coping style and being at high risk for disturbed eating. It has also been found in a study involving Spanish adolescents that there is a positive relationship between binge eating and avoidance coping (Baigrie & Giraldez, 2008). The association between avoidance coping and unhealthy eating habits was also found in a study of children with Type 1 diabetes ( Grylli, Wagner, Hafferl Gattermayer, Schober, & Karwautz, 2005). Overall, there is some evidence that a relationship exists between coping styles and both HPL behaviors and overall health. It seems clear that the active coping style is related to improved HPL behaviors. Alternatively, the research is inconclusive regarding the relationship between avoi dance coping and HPL behaviors. There does seem to be a relationship between both support seeking coping and distraction coping and engagement in positive adjustment behavior s; however it is unclear as to whether these coping styles are associ ated with HPL behaviors. Thus there is a need for more research investigating this association among children and adolescents.
25 Impact of Gender The research investigating the relationship between gender and engagement in HPL behaviors indicates that females engage in significantly less physical activity than males (Robbins, Sikorskii, Hamel, Wu, & Wilbur, 2009; Page et al. 2009; Taylor et al., 1999); yet, there is mixed evidence about the existence of gender differences in healthy eating and nutrition (Sabbe, De Bordeaudhuij, Legiest, & Maes, 2008; Gould, Russell, & Barker, 2006; Sweeting & West, 2005). Within the coping literature, there is evidence that there are gender differences in coping styles among youth (i .e., children and adolescents). Researchers investigating gender differences in the use of active coping styles among children have generally specifically focused on problem focused coping and positive reframing coping. Research addressing gender differences in the use of problem focused coping strategies has had inconsistent findings. These findings include that girls use more problem focused coping strategies than boys (Eschenbeck, Kohlmann, & Lohaus, 2007; Hampel & Petermann, 2006; Li, DiGiuseppe, & Froh, 2006), that boys use more problem fo cused coping strategies than girls (Stone & Neale, 1984), and that there are no gender differences in the use of problem focused coping strategies among children (Mullis & Chapman, 2000; Williams & McGillicuddy De Lisi, 1999). Positive reframing coping st rategies have been shown to be used more frequently by girls than boys (Li et al. ; Donaldson, Prinstein, Danofsky, & Spirito, 2000; Lengua & Stormshak, 2000). The relationship between the use of active coping strategies and gender has also been found to vary based on other variables, i ncluding setting and age group. Eschenbeck et al. (2007) found that gender differences in problem focused coping strategies were more significant in a social setting than in an academic setting, for
26 example. Further, Hampel and Petermann (2005) found that as girls got older they showed a decrease in their use of active coping strategies. There is also some research evidence that use of avoidance coping styles also varies by gender Specifically, it has been reported that girls use more avoidance coping strategies than boys (de Boo & Wicherts, 2009; Hampel & Petermann, 2005; Lengua & Stormshak, 2000). In a study of coping with bullying, researchers found that among males, avoidance coping was positively correlated with peer victimization, but this was not the case among females (Kochenderfer Ladd & Skinner, 2002). However, in a study investigating childrens coping strategies following the divorce of their parents, Armistead et al. (1990) found that the avoidance coping s tyle was associated with increased internalizing, externalizing, and physical problems for girls, but had no significant association with overall functioning for boys. Similarly, Seiffge Krenke and Stemmler (2002) found that avoidance coping was associated with depressive symptoms in adolescent girls, but not in boys. In sum, it is apparent that the use of avoidance coping is more frequently used by girls than boys and that while it is unclear whether it is consistently harmful for boys or girls, all of t he available evidence suggests that avoidance coping is not significantly beneficial to children of either gender. Research on t he association between gender and use of both the support seeking and distraction coping styles among children have also garnered mixed results. In a study of children aged 8to 12years old, de Boo and Spiering (2010) found no gender differences in the use of support seeking coping. However, in studies of older adolescents the female adolescents have been found to use significantly more support seeking coping than the male adolescents (Lengua & Stormshak, 2000; Hampel, 2007).
27 Li et al. (2006) found that distraction coping strategies were associated with masculinity in adolescents, and de Boo and Wicherts ( 2009) found that girls were more likely to use the coping strategies associated with the distraction coping style. It is important to understand gender differences in the use of coping styles and in the effectiveness of coping styles among youth as this i nformation may be helpful in designing interventions intended to help youth improve their health outcomes. There is a lack of research investigating gender differences in the relationship between coping styles and engagement in health promoting behaviors. Nicolotti, ElSheikh, and Whitson (2003) studied the association between childrens coping and their physical health when coping with the stress of their parents marital conflict. Results indicated that, for boys and girls, the combined use of active co ping and support seeking coping, as well as distraction coping was significantly associated with being protective against the negative physical health consequences that often occur when there are marital problems in the home. Additionally, for boys, higher levels of avoidance coping were associated with higher levels of physical health. Impact of Age Group An additional demographic variable that has been found to be associated with differences in the use of coping styles among youth is age group (i.e., children vs. adolescents). Research aimed at investigating the coping styles used by youth has generally found that with increased development during adolescence there is an increase in the diversity of coping styles used and the flexibility with which copi ng styles are used (Kavsek & Seiffge Krenke, 1996; Skinner & Zimmer Gembeck, 2007; Williams & McGillicuddy De Lisi 1999). This suggests that as younger adolescents become older adolescents, they are able to cope more effectively. A similar trend has been
28 found when comparing preschool aged children with adolescents ; that is effectiveness of coping styles is higher in older as compared to younger age groups (Fields & Prinz, 1997) T here is little published research examining whether there are age differences in the use of the active coping style, and this limited research has primarily focused on emotionfocused and problem focused coping strategies separately. Some r esearch indicates that the use of emotionfocused coping strategies and problem focused coping strategies both increase with age ( Frydenberg & Lewis, 1993; Eschenbeck et al. 2007; Sieffge Krenke, 1993). However, other researchers have found that there are no significant age differences in either of these dimensions of active coping (i.e., problem focused coping or emotionfocused coping) ( Mullis & Chapman, 2000; Stern & Zevon, 1990). Researchers investigating age group differences in the use of the distraction coping style have also found mixed results. Some studies have demonstrated that the use of the distraction coping style tends to increase with age ( Rossman, 1992; Ryan, 1989) s uch that older children and adolescents are more likely to use these coping strategies than younger children. Other research has indicated that the us e of the distraction coping style decreases with age such that children are more likely than adolescents to use this coping style ( Hampel & Petermann, 2005; Donaldson, Prinstein, Danovsky, & Spirito 2000). Changes in the use of support seeking coping strategies have not been found to be associated with age group (Hampel & Petermann, 2005; Eschenbeck et al. 2007). However, Eschenbeck et al. found that older girls used the support seeking coping style
29 signif icantly more than older boys. No gender by age group interactions effects were found for the use of the other coping styles. Age group differences (i.e., children vs. adolescents) in engagement in physical activity have also been found among yout h. For ex ample, it has been found that age is inversely related to engagement in moderate to intense physical activity Specifically, it has been found that as children get older during childhood and adolescence they are less likely to engage in physical activity (Trost et al. 2002; Troiano, 2008; Nader, Bradley, Houts, McRitchie, & OBrien, 2008). No known study has investigated age differences in levels of engagement in healthy eating among youth. Age group classification (i.e., children vs. adolescents) is evi dently associated with an individuals use of coping styles and engagement in at least one of the HPL behaviors Thus, in the present study, age group differences in the investigated coping styles and HPL behaviors will be investigated. Impact of Race/Ethnicity There is a paucity of literature investigating the relationship between race/ethnicity and coping styles (i.e., active coping, distraction coping, avoidance coping, support seeking coping) among children and adolescents. In a study investigating cultural differences in adolescent coping in seven countries in Europe, Gelhaar et al. (2007) found no significant cultural differences in coping with stressors related to self and future related problems Similarly, in a study comparing Israeli and Arab adolescents, BraunLewensohn, Sagy, and Roth (2010) found that these two different cultural groups used similar levels of active coping strategies. This research suggests that among children and adolescents there may be minimal cultural differences w ith regard to coping styles.
30 Research investigating race/ethnicity differences in engagement in HPL behaviors among children is mixed. Some research suggests that there are no race/ethnicity differences in childrens engagement in physical activity (Dowda, Saunders, Hastings, Gay, & Evans, 2009) while other research indicates that there are race/ethnicity differences (Andersen, Crespo, Bartlett, Cheskin, & Pratt, 1998). Examination of r ace/ethnic differences in healthy eating among children and adolescents has also garnered mixed results (Mackey & La Greca, 2007; Striegel Moore et al., 2006; Lowry, Wechsler, Galuska, Fulton, & Kann, 2002) The inconsistency in findings related to race/ethnic differences in healthy eating patterns is reflected in a review of the literature on fruit and vegetable intake among children and adolescents where researchers found that of 13 articles reviewed 11 had inconsistent findings (Rasmussen et al., 2006). In sum, there is a lack of evidence of racial/ethnic differences i n coping styles among youth and some lack of consistency in findings related to racial/ethnic differences in health promoting lifestyle behaviors among youth. As such the present study focuses on the coping styles and health promoting lifestyle behaviors among a culturally diverse sample of children and adolescents without examining race/ethnicity differences in these variables or in the relationships among these variables.
31 CHAPTER 3 METHODS Participants The youth (i.e., child and adolescent) participants in the earlier mentioned Family Health Self Empowerment (FHSE) Program, of which this study is a part, were the participants in this study. Initially, 121 children and adolescents were recruited for the larger study (and thus for the present study) and completed the initial assessments (i.e., Assent Form and Demographic Data Questionnaire), however only 74 (61.2%) participants completed the full assessment battery for th e present study. The 74 participants in this study ranged in age from 9 to 17 year s old ( M = 12.5 years ) There were 33 children ( ages 9 to 12) and 37 adolescents ( ages 13 to 17). Four participants did not report their age. Demographic information for the total sample is presented in Table 3 1. Among the participants who were children (ages 9 to 12), 16 (48.5%) identified as African American/Black, 9 (27.3%) identified as White/Caucasian/European American, 3 (9.1%) identified as Hispanic/Latino, and 5 (15.2%) identified as other. Those who sel f identified as other included American Indian or Alaska Native, Asian American, Native Hawaiian or other Pacific Islander, West Indian, Bahamian, and multiracial participants and are therefore considered a group of racial/ethnic minorities. Twenty two (66.7%) of the participants who were children were male and 11 (33.3%) were female. Among the participants who were adolescents (ages 13 to 17), 10 (27.0%) identified as African American/Black, 7 (18.9%) identified as White/Caucasian/European American 9 ( 24.3%) identified as Hispanic/Latino, and 11 (29.7%) identified as other.
32 Twenty two (59.5%) of the participants who were adolescents were male and 15 (40.5%) were female. Participants were initially asked whether they were on a special diet because of a health condition such as diabetes or hypertension. Seventy four (100%) indicated that they were not on a special diet. Additionally, participants were asked whether they were currently trying to lose weight. Forty seven (63.5%) participants responded that they were not trying to lose weight and 27 (36.5%) participants responded that they were trying to lose weight. Of the adolescent participants (ages 13 to 17), 12 (32.4%) reported that they were trying to lose weight which is a lower percent than th e percent of adolescents reported in other studies as trying to lose weight (Lowry, Galuska, Fulton, Wechsler, & Kann, 2002; Nystrom, Schmitz, Perry, Lytle, & Neumark Sztainer, 2005). Of the children participants (ages 9 to 12), 15 (45.5%) reported that they were trying to lose weight which is consistent with the percent of children in other studies who reported wishing they could weigh less, but higher than the percent of children in other studies who reported activel y trying to lose weight (Schur, Sanders, & Steiner, 2000; Sands & Wardle, 2005). S elf reported household income levels of the parents/ guardians with whom the participating youth lived were used as the household income levels of the respective youth partic ipants. Using this parent/ guardianparticipant youth household link, the household incomes of the participating youth as reported by their guardian larger study participants are reported in Table 3 1 along with the other d emographic characteristics of the total sample.
33 Measures A ll participants in this study completed an Assessment Battery (AB) that included the following instruments: (1) a Demographic Data Questionnaire (DDQ) (2) the Childrens Coping Strategies Checklist Revision 1 (CCSCR1) and (3) the Health Promoting Lifestyles Profile (HPLP). Detailed descriptions of these instruments are provided below and each instrument may be found in the appendices. The Demographic Data Questionnaire (DDQ ; see Appendix C ) was constructed by the researchers It was used to collect demographic information including age, race, and gender. Childrens Coping Strategies Checklist Revision 1 The Childrens Coping Strategies Checklist Revision 1 (CCSCR1; Ayers et al. 1996; see Appendix D ) was used to assess levels of four coping styles (i.e., active coping, distraction coping, avoidance coping, and support seeking coping) The CCSCR1 is a 54item Likert type self report measure of childrens coping styles and consists of four sub scales one to measure each of the coping styles that it measures. Instructions on the CCSC R1 to any respondent are to answer the listed questions about her/his usual behavior during the last month and to indicate how often she/he does each behavior for the purpose of making oneself feel better. A 4 point behavior frequency rating scale ranging from 1 ( n ever ) to 4 ( m ost of the t ime ) is provided. Subscale scores are calculated for the CCSC R1 by obtaining the mean of responses within each coping sub scale. Cronbach alpha reliability coefficients for the subscale scores except for scores on the distraction coping subscale have been reported to be as follows: active coping, 0.88; avoidance coping, 0.65; and support seeking coping, 0.86 (Program for Prevention Research, 2001). Cronbach alpha reliability coefficents for the
34 distraction coping subscale scores were not earlier reported by Program for Prevention Research (2001) along with the other such coefficients for the CCSC R1 however other researchers found scores on the distraction subscale to have a reliability coefficient of 0.72 (Smith et al., 2006). Active coping. The active coping sub scale consists of 24 items and is made up of the following two dimensions : problem focused coping (12 items) and positivereframing coping (12 it ems). The problem focused coping dimension includes items categorized as cognitive decision making (i.e., thinking about ways to solve the problem), direct problem solving (i.e., making efforts to solve the problem), and seeking understanding (i.e., making efforts to better understand the problem). The positivereframing coping dimension includes items categorized as positive thinking (i.e., trying to think about the good things that are happening), optimistic thinking (i.e., thinking about the future in a positive way), and control (i.e., thinking that one is able to deal with whatever happens). An example of an active coping scale item is, You thought about which things are best to do to solve the problem. Distraction coping. The distraction coping subscale consists of 9 items and includes items categorized as physical release of emotions (i.e., efforts to physically work off feelings with physical exercise) and distracting actions (i.e., efforts to avoid thinking about the problem situation by using distracting stimuli). An example of a distraction coping subs cale item is, You went bicycle riding.
35 Avoidance coping. The avoidance coping subscale consists of 12 items and includes items categorized as avoidant actions (i.e., efforts to avoid the problem by staying away from it), repression (i.e., avoidance of thoughts about the problems), and wishful thinking (i.e., using wishful thinking in relation to the problem or imagining the problem was better). An example of an avoidance coping subscale it em is, You daydreamed that everything was okay. Support seeking coping. The support seeking coping s ubs cale consists of 9 items and includes items categorized as support for actions (i.e., the use of other people as resources in seeking solutions to a problem) and support for feelings (i.e., the involvement of other people in listening to feelings). An example of a support seeking coping subscale item is, You told people how you felt about the problem. Health Promoting Lifestyles Profile The Health Promoting Lifestyle Profile (HPLP ; Walker, Sechrist, & Pender, 1987; see Appendix E for subscales used in this study ) was used to asses s health promoting lifestyle (HPL) behaviors (i.e., physical activity and healthy eating behaviors ). This instrument is a 52item Likert type self report inventory that measures the level at which individuals engage in an overall HPL and their level of engagement in each of six specific HPL behaviors There are six HPLP subscales consisting of questions that assess levels of the following specific HPL behaviors: exercising consistently (8 items), eating a healthy diet (9 items), engaging in stress management practices (8 items) displaying health responsibility (9 items), seeking to reach ones fullest potential (9 items), and displaying the ability to form close interpersonal relationships (9 items). For
36 the purpose of this study, only the first two scales (i.e., exercising consistently and eating a healthy diet) were used to measure levels of engagement in physical activity and healthy eating. Instructions on the HPLP are to rate how often one engages in each activity asked about using a 4point scale ranging from 1 ( never ) to 4 ( routinely/very often). A sample question on the exercising consistently subscale is, D o you exercise vigorously for 20 or more minutes at least three times a week (such as brisk walking, bicycling, aerobic dancing, using a stair climber) ? A sample item on the eating a healthy diet subscale is, Do you eat 611 servings of br ead, cereal, rice, and pasta each day? Based on data from a normative sample, Cronbach alpha reliability coefficients for the subscale scores of exercising consistently and eating a healthy diet are 0.81 and 0.76, respectively (N = 95; Walker et al., 1987). Subscale scores on the HPLP are calculated by obtaining the mean of responses within each subscale. Procedure Following approval of the larger study (of which the present study is a part) from the University of Florida (UF) Institutional Review Board (IRB) culturally diverse families (children, adolescents, and there adult parents/ guardians) in Alachua County, Florida were recruited to be particip ants in the larger study. The children in the recruited participating families who met the participation inclusion criteria for the present study were identified as participants in the present study. In other words the part of the baseline data collected on the children participating with their families in the larger study was used to test the hypotheses and address research questions set forth in the present study. The participation criteria for the youth selected for the present study are as follows: (a) being between the ages of 9 and 17, (b) having at least one parent/ adult
37 guardian who gave written consent to be a participant in the larger study and who gave written consent for their child or adolescent (who lived in the same household with the guardian) to be a research participant in the larger study, and (c) giving verbal assent to participate in the larger study. Research exclusion criteria are that either the youth participant or their adult guardian participant does the following: (a) self reports or engages in behaviors that suggest the presence of a psychological disorder, (b) self reports having an eating disorder, or (c) self reports adhering to a special diet due to diabetes or other reasons. A ll parents/guardians of the youth participants in the larger study and thus the present study completed a Parental Consent Form (PCF; see Appendix A ) t hat outlines the following: (a) the purpose of the study, (b) what the childs participation would involve (c) the required time commitment for completing the baseline assessment battery as well as the intervention aspect of the larger the study, (d) any possible risks and benefits to being a part icipant in the study, (e) the monetary participation incentive, and (f) procedures to protect the confidentiality of all provided information. The PCF also stated that participation is voluntary and that participants have the right to withdraw at any point during the study, without penalty. Additionally, all youth participants provided their verbal agreement to participate by listening to an assent script and agreeing to participate. The assent script (see Appen dix B) outlined the following: (a) the purpose of the study, (b) a description of participation tasks, and ( c) information on how the participants confidentiality will be protected.
38 The present study involved two procedural phases: (a) the participant recruitment phase and (b) the research enrollment and baseline data collection phase. Both of these procedural phases were implemented by trained undergraduate research assistants and community member research assis tants who were members of or recruited by the Principal Investigator for the larger health promotion study of which this study is a part The participant recruitment strategies that these research assistants used include: (a) reading announcements about t he study on local radio stations; (b) publishing advertisements in local newspapers; (c) posting flyers about the study at local businesses (e.g., grocery stores, specialty ethnic food stores, and shopping centers), recreation centers (e.g., cultural centers and recreational facilities), apartment complexes, elementary and middle schools, health care facilities (e.g., hospitals), and a selection of churches that together were religiously and ethnically diverse; and (d) tabling at the aforementioned sites Tabling involved setting up a table where there were (a) banners advertising the name of the project, and (b) flyers specifying what participation in the study would involve, the participation compensation amount, participation criteria, the procedures for enrolling in the study and a telephone number to call to get more information about the study The research assistants stood near these tables, gave out the flyers to individuals who passed by the table, and asked these individuals to sign up to partici pate in the study and to receive a reminder call about the study enrollment and data collection sessions at a nearby community center. Individuals who were given flyers but did not enroll in the study were told to consider
39 calling later to learn more about the study and hopefully enroll later by telephone. Participant recruitment lasted three months. The enrollment and data collection phase involved having participants attend a local community center to enroll in the study if they had not done so earlier and to provide baseline assessment data. These participants would have been told by telephone or at the tabling event the several dates, times and places of the enrollment/data collection sessions and asked to choose a session that they preferred. Upon arrival at this community center, participants in the present study engaged in the following enrollment and data collection activities: (a) listened to and assented to an assent script read by researchers after their parent/ guardian read and signed an infor med consent form indicating agreement to participate in the larger project, and thus the present study, and (b) completed a precoded DDQ and the assessment battery without placing a name on these documents so as to ensure confidentiality of the provided d ata. The research assistants gave the participants the Assessment Battery (AB) to complete immediately. A large team of r esearch assistants (N = approximately 15) were onsight at each enrollment/data collection session to answer questions and give instructions. Data collection took place on several days over a onemonth period. Compensation for youth who participated in the study being proposed was $10, which was included in the $25 that was paid to their family for completing the baseline A Bs for the larger health promotion study of which the study being proposed is a part. The $25 compensation was paid to the participating families when all family member participants
40 submitted a completed AB to a research assistant. It took approximately 30 minutes for the youth participants (i.e., the participants in the study being proposed) to complete the entire AB.
41 Table 3 1 Demographic characteristics of p articipants Demographic variables N % Gender Male Female Age group Children (9 12) Adolescents (13 17) Unreported Race/ethnicity African American/Black White/Caucasian/European American Hispanic /Latino Other Trying to lose weight No Yes Household income (parent/guardian reported) Less than $10,000 $10,000 $19,999 $20,000 $29,999 $30,000 $39,999 $40,000 and over Unreported 45 29 33 37 4 28 17 13 16 47 27 6 14 21 17 3 26 60.8 39.2 43.6 51.0 5.4 37.8 23.0 17.6 21.6 63.5 35.5 6.9 16.1 24.1 19.5 3.4 29.9
42 CHAPTER 4 RESULTS This chapter presents the results of the analyses conducted to address the hypotheses and research questions for the present study. First, the descriptive data for the major variables in this study are reported. Second, reliability (i.e., Cronbachs alpha reliability coefficients) of the scores on the instruments are presented. Third, the results of the preliminary Pearsons correlation analysis that was conducted to address the first two hypotheses are presented and discussed. Fourth, the results of the two separate moderated regression analy ses that were conducted to address the third hypothesis are presented and discussed. Finally, the results of both multivariate analyses of variance (MANOVAs) that were conducted to address both research questions are presented and discussed. Descriptive Data for all Major Variables Initially, tests of normality were run on each of the dependent variables (i.e., active coping, distraction coping, avoidance coping, support seeking coping, engagement in healthy eating, and engagement in physical activity) to verify that they were normally distributed and appropriate for parametric tests. Means and standard deviations for these variables are presented in Table 4 1 Reliability of Instruments As discussed further in this chapter, f or the purposes of this study, the active coping style subscale and the support seeking coping style subscale of the Childrens Coping Strategies Checklist Revision 1 (CCSCR1) were combined to create the active support seeking coping subscale. Using the data from the present study Cronbach alpha reliability coefficients were calculated for this combined subscale and for the other
43 two individual subscales of the CCSC R1 (i.e., the avoidance coping subscale and the distraction coping subscale). Results indicated that for the subscal es of the CCSC R 1 the Cronbach alpha reliability coefficients are as follows: active support seeking coping .80. These results provide support for the use of these subs cales of the CCSC R1 in assessing the coping styles used by the culturally diverse sample of youth (i.e., children and adolescents) in the present study. Using data obtained in the present study, Cronbach alpha reliability coefficients were also calculated for scores on both scales of the Health Promoting Lifestyle Profile (HPLP) that were used in this study. Results indicated that for t he HPLP subscale healthy eating the Cronbach alpha reliability was 0.73. For the HPLP subscale engagement in physical activity the Cronbach alpha reliability was 0.66. These results provide support for the use of these subscales of the HPLP in assessing the health promoting lifestyle behaviors of the culturally diverse sample of youth in this study. Results of the Preliminary Pearson Correlation Analysis An initial Pearson s correlation analysis was run in order to investigate the associations between coping styles (i.e., active coping, distraction coping, avoidance coping, and support seeking coping) and HPL behav ior s (i.e., engaging in healthy eating and physical activity). Additionally, th is correlation analysis was used to examine the relationships among each of the coping styles to ascertain whether or not all four variables should be studied independently. T his correlation analysis is presented in Table 4 2
44 Coping Style Variable Associations The initial analysis showed that active coping and support seeking coping were highly correlated with one another ( r = .63, p < .001). Given the high correlation as well as previous literature supporting the collapse of the two named coping style variables (Nicolotti et al. 2003), a combined coping style (activesupport seeking coping) was created by calculating the mean of these two coping style variables. As such, the first hypothesis, stating that three coping styles (i.e., active coping, distraction coping, and support seeking coping) would have significant positive correl ations with both HPL behavior variables (i.e., engaging in healthy eating and physical activity) was amended to include only two coping styles: activesupport seeking coping and distraction coping. Active coping had significant positive correlations with distraction coping ( r = 0. 51, p < .001), avoidance coping ( r = 0.59, p < .001), and support seeking coping ( r = 0.63, p < .001). Distraction coping had significant positive correlations with avoidance coping ( r = 0.53, p < .001) and support seeking coping ( r = 0.39, p < .01). Avoidance coping had a significant positive correlation with support seeking coping ( r = 0.35, p < .01). Health Promoting Lifestyle Behavior Variable Associations The preliminary Pearsons correlation analysis indicated that engaging in healthy eating and physical activity (i.e., the health promoting lifestyle [HPL] behavior variables of interest in this study) had a significant positive correlation with one another ( r = 0.63, p < .001). Additionally, healthy eating had significant positive correlations with active coping ( r = 0.47, p < .001), distraction coping ( r = 0.32, p < .01), and support seeking coping ( r = 0.45, p < .001). Engaging in physical activity also had significant positive correlations with active coping ( r = 0.43, p < .001), distraction coping ( r = 0.41, p < .001), and support seeking coping ( r = 0.39, p < .01). Neither of the included HPL
45 behavior variables had significant positive correlations with avoidance coping. As a result, avoidance coping was removed from further analyses of the relationship betw een coping styles and HPL behaviors Results of the Analyses to Test Hypotheses One and Two Associations between the ActiveSupport Seeking and Distraction Coping Style Variables and Health Promoting Lifestyle Behavior Variables In order to address the amended first hypothesis, which states that the two coping styles (i.e., active support seeking coping and distraction coping) will have significant positive correlation s with both of the HPL behavior variables (i.e., engaging in healthy eating and physica l activity) another Pearson s correlation analysis was performed using just the variables investigated in this hypothesis. The results of this analysis are presented in Table 4 3 Results of this analysis indicate that engaging in physical activity is significantly associated with both activesupport seeking coping ( p < .001) and distraction coping ( p < .001). Additionally, results indicate that engaging in healthy eating is significantly associated with activesupport seeking coping ( p < .001) and dist raction coping ( p < .01). These findings support hypothesis one that the named coping styles (i.e., activesupport seeking coping and distraction coping) will have significant positive correlations with both of the HPL behavior variables Associations between the Avoidance Coping Style Variable and Health Promoting Lifestyle Behavior Variables In order to address the second hypothesis, which states that the use of avoidance coping will have a significant negative correlation with the HPL behavior variables engaging in healthy eating and physical activity, the above mentioned Pearsons correlation analysis was examined. The coping style avoidance coping was not significantly correlated with either of the HPL behaviors, in either direction. These
46 results fail to support hypothesis two that avoidance coping would have a significant negative correlation with both of the HPL behavior variables. Results of the Analyses to Address Hypothesis Three Given the combining of the active coping and support seeking coping style variables to form the active support seeking coping style variable, as well as the omission of avoidance coping from this analysis based on a nonsignificant relationship between avoidance coping and the HPL behavior variables, the third hypothesis was modified to state t hat the relationship between each coping style variable (i.e., active support seeking coping and distraction coping) and each HPL behavior (i.e., engaging in healthy eating and physical activity) will differ by gender In order to test this hypothesis two moderated regression analyses were run with each having one of the HPL behavior variables as the criterion variable. The predictor variables in both moderated regressions were the coping styles (i.e., active support seeking coping and distraction coping) and the interaction of each of these coping styles with gender Results from Assessing Gender Differences in the Associations between Coping Styles and Engagement in Healthy Eating A moderated regression analys i s was performed with engaging in healthy eating as the criterion variable and the following variables as predictor variables: activesupport seeking coping, distraction coping, gender, gender x active support seeking coping, and gender x distraction coping. This analys is allowed for (a) examination of the influence of coping styles and gender on the healthy eating variable, and (b) examination of gender differences in any found relationships between each coping style and healthy eating. Prior to entering the predictor variables into the regression, each coping style and gender was centered to reduce multicollinarity among the predictor
47 variables. Table 4 4 presents regression weights for each of the predictors in this model. The overall regression model was significant ( F = 5.52, p < .001), accounting for 28.9% of the total variance in engagement in healthy eating. Active support seeking coping was the only significant independent predictor ( = 0.5, p < .001), accounting for 18.1% of the variance in healthy eating. Although distraction coping was significantly correlated with the healthy eating variable in the Pearsons correlation analysis, it did not reach significance in the regression model These findings failed to support hypothesis three stating that the relationship between each coping style variable (i.e., active support seeking coping and distraction coping) and engaging in healthy eating would differ by gender. Results from Assessing Gender Differences in the Associations between Coping Styles and Engagement in Physical Activity A moderated regression analyses was performed with engaging in physical activity as the criterion variable and the following variables as predictor variables: activesupport seeking coping, distraction copi ng, gender, gender x active support seeking coping, and gender x distraction coping. This analysis allowed for (a) examination of the influence of coping styles and gender on the physical activity variable, and (b) examination of gender differences in any found relationships between each coping style and physical activity. Prior to entering the predictor variables into the regression, each coping style and gender was centered to reduce multicollinarity among the predictor variables. Table 4 5 presents regression weights for each of the predictors in this model. The overall regression model was significant ( F = 4.66, p = .001), accounting for 25.6% of the total variance in engagement in physical activity. Active support seeking coping was a significant i
48 0.32, p = .01), accounting for 7.5% of the variance in this variable. Additionally, distraction coping was a significant independent predictor of engagement in physical p < 05), accounting for 4.5% of the variance in this variable. Despite the found significant independent predictors, these findings failed to support the hypothesis three that the relationship between each coping style variable (i.e., activesupport seeking c oping and distraction coping) and engaging in physical activity would differ by gender. Results of the Analyses to Address Research Questions One and Two To address the first research question, which asks whether coping styles differ in association with age group and gender, a multivariate analysis of variance (MANOVA) was performed. In this MANOVA the three coping styles (i.e., activesupport seeking coping, distraction coping, and avoidance coping) were the dependent variables and age group, gender, and the interaction term age group x gender were the independent variables. In order to test the assumption of homogeneity, Boxs test of the assumption of equality of covariance and Levenes test of equality of error variances were conducted. Boxs test was significant ( F = 2. 00, p < .01), indicating that the homogeneity assumption was violated. Levenes test was nonsignificant for all three coping style variables ( p > .05), indicating homogeneity of variance. In order to reduce harm of the violation of the assumption of equality of covariance, a conservative F score was used (Pillais trace). No significant interaction effect of age group x gender was found (Pillais trace = 0. 08, F [ 6 1 34] = 0.93, p = 48), and there were no significant effects of age group ( p = .43) or gender ( p = .08) on the coping style variables. Tests of between subjects effects
49 showed no significant main effects for age group or gender on any of the coping style variables. To address the second research question, which asks whether HPL behavior variables differ in association with age group and gender, a second MANOVA was performed. In this MANOVA the HPL behaviors were the dependent variables and age group, gender, and the interaction age group x gender were the independent variables. In order to test the assumption of homogeneity, Boxs M test of the assumption of equality of covariance and Levenes test of equality of error variances were conducted. Both tests were nonsignificant ( p > .05). No interaction effects for the age group x gender term were found 97, F [ 4 ,134 ] = 0 46, p = 0 77) and there were no significant main effects found for age group or gender ( p = 0.79; p = 0.36) on the HPL behaviors. T est of between subjects effects showed no significant main effect s for age group or gender on the HPL behavior s engaging in healthy eating and physical activity.
50 Table 4 1 Means and standard deviations for the variables investigated in the present study for the total sample and by gender and age group Variable N Norm sample mean a Mean Range SD Total sample Active coping 74 2.63 b 2.49 (1.29 4.00) 0.60 Distraction coping 74 2.36 b 2.28 (1.10 4.00) 0.61 Avoidance coping 74 2.61 b 2.43 (1.08 3.83) 0.51 Support seeking coping 74 2.44 b 2.22 (1.00 4.00) 0.65 Healthy eating 74 2.28 (1.00 3.63) 0.52 Physical activity 74 2.13 (1.00 3.75) 0.59 Males Active coping 45 2.48 (1.33 4.00) 0.63 Distraction coping 45 2.23 (1.10 4.00) 0.61 Avoidance coping 45 2.42 (1.08 3.83) 0.56 Support seeking coping 45 2.33 (1.10 4.00) 0.65 Healthy eating 45 2.24 (1.00 3.63) 0.51 Physical activity 45 2.15 (1.13 3.75) 0.63 Females Active coping 29 2.50 (1.29 3.75) 0.55 Distraction coping 29 2.35 (1.20 3.75) 0.61 Avoidance coping 29 2.45 (1.58 3.33) 0.43 Support seeking coping 29 2.04 (1.00 4.00) 0.61 Healthy eating 29 2.35 (1.38 3.50) 0.54 Physical activity 29 2.12 (1.00 3.25) 0.55 Children (ages 9 to 12) Active coping 33 2.49 (1.29 4.00) 0.67 Distraction coping 33 2.41 (1.10 4.00) 0.67 Avoidance coping 33 2.40 (1.58 3.83) 0.53 Support seeking coping 33 2.32 (1.30 4.00) 0.66 Healthy eating 33 2.30 (1.00 3.50) 0.57 Physical activity 33 2.10 (1.00 3.75) 0.67 Adolescents (ages 13 to 17) Active coping 37 2.49 (1.38 4.00) 0.54 Distraction coping 37 2.19 (1.10 3.25) 0.54 Avoidance coping 37 2.44 (1.08 3.33) 0.51 Support seeking coping 37 2.16 (1.10 4.00) 0.61 Healthy eating 37 2.27 (1.38 3.63) 0.50 Physical activity 37 2.15 (1.25 3.63) 0.54 aThe norm sample mean is adapted from Childrens Coping Strategies and Coping Efficacy: Relations to Parent Socialization, Child Adjustment, and Familial Alcoholism by C. L. Smith et al., 2006, Development and Psychopathology, 18, p. 452. bn = 96. cn = 110.
51 Table 4 2 Pearsons correlation a nalysis a mong t he v ariables of i nterest in the p resent study for the t otal sample Coping styles Health promoting lifestyle behaviors Active Distraction Avoidance Support seeking Healthy Eating Physica l activity Coping styles Active -------0.51*** 0.59*** 0.63*** 0.47*** 0.43*** Distraction 0.51*** -------0.53*** 0.39** 0.31** 0.41*** Avoidance 0.59*** 0.53*** -------0.35** 0.22 0.21 Support seeking 0.63*** 0.39** 0.35** -------0.45*** 0.39** Health promoting lifestyle behaviors Healthy eating 0.47*** 0.31** 0.22 0.45*** -------0.63*** Physical activity 0.43*** 0.41*** 0.21 0.39** 0.63*** -------**p < .01. *** p < .001. Table 43 Pearsons correlation analysis among the variables of interest for hypothesis one and hypothesis two Coping styles Health promoting lifestyle behaviors Active support seeking Avoidance Distraction Healthy eating Physical activity Coping styles Active support seeking -------0.52*** 0.49*** 0.51*** 0.45*** Avoidance 0.52*** -------0.53*** 0.22 0.21 Distraction 0.49*** 0.53*** -------0.32** 0.41*** Health promoting lifestyle behaviors Healthy eating 0.51*** 0.22 0.32** -------0.63*** Physical activity 0.45*** 0.21 0.41*** 0.63** -------**p < .01. *** p < .001.
52 Table 4 4 Unstandardized beta weights (B), standard error coefficients of beta weights and standardized regression weights predicting engagement in healthy eating from all investigated predictor variables Predictor v ariables B SE B Gender 0.17 0.11 .16 Active support seeking coping 0.47 0.11 .50** Distraction coping 0.05 0.10 .06 Active support seeking coping x gender 0.18 0.23 .09 Distraction coping x gender 0.08 0.21 .04 Note : R2 = .29. p < .05. ** p < .01. Table 4 5 Unstandardized beta weights (B), standard error coefficients of beta weights and standardized regression weights predicting engagement in physical activity from all investigated predictor variables Predictor Variables B SE B Gender 0.02 0.13 0.01 Active support seeking coping 0.34 0.13 0.32** Distraction coping 0.24 0.12 0.25* Active support seeking coping x gender 0.13 0.27 0.06 Distraction coping x gender 0.02 0.24 0.01 Not e: R2 = .26. p = .05. ** p < .01.
53 CHAPTER 5 DISCUSSION This chapter includes a summa ry of and interpretations of the results of this study. Additionally, in this chapter is a discussion of the limitations and strengths of th is study Finally, this chapter includes directions for future research and a discussion of the implications of this study for counseling psychologists. Summary of the Results Hypotheses O ne and T wo The purpose of the present study was to investigate the relationship between coping styles (i.e., active coping, distraction coping, avoidance coping, and support seeking coping) and health promoting lifestyle (HPL) behaviors (i.e., engaging in healthy eat ing and physical activity) among culturally diverse youth ( children and adolescents ) from low income families. Additionally, whether any found associations between the investigated coping styles and HPL behaviors differed in association with age group and/or gender was examined. Finally, whether the investigated coping styles and the HPL behavior s differed by age group and/or gender was examined The preliminary Pearsons correlation analysis revealed that all four coping styles (i.e., active coping, dist raction coping, avoidance coping, and support seeking coping) had significant positive associations with one another. Given these significant correlations and previous relevant research literature (Nicolotti et al. 2003) the coping styles active coping and support seeking coping were combined into one coping style variable (i.e., activesupport seeking coping). Specifically, Nicolotti et al. found that both active coping styles and support seeking coping styles were significantly associated with improved emotional and behavioral adjustment among children and adolescents.
54 Thus, the significant correlation between these two copying styles likely suggests that there is an overlap in the construct that they are measuring. The significant positive association found between avoidance coping and active coping was surprising given that most of the literature on coping suggests that active coping is clearly positively associated with improved emotional and behavioral characteristics and the research literature for avoidance coping indicates that it is primarily associated with negative emotional adjustment and behavior. Any literature supporting the positive relationship between avoidance coping and well being seems to sugges t that the benefits of avoidance coping are gender specific and the sample in the present study is reasonably equally represented by males and females, indicating that a gender bias in the results does not explain the significant positive relationship betw een avoidance coping and active coping. The first research hypothesis in this study stated that the use of the active coping, support seeking coping, and distraction coping styles would have significant positive correlation s with engaging in healthy eating and physical activity (i.e., the two investigated HPL behaviors) Because the active coping style and support seeking coping style were combined to form the active support seeking coping style, this hypothesis was modified to read as follows: the two co ping styles (i.e., activesupport seeking coping and distraction coping) will have significant positive correlations with both of the HPL behavior s (i.e., engaging in healthy eating and physical activity). A Pearsons correlation analysis revealed that both of the investigated coping styles (i.e., active support seeking coping and distraction coping) were significantly correlated with both of the HPL behaviors. Specifically, active support seeking coping
55 was more highly associated with engaging in healthy eating ( p < .001), followed by distraction coping (p < .01). Additionally, distraction coping and activesupport seeking coping were both highly associated with engaging in physical activity ( p < .001) The second research hypothesis in this study posited that the use of avoidance coping will have a significant negative correlation with level of engagement in HPL behaviors (i.e., engaging in healthy eating and physical activity). Contrary to this hypothesis, r esults indicated that the correlations between avoidance coping and both engagement in healthy eating and engagement in physical activity were nonsignificant. This nonsignificant finding is surprising given the literature indicating the detrimental emotional and behavioral effects of avoidance coping (Liu et al., 2004; SeiffgeKrenke, 2000; deBoo & Spiering, 2010; Compas et al., 2004). However, these findings may be explained by the re search literature indicat ing that a voidance coping can be signi ficantly beneficial to individuals in certain situations (e.g., children and adolescents who are being criticized for their weight; Faith et al., 2002) which we did not fully account for in this study Because of the nonsignificant relationship between avoidance coping and the HPL behaviors, the avoidance coping variable was eliminated from the analyses that examined the relationship between coping styles and HPL behaviors. In sum, hypothesis one was supported by the present study, while hypothesis two was not. Hypothesi s T hree The third research hypothesis in the present study stated that the relationship between each coping style (i.e., active support seeking coping and distraction coping) and each HPL behavior ( i.e., engaging in healthy eating and physical activity ) would differ by gender. In order to examine whether any associations between coping styles and engagement in healthy eating would differ by gender, a moderated regression
56 analysis was performed using healthy eating as a criterion variable and the following variables as predictor variables: activesupport seeking coping, distraction coping, gender, gender x activesupport seeking coping, and gender x distraction coping. Results of this analysis indicated that the model was significant and accounted for 28.9% of the variance in healthy eating. There were no significant interaction effects and the only significant independent predictor was activesupport seeking coping, which accounted for 18.1% o f the variance in health y eating. In order to examine whether any association s between coping styles and engagement in physical activity would differ by gender, a moderated regression analysis was performed using engagement in physical activity as a crit erion variable and the following variables as predictor variables: activesupport seeking coping, distraction coping, gender, gender x active support seeking coping, and gender x distraction coping. Results of this analysis indicated that the regression m odel was significant and accounted for 25.6% of the total variance. There were no significant interaction effects, but there were two significant independent predictor s. Specifically, active support seeking coping accounted for 7.4% of the variance in engagement in physical activity and distraction coping accounted for 4.5% of the variance in engagement in physical activity. A possible explanation for the nonsignificant interaction effects in the analyses to test the third hypothesis may be that the sample size was inadequate to have enough power to investigate gender by each coping style interaction effects in these analyses It is also possible that there are no gender differences in relationships between the investigated coping styles and engaging in healthy eating or engaging in physical
57 activity This finding is consistent with that of Nicoletti et al. (2003) who found that among children who were coping with parents marital stress, the relationship between coping style (i.e., active coping, distraction coping, and support seeking coping) and physical health did not differ by gender. Regardless of the explanations for the findings from the analyses to test the third hypothesis, these findings clearly fail to support the third hypothesis. Research Question One The first research question addressed in the present study asked if coping styles would differ by age group and gender. In order to investigate this research question, a multivariate analysis of variance (MANOVA) was performed, using the coping styles (i.e., active support seeking coping, distraction coping, and avoidan ce coping) as the dependent variables and age group, gender, and the interaction term age group x gender as the independent variables. Results revealed no signi ficant age group x gender interaction effect ( p > .05) in the multivariate test and none of the separate ANOVAs revealed a significant interaction effect. Additionally, there were no significant main effect s of age group or gender on any of the coping sty les (i.e., active support seeking coping, distraction coping, and avoidant coping). T he research findings from investigating the first research question suggest that among a culturally diverse sample of youth, there are no significant age group (i.e., children vs. adolescents) differences or gender differences in the use of the named coping styles. The nonsignificant findings with regard to the age group x gender interaction are surprising given some research suggesting that girls coping styles can change significantly as they go from childhood to adolescence (Hampel & Petermann, 2005). Additionally, research indicates that as children become adolescents, their
58 coping styles become more effective and broad. As such, a significant difference in coping sty les between children and adolescents should be expected. One explanation for these surprising findings is that there may be other confounding variables, such as race/ethnicity, situation/setting, education level, or family income level. These variables m ay have a more significant impact on an individuals coping styles than age group. The nonsignificance of the association between gender and the activesupport seeking coping, distraction coping, and avoidance seeking coping styles in the present study i s not surprising given the inconsistent findings on this topic in the research literature. Active coping has two dimensions (i.e., problem focused and positive reframing), and each of these dimensions has garnered mixed results with regard to gender differences among youth. The research literature indicates that the relationship between all three of these coping styles and gender tends to vary based on other variables, including situation and setting. The current study suggests that coping styles among a culturally d iverse sample of youth from low income families may be influenced by variables other than gender or age group. Regardless of the explanation for the results from testing the first research question, support is provided by these results for future research with larger samples to investigate age group and gender differences in the use of different coping styles among culturally diverse youth, particularly those from lowincome households such as most of the participants in the present study. Research Question Two The second research question addressed in the present study asked if HPL behaviors would differ by age group and gender. In order to investigate this research question, a multivariate analysis of variance (MANOVA) was run, using the HPL behavior variables (i.e., engaging in healthy eating and physical activity) as the
59 dependent variables and age group, gender, and the interaction term age group x gender as the independent variables. Results indicated that the interaction effect of age group x gender was nonsignificant. There were no significant main effect s of age group or gender on either of the HPL behavior s (i.e., engaging in healthy eating and physical activity). The finding of no significant differences in engaging in physical activity in association with age group is surprising given the research literature indicating that younger children engage in significantly more physical activity than do older children. Similarly, the finding of no significant differences in engaging in physical activity in association with gender is surprising given the research literature indicating that boys engage in significantly more physical activity than girls. The inconsistency between these findings and previous literature may be due to the fa ct that participants tended to be from low income households and thus may not have access to physical activity resources regardless of age group and/or gender. Specifically, younger children in families with low incomes m ay be even less likely than their older counterparts to have access to physical activity resources because of safety and transportation issues. The finding of no significant age group and/or gender differences in engaging in healthy eating i s not surprising given the inconsistency in research findings among published research studies that have studied the association between both age group and gender and engaging in healthy eating. It may be that healthy eating is very much controlled by household income and the related food purchases of the adults in the homes of youth, thus rendering the age group and gender irrelevant to a large degree when it comes to the level of engagement in healthy eating by youth living in
60 households with low incomes. Future similar research with larger samples and representation of youth across the socioeconomic spectrum is needed to further understand t he role of both age group and gender in the engagement of youth in HPL behaviors. Indeed, income and/or some other demographic variables may moderate relationshi ps between both named demographic variables (i.e., age group and gender) and levels of engaging in HPL behaviors. Limitations Strengths, and Future Directions from the Present Study Though this study is important and contributed much to the research literature on coping styles and engaging in health promoting lifestyle behaviors among youth, it also had some noteworthy limitations. One limitation is the small sample for this study The sample size in the present study is in part the result of the well documented difficulty involved with recruiting research participants in families with low household incomes and/or who are racial/ethnic minorities such as those in the present study. It is also the case that the small sample size was the product of participants being removed from the present study because of much incomplete data. The length of the assessment battery deterred many partici pants from completing all of it thus resulting in data sets of participants that were not useable, which in turn resulted in removal of the participants with incomplete data sets from the study. Another limitation of the present study is having numbers of participants in each of the major race/ethnic groups that were too small to conduct analyses to examine racial/ethnic group differences in the variables and relationships among them of interest. Yet, t here is inconclusive evidence in the existing research literature regarding race/ethnicity differences in coping styles engaging in physical activity, and engaging in healthy eating among youth. Given our lack of significant results with regard to age
61 group and gender differences in the investigated variables, it would be important to further investigate other demographic variables that may be significantly associated with coping styles and HPL behaviors. Future studies similar to the present study need to include large numbers of children and adolescents in each of the major racial/ethnic groups in the U S. Such studies would then enable reexamination of race/ethnicity (and other demographic variables) as potential influences on coping styles and HP L behaviors of children and adolescents, including those in low income families. The fact that the participants in the present study were volunteers who were recruited using various recruitment strategies is also a limitation given that the resulting sample is not representative of the target low income community. Though the recruitment strategies used in the present study are commonly used to recruit low income and racial/ethnic minority participants for research studies, it is not known if the findings are generalizable to the target community. Future similar studies should attempt to recruit partici pants using stratified random sampling procedures and household income should be based on the number of family members in additions to the self reported household income. Despite the aforementioned limitations this study is important because it addresses the following important and not well published research topics : (a) the coping styles of children and adolescents; (b) the relationship between coping styles and health promoting lifestyle behaviors among children and adolescents; and (c) the relationships between coping styles and health promoting lifestyle behaviors among culturally diverse youth from low income families.
62 Implications for Counseling Psychologists A major charge of counseling psychologists is to engage in and address social j ustice issues through both research and practice. Additionally, a core aspect of counseling psychology is conducting culturally sensitive research and implementing and evaluating interventions that are culturally sensitive. The present study relates to both of these integral aspects of counseling psychology. Because low income and racial/ethnic minority youth are particularly vulnerable to the conditions of overweight and obesity that come with not engaging in health promoting lifestyle behaviors and gi ven that these youth are often powerless when it comes to having the needed resources to engage in these behaviors the empowerment and social justice orientations of counseling psychologists render them to be well suited for conducting research and interv entions to promote these behaviors. Furthermore, increasing health promoting behaviors among vulnerable populations is consistent with the focus of counseling psychology on health promotion and illness prevention rather than on mental illness. T hus, it i s appropriate and necessary for counseling psychologists to assume leadership in promoting behaviors to facilitate health and eliminate health disparities that plag ue our nation, particularly those disparities related to overweight and obesity that have a disproportionately negative impact on youth and adults who are racial/ethnic minorities or are members of families who have low household incomes. Given that obesity and overweight in childhood tends to be developmental in that it tends to continue into adulthood, the focus of counseling psychologists on development across the lifespan also renders them to be well suited for studying health promoting lifestyle behaviors among youth as well as among adults Furthermore, the
63 training that counseling psychol ogists have in conducting multicultural assessments and research makes them ideal for conducting research with culturally diverse samples similar to what is done in the present study. Conclusions In conclusion, the present study examined the relationships between coping styles (i.e., active support seeking coping, distraction coping, and avoidance coping) and HPL behaviors (i.e., engagement in healthy eating and physical activity) and age group and gender differences in these relationships and in each coping style and HPL behavior among culturally diverse children and adolescents from low income families. Results of this study suggest that there are significant relationships between activesupport seeking coping and both measured HPL behaviors, as well as between distraction coping and both measured HPL behaviors. It is recommended that future research investigates the relationships examined in this study in a larger representative sample of culturally diverse children and adolescents from low income families. If the findings in the present study are validated in future similar research with larger repres entative samples, support will be provided for testing the effects of interventions to promote activesupport seeking coping styles and distraction coping styles on the HPL behaviors of culturally diverse youth living in low income households
64 APPENDIX A PARENTAL INFORMED CO NSENT FORM Family Health Self Empowerment Project Parental Consent Please read this consent document carefully before you decide to give permission for your child to participate in this study. Purpose of the research study : The purpose of this study is to create a questionnaire to measure what helps or stops adults, children, and adolescents from doing things to benefit their health. What your child will be asked to do in the study: Your child will be asked to complete questionnaires about themselves and what makes it easier or makes it difficult for them to do things to benefit their health. Time required: 3045 minutes Risks and Benefits: We do not expect any risk to your child of participating in this study. However, your child may experience minor discomfort answering some of the questions on the questionnaires. We do not anticipate that your child will benefit directly by participating in this project. Compensation: Your child will be paid $10 compensation for participating in this research. Confidentiality: Your childs identity will be kept confidential to the extent provided by law. The information we obtain will be assigned a code number. The list connecting your childs name to this code number will be kept in a locked file. Your childs name will not be used in any report about this research. Voluntary participation: Allowing your child to participate in this study is completely voluntary. There is no penalty for not allowing your child to participate.
65 Right to withdraw from the study: You have the right to withdraw your child from the study at any time without consequence. Whom to contact if you have questions about the study: Carolyn Tucker, PhD, Department of Psychology University of Florida (352)3920601, ext. 260 Whom to contact about your rights as a research participant in the study: UFIRB Office Box 112250 University of Florida Gainesville, FL 3261122250 (352)3920433 Agreement: I have read the procedure described above. I voluntarily give consent for my child _____________________, to participate in the study titled, Family Health Empowerment Project. I have received a copy of this description. Primary Parent/ Guardian:____________________________ Date:___________
66 APPENDIX B CHILD ASSENT SCRIPT Assent Script We are researchers from the University of Florida working on a study to determine how well a workshop is at helping families increase healthy behaviors such as exercising. We are inviting you to participate in this study by filling out some questionnaires and participating in a workshop with you parent/caregiver. You may complete your questionnaires in a separate room during the workshop and return them to the researchers or you may return your questionnaires in a separate envelope so that other family memb ers will not view your responses. You can stop participating at any time. Do you agree to participate in this study?
67 APPENDIX C DEMOGRAPHIC DATA QUESTIONNAIRE Family Health Self Empowerment Project Youth Information Questionnaire Directions : Please fill in the blanks and answer the questions in this questionnaire. For questions that have bubbles ( O ), completely fill in the bubble beside the response that you choose. Filledin bubbles should look like this: Please PRINT your name: _____________________________________ ____________ Please PRINT your address: _____________________________________ _____________________________________ _____________________________________ Home telephone: _____________________ Other telephone: _____________________ Do you consider yourself to be Hispanic/Latino? O Yes O No What is your race? (Bubble in all that apply) ( Note : Even if you consider yourself to be Hispanic/Latino, you may also consider yourself to be one or more of the following races.) O American Indian or Alaska Native O Asian American O African American / Black O Caucasian/ White / European American O Native Hawaiian or other Pacific Islander O Other ________________________________ Please write in your race if it is not listed
68 What is your sex? O Female O Male What is your height? ________ feet and _________ inches What is your weight? _________ pounds What is your age? _________ When we mail you letters and other documents, what language would you like them to be written in? O English O Spanish Are you on a special diet because of a health condition such as diabetes or high blood pressure? O Yes O No Are you on a diet or trying to lose weight? O Yes O No Thank you for helping us with this research!
69 APPENDIX D CHILDRENS COPING STRATEGIES CHECKLIST R1 CCSC R1 Never Sometimes Often Most of the time 1. You thought about what you could do before you did something. O O O O 2. You tried to notice or think about only the good things in your life. O O O O 3. You tried to ignore it. O O O O 4. You told people how you felt about the problem. O O O O 5. You tried to stay away from the problem. O O O O 6. You did something to make things better. O O O O 7. You talked to someone who could help you figure out what to do. O O O O 8. You told yourself that things would get better. O O O O 9. You listened to music. O O O O 10. You reminded yourself that you are better off than a lot of other people. O O O O 11. You daydreamed that everything was okay. O O O O 12. You went bicycle riding. O O O O 13. You talked about your feelings to someone who really understood. O O O O Directions: Sometimes people have problems or feel upset about things. When this happens, they may do different things to solve the problem or make themselves feel better. For each item below, choose the answer that BEST describes how often you usually did this to solve your problems or make yourself feel better during the past month. There are no right or wrong answers, just indicate how often YOU USUALLY did each thing in order to solve your problems or make yourself feel better during the past month.
70 Never Sometimes Often Most of the time 14. You told other people what you wanted them to do. O O O O 15 You tried to put it out of your mind. O O O O 16. You thought about what would happen before you decided what to do. O O O O 17 You told yourself that it would be OK. O O O O 18. You told other people what made you feel the way you did. O O O O 19. You told yourself that you could handle this problem. O O O O 20 You went for a walk. O O O O 21. You tried to stay away from things that made you feel upset. O O O O 22. You told others how you would like to solve the problem. O O O O 23. You tried to make things better by changing what you did. O O O O 24. You told yourself you have taken care of things like this before. O O O O 25 You played sports. O O O O 26 You thought about why it happened. O O O O 27 You didnt think about it. O O O O 28 You let other people know how you felt. O O O O 29. You told yourself you could handle whatever happens. O O O O 30. You told other people what you would like to happen. O O O O
71 Never Sometimes Often Most of the time 31. You told yourself that in the long run, things would work out for the best. O O O O 32. You read a book or magazine. O O O O 33. You imagined how youd like things to be. O O O O 34. You reminded yourself that you knew what to do. O O O O 35. You thought about which things are best to do to handle the problem. O O O O 36. You just forgot about it. O O O O 37. You told yourself that it would work itself out. O O O O 38. You talked to someone who could help you solve the problem. O O O O 39. You went skateboard riding or roller skating. O O O O 40. You avoided the people who made you feel bad. O O O O 41. You reminded yourself that overall things are pretty good for you. O O O O 42. You did something like video games or a hobby. O O O O 43. You did something to solve the problem. O O O O 44. You tried to understand it better by thinking more about it. O O O O 45. You reminded yourself about all of the things you have going for you. O O O O 46. You wished that bad things wouldnt happen. O O O O 47. You thought about what you needed to know so you could solve the problem. O O O O
72 Never Sometimes Often Most of the Time 48. You avoided it by going to your room. O O O O 49. You did something in order to get the most you could out of the situation. O O O O 50. You thought about what you could learn from the problem. O O O O 51. You wished that things were better. O O O O 52. You watched TV. O O O O 53. You did some exercise. O O O O 54. You tried to figure out why things like this happen. O O O O
73 APPENDIX E HEALTH PROMOTING LIF ESTYLE PROFILE: EXER CISING CONSISTENTLY SUBSCALE AND EATING A HEALTHY DIET SUBSC ALE Health Promoting Lifestyles Profile This questionnaire contains statements about your present way of life or personal habits. Please respond to each item as accurately as possible and try not to skip any item. Indicate the frequency with which you engage in each behavior by filling in the appropriate circle. N = Never S = Sometimes O = Often R = Routinely N S O R 1. Choose a diet low in fat, saturated fat, and cholesterol. 2. Follow a planned exercise program. 3. Limit us e of sugars and f ood containing sugar (sweets). 4. Exercise vigorously for 20 or more minutes at least three times a week (such as brisk walking, bicycling, aerobic dancing, using a stair climber) 5. Eat 6 11 servings of bread, cereal, rice, and pasta each day. 6. Take part in light to moderate physical activity (such as sustained walking 30 40 minute s five or more times a week). 7. Eat 24 servings of fruit a day. 8. Take part in leisure time (recreational) physical activities (such as swimming, dancing, bicycling). 9. Eat 3 5 s ervings of vegetable each day. 10. Do stretching exercises at least 3 times per week. 11. Eat 2 3 servings of mi lk, yogurt, or cheese each day. 12. Get exercise during usual daily activities (such as walking during lunch, using stairs instead of elevators, parking car away from destination and walking).
74 N S O R 13. Eat only 23 servings from the meat, poultry, fish, dried beans, eg gs, and nuts group each day. 14. Check my pulse rate when exercising. 15. Read labels to identify nutrients, fats, and sodium content in packaged food. 16. Reach my target heart rate when exercising. 17. Eat breakfast.
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86 BIOGRAPHICAL SKETCH Sarah Nolan was born in New York, New York and grew up in the New York suburb of Maplewood, New Jersey In 2001, Sarah graduated from Columbia High School and moved to North Carolina to pursue a Bachelor of Science in Psychology at Davidson College. While at Davidson, Sarah independently studied the cross cultural interactions of racially diverse children. In 2005, after graduating from Davidson, Sarah went on to Lynchburg College, in Virginia, to pursue a Master of Edu cation in Community Counseling. Wh ile at Lynchburg, Sarah interned as a counselor at The Alliance for Families and Children, a United Way funded organization aimed at serving low income families and children. Additionally, Sarah worked with a team of researchers in the counseling department on an intervention project aimed at helping young adults lose weight and maintain weight loss. After graduating from Lynchburg in 2008, Sarah moved to Florida to pursue her Doctor of Philosophy in counseling p sycholog y at the University of Florida. S he is in her third year of the program and her research interests include health disparities among lowincome minorities and other marginalized and oppressed groups. Sarah currently serves as a Director of Research on Dr. Carolyn Tuckers Health Psychology Research Team.