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Adolescents’ perceptions of food and food behaviors : an interpretive study 1982

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ADOLESCENTS' PERCEPTIONS OF FOOD AND FOOD BEHAVIORS: AN INTERPRETIVE STUDY by MARY JUDITH LYNAM B.Sc.(N)., McGill U n i v e r s i t y , 1974 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING in THE FACULTY OF GRADUATE STUDIES The School of Nursing We accept t h i s t h e s i s as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA March, 1982 © Mary J u d i t h Lynam, 1982 In presenting t h i s t h e s i s in p a r t i a l f u l f i l m e n t of the requirements f o r an advanced degree at the U n i v e r s i t y of B r i t i s h Columbia, I agree that the L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r reference and study. I f u r t h e r agree that permission f o r extensive copying of t h i s t h e s i s f o r s c h o l a r l y purposes may be granted by the head of my department or by his or her r e p r e s e n t a t i v e s . It i s understood that copying or p u b l i c a t i o n of t h i s t h e s i s f o r f i n a n c i a l gain s h a l l not be allowed without my wr i t t e n permission. i i A b s t r act This study reports an i n v e s t i g a t i o n of teenagers' perceptions of food and t h e i r food behaviors. The study was q u a l i t a t i v e in design. Data were c o l l e c t e d on eleven teenagers in t h e i r homes through interviews and observations. Data were analysed using the method of constant comparative a n a l y s i s . The adolescents' r a t i o n a l e s f o r t h e i r food behaviors r e f l e c t e d both t h e i r perceptions of what was important regarding foods and food behaviors and how these perceptions or actual behaviors might change over time or as s i t u a t i o n s changed. The data were i n t e r p r e t e d to show that teenagers have frameworks which guide t h e i r d e c i s i o n making about food. Processes which c o n t r i b u t e d to the development of the adolescents' frameworks were t h e i r i n t e r p r e t a t i o n of cues and knowledge, the comparison of themselves with others and the d e s i r e to resolve issues of personal concern. The adolescents were also described as having food behaviors d i r e c t e d by issues r e l a t e d to e i t h e r " c o n v i c t i o n s " or "convenience." The knowledge guiding the teenagers' d e c i s i o n making was based on t h e i r i n t e r p r e t a t i o n s of information and personal experiences. Adolescents assessed the usefulness of information presented to them by examining i t s relevancy to t h e i r own s i t u a t i o n , i t s c o m p a t i b i l i t y with personal b e l i e f s and i t s consistency with sources i d e n t i f i e d as c r e d i b l e . Such c r e d i b l e sources might include parents, nurses or teachers. i i i As well as presenting the view that t h e i r food behaviors were good, the boys and g i r l s held b e l i e f s about p a r t i c u l a r foods and the e f f e c t s of c e r t a i n foods on physical development or sense of well being. They discussed food i n r e l a t i o n to general concerns such as body image, a t h l e t i c a b i l i t y or the d e s i r e to have f r i e n d s . Two food behavior patterns were described. Behavior patterns as s o c i a t e d with " c o n v i c t i o n s " were c h a r a c t e r i z e d by d e c i s i o n making about food which was guided by stated b e l i e f s or r a t i o n a l e s . A s s o c i a t e d food behaviors were c o n s i s t e n t across s i t u a t i o n s . The second food behavior pattern was r e l a t e d to "convenience." Decision making about food was guided by issues of convenience such as a v a i l a b i l i t y and food behaviors were more s i t u a t i o n a l l y dependent. The study's f i n d i n g s are discussed in r e l a t i o n to other studies about n u t r i t i o n . As well as providing new explanations f o r behavior patterns described in reviewed l i t e r a t u r e the reported study provides new i n t e r p r e t a t i o n s of teenagers' food behaviors. The d e c r i p t i o n of the processes involved as adolescents develop the frameworks on which they base t h e i r food d e c i s i o n s and the two behavioral patterns described c o n c e p t u a l i z e the adolescents' perspectives d i f f e r e n t l y from what has been proposed in the l i t e r a t u r e reviewed. Implications f o r health care are addressed, and questions f o r f u r t h e r research are r a i s e d . i v TABLE OF CONTENTS Ab s t r a c t i i Table of Contents i v Acknowledgements v i Chapter I: INTRODUCTION Background of the Problem 1 Statement of the Problem and Purposes 5 D e f i n i t i o n of Terms 5 Introduction to the T h e o r e t i c a l Perspective 6 Assumptions 8 L i m i t a t i o n s 9 Summary 9 Chapter I I : REVIEW OF RELATED LITERATURE Studies of the I n i t i t i a t i o n and Maintenance of Change in Health Behaviors 10 Studies of N u t r i t i o n 16 Food Patterns as an Element of Culture 17 Studies of Adolescent N u t r i t i o n and Food Patterns . . 21 Th e o r e t i c a l perspectives and methodologies . . . . 21 Patterns of food consumption during adolescence . . 24 Described i n f l u e n c e s on teenagers' food behaviors . 26 Teenagers' knowledge of n u t r i t i o n 27 Influence of s o c i a l status and family 29 Summary 31 Chapter I I I : METHODOLOGY S e l e c t i o n of the Study Group 34 C r i t e r i a f o r P a r t i c i p a t i o n 34 Procedure f o r P a r t i c i p a n t S e l e c t i o n 35 C h a r a c t e r i s t i c s of the P a r t i c i p a n t s 36 Data C o l l e c t i o n 38 E t h i c a l Considerations 38 Data C o l l e c t i o n Procedure 39 Data A n a l y s i s 40 Summary 43 V Chapter IV: PRESENTATION AND DISCUSSION OF ACCOUNTS Cons t r u c t i o n of Accounts 45 Relationship of "Accounts" to the Study's Purposes ... 48 I n t e r p r e t a t i o n s of Accounts 49 I n t e r p r e t i n g Cues and Applying Knowledge 50 The Process of Comparing Oneself to Others 57 Personal Issues 58 Food P a t t e r n s Associated with Convictions 64 Food Patterns Associated with Convenience 67 D i s c u s s i o n of Accounts 70 I n i t i a t i o n and Maintenance of Change i n Health Behaviors 70 Studies of N u t r i t i o n 74 Food Patterns as an Element of Culture 74 Studies of Adolescent N u t r i t i o n and Food Patterns . 78 Patterns of food consumption during adolescence 78 Described i n f l u e n c e s on teenagers' food behaviors 79 Teenagers' knowledge of n u t r i t i o n 80 i n f l u e n c e of s o c i a l status and family 82 Summary 83 Chapter V: SUMMARY, CONCLUSIONS, IMPLICATIONS, AND RECOMMENDATIONS FOR FURTHER STUDY Summary 86 Conclusions 90 Implications 91 Recommendations f o r Further Study 93 Reference Notes 96 Bibliography 97 Appendix A 107 Appendix B 109 v i Acknowledgements Carrying out a study such as t h i s one requires the as s i s t a n c e of many people. I t i s here the w r i t e r acknowledges t h e i r c o n t r i b u t i o n s . Dr. Joan Anderson, chairman of my t h e s i s committee shared her knowledge and provided a challenge. Dr. M a r i l y n W i l l man l i s t e n e d as I wrestled with ideas and provided c o n s t r u c t i v e c r i t i c i s m and encouragement throughout the process. I thank both of you f o r helping me to l e a r n . The teenagers who p a r t i c i p a t e d in the study deserve s p e c i a l thanks. They, and t h e i r f a m i l i e s gave many hours and welcomed me i n t o t h e i r homes. In doing so and by sharing t h e i r perceptions with me they made t h i s study p o s s i b l e and enjoyable. I am indebted to those who helped by e n l i s t i n g study p a r t i c i p a n t s and to colleagues who provided support and c r i t i c a l review throughout the research process. F i n a l l y , I am most g r a t e f u l to my family and f r i e n d s who did not allow geography or timetables to diminish t h e i r innumerable demonstrations of c a r i n g and support. Chapter I INTRODUCTION Background of the Problem As a r e s u l t of the health p o l i c y e s t a b l i s h e d by Lalonde (1974), Canadian health care workers in general and nurses in p a r t i c u l a r have involved themselves in i n t e r v e n t i o n programmes and research aimed at the m o d i f i c a t i o n of l i f e s t y l e s (Saucier & Gauthier, Note 2 ) . The t o p i c of health behaviors has become a matter of concern to health p r o f e s s i o n a l s . A goal of nurses involved in prevention o r i e n t e d programmes i s to see that behavior patterns supportive of health are e s t a b l i s h e d or maintained. One category of health behavior c l e a r l y l i n k e d to both long and short term health status i s d i e t (Caliendo, 1981; Valadian, Berkey & Reed, 1981). The study described here was designed to explore one category of health behaviors, s p e c i f i c a l l y , the n u t r i t i o n a l behavior of teenagers. From observations of teenagers in a v a r i e t y of s e t t i n g s ( i . e . , schools, h o s p i t a l s and r e s i d e n t i a l treatment f a c i l i t i e s ) , i t appears the meaning d i e t holds f o r adolescents i s i n f l u e n c e d by a v a r i e t y of f a c t o r s and may vary from s i t u a t i o n to s i t u a t i o n . Moreover, teenagers appeared to lack r e c e p t i v i t y to teaching programmes and have t h e i r own set of values and b e l i e f s about d i e t a r y h a b i t s . While some w r i t e r s mention the need to explore the meaning of foods f o r i n d i v i d u a l s as well as t h e i r a t t i t u d e s towards foods (Mead, 1964), t h i s has not been done f o r the adolescent age group. A majority of studies addressing teenagers' n u t r i t i o n have 1 2 explored elements and consequences of the food behaviors of t h i s age group. These studies include d e s c r i p t i o n s of meal patterns ( Hinton, Eppright, Chadderdon, & Wolins, 1963; Huenemann, Shapiro, Hampton, & M i t c h e l l , 1966), biochemical d e f i c i e n c i e s ( F a i g l e , 1973; N u t r i t i o n , 1973; N u t r i t i o n Canada, 1975), and changing n u t r i t i o n a l needs as a r e s u l t of growth (Cohen, 1979; Marino & King, 1980; Stare & McWilliams, 1973). In order to understand why some teenagers choose healthy d i e t s and others do not, some researchers have examined the r e l a t i o n s h i p between a t t i t u d e s towards foods and food p r a c t i c e s (Thompson & Schwartz, 1977) as well as knowledge of n u t r i t i o n and food p r a c t i c e s (Saucier & Gauthier, Note 2 ) . What i s most s t r i k i n g about the l i t e r a t u r e i s the lack of studies seeking the teenagers' perspectives on food. I t i s c l e a r from p r i o r s t u d i e s that teenagers' eating patterns and n u t r i t i o n a l needs are d i f f e r e n t from those of both younger and o l d e r groups. Nonetheless, there i s a lack of understanding of how teenagers i n t e r p r e t or make sense of f a c t s , how teenagers develop t h e i r a t t i t u d e s and in turn, how they make deci s i o n s about t h e i r food behaviors. L i t e r a t u r e from the s o c i a l science p e r s p e c t i v e supports the view that food i s an element of c u l t u r e . D i e t and d i e t a r y behaviors are seen to be learned as a r e s u l t of s o c i a l i z a t i o n p r a c t i c e s and everyday experience (Cussler & De Give, 1952; Mead, 1964). Nonetheless, few st u d i e s have sought to describe adolescent n u t r i t i o n a l behaviors by viewing adolescents as a c u l t u r a l group or by examining t h e i r everyday experiences. Some authors suggest that l i f e s t y l e (Schorr, Sanjur & E r i k s o n , 1972) or s o c i a l s i t u a t i o n s (Huenemann et a l , 1966; Roth, 1960) a c t to mold or modify behavior p a t t e r n s . However, l i t t l e research has 3 been done which describes teenagers' b e l i e f s about n u t r i t i o n or t h e i r n u t r i t i o n a l behavior i n d i f f e r i n g s o c i a l s i t u a t i o n s . Moreover, there are no d e s c r i p t i o n s of how food f i t s i n t o the teenager's l i f e s t y l e . There i s also evidence that p r o f e s s i o n a l s ' assumptions about teenagers' food preferences are inaccurate or exaggerated (Crawford, 1977). There are few studies which describe the f a c t o r s that are important to teenagers as they make de c i s i o n s regarding food. Recognizing the need to understand teenagers' points of view, some studies have examined broader c a t e g o r i e s of health behaviors (Saucier, Note 1) and b e l i e f s (Gochman, 1972; Saucier, Note 1) as well as e l i c i t i n g adolescents' perspectives on i l l n e s s (Radius, Dillman, Becker, Rosenstock, & Horvath, 1980). In the present study, adolescents are considered to be a c u l t u r a l group. Adolescence i s a period of ac c e l e r a t e d physical growth as well as a time of l e a r n i n g and developing s o c i a l r o l e s . Teenagers' everyday experiences, such as those with f a m i l i e s and in high schools, c o n t r i b u t e to the development of l i f e s t y l e s and i n t e r e s t s which d i f f e r from those of other s o c i a l groups. While there are a few studies examining food behaviors i n t h e i r s o c i a l developmental context, and other researchers have studied health r e l a t e d issues from a s o c i a l c u l t u r a l p e r s p e c t i v e , there are no studies examining teenagers' behaviors i n t h i s context. Several reasons f o r seeking to understand the pe r s p e c t i v e of a group or i n d i v i d u a l on a p a r t i c u l a r issue may be c i t e d . Kleinman (1978) and Le i n i n g e r (1978) have examined c u l t u r a l i n f l u e n c e s on i n d i v i d u a l ' s health behaviors. Both researchers were motivated by the f e l t need f o r p r a c t i t i o n e r s to provide health care i n a manner which would be c u l t u r a l l y acceptable to the 4 c l i e n t s . Both document that taking i n t o account the c l i e n t ' s c u l t u r e i n the p r o v i s i o n of health care increases the c l i e n t ' s s a t i s f a c t i o n with care. Considering c u l t u r a l background i s a l s o seen as i n c r e a s i n g the l i k e l i h o o d that i n d i v i d u a l s w i l l comply with p r e s c r i b e d regimens. Cassel (1957), f o r example, documents that awareness of a c u l t u r a l group's food b e l i e f s , values and h i s t o r i c a l e v o l u t i o n allowed health care workers to s u c c e s s f u l l y design and implement n u t r i t i o n i n t e r v e n t i o n programmes. More r e c e n t l y , i n d i s c u s s i n g the s t a t e of nursing knowledge concerning the e f f e c t i v e n e s s of nursing i n t e r v e n t i o n s and teaching programmes, Hogue (1979) includes as a concern of nursing the i n i t i a t i o n and maintenance of healthy behaviors in c l i e n t s . Awareness of the c l i e n t ' s point of view i s seen to f a c i l i t a t e the p r o v i s i o n of information which i s relevant to the c l i e n t , thereby enhancing compliance. In summary, the value of the i n d i v i d u a l p e r s p e c t i v e i s twofold. F i r s t , i t gives the researcher a c l e a r e r p i c t u r e of the cues or events which have acted to shape the i n d i v i d u a l ' s perception of the s i t u a t i o n . A d d i t i o n a l l y , in attempting to describe the i n d i v i d u a l ' s b e l i e f s , the importance of the b e l i e f s to him or her and the o r i g i n of the b e l i e f s , the researcher may come both to understand how observed patterns have evolved and to postulate how they might be sustained, changed or m o d i f i e d . In the present study, information gained w i l l c o n t r i b u t e to our understanding of teenagers' perceptions of t h e i r s i t u a t i o n s , a i d in designing teaching programmes aimed at the adolescent population and guide the p r o v i s i o n of nursing care to i n d i v i d u a l teenagers. 5 Statement of the Problem and Purposes Some studies have explored adolescents' n u t r i t i o n a l patterns by examining what i t i s that teenagers eat. There are no studies which have sought to explore teenagers' reasons f o r eating as they do. There i s a lack of understanding of how adolescents i n t e r p r e t or make sense of knowledge or f a c t s , how they develop t h e i r a t t i t u d e s and in turn how they make d e c i s i o n s about t h e i r food behaviors. There i s a general lack of knowledge of what teenagers consider to be important or what they perceive to i n f l u e n c e t h e i r food b e l i e f s or behaviors. Based on the described lack of information, observations i n c l i n i c a l s e t t i n g s , and a review of l i t e r a t u r e addressing problems of teenage n u t r i t i o n , the proposed study was designed f o r the f o l l o w i n g purposes: - to describe adolescents' perceptions of t h e i r food r e l a t e d behaviors. - to develop an understanding of the p o s i t i o n food and food r e l a t e d behaviors have within the values of the adolescent group. - to describe v a r i a t i o n s or changes i n food r e l a t e d a c t i v i t i e s as adolescents are observed i n s e l e c t e d s i t u a t i o n s a t s e l e c t e d times. D e f i n i t i o n of Terms Adolescent or teenager - a youth, male or female, aged 12-17 years i n c l u s i v e . A t t i t u d e s - expressions of personal sentiment, which may range from p o s i t i v e to negative, about an ob j e c t or event. Food - any oral intake. Food b e l i e f s - may inc l u d e a t t i t u d e s towards food but as well include notions of e f f e c t s of consuming or avoiding c e r t a i n foods or food combinations. Food r e l a t e d behaviors - a c t i v i t i e s a s s o c i a t e d with the planning, preparation, or consumption of any oral intake. 6 Health behavior - any a c t i v i t y undertaken by a person f o r the purpose of preventing disease or d e t e c t i n g disease i n an asymptomatic stage (Rosenstock, 1974) or the promotion of well being. Perceptions - thoughts, f e e l i n g s and a t t i t u d e s of i n d i v i d u a l s about objects or events as r e l a t e d v e r b a l l y . Introduction to the T h e o r e t i c a l P e r s p e c t i v e This study was guided by the perspective derived from the i n t e r p r e t i v e school. T h i s school takes d i r e c t i o n from the p h i l o s o p h i c a l works of Husserl (1964) and Schutz (1973, 1970). I t was developed by researchers who were concerned about studying the everyday world, l i f e and r a t i o n a l i t y . Researchers who have used t h i s p erspective i n t h e i r work i n c l u d e Anderson (1981), Becker (1973), Lindemann (1974), Shaw (1966), and Spradley (1970). This perspective seeks to understand the i n d i v i d u a l ' s p o i n t of view: Theory i s developed from an understanding of the experiences of the p a r t i c i p a n t and the observer. The i n v e s t i g a t o r begins with f i r s t hand knowledge of events ( R i s t , 1979, p.19). The appropriateness of the method in c l i n i c a l nursing i s stressed by Davis (1978). She argues that a major concern of nursing i s the a b i l i t y to understand and take d i r e c t i o n from the c l i e n t . Other aspects of t h i s research process are the f o l l o w i n g : i n t e r s u b j e c t i v i t y , s e l e c t i o n of p a r t i c i p a n t s , theory development, and v a l i d i t y . While research methods based on the tenets of natural science support the view that there i s an o b j e c t i v e , measurable s o c i a l r e a l i t y ( R i s t , 1979), the i n t e r p r e t i v e school considers a l l knowledge to be s o c i a l l y c onstructed. I n d i v i d u a l s produce information within t h e i r s o c i a l and c u l t u r a l context ( R i s t , 1979). As such, the research process 7 i s i n t e r s u b j e c t i v e . The researcher i s incorporated i n t o the study process and const r u c t s accounts of events with i n d i v i d u a l p a r t i c i p a n t s . In a study of t h i s nature i n d i v i d u a l p a r t i c i p a n t s are s e l e c t e d f o r t h e i r a b i l i t y to address issues of concern: On the assumption that a l l members of a c u l t u r e are c a r r i e r s of that c u l t u r e , any person who belongs to the group under study i s a p o s s i b l e informant (Brink & Wood, 1978, p. 123). How might one formulate c o n s t r u c t s from data c o l l e c t e d f o r the purposes described? D i r e c t i o n i n responding to t h i s question may be taken from the works o f Glaser and Strauss (1967) as they discuss the formulation of a theory. Glaser and Strauss take the approach that i t i s through the c o l l e c t i o n of q u a l i t a t i v e data, v i a p a r t i c i p a n t observation, that one may generate a theory. Theory i s developed based on observations grounded in the data. A theory or c o n c e p t u a l i z a t i o n of the process under study i s developed as the researcher makes sense of the data. The technique i s based on observations of the way people are seen to question and make sense of t h e i r world: What the f i e l d worker does i s to make t h i s normal strategy of r e f l e c t i v e persons i n t o a successful research strategy (Glaser & S t r a u s s , 1965a, p.9). In t h i s research approach the process of data c o l l e c t i o n and a n a l y s i s are intertwined and occur simultaneously. Based on i n i t i a l observations and recorded data, the researcher begins to develop c a t e g o r i e s . These c a t e g o r i e s are then r e f i n e d and v a l i d a t e d by seeking out new information i n the f i e l d s e t t i n g (Glaser & Str a u s s , 1965a). Having explored c o n d i t i o n s in one group or s e t t i n g , the researcher may choose to examine developing c a t e g o r i e s and c o n s t r u c t s , or p o s t u l a t i o n s 8 concerning the r e l a t i o n s h i p s between t h e i r dimensions in a new s e t t i n g or with a comparison group. The purpose of t h i s a c t i v i t y i s to understand b e t t e r under what sets of s t r u c t u r a l c o n d i t i o n s these categories are minimized and maximized (Glaser & Strauss, 1965a). The t h e o r i e s and c o n c e p t u a l i z a t i o n s are grounded i n the data. The reader i s given i n s i g h t i n t o how c a t e g o r i e s were constructed. Theory developed i n t h i s way has demonstrated usefulness i n a p p l i c a t i o n to c l i n i c a l s e t t i n g s (Glaser & S t r a u s s , 1965b; Lindemann, 1974; Quint 1966) and has been used to provide i n t e r p r e t a t i o n s of s t a t i s t i c a l data (Lindemann, 1974). In d i s c u s s i n g the t h e o r e t i c a l foundation of t h i s study four points have been addressed. F i r s t , i n research of t h i s nature the c l i e n t ' s p erspective i s valued. Second, conceptual c a t e g o r i e s concerning the nature of health r e l a t e d i n t e r a c t i o n s are developed from the data. T h i r d , the researcher and c l i e n t are involved in the process of c o n s t r u c t i n g accounts of events. Fourth, the processes of data c o l l e c t i o n and a n a l y s i s are intertwined and study f i n d i n g s are based on observations grounded in the data. Assumptions I t i s assumed that i n d i v i d u a l s act p u r p o s e f u l l y and that patterns of a c t i o n are i n f l u e n c e d by the i n d i v i d u a l ' s i n t e r p r e t a t i o n of the s e t t i n g or behavior of i n d i v i d u a l s in the s e t t i n g . I t i s f u r t h e r assumed that as a r e s u l t of t h e i r d a i l y experiences and growth needs, teenagers' perceptions, a t t i t u d e s and values may d i f f e r from those of adults and younger c h i l d r e n . I t has been noted that a p r i n c i p l e guiding the s e l e c t i o n of p a r t i c i p a n t s i s the assumption that a l l members of a c u l t u r e 9 are c a r r i e r s of that c u l t u r e , and any member i s a p o s s i b l e informant. I t i s a l s o assumed the s e l e c t i o n of informants i s dependent upon t h e i r a b i l i t y and w i l l i n g n e s s to communicate perceptions v e r b a l l y . L i m i t a t i o n s While the researcher seeks common themes in constructed accounts, there are l i m i t a t i o n s to the g e n e r a l i z a b i l i t y of accounts to other groups. This study was l i m i t e d to a group of middle c l a s s teenagers. Without f u r t h e r study one may not know the d i f f e r e n c e s or s i m i l a r i t i e s between t h i s group and teenagers of other socio-economic or c u l t u r a l groups. Furthermore, despite the knowledge shared by members of a community or c u l t u r a l group, there i s a unique aspect of an i n d i v i d u a l ' s knowledge which may preclude complete understanding of an i n d i v i d u a l ' s s i t u a t i o n . Summary Several t h e o r i s t s have presented the view that an understanding of the c l i e n t ' s p erspective i s c r i t i c a l to the e f f e c t i v e p r o v i s i o n of care. P r o v i s i o n of care i n the context of t h i s study would mean communicating n u t r i t i o n information in a manner that would be acceptable to teenagers and r e s u l t i n t h e i r adoption of the recommended eating patterns. T h i s study has been designed to c o n t r i b u t e to the development by nurses of an understanding of teenagers' notions of t h e i r food behaviors. By doing so i t w i l l c o n t r i b u t e to another goal: the p r o v i s i o n of e f f e c t i v e care. Chapter II REVIEW OF RELATED LITERATURE The t o p i c of concern in t h i s study i s a p a r t i c u l a r category of health behaviors, the d i e t a r y habits of adolescents. As health p r o f e s s i o n a l s i n t e r a c t with teenagers in health care s e t t i n g s or design i n t e r v e n t i o n programmes they question how they might increase the e f f e c t i v e n e s s of t h e i r i n t e r v e n t i o n s . As has been suggested, t h i s study i s designed to c o n t r i b u t e to understanding the problem of teenagers' n u t r i t i o n by studying t h e i r perceptions and points of view. The lack of l i t e r a t u r e which bears d i r e c t l y on t h i s problem n e c e s s i t a t e s the i n c l u s i o n in t h i s review not only of l i t e r a t u r e r e l a t e d to the t o p i c of teenagers' n u t r i t i o n , but also of studies r e l a t e d to health behavior and n u t r i t i o n i n general. In the review, both the methodologies used in the study of health behaviors and n u t r i t i o n and the f i n d i n g s of previous s t u d i e s of health behaviors, n u t r i t i o n i n general and adolescent n u t r i t i o n i n p a r t i c u l a r are discussed. The l i t e r a t u r e review i s organized i n t o three major s e c t i o n s : f i r s t , studies of the i n i t i a t i o n and maintenance of change in health behaviors; second, general studies of n u t r i t i o n ; and t h i r d , studies of adolescent n u t r i t i o n and food patterns. Studies of the I n i t i a t i o n and Maintenance of Change in Health Behaviors Assuming food behaviors are a category of health behaviors and that the adoption of healthy eating habits i s seen to c o n t r i b u t e to long 10 11 term hea l t h , s t u d i e s which have examined issues r e l a t e d to the i n s t i t u t i o n and maintenance of change in health and l i f e s t y l e behaviors are explored below. Research which has examined l i f e s t y l e issues i n general i s important to an understanding of food behaviors in p a r t i c u l a r because of four f a c t o r s they are seen to have in common. One f a c t o r i s that p r e s c r i b e d behaviors are a s s o c i a t e d with, but do not n e c e s s a r i l y r e s u l t in good hea l t h . A second i s that the reasons f o r i n i t i a t i n g the recommended behavioral pattern may be v a r i e d . The non-healthy pattern may, or may not, be c r e a t i n g a problem f o r the i n d i v i d u a l . The unhealthy behavior may not create a problem, but may increase the r i s k of problems. T h i r d , the l i f e s t y l e change i s u s u a l l y dependent upon the m o d i f i c a t i o n of a range of behaviors, not simply one behavior. Fourth, the nature of the recommended l i f e s t y l e change, l i k e changes in food behaviors, u s u a l l y r e q u i r e s long term or l i f e t i m e maintenance (Hulka, 1979). Several themes emerge from t h i s category of l i t e r a t u r e . A c o n c l u s i o n of Powers and Ford (1976) as they reviewed nursing l i t e r a t u r e r e l a t e s to the type of knowledge needed to guide successful i n t e r v e n t i o n s ; " . . . t r u l y e f f e c t i v e i n t e r v e n t i o n s must be based not only upon knowledge per se but also knowledge of the way the p a t i e n t defines h i s s i t u a t i o n " (p. 59). Compliance i s often a measure accoc i a t e d with e f f e c t i v e i n t e r v e n t i o n s . As researchers have examined compliance with p r e s c r i b e d regimens r e q u i r i n g long term m o d i f i c a t i o n of healthy behaviors, they have ge n e r a l l y concluded, l i k e Powers and Ford, that the i n d i v i d u a l ' s knowledge and perceptions of the s i t u a t i o n are f a c t o r s a s s o c i a t e d with compliance. Taylor (1979), f o r example, as he studied 12 p a t i e n t s on regimens to control t h e i r blood pressure, suggested that knowledge of hypertension alone was not a good p r e d i c t o r of compliance. Rather, p a t i e n t s ' perceptions of safety of the drugs, as well as perceived seriousness of the i l l n e s s were bet t e r p r e d i c t o r s . Further evidence that perceptions of the s i t u a t i o n c o n t r i b u t e to behaviors may be c i t e d . The mother's perceptions of how obesity a f f e c t s her c h i l d ' s health and s o c i a l a c t i v i t i e s , f o r example, have been described as i n f l u e n c i n g compliance with a weight reduction programme for her c h i l d r e n (Becker, Maiman, K i r s c h t , Haefner, & Drachman, 1979). One might assume s i m i l a r f a c t o r s may i n f l u e n c e i n d i v i d u a l s as they make de c i s i o n s about t h e i r food behaviors. Working with the i n d i v i d u a l ' s s i t u a t i o n also increases the successfulness of i n t e r v e n t i o n s . This might be done by addressing i n d i v i d u a l needs ( S e l l e r s , Cappell & Marshman, 1979) or communicating e f f e c t i v e l y to decrease the e f f e c t s of s o c i o - c u l t u r a l d i f f e r e n c e s (Hogue, 1979). S t r a t e g i e s useful in i n i t i a t i n g change r e l a t e to appealing to perceived needs (Becker, Maiman, K i r s c h t , Haefner, & Drachman, 1979), a t t i t u d e s or enhancing a c c e s s i b i l i t y of s e r v i c e s (Green, 1979). The maintenance of change i s more l i k e l y i f one i s aware of and seeks to i n v o l v e the i n d i v i d u a l ' s support system (Hogue, 1979). However, the most e f f e c t i v e p r e d i c t o r of long term compliance i s the i n d i v i d u a l ' s commitment to s u s t a i n the behaviors (Becker, Maiman, K i r s c h t , Haefner, & Drachman, 1979; T a y l o r , 1979). The f i n d i n g s of the above c i t e d s t u d i e s both emphasize the value of understanding the i n d i v i d u a l ' s perception of his s i t u a t i o n and d i r e c t 13 the e x p l o r a t i o n of p a r t i c u l a r aspects of i n d i v i d u a l s ' perceptions. These f i n d i n g s suggest the researcher should examine and c l a r i f y i n d i v i d u a l s ' perceptions of t h e i r s i t u a t i o n s . The i n t e r p r e t i v e method i s appropriate to explore questions of t h i s nature. Rosenstock (1966, 1974) has w r i t t e n about the Health B e l i e f Model which was developed by behavior s c i e n t i s t s in the 1960's to provide an explanation f o r patterns of health behavior. The Model i s considered here because i t deals with the i n d i v i d u a l ' s point of view and p o s t u l a t e s how point of view or b e l i e f s a c t to i n f l u e n c e health behavior. The Model i s a l s o considered because i t has been useful in the study of h e a l t h , l i f e s t y l e and compliance issues since i t s i n c e p t i o n (Becker, Maiman, K i r s c h t , Haefner, & Drachman, 1979; Best, & Bloch, 1979; K i r s c h t , 1974; K i r s c h t , Haefner, Kegeles & Rosenstock, 1966; T a y l o r , 1979; Saucier & Steinberg, Note 3). Rosenstock's i n i t i a l formulation of the Model to e x p l a i n preventive health behavior suggested that there were three major sources of i n f l u e n c e on health behaviors and emphasized the i n d i v i d u a l ' s p o i n t of view. The f i r s t i n f l u e n c e implies a s u b j e c t i v e state of readiness to take a c t i o n . Elements of t h i s i n f l u e n c e are the extent to which the i n d i v i d u a l perceives he i s s u s c e p t i b l e to a disease and how serious the occurrence of that disease would be. The second i n f l u e n c e i s how e f f e c t i v e people b e l i e v e c e r t a i n actions would be and the d i f f i c u l t i e s i n v o l v e d in c a r r y i n g out such a c t i o n . The t h i r d i n f l u e n c e r e l a t e s to cues which would i n s p i r e one to act (Rosenstock, 1966). The author provides a behavioral i n t e r p r e t a t i o n of the i n t e r r e l a t i o n s h i p of these 14 v a r i a b l e s . An i n d i v i d u a l would carry out preventive behaviors i f i t were perceived the r i s k s were greater than any personal inconvenience (Rosenstock, 1966). Haefner and K i r s c h t (1970) confirm that t h i s i s more l i k e l y to happen when the behaviors are not long e s t a b l i s h e d habits or patterns. While Rosenstock (1966, 1974) i n i t i a l l y suggested motivation arose out of fear of consequences, the Model has since been r e v i s e d to suggest that one might also be motivated by the d e s i r e to maintain health (Becker, Maiman, K i r s c h t , Haefner, Drachman, & T a y l o r , 1979). This r e v i s i o n would make the Model appropriate f o r the study of n u t r i t i o n as an element of l i f e s t y l e , viewing food behaviors as one category of health behaviors. While several studies support the usefulness of the Model in p r e d i c t i n g behavior, others have i d e n t i f i e d l i m i t a t i o n s . The most important l i m i t a t i o n f o r our purpose r e l a t e s to the existence of b e l i e f s . The Health B e l i e f Model was developed employing Lewin's p r i n c i p l e s of f i e l d theory (Rosenstock, 1966). An assumption of t h i s theory i s that an i n d i v i d u a l must have an i n i t i a l awareness or concern before material or s t i m u l i w i l l be perceived as r e l e v a n t (Rosenstock, 1966). This phenomenon may e x p l a i n study r e s u l t s which suggest that the b e l i e f s being measured as model parameters do not seem to be present in a l l i n d i v i d u a l s (Rosenstock, 1974; K i r s c h t et a l . , 1966). The importance of t h i s was discussed by Gochman (1972). He suggested that i f health was not meaningful or s a l i e n t to an i n d i v i d u a l the Model d i d not provide d i r e c t i o n f o r the i n t e r p r e t a t i o n of observed behaviors. Therefore t h i s 15 w r i t e r questions the value of employing the Model to study teenagers. Radius e t a l . , (1980) studied health r e l a t e d b e l i e f s and p r a c t i c e s of 112 teenagers. T h e i r f i n d i n g s were c o n s i s t e n t with Gochman's observations as described above. In a d d i t i o n , they found that health was not a concern f o r more than 50 per cent of the boys and g i r l s they studied. Saucier and Steinberg (Note 3) i n d i c a t e that teenagers tend to fe e l serious i l l n e s s w i l l not happen to them and as t h e i r age increases they tend to decrease the number of health o r i e n t e d a c t i v i t i e s they pursue. Subsequent work on the Health B e l i e f Model suggests that there i s a "cue to a c t i o n " phenomenon which a c t i v a t e s or makes s a l i e n t p e r t i n e n t b e l i e f s ( K i r s c h t , 1974). Such a phenomenon would expl a i n changes in the presence of b e l i e f s (e.g., an i n d i v i d u a l might experience an event which might change the perceptions of v u l n e r a b i l i t y or s u s c e p t i b i l i t y ) . This suggests that the i d e n t i f i c a t i o n of cues which stimulate awareness would be valuable and the r e s u l t i n g behaviors would l i k e l y be t e s t a b l e within the context of the Model. Although the Health B e l i e f Model focuses on the per s p e c t i v e of the i n d i v i d u a l , i t seems to require that i n d i v i d u a l s view t h e i r behaviors in r e l a t i o n to health (or i l l n e s s ) . Observations such as those of Gochman (1972), Radius et a l . (1980), Saucier and Steinberg (Note 3) suggest two t h i n g s . One, health i s not a universal value of the adolescent group. Second, while d i e t a r y b e l i e f s or p r a c t i c e s may be l i n k e d to health by p r o f e s s i o n a l s , f o r the layman t h i s may not always be so. Considering t h i s and the observations of Hinton et a l . (1963) and 16 Huenemann et a l . (1966, 1968) that teenagers have a range of reasons (which appear to be conceptually unrelated to health) f o r eating as they do, i t seems i t would be more i n s t r u c t i v e to adopt a d i f f e r e n t focus f o r the study of teenagers' food p r a c t i c e s . One may suggest i t would be valuable to describe not only teenagers' food b e l i e f s , but also the nature of the conceptual l i n k s teenagers make between t h e i r food behaviors and personal goals or consequences. The l i t e r a t u r e reviewed thus f a r has examined health behaviors and i d e n t i f i e d f a c t o r s i n f l u e n c i n g the i n i t i a t i o n and maintenance of change in health behaviors. The l i t e r a t u r e review that follows w i l l d iscuss whether s i m i l a r f a c t o r s have been i d e n t i f i e d as i n f l u e n c i n g compliance with n u t r i t i o n i n t e r v e n t i o n programmes. The d e c i s i o n to include n u t r i t i o n l i t e r a t u r e (non adolescent) was made because e a r l y studies of n u t r i t i o n seemed to address issues s i m i l a r to the concerns of the present study. Studies of N u t r i t i o n Studies of n u t r i t i o n g e n e r a l l y have as t h e i r focus one of two major purposes. The f i r s t of these i s to understand the n u t r i t i o n a l needs of i n d i v i d u a l s and how they might best be met. The second i s how to best address the "human element" in the problem of encouraging i n d i v i d u a l s , often of d i f f e r i n g c u l t u r e s , to modify t h e i r eating patterns to support health or to accommodate the a v a i l a b i l i t y of resources (Cussler & De Give, 1952; Mead, 1964). This l a t t e r problem, which i s more p e r t i n e n t to t h i s study, has been addressed d i f f e r e n t l y over time. E a r l y s t u d i e s 17 examined d i e t as an element of c u l t u r e and tended to employ q u a l i t a t i v e methods. One might say researchers were attempting a r a t i o n a l approach to the study of what has been r e f e r r e d to as " i r r a t i o n a l " behavior (C u s s l e r & De Give, 1952). Later studies tended to employ q u a n t i t a t i v e methods and examined both n u t r i t i o n a l status and behaviors. Studies of n u t r i t i o n which i d e n t i f i e d s o c i a l f a c t o r s as i n f l u e n c e s on behavior have considered and studied food patterns as an element of c u l t u r e . Food Patterns as an Element of Culture C u s s l e r and De Give (1952) i d e n t i f y numerous examples throughout h i s t o r y which support the view that human behavior in general, and food behavior in p a r t i c u l a r , i s i r r a t i o n a l . The idea that i n d i v i d u a l s do not always pursue a healthy d i e t even i f they are knowledgeable i s supported by Bruch (1973): There i s no human s o c i e t y that deals r a t i o n a l l y with food in i t ' s ( s i c ) environment, that eats according to the a v a i l a b i l i t y , e d i b i l i t y , and n u t r i t i o n a l value alone (p.3). Studies from the s o c i a l science p e r s p e c t i v e have examined the s o c i a l environment of f a m i l i e s and communities both to assess the nature of family i n f l u e n c e on i n d i v i d u a l s and to understand t h e i r apparently i l l o g i c a l behavior. Anthropological studies have described food patterns of p r i m i t i v e and d i f f e r e n t c u l t u r e s (Graubard, 1943; Chang, 1977). Mead (1964) was one of the f i r s t researchers to provide d i r e c t i o n in the a p p l i c a t i o n of anthropology to the question of d i e t a r y compliance. The determination of the s o c i o - c u l t u r a l aspects of food and how they are 18 a f f e c t e d by change was her g o a l . She found that d i e t and d i e t a r y behaviors were learned as a r e s u l t of s o c i a l i z a t i o n p r a c t i c e s . With knowledge of the perceived importance of foods, Cassel (1953) reports that v i s i t i n g health care workers were able to s u c c e s s f u l l y introduce change in d i e t s . The type of knowledge gained from both the studies of Cassel and C u s s l e r and De Give has increased health care workers' understanding of the c u l t u r a l group's perspective of i t s food behaviors. These studies exemplify how knowledge of c u l t u r a l perspectives may be applied in p r a c t i c e to promote compliance i n s i t u a t i o n s r e l a t e d to n u t r i t i o n . C u s s l e r and De Give (1952) c a r r i e d out the f i r s t comprehensive study of the s o c i o - c u l t u r a l f a c t o r s a f f e c t i n g food patterns, e s p e c i a l l y i n the r u r a l south of the United S t a t e s . The purpose of the study, which was q u a l i t a t i v e in design was to study the "food habits" and "foodways" of a r u r a l area composed of several communities. They both interviewed and acted as p a r t i c i p a n t observers in a range of community meeting places and f a m i l i e s ' homes and inter-community comparisons were made. "Food h a b i t s " were defined as: ...the s p e c i f i c elements connected with the i n d i v i -dual's food a c t i v i t i e s . . . i n c l u d i n g in that term not only the d i e t i t s e l f but also i n d i v i d u a l habits of producing, purchasing and preparing food, and a t t i -tudes, t a s t e s , and habits of eating (p.50). "Foodways," on the other hand are more general, i n c l u d i n g " . . . a l l those p a r a l l e l elements of the food pattern which have considerably more than i n d i v i d u a l a p p l i c a t i o n " (p.49). The a p p l i c a t i o n r e f e r r e d to may vary by 19 degrees; examples are s o c i a l c l a s s , community or a region. These d e f i n i t i o n s continue to be accepted and employed (Lowenberg, Todhunter, Wilson, Savage, & Labawski, 1974). In a d d i t i o n to observations of the impact of values on "foodways," the authors i n d i c a t e that informants' main concerns as they were interviewed were with thoughts and f e e l i n g s about both the food and the s o c i o - c u l t u r a l patterns. This suggests that interviews might e l i c i t d e s c r i p t i o n s of what i n d i v i d u a l s in a c u l t u r a l group perceive as important or of value. The researchers comment that information about p r a c t i c e s was more l i k e l y to be derived from t h e i r observations than from t h e i r i nterviews, while interviews produced i n s i g h t i n t o the mechanisms of transmission of "foodways." Food b e l i e f s were explored as were p r a c t i c e s within and between s o c i a l groups. What might be i n f e r r e d from the d i s c u s s i o n by C u s s l e r and De Give i s that, while knowledge and p r a c t i c e may be r e l a t e d , i n d i v i d u a l s in a community such as the one they studi e d have a p a r t i c u l a r way of formulating knowledge or viewing t h e i r own s i t u a t i o n . An important element i d e n t i f i e d i n the above study was the r o l e of i n d i v i d u a l s in passing on "foodways." Women's p o s i t i o n in the family u n i t and t h e i r r e s p o n s i b i l i t i e s f o r c h i l d s o c i a l i z a t i o n p r a c t i c e s was one kind of r o l e i n f l u e n c e . That foods could be a l l o c a t e d to c l a s s e s of members (e.g., White landowner versus Black labourer) as well as being a s c r i b e d s p e c i a l status (e.g., s p e c i a l occasion foods and d a i l y foods) was a l s o i d e n t i f i e d . P r i o r to the Cussler and De Give study, lack of 20 knowledge of these types of c u l t u r a l values made i t d i f f i c u l t to introduce change or modify food behaviors i n t h i s community. T h e i r study provided information which c o n t r i b u t e d to the e f f e c t i v e i n t r o d u c t i o n of change in d i e t a r y patterns, i d e n t i f i e d c l e a r l y a range of b e l i e f s about food (that may stand i n c o n t r a s t to b e l i e f s of other groups or s c i e n t i f i c f i n d i n g s ) and cont r i b u t e d to the i n t e r p r e t a t i o n of q u a n t i t a t i v e , frequency data ( C u s s l e r & De Give, 1952). The study discussed above did not focus on teenagers, but i t does support the questions r a i s e d i n the studies c i t e d which addressed issues r e l a t e d to the m o d i f i c a t i o n of health behaviors. The authors sought both to describe the meaning of food within the c u l t u r e and to explai n how personal and community values, i n d i v i d u a l food b e l i e f s and family and community members co n t r i b u t e d to the maintenance and change of food p a t t e r n s . C u s s l e r and De Give's (1952) work could act as a model f o r the design of a study focusing on teenagers as a s o c i a l group. T h e i r methodology would d i r e c t one to examine the food behaviors of adolescents i n the context of t h e i r surroundings. The format would seek the teenagers' r a t i o n a l e s f o r t h e i r a c t i o n s i n t h e i r own terms. One may not assume that observations of a p a r t i c u l a r group w i l l be useful f o r a l l other c u l t u r a l groups, but i t does c l e a r l y i n d i c a t e that there are patterns which, when i n t e r p r e t e d from the perspective of the i n d i v i d u a l s i n the community, are c o n s i s t e n t . The l i t e r a t u r e i n the 1960's and 1970's documents a s h i f t i n the 21 methodologies employed to study food behaviors, in p a r t i c u l a r teenagers' food behaviors. As a r e s u l t , there i s also a d i f f e r e n c e in the type of f i n d i n g s . The next s e c t i o n of the l i t e r a t u r e review examines st u d i e s of teenagers and t h e i r food behaviors and patterns. Studies of Adolescent N u t r i t i o n and Food Patterns Studies of adolescent n u t r i t i o n were reviewed with the f a c t o r s found to i n f l u e n c e the i n i t i a t i o n and maintenance of health behaviors in mind. The review of l i t e r a t u r e r e l a t e d to adolescent n u t r i t i o n a l s o describes the state of knowledge of adolescent n u t r i t i o n and i s organized as f o l l o w s . F i r s t , t h e o r e t i c a l and methodological issues in f i v e s e l e c t e d studies are addressed. Then, the f i n d i n g s of these f i v e studies are combined with those of other studies of teenage n u t r i t i o n and are presented in four content areas. These are: patterns of food consumption during adolescence, i n f l u e n c e s on teenagers' food behaviors, teenagers' knowledge of n u t r i t i o n , and i n f l u e n c e s of s o c i a l status and f a m i l y . T h e o r e t i c a l perspectives and methodologies. While teenagers have often been included in n u t r i t i o n a l surveys of a l l age groups ( N u t r i t i o n , 1973; N u t r i t i o n Canada, 1975), f i v e studies in p a r t i c u l a r have had the adolescent age group as t h e i r focus. These f i v e s t u d i e s , three c a r r i e d out in the United States and two in Canada, have been chosen f o r s p e c i a l d i s c u s s i o n f o r two reasons. F i r s t , they explored a range of issues r e l a t e d to adolescent n u t r i t i o n ; and second, they adopted d i f f e r i n g perspectives and methodologies. While s p e c i f i c f i n d i n g s of the 22 studies are discussed l a t e r i n t h i s chapter, i t i s useful to examine i n more d e t a i l the t h e o r e t i c a l perspectives adopted by the researchers and the s i m i l a r i t i e s and d i f f e r e n c e s i n t h e i r f i n d i n g s . The study most e x t e n s i v e l y c i t e d was c a r r i e d out by Huenemann et a l . (1966,1968). The same group of 1000 teenagers was followed for a perio d of four y e a r s . Each year the Berkeley high school students were assessed f o r physical growth changes as well as being weighed and measured anthropometrically and c i r c u m f e r e n t i a l l y to determine gross body composition, conformation, and body weight. Some were given a c l i n i c a l exam. These p r a c t i c e s f i t with recommendations f o r measurement of body s i z e except that they lack documentation of maturity (McKigney & Munro, 1973). A l s o , once y e a r l y (grades 9-12) the teenagers answered questions on food and meal preferences, reasoning, a c t i v i t y l e v e l , and opinions and knowledge of food p r a c t i c e s . The t o t a l study group included 10 per cent O r i e n t a l and 30 per cent Black teenagers. Hinton et a l . (1963) studied 12 and 14 year o l d middle c l a s s g i r l s p u r p o s e f u l l y chosen to be pre- and post-puberty. They employed food records f o r two periods i n high school. They also measured height, weight and bone age by X-ray. Tools were employed to measure knowledge of n u t r i t i o n , food enjoyment, food values, and psychologic adjustment of the group. The bases f o r tool development were not described. In a t h i r d U.S. study, 404 students aged 12 to 15 years from three high schools i n Syracuse were studied. The major data sources were biochemical assays of blood and urine samples. As w e l l , measurements were 23 recorded of age, height, weight, and t r i c e p s k i n f o l d s . A second data base was interviews which provided researchers with a p r o f i l e of the frequency and types of breakfasts consumed by the teenagers studied. The data also included socio-economic s t a t u s . The sample had approximately equal d i s t r i b u t i o n of males and females and the r a c i a l d i s t r i b u t i o n was 2/3 White and 1/3 Black ( D i b b l e , B r i n , McMullen, Peel, & Chen, 1965). Au Coin, Haley, Ray, and Cole (1972) s t u d i e d Nova S c o t i a teenagers aged 10 to 12 y e a r s . They r e - t e s t e d a d i e t a r y assessment tool which had been developed from the Canada Food Guide. Intake was assessed as adequate when teenagers consumed 70 per cent or more of the Canada Food Guide's recommended d a i l y allowances. Measurements were c a r r i e d out on one occasion and teenagers recorded what they had eaten that day. Data were analysed f o r v a r i a t i o n s across age and sex. The n u t r i t i o n a l component of the study by Saucier and Steinberg (Note 3) was only one element in a more complex design examining a range of health and l i f e s t y l e behaviors. They surveyed 5000 Quebec students in f i v e high school grades and two j u n i o r c o l l e g e l e v e l s . A l l information was gathered by q u e s t i o n n a i r e . The t h e o r e t i c a l foundation was based on the Health B e l i e f Model (Rosenstock, 1966), value theory, and developmental t h e o r i e s of adolescence. In a d d i t i o n to assessing teenagers' health b e l i e f s and a t t i t u d e s towards prevention, food patterns were a l s o assessed. To do t h i s , a c h e c k l i s t of foods consumed i n the previous twenty-four hours was employed. The purpose was to i d e n t i f y p a t t erns and frequencies of consumption of key food groups. U n l i k e Dibble et a l . , and Au Coin et a l . , Saucier and Steinberg were not 24 assessing n u t r i t i o n a l s t a t u s . Although d i f f e r e n t methods were employed in these s t u d i e s , trends may be i d e n t i f i e d from the f i n d i n g s . Four p a r t i c u l a r content areas have been addressed. Patterns of food consumption during adolescence. The f i v e studies c i t e d and others reviewed assessed teenagers' n u t r i t i o n a l status and patterns of food intake and document that there i s a wide range in p r a c t i c e s . They also support the f i n d i n g s of studies c i t e d in Chapter I suggesting that many teenagers do have d e f i c i e n c i e s in t h e i r d i e t s . While some f a c t o r s such as age, sex, and regional d i f f e r e n c e s emerge to de s c r i b e which teenagers have n u t r i t i o n a l problems, the authors report d i f f i c u l t i e s i n accounting f o r d i f f e r e n c e s within groups. One pattern described i s in the d i f f e r e n c e s between boys and g i r l s . Most studies support the view that males have a more n u t r i t i o u s d i e t than females ( N u t r i t i o n , 1973; N u t r i t i o n Canada, 1975; Saucier & Steinberg, Note 3 ) . In a study which included a d e s c r i p t i o n of adolescent meal patterns, Huenemann et a l . (1968) found that boys g e n e r a l l y ate more than g i r l s , an observation supported by Saucier and Steinberg (Note 3 ) . I t would seem there are i n f l u e n c e s other than those that can be a t t r i b u t e d to sex d i f f e r e n c e s . In c o n t r a s t to the f i n d i n g s of the Quebec and U.S. s t u d i e s , the Nova S c o t i a study of 10 to 15 year olds did not reveal d i f f e r e n c e s between the sexes. Rather, i t i n d i c a t e d that few teenagers consumed even 70 per cent of the amounts recommended by the Canada Food Guide (Au Coin et a l . , 1972). 25 Comparison of food intakes between age groups showed a p r o g r e s s i v e d e c l i n e in the adequacy of intake as growth needs increased. One i n t e r p r e t a t i o n f o r the observed d e c l i n e i s that teenagers do not increase consumption of s p e c i f i c food groups to match recommended needs (Au Coin e t a l . , 1972). Saucier and Steinberg (Note 3) also describe a lack of change in amount of food intake with i n c r e a s i n g age. Other examples of ranges of p r a c t i c e s may be c i t e d . Huenemann e t a l . , (1966, 1968) describe f i v e c a t e g o r i e s of meal patterns ranging from three regular meals with snacks to no regular meals and several snacks. I t i s documented that teenagers consume "junk foods" two to three times a day on the average (Huenemann et a l . , 1966, 1968; Saucier & Steinberg, Note 3 ) . Crawford (1977) demonstrated, however, that, although teenagers d i d buy junk food from vending machines placed in high schools, when given the choice of more n u t r i t i o n a l food such as apples and milk, "junk food" purchases not only decreased but vending machine revenue increased. When made a v a i l a b l e , a l a r g e r number of n u t r i t i o u s snacks were bought by teenagers. The data were employed to challenge assumptions of school a d m i n i s t r a t o r s that teenagers w i l l not eat healthy foods. This l a t t e r study i n d i c a t e s the value of e x p l o r i n g the a v a i l a b i l i t y of n u t r i t i o n a l foods to the teenager. Lack of a v a i l a b i l i t y was reported to i n f l u e n c e n u t r i t i o n a l patterns (Huenemann et a l . , 1966; 1968). I t was a l s o p o s t u l a t e d to c o n t r i b u t e to the poor health of n a t i v e teenagers on i s o l a t e d reserves (Stepien, 1978). While the c i t e d studies document c l e a r l y that teenagers do have a range of food behaviors, only one of the studies even t r i e s to explore 26 t h e i r reasons f o r choosing s p e c i f i c foods. Some f a c t o r s i n f l u e n c i n g teenagers' d e c i s i o n making w i l l be discussed in the next category of 1 i t e r a t u r e . Described i n f l u e n c e s on teenagers' food behaviors. Besides having d i f f e r e n t needs than boys, teenage g i r l s are described as having d i f f e r e n t concerns about t h e i r body shapes and rates of growth (Dwyer, Feldman & Mayer, 1967; Huenemann et a l . , 1966). These concerns are seen to i n f l u e n c e t h e i r d i e t and a c t i v i t y . Teenage boys and g i r l s are described as choosing d i f f e r e n t foods to provide c a l o r i e s ( i . e . , boys eat l a r g e r amounts g e n e r a l l y , g i r l s eat more raw f r u i t s and vegetables, Huenemann et a l . , 1968). More teenage g i r l s choose to p u r p o s e f u l l y r e s t r i c t t h e i r intake to minimize growth while boys wish to maximize i t . If weight control i s d e s i r e d , boys tend to e x e r c i s e (Huenemann et a l . , 1966). In t h e i r study of 5000 French Canadian teenagers, Saucier and Steinberg (Note 3) reported t h a t 33 per cent of the females had d i e t e d f o r weight l o s s as compared to only 10 per cent of the males. Huenemann et a l . (1966; 1968) report s i m i l a r f i n d i n g s . They assessed approximately 25 per cent of the teenage g i r l s to be overweight; however, more than 50 per cent of the g i r l s perceived themselves to be f a t . The boys, however, seemed to hold views of themselves which were c o n s i s t e n t with the researchers' measurements of f a t n e s s . Hinton et a l . , (1963) i n d i c a t e d t h a t e a r l y maturing g i r l s had a tendency to be overweight. In another study, Kaufman, Poznanski and Guggenheim (1975) found t h a t 480 grade 8 27 boys' and g i r l s ' perceptions about foods ( i . e . the f a t t e n i n g value of c e r t a i n foods) c o n t r i b u t e d to choices about consumption. What begins to emerge from a review of these studies i s the impression that teenagers' perceptions of themselves as they pass through t h i s period of a c c e l e r a t e d growth i n f l u e n c e in some way the choice of d i e t . Several reports i n d i c a t e d t h a t , besides i n f l u e n c i n g choice, the s o c i a l aspects of food consumption increase in importance to the teenager (Huenemann et a l . , 1966, 1968). The observation that teenagers who value the s o c i a l aspects of eating tend to have eating patterns which are l e s s healthy i s also reported (Hinton et a l . , 1963). On the other hand, teenagers who value health are also seen to have more healthy d i e t s (Hinton et a l . , 1963). This view d i f f e r s from comments made by Saucier (Note 1), who i n d i c a t e s that while some teenagers reported that they valued health and i n d i c a t e d readiness to pursue a healthy l i f e s t y l e , i n a c t u a l i t y they d i d not do so. The l i t e r a t u r e reviewed to t h i s point i n d i c a t e s that teenage ea t i n g patterns may vary by sex, age, perceptions of s e l f , and perceptions of the s o c i a l s i t u a t i o n s r e l a t e d to food a c t i v i t i e s . Other f a c t o r s have been examined f o r t h e i r r e l a t i o n to d i e t a r y p a t t e r n s . A t t i t u d e s , knowledge and b e l i e f s about d i e t , socio-economic status and family s t r u c t u r e are examples which w i l l be addressed in the f o l l o w i n g s e c t i o n s . Teenagers' knowledge of n u t r i t i o n . Teenagers' n u t r i t i o n a l knowledge has been assessed in a v a r i e t y of ways. Two studies of 28 grade 8 students assessed knowledge and found i t to be s a t i s f a c t o r y (Kaufman et a l . , 1975; Thompson & Schwartz, 1977). Knowledge was not always found to c o r r e l a t e s i g n i f i c a n t l y with p r a c t i c e ; however, i t was noted that knowledge and a t t i t u d e s were s i g n i f i c a n t l y r e l a t e d as, to a l e s s e r extent, were a t t i t u d e s and p r a c t i c e (Thompson & Schwartz, 1977). While Saucier and Gauthier (Note 2) found a p o s i t i v e r e l a t i o n s h i p between knowledge of healthy p r a c t i c e s and p o s i t i v e a t t i t u d e s and health behaviors, t h i s c o r r e l a t i o n was described as s u r p r i s i n g l y weak. In the study by Huenemann et a l . (1966), assessment of knowledge of 14 to 15 year o l d boys and g i r l s l e d to the conclusion that knowledge was l i m i t e d . The teenagers were asked to describe foods that should be eaten d a i l y . F i f t y per cent of the students did not mention any of the four food groups. These teenagers, as well as having l i m i t e d knowledge, a l s o were described as holding numerous misconceptions about foods. Examples include b e l i e f s about e f f e c t s of foods on t h e i r bodies, the lack of i n c l u s i o n of milk as a d a i l y d e s i r e d food, and the tendency f o r a l l but Caucasian boys to view obesity only in r e l a t i o n to d i e t and not to e x e r c i s e . F i n a l l y , the study by Hinton et a l . (1963) did not measure knowledge per se, but did measure teenagers' a b i l i t y to choose healthy d i e t s . The teenagers in t h e i r study who were able to choose healthy d i e t s also were described as having healthy d i e t s . In t h e i r study, a b i l i t y to s e l e c t c o r r e l a t e d with d a i l y p r a c t i c e s . In general, adolescents' choices of foods are not seen to be c l e a r l y r e l a t e d to knowledge. These observations, as well as those which 29 mention that knowledge d i f f e r e d from group to group, suggest that i t would be valuable to explore with teenagers t h e i r processes of d e f i n i n g or using knowledge. A d i f f i c u l t y in making comparisons between these s t u d i e s i s that the techniques of measuring knowledge were quite d i f f e r e n t . A s i m i l a r problem occurred in attempting to compare studies examining the i n f l u e n c e of socio-economic status on teenagers' d i e t a r y p r a c t i c e s . Influence of s o c i a l status and f a m i l y . As knowledge and s o c i a l status were compared, one study demonstrated that knowledge increased with s o c i a l s t a t u s , but the i n f l u e n c e was described to be l e s s than the i n f l u e n c e s of c u l t u r e (Huenemann et a l . 1968). The observations of Dibble et a l . (1965) stand in c o n t r a s t to those of other i n v e s t i g a t o r s which d i d not f i n d t h a t the behavior of the groups studied v a r i e d with t h e i r socio-economic status (Thompson & Schwartz, 1977; Kaufman et a l . , 1975). Au Coin et a l . (1972) noticed a v a r i a t i o n in the healthiness of intake which corresponded to l e v e l of parents' education. While they postulated t h i s may p a r a l l e l f i n d i n g s f o r socio-economic s t a t u s , t h i s was not t e s t e d . Dibble et a l . (1965) document that the q u a l i t y of breakfasts consumed v a r i e s with socio-economic s t a t u s . They also comment on the f a m i l y s t r u c t u r e of t h e i r study group; 30 per cent of the low socio-economic school group were from s i n g l e parent f a m i l i e s , compared to 3 per cent s i n g l e parent f a m i l i e s i n the school groups where fa t h e r s were ranked prof e s s i o n a l / m a n a g e r i a l . They i n d i c a t e that many of t h e i r 30 observations c o r r e l a t e with socio-economic status and imply c o r r e l a t i o n s with family s t r u c t u r e . A t h i r d c h a r a c t e r i s t i c of the group which was not addressed was t h a t 90 per cent of the low socio-economic group was Black while only one per cent of the group in the school of highest socio-economic status was Black. These c u l t u r a l and family s t r u c t u r e d i f f e r e n c e s were not explored. Such a study, though documenting frequencies and trends, also suggests the need to examine how d i f f e r e n t groups account f o r t h e i r behaviors. Although Huenemann et a l . (1966) postulated an impact of c u l t u r e on food behaviors of teenagers in t h e i r study, they also suggested the i n f l u e n c e of c u l t u r e required f u r t h e r e x p l o r a t i o n . Family i n f l u e n c e on d i e t a r y p r a c t i c e s i s implied, but none of the research c i t e d studied teenagers within the context of t h e i r f a m i l i e s . F u r t h er references to the nature of family i n f l u e n c e may be noted. Two studies i n d i c a t e eating patterns were unrelated to family s i z e (Au Coin et a l . , 1972; Thompson & Schwartz , 1977). When asked who they considered to be food a u t h o r i t i e s , teenagers named t h e i r parents (Huenemann et a l . , 1966). Factors such as age, sex, c u l t u r a l background and a v a i l a b i l i t y of foods have been found to i n f l u e n c e the teenager's behavior. The e f f e c t s of teenage e a t i n g p r a c t i c e s are confirmed by biochemical analyses. The l i t e r a t u r e reviewed also i n d i c a t e s points needing c l a r i f i c a t i o n . One i s the i n c o n s i s t e n c y between teenagers' knowledge and p r a c t i c e . There i s , however, apparent consistency between the teenagers' perceptions and t h e i r behaviors. For example; Huenemann et a l . (1966) described the 31 tendency of females who perceived themselves as f a t to pursue a s e l f s t y l e d weight reduction programme, even when o b j e c t i v e measures did not confirm obesity i n a majority of the g i r l s . While teenagers' perceptions of the adequacy of t h e i r d i e t were not always confirmed by the researchers, they suggest that the d i e t was more l i k e l y c o n s i s t e n t with the c r i t e r i a the adolescent defined to be acceptable. The teenagers' c r i t e r i a i ncluded acceptance of parental guidance, comparison of t h e i r own behaviors with observed a d u l t eating behaviors and awareness of ideal standards (Huenemann et a l . , 1966). Three a d d i t i o n a l observations may be made from the l i t e r a t u r e . F i r s t , i n the n u t r i t i o n a l s t u d i e s , l i k e the studies of compliance, the perception of the e f f e c t on other aspects of the i n d i v i d u a l ' s l i f e s t y l e was seen to i n f l u e n c e the adoption or maintenance of a behavior p a t t e r n . A second observation suggesting f u r t h e r e x p l o r a t i o n i s the d i f f e r e n c e between the a t t i t u d e s of male and female teenagers. F i n a l l y , f u r t h e r e x p l o r a t i o n of the nature of family i n f l u e n c e i s warranted. The patterns observed suggest that motivations to act may be g r e a t l y i n f l u e n c e d by values, s o c i a l i z a t i o n , c u l t u r e , perceptions, and s i t u a t i o n s . Summary The problem which i s the focus of t h i s study i s the lack of understanding of how teenagers i n t e r p r e t or make sense of knowledge or f a c t s , how they develop t h e i r a t t i t u d e s , and, in turn, how they make de c i s i o n s about t h e i r food behaviors. There i s also a general lack of 3 2 knowledge about what adolescents consider to be important regarding foods and food behaviors or what they perceive to i n f l u e n c e t h e i r food b e l i e f s or behaviors. This chapter has reviewed studies r e p r e s e n t a t i v e of the current s t a t e of knowledge regarding teenagers' n u t r i t i o n a l behaviors and a t t i t u d e s . I t has been argued that addressing the problem of teenage n u t r i t i o n from the ethnographic perspective w i l l c o n t r i b u t e information needed to remedy the described lack of knowledge. A review of compliance l i t e r a t u r e and c l i n i c a l studies from the ethnographic p e r s p e c t i v e documents that c l i n i c i a n s ' understanding of how i n d i v i d u a l s view a p a r t i c u l a r problem or s i t u a t i o n may c o n t r i b u t e to the p r o v i s i o n of care which i s perceived s a t i s f a c t o r y to the c l i e n t . N u t r i t i o n a l studies demonstrate that the use of ethnographic methods provides information useful in the design of n u t r i t i o n i n t e r v e n t i o n programmes. Other researchers observe that the way people c l a s s i f y n u t r i t i o n information and define knowledge i s i n f l u e n c e d by c u l t u r e . They also i n d i c a t e that by a c t i n g as a p a r t i c i p a n t observer a researcher might i d e n t i f y how c u l t u r a l o r i e n t a t i o n s and values i n f l u e n c e food behaviors. However, ethnographic studies of teenage n u t r i t i o n were not found. Findings of other kinds of studies of teenage n u t r i t i o n did not provide answers to questions of how teenagers view t h e i r food behaviors, what i s important to them, or how they a r r i v e at t h e i r food d e c i s i o n s . Although i t i s often assumed that p r a c t i c e w i l l correspond to knowledge, both the compliance l i t e r a t u r e reviewed and studies r e l a t i n g 33 adolescents' n u t r i t i o n a l knowledge to behavior suggest two t h i n g s . I n d i v i d u a l s are more able to comply with p r e s c r i b e d regimens when they have information which w i l l help them cope with the consequences of the regimen on l i f e s t y l e a c t i v i t i e s or i n t e r p e r s o n a l r e l a t i o n s . I t i s l e s s l i k e l y c l i e n t s w i l l comply i f they only have information on, or knowledge o f , t h e i r disease. Recent studies of teenage n u t r i t i o n imply that family, c u l t u r e and perceptions of s e l f i n f l u e n c e food behaviors. They also suggest that teenagers i n t e r p r e t knowledge d i f f e r e n t l y than i s i n d i c a t e d by researchers' o b j e c t i v e measures. I t would seem, then, that there i s a need to describe the f a c t o r s i n f l u e n c i n g teenagers' use of knowledge as they develop the notions which guide t h e i r p a r t i c u l a r food behaviors. Although food behaviors ranging in degrees of healthiness have been documented, there are no s a t i s f a c t o r y explanations f o r i n d i v i d u a l d i f f e r e n c e s in observed p r a c t i c e s . Therefore, i t seems to be worthwhile to seek adolescents' explanations f o r t h e i r food behaviors. Chapter III METHODOLOGY Thi s study was guided by the perspective derived from the i n t e r p r e t i v e approach. As teenagers were both interviewed and observed, data c o l l e c t e d were analysed employing constant comparative a n a l y s i s . This chapter w i l l describe how the i n t e r p r e t i v e method was adapted f o r t h i s study. To be addressed are: s e l e c t i o n of p a r t i c i p a n t s , processes of data c o l l e c t i o n , e t h i c a l c o n s i d e r a t i o n s and data a n a l y s i s . S e l e c t i o n of the Study Group C r i t e r i a f o r P a r t i c i p a t i o n As has been described, the s e l e c t i o n of study p a r t i c i p a n t s was based on t h e i r a b i l i t y to address the to p i c of the study. As the data c o l l e c t e d r a i s e d a d d i t i o n a l questions, new candidates or groups were included (see Glaser & Strauss, 1965; Lindemann, 1974). I n i t i a l c r i t e r i a f o r s e l e c t i o n were: -male and female teenagers of high school age -healthy and not f o l l o w i n g a therapeutic d i e t -able to converse i n Engl i s h -from middle c l a s s f a m i l i e s As the study progressed and as i n i t i a l interviews were analysed, i t became a concern that p a r t i c u l a r c h a r a c t e r i s t i c s of the family might be i n f l u e n c i n g the teenagers' per c e p t i o n s . As teenagers described r a t i o n a l e s f o r t h e i r food behaviors they often r e f e r r e d to the mother as 34 35 a r o l e model and some q u a l i f i e d t h i s with "my mother who i s a nurse." Before a l l p a r t i c i p a n t s were chosen, two a d d i t i o n a l s e l e c t i o n c r i t e r i a were added so the researcher could explore more f u l l y the i m p l i c a t i o n s of these family c h a r a c t e r i s t i c s . The researcher also chose to include an extra p a r t i c i p a n t in the study. For these reasons, both the eighth and ninth study p a r t i c i p a n t s were s e l e c t e d according to the f o l l o w i n g a d d i t i o n a l c r i t e r i a . -not having a mother who was a nurse -not l i v i n g in a s i n g l e parent family Having i d e n t i f i e d c r i t e r i a f o r the s e l e c t i o n of p a r t i c i p a n t s , procedure f o r s e l e c t i o n and the c h a r a c t e r i s t i c s of the f i n a l group w i l l be described. Procedure f o r P a r t i c i p a n t S e l e c t i o n The study p a r t i c i p a n t s were volunteers from f a m i l i e s recommended by f r i e n d s or acquaintances of the researcher. The researcher had met one of the p a r t i c i p a n t s p r i o r to the study. Although the teenagers were l e g a l l y minors and parental consent was required, i t was considered important that the teenager be involved in the d e c i s i o n making process. To emphasize t h i s point, wording of the consent l e t t e r was d i r e c t e d to the adolescent. A l e t t e r and consent form (Appendices A and B) e x p l a i n i n g the study were given to each p a r t i c i p a n t by a person known to themselves and the researcher. The l e t t e r , as well as e x p l a i n i n g the study's purpose, i n d i c a t e d the researcher's d e s i r e to interview and observe the teenagers i n t h e i r homes. If the adolescents and t h e i r parent(s) agreed to p a r t i c i p a t e , the researcher contacted them by telephone to provide 36 f u r t h e r c l a r i f i c a t i o n of the study's purpose, answer questions and to arrange an in t e r v i e w time. Interview times were then scheduled at the convenience of the boys or g i r l s and t h e i r f a m i l i e s . C h a r a c t e r i s t i c s of the P a r t i c i p a n t s F i v e boys and four g i r l s p a r t i c i p a t e d i n two interview s e s s i o n s . Their ages ranged from 13 years one month to 15 years ten months and they attended seven d i f f e r e n t high schools i n Vancouver and i t s surrounding suburban areas. Three of the group were in grade 8, two were in grade 9, two were in grade 10, and two were in grade 11. A l l the teenagers p a r t i c i p a t e d in at l e a s t one, and sometimes three to four, e x t r a c u r r i c u l a r i n t e r e s t s depending upon the season. While most were s p o r t s - r e l a t e d , such as hockey, b a s k e t b a l l , v o l l e y b a l l , swimming, cheerleading, f l o o r hockey, or skating, others included music, dance and Sunday school teaching. Several teenagers had some source of revenue such as d e l i v e r i n g papers, b a b y s i t t i n g , mowing lawns, or working at gas s t a t i o n s or re s t a u r a n t s . Although family s i z e v a r i e d , a l l of the p a r t i c i p a n t s l i v e d at home with one or both parents and a l l had one or more s i b l i n g s . Two s i n g l e t r i a l interviews were conducted at the beginning of the study f o r the purpose of acquainting the researcher with the in t e r v i e w technique. Two teenagers, aged 15 and 18 y e a r s , each p a r t i c i p a t e d in one interview. These two interviews c o n t r i b u t e d data to the study. In c o n t r a s t to the r e s t of the p a r t i c i p a n t s , these two teenagers were temporarily away from home. One was on vacation with h i s fa m i l y and the other was staying with family f r i e n d s while attending a course i n Vancouver. Both of these teenagers normally l i v e d with both 37 parents. One had several s i b l i n g s and one was an only c h i l d . While some of the p a r t i c i p a n t s interviewed i d e n t i f i e d with c u l t u r a l groups such as B r i t i s h and I t a l i a n , a l l were White. In the f i n a l a n a l y s i s the researcher came to question the apparent homogeneity of family c h a r a c t e r i s t i c s . Three q u a l i t i e s were dominant: the number of working mothers, 9 out of 11; the number of s i n g l e parent f a m i l i e s , 5 out of 11; and the number of mothers who were nurses, 6 out of 11. The researcher chose to explore the current family trends f o r these three c h a r a c t e r i s t i c s . That more women are working i s c l e a r l y documented ( S t a t i s t i c s Canada, 1976). I f mothers are working, i t i s more l i k e l y that t h e i r c h i l d r e n w i l l be of school age, p a r t i c u l a r l y high school age. On the second point, Vancouver and i t s surrounding area i s estimated to have approximately 30,000 lone parent f a m i l i e s ( S t a t i s t i c s Canada, 1976). While the family s i t u a t i o n s of the study group may not be considered r e p r e s e n t a t i v e of a l l teenagers, the i n c l u s i o n of teenagers from s i n g l e and two parent f a m i l i e s in t h i s study i s not i n c o n s i s t e n t with l o c a l trends. On the t h i r d p o i n t , i t would seem that mothers who were nurses were overrepresented i n the group. I t was decided that teenagers' perceptions of t h e i r parents' r o l e i n t h e i r food behavior would be more c l e a r l y presented i f the researcher could explore whether expressed s i m i l a r i t i e s and d i f f e r e n c e s r e l a t e d to parental r o l e s or p r o f e s s i o n a l r o l e s . Trends i n the data and the need to address the defined purposes of the study, c l a r i f y i n g with teenagers t h e i r perceptions, were two more reasons f o r the w r i t e r s ' d e c i s i o n to include the extra p a r t i c i p a n t i n the study group. 38 Data C o l l e c t i o n E t h i c a l Considerations In c a r r y i n g out a study one must ensure the r i g h t s of the i n d i v i d u a l p a r t i c i p a n t s . The p a r t i c u l a r r i g h t s i n question are those of informed consent, c o n f i d e n t i a l i t y and minimization of r i s k s or costs to p a r t i c i p a n t s . T h is study was conducted c o n s i d e r i n g the d i r e c t i v e s of the U n i v e r s i t y of B r i t i s h Columbia E t h i c s Committee. As has been described, a l l teenagers were f i r s t contacted by a person known to them. The study's purpose and the nature of t h e i r requested involvement was then described in a l e t t e r from the researcher. Written consent was obtained from the teenager and one parent. When the researcher re-contacted the teenagers f o r the second interview, a l l teenagers and parents were asked i f they were i n t e r e s t e d i n c ontinuing to p a r t i c i p a t e in the study. The researcher i n d i c a t e d they were not under o b l i g a t i o n to do so. To maintain c o n f i d e n t i a l i t y , t r a n s c r i p t i o n s of tape recordings d i d not i d e n t i f y the p a r t i c i p a n t s , and i f family names were mentioned on the tapes they were erased p r i o r to the t r a n s c r i p t i o n s . Although i n the process of data a n a l y s i s the researcher consulted with committee members and other graduate students f a m i l i a r with the method, i d e n t i t y of i n d i v i d u a l teenagers was not revealed. The method of s e l e c t i o n of p a r t i c i p a n t s and the concern to maintain c o n f i d e n t i a l i t y presented some d i f f i c u l t y to the researcher. Those who r e f e r r e d teengers were often i n t e r e s t e d in enquiring how the interview went. Such s i t u a t i o n s were managed best by i n d i c a t i n g the 39 researcher's concern to not breach the c o n t r a c t e s t a b l i s h e d with the adolescents and t h e i r f a m i l i e s . I t was u s u a l l y i n d i c a t e d that the teenager had been a h e l p f u l p a r t i c i p a n t . In the process of the study the teenagers and t h e i r f a m i l i e s c o n t r i b u t e d a great deal by g i v i n g up t h e i r time and accommodating the researcher in t h e i r homes. While the b e n e f i t s to i n d i v i d u a l teenagers were not assessed, i t was of i n t e r e s t to note that comments made to r e f e r r i n g i n d i v i d u a l s included several which i n d i c a t e d such involvements made the teenagers f e e l "quite s p e c i a l . " Thus, the researcher might assume that the experience f o r the majority was perceived to have had some p o s i t i v e outcomes. Data C o l l e c t i o n Procedure The teenagers were interviewed in t h e i r homes on two occasions during the l a t e summer and e a r l y f a l l , 1981. Two forms of data were c o l l e c t e d . Audiotapes of interviews formed one category of data and hand recorded notes of the interviewer's observations formed the second. The data c o l l e c t e d during interviews and observations were guided by the three study purposes. An interview schedule was not employed. The study purpose was described to the teenagers and i t was suggested to them they might begin by d e s c r i b i n g what they did in a t y p i c a l day. Combined interview-observation times ranged from one to three hours. Tapes of the interview period alone ranged from 30 to 60 minutes. Each interview was t r a n s c r i b e d and a n a l y s i s of i t d i r e c t e d the researcher in seeking c l a r i f i c a t i o n or i n t e r p r e t a t i o n of accounts in subsequent i n t e r v i e w s . Spradley (1979) considers the best source of data f o r ethnographic d e s c r i p t i o n s to be f u l l y t r a n s c r i b e d tape recorded 40 interviews. The interview process as i t has been i n i t i a l l y described has two boundaries or dimensions. One i s i t s focus, that i s , on food behaviors and b e l i e f s of teenagers. The second i s i t s p e r s p e c t i v e , that i s , a goal of the interview i s f o r the researcher to i d e n t i f y teenagers' points of view or s u b j e c t i v e impressions of events or t o p i c s r e l a t e d to t h e i r food patterns. Although the interviews had these boundaries, i t was the i n t e n t i o n of the interviewer to allow the teenager to provide the d i r e c t i o n and the s t r u c t u r e . I t i s an assumption of the method that each p a r t i c i p a n t w i l l have d e f i n i t i o n s or impressions that d i f f e r from those of the researcher. Allowing the teenager to define the p e r t i n e n t thoughts and issues f a c i l i t a t e d t h i s task of d e s c r i b i n g the teenagers' p e r s p e c t i v e s . The r o l e of the researcher in the interview has been described as an a c t i v e one. The researcher, once given a general view, seeks c l a r i f i c a t i o n by r e f l e c t i n g upon i t , c o n t r a s t i n g i t with her own view, or asking the teenager to make comparisons with other views presented. Thus, the interview process i s one in which the researcher p a r t i c i p a t e s . She follows the lead taken by the subject, as well as r e f l e c t i n g upon the subject's comments and her own i n t e r p r e t a t i o n s of those comments. Observations c o n t r i b u t e d to the enrichment of data c o l l e c t e d in two ways. The f i r s t c o n t r i b u t e d to the researcher's understanding of teenagers' "taken f o r granted" knowledge or f u n c t i o n i n g . The second was the researcher's need f o r knowledge of what Schutz (.1970) describes as the o v e r a l l plan. Observations were made in the time spent with the teenager and d i f f e r e n t family or household members p r i o r to, during 41 and a f t e r the interviews took p l a c e . Although on occasion observations were recorded simultaneously, most recordings were made immediately a f t e r the interview. These observations c o n t r i b u t e d awareness of both unspoken routines and those that had been more r e a d i l y described. The study method i s dependent upon both the teenager's a b i l i t y to describe and the researcher's a b i l i t y to achieve understanding of the intended meaning. Some teenagers r e l a t e d d a i l y experiences with greater f a c i l i t y than others. Observations c o n t r i b u t e d to the researcher's a b i l i t y to formulate questions which were more re l e v a n t to each s i t u a t i o n . This might include asking teenagers to rank i n t e r e s t s or place them into the context of t h e i r l a r g e r s o c i a l l i f e . The observation period on occasion provided the opportunity f o r the researcher to compare statements made by the teenager with respect to behaviors and actual behaviors observed. In order to meet the second goal, that of c o n t r i b u t i n g to the researcher's understanding of the o v e r a l l p i c t u r e , the researcher spent time varying from 30 minutes to 3 hours with the teenagers and others present i n the household. On occasion, a t t e n t i o n was focused on p a r t i c u l a r meal behavior. At other times, the researcher p a r t i c i p a t e d i n di s c u s s i o n s of the adolescents' i n t e r e s t s and a c t i v i t i e s at home and school, family p r o j e c t s and understanding how the teenagers spent t h e i r time. Data A n a l y s i s Data a n a l y s i s was based on the p r i n c i p l e s of constant comparative a n a l y s i s . This technique d i r e c t s the researcher to examine data c o l l e c t e d f o r basic patterns and to v a l i d a t e patterns or 42 c o n c e p t u a l i z a t i o n s by seeking c l a r i f i c a t i o n from the study group or i n the research s e t t i n g . As such, the processes of data c o l l e c t i o n and a n a l y s i s are intertwined. In t h i s study, the researcher was guided by the i n i t i a l three purposes, that i s , the d e s c r i p t i o n of teenagers' perceptions of food and the value placed upon food. As each interview was conducted, the data were examined f o r themes and patterns and these d i r e c t e d subsequent i n t e r v i e w i n g and a n a l y s i s . Several emerging themes may be remarked upon. A f i r s t i s r e l a t e d to terminologies. Terms such as "junk food," "good food," "normal food," "healthy food," and "balanced meal" a l l held s p e c i a l meaning f o r each teenager. The e x p l o r a t i o n of these concepts allowed the researcher access to the teenagers' reasoning and i t was by e x p l o r i n g these patterns that new i n t e r p r e t a t i o n s of data emerged. Both i n a nalysing c o l l e c t e d data and during the interviews the researcher explored the nature of apparent i n c o n s i s t e n c i e s and c o n t r a d i c t i o n s i n accounts to make sense of them. Themes which began to develop and c o n t r i b u t e d to f u r t h e r development of the c o n c e p t u a l i z a t i o n of the meaning of food behaviors r e l a t e d to the e x p l o r a t i o n of family patterns f o r transmission of "food ways," the expectations of teenagers i n f a m i l i e s , the r o l e of s i g n i f i c a n t others in the formation of b e l i e f s , and the r e l a t i o n s h i p of knowledge and b e l i e f s to p r a c t i c e . In presenting the data, the goal was to organize the teenagers' accounts in a way that would be c o n s i s t e n t with how the teenagers viewed t h e i r s i t u a t i o n s , as well as in a form that might be useful to health p r o f e s s i o n a l s . Despite t h i s i n t e n t i o n , one must note that the p r e s e n t a t i o n of accounts represents the w r i t e r ' s i n t e r p r e t a t i o n s of the teenagers' accounts. 43 Summary The method used to address the study problem i s derived from the i n t e r p r e t i v e school. Three c h a r a c t e r i s t i c s of the study method make i t p a r t i c u l a r l y appropriate. These are; s e l e c t i o n of p a r t i c i p a n t s , the processes of data c o l l e c t i o n and the r e l a t i o n s h i p between data c o l l e c t i o n and data a n a l y s i s . S e l e c t i o n c r i t e r i a were e s t a b l i s h e d in order to i d e n t i f y a group of teenage subjects with c e r t a i n common c h a r a c t e r i s t i c s . In t h i s study method data a n a l y s i s i s ongoing and may d i r e c t the researcher to include extra p a r t i c i p a n t s exemplifying d i f f e r i n g c h a r a c t e r i s t i c s . Based on data analysed e a r l y i n t h i s study, the researcher chose to r e f i n e the c r i t e r i a and augment the group s i z e . Data were c o l l e c t e d employing both interviews and observations. The interviews had as t h e i r focus the i d e n t i f i c a t i o n of each i n d i v i d u a l ' s way of t h i n k i n g about the t o p i c of food rather than the c a t e g o r i z a t i o n of his or her knowledge about food. In t h i s way, the method d i f f e r s s u b s t a n t i a l l y from others. The interviews were d i r e c t e d by what the adolescent p a r t i c i p a n t s perceived was important to share. This type of data c o l l e c t i o n process allowed the teenagers to i d e n t i f y issues or ideas they perceived to be relevant to t h e i r food behaviors. In t h i s way, they c o n t r i b u t e d the type of information sought by the researcher as defined by the study's purposes. The observations and second interviews allowed the w r i t e r to i d e n t i f y consistency in behaviors and accounts and provided the opportunity to c l a r i f y i n t e r p r e t a t i o n s . In the study method used, data c o l l e c t i o n and a n a l y s i s occurred c o n c u r r e n t l y . The a c t i v i t i e s of l i s t e n i n g , r e f l e c t i n g upon comments, 44 assessing the nature of s i m i l a r i t i e s and d i f f e r e n c e s , i n t e r p r e t i n g accounts, and then r e t u r n i n g to the teenagers f o r f u r t h e r c l a r i f i c a t i o n represent the major elements of the combined processes of data c o l l e c t i o n and a n a l y s i s . T h is aspect of the study method d i f f e r s s u b s t a n t i a l l y from other methods but i t i s t h i s process which i s seen to be most appropriate i n c o l l e c t i n g the type of information necessary to address the purposes of t h i s study. Chapter IV PRESENTATION AND DISCUSSION OF ACCOUNTS This chapter describes the processes involved as the researcher moved through the research process from the f i r s t stage of data c o l l e c t i o n to the l a t t e r stages of c o n c e p t u a l i z a t i o n . The process of data c o l l e c t i o n and a n a l y s i s i n i n t e r p r e t i v e studies such as t h i s one are int e r t w i n e d . The f i r s t t o p i c addressed i s the c o n s t r u c t i o n of accounts. Included i n t h i s d e s c r i p t i o n are examples of how i n i t i a l data, once analysed, c o n t r i b u t e d to f u r t h e r data c o l l e c t i o n . The r e l a t i o n s h i p between t h i s data c o l l e c t i o n process and the i d e n t i f i e d study purposes i s the second t o p i c addressed. The t h i r d t o p i c i s the presentation of accounts. In presenting accounts the researcher attempts to make e x p l i c i t how the teenagers made sense of information presented to them. How the a c t i v i t i e s i n which the adolescents were involved contributed to the development of t h e i r p a r t i c u l a r frameworks or plans of ac t i o n f o r t h e i r food behaviors i s also discussed. As a r e s u l t of d e s c r i b i n g how teenagers were seen to develop t h e i r frameworks, the researcher describes c h a r a c t e r i s t i c s of two d i f f e r e n t patterns of food behaviors. Construction of Accounts I t has been described that the interview process c o n t r i b u t e d to the researcher's understanding of the p a r t i c i p a n t s ' perceptions and 45 46 points of view. This process involved both members of the i n t e r a c t i o n . Preconceptions of nurses and nurses' knowledge of food seemed to lead some subjects to expect that the researcher might in some way be e v a l u a t i n g t h e i r d i e t s or assessing t h e i r knowledge. In the second s e r i e s of interviews the researcher chose to explore questions p e r t a i n i n g to these expectations. While the teenager might have ideas of what to expect of nurses or guests, researchers were another matter. Several teenagers were i n t e r e s t e d to know what kinds of information would be u s e f u l , how the information gathered might be used and i f they had answered the questions thoroughly enough. In e f f e c t , most teenagers and t h e i r f a m i l i e s were eager to be h e l p f u l . As such, one might assume that at times they were attempting to provide what they perceived the researcher to be looking f o r . As the study evolved, the a n a l y s i s of the data d i r e c t e d the researcher to seek c l a r i f i c a t i o n and e v a l u a t i o n of her i n t e r p r e t a t i o n s . I n t e r a c t i o n s between the researcher and p a r t i c i p a n t s then changed somewhat because of the researcher's developing way of looking at the s i t u a t i o n s . As i t has been i n d i c a t e d , the goal of the interview was to allow the teenagers to present t h e i r perceptions without undue i n t e r f e r e n c e . While t h i s was e a s i l y accomplished in most interviews, i t presented d i f f i c u l t i e s i n two types of s i t u a t i o n s . As the researcher summarized or made inferences from the data, these had to be v a l i d a t e d with i n d i v i d u a l teenagers. Spradley (1979) cautions that one must guard against 47 transforming the p a r t i c i p a n t s ' meanings to the language of the researcher. This might occur n a t u r a l l y when the researcher f a i l s to recognize the d i f f e r e n c e s in meaning between the teenagers' use of a term and her own. The interview process, then, included the researcher's developing awareness of her own assumptions or expectations in d i f f e r e n t s i t u a t i o n s . Mutual e x p l o r a t i o n was an important part of the "Construction of Accounts." For example, in the i n i t i a l interviews teenagers often employed the term "junk food" as they described what they or others might eat. I n i t i a l assumptions of the researcher about what t h i s food category might be were r e l a t e d to preconceived notions and how°"junk food" had been defined in n u t r i t i o n s t u d i e s . I t became c l e a r that the teenagers had d i f f e r i n g perceptions of t h i s type of food. As the inteviews progressed, i f the teenager introduced the term, the researcher asked f o r an e l a b o r a t i o n . If the teenager did not introduce the word then the researcher asked the teenager to comment on the "junk food" concept or enquired i f i t might be f a i r to include foods that had already been described as "unhealthy" or "bad" in such a category. A second s i t u a t i o n where i t was d i f f i c u l t not to d i r e c t responses occurred when the teenager had d i f f i c u l t y e x p l a i n i n g what was meant by an expression, or d i f f i c u l t y in i d e n t i f y i n g patterns that were so much a part of the everyday experience they were not considered remarkable to note. The researcher managed t h i s s i t u a t i o n in two ways. One technique was to ask the teenagers to make comparisons between t h e i r behaviors and those of other groups such as same and opposite sex 48 f r i e n d s , s i b l i n g s , or adults or t h e i r behaviors at d i f f e r e n t times and i n d i f f e r e n t s e t t i n g s . Such co n t r a s t s e l i c i t e d perceptions of elements which were important, d i f f e r e n t , or the same. Another technique f o r understanding what the teenagers might have meant was to explore why a p a r t i c u l a r word was used and in what context, an approach recommended by Spradley (1979). The researcher's observations also c o n t r i b u t e d to the u n r a v e l l i n g of meaning in these s i t u a t i o n s . At d i f f e r e n t points i n the interview, the researcher might comment on or seek i n t e r p r e t a t i o n s of the teenager's a f f e c t . This often introduced new dimensions to the d i s c u s s i o n . As well as providing the researcher with the opportunity to observe food behaviors, f e e l i n g s about the t o p i c of food might be voiced or personal concerns introduced. R e l a t i o n s h i p of "Accounts" to the Study's Purposes Accounts were constructed in order to c o n t r i b u t e to an understanding of teenagers' r a t i o n a l e s f o r t h e i r food behaviors. In order to do t h i s , three study purposes were i d e n t i f i e d . Each purpose d i r e c t e d the researcher to seek p a r t i c u l a r kinds of information with respect to teenagers' b e l i e f s and food behaviors. As a r e s u l t of the information gained by inte r v i e w i n g teenagers about t h e i r perceptions of food and by observing them in s e l e c t e d s i t u a t i o n s at sel e c t e d times, the researcher developed an understanding of teenagers' perceptions of t h e i r food behaviors. The accounts were i n t e r p r e t e d and organized to i d e n t i f y processes involved i n d e c i s i o n making and to describe two conceptual c a t e g o r i e s . 49 I n t e r p r e t a t i o n s of Accounts An important observation in t h i s study was that there were i m p l i c i t frameworks guiding the teenagers' reasoning processes concerning t h e i r food behaviors. A f i r s t goal in presenting the accounts i s to describe how the teenagers used t h e i r frameworks in making sense of t h e i r d a i l y s i t u a t i o n s . I t has already been noted that Kleinman (1978a) describes i n d i v i d u a l s or c l i e n t s i n the health care system as having "explanatory models" which help them to understand t h e i r i l l n e s s experience. One might consider the frameworks being described in t h i s study to be comparable to these "explanatory models." Three p a r t i c u l a r a c t i v i t i e s which c o n t r i b u t e d to the development of the frameworks are described.. These included the teenagers' i n t e r p r e t a t i o n s of cues and the use of knowledge, the comparison of themselves with others and the conceptual l i n k s seen between issues of personal concern and food behaviors. There were s i m i l a r i t i e s i n how several teenagers thought about foods or the e f f e c t s of foods on themselves or others. Observations of such s i m i l a r i t i e s and d i f f e r e n c e s l e d to the e l a b o r a t i o n of c a t e g o r i e s . Two c a t e g o r i e s or patterns of t h i n k i n g about food behaviors with d e s c r i p t i o n s of how they were seen to i n f l u e n c e r e s u l t i n g behaviors were formulated. The patterns which have been l a b e l l e d " c o n v i c t i o n s " and "convenience" w i l l be presented and t h e i r i m p l i c a t i o n s discussed. The pr e s e n t a t i o n of accounts w i l l flow from general observations to the development of these s p e c i f i c c a t e g o r i e s . 50 I n t e r p r e t i n g Cues and Applying Knowledge A general and, indeed, universal view held by the teenagers p a r t i c i p a t i n g i n the study was that they a l l viewed t h e i r food behaviors p o s i t i v e l y . They employed terms l i k e "good," "healthy," or "average" to describe t h e i r own s i t u a t i o n s . That i s , although some teenagers might report they had some p a r t i c u l a r l y "good" or p a r t i c u l a r l y "bad" behaviors, t h e i r o v e r a l l assessment was t h e i r food behaviors were "okay." How did the teenagers develop t h i s view? As the interviews progressed the researcher became aware of the v a r i e t y and types of cues and events c i t e d by the teenagers to support the development of t h e i r r a t i o n a l e s f o r a c t i n g . An example of cues to which the adolescents might attend was the response of t h e i r bodies to p a r t i c u l a r foods or a c t i v i t i e s . In essence, the researcher became aware of some of the processes involved as the teenagers came to t h e i r d e f i n i t i o n s of "normal," "healthy" or "good." I t has been suggested that i n d i v i d u a l s respond to or i d e n t i f y cues in making food d e c i s i o n s or looking f o r consequences to food behaviours. The kinds of cues and meanings a t t r i b u t e d to the cues were many and v a r i e d . During an interview, one adolescent both described a p a r t i c u l a r pattern of food behaviors and discussed the reasoning behind i t . The f o l l o w i n g account i s a comment on information that had been shared which apparently suggested that some patterns of eating were more healthy than others and might make one feel b e t t e r . How t h i s teenager responded to behavioral d e s c r i p t i o n s may be noted: T: I t doesn't seem to make any d i f f e r e n c e 51 so why bother with i t anyways? I t ' s j u s t how most people f e e l . L i k e what kind of d i f f e r e n c e s would you look for? Well I mean, the way people describe junk food compared to normal food? Yes Somebody who eats a l o t of junk food would be walking around, you know, eyes a l l j e r k y , and kinda, sagging along, and somebody who eats regular food w i l l be running along. You know, that's the kind of d i f f e r e n c e you'd expect i f you l i s t e n e d to a l o t of people (laughs). Discussion such as t h i s suggested to the w r i t e r that i n t h i s instance the teenager was operating from a framework which questioned the v a l i d i t y and c r e d i b i l i t y of conveyed knowledge. His i n t e r p r e t a t i o n s i n t h i s instance suggested the consequences of eati n g some foods were exaggerated. The i n t a n g i b l e nature of some of the c r i t e r i a measuring hea l t h i n e s s might be considered one source of the problem. Another teenager seems to have examined her own s i t u a t i o n quite c l o s e l y looking f o r cues r e l a t e d to healthy and unhealthy eating patterns: T: ...when I went dancing there was a l o t of ex e r c i s e i n v o l v e d . . . i t was more l i k e t i g h t e n i n g and toning of muscles, not so much in l o s i n g weight ...So when I did dance according to the foods that I ate I co u l d r e a l l y f e e l the d i f f e r e n c e . You know, i f I went out and ate a l o t of p i z z a or, uh, pies and s t u f f l i k e t hat, I could r e a l l y t e l l by the way my body reacted a f t e r I had exercised. R: T: R: T: R: L i k e what? 52 T: Well I'd r e a l l y f e e l , uhm, blah, you know more pep more energy things l i k e t h at. ( I f we ate p i z z a f i r s t ) . . . b y the time we were ready to go home i t was l i k e , ohh, I need some water, I need a glass of coke, I need t h i s . Other times I'd j u s t have a nice qu i e t dinner at home with regular, meat, vegetables, potatoes and by the time we were f i n i s h e d , an apple would s a t i s f y my t h i r s t . This second account, l i k e the f i r s t , suggests that the teenagers examine and present reasons f o r a c t i n g as they do. Both of these accounts, l i k e others, present views of what i s "normal" or " r e g u l a r " food. Both of these teenagers i d e n t i f i e d cues which would be d i f f i c u l t to measure but nonetheless c o n t r i b u t e d to t h e i r developing c o n v i c t i o n s about food. Both of the teenagers looked f o r cues in terms of t h e i r body's response. I t would seem t h e i r i n t e r p r e t a t i o n s were l i m i t e d e i t h e r by the extensiveness of t h e i r knowledge or by accepting l i t e r a l meanings which were presented to them. The process of developing a r a t i o n a l e f o r a c t i n g was an a c t i v e one. The teenagers were seen to be t e s t i n g a c t i o n s , consequences and weighing a l t e r n a t i v e s . Sometimes, as in the f o l l o w i n g instance, the feedback was immediate: T: i f you have to have energy, l i k e i n b a s k e t b a l l , I get cramps i f I don't eat. R: Stomach cramps? T: Yes, I get r e a l l y bad cramps but l i k e that's what happens so I can't skip i t (lunch) 'cause I fe e l r e a l l y bad. The three previous accounts suggest that the teenager's body might act as a moderator f o r information or knowledge he or she might 53 have r e c e i v e d . As such, the boys and g i r l s i n t e r p r e t e d t h e i r bodies' responses to foods within the context of t h e i r knowledge about food. Some teenagers a c t i v e l y sought d i e t a r y information or advice from sources such as t h e i r mother, physical education teacher or l i b r a r y books. T h e i r purposes appeared to be the d e s i r e to gain knowledge of how they might modify food behaviors. Some reasons presented f o r doing t h i s were to increase rates of growth, decrease weight or achieve a higher l e v e l of f i t n e s s . Despite the teenagers' choices to seek information they s t i l l d escribed that they "tested" i t out. As a r e s u l t of such t e s t i n g , some adopted new food behaviors as suggested and others s e l e c t e d some elements of the change which they viewed to be most he l p f u l or e a s i e s t to maintain. In the next account a boy i s commenting on how he a r r i v e d at the d e c i s i o n to i n s t i t u t e changes i n his food behaviors: T: urn, How d i d I get there? Probably because one day I j u s t decided and I asked my mom. S t a r t e d asking my mom, since she's a nurse, what would be good f o r me and how I could get slimmer and what foods you should s t i c k with and she gave me some answers and I kept asking her and asking her. Other teengers s e l e c t e d elements of advice or information viewed to be most h e l p f u l or perhaps e a s i e s t to maintain: T: I t r y r e a l l y hard, I was on a, well not r e a l l y a doctor's d i e t , but t h i s d i e t out of a book. And I d i d n ' t follow i t e x a c t l y or anything, but i t was more or l e s s . I t r i e d to have meats and vegetables and a l o t of salad and water. And a l o t of f r u i t s in between i f I was hungry f o r my between meal snacks. And my energy l e v e l was r e a l l y good and I was f e e l i n g r e a l l y good, about i t . 54 R: uh hum T: And then something would change, you know change my, r o u t i n e , you know l i k e I would go away l i k e f o r a weeks vacation, somewhere ...things l i k e that and then I s t a r t e d e a t i n g d i f f e r e n t l y . The t e s t i n g of knowledge was something a l l of the teenagers d i d . It appeared that on occasion information acted to r e i n f o r c e the maintenance of food behaviors or provided teenagers with a new awareness of reasons behind recommended or family patterns. Some teenagers described that they sought new information, and as such might be described as being more open to i n c l u d i n g information from other sources. The way they discussed t h e i r behaviors included references to these d i f f e r e n t sources of information. Several adolescents had problems with acne; such problems might prompt them to seek help: T: Well eating too much sugar gives me ' z i t s . 1 And so now I'm t r y i n g to cut down on sugar and eat more things that w i l l help. L i k e , the head guy at the gym t o l d me there's l o t s of s t u f f that I can eat instead of sugar, l i k e natural sugar. Oranges and apples and s t u f f i n s t e a d of man made sugar. He says those work j u s t as well except you have to eat more. This l a t t e r account demonstrates an instance where the teenager has expanded information on which d e c i s i o n s to act were based and sought information from an outside source. Rationales f o r a c t i n g include t h i s i n f o r mation. On the other hand, there were adolescents who seemed to place l e s s value on knowledge from other sources and r e l i e d more on t h e i r own 55 measurements of success as they decided they had "good," "normal" or "healthy" food behaviors. Despite d i f f e r e n c e s in the number of information sources s e l e c t e d , a l l set l i m i t s on the nature of the information they would consider. Such l i m i t s might be based e i t h e r on the teenagers' d e c i s i o n s that t h e i r behaviors were "okay," or t h e i r perceptions of the c r e d i b i l i t y of the information source. To t h i s point, the d i s c u s s i o n suggests the p a r t i c i p a n t s in the study had p a r t i c u l a r ways of employing knowledge as they made d e c i s i o n s about t h e i r food behaviors. They had varying amounts of knowledge and some were seen to be seeking out or using t h i s knowledge more than others. In d i s c u s s i n g the Construction of Accounts i t was suggested that one type of food which held d i f f e r i n g meanings f o r each p a r t i c i p a n t i n the study was "junk food." An examination of some of the teengers' d e f i n i t i o n s of t h i s concept supports the view that the teenagers developed t h e i r notions not only from information from others, but also from t h e i r own experiences: T: I t ' s not good f o r you, i t hasn't got the p r o t e i n and a l l t h a t . That's c a l l e d junk food, that's why i t t a s t e s good. ...No junk food doesn't r e a l l y hurt me 'cause I guess I eat what I'm supposed to a l s o . I t gives me the c a l o r i e s . If I d i d n ' t eat junk food with a l l those c a l o r i e s , I'd j u s t be a toothpick, worse than I am r i g h t now. The idea that teenagers s e l e c t e d out knowledge which was useful or a p p l i c a b l e to them i s portrayed in the l a t t e r account. Not only did t h i s adolescent have a d e t a i l e d view of "junk food" but the account also 56 suggested why, despite information to the contrary, the adolescent f e l t the food was a l r i g h t to eat. I t becomes c l e a r from t h e i r d e f i n i t i o n s t h at they a l l have some ideas about foods which r e a l l y are not healthy and should be avoided. An account which presents foods i d e n t i f i e d as "okay" or "good" and "bad" f o l l o w s . The teenager was prepared to l i m i t intake of sugar, but considered i t l u d i c r o u s that popcorn might be considered "junk food" by others. One argument presented i s based on absence of media support. The strength of the p o s i t i o n taken i s supported by suggesting the u n l i k e l y but grave consequences of cancer or death: T: Well popcorn's never done anything to me, so. I've never heard...you see headlines saying sugar i s b l a , b l a , b l a , but then you don't see popcorn k i l l s you or popcorn causes cancer in the head or anything l i k e t h at, so.(laughs) As one examines accounts of the teenagers' reasoning p a r t i c u l a r l y when viewed out of context, one might question i f indeed any notions or actions are based on knowledge or l o g i c . One would think i f a l l i s l o g i c a l that everyone would agree on what are "good" or "bad" foods or food behaviors. Instead, i t appears that when i n d i v i d u a l s are faced with ambiguous cues or are required to overgeneralize knowledge, plans of ac t i o n are developed which decrease ambiguity and d i r e c t d a i l y decision-making. Two sources which c o n t r i b u t e to the development of reasoning have been i d e n t i f i e d . They are the i n t e r p r e t a t i o n of cues and the use of knowledge. Other a c t i v i t i e s were seen to co n t r i b u t e to the development of the teenagers' r a t i o n a l e s f o r a c t i n g . These w i l l be addressed i n the se c t i o n s which f o l l o w . 57 The Process of Comparing Oneself to Others The second set of a c t i v i t i e s which provided teenagers with r a t i o n a l e s f o r concluding t h e i r food behaviors were "good" r e l a t e s to t h e i r comparison of themselves with others. As the adolescents defended t h e i r stance they described that they compared t h e i r food behaviors with those of others such as family members, a d u l t s , peers and perhaps a t h l e t e s . As they compared themselves, they might choose a c h a r a c t e r i s t i c of the other they would l i k e to emulate or avoid, and hence commented on the d i e t : T: Well they (food habits) aren't that good, they're j u s t average. But I don't think they're any worse than most other people's. Well, even my own parents. L i k e I don't eat that much d i f f e r e n t . I have the same lunches p r a c t i c a l l y , I have the same dinners, the same br e a k f a s t s . One can see from t h i s account that c h a r a c t e r i s t i c s are not always c l e a r l y r e l a t e d to consequences of d i e t . In t h i s instance, the f a c t the behaviors are as good as those of the adults provides support f o r the teenager's argument that i t i s inappropriate f o r adults to c r i t i c i z e teenagers' food behaviors. In other instances, d i f f e r e n c e s between the teenager's own response to foods and the responses of others c o n t r i b u t e d to the development of notions concerning concepts such as varying metabolic r a t e s , or p r e d i s p o s i t i o n to c e r t a i n c h a r a c t e r i s t i c s such as "fatness" or "thinness," through h e r e d i t y . While some teenagers might accept a 58 p r e d i s p o s i t i o n to being t a l l or f a t , they also compared t h e i r behaviors to those of others in the hopes of achieving in a fashion s i m i l a r to that of t h e i r r o l e model: T: When you become a teenager, you kind of want to be as t a l l as everybody or as strong as everybody and you t r y and f i g u r e out what would be the best foods that you could eat to get you to be l i k e the person you'd want to be. Let's see, the guy that won the decatholon, in the United S t a t e s , in the Olympics, Bruce Jenner. Well, he had his name on Weetabix, Wheaties, you know the s t u f f , and everybody j u s t went out and bought Wheaties, 'cause they thought oh wow, l e t ' s eat cereal and be j u s t l i k e Bruce Jenner. Although a l l the teenagers in the study possessed information and compared themselves to others, i t would seem that they did so f o r varying purposes and from d i f f e r i n g p e r s p e c t i v e s . This teenager admired the a t h e l e t e f o r his success in s p o r t s . I t i s also evident in the account that the boy was a c t i v e l y t r y i n g to f i g u r e out what would make him at l e a s t as t a l l or strong as others. Food presents i t s e l f as something which can c o n t r i b u t e to the d e s i r e d goals. Another dimension or boundary in the information s i f t i n g process p e r t a i n s to what the w r i t e r has l a b e l l e d issues of personal concern. Information s i f t i n g p e r t a i n s to the teenagers' c o n s i d e r a t i o n of information in l i g h t of such things as b o d i l y responses or habits of themselves and others. Conceptual Links between Behaviors and Issues of Personal Concern Not only did the teenagers seek out or l i m i t the types of knowledge they perceived to be useful and base on them some assessments 59 of t h e i r own behaviors or the behaviors of others, but they also defined areas of focus depending upon issues seen to be of personal importance. Issues of personal concern helped the teenagers to define what food behaviors were most important to maintain or modify. A l l the teenagers c i t e d at l e a s t one, and most teenagers c i t e d more than one, of three personal issues which they considered to in f l u e n c e t h e i r food d e c i s i o n s . These were body image, f r i e n d s and s p o r t s . While one may not assume that these were the only issues of concern to the teenagers i n the study, they d id c o n t r i b u t e i n important ways to the p a r t i c u l a r food behaviors of the teenagers s t u d i e d . For example, body image concerns were almost universal although they v a r i e d . Most teenagers wished to lose weight or maintain t h e i r weight. Some teenagers wished to b u i l d c e r t a i n muscles and others had concerns about t h e i r s k i n , teeth or height. Why these issues were of concern was quite unrelated to food. Their importance to the teenagers, however, was c l e a r . They perceived that how one looked i n f l u e n c e d one's r e l a t i o n s h i p s with f r i e n d s and one's f e e l i n g s about o n e s e l f . Food or p a r t i c u l a r food behaviors were seen as instrumental in r e s o l v i n g these i s s u e s . As teenagers described how they made d e c i s i o n s about what they ate they employed varying c r i t e r i a . The p a r t i c i p a n t s described t r i a l periods of t e s t i n g p a r t i c u l a r foods, e l i m i n a t i n g foods, or adopting meal patterns and assessing the e f f e c t s i n terms of the des i r e d outcome. When the outcome was not e a s i l y or r e a d i l y achieved, the teenagers sometimes described that they weren't convinced the p a r t i c u l a r food was c o n t r i b u t i n g to the problem or that they had sought 60 a d d i t i o n a l s o l u t i o n s . Such s o l u t i o n s might include e x e r c i s i n g , or the a d d i t i o n of sp e c i a l foods or vitamins to the d i e t . Teenagers had more or l e s s comprehensive approaches to s o l v i n g problems or addressing issues of concern. Some focussed on the a d d i t i o n or e l i m i n a t i o n of a p a r t i c u l a r food, while others emphasized a c t i v i t y versus food, and s t i l l others strove more co n s c i o u s l y to achieve some type of o v e r a l l balance. As such, the observed behaviors and expressed r a t i o n a l e s ranged i n complexity. A second personal issue of concern to teenagers i n the group s e l e c t e d was the need to have f r i e n d s . To have f r i e n d s was most f r e q u e n t l y c i t e d as the most important or most valued thing f o r the boys and g i r l s i n the study. The idea that not having f r i e n d s r e f l e c t e d on the i n d i v i d u a l in a negative way was introduced as w e l l . The d e s i r e to have f r i e n d s was seen to i n f l u e n c e the teenagers' food behaviors and perceptions of food. As they contemplated what would c o n t r i b u t e to the development of f r i e n d s h i p s , the adolescents considered f a c t o r s such as body s i z e or weight, a t h l e t i c a b i l i t y , academic a b i l i t y , looks, and common i n t e r e s t s . One may note that while f r i e n d s h i p s were most valued, food behaviors were only one aspect of what teenagers described they would modify, change or think about to ensure or maintain them. The f o l l o w i n g accounts describe some of the ways teenagers conceptualized the r e l a t i o n s h i p between t h e i r food behaviors and f r i e n d s h i p s : T: Everybody wants to be popular. So I guess one way to be popular, or to be l i k e d i s to look good. And so I guess that's one of the reasons that I changed, so I could look b e t t e r . 61 R: Do you think that a f f e c t s the way people r e l a t e to him, that he's so big? T: Yes, he, no one wants to be seen with him! R: Why i s that? T: 'Cause he's so grotesque, kind of bad f o r your image too 'cause he's such a j e r k . L i k e i f he was nice i t would be d i f f e r e n t but, he's not. Some teenagers i n d i c a t e d t h e i r food behaviors were modified to achieve goals with respect to body image changes, which they perceived would c o n t r i b u t e to t h e i r a t t r a c t i v e n e s s and hence f r i e n d s h i p s . Other teenagers thought about food or food a c t i v i t i e s w ithin the context of f r i e n d s h i p a c t i v i t i e s . These teenagers i n d i c a t e d they consumed d i f f e r e n t foods when at home or when with f r i e n d s . For some adolescents "going to the s t o r e " was an outing with f r i e n d s , and meal times at school f o r h a l f of the teenagers provided o p p o r t u n i t i e s to s o c i a l i z e and v i s i t with f r i e n d s . Doing well i n sports or a p a r t i c u l a r sport was a t h i r d issue seen to be important f o r many of the teenagers studied. Again, the value of p a r t i c i p a t i n g i n a p a r t i c u l a r sport was independent of food per se. Some teenagers enjoyed the competition, the development of s k i l l s , the physi c a l e x e r t i o n and the idea that they might become a s t a r . As with the two personal issues of body image and f r i e n d s , food b e l i e f s and behaviors of teenagers were conceptualized and tested according to t h e i r notions about what would best support or c o n t r i b u t e to p a r t i c i p a t i o n in a sp o r t . 62 There are many instances which demonstrate how the teenagers might have a r r i v e d at, or reasoned out, what impact p a r t i c u l a r food behaviors might have on t h e i r performance. The c r i t e r i a f o r decision-making employed by the teenagers r e l i e d predominantly on "how they f e l t " . They a t t r i b u t e d causes of " f a t i g u e , " "cramps" or "energy l e v e l " to various foods or the lack thereof: T: Well, I guess since I'm in sports and s t u f f , I don't eat a l o t , l i k e maybe before a game or something I don't l i k e to go out and eat a l o t . 'Cause i t ' s about the only thing that concerns me. I j u s t l i k e to get a good meal, a balanced meal, or something before a game. I j u s t don't l i k e to carry a l o t of weight around when I play. The e f f e c t t h i s personal issue had on the p a r t i c i p a n t ' s described food behaviors was not constant. That i s , the teenager also stated that what was eaten was not of p a r t i c u l a r concern except in the instances where i t might i n t e r f e r e with p a r t i c i p a t i o n in spo r t s . As such, while personal issues might c o n t r i b u t e to the development of notions about what was "good" to eat, t h i s notion f o r some could be seen to change. An important observation i n both the previous and the f o l l o w i n g account i s the i d e n t i f i c a t i o n of what i s r e a l l y important to the teenager. One element seen to be involved in the decision-making process was the weighing of r i s k s . When i t was r e a l l y important to do w e l l , despite perceived lacks of p o s i t i v e e f f e c t , the teenager c a r r i e d out a plan that would not harm, but might not help: T: Like i t doesn't have any e f f e c t on me no matter what I eat. R: Okay. 63 T: I can eat steak or something l i k e t h at, i t ' s supposed to be f u l l of i r o n or whatever, i t doesn't make any d i f f e r e n c e to me. I j u s t don't even seem to notice i t so, I f i n d i t hard to b e l i e v e that, you know what most people would...The only t h i n g I've ever thought about i s having steaks before the game. You know the o l d thing that you have to have a steak before a game. T h i s account again demonstrates that some of the teenagers question the knowledge statements given to them. In t h i s instance, the teenager appeared to be expecting a change i n f e e l i n g with the intake of i r o n . Another element present in t h i s account i s the idea that there are patterns or t r a d i t i o n s that c o n t r i b u t e to d e c i s i o n s in d i f f e r e n t s i t u a t i o n s . In t h i s instance i t was "the o l d thin g , " at other times i t was described to be "we always do i t t h i s way," or "we always, eat f i s h on Fr i d a y , . . . I think i t has something to do with the r e l i g i o n or something." As with the r e s o l u t i o n of concerns r e l a t e d to body image, the complexity of approaches employed by the boys and g i r l s as they assessed the usefulness or e f f e c t i v e n e s s of d i e t a r y change to r e s o l v e concerns about t h e i r a t h l e t i c a b i l i t y v a r i e d . The s i g n i f i c a n c e of the three i d e n t i f i e d personal issues to the d i s c u s s i o n of how the teenagers i n the study employed t h e i r frameworks in assessing food behaviors, l i e s in how personal issues guided the teenagers' d e c i s i o n s about what information was re l e v a n t or the p r i o r i t i z a t i o n of i t s relevance. In a sense, then, the personal issues were seen by the w r i t e r to provide the teenagers with a context f o r i n t e r p r e t i n g knowledge, cues and behaviors of themselves and others. 64 To t h i s point in presenting the accounts the w r i t e r has argued t h a t each teenger has notions concerning food. The notions have developed from i n t e r p r e t a t i o n s of experiences and knowledge and c o n t r i b u t e to the development of what has been c a l l e d a framework. This framework, in t u r n , guides d e c i s i o n making about food and hence i n f l u e n c e s food behaviors. Despite the i n d i v i d u a l ways information was assessed and the v a r i a t i o n in concerns or p r a c t i c e s , there were s i m i l a r i t i e s i n teenagers' e v a l u a t i o n s of t h e i r food behaviors and in t h e i r patterns of assessing the usefulness of information. Having made the processes of developing and employing these described frameworks more e x p l i c i t , i t w i l l now be argued that, depending on the teenagers' r a t i o n a l e s , two p a r t i c u l a r food behavior patterns can be described. These have been l a b e l l e d " c o n v i c t i o n s " and "convenience." Food Patterns Associated With Convictions Teenagers whose food patterns were c o n s i s t e n t with what the w r i t e r has defined as the " c o n v i c t i o n s " category were seen to have developed a r a t i o n a l e f o r a c t i n g which was a r t i c u l a t e d in terms of b e l i e f s and s p e c i f i c a c t i o n s , and which was applied across most s i t u a t i o n s . As these teenagers discussed t h e i r r a t i o n a l e s they tended to employ terms l i k e "We should do i t t h i s way," "I b e l i e v e doing x has the e f f e c t y" and "I b e l i e v e i t i s good f o r x." The teenagers who thought t h i s way seemed to be more l i k e l y to plan t h e i r meals in advance. Or, i f i n a restaurant or c a f e t e r i a , they t r i e d to make choices that were 65 c o n s i s t e n t with t h e i r b e l i e f s . There seemed to be a c e r t a i n p r e d i c t a b i l i t y i n the food behaviors of t h i s group. The described b e l i e f s seemed to be based on or at l e a s t were c o n s i s t e n t with knowledge, but as well might have emotional, c u l t u r a l or p a r t i a l knowledge o r i g i n s . Teenagers described c e r t a i n b e l i e f s as having evolved from taking a stand on a moral issue or being part of t h e i r family or c u l t u r a l p a t t e r n . As was stated e a r l i e r , the process of c o n s i d e r i n g information and making d e c i s i o n s about a c t i o n s was an a c t i v e one. These teenagers' conclusions appeared to be that c e r t a i n foods and food patterns are "good f o r you" or p r e f e r r e d over others. The f o l l o w i n g account describes how one teenager reasoned out the d i f f e r e n c e between "junky" foods and the "good" foods that were seen to be b e t t e r to eat: T: ...hamburgers, i t depends what you r e a l l y mix with hamburgers, whether they're junky or bad. I f you eat hamburgers and potato chips and a pop or something, that would be junky...But i f you had a glass of milk, a hamburger, a couple of c h i p s , and c a r r o t s , and l e t t u c e i n your hamburger and s t u f f t h at would make i t a b i t b e t t e r . An important element to behaviors of teenagers whose food d e c i s i o n were guided by " c o n v i c t i o n s " was the element of consistency. One reason c i t e d by a teenager was dependent upon the strength of one's b e l i e f s : R: What do you suppose i s the d i f f e r e n c e between s t i c k i n g with i t or not s t i c k i n g with i t ? T: Well i t depends how s t r o n g l y you f e e l about i t , i f you do i t j u s t f o r the sake of doing i t or i f you do i t because you b e l i e v e in i t . 66 What comes across in the l a t t e r two accounts, as in others, i s t h a t there i s a value or merit attached to behaving i n a c e r t a i n way. In a d d i t i o n , most of these teenagers took actions to ensure "good" meals by taking t h e i r own lunches. I t was reported e a r l i e r that the teenagers made d e c i s i o n s about the relevancy of information and were seen to compare themselves with others. Some of the teenagers i t would seem, were committed to seeking out new knowledge and were w i l l i n g to change t h e i r behaviors a c c o r d i n g l y . T h e i r r e s u l t i n g behaviors were c o n s i s t e n t with t h e i r b e l i e f s . One teenager commented on how a teacher modified an approach to be c o n s i s t e n t with described b e l i e f s : T: Like l a s t week we made c h i l i , we work in partners and we j u s t made ours without meat. (We) made the meat in a separate f r y i n g pan and my partner j u s t put the hamburger i n . We never thought of doing that at home. While i n t h i s instance the teenager incorporated the information and considered using the information in l a t e r p r a c t i c e , other teenagers had d i f f e r e n t a t t i t u d e s . Some seemed to present the view that t h e i r knowledge and behaviors were adequate and the maintenance rather than m o d i f i c a t i o n of them was what was important. This appeared to be the case i n two c l a s s room i n s t a n c e s . One was a s i t u a t i o n where the p a r t i c i p a n t f e l t that a teacher u n j u s t i f i a b l y assumed that the students were l a c k i n g knowledge and s k i l l s . The teenager's impression was that the students would be prepared to p a r t i c i p a t e i f they f e l t they were going to gain knowledge they perceived to be r e l e v a n t . In a second instance the teenager was w i l l i n g to "make i t " but 6 7 not "eat i t . " Lessons were not perceived valuable because the foods prepared were outside of the adolescent's "normal" d i e t . In one instance the p r e f e r r e d d i e t would not have been assessed as adequate. In several of the instances, the emotional element to t h e i r arguments provided reasons f o r c h a l l e n g i n g knowledge. One sensed from several of the accounts that there was commitment to the o r i g i n of the b e l i e f s and the m o d i f i c a t i o n of such b e l i e f s might be a form of b e t r a y a l . Examples of t h i s i n c l u d e teenagers' accounts which i n d i c a t e d t h e i r behaviors were part of a family pattern and they i d e n t i f i e d with t h e i r f a m i l y . Those adolescents whose food behavior pattern might correspond with t h e i r " c o n v i c t i o n s " are seen to have p a r t i c u l a r sets of food b e l i e f s t h a t d i r e c t them to ensure t h e i r food behaviors are c o n s i s t e n t across s i t u a t i o n s . These b e l i e f s also i n f l u e n c e d t h e i r use of information. The second pattern i n t e r p r e t e d from the teengers' accounts and observations of t h e i r behaviors i s r e l a t e d to issues of "convenience." Food Patterns Associated With Convenience The teenagers who have been included in t h i s category i n t e r p r e t e d information given to them and responded to cues, but were seen to come to the d e c i s i o n that i t was not p a r t i c u l a r l y important to ensure that c e r t a i n foods were eaten d a i l y . I t would seem the greatest tendency was to make d e c i s i o n s based on a v a i l a b i l i t y . The teenagers reported they didn't think much about what they ate or tended to choose foods based on t h e i r preferences. T h e i r experiences suggested to them that there was u s u a l l y no harm in eating whatever was there. I t would appear some 68 adolescents had behaviors which were more s i t u a t i o n a l l y dependent. The f o l l o w i n g accounts suggest that often the adolescents were concerned about things other than food per se. T: If you're hungry, you j u s t grab something, whatever there i s to eat in the c a f ' . Most of the times i t ' s u s u a l l y what you have enough money f o r . T: Well, . . . i t depends on when you wake up. Depends how you f e e l . I f you f e e l l i k e you want to eat junk food or, i f you want to eat somethin that's good f o r you, healthy f o r you....It depends what you do with your f r i e n d s . I f your f r i e n d s say, 'Let's go f o r a hamburger.' You can't r e a l l y t e l l what you w i l l do. L i k e say today I'm going to do t h i s and tomorrow I'm going to eat that. More than having decided p a r t i c u l a r foods were important or p r e f e r r e d , these teenagers reported that the consumption of p r e f e r r e d foods was l i k e l y to be l i m i t e d by issues r e l a t e d to a v a i l a b i l i t y . Such f a c t o r s might include what was a v a i l a b l e at home or school, what they could a f f o r d or what they had time f o r . As the teenagers supported t h e i r view that t h e i r food behaviors were "normal," "healthy" or "good," they p a r t i c i p a t e d i n s i m i l a r processes as those who were guided by c o n v i c t i o n s . They attended to cues examined t h e i r own bodies' responses to foods, queried the a p p l i c a b i l i t y o f knowledge to t h e i r own s i t u a t i o n and compared themselves to others. The conclusions or thoughts of those concerned about "convenience" were often quite d i f f e r e n t from those who were " c o n v i c t i o n s " o r i e n t e d . This might i n f l u e n c e how ready they were to incorporate new information or 69 change t h e i r behaviors. Those who were concerned about issues of "convenience" have been described as having behaviors which were s i t u a t i o n a l l y dependent or changing. Another reason f o r changing behavior was sometimes a t t r i b u t e d to gaining new knowledge. In t h i s sense, new information provided a new s i t u a t i o n . Some teenagers were qu i t e i n t e r e s t e d in adopting new behaviors or t r y i n g new "programmes." However, some of them i n d i c a t e d changes might only be maintained u n t i l new information provided another a l t e r n a t i v e . I t might seem they were not committed to, or perhaps convinced of, the idea that one pattern of a c t i n g i s p r e f e r a b l e to another and might be s u s c e p t i b l e to fads. As opposed to those who were guided by " c o n v i c t i o n s , " these teenagers were l e s s l i k e l y to think of foods in e v a l u a t i v e terms. "I don't l i k e to think of i t as junk food, j u s t food." As they discussed t h e i r preferences or challenged recommendations, they described things in terms of what was " e a s i e r " or "more economical." They supported t h e i r arguments by suggesting there was not r e a l l y any documentable d i f f e r e n c e in how they f e l t or how well they performed. I t i s i n t e r e s t i n g to note t h a t while those who wished to a c t in accordance with " c o n v i c t i o n s " evaluated courses such as home economics i n terms of the type o f knowledge that was shared, those who were "convenience" o r i e n t e d assessed courses more in terms of i n c r e a s i n g personal autonomy. As a r e s u l t of examining accounts and explo r i n g with the adolescents the e v o l u t i o n of t h e i r reasoning, the researcher was made aware that, although they behaved in ways that were very i n d i v i d u a l , t h e i r own pattern was c o n s i s t e n t with t h e i r developed b e l i e f s and 70 notions. Such behaviors when observed or measured outside of the i n d i v i d u a l ' s framework might appear to be i n c o n s i s t e n t , i l l o g i c a l or i r r a t i o n a l . When viewed in the context of his or her explanations or accounts one has a b e t t e r understanding of the i n d i v i d u a l ' s view of the s i t u a t i o n . D i s c ussion of Accounts Having presented the accounts, the w r i t e r w i l l discuss how t h i s study adds to an understanding of teenagers' food behaviors. L i t e r a t u r e reviewed in Chapter II i d e n t i f i e d the merits of studying n u t r i t i o n from an ethnographic perspective and discussed how information from such s t u d i e s might be employed to increase the e f f e c t i v e n e s s of n u t r i t i o n i n t e r v e n t i o n programmes. Reviews of studies of adolescent n u t r i t i o n i d e n t i f i e d a decided lack of information of adolescents' p e r s p e c t i v e s of n u t r i t i o n . This was the general problem i d e n t i f i e d f o r t h i s study. The d i s c u s s i o n w i l l review accounts in r e l a t i o n to c i t e d l i t e r a t u r e and w i l l describe how the study problem has been addressed. I n i t i a t i o n and Maintenance of Change in Health Behaviors I t was assumed food behaviors are a category of health behaviors. For t h i s reason l i t e r a t u r e was reviewed to i d e n t i f y issues r e l a t e d to the i n i t i a t i o n and maintenance of change in health and l i f e s t y l e behaviors. Findings of these studies i n d i c a t e i n d i v i d u a l s ' perceptions of the value of a treatment regimen, how they perceive i t to i n f l u e n c e other aspects of t h e i r l i f e s t y l e s , how i n d i v i d u a l s define t h e i r s i t u a t i o n , 71 and t h e i r commitment to the change a l l i n f l u e n c e the l i k e l i h o o d they w i l l comply with p r e s c r i b e d regimens. This l i t e r a t u r e , as was suggested e a r l i e r , a l s o i n d i c a t e s that modifying or maintaining change i n health or l i f e s t y l e behaviors requires the use of approaches d i f f e r e n t from those successful i n achieving adherence to pr e s c r i b e d i l l n e s s o r i e n t e d i n t e r v e n t i o n s . Some reasons f o r t h i s are that the pr e s c r i b e d regimens can be more complex and can a f f e c t more aspects of the i n d i v i d u a l ' s l i f e . Furthermore, negative consequences of non-compliance with health or l i f e s t y l e regimens, i f perceived at a l l , may be l e s s meaningful to i n d i v i d u a l s than consequences of non-compliance with i l l n e s s regimens. These f i n d i n g s merit d i s c u s s i o n in l i g h t of the observations made in the present study. In t h i s study teenagers made d e c i s i o n s about the v a l i d i t y of recommended eating p r a c t i c e s . They assessed the e f f e c t s of consuming c e r t a i n foods through b o d i l y changes and how they f e l t . T h i s p r a c t i c e s e n s i t i z e s one to the perceived ambiguity of messages which suggest e a t i n g w i l l make you " f e e l b e t t e r " or make you " h e a l t h i e r . " Several teenagers concluded non-compliance with recommended eating p r a c t i c e s would have negative consequences. This study demonstrated that adolescents' perceptions i n f l u e n c e d food behaviors. The teenagers' d e f i n i t i o n s of what was important such as issues r e l a t e d to " c o n v i c t i o n s " or "convenience" c o n t r i b u t e d to the adoption of d i f f e r e n t food behavior p a t t e r n s . Consuming c e r t a i n foods was perceived as c o n t r i b u t i n g to the r e s o l u t i o n of issues of personal concern. These issues also i n f l u e n c e d the food behaviors adopted. Three issues of personal concern were body . 72 image, to succeed in sports or to have f r i e n d s . Reasons f o r non-compliance with a recommended food pattern could be r e l a t e d to teenagers' perceptions that the recommended patterns were not r e l e v a n t to t h e i r own s i t u a t i o n or recommendations based on concepts such as " y o u ' l l f e e l b e t t e r " may be too broadly i n t e r p r e t e d . I t has already been mentioned that food and food behaviors were perceived by the teenagers as instrumental i n the r e s o l u t i o n of three personal i s s u e s . On f i r s t examination the meaning of these observations i s not at a l l c l e a r . The l i t e r a t u r e does not present such problems or concerns as r a t i o n a l e s f o r encouraging the m o d i f i c a t i o n of food behaviors. However, re-examination of the works of Becker and Maiman (1975) and T a y l o r (1979) provide one basis f o r i n t e r p r e t a t i o n . The authors describe an i n d i v i d u a l ' s perception of the e f f e c t s of e i t h e r a p r e s c r i b e d regimen or i l l n e s s on other a c t i v i t i e s as f a c t o r s i n f l u e n c i n g compliance. A c o n t r i b u t i o n of t h i s present study i d e n t i f i e s some f a c t o r s the adolescents would consider in making d e c i s i o n s to modify t h e i r food behaviors, what they perceive to be important in r e l a t i o n to foods and how such perceptions can i n f l u e n c e subsequent food behaviors. As the w r i t e r described the patterns of behavior associated with c a t e g o r i e s of " c o n v i c t i o n " and "convenience," major behavioral d i f f e r e n c e s were noted. The behavior patterns associated with " c o n v i c t i o n s " were c h a r a c t e r i z e d by consistency across s i t u a t i o n s and the adolescents described s p e c i f i c b e l i e f s which guided t h e i r food d e c i s i o n making. Food behavior patterns were described as something "valued" or "important." Commitment was also i d e n t i f i e d by both Becker, 73 Maiman, K i r s c h t , Haefner, & Drachman (1979) and Taylor (1979) as a f a c t o r which p r e d i c t s sustained behavioral change or long term compliance. Perhaps teenagers whose food patterns were c o n s i s t e n t with t h e i r " c o n v i c t i o n s " could be described as committed to t h e i r p a r t i c u l a r food behaviors. Several comments may be made as one examines the w r i t e r ' s i n t e r p r e t a t i o n of accounts in the l i g h t of the Health B e l i e f Model. Rosenstock (1966) described four sources of i n f l u e n c e on an i n d i v i d u a l ' s health behaviors; one of these was the desire to maintain h e a l t h . A c o - r e q u i s i t e to the Model's usefulness as a health behavior p r e d i c t o r was that the concept of health be meaningful or s a l i e n t to the i n d i v i d u a l . This study did not examine health b e l i e f s in general, but i t did assume food behaviors to be a category of health behaviors. While some of the study p a r t i c i p a n t s would have been described as valuing h e a l t h , i t seemed that most teenagers did not view t h e i r food behaviors in r e l a t i o n to h e a l t h . They considered food in r e l a t i o n to more general i s s u e s , f o r example, what was important to the teenagers was how t h e i r perceptions o f how food a f f e c t e d t h e i r d a i l y f u n c t i o n i n g or t h e i r i n t e r a c t i o n s with peers. As such, d e s c r i p t i o n s i n t h i s study would be c o n s i s t e n t with those of Radius et a l . (1980) who concluded that many teenagers do not value health. The conceptual c a t e g o r i e s and processes described in the present study provide an a l t e r n a t i v e way of looking at teenagers' food behaviors which i s not n e c e s s a r i l y dependent upon val u i n g h e a l t h . In d e s c r i b i n g health behaviors using the Health B e l i e f Model, Rosenstock (1966) i n d i c a t e d that i n d i v i d u a l s would carry out preventive 74 actions i f they perceived the r i s k s of i l l n e s s to be greater than personal inconvenience. That i s , i n d i v i d u a l s would consider the l i k e l i h o o d they would develop an i l l n e s s , what they would have to do to decrease t h e i r chance of c o n t r a c t i n g i t , and the degree of behavioral change such preventive a c t i o n s would r e q u i r e . The present f i n d i n g s suggest convenience i s not the only c o n s i d e r a t i o n . The c a t e g o r i e s , as they have been described, suggest that f a c t o r s r e l a t e d to convenience such as a v a i l a b i l i t y or cost are p r e d i c t o r s of food behaviors only f o r some i n d i v i d u a l s . Those whose food behaviors are c o n s i s t e n t with the d e s c r i p t i o n s of the "convenience" pattern might be the i n d i v i d u a l s whom Rosenstock (1966) describes as weighing r i s k s of i l l n e s s and basing d e c i s i o n s on what i s e a s i e r or more convenient. Those i n d i v i d u a l s whose food d e c i s i o n s are guided by t h e i r c o n v i c t i o n s might be prepared to work around inconveniences i n order to ensure compliance with the p r e s c r i b e d regimen. Studies of N u t r i t i o n Food Patterns as an Element of Culture The problem of encouraging i n d i v i d u a l s to modify t h e i r eating patterns to support health or to accommodate the a v a i l a b i l i t y of resources has been addressed d i f f e r e n t l y over time. Research which has been instrumental in the design of n u t r i t i o n i n t e r v e n t i o n programmes i s that which has increased health care workers' understanding of the c u l t u r a l group's perspective of i t s food behaviors. Studies which have examined food patterns as an element of 75 c u l t u r e c o n t r i b u t e two types of information. They describe food b e l i e f s held by the groups studied and provide i n s i g h t i n t o how b e l i e f s were developed. Researchers who studied food behaviors from the c u l t u r a l p e r s p e c t i v e report that i n d i v i d u a l s have a need to communicate both thoughts and f e e l i n g s about food. They also suggest that food i s more c l e a r l y understood when examined in the context of other l i f e events. While l i f e events may account f o r v a r i a t i o n s in food behaviors there i s a group i n f l u e n c e which c o n t r i b u t e s to s i m i l a r i t i e s i n food behaviors. D i f f e r e n t groups of people are described as c o n c e p t u a l i z i n g or developing t h e i r notions d i f f e r e n t l y . C u s s l e r and De Give (1952) i d e n t i f i e d v a r i a t i o n s between community members and pr o f e s s i o n a l groups or between community members of d i f f e r i n g s o c i a l standing. They label the food patterns a s s o c i a t e d with groups as "food ways." Cussler and De Give (1952) al s o describe how i n d i v i d u a l s are involved i n the transmission of "food ways." The authors described the meaning of food within the c u l t u r e and explained how personal and community values, i n d i v i d u a l food b e l i e f s and family and community members cont r i b u t e d to the maintenance and change of food behaviors. T h i s study of teenagers perceptions of t h e i r food behaviors demonstrated i t was important f o r adolescents to communicate t h e i r ideas and concerns about foods. I t al s o supports the view that food behaviors are more c l e a r l y understood when examined in the context of other l i f e events. As has been mentioned e a r l i e r in t h i s d i s c u s s i o n , understanding the development of r a t i o n a l e s f o r act i n g requires one to explore food i n 76 r e l a t i o n to family and l i f e s t y l e . The p a r t i c i p a n t s ' accounts only began to make sense to the w r i t e r when she broadened her d e f i n i t i o n s of the d e s i r a b i l i t y of c e r t a i n food behaviors and the negative consequences of others. Instead, an e f f o r t was made to understand the boys' and g i r l s ' ideas of these same i s s u e s . I t has been proposed that d i f f e r e n t groups of people conceptualize or develop t h e i r notions d i f f e r e n t l y . The researcher discovered that adolescents perceive t h e i r behaviors to be s i m i l a r to those of some groups and d i f f e r e n t from those of others. Most often the perceived or desi r e d s i m i l a r i t i e s were with groups with whom the teenager i d e n t i f i e d . Such groups might be family or f r i e n d s . The w r i t e r ' s study i d e n t i f i e d the i n d i v i d u a l s teenagers perceived as i n f l u e n c i n g the development of t h e i r food b e l i e f s . In t h i s study parents and f r i e n d s were i n d i v i d u a l s with whom teenagers compared t h e i r food behaviors. One reason comparisons were made was to j u s t i f y food patterns adopted. The teenagers a l s o sought information from others. Most frequent information sources were parents, p r o f e s s i o n a l s or on occasion people with desired c h a r a c t e r i s t i c s such as a t h l e t e s . By prov i d i n g information and acti n g as r o l e models these i n d i v i d u a l s c o n t r i b u t e d to the development of teenagers' d e f i n i t i o n s of what were appropriate or "good" food behaviors. These observations are s i m i l a r to those of Cuss l e r and De Give (1952) who i d e n t i f i e d mechanisms of tr a n s m i t t i n g "food ways" which included input from family and community members. Awareness of food b e l i e f s i s important i n planning to change 77 behaviors. The patterns of food behaviors associated with " c o n v i c t i o n s " and "convenience" could be considered as representing two d i f f e r i n g value s e t s . The teenagers considered both information and recommended a c t i o n s i n l i g h t of t h e i r frameworks. Those guided by issues of "convenience" had d i f f e r e n t food b e l i e f s and behaviors than those who considered food i n r e l a t i o n to " c o n v i c t i o n s . " The conceptualized food patterns associated with " c o n v i c t i o n s " and "convenience" might be seen as representing the value sets of d i f f e r i n g c l a s s e s or groups of community members and representing two d i f f e r i n g points of view. If i n d i v i d u a l s i n t e r p r e t information or formulate knowledge in l i g h t of t h e i r own s i t u a t i o n and b e l i e f s and values then those with d i f f e r e n t values would perceive d i f f e r e n t types of information important. C l e a r l y i n t e r v e n t i o n s t r a t e g i e s that would appeal to one set of values would not n e c e s s a r i l y appeal to the other. The w r i t e r did not c o n t r a s t teenagers' perceptions of t h e i r food behaviors with those of other groups, but the c o n c e p t u a l i z a t i o n s developed in t h i s study may c o n t r i b u t e to the e x p l o r a t i o n of p o t e n t i a l d i f f e r e n c e s between groups in several ways. The c o n c e p t u a l i z a t i o n of teenagers' perceptions of t h e i r food behaviors which has been proposed i s a c l e a r example that teenagers have t h e i r own ways of viewing t h e i r food behaviors and that t h e i r views may d i f f e r from those of others. A l s o , c o n t r a s t i n g one's own c o n c e p t u a l i z a t i o n with that of another implies that i n d i v i d u a l s must begin to c l a r i f y t h e i r own b e l i e f s about food behaviors. Such notions might be personal and based on knowledge and experiences or they might r e f l e c t defined p r o f e s s i o n a l o r i e n t a t i o n s . Making e x p l i c i t 78 one's own framework i s important i f a p r o f e s s i o n a l i s going to enter i n t o n e g o t i a t i o n of therapeutic i n t e r v e n t i o n s . Studies of Adolescent N u t r i t i o n and Food Patterns Patterns of food consumption during adolescence. The review of t h i s category of l i t e r a t u r e i n d i c a t e s that, while researchers document a range of adolescent food behaviors, the patterns are not e a s i l y e xplained. Two studies suggest that food consumption i s r e l a t e d in some way to the a v a i l a b i l i t y of foods (Crawford, 1977; Stepien, 1978). Other studies suggest a lack of responsiveness to increased energy and n u t r i t i o n a l requirements of the age group. Reasons proposed to e x p l a i n the described patterns include lack of awareness of the nature of increased needs and lack of knowledge. The behavior patterns associated with " c o n v i c t i o n s " and "convenience," and the c h a r a c t e r i s t i c s of s i t u a t i o n a l independency and dependency, c o n t r i b u t e to an explanation of how or why teenagers' food behaviors might a l t e r with changing c o n d i t i o n s . Changing the a v a i l a b i l i t y of foods might change the kinds of foods consumed by teenagers whose food behaviors were guided by f a c t o r s r e l a t e d to "convenience." Changing the a v a i l a b i l i t y of foods would l i k e l y r e s u l t i n a change in food behaviors, but not n e c e s s a r i l y foods consumed, i f teenagers were operating under the o r i e n t a t i o n s r e l a t e d to the " c o n v i c t i o n s " category. In t h i s l a t t e r instance food behaviors would include e a t i n g as well as planning, purchasing or preparing meals or snacks. 79 Another explanation f o r the range of food behaviors reported i n the l i t e r a t u r e can be a t t r i b u t e d to the b e l i e f s teenagers hold about p a r t i c u l a r foods. As the adolescents a r t i c u l a t e d t h e i r notions about why they might eat c e r t a i n foods and avoid others, they included the c h a r a c t e r i s t i c s a s c r i b e d to foods as reasons. The q u a l i t i e s such as " l i g h t , " "quick," "greasy," or " f a t t e n i n g " were named, as were the d e s i r e s to include " l i g h t " foods when one was concerned about one's weight or to exclude "greasy" foods i f one was concerned about complexion. Foods were also discussed i n terms of being "healthy," "junky" or " n u t r i t i o u s . " An i n t e r e s t i n g part of these observations was that although the adolescents might use the same terms, they were not always d e s c r i b i n g the same foods or the same food q u a l i t i e s . S i m i l a r observations were reported by Kaufman et a l . (1975). Described i n f l u e n c e s on teenagers' food behaviors. When Kaufman et a l . (1975) reported that adolescents a t t r i b u t e d q u a l i t i e s to d i f f e r e n t foods and food types, they i n d i c a t e d t h i s i n f l u e n c e d the teenagers' d e c i s i o n s about food consumption. The present study suggests food d e c i s i o n s are al s o i n f l u e n c e d by the p a r t i c i p a n t s ' perceptions of t h e i r bodies' responses to food and how they perceive foods to a f f e c t t h e i r personal development or f u n c t i o n i n g . The presentation of accounts described processes which involved the teenagers' attendance to cues and t h e i r use of knowledge. Cues which were described as c o n t r i b u t i n g to the development of the teenagers' r a t i o n a l e s included food q u a l i t i e s l i k e " l i g h t n e s s " or "greasiness" and corresponding b o d i l y responses 80 such as "strength," "energy" or " h e a l t h i n e s s . " A d d i t i o n a l i n f l u e n c e s on food behaviors may also be considered. Three issues of personal concern have been discussed in r e l a t i o n to how perceptions i n f l u e n c e behaviors. As the patterns of eating a s s o c i a t e d with " c o n v i c t i o n s " and "convenience" were described, the w r i t e r i d e n t i f i e d f a c t o r s i n f l u e n c i n g not only food behaviors but adolescents' r a t i o n a l e s f o r seeking n u t r i t i o n information. One f a c t o r i s the d e s i r e to acquire s k i l l s i n food preparation or purchase in order to increase personal autonomy. A second i s that f o r those who are guided by issues of "convenience" new information can induce changes i n food behavior patterns but these behavioral changes may not n e c e s s a r i l y be maintained. Deciding to maintain "healthy" or recommended food behavior patterns depends upon the teenagers' i n t e r p r e t a t i o n s of t h e i r bodies' responses to foods as well as t h e i r a b i l i t i e s to c r i t i c a l l y examine information. Perhaps f o r some teenagers the source of information and i t s mode of presentation are more important reasons to modify behaviors than the nature of the information i t s e l f . Teenagers' knowledge of n u t r i t i o n . Several studies in the l i t e r a t u r e report varying l e v e l s of knowledge among d i f f e r i n g groups of teenagers. An assumption in assessing knowledge i s that i t i s a pre- or c o - r e q u i s i t e to healthy p r a c t i c e . Studies such as those by Thompson and Schwartz (1977) and Saucier and Gauthier (Note 2) suggest that knowledge of n u t r i t i o n does not c o r r e l a t e with recommended p r a c t i c e s . One explanation f o r t h i s observation may be found in the r e s u l t s of t h i s 81 study. As accounts were presented the researcher decribed how teenagers used t h e i r experiences and perceptions in d e f i n i n g how " f a c t s " were incorporated i n t o r a t i o n a l e s f o r a c t i n g . In assessing the usefulness of information given to them by teachers, nurses or others, the teenagers v a l i d a t e d i t by examining i t s relevancy to t h e i r own s i t u a t i o n , i t s c o m p a t i b i l i t y with personal b e l i e f s or notions, and i t s consistency with messages from other sources i d e n t i f i e d as c r e d i b l e . Such c r e d i b l e sources might include parents, teachers or nurses. The teenagers sought information f o r the purposes of s o l v i n g problems or to expand the amount of information used in making d e c i s i o n s . Learning new s k i l l s was also described as being motivated by the d e s i r e to increase choices and to increase personal autonomy. A l l of the adolescents described that on r e c e i v i n g information they "tested" i t out. In making sense of information presented to them, the teenagers i n t e r p r e t e d i t in l i g h t of t h e i r perceptions of what was important, valued, or l i k e l y to c o n t r i b u t e to the r e s o l u t i o n of issues of personal concern. These observations emphasize that information or a d i e t a r y routine recommended by a p r o f e s s i o n a l w i l l l i k e l y be pondered, examined, t e s t e d , and p r i o r i t i z e d f o r i t s perceived relevance to the i n d i v i d u a l ' s s i t u a t i o n . Information may be challenged not only by the teenagers but a l s o by t h e i r e s t a b l i s h e d r o u t i n e s , p r a c t i c e s or preferences as well as t h e i r observations of general trends. This process of i n t e r p r e t i n g information in context of the 82 i n d i v i d u a l ' s experiences c o n t r i b u t e s one explanation of why recommendations may not always r e s u l t i n the d e s i r e d behavioral change. It also has i m p l i c a t i o n s f o r how health care workers might assess an i n d i v i d u a l ' s understanding of conveyed information. The measurement of knowledge by a b i l i t y to r e c a l l " f a c t s " does not assess how teenagers have i n t e r p r e t e d information in l i g h t of t h e i r everyday experiences. Everyday knowledge i s more l i k e l y to be assessed i f one explores what i s understood or how information i s incorporated into an e x i s t i n g knowledge base or framework. One type of knowledge assessment reveals " f a c t s " and the other, the framework which i s guiding d a i l y d e c i s i o n making. Influence of s o c i a l status and f a m i l y . The p a r t i c i p a n t s in t h i s study were a l l from middle c l a s s f a m i l i e s . It i s worthy of note that as well as having a range of food behaviors, the teenagers within the study group held d i f f e r i n g views of what was important or valued as f a r as t h e i r food behaviors were concerned. Studies such as that by Dwyer et al (1967) suggest that c u l t u r a l and f a m i l i a l f a c t o r s in some way i n f l u e n c e d adolescents' food p r a c t i c e s . In the process of developing t h e i r perceptions of food, the teenagers in the study described here c i t e d t h e i r parents as sources of knowledge. They also v a l i d a t e d t h e i r food behaviors by comparing them with those of t h e i r parents or peers. Many teenagers, as well as i d e n t i f y i n g family members as sources of information, i n d i c a t e d that some food behaviors or b e l i e f s derived from fam i l y patterns or t r a d i t i o n s . Some teenagers perceived i t more important to maintain these t r a d i t i o n s than others. The importance of 83 maintaining t r a d i t i o n s could be seen to correspond with the types of behaviors and b e l i e f s c h a r a c t e r i z e d by the " c o n v i c t i o n s " category. The idea that knowledge i s s o c i a l l y constructed and t h a t information i s i n t e r p r e t e d in l i g h t of b e l i e f s and experiences r e i n f o r c e s the need f o r health care workers to assess i n d i v i d u a l s ' food behaviors and r a t i o n a l e s f o r t h e i r behaviors i n the context of the family. Family environments c o n t r i b u t e to the i n d i v i d u a l ' s assessments of what i s meaningful and what types of information or behaviors are perceived by the teenagers as important to consider. Summary The presentation of accounts described processes involved in the development of teenagers' r a t i o n a l e s f o r t h e i r food behaviors. The d i s c u s s i o n addressed how t h i s study adds to an understanding of why teenagers have the food behaviors they do, how they make food d e c i s i o n s , how they make sense of information and how they develop t h e i r a t t i t u d e s towards food. In c o n s t r u c t i n g accounts the w r i t e r was guided by the three purposes of the study. One purpose was to explore with the teenagers t h e i r perceptions of t h e i r food behaviors. A second was to understand the p o s i t i o n food and food behaviors have within the values of the adolescent group. The t h i r d was to describe v a r i a t i o n s or changes in adolescents' food r e l a t e d a c t i v i t i e s by observing them. Data c o l l e c t i o n was guided by the study purposes and data a n a l y s i s organized accounts i n t o conceptual c a t e g o r i e s . 84 This chapter described that teenagers have frameworks which guide t h e i r food d e c i s i o n making. Processes which co n t r i b u t e d to the development of the frameworks were the i n t e r p r e t a t i o n of cues and knowledge, the comparison of themselves with others and the d e s i r e to resolve issues of personal concern. The teenagers were also described as having food behaviors d i r e c t e d by issues r e l a t e d to e i t h e r " c o n v i c t i o n s " or "convenience." The presentation of accounts i s unique in comparison to reviewed l i t e r a t u r e i n that i t represents the teenagers' points of view and i d e n t i f i e s , f o r example, who they view as information resources, t h e i r i n t e r p r e t a t i o n s of the e f f e c t s of recommended eating patterns on t h e i r bodies or sense of well being and t h e i r perceptions of both the p o s i t i v e and negative outcomes of adopting p a r t i c u l a r food behavior patterns. The w r i t e r ' s d e s c r i p t i o n of both the processes which co n t r i b u t e d to the development of the adolescents' frameworks and the two behavioral patterns associated with " c o n v i c t i o n s " and "convenience" conceptualizes the adolescents' perspectives d i f f e r e n t l y than what i s presented i n reviewed l i t e r a t u r e . In d i s c u s s i n g t h i s study in r e l a t i o n to the l i t e r a t u r e i t was also proposed that presented accounts can both provide explanations f o r patterns of food intake which were described in studies c i t e d and i d e n t i f y f a c t o r s which i n f l u e n c e teenagers' food behaviors. This study demonstrated that food behaviors are most often perceived in r e l a t i o n to issues of l i f e s t y l e such as a c t i v i t i e s or f r i e n d s h i p s and not n e c e s s a r i l y in r e l a t i o n to concerns of health or i l l n e s s . In d e s c r i b i n g the patterns of food behaviors associated with 85 " c o n v i c t i o n s " and "convenience," the w r i t e r proposes a way of e x p l a i n i n g teenagers' food behaviors in a way that i s not n e c e s s a r i l y dependent upon va l u i n g health. Chapter V SUMMARY, CONCLUSIONS, IMPLICATIONS AND RECOMMENDATIONS FOR FURTHER STUDY Summary Both the w r i t e r ' s observations of teenagers i n c l i n i c a l s e t t i n g s and a review of re l e v a n t l i t e r a t u r e i d e n t i f i e d that we know l i t t l e about adolescents' food behaviors. This presents a problem to nurses and other health care workers as they i d e n t i f y the need to design or implement n u t r i t i o n i n t e r v e n t i o n programmes. Understanding why people behave as they do can help health care p r o f e s s i o n a l s provide care in terms meaningful to the c l i e n t s and in a way which i s c o n s i s t e n t with c l i e n t s ' e xpectations. Studies which examined issues r e l a t e d to the i n i t i a t i o n and maintenance of change in health behaviors were reviewed. They addressed questions r e l a t e d to when and why i n d i v i d u a l s carry out pr e s c r i b e d behaviors. Reviewed studies of health behaviors i n d i c a t e d that, while some aspects of "preventive" actions are viewed s i m i l a r l y to " c u r a t i v e " ones, there are also d i f f e r e n c e s . Examples of c i t e d d i f f e r e n c e s are c l i e n t s ' perceptions of the value of the p r e s c r i b e d behaviors, perceptions of the pr e s c r i b e d regimen's impact on other aspects of t h e i r l i f e s t y l e and the complexity of the pres c r i b e d r o u t i n e . E a r l y n u t r i t i o n researchers studied problems r e l a t e d to the i n i t i a t i o n and maintenance of change in food behaviors. They employed ethnographic methods and studied food as part of a c u l t u r e . The 86 87 understanding gained by t h e i r research c o n t r i b u t e d to the design of more e f f e c t i v e n u t r i t i o n i n t e r v e n t i o n programmes. S i m i l a r research methods and a p p l i c a t i o n s of f i n d i n g s have been described more r e c e n t l y i n understanding how d i f f e r e n t c u l t u r a l groups perceive and r e s o l v e i l l n e s s concerns. I t i s important to describe and i d e n t i f y patterns of what i t i s people eat to assess the incidence and type of n u t r i t i o n a l problems. Several researchers have done t h i s f o r the adolescent population. Recent studies also suggest that family, c u l t u r e and perception of s e l f i n f l u e n c e food behaviors. Although adolescent food behaviors ranging in degrees of healthiness are documented in l i t e r a t u r e reviewed, there are not s a t i s f a c t o r y explanations of i n d i v i d u a l d i f f e r e n c e s in observed p r a c t i c e s . What has not been responded to are the questions r e l a t e d to why teenagers a c t as they do. Such information has been described as c r i t i c a l to the e f f e c t i v e p r o v i s i o n of care. P r o v i s i o n of care in the context of t h i s study would mean communicating n u t r i t i o n information in a manner that would be acceptable to teenagers and r e s u l t i n t h e i r adoption of recommended ea t i n g patterns. I t was proposed that providing a d e s c r i p t i o n of how teenagers e x p l a i n t h e i r food behaviors would help to increase understanding of how adolescents i n t e r p r e t or make sense of knowledge or f a c t s , how they develop t h e i r a t t i t u d e s and in turn how they make de c i s i o n s about t h e i r food behaviors. I t could also provide information about what teenagers consider to be important or what they perceive to i n f l u e n c e t h e i r food 8 8 b e l i e f s or behaviors. The i n t e r p r e t i v e method was chosen to address the study problem. C h a r a c t e r i s t i c s of the method include researcher involvement in the research process of understanding how i n d i v i d u a l s develop t h e i r views. The researcher both interviewed and observed teenagers to i d e n t i f y f a c t o r s which were meaningful to them and to understand why they were meaningful. This enabled the researcher to respond to the study's purposes which were; to describe adolescents' perceptions of t h e i r food r e l a t e d behaviors, to develop an understanding of the p o s i t i o n food and food r e l a t e d behaviors have within the values of the adolescent group and to describe v a r i a t i o n s or changes in food r e l a t e d a c t i v i t i e s as adolescents were observed in s e l e c t e d s i t u a t i o n s at s e l e c t e d times. In t h i s study method, data a n a l y s i s i s ongoing and may d i r e c t the researcher to include extra p a r t i c i p a n t s exemplifying d i f f e r i n g c h a r a c t e r i s t i c s . Based on i n i t i a l data a n a l y s i s the researcher chose to augment the sample s i z e and to r e f i n e the s e l e c t i o n c r i t e r i a of age, sex and a b i l i t y to speak E n g l i s h . Nine teenagers were interviewed and observed on two occasions and two teenagers were interviewed and observed on one occasion. The t r a n s c r i b e d interviews and recorded observations formed the data f o r the study. P r e s e n t a t i o n of an i n t e r p r e t i v e study does not i n v o l v e the measurement of the incidence of p a r t i c u l a r behaviors or statements, but describes how f a c t o r s such as events, a c t i v i t i e s or knowledge become meaningful to i n d i v i d u a l s . A goal was to i d e n t i f y each i n d i v i d u a l ' s way of t h i n k i n g about the t o p i c of food. T h i s method was p a r t i c u l a r l y 89 appropriate to study the described problem because observations and second interviews allowed the researcher to i d e n t i f y consistency in behaviors and accounts and provided the opportunity to c l a r i f y i n t e r p r e t a t i o n s . In t h i s way, the researcher constructed accounts of food behaviors with the teenage p a r t i c i p a n t s . The presentation of accounts demonstrated that teenagers have frameworks which guide t h e i r d e c i s i o n making about food. Processes which c o n t r i b u t e d to the development of the frameworks were the i n t e r p r e t a t i o n of cues and knowledge, the comparison of themselves with others and the d e s i r e to r e s o l v e issues of personal concern. The adolescents were also described as having food behaviors d i r e c t e d by issues r e l a t e d e i t h e r to " c o n v i c t i o n s " or "convenience." An example of cues to which they might attend was the response of t h e i r bodies to p a r t i c u l a r foods or a c t i v i t i e s . In t h e i r use of knowledge, the teenagers were described to both assess the usefulness of shared f a c t s and to a c t i v e l y seek s o l u t i o n s to p a r t i c u l a r problems i d e n t i f i e d . The teenagers defined the relevancy of such cues or knowledge in terms of how they might c o n t r i b u t e to reaching i d e n t i f i e d personal goals. The reasoning processes used by the boys and g i r l s provide i n s i g h t i n t o how b e l i e f s about foods and food behaviors are developed and how teenagers use information. The presentation of accounts c o n t r i b u t e s to an understanding of teenagers' food behaviors by i d e n t i f y i n g not only what the teenagers' perceptions are, but also what f a c t o r s c o n t r i b u t e to t h e i r development. In d i s c u s s i n g t h i s study in r e l a t i o n to the l i t e r a t u r e , the 90 w r i t e r i d e n t i f i e d that making e x p l i c i t the frameworks guiding teenagers' food d e c i s i o n s c o n t r i b u t e s to an understanding of what issues are perceived as important by teenagers and how the issues i n f l u e n c e food d e c i s i o n s made. In c o n c e p t u a l i z i n g food patterns associated with " c o n v i c t i o n s " and "convenience," the w r i t e r presents ways of e x p l a i n i n g teenagers' food behaviors which r e f l e c t t h e i r perceptions, a t t i t u d e s and values. Understanding how adolescents develop t h e i r points of view, the nature and types of cues to which they attend, the r o l e models they choose, and the way they i n t e r p r e t information in l i g h t of t h e i r b e l i e f s can provide d i r e c t i o n to health care p r o f e s s i o n a l s as they develop i n t e r v e n t i o n programmes. There i s a need to present n u t r i t i o n information in r e l a t i o n to issues of importance to teenagers and in terms understood by them. Conclusions The observations and conceptual c a t e g o r i e s developed in t h i s study represent how teenagers view t h e i r food behaviors. As such, t h i s study c o n t r i b u t e s one explanation of adolescents' everyday food d e c i s i o n making. This study, l i k e others, r e i n f o r c e s the notion that i n d i v i d u a l s develop ways of viewing t h e i r own s i t u a t i o n s that may d i f f e r from those of others. Health care workers most fr e q u e n t l y conceptualize and present n u t r i t i o n information within the context of health r e l a t e d i s s u e s . While some teenagers in t h i s study were concerned about health, most were more concerned about the impact food behaviors had on other parts of t h e i r 91 l i f e . As such, health care workers and teenagers might be seen to have d i f f e r i n g "explanatory models," (Kleinman, 1975) or in the context of t h i s study, frameworks. That teenagers perceive t h e i r food behaviors to be "normal" or "good" i s an important observation which c o n t r a s t s with reports of n u t r i t i o n researchers. This b e l i e f was c i t e d as a r a t i o n a l e by the adolescents as they j u s t i f i e d d e c i s i o n s made, considered how they would use knowledge and chose t h e i r food behavior r o l e models. N u t r i t i o n research, however, reports that many teenagers have "bad" or "unhealthy" d i e t s . The conceptual c a t e g o r i e s of " c o n v i c t i o n s " and "convenience" and the described processes of d e c i s i o n making suggest the adolescents' r a t i o n a l e s f o r a c t i n g are more c l e a r l y r e l a t e d to issues of personal concern, e s t a b l i s h e d patterns or r o u t i n e s , and i n t e r p r e t a t i o n s of information communicated than they are to issues of h e a l t h . D e s c r i p t i o n s of the processes involved as teenagers develop t h e i r p a r t i c u l a r food b e l i e f s s t r o n g l y suggest that, although one may control the content and types of information shared (such as in n u t r i t i o n teaching or i n t e r v e n t i o n programmes), how the i n d i v i d u a l teenager might use i t or make sense of i t i s l e s s p r e d i c t a b l e . Imp!ications This study assumed that i n d i v i d u a l respondents spoke as competent members of the adolescent group. The w r i t e r through the use of interviews and observations sought to c l a r i f y with the teenagers t h e i r 0 92 perceptions of t h e i r food behaviors. The importance of the d e s c r i p t i o n , then, l i e s in the c l a r i t y of p r e s e n t a t i o n , allowing others to develop, question and r e f i n e the observations and c o n c e p t u a l i z a t i o n s i n i n t e r a c t i o n with teenagers or groups. The accounts presented show that i n d i v i d u a l teenagers think about t h e i r food behaviors in ways that d i f f e r from health or p r o f e s s i o n a l models. Kleinman (1978a) s t a t e s the i m p l i c a t i o n s of d i f f e r i n g points of view on the e f f e c t i v e p r o v i s i o n of c a r e . In order to increase s a t i s f a c t i o n with care and f o r p r o f e s s i o n a l s to be able to achieve higher l e v e l s of compliance with regimens they p r e s c r i b e , awareness of how i n d i v i d u a l s a r r i v e at d e c i s i o n s or view t h e i r s i t u a t i o n s i s r e q u i r e d . Inherent in such a statement i s the i m p l i c a t i o n f o r p r o f e s s i o n a l s to a r t i c u l a t e t h e i r models or ways of viewing a t o p i c such as food. T h i s study supports the view that in order to increase the e f f e c t i v e n e s s of teaching i n t e r v e n t i o n s the teaching s i t u a t i o n should provide o p p o r t u n i t i e s f o r e x p l o r a t i o n of preconceived notions concerning the t o p i c of food. Such a process would f a c i l i t a t e assessment of what teenagers would perceive as necessary information as well as a i d i n g the i n t e r v e n i n g nurse in presenting information in a manner the adolescent would perceive to be r e l e v a n t . The process o r i e n t e d approach would also encourage the nurse to seek the i n d i v i d u a l ' s perceptions of what had been "taught." In t h i s way the i n t e r v e n i n g nurse would have the opportunity to c l a r i f y misconceptions, add more information, or i d e n t i f y conceptual b a r r i e r s i n h i b i t i n g the c l i e n t ' s a b i l i t y to incorporate new information. 9 3 People i n f l u e n c e the types of b e l i e f s developed or food behaviors adopted because, through a process of v a l i d a t i o n , the teenagers compare t h e i r food behaviors and seek information or advice. This implies health care workers should i d e n t i f y the teenagers' p r e f e r r e d r o l e models and t h e i r sources f o r information. L i t e r a t u r e , observations and t h i s study reported that most teenagers have reasons f o r t h e i r food behaviors which were not r e l a t e d to health and t h i s could account f o r an observed lack of r e c e p t i v i t y to i n t e r v e n t i o n programmes. A v a r i e t y of d i f f e r e n t views were described. For example, food behaviors were i n f l u e n c e d by b e l i e f s and the teenagers' perceptions that p a r t i c u l a r foods would c o n t r i b u t e to the r e s o l u t i o n o f issues of personal concern. The behavioral patterns associated with " c o n v i c t i o n s " and "convenience" are examples of how d i f f e r e n t o r i e n t a t i o n s or value sets may i n f l u e n c e food d e c i s i o n s and food behaviors. These observations and the adolescents' perceptions t h a t t h e i r food behaviors are "good" or "healthy" suggest some reasons why teenagers might consider they do not need n u t r i t i o n i n t e r v e n t i o n programmes or that n u t r i t i o n information i s not useful to them. This study can provide d i r e c t i o n to health care workers i n t e r e s t e d i n encouraging teenagers to p a r t i c i p a t e in n u t r i t i o n i n t e r v e n t i o n programmes by presenting information in a manner which would be meaningful to them. Recommendations For Further Study As the teenagers recounted experiences and t h e i r reasons f o r f o r adopting new food behaviors, they often i n d i c a t e d something had 94 happened to change the way they p r i o r i t i z e d the importance of some food r e l a t e d i s s u e s . Developing an awareness of new food ideas was one reason c i t e d ; others were often r e l a t e d to changing perceptions of themselves. Further research might u s e f u l l y explore the process of s e n s i t i z a t i o n of teenagers to food r e l a t e d i s s u e s , what might be an optimum time f o r teaching or i n t e r v e n t i o n programmes, i . e . p r i o r to or post puberty, and the i d e n t i f i c a t i o n of s t r a t e g i e s of i n t e r v e n t i o n which would support the i n t r o d u c t i o n of change in teenagers' d i e t s . While t h i s study focused on healthy teenagers, a s i m i l a r study of teenagers on therapeutic d i e t s would c o n t r i b u t e to an understanding of how they develop views of t h e i r food behaviors and in what ways, i f any, they may d i f f e r from teenagers such as those included i n t h i s study. The notion that some persons were i d e n t i f i e d by the teenagers as more " r e l i a b l e " or c r e d i b l e information sources than others r a i s e s questions r e q u i r i n g f u r t h e r e x p l o r a t i o n . How might nurses enhance t h e i r c r e d i b i l i t y as informants? Or, how might one intervene to change a s i t u a t i o n where e s t a b l i s h e d routines are supported by persons i d e n t i f i e d as " c r e d i b l e ? " The boys and g i r l s i n the study a l l p a r t i c i p a t e d , in a c t i v i t i e s outside of school. One had the sense that most of them were very busy. Some teenagers would say that, despite being busy, planning a "good" lunch was important so "you make time." Several of the adolescents who were more s i t u a t i o n a l l y dependent valued o p p o r t u n i t i e s which would increase t h e i r range of c h o i c e s . These might include having increased 95 spending money, d e s i r i n g greater v a r i e t y in c a f e t e r i a s , or l e a r n i n g s k i l l s r e l a t e d to food preparation. Such observations make one question whether the described tendencies are only r e l a t e d to food behaviors or i f they represent two d i f f e r i n g ways of coping with a busy l i f e s t y l e , by planning or by responding. The two d i f f e r i n g value sets also suggest that, although a l l of the adolescents may have known what they "should" eat, t h e i r perceptions of t h e i r own a b i l i t i e s to provide the foods e i t h e r through preparation or purchase i n f l u e n c e d t h e i r food behaviors. It would be worthwhile to f u r t h e r explore t h i s notion. F i n a l l y , although t h i s study focused on adolescents' p e r c e p t i o n s , understanding the extent to which such perceptions might be shared by those of d i f f e r e n t age groups and with d i f f e r e n t c u l t u r a l o r i e n t a t i o n s would also be useful to explore. 96 REFERENCE NOTES 1 - S a u c i e r , Jean-Francois. 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I understand that we w i l l get together twice in my home where Judy w i l l ask me some questions and observe me. An example of a question I might be asked would be to describe a t y p i c a l day's eating p a t t e r n . Observations made might i n c l u d e ; time, place and composition of meal and type of i n t e r a c t i o n s between those present. As we ta l k the d i s c u s s i o n w i l l be tape recorded. These tapes w i l l be kept c o n f i d e n t i a l . I am aware that I may refuse to answer any s p e c i f i c question(s) or completely withdraw from the study, without p r e j u d i c e , at any time. I have discussed t h i s with my parents. Date Teenager I (agree/do not agree) to allow my son/daughter * to p a r t i c i p a t e in the study as i t has been described. Date Parent

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