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

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Impact of the health risk appraisal process on health behaviors and beliefs of college freshmen
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Stiles, Claire Ann
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ix, 204 leaves : ill. ; 28 cm.

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College freshmen ( jstor )
College students ( jstor )
Colleges ( jstor )
Death ( jstor )
Disease risks ( jstor )
Diseases ( jstor )
Health education ( jstor )
Health promotion ( jstor )
Investment risks ( jstor )
Questionnaires ( jstor )
College freshmen -- Health and hygiene ( lcsh )
Counselor Education thesis Ph. D
Dissertations, Academic -- Counselor Education -- UF
Health attitudes ( lcsh )
Health behavior ( lcsh )

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

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IMPACT OF THE HEALTH RISK APPRAISAL PROCESS
ON HEALTH BEHAVIORS AND BELIEFS
OF COLLEGE FRESHMEN








BY

CLAIRE ANN STILES


A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN
PARTIAL FULFILLMENT OF THE REQUIREMENTS
FOR THE DEGREE OF DOCTOR OF PHILOSOPHY


UNIVERSITY OF FLORIDA

1987

































Copyright 1987

by

Claire Ann Stiles



























To Pearl and Charles Schmidt,

my beloved parents,

whose love, faith, and humanitarian ideals have been

a constant source of strength and inspiration for me















ACKNOWLEDGMENTS

The support of many beautiful people has made the


completion of this dissertation possibi


Without their


help and encouragement, it could not have been done.


extend my


sincere gratitude to Dr


. Peggy Fong-Beyette


for her expert guidance and special efforts to meet with me

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

the time and assistance she so generously gave to me.

Without her friendship and support, I would have lost my


way.


I also want to express my thanks to my other committee


member


, Dr


. Jim Pitt


and Dr


. Owen Holyoak, who provided


valuable


suggestions, critical comments, and their own


unique perspectives which enhanced my work on thi


project.


To my Gainesville friends and colleagues Shari Miller,

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

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

keeping my spirits up during the hard times and sharing the

agony and ecstacy of this experience with me.


Thank


are also due to the Eckerd College students who


participated in thi


research and to th


resident advisors,


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


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


F









labors.


I would


especially like to thank administrators,


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


faculty members, Peg Malchon, Sarah Dean,


McDowell, Nancy Carter


Tom West, Barry


, and Howard Carter; staff members,


Eleanor Pugh and Myrtle Coursin; and students, Kathy

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


Smith, and Joni Smith for an abundance of


ass


distance and


support throughout the year.

Finally, I cannot fail to thank the network of friends

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

patience have kept me going through the past five years.


Lastly, words are inadequate to expre


very exceptional people


graduate school experience


my gratitude to two


who have stood by me throughout this


and offered constant support and


help


My very special thank


are extended to my mother


Pearl Schmidt, and to my friend, Ruth Petti


for their


extraordinary contributions to my work.















TABLE OF CONTENTS


PAGE


ACKNOWLEDGMENTS


ABSTRACT.

CHAPTER

I IN


. . Viii


ITRODUCTION


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


Importance of the S
Definition of Terms


tudy


S. 4 .


Organization of the Study .

REVIEW OF LITERATURE .

Health Behavior and Health Belief
Health Behavior .


Health Belief


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


to Motivat


Change


Health Behavior and Belief


of College
Alcohol and
Cigarette S


student


Substance Use
making. .


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


Health Behavior Change
on College Campuses


Summary


METHODOLOGY


* 85


trategie


4 4 4 4 4 4 4 4 4 4


. -. Qr;










CHAPTER


PAGE


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


Hea
ta


Ith
Anal


Beli
yses


RESULTS


Descr
Testi
Hea
Per
Per
Per
Summa


Sample.


Hypoth


ese


ptibil ity
acy .
efficacy.


. . .


DISCUSSION, CONCLUSIONS, AND RECOMMENDATIONS


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


APPENDICES.

A HEAL
AN
B HEAL
C HEAL
QU
D REMI
E INFO
F HEAL


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


TH RI
D PRI
TH RI
TH BE
ESTIO
NDER
RMED
TH SE


SK APP
NTOUT
SK APP
LIEFS
NNAIRE
LETTER
CONSEN
SSION


RAISAL QUESTIONNAIRE

RAISAL SESSION .
AND HEALTH BEHAVIOR

S FOR GROUPS .
T FORM .
TAPE EVALUATION FORM


* S S S
. S
* .
* .


REFERENCES


S S S S S S S S S S S S S S S S


BIOGRAPHICAL SKETCH


In


Da








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


Requirement


for the Degree of Doctor of Philosophy


IMPACT OF THE HEALTH RISK APPRAISAL PROCESS
ON HEALTH BEHAVIORS AND BELIEFS
OF COLLEGE FRESHMEN

By

Claire Ann Stiles


August 1987


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


The purpose of this study was to determine the impact

of the Health Risk Appraisal process on health behaviors and


health belief


health risk level


of college freshmen at average and high


Based in Health Belief Model research,


an underlying assumption of thi


investigation was that


behavior change resulting from the intervention was


attributable


to a change in one or more of three beliefs:


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

(c) perceived self-efficacy.

A randomized, pretest-posttest control/comparison group


design was used in this study.


The Martin Index of Health


Behavior and three ind


ices


on a Health Belief Questionnaire


were administered to 101 voluntary subjects who were divided


by risk level into two groups and randomly


ass


signed to one


of three treatment conditions:


(a) Health Risk Appraisal








3(treatment)


x 2(risk level) factorial analysis of


covariance was employed to analyze the adjusted posttest


means for each of the four dependent variable


Significant differences (p


susceptibility and perceived


< .05) in both perceived

If-efficacy were found among


the thr


groups.


The Health Risk Appraisal process group


scored lower in perceived susceptibility and the control

group scored lower in perceived self-efficacy than either of


the other two groups, respectively. Higher risk subjects

reported fewer health behaviors and weaker self-efficacy


beliefs than average risk subject

intercorrelations between variabi


Significant

revealed moderate


negative correlations between health behavior and perceived

susceptibility and positive correlations between health


behavior and perceived


self-efficacy.


Conclusions were that the Health Risk Appraisal process

lowers perceived susceptibility and raises perceived self-

efficacy but has no direct effect on health behaviors of


college freshmen.


Since outcomes further suggest that self-


efficacy may be the key variable in th


actual performance


of health behavior


it was speculated that u


of health


risk appraisal emphasizing participant


abilities to


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














CHAPTER I
INTRODUCTION

Since the early 1900s, chronic disease has gradually

replaced infectious disease as the leading cause of


premature death in America.


Heart disease, cancer, and


cerebrovascular disease claim the greatest number of lives

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


degenerative diseases (Califano, 1979)


In addition to the


increase in mortality caused by chroni


ase


since 1950


deaths due to motor vehicle accidents have also increased


substantially for those under th


age of 40 (P


. R. Harris,


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


Deficiency Syndrome (AIDS), an incurabi


pidemi


infectious disease


proportion, has caused the death of over 15,000


people


in th


United States (Koop, 1986).


supported by epidemiological, biomedical, and


behavioral research, the 1979 Surgeon General'


Report


stated that a reduction in th


ese


premature death rates and


further improvement in health status would be achieved only

through the promotion of health and prevention of disease


efforts, not through treatment (Califano, 1979)


more










life-threatening, sexually transmitted disease.


With the


leading causes of death in our country strongly linked to


individual health behavior


, the development of more


effective techniques for motivating changes in lifestyle


become


essential to lower health risk


and the rising costs


of health care (Matarazzo, 1984).

Although disease or death is not caused by any single

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


development of lung cancer; of


exces


saturated fat,


cholesterol consumption, and Type A behavior patterns to


heart disease; and of


excess


ive alcohol use and non-use of


seat belts to traffic


fatalities are well documented (Reed,


1983).


been a


In a 1


ssoc


ess


substantial way chronic disease has also


iated with poor


leep patterns, low physical


activity level


fiber


diet


high in sodium and sugar and low in


, overweight, and high level


(Mechanic & Cleary, 1980).


etiologic factors in


In fact,


of psychological stress


trong if not major


of the 10 leading cau


of death


among Americans today are related to lifestyle and

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


sexual practi


ces


and intravenous drug use have been


correlated with death


caused by the AIDS virus (Koop,


1986f.








3

mortality patterns of Americans reflect the impact of


lifestyle


As Knowl


(1977) so succinctly stated "over 99


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

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


Earlier public


Public Health


admonitions to change health behavior


service, 1964), the urgency of the


message


linking behavior to mortality in th


1979


urgeon


General's Report, and


subsequent governmental publications


have prompted some peopi


who might b


defined


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


suggested health behavior


and abandon destructive habits


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


Over the past


15 years mortality from all causes has declined because of


changes in smoking, diet, and exercise pattern


treatment for hypertension (P


. R. Harris, 1981; Oberman,


1984).


Estimates are that 30 million American


have


successfully quit smoking (Schachter


1982) and that this


type of change is attributable to stronger governmental and

professional endorsement of prevention programs and


trategi


Apparently, where enough resources are


allocated to raise the level of consciousness about risks to


health, some people


will voluntarily modify their health


c Lk t U








4

disappointing in our adolescent and young adult


subpopulation.


As a result of health-compromising behavior,


such as alcohol and drug abuse and not wearing a seatbelt

while driving, premature death and disability rates are high


among this relatively healthy adolescent population.


Whil


decreasing in the general population, smoking "appears to be


on the increa


among some adolescents [primarily females],


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


teenage pregnancy rates are on the increa

disproportionate percentage of our youth


, and a

physically


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

According to data from the National Center for Health

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

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


did in 1960.


Major causes of death were attributed to


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


Not only i


current health status jeopardized by


health-compromising behavior


but "there is good evidence


that many of th


causes of death at age 40 ar


the result of


behaviors that were established during the adolescent and


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


In a


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


almost


000 adults surveyed in California


seven individual


.


I








5

followed, the better the physical health status experienced.

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

clear relationship of lifestyle to mortality; the proportion

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


smaller for those following mor


practices, i.


of the


seven to eight hours of


seven health


leep, regular


meals, daily breakfast, frequent exercise, moderate alcohol

consumption, no smoking, and maintenance of appropriate body

weight (Breslow & Enstrom, 1980).


Responsible for their own health habits for perhaps


first time, the approximately 12.4 million youth enrolled in

institutions of higher education and post-secondary


technical school


(Department of Education, 1984) are


particularly at risk for developing unhealthy patterns of


living.


The uniqueness


of th


college setting and the


developmental tasks of late adolescence create a challenge

for even the most conscientious and health-minded students.

College students are dealing with the major tasks of

competence, autonomy, identity, interpersonal relationships,


and intimacy (Chickering, 1969).


parated from home and


family for the first time, many students are faced with

pressures to experiment sexually and with mood-altering


subItances achiPev acadPmicallvy commit themsel


ves








6

compensation for unresolved problems and ineffective coping

can easily result in poor eating habits, lack of adequate

sleep, alcohol/drug abuse, relationship conflicts,


depr


ion, and suicide for a growing number of these young


adults (Falk, 1975).

Though "college students are at risk of failing to

develop adequate solutions to the challenges of independent

living and the increased responsibilities of adulthood"


(Drum


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


are also an


ideal time for remolding of patterns.


College


universities are natural settings in which to influence

current and future health practices of a large segment of


our population.


A unique opportunity, therefore, exists to


affect the future well-being and lifespan of these young

people by helping them to appreciate the importance of

health, to accept individual responsibility for their


behaviors, to develop the knowledge and


kills necessary for


health attainment and maintenance, and to moderate self-

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

Although promoting healthier behaviors among college

students would have positive impact on immediate and long


term health status, the obstaci


rhanna 0 ar nimorn nlc


uch health behavior


Frnm tfh nutcaf t health hphavinr rhannp








7

Gestalt, individually unique and created over many years


(Milsum, 1980b).


Green et al. (1980) have proposed that


health behaviors are more difficult to change when they are

long established habits and intimately connected to an


individual's lifestyle


and culture; smoking, alcohol use,


and sedentary lifestyles are but a few of our socially


acceptable behavior


which meet the


riteria of difficulty


for change


Initially effortful and lacking in immediate


gratification, the adoption of health behaviors may also

conflict with values of higher priority such as academic


achievement, economic


gain,


ial approval, and meeting the


expectation


of significant oth


ers


(Mechanic & Cleary,


1980).


In a culture where the economy depends upon high


production and consumption, even in the area of medical

care, where instant gratification is expected, and

unrestricted individual freedom at any cost is considered a


right, these value conflicts are inevitable


Furthermore, the link between behavior and di


(Knowl


sease


1977).


is not


directly observable


because symptoms of developing chronic


sease are often not diagnosed until several decades after


health-compromising habits begin.


Reasons for change are


therefore not immediately compelling.


The maior obstacle


to behavior change encountered on


e










peer and environmental press


res


to engage in unhealthy


behaviors


rates a real


challenge for health promoters and


educators (Bloom, 1981)


Whil


peer norms and expectations


frequently interfere with health behaviors and the taking of

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

research has shown that young people are unrealistically

optimistic about susceptibility to health problems and that

this optimistic bias undermines interest in risk reduction


(Urberg & Robbins, 1984


Weinstein, 1982


, 1984).


A dilemma


for health prof


ess


ional


on most college campuses is,


therefore, how to motivat


the retention or adoption of


health behaviors despite lack of a felt need and peer


support to the contrary


Over the years college and university campuses have

been the focus of many different health behavior change


initiatives.


For many years health education classes were


the main vehicle for promotion of health-protective


behaviors on college campuses.


By increasing pertinent


health knowledge through structured academic


classes, health


professionals sought to change attitudes, values, and


behaviors of students (Zapka & Love, 1985)


Although


positive associations between health knowledge and action


were reported for those students who took the el


ective








9

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

p. 72).


During the 1970s and early 1980


there was widespread


development of extra-curricular health education programs,

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

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

motivate individual behavior change, and, more recently,

wellness and health promotion programs which attempted to

affect not only individual behavior change but institutional


norms and policies


well (Hettler


1984)


Again, only


those students with prior interest in health were attracted


to these non-credit program


which frequently conflicted


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

A particularly promising health behavior change

strategy, health risk appraisal, has been used in many

health education and promotion programs to motivate the

adoption of health behavior among college students since the


mid-1970s (Hettler


, 1980)


Arising from the prospective


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

appraisal was originally developed as an instrument for

physicians to use in counseling patients to "promote a

healthy life by preventing death and disability due to


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


Combining a








10

vulnerability to illness or disability, increasing


awareness of


self-responsibility for health status, and


recommending behavioral


changes to minimi


risks to health.


By using the instrument a person


known risk factors


may be compared with his or her peers in the general

population and an appraised age or risk score over the next


10 years projected.


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


an individual based on risk factors, and an achievabi


age,


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

generally given with recommendations for adaptation of


behaviors conducive to health


A wellness score, i.e., the


total achievabi


death rate divided by the total appraisal


death rate multiplied by 100 points, can also be


omputed


"an alternative means of communicating the overall level of

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


1985, p. 64).


Separate risk factor levels for each of the


applicable

on (a) U.


top 12 causes of death are also provided.


. mortality data by age, race, and gender


Based

(b)


relative risk data from epidemiological studi


prevalence


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


age/race/


sex


(Lasco, 1984), calculations are made concerning


probabilities of death occurring in the next 10 years and


rprliirinn nf ric nnccihl


hv mnHifiratinn nf cncr-ifir


II .


Y~








11

questionnaire has the potential to change health behavior by

first modifying the beliefs which precede or accompany the


initiation of that behavior


According to the original


Health Belief Model, adoption of recommended health


behavior


likely when people perceive themselves as


susceptible to illness or accident and the condition as

serious, believe in the efficacy of the behavior to reduce


the threat to health, and


see


minimal difficulty in


undertaking the action.


In addition, an internal or


external "cue" to take action and a general health

motivation or concern for health are assumed to be necessary


for the initiation of health behavior change.


Finally,


factors which modify or enable th


ese


beliefs and the


readiness to take action are included in the Health Belief


Model.


Information from a health risk appraisal, therefore,


has the potential to heighten perceived susceptibility by

personalizing health risks, to enhance the belief in the

benefits of taking action by showing the lowering of risk

with suggested behavior change, and to decrease barriers to

action by providing resource and referral information to


ist with change.


Additionally, health risk appraisal


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

initiation of previously considered changes.










review of the most current literature.


In a recent survey,


alcohol abuse, smoking, drug abuse, intimate relationships,

and weight control were among the top 12 most serious


problems reported by university students (Henggeler


& Cooper, 1980).


, Sallis,


With an increase in substance use and


sexual activity among this population, the need for health


education and promotion, with an empha


on reduction of


health risks through behavior change, has intensified over

the past decade.

Lester and Leach (1983) reported significant increases

in alcohol use, marijuana use, and sexual activity among


college undergraduates, particularly women. Wi

increase in the drinking age to 21 in most stat


official


th the recent


, college


are also predicting an increase in alcohol use and


related problems


students drink in uncontrolled settings


or turn to other drugs (Ingall


1985).


Even alcohol-


related fatalitie


among 18


- 20 year old individual


not shown a


consistent decrease in states raising th


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

The use of cocaine on college campuses has also


increased


substantially from 2.5% in 1970 to 44% trying


cocaine at least once in 1984 (Greene, 1985)


According to


most health officials, cocaine is more addictive than heroin








13

In addition to the prevalence of substance use,

researchers have estimated that as many as 1 in 10 college

students suffers from chlamydia, the most prevalent sexually

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


1985).


Less monogamous but more sexually active than the


adult population, college students are at high risk for this

disease and its accompanying symptoms and long-term


complications, including

although the number of c


terility for women.


ases


Furthermore,


of AIDS among college


undergraduates is small, this population is at risk for

exposure to the AIDS virus, for the development of Aids


Related Compl


(ARC) or AIDS, and for premature death due


to the invasion of "opportunistic disease


pneumonia, tuberculosis


" such as


ancer, within 5 to 10 years


after graduation (Biemiller, 1987a)


Finally, 1 out of every 20 students


, primarily female


is estimated to be at risk for developing an eating disorder

which commonly begins in the freshmen year when pressures to

achieve and adjust to college life can be overwhelming


(Greene, 1986).


The real extent of this disorder, which has


been linked to weight control and inadequate coping with

stress, is currently unknown, but the effects upon health

status have been well documented.










Foundation survey of 5000 undergraduates at 310


colleges and


universities, 99.4% of the participants responded that good

health was a goal considered very important or fairly


important to them.


In fact, among the 10 goals listed, good


health received the highest percentage of responses for an

important goal to be achieved (Jacobson, 1986).


Despite evidence


of increased need and interest among


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

unwilling to attend health promotion programs or register


for health education cl


asses


because of competing demands


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

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

Time demands for students prevent many of them from

participating in structured health promotion activities.

Moreover, interest in reducing health risks and achieving


good health status i


often undermined by unrealistic


optimism about susceptibility to illness or accidents

(Weinstein, 1984).

Although the use of health risk appraisal in college


health programs


a motivator of behavior seems justified,


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


appear


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


1983: Petosa. Hvner


. & Melbv. 1986)


. exDerimental research








15

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


Moriarty, 1983; Wagner


, Beery, Schoenback, & Graham, 1982).


Researchers investigating the use of health risk

appraisal with college students have reported inconsistent


results.


Wilson, Wingender, Redican, and Hettler (1980)


found no significant differences in health behaviors between

27 undergraduates receiving Risk of Death feedback from the


Lifestyle


Assessment Questionnai


and a control group of 62


who did not receive results


freshmen, Nagelberg (1981)


Similarly, in a total sample


tated that there were no


significant differences in health attitudes, values, locus

of control, and enrollment in voluntary intervention

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

group, and a peer heath education group after administration

of the Database Acquisition for Student Health

questionnaire.

More recently, Chan and Davis (1985) reported a

significant difference in smoking behavior between two

groups of 300 freshmen, one which received a health risk

appraisal with interpretation of results and one which did


not.


At the end of the school year students in the feedback


group were more likely to quit smoking, reduce th


cigarettes, or to not begin smoking.


number of


Authors of two








16

appraised age or health behaviors between health risk

appraisal and non-health risk appraisal feedback groups

resulted.

Health risk appraisal research with non-college

populations has been even more supportive of modest

appraised age and behavior changes with health risk


appraisal use (Bartlett, Pegues,


LaDou, Sherwood, & Hughes, 1979


haffer


Lauzon, 197


, & Crump, 1983;


Rodnick,


1982).


However


a review of this research reveal


extreme


variations and inconsistency in research design with most


studies weakened or confounded by


(a) lack of a strong


theoretical model guiding th
!


study,


b) emphasis on


behavior change as the only dependent variabi


without


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


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


size,


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

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

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

individual or small group health counseling sessions, health

education classes, and fitness programs.

The timing of the evaluation has also affected the


results of such studies.


Whether health risk appraisal has


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










change.


Health risk appraisal was intended to be used


primarily as the first phase in facilitating health behavior


change (Hyner & Melby, 1985).


If it can be shown that


initial behavior change is motivated by health risk

appraisal, then more comprehensive follow-up strategies to


ass


ist participants in the maintenance of that change can be


employed.


Most


earcher


exploring the effects of health risk


appraisal on health behavior chang


to 12 months after the intervention.


have measured change 3


Considering that th


short-term effects of many health behavior change strategies


and the subsequent relapse of individual


into previous


modes of behavior are well-documented in this field

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

behavior change resulting from health risk appraisal may not


have been maintained over this extended length of time.


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


is not possible


, and assumptions made about the effect of


any strategy on behavior may be highly inaccurate.


timing of an evaluation of treatment outcome


crucial to


results of a study and "must distinguish among the


initial induction of therapeutic change, its generalization

to the natural environment, and its maintenance over time"










of the evaluation is al


important.


Following an


intervention in two recent studies, the immediate increases

in posttest scores measuring perceived susceptibility,

perceived severity, and perceived barriers decayed over a


one-month period of time (Kolbe, 1979;


1984).


ero, Kok, & Pruyn,


Since the initial adoption or activation of belief


are addressed in the Health Belief Model, researcher


examining changes in dimensions of the Health Belief Model

after a health risk appraisal intervention have generally

measured change occurring within a month or less of the


intervention to allow enough time for th


acceptance


of the


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


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


Any longer term


follow-up would also be measuring the maintenance of beliefs


rather than the initial change or adoption of beliefs.


more immediate belief change can also be used


intervention effectiveness in the


evidence of


hort-term because the


activation of existing health beliefs or changing of beliefs

makes health behavior more likely in the future (Kirscht,

1974).

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

the immediate effects of a intervention, is the most

practical and necessary method of assessing a health belief








19

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

By assessing the short-term impact of health risk appraisal


on either health beliefs or behaviors, researcher


data which clarify the next best


provide


tep in a logical sequence


of strategies necessary to


assis


t individual


in initiating,


adhering to, and, eventually, maintaining health behaviors


over the long term.


approach


Innovative and effective short-term


are needed as well as techniques to prevent


relapse (Brownell, 1982)


To plan and implement a program


without determining the immediate impact of health risk

appraisal on health beliefs and/or behaviors may result in

duplication of efforts and a waste of time and resources.

Finally, the characteristics of subjects at different

health risk levels, the interaction of initial risk level

with a health risk appraisal itself, and the subsequent

effect on behavior and belief change has rarely been


directly addressed.


One notable exception was the study by


Cioffi (1980) who reported that low risk individual


whose


appraised age was mor


than two year


ess


than their


chronological age had low anxiety about health, a high


health value, and perception of


health status.


If as above average in


Nevertheless, no changes in health beliefs


were found to be related to the health risk level.







21

risk appraisal, the present study was designed to determine

whether the Health Risk Appraisal process had any immediate

effect on either the adoption or retention of health

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

accident, perceived efficacy of preventive behaviors, and

perceived self-efficacy to perform suggested health

behaviors, and/or the adoption or retention of health


behaviors.


The extent to which risk level of the students


influenced adoption or retention of health beliefs and

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

Appraisal process had a differential effect upon the health


belief


and behaviors of high and average risk students.


Research Hypoth


ese


In this study the effects of involvement in a Health

Risk Appraisal process on the health beliefs and behaviors

of high and average health risk college freshmen were


examined.


The following hypotheses were tested at the .05


level of significance.


There is no significant difference in adjusted


scores on a health behavior ind


among


olleg


freshmen involved in the


Health Risk Apprai


sal pr


ocess,


in a health


information session, or in neither








20

years and can gain a minimal number of years of life


expectancy under th


health risk appraisal system of risk


age calculation, they may be 1


ess


amenable


to health risk


appraisal than adults over th


age of 40 (Cottrell & St.


Pierre, 1983; Nagelberg, 1981


afer, 1982).


Dunton and


Rasmussen (1977) also concluded that the amount of positive

behavior change was directly related to the amount of

initial risk identified by a health risk appraisal.

However, despite the assumed relationship between risk level

and subsequent change and the alleged limitations of using


health risk appraisal with healthy young adult


litti


been done to actually


assess


the eff


ects of risk level on


cognitive and behavioral outcomes of health risk appraisal.

As a relatively new strategy for health behavior and

belief change, the immediate impact of health risk appraisal

had not been adequately evaluated, particularly for the


college student population


In addition, it was unknown


whether the impact of health risk appraisal varied on the


basis on the student


initial


evel of risk


Finally, it


was unclear whether health risk appraisal acted to motivate

retention of current health behaviors or beliefs and/or

adoption of additional health behaviors.


Purpose of the


Study


__~~ _


Study







22

between high and average health risk level

college freshmen.


There is no significant interaction effect of risk


level and treatment on the adjusted scores on a

health behavior index of college freshmen.


There is no significant difference in adjusted


scores on the health beliefs index measuring

perceived susceptibility to illness or accidents


among


college freshmen involved in the


Health Risk Appraisal process, in a health

information session, or in neither.


There is no significant difference in adjusted


scores on the health beliefs index measuring

perceived susceptibility to illness or accidents

after treatment between high and average health

risk levels of college freshmen.


There is no significant interaction effect of risk


level and treatment on the adjusted scores on the

health beliefs index measuring perceived

susceptibility to illness or accidents of college

freshmen.


There is no significant difference in adjusted


scores on the health beliefs index measuring







23

Appraisal process, in a health information

session, or in neither.


There is no significant difference in adjusted


scores on the health beliefs index measuring

perceived efficacy of preventive action after

treatment between high and average health risk

levels of college freshmen.


There is no significant interaction effect of risk


level and treatment on the adjusted scores on the

health beliefs index measuring perceived efficacy

of preventive action of college freshmen.


There is no significant difference in adjusted


scores on the health beliefs index measuring

perceived self-efficacy to perform a health

behavior among college freshmen involved in the

Health Risk Appraisal process, in a health


information


session, or in neither


There is no significant difference in adjusted


scores on th

perceived se


health beliefs index measuring


If-efficacy to perform a health


behavior after treatment between high and average

health risk levels of college freshmen.


There is no significant interaction effect of risk







24

self-efficacy to perform a health behavior of

college freshmen.

Importance of the Study


The impact of health risk appraisal on college students


is further


larified in this


Belief Model (Becker


, 1974),


tudy based on the Health


self-efficacy theory (Bandura,


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


1981).


In addition, a contribution is made to the growing


body of literature addressing the effect of this strategy on


health beliefs and behaviors.


investigation ha


Additionally, this


important implications for the development


and delivery of health risk reduction programs in higher

education and for the professional in health counseling.


According to cognitive model


change, prebehavioral change


of health behavior


in knowledge, attitude


values, and perceptions may be predisposing factors to


actual behavior change (Green et al., 1980)


Beliefs


concerning health, particularly beliefs identified as

perceptions of susceptibility to disease or disability,

response or outcome efficacy, and barriers to action,


particularly pers-onal or self-efficacy


be related to and predictiv


have been shown to


of health behavior (Bandura,


1977a; Beck & Frankel, 1981


Janz & Becker


1984)


Findings







25

in addition to determining the effect of health risk

appraisal on health behaviors, the impact of health risk

appraisal on health beliefs is also determined.

Despite a continuing need for the development and

evaluation of risk reduction programs, particularly for

places where large populations can be reached over time and


the benefit-to-cost ratios are favorabi


(Knowl


1977)


limited resources and budget cuts in higher education make a

reduction in student health and counseling services likely


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


If cost


containment efforts in higher education are not to result in


the virtual


elimination of college health promotion


programs, the most efficient yet least offensive ways of

motivating the retention or adoption of health behaviors by

college students must be identified.

A primary prevention strategy, health risk appraisal,

selectively applied, may be a cost effective method to

reduce the current and future health risks for a large


number of students.


Computerized assessments are typically


"inexpensive, noninvasive, personalized health assessment

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

with large groups where general risk reduction is the


objective (Neutens & Pursley, 1985)


By determining the







26

beliefs among college freshmen of different risk levels i


revealed.


For whom and in what way health risk appraisal is


most effectively utilized is also


clarified.


Therefore, the


future investment of time and energy in health risk

reduction programming for this young adult population can be

guided more efficiently by the results of this study.

In an era of limited resources and increased demands

for accountability, empirical evaluation of health risk

reduction strategies becomes essential to justify their use.


Although the efficacy of health risk appraisal ha


preliminary support


received


an approach to stimulate behavior


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

designs and a plethora of contradictory results from studies

done on college campuses necessitates continued investment

of time and energy in the development and evaluation of this


risk reduction strategy (Fielding, 1982; Wagner


Schoenbach, & Graham


, Beery,


, 1982).


By further testing th


effectiveness of a widely


adopted health promotion


strategy


this


tudy also


contributes to knowledge utilized by health counseling


professional


whose primary role is to identify health risks


and plan intervention strategies before the onset of illness


or disability (Childe


& Guyton, 1985).


Health counselors









1981).


By basing their use of facilitation strategies on


well-designed research, health counselors can have a greater


impact on the health status of their clients.


Results of


this research facilitates increased awareness of the

appropriate applications and potential effects of health

risk appraisal on clients' adoption or retention of health

behaviors and health beliefs.

Definition of Terms


To further one's understanding of the research


hypotheses and methodology used in thi


terms ar


study, the following


clarified:


College freshmen are students, with 12 semester hours


or 1


ess


of college level work credited toward graduation


requirements, entering a four-year private, protestant

college in the autumn term of 1986.

Health risk appraisal is a general method using a

standardized questionnaire and health status feedback

describing an individual's chances of dying or acquiring


specific disease


usually within a 10-year period of time


(Fielding, 1982).

Health Risk Appraisal process refers to the

administration of the Centers for Disease Control (CDC),

Atlanta, Georgia, Health Risk Appraisal questionnaire,







28

results, response to questions, advocacy of and


recommendation


for adoption or retention of health


behaviors, and dissemination of resource and referral

information to assist with voluntary behavior changes (see

Appendix B).


Health information session refers to a group


sessi


incorporating advocacy of and recommendations for adoption

or retention of health behaviors and dissemination of

resource and referral information to assist with voluntary


behavior changes.


This session duplicates the Health Risk


Appraisal pr


ocess


with the exclusion of the return and


interpretation of the computerized feedback form from the

Health Risk Appraisal questionnaire.

Health risk level is the classification of an

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

value obtained by substracting the health risk appraisal

appraised age from the individual's actual age.

Low health risk is a lower than average risk for


disease or accidents within the next 10 years.


In this


study an individual whose appraised age was more than two

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

Average health risk is an average risk for disease and


accidents within the next 10 years.


In thi


study an







29

High health risk is a greater than average risk for


disea


or accidents in the next 10 years.


In this study an


individual whose appraised age was two or more years greater


than his or her actual age i


Health behavior i


at high health risk.


any behavior performed by a person


to protect, promote, or maintain hi


or her health as


measured by a health behavior questionnaire (


see


Appendix


C).

Health beliefs are beliefs identified in the Health

Belief Model concerning susceptibility to disease or

accident, the efficacy of recommended action, and barriers

to suggested action, particularly self-efficacy, as

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


Organization of the


tudy


The remainder of this study is organized into four


chapters.


The second chapter is a review of literature and


includes discussion of (a) health behavior and belief

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

risk appraisal as a health behavior and belief change

strategy, (d) health behavior and beliefs of college

students, and (e) health behavior change strategies in


higher education.


methodology,


Chapter III contains the research


chapter IV incorporates the results of the














CHAPTER II
REVIEW OF THE LITERATURE

In this chapter literature related to the current study


is reviewed in five topical areas:


(a) the nature of health


behavior and the relationship between health behavior and

health beliefs, (b) current approaches to changing health


behavior, (c) health risk appraisal a


behavior


a health belief and


change strategy, (d) health behavior and beliefs of


college


students, and (e)


trategi


employed to change


college


student health behavior


Health Behavior and Health Beliefs


Health Behavior


Although behavior related to health has been described

in elaborate terms, any behavior undertaken to promote

health and to reduce risks to health is simply a health


behavior (Taylor, 1986)


The classic term, preventive


health behavior, has referred primarily to medically

approved and recommended behavior "undertaken by a person


believing himself to be healthy

preventing disease or detecting


(Kasl & Cobb, 1966, p.


, for the purpose of


it in an asymptomatic stage"


The newer phrase, health








31

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

not such behavior is objectively effective toward that end"


(p. 18).


This latter definition included a wide range of


activities believed to promote health, some of which were


not necessarily sanctioned by health care professional


supported by scientific research.

Recently researchers have suggested that "disease

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

assistance of a health professional, and "health promotion


behavior, i.e.


contact such as exerci


different entities" (Yoder, Jone


, behaviors not requiring professional


and eating nutritiously, are "two


& Jones, 1985, p. 30) and


that practicing disease prevention does not nece


correlate with practicing health promotion.


arily


Firmly


established health behaviors, performed automatically

without conscious awareness and partially independent of

reinforcement, have been further delineated as "health


habits" which ar


maintained primarily through practice and


repetition (Hunt, Matarazzo, W


eiss,


& Gentry, 1979).


Thus health behavior may be multidimensional rather


than unidimensional and the performan


of one type of


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










Two independent


lust


ers


of health behaviors,


"direct


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


personal hygiene, and smoking, and "indirect risk

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

immunizations, nutrition, and exercise, were found in a


survey of 617 adult


in Illinois by Langlie (1979).


A study


based on 84


interviews of adults in Ohio (Harris & Guten,


1979) revealed that health protective behavior clustered


into five groups:


(a) health practices such as


leep, diet,


weight control, and exerci


(b) safety practices


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

environmental hazard avoidance; and (e) harmful substance


avoidance.


Conversely, in a study of 330 adults, Mechanic


(1979) stated that the 10 dimensions of health behaviors


assessed were only modestly intercorrelated.


However


combined eight of the dimensions into a single index of

degree of positive health behavior for each subject and drew

the conclusion from an additional analysis that positive


behavior for an adult is part of a comprehensive lifestyle


reflecting the ability to anticipate health problems,

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

1980).

This cnn rnt nf a hrnaH health nrinntatinn nr lifoctvla










1979; Epstein, 1979; Matarazzo, 1984).


Agreement on the


underlying elements of this orientation has not been

reached.

Much of the problem in determining the association


among health behaviors ha


been a function of measurement.


Epstein (1979) demonstrated that when measures of a behavior


were averaged over a greater number of events,


ability


coefficients for such behaviors increased to high level


Most researchers have assessed health behaviors on only one

or two occasions and therefore have obtained low

correlations.


Other problems a


ssoc


lated with


asses


ing health


behavior are related to the method of attaining data which


has primarily been through


self-report.


In particular, the


need for social approval has been


strongly a


ssoc


iated with


general measures of preventive health behavior


In a


tudy


measuring this relationship within sample


of the British


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

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

health behaviors and the scores on a social desirability

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


Optimal


asses


sment procedures for


socially sensitive health


behaviors


such as smnkina or alcnhnl uip hav


invnl vpd


S








34

The inconsistency of health behavior over time has also


been noted (Mechanic 1979)


With the exception of firmly


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

internal and external factors influencing the individual'

behavior has resulted in the modification of the health


behavior


This has been most apparent in


studies of


consciously made and highly desired health behavior change

where maintenance rates have been low (Brownell, 1982;

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


Dubbert, 1982)


The fact that health behavior is a highly complex

phenomenon and a function of multiple factors has been

supported by the information from health behavior surveys.

The next step of identifying the factors which influence

health behavior has been of central concern to those in the


health-related professions attempting to assist peopi


the modification of such behavior.

The significance of education, age, income, and

involvement in a social network in predicting health

behavior was revealed in an analysis of a 1979 national


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


this study, income, education, and social support were

Dositivelv related and ano was nPnativPIv rPlatPd tn hPalth










practices.


For mal


the direct effect of age on health


practices was not significant


The social network elements


of church attendance and marriage were also positively


related to a reduction of alcohol and tobacco u


for both


men and women. Marriage was, however, negatively associated

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


reported that female gender is positively related to health

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

of preventive medical checkups were more common among adult


males than adult femal


An examination of the data on ag


and health behavior


indicated that while


younger


children and adults take


moderately good care of their health, adolescent


and young


adults compromise their health behavior in an attempt to


achieve independent


ress,


confirm a personal identity, cope with


rebel against conventional norms, or achieve an


alliance with their peers (Green, 1981).


In the 1980s, a


pattern of heavy alcohol and illicit drug use, cigarette


smoking, and precocious


ual activity h


emerged among


adolescents that is the antith


Equally prevalent for males and femal


is of health behavior


, this problem


behavior may constitute a syndrome or interrelated cluster


of behaviors (Jessor


1982)


S


. Th


occurrence of thi


1 __ w --


.








36

increase among adolescents moving from 7th to 12th grades

(Jessor, 1984).

Considering the numerous potential determinants of

health behavior among different age, gender, socioeconomic


status, marital status, and educational level groups,


it is


not surprising that county


ess


theori


have been developed


to explain health behavior


Currently no comprehensive


single model has been widely accepted or consistently

applied in research to meet the criterion of being a


paradigm in this field (Parcel, 1983)


In an attempt to develop a unified framework for

explaining health behavior, Cummings, Becker, and Maile

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


variable


from 14 different models into 12


imilarity


factors emerged:


Using a small


(a) ac


- 14 groups based


est space analysis,. six common


ibility to health service


including cost and availability; (b) attitudes toward

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


and beliefs about susceptibility and


sequen


sease


(d) social network characteristic


about disease


(e) knowledge


and (f) demographic characteristic


These


finding


have suggested that the models are not independent


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










Health Beliefs


In the most widely applied approach to th


of health behavior,


1. e.,


explanation


the Health Belief Model


(Rosenstock & Kirscht, 1979), health behavior i


consequence of prebehavioral beliefs.

has been applied extensively to the e


based action,


Although this model


explanationn of medically


it has also been applied to the investigation


of other health behavior


e.g., contraceptive behavior


ester & Macrina, 1985), exercise (Slenker


, Price, Roberts,


& Jurs, 1984), and breast


self


-ex


am (Calnan & Moss, 1984).


ince its inception in 1966, the Health Belief Model ha


continued to evolve and currently has a number of variables

in common with many other models, particularly social


learning theory and fear appeal


communication theory.


According to the original Health Belief Model


senstock, 1974),


the likelihood of an individual adopting


a health behavior is a function of four


specific beliefs:


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


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


ived


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


action.


More recent modifications of the model have also


incorporated "cues" to action which bring a health decision


intn rnn'rin 1


awarpnpce a nncifivu h.mlth mntiu.ftinn an


,










1977).


Although many researchers have suggested further


refinement


of the model, e.g.


locus of control (Wallston &


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


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


remain the focu


of most research.


Related to psychological theories of decision-making

under conditions of uncertainty, the revised Health Belief

Model is an expectancy-theory approach which views action as


related to a subjective desire


severity and an estimation of benefit


incentive value of any health action i


to lower susceptibility and


minus costs; the


therefore its


ability to lower perceived susceptibility and severity


(Maiman & Becker, 1974)


Thus health behavior becomes more


likely when both the perception of threat or ill health and

the perceived value of the behavior are increased as the


perceived obstacle


to action are reduced (Kirscht, 1974).


Behavior change strategies based on this model tend


primarily to emphasize increasing an individual'


perception


of personal risk, enhancing the belief that change will


ult in the expected outcome of reduced risk, and reducing


the perception of barriers by increasing opportunities for


action, personal health skill


and the individual's


perceived caoabilitv to take aoorooriate action.








39

for the Health Belief Model from both prospective and

retrospective research and have confirmed the strength of

the Health Belief Model to provide a conceptual basis for


health behavior and its modification.


Research over the


past


0 year


in the area of health beliefs has continued to


support a high correlation between both perceived


susceptibility to illne


and perceived benefits of taking


action and adopting health behaviors (Shortell, 1984).

However, beliefs concerning perceived barriers and perceived

susceptibility have proven to be the most powerful of the

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

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


Roberts, and Jur


(1984) reported that 61% of the variance


between the sample


of 124 jogger


and 96 nonexercisers was


accounted for through an analysis


based on eight predictor


variable


of the Health Belief Model


The top three items


on the questionnaire with the high


t correlation to the


criterion variable of jogging vs. nonexercising wer


measurements of barriers.


The authors concluded that the


major factor separating joggers from nonexercisers was

perceived barriers.


similarly,


in a sample


of 111 college students,


secondary schnnl tPacrhPr and lirpncpd nrartiral nlur~cC thh










effectiveness correspond


res


pectively to the concepts


perceived costs or barriers and perceived benefit


Health Belief Model.


of the


The fact that students and teachers


were more concerned with effectiveness while nurses were

more concerned with effort also suggested that perhaps

different dimensions of the Health Belief Model were

relevant for different populations in explaining health

behavior.


The Health Belief Model provides an


explanation for the


impact of the health risk appraisal process on health


behaviors.


By increasing the perceived susceptibility to


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

of death within the next 10 years and the perceived benefits

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

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

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


action and the availability of resources, and lack of


self-


confidence, the health risk appraisal process may directly

affect the beliefs which precede health behavior.

Health Behavior Change


"Inconsistencies, unanswered questions, and rapid

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


icrrPnt 'tata nf thP art nf r cparrh and nrarti


I -


in hpa1th








41

individual, group, and community level and have included

both passive and active approaches (Williams, 1982).


In the public health domain the passive


approach ha


been successful in reducing potential harm to health with

pasteurization of milk and treatment of water serving as two


good exampi


Even mor


recently federal standards for new


cars manufactured since 1968 resulted in a decrease of an

estimated 9,000 deaths per year of drivers and passengers


(Robertson, 1981)


However


, the enactment of laws requiring


behavior change has not been


successful as environmental


modification, particularly with behaviors which are not


publically observable.


It has been estimated that only


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

alcohol are actually arrested for the offense (Robertson,

1984).


Although


rese


archers have


continued to


how that


environmental conditions contribute


substantially to chronic


disease and accident rates, most solutions also involve


individual behavior change,


i.e.


, active strategic


contrast to the passive approach, active strategic


require


implementation by individuals and have been useful only when

people are influenced through education, mass media


communication,


leqal sanctions, and behavior modification








42

they have been the main targets of intervention and have

spawned a new approach to medical care that is both


behavioral and preventive (Matarazzo, 1984).


The concept of


risk was basically derived from epidemiological


investigation in which incidence rates of a disea


or cause


of death were related to a given factor suspected of


affecting health (Milsum, 1984).


Reducing the risk factors


became a national commitment when the federal government


established 15 health goals which, if attained, were


intended to produce


better health for Americans by 1990


. Harri


1981)


Goals under the area of health


promotion included reduction of risk through change in the


targeted behaviors of smoking, alcohol and drug misu


nutrition, physical fitness and exerci


and control of


stress and violent behavior


The difficulty with these and similar behaviors has


been that individual


must be personally motivated to adopt


and maintain health practices over a lifetime if health


risks are to be minimized.


In addition, health behavior,


ess


it threatens the welfare of another, i


voluntary


behavior and thus change cannot be imposed but must be

motivated through education and persuasion (Green et al

1980).








43

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


that the


expectation of immediate change in health practices


for the majority of participants has been unrealistic and

nai ve.

One explanation posited for this lack of change has

been related to the nature of the health behavior change


process.


According to Brown (1976), health behavior change


occurs progre


ively and by


sequential


tages


She has


proposed that the five


tages organic


n a hierarchical


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


of information concerning the health risk,


of this information into the


behavior change


(c) integration


self-image, (d) effort toward


, and (e) achievement of behavior change.


This concept of stages in the adoption of a behavior has

grown out of the research in communication, education, and

public health.

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


in behavior change in the PRECEDE,


Reinforcing


, Predisposing,


, and Enabling Causes in Educational Diagnosis


and Evaluation, model of health education programming


accordance with thi


followed by th


behavior, and th


approach, an initial motivation to act,


deployment of resources to enable the


reaction to the behavior by others act








44

With the inception of the Health Belief Model this

concept of belief change preceding behavior change has been


widely supported


however


, the process


of building toward


the threshold of actual initiation of change as explained by


the PRECEDE and


similar model


has not yet been fully


larified (Milsum 1980b).


The concept of


tages and


evidence that the effectiveness of a health behavior change


strategy i


enhanced when a variety of methods are used have


led theorists to suggest that the optimal strategies to

change behavior are dependent not only upon the specific


haracterisitics of the health behavior itself, but also


upon which predisposing belief


and knowledge, enabling


resources and skills, and reinforcing factors,


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


1986)


Only through a thorough assessment of the health


problem and related behavior could the focus of the most

effective intervention be identified.

Another conceptual basis for health behavior change is

found in the persuasive communication research regarding


fear appeal


(Beck & Frankel, 1981)


Although varied


results and marked inconsistency have characterized the

history of research in threatening health communications


Kirtrht 1QR31 ovidpnro


Yitc that holiaf in ridc a nr itc


I


CI









45

increased attitude and behavior change occurs under


conditions of


trong threat information.


Exposing 80 adults to on


of four versions of a 13-


minute,


lide-tap


communication about periodontal disease,


Beck and Lund (1981) investigated the relationship between


high fear arousal and performing th


prevent the disease.


recommended behavior to


The four messages varied in


seriousness and susceptibility information and, across all

versions, recommended effective oral hygiene procedures to


reduce the health threat. T

the greatest amount of fear,


'he high threat message generated

intention to comply, and actual


compliance with the procedures


in addition, th


researchers


found that perceived


self-efficacy in performing the


behavior was the best predictor of the actual behavior.

Although fear may act to focus attention on risks,


earchers have generally confirmed that fear arousal alone


is insufficient for immediate and long term changes (Beck &


Lund, 1981; Leventhal, 1970


Smith, 1982).


Basing their


research on protection motivation theory, Rogers and Mewborn


(1976) demonstrated that for


making, driving


and venereal


disease,


increments in the outcome efficacy variable and the


noxiousness variable increased the intentions of 176 college


S1i1Annt


- *II -I u 11 *|- -


tn drnnt tho rarnmmmnrdI nrartiroc


h nwi\ar


whan


w








46

apparently strengthened the intentions to adopt recommended


behaviors whereas lack of control had th


opposite effect.


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

examined the effects of viewing a highly threatening video


tape on smoking and health risks with a sample


in London.


of 61 adults


Intention to stop smoking was significantly


correlated with high fear arousal and high reported


confidence in the ability to stop smoking.


later


Three months


self-reported behavior was directly affected by


intention.

In integrating existing theoretical approaches in the

fear appeal literature, Beck and Frankel (1981) have

theorized that beliefs concerning personal success in

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

appear to be prime factors in determining whether or not


subsequent behavior will be initiated.


It was suggested


that the motivational effect of a health threat

communication depends primarily on two of the recipient'


beliefs:


response efficacy or the perceived ability of the


recommended actions to control the threat (called perceived

benefit of action in the Health Belief Model) and personal

efficacy or perceived ability of a person to perform


recommended actions suc


- .-


fully (called perceived barriers








47

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

1978).

Another more familiar term for personal efficacy, self-

efficacy, has been associated with social learning theory


(Bandura, 1977b).


Social learning theory supports the view


that behavior is significantly influenced by three


regulatory systems:


antecedent events, consequent events,


and mediational cognitive process


A recent refinement of


social learning theory has focused on the significance of

self-efficacy or personal control in the generalization of


coping behavior (Bandura & Adams, 1977).


The conviction


that one can successfully perform a behavior to produce a


specific outcome ha


been shown to influence the execution


and persistence of behavior and the generalization of the


behavior to other


situations (Wilson, 1980)


In th


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

extinguished anxiety reactions through desensitization, yet


subjects emerged with varying degrees of


expectations.


self-efficacy


The actual post-treatment performance of


subjects corresponded closely to level of self-efficacy

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


tasks.


In other studi


investigators have shown that the


evel of self-efficacy is


a


ianificantlv related tn smnkinn


1










Most behavior change strategic


can be classified as


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


behavioral-change or skills training approaches


many are a


combination of the two


Attitude change


trategi


have


primarily been applied in primary prevention effort

encourage the maintenance of health behavior and th


avoidance of risk factors while behavioral-change methods

have been more frequently applied in secondary prevention

efforts to change frequent and complex behaviors (Taylor,

1986).

In recent years mass media campaigns have been

advocated as a way to communicate health-related information

and to change health attitudes and behaviors on a large-


scale basi


in the community


An increasing number of


attempt


have been made to influence general health, safety,


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

heckup behavior via the electronic and print media


(Alcalay, 1983; Flay, DiTecco, &


hlegel, 1980).


Although


"public communication campaigns to induce people to adopt


more healthful lifestyle

(McGuire, 1984, p. 303)


have had only modest success"


, the Stanford Three Community


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


and the North Karplia nrnnram in Finland rl P cc


T 1nmil hfn









49

One of the largest preventive medicine research efforts

in the United States, the Stanford Three Community study was

a mass media campaign initiated in 1972 to reduce the risks

associated with heart disease in three California


communities.


In the first phase residents of two small


communities similar in size and socioeconomic status were

exposed to a three-year massive media campaign to modify


smoking, fat consumption, and exerci


behavior; to increase


knowledge of risk factors; and to alter various physiologic


indicators of risk. Receiving no information, the third

community acted as a control. In addition to the


information received through the electronic and print media,

in one of the experimental communities people at high risk

for heart disease received intensive face-to-face


instruction in behavioral


self-control techniques.


For both


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


risk index


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


chol


esterol level, consumption of fat


and smoking resulted


from the interventions.


The media plus face-to-face


intervention group also maintained a significantly greater


reduction in smoking behavior


In general, it was


discovered that the media alone successfully reduced risk to


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


Ph r < /


kn~l-/ avi+ *-








50

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

assessment of the stage of readiness of the target

population for various lifestyle changes and a determination

of the preferred strategy was needed to increase the power


of th


mass media intervention.


A five-year mass media campaign directed at North

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


high incidence of heart di


sease


, also


ulted in a


reduction in the level


1979).


of risk factors (Puska et al


A 17% decrease in cardiovascular disease risk for


and an 11.5% decrease for female


resulted.


A 10-


year followup evaluation showed an even further reduction in

risk level (Puska, 1984).

In contrast to these promising results, television

campaigns promoting the use of seat belts have resulted in


no significant changes in level


of use (Robertson, 1978).


Furthermor


in evaluating th


effectiveness of a series of


public television shows on alcohol u


(1977) found that few peopi


Dickman and Keil


watched the series, and of


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


alcohol as a personal problem.


A decision to seek treatment


or recommend treatment for another also did not result.


Althnuinh inrnnrllusivp cvi


1I r |


nf mn~a cft i nd a n










have been combined (Maccoby & Alexander, 1980)


How much


change in knowledge, belief, and behavior has been


facilitated by exposure


been


to a mass media campaign has not yet


clearly determined.


Within the school


setting attempts to influence health


behavior have been through formal instruction in a health


education course.


Lectur


discu


ion and audiovisual aids


have been used to convey factual information to


adolescents while


children and


peer-group discussions have been held to


encourage peer support for health behavior


Currently


computer software has been introduced as a motivational


devi


with


self-assessment


games, and programmed


instruction mad


lasse


increasingly available in health education


(Gold & Duncan, 1980).


school health education classes


impact on the health knowledge, attitude


have had a limited


kills, and


behaviors of children and adolescent


Knowl


(1977) noted


that health education programs in


school


wer


generally


abysmal and that the effectiveness of th


ese


intervention


reducing overall risk-taking behavior among youth had not


been properly


asses


In a review of several health


knowledge


studies, Pigg (1983) found that American children


ani' vnunn a2rHln taA nart


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










lacked appropriate


self-care education programs.


As a


result of these poorly financed and delivered health

education programs, high school graduates have frequently

exited the formal educational system without adequate health


knowledge or the


kill


and motivation necessary to adopt


health behaviors.

A notable exception has been a skills training approach

to inoculate young adolescents against the peer pressure


which encourage


smoking behavior


Referred to as the


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

developed a preventive approach by focusing on training

adolescents to be more aware of and to cope actively with

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


Rates of smoking were significantly reduced


n the


experimental school


using this approach.


Botvin, Eng, and


Williams (1980) further refined thi


concept in the life


kill


curriculum for adolescents to build a positive


self-


image, assertiveness and decision-making skill


and coping


strategies to deal with peer pressure to smoke.

Where the focus of health educators and public health


professional


has been on risk reduction in large


populations within the school and community, the focus of


Pffnrt fnr rlinirianc


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








53

described extensively in the literature (Stachnik,


Stoffelmayr, & Hoppe, 1983)


C An emphasis


on individuals,


the assessment of overt target behavior, the antecedents and


consequences of the behavior, and, for cognitive


proponents, accompanying thoughts, belief


behavioral


and images, has


characterized the behavioral approach to health behavior


modification (Chesney, 1984).


Some specific technique


have


included reinforcement of desired behavior, contingency


shaping, modeling, stimulus control,


contracting, skill


training, and monitoring of targeted behavior


Behavioral


self-management techniques,


including


self-monitoring,


self-


evaluation, self-reinforcement, and


timulu


control, have


also received increased attention and have been recommended

as a way to prevent relapse of behavior to pretreatment


level


, particularly with smoking cessation, exercise, and


weight control behavior (Kanfer, 1980).

For the management of difficult health problems, such

as obesity, smoking, and alcohol use which involve the

acquisition of new behavior and the elimination of undesired

behavior, behavior modification methods have been the most


successful


however,


long-term adherence rates for most


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


In a


rPviPw nf thp litfrntirQ nn tho opffrtfimnnocc nf cmnLinn








54

Martin and Dubbert (1982) made the same observations about

behavior related to obesity and exercise respectively.

A major intervention study based primarily upon


behavioral modification strategic


es, the Multiple Risk Factor


Intervention Trial Research Group (1982) involved 1


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


risk factor for heart disease.


During a 5-year study, 6000


of the patients were randomly assigned to a special

intervention program where informational and group


behavioral


trategies to reduce smoking, change dietary


habits, and increase exercise were used to supplement


traditional treatment for hypertension.


compared at regular interval


These men were


for 7 years to a control group


which only received usual care for risk reduction from


personal physicians.


In comparison to predicted rat


results indicated that for both group


risk factors declined


but to a greater degree for the experimental group.

Although the rate of mortality due to coronary heart disease

between the two groups was not statistically significant,


confounding variable


such as unfavorable reactions to a


hypertension drug and unexpected risk factor reduction among


the control group, were cited


reasonable


explanations for


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










time consumption of such


major issue concerning maintena

to be addressed and resolved.


trategies have surfaced.


of change has only begun


Whereas communication and


behavioral change strategies have overlapped considerably


and have been applied in many


tors to reduce risks to


health status (Faber, 1980), controversy continue


to exist


about the most effective methods for change and the most

appropriate level of intervention (Creswell, 1985; Kasi,


1980;


tachnik,


toffelmayr, & Hoppe, 1983).


Health Risk Appraisal


Health risk appraisal i


basically the computation and


persuasive communication of personal health risks and has


been used with increasing frequency in medical practi


ces,


governmental agencies, business and industry, and


educational institutions.


By October 1982,


The Center


sea


Control in Atlanta had disseminated their Health


Risk Appraisal software to 194 agencies and found that the


appraisal


school


had been u


(Hargraves, 1


sed most often at the worksite and in

983). In the same year a review of 217


health risk appraisal program


indicated that half were


conducted in the workplace followed by programs located in

public health departments, colleges and universities, and


mPdic alr


rp nrn ani tinn i 7 (W nnar


R rr-l i/ Crknnha 9.











consequen


and (c) the efficacy of health behavior to


reduce risk, health risk appraisal ha

individual and group level to motivat


been applied at the

the retention or


adoption of health behavior (Hyner & Melby, 1985)


analysis of family history, personal


self-reported behavior


From an


characteristics, and


health risk appraisal printout


represents a communication about life expectancy which


varies in degree of threat for each individual.


appraisal, however


Health risk


is more than a computer printout; it is


a pr


ocess


which ha


a minimum of three components:


intake questionnaire, a risk estimation procedure, and a

written or printed output known as an individual risk


appraisal


Goetz & McTyre, 1981)


supplementary tool for us


Originally developed as a


by physician


in the practice of


prospective medicine, health risk appraisal was meant to b


combined with an interpretive-educational counseling


sess


where recommendations for risk reduction and assistance with

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


Shult


(1984) has reported that health risk appraisal has


been most effective in motivating behavior change when used

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


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


' a








57

Health hazard or risk appraisal was first tested in


1959 with 25 medical students at Templ


University under the


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


system of probability of death tabi


derived from national


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


From the


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


estimates ba


sed on th


publication How to Practice


Prospective Medicine by Robbin


and Hall (1970), the health


risk appraisal system has evolved into mass processing of


standardized questionnaires via mainframe


computers and then


into microcomputer-interactive programs (Ellis & Raines,

1983).

Within the past 15 years many versions of health risk


appraisal questionnaires hav


been developed.


In an


inventory of 29 representative instruments made by the

National Health Information Clearinghouse in 1980, Fielding

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


scope, and population applicability among th


Health risk appraisal


instruments.


instruments vary in the


extensiveness of the data collected from the participant and


the intended age of use


At one extreme are those


instruments used in clinical settings which include complete


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

HlnnA










continuum are appraisal


that focus only on lifestyle


avoid medical assessments (Wellness check, 1982).


most health risk appraisal


Although


such as the Centers for Disease


Control 1984 version have been developed for adult

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


created for adol


esc


ents and college students (Hettler, 1980;


Moody & Moriarty, 1983).

Reliability and Validity


Despite their widespread u


, concerns have been voiced


regarding the accuracy and predictive ability of the


instruments used to


assess


risk


Controver


surrounded many of the risk indicators to di


sease


and the


level at which these precursors become hazardous.


Scientific evidence of the risk of dietary c

sodium intake, overweight, and lack of exerc


cholesterol,


has remained


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

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

derivation and method of combining risk factors has been


questioned as well (Goetz, Duff

Schoenbach, Wagner, & Karon, 191


, & Bernstein, 1980;

33). Petosa, Hyner and Melby


(1986) have


suggested that the


combined effect of multiple


risk factors i


synergistic and that, in using an additive


ADDroaChK multinlp rick fa.rntc mai h i nnAriacfimfaMl Tn










accurate.


Most health risk appraisal instruments are based


on actuarial tabi


from national averages of white, middle-


lass populations; socioeconomic status,


educational level,


geographic region, and ethnic background have not generally


been included (Imrey & Williams, 1977).


average mortality tabi


Furthermore,


used to predict future chances of


dying are by nec


ess


ity out of date when projecting


probability of death 10 years into th


future.


These 10-


year projections are also inadequate


35 and over 65.


for participants under


Chronic diseases do not usually appear


until after age 40 and,


therefore,


the .risk appraisal


printout


of youth ar


likely to show negligible risk to


health of current health-compromising behaviors.


contrast


since death i


quite likely for many within 10


years of age 65, th


printout for the aging individual may


be unnecessarily alarming (Brothers, 1981; Safer


, 1982).


The reliability of health risk appraisal instruments


over time was challenged by


controlled


seven


clinical trial of 203 adult


recent studies.


subjects,


In a


acks,


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


logical inconsistency between the response


on a b


ase


line


and follow-up health hazard appraisal questionnaire


approximately 85 days after th


e baseline.


Resoonses mnst








60

(1977) had discovered that of 21 subjects completing a

baseline and follow-up risk appraisal questionnaire 6 months


later,


individual


reported on the average more than one and


a half


changes which the authors concluded probably did not


occur


Change


in reports of past chronic diseases, the


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


improbable


ponses found on the second administration of


the appraisal.

Although the apparent lack of reliability of the risk


appraisal questionnaires has


caused som


researchers to


express


(Neuten


skepticism regarding the use of these instruments

& Pursley, 1985), others have questioned the data


and methodology upon which the estimates wer


(Goet


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


use of health risk appraisal


Elias and Dunton (1981) have


argued that, although lack of reliability exists in health

risk appraisals instruments, for most age groups reliability


ponses had a small


effect on risk age accuracy.


exce


ption was for the younger participant where


ven a small


unreliability effect in alcohol consumption and mileage


would have a large impact on appraisal age


issues have b


Reliability


become more of a problem when the health risk


aoorai sal auestionnairP ha


heP n i1cod a c tIho dnonArint


s








61

behavior change should interpret results cautiously (Petosa,

Hyner, & Melby, 1986).

Research on the technical characteristics of the health

risk appraisal instruments has been in its infancy (Doerr &


Hutchins, 1981)


Validity and reliability studies have not


kept pace with the proliferation of instrument


which vary


widely in the data and assumption upon which they are


founded.


Only recently have researchers addressed the need


to improve the quality of the health risk appraisal

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

personal communication, April 23, 1987).

Use of Health Risk Appraisal to Motivate Change


Controlled research studies assessing the efficacy of

health risk appraisal to motivate change are presently only


embryonic in design and have yielded conflicting result


Initial studies with adult populations have been descriptive

in nature or, if experimental, lacked controlled designs.

Although positive attitudinal and behavioral responses to

health risk appraisal are generally reported in these


studied


they lack an adequate basis from which to draw


empirical conclusions.

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








62

family practice patients in a clinical setting (Bartlett,


Pegues, Shaffer, & Crump, 1983).


In all of these studies


subjects reported either the intention to make recommended

changes or actual health behavior change within 3 to 12


months of


exposure to health risk appraisal.


However, high


experimental mortality and the unreliability of the


behavioral change measure


make it difficult to draw


accurate inferences from these results.


More controlled


clinical studies from which mor


accurate conclusion


can be


made about the effectiveness of health risk appraisal in

motivating adults to change health behavior have been


limited in number


From these some positive trends can be


noted.


In a


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


multispecialty medical clinic in Utah completed the

Interhealth Health Risk Appraisal Questionnaire and were


assigned to either an interpretive health


ses


sion with a


physician, an interpretive

or to a control group. Ni


sessi


on with a health educator,


nety of the original sample


were


then retested with the same questionnaire four month


later


Despite a lack of statistical significance, Johns contended


that in comparison to th


control group who had received no


feedback from their health risk annraical


ihiart


in tho


s


.








63

a relatively healthy, predominantly Mormon population; and

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


the lack of


statistical significance in this investigation


Lauzon (1977) evaluated whether exposure to the Health


Hazard Appraisal/Evalu*vi


stimulated risk-reduction


behavior among


93 federal


mploy


in Ontario, Canada.


initial volunteer sample of 346


illness or disability between the ag


randomly assigned to one of the thr


subjects without


of 30 and


groups:


current


5 years was


control,


(b) interpretation only of appraisal results, and


interpretation of appraisal and health counseling by a unit


nurse.


After 1


weeks, the appraisal and supplementary


questionnaires were readministered.


Although in both


experimental groups th


appraised ag


was reduced,


the risk


appraisal stimulated


significant positive changes only in


alcohol habits, weight, exercise


behavior, breast


self-exam,


and diastolic blood pressure


Minimal or no change was


reported for smoking, seat belt use, systoli

pressure, rectal exams, and Pap smears. Add


blood


itionally,


health hazard appraisal with counseling was associated with


superior results as


compared to health hazard appraisal


alone regarding alcohol habits, breast


self-exam, and


anoraised aaP.










subjects, among mal


between the ages of 30 and 40 years,


and among femal


between 41 and 55 years.


The health


hazard appraisal was more


effective in motivating change in


male exercise habits among high risk mal


and in seatbelt


usage of females aged 41


- 55 year


Although this research


was a more highly controlled trial than previous studies,


the fact that health hazard appraisal


pret


score


est and posttest measures again makes th


were used as


result


ect considering the lack of strong reliability data for


the health hazard appraisal instruments.


Also using a follow-up d


approximately 700 employee


esign with a group of

n California, Rodnick (1982)


found similar positive results using health hazard appraisal


with an hour interpretation


sessi


on which included


plantations of extensive lab test


the one-year follow-up, 292 individual


and physical exams.


volunteered for a


retesting


A significant reduction in risk age,


i.e. from


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


.001) resulted for men in particular


0 to 24 year


Young men aged


reduced their risk age by 6.5 years


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


Citing the


riticisms of the unreliability of the health


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








65

consistent from the first testing to the second testing


session.


However, no control group,


If-selected


participants, and a multiple component intervention make it

impossible to interpret these results accurately.

Health risk appraisal studies that have been conducted

with college student populations also contain methodological


problems in health risk appraisal research.


It has been


established that a health education course alone can


motivat


behavior and attitude changes.


McClaran and Sarris


(1985) examined the effect


of a 6-week health and lifestyle


course on the health behaviors, attitudes, and knowledge of

85 undergraduate students during the 1982-82 academic year.


For this


self-selected group, 74% of which wer


femal


comparison of pretest and posttest data revealed significant

positive changes in eating behavior, alcohol use, exercise,


and driving behavior


In addition significant changes were


reported for the attitude that one could prevent illness.

A major dilemma in many of the studies has been the

lack of objective assessment instruments and the difficulty


of separating out the effect


of health risk appraisal from


those of an intensive health education course.


In early


studies of health risk appraisal, investigators reported on


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


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








66

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

1979).


Another typical example


is the research by Cottrell and


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


appraisal on behavior


change as measured by a questionnaire


developed and validated specifically for their


Participants included 234 undergraduates


health education


tudy.


enrolled in seven


tions at Pennsylvania State University


in the


spring of 1981


Three sections served as th


experimental group,


lifestyle


health risk appraisal plus health


course; two sections served as the health


lifestyle course only group; and two sections acted as a

control.


During the first and last cl


all students were administered th


questionnaire.


of an 11-week semester,


self-report


Only students in the health risk appraisal


plus course group completed a Medical Datamation Health Risk


Appraisal qu


tionnaire.


In the fifth class, print-out


were returned to students, explained in great detail, and

utilized in conjunction with discussion of each health risk


factor in subsequent cla


sses


Throughout the semester both


experimental groups received instruction in the relationship


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


.e.,








67

two experimental groups; however, there were no significant


difference


between the health risk appraisal plu


course and lifestyle


itself was an intensive


course alone groups.


exploration of lifestyle


lifestyle


the cour


and risks,


virtually duplicating the information supplied by the health


risk appraisal questionnaire,


it was not surprising that the


health behaviors of the two experimental groups were not


significantly different.


A more effective comparison would


have been to


assess


the differences in health behaviors of


students


exposed to the health risk appraisal procedure


alone with those exposed to a course.


In previous


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


and Chenoweth (1981) had also reported similar changes in

attitude, knowledge, or health behavior for interventions

combining health education classes with health risk


appraisal.


Again whether exposure to health risk appraisal


by itself would have resulted in the


ame changes as


exposure to health risk appraisal within the context of the

health education course cannot be determined from these


studied


In the few studied


assess


ing the effect of health risk


appraisal alone on college student health behaviors,


researchers havP rPnnrtpd nn


innifirant differ anre in


m










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


Clearly the problems


associated with research designs with the college student


population and the limited number of controlled


studies have


made it difficult to a


sses


the utility of health risk


appraisal in altering health behaviors.


Recently interest ha


risk appraisal on health belief


developed in the effect of health


Using the Health Belief


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


risk appraisal work by evaluating the effect


of the health


risk appraisal message or printout on the health beliefs of


97 Blue Cross employees in Georgia.


in accordance with recommended


research, Cioffi measured th


Creating an instrument


standards for health belief


effects of health risk


appraisal feedback within a 30-minute interpretive


sess


and feedback via printed material alone on beliefs about


susceptibility to disea


benefit


of preventive health


behaviors, and general health motivation one month after the


health risk appraisal feedback.

feedback prior to post-testing.


A control group received no

In addition, Cioffi


examined the association between belief change and (a)


level


of risk for a specific di


sease


and (b) discrepancy of


information received with pre-existing perceptions of


e ,lenln44 K 4144.


1* f *


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


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










were significant differences


ociated with discrepancy of


susceptibility views and susceptibility belief


after


treatment.


Despite the lack of


significant


effect on


beliefs, the author intimated that the possibility of a


subsequent effect on behavior should not be


1imi nated.


Although health beliefs have been shown to be predictive of


health behavior


, the failure to change health beliefs does


eliminate


the p


iblity of a change in behavior


(Becker, 1974)


One additional finding of interest from


this study was that the construct "motivation to control"


measured by the Health Locus of Control


Wallston, Kaplan, & Maid


(Wallston,


1976), best delineated the high


and low risk groups.

Building upon the previous research, Faust, Graves, and

Vilnius (1981) studied the effects of three different health


hazard appraisal


on perceived susceptibility to disease,


perceived efficacy of action to prevent heart attacks, and


knowledge of risk factors.


Eleven Blue Cross and Blue


Shield offices in Michigan were allocated to three groups.


Out of the 247 eligible employees, 18


volunteered to


participate in this study and an additional 75 employees


were used as control


snrciallv dlpinnpd fnr thi


A Health and Attitude Survey


nrni0rtf Iwa arminictrrlA n all


s










Centers for Disease Control version.


One week after receipt


of the report, participants were retested to as


sess


the more


immediate impact of the risk appraisal on beliefs


perceived susceptibility to disease nor perceived


Neither

fficacy


of action to prevent heart attacks was significantly changed

one week after exposure to printed feedback from either of


three health risk appraisal


The one exception was an


increased belief in the benefits of exercise, weight

control, and medical checkups to prevent heart attack.


Although Faust et al.


questioned th


(1981) and Cioffi (1980) have


impact of health risk appraisal on two


specific health beliefs, more research studies with

different populations, timing of measurement, and


interpretive protocol ar


necessary before it can be stated


with any degree of certainty that health risk appraisal does


or does not change belief


The effectiveness of health risk appraisal needs to be


fully


asse


sed, particularly in relation to more immediate


belief and behavior changes. More e

needed to evaluate the impact of thi


empirical eviden


strategy on different


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


goal of the current


tudy was to further explore the


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









71

Health Behavior and Beliefs of College Students


In the contemporary Western life cycle, the year


between 17 and


period.


have been regarded as a transitional


Levinson (1978) has designated this period as the


"early adult transition" in which individuals leave


childhood behind and form an adult lif


structure.


college years have been conceptual


zed a


a mini-life cycle


in which certain psychosocial task


confront students as


they progr


ess


through their four-year college experience


(Blimling & Miltenberger, 1984; Medalie, 1981)


theorist


Different


previously described these developmental


tasks which


hare many principal


developing autonomy, id

and purpose (Chickering


entity,


1969


in common,


interpersonal relationships,

Knefelkamp, 1981; Prince,


Miller, & Winston, 1977).


As college students explore


different identity options, confront constant change


decision points, and develop new relationships,


kil


interests, rapid shifts in behavior can be expected.


Astin (1977) ha


Is, and

As


pointed out, health behavior has been no


exception.


It ha


been shown in recent surveys that health


enhancing behaviors not only decrease

college experience but that freshmen


1 I S a a a *


e during the four-year


students are entering


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


__


^ ^ 1










for many college students.


Over thi


time period, Astin


(1977) noted that drinking of alcohol


35%,


increased from 27% to


making increased by 10%, and taking vitamins declined


by 9% in the


ohorts that were freshmen in 1969.


Larger


than average increases in drinking, smoking, gambling,

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


Roman Catholics, and student

well-educated families, livi


who were highly able, from


ng in a dormitory, members of a


sorority or fraternity, or attending a larger institution.

Smaller increases occurred among women, older students, and


religious students.


Finally, while


increases in


making were particularly great among younger students,


blacks, dormitory residents, fraternity and


member


orority


, and drinkers, drinking was more likely to increase


among men, Catholics, younger students, and smokers.

In more current research an increase in pre-college


alcohol and marijuana use


, sexual activity, and femal


smoking behavior has been reported (P


. R. Harris, 1981


Lester & Leach, 1983)


Furthermore,


in a survey of 1,203


student


in grades 4 to 11 in two


ommunitie


from the north


central United States, unhealthy food


particularly among mal


out-of-s~hnnl aPrnhi


selection,


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


I








73

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

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


femal


, 6.6% mal


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


stayed up all night during the past year


approximately 50% rated them


Only


Lives above average in


emotional and physical health.

A lifestyle of increased health compromising behaviors


among adolescents and entry-level student


coupled with the


rapid change in a hedonistic direction of health behaviors


during the college year


the health


endangered.


can result in a situation wherein


tatus of college students is increasingly


ese health-compromising behaviors and the


high level of emotional distr


ess


reported by today's


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

for serious health problems in the near and distant future.

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


health-compromising behaviors among college student


have


been correlated with more immediate health-related


consequences.


Furthermore, college student health behaviors


may be intercorrelated, and unlik


adult health behavior,


constitute a syndrome or lifestyle not unlike that

identified by Jessor (1984) with younger adolescents.


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


th It nam eans


f.l








74

cigarette smoking, coffee consumption, and work correlated


positively, and adequate


negatively (p


leep and


exercise correlated


.05) with perceived illness.


Furthermore,


cigarette smoking, alcohol use, coffee consumption, sexual

activity, and overweight correlated positively, and exerci


correlated negatively with use of medical services.


a factor analysis procedure, three lifestyle


Through


were


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

compromising behaviors were more highly correlated with the


stressful and hedonic lifestyle


students.


In student surveys at different institutions

similarities in health behaviors, interests, and expressed


needs among college students have been revealed.


Stanford University an analysis of perceived health behavior

and interests indicated that weight and eating problems,


smoking,


substance use, nonexercise, and emotional distress


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

Health behavior issues of concern at the University of

Maryland included exercise, stress, contraception,


nutrition, and weight control (Downey, 1984).


Eating


habits, weight control


exercise,


smoking, and alcohol use


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










sexual activity are among the major health risks for the


college


age population.


Moreover, the risks of death or


disability associated with motor vehicle and other accidents


are well documented for the 15


- 24 year


age range


(National Center for Health Statisti


1981).


Alcohol and Substance Use


An increase in alcohol and substance use of


student


olleg


been cited in the literature (Blane & Hewitt,


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


In a


tudy in


Canada, high


school


student


also indicated a


significant


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


(Altorf, 1985).


Although it has been difficult to measure


the extent of use with any accuracy, especially with illegal


drug


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


of literature, a vast majority of the college student

population have experimented with alcohol and recreational


drugs.


Respon


on yearly


urveys at the University of


Massachusetts have indicated that approximately 80% of the

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

Laworskt, 1981).

In an anonymous survey of over 900 students at the


University of Illinois in 198


CC 0^ C-


In f L f i i fnr I r


Valois (1986) observed that


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


1,,~,,L








76

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

Alcohol, marijuana, nicotine, and caffeine were clearly the


most frequently used drugs in thi


representative sample.


In a New England college during the 1976-1977 academic


year, a stratified sample of 195 student


representative of


college population was interviewed about alcohol u


(Hashway, Hesse

in their reason


, Nutile, & Taylor, 1980).


for drinking,


Students differed


in their classification of


drinking types,


in their location for drinking, and in their


reasons


for not drinking


. The researchers determined that


the major reasons for drinking were to relieve academic


tension and social tension.


The two typ


of drinkers


identified wer


environment


intimate and group drinkers.


in which students drank included dormitory,


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

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


for intimate drinker


for the formal drinker


and in bars, taverns, and restaurants


reason for not drinking was a


general dislike for the effect of alcohol.


college students are learning to u


alcohol to


relieve


ress


rather than a health promoting alternative,


the long-term


consequences may be a lack of effective coping


c ill


i n adult l if


J I I I t UJ L L. I l


and nrpat r rick fnr namain^ra va=Fh








77
particularly vulnerable to the health risks associated with


the use of illegal substances,


e.g., marijuana and cocaine,


and the illegal use of sedatives and tranquilizers.

Research on the adverse biological and psychological


effects of marijuana and estimate


that


1 million students


have used the substance and several million


smoke it daily,


also have implications for the present and future health


status of thi


age group (Nicholi, 1983).


In reviewing past


research, Nicholi (1983) mad


the following observation


the long- and short-term effect


of marijuana use on


college


students.


Moderate doses of the drug have been found to


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


recall information; and communication


kill


In addition,


motor coordination, particularly driving


concentration


kills;


and judgment have also been impaired.


Although long-term effects remain unclear


impairment of


lung function, reproductive functions in both mal


femal


, birth defects, and mental disorder have also been


linked to regular usage.

An increase in cocaine, sedative, and tranquilizer use


among


college students has also been documented (Nicholi,


1984a, 1984b).


Within the


ollege-age group the reported


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










1982)


Adverse biological and psychological effects have


also been associated with these drugs which are a large part


of the college scene.


Belief in the harmlessne


of the


substances, peer


action, and a desire to feel better are


among the


strongest reason


for their prevalence among


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

Cigarette Smoking


Smoking cigarettes has been another health-


compromising behavior, especially for college women.


In an


asse


sment of smoking behavior among 7,016 student


in 34


New England colleges, 32% of the mal


and 44% of th


femal


reported smoking


igarett


(Wechsler & Gottlieb,


1979).


In addition,


making for both


exes


was


significantly related to per


ived health status; heavier


smokers reported the poorest health statu


Page and Gold (1983) have speculated that smoking


pattern


between mal


and femal


may be a function of


systematic


gender differences.


In a study of


students


at Southern Illinois University at Carbondale,


ignifi cant


gender differences on b


iefs were found.


Femal


were more


likely than mal


to believe that smoking left a bad odor on


clothing,


hplnPrld r


increased their dependency on


nntrnl thair wolnhf


cigarettes, and


M2l 1 ac warn mnra 14 tlal ^, 4


1










more willing than mal


mothers,


to comply with the wishes of their


important others, and doctors.


In another study investigating the effect of beliefs of

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


sample


of 953 college women from four colleges in the Boston


area, 86.1% had begun smoking before entering college


were primarily motivated to smoke because


making helped


them to manage stress associated with school work,


situation, and jobs.


pregnancy, an


social


Furthermore, over half stated that


asy way to quit, and definite proof of their


personal vulnerability to lung cancer would definitely


motivate them to quit.


Former smokers indicated that they


quit smoking primarily for health reasons, dislike of


of control of their lives, and social eff


smokers were also most


likely to believe that


oss


former

making wa


serious health risk than current smokers


research


Results of this


support the Health Belief Model in that


susceptibility to a threatening consequence was a factor in

motivating college women to quit smoking.


In addition to smoking


cigarettes in an attempt to


control weight and deal with e


xces


ess,


college femal


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


I II 1-


hfrnp nf thmir nwn oftinn hahitc fiA wtfh


2rralC rn










Weight Control


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


college-age women engage in th


binging-purging cycle known


as bulimia (Blimling & Miltenberger, 1984).


reliable statistics are lacking,


Although


experts such as Elizabeth


S. Ohirich, Medical Director of the University of Wisconsin

Eating Disorders Program in Madison have asserted that the

prevalence of both bulimia and anorexia nervosa has been


increasing on college


campuses (Greene, 1986).


Used as a


tension relea


and weight control method for young women,


bulimia-type behavior has serious long-term health

consequences.


separate yet related bulimic-like syndrome,


"fad


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


more prevalent than clinically diagnosed


ating disorders


(Cesari, 1986)


Although "fad bulimia" involves


intense and more public eating behavior,


it i


less


a serious


concern because


ome students participating in frequent


binge-purge behaviors are candidates for a life-threatneing


clinical bulimic disorder in th


future.


Although all forms of substance use create potential


health problem


for college students, perception of the


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


Cdrinilc rc riE nF- -ht^^^/








81
mental-health problems reported as most serious for this

random and representative sample were alcohol abuse,

smoking, and drug abuse; coping with stress and weight

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


& Cooper, 1980).

professionals on


students.


In contrast, rankings by 30 mental health


ampus differed considerably from those of


From their viewpoint career choices, academic


difficulties, and coping with


tres


were the top three


problems, and substance use and weight control problems were


ranked much lower


This discrepancy in perspective may


account for inappropriate and ineffective programming and


service provision in many college campuses.


A direct


assessment of student health behaviors and expressed needs

has led to more relevant health promotional efforts in a

number of college communities (Hettler, 1980).


Health risks associated with


exual activity have also


been perceived as less critical by health professional


than


by students (Henggeler, Sallis, & Cooper


, 1980).


Sexually


transmitted diseases and unplanned pregnancy


to the physical and mental health


increased by th


college


are two risks


tatus of college students


frequency and variety of sexual contact


campuses.


PYIIal Activity











campu


ses.


Estimates have b


een that 10% of students are


infected with chlamydia and that a significantly higher

incidence of herpes has been found among college student


than for the general population (T


. J. Meyer, 1985; NIAID


Study Group, 1980).

In a study of 416 minority students at an undergraduate

college in New York City, analysis of a questionnaire


asses


sing health beliefs and venereal disease preventive


behaviors showed that, of those responding to thi


item


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


venereal disease


and 13.7% went every 3


4% went for checkup


- 6 month


every 9


for checkup


months,


(Simon & Das,


1984).


A direct relationship between perceived


susceptibiltiy to venereal disease and perceived benefits of

taking active and frequent asymptomatic checkups was noted.


Those


student


who perceived barriers as minimal also were


more likely to seek preventive medical care.


Of the entire


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


they or their partner douched after intercour


or were


always


lean


one-quarter wer


concerned about pain,


embarrassment, and confidentiality when seeking a venereal


disease checkup.


Approximately


- 40 % of the sampi


were


a a. I 1 1 1 I I a








83
indicated which personal beliefs hampered the adoption of

health behaviors related to their sexual activity.

Despite widespread publicity about the seriousness of


the AIDS epidemic and th


need to modify sexual behavior to


control the spread of thi


infectious d


disease,


college


students have also continued to believe that they are immune


to thi


threat (Biemiller, 1987a)


In a survey of 13,000


students at Stanford University, 74% reported that they did


not discu


sexually tranmitted diseases (STD's) with


partners before engaging in sexual


intercourse, and 25% of


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


(Hirschorn, 1987). Furthe

Austin, 50% of the student


rmore, at the University of Texas,


surveyed revealed that AIDS had


no effect on their sexual behavior.

Although students are increasingly aware of the dangers

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


with th


use


of alcohol and drugs has continued to promote


sexual promiscuity among many college-age students. I

addition, the fear of breach of confidentiality and of

mislabeling as homosexual have prevented students from


eking protection or from


hanging their sexual behavior


(Biemiller, 1987b).


Rpl isMf


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










sample


of 171 femal


students seeking care at a family


planning clinic at the University of Illinois, 50.5%


employed effective use of


ontracepti v


49.4% employed


ineffective u


and were either inconsistent in their use


.4%), relied upon unreliable method


(28.6%), or failed


to use any method (16.7%).


None of the women in the


ample


were attempting to get pregnant at the time.


The variabi


most predictive of adequate contraceptive behavior were

perceived benefits and barriers and perceived susceptibility.


Inadequate users were mor


embarrassed to obtain birth


control, believed that it interfered more with enjoyment,


and perceived it as more of an inconvenience


user


than adequate


Adequate users believed that benefits out-weighed


the costs.


The seriousness


of this inadequate use of


contraceptives


an be


clearly seen when national estimates


of pregnancy rat


on college campuses are considered.


Pregnancy rates have been conservatively estimated at


between 6% and 10%, an increase from 5


- 6% in the early


1970s, and the number of women who terminate the


pregnancy


has been approximately 90% (Dorman, 1981).


Ineffective contraceptive use was found to be th


primary


reason for nrpnnanrv_


nnrea Anin in c11nnnrt mnf h


Cl


UL 1a s










In a more recent


asses


ment at the University of


Arizona, Price,


hawn, and LaViola (1985) found that out of


515 students who returned th


questionnaire, 79% were


sexually active and 20% used no birth control. Although

pregnancy may not constitute a risk to physical health,

emotionally and socially it poses a threat to many young


women and the

similar threat


choice to terminate a pregnancy also poses


Although free from the direct health risks associated


with unplanned pregnancy, young males are mor


vulnerable


than female college students to the risks of death or

disability caused by motor vehicle and other accidents

(Matarazzo, 1984).

Motor Vehicle and Other Accidents


Motor vehicle and non-motor vehicle accidents also


threaten th


health of


college


students.


Among the major


threats to life and health, accidents ar


of morbidity and mortality for individual


age, and the highest rat


the greatest cause


under 45 years of


of fatal accidents occur in the


late teenage to young adulthood years (National Center for


Health Statisti


, 1981).


In th


4 years age range,


have a 372% higher rate of fatal injuries than femal


in that aae arouo (National Center for Health Statisti


t.. -3








86

populations places them at higher than average risk (Rivara,


1984)


The extent to which students drove automobile


while


under the influence of either alcohol or marijuana was


revealed in a recent study by Valois (1986).


Driving while


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

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


times per year


Using marijuana and driving was reported by


6.3% on a weekly-daily basis, 9


% on a monthly basis, and


18.6% 1


ess


than 10 tim


per year


Twice as many mal


femal


marijuana


admitted to driving while using either alcohol or

a. Significant associations between regular use of


these substances and moving traffic violations and accidents

were also discovered.

Beck (1981) explored this association between alcohol


use and driving in a survey of


college students enrolled


in various health education


lass


and consisting of a high


percentage of seniors, 39.7%, and behavioral-social


majors, 40.3%.


science


Both drinking-driving intentions and actual


behavior were significantly related to the beliefs that one

could effectively avoid getting caught by the police and


avoid causing an accident while


alcnhnl.


under the influence


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








87

related to the prevalence of drinking and driving in this

population.

Accidents other than motor vehicle accidents are also a


leading cau


of death for the college-age population and


multiple life chang


within


hort period


of time have been


associated with vulnerability to accident and injury.


From a


tudy of 241 college-age mal


at a southern


university, Furney (1983) presented evidence that an

increase in life change events was associated with increased


accident rates.


Numbers of accidents of varying level


severity were assessed over a 12-week period and the

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


a life change events questionnaire


were compared.


significantly higher rate of accidents was associated with


high scores on the College Schedule of Recent Experience.

Although no one theory of accident causation exists,

generally the inability to respond appropriately to


hazardous situations has been


linked to the incidence of


accidents.


The use of substan


and high


level


have been known to increa


an individual '


susceptibility


to accidents (Rivera, 1984).


In reviewing th


literature on the health behavior and


beliefs


of college students_


it has harnmP Pvident thAt wi








88
recreational drug use has increased, as well as the number


of traffic accidents associated with this substance use


percentage of college students, particularly women, who are

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


and the increase in


sexual activity without a subsequent


increase


n the use of


contraception has led to higher rates


sex


ually transmitted disease and unwanted pregnancy.


It ha


become apparent that a reduction of health risks


is necessary to prevent


hort- and long-term premature


losses


of functional ability and of life among


college


students.


Efforts to change health beliefs and increase


health behaviors in this population have ranged from


traditional


instruction in health education to campus-wide


health promotion programs.

Health Behavior Change Strategies on College Campuses


From their inception in 1818 at Harvard College, health


education class


have traditionally been the primary


strategy for influencing th


health belief


and behaviors of


college students.


However


since it


enthusiastic


acceptance in the 19th century, over time health education

has lost credibility and support in higher education.


From a


urvey of schools which offer health education


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








89
that enrollment in these courses has been voluntary and that

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

general health education of all its students for graduation"

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

health education on college campuses.


Despit


the limited number of college students


receiving formal health instruction, health educators have

increasingly applied behavioral techniques in their classes

in an attempt to more effectively motivate the adoption of


health behaviors


Behavioral assessment, behavioral


contracting, and the designing and implementation of

individual behavior change projects have been incorporated


with varying degrees of


(McClaran, & Sarris, 1985


ucces


Melby


in health education courses

, 1986; Petosa, 1984).


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


wide basis.


Since most college health services are prepaid


plans where costs are spread over the entire student body,

it has become feasible to offer a broad scope of organized


health education programs (Zapka & Love, 1985).


A survey of


158 American College Health Association Member institutions

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










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


The type and


extent of programming has varied greatly among institutions

with the large four-year universities generally offering

more programs.

A major trend in health promotion in higher education


has been the establishment of institutional


commitment to


organized and coordinated programming involving the

collaborative efforts of academic departments, student


health and mental health services, and the


student life


division (Zapka & Love, 1985)


In the past


0 years a


philosophy of student development has emerged wherein


student


are viewed more as whol


person


needing emotional,


social, psychomotor, and


spiritual growth as well as


intellectual development (Opatz, 1985).


institutions have


A number of


established programs focusing on total


development and optimal well-being.


A key element to these


programs has been student participation in planning and


implementation.


Along with administration and clinical


advisement, student health council


and intern and practicum


students from various academic departments have provided

direction and leadership to these comprehensive health

promotion programs (Chandler, 1979).


Tn c CIivnv nf w1al na


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


---A


.


r,









91

were student health center staff and 44% were faculty


related positions.


For a majority of the respondents, the


student health center was the organizational home of the


center


Although the campus health center has been


perceived as the most obvious and appropriate location for

the health promotion efforts, particularly in a small


college campu


(Parker, 1985), campus-wide programs


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

University of Wisconsin, Stevens Point, have been advocated

(Hettler, 1980).

Using a model by Allen (1981) which emphasizes

environmental modification and cultural support for


successful health behavior change, William Hettler


launched the first comprehensive wellnes


, M.D.,


program on a


university campus in 1972


In implementing thi


model,


Hettler and the Student Life Division of the university

mobilized the student affairs and residence hall staff, food


servi


taff, health center personnel, counseling


center


staff,


interested faculty, students, and administrators to


establish a supportive


change.


environment for attitude and behavior


The guiding philosophy of this lifestyle


improvement model wa


pursuit of high-level wellness in


iY dimancinn


{ I infallatf fial


(k\ amn* alnn


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s


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